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

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MSSAMRSA CDSC Data September 20090.400.350.300.250.200.150.100.050.00Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3MRSA patient episodes per 1,000 episodic occupied bed days25201510MRSA Cumulative TotalApr 2009 – 8 th Feb 20102 DaysTargetBelfast Trust Quarterly RatesNorthern Trust Quarterly RatesSouth Eastern Trust Quarterly RatesSouthern Trust Quarterly RatesWestern Trust Quarterly Rates2008 Trust annual MRSA rate52008 2009 2008 2009 2008 2009 2008 2009 2008 2009Belfast Northern SouthEastern Southern Western0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar3Monthly Performance Report 16 February 10 34
0.400.350.300.250.200.150.100.05MSSA CDSC Data September 20090.00Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3MSSA patient episodes per 1,000 episodic occupied bed days403530252015105MSSA Cumulative TotalApr 2009 – 8 th Feb 20102 DaysTargetBelfast Trust Quarterly RatesNorthern Trust Quarterly RatesSouth Eastern Trust Quarterly RatesSouthern Trust Quarterly RatesWestern Trust Quarterly Rates2008 Trust annual MSSA rate0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2008 2009 2008 2009 2008 2009 2008 2009 2008 20094Belfast Northern SouthEastern Southern WesternMonthly Performance Report 16 February 10 35`
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 20 and 21: SSI rate (Hipsonly)BundleCompliance
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 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 77 and 78: and nurses station.EC Departmental

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