Manchester Health and Care Commissioning Board
Agenda Item: 3.2 Date: 24 January 2018
Report Title: Quality and Performance Improvement Report
Prepared by: Michelle Buls – Performance and Quality 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 board. 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 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 providing an Summary of Report: update on the following areas:
• Adult social care • Primary care improvement and assurance framework • Infant mortality • Small provider updates • Contract planning • Quality premium • Resilience • Quality dashboard
1 • 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. Quality IA or N/A Equality IA):
Outline public engagement – clinical, stakeholder and N/A public/patient: The board is asked to support the actions being undertaken to Recommendation: improve the quality and performance for the population of Manchester.
2 1.0 Introduction
1.1 This report summarises the quality and performance highlights, to be brought to the attention of the Manchester Health and Care Commissioning’s (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 Manchester Health and Care Commissioning’s (MHCC) main providers – Manchester University Foundation Trust (MFT) and Pennine Acute Hospitals Trust (PAHT).
1.2 The following scorecards are attached:
• MHCC 5 year Forward View (Appendix A) • MFT Contract Key Performance Indicators(Appendix B) • MFT (formerly CMFT) Contract Key Performance Indicators(Appendix C) • MFT (formerly UHSM) Contract Key Performance Indicators (Appendix D) • PAHT Contract Key Performance Indicators (Appendix E)
1.3 For ease of reporting and to cut down on repetition, we have created “family groupings” of indicators that link one specific action plan, rather than outlining actions for each exception identified. We have also rationalised the reporting frequency against these family groupings as follows:
Monthly • Urgent care • Elective care • Mental health and learning disability Quarterly • Cancer • Information and data quality • Primary care • Quality – safety • Quality – experience • Quality – effectiveness • Child and family health • E-referrals
1.4 In addition, there will be a “focus on” section every month, a timetable has been agreed. Focus areas include: Community providers Patient experience Mental health Stroke Primary care Resilience Adult social care Walk rounds Public health CCG improvement and assessment Small providers framework Quality dashboard (including CQUIN) CQC provider update Quality premium
3 1.5 This month’s focus areas are contained in section 3 of this report as below: 3.1 Adult social care 3.2 Primary care improvement and assurance framework 3.3 Small provider updates 3.4 Contract planning 3.5 Quality premium 3.6 Resilience 3.7 Quality dashboard and Pennine Acute quality
1.6 The data contained in this report is the latest published data. However, the narrative has been updated to the most recent local information.
4 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 and Care Commissioning
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value November Percentage of patients who spent 4 hours or less in A&E 95.0% 90.2% 95.0% 87.7% 2017 result
Manchester University NHS Foundation Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value Percentage of patients who spent 4 hours or less in A&E November N/A 91.8% 90.8% 88.4% (STF) 2017 result November Ambulance Handover Delays over 30 Minutes 0 1950 0 407 2017 result November Ambulance Handover Delays over 1 Hour 0 307 0 89 2017 result November Ambulance Handover Delays over 2 Hours 0 30 0 12 2017 result
Manchester University NHS Foundation Trust (formerly CMFT)
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value Percentage of patients who spent 4 hours or less in A&E 91.07 October N/A 92.96% 90.30% (STF) % 2017 result November Ambulance Handover Delays over 30 Minutes 0 927 0 173 2017 result November Ambulance Handover Delays over 1 Hour 0 191 0 59 2017 result November Ambulance Handover Delays over 2 Hours 0 26 0 11 2017 result
Manchester University NHS Foundation Trust (formerly UHSM)
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value Percentage of patients who spent 4 hours or less in A&E October N/A 90.4% 90.0% 88.1% (STF) 2017 result
5 November Ambulance Handover Delays over 30 Minutes 0 1023 0 234 2017 result November Ambulance Handover Delays over 1 Hour 0 116 0 30 2017 result November Ambulance Handover Delays over 2 Hours 0 4 0 1 2017 result DTOCs: Average number of DTOCs per day (attributable September N/A 23.7 58.4 to NHS, social care or both) 2017 result October Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 9.4% 2017 result
Pennine Acute Hospitals NHS Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value Percentage of patients who spent 4 hours or less in A&E November N/A 85.1% 89.5% 85.8% (STF) 2017 result November Trolley Waits in A&E 0 91 0 5 2017 result November Trolley Waits in A&E (NMGH) 0 59 0 2 2017 result November Ambulance Handover Delays over 30 Minutes 0 4714 0 804 2017 result November Ambulance Handover Delays over 1 Hour 0 1389 0 226 2017 result November Ambulance Handover Delays over 2 Hours 0 244 0 32 2017 result DTOCs: Average number of DTOCs per day (attributable October N/A 36.0 42.3 to NHS, social care or both) 2017 result October Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 3.8% 2017 result
6 7 2.1.1 Accident and Emergency (A and E) - 4 hour target
Definition • 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.
A and E 4 hour performance continues to be challenging across Manchester’s acute trusts. All three of Manchester’s acute sites are underachieving against their required trajectories.
Issues
Common issues impacting performance achievement are: • High acuity of patients • Increasing variation in attendance and admission levels that are outside of predicted levels • Compromised flow due to restricted bed capacity • Low staffing and high levels of staff sickness
Key actions taken/planned
• Daily monitoring of performance and pressure continues to be delivered by the MHCC resilience and improvement team • Escalation is managed routinely by the resilience team co-ordinating all partners to escalate and de-escalate systems via the national operational pressure escalation levels (OPEL) process • Weekly tactical conference calls • Weekly winter assurance reporting • Daily briefing updates • Daily system update calls • Manchester winter schemes to support resilience are in the implementation phase of delivery. An extraordinary meeting was held in December 2017 with Manchester City Council (MCC) to review the list of key performance indicators KPIs for accuracy and relevance. Changes to the original (KPIs) were agreed and work is underway to update the monitoring process to reflect this • MHCC resilience team have finalised system wide additional winter assurance schemes to further support 4 hour performance in winter. Work is beginning to agree appropriate metrics and finalise the monitoring process • During November the Chancellor announced additional funding for the NHS in 2017/18 to help further support 4 hour performance in winter. MHCC system resilience team secured proposals and presented a bid for consideration. Confirmed schemes for funding have been agreed and are due to come online January 2018 • MHCC system resilience team are coordinating daily information returns to be made available to the Greater Manchester urgent and emergency care hub (GM UEC) • Three Greater Manchester (GM) policies previously issued in relation to transfers of care and local systems are to undergo a 90 day improvement project. The first meeting took place in December 2017 and various areas of work are being carried forward for a meeting in January 2018 • MHCC system resilience team led a review of our three acute main Trusts’ Christmas and new year plans and supported submission to the Greater Manchester Health and Social Care Partnership (GMHSCP) • Identified trolley waits are discussed at operational delivery group (ODG). Those identified with harm are reported on STEIS.
8 In addition, NHS England/NHS Improvement (NHSE/NHSI) has nationally mandated “must dos” to improve accident and emergency 4 hour performance to a sustainable position include two main areas, detailed below:
• Freeing up hospital beds • Managing A and E demand
MHCC is committed to delivery of the above and plans and progress will be managed by the locality operational delivery groups (ODG) and Manchester and Trafford urgent and emergency care transformation and delivery board.
2.1.2. Delayed Transfer of Care (DTOC)
Definitions • Average number of DTOCs per day • The number of beds in which people are classed as delayed as a proportion of all available general and acute beds
Issues
Work continues to reduce DTOC numbers in Manchester’s hospitals. Improvements have been seen in the number of delayed patients in November and December. The number of delays at North Manchester General Hospital (NMGH) and MFT (formerly UHSM) site remains higher than the targets set by the GMHSCP (no more than 3.3% of beds are occupied by patients whose transfer is delayed), this can impact the trust’s ability to respond to surges in demand, and maintain hospital flow.
Manchester Royal Infirmary (MRI) and Trafford General are currently meeting the 3.3% target.
All stakeholders are aware of the complex issues involved with delayed transfers and actively engaged in proactive measures to improve performance. The use of resilience funding and additional adult social care funding is being targeted at sectors where challenges exist.
Key actions taken/planned
• Manchester and Trafford transfer of care action plans and improvement trajectories are in place and being monitored • Manchester and Trafford resilience funded schemes were implemented in quarter 3 and these are supporting the discharge of patients • Monitoring of action plans and trajectories will take place at the ODGs and oversight takes place at the Urgent Care Board (UCB) • Performance and Quality Improvement (PQI) manager onsite providing support for escalation and DTOC related issues at NMGH and MFT (formerly UHSM) site every week. • Daily reporting of DTOC performance to all system stakeholders • Integrated discharge team manager at the MFT (formerly UHSM) site in place from 8 January 2018, with building work on the new office starting in December 2017. The estimated completion is spring 2018 • Trafford and Manchester have established independent DTOC control rooms that monitor the daily issues with DTOC and forensically reviews each patient • Focused quality improvement work has been taking place at NMGH with the PQI team. The making safety visible work has looked at quality improvement by implementing the NHSI’s SAFER (the SAFER patient flow bundle blends five elements of best practice. The five
9 elements of the SAFER patient flow bundle are: senior review. All patients have an expected discharge date and clinical criteria for discharge. Flow. Early discharge. Review) patient flow bundle on wards to help reduce DTOC. The outcome has seen reduced DTOC and reduced total length of stay for patients
Risks
Risks remain associated with the DTOC work due the complex system issues involved and the reactive nature of discharging patients to new care homes and fragile markets that support patients.
Timescales for Delivery
The trusts are meeting the agreed trajectories in December and will see stepped improvement over winter and are expected to meet the 3.3% target before March 2018.
2.1.3 Ambulance Performance – handover times
Definitions • Number of ambulance handovers taking more than 30 Minutes • Number of ambulance handovers taking more than 30 Minutes • Number of ambulance handovers over an hour • Number of ambulance handovers over two hours
The PQI team continue to lead work with North West Ambulance Service (NWAS) and trusts across Manchester. The aim is to improve ambulance handover times and reduce handover breaches by sharing best practice. A monthly performance meeting led by PQI with stakeholders takes place and progress reported to the North, Central / Trafford and South Manchester A and E operational delivery groups (ODGs).
Issues
Pressures with surge in volume of patients within A and E resulted in ambulance crews being delayed at all sites.
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.
Lengthy handovers often demonstrates pressures in different places on site, including higher levels of delayed transfer of care and the lower A and E performance against 4 hour target.
Key actions taken/planned
Daily handover reports identify handover breaches across the city hospitals: • 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 (RCA) on each lengthy handover breach and share this with the PQI Manager, with trends shared with A and E ODGs • Escalation triggers have been identified within the OPEL score cards to proactively manage surge in demand • Monitoring of monthly handover performance takes place with stakeholders at PQI led meetings between trusts and NWAS
10 • NMGH, MFT (formerly CMFT and UHSM) sites have performed well in November, with faster average handover times against NWAS and GM averages. There has been a deterioration of performance over the Christmas and New Year period.
Risks
The performance of the A and E departments in winter has a direct impact on the ability to handover patients in a timely way. The impact of slower handovers will prevent the crews from responding to other emergency calls. This increases the risk to patients and the achievement of response time targets.
Timescales for Delivery
The monthly meetings continue to monitor performance and daily internal reflection takes place. Stepped improvement is expected over winter; with delivery of national targets for handovers expected plans have been developed to deliver by March 2018.
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2.2 Elective Care
Manchester Health and Care Commissioning
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value October Diagnostic Waiting Times % waiting > 6 weeks 1.0% 2.4% 1.0% 1.6% 2017 result Septemb Utilisation of the NHS e-Referral Service to enable choice N/A 73.0% 86.0% 79.0% er 2017 at first routine elective referral result October RTT: Incomplete pathways % within 18 weeks 92.0% 91.1% 92.0% 91.1% 2017 result October Number of patients waiting >52 weeks on incomplete 0 15 0 2 2017 pathways result
Manchester University NHS Foundation Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value October Diagnostic Waiting Times % waiting > 6 weeks 1.0% 3.0% 1.0% 2.2% 2017 result October RTT: Incomplete pathways % within 18 weeks (NHS 92.0% 90.6% 92.0% 90.6% 2017 Constitution) result October Percentage of cancelled elective operations that are 0.8% 1.1% 0.8% 1.5% 2017 cancelled at the last minute for non-clinical reasons result
Manchester University NHS Foundation Trust (formerly CMFT)
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value October Diagnostic Waiting Times % waiting > 6 weeks (NHS 1.0% 3.3% 1.0% 3.2% 2017 Constitution) result October RTT: Incomplete pathways % within 18 weeks 92.0% 91.7% 92.0% 91.7% 2017 result October Percentage of cancelled elective operations that are 0.8% 1.1% 0.8% 1.4% 2017 cancelled at the last minute for non-clinical reasons result October Cancelled elective operations - breaches of 28 day 0 58 0 4 2017 standard result
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Manchester University NHS Foundation Trust (formerly UHSM)
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value October Number of patients waiting >52 weeks on incomplete 0 75 0 17 2017 pathways result October Percentage of patients waiting more than 36 weeks on 1.00% 1.03% 1.00% 1.03% 2017 incomplete pathways result October Percentage of cancelled elective operations that are 0.8% 1.2% 0.8% 1.8% 2017 cancelled at the last minute for non-clinical reasons result October RTT: Incomplete pathways % within 18 weeks (STF) 88.6% 92.0% 88.6% 2017 result
Pennine Acute Hospitals NHS Trust
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value RTT: Incomplete pathways % within 18 weeks (NHS October 92.0% 90.4% 92.0% 90.4% Constitution) 2017 result Cancelled elective operations - breaches of 28 day October 0 55 0 3 standard 2017 result
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2.2.1 Diagnostic waiting times
Definition • The percentage of patients waiting 6 weeks or more for a diagnostic test as at the end of the reporting period
Issues
In October, MFT (formerly CMFT) site reported a position of 3.2%. This represents 344 patients waiting more than 6 weeks out of 10,761.
The main issues, as has been the case for much of the year, relate to waiting times within the endoscopy service both in adults and paediatrics. Capacity has been comprised due to estates work linked to Joint advisory group (JAG) accreditation.
Key actions taken / planned
The trust is working to deliver the action plans reported to board.
Risks
• MFT (formerly CMFT) site report that they will not meet the target within quarter 3
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Timescales for delivery
November provisionally reported as 2.23% with December forecast to be 2.79% to deliver by end of quarter 4.
2.2.2 Referral to Treatment (RTT) Incomplete 18 week and 52 week waiters
Definitions • The percentage of incomplete RTT pathways (patients waiting to start treatment) of 18 weeks or more at the end of the reporting period. • Number of patients on incomplete pathways waiting more than 52 weeks or more at the end of the reporting period
MFT (formerly CMFT)
Issues / Key actions taken / planned
Provisional November performance is reported as 91.56% at MFT (formerly CMFT) site. The key issues at MFT (formerly CMFT) site are workforce pressures within Gynaecology which they have plans in place for. These issues have affected both the cancer 2 week wait and RTT performance in quarter 3. There is also a long standing underperformance at MFT’s(formerly CMFT), Royal Manchester Children’s’ Hospital (RMCH), however this has been an improving picture over the last 3 months and in November was 87.29%, their best performance in the year.
Timescales for delivery
MFT are reviewing the trajectory in light of the change to the non-elective operations approach.
MFT (formerly UHSM)
Issues
Performance for October, at aggregate level, was 88.6%.
There are a number of specialty level issues, with specific challenges in the cardiothoracic service.
These are as follows:
• There has been an impact on tip over from cardiology into the backlog – the Trust is working on this as part of our sustainability and improvement plan • Over the summer a discrete review of cardiac and thoracic (CT) indicated that thoracic, which normally performs well but dipped in August/September and the backlog increased in cardiac from April to July • Over this period there were cancellations due to lack of beds and theatre staffing • Transplants displace elective activity when they occur – which will remain an on-going issue as a nature of the service
Key actions taken / planned
Improvement actions include: • Deep dive into cancellations and regular meeting to ensure issues are addressed • Split of cardiac and thoracic on the recovery trajectory so granular detail of cardiac performance by itself and take action to address • Work in cardiology to prevent long waiters tipping into the backlog in cardiac surgery 15
Timescales for delivery
The trust has revised the improvement trajectory to deliver the standard by March 2018. Within this are specialty level improvement trajectories. October performance of 88.6% met the revised improvement trajectory. Provisional performance for November is 89.24%.
Trajectory Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Backlog (≥18 2,916 2,723 2,561 2,344 2,134 1,952 weeks)
Performance, % 88.6% 89.23% 89.81% 90.59% 91.36% 92.04%
Pennine Acute Hospitals NHS
Issue
The trust continues to report underperformance at aggregate level. As described in previous reports, there are a number of specialty level challenges including digestive diseases, ear nose and throat (ENT) and orthodontics.
Key actions taken/planned
Oversight remains with PAHT’s North East sector (PAHT NES) elective care tactical performance group who meet monthly to monitor performance across PAHT and ensure action plans are progressing.
Risks
There continues to be a number of challenging specialties with action plans in place for recovery.
The 52 week breaches continues to be a risk especially for gastroenterology and colorectal.
Timescales for delivery
The trust is working to confirm aggregate and speciality level compliance as well as the impact of cancelling the elective programme in January.
MFT (formerly UHSM)
RTT – over 52 week waiters
Issue
October data shows 17 patients waiting longer than 52 weeks, an increase from 14 in September.
Actions
There remains one outstanding issue to be resolved in relation to DIEP (deep inferior epigastric perforator) procedures. Following a number of performance / clinical and commissioning meetings, it was collectively recognised that the limiting factor in developing a robust business case for expansion was that tariff did not cover costs. In the first 2 weeks of December, the16 contracts teams at the Trust and MHCC have overcome this obstacle and agreed on a local tariff that is fit for purpose and will now allow the trust to progress with short and longer terms solutions to delivering a sustainable service.
Timescales for delivery
The trust is working on a planned improvement trajectory for 52 week waiters which will be reported in future meetings.
2.2.3 Cancelled operations
Definition • 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 or fund the patient's treatment at the time and hospital of the patient's choice • percentage of cancelled elective operations that are cancelled at the last minute for non-clinical reasons
Issue
At the sites formerly known as UHSM and CMFT the number of cancellations are in access of the local standard of 0.8%.
There are a small number of cancellations where it hasn’t been possible to reschedule within 28 days at PAHT and MFT (formerly CMFT and UHSM).
Key actions taken / planned
At MFT (formerly CMFT and UHSM), each division / hospital has its own local key performance indicator meetings, which meet weekly to clinically assess and schedule patient bookings for surgery. However, additional actions have been implemented by the division of surgery in response to the transformational programme to improve efficiency. These include:
• 28 day breaches are actively managed through the KPI weekly meeting, with oversight by the deputy director of surgery • The appointment of a new admissions coordinator to manage daily admissions and day case capacity • Improved admission process and pre-op triage to reduce any missing checks or patient preparation before theatre • On the day pre-op service is in place • A standard operating policy for reducing cancellations is in place with on day escalation to senior managers and directors to sign off any operations which require cancellation for non-medical reasons • Improved information checks with the patient to ensure accuracy of phone numbers reminder text messages • Improved process for being developed with anaesthetics, labs and haematology • Pre-op tracker was recently introduced to check all patients due into theatre in the next two weeks have all pre-op actions completed
PAHT ensure escalation to senior managers to explore all options before cancelling operations.
Timescales for delivery
Not yet identified. 17
2.2.4 Utilisation of the NHS e-Referral Service to enable choice at first routine elective referral
Definition - The percentage of referrals for a first outpatient appointment that are made using the NHS e-Referral Service (ERS).
There is a commissioning for quality and innovation scheme (CQUIN) in place to support the implementation of the e-referral programme.
The basis for the CQUIN is:
• Publish all first outpatient appointment slots available on the NHS ERS by 31 March 2018 following an agreed trajectory • Undertake required work on the Directory Of Service (DOS) to publish ALL services on the NHS ERS
The standard CQUIN targets to be achieved are:
1. 100% of referrals for 1st Consultants Outpatients appointments to be received through e- Referral from Primary Care by 31 March. 95% has already been negotiated for MFT (formerly CMFT) site 2. Appointment SIot Issues (ASI) to be less than 4% by quarter 4 2017/2018 3. Provide evidence that polling ranges for directly bookable services match or exceed waits for paper referrals
NHSE has mandated, via the NHS standard contract that that from 1 October 2018 any GP referred outpatient appointments (received on or after this date) that are subsequently booked will not receive any income unless booked via ERS i.e. appointments generated from paper referrals will not be funded.
The CQUIN is in support of this end target, and also NHS Digital are supporting trusts to ensure that a paper switch off takes place meaning that all referrals from GPs to first consultant led outpatient services must come through and be booked on the ERS system
There is a monthly programme board that oversees the implementation of the e-referral programme. Membership includes representation from NHS Digital, MHCC and Trafford CCG. The programme of work to implement the e-referral includes:
• A detailed project plan to implement ERS • Monthly divisional updates in relation to progress against the e-referral project plan • Communication strategy in relation to e-referral
This programme board will continue after the completion of the CQUIN in March 2018 to support full implementation prior to October 2018.
There have been some exceptions agreed in relation to the implementation of the CQUIN these are detailed below:
• Local exemption until October 2018 for the patients entering the system on the cancer pathway.
This is to give MFT (formerly CMFT and UHSM) the opportunity to work through the best practice for electronic referral for this high risk group of patients. MFT (formerly CMFT and UHSM) will 18 look to provide a referral assessment service (RAS) solution for GP’s for cancer referrals from April 2018, to allow a common electronic process for all referrals.
• Local exemption for referrals to the anti-coagulation service
These referrals are currently managed through specific software and any move away from the current model would be detrimental clinically. Other trusts in GM have requested/agreed this exemption.
ERS - Publishing of Services & Appointment Slot Issues (ASI) Rate
• ASI % will be tracked to review improvement
It is acknowledged that there will be a number of services where the capacity pressures mean that the ASI rate will remain high. There will be a number of factors affecting capacity including the existing patients within the system once the ERS capacity is published. Given that trusts cannot necessarily generate sufficient additional capacity (particularly scarcely available staff in certain key specialties) it was recognised that proposals or business cases will need to be developed for those services over a longer period, that will be reviewed and the financial and performance target delivery risks/benefits will need to be assessed by the health and social care economy as a whole.
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2.3 Mental Health
Mental Health
Manchester Health and Care Commissioning
Annual 2017/18 Period Performance Indicator Target Period Target in Period 2017/18 Value August IAPT Achieving better access 16.80% 6.10% 1.40% 1.26% 2017 result August IAPT Recovery rate 50.0% 37.4% 50.0% 38.5% 2017 result August IAPT Waiting times (6 weeks) 75.0% 61.3% 75.0% 62.4% 2017 result August IAPT Waiting times (18 weeks) 95.0% 91.9% 95.0% 93.6% 2017 result
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2.3.1 Improving Access to Psychological Therapies (IAPT)
Definitions • the percentage of service users referred to an IAPT programme who wait six weeks or less from referral to entering a course of IAPT treatment • the percentage of Service Users referred to an IAPT programme who wait 18 weeks or less from referral to entering a course of IAPT treatment • increase access to those people who have depression and/or anxiety disorders • ensure patients completing a course of treatment in IAPT services move to recovery
Issues
Manchester has had historically long waits and consistently under-performed against the IAPT national standards. However, following acquisition of mental health services by GMMH (Greater Manchester Mental Health Trust) in January 2017, an IAPT transformation programme has been put into action and its impact will begin showing improvements over the coming months. For the month of August, the IAPT standards were not met, although we are beginning to see signs of improvements against the 18 week wait.
Access
A total of 1110 people received psychological therapy treatment in the month of August. Since April, 5390 people have received treatment, which equates to 6.1% of all adults with common mental health disorders. This is below the target of 7% by the end of August. The annual target is to ensure that by end of March 2018 at least 16.9% of adults with a common mental health disorder receive psychological therapies.
Waiting times
The proportion of people that wait 18 weeks or less from referral to IAPT treatment currently stands at 92%, against the 95% target, and those waiting 6 weeks or less currently stands at 62%, against the 75% target. It is encouraging to note the continued improvement, towards the 18 week wait, which is now close to meeting the 95% target. GMMH has initially targeted resources at improving compliance with the 18 week target and over the next few months the focus will move towards improvement of the 6 week target.
Recovery
The proportion of people who finished their treatment and moved to recovery continues to remain static. As of the end of August 37.4% of people recovered following treatment, which is below the 50% standard.
Key actions taken / planned
A transformation plan is currently underway. A key aspect of the IAPT transformation is to deliver a more integrated pathway across Step 2, 3 and 4.
Key improvements include:
• The new clinical triage hub at Self Help Service (SHS), which became operational in October. Patients requiring therapy will now go to step 2 initially and will only access step 3 if they require more intensive treatment. Since step 2 has always had better recovery rates than step 3, this expansion of step 2 involvement will increase the overall aggregate recovery rate for the MHCC
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• A new IAPT Step 3 Plus service will commence in January 18. It is anticipated that referral rates to step 4 will reduce within the new service which will integrate steps 3 and 4 into a single pathway and clinical team. Recovery rates are also likely to improve with introduction of new service model • An additional 8 staff have been recruited, most of whom will be in post by December 2018. This will lead to a significant reduction in numbers waiting by the end of the calendar year • Investment in estates for the North and Central Manchester IAPT services has created an additional 24 consulting rooms. Work is ongoing to identify a further clinical hub in the South Manchester locality • Robust performance management of the service continues, through weekly IAPT senior leadership meetings. The focus in these meetings is on improving waiting times, reducing did not attend (DNA)/cancellation and effective caseload management
Risks
There is a need to secure further investment in establishing an IAPT hub and access to clinical space in satellite locations in the South of Manchester.
Timescales for Delivery
As a result of the transformational programme currently being implemented, it is anticipated that all the IAPT standards will meet the national requirements by quarter1 of 2018/19.
Step 4 waiting list update
There is currently a large waiting list of people waiting for step 4 psychological therapies. In November 2017 GMMH reported a waiting list of 1029 for step 4 psychological therapies, which is a service offering psychological assessment and treatment for adults with complex psychological/mental health difficulties. On 18 December this figure had fallen to 968. This service provides specialist, evidence-based, NICE compliant psychological therapies to clients with chronic, complex emotional adjustment disorders who are referred either direct from GP's and other healthcare providers e.g. Consultant Psychiatrists or whom are 'stepped-up' from briefer, less intensive interventions provided by primary care mental health teams at Steps 2 and 3. It does not provide urgent or crisis care. Issues that our service may be able to help with include:
• Anxiety, panic and stress • Effects of abuse • Post-Traumatic Stress Disorder (PTSD) • Obsessions / compulsions • Chronic physical health difficulties • Depression • Personality related difficulties • Medically unexplained symptoms
Therapists will have received training in one or more NHS approved, evidence-based psychological therapies and work collaboratively with clients to help decide on the most appropriate type of therapy for their particular needs.
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As of 18 December 2017, 633 people were waiting for longer than 18 weeks, of which 202 people were waiting for over 52 weeks.
The Trust have committed additional financial investment, sourced from the Greater Manchester Transformation Fund and a n MHCC non recurrent resource, secured within the acquisition to enable transformation, to address the waiting list, and 7.8 whole time equivalents staff have been recruited. All of these staff will be in post by the beginning of January 2018.
Historically, the routine process for managing referrals to the service was as follows:
• Where patients were stepped up from step 3 psychological therapies, they were automatically included on the waiting list as they would have had a recent discussion and assessment with a therapist about the service to which they were being stepped-up. In this case GMMH would write to them with a copy to their GP to let them know they are on the list. Stepping up to step 4 psychological therapy does not preclude referral and/or signposting to additional services and our step 3 clinicians routinely facilitate clients’ engagement with a whole range of services including support groups, helplines, recovery based activities, family support, advice agencies offering social support. All patients are given a leaflet listing services which they can contact for additional support and a letter is written to the GP including the agreed risk management plan where this is relevant. Risk management plans contain a range of actions including effective self-management, seeking support from friends and relatives and accessing urgent care services where required. • When patients were allocated directly to step 4 psychological therapies, without entering step 3 services, GMMH sent out an opt-in letter on receipt of the referral. A copy of this also went to the GP. If the opt-in form was not returned, GMMH wrote to the patient, again copying to the GP, informing them that they had been discharged. This gave both client and GP a chance to raise any concerns about discharge. • When patients opted in they were included on the waiting list. In previous discussions with commissioners and the GPSI it has been understood that responsibility for the care of the patient remains with the GP during the waiting period. Urgent care services are available to the GP should risks escalate during this period. The ultimate aim of the WLI in combination with the redesign of the service is to significantly reduce waiting times to comply with RTT time targets, thus mitigating against escalation of risk while waiting. • If patients were referred with levels of high risk, they were referred to either CMHT’s or Home Based Treatment where appropriate. The requirement for other Trust or non-Trust services was considered by the clinical lead at the point of paper triaging the referral and referrals to other services would be made at that point if indicated. This would then be re- considered at the first appointment.
Psychological services have now begun a process of revalidating the waiting list. Given the length of time people have waited, it is inevitable that some will no longer need or want to engage in psychological therapy, and it is important for these people to be identified prior to offering an appointment in order to ensure the resource is used optimally. It should be noted that effective psychological therapy requires the active and collaborative participation of the patient, thus an inability to respond to an opt-in letter is an indicator of likely poor engagement and outcome. This approach has previously been used effectively, in order to address a long historical waiting list for psychological therapy in Salford. The process for validating the waiting list is described below:
• The clinical lead reviews the waiting list and writes to patients who have waited longer than 3 months asking them to make contact by telephone to confirm that they wish to remain on the waiting list for an appointment. The letter informs the patient that if we have not heard from them in 2 weeks they will be removed from the waiting list 23
• Patients who have recently made contact with the service automatically remain on the list and do not receive a letter. Patients who do not speak English are provided with a reply slip so that they do not need to make a telephone call • Patients who reply to the letter within two weeks remain on the waiting list
Following discussions with commissioners regarding the potential risks of inappropriately discharging patients with ongoing needs, the decision was made to introduce the following additional proactive steps. These proposals were presented at the GMMH/MHCC Quality and Performance Meeting in December, where they were positively received. • If patients do not reply, the following further actions are taken to mitigate the risk of inappropriate discharge of a patient whose mental health may have deteriorated whilst waiting. The GMMH patient record is checked to establish whether the patient is under the care of other mental health services. If the record indicates that the individual’s needs are being met by other services then they are discharged from the service. The patient, their GP and other mental health service involved will be informed of this discharge. If the record indicates that no other mental health services are involved then the service will attempt to contact the patient by telephone to enquire about the reason for not making contact and to establish whether the patient does still wish to be offered an appointment. Depending upon the outcome of this conversation the patient will either remain on the list, be discharged and/or be signposted to other services. If contact cannot be made by telephone the patient will be discharged. In all cases where patients are discharged, a letter will be sent to the patient and the GP informing them of discharge, and offering consultation about alternatives to psychological therapy should the GP wish to make contact with the service to discuss the patient’s needs. If the patient or GP contact the service following discharge and it is deemed clinically appropriate to offer psychological therapy, they will be reinstated on the list without disadvantage in terms of waiting time. The timescale for this piece of work is to remove the historic waiting list by the end of 2018. A detailed trajectory will be provided in January 2018. It is anticipated that once the new service model is implemented in January 2018 referral rates to step 4 will reduce as it will be incorporated into a single stepped-care pathway, thereby preventing the recurrence of long waits in the future.
2.3.2 A and E 4 hour standard for patients presenting with mental health conditions
Definition • 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 for patients presenting with mental health
Issues
In October, 81% of patients attending A and E due to a mental health conditions were either admitted or discharged within four hours, compared to 84% the previous month. There were a total of 160 breaches out of a total of 843 referrals in October.
The main causes for the mental health breaches are well known and are due to: a) Delays in being seen by a liaison practitioner within 1 hour b) Delays in the Mental Health Act team carrying out an assessment for those patients referred by the liaison practitioner c) Bed unavailability for those assessed and requires admitting
The greatest opportunity to reduce waiting times in A and E appears to be an improved performance against the 60 minute standard to be seen by the mental health liaison team. In
October however, a total of 256 patients were not seen within the 1 hour target, by a member24 of the liaison team. Staff sickness caused significant capacity gaps; however these have now been resolved (mid November). Also the liaison service has limited capacity to respond to surges in demand.
Key actions taken / planned
Funding has been sought from the GM, which if successful will provide additional resources to the Mental Health Liaison Team to respond to surges in demand at A and E.
The wider and more complex delays related to bed unavailability and the Mental Health Act are both subject to ongoing transformational acute care pathway redesign and which will be focusing on acute and urgent care system improvements. In addition to this there is a winter resilience scheme to pilot a 24 hour approved mental health (AMH) service. This pilot will look to increase the number of approved mental health professionals (AMHP) supporting A and E departments particularly out of hours. This will help to see some improvements in some of the Mental Health Act Team delays that are currently caused by a lack of AMHP capacity.
The AMHP pilot is currently at mobilisation stage. However the staff offered the posts are currently NHS staff moving to Local Authority AMHP positions. Issues related to the transfer of terms and conditions of NHS staff to LA positions are currently delaying implementation of the pilot. These have been escalated for human resource (HR) colleagues to address.
Risks
Risk remains to mobilisation of resilience funded out of hours AMHPs pilot due to recruitment of NHS staff into local authority delivered AMHP positions. This has been escalated for HR colleagues to consider with a GM perspective.
Children and Young People (CYP) Mental Health
Future reports will include performance against a number of national indicators related to improving access to mental health services for children and young people (CYP). Issues in relation to the data quality and the data flow of a number of these national indicators are currently being addressed, as well as clarity on indicator definitions and targets.
Work is also underway with the child and adolescent mental health services (CAMHS) at MFT (formerly CMFT and UHSM), to begin reporting on local performance against indicators related to the CAMHS service. A meeting is planned in January with the CAMHS service to agree reporting requirements and processes going forward.
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3.0 Focus Area Updates
3.1 Adult Social Care
CQC Position Update
The tables below shows; the current Care Quality Commission (CQC) inspection rating for the care homes and home care across Manchester that have had completed inspections by the CQC in the last 18 months.
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CQC rating of Manchester care homes by locality
North (N1&2) Central (C1&C2) South (S1&S2) Blackley City Centre, Ardwick, Gorton Old Moat and Withington North and Gorton South
Allendale Residential Home Beyer Lodge Nursing Home Brocklehurt Nursing Home Blackley Premier Care Gorton Parks Downing House Eachstep Blackley The Dell Polefield Nursing Home St Euphrasia’s Care Home Charlestown, Crumpsall and Hulme, Moss Side, Whalley Chorlton Park, Didsbury and Harpurhey Range, Burnage Chataway Nursing Home Abbotsford Nursing Home Ashley House Residential Home Chestnut House Alness Lodge Ltd Chorlton Place Nursing Home Holmeleigh Dom Polski Residential Care Clyde Court Nursing Home Israel Sieff Court Fairleigh House Holmefield Care Oakbank Care Home Mariana House Laurel Court Wellfield House Rowsley House Russley House Yorklea Nursing Home
Moston, Cheetham, Miles Rusholme, Longsight and Northenden, Sharston and Platting and Newton Heath Levenshulme Woodhouse Park Acacia Lodge Grange Avenue Mainwaring Terrace Averill House Oakland House Nursing Home Marion Lauder House Beechill Nursing Home NWCS (Manchester) 62 Bradgate Brookdale View Park Crescent Cl Doves Nest Nursing Home Richmond Care Ringway Mews Lightbowne Hall St James House St Bonaventures Lindenwood Residential Care St Joseph’s Manchester The Peele Moston Grange Nursing Home Victoria Nursing Home The White House Norlands Nursing Home Yew Tree Manor 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
Inadequate
The information below will give a brief overview for each of the homes rated as ‘Inadequate’
Beechill Nursing Home Locality: Cheetham Number of Beds: 31
Safe Effective Caring Responsive Well led
• MHCC QPC suspended service 18th August 2017, following site visit and serious concerns identified • CQC visited 29th and 30th August 2017 and reported that the home required improvement, report never published 27
• 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 QPC 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 QPC for SIP development • Regular site visits from infection control and medication management • CQC revisited 23rd October 2017 and removed the embargo on new placements, however MHCC’s suspension remains in place to date • MHCC QPC 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 15th February 2017, provider made representations in March 2017 • QPC developed SIP with provider and MDT • CQC issued NOP to deregister the manager and site 18th September 2017 • Service Suspended 10 October 2017 • Manchester City Council met with families on 3rd 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 2nd January 2018, currently awaiting outcomes
It is the opinion of the QPC team that they are not confident in the actions and improvements made by the provider since having been first inspected and despite weekly visits, support, and signposting from QPC, the provider has failed to make the desired long term improvements required to avoid a possible tribunal for the NOP to deregister
The Dell, Residential Care home Locality: Gorton Number of Beds: 40
Safe Effective Caring Responsive Well led
• CQC inspected The Dell on 14th September 2017 • At the time of the inspection the Management team were new to the service • Information was requested to demonstrate that residents were safe as this was not available at the time of the inspection • QPC completed a site visit along with Health and Safety (H&S) lead from Manchester City Council in September 2017 • SIP created with the new home manager • Reassurance on the H&S reports gained and immediate actions completed 28
• Provider fully engaged in the improvement plan • All actions completed and reassurance gained • Monitoring visits reduced to 6-8 weekly
Requiring improvement
There are currently 26 Care Homes across Manchester that have been rated as “Requires Improvement”
The QPC team are in the process of reviewing the 26 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 QPC team have carried out. Visits to the homes are prioritised in terms of risk and the RAG rating given, is captured on the QPC risk log. All of these homes are being monitored on a regular basis by the QPC team.
Recent inspection resulting in revised CQC rating
Viewpark – revised CQC rating January 2018 (Awaiting Outcome) Locality: Moston Number of Beds: 27
Safe Effective Caring Responsive Well led
• CQC re-inspected the Viewpark service week commencing 2nd January 2018 • Awaiting outcomes, no feedback so far
Clyde Court Locality: Didsbury Number of Beds: 41
Safe Effective Caring Responsive Well led
• CQC re-visited 27, 28 September and 4th October 2017 • Although some improvements where identified the home remains as “Requires Improvement” • Issues specifically around leadership, both clinical expertise and the ability to drive change • Difficult environment with the owners, on site daily, over riding and inputting to the homes daily operation, one being a registered nurse, one being an accountant • Lack of insight of the issues • Lack of response to improve issues • Owner has previously closed failing care home and sold for land values • QPC site visits • SIP developed with Manager and identifying MDT input requirements
Additional Care and Quality concerns
Yew Tree Manor CQC rating – Requires Improvement Locality: Northenden Number of Beds: 43 29
• 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
Next Steps MHCC QPC is in the process of developing a Quality Assurance Improvement Framework for Adult Social Care, the purpose of the framework will be to:
• Outline MHCC’s approach to quality and safety for adult social care • Set out the processes that MHCC PQI Team will follow to monitor, support and manage quality in residential and community social care provision, moving to performance and quality improvement assurance processes • Set out the reporting and accountability structures for adult social care provider management arrangements • Identify and embrace areas of good practice • Embed and develop an MDT team approach, including access to services and support, working collaboratively with the social care providers – MHCC health and social care performance & quality improvement team, commissioners, BI (Business intelligence) team, and draw upon our support options • Develop levels of support to providers, offering either intensive support, moderate support or minimal support. The levels will be identified as a result of a monitoring or site visit, CQC data or qualitative evidence, including complaints, safeguarding and whistle blowing concerns.
Intensive Support
• Establish MDT to the issues and concerns identified • Actions will be to create improvement plan, identified leads, engage with provider, consider formal suspension, notify via North West protocol • Weekly review of action plans and progress made • Visits increased in line with risk • Escalation or de-escalation of areas of concern • Inclusion of new actions • Facilitating and signposting to other support mechanisms • Establish training provision • Escalation to board
Moderate Support
• Increased ratio of visits • Action plan establishment and delivery agreed • Visits increased in line with risk • Escalation or de-escalation of areas of concern • Inclusion of new actions • Facilitating and signposting to other support mechanisms • Establish training provision if required • Escalation to board
Minimal Support 30
• Visits as determined by risk areas • Escalation of areas of concern following concurrent evidence review • Establishment of plan and inclusion of new actions as required • Facilitating and signposting to other support mechanisms as required • Establish training provision as required • Escalation to board as required
There is an ongoing programme of work to evaluate the adult social care QPC team roles, responsibilities, systems and process to support in the integration with MHCC PQI team. Part of this work is to seek to establish a consolidated health and social care contract to allow single commissioning format for adult social care providers. • Identify providers to implement concept April 2018 onwards • Initial input to new assurance process will be led by existing team members • Rollout programme established through 2018/19
Homecare
Homecare providers that “Require Improvements” receive a site visit from a contracts officer in the Quality Performance and Compliance (QPC) 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.
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3.2 Primary Care Improvement and Assurance Framework
Position update
The table below shows the current Care Quality Commission (CQC) inspection rating for all GP practices across Manchester:
Figure 1 above equates to:
• 4.3% of Manchester’ registered population supported by a CQC Outstanding practice (22,787* people) • 91.8% of Manchester’ registered population supported by a CQC Good practice (486,587 people) • 1.2% of Manchester’s registered population supported by a practice that is CQC Requiring Improvement (6,464 people) • 2.72% of Manchester’s registered population supported by a practice rated as CQC Inadequate (14,434 people)
The information below will give a brief overview for each of the practices rated as ‘Inadequate’ or ‘Requires Improvement’.
Wilmslow Road Medical Centre Neighbourhood: Hulme, Moss Side and Rusholme List size: 4823
Safe Effective Caring Responsive Well led
A CQC inspection took place at Wilmslow Road Medical Centre on 13 December 2017. The CQC report is awaited and members will be updated accordingly in due course.
Droylesden Road Family Practice (DRFP) Neighbourhood: Miles Platting, Newton Heath, City Centre & Moston List size: 4427
Safe Effective Caring Responsive Well led 32
In 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.
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 this date the contract was varied onto a neighbouring practice’s contract by mutual agreement in anticipation of a formal practice merger expected to take place in January 2018.
Requires Improvement
Artane Medical Centre Neighbourhood: Crumpsall & Cheetham List size: 2616
Safe Effective Caring Responsive Well led
PQI and Board 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 termination, a weekly coordination meeting has 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 the MHCC Executive Team and Board. GMH&SCP also has representation at this group.
The Neville Family Medical Centre Neighbourhood: Crumpsall & Cheetham List size: 3848
Safe Effective Caring Responsive Well led 33
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. A further update to PQI members will be submitted in due course.
Next steps
A small proportion of primary care investment fund (£250K) for 2017-18 has been set aside to support primary care resilience and transformation throughout 2017-18. The funds are being drawn upon to provide a level of contingency and support transitional arrangements where quality concerns have been identified.
The implementation of the Primary Care Quality Assurance and Improvement Framework, which is currently being finalised, will help the move towards a more proactive approach to help identify quality issues and offer a targeted programme of support.
Alongside this, MHCC is working with the CQC to improve communications and work towards establishing the new inspection structure.
3.3 Small Provider Updates
In the last report the PQI Team gave 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:
• African Caribbean mental health service (ACMHS) – mental health • Age UK - mental health • Alliance medical – MRI (Magnetic resonance imaging) • Creative support - mental health • Gaddum - mental health • Concordia - Dermatology • Beacon medical services group – deep vein thrombosis (DVT), endoscopy, minor surgery, ear, nose and throat
In addition for this month, the PQI team include Optegra which has recently been visited by Care Quality Commission (CQC) and received a rating of “requires improvement”.
The following gives an update on the issues and risks per provider.
ACHMS
It is clear that ACHMS took all advice and guidance into consideration and has provided a vastly improved submission. Therefore this provider will be stepped down from the “hotspot” report.
Age UK
This provider was asked to review/revise their quality submission as the original did not support compliance with quality requirements. Having received and reviewed the revised quality submission the PQI team deemed the service still required support particularly around the understanding the role of policies and procedures to support governance.
A meeting is being arranged between MHCC leads and the Age UK to find a mutual resolve and a collaborative way forward.
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Alliance medical
In the last report PQI relayed that there appeared to be a decrease in quality and KPI compliance from the service. In order to support discussion and plan improvements the Contract Review Meeting with the provider has been brought forward to 9/1/18. Further detail will be provided in the February board report.
Creative support & Gaddum
In the last report PQI advised that further information had been requested from these services in order to support quality requirements. Having received the detail and having met with both providers the PQI team are assured that they meet quality requirements. With this in mind these providers will be stepped down from this report.
Concordia
Concordia continue to adhere to the monitoring requirements within the Contract Performance Notice (CPN) and providing re-assurance to MHCC. Systems and processes implemented as a result of the Remedial Action Plan (RAP) should support the move from reassurance to assurance with visible signs of improvement.
A risk has been added to the MHCC performance and quality committee register with a rating of 12 to reflect the quality elements and improvements needed to reduce the risk.
There has been a decrease in performance for the following and detailed action plans have been requested from Concordia:
• 4 week wait from referral to telederm appointment • Clinics cancelled by Concordia • Complaints
Beacon medical services group
Following the last report, the service continues to meet deadlines for reporting and improvements are being observed. It has been suggested that if improvements continue the action plan will be closed at the contract review meeting in February 2018 at which point it will be removed from this report.
Optegra
This service provides cataract surgery for MHCC. The CQC undertook an inspection at Optegra Manchester eye hospital in July 2017. The CQC report published on 23 November 2017 confirms an overall rating of ‘requires improvement’ and rates each aspect of service as noted below:
• Safe - Requires improvement • Effective - Good • Caring- Good • Responsive - Good • Well-led - Requires improvement
The report highlighted concerns regarding medicines management including, insufficient information to support prescribing, use of unsigned patient group directives and not completing 35
competency assessments for nurse prescribers. A site visit is from MHCC’s medicines management team is being arranged.
In addition the report raised concern about patients walking from theatre following sedated. Optegra advised this ceased immediately on the day of the inspection.
A draft action has been submitted to CQC and a copy has been received by MHCC. The PQI team will monitor progress of the action plan and further updates will be relayed via the PQI committee and this exception report.
3.4 Contract and Planning round up
The PQI team is working to review the current quality and performance elements of contract schedules to ensure they are fit for 2018/19.
An overriding principle is to ensure provider contracts contain standardised quality and performance standards that are based on best practice. A list of changes to the quality schedules proposed for all contracts is in Appendix 1.
Leads have been allocated to each sector, an update against these sectors 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.
This working group has been expended to include adult social care (ASC) colleagues. The next step is to develop a number of high level ASC indicators that can be included in the LCO contract.
Small Providers
All contractual quality and performance schedules have been reviewed to ensure consistency across similar services e.g. endoscopy services.
There are minimal changes and negotiations are expected to be completed by the end of March 2018.
Mental health small providers
All contractual quality and performance schedules have been reviewed and there is further work required to align and negotiate these, working with the commissioning teams.
All work will be completed by March 2018.
Greater Manchester Mental Health
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. 36
All work will be completed by January 2018.
Single hospital services (MFT (formerly CMFT and UHSM) and PAHT))
MHCC will be working to add a small number of new quality and performance measures in line with local priorities these include children’s, maternity and children mental health services.
All work will be completed by January 2018.
3.5 Quality Premium (2017/18)
Quality Premium (QP) update (December 2017 - Manchester)
The information below provides an update on progress against the QP indicators for 2017 / 18.
Introduction
There are five national measures and in total these are worth 85% of the QP.
Indicator Theme Weighting
1 Early Cancer Diagnosis 17%
2 GP Access and Experience 17%
3 Continuing Healthcare 17%
4 Mental Health 17%
5 Bloodstream Infections 17%
CCGs also selected one local indicator which will be worth 15% of the QP. The indicator was selected from the Right Care suite of indicators – as set out in the Commissioning for Value packs, focussing on an area of unwarranted variation locally which offers the potential for CCGs to drive improvement.
NHS Constitution measures
As in previous years, a CCG may have its QP award reduced via the NHS constitution gateway. In 2017/18, some providers will have agreed bespoke trajectories as part of the delivery of the operation of the STF for the delivery of RTT, 4 hour A and E, 62 day Cancer waits and Red 1 Ambulance response times. On this basis, the CCG gateway test in respect of these measures will be adjusted to reflect these differential requirements.
NHS Constitution Requirement Reduction to Quality Premium Maximum 18 weeks from referral to treatment - Incomplete 25% (National standard 92%)
Maximum four hour waits in A&E departments (National 25% standard 95%) 37
Maximum 62 day wait from an urgent GP referral to first 25% definitive treatment for cancer (National standard 85%)
Maximum 8 minutes responses for Category A (Red 1) 25% ambulance calls (National standard 75%)
In keeping with the need to keep the QP and CCG assessment processes well aligned, it is important to ensure alignment between the payment of the QP and the NHS constitution gateway. Should the measures in the NHS Constitution be updated, as occurred with RTT, or expectations around the operation of the Sustainability and Transformation Fund change, NHSE may amend the above criteria in order to maintain alignment.
Overall, the QP payment could potentially equal £3 million.
Update Early Cancer Diagnosis
Indicator Target Current Period Performance
Cases of cancer diagnosed at stage 1 or 2 4% improvement on as a % of all new cases of cancer. 2016 calendar year Data not yet available
Key Actions
• Trying to improve uptake to national cancer screening programme – included in primary care standards for cancer • Lung health checks in North Manchester • Next year will see faecal immunochemical (FIT – this a newer, more effective bowel cancer check) test roll out across GM – bowel cancer
GP Access and Experience
Indicator Target Current Period Performance
Overall experience of making a GP 73.3% (3% appointment assessed through question 18 improvement on 2016 / Data not yet available of the GP patient survey. 17)
Key Actions
In relation to GP Appointments, MHCC has in place the Manchester Primary Care Neighbourhood Development Scheme 2017/18 which was rolled out from July 2017 and encompasses the Primary Care Standards.
88 out of 89 GP practices have signed up to deliver the standards this year which may help towards achievement of the QP indicators for Primary Care.
Primary Care Standard 1 – Improving access to General Practice sets out the following:
• Ensure patients are able to book routine, pre-bookable appointments until 8pm, 5 days per week; and at weekends. Note that: 38
Appointments outside core contractual hours are delivered via the neighbourhood model Appointments should be with the right person, right place; not always requiring GPs, using skill mix in the Practice including Pharmacists, nurse practitioners, etc. where appropriate • Improve the continuity of care for patients; where evidence suggests that this improves patient outcomes and experience; including those with long term conditions or complex needs. This should be done through the provision of pre-bookable, longer appointments were necessary, for those patients with complex needs • Ensure that any patient who is considered as having an urgent clinical need have same day access – which can be supported by the neighbourhood model • Ensure patients are able to book appointments and order repeat prescriptions online, as per the GP contract • Provide alternative modes of consultation, such as telephone consultations, online consultations, (e.g. SKYPE), group consultations etc. • Offer access to both male and female clinicians (note this does not have to be all 10 sessions, and can be delivered through the neighbourhood model) • Offer pre-bookable appointments 1 month in advance with a named clinician
Continuing Healthcare (CHC)
Indicator Target Current Period Performance Percentage of cases where NHS continuing healthcare 80% 17.5% Q1 2017 / (CHC) eligibility decision is made within 28 days from 18 receipt of CHC checklist Percentage of full comprehensive NHS CHC <15% Data not yet available assessments completed whilst the individual was in an acute hospital
Key Actions
• To arrange a meeting with the MFT (formerly CMFT and UHSM) site’s hospital discharge team (highest % of hospital MDT’s) to reaffirm. parameters of the JWA/discharge to assess (D2A) policy • To revise the parameters of the Joint Working Agreement (JWA) to extend the remit to out of area hospitals • To meet with hospital discharge MDT’s to reaffirm parameters of the JWA/discharge to assess (D2A) policy • To arrange a meeting with all CHC staff to impress upon them the need to use the D2A policy at every opportunity possible • To arrange a meeting with the discharge teams to agree that wherever possible the discharge team will contact the CHC team prior to any hospital checklist/MDT being arranged. This will allow for the D2A options to be assessed and used more often • MHCC are currently aligning all their actions within the plan to our overarching urgent care plan to which DTOC is included • To allocate to all CHC clinical staff a work based trajectory or target to help them achieve realistic numbers for full process consideration • To amend the way MHCC has been erroneously recording the completion date for the CHC process and as a result this has been negatively impacting on the time reported from checklist to decision made • Arrange and plan a number of meetings with the clinical staff to drive home the message about performance within framework timescales
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• To purchase and roll out to the CHC “Team Dragon” dictate (voice recognition software) to enable quicker typing of letters • To manage the inherited MDT backlog • To recruit substantive and additional staff • Where vacancies exist, temporary or agency staff will be used to facilitate full process assessments
Mental Health
Indicator Target Current Period Performance
Out of area placements (OAPs) for acute mental health Baseline and target yet to be agreed inpatient care (Number of bed days people sent inappropriately out of area as proportion of baseline 2016/17)
Key Actions
• GMMH continue to do all it can to repatriate patients back to Manchester. Bed occupancy levels remain high across the city and this impacts upon the number of OAPS • There is a dedicated work-stream looking at improving access to inpatient services and reducing the average length of stay in patient care. GMMH will continue to monitor use of inpatient beds across Manchester and length of stays over 150 days, to ensure flow through the system to create capacity • A review of all OAP patients is underway, led by a senior clinician to repatriate/discharge those OPA at the earliest opportunity • Further improvement work and redesign of the acute care pathway is underway, which includes expansion of community mental health team to operate on a 7-day basis and increasing capacity to deliver a 24/7 crisis response and home based treatment team – this will offer real alternatives to out of area admissions
Bloodstream Infections
Indicator Target Current Period Performance
Antibiotic prescribing for UTI (urinary tract infection) in 1.272 1.098 August primary care - ratio of trimethoprim to nitrofurantoin 2017 (rolling 12 mths)
Antibiotic prescribing for UTI in primary care - number of 8,757 8,232 August trimethoprim items prescribed to patients aged 70+ 2017 years (rolling 12 months)
Anti-microbial resistance - appropriate prescribing of 1.161 1.135 August antibiotics in primary care (items per STAR-PU) (Rolling 2017 12 months)
Key Actions 40
• Antimicrobial project lead technician and clinical pharmacist assigned to lead on antimicrobial strategy development and coordinate delivery. • E-coli Ambition working group set up at MHCC and meets monthly, Medicines Optimisation technician and pharmacist attend, with: Nursing Team Infection prevention and Control team, Commissioning – primary care Commissioning – care homes and domiciliary care GP infection control lead.
• Planned audits for antibiotic prescribing in UTIs • Baseline antibiotic audit planned for those practices who have received chief medical officer letters identifying them as top 10% or 20% antibiotic prescribers in the country • City-wide launch of Greater Manchester Medicines Management Group (GMMMG) antibiotic prescribing guidelines planned for practices via Medicines Optimisation team members and neighbourhood practice meetings. • Communications to practices to promote Target toolkit for prescribers. • Monitor progress with near-patient testing initiatives and support local implementation as and when appropriate. • Member of GM antimicrobial steering group for sharing of best practice across GM. • Monitor / review prescribing locally and provide feed-back to individual prescribers; (e.g. using commissioning Support Unit (CSU) Business Intelligence tool; NHS BSA Medicines Optimisation Key Therapeutic Topics (MOKTT) data.
Local indicator – Respiratory
Indicator Target Current Period Performance
Percentage of patients with Chronic Obstructive Pulmonary Disease (COPD) who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using 89.6% 35.6% Q1 2017 / 18 the Medical Research Council dyspnoea scale in the preceding 12 months (net of exceptions)
Key Actions
COPD annual reviews are covered by Primary Care Standard 6 – Improving outcomes for people with Long Term Conditions. This outlines that;
• Patients are to receive an annual review (a 30 minute appointment is recommended) which includes a review of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months • Practices are required to audit the quality of the reviews • A defined sample size will be agreed, to audit pre and post the patient review. The audit tool is the British Lung Foundation COPD Patient Passport questions • For monitoring, the target population is the practice COPD register and baseline performance from 2016/17 Standards • The local standard is additional to (and over and above) the quality and outcomes framework (QOF) requirements
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3.6 Winter Resilience
System Resilience – Christmas and New Year Performance
Significant effort went into developing the Christmas and New Year resilience plans that provided assurance on:-
• Staffing • Mobilization of additional winter schemes • Surge and escalation
The Christmas period was relatively stable across the city, but the New Year week was extremely challenging. Performance against the A and E 4 hour target was below expectations and staffing challenges compounded the problems associated with the rise in activity and acuity.
Daily system wide conference calls have been initiated, including weekends and additional support has been given to our hospital providers to ensure safe and effective discharges. The number of DTOCs continues to reduce and a focus on medically optimised patients has been a priority.
The acute hospitals have taken a pragmatic approach to reducing the elective program - outpatients, diagnostics and in-patients. This is being reviewed on a daily basis to ensure decisions are proportionate to the pressures experienced.
Flu has hit our hospital wards, but effective plans are in place to ensure cohorts are managed appropriately and MHCC’s resilience team continues to co-ordinate resilience across the city, with communication and escalation working effectively.
3.7 Quality Dashboard
The purpose of this section is to present to the Board an overview of the newly introduced Quality Dashboard for MFT (formerly CMFT and UHSM).
Each section below will describe what quality indicators MHCC are monitoring to provide a general picture of the quality agenda. Additionally, there are screenshots to illustrate how the Dashboard is presented.
The graphs represent current figures on the live dashboard.
Background
Historically, there has not been a Quality Dashboard in operation to monitor quality standards at our commissioned acute providers.
A dashboard has now been created and implemented to provide a helicopter view of the quality agenda at MFT (formerly CMFT and UHSM). This is a first draft of measures to be monitored and as Key Performance Indicators (KPIs) are agreed for the 2018/19 contract additional metrics will be incorporated into the dashboard. Therefore, it is worth noting that the Quality Dashboard is currently not the finished product, but an evolving document to ensure we capture the most appropriate and meaningful information.
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This dashboard will form the basis of a Performance, Quality and Improvement Dashboard that will monitor compliance with national standards and will in due course be rolled out across all our providers including mental health; primary care and the small providers.
The Quality Dashboard has eight sections, namely:
• Governance • Leadership • Safety • Maternity and Children • Patient Experience • Effectiveness • Safeguarding • Equality and Diversity The front view of the dashboard is illustrative, in the form of graphs and pie charts. This is to provide a visual representation of quality performance over time. There is narrative to support each section either where exceptions to targets are evident or to support good and best practice. The format of the dashboard is presented in colour coded banners to link each section’s graphical evidence and its description.
Only data from October 2017 is recorded as MFT (formerly CMFT and UHSM) however, in order to have a greater understanding of the quality standards across both sites prior to October 2017 information is recorded from MFT (formerly CMFT and UHSM). Once fully developed, this dashboard will be reported in full on a quarterly basis to committee and board.
Governance The Governance section illustrates the Care Quality Commission (CQC) rating for each domain of Safe; Caring; Responsive; Effective; Well Led and specific services last inspected.
The narrative provides qualitative information of the action plan including the progress made to deliver the ‘must do’ and ‘should do’ actions, as recommended by the CQC, to deliver demonstrable improvements.
CQC ratings
Leadership The Leadership section provides information gleaned from the staff survey and Friends and Family Test (FFT) for staff. The graphs illustrate the percentage of staff that would and would not recommend their organisation to family and friends for care/ treatment and as a place to work.
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Friends and family test
NB- typing error from the national database- UHSM 2nd graph is recommendation as a place to work not care/ treatment
There have been no explicit training KPIs in the 2017/18 contract and therefore MHCC currently do not monitor compliance with mandatory training for example. However, negotiations are taking place to monitor safeguarding and Infection Control and Prevention training for 2018/19. We expect these to be agreed and data will therefore be monitored on the dashboard from April 2018.
Staff sickness rates are being observed on the dashboard and where targets aren’t met narrative is given to add context to the work being done by MFT (formerly CMFT and UHSM) to reduce staff absence.
Sickness absence
Safety The safety section is the biggest section, in terms of graphical illustrations and qualitative description of exceptions and it covers the following subject areas: • Staffing- Registered Nurses and support workers • Medicines Management • Patient Safety incidents including all levels of harm and serious incidents • Harm free care including falls; pressure ulcers; Venous Thromboembolic disease (VTE); Urinary Tract Infections (UTI) in patients with indwelling urinary catheters • Summary Hospital-level Mortality Indicator (SHMI)
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As the dashboard progresses further safety data around safer staffing is anticipated such as, medical staffing rates; use of locum and agency staff; recruitment and retention figures and strategies; gap analysis and action planning.
Additionally, the internal ward accreditation status of all eligible clinical areas will be incorporated into the safety domain of the dashboard.
Staffing
Medicines Management
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Patient Safety Incidents
Serious Incidents
Harm free care
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Maternity and children As the highest litigation area in the NHS, in terms of financial cost, it is prudent for MHCC to monitor quality within Maternity Services.
The Maternity section will monitor data from the National Safety Thermometer and the Maternity Services Data Set. Specific measures include the proportion of: • Methods of delivery • Women with infection • Women that have 3rd and 4th degree trauma • Women that have Post-Partum Haemorrhage (PPH) >1,000mls • Term babies with an Apgar score of <7 at 5 minutes • Women and babies that receive harm free care
2018/19 Maternity KPIs are currently being negotiated to support the Maternity Safer Care ambition to reduce stillbirths; neonatal deaths and hypoxic brain injuries by 50% by 2025. The suggested KPIs that we intend to monitor are listed below: • Breastfeeding rates at birth • Breastfeeding rates at 6-8 weeks • Skin to skin contact at birth (directly impacts success of breastfeeding) • One to one care in labour • Stillbirth rates • Neonatal death rates
Method of Delivery
Maternal Infection/ 3rd & 4th degree trauma/ PPH
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Apgar scores / harm free care
Children’s services data is extracted from the National Safety Thermometer which monitors the incidents of pressure ulcers and the Early Warning Score of clinical observations, such as blood pressure; temperature and pulse. Only the MFT (formerly CMFT) site reports children’s data to NHS Digital.
The newly agreed Children’s KPIs for 2018/19 will include health assessments and immunisation compliance of looked after children (LAC) in Manchester city.
An additional 2018/19 KPI for the monitoring of children’s referral to treatment (RTT) has been agreed and this will be monitored through the performance dashboard.
The potential KPIs under negotiation include: • The number of new children receiving treatment from NHS funded community mental health services • The proportion of children with a diagnosable mental health condition receiving treatment from NHS funded community mental health services • The proportion of children with eating disorders (routine) that wait 4 weeks or less from referral to the start of NICE approved treatment • The proportion of children with eating disorders (urgent) that wait 1 week or less from referral to the start of NICE approved treatment
Patient Experience 3. The patient experience segment will monitor information from the friends and family test including patients that would or would not recommend MFT (formerly CMFT and UHSM) inpatient; A and E and Maternity services to friends and family. Additional information and narrative will be taken from the Trust Annual Patient Experience Report; the Quality walk round programme; patient and carer surveys and the annual cancer survey.
Further development and input from the Patient Public Advisory Group (PPAG) is required to ensure we capture the appropriate intelligence regarding patience experiences of MFT (formerly CMFT and UHSM). 48
Effectiveness
The effectiveness sector is currently being developed. The indicators for next year have not yet been agreed. However, this section will likely hold data for national and local clinical audit, including Sepsis, acute kidney injury (AKI), chronic obstructive pulmonary disease (COPD), acute myocardial infection (AMI), pneumonia; complaints; litigation claims and Medical Outliers.
Safeguarding
This section is also in development. The aim is to monitor safeguarding training compliance, through 2018/19 KPIs, of Adult and Children’s Safeguarding levels 1; 2 and 3 for appropriate staff. This means that staff working in clerical and administration roles would only be required to complete safeguarding of adults level 1, whereas staff working in Accident and Emergency and Maternity would need Safeguarding Adults and Children levels 1 and 2 as a minimum. Similarly those staff working specifically in safeguarding would be expected to undertake and comply with the highest level of training.
There a number of aspirational indicators that the safeguarding team at MHCC and Trafford CCG would like to observe within the Quality Dashboard. There is no explicit date set as yet for the inclusion of them as some additional work will be required to support MFT (formerly CMFT and UHSM). These are:
• Domestic Violence and Abuse Training compliance • Proportion of admitted patients with Learning Disabilities that are reconciled with their care passport (emergency <24 hours & elective <12 hours) • Proportion of safeguarding referrals made directly from source to the Local Authority (not via internal Safeguarding Team) • Audit of all Do Not Resuscitate (DNR) orders- to demonstrate compliance with consideration for mental capacity assessment and best interests meetings • Proportion of eligible serious incident RCA reports reviewed by a safeguarding professional • Proportion of media worthy serious incidents referred to safeguarding
Equality and Diversity
The Equality and Diversity tab is currently in development. Initial indicators for next year have been agreed. The Workforce Race Equality System (WRES) and Workforce Disability Equality System (WDES) only publish data on an annual basis nationally and this means that some information will only be inputted from April 2018.
The agreed indicators are as follows: • The proportion of the MFT (formerly CMFT and UHSM) workforce by ethnicity; gender and disability • EDHR training compliance • The proportion of patients that access services at MF (formerly CMFT and UHSM) from Black, Asian and minority ethnic (BAME) backgrounds • The proportion of patients from BAME backgrounds that do not attend appointments etc.
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PAHT Quality Update
Never Events
Definition
Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers.
Issues
There have been three Never Events on the North Manchester General Hospital site. These did not affect Manchester patients. There were three wrong site surgeries and a retained foreign object post-procedure.
Key actions taken/planned
MHCC will be undertaking a walk-round of the surgical areas to gain assurance around compliance with the World Health Organisation safer surgery checklist and to review improvements that have been put in place to ensure that these do not occur again.
Mixed sex accommodation breaches
Definition
National reporting of unjustified mixing (i.e. breaches) in relation to sleeping accommodation commenced on 1 February 2010 “Sleeping accommodation” includes areas where patients are admitted and cared for on beds or trolleys, even where they do not stay overnight. It therefore includes all admissions and assessment units (including clinical decision units), plus day surgery and endoscopy units.
Issues
There were 20 breaches in October. These breaches were all step down from critical care beds at NGMH and were caused because of pressures on the hospital resulting in problems with patient flow.
Key actions taken/planned
Work to improve flow continue and are described in detail previously in this paper.
Risks
While there is pressure on the hospital the breaches in mixed sex accommodation are likely to keep happening.
Venous thromboembolism (VTE) Definition
Venous thromboembolism (VTE) is a condition where a blood clot forms in a vein. This is most common in a leg vein, where it's known as deep vein thrombosis (DVT). A blood clot in the lungs is called pulmonary embolism (PE).
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Issues
The provider is below the target for VTE risk assessments. Failure to have processes in place to adequately assess patient’s risk of VTE and treat appropriately can lead to the development of either a DVT or PE, putting the patient at risk of significant harm.
Key actions taken/planned
PAHT have a VTE Committee in place. An update on the work of this Committee was presented at the Clinical Quality Leads (CQL) meeting with the North East Sector CCGs. The Trust currently has a manual processes for capturing VTE assessments. There is a newly developed online assessment form. The forms have been piloted on ward F11 and during the period of testing VTE assessments were 100%. Unfortunately these have not been able to be rolled out throughout the Trust due prolonged IT issues. It was noted that IT issues are unlikely to be resolved by April 2018. Currently until the IT issues are resolved the Trust has not updated its VTE policy and or forms being used by medics. The IT risks are significant and on the corporate risk register but will take time to resolve. The risk rating is at the same level as workforce.
This issue has been escalated as a concern by CQL to the contract meeting. There are still issues in relation to reporting KPI’s in the contract performance report, this is still outstanding. Sharing of the minutes of the VTE committee would be used to provide assurance on Root Cause Analyses learning.
It was agreed that a project improvement plan will be developed and a further update be provided at the CQL meeting in December. Further the KPI requirements in the contract would be shared with PAHT to ensure that these are all complied with.
Risks
There have been serious incidents in relation to VTE and there is a risk that there will be more until the Trust has robust procedures in place to risk assess and treat patients at risk.
Medicines key performance indicators Definition
Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital.
Issues
There are two KPIs in the contract with PAHT in relation to medicines reconciliation. One requires that for intensive care units and high dependency units medicines are reconciled within 24 hours, for all other areas this target is 72 hours. The Trust has missed both targets for three consecutive quarters.
Key actions taken/planned
Tracking of medicines reconciliation continues via the Electronic Prescribing and Medicines Administration (EPMA) systems but remains a challenge due to the capacity of the clinical pharmacy team. Business cases have been developed on each site to expand the current levels of pharmacy provision and await approval. It is anticipated that delivery of this indicator 51 will remain extremely challenging until the business cases are approved and positions recruited to.
Nutrition and Hydration key performance indicators Definition
Good management of nutrition and hydration aids patient recovery and safeguards those at risk of malnutrition.
Issues
There are a number of KPIs in the contract that relate to nutritional assessment, referral of high risk patients to a dietician and having a care plan in place where needed. Earlier in the year the electronic system that was capturing the data in relation to these KPIs was turned off while a new system was introduced. This has resulted in absences in reporting, under-reporting and use of alternative monitoring methods such as local audits. This is still not fully resolved.
Key actions taken/planned
PAHT have reinstated the Nutrition Steering Group which will review the KPI data alongside information from the Nursing Accreditation Assessment Score on each ward which includes, dietetic response time and the nutrition and hydration domain which gives a view across the inpatient wards at NMGH and meal time audits which are undertaken monthly focusing on one ward per month and involves assessment of fluid balances and nutritional needs.
There is still manual collection of data undertaken. PAHT have provided some data on a site specific basis and data collection and quality is improving. MHCC met monthly with the Director of Nursing for North Care Organisation and the Associate Director of Governance to ensure oversight of this issue, this is also monitored through the walk round process.
Complaints Definition
Good quality complaints handling is vital to ensuring continuous improvement in the quality and safety of care at NHS organisations. It provides a tangible and measurable reflection of the organisation's commitment to an open and responsive safety culture.
Issues
Managing complaints in line with the timescale as agreed with the patient has been a KPI which has been underperforming against the target this year. A trajectory for improvement was agreed with the Trust. The percentage of complaints responded to within timescales has slightly decreased from last month, and continues to be lower than the agreed trajectory.
Key actions taken/planned
Complaints are closely monitored by PAHT and reported back to the Divisional Teams on a weekly basis. The Head of Complaints and PALs are progressing a comprehensive improvement plan for the department and liaising with Care Organisation leaders. Whilst the Trust is reporting compliance figures which are below the trajectory targets, generally, improvements are incrementally tracking the trajectory. Work continues with the Care Organisations to deliver improved compliance. Care Organisations have appointed to their 52 leadership structures with an emphasis on managers being involved in the timely resolution of complaints.
Timescales for delivery
It is unlikely that the Trust will be able to meet their current trajectory and there are on-going discussions about developing a revised trajectory for this indicator.
The Salford Royal Foundation Trust (SRFT) and CQC Improvement Plan for Pennine Acute Hospitals NHS Trust
The Improvement Plan Focus remains on addressing those projects rated amber which requires constant leadership attention. For the fragile services this can be summarised as:
• Emergency Department (ED)/Acute Medical Unit (AMU) capacity to meet demand • The delivery of reliable ED pathways • Paediatric bed capacity to meet demand. The underlying root cause to these challenges remains the recruitment of medical and nurse staffing. The absence of permanent staffing is creating variation in both performance against access standards and the delivery of reliable care.
Flow projects also remain amber rated and the Quality Improvement leads across all sites are working closely with their Care Organisation teams to drive forward improvements using Quality Improvement methodology.
Workforce elements of the plan remain either amber red or red rated and all mitigating actions continue to be taken to ensure no breaches of safety standards. Nursing and midwifery numbers have increased in Sept/October and focus remains on retention efforts to ensure these gains are not lost over the coming months.
The Maternity and Paediatric sub group of the Improvement Board has now been stepped down with monitoring of maternity and paediatric services moving back into business as usual. No issues of immediate concern were identified through the CQC revisit of the services. Centralised CTG scanning is now in place.
CQC Re-Inspection
The Trust and all Care Organisations have now participated in two ‘core services’ unannounced hospital inspections. A separate well-led review is underway and feedback from both inspection teams, along with data requested will be collated by the CQC resulting in a final rating review meeting anticipated for the 11th January 2018. The Trust will receive the draft report shortly after this date to review for factual accuracy and final ratings published thereafter.
To date the inspection team have not raised any immediate safety concerns that they would wish to bring to the attention of the executive team.
Information Management and Technology Infrastructure (IM and T) During April – June 2016 Salford undertook a diagnostic to discover the key issues and risks that had led to the CQC early findings and performance issues of PAHT. This diagnostic included a high level review of data systems. The review of data systems indicated significant issues and risks about the stability and suitability of the PAHT IT infrastructure. Further reviews supplemented by external advisors revealed more risks, remedial action plans were developed and funding identified for this. 53
The key risk themes are:
• Poor performance of key IM and T infrastructure and applications • Threats to the availability of IM and T infrastructure and applications • Functional issues of key clinicians applications • Threats to the delivery of new clinical IM and T requirements • The Cyber threat.
There are currently 4 IM and T entries on the Salford/PAHT Board Assurance Framework, all scoring 12 (red):
• Timely accessible and reliable retrieval of clinical notes from Evolve • The Cyber threat • Failure to achieve a coherent range of IM and T clinical systems • Investment in end of life, end of contract and unfit for purpose IM and T infrastructure.
Recent IM and T infrastructure challenges have led to clinical incident reports. Issues with record retrieval from within Evolve reflect Health Records challenges that have resulted from loss of Records Management capacity and rigor following deployment.
There are plans in place to address all the risks that have been identified and a group overseeing the plans to address these risks. Lack of robust IM and T infrastructure will have an impact on the provider’s ability to report against KPI and has resulted in clinical incidents. This will continue to be monitored closely.
4.0 Recommendations
The Board is asked to support the actions being undertaken to improve the quality and performance for the population of Manchester.
54 APPENDIX A: 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% Percentage of patients who spent 4 hours or less in A&E 88.6% 90.2% 95.0% 21,293 22,826 21,250 22,809 20,690 21,406 24,112 22,802 23,444 24,919 23,489 24,889 22,841 23,853 26,955 25,995 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% Diagnostic Waiting Times % waiting > 6 weeks 2.8% 2.4% 1.0% 146 234 276 195 409 260 178 8,786 9,794 10,121 9,900 9,891 10,310 11,202 72.3% 72.0% 69.7% 72.5% 72.9% 79.0% Utilisation of the NHS e-Referral Service to enable choice at first 81.7% 73.0% 86.0% 6,530 7,439 7,579 7,562 7,794 7,718 routine elective referral 9,033 10,332 10,874 10,435 10,697 9,774 91.3% 91.4% 91.5% 91.1% 90.4% 90.9% 91.1% RTT: Incomplete pathways % within 18 weeks 91.8% 91.1% 92.0% 32,272 32,906 33,701 34,240 34,264 33,965 33,594 35,341 36,006 36,847 37,579 37,909 37,347 36,861
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 15 0 5 4 2 0 0 2 2
2016/17 2017/18 Indicator Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4 2017/18 Value Value Percentage of children waiting less than 18 weeks for a wheelchair 90.5% 86.1% 83.8% 87.9%
55 62 80 74 91 86.7% 90.2% Percentage of children & young people with eating disorders (routine 88.7% 26 37 cases) that wait 4 weeks or less (rolling 6 mths) 30 41 100.0% 75.0% Percentage of children & young people with eating disorders (urgent 80.0% 2 6 cases) that wait 1 week or less (rolling 6 mths) 2 8
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% M 55 63 51 57 56 77 71 64 85 67 75 67 94 91 Cancer 62 day waits following urgent GP referral 83.9% 80.0% 85.0% 78.7% 81.3% Q 174 191 221 235 92.2% 94.0% 93.1% 92.7% 90.8% 91.9% 94.5% M 1,127 1,372 1,439 1,319 1,384 1,302 1,482 1,223 1,460 1,546 1,423 1,525 1,417 1,569 Cancer two week waits (urgent referrals) 94.5% 92.8% 93.0% 93.8% 91.8% Q 3,980 4,001 4,241 4,360 90.7% 92.4% 94.5% 94.8% 94.7% 97.5% 96.4% M 196 194 208 200 216 199 187 216 210 220 211 228 204 194 Cancer two week waits for breast symptoms 90.7% 94.9% 93.0% 94.2% 95.6% Q 604 615 641 643 100.0% 100.0% 97.2% 99.3% 98.6% 98.4% 100.0% Cancer 31 day waits for first definitive treatment (All cancers) 98.5% 98.9% 96.0% M 131 165 140 134 142 186 157
56 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 131 165 144 135 144 189 157 99.1% 98.7% Q 444 467 448 473 92.6% 100.0% 100.0% 100.0% 100.0% 96.6% 100.0% M 25 31 24 26 27 28 28 27 31 24 26 27 29 28 Cancer 31 day waits for subsequent treatment (Surgery) 97.8% 98.8% 94.0% 98.8% 98.8% Q 82 84 83 85 100.0% 100.0% 97.4% 100.0% 100.0% 100.0% 100.0% M 24 36 37 32 42 32 35 24 36 38 32 42 32 35 Cancer 31 day waits for subsequent treatment (Drugs) 99.5% 99.5% 98.0% 99.0% 100.0% Q 98 108 99 108 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% M 31 47 43 54 57 40 50 31 47 43 54 57 40 50 Cancer 31 day waits for subsequent treatment (Radiotherapy) 100.0% 100.0% 94.0% 100.0% 100.0% Q 121 152 121 152 100.0% 81.8% 88.9% 100.0% 100.0% 83.3% 100.0% M 11 9 8 5 8 5 6 11 11 9 5 8 6 6 Cancer 62 day waits following referral from NHS screening service 92.9% 93.9% 90.0% 93.3% 94.7% Q 28 18 30 19 Cancer 62 day waits following consultant decision to upgrade 87.1% 90.8% 85.0% M 83.3% 95.5% 83.3% 93.8% 96.2% 91.3% 91.7%
57 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 15 21 20 15 25 21 22 18 22 24 16 26 23 24 87.5% 93.9% Q 56 62 64 66
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 83 127 11 13 8 9 15 16 11 Incidence of MRSA - Total Attributed 13 8 0 1 2 3 0 0 1 1 Incidence of MRSA - CCG Assigned 9 1 0 0 0 0 0 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% Dementia diagnosis rate (aged 65+) 83.2% 75.7% 67% 2,765 2,790 2,806 2,795 2,815 2,815 2,788 3,667.4 3,675.8 3,675.9 3,684.9 3,681 3,682.3 3,682.3 88% 64% 76% 53% 57% 55% 73% First episode of psychosis or ARMS (at risk mental state) treated 83% 66% 50% 14 14 16 10 12 16 19 with a NICE approved care package within two weeks of referral 16 22 21 19 21 29 26
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% 6.10% 1.40% 1.10% 1.33% 0.89% 1.52% 1.26%
58 IAPT Roll-out - number receiving therapy 12280 5390 975 1175 785 1345 1110 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% IAPT Recovery rate 36.6% 37.4% 125 240 165 200 200 420 565 510 470 520 59.1% 59.3% 56.6% 69.7% 62.4% IAPT Waiting times (6 weeks) 56.0% 61.3% 260 350 300 345 340 440 590 530 495 545 90.9% 90.7% 89.6% 94.9% 93.6% IAPT Waiting times (18 weeks) 85.0% 91.9% 400 535 475 470 510 440 590 530 495 545
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 49.70 49.27 54.02 51.86 51.86 51.86 51.86 51.86 49.70 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 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 70 75 70 70 70 70 70 70 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 22.6% 5.7% 7.8% 5.7% Number of individual children and young people aged 0-18 receiving 2800 700 700 treatment
59 Prevalence - total number of individual children and young people 12364 12364 12364 12364 12364 12364 aged 0-18 with a diagnosable mental health condition Number of new children and young people aged 0-18 receiving treatment from NHS funded community services in the reporting 1390 395 420 395 period.
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 98.0 18.0 18.0
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
60 APPENDIX B - 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 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Value Value 2017/18 2017/18 2017/18 2017/18 93.3% 92.2% 89.1% 93.7% 92.0% 90.9% 89.8% 88.4%
Percentage of patients who spent 4 hours or less in A&E 90.2% 92.5% 90.8% 92.4% 92.5% 92.5% 90.8% 90.8% 90.4% 91.8% 90.8% (STF) 95,105 92,463 62,413 32,523 29,432 30,508 32,081 30,332 101,942 100,234 70,058 34,693 31,978 33,563 35,744 34,314 93.3% 92.8% 91.8% 93.4% 93.1% 92.8% 92.3% 91.8%
Percentage of patients who spent 4 hours or less in A&E 90.2% 91.3% 91.2% 90.8% 91.1% 91.3% 91.2% 91.2% 90.4% 91.8% 91.2% - Cumulative performance 95,105 187,568 249,981 127,628 157,060 187,568 219,649 249,981 101,942 202,176 272,234 136,635 168,613 202,176 237,920 272,234
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.2% 94.3% 94.7% 93.7% 94.1% 95.0% 94.6% 94.7% Ambulance: Compliance with recording patient handover 92.2% 94.4% 90.0% 90.0% 13,252 13,832 14,293 4,603 4,641 4,588 4,823 4,689 14,066 14,672 15,098 4,910 4,934 4,828 5,101 4,953
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 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 Ambulance Handover Delays over 30 Minutes 4506 2759 0 0 507 689 1563 164 252 273 347 407 Ambulance Handover Delays over 1 Hour 1363 569 0 0 71 88 410 15 36 37 59 89 Ambulance Handover Delays over 2 Hours 232 77 0 0 7 1 69 0 1 0 10 12 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0
61
Elective
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.2% 93.6% 94.8% 92.0% 94.0% 96.2% Cancer two week waits (urgent referrals) 95.0% 93.9% 93.0% 93.0% 5,530 5,693 1,894 1,997 1,820 2,024 5,873 6,085 1,997 2,171 1,936 2,103 92.8% 95.5% 94.6% 95.8% 96.2% 95.1% Cancer two week waits for breast symptoms 93.8% 94.1% 93.0% 93.0% 953 972 348 322 304 294 1,027 1,018 368 336 316 309 98.7% 97.9% 96.8% 98.6% 97.8% 98.2% Cancer 31 day waits for first definitive treatment (All 98.2% 98.3% 96.0% 96.0% 943 957 298 344 317 319 cancers) 955 978 308 349 324 325 97.4% 98.6% 98.9% 97.5% 99.0% 97.3% Cancer 31 day waits for subsequent treatment (Surgery) 97.8% 98.0% 94.0% 94.0% 223 276 94 78 97 73 229 280 95 80 98 75 100.0% 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 13 31 31 37 63 71 13 31 31 37 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 (Radiotherapy) 0 0 0 0 0 0 84.0% 84.9% 80.4% 91.1% 83.3% 91.5% Cancer 62 day waits following urgent GP referral 86.5% 84.5% 85.0% 85.0% 310 313 100.5 108 104.5 113 369 368.5 125 118.5 125.5 123.5 94.6% 98.8% 93.9% 98.6% 97.4% 89.7% Cancer 62 day waits following referral from NHS 95.0% 96.5% 90.0% 90.0% 105 85.5 31 35.5 19 26 screening service 111 86.5 33 36 19.5 29
Cancer 62 day waits following consultant decision to 89.0% 89.3% 89.8% 90.3% 88.0% 95.2% 90.4% 89.2% 85.0% 85.0% upgrade 154.5 163 44 60.5 58.5 60
62 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 173.5 182.5 49 67 66.5 63 2.8% 3.4% 2.2% 2.2% 4.6% 3.5% 2.2% 2.2% Diagnostic Waiting Times % waiting > 6 weeks 3.1% 2.9% 1.0% 1.0% 1,371 1,666 742 373 748 545 367 375 49,754 48,620 33,585 16,750 16,185 15,685 16,770 16,815 75.7% 75.8% 77.2% 76.0% 74.9% 76.6% 77.2% RTT: Admitted pathways % within 18 weeks 74.3% 76.0% 8,628 9,603 3,495 3,211 3,217 3,175 3,495 11,394 12,663 4,525 4,223 4,296 4,144 4,525 90.2% 89.5% 89.7% 90.0% 90.0% 88.7% 89.7% RTT: Non-Admitted pathways % within 18 weeks 89.0% 89.9% 52,873 53,869 19,280 18,064 17,833 17,972 19,280 58,600 60,161 21,492 20,080 19,821 20,260 21,492 90.5% 90.5% 90.3% 90.0% 90.5% 90.6% RTT: Incomplete pathways % within 18 weeks (NHS 90.9% 92.0% 92.0% 66,051 65,706 66,399 66,177 65,706 65,330 Constitution) 73,017 72,627 73,569 73,502 72,627 72,143 0.7% 0.7% 0.8% 0.7% 0.8% 0.7% 0.8% Percentage of patients waiting more than 36 weeks on 1.0% 0.7% 1.0% 1.0% 1,529 1,639 555 533 590 516 555 incomplete pathways 213,897 219,698 72,143 73,569 73,502 72,627 72,143 1.2% 0.9% 1.6% 1.1% 0.8% 0.8% 1.5% 1.6% Percentage of cancelled elective operations that are 1.3% 1.2% 0.8% 0.8% 467 371 459 149 113 109 221 238 cancelled at the last minute for non-clinical reasons 38,502 40,747 29,298 13,520 13,834 13,393 14,399 14,899
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 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 95 0 0 45 34 16 10 11 13 16 pathways Cancelled elective operations - breaches of 28 day 72 76 0 0 47 25 4 11 7 7 4 standard
63 Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 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 4 0 0 4 0 0 0 0 0 0 0 Overall number of MRSA bacteraemia - Non-attributable 10 3 0 0 2 1 0 1 0 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 27 22 105 70 12 6 4 3 1 2 3 1 CDiff infections - Overall number of cases (NHS Patients) 118 87 31 37 19 14 11 12 7 12
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.9% 97.7% 97.1% 97.9% 98.0% 97.2% 97.2% 97.0% Percentage of patients receiving harm free care 96.2% 96.9% 95.0% 95.0% 6,492 6,537 4,386 2,186 2,203 2,148 2,170 2,216 6,770 6,694 4,517 2,234 2,249 2,211 2,233 2,284 0.37% 0.64% 0.35% 0.45% 0.62% 0.86% 0.31% 0.39% Percentage of adult VTE Incidences that occurred whilst 0.47% 0.47% 0.25% 0.25% 25 43 16 10 14 19 7 9 receiving care from the provider 6,770 6,694 4,517 2,234 2,249 2,211 2,233 2,284 0.53% 0.21% 0.29% 0.31% 0.18% 0.14% 0.31% 0.26% Percentage of pressure ulcer incidences that occurred 0.55% 0.35% 1.00% 1.00% 36 14 13 7 4 3 7 6 whilst receiving care from the provider 6,770 6,694 4,517 2,234 2,249 2,211 2,233 2,284 0.31% 0.49% 0.91% 0.58% 0.31% 0.59% 0.76% 1.05% Percentage of falls incidences that occurred whilst 0.18% 0.53% 1.00% 1.00% 21 33 41 13 7 13 17 24 receiving care from the provider 6,770 6,694 4,517 2,234 2,249 2,211 2,233 2,284 0.22% 0.15% 0.35% 0.09% 0.09% 0.27% 0.27% 0.44% Percentage of catheter acquired UTIs incidences that 0.19% 0.23% 0.25% 0.25% 15 10 16 2 2 6 6 10 occurred whilst receiving care from the provider 6,770 6,694 4,517 2,234 2,249 2,211 2,233 2,284 4.2% NHS staff sickness absence rate 4.7% 4.2% 65,540 1,573,086 88.8% 85.9% 87.8% 85.0% 85.2% Safe Staffing - Day Nurse Staff Fill Rate % 88.8% 87.3% 479,910 476,454 149,331 164,860 162,263
64 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 540,414 554,570 170,101 194,011 190,458 97.1% 95.3% 99.6% 92.7% 94.4% Safe Staffing - Day Care Staff Fill Rate % 97.7% 96.2% 237,338 240,762 74,184 83,979 82,599 244,369 252,578 74,519 90,568 87,491 91.4% 88.9% 91.4% 87.4% 88.1% Safe Staffing - Day Staff (Overall) Fill Rate % 91.6% 90.1% 717,248 717,215 223,515 248,838 244,862 784,783 807,147 244,619 284,579 277,949 89.9% 88.1% 86.4% 88.7% 89.7% Safe Staffing - Night Nurse Staff Fill Rate % 92.9% 89.0% 392,966 396,335 156,773 121,145 118,417 436,925 450,057 181,397 136,575 132,085 101.0% 100.9% 96.7% 103.8% 104.3% Safe Staffing - Night Care Staff Fill Rate % 109.6% 101.0% 179,824 188,037 76,868 55,671 55,498 178,038 186,305 79,471 53,613 53,221 93.1% 91.8% 89.6% 93.0% 93.9% Safe Staffing - Night Staff (Overall) Fill Rate % 97.6% 92.5% 572,790 584,370 233,640 176,816 173,914 614,963 636,361 260,867 190,188 185,306
Healthcare Worker Flu vaccination uptake (October to 46.1% 75.0% February surveys)
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 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
65 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 45.6% 53.6% 56.6% 52.2% 56.9% 51.4% 53.7% 60.0% Percentage of complaints responded to within timescale 47.8% 51.6% 90.0% 90.0% 178 209 172 59 78 72 88 84 390 390 304 113 137 140 164 140 97.1% 99.5% 92.1% 98.6% 100.0% 100.0% 93.3% 90.9% Percentage of complaints acknowledged in 3 working 96.5% 96.6% 339 425 303 144 154 127 154 149 days of day following receipt of complaint 349 427 329 146 154 127 165 164 5.7% 5.6% 6.3% 7.1% 4.7% 5.3% 6.3% FFT - A&E % not recommend 7.1% 5.7% 601 615 281 204 195 216 281 10,607 11,048 4,474 2,877 4,118 4,053 4,474 89.3% 90.0% 85.0% 87.9% 90.8% 90.7% 85.0% FFT - A&E % recommend 87.3% 88.9% 9,474 9,946 3,805 2,530 3,739 3,677 3,805 10,607 11,048 4,474 2,877 4,118 4,053 4,474 14.1% 15.2% 18.0% 11.2% 17.5% 17.1% 18.0% FFT - A&E response rate 9.4% 15.1% 10,607 11,048 4,474 2,877 4,118 4,053 4,474 75,406 72,803 24,817 25,587 23,512 23,704 24,817 1.0% 1.3% 1.3% 1.1% 1.5% 1.3% 1.3% FFT - Inpatient % not recommend 1.1% 1.2% 167 228 71 63 91 74 71 17,009 17,164 5,615 5,610 6,062 5,492 5,615 96.7% 96.5% 96.5% 96.8% 96.3% 96.4% 96.5% FFT - Inpatient % recommend 95.8% 96.6% 16,447 16,565 5,420 5,430 5,840 5,295 5,420 17,009 17,164 5,615 5,610 6,062 5,492 5,615 0.0% 2.2% 1.5% 3.6% 0.0% 1.7% 1.5% FFT - Maternity % not recommend 0.4% 1.5% 0 5 3 3 0 2 3 120 231 199 83 32 116 199 100.0% 97.4% 97.5% 96.4% 100.0% 97.4% 97.5% FFT - Maternity % recommend 97.6% 98.0% 120 225 194 80 32 113 194 120 231 199 83 32 116 199 4.8% 6.8% 17.3% 7.2% 2.9% 10.2% 17.3% FFT - Maternity response rate 7.3% 7.5% 158 231 199 83 32 116 199
66 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3,315 3,406 1,150 1,160 1,110 1,136 1,150
67 APPENDIX C: 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value 2017/18 2017/18 2017/18 2017/18 93.57% 93.30% 90.30% 93.39% 94.66% 92.93% 92.26% 90.30%
Percentage of patients who spent 4 hours or less in A&E 90.25% 92.98% 91.07% 90.25% 92.98% 92.98% 92.98% 91.07% 91.07% 91.99% 92.96% 91.07% (STF) 71,969 70,043 24,331 23,175 24,518 22,151 23,374 24,331 76,915 75,071 26,945 24,814 25,900 23,835 25,336 26,945 93.57% 93.44% 92.96% 93.57% 93.85% 93.67% 93.44% 92.96%
Percentage of patients who spent 4 hours or less in A&E 90.25% 91.61% 91.53% 90.25% 90.93% 91.33% 91.61% 91.53% 91.47% 91.99% 92.96% 91.53% (STF) - Cumulative performance 71,969 142,012 166,343 71,969 96,487 118,638 142,012 166,343 76,915 151,986 178,931 76,915 102,815 126,650 151,986 178,931
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.7% 95.9% 96.2% 96.2% 95.7% 95.9% 96.3% 95.5% 97.0% Ambulance: Compliance with recording patient handover 93.2% 95.9% 90.0% 90.0% 7,093 7,364 5,015 2,475 2,450 2,482 2,432 2,562 2,453 7,415 7,675 5,212 2,572 2,561 2,588 2,526 2,682 2,530
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Ambulance Handover Delays over 30 Minutes 3392 927 0 0 308 270 349 94 74 130 66 176 173 Ambulance Handover Delays over 1 Hour 1169 191 0 0 55 40 96 13 6 28 6 37 59 Ambulance Handover Delays over 2 Hours 212 26 0 0 6 1 19 0 0 1 0 8 11 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0
68 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 DTOCs: Average number of DTOCs per day (attributable 35.0 34.7 29.3 34.9 29.7 34.2 to NHS, social care or both)
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 3.1% 2.6% 3.1% 2.8% 3.2% Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 34.7 29.3 34.9 29.7 34.2 1,118 1,118 1,118 1,062 1,062 57.1% 63.6% 100.0% 66.7% 100.0% 100.0% 33.3% 100.0% Percentage of high risk TIA cases investigated and 47.9% 65.0% 60.0% 60.0% 4 7 2 2 2 3 2 2 treated within 24 hours 7 11 2 3 2 3 6 2 64.5% 51.5% 62.5% 53.8% 45.5% 55.6% Percentage of patients who spend at least 90% of their 57.8% 80.0% 80.0% 20 17 5 7 5 5 inpatient stay on a stroke unit 31 33 8 13 11 9
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 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 CMFT TGH
69 Elective
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value 2017/18 2017/18 2017/18 2017/18 79.56% 79.44% 68.82% 70.11% 88.66% 78.64% 79.00% 82.17% 85.00% 85.27% 80.00% 81.40% 81.40% 83.72% 85.00% 85.00% Cancer 62 day waits following urgent GP referral (STF) 82.72% 79.50% 83.72% 109 114 32 30.5 43 40.5 137 143.5 46.5 43.5 48.5 51.5
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 93.2% 91.5% 94.7% 93.3% 89.1% 92.3% Cancer two week waits (urgent referrals) 94.1% 92.3% 93.0% 93.0% 2,483 2,580 871 821 907 853 2,664 2,820 920 880 1,018 924 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 97.2% 93.9% 96.8% 90.5% 96.8% 93.4% Cancer 31 day waits for first definitive treatment (All 96.5% 95.6% 96.0% 96.0% 277 262 92 86 91 85 cancers) 285 279 95 95 94 91 94.1% 97.1% 94.7% 97.1% 96.6% 97.1% Cancer 31 day waits for subsequent treatment (Surgery) 95.2% 95.8% 94.0% 94.0% 80 102 18 34 28 34 85 105 19 35 29 35 100.0% 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 2 8 7 7 11 20 2 8 7 7 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 (Radiotherapy) 0 0 0 0 0 0
Cancer 62 day waits following referral from NHS 47.1% 66.7% .0% 40.0% 50.0% 50.0% 62.0% 52.2% 90.0% 90.0% screening service 4 2 0 1 0.5 0.5
70 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 8.5 3 0.5 2.5 1 1 88.1% 88.6% 82.9% 88.2% 96.9% 82.5% Cancer 62 day waits following consultant decision to 90.7% 88.3% 85.0% 85.0% 44.5 46.5 14.5 15 15.5 16.5 upgrade 50.5 52.5 17.5 17 16 20 3.6% 3.1% 3.2% 3.8% 2.9% 3.2% 3.3% 3.2% Diagnostic Waiting Times % waiting > 6 weeks (NHS 4.3% 3.3% 1.0% 1.0% 1,158 983 344 414 320 337 326 344 Constitution) 32,414 31,398 10,761 10,933 10,963 10,471 9,964 10,761 84.0% 85.6% 87.3% 84.5% 84.3% 85.1% 87.4% 87.3% RTT: Admitted pathways % within 18 weeks 81.9% 85.2% 90.0% 6,185 7,411 2,572 2,360 2,490 2,491 2,430 2,572 7,363 8,662 2,946 2,794 2,954 2,928 2,780 2,946 91.6% 90.9% 90.3% 90.7% 91.0% 91.2% 90.5% 90.3% RTT: Non-Admitted pathways % within 18 weeks 91.9% 91.1% 95.0% 34,671 35,225 12,577 11,912 12,002 11,499 11,724 12,577 37,831 38,755 13,923 13,131 13,188 12,612 12,955 13,923 92.2% 92.0% 91.7% 92.2% 92.0% 92.1% 92.0% 91.7% RTT: Incomplete pathways % within 18 weeks 92.7% 91.7% 92.0% 92.0% 43,574 43,220 43,236 43,574 43,530 43,750 43,220 43,236 47,278 46,964 47,170 47,278 47,298 47,524 46,964 47,170 0.5% 0.5% 0.6% 0.5% 0.5% 0.6% 0.5% 0.6% Percentage of patients waiting more than 36 weeks on 0.4% 0.6% 1.0% 1.0% 245 251 297 245 251 288 251 297 incomplete pathways 47,278 46,964 47,170 47,278 47,298 47,524 46,964 47,170 1.1% 0.9% 1.4% 1.2% 1.0% 0.9% 0.9% 1.4% Percentage of cancelled elective operations that are 1.2% 1.1% 0.8% 0.8% 281 246 130 107 87 81 78 130 cancelled at the last minute for non-clinical reasons 25,431 26,709 9,301 9,302 8,898 9,056 8,755 9,301
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 2 2 2 0 0 pathways Cancelled elective operations - breaches of 28 day 54 58 0 0 30 24 4 20 10 7 7 4
71 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 75.1% 77.7% 77.3% 77.8% 79.6% 75.7% 77.8% 77.3% Percentage of women who have seen a midwife or a maternity healthcare professional by 12 weeks and 6 73.4% 76.5% 90.0% 90.0% 1,972 1,952 723 713 676 642 634 723 days of pregnancy 2,627 2,512 935 916 849 848 815 935 95.6% 96.7% 97.5% 95.6% 98.2% 96.9% 96.7% 97.5% Percentage of women (who present) who have seen a midwife or a maternity healthcare professional by 12 93.9% 96.1% 90.0% 90.0% 689 606 699 689 656 615 606 699 weeks and 6 days of pregnancy 721 627 717 721 668 635 627 717 68.2% 81.3% Percentage of patients achieving recommended length of 78.6% 75.9% 80.0% 15 26 stay (LOS) for gynaecological procedures (≤5 days)* 22 32 50.0% 55.6% Percentage of patients achieving recommended length of 41.4% 52.3% 50.0% 19 15 stay (LOS) for colorectal procedures (≤7 days)* 38 27 83.3% 100.0% Percentage of patients achieving recommended length of 89.7% 92.3% 80.0% 80.0% 5 7 stay (LOS) for urological procedures (≤5 days) 6 7 92.3% 83.3% Percentage of applicable MDT meetings that are quorate 66.0% 88.0% 95.0% 95.0% 12 10 13 12 100.0% 100.0% Colorectal surgeon (1) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 12 100.0% 91.7% Colorectal surgeon (2) - % of MDT meetings attended 92.5% 96.0% 66.6% 66.6% 13 11 13 12
72 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.3% 83.3% Clinical oncologist - % of MDT meetings attended 77.4% 88.0% 66.6% 66.6% 12 10 13 12 76.9% 66.7% Oncologist - % of MDT meetings attended 92.5% 72.0% 66.6% 66.6% 10 8 13 12 100.0% 100.0% Imaging specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 12 100.0% 100.0% Histopathologist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 12 0.0% 0.0% Colonoscopist - % of MDT meetings attended 7.3% 0.0% 66.6% 66.6% 0 0 13 12 100.0% 100.0% Colorectal nurse specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 13 12 13 12 100.0% 100.0% MDT coordinatory/secretary - % of MDT meetings 100.0% 100.0% 66.6% 66.6% 13 12 attended 13 12 30.5% 33.8% Compliance with key elements of the cancer pathway - 32.6% 32.2% 51.1% 815 956 1st appointment within 7 days* 2,672 2,828 28.6% 39.8% Compliance with key elements of the cancer pathway - 43.4% 34.5% 95.0% 44 70 Confirmed diagnosis within 28 days 154 176
Compliance with key elements of the cancer pathway - 72.0% 76.5% 70.4% 74.4% 74.0% MDT to take place within 35 days 237 289
73 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 329 378 65.9% 65.2% Compliance with key elements of the cancer pathway - 63.3% 65.5% 79.8% 60 88 Decision to treat within 42 days 91 135 79.2% 96.3% 85.0% 75.8% 90.9% 95.5% 100.0% 85.0% Percentage of patients diagnosed with a macular 86.7% 86.1% 97.0% 97.0% 20.333 17.333 17 25 10 21 21 17 condition who receive first injection within 14 days 25.667 18 20 33 11 22 21 20 67.3% 68.6% 80.1% 67.8% 66.1% 70.7% 68.9% 80.1% Follow-up injection within 7 days of the planned date for 76.3% 69.6% 90.0% 90.0% 3,111 3,220 1,164 1,059 1,022 1,131 1,067 1,164 patients who have active disease (treatment to plan) 4,623 4,695 1,454 1,562 1,547 1,600 1,548 1,454 76.2% 79.3% 86.9% 73.7% 84.6% 72.6% 84.1% 86.9% % of patients referred to EMAC with suspect macular 78.9% 95.0% 95.0% 157 115 53 56 33 45 37 53 condition and clinically assessed within 3 days 206 145 61 76 39 62 44 61
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 0 0 1 0
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 0 0 0 0 0 0 0 0 0 0 0 Overall number of MRSA bacteraemia - Non-attributable 7 3 0 0 2 1 0 1 1 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 12 11 66 39 4 5 2 1 3 0 2 2 CDiff infections - Overall number of cases (NHS Patients) 74 47 18 24 5 6 12 4 8 5
74 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 98.5% 98.5% 98.7% 98.5% 97.5% 98.1% 98.5% 98.7% Compliance with the hand hygiene audit 97.7% 98.7% 95.0% 95.0% 856 875 888 856 849 877 875 888 869 888 900 869 871 894 888 900 100.0% 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 5 9 7 6 3 5 Cause Analysis Investigation Report and on STEIS 18 16 5 9 7 6 3 5 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% above excluding SIs) reported in month where the 100.0% 100.0% 100.0% 100.0% 39 50 24 15 20 19 11 24 patient/family were notified of suspected or actual incident 39 50 24 15 20 19 11 24 97.5% 97.6% 97.3% 97.1% 97.9% 97.7% 97.2% 97.3% Percentage of patients receiving harm free care 98.3% 97.5% 95.0% 95.0% 4,143 4,170 1,294 1,372 1,377 1,408 1,385 1,294 4,248 4,272 1,330 1,413 1,406 1,441 1,425 1,330 0.35% 0.87% 0.30% 0.21% 0.64% 0.97% 0.98% 0.30% Percentage of adult VTE Incidences that occurred whilst 0.56% 0.57% 0.25% 0.25% 15 37 4 3 9 14 14 4 receiving care from the provider 4,248 4,272 1,330 1,413 1,406 1,441 1,425 1,330 95.3% 95.7% 95.1% 95.1% 95.7% 95.4% 95.9% 95.1% Percentage of all adult patients who have had a VTE risk 95.3% 95.4% 95.0% 95.0% 30,884 32,159 11,137 10,818 10,711 10,671 10,777 11,137 assessment using an approved assessment tool 32,392 33,621 11,711 11,376 11,198 11,190 11,233 11,711 0.38% 0.26% 0.38% 0.21% 0.36% 0.28% 0.14% 0.38% Percentage of pressure ulcer incidences that occurred 0.26% 0.32% 1.00% 1.00% 16 11 5 3 5 4 2 5 whilst receiving care from the provider 4,248 4,272 1,330 1,413 1,406 1,441 1,425 1,330
Number of pressure ulcer incidences that occurred whilst 52 receiving care from the provider
0.38% 0.49% 0.90% 0.78% 0.57% 0.21% 0.70% 0.90% Percentage of falls incidences that occurred whilst 0.11% 0.50% 1.00% 1.00% 16 21 12 11 8 3 10 12 receiving care from the provider 4,248 4,272 1,330 1,413 1,406 1,441 1,425 1,330
Percentage of catheter acquired UTIs incidences that 0.09% 0.12% 0.00% 0.14% 0.07% 0.07% 0.21% 0.00% 0.21% 0.09% 0.25% 0.25% occurred whilst receiving care from the provider 4 5 0 2 1 1 3 0
75 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 4,248 4,272 1,330 1,413 1,406 1,441 1,425 1,330
Healthcare Worker Flu vaccination uptake (October to 47.6% February surveys)
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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% 84.5% 85.0% 85.0% 88.7% 72.7% 84.5% 88.7% 83.7% 73.7% 72.7% 84.5% within 24 hours Percentage of medication omissions that occurred whilst 85.2% 119.2% 12.0% 12.0% 43.7% 53.1% 22.4% 17.2% 15.4% 20.7% 17.0% 22.4% receiving care from the provider (excluding valid reasons) Percentage of patients with allergy status documented in 96.2% 98.3% 95.0% 95.0% 98.7% 95.5% 98.3% 98.7% 95.6% 97.0% 95.5% 98.3% medication chart
2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 4.20% 4.23% NHS staff sickness absence rate 4.92% 4.20% 44,213 14,721 1,053,916 348,100 88.9% 86.4% 92.0% 88.0% 85.7% 85.8% Safe Staffing - Day Nurse Staff Fill Rate % 88.0% 87.7% 284,564 280,751 73,374 81,928 99,875 98,948 319,957 324,946 79,754 93,087 116,474 115,385 92.2% 93.0% 98.7% 98.1% 90.3% 92.1% Safe Staffing - Day Care Staff Fill Rate % 91.6% 92.6% 129,125 131,842 30,221 36,698 47,872 47,272 140,048 141,755 30,631 37,410 52,994 51,351 89.9% 88.4% 93.8% 90.9% 87.2% 87.7% Safe Staffing - Day Staff (Overall) Fill Rate % 89.2% 89.2% 413,689 412,593 103,595 118,626 147,747 146,220 460,005 466,700 110,385 130,496 169,468 166,736
76 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 90.4% 88.4% 88.1% 85.7% 90.0% 91.1% Safe Staffing - Night Nurse Staff Fill Rate % 92.3% 89.4% 255,279 257,314 102,863 109,521 74,432 73,361 282,431 291,063 116,693 127,835 82,702 80,526 94.9% 95.5% 90.8% 90.1% 99.5% 101.4% Safe Staffing - Night Care Staff Fill Rate % 101.9% 95.2% 110,129 115,525 46,837 51,966 31,547 32,012 116,028 120,962 51,605 57,664 31,721 31,577 91.7% 90.5% 88.9% 87.1% 92.6% 94.0% Safe Staffing - Night Staff (Overall) Fill Rate % 95.0% 91.1% 365,408 372,838 149,700 161,486 105,979 105,373 398,459 412,024 168,298 185,498 114,423 112,103
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 27.2% 33.7% 39.0% 20.8% 33.3% 40.0% 27.5% 39.0% Percentage of complaints responded to within timescale 23.8% 31.9% 90.0% 90.0% 76 89 46 16 26 38 25 46 279 264 118 77 78 95 91 118 100.0% 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% 247 299 113 87 104 105 90 113 days of day following receipt of complaint 247 299 113 87 104 105 90 113 5.6% 5.0% 6.2% 6.5% 4.3% 4.8% FFT - A&E % not recommend 7.0% 5.3% 417 402 184 119 135 148 7,503 8,051 2,960 1,835 3,138 3,078 FFT - A&E % recommend 87.2% 90.1% 89.4% 90.8% 88.8% 88.2% 91.4% 91.7%
77 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 6,705 7,309 2,628 1,619 2,868 2,822 7,503 8,051 2,960 1,835 3,138 3,078 12.9% 14.4% 15.7% 9.4% 17.4% 17.0% FFT - A&E response rate 7.4% 13.7% 7,503 8,051 2,960 1,835 3,138 3,078 57,998 55,791 18,875 19,594 18,048 18,149 1.4% 1.8% 1.3% 1.4% 2.0% 2.1% FFT - Inpatient % not recommend 1.8% 1.6% 115 169 45 39 68 62 8,509 9,149 3,598 2,707 3,468 2,974 95.9% 95.8% 96.1% 96.2% 96.0% 95.1% FFT - Inpatient % recommend 94.4% 95.8% 8,156 8,762 3,458 2,604 3,331 2,827 8,509 9,149 3,598 2,707 3,468 2,974 31.6% 32.3% 36.9% 28.4% 37.1% 31.6% FFT - Inpatient response rate 16.8% 32.0% 8,509 9,149 3,598 2,707 3,468 2,974 26,911 28,298 9,758 9,541 9,338 9,419 0.0% 3.4% 0.0% 5.2% 0.0% 2.7% FFT - Maternity % not recommend 0.7% 2.7% 0 5 0 3 0 2 38 149 17 58 18 73 97.4% 96.6% 100.0% 94.8% 100.0% 97.3% FFT - Maternity % recommend 96.4% 96.8% 37 144 17 55 18 71 38 149 17 58 18 73 1.7% 6.4% 2.4% 7.5% 2.3% 9.6% FFT - Maternity response rate 5.9% 4.1% 38 149 17 58 18 73 2,275 2,316 720 777 776 763
Quality - Effectiveness
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18
78 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 99.3% 99.2% 99.4% 99.2% 99.2% 99.2% 99.3% 99.4% 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 24,721 24,578 24,581 25,274 24,996 24,721 Inpatient 71,431 75,419 24,875 24,780 24,790 25,467 25,162 24,875 99.31% 99.36% 99.49% 99.28% 99.30% 99.35% 99.42% 99.49% Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS - 99.15% 99.36% 99.00% 99.00% 324,414 325,885 116,248 114,938 109,236 107,886 108,763 116,248 Outpatient 326,669 327,996 116,848 115,776 110,006 108,588 109,402 116,848 91.8% 95.4% 95.0% 91.8% 91.1% 94.4% 95.4% 95.0% Completion of a valid NHS Number field in A&E 90.0% 92.6% 95.0% 95.0% 20,152 21,257 22,556 20,152 20,661 19,672 21,257 22,556 commissioning data sets submitted via SUS 21,956 22,293 23,739 21,956 22,691 20,844 22,293 23,739
79 APPENDIX D: 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value 2017/18 2017/18 2017/18 2017/18 92.4% 89.1% 88.1% 90.1% 91.0% 89.4% 86.7% 88.1%
Percentage of patients who spent 4 hours or less in A&E 90.0% 90.8% 90.0% 90.0% 90.8% 90.8% 90.8% 90.0% 90.0% 85.6% 90.4% 90.0% (STF) 23,136 22,420 7,750 7,561 8,005 7,281 7,134 7,750 25,027 25,163 8,799 8,388 8,793 8,143 8,227 8,799 92.44% 90.77% 90.37% 92.44% 92.08% 91.56% 90.77% 90.37%
Percentage of patients who spent 4 hours or less in A&E 90.00% 90.40% 90.34% 90.00% 90.20% 90.32% 90.40% 90.34% 90.30% 85.58% 90.37% 90.34% (STF) - Cumulative performance 23,136 45,556 53,306 23,136 31,141 38,422 45,556 53,306 25,027 50,190 58,989 25,027 33,820 41,963 50,190 58,989
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.6% 92.4% 92.9% 91.5% 91.7% 92.0% 93.7% 93.5% 92.3% Ambulance: Compliance with recording patient handover 91.0% 92.6% 90.0% 90.0% 6,159 6,468 4,497 2,094 2,153 2,159 2,156 2,261 2,236 6,651 6,997 4,842 2,288 2,349 2,346 2,302 2,419 2,423
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Ambulance Handover Delays over 30 Minutes 1114 1023 0 0 199 419 405 94 90 122 207 171 234 Ambulance Handover Delays over 1 Hour 194 116 0 0 16 48 52 10 9 8 31 22 30 Ambulance Handover Delays over 2 Hours 20 4 0 0 1 0 3 1 0 0 0 2 1 Urgent operations cancelled for a second time 0 0 0 0 0 0 0 0 0 0 0 0
80 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 DTOCs: Average number of DTOCs per day (attributable 23.7 58.7 60.8 60.5 58.4 to NHS, social care or both)
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 7.9% 8.2% 8.1% 8.1% 9.4% Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 58.7 60.8 60.5 58.4 67.7 745 745 745 718 718 74.5% 69.8% 83.3% 72.7% 63.0% 73.7% 76.5% 83.3% Percentage of high risk TIA cases investigated and 57.5% 73.9% 60.0% 60.0% 41 44 20 16 17 14 13 20 treated within 24 hours 55 63 24 22 27 19 17 24 61.2% 54.1% 52.9% 47.1% 59.1% 45.0% 57.9% 52.9% Percentage of patients who spend at least 90% of their 56.5% 57.2% 80.0% 80.0% 41 33 9 8 13 9 11 9 inpatient stay on a stroke unit 67 61 17 17 22 20 19 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 3 4 3 UHSM
Elective
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Value Value 2017/18 2017/18 2017/18 2017/18 87.3% 87.6% 88.6% 87.1% 87.3% 87.1% 86.3% 87.6% 88.6% RTT: Incomplete pathways % within 18 weeks (STF) 87.4% 88.6% 92.0% 87.3% 90.8% 92.0% 86.2% 87.3% 88.5% 89.7% 90.8% 92.0%
81 2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Current Target May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Value Value 2017/18 2017/18 2017/18 2017/18 22,477 22,486 22,570 21,261 22,477 22,869 22,427 22,486 22,570 25,739 25,663 25,488 24,402 25,739 26,271 25,978 25,663 25,488
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 95.0% 95.3% 94.7% 96.1% 94.5% 95.6% Cancer two week waits (urgent referrals) 95.7% 95.1% 93.0% 93.0% 3,047 3,113 1,143 1,073 1,090 967 3,209 3,265 1,207 1,117 1,153 1,012 92.8% 95.5% 93.1% 94.6% 95.8% 96.2% Cancer two week waits for breast symptoms 93.8% 94.1% 93.0% 93.0% 953 972 326 348 322 304 1,027 1,018 350 368 336 316 99.4% 99.4% 99.2% 99.5% 99.2% 99.6% Cancer 31 day waits for first definitive treatment (All 99.1% 99.4% 96.0% 96.0% 666 695 238 212 253 232 cancers) 670 699 240 213 255 233 99.3% 99.4% 100.0% 100.0% 98.0% 100.0% Cancer 31 day waits for subsequent treatment (Surgery) 99.0% 99.4% 94.0% 94.0% 143 174 46 60 50 63 144 175 46 60 51 63 100.0% 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 5 5 24 24 52 51 5 5 24 24 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% 89.9% 85.9% 92.9% 86.5% Cancer 62 day waits following urgent GP referral 89.1% 87.5% 85.0% 85.0% 201 199 62.5 70 65 64 232 225 69.5 81.5 70 74
Cancer 62 day waits following referral from NHS 98.5% 100.0% 96.6% 98.4% 100.0% 100.0% 98.0% 99.2% 90.0% 90.0% screening service 101 83.5 42.5 30 35 18.5
82 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 102.5 83.5 44 30.5 35 18.5 89.4% 89.6% 92.7% 90.6% 88.2% 90.3% Cancer 62 day waits following consultant decision to 90.3% 89.5% 85.0% 85.0% 110 116.5 44.5 29 45 42 upgrade 123 130 48 32 51 46.5 1.2% 4.0% 0.4% 1.8% 0.9% 7.2% 3.8% 0.4% Diagnostic Waiting Times % waiting > 6 weeks 0.5% 2.3% 1.0% 1.0% 213 683 23 106 53 411 219 23 17,340 17,222 6,009 5,760 5,787 5,714 5,721 6,009 60.6% 54.8% 58.9% 62.4% 56.8% 53.1% 54.6% 58.9% RTT: Admitted pathways % within 18 weeks 64.2% 57.9% 90.0% 2,443 2,192 946 930 721 726 745 946 4,031 4,001 1,607 1,490 1,269 1,368 1,364 1,607 87.6% 87.1% 88.7% 87.9% 88.0% 87.9% 85.5% 88.7% RTT: Non-Admitted pathways % within 18 weeks 83.3% 87.6% 18,202 18,644 6,912 6,520 6,062 6,334 6,248 6,912 20,769 21,406 7,795 7,418 6,892 7,209 7,305 7,795 1.30% 1.03% 1.03% 1.30% 1.07% 1.16% 1.03% 1.03% Percentage of patients waiting more than 36 weeks on 0.91% 1.03% 1.00% 1.00% 334 265 263 334 282 302 265 263 incomplete pathways 25,739 25,663 25,488 25,739 26,271 25,978 25,663 25,488 88.7% 89.5% Percentage of children waiting less than 18 weeks for a 89.1% 87.9% 126 111 wheelchair 142 124 1.4% 0.9% 1.8% 1.3% 1.3% 0.7% 0.7% 1.8% Percentage of cancelled elective operations that are 1.6% 1.2% 0.8% 0.8% 186 125 91 59 62 32 31 91 cancelled at the last minute for non-clinical reasons 13,071 14,038 5,098 4,660 4,622 4,778 4,638 5,098
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 75 0 0 28 30 17 11 8 9 13 17 pathways Cancelled elective operations - breaches of 28 day 18 18 0 0 17 1 0 5 1 0 0 0
83 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 96.5% 94.5% 95.8% 94.6% 93.0% 97.9% 92.1% 95.8% Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 99.1% 95.6% 90.0% 90.0% 1,061 966 339 336 306 369 291 339 of pregnancy 1,099 1,022 354 355 329 377 316 354 100.0% 100.0% Percentage of patients achieving recommended length of 100.0% 80.0% 80.0% 3 3 stay (LOS) for gynaecological procedures 3 3 92.9% 40.0% Percentage of patients achieving recommended length of 47.0% 78.9% 60.0% 13 2 stay (LOS) for colorectal procedures* 14 5 N/A N/A Percentage of patients achieving recommended Length 100.0% N/A 80.0% 80.0% 0 0 of stay (LOS) for urological procedures 0 0 88.2% 91.2% Percentage of patients achieving recommended length of 99.1% 89.7% 60.0% 165 156 stay (LOS) for breast procedures* 187 171 100.0% 100.0% Percentage of applicable MDT meetings that are quorate 90.4% 100.0% 95.0% 95.0% 11 13 11 13 100.0% 100.0% Colorectal surgeon (1) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Colorectal surgeon (2) - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13
84 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 100.0% 100.0% Clinical oncologist - % of MDT meetings attended 94.2% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Oncologist - % of MDT meetings attended 94.2% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Imaging specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Histopathologist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Colonoscopist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% Colorectal nurse specialist - % of MDT meetings attended 100.0% 100.0% 66.6% 66.6% 11 13 11 13 100.0% 100.0% MDT coordinatory/secretary - % of MDT meetings 100.0% 100.0% 66.6% 66.6% 11 13 attended 11 13 19.7% 23.3% Compliance with key elements of the cancer pathway - 24.8% 21.5% 50.0% 620 764 1st appointment within 7 days* 3,143 3,282 62.4% 71.8% Compliance with key elements of the cancer pathway - 66.2% 67.0% 67.0% 148 163 Confirmed diagnosis within 28 days 237 227
Compliance with key elements of the cancer pathway - 47.6% 45.8% 53.7% 46.8% 68.0% MDT to take place within 35 days* 79 66
85 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 166 144 92.1% 77.8% Compliance with key elements of the cancer pathway - 74.7% 83.7% 79.0% 93 112 Decision to treat within 42 days 101 144
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 2 0 0 0 0 Overall number of MRSA bacteraemia - Non-attributable 3 0 0 0 0 0 0 0 0 0 0 0 CDiff infections caused by lapse in care (NHS Patients) 15 9 39 23 8 1 0 3 0 1 0 0 CDiff infections - Overall number of cases (NHS Patients) 44 26 13 13 0 4 2 7 4 0
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18
Compliance with the hand hygiene audit 95.4% 95.0%
93.1% 97.7% 97.0% 92.0% 97.7% 98.4% 97.1% 97.0% Percentage of patients receiving harm free care 92.5% 95.6% 95.0% 95.0% 2,349 2,367 876 761 809 795 763 876 2,522 2,422 903 827 828 808 786 903 0.40% 0.25% 0.33% 0.48% 0.12% 0.00% 0.64% 0.33% Percentage of adult VTE Incidences that occurred whilst 0.30% 0.32% 0.25% 0.25% 10 6 3 4 1 0 5 3 receiving care from the provider 2,522 2,422 903 827 828 808 786 903 95.8% 95.2% 95.1% 97.3% 95.3% 95.1% 95.0% 95.1% Percentage of all adult patients who have had a VTE risk 95.2% 95.4% 95.0% 95.0% 22,142 23,145 8,151 7,689 7,698 7,775 7,672 8,151 assessment using an approved assessment tool 23,107 24,324 8,568 7,903 8,075 8,176 8,073 8,568
86 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 0.79% 0.12% 0.22% 1.21% 0.24% 0.00% 0.13% 0.22% Percentage of pressure ulcer incidences that occurred 1.09% 0.43% 1.00% 1.00% 20 3 2 10 2 0 1 2 whilst receiving care from the provider 2,522 2,422 903 827 828 808 786 903 0.24% 0.38% 0.55% 0.24% 0.60% 0.50% 0.38% 0.55% Percentage of falls incidences resulting in harm that 0.32% 0.38% 1.00% 1.00% 2 3 5 2 5 4 3 5 occurred whilst receiving care from the provider 827 786 903 827 828 808 786 903 0.44% 0.21% 0.55% 0.97% 0.12% 0.12% 0.38% 0.55% Percentage of catheter acquired UTIs incidences that 0.17% 0.36% 0.25% 0.25% 11 5 5 8 1 1 3 5 occurred whilst receiving care from the provider 2,522 2,422 903 827 828 808 786 903 57.5% Healthcare Worker Flu vaccination uptake (October to 66.1% 57.5% 3,088 February surveys) 5,375
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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% 83.0% 85.0% 85.0% 82.1% 87.7% 83.0% 82.1% 85.7% 84.7% 87.7% 79.1% 83.0% within 24 hours Percentage of medication omissions that occurred whilst 71.9% 11.0% 12.0% 12.0% 11.8% 7.9% 11.0% 11.8% 5.6% 7.1% 7.9% 11.0% receiving care from the provider (excluding valid reasons) Percentage of critical medication omissions that occurred 52.1% 10.0% whilst receiving care from the provider Percentage of patients with allergy status documented in 98.8% 98.0% 95.0% 95.0% 97.2% 99.6% 98.0% 97.2% 99.2% 98.4% 99.6% 96.7% 98.0% medication chart
2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 4.11% 4.32% NHS staff sickness absence rate 4.10% 4.11% 21,327 7,413 519,170 171,724
87 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 88.6% 85.2% 90.3% 87.5% 83.8% 84.3% Safe Staffing - Day Nurse Staff Fill Rate % 90.1% 86.9% 195,346 195,703 66,798 67,403 64,985 63,315 220,457 229,624 73,981 77,014 77,537 75,073 103.7% 98.3% 103.7% 101.0% 96.1% 97.8% Safe Staffing - Day Care Staff Fill Rate % 108.5% 100.9% 108,213 108,920 36,838 37,486 36,107 35,327 104,321 110,823 35,517 37,109 37,574 36,140 93.5% 89.5% 94.6% 91.9% 87.8% 88.7% Safe Staffing - Day Staff (Overall) Fill Rate % 96.0% 91.4% 303,559 304,622 103,637 104,889 101,091 98,642 324,778 340,447 109,498 114,123 115,111 111,213 89.1% 87.4% 90.2% 88.2% 86.7% 87.4% Safe Staffing - Night Nurse Staff Fill Rate % 93.8% 88.3% 137,687 139,021 46,641 47,252 46,713 45,056 154,494 158,994 51,721 53,562 53,873 51,559 112.4% 111.0% 112.2% 114.2% 110.2% 108.5% Safe Staffing - Night Care Staff Fill Rate % 122.2% 111.7% 69,695 72,512 23,609 24,902 24,124 23,486 62,010 65,343 21,044 21,807 21,892 21,644 95.8% 94.3% 96.5% 95.7% 93.5% 93.6% Safe Staffing - Night Staff (Overall) Fill Rate % 101.7% 95.0% 207,382 211,532 70,250 72,154 70,837 68,541 216,504 224,337 72,765 75,369 75,765 73,203
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 Percentage of complaints responded to within timescale 96.0% 93.3% 90.0% 90.0% 91.9% 95.2% 91.3% 94.6% 94.3% 95.2% 95.9% 91.3%
88 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 102 120 42 35 33 40 47 42 111 126 46 37 35 42 49 46 90.2% 98.4% 78.8% 78.0% 95.2% 100.0% 100.0% 78.8% Percentage of complaints acknowledged in 3 working 89.6% 91.8% 90.0% 90.0% 92 126 41 32 40 49 37 41 days of day following receipt of complaint 102 128 52 41 42 49 37 52 5.9% 7.1% 6.2% 8.2% 6.1% 7.0% FFT - A&E % not recommend 7.4% 6.5% 184 213 66 85 60 68 3,104 2,997 1,060 1,042 980 975 89.2% 88.0% 88.5% 87.4% 88.9% 87.7% FFT - A&E % recommend 87.4% 88.6% 2,769 2,637 938 911 871 855 3,104 2,997 1,060 1,042 980 975 17.8% 17.6% 18.3% 17.4% 17.9% 17.6% FFT - A&E response rate 17.4% 17.7% 3,104 2,997 1,060 1,042 980 975 17,408 17,012 5,788 5,993 5,464 5,555 0.6% 0.7% 0.4% 0.8% 0.9% 0.5% FFT - Inpatient % not recommend 0.7% 0.7% 52 59 11 24 23 12 8,500 8,015 2,687 2,903 2,594 2,518 97.5% 97.4% 97.6% 97.3% 96.7% 98.0% FFT - Inpatient % recommend 96.6% 97.5% 8,291 7,803 2,623 2,826 2,509 2,468 8,500 8,015 2,687 2,903 2,594 2,518 41.1% 37.2% 37.7% 41.1% 35.7% 34.8% FFT - Inpatient response rate 41.0% 39.1% 8,500 8,015 2,687 2,903 2,594 2,518 20,675 21,567 7,120 7,059 7,274 7,234 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% FFT - Maternity % not recommend 0.0% 0.0% 0 0 0 0 0 0 83 82 36 25 14 43 100.0% 98.8% 100.0% 100.0% 100.0% 97.7% FFT - Maternity % recommend 99.1% 99.4% 83 81 36 25 14 42 83 82 36 25 14 43
89 2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 11.5% 7.5% 11.0% 6.5% 4.2% 11.5% FFT - Maternity response rate 10.4% 9.5% 120 82 36 25 14 43 1,040 1,090 328 383 334 373
Quality - Effectiveness
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18
Summary Hospital-level Mortality Indicator (SHMI) - 0.955 Deaths associated with hospitalisation
Information and Data Quality
2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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% Completion of a valid NHS Number field in mental health 99.8% 99.8% 99.0% 99.0% 67,713 66,384 64,404 67,713 65,486 65,574 66,384 64,404 and acute commissioning data sets submitted via SUS 67,832 66,515 64,514 67,832 65,637 65,698 66,515 64,514 98.6% 98.1% 97.3% 98.5% 98.3% 98.3% 97.6% 97.3% Completion of a valid NHS Number field in A&E 98.5% 98.2% 95.0% 95.0% 24,982 24,775 8,595 8,312 8,677 8,032 8,066 8,595 commissioning data sets submitted via SUS 25,335 25,262 8,837 8,439 8,830 8,171 8,261 8,837
90 APPENDIX E - 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value 2017/18 2017/18 2017/18 2017/18 83.7% 84.8% 84.2% 83.5% 84.5% 85.0% 85.0% 88.5% 85.8%
Percentage of patients who spent 4 hours or less in A&E 81.9% 85.4% 86.0% 86.4% 88.9% 89.5% 82.1% 84.2% 90.2% (STF) 68,130 69,391 84,056 22,553 24,431 22,211 22,749 29,839 28,284 81,436 81,801 99,799 27,018 28,926 26,126 26,749 33,702 32,967 83.7% 84.2% 84.2% 83.7% 83.9% 84.1% 84.2% 85.0% 85.1%
Percentage of patients who spent 4 hours or less in A&E 82.1% 84.2% (STF) - Cumulative performance 68,130 137,521 221,577 68,130 92,561 114,772 137,521 167,360 195,644 81,436 163,237 263,036 81,436 110,362 136,488 163,237 196,939 229,906
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 94.0% 92.6% 92.4% 93.8% 92.5% 92.9% 92.3% 91.7% 93.2% Ambulance: Compliance with recording patient handover 92.8% 93.0% 90.0% 90.0% 16,595 17,592 18,626 5,743 6,051 5,843 5,698 6,027 6,249 17,646 19,002 20,154 6,121 6,541 6,288 6,173 6,573 6,705
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 786 103 0 0 50 31 22 1 22 3 6 5 5 Trolley Waits in A&E (NMGH) 571 67 0 0 46 8 13 1 4 2 2 3 2 Ambulance Handover Delays over 30 Minutes 7584 5803 0 0 1515 1758 2530 455 633 468 657 637 804 Ambulance Handover Delays over 1 Hour 2770 1776 0 0 465 528 783 115 222 125 181 170 226 Ambulance Handover Delays over 2 Hours 675 344 0 0 90 94 160 17 34 27 33 28 32
91 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 DTOCs: Average number of DTOCs per day (attributable 36.0 29.4 36.7 47.8 42.7 42.3 35.4 to NHS, social care or both)
2016/17 2017/18 Annual Current Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Target 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 2.7% 3.3% 4.4% 3.9% 3.8% Delayed transfers of care - DTOCs as a % of total beds 3.3% 3.3% 29.4 36.7 47.8 42.7 42.3 1,096 1,096 1,096 1,101 1,101 60.9% 53.1% 77.8% 58.2% 60.4% 51.2% 48.1% 77.8% % of high risk TIA cases investigated and treated within 76.9% 60.7% 60.0% 60.0% 98 77 49 32 29 22 26 49 24 hours 161 145 63 55 48 43 54 63
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 5 4 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 92.1% 84.9% 85.1% 85.7% 82.6% 86.8% 84.1% 97.8% Cancer two week waits (urgent referrals) 94.2% 88.5% 93.0% 93.0% 5,272 4,955 1,683 1,628 1,734 1,591 1,894 1,988 5,725 5,836 1,978 1,900 2,100 1,834 2,251 2,033
92 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 99.7% 98.7% 100.0% 98.3% 98.3% 99.4% 100.0% 99.5% Cancer two week waits for breast symptoms 85.8% 99.2% 93.0% 93.0% 645 587 235 175 234 179 225 188 647 595 235 178 238 180 225 189 99.2% 98.5% 100.0% 99.4% 97.1% 98.7% 99.4% 96.3% Cancer 31 day waits for first definitive treatment (All 99.1% 98.8% 96.0% 96.0% 472 473 147 158 134 156 180 155 cancers) 476 480 147 159 138 158 181 161 95.5% 98.2% 100.0% 100.0% 95.5% 100.0% 94.7% 87.0% Cancer 31 day waits for subsequent treatment (Surgery) 98.5% 97.0% 94.0% 94.0% 42 54 11 14 21 15 18 20 44 55 11 14 22 15 19 23 97.8% 100.0% 94.7% 100.0% 100.0% 100.0% 100.0% 100.0% Cancer 31 day waits for subsequent treatment (Drugs) 100.0% 98.8% 98.0% 98.0% 45 34 18 4 16 16 14 8 46 34 19 4 16 16 14 8 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% 67.6% 77.3% 77.4% 74.5% 79.0% Cancer 62 day waits following urgent GP referral 79.3% 74.5% 85.0% 85.0% 250 260.5 73 97 85.5 76 109 345 340 108 125.5 110.5 102 138 86.7% 70.8% 100.0% 61.5% 100.0% 60.0% 33.3% 75.0% Cancer 62 day waits following referral from NHS 60.6% 79.6% 90.0% 90.0% 13 8.5 2 4 3 1.5 2 1.5 screening service 15 12 2 6.5 3 2.5 6 2 83.6% 94.4% 82.9% 90.5% 97.0% 95.8% 86.3% 94.9% Cancer 62 day waits following consultant decision to 84.5% 89.2% 85.0% 85.0% 48.5 59 14.5 19 16 23 22 28 upgrade 58 62.5 17.5 21 16.5 24 25.5 29.5 1.4% 2.2% 0.9% 2.5% 2.4% 2.5% 1.7% 0.8% 1.0% Diagnostic Waiting Times % waiting > 6 weeks (NHS 3.5% 1.6% 1.0% 1.0% 441 635 175 266 244 240 151 80 95 Constitution) 30,712 29,107 19,885 10,744 10,283 9,722 9,102 10,024 9,861 77.3% 74.0% 71.9% 77.5% 76.4% 74.1% 71.5% 72.0% 71.8% RTT: Admitted pathways % within 18 weeks 80.9% 74.7% 5,923 5,210 3,822 2,027 1,777 1,723 1,710 2,027 1,795
93 2016/17 2017/18 Annual Q1 Q2 Q3 Q4 Indicator Target Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 2017/18 2017/18 2017/18 2017/18 Value Value 2017/18 7,659 7,043 5,317 2,614 2,326 2,325 2,392 2,817 2,500 96.8% 96.1% 94.5% 97.0% 95.7% 96.6% 96.0% 95.6% 93.5% RTT: Non-Admitted pathways % within 18 weeks 95.7% 95.9% 40,713 42,006 30,244 14,408 13,431 14,417 14,158 15,217 15,027 42,061 43,707 31,988 14,849 14,032 14,925 14,750 15,914 16,074 92.2% 90.4% 90.3% 92.2% 91.0% 89.9% 90.4% 90.4% 90.3% RTT: Incomplete pathways % within 18 weeks (NHS 92.2% 90.3% 92.0% 92.0% 29,650 33,054 34,065 29,650 31,059 31,515 33,054 34,311 34,065 Constitution) 32,155 36,574 37,740 32,155 34,138 35,050 36,574 37,964 37,740 0.6% 0.5% 0.6% 0.6% 0.6% 0.7% 0.5% 0.5% 0.6% Percentage of patients waiting more than 36 weeks on 0.6% 0.6% 2.6% 2.6% 185 190 214 185 215 256 190 187 214 incomplete pathways 32,155 36,574 37,740 32,155 34,138 35,050 36,574 37,964 37,740
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 2 0 0 1 1 0 1 0 0 1 0 0 pathways Cancelled elective operations - breaches of 28 day 58 65 0 0 27 35 3 23 13 19 3 3 standard Cancelled outpatient appointments (hospital fault) <5 22.2% 11.9% 3.0% 3.0% 4.6% 5.8% 1.5% 1.6% 2.0% 2.1% 1.7% 1.5% working days Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 81.4% 90.0% 90.0% 81.5% 81.2% of pregnancy Percentage of women who have seen a midwife or a maternity health professional by 12 weeks and six days 93.8% 94.6% 90.0% 90.0% 94.3% 94.8% of pregnancy (referred 10wks 3 days)
Quality - Safety
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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
94 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 - Avoidable 1 2 0 0 0 2 0 0 0 0 2 0 0 Overall number of MRSA bacteraemia - Unavoidable 9 4 0 0 1 2 1 1 1 0 1 1 CDiff infections caused by lapse in care (NHS Patients) 23 13 55 32 6 7 0 0 5 1 1 0 CDiff infections - Overall number of cases (NHS Patients) 59 30 14 12 4 5 9 1 2 2 2 Harm Free Care - Venous Thromboembolism (VTE) 99.0% 95.0% 95.0% 99.6% 99.8% 99.9% 99.7% 99.8% Harm free care - Pressure ulcers 99.5% 95.0% 95.0% 99.8% 99.4% 99.5% 99.6% 99.5% Harm Free Care - Falls 99.6% 99.9% 95.0% 95.0% 99.9% 99.7% 99.6% 99.8% 99.9% Harm Free Care - Catheter Induced Urinary Tract 99.4% 99.9% 95.0% 95.0% 99.8% 99.8% 99.8% 99.9% 99.9% Problems Harm Free Care - VTE - risk assessment 96.1% 95.4% 95.0% 95.0% 95.1% 95.1% 95.6% 94.5% 95.4% Harm Free Care - VTE - root cause analysis 100.0% 100.0% 100.0% Medicines reconciled <72 hours 89.7% 87.4% 95.0% 95.0% 86.7% 87.4% Medicines reconciled <24 hours 195.4% 47.3% 50.0% 50.0% 45.8% 47.3% IP (>60 years) undergo MUST <6 hours of admission 90.0% IP (>60 years) with MUST score >2 referred for 90.0% 90.0% assessment/treatment plan % of nutritional assessments complete,dated and signed 95.0% by assessing staff member % 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% 55.8% are referred to a dietician % of inpatients (>18yrs) identified as a 'High Risk', (score of 3 or above) following a nutritional assessment, which 100.0% are referred to a dietician within 72 hours % of inpatients (>18yrs) who undergo a nutritional assessment using a recognised assessment tool. i.e. The 90.0% Malnutrition Universal Screening Tool (must) within 6 hours of admission Dementia - basic level awareness training 98.0% 83.0% 84.0% 86.0% 90.0% Midwife to birth ratio
Indicator 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017
95 Value Value Target 2017/18 2017/18 2017/18 2017/18 3.98% 4.22% 4.05% 4.31% 4.14% NHS staff sickness absence rate 4.24% 4.08% 40,709 29,580 13,620 14,943 14,637 1,022,647 700,792 336,235 347,013 353,779 92.8% 89.0% 89.4% 92.0% 91.1% 87.9% 87.9% 88.8% 90.1% Safe Staffing - Day Nurse Staff Fill Rate % 92.7% 90.5% 336,248 328,471 224,003 109,800 111,885 109,478 107,108 112,568 111,435 362,364 369,248 250,433 119,363 122,835 124,583 121,830 126,758 123,675 100.6% 97.5% 97.2% 98.6% 100.2% 95.8% 96.5% 96.2% 98.3% Safe Staffing - Day Care Staff Fill Rate % 99.6% 98.6% 240,166 243,526 161,281 77,873 82,088 81,960 79,478 81,518 79,763 238,628 249,750 165,863 78,953 81,885 85,515 82,350 84,743 81,120 95.9% 92.4% 92.6% 94.6% 94.8% 91.1% 91.4% 91.8% 93.4% Safe Staffing - Day Staff (Overall) Fill Rate % 95.4% 93.7% 576,413 571,996 385,283 187,673 193,973 191,438 186,585 194,085 191,198 600,991 618,998 416,295 198,315 204,720 210,098 204,180 211,500 204,795 94.0% 92.5% 93.2% 94.1% 93.7% 92.4% 91.4% 91.7% 94.7% Safe Staffing - Night Nurse Staff Fill Rate % 95.0% 93.2% 208,489 206,399 141,558 68,639 70,329 69,573 66,497 70,385 71,173 221,877 223,116 151,889 72,923 75,044 75,296 72,776 76,750 75,139 119.4% 116.7% 114.2% 118.4% 120.9% 114.7% 114.7% 114.5% 114.0% Safe Staffing - Night Care Staff Fill Rate % 113.7% 117.0% 140,890 145,930 98,679 47,418 49,088 49,130 47,712 49,898 48,781 118,010 125,066 86,382 40,037 40,614 42,851 41,601 43,576 42,806 102.8% 101.2% 100.8% 102.7% 103.3% 100.5% 99.9% 100.0% 101.7% Safe Staffing - Night Staff (Overall) Fill Rate % 101.2% 101.7% 349,378 352,329 240,237 116,057 119,417 118,703 114,209 120,283 119,954 339,886 348,181 238,270 112,959 115,658 118,146 114,377 120,326 117,944
Healthcare Worker Flu vaccination uptake (October to 53.6% February surveys)
Quality - Experience
Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 284 102 0 0 25 43 34 6 17 12 14 20 14
96 Annual Q1 Q2 Q3 Q4 2016/17 2017/18 Current Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 complaints acknowledged in 3 working 99.0% 97.0% 90.0% 90.0% 96.0% 99.0% 97.0% 96.0% 96.0% 96.0% 99.0% 97.0% days of day following receipt of complaint Complaints - responded to within timescale agreed at the 44.0% 55.0% 70.0% 41.0% 55.0% 41.0% 50.0% 47.0% 55.0% outset of complaint Complaints - satisfied on conclusion of complaint 3.0% 6.0% 30.0% 30.0% 7.0% 6.0% Complaints - Number of Complaints still open > 100 days 0 0 0 0 0 0 1 2 0
2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 9.1% 9.2% 9.2% 9.0% 8.8% 8.9% 9.8% 9.2% FFT - A&E % not recommend 10.5% 9.2% 851 995 338 285 316 326 353 338 9,333 10,855 3,672 3,151 3,591 3,646 3,618 3,672 83.7% 83.6% 84.5% 83.7% 83.6% 85.1% 82.1% 84.5% FFT - A&E % recommend 81.5% 83.8% 7,814 9,077 3,103 2,637 3,003 3,102 2,972 3,103 9,333 10,855 3,672 3,151 3,591 3,646 3,618 3,672 13.8% 16.0% 16.5% 14.0% 14.8% 16.8% 16.5% 16.5% FFT - A&E response rate 16.4% 15.1% 9,333 10,855 3,672 3,151 3,591 3,646 3,618 3,672 67,746 67,932 22,321 22,545 24,237 21,735 21,960 22,321 4.0% 4.1% 4.2% 4.3% 4.5% 4.0% 3.4% 4.2% FFT - Inpatient % not recommend 3.3% 4.0% 546 444 161 201 206 142 96 161 13,817 10,946 3,862 4,697 4,541 3,563 2,842 3,862 90.4% 89.9% 90.8% 89.8% 88.5% 90.2% 91.8% 90.8% FFT - Inpatient % recommend 88.2% 90.3% 12,489 9,841 3,507 4,220 4,019 3,213 2,609 3,507 13,817 10,946 3,862 4,697 4,541 3,563 2,842 3,862 22.2% 25.3% 30.9% 21.0% 19.6% 35.9% 28.0% 30.9% FFT - Inpatient response rate 28.4% 24.3% 13,817 10,946 3,862 4,697 4,541 3,563 2,842 3,862 62,232 43,311 12,482 22,389 23,213 9,931 10,167 12,482 2.3% 2.8% 0.7% 0.9% 0.8% 6.2% 1.0% 0.7% FFT - Maternity % not recommend 1.7% 2.3% 8 10 1 1 1 8 1 1
97 2016/17 2017/18 Current Q1 Q2 Q3 Q4 Indicator Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Value Value Target 2017/18 2017/18 2017/18 2017/18 341 362 136 108 132 130 100 136 94.7% 85.4% 97.1% 97.2% 97.0% 90.0% 64.0% 97.1% FFT - Maternity % recommend 81.2% 91.1% 323 309 132 105 128 117 64 132 341 362 136 108 132 130 100 136 15.6% 15.5% 17.3% 15.2% 17.6% 16.0% 12.9% 17.3% FFT - Maternity response rate 26.3% 15.8% 341 362 136 108 132 130 100 136 2,189 2,337 786 712 750 811 776 786
Quality - Effectiveness
2016/17 2017/18 Q1 Q2 Q3 Q4 Indicator Target Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 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% 99.8% 99.0% 99.0% 99.7% 99.7% 99.7% 99.8% and acute commissioning data sets submitted via SUS Completion of a valid NHS Number field in A&E 99.0% 98.4% 95.0% 95.0% 98.1% 98.4% 98.8% 98.6% 98.4% commissioning data sets submitted via SUS Outpatient letters < 10 working days of first attendance 95.4% 97.2% 95.0% 95.0% 96.4% 96.4% 97.7% 96.7% 97.2% Discharge summaries <24 hours of all A&E attendances 94.7% 95.0% 95.0% 95.0% 92.9% 95.0% 95.0% 94.9% 95.0% & IP discharges
98