Docstoc

Quality dashboard - Q4 2009 - NHS Bristol

Document Sample
Quality dashboard - Q4 2009 - NHS Bristol Powered By Docstoc
					                                                                                              8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls

                                                       Quality Dashboard - Year to Date to March 2010
                                                                                                                                                                  Acute
                                                                                                                                   NBT               Trend         UHBT               Trend   UKSH (in future)

Clinical Effectiveness & Outcomes
                                                   Reduce by 25% the number of patients acquiring Grade 4 pressure
                  Pressure Ulcers
                                                   ulcers in hospital against baseline year
                                                                                                                            Data not yet available          Data not yet available    
                                                   95% of all admissions to inpatient wards (both elective and non-
   Prevention of Venous Thromboembolism (VTE)
                                                   elective but excluding paediatrics) to be risk assessed on admission
                                                   in line with recommendations laid out in the VTE National Working
                                                                                                                                   59.6%                    Audit being arranged      
                                                   Party Recommendations

                                                   Percentage of patients who present with a fractured neck of femur
             Fractured Neck of Femur
                                                   and who wait 24 hours or less for surgery
                                                                                                                            Data not yet available          Data not yet available    
                                                   95% of fractures requiring surgery will be operated on within 24 hours
            Fractures requiring Surgery            of admission or fit for surgery                                          Data not yet available          Data not yet available    
        Acute Medical Patient Assessments
                                                   95% of acute medical patients will have an assessment by an acute
                                                   physician consultant within four hours of admission
                                                                                                                            Data not yet available          Data not yet available    
                                                   Increase the normal birth rate by 1% per year and as a result reduce
                                                   caesarean section rates until there is research evidence available
                                                   about the optimum level and a clear improvement in maternal and                 -0.02%                           -0.08%
                                                   perinatal morbidity - Apr 08-Mar 09 vs. Apr 09-Mar 10

                 Maternity Services
                                                   80% of all mothers where the Trust was responsible for antenatal care
                                                   initiating breast-feeding in-hospital - YTD to Mar 10
                                                                                                                                   78.1%                           76.6%              
                                                   90% of all mothers who deliver at the Trust who are not smokers at
                                                   the time of delivery - YTD to Mar 10
                                                                                                                                   90.8%                           87.9%              
                                                   Relative Risk : Ratio of number of actual deaths to expected deaths -
    Hospital Standardised Mortality Ratio (HSMR)                                                                                    72.1                             89.1
                                                   NBT and UHBT (12 months to Dec 09)

                                                   The number of mortality alerts in a reporting period (Dec 09-Feb 10)
      Care Quality Commission Mortality Alerts                                                                                        0                                0

                                                   95% of people who have suffered a stroke will receive brain imaging if
                                                   required within 30 minutes of arrival at hospital, seven days a week -
                                                   UHBT YTD to Mar 10
                                                                                                                            Data not yet available                  15.5%              
                Stroke Management
                                                   90% of stroke patients will spend 90% of their time in hospital in an
                                                   acute specialist multi-disciplinary stroke unit - YTD to Mar 10
                                                                                                                                   76.1%                           65.8%              
                                                   A year-on-year increase in the proportion of heart attack patients
                Primary Angioplasty                treated by primary angioplasty, meeting national standards for           Data not yet available           Data not yet available
                                                   treatment within 120 minutes of calling for help

               Cardiac Rehabilitation
                                                   At least 50% of people who have a heart attack, bypass surgery or
                                                   coronary angioplasty will receive cardiac rehabilitation
                                                                                                                            Data not yet available          Data not yet available    
                                                   % expressing a good or excellent outcome for: Clinical outcomes of
                                                   NHS services from the patients perspective - Varicose Veins              Data not yet available          Data not yet available    
                                                   % expressing a good or excellent outcome for: Clinical outcomes of
                                                   NHS services from the patients perspective - Hernia Repair               Data not yet available          Data not yet available    
   Patient Reported Outcome Measures (PROMS)
                                                   % expressing a good or excellent outcome for: Clinical outcomes of
                                                   NHS services from the patients perspective - Hip Replacement             Data not yet available          Data not yet available    
                                                   % expressing a good or excellent outcome for: Clinical outcomes of
                                                   NHS services from the patients perspective - Knee Replacement            Data not yet available          Data not yet available    
                                                                                                 8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls

                                                         Quality Dashboard - Year to Date to March 2010
                                                                                                                                                                       Acute
                                                                                                                                      NBT                Trend          UHBT               Trend   UKSH (in future)

Patient Safety
                                                     Reduce number of patients acquiring MRSA infections - measured
                                                                                                                                        33                                 15
                                                     against NHS South West Ambition - YTD to Mar 10

                                                     Reduce number of patients acquiring Clostridium Difficile infections -
                                                                                                                                        181                               100
                                                     measured against NHS SW Ambition - YTD to Mar 10
             Hospital acquired infections            MRSA Screening - % of patients for whom the period between MRSA
                                                     screening and elective admission is no more than 3 weeks - Target
                                                     100% - YTD to Mar 10
                                                                                                                                      68.4%                             84.6%              
                                                     Number of HCAI SUIs (deaths or major impact on services) reported
                                                                                                                                        14                                 13
                                                     (establish baseline 2009/10)

                                                     Number of Non HCAI SUIs reported (establish baseline 2009/10)
          Serious Untoward Events (SUIs)                                                                                                43                                 63

   National Patient Safety Agency (NPSA) - Patient   Correct patient, correct drug, correct route, correct dose (establish
                                                                                                                                        931                      Audit being arranged
         Safety Initiative - Medication Safety       baseline 2009/10)

                                                     Adverse event rate per 1,000 bed days
                   Adverse Events                                                                                              Data not yet available           Data not yet available     
                    Hospital Falls
                                                     Reduce by 25% number of patient falls in hospital from baseline year
                                                     (NBT Falls < Last Year Target = 2076)
                                                                                                                                       2300                      Data not yet available     
                                                     Wrong site surgery - YTD to Mar 10
                                                                                                                                         0                                0                
                                                     Retained instrument post-operation - YTD to Mar 10
                                                                                                                                         0                                1                
                                                     Wrong route administration of chemotherapy - YTD to Mar 10
                                                                                                                                         0                                0                
                    Never Events
                                                     Misplaced naso or gastric tube not detected prior to use - YTD to Mar
                                                     10
                                                                                                                                         1                                0                
                                                     In-hospital maternal death from post-partum haemorrhage after
                                                     elective caesarean section - YTD to Mar 10
                                                                                                                                         0                                0                
                                                     Intravenous administration of mis-selected concentrated potassium
                                                     chloride - YTD to Mar 10
                                                                                                                                         0                                0                
                                                     Reporting rate per 100 admissions (compared with similar trusts) as      Higher than similar size           Lower than similar size
                                                     at October 2008-March 2009                                                  Trusts (6.1 v 5.4                  Trusts (5.9 v 5.8
                                                                                                                                      Median)                           Median)
      National Patient Safety Agency (NPSA)
                                                     Frequency of reporting as at October 2008-March 2009
    Reporting and Learning Systems (6 monthly)                                                                                        Monthly                           4 from 6

                                                     Timescale for reporting as at October 2008-March 2009                     60 days compared to               47 days compared to
                                                                                                                                median of 50 days                 median of 50 days

                                                     CAS Alerts implemented by deadline date - alerts due for completion
        Central Alerting System (CAS) Alerts                                                                                          79.0%                              96.0%
                                                     between Jan 10 and Mar 10

                                                     The check list is being completed 100% of the time
           WHO Surgical Safety Checklist                                                                                              98.0%                              91.8%
                                                                                               8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls

                                                       Quality Dashboard - Year to Date to March 2010
                                                                                                                                                                  Acute
                                                                                                                                   NBT               Trend         UHBT               Trend   UKSH (in future)

Patient Experience
                                                   The number of patients whose operation has been cancelled twice or
          Multiple Cancelled Operations                                                                                     Data not yet available           Data not yet available
                                                   more

                                                   % Resolved within local resolution plan
                                                                                                                            Data not yet available                    9%
                    Complaints
                                                   % Satisfied with resolution
                                                                                                                            Data not yet available           Data not yet available

                                                   Were you involved as much as you wanted to be in decisions about
                                                                                                                                     71                               73
                                                   your care?

                                                   Did you feel you were treated with respect and dignity while you were
                                                                                                                                     88                               90
                                                   in the hospital?
     National CQC inpatient survey (Note: CQC
   results are a weighted score out of 100 based   Did you find someone on the hospital staff to talk about your worries
                                                                                                                                     62                               61
    on survey responses - a high score is good)    and fears?
                    2008 results
                                                   Were you offered a choice of hospital for your first hospital
                                                                                                                                     34                               19
                                                   appointment?

                                                   Did you have confidence and trust in the nurses treating you?
                                                                                                                                     85                               87

                                                   Have you been involved as much as you wanted to be in decisions
                                                                                                                            Data not yet available           Data not yet available
                                                   about your care and treatment?

                                                   Do you feel that you have been treated with dignity and respect while
                                                                                                                            Data not yet available           Data not yet available
     Local real time tracking (Patient SPACE       on this ward?
                      themes)
                                                                                                                            Data not yet available           Data not yet available
                                                   Are the staff on this ward friendly and helpful?

                                                   Would you recommend this hospital to your friends and family? -
                                                                                                                            Data not yet available           Data not yet available
                                                   Confirm "Recommender"

                                                   Satisfaction of the Provider’s obligations under the Mixed Sex
                                                   Accommodation Reduction Plan - 50% reduction in no of reported           Data not yet available           Data not yet available
                                                   breaches in Q3 and 4 over Q1 and 2

                                                   National Inpatients - Did you ever share a sleeping area with patients
            Mixed Sex Accommodation                of the opposite sex? (Note: CQC results are a weighted score out of
                                                                                                                                     71                               70
                                                   100 based on survey responses - a high score is good) 2008 results


                                                   Local survey - to be confirmed - Aim to have local surveying in place
                                                                                                                                 21% / 15%                        35% / 13%
                                                   for Q3 - duplicate national survey questions

                                                   Reduce number of women who are turned away in labour and deliver
                Maternity Services                                                                                          Data not yet available           Data not yet available
                                                   at alternative locations - Confirm % reduction
                                      Quality Dashboard - Year to Date to March 2010
                                                                                                                                                Mental Health
                                                                                                                                    AWP                Trend   Turning Point
                                                                                                                                                                  (in future)


Clinical Effectiveness & Outcomes
                                                     Maximum of 6 week wait (referral to first appointment) - Adult of
                                                     Working Age (AOWA), Older People (OP) & Child and Adolescent
                                                     Mental Health Services (CAMHS) (Dec 2009 target) - Target 98%
                                                                                                                                    100.0%              
                                                                                                                                                        
     Wait times from referral to first appointment   Maximum of 8 week wait (referral to first appointment) - AOWA, OP &
                                                                                                                                    100.0%
                                                     CAMHS (2008/9 target for comparison purposes) - Target 100%

                                                     Maximum of 13 week wait for treatment from point of referral - AOWA,
                                                     OP & CAMHS
                                                                                                                             Data not yet available    
                      Follow up
                                                     Follow up within 7 days of discharge (cumulative) - Target 95%
                                                                                                                                     97%                
                                                     % of service users receiving assessment within 4 hrs of referral to
                                                                                                                                    92.0%
                                                     Crisis Team - Target 95%
            Assessments and Care Plans
                                                     % of carers with an assessed need who have a care plan within 4
                                                     weeks of assessment - Target 100%
                                                                                                                                     40%                
            Service users in employment
                                                     Service users in employment (NI 150) - Target 10%
                                                                                                                                     12%               
       Service users in settled accommodation
                                                     Service users in settled accommodation (NI 149) - Target 70%
                                                                                                                                     88%                
     Patients' assessments of meeting physical       Patients' assessments of meeting physical health care needs            Amber based on Oct 09
                  health care needs                                                                                            Patient Survey

       Meet timescales for RIO implementation
                                                     Meet timescales for RIO implementation
                                                                                                                                   On track            
Patient Safety
   National Patient Safety Agency (NPSA) - Patient   Correct patient, correct drug, correct route, correct dose - 10%
                                                                                                                             Data not yet available
         Safety Initiative - Medication Safety       reduction in errors

                                                     Reduce number of patient falls in hospital
                    Hospital Falls                                                                                           Data not yet available

                                                     Inpatient suicide using non-collapsible rails
                                                                                                                                       0
                    Never Events
                                                     Escape from within the secure perimeter of medium or high secure
                                                                                                                                       0
                                                     mental health services by patients who are transferred prisoners

                                                     Number of suicides/unexpected deaths - YTD to Mar 10
                                                                                                                             Data not yet available

                                                     Compliance to 24 hour SUI reporting deadline (most recent month
                                                                                                                                       0
                                                     only)
          Serious Untoward Events (SUIs)
                                                     Compliance to 72 hour detailed management report deadline (most
                                                                                                                                       0
                                                     recent month only)

                                                     Compliance to SUI/unexpected death audit - completed < 60 working
                                                                                                                                       0
                                                     days

                                                     Reporting rate (compared with similar trusts) as at October 2008-      20 per 1000 bed days
                                                     March 2009                                                              versus 21.5 median

       National Patient Safety Agency (NPSA)         Frequency of reporting as at October 2008-March 2009
                                                                                                                             Data not yet available
          Reporting and Learning Systems

                                                     Timescale for reporting as at October 2008-March 2009
                                                                                                                             Data not yet available

                                                     Appropriate action against CAS alerts                                  Only reported internally
            Central Alerting System Alerts
                                                                                                                                   at present




    8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls                                                                                                                           Page 4 of 7
                                    Quality Dashboard - Year to Date to March 2010
                                                                                                                                            Mental Health
                                                                                                                                AWP                Trend   Turning Point
                                                                                                                                                              (in future)


Patient Experience
                                               Do you have enough say in decisions about your care and treatment?
                                                                                                                                 45%
                                               (Service User Survey Results 2009)

                                               Do you have enough say in decisions about your care and treatment?
                                                                                                                                 32%
                                               (National MH Inpatient Survey Results 2009)

                                               Did the psychiatrist treat you with respect and dignity? (Service User
                                                                                                                                 84%
                                               Survey Results 2009)

                                               Did the psychiatrist treat you with respect and dignity? (National MH
                                                                                                                                 66%
                                               Inpatient Survey Results 2009)

                                               Did the community psychiatric nurse treat you with respect and
        National CQC Mental Health Survey                                                                                        88%
                                               dignity? (Service User Survey Results 2009)

                                               Did the nurse treat you with respect and dignity? (National MH
                                                                                                                                 52%
                                               Inpatient Survey Results 2009)

                                               Did you have trust and confidence in the psychiatrist you saw?
                                                                                                                                 64%
                                               (Service User Survey Results 2009)

                                               Did you have trust and confidence in the psychiatrist you saw?
                                                                                                                                 47%
                                               (National MH Inpatient Survey Results 2009)

                                               Did you have trust and confidence in the community psychiatric
                                                                                                                                 75%
                                               nurse? (Service User Survey Results 2009)

                                               Did you have trust and confidence in the nurse? (National MH
                                                                                                                                 43%
                                               Inpatient Survey Results 2009)

                                               TBC
                                                                                                                        Data not yet available

                                               TBC
                                                                                                                        Data not yet available
              Local real time tracking
                                               TBC
                                                                                                                        Data not yet available

                                               TBC
                                                                                                                        Data not yet available

                                               Mixed sex accommodation breaches                                         Delivery Plan on target;
            Mixed Sex Accommodation
                                                                                                                         no forward breaches

                                               % Resolved within local resolution plan (closed within 25 days YTD
                                                                                                                                 100%
                                               excluding most recent month)
                    Complaints
                                               % Satisfied with resolution
                                                                                                                        Data not yet available




    8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls                                                                                                                       Page 5 of 7
               Quality Dashboard - Year to Date to March 2010
                                                                                                                           Primary Care
                                                                                                                                 GPs

Clinical Effectiveness & Outcomes
                                                 CHD 8 - % of patients with coronary heart disease whose measured
             Coronary Heart Disease              total cholesterol is 5mmol/l or less (17pts, 40-70% payment threshold)          74.6%


                                                 Stroke 12 - % of patients with stroke (non haemorrhagic) or history of
                 Stroke and TIA                  TIA who have a record that an anti-platelet agent or an anti-coagulant          90.0%
                                                 is being taken (4pts, 40-60% payment threshold)

                                                 BP5 - % of patients with hypertension in whom last blood pressure is
                  Hypertension                                                                                                   59.9%
                                                 150/90 or less (57pts, 40-70% payment threshold)

                                                 DM12 - % of patients with diabetes in whom the last blood pressure is
                                                                                                                                 74.8%
                                                 145/85 or less (18pts, 40-60% payment threshold)
                    Diabetes                     DM21 - % of diabetic patients who have a record of a retinol
                                                 screening in previous 15 months (5 pts, 40-90% payment threshold)               73.5%


                                                 EP7 - % of patients over 18 on drug treatment for epilepsy have a
                    Epilepsy                     record of a medication review involving patient and/or carer in                 72.0%
                                                 previous 15 months (4pts, 40-90% payment threshold)

                                                 SM4 - % of patients with any combination of following conditions;
                                                 CHD, Stroke or TIA, hypertension, diabetes, COPD, CKD, Asthma,
                                                 schizophrenia, bipolar or other psychoses who smoke, whose contain
                    Smoking                                                                                                      77.8%
                                                 a record that smoking cessation advice or referral to a specialist
                                                 service has been offered in previous 15 months (30pts, 40-90%
                                                 payment threshold)

                                                 PP1 - in those patients with a new diagnosis of hypertension, the % of
                                                 patients who have had a face to face cardiovascular risk assessment
            CVD - Primary Prevention                                                                                             47.6%
                                                 at the outset of diagnosis using an agreed risk assessment tool (8 pts,
                                                 40-70% payment threshold)

                                                 Increase the percentage of women breastfeeding their children at six
                  Breastfeeding                                                                                                  53.9%
                                                 to eight weeks to 60% - YTD as at Dec 09

                                                 % of patients aged 25 to 64 whose notes record that a cervical smear
                Cervical Screening               has been performed in the last 5 years (11pts, 40-80% payment                   81.6%
                                                 threshold)


                                                 % 1 yr olds immunised - DTaP/IPV/Hib - YTD as at Mar 10                        94.3%


                                                 % 2 yr olds immunised - Pneumococcal (PCV) - booster - YTD as at
                                                                                                                                82.9%
                                                 Mar 10


                                                 % 2 yr olds immunised - Hib/MenC (booster) - YTD as at Mar 10                  88.0%


                                                 % 5 yr olds immunised - Diph, tet, polio, pertussis - booster - YTD as
                                                                                                                                79.4%
             Childhood Immunisations             at Mar 10


                                                 % 2 yr olds immunised - MMR (primary course) - YTD as at Mar 10                83.6%


                                                 % 5 yr olds immunised - MMR - 1st & 2nd dose - YTD as at Mar 10                75.7%


                                                 % of females aged 12-13 who have completed a full course of
                                                 immunisation for HPV (i.e. three doses) - Results are for the 2008/09          72.9%
                                                 school year

Patient Safety
                                                 Number of incidents occurring at GP Practices - YTD to Mar 10
                    Incidents                                                                                                     38

                                                 Out of the number of incidents occurring at GP Practices, the number
                Medication errors                                                                                                  3
                                                 which relate to medication errors - YTD to Mar 10

                                                 Number of referrals of GPs to PDMG - YTD to Dec 09                        Data Not Available
   Performance Decision Making Group Referrals

                                                 Number of complaints received by GP Practices reported to the PCT -
                   Complaints                                                                                                   554.0%
                                                 YTD to Dec 09

                                                 CAS Alerts implemented by deadline date - alerts due for completion            58.0%
          Central Alerting System Alerts
                                                 between Oct 09 and Dec 09




   8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls                                                                                                     Page 6 of 7
                 Quality Dashboard - Year to Date to March 2010
                                                                                                                                Primary Care
                                                                                                                                        GPs

Patient Experience
                                                       Involving you in decisions about your care [Very good or good , 10%
                                                                                                                                         76%
                                                       n/a]
           GP Patient Satisfaction Survey
                                                       Treating you with care and concern [Very good or good, 2% n/a]
   Last time you saw a doctor at your GP surgery                                                                                         87%
    or health centre, how good was the doctor at
                each of the following:-                Did you have confidence and trust in the doctor you saw?
                                                                                                                                         96%
     (Patient SPACE selections) Latest results
                   available Q1/Q2
                                                       In general, how satisfied are you with the care you get at your GP
                                                                                                                                         92%
                                                       surgery or health centre? [Very or fairly satisfied]

                                                       In the last 6 months, how easy have you found getting through on the
                                                                                                                                         68%
                                                       phone? [Very easy or fairly easy, 10% n/a]

       GP Patient Satisfaction Survey Access           Were you able to see a doctor on the same day or in the next two
                                                                                                                                         79%
                    selections                         days the GP surgery or health centre was open? [Yes]

                                                       Were you able to get an appointment with a doctor more than 2 full
                                                                                                                                         72%
                                                       days in advance? [Yes]

                                                       Before you visited your GP, did you know that you now have a choice
                                                       of hospital that you can go to for your first hospital appointment?               47%
     Choice (Latest available data March 2009)
                                                       Were you offered a choice of hospital for your first hospital
                                                                                                                                         50%
                                                       appointment?

                                                       It was easy to get through to someone on the phone [Agree a lot /
                                                                                                                                         55%
                                                       agree a bit]

                                                       The receptionist was friendly and helpful [Agree a lot / agree a bit]
    Local real time tracking survey via handheld                                                                                         80%
   devices (Preliminary data from pilot tracking - 5
         practices - commenced during Q3)              I felt involved in decisions about my care [Agree a lot / agree a bit]
                                                                                                                                         75%

                                                       I am happy with my visit to the practice today [Agree a lot / agree a
                                                                                                                                         80%
                                                       bit]

                                                       Number of PALS enquiries received in relation to GP Practices -
                                                                                                                                          313
                                                       Concern - YTD to Mar 10

                                                       Number of PALS enquiries received in relation to GP Practices -
                                                                                                                                           4
                                                       Compliments - YTD to Mar 10
         Patient Advice and Liaison Service
                                                       Number of PALS enquiries received in relation to GP Practices -
                                                                                                                                          99
                                                       Information and Advice - YTD to Mar 10

                                                       Number of PALS enquiries received in relation to GP Practices -
                                                                                                                                           0
                                                       Suggestions - YTD to Mar 10

                                                       % Resolved within local resolution plan
                                                                                                                                  Data Not Available

                                                       % Satisfied with resolution
                     Complaints                                                                                                  7 complainants went to
                                                                                                                                the Ombudsman, we do
                                                                                                                                 not record satisfaction
                                                                                                                                    in other means. %




   8bbe744f-44a2-4f20-8330-22fe2f8faa01.xls                                                                                                                Page 7 of 7

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:65
posted:7/17/2011
language:English
pages:7