January 2012 - Sandwell & West Birmingham Hospitals

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 Sandwell 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 =