Integrated Performance Report. June 2015 (May data)

Transcription

1 Integrated Performance Report June 2015 (May data) 1

2 Executive Summary Executive summary reas of good performance reas requiring performance improvement Responsive Reporting sub committee - F&P Indicators achieving Indicators achieving but close to target/threshold May pr Mar Indicators not achieving Diagnostic wait times delivered to the performance standard for pril and May Provisionally for May, cancer 2 week wait, 31 day and 62 day screening indicators are delivering to the performance standard. The percentage of RTT pathways within 18 weeks has improved and the indicator is in line with its trajectory &E 4 hour wait (all types) performance was 90.8% for May Referral to treatment indicators continue to report under the performance standards, however this is anticipated as the team works towards the target of end of Q1 for aggregate compliance. Cancer 2 week wait (breast symptomatic) and 62 day indicators are not expected to be compliant for May (currently provisional) Formal delayed transfers of care continue to report above the performance standard (8.8% for May) dmission to stroke ward within 4 hours and patients spending 90% of their time on the stroke unit reported under the performance standard for May Safe Effective Caring Reporting sub committee - PSQR Performance relative to targets/ thresholds reas of good performance reas requiring performance improvement Indicators achieving Indicators achieving but close to target/threshold May pr Mar Indicators not achieving The number of serious incidents was 10 at the end of May, down from 30 at the end of March Clostridium difficile year to date total for May was 4 Mortality remains statistically significantly lower than (against a trajectory of no more than 23 cases for the year). expected for HSMR and within the expected range for SHMI One never event was reported for May Zero MRS bacteraemias VTE risk assessments was below threshold for May Reduction in pressure ulcers reas of good performance reas requiring performance improvement Well led Reporting sub committee - Workforce Indicators achieving Indicators achieving but close to target/threshold May pr Indicators not achieving number of other workforce indicators continue to report underperformance, including staff turnover rate, vacancy rate, appraisals and mandatory training. The sickness rate has recorded a second consecutive month ahead of target, reducing from 3.8% in March to 3.1% in pril and 2.9% in May Mar NB. Indicators achieving relate only to where targets have been set 2

3 Responsive Indicator Summary Latest three data points Domain Indicator Target Most YTD ctual Recent YTD Target Executive Lead Month Threshold Trend Data Quality R Referral to Treatment - dmitted* 90.0% 66.6% 66.8% 71.4% 69.2% 90.0% DCEO May-15 National Referral to Treatment - Non dmitted* 95.0% 88.8% 88.8% 90.1% 89.4% 95.0% DCEO May-15 National Referral to Treatment - Incomplete* 92.0% 89.3% 90.0% 91.3% 90.7% 92.0% DCEO May-15 National Referral to Treatment - 52 week waits* DCEO May-15 National Diagnostic wait times 99.0% 98.5% 99.2% 99.5% 99.3% 99.0% DCEO May-15 National ED 4hr waits (Type 1, 2 & 3) 95.0% 88.4% 86.2% 90.8% 88.5% 95.0% DCEO May-15 National ED 12hr trolley waits DCEO May-15 National mbulance turnaround time between 30 and 60 mins DCEO May-15 Local mbulance turnaround time > 60 mins DCEO May-15 Local Cancer - Two week wait * 93.0% 98.9% 95.5% 96.8% 96.1% 93.0% DCEO May-15 National u Cancer - Breast Symptomatic two week wait * 93.0% 98.0% 94.2% 86.1% 90.0% 93.0% DCEO May-15 National Cancer - 31 day * 96.0% 97.7% 96.3% 98.1% 97.2% 96.0% DCEO May-15 National Cancer - 31 day subsequent drug * 98.0% 100.0% 100.0% 100.0% 100.0% 98.0% DCEO May-15 National Cancer - 31 day subsequent surgery * 94.0% 94.1% 100.0% 100.0% 100.0% 94.0% DCEO May-15 National u Cancer - 62 day * 85.0% 83.1% 94.6% 81.4% 89.2% 85.0% DCEO May-15 National Cancer - 62 day screening * 90.0% 84.6% 94.4% 100.0% 97.0% 90.0% DCEO May-15 National *RTT and cancer performance for latest month is provisional and subject to validation Exception indicators key Red for a minimum of two data points and amber for one, out of the latest three data points ured for the latest data point Data Quality R key Red Standard of data accuracy is not known, it is incomplete and inconsistent with relevant standards mber Data is assumed to be complete and accurate, although there may be limitations or unresolved queries reen Data is complete, accurate and consistent with the standards set for the specific indicator 3

4 Safe, Effective, Caring Responsive Indicator Summary Domain Indicator Target Latest three data points Most Recent YTD ctual YTD Target Executive Lead Month Threshold Trend Data Quality R Urgent operations cancelled for a second time DCEO May-15 National Number of patients not treated within 28 days of last minute cancellation DCEO May-15 National Delayed Transfers of Care (DToC) 3.5% 6.1% 3.7% 8.8% 6.3% 3.5% DCEO May-15 National Outpatient cancellation rate 8.0% 13.6% 12.7% 10.5% 11.6% 8.0% DCEO May-15 Local Patients admitted directly to stroke unit within 4 hours of hospital arrival * Stroke patients spending 90% of their time on stroke unit * 90.0% 32.3% 86.8% 81.6% 84.2% 90.0% DCEO May-15 Local 80.0% 64.5% 55.3% 60.5% 57.9% 80.0% DCEO May-15 Local SHMI (Rolling 12 months) MD Oct-Sep 14 National HSMR - Total (Rolling three months) MD Feb-15 National 30 Day Emergency Readmissions - Elective tbc 3.5% 3.2% 3.9% 3.6% tbc MD May-15 National 30 Day Emergency Readmissions - Emergency tbc 11.7% 10.7% 10.9% 10.8% tbc MD May-15 National Number of patients with a length of stay > 14 days Discharges between 8am and 12pm* (main adult wards excl U) Electronic discharge summary sent to P practices* tbc tbc MD May-15 Local tbc 18.2% 20.2% 17.0% 18.6% tbc DCEO May-15 Local 90.0% 40.1% 35.9% 35.4% 35.6% 90.0% CIO May-15 Local 4

5 Safe, Effective, Caring Indicator Summary Domain Indicator Target Latest three data points Most Recent YTD ctual YTD Target Executive Lead Month Threshold Trend Data Quality R Staff FFT % recommended care tbc % 57.5% tbc DoW Mar-15 National Inpatient Scores FFT % positive tbc % 94.1% 93.7% tbc CN May-15 National &E FFT % positive tbc % 91.0% 90.6% tbc CN May-15 National Daycase FFT % positive tbc % 96.4% 97.0% tbc CN May-15 National Maternity FFT % positive tbc % 91.3% 93.2% tbc CN May-15 National % Complaints responded to within one month tbc 57.6% 64.5% 53.3% 53.3% tbc CN pr-15 Local Complaints - rate per 10,000 bed days tbc tbc CN pr-15 National u Mixed sex accommodation breaches CN May-15 National Clostridium Difficile CN May-15 National MRS bacteraemias CN May-15 National u Never events MD May-15 National 5

6 Safe, Effective, Caring Indicator Summary Domain Indicator Target Latest three data points Most Recent YTD ctual YTD Target Executive Lead Month Threshold Trend Data Quality R Serious incidents - number* tbc tbc MD May-15 National Serious incidents - % that are harmful* tbc 6.7% 23.1% 70.0% 43.5% tbc MD May-15 National Medication errors causing serious harm * MD May-15 National Open CS lerts tbc CN May-15 National u VTE risk assessment* 95.0% 96.3% 96.2% 94.4% 95.3% 95.0% MD May-15 National Harm Free Care 95.0% 91.8% 91.1% 92.5% 91.8% 95.0% CN May-15 National Caesarean Section rate - Emergency* tbc 18.8% 18.4% 20.9% 19.7% tbc MD May-15 Local Caesarean Section rate - Elective* tbc 12.8% 12.6% 9.4% 10.9% tbc MD May-15 Local Maternal deaths MD May-15 National Hospital cquired Pressure Ulcers - rade CN May-15 Local Number of Falls* tbc tbc DE May-15 Local * Performance may change for the current month due to data entered after the production of this report 6

7 Well Led Indicator Summary Domain Indicator Target Latest three data points Most Recent YTD ctual YTD Target Executive Lead Month Threshold Trend Data Quality R Staff turnover rate 12.0% 16.9% 17.6% 17.2% 17.4% 12.0% DoW May-15 National Sickness rate 3.5% 3.8% 3.1% 2.9% 3.0% 3.5% DoW May-15 National Vacancy rate 5.0% 12.3% 15.9% 15.0% 15.4% 5.0% DoW May-15 National ppraisal rate (non-medical staff only) 95.0% 70.1% 76.4% 78.3% 78.3% 95.0% DoW May-15 National Mandatory Training 90.0% 80.3% 80.4% 81.7% 81.1% 90.0% DoW May-15 Local % Bank Pay tbc 7.0% 6.8% 6.7% 6.8% tbc DoW May-15 Local % gency Pay tbc 16.9% 16.5% 16.2% 16.4% tbc DoW May-15 Local Temporary costs and overtime as % of total paybill* tbc 24.5% 23.9% 23.3% 23.5% tbc DoW May-15 National Inpatient FFT response rate tbc % 53.0% 57.8% tbc CN May-15 National &E FFT response rate tbc - 7.5% 5.5% 6.5% tbc CN May-15 National Daycases FFT response rate tbc % 33.0% 48.6% tbc CN May-15 National Staff FFT response rate tbc % 17.9% tbc DoW Mar-15 National Staff FFT % recommended work tbc % 49.4% tbc DoW Mar-15 National Maternity FFT response rate tbc % 44.9% 41.1% tbc CN May-15 National NHS number utilisation - outpatients* 99.0% 99.8% 99.8% 99.8% 99.8% 99.0% CIO May-15 Local Data quality of returns to HSCIC Data not currently available. *Perfomance for current month may change due to data entry post production of this report *Medication errors causing serious harm data for latest month is provisional and subject to validation. Temporary costs and overtime performance is provisional for the current month 7

8 Financial Viability Indicator Summary Latest three data points Domain Indicator Target Most YTD ctual Recent YTD Target Executive Lead Month Threshold 000s 000s 000s 000s Bottom line Income & Expenditure position forecast against plan 0-14,000-32,800-32,800 DoF May-15 National Bottom line Income & Expenditure position year to date actual against plan 0-13,838-4,756-10,622 DoF May-15 National ctual efficiency recurring- forecast against plan 0 5,315 12,760 10,432 DoF May-15 National ctual efficiency recurring - year to date against actual plan 0 5, DoF May-15 National ctual efficiency non-recurring- forecast against plan 0 3, ,568 DoF May-15 National ctual efficiency non -recurring - year to date against actual plan 0 3, DoF May-15 National Forecast underlying surplus/deficit against plan 0-27,500-25,700-27,600 DoF May-15 National Forecast year end charge to capital resource limit 0 16,961 1,178 1,846 DoF May-15 National Is the Trust forecasting permanent PDC for liquidity purposes? 0 22,700 35,500 35,500 DoF May-15 National Cumulative I&E surplus or deficit 0-13,838-4,756-10,622 DoF May-15 National Month s I&E surplus or deficit 0 3,703-4,756-5,866 DoF May-15 National Cumulative EBITD margin (%) 0.0% -0.8% -15.3% -17.6% DoF May-15 National NHS income variance (%) 0.0% -4.0% -0.6% 0.1% DoF May-15 National Year on year change in income 0 22, DoF May-15 National Year on year change in pay costs 0 12, ,768 DoF May-15 National Year on year change in non pay costs 0 10,664-1,951-3,205 DoF May-15 National Year on year change in capital spend DoF May-15 National Capital spend as a % of annual CRL % 6.50% 6.76% DoF May-15 National Continuity of services risk rating DoF May-15 National Liquidity ratio DoF May-15 National Capital servicing capacity DoF May-15 National NHS clinical income per consultant P DoF May-15 National Outstanding loans value 0 10,707 10,707 10,707 DoF May-15 National Debtor days DoF May-15 National Creditor days DoF May-15 National Purchase order compliance % 2.00% 1.00% DoF May-15 National % of turnover saved in month 0.0% 7.56% 1.20% 3.19% DoF May-15 National Forecast savings as % of turnover 0.0% 3.21% 4.19% 3.93% DoF May-15 National 8

9 Exception Reports 9

10 Number of patients % patients within 18 weeks Responsive Reporting sub committee - F&P Completed pathways within 18 weeks 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% ccess indicators - RTT, diagnostics, cancelled operations and outpatient appointments pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 dmitted performance dmitted trajectory dmitted target Non admitted performance Non admitted trajectory Non admitted target Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds Indicators achieving Lynn Hill Jeremy Livingstone Jane Shentall Indicators achieving but close to May pr Mar Recovery plan/ existing actions and update Indicators not achieving WHHT has undertaken to achieve organisational compliance in Referral to Treatment (RTT) and diagnostics by the end of Q1 2015/16. RTT standards include the 90% admitted, 95% non admitted patients receiving their definitive treatment within 18 weeks of referral. The RTT incomplete standard requires 92% of patients who have not received definitive treatment to be waiting under 18 weeks. The diagnostic waiting time standard is for 99% of patients referred for 15 diagnostic tests/procedures, should wait no longer than 6 weeks. Incomplete pathways within 18 weeks 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 The operational recovery plan has identified specialty level RTT plans to achieve organisational compliance, noting that compliance at a specialty level will require additional time for some of the more challenged specialties to achieve compliance. The operational recovery plan has put in place more robust access, admissions and outsourcing teams and recruitment to vacant DM posts have been successful, strengthening waiting list governance, engagement in the access agenda and provided better support to the services. Regular meetings with external partners have begun which provide an opportunity for the Trust to focus the search for capacity in the independent sector to specific areas of significant demand. Incomplete pathways WL profile 30,000 25,000 20,000 15,000 10,000 5,000 dmitted performance dmitted trajectory Target 92% 90% 88% 86% 84% 82% 80% 78% Progress has been made in acquiring additional equipment in both Cardiology and ynaecology, which will provide some resilience and will also deliver an increase in capacity for Echocardiology and Urodynamic diagnostic tests. The recovery plan also includes the ring-fencing of some elective surgical beds on the WH site in order to reduce the number of elective cancellations due to lack of beds. In addition, capacity has been increased from the Vanguard modular theatre which became operational on 18 May pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 76% 2014/ / < ,09 1,06 1,29 1,55 1,53 1,68 1,73 1,68 1, <26 2,21 2,37 2,81 3,06 3,07 2,67 3,32 3,01 2,82 2,25 1,58 1,48 1,62 1,54 <18 21,1 22,6 22,5 22,4 22,0 21,3 21,9 20,6 20,1 18,4 19,1 19,5 20,7 21,8 % of PTL within 18 weeks 87.0% 86.7% 85.3% 83.7% 82.7% 83.5% 81.4% 81.2% 81.7% 83.2% 88.3% 89.5% 89.9% 90.6% 10

11 Diagnostics Number of patients not treated within 28 days of last minute cancellation 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Performance Trajectory Target pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Performance Trajectory Target Summary issues Referral to treatment completed indicators continue to report under the performance standards, however this is anticipated as the team works towards the target of end of Q1 for aggregate compliance. Performance against the incomplete standard is ahead of its trajectory for May and demonstrates that the Trust is on target to meet its operational recovery plan. Diagnostic wait times delivered to the performance standard for pril and May. The Director of the NHS IMS Intensive Support team has signed off on our RTT recovery plan having reviewed progress to date and the trajectories and processes now in place. In addition, the Trust has been asked to speak at next year s IMS conference on RTT. On 4 June 2015, Simon Stevens, CEO of NHS England, wrote to all Chief Executives of NHS providers to advise that the tracking of RTT waiting times is to be rationalised with a focus on the incomplete standard. However, we will continue to monitor performance against all standards in line with the undertaking to deliver an aggregate position from Q2. Immediate and additional actions The following weekly meetings and discussions review waiting times performance, including cancelled operations and outpatient appointments. a) weekly organisational level ccess/performance meetings b) weekly divisional level ccess meetings (RTT) c) trajectories shared with services weekly, mapping progress towards target d) patient level detailed review of PTLs by Director of Operations for Elective Care These meetings will review any systemic issues leading to last minute cancellations and failure to re-book within 28 days. Ongoing management of leave processes and adherence continues to prevent cancellations of hospital appointments within six weeks. Hospital outpatient cancellations 16% 14% 12% 10% 8% 6% 4% 2% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Next steps 1) Completion of the review of the Trust's ccess policy, to include clear guidance for diagnostic and cancer waiting times, with steps in place to ensure that the Trust's ccess Policy is followed by all scheduling staff. 2) Continued focus in sustaining the progress made to date and ensuring compliance with the national standards. more forward looking approach to RTT performance must be embedded into business as usual. This is to become part of the weekly ccess meeting agenda. 3) Development of the demand and capacity tool in partnership with NHSE and Herts Valleys CC. 4) Development of the OO (general other outcome - patients who have had a first appointment but are without any definitive pathway outcome) report. 5) Refresher 18 week RTT training for all staff involved in the administration of the patient pathway and inclusion in mandatory training requirements for relevant staff groups. Performance Trajectory Target 11

12 Responsive Reporting sub committee - F&P 100% 95% 90% Unscheduled care indicators - &E, ambulance turnaround, stroke and DToC Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds Indicators achieving Lynn Hill Dr David aunt Caroline Landon Indicators achieving but close to May pr Mar Recovery plan/ existing actions and update Indicators not achieving &E mbulance turnaround time 85% 80% 75% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Performance Trajectory Target pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 mbulance turnaround 60 mins+ mbulance turnaround between 30 and 60 mins The &E performance goal is reliant on not just the hospital improving processes internally, it is also focusing on system delays impacting on patient flow. There are a significant number of external factors which need to be addressed with partner organisations in order to achieve the improvement trajectory: - Significant reduction in DToCs in medically fit patients - Significant reduction in overall system waits - P heralded patients managed flow throughout the day to allow the hospital teams to deal with a steady flow of admissions and reduction in perceived batched arrivals - Improved ambulance traffic management (reducing peaks in arrival numbers) - Sufficient CMHS capacity - Sufficient Neuro Rehab capacity - District Nurse capacity (as well as a streamlined referral process) - Transport contract with flexibility which supports the Trust s needs. In the past month, key achievements have been: - Changing the P heralded admission process to go via mbulatory care - Implementation of the Floor Coordinator and Patient Safety Office in the Emergency Department - Implementation of lead nurse in U. This appeared to have a positive impact on performance and admissions, but it is too early to see if these gains are sustainable. Delayed Transfers of Care (DToC) 10% 9% 8% 7% 6% 5% 4% 3% Trajectory Target The Sarratt ward project has formally launched with a number of sessions working with the ward team to identify and implement changes to the ward. Early signs of improvement are encouraging, including achieving 20% of discharges before 12pm in May and a drop in reported clinical incidents of 50%. 2% 20 1% 10 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar / /16 Beds used by DToC patients in month DToCs Trajectory DToC target 12

13 Patients admitted directly to stroke unit within 4 hours of hospital arrival 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Summary issues Key performance indictors across the unscheduled care programme have improved on the last month, seeing an upward trend in all except three areas; discharge before 12pm, and admissions to surgical and medical ambulatory care. The improvements in other KPIs suggests an early indication of some of the changes made to date having an impact, although this will need to be monitored closely to see a continuation of the trend. Performance Trajectory Target 100% 90% Stroke patients spending 90% of their time on stroke unit 80% 70% 60% 50% 40% 30% 20% Immediate and additional actions 10% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar 2014/ /16 Performance Trajectory Target Wards - Continuation of Sarratt project, and initiate the roll out plan for the next phase of DPOW (Developing the Perfect Operating Ward). - gree the plan for moving to ward based discharge co -ordinators and the HR management of change - Embedding Discharge Checklists, Board Round Standards, and Criteria Led Discharge &E - Workforce review and assessment of revenue implications, including long term planning for the department, winter planning and risk mitigation. - U review outcome of process mapping exercise, implementing agreed actions by the U working group - Simulation modelling for &E reconfiguration and progression with Urgent Care Centre pilot model. 13

14 Cancer Breast Symptomatic u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Cancer - Breast Symptomatic two week wait * Lynn Hill Dr ndy Barlow Jane Shentall ctual Target ctual Target Indicator Description 14 day target relates to patients referred from P to hospital on a breast symptomatic pathway, timed from date of receipt of referral to first attended outpatient appointment. 100% 86.1% 93.0% 90.0% 93.0% Number of months not achieving target 1 out of 2 (in current financial year) Description of Risk 90% 80% Patient safety, financial and reputational, due to the non-delivery of the breast symptomatic two week wait NHS constitution standard. 70% 60% 50% Immediate ctions Date 1. Weekly access meetings with divisions In place 2. Forensic weekly validation of all patients on PTL (previous focus was in month) In place 3. Weekly cancer project team meetings In place 40% 30% 20% 10% 4. Cancer validation team reviewing all patients on a cancer pathway In place 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Cancer - Breast Symptomatic two week wait * ctual Cancer - Breast Symptomatic two week wait * Trajectory Cancer - Breast Symptomatic two week wait * Target ctions to achieve target and deliver sustainability Patient choice has had a significant impact where at least 17 of the 21 breaches were due to patients electing to be seen outside of two weeks. Ongoing monthly monitoring and updating of cancer improvement plan in response to Independent Review and IST reports. Cancer validation team in place to support accurate reporting from 2WW referral through to 31 and 62 day treatments. Weekly organisational level ccess/ performance meetings with patient level review of PTL by Director of Operations for elective care. ssurance is also provided by reviewing progress against recovery plan trajectories to ensure services are on track to meet operational standards. * Latest month's cancer data is provisional and subject to further validation 14

15 Cancer 62 Day u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Cancer - 62 day * Lynn Hill Dr ndy Barlow Jane Shentall ctual Target ctual Target Indicator Description 62 day target relates to time from P referral to first definitive treatment. Description of Risk 100% 95% 81.4% 85.0% 89.2% 85.0% Number of months not achieving target 1 out of 2 (in current financial year) Patient safety, financial and reputational, due to the non-delivery of the 62 day NHS constitution standard. 90% 85% Immediate ctions Date 1. Weekly access meetings with divisions In place 2. Forensic weekly validation of all patients on PTL (previous focus was in month) In place 3. Weekly cancer project team meetings In place 4. Cancer validation team reviewing all patients on a cancer pathway In place 5. Demand and capacity models by tumour site being produced End of Q1 80% 75% 70% 65% 60% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Cancer - 62 day * ctual Cancer - 62 day * Target ctions to achieve target and deliver sustainability Ongoing monthly monitoring and updating of cancer improvement plan in response to Independent Review and IST reports. Cancer validation team in place to support accurate reporting from 2WW referral through to 31 and 62 day treatments. Patients on waiting lists continue to be actively managed to ensure their treatment date is within 62 days. Reintroduce breach sharing protocol with all referring organisations in order to share accountability and learnings. Weekly organisational level ccess/ performance meetings with patient level review of PTL by Director of Operations for elective care. ssurance is also provided by reviewing progress against recovery plan trajectories to ensure services are on track to meet operational standards by end July * Latest month's cancer data is provisional and subject to further validation 15

16 Electronic Discharge Summary sent to P Practices Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Electronic discharge summary sent to P practices* Lisa Emery Dr David aunt ctual Target ctual Target Indicator Description Percentage of discharge summaries that are sent electronically to P practices. standardised electronic discharge summary enables the continuous care of patients once they have been discharged from hospital, with consistent and relevant information in the right place, quickly. Description of Risk 100% 90% 35.4% 90.0% 35.6% 90.0% Number of months not achieving target 2 out of 2 (in current financial year) 80% Risk to the timely provision of discharge information to Ps following a patient's discharge from hospital. 70% 60% 50% Immediate ctions 1 functionality to be provided within the Trust Infoflex system. This required a test (server) environment to be created 2 Testing of functionality by Infoflex applications team (was pr) Date In place Ongoing 40% 30% 20% 3 User acceptance testing by service users (was May) Jun-15 10% 4 Sign off user acceptance testing and go live (was May) Jul-15 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Electronic discharge summary sent to P practices* ctual Electronic discharge summary sent to P practices* Target ctions to achieve target and deliver sustainability Once electronic solution is in place this will ensure sustainable delivery of discharge summaries in a timely fashion 16

17 Mixed Sex ccommodation u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Mixed sex accommodation breaches Indicator Description The number of breaches of mixed-sex accommodation. Professor Tracey Carter ctual Target ctual Target Number of months not achieving target 2 out of 2 (in current financial year) Description of Risk Patient dignity, financial and reputational, due to the non-delivery of the Mixed- Sex ccommodation NHS constitution standard Immediate ctions 1 Review of Root cause of breach in ITU ctions to achieve target and deliver sustainability Working with System Resilience roup (SR) to improve overall patient flow. Date Jun pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Mixed sex accommodation breaches ctual Mixed sex accommodation breaches Trajectory Mixed sex accommodation breaches Target 17

18 Clostridium Difficile u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Clostridium Difficile Professor Tracey Carter ctual Target ctual Target Indicator Description Number of Clostridium difficile cases recorded in the period Number of months not achieving target 1 out of 2 (in current financial year) Description of Risk Clostridium difficile has been recognised as a cause of diarrhoea, usually acquired during a hospital admission, which occasionally, and particularly in the elderly, may result in a serious illness and even death Immediate ctions Date Review of all RCs 2 Typing of all cases to see if linked Jun-15 Jun Meeting with CC and TD to discuss overview 4 5 Jul-15 0 pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / / Clostridium Difficile ctual Clostridium Difficile Target Clostridium Difficile Trajectory Clostridium Difficile ctual YTD Clostridium Difficile Target YTD 8 ctions to achieve target and deliver sustainability 18

19 Never Events u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Never events Dr Michael Van der Watt ctual Target ctual Target Indicator Description Number of never events recorded in period. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been Description implemented. of Risk Number of months not achieving target 1 out of 2 (in current financial year) ll never events are serious incidents which need scrutiny since they are largely preventable if available preventable measures have been implemented. 1 Immediate ctions 1. Investigation commenced Date Jun ctions to achieve target and deliver sustainability Never event investigated and lessons learned disseminated through Divisional governance 0 pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Never events ctual Never events Trajectory Never events Target 19

20 VTE Risk ssessment u Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date VTE risk assessment* Dr Michael Van der Watt ctual Target ctual Target Indicator Description Venous Thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein. Risk assessment is for all inpatients to ensure they receive appropriate interventions if they have a high risk. Description of Risk 100% 98% 96% 94.4% 95.0% 95.3% 95.0% Number of months not achieving target 1 out of 2 (in current financial year) ppropriate patients need to be risk assessed on admission to ensure the right timely care is delivered 94% 92% 90% Immediate ctions 1. VTE action plan is in place overseen by a multi-disciplinary group. 2. Relaunched medical VTE assessment forms. 3. Increased awareness education around VTE. 4. ppointed a thrombosis Clinical Nurse Specialist to validate data and educate. Date Ongoing Completed Ongoing Completed 88% 86% 84% 82% 80% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 5. udit of VTE assessment reporting. Completed 2013/ / /16 6. To audit performance following exclusion of obstetric triage. Completed 7 VTE risk assessment* ctual VTE risk assessment* Target 8 ctions to achieve target and deliver sustainability The Trust is reviewing the data for May in response to an administrative process to record assessments not being followed. The underperformance is likely to be due to a recording issue rather than a real drop in VTE assessments. multidisciplinary team (TP) leads on VTE medical assessment. Each division has a target to achieve. Test your care is looking at compliance to nursing standards and process outcomes. VTE assessments are performance managed via the divisional directors. Criteria for excluding patients not requiring a VTE assessment are being reviewed by the TP. 20

21 Harm Free Care Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Harm Free Care Professor Tracey Carter ctual Target ctual Target Indicator Description Data is sourced from the Safety Thermometer, a snapshot of the condition of a large number of patients, reporting on falls, catheter UTI, pressure ulcers and Venous Thromboembolism (VTE). Description of Risk 100% 95% 92.5% 95.0% 91.8% 95.0% Number of months not achieving target 2 out of 2 (in current financial year) The safety thermometer is a point prevalence survey (one day) to give and indication of the level of harm free care through the organisation. Other metrics are collected on a more regular basis to ensure delivery of harm free care in relation to falls, catheter usage, pressure ulcer care and VTE identification and management. 90% 85% Immediate ctions 1. National audit of falls 2. Pathway work with the community for patients with falls Date Jun-15 Sep-15 80% 75% 70% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Harm Free Care ctual Harm Free Care Target ctions to achieve target and deliver sustainability Fundamentals of care panel oversee delivery. Serious incidents are investigated as per policy. Learning from serious incidents and near misses to be further embedded throughout divisions around lessons learnt and via patient safety and quality committee. Metric boards in place in ward areas displaying information on quality indicators Promotion across the wards on safety thermometer days and educational sessions regarding the Best Shot pressure ulcer campaign 21

22 Staff Turnover Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Staff turnover rate Paul Da ama ctual Target ctual Target Indicator Description Proportion of workforce leaving in a given period. Description of Risk Increasing labour turnover results in the Trust losing key skills, increased use of temporary staff to cover service need, and additional recruitment of staff to replace leavers. 18% 16% 14% 12% 17.2% 12.0% 17.4% 12.0% Number of months not achieving target 2 out of 2 (in current financial year) Immediate ctions 1. Revised promotional material for recruitment purposes to be produced (was pr) 2. Implementation of LinkedIn proposal Date ug-15 Jun-15 10% 8% 6% 3. Roll out of initiatives such as new vending machines, staff only sections of the staff restaurant (delayed from May) 4. Proposal re: incentivising student nurses to join us prepared and follow up R+R focus groups with student nurses 5. Recruitment of personnel to manage overseas nurse recruitment ug-15 Jun-15 Jun-15 4% 2% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 6. Filming for new recruitment microsite to begin July, microsite launch ugust 2015 ug / / /16 Staff turnover rate ctual Staff turnover rate Target ctions to achieve target and deliver sustainability Key actions undertaken in the previous month included: Successfully recruited 174 nurses from the Philippines uto enrolment of nurses and midwifes to bank completed Changes to HR streamlining processes implemented Changes to OHS recruitment completed 22

23 Vacancy Rate Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Vacancy rate Paul Da ama ctual Target ctual Target Indicator Description Percentage of vacancies against total establishment (WTE). Description of Risk High vacancy rates result in leads to diminished staff engagement, poorer patient experience. increased replacement costs and loss of organisational talent. 16% 14% 12% 10% 15.0% 5.0% 15.4% 5.0% Number of months not achieving target 2 out of 2 (in current financial year) Immediate ctions For detailed actions please refer to the Staff Turnover exception report Date 8% 6% 4% 2% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 Vacancy rate ctual Vacancy rate Target ctions to achieve target and deliver sustainability Longer term the action around this area must focus upon improving retention, developing WHHT's appeal as a future employer and ensuring that our recruitment processes are able to process and recruit people as quickly as possible. 23

24 ppraisal Rate Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date ppraisal rate (non-medical staff only) Paul Da ama ctual Target ctual Target Indicator Description Percentage of substantive staff members with an up to date appraisal recorded on ESR. 100% 78.3% 95.0% 78.3% 95.0% Number of months not achieving target 2 out of 2 (in current financial year) Description of Risk Over 600 managers have received Values Based ppraisal Training, but completion rates are very low leading to reduced engagement and potentially poor performance not being actively managed. (Important to note that the completion rates only include appraisals completed as part of the values based appraisals process with the training for this work having finished in September). Immediate ctions 1. Production of team based reports detailing who has not yet completed their appraisal 2. Fortnightly reporting on appraisal completion by HR Business Partner to divisions/directorates 3. Introduction of fortnightly league table Date Ongoing Ongoing Ongoing 90% 80% 70% 60% 50% 40% 30% 20% 10% Data from May 2014 onwards is for DO appraisals 4. Involvement of CEO with divisions and directorates where low rates require an action plan Ongoing 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 2013/ / /16 ppraisal rate (non-medical staff only) ctual - New ppraisal rate (non-medical staff only) ctual - Old ctions to achieve target and deliver sustainability ppraisal process to be established across the Trust. Monthly feedback on targets to Board and Divisions. Higher levels of appraisals indicate staff are familiar and aligned with organisation objectives and have a clear view of effective and ineffective behaviour. Please note appraisals for Medical Staff is at 99.6% of those able to be appraised. 24

25 Mandatory Training Indicator Executive Lead Clinical Lead Operational Lead Current Month is May-15 Year to Date Mandatory Training Paul Da ama ctual Target ctual Target Indicator Description This is the training requirement that has been deemed mandatory by the Trust. Mandatory training is concerned with minimising risk, providing assurance against policies and ensuring the Trust meets external standards. Description of Risk 100% 90% 81.7% 90.0% 81.1% 90.0% Number of months not achieving target 2 out of 2 (in current financial year) Staff who are not up to date with their mandatory training requirements may be at risk of harming our patients or themselves through incorrect use of equipment or out-dated skills. In the case of statutory requirements there is the additional risk of legal ramifications from bodies such as the Health and Safety Executive or local Fire Service. 80% 70% 60% 50% Immediate ctions 1. Setting up task and finish group with IT, medical education and HR business partner colleagues to work towards resolving issues with access to e-learning (was pr-15) 2 Review of requirement for Level 1 and 2 Safeguarding for staff undertaking Level 3 3. Monthly review of mandatory training as part of divisions' performance meetings 4. Monthly s to all divisions setting out compliance figures Date Jul-15 Ongoing Ongoing Ongoing 40% 30% 20% 10% 0% pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May Jun Jul ug Sep Oct Nov Dec Jan Feb Mar pr May 5. Proposals to be implemented to ensure that all new joiners are offered mandatory training prior to starting in their roles Jul / / /16 Mandatory Training ctual Mandatory Training Trajectory Mandatory Training Target ctions to achieve target and deliver sustainability Monthly review of classroom capacity dditional sessions across all subjects for Estates department Bespoke conflict resolution for surgical secretaries 25

26 Ward Scorecard Division Medicine Surgery Matron Quality Checks/Pati ents Matron Quality TYC Overall Checks/Staf f TYC/TVN section Pressure Ulcers Falls Falls with Harms Commode udit Hand Hygiene udit Hospital accquired C.diff Hopsital accquired MRS F and F Extremely Likely and Likely % IWC Response % Red Flag Number of shifts than 2 RN's on shift Red Flag Number of shifts more than 8 hours less than planned U B/Y 3 81% 96% 88% 93% % 100% % 72% % U B1 86% 99% 94% 96% % 75% % 71% % U 1 98% 100% 90% 100% % 100% % 83% 0 N 90% U PB 3 N N N N N N N N N N 0 N N N N N U P1 93% 98% 92% 83% % 98% % 44% % U Y1 89% 96% 87% 76% % 96% % 46% % U Y3 N N N N N N N N N N N N N N N N ldenham 88% 97% 81% 90% % 95% % 36% % Bluebell 75% N 96% 100% % 99% % 50% % Cassio 91% 92% 70% 62% % 100% % 48% % CCU/ P/ 3 87% 98% 92% 99% % 100% % 64% % Churchill N N N N N 0 0 N N 0 0 N N N N N Croxley 84% 91% 90% N % 64% % 63% % ade N N N N N 1 0 N N 0 0 N N N N N Heronsgate 86% 99% 90% 96% % 98% % 53% % Oxhey 87% 93% 88% 92% % 75% % 50% % Red 90% 8800% 92% 79% % 100% % 43% % Sarratt 73% 91% 81% 61% % 67% % 51% % Simpson 86% 95% 93% 99% N 100% % 15% % Stroke 83% 92% 85% 97% % 100% % 41% % Tudor 8500% N 61% 61% % 7500% 0 0 N N % Castle N N N N N % N 0 0 N N N N N Winyard 85% N 92% 99% % 100% % 97% % Cleves 91% 100% 86% 80% % 100% % 59% % DLM 88% 75% 95% 94% N 100% % 67% % Flaunden 97% 99% 85% 73% % 96% % 69% % ICU 89% 94% N N % 71% 0 0 N N % Langley 100% 97% 93% 100% % 48% % 63% % Letchmore 95% 96% 84% 71% N % 100% % 53% % Ridge 93% 92% 88% 79% N % 99% % 40% % WCS Elizabeth N N 90% 98% % 66% % 48% % Paeds Ward SCBU 90% 92% 95% N 0 0 N N 98% % 140% 0 15 N Starfish N N 80% N 0 0 N ND 72% % 19% % CED N N N N 0 0 N N 100% 0 0 N N 0 2 N Safari N N N N 0 0 N N 64% 0 0 N N % May-2015 % of Supervisory filled Hours reen >=90 >=90 >=90 >= >=90 >= >=90 >= >=90 mber n/a 1-4 n/a n/a n/a n/a Red <=79 <=79 <=79 <=79 >=1 >=5 >=1 <=79 <=79 >=1 >=1 <=79 <=24 >=2 >=1 <=74 26