Integrated Performance Dashboard: Published February Contents

Transcription

1 Integrated Performance Dashboard: Published February 214 Contents No. Section Page No. 1 Key Messages 2 2 Performance Dashboard 3 3 Analytics 4 4 Mental Health 5 5 Quality & Safety 6 6 Glossary 8 The Month 12 Report is published in April 214, and contains the following performance for the CCG: - Performance against KPIs as at March 214 (with the December 213 position reported across some indicators) - Performance against key Quality Indicators at CCG level for March 214 (Trust position is reported for February 214) The report focuses on the following key providers: - North Middlesex University Hospital NHS Trust () - Whittington Health (WH) - University College London Hospital NHS Foundation Trust (UCLH) NHS Haringey CCG are the coordinating commissioner for, and these three providers account for circa 9% of the annual acute care budget of the CCG. The report now includes details on Mental Health Services commissioned by the CCG. Currently, this report focuses on the acute services commissioned by the CCG. It is planned that in future months, the following services will be included: - Community Services Services These services will be included in a phased manner over the next few months, as the report develops. Additionally, the report is intended to develop further and report on the CCG's performance against the agreed Local Priorities. `

2 Haringey CCG Integrated Perforance Dashboard Key Messages - Haringey CCG Integrated Performance Dashboard- Month 1 Achievements Key Performance Indicators: Diagnostics The CCG met this standard for the 7th consecutive month. Cancer Waiting Times The CCG achieved 6 out of the 8 cancer standards for February hour A&E standard Both and WH have achieved the 4 hour standard for Quarter 4 and year to date. For month 12, the CCG was compliant against this Quality Premium measure. Ambulance Response Times London wide, LAS achieved all three standards for ambulance response times in March 214. Quality Indicators: MRSA There were no MRSA cases reported for Haringey residents in March 214. MSA reported MSA cases in March. The CCG had 7 breaches in total for March from WH and Barts. Friends and Family Test and WH met the FFT target in March. QUALITY PREMIUM (YTD position) (NHS Constitution rights and pledges) Measure YTD performance Measure Achieved Referral to treatment times (18 weeks incomplete) 9.9% N 92% A&E waits - All types* 95% Cancer Waits - 62 days 88.1% Y 85% Category A Red 1 ambulance 76.3% Y 75% calls * For the purposes of the quality premium, the percentage of Incomplete pathways within 18 weeks will be calculated by summing the numerators (patients waiting within 18 weeks) from each month end and then dividing by the sum of all the denominators (patients waiting) from each month end. NHS England has not yet supplied the Providers/CCGs mappings that will be derived from Hospital Episodes Statistics (HES) figures for A&E waits all types. Performance Issues Finance: There are no reported variances as contractual performance information from Provider Trusts will be available from M2 onwards.. Run rate information will be availiable from M2 onwards. Key Performance Indicators: 18 weeks Referral to Treatment times Haringey CCG did not meet the Quality Premium standard for 18 weeks incomplete RTT pathways for 213/14. This does not include data from WH due to on-going reporting issues (these have been reported in previous months). and UCLH contribued to the CCG's underperformance against the admitted and non-admitted standards in March 214. Actions: WH and are testing reporting solutions. WH uploaded non-admitted and admitted data in March and expect to report on all standards in May. UCLH have RTT plans in place. The CSU will request a recovery plan and trajectory from. Cancer standards The 2 week wait standards for both GP referral for suspected cancer and breast symptoms were met at CCG level in March. At provider level, achieved all standards, while WH failed the breast symptoms standard. All NCL providers achieved the 2-week wait standard for suspected cancer. Action: WH has a plan in place to improve performance against the breast symptomatic standard and has just received approval from the Royal College of Physicians for a substantive medical oncologist to lead the breast service. This service is currently being covered by a locum. Quality Indicators: MRSA has not reported any MRSA in April bringing them to YDT. They reported a total of 6 for C.Diff The total number of C.Diff for Haringey CCG in 213/14 was 37. This was below the annual total of 37. Due to changes in patient flow as a result of the BEH Clinical Strategy, the Director of Quality, HCCG, is currently liaising with Publlic Health England and NHS England to agree an amended trajectory for 214/15. reported 2 cases in March bringing them above their annual trajectory of 16. The Trust reported 3 cases in April 214. MSA The CCG ended 213/14 with a total of 72 MSA breaches across all of its providers. Two breaches have been reported so far in 214/15 which is clearly above the zero tolerance trajectory. The Whiitington was the CCG's worst perfoming provider during 213/14. Friends & Family Test The net-promoter score for both inpatients and A&E at is low, with the Trust raking 6th from the bottom in London. In addition, the inpatient net promoter score is 2nd from the bottom in London. Action: are targeting key areas for improvement. Rating AMBER-GREEN AMBER - RED GREEN RED No RAG Rating Balanced Scorecard (Q2 Position from NHS England dashboard) Domain Details Domain 1: Are local people getting good quality care? Domain 2: Are patient rights under the NHS Constitution being promoted? Domain 3: Are health outcomes improving for local people? Domain 4: Are CCGs delivering services within their financial plans? Domain 5: Are conditions of CCG authorisation being addressed and removed (where relevant)? Key Messages Page 2

3 Key Performance Metrics (March 214) 98.% 96.% 94.% 92.% 9.% 88.% 86.% 84.% 82.% Haringey CCG: 18 Weeks RTT & Achievement 18 Weeks RTT Adjusted Admitted 18 Weeks RTT Non-Admitted 18 Weeks RTT Incomplete Pathways Mar YTD 97.5% 97.% 96.5% 96.% 95.5% 95.% 94.5% 94.% 93.5% 93.% Key Providers: 4 Hour A&E Standard Mar YTD Mar YTD Mar YTD WH UCLH A&E Type I Performance A&E All Types Performance Haringey CCG: Cancer Wait s 62 Day Cancer Wait: Consultant Upgrade 62 Day Cancer Wait: Screening service 62 Day Cancer Wait: GP Referral 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 31 Day Cancer Wait: Subsequent treatment (Surgery) 31 day Cancer Wait: 1st definitive treatment 2 Week Cancer Wait: Breast Symptoms 2 Week Cancer Wait.% 1.% 2.% 3.% 4.% 5.% 6.% 7.% 8.% 9.% 1.% YTD Feb 4 Hour A&E Standard Key providers: Mar Other Providers: Mar WH UCLH Moorfields RFH BHRUT Mar YTD Mar YTD Mar YTD Mar YTD* Mar YTD Mar YTD Mar YTD A&E Type I Performance 95% 95.9% 94.5% 97.1% 94.8% 97.% 94.9% 96.3% 96.% 88.9% 89.8% 85.7% 86.2% A&E All Types Performance 95% 95.9% 95.2% 97.1% 94.8% 97.% 94.9% 99.9% 99.8% 96.3% 96.% 91.4% 9.3% 86.1% 88.6% Mar 18 Weeks Referral to treatment and Diagnostics Key Providers: Feb Mar YTD Trajectory Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD 18 Weeks RTT Adjusted Admitted 9% 87.6% 9.4% 9.3% 93.5% 93.9% 9.1% 89.4% 9.9% 9.5% 91.8% 89.9% 93.1% 18 Weeks RTT Non-Admitted 95% 94.6% 95.4% 96.% 96.5% Whittington were unable to 96.8% 96.% 95.1% 95.4% 96.7% 97.% 95.% 95.5% 18 Weeks RTT Incomplete Pathways 92% 9.9% 9.9% 92.5% 92.5% 87.7% 87.7% 91.1% 91.1% 92.1% 92.1% 93.4% 93.4% >52 week waits Weeks Diagnostic Waits 99% 99.3% 99.3% 1.% 1.% 1.% 1.% 98.2% 98.2% 1.% 1.% 98.1% 98.1% 1.% 1.% 99.3% 99.3% Q1 Data- Cancelled operations (breaches of 28 day standard over number of cancelled operations) CCG Position: (Patients registered in Haringey only) WH 1% 1.% 98.5% 88.4% 98.4% 1.% 1.% 91.5% CCG Position: (Patients registered in National Haringey only) Average WH UCLH Moorfields RFH RNOH Feb YTD Trajectory Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD 2 Week Cancer Wait 93% 92.8% 93.9% 95.7% 95.1% 95.4% 94.5% 93.3% 93.8% 93.6% 1.% 97.1% 95.1% 95.4% 1.% 99.1% 95.4% 93.8% 2 Week Cancer Wait: Breast Symptoms 93% 92.4% 93.8% 96.2% 99.1% 95.8% 92.5% 9.7% 99.1% 92.7% 99.1% 96.2% 94.2% 93.5% 31 day Cancer Wait: 1st definitive treatment 96% 1.% 98.7% 97.6% 1.% 99.6% 1.% 99.7% 99.2% 97.7% 1.% 1.% 99.% 9.% 95.4% 1.% 99.2% 31 Day Cancer Wait: Subsequent treatment (Surgery) 94% 1.% 97.% 97.4% 1.% 1.% 1.% 1.% 98.3% 96.5% 1.% 1.% 99.4% 95.5% 96.1% 1.% 1.% 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 98% 1.% 1.% 99.8% 1.% 1.% 1.% 1.% 1.% 99.9% 1.% 1.% 1.% 1.% 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 94% 1.% 1.% 98.% 1.% 99.2% 1.% 1.% 1.% 99.8% 1.% 1.% 1.% 62 Day Cancer Wait: GP Referral 85% 85.7% 87.9% 84.7% 86.8% 91.9% 94.3% 84.6% 8.6% 81.1% 88.1% 9.1% 1.% 87.5% 85.7% 86.6% 62 Day Cancer Wait: Screening service 9% 1.% 1.% 94.5% 1.% 1.% 1.% 83.3% 91.2% 1.% 1.% 96.8% 97.8% 62 Day Cancer Wait: Consultant Upgrade % 1.% 9.4% 92.4% 97.6% 98.2% 81.8% 81.6% 5.% 72.3% 81.8% 74.2% 1.% 96.8% 97.8% Ambulance Handover Times : Mar submit RTT data in November UCLH Other Providers: Feb Cancer Waits Feb Key Providers: Feb Other Providers: Feb Ambulance Clinical Quality Response Time: Mar Whittington London Average London Ambulance Mar YTD Trajectory Mar YTD Mar YTD Mar YTD Trajectory 3 minute validated and tracked breaches % HAS completed 9% % % % % % % Category A calls resulting in emergency response arriving Category A calls resulting in emergency response arriving % within 15 mins 6 minute validated and tracked breaches 1% 28.% % % % % % 221 Category A calls resulting in emergency response arriving within 8 mins (RED 2) within 19 mins % within 3 mins 1% 82.1% 89.6% 92.8% 94.3% 94.2% 96.6% within 8 mins (RED 1) 75% 75% 95% 81.9% 8.2% 98.2% 76.8% 75.1% 97.8% Moorfields RFH RNOH were unable to submit RTT data in November Performance Dashboard 1 / 2 Page 4

4 No of Spells No of Spells No of Spells No of Spells No of Attendances Number of Attendances Attendances Summary (February 214) 12,5 12, 11,5 11, 1,5 1, 9,5 9, 8,5 8, A&E Attenders for Haringey CCG OP Attendance by Referral Source NHS Haringey CCG Performance Commentary 18 weeks Referral to Treatment (RTT) Haringey CCG did not meet the Quality Premium standard for 18 weeks incomplete RTT pathways for 213/14. In the absence of Whittington information, provisional March data shows non-compliance at CCG level for all three RTT standards. With the exception of the incomplete pathway measure, two out of three standards are compliant at year end. The main providers contributing to this adverse position are and UCLH. Incomplete pathway volumes are of concern with eight specialties individually falling below the standard. Particular pressure points include General Surgery, Neurology and Other category. Though compliant at the end of March, was only.1% over each standard which is indicative of a potentially vulnerable position. The CCGs backlog attributable to has increased from 74 in August to over 3. UCLH has increased by 7 in three months. There are four 52 week-waiters with UCLH and Barts Health NHS Trust. WH achieved the admitted and non-admitted standards in February and expect to submit a full data set in May 214. Actions: With additional funding allocated in February, increased clinic capacity in the most challenged specialties. In view of March performance showing some vulnerability, the CSU is requesting a backlog plan and trajectory to sustain and achieve individual specialty level performance. This will enable progress to be tracked against the contract uplift of 1m for RTT. UCLH has stated that it will recover performance within agreed contracted levels. A&E Attendances Linear (A&E Attendances) GP Dental C2C Other Cancer Waiting Times At CCG level, the 2weeks wait standards for suspected cancer and breast symptoms, underperformed in February. All other waiting times standards were achieved and all cancer standards are compliant year to date. achieved all cancer standards in February and WH all but breast symptomatic. Actions: Both and WH are increasing clinic capacity and introducing initiatives aimed at reducing the volumes of breaches caused by patient choice. WH has received Royal College approval for a substantive medical oncologist to manage the breast service, currently covered by a locum Emergency Admissions Haringey CCG ` All Elective Activity Haringey CCG A&E Waiting Times (4-hour waiting time standard) Haringey CCG achieved the Quality Premium standard for the A&E 4-hour waiting time target outturning at year end with 95.7%. recovered Q4 performance, securing its full year position and has more recently achieved the month of April. Despite examples of excellent performance by, there are apparent weaknesses in the Trust's overall operational resilience and ability to balance demand peaks and troughs. The result is extreme performance variability and general concern about sustainability. WH targets were achieved in Q4, yearend and in April 14. Actions: Haringey and Enfield CCGs have reviewed a deep dive of A&E performance and will be meeting with the Trust imminently. WH has opened its new Ambulatory Care Unit and is citing a positive impact for patients and GPs using this model Ambulance Handover Times The use of overrides at WH is below the London average. Performance against the 3 minute handover standard though red rated is one of the better positions in NCL. Conversely, North Middlesex is the worst performing Trust in NCL and in London. Actions: LAS has been working with since the end of April and is expected to report findings at the Haringey Urgent Care working Group in May. Emergency Admissions Linear (Emergency Admissions) Elective Inpatient Activity Rolling 3 mth avg Ambulance Clinical Quality Response Times: London wide, LAS met the standard for all 3 ambulance response time targets in March and achieved compliance year to date. At CCG level, Haringey achieved two out of three standards for the month of March and one out of three at year end, Red 1 & 2, 8 minute response times underperforming. NEL Admission Haringey CCG (Excludes DC/ Transfers) Daycase Rate Haringey CCG (Excludes Transfers) NEL Linear (NEL) NEL Linear (NEL) Analytics (Attendances) Commentary The charts (left) show an overall decreasing trend in activity for Haringey CCG. Despite the missing data for the WH, an estimated forecast of Haringey CCG also points to a downward trend in activity. In September 213, WH implemented a new Electronic Patient Records (EPR) system. Despite assurances from the Trust that CSU would receive missing activity for month 6, 7, 8 and month 9 this has failed to materialise. The CSU have been in regular communication with Trust and have been told that the issues will be resolved for Month 9 submission but this has not occurred. The CSU are still seeking further assurances supported by a detailed action plan and will continue to monitor the situation. Therefore the data generating the above charts contains activity for months 1-5 ONLY for WH for this year. The second main provider - shows the following activity forecasts: A&E activity is to be less this reporting year compared to last by just under 1%, despite this emergency admissions are forecast to increase by 5.6%. In terms of Elective activity - Inpatient activity is forecast to decrease by 3.5%, yet daycase activity to increase by a notable 8.1%. GP OP referrals are forecast to reduce by 4.7 %, yet overall OP first attendances are forecast to increase by 4.6% as this is being driven by the forecasted 8.7% increase by consultant to consultant referrals. The charts show an overall decreasing trend in activity for Haringey CCG which is primarily due to the missing data for the WH. However, if we extract the same data (m6-12) for WH in 12/13, to make it more comparable for an overall estimated forecast of Haringey CCG, it reflects an overall upward trend in activity for the CCG. Performance Dashboard 12/ 2 Page 5

5 Mental Health Indicators NATIONAL INDICATORS Provider Q3 Actual Trajectory IAPT IAPT Access Rate 2% BEH 7.3% IAPT Recovery Rate 5% BEH 34% OTHER MENTAL HEALTH INDICATORS CPA Follow Up 95% BEH 99.4% Description of Indicator The proportion of people that enter treatment compared to the level of need in the Borough Percentage of referrals moving to recovery Proportion of patients on CPA that were followed up within 7 days of discharge from inpatient acute mental health care Early Intervetion in Psychosis Crisis Resolution / Home Treatment Service 42 BEH 52 95% BEH 98.7% Number of newly diagnosed cases of psychosis between the ages of 14 and 35 who are receiving early intervention in psychosis services Proportion of service users admitted to acute inpatient mental health units, who were gate-kept by crisis resolution services Readmission within 28 days Delayed Transfer of Care (DTOC) Early Intervention in Psychosis - Caseload Percentage of Service Users waiting for over 11 weeks for 1st Appointment from date of Referral DNA Rates LOCAL INDICATORS Provider Q3 Actual Trajectory 5% BEH 2% 5% BEH 11% 55 BEH 56 5% T&P.3% 1% T&P 1.% Description of Indicator Proportion of discharges from acute inpatient mental health services who had unplanned readmission within 28 days of discharge Proportion of patients deemed medically fit to depart from their current inpatient care, but unable due to do so due to non-clinical reasons Number of cases of Psychosis (between the ages of 14 and 35) who are on the caseload of the early intervention team Percentage of Service Users who have waited for more than 11 weeks from date of referral for first appointment Percentage of Service Users who did not attend a scheduled appointment without providing appropriate notice to cancel appointment IAPT Access Rate for Q3 for Haringey CCG reported 7.3% against the quarterly target of 6.%, 5.% against target of 4.% in Q2 and 2.5% against target of 2.% in Q1. IAPT Recovery rate: the Omnibus data reported 34% in Q3, 37% in Q2 and 4.4% in Q1 against the quarterly target of 5%. Other Mental Health Indicators (National & Local) BEH performed above agreed target for CPA Follow-up, New cases in Early Intervention in Psychosis and Acute admissions gate-kept by CR/HT (Crisis Resolution/Home Treatment) in all the three quarters. BEH overall reported 99.3% against target of 95% in Q3 Delayed Transfer Of Care (DTOC) reported 11 in January, a slight improvement when compared to 14 reported in December, however, there are discrepancies on the numbers being reported against those held by the CCG s record. BEH - CLUSTER TRANSITION PROTOCOL COMPLIANCE Cluster No. Cluster Description Mental Health Tariff (Barnet Enfield & Haringey Mental Health NHS Trust) Recommended Review Period (days) No. over receommended period (days) No. within Recommended Period (Days) Total Service Users in Cluster % Within Recommended Review Period 1 Common mental health problems (low severity) % 2 Common mental health problems % 3 Non-psychotic (moderate severity) % 4 Non-psychotic (severe) % 5 Non-psychotic (very severe) % 6 Non-psychotic disorders of overvalued Ideas % 7 Enduring non-psychotic disorders (high disability) % 8 Non-psychotic chaotic and challenging disorders % 1 First episode in psychosis % 11 Ongoing recurrent psychosis (low symptoms) % 12 Ongoing or recurrent psychosis (high disability) % 13 Ongoing or recurrent psychosis (high symptom and disability) % 14 Psychotic crisis % 15 Severe psychotic depression % 16 Dual diagnosis (substance abuse and mental illness) % 17 Psychosis and affective disorder difficult to engage % 18 Cognitive impairment (low need) % 19 Cognitive impairment or dementia (moderate need) % 2 Cognitive impairment or dementia (high need) % 21 Cognitive impairment or dementia (high physical or engagement) % BEH - CLUSTER PROFILE: March 214 What is Mental Health Tariff? The Department of Health is introducing a tariff system for mental health services in the UK. A similar system (Payments by Results) is already being used in the acute healthcare sector, but is still being developed for application in mental healthcare. What is a Cluster? In tthe context of mental health tariff, a cluster is a global description of a group of people with similar characteristics as identified from a holistic assessment and rated using the Mental Health Clustering Tool (MHCT). The clusters allow for a degree of variation in the combination and severity of rated needs however, as the clusters are statistically underpinned, definite patterns in the MHCT ratings exist for each. These ranges are supplemented by the contextual information, which is particularly useful when reviewing the appropriateness of previous cluster allocations. When should someone be clustered? People s needs change over time, and over the course of their treatment. The Mental Health Tariff must reflect the differing levels of input that are provided throughout changing and unpredictable episodes of care. In order to achieve this, it is essential that people are not only assessed and clustered at the point of referral, but also re-assessed and re-clustered periodically. In practice this will equate to assessing and clustering people at: The end of the initial assessment (typically within 2 contacts). All planned CPA or other formal care reviews. Any other point where a significant change in planned care is deemed necessary (e.g. unplanned reviews, urgent admissions etc.) What is Cluster Transition Protocoll? The points at which the appropriateness of the current cluster allocation is reconsidered should not be arbitrary. It should occur at natural and appropriate points in the individual s care pathway. Typically these are termed as reviews but it is important to note that reviews can be relatively informal as well as formal, and can be in response to unforeseen changes in need i.e. unplanned as well as pre-planned. In general, cluster reviews should be aligned to care reviews: the review periods quoted are outer limits, 2 BEH INPATIENT - HARINGEY CCG (BASED ON CURRENT CASELOAD AS AT 3 April 214) 7 CLUSTERING OUTCOME - HARINGEY CCG (BASED ON CURRENT CASELOAD AS AT 3 April 214) 18 BEH OVERALL CLUSTERING OUTCOME (BASED ON CURRENT CASELOAD AS AT 3 April 214) Services Users Not on CPA Services Users on CPA Services Users Not on CPA Services Users on CPA Services Users Not on CPA Services Users on CPA Mental Health Dashboard 1/1

6 MRSA reported infections C. Difficile reported infections Mixed Sex Accommodation (MSA) (No. of breaches) *VTE (% admitted patients assessed for VTE risk) - October Friends and Family Test: Inpatient Score - December Friends and Family Test - Inpatient Response Rate - December Friends and Family Test - A&E Score - December Friends and Family Test - A&E Response Rate - December Friends and Family Test - Overall Response Rate - Inpatients - December Complaints - Number received Complaints - Percentage Responded to within 25 working days CCG 8 (See individual Trust target) Feb YTD Trajectory Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Feb YTD Mar 95% 96.1% 96.4% 95% 96.5% 95.7% 95% 96.1% 95.7% 95% 99.1% 97.4% 95% 98.5% 96.6% 95% 99.3% 98.7% 95% 97.% 95.5% 95% % 31% 39% 34% 78% 49% 7% 25% % 18% 18% 37% 22% 44% 29% 15% 2% 22% 36% 23% 45% 7% 28%.% CCG Position (Patients registered in Haringey only) MSA figures for Quality Indicators (Feb 214) Key Providers WH UCLH Moorfields RFH Other Providers RNOH Quality Commentary MRSA At CCG level there were no further cases of MRSA in February. : The Trust reported a 6th MRSA BSI case for March 214. PIR concluded that MRSA present in the blood culture was a contaminant and did not reflect a true bacteraemia. The patient was known to be colonised with MRSA and has dry, exfoliating skin, which makes MRSA decolonisation less likely. The doctor who took the blood for culture was trained and assessed in aseptic technique and the procedure had been correctly carried out. The review panel concluded that nothing further could have been done to reduce the risk of contamination. WH: The Trust s YTD position remains 2, which is above both TYD trajectory. : The Trust reported 1 case of MRSA in February 214 bringing them to a YTD position of 6 cases against a National target of.nhse Data published on the 21st March 214 shows the Trust reported a further one case in February taking them to a YTD position of 7. C. Difficile Infections (CDI) At the CCG level, 3 cases of C. Diff have been reported for February. : The Trust reported 4 cases in February and 3 were reported in March of which 2 cases occurred on the same ward. This brings the Trust to YTD position for 213/14 of 2 against a yearly target of no more than 16. WH: The Trust s validated position on is that the number of cases YTD is 21, (of these 3 cases were reported in March 14). They remain above their annual trajectory of 1. UCLH: The Trust has reported 1 cases of C Diff in February-14. The Trust's validated YTD position on is 95 with 5 cases reported in March. This is significantly above their annual target of 39. UCLH is following a detailed Healthcare associated bacteraemia reduction plan and C. Diff reduction action plan for 213/14 and assured the CQRG that their Trust Infection Control team further discuss this at the Safety Committee. The Trust advised that progress is being made to enable staff to learn from root causes of C.Diff cases and that embedding of Trust wide learning is in place as part of the overall learning. :The Trust has reported a total of a further seven validated cases in February 214. Public Health England figures show a YDT position of 34 for ther position; this indicates 6 further CDIs in March. MSA 1 MSA breaches were reported at CCG level in February and 5 in March. WH: The published data for MSA shows WH reported 37 cases in February and 16 cases in March, which represents a month-on-month reduction. On , Islington & Haringey CCGs visited WH to gain assurance that the Trust is meeting the MSA national guidance, subsequent to the 1 breaches reported in January.The Deputy Director of Nursing at WH gave assurance that the medical assessment unit was now compliant and that the Trust was focused on taking the necessary steps to ensure full compliance. UCLH: There were 1 confirmed mixed sex accommodation breaches in March at UCLH with a YTD figure of 19. The 1 case relates to the National Hospital for Neurology and Neurosurgery in Queens Square. : The Trust reported 26 cases of MSA in February 214 at Barnet Hospital. All of these were in recovery at Barnet Hospital due to capacity issues. The CCG has requested an action plan to address these issues to be presented to the CQRG meeting in March 214. Friends & Family Test : The inpatient FFT response rate in January was 15% and rose to 27% in February. The A&E response rate was 18% in January but has risen slightly in February to 22%. The aggregated response rate across inpatient and A&E is 23%. The net promoter score in February for A&E is +44 and ranked combined 6th from the bottom. For inpatients this has slightly risen compared to previous months to +51 but is ranked 2nd from the bottom for London. Long waits in A&E and quality of food and staff attitude and noise levels during the night time for inpatients have been cited most frequently as negative feedback. WH: Inpatient / A&E: The Trust response rates for February 214, for Inpatients is 4.43%, and A&E response rate is 16.74%. The combined aggregated response rate for both is 2.6%, which is above the 15% target. The FFT net promoter in February 214 for A&E is +54, which is the same as the London-wide score. The inpatient score is +7 compared to the London-wide score of +65. The combined score is +59, in comparison to the London- wide score of +65. Complaints The CSU Patient Experience Team are starting to gather basic complaints data regarding numbers of complaints and response timescales. It is envisaged that this will be reported at future governing body meetings for our main providers. Friends & Family Test: Scores & Response Rates: March % % 78% 8 7% % 7% % % 5% % 39% 37% 44% 4% % 36% 39 31% 33 29% 3% % 2% 25% 22% 23% 22% 2% 2 18% 18% 1 1% % WH UCLH Moorfields RFH RNOH Inpatient Score A&E Score Inpatient Response Rate A&E Response Rate Overall Response Rate Quality and Safety Dashboard 1/2 Page 6

7 Serious Incident Reporting North Middlesex University Hospital NHS Trust: March 214 Key Risks & Issues Serious Incident Risks and Issues reported one Grade 1 Serious Incident (SI) in December, a marked decrease on previous months and the lowest volume reported since April 212. Whilst this was largely accounted for by the fact that no pressure ulcers (which usually account for the majority of incidents) were reported in December, it was still the lowest number of non pressure ulcer incidents reported since April 213 Nil exceptional this month. Actions Whittington Health: March 214 Key Risks & Issues Serious Incident Risks and Issues WH reported 4 serious incidents in March 214, all of which were Grade 1 SIs. The volume of incidents reported each month in the year to date has fluctuated considerably, with this month seeing the second lowest volume of monthly reporting since April 212. Actions A meeting has been requested by the CSU between the Trust, CCG and CSU to review the evidence of action plan completion for four Grade 2 SIs which are still open on STEIS pending assurance that the action plans have been fully implemented. NB: Any marked increase or decrease in the number of SIs the Trust are reporting, may be as a result of reasons other than worsening clinical practice and therefore caution is advised when interpreting increases or decreases of reported SI numbers Quality and Safety Dashboard 2/2 Page 7

8 Abbreviation Term Definition A&E Accident and Emergency Accident and Emergency department is the part of a hospital that is staffed and equipped to provide rapid and varied emergency care, especially for those who are stricken with sudden and acute illness or who are the victims of severe trauma. The emergency department may use a triage system of screening and classifying clients to determine priority needs for the most efficient use of available personnel and equipment.. (Also referred to as ED) C.Diff Clostridium Difficile Clostridium Difficile is an infection that may occur within a healthcare environment. Often caused by antibiotics which wipe out the 'good' flora in the intestine, leading to diarrhoea. If not treated, C.Diff can lead to a serious infection of the colon. CCG Clinical Commissioning Group Clinical Commissioning Groups (CCGs) are responsible for implementing the commissioning of roles as set out by the Healthcare Act 212. CCGs are groups of GP Practices that work in partnership with other healthcare professionals, local communities and Local Authorities to commission the majority of NHS services for patients within their local communities. CCGs hold their constituent GP Practices to account for stewardship of resources and the outcomes they achieve. Anyone experiencing mental health problems is entitled to an assessment of their needs with a mental healthcare professional, and to have a care plan that's regularly reviewed by that professional. They should also be able to get a community care assessment from their local authority to look at their social care needs. CPA CSU Care Programme Approach Commissioning Support Unit Anyone who has severe mental health problems, or a range of different needs, their care may be co-ordinated under a Care Programme Approach (CPA). This is a particular way of assessing, planning and reviewing someone's mental health care needs. Further details are available at: The Commissioning Support Units provide support services such as contract management, service redesign, analytical support as well as other professional services to CCGs to help in the overall commissioning function in the NHS. DNA Did Not Attend Did not attends or DNAs have an enormous impact on the healthcare system in terms of cost and waiting time, significantly adding to delays along the patient pathway. A DNA occurs when a patient / service user fails to attend an appointment with an NHS staff member, without providing adequante notice to cancel the appointment. ED Emergency Department See A&E above FOT Forecast Outturn An assumption at a point in time of what the end of year position will be. FY Financial Year A financial year is a period used for calculating annual financial statements in businesses and other organisations. The financial year runs from 1st April until 31st March, every year. HCAI Healthcare Associated Infections Healthcare-Associated Infections (HCAI) are those infections that develop as a direct result of any contact in a healthcare setting. They occur in hospitals and in the community, and affect both patients and healthcare workers. HAS Hospital Alert System The Hospital Alert System is an electronic replacement to the paper forms used for documenting patient handover. The target performance measure is 9% completeness. Integrated Performance The Integrated Performance Report is published monthly and includes a set of indicators covering all aspects of Trust & CCG IPD Dashboard performance, including quality measures such as serious incidents (SIs), complaints and same-sex accommodation breaches Improving Access to Psychological Therapies is an NHS programme rolling out services across England offering interventions Improving Access to Psychological IAPT approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety Therapies disorders. The report focuses on the following key providers: - North Middlesex University Hospital NHS Trust () Key Providers - Whittington Health (WH) - University College London Hospital NHS Foundation Trust (UCLH) NHS Haringey CCG are the Lead Commissioner for. In addition,, WH & UCLH account for circa 9% of the annual acute care budget of the CCG. KPI Key Performance Indicator Key Performance Indicators (KPIs) help define and measure progress towards organisational goals. As the primary means of communicating performance across the organisation, KPIs focus on a range of areas. Once an organisation has analysed its mission, identified all its stakeholders and defined its goals, KPIs offer a way of measuring progress toward these goals. Full guidance on KPIs can be found at MRSA MRSA is a type of bacterial infection that is resistant to a number of widely used antibiotics. This means it can be more Methicillin Resistant difficult to treat than other bacterial infections. MRSA infections are more common in people who are in hospital or nursing Staphylococcus Aureus homes. Doctors often refer to this as healthcare-associated MRSA MSA Mixed Sex Accommodation All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient. Since April 211, all providers of NHS funded care have routinely reported breaches of sleeping accommodation, as set out in national guidance, and hence attract contract sanctions in respect of each patient affected. NCL North Central London North Central London (NCL) is a collective descriptor for five Clinical Commissioning Groups (CCGs), which are Barnet, Camden, Enfield, Haringey and Islington, as well as the geographical area they cover. NHS Constitution The NHS constitution for England is a formal constitution which, in one document, lays down the objectives of the National Health Service, the rights and responsibilities of the various parties involved in health care, (public, patients and staff) and the guiding principles which govern the service. Full details can be found at NTDA NHS Trust Development Authority The NHS Trust Development Authority (TDA) is responsible for providing leadership and support to the non-foundation Trust sector of NHS providers. This includes 99 NHS Trusts, providing around 3bn of NHS funded care each year. The TDA oversees the performance management of these NHS Trusts, ensuring they provide high quality sustainable services, and will provide guidance and support on their journey to achieving Foundation Trust status OP Outpatients A patient who receives medical treatment without being admitted to a hospital: "attending a clinic as an outpatient". PIR Post Infection Review As of 1 April 213, all NHS organisations reporting positive cases of meticillin-resistant Staphlococcus aureus (MRSA) bacteraemia via the Healthcare Associated Infections Data capture system ( HCAI DCS) will be required to complete a Post Infection Review (PIR). QIPP Quality, Innovation, Productivity and Prevention (QIPP) is a set of 'stretch' targets, varying from Trust to Trust, which aim to Quality, Innovation, Productivity achieve more efficient commissioning and higher levels of productivity e.g. reducing pressure ulcer cases to a lower number and Prevention or spending less on follow-up appointments. The quality premium is intended to reward Clinical Commissioning Groups (CCGs) for improvements in the quality of the Quality Premium services that they commission and for associated improvements in health outcomes and reducing inequalities. Full details can be found at RCA Root Cause Analysis Every day a million people are treated safely and successfully in the NHS. However, when incidents do happen, it is important that lessons are learned to prevent the same incident occurring elsewhere. Root Cause Analysis investigation is a well recognised way of doing this. Investigations identify how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for our patients. RTT Referral to Treatment RTT data is collected from NHS providers (NHS Trusts and other providers) and signed off by commissioners (CCGs). The RTT data measures referral to treatment (RTT) waiting times in weeks, split by treatment function. The length of the RTT period is reported for patients whose RTT clock stopped during the month. SI Serious Incident A serious incident is defined by the National Patient Safety Agency as an incident that occurs in NHS-funded services and care resulting in various levels of harm. SLA Service Level Agreement A Service Level Agreement outlines specific services and products delivered by the CSU. SUS Secondary Users Service The Secondary User Service is designed to provide anonymous patient based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development. Venous Thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE Venous Thromboembolism It is a common, lethal disorder that affects hospitalised and non-hospitalised patients, recurs frequently, is often overlooked, and results in long-term complications including chronic thromboembolic pulmonary hypertension (CTPH) and the postthrombotic syndrome (PTS). YTD Year to Date Year-to-date is a period, starting from the beginning of the current financial year, and continuing up to the present day. The financial year starts on 1st April. Abbreviations of Trust Names BEH Barnet and Chase Farm Hospitals NHS Trust Barnet Enfield & Haringey NHS Mental Health Trust BHRUT LAS RFH RNOH T&P Barking, Havering and Redbridge University Hospital NHS Trust London Ambulance Service NHS Trust North Middlsesex University Hospital NHS Trust Royal Free Hospital NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust Tavistock & Portman NHS Foundation Trust UCLH WH University College London Hospitals NHS Foundation Trust Whittington Health Glossary of Abbreviations Glossary Page 8