Integrated Quality and Performance Report

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1 Integrated Quality and Performance Report Agenda Item No: 12.1

2 The Royal Wolverhampton NHS Trust Meeting Date: 28 th April 214 Trust Board Report Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private: (with reasons if private) References: (e.g. from/to other committees) Integrated Quality & Performance Report This report provides the Board with an update of performance against national and local quality and performance indicators for March 214. It also provides assurances to the Board of the actions taken for any indicator that is underperforming. To note: current progress To approve: any corrective actions identified. To sign off: Single Operating Model self-certification Chief Operating Officer Head of Performance & Compliance Tel: None Public Session Appendix 1 Single Operating Model (SOM) Appendices/ References/ Background Reading NHS Constitution: (How it impacts on any decision-making) In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny Page 1 of 1

3 Integrated Quality & Performance Report March 214 1/29

4 Contents Executive Summary Quality Patient Experience Patient Outcomes Patient Safety Maternity Mortality National & Contractual Standards Workforce Waiting Times Urgent Care Cancer Stroke Organisational Efficiency Public Health Indicators 2/29

5 QUALITY EXECUTIVE SUMMARY Safety: There were two amber Medication Incidents involving community services and insulin incidents, no harm was caused. Infection Prevention: C.Difficile achieved the external target of 39 out of 39 cases. The rate of harm free care monitored through the NHS Safety Thermometer continued at 94% for March. The burden of harm is shifting from 'old' pressure ulcers to catheter associated urinary tract infections as performance in tissue viability improves. This will be a focus for the IP continence team annual plan for 14/15. There were 7 safeguarding incidents reported against the Trust. A new set of ward to board indicators have been developed which allow the Trust to drill down into detail around individual ward KPIs. This will be governed through the Patient Safety Improvement Group and will be used at Board in the future. Experience: The FFT score for inpatients remains above the national average at 75 and ED at 56 with an above average combined response rate of 22.9% just achieving the CQUIN payment through the use of text messaging. The response to nurse call bells remains an improving picture from January with a 29% increase on numbers of patients asked the question. PERFORMANCE RTT: The overall targets for Referral to Treatment were compliant for the month, however, we did not achieve compliance for 2 specialities (General Surgery and Trauma & Orthopaedics) against the 92% incomplete target, the fine for this is likely to be around 17,667. There is a further fine in March, across the same two specialties, of around 2,782 for failing the admitted target. These figures are approximated and need to be confirmed by the commissioner. The Trust has developed, and agreed, a detailed recovery plan with both the CCG and the TDA for Trauma & Orthopaedics. Emergency Department: A&E saw another busy month with attendances 1.34% higher than the same period last year this equates to an additional 127 attendances, for the same month we also saw a significant reduction in 4 hour breaches compared with the same period last year (997 breaches in March 13 compared with 363 breaches in March 214). The Trust did achieve both Type 1 and the overall for the month of March and also achieved the overall target for Quarter 4. Ambulance handover saw an improvement in month for 3-6 minutes, and again saw no patients >6 minute target. The fine for Ambulances during March was 7,6. This is based on 38 patients between per patient and patients >6 1, per patient. There were no patients who breached the 12 hour target during the month. Cancer: We are currently predicting possible failure of the 62 day traditional and the 62 day screening targets during March, validation is on-going and we continue to explore the possibility of re-allocation of late tertiary referrals back to the referring organisations. Final cancer data is uploaded nationally 6 weeks after month end. 62 Day Referral to first treatment - there were 2 patient breaches during the month of March - 5 x tertiary referrals received as late as day 7 (operating guidelines state referrals should be made within 42 days), 8 x capacity issues (6 x Urology, 2 x Head & Neck), 2 x Patient Initiated and 5 x Complex Pathway. 62 Day Screening - We had two breaches against this target for patients that we were unable to bring forward their TCI dates (due to capacity and anaesthetic assessment needed). 3/29

6 WORKFORCE Staff turnover - remains below the national NHS average. Staff sickness - saw a significant improvement in month, and is reported at.1% above the target of 3.24% by the end of March 214. Absence during March, was.44% lower than the same period last year and is the lowest in-month rate since May 29 (3.25%). Additionally, this month sees all four Divisions with a rate of below 4% for the first time in several years. Sickness absence workshops continue in a majority of areas as does the targeted advice and support from Human Resources. esams has now been rolled our across the Trust. A programme of audits to monitor compliance with policy in hot spot areas is continuing. 4/29

7 Patient Experience Cancelled Operations - Non-medical Reasons Q3 Results 213/14 QUALITY Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Q4 Breakdown of Monthly Cancellations for Non-medical Reasons Mar-14 Ran out of More Urgent Staff 12 Theatre No Beds Other Total Case(s) Shortage Time 1 Cardiac Surgery Cardiology General Surgery Gynaecology Head & Neck Ophthalmology Orthopaedics Urology Total Q4 Results 213/14 Surveillance Number of Cancelled Operations only Cancelled Ops as a % of Elective Admissions <.8%.38%.91% 1.21%.63%.96%.83%.8% Cancelled Ops as a % of Elective Admissions (Cumulative) <.8%.81%.83%.87%.84%.85%.85% Comments: 55 operations were cancelled during March, this is an improvement from 61 in February. A root cause analysis continues to be undertaken for every cancelled operation for non-medical reasons and is reviewed weekly at the Divisional Managers meeting. This is also a 33.7% improvement on the same period last year (83 cancellations). The cancelled operations that fall into the 'other' category consist of 1 General Surgery (No interpreter available) 2 x Orthopaedic (Electrical fault in theatre). Cancelled Operations not Re-admitted within 28 days Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Number of patients not re-admitted within 28 days Number of Urgent Operations cancelled for 2nd time 5/29

8 Patient Experience cont. Complaints Number of Complaints Received Number of Complaints Re-opened The Trust received 36 complaints during March 214 in comparison to 24 received in the previous year. 3 complaints were re-opened in March 214 compared to 6 in the previous year, which is a 5% decrease. Division 1 saw 2 complaints re-opened (Trauma/Orthopaedics x 1, Radiology x 1) and Estates and Facilities saw 1 complaint re-opened. Both of Division 1's re-opened complaints were responded to informally by the directorates and closed within 8 days. The Estates and facilities complaint has been referred to Legal Services as the complainant is seeking compensation. Response Time of Complaints 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % 41 complaints were closed in March 214. Of these 41 complaints 22 complaints were responded to within 25 days. 14 complaints took between 25 to 35 working days to investigate and respond (4 with consent to breach, 1 without consent to breach). 5 complaints took longer than 36 working days to investigate and respond (3 with consent to breach, 2 without consent to breach). Overall the Trust response rate for March is 71% (a slight decrease on last months 76%). -25 Days Days Over 35 Days 6/29

9 Patient Experience cont. Mixed Sex Accommodation Breaches 8 7 Comments: There were no single sex breaches reported during March Number of Breaches Total Number of Patients Impacted Friends & Family Net Promoter Score The net promoter remains steady at 75 and 56, we have achieved the CQUIN target with ED FFT increasing through the use of text messaging to every patient who has been to ED. We plan to roll this out across the Trust pending approval of business case funded through CQUIN money at TMC later this month. At the time of the report the national data set is not available. The bar charts below indicate ward scores which have all increased or remained the same in Q4 apart from: A12 (surgery), C19 (medicine) and Ward 1 at West Park (Rehabilitation). RWT FFT Score RWT ED FFT Score Nat Avge FFT Nat Avge ED FFT 7/29

10 Patient Experience cont. Friends and Family Test Results by Division and Ward The Friends and Family Test by Division and Ward bar charts show quarterly results. 12 Division 1 - FFT Score results by ward Quarter 1 Quarter 2 Quarter 3 Quarter 4 12 Division 2 - FFT Score results by ward Quarter 1 Quarter 2 Quarter 3 Quarter 4-2 8/29

11 Patient Experience cont. Patient and Carer Voice The Patient and Carer voice asks specific questions where we know, from the inpatient survey, that we can improve on. National Survey - Question RWT Baseline Score (n=415) Did you feel cared for? Not Applicable Responses to patient buzzers 6% Pain control 79% Discussing worries and fears 54% Patient involvement in decisions about discharge 65% RWT Score 64.5% January 214 Score (n = av 925 ) 94.6% 79.5% 94.7% 88.% 86.4% 88.7% February 214 Score (n = av 729 ) 95.3% 83.% 95.7% 9.1% 86.7% 9.2% March 214 Score (n = av 957 ) 95.% 82.6% 95.4% 88.6% 87.7% 89.9% Whilst Patient's Voice appears to have reduced, in fact the buzzer response time maintains momentum because the sample number is 228 (23.8%) more than last month. A similar sample of 925 patients in January yielded a response of 79.5% so this month is a definite improvement that must now be sustained. 9/29

12 Patient Outcomes: Safety Thermometer: Harm Free Care The Safety Thermometer is a national initiative that records the presence of four harms on all patients on one day every month. The rationale for focusing on the four harms is because they are common and because clinical consensus is that they are largely preventable through appropriate patient care The Proportion of patients with any harm from a fall Pressure Ulcer Prevalence New Old In March there were 5 patients who suffered a serious harm from falls; 4 fractured neck of femurs (A8, C18, AMU, Ward 1) and one fractured rib (A8). This is using incident data which is more robust than prevalence data in the Safety Thermometer for falls. The prevalence of all pressure ulcers continue to decline in line with incident data. 1.2% 1.%.8%.6%.4%.2%.% Catheters & UTIs 1.%.9%.8%.7%.6%.5%.4%.3%.2%.1%.% New VTEs 96% 95% 94% 93% 92% 91% 9% 89% 88% 87% Safety Thermometer UTI's New UTI'S Linear (New UTI'S) The burden of harm from catheter associated urinary tract infections is taking over from harm caused by pressure ulcers and is a topic of focus for the continence team in their forthcoming annual plan. The number of new VTEs by incident is not yet validated The safety thermometer rate continues to remain stable around 94%. Our target for the forthcoming year is to continue to maintain high sample numbers and a safety thermometer rate at or above 94. 1/29

13 Patient Safety Clostridium Difficile MRSA Comments: 17 positive by PCR. Of these 9 were attributed to RWT according to the internal definition of attribution. 7 were positive by toxin test; 3 were attributed to RWT using the official external definition of attribution, against a target of 3 for March. Against our internal target we were considerably over for the year against a target of 18. Against the official external target we were on target for the year to date - 39 cases against a target of E Coli Comments: No MRSA bacteraemias: The November case has now been formally attributed to RWT, this means that we have finished the year with one case (which was a contaminant) against a target of zero MSSA Comments: 25 in total: 7 attributable to RWT using our internal definition of attribution, 5 attributable to RWT using the DH s definition of attribution. One of these was a device related hospital acquired bacteraemia (urinary catheter). No internal or external targets set. Comments: 7 in total: 3 attributable to RWT using our internal definition of attribution, 3 attributable to RWT using the DH's definition. No external target set, but internal target is 24 for the year, so 3 cases is above the monthly target. We finish the year with 3 cases according to our internal definition, so we are 6 cases over target at year end. According to DH's definition of attribution we had 24 cases during the year. Serious Incident Reporting Report Incidences within 48 hours 19/19 Mar-14 1.% Comments: 19 incidents were reported to STEIS in March. Update on immediate actions of incident within 72 hours Share investigations report grade 1 (45 days) Share investigation report grade 2 (6 days) 19/19 1.% 11/29

14 Patient Safety cont. Medication Incidents This report details the number of medication incidents reported through Datix. The data encompasses incidents involving nurses, pharmacists and doctors. Medication Incidents Division 1 Division 2 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 No Incidents causing serious harm (as classified by RPS) Comments: Two amber incidents in Division 2 : Comm Adult Service NE1; Wrong insulin administered to patient in residential home (High Croft Hall) by student nurse under supervision by mentor. Comm Adult Service NE2: Incorrect insulin given to patient by Bank Nurse working on community services on a visit to a residential home (Swan Bank) Safeguarding Adults 8 Comments: 7 referrals were received during March. 7 Division 1-3 referrals received in March - 1 neglect relating to falls, RCA has 6 been completed and submitted to daughter. 1 physical/emotional abuse of 5 patient by staff, still being investigated. 1 neglect pressure damage, which has 4 been deemed unavoidable by Scrutiny & Accountability meeting on 5th March Division Division 1 2 Division 2-4 referrals received in March - 1 neglect relating to nursing/medical 1 care raised by IMCA, investigated and closed. 1 neglect relating to discharge to wrong destination, investigated and closed. 2 neglect both pressure damage, 1 of which was inherited (so should be closed and not substantiated against the Trust). Safeguarding Children Community Hospital Site Comments: 26 Referrals were made to Social Care during March - 21 Child Protection referrals were submitted from the Hospital site and 5 from Community sites. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 12/29

15 Patient Safety cont.. Radiation Incidents Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Radiotherapy Incident Rate per 1 Fractions Diagnostic Radiology Incident Rate per 1 Procedures Comments: Radiology reported 3 radiation incidents (2 were logged on Datix for the same incident) including 1 'near miss' in March against 2,647 examinations, therefore rate per 1, is.14. The number of radiation incidents reported in Radiotherapy in March was 3 at a rate of 1.1 per 1, fractions, this is an improvement.7 from last month. WHO Surgical Checklist Compliance 1.1% 1.% 99.9% 99.8% 99.7% 99.6% 99.5% WHO Surgical safety checklists are carried out in all operating theatres. 74 theatre sessions took place during March and compliance for the surgical safety checklist is reported at 1% for the month. VTE 1.% 95.% 9.% 85.% VTE assessment remains high at 97.29%, remaining above target. The number of VTEs was 26 of which 2 were community acquired and 6 hospital acquired. % VTE Assessment % VTE Assessment Hospital Acquired VTE Community Acquired VTE 13/29

16 Patient Safety cont.. Failure to Rescue and % of late or missed observations Failure to recognise deterioration of the patient s physiological status may culminate in cardio respiratory arrest. Fewer than 2% of patients who suffer cardiac arrest survive to discharge. The ability of a hospital to successfully treat a complication once it occurs is strongly related to the quality of care provided. The Failure to rescue indicator is intended to show how well hospitals perform once the complication occurs. Potential points of failure include: Not Taking observations Not recording observations Not recognising early signs of deterioration Not communicating observations The indicator the Trust measures is the percentage of late observations calculated by the number of patients on the ward and numbers of observations that are indicated to be taken, this is calculated using an electronic Track and Trigger system or VitalPac. The Trust has a baseline target of 5% late observations per ward Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Improving picture of late observations across the Trust. 6 areas greater than 7%:- Division 1 - A12-7.4% A5-8.8% A6-11% Division 2 - C24-7.7% C25-8.3% C19-9.4% 14% 12% 1% 8% 6% 4% 2% % Number of Cardiac Arrests outside of ICCU and Cath Lab or Pacing Lab Number of Cardiac Arrests Overall % Late Observations % Late Observations on VitalPac Wards Linear (Number of Cardiac Arrests outside of ICCU and Cath Lab or Pacing Lab) 14/29

17 Maternity Admissions of Full Term Babies to Neo Natal Unit 33.% 31.% 29.% 27.% 25.% 23.% 21.% 19.% 17.% C Section Rates 6 admissions to NNU during March this is a significant improvement on last months performance and has taken us below target for the first time since April 213. March saw 329 births. C/S births saw a slight improvement. The directorate continues to review its induction processes as initial audit data findings identifies Primigravida inductions as a key factor in rising C/S rates. 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% 3rd & 4th Degree Tears 3rd & 4th degree tears are classed as significant perineal trauma at birth. The directorate grades the perineal tears as 3A - C and grade 4 and incidence is scrutinised locally to determine cause. Performance for March was 2.1% this is a significant improvement in month and has taken us below target for the first time since October /29

18 Maternity cont Midwife to Birth Ratio 22% 2% 18% 16% 14% 12% Smoking at Delivery Static position in month. The directorate continues to liaise closely with HR with regards to recruitment. Smoking at time of delivery saw deterioration of 2.1% from the previous month, we remain above target by 4.8% Adms of Full Term Babies to Neo Natal Unit C-Section Rates 3rd & 4th Degree Tears Maternal Deaths Midwife to Birth ratio Smoking at Delivery Breast Feeding Initiated Early Neonatal Death (Born Here) Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 < <26% 27.6% 27.6% 22.8% 28.% 27.5% 27.1% <3% 2.7% 4.9% 4.5% 4.3% 5.9% 2.1% < <15% 14.6% 16.3% 2.8% 17.9% 17.7% 19.8% >64% 66.2% 61.9% 65.4% 65.% 66.4% 65.9% /29

19 Mortality Mortality ALL Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 HSMR Observed Death Rate 3.7% 4.1% 3.5% 4.2% 3.2% 3.3% 3.5% 3.4% 3.1% 3.9% 3.4% Expected Death Rate 3.8% 4.% 3.7% 3.9% 3.4% 3.7% 3.4% 3.4% 3.6% 4.2% 4.% No of in Hospital Deaths 1, Expected Deaths 1, Excess Deaths The HSMR for is currently benchmarked against and the Trust position is within expected range. England average has, however, improved considerably during this period for the basket of 56 diagnoses group, therefore it is predicted that the benchmark for will be rebased by 8 to 1 points to reflect the activity in England in To note, there is variation between Trusts in relation to the proportion of deaths captured within the basket of 56 diagnoses. This will result in an increase in HSMR that is likely to be significantly worse than expected for RWT using a 1 points shift prediction (based on April to January data). When looking at RWT's HSMR in the regional context the HSMR increases further by 1 point due to the deaths attributed through transfers. This prediction is based on data including January 14 discharges. It is expected that a further improvement is observed, once some data corrections are reflected in Dr Foster analysis. RWT SHMI: April October 213 Trust Name SHMI SHMI 95% CI Lower SHMI 95% CI Upper Total Discharges Obs. Deaths Exp. Deaths In Hospital Deaths % In Hospital Deaths Crude Mortality Rate The Royal Wolverhampton NHS Trust ,555 1,194 1, % 3.36% There is some discrepancy between the SHMI and the Dr Foster HSMR for this financial year for our Trust and we are investigating potential explanations. Some of the likely reasons are the differences in methodology between the two indicators. The main impact is likely to come from an increase in Palliative Care coding nationally, a decrease of crude death rates in England within the basket of 56 diagnoses and deaths attributed in the superspell which increase our HSMR. A data quality piece of work is in progress to address issues related to our data that are likely to impact on the HSMR and to a lesser extent on the SHMI. 3 Day Emergency Readmission Rate 6.% 5.5% 5.% 4.5% 4.% 3.5% 3.% Comments: This is a significant improvement of.38% from last months performance, and takes us below target by.9%. 17/29

20 Waiting Times Referral to Treatment 18 Weeks - Admitted 18 Weeks - Non-admitted 18 Weeks - Incomplete Community - Referral to treatment information Community - Referral information Community - Treatment Activity information % of patients waiting >6 weeks or more for a diagnostic test Number of patients waiting >52 weeks 94% 93% 92% 91% 9% 89% 88% NATIONAL & CONTRACTUAL STANDARDS Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 9% 91.16% 91.34% 9.49% 9.2% 9.47% 9.35% 95% 97.85% 97.56% 97.39% 96.16% 97.28% 97.28% 92% 94.77% 93.87% 93.12% 92.2% 93.63% 94.7% 5% 62.96% 66.7% 66.7% 75.6% 75.5% 75.99% 5% 98.2% 98.33% 98.3% 98.2% 96.6% 97.6% 5% 99.7% 99.5% 99.8% 99.7% 99.7% 99.7% <1%.%.%.%.%.%.% RTT Admitted 99% 98% 97% 96% 95% 94% 93% Comments: Non-admitted continues to be achieved both by specialty and bottom line. Admitted and Incomplete pathways was achieved at bottom line level and with the exception of General Surgery and Orthopaedics this was also achieved by every other specialty. RTT Non-Admitted 96% 95% 94% 93% 92% 91% 9% RTT Incomplete Fine: The fine for not achieving incompletes by specialty is likely to be around 7,292 for General Surgery & 1,375 for Orthopaedics. Admitted fine is likely to be around 7,813 for General Surgery & 12,969 for Orthopaedics. 18/29

21 Urgent Care Total Time Spent in Emergency Department (4 hours) Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Q4 New Cross 95% 95.79% 91.7% 91.9% 92.88% 92.29% 96.32% 93.8% Walk in Centre 95% 99.97% 1.% 99.94% 1.% 1.% 1.% 1.% YTD Combined 95% 96.77% 93.76% 93.34% 94.58% 94.3% 97.26% 95.37% 95.43% 13% 98% 93% 88% Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 New Cross Walk in Centre Combined Ambulance Handover Number between 3-6 minutes Number over 6 minutes Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar Trolley Waits in Emergency Department over 12 Hours Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Number of patients waiting over 12 hours in A&E 1 2 Comments: The fine for Ambulances during March was 7,6. This is based on 38 patients between per patient and patients >6 1, per patient. There were patients who breached the 12 target during March. 19/29

22 Urgent Care cont A&E All Types Performance = 95% seen within 4 hours Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total Attendances YTD Number Over 4 Hours YTD YTD % Birmingha m Children's Hos pital NHS Founda tion Trus t 98.11% 98.69% 96.95% 97.27% 5,259 1, % Burton Hos pitals NHS Founda tion Trus t 95.29% 98.68% 97.84% 95.94% 114,39 3, % George Eliot Hos pital NHS Trus t 94.65% 97.57% 95.56% 97.% 63,945 2, % The Roya l Wolverha mpton Hos pitals NHS Trus t 95.8% 96.62% 94.66% 95.37% 143,875 6, % Univers ity Hos pitals Birmingha m NHS Founda tion Trus t 94.8% 95.32% 95.18% 96.11% 97,33 4, % South Wa rwicks hire NHS Founda tion Trus t 91.73% 96.12% 95.58% 96.76% 63,384 3, % Sa ndwell & Wes t Birmingha m Hos pitals NHS Trus t 94.15% 94.95% 94.35% 94.32% 241,592 13, % Univers ity Hos pitals Coventry & Wa rwicks hire NHS Trus t 9.12% 93.71% 96.7% 95.19% 175,98 1, % The Dudley Group of Hos pitals NHS Founda tion Trus t 94.55% 96.6% 93.43% 9.58% 95,61 5, % Wa ls a ll Hea lthca re NHS Trus t 95.6% 94.59% 93.56% 91.7% 13,784 6, % Worces ters hire Acute Hos pitals NHS Trus t 93.2% 94.83% 94.7% 91.79% 138,365 9, % Shrews bury & Telford Hos pital NHS Trus t 93.5% 94.51% 93.31% 92.37% 114,998 7, % Wye Va lley NHS Trus t 93.19% 9.69% 93.43% 91.8% 52,728 4, % Univers ity Hos pital of North Staffords hire NHS Trus t 9.3% 93.23% 93.5% 88.87% 147,68 12, % Hea rt of Engla nd NHS Founda tion Trus t 91.57% 92.91% 88.83% 91.21% 236,897 2, % Mid Staffords hire NHS Founda tion Trus t 91.86% 94.6% 87.24% 86.87% 46,761 4, % A&E Attendances Diff 1-Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr West Midlands 93.22% 94.94% 93.82% 93.16% 1,886,66 117, % England 95.66% 96.27% 95.64% 95.16% 21,778, , % The table on the left and the graph above show the current number of attendances for April 214 compared with the same period last year. In the first 16 days of the month we have seen an additional 54 attendances this is a current increase of 9.74% /29

23 Cancer Waiting Times 2 Week Wait Cancer s 2WW Cancer 2WW Breast Symptomatic 13/14 Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Q4 93% 95.2% 93.1% 93.1% 94.89% 96.69% 96.62% 96.11% 93% 1.% 96.8% 1.% 98.14% 94.12% 94.85% 95.62% 31 Day Cancer s 31 Day First Treatment 31 Day Sub Treatment - Anti Cancer Drug 31 Day Sub Treatment - Surgery 31 Day Sub Treatment - Radiotherapy 13/14 Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Q4 96% 98.95% 98.6% 96.59% 98.89% 98.33% 98.77% 98.68% 98% 1.% 1.% 1.% 1.% 1.% 1.% 1.% 94% 95.83% 94.74% 96.97% 94.74% 88.% 95.65% 93.2% 94% 99.41% 1.% 96.4% 98.24% 1.% 99.15% 98.64% 62 Day Cancer s 62 Day Wait for First Treatment 62 Day Wait - Screening 62 day Wait - Consultant Upgrade (local target) 13/14 Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Q4 85% 81.21% 85.35% 72.9% 73.29% 79.26% 7.43% 74.94% 9% 92.31% 94.12% 9.% 92.31% 91.67% 84.62% 89.6% 88% 96.2% 96.18% 89.47% 91.59% 91.36% 92.98% 92.16% Comments: 62 day to first treatment - there were 2 patient breaches during the month of March - 5 x tertiary referrals received as late as day 7 (operating guidelines state referrals should be made within 42 days), 8 x capacity issues (6 x Urology, 2 x Head & Neck), 2 x Patient Initiated and 5 x Complex Pathway. 62 Day Screening - We had two breaches against this target for patients that we were unable to bring forward their TCI dates (due to capacity and anaesthetic assessment needed). 21/29

24 Cancer Waiting Times cont The tables below show the Trust performance against the 62 Day Referral to Treatment target year to date:- Table 1 shows total Trust monthly performance Table 2 shows Urology performance only Table 3 shows Trust performance excluding Urology. Table 1 Total Trust 62 Day Traditional (target 85%) Patients Seen within Standard Total Number of Patients Seen Monthly Performance Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb % 86.13% 87.42% 9.79% 77.4% 86.57% 81.21% 85.35% 75.59% 73.29% 79.26% Table 2 Urology 62 Day Traditional (target 85%) Patients Seen within Standard Total Number of Patients Seen Monthly Performance Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb % 84.21% 76.47% 75.% 69.57% 76.% 54.55% 75.% 42.86% 39.2% 63.41% Table 3 Total Trust (excluding Urology) 62 Day Traditional (target 85%) Patients Seen within Standard Total Number of Patients Seen Monthly Performance Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb % 86.87% 9.6% 93.75% 81.% 88.99% 87.88% 87.22% 79.65% 86.67% 86.17% 22/29

25 Stroke Patients admitted with primary diagnosis of stroke should spend greater than 9% of their hospital stay on a dedicated stroke unit High risk patients will be assessed and treated within 24 hours 88% 86% 84% 82% 8% 78% 76% 74% 72% 12% 1% 8% 6% 4% 2% % Comments: This is a static position from the one reported in February, we remain above target by 1%. Comments: This is a deterioration in month, however, we remain above target by 27%. 23/29

26 Organisational Efficiency Choose and Book - Sufficient Appointment Slots This indicator measures RWT ability to offer appointment slots via Choose and Book. The target is to achieve less than 1% failure rate for all directly bookable appointments. 15% Comments: This is a deterioration in month and we remain above the upper limit by 1.9%. 1% The areas facing the biggest challenge are Orthopaedics, Urology, GI & Liver and Ophthalmology. 5% These issues continue to be escalated daily and are discussed weekly at the Divisional Managers meeting. % Upper Limit Delayed Transfers of Care Delayed transfers of care is based on the number of occupied bed days versus the number of delayed bed days during the month. The target is no more than 5%. 6% Delayed Transfers of Care 5% 4% 3% 2% Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Delay awaiting assessment Delay awaiting public funding Delay awaiting further NHS care Delay awaiting residential/nursing home Delay awaiting domiciliary package Delay awaiting equipment Delay awaiting family choice March 29.3% 1.7% 8.6%.% 2.7% 6.9% 32.8% 24/29

27 Organisational Efficiency cont.. Discharge Summary within 24 hours of Patient Discharge 1% 95% 9% 85% Comments: Discharge summary saw a slight deterioration in month and is reported at 91.82%, this means that we failed to achieve the revised target for the month of March. 8% Fine: The fine for not achieving this target in March is 16,. Patients with Fractured Neck of Femur Mar-14 Feb-14 Jan-14 Dec-13 Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 May-13 Apr-13 Mar-13 1% of patients admitted with a fractured neck of femur underwent surgery within two days of admission % 2% 4% 6% 8% 1% 25/29

28 14.% 12.% 1.% 8.% 6.% 5.% 4.5% 4.% 3.5% 3.% Turnover Sickness Absence WORKFORCE Turnover: We continue to achieve a much better turnover rate than the National NHS rate of 13.2%. Sickness Absence: Trust absence rate for March 214 decreased by.83% from 4.17% in February 214 to 3.34% in March 214, which is.1% above the Trusts target of 3.24% by March 214. March 214 absence level is.44% lower than March 213 and is the lowest in-month rate since May 29 (3.25%). Additionally, this month sees all four Divisions with a rate of below 4% for the first time in several years. The top 4 reasons for absence during March 214 were the same as February 214, however, 3 out of the 4 areas have seen a decline. 'Other musculoskeletal problems' is now the top reason for absence (it was the second highest in February 214). Reasons are as follows:- Other Musculoskeletal problems 16.94% (increase of 2.4% from last month), Anxiety/stress/depression/other psychiatric illness 16.46% (decrease of 1.48%), Gastrointestinal problems 1.24% (decrease of.33%), Cold, cough, flu, influenza at 9.93% (decrease of.72%). Actions: Sickness absence workshops continue in a majority of areas as does the targeted advice and support from HR. esams has been rolled out across the Trust, work is on-going with IT to resolve continuing issues. A programme of audits to monitor compliance with policy in hot spot areas is continuing. Temporary Medical Staff - Agency Spend Temporary Nursing Staff - Agency Spend 8.% 6.% 4.% 2.%.%.6%.5%.4%.3%.2%.1%.% Comments: Medical agency costs saw an deterioration in month from 5.8% in February to 6.9% in March. Surgical Division: saw an increase in month from 41K in February to 52K in March. Cardiology spend remained high in month due to continued locum cover Medical Division: also saw an increase in month from 255K in February to 31K in March. A&E continues to remain high due to on-going vacancies at Consultant and Middle Grade level, as does Oncology due to Locum Consultants covering a vacant post and maternity leave. 26/29

29 Workforce cont. Annual Appraisal Rates Surgical Division Medical Division Estates & Facilities Corporate Services Trust Total Q3 Results 213/14 Q4 Results 213/14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 8% 89.3% 88.% 85.6% 85.1% 86.3% 84.8% 8% 87.9% 88.3% 87.1% 85.6% 88.4% 89.6% 8% 94.8% 92.2% 92.6% 91.% 92.4% 91.3% 8% 86.2% 85.8% 83.6% 85.4% 85.8% 85.9% 8% 89.1% 88.4% 86.9% 86.1% 87.9% 87.7% Comments: March's position saw a very slight deterioration in month, however, we remain above the target set for 213/14. The following areas are showing RED for under compliance i.e. <7% overall compliance. Surgical Division - Currently showing no departments as Red. Medical Division - Diabetes (69.2%) Estates & Facilities - Engineering Services (64%) and Estates Services (57.1%) Corporate Services - Human Resources (69%), IT Department (51.7%) and Medical Illustration (16.7%) 95% 9% 85% 8% Trust Wide Annual Appraisal Rates 75% Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 % of Nurses - Registered Nurses Trained Nurses Head Count 2,65 % 73.33% Comments: Out of a total number of 2,816 nursing staff 73.3% are Registered Nurses (band 5 and above) Untrained Nurses % Total Nursing Staff 2,816 1.% 27/29

30 PUBLIC HEALTH INDICATORS The following Public Health indicators are reported on a quarterly basis. Number of NHS Health Checks completed The Healthy Life Style Database for Healthchecks was completed in December 213. Roll out to GP practices started in January 214. Short term Commissioning contract - there is a high turnover of staff due to fixed term contract to the end of March 214, this has remained unchanged in quarter 4. The fixed term funding will be recurrent awaiting final sign off from Commissioners for 214/15. Quarterly meetings with GP practices continue to encourage participation in the Health Check programme and to ensure letters to patients are sent out regularly. Smoking Cessation The smoking cessation numbers are not complete for the year (due to the data lag period). The final report to the Department of Health takes place in June 214 when the total numbers for 213/14 will be complete. Smoking campaign in line with the national campaigns took place in January - New Year, New You and No Smoking day March 214. Information distributed to all GP, Pharmacies and marketing in many locations in Wolverhampton took place. 28/29

31 Public Health Indicators cont 12% 1% 8% 6% 4% 2% % Human Papilloma Virus Vaccine (HPV) 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % Tetanus, Diphtheria & Polio Vaccine (TDP) The performance for both of these indicators reflect the start of the school year as this indicator tracks girls through the academic year, therefore the target for the year is profiled to reflect this and this is also the reason that there is no target set for August. The TDP indicator is currently slightly under target, however, the final figures for the academic year will be available at the end of July 214. Health Visitor Numbers The target for 61 WTE should be after September 214 hence the reason for the increase in the Student numbers for September 213 and January 214. Students who have qualified but still awaiting confirmation on NMC register. 29/29

32 SELF-CERTIFICATION RETURNS Organisation Name: The Royal Wolverhampton NHS Trust Monitoring Period: March 214 NHS Trust Over-sight self certification template Returns to XXX by the last working day of each month

33 NHS Trust Governance Declarations : 212/13 In-Year Reporting Name of Organisation: The Royal Wolverhampton NHS Trust Period: March 214 Organisational risk rating Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any contractual issues and compliance with CQC essential standards: Governance Risk Rating (RAG as per SOM guidance) Key Area for rating / comment by Provider Score / RAG rating* AR Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 4 * Please type in R, AR, AG or G and assign a number for the FRR Governance Declarations Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation. Supporting detail is required where compliance cannot be confirmed. Please complete one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand written or electronic, you are required to print your name. Governance declaration 1 The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board Statements. Signed by: Print Name: on behalf of the Trust Board Acting in capacity as: Signed by: Print Name: on behalf of the Trust Board Acting in capacity as: Governance declaration 2 At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board Statements. Signed by : Print Name : on behalf of the Trust Board Acting in capacity as: Signed by : Print Name : on behalf of the Trust Board Acting in capacity as: If Declaration 2 has been signed: For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain briefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail. /Standard: The Issue : Action : /Standard: The Issue : Action : /Standard: The Issue : Action : /Standard: The Issue : Action : /Standard: The Issue : Action :

34 QUALITY Information to inform discussion meeting The Royal Wolverhampton NHS Trust Insert Performance in Month Criteria Unit Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Dec-13 Jan-14 Mar-14 Board Action 1 SHMI - latest data Score Venous Thromboembolism (VTE) Screening % a Elective MRSA Screening % b Non Elective MRSA Screening % Single Sex Accommodation Breaches Number Open Serious Incidents Requiring Investigation (SIRI) Number Total number of SUI's open on STEIS - 21, number over 45 days - (SHA reported figure) 6 "Never Events" occurring in month Number CQC Conditions or Warning Notices Number 8 Open Central Alert System (CAS) Alerts Number Total number of CAS alerts - 1, number overdue - 1 NPSA 9 RED rated areas on your maternity dashboard? Number N/A N/A N/A N/A Falls resulting in severe injury or death Number Grade 3 or 4 pressure ulcers Number x Community and 4 x Acute 12 1% compliance with WHO surgical checklist Y/N Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 13 Formal complaints received Number Agency as a % of Employee Benefit Expenditure % Sickness absence rate % Consultants which, at their last appraisal, had fully completed their previous years PDP %

35 FINANCIAL RISK RATING The Royal Wolverhampton NHS Trust Risk Ratings Insert the Score (1-5) Achieved for each Criteria Per Month Reported Position Normalised Position* Criteria Indicator Weight Year to Date Forecast Outturn Year to Date Forecast Outturn Board Action Underlying performance Achievement of plan Financial efficiency EBITDA margin % 25% < EBITDA achieved % 1% < Net return after financing % 2% > < I&E surplus margin % 2% < Liquidity Liquid ratio days 25% < Weighted Average 1% Overriding rules Overall rating Overriding Rules : Max Rating Rule 3 Plan not submitted on time No 3 Plan not submitted complete and correct No 2 PDC dividend not paid in full No 2 Unplanned breach of PBC No One Financial Criterion at "1" One Financial Criterion at "2" Two Financial Criteria at "1" Two Financial Criteria at "2" * Trust should detail the normalising adjustments made to calculate this rating within the comments box.

36 FINANCIAL RISK TRIGGERS The Royal Wolverhampton NHS Trust Insert "Yes" / "No" Assessment for the Month Historic Data Current Data Criteria Qtr to Jun-13 Qtr to Sep-13 Qtr to Dec-13 Jan-14 Feb-14 Mar-14 Qtr to Mar-14 Board Action Unplanned decrease in EBITDA margin in two consecutive quarters Quarterly self-certification by trust that the normalised financial risk rating (FRR) may be less than 3 in the next 12 months Working capital facility (WCF) agreement includes default clause Debtors > 9 days past due account for more than 5% of total debtor balances Creditors > 9 days past due account for more than 5% of total creditor balances Two or more changes in Finance Director in a twelve month period Interim Finance Director in place over more than one quarter end Quarter end cash balance <1 days of operating expenses No No No No No No No No No No No No No No N/a N/a N/a N/a N/a N/a N/a No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No 9 Capital expenditure < 75% of plan for the year to date No No No No No No No 1 Yet to identify two years of detailed CIP schemes No No No No No No No

37 Safety Quality Patient Experience Effectiveness GOVERNANCE RISK RATINGS The Royal Wolverhampton NHS Trust Insert YES, NO or N/A (as appropriate) See 'Notes' for further detail of each of the below indicators Area Ref Indicator Sub Sections Threshold Referral to treatment information 5% 1a Data completeness: Community services Referral information 5% comprising: Treatment activity information 5% Weighting 1. Qtr to Jun-13 Yes Historic Data Qtr to Sep-13 Yes Qtr to Dec-13 Yes Current Data Jan-14 Feb-14 Mar-14 Yes Yes Yes Qtr to Mar-14 Yes Board Action 1b Data completeness, community services: (may be introduced later) Patient identifier information 5% N/a N/a N/a N/a N/a N/a N/a Patients dying at home / care home 5% N/a N/a N/a N/a N/a N/a N/a 1c Data completeness: identifiers MHMDS 97%.5 N/a N/a N/a N/a N/a N/a N/a 1c 2a 2b 2c 2d 3a 3c 3e 3g 3h 3i Data completeness: outcomes for patients on CPA From point of referral to treatment in aggregate (RTT) admitted From point of referral to treatment in aggregate (RTT) non-admitted From point of referral to treatment in aggregate (RTT) patients on an incomplete pathway Certification against compliance with requirements regarding access to healthcare for people with a learning disability 3b All cancers: 62-day wait for first treatment: 3d 3f All cancers: 31-day wait for second or subsequent treatment, comprising : All Cancers: 31-day wait from diagnosis to first treatment Cancer: 2 week wait from referral to date first seen, comprising: A&E: From arrival to admission/transfer/discharge Care Programme Approach (CPA) patients, comprising: Minimising mental health delayed transfers of care Admissions to inpatients services had access to Crisis Resolution/Home Treatment teams Meeting commitment to serve new psychosis cases by early intervention teams 5%.5 N/a N/a N/a N/a N/a N/a N/a Maximum time of 18 weeks 9% 1. Yes Yes Yes Yes Yes Yes Yes Maximum time of 18 weeks 95% 1. Yes Yes Yes Yes Yes Yes Yes Maximum time of 18 weeks 92% 1. Yes Yes Yes Yes Yes Yes Yes N/A.5 Yes Yes Yes Yes Yes Yes Yes Surgery 94% Anti cancer drug treatments 98% 1. Yes Yes Yes Yes No Yes No Radiotherapy 94% From urgent GP referral for 85% suspected cancer 1. Yes Yes No No No No No From NHS Cancer Screening 9% Service referral 96%.5 Yes Yes Yes Yes Yes Yes Yes all urgent referrals 93% for symptomatic breast patients.5 Yes No Yes Yes Yes Yes Yes 93% (cancer not initially suspected) Maximum waiting time of four hours 95% 1. Yes Yes No No No Yes Yes Receiving follow-up contact within 7 95% days of discharge 1. N/a N/a N/a N/a N/a N/a N/a Having formal review 95% within 12 months 7.5% 1. N/a N/a N/a N/a N/a N/a N/a 95% 1. N/a N/a N/a N/a N/a N/a N/a 95%.5 N/a N/a N/a N/a N/a N/a N/a 3j 3k Category A call emergency response within 8 minutes Category A call ambulance vehicle arrives within 19 minutes Red 1 8%.5 N/a N/a N/a N/a N/a N/a N/a Red 2 75%.5 N/a N/a N/a N/a N/a N/a N/a 95% 1. N/a N/a N/a N/a N/a N/a N/a Is the Trust below the de minimus 12 N/a N/a N/a N/a N/a N/a N/a 4a Clostridium Difficile 1. Is the Trust below the YTD ceiling 39 Yes Yes No No Yes Yes Yes Year end performance 39 against 39 4b MRSA Is the Trust below the de minimus 6 N/a N/a N/a N/a N/a N/a N/a 1. Is the Trust below the YTD ceiling Yes Yes No No No No No CQC Registration Non-Compliance with CQC Essential A Standards resulting in a Major Impact on Patients B Non-Compliance with CQC Essential Standards resulting in Enforcement Action 2. No No No No No No No 4. No No No No No No No C NHS Litigation Authority Failure to maintain, or certify a minimum published CNST level of 1. or have in place appropriate alternative arrangements 2. No No No No No No No TOTAL RAG RATING : G G AR AR AR AG AR GREEN = Score less than 1 AMBER/GREEN = Score greater than or equal to 1, but less than 2 AMBER / RED = Score greater than or equal to 2, but less than 4 RED = Score greater than or equal to 4

38 GOVERNANCE RISK RATINGS The Royal Wolverhampton NHS Trust Insert YES, NO or N/A (as appropriate) See 'Notes' for further detail of each of the below indicators Area Ref Indicator Sub Sections Threshold Weighting Qtr to Jun-13 Historic Data Qtr to Sep-13 Qtr to Dec-13 Current Data Jan-14 Feb-14 Mar-14 Qtr to Mar-14 Board Action Overriding Rules - Nature and Duration of Override at SHA's Discretion i) Meeting the MRSA Objective Greater than six cases in the year to date, and breaches the cumulative year-to-date trajectory for three successive quarters ii) iii) iv) Meeting the C-Diff Objective RTT Waiting Times A&E Clinical Quality Indicator Greater than 12 cases in the year to date, and either: Breaches the cumulative year-to-date trajectory for three successive quarters Reports important or signficant outbreaks of C.difficile, as defined by the Health Protection Agency. Breaches: The admitted patients 18 weeks waiting time measure for a third successive quarter The non-admitted patients 18 weeks waiting time measure for a third successive quarter The incomplete pathway 18 weeks waiting time measure for a third successive quarter Fails to meet the A&E target twice in any two quarters over a 12-month period and fails the indicator in a quarter during the subsequent nine-month period or the full year. v) Cancer Wait Times vi) Ambulance Response Times Breaches either: the 31-day cancer waiting time target for a third successive quarter the 62-day cancer waiting time target for a third successive quarter Breaches: the category A 8-minute response time target for a third successive quarter the category A 19-minute response time target for a third successive quarter either Red 1 or Red 2 targets for a third successive quarter vii) Community Services data completeness Fails to maintain the threshold for data completeness for: referral to treatment information for a third successive quarter; service referral information for a third successive quarter, or; treatment activity information for a third successive quarter viii) Any other Indicator weighted 1. Breaches the indicator for three successive quarters. Adjusted Governance Risk Rating G G AR AR AR AG AR

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