Our performance

The Trust aims to be open and honest about how it performs. Below is a selection of Key Performance Indicators with the latest available data:

A&E 4 Hour Wait
Cancer
Friends and Family
Infection
Mortality
Pressure Ulcers
Staffing Levels
Waiting Times

A&E 4 Hour Wait
Indicator Month Achievement Target Met or Failed
A&E 4 Hour Wait Target September 2018 Achievement 91.0% 95% FAILED
August 2018 Achievement 85.9% 95% FAILED
This indicator reports the percentage of A&E attendances where the patient spends four hours or less in A&E from arrival to transfer, admission or discharge. This is a measure against the national waiting time standard, for which the target is 95%.

  

Cancer
Indicator Month Achievement Target Met or Failed
Cancer: 2 Week cancer wait (GP Referral to outpatient appointment August 2018 Achievement (1 month arrears) 87.93% 93% FAILED

July 2018

Achievement (1 month arrears)

91.72% 93% FAILED
Cancer: 31 day diagnosis to treatment cancer target August 2018 Achievement (1 month arrears) 97.50% 96% ACHIEVED
July 2018 Achievement (1 month arrears) 97.10% 96% ACHIEVED
Cancer: 62 days urgent referral to treatment cancer target August 2018 Achievement (1 month arrears) 85.91% 85% ACHIEVED
July 2018 Achievement (1 month arrears) 85.91% 85% ACHEIVED

Cancer: 2 Week cancer wait (GP Referral to out-patient appointment)

This indicator reports the percentage of patients first seen within two weeks of an urgent GP / GDP referral for suspected cancer. The organisation's performance is measured against a national target of 93%. This indicator is reported 1 month in arrears.

Cancer: 31 day diagnosis to treatment cancer target

This indicator reports the percentage of patients receiving their first definitive treatment within one month of a cancer diagnosis. The organisation's performance is measured against a national target of 96%. This indicator is reported 1 month in arrears.

Cancer: 62 days urgent referral to treatment cancer target

This indicator reports the percentage of patients receiving their first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer. The organisation's performance is measured against a national target of 85%. This indicator is reported 1 month in arrears. 

  

Friends and Family
Indicator Month Achievement Target (Based on Latest National Achievement) Met or Failed
Friends and Family Test A&E Recommenders

September 2018 Achievement

83.0% 87% FAILED
August 2018  Achievement 82.7% 87% FAILED
Friends and Family Test Inpatient Recommenders (Including day cases) September 2018 Achievement 91.3% 95% FAILED
August 2018 Achievement 92.0% 95% FAILED

Friends and Family Test Recommenders A&E

The Friends and Family Test (FFT) is part of a national initiative requiring that patients are asked whether they would recommend the ward or department to their friends and family. The trust already has an established patient experience feedback process, but this national requirement asks the key question on which we will be compared with other hospitals across the UK.

The FFT question is: How likely are you to recommend our ward/Unit/Service to friends and family if they needed similar care or treatment? Answers chosen from the following options: Extremely likely; Likely; Neither likely nor unlikely; Unlikely, Extremely Unlikely or Don't know. The Trust has set a local target to encourage greater performance and therefore is an aspirational target to achieve. The score is worked out by taking the Proportion of respondents who would be extremely likely to recommend (response category: “extremely likely”)) MINUS Proportion of respondents who would not recommend (response categories: “neither likely nor unlikely”, “unlikely” & “extremely unlikely”) "Don't know" responses are omitted completely from the calculation. The Friends and Family Test gives patients the opportunity share their views of the care or treatment they have received providing us with valuable feedback. We use the feedback, alongside other information, to identify and tackle concerns at an early stage, improve the quality of care we provide, and celebrate our successes. Our FFT results are also published on NHS Choices allowing the public to compare us with other hospitals and assess whether we are improving over time. For more information on the Friends and Family Test, please visit www.nhs.uk/friendsandfamily.   

Friends and Family Test Recommenders Inpatient

The Friends and Family Test (FFT) is part of a national initiative requiring that patients are asked whether they would recommend the ward or department to their friends and family. The trust already has an established patient experience feedback process, but this national requirement asks the key question on which we will be compared with other hospitals across the UK.

The FFT question is: How likely are you to recommend our ward/unit/service to friends and family if they needed similar care or treatment? Answers chosen from the following options: Extremely likely; Likely; Neither likely nor unlikely; Unlikely, Extremely Unlikely or Don't know. The Trust has set a local target to encourage greater performance and therefore is an aspirational target to achieve. The score is worked out by taking the number of respondents who would recommend the service (response being “likely” or: “extremely likely”) against the total number of all types of responses. The Friends and Family Test gives patients the opportunity to share their views of the care or treatment they have received providing us with valuable feedback. We use the feedback, alongside other information, to identify and tackle concerns at an early stage, improve the quality of care we provide, and celebrate our successes. Our FFT results are also published on NHS Choices allowing the public to compare us with other hospitals and assess whether we are improving over time. For more information on the Friends and Family Test, please visit www.nhs.uk/friendsandfamily.  

  

Infection
Indicator Month Number Target Met or Failed
Infection: Clostridium Difficile (Trust acquired) September 2018  Number (Cumulative) 18 21 ACHIEVED

August 2018 Number (Cumulative)

16 19 ACHIEVED
Infection: MRSA Incidence September 2018 Number (Cumulative) 0 0

ACHIEVED

August 2018  Number (Cumulative) 0 0

Infection: Clostridium Difficile (Trust acquired) 

This indicator reports the number of incidences of Clostridium difficile in a calendar month as a cumulative figure per annum. The reporting of Clostridium Difficile rates is set by the SHA (as set out in Section B Part 8.5). By achieving our target, the organisation can demonstrate its standard of practice in relation to Control of Infection, links to quality of patient care and to managing its reputation as a healthcare provider. This can also affect the organisation's registration with the Care Quality Commission.

Infection: MRSA Incidence

This indicator reports the total number of new MRSA Bacteraemia in a calendar month cumulatively per annum. The organisation has a target of 0 new incidences per annum. By achieving this target, the organisation can demonstrate the standard of practice in relation to Control of Infection, links to quality of patient care and to managing its reputation as a healthcare provider. Non-achievement can also affect registration with the Care Quality Commission. 

 

Mortality
Indicator Month Achievement Target Met or Failed
Mortality: HMSR (Basket of 56 diagnosis groups) June 2018 Achievement (3 months in arrears) 98.28 Relative Risk Within Expected
May 2018 Achievement (3 months in arrears) 98.24 Relative Risk

Within Expected

Mortality: SHMI

March 2018 Reporting Period

113.33 Relative Risk Higher than Expected
February 2018 Reporting Period 113.33 Relative Risk Higher than Expected

Mortality: HMSR (Basket of 56 diagnosis Groups)

HMSR stands for Hospital Standardised Mortality Ratio. This indicator reports the comparison of the number of expected deaths (denoted by 100) with the number of actual deaths. This indicator reports the comparison of the number of expected deaths with the number of actual deaths. The data are based on the diagnoses that lead to 80 per cent of all deaths and are adjusted for factors statistically associated with hospital death rates. The trust has a target of 100 or below. This indicator is reported three months in arrears.

Mortality: SHMI

SHMI stands for Summary Hospital-Level Mortality Indicator. The indicator reports how many deaths would be expected to occur if the organisation were like the national average at that point in time (denoted by 100). This indicator reports how many deaths would be expected to occur if the organisation were like the national average at that point in time. The SHMI model takes into account a number of factors such as differences in age, sex, diagnosis, type of admission and other diseases (co-morbidity). The organisation has a target of 100 or below. This indicator is reported quarterly, six months in arrears. 

 


Pressure Ulcers
Indicator Month Achievement Target Met or Failed

Pressure Ulcers Grade 3 

 

Pressure Ulcers Grade 4

August 2018 (Number)

July 2018 (Number)

2

0

1

1

FAILED

August 2018 (Number)

July 2018 (Number)

0

0

0

0

ACHIEVED

Pressure Ulcers Grade 3 & 4

This indicator reports the number of incidences of grade 3 and 4 avoidable pressure ulcers acquired by in patients in the care of the organisation in the calendar month. Monitoring this will encourage best practice in prevention and management for all patients at risk of developing pressure ulcers. 

 


Staffing Levels
Indicator Month Achievement Target Met or Failed
Safer Staffing Levels September 2018 Achievement 104.23% 100% ACHIEVED
August 2018 Achievement 102.99% 100% ACHIEVED

Staffing Levels

Target levels of staffing are specified for every ward and every shift. This overall percentage takes the total target number of staff and against the total actual number of staff who worked. Targets are specified by the Trust. It is possible to see a value over 100% if staffing levels were above the target. This link provides a breakdown of the staffing levels on each ward.

 

Waiting Times
Indicator Month Achievement Target Met or Failed

Waiting Times: Percentage of Patients Currently Waiting Less than 18 Weeks to Start Treatment

August 2018 Achievement (1 month arrears) 83.5% 92% FAILED
July 2018 Achievement (1 month arrears) 84.3% 92% FAILED

Waiting times: Percentage of incomplete patients seen within 18 weeks

This indicator reports the percentage of patients on incomplete pathways within 18 weeks against the total number of patients on an incomplete pathway as at the end of a calendar month. The organisation's performance is measured against a target of 92%.