Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

3. Quality Indicators
Royal Devon and Exeter NHS Foundation Trust
Quality Report 2012/13
51
Monitor Indicators and CQUIN
The Trust has reduced the number of indicators reported in the Quality Account, reporting only on those indicators which are
mandatory, as outlined in the Monitor Reporting Manual 2013. The rationale for this change in approach is to focus on those
indicators that are relevant, current and meaningful to the public.
Indicator Group Indicator Description Data
Monitor Indicators -
Safety
Monitor Indicators -
Safety
Monitor Indicators -
Quality
Monitor Indicators -
Quality
Monitor Indicators -
Quality
Monitor Indicators -
Quality
Clostridium (C.) difficile – meeting the C.
difficile objective
Definition: infections relate to patient aged two years
old or more; a positive laboratory test result for C Diff
recognised as a case according to the Trust’s diagnostic;
positive results on the same patient more than 28 days
apart are required as separate episodes, irrespective
of the number of specimens taken in the intervening
period, or where they were taken; and the Trust is
deemed responsible. This is defined as a case where
the sample was taken on the fourth day or later of an
admission to the Trust (where the day of admission is
day one)
Methicillin-resistant Staphylococcus aureus
(MRSA) bacteraemia – meeting the MRSA
objective
All cancers: 31-day wait for second or
subsequent treatment comprising: surgery
All cancers: 31-day wait for second or
subsequent treatment comprising: anti-cancer
drug treatments
All cancers: 31-day wait for second
or subsequent treatment comprising:
radiotherapyy
*All cancers: 62-day wait for first treatment
from: urgent GP referral for suspected cancer
Definition: The indicator is expressed as a percentage
of patients receiving first definitive treatment for cancer
within 62 days of an urgent GP referral for suspected
cancer. An urgent GP referral is one which has a two
week wait from date that the referral is received to first
being seen by a consultant. The indicator only includes
GP referrals for suspected cancer (i.e. excludes consultant
upgrades and screening referrals and where the priority
type of the referral is National Code 3 – Two week wait).
The clock start date is defined as the date that the
referral is received by the Trust; and the clock stop date
is the date of first definitive cancer treatment as defined
in the NHS Dataset Set Change Notice. In summary, this
is the date of the first definitive cancer treatment given
to a patient who is receiving care for a cancer condition
or it is the date that cancer was discounted when the
patient was first seen or it is the date that the patient
made the decision to decline all treatment.
2012/13 - 46 (target 67)
2011/12 - 85 (target 74)
2010/11 - 93 (target 162)
2012/13 - 0 (target 2)
2011/12 - 1 (target 3)
2010/11 - 2 (target 4)
2012/13 - 92.4%
2011/12 - 97.9%
2010/11 - 97.0%
2012/13 - 99.8%
2011/12 - 99.8%
2010/11 - 99.7%
2012/13 - 98.7%
2011/12 - 99.0%
2010/11 - 94.7%
2012/13 - 83.6%
2011/12 - 85.7%
2010/11 - 85.4%
*All cancers: 62-day wait for first treatment from: urgent GP referral for suspected cancer – the assurance review undertaken by
PriceWaterhouseCoopers LLP of this indicator has identified clerical errors in the recording of data of the sample tested. These recording errors have
been double checked by the Lead Consultant and Manager responsible for the service who have advised that the delivery of patient care has not been
affected by these errors. The Trust is currently reviewing the administrative and clerical processes for collecting and recording 62 day wait for first
treatment and the training provided to staff, to ensure the correct data is recorded for all patients.