13. Monthly Performance Report - Southern Health and Social Care ...

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SSI rate (Hipsonly)BundleCompliancerate-CaesareanSection (auditof 20 cases permonthSSI Rate(C-section)Central LineInfections-Infection Rateper 1000 linedaysQ2 20080%CAH5%DHH5.26%Q2 2008CAH9.2%DHH19.2%Oct 08CAH3%DHH3%-95%95%25%reductionon Q42008 SSIRate (as ofFeb 09) –Target14.21%(NI Average14.5%)1.17%1.17%Q3 20090%(NI Ave:1.0%)95%85.71%Q3 2009CAH7.2%DHH1.4%(NI Ave:11.2%)Jan 1000may have animpact onoverall BundleCompliance inthe monthsahead until anynew practicesare embeddedsuccessfully.SSI Infectionrates, availableas a quarterlyposition, arenow included inreporting.This targetmeasures thenumber ofcentral linecatheter-relatedbloodstreaminfections-Compliancewith bundleCAH30%DHH0%95%95%70%80%Measurementreflects allCentral Lines atCAH & DHHand compliancewith the carebundleelements.VentilatorAcquiredPneumonia(VAP)- Ventilatordays betweeninfectionsOct 08517Mar 10300Jan 10366(Cum daysbetweeninfections584)This targetaims to achieve95%compliancewith all bundleelements inICU in CAH.The Trust metthe regionaltarget of 300Monthly Performance Report 16 February 10 20
- Compliancewith bundle100% 95% 100%Vent Daysbetweeninfections (584days free ofinfections).Crash CallRate-Rate per 1000deaths/dischargesMonitoringrolled over from2008/09Oct 08CAH3.7DHH0.9Mar 101.89 per1000deaths/dischargesJan 10CAH1.17 per1000DHH0.45 per1000(NI Range 0– 7.5)This QIP targetis focused onreducing crashcalls in A&E,ICU andcoronary care.Crash callsdecreasedsignificantly onboth sites inJan.MEWSModified EarlyWarningScoringSystemMental HealthIndicators-%compliancewith multidisciplinaryreviewSept 09CAH94.44%DHH100%TrustAve85.79%Oct 08CAH79%SLH67%Mar 1095%Mar 09100%Jan 10CAH90%(190/210)DHH93%(112/120)TrustAve91.5%Non-AcuteSites93%(112/120)Jan 10CAH100%SLH100%The modifiedearly warningscoring systemis a tool tosupport clinicalstaff assesspatientprogress viarecording ofkeyobservationaldata.This waspiloted in twowards and hasbeen rolled outTrust wide inSeptember2009. TheTrust will striveto meet the95% target.These targetsfocus oninpatientreview,assessmentand complianceMonthly Performance Report 16 February 10 21
Page 4 and 5: CONTENTPage1.0 Context 52.0 Reporti
Page 6: 3 SUMMARY REPORT3.1 DOMAIN: EFFICIE
Page 9: KPI : %DischargesCoded-cumulativeco
Page 12 and 13: PFA AHP AccessBy March 2010-no pati
Page 14 and 15: PSA 5.4: CareleaversBy March 2010in
Page 16 and 17: 3.3 DOMAIN: CLINICAL AND SOCIAL CAR
Page 18 and 19: PSA 5.2FamilysupportinterventionsOc
Page 22 and 23: -%compliancewith riskassessment-%co
Page 24 and 25: Priority 5(Target 7)PFA -Assessment
Page 26 and 27: 3.4 DOMAIN: WORKFORCETarget/Indicat
Page 28 and 29: • Re-admission Rates with Peer co
Page 30 and 31: Monthly Performance Report 16 Febru
Page 32: Renal - dialysis via fistula: This
Page 35 and 36: 0.400.350.300.250.200.150.100.05MSS
Page 37 and 38: MRSA AnalysisNew cases of MRSA2009
Page 39 and 40: Hand Hygiene Compliance AuditsHand
Page 41 and 42: Compliance with AntibioticsHospital
Page 43 and 44: MRSA - Annual trend by hospital sit
Page 45 and 46: % Bundle Compliance100%90%80%70%60%
Page 47 and 48: CHILDREN AND YOUNG PEOPLE REPORTING
Page 49 and 50: Appendix I - Daycase Rates by Proce
Page 51 and 52: Hydrocele exc IS 9 10 47.4%PROCEDUR
Page 53 and 54: STH 3 0 100.0%Varicose Veins exc IS
Page 55 and 56: ContentsSection1 Introduction2 Depa
Page 57 and 58: The overall score is an average of
Page 59 and 60: 3. Departmental Audit Results - Bre
Page 61 and 62: St Luke's Hospital1009590Score85807
Page 63 and 64: 4. ICNA Audit Results143 audits hav
Page 65 and 66: Daisy Hill Rehab Environment 24/06/
Page 67 and 68: 5. Action PlanThis Action Plan was
Page 69 and 70: MonthHospitalRisk CategoryDepartmen
Page 71 and 72:
MonthHospitalRisk CategoryDepartmen
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
and nurses station.EC Departmental
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