Hammersmith & Fulham CCG Performance & Quality Report August 2013 Month 5
Section 1: Table of contents Executive Summary & Key Messages Section 2 CCG Operating Framework CCG Outcomes framework Quality premium NHSE Assurance provider quality Shaping a Healthier Future Provider issues 111 Pilot Services Action log Section 3 Section 4 Section 5 Section 6 Section 7 Section 8 Section 9 Sections 10 Recommendations and next steps Sections 11 1
Section 2: Executive Summary CCG Operating Framework - The CCG is currently meeting constitutional performance measures with the exception of RTT performance standards at specialty level and 52 week standards. The CCG performance was largely impacted by Imperial College Hospitals Trust (ICHT) and Chelsea & Westminster hospital (CW). Cancer: H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date, with performance in M5 driven by ICHT. Health Care Acquired Infection (HCAI) H&F CCG reported 17 C.Diff cases against a tolerance of 13 cases with no hospital acquired cases in M5. Performance year to date driven by ICHT with all 11 hospital acquired cases for H&F CCG. No patient tested positive for MRSA bacteraemia in M5 with 4 cases reported year to date. Quality Premium H&F CCG is not meeting the cancer 62 days to treatment standard a gateway metric to receiving quality premium funding. In addition, the CCG is not meeting HCAI and MMR immunisation standards and the MRSA tolerance has been exceeded for 2013/14. Under current DH guidance the HCAI Quality Premium is awarded only where both HCAI tolerances are met. Information on other metrics is not currently available as these are annual or quarterly measures. Areas where provider performance (trust-wide across all CCGs) is below standard: CW, ICHT and RBH are meeting RTT standards overall but not at a speciality level. ICHT also reported 3 breaches of the 52 week standard and has confirmed that all 3 were treated in M5 and there are no patients waiting over 52 weeks at month end. Cancer: ICHT did not meet the 62 days to treatment standard following urgent referral in M5 achieving 65.6%. RBH did not meet the 62 day consultant upgrade standard with 1 breach due to a complex pathway. ICHT is not meeting the 31 days to treatment standard year to date achieving 95.2% against a 96% standard. HCAI: 1 MRSA was reported in M5 by CW and ICHT. CW, ICHT and RBH will not meet the zero tolerance MRSA requirement for 2013/14 reporting 2, 5, and 2 cases respectively. ICHT met C.Diff tolerance in M5 but not year to date and RBH has exceeded its C.Diff tolerance year to date but is within the Monitor de-minimis tolerance. LAS arrival to handover waits greater than 30mins : 4 and 26 patient breaches reported at CW and ICHT respectively in M5. ICHT reported that 5.4% of operations cancelled on the day for non clinical reasons were not rebooked within 28 days in M5. WLMHT did not meet the 11% target for DNA Follow Up and 8.1% target for Readmission Within 30 days with 12.3% and 9.6% respectively CLCH achieved 96.0% at M5 against 98.0% target for LAC Initial Health Assessments conducted within 20 operational days Actions being taken or in place by individual providers are outlined in Section 11 of this report. 2
Section 2: Executive Summary (contd) The CCG, supported by CSU, is taking the following actions to address these performance concerns: Contract penalties will be applied to all Trusts breaching national standards, for example 5000 for each 18 week 52 week wait, 1000 for a 60 minute handover breach, and 200 for a 30 minute handover breach. Root cause analyses, exception reports and action plans are required where providers have breached quality standards which are discussed at relevant contractual meetings. Where required the CSU performance and quality teams undertakes critical analysis of exception reports, demand and capacity assessments, and action plans submitted by providers. The CSU also monitors action plans on a weekly / month basis and A&E pressures on a daily basis. Where necessary the CSU meet with providers to agree additional actions required. Recovery actions for individual providers are detailed in Section 11 3
Section 2: Key Messages NHS CCG Operating Framework Outcomes Framework Quality Premium NHSE Assurance Key Messages The CCG currently assessed green for 18 indicators, and red on 2 indicators. A further 19 indicators are not assessed as data is either not yet available or the indicator is in development. The CCG currently assessed as improving for 11 indicators with a fall in performance for 9 indicators. A further 10 indicators are not assessed as data is either not yet available or the indicator is in development. 1 national domain measure is assessed as not met 3 national domain measures are currently not assessed. The CGG is not meeting 1 local measure and is not assessed on 2 local measures The CCG currently assessed green for 20 indicators, and red on 5 indicators. A further 26 indicators are not assessed as data is either not yet available or the indicator is in development. Further Detail Please see section 3 Please see section 4 Please see section 5 Please see section 6 4
Section 3: NHS CCG Operating Framework H&F CCG is meeting RTT performance standards overall but not specialty or 52 week standards. The admitted patient that waited longer than 52 week wait was reported by ICHT and has been treated in M5. The Trust has confirmed that no further patients are waiting over 52 weeks at month end. H&F CCG specialty performance has been impacted by ICHT reducing its backlog within General Surgery, T&O and Urology. Plastic Surgery and General Medicine did not meet non admitted RTT standards due to a small number of breaches at CW. CW, ICHT and RBH are meeting RTT standards overall but not at a speciality level. Action plans are in place to improve the management of 18 week RTT at both ICHT and CW. CW has reviewed waiting list management processes after reporting a number of surgical specialties did not meet RTT standards in M5 and has reported an improved position in M6. ICHT has reported that it is on plan to meet T&O admitted standard by the end of October 2013 but not the non-admitted General Surgery standard by the end of September 2013. An update to the Trust planned trajectory has been requested. ICHT reported 5.4% of operations cancelled on the day for non-clinical reasons were not rebooked within 28 days in M5. ICHT has provided an action plan and is on trajectory to meet standard in Q2. Performance Measure Description Reporting Frequency Reporting Period Threshold NHS Hammersmith & Fulham CCG In mth/qtr YTD Variance Chelsea and Westminister Hospital NHS Foundation Trust In mth/qtr YTD Variance Imperial College Healthcare NHS Trust In mth/qtr YTD Variance Royal Brompton and Harefield NHS Foundation Trust In mth/qtr YTD Variance 18 weeks RTT - admitted performance within 18 weeks 91.6% 90.7% 91.0% 90.7% 93.6% 92.8% 94.7% 93.1% 18 weeks RTT - admitted performance within 18 weeks: specialties that failed to achieve the threshold 90% General Surgery 88.1% Urology 85.1% T&O 84.7% Urology 84.9% T&O 87.5% Ophthalmology 88.5% Plastic Surgery 85.7% T&O 71.4% Other Specialties 88.9% 18 weeks RTT - non-admitted performance within 18 weeks 97.1% 97.2% 98.0% 97.6% 96.8% 97.0% 97.1% 97.9% 18 weeks RTT performance within 18 weeks 18 weeks RTT - non-admitted performance within 18 weeks: specialties that failed to achieve the threshold 18 weeks RTT - incomplete pathways performance within 18 weeks Monthly M5 95% General Surgery 91.6% Urology 86.8% Plastic Surgery 91.9% General Medicine 92.3% Gastroenterology 92.9% Rheumatology 93.0% General Surgery 85.6% Urology 82.8% 95.1% 95.5% 92.3% 93.1% 95.6% 96.0% 94.8% 95.1% Cardiology 94.9% 18 weeks RTT - incomplete pathways within 18 weeks: specialties that failed to achieve the threshold 92% General Surgery 91.5% Urology 90.6% T&O 89.8% Cardiothoracic Surg 85.0% General Surgery 88.6% Urology 91.9% T&O 89.1% Plastic Surgery 87.0% Number of 52 week RTT pathways - admitted 0 1 9 0 1 2 6 0 0 Number of 52 week RTT pathways - non-admitted 0 0 5 0 5 1 10 0 0 Other Specialties 90.7% Number of 52 week RTT pathways - incomplete pathways 0 0 2 0 2 0 4 0 3 Diagnostic Waits Patients waiting more than 6 weeks for a diagnostic test Monthly M5 1% 0.5% 0.2% 0.00% 0.03% 0.29% 0.16% 0.00% 0.00% Cancelled Operations Urgent operations cancelled for a second time Cancelled ops - breaches of 28 days readmission guarantee as % of cancelled ops Number of urgent operations that are cancelled by the trust for non-clinical reasons, which have already been previously cancelled once for non-clinical reasons Monthly M5 5% Data not available by CCG 0.0% 0.0% 5.4% 14.3% 0.0% 0.0% Monthly M5 0 Data not available by CCG 0 0 0 0 0 0 Please see Appendix 2 for further report definitions guidance 5
Section 3: NHS CCG Operating Framework (contd.) Cancer: H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date. All three 62 days to treatment breaches were reported by ICHT, 1 patient choice, 1 due to poor administrative processes and 1 is being investigated. RCA s are being provided by all providers not meeting cancer standards and these will be reviewed by the CSU cancer commissioning team. ICHT did not meet the 62 days to treatment standard in M5 or the year to date achieving 72.7%, a total of 24 breaches (4 shared). Although full RCA s are awaited initial findings indicate a number of breaches were due to poor administrative processes and capacity issues particularly in Urology. A new consultant Urologist and CNS have started in October and improvement is expected from M7. The CSU contracting team is meeting with the Trusts cancer lead to review progress against ICHT s revised cancer plan and agree an improvement trajectory. RBH did not meet the 62 day consultant upgrade standard with 1 breach due to a complex pathway. LAS arrival to handover waits greater than 30mins : 4 and 26 patient breaches reported at CW and ICHT respectively in M5 an improving position on M4. Recovery and improvement plans are in place. Performance Measure Description Reporting Frequency Reporting Period Threshold NHS Hammersmith & Fulham CCG In mth/qtr YTD Variance Chelsea and Westminister Hospital NHS Foundation Trust In mth/qtr YTD Variance Imperial College Healthcare NHS Trust In mth/qtr YTD Variance Royal Brompton and Harefield NHS Foundation Trust In mth/qtr YTD Variance A&E Total time spent in A & E < 4 hours (all activity types) Monthly M5 95% Data not available by CCG 98.3% 98.6% 96.5% 96.4% N/A N/A Trolley Waits in A&E Ambulance Handover Patients who have waited over 12 hours in A&E from decision to admit to admission Monthly M5 0 Data not available by CCG 0 0 0 0 N/A N/A Number of LAS arrival to handover > 30mins Monthly M5 0 Data not available by CCG 4 23 26 168 N/A N/A Number of LAS arrival to handover > 60mins Monthly M5 0 Data not available by CCG 0 0 0 1 N/A N/A Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer Cancer 2 Week Percentage of patients seen within two weeks of an Waits urgent referral for breast symptoms where cancer is not initially suspected Cancer 31 Day Waits Cancer 62 Day Waits Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is Surgery Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is an Anti-Cancer Drug Regime Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is a Radiotherapy Treatment Course Percentage of patients receiving first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status Monthly Monthly Monthly M5 93% 98.9% 97.7% 98.4% 96.1% 98.6% 98.3% 100.0% 100.0% M5 93% 98.8% 98.4% No Patients Treated No Patients Treated 98.0% 97.6% No Patients Treated No Patients Treated M5 96% 100.0% 96.4% 100.0% 98.2% 97.7% 95.2% 100.0% 98.8% M5 94% 100.0% 96.1% M5 98% 100.0% 100.0% M5 94% 100.0% 100.0% No Patients Treated No Patients Treated No Patients Treated 100.0% 96.0% 95.8% 100.0% 100.0% 100.0% 100.0% 99.6% No Patients Treated 100.0% 97.9% No Patients Treated No Patients Treated No Patients Treated No Patients Treated M5 85% 75.0% 75.3% 100.0% 91.2% 65.6% 72.7% 90.9% 72.2% M5 90% 100.0% 100.0% No Patients Treated No Patients Treated 91.2% 93.1% N/A N/A M5 85% 100.0% 94.4% 100.0% 100.0% 92.3% 92.0% 50.0% 90.0% Please see Appendix 2 for further report definitions guidance 6
Section 3: NHS CCG Operating Framework (contd.) Infection control: H&F CCG met the C.Diff standard in M5 with 1 case but not for the year to date with 17 cases (11 apportioned to acute providers) reported against a tolerance of 13 cases. The CDiff case in M5 was assessed as not hospital acquired. All 11 acute provider apportioned cases were reported by ICHT. H&F CCG met the zero tolerance MRSA standard in M5, but not year to date with 4 cases, of which 2 were assessed as hospital acquired with CW and ICHT both reporting 1 case. An additional case is expected to be allocated to ICHT in M 4 following post infection review. CW, ICHT and RBH are not meeting the zero tolerance MRSA bacteraemia standard, reporting 2, 5 and 2 cases year to date respectively, with 1 case reported by both CW and ICHT in M5. A post infection review has been undertaken for the ICHT case and this has been assessed as not hospital acquired therefore the HPA has been asked to reallocate. ICHT and RBH reported 3 and 1 C.Diff cases in M5 respectively with both Trusts in excess of their year to date tolerance. ICHT has now been within tolerance for the second consecutive month and is currently reporting a similar position for M6. RBH has reported 5 C.Diff cases year to date, which is in line with its Monitor de-minimis tolerance. Performance Measure EMSA MSA breaches 0 0 1 0 0 0 0 0 0 Monthly M5 MSA breach rate 0.00 0.00 0.05 0.00 0.00 0.00 0.00 0.00 0.00 Unplanned hospitalisation for chronic ambulatory care sensitive conditions 566.2 58 341 196 1,099 4 29 Unplanned (adults)* M5 Rolling 12 Monthly hospitalisation Unplanned hospitalisation for asthma, months Reduction hypertension, diabetes and epilepsy in 246.8 6 58 11 64 0 0 under 19s* Emergency Admissions Emergency admissions for acute conditions that should not usually require hospital admission* Monthly M5 Reduction 860.0 92 528 324 1,529 N/A N/A PROMs Friends & Family Test Patient Experience HCAI Description Patient reported outcomes measures for elective procedures - hip replacement Patient reported outcomes measures for elective procedures - knee replacement Patient reported outcomes measures for elective procedures - groin hernia Patient reported outcomes measures for elective procedures - varicose veins Net promoter score of recommendations to friends and family by people receiving Inpatient NHS Treatment Net promoter score of recommendations to friends and family by people receiving A&E NHS Treatment Net promoter score of recommendations to friends and family by people receiving Inpatient/A&E NHS Treatment Patient Experience: Overall score across 5 domains (inpatient survey) Reporting Frequency Annual Reporting Period Provisional Apr-Dec 2012 In mth/qtr YTD Variance In mth/qtr YTD Variance In mth/qtr YTD Variance In mth/qtr N/A N/A YTD N/A N/A 0.058 N/A N/A 0.100 N/A N/A Monthly M5 Improvement Data not available by CCG 64 69 87 Monthly M5 Improvement Data not available by CCG 77 53 N/A N/A Monthly M5 Improvement Data not available by CCG 67 60 87 Annual 2012 4-5 passes out of 5 themes Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers 74.4 74.4 83.6 MRSA Monthly M5 0 0 4 1 2 1 5 0 2 C.Diff Monthly M5 Threshold Increase NHS Hammersmith & Fulham CCG Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers Data suppressed due to small numbers Data not available by CCG Chelsea and Westminster Hospital NHS Foundation Trust Imperial College Healthcare NHS Trust Royal Brompton and Harefield NHS Foundation Trust Monthly Target 3 13 1 6 5 26 0 2 Annual Target 39 13 65 7 Actual 1 17 0 1 3 32 1 5 Please see Appendix 2 for further report definitions guidance Variance 7
Section 3: NHS CCG Operating Framework (Dementia and IAPT) IAPT - Remedial and improvement actions are detailed in section 11. IAPT Figures below are reported locally to M5 13/14 because national reporting has been ceased in 13/14. Performance Measure Description Reporting Frequency Reporting Period Threshold West London Mental Health Trust In mth/qtr YTD Proportion of people with depression and/or anxiety disorders referred for and receiving psychological therapies Quarterly M5 Local Target 0.80% 3.92% Actual 1.12% 5.24% Mental Health - IAPT Proportion of people with depression and/or anxiety disorders receiving psychological therapies who are moving to recovery Quarterly M5 Local Target 46.3% 46.3% Actual 46.4% 46.3% Mental Health- CPA 7 day follow up The proportion of patients on Care Programme Approach (CPA) discharged from in patient care who are followed up within 7 days Quarterly Q1 Target 95.0% 95.0% Actual 95.1% 95.1% People with dementia Diagnosis rate for people with dementia, expressed as a percentage of the estimated prevalence Annual N/A Improvement Data not available Please see Appendix 2 for further report definitions guidance 8
Section 3: Out of Area (M5 performance) Please note: the dashboard shows the position for local Out of Area (OOA) Trusts. Only measure where data is available from validated published data sources are included. The M5 dashboard will include all mandated and constitutional standards and year to date position. Where out of area providers have impacted on CCG performance, commentary is included in Section 3. Performance Measure Ashford & St Peters UCLH Guy s & St Thomas Royal Free In month YTD In month YTD In month YTD In month YTD 18 weeks admitted 92.3% (M5) Data not available 90.3% (M4) 91.2% (M4) 93.0% (M5) Data not available 92.6% (M4) 91.8% (M4) 18 weeks - non-admitted 97.8% (M5) Data not available 96.2% (M4) 96.9% (M4) 96.6% (M5) Data not available 96.5% (M4) 97.3% (M4) 18 weeks - incomplete 98.3% (M5) Data not available 92.1% (M4) 92.1% (M4) 93.5% (M5) Data not available 92.1% (M4) 92.1% (M4) 6 week diagnostic test waiters 0.0% (M5) Data not available 0.5% (M4) 0.9% (M4) 5.1% (M5) Data not available 0.7% (M4) 0.6% (M4) A&E 4hr waits all types 97.7% (M5) Data not available 96.3% (M5) 95.6% (M5) 95.4% (M5) 95.7% (M5) 96.5% (M5) 95.7% (M5) Trolley waits in A&E 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) LAS handovers >30mins 13 (M5) 244 (M5) 7 (M5) 51 (M5) 8 (M5) 139 (M5) 4 (M5) 51 (M5) LAS handovers >60mins 3 (M5) 18 (M5) 0 (M5) 0 (M5) 0 (M5) 11 (M5) 0 (M5) 1 (M5) Cancer 2 week wait 96.6% (M5) Data not available 94.2% (M4) 93.8% (M4) 94.1% (M5) Data not available 97.7% (M4) 97.7% (M4) Cancer 2 week wait breast 93.2% (M5) Data not available 83.4% (M4) 88.4% (M4) 96.8% (M5) Data not available 96.5% (M4) 96.6% (M4) Cancer 31 day standard 100% (M5) Data not available 97.4% (M4) 97.3% (M4) 96.9% (M5) Data not available 100% (M4) 99.0% (M4) Cancer 31 day treatment surgery 100% (M5) Data not available 89.2% (M4) 95.3% (M4) 98.7% (M5) Data not available 100% (M4) 98.9% (M4) Cancer 31 day treatment drugs 100% (M5) Data not available 100% (M4) 100% (M4) 99.3% (M5) Data not available 100% (M4) 100% (M4) No patients Cancer 31 day treatment radiotherapy treated Data not available 100% (M4) 100% (M4) 94.0% (M5) Data not available 100% (M4) 100% (M4) Cancer 62 day standard 91.0% (M5) Data not available 76.5% (M4) 82.6% (M4) 80.0% (M5) Data not available 87.2% (M4) 89.5% (M4) Cancer 62 day treatment screening 100% (M5) Data not available 83.3% (M4) 93.3% (M4) 71.4% (M5) Data not available 100% (M4) 100% (M4) Cancer 62 day consultant upgrade 100% (M5) Data not available 78.6% (M4) 73.3% (M4) 89.8% (M5) Data not available 77.8% (M4) 78.9% (M4) Mixed sex accommodation breaches 0 (M5) 1 (M5) 1 (M5) 9 (M5) 0 (M5) 9 (M5) 0 (M5) 0 (M5) Mixed sex accommodation breach rate 0.0 (M5) Data not available 0.1 (M5) Data not available 0.0 (M5) Data not available 0.0 (M5) 0.0 (M5) Cancelled operations 28 day standard 0.0% (M5) 0.0% (M5) 19.2% (Q1) 1.0% (Q1) 0.0% (Q1) Urgent operations cancelled for a second time 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) 0 (M5) Please see Appendix 2 for further report definitions guidance 9
Section 3: Out of Area (M5 performance) (contd.) Please note: the dashboard shows the position for local Out of Area (OOA) Trusts. Only measure where data is available from validated published data sources are included. The M5 dashboard will include all mandated and constitutional standards and year to date position. Where out of area providers have impacted on CCG performance, commentary is included in section 3. Performance Measure Ashford & St Peters UCLH Guy s & St Thomas Royal Free PROMS hip replacement 0.406 0.393 0.407 0.384 PROMS knee replacement 0.297 0.242 0.249 0.261 PROMS groin hernia 0.093 0.067 0.084 0.051 PROMS varicose veins Data not available due to low numbers 0.078 0.079 0.078 Friends & family test score A&E 50 (M5) 45 (M5) 52 (M5) 39 (M5) Friends & family test score Inpatient 74 (M5) 70 (M5) 79 (M5) 45 (M5) Friends & family test score Combined 59 (M5) 58 (M5) 71 (M5) 41 (M5) Patient experience of hospital care 73.7 78.1 78.9 73.6 MRSA cases 0 (M5 YTD) 3 (M5 YTD) 3 (M5 YTD) 0 (M5 YTD) C.Diff cases 2 (M5 YTD) Annual target = 13 33 (M5 YTD) YTD target = 15 12 (M5 YTD) Annual target = 47 13 (M5 YTD) YTD target = 12 Please see Appendix 2 for further report definitions guidance 10
Enhancing the quality of life of people with long term conditions Preventing people from dying prematurely Section 4: CCG Outcomes Framework This section is a performance dashboard that gives the CCG an overview of its position in relation to the indicators listed in the CCG Outcomes Framework. All indicators have an improvement threshold. HCAI is reported monthly and related comments have been provided in Section 14 of this report. Domain Description Period Baseline Target Previous Current Performance Reporting Date next Performance Performance assessment Frequency available Potential years of life lost (PYLL) from causes considered 2552.0 2058.8 2012 reduction amendable to healthcare - MALE (2011) (2012) Annual TBC Potential years of life lost (PYLL) from causes considered 1748.8 1968.1 2012 reduction amendable to healthcare - FEMALE (2011) (2012) Annual TBC Potential years of life lost (PYLL) from causes considered 2132.9 1998.2 2012 reduction amendable to healthcare - ALL PERSONS (2011) (2012) Annual TBC Under 75 mortality rate from cardiovascular disease 80.7 61.6 2012 reduction (2011) (2012) Annual TBC Under 75 mortality from respiratory disease 24.8 29.8 2012 reduction (2011) (2012) Annual TBC Under 75 mortality rate from liver disease 24.5 21.7 2012 reduction (2011) (2012) Annual TBC Emergency admissions for alcohol-related liver disease 33.89 29.7 2011/12 reduction (10/11) (11/12) Annual TBC Under 75 mortality rate from cancer 119 107.6 2012 reduction (2011) (2012) Annual TBC Antenatal assessments <13 weeks 536 542 Q4 2012/13 increase (Q3 12/13) (Q4 12/13) Quarterly TBC Maternal smoking at delivery 4.0% 3.3% Q4 2012/13 reduction (Q3 12/13) (Q4 12/13) Quarterly Nov-13 Breast feeding prevalence at 6-8 weeks 77.4% 74.1% Q4 2012/13 increase (Q3 12/13) (Q4 12/13) Quarterly TBC People suffering from a long term condition feeling 80.7% 74.9% 2012/13 increase supported (Apr-Jun) (Jul-Mar) Six monthly not known Unplanned hospitalisation for chronic ambulatory care 914.7 982 2011/12 reduction sensitive (ACS) conditions (adults) (10/11) (11/12) Annual TBC Unplanned hospitalisation for asthma, diabetes and 269.97 267.7 2011/12 reduction epilepsy (under 19s) (10/11) (11/12) Annual TBC Estimated diagnosis rate for people with dementia no data no data no data no data no data no data no data Please see Appendix 2 for further report definitions guidance 11
Treating for people in a safe environment and protecting them from avoidable harm Ensuring that people have a positive experience of care Helping people to recover from ill health or following injury Section 4: CCG Outcomes Framework (contd.) Domain Description Period Baseline Target Previous Performance Emergency admissions for acute conditions that should not 1334.38 2011/12 reduction usually require hospital admission (10/11) Emergency readmissions within 30 days of discharge from hospital 2010/11 reduction not available Increased health gain as assessed by patients for elective 0.456 2011/12 increase procedures - hip replacement (10/11) Increased health gain as assessed by patients for elective data supressed procedures - knee replacement 2011/12 increase due to small numbers Increased health gain as assessed by patients for elective data supressed procedures - groin hernia 2011/12 increase due to small numbers Increased health gain as assessed by patients for elective procedures - varicose veins. 2011/12 increase Emergency admissions for children with lower respiratory tract infections (LRTIs) Patient experience of GP out of hours services Patient experience of hospital care (CCG weighted average) Patient experience of outpatient services Improvement in hospitals responsiveness to personal needs Patient experience of accident and emergency (A&E) services. Patient safety incidents reported Incidence of healthcare associated infection (HCAI): MRSA Incidence of healthcare associated infection (HCAI): Clostridium difficile (C.difficile) 2011/12 reduction 2012/13 improvement data supressed due to small numbers 335.47 (10/11) 65.7% (Apr-Jun) 2011 improvement not available 2011 improvement not available 2011 improvement not available 2011 improvement not available Apr-12 to Oct-12 0 not available Apr-Aug 13 1 Apr-Aug 13 13 4 (2012/13) 36 (2012/13) Current Performance 1265.7 (11/12) 13.3 (10/11) 0.452 (11/12) 0.305 (11/12) 0.046 (11/12) data supressed due to small numbers 255.8 (11/12) 60.1% (Jul-Mar) 75 (2011) 78 (2011) 66 (2011) 78 (2011) 4 (Apr-Sep) 4 (Apr-Aug) 17 (Apr-Aug) Performance assessment Reporting Frequency Annual Annual Annual Annual Annual Annual Annual Six monthly Annual Date next available TBC TBC TBC TBC TBC TBC TBC not known TBC Annual Autumn 13 Annual Annual Six monthly Monthly Monthly TBC TBC Oct-13 Nov-13 Nov-13 Please see Appendix 2 for further report definitions guidance 12
Section 5: Quality premium H&F CCG reported a total of 17 C.Diff YTD cases which is 4 cases above its year to date tolerance of tolerance of 13 cases. All hospital acquired cases (11 out of 17) were reported by ICHT. H&F CCG is above the zero tolerance for MRSA bacteremia with 4 cases reported YTD (1 case reported by ICHT, 1 by CW and 2 cases which was assessed as not hospital acquired). Both providers have undertaken Root Cause Analysis with action Plans in place. Under current DH guidance the HCAI Quality Premium is awarded only where the number of cases are at or below both C.Diff and MRSA tolerances. Gateway measures Actual Target Max. Value ( ) Potential loss of income ( ) Frequency 18 week RTT (incomplete pathway) 95.5% (M5 YTD) 92% N/A N/A Monthly A&E waits (CCG mapped from HES provider data) 97.7% (M5 YTD) 95% N/A N/A Monthly Cancer waits - 62 days (urgent GP referral) Cat A red 1 ambulance calls (LAS performance) 75.3% (M5 YTD) 85% N/A N/A Monthly 77.7% (M5 YTD) 75% N/A N/A Monthly Domain measures Reducing potential years of lives lost through amenable mortality Reducing avoidable emergency admissions (composite measure) Patient experience of acute inpatient care and A&E using the Friends and Family Test Preventing healthcare associated infections 1,998 (2012) Available later in 2013 111,417 TBD Annual Not yet available Not yet available 222,834 TBD Annual Not yet available Not yet available 111,417 TBD Annual 4 MRSA (M5 YTD) 17 C.Difficile (M5 YTD) 0 MRSA (M5 YTD) 13 C.Difficile (M5 YTD) 111,417 111,417 Monthly Local measures Year 2 first dose Immunisation MMR 81.3% (Q4 12/13) 84.90% 111,417 111,417 Quarterly Care Planning: X-PERT Programme for Diabetes Physical health checks for people with severe and enduring mental illness Not yet available 18% 111,417 TBD TBD Not yet available 86% 111,417 TBD TBD Please see Appendix 1 for Quality Premium calculation guidance Please see Appendix 2 for further report definitions guidance 13
Section 6: NHSE Assurance provider quality of care No provider has been subject to a local enforcement action by the Care Quality Commission and no provider has been flagged as a quality compliance risk by Monitor Chelsea and Westminster Friends & Family Test improvement action plans in place; CQUIN target is for a minimum of 15% response rate. Similarly all providers that have reported single sex accommodation breaches and or MRSA cases have action plans in place. Domain 1: Are local people getting good quality care? Providers Provider 1 Provider 2 Provider 3 Provider 4 CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST Provider Name WEST LONDON MENTAL IMPERIAL COLLEGE HEALTH NHS TRUST HEALTHCARE NHS TRUST Please identify the percentage of provider income for CCG: 14 18 47 21 Is this CCG the lead or associate commissioner? Associate Associate Lead Associate Has local provider been subject to local enforcement action by the CQC? No No No No Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions? Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern? No No No No No No No No No No No No Has the provider been identified as a 'negative outlier' on SMHI or HSMR? No No No No Do provider level indicators from the National Quality Dashboard show that No MRSA cases are above zero? No Yes Action plan in place Yes Action plan in place Do provider level indicators from the National Quality Dashboard show that No the provider has reported more C difficile cases than trajectory? No Yes Action plan in place No Do provider level indicators from the National Quality Dashboard show that No MSA breaches are above zero? No No No Does provider currently have any unclosed Serious Untoward Incidents (SUIs)? Yes Action plan in place Yes Action plan in place Yes Action plan in place Yes Action plan in place Has the provider experienced any 'Never Events' during the last quarter? No No Yes Action plan in place No Is provider meeting the 15% response rates on FFT? (Domain 3) Further development required Further development required Yes No action plan in place Yes No action plan in place 14
Section 6: NHSE Assurance provider quality of care (contd.) RTT performance 52 week standard with 1 breach reported by ICHT. The patient was treated in M5. H&F CCG did not meet the 62 day to treatment standard in M5 or the year to date, with performance in M5 driven by ICHT. H&F CCG met Health Care Acquired Infection in M5 but not year to date. National CPA Target is reported quarterly. The Trust was not meeting the target for Q1, however local Trust reporting indicates that the M5 target has been met Domain 2: Are patient rights under the NHS Constitution being promoted? 15
Section 7: Shaping a Healthier Future tracker information: UCC and A&E attendances, non-elective admissions and community events Key message The Shaping a Healthier Future programme requires Out of Hospital strategies to reduce unnecessary attendances and non-elective admissions. They do this by (i) providing improved care in the community to prevent emergency attendances; (ii) diverting minor A&E attendances away from A&E departments to Urgent Care Centres and primary care. The graphs show trends in Hammersmith & Fulham for UCC and A&E attendances and non-elective admissions. For Hammersmith & Fulham UCC & A&E attendances are increasing and non-elective admissions are decreasing. Investigations are planned into the completeness and quality of Rapid Response data hence its absence from this month s report. Note: Rapid response data subject to review Note: Activity being verified and subject to change 16
Section 8: Acute provider operational performance exceptions and early warnings ICHT Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend No. 52 week waiters admitted pathways 2 6 0 No. 52 week waiters non-admitted pathways 1 10 0 No. 52 week waiters incomplete pathways 0 4 0 LAS arrival to handover > 30mins 26 (Hammersmith Hosp. 6) (Charing Cross 7) (St Mary s 13)* LAS arrival to handover > 60mins 0 Cancelled operations breaches of 28 days readmission standard 168 (Hammersmith Hosp. 33) (Charing Cross 31) (St Mary s 104)* 1 (Hammersmith Hosp. 1) 5.4% 14.3% 5.0% 0 0 Note: site specific data subject to futher validation Please see Appendix 2 for further report Definitions guidance 17
Section 8: Acute provider operational performance exceptions and early warnings ICHT (contd.) Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend First definitive treatment for cancer within 31 days of diagnosis 97.7% 95.2% 96% First definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer 65.6% 72.7% 85% No. of MRSA cases 1 5 0 No. of C.Diff Cases 3 32 5 (M5) 26 (YTD) A&E 4hr wait type 1 92.6% 92.7% 95% Please see Appendix 2 for further report Definitions guidance 18
Section 8: Acute provider operational performance exceptions and early warnings ICHT (contd.) Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend CMS Compliance (KPI 1): updating of ED status page outside of the hours 01:00-06:00 CMS Provider Compliance KPI 2: Updating of Bed Status page between the hours of 06:00-22:00 within 4 hours 54.6% 53.0% 75.6% 79.6% 80% within 2 hours 80% within 2 hours Choose & Book: slot availability 18.8% 16.8% 2% Breastfeeding initiation rate 89.4% 88.2% 90% Newborn blood spot screening tests 76.7% 79.9% 100% Midwife to birth ratio 1:33 (SMH) 1:31 (QCCH) Not applicable 1:30 Not Applicable Home births 1.35% 0.8% 1.35% NRLS System Uploads in the past 6 months Not applicable 5/6 months uploaded (Apr-Sep12) 6/6 months Not Applicable Please see Appendix 2 for further report Definitions guidance 19
Section 8: Acute provider operational performance exceptions and early warnings CW Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend No. 52 week waiters admitted pathways 0 1 0 No. 52 week waiters non-admitted pathways 0 5 0 No. 52 week waiters incomplete pathways 0 2 0 LAS arrival to handover > 30mins 4 23 0 No. of MRSA cases 1 2 0 Home births 0.5% 1.2% 2.0% Percentage of elective c-sections 12.3% 15.5% 15% Percentage of non-elective c-sections 15.4% 18.2% 12% Please see Appendix 2 for further report Definitions guidance 20
Section 8: Acute provider operational performance exceptions and early warnings CW (contd.) Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend Midwife to birth ratio 1:36 Not Applicable 1:30 Not Applicable CMS Compliance (KPI 1): updating of ED status page outside of the hours 01:00-06:00 60.5% 64.9% 80% within 2 hours Choose & Book: slot availability 2.1% 2.1% 2% Delayed transfers of care 2.5% 1.5% 2% Stroke TIA - % of people referred with a suspected TIA, who are at high risk of stroke, who are assessed and treated within 24 hours 66.7% 80.8% 75% Please see Appendix 2 for further report Definitions guidance 21
Section 8: Acute provider operational performance exceptions and early warnings RBH Remedial and improvement actions are detailed in section 10 & 11 Red/amber indicators In month YTD Threshold Trend No. 52 week waiters incomplete pathways 0 3 0 First definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer First definitive treatment for cancer within 62 days of a consultant decision to upgrade 90.9% 72.2% 85% 50.0% 90.0% 85% Urgent operations cancelled for the second time 0 2 0 No. of MRSA cases 0 2 0 No. of C.Diff Cases 1 5 0 (M5) 2 (YTD) Choose & Book: slot availability 0.7% 2.1% 2% Please see Appendix 2 for further report Definitions guidance 22
Section 9: Acute provider quality performance exceptions and early warnings ICHT The Maternal Mortality Ratio (MMR): the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers. Serious Incidents Reported: YTD SI data does not take into account de-escalations. Average Delay (in days) of Reporting Serious Incidents from date identified: 12% (8) of reported Serious Incidents did not have the date of identification available and are not included in the indicator Red/amber indicators In month YTD Threshold Trend Maternal Mortality Rate (per 100,000) < 42 days 0 (0) 13.98 Not Applicable Maternal Mortality Rate (per 100,000) > 42 days 22.67 (2) 13.98 Not Applicable Standardised Hospital Mortality Indicator (SHMI) Jan 12 - Dec 12 76.49 100 Serious Incidents Reported 11 65 Never Events 0 1 0 Average Delay (in days) of Serious Incidents Reporting from date identified 3 5 2 New metric Number of Serious Incident RCA Reports Overdue 2 14 0 New metric Pressure Ulcer Prevalence (All) 3.18% 3.25% National avg 5.07% Please see Appendix 2 for further report definition guidance Actions detailed in section 12 23
Section 9: Acute provider quality performance exceptions and early warnings ICHT Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness including hand hygiene (2) Buildings and facilities condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration The RAG rating for the PLACE indicators is based upon the national averages Red/amber indicators In month YTD Threshold Trend Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14 Cleanliness 99.03% National avg 95.74% Food and Hydration 80.91% National avg 88.75% Privacy, Dignity and Wellbeing 88.61% National avg 88.87% Condition, Appearance and Maintenance 89.22% National avg 84.98% Friends and Family Test (FFT) FFT Response Rate A&E 16.3% 17.9% 15% FFT Score A&E 53 50.4 FFT Response Rate - Inpatient 31.6% 26.0% 15% FFT Score - Inpatient 69 69.8 New metric New metric New metric New metric Please see Appendix 2 for further report definition guidance Actions detailed in section 12 24
Section 9: Provider Serious Incidents and Complaints Categories ICHT (contd.) Remedial Complaints and category improvement data is not actions in contract are specification detailed in section 14 Complaints indicators are one month behind Serious Incidents Categories Complaints Indicators Target Jul-13 YTD % of complaints acknowledged within 3 days of receipt % of complaints responded to within the agreed target Aug-13 C.Diff & Health Care Acquired Infections 1 Delayed diagnosis 1 Maternity Services - Maternal unplanned admission to ITU 1 Maternity Services - Unexpected admission to NICU (neonatal intensive care unit) Pressure ulcer Grade 3 3 Radiology/Scanning incident 1 Screening Issues 1 Unexpected Death (general) 1 Unexpected Death of Outpatient (not in receipt) 1 TOTAL 11 100% 100% 100% 100% 95% 95.5% 1 Complaints Categories Apr-13 May-13 Jun-13 Jul-13 Aug-13 YTD Admission, transfer and discharge arrangements Delay or cancellation of an inpatient appointment 6 9 3 5 5 28 2 1 4 3 10 Delay or cancellation of outpatient 7 8 9 12 5 41 Attitude of staff 4 7 3 11 2 27 All aspects of clinical care 41 44 28 41 39 193 Communication to patients or relatives 5 5 4 7 6 27 Patient s property or expenses 1 2 1 2 6 Policy or commercial decisions of the Trust 1 2 3 Hotel services 1 1 Transport 3 2 1 4 10 Pt. Status / Discrimination 1 1 1 3 Personal Records 1 1 Privacy & Dignity 1 1 3 5 Aids & Appliances 1 1 TOTAL 67 80 58 82 69 356 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 25
Section 8: Acute provider quality performance exceptions and early warnings CW The Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers. YTD SI data does not take into account de-escalations. 8% (3) of reported SIs do not have date identified available and are not included in the average delay in days of serious incident reporting indicator we are currently chasing up the missing information Red/amber indicators In month YTD Threshold Trend Maternal Mortality Rate (per 100,000) < 42 days 20.08 (1) 13.98 Not Applicable Maternal Mortality Rate (per 100,000) > 42 days 0 (0) 13.98 Not Applicable Standardised Hospital Mortality Indicator (SHMI) Jan 12 - Dec 12 78.1 100 Serious Incidents Reported 8 36 Never Events 0 1 0 Average Delay (in days) of Serious Incidents Reporting from date identified 10 19 2 New metric Number of Serious Incident RCA Reports Overdue 6 26 0 New metric Pressure Ulcer Prevalence (All) 4.73% 3.59% National avg 5.07% Please see Appendix 2 for further report definition guidance Actions detailed in section 11 26
Section 9: Acute provider quality performance exceptions and early warnings CW The Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births over a 12 month period. The actual number of maternal deaths is specified in brackets after the Maternal Mortality Ratio. It is a pathway measure across a number of providers. Serious incidents Reported: YTD SI data does not take into account de-escalations. Average Delay (in days) of Serious incidents Reporting from date identified: 8% (3) of reported SIs do not have date identified available and are not included in the average delay in days of serious incident reporting indicator we are currently chasing up the missing information Red/amber indicators In month YTD Threshold Trend Maternal Mortality Rate (per 100,000) < 42 days 20.08 (1) 13.98 Not Applicable Maternal Mortality Rate (per 100,000) > 42 days 0 (0) 13.98 Not Applicable Standardised Hospital Mortality Indicator (SHMI) Jan 12 - Dec 12 78.1 100 Serious Incidents Reported 8 36 Never Events 0 1 0 Average Delay (in days) of Serious Incidents Reporting from date identified 10 19 2 New metric Number of Serious Incident RCA Reports Overdue 6 26 0 New metric Pressure Ulcer Prevalence (All) 4.73% 3.59% National avg 5.07% Please see Appendix 2 for further report definition guidance Actions detailed in section 12 27
Section 9: Provider Serious Incidents and Complaints Categories CW (contd.) Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness including hand hygiene (2) Buildings and facilities condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration Overdue NPSA alerts involve Safer spinal (intrathecal), epidural and regional devices (Part A and B) and Minimising risk of mismatching spinal, epidural and regional devices with incompatible connectors alerts overdue because no suitable replacements are available. Alerts are being monitored by the trust through the risk register and the Governance and Quality Committee as per advice from the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Red/amber indicators In month YTD Threshold Trend Central Alerting System overdue NPSA alerts 3 3 Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14 Cleanliness 95.36% Food and Hydration 82.92% Privacy, Dignity and Wellbeing 90.72% Condition, Appearance and Maintenance 88.27% Friends and Family Test (FFT) National avg 95.74% National avg 88.75% National avg 88.87% National avg 84.98% New metric New metric New metric New metric FFT Response Rate A&E 11.9% 11.8% 15% FFT Score A&E 77 72.4 FFT Response Rate Inpatient 33.8% 36% 15% FFT Score Inpatient 64 64.6 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 28
Section 9: Provider Serious Incidents and Complaints Categories CW (contd.) Complaints categories data is not in contract specification. Complaints indicators are one month behind. Complaints Categories Admission, transfer and discharge arrangements Failure to follow agreed procedure 2 Jul-13 Aug-13 1 2 Attitude of staff 8 3 All aspects of clinical care 19 12 Communication to patients or relatives 5 Information/Communication 2 Delay/Cancellation 1 Other 1 5 TOTAL 36 25 Complaints Indicators Target Jul-13 YTD % of complaints acknowledged within 3 days of receipt % of complaints responded to within the agreed target Serious Incidents Categories 100% 100% 100% 100% 85.7% 82.9% Aug-13 Allegation Against HC Professional 2 Communicable Disease and Infection Issue 2 Pressure ulcer Grade 3 3 Safeguarding Vulnerable Adult 1 TOTAL 8 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 29
Section 9: Acute provider quality performance exceptions and early warnings RBH Serious Incidents Reported: YTD SI data does not take into account de-escalations. Average Delay (in days) of Serious Incident Reporting: 33% (3) of reported Serious Incidents did not have the date of identification available and are not included in the indicator Red/amber indicators In month YTD Threshold Trend Serious Incidents Reported 2 9 Never Events 0 1 0 Average Delay (in days) of Serious Incidents Reporting from date identified 3 13 2 New metric Number of Serious Incident RCA Reports Overdue 0 3 0 New metric Pressure Ulcer (All) 1.92% 1.84% National avg 5.07% NRLS System Uploads in the past 6 months 6/6 Not Applicable Please see Appendix 2 for further report definition guidance Actions detailed in section 12 30
Section 9: Acute provider quality performance exceptions and early warnings RBH Patient-Led Assessments of the Care Environment (PLACE) are new and replaces the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness including hand hygiene (2) Buildings and facilities condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration The RAG rating for the PLACE indicators is based upon the national averages. Overdue NPSA alerts involve Safer spinal (intrathecal), epidural and regional devices (Part A and B) and Minimising risk of mismatching spinal, epidural and regional devices with incompatible connectors alerts overdue because no suitable replacements are available. Alerts are being monitored by the trust through the risk register and the Governance and Quality Committee as per advice from the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Red/amber indicators In month YTD Threshold Trend Central Alerting System overdue NPSA alerts 3 3 NRLS uploading 5/6 6/6 Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14 Cleanliness 95.82% Food and Hydration 83.54% Privacy, Dignity and Wellbeing 83.87% Condition, Appearance and Maintenance 85.47% Friends and Family Test (FFT) National avg 95.74% National avg 88.75% National avg 88.87% National avg 84.98% New metric New metric New metric New metric FFT Response Rate A&E n/a n/a Not Applicable FFT Score A&E n/a n/a Not Applicable FFT Response Rate - Inpatient 20.4% 23.0% FFT Score - Inpatient 87 85.6 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 31
Section 9: Provider Serious Incidents and Complaints Categories RBH (contd.) Complaints categories data is not in contract specification; NWL CSU will be obtaining complaints categories data from NHS England. Complaints indicators are one month behind Serious Incidents Categories Aug-13 C.Diff & Health Care Acquired Infections 1 Pressure ulcer Grade 3 1 TOTAL 2 Complaints Categories Apr-13 May-13 Jun-13 Total Admission, transfer and discharge arrangements Delay or cancellation of an inpatient appointment 2 1 1 4 1 0 1 2 Delay or cancellation of outpatient 3 0 1 4 Attitude of staff 3 5 4 12 Complaints Indicators Target Jul-13 YTD % of complaints acknowledged within 3 days of receipt % of complaints responded to within the agreed target 100% 100% 100% 100% 100% 100% All aspects of clinical care 12 15 10 37 Communication to patients or relatives 2 3 1 6 Patient s property or expenses 2 0 0 2 Hotel services 0 1 2 3 Other 2 2 1 5 TOTAL 27 27 21 75 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 32
Section 9: Community provider performance exceptions and early warnings Central London Community Healthcare (H&F) Serious Incidents Reported: YTD SI data does not take into account de-escalations. Average Delay (in days) of Serious Incidents Reporting from date identified: 20% (2) of reported Serious Incidents did not have the date of identification available and are not included in the indicator Patient-Led Assessments of the Care Environment (PLACE) are new and replaces the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness including hand hygiene (2) Buildings and facilities condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration The RAG rating for the PLACE assessment is based upon the national averages Red/amber indicators In month YTD Threshold Trend Serious Incidents Reported 1 10 Average Delay (in days) of Serious Incidents Reporting from date identified 1 10 2 New metric Number of Serious Incident RCA Reports Overdue 1 5 0 New metric Pressure Ulcer Prevalence (All) 6.22% 5.87% Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14 Cleanliness 99.42% Food and Hydration 92.06% Privacy, Dignity and Wellbeing 94.08% Condition, Appearance and Maintenance 87.39% National avg 5.07% National avg 95.74% National avg 88.75% National avg 88.87% National avg 84.98% New metric New metric New metric New metric Please see Appendix 2 for further report definition guidance Actions detailed in section 12 33
Section 9: Provider Serious Incidents and Complaints Categories Central London Community Healthcare (H&F) Complaints categories data is not in contract specification. The category of the complaints received in month was requested from the provider but was not received in time to be included in this report. Serious Incidents Categories Aug-13 Pressure ulcer Grade 3 1 TOTAL 1 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 34
Section 8: Mental provider performance exceptions and early warnings WLMHT (H&F CCG Performance) 10 &11 Remedial and improvement actions are detailed in section 10 &11 Red/amber indicators In month YTD Threshold Trend % of CPA follow up 7 days after discharge 89.2% (Q1) Not available 95% Not Available % of DNA for follow up 11.6% % of Patients readmitted within 30 days of discharge 13.2% Not available Not available 11.0% (by end Q4) 8.1% (by end Q4) Not Available Not Available % of complaints resolved within timescale 33.3% Not available 100% Not Available Please see Appendix 2 for further report definitions guidance 35
Section 9: Mental Health provider performance exceptions and early warnings - West London Mental Health Trust (H&F) Serious Incidents Reporting: YTD SI data does not take into account de-escalations. Average Delay (in days) of Serious Incidents Reporting: 14% (1) of reported Serious Incidents did not have the date of identification available and are not included in the indicator Patient-Led Assessments of the Care Environment (PLACE) are new and replace the Patient Environment Action Team (PEAT) programme. This new process and assessment is a collaboration between hospital staff and patient assessors, focusing on the four key areas: (1) Cleanliness including hand hygiene (2) Buildings and facilities condition, appearance and maintenance of the building, fixtures and fittings (3) Privacy and Dignity (4) Food and hydration. The RAG rating for the PLACE indicators is based upon the national averages. Red/amber indicators In month YTD Threshold Trend Serious Incidents Reported 1 7 Average Delay (in days) of Serious Incidents Reporting from date identified 8 9 2 New metric Number of Serious Incident RCA Reports Overdue 1 2 0 New metric Pressure Ulcer Prevalence (All) 2.63% 5.18% Patient-Led Assessments of the Care Environment (PLACE) Q1 2013/14 Cleanliness 90.41% Food and Hydration 85.82% Privacy, Dignity and Wellbeing 87.81% Condition, Appearance and Maintenance 83.61% National avg 5.07% National avg 95.74% National avg 88.75% National avg 88.87% National avg 84.98% New metric New metric New metric New metric Please see Appendix 2 for further report definition guidance Actions detailed in section 12 36
Section 9: Provider Serious Incidents and Complaints Categories West London Mental Health Trust (H&F) Complaints categories data is not in contract specification. Complaints data relate to H&F only. Serious Incidents Categories Aug-13 Complaints Categories Jul-13 Attempted Suicide by Outpatient (in receipt) 1 TOTAL 1 All aspects of clinical care 1 Other 1 TOTAL 2 Please see Appendix 2 for further report definition guidance Actions detailed in section 12 37
Section 9: 111 Pilot Services Recovery plans are in place with both providers and will begin to address the longer waits in CWLH The CSU are monitoring providers work force plans to address the level of clinical call backs across NWL. 04-Aug 11-Aug 18-Aug 25-Aug Call Standards *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng *BEHH Hillingdon **CLWH Eng Percentage of calls answered in 60 seconds 97.7% 98.3% 96.2% 97.7% 98.4% 98.9% 95.4% 98.2% 98.8% 98.9% 97.1% 98.3% 97.7% 98.6% 95.7% 97.5% Percentage of calls abandoned after 30 seconds 1.6% 1.4% 0.5% 0.6% 0.2% 0.1% 0.6% 0.5% 0.1% 0.2% 0.6% 0.4% 0.3% 0.3% 0.4% 0.6% Percentage of calls triaged 92.6% 117.6% 100.0% 78.1% 81.6% 92.6% 100.0% 86.1% 80.7% 82.2% 100.0% 86.0% 74.4% 84.5% 100.0% 85.7% % of calls requiring clinical advice offered call back *** Percentage of clinical call backs within 10 minutes 14.5% 16.4% 9.3% 8.3% 7.1% 8.0% 9.2% 8.0% 5.4% 4.8% 8.4% 6.9% 2.2% 4.2% 6.2% 7.0% 57.6% 57.7% 73.0% 45.2% 66.3% 62.0% 69.4% 44.0% 72.6% 61.0% 68.3% 45.4% 69.0% 58.9% 65.5% 61.3% Dispositions BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng BEHH Hillingdon **CLWH Eng Led to ambulance dispatches 11.2% 14.3% 10.5% 8.4% 10.8% 13.4% 9.1% 9.3% 11.3% 10.2% 10.5% 9.3% 10.1% 11.9% 10.5% 8.6% Recommended to attend A&E 8.5% 9.9% 7.8% 9.2% 6.0% 7.6% 7.8% 6.9% 7.8% 6.6.% 8.5% 6.8% 7.2% 7.4% 8.4% 6.4% Recommended to attend primary and community care 56.8% 72.1% 74.5% 45.4% 49.1% 56.5% 72.8% 53.9% 47.7% 52.6% 59.3% 53.5% 45.9% 50.6% 63.4% 54.8% Recommended to attend other service 2.3% 3.0% 4.3% 3.6% 2.2% 1.4% 6.3% 4.0% 2.5% 1.6% 6.8% 3.9% 1.5% 1.9% 4.8% 4.1% Did not recommend to attend other service 13.6% 18.1% 2.9% 11.4% 13.5% 13.8% 3.9% 12.4% 11.4% 11.1% 15.0% 12.4% 9.8% 12.6% 12.9% 11.8% *BEHH = Brent, Ealing, Harrow, Hounslow ** CLWH = Central London, West London, Hammersmith & Fulham *** It is expected that call backs are an Exception Source: Unify 2, a query has been raised about the calculations used for the disposition data with NHSE 38
Section 9: 111 Governance Name of service NHS 111 Live Site Report to Pan London Clinical Leads Group 111 INWL 111 Service Report for the month of August 2013 Audit Update No. of local/internal CG audits carried out Audit Update No. of End to End Call Reviews (include review of full NHS Pathway) Nil 2 nd August 4 call reviews undertaken Governance Activity Attendance at Pan London 111 CGG. Call review meeting with LAS in relation to Serious Incident SI RCA panel meeting and investigation process, LAS call reviews undertaken in relation to case, independent call reviews organised of LAS calls. Safeguarding audit in progress Total number of calls this month 6558 Serious Incidents SIs opened this month 0 SIs this calendar year 1 Of the total for this calendar year Closed and actual 0 Closed and NOT SI 0 Still open 1 39
Section 10: Action Log: provider performance Key lines of enquiry Issue Provider Root Cause Action Closed Risk None Actions for CSU Not meeting specialty or 52 week standards RBH did not meet M3 C.Diff tolerance RBHT Poor waiting list management Critical review of action plan and reasons for the 52 week wait RBH Poor infection control processes Review tolerance for 13/14 with DH No (Due to be Lack of assurance on mitigating actions in place NHSE contacted reviewed at and requested to review as lead Oct. CQG) commissioner. Not applicable No Not meeting 31day to treatment, and 62 days to treatment cancer standards. Not meeting 18 week RTT specialty standards ICHT RBH Currently under review -A detailed review of the root cause analysis of M4 breaches to identify additional actions required. -Update of ICHT cancer action plan at CQG ICHT Poor waiting list management -Review updated action plan and trajectories Yes LAS handover breaches ICHT & CW A&E processes -Daily monitoring of A&E pressures and provider actions in place -Submission of winter assurance and demand and capacity plans to NHS England Yes Last minute cancelled operations ICHT Poor escalation processes Monitor progress against action plan Yes Yes ICHT did not meet YTD C.Diff tolerance and MRSA tolerance ICHT Poor infection control processes Update to action plan to be reviewed at CQG. No Lack of assurance on mitigating actions in place to reduce Choose and Book Compliance ICHT Outpatient capacity and administrative processes Review of ICHT action plan (due for submission at the end of September) No Not applicable 40
Section 10: Action log: provider performance (contd.) Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Owner Closed Risk CPA 7 day follow up WLMHT National CPA Target is reported quarterly. The Trust were not meeting the target for Q1, however local Trust reporting indicates that the M5 target has been met WLMHT Yes Not applicable Percentage of DNA for follow up Percentage Readmissions within 30 days Percentage of complaints resolved within timescale WLMHT WLMHT High number of patients on holiday during August Patients that were discharged had relapse and returned to inpatient unit within 30 days. E-referral has been rolled out to some GP practices across the WLMHT boroughs which has helped to reduce the DNA rate. E-referral s currently being rolled out to all GP practices. For patients with a readmission within 30 days, a review by the whole clinical team will take place to ascertain reasons and lessons WLMHT learnt WLMHT Staffing Recruitment drive completed and month on month improvement although below target. CSU to monitor. WLMHT No No No Patients may continue to DNA appointments due to reasons out of the control of the service Patients may continue to be discharged appropriately but there is a risk that the reasons for relapse and consequent readmission may be out of control of the service Not applicable 41
Section 10: Action log: provider performance (contd.) Key lines of enquiry Issue CCG Root Cause Action Closed Risk Actions for CCG CSU does not have access to HCAI database at a CCG level CCG Unknown CCG need to approve CSU access to HCAI database Not meeting specialty or 52 week ICHT Poor waiting list management - CCG to approve plan. Yes standards No CSU unable to review individual infections leading to lack of detail within reports. Referrals responded to during the CLCH day, twilight or night service periods within 4 hours Referrals responded to during the day, twilight or night service periods within 24 hours Finalised KPI definitions were circulated at Care Quality Group on 15.09.13. The provider is still putting procedures in place to collect the data appropriately. Provider to commence data collection by M6 reporting. CSU to ensure this issue is addressed at Data Quality and Reporting Improvement Group with CLCH to be will be held on 14.10.13 No Risk that data collection may not commence in time of M6 reporting LAC Initial Health Assessments CLCH The new changes introduced in the spring of 2013 have meant that a cohort of children under 18 are now classed as Looked after Children (LAC). The acute paediatrician has arranged a visit to Feltham Young Offenders Prison to undertake the assessments there. 12 outstanding referrals have caused the dip in performance. The Associate Director for Safeguarding in CWHH will clarify the reporting position with regards to referrals from Feltham Young Offender Prison at CQG on 30 th October 2013. The 12 outstanding cases are being reviewed by the Designated Nurse for LAC and the an update will be provided by the Associate Director for Safeguarding in CWHH at CQG on 30 th October 2013 No Impact on performance may be affected by inclusion of new cohort of children 42
Section 10: Action log: provider quality Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Owner Closed Risk The trust has now submitted data on complaints. 99% are responded to within the agreed time frame. ICHT Trust not responding within agreed time frames Discussed at CQG. CSU to monitor performance. ICHT Yes 43
Section 11: Recommendations and next steps Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Accountable Officer Not meeting 31day to treatment, and 62 days to treatment cancer standards. Not meeting 18 week RTT specialty standards Not meeting 18 week RTT specialty standards ICHT RBH ICHT CW Poor administrative processes and capacity issues at ICHT RBH reported complex pathway Poor waiting list management Poor waiting list management A detailed review of the root cause analysis of M5 breaches to identify additional actions required. Review of progress against cancer action plan and agree trajectory with ICHT. Contract penalty to be applied Review updated action plan, reasons for 52 week breaches and trajectories Contract penalty to be applied CSU performance team CSU Contract team CSU performance team Date October 2013 October 2013 October 2013 CSU Contract team Monitor plan CSU performance team October 2013 LAS handover breaches ICHT & CW A&E processes Daily monitoring of A&E CSU performance team October 2013 pressures and provider actions in place Last minute cancelled operations ICHT Poor escalation processes Monitor progress against action plan CSU performance team October 2013 1 MRSA bacteraemia CW Unknown Review post infection review Contract penalty to be applied 1 MRSA bacteraemia ICHT Complex case Review post infection review Contract penalty to be applied CSU quality team CSU Contract team CSU quality team CSU Contract team October 2013 Completed 44
Section 11: Recommendations and next steps Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Accountable Officer Delay in reporting SI's Chelsea and Westminister, ICHT, RBH, WLMHT Trust not reporting onto StEIS within the NPSA timeline. Delay in reporting SI's ChelWest Trust not reporting onto StEIS within the NPSA timeline. Delay in reporting SI's ICHT Trust not reporting onto StEIS within the NPSA timeline. Delay in reporting SI's RBH Trust not reporting onto StEIS within the NPSA timeline. Delay in reporting SI's WLMHT Trust not reporting onto StEIS within the NPSA timeline. SI reports overdue Chelsea and Trust not completing reports Westminister, ICHT, within the NPSA timeline. WLMHT, CLCH SI reporting RBH Trust delay in completing all SI actions NWL CSU have written to trusts to highlight these delays. Delay in reporting has been reducing, when looking across all trusts, from 22 days in M1 to 12 days in M5. Suggest monthly monitoring at individual trusts level until NPSA target achieved. NWL CSU have previously written to trusts to highlight these delays. Chelwest has seen a reduction in delays, from 16 days average delay in M1 to 6 days average delay in M5, however, it is still significantly above the NPSA guidance of 2 days NWL CSU have previously written to trusts to highlight these delays. ICHT has seen a slight decrease in delays, from 6 days average delay in M1 to 3 days average delay in M5, which is slightly above the NPSA guidance of 2 days. NWL CSU have previously written to trusts to highlight these delays. RBH has seen a slight decrease in delays, from 8 days average delay in M1 to 3 days average delay in M5, which is slightly above the NPSA guidance of 2 days. THH has seen a slight decreased in delays, from 11 days average delay in M1 to 7 days average delay in M5, which is significantly above the NPSA guidance of 2 days. Please note that the data is not borough specific NWL CSU have written to each trust to highlight all cases still open and request resolution. There has been an improvement when looking across all trusts. In M3 30% of reports were received on time, whereas in M5 57% of reports were received on time There has been a decrease in numbers of SI reports overdue. The main issue is one RCA; the CSU is following this up before hand over to NHS England. Chelsea and Westminister, ICHT, RBH, WLMHT ChelWest ICHT RBH WLMHT Chelsea and Westminister, ICHT, WLMHT NWL CSU Date Closed On-going On-going On-going October October October 45
Section 11: Recommendations and next steps Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Accountable Officer FFT Inpatient score ChelWest A decrease in M5 compared with M4 FFT A&E Response Rate ChelWest A decrease in M5 compared with M4 Slight drop in Inpatient score in M5 compared to M4, which was a decrease compared to M3. However the response rate has increased whilst the score has decreased. Drop in A&E response rate in M5 compared to M4, which was a decrease compared to M3. n/a n/a Date Not applicable Not applicable FFT Inpatient score ICHT A decrease in M5 compared with M4 % of complaints responded to within time frame % of complaints responded to within the agreed target New-born blood spot screening tests ICHT ChelWest Trust not responding within time scale Trust not responding within time scale Slight drop in Inpatient score in M5 compared to M4, which was a decrease compared to M3. However the response rate has increased whilst the score has decreased. Nil. Has been discussed at CQG and Improving trajectory Nil. Has been discussed at CQG and Improving trajectory n/a Not applicable Not applicable Not applicable ICHT Difficulty with Data collection New metric that requires liaison with community teams to capture ICHT October accurate data. To raise at next CQG To discuss at CQG ICHT October Home births ICHT Low numbers of home births being reported by the trust Never Event - 2013/21061 - Surgical Error Chelsea and Westminster TBD - RCA due 8th October 2013 Review of RCA once received and monitoring of action plans NRLS uploading RBH Upload missed in M3 Discuss at CQG and monthly monitoring Chelsea and Westminster NWL CSU November October 46
Section 11: Recommendations and next steps Key lines of enquiry Actions for CSU Issue Provider Root Cause Action Accountable Officer Percentage of DNA for follow up Percentage Readmissions within 30 days WLMHT WLMHT High number of patients on holiday during August Patients that were discharged had relapse and returned to inpatient unit within 30 days. Persistent offenders (patients that have DNA d more than once) will be identified, contacted and reviewed SMS text reminders have been trialled across the borough, whereby patients are called 7 days before their appointment. This is planned to be rolled out to the whole service as standard practice. Discharged patients to receive regular weekly contact for four weeks after discharge. CSU Contracting & Performance Teams to continue to monitor progress against action plan WLMHT WLMHT WLMHT NWL CSU Contracting & Performance Team Date October 2013 October 2013 November 2013 October 2013 47
Appendix 1:Quality Premium Calculation Guidance 48
Helping people to recover from ill health or following injury Treating for people in a safe environment and protecting them Preventing people from dying prematurely Enhancing the quality of life of people with long term conditions Ensuring that people have a positive experience of care Appendix 2: Report Guidance & Definitions Slide 5 A&E 4hr waits. Please note that the formal measure for this indicator is reported at provider level only. Performance at CCG level is not yet available. Slide 7 HCAI data is reported at CCG level, provider Trust data is provided at Trust-wide level (i.e not at CCG level) Slides 5-8, 18-34, 36-37 Where provider Trust data is provided this figure is at Trust level (i.e not at CCG level) Slides 5-7, 27,30 Variance arrows indicate change from previous period Slide 13 (Quality Premium). N/A = not applicable, TBD = to be determined Slide 13 (Quality Premium). CCG performance data for A&E 4hrs waits is calculated using provider HES data mapped by the DH to commissioner level Slides 9-10 CCG Outcomes Framework. Where the current RAG status is greyed out this indicates data for the previous period is not yet available Slide 9-10 CCG Outcomes Framework. Indicators have been excluded from the dashboard where data is currently not yet available (data sources are shown in the table below) Slide 22 maternity mortality indicator definition is taken from the Organisation Health Intelligence Reports produced by NHS London in 12/13, as below: NHS London has developed the following RAG rating: GREEN is below the London maternal death rate (deaths/100,000 deliveries) and no two deaths occurring within 31 days of each other. AMBER is equal to or more than London Maternal Death Rate but less than twice the London Maternal Death Rate. RED is if there have been two death within 31 days of each other and/or greater than twice the London Maternal Death Rate. (Trusts that have <4000 deliveries/year will show as red even though they may have only one maternal death in the reporting period due to the way that the maternal death rate is calculated). Domain In 13/14 the same Description definition is used however Data Source this also Domain broken down by Description the number of deaths Data with Source 42 days of Domain birth and those Description after. Data Source Potential years of life lost (PYLL) from causes Health and Social Care considered amendable to healthcare - MALE Information Centre Portal Potential years of life lost (PYLL) from causes Health and Social Care considered amendable to healthcare - FEMALE Information Centre Portal Under 75 mortality rate from cardiovascular disease Health and Social Care Information Centre Portal Under 75 mortality from respiratory disease Health and Social Care Information Centre Portal Under 75 mortality rate from liver disease Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal People suffering from a long term condition feeling supported GP Patient Survey Patient experience of GP out of hours services GP Patient Survey Unplanned hospitalisation for chronic ambulatory Health and Social Care Patient experience of hospital care (CCG CQC Inpatient Survey care sensitive (ACS) conditions (adults) Information Centre Portal weighted average) Unplanned hospitalisation for asthma, diabetes and Health and Social Care Patient experience of outpatient services CQC Outpatient Survey epilepsy (under 19s) Information Centre Portal Estimated diagnosis rate for people with dementia QOF & Health and Social Improvement in hospitals responsiveness to CQC Inpatient Survey Care Information Centre personal needs Portal Emergency admissions for acute conditions that should not usually require hospital admission Emergency admissions for alcohol-related liver disease Emergency readmissions within 30 days of discharge from hospital Under 75 mortality rate from cancer Increased health gain as assessed by patients for elective procedures - hip replacement Antenatal assessments <13 weeks Unify2 (IPMR return) Increased health gain as assessed by patients for elective procedures - knee replacement Maternal smoking at delivery OMNIBUS Increased health gain as assessed by patients for elective procedures - groin hernia Breast feeding prevalence at 6-8 weeks Unify2 (IPMR return) Increased health gain as assessed by patients for elective procedures - varicose veins. Emergency admissions for children with lower respiratory tract infections (LRTIs) Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Health and Social Care Information Centre Portal Patient experience of accident and emergency (A&E) services. Patient safety incidents reported Incidence of healthcare associated infection (HCAI): MRSA Incidence of healthcare associated infection (HCAI): Clostridium difficile (C.difficile) CQC A&E Survey National Reporting and Learning System NRLS Health Protection Agency - HCAI Data Capture System Health Protection Agency - HCAI Data Capture System 49
Q1 Balanced score-care report 28/10/2013
Summary of the balanced score-cared for CWHH in Q1 Central West H&F Hounslow Domain 1 AMBER-GREEN AMBER-GREEN AMBER-GREEN AMBER-GREEN - A number of indicators re quality - A number of indicators re quality - A number of indicators re quality - A number of indicators re quality Domain 2 AMBER-RED AMBER-RED RED RED - Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer - Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer - Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer - Mental illness specialities on CPA followed up within 7 days of discharge - Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer - Maximum 62 day wait from referral from an NHS screening service to first definitive treatment for all cancers Domain 3 AMBER-RED AMBER-RED RED AMBER-RED - Incidence of healthcare associated infection (MRSA) - Are providers meeting the 15% response rates on FFT - Incidence of healthcare associated infection (MRSA) - Are providers meeting the 15% response rates on FFT - Incidence of healthcare associated infection (MRSA) - Incidence of healthcare associated infection (cdiff) - Are providers meeting the 15% response rates on FFT - Incidence of healthcare associated infection (MRSA) - Are providers meeting the 15% response rates on FFT Domain 4 AMBER-RED AMBER-RED GREEN AMBER-GREEN Domain 5 - Surplus YTD - Surplus YTD Fully authorised Fully authorised Fully authorised Fully authorised
Domain 1: Are local people getting good quality care? This domain includes: 8 performance indicators for our main providers (WLMHT, Imperial, Chel West, CLCH) 1. Has local provider been subject to local enforcement action by the CQC? 2. Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place around breaches of provider licence conditions? 3. Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? 4. Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for concern? 5. Has the provider been identified as a 'negative outlier' on SMHI or HSMR? 6. Do provider level indicators from the National Quality Dashboard show that MRSA cases are above zero? 7. Do provider level indicators from the National Quality Dashboard show that the provider has reported more C difficile cases than trajectory? 8. Do provider level indicators from the National Quality Dashboard show that MSA breaches are above zero? 6 clinical governance indicators: Are there Concerns about quality issues being discussed regularly by the CCG governing body? Concerns about the arrangements in place to proactively identify early warnings of a failing service? Concerns around the arrangements in place to deal with and learn from serious untoward incidents and never events? Concerns around being an active participant in its Quality Surveillance Group? If there was an emergency event in the last quarter, has the CCG self assessed and identified any areas of concern on the arrangements in place for dealing with such an event? Has the CCG self assessed and identified any risk to progress against its Winterbourne View action plan? Domain 1 Status AMBER-GREEN
Domain 2: Are patients rights under the NHS constitution being promoted? This domain includes: Referral to treatment times for non-urgent treatments Diagnostic test waiting times A&E waits Cancer patients 2 week waits Cancer waits 31 days Cancer waits 62 days Category A ambulance calls Mixed sex accommodation breaches Mental Health Care Programme Approach Domain Status RED This is the result of the issues below: Indicator Maximum on month (31day) wait from diagnosis to first definitive treatment for all cancers Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer Operationa l Standard 96% 85% Perfor mance 94.21 % 70.83 % Action plan Q1 performance against the 62 day and 31 days waits is driven by capacity constraints in Urology and Lower GI as specialities. The Trust has undertaken a redesign of both pathways with the following actions: Across LGI the Trust has implemented direct access for the 1 st OPD clinic into the endoscopy service. This has reduced the DNA rate from 42% to 2% Across Urology an additional Nurse Practitioner is in post and Consultant cover is being increased by 1wte from October 2013 The Trust has moved from Consultant led follow up clinic to Nurse led clinics where clinically appropriate to maximise OPD capacity. A one stop Urology diagnostic clinic will be in place from October 2013 to facilitate timely assessment and treatment and improve patient experience The Trust expects to start recovering the position from October when all these actions have been fully implemented Care Programme Approach (CPA): The proportion of people under mental illness specialties on Care Programme Approach (CPA) who are followed up within 7 days of discharge from psychiatric in patient care 95% 89.25 % There 6 breaches in May 2013. A local investigation is being carried out to understand this issue. In addition: Internal processes will be improved by the compilation of a 'Daily Notification' form by Ward Admin highlighting all discharges from the wards. This form will then be sent to the CMHTs on a daily basis. The updating of patient's contact details will be prioritised prior to them being discharged from the ward. This will give the community teams a better chance of completing the 7 day follow up. H&F Inpatient managers will work with their community colleagues to implement the Hounslow system whereby the CMHTs have a NHS.net 'Duty' email address that is checked regularly though out the day by the Duty Clinician. The 'Duty' NHS.net email address will be a safe and consistent place for Ward staff to send all discharge notifications. Manual validations are to be phased out
Domain 3: Are health outcomes improving for local people This domain includes: Treating and caring for people in a safe environment and protecting them from avoidable harm Friends and family response rate IAPT Delivery of operating plan local priorities (Year 2 first dose MMR, X-PERT Programme for diabetes, Physical health checks for people with severe and enduring mental illness) Domain Status RED This is the result of the issues below: Indicator Incidence of healthcare associated infections: MRSA Incidence of healthcare associated infections: C difficile Baseline position Performance 0 1 10 15 Friends & Family rates 0 Analysis Action plan: ICHT continue to provide post infection review of C.Diff cases to CQG with analysis of patients fed through into CQG ICHT have developed a new management reporting algorithm and control mechanisms are in place which are being integrated with an external mandated review process. C-Diff forensic examination of the C-Diff patients has taken place. The patients who acquired C-Diff were largely on antibiotics. Antibiotic exposure was therefore being examined. Have introduced the isolation of patients with infectious diarrhoea within 2 hours,. Continue to work closely with bed management teams and regularly reviewing plans. ICH is working with other teaching hospitals and working on best practice MRSA all cases were complex and centred around tertiary in-patients with long LoS. After investigating, the source of the risk was deemed to be around devices, therefore extra care was being taken around devices and a letter had been sent to all doctors and ward managers identifying the extra review processes to be put in place. 11 cases reported by ICHT and 4 cases occurred in a non acute setting Both ICHT and CW have provided post infection reviews and action plans which are monitored via CQG All providers are above 15% in the combined score using NHSE guidance, so RAG rating should be green
Domain 4: Are CCGs delivering services within their financial plans? This domain includes: Underlying recurrent surplus Activity trends year to date Activity trends full year forecast Financial management Domain 4 Status AMBER-GREEN
Appendix RAG criteria