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Q2
2015/16
CCG Quarterly Report
Hayley Wardle
Director of Quality & Patient
Care
Ashgate Hospice
29/10/2015
2
ASHGATE HOSPICE
Key Messages by Project - Summary
Q2 2015 – 2016
This summary report highlights the key messages from the data we have provided. It
highlights trends and demonstrates how we are doing against targets set by the CCG.
• 23 Acute admissions avoided, over KPI target (29 YTD)
Add beds • Average patient wait is 0.69 days for Q1 15/16
H@H
• 175 acute admissions avoided YTD (Q1 & Q2) against a
full year target figure of 202
• All other KPI's achieved
• SPCC Referrals starting to rise in Quarter 2
3rd Cons • Data sharing between Ashgate & CRHFT to started in Q2
• IPU continues to meet all targets set in the SLA
SLA - IPU • Patient Survey for Q1 15/16 ; 100% positive feedback
• Average attendances have been increasing in 2015/16
SLA - DH • Occupancy rate consistently around 77 - 80% in Q2 15/16
SLA -CNS
• Q2 Referrals remain consistent for both community and
hospital teams
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
3
Additional Inpatient Unit beds 2015-16
9 Key Performance Indicators
Ref
Description
Threshold
Q1 DATA
Q2 DATA
AD1
Waiting time from
referral to
admission
Patients admitted
within 2 working days
>=80%
(increasing by
5% annually to
upper threshold
of 90%)
0.68 Days
(Average)
0.69 Days
(Average)
AD2
Admission
numbers
No of admissions
Actual numbers
120
Admissions
110
Admissions
AD3
Bed occupancy
levels
% based on bed days
utilised against bed
days available
>=80%
89%
89%
AD4
Length of stay
Average number of
days for all patient
types
Actual numbers
14.8 Days
(Average)
15.0 Days
(Average)
AD5
Acute admission
avoidance
Current Vs 3 yearly
average at 17 beds
N=85 (based on
4 beds)
33 in Q1
23 in Q2
As recorded on
admission to hospice
80% (from
admissions and
deaths in same
financial year)
85% (Annual
data)
85%
(Annual
data)
AD7
Patient / carer
experience
No of surveys with a
satisfactory score
using QH tool
>=80%
increasing year
on year to
upper threshold
of 90%
100%
100%
AD8
No of patients
with a diagnosis
other than cancer
Split by disease group,
renal, neurology,
respiratory, cardiovascular, other
12
12
No of patients
with a cancer
diagnosis
Split by disease group,
renal, neurology,
respiratory, cardiovascular, other
108
98
AD6
AD9
Measure
Death in
preferred place of
care / outside an
acute
environment
IPU Diagnosis Split Q2.xlsx
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
4
Additional Data – Historic Requirement
Ref
Measure
Description
Threshold
Q1 DATA
Q2 DATA
SLA
(C)
Activity split by
CCG
Admissions split by
locality
Standard
ND = 94
HH = 26
ND = 80
HH = 28
SLA
(F)
Discharge
destination
breakdown
Split by discharge
locations
Standard
Home = 42
Hospital = 3
Nursing
home = 0
Home = 44
Hospital = 2
Nursing
home = 4
SLA
(G)
Deaths within
hospice
Number of deaths
Standard
71 Deaths
65 Deaths
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
5
Hospice At Home Report 2015-16
10 Key Performance Indicators
Ref
Measure
Description
Threshold
Q1 DATA
Q2 DATA
H1*
Number of
patient’s
supported by
H@H service
Activity Numbers
split by CCG and by
practice
2013/14
baseline of 360
referrals
ND = 80
HH = 18
ND = 102
HH = 22
H2
Number of
referrals avoiding
hospital
admissions
Admission
avoidance - 202
75 Achieved
in Q1 15/16
100 Achieved
in Q2 15/16
H4
Reason for
referral
Numbers
CR = 36
EE = 47
SNC = 62
CR = 51
EE = 61
SNC = 73
CNS = 66
OHT = 11
Cons = 10
GP = 5
Other = 5
100% based
on internal
surveying, QH
survey to
come in
2015/16
CNS = 91
OHT = 26
Cons = 4
GP = 3
Other = 2
100% based
on internal
surveying, QH
survey to
come in
2015/16
H5
Referral source
Split by carer
respite, supportive
nursing care and
emergency
equipment
Split by:- Carer
respite (CR),
emergency
equipment (EE),
supportive nursing
care (SNC)
Split by:- CNS &
other hospice
teams (OHT),
consultant, GP, DN,
Community Matron
Numbers
Patient / Carer
experience
No of surveys with
a satisfactory score
using Quality
Health tool
>80% increasing
year on year by
5% to upper
threshold of
90%
H7
Response times
Response times
split by urgent and
emergency
Emergency
within 4 hours,
urgent within 1
working day
2= Emergency
45 = Urgent
1= Emergency
60 = Urgent
H8
Time from
referral to
response time
For standard
referrals with the
parameter being 2
working days
>85% increasing
to 90% by 2016
0.93
(Average)
1.12
(Average)
10
10
88
114
H6
H9
H10
Patients with a
primary diagnosis
other than cancer
Patients with
primary diagnosis
of cancer
Non cancer split by
body site
Cancer split by
body site
H@H Diagnosis Split Q2.xlsx
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
6
H1* - Activity Numbers split by CCG and by practice:-
Referrals by GP
Practice - Q2 2015-16.xlsx
Historical Data Report 2015/16
Additional Day Hospice & CNS data
Ref
Measure
Description
Thres
hold
Q1 DATA
Q2 DATA
SLA
(H)
Day Hospice Referrals
Number of referrals
Standard
57 Referrals
65 Referrals
SLA
(I)
Day Hospice Attendances
Number of attendances
including average per
session
Standard
652
Attendances
678
Attendances
SLA
(J)
Day Hospice Non attendances
Number of DNA’s
including % rate
Standard
75 DNA’s, Av
10% rate
61 DNA’s,
Av 8% rate
SLA
(K)
Day Hospice Attendee’s from IPU
Number of attendances
via IPU patients
Standard
14
17
CNS – Referrals
Referrals from both
community and hospital
teams
Standard
Com = 334
Hosp = 266
Com = 365
Hosp = 300
SLA
(L)
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
7
Specialist Palliative Care Consultant 2015-16
10 Key Outcome measures
Ref
SP1
SP2
Measure
No of patients
with a primary
diagnosis other
than cancer
No of patients
with primary
diagnosis of
cancer
Description
Threshold
Non cancer
diagnosis’s split by
disease group
Split into
MDS
groupings
Cancer diagnosis’s
split by disease
group
SP3
Location where
patients are seen
Split by Outpatients,
Domiciliary visit,
Hospital consultant
led service
SP4
Urgent referrals
Split into
MDS
groupings
Q1 DATA
SPCC Diagnosis Split
- Q1.xlsx
Q2 DATA
SPCC Diagnosis Split
- Q2.xlsx
Actual
DV’s = 20
referrals
Outpatient =
13 referrals
DV’s = 25
referrals
Outpatient =
19 referrals
Offered slot within 2
working days
>=80%
100%
100%
SP5
Non urgent
referrals
Offered
appointment to be
seen within 2 weeks
>=80%
100%
100%
SP6
Reduction of
number of
avoidable
admissions per
year
Where admission to
an acute setting
would have
occurred without
access to this service
N=92
33 Admissions
avoided
44 Admissions
avoided
Referral source
Referral to
Consultant from, GP
/ primary care,
Other hospital,
Consultant
Numbers
split by
outpatients,
domiciliary,
other
GP = 4
CNS = 19
Cons = 9
Oth = 1
GP = 4
CNS = 29
Cons = 9
Oth = 2
SP7
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16
8
SP8
SP9
SP10
Educational
support for
professionals
Patient / Carer
experience
measures
Proportion of
patients
achieving death
outside an acute
setting
Structured
educational sessions
to be offered to
primary care,
community, care
homes and acute
hospital colleagues
Minimum
of 10
structured
educational
sessions
offered a
year and
numbers
attending
3 educational
sessions (CPD
events)
6 educational
sessions (CPD
events)
No of surveys with a
satisfactory score
using the Quality
Health tool
>=80%
increasing
year on
year by 5%
(to upper
threshold
of 90%)
FamCare now
started
Results of
FamCare
expected
within Q3
2015/16
Numerator: number
of patients who
have been referred
as OP or DV in the
financial year who
die outside acute
care
Denominator:
number of patients
who have been
referred as OP or DV
who die in the
financial year
>=80%
increasing
year on
year by 5%
(to upper
threshold
of 90%)
85% (annual
stat completed
in Q2 15/16)
85% (annual
stat completed
in Q2 15/16)
Ashgate Hospice | North Derbyshire Clinical Commissioning Group Quarterly Report 2015/16