1. society
2. welfare
3. healthcare
4. hospital

Quality & Performance Report: Priority
Objectives
Reporting period: to April 2013
Finance & Performance Committee - 6th June 2013
Contents
Strategic priority: Improving patient care and safety
-
HSMR & SHMI
Actual harm incidents [maps to BAF risk 39]
Pressure Ulcers
Infection control: MRSA bacteraemias and C-difficile cases
NPSA/MHRA safety alerts
Stroke care
CURRENT RISK
End April 2013
(to Mar)
(to Mar)
TREND *
↓
↑
↑
↑
↓
↑
PREVIOUS RISK
End Qtr 4 12/13 End Qtr 3 12/13
Qtrly
Strategic priority: Improving patient experience
- Complaints
- Patient experience (surveys)
- Same sex accommodation [maps to BAF risk 33]
(to Mar)
↑
↔
↑
Strategic priority: Clinical excellence and effectiveness
-
Delayed Transfers of Care
Trust 4hr wait standard in A&E [maps to BAF risk 3]
Cancer 62-day wait
18-week RTT admitted patients
EPC [maps to BAF risk 3 & 13]
Emergency re-admissions within 30 days [maps to BAF risk 13]
Clinical studies recruitment
(to Mar)
(to Mar)
(to Mar)
(to Mar)
↑
↑
↑
↑
↓
↔
↑
- 2013/14 CQUINs summary
- Latest Quality & Risk profile published by the Care Quality Commission
* Key:
Improvement on previous month
Decline on previous month
No real change on previous month
2
↑
↓
↔
Qtrly
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Hospital Standardised Mortality Ratio (HSMR)
Current target: Performing at upper decile levels for the out of London teaching hospital peer group and score < 90
CUH trend analysis
▪ Apr 2012 to Mar 2013 - 79.0* Relative Risk (HSMR
was 89.2* through the latest month)
▪
▪
▪
▪
Apr
Apr
Apr
Apr
2011
2010
2009
2008
to
to
to
to
Mar
Mar
Mar
Mar
2012
2011
2010
2009
-
80.8
74.4
81.2
80.8
Relative
Relative
Relative
Relative
Risk
Risk
Risk
Risk
* This is against 2011/12 baseline
Comparative analysis
Guy's & St Thomas', 67.0
King's College, 70.2
UCLH, 70.7
Imperial College, 72.7
Salford, 75.8
Cambridge, 79.0
St George's, 79.9
Bristol, 81.9
Leeds, 87.8
Barts Health, 89.3
Sheffield, 91.4
Newcastle, 91.5
Royal Liverpool, 93.3
Leicester, 96.2
Derby, 98.8
Oxford, 99.0
Southampton, 99.5
Nottingham, 100.1
South Manchester, 100.2
Lancashire, 100.5
Central Manchester, 104.5
Birmingham, 106.0
Relative Risk
HSMR Relative Risk for ATHOL & London Peer Groups: Apr 2012 to Mar 2013
115.0
110.0
105.0
100.0
95.0
90.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
45.0
40.0
Guy's & St Thomas'
King's College
UCLH
Imperial College
Salford
Cambridge
St George's
Bristol
Leeds
Barts Health
Sheffield
Newcastle
Royal Liverpool
Leicester
Derby
Oxford
Southampton
Nottingham
South Manchester
Lancashire
Central Manchester
Birmingham
▪ 2nd best performance against EoE peer group
(Papworth is ahead of us)
▪ 2nd best performance against ATHOL peer group
(Salford is ahead of us)
▪ Some of the London Hospitals have also been
included in the peer group. Guy's & St Thomas',
King's, UCLH and Imperial perform better than us.
Actions in progress
▪ The HSMR for the latest month available (March 2013 ) was 89.2, placing CUH as 6th best performing Trust for our peer group
(inclusive of London hospitals).
▪ We are still awaiting confirmation from the CQC as to whether they still view the Trust as an outlier for acute myocardial infarction
(MI) mortality following the response made to their alert issued in 2012. The CQC responded in May, however the letter did not confirm
whether we are an outlier or not. Discussions are ongoing.
▪ Formal consultant level sign-off of death certificates was implemented from 1st March 2013 and the first audit results were presented
to Clinical Directors in May. The results from the audit of deaths from 8 - 30 April evidenced 32.5% of death certificates were signed by
Consultants or that the Consultant had been consulted by the junior doctor completing the certificate. Some amendments to process
are taking place. Consultants are being reminded and an audit of May deaths will be undertaken.
Data Source: Dr Foster
3
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Summary Hospital-Level Mortality Indicator (SHMI)
Current target: Maintain 2012/13 level
SHMI for ATHOL & London Peer Groups: July 2011 to June 2012
SHMI Trend for all Activity Across the Last 3 Years
105
100
95
90
Derby, 108.26
Central Manchester, 110.48
Sheffield
Royal Liverpool, 106.42
Leeds
Birmingham, 106
Southampton
Leicester, 104.53
King's College
Lancashire, 102.11
Guy's & St Thomas'
South Manchester, 96.74
Salford
Oxford, 96.45
Barts Health
Nottingham, 93.75
Cambridge
Bristol, 93.63
Southampton, 90.79
Leeds, 91.54
St George's
Newcastle, 93.58
King's College, 89.92
40
Guy's & St Thomas', 87.48
Raw % rate
Salford, 85.73
45
Low
Barts Health, 83.71
60
50
Nat Av
Imperial College
65
55
SHMI
UCLH
70
St George's, 79.82
75
Cambridge, 83.64
80
Sheffield, 91.86
85
Imperial College, 75.82
Relative Risk
110
UCLH, 71.41
3.00
2.00
1.00
0.00
115
Relative Risk
30.00
20.00
10.00
0.00
90.00
80.00
70.00
120
Crude Mortality Rate (%)
60.00
50.00
40.00
12.00
11.00
10.00
9.00
8.00
7.00
6.00
5.00
4.00
120.00
110.00
100.00
Newcastle
Bristol
Nottingham
Oxford
South Manchester
Lancashire
Leicester
Birmingham
Royal Liverpool
Derby
Central Manchester
CUH trend analysis
Key differences between HSMR & SHMI:
▪ HSMR is in-hospital deaths only; SHMI
also includes those up to 30 days post
discharge
▪ HSMR adjusts for palliative care; SHMI
does not
▪ HSMR based on 56 diagnosis groups
(accounts for approx 80% of in-hopsital
deaths); SHMI group is wider (unspecified)
▪ Charlson Comorbidity Index is weighted
differently for each
▪ HSMR includes specialist, mental health
and community trusts; SHMI is nonspecialist acute trusts only
NB Quarterly update published only
Data Source: Dr Foster
4
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Patient Incidents resulting in Actual Harm
Current target: < 0.2% patient contacts resulting in harm recorded
CUH trend analysis
Actual Harm Patient Incidents per 1000 Bed Days
5.0
▪ The number of reported incidents resulting in
actual harm in April was 110 compared with 123 in
March, and 110 in February.
▪ 90% of actual harm is recorded as minor.
▪ The overall number of incidents (including nonharm) reported in April was 846 compared with 998
in March, and 832 in February.
▪ There were 70,065 patient encounters in April,
0.16% resulted in a reported incident where harm
occurred, compared with 0.18% in March.
Incident Rate
4.0
3.0
2.0
Rate
1.0
Mean
LCL
UCL
0.0
No of Harm Incidents
Comparative analysis
Physical Harm SPC Chart (Patient Incidents)
250
1200
1000
200
800
150
100
104 104 105 107 107 100 99
84
50
0
114 117
94
99
104
127 126
116
94
97
98
110
93
92
All
Harm (w/o non CUH PU)
All Harm
Mean
LCL
UCL
110
123
600
110
400
200
0
[based on NHS Commissioning Board April 2012 September 2012 data]
▪ 4th highest reporter in our peer group; 9.0 incidents per
100 admissions (median = 6.8)
▪ 86.7% incidents reported as no harm (peer group 74%)
▪ 11.3% incidents reported as low harm (peer group
21.1%)
▪ 1.7% caused moderate or severe harm (peer
group 4.3%)
▪ Incident type profile broadly similar to cluster
except reporting indicates we have less patient
accidents, but more medication, medical device and
infrastructure incidents.
Actions in progress
▪ The decrease in reported incidents for April was most noticable in Cancer (42% lower), Investigative Sciences (36%), Surgery (29%)
and Womens and Childrens (29%).
▪ In terms of types of incidents reported, decreases occurred in the areas of discharge, maternity (although the drop is accounted for by
incidents yet to be classified), medication (with decreases across administration, dispensing and prescribing) and finally patient care
where the majority of sub-classes have decreased.
Data Source: Risk Management
5
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Pressure Ulcers
Current target: 50% reduction of category 2 - 4 avoidable pressure ulcers (from 2012/13 level)
CUH trend analysis
Pressure ulcers - hospital acquired
25
20
2
1
3
15
10
16
3
6
1
17
7
10
9
1
1
0
1
10
9
12
8
7
7
6
8
8
8
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
0
11
0
7
13
5
0
2
4
4
May-12
Jun-12
7
Jul-12
4
6
Aug-12
Sep-12
Oct-12
Grade 1
Grade 2
▪ The 2013/14 CQUIN target for pressure ulcers
(PUs) is a 50% reduction in grade 2 - 4 incidents
including 'old harm'. It will be measured using the
Safety Thermometer.
▪ We have signed up and remain committed to the
SHA ambition to achieve zero hospital acquired
grade 2, 3 and 4 'avoidable' pressure ulcers within
the organisation.
▪ The one grade 3 registered for March and one
grade 4 - root cause analysis completed and for
scrutiny at the Harm-free Care Panel on 24th May.
▪ There were no grade 3 or 4 PUs in April.
Grade 3
Actions in progress
▪ The Trust has an action plan to deliver the 100% ambition to reduce 'avoidable' pressure ulcers and the CQUIN to reduce all PUs by 50%. This will be
challenging due to the inclusion of 'old' PUs (non-hospital aquired) within the CQUIN target. We have started collaborative working with our community
Tissue Viability colleagues to deliver the improvements across primary and secondary care. The CUH improvement work includes root cause analysis of
all hospital acquired grade 2, 3 and 4 pressure ulcers by the Senior Clinical Nurses and Senior Sisters. This improvement work will be developed and
overseen by the cross divisional prevention strategy group.
▪ A Harm Free Care scrutiny panel (commenced Feb 2013) oversees all falls resulting in moderate and severe harm alongside all grade 3 PUs. The
meetings have identified organisational learning and opportunities to share good practice.
▪ Ward L5 has completed the NHS Midlands and East PU Collaborative programme and are > 280 days without a PU (grade 1 & above). A PDSA pilot of
their improvement actions, safety processes and revised intentional rounding documentation are in place across 9 other wards. A phased organsation
rollout is planned for June.
▪ Both Medicine and Cancer have a SCN who has completed the PU Change Champion Programme. The change champions have worked with the Tissue
Viability Team to review and refresh the PU paperwork. The paperwork now follows the NHS Midland and East SSKIN bundle and compliance will be
measured via the Nursing Quality Metrics.
Data Source: Nursing Quality Metrics/CHEQS QlikView
6
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: MRSA bacteraemias
Current target ceiling: zero avoidable cases in 2013/14 (post 48hr infections only)
CUH trend analysis
▪ There were no cases of trust acquired MRSA bacteraemia during the month of April. ▪ Ceiling for 2013/14: no avoidable cases of MRSA bacteraemia Comparative analysis
Funnel chart showing Addenbrooke's Hospital's (in red) position
amongst other teaching hospitals in England for MRSA bacteraemia
rates (blood stream infections per 10,000 occupied bed days)
MRSA rate (latest 12 months to March 2013)
▪ 19th out of 25 UK teaching hospital peer group (23rd in Dec 2012, 23rd in Sept 2012 and 20th in Jun 2012)
0.5
0.4
Rate
Mean
3sd
2sd
▪ 16th out of 17 EoE hospitals (17th in Dec 2012, 17th in Sept 2012 and 16th in Jun 2012)
0.3
0.2
Actions in progress
0.1
0
0
100000
200000
300000
400000
500000
600000
700000
800000
-0.1
▪ Continue to audit compliance with MRSA decolonisation with feedback of results. -0.2
Data Source: Infection Control/CHEQS QlikView
▪ Increased MRSA screening on wards having a longer LoS for three month pilot to ascertain whether secondary transmission is occurring. 7
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Clostridium difficile cases
Current target ceiling: <= 39 cases in 2013/14
CUH trend analysis
▪ There were 6 cases of Clostridium difficile in the Trust within April.
▪ Ceiling for 2013/14: no more than 39 Trust acquired cases. Trajectory ceiling of 3 cases per month Apr to Dec 2013 and 4 cases per month Jan to Mar 2014.
▪ 6 cases for April, 3 over trajectory of 3 cases.
Comparative analysis
C‐diff rate (latest 12 months to March 2013)
Funnel chart showing Addenbrooke's Hospital's (in red) position
amongst other teaching hospitals in England for C. difficile rates (C
difficile infections per 1000 occupied bed days)
▪ 21st out of 25 UK teaching hospital peer group (14th in Dec 2012, 6th in Sept 2012 and 3rd in Jun 2012)
0.3
▪ 15th out of 17 EoE hospitals (14th in Dec 2012, 13th in Sept 2012 and 12th in Jun 2012). 0.25
0.2
0.15
Actions in progress
▪ C difficile summit held 17th April, attended by representatives from across the region. Formal report awaited from CCG. 0.1
0.05
Rate
Mean
3sd
2sd
0
0
100000
200000
300000
400000
Data Source: Infection Control/CHEQS QlikView
500000
600000
700000
8
▪ Visit to two hospitals in Nijmegen, Netherlands to observe policies & practices and implement what has been learnt. Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: NPSA/MHRA safety alerts acted upon within timescale
Current target: 95%
% NPSA/MHRA alerts acted upon within timescale
100%
CUH trend analysis
[Quarterly update only]
▪ 2012/13 financial year performance was 92%
▪ In quarter 4 (Jan-Mar 2013), 15/16 alerts received
were completed within time (94%).
▪ Financial year Q1: 74%, Q2: 100%, Q3: 100%, Q4:
94%.
▪ Internal target was increased to 95% (from 90%).
We failed to achieve this due to poor Q1 performance.
90%
80%
70%
Rolling 12mths
60%
Target
50%
40%
Actions in progress
▪ There is currently one overdue NPSA alert. This relates to introducing safer spinal needles and was due to be implemented by 1 April
2013. Final trials are being completed and implementation is scheduled for July 2013.
▪ The Patient Safety Executive (PSE) monitors compliance, and ensures action to address any non-compliance is undertaken.
Data Source: Risk Management
9
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient care and safety
Performance indicator: Stroke care patients who spent at least 90% of their time on a stroke unit
Current target: 80%
CUH trend analysis
Stroke patients > 90% their stay on a Stroke Unit
▪ April 2013 performance was 83.8% and favourable to
target.
▪ Overall 2012/13 year compliance was 76.7% adverse to
80% target.
▪ National Guidance methodology changed to 'hours/ minutes'
calculation from April 2012.
100.0%
90.0%
80.0%
70.0%
60.0%
National Guidance
50.0%
Internal Monitoring (in hours)
Current information:
▪ SSNAP test data collection has been succesful. Jan - Mar
2013 data was uploaded on 17th May.
▪ 19 patients missed the Best Practice Tariff in April because
of not achieving either the four hour admission to the stroke
unit or 90% time on the stroke unit.
Target
40.0%
Root cause analysis and action plan
37 stroke patients were admitted to the Trust in April and overall the target for th 90% of time on a stroke unit was achieved. Six of these patients did not meet the
required standard.
Theme 1: Lack of capacity on the stroke unit
Stroke unit full to capacity, with 100% stroke patients on occasion.
Action: Community rehab and ESD services. CUH is currently responding to further commissioning queries regarding our bid to manage the early supported discharge
service (ESD). An updated submission, which involves CUH as the single service provider, is currently being worked up and should be finalised by the beginning of June.
Theme 2: Unclear presentation
Unconfirmed diagnoses of stroke whilst in the ED meant the need for stroke bed was not identified. Lack of ROSIER (recognition of stroke in the emergency room) tool
contributed to delayed diagnosis.
Action: ROSIER tool now included in the nursing notes (neurological chart). Stroke nurse consultant to resume teaching sessions in the ED in May.
Theme 3: Delay in medical review in the ED combined with short LOS
Time taken to assess patients in the ED meant that 90% of length of their stay was not in the stroke unit.
Action: Stroke team to liaise with the ED medical team over the length of time patients spend in ED. Operational team to monitor use of, and adherence to, the revised
operational policy, including use of the bedstate plan which is produced by the stroke nurse bleepholder.
Theme 4: Failure to request a stroke bed from the ED
Prompt diagnoses of stroke but this was not communicated when requesting a bed.
Action: Stroke clinical director to follow up with the medical team involved to ensure that medical staff liaise with the ED nurse bleepholder over the need for the
appropriate bed. ED nurse bleepholder, in turn, to follow the operational policy and liaise with the site co-ordinator.
Other issues affecting patient flow in month
The stroke service lost 111 bed days due to medical outliers being placed on the acute stroke unit. Neuro rehab occupied beds on Lewin for 145 bed days.
Data Source: HISS
10
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient experience
Performance indicator: Timeliness of complaint responses
Current target: 90% within 25 days
Actions in progress (as result of a complaint investigation
during March 2013)
60
50
40
Nursing/Midwifery Care:
Significant action plan for Ward C8 in respect of pressure sore management (Deputy Chief Nurse involved). Stop The Pressure work ongoing on the ward.
Action for Ward C2 Ward Manager in respect of ensuring that documentation is correct when medication is given where the dosage is dependent on the patient’s weight. Pharmacy to also be involved in this action to ensure prescriptions are weight adjusted. Action for Ward Manager for Lady Mary Ward in respect of ensuring staff respond to call buzzers in a timely manner.
Action for SCN for PSSU in respect of water jugs, poor communication and ensuring that patients are appropriately clothed on discharge. 30
20
10
0
Within 25 days
Over 25 days
Total number of Complaints and PALS Enquiries
700
Complaints
600
Concerns
Other
431
500
379
400
131
300
200
0
40
314
237
228
100
146
124
123
42
36
37
92
99
117
230
246
244
26
43
86
286
208
43
149
120
128
50
255
51
26
294
263
189
31
42
286
55
Training:
Staff training required for Ward D2 in respect of the use of photo light therapy equipment. Practice Development Team now involved in education sessions.
Change to a process or procedure:
Change in administration process for CDC – clinic list is now printed off the night before the clinic in case for any reason a receptionist is absent. Admin staff also reminded to update parents when there is a delay. CUH trend analysis
▪
▪
▪
▪
▪
▪
In March, all of the 55 complaints were resolved within 25 days.
88.8% complaints resolved within standard for the financial year 2012/13, adverse to the target.
89.9% complaints resolved within standard in the 2011/12 financial year, marginally adverse to the target, and 91.9% during 2010/11.
The number of PALS enquiries and concerns are also included to highlight all issues identified by patients.
All issues received are investigated - any common themes identified by the PALS team are fed back to relevant parties so they can be addressed.
The PALS team prioritise their attendance at SDU Clinical Governance meetings accordingly.
Data Source: PALS/CHEQS QlikView
11
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient experience
Performance indicator: Internal patient discharge survey scores (- selected questions)
Current target: >= 2012/13 met/exceeded expectations levels
Were the staff kind & caring:
CUH trend analysis
These 3 questions are focussed upon because they reflect the Trust values ‐ kind, safe & excellent
▪ 'Were the staff kind & caring' ‐ 95.5% patients reported met/exceeded expectations in the latest April 2013 survey, a 1.5% decrease on March. Wards D7 (29.4%), C5 and C4 all received scores of > 10% below expections. This is not a trend.
Doctors kept me informed about my condition and treatment:
▪ 'Doctors kept me informed about my condition & treatment' ‐
93% patients reported met/exceeded expectations in the latest April 2013 survey, a 1% increase on March. Wards F4 (25%), D6, D7, D8, C8, C6, G5 and L5 all received scores of >10% below expectations.
This is consistant for wards D8, D6, C8 and L5 in March.
I felt safe as a patient:
▪ 'I felt safe as a patient' ‐ 95% patients reported met/exceeded expectations in the latest April 2013 survey, 1% decrease on March. Wards D7 (23.5%), C5 and F4 all received scores of >10% below expectations. Divisional nurses meeting with a member of the Patient Experience directorate on a monthly basis to discuss their net promoter scores and other results
from patient experience surveys. Actions are identified and implemented across the Trust. These actions are reviewed at the following month's
meeting:·
∙ Establishment of a group led by the Chief Nurse, looking at actions as a result of the Francis Report. More work on patient & staff experience will come out of
this in due course.
· Patient flow project working to plan the following day’s discharges aiming for discharges early in the day – ongoing review including medicine sharing surgical
division improvement model. New paper work also being implemented.
· In terms of the Rosie, group discharge on the postnatal ward continues to work well. Patient info DVD being developed which will further release time to care.
Improvement pre-assessment in Surgery also in place.
· Pilot of Case Management, transforming internal processes on the pilot wards through ownership and proactive management of the entire patient
journey, leading to reductions in length of stay – excellent patient feedback received.
· Workshop planned for trauma and Orthopaedic Band 6’s – complaints being shared at ward level.
· Specific Trauma and Orthopaedic DVD being produced, as part of update to the website and all Surgical wards are reviewing /updating their information for inpatients.
· Ongoing work within Surgery with specialist nurses to work clinically with staff/ patients to help improve communication and advice around discharge.
· Again, across surgery, senior nurses have been rostered on shifts for the weekends to provide clinical support but also to support and pro-actively manage
patient concerns.
· Senior nurses were working on improving the patient experience at night – showing improvement, Rosie next to implement.
· Theatres ATC Recovery ATC focus group held and third Main Recovery Focus group for patients and their families.
· Within theatres, the establishment of a phone line for relatives only, to enable easier contact for families and the appointment of a new patient advisor appointed.
· Senior Sister for theatres now has a patient experience lead for theatres and recovery linking in with day surgery.
Data Source: Discharge Survey/CHEQS QlikView
12
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Improving patient experience
Performance indicator: Achieving single sex accommodation (SSA)
Current target: 100% compliance, 0 sleeping breaches
Number of SSA incidents reported
4
Sleeping breaches
Patient placement
CUH trend analysis
3
SSA incidents include:
▪ Sleeping breaches - no sleeping breaches in April 2013.
▪ Patient placement (where the patient has no co-located
same sex sanitary facility) - 1 reported incident in April.
These are considered 'justifiable' breaches and therefore do
not incur a financial penalty.
2
3
1
2
2
0
0
1
0
0
0
0
0
1
0
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Feb-13
98%
97%
98%
95%
96%
▪ Inpatient experience questionnaire data reflects the
patients' perception of same sex facilities.
96%
% compliance
Inpatient Experience Questionnaire results
100%
99%
98%
97%
96%
95%
94%
93%
92%
Mar-13
Apr-13
Sleeping with patients of same sex
Use same sex toilets/showers
Question
Actions in progress
▪ Incidents above include all sanitary and sleeping accommodation breaches reported.
▪ There have been no sleeping beaches reported since April 2012.
▪ We have completed the actions within our SSA action plan and refreshed our compliance statement.
Data Source: Risk Management, Nursing Quality Metrics/CHEQS QlikView
13
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: Delayed Transfers of Care (DTOCs)
Current target ceiling: 20 Patients overall per week
Delayed Discharges Monitoring Report
70
Numbers of Patients Per Week
60
50
40
30
20
10
0
Overall target
Delayed Discharges Cambs PCT - Actual
Other PCT's - Actual
Actions in progress
Good progress in both assessment and capacity delays had been achieved until the beginning of April. Assessment delays and Rehab capacity both had achieved the agreed trajectory . This progress has not been sustained in April and indeed increases have been well above the March 31st trajectories. Assessment delay saw a loss of focus and loss of capacity within the team due to sickness both are being addressed ‐senior manager running the twice weekly PTL and escalation,daily review of assessment requests and allocation undertaken, additional staff moved to the team. Staff from within the trust will be trained to support this team to address the ongoing management of workload variation .
CCS were delaying in opening beds at Brookfields leading to Rehab delays; the CCG have commissioned aditional beds from Cambridge Nursing Centre to improve the situation and provide a more flexible resource.
At the CEO meeting there was agreement to develop a better process to give the system leverage with the independent sector for both home care and
care homes. CUH have also been asked to work with the CCG to develop a plan to manage community beds over the winter period.
Data Source: DT Office
14
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: A&E Clinical Quality
Current target: Total time in A&E - 95% within 4 hours
CUH trend analysis
▪ In April 2013 performance was 92.79%
▪
▪
▪
▪
▪
2012/13 overall performance was 94.64%
Q4 2012/13 - 94.15%
Q3 2012/13 - 96.01%
Q2 2012/13 - 95.84%
Q1 2012/13 - 92.53%
▪ 2011/12 overall performance was 94.98%
Latest performance
▪ The CHEQS live target monitoring tool continues to be
reviewed daily.
▪ Q1 2013/14 (to 22nd May) is 94.1%.
In April we only achieved 92.8% against the ED 4 hour standard, which was the second consecutive month we have missed the required 95%. We have
particularly felt pressures in March and April 2013. Attendances in this period have been 3.6% up on 2012, and admissions from A&E 9.8% up on 2012.
Admissions in the over 85 age group increased by 11.6% on the previous year. Emergency medical admissions in the first 2 weeks of April were the highest
weeks we have recorded. Conversion rate for the month was 33.5% but saw the first 2 weeks up at 36.9% and 34.6%.
Performance in May is 96.1% (22nd) , with a breach tolerance of 10 breaches per day to achieve Quarter 1 against an average of 11 per day in May to date. We
have met this threshold on 17/22 days so far this month.
Actions in progress
On 9th May, NHS England issued a call to all Area Directors to facilitate CCGs in the preparation of local recovery and improvement plans centred around each
A&E department. These system plans are to be submitted to Regional Directors by the 31st May. Cambridgeshire and Peterborough CCG are co-ordinating the
system plan by 23rd May. We have submitted our plans focused on the stages of the patient journey:
Pre-Hospital - primarily primary care and community actions focused on attendance/admission avoidance. It also includes 111 NHS Direct implementation.
Emergency Department - actions internal to the ED including ambulance handover, liaison psychiatry, ambulatory care, Rapid assessment and treatment
(RAT)
Acute Inpatient Flow - Incorporating the actions of the Trusts Unplanned Care and LOS Programmes
Acute and Community Discharge Planning - Covering the actions associated with reducing both internal and external delays for Delayed Transfers of Care.
Data Source: HISS/CHEQS QlikView
15
Document owner: Director of Information Systems and Analysis
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: A&E Ambulance Handover Delays
CUH trend analysis
100%
▪ Q4
▪
▪
▪
90%
80%
2012/13:
56% of patients were seen within 15 minutes
92% of patients were seen within 30 minutes
99% of patients were seen within 60 minutes
70%
% of Patients handed over within 15 mins
60%
50%
% of Patients handed over within 30 mins
40%
30%
% of Patients handed over within 60 mins
20%
0%
Apr 12 May Jun 12 Jul 12 Aug 12Sep 12 Oct 12 Nov Dec 12 Jan 13 Feb 13 Mar Apr 13 May Jun 13
12
12
13
13
No. of Patients
over within 30
No. of Patients
over within 60
not handed
mins
not handed
mins
Latest performance
▪ In April 2013:
▪ 65% of patients were seen within 15 minutes
▪ 95% of patients were seen within 30 minutes
▪ 99.8% of patients were seen within 60 minutes
10%
Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013
365
345
390
191
174
186
239
157
198
170
165
118
97
48
30
51
14
18
10
27
7
15
9
17
6
4
▪ With effect from April 2013 there are financial penalties of
£200 for every patient over 30 mins, and £1000 for every
patient over 60 mins. This equates to £23,400 for April but
data from EEAST is still unvalidated.
Key issues and actions
Ambulance handover performance has been steadily improving throughout the last year. These delays occur when the Emergency Department is overcrowded. We are 1 of only 5
Trusts out of the 18 in the region who are risk rated green for Ambulance handover delays over 60 minutes throughout April.
▪ New red and green light process agreed and implemented. When Ambulance crew see the green light they know to off load the patient immediately without coming into the department first to
establish if there is space to offload.
▪ Tripartite handover protocol and escalation plans in place
▪ Monthly tripartite performance and operational review meeting established with EEAST and CCG, with associated actions driving improvements.
▪ Ongoing Ambulance Trust and ED communications and training programme in place.
▪ Clarification on the validation of the data is still being sought via Commissioners. Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: Cancer monitoring - 62-day wait target 85%
Type
2Wk Wait (93% )
2wk Wait SBR (93% )
31 Day FDT (96% )
31 Day Subs (Anti Cancer) (98% )
31 Day Subs (Other) (93% )
31 Day Subs (Radiotherapy) (94%)
31 Day Subs (Surgery) (94% )
62 Day from Screening Referral (90%)
62 Day from Urgent Referral (85%)
62 Day from Urgent Referral with reallocations (85%)
62Day from Screening Referral with reallocations (90%)
62 Day from Consultant Upgrade (Target TBC)
12-13 Q1 12-13 Q2 12-13 Q3
93.7%
96.2%
96.2%
99.6%
100.0%
94.4%
96.5%
92.3%
76.9%
78.1%
93.1%
75.0%
Jan-13
Feb-13
Mar-13
12-13 Q4
93.3%
97.7%
96.2%
99.6%
100.0%
95.2%
93.0%
90.2%
80.8%
95.7%
94.6%
96.4%
100.0%
100.0%
97.6%
94.9%
98.1%
80.3%
95.5%
96.4%
97.3%
100.0%
100.0%
97.9%
96.9%
100.0%
83.9%
97.1%
90.9%
97.7%
100.0%
100.0%
97.1%
96.0%
100.0%
83.3%
96.5%
93.7%
98.4%
100.0%
100.0%
96.8%
95.3%
100.0%
88.3%
96.4%
93.6%
97.8%
100.0%
100.0%
97.3%
96.1%
100.0%
85.0%
82.7%
90.2%
81.7%
98.1%
85.2%
100.0%
86.7%
100.0%
89.8%
100.0%
87.0%
100.0%
89.36%
92.50%
87.50%
83.30%
93.30%
88.60%
Key performance issues:
In March all cancer standards were achieved even without the inclusion of any agreed reallocations. This also resulted in all the standards for overall
Quarter 4 being achieved.
Analysis of 62 Day urgent referral performance
7 cancer sites incurred breaches of the 62 day standard in March. Urology accounted for 47% of the breaches this month. The most significant reason
for breaches in the month was late referral between Trusts (33%). Of the 8 patients who breached for this reason we secured reallocations for 4, but
had to concede 1 breach on a patient we were unable to treat in time despite being referred before day 38.
Performance projection for April onwards
In April, all standards except the 31 day subsequent radiotherapy standard are expected to be achieved. Following the previously reported issues with a
Linac being taken out of service, we do expect to recover this standard for Quarter 1.
In May we will not achieve the 62 day screening standard with 3.5 accountable breaches against an average monthly tolerance of one breach. 3 patients
had diagnostics / treatments delayed for medical reasons, and one patient was referred on day 50 from Peterborough. Therefore performance for May
will take us up to the maximum tolerance breach for the entire quarter putting this target at risk.
Data Source: HISS, JCIS
17
Document owner: Interim Chief Operating Officer
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: 18-week referral to treatment (RTT)
Current target: Admitted patients 90%, Non-admitted patients 95%, Still Waiting 92%
DOH Group
Trus t Aggregate
100 - General Surgery
101 - Urology
110 - Traum a & Orthopaedics
120 - ENT
130 - Ophthalm ology
140 - Oral Surgery
150 - Neuros urgery
160 - Plas tic Surgery
170 - Cardiothoracic Surgery
300 - General Medicine
301 - Gas troenterology
320 - Cardiology
330 - Derm atology
340 - Thoracic Medicine
400 - Neurology
410 - Rheum atology
430 - Geriatric Medicine
502 - Gynaecology
X01 - X-Other
% Adm <= 18 Weeks
(90%)
92.7%
95.6%
93.3%
82.7%
94.0%
94.8%
94.4%
88.6%
92.1%
100.0%
97.8%
100.0%
91.7%
93.8%
100.0%
92.3%
100.0%
97.6%
93.7%
% Non Adm <= 18 Weeks
(95%)
97.7%
95.1%
96.4%
95.2%
96.6%
96.4%
96.4%
95.6%
95.4%
100.0%
100.0%
98.6%
94.6%
97.6%
100.0%
99.6%
98.4%
100.0%
99.5%
98.7%
% Still <= 18 Weeks
(92%)
97.1%
97.5%
97.6%
94.5%
95.7%
98.0%
97.6%
95.6%
96.6%
98.0%
96.2%
99.9%
96.7%
96.9%
97.8%
99.2%
99.3%
100.0%
98.1%
97.0%
Key performance issues:
The Trust aggregate admitted patient standard was achieved for the fifth consecutive month in April at 92.7%. 3 specialties underachieved against the RTT
standard in the month.
The number of patients exceeding 18 weeks (admitted and non-admitted) has reduced from 652 last month to 479 as at 13th May. Admitted backlog has
decreased slightly to 197 from 217, #N/A
and non-admitted backlog from 435 to 282.
We have one patient who has exceeded 52 weeks reportable this month. An orthopaedic patient did not have their waiting list entry processed, and it was not
until the patient rang to enquire a year later that the booking teams were aware. The patient was admitted within 2 weeks of making contact.
Orthopaedics achieved the non-admitted target in April for the first time since 2011. The backlog of admitted patients waiting at the end of June is expected
to be below the ~30 threshold for admitted performance. High referral rates in March are resulting in a high surgical demand for July 2013.
ENT achieved the admitted standard in April but this is not yet sustainable. The shared Consultant post with Peterborough, and the CUHFT Paediatric ENT
Consultant post have both been appointed to, but are unlikely to commence until Sept /Oct 2013.
Neurosurgery continue with a backlog of admitted patients following elective cancellations in March and April. Weekend and independent sector activity is
planned.
Cardiology have reduced their backlog of patients exceeding 18 weeks by 60% in 6 weeks, which is resulting in failure of the non-admitted target. This is
likely to continue to impact performance in May.
Data Source: HISS, JCIS
18
Document owner: Interim Chief Operating Officer
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: Upper decile performance
Current target: 155 bed equivalents saved in 2013/14
CUH trend & comparative analysis
EPC - Cumulative Savings Progress
35000
Bed Days Saved
30000
▪ EPC programme has delivered -15.5 cumulative beds
for the 2012/13 year against a trajectory of 88.5.
▪ Allowing for 50% of DTOCs would improve
performance to 21.3 beds saved.
▪ Overall non-elective was LoS 5.9 days for March
(baseline 5.7).
▪ Overall elective LoS was 0.8 days for March (baseline
0.9).
▪ Day case basket rate (inclusive of BADS day cases and
outpatient procedures) was 86.5% for the financial year
against target of 90%.
Planned Cumulative Bed Day Saving
25000
20000
15000
10000
Actual Cumulative Bed Day Saving
Actual Cumulative Bed Day Saving (With 50%
allowance for delayed transfers)
5000
0
-5000
-10000
It is primarily non-elective LoS in Medicine and Surgery
that has resulted in the deterioration against the
baseline. Medicine's finacial year performance was 8.5
compared to 8.2 baseline, whilst Surgical Services was
5.8 compared to 5.4 baseline.
Key Issues and Actions
▪ The March position deteriorated further from the previous month by -1.6 bed equivalents. At Trust level, the non-elective LoS did recover from the
poor February position, but remained adverse to baseline. Elective LoS has remained equivalent to baseline for the full year, but was marginally
improved in March.
▪ Medicine non-elective LoS was 0.4 days up on baseline at year end. Perfromance deteriorated against baseline by more than 1 day in Stroke,
Gastroenterology, Geriatric Medicine, General Medicine , Infectious diseases and Hepatology.
▪ Surgical non -elective LOS also ended the year 0.4 up on baseline. Plastic surgery and Orthopaedics deteriorated by more than 1 day compared to
baseline.
▪ Neurosciences achieved gains of 5.7 bed equivalents during the year. Women's and Children's 4.8, and Cancer 4.1.
▪ The only Division that met trajectory for LoS savings this year was Investigative Sciences which includes Radiology, Clinical immunology, Diabetic
Medicine and Endocrinology, although the latter 2 deteriorated on baseline LOS. This was likely the impact of opening the radiology day unit and
recording more elective activity under this Division.
The LoS Transformation programme will be taking forward the agenda to reduce LoS for 2013/14. Together with Unplanned Care and Variation of
Care the target is to gain 155 bed equivalents in capacity during 2013/14.
Data Source: HISS, LBC, Dr Foster/CHEQS QlikView
19
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: Emergency re-admissions within 30 days
Current target: < 10% avoidable re-admissions (via the local health economy audit)
400
300
250
292
286
316
236
271
296
244
200
100
95
95
90
109
89
81
101
96
CUH trend analysis
346
319
308
109
83
▪ The readmission policy for 2012/13 also excludes transplant
patients who are readmitted. Past data has been refreshed to
take account of this additional exclusion.
280
116
108
▪ The total volume of readmissions for March 2013 has again
increased from last month, with the highest volume of non
elective readmissions all year.
0
Elective
▪ Of the 346 non-elective readmissions in March, 49% of
these were originally discharged from the Medical Division,
with a further 26% from the Surgical Division and 12% from
Emergency Assessment.
Non‐Elective
Readmission Primary Diagnosis
Total
J440 Other chronic obstructive pulmonary disease Chronic obstruct pulmonary dis with acute lower resp infec
R074 Pain in throat and chest Chest pain, unspecified
N390 Other disorders of urinary system Urinary tract infection, site not specified
J181 Pneumonia, organism unspecified Lobar pneumonia, unspecified
R103 Abdominal and pelvic pain Pain localized to other parts of lower abdomen
A099 A099
T391 Poison by nonopioid analgesic antipyretic and antirheumatics Poisoning by 4-Aminophenol derivatives
J22X Unspecified acute lower respiratory infection Unspecified acute lower respiratory infection
I269 Pulmonary embolism Pulmonary embolism without mention of acute cor pulmonale
J459 Asthma Asthma, unspecified
R296 R296
T810 Complications of procedures, not elsewhere classified Haemorrhage and haematoma complicating a procedure NEC
R104 Abdominal and pelvic pain Other and unspecified abdominal pain
T814 Complications of procedures, not elsewhere classified Infection following a procedure, not elsewhere classified
R31X Unspecified haematuria Unspecified haematuria
21
15
13
12
12
10
9
9
9
8
8
8
8
7
7
▪ There were 108 elective readmissions in March.
53% of which were discharged from the Surgical
Division and 24% from the Medical Division, and 10% from
Women's and Children's.
Key Issues and Actions
▪ Non-elective readmissions were the highest for 2012/13 in March. Over 75 yr old age group accounted for 40% of non-elective readmissions in the
month which was consistent with the full year. The readmission for COPD were 60% higher in March than in any other month in the year. The COPD
business case is still to be approved by the local commissioning group, and a further meeting is due in the next 2 weeks.
▪ The elective readmissions dropped in the month. Of the 108 elective readmissions 36 were readmitted for conditions within the same HRG chapter.
13 this month were following elective diagnostic admissions through Endoscopy. Excluding these, the specialties with the highest number of elective
patients readmitted were Orthopaedics (12), Ophthalmology (7), Urology(7) and ENT (7). 50% of these were readmitted to the same specialty.
▪ The credits given against the readmission policy for 2012/13 totalled £1.02 million , £782k non-elective and £239k elective.
Data Source: HISS, LBC
20
Document owner: Director of Information Systems and Analysis
Cambridge University Hospitals NHS Foundation Trust
Strategic Priority: Clinical excellence and effectiveness
Performance indicator: Percentage of studies meeting the NIHR time and target metric of 70 days from the submission of a valid research
application until recruitment of the first patient
Situation as of 29/04/2013 reported to NIHR
CUH trend analysis
[Quarterly update only]
NIHR 70 day time and target metric Q4 2012‐2013
R&D 35 day approval target
100%
90%
22%
20%
11%
20%
SK to provide
80%
70%
60%
50%
40%
30%
67%
60%
20%
10%
0%
Non‐commercial
Commercial
Not yet recruited, outside 70 days or recruited outside target
Not yet recruited but still within target
Recruited within 70 days
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
94%
100%
Comparative analysis
6%
Non‐comm
The NIHR time and target initiative aims for studies to
recruit their 1st patient within 70 days from the submission
of a valid research application.
▪ Internally R&D are working towards a 35 day target to
approve the submission, with 35 days (or more if approved
quickly) allotted to the PI to recruit.
▪ In Q4 10 commercial studies and 18 non-commercial
studies met the NIHR reporting criteria.
▪ Of these, 80% of commercial and 78% of noncommercial studies met, or still have the potential to meet,
the 70 day target.
▪ 100% of commercial and 94% of non-commercial
studies were given R&D approval within 35 days. This
equates to a median of 4 days for commercial study
approval and 7 days for non-commercial study approval.
Comm
R&D approval 35 day target met
R&D approval 35 day target not met
Comparative analysis Q3 and Q4 2012-2013
▪ For non-commercial studies, the % of studies that have
met or will meet the NIHR target has increased from 62%
to 78%. The number approved within 35 days has
remained 94%.
▪ For commercial studies this figure has increased from
17%-80%. The number approved within 35 days has
increased from 84% to 100%.
Actions in progress
▪ Over the 2012-2013 year systems have been established to improve recruitment times and meet the NIHR's 70 day requirement. Considerable
improvement has occurred, despite quarterly fluctuations. R&D continue to pro-actively engage investigators throughout the approval process
and beyond in order to achieve first patient recruitment in a short time period.
Data Source: Research and Development Office
21
Document owner: Director of Information Systems and Analysis
CQUIN Indicators 2013/14
Q1 target
Pressure Ulcers
30%
100%
NATIONAL 3
Dementia
60%
20%
20%
NATIONAL 6 Highly
Specialised
NATIONAL 5
Specilaised
NATIONAL 4
VTE
VTE Risk Assessment
25%
VTE Root Cause Analysis
Clinical Dashboard for
Specialised Services
Highly specialised services
clinical outcome
collaborative audit
workshop and provider
report
75%
Roll out
Roll out
Maternity Oct additional
2013
services Mar
2014
Deliver the nationally agreed roll-out plan to
the national timetable - Maternity by end of
October 2013 and additional services
(TBD) by end March 2014
Increasing response rate in acute inpatient Set baseline
and A&E areas. Achieve in top 50% which (min 15%)
also improves on Q1 rate.
National top
50%
>Q1
> 20%
Improved perfromance on the staff friends
and Family test compared to 2012/13, or
remain in top quartile
% of target
reduction
achieved:
< 20% =£0%
20-39%=£10%
40-59%=£20%
60-79%=£30%
80-95%= £40%
95%+=£50%
Number of patients recorded as having a
category 2-4 pressure ulcer as measured
using the NHS Safety Thermometer.
CQUIN focuses on all Pus in the data
collection with aim to reduce 2012/13
prevalence rate baseline by 50%
% of the number of patients above who
answered positively to the case finding
question who have had diagnostic
assessment
% of patients who had a positive of
inconclusive assessment outcome who
were referred on to specialist services
Named clinician for Dementia and
appropriate training for staff
Clincal Leadership
Supporting Carers
CQUIN Value
March 2014
£158,620
Q4 average
£211,492
February 2014
£158,621
Assessed at 6
monthly intervals
£528,735
Lead
National top 50%
>Q1
> 20%
>2012/13, or
remaining top
quartile
% of target
reduction
achieved:
< 20% =£0%
20-39%=£10%
40-59%=£20%
60-79%=£30%
80-95%= £40%
95%+=£50%
12-13 baseline =
2.9%
Target = 1.4%
Improvement % =
1.4%
Apr - 92.6%
90%
90%
90%
90%
Apr - 100%
90%
90%
90%
90%
90%
90%
90%
Apr - 100%
90%
Confirm named
clinician and
planned training
programme pre
April
Planned training
programme has
been
undertaken
Monthly audit
reported to
Board
Monthly audit of carers of patients admitted
with dementia during their stay. Results
reported to the Board.
% pf adult inpatients who have had a VTE
risk assessemnt on admission to hospital
Roll out plan
implemented
>2012/13, or
remaining top
quartile
Monthly audit Monthly audit
reported to reported to
Board
Board
Apr - 98.9%
95%
95%
The number of root cause analyses carried 25% of cases
have RCA
out on cases of hospital assocaited
thrmobosis
To embed and demonstrate routine use of
specialised services clincal dashbaords
35% of cases
have RCA
95%
50% of
cases have
RCA
95%
85% of cases
have RCA
Mar-14
An average of 90%
or greater in each
element each
month for any 3
consecutive months
in the first year
Full participation of provider's highly
specialised services in the collaborative
audit workshop
Confirm
represntatives
for all relevant
services and
collection and
analysis
underway
22
Update on
preparaton for
the workshop
Confirm
attendance
across all
relevant
servcies
Submit a
professional
standard report
as defined
Mar-14
£317,241
Mar-14
Planned training
programme has
been undertaken
Mar-14
average response
Apr-13 to Mar 14
rate 25%
Monthly
achievement paid
Qrtrly as long as Apr-13 to Mar 14
Qtrly RCA target
achieved
Quarterly
achievement
Apr-13 to Mar 14
Quarterly monitoring
to be agreed by
end June 13
100%
100%
2013-2014 Final
Indicator period
Indicator description
% of emergency admissions aged 75 who
have been asked the dementia case
finding question
Find, Assess, Investigate
and Refer
Year end Target
Brenda Hennessey
Staff Friends and Family
Test
40%
Q4 target
Sharon McNally
Increased response rate
30%
Q3 target
Sharon McNally
NATIONAL 2
Safety Thermometer Improvement
NATIONAL 1
Friends and Family Test
Phased Expansion
Q2 target
£83,583
£127,912
£132,184
£396,551
Mar-14
£443,294
Mar-14
£443,294
All quarterly
requirements met
50% payment if
workshops
attended
50% payment on
approved reports
Caroline Baglin
CQUIN
Quarter 1
Actual
CQUIN Programme Manager*
Goal Number
% Indicator
weighting
Q1 target
100%
100%
Agree baseline
% of emergency admitted patients aged
85yrs and over whose carers or relatives
have been contacted during their
admission.
Determine
baseline
Improvement on
baseline
Orthopaedic trauma patients aged over
65yrs are medically assessed by a
consultant orthogeriatrician/ ST3 within 72
hrs of admission( baseline 52.8%)
Advertise
Consultant
All frail elderly patients admitted to the Trust
are to be managed under the care of a
senior member of the DME team
% of heart failure patients given a
personalised management plan shared
with the, their carer, their GP.
Reduce to 10% or less the number of new
shunts requiring revisions within 30 days of
insertion due to infection
LOCAL 8
100%
LOCAL 9
Neurosurgical Shunt
Surgery
LOCAL 10
Specialist DME staff to be contactable by
GPs, district nurses, or community
matronsin order to support earlier and
more robust discharge arrnagements
Neonatal Intensive Care timely administration of total
parental nutrition
Recruit
Consultant
25%
Recruit staff
LOCAL 11
Renal transplant cold iscahemic
time
100%
Appoint staff Achieve 10%
and
improvement
commence
improvement
Improvement
on baseline
60%
1. July -13
Evidence of
recruitment plan
supplied
2. July -13 Report
on mobilisation plan
3. March-14 10%
improvement
achieved
1. July -13 £10%
2. July -13 £20%
3. March-14
£70%
£2,456,705
Apr-14
£343,939
50% improvement 50% improvement on
on baseline
baseline
75%
Jan -14 £40%
Apr - 14 £60%
75%
50%
25%
50%
75%
Oct 13 £20%
Jan 14 £30%
Apr 14 £50%
75%
75%
£343,939
Oct 13 £25%
Jan 14 £25%
Apr 14 £50%
£147,402
Reporting format
to be proposed
and agreed
10%
Quarterly report Quarterly
provided on use report
of service
provided on
use of
service
10%
Quarterly report
provided on use
of service
10%
Scheme of 4 elements to gain better
understanding and improvement on
processes to identify unrelated donors
Qtrly report as
defined
Increase the number of severe and
moderate haemophilia A and B patients
who have clotting factor data provided on
Haemtrack
Qtrly qualitative
progress report
Qtrly qualitative Qtrly
progress report qualitative
progress
report
50%
Submit Qtrly
data, rationale,
action plan
update
Submit Qtrly
data, rationale,
action plan
update
% of babies <30+0 weeks gestation or
data, rationale,
<1500g birthweight who start TPN by day 2 action plan
of life (excluding babies who have
undergone surgery)
Activity report
Working group
Action plan
To reduce cold ischaemic time for all first
recipient kidney transplants
DBD donors under 18hrs
DCD donors under 12hrs
23
Qtrly report
as defined
Submit Qtrly
data,
rationale,
action plan
update
Jul-13 £25%
Oct-13 £25%
Jan -14 £25%
Apr-14 £25%
10%
Qtrly report as
defined
Submit baseline
100%
£737,011
£147,402
Enhanced discharge summary for frail
elderly patients 75yrs and over that
supports development of community
management plan
100%
100%
Q2 - 20%
Q3 - 40%
Q4 - 40%
85% of patients
screened
10%
Qtrly report as
defined
£25% per Quarter
providing Q4
<10%
£25% for each
Qtrly report
50%
95%
and year end
report
90% within target
90%
timescales
Activity
infromation and Year end report
final report
25% for each
Qtrly milestone,
providing Q4 50%
target met
25% for each
Qtrly milestone,
providing Q4 95%
target met
25% for each
Qtrly milestone,
providing Q4 90%
target met
If not met:
<80% = £0
80%-<90% =
£50%
£737,011
£531,952
£531,952
£531,952
£531,952
£531,952
Ciara Moore / Richard
Biram
Commence
recruitment of 2
additional DME
Consultants and
Nurse Consultant.
Mobilisation plan
written
Designated DME Specialist
Staff
Haemophilia - Haemtrack
monitoring
Screening tool in 40% of
place and staff patients
trained
screened
All patients aged 75yrs and over admitted
as emergencies to be screened for frailty
using the clincal frialty score (CFS)within
72hrs of admission
100%
25% per
element
Lead
Indicator description
Heart Failure Patients with a
Personalised Management
Plan
Bone Marrow Transplant donor
acqusition measures
CQUIN Value
TOPAS /
Jenny Able
Orthogeriatrician
Assessment
2013-2014 Final
Indicator period
Claudia
MacFarlane
100%
Year end Target
Ciara Moore /
Richard Biram
Improved Communication to
Carers/Relaltives
Enhanced discharge
summary
LOCAL 7
100%
Q4 target
Kathy Ciara Moore / Ciara Moore and
Haynes Richard Biram Catherine Jeffery
LOCAL 5
Frail Elderly under the care
of a Geriatrician/ DME Team
100%
Q3 target
Liz Hunt
Frail Elderly identified at
point of admission
Q2 target
Julie Smith
CQUIN
Quarter 1
Actual
Claudia McFarlane Amanda Cahn
Goal Number
% Indicator
weighting
Stephen
Wallis/Richard
Biram/Richard
Kendall
CQUIN Indicators 2013/14
Cambridge University Hospitals NHS Foundation Trust
Care Quality Commission - Quality and Risk Profile (QRP)
What is the QRP?
The QRP is a tool used by the CQC that brings together a wide range of information about a provider in one place.
How often is the QRP published?
The QRP was first published in September 2010 and the CQC will be publishing it on a monthly basis.
How do the CQC use the QRP?
The QRP enables the CQC to regularly identify and prioritise potential areas of non-compliance and prompt front line regulatory activity where appropriate e.g. an inspection.
When carrying out planned reviews of compliance, the QRP enables the CQC to make robust judgements about the quality of services.
How will the Trust use the information in the QRP?
The QRP will enable the Trust to support the internal monitoring of compliance with the essential standards of quality and safety, assist with the identification of lower than
average performance and where necessary, take action to address them.
How is information presented and analysed?
Information is presented relating to the essential standards of quality and safety and is broken down into each of the individual outcomes. The QRP also includes contextual
risk measures i.e. risks related to the type of health or care service, the type of people who may be affected and risks arising from the organisation itself.
For each item listed in the QRP, the organisation’s observed result is compared to an expected result. How far the observed result is from the expected result and the direction
of the difference (i.e. better or worse than the expected result) is analysed. This analysis produces a statistical measure, which is presented as one of seven categories
ranging from “much worse than expected” to “much better than expected”.
The results of our QRPs to April 2013 can be found in the table on next page, however the summary and actions taken is by exception including only those where the Trust
was highlighted as “worse" or "much worse than expected”.
Note: “Much worse than expected” is defined in the CQC publication How to use your Quality & Risk Profile as the provider’s outcome being statistically much worse than
expected – equating roughly to the provider being outside the 97.5% confidence interval. 'Worse than expected' is defined as the provider's result being statistically noticeably
worse than expected - roughly this equates to the provider being outside the 95% confidence interval
Care Quality Commission - Quality and Risk Profile (QRP) - April 2013
Outcome
Outcome 1 - Respecting and Involving
Negative
Comments
Much Worse than
expected
8
1
Worse than
expected
Tending towards
worse than
expected
Similar to
expected
Tending towards
better than
expected
Better than
expected
51
16
3
1
Outcome 2 - Consent
18
Outcome 4 - Care and Welfare
Outcome 5 - Nutrition
3
Outcome 6 - Co-operating with others
1
Outcome 7 - Safeguarding
1
Outcome 8 - Infection Control
1
Outcome 9 - Management of Medicines
2
3
1
1
1
2
1
83
16
16
Outcome Risk
Estimates
(overall rating)
16
9
1
2
Low green
Low green
47
16
Low green
7
2
3
10
1
3
2
Low yellow
1
High green
3
3
High green
1
1
1
1
33
6
1
14
Outcome 10 - Premises
1
16
2
Outcome 11 - Equipment
1
6
1
2
1
0
1
Outcome 13 - Staffing
6
1
30
2
9
1
Low yellow
10
2
Outcome 12 - Workers
1
Much Better than Positive Comments
expected
1
2
High green
Low green
2
Low yellow
15
2
High green
14
5
Low yellow
4
2
Low yellow
Low green
Outcome 14 - Supporting Staff
2
1
Outcome 16 - Assessing and Monitoring
3
4
Outcome 17 - Complaints
3
2
Outcome 21 - Records
3
31
9
14
28
1
1
Low yellow
Low green
Total April QRP:
45
4
11
4
299
58
39
149
47
Total March QRP:
43
7
4
9
352
62
34
165
48
Exception Reporting (Worse / Much Worse than expected)
Outcome
1
Outcome
Risk
Estimate
Low
green
Item
Description
Data Source
Much
The proportion of respondents to the outpatient survey who stated that they had to CQC Survey of Outpatients, 2011
Worse than wait longer than told for their appointment to start, or were not told they would have 01.3.2011 - 31.5.2011
expected to wait.
Action being taken to address
The key issue identified from the July 2012 Trust outpatient survey related to patient
awareness regarding delays. These results have been fed back to the Outpatient
Improvement Group chaired by Tom Bennett to inform actions/future changes.
The Trust's internal Outpatient Survey was repeated in February 2013, the results have
been collated with the report expected shortly.
4
Low
green
Much
Proportion of eligible patients with a discharge diagnosis of nSTEMI who were
Worse than seen by a cardiologist or member of their team. Data for Addenbrookes and the
expected Rosie Hospitals
4
Low
green
Worse than The proportion of patient's receiving their first definitive treatment for cancer within 2 Department of Health; Cancer Waits
expected months (62 days) of GP or dentist urgent referral for suspected cancer.
Database; 01.10.2012 - 31.12.2012.
6
Low
yellow
Worse than The ratio of the number of patients whose transfer of care is delayed to average
expected daily number of occupied beds open overnight in the quarter, where the delay is
attributable to the NHS.
6
Low
yellow
Worse than The ratio of the total number of days delayed to the total no. of occupied beds over Department of Health; Delayed Transfers see above
expected the quarter, where the delay is attributable to the NHS.
of Care; 01.07.2012 - 30.09.2012.
National Institute
for Clinical Outcomes
Research, Myocardial
Ischaemia National Audit Project
01/04/11 - 31/03/12
In February 2013, the 62 day urgent standard was 86.7% with 8 reallocations against a
performance target of 85%. Performance against this target was also achieved in March,
securing compliance in quarter 4 overall (Quality & Performance Report; FOPC
30.4.2013).
Department of Health; Delayed Transfers Delayed Transfers of Care ran at an average of 72 throughout March 2013 against a
of Care; 01.04.2012 - 30.06.2012.
target of 11 patients per week. The Trust is responsible for the assessment component
and
have been working to reduce delayed days due to assessment - currently at 29 delayed
days. There is concern that issues with the reliability of the RealTime system has caused
delays in April and that this figure is artificially low at present(Quality & Performance
Report; FOPC 30.4.2013)
9, 10, 11 Low yellow; low Worse than Does the LSMS sufficiently attend the CFSMS quarterly regional LSMS meetings? Counter Fraud & Security Management
green; high
expected
Service (CFSMS) - Compliance data;
& 14
green
The audit report was published on 15 Nov 2012. MINAP forms were completed for all
nSTEMI/acute coronary syndrome positive troponin patients in the whole hospital who had
a raised troponin, however, not all of these patients were under the care of the Cardiology
team or were appropriate for any cardiac investigations. There are many elderly patients in
other specialities for whom the MINAP data is also collected but who never see
cardiologists. MINAP data is also collected for patients in critical care areas e.g.
ICU/NCCU etc. The above factors are not currently reflected in the MINAP data collection
forms. The recommendations from the national audit are currently being reviewed by the
relevant specialties and an agreed action plan will be put in place to address any issues
/concerns. Meeting arranged to agree and finalise action plan on 22 April 2013.
01.10.2012 - 31.12.2012
The Trust's Local Security Management Specialist (LSMS) has confirmed that he has
attended all the regional quarterly LSMS meetings in the past 12 months plus other events
and project meetings NHS Protect have held. We are therefore querying this item with the
CQC as it appears in 4 Outcomes i.,e. Outcomes 9, 10, 11 & 14. Awaiting a response
from CQC.
16
Low
yellow
Worse than Proportion of alerts completed out of the total number of alerts issued and due for
expected completion within the time period.
MHRA Central Alerting System;
01.09.2009 - 15.03.2013
16
Low
yellow
Worse than Participation - did the eligible organisation take part in the Stroke Improvement
expected National Audit Programme; Data for Addenbrookes & Rosie Hospitals
Royal College of Physicians: Stroke
We did not participate in the Stroke Improvement National Audit Programme (SINAP).
Improvement National Audit Programme; SINAP pre-dates the Stroke Sentinel National Audit Programme (SSNAP), which
01.10.2012 - 31.12.2012
commenced in October 2012 and which the Trust is participating in.
16
Low
yellow
Worse than NJR Compliance: Percentage of cases submitted to NJR compared to HES.
expected (NEW ITEM IN QRP DECEMBER 2012)
National Joint Registry
01.01.2012 - 31.03.2012
4
Low yellow
Much
Did the patient attend an exercise
Worse than programme within 12 weeks of the
expected fall? (Non-Hip)
Royal College of
Physicians, Audit
of Falls & Bone
Health in Older
4
Low yellow
Much
Total 30 day mortality rates by Health Resources Group chapters: N - Obstetrics &
Worse than Neonatal Care
expected
Information Centre (IC); Hospital Episode NO FURTHER ACTION REQUIRED - CLOSED FEB 2013
Statistics (HES)
01.01.2011 - 31.12.2011
16
Low
yellow
Worse than Case ascertainment: ratio of cases reported to the National Bowel Cancer audit
expected compared with HES records.
National Clinical Audit Support
Programme (NCASP); National Bowel
Cancer Audit Project (NBOCAP)
We have queried this with the CQC and their response is as follows: The data received
from the MHRA for the time period 01/09/09 to 15/03/13 was 100 completed alerts with a
completion deadline before 15/03/13 and 104 total alerts issued that were due for
completion before 15/03/13, giving a value for the Trust of 96.2% compared with an
This was a new item in December QRP and the data and current processes are being
reviewed. The fact that the Trust is listed as "worse than expected " for this item could be
explained by the work that is outsourced to the private sector. Although it is the Trust's
activity, we suspect that both the Trust and the private organisation are submitting their
NO FURTHER ACTION REQUIRED - CLOSED FEB 2013
NO FURTHER ACTION REQUIRED - CLOSED FEB 2013.