Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital
Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital
Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital
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54 3. Quality Indicators<br />
<strong>Royal</strong> <strong>Devon</strong> <strong>and</strong> <strong>Exeter</strong> NHS Foundation Trust<br />
Quality <strong>Report</strong> <strong>2012</strong>/<strong>13</strong><br />
Indicator Group Indicator Description Data<br />
CQUIN Indicator 8. Emergency Department Patient Flows Q1 - Action Plan agreed (Target Agree Action Plan)<br />
Q2 - Reviewed <strong>and</strong> developed joint action plan with PCT<br />
(Target Agreement of objectives <strong>and</strong> measures for Q3 <strong>and</strong> 4)<br />
Q3 - Reviewed <strong>and</strong> developed joint action plan with PCT<br />
(Target Agreement of objectives)<br />
Q4 - Tests of change achieved <strong>and</strong> 95% access target<br />
achieved (Target Achieve agreed action plan)<br />
CQUIN Indicator 9. Early Supported Discharge for Stroke Q1 - N/A (Target N/A)<br />
Q2 - N/A (Target N/A)<br />
Q3 - N/A (Target N/A)<br />
Q4 - Data no yet available, but achievement is anticipated<br />
(Target Reduction in super spell length of stay)<br />
CQUIN Indicator<br />
CQUIN Indicator<br />
CQUIN Indicator<br />
CQUIN Indicator<br />
CQUIN Indicator<br />
Additional Indicators<br />
as chosen by Trust<br />
Additional Indicators<br />
as chosen by Trust<br />
10a. Nutrition <strong>and</strong> Hydration<br />
(Implementation of ‘Nil by Mouth’)<br />
10b. Nutrition <strong>and</strong> Hydration (MUST<br />
Assessment)<br />
11a. Nosocomial Pneumonia (Head up Tilt<br />
Positioning)<br />
11b. Nosocomial Pneumonia (Compliance<br />
with NGTube Placement)<br />
11c. Nosocomial Pneumonia (compliance with<br />
Naso-Gastric Tube Management Bundle)<br />
Q1 - Baseline established (Target Production of a baseline<br />
<strong>and</strong> agree trajectory)<br />
Q2 - 55% Hydration, 64% Nutrition (Target 30%)<br />
Q3 - 92% Nutrition (Target 60%)<br />
Q4 - 95%, 65%, 100% (Targets 90%, 60%, 90%)<br />
Q1 - Baseline established (Target Production of a baseline<br />
<strong>and</strong> agree trajectory)<br />
Q2 - Achieved 90.3% <strong>and</strong> 87.6% (Target 40%)<br />
Q3 - Achieved 89.0% <strong>and</strong> 83.0% (Target 75%)<br />
Q4 - Achieved 98.0% <strong>and</strong> 100% (Target 90%)<br />
Q1 - Approach agreed, baseline identified (Target Agree<br />
approach <strong>and</strong> definition of high risk groups)<br />
Q2 - 100% in identified high risk groups (Target N/A)<br />
Q3 -100% in identified high risk groups (Target N/A)<br />
Q4 - 100% in identified high risk groups (Target Achieve<br />
agreed trajectory 85%)<br />
Q1 - Trajectory agreed (Target Produce baseline <strong>and</strong> agree<br />
trajectory)<br />
Q2 - 84% (Target 76%)<br />
Q3 - 90% (Target 87%)<br />
Q4 - 94% (Target 90%)<br />
Q1 - Trajectory agreed (Target Produce baseline <strong>and</strong> agree<br />
trajectory)<br />
Q2 - 96% (Target 82%)<br />
Q3 - 98% (Target 88%)<br />
Q4 - 99% (Target 90%)<br />
Patient Safety – The NHS Safety Thermometer <strong>2012</strong>/<strong>13</strong> (May12-Mar<strong>13</strong>) - 94.20%<br />
Patient Safety – Incidence of Pressure Ulcers <strong>2012</strong>/<strong>13</strong> - 0.34% (target 0.80%)<br />
2011/12 - 0.58% (target 0.80%)<br />
2010/11 - 0.67% (target 0.80%)
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