SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators July Regular report to Trust Board

Transcription

1 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators July 8 Report to: Trust Board nd September 8 Report from: Sponsoring Executive: Aim of Report/Principle Topic: Review History to date: Recommendation(s): Susan Moore, Acting Director of Performance Management, Chief Operating Officer Provides a summary of the Trust s performance against a range of high level key performance indicators as agreed by Trust Board. Regular report to Trust Board Trust Board are asked to note the Key Performance Indicators Report attached. 1. Strategic context: Range of high-level indicators to give an overview of performance within the Trust and to support the development of the Intelligent Board principles within the organisation.. Specific Detail.1 Background.1.1 The key performance indicators have been selected / developed by the Trust Board to support the Trust s Vision, Strategy and specific objectives for the 8/9 financial year..1. The indicators are divided into two groups year to date and quarterly/annual - and themed to align with the Trust s Strategy (tbd = to be developed): Indicators Year to Date Quarterly / Annual In Use tbd In Use tbd Hospital of Choice 15 5 Productivity 11 Clinical Quality 6 tbc 5 tbc Clinical Research and Development 9 Education and Training 7 Financial Position 15 7 Excellent Employer 6 1 Information Management and Technology Estates 5 7 Total 6 5 1

2 .1. There are three possible scores for each indicator (red, amber or green), with arrows showing either improvement or deterioration in performance across the most recent month (a sideways arrow indicates no significant change from the previous month). All indicators with a red score have a high-level action plan as part of the report. All amber indicators should have an executive sponsored improvement plan in place.. Individual Scorecards..1 Individual scorecards have been developed for each theme (as per the Trust s Strategic Objectives). These scorecards are attached at Appendix and provide more detail on each indicator including tolerances and trends. The scorecards are designed to support the KPI Summary and be reflected in the other regular reports to Trust Board... Please note that these scorecards continue to be work-in-progress and we do not yet have an exact match with the more detailed reports. Both the scorecards and other regular reports will continue to be aligned to ensure that a full suite of performance information is provided to Trust Board on a monthly basis.

3 . Performance (year to date) at the end of July 8 (Appendix 1)..1 Summary Year to Date Qtr/Annual Indicators Red Indicators 9 Cardiac Waits (RACPC); MRSA; Complaints Response Times; Theatre Utilisation; Performance Improvement Plan; SLA Activity (ICU/HDU bed days); Bank FTE; Agency FTE; Overtime/Excess Hours FTE Amber Indicators 1 Green Indicators 7 To be confirmed Maternity Leave FTE; Delayed Transfers of Care; Pre-operative (Elective) LoS.. Red Indicators Total 6 Summary action plans are attached as part of Appendix to support the majority of the Red Indicators with additional information where applicable. Detailed action plans are in use across the organisation to support both the Hospital Acquired Infections and A&E access. These plans are updated regularly but have not been included in this report because of their size and level of detail... Amber Indicators Current Improvement Projects Progress towards 18 weeks (covers inpatients, outpatients and diagnostic waits) Length of Stay (Elective and Non-elective) Delayed Transfers of Care Bed Capacity New to Follow-up Outpatient Rate Theatre Utilisation Hospital Acquired Infection Complaints Pre-11am Discharge Trust Improvement Programme Project Lead Mark Hackett Judy Gillow Judy Gillow Jane Hayward. Conclusions..1 Trust Board are asked to note the Key Performance Indicators Report attached.

4 Year to Date (April 8 to June 8) DN Separate Excel File containing Appendices 1 and to be inserted here Appendices 1 and

5 Appendix High Level Action Plans Productivty Theatre Utilisation Data on theatre utilisation is now available in detail for the first time this financial year. This is being shared with the Divisional Management Teams. The recent Divisional Performance Reviews highlighted areas of concern in a number of specialties and the Executive Team have requested detailed action plans. This will be followed up with individual specialties via the COO and Divisional Management Teams and an improvement trajectory agreed. This will continue to be monitored via the Monthly Divisional Performance Reviews.

6 Clinical Quality: July 8 HCAI MRSA Bacteraemia MRSA Bacteraemia Acquisition MRSA Trajectory Divisional RAG Report SUHT MRSA BSI 5-9 SUHT MRSA BSI (5-9) Cumulative Versus Trajectory July 8 Target Actual Rating Year to Date Target Actual Rating DIVISION 1 1 R 1 5 R No of Cases No of Cases 6 5 DIVISION 1 1 A 5 R DIVISION 1 G G DIVISION G A DIVISION 5 G G Community/other provider G G SUHT TOTAL A 9 1 R Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar Jul-6 Aug-6 Sep-6 Oct-6 Nov-6 Dec-6 Jan-7 Feb-7 Mar Jul-7 Aug-7 Sep-7 Oct-7 Nov-7 Dec-7 Jan-8 Feb-8 Mar Jul-8 April May June July August September October November December January February March Actual Cases Trajectory Linear Trend (Actual Cases) Actual 5/6 Actual 6/7 Actual 7/8 Actual 8/9 Trajectory 5/6 Trajectory 6/7 Trajectory 7/8 & 8/9 Focus on hand hygiene, IV practice and blood culture technique continues and is having impact compared to Aug-Dec 7. Department of Health observation of care team visited SUHT on rd April 8 very positive generally and confirmed high standards being achieved in many areas. Work on specific issues identified from the visit being taken forward through trust programme. Trust is over trajectory so far for this year to end July, and disappointingly has a higher number than that reported at the same time last year. Target of 5 is still achievable for 8-9 provided we continue to implement focussed action. Emergency Medicine Care group, Surgery (with input from radiology), and the Cardiac care group/cardiac theatres remain on special measures. This appears to be having impact in all the areas. Formal review meetings planned over next 6 weeks. MRSA Baseline Target to end June = 9 Cases. SUHT Trajectory = 1 Special measures involve weekly meeting with Infection Prevention Team and scrutiny of local action plans to support progress, plus regular review by DIPC. Divisional Performance Division 1 Cases. Division Cases. Division Cases. Division Cases. Division 5 Cases. Key Issues From MRSA Bacteraemia x : July 8 1 =. Previous MRSA bacteraemia 1/6/8 whilst inpatient at SUHT Pt responded to treatment and discharged. Readmitted to AMU 16/7/8 with suspected sepsis. Clinically complex review meeting arranged for Weds th Aug 8. Avoidable? = Unknown at present 1 =. Inpatient since 9/6/8. Previous MRSA bacteraemia /6/8 Clinically the same episode and cause. Case to be made by IPT to HPA for de-flagging of this case. Avoidable? = No

7 Healthcare Associated Infection Clostridium difficile (All cases over years of age) No. of Cases C. difficile Acquisition C. difficile Trajectory Divisional RAG Report Number of C. difficile Cases Including SHA Trajectory SUHT Other Jul SHA Trajectory Jul-6 Aug- 6 Sep- 6 Oct- 6 Nov- 6 Dec- 6 Jan- 7 Feb- 7 Mar Aug- Jul-7 7 Sep- 7 Oct- 7 Nov- 7 Dec- 7 Jan- 8 Feb- 8 Mar Jul- 6 Aug- 6 Sep- 6 Oct- 6 Nov- 6 Dec- 6 Jan- 7 Feb- 7 Mar Jul- 7 Aug- 7 Sep- 7 Oct- 7 Nov- 7 Dec- 7 Jan- 8 Feb- 8 Mar Jul-8 SUHT Other SHA Traject No of Cases SUHT C.diff Versus Trajectory April May June July August September October November December January February March Actual 7/8 Trajectory 7/8 Actual 8/9 Trajectory 8/ July 8 Target Actual Rating Year to Date Target Actual Rating DIVISION 1 8 G 1 1 G Surgery 6 G 11 G Trauma & Orthopaedics G 9 G Ophthalmology G G DIVISION 15 G 8 56 G Cancer Care R A Acute Medicine 1 G 1 5 G Medicine 7 R R Elderly Care G G DIVISION 1 R 1 R Child Health G 1 1 A Obstetrics & Gynaecology 1 R R DIVISION 5 6 R R Cardiothoracic 1 R 7 8 R Critical Care 1 1 A 7 R Neurosciences 1 G 7 G DIVISION 5 G G Pathology G G Radiology G G Community/other provider 16 5 SUHT TOTAL 5 G 1 95 G Focus on high impact intervention: immediate isolation, antibiotic prescribing, hand hygiene, chlorine cleaning is having a sustained impact. Work continues to drive up compliance with immediate isolation, including focussed review of each case of non-compliance and identification of the reasons for this. Clostridium difficile Baseline Target to end June = 1 Cases. (Revised Trajectory) Actual = 95 The Trust continues to make good progress with a below trajectory position. Red status in Division relates to a very small number of cases and does not necessarily reflect poor practice. Division are reviewing the RCA for all cases in recent weeks in order to drive improvement. Trust remains green against trajectory. Divisional Performance: Division 1 cases. Division 15 Cases. Division 1 Case. Division 6 Cases. Division 5 - Cases.

8 Total Number of Complaints In order to tackle the decline in response times for the 5 day target, the actions being taken are: - Care Group and Divisional management teams alerted about all individual concerns - Concerns being raised at the Delivery Group Meeting on A new escalation policy is in place to ensure compliance with response times - A weekly review of response times is taking place to help pick up problems at an early stage. - Additional alert systems are being set up within the complaints database to highlight delays in receipt of statements required to prepare responses. Finance Performance Improvement Programme A review by Division of the PIP between the CEO, FD and COO has been undertaken with Divisional Management Teams. The level of unidentified PIP continues to reduce and the value of unidentified schemes now totals 66k (%). PIP performance continues to be high on the agenda within Divisional Performance reviews. Strong performance management of the PIP position will continue until the Trust is back on track. Excellent Employer Agency, Bank and Overtime WTEs Bank, Agency and Overtime usage are above target, due largely to the high level of vacancies in Division. The action plan to crack this problem is outlined in the HR Quarterly Progress Report.