Performance ReportJuly 2016
Date: 12 August 2016
Version: 0f
Purpose and Summary of Document:
The purpose of this report is to provide an update on Public Health Wales’
performance, including against the:

public health indicators within the NHS Wales Delivery Framework

key service indicators
An overview of performance indicators, including those that relate to
public health within the NHS Delivery Framework, is provided within our
July dashboard (see page 3). The dashboard provides a summary of
progress against our key performance indicators reported for this period
and includes the latest available performance information. The arrows in
the table indicate the change from the previous period, where applicable.
Targets stated in the dashboard are the agreed performance trajectories
within the Integrated Medium Term Plan. The full performance dashboard
can be found in appendix 1.
Further service level detail is provided in pages 5 – 14 and includes
current performance, including a high level summary of the actions that
we are taking to improve where required.
Date: 12/08/16
Version: 0f
Page: 1 of 16
Overview of performance
This report (July 2016) includes updates against 35 of Public Health Wales’ performance
indicators (these are marked in blue on the dashboard). 26 of these indicators are green, 2
amber and 5 are red (2 are not RAG rated due to nature of the indicator).
Like for like comparisons with the last available month/quarter show:

reds remain at 5

ambers have decreased from 5 to 1

Greens have increased from 9 to 13
The majority of our Screening programmes continue to show improvements in performance.
For Breast Test Wales, normal results sent within 2 weeks continue to remain above target at
98%. However, the number of assessments given within 3 weeks has decreased from 90%
to 72% and is below standard. This is due to medical staffing issues in the West Wales region
of the service.
Cervical screening is showing an increase from 87% to 92% in laboratory turnaround times.
This reflects an ongoing trend of improved performance over the past 4 months. Waiting
times from sample being taken to test results being sent is above target for the sixth
consecutive month and waiting times for colposcopy appointments also remain above target
at 97%.
Bowel screening has shown further significant improvement in performance in relation to
waiting times for screening test results (from 48% in May to 100% in July). LIMS
implementation has now settled and staffing required to maintain data entry has reduced,
which has led to an increase in performance. Waiting times for colonoscopy which has also
seen a significant increase from 74% in May to 91% in June and is achieving the standard for
the first time since February.
Newborn Hearing screening programme continues to exceed the national standard for
babies who complete screening within 4 weeks. Coverage has increased for the 4th
consecutive month and remains above target. However, babies completing the assessment
procedure by 3 months of age has fallen below standard for the first time since November
2015 (81% in July).
Microbiology achieved the majority of its targets for quarter 1. Bacteriology turnaround time
compliance was slight under the target at 94% and the data is currently being reviewed to
identify any data outliers and actions will be implemented as required.
The National Exercise Referral Scheme achieved all its targets in quarter 1. There were 7,215
referrals to the service of which over 50% took up a place on the scheme.
Our sickness absence rate for the rolling 12 month period (July 2015 to June 2016) reduced
from 3.84% to 3.79%, although is still above the Welsh Government target of 3.25%.
However, the monthly figure for July 2016 was 3.24%.
C diff rates have decreased from 41.6 in June to 32.29 in July, while there has been a slight
increase in rates for staph aureus bacterameis from 25.5 to 25.8 over the same period. Both
remain above the performance trajectory for July 2016 and as a result support has been
offered to health boards.
Stop Smoking Wales’ performance for number of clients that became treated reduced from
552 smokers in May to 510 in June and did not meet the monthly target. This is due to
insufficient numbers contacting Stop Smoking Wales for advice and support to quit and
several posts within the service being vacant. However, our target for waiting times for
appointment (14) has decreased from the previous month and is currently at 7 days.
Date: 12/08/16
Version: 0f
Page: 2 of 16
Performance dashboard July 2016
The performance dashboard includes the latest available performance
information. Further detail on specific service performance is provided
within subsequent sections of this report.
Performance Updates - July 20163



1
Targets
95%
70%
98.3%
90.2%
98.3%
72.8%


90%
Jun-16
87.0%
Jul-16
92.1%

92%
93.4%
96.4%

95%
96.5%
Not available
Jun-16
93.4%
91.3%
Jun-16
93.1%
Jul-16
99.7%
Bowel Screening Wales (page 7)
Waiting time for screening test results
Waiting time for colonoscopy
95%
95%
Abdominal Aortic Aneurysm Screening Wales (page 8)
Surveillance uptake
Latest
Status
Jul-16
Cervical Screening Wales (page 6)
Laboratory turnaround time for gynae cytology test results (3 weeks)
Waiting time from sample being taken to screening test result being sent
(4 weeks)
Waiting time for colposcopy appointment (all CSW direct referrals with
abnormal cytology)
Time Frame
Jun-16
Breast Test Wales (page 5)
Normal results sent within 2 weeks of scan
Assessment invitations given within 3 weeks of screen
Improvement from previous period
Reduction from previous period
Unchanged from previous period
90%

Not available
Jul-16
Not available
Newborn Hearing Screening Wales (page 9)
% of babies who complete programme (within 4 weeks)
Babies completing assessment procedure (by three months of age)
98%
95%
Newborn Bloodspot Screening (page 10)
Newborn bloodspot screening coverage (newborn babies)
94.5%
Stop Smoking Wales (page 11)
No. of clients that became a treated smokers
Average waiting time for an appointment in this month (days)
National Exercise Referral Scheme
Take up
Number
Number
Number
Number
of
of
of
of
16 week consultations
52 week consultations
referrals
1st consultations
Date: 12/08/16
Version: 0f
817
14
Q1 Target
3246
1623
811
5796
4057
98.7%
90.6%
Jun-16
94.6%
Not available
Jun-16
Jul-16
510
7
Q1
3949
2172
1052
7215
4588
Not available
Page: 3 of 16
81.4%
Jul-16
95.5%
Not available
Q2
Not available


Microbiology
CPA accreditation status and move to ISO 15189 (Microbiology)
EQA performance (Bacteriology)
EQA performance (Virology)
EQA performance (Specialist and reference units)
EQA performance (Food, Water and Environmental Laboratories)
Turnaround time compliance (Bacteriology)
Turnaround time compliance (Virology)
Turnaround time compliance (Specialist and reference units)
Turnaround time compliance (Food, Water and Environmental Labs)
Turnaround time compliance urgent samples (bacteriology/virology)Annual
Non processed samples (Bacteriology)
Non processed samples (Virology)
Non processed samples (Specialist and Reference Units)
Q1 target
Accredited
95%
95%
95%
90%
95%
95%
95%
95%
<=1.5%
<=1.9%
<=0.3%
Not available4
29.3
20.9
N/A
100%
Concerns and Complaints
Number of written concerns/complaints received
Written concerns/complaints responded to within target timescales
N/A
100%
Performance Appraisal
% of medical staff performance appraisal (last 15 months)
100%
Sickness absence rate (page 13)
Sickness absence rate (rolling 12 month period)
3.25%
Status
Not
available
Reported annually
Incidents
Number of SUIs reported
SUI investigations completed within the timescales
Q2
95%
Healthcare Associated Infections 2 (page 12)
Clostrium difficile rate (per 100,000 population)
Staph aureus bacteraemis rate (per 100,000 population)
Q1
Accredited
99.0%
99%
100%
98.0%
94.0%
98.0%
98.0%
98.0%
Jun-16
41.6
25.5
Jun-16
1
100%
Jul-16
32.29
25.83
Jul-16
1
100%
Jun-16
4
100%
Jun-16
Jul-16
3
100%
Jul-16
100%
Jun 15May 16
3.84%
100%
Jul 15Jun 16
3.79%


N/A

N/A



1. Data reported against 2016/17 targets or, where a performance trajectory has been agreed to facilitate reaching the target, the Q1 trajectory has been used as defined within
the IMTP 2016-2019
2. Performance figures reported against a monthly decreasing trajectory for C.Difficle and S.aureus bacteramia to attain the required national target rates of 28 per 100000 for
C.Difficile and 20 per 100000 for Staph aureus bacteraemia from October 2016 to March 2017.
3. Previous month’s data for Cervical Screening, Bowel Screening and Healthcare Associated Infections has been validated and changes refelected in the dashboard.
4. Issue collecting workload figures. Unable to determine percentage of non processed samples.Meeting arranged with business manager and Head of Operations
Date: 12/08/16
Version: 0f
Page: 4 of 16
Breast Test Wales
Breast Test Wales: Assessment
invitations given within 3 weeks of
screen
Breast Test Wales: Normal results sent
within 2 weeks of screen
100.00%
100.0%
80.00%
80.0%
60.00%
60.0%
40.00%
40.0%
20.00%
20.0%
Jul-16
Jun-16
May-16
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
0.00%
0.0%
Standard
Standard
Summary of Performance

Normal test results sent within two weeks of scan remains above target at 98.3%.

However, assessment invitations given within three weeks of scan have reduced from 90.2% in June to 72.8% in July and is now
below the standard. This is due medical staffing issues (vacancy, annual leave and sickness) within the West Wales region of the
service, which locally achieved a figure of 38% seen within 3 weeks of screen.
Actions to improve areas of underperformance






Cross cover to reduce clinic cancellations – A breast clinician was paid additional sessions to cover short notice sick leave to
prevent late clinic cancellation.
An additional Breast Clinician and advanced practice Radiographer is being trained to further support the service
Service users are backfilled into cancellation slots where sufficient notice is given, to ensure clinics run at maximum capacity.
An additional ultrasound machine has been deployed to increase clinic throughput and support workforce training
Result consultations within assessment clinics are being reduced and moved to other dates / times to ensure the maximum
amount of new patient slots are available.
A proposal is being developed to address capacity issues on the Wrexham Assessment Centre site
Date: 12/08/16
Version: 0f
Page: 5 of 16
Cervical Screening Wales
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Cervical Screening Wales: Laboratory
turnaround time for gynaecological
cytology test results
- 3 weeks
2015
2016
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Standard
Cervical Screening Wales: Waiting time
from sample being taken to screening test
result being sent - 4 weeks
2015
2016
Standard
Summary of Performance

Laboratory turnaround times for gynae cytology test results has improved from 87% (June) to 92.1% in July and is exceeding
the agreed performance trajectory. It must be noted that, due to the nature of the service, 100% compliance with the standard
cannot be achieved.

Waiting times for sample being taken to screening test results being sent has increased from 93% in June to 96% in July and is
exceeding the Public Health Wales trajectory for 2016/17 and the national standard.

Waiting times for colposcopy appointment are above target at 97%.
Actions to improve areas of underperformance




Laboratories across Wales are using locum staff and outsourcing work as required
The Magden Park laboratory has three additionally qualified staff members (1 additional post, and 2 recently qualified trainees),
increasing in-house capacity
Magden has taken additional work from North Wales laboratory to clear a backlog associated with introduction LIMS and HPV
triage
Planning session for further implementation of HPV (Pilot and full primary screening) scheduled for August 2016
Date: 12/08/16
Version: 0f
Page: 6 of 16
Bowel Screening Wales
Bowel Screening Wales: Waiting time
for screening test results
100.0%
100.0%
80.0%
80.0%
60.0%
Bowel Screening Wales: Waiting time
for colonoscopy within 4 weeks of
booking appointment
60.0%
40.0%
40.0%
20.0%
20.0%
0.0%
0.0%
2015
2016
2015
2016
Summary of Performance


Waiting times for test results have increased from 93% in June to 100% in July and is exceeding the target for the first time in 5
months.
Waiting times for colonoscopy have shown a significant increase from 74% in May to 91% in June and is also now exceeding the
standard for the first time since February 2016.
Actions to improve areas of underperformance




Although the targets have been achieved it is anticipated that list cancellations will rise over the summer months resulting in
lengthening waits in several Health Boards
The Bowels Screening Wales team continue to work with health boards to put plans in place to address the number of required
appointments over the forthcoming months.
A regional service covering Abertawe Bro Morgannwg and Hywel Dda has been agreed in principle and a proposal is currently
being developed for consultation with both health boards
Issues remain in Betsi Cadwaladr and Aneurin Bevan with a service review meetings planned with the Director of Screening to
address issues.
Date: 12/08/16
Version: 0f
Page: 7 of 16
Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm:
Surveillance Uptake
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
2015
2016
2016/17 Target
Summary of Performance

Surveillance uptake remains above target at 93% in May.
Actions to improve areas of underperformance

N/A
Date: 12/08/16
Version: 0f
Page: 8 of 16
Newborn Hearing Screening
Percentage of babies who complete
screening within 4 weeks
Percentage of babies completing the
assessment proecedure by 3 months of age
100.00%
100.00%
80.00%
80.00%
60.00%
60.00%
40.00%
40.00%
20.00%
20.00%
0.00%
0.00%
2016/17 Target
2016/17 Target
Summary of Performance


Performance continues to exceed targets for per cent of babies who complete programme within 4 weeks (99%)
The number of babies completing the assessment procedure has decreased from the previous reporting period to 81% in July
from 91% in June. This relates to the late booking of two babies in Wales by 2-3 days.
Actions to improve areas of underperformance

Programme coordinators are monitoring these referrals and follow up with the audiology departments on a case by case basis.
Date: 12/08/16
Version: 0f
Page: 9 of 16
Newborn Bloodspot Screening
Newborn Bloodspot Screening:
Coverage. (PHW trajectory Q1 & Q2 =
94.5%)
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
2016/17 Target
Summary of Performance

Screening coverage has increased to 96% in July from 95% in June and is exceeding the standard. This corresponds with the
increase in avoidable repeat rates during the period which have also increased from 93% in June to 95% in July. It is anticipated
when these improve there will be a corresponding improvement in the coverage figures.
Actions to improve areas of underperformance

N/A
Date: 12/08/16
Version: 0f
Page: 10 of 16
Stop Smoking Wales
Monthly total of clients that
became a treated smoker - all
2,200
Wales
Average waiting time for an
appointment in this month
(days)
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
Monthly Total
Average waiting times (days)
Jun-16
May-16
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
16
14
12
10
8
6
4
2
0
Target (days)
Summary of Performance

Figures for the number of clients that became a treated smoker are below target with 510 clients that were treated. This is due to
insufficient numbers contacting Stop Smoking Wales for advice and support to quit and several posts within the service have
become vacant, alongside long term sickness. This has resulted in a number of clinics having limited bank cover and increased use
of telephone support as an interim measure.

The average waiting time for an appointment continues to be achieved and is below target at 7 days(14 days)
Actions to improve areas of underperformance






Development sessions are being held for advisors looking at case studies and ways of developing skills to retain clients at sessions
Senior Advisors are targeting clinics which are quiet, including: engaging with Communities First teams to support cessation work,
liaising with the workplace health teams and working with health boards to support Making Every Contact Count and other
ongoing projects.
Work is ongoing to attend cluster group meetings to promote streamlined referral to service.
Work is ongoing in ABMU health board to ensure that maternity referrals are automatically generated using Myrddin.
Promotion work by the Healthy Living Advisors continues, with attendance at a range of community events and via leafleting
Engagement work with several workplaces resulted in new work place groups being established.
Date: 12/08/16
Version: 0f
Page: 11 of 16
Healthcare Associated Infections
Clostridium difficile rate per
100k population (all Wales)
Staph aureus rate per 100k
population (all Wales)
50
30
25
40
20
30
15
20
10
10
5
Jul-16
Jun-16
May-16
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Aug-15
Sep-15
0
0
National Target. New target agreed with Welsh
Government from 01/10/2016 to 31/03/2017.
National Target. New target agreed with Welsh
Government from 01/10/2016 to 31/03/2017.
Summary of Performance

C. difficile rates have decreased from 41.6 in June to 32.3 in July 2016, while S. aureus rates have increased slightly from 25.5 in
June to 25.8 in July. As a result, both are above the agreed performance trajectory for July 2016.
Actions to improve areas of underperformance





Work continues with health boards in specific areas, including: support with strategy development, data analysis and advice and
assistance in the case of increased incidence or outbreak.
As part of implementation of the antimicrobial delivery plan, formal reviews of local health board implementation plans are being
organised to inform partnership working to improve infection prevention and control and reduce inappropriate prescribing.
The overarching Aseptic Non-Touch Technique Steering Group will meet in August and highlight the need for embedding the
technique outside of IV care scenarios.
The report on the audit of MRSA admission screening has been distributed to health boards and Welsh Government providing
recommendations for Public Health Wales and health boards to identify high risk patients at admission.
WHAIP have been exploring with the Drug and Alcohol Team possible interventions around skin disinfection in needle exchange
packs; MSSA bacteraemia in IV drug users has been identified as an issue in a number of health boards.
Date: 12/08/16
Version: 0f
Page: 12 of 16
Sickness Absence
5.00%
4.50%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Sickness Absence Rate
(rolling 12 months)
Summary of Performance

Our sickness absence rate for the rolling 12 month period (July 2015 to June 2016) reduced from 3.84% to 3.79%, although is still
above the Welsh Government target of 3.25%. However, the monthly figure for July 2016 was 3.24%.
Actions to improve areas of underperformance

A 1st draft of the Trust’s refreshed Sickness Action Plan has been completed, as well as local level plans to address specific issues. This
will be finalised by end of September 2016.

Sickness audits in hotspot areas have now been concluded. Sickness Management Panels are being held with these areas to work
through the findings, which will result in management action being taken.

Support continues to be provided for complex long term sickness cases, or persistent cases of short term sickness, with a view to
reaching a suitable conclusion to each case.
Date: 12/08/16
Version: 0f
Page: 13 of 16
Appendix 1- Full Performance Dashboard
Monthly
NHS Delivery Framework
Target
Jun-16
Jul-16
Quarterly
Status
% smoking population treated by Stop Smoking Wales
All Wales uptake of all scheduled vaccinations at age 4
Influenza vaccination uptake among the over 65s
Influenza vaccination uptake among the under 65s in high risk
groups
Influenza vaccination uptake among pregnant women 1
Target
(Q4)
2.80%
Target
95.0%
Target
Q4
(15/16)
1.57%
Q4
86.2%
Not available
23-Mar-16
06-Apr-16
Q1
Q4
Status
Status
Not available
Status
Not reported monthly
Only reported during influenza season
Influenza vaccination uptake among healthcare workers
Clostrium difficile rate (per 100,000 population)
Staph aureus bacteraemis rate (per 100,000 population)
Target2
31.5
22.4
Target
Sickness absence rate (rolling 12 month period)
3.25%
Jun-16
41.6
25.5
Jun 15May16
Jul-16
32.29
25.83
Jul 15June 16
Status


3.84%
3.79%

Status
Target
No. of clients that became a treated smokers
% of treated smokers who are carbon monoxide validated as
successful
% of treated smokers who have a carbon monoxide reading at 4
weeks
Average waiting time for an appointment in this month (days)
% of treated smokers that Quit smoking at 4 weeks (Self Reported)
52 week success rate of four week quitters
Target
Jun-16
Jul-16
668
510
Not available
Q1
Target
(Q1)
Q3
Q4
Quarterly
Status
Not reported monthly
Target
(Q4)
Q4
(15/16)
Q1
4696
2033
Not available
>=40%
45.9%
Not available
14
Not
available
7
Not reported monthly
Not reported monthly
>=50%
>=15%
Jun-16
Jul-16
Not reported quarterly
Not available
59.2%
Not available
22.3%
Quarterly
Status
Target
(annual)
Q1
Q1-2
65
25
Not available
Smoking Prevention Programme
Not reported monthly
Healthy Working Wales
Date: 12/08/16
Status
To be reported from Q1 2016/17
Target
Organisations completing a CHS mock assessment
Private sector organisations completing a mock assessment
Organisations completing a full assessment
Private sector organisations completing a full assessment
Organisations achieving a Small Workplace Health Award
Number of Workboost interventions delivered
Status
Not reported quarterly
Monthly
Number of secondary schools targeted
Status
Not reported quarterly
Monthly
Stop Smoking Wales
Q4
Not available4
Not reported monthly
Version: 0f
Page: 14 of 16
Status
Monthly
Target
Jun-16
Jul-16
Quarterly
Status
Target
Q1
Q1-2
200(annual)
30 (annual)
Target
(Q1)
3246
1623
811
5796
4057
83
17
Not available
Q1
Q2
3949
2172
1052
7215
4588
Not available
Target
(Q4)
72.0%
95.0%
80.0%
90.0%
Q4
(15/16)
73.1%
97.1%
66.9%
81.8%
80.0%
100.0%
77.8%
82.5%
100.0%
87.6%
90.0%
98.5%
55.0%
95.0%
95.0%
51.2%
97.7%
95.5%
Not available
Status
Welsh Network of Healthy School
Schools achieving level 1 - 5 award
Schools undertaking National Quality Award
Not reported monthly
National Exercise Referral Scheme
Take up
Number
Number
Number
Number
of
of
of
of
16 week consultations
52 week consultations
referrals
1st consultations
Not reported monthly
Monthly
Target
Breast Test Wales
Uptake
Normal results sent within 2 weeks of scan
Assessment invitations given within 3 weeks of screen
% women invited within 36 months previous screen
3
90%
70%
Jun-16
Jul-16
Not reported monthly
98.3%
98.3%
90.2%
72.8%
Not reported monthly
Status
Quarterly
Status


Q1
Status
Not available
Cervical Screening Wales
Coverage
Laboratory turnaround time for gynae cytology test results (3 weeks)
Waiting time from sample being taken to screening test result being
sent (4 weeks)
Waiting time for colposcopy appointment (all CSW direct referrals
with abnormal cytology)
90%
Not reported monthly
87.0%
92.1%
92%
93.4%
96.4%
95%
96.5%
Not available

Not available
Bowel Screening Wales
Coverage
Waiting time for screening test results
Waiting time for colonoscopy
95%
95%
Not reported monthly
93.4%
99.7%
Not available
91.3%
Uptake
Surveillance uptake
90%
Not reported monthly
Not available
93.1%
76.0%
90.0%
67.4%
91.6%
Not available
98%
95%
Not reported monthly
Not reported monthly
Not available
98.7%
87.9%
81.4%
100.0%
99.4%
98.9%
93.8%
Not available

99.0%
99.0%
90.0%
80.0%
94.5%
Not reported monthly
94.6%
95.5%

Abdominal Aortic Aneurysm Screening Wales

Newborn Hearing Screening Wales
% offered screening
% entering screening programme
% of babies who complete programme (within 4 weeks)
Babies completing assessment procedure (by three months of age)
Newborn Bloodspot Screening
Newborn bloodspot screening completeness of offer (all babies)
Newborn bloodspot screening coverage (newborn babies)
Date: 12/08/16
Version: 0f
To be reported from Q1 2016/17
Page: 15 of 16
Monthly
Microbiology
Target
Jun-16
Jul-16
Quarterly
Status
CPA accreditation status and move to ISO 15189 (Microbiology)
Target
(Q1)
Q2
Status
Accredited Accredited
EQA performance (Bacteriology)
EQA performance (Virology)
EQA performance (Specialist and reference units)
EQA performance (Food, Water and Environmental Laboratories)
Turnaround time compliance (Bacteriology)
Turnaround time compliance (Virology)
Turnaround time compliance (Specialist and reference units)
Not reported monthly
Turnaround time compliance (Food, Water and Environmental Labs)
95%
95%
95%
90%
95%
95%
95%
99.0%
99%
100%
98.0%
94.0%
98.0%
98.0%
95%
98.0%
Turnaround time compliance urgent samples (bacteriology/virology)Annual
Non processed samples (Bacteriology)
Non processed samples (Virology)
<=1.5%
<=1.9%
Non processed samples (Specialist and Reference Units)
<=0.3%
95%
Not
available
Reported annually
Not available5
Target
Jun-16
Jul-16
Status
Target
(Q1)
Q4
(15/16)
Q1
Status
N/A
100%
1
100%
1
100%
N/A

N/A
100%
0
100%
2
100%
N/A

N/A
100%
4
100%
3
100%
N/A

N/A
100%
13
100.0%
13
85.0%
N/A

Target
Jun-16
Jul-16
Status
Target
(Q1)
Q4
(15/16)
Q1
Status
100%
100%
100%

100%
100%
100%
N/A
Incidents
Number of SUIs reported
SUI investigations completed within the timescales
Q1
Concerns and Complaints
Number of written concerns/complaints received
Written concerns/complaints responded to within target timescales
Performance Appraisal
% of medical staff performance appraisal (last 15 months)
1. These figures for uptake of influenza vaccine in pregnant women are a snapshot of coverage in women who are currently pregnant. Automated measuring of immunisation uptake in women who are pregnant during the influenza season is difficult due
to number of reasons, including the number and variable use of Read codes that can be used to identify pregnant women and timeliness in removing these Read codes following birth or loss of pregnancy. For these reasons, data for pregnant women
presented here is an indicator of uptake in women who are pregnant at this point during the season. The figures should be interpreted with caution.
2. Performance figures reported against a monthly decreasing trajectory for C.Difficle and S.aureus bacteramia to attain the required national target rates of 28 per 100000 for C.Difficile and 20 per 100000 for Staph aureus bacteraemia from October 2016 to
March 2017.
3. Data reported against 2016/17 targets or, where a performance trajectory has been agreed to facilitate reaching the target, the Q1 trajectory has been used as defined within the IMTP 2016-2019
4. Programme has received confirmation in Quarter 1 that funding for a further year has been agreed. Public Health Wales is in dialogue with Welsh Government to agree Performance Targets. It is anticipated that this will be concluded by October 2016
5. Issue collecting workload figures. Unable to determine percentage of non processed samples.Meeting arranged with business manager and Head of Operations
Date: 12/08/16
Version: 0f
Page: 16 of 16