Board of Directors Meeting

Transcription

1 Board of Directors Meeting Date: 29 July 2009 Agenda item: 8.2, Part 1 Title: Prepared by: Presented by: Action required: Monitoring Information Performance Report Richard Blackwell, Operational Performance Manager Elaine Hobson, Chief Operating Officer The Board is asked to receive the Performance Report which sets out the Trust s performance against: Monitor Compliance Targets Care Quality Commission National Contractual Targets Local Contractual Targets for the period to the end of June Please specify HC standard numbers and tick other boxes as appropriate Healthcare Standards CORE Healthcare Standards DEVELOPMENTAL Monitor Standard numbers Standard numbers C19 Finance Service Development Strategy Performance Management Local Delivery Plan Assurance Framework Business Planning Complaints Equality, diversity, human rights implications assessed Other (please specify) Performance Report Board Date: 29 th July 2009 Page 1 of 21

2 1. PURPOSE 1.1 To advise the Board of the Trust s performance against the key performance standards and targets. 2. BACKGROUND 2.1 The Trust s Annual Plan sets out the programme of work to be undertaken to ensure compliance with the Monitor Compliance Framework and local and national standards and targets included in PCT commissioning contracts. The Care Quality Commission annually reviews the performance of all NHS organisations against the milestones and targets set out in the NHS Plan and annual operating framework. The outcome of this assessment is the publication of the Annual Health Check in October each year. 2.2 Detailed results of achievement as at 30 th June 2009 are presented in Appendix A: Performance Summary and Appendix B: Performance Targets KEY ISSUES 3.1 The Trust s key performance standards and targets for have been classified into the following four groups which reflect the source of the targets: Monitor Compliance Targets Care Quality Commission National Contractual Targets Local Contractual Targets Details of these are set out in Appendix B 3.2 It should also be noted that there are a number of targets for which the threshold for delivery has yet to be confirmed by Monitor, the PCT or the Care Quality Commission. 3.3 During June 2009 and the financial year 2009/10 all performance standards for which there are indicative targets have been achieved with the following exceptions: Cancelled Operations the target was achieved during June but the year to date performance is below target, Discharge summaries it has not been possible to provide the commissioner with an accurate figure for the percentage of discharge summaries transmitted within 48 hours of discharge For those targets that have yet to be confirmed it is expected that no threshold will be published prior to the release of the Annual Health Check ratings in October The Trust has continued to achieve the required level of performance against the targets classified as the highest risk in the Annual Plan. The Trust is achieving the national 18 week referral to treatment target for both admitted and non-admitted patients including the data completeness measure as defined by Monitor. The thresholds for the Care Quality Commission targets have yet to be confirmed. Performance Report Board Date: 29 th July 2009 Page 2 of 21

3 4. ACTIONS 4.1 Performance against plan will continue to be monitored. Detailed performance reports on cancelled operations are reviewed at specialty meetings and at monthly directorate review meetings. 5. FINANCIAL/OTHER IMPLICATIONS 5.1 Achieving NHS plan targets and milestones is an important feature of the Trust s overall performance and demonstrates our commitment to delivering good quality care to patients. A positive Annual Health Check declaration from the Care Quality Commission provides external validation of the Trust s performance. There are two specific performance indicators within the contract where Commissioners have the discretion to apply financial penalties in respect of underperformance: nonachievement of the clostridium difficile target (up to 2% of the contract revenue) and non-achievement of the referral to treatment time target (up to 5% of monthly elective care revenue). 6. RECOMMENDATIONS 6.1 The Board is asked to receive the Performance Report and note the progress that has been made together with any actions that are planned. Performance Report Board Date: 29 th July 2009 Page 3 of 21

4 Operational Performance Dashboard as at 30th June 2009 Accident and Emergency Maximum 4 Hour Wait Referral to Treatment for Admitted Pathways Referral to Treatment for Non Admitted Pathways % % % 99.50% 99.00% 98.50% 98.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 99.00% 98.00% 97.00% 96.00% 95.00% 94.00% 93.00% % Treated Within 4 Hours % Treated Within 18 Weeks % Treated Within 18 Weeks 84.00% 97.50% 82.00% 92.00% 91.00% 97.00% 80.00% 90.00% Apr 07 Jun 07 Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 Jun 08 Aug 08 Oct 08 Dec 08 Feb 09 Apr 09 Jun 09 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Maintaining good performance. Maintaining performance but orthopaedic specialty level performance remains a challenge. Maintaining performance. Cancer 31 Day Wait Cancer 62 Day Wait Cancelled Operations 100.0% 100.0% 2.50% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 95.0% 90.0% 85.0% 80.0% 2.00% 1.50% 1.00% % Treated Within 31 Days % Treated Within 31 Days % Cancelled on or after admission 92.0% 0.50% 75.0% 91.0% 90.0% 70.0% 0.00% Apr 07 Jun 07 Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 Jun 08 Aug 08 Oct 08 Dec 08 Feb 09 Apr 09 Jun 09 Apr 07 Jun 07 Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 Jun 08 Aug 08 Oct 08 Dec 08 Feb 09 Apr 09 Jun 09 Apr 07 Jun 07 Aug 07 Oct 07 Dec 07 Feb 08 Apr 08 Jun 08 Aug 08 Oct 08 Dec 08 Feb 09 Apr 09 Jun 09 The threshold for this target has yet to be published, the position for June shows performance is being maintained at between 94% and 95%. The position shows no sign of improvement and the latest figures have fallen below 80%. Maintaing improvement in June but this will have to continue if the 0.8% is to be hit by year end. Perform ance Report Board Date: 29 th July 2009 Page 4 of 21

5 Appendix A Performance Summary 1. Performance Targets The Trust s key performance standards and targets for are set out in Appendix B. These have been classified into the following four groups which reflect the source of the targets: Monitor Compliance Targets Care Quality Commission Targets National Contractual Targets Locally Agreed Contractual Targets The analysis includes the target for delivery during 2009/10, the June 2009 and financial year 2009/10 performance and the current risk rating. There are a number of targets for which the threshold for delivery has yet to be confirmed by Monitor, the PCT or the Care Quality Commission There is some duplication between the Care Quality Commission, Monitor and Contractual key targets; for clarity these are reported in each section. 2. Key Performance Risks June 2009 The areas considered to have the most significant performance risks are highlighted below: 2.1 Healthcare Acquired Infection Clostridium Difficile (C-Diff) A local reduction target has been agreed with Devon PCT to reduce the incidence of C-Diff in over 2 year olds to a level of a maximum 183 infections during 2009/10. Clostridium Difficile Infections (Patients aged 2 or over specimen taken on or after 3 rd day after admission) Period Actual Target Apr May Jun Year to Date It is planned that the previous good progress in reducing the number of patients with Clostridium Difficile will be built upon. A key element of this is the trust wide deep cleaning programme of all wards. The 2009/10 programme covering all adult wards has commenced and is expected to be completed in September. Performance Report Board Date: 29 th July 2009 Page 5 of 21

6 MRSA The 2009/10 target is for a maximum of 18 MRSA bacteraemia for the year which maintains last year s position. There were no MRSA bacteraemia reported during June and consequently the Trust has achieved the target for Quarter 1. MRSA Bloodstream Infections Period Actual Target Apr May Jun Year to Date Cancer Waiting Times The target for monitoring the delivery of timely care for patients with cancer has been significantly expanded from December The Department of Health has not set a threshold for these targets which were expected in early The Trust can not certify compliance against these targets until the confirmation of these thresholds. The new extended targets recognise the need for all patients who may have cancer to be managed equitably irrespective of their referral route, including referral pathways from within the Trust. The method of recording waiting times has changed to fall in line with the Referral to Treatment methodology for all patients. The impact of this change is a reduction in performance using the new method, which reflects national experience. An exception report has been included as the position has deteriorated against the 62 day target although no threshold has yet been released. Cancer 14 day Referral to Outpatient Appointment Period Breaches Referrals Compliance Apr % May % Jun % Year to Date % Cancer 31 day Decision to Treat to First Definitive Treatment Target Period Breaches Referrals Compliance Apr % May % Jun % Year to Date % Cancer 31 day Decision to Treat to Subsequent Treatment Target Period Breaches Referrals Compliance Apr % May % Jun % Year to Date % Performance Report Board Date: 29 th July 2009 Page 6 of 21

7 Cancer 62 day GP Urgent Referral to Treatment Target Period Breaches Referrals Compliance Apr % May % Jun % Year to Date % The main reason for the breaches for the 62 day target this month were complex diagnostic pathways (10 breaches). Key milestones along the treatment pathway will be identified and early warnings will be shown when any of these milestones have not been met. Further details are given in the exception report in Appendix C. 2.3 Maximum Waiting Time in the Emergency Department This target is for 98% of patients to have a maximum 4-hour wait in A&E from arrival to admission, transfer or discharge. This includes attendances at all types of A&E Department run by the Trust or attendances to the minor injury units run by Devon PCT. The individual RD&E performance for the month of June 2009 was 98.4%, with the combined community-wide performance of 99.3% giving a year to date position of 98.3% for the RD&E and 99.2% for the health community. The graph below summarises the trends in the Trust s cumulative performance for the three financial years 2007/08, 2008/09 and 2009/10 to date. Cumulative Percentage of Patients Attending RD&E ED Seen Within 4 Hours 99.00% 98.50% 98.00% Percentage Seen Within 4 Hours 97.50% 97.00% 96.50% 96.00% 95.50% 95.00% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 Week 36 Week 37 Week 38 Week 39 Week 40 Week 41 Week 42 Week 43 Week 44 Week 45 Week 46 Week 47 Week 48 Week 49 Week 50 Week 51 Week 52 Week 2007/ / /10 Target It can be seen from the graph that the current performance is in line with that of 2007/08, and a marked improvement against the start of 2008/ Referral to Treatment Waiting Time Targets The target for both Monitor and the Care Quality Commission was that by December 2008 no-one would wait longer than 18 weeks from GP referral to first definitive hospital treatment. This was defined as 90% of patients on an admitted pathway and 95% of those on a non-admitted pathway seen within 18 weeks. Performance Report Board Date: 29 th July 2009 Page 7 of 21

8 During June 2009 the Trust achieved the following performance against the 13, 15 and 18 week targets: Admitted Pathways All Specialties Non-Admitted Pathways All Specialties Admitted Pathways Excluding Orthopaedics Non-Admitted Pathways Excluding Orthopaedics Admitted Pathways Orthopaedics only Non-Admitted Pathways Orthopaedics only 13 weeks 15 weeks 18 weeks 83.3% 87.0% 90.9% 92.3% 93.8% 95.9% 91.3% 94.1% 96.3% 93.7% 95.0% 96.8% 36.2% 45.5% 59.1% 80.0% 82.7% 87.7% The targets are all measured on performance during March 2010; internal trajectories will be used to monitor performance. To achieve the target for referral to treatment the Trust is also required to ensure that a data completeness target associated with this is reached. This requires the number of clock stops in the month to be within the range of % of reported admission or outpatient attendances. The June position for data completeness was 107.4% and 109.9% for admitted and non-admitted pathways respectively and therefore the target was met. 2.5 Cancelled Operations The improved performance against target continued in June with a position of 43 patients (0.74%) against the target of 0.8%. The year to date position is still above the target at 1.07% and in order for the Trust to achieve the local contractual target of 0.8% the average cancellation rate would have to drop to an average of 0.71% for the rest of the year. Further information is given in the updated exception report. 2.6 Performance Notices Following the regulations set out in the new national contract, the Trust received two performance notices from Devon PCT relating to Cancelled Operations and Discharge Summaries. The Performance Notice relating to Cancelled Operations advised that the PCT requires an action plan, with a maximum permissible 3 months to rectify the deficiency. An action plan has been shared with the PCT, and includes actions required by the PCT, as the increase in emergency admissions and difficulty in discharging patients has led to cancelled elective surgery. It is possible that the Trust could be issued with another performance notice if the Trust does not continue with its current good performance. Performance Report Appendix B Board Date: 29 th July 2009

9 The Performance Notice relating to Discharge Summaries requires a plan to report actual performance from the month ending July 2009 onwards. Performance will be able to be reported for July However, it is likely that the performance will be below 100% target and therefore another performance notice may be issued. Performance Report Appendix B Board Date: 29 th July 2009

10 Appendix B Performance Targets 2009/10 Performance Report Appendix B Board Date: 29 th July 2009

11 Monitor Compliance Framework Targets Risk Code Target Description Target YTD Quarter 1 Jun-09 Current Position Likelihood Consequence Rating MON01 Clostridium Difficile (target for period) (41) 21 (41) 5 (18) Achieving Unlikely Major Low MON02 MRSA (target for period) 18 3 (3) 3 (3) 0 (1) Achieving Possible Major Medium MON03 Cancer: 31 day for subsequent treatments 92.1% 92.1% 84.3% (15 of 191) (15 of 191) (13 of 83) MON04 Cancer: 62 day referral to treatment 80.4% 80.4% 77.2% (52.5 of 268.5) (52.5 of 268.5) (21 of 92) MON05.I 18 wk RTT admitted 91.2% 90.9% 90% (824 of 9319) (316 of 3480) Achieving Unlikely Major Low MON05.II 18 wk RTT admitted data completeness 105.5% 107.4% 90%-110% (8829 of 9319) (3239 of 3480) Achieving Unlikely Major Low MON06.I 18 wk RTT non-admitted 96.2% 95.9% 95% (419 of 10898) (171 of 4139) Achieving Unlikely Major Low MON06.II MON07 MON08 18 wk RTT non-admitted data completeness 4 Hour A&E Community Thrombolysis 90%-110% 98% 99.2% (396 of 48974) 100.4% (10858 of 10898) 99.2% (396 of 48974) Not applicable if fewer than 20 cases in a year 109.9% (3765 of 4139) 99.3% (115 of 15592) Not Known Possible Major Medium Not Known Possible Major Medium Achieving Possible Major Medium n/a Rare Moderate Very Low Exception Report MON09 MON10 MON11 Cancer: 14 day from urgent GP referral to first seen Cancer: 31 day from diagnosis to first definitive treatment MRSA Screening 100% 99.1% (17 of 1855) 93.6% (34.5 of 539) 111.8% (8213 of 7344) 99.1% (17 of 1855) 93.6% (34.5 of 539) 111.8% (8213 of 7344) 99.9% (1 of 694) 95.2% (9 of 187) 108.3% (2882 of 2661) Not Known Possible Moderate Low Not Known Possible Moderate Low NB: The consequence weighting for targets CQC15 and CQC16 differ from MON01 and MON02 due to the greater effect of not achieving a Monitor target on the overall rating for the Trust compared to not achieving a CQC target. It should also be noted that the consequence for the Monitor targets is set as Major for those targets that are weighted 1.0 and Moderate for those weighted 0.5 Performance Report Appendix B Board Date: 29 th July 2009 Page 11 of 21

12 Care Quality Commission Targets Risk Code Target Description Target YTD Jun-09 Current Position Likelihood Consequence Rating CQC01 Data quality on ethnic group 85.44% 84.9% 85% (33637 of 39370) (11694 of 13768) CQC02.I Time to reperfusion for patients who have had a heart attack - Position Not applicable if fewer than 20 cases in a year n/a Rare Moderate Very Low CQC02.II Time to reperfusion for patients who have had a heart attack - Data Quality on key field "3.02 Date/time of 80% Not Yet Known Not Known Unlikely Moderate Very Low call for help" CQC02.III Time to reperfusion for patients who have had a heart attack - Data Quality on key field "3.09 Date/time of reperfusion (BCIS angioplasty audit field 3.26)" 80% Not Yet Known Not Known Unlikely Moderate Very Low Exception Report CQC03 CQC04 CQC05 CQC06 CQC07 CQC08 CQC09.I CQC09.II CQC10 CQC11.I CQC11.II Delayed transfers of care 4 hour A&E target Inpatients waiting longer than the 26 week standard Outpatients waiting longer than the 13 week standard Patients waiting longer than three months (13 weeks) for revascularisation Waiting times for Rapid Access Chest Pain Clinic Cancelled operations Cancelled operation not admitted within 28 days Access to healthcare for people with a learning disability Infant health and inequalities: smoking during pregnancy Infant health and inequalities: breastfeeding initiation 3.5% 98% 0.03% 0.03% 0% 100% 0.80% 5% <=0% change on 12.1% >=-5% change on 75.2% 1.55% (135 of 8696) 99.2% (396 of 48974) 0% (0 of 10717) 0.02% (3 of 15225) 0.0% (0 of 185) 100% (0 of 158) 1.07% (174 of 16333) 0% (0 of 174) 10.8% (98 of 909) 71.9% (654 of 909) Not yet known 1.03% (34 of 3292) 99.3% (115 of 15592) 0% (0 of 3898) 0.06% (3 of 5015) 0.0% (0 of 62) 100% (0 of 47) 0.74% (43 of 5772) 0% (0 of 43) 9.2% (28 of 306) 63.1% (193 of 306) Not Achieving Likely Moderate Medium Not Known Performance Report Appendix B Board Date: 29 th July 2009 Page 12 of 21

13 Care Quality Commission Targets continued Risk Code Target Description Target YTD Jun-09 Position Likelihood Consequence Rating CQC12.I Participation in heart disease audits - BCIS Audit Trust participates in audit CQC12.II Participation in heart disease audits - MINAP Audit Trust participates in audit CQC12.III Participation in heart disease audits - ACS Audit n/a n/a Unlikely Moderate Very Low CQC12.IV Participation in heart disease audits - CRM Audit Trust participates in audit CQC12.V Participation in heart disease audits - CHD Audit n/a n/a Unlikely Moderate Very Low CQC13 Stroke care Sentinel Audit Not Known Possible Moderate Low CQC14 Maternity Hospital Episode Statistics: data quality indicator Not known Not Known CQC15 Incidence of MRSA Bacteraemia (target for period) 18 3 (3) 3 (3) CQC16 Incidence of Clostridium difficile (target for period) (41) 5 (18) CQC17.I 18 week referral to treatment times - Admitted Data 107.4% 90%-110% Completeness (3239 of 3480) CQC17.II 18 week referral to treatment times - Non-Admitted 109.9% 90%-110% Data Completeness (3765 of 4139) CQC17.III 18 week referral to treatment times - Admitted RTT 90.9% 90% Position (316 of 3480) CQC17.IV 18 week referral to treatment times - Non-Admitted 95.9% 95% RTT Position (171 of 4139) CQC18 All cancers: 14 day wait including proportion of patients 99.1% 99.9% with breast symptoms referred to a specialist who are (17 of 1855) (1 of 694) seen within two weeks of referral Not Known Possible Moderate Low CQC19 All cancers 31 day wait including proportion of patients waiting no more than 31 days for second or 93.2% 91.9% subsequent cancer treatment (surgery and drug (49.5 of 730) (22 of 270) Not Known Possible Moderate Low treatments and radiotherapy treatments) CQC20 All cancers 62 day wait including proportion of patients with suspected cancer detected through national screening programmes or by hospital specialists who wait less than 62 days from referral to treatment 80.5% (52.5 of 268.5) 77.2% (21 of 92) Not Known Possible Moderate Low Exception Report CQC21 Patient Experience Not yet known Not Known Possible Moderate Low CQC22 NHS staff satisfaction Not yet known Not Known Possible Moderate Low NB: The consequence weighting for targets CQC15 and CQC16 differ from MON01 and MON02 due to the greater effect of not achieving a Monitor target on the overall rating for the Trust compared to not achieving a CQC target. Performance Report Appendix B th Board Date: 29 July 2009 Page 13 of 21

14 National Contractual Targets Risk Exception Code Target Description Target YTD Jun-09 Current Position Likelihood Consequence Rating Report CON01.I Provider cancellation of Elective Care operation for nonclinical reasons either before or after Patient admission 0.80% 1.07% 0.74% (174 of 16333) (43 of 5772) Not Achieving Likely Moderate Medium CON01.II 100% of patients whose operation is cancelled on the day of admission or later for non clinical reasons, are offered another binding date to treat the patients within 28 days or to fund the patient s treatment at the time and hospital of the patient s choice CON02 Provider failure to ensure that sufficient appointment slots are made available on the Choose and Book system CON03 4 hour maximum wait in A&E from arrival to admission, transfer or discharge CON04 Maximum wait of 11 weeks for revascularisation 5% 20% by 31/3/10 0% (0 of 132) 24.9% (2189 of 8801) 0% (0 of 43) 24.2% (681 of 2812) 98% 99.2% 99.3% (396 of 48974) (115 of 15592) 0% 0% 0% (0 of 185) (0 of 62) CON05 Maximum waiting time of 31 days from diagnosis to 93.2% 91.9% treatment for all cancers (49.5 of 730) (22 of 270) Not Known Possible Moderate Low CON06 Maximum waiting time of 62 days from urgent referral to 80.5% 77.2% treatment for all cancers (52.5 of 268.5) (21 of 92) Not Known Possible Moderate Low CON07 2 weeks maximum wait for urgent suspected cancer 99.1% 99.9% referrals from GP to first outpatient appointment (17 of 1855) (1 of 694) Not Known Possible Moderate Low CON08 2 weeks maximum wait for rapid access chest pain 100% 100% 100% clinic (0 of 158) (0 of 47) CON09 Percentage of SUS data altered in period between 5 Operational Days after month-end, and the relevant 95% 90% (70%) 92% (70%) Reconciliation Point (target for period) CON10 Satisfaction of the Provider s obligations under each A&E/Ambulance Services Handover Plan Compliance CON11 Satisfaction of the Provider s obligations under the Mixed Sex Accommodation Reduction Plan Not Known CON12.I Emergency Readmissions within 28 days of Discharge 103.9% 74.9% after Initial Emergency Admission (YTD figure Oct-08 to LCL > 87.1% (150 of 2205) (42 of 772) Achieving Possible Major Medium Dec-08, latest data Jan-09) LCL = 76.6 LCL = 53.9 CON12.II Emergency Readmissions within 28 days of Discharge 84.9% 95.8% after Initial Elective Admission (YTD figure Oct-08 to LCL > 92.1% (265 of 8975) (98 of 3082) Achieving Possible Major Medium Dec-08, latest data Jan-09) LCL = 68.0 LCL = 77.8 CON13 Proportion of admissions screened for MRSA 111.8% 108.3% 100% (8213 of 7344) (2882 of 2661) Performance Report Appendix B Board Date: 29 th July 2009 Page 14 of 21

15 Local Contractual Targets Risk Exception Code Target Description Target YTD Jun-09 Current Position Likelihood Consequence Rating Report LOC1 13 week maximum wait by 31 March 2010 for admitted 91.3% 90% patients (excl orthopaedics) (258 of 2974) LOC2 13 week maximum wait by 31 March 2010 for nonadmitted patients (excl orthopaedics) (236 of 3734) 93.5% 95% LOC3 18 week maximum wait by 31 March 2010 for admitted 59.1% 90% orthopaedic patients (207 of 506) LOC4 18 week maximum wait by 31 March 2010 for nonadmitted orthopaedic patients (50 of 405) 87.7% 95% LOC5 Data completeness measure (admitted patients) 107.4% 90%-110% (3239 of 3480) LOC6 Data completeness measure (non-admitted patients) 109.9% 90%-110% (3765 of 4139) LOC7 Diagnostic waiting times for 15 key diagnostic tests 99.1% 99.1% within 6 weeks 95% (74 of 7908) 21 pt choice (25 of 2733) 5 pt choice LOC8 Transmission of Discharge Summaries within 48 hours of discharge 100% Not Yet Known Not Yet Known Likely Moderate Medium Performance Report Appendix B Board Date: 29 th July 2009 Page 15 of 21

16 Performance Report Appendix B Board Date: 29 th July 2009 Page 16 of 21

17 Appendix C Exception Reports Performance Report Appendix C Board Date: 29 th July 2009 Page 17 of 21

18 BOARD EXCEPTION REPORT CORPORATE TARGET NUMBER & DESCRIPTION: CURRENT CORPORATE RATING: RESPONSIBLE DIRECTOR: LOC8 - Transmission of Discharge Summaries within 48 hours Medium Chief Operating Officer Brief description of how the rating was derived The indicator is derived from the number of discharge summaries sent to GPs within 48 hours of discharge as a percentage of all discharges. Details of actions necessary to return performance back to either good or excellent The following actions are being undertaken: Performance reporting to the PCT will be provided from the ward whiteboard by the end of July 2009 to comply with the Performance Notice. The Medical Director is agreeing with PCT Practice based commissioning GP leads where discharge summaries are not required, some areas already agreed Weekly performance reports at specialty level are provided to directorate leads The current processes for the production and provision of a discharge summary are being reviewed, reasons for delay being identified and a detailed action plan being developed. Discharge summaries will be audited to ensure they comply with standards for content A plan to ensure a copy of the discharge summary is given to the patient is being drawn up. Electronic transfer of discharge summaries to GPs is being scoped. It is noteworthy that the target changes in 10/11 to: By April 2010 ensure 100% transmission of discharge summaries within 24 hours of discharge Performance Report Appendix C Board Date: 29 th July 2009 Page 18 of 21

19 BOARD EXCEPTION REPORT CORPORATE TARGET NUMBER & DESCRIPTION: CURRENT CORPORATE RATING: RESPONSIBLE DIRECTOR: CQC09.I and CON01.I - Provider cancellation of Elective Care operation for non- clinical reasons either before or after Patient admission Medium Chief Operating Officer Brief description of how the rating was derived The indicator is derived from the number of patients whose operation was cancelled by the hospital for non-clinical reasons on or after the day of admission as a percentage of all elective admissions (both daycase and inpatient). Details of actions necessary to return performance back to either good or excellent In order to prioritise our services for those patients who have an urgent need for treatment, in June 2009, 43 planned admissions for non urgent surgery were cancelled on or after the day of admission giving the year to date position of 1.07% against a target of 0.8%. The main reason for cancellations was due to list over-runs and bed shortages (11 and 12 cancellations respectively). The main specialties affected were General Surgery (list overruns, Cardiology (bed shortages) and Orthopaedics (list overruns and more urgent cases). Cancelled operations on or after the day of admission due to lack of beds remained fairly constant with 12 in June and 9 in May compared to 58 in April. To reduce the number of cancellations several actions are being undertaken. 1. Reduce cancellations due to lack of bed capacity: Work with Devon Primary Care Trust and Devon Provider Services to increase use of community hospitals, reduce emergency admissions, reduce delayed discharges Transfer day surgery to Heavitree and community theatres 2. Strengthen system for escalating potential last minute cancellations to operational management teams to seek avoidance. 3. Provide monthly data at specialty level on reason for breaches and percentage achievement by specialty to highlight areas for improvement 4. A breach analysis form to be completed for all reportable breaches to identify trends and actions required to avoid repeat 5. Improve system to validate all breaches before they are reported Performance Report Appendix C Board Date: 29 th July 2009 Page 19 of 21

20 BOARD EXCEPTION REPORT CORPORATE TARGET NUMBER & DESCRIPTION: CURRENT CORPORATE RATING: RESPONSIBLE DIRECTOR: MON03, MON4, MON10, CQC19, CQC20, CON05, CON06 Cancer 31 Day and 62 Day Targets Medium Chief Operating Officer Brief description of how the rating was derived The June 2009 cancer performance figures show a continued downward trend in performance on previous months for 62 day waits. The 2 week wait breach for this month was due to patient choice, which under the new rules does not stop the clock. The 31 and 62 day waits have elements of complex diagnostic pathways, however there are issues around diagnostic results, admin delays, patients not appearing on the Cancer Waiting Time Tracking Database and 4 shared breaches with other Trusts. There is ongoing work to improve the functionality of the Cancer Waiting Times Tracking Database which will make the tool more user-friendly. The weekly Patient Tracking List (PTL) continues to be sent out to Directorate teams, which highlight those patients who need some action taken either to avoid a breach, or the Database updating if action has already been taken. Weekly meetings take place in most areas with Administrative Service Managers and secretaries/multi-disciplinary Team coordinators involved in tracking with a view to proactively address problem areas, this practice should now have been implemented in all tumour sites. In light of the recent letter from the National Cancer Director which shows national performance against Q4 figures, the Trust needs to be able to demonstrate compliance against what would appear to be proposed thresholds. The Trust s Q1 performance would indicate that we would not currently meet the 31 day 1 st treatment and the 62 day targets. In view of this an urgent meeting was called with the Cancer Services Team and relevant Directorate staff on 16 July in order to discuss the Trust s position and agree Directorate action plans to improve specialty performance. Actions from this meeting are noted below. Details of actions necessary to return performance back to either good or excellent Proactive tracking by Directorates via Cancer Tracking Database. Use of weekly PTLs by Directorates to pick up and rectify potential problems. In month validation of potential breaches rather than retrospective validation. Circulation of performance data by tumour site/clinician level to Directorates. Stages of treatment pathways to be developed in all tumour sites to alert trackers as to when treatment should be expected within the pathway. Roles and responsibilities and cancer waiting times definitions documents to be updated and circulated. Further training sessions to be held for tracking staff with specific emphasis on consultant upgrades and subsequent treatment definitions. Audit on subsequent treatments. Urgent meeting to take place with Diagnostics. Performance Report Appendix C Board Date: 29 th July 2009 Page 20 of 21

21 BOARD EXCEPTION REPORT CORPORATE TARGET NUMBER & DESCRIPTION: CURRENT CORPORATE RATING: RESPONSIBLE DIRECTOR: LOC03, LOC04 18 Week Maximum Wait for Admitted and Non-Admitted Orthopaedic Patients Medium Chief Operating Officer Brief description of how the rating was derived The indicator is calculated as the number of patients whose referral to treatment pathway was completed within 18 weeks divided by the total number of patients whose referral to treatment pathway was completed during the month. Details of actions necessary to return performance back to either good or excellent In order to achieve the 18 week target by 31 st March 2010 approximately 1200 additional surgical procedures will need to take place. The action plan for delivering this additional activity is as follows: Number of Risk of non Activity type cases delivery Additional Saturday lists 480 Low Risks Slippage in plastics Capacity freed up by plastics 184 Medium timescale Beds tariff + 10% 156 Medium Low take up so far Mobile orthopaedics theatre 507 Low Plymouth ISTC 100 Medium Total 1377 Medium Beds Requires PCT funding Medical staffing Planning permission Procurement Contracting with PCT Patient take up is a problem The actual number of cases will vary according to case mix and the nature of future referrals. The above action plan allows some contingency in case various elements do not deliver as planned. Whilst there are a number of obstacles relating to the use of a mobile orthopaedic theatre, a considerable amount of management time is being focused upon managing the work up process. The Divisional Manager responsible for ensuring the achievement of the 18-week target in this area is confident that a mobile theatre is a viable option and will provide the required infrastructure. An additional 500 outpatient appointments are also required and negotiations with surgeons are currently underway to provide these. A business case for the conversion of an office to an additional outpatient room to accommodate extra clinics has been submitted for consideration. Performance Report Appendix C Board Date: 29 th July 2009 Page 21 of 21