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

Transcription

1 SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators May 20 Report to: Trust Board July 20 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, the new indicators for IM&T, Estates and Finance, and the indicator changes made following discussion with the Chief Executive. 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. 2. Specific Detail 2.1 Background The key performance indicators have been selected / developed by the Trust Board to support the Trust s Vision, Strategy and specific objectives for the 20/2009 financial year 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 Productivity Clinical Quality Clinical Research and Development Education and Training Financial Position Excellent Employer Information Management and Technology Estates Total

2 2.1.4 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. 2.2 Individual Scorecards Individual scorecards have been developed for each theme (as per the Trust s Strategic Objectives). These scorecards are attached at Appendix 2 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. 2. New Indicators 2..1 Performance Management of the Estate Key Performance Indicators The following draft indicators have been included this month To be reported annually Space efficiency } Asset productivity } Asset deployment } from DH Estate Returns ERIC Estate quality } Costs of occupancy } Number and cost of projects over 250k completed Number and value of post project evaluations completed - projects over 1M To be reported quarterly Energy consumptions/reductions (electricity/ gas) (reported quarterly) To be reported monthly Level of Maintenance requests/defects outstanding, including misuse incidents (reported monthly) 2..2 IM&T - Key Performance Indicators The following indicators have been included this month To be reported annually Data Quality Audit Commission PBR Audit Information Governance To be reported quarterly IT Projects (progress against milestones) Core System Reliability (aggregate score) To be reported monthly Data Quality Preparedness for 5-day turnaround Timeliness and Completeness of Data

3 2.. Finance A new monthly indicator showing cashflow has been included this month Excellent Employer The workforce metrics in the Excellent Employer section of this report are under review and will be recast for the next Board Report. The main areas for change will be: more realistic targets for the use of agency staff; a proper reconciliation between figures provided by Finance and HR. On this latter point, the two functions account for human resources differently, particularly in relation to staff who are recharged between organisations. 2.4 Indicator Changes A number of changes to the Key Performance Indicators were requested by Trust Board last month. The KPIs have been reviewed and revised with the Chief Executive, Chief Operating Officer and Acting Director of Performance Management and the following changes made: KPI Change Timescale All KPIs Forecast Year End to be included High level action plans to be included for all Red and deteriorating Amber indicators Majority completed - some outstanding End July 20 All KPIs Review FT scoring (new weightings in use by Monitor from May ) Completed A&E (4 hour) New thresholds Completed Hospital of Choice Cancer Waits - 62 day Counting of shared breaches and late referrals to be reviewed End July 20 Diagnostic Waits New thresholds Completed Thrombolysis Cardiac Access - RACPC To be reported monthly New thresholds End July 20 Completed

4 Length of Stay Revised targets (to be taken from Capacity Plan) End July 20 Additional Capacity Open To be replaced by Medical Outliers Some data quality concerns Productivity New indicator To show admissions against production plan End July 20 To be confirmed Theatres - operations performed Target to be established (data completeness issues outstanding) End August 20 Clinical Quality Citizen Experience Mortality rate Mortality rate To be replaced by crude mortality numbers until HSMR available To be replaced by HSMR Completed October 20 All KPIs To be removed Completed 2.5 Performance (year to date) at the end of May 20 (Appendix 1) Summary Year to Date Qtr/Annual Indicators Red Indicators 12 0 Rapid Access Chest Pain Clinic; Income and Expenditure; Performance Improvement Plan; ICU and HDU Bed Day Usage; SLA Income (Month 1); Income and Expenditure Surplus Margin; Theatre Utilisation; Agency Expenditure and FTE; Bank Expenditure and FTE Amber Indicators 29 7 Green Indicators To be confirmed 1 1 Total 66 6

5 2.5.2 Red Indicators 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 2.6 Conclusions Trust Board are asked to note the Key Performance Indicators Report attached, the new indicators for IM&T, Estates and Finance, and the indicator changes following discussion with the Chief Executive.

6 Year to Date (April 20 to May 20) DN Separate Excel File containing Appendices 1 and 2 to be inserted here Appendices 1 and 2

7 Appendix High Level Action Plans Hospital of Choice Accident and Emergency Access Times (4 hour target) The NHS target requires that at least 98% of patients spend four hours or less in the Emergency Department from arrival to admission, transfer or discharge. The Trust was not meeting the target for Accident and Emergency Access times (either SUHT alone or with Partners) at the end of May 20. Performance has improved considerably during May and June and we are now meeting the 98% target for SUHT alone and with Partners each week as well as the year to date target with Partners. Current Position Week ending 15/6/ SUHT 98.49% SUHT and Partners 99.7% Year to date 15/6/ SUHT 95.69% SUHT and Partners 98.20% Over the last 20 weeks the Trust, in collaboration with the ATOS Lean Team, have developed and implemented an Emergency Department Improvement Plan. The plan was piloted in ED for two weeks from 5 to 18 May 20 - the main focus of the work being the flow of patients through the department. These changes, combined with the hard work and enthusiasm of the ED Teams, have delivered the 98% target for the last three weeks. The Lean Team has now withdrawn with the Service Improvement Team continuing to support the department on a daily basis. Future work will need focus on both maintaining the system in ED and patient flow through the downstream wards. Rapid Access Chest Pain Clinic (2 week wait) GPSI with acute injury caused clinic cancellations (no cover arrangements). Also sickness in nursing team led to further clinic cancellations. Nursing team now absorbed in larger team to manage absence cover. 18 Week RTT Milestones Patients Waiting >6 Weeks for Diagnostics Summary actions include: 1. Radiology have detailed plans and a weekly Delivery Group that is focusing on meeting the 6-week target and further reducing waits. 2. Neurophysiology, echo, audiology are effectively at 6 weeks.. Endoscopy are provided with a weekly report which covers both inpatient and outpatient cases. 4. There are problems with identifying diagnostic cases that are on the inpatient waiting list

8 Clinical Quality: May 20 Healthcare Associated Infection MRSA Bacteraemia 15 MRSA Bacteraemia Acquisition MRSA Trajectory Divisional RAG Report May 20 Year to Date SUHT MRSA BSI SUHT MRSA BSI ( ) Cumulative Versus Trajectory 0 Target Actual Rating Target Actual Rating DIVISION A 1 2 R DIVISION A 2 2 A No of Cases No of Cases DIVISION 0 0 G 1 0 G DIVISION R 1 2 R DIVISION G 0 0 G Community/other provider 0 0 G 0 0 G SUHT TOTAL 2 R 5 6 R Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan- Feb- Mar- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- 0 Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- 0 April May June July August September October November December January February March Actual 2005/20 Actual 20/20 Actual 20/20 Actual 20/2009 Actual Cases Trajectory Linear Trend (Actual Cases) Trajectory 2005/20 Trajectory 20/20 Trajectory 20/20 & 20/2009 Focus on hand hygiene, IV practice and blood culture technique continues and is having impact compared to Aug-Dec 20. DH observation of care team visit on 2 rd April 20 very positive generally and confirmed high standards being achieved in many areas. Work on specific issues identified being taken forward through trust programme. Trust is on trajectory so far for this year to end May, though note is broadly 1-year behind against annual trajectories. Target of 25 is achievable for Emergency Medicine Care group remains on special measures in order to support focus on practice improvement. Cardiac care group and theatres placed on special measures in response to 2 recent MRSA bacteraemias. MRSA Baseline Target to end May = 5 Cases. SUHT Trajectory = 6 Special measures weekly meeting with Infection Prevention Team and scrutiny of local action plans to support progress, plus regular review by DIPC. Divisional Performance: Division 1 1 Case. Division 2 1 Case. Division 0 Cases. Division 4 1 Case. Division 5 0 Case. Key Issues From MRSA Bacteraemia x : May 20 1 = MRSA Infection in Urine & Possible deep collection of pus related to ureteric stent Follow up practices in Radiology. Follow up Urinary Catheter & PVC Care via Saving Lives Audits 1 = MRSA Infection in Chronic Leg Wounds - Patient confused, removed dressings and PICC Line. Follow up practices in Radiology 1 = Sternal Wound Review of decolonisation algorithm. Follow up practices in theatre and non invasive cardiology

9 Healthcare Associated Infection Clostridium difficile (All cases over 2 years of age) C. difficile Acquisition C. difficile Trajectory Divisional RAG Report Number of C. difficile Cases Including SHA Trajectory SUHT C.diff Versus Trajectory May 20 Year to Date No. of Cases SUHT Other Jun- SHA Trajectory Aug- Jul- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Jun- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Aug- Jul- Sep- Oct- Nov- Dec- Jan- Feb- Mar- SUHT Other SHA Traject No of Cases April May June July August September October November December January February March Actual 20/20 Trajectory 20/20 Actual 20/2009 Trajectory 20/2009 Target Actual Rating Target Actual Rating DIVISION 1 2 G 20 8 G Surgery 7 2 G 14 6 G Trauma & Orthopaedics 0 G 6 2 G Ophthalmology 0 0 G 0 0 G DIVISION G G Cancer Care 4 4 A 8 6 G Acute Medicine 1 G 6 2 G Medicine 5 G 5 G Elderly Care 11 6 G G DIVISION 0 0 G 1 1 A Child Health 0 0 G 1 0 G Obstetrics & Gynaecology 0 0 G 0 1 R DIVISION R 12 G Cardiothoracic 2 2 A 4 G Critical Care 1 4 R 2 4 R Neurosciences 1 G 6 G DIVISION G 0 0 G Pathology 0 0 G 0 0 G Radiology 0 0 G 0 0 G Community/other provider 0 8 R 0 19 R SUHT TOTAL 9 2 G 79 4 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 May = 79 Cases. Actual = 4 The Trust has made a good start to the year with a below trajectory position. All divisions and care groups green for C.difficile except Women & Children and Critical Care Divisional Performance: Division 1 2 cases. Division 2 14 Cases. Division 0 Cases. Division 4 7 Cases. Division 5-0 Cases.

10 Complaints Response Times Response times improved in May to 59%. In accordance with NHS Complaint regulations, holding letters are being sent to complainants where a delay is anticipated to agree a new date to respond. Taking these holding letters into account, the combined response time for the Trust is 85%. As previously explained, this delay is seen as a temporary position and will improve in the next 2 months. Finance Paybill and Performance Improvement Programme There are two reds on the financials for paybill and PIP, which we do not expect to continue, hence no action plans at this stage of the year. SLA Activity and Income The low numbers reported for Month 1 for ICU and HDU bed usage is being investigated by Income Management and the Divisions. First indications are that there was some late data, which is expected to flow through into Month2. April is traditionally a low month for activity and the position is following previous trends. Partnerships will continue to monitor this position and are working with the Divisions to address areas of concern. Excellent Employer Staff in Post Although we are showing a RAG rating of green for Staff in Post, the Board should note that the target staffing level is the original workforce planning number at the beginning of the financial year that was reported to the SHA and DH. The target has not been updated to take account of any in-year adjustments that have been agreed within the Trust. The Board should also note that there are recruitment hotspots in some Divisions, most notably in Unscheduled Care where nursing vacancy levels and Agency staff usage are high. There is an action plan to address this hot-spot, and the Chief Executive has approved additional non-recurring funds to support a special recruitment campaign. Agency Expenditure Agency expenditure is kept under review in Divisional Performance meetings. The Trust has funded a recruitment campaign in Division 2 (Unscheduled Care) where the high level of vacancies (80 nursing posts unfilled) is driving usage of the high-cost agencies.