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Trust Board papers - University Hospital Southampton NHS ...

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Appendix 1Summary Risk Assessment of Key Performance Indicators as at the end of November 2012Please Note: These about RAG ratings show the risk assessment for the key <strong>Trust</strong> performanceindicators. These may differ from the individual monthly, quarterly and YTD RAGs but highlightareas of concern.% Appraisals1. WorkforceCompleted2. Patient Experience3. Patient Safety4. Patient Flow and OutcomesSickness AbsenceSurvey - Overallsatisfaction withcareTurnover(excluding Percentage Junior ofDoctors) complaints closedin target timeSurvey -Recommendhospital to familyand friendsNutrition - %Patients withMUST Screeningin 24 hoursSurvey - SameSexAccommodationMRSAbacteraemiareductionNever EventsClostridiumdifficile reductionSerious IncidentsRequiringInvestigation(SIRI)Pressure Ulcers(Grades III and IV)No. of Falls% Pts spending90% of time onStroke UnitHigher Risk TIAcases seen within24 hoursRe-adsmissionswith 30 days<strong>Hospital</strong>StandardisedMortality Rate(HSMR) - UHStotal% Patients VTEAssessedTotal WorkforceSigned off by(FTE)the Director of Nursing Signed off by the Director of Nursing Signed off by the Director of Nursing Signed off by the Medical Director and ChiefOperating Officer5. R&Dand to targetTotal recruited toNIHR portfoliocommercialstudiesTotal recruited toNIHR portfolio noncommercialstudies (excl. % of studiesband 1)% of NIHRportfolio studiesrecruiting on timeachieving <strong>NHS</strong>permission within30 days of receiptof application.Income fromcontractcommercialstudiesDamage/Misuse -Number ofBreakdownsTotal noncommercialincome% Maintenancecompleted withinplanned time6. Estates% PlannedMaintenanceCompleted -MandatorySystem Reliability% PlannedMaintenanceCompleted -Statutory7. IM&T ‐ Updated QuarterlyReportingReliabilityTraining NeedsAnalysisMandatoryTraining8. Education ‐ Updated QuarterlyE-prescribing% PlannedProjectEvaluation ofSigned off by the Medical Director Signed off by the Director Maintenance of Finance Signed off by the Director of IM&T Signed off by the DirectorClinicalof NursingCompleted - GoodPlacementsPracticeExternalAccreditationVisitsEffective Use ofEducationBudgetsEnc 8 ii Appendix 1 Key Performance Indicators Page 1

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