January 2012 - Sandwell & West Birmingham Hospitals

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SWBTB (1/12) 273 ALIGNMENT TO OBJECTIVES AND INSPECTION CRITERIA: Accessible and Responsive Care, High Quality Care and Good Strategic objectives Use of Resources Annual priorities National targets and Infection Control NHS LA standards CQC Essential Standards Quality and Safety Auditors’ Local Evaluation Internal Control and Value for Money IMPACT ASSESSMENT (Indicate with ‘x’ all those that apply in the second column): Financial Business and market share Clinical Workforce Environmental Legal & Policy x x x x x x Equality and Diversity Patient Experience x Communications & Media Risks PREVIOUS CONSIDERATION: Financial Management Board, Trust Management Board and Finance and Performance Management Committee. Page 2
SANDWELL AND WEST BIRMINGHAM HOSPITALS CORPORATE QUALITY AND PERFORMANCE MONITORING REPORT - DECEMBER 2011 - EXCEPTION REPORT SWBTB (1/12) 273 (a) AREA PERFORMANCE National Indicator(s) Local Indicator(s) COMMENTS Current Year to date Current Year to date Cancer • • Cancelled Operations • • • • Delayed Transfers of Care • • Stroke Care • • • • • • Accident & Emergency • • Infection Control • • Referral to Treatment • • • • Cervical Cytology • • Same Sex Accommodation • • Mortality • • Sickness Absence • • Learning & Development • • • • • • CQUIN • • Referrals • • • • • • Activity • • • • Ambulance Turnaround • • The Trust has met, in month (September) and year to date performance thresholds for each of the 9 (national) headline, 2-week, 31-day and 62-day cancer indicators. The overall percentage of Cancelled Operations increased on both sites to 0.9% overall during the month of December. There was a breach of the 28-day standard reported following an initial cancellation, this is the first breach of this nature since May 2010. During the month (December) Delayed Transfers of Care increased on both sites to 5.4% overall. On the census date 50% of delays were attributable to <strong>Sandwell</strong> Local Authority. Year to date Delayed Transfers of Care (5.7%) remain in excess of the 3.5% performance threshold. Stroke Care - provisional data for the month of December indicates that the percentage of patients who spent at least 90% of their hospital stay on a Stroke Unit has been maintained above the national target of 80%. TIA (High Risk) Treatment (within 24 hours of initial presentation) is reported as 28.5% for the month. In excess of 90% of patients presenting with Stroke during the month received a CT Scan within 24 hours of arrival and admission. A/E 4-hour waits - performance for the month of December fell to 94.00%. Performance for the year to date is 95.06%. Accident & Emergency Clinical Quality Indicators - for the purpose of performance monitoring the indicators are grouped into two groups, timeliness and patient impact. Organisations will be regarded as achieving the required minimum level of performance where robust data shows they have achieved the thresholds for at least one indicator in each of the two groups. During December 2 of the 5 indicators was met, one in each of the 2 groups. for the year to date 3 of the 5 indicaors are being met. There were 2 cases of C Diff reported across the Trust during the month of December compared with a trajectory of 9. The number of C Diff cases reported for the year to date are also within the trajectory for the period. There was 1 case of MRSA Bacteraemia, during the month which is the first case reported during the year to date. All 5 National and 3 Local high level RTT Performance Indicators were met in month (November) and year to date. The only exception by specialty was Trauma & Orthopaedics, where 80.1% of admitted patients commened treatment within 18 weeks of referral (target 90%), similar to the previous month. The Turnaround Time of Cervical Cytology requests has been less than 9 days for each month for the year to date. There were 0 Breaches of Same Sex Accommodation reported during the month of October. No breaches have been reported since August. The Hospital Standardised Mortality Rate (HSMR) for the Trust for the most recent 12 month cumulative period (ending September 2011) is 101.9, compared with a Peer (SHA) rate of 104.5 and a Peer (National) rate of 95.7. Sickness Absence for the month of December improved (reduced) to 4.28% (target for Q3 =
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SWBTB (1/12) 264 AGENDA Trust Board
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12 Minutes from the meeting of the
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SWBTB (12/11) 263 4 Update on actio
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strengthened in the forthcoming mon
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advised that the tariff adjustment
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outine review of feedback posted on
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preparation of the annual report sh
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SWBTB (12/11) 263 (a) Next Meeting:
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SWBTB (1/12) 265 TRUST BOARD DOCUME
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SWBTB (1/12) 265 (a) ` REGISTER OF
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Sandwell & West Birmingham Hospital
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SWBTB (1/12) 276 ALIGNMENT TO OBJEC
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SWBTB (1/12) 276 (a) Summary of our
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SWBTB (1/12) 276 (a) "Nothing could
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SWBTB (1/12) 276 (a) The following
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SWBTB (1/12) 276 (a) highly about t
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SWBTB (1/12) 276 (a) Outcome 05: Me
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SWBTB (1/12) 276 (a) records were c
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SWBTB (1/12) 276 (a) Information fo
Page 41 and 42: ALIGNMENT TO OBJECTIVES AND INSPECT
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Page 59 and 60: SWBTM (1/12) 236 (a) SWBTB (1/12) 2
Page 69 and 70: SWBTM (1/12) 236 (b) SWBTB (1/12) 2
Page 71 and 72: March 2011 - August 2011 (Trust res
Page 73 and 74: SWBTB (1/12) 284 TRUST BOARD DOCUME
Page 75 and 76: SANDWELL AND WEST BIRMINGHAM HOSPIT
Page 77 and 78: SUMMARY PROFILE OF COMPLAINTS FIGUR
Page 79 and 80: SWBTB (1/12) 284 (a) 5. Number of F
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Page 85 and 86: Variance (£000) Variance (£000) S
Page 91: SWBTB (1/12) 273 TRUST BOARD DOCUME
Page 95 and 96: SWBTB (1/12) 274 ALIGNMENT TO OBJEC
Page 99 and 100: SWBTB (1/12) 266 (a) ANNUAL PLAN 20
Page 101 and 102: SANDWELL AND WEST BIRMINGHAM HOSPIT
Page 103 and 104: Trust Objectives 2011/12 SWBTB (1/1
Page 119 and 120: Report ID: SWBH 02b Overview Status
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Page 125 and 126: SWBTB (1/12) 283 (a) 4.0 Progress t
Page 127 and 128: SWBTB (1/12) 283 (a) The NHS Leader
Page 129 and 130: SWBTB (01/12) 268 TRUST BOARD DOCUM
Page 131 and 132: SWBTB (1/12) 268 (a) Report to the
Page 133 and 134: SWBTB (1/12) 268 (b) Appendix 1 Org
Page 135 and 136: staff and skills. Diagnostic activi
Page 137 and 138: organisation as a whole and its cri
Page 139 and 140: 7. Conclusion This strategy outline
Page 141 and 142: 3. MEMBERSHIP Non Executive
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SWBTB (1/12) 286 ALIGNMENT TO OBJEC
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SWBTB (1/12) 286 (a) The Department
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SWBTB (1/12) 286 (a) OUTLINE BUSINE
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SWBTB (1/12) 286 (a) Cluster Direct
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SWBTB (1/12) 286 (a) physicians and
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SWBTB (1/12) 286 (a) availability o
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SWBTB (1/12) 286 (a) Table 4 - Reco
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SWBTB (1/12) 286 (a) The evaluation
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SWBTB (1/12) 286 (a) appropriate ti
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SWBTB (1/12) 286 (a) Table 5: Ambul
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SWBTB (1/12) 286 (a) These costs ar
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SWBTB (1/12) 286 (a) It could be ar
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SWBTB (1/12) 286 (a) commissioners
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SWBTB (1/12) 286 (a) In making this
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SWBTB (1/12) 286 (a) Appendix 1 ACU
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SWBTB (1/12) 286 (a) Appropriately
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SWBTB (1/12) 286 (a) Provide a two
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SWBTB (1/12) 286 (a) Ap
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SWBTB (01/12) 269 ALIGNMENT TO OBJE
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SWBTB (1/12) 269(a) 2.3 Creating a
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SWBTB (1/12) 269(a) 4.0 Timeline 5.
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SANDWELL AND WEST BIRMINGHAM HOSPIT
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APPENDIX 1 - RCRH Activity Summarie
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2011/12 trajectories and ongoing pr
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SWBTB (1/12) 278 FT PROGRAMME BOARD
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SWBTB (1/12) 278 (a) FT Programme D
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MINUTES the New Year. In terms of t
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MINUTES respectively. 7 Programme r
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MINUTES It was reported that a self
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SWBAC (12/11) 068 Mr White reported
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SWBAC (12/11) 068 Implementation ac
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SWBAC (12/11) 068 Mrs Hunjan asked
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SWBAC (12/11) 068 ACTION: Mr White
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SWBAC (12/11) 068 The date and time
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January 2012 - Sandwell & West Birmingham Hospitals

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