Integrated Quality and Operational Compliance Report. 01/03/18 10:30 Final Report v1.4. February 2018

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1 Integrated Quality and Oational Compliance Report //8 : Final Report v. February 8

2 Contents Domain Pages Safe to Effective to 8 Caring to Responsive to Well-led - Workforce to Domain Scorecard Summary to 6 Glossary 7 to

3 Safe Commentary - Is Care Safe? February 8 Pressure Ulcers Draft Report v. Author: Jane Wilson, Medical Director //8 : Pressure Ulcers There has been a significant reduction in pressure ulcers in February 8, particularly in Grade. The numbers are more typical for the ly Trust formance however all preventative and review actions are in place as formance needs to be maintained and the more serious pressure ulcers were deemed avoidable by the PUMP group. Falls The number of falls has returned within the Trusts usual formance in February 8 and those associated with harm are continuing to be investigated through the SI process. Infection Control The Trust reported cases of C.Difficile infections in February. These cases have undergone review and been presented to the serious incident group. All occurred in elderly patients treated with antibiotics in line with Trust guidelines and were therefore deemed unavoidable. Patients were appropriately treated with antibiotics for C.Difficile and responded well to the treatment. The KPIs for other hospital acquired infection remain in control. Author: Sally Brittain, Director of Nursing and Quality Patient Safety Thermometer The safety thermometer is reporting 88.8% Harm Free Care for February 8. The safety thermometer is a measurement tool for improvement that focuses on the four most commonly occurring harms in healthcare: pressure ulcers, falls, UTI (in patients with a catheter) and VTEs. Data is collected through a point of care survey on a single day each on % of patients. Of note the data collected includes harm that has occurred outside of the acute Trust. For February 8 there were harms recorded however of these only were new harms. For example, old pressure ulcers were recorded, these were pressure ulcers that were present on admission or developed within 7 hours of admission and therefore are not attributed to care in the Trust. Only new pressure ulcers were recorded. It is therefore important not to view the safety thermometer data in isolation but to review it alongside the other measures the Trust uses to assure itself of the safety and quality of the care it provides.

4 Mar-6 Mar-6 Mar-6 Mar-6 Safe February 8 k. Number of patients with hospital acquired pressure ulcers (Grade &) k. Number of patients with hospital acquired pressure ulcers (Grade &) beddays 9 8 <=.7.6 <= //8 : Draft Report v. k. Number of patients with hospital acquired pressure ulcers (Grade ) k.. Number of patients with hospital acquired pressure ulcers (Grade ) beddays <= <=......

5 Safe February 8 k./ Number of patients with hospital acquired pressure ulcers (Grade &) - Avoidable / Unavoidable k./ Number of patients with hospital acquired pressure ulcers (Grade ) - Avoidable / Unavoidable Draft Report v. //8 : Avoidable Unavoidable Avoidable Unavoidable

6 Mar-6 Mar-6 Mar-6 Mar-6 Safe February 8 k. MRSA Bacteraemias (Hospital Assigned) k.6 MSSA Bacteraemias (Hospital Apportioned) Zero 6 <= //8 : Draft Report v. k.7 Clostridium difficile infections (Hospital Apportioned) k.8 Clostridium difficile infections (Hospital Apportioned) due to confirmed Lapse in Care 7 9 for year 6

7 Mar-6 Mar-6 Mar-6 Safe February 8 k.9 Number of Escherichia (E. coli) bacteraemia (all) k.9 Completed Patient Observations - Adult inpatients % 98% 96% 9% 9% 9% >=97% 88% 86% //8 : Draft Report v. k. Completed Patient Observations - Paediatric inpatients k. Patient Safety Thermometer - % Harm Free Care % 9% 8% 7% 6% % 98% 96% 9% 9% % 9% % 88% % 86% % 8% % 8% % 8% Kingston National

8 Mar-6 Mar-6 Mar-6 Mar-6 Safe February 8 k. Number of Patient Safety Incident (PSI) Falls k. Number of Patient Safety Incident Falls G&A beddays <= <= //8 : Draft Report v. k. Number of Patient Safety Incident Falls where moderate or severe harm occurred k. Never Events 7 <=6 Zero 6

9 Mar-6 Mar-6 Mar-6 Safe February 8 k.6 Medication Incidents k.7 % of Medication Incidents Where Moderate or Severe Harm Occurred 9 % <=% % % % % % //8 : Draft Report v. k.8 Number of Serious Untoward Incidents 9 8 6

10 AAU Alexandra Ward Astor Ward Blyth Ward Bronte Ward Cambridge Ward Canbury Ward Claremont Ward Derwent Ward Hamble Ward Hardy Ward Critical Care Unit Isabella Keats Ward Kennet Ward Neonatal Unit Paediatric Unit Maternity Trust Safe Safer Staffing : Ward and Shift Analysis February 8 To be received //8 : Draft Report v. Ward Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCA Care Hours Per Patient Day (CHPPD) AAU 8.%.% 9.8%.% 7. RN Registered Nurse Alexandra Ward 6.% 9.%.9% 7.% 6. MW Registered Midwife Astor Ward 88.%.6% 96.% 7.%.9 HCA Healthcare Assistant Blyth Ward 77.%.% 96.% 8.9% 6. Bronte Ward 9.% 8.% 9.6%.7%.7 Cambridge Ward 9.% 6.% 9.%.7% 6. Canbury Ward 98.% 8.% 98.% 7.9% 7. Claremont Ward.9% 9.% 7.%.% 6.8 Derwent Ward 89.%.% 96.%.% 6.7 Hamble Ward.8% 6.% 9.8%.7% 7. Hardy Ward 9.%.7%.%.7%. Critical Care Unit 9.8% 9.9% 7. Isabella 9.%.8% 6.%.6% 6. Keats Ward 88.%.%.%.% 6. Kennet Ward 8.% 6.6% 97.7%.7%.8 Neonatal Unit 8.9% 89.% 9.% 6.%.7 Paediatric Unit 88.7% 8.%.% 7.%. Maternity 9.% 86.% 98.% 77.%. Trust 9.% 7.% 99.% 6.% 8. Key % Day Staffing Rate - RN/MW Day Staffing Rate - HCA Night Staffing Rate - RN/MW Night Staffing Rate - HCA % % % % %

11 Mar-6 Mar-6 Mar-6 Mar-6 Safe Safer Staffing February 8 k. Day - Registered Midwives / Nurses Fill Rate k. Day - Assistant Fill Rate % % % % % % % 9% % % % 9% % 8% 9% 8% 8% //8 : Draft Report v. k. Night - Registered Midwives / Nurses Fill Rate k. Night - Assistant Fill Rate % % % % % % % % % % % 9% 9% 8% % 9% 8% 8%

12 Mar-6 Mar-6 Mar-6 Safe Safer Staffing February 8 k. Overall Trust Fill Rate k.6 % of Registered Nurse and Midwife Expenditure on Agency Staff % 8% % 6% % % % % % 8% 9% 6% 9% % % 8% % //8 : Draft Report v. k.7 Care Hours Patient Day (CHPPD)

13 Mar-6 Mar-6 Mar-6 Mar-6 Safe Maternity February 8 k. Caesarean section rate k. % women with a primary postpartum haemorrhage of ml or more % <=6% 6% <.% % % % % 8% 6% % % % % % % % //8 : Draft Report v. k. % women with a primary postpartum haemorrhage of ml or more k. Significant Perineal Trauma.% <=.% %.%.% %.%.% %.% %.%.% %

14 Effective Commentary - Is Care Effective? February 8 Author: Jane Wilson, Medical Director Re-Admissions In view of the rising emergency readmission following emergency admission the Medical Director has undertaken a review of a random sample of cases since November 7. The aim of the review is to attempt to determine if there were any trends in the readmissions. The review has not identified evidence of unsafe discharge. It has however identified that the cohort of patients most likely to be readmitted are elderly and frequently frail. Failures or changes in care need occur frequently in this cohort. Some patients have multiple readmissions. A smaller cohort of patients could be deemed planned re-attendances: this includes patients attending AEC and patients returning for orthopaedic procedures. Discussion is underway to determine how these patient episodes are recorded. Data quality issues were identified on occasion, the commonest error being patients being readmitted from a CDU admission to the ward rather than a transfer. Mortality The indices for mortality remain good with falling unadjusted mortality and ised Mortality ratio. The processes in line with the National Learning from deaths programme are working well. The Non-Executive lead for Learning from Deaths attended the Trust Mortality Group to gain assurance that the procedures were in place. The Structured Judgement Review process continues with more reviewers being trained across the Trust. The main themes from the reviews have included documentation issues, late recognition of irreversibility of disease and involvement of palliative care. Examples of good and excellent acre have also been identified. Sepsis Screening Quarter data is not yet available. Safe Storage of Medicines Author: Joscelin Miles, Head of Clinical Audit and Effectiveness Safe Storage of Medicines An inspection by the Care Quality Commission in January 6 identified improvements required for the safe and secure storage of medicines in outpatients, radiology, theatres, some wards, and the emergency department. As a result a Quality Improvement Project was undertaken with the aim of ensuring that; Medicines and prescription pads are securely locked away. Tematures are regularly monitored in areas where medicines are stored. The use of patients own medicines is supported in accordance with Trust policy. Controlled drugs are managed in accordance with Trust policy. A ly audit commenced in inpatient areas in June 6 and has since been rolled out to maternity, outpatients and departments. The purpose of the audit is to regularly review compliance with Trust policy for storage and security of medicines to enable continuous improvement. The latest audit report for quarter, 7/8 demonstrates improved formance compared to 6/7 across all areas and provides assurance that formance is in line with, or exceeding, the target set. Inpatient areas Improvements in compliance with Trust policy for the secure and safe storage of medicines achieved in 6-7 have been sustained in most inpatient areas in quarter, quarter and quarter, with overall compliance at 8% for the year to date. This is an improvement from 6% achieved for 6/7, and is in line with the target of 8%. Maternity Overall compliance in maternity is currently 8% for the year to date. This is an improvement from 7% achieved for 6/7, and exceeds the target rate of 7%. Outpatients and Departments Compliance in outpatient areas and departments remains relatively high at 9% for the year to date. This is an improvement from 86% achieved in 6/7, and exceeds the target rate of 7%.

15 Mar-6 Mar-6 Mar-6 Mar-6 Effective February 8 k. SHMI k. Unadjusted Mortality Rate <=9.8%.6%.%.% 9.% %.6%.%.% 8.% //8 : Draft Report v. k. Sepsis - % of eligible patients screened for sepsis - Emergency Department k. Sepsis - % of eligible patients who received antibiotics within hour of arrival - Emergency Department % >=9% % >=9% 9% 9% 8% 8% 7% 7% 6% 6% % % % % % % % % % % % %

16 Mar-6 Mar-6 Mar-6 Mar-6 Effective February 8 k. Sepsis - % of eligible patients screened for sepsis - Inpatients k. Sepsis - % of eligible patients who received antibiotics within hour - Inpatients % >=9% % >=9% 9% 9% 8% 8% 7% 7% 6% 6% % % % % % % % % % % % % //8 : Draft Report v. k. Prevention of hospital acquired VTE - % patients risk assessed k.6 Incidence of Hospital Acquired VTE (HAT) % 99% 98% 97% 96% 9% >=9% 6 9% 9% 9% 9% 9%

17 Mar-6 Mar-6 Mar-6 Mar-6 Effective February 8 k.7 % of eligible patients screened for dementia k.8 % of patients with dementia who were appropriately assessed % 9% >=9% % >=9% 8% 9% 7% 8% 6% % % % % % 7% 6% % % % % % % % //8 : Draft Report v. k.9 % Emergency Readmissions following an elective admission - days k. % Emergency Readmissions following an emergency admission - days.%.%.%.% % 8% 6% % %.% %.% 8%.%.% 6% % %.% %

18 Mar-6 Mar-6 Effective February 8 k. Hand Hygiene k. Open Incidents - % of Managers Reports completed within policy guidelines % 9% 8% 7% 6% % % % % >=9% % 9% 8% 7% 6% % % % % % % % % //8 : Draft Report v.

19 Effective Learning from Deaths February 8 Author: Jane Wilson, Medical Director & Consultant Obstetrician & Gynaecologist Reporting Month Total Number of Deaths Total Deaths Reviewed Death Rate (Trust) This Month Last This Month Last This Month % This Year (YTD) Last Year (same YTD) This Year (YTD) Last Year (same YTD) This Year (YTD) % Last 7.8% Last Year (same YTD).78% SJR outcome Number of Investigations SHMI (July 6 - June 7) Avoidable deaths (SJR score -) SI's Score.8 Unavoidable deaths ( SJR score >) SJR's Excpected Deaths Actual Deaths 8 Difference Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ""Total No. of Deaths 6/7" "Total No. of Deaths 7/8" "Death Rate 6/7" "Death Rate 7/8" 9% 8% 7% 6% % % % % % %

20 Caring Commentary February 8 Complaints Author: Ambreen Yaqoob, Complaints Analyst The Trust received formal complaints in February 8 compared to 7 in February 7. There were an additional car parking related complaints which related to new charges for blue badge holders. Specialist Services received the highest number of complaints accounting for 7% of the total, followed by Emergency Services (7%), Trust (%) and Clinical Support Services (7%). Within Specialist Services, the following Service Lines received complaints in February 8: Trauma & Orthopaedics (), General Surgery & Urology (), Gynaecology & Breast (), Oral & ENT (), Paediatrics & NNU (), Maternity () and Ophthalmology (). Within Emergency Services, the following Service Lines received complaints in February 8: Reopened complaints Three complaints were reopened in February 8, arising from complaints first received in November 7 () and January 8 (). The reasons for these complaints reopening were: Further Questions Ombudsman Referrals One complaint was referred to the Ombudsman in February The daughter of a deceased patient raised her concerns about the medical and nursing care given. The Ombudsman is currently investigating this complaint. Accident & Emergency (), Elderly Care (), Cardiology & Haematology (), Respiratory (), Gastroenterology & Endoscopy (). The most frequent complaint subjects that were received related to communication (%), estates and care & treatment (7% each), procedure (Incl. surgery/endoscopy/anaesthesia etc.) and appointments (% each), infection (7%), accidents (Incl. falls/sharps/manual handling), tests/investigations, diagnosis, information governance, infrastructure & resources and maternity (% each). Three out of five estates related complaints were about poor car parking facilities generally i.e. not blue badge related, one related to faulty patient bedside facilities in the Accident and Emergency Department and one complaint related to a patient being admitted to an unsafe clinical environment.

21 Mar-6 Mar-6 Mar-6 Mar-6 Caring February 8 k. Number of Complaints received k. Number of Complaints reopened //8 : Draft Report v. k. Number of Complaints referred to ombudsman k. % Complaints responded to within working days or date as agreed with complainant % >=9% 9% 9% 8% 8% 7% 7% 6% 6% % %

22 Mar-6 Mar-6 9.% 87.7% 9.7% 9.9% 96.% 9.6% 9.% 9.% 88.8% 97.%.% 9.6% 9.9% 87.% 97.% 9.% 86.7% 89.% 9.% 9.%.%.% 97.% 9.6% 8.9%.%.% 9.7% 9.% 9.8% 9.% 9.% 9.7% 9.% 9.% 9.7% 9.7% 9.6% 9.7% 96.% 96.% 9.% 9.% 9.8% 9.% 9.% 9.6% 96.7% Mar-6 Mar-6 9.% 9.% 9.6% 9.% 9.7% 9.6% 9.% 96.% 9.% 9.9% 9.9% 9.% 9.6% 9.% 9.% 96.% 9.7% 9.8% 9.% 9.6% 87.% 86.% 88.% 88.9% 9.6% 9.% 9.% 9.8% 9.% 96.% 9.7% 96.% 96.% 96.% 9.% 9.% 9.8% 9.8% 9.% 98.% 97.% 9.9% 97.% 96.7% 9.% 9.% 9.% 9.9% Caring February 8 k. Friends and Family Score - Trust k.6 Friends and Family Score - Inpatients (excluding daycases) % % >=96% 8% 8% 6% 6% % % % % % % Draft Report v. //8 : % Would Recommend % Would Not Recommend Response Rate % Would Recommend % Would Not Recommend k.7 Friends and Family Score - Paediatric Inpatient k.8 Friends and Family Score - Outpatient % % 8% 8% 6% 6% % % % % % % Response Rate % Would Recommend % Would Not Recommend % Would Recommend % Would Not Recommend

23 Mar-6 Mar-6 98.% 98.% 98.% 97.% 98.% 98.% 98.% 98.% 97.9% 98.8% 99.%.% 99.% 98.% 98.%.% 98.% 98.% 97.6% 96.9% 99.% 9.9% 9.% 9.9% Mar-6 Mar-6 9.9% 9.9% 9.% 9.% 97.% 97.% 9.% 96.% 9.% 96.% 9.% 9.9% 9.% 9.% 88.% 9.6% 88.% 9.% 89.% 9.% 8.% 8.% 8.9% 8.% 97.6% 96.7% 96.% 96.% 97.% 96.% 98.9% 97.% 9.7% 9.9% 96.% 97.% 98.% 97.8%.%.% 97.% 9.9% 98.% 9.% 9.% 9.% 96.% 98.% Caring February 8 k.9 Friends and Family Score - A&E k. Friends and Family Score - Maternity % % 8% 8% 6% 6% % % % % % % //8 : Draft Report v. Response Rate % Would Recommend % Would Not Recommend % Would Recommend % Would Not Recommend k. Friends and Family Score - Daycases k. Number of Mixed Sex Accommodation Breaches % Zero 8% 6% % % % Response Rate % Would Recommend % Would Not Recommend

24 Responsive Commentary - Is Care Responsive? February 8 Author: Jo Hunter, Associate Director - Planned Services Cancer All cancer targets were met in January with the exception of the -week wait breast symptomatic which was 9.8% against the 9% target. Our 6-day target formance was lower than we have been used to at 9%, but was an improvement from December. There were no -day breaches, which is an excellent achievement given the pressure on the inpatient beds during January. The February position has not yet to finalised, but it is hoped that all targets will be met. It should be noted that from April st the 8 day target will be live. This target determines the point at which patients have to be transferred to other trusts (if that is their agreed pathway). This is likely to have a negative impact on the 6 day treatment formance at Kingston as we will have a reduced number of total treatments (impacting on the denominator) and and increase in full breaches (rather than shared). RTT 8 Week RTT Incomplete Pathway position for February was 9.% against the 9% target. REU were compliant for a second in a row since August 7 at 9.%. This gives real confidence that the changes made in the department are being sustained and making a real difference. Capacity is being better managed and fully utilised. The DNA rate is one of the lowest in the trust. ENT continue to have a number of breaches due to the transfer of work from St George's Hospital. Gynae formance was 89.8%. There were two week waiters reported all within the uro-gynae sub-specialty. The team continue to work hard to date the uro-gynae patients for surgery and bring down the long waits. to 9 Emergency Department (ED) Author: Tracey Moore, Associate Director Emergency Services & Deputy Chief Oating Officer In February formance against the emergency standard was 8.77%. This was lower than February 7 although it is important to note that activity in February 8 was.6% higher than it had been in February 7. Ambulance breaches remained constant at 6 over minute breaches and over 6 minute breaches. An internal critical incident was declared on th February in response to the high number of attendances in ED overnight and the lack of bed capacity. Silver command was established and was effective in maintaining effective communication internally and externally and in managing flow across the organisation. The ED service line team is currently reviewing its rota in light of the increase in activity during the evening/night and assessing whether it is feasible to shift resource in response. Further work is also being undertaken to clarify the roles and responsibilities of the medical and nursing shift leads and the ED coordinator to avoid duplicated effort. The additional capacity in ED opened in January proved invaluable to manage peaks in activity in ED, particularly during the evenings. The DTOC position was.9% - representing a loss of 7.9 bed days in the. This was an increase on the previous which saw the lowest DTOC rate since March 6 at %. Waits for community rehabilitation beds remained a significant contributor to the delays. Health delays were evenly distributed across the broughs of Richmond, Kingston and Surrey Downs. The work of the emergency care programme board continued with progress against the following Preparation for the multiagency discharge event which saw all partners coming together in silver command and a joint assessment and discharge team to expedite discharge delays and to identify gaps in service provision. Pilot on Hamble Ward in the early identification and transfer of suitable patients from AAUled by the consultant respiratory physicians. Management of % of emergency department activity through the UTC, during the hours of oation.

25 Mar-6 Mar-6 Mar-6 Mar-6 Responsive February 8 k6. Average length of stay - Emergency Admissions k6. 8 weeks Referral to Treatment - Incomplete pathways <=. 98% 97% 96% 9% 9% 9% 9% 9% 9% >=9% //8 : Draft Report v. k6. 8 weeks Referral to Treatment - number of incomplete over week waiters k6. Diagnostic test - % waiting 6 weeks or less Zero % >=99% 99% 98% 97%

26 Mar-6 Mar-6 Mar-6 Mar-6 Responsive February 8 k6. A&E hour waiting time (type ) k6.6 A&E hour waiting time (all types) % 98% % 98% >=9% 96% 96% 9% 9% 9% 9% 9% 9% 88% 88% 86% 86% 8% 8% 8% 8% 8% 8% //8 : Draft Report v. k6.7 Number of A&E hour trolley waits k6.8 LAS Ambulance Handovers - % within minutes Zero % 9% 8% 7% 6% % % % % % %

27 Mar-6 Mar-6 Mar-6 Mar-6 Responsive February 8 k6.9 LAS Ambulance Handovers - min waits k6. LAS Ambulance Handovers - 6 min waits 9 Zero 8 Zero //8 : Draft Report v. k6. Cancer - Two week wait k6. Cancer - Two week referral to st outpatient - breast symptoms % >=9% % >=9% 98% 98% 96% 96% 9% 9% 9% 9% 9% 88% 86% 9% 8% 8% 88% 8%

28 Mar-6 Mar-6 Mar-6 Mar-6 Responsive February 8 k6. Cancer - Patients receiving first definitive treatment within one ( days) of a cancer diagnosis k6. Cancer - day second or subsequent treatment - drug % >=96% % >=98% 99% 98% 97% 96% 9% 9% 9% //8 : Draft Report v. k6. Cancer - day second or subsequent treatment - surgery k6.6 Cancer - Two urgent referral to treatment wait % >=9% % >=8% 99% 98% 9% 97% 96% 9% 9% 8% 9% 9% 8% 9% 9% 7% 9% 7%

29 Mar-6 Mar Mar-6 Mar-6 Responsive February 8 k6.7 Cancer - 6 day wait for first treatment following referral from a NHS Cancer Screening Service k6.8 Cancer - 6 day wait for first treatment following consultant upgrade % >=9% % >=8% 9% 9% 9% 9% 8% 8% 8% 8% 7% 7% 7% 7% //8 : Draft Report v. k6. Number of delayed transfers of care - bed days k6. Delayed transfers of care - Rate occupied bed day,, 9% 8% 7% <=% 8 6% 6 % % % % % %

30 Mar-6 Mar-6 Responsive February 8 k6. Number of cancelled oations k6. Number of patients not treated within 8 days of last minute cancellation 9 Zero //8 : Draft Report v.

31 Well-led February 8 Author: Carolyn Floyd, Workforce Information & Planning Manager Vacancy (k7.) The vacancy rate has reduced to 8.% this, This is due to a large intake of new joiners () and a lower rate of leavers ().The highest vacant WTE remains in the Qualified Nursing staff group (9wte) and Admin & Estates (68wte). The Service Line with highest number of vacancies are; Elderly Care (7wte), Anaesthetics, Theatres & DSU (7wte) and A&E (wte). The average vacancy rates for our comparator's is.% (), which we fall.% below. We are the only Trust that reports below 9%. Turnover (k7.) The Turnover rate has also reduced again this (.96%) and is amber rated for the first time this financial year. It is also the lowest rate for the past three years. The past five s has seen the number of leavers reduced and so this should continue to improve the overall turnover figure. High turnover remains within the Accident & Emergency and Ophthalmology Service Lines and within the Unqualified Nursing staff group. The HR Business Partners are working with Service Lines in deep dive areas to better understand their retention issues and improve the high turnover rates. The average turnover rate for our comparator's is.6% () which we currently sit some way above with only two other Trust record a higher centage. Mandatory Training (k7.) This the compliance rates have increased to 77.6%. All face-to-face training has lower rates and this needs to be tackled to increase compliance. The new Induction programme was launched last, and this will go someway to increasing rates too. Staff falling out of compliance need to be completing refresher training in a more timely manner to ensure they remain compliant. This three pronged approach should help increase our overall compliance. Only 6 Service Lines are green rated and amber rated all others are red. Lowest compliance rates are in the Unplanned Care Division and in the Unqualified Nursing staff group. The average Mandatory Training compliance for our comparator's is 8.86% () and the Trust record the lowest centage. Appraisals (k7.) Appraisals remains at an amber rating 88.%, Still % off the target There are still 6 Service Lines who are still recording a red rating. Completing Objectives for all new starters within s will also help keep compliance higher. The average appraisal compliance for our comparators in 7.% () which we fall above. Comparators ( Trusts): St George's Healthcare, Epsom & St Helier, Croydon Health, Guy's and St Thomas', Imial College Healthcare, Chelsea & Westminster, West Middlesex, Ashford & St Peter's, Frimley,Royal Surrey, West Hertfordshire Hospitals, Dartford & Gravesham, Barking, Havering & Redbridge and Hillingdon Hospital. Sickness (k7.) The Sickness rate has reduced this to.% with both long & short term sickness decreasing. The Unqualified Nursing staff group remains the group with the highest centage lost to sickness (.8%). Service Lines with a high WTE lost to sickness are: Elderly Care (96.), Maternity (8.) and Anaesthetics, Theatres & DSU (7.6). The average sickness rate for our local comparator's is.% (), which we fall below.

32 Mar-6 Mar-6 Mar-6 Mar-6 Well-led February 8 k7. Vacancy rate k7. Turnover rate % <=% % <=% % % 8% % 6% % % % % % % //8 : Draft Report v. k7. Sickness rate k7. Mandatory training.%.%.% <=.% 9% 8% 7% 6% >=8%.% %.% %.%.% % % %.% %

33 Mar-6 Well-led February 8 k7. Appraisals / PDRs completed % 9% 8% 7% 6% % % % % % Actuals reset at start of financial year >=9% % //8 : Draft Report v.

34 Type Draft Report v. to Domain Scorecard Summary Rolling -Month Scorecard KPI Description YTD 6/7 Safe k. Pressure ulcers - Hospital acquired (Grade and ) <= Number 6 6 k. Pressure ulcers - Hospital acquired (Grade and ) - Avoidable Number 9 k. Pressure ulcers - Hospital acquired (Grade and ) - Unavoidable Number 8 k. Patients with Hospital acquired pressure ulcers (Grade and ) beddays k. Pressure ulcers - Hospital acquired (Grade ) <=. <= Rate Number k. Pressure ulcers - Hospital acquired (Grade ) - Avoidable Number 7 k. Pressure ulcers - Hospital acquired (Grade ) - Unavoidable Number 6 k. Patients with Hospital acquired pressure ulcers (Grade ) beddays k. MRSA Bacteraemias (Hospital Assigned) k.6 MSSA Bacteraemias (Hospital Apportioned) <=. = <= Rate Number Number k.7 Clostridium difficile Infections (Hospital Apportioned) Number 7 6 k.8 Clostridium difficile Infections (Hospital Apportioned) due to Lapse in Care (confirmed cases) k.9 Completed Patient Observations - All (same as Adult inpatients) k. Completed Patient Observations - Paediatric <=9 >=.97 >=.97 annum Number % 9.79% 99.% 97.7% 98.% 9.8% 9.% 97.79% 97.9% 97.% 97.8% 96.% 98.6% 97.9% 9.89% %.% 98.99% 99.%.%.% 9.8% 96.% 98.%.%.%.% 97.% 98.% 9.6% k. Harm Free Care (All) (PST) - KHT - % 9.8% 98.6% 98.% 98.% 99.% 96.6% 98.% 98.% 97.66% 9.79% 9.88% 88.6% 96.7% 9.6% k. Patient Safety Incident (PSI) Falls k. Number of Patient Safety incident Falls (G&A) bed days k. Patient Safety Incident Falls where moderate or severe harm occurred k. Never Events <=8 <=. <=6 = Number Rate Number Number k.6 Medication Incidents - Number k.7 Medication Incidents where Moderate or Severe Harm occurred <=. %.%.%.%.%.%.%.%.%.%.%.%.%.%.% k.8 Serious Untoward Incidents - Number 8 k.9 Escherichia coli (E. coli) bacteraemia (all) - Number k. Safer Staffing - Day - Registered Midwives / Nurses fill rate - % 98.% 98.6%.9% 9.% 9.% 9.7% 9.8% 9.% 9.% 9.9% 9.7% 9.9% 9.9% 98.9% k. Safer Staffing - Day - Assistant Fill Rate - %.8% 9.%.76% 8.%.8% 99.7%.6%.%.%.6%.96% 7.%.% 7.% k. Safer Staffing - Night - Registered Midwives / Nurses fill rate - % 97.% 97.%.%.7%.6% 9.7% 9.8% 9.7% 9.99% 9.7% 99.% 99.7% 98.76% 99.98% k. Safer Staffing - Night - Assistant Fill Rate - % 7.6% 7.7%.%.9% 7.6%.8%.89% 9.6%.98%.% 8.% 6.7% 8.%.% k. Safer Staffing - Overall trust fill rate - %.8%.%.9%.% 7.7% 9.7% 99.77% 99.%.9% 98.8%.%.%.%.% k.6 Safer Staffing - % of Registered Nurse and Midwife expenditure on agency staff - % 6.8%.9% 7.%.8%.%.68%.6%.9% 6.%.%.6% 6.8%.6% 7.% k.7 Safer Staffing - Care Hours Patient Day - Rate k. Maternity - Caesarean section rate k. Maternity - % of women with a primary postpartum haemorrhage of ml or more <=.6 <. %.7% 6.97%.9% 7.%.79%.9%.8% 8.7%.8% 7.78% 8.% 7.79% 8.7% 9.98% %.%.7%.8%.%.7%.%.%.9%.9%.%.9%.7%.%.9%

35 Type Draft Report v. to Domain Scorecard Summary Rolling -Month Scorecard KPI Description YTD 6/7 k. Maternity - % of women with a primary postpartum haemorrhage of ml or more <=. %.8%.%.%.8%.9%.6%.%.%.%.%.7%.99%.%.% k. Maternity - Significant Perineal Trauma - %.79%.7%.69%.%.7%.%.66%.8%.7%.%.99%.%.%.8% Effective k. ised healthcare mortality index (SHMI) - most recent score <=9 Index k. Unadjusted Mortality Rate - %.9%.9%.%.7%.7%.96%.87%.%.%.8%.7%.6%.%.% k. Sepsis - % of eligible patients screened for sepsis - ED k. Sepsis - % of eligible patients who received antibiotics within hour of arrival - ED k. Sepsis - % of eligible patients screened for sepsis - Inpatients k. Sepsis - % of eligible patients who received antibiotics within hour - Inpatients k. VTE Assessments (Trust) >=9% >=9% >=9% >=9% >=9% % 76.9% 68.% 6.%.% 86.% 88.% 9.% 76.% 8.% 86.% 77.% 7.6% %.%.%.% 6.% 78.% 6.% 7.7% 78.9% 87.88% 8.8% 69.% 6.78% %.% 7.% 8.%.% 6.% 66.% 7.% 7.% 7.% 68.% 6.%.6% %.7%.9% 8.8%.%.%.%.% 77.78% 66.67% 7.7% 7.8%.76% % 98.% 97.99% 97.6% 98.9% 98.9% 97.88% 97.7% 97.97% 98.7% 97.9% 97.77% 97.7% 97.9% 98.% k.6 Incidence of Hospital Acquired VTE (HAT) - Number k.7 % of eligible patients screened for dementia k.8 % of patients with dementia who were proly assessed >=9% >=9% % 7.9% 7.66% 76.68% 7.% 66.99% 6.6% 69.% 6.6% 7.% 66.87% 68.% 68.97% 6.% % 9.8% 8.7% 9.% 86.96% 9.% 8.%.% 9.% 9.% 89.8% 9.9% 89.8% 7.8% k.9 % emergency readmissions following elective admission - days - %.%.6%.78%.7%.8%.9%.%.%.77%.%.%.%.%.9% k. % emergency readmissions following emergency admission - days - %.%.76%.67% 6.% 6.%.8% 7.9%.7%.%.7% 7.%.%.7%.9% k. Hand Hygiene (Infection Control - Core Elements Tool) >=9% % 96.% 9.% 96.6% 96.8% 97.8% 97.% 96.6% 96.7% 96.88% 97.7% 97.6% 97.7% 96.8% 9.9% k. Open Incidents - % of managers reports completed within days - %.% 7.8%.%.9%.%.9%.9%.8%.8% 7.9%.9% 9.6%.98%.9% Caring k. Number of complaints received this - Number k. Number of complaints reopened this - Number k. Number of complaints referred to ombudsman this - Number k. Complaints Response Rate - % 8.% 6.% 8.% 79.7% 7.% 68.97% 7.% 66.67% 6.% 86.96% 66.67% 7.% 7.77% 8.9% k. FFT - Trust - % Would Recommend - % 9.7% 9.% 9.9% 96.% 9.68% 9.8% 9.7% 9.6% 87.8% 86.% 88.9% 88.9% 9.% 9.6% k.6 FFT - InPatients - % Would Recommend >96% % 9.79% 9.8% 9.% 98.6% 97.% 9.9% 97.7% 96.6% 9.% 9.8% 9.% 9.87% 9.9% 9.6% k.7 FFT - Paediatric InPatients - % Would Recommend - % 9.% 86.67% 89.6% 9.% 9.%.%.% 97.% 9.9%.%.% 8.9% 9.% 9.% k.8 FFT - OutPatients - % Would Recommend - % 9.7% 9.6% 9.7% 9.98% 96.6% 9.% 9.% 9.8% 9.% 9.% 9.6% 96.7% 9.86% 9.% k.9 FFT - A&E - % Would Recommend - % 9.% 9.8% 88.% 9.9% 88.8% 9.% 89.% 9.% 8.% 8.9% 8.88% 8.% 86.% 9.% k. FFT - Maternity - % Would Recommend - % 98.8% 97.7%.%.% 97.% 9.86% 98.7% 9.7% 9.99% 9.% 96.% 98.% 96.7% 96.6%

36 Type Draft Report v. to Domain Scorecard Summary Rolling -Month Scorecard KPI Description YTD 6/7 k. FFT - Daycases - % Would Recommend - % 99.% 98.9% 98.%.% 98.8% 98.% 97.% 96.9% 99.% 9.88% 9.9% 9.9% 97.% 98.% k. Number of Mixed Sex accommodation breaches = Number 6 Responsive k6. Average length of stay - Emergency Services (Emergency admissions only) k6. RTT - incomplete 9% in 8 weeks (NONC) k6. RTT - incomplete + Week Waiters (NONC) k6. Diagnostic Test Waiting Times - Completed within 6 weeks (ALL) <=. >=9% = >=99% Rate % 9.% 9.6% 9.67% 9.% 9.% 9.7% 9.69% 9.% 9.6% 9.6% 9.77% 9.% 9.% 9.7% Number 8 % 99.79% 99.7% 99.7% 99.% 99.8% 99.6% 99.% 99.7% 99.% 99.8% 99.68% 99.8% 99.7% 99.7% k6. A&E hour waiting time (type ) - % 89.% 89.% 87.78% 88.96% 9.% 9.% 9.67% 9.76% 88.% 8.% 8.77% 8.99% 88.8% 88.99% k6.6 A&E hour waiting time (all types) k6.7 A&E hour trolley waits >=9% = % 9.66% 9.9% 89.% 9.7% 9.9% 9.% 9.69% 9.6% 89.% 86.% 87.9% 8.77% 89.67% 9.6% Number k6.8 LAS Ambulance Handovers - within minutes - %.%.9% 9.7%.6%.%.% 9.%.%.6% 7.% 7.9% 8.8% 6.6%.7% k6.9 LAS Ambulance Handovers - min handover waits k6. LAS Ambulance Handovers - 6 min handover waits k6. All Cancer Two Week Wait k6. week GP referral to st outpatient - breast symptoms k6. Percentage of patients receiving first definitive treatment within one (-days) of a cancer diagnosis (measured from date of decision to treat ) k6. day second or subsequent treatment - drug k6. -Day for Subsequent Cancer Treatments-Surgery k6.6 All Cancer Two Month Urgent Referral to Treatment Wait k6.7 6-Day Wait for First Treatment Following Referral from an NHS Cancer Screening Service k6.8 6-Day Wait for First Treatment Following Referral from Consultant Upgrade = = >=9% >=9% >=96% >=98% >=9% >=8% >=9% >=8% Number Number % 99.% 99.% 99.% 98.% 98.96% 97.89% 98.88% 97.7% 98.% 98.9% 97.6% 98.9% 98.% % 99.% 98.% 98.8%.% 98.% 98.6% 99.6% 99.8%.% 96.% 9.8% 97.87% 98.66% %.%.%.%.%.% 99.%.% 97.78% 99.% 98.% 97.67% 99.8% 99.7% %.%.%.%.%.%.%.%.%.%.%.%.%.% %.%.%.%.% 9.%.%.%.%.%.%.% 99.% 99.% % 9.% 9.8%.% 9.7% 9.% 9.8% 9.% 86.9% 9.% 88.78% 9.99% 9.7% 9.7% %.%.%.% 8.%.% 9.% 88.89%.%.%.%.% 9.9% 96.% %.% 8.7% 8.%.% 87.% 8.%.%.% 9.%.%.% 9.8% 98.67% k6. Delayed transfers of care (bed days) - Number k6. Delayed transfers of care (rate occupied bed days) <=% %.% 6.% 7.7% 6.%.6%.%.%.8%.69%.%.%.%.9% 6.% k6. Number of last minute cancelled oations - Number k6. Number of patients not treated within 8 days of last minute cancellation = Number Well-led k7. Vacancy rate k7. Turnover rate k7. Sickness rate k7. Mandatory Training <=% <=% <=.% >=8% %.99%.7%.9%.%.%.6%.89% 8.8% 9.% 9.6% 8.8% 8.% 9.%.% % 6.% 6.9% 7.% 7.9% 7.7% 7.7% 7.6% 7.8% 7.7% 6.97% 6.%.96% 7.7% 7.% %.76%.%.6%.9%.7%.%.96%.7%.8%.9%.7%.%.89%.7% % 8.% 8.78% 8.8% 78.6% 7.6% 7.7% 7.6% 7.76% 7.79% 7.% 7.7% 77.6% 7.79% 8.86% k7. Appraisals / PDRs completed >=9% year end % 76.%.9%.%.77% 6.% 7.86% 77.% 8.6% 8.% 87.% 88.% 88.% 8.% 68.%

37 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Safe k. Patients with hospital acquired pressure ulcers (Grades & ) Number of patients with a newly hospital acquired pressure ulcers (Grades & ) Ulysses Safe k. Patients with hospital acquired pressure ulcers (Grades & ) beddays Number of patients with a newly hospital acquired pressure ulcers (Grades & ) divided by number of General and Acute (G&A) occupied beddays (n) Ulysses (d) Internal bedstate summary Safe k. Patients with hospital acquired pressure ulcers (Grade ) Number of patients with hospital acquired pressure ulcers (Grade ) Ulysses Safe k. Number of patients with hospital acquired pressure ulcers (Grade ) beddays Number of patients with a newly hospital acquired pressure ulcers (Grade ) divided by number of General and Acute occupied beddays (n) Ulysses (d) Internal bedstate summary Number of hospital assigned MRSA bacteraemia. Safe k. MRSA Bacteraemias (Hospital Assigned) Safe k.6 MSSA Bacteraemias (Hospital Apportioned) Safe k.7 Safe k.8 Clostridium difficile Infections (Hospital Apportioned) Clostridium difficile Infections (Hospital Apportioned) due to Lapse in Care (confirmed cases) This includes all cases that are assigned through a post infection review (PIR). Any 'hospital apportioned' MRSA cases with an ongoing PIR investigation will also be reported - this includes all MRSA cases that where the patients' first positive test for MRSA was taken on their third day of admission or afterwards. Number of hospital apportioned cases of MSSA bacteraemia. This includes all MSSA cases that where the patients' first positive test for MSSA was taken on their third day of admission or afterwards. Number of hospital acquired C diff bacteraemia. Includes all CDiff cases that where the patients' first positive test for CDiff was taken on their fourth day of admission or afterwards. Number of Clostridium Difficile Infections which are attributable to a lapse in care. Only applies to Cdiff cases here the patients' first positive test for CDiff was taken on their fourth day of admission or afterwards. Infection Control team - as reported to PHE Infection Control team - as reported to PHE Infection Control team - as reported to PHE Infection Control team - as reported to PHE Safe k.9 Completed Patient Observations (NEWS) - Adult Inpatients The centage of patients who have received or more completed sets of NEWS observations within a hour iod - Inpatients Only (Excluding Paeds) Clinical Audit Safe k. Completed Patient Observations (NEWS) - Paediatric Inpatients The centage of patients who have received or more completed sets of NEWS observations within a hour iod - Paeds only Clinical Audit Safe k. Patient Safety Thermometer - % Harm Free Care % of patients audited on Patient Safety Thermometer where no harm recorded. Harms relate to falls, pressure ulcers, hospital-acquired VTE, or UTIs as the result of a catheter Patient Safety Thermometer Safe k. Number of Patient Safety Incident (PSI) Falls Number of falls reported Ulysses Safe k. Number of Patient Safety Incident Falls G&A beddays Number of reported falls divided by number of General and Acute (G&A) occupied beddays (n) Ulysses (d) Internal bedstate summary

38 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Safe k. Number of Patient Safety Incident Falls where moderate or severe harm occurred Includes falls resulting in moderate harm to severe harm/death Ulysses Safe k. Number of Never Events Safe k.6 Number of Medication Incidents "Never events" are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. The number of incidents which actually caused harm or had the potential to cause harm involving an error in administrating, prescribing, preparing, dispensing or monitoring medication. Ulysses Safe k.7 % of Medication Incidents Where Moderate or Severe Harm Occurred The number of Medication Incidents Where Moderate or Severe Harm Occurred divided by the total Number of Medication Incidents Ulysses Safe k.8 Number of Serious Untoward Incidents Total number of serious untoward incidents reported Ulysses Effective k. ised healthcare mortality index (SHMI) - most recent score This ratio demonstrates the ratio between the actual number of deaths following hospital care in relation to the number of patients who were expected to die based on the patient's characteristics and comorbidities HSCIC Effective k. Unadjusted Mortality Rate The number of deaths as a centage of all discharges, including daycase patients CRS Effective k. Sepsis - % of eligible patients screened for sepsis - Emergency Dept. The centage of patients sampled who met the criteria of the local protocol and were screened for sepsis. Clinical Audit Effective k. Sepsis - % of eligible patients who received antibiotics within hour of arrival The total number of patients sampled who received antibiotics within hour of arrival as a centage of those who should have received antibiotics within hour of arrival. Clinical Audit Effective k. VTE Assessments (Trust) Percentage of patients risk-assessed for Venous-Thromboembolism within hours of admission CRS Effective k.6 Incidence of Hospital Acquired VTE (HAT) Number of recorded instances of VTE acquired while admitted Ulysses Effective k.7 % of eligible patients screened for dementia Of the patients who were eligible to be screened for dementia (aged 7 and with a length of stay of 7 hours or greater), how many were screened Clinical Audit Effective k.8 % of patients with dementia who were proly assessed Of the patients who were identified using the dementia screening assessments, how many were appropriately assessed. Clinical Audit Effective k.9 % emergency readmissions following elective admission - days Percentage of patients re-admitted within days of a previous elective admission CRS Effective k. % emergency readmissions following emergency admission - days Percentage of patients re-admitted within days of a previous emergency admission CRS

39 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Effective k. Hand Hygiene Compliance rate with the Infection Control Saving Lives Audit Infection Control Effective k. Open Incidents - % of managers reports completed within days Percentage of Incidents Recorded on Ulysses that have been completed within appropriate time frame Ulysses Patient Exience k. Number of complaints received this Number of complaints received this Ulysses Patient Exience k. Number of complaints reopened this Number of complaints reopened this Ulysses Patient Exience k. Number of complaints referred to ombudsman this Number of complaints referred to ombudsman this Ulysses Patient Exience k. % complaints responded to within agreed timeframe Percentage of complaints that have received a response within the agreed time frame, based on the in which the response was due. Ulysses Patient Exience k. Friends and Family Score - Trust Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k.6 Friends and Family Score - Inpatient (excluding daycases) Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k.7 Friends and Family Score - Paediatric Inpatient Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k.8 Friends and Family Score - Outpatient Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k.9 Friends and Family Score - A&E Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k. Friends and Family Score - Maternity Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k. Friends and Family Score - Daycases Number of patients who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k. Friends and Family Score - Dementia Carers Number of carers of patients with dementia who would recommend the Trust to friends and family, as a centage of all respondents. FFT Patient Exience k. Number of Mixed Sex accommodation breaches Number of Mixed Sex accommodation breaches CRS

40 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Safer Staffing k. Safer Staffing - Day - Registered Midwives / Nurses fill rate Total hours worked by registered nurses and midwives as a centage of the planned hours - Day shift HealthRoster Safer Staffing k. Safer Staffing - Day - Assistant Fill Rate Total hours worked by healthcare assistants as a centage of the planned hours - Day shift HealthRoster Safer Staffing k. Safer Staffing - Night - Registered Midwives / Nurses fill rate Total hours worked by registered nurses and midwives as a centage of the planned hours - Night shift HealthRoster Safer Staffing k. Safer Staffing - Night - Assistant Fill Rate Total hours worked by healthcare assistants as a centage of the planned hours - Night shift HealthRoster Safer Staffing k. Safer Staffing - Overall trust fill rate Total hours worked as a centage of the planned hours - All shifts HealthRoster Safer Staffing k.6 Safer Staffing - % of Registered Nurse and Midwife expenditure on agency staff Safer Staffing - % of Registered Nurse and Midwife expenditure on agency staff HealthRoster Safer Staffing k.7 Safer Staffing - Care Hours Patient Day Total hours worked by staff proportionate to the number of occupied beds at midnight HealthRoster/CRS Maternity k. Maternity - Caesarean section rate Percentage of caesarean sections relative to all births CRS/Maternity Forms Maternity k. Maternity - % of women with a primary postpartum haemorrhage of ml or more Maternity - % of women with a primary postpartum haemorrhage of ml or more CRS/Maternity Forms Maternity k. Maternity - % of women with a primary postpartum haemorrhage of ml or more Maternity - % of women with a primary postpartum haemorrhage of ml or more CRS/Maternity Forms Maternity k. Maternity - Significant Perineal Trauma Maternity - Significant Perineal Trauma CRS/Maternity Forms Responsive k6. Average length of stay (ALOS) - Emergency Admissions The mean length of stay for patients, calculated by dividing the total inpatient days by the number of discharges CRS Responsive k6. Referral to Treatment (RTT) within 8 weeks - incomplete pathways RTT 8 weeks - incomplete pathway UNIFY / NHS England Responsive k6. RTT 8 weeks - incomplete pathway + week waiters RTT 8 weeks - incomplete pathway + week waiters UNIFY / NHS England Responsive k6. Diagnostic test waiting times Diagnostic test waiting times UNIFY / NHS England

41 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Responsive k6. A&E hour waiting time (type ) Percentage of patients who received treatment and were admitted or discharged within hours of arrival - Main A&E Only UNIFY / NHS England Responsive k6.6 A&E hour waiting time (all types) Percentage of patients who received treatment and were admitted or discharged within hours of arrival - Both Main A&E and Royal Eye Unit UNIFY / NHS England Responsive k6.7 A&E hour trolley waits A&E hour trolley waits UNIFY / NHS England Responsive k6.8 London Ambulance Service (LAS) Handovers - % within minutes Percentage of Ambulance handovers completed within minutes of Arrival at A&E LAS portal Responsive k6.9 LAS Ambulance Handovers - min waits LAS Ambulance Handovers - min waits LAS portal Responsive k6. LAS Ambulance Handovers - 6 min waits LAS Ambulance Handovers - 6 min waits LAS portal Responsive k6. Cancer - Two week wait Percentage of patients seen by a specialist within two weeks of an urgent GP referral for suspected cancer Infoflex Responsive k6. Cancer - Two week referral to st outpatient - breast symptoms Percentage of patients seen by a specialist within two weeks of an urgent GP referral for suspected breast cancer Infoflex Responsive k6. Cancer - Patients receiving first definitive treatment within one ( days) of a cancer diagnosis Percentage of patients who began first definitive treatment within days of receiving a cancer diagnosis Infoflex Responsive k6. Cancer - day second or subsequent treatment - drug Percentage of patients who began treatment within days of diagnosis, where the required treatment was an anti-cancer drug regimen Infoflex Responsive k6. Cancer - day second or subsequent treatment - surgery Percentage of patients who began treatment within days of diagnosis, where the required treatment was surgery Infoflex Responsive k6.6 Cancer - Two urgent referral to treatment wait Percentage of patients treated within two s of an urgent GP referral Infoflex Responsive k6.7 Cancer - 6 day wait for first treatment following referral from an NHS Cancer Screening Service Percentage of patients treated within two s of an urgent referral from an NHS Cancer Screening Service Infoflex Responsive k6.8 6-Day Wait for First Treatment Following Referral from Consultant Upgrade Percentage of patients treated within two s of a consultant's decision to upgrade their priority Infoflex Responsive k6.9 Delayed transfers of care (number) Number of patients whose transfer is delayed at midnight on the last Thursday of the

42 Report Glossary Domain Indicator reference Description Indicator Methodology Data source Notes Responsive k6. Delayed transfers of care (bed days) Number of General and Acute (G&A) occupied beddays Responsive k6. Delayed transfers of care (rate occupied bed days) Delayed transfers, bed days Responsive k6. Number of last minute cancelled oations Number of oations cancelled within hours of the planned oation Responsive k6. Number of patients not treated within 8 days of last minute cancellation Number of patients not treated within 8 days of last minute cancellation Enablers k7. Vacancy rate Vacancy rate Human Resources Enablers k7. Turnover rate Turnover rate Human Resources Enablers k7. Sickness rate Sickness rate Human Resources Enablers k7. Mandatory Training Mandatory Training Human Resources Enablers k7. Appraisals / PDRs completed Appraisals / PDRs completed Human Resources Enablers k7.6 Flu Immunisation Percentage of staff who have received the flu vaccination Human Resources Enablers k7.7 Staff FFT (Work) - Score Percentage of staff who would recommend the Trust to friends and family as a place to work NHS England Enablers k7.8 Staff FFT (Care) - Score Percentage of staff who would recommend the Trust to friends and family if they needed care or treatment NHS England Enablers k7.9 Staff Survey - Response Rate Percentage of staff who completed the survey, of those who were asked to complete it Human Resources Annual Survey

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