Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 9 DETAILED REPORT Trust Board June 2013 Subject Performance Report (Month 2) Prepared by Approved by Presented by 1 Introduction Advanced Performance Analyst Deputy Head of Performance Chief Executive and Executive Leads This paper summarises Trust performance against the key national and local targets up to end of May 2013. Mitigating actions are described where underperformance is identified. This report accompanies the detailed Performance Dashboard for May 2013. 2 Safety & Quality The below diagram provides headlines on current performance across the safety and quality domain. Safe Care The Trust remains top performer in the South‐West for HSMR and benchmarks well for SHMI Incident reporting rate remains in the national upper quartile demonstrating a positive reporting culture % of incidents resulting in harm remains above internally set threshold Effective Care The Trust's readmission rate is ~4% better than expected Despite positive performance against expected levels, the Trust does not benchmark well vs other SW Trusts SAFETY & QUALITY Patient Experience % of complaints responded to in timeframe remains above target Zero non‐clinically justified single sex breaches this year Friends and family test response rates are below suggested levels of 15% Number of cancelled operations and associated 28‐day breaches remains high Infection Control Zero cases of hospital apportioned MRSA this year Number of hospital apportioned C‐Diff cases remains below trajectory No ward closures for Norovirus Other >95% of eligible patients risk assessed for VTE in April and May Hip fracture and stroke targets failed in April and May Follow‐up backlog continues to grow Safe Care (Section B1 of Performance Dashboard) 2.1 The Trust continues as the South-West’s top performer for HSMR and performs approximately 5% better than expected for the SHMI measure. These areas remain under scrutiny via the Clinical Effectiveness Group. 2.2 The Trust’s incident reporting rate of 9.7 incidents per 100 admissions remains within the national upper quartile and demonstrates a positive reporting culture. Conversely, the data demonstrates a harm rate above the internal threshold set at 28%. 2.3 Surgical safety checklist compliance remains high (98% in May) however the data shows that particular specialties continue to underperform in this area. A review of the data is underway to ensure that instances where only a partial checklist is required are not counting against the service lines inappropriately. 3
Item 9 Effective Care (Section B2 of Performance Dashboard) 2.4 The Trust’s readmission rate remains ~3% lower than expected resulting in a benchmarked South-West position of 12 th from 18 Trusts. Patient Experience (Section B3 of Performance Dashboard) 2.5 The friends and family test was introduced to the Trust in April and has started to feedback information about patient opinion. Although we are yet to reach the recommended response rate of 15% for both cohorts (A+E and inpatients) the data shows a gradual improvement in the number of A+E attendees recommending our service but conversely a reduction in the number of inpatients who would recommend the Trust. 2.6 61 operations were cancelled on the day of admission for non-clinical reasons in May representing 1.27% of all elective admissions. This is a significant improvement on April which saw 130 operations cancelled on the day (2.65% of all elective admissions). The availability of general beds continues to be the most prevalent reason for cancellation. See Annex 3 for exception report. Infection Control (Section B4 of Performance Dashboard) 2.7 The Trust has reported no cases of hospital apportioned MRSA this year whilst the 4 cases of hospital apportioned C.Difficile are in line with the trust’s trajectory of no more than 2 cases per month. 2.8 Patient level MRSA screening for elective admissions has reduced to 91% in May, 5% lower than this time last year. This drop in performance has been escalated at the Matrons meeting and individual pockets of poor performance are being addressed. 2.9 The Trust has reported no ward closures due to Norovirus in 13/14. Other Quality and Safety Measures (Section B5 of Performance Dashboard) 2.10 The Trust continues to achieve the national VTE risk assessment standard with 95% of eligible patients being risk assessed. Work continues to focus on those areas where non-compliant patients are identified whilst qualitative audits are also underway to ensure the procedure is being carried out effectively. 2.11 The Trust has failed to operate on at least 85% of fractured neck of femur patients within 36hrs of admission in April and May. Of the 13 May patients who failed to get to theatre within the required timeframe, 8 were medically unfit. 2.12 Despite an improvement on April’s performance (59%), the Trust has failed to deliver the stroke target in May with only 67% of stroke patients spending 90% or more of their stay on the acute stroke unit. See Annex 1 for exception report. 2.13 As at the 31 st May, the follow-up backlog had risen to 24,305 patients, an increase of 767 patients from April. 4
Page 1 and 2: Trust Board Friday 5 July 2013, 9.0
Page 3 and 4: Members of Plymouth Hospitals NHS T
Page 5 and 6: Item 3 observer. The Chairman requi
Page 7 and 8: Item 3 Board oversight of contribut
Page 9 and 10: Item 3 the Board next month. • Th
Page 11 and 12: Item 3 been involved and there was
Page 13 and 14: Item 3 continuing to build. Mr Babe
Page 15 and 16: Item 3 to Norovirus, Professor Lewi
Page 17 and 18: Item 3 • Careful communication of
Page 19 and 20: Item 3 • Approved the writing off
Page 21 and 22: Updated: prior to July Board Item 4
Page 23 and 24: Updated: prior to July Board Item 4
Page 25 and 26: Item 8 Quality Impact Assessment Pa
Page 27 and 28: Item 8 3.2 Quarterly Summary Hospit
Page 29 and 30: Item 8 4.4 Monthly Proportion of Pa
Page 31 and 32: Item 8 Inpatient falls are currentl
Page 33 and 34: Item 8 REI signage PALS were contac
Page 35 and 36: Item 8 Complaints received listed b
Page 37 and 38: Item 8 The graphs below illustrate
Page 39 and 40: Item 8 5.5 Friends and Family Test
Page 41 and 42: Item 8 1. Pressure Ulcers (EoC) 2.
Page 43 and 44: Item 8 Observations The essence of
Page 45 and 46: Item 8a SUMMARY REPORT Trust Board
Page 47 and 48: Annex 2 Item 8a Summary of Serious
Page 49: Item 9 Key Recommendations The Trus
Page 53 and 54: Item 9 Description 31 days from 'de
Page 55 and 56: Item 9 4.6 Non Elective Activity is
Page 57 and 58: Item 9 Summary of performance excep
Page 59 and 60: Item 9 Ensure that all patients adm
Page 61 and 62: Item 9 Forecast Significant progres
Page 63 and 64: Item 9 Update on previous actions C
Page 65 and 66: Contents EXECUTIVE SUMMARY D FINANC
Page 67 and 68: B1 Safe care Description Hospital S
Page 69 and 70: Response Rate Recommender Score B3
Page 71 and 72: B5 Other safety & quality metrics D
Page 73 and 74: C2 Non-Elective Activity Descriptio
Page 75 and 76: C4 Referral To Treatment (RTT) Desc
Page 77 and 78: C6 Other access & activity metrics
Page 79 and 80: D2 Cost improvement programme (CIP)
Page 81 and 82: D4 Cash Management Description Revi
Page 83 and 84: E1 Staffing numbers Description Est
Page 85 and 86: E3 Sickness absence PERFORMANCE IND
Page 87 and 88: Risk Rating F2 Monitor's Financial
Page 89 and 90: Item 10 DETAILED REPORT Trust Board
Page 91 and 92: Item 10 4. Key Issues for the Board
Page 93 and 94: Item 11 SUMMARY REPORT Trust Board
Page 95 and 96: Item 11 DETAILED REPORT Trust Board
Page 97 and 98: Item 11 • Challenge in respect of
Page 99 and 100: Item 11 Over the past two years, me
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Item 11 Getting it Right Charter An
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Item 11 Outcome of review with exte
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Item 11 Learning Disabilities Natio
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Item 11 Peer Review 2.5 Peer Review
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Item 12 Next Steps 1. Conversation
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Item 12 2. Board Inclusion Developm
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Item 12 EDS Grades and E & D Object
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Item 12 Plymouth Hospitals Trust -
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Item 12 3.6 The workforce is suppor
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Item 13 Key Recommendations The Tru
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Item 13 Telephone conversations.
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Item 13 19. The Medical Director ha
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Item 14 SUMMARY REPORT Trust Board
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Item 15 incident investigations to
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Item 15, Annex 1 3. Review of Actio
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Item 15, Annex 1 • Top three issu
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Item 15, Annex 1 The Chair asked SS
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Item 16 COMMITTEE MINUTES Finance,
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Item 16 pay and staffing, highlight
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Item 16 • PACS contract - likely
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Item 17 Terms and Conditions of Emp
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Item 17, Annex 1 29/2013 Minutes an
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Item 17, Annex 1 31/2013 Francis Re
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Item 18 SUMMARY REPORT Trust Board
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Item 18 Next Steps The Audit Commit
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Item 18, Annex 1 Matters arising 4/
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Item 18, Annex 1 time to embed and
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Item 18, Annex 1 Payroll & Expenses
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Item 18, Annex 1 The Committee note
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Item 18, Annex 1 Going Concern Revi
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Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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