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HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007 APPENDIX B EXISTING NATIONAL TARGETS Healthcare Commission Thresholds PCT Target Description Achieved Underach'd Failed Actual Score Comments number of people with diabetes receiving 100% of patients on diabetes registers offered screening for the early detection (and Diabetic Retinopathy Screening 80% >70% <60% 91.05% Ach'd screening, however, not all choose to take up treatment if needed) of diabetic the offer. retinopathy Robust partnership working arrangements in place between the PCT and all secondary care providers to ensure the national waiting time Achieved Maintain a maximum of 26weeks number of patients waiting longer than 26 standards are maintained. New services in <0.1% <0.3% >0.3% 0.02% Inpatient Waits weeks place in primary care to reduce referrals and waiting times in secondary care, ie. Colposcopy, Dermatology, Musculoskeletel with more to follow. Maintain a maximum wait of 13 number of outpatients waiting longer than weeks for an outpatient <0.1% <0.3% >0.3% 0.00% Ach'd as above 13 weeks appointment. Maintain a maximum waiting time All cancers: number of patients waiting of two months from urgent longer than two months from GP urgent 93% 87% <87% 96% Ach'd as above referral to treatment for all referral to treatment cancers. Underachieved Joint initiative between the Yorkshire Ambulance Service and the PCT established - Category A calls meeting eight All ambulance trusts to respond to 75% of 75% >70% <70% 72.44% Community Paramedic Scheme Pilot. The minute target category A calls within 8 minutes aim being to improve CAT response times. Evaluation of the Pilot is underway. Category A calls meeting All ambulance trusts to respond to 95% of 95% >90% <90% 96.81% Ach'd as above nineteen minute target category B calls within 19 minutes. The PCT will continue to support Whole Maintain delayed transfers of care at a Systems Approach to develop best practice in Delayed transfers of care 3.5% <5% >5% 0.77% Ach'd minimal level. discharge management and build on existing positive joint arrangements The PCT is actively involved on the West Deliver a ten percentage point increase <38% without Yorkshire Thrombolysis Specialist Group. 38% or a 20 Achieved per year in the proportion of people 68% with a 20 a 20 Various initiatives ongoing; continued roll-out Thrombolysis - 60 minute call to percentage suffering from a heart attack who receive percentage point percentage of nurse led thrombolysis work with WYMAS needle time point annual thrombolysis within 60 minutes of calling annual increase point annual and clinicians to ensure paramedic led increase for professional help. increase thrombolysis will ensure improvements in call to needle time Maintain a maximum waiting time of one Robust performance management/systems & All cancers: one month diagnosis month from diagnosis to treatment for all 96% 92% <92% 99.71% Ach'd processes in place to actively maintain the to treatment cancers. waiting time standard. EXISTING NATIONAL TARGETS Healthcare Commission Thresholds PCT APPENDIX B Target Description Achieved Underach'd Failed Actual Score Comments Every hospital appointment to be booked for the convenience of the patient, making Issues remain with counting Choose and Book it easier for patients and their GPs to and comparing with total GP referrals which 75% of 55% of <55% of Failed PCT facilities in place to support choose a hospital and consultant that are gradually being worked through that planned planned planned 49.33% choice best meets their needs. Patients should should improve PCT achievement of what is performance performance performance be able to choose from at least four acknowledge nationally to be a challenging health care providers for planned hospital target. care. Guaranteed access to a primary care All GMS and PMS practices within Kirklees Primary Care Access professional within 24 hours and to a 100% 99% <99% 99.84% Ach'd are committed to delivery of this target. primary care doctor within 48 hours. A full CR Team in place locally, however, national issue with counting the numbers of people accessing the Teams, which is being re-evaluated by the DoH. An independent Improve life outcomes of adults and performance performance performance review of all CRTs, undertaken by NIMHE, Failed Commissioning of crisis children with mental health problems by poorer than consistent with poorer than was completed in September 2007 and the resolution services ensuring that all patients who need them plans by a plans plans PCT is awaiting feedback and have access to crisis resolution services clear margin recommendations for 'way forward'. The PCT is actively working with SWYMHT with regard to care pathway re-design and delivery of key national targets. 3 part indicator assessing PCTs on their commissioning of a comprehensive CAMHS: 1. Are arrangements in place to ensure that 24/7 cover is available to meet the urgent needs of children and young people and specialist mental health Underachieved assessments undertaken within 24 hours yes' to only Healthcare Commission carried out evaluation Commissioning a comprehensive or during the next working day where yes' to two yes' to all three one or none of of service provision at Q3 (Sept 06), however, child and adolescent mental indicated? 2. Is a full range of CAMHS out of three questions the three the PCT position changed at Q4 (March 07), health service for children and young people who also questions questions showing 'yes' to all 3 questions. have a learning disability explicitly commissioned by or on behalf of the PCT? 3. Do all 16 and 17 year olds in the PCT who need CAMHS have access to service appropriate to their age and level of maturity. Data should be consistent with 2006/2007 CAMHS service mapping. EXISTING NATIONAL TARGETS Healthcare Commission Thresholds PCT APPENDIX B Target Description Achieved Underach'd Failed Actual Score Comments The PCT was not assessed against this indicator as no Local Delivery Plans submitted to the SHA as part of the original 2003-2005 Update practice-based registers so that LDP process or subsequent 'refresh' Not assessed patients with coronary heart disease and processes. No plans in place and no 'actuals' diabetes, and the majority of patients at Practice based registers - reported during 2006/07. This is a PCT high risk of coronary heart disease, data not available - indicator not assessed patients called for review priority for the immediate future and the continue to receive appropriate advice performance team will work with the Lead and treatment in line with national service Manager(s) to ensure plans are submitted for framework standards. 2007/08 as a matter of urgency and robust systems & processes in place to support delivery. Maintain a two week maximum wait from urgent GP referral to first outpatient Robust systems and processes in place to All cancers: two week wait 97% 94% <94% 100% Ach'd appointment for all urgent suspected support delivery. cancer referrals. Maintain the four hour maximum wait in Emergency Care Strategy developed and A & E Waits A&E from arrival to admission, transfer or 98% 97% <97% 98.67% Ach'd implemented in collaboration with the PCT and discharge. all relevant partners Maintain a three month maximum wait for Robust systems and processes in place to CHD - Revascularisation 0.5% 1% >1% 0% Ach'd revascularisation support delivery. APPENDIX C HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007 NEW NATIONAL TARGETS Healthcare Commission Thresholds PCT Target Description Achieved Undera'chd Failed Actual Score Comments Achieve year on year reductions in MRSA The PCT is monitored against the levels, expanding to cover other performance of the 2 local acute Trusts. yes' to all 4 yes' to 3 of 4 yes' to fewer yes' to all Infection Control - MRSA healthcare associated infections as data Achieved Root Cause Analysis is carried out for each questions questions than 3 questions 4 from mandatory surveillance becomes case and any actions identified, available. implemented. National target - 100% of equipment to be Improve the quality of life and delivered within 7 working days. The independence of vulnerable older people national target has not been achieved due Older People - Community Under- by increasing the proportion of older 95% 85% <85% 87.88% to Joint Contingency, this equipment is Equipment achieved people being supported to live in their specially built, ordered and fitted on an own home by 2008. individual basis which is not feasible within 7 working days. Increase the participation of problem drug Number of actions taken to users in drug treatment programmes by Performance maintain/improve performance; Service Performance Performance 2008; and increase year on year the poorer than plan provider has completed a Retention Substance Misuse consistent poorer than Achieved proportion of users successfully by a clear Improvement Plan; service users with lower with plan plan sustaining or completing treatment margin support needs are transferred into shared programmes. care services with GP practices, etc. Reduce smoking during pregnancy by 1% Dedicated 'specialist advisers' working with below plan Under-achieved year-on-year the acute Trusts to support women to stop Increase breastfeeding initiation rates by smoking during pregnancy. Smoking above plan Reduce Health Inequalities 2% year-on-year Cessation, service moving to operate by 10% by 2010 Increase data quality on ethnic group above plan Kirklees-wide and planning to achieve Reduce number of people smoking 75% 55% <55% 81% challenging targets set by the SHA. Increase number of four week smoking 100% 90% 85% 93.22% Outcomes of 'Smoking Summit' held to look quitters at reducing health inequalities and improve APPENDIX C NEW NATIONAL TARGETS Healthcare Commission Thresholds PCT Target Description Achieved Undera'chd Failed Actual Score Comments Various initiatives ongoing; Implement and evaluate Teenage Pregnancy Strategy; Under-achieved Implement Sex and Relationship Education Performance Reduce the under-18 conception rate by Performance Performance programmes in community as well as Sexual Health - Teenage poorer than 2010, as part of a broader strategy to consistent poorer than school setting and involving community Conception Rates plan by a clear improve sexual health. with plan plan workers, schools nurses, Sure Starts, etc; margin increase access to condoms and sexual health advice for young people in a range of settings Secure sustained national improvements Performance Performance Performance Action plans produced from feedback of in NHS patient experience by 2008 as consistent poorer than Patient Experience poorer than Achieved survey results, implemented to improve measured by independently validated with or better average by a average patient experience. surveys than average clear margin Mental Health - substantially Care programme approach seven day consistent with plan reduce mortality rates by follow up The PCT has now commissioned an Early 2010 from suicide and Commissioning of early intervention in Intervention Service that will be up and Failed undetermined injury by 20% psychosis services poorer than plan by a clear margin running from December 2007. Cancer mortality rate consistent with plan Cancer - substantially Implementation of NICE improving Robust systems and process in place to reduce mortality rates by 11 out of 24 milestones Achieved outcomes guidance performance manage/monitor the service. 2010 Breast cancer screening consistent with plan Under-achieved Under-achieved Blood pressure consistent with plan Substantially reduce The PCT continues to actively support Cholesterol levels consistent with plan mortality rates by 2010 from practices in the establishment of disease heart disease and stroke Practice based registers poorer than plan by a clear margin management registers, moving from and related diseases. secondary to primary care prevention Cardio Vascular Disease Mortality consistent with plan Halt the rise in obesity among children under 11 by Issues with DoH definitions for recording. 2010, as part of a broader The PCT is actively working with practices GP recording of body mass index 75% 55% <55% 58% strategy to tackle obesity in to ensure recording improvement during the population as a whole. 2007/08. APPENDIX C NEW NATIONAL TARGETS Healthcare Commission Thresholds PCT Target Description Achieved Undera'chd Failed Actual Score Comments Waiting times for diagnostic tests poorer than plan by a clear margin Outpatient waiting times milestone above plan Under-achieved Ensure that by 2008 nobody The PCT is actively working with all waits more than 18 weeks Inpatient waiting times milestone above plan secondary care providers to ensure national from GP referral to hospital waiting time standards are maintained/met. treatment. Data collection for referral to treatment all three months data submitted on time waiting times Emergency bed days consistent with plan Improve health outcomes for people with long term Community matrons and additional case poorer than plan by a clear margin managers Action plan developed to deliver the conditions by offering a challenging targets assigned to the PCT for personalised care plan for staffing levels and numbers of VHIUs. vulnerable people most at Failed Specifically, an additional 495 patients have risk; and reduce emergency been identified as having the potential to bed days by 2008 through Very high intensity users poorer than plan by a clear margin benefit from a case management approach improved care in primary to care through the use of the PARR+ care and community predictive tool. settings for people with long term conditions. APPENDIX A HEALTHCARE COMMISSION PERFORMANCE RATINGS 2006/2007 CORE STANDARDS Safety (9 standards - C01a-C04e) Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents. Healthcare organisations protect patients through systems that ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales. Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations. Healthcare organisations protect patients by following National Institute for Clinical Excellence (NICE) interventional procedures guidance. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA). Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely. Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. Clinical and cost effectiveness (5 standards: C05a-C06) Healthcare organisations ensure that they conform to National Institute for Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care. Healthcare organisations ensure that clinical care and treatment are carried out under supervision and leadership. Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work. APPENDIX A Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services. Healthcare organisations cooperate with each other and social care organisations to ensure that patients’ individual needs are properly managed and met. Governance (12 standards: C07a-C12) Healthcare organisations apply the principles of sound clinical and corporate governance and C7c Healthcare organisations undertake systematic risk assessment and risk management. Healthcare organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources. Healthcare organisations challenge discrimination, promote equality and respect human rights. Healthcare organisations support their staff through having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services. Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups. Not met Healthcare organisations have a systematic and planned approach to the management of records to ensure Issue Due to changes in assessment criteria the PCT was not meeting this standard up to 28th March 2007. The PCT has now an identified lead for records management/information governance who has the necessary experience to carry out the function of records management, and also advise staff around specific records management issues. Action Actions planned to rectify this gap in assurance. Role of records manager has been identified within the structure for corporate services directorate of the PCT. Action plan developed, lead identified to ensure PCT address gaps in compliance. 28th March 2007 actions completed to address gap. Records management/information governance lead in post. Patient focus (9 standards: C13a-C16) Healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect. APPENDIX A Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all contacts with patients and for the use of any confidential patient information. Healthcare organisations have systems in place to ensure that staff treat patient information confidentially, except where authorised by legislation to the contrary. Healthcare organisations have systems in place to ensure that patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services. Healthcare organisations have systems in place to ensure that patients, their relatives and carers are not discriminated against when complaints are made. Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery. Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet. Where food is provided, healthcare organisations have systems in place to ensure that patients’ individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day. Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care. Accessible and responsive Care (2 standards: C17-C18) The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services. Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably. Care environment and amenities (3 standards: C20a-C21) Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation. Healthcare services are provided in environments which promote effective care and optimise health outcomes by being supportive of patient privacy and confidentiality APPENDIX A Public health (4 standards: C22a-C24) Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organisations and C22c Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by ensuring that the local Director of Public Health’s annual report informs their policies and practices. Healthcare organisations have systematic and managed disease prevention and health promotion programmes Healthcare organisations protect the public by having a planned, prepared and, where possible, practised response to incidents and emergency situations, which could affect the provision of normal services.
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