item - moorfields eye hospital · the neuro ophthalmology doctor saw the patient again on the 8th...

Item

Reference documents that are not attached

(e.g. previous reports or appendices)

List of attached appendices (if applicable)

State impact on corporate priorities

The report uses a number of mechanisms to put performance in context, showing achievement against target, in comparison to previous

periods and as a trend. The first section of the document also contains an exception report which explains the current position with those

indicators which fall short of target and outlines the corrective action being taken to improve that position.

Action Required/Recommendation (for information), (for decision)

The report is primarily for information purposes but will inform discussion regarding how the Trust is performing against its Operational

measures. This may in turn generate subsequent action.

State impact on CQC domain (if applicable)

Prepared by

This report will reflect, in performance terms, progress in meeting a range of the corporate

priorities.

Not Applicable

Not Applicable

Brief Summary of Report

This report highlights a series of metrics regarded as the Key Indicators of Operational Performance. They cover a variety of activities

covering including the management of Referral to Treatment waiting times, Accident & Emergency accessibility, cancer treatment, access

to services, efficiency (including activity levels, attendance and cancellation rates and journey times), effectiveness and safety measures,

patient feedback and information relating to staffing levels.

Report to Trust Board – 30/06/2016

Operational Performance Report - May 2016

John Quinn, Director of Operations

Stephen Chinn, Senior Performance Analyst (Produced on 23/06/2016)

This report will encompass all five key CQC domains/questions.

Report from

Report Title

Board of Directors Operational Performance Report - May 2016

Exception Report Pages 2 - 4

Compliance Performance Summary Page 5

Access - Referral to Treatment Pages 6 - 7

Access - A&E Pages 8 - 9

Access - Cancer Waiting Times Page 10

Access - Other Page 11

Efficiency Pages 12 -13

Effectiveness Page 14

Safety Page 14

Ward Staffing Levels Page 15

Patient Experience Page 16

Bank and Agency Staff Information Page 17

CONTENTS

Page 1


Exception Report - May 2016

RTT Performance

Please note since the last report April's RTT figures were finalised, which followed further validation. The only significant change was to the Non-admitted Performance, increasing from 95.7% to 96.1%.

18 weeks Referral to Treatment - Incomplete Performance (All Pathways) again continues to improve, with May 2016 reaching a highest recorded performance of 98.1% (M1 (Apr 2016): 97.9%), so remaining well above the 92% target which has not been breached since August 2014.

18 weeks Referral to Treatment -Incomplete (Pathways with DTA) also recorded a new highest performance level of 93.9%, up from 92.6% in April.

18 weeks Referral to Treatment - Admitted Performance saw an increase to 89.2% from 87.4% in April, while 18 weeks Referral to Treatment - Non-Admitted Performance also increased to 97%. For both these measures, the change of emphasis in RTT18 reporting on current long waiters and closing their pathways means this would have an adverse effect on closed pathway performance as the pathways of longer waiting patients are closed.

However there was one 52 week non-admitted breaches reported in May. This breach occurred as patient who was being treated under the Neuro Ophthalmology service was referred to Adnexal and Glaucoma on 8th May 2015, this would have started two new RTT pathways. The referrals were made on PAS but missed by the booking office, however no internal referral letters were written. The patient returned to Neuro Ophthalmology in December 2015 and told the doctor that he had not received an appointment from the adnexal or Glaucoma service. The patient was referred to both services again. The patient was seen on May 9th 2016 in the Glaucoma service and treated, however the adnexal referral was not actioned. The Neuro Ophthalmology doctor saw the patient again on the 8th April 2016 and noted that the patient has still not had an appointment in the adnexal service and wrote a referral letter. The delay this patient had experienced was identified by the validation team and the patient’s appointment was brought forward to 24th May. The adnexal consultant completed a clinical harm review and identified that the patient had experienced low harm which was mainly discomfort and discharged the patient. Accident and Emergency

Monthly A&E performance was at 97.3% within four hours as per national guidance. This is an increase from the 96.3% position in April 2016 and remains above the 95% four hour target. Out of the 31 days in May we failed to achieve the 95% target on 4 occasions, with performance failing below 90% on 2 of these days. There were zero 12 hour breaches reported, but there was an increase in the number of six hour breaches for the month due to a single low performing day where 20 breaches were recorded. The total recorded for the month was 24. Three hour performance also fell to 74.9% (M1: 77.0%), below the 80% target

Overall A&E monthly Activity was at 9,140 which is a slight decrease (-0.7%) compared to May 2015. There was a drop in ‘working day’ activity with 321 patients per day seen compared to 328 last month and 343 in May 2015, however weekend and bank holiday activity remains higher at 226 per day, a slightly increase compared to both the previous month and year.

Page 2


Exception Report - May 2016 (Continued)

Accident and Emergency (Cont.)

As part of a regular review of A&E metrics, the department found that the calculation method for the % of patients re-attending A&E within 7 days was not in line with national guidance. The historic method of calculating A&E re-attendances within 7 days used the 'Attendance Category' exclusively (whether the attendance was planned or unplanned) to determine the patient’s status. The guidance uses a more conservative method that assumes anyone not listed as planned who re-attends in 7 days to be an unplanned re-attendance. This does not mean that our re-attendance rate has increased, but is a reflection of a change in methodology. Compared to recent years, under this method the re-attendance rate has been decreasing, with financial year 2015/16 being 6.9%. The re-attendance rate for May was at 6.5%, a slight increase from 6.3% recorded in April.

Cancer Performance

There were no 2 week, 31 or 62 days breaches reported in May 2016.

There were five ‘2 week waits - first appointment urgent GP referral’ cases, with the YTD just short of the 93% performance target at 92.9%.

There was 12 'Cancer 31 day wait - diagnosis to first appointment’ cases with performance above the 96% target at 97.4%. There were two cases within the 'Cancer 31 day wait - subsequent treatment’ category so YTD performance is at 100%, There were no 62 day cases reported so the YTD also remains at 100%.

NHS England requires that all referrals of suspected cancers from whatever source will be seen by a senior doctor within 14 days, with a target of 93%. This continued to be below the 93% at 83.8% with 13 breaches from 80 cases. The YTD position is at 84.1%.

ASI Performance for E-Referral (Previously Choose and Book)

We have recently received Monthly ASI data from the E-Referral system for the previous financial year. For the financial year 2015/16 performance (percentage of successful electronic bookings) was at 78.2% against a 96% target. Of these, 21.1% of bookings failed due to slot unavailability (no capacity) while a further 0.8% failed due to system unavailability. At this time we are unable to report on this year's performance (April and May 2016) due to ongoing reporting functionality development by the national E-Referral development team.

Outpatient and Admission Activity

Following on from the last financial year, outpatient activity continues to be higher with overall activity against at its highest ever average level with 2,209 attendances per working day. Compared to May 2015, first appointment activity was up 5.6% and follow up activity is up 2.8%.

Admission activity saw a slightly drop to an average of 147 admissions every working day, which is down on both the previous four months and May 2015 by 3.2%

Page 3


Exception Report - May 2016 (Continued)

Outpatient DNA rates

First appointment DNA rates remain high at 13.4% (M1: 13.3%), while follow up DNA rates are at 11.7% (M1: 11.4%). Cost improvement programmes are being implemented to address this across a number of sites.

Theatre Cancellations Performance

The theatre cancellation rate remains stable at 8.0% (M1: 8.1%). As previously reported the Trust has now recruited a member of staff to telephone all pre-admissions one week prior to admission and this indicator should therefore continue to improve.

Theatre Sessions Starting Late

Performance for May continues to deteriorate and is now at 44.3% compared to 41.9% in March. The Trust performance level for this indicator is heavily influenced by the performance at City Road and analysis recently produced has identified the key reasons for City Road theatre sessions starting late and these vary depending upon whether the session starts in the morning or afternoon. The two key reasons for morning late starts are a) Surgeon unavailable due to clerking patients and b) Anaesthetist Seeing Patients / Pre-meds. Key reasons for sessions starting late during afternoon sessions are a) Previous List Over Ran and b) Surgeon Unavailable Clerking Patients. These issues will be addressed as part of the Theatre Improvement Programme.

Ward Staffing Levels

From May 2016, to provide a single consistent way of recording and reporting deployment of staff working on inpatient wards/units, a new measure has been adopted called Care Hours per Patient Day (CHPPD).

CHPPD is calculated by adding the hours of registered nurses to the hours of healthcare support workers and dividing the total by every 24 hours of in-patient admissions (or approximating 24 patient hours by counts of patients at midnight)

CHPPD reports split out registered nurses and healthcare support workers to ensure skill mix and care needs are met.

Page 4


COMPLIANCE PERFORMANCE SUMMARY

Threshold May-16YTD

2016/17

Monthly

TrendSource Threshold May-16

YTD

2016/17

Monthly

TrendSource

≥ 92% 98.1% 98.0% CQC, Monitor,TDA ≥ 99% 100% 100% CQC, TDA

n/a 93.9% 93.3% CQC, Monitor,TDA n/a 90.9% 91.2% Local

≥ 90% 89.2% 88.3% Local from October

2015≥ 96% n/a n/a w Local

≥ 95% 97.0% 96.5% Local from October

20150 0 0 CQC, TDA

n/a 11,052 22,289 CQC, Monitor,TDA n/a 5.3% 4.8% Monitor

0 0 0 CQC, Monitor,TDA n/a 5.8% 5.2% CQC, TDA, Outcomes

Framework

0 0 0 CQC, Monitor,TDA n/a 57.6% 58.0% Local

0 1 1 CQC, Monitor,TDA 0 0 0 CQC, Monitor,TDA

≥ 95% 97.3% 96.8% CQC, Monitor,TDA 0 0 0 CQC, Monitor,TDA

≥ 80% 74.9% 75.9% Local ≥ 95% 99.0% 99.1% CQC, TDA

≤ 5% 2.8% 2.7% CQC, TDA 0 0 11 Local From Nov

2015

≥ 30% 23.6% 23.7% Local ≥ 20% 18.1% 13.8% CQC,TDA, Outcomes

Framework

≤ 5% 6.5% 6.4% CQC, TDA ≥ 30% 61.2% 61.3% CQC,TDA, Outcomes

Framework

≥ 93% 100.0% 92.9% CQC, Monitor,TDA ≥ 15% 14.0% 12.5% Local

≥ 93% 83.8% 84.1% CQC, Monitor,TDA n/a 99.1% 98.6% CQC, TDA

≥ 96% 100.0% 97.4% CQC, Monitor,TDA

≥ 94% 100.0% 100.0% CQC, Monitor,TDA

≥ 85% n/a 100.0% w CQC, Monitor,TDA

Key Reference:

% Cancer 31 day waits - subsequent

treatment

% Cancer 62 days from urgent GP

referral to first definitive treatment

Within tolerance and drop in figures

On or above target

Stable on/above target

On target and drop in figures

Within tolerance and stable

Within tolerance and rise in figuresBelow target and rise in figures

Below target and stable

Below target and fall in figures

No target or N/Aw

% Cancer 31 day waits - diagnosis to

first appointment

Left without being seen

A&E ENP Pathway

A&E Unplanned Re-attendance

Friends & Family Test - Outpatients

(Response Rate - Estimated)

Number of Mixed Sex

Accommodation Breaches

Friends & Family Test - Inpatients

(Response Rate)

Friends & Family Test - A&E

(Response Rate)

% Cancer 14 Day Target - NHS

England Referrals (Ocular Oncology)

Ward Staffing Levels

(Inpatient Wards Only)

* Figures are provisional

52 Week RTT Breaches - Non

Admitted *Number of MRSA cases

Outpatient appointment - Over 6

week waiters

% Cancer 2 week waits - first

appointment urgent GP referral

52 Week RTT Breaches - AdmittedGP referrals first outpatient using

Choose & Book

VTE Screening - all admissionsA&E Three Hour Performance

A&E Four Hour Performance Number of C.Diff cases

Emergency Readmissions within 30

days of discharge52 Week RTT Breaches - Incomplete

Performance 2016/17Performance 2016/17

18 weeks Referral to Treatment -

Incomplete With DTA

Emergency Readmissions within 28

days of discharge


Admitted

Indicator Indicator


Incomplete

Cancelled Operations - 28 Days Re-

Book *

18 weeks Referral to Treatment - Non

Admitted

New RTT Periods (Clock Starts) - All

Patients

Choose & Book Appointment

Availability

Diagnostic waiting times - 6 weeks

Page 5


18 Weeks Referral to Treatment

Year End YTD

Current

Month

Previous

Month Qtr1 Qtr2 Qtr3 Qtr4 YTD

≥ 92% 94.7% 94.1% 98.1% 97.9% 98.0% n/a n/a n/a 98.0% Monitor, CQC, TDA

n/a 89.0% n/a 93.9% 92.6% 93.3% n/a n/a n/a 93.3% Monitor, CQC, TDA

≥ 90% 88.9% 90.7% 89.2% 87.4% 88.3% n/a n/a n/a 88.3% Local from October 2015

≥ 95% 96.3% 96.8% 97.0% 96.1% 96.5% n/a n/a n/a 96.5% Local from October 2015

n/a 66,658 n/a 11,052 11,237 22,289 n/a n/a n/a 22,289 Monitor, CQC, TDA

Year End YTD

Current

Month

Previous


0 2 1 0 0 0 n/a n/a n/a 0 Monitor, CQC, TDA

N/A 15,683 2,872 461 507 968 n/a n/a n/a 968 Local

N/A 7,917 1,050 1,468 1,385 2,854 n/a n/a n/a 2,854 Local

0 0 n/a 0 0 0 n/a n/a n/a 0 Monitor, CQC, TDA

N/A 2,372 n/a 219 262 481 n/a n/a n/a 0 Local


N/A 3,454 463 282 361 643 n/a n/a n/a 643 Local

N/A -335 36 -21 -74 -94 n/a n/a n/a -94 Local


N/A 3,181 421 228 299 527 n/a n/a n/a 527 Local

N/A 1,139 230 146 84 231 n/a n/a n/a 231 Local

* Incomplete (Pathways with DTA) & New RTT Periods: YTD from October 2015 as figures prior to this date not available at this time

Compliance Source

Patients Waiting >18 weeks

18w(92%) Shortfall/Surplus

Monthly

Trend

Monthly

TrendThreshold

Performance 2016/17

Threshold

Performance 2016/172015/16

2015/16

52 Week RTT Breaches

Compliance Source

Trust Total

18 weeks Referral to Treatment -Incomplete

(Pathways with DTA) *

18 weeks Referral to Treatment - Admitted

Indicator




Indicator

18 weeks Referral to Treatment -Incomplete (All

Pathways)

Admitted

18 weeks Referral to Treatment -Non Admitted

New RTT Periods - All Patients *



52 Week RTT BreachesIncomplete

(Pathways

with DTA) * Patients Waiting >18 weeks


Non Admitted

Incomplete

(All Pathways)

Page 6


18 Weeks Referral to Treatment (Provisional) (Cont.)

Trust Total

Page 7


Year End YTD

Current

Month

Previous


N/A103,922 17,865 9,140 8,905 18,045 n/a n/a n/a 18,045

N/A99,313 16,741 9,532 9,464 18,996 n/a n/a n/a 18,996

≥ 95% 97.5% 97.6% 97.3% 96.3% 96.8% n/a n/a n/a 96.8% CQC, Monitor, TDA

≥ 80% 78.1% 75.2% 74.9% 77.0% 75.9% n/a n/a n/a 75.9% Local

N/A 2469 390 243 320 563 n/a n/a n/a 563

N/A 139 0 24 16 40 n/a n/a n/a 40

≤ 5% 2.5% 2.6% 2.8% 2.7% 2.7% n/a n/a n/a 2.7% CQC, Monitor, TDA

≤ 60 mins 30 30 46 42 42 n/a n/a n/a 42 CQC, TDA



≥ 30% 22.3% 23.9% 23.6% 23.8% 23.7% n/a n/a n/a 23.7% Local

≤ 5% 0.4% 0.3% 6.5% 6.3% 6.4% n/a n/a n/a 6.4% CQC, TDA

A&E Three Hour Performance

Time to Treatment in Department - median

Total number of 4 hour breaches

Total number of 6 hour breaches

Left without being seen

Total time spent in A&E -Admitted 95th Percentile

Total time spent in A&E - Non Admitted 95th

Percentile

A&E Unplanned Re-attendance

A&E ENP Pathway

Compliance Source

2015/16

Monthly

Trend

A&E Four Hour Performance

Threshold

Performance 2016/17

Total number of Arrivals in A&E

Accident & Emergency

Indicator

Total number of Expected Arrivals in A&E

Page 8


Accident & Emergency (Cont.)

The changes to the % Unplanned Re-attendance has been explained in the Exception report. Due to the change in process the unplanned re-attendance graph has been removed as only April

and May figures are available.

Percentage of patients treated by an ENP (emergency nurse practitioner) and those who left A&E before treatment remains stable.

The large number of 6 hr + breaches can be linked closely to the increasing pressure experienced by the A&E department - these long breaches occur overnight, where capacity is limited, and

periods of high activity which overwhelm the available resources. The increased level of activity (approximately 6 - 8% per year) correspond to an increased risk of both 4 hour and 6 hour +

breaches occurring.

Page 9


Cancer Waiting Times

Year End YTD

Current

Month

Previous


Cases 67 5 5 9 14 n/a n/a n/a 14 ≥ 93% 91.0% 100.0% 100.0% 88.9% 92.9% n/a n/a n/a 92.9% Cases 701 0 80 84 164 n/a n/a n/a 164 ≥ 93% 81.3% n/a 83.8% 84.5% 84.1% n/a n/a n/a 84.1% Cases 164 0 12 27 39 n/a n/a n/a 39 ≥ 96% 91.5% n/a 100.0% 96.3% 97.4% n/a n/a n/a 97.4% Cases 29 3 2 4 6 n/a n/a n/a 6 ≥ 94% 89.7% 100.0% 100.0% 100.0% 100.0% n/a n/a n/a 100.0% Cases 2 0 0 2 2 n/a n/a n/a 2 ≥ 85% 100.0% n/a n/a 100.0% 100.0% n/a n/a n/a 100.0%

Cases 42 2 2 7 9 n/a n/a n/a 9 ≥ 93% 85.7% 100.0% 100.0% 85.7% 88.9% n/a n/a n/a 88.9% Cases 150 0 12 25 37 n/a n/a n/a 37 ≥ 96% 90.7% n/a 100.0% 96.0% 97.3% n/a n/a n/a 97.3% Cases 15 0 2 1 3 n/a n/a n/a 3 ≥ 94% 86.7% n/a 100.0% 100% 100.0% n/a n/a n/a 100.0% Cases 0 0 0 2 2 n/a n/a n/a 2 ≥ 85% n/a n/a n/a 100.0% 100.0% n/a n/a n/a 100.0%

Cases 25 3 3 2 5 n/a n/a n/a 5 ≥ 93% 100.0% 100.0% 100.0% 100.0% 100.0% n/a n/a n/a 100.0% Cases 14 0 0 2 2 n/a n/a n/a 2 ≥ 96% 100.0% n/a n/a 100.0% 100.0% n/a n/a n/a 100.0%

Cases 14 3 0 3 3 n/a n/a n/a 3 ≥ 94% 92.9% 100.0% n/a 100.0% 100.0% n/a n/a n/a 100.0%

Cases 2 0 0 0 0 n/a n/a n/a 0 ≥ 85% 100.0% n/a n/a n/a n/a n/a n/a n/a n/a

CQC, Monitor, TDA

CQC, Monitor, TDA

CQC, Monitor, TDA

CQC, Monitor, TDA

Compliance SourceIndicator

Cancer 31 day waits - diagnosis to first

appointment

Cancer 2 week waits - first appointment urgent GP

referral

Threshold

Performance 2016/17

Monthly

Trend

2015/16

% Cancer 14 Day Target - NHS England Referrals

(Ocular Oncology)

Cancer 31 day waits - subsequent treatment

Cancer 62 days from urgent GP referral to first

definitive treatment

Ocular Oncology (Brain and Nervous System Tumours - see above for 14 Day Performance)


referralCQC, Monitor, TDA


appointmentCQC, Monitor, TDA

Cancer 31 day waits - subsequent treatment CQC, Monitor, TDA

Cancer 31 day waits - subsequent treatment

CQC, Monitor, TDA


appointmentCQC, Monitor, TDA

CQC, Monitor, TDA

CQC, Monitor, TDA


definitive treatmentCQC, Monitor, TDA


definitive treatmentCQC, Monitor, TDA

Skin Cancer


referral

Page 10


Year End YTD

Current

Month

Previous


≥ 99% 100% 100% 100% 100% 100% n/a n/a n/a 100% CQC, TDA

TBA 89.1% 86.0% 90.9% 91.5% 91.2% n/a n/a n/a 91.2% Local

TBA 23.3% 19.1% 21.2% 22.4% 21.8% n/a n/a n/a 21.8% Local

≥ 96% 78.2% 84.7% n/a n/a n/a n/a n/a n/a n/a Local

N/A 21.1% 13.5% n/a n/a n/a n/a n/a n/a n/a Local

N/A 0.8% 1.8% n/a n/a n/a n/a n/a n/a n/a Local

Access - Other (Cont.)

* April and May 2016 Electronic Booking Figure unavailable (See notes below)

Electronic Booking System Issue Rate

Indicator Threshold

Monthly

Trend

2015/16 Performance 2016/17

Diagnostic waiting times Performance remains at 100%.

The percentage of patients both waiting more than 6 weeks for a first appointment and waiting for admission within 13 weeks have seen a slight decrease compared to the previous month.

We have recently received Monthly ASI data from the E-Referral system for the previous financial year. For the financial year 2015/16 performance (percentage of successful electronic

bookings) was at 78.2% against a 96% target. Of these, 21.1% of bookings failed due to slot unavailability (no capacity) while a further 0.8% failed due to system unavailability. At this time we

are unable to report on this year's performance (April and May 2016) due to ongoing reporting functionality development by the national E-Referral development team.

Electronic Booking Capacity Issue Rate

First Outpatient Appointment Waiting more than 6

weeks

Patients Waiting more than 13 weeks for

Admission

Diagnostic waiting times - 6 weeks

Electronic Booking appointment availability

Access - Other

Compliance Source

Page 11


Year End YTD

Current

Month

Previous


N/A 116,152 18,058 9,674 9,863 19,537 n/a n/a n/a 19,537 Local

N/A 412,446 65,960 34,507 36,409 70,916 n/a n/a n/a 70,916 Local

N/A 10.9% 10.9% 11.2% 11.6% 11.4% n/a n/a n/a 11.4% Local

N/A 12.7% 11.8% 13.4% 13.3% 13.3% n/a n/a n/a 13.3% Local

N/A 12.1% 11.9% 11.7% 11.4% 11.5% n/a n/a n/a 11.5% Local

N/A 58.1% 56.4% 59.7% 57.7% 58.7% n/a n/a n/a 58.7% Local

N/A 71.2% 70.5% 67.7% 67.6% 67.6% n/a n/a n/a 67.6% Local

N/A 36,956 6,002 3,201 3,238 6,439 n/a n/a n/a 6,439 Local

N/A 35,864 5,813 2,936 3,209 6,145 n/a n/a n/a 6,145 Local

N/A 7.8% 6.7% 8.0% 8.1% 8.1% n/a n/a n/a 8.1% Local

N/A 35.8% 34.5% 44.3% 41.9% 43.1% n/a n/a n/a 43.1% Local

0 1 0 0 0 0 n/a n/a n/a 0 CQC, TDA

Monthly

Trend

Compliance

Source

Performance 2016/17

Threshold

Cancelled Operations - 28 Days Re-Book

(Provisional - submitted quarterly)

2015/16

Efficiency

Trust Total

Outpatient DNA rate

- First Appointment

Theatre Sessions Starting Late

Clinic Journey Times Less Than 2 Hours

- Outpatient First Appointment

Clinic Journey Times Less Than 2 Hours

- Outpatient Follow Up Appointment

Outpatient DNA rate

- Follow Up Appointment

Theatre Cancellation Rate

Admission Demand

- Decision to Admit (DTA)

Admission Activity

Outpatient Cancellations

Outpatient Total Attendances

- First Appointment

Outpatient Total Attendances

- Follow Up Appointment

Page 12


Key: :4 Month Average

Efficiency (Cont.)

:Monthly Trend

Page 13


Effectiveness

Year End YTD

Current

Month

Previous


N/A 4.0% 5.0% 5.3% 4.2% 4.8% n/a n/a n/a 4.8% Monitor

Cases 115 24 13 10 23 n/a n/a n/a 23

N/A 4.2% 5.4% 5.8% 4.6% 5.2% n/a n/a n/a 5.2% CQC, TDA

Cases 121 26 14 11 25 n/a n/a n/a 25

N/A 51.8% 57.2% 57.6% 58.3% 58.0% n/a n/a n/a 58.0% Local

Safety

Year End YTD

Current

Month

Previous


0 0 0 0 0 0 n/a n/a n/a 0 CQC, TDA,

Monitor

0 0 0 0 0 0 n/a n/a n/a 0 CQC, Monitor,

TDA

≥ 95% 98.4% 98.7% 99.0% 99.2% 99.1% n/a n/a n/a 99.1% CQC, TDA

0 32 3 0 11 11 n/a n/a n/a 11 Local From

Nov 2015

Compliance

SourceThresholdIndicator

VTE Screening

Mixed Sex Accommodation

There were no MRSA or C.Diff Cases recorded at Moorfields this financial year.

VTE Screening Performance remains above the 95% target.

Following a review of the Mixed Sex Accommodation guidance and further confirmation from DoH, Moorfields are now exempt from submitting MSA breaches as the number of overnight

beds at our sites are less than the required standard to submit (10 beds per site), however any MSA breaches are still monitored locally.

Monthly

Trend

2015/16

Number of C.Diff cases

Performance 2016/17

Number of MRSA cases

Monthly

Trend

Compliance

Source

Performance 2016/172015/16

% GP referrals From Electronic Booking (Choose & Book

/E-referrals)

Indicator Threshold

Emergency Re-admission within 28 days of discharge

Emergency Re-admission with 30 days for elective and

emergency cases

Page 14


Ward Staffing Levels (Only 'wards with inpatient beds' as per report requirement)

From May 2016, to provide a single consistent way of recording and reporting deployment of staff working on inpatient wards/units, a new measure has been adopted called Care Hours

per Patient Day (CHPPD).

• CHPPD is calculated by adding the hours of registered nurses to the hours of healthcare support workers and dividing the total by every 24 hours of in-patient admissions (or

approximating 24 patient hours by counts of patients at midnight)

• CHPPD reports split out registered nurses and healthcare support workers to ensure skill mix and care needs are met.

The overall fill rate was 99%, which is up 3% from April’s overall fill rate figure.

Obs Bay fill rate remains slightly lower than normal (90%) – there is a member of staff on maternity leave, and a small number of days lost to sickness and carer’s leave, which is reasonably

in line with the hours lost.

There was a drop in St George’s day nurse staffing fill rate (93%, from 99% the previous month) – this appears to be due to a combination of leave and study leave resulting in lower than

planned hours taking place.

Cumberlege had over 100% fill rate for day and night nurse staffing fill rates (110% and 131% respectively) – the overall hours were similar to the previous month, however the planned

hours were lower than previously. The majority of the additional hours came from temporary or bank staff, which suggests that these were additional hours put on in response to short

term demand.

Page 15


Patient Experience - Friends and Family Test (FFT)

The scoring system is represented as a simple percentage method, where patients who are ‘Extremely likely’ or ‘Likely’ to recommend Moorfields to friends and family are listed as ‘Would

Recommend’ the hospital, and patients who are ‘Unlikely’ or ‘Extremely Unlikely’ to recommend Moorfields are listed to ‘Would Not Recommend’ the hospital.

The eligible patient population includes under-16’s in all categories.

The ‘Inpatient’ FFT responses include ‘day case’ patients as well as patients who stayed overnight, which has increased the number of results received in this category.

The ‘outpatient’ FFT scores and response rates are also included in this report, covering most patients who attended an outpatient clinic.

Accident and Emergency FFT response rate method remains unchanged from last year (aside from the aforementioned inclusion of under-16s).

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Nursing Bank and Agency Staff Information

Proportion of Nursing Bank and Agency Staff Hours filled, with total hours worked

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