Dimension: Access and Patient Flow (A+PF)

Rationale for measurement

Overcrowding within ED negatively impacts on both dignity and privacy for patients and the ability of staff to deliver fully effective care / treatment. Related international studies have also demonstrated extended length of stay within overcrowded EDs leads to poorer clinical outcomes for concerned patients.

Measurement methodology and data sources

  • data refers to the daily number of patients on trolleys in ED, at 8.00am daily, as recorded by the hospital
  • data set is provided by BIU – HSE

Target

The following daily targets were set by the HSE Acute Hospital Division:

  • Beaumont Hospital: 12
  • Cavan General Hospital: 8
  • Connolly Hospital: 8
  • Our Lady of Lourdes Hospital: 12
  • RCSI Hospital Group: 40
  • National: 228

Performance

Beaumont Hospital

  • performance maintenance in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 100% n=526 Jan-Aug)
    • performance improvement commenced in July 2016 generally maintained during 2020 reporting period
    • an average daily count value of 0 demonstrated for August 2021 (Target <12 achieved)

Cavan General Hospital

  • increase from n=1 to n=2 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 7% n=39 Jan-Aug)
  • an average daily count of 2 demonstrated for August 2021 (Target <8 achieved)

Connolly Hospital

  • performance maintenance in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 100% n=401 Jan-Aug)
  • an average daily count of 0 demonstrated for August 2021 (Target <8 achieved)

Drogheda Hospital

  • increase from n=0 to n=3 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 54% n=366 Jan-Aug)
  • an average daily count of 3 demonstrated for August 2021 (Target <12 achieved)

RCSI Hospital Group

  • increase from n=1 to n=5 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 62% n=1332 Jan-Aug)
  • an average daily count of 5 demonstrated for August 2021 (Target <40 achieved)

National Performance Comparator

  • 85% increase in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for August (total count reduction 22% n=7607 Jan-Aug)
  • an average daily count of 196 demonstrated for August 2021 (Target <228 achieved)
  • national performance not available via TrolleyGAR for May and June 2021 due to cyber attack.

Rationale for measurement

International studies have demonstrated extended length of stay within overcrowded EDs leads to poorer clinical outcomes for patients.

Measurement methodology and data sources

  • Data extract from hospital site patient administration system (PAS), extrapolated by HSE Business Intelligence Unit, measuring for all ED attendances the length of time spent in the Emergency Department.


Average time spent in ED – non admitted / admitted

Target

  • 100% of patients admitted / discharged from ED within 24 hours

Performance

Beaumont Hospital

  • average time spent in ED for admitted patients is 12 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 8 hours for reporting month 2021

Cavan General Hospital

  • average time spent in ED for admitted patients is 11 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 5 hours for reporting month 2021

Connolly Hospital

  • average time spent in ED for admitted patients is 10 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 5 hours for reporting month 2021

Drogheda Hospital

  • average time spent in ED for admitted patients is 9 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 6 hours for reporting month 2021

Target

  • 100% patients admitted or discharged or non-admitted from ED within 9 hours

Performance

Beaumont Hospital

  • August 2021 67.2% compliance with 9 hour non-admitted PET / 31.6% compliance with admitted PET

Cavan General Hospital

  • August 2021 87.1% compliance with 9 hour non admitted PET / 43.8% compliance with admitted PET

Connolly Hospital

  • August 2021 88.0% compliance with 9 hour non admitted PET / 53.0% compliance with admitted PET

Drogheda Hospital

  • August 2021 79.0% compliance with 9 hour non admitted PET / 57.0% compliance with admitted PET

RCSI Hospital Group

  • August 2021 80.3% compliance with 9 hour non admitted PET / 46.4% compliance with admitted PET

National Performance Comparator

  • July 2021 82.3% compliance with 9 hour non admitted PET / 56.0% compliance with admitted PET
  • August national performance not available at time of report publication

Target:    

  • 100% of patients wait less than 24 hours in Emergency Department for ward bed accommodation

Performance

RCSI Hospital Group



  • Beaumont Hospital – August 2021 0.7% >24hours (0.1% August 2020) performance deterioration demonstrated
  • Cavan Hospital – August 2021 0.3% >24hours (0.7% August 2020) performance improvement demonstrated
  • Connolly Hospital – August 2021 0% >24 hours  (0% August 2020) performance maintenance demonstrated
  • Drogheda Hospital – August 2021 2.9% >24hours (0.2% August 2020) performance deterioration demonstrated

  • RCSI HG – August 2021 1.2% > 24hours (0.2% August 2020)
  • National – July 2021 2.4% > 24hours (1.2% July 2020)

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome for patients.

Measurement methodology and data source

  • Compliance % with <52 weeks waiting time. Periodic local data extracts submitted to NTPF extrapolated for analysis and publication.

Target

  • 100% patients waiting <52 weeks for new outpatient appointment (RCSI Hospital Group target)
  • 75% patients waiting <52 weeks for new outpatient appointment (National target)

Performance <52 weeks

Beaumont Hospital

  • 90% of patients waiting <52 weeks on OPD wait list (2021)

Cavan General Hospital

  • 77% of patients waiting <52 weeks on OPD wait list (2021)

Connolly Hospital

  • 93% of patients waiting <52 weeks on OPD wait list (2021)

Drogheda Hospital

  • 78% of patients waiting <52 weeks on OPD wait list (2021)

Louth County Hospital

  • 79% of patients waiting <52 weeks on OPD wait list (2021)

Rotunda Hospital

  • 100% of patients waiting <52 weeks on OPD wait list (2021)

RCSI Hospital Group – % of OPD Patients <52 weeks – as at August 2021

National Hospital Groups – % of OPD Patients <52 weeks – as at August 2021

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

Number of adult patients waiting for admission / attendance. Periodic local data submission to NTFP extrapolated for analysis and publications excluding patients with ‘to come in date‘ (tci) (NTPF – definition).

Target

  • 85% patients waiting <15 months for admission / attendance (National target)
  • 100% patients waiting <8 months for admission / attendance (RCSI HG target)

Performance

Beaumont Hospital

  • 79% of patients waiting <8 months for admission / attendance (2021)

Cavan General Hospital

  • 92% of patients waiting <8 months for admission / attendance (2021)

Connolly Hospital

  • 100% of patients waiting <8 months for admission / attendance (2021)

Drogheda Hospital

  • 79% of patients waiting <8 months for admission / attendance (2021)

Louth County Hospital

  • 87% of patients waiting <8 months for admission / attendance (2021). Ophthalmology excluded which comprises 9.8% DC activity and is under the control of IEHG 

RCSI Hospital Group

  • 82% of patients waiting <8 months for admission / attendance (2021)

National Performance by Hospital Group Comparator

  • national performance for August not available at time of report publication

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

  • periodic local data extracts submitted to the National Cancer Control Programme (NCCP), extrapolated for analysis and publication

Target

  • 95% of attendances whose referral was triaged as urgent by the cancer centre and attended or were offered an appointment within 2 weeks

Performance

Beaumont Hospital

  • Beaumont Hospital exceeded National Target set for 2021 reporting period (99% achieved against a target of 95%). National Performance for April, May, June, July and August 2021 not available at time of publication due to cyber attack. National Performance for March 2021 (70.5%) did not achieve target.

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

  • periodic local data extracts submitted to NCCP, extrapolated for analysis and publication

Target:

  • 95% of patients attending the rapid access clinic who attended or were offered an appointment within 10 working days of receipt of referral in the cancer centre

Performance

Beaumont Hospital

  • Beaumont Hospital attained National Target set for 2021 reporting period (100% achieved against a target of 95%). National Performance for April, May, June, July and August 2021 not available at time of publication due to cyber attack. National Performance for March 2021 (92.8%) did not achieve target.

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

  • periodic local data extracts submitted to NCCP, extrapolated for analysis and publication

Target:

  • 95% of patients attending the rapid access clinic who attended or were offered an appointment within 20 working days of receipt of referral in the cancer centre

Performance

Beaumont Hospital

  • Beaumont Hospital exceeded National Target set for 2021 reporting period (100% achieved against a target of 95%). National Performance for April, May, June, July and August 2021 not available at time of publication due to cyber attack. National Performance for March 2021 (57.9%) did not achieve target.

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome for patients.

Measurement methodology and data source

  • Periodic local data extracts submitted to NTPF, extrapolated for analysis and publication

Target

  • 100% of patients identified a requiring urgent colonoscopy undertaken / offered appointment within 28 days

Performance

RCSI Hospital Group

  • 100% compliance within the RCSI Hospital Group for August 2021 monthly reporting period
  • May and June data not available at time of report publication due to cyber attack
  • July data reflects 2 reporting weeks. Connolly data unavailable for both weeks; Cavan unavailable for 1 week

National Performance

  • 77% compliance nationally for August 2021 monthly reporting period. n=2515 total patient volume nationally requiring urgent colonoscopy at end of Aug-21 (performance maintenance vs same period in 2020)
  • May and June data not available at time of report publication due to cyber attack
  • July data reflects 2 reporting weeks. 9 hospitals nationally did not report data for the 2 reporting weeks

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data sources

  • Periodic local data extracts submitted to NTPF, extrapolated for analysis and publication

Target

  • 65% of patients identified as requiring routine GI endoscopy undertaken or offered appointment within 13 weeks

Performance

Beaumont Hospital

  • Beaumont Hospital is currently achieving this target for August reporting period (94% compliance)

Cavan General Hospital

  • Cavan General Hospital is currently achieving this target for August reporting period (94% compliance)

Connolly Hospital

  • Connolly Hospital is currently not achieving this target for August reporting period (58% compliance)

Drogheda Hospital

  • Drogheda Hospital is currently achieving this target for August reporting period (91% compliance)

Louth County Hospital

  • Louth County Hospital is currently achieving this target for August reporting period (82% compliance)

RCSI Hospital Group

  • RCSI Hospital Group is currently achieving this target for August reporting period (81% compliance)

National Performance Comparator

  • nationally this target is not being met for reporting period July 2021 (36% compliance)
  • national performance for June (due to the cyber attack) and August 2021 not available at time of report publication

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data sources

  • Monthly data provided by BowelScreen programme

Target

  • Minimum standard target is ≥90% of clients offered a colonoscopy appointment that occurs within 20 working days from when a client was deemed clinically suitable following pre-assessment / notification of positive FIT

Performance

RCSI Hospital Group

  • Connolly achieved target of 100% compliance Aug-21
  • May data not produced by BowelScreen Programme due to cyber attack

  • LCH achieved target of 100% compliance Aug-21
  • May data not produced by BowelScreen Programme due to cyber attack

  • national performance for May not produced by BowelScreen Programme due to cyber attack. National performance for August 92%.

Introduction

A cervical screening test (previously known as a smear test) looks to see if a woman might be at greater risk of developing cervical cancer in the future. Occasionally following smear test abnormal cells may be identified and a further test called a colposcopy may be required. A colposcopy is a simple examination that is carried out in the same way as a smear test. A doctor or nurse will look at the cervix (neck of the womb) using a type of microscope called a colposcope. During the examination, a liquid or dye may be applied to the cervix to help identify any changes to the cells and to decide if any treatment is needed.

Rationale for measurement

There are two centres providing colposcopy services in the RCSI Hospital Group, Louth County Hospital and the Rotunda Hospital.

Delays have the potential to result in less than optimal outcomes for patients

Measurement methodology and data sources

  • % of patients referred to the Colposcopy Service who were offered an appointment
  • periodic local data extracts submitted to Cervical Screening Service, extrapolated for analysis and publication

Target

  • Urgent Referral – 90% seen within 2 weeks of referral
  • High Grade Referral – 90% seen within 4 weeks of referral
  • Low Grade Referral – 90% seen within 8 weeks of referral

Performance

  • national comparative data not produced due to cyber attack

Rationale for measurement

Beaumont Hospital is the National Referral Centre for Neurosurgery in Ireland. Neurosurgery concerns the operative and non-operative management of patients with disorders of the central and peripheral nervous systems. The specialty developed initially through the treatment of cranial trauma and intracranial mass lesions. Subsequent advances in microsurgical techniques, non-invasive imaging, neuro-anaesthesia, intensive care, image-guided surgery, and the introduction of sophisticated radio-oncological and interventional treatments have substantially enhanced and widened the scope of effective neurosurgical treatment. Delay in access to Unit can result in delay in treatment commencing with potential for less than optimal outcome for patients.

Measurement methodology and data sources

  • Beaumont is the National Neurosurgical Unit. Therefore data for Beaumont hospital only is represented.
  • Periodic local data extracts submitted quarterly and retrospectively extrapolated for analysis and publication.

 Targets

  1. 100% of patients triaged as Traumatic Brain Injury (TBI) admitted to Unit within 12 hours of acceptance.
  2. 90% of patients triaged as Grade I / II Sub-arachnoid Haemorrhage (SAH) admitted to Unit within 24 hours of acceptance.
  3. 90% of patients triaged as having a brain tumour are transferred to Unit within 5 working days / 7 calendar days of acceptance

Performance

RCSI Hospital Group

  • 97% compliant
  • patient delayed due to appropriate bed availability (n=1)

  • 97% compliant

  • 86% compliant
  • missed target by 24 hours (n=14)

Rationale for measurement

Significant delay in securing necessary diagnostic image report can delay primary diagnosis, treatment commencement or treatment review with potential for less than optimal outcome for patients.

Measurement methodology and data sources

  • waiting time from diagnostic order identification and diagnostic being undertaken (either GP or Consultant)
  • local site data sets extrapolated for analysis and publication, by definition excluding time staged diagnostic order requirements
  • national data set currently combines CT, MRI and US patient cohorts segregates into urgent, semi urgent, routine, excludes these patients not vetted using ‘new’ criteria or not vetted electronically – accordingly actual national performance for their specific diagnostics is not readily discernible or comparable

Target

  • Ultrasound – 100% compliance < 3 months (RCSI HG target)
  • MRI – 100% compliance < 6 months (RCSI HG target)
  • CT – 100% compliance < 6 months (RCSI HG target)

Performance

Beaumont Hospital

  • US 97% waiting < 3 months – Beaumont did not achieve target
  • MRI 97% waiting < 6 months – Beaumont did not achieve target
  • CT 98% waiting < 6 months – Beaumont did not achieve target

Connolly Hospital

  • US 89% waiting < 3 months – Connolly did not achieve target
  • MRI 100% waiting < 6 months – Connolly achieved target
  • CT 100% waiting < 6 months – Connolly achieved target

Cavan Hospital

  • US 60% waiting < 3 months – Cavan did not achieve target
  • MRI 96% waiting < 6 months – Cavan did not achieve target
  • CT 96% waiting < 6 months – Cavan did not achieve target

Drogheda Hospital

  • US 70% waiting < 3 months – Drogheda/LCH did not achieve target
  • MRI 95% waiting < 6 months – Drogheda did not achieve target
  • CT 85% waiting < 6 months – Drogheda did not achieve target (Drogheda CT includes out-patients scanned in LCH)

RCSI Hospital Group

  • US 76% waiting < 3 months – Group did not achieve target
  • MRI 96% waiting < 6 months – Group did not achieve target
  • CT 94% waiting < 6 months – Group did not achieve target

Rotunda Hospital (not included in Group total – only Gynae scans)

  • US 64% waiting < 3 months – Rotunda did not achieve target

NB – actual national performance for diagnostics is not readily discernible or comparable

Rationale for measurement

Non-attendance of new patients for OPD appointment negates the ability to diagnose and treat and generally wastes clinical time. This wasted clinical time significantly adds to wait times for other patients.

Measurement methodology and data sources

  • periodic local data extracted and extrapolated for analysis and publication by HSE BIU
  • source for national data provided by BIU OPD MDR

Target

  • <12% of new OPD bookings do not attend scheduled appointment

Performance

RCSI Hospital Group May & Jun data does not include Rotunda (~3,000 OPD Attendances)

  • cumulative for 2021 reporting period 12.3% (n=12,130) of total new bookings did not attend (DNA) scheduled appointments / 2020 11.1% DNA (n=8,715) – represents 39.2% increase
    • Beaumont 2021 16.2% DNA / 2020 13.7% DNA
    • Cavan 2021 6.1% DNA / 2020 8.6% DNA
    • Connolly 2021 16.0% DNA / 2020 9.9% DNA
    • Drogheda 2021 8.5% DNA / 2020 7.0% DNA
    • Louth 2021 7.9% DNA / 2020 8.8% DNA
    • Monaghan 2021 7.6% DNA / 2020 6.8% DNA
    • Rotunda 2021 9.5% DNA / 2020 12.0% DNA

National Performance Comparator

  • during July 2021 monthly reporting period 12.6% of total new bookings (n = 9,407) did not attend scheduled appointment
  • national data for August 2021 not available at time of report publication

Introduction:

A colonoscopy is an examination of the bowel using a small camera on the end of a thin flexible tube. The tube is inserted into the rectum and then into the large bowel.

During the examination a small sample of the lining of the bowel may be taken to look at more closely. This is called a biopsy. The test looks for any polyps or signs of disease in the lining of the bowel. Polyps are small growths that are not cancer but, if not removed, might turn into cancer over time. If polyps are found they are usually removed during the colonoscopy. This is to reduce the risk of cancer developing.

Rationale for measurement

Internationally accepted guidelines on performance indicators for colonoscopy recommend monitoring of the detection rates of suspicious lesions including polyps and adenomas. 

Measurement methodology and data sources

The data is recorded at local hospital Endoscopy Units. It is subsequently reported into Conjoint Board in Ireland of the Royal College of Physicians and Royal College National Quality Improvement Programme in GI Endoscopy (NEQI Programme) in collaboration with the National Cancer Control Programme. Results are reported as colonoscopies with polyp detected expressed as a % of total colonoscopies per endoscopist.

Data Sources:

  1. https://www.rcpi.ie/quality-improvement-programmes/gastrointestinal-endoscopy
  2. National GI Endoscopy Quality Improvement Programme 2019 Data Report, Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons

Target

  • ≥ 20% of all colonoscopies should have a polyp(s) detected

Performance

  • all hospitals in RCSI Hospital Group achieved target

  • all hospitals in RCSI Hospital Group achieved target

Introduction:

Caecal intubation is defined as the passage of the tip of the colonoscope to a point proximal to the ileocecal valve so that the entire cecum is visualised.

Rationale for measurement

Caecal intubation rates (CIR) are a key quality indicator of colonoscopy. Caecal intubation can be expected to be difficult in 5%–15% of colonoscopies, but skilled colonoscopists should be able to apply techniques to overcome the difficulties in most of these instances and reach the cecum in ≥90% of all cases.

Measurement methodology and data sources

The data is recorded at local hospital Endoscopy Units. It is subsequently reported into Conjoint Board in Ireland of the Royal College of Physicians and Royal College National Quality Improvement Programme in GI Endoscopy (NEQI Programme) in collaboration with the National Cancer Control Programme.

Results are reported as number of colonoscopies where the terminal ileum/caecum/anastomosis has been reached as a % of total colonoscopies per endoscopist.

Data Sources:

  1. https://www.rcpi.ie/quality-improvement-programmes/gastrointestinal-endoscopy
  2. National GI Endoscopy Quality Improvement Programme 2019 Data Report, Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons

Target

  • ≥ 90% of all colonoscopy cases should reach the terminal ileum/caecum/anastomosis

Performance

  • all hospitals in RCSI Hospital Group achieved target

  • all hospitals in RCSI Hospital Group achieved target

Introduction

Elective day surgery is the admission of selected patients to hospital for a planned surgical procedure who return home on the same day. Elective day surgery benefits patients as they receive treatment that is suited to their needs and allows them to recover in their own home. In addition the risk of patients contracting a hospital acquired infection is reduced. Elective day case surgery releases inpatient beds for major cases, this improves throughput of patients and reduces waiting lists.

Rationale for measurement

75% of elective admissions on each of the 24 procedures identified can be carried out as day cases (National Elective Surgery Programme, Royal College of Surgeons in Ireland, Irish College of Anaesthetists and Health Service Executive).

(Orchidopexy, Circumcision, Inguinal Hernia Repair, Excision of Breast Lump, Anal Fissure Dilatation or Excision, Haemorrhoidectomy, Laparoscopic Cholecystectomy, Varicose Vein Stripping or Ligation, Transurethral Resection of Bladder Tumour (<2cm), Excision of Dupuytren’s Contracture, Carpal Tunnel Decompression, Excision of Ganglion, Arthroscopy, Bunion Operations, Removal of Metal-ware, Extraction of Cataract with/without Implant, Correction of Squint, Myringotomy, Tonsillectomy, Sub Mucous Resection, Reduction of Nasal Fracture, Operation for Bat Ears, Dilatation and Curettage/Hysteroscopy, Laparoscopy).

Measurement methodology and data sources

Local Hospital HIPE Data extrapolated for analysis and publication and published on a quarterly basis.

Target

75% of elective admissions on each of the 24 procedures identified are carried out as a day case.

Performance

  • 82% of procedure basket undertaken on a day case basis – overall target achieved
  • national dataset not available

Rationale for measurement

Four key reasons may cause delay in patients receiving timely diagnosis and treatment and can also waste clinical treatment time:

  • tardy recording of patient details onto scheduled care waiting list record (OPD / IP / DC)
  • absence of advance patient notification in regard to intended scheduled care: OPD appointment / Day Care attendance / Inpatient admission date
  • incomplete patient specific minimum data set record
  • non-compliance with Hospital Group policies in regard to patients not being able to attend (CNA) scheduled OPD appointment / Day Care attendance / Inpatient admission date or patients who do not attend (DNA) scheduled OPD appointment / Day Care attendance / Inpatient admission (see 3.14)

Measurement methodology and data sources

  • periodic sampling (taken on a quarterly basis) of Hospital Group ‘waiting list’ data sets to ascertain:
    • time period from receipt of GP referral letter / treatment requirement identification and waiting list record entry
    • advance patient notification in regard to intended scheduled care: OPD appointment / Day Care attendance / Inpatient admission date
    • completeness of patient specific minimum data set record: all hospital waiting list cards examined for inclusion of 25 items
    • for those patients identified as ‘could not attend’ (CNA) i.e. sickness, leave, family commitments review of subsequent practises in terms of record keeping including patient waiting time
    • for those patients identified as ‘did not attend’ (DNA) review of subsequent practices in terms of record keeping including patient waiting time

Target:

  • > 95% of New OPD / Day Care / Inpatient record entries. Two measurements of compliance
    • WL record is updated within 3 working days of receipt of WL booking form
    • start date on WL record = Decision to Admit date
  • > 95% of patients are directly notified in regard to intended scheduled care appointment / attendance
  • > 95% compliance with sending acknowledgement letter (outpatients)
  • > 85% compliance with completeness of patient specific minimum data set record
  • > 90% compliance with DNA / CNA RCSI HG policies

Performance

% compliance recording of patient details onto scheduled care waiting list record ≤ 3 days

  • note overall sample size n=100 patients (20 per hospital)
  • during Q2 2021 overall sample group demonstrated 98% compliance with data entry requirements

% compliance of recording of patient details onto scheduled care waiting list record (Start date = DTA)

  • note overall sample size n=100 patients (20 per hospital)
  • during Q2 2021 overall sample group demonstrated 98% compliance with data entry requirements

% compliance with advance patient notification ≥ 14 days’ notice

  • note: overall sample size n=100 patients (20 per hospital)
  • during Q2 2021 overall sample group demonstrated 100% compliance with patient notification requirements (IP.DC)

% compliance of sending acknowledgement letter (Out Patients)

  • note: overall sample size n=100 patients (20 per hospital)
  • during Q2 2021 overall sample group demonstrated 100% compliance with requirement to send acknowledgement letter

compliance of patient specific minimum data set completeness on WL Record

  • note: sample size n=500 data points
  • during Q2 2021 overall sample group demonstrated 96% compliance with completion of patient specific minimum data set

compliance of DNA / CNA Policy compliance

  • note: DNA policy: DNA patients are removed from waiting list
  • note: if patient cannot attend (CNA) their wait time clock restarts
  • note: report sample size (n=100)
  • note: insufficient cancellations/ dnas to comply with 100 records being checked
  • during Q2 2021 overall sample group demonstrated 100% compliance with DNA and CNA policies
  • national performance not produced