Appendix 1 Quality Update Report for Salford CCG Open Board. Salford Royal, Oaklands and other providers of clinical services November 201
Contents Purpose of Paper... Ошибка! Закладка не определена. Greater Manchester Acute Providers Key Performance Snapshot... Exception Reporting:... 5 Salford Royal NHS Foundation Trust (SRFT)... 5 Oaklands... Bolton NHS Foundation Trust... 9 Central Manchester Foundation Trust... 10 Pennine Acute Hospital Trusts... 12 Greater Manchester West... Ошибка! Закладка не определена. Serious Untoward Incidents... Ошибка! Закладка не определена. 2
Performance Information from recent Provider Contracts & Quality Meetings This information provides an update to the Salford Clinical Commissioning Group (CCGs) Open Board in respect of performance against Key Quality Indicators, measures and actions taken for Salford Royal NHS Foundation Trust (SRFT) and Oakland s. This is done by reporting on exceptions against KPIs It also conveys a snapshot of other Greater Manchester Trusts performance for benchmarking purposes.
Greater Manchester Acute Providers Key Performance Snapshot September Month Royal Bolton NHS FT Central Manchester NHS FT Pennine Trust Salford Royal NHS FT Stockport NHS FT University hospital of Wrightington, Wigan South Manchester FT and Leigh FT Tameside and Glossop NHS FT A & E handovers within 15 minutes (Number of breaches) 160 2 9 1 56 1 A&E hour waits (95% Plan) 9. 9. 9. 2 1 9. 6 9. 1 Trolley waits in A&E exceeding 12 hours (Zero tolerance) 0 0 0 0 0 0 0 0 Non-admitted patients starting treatment within 1 weeks (95% Plan) 9 1 9. 5 9. Patients on incomplete non emergency pathways waiting no more than 1 weeks (92% Plan) 9. 9 92. 9 9. 9 5 95 9 Patients waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer (5% Plan) 91.. 2 5. 6. Percentage of patients referred urgently with suspected cancer by a GP waiting no more than two weeks for first outpatient appointment (9% Plan) 6 96 9. 1 1 Percentage of patients waiting no more than one month (1-days) from diagnosis to first definitive treatment for all cancers (96% Plan) 100 Patients waiting less than 6 weeks for diagnostics tests (99% Plan) 92. 9 99 100 99 C-Difficile (Variance) 0 2-1 - 0 1 0-1 MRSA (Zero Tolerance) 0 0 1 0 0 0 0 0 EMSA (Zero Tolerance) 1 0 15 0 0 0 0 0 Never events 1 1 1 0 0 0 September cumulative Royal Bolton NHS FT Central Manchester NHS FT Pennine Trust Salford Royal NHS FT Stockport NHS FT University hospital of Wrightington, Wigan South Manchester FT and Leigh FT Tameside and Glossop NHS FT A & E handovers within 15 minutes (Number of breaches) 66 56 51 11 1 56 A&E hour waits (95% Plan) 9 1 9. 5 9. 9 Trolley waits in A&E exceeding 12 hours (Zero tolerance) 0 0 0 0 0 0 0 0 Non-admitted patients starting treatment within 1 weeks (95% Plan) 6 9. 6 9. 5 Patients on incomplete non emergency pathways waiting no more than 1 weeks (92% Plan) 9. 2 9. 5 95 9. 2 Patients waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer (5% Plan) 90.. 2. Percentage of patients referred urgently with suspected cancer by a GP waiting no more than two weeks for first outpatient appointment (9% Plan) 9. 96 9 Percentage of patients waiting no more than one month (1-days) from diagnosis to first definitive treatment for all cancers (96% Plan) Patients waiting less than 6 weeks for diagnostics tests (99% Plan) 9. 6 100 5 C-Difficile (Variance) 11 11 1-6 2 12 MRSA (Zero Tolerance) 0 0 0 0 1 1 EMSA (Zero Tolerance) 2 0 15 0 0 0 0 0 Never events 1 1 2 2 0 0
Exception Reporting: Salford Royal NHS Foundation Trust (SRFT) (65% of current secondary care contract) ACCESS: - Patients should receive their first definitive treatment within 1 weeks from receiving a referral. Providers must treat 95% of all non-admitted patients and 90% of admitted within the 1 weeks. Also for those patients not treated (incomplete) 92% should be less than 1 weeks. At SRFT all specialties with the exception of Dermatology are meeting the admitted/non-admitted and incomplete pathways targets. Dermatology achieved 9.1% for non-admitted and 91.% for Incomplete patients in Quarter 2. This relates to a specialist service (MOHS) which only two providers in the North West operate and as such demands are high and patients are often onwardly referred from other NHS organisations to SRFT having already waited more than 1 weeks As previously reported the amnesty granted by commissioners for patients waiting for MOHS treatment is ongoing and the longest waiting patient time has decreased from weeks to 0 weeks. The trust has provided reassurance to commissioners and is confident that longest wait time will continue to decrease. ACCESS: - Patients who present with breast symptoms where cancer is not initially suspected should be seen as an outpatient within two weeks. At least 9% must meet this criteria in order for the trust to achieve the KPI. Cancer figures are reported one month in arrears, based on performance Apr-Aug the trust have achieved 92.6% against the benchmark of 9%. This cumulative underperformance is due to lower figures reported in Jul (.%) and Aug (91.9%). It was established the reason for low performance in Jul was due to a change in the choose and book system which the trust recognised was not rolled out and trained effectively to frontline staff. This has now been rectified and the issues have been escalated to through SRFTs Serious Incident committee for investigation. The lower figure in August is a legacy from the issues in July. Final figures for September will not be reported until next month, however early indication of the September figures shows no breaches and it is expected the target (9%) will be achieved for quarter 2. Patients who are diagnosed with Cancer and require surgery should receive surgery within 1 days At least 9% of patients should be treated in 1days for the trust to achieve this KPI. The number has dipped in August to 9.% but achieved 100% in July meaning cumulatively the trust are at 9.%. No actions required ACCESS: - Patients who are diagnosed with Cancer should be treated within 62 days 5% of patients should start treatment within 62days for the KPI to be achieved. 5
Performance in August fell to 2.% (.9% in July). The trust have advised that early review of the September figures look like they will achieve the 5% benchmark for Q2 On review of the August breaches the trust report there are currently some very complex cases in terms of patients with 2 or more primary cancers. These patients have to be investigated for both cancers before 1st definitive treatment can commence so this introduces delays. There were also patients whose treatment plan changed, or who had metastatic cancer, or who were unwell and couldn t be treated as well as a couple of breaches that could have been avoided. The trust will provide September figures at the first opportunity for review. COMMUNICATION: - 95% of A&E letters and inpatient discharge summaries should arrive with the patients GP within 2 hours The trust achieved 9.% in Q1 and an increase to 9.62% in Q2 with performance cumulatively at 9.99%. Work is ongoing at the trust to improve the position. A snapshot report of the week s discharges will be reported to commissioner s (Quality and outcomes group) on 1th November in order to gain a better knowledge on the breaches and the area of specialties they occur. Following these actions, if required, will be agreed. COMMUNICATION: - 95% or more of outpatient clinic letters should arrive with the patients GP within 5 days The trust achieved 92.66% in August and 91.6% in September which shows a deterioration each month from July (9.91%) cumulatively achievement is 92.6%. The trust has identified which areas are below the target and have written and presented a report to the Clinical communications group which described the methodology for measuring performance against this indicator. A proposal has also been presented suggesting an alternative methodology going forward, commissioner feedback is awaited. SAFETY: - Inpatientsthat are over the age of 60 and malnourished should have a treatment plan agreed with dietetics. At least 90% of all patients in this category must have a treatment plan in place for the KPI to be achieved. The trust is currently reviewing the basis of the calculation as they believe this to be incorrect so cannot currently report a figure. However work is ongoing to ensure achievement and the trust have recognised that there is an issue around patients who receive a second high MUST score not being followed up. The IM&T team and a consultant dietician are working on this issue. Areas being considered are: Were patients referred to dietetics Were patients referred but not accepted Were patients referred or seen late Were patients seen appropriately but data recorded incorrectly Can an automatic alert be set up to notify dietetics immediately after the second high MUST score? This work is ongoing and SRFT will feedback results to the commissioners as soon as it is available. SAFETY: - Inpatients that are staying on a ward with a daily pharmacy visit should have 6
their medicines reconciled after being admitted. To achieve two KPIs the trust must reconcile 0% within 2 hours and 95% within 2 hours. The trust has achieved the 2 hour target (0%) for both Q1 and Q2, with an overall cumulative performance of 1.1%. The 2 hours target has not been achieved and year to date performance up to the end of September is 92.6%. It was noted previously that although the trust is performing below the benchmark this is consistent with other trusts. However it is felt that in the main part the under achievement is due to the vacancies available in pharmacy. The trust is currently recruiting to 5 vacancies and maternity leaves and once staff are in place the trust have re-assured commissioners that the targets will be met. ACCESS: - The indicator states that the trust must only satisfy one of the indicators. 1. No more than 6.% of patients should re-attend A&E unplanned 2. No more than 5% of patients should leave the department after triage without being seen The re-attendance indicator was rebased and agreed to be increased by commissioners based on the average from 2012/1. Cumulative performance of this indicator is 6.9% with.0% being achieved in Q2 which is an increase on Q1 at 6.%. However whilst this target is not being achieved the second indicator based on patients leaving A&E before being seen has been achieved cumulatively at.1% (Q1,.16%. Q2,.1%) None currently as overall requirements are being met. QUALITY: - Only 5% of patients who attend A&E and present with Deep Vein Thrombosis (DVT) should be admitted. The trust reported a number of.96% in Q2 and combined with the Q1 performance means cumulatively the achievement is currently 6.25%. The trust report no patients were admitted for DVT in September. An audit of admissions is underway at the trust and will be reported in next month s report. CLINIAL EFFECTIVENESS: - The target is for the trust to eliminate all avoidable readmissions within 0 days of discharge. The trust are expected to improve on the 2012/1 readmission rate of 11.1%. The performance in September is reported at 9.9% which is within the 11.10%. Cumulative Performance is now 11.2% which is a further improvement from July 11.% and August 11.5% Following a series of meeting as previously reported the trust have reviewed the readmissions and identified which specialties are breaching. As a result of this work the re-admission rate is falling and the 11.10% has been achieved in the last two months. ACCESS: -Patients who are seen in community and required to be referred for Doppler ultrasound examination for peripheral vascular disease should wait for the test no longer than 1 days. Performance in September is reported at an average of 2. days which adds to the steady performance deterioration since April.
There is some discrepancy between the target (1 days) and the waiting time in the service spec (1 month). Now the service is offered on choose & book the polling time was set at 2 days which has affected the target as patients have been given the option and chosen to wait longer than 1 days. The polling time has now been amended and patients can only choose an appointment within 1 days, this should see the figure improve. ACCESS: - Looked after children (children who the trust is commissioned to provide a service) should receive health assessments in line with the national guidance. To achieve this target the trust must achieve: 92% of looked after children under the age of 5 years should have 2 health assessments annually. 92% of looked after children over the age of 5 years should have an annual health assessment. As in September the achievement for under 5 s is currently cumulatively at 5.9% and for over 5 s 9.6%. Both these measures are subject to a report that has been written and presented to commissioners. The report also contains an action plan. It is stated that the trust feel the difficulty comes when children are moved out of the Salford area, meaning there is a reliance on other trusts to complete the work. Sometimes this is not completed on time and/or not reported back to the looked after children administrators for recording in a timely fashion. Actions include a more robust admin system for reporting to ensure that assessment returns are not missed, LAC health coordinator to meet with the local authority to see if timescales can be improved. Health Visitors and School Nurses to plan and complete health assessments when due and not wait for Local Authority request and to improve sharing information re: outstanding health assessments with HV Matrons and School Health cluster leave for follow up. Healthcare Acquired Infections HCAI s MSSA (Meticillin Sensitive Staphylococcus Aureus) To the end of September there have been cases of MSSA against the objective to date of 5. The rolling projection is 11.5 against the annual objective of 10 MRSA There were no MRSA cases in September. The cumulative achievement is 0. This is a zero tolerance target. E-Coli There was one E-Coli case in September; this was an improvement on August which had cases within the month. This has also had a positive effect on the rolling projection which is now 5.92 (61.9 in August) C-Diff There were no cases of C-diff in September. This means the rolling projection is 2 against an objective of 5. It is noted that at this point SRFT are the only GM trust on track to meet this target. SRFT have undertaken investigations to establish more detail around the MSSA cases. Infomation on the first case has now been fedback to the commitee, the second MSSA case did not impact patient safety but an action plan to assure clinical saftey has been developed following it. The trust feel that cases -6 would not have happened had the developed action plan been implemented. Work is underway to undertake RCA on all E-coli incidents. Oaklands Summary:
No Exceptions to report against their key performance indicators. Oakland s achieve all applicable National RTT targets. Have had no HCAIs, no never events and no Serious Incidents this financial year. Bolton NHS Foundation Trust (10% of current secondary care contract) ACCESS:- Referral to treatment (RTT) 1 weeks At an overall trust level the target in September was achieved, at specialty level the following failed to achieve the indicator: Admitted (90%) All Specialities achieved in September Non-admitted (95%) Two specialities failed, T&O at.6% and Plastics at 9.5% Incomplete (92%) T&O achieved 91% 52 Weeks Bolton FT had two 52 week breaches in September, one in Plastic surgery, one in general surgery. Diagnostic Waits In September Bolton FT achieved 92.9 % against a target of 99% this is an improvement of.% on the previous month. The 20 month-end breaches have been validated,1 of these are in Colonoscopy - 0 of these breaches are undated and 15 are due to Capacity problems The decrease in the number of people waiting over 6 weeks for diagnostics is mainly down to 9 less Colonoscopies, 105 less MRI scans, 6 less Gastroscopies and 0 less Flexi's. There are other slight variations in the other diagnostic tests. The sharp decline in MRI Scan wait times is due to the extra sessions within Radiology. The sharp decline in Endoscopy (Colo, Gastro and Flexi) wait times is due to the extra capacity that is available since the Mobile Endoscopy Unit came into effect at the start of August. Cancer Targets 2 week waits Against the target of 95%, achievement in September was 90.5%. This equates to 5 breaches (2 Salford patients). The lack of Endoscopy and colorectal clinics during August led to the deterioration in position, the Mobile Endoscopy Unit is now supporting timely assessment / diagnostic testing. In addition Bolton FT has secured additional colorectal clinic capacity to allow timely appoint for consultation. The highest single reason for appointments not within the two weeks was due to patient cancellations, followed by capacity issues. Unscheduled Care A&E In September 9.% of patients were seen within hours (against the target of 95%) This is the first month this financial year that Bolton FT have missed this target. Ambulance Handover 9
In September a total of 160 patients waited over 15 minutes but less than 60 minutes for the handover to take place. 52 patients in September waited over 60 minutes. This is an increase on August when 2 patients waited for longer than 60 minutes. There are high volumes of ambulances arriving at certain times this coupled with problems with outflow from the departments has led to breaches. The trust is working on this and will share with commissioners; engagement is required from NWAS to fully address the issues. Jackie Bell at Bolton CCG is heading up some work across GM with regards to GM control on the ambulance contract. Communication Clinic Letters & Discharge Letters Against a target of 95% the trust have achieved.5% of Clinic Letters and.2% of discharge summaries. This is an ongoing issue and failure of this target has been apparent for a long time. The trust has now split the reporting by specialty so they can begin to concentrating improvement in the poorest performance area. Complaints In August 6% of complaints were responded too within the required time against a target of 95%, an improvement on this of 11% was reported in September and.%. This improvement is due to a new policy that the trust adapted in September, the backlog of complaints is now clear and it is now predicted this target will be back on track in November. Central Manchester Foundation Trust (16% of current secondary care contract) Unscheduled Care Ambulance Handover Hospital Trusts need to ensure that the time of arrival for 95% of patients arriving by ambulance is recorded on to the Hospital Arrival Screens (HASs) by the end of quarter. In August the Trust recorded times in 0.6% of cases. Following assurance of data quality, the focus will move towards ensuring swift ambulance to Trust handover times. An audit is taking place to establish which staff groups are not recording data. This will allow Operational Managers to work with those staff groups who are not consistently recording the required data on the electronic system. A further meeting is taking place between CMFT and NWAS to further explore opportunities to improve compliance with recording requirements. HCAI s (Healthcare acquired infections) MRSA There have been five MRSA cases (2 avoidable, unavoidable) in 201/1 assigned to CMFT between April and June 201. There have been no reported cases in July or August. The PIRs carried out at CMFT show there is no discernible pattern to the cases in terms of the settings in which they occurred, or their root causes. All of the cases occurred, as would be expected, in complex 10
patients requiring higher risk interventions. The Peer review by UCLH t establish if there are any further lessons learnt has taken place and the preliminary report has been shared with the CCG. The following recommendations were included; Antibiotic pharmacist spending more time on the wards Audit and risk assessment of the provision and position of hand hygiene facilities To establish a centralised central line service Monitor and Public Health have confirmed that they are assured by the infection control practices which are in place at CMFT. C-DIFF CMFT have drawn up new guidelines for testing C-Diff which have been agreed internally. The Trust believe that not all the cases reported have C-Diff as the main cause of infection, and therefore the number of cases reported is currently inflated. The CCG and Trust are currently working to agree the new guidelines externally and establish if the national infection data can be amended retrospectively. CMFT continue testing the University Hospital of Birmingham's algorithm, to determine avoidable and unavoidable C-Diff cases. Full implementation will take place following approval from the infection control committee. Public Health has confirmed that they are assured by the infection control practices which are in place at CMFT. Horizon Scanning Winter Planning In July 201, the Area Team (AT) wrote to CCGs seeking assurance that robust action plans to deal with seasonal variations in urgent and emergency activity expected in winter 201/1. In response, the health economy wide debrief of Winter 2012/1 took place, Trust level winter schemes were reviewed and the Surge and Escalation Plan revised. Subsequently, the AT released an assurance checklist. This was completed by the CCG and submitted in September. The AT has fed back that they are fully assured by the CCG plans for Central, South and Trafford. Winter planning for other GM CCGs is being complete by Greater Manchester CSU. Stroke Stroke performance has significantly improved on last year. In August 201, 9.% of patients spent 90% of their stay on a stroke ward against a target of 0%. Although this is slightly under target and below July (%), CMFT remains on track to deliver Q2 performance. The TIA target (60% high risk patients assessed within 2 hours) was achieved in August with performance at 62.5%. The number of patients reaching a stroke ward within hours of arrival at hospital fell from 6% in July to.% in August, against a target of 55%. There is a Commissioner and Provider forum to monitor the implementation of improvement plans and review performance. Main features of the current action plan include: Early Supported Discharge (ESD) Team sessions to improve communication across the service helping patients get to the stroke ward more quickly after admission Plans to work in a more integrated way with Social Care Implementation of day access to stroke assessment team Monitoring of patient level reports by improvement manager on leading indicators Establishing quarterly review meetings across the health economy to assess progress, provide assurance and develop remedial plans where necessary Delayed Transfers As part of 201/1 contract negotiations, the Trust agreed to a 20% reduction of number of bed days lost to 11
delayed transfer of care. The number of bed days lost to delays is within control limits but has increased in July (the CCG is awaiting August data). The current number of bed days lost is very low in comparison to other Trust of similar size and this is recognised nationally. Reduction of the numbers will therefore be difficult to achieve. In order to understand if the target is reasonable the CCG and CMFT have agreed to a number of actions. To understand and evaluate the current target by; CCG to benchmark CMFT against the Shelford Group CMFT to understand the reason for NHS delays (approx 6 days) CMFT to ensure that the definition of an NHS delay is being applied correctly and consistently Continued actions to improve performance; Daily escalation of delays to senior managers and clinicians Focus on improving discharge planning, particularly in patients with complex needs Patients assigned an estimated date of discharge on arrival at hospital and close monitoring of delivery. Pennine Acute Hospital Trusts (5% of current secondary care contract) RTT Targets (Referral to treatment) 1 weeks At an overall trust level the target in September was achieved, at specialty level the following failed to achieve the indicator: Admitted (90%) T&O.62%, Opthalmology 5.1% Non-admitted (95%) T&O 90.0%, Oral Surgery 9.5% Incomplete (92%) General Surgery 90.2%, T&O 90.0% Unscheduled Care A&E In September 9.% of patients were seen within hours (against the target of 95%) In the main this is due bed capacity, within PAHT and Community setting as well as, delays due to Patient / family choice for CHC placements and Social Care assessments. This highlights an increased risk in terms of seasonal pressures. Communications Clinic Letters & Discharge Letters Against a target of 95% the trust have achieved 0.% of Clinic Letters and 9% of discharge summaries. PAHT are working towards achievement in Q & based on a planned roll out of Electronic Prescribing (as agreed as part of last year s CQUIN) Complaints 12
Complaints responded to within 25 working days: 66% for July (90% Target). Work has been on-going between the Trusts Head of Corporate Development and the Interim Head of Complaints and PALS. From 0 September 201, the Trust has a full-time Head of Complaints and PALs managing the service. Detailed KPIs are being finalised so that the new departmental head is clear of expectations for him, his team and the service. Additional resources are being recruited into the complaints department and these should be in place by November. Stroke Stroke performance has significantly improved on last year. In August 201, 9.% of patients spent 90% of their stay on a stroke ward against a target of 0%. Although this is slightly under target and below July (%), CMFT remains on track to deliver Q2 performance. The TIA target (60% high risk patients assessed within 2 hours) was achieved in August with performance at 62.5%. The number of patients reaching a stroke ward within hours of arrival at hospital fell from 6% in July to.% in August, against a target of 55%. There is a Commissioner and Provider forum to monitor the implementation of improvement plans and review performance. Main features of the current action plan include: Early Supported Discharge (ESD) Team sessions to improve communication across the service helping patients get to the stroke ward more quickly after admission Plans to work in a more integrated way with Social Care Implementation of day access to stroke assessment team Monitoring of patient level reports by improvement manager on leading indicators Establishing quarterly review meetings across the health economy to assess progress, provide assurance and develop remedial plans where necessary Delayed Transfers As part of 201/1 contract negotiations, the Trust agreed to a 20% reduction of number of bed days lost to delayed transfer of care. The number of bed days lost to delays is within control limits but has increased in July (the CCG is awaiting August data). The current number of bed days lost is very low in comparison to other Trust of similar size and this is recognised nationally. Reduction of the numbers will therefore be difficult to achieve. In order to understand if the target is reasonable the CCG and CMFT have agreed to a number of actions. To understand and evaluate the current target by; CCG to benchmark CMFT against the Shelford Group CMFT to understand the reason for NHS delays (approx 6 days) CMFT to ensure that the definition of an NHS delay is being applied correctly and consistently Continued actions to improve performance; Daily escalation of delays to senior managers and clinicians Focus on improving discharge planning, particularly in patients with complex needs Patients assigned an estimated date of discharge on arrival at hospital and close monitoring of delivery. HCAI s (Healthcare acquired infections) 1
C-DIFF There were cases of Clostridium difficile cases reported in September 201, meaning the year to date position is 1 against a plan of 0. The seasonal pattern is well-established. Seasonality is driven by one or more risk factors to which exposure is greater in the older age group. Possible risk factors include disproportionately large increases in hospital admissions and changing antibiotic usage in elderly patients during what was a prolonged and unusually severe winter. Work continues ensuring that the basics of care (cleanliness, hand hygiene and personal protective equipment, immediate isolation of suspected or affected patients and antimicrobial stewardship) are priorities for all clinical staff. Updates continue to be given at the Infection Prevent and Control Committee which CCG Infection Control Leads attend. 1