Agenda Item 12.5

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Integrated Healthcheck and Staffing Paper

Public Board Meeting

23 May 2019

Presented for: Governance

Presented by: Lisa Grant, Chief Nurse

Author: Breeda Columb, Head of Nursing, Professional Practice Katie Robinson, Head of Nursing, Workforce and Education

Previous Committees: NONE

Key points

1. 8 wards in escalation in March including 3 wards in 3rd stage For Information

2. 40 wards and departments have been presented with green/silver certificates for excellence in metrics scores

For information

3. No red rated wards in April 2019 on the Heathcheck Metrics For Information

4. NSSR system expanded to include weekends

For Information

5. Development of a new staffing establishment tool

For Information

6. Pilot to commence in May 2019 to test new SafeCare e-roster deployment tool

For information

Trust Goals

The best for patient safety, quality and experience ✓

The best place to work ✓

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability ✓

Agenda Item 12.5

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1. Summary

The Integrated Healthcheck and Staffing Paper, provides a review of nursing, midwifery and perioperative

staffing and Ward Healthcheck data for the period March and April 2019.

This paper reports on a number of staffing metrics and presents performance across a number of domains

and considers this in the context of staffing, recruitment and ward/department performance within

Healthcheck domains.

2. Background

Safe levels of nurse, midwifery and theatre staffing are essential for the delivery of quality patient care.

Actual nurse establishments are calculated using a range of data with staffing updates submitted nationally

each month incorporating both substantive LTHT staff and additional temporary staff (bank and agency).

The ward/department Healthcheck provides a systematic overview of performance across a range of key

areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in

LTHT. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic

picture.

3.0 Nursing and Midwifery Staffing

The LTHT Nursing, Midwifery and AHP Workforce Group (NMAWG) held its first meeting in March 2019,

the primary focus of the meeting was to scope and design a new LTHT staffing review tool and guidance.

The new staffing review tool will utilise evidence based indicators in conjunction with professional judgement

to provide assurance in relation to Nursing and Midwifery staffing levels.

3.1 Establishment reviews

The Chief Nurse has requested to meet with each ward area to review the agreed staffing plans set during

the 19/20 establishment review process. The meetings will commence in May 2019 and will test the new

LTHT staffing review tool. The findings of the review will be presented to the Board through future staffing

papers.

3.2 LTHT Operational Processes to support staffing

The purpose of the Nurse Staffing Status Report (NSSR) is to provide assurance in relation nurse staffing.

Weekly reports from NSSR continue to be reviewed at the Trust weekly quality meeting chaired by the

Chief Nurse or Chief Medical Officer. The purpose of the report is to highlight any clinical area that reports

its status as Amber for 100%, Red for 50% or greater of the shifts in one week or any area that has rated

itself Blue at any time.

The NSSR has increased its scope to now include weekend submissions since the 23rd March. The

escalation process and monitoring remains the same. At implementation some IT issues were identified in

relation to access which has now been resolved.

The Trust has had approval to trial a proof of concept with the Allocate Safe Care module (e-roster

deployment tool). The proof of concept will commence on five wards within the cardio-respiratory CSU in

May 2019. This will be supported by the workforce systems team and a clinical project lead from

corporate nursing.

Agenda Item 12.5

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3.3 Nursing and Midwifery Staffing Return (Hard Truths)

The Trust reports nurse staffing numbers including registered, unregistered, substantive and temporary to

NHS England via a monthly Nurse Staffing Return (Hard Truths) for 87 inpatient areas. The hard truths data

also contains a breakdown of planned care hours per patient day (CHPPD) against actual CHPPD achieved.

Appendix 1 provides a trend report of CHPPD by registered and unregistered staff over the last 12 months.

The figures in Appendix 2 show the number of areas where actual staffing hours available fell below 80%

of the current plan of staffing hours on the roster.

• Number of clinical areas that reported staffing levels lower than the current 80% threshold: 18 in

February 2019 and 19 in March 2019

Data also portrays actual staffing levels of greater than 130% against planned levels for unregistered staff

in many areas. These higher than planned levels are due to the deployment of unregistered staff to mitigate

risk for registered nursing shortfalls and to deliver enhanced care for patients identified as at risk.

3.4 Temporary staffing

Temporary staffing, bank and agency workers continue to be used across the Trust to support safe staffing

provision. Since January 2019 there has been an increase in fill rate by registered staff over Q4 which is

the highest it’s been in the last 6 months.

Figure 3 Total Bank and Agency hours (Registered and Unregistered)

We do not expect to see significant reduction in overall temporary staffing use due to a purposeful drive to

move LTHT staff towards working Bank in order to qualify for incentive schemes, and to support back fill

requirements for apprentice nurses and trainee nursing associates whilst undertaking education or

supernumerary placements.

3.6 Recruitment

Agenda Item 12.5

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LTHT continues to recruit band 5 registered midwives, nurses and operating department practitioners with

regular advertising and open days throughout the Trust. Interviews are often offered on the day and offers

of employment targeted at third year student nurses. Band 2 Clinical Support Worker (CSW) and apprentice

Clinical Support Workers (ACSW) remains consistent with regular planned assessment centres provided

throughout the year.

Breakdown of recruitment activity for March and April 2019

• Band 5 Registered Nurses cohort - 169 WTE

• Band 2 Clinical Support Workers - 21 WTE

• Band 2 Apprentice Clinical Support Workers - 79 WTE

• ODP - 14 WTE

3.7 Clinical Service Units (CSU) Specific Staffing Issues

The WTE vacancy calculation is now taken from the ‘in month’ finance ledger. In line with the calculations

used for the finance and performance committee only clinical staff within bands 1-7 are included as part of

the vacancy calculation.

• The overall registered vacancy percentage for all clinical CSU’s from the April finance ledger is

11.8% which equates to 519 WTE

The CSUs that have a registered nurse vacancy greater than 15% are:

• Emergency and Speciality Medicine 16.9%

• Cardio-Respiratory 21.7%

• Neurosciences 19.9%

• Trauma and related services 17.4%

3.8 Retention

Turnover of overall registered nurses, midwives and ODPs in February and March remains consistent at 10.2%. Turnover of band 5 registered staff remains slightly higher than the overall figure at 13.4%, this would be expected in this staff group and has been decreasing since August 2018.

Turnover of unregistered staff in March is 9.5% which again is a reduction since August 2018 . The Resource Management Group is focusing on retention of registered staff as a priority, with CSU level workforce data being analysed for themes and trends.

National 12 month turnover comparison data (NHSI November 2018) for registered nurses and midwives in acute teaching trusts shows LTHT as the green bar below:

Agenda Item 12.5

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3.9 Maternity Staffing

The current midwife: birth ratio for LTHT in March 2019 based on the March births remains at 1:26 as per previous months. The Birthrate Plus workforce acuity tool continues to monitor staff vs acuity on delivery suites with daily, weekly and monthly monitoring within the CSU. This data is available and reported into the Women’s governance meeting with the clear breakdown of Birthrate Plus calculations. The Delivery Suite coordinators remain supernumerary as evidenced via the health roster enabling the coordinators to have oversight of all birth activity on the delivery suites. Additionally 1 to 1 care has been maintained at 100% across both delivery suites. In March 2019 on LGI delivery suite (L45) there were 10 red flag events - 8 for delays greater than 6 hours for the commencement of induction of labour and 2 for single site closures due to increased acuity and capacity on the delivery suite. On the SJUH delivery suite In March there were 18 red flag events - 13 for delays greater than 6 hours for the commencement of induction of labour, 3 red flags for single site closures resulting in diversion to the LGI due to acuity to maintain patient safety and 2 red flag generated due to an aspect of missed or delayed care due to high acuity on the delivery suite. No harm occurred in any of the red flag events. On-going work to refine the Birthrate plus acuity tool for the Ante and Post natal wards as the tool does not currently include support staff, therefore Professional judgement is currently required to interpret the current reports. The antenatal ward at St James (J04) have reported 2 delays in transferring women to delivery suite and 3 delays in the commencement of induction of labour, and their counterparts at LGI (L44) have reported 1 for staff redeployment. The postnatal ward at St James (J05) and (L36) at LGI haven’t reported any red flags.

4. Ward Healthcheck

Agenda Item 12.5

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There is a professional requirement to measure standards of record keeping for the core activities that we

undertake for our patients. This includes measuring how we assess patient needs and deliver care to meet

these needs in order to improve the quality and consistency of care.

At LTHT the ward/department Healthcheck is the way we assess against a suite of standards. It is

undertaken in all adult and paediatric in-patient areas including Theatres, PACU, Emergency Departments,

Outpatients and wards staffed by the Independent provider Villa Care. It provides assurance on the quality

and safety of care provided.

An escalation process comprising of seven KPI’s is in place for all in-patient ward areas, excluding Villa

Care wards. For Villa Care this information is discussed in monthly governance meetings chaired by the

Director of Nursing Operations/Deputy Chief Nurse. In April there were 4 unannounced visits to Villa Care

wards, no safety concerns were identified on the visits.

There are 91 in-patient wards included in the ward/department Healthcheck. The number of wards in

escalation varies month on month (see Figure 4). In March 2019 there were eight wards that triggered

escalation. Five wards triggered first stage escalation (L43, J10, J14, J17, J20) and three wards triggered

third stage escalation (J09, J07, J27). Two of the wards in third stage escalation have had assurance

meetings with Director of Nursing Operations/Deputy Chief Nurse and Deputy Chief Medical Officer.

Appropriate action plans are in place, with follow up meetings as required. The third ward is being closely

monitored by the Head of Nursing for the CSU with a robust action plan in place. Wards that triggered first

stage escalation will be offered informal support for any identified areas for improvement from the Clinical

Support Team. All wards will have local action plans in place to ensure improvement in the healthcheck is

achieved.

Figure 4

5.1 Clinical Standards - Healthmetrics

The Healthmetrics monthly audit programme focuses on processes at ward/department level for identifying

and managing risk of harm rather than outcome (incidence of harm). A RAG rating is awarded based on

percentage compliance with assessment, clear interventions, evaluation and documentation.

The individual standard scores are collated to give an overall score;

• 79.9% or below is Red

• 80-89.9% is Amber

0

2

4

6

8

10

Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

No. of Areas 4 3 3 6 5 8

Number of Clinical Areas in Escalation 2018/2019

Agenda Item 12.5

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• 90% and above is Green.

The Figure in Appendix 3, illustrates a breakdown of Healthmetrics score by standard group. April 2019 has

shown an improvement in hydration domain and pressure ulcer assessment. An improved fluid balance

chart and notation on PPM+ is providing clear assurance around these domains.

Two CSU’s have received support throughout April 2019 and these are:

• Cardio Respiratory

• Trauma and Related Services

Both are showing positive improvements in overall metric scores for April 2019.

Appendix 4 highlights the overall score by Trust and CSU level. All CSU have worked hard to improve and

maintain their Healthmetric scores. For the past three months all CSUs have had an average overall score

> 90%. The Clinical Support Team (CST) identifies wards whose Healthmetrics score is consistently amber

(80 - 89.9%). CST offers these areas informal support, sharing ideas from other green wards to enable ward

teams to achieve their potential.

A review of the fourteen wards with lower than 80% in the reported actual staffing (Appendix 2) has been

undertaken. Harm free care (new harms), falls and Pressure Ulcer (PU) incidents have been triangulated

with metrics scores and wards with lower than 80% in the reported actual staffing.

There are no reportable increase in harms relating to falls and pressure ulcers in these fourteen wards.

Healthcheck overall scores are RAG rated. Figure 5 shows LTHT performance for the last three months.

There were no LTHT red wards in April 2019; this is the first time for six months.

Figure 5

Sustained performance in Healthcheck scores is now recognised through the certification programme. 40

wards and departments have been awarded either Bronze, Silver or Gold certificates of excellence in March

and April for consecutive months of green metrics. All teams were delighted to receive this accolade, and

presentation photographs were shared on social media platforms.

Feb 2019 Mar 2019 Apr 2019

Red 1% 1% 0%

Amber 9% 10% 14%

Green 90% 88% 86%

75%

80%

85%

90%

95%

100%

105%

Pe

rce

nta

ge

RAG rated metrics scores Feb - Apr 2019

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There has been significant work on the ward accreditation programme. Whilst still in development this will

be the next step for recognising and learning from wards that have sustained high level of standards and

practice.

5.2 Summary of Actions being taken

• NSSR stage two commenced with the inclusion of weekends

• Safer Care module proof of concept test on 5 wards in Cardio-respiratory CSU to commence in

May 2019

• 91 wards and departments continue to be monitored for standards of care delivered, outcomes of

harm and patient experience.

• There is no direct correlation of below 80% staffing levels and outcomes relating to patient harm.

• There was an increase in wards in escalation for March 2019 compared to previous months (Dec,

Jan, Feb)

• Wards in sustained improvement associated with the ward metrics are now recognised through a

celebration programme.

• Nursing E-Documentation continues to be developed and is being received positively providing

clear assurances around the domains where it has been fully implemented.

7. Recommendations

The Trust Board is asked to:

• Receive this report and note the Nurse Staffing and Healthcheck data for May 2019.

Katie Robinson Head of Nursing, Workforce and Education Breeda Columb Head of Nursing, Professional Practice & Safety Standards May 2019

Agenda Item 12.5

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Appendix 1

Care Hours per Patient Day (CHPPD)

CHPPD is calculated using actual registered and unregistered staffing alongside ward activity (bed

occupancy at midnight). This generates the number of hours of care available for patients per day. David

Beevers Day Unit, J43, L14, L28 and W1 have been excluded as they do not always have beds open at

12 midnight consistently over 7 days

CHPPD - Trust level data by registered, unregistered and overall

Variation in CHPPD is caused by a number of factors including:

• Acuity and dependency

• Enhanced care support is not captured on planned staffing templates

• Units that reduce base bed at night

• Bed occupancy (activity) data is based on PAS information of which is not always consistently

updated

• Recent recruitment activity

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Appendix 2 Nurse Staffing Return (Hard Truths)

The Trust reports staffing numbers to NHS England via a monthly Nurse Staffing Return (Hard Truths) for

87 inpatient areas. This report details the monthly staffing hours within a clinical area against their planned.

CHPPD data is recorded within the same report and the overall healthcheck score is included for

information.

Wards triggering < 80% staffing against planned

Trust wide planned against actual staffing (fill rate)

Day Registered Day Care staff Night Registered Night Care staff Total wards % of wards

Mar-18 3 1 11 2 17 19.5%

Apr-18 1 0 7 1 9 10.3%

May-18 0 0 7 0 7 8.0%

Jun-18 2 3 5 2 11 12.6%

Jul-18 2 2 12 0 14 15.9%

Aug-18 4 3 12 1 17 19.3%

Sep-18 4 0 12 0 14 15.9%

Oct-18 8 3 12 1 19 21.6%

Nov-18 10 4 8 2 20 22.7%

Dec-18 12 4 10 2 21 24.1%

Jan-19 8 2 9 10 16 18.4%

Feb-19 9 5 7 2 18 20.7%

Mar-19 15 2 10 0 19 21.8%

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The table below represents the integrated Nurse Staffing Return inclusive of CHPPD for the individual

areas and the overall score on Healthcheck for March 2019. Wards triggering < 80% staffing against

planned are highlighted in red, and amber for >130%. The data includes, Falls Pressure Ulcer and Harm

Free Care data as collected through Safety Thermometer.

Agenda Item 12.5

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Metrics

RegisteredUn-

registeredOverall

A M & S J42 Urology 84.7% 97.0% 107.3% 122.3% 2.5 3.3 5.798.7% 1 92.9%

A M & S J43 Short Stay Surgery 98.1% 119.6% 98.3% 117.7%97.9% 1 1 100.0%

A M & S J44 General Surgery 78.2% 116.2% 77.4% 94.0% 2.3 3.2 5.597.5% 4 100.0%

A M & S J45 General Surgery 76.6% 121.2% 66.6% 98.0% 2.4 3.3 5.781.8% 2 1 91.7%

A M & S J46 Colorectal Surgery 86.7% 84.9% 102.3% 98.7% 2.3 3.3 5.698.8% 1 100.0%

A M & S J47 Colorectal Surgery 70.6% 91.3% 101.3% 109.0% 2.7 4.3 7.097.9% 100.0%

A M & S J49 Renal Medicine Male 98.3% 122.3% 99.8% 135.5% 2.8 3.0 5.897.1% 2 0 95.5%

A M & S J50 Renal Medicine Female 91.4% 99.5% 100.3% 125.8% 3.1 3.5 6.798.2% 2 0 94.7%

A M & S J82 UGI & HPB Surgery 82.5% 109.1% 83.7% 118.2% 2.5 3.0 5.596.7% 1 0 100.0%

A M & S J91 Gastro 99.4% 99.6% 100.0% 120.9% 2.4 3.6 6.099.6% 4 100.0%

A M & S J92 Gastro 87.9% 94.3% 103.1% 103.2% 2.6 4.0 6.683.0% 2 92.0%

A M & S J83 Leeds Liver Unit 76.2% 117.1% 83.4% 109.6% 2.9 4.1 7.097.5% 6 100.0%

Adult Critical Care J54 Intensive Care Ward 94.6% 99.1% 95.8% 108.5% 25.3 3.1 28.492.9% 0 2 92.9%

Adult Critical Care J81 HDU 95.6% 80.0% 87.4% 93.5% 14.6 5.1 19.696.9% 100.0%

Adult Critical Care L03 ITU 97.5% 104.1% 100.0% 120.6% 28.1 6.3 34.497.7% 100.0%

Adult Critical Care L04 Cardiac ITU 101.0% 100.0% 100.4% 117.9% 24.7 2.6 27.299.5% 1 100.0%

Adult Critical Care L06 Neuro ICU 95.2% 103.9% 100.0% 110.5% 22.0 3.2 25.399.2% 2 100.0%

Cardio-Respiratory J10 Respiratory Medicine 86.4% 105.9% 83.8% 85.0% 4.8 5.3 10.195.6% 0 6 100.0%

Cardio-Respiratory J12 Respiratory Medicine 84.3% 104.1% 88.2% 126.8% 2.2 4.0 6.288.1% 0 0 100.0%

Cardio-Respiratory J06 Adult Cystic Fibrosis 91.0% 121.5% 99.8% 100.0% 5.3 3.2 8.598.1% 100.0%

Cardio-Respiratory J09 Respiratory Medicine 81.7% 113.8% 77.4% 128.2% 1.9 3.9 5.873.0% 5 1 96.6%

Cardio-Respiratory L14 Cardiology Day Case 104.8% 121.6% 100.0% 121.0%2

Cardio-Respiratory L16 Cardiac Surgery 105.0% 121.8% 100.0% 225.8% 3.2 2.7 5.999.4% 3 100.0%

Cardio-Respiratory L18 Cardiology 95.1% 126.6% 107.8% 133.0% 2.2 4.3 6.599.5% 4 1 100.0%

Cardio-Respiratory L19 Cardiology 97.8% 94.1% 92.5% 121.7% 2.9 4.0 6.992.5% 6 1 100.0%

Cardio-Respiratory L20 CCU 94.9% 132.0% 94.5% - 8.6 2.4 11.095.0% 1 1 100.0%

Chapel Allerton C02 95.5% 104.76% 98.4% 183.87% 4.8 4.5 9.284.5% 2 91.7%

Chapel Allerton C01 Neuro Rehabilitation 105.0% 114.8% 100.1% 108.1% 3.3 5.1 8.394.3% 95.8%

Chapel Allerton C03 Orthopaedic Centre 122.2% 123.2% 101.6% 100.0% 8.2 4.7 12.994.2% 4 100.0%

Chapel Allerton Ward 01 - WGH 107.8% 93.0% - -

ChildrensL30 Childrens

Respiratory/Cystic Fibrosis79.0% 127.6% 79.0% 100.0% 6.5 4.0 10.5

97.7% 1

Childrens L31 Childrens Oncology 85.3% 84.0% 93.1% 103.6% 15.7 2.5 18.297.6%

Childrens L40 Childrens General Medicine 100.6% 87.0% 129.0% 100.0% 5.5 1.0 6.693.0% 1

Childrens L41 Childrens Surgery 93.9% 115.4% 110.0% 103.2% 5.1 2.1 7.196.1%

Childrens L42 Paediatric Surgery 98.6% 97.6% 99.8% 110.0% 6.7 1.6 8.398.4%

Childrens L47 PICU 96.5% 113.8% 98.5% - 33.8 2.0 35.897.4% 1

Childrens L48 Childrens HDU 87.0% 80.6% 92.2% 83.9% 12.6 3.8 16.495.3%

Childrens L51 Childrens Cardiac Surgery 99.1% 119.2% 109.8% - 8.3 1.1 9.493.1% 1

Childrens L52 Childrens Neurosciences 81.3% 103.0% 105.6% 132.25% 6.2 2.9 9.194.3% 1

Childrens Transitional Care - SJH 93.5% 97.8% 167.0% 135.5% 6.7 3.3 10.097.0%

Childrens L09 Childrens Medicine 101.3% 79.0% 100.0% 95.0% 13.0 3.3 16.395.6%

Childrens J01 Neonatal Unit 90.3% 103.5% 99.4% 96.2% 7.9 1.2 9.298.2%

Childrens L43 Neonatal Unit 92.5% 99.9% 93.8% 87.5% 16.0 1.0 17.097.9%

Childrens L50 Childrens Liver & Renal 96.1% 122.8% 102.1% 96.9% 6.4 2.5 8.995.3% 1

March 2019

CSU Ward name

Average fill

rate -

registered

nurses/midwi

ves (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/midwi

ves (%)

Average fill

rate - care

staff (%)

Health-

check

Scores

Falls

Day NightCHPPD

Patient Safety

Pressure

Ulcers

New Harm

Free Care

Agenda Item 12.5

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Metrics

RegisteredUn-

registeredOverall

E & S M J14 Older Peoples Services 65.1% 90.4% 100.5% 105.8% 2.2 5.7 7.997.8% 1 0 95.8%

E & S M J15 Older Peoples Services 71.6% 96.2% 100.4% 117.0% 2.0 5.2 7.297.9% 4 0 100.0%

E & S M J17 Older Peoples Services 61.3% 102.4% 98.4% 113.9% 1.9 4.4 6.2100.0% 6 2 96.3%

E & S M J19 Acute Medicine 97.9% 93.0% 100.0% 106.3% 2.1 3.3 5.486.1% 5 93.1%

E & S M J20 Infection & Travel Medicine 102.0% 83.3% 95.5% 106.5% 2.8 3.4 6.199.1% 4 1 100.0%

E & S M J21 Acute Medicine 94.0% 85.7% 99.6% 106.9% 2.0 3.5 5.599.1% 1 2 100.0%

E & S M J26 Medical Admissions Unit 74.1% 78.0% 73.6% 129.3% 2.7 4.7 7.3100.0% 1 2 100.0%

E & S M J27 General Admissions 85.8% 106.1% 82.9% 177.0% 3.8 6.7 10.695.2% 4 2 100.0%

E & S MJ28 Elderly Short Stay

Assessment79.8% 89.5% 69.5% 119.1% 2.1 4.8 6.9

95.2% 6 1 100.0%

E & S M J29 Elderly Admissions 79.0% 86.6% 71.9% 113.7% 2.2 4.8 6.987.2% 3 1 100.0%

E & S M J07 Older Peoples Services 66.4% 97.0% 100.0% 116.2% 1.8 4.2 6.082.1% 2 3 100.0%

E & S M J08 Older Peoples Services 64.6% 89.8% 100.1% 127.4% 1.8 3.9 5.785.5% 7 1 100.0%

Head & Neck L23 ENT/Spines 98.7% 113.8% 108.2% 124.3% 3.1 3.5 6.691.8% 2 100.0%

Neurosciences L12 Stroke Rehab 84.0% 96.7% 101.6% 115.8% 2.6 3.2 5.895.3% 3 96.3%

Neurosciences L21 Acute Stroke Unit 81.6% 82.0% 81.0% 114.7% 3.5 4.7 8.299.1% 4 0 96.8%

Neurosciences L24 Neuro/Spines 102.0% 123.0% 73.0% 220.0% 2.8 5.2 8.092.8% 6 3 96.8%

Neurosciences L25 Neuro/Spines 68.8% 121.4% 93.6% 153.5% 3.1 6.2 9.392.3% 4 1 100.0%

Neurosciences L17 Neurology 83.3% 158.6% 111.9% 219.5% 2.7 4.9 7.795.6% 3 0 100.0%

Neurosciences L28 Surgical Day Unit 96.7% 125.6% 106.0% 101.0%96.9% 1 100.0%

Oncology J84 Thoracic Surgery 85.5% 119.4% 96.0% 124.16% 3.8 3.3 7.187.1% 3 100.0%

Oncology J88 Haematology 115.3% 126.9% 101.61% 118.4% 2.9 2.8 5.796.3% 1 1 94.7%

Oncology J89 Haematology BMTU 81.5% 119.9% 89.1% 95.16% 4.5 2.4 6.999.6% 2 1 100.0%

Oncology J93 Oncology 126.88% 100.0% 100.0% 124.7% 2.8 2.6 5.493.0% 4 100.0%

Oncology J94 Young Adults Unit 84.4% 125.80% 98.3% - 6.4 2.1 8.587.7% 1 100.0%

Oncology J96 Oncology Assessment 91.7% 90.32% 91.1% 121.50% 4.1 3.9 8.095.7% 2 100.0%

Oncology J97 Oncology 122.7% 128.1% 101.61% 121.8% 2.8 2.5 5.497.7% 3 0 100.0%

Oncology J98 Gynaecology 102.0% 94.62% 100.0% 97.84% 2.6 3.0 5.588.1% 4 0 100.0%

Oncology J23 Breast Surgery 96.7% 97.6% 70.9% 112.9% 6.9 8.1 14.992.1% 100.0%

Theatres David Beevers Day Unit - SJH 80.0% 81.0% 100.0% 100.0%

T & R S L10 Major Trauma Ward 81.3% 126.1% 99.1% 114.0% 3.6 7.0 10.595.0% 2 1 100.0%

T & R S L15 Vascular 79.0% 99.6% 78.4% 124.7% 2.6 4.2 6.896.6% 1 0 100.0%

T & R SL35 Orthopaedic

Trauma/Vascular91.6% 84.4% 98.4% 104.8% 2.4 4.3 6.7

94.2% 3 0 100.0%

T & R SL37 Female Trauma

Orthopaedics81.1% 102.7% 100.4% 118.6% 2.3 4.9 7.2

92.7% 3 1 95.7%

T & R S L22 Plastics 87.5% 109.3% 100.0% 106.3% 2.6 3.4 6.079.8% 3 100.0%

T & R S L34 Orthopaedic Trauma 89.0% 87.1% 98.4% 92.2% 2.7 4.9 7.699.1% 5 1 95.0%

T & R S L08 Orthoplastic HDU 93.6% 100.4% 99.3% 123.1% 10.0 7.0 17.098.1% 1 100.0%

Womens J05 Obstetrics 91.9% 126.9% 92.1% 98.4% 4.6 3.3 7.990.3% 100.0%

Womens L36 Maternity 88.4% 87.0% 92.7% 84.9% 5.0 3.3 8.397.4% 0 100.0%

Womens L44 Maternity 100.0% 100.0% 90.0% 100.0% 8.8 3.3 12.189.9% 1 100.0%

Womens J03 Delivery Suite 96.6% 98.8% 95.8% 91.5% 31.9 6.9 38.897.1% 100.0%

Womens J04 Ante Natal 82.1% 99.2% 100.0% 95.2% 12.8 6.0 18.899.2% 100.0%

Womens L45 Delivery Suite 93.1% 98.3% 90.2% 106.5% 31.6 7.3 38.997.2% 100.0%

Womens J24 Gynaecology 110.5% 126.3% 100.1% 105.5% 10.8 8.6 19.31

March 2019

CSU Ward name

Average fill

rate -

registered

nurses/midwi

ves (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/midwi

ves (%)

Average fill

rate - care

staff (%)

Health-

check

Scores

Falls

Day NightCHPPD

Patient Safety

Pressure

Ulcers

New Harm

Free Care

Agenda Item 12.5

14

Appendix 3 - Overall Healthmetrics Score Question Group March and April 2019

Question Group

Abdominal

Medicine and

Surgery

Adult Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and Specialty

Medicine Head & Neck

Institute of

Oncology

Trauma and

Related

Services Womens

Emergency Equipment 91.5% 100.0% 84.8% 89.5% 75.0% 91.2% 97.9% 66.7% 100.0% 91.3% 85.0%

Infection Prevention 91.0% 98.2% 97.5% 93.8% 96.0% 95.6% 93.9% 100.0% 89.9% 95.3% 95.3%

Medicines Management 91.1% 97.0% 83.8% 92.3% 80.0% 95.1% 93.5% 92.9% 96.8% 89.6% 93.3%

Patient Dignity 98.3% 100.0% 96.6% 97.8% 93.2% 99.4% 98.0% 100.0% 100.0% 97.7% 100.0%

Continence 96.4% 98.9% 98.5% 83.0% 95.0% 95.1% 96.6% 87.5% 90.6% 100.0% 90.5%

Discharge 98.4% 100.0% 87.9% 84.9% 100.0% 97.2% 98.7% 94.4% 82.5% 90.9% 100.0%

Falls Assessment 95.9% 93.4% 95.5% 99.2% 94.4% 99.0% 93.6% 83.3% 93.5% 100.0% 100.0%

Nutrition 91.9% 97.6% 84.6% 96.5% 88.9% 94.6% 86.8% 95.7% 91.6% 91.0% 100.0%

Pain Management 97.6% 97.8% 98.8% 98.2% 96.8% 97.5% 98.0% 95.5% 98.3% 100.0% 96.4%

Patient Observations 96.4% 97.1% 91.0% 100.0% 100.0% 98.5% 94.8% 100.0% 89.5% 97.3% 95.5%

Pressure Area Care 92.3% 98.3% 90.3% 91.3% 76.4% 85.8% 94.6% 68.8% 93.4% 91.0% 63.4%

Documentation 96.0% 96.0% 92.4% 97.3% 85.3% 95.2% 92.0% 96.0% 95.6% 78.9% 99.3%

Magnetic Symbols 90.0% 75.0% 71.4% 100.0% 100.0% 100.0% 100.0% 100.0% 77.8% 85.7% N/A

Patient Identification 98.9% 97.1% 100.0% 97.6% 100.0% 97.2% 98.1% 100.0% 100.0% 100.0% 100.0%

Hydration 97.5% 96.9% 84.0% 96.2% 87.5% 98.5% 88.5% 80.0% 83.9% 97.4% 100.0%

Mar-19

Question Group

Abdominal

Medicine and

Surgery

Adult Critical

Care

Cardio-

Respiratory

Centre for

Neurosciences

Chapel

Allerton

Hospital Childrens

Emergency

and Specialty

Medicine Head & Neck

Institute of

Oncology

Trauma and

Related

Services Womens

Emergency Equipment 94.9% 100.0% 96.3% 80.0% 100.0% 90.9% 95.7% 100.0% 87.9% 92.0% 81.3%

Infection Prevention 91.1% 100.0% 95.6% 97.8% 100.0% 98.6% 96.2% 100.0% 93.8% 90.5% 92.3%

Medicines Management 91.3% 96.0% 86.6% 78.2% 92.6% 96.5% 92.5% 100.0% 86.0% 89.3% 87.5%

Patient Dignity 97.7% 99.0% 96.8% 98.6% 98.6% 97.4% 98.6% 100.0% 98.6% 98.8% 99.2%

Continence 99.2% 95.0% 91.2% 91.9% 93.8% 100.0% 91.6% 100.0% 94.3% 100.0% 96.6%

Discharge 94.5% 100.0% 83.1% 88.4% 97.7% 91.7% 98.1% 93.8% 92.8% 88.9% 100.0%

Falls Assessment 99.5% 96.2% 94.3% 96.0% 94.1% 95.4% 95.0% 100.0% 92.7% 98.2% 100.0%

Nutrition 99.2% 97.5% 94.9% 94.8% 95.0% 97.3% 88.3% 100.0% 85.9% 86.7% 100.0%

Pain Management 96.8% 99.1% 99.3% 98.3% 97.2% 98.5% 96.9% 100.0% 94.9% 97.6% 95.8%

Patient Observations 93.9% 100.0% 89.7% 95.9% 90.2% 96.2% 98.7% 100.0% 92.6% 95.9% 100.0%

Pressure Area Care 96.6% 98.3% 88.7% 92.1% 81.8% 86.9% 91.6% 100.0% 86.1% 94.0% 94.4%

Documentation 92.9% 96.8% 84.0% 90.7% 89.3% 94.7% 93.7% 80.0% 90.7% 86.9% 100.0%

Magnetic Symbols 60.0% 100.0% 100.0% 83.3% 100.0% 100.0% 100.0% 100.0% 77.8% 83.3% 100.0%

Patient Identification 97.3% 100.0% 100.0% 100.0% 100.0% 96.0% 97.9% 100.0% 100.0% 100.0% 100.0%

Hydration 95.8% 96.6% 82.4% 92.7% 72.0% 99.4% 86.3% 93.8% 86.8% 98.7% 95.0%

Apr-19

Agenda Item 12.5

15

Appendix 4: Accumulated Metrics Score by Trust and CSU December 2018 - February 2019

A M SAdult

CriticalCare

Cardio-Respiratory

Neurosciences

ChapelAllerton

ChildrensHead &

NeckOncology

Emergency& SpecialtyMedicine

Trauma & RS

Womens

Feb-19 97.4 97.7 90.4 94.9 92.7 95.9 99.5 93.8 91 94 97

Mar-19 95.5 97.4 92.3 95.4 90.9 96 91.8 93.5 94.2 93.7 95.3

Apr-19 95.7 97.7 91.6 93.7 93.1 96 96.6 91.6 94.5 93.9 97

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Metric Standards - Overall Percentage by CSU Feb - Apr 2019

Health

che

ck Go

al