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Trust Board Committee – 2nd July 2010. Robust Action Plan developed. Performance Management and Monitoring. Improved Escalation Review of Cohort Unit. - Failure to deliver the 4 hour core access target for the year. - Failure to achieve C-Difficile target for the year. SUFFICIENT.

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Robust Action Plan developed.

  • Performance Management and Monitoring.
  • Improved Escalation
  • Review of Cohort Unit

- Failure to deliver the 4 hour core access target for the year.

- Failure to achieve C-Difficile target for the year.


Note the Trust Performance to May 2010

1. Introduction

2. Emergency Care A&E

2.1 – Emergency Care & Pharmacy

3. 18 Weeks – Referral to Treatment – April’s Actual’s by Specialty

3.1 – Referral to Treatment – April’s Graphs

3.2 - Referral to Treatment – May’s Indicative position by Specialty

3.3 – Data Completeness

4. Cancelled Operations

5. LOS

6. New to Follow Up Ratios

7. Key Performance Indicator Dashboard

8. Outcomes and Effectiveness

9. Patient Safety

10. Patient Experience

11. Conclusion


1.& 2. Introduction & Emergency Care

2. Introduction:This report provides a briefing to the Board members on the performance against key targets up to May 2010.

The paper focuses on the main targets, identified by the Department of Health and the Care Quality Commission.

3. Emergency Care – A&E

Target: 98% of patients seen/treated/discharged within 4 hours

The Trust met the 98% Target for the month of May (98.14%).

Key actions:-

Increased focus on discharge planning and earlier in the day discharges.

Additional Medical Registrar working in A&E at weekends when available.

Daily (08.00) debrief to review previous day/night -identifying any issues.

Appt offer made to the current A&E Consultant Vacancy.

DH Intensive Support team report finalised.

Further external assurance commissioned from Intensive Support Team in April that will also support the FT authorisation process. Clinical challenge event May 2010.

Improved liaison with mental health services.

Integrated Action Plan agreed and monitored weekly, via weekly A&E departmental meetings.

West of Suffolk urgent care transformation programme May 2010.

Analysis of care of elderly non-elective activity has shown reduction in LOS (episode) from 9.22 days in 2008/2009 to 5.82 days (YTD) or in spells from 17.44 days to 10.34 days (YTD). 

The updated detailed A&E 4 hour performance action plan is attached as a separate paper.

Page 1


4. 18 Weeks – Referral to Treatment Monitoring (RTT)



From the DH Returns

Page 3


4.1 - 18 Weeks – Referral to Treatment Monitoring (RTT)

Target: 90% admitted patients and 95% non admitted patients to be seen in 18 weeks. Target has to be achieved by each specialty. The charts show the Trusts overall position.

All Specialities are achieving the 90% and 95% targets and the Trust is currently the best performing in the East of England.

Page 4


4.2 - 18 Weeks



Page 5


4.3 - 18 Weeks – Data Completeness

Data Completeness

Data completeness for May is as follows:

Admitted: - 108.8%%

Non Admitted: - 97.5%

Please note the tolerances for this part are between 90% and 110%.

The data completeness calculation is designed to check that patients are seen in turn, and that Trusts are not focussing their efforts on seeing patients who have not breached 18 week at the expense of people who have already passed their target date.

The data completeness calculation is based on the assumption that the number of patients that start an 18 week pathway should equal the number whose pathway finishes (clock stop) in any given month.  Moreover, the figures used to check that this assumption is correct have to be adjusted based on the particular data counting differences in each Trust – that is why there is a + and – tolerance level to account for the assumptions underlying the calculation.

To  make our figures as consistent as possible with the current calculation, and therefore fall within the tolerance levels,  we have recently adjusted the data set (Monthly Activity Return) used by the DH for the data completeness calculation so that it more accurately reflects clock starts and stops rather than capturing all activity that happened in a month (which was the original rationale for the return).

Page 6


5. Cancelled Operations

  • The cancelled operations target was met in May with only 4 patients being cancelled on the day of surgery.
  • Work continues to reduce the number of cancellations:-
  • Learn from cancellations to improve the pre-admission process
  • Progress the business case for a day of surgery admission area
  • Improve the ward admission process
  • Reduce theatre late starts
  • Reduce the impact of emergency work on elective surgery
  • Target 0.8%
  • Actual 0.73% (YTD)

Page 7


7. New to Follow Up Ratio

For Surgery – areas of under performance are being addressed within the specialty.

Performance management and review for the specialties where performance needs to improve is undertaken at the monthly performance meetings

= Excluded from the Contract

Green = On/Delivering to plan/below target

Amber = Within 10% tolerance of target

Red = Above 10% tolerance of target

Page 9

8 outcomes and effectiveness
8. Outcomes and Effectiveness

Hospital Standardised Mortality Ratio

HSMR remains below the expected level as can be seen by the overall mortality shown in the graphs and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators.

Green: Significantly better than benchmark

Blue: No significant variation from benchmark

Page 10

8 outcomes and effectiveness14
8. Outcomes and Effectiveness

Clostridium difficile

The target for 2010/11 is a maximum of29. A total of 2 additional C. difficile infections this month. RCAs were carried out and as a result, action was taken to provide additional information regarding appropriate antibiotic prescribing. In addition the cohort unit was re-opened to ensure appropriate isolation of C. difficile patients


No hospital acquired MRSA bacteraemias this month.

Cannula and Catheter High Impact Interventions

Good compliance with urinary catheter insertion and ongoing care. However, a small number of peripheral cannulas were identified that had not been removed when no longer required.

Page 11

9 patient safety
9. Patient Safety

Pressure Ulcers

No ward acquired grade 3 or 4 pressure ulcers this month. There were a total of 8 Grade 2 pressure ulcers that developed after admission, all of which had a concise RCA completed. Three of these developed in patients in the last 48 hours of life and were considered unavoidable. One further patient refused all preventative interventions. There was one patient in whom repeat risk assessments had not been carried out in a timely fashion and this has been addressed with the ward concerned.

Patient Falls

This month for the first time, we are reporting falls resulting in harm. Harm is defined by the PCT as falls resulting in physical injury however slight. All of these are required to have a concise RCA carried out. In total 21 falls resulted in harm, the majority of which were minor grazes or bumps. However, one fall resulted in a fracture; this patient had been advised not to walk without using a walking frame but unfortunately fell when mobilising without a frame. Concise RCAs were introduced in the middle of the month and were carried out on 16 of the 21 falls.

Page 12

9 patient safety16
9. Patient Safety


CQUIN requires the reporting of nutritional assessments carried out. This is one part of the nutritional outcomes assessment carried out by the matrons. Therefore from this month, the graph indicates the overall nutritional outcome result and also the percentage of patients that have had a nutritional assessment. Nutritional care is improving as a result of the input of the Matrons and the Productive Ward initiative, with particular improvements being seen on ward F4, F6, F9 and F10 all of whom had 100% compliance.

Assessment of Venous Thrombo-Embolism risk

Quarterly in-depth audits carried out by junior medical staff are to continue, but from this month we will also be commencing monthly reporting of VTE assessments on all patients throughout the Trust. These will be carried out by the coding department and will only look at whether the Assessment Proforma has been completed rather than examining the full content of the notes for evidence of assessment. As reported previously, utilisation of the proforma, is not consistent and therefore the monthly audits will give a lower score than the quarterly audits until this is corrected. The score for May 2010 using this method was 59% overall.

Page 13


10. Patient Experience

Patient Satisfaction (Near patient TV)

The number of responses increased to 251 this month following the introduction of the surveys to the Medical Treatment Unit. A full analysis of this survey and the PET survey over the last year has been provided to the Board this month.

Patient Satisfaction (PET)

A satisfaction rating of 85% was achieved this month using the PET system. 439 patients completed the survey.

Page 16

10 patient experience
10. Patient Experience

Same Sex Accommodation

A full analysis of breaches in EAU during May has taken place. Many were based on clinical need of patients, but some were due to capacity and patient flow issues. Consideration is being given as to whether re-organisation of bed capacity in EAU could improve utilisation of the bed capacity, and the impact that would have on patient flow and waiting time targets for A&E.

Page 17


12. Conclusion

  • An action plan is in place to improve 4 Hour Performance and ensure that performance improves for 2010/11. The Trust intends to ensure that in light of the announcement in the operating framework on Monday 21st June, patients are still seen as quickly and appropriately as possible within the A&E department.
  • Performance management of cancelled operations has been enhanced at the surgical directorate performance review meeting, focussing on reasons, specialty and individual if required.
  • Infection control indicators demonstrate good levels of compliance with procedures. There have been no new cases of MRSA bacteraemia and the level of C. difficile has reduced this month.
  • Nutritional care continues to improve and exceeds the CQUIN target.
  • Mortality rates continue to be better than the national average.

Page 18