PWYLLGOR CYNLLUNIO BUSNES A SICRHAU PERFFORMIAD BUSINESS PLANNING & PERFORMANCE ASSURANCE COMMITTEE

Transcription

1 Attachment 6 PWYLLGOR CYNLLUNIO BUSNES A SICRHAU PERFFORMIAD BUSINESS PLANNING & PERFORMANCE ASSURANCE COMMITTEE DYDDIAD Y CYFARFOD: DATE OF MEETING: TEITL YR ADRODDIAD: TITLE OF REPORT: ARWEINYDD CYFARWYDDWR: EXECUTIVE LEAD: SWYDDOG ADRODD: REPORTING OFFICER: 27 th June 2017 Integrated Performance Assurance Report - Month /18 Karen Miles, Director of Planning, Performance, Informatics & Commissioning In association with all Executive Leads Karen Miles, Director of Planning, Performance Informatics & Commissioning Pwrpas yr Adroddiad (dilewch fel yn addas) Purpose of the Report (delete as appropriate) Ar Gyfer Penderfyniad Ar Gyfer Trafodaeth For Decision For Discussion ADRODDIAD SCAA SBAR REPORT Sefyllfa / Situation Er Gwybodaeth For Information NHS Wales Delivery Framework The NHS Wales Delivery Framework will measure the NHS throughout the year on the delivery of services and process that contribute towards the goals of the Public Health Outcomes Framework for Wales, and ultimately the national healthier Wales indicators of the Well-being of Future Generations (Wales) Act By focusing upon a set of key delivery measures that link directly to the aforementioned goals, this Framework will evidence how the NHS is positively influencing the health and well-being of the citizens of Wales. The key delivery measures for the NHS and how they link to the Public Health Outcomes Framework for Wales and the Well-being of Future Generations (Wales) Act are presented by domain. In total there are seven domains, which identify the priority areas that patients, clinicians and stakeholders wanted the NHS to be measured against: 1. Staying healthy: People in Wales are well informed and supported to manage their own physical and Mental Health; 2. Safe care: People in Wales are protected from harm and supported to protect themselves from known harm; 3. Effective care: People in Wales receive the right care and support as locally as possible and are enabled to contribute to making that care successful; 4. Dignified care: People in Wales are treated with dignity and respect and treat others the same; 5. Timely care: People in Wales have timely access to services based on clinical need and are actively involved in the decisions about their care; 6. Individual care: People in Wales are treated as individuals with their own needs and responsibilities; 7. Our staff and resources: People in Wales can find information about how their NHS is resourced and make careful use of them.

2 Cefndir / Background Our aim is to develop a fully integrated performance report that provides assurance to the Business Planning & Performance Assurance Committee (BP&PAC) in an abridged manner, in addition to the full performance report. Performance has been RAG - rated (red; amber; green), as per the following key, and in line with Committee & Board member requests on the same. Throughout the report, our All Wales ranking has included and wherever possible, number counts as well as percentages. Also some other associated terms have been further explained. Target not delivered Within 5% of target* Target delivered Est. Estimated N/A not available R12 rolling rolling 12 month period * For measures where there is a reduction or improvement target, these will be scored red or green, except where Performance remains static. This also applies to measures with a small percentage target (10% and under), e.g. Sickness/absence, smoking cessation. For measures where the target is 0, these will only be scored red or green. Green for 0, red for anything above. Key Delivery Framework Changes The framework for no longer includes a set of outcome indicators that are unique to the NHS. Instead, the framework will measure the NHS throughout the year on the delivery of services and process that contribute towards the achievement of particular outcomes in the Public Health s framework, and ultimately the national indicators of the Well-being of Future Generations (Wales) Act This approach not only strengthens the alignment between NHS and Public Health, but it ensures that we have a shared understanding of the health outcomes that are important to the people of Wales and how the NHS contributes towards these. The Delivery Framework continues to move towards an outcome approach and to ensure that all aspects of care are represented. To strengthen this approach, a number of new delivery measures have been identified, whilst some of the existing measures have been revised. The new measures (which include areas such as safeguarding, equality and satisfaction of care) will either be reported through existing information sources or by completing a self assessment reporting template. New delivery measures will be reported upon as performance information is made available throughout the year. New Delivery Measures Staying Healthy Percentage of children who received 3 doses of the 5 in 1 vaccine by age 1; Percentage of children who received 2 doses of MMR vaccine by age 5; Percentage of children who are 10 days old and have accessed the Health Visitor contact; Percentage of people who found it difficult to make a convenient appointment with a GP. Safe Care Continuous periods of hospital care with any mention of self harm for children and young people; Amenable Mortality per 100,000; Total antibacterial items per 1,000 STAR-PU s; Page 2 of 15

3 Fluroquinolone, cephalosoporin and co-amoxiclav items as a percentage of total antibacterial items prescribed (New development 2017/18); Rate of laboratory confirmed E.coli bacteraemias; Number of patients with grade 1,2,3,4 suspected deep tissue injury and un-stageable pressure ulcers acquired in hospital per 100,000 hospital admissions. Effective Care Percentage of universal mortality reviews undertaken within 28 days of death; All new medicines recommended by AWMSG and NICE, including interim recommendations for cancer medicines, must be made available where clinically appropriate, no later than two months from the publication of the NICE Final Appraisal Determination and the AWMSG appraisal recommendation. Dignified Care The average rating given by the public (age 16+) for the overall satisfaction with health services in Wales; Number of patients aged 75 and over with an AEC (Anticholinergic Effect on Condition) of 3 or more for items on active repeat, as a percentage of all patients aged 75 years and over; The percentage of concerns that have received a final reply (under Regulation 24) or an interim reply (under Regulation 26) up to and including 30 working days from the date the concern was first received by the organisation ; Percentage of adults (age 16+) who reported that they were very satisfied or fairly satisfied about the care that they received at their GP/family doctor; Percentage of adults (age 16+) who reported that they were very satisfied or fairly satisfied about the care that they received at an NHS hospital. Timely Care Percentage of urgent calls for Health Boards that only have GP Out of Hours (defined as P1 for Health Boards with the 111 Service) that were logged and the patient started their definitive clinical assessment within 20 minutes of the initial call being answered; Percentage of patients that were prioritised as very urgent for Health Boards that only have GP Out of Hours (defined as P1 for Health Boards with the 111 Service) and seen (either in the primary care centre or via a home visit) within 60 minutes following their clinical assessment or face to face triage (in the case of walk in patients); Percentage of survival within 30 days of emergency admission for a hip fracture. Individual Care Qualitative report detailing evidence of advancing equality and good relations in the day to day activities of NHS organisations. Our Staff & Resources Quantity of biosimilar medicines prescribed as a percentage of total reference product plus biosimilar; Number of procedures that do not comply with selected NICE Do Not Do guidance for procedure of limited effectiveness (selected from a list agreed by the Planned Care Board. New Self Assessment reporting templates where established data flows are not in place Safeguarding Adults & Children - Bi-annually; Dementia Training - Bi-annually; Advancing Equality and Good Relations -Bi-annually; Accessible Communication and Information - Bi-annually. Page 3 of 15

4 Asesiad / Assessment The volume of Key Deliverables being measured in Month 2, 2017/2018 compared to prior months has increased from 22 to 28. This change is to ensure HDUHB key deliverable measures, mirror those, Welsh Government are reporting. The table below demonstrates the 28 Key Deliverable measures. 16 are currently either successful, or are in close proximity of being successful and the other 12 being classed as non successful. Using the last published All Wales data, the Health Board is performing first on 6 of these measures and is in the top 3 for a further 8 measures. In pursuance of our aim to produce a more Integrated Performance Assurance Report, certain key deliverable measures which bring together the pathway challenges have been grouped by Directorate, irrespective of the Domain they sit within. A set of 4 dashboards, Unscheduled Care; Scheduled Care; Hospital Acquired Infections and Oncology & Cancer have been included in an attempt to contextualise the Directorates overall performance and run in the following order: The first part of each Dashboard notes current performance for key metrics; The second part provides a view of current finances and workforce measures using the latest available outturn; The third part of the dashboard contextualises Hywel Dda University Health Board (HDUHB) performance against All of Wales, using latest available outturn; In time, a fourth part would be developed to properly capture patient outcomes and experience; Salient points from exception reports contained within the full Integrated Performance Assurance Report are then summarised. Page 4 of 15

5 Unscheduled Care (see Integrated Performance Assurance Report Timely Care, Effective Care & Our Staff & Resources Domains) Unscheduled Care Dashboard - May 2017 Lead Executive - Joe Teape Responsible Officers - Sarah Perry, Hazel Davies, Brett Denning, John Evans Ambulance A&E Waits Stroke Delayed Transfer of Care (Local Authority Area) Red Calls (estimate) >1 hour Handovers <4 hour wait >12 hour wait Direct to Stroke Unit <4 hours CT <12 hours Assessed by Stroke Consultant < 24 hours Thrombolysed patients door to needle <= 45mins Non Mental health (75+) per 10,000 LHB population Est 73.1% % % 100.0% 79.7% 50.0% 55.3 Sickness (R12m end April 2017) 4.94% Staffing Proxy vacancies (budget vs actual wte) (Month 2) including Pathology & Radiology Finance (Year to Date - Month 2) - including Pathology & Radiology Budget ( m) Pay ( m) Agency Fees ( m) Savings Target ( m) (Total Unscheduled Care target) Budget to date Premium Pay * Annual Savings Target = Spend to date Variable Pay * Year to Date Target =0.254 Variance % Variance 1.2% Last available All Wales data published May 2017 Ranking (1st being the best and 7th being the worst) Ambulance A&E Waits Stroke Delayed Transfer of Care Red Calls >1 hour Handovers <4 hour wait >12 hour wait Direct to Stroke Unit <4 hours CT <12 hours Assessed by Stroke Consultant < 24 hours Thrombolysed patients door to needle <= 45mins Non mental health (aged 75+) per 10,000 LHB population Hywel Dda Performance & Position in Wales 78.3% % % 97.4% 71.4% 33.3% th out of 7 2nd out of 6 2nd out of 6 3rd out of 6 1st out of 6 2nd out of 6 6th out of 6 2nd out of 6 1st out of 7 All Wales Performance 80.5% 1, % 2, % 95.3% 85.2% 27.3% * Actual savings have been achieved against a number of Health Board wide workstreams including medical and nursing variable pay and nonpay procurement schemes.identified savings schemes for medicines management are also achieving against profile. We are currently working through how we can best identify and attribute actual savings achieved against these HB wide schemes to individual Directorates. Page 5 of 15

6 IPAR Metric Performance Summary Page Number Ambulance Red Calls Provisional May 2017 data showed Red call performance Ambulance Handovers over 1 hour target was met at 73.1%. Daily average delays have decreased in May 2017 to 1.2 compared to 2.2 in April A&E - 4 hour Waits Of the 13,334 patients arriving at our A&E units, 11,660 were seen/treated within 4 hours (87.5%). Performance has remained static when compared to April A&E - 12 hour Waits Stroke 72 Hour Pathway Care Performance Indicators Admission to Stroke unit in 4 hours Of the 13,334 patients, 12,956 were treated within 12 hours (97.2%). Performance deteriorated by 0.6% when compared to April Direct Admission to Acute Stroke Unit (ASU) within 4 hours Performance has decreased from 80% in April to 68.8% in May 2017, although the SSNAP UK average target has been met. CT scan within 12 hours Assessed by a Stroke Consultant within 24 hours Thrombolysed patients with Door-to-Needle <= 45 minutes Delayed Transfers of Care (Mental Health DTOC) Delayed Transfers of Care (Non Mental Health DTOC) Finance and Workforce & Organisational Development CT scan within 12 hours The Health Board continually performs well in this target and achieved 100% performance in May 2017 for the second month running. Assessed by a Stroke Consultant within 24 hours The Health Board improved on April s position, with 79.7% compliance in May 2017 and came within 2.2% of meeting the target. Thrombolysed patients with Door-to-Needle <= 45 minutes Performance improved from 33.3% in April to 50% in May 2017, and the Health Board achieved the 12 month improvement target. The performance trend has remained static for 7 months. For the rolling 12 month period, at May 2016 and May 2017, the rates were 4.4 and 4.0 respectively. The performance continues to improve from October For the rolling 12 month period May 2016 to May 2017, the rate was 65.8 and 55.3 respectively. The number of patients reported in May 2017 was 15, which is a reduction of 4 cases when comparing to May The Unscheduled Care Directorate is 0.27m overspent in Month 2. Gross variable pay is 4.112m and the point to note is that whilst vacancies contribute/offset these costs, the cost of inefficiency/poor productivity because of teams working in an ad hoc way, either because staff are external or because of overtime, has an impact on all indicators. Although sickness rates have improved slightly from 5.03% to 4.94%, they still remain above the 4.79% target and there are an approximate 89 whole time equivalent (WTE) vacancies m of the 7.413m savings target has been delivered to date. Page 6 of 15

7 Scheduled Care (see Integrated Performance Assurance Report Timely Care, Dignified Care & Our Staff & Resources Domains) Lead Executive - Joe Teape Scheduled Care Dashboard - May 2017 Responsible Officer - Stephanie Hire Referral To Treatment Diagnostic Waits Postponed Procedures Delayed Follow Ups Waits >36 wks Waits <26 Wks Waits >8 weeks Treated <14 days Wait >Target Date Total open pathways Total >36 weeks Total open pathways Total < 26 weeks 0 33% 27,272 57,438 3,086 57,438 48,220 Outpatient DNA Rates (In Month) Follow Up DNA Rates (In Month) 5.4% 84.0% 10.20% 9.30% Staffing Sickness (R12m end April 2017) 4.92% Proxy vacancies (budget vs actual wte) (Month 2) Finance (Year to Date - Month 2) Budget ( m) Pay ( m) Agency Fees ( m) Savings Target ( m) Budget to date Premium Pay * Annual Savings Target = Spend to date Variable Pay * Year to Date Target = Variance % Variance 3.6% Last available All Wales data published May 2017 Ranking (1st being the best and 7th being the worst) Referral To Treatment Diagnostic Waits Postponed Procedures Delayed Follow Ups Waits >36 wks Waits <26 Wks Waits > 8 weeks Treated <14 days Wait >Target Date Hywel Dda Performance & Position in Wales 2, % % 25,225 5th out of 7 6th out of 7 Joint 1st out of 7 4th out of 6 3rd out of 7 All Wales Performance 12, % 4, % 294,796 * Actual savings have been achieved against a number of Health Board wide workstreams including medical and nursing variable pay and nonpay procurement schemes.identified savings schemes for medicines management are also achieving against profile. We are currently working through how we can best identify and attribute actual savings achieved against these HB wide schemes to individual Directorates. Page 7 of 15

8 IPAR Metric Page Number Referral to Treatment Time 36 week breaches Patients seen within 26 weeks Performance Summary There are 3,086 patients waiting 36 weeks and over at the end of May 2017, compared to 4,798 at the end of the previous year. 26 week performance is 84% at the end of May 2017, which is an improvement in performance compared to 80.2% in May Estimated 52 week There are 773 patients waiting over 52 weeks at the end breaches of May 2017, compared to 1,112 at the end of May This is a decrease of 339 patients. 79 Diagnostic Waits over 8 weeks In May 2017, the Health Board maintained a zero breach Postponed Admitted Procedures (Programme for Government Commitment) Delayed Follow Up Appointments Finance and Workforce & Organisational Development position for the eighth month running. In April 2017, 8 procedures were postponed on more than 1 occasion for non clinical reasons, of which 5 patients were cancelled on the day of admission. 2 patients could not attend the appointments offered and 2 of the remaining 6 patients were treated within the 14 day programme for Government Commitment. In May 2017, the number of patients waiting for a followup appointment past their target date has reduced from 28,576 in May 2016 to 27,272 in May Despite an increase compared to the previous few months, the Health Board has met its 12 month reduction target. The Scheduled Care Directorate is 0.662m overspent in Month 2. Gross variable pay is 1.789m, and the issues outlined for high levels of non-core staffing in Unscheduled Care are also applicable here. Although sickness rates have improved slightly (from 4.98% to 4.92%, they still remain above the 4.79% target and there are an approximate 72 WTE vacancies m of the 9.480m savings target has been delivered to date. Page 8 of 15

9 Healthcare Acquired Infections (HCAI) (see Integrated Performance Assurance Report Safe Care Domain) Lead Executive - Mandy Davies Healthcare Acquired Infections Dashboard (under development) - May 2017 C.difficile S.aureus bacteraemias (MRSA and MSSA) Responsible Officer - Sharon Daniel E.coli bacteraemias Less than or equal to 26 per 100,000 population (cumulative) Less than or equal to 20 per 100,000 population (cumulative) Less than or equal to 67 cases per 100,000 population (cumulative) C.difficile * Old target of 28 5th out of Last available All Wales data published May 2017 Ranking (1st being the best and 7th being the worst) The rate of laboratory confirmed cases per 100,000 population S.aureus bacteraemias (MRSA and MSSA) Hywel Dda Performance & Position in Wales rd out of 6 All Wales Performance E.coli bacteraemias Not Available Not Available Not Available IPAR Metric Page Number For C.difficile - ensure a rate of no more than 26/100,000 population For S.aureus bacteraemias ensure a rate of no more than 20/100,000 population For E.coli bacteraemias ensure a rate of no more than 67/100,000 population Performance Summary The cumulative reduction target has not been met and is reported as The cumulative reduction target has not been met and is reported as The cumulative reduction target has not been met and is reported as Page 9 of 15

10 Oncology and Cancer Services (see Integrated Performance Assurance Report Timely Care and Our Staff & Resources Domains) Lead Executive - Joe Teape Oncology & Cancer Services Dashboard - May 2017 Cancer Waiting Times Responsible Officer - Keith Jones Urgent Suspected Cancer Non Urgent Suspected Cancer 90.9% Estimate 95.7% Estimate Sickness (R12m end April 2017) 2.82% Staffing Proxy vacancies (budget vs actual wte) (Month 2) Finance (Year to Date - Month 2) Budget ( m) Pay ( m) Agency Fees ( m) Savings Target ( m) Budget to date Premium Pay * Annual Savings Target =0.101 Spend to date Variable Pay * Year to Date Target = 0.07 Variance Overspend % Variance 3.2% Urgent Suspected Cancer 90.7% Last available All Wales data published May 2017 Ranking (1st being the best and 7th being the worst) Hywel Dda Performance & Position in Wales Non Urgent Suspected Cancer 96.7% 4th out of % All Wales Performance 5th out of % * Actual savings have been achieved against a number of Health Board wide workstreams including medical and nursing variable pay and nonpay procurement schemes.identified savings schemes for medicines management are also achieving against profile. We are currently working through how we can best identify and attribute actual savings achieved against these HB wide schemes to individual Directorates. IPAR Metric Page Number 73 Urgent Suspected Cancer (USC) - Over 62 Days (Target 95%) Performance Summary Confirmed performance for April 2017 was 94.6%, which represents the highest monthly percentage performance year to date. Forecast performance for May 2017 is currently projected to be 90.9%. Whilst this forecast position shows a slight fall compared with the April 2017 position, the overall trend in performance improvement remains stable. Page 10 of 15

11 74-75 Non-Urgent Suspected Cancer Waiting Times Over 31 Days (Target = 98%) Finance and Workforce & Organisational Development Performance year to date has generally exceeded or been close to target (apart from November when HDUHB performance was significantly compromised due to treatment delays at the tertiary centre). Confirmed performance for April 2017 was above target at 100%. Forecast performance for May 2017 is currently projected to be 95.7% based on 5 projected breaches (which are subject to validation). The Oncology & Cancer Services Directorate is marginally over spent by 0.049m. Sickness rate is 2.82% which is below the 4.79% target and there no vacancies. 0.07m of the 0.101m savings target has been delivered to date. HDUHB Financial Performance Update (see Integrated Performance Assurance Report Our Staff & Resources Domain pages ) The financial position at the end of May 2017 is m deficit. The Health Board s 2017/18 draft Annual Plan forecast a full year deficit of 58.9m and 9.816m for the year to date. At Month 2 there is 17.7m held in Reserves, of which 3.26m of non-pay inflation and Continuing Health Care growth is offsetting Directorate expenditure pro rata pending release to expenditure budgets in the coming months. The remaining 14.4m is in respect of new expenditure. Within the 32m savings delivery required by the Annual Plan there is 4m of Accountancy Gains. Following the recent approval of the accounts the aim is to release up to 2m once the review of accrual methodology has been concluded. In addition to this a number of VAT opportunities are being examined to consolidate this figure. The value of identified savings plans has increased by 6.5m from 15.1m to 21.6m in Month 2. In summary, the May 2017 financial position is as follows: Summary Financial Position To date Annual Plan m Year to Date Plan m Year to Date Actual m Adverse/ (Positive) Variance m Annual Plan Forecast Variance m Income Miscellaneous Income (47.281) (7.944) (7.878) Revenue Resource Limit ( ) ( ) ( ) Non Resource Limited Income Total Income ( ) ( ) ( ) Expenditure LHB Provided Services - Pay LHB Provided Services - Non Pay Primary Care Prescribed Drugs & Appliances (0.055) Primary Care Services Healthcare & Non Healthcare Services Provided By Other NHS Bodies including Specialised Services (0.030) Private & Voluntary Sector Joint Financing & Other (0.055) Other (mainly reserves) (0.792) IMTP Deficit (58.900) (9.817) Total Expenditure Total Deficit Page 11 of 15

12 Substantive & Total Pay '000 Variable Pay '000 Tackling premium rate variable pay continues to be one of the Health Board s key challenges. The graph below shows the relationship between substantive and variable pay for the organisation since 2013/14. It can be seen that spend grew steeply between 2014/15 and the end of 2015/16. The rate of growth was reduced in 2016/17 with some improvements seen in the last few months. This position has to be maintained and improved for the coming year. Up to Month 2 the performance of variable pay has been encouraging showing marked reductions in the first two months. 35,000 6,000 33,000 5,500 5,000 31,000 4,500 29,000 27,000 4,000 3,500 3,000 25,000 2,500 23,000 2,000 1,500 21,000 1,000 Substantive pay Total Pay Variable pay Linear (Substantive pay) Linear (Total Pay) Linear (Variable pay) The breakdown of variable pay costs by category for the same period is shown in the following table. The improvement compared with Month /17 seen in Month 1 has been maintained but checks continue to be made to ensure that performance is due to planned actions. However, it is pleasing to note the decrease in Additional Clinical Services spend with the increased recruitment kicking in. Figures for this month are as follows: Page 12 of 15

13 There is a total savings requirement of 32m to meet the forecast deficit set out in the March iteration of the Annual Plan. This is significantly higher than the Health Board has delivered in recent years. In recognition of this a stretch target to identify opportunities of circa 40m has been set with the aim of achieving a real reduction of 32m. The main areas being targeted are Savings Theme Target m Out-Patients/Theatres/Orthopaedics (Efficiency & Productivity) 4.5 Variable Pay 10.4 Medicines management 4.3 Non Pay 3.1 CHC 3.0 General CIP (Estates and Non Clinical) 1.0 Targeted voluntary workforce reduction 1.0 Other Schemes 1.0 Sub total Savings 28.3 Medicines management - Invest to Save Posts (0.3) Other Accountancy Gains 4.0 Required benefit to bottom line 32.0 Additional target to meet 3% minimum for each budget holder 5.4 Total savings targeted 37.7 Internally within the Health Board a stretch savings target of 32.7m has been distributed to Directorates with 4m of accountancy gains and 1m of voluntary workforce reduction savings being managed centrally i.e. a total of 37.7m with the aim of securing our required 32m. This is also with the view to put the Health Board in a good position for future years. The targets have been identified through a combination of benchmarking with other Health Boards and by looking at historic patterns within Hywel Dda. Work is ongoing to refine this and examine in more detail where efforts need to focus. The Turnaround process is now underway. The first 60-day improvement cycle, which will provide a planned, organised and structured way in which to develop clarity around an issue and arrive at an agreement on outcome measures, is looking at the largest directorate (Scheduled Care) within the Health Board that also has the biggest savings target. The areas that Turnaround will focus on are those that will benefit or are unlikely to succeed at pace without this approach. Full year identified savings at Month 2 amount to 21.6m. This is against a requirement of 28.3m. (The slight increase accounts for a gross requirement of 4.3m for medicines management offset by 0.3m investment in posts with the balance of 4m accountancy gains.) The actual saving reported in Month 2 is 2.118m against a profile of identified savings to date of 1.539m. NHS External Providers Direct Patient Care Update A report on the position on external NHS provider contracts at the end of May 2017 is included in the full Integrated Performance Assurance Report pages 105 to 106. There are no major performance variations to report. HDUHB Workforce & Organisational Development (see Integrated Performance Assurance Report Our Staff and Resources Domain pages ) Sickness Absence: The sickness information reported relates to the position as at 30 th April The figure reported for April equates to 4.25%, which represents a decrease of 0.14% against the previous month (March 2017). This rate also represents a significant improvement of 0.87% against the corresponding month in Page 13 of 15

14 Recruitment: International Nurse, Medical, Consultant, Middle Grade and Junior Doctor recruitment continues. Work has commenced with Work Education and Development Services (WEDS) to scope nursing places. Alternative routes into nurse training are also being developed as part of the Grow your Own project. Campaigns are being undertaken including recruitment videos, London Underground advertising, recruitment days and Social Media. The Welsh Government, Train, Work, Live concept has been incorporated into our advertising campaigns. Various other campaign and recruitment planning meetings continue to take place across the services and sites. Bank: May 2017 has seen a further decrease in Health Care Support Worker (HCSW) agency usage. This is the outcome of improved risk profiling of patients requiring personalised care, and the introduction of a pool of staff on three sites. Registered nurse agency usage has reduced slightly in May and the Health Board is working with new agencies in terms of how we interact and the processes used. Mandatory Training: Mandatory Training rates have improved in May by 0.8% on the April 2017 figure. Whilst this is significantly below the 85% target, there have been increases in 8 of the 10 UK Core Skills Framework Level 1 areas, with the remaining 2 areas having less than a 1% decrease. The e-learning programme within ESR, which holds the learning material for these modules, is being further upgraded, and access to the material should become increasingly easier over the next few weeks. For staff who have difficulty accessing the e-learning courses, support including telephone or on-line advice, as well as supported drop-in sessions are in place and will continue. Personal Appraisal Development Review (PADR) Appraisal/PADR rates show an overall improvement of 2% on the combined Health Board total from 55% in April to 57% in May 2017, which is the highest combined performance since reporting commenced. Within this combined figure, medical appraisal rates have dropped by 1% to 92%. Nonmedical rates have increased during May to 53.84%, but while this is an improvement on last month, it is still 1.25% less than May PADR compliance now features in the operational performance meetings, as well as Workforce & Organisational Development Sub-Committee, and this scrutiny has assisted in driving the improvement. Argymhelliad / Recommendation The Business Planning & Performance Assurance Committee is asked to discuss the report and to raise any issues arising from the content. Amcanion: (rhaid cwblhau) Objectives: (must be completed) Safon(au) Gofal ac Iechyd: Health and Care Standard(s): Amcanion Strategol y BI: HB Strategic Objectives: Gwybodaeth Ychwanegol: Further Information: Ar sail tystiolaeth: Evidence Base: Rhestr Termau: Glossary of Terms: IMTP NHS Wales Delivery Framework WG Welsh Government IMTP Integrated Medium Term Plan USC Urgent Suspected Cancer RTT Referral to Treatment DNA Did not Attend Page 14 of 15

15 Partïon / Pwyllgorau â ymgynhorwyd ymlaen llaw y Pwyllgor Cynllunio Busnes a Sicrhau Perfformiad: Parties / Committees consulted prior to Business Planning & Performance Assurance Committee: Effaith: (rhaid cwblhau) Impact: (must be completed) Ariannol / Gwerth am Arian: Financial / VFM: Risg / Cyfreithiol: Risk / Legal: Answadd / Gofal Claf: Quality / Patient Care: Gweithlu: Workforce: Cydraddoldeb: Equality: A&E Accident & Emergency IPFR Individual Patient Funding Request WHSSC Welsh Health Specialised Services Committee NICE National Institute for Health and Care Excellence AWMSG All Wales Medicines Strategy Group AWTTC - All Wales Therapeutic and Toxicology Centre INNU Interventions Not Normally Undertaken EqIA - Equality Impact Assessment Finance, Performance, Quality and Safety, Nursing, Information, Workforce, Mental Health, Primary Care Better use of resources through integration of reporting methodology Better use of resources through integration of reporting methodology Use of key metrics to triangulate and analyse data to support improvement Development of staff through pooling of skills and integration of knowledge Has EqIA Screening been undertaken? No, not applicable Has a full EqIA been undertaken? No, not applicable Any potential negative impacts identified in the EqIA documentation Not applicable Page 15 of 15

16 Integrated Performance Assurance Report Position as at 31 st May 2017 (Month 2) Business Planning & Performance Assurance Committee Meeting date 27 th June 2017 Hywel Dda University Health Board Integrated Performance Assurance Report 1

17 Hywel Dda University Health Board Integrated Performance Assurance Report This performance report aims to provide an integrated picture of performance against the Welsh Government Delivery & Outcomes Framework and the alignment of this to the step improvement we are trying to secure in population health as part of the Integrated Medium Term Plan (IMTP). The Welsh Government Delivery & Outcomes Framework incorporates seven domains which specify what people can expect from the National Health Service (NHS) in Wales as follows: Staying healthy I am well informed and supported to manage my own physical and mental health Safe care I am protected from harm and protect myself from known harm Effective care I receive the right care and support as locally as possible & I contribute to making that care successful Dignified care I am treated with dignity and respect & treat others the same Timely care I have access to services based on clinical need and am actively involved in decisions about my care Individual care I am treated as an individual, with my own needs and responsibilities Our staff & resources I can find information about how the NHS is open and transparent on its use of resources and I can make careful use of them One of the overarching objectives of the IMTP is to tackle variation in performance against the above domains, and to do this systematically over our 3 Counties, our 7 Localities, and our 4 Hospital sites which by so doing, allows for targeted improvement actions which deliver improvement at pace. In addition to national indicators, as part of the 2016/17 IMTP, the Board has also agreed a number of local indicators in order to provide a richer picture of performance against our longer term aims of population health improvement. These local indicators are drawn from our 10 Strategic Objectives, which are as follows: 1. To encourage and support people to make healthier choices for themselves and their children and reduce the number of people who engage in risk taking behaviours; 2. To reduce overweight and obesity in our local population; 3. To improve the prevention, detection and management of cardiovascular disease in the local population; 4. To increase survival rates for cancer through prevention, screening, earlier diagnosis, faster access to treatment and improved survivorship programmes; 5. To improve the early identification and management of patients with diabetes, improve long term wellbeing and reduce complications; 6. To improve the support for people with established respiratory illness, reduce acute exacerbations and the need for hospital based care; 7. To improve the mental health and wellbeing of our local population through improved promotion, prevention and timely access to appropriate interventions; 8. To improve early detection and care of frail people accessing our services including those with dementia, specifically aimed at maintaining wellbeing and independence; 9. To improve the productivity and quality of our services using the principles of Prudent Health Care and the opportunities to innovate and work with partners; 10. To deliver, as a minimum requirement, Outcome and Delivery Framework Targets and specifically eliminate the need for unnecessary travel and waiting times, as well as return the organisation to a sound financial footing over the lifetime of this Plan. Hywel Dda University Health Board Integrated Performance Assurance Report 2

18 The local indicators as per Strategic Objectives 1-8 are being developed. Strategic Objectives 9 and 10, in the main, support the national aims of the Welsh Government Delivery & Outcomes Framework, and as such, progress is reported within the 7 domains. In summary, this performance framework seeks to provide assurance across every area of business in the Health Board on: Delivery of strategic IMTP objectives, in line with our 10 Strategic Objectives; Delivery of Ministerial priorities, in line with Welsh Government s Delivery and Outcomes Framework; Delivery of key enablers including Workforce, Estates & Capital, Information and Informatics, Telehealth and Telemedicine; Ongoing preservation of our University Health Board status. Also within the report: Performance has been RAG - rated (red; amber; green), as per the following key, and in line with Board member requests on the same, throughout the report, we have included our All Wales ranking and wherever possible, number counts as well as percentages. Also some other associated terms have been further explained. Target not delivered Within 5% of target* Target delivered Est. Estimated N/A not available R12 rolling rolling 12 month period * For measures where there is a reduction or improvement target, these will be scored red or green, except where Performance remains static. This also applies to measures with a small percentage target (10% and under), e.g. Sickness/absence, smoking cessation. For measures where the target is 0, these will only be scored red or green. Green for 0, red for anything above. Exception reports are included for areas where performance targets and or improvement trajectories have not been met; Where available, the latest All Wales position is shown in the overviews from pages 5 to16. Hywel Dda University Health Board Integrated Performance Assurance Report 3

19 Report Contents are as follows: Domain Number Section Content Lead Executive Page Performance in key priority areas specified in the seven domains of the outcomes framework 1 7 Snapshot of Performance Trend: National Priority Domains. Steve Moore Staying Healthy I am well informed and supported to manage my own physical and mental health. Dr. Michael Thomas/ Dr Boika Rechel/ Joe Teape Safe Care 2 I am protected from harm and protect myself from known harm. Mandy Davies/ Joe Teape Effective Care I receive the right care and support as locally as possible and I contribute to making that care successful. Phil Kloer/ Jill Paterson/ Mandy Davies/ Karen Miles/ Joe Teape Dignified Care I am treated with dignity and respect and treat others the same. Timely Care Joe Teape/ Mandy Davies I have timely access to the services based on clinical need and am actively involved n decisions about my care. Individual Care I am treated as an individual, with my own needs and responsibilities. Joe Teape/ Jill Paterson Joe Teape/ Jill Paterson Our Staff & Resources I can find information about how the NHS is open and transparent on its use of resources and I can make careful use of them. Lisa Gostling/ Joe Teape/ Stephen Forster Hywel Dda University Health Board Integrated Performance Assurance Report 4

20 Target not Delivered Within 5% of target * Target delivered Estimated Not available = not available * For measures where there is a reduction or improvement target, these will be scored red or green, except when Performance remains static. This also applies to measures with a small percentage target (10% and under), e.g. Sickness/absence, smoking cessation. For measures where the target is 0, these will only be scored red or green. Green for 0, red for anything above 1 - STAYING HEALTHY - I am well informed and supported to manage my own physical and mental health Latest all Wales comparison Reporting Frequency - Monthly Status Target Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 The rate of emergency hospital admissions for basket 8 chronic conditions per 100,000 of the health board population The rate of emergency hospital readmissions (within a year) for basket 8 chronic conditions per 100,000 of the health board population Time period All Wales Hywel Dda Continue 1,229 1,237 1,226 1,211 1,215 1,215 1,218 1,223 1,229 1,230 1,250 1,259 1,269 Dec-16 1,152 1,260 3rd out of 6 12 month reduction trend Continue Dec rd out of 6 Position in Wales Reporting Frequency - Quarterly Status Target The percentage of adult smokers make a quit attempt via smoking cessation services Continue 5% annual target The percentage of those smokers who are Carbon Monoxide (CO) validated as quit at 4 weeks Continue 40% annual target Q3 2015/16 (Oct - Dec 15) Q4 2015/16 (Jan - Mar 16) 1.5% 2.0% Q1 2016/17 (Apr - Jun 16) Q2 2016/17 (Jul - Sept 16) Q3 2016/17 (Oct - Dec 16) Q4 2016/17 (Jan - Mar 17) 0.6% 1.1% 1.5% 2.5% 50.1% 51.1% 52.2% 63.8% 57.1% 59.4% Time period Q1-Q3 2016/17 Q1-Q3 2016/17 All Wales Hywel Dda Position in Wales 2.1% 1.6% 5th out of % 57.0% 1st out of 7 Percentage of children who received their scheduled vaccinations at age 4 Percentage of children who received the following scheduled vaccinations at age 4-4 in 1 pre school booster Percentage of children who received the following scheduled vaccinations at age 4 - Hib/MenC booster Percentage of children who received the following scheduled vaccinations at age 4 - Second MMR dose Revised 95% 86.2% 85.3% 84.5% 83.8% 84.6% 81.6% Q3 2016/ % 84.6% 5th out of 7 Revised 95% 89.4% 88.5% 88.0% 86.9% 87.5% 84.4% Not available Revised 95% 93.2% 93.3% 92.9% 93.0% 92.7% 93.4% Not available Revised 95% 88.2% 87.6% 86.9% 87.2% 86.3% 82.7% Not available Reporting Frequency - Annually Status Target 2015/ /2017 Time Position in All Wales Hywel Dda (at 28th March 2017) period Wales % uptake of Influenza vaccination - 65 year olds and over Continue 75% 63.9% 63.5% 2015/ % 63.9% 7th out of 7 % uptake of Influenza vaccination - Under 65 s in risk groups % uptake of Influenza vaccination - Pregnant women Continue 75% 43.2% 42.4% 2015/ % 43.2% 7th out of 7 Continue 75% 42.7% Not available 2015/ % 42.7% 7th out of 7 % uptake of Influenza vaccination - Healthcare workers Continue 50% 48.7% 47.0% 2015/ % 48.7% 5th out of 10 Percentage of pregnancies where the initial assessment was carried out by 10 completed weeks of pregnancy Percentage of patients with hypertension in whom the last blood pressure reading (measures in the preceding 12 months) is 150/90 mmhg or less Of those who had a condition or illness that reduced their ability to carry out day to day activities, the percentage who said that they had a personal care plan New target 16/17 Annual Improvement Not available Not available 2014/ % 45.2% 7th out of 7 New target 16/17 Annual Improvement 81.60% Not available 2015/ % 81.6% 5th out of 7 New target 16/17 Annual Improvement Not available Not available 2014/15 24% 26% 3rd out of 7 Hywel Dda University Health Board Integrated Performance Assurance Report 5

21 2 - SAFE CARE - I am protected from harm and supported to protect myself from known harm Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Percentage of in-patients with a positive sepsis screening who have received all elements of the Sepsis Six first hour care bundle within one hour of positive screening Percentage of patients who presented to the Emergency Department with a positive sepsis screening who have received all elements of the Sepsis Six first hour care bundle within one hour of positive screening The rate of laboratory confirmed E.coli bacteraemias cases per 100,000 population The rate of laboratory confirmed C.difficile cases per 100,000 population The rate of laboratory confirmed S.aureus bacteraemias (MRSA and MSSA) cases per 100,000 population Percentage of serious incidents assured within the agreed timescales Revised Revised New Revised Continue 12 month improvement trend 12 month improvement trend Less than or equal to 67 cases per 100,000 pop Less than or equal to 26 cases per 100,000 pop Less than or equal to 20 cases per 100,000 population 31.40% 52.60% 47.80% 45.00% 31.00% 44.83% 51.60% 57.90% 63.64% 76.92% 65.38% 77.14% 78.43% 71.9% 70.4% 74.3% 70.7% 67.0% 71.7% 84.0% 83.9% 87.46% 88.50% 92.00% 94.50% 88.74% Hywel Dda University Health Board Integrated Performance Assurance Report Time period Oct 16 to Mar 17 (Target less than equal to 28) Oct 16 to Mar 17 (Target less than equal to 28) All Wales Hywel Dda Position in Wales th out of rd out of 6 Data not currently available - Continue 90% (Data sourced via Serious 45.0% 40.0% 45.0% 46.0% 46.0% 43.5% 55.6% 44.0% 42.0% 40.0% 45.0% Apr % 38.5% 7th out of 8 Incident Reporting Form) Number of new never events Continue Apr Number of Patient Safety Solutions Wales Alerts that were not assured within the agreed timescale Reporting Frequency - Quarterly Status Target The number of preventable hospital acquired thrombosis Revised 0 Revised target 2017/18 - (Data sourced via Patient Safety Wales) 1 Continue 4 quarter reduction trend Critical Care DTOC - DTOC over 5% tolerance Local Measure 5% Critical Care DTOC - % Bed occupancy Percentage compliance with the Patient Safety Solutions Wales Alerts issued after April 2014 Percentage compliance with the Patient Safety Solutions Wales Notices issued after April 2014 Fluoroquinolone items as a percentage of total antibacterial items prescribed Cephalosporin items as a percentage of total antibacterial items prescribed Co-amoxiclav items as a percentage of total antibacterial items prescribed Local Measure 75% (Indicator from Intensive Care Continue 100% 80% Continue 100% 87% Continue Continue Continue Maintain performance levels within the lower quartile or show a reduction towards the quartile below Maintain performance levels within the lower quartile or show a reduction towards the quartile below Maintain performance levels within the lower quartile or show a reduction towards the quartile below Reporting Frequency - Annually Status Target Non steroid anti-inflammatory drug (NSAID) average daily quantity per 1,000 STAR-PUs (specific therapeutic group age related prescribing unit) Percentage of GP practices that report at or above the national prescribing indicator target for the submission of yellow cards that monitor the safety of medicines New target 16/17 New target 16/17 Maintain performance levels with the lower quartile or show a reduction towards the quartile below Q1 2016/17 (Apr - Jun 16) 0 Previously reported on monthly basis 2.13% 2016/2017 5,053 (Q1-Q3) Q2 2016/17 (Jul - Sep 16) 2 Not available Not available 91.0% New target 2017/18 - (Data sourced via Public Health Wales) Revised target 2017/18 - (Data sourced via Public Health Wales) Q3 2016/17 (Oct -Dec 16) 80.0% 80.0% Q4 2016/17 (Jan -Mar 17) 91.0% 93.0% Apr - May 2017 Not available Not Available Not Available Mar Time period Q3 2016/17 Q3 2016/17 Q3 2016/17 Time period Q3 2016/17 All Wales 19.77% 12.20% Not available Not available 70.33% 61.45% Not available Not available 83.0% 2.26% 2.03% Not available 3.55% 3.81% 3.15% Not available 4.70% 4.80% 4.00% Not available Hywel Dda Joint 1st out of 10 Joint 7th out of 7 Position in Wales 1.89% 2.03% 4th out of % 3.15% 5th out of % 4.00% 7th out of 7 All Wales Not Available Not Available Hywel Dda Position in Wales 1,587 1,615 5th out of 7 Annual Improvement Not available 2015/ % 22.2% 4th out of % 93.0% Not available Not available Not available Not available Not available Not available Not available

22 3 - EFFECTIVE CARE - I receive the right care and support as locally as possible and I contribute to making that care successful Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Delayed transfer of care delivery per 10,000 LHB population mental health (all ages) Delayed transfer of care delivery per 10,000 LHB population non mental health (aged 75+) Crude hospital mortality rate (less than 75 years of age). Data Source CHKS. % of deaths within 30 days of emergency admission for a heart attack for patients aged 35 to 74 % of deaths within 30 days of emergency admission for a stroke % of deaths within 30 days of emergency admission for a hip fracture (Age 65+) Continue Continue Revised Local Measure Local Measure Local Measure 12 month reduction trend 12 month reduction trend 12 month reduction trend 12 month reduction trend 12 month reduction trend 12 month reduction trend Time period All Wales Hywel Dda Position in Wales Apr th out of Apr st out of % 0.74% 0.71% 0.72% 0.71% 0.72% 0.71% 0.72% 0.72% 0.72% 0.71% 0.69% 0.68% Feb % 0.72% 5.7% 6.3% 5.6% 5.9% 4.9% 4.8% 4.7% 4.7% 3.6% 3.6% 3.7% 2.4% 2.1% 13.7% 12.4% 12.5% 12.5% 11.8% 12.3% 12.1% 11.4% 11.5% 11.7% 11.3% 11.0% 10.8% 5.2% 5.8% 6.0% 5.6% 4.6% 4.5% 4.2% 4.4% 3.8% 4.1% 3.4% 3.4% 3.5% Percentage of episodes clinically coded within one reporting month post episode end date Revised 95% 73.1% 74.2% 86.7% 86.3% 87.1% 85.8% 89.3% 88.0% 90.5% 94.2% 65.6% NA NA Feb % 94.2% 3rd out of 8 Not available Not available Not available 3rd out of 6 Reporting Frequency - Annually Status Target Division for Social Care and Health Research (DSCHR) - Number of Clinical Research Portfolio Studies Division for Social Care and Health Research (DSCHR) - Number of Commercially Sponsored Studies Division for Social Care and Health Research (DSCHR) - Number of patients recruited into Clinical Research Portfolio Studies Division for Social Care and Health Research (DSCHR) - Number of patients recruited into Commercially Sponsored Studies Indication of progress against the 21 criteria for the operational use of the NHS number Percentage of staff who have undergone information governance training as outlined in C- PIP Guidance Percentage of clinical coding accuracy attained in the NWIS national clinical coding accuracy audit programme Continue Continue Continue Continue Development for 2017/18 Reporting New New Annual improvement Annual improvement Annual improvement Annual improvement Annual improvement Annual improvement Annual improvement 2014/ / / ,119 1,195 1, Target under development for reporting - (Data sourced via Operational Use of NHS Number Report) Not Available Not Available 89.1% Time period Q1 to Q /17 Q1 to Q /17 Q1 to Q /17 Q1 to Q /17 All Wales Hywel Dda ,317 1, Not available Not available Position in Wales 6th out of 10 6th out of 10 5th out of 10 6th out of / % 89.10% 6th out of 8 Hywel Dda University Health Board Integrated Performance Assurance Report 7

23 4 - DIGNIFIED CARE - I am treated with dignity and respect and treat others the same Latest all Wales comparison Reporting Frequency - Monthly Status Target Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 The percentage of patients who had their procedures postponed on more than one occasion for non clinical reasons with less than 8 days notice and are subsequently carried out within 14 calendar days or at the patient s earliest convenience % compliance with Hand hygiene (World Health Organisation (WHO) 5 moments) Continue Local Measure 12 month improvement trend Time period All Wales 63.2% 27.3% 63.2% 42.9% 81.8% 20.0% 100.0% 76.9% 20.0% 41.9% 82.2% 41.7% 33.3% Jan % 41.9% 95% 93% 91% 90% 92% 92% 93% 91% 97% 89% 90% 91% 90% 90% Hywel Dda Not available Position in Wales 4th out of 6 Percentage of Nutrition Score Completed and Appropriate Action Taken within 24 hours of admission Local Measure 85% 90.9% 92.4% 93.1% 88.0% 91.4% 89.6% 90.5% 91.7% 89.2% 92.3% 90.0% 90.2% 90.1% Not available Reporting Frequency - Annually Status Target Evidence of how NHS organisations are responding to patient feedback to improve services Percentage of people with dementia in Wales age 65 years or over who are diagnosed (registered on a GP QOF register) Percentage of GP practice teams that have completed mental health training in dementia care or other training as outlined under the Directed Enhanced Services for mental illness Revised Revised Continue Not available Annual improvement Annual improvement Reporting Frequency -Bi Annual Status Target 2014/ / /2017 Revised target for reporting (Data sourced via Evidence of Responding to Patient Feedback to Improve Services Monitoring Return) 41.6% 43.4% Not available 29.6% 24.1% Not available 2014/ / /2017 Time period All Wales Hywel Dda Position in Wales 2015/ % 43.4% 7th out of / % 24.1% 4th out of 7 Time period Not available All Wales Hywel Dda Position in Wales Percentage of NHS employed staff who come into contact with the public who are trained in an appropriate level of dementia care Revised 75% New target for reporting (Data sourced via Dementia Training Data Monitoring Return) Not available Dignified Care Status Target 2014/ / /2017 Time period All Wales Hywel Dda Position in Wales Timely and responsive handling of concerns and complaints Continue To be confirmed Target under development for reporting (Data source to be confirmed) Not available Hywel Dda University Health Board Integrated Performance Assurance Report 8

24 5 - TIMELY CARE - I have timely access to services based on clinical need and am actively involved in decisions about my care Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Time period All Wales Hywel Dda Position in Wales The percentage of emergency responses to red calls arriving within (up to and including) 8 minutes Number of ambulance handovers over one hour (PPH not included in May and June 2016 but included from July 2016 onwards. Prior months are not adjusted) The percentage of patients who spend less than 4 hours in all major and minor emergency care facilities from arrival until admission, transfer or discharge The number of patients who spend 12 hours or more in all hospital major and minor care facilities from arrival until admission, transfer or Revised 65% 68.8% 68.0% 71.5% 72.9% 69.6% 68.9% 67.2% 67.6% 76.1% 63.2% 75.0% 78.3% Est 73.1% Apr % 78.3% 5th out of 7 Continue Apr-17 1, nd out of 6 Continue 95% 84.5% 84.2% 87.9% 86.6% 83.5% 85.2% 86.2% 84.2% 82.8% 84.2% 85.9% 87.5% 87.5% Apr % 87.5% 2nd out of 6 Continue Apr-17 2, rd out of 6 Percentage of patients who are diagnosed with a Stroke who have a direct admission to an acute stroke unit within 4 hours Revised 58.5% (SSNAP UK average Aug to Nov 16) 63.5% 36.5% 54.8% 50.0% 61.4% 65.9% 70.2% 72.7% 70.5% 70.2% 65.6% 80.0% 68.8% Mar % 65.6% 1st out of 6 Percentage of patients who are diagnosed with a Stroke who are thrombolysed within 45 minutes (door to needle) New Improvement (12 month trend) 41.7% 25.0% 40.0% 12.5% 62.5% 20.0% 50.0% 20.0% 27.3% 44.4% 33.3% 33.3% 50.0% Mar % 33.3% 2nd out of 6 Percentage of patients who are diagnosed with a Stroke who receive a CT scan within 12 hours Percentage of patients who are diagnosed with a Stroke who have been assessed by Stroke Consultant within 24 hours Revised New 93.5% (SSNAP UK average Aug to Nov 16) 81.9% (SSNAP UK average Aug to Nov 16) 100.0% 100.0% 100.0% 96.5% 100.0% 98.0% 100.0% 100.0% 100.0% 100.0% 97.4% 100.0% 100.0% Mar % 97.4% 3rd out of % 70.0% 70.0% 82.6% 77.3% 84.3% 77.4% 55.4% 80.4% 73.7% 71.4% 75.8% 79.7% Mar % 71.4% 6th out of 6 Hywel Dda University Health Board Integrated Performance Assurance Report 9

25 5 - TIMELY CARE - I have timely access to services based on clinical need and am actively involved in decisions about my care Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Time period All Wales Hywel Dda Position in Wales The percentage of patients newly diagnosed with cancer, via the urgent suspected cancer route, that started definitive treatment within (up to & including) 62 days of receipt of referral Continue 95% 89.1% 82.7% 80.6% 86.2% 87.6% 88.7% 91.5% 92.2% 90.9% 91.1% 90.7% 94.6% 90.9% Est. Mar % 90.7% 4th out of 6 The percentage of patients newly diagnosed with cancer, not via the urgent route, that started definitive treatment within (up to & including) 31 days of diagnosis (regardless of referral route) The percentage of patients waiting less than 26 weeks for referral to treatment The number of patients waiting more than 36 weeks for referral to treatment The number of patients waiting more than 8 weeks for a specified diagnostic Continue 98% 98.2% 97.8% 97.3% 97.4% 98.6% 96.9% 94.6% 99.1% 98.04% 96.4% 96.7% 100.0% 95.7% Est. Mar % 96.7% 5th out of 6 Continue 95% 80.2% 81.5% 81.8% 80.7% 80.6% 80.0% 80.5% 79.9% 81.4% 83.8% 85.6% 85.2% 84.0% Mar % 85.6% 6th out of 7 Continue 0 4,798 4,788 5,002 5,192 4,852 4,809 4,730 5,040 4,827 4,059 2,666 2,965 3,086 Mar-17 12,354 2,666 5th out of 7 Continue Mar-17 4,741 0 Joint 1st out of 7 The number of patients waiting for an outpatient follow-up ( booked and not booked) who are delayed past their agreed target date Revised 12 month reduction trend 28,576 28,418 29,306 29,434 29,932 29,506 30,612 31,728 29,318 25,089 25,225 26,346 27,272 Mar ,796 25,225 3rd out of 7 The percentage of mental health assessments undertaken within (up to and including) 28 days from the date of receipt of referral Continue 80% 85.5% 89.7% 89.8% 89.5% 89.0% 97.4% 94.7% 96.0% 91.0% 95.0% 96.6% 90.0% Not available Mar % 96.6% 1st out of 7 The percentage of therapeutic interventions started within (up to and including) 28 days following an assessment by Local Primary Mental Health Support Services (LPMHSS) Continue 80% 84.4% 85.7% 81.5% 80.7% 90.0% 82.6% 91.8% 87.5% 81.9% 89.3% 93.3% 90.8% Not available Mar % 93.3% 1st out of 7 Hywel Dda University Health Board Integrated Performance Assurance Report 10

26 5 - TIMELY CARE - I have timely access to services based on clinical need and am actively involved in decisions about my care Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Time period All Wales Hywel Dda Position in Wales RTT - Hywel Dda residents waiting over 36 week's for treatment by other providers % of patients waiting less than 14 weeks for all Therapies Number of patients waiting 14 weeks plus for all Therapies % of patients waiting less than 14 weeks for Audiology Number of patients waiting 14 weeks plus for Audiology % of patients waiting less than 14 weeks for Dietetics Number of patients waiting 14 weeks plus for Dietetics % of patients waiting less than 14 weeks for Occupational Therapy (excludes MHLD) Number of patients waiting 14 weeks plus for Occupational Therapy (excludes MHLD) % of patients waiting less than 14 weeks for Physiotherapy Number of patients waiting 14 weeks plus for Physiotherapy % of patients waiting less than 14 weeks for Podiatry Number of patients waiting 14 weeks plus for Podiatry % of patients waiting less than 14 weeks for Speech and Language Therapy Number of patients waiting 14 weeks plus for Speech and Language Therapy Number of patients waiting 8 weeks for Clinical Musculoskeletal Assessment and Treatment Of the practices capable of offering My Health on Line, the percentage who are offering appointment bookings Of the practices capable of offering My Health on Line, the percentage who are offering repeat prescriptions Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Local Measure Not available 100% 82.6% 83.5% 81.0% 79.8% 77.3% 77.5% 79.3% 80.9% 81.1% 81.6% 81.0% 81.1% 75.1% 0 1,386 1,312 1,453 1,436 1,433 1,320 1,359 1,491 1,514 1,514 1,643 1,736 2, % 65.7% 67.8% 74.5% 73.9% 66.2% 66.4% 64.3% 61.8% 0% % 54.2% 54.8% 58.5% 58.3% 61.1% 63.1% 66.0% 70.7% 67.9% % 66.3% 81.0% 79.0% 75.6% 60.6% 68.5% 61.3% 56.2% 57.8% % Not Reported 93.1% 93.1% 93.1% 94.1% 97.0% 97.9% 96.6% 94.1% 86.9% 0% % 76.8% 72.3% 75.7% 70.5% 69.0% 71.6% 71.8% 74.1% 65.3% % 92.9% 89.7% 83.2% 82.7% 80.2% 77.8% 71.8% 79.6% 75.1% Continue 12 month 35.2% 44.4% 41.5% 45.3% 43.0% 32.0% 32.0% 30.0% 32.1% 37.7% 34.0% 34.0% improvement Continue trend 61.1% 70.4% 66.0% 73.6% 75.0% 60.0% 60.0% 62.0% 64.2% 67.9% 77.4% 79.2% Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Apr % 34.0% 5th out of 7 Apr % 79.2% 7th out of 7 Hywel Dda University Health Board Integrated Performance Assurance Report 11

27 5 - TIMELY CARE - I have timely access to services based on clinical need and am actively involved in decisions about my care Latest all Wales comparison Reporting Frequency - Quarterly Status Target Q4 2015/16 (Jan - Mar 16) Q1 2016/17 (Apr - Jun 16) Q2 2016/17 (Jul - Sep 16) Q3 2016/17 (Oct - Dec 16) Q4 2016/17 (Jan - Mar 17) Time period All Wales Hywel Dda Position in Wales Individual Patient Funding Request (IPFR) - Total number received Local Measure N/A Not Available Not available Individual Patient Funding Request (IPFR) - Total number approved Local Measure N/A Not Available Not available Individual Patient Funding Request (IPFR) - Total number declined Local Measure N/A Not Available 5 8 <5 <5 Not available Number of CHC package delivered Local Measure N/A 1,354 1,357 1,387 1,360 1,309 Not available Total Health board CHC spend Percentage of the health board population regularly accessing NHS primary dental care DXA (dual X-ray absorptiometry) Services - Total number of patients waiting 8 weeks and over DXA (dual X-ray absorptiometry) Services - Longest wait in weeks Local Measure Continue Local Measure Local Measure N/A 4 quarter improvement trend 0 8 weeks m m m m m Not available 45.9% (as at Jun-16) % (as at Sept- 16) Not Available Sep % 46.0% 7th out of Not available 12 weeks 8 weeks 8 weeks 6 weeks 6 weeks Not available Access Times for Re-Accessing Audiology Services - Total number of patients waiting 14 weeks and over Local Measure ,237 1,330 1,276 Not available Access Times for Re-Accessing Audiology Services - Longest wait in weeks Local Measure 14 weeks 52 weeks 54 weeks 59 weeks 64 weeks 70 weeks Not available Reporting Frequency - Annually Status Target 2013/2014 (as at 30/11/13) 2014/2015 (as at 30/11/14) 2015/2016 (as at 30/11/15) 2016/2017 (as at 12/06/17) Time period All Wales Hywel Dda Position in Wales Percentage of GP practices open during daily core hours or within 1 hour of daily core hours Continue Annual improvement 58.2% 67.0% 64.8% 74.0% % 74.0% Joint 6th out of 7 Percentage of GP practices offering daily appointments between 17:00 and 18:30 hours Revised Annual improvement 94.5% 100.0% 98.1% 75.0% % 75.0% 6th out of 7 % of practices with one half day closure per week % of practices offering appointments at any time between 5.00pm & 6.30pm anytime, every week day (i.e. 5 days pw) % of practices with extended opening hours and offering appointments after 18:30 at least one week day Local Measure Local Measure Local Measure 6% 12.7% 9.3% 9.3% 5.7% Not available 79% 90.9% 98.1% 98.1% 98.1% Not available 7% 1.8% 5.6% 7.4% 7.5% Not available Hywel Dda University Health Board Integrated Performance Assurance Report 12

28 6 - INDIVIDUAL CARE - I am treated as an individual, with my own needs and responsibilities Latest all Wales comparison Reporting Frequency - Monthly Status Target Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 The percentage of health board residents in receipt of secondary mental health services (all ages) who have a valid care and treatment plan (CTP) All health board residents who have been assessed under part 3 of the mental health measure to be sent a copy of their outcome assessment report up to and including 10 working days after the assessment has taken place Percentage of qualifying compulsory/voluntary patients have been offered advocacy services in the Mental Health Services Continue 90% 91.0% 90.3% 91.8% 92.0% 91.4% 92.2% 90.3% 92.0% 91.4% 91.4% 91.6% 92.2% 90.7% Mar % 92.2% 3rd out of 7 Continue 100% 53.3% 61.5% 92.3% 93.3% 100.0% 100.0% 100.0% 85.7% 100.0% 100.0% 90.0% 100.0% 100.0% Mar % 100.0% Local Measure 100% (Local Target) 86.2% 89.7% 87.8% 92.1% 95.3% 95.7% 93.5% 94.8% 92.6% 91.1% 98.2% 97.6% 93.1% 95% of service users admitted to a psychiatric hospital between 0900 and 2100 will have received a gate-keeping assessment by the Crisis Resolution Home Treatment (CRHT) service prior to Local Measure 95% 97.9% 100.0% 98.1% 100.0% 92.3% 100.0% 94.0% 90.1% 95.9% 98.3% 95.5% 98.2% 95.7% admission 100% of service users admitted to a psychiatric hospital, who have not received a gate keeping assessment by the Crisis Resolution Home Treatment (CRHT), will receive a follow-up assessment by 100% 100.0% 75.0% 0.0% 100.0% 33.3% 100.0% 10.0% 43.8% 50.0% 71.4% 50.0% 75.0% 25.0% the CRHTS within 24 hours of admission periodical Local Measure To maintain a maximum waiting time for first appointment with specified therapies of 14 weeks To maintain a maximum waiting time for first outpatient appointments of 10 weeks Child & Adolescent Mental Health Services (CAMHS) - To maintain a maximum waiting time for first outpatient appointments of 28 days Time period All Wales Hywel Dda Not Available Not Available Not Available Not Available Not Available Not Available Position in Wales Joint 1st out of 7 Reporting Frequency - Quarterly Status Target Q4 (2015/16) Q1 (2016/17) Q2 (2016/17) Q3 (2016/17) Q4 (2016/17) Time Hywel All Wales Jan - Dec Apr - Jun Jul - Sep Oct - Dec Jan - Mar period Dda Rate of calls to the mental health line CALL (Community Advice and Listening Line) by Welsh residents per 100,000 of the population Continue Q4 16/ Rate of calls to the Welsh dementia helpline by Welsh residents 4 quarter per 100,000 of the population (age 40+) Revised improvement trend Revised target for 2017/18 - (Data via CALL Database) Q4 16/ Rate of calls to the DAN 24/7 helpline by Welsh residents per 100,000 of the population % of hospitals in the Health Board which have arrangements in place to ensure advocacy is available for all qualifying patients. Revised target for 2017/18 - changed from Bi-Annually (Data via Mental Health Wales Measures 2010 Data Collection - Part 4) Continue Q4 16/ th out of 7 New 100% 100.0% 100.0% 100.0% 100.0% 100.0% Q3 16/ % 100.0% Position in Wales 3rd out of 7 3rd out of 7 Joint 1st out of 7 Hywel Dda University Health Board Integrated Performance Assurance Report 13

29 6 - INDIVIDUAL CARE - I am treated as an individual, with my own needs and responsibilities Latest all Wales comparison Individual Care Increase the number of clients who engage with services between assessment and planned ending of treatment, by reducing the incidences of clients who do not attend (DNA) or respond to follow up contact post assessment date. Substance Misuse Service - Quarterly Targets Target Quarter 2 (Jul - Sep) Quarter 3 (Oct -Dec) Quarter 4 (Jan - Dec) Carmarthen Welsh Government 7.48% G 11.11% G 8.54% G Ceredigion Baseline 20% Decrease in DNAs 2.29% G 7.63% G 7.96% G [Rating; Red >=30%, Pembrokeshire Amber % 12.50% G 7.98% G 7.64% G and Green <=20%] Quarter 1 (Apr - Jun) 2016 / 2017 Quarter 1 (Apr - Jun) 16.99% 16.85% 21.33% Achieve a waiting time of less than 20 working days between referral and treatment Carmarthen Welsh 79.40% A 90.13% G 87.85% G Government Ceredigion baseline 80% 78.52% A 94.55% G 92.98% G [Rating; Red <=70%, Amber % Pembrokeshire and Green >=80%] 75.69% A 92.66% G 90.64% G 72.07% 80.70% 59.54% Substance misuse is reduced for problematic substance between start and most recent review/exit. Achievement to show continual improvement against own baseline & adherence to the Welsh benchmark figure. Quality of life is improved between start and most recent review/ exit Treatment Outcome Profile (TOP). Achievement to show continual improvement against own baseline & adherence to the Welsh benchmark figure. Number/percentage of cases closed (with a treatment date) as treatment completed. Achievement to show continual improvement against own baseline & adherence to the Welsh benchmark figure. Carmarthen Welsh 90.61% G 88.89% G 92.58% G 87.63% Ceredigion Government Baseline 74.72% 78.99% G 75.83% G 89.32% G Not Available 81.93% [Rating; Red <=Baseline, Pembrokeshire 71.18% R 77.96% G 86.27% G 80.21% and Green >=Baseline] Carmarthen Ceredigion Welsh Government Baseline 66.17% Increase 74.49% 68.18% G G 73.51% 57.58% G G 76.00% 58.18% G R 74.79% 57.32% [Rating; Red <=Baseline, and Green >=Baseline] Pembrokeshire 69.79% G 74.53% G 70.07% G 71.35% Carmarthen Ceredigion Welsh Government Baseline 71.77% Increase 92.79% 96.23% G G 86.60% 88.89% G G 89.71% 90.82% G G 75.32% 77.42% [Rating; Red <=Baseline, and Green >=Baseline] Pembrokeshire 81.69% G 90.42% G 90.13% G 72.90% Hywel Dda University Health Board Integrated Performance Assurance Report 14

30 7 - STAFF AND RESOURCES - I can find information about how the NHS is open and transparent on its use of resources and I can make careful use of them Latest all Wales comparison Reporting Frequency - Monthly Status Target May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Time period All Wales Hywel Dda Position in Wales Financial balance: Expenditure does not exceed the aggregate of the funding allotted to it over a period of 3 financial years (as agreed by the Planned Care Board) Revised <= m deficit m deficit m deficit m deficit m deficit m deficit m deficit m deficit m deficit m deficit m deficit 5.25m deficit 4.899m deficit Financial balance: Stay Within Capital Resource Limit (cumulative year to date position) Local Measure <= Cash Expenditure is less than the Cash Limit Local Measure Year end forecast m shortfall m shortfall m shortfall m shortfall m shortfall m shortfall m shortfall m shortfall m shortfall 0.658m surplus 1.212m surplus Not Reported in Month m shortfall Not available The Savings Plan is on target (cumulative year to date position) Local Measure 100% 28.20% 38.00% 38.00% 38.00% 36.10% 33.90% 32.70% 31.50% 30.70% 30.36% 30.13% 90.70% % Variable pay (Agency, Locum, Bank & Overtime) Local Measure Reduction on 2014/15 (Avg m) 4.751m 4.715m 3.719m 4.558m 5.489m 4.634m 4.717m 4.749m 5.142m 4.676m 5.194m 4.333m 3.913m % of full time equivalent (FTE) days lost to sickness absence - for rolling 12 month period Revised Rolling twelve month reduction 5.50% 5.45% (as at 10/8) 5.41% 5.38% (as at 03/10) 5.28% (as at 03/11) 5.24% (as at 05/12) 5.18% 5.15% 5.20% 5.15% 5.08% 5.0% (as at 6/6) NA Jan % 5.2% 6th out of 10 Percentage of staff undertaking performance appraisal combined New Revised 85% measure in 54.0% 55.0% 55.0% 55.0% 55.0% 53.0% 54.0% 54.0% 56.0% 56.0% 55.0% 57.0% 2016/17 Not available Rate of patients who did not attend a GP appointment Revised 12 month reduction trend Revised target under development for reporting - (Data sourced via Audit +) The percentage of patients who did not attend a new outpatient appointment (In Month Rate) Continue 12 month reduction trend 8.70% 8.40% 8.60% 8.40% 8.50% 8.50% 9.20% 10.70% 10.30% 9.00% 10.80% 10.20% NA Mar % 10.8% 7th out of 7 The percentage of patients who did not attend a follow-up outpatient appointment (In Month Rate) Continue 12 month reduction trend 9.40% 9.70% 9.20% 8.90% 9.50% 8.80% 8.60% 9.10% 9.80% 9.10% 8.30% 9.30% NA Mar % 8.3% 5th out of 7 Hywel Dda University Health Board Integrated Performance Assurance Report 15

31 7 - STAFF AND RESOURCES - I can find information about how the NHS is open and transparent on its use of resources and I can make careful use of them Latest all Wales comparison Reporting Frequency - Quarterly Status Target Q4 2015/16 (Jan - Mar 16) Q1 2016/17 (Apr - Jun 16) Q2 2016/17 (Jul - Sep 16) Q3 2016/17 (Oct - Dec 16) Q4 2016/17 (Jan - Mar 17) Time period All Wales Hywel Dda Position in Wales Percentage of inhaled corticosteroids prescribed in primary care that are low strength inhaled corticosteroids Non NHS Invoices by Number are Paid within 30 Days (cumulative year to date position) Number of procedures that do not comply with selected NICE Do Not Do guidance for procedure of limited effectiveness (selected from a list agreed by the Planned Care Board) Quantity of biosimilar medicines prescribed as a percentage of total reference product plus biosimilar New target 16/17 Maintain performance level within upper quartile or show an increase towards the quartile above Local Measure 95% New 0% New TBC Not available Moved to Quarterly reporting in 2016/17 Not available 50.3% 51.8% Not available 81.0% 85.2% 87.3% 89.1% New target 2017/18 - (Data via Patient Episode Database for Wales) New 2017/18 Target - (Data via All Wales Therapeutic & Toxicology Centre) Q3 2016/ % 51.8% 6th out of 7 Not available Not available Reporting Frequency - Bi-Annually Status Target Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Number of ENT procedures that do not comply with NICE Do Not Do guidance for procedure of limited effectiveness (as agreed by the Planned Care Board) Number of ophthalmology procedures that do not comply with NICE Do Not Do guidance for procedure of limited effectiveness (as agreed by the Planned Care Board) Number of orthopaedics procedures that do not comply with NICE Do Not Do guidance for procedure of limited effectiveness (as agreed by the Planned Care Board) Number of urology procedures that do not comply with NICE Do Not Do guidance for procedure of limited effectiveness (as agreed by the Planned Care Board) New target 16/17 New target 16/17 New target 16/17 New target 16/ Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Time period All Wales Hywel Dda Position in Wales Dec rd out of Dec Joint 2nd out of Dec th out of Dec Joint 5th out of 7 Reporting Frequency - Annually Status Target Percentage of staff who are undertaking a performance appraisal who agree it helps them improve how they do their job Overall staff engagement score scale score Percentage of staff who would be happy with the standards of care provided by their organisation if a friend or relative needed treatment Time period All Wales Hywel Dda Position in Wales New target for 2017/18 reporting - (Data Revised Improvement 51% % 51% 8th out of 10 sourced via Staff Survey, Pulse Survey) New target for reporting method Revised Improvement (Data sourced via Staff Survey, Pulse Joint 5th out of 10 Survey) New target for reporting Revised Improvement (Data sourced via Staff Survey, Pulse 67% % 67% 8th out of 10 Survey) Hywel Dda University Health Board Integrated Performance Assurance Report 16

32 1 Staying Healthy High-level Overview Lead Executives Dr. Michael Thomas, Dr. Boika Rechel & Joe Teape Hywel Dda University Health Board Integrated Performance Assurance Report 17

33 1 Staying Healthy Exception Report Lead Executive Joe Teape Where are we and are we on target? Chronic Conditions Senior Responsible Officer Linda Williams The 12 month reduction target has not been met for both admissions and re-admissions based on January 2017 data. Whilst the actual admissions performance to December is just under the 2016/17 Operational Plan Profile, it can be seen that to the end of January there has been a Hywel Dda University Health Board Integrated Performance Assurance Report 18

34 steady rise, albeit small numbers, in admissions especially during the winter. The pattern seems similar for re-admissions. Based on the latest All Wales data published in May 2017, the Health Board is ranked 3 rd out of 6 for both targets. What are the challenges? During the winter months there is an expectation that admissions will increase. It must also be noted that there is limited capacity within specialist community teams, especially at times of annual leave and sickness. There has been some long term sickness within the specialist Community teams. What is being done? There has been some small investment in the specialist community teams in Pembrokeshire through Intermediate Care Funding (ICF). In addition, work is underway to review the caseloads of the Community Specialist Nurses. There has been a focus on diabetes care in Ceredigion through Cluster funding. The focus within the Health Board of the Frailty Programme and the Dementia programme will result in a positive impact to reduce admissions and readmissions for the basket of 8 Chronic Conditions. The preventative agenda of the Community Resource Teams in focussing on proactive case findings, in conjunction with the Primary Care disease registered patients, will improve performance. When can we expect improvement and by how much? Some improvement is expected in the final quarter of the year to reflect investment and caseload reviews. How does this impact on both patients and finances? The impact on patients that are admitted is the risk of acquiring a hospital infection, and loss of confidence to manage their condition. The impact on finances when additional capacity is opened to meet need, creates the use of surge beds that are not funded. Hywel Dda University Health Board Integrated Performance Assurance Report 19

35 1 Staying Healthy Exception Report Lead Executive Dr. Michael Thomas Smoking Cessation Senior Responsible Officer Dawn Davies Where are we and are we on target? Treated Smokers: Improved year end performance compared to 2015/16 but still below the 5% target; CO Validated Smokers: Performance continues to exceed the target. What are the challenges? The delayed recruitment into Glangwili has now been resolved, and as a result, there has been an improvement in performance during Quarter 4; A delay in trained Level 3 Pharmacists providing Smoking Cessation Services; There has been a national decision to bring all Smoking Cessation Services under one national brand with a national contact centre. This new brand is called Help Me Quit, formally Stop Smoking Wales. There is an expectation that all other locally funded services e.g. in Hywel Dda iquit for Pharmacy Level 3, and the Hospital Smoke Free Service, will adopt the new national branding (rebranding to be funded locally). The brand assets for Help Me Quit were not released until April 2017, so this has meant that promoting pathways into local services from both secondary care and community settings has been delayed; As part of the Early Year s service to promote Smoking Cessation during pregnancy (NICE PH26), all Midwives have received brief intervention training and have each been provided with a CO monitor. The expectation is that all women, regardless of smoking status, are CO validated at the booking appointment as part of standard practice (in the same way blood pressure is monitored etc). The CO reading for all women is recorded in the hand held record and the woman is then asked any smoking related questions e.g. Do you smoke? Does anyone in your household smoke? If the woman has a CO reading above 4ppm, or has given up smoking in the previous two weeks, then the recommendation is that they are referred to the hospital Smoke Free Service to discuss options to support a smoke free pregnancy. An audit of the handheld maternity record has found compliance to be low. What is being done? Pharmacy Level 3 Smoking Cessation Service: o Expanding Pharmacy Level 3 Smoking Cessation Service. To date 41 Pharmacists are now part of the scheme. This exceeds the Health Board (HB) target of 35 Community Pharmacies offering a Level 3 service by March Additional training will be delivered in June 2017; o Training is provided for a full day, to ensure all Pharmacy staff have the opportunity to complete the online assessment, following the morning face-to-face training session; o A Community Pharmacist has been seconded for 2 days per month, to ensure all Level 3 Pharmacists support the HB to achieve the 5% target. This has been very successful, and the role will be continuing until March 2018; Hywel Dda University Health Board Integrated Performance Assurance Report 20

36 o Provide incentives for achieving targets, including CO validation at 4 weeks post quit, treating a minimum of one smoker per month. Hospital Smoke Free Service: o Training of staff is now complete; o A referral pathway using the recommended 3A s approach (Ask, Advice, Act), has been developed to support decision making on the wards; o A new hospital database called QM10 has been piloted in Hywel Dda and will now be rolled out to all Hospital Cessation Services across Wales. This software supports more efficient patient management and reporting on key performance indicators. Early Year s Service: o The Public Health Team are working closely with Maternity Services to understand some of the barriers to referral, and to develop a better understanding of the needs of pregnant women who may find it difficult to stop smoking; o Planning currently taking place to develop a joint work plan with Flying Start Midwives; o Planning currently taking place to develop a Specialist Health Visitor role to support Smoking Cessation and promote smoke free homes; o Planning currently taking place to develop initiatives to be delivered through Family Centres. When can we expect improvement and by how much? The aim is for an improved position by March 2018, but the forecast will be below the Welsh Government Delivery and Outcomes Framework target for treated smokers. How does this impact on both patients and finances? While overall death rates from smoking are falling, it still continues to be the largest single preventable cause of ill health and premature death; Reducing smoking has an immediate benefit for individuals and also a reduction in demand for services, through reduced rates of infection and length of hospital stay. Hywel Dda University Health Board Integrated Performance Assurance Report 21

37 1 Staying Healthy Exception Report Lead Executive Dr. Boika Rechel Childhood Vaccinations Senior Responsible Officer Buddug Nelson Where are we and are we on target? COVER Report 122 states that the Health Board (HB) is below the target for the four Childhood Vaccination measures. What are the challenges? Hywel Dda has similar challenges to other Health Boards, with pockets of the population resisting the vaccination of their children for religious and ethical reasons. The Health Board has workforce issues, and localities where Health Visitors vaccinate (Ceredigion and 3 GP Practices in Carmarthenshire) are found to have the best vaccination rates. Workforce issues within School Nursing, has resulted in staff being asked to do additional hours to cover more cohorts for the Childhood Influenza and Men ACWY vaccination. Queue lists have recently been highlighted as a possible reason why some children have not been vaccinated. What is being done? The Health Board has successfully appointed two band 5 Community Nurse Immunisers to work with the vulnerable amongst the population, and support existing immunisation clinics within Hywel Dda, subject to assessment of need etc. The HB has also appointed a Support Manager to the Children s Public Health Nursing Team, who will support the Immunisation Coordinator with business cases for trying different models of immunisation delivery within all sectors of the population, beginning with childhood immunisation. Within the Childhood Immunisation Group, a task group will look at the data reporting, data recording and other data related issues, to cleanse the data to truly reflect the vaccination status of the population. When can we expect improvement and by how much? Expectations are that a number of children will be vaccinated and that future COVER Reports will reflect this. How does this impact on both patients and finances? The service is looking at the finances surrounding vaccination, to establish that what it receives from Welsh Government is adequate for the population that it is protecting, and that all the services involved in vaccinating are allocated the right amount of finance to provide their part of the service. Increasing vaccination rates has an impact on all of us, especially members of the public that cannot be vaccinated, but still require protection from vaccine preventable diseases. Hywel Dda University Health Board Integrated Performance Assurance Report 22

38 1 Staying Healthy Exception Report Lead Executive Dr. Boika Rechel Influenza Vaccinations Senior Responsible Officer Buddug Nelson Where are we and are we on target? Overall, Hywel Dda University Health Board (HDUHB) has the lowest uptake rates by Health Board (HB) in Wales, as of 28 th March This is despite an additional 639 vaccinations given in Primary Care this season, as opposed to the equivalent date last year, which reflects the change in numbers of the population eligible for this intervention. What are the challenges? Cultural barriers to influenza vaccination uptake remain in large parts of the population of the HB area, and challenging and overcoming these barriers remains a long term process. These barriers extend to a sizeable proportion of the HB workforce, who are resistant to accepting the offer of vaccination. What is being done? A range of actions are being undertaken to boost vaccination uptake levels including: GP Practices/Primary Care Data profiles produced for each GP surgery, along with details of resources and support available; Updates given at all cluster meetings on latest uptake data and comparison with equivalent period last year; The December General Medical Services (GMS) newsletter reiterated support available to Primary Care to increase uptake; Additional targeted support offered to North Ceredigion cluster in January 2017, which resulted in an increase in vaccinations over what would have been expected for this time of the season. Communities and Voluntary Sector The Ceredigion Community Engagement Programme is continuing, to test and apply behavioural insights research conducted earlier this year; Volunteers Briefing distributed via third sector, providing information and key messages to support community promotion. Hospitals Staff Uptake Staff clinics took place up until January 2017 and were promoted via the HDUHB website; Leaflets encouraging staff vaccination distributed to all HDUHB staff in October payroll; Monthly ward-level uptake data to be provided to Hospital Management Teams. Hospitals Secondary Care Vaccination of Patients Hywel Dda University Health Board Integrated Performance Assurance Report 23

39 Proposals were approved by the HB Executive Team to pilot vaccination in Secondary Care settings in Withybush General Hospital (WGH), for the months of February and March Due to the complexities of addressing governance arrangements, this pilot has developed a standard operating procedure and supporting documentation, but has not been in a position to provide active vaccination of patients. Communications/Social Media etc Media releases featuring local case studies and special focuses on the at risk groups every fortnight; Radio adverts ran for two weeks at the start of the campaign on each county radio station; Letters from Dr Phil Kloer were sent with all outpatient appointment letters from November 2016; Global messages to staff and articles in Hywel's Voice and Team Brief; On-going social media messages via Twitter and Facebook, including video clips (GIFs); Clean Graffiti messages in Aberystwyth town centre; Flu Bug mascot visits and promotional events around sites in Pembrokeshire / Ceredigion / Carmarthenshire. When can we expect improvement and by how much? A Situation, Background, Assessment Recommendation (SBAR) was presented to the HB Executive Team in early January 2017, with proposals to increase uptake rates, with an emphasis on the potential for vaccinating patients in Secondary Care settings. Additional improvement actions continued across the remainder of the influenza vaccination season, up until 31 st March How does this impact on both patients and finances? Additional pressures on both Primary and Secondary Care would follow when influenza is actively circulating in the community. Alongside this, lower levels of vaccine uptake in healthcare staff may affect the ability of the workforce to cope with patient pressures if sickness levels increase. Hywel Dda University Health Board Integrated Performance Assurance Report 24

40 2 Safe Care High-level Overview Lead Executives Mandy Davies & Joe Teape Hywel Dda University Health Board Integrated Performance Assurance Report 25

41 2 Safe Care Exception Report Lead Executive Mandy Davies Safe Care The rate of laboratory confirmed E.coli bacteraemias cases per 100,000 population The rate of laboratory confirmed C.difficile cases per 100,000 population The rate of laboratory confirmed S.aureus bacteraemias (MRSA and MSSA) cases per 100,000 population * Revised target in 2017/18 from 28 to 26 Senior Responsible Officer Sharon Daniel Healthcare Associated Infections (HCAI) Target 67 per 100,000 population 26 per 100,000 population* 20 per 100,000 population May 2017 (Cumulative Rate) April 2017 (Cumulative Rate) March 2017 (cumulative Oct 16 - Mar 17) May 2016 (In Month) R Not Available Not Available R Not Available Not Available R Where are we and are we on target? During May 2017 there were 36 verified Escherichia coli (E.coli) blood stream infections (BSI), which is an increase compared to the 32 reported in April. This equates to 14 less Ecoli BSI than in the same time frame April May This has resulted in a cumulative infection rate of Hywel Dda University Health Board maximum cumulative monthly numbers of E. coli bacteraemia to achieve the 2017/18 reduction expectation and current cumulative monthly numbers for April to May 17 Mth-Yr Maximum cumulative monthly numbers of E. coli bacteraemia to achieve reduction expectation Current cumulative monthly numbers of E. coli bacteraemia Difference between current and expected cumulative monthly numbers of E. coli bacteraemia Revised maximum cumulative monthly numbers of E. coli bacteraemia to achieve reduction expectation Current cumulative monthly rate of E. coli bacteraemia /100,000 population Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Hywel Dda University Health Board Integrated Performance Assurance Report 26

42 During May 2017 there were 20 verified Clostridium difficile (C.diff) infections, which is an increase compared to the 8 reported in April. This has resulted in a cumulative infection rate of Hywel Dda University Health Board maximum cumulative monthly numbers of C. difficile to achieve the 2017/18 reduction expectation and current cumulative monthly numbers for April to May 17 Mth-Yr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Key Not on trajectory to achieve reduction expectation by Mar-18 On trajectory to achieve reduction expectation by Mar-18 During May 2017 there were 13 verified Staphylococcus aureus (S. aureus) blood stream infections (BSI), which is an increase compared to the 14 reported in April. This has resulted in a cumulative infection rate of This is 4 cases less than in the same time period April May Hywel Dda University Health Board maximum cumulative monthly numbers of S. aureus bacteraemia to achieve the 2017/18 reduction expectation and current cumulative monthly numbers for Apr to May 17 Mth-Yr Maximum cumulative monthly numbers of C. difficile to achieve reduction expectation Maximum cumulative monthly numbers of S. aureus bacteraemia to achieve reduction expectation Current cumulative monthly numbers of C. difficile Current cumulative monthly numbers of S. aureus bacteraemia Difference between current and expected cumulative monthly numbers of C. difficile Difference between current and expected cumulative monthly numbers of S. aureus bacteraemia Revised maximum cumulative monthly numbers of C. difficile to achieve reduction expectation Revised maximum cumulative monthly numbers of S. aureus bacteraemia to achieve reduction expectation Current cumulative monthly rate of C. difficile /100,000 population Current cumulative monthly rate of S. aureus bacteraemia /100,000 population Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr What are the challenges? E. coli Blood Stream Infection (BSI): The new reduction expectation target for all Health Boards in Wales is a rate of no more than 67/100,000 population. The E. coli reduction expectation for Hywel Dda University Health Board (HDUHB) for 2017/18 is 30%. May 2017 data indicates there were 36 E. coli BSIs; 22 of these blood cultures were taken within 48 hours of admission; Hywel Dda University Health Board Integrated Performance Assurance Report 27

43 Enhanced surveillance on these infections is in progress; To date with the exception of 1 case, the infections relate to Urinary Tract, Hepatobiliary, Respiratory or other Abdominal Sepsis secondary to malignancy. C. difficile Infection (CDI): The reduction expectation target for C. difficile has been reduced this year to a rate of 26 per 100,000 population: May data indicates that there were 20 CDI; 8 were classified as Community acquired, 1 relapse and 1 transfer from another Health Board; There were no hospital outbreaks of CDI during 2016/17; Root Cause Analysis indicates that Antibiotic usage is a significant risk factor and a contributory factor in 90% of cases; The high incidence of Respiratory Infection evidence in the Top 20 Discharge Diagnosis, is contributing to antibiotic prescribing. S. aureus Blood Stream Infection (BSI): The reduction expectation for S. aureus remains at 20 per 100,000 population: There were 14 S.aureus BSIs in April 2017, 9 of which are deemed community acquired and were present on admission to hospital, and not associated with a previous admission to hospital; Of the remaining five, one was MRSA BSI related to complex health condition. What is being done? E.coli Work continues towards developing an integrated Acute and Community Infection, Prevention and Control (IP&C) Service across Hywel Dda University Health Board (HDUHB), with appointment of an Advanced Nurse Practioner (from within existing resources), to work across the Health Economy, with partners focusing on health promotion and vaccine preventable diseases. Further discussion to be held on an All Wales basis with Public Health Wales (PHW) in relation to Public Awareness; Due to the increased workload associated with the enhanced surveillance of E. coli BSIs, findings in future will be reported one month retrospectively; A Prevalence survey of HCAI and Device Usage in all in-patients is planned for the first 2 weeks of June; Review of Sepsis Screening criteria to determine the impact of Sepsis 6 on blood culture sampling, antibiotic prescribing and patient outcomes; Further discussion is needed on an All Wales basis regarding Sepsis Screening criteria and a standardised approach; Health Board projects relating to prevention & management of Urinary Tract Infections & Hydration will be presented at the All Wales Workshop on the 20 th June; A further project exploring the HOUDINI principles, relating to urinary catheterisation, will be taken forward with the Continence Team. C. difficile The high incidence of Respiratory Tract Infection and corresponding high use of Co- Amoxiclav has been recognised and a review of current antibiotic policy is underway, with consideration to a switch to Amoxicillin; Stool sampling protocols have been reviewed in line with Evidence Based Guidance. Further discussion is needed on an All Wales basis to standardise surveillance parameters; Antimicrobial drug charts are due to be piloted in Glangwili General Hospital (GGH) in June to improve antibiotic stewardship; Funding has been approved for a Community Antibiotic Pharmacist to review prescribing in Primary Care; Hywel Dda University Health Board Integrated Performance Assurance Report 28

44 Discussing the potential for an interventional study for Procalcitonin testing in an admission unit to the determine the impact on antimicrobial prescribing; World Health Organisation Hand Hygiene Day on May 5 th was promoted on all sites with the message Clean your hands stop the spread of drug-resistant germs! A promotional visit was also made to Folly Farm to raise awareness amongst the public of the importance of hand hygiene and vaccination; A series of Task & Finish Groups have been established to improve the uptake of Influenza vaccine to reduce the burden of vaccine preventable diseases. S. aureus The STOP campaign was re launched in May to reduce inappropriate usage of indwelling medical devices (peripheral venous catheters and urinary catheters). The Infection Prevention Team have delivered County based training sessions for all Care Home staff during May. The focus will be on rolling out the training on the prevention, identification and management of Urinary Tract Infections, which incorporates advice on good hydration and appropriate urine sampling. When can we expect improvement and by how much? E. coli: This is a new reduction expectation which incorporates a significant number of Community Acquired Infections. The drivers for E. coli BSI have been identified (see chart below). Service and Improvement Programmes are being developed in order to work towards achieving this target. C. difficile: The Health Board has not achieved the target for this month and more work is required in order to provide assurance that antimicrobial prescribing is appropriate and compliant with best practice. S. aureus bacteraemia: The incidence of Community Acquired Infection and medically complex patients, once again demonstrates how difficult it is to achieve the expected reduction target. Current focused service improvements relate to reduction in device usage and a review of the Sepsis Screening Tools. Hywel Dda University Health Board Integrated Performance Assurance Report 29

45 How does this impact on both patients and finances? Each Hospital Acquired Infection is estimated to increase the average length of stay by 11 days, together with additional pain and suffering which cannot be quantified. In 2014 the National Institute for Health and Care Excellence (NICE) attached a cost of 636 for each in-patient each day. It is not possible to quantify the impact of admission avoidance through infection prevention strategies. Currently marginal gains are being monitored. An automated infection surveillance system soon to be implemented across Wales will facilitate the monitoring, scrutiny & assurance reporting of this key delivery target, once the interface with the Patient Administration System is completed. Hywel Dda University Health Board Integrated Performance Assurance Report 30

46 2 Safe Care Exception Report Lead Executive Mandy Davies Patient Safety Senior Responsible Officer Sian Passey Where are we and are we on target? Serious Incidents Reported to Welsh Government (WG) At 31 st May 2017, 277 Serious Incidents have been reported since 1 st April 2015, which are categorised as follows: Category Total Absconded Patient 3 Alleged Abuse 7 Data Breach 2 Homicide 3 Infection Control 28 IRMER 12 Pressure Damage 100 Retained Foreign Object 2 Self Harm 3 Serious Harm 35 Service Provision 1 Suspected Suicide 20 Under 18 Admission 22 Unexpected Death 25 Women and Children 12 Wrong Site Surgery 2 Total 277 Of the 277 Serious Incidents reported, 179 have been closed, with 98 remaining open to Welsh Government, as shown in the table below: Area Type of Incident Open more than 6 months Open less than 3 months Grand Total Community Service Carms Pressure Damage Community Service - Ceredigion Pressure Damage Community Service - Pressure Damage Hywel Dda University Health Board Integrated Performance Assurance Report 31

47 Area Type of Incident Open more than 6 months Open less than 3 months Grand Total Pembrokeshire Serious Harm 1 1 Alleged Abuse 3 3 Serious Harm 3 3 Mental Health/Learning Suspected Suicide Disabilities Under 18 Admission 2 2 Unexpected Death Primary Care Unexpected Death 1 1 Scheduled Care Unscheduled Care Infection Control 1 1 Pressure Damage Serious Harm Unexpected Death Infection Control IRMER Pressure Damage 1 1 Self Harm 1 1 Serious Harm Unexpected Death 1 1 Unexpected Death Women & Children's Health Women and Children 3 3 Grand Total There is a 60 working day target to investigate and close all Serious Incidents. As at 31 st May 2017, 45% of closures were within the 60 day target compared to 40% in April 2017, 42% in March and 44% in February; The last Never Event was reported in April What are the challenges? The 6 month feedback report from Welsh Government was due at the end of May However, they have already highlighted that the total number of overdue closures are increasing, and it has been noted that although closure forms are being submitted on a regular basis, the volume is insufficient to have a positive impact on reducing the overall number of closures overdue. What is being done? Review of Serious Incident Processes A review of the management of Serious Incidents is underway, with benchmarks being sought from various NHS Wales organisations. Falls Investigation Workshop A Falls Investigation Workshop was run on 25 th May, with good attendance from Nursing and Pharmacy. A number of investigations were completed on the day, with closure forms also completed. These closures are underway and are subject to the Health Board s internal governance processes, before sending to Welsh Government for closure. Meetings with Service Areas Meetings have been arranged with Service Leads in order to identify barriers to the investigation and closure of these Serious Incidents. When can we expect improvement and by how much? It is expected that by June, the following actions will have been taken: Review of Serious Incident processes with a new process implemented; Hywel Dda University Health Board Integrated Performance Assurance Report 32

48 Inpatient fall Serious Incidents will be investigated and closure forms completed and sent to Welsh Government; Meetings with service areas will have been undertaken and a way forward planned to close any Serious Incidents which fall under their remit. How does this impact on both patients and finances? Comprehensive investigation and action planning will inform service improvement activities, which should result in better and safer care for patients. This in turn will have an impact on monies used following on from complaints and redress. Welsh Government Patient Safety Solutions - Alerts & Notices 8 Welsh Government Safety Alerts have been issued since June of these Alerts are overdue for compliance, with the Health Board currently compliant with 5/6 (83%) Safety Alerts; 36 Welsh Government Safety Notices have been issued since they were first published in June of these Notices are overdue for compliance, with the Health Board currently compliant with 31/33 (93%) Safety Notices. What are the challenges? Regarding the non-compliant Alerts/Notices, please see below for the following updates: Patient Safety Alert PSA003 - Safer spinal [intrathecal], epidural and regional devices: Work continues to bring the Health Board into compliance with more aspects of the alert being compliant. This is being managed by the Health Board s Medical Devices Group via a dedicated Task and Finish group, chaired by the Assistant Director of Therapies and Health Sciences, with appropriate support and clinical advice. Recent reviews have shown that none of the Health Boards in Wales are compliant with this alert. Regarding the non compliant Notices, these are reported in detail via the Quality, Safety and Experience Assurance Committee (QSEAC). It is worth noting that two of the notices require considerable investment to achieve compliance, one which would require a significant investment in Pharmacy staff to achieve extended normal working across 7 days, and one which requires significant capital investment to change the drugs cupboards in use across large parts of the Health Board. The Board accepts this risk. Patient Safety Notice PSN028 - Medicines Reconciliation: Reducing the risk of serious harm; Patient Safety Notice PSN030 - The safe storage of medicines: Cupboards. The Alerts and Notices below have been issued by Welsh Government, but are not yet overdue for compliance. An update is provided below: Patient Safety Alert PSA007- Restricted use of open systems for injectable medication: This work is being led by the Theatre managers. The required compliance date for this Alert is August 2017; Patient Safety Alert PSA008 Nasogastric tube misplacement: Continuing risk of death and severe harm; Patient Safety Notice PSN034 - Supporting the introduction of the National Safety Standards for Invasive Procedures: An implementation group has been formed with the aim of bringing the Health Board into compliance by the required date of September 2017; Patient Safety Notice PSN036 Estates department are taking the lead on this Notice; Patient Safety Notice PSN037 Resources to support the safety of girls and women who are being treated with Valproate. Hywel Dda University Health Board Integrated Performance Assurance Report 33

49 National Patient Safety In addition to the Safety Alerts, the Health Board is currently non-compliant with a National Patient Safety Agency (NPSA) Rapid Response Report published in 2009: Preventing delay to follow-up for patients with glaucoma. An update was presented at the Hywel Dda University Health Board (HDUHB) QSEAC meeting in February It was noted that the Health Board has made further progress in meeting the recommendations set by the National Institute for Health and Care Excellence (NICE) in relation to the Alert issued in The report identifies that full compliance with this alert can only be achieved if the Health Board increases its current Ophthalmology clinic capacity and thus can provide a safe and sustainable Eye Care service across the region. This will provide a particular challenge not only for Hywel Dda, but for all Health Boards where it is estimated that 42,000 patients are currently waiting for follow-up Eye Care appointments across Wales. Considerable work has been undertaken; however the Health Board is not yet compliant with this Alert. Overall, the Health Board s compliance against Patient Safety Alerts and Notices is better than other Health Boards across Wales. What is being done? A detailed report was presented at QSEAC in April 2017 which covers all of these areas. When can we expect improvement and by how much? The major challenge will be to the Notices referred to above, but all other Alerts are being progressed and are subject to bi monthly scrutiny through the QSEAC Dashboard. How does this impact on both patients and finances? Achieving compliance with Patient Safety Alerts and Safety Notices will minimise the risk of harm to patients. Robust investigations and learning from events will improve the quality of care delivered to patients. Hywel Dda University Health Board Integrated Performance Assurance Report 34

50 2 Safe Care Exception Report Lead Executive Mandy Davies Senior Responsible Officer Chris Hayes Healthcare Acquired Pressure Sores in a Hospital Setting Where are we and are we on target? Table 1: Number of Pressure Sores against projected target Table 1 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Total Projected Health Board Target per Month Total Actual Health Board Numbers per Month Table 2: Number of patients with Pressure Sores in month Table 2 Health Board total number of Patients who developed any grade of Pressure Sores Health Board total number of Patients who developed grade 3, 4 and unstageable Pressure Sores Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar Total Table 3: Number and percentage of avoidable/unavoidable Pressure Sores Table 3 Avoidable Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar % 47.4% 40.0% Total Un avoidable % 52.6% 60.0% Hywel Dda University Health Board Integrated Performance Assurance Report 35

51 Unavoidable Avoidable Table 4: Avoidable/unavoidable Pressure Sores per grade Table 4 Apr 2017 May 2017 Grade Grade Grade STDI 4 3 Unstageable 2 0 Grade Sub total 7 9 Jun 2017 Jul 2017 Aug 2017 Grade Grade Grade STDI 4 1 Unstageable 0 0 Grade Sub Total Total The cumulative number of Hospital Acquired Pressure Sores for the period April to May 2017 was 40, which matches the projected Health Board (HB) target. What are the Challenges Of the 40 incidents reported, 16 were deemed to be avoidable (40%). The average percentage of avoidable Pressure Sores in 2016/17 was 49%. The table below gives a breakdown of each incident in April and May 2017: (A patient may have more than one reason why the Pressure Sore was deemed avoidable) Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Definitions* Reason April 2017 May 2017 Did not evaluate the person s clinical condition and Pressure Sore risk factors Did not plan and implement the interventions that are consistent with the person s needs and goals and recognised standards of practice Did not monitor and evaluate the impact of the interventions Did not revise the interventions as appropriate Recognition (including incident reporting) 3 2 Incomplete documentation risk assessment 0 0 External Devices (e.g. anti-embolic stockings, slippers, oxygen mask/cannula) 0 3 Patient Positioning 0 2 Incomplete documentation no care plans in place Incomplete documentation lack of evidence of ongoing monitoring/evaluation (e.g. incomplete intentional rounding document) Failure to monitor equipment (e.g. dynamic mattress left unplugged) Delay in putting appropriate equipment into place (e.g. delay in dynamic mattress being put into place). Inappropriate equipment (e.g. dynamic mattress not used when indicated) Definitions of avoidable damage as defined by the Department of Health/National Patient Safety Agency (2010) as referenced in the All Wales Guidance Pressure Ulcer Reporting and Investigation (2013). 0 0 Mar of the 40 incidents (62.5%) reported are Pressure Sores to heels. Heels Apr (57% of the total) May (68% of the total) Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Hywel Dda University Health Board Integrated Performance Assurance Report 36

52 When can we expect improvement and by how much? As predicted, the figures for 2016/17 did not achieve the expected percentage reduction, and the final figure for the number of incidents for the year showed a percentage increase of 34%. The aim in 2017/18 is to reduce the number of Pressure Sores by 5%. What is being done? Scheduled Care are going to test the use of Pressure Damage Scrutiny Meetings as of June 2017, with the intention of reviewing each incident to identify any themes, actions and opportunity for shared learning; Health Board representatives are continuing to contribute to the national discussions currently taking place on the Welsh Government indicators, to ensure the Health Board is in a position to provide robust data against the agreed indicators. The proposed indicators are the number of patients who developed any grade of Pressure Sore within the month, and the total number of patients who developed grade 3, 4 or unstageable Pressure Sores within the month. To date, the Health Board has reported on the number of incidents not the number of patients. There are concerns within the Health Board that the change to the number of patients will mean the true picture is not being shown, and will result in limited ability to compare to previous years. This report includes the number of patients with Pressure Sores within the month, but the Health Board will also continue to report the number of incidents; A Task & Finish group has been set up to determine the operational procedures for the mattress storage facility in Prince Philip Hospital (PPH); The Health & Safety Executive (HSE) has reviewed the practices of the Health Board in relation to the maintenance and service of dynamic mattresses as a result of an incident involving a member of staff. A HSE order was put into place and a Health Board action plan has been developed; Two wards in Glangwili General Hospital (GGH) were testing the use of two different Hybrid Mattresses. One Orthopaedic ward has discontinued the pilot, as five incidents of avoidable Pressure Sores to heels were reported in the 8 week pilot period, compared to five incidents for the whole of the preceding 12 months. The investigations identified that the damage occurred as a result of a design flaw with the mattress, when used in conjunction with the Orthopaedic wedge. The other ward is continuing with the pilot of a different mattress; the Tissue Viability Team is closely monitoring the situation and are working with the operation team to evaluate their effectiveness; A Situation, Background, Assessment Recommendation (SBAR) has gone to the Senior Nurse Management Team (SNMT) around the work to date on foot care assessment, with the recommendation that a Task & Finish Group is set up to oversee the implementation of the group s work to date. How does this impact on both patients and finances? Pressure Sores remain a serious and potentially life-threatening problem across all age groups, from the very young to the very old and across all medical specialties and care settings. Overall, up to 4 billion (4% of NHS spending) is spent treating Pressure Sores and related conditions annually, with individual costs of treating the most severe cases ranging from 11,000 to 40,000. Hywel Dda University Health Board Integrated Performance Assurance Report 37

53 3 Effective Care High Level Overview Lead Executives Phil Kloer, Jill Paterson, Mandy Davies, Karen Miles, Joe Teape Hywel Dda University Health Board Integrated Performance Assurance Report 38

54 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Number of Patients Number per 10,000 population 3 Effective Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Julie Denley Delayed Transfers of Care Mental Health (Reduction Target) Effective Care Target May 2017 (monthly) April 2017 (monthly) March 2017 (monthly) May 2016 (monthly) Delayed transfer of care delivery per 10,000 LHB population mental health (all ages) 12 month reduction trend 4.0 G Where are we and are we on target? As at the end of May 2017, the reduction (12 month trend) target has been met. The latest All Wales data published in May 2017 ranked Hywel Dda University Health Board (HDUHB) 5 th out of 7, with a DTOC rate of 4.0. The All Wales performance was 3.4. The table below details the Local Authority (LA) split, year on year: Delayed Transfers of Care Mental Health (Reduction target) - year on year Performance (May 2017) Performance (May 2016) Performance (May 2017) Performance (May 2016) Carmarthenshire Local Authority Ceredigion Local Authority Pembrokeshire Local Authority Health Board In June 2016 the population estimates used were updated to the 2015 mid year estimates Delivery per 10,000 population (all ages) - year on year Number of DTOC - monthly Hywel Dda University Healthboard - Mental Health Mental Health DTOCs (Local authority) Rolling 12 month DTOC delivery per 10,000 population (all ages) 2016/17 Operational Plan Profile What are the challenges? One person shown as having a longstanding DTOC is awaiting a suitable cohort of other clients to be identified, in order to progress the bespoke commissioning of a new placement for four people with complex needs. Hywel Dda University Health Board Integrated Performance Assurance Report 39

55 Mental Health adult inpatient beds are currently running at over 100% capacity and this position has been sustained throughout May The position in terms of older adult Mental Health DTOCs has fluctuated over the year. The main reasons for delays are due to awaiting placements in care homes, waiting for specialist beds to become available, and home of choice or family being undecided. The complexity of older people needing placements has changed and the private sectors are struggling to meet very complex needs. Recently a number of applications have not been agreed by the Health Board, to ensure the correct placement fit for the person and the need to avoid repeat admissions. What is being done? Service Managers are working closely with the commissioning team to ensure that suitable placements are facilitated; and clinicians are actively attending joint Local Authority panel meetings. Care Coordinators are prioritising people who are currently DTOCs and escalating any barriers to placement to the relevant Service Managers for action. As part of a Medium Term Plan, the Directorate is currently exploring a repatriation project to release funding for developing local service, in conjunction with third sector parties. This work is specifically for females with Borderline Personality Disorder to address a local need and gap. An extraordinary meeting has been held with Heads of Service, Service Managers and Ward Managers to review all inpatients and consider actions to relieve bed pressures, some of which related to DTOC and people with a long length of stay. Weekly progress and performance meetings take place with operational and commissioning services, and this appears to be having a favourable impact on adult services. A revised process for agreeing funding for joint Continuing Health Care (CHC) and Mental Health (MH) placements has been developed. In relation to the longstanding client with a Learning Disability, a suitable building has now been identified and architects have drawn up plans for an annex for the client. The property will provide accommodation for four people, with this in mind, a review of Out of County placements is also being undertaken, to see if people can be moved closer to home. Some suitable people have now been identified as a potential match for the beds, and the clinical team are exploring this further. Older Adult Mental Health Services engage in weekly meetings held to consider all DTOCs within Prince Phillip Hospital and Glangwili General Hospital, in order to ensure there are ongoing discussions with leads within Social Care to support discharge planning. Meetings with Continuing Health Care (CHC) colleagues and the County Teams are scheduled and a plan to develop a clear strategy for joint working between Mental Health Services and the Continuing Healthcare team has been agreed, to ensure maximum support to the Care Home sector and effective support for those in need of long term care. An Intermediate Care Fund has been prepared and submitted for consideration, to enable the development of Mental Health Care Home support to prevent placement breakdown. A home of choice policy is being developed by the Community Primary Care Manager and the County Director, who are leading this work on behalf of the Health Board. A National Policy is also due to be issued by Welsh Government (WG). When can we expect improvement and by how much? There has been a significant in month improvement of adult age people recorded as having a delayed transfer of care (only one person). The performance against the target is likely to Hywel Dda University Health Board Integrated Performance Assurance Report 40

56 fluctuate in the short to medium term as the longer term solutions are progressed to ensure effective onward transitions. The number of older adults subject to a delayed transfer of care remains high, and are unlikely to reduce quickly, as this is dependent on strengthening the independent sector for both older adults with dementia and challenging behaviour. It is anticipated that the client with Learning Disabilities could be discharged in approximately four to five months. The Directorate will aim to continue to reduce the significant variation in the number of delays seen monthly. How does this impact on both patients and finances? Almost all patients have been admitted locally despite the delayed transfer of care position. The continued inability to source appropriate placements mean some people are not being cared for in the most appropriate and least restrictive environment to meet their needs, and this can have an impact on other clients. As appropriate placements become available, there will be an increase in the Continuing Healthcare spend. Hywel Dda University Health Board Integrated Performance Assurance Report 41

57 3 Effective Care Exception Report Lead Executive Joe Teape Senior Responsible Officer County Directors Delayed Transfers of Care Non Mental Health (Reduction Target) Effective Care Target May 2017 (monthly) April 2017 (monthly) March 2017 (monthly) May 2016 (monthly) Delayed transfer of care delivery per 10,000 LHB population non mental health (aged 75+) 12 month reduction trend 55.3 G As at the end of May 2017, the reduction (12 month trend) target has been met. The latest All Wales published data ranked Hywel Dda 1 st out of 7, with a DTOC rate of This is significantly better than the All Wales performance of The table below details the Local Authority (LA) split, year on year. Delayed Transfers of Care (DTOC) Non Mental Health (Reduction target) - year on year Performance (May 2017) Performance (May 2016) Performance (May 2017) Performance (May 2016) Carmarthenshire Local Authority Ceredigion Local Authority Pembrokeshire Local Authority Health Board In June 2016 the population estimates used were updated to the 2015 mid year estimates Delivery per 10,000 population (Age 75+) - year on year Number of DTOC - monthly Whilst recognising the challenge of continued pressures within the acute hospitals, Counties continue to work collaboratively with their partners to minimise DTOC cases and bed days lost to the organisation. This is demonstrated in the reduction from 21 cases in April 2017 to 15 in May Hywel Dda University Health Board Integrated Performance Assurance Report 42

58 What are the challenges? The challenge is to reduce not only the number of DTOC counted on the Census date, but to also reduce the associated number of days lost and improve other discharge rates for patients, where the Acute Medical episode has ended, specifically: Accurately reflecting DTOC within the Acute and Community Hospital sector; Ensuring policies and processes within the Health Board (HB) and Local Authority (LA) do not delay discharges e.g. Continuing Health Care (CHC) processes within the Health Board and eligibility panels within the Local Authority; Ensuring timely and efficient organisation of assessment processes and Multi-Disciplinary Team (MDT) meetings, which underpin discharge planning to accommodate all disciplines; Supporting ward areas where staff shortages or inexperienced staff may not understand the necessity for early discharge planning; Increased demands on Community Nursing service of non-commissioned activity e.g. Leg Ulcer Clinics; There is limited availability of commissioned service specifically for Packages of Care (POC), either through CHC or LA; Communication at ward level, the wider multi disciplinary team and to external agencies can be difficult; There remains a current challenge within Carmarthenshire where one of the Domiciliary Care Agencies are finding it difficult to recruit staff, which may lead to delays in providing packages of care. Across the Hywel Dda footprint, there are issues with the provision of timely domiciliary care packages to support discharges. Recruitment and retention remains a challenge for domiciliary care providers. What is being done? There is a pro-active process in place to manage the non-mental health delays, these include: Senior level reviews are undertaken of the daily Medically Fit Working List; The working list is being reviewed to confirm definition and improve the functionality of the reporting spreadsheet; An escalation process is in place, to ensure identified actions are implemented to facilitate complex discharges; Weekly DTOC meeting with senior representation from the Health Board and Local Authority; Daily focus on the Medically Fit Working List, focusing on facilitating discharge and challenging delays; Trends are being monitored to identify capacity and commissioning gaps; Health Board Discharge and Transfer of Care Policy has been updated (June 2016); Complex Patient Discharge Pathways have been rolled out across all hospital sites to provide guidance for ward based staff in ensuring safe discharge; The Home of Choice Policy has been re-written. This policy was presented to the Clinical Policy Group in May 2017, who have recommended further internal and external consultation with partner agencies to meet the requirements of the legal framework; Investment of teams at the front door and within the hospital, to improve patient flow and facilitate discharge processes has occurred at all acute hospitals; Additional provision commissioned of Interim Beds, providing an alternative environment to the acute sector for assessment by a Community MDT; Commissioning and resourcing discussions continue to take place with LAs where outsourced reablement and domiciliary care provision is contributing to delays in sourcing POC; Hywel Dda University Health Board Integrated Performance Assurance Report 43

59 The continued emphasis of Board rounds on all wards, which is an MDT approach when Estimated Date for Discharge (EDD) are agreed, referrals for assessment can be made and actions can be followed through. Further improvements are being explored through Red/ Green methodology; Weekly commissioning and eligibility panels to improve the efficiency of these processes have been introduced in March 2017 which continue to reduce delays in process; Further development and growth of Community Services, to prevent avoidable admissions. This has been achieved through Intermediate Care Fund (ICF), cluster funding and Integrated Medium Term Plan (IMTP) investment; Collaborative working between the Health Board and Local Authority underpins all actions. How does this impact on both patients and finances? Prolonged length of stay (LOS) can have a negative impact on patients wellbeing and long term outcomes; High LOS puts patients at risk of Hospital Acquired Infections and increased dependency; Assessments undertaken in the correct environment outside of the General Hospitals has been proved to be more effective, with appropriate decisions made at the right time; Financially it is more cost effective to discharge to assess as the cost of a Nursing Home or Residential Home bed is less than that of an Acute bed, and also benefits the patient due to positive long term outcomes. Hywel Dda University Health Board Integrated Performance Assurance Report 44

60 4 Dignified Care High Level Overview Lead Executives Joe Teape & Mandy Davies 4 - DIGNIFIED CARE - I am treated with dignity and respect and treat others the same Reporting Frequency - Monthly Historical Data Dignified Care Target April 2017 (monthly) Exception Report March 2017 (monthly) March 2017 (monthly) April 2016 (monthly) The percentage of patients who had their procedures postponed on more than one occasion for non clinical reasons with less than 8 days notice and are subsequently carried out within 14 calendar days or at the patient s earliest convenience 12 month improvement trend 33.3% R Yes 41.7% 41.7% 63.2% Dignified Care % compliance with Hand hygiene (World Health Organisation (WHO) 5 moments) Reporting Frequency - Monthly Target April 2017 (monthly) Exception Report March 2017 (monthly) Historical Data March 2017 (monthly) April 2016 (monthly) 95% 90% A No 90% 90% 93% Reporting Frequency - Monthly Historical Data Dignified Care Target April 2017 (monthly) Exception Report Quarterly March 2017 (monthly) March 2017 (monthly) April 2016 (monthly) Percentage of Nutrition Score Completed and Appropriate Action Taken within 24 hours of admission 85% 90.1% G No 90.2% 90.20% 90.90% Dignified Care Evidence of how NHS organisations are responding to patient feedback to improve services Percentage of the population in Wales who are registered with dementia with their GP practice Reporting Frequency - Annually Target Exception Report Historical Data Historical Data Historical Data 2014//2015 (financial year) 2013/2014 (financial year) 2012/2013 (financial year) Revised target for Not Available Not Available Not Available Not Available 2016/17 reporting Annual improvement 2015/2016 (financial year) 43.4% G 41.6% 42.3% 39.6% Evidence of public engagement events/opportunities offered locally by health boards and trusts Annual improvement New target under development for 2016/17 reporting No Not Available Not Available Not Available Percentage of GP practice teams that have completed mental health Direct Enhanced Services (DES) in dementia care or other directed training Annual improvement 24.1% R 29.6% 46.4% Not Available Dignified Care Percentage of NHS employed staff who come into contact with the public who are trained in an appropriate level of dementia care Reporting Frequency - Bi-Annually Target 2016/2017 (financial year) Exception Report 2015/2016 (financial year) Historical Data 2014/2015 (financial year) 2013/2014 (financial year) New target for 75% No Not Available Not Available Not Available 2016/17 reporting Reporting Frequency - To be confirmed Historical Data Dignified Care Timely and responsive handling of concerns and complaints Target To be confirmed 2016/2017 (financial year) Target under development for 2017/18 reporting Exception Report Yes 2015/2016 (financial year) 2014/2015 (financial year) Not Available 2013/2014 (financial year) Hywel Dda University Health Board Integrated Performance Assurance Report 45

61 4 Dignified Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Stephanie Hire Postponed Admitted Procedures - Programme for Government Commitment Where are we and are we on target? The Programme for Government Commitment rules apply to all patients who previously had their operation postponed by the hospital, on more than 1 occasion for non clinical reasons. The commitment is that should this occur, patients should be treated within 14 days or at their earliest convenience. At the end of April 2017, 8 procedures were postponed on more than 1 occasion for non clinical reasons, of which 2 patients could not attend the appointments offered. 2 of the remaining 6 patients were treated within the 14 day programme for Government Commitment (33.3%). The remaining 4 patients have subsequently been treated. The Health Board has not met its 12 month improvement target for the first time in 9 months. The latest All Wales published data ranks Hywel Dda Health Board 4th out of 6. What is being done? Staff are and will continue to work pro-actively with patients, to meet their needs within the required timelines. Ongoing reporting and monthly review of this patient cohort will assist in identifying areas which may be within the Health Board s ability to address. Hywel Dda University Health Board Integrated Performance Assurance Report 46

62 What are the challenges? During April 2017, booking patients within the 14 day government commitment has been compounded by the Easter break, which impacted on elective lists. Additionally it is unclear whether this impacted on patient choice (due to convenience), and they chose a later more suitable date, as this is not always easily recorded on Myrddin. The small number of patients who fall into the government commitment also contributes to the variability in performance. When can we expect improvement and by how much? Having maintained improvement until month 12, the patient management process in place in support of cancellations, and rebooking is overall effective. The objective is to recover performance within month and to sustain improvement understanding mitigation for non compliance through a review process of this patient cohort. This is not separate to prevention of cancellations overall, but an integral part of supporting the patient and their choices in surgery. Hywel Dda University Health Board Integrated Performance Assurance Report 47

63 4 Dignified Care Exception Report Lead Executive Mandy Davies Senior Responsible Officer Louise O Connor Concerns and Complaints Where are we and are we on target? There are currently 2 outstanding complaints for the period 2015/16. There were 3 cases at the time of last month s report. Overall position at month end for Concerns received from 1st April 2017 April 2017 Total number of Formal Concerns received (from 1 st April 2017) May 2017 Total number of Formal Concerns awaiting response (from 1 st April 2016) All Formal Concerns awaiting response (exceeding 6 months) Grade 3 (moderate) Concerns exceeding 3 months (local target) Grade 2 (minor) cases exceeding 30 working days (Welsh Government target) 0 0 PALS (Patient Advice & Liaison Service) Total number received Total number open Total open over 30 working days 0 2 Public Services Ombudsman (excluding primary care) Number of Ombudsman Investigations commenced since April 2016 (7 of these relate to complaints received during 2016/17) Number of new cases received during the month 5 8 Number of Ombudsman Investigations closed concern upheld/partly upheld 0 1 Number of Ombudsman Investigations closed not upheld 0 1 Number of Investigations closed as a result of a proposal accepted by the Ombudsman 0 0 What are the challenges? At the end of the 2016/17 financial year, 40 cases were awaiting a response over 6 months, with 57 of the moderate grade 3 Concerns remaining open over the 3 month target period. There was a marked reduction in those cases awaiting a response over 6 months in April 2017, down to 28, but these have risen to 41 in May, partially due to staff absence within the Complaints team. However, there has been a steady decrease in those cases remaining open over the 3 month target period in May Whilst significant improvement has been made in the timeliness of Concern responses, further improvement is required to ensure the Health Board achieves the 100% compliance target of responding to all Concerns within a 6 month timeframe. It is appreciated there will be exceptions, due to matters outside the control of the investigating team, particularly where expert evidence is required, or where essential information required for the conduct of the investigation is not available. Hywel Dda University Health Board Integrated Performance Assurance Report 48

64 What is being done? The Concerns team continues to work closely with the operational services, to ensure closure of these cases as a priority, in addition to regularly reviewing and identifying the barriers faced at weekly team meetings. The PALS (Patient Advice and Liaison Service) responded to 147 queries in April, with a further 170 queries in May, which on average is three times the number of formal complaints received. Recruitment is currently underway for new members of staff within this team, which will further improve the service that is offered for the benefit of patients and staff alike. The Concerns team is continuing to implement the previously agreed actions, as follows: Concerns leads within Directorates continue to have a positive impact on the monitoring and co-ordination of the investigations; Improved access to monitoring information has been provided to Service Delivery Managers. Dashboards have been, and continue to be set up and made available for ongoing review, and monthly reporting to services has been strengthened; Weekly case review meetings continue to be held within the Concerns Investigation Team, which informs the weekly escalation process of cases which are approaching or exceeding the target; Restructure of the department is ongoing, which will increase the resources to manage claims/redress, PALS and the investigation process. This will enable a faster and more efficient response to low level Concerns and queries; Revisions to the Concerns and Investigation policies/process have been undertaken, which will be reviewed and monitored by the Improving Experience Sub-Committee. When can we expect improvement and by how much? Work is continually ongoing to improve on the current performance of the management of all Concerns, particularly those graded 3 (moderate). What is not clearly shown above, is the much improved picture of the management of grade 4/5 Concerns. In 2015/16, 42 new cases were received, with only 15 of these cases being closed within the year. In 2016/17, 46 new cases were received, in addition to the remainder of the previous year s cases, with 38 cases being closed within the year. Since April 2017, 4 new cases have been received, with 13 cases being closed. The number of grade 4/5 Concerns is at its lowest for some time, currently 26, and whilst 7 of these have breached the six month target, all are nearing conclusion. It is envisaged that based on current performance, all future grade 4/5 cases will be responded to within the target of six months. Hywel Dda University Health Board Integrated Performance Assurance Report 49

65 5 Timely Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 50

66 5 Timely Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 51

67 5 Timely Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 52

68 5 Timely Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 53

69 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Target % 5 Timely Care Exception Report Lead Executive Jill Paterson Senior Responsible Officer Jill Paterson Ambulance % of Red Call Responses within 8 Minutes Timely Care Target May 2017 (monthly) April 2017 (monthly) March 2017 (monthly) May 2016 (monthly) The percentage of emergency responses to red calls arriving within (up to and including) 8 minutes 65% Est 73.1% G 78.3% 75.0% 68.8% Where are we and are we on target? % of Red call responses within 8 minutes 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 57.6% 63.2% 63.8% 67.4% 63.0% 61.8% 67.4% 68.8% 68.0% 71.5% 72.9% 69.6% 68.9% 67.2% 67.6% 76.1% 63.2% 75.0% 78.3% 73.1% National Target HDUHB Actual Performance Provisional May 2017 data showed Red call performance at 73.1%. There were 208 calls of which 152 were met within the 8 minute target (April 2017: 207 calls of which 162 were met within the 8 minute target). In all localities the Welsh Government (WG) target of 65% was met. The latest All Wales published data ranks the Health Board 5 th out of 7, with All Wales performance at 80.5%. The table below shows the month on month breakdown by County and call type: Red Calls May 2017 April 2017 Carmarthenshire 71.6% 78.8% Ceredigion 72.5% 82.9% Pembrokeshire 76.3% 75.3% Hywel Dda 73.1% 78.3% Amber Calls Carmarthenshire 65.7% 64.7% Ceredigion 69.3% 69.8% Pembrokeshire 75.6% 75.9% Hywel Dda Total 69.8% 69.5% Amber Calls Amber 1-20 minute target 1,780 1,661 Amber 2-30 minute target P16 Treat at Scene Carmarthenshire 8.3% 7.5% Ceredigion 11.3% 8.3% Pembrokeshire 11.4% 10.3% Hywel Dda 9.9% 8.6% Hywel Dda University Health Board Integrated Performance Assurance Report 54

70 P17 Referred to Alternative Provider Carmarthenshire 5.6% 5.2% Ceredigion 9.7% 10.2% Pembrokeshire 8.0% 9.3% Hywel Dda 7.2% 7.6% P18 Conveyance Rates Carmarthenshire 78.0% 78.9% Ceredigion 69.0% 70.0% Pembrokeshire 72.1% 68.5% Hywel Dda 74.4% 73.9% HDUHB Crews - Lost Hours Notification to Handover by May 2017 April 2017 Site Bronglais Glangwilli Prince Phillip Withybush Morriston Singleton Amber combined calls showed a slight increase on the April figure of 2,749 calls. The total emergency demand across all categories, Red, Amber and Green was 3,923 (April 3,698). Out of area activity continues to show a sustained reduction following the introduction of the enhanced performance plan, to ensure that P1/P2 priority postings will be covered at all times. It may still be necessary to deploy vehicles to Red 1 or Amber 1 if they are the closest available vehicle but the vehicle is expected to be returned to area at the conclusion of the detail (postings are ranked in order of priority, i.e. P1 will be the highest demand area, P4 would be the lowest demand area): o Hywel Dda to ABMU 118 responses; o ABMU to Hywel Dda 72 responses; o Hywel Dda to Powys 39 responses; o Powys to Hywel Dda 35 responses. What are the challenges? The service is challenged in Hywel Dda due to the geography of the region, making the 8 minute response target more challenging, as well as the issue for Hywel Dda ambulances being deployed into Abertawe Bro Morgannwg University Health Board (ABMUHB), together with some deployments into Betsi Cadwaladr University Health Board (BCUHB) and Powys. Notification to handover across Hywel Dda continues to maintain the month on month reduction in lost hours, although there was a marginal increase from the April figure of 9 hours, and this remains the main focus, together with handover to clear. What is being done Recruitment continues across all localities, with a further recruitment event being held on the 26 th June. Currently there are 4 Trainee Emergency Medical Technicians (EMT), 4 Paramedic and 4 Urgent Care (UCS) vacancies. Ambulance Practitioners (AP) continue to work across both organisations, with an additional trial currently being undertaken within the North Pembrokeshire GP cluster which concludes on the 21 st June, following which an evaluation will be undertaken. Hywel Dda University Health Board Integrated Performance Assurance Report 55

71 5 Timely Care Exception Report Lead Executive Joe Teape Senior Responsible Officers Hospital Site General Managers & County Directors Timely Care Number of ambulance handovers over one hour Unscheduled Care Services Target May 2017 (monthly) April 2017 (monthly) March 2017 (monthly) May 2016 (monthly) 0 37 R The percentage of patients who spend less than 4 hours in all major and minor emergency care facilities from arrival until admission, transfer or discharge The number of patients who spend 12 hours or more in all hospital major and minor care facilities from arrival until admission, transfer or discharge 95% 87.5% R 87.5% 85.9% 84.5% R Where are we and are we on target? Demand for Unscheduled Care services has grown since last month, but despite this increase, Ambulance Handovers over 1 hour performance has improved, and 4 hour A&E performance has remained static while 12 hour A&E performance has deteriorated. The latest All Wales data ranks the Health Board 2 nd for Ambulance handovers over 1 hour and 4 hours performance, and 3 rd for 12 hour performance out of 6 Health Boards. The daily average Ambulance arrivals have increased in May 2017 from 95.4 in April to A comparison of Ambulance arrivals and handover performance cannot be made to the prior year, as not all of the arrivals were captured and reported for Prince Philip Hospital; The daily average of new attendances has increased in May 2017 from 411 in April to 430. New attendances have grown by 2.4% compared to May 2016; The spilt of attendances has moved by 0.9% from Major to Minor from the previous month; 98.8% of patients conveyed to the emergency care facilities by Ambulance during May 2017 were handed over within 1 hour, however 37 patients did wait 1 hour or longer. This is an improvement compared to the previous month, where 62 patients waited over 1 hour; 87.5% of patients spent less than 4 hours in all emergency care facilities from arrival until admission, transfer or discharge. This is an improvement on 84.5% in May 2016; 378 patients spent 12 hours or more in an emergency care facility from arrival until admission, transfer or discharge. This is an increase to the daily average from 9.1 at April to 12.2 at May Hywel Dda University Health Board Integrated Performance Assurance Report 56

72 No. of Handovers May 2017 Ambulance Arrivals Ambulance Handovers Over 1 Hour New Attendances 4 Hour National Target 4 Hour Performance 4 Hour Breaches 12 Hour National Target 12 Hour Breaches 12 Hour Performance Bronglais General Hospital Glangwili General Hospital Prince Philip Hospital Withybush General Hospital ,611 95% 88.4% % 1, ,829 95% 83.8% % ,898 95% 97.1% % ,757 95% 82.3% % Health Board * 3, ,334 95% 87.5% 1, % * The figures for the Health Board include Llandovery and Cardigan Minor Injury units 180 Hywel Dda University Health Board - Ambulance Handovers over 1 hour, Target = Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 BGH GGH PPH WGH HDUHB HDUHB Trajectory Hywel Dda University Health Board Integrated Performance Assurance Report 57

73 No. of Patients % Performance Hywel Dda University Health Board - % new patients spending less than 4 hours in A&E, Target = 95% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Apr-16 May- 16 Jun-16 Jul-16 Aug-16Sep-16Oct-16 Nov-16Dec-16Jan-17 Feb-17Mar-17 Apr-17 May- 17 BGH 89.1% 90.9% 89.6% 90.7% 91.5% 90.4% 87.5% 93.7% 88.8% 87.1% 88.2% 91.6% 90.5% 88.4% GGH 78.8% 78.1% 82.0% 82.7% 80.1% 74.1% 80.9% 80.4% 80.2% 76.3% 80.4% 82.9% 85.3% 83.8% PPH 95.9% 98.2% 96.2% 96.5% 97.8% 97.9% 96.6% 96.9% 98.1% 95.8% 96.7% 95.1% 98.3% 97.1% WGH 72.5% 74.9% 72.1% 83.9% 81.1% 74.9% 78.3% 77.4% 74.1% 75.8% 75.1% 76.7% 78.5% 82.3% HDUHB 83.4% 84.5% 84.2% 87.9% 86.6% 83.5% 85.2% 86.2% 84.2% 82.8% 84.2% 85.9% 87.5% 87.5% HDUHB Trajectory 83.0% 85.0% 86.0% 86.0% 86.0% 87.0% 89.0% 89.0% 87.0% 84.0% 85.0% 88.0% Hywel Dda University Health Board - Number of patients spending 12 hours or more in A&E, Target = Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 BGH GGH PPH WGH HDUHB HDUHB Trajectory Cumulatively to May 2017, new attendances have grown by 2.4% compared to May The variances for year to date new attendances are shown in the table below: Hywel Dda University Health Board Integrated Performance Assurance Report 58

74 Hospital Site Year to Date May 2017 New Attendances Year to Date May 2016 New Attendances Variance Variance % Bronglais 5,026 4, % Glangwili 7,299 7, % Prince Philip 5,686 5, % Withybush 7,243 7, % HDUHB 25,676 25, % The spilt of attendances has moved by 0.9% from Major to Minor, from the prior month; The variances for the split of Major versus Minor are shown in the table below: Average Length of Stay (LOS) Medical Emergency Inpatients including zero days Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May The Average LOS increased to 9.4 days in May 2017, compared to 8.8 days in April What is being done? All hospital sites are aiming to implement the SAFER patient flow model: S - Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A All patients will have an Expected Discharge Date and Clinical Criteria for Discharge. This is set assuming ideal recovery and assuming no unnecessary waiting. F - Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10am. E Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R Review. A systematic Multi Discipline Team (MDT) review of patients with extended lengths of stay (> 7 days stranded patients ) with a clear home first mind set. Whilst the Hywel Dda University Health Board (HDUHB) overarching improved performance is summarised above, the individual acute site performance variances are outlined in further detail below, giving a flavour of their challenges. Bronglais General Hospital (BGH) Where are we and are we on target? Hywel Dda University Health Board Integrated Performance Assurance Report 59

75 During May 2017, the number of ambulance arrivals compared to May 2016 has reduced by 0.1% from 504 to 498. However there has been an increase to the daily average from 15.6 at April to 16.1 at May 2017; 71.1% of ambulances handed over within 15 minutes, similar to the 71.2% May 2016 position. Ambulance handovers over 1 hour performance deteriorated on the May 2016 and April 2017 performance, from 11 in April to 20 in May 2017, and this area continues to receive significant focus; There was a 1.5% decrease in the number of new attendances from 2,650 to 2,611 compared to May 2016, but an increase to the daily average from 80.5 at April 2017 to 84.2 at May 2017; The 4 hour performance has shown deterioration on the May 2016 performance from 90.9% to 88.4%. This will receive enhanced focus to ensure performance recovery. Non Admitted data remains above 95% however. Top breach reason continues to be lack of medical beds compounded by significant community/social capacity issues; 12 hour delays currently stand at 33 for May 2017, which is a deterioration compared to 18 in May The daily average has deteriorated from 0.87 at April to 1.1 at May SAFER implementation continues with the wards, roll out of Red to Green is established and reports through the daily 12.30pm site safety meeting; Non mental health delayed transfers of care (DTOC) remains static at 5 patients. What are the challenges? Bed capacity deficit ongoing focus on admissions/discharges (non admitted performance remains favourable), working with community colleagues. BGH site hosts the busiest Emergency Department (ED) in the Health Board (pro rata) with an average 222 attendances per bed per annum. Despite these challenges performance has been favourable, although there has been a drop in performance in May; Workforce a significant recruitment deficit in nursing and senior medics (Consultant posts and middle grades in Medicine x 2 vacancies) Average Length of Stay (LOS) Medical Emergency Inpatients including zero days Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May May 2017 LOS has increased to 10.1 compared to 8.3 in April. This is reflected in the site pressures, particularly early in the month which were compounded by the number of South Gwynedd patients situated at BGH (15 at its highest point, which is close to 10% of the bed case). This situation improved in late May. What is being done? Dr Phil Jones attends the North GP cluster meeting Progress on agreements and developments for clinical strategy for colorectal surgery; Acute & Community leads met with clinical teams from South Gwynedd (Twywn & Dollgellau). The purpose of the meeting was to build on existing relationships and to improve on the understanding of each other s constraints. Short & medium term actions for improvement were agreed and the meeting will become a quarterly event with rotating locations; Ceredigion Community Management has also met similarly with the clinical leads for Machynlleth to discuss patient flow and different models of working; Commenced daily huddle between acute site leadership and discharge liaison nursing teams to ensure collaborative working and review the work list (delayed transfer of care and medically fit for discharge); Assessing Alternatives to Admission (AA2A) team which is funded by Integrated Care Fund will soon commence 7 day working; Hywel Dda University Health Board Integrated Performance Assurance Report 60

76 Palliative Care improvements new links between Machynlleth & Ceredigion team to provide support, enable discharge, as well as prevent admissions (in partnership with Severn Hospice); 2.5 days per week of dedicated Specialist Palliative Care Nurse support for wards in Bronglais Hospital; Awaiting delivery of treatment chairs to enable commencement of the Ambulatory Care model on site. Recruitment Therapies 6 candidates for 2 posts subject to interview, potential to consider a skill mix review for designated areas as appropriate to enable reduction in the need for agency; Local process for bank booking of shifts will be in place by month end; Recruitment to training posts in Carmarthen will enable dedicated time in the North for local training provision and development of the Band 4 role (Health Care Support Worker development); Plan to advertise for return to practice nurses and to offer annualised contracts to attract agency nurses to take substantive posts; 1 of 2 middle grade posts in A&E now filled. 1 vacancy remains in Emergency, with 2 in Medicine. When can we expect improvement and by how much? There will be significant focus on improved performance to regain and improve upon the benefits seen during March & April. The aim is to regain the 90% plus position during June and continue efforts to reach 95% by September, with an acceptance that performance is likely to drop again during winter. There are a significant number of initiatives in train to try to improve recruitment in all clinical areas. How does this impact on both patients and finances? As a result of recruitment initiatives, the aim will be to reduce agency spend in medics and nursing to support the need for financial recovery. Glangwili General Hospital (GGH) Where are we and are we on target? During May 2017, the number of ambulance arrivals compared to May 2016 has reduced by 2.2%, from 1,225 to 1,198. However there has been an increase to the daily average from 37.3 in April 2017 to 38.6 at May 2017; 82.9% of ambulances handed over within 15 minutes and improved upon the 73.5% May 2016 position. Ambulance handovers over 1 hour performance improved on May 2016 performance from 67 to 10 in May 2017; There was a 2.8% decrease in the number of new attendances from 3,941 to 3,829, compared to May 2016, and the daily average increased from at April 2017 to at May 2017; 4 hour performance has shown an improvement on the May 2016 position from 78.1% to 83.8%. The top breach reason continues to be lack of medical beds followed by orthopaedic bed and A&E clinician; 12 hour delays currently stand at 209 for May 2017, which is a deterioration compared to 150 in May Average Length of Stay (LOS) Medical Emergency Inpatients including zero days: Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May Hywel Dda University Health Board Integrated Performance Assurance Report 61

77 This LOS report now excludes Ceri ward as these patients are Orthogeriatric and not medical admissions. LOS has increased by 1 day from the previous month and is the highest over the last 13 months. The table below shows the LOS for over 28 days and under 28 days: Over 28 days Medical Emergencies Number of Patients Average Length % Bed days Bed days No pts discharged Under 28 days Ave Los Bed days discharged of Stay May , % ,270 Apr , % ,593 Mar , % ,682 Feb , % ,540 Jan , % ,004 Dec , % ,085 Nov , % ,815 Oct , % ,593 Sep , % ,833 Aug , % ,172 Jul , % ,173 Jun , % ,914 May , % ,988 Cumulative ,809 N/A 5, ,799 The bed days lost for the long LOS patients has increased over 5% compared to the previous month. What are the challenges? A&E medical staffing continues to be a concern with only 3 out of 9 middle grade posts substantively recruited to. The consultants will cover gaps where possible but often there is limited cover and no overnight middle grade unless filled by agency. There is a weekly meeting to review the department staffing and longer term locums have been requested via Medacs Healthcare recruitment. Additional Emergency Nurse Practitioner (ENP) shifts are put in place where possible to cover the deficits, with 2 shifts at the weekend. When there are more junior staff, there are increased waiting times to be seen. The A&E clinician breaches are often later in the evening when there are less staff available and there are gaps in the rota. Unscheduled care has 50 whole time equivalent (WTE) trained nurse vacancies, and despite continued local recruitment, this does not deliver an increase in staff, with staff also leaving posts. Active student nurse recruitment is underway with local and international recruitment. Glangwili Hospital has been advised that 10 Core Medical Training posts have not been filled at the second round of Deanery recruitment, which will leave a deficit of junior doctors at 56% of the WTE establishment. These posts have been advertised outside of the Deanery process to recruit sufficient junior doctors. A weekly medical staffing meeting is in place to detail the external recruitment and timelines, and establish when the doctors will be able to participate in the on call rota. The Director of Operations is chairing a Health Board wide meeting to oversee the actions and impact. Overnight patients in A&E requiring inpatient beds continue to cause 4 and 12 hour breaches, also the department is then full and has difficulty in assessing and treating new patients. Hywel Dda University Health Board Integrated Performance Assurance Report 62

78 The hospital continues to see an increase in the acuity and complexity of patients requiring Medical care and supported discharge. Ceredigion County are seconding a nurse to Carmarthen to focus on patients from Ceredigion, to enable timely discharge from the hospital. What is being done? Red and green days have been implemented on all of the Medical wards, and this is now also being supported by the Service Improvement team. 3 wards have been identified for a detailed review and support to reduce delays and improve length of stay. End Pyjama Paralysis has been implemented across the medical wards, where patients are encouraged to dress while in hospital and relatives advised to bring patient s own clothes into hospital. There is a development session in June supported by Pete Gordon from the NHS Emergency Care Intensive Support Team (ECIST) to further embed this process and capture a wider audience of clinical staff. Work is ongoing to further develop and refine the process, ensuring delays are escalated and actioned. Expected date of discharge is a continued focused, and these are in place for all admitted patients, and are updated if the patient s clinical condition changes. Continued work is taking place to ensure patients and relatives are aware of the planned discharge date, to enable earlier plans to be put in place and to reduce delays. The relocation of the Minors pathway will create more space in A&E to see new patients, reduce the number of minor s breaches and significantly improve patient flow in the department. The estate plans have been costed and capital money approval has now been agreed for the building works to commence. The A&E medical and nursing team have developed the operational plan for implementation. The GGH Frailty Operational Group is progressing well with membership from Community, Social Services and Primary Care. Frailty clinics commence in June 2017, supported by Pharmacy, Radiology, Occupational Therapy and Physiotherapy. Ambulatory Care protocols are in place, with further pathways being developed to support patients to be treated as a day case where appropriate, including increased use of the Medical Day Unit. The key area of improvement at GGH is to reduce the number of patients with a LOS over 28 days, and therefore reduce the average LOS of these patients. May 2017 showed the over 28 days accounted for 57% of medical bed occupancy. A review of the long LOS patients from March 17 (Acute and Community) took place on the 30 th May and this is now being collated to ensure actions and improvements are made to the patient pathway. This will be a joint action plan from the Acute, Community and Social care leads. When can we expect improvement and by how much? A revised performance trajectory is being detailed and aligned with the cost improvements that need to be delivered. This will be reviewed with projected recruitment to posts, and delivery of action plans to improve patient pathways. How does this impact on both patients and finances? Financial overspend continues to be a concern with the high number of unfilled posts in A&E medical staff, Unscheduled Care, nursing and backfill for Emergency Nurse Practitioner shifts. Until posts are recruited to substantively, agency will have to be sought to provide basic cover for A&E and ward areas. Prince Philip Hospital (PPH) Hywel Dda University Health Board Integrated Performance Assurance Report 63

79 Where are we and are we on target? During May 2017, the daily average ambulance arrivals have increased from 14.8 at April 2017 to 15.3 at May 2017; 85.2% of ambulances handed over within 15 minutes during May 2017 and there were 3 Ambulance handovers over 1 hour; There was a 3.6% increase in the number of new attendances from 2,797 to 2,898 compared to May 2016, and an increase to the daily average from 92.9 at April 2017 to 93.5 at May 2017; The 4 hour performance for May 2016 was 98.2% compared to 97.1% at May Top breach reason continues to be access to Acute Medical Assessment Unit (AMAU) Clinicians; 12 hour delays currently stand at 5 for May 2017, which is a deterioration compared to 3 in May 2016 and none in April Average Length of Stay (LOS) Medical Emergency Inpatients including zero days Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May This improved by 0.4 days in May What are the challenges? In mid May the decision was taken to return all elective Orthopaedic beds to Orthopaedic use which effectively reduced the number of beds available to emergency medicine by 7. This factor combined with the medically fit running above target, resulted in an increase in 12 hour breaches in May compared to April. In terms of ambulance offload in May 2017, there were a small number of offload delays in excess of 1 hour. The problem arises when multiple ambulances arrive at the same time. There is a physical limit to the amount of patients who can be admitted at one time, so when 3 or more ambulances arrive within a short period, the patients on the ambulances undergo a medical assessment and patients are offloaded in clinical priority, sometimes resulting in delays for patients who have a lower clinical priority. What is being done? As part of the rolling improvement plans PPH launched Red to Green days on Ward 5 in April and based on the positive results will be starting this on a second ward in early June. A PPH workshop on the Red to Green days is planned for the 6 th July with Pete Gordon from the NHS Emergency Care Intensive Support Team (ECIST). Plans for surge areas that do not impact on elective work have been completed and are now subject to a bid from discretionary capital. Carmarthenshire Community Services The Delayed Transfer of Care (DTOC) in Carmarthenshire shows an improved position on last month s census numbers, with 7 patients delayed by either Health or Social Care. Of these, 3 were delayed for Social Care reasons, 2 for health reasons and 2 patients were Out of Area. Of those delayed due to Health and Social Care reasons, a total of 127 days were lost. Improvement continues in relation to previous performance, particularly in the reduced number of DTOC attributed to the Continuing Health Care (CHC) process since the introduction of weekly panels. The paucity of long term domiciliary care provision by the independent sector also remains problematic, and mirrors the national position in this area. What are the challenges? Hywel Dda University Health Board Integrated Performance Assurance Report 64

80 A review of performance against complex discharge standards in Q4 2016/17 has demonstrated that compliance has been variable across all three of the localities. Significant delays have been identified in relation to completion of integrated assessment for care provision on discharge, as well as in the timely availability of care. An audit of the case notes in relation to patients discharged during this quarter highlighted the following as compromising efficient completion of integrated assessment: Outstanding assessments by Physiotherapy, Occupational Therapy, Mental Health Liaison and other clinical specialities, which were required to lawfully complete the integrated assessment; Poor communication between ward nursing, clinical staff and the wider multidisciplinary team (community and hospital based) resulting in delays; Hospital based nursing and clinical staff unrealistic expectations of care provision and paucity of knowledge regarding eligibility and assessment; Fluctuating needs of the patients, making it difficult to determine / agree ongoing care requirements; Family / Carer dispute regarding discharge destination and / or care required. Similarly, the audit identified the following issues in relation to timely availability of care: Changing needs of the patient and the requirement to reassess and review the care and support plan; Continuing Health Care (CHC) commissioning panel held monthly, now being held weekly; Home of Choice process; Family / carer disputes regarding discharge destination and / or care required; Patient being discharged out of area and a reliance on family and social workers in another Authority to adhere to the standards; Legal challenge to transferring patients from their current environment (Court of Protection, Mental Health Legislation); Safeguarding issues; Housing / environmental issues; Paucity of domiciliary social care. What is being done? Despite significant investment in training staff (both nursing and clinical) on frailty and the discharge standards, challenges persist in relation to communication and timely discharge planning. As such, it has been agreed that the existing Transfer of Care Advice and Liaison Service (TOCALS) in both hospitals will be enhanced by additional Occupational Therapists and Social Workers funded by the Integrated Care Fund (ICF). This additional resource will support daily discussions at Board Rounds and will be instrumental in mitigating some of the issues relating to assessment identified in the Q4 discharge review, including eligibility, communication processes and coordination of the integrated assessment process. The Work List has long been considered a valuable tool for indicating pressures within the system. The number of patients on the Daily Work List exceeds the number considered to be acceptable in order to maintain efficient patient flow. This number does however represent around 20% of the total patient number, which the Welsh Government Delivery Unit have suggested in their recent Unscheduled Care report is representative of the proportion of complex inpatients at any one time. The Work List has been revised to support reporting against SAFER methodology and its associated measures. The Work List will be available on SharePoint in June, and administered by a newly appointed administrative officer within the TOCALS team. The Transfer of Care Advice and Liaison Service (TOCALS) continue to support comprehensive Geriatric assessment, to support efficient discharge of complex frail adults at both hospital front door and throughout the hospital. On average this month, between 40% and 50% of patients Hywel Dda University Health Board Integrated Performance Assurance Report 65

81 assessed at the front door were supported to avoid admissions within the critical time period of 72 hours. Nursing care residential beds have been commissioned to support assessment on a spot purchase basis. While the use of these beds has been successful, the limited number of Nursing Home beds in the County has proved challenging. With this in mind, the team are exploring opportunities to enhance residential Social Care beds into an intermediate care community facility. This will be able to accommodate patients with more complex needs, with the necessary 24/7 support from community nursing and therapy throughout the year. It will need to comply with Care and Social Services Inspectorate Wales (CSSIW) and their regulatory framework and associated governance. This piece of work is progressing against agreed timescales. The Unscheduled Care Coordinator posts were introduced to both hospitals in October 2016 to lead the TOCALS teams. Their role was enhanced during the winter period to identify and assess suitable patients for discharge to ICF commissioned step down beds. The use of these beds was recently evaluated and was found to have saved approximately 640 bed days, a saving of 240k net. When can we expect improvement and by how much? The Health Board s DTOC performance is currently aligned to existing expectations outlined in the 2017/18 trajectory, and the Health Board will ensure that this continues. At the end of Quarter 2, the Health Board anticipates performance against discharge standards for reablement assessment to have improved by 25% on the Quarter /17 position across all localities. Withybush General Hospital (WGH) Where are we and are we on target? During May 2017, the number of ambulance arrivals compared to May 2016 has increased by 29% from 679 to 874 and the daily average increased from 27.7 at April 2017 to 28.2 at May 2017; 76.9% of ambulances handed over within 15 minutes during May Ambulance handovers over 1 hour performance improved considerably from 9 at May 2016, 13 in April 2017 to 4 in May 2017; There was a 4.5% increase in the number of new attendances from 3,594 to 3,757 compared to May 2016, and an increase to the daily average from at April 2017 to at May 2017; The 4 hour performance in May 2017 was 82.3%, a further improvement from the April 2017 position of 78.5%. This is also over 7.4% greater than the May 2016 position which was 74.9%. Top breach reason continues to be lack of medical beds; 12 hour delays currently stand at 131 for May 2017, which is an improvement compared to 158 in May Average Length of Stay (LOS) Medical Emergency Inpatients including zero days Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May The Average Length of Stay of patients discharged in May 2017, has been materially impacted upon due to the discharge of a small number of considerably high length of stay patients, including a single episode of over 660 days. This is a considerable one-off variation that has materially impacted the in-month Average LOS figure. The figure for May 2017 is 8.0 days against 7.0 in April Even with these outliers, the LOS has improved compared to the May 2016 outturn of 8.2 days. What are the challenges? Hywel Dda University Health Board Integrated Performance Assurance Report 66

82 The main challenge for May has been the flow of patients between A&E and medical wards. An increase in demand and a shortage of beds has led to increased numbers of unplaced medical patients both in Major and Minor spaces within the department. The shortage of capacity in the Community to discharge medically fit patients is an area the team are working collectively with Community colleagues to improve. The number of medically fit remains above the target number of 12 patients and is often running at 30. What is being done? Recruitment remains the highest priority. The Medical Recruitment Working Group is addressing the high levels of agency & locum spend, that is both presenting additional financial pressure but also limits high standards of patient care. A recruitment Open Day was held on 10 th June 2017, which showcased the best of what Withybush, Community and Primary Care within Pembrokeshire has to offer, and had planned interview slots at the end of the day. Over 90 candidates had signed up to this event at the time of writing. An area within the Acute Clinical Decision Unit (2 assessment rooms) has been converted into a proxy Ambulatory Care Unit, which will fast-track GP admitted patients through A&E into this area. This has a positive impact on patient waiting times and experience, and also improves the 4 hour waiting target. A group is now established to focus on discharge planning, and the introduction of the SAFER patient flow methodology. The SAFER patient flow programme is being rolled-out across the medical wards, to enable the Emergency Care Improvement Programme (ECIP) initiatives including: Red 2 Green days; 33% discharges before noon; End Pyjama (PJ) Paralysis; Estimated Discharge Dates (EDD); Complex discharge pathways; Community pull focussing on complex issues for both District General and Community Hospitals. When can we expect improvement and by how much? The Financial settlement and required savings to achieve the Health Board savings, will impact significantly on the ability to achieve the planned improvement. How does this impact on both patients and finances? The turnaround agenda and savings schemes are being implemented. The Team are working closely with Finance colleagues to identify and implement cost improvement schemes, whilst ensuring patient quality and safety is maintained. The initiatives detailed above will help ensure that Withybush Hospital provides high quality patient care and improved safety for both staff and patients. The financial impact of recent medical and nursing recruitment is significant and will impact the run-rate in the coming months when onboarding is realised. Hywel Dda University Health Board Integrated Performance Assurance Report 67

83 5 Timely Care Exception Report Lead Executive Joe Teape Stroke Quality Improvement Measures 72 Hour Pathway Care Performance Senior Responsible Officer John Evans Where are we and are we on target? Stroke admissions remain variable on a monthly basis across Hywel Dda University Health Board (HDUHB). This month saw a decrease of 3 admissions, from 62 in April to 59 in May Stroke admissions by site consist of 13 from Bronglais General Hospital (BGH), 14 from Glangwili General Hospital (GGH), 8 from Prince Philip Hospital (PPH) and 24 from Withybush General Hospital (WGH). The change in admission numbers impacts on the performance percentage variations being witnessed. There were no new performance related issues raised from acute sites that would have impacted on the Stroke performance in May Admissions to the Stroke unit within 4 hours have decreased by 11.2% this month, with performance at 68.8% in May 2017, compared to 80.0% in April. However, the Health Board (HB) continues to exceed the UK average in this measure; In May 2017, the HB achieved 100% performance for the second month running in scanning patients within 12 hours; 72.9% of patients received a CT Scan within 1 hour of arrival at hospital, and the breakdown by site is outlined in the table below: Hywel Dda University Health Board Integrated Performance Assurance Report 68

84 Hospital <=1 hour compliant <=1 hour total % within 1 hour BGH % GGH % PPH % WGH % HDUHB % Performance for assessment by a Stroke Consultant within 24 hours has improved for the second month running, 79.7% in May 2017 compared to 75.8% in April, and the HB is currently within 2.2% of meeting the UK average target; Thrombolysed patients with Door-to-Needle <= 45 minutes performance was 50% in May 2017 and has met the 12 month improvement target; The most recent All Wales performance data published in May 2017, shows the latest Health Board position as follows: o 1 st in Wales for Direct admission to a Stroke Unit within 4 hours; o 3 rd in Wales for CT scan within 12 hours; o 6 th in Wales for being assessed by a Stroke Consultant <24 hours; o 2 nd in Wales for Thrombolysing patients with door-to-needle <= 45 minutes. 72 Hour Pathway Care: Hywel Dda University Health Board Integrated Performance Assurance Report 69

85 Thrombolysis Care: What are the challenges? Thrombolysis: Although it is recognised that thrombolysing patients with a door to needle time of within 45 minutes is a challenging target, this is one of the key areas for improvement across the Health Board. Bronglais and Withybush General Hospitals have Stroke thrombolysis pathways, enabling direct access to CT scanning on arrival to hospital. This reduces the potential for delay pre scan, and allows the medical teams to complete a clinical assessment whilst awaiting a CT scan report, therefore saving time. Other challenges to achieving this target include a lack of Stroke specific staff on call, and given the relatively small numbers of patients through the pathway, the potential for the skills of non- Stroke specific staff to dwindle. Regular Stroke thrombolysis education and training for all staff, specific to each site, is in place with the aim of minimising this potential challenge. For the 4 hour target: Direct admission to the Acute Stroke Unit (ASU) within 4 hours has shown a broad improvement over the last six months, but remains a challenge across all sites. A number of factors influence performance, such as delays in diagnosis, break down of communication between professions and departments, acuity and dependency in the A&E departments, delays in the handover of patients between emergency/medical teams, and patient flow/delayed discharges. These challenges are being addressed on a weekly basis at site specific Stroke Service Improvement meetings; with local action plans to support further service improvement. For the 24 hour target: The challenges associated with the new 24 hour target of being assessed by a Stroke Consultant within 24 hours, are related to the provision of a 7 day service. The current service model is unable to provide Stroke Consultant cover 7/7, although the HB Stroke Steering Group is discussing and considering options to facilitate this service. These options are being included in the Stroke Plan and will link into the Integrated Medium Term Plan. For the 72 hour target: Factors influencing performance are directly related to a lack of 7 day working, with no Speech and Language Therapy cover for bank holidays. What is being done? Hywel Dda University Health Board Integrated Performance Assurance Report 70

86 Weekly Multi Disciplinary Teams (MDT) Stroke Service Improvement meetings across all sites; Monthly site Stroke Service Improvement meetings; Monthly Health Board Stroke Steering Group meetings; Working regionally as part of ARCH (A Regional Collaborative for Health) programme to review Stroke Services and the development of a Hyper Acute Stroke Unit; Education and training sessions facilitated by Stroke teams across all sites; A Health Board Understanding Stroke Management course is run quarterly, facilitated by Clinical Nurse Specialists; Daily decant plan for ASU beds to support bed availability; New Swallow Screen training is being rolled out across the HB for nurses working in emergency care and Stroke units; Stroke Plan paper describing current Stroke services across the HB, with supporting evidence highlighting Stroke specific resources, required to support service improvement, to feed the Integrated Medium Term Plan (IMTP) process; Glangwili & Prince Philip Hospitals implementing direct access to CT scans, through participation in Paramedic Acute Stroke Treatment Assessment (PASTA) trial; Stroke Service Delivery Manager (SDM) meeting with the Delivery Unit (DU) to support driving service improvements; Collaborative working with the community Multi Assessment Support Team (MAST) in Pembrokeshire, to support the Stroke service at Withybush Hospital. This enables assessments to be initiated for new Stroke patients at weekends, thus supporting a 7 day service; The HDUHB Stroke Steering Group has agreed a process for reviewing and reporting Stroke mortality. When can we expect improvement and by how much? The Stroke Steering Group has developed a Health Board Stroke Plan that identifies the investment required to meet the Royal College of Physicians standards for multi professional resources that would deliver an improved 7 day service. Work is now underway to prioritise investment against this plan, although exact timescales will be dependent upon agreement on this investment and recruitment. How does this impact on both patients and finance? Stroke teams on each acute site continue to review Stroke services at weekly and monthly Stroke Service Improvement meetings, and set actions for service improvements that are cost neutral. The Stroke Plan identifies targeted investments in the Stroke service that support service improvements, as recommended by the Royal College of Physicians. Hywel Dda University Health Board Integrated Performance Assurance Report 71

87 5 Timely Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Keith Jones Urgent Suspected Cancer (USC) Waiting Times Over 62 Days (Target =95%) Where are we and are we on target? Confirmed performance for April 2017 was 94.6% and this represents the highest performance achieved by the Health Board since 2014, continuing the recent performance trend. Estimated performance for May 2017 is 90.9%. Whilst this remains subject to further validation, the reduction in forecast performance is mainly attributable to the treatment of an increased number of patients who have previously experienced complex, lengthy diagnostic pathways and the ongoing impact of tertiary oncology and surgery delays. What are the challenges? April performance was based on 5 breaches for the following reasons/areas: 1 x complex diagnostic pathway (Head & Neck pathways); 1 x oncology delay (LGI pathways); 2 x whole pathway delays (Urology pathway); 1 x tertiary surgery delay (Lung pathway). What is being done? A sustained reduction in the number of patients in the 63 + and 53 to 62 day Urgent Suspected Cancer backlog is essential if the Health Board s performance is to improve in line with agreed profiles. The number of patients in the 63 day and over cohort (14 at the end of May 2017) has reduced since Autumn 2016 and continues to run at its lowest range for the past 12 months. Similarly, the significant reduction achieved in the number of patients in the 53 to 62 day cohort (currently 16 at the end of May 2017) since mid September 2016 has been sustained and continues to run at the lowest range for the past 12 months. Hywel Dda University Health Board Integrated Performance Assurance Report 72

88 Non-Urgent Suspected Cancer (NUSC) Waiting Times Over 31 Days (Target = 98%) Where are we and are we on target? Confirmed performance for April 2017 was 100% based on no breaches. Estimated performance for May 2017 is 95.7%. Whilst this remains subject to further validation, the reduction in forecast performance is attributable to the ongoing impact of tertiary oncology and surgery delays and local Urology surgery delays, due to annual leave within the consultant team. What are the challenges? There are several emerging risks relating to tertiary surgical and oncology capacity, which have the potential to impact upon the Health Board s performance across a number of USC and NUSC pathways. These have been escalated to Abertawe Bro Morgannwg University Health Board (ABMUHB). The extent to which these risks impact upon overall Health Board USC and NUSC performance varies month to month, depending upon the volume of Hywel Dda patients requiring tertiary treatment and overall demand at ABMUHB. What is being done? The table below provides a summary of key tertiary pathway risks as advised by ABMUHB: Pathway Gynaecology Tertiary Capacity Risk Delays for surgical treatment at the tertiary centre in Swansea; Situation reflects ongoing sickness/ absence with the ABMUHB Gynaecology consultant team and periodic bed capacity Current Position: Hywel Dda University Health Board Integrated Performance Assurance Report 73 Consultant sickness / absence remains unresolved with no alternative locum solution secured; This remains a risk to sustained performance improvement; ABMUHB unable to confirm robust plan to mitigate these risks in the short term; No available capacity at alternative units in Wales.

89 Pathway Lower Gastrointestinal Lung Urology Head & Neck Tertiary Capacity Risk pressures at Morriston Hospital. Service is heavily dependent upon tertiary oncology service (for radiotherapy treatments). Delays for tertiary Thoracic surgery; Reflects waits for outpatient assessment and surgery via the tertiary centre. Service is heavily dependent upon tertiary surgical and oncology service (for specific, specialist treatments); Robotic prostate surgery service for Wales is based in Cardiff and demand is significantly oversubscribed. Service is heavily dependent upon tertiary oncology service (for radiotherapy treatments). Current Position: Pressures on tertiary oncology service escalated with ABMUHB actively seeking additional clinical oncologist capacity to reduce delays; Pressures impact upon waiting times for radiotherapy treatments at Singleton Hospital (as chemotherapy treatments are generally delivered locally within Hywel Dda); ABMUHB unable to confirm robust plans to mitigate these risks in the short term. HDUHB escalation to Welsh Health Specialised Services Committee (WHSSC;) Outsourcing of Thoracic surgery patients via the WHSSC Thoracic Surgery Project is due to commence in May 2017; Outsourcing of Thoracic surgery is expected to release pressure on ABMUHB Thoracic service and improve waiting times. Pressures on tertiary oncology service escalated with ABMUHB actively seeking additional clinical oncologist capacity to reduce delays; Pressures impact upon waiting times for radiotherapy treatments at Singleton Hospital (as chemotherapy treatments are generally delivered locally within Hywel Dda); ABMUHB unable to confirm robust plans to mitigate these risks in the short term; Welsh Government has requested Wales Cancer Network to review robotic surgical service. Pressures on tertiary oncology service escalated with ABMUHB actively seeking additional clinical oncologist capacity to reduce delays; Pressures impact upon waiting times for radiotherapy treatments at Singleton Hospital (as chemotherapy treatments are generally delivered locally within Hywel Dda); ABMUHB unable to confirm robust plans to mitigate these risks in the short term. Hywel Dda University Health Board Integrated Performance Assurance Report 74

90 5 Timely Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Stephanie Hire Referral to Treatment (RTT) Waiting Times Where are we and are we on target? The percentage of patients waiting less than 26 weeks from referral to treatment has improved from 80.2% in May 2016 to 84.0% in May The number of patients waiting more than 36 weeks from referral to treatment has improved from 4,798 in May 2016 to 3,086 in May There is a decline in performance when comparing May 2017 to the previous month. Hywel Dda University Health Board Integrated Performance Assurance Report 75

91 What is being done? In order to meet the Planned Profile, the Operational team, in collaboration with clinical colleagues, used various methods of validation to ensure the waiting list was clean and patients were seen and treated in turn. These methods included: Virtual validation, where internal validators and clinicians reviewed stage 2 and 3 patients, and made office based decisions regarding investigations. Patients were contacted by letter when no further treatment was required, and pathways were subsequently closed. This also removed the lengthy wait for a follow up appointment; Patients were contacted either by letter or telephone, to ascertain if they wished to remain on the waiting list; The Operational teams consisting of Service Managers and the internal validation team, undertook a review of the overall Patient Tracking List (PTL) on each new data file which was run every other day. This ensured the Directorate achieved a clearer position to schedule and prioritise patients in the 36 week and over cohort; Weekly Watchtower meetings prioritised the work of both the validation team and the service management team, as improvements were seen across stages and the priorities shifted. When can we expect improvement and by how much? All potential 36 week and over breaches continue to be validated, providing assurance that longer waits on the PTL are accurate and still waiting for treatment. Services continue to work on improvement projects, interventions and changes to facilitate a further reduction in breach numbers. The Operational team have engaged with the newly established Transformation Team to assist and support in a number of improvement initiatives. These are outlined as follows: A review of all Outpatient clinic templates, including the number of slots and variation between clinicians. This will ensure clinic sessions are maximised and there is uniformity across the service; Identification of referral criteria for the top three clinical conditions within services; Monitor impact of referral criteria for the top three clinical conditions; Establish access to specialist advice for the top three clinical conditions. In addition there continues to be: RTT awareness and training with secretaries on all sites; All stages of the PTL are monitored on a daily basis by the Scheduled Care General Manager and relevant Service Delivery Managers. How does this impact on both patients and finances? Going forward, the Health Board aims to reduce its RTT breach position further, by ensuring accurate representation at the National Planned Care Programme meetings, and appropriate sub/collaborative groups across the Health Board, together with the involvement of the Transformation Team. The Orthopaedic backlog projection for the next financial year anticipates that an external solution is needed, and as such, the Health Board is working closely with Welsh Government to address this. Hywel Dda University Health Board Integrated Performance Assurance Report 76

92 New and Follow-up Outpatient Did Not Attend (DNA) Rates Where are we and are we on target? A total of 742 patients did not attend their new outpatient appointment in April 2017, resulting in a DNA rate of 10.2%; the 12 month reduction target has not been met. This is a 1.9% deterioration in performance when compared to 8.3% in April A total of 1,270 patients did not attend their follow-up outpatient appointment in April 2017, resulting in a DNA rate of 9.3%; the 12 month reduction target has been achieved. This is only a slight deterioration when compared to 9% in April According to the latest All Wales published data, Hywel Dda University Health Board is 7 th out of 7 in Wales for new outpatient DNA rates and 5 th out of 7 for follow-up outpatient DNA rates. What is being done? The reduction of DNA rates across all identified specialties is a key milestone within the Outpatient Transformation Programme Plan. The aim is to reduce DNA rates within the identified specialties, which have a greater DNA rate over 5% by 50%. A working group has been established which is progressing key actions to impact on the reduction of DNA numbers. These include: An Access Policy; Patient acknowledgement, invitation and confirmation letters; Co-design with the public and aligning with the new Access Policy; An improved text reminder service; Implementation of a no follow-up process for diagnostic results until formally reviewed; A DNA policy enforced and monitored by scrutiny of the data; Increase the use of virtual clinics, contacting patients via various methods to convey information and clinic appointments; Weekly meetings with Service Delivery Managers and Senior Nurse Managers to review and facilitate improvement. Hywel Dda University Health Board Integrated Performance Assurance Report 77

93 5 Timely Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Stephanie Hire Diagnostic waits over 8 weeks (Target = 0) Where are we and are we on target? In May 2017, the Health Board maintained a zero breach position for the eighth month running. What is being done? Each area maintained their position by following their current plans, outlined as follows: Radiology continued to use overtime, an agency locum and bank working; Cardiology Heads of Service continually monitor diagnostic lists closely. The department is supported by locum echo-cardiographers that are in the process of being recruited on a substantive basis; In Urodynamics, the department is continuing to offer respective tests at different sites until staffing levels are replaced; In Endoscopy, Service Managers and waiting list teams continually monitor patient lists to resolve potential breaches. Hywel Dda University Health Board Integrated Performance Assurance Report 78

94 5 Timely Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Stephanie Hire Delayed Follow-up Appointments (12 month reduction target) The 2015 Welsh Audit Office (WAO) Review of Follow-up Outpatient Appointments report, found key challenges across Wales with delivery of outpatient services and management of follow-ups. More specifically to Hywel Dda University Health Board; outpatient services need to modernise the way care is being delivered, follow up pathways need to transform to address an ageing population which may present with increased chronic conditions and co-morbidities, data standard requirements must improve the accuracy, reliability and range of information available on outpatient follow-up; and assessment of clinical risk and harm to patients must be paramount. In response to the recommendations, the Health Board has established an Outpatient and Transformation Group under the leadership of the Director of Operations, to address the current cohort of patients on the follow-up waiting list, to assess patients coming to harm or clinical risk on the follow-up waiting list, to design, implement and monitor the modernisation of outpatient services, to work with Secondary and Primary Care clinicians to transform follow-up pathways, and to ensure the key recommendations set out in the WAO report are actioned. Where are we and are we on target? In May 2017, the number of patients waiting for a follow-up appointment past their target date has reduced from 28,576 in May 2016 to 27,272 in May Despite an increase compared to the previous few months, the Health Board has met its 12 month reduction target. The latest All Wales published data ranks the Health Board 3rd in Wales for this measure. In order to shift demand from Secondary Care and to provide sustainable Planned Care Services, the Outpatient Programme will be supported through translating evidence and best practice into local Hywel Dda University Health Board Integrated Performance Assurance Report 79

95 solutions which are clinically owned and led. This will include short term quick wins alongside longer term interventions. This work will be linked to the National Planned Care Programme, and the initial focus of the Outpatient Programme will be on Dermatology, Ear Nose and Throat, General Surgery, Ophthalmology, Trauma and Orthopaedics (encompassing Musculoskeletal Physiotherapy/ Rheumatology) and Urology. The current follow-up position relating to these six specialties are shown in the graphs below: Hywel Dda University Health Board Integrated Performance Assurance Report 80

96 Hywel Dda University Health Board Integrated Performance Assurance Report 81

97 The following table indicates the follow-up waiting list at the end of May 2017 for Obstetrics, Nursing, Clinical Haematology and Midwifery. These specialties are excluded from national reporting. The table below outlines the change between May and the previous month. Overall there has been an increase of 320 patients when comparing May 2017 to April What are the challenges? The challenge is the balance between addressing the current follow-up cohort and resourcing required to do this, and developing and transforming pathways, informatics and administrative processes to prevent this happening in the future. The increase in the number of patients with a follow-up appointment not booked during May 2017 is in part due to the number of Bank Holidays during the month. What is being done? An administrative validation exercise has been undertaken for those patients on the follow-up not booked waiting list, and administrative validators have been recruited to continue cleaning the list. Weekly scrutiny meetings are being established with Service Delivery Managers to review patients on the follow-up not booked list. A GP pilot is being developed to clinically validate a cohort of patients on the list, with the aim to capture lessons learned and inform follow-up and discharge criteria. A pilot is being undertaken in one speciality to flex the new to follow-up ratio, to ensure the new and follow-ups have equal priority Lives Improvement is supporting a piece of work in Trauma and Orthopaedics to improve the follow-up pathway. The Outpatient Programme is utilising a Programme Management Office approach, setting up robust governance and accountability structures and key deliverables for this work, which is being tracked Hywel Dda University Health Board Integrated Performance Assurance Report 82

98 and managed under this framework. This has now been established and includes a programme initiation document, with key performance indicators which are monitored and linked, with efficiency value realised. Weekly meetings have now been established with the Service Delivery Managers, Service Managers and Senior Nurse Managers to support the outpatient work. This work is now being supported by an enhanced Service Improvement and Transformation team. Examples of work being undertaken includes the information department circulating weekly updates, alongside the PTL, on delayed follow-up numbers to allow Service Delivery Managers to drill down and target improvement. This will allow week on week tracking of longest waiting patients and consultants with higher than expected follow-up numbers. In Pain Management there is currently no follow-up problem in Withybush General Hospital (WGH). With regard to the other three sites, the following actions are being undertaken: Clinical validation to be undertaken of Carmarthenshire long waiters; There is continued validation of patients across all areas and patients are redirected to WGH (if a patient lives within a certain distance) where the demand is less; Templates have been agreed with Consultants and Clinical Nurse Specialists (CNS) as per Pain Management Guidelines, but these are monitored routinely and are flexible due to demand; Discussions will be undertaken regarding discharge criteria. In Urology the following actions are being undertaken: All CNS templates are currently under review to free up capacity; Team meetings with Consultants are being set up to discuss clinical validation, discharge criteria, templates and pathway review of all Urological conditions; Roll-out of electronic referrals will see a decrease in the number of patients added to the waiting list, which in turn will decrease the need for a follow-up; A pro-forma has been devised so that patients, when initially seen by a Consultant, remain under that Consultant and do not form part of a pooled patient cohort. In Ophthalmology the Directorate continues to work with Community Services, Optometrists and the Acute Service Clinicians, to reduce the number of patients not booked for a follow-up appointment. The longest waiting patients are being seen by Optometrists, with a sustainable plan being worked through to ensure the list is managed and reduced. In Gastroenterology a re-vetting exercise is currently being undertaken. Patients that over time have had investigations, been admitted, come directly for tests or seen in clinic; are either taken off the list or dealt with virtually. Once the vetting process is complete, additional clinics will be scheduled for July An additional core clinic has been set up on a weekly basis in GGH for new and follow up appointments. An additional locum has been recruited in Prince Philip Hospital (PPH) with an approximate start date of 3 months. Work continues with the transformation team to improve clinic templates. In Neurology the numbers have remained static for the past 3 months. The following actions are currently being undertaken to reduce this position: There is an ongoing review of Medinet clinic templates to accommodate follow-ups; A new Consultant post has been agreed in principle. The job description is currently with the Royal College. This additional clinic template will allow for 378 new and 504 follow-ups per year; A clinician meeting is scheduled to propose additional follow-up slots potentially providing an additional 84 follow-up slots per year; Work continues with the Transformation Team to improve clinic templates. Hywel Dda University Health Board Integrated Performance Assurance Report 83

99 When can we expect improvement and by how much? The Outpatient Transformation Team will continue with an action focused agenda, with high level objectives to achieve the improvements needed. These monthly meetings are attended by key stakeholders, including Primary Care colleagues, senior managers, Quality and Service Improvement colleagues, front line staff from outpatient departments, Informatics, Medical Records, an Outpatient Service Delivery Manager, a Senior Nurse and Patient Experience and Assurance representatives. It is proposed the six specialties will form transformation subgroups linked to the Planned Care Programme Board where appropriate. Each subgroup will utilise the Programme Management Office approach as above. How does this impact on both patients and finances? For the Health Board s patients, this work is a priority in assessing those who have come to harm, improving patient experience, communication and expectation and providing a better service now and in the future. Financially, the impact is ensuring there are appropriate resources to complete this work, particularly regarding validation of the current waits. Hywel Dda University Health Board Integrated Performance Assurance Report 84

100 5 Timely Care Exception Report Lead Executive Jill Paterson Senior Responsible Officer David Eve Referral to Treatment - Hywel Dda University Health Board Residents Awaiting Treatment in Other Health Boards Timely Care Target April 2017 (monthly) March 2017 (monthly) April 2016 (monthly) RTT - Hywel Dda residents waiting over 36 week's for treatment by other providers R Where are we and are we on target? As at the 30 th April 2017, there are currently 5,329 Hywel Dda University Health Board (HDUHB) residents on open pathways at other provider sites; 97% are waiting to be treated in Wales. Of these 5,329 residents, 356 patients are currently breaching the maximum backstop of 36 weeks, (349 in Wales; 7 in England). English Provider Sites: The 3 main hospitals in England treating HDUHB residents are, University Hospital Bristol, Robert Jones & Agnes Hunt (RJAH) and University Hospital Birmingham. There are a total of seven patients breaching 36 weeks. There were five breaches between weeks in Trauma & Orthopaedic treatment at RJAH. Of the five, only one is undated and that patient requires Complex Scoliosis surgery. The second and third patients have now had their procedures. The fourth patient breaching has requested to be removed from the waiting list. The last patient at RJAH had a To Come In (TCI) date of the 4 th July, but this has been deferred for medical reasons. The University Hospital Bristol has two breaches, one in Ophthalmology at 44 weeks and one in Paediatric Cardiology at 37 weeks. As yet there has been no update on these patients. Welsh Provider Sites: Abertawe Bro Morgannwg University Health Board (ABMUHB). 82% of Hywel Dda patients waiting to be treated outside Hywel Dda in Wales are in ABMUHB. In the ABMUHB 2016/17 Integrated Medium Term Plan (IMTP), the following commitments were made to reduce waiting times: There will be no patients waiting over 26 weeks for a first new outpatient appointment (stage 1) with the exception of Ophthalmology, by March 2017; To clear over 36 week waits in all specialities other than Ophthalmology and Orthopaedics, by March 2017; For 2017/18: - Ophthalmology and Orthopaedics to have no 36 week waits by March Outpatients: 26 Week Target - At the end of April 2017 there were 32 patients waiting at stage 1 over 26 weeks as follows: Hywel Dda University Health Board Integrated Performance Assurance Report 85

101 Speciality Total Patients Longest Weeks Wait Ophthalmology 4 35 Oral Surgery Trauma And Orthopaedics 2 29 ENT 1 27 Gastroenterology 1 26 Total Week Target At the end of April 2017 there were 291 patients with waiting times in excess of 36 weeks, with the longest week wait being 105 weeks, as shown below: Speciality Total Patients Longest Weeks Wait General Surgery Oral Surgery Trauma And Orthopaedics ENT Plastic Surgery Cardiology Urology 1 48 Cardiothoracic Surgery 1 38 Ophthalmology 5 37 Total 291 ABMUHB have been asked to provide a profile, setting out when the waiting time reduction targets will be achieved for Hywel Dda residents. Cardiff & Vale University Health Board: 17% of Hywel Dda patients waiting to be treated in Wales are in Cardiff & Vale; 55 are breaching, with the longest wait being 105 weeks in Paediatric Surgery. Outpatients: 26 Week Target - At the end of April, there were 54 patients waiting at stage 1 over 26 weeks as follows: Speciality Total Patients Longest Weeks Wait Paediatric Surgery Trauma And Orthopaedics 5 37 Clinical Immunology & Allergy Ophthalmology 2 36 Neurology 4 36 Paediatrics 1 35 Urology 2 35 Neurosurgery 6 32 Gynaecology 2 31 Clinical Haematology 1 31 Clinical Pharmacology 2 29 Dermatology 1 28 ENT 1 28 Cardiothoracic Surgery 1 27 Total 54 Hywel Dda University Health Board Integrated Performance Assurance Report 86

102 36 Week Target At the end of April 2017 there were 55 patients with waiting times in excess of 36 weeks, with the longest wait being 105 weeks, as shown below: Speciality Total Patients Longest Weeks Wait Paediatric Surgery Nephrology Neurosurgery 8 80 Trauma And Orthopaedics ENT 2 52 Ophthalmology 2 44 Clinical Immunology & Allergy 2 44 Paediatrics 1 39 General Surgery 2 39 Cardiothoracic Surgery 1 38 Neurology 1 36 Total 55 Cardiff & Vale have been asked to provide a profile setting out when the waiting time reduction targets will be achieved for Hywel Dda residents, in line with the IMTP that has been submitted. Other Providers in Wales: There is one breach in Aneurin Bevan University Health Board where a patient had a 72 week wait in Trauma & Orthopaedics. This patient agreed a date for 17 th May which was cancelled and rearranged for 1 st June. In Betsi Cadwaladr University Health Board; one patient is breaching 37 weeks in Trauma & Orthopaedics. Betsi Cadwaladr have been asked to confirm when the patient will be seen. Hywel Dda University Health Board Integrated Performance Assurance Report 87

103 6 Individual Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 88

104 6 Individual Care High-level Overview Lead Executives Joe Teape & Jill Paterson Hywel Dda University Health Board Integrated Performance Assurance Report 89

105 6 Individual Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Julie Denley Mental Health Measure Part 3 (Target = 100%) Where are we and are we on target? The Directorate has maintained the target in April 2017 which is an improvement compared to April What are the challenges? There was a lack of understanding in relation to Part 3 of the Measure within some teams who have infrequent requests for assessments, this has been addressed and seems to be resolved. What is being done? Awareness raising across all teams has taken place. The improved position has been fed back to the teams to help maintain this position. When can we expect improvement and by how much? 100% target achieved but this will be closely monitored through the mental health scrutiny structures. How does this impact on both patients and finances? There is no significant impact on patients or finances. Hywel Dda University Health Board Integrated Performance Assurance Report 90

106 6 Individual Care Exception Report Lead Executive Joe Teape Advocacy Services Senior Responsible Officer Julie Denley Where are we and are we on target? In April 2017 the Directorate has not met the 100% target. However the Directorate has consistently remained above 90% since July What are the challenges? This is the second month where there has been a reduced compliance with this standard in Older Adult Mental health Services and an improving position in Adult Mental health Patients being offered advocacy. The admission pathway is fit for purpose and requires all newly admitted patients to be offered advocacy on or as soon as possible after admission. The challenge is for all staff to comply with this pathway consistently. What is being done? The Directorate reviews the advocacy figures recorded on a monthly basis, to identify those areas where performance is low. The service managers with ward managers will scrutinise every breach that has occurred and address non-compliance with the individual staff responsible at the time of admission to help increase staff awareness and improve compliance. When can we expect improvement and by how much? The services strived to achieve a position of 100% compliance by end of April 2017 but this was not reached. Close monthly scrutiny will continue until all areas achieve 100% consistently. How does this impact on both patients and finances? The impact on patients is that there is a delay in accessing advocacy services should they wish to receive them. The financial impact is negligible. Hywel Dda University Health Board Integrated Performance Assurance Report 91

107 6 Individual Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Julie Denley Crisis Resolution Home Treatment (CRHT) Where are we and are we on target? The first target was met for the 5 th month running. With regard to the second target, one of the four admissions (25%) was followed up by the CRHT within twenty four hours. Variability in performance is witnessed due to the small number of patients who fall into this target. There was one breach each in the Pembrokeshire and Llanelli team and a further breach admitted to the Psychiatric Intensive Care Unit. What is being done? The requirement is continually being reinforced by the service and if the breaches occur in the same team next month a review of individual breaches will take place to identify learning. When can we expect improvement and by how much? It was anticipated that the target would be met by May 2017, part one has but part two continues to breach and close scrutiny will remain in place until this second part is consistently achieved. How does this impact on both patients and finances? The impact on the patients is a delay in accessing support for home treatment. The impact on finances could be measured by inappropriate use of bed days. Hywel Dda University Health Board Integrated Performance Assurance Report 92

108 6 Individual Care Exception Report Lead Executive Joe Teape Senior Responsible Officer Julie Denley Mental Health Therapy waits over 14 weeks (Target = 0) Where are we and are we on target? In April 2017, an improvement can be seen, with 15 less patients waiting longer than the target time for therapy compared to the previous month. The most notable improvement being Occupational Therapy for non Learning Disability patients. What are the challenges? Occupational Therapy (OT) in mental health services have experienced higher than usual numbers of vacancies and additional pressures arising from sickness and maternity leave. All posts are now recruited to and people are commencing in their roles hence the improvement. Dietetics remains high as there has been insufficient capacity to meet the demand. What is being done? Funding has been allocated to a professional lead in the OT Service in Learning disability. This will afford greater oversight of working practices to ensure an efficient service. A Situational Background Assessment and Recommendation (SBAR) has been submitted outlining Dietetic resource deficits, challenges and solutions in relation to Dietetics. An additional 34,073 was being sought for the next and recurring years. This will enable the service to manage demand and drive/lead nutritional care improvements across all Mental Health and Learning Disability areas of the Health Board, by up-skilling staff across the service to build a sustainable and prudent approach to managing nutritional care, which will in turn stem continued increasing demand. The Directorate has allocated funding from the 2017/18 new allocation to fund dietetics in line with the SBAR as funding was not secured through the SBAR process. The additional capacity should be available from Month 7 onwards. When can we expect improvement and by how much? Dietetic capacity will increase from October 2017 onwards if the post is successfully recruited to and thus improvement should start to be seen in Quarter 3. Hywel Dda University Health Board Integrated Performance Assurance Report 93

109 How does this impact on both patients and finances? The inability to respond to referrals and the lack of nutritional screening in the MHLD Community is adversely impacting on patients well being, for example, undetected or unmanaged malnutrition results in poor clinical outcomes, poor response to interventions and increases healthcare utilisation with associated increase in costs. Although urgent referrals will be seen in a timely way, those with lower priority will have to wait longer for assessment which might contribute to deterioration in their condition. Staff will continue to experience high demand on their caseloads which could compromise the quality of care being provided to patients and may impact on sickness levels. Hywel Dda University Health Board Integrated Performance Assurance Report 94

110 6 Individual Care Exception Report Lead Executive Joe Teape Mental Health Outpatient Waiting Times Senior Responsible Officer Julie Denley Where are we and are we on target? The number of patients waiting longer than 10 weeks for an appointment has improved from 82 in April 2016 to 61 in April The waiting times for the Older Adult Service continue to be of concern. The maximum outpatient wait in weeks is outlined as follows: Adult 28 weeks; Older Adult 33 weeks; Learning Disabilities 15 weeks; Child & Adolescent Services 5 weeks. Despite one Child and Adolescent patient waiting more than 28 days for an appointment in April 2017 the target has consistently been met since December What are the challenges? Sustaining consistency in improvement is difficult as vacancies change frequently which impact on capacity. With regards to the Hywel Dda University Health Board (HDUHB) wide Older Adult position; The HDUHB has three vacant substantive consultant posts and this has been the situation for several years. These have been addressed through a variety of interventions, namely: Ceredigion is covered by a long term Agency Locum. This vacant post has been out to advert on numerous occasions with no substantive appointable applicants to date. The department is in the process of securing an NHS locum consultant via Medical recruitment with the possibility of permanent appointment; In Carmarthenshire there is one vacant consultant post. Long term internal cover arrangements have been utilised but are not sustainable. In addition to this, one Consultant was taken unwell suddenly and cover for clinics could not be achieved in a timely way, so a number of people were further delayed, hence the deteriorating picture in older adults. What is being done? Hywel Dda University Health Board Integrated Performance Assurance Report 95

111 The Mental Health Directorate continues to work very closely with the corporate Medical Staffing and Medical Recruitment teams to secure substantive appointments. The current vacant posts are covered by Agency Locums wherever possible to ensure the delivery of safe services. Older adult services are developing a contingency plan for the areas with the most breaches. With regards to the Adult Community position, the South Pembrokeshire consultant and speciality Doctor are working to achieve the required waiting time targets and have scheduled additional outpatient sessions to address the current waiting times. An analysis of December leave is being undertaken to inform a review of the winter plan. This will help better understand the capacity this December to help prevent a similar reduction in performance in December In addition to the current position, the Mental Health Learning Disability (MHLD) Directorate continues to invest in expanding the Advanced Nurse Practitioner (ANP) training opportunities this academic year and three nurses started the ANP course in September Two of these nurses are interested in an ANP role within Older Adult Services once they successfully complete their ANP training. This is an investment in building a more sustainable workforce for the future and will not have an impact on the current waiting time challenges. When can we expect improvement and by how much? The agreed Older Adult waiting list initiative was expected to achieve the required targets and sustain the position by the end of March 2017 but to further sickness in the service this was not achieved. Additional capacity will continue to be resourced until a sustained achievement of the target is seen. How does this impact on both patients and finances? The waiting list initiative will cost circa 1,000 a month. The impact on patients are both in terms of the direct consequences of waiting longer to be seen by an appropriate qualified and experienced clinician and the indirect consequences of a delay in diagnoses and the initiation of appropriate treatment. There is therefore a risk to the organisation with regards to the deteriorating position, especially with regards to the Older Adult waiting lists. The financial implications and risks to the Directorate and Organisation are significant both in terms of the cost implications of sustaining essential Medical services by employing Agency Locums and in the context of not having Substantive Consultants that will drive forward further service improvements and service innovation within their Multi Disciplinary Teams. However, the department has now shortlisted two candidates for the Substantive Consultant post in Carmarthenshire and the successful appointment will have a significant positive impact on patient care and the locum spend. Hywel Dda University Health Board Integrated Performance Assurance Report 96

112 7 Our Staff and Resources Monthly Brief Lead Executives Lisa Gostling, Joe Teape & Stephen Forster Hywel Dda University Health Board Integrated Performance Assurance Report 97

113 7 Our Staff and Resources Monthly Brief Lead Executives Lisa Gostling, Joe Teape & Stephen Forster Hywel Dda University Health Board Integrated Performance Assurance Report 98