West London CCG Performance Report. Month 1

Transcription

1 West London CCG Report Month 1

2 1. Introduction & Key Messages This report provides details of the current position relating to quality, performance and finance in Month 1 on acute, community and mental health Trusts. The report describes the key drivers and actions in addressing performance issues. A headline report for Month 1 is provided below. Quality Operational (Acute Trusts) Infection Control Operational (Community) Operational (Mental Health) Finance Key Areas Never Events Complaints SI s Headline Actions No new Never Events reported in April relating to West London CCG. Downward trend in Complaints performance. To be discussed a CQG meetings with providers. SI s actively reviewed with actions in place. A detailed trend review of SI s is being undertaken and will be reporting to the July Quality and Risk meeting. 18 weeks West London CCG is meeting all 18 week RTT standards overall. is meeting all 18 week RTT standards overall but is not meeting specialty standards for Gen Surgery, Urology and Orthopaedics. Trajectories are in place to recover Gen Surgery and Urology performance by July and August 13/14 respectively. The Trust has presented an Orthopaedic recovery plan for CCG sign off. Cancer Waits CCG data not available for M1 due to the migration from PCT to CCG localities within the national cancer database. This is expected to be resolved by the end June 213. did not meet the 62 day GP referral and screening standard achieving 75.% and 79.3% respectively. The 3 breaches on the 62 day cancer screening pathway were due to complex diagnostic pathways or patients co-morbidity. For the 62 day GP referral pathway 6 breaches were assessed as unavoidable due to complex diagnostic pathways or patient co-morbidity. A further 1 breaches were caused by administrative errors, inter Trust transfers and 1 elective cancellation. The Cancer Commissioning Team are undertaking a detailed review of the root cause analysis reports provided by the Trust and actions to improve performance. This review will be completed by the end of June.. A&E 4hr waits MRSA & C.Diff HPV vaccination IAPT Month 1 Imperial is not meeting the national 95% A&E all types standard and local type 1 standard achieving 94.99% and 89.8% in month 1 respectively. Key actions in place include increased medical staffing at peak periods to manage demand, continuing to use treat and transfer to manage specialist bed base efficiently and case management approach for patients with a length of stay over 14 days. in M 2 has improved with meeting the national A&E standard. The 2 nd meeting of the Urgent Care Network took place on 12 th June and was attended by the CSU (Account Directors responsible for Chelsea & Westminster and Imperial). An Emergency Care Board is in the process of being established at. WL CCG did not meet M1 tolerance for C.Difficile reporting 6 cases in month. reported 12 C.Diff cases against the tolerance of 6 and is undertaking a detailed root cause analysis that will be submitted by the 14th June 213. Discussion on further actions required to mitigate risk will be agreed at the June CQG meeting. Contracted 213/14 data for Community Providers will be available from Quarter 2. In the interim NWLCSU will continue to report against 212/13 indicators by exception. For HPV vaccination, figures from Month 1 remain unchanged as the programme runs on an academic year rather than the financial year. The vaccine is given at 3 separate points between September and March. The final HPV figure is scheduled to be confirmed at the end of September. Contracted 213/14 data for Mental Health Providers will be available from Quarter 2. In the interim NWLCSU will continue to report against 212/13 indicators by exception. For IAPT: a recovery plan has been agreed with the Provider which includes the use of Step 2 workers undertaking triage to support improvements in access. West London and CNWL have agreed to meet and agree a suite of remedial actions for 213/14 with regards to the proportion of patients moving to recovery. Year to date spend at Month 1 is 18,67k compared with an estimated plan of 17,192k, however this based on the M1 SLAM reports which are very variable in quality. Work is underway to improve the quality of the data for Month 2. 2

3 2. Operational This section of the report provides an update on operational performance for acute, community and mental health Trust. The current position against plan with RAG assessment and trend is shown for both the CCG and local providers where possible. Reporting is by exception only. A summary of the key drivers for the variance from plan, actions and update on previous actions is provided. 2.1 Acute Providers National 18 weeks referral to treatment: Current (CCG & Trust) 9% 85% Measure H&F CCG CCG Chel West RBH Imperial Rank Varianc M1 YTD (NWL M1 YTD Variance M1 YTD M1 YTD Variance e ) 18 weeks RTT - 9% 9.5% 9.5% 5 th % 9.1% % admitted 18 weeks RTT 95% 97.% 97.% 6 th % 97.% non- admitted % 18 weeks RTT 92% 95.1% 95.1% 5 incomplete th % 93.3% % CCG Trend Admitted Non-Admitted Incomplete 95% 1% 96% 98% 96% 94% 94% 92% 9% 92.1% 91.3% 91.3% 98.1% 96.7% 96.7% 94.4% 95.% 95.% Imperial at specialty level specialties not met General Surgery 84% T&O 56.6% Neurosurgery % General Surgery 8.7% Urology 83.1% Urology 89.7% T&O 9.1% Specialty targets not met in M1 for: General Surgery Urology Orthopaedics Action plan submitted to recover speciality level performance for General Surgery and Urology by July and August 213 respectively. current plan to recover Orthopaedics performance by October 213. CSU undertaken a critical assessment of the action plan. CCG to approve plan. Completed June 213 CSU performance team CCGs RBH CW 5 patients treated over 52 weeks in month 1 with an additional patient waiting for treatment at month end. Specialty targets not met in M1 for: Other Admitted specialty targets not met in M1 for Other. Incomplete pathway standard not met at specialty level. Although pathway issues with current patient waiting over 52 weeks the patient was not treated in April due to patient choice. RBH reduced admitted backlog from 193 on 6/1/213 to 72 on 24/3/213 and are now meeting all RTT targets overall in M1 13/14. Not applicable Plan in place for the patient waiting over 52 weeks. Financial penalties applied for failing at specialty level and for patients waiting over 52 weeks. Trust required to provide an assessment and actions to recover performance within the other specialty. Action plan to recover speciality level performance to be submitted to the June CQG meeting. May 213 On-going June 213 June 213 CSU RBH CW Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 3

4 2. Operational This section of the report provides an update on operational performance for acute, community and mental health Trust. The current position against plan with RAG assessment and trend is shown for both the CCG and local providers where possible. Reporting is by exception only. A summary of the key drivers for the variance from plan, actions and update on previous actions is provided National : Cancer Waits: Current by exception (CCG and Trust) Measure 2 week wait suspected cancer 31 day wait subsequent surgery treatment 62 day standard GP referral 62 day wait from screening 93% 94% 85% 9% WL CCG CCG Chel West RBH Imperial Rank M1 YTD M1 YTD Variance M1 YTD Variance M1 YTD Variance (NWL) No patients Available Available 96.1% 96.1% 21/6 21/6 8.% 8.% treated last 98.6% 98.6% month Available 21/6 Available 21/6 Available 21/6 Available 21/6 Available 21/6 Available 21/6 No patients treated No patients treated 1% 1% 94.2% 94.2% 85.7% 85.7% 66.7% 66.7% 75.% 75.% No patients treated No patients treated Not applicable Not applicable 79.3% 79.3% Note - CCG data not available for M1 due to the migration from PCT to CCG localities with the national cancer database. This is expected to be resolved by the end June 213. RBH -1 breach (2 week rule) -2 breaches (62 day urgent GP referral) -RBH has stated that there are no 2 week rule breaches in M1 and has raised with the CCT for investigation. -Both shared breaches with Wycombe Hospital and were due to complex diagnostic pathways and patient fit ness for surgery. N/A A detailed review of the root cause analysis to identify N/A June 213 N/A CCT 75% (62 day from GP referral) 3 breaches (62 day screening) Detailed RCA s will be submitted on both cases in June 213. Root cause analysis have been provided and breaches were due to -6 breaches due to complex diagnostic pathway and co-morbidity -5 inter Trust delays -4 administrative errors -1 elective cancellation Root cause analysis have been provided and breaches were due to a complex diagnostic pathway, patient co-morbidity requiring referral to respiratory unit, and patient choice. additional actions required. A detailed review of the root cause analysis to identify additional actions required. Further information on actions in place to prevent administrative errors has been requested. July 213 June 213 Cancer Commissioning Team Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 4

5 2.1.3 National: A&E 4hr waits: Current (Trust) Measure A&E 4hr wait all types A&E 4hr wait local type 1 Chel West Imperial M1 YTD Variance M1 YTD Variance 95% 98.12% 98.12% 94.99% 94.99% 95% 98.12% 98.12% 89.76% 89.76% Trust Trends Chel West Type 1 All Types Imperial Type 1 1% 99% 98% 97% 1% 99% 98% 97% 1% 95% 9% 1% 9% 8% did not meet national all types A&E standard in M1 achieving 94.99%. On-going Trust experienced an increase in both A&E attendances and ambulance conveyances in M1 213/14 compared to the same period in the previous year. was due to increasing A&E demand placing pressure on medical staffing and bed management processes. The Trust has : increased medical staffing at peak periods to manage demand continuing to use treat and transfer to manage specialist bed base efficiently introduced a new case management approach for patients with a length of stay over 14 days has developed a whole system action plan that has been approved by CCGs and submitted to NHS England on the 31 st May performance has improved in M2 and the Trust has achieved the national A&E standard and improved against the local A&E type 1 standard achieving 94.1%. Continue close monitoring of Trust Whole system plan to form the basis for pressure surge assurance process for 13/14. July 213 CSU performance team CSU performance team Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 5

6 2.1.4 LAS Hospital handover KPIs Measure Chel West M1 YTD Variance M1 YTD Variance 3 min breaches > min breaches > Percentage of patient handovers within 3 mins 1% 99.5% 99.5% 98.7% 98.7% Chel West 6 patients awaited hospital handover for over 3 minutes Trust achieved 99.5% against the 3 minute 1% standard, which is an improved position from the same period last year. No further action at this stage Not Applicable Not Applicable A&E processes Increase in ambulance conveyances in M1 213/14 compared to the same period in the previous year. Actions taken by the Trust include: Extending UCC hours Increased A&E consultant presence Ambulatory emergency care pilot initiated from 23/4 at Charing Cross 29% reduction in 3 minute breaches in M2 213/14 compared to M1. Continue weekly review of Trust performance. Ensure that actions related to handover times in whole system plans are reviewed as part of winter assurance process. On-going Starting in July 213 CSU performance team CSU performance team Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 6

7 2.2 Hospital Infection (National) National: MRSA and C.Diff: Current (CCG and Trust) Measure MRSA cases WL CCG Chel West RBH Imperial M1 YTD M1 YTD Variance M1 YTD Variance M1 YTD Variance Target Actual 1 1 C.Diff cases Target Actual CCG Trends 2 MRSA 1 C.Diff 1 5 West London CCG Annual C.Difficile tolerance is 33 cases with 6 cases reported in M1. Application submitted to HPA to access detailed CCG information by the end of June 213. CSU to obtain password access from CCGs June 213 CSU performance team Chel West 1 MRSA case reported Detailed root cause analysis is being undertaken. To date, no further cases have been reported in 213/14. No further action at this stage Not Applicable Not Applicable RBH Annual C.Difficile tolerance is 7 cases. Detailed root cause analysis is being undertaken. To date, no further cases have been reported in 213/14. No further action at this stage Not Applicable Not Applicable Annual C.Difficile tolerance is 65 cases with 12 cases reported in M1. - Detailed root cause analysis is being undertaken and will be submitted by the 14 th June 213. Discussion on further actions required to mitigate risk will be agreed at June CQG meeting. - A further 6 C.Diff and 4 MRSA bacteraemia have been reported in May 213/14. Any additional actions will be identified at the CQG. June 213 Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 7

8 2.3 Community & Mental Health Community Providers Contracted 213/14 data for Community providers will be available from Quarter 2. In the interim NWLCSU will continue to report against 212/13 indicators by exception. HPV Immunisation rate Measure Immunisation rate for HPV vaccination (12-13yrs) CLCH In mth YTD Target 9.% Actual 81.5% Trend CLCH HPV: Take up. Currently performance is shown to be below trajectory but year end has not been reached Final figures for 212/13 HPV immunisation rates will not be available until September 213. NHS England will be responsible for the collation of this information. HPV final position to be confirmed in September 213 September 213 NHS England ( London) Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 8

9 2.3.2 Mental Health Contracted 213/14 data for Mental Health Providers will be available from Quarter 2. In the interim NWLCSU will continue to report against 212/13 indicators by exception. Measure Proportion of people with depression and/or anxiety disorders referred for and receiving psychological therapies Reporting Frequency Quarterly Q4 West London CCG M12 212/13 YTD Local Target 2.9% 1.1% Actual 2.1% 7.9% Trend Proportion of people with depression and/or anxiety disorders receiving psychological therapies who are moving to recovery Quarterly Q4 Local Target 45.% 4.6% Actual 37.2% 36.% (Q2 YTD) CNWL Capacity in the service A recovery plan has been agreed with the provider (CNWL) which includes the use of Step 2 workers undertaking triage in order to facilitate wider access. The recent recruitment of two step 2 staff will support continued improvement. To be reviewed at monthly contract meetings. On-going CNWL CNWL Staffing capacity West London CCG and CNWL have arranged to meet to agree a recovery plan with mitigating actions for 13/14. Meeting scheduled for mid June June 213 CNWL /CSU Please note: further details on current CCG and Provider performance can be accessed via the CSU Portal: 9

10 3. Quality This section of the report provides an update on the current performance of key provider quality indicators. The current position against plan with RAG assessment and trend is shown. A summary of the key drivers for variance from plan, actions and update on previous actions is provided Safety: Serious Incidents, Never Events Quality Chelsea and Royal Imperial* CLCH - K&C CNWL - K&C Measure Westminster* Brompton* No. of Serious M1 YTD M1 YTD M1 YTD M1 YTD M1 YTD Incidents Reported (StEIS download 3/5/13) Actual No. of Never Events Reported SI report submissions outstanding M1 YTD M1 YTD M1 YTD M1 YTD M1 YTD Actual n/a n/a n/a n/a At end April 13 At end April 13 At end April 13 At end April 13 At end April 13 Actual *Information available only at provider level 5 Provider Issue Update on previous action CLCH, Chelsea and Westminster CNWL K&C SIs Overdue SI reports Nil Action Timeline Owner -NWL CSU have reminded Trust that these reports are overdue. -NWL CSU have sent providers a breakdown of all overdue SI s -NWL CSU to use contractual levers to enforce action on overdue reports 1 CLCH K&C SIs Completed Completed July 213 NWL CSU NWL CSU NWL CSU 2 Imperial Serious Incidents 5 Imperial Never Events Chelwest Serious Incidents 2 Chelwest Never Events 1 1 Royal Brompton SIs Royal Brompton Never Events 2 Type of SI Chelwest CLCH - CNWL - K&C K&C Imperial RBH FT Total C.Diff & Health Care Acquired Infections 1 1 Child Death 1 1 Communication issue 1 1 Maternity Services - Intrauterine death 2 2 Maternity Services - Maternal unplanned admission to ITU 1 1 Maternity Services - Unexpected admission to NICU 1 1 Maternity Services - Unexpected neonatal death 1 1 Pressure ulcer Grade Pressure ulcer Grade Serious Incident by Inpatient (in receipt) 1 1 Serious Incident by Outpatient (in receipt) 1 1 Sub-optimal care of the deteriorating patient 1 1 Unexpected Death of Outpatient (in receipt) 1 1 Total

11 Safety: CAS, NRLS, SHMI, Maternal Mortality Quality Measure Chelsea and Westminster Imperial Royal Brompton CAS Actual 3 3 NRLS Uploading (March & Sept) SHMI (Quarterly) Maternal Mortality Rates Period Period Period Actual April 12 - Sept 12 6 out of 6 April 12 - Sept 12 5 out of 6 April 12 - Sept 12 6 out of 6 Period Q Not Applicable Period 212/ Not Applicable Chelsea and Westminster X 3 outstanding CAS alerts Legacy case that the NPSA have marked as Determine the reason for the NPSA July CSU quality team ONGOING. classification. Imperial maternity Serious Incidents in relation to maternity services at Imperial. NWL CSU report discussed at Collaborative meeting and discussed at the last CQG. Action plan to be developed. 19 th June Imperial Chelsea and Westminster Maternal Mortality Extension granted until 22 nd June for RCA report. This is due to the request for a joint review with WLMHT. Complete RCA 22 nd June CW 11

12 National Safety Thermometer Is a point of care survey instrument. it is used to describe only a fraction of possible healthcare complications (or harm), qualified as harm free care from pressure ulcers, falls, urinary catheter infections and VTE. It is not meant to be used as a benchmarking tool as it does not take into account the acuity. It is useful to see the trajectory within a trust. % of patients receiving Harm Free Care North West London NHS Trust Ealing Hospital NHS Trust* Imperial College NHS Trust West Middlesex NHS Trust Chelsea and Westminster NHS Foundation Trust Hillingdon NHS Foundation Trust Royal Brompton and Harefield NHS Trust No harm 92.73% 9.7% 95.12% 9.38% 94.49% 94.79% 96.54% Note - There have been some data quality/validity issues identified at a national level that are currently being resolved. CLCH Patient Safety Thermometer pressure ulcer goal setting progress July CLCH An anomaly in the national data set has been found and therefore changed the baseline value. NWL CSU has informed NHS England and the provider has contacted HSCIC to resolve data issue. -CLCH to liaise with HSCIC. -CLCH to inform NWL CSU of outcome and provide validated data from HSCIC. All other providers Patient safety Thermometer pressure ulcer goal setting progress Baseline information has been shared. assessment based on future trends. Include trend lines for harm free care and Pressure Ulcer prevalence by provider within integrated performance report. July 213 NWL CSU 12

13 Patient Experience (Acute data only) Quality Measure Patient Survey results - Inpatient All improved from 211 Chelsea & Imperial Royal Brompton Westminster Outcome Period Outcome Period Outcome Period Provider Issue Update on previous action Imperial, Complaints Not applicable Chelsea and responded to Westminster within agreed time frame Action Timeline Owner Discuss at next CQG meetings. For Imperial, Chelsea and Westminster and West Mid July 213 Imperial, Chelsea and Westminster *Friends and Family Test to be incorporated when validated results available. % of Patient Complaints acknowledged within 3 days of receipt M1 YTD M1 YTD M1 YTD Target 1.% 1.% 1.% Actual - March 13 % of Patient complaints responded to within Actual - agreed time frame March 13 Not reported Target 1.% 1.% 1.% M1 YTD M1 YTD M1 YTD 1.% 1.% 93.7% 96.% 77.8% 1.% M1 YTD M1 YTD M1 YTD 13