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["Metric","Units","Source","CQC Domain","Benchmark","Top Quartile Average","YTD","Q1 16/17 ","Trend Apr16- June 16","2016-04-01","2016-05-01","2016-06-01"]
["SAFE AMBITION  1:  Reduction of Harm Associated with Mortality "]
["HSMR  (April 15 - March 16)","Ratio","Dr Foster","Safe",100,null,101.46,101.46,null,99.54,99.88,101.46]
["SHMI (Jan 15 - Dec 15)","Ratio","Dr Foster","Safe",100,null,110.99,110.99,null,111.21,111.21,110.99]
["Crude Mortality (HSMR basket 56 diagnosis) (June 16)"," Mthly Number","Dr Foster","Safe",null,null,{"$f":"AVERAGE(J5:L5)","v":1.6566666666666671E-2},{"$f":"AVERAGE(J5:M5)","v":1.6566666666666671E-2},null,1.8100000000000002E-2,1.7000000000000001E-2,1.46E-2]
["SAFE AMBITION  2:  Reduction of Harm Associated with Harm Free Care  "]
["Harm free care (new & old)","Mthly %","ST",null,0.95,0.94499999999999995,{"$f":"AVERAGE(J7:L7)","v":0.91999999999999993},{"$f":"AVERAGE(J7:M7)","v":0.91999999999999993},null,0.91749999999999998,0.9133,0.92920000000000003]
["Harm free care (new)","Mthly %","ST",null,0.98,0.98,{"$f":"AVERAGE(J8:L8)","v":0.96919999999999995},{"$f":"AVERAGE(J8:M8)","v":0.96919999999999995},null,0.97509999999999997,0.95609999999999995,0.97640000000000005]
["SAFE AMBITION  3:  Reduction of Harm Associated with Falls"]
["Falls per 1000 OBD","Mthly %","Datix","Safe",3.9E-2,3.9E-2,{"$f":"AVERAGE(J10:L10)","v":3.7899999999999996E-2},{"$f":"AVERAGE(J10:M10)","v":3.7899999999999996E-2},null,3.2599999999999997E-2,3.8899999999999997E-2,4.2200000000000001E-2]
["Falls with harm per 1000 OBD","Mthly %","Datix","Safe",1.9E-3,1.9E-3,5.3333333333333332E-3,{"$f":"AVERAGE(J11:M11)","v":5.3333333333333332E-3},null,1.01E-2,3.3E-3,2.5999999999999999E-3]
["Combined SQD Metrics (Falls)","Mthly %","SQD","Safe",0.9,null,0.71130000000000004,0.71130000000000004,null,null,0.7097,0.71289999999999998]
["SAFE AMBITION  4: Reduction of Harm Associated with Pressure Ulcers"]
["Category 4 hospital acquired incidents"," Mthly Number","PUNT","Safe",0,0,{"$f":"SUM(J14:L14)","v":4},{"$f":"SUM(J14:M14)","v":4},null,0,2,2]
["Category 3 hospital acquired incidents"," Mthly Number","PUNT","Safe",0,0,8,{"$f":"SUM(J15:M15)","v":8},null,1,4,3]
["Category 2 hospital acquired incidents"," Mthly Number","PUNT","Safe",27,null,100,{"$f":"SUM(J16:M16)","v":100},null,27,39,34]
["Pressure ulcers per 1000 OBD","Mthly %","IS","Safe","TBC","TBC",null,null,null,"TBC","TBC","TBC"]
["Tissue viability compliance","Mthly %","SQD","Effective",0.9,null,{"$f":"AVERAGE(J12:L12)","v":0.71130000000000004},{"$f":"AVERAGE(K12:M12)","v":0.71130000000000004},null,null,0.9274,0.91520000000000001]
["SAFE AMBITION  5: Reduction of Harm Associated with Medication"]
["Medication incidents "," Mthly Number","Datix","Safe",null,null,{"$f":"SUM(J20:L20)","v":340},{"$f":"SUM(J20:M20)","v":340},null,108,110,122]
["Medication incidents resulting in harm (Low,Moderate, Severe & Death)"," Mthly Number","Datix","Safe",0,0,{"$f":"SUM(J21:L21)","v":36},{"$f":"SUM(J21:M21)","v":36},null,12,9,15]
["Medication errors per 1000 OBD","Mthly %","Datix","Safe","TBC","TBC",{"$f":"AVERAGE(J22:L22)","v":3.2666666666666671},{"$f":"AVERAGE(J22:M22)","v":3.2666666666666671},null,3.45,2.9,3.45]
["CD Audit Compliance (Q1 April - June 16)","Mthly %","Pharmacy",null,1,1,{"$f":"AVERAGE(J12:L12)","v":0.71130000000000004},{"$f":"AVERAGE(K12:M12)","v":0.71130000000000004},null,0.82,null,0.76]
["SAFE AMBITION  6: Reduction of Harm Associated with Infections"]
["MRSA Cases"," Mthly Number","IPC","Safe",0,0,{"$f":"SUM(J25:L25)","v":1},{"$f":"SUM(J25:M25)","v":1},null,0,1,0]
["C difficile Cases"," Mthly Number","IPC","Safe",46,null,11,{"$f":"SUM(J26:M26)","v":11},null,1,5,5]
["CAUTIs","Mthly Number","ST","Safe",2,"TBC",4,{"$f":"SUM(J27:M27)","v":4},null,1,2,1]
["Service trac","Mthly %","Facilities",null,0.95,0.98,{"$f":"AVERAGE(J28:L28)","v":0.8458},{"$f":"AVERAGE(J28:M28)","v":0.8458},null,0.81,0.85,0.87739999999999996]
["SAFE AMBITION 7: Reduction of Harm Associated with Deterioration"]
["Sepsis Bundle compliance in A&E / Emergency wards","Mthly %","QG","Effective",0.9,null,{"$f":"AVERAGE(J30:L30)","v":0.73109999999999997},{"$f":"AVERAGE(J30:M30)","v":0.73109999999999997},null,0.66,0.74260000000000004,0.79069999999999996]
["IVAB within 1 hour for sepsis in A&E / Emergency wards ","Mthly %","QG","Effective",0.9,null,{"$f":"AVERAGE(J31:L31)","v":0.38046666666666668},{"$f":"AVERAGE(J31:M31)","v":0.38046666666666668},null,0.38100000000000001,0.38159999999999999,0.37880000000000003]
["VTE rate"," Mthly Number","ST",null,"TBC",null,{"$f":"SUM(J32:L32)","v":6},{"$f":"SUM(J32:M32)","v":6},null,2,3,1]
["VTE risk assessments completed on\nadmission ","Mthly %","Medway","Effective",">95%",1,{"$f":"AVERAGE(J33:L33)","v":0.96456666666666668},{"$f":"AVERAGE(J33:M33)","v":0.96456666666666668},null,0.96730000000000005,0.96640000000000004,0.96]
["Physiological observations on time ","Mthly %","SQD","Effective",0.9,null,{"$f":"AVERAGE(J34:L34)","v":0.79150000000000009},{"$f":"AVERAGE(K34:M34)","v":0.79150000000000009},null,null,0.79200000000000004,0.79100000000000004]
["Cardiac Arrests outside of the Emergency Department (not including peri-arrests)"," Mthly Number","Resus","Effective","TBC",null,{"$f":"SUM(J35:L35)","v":43},43,null,13,15,15]
["DNACPR compliance","Mthly %","SQD","Effective",0.9,null,{"$f":"AVERAGE(J36:L36)","v":0.95310000000000006},{"$f":"AVERAGE(K36:M36)","v":0.95310000000000006},null,null,0.96660000000000001,0.93959999999999999]
["SAFE AMBITION  8: Reduction of Harm Associated with Surgery"]
["Compliance WHO checklist completion ","Mthly %","QG","Effective",1,null,{"$f":"AVERAGE(J38:L38)","v":0.98299999999999998},{"$f":"AVERAGE(J38:M38)","v":0.98299999999999998},null,0.99299999999999999,0.96899999999999997,0.98699999999999999]
["SAFE AMBITION  9: Reduction of Harm by Building a Positive Patient Safety Culture"]
["Incidents reported"," Mthly Number","DATIX","Well Led",null,null,{"$f":"SUM(J40:L40)","v":3426},{"$f":"SUM(J40:M40)","v":3426},null,1054,1134,1238]
["Never Events"," Mthly Number","DATIX","Well Led",0,null,1,{"$f":"SUM(J41:M41)","v":1},null,0,0,1]
["Incidents reported on STEIS"," Mthly Number","STEIS","Well Led","TBC",null,18,{"$f":"SUM(J42:M42)","v":18},null,8,5,5]
["Incidents resulting in severe harm / death"," Mthly Number","DATIX","Well Led","TBC",null,54,{"$f":"SUM(J43:M43)","v":54},null,9,24,21]
["Duty of Candour compliance","Mthly %","DATIX","Well Led",1,1,{"$f":"AVERAGE(J44:L44)","v":0.50333333333333341},{"$f":"AVERAGE(J44:M44)","v":0.50333333333333341},null,0.17,0.67,0.67]
["Serious incidents relating to sub-optimal care"," Mthly Number","DATIX","Effective","TBC",null,"TBC","TBC",null,"TBC","TBC","TBC"]
["CARING AMBITION 10:  Improvement of Patient Experience Associated with Reduction of Complaints"]
["Complaints"," Mthly Number","DATIX",null,null,null,{"$f":"SUM(J47:L47)","v":198},{"$f":"SUM(J47:M47)","v":198},null,72,63,63]
["PALS"," Mthly Number","Pt Exp",null,null,null,{"$f":"SUM(J48:L48)","v":1046},{"$f":"SUM(J48:M48)","v":1046},null,367,326,353]
["CARING AMBITION 11:  Reduction of Harm by Improving the Patient Experience"]
["Inpatient FFT Recommend","Mthly %","Pt Exp",null,0.94,0.96,{"$f":"AVERAGE(J50:L50)","v":0.8833333333333333},{"$f":"AVERAGE(J50:M50)","v":0.8833333333333333},null,0.88,0.88,0.89]
["Day Case FFT Recommend","Mthly %","Pt Exp",null,0.88,0.87,{"$f":"AVERAGE(J51:L51)","v":0.94999999999999984},{"$f":"AVERAGE(J51:M51)","v":0.94999999999999984},null,0.96,0.95,0.94]
["Emergency Services  FFT Recommend","Mthly %","Pt Exp",null,0.88,0.87,0.80666666666666664,{"$f":"AVERAGE(J52:M52)","v":0.80666666666666664},null,0.81,0.82,0.79]
["Maternity (Birth) FFT Recommend","Mthly %","Pt Exp",null,0.97,0.96,0.97000000000000008,{"$f":"AVERAGE(J53:M53)","v":0.97000000000000008},null,1,1,0.91]
["Outpatient FFT Recommend","Mthly %","Pt Exp",null,0.92,0.92,0.92,{"$f":"AVERAGE(J54:M54)","v":0.92},null,0.92,0.92,0.92]
["Mixed Sex Accomodation"," Mthly Number","DATIX",null,0,0,{"$f":"SUM(J55:L55)","v":15},{"$f":"SUM(J55:M55)","v":15},null,10,2,3]
["EFFECTIVE AMBITION 13: Reduction of Harm Associated with Timeliness of Communication to GP"]
["eDD compliance","Mthly %","IS",null,0.95,0.95,{"$f":"AVERAGE(J57:L57)","v":0.75606666666666678},{"$f":"AVERAGE(J57:M57)","v":0.75606666666666678},null,0.74019999999999997,0.76719999999999999,0.76080000000000003]
["EFFECTIVE AMBITION 13: Reduction of Harm Associated with Maternity"]
["Number of Births","Mthly number","Maternity",null,500,null,{"$f":"SUM(J59:L59)","v":1325},{"$f":"SUM(J59:M59)","v":1325},null,427,445,453]
["Normal Birth Rate","Mthly %","Maternity",null,"> 63.5%",null,{"$f":"AVERAGE(J60:L60)","v":0.58396666666666663},{"$f":"AVERAGE(J60:M60)","v":0.58396666666666663},null,0.56440000000000001,0.61799999999999999,0.56950000000000001]
["Section Rate","Mthly %","Maternity",null,"< 20.7%",null,{"$f":"AVERAGE(J61:L61)","v":0.25606666666666666},{"$f":"AVERAGE(J61:M61)","v":0.25606666666666666},null,0.2482,0.2404,0.27960000000000002]
["Number of Induction","Mthly %","Maternity",null,0.3,null,0.26889999999999997,{"$f":"AVERAGE(J62:M62)","v":0.26889999999999997},null,0.31440000000000001,0.1769,0.31540000000000001]
["Number of still births","Mthly number","Maternity",null,"< 1 mth",null,{"$f":"SUM(J63:L63)","v":5},{"$f":"SUM(J63:M63)","v":5},null,3,1,1]
["PPH >2 lit","Mthly number","Maternity",null,"< 11 mth",null,15,{"$f":"SUM(J64:M64)","v":15},null,4,6,5]
["Numner of times unit closed","Mthly number","Maternity",null,"< 1 mth",null,1,{"$f":"SUM(J65:M65)","v":1},null,0,1,0]

{"sheet":"Key","index":1,"n_rows":18,"n_cols":2,"rows_kept":18,"cut":false,"hidden":true,"merged":[]}
["Key Identifiers"]
[]
["All Reports"]
["Black Text is Trust or Site Level data Only"]
["Purple Text holds data that transcends to Ward analysis"]
[]
[]
["Trust Report"]
[]
["Bold and underline headings link into the Quality Report."]
[]
[]
[]
[null,"= Outside the Trust and National Target"]
[null,"= Is within the Trust and National Target"]
[]
[]
["Methodology for Heat Map"]