Haringey CCG Performance and Quality Summary March 2017

Transcription

1 Haringey CCG Performance and Quality Summary March 2017

2 Contents Item Haringey CCG Quality and Performance Dashboard Haringey CCG Performance Summary North Middlesex University Hospital Performance Dashboard Whittington Health Performance Dashboard Whittington Health Provider Summary Haringey CCG Quality Summary Barnet, Enfield and Haringey MH Trust Quality and Performance Summary Integrated Urgent Care Summary (NHS 111 and GP Out of Hours) LAS Summary Data Sources and Glossary of Terms Appendices Appendix A: Barnet, Enfield and Haringey MH Trust Mental Health Performance Dashboard Appendix B: Integrated Urgent Care Summary Page

3 Quality Cancer Waits 18 Weeks Referral to treatment and Diagnostics Haringey CCG Quality and Performance Dashboard Theme KPI / Measure 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 YTD Target A&E A&E All Types Performance 77.3% 77.8% 77.6% 80.5% 81.2% 84.0% 90.2% 93.0% 90.4% 88.8% 85.9% 87.9% 86.3% 95% 18 Weeks RTT Admitted 81.3% 83.2% 82.1% 81.4% 84.7% 85.3% 85.4% 86.3% 82.2% 83.0% 82.5% 83.6% 81.9% 83.7% N/A 18 Weeks RTT Non-Admitted 93.6% 94.0% 93.1% 92.6% 93.6% 92.3% 94.0% 93.6% 92.6% 93.2% 92.9% 93.5% 94.1% 93.2% N/A 18 Weeks RTT Incomplete Pathways 93.4% 93.4% 93.5% 94.2% 94.3% 94.5% 94.7% 93.6% 93.8% 93.8% 94.0% 93.5% 93.5% 94.0% 92% 6 Weeks Diagnostic Waits 5.0% 3.0% 0.9% 1.9% 1.4% 0.9% 1.03% 1.14% 0.7% 1.1% 1.1% 1.4% 1.3% 1.2% 1% >52 week waits Admitted >52 week waits Non Admitted >52 week waits Incomplete Week Cancer Wait 91.9% 94.8% 97.3% 95.2% 93.4% 95.5% 96.5% 95.9% 95.0% 95.5% 96.3% 94.3% 95.3% 93% 2 Week Cancer Wait: Breast Symptoms 31 day Cancer Wait: 1st definitive treatment 31 Day Cancer Wait: Subsequent treatment (Surgery) 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 62 Day Cancer Wait: GP Referral 62 Day Cancer Wait: Screening service 62 Day Cancer Wait: Consultant Upgrade 87.3% 90.9% 95.6% 89.2% 90.1% 95.4% 95.4% 95.4% 97.2% 97.4% 98.7% 94.0% 94.9% 93% 98.2% 100.0% 97.3% 98.5% 97.1% 98.2% 97.0% 97.6% 96.3% 98.6% 98.7% 97.7% 97.7% 96% 87.5% 100.0% 100.0% 100.0% 91.7% 100.0% 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% 97.5% 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.4% 100.0% 100.0% 99.6% 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.2% 100.0% 100.0% 93.1% 100.0% 98.7% 94% 83.3% 65.5% 96.3% 71.4% 79.5% 91.7% 85.2% 76.9% 65.6% 75.7% 86.7% 85.7% 79.6% 85% 100.0% 50.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.1% 93.3% 83.3% 85.7% 83.3% 92.2% 90% 91.7% 83.3% 92.9% 86.7% 93.3% 88.9% 92.3% 92.9% 77.8% 100.0% 92.3% 85.0% 89.7% No Threshold MRSA reported infections C. Difficile reported infections Mixed Sex Accommodation (MSA) (Number of breaches)

4 Haringey CCG Performance Summary Key Messages Accident & Emergency (A&E) Haringey CCG (HCCG) continues to underperform against the 4 hour A&E access standard, however there was a slight increase in performance month on month (85.9% in November and 87.9%). The underperformance is due to HCCG s two main A&E providers; North Middlesex University Hospital (NMUH) and Whittington Health (WH) where performance remains below the operational standard and the Sustainability and Transformation Fund (STF) performance trajectories. Within the financial year North Middlesex University Hospital has seen significant improvement, however improvement has stagnated in recent months. The issues effecting performance relate to higher demand, a high number of both Delayed Transfers of Care (DTOC) and Medically Optimised (MO) patients as well as a higher proportion of patients needing health and social care support on discharge. This had a significant impact on the flow within ED. The Trust are working alongside commissioners to support the reduction of MO/DToC patients. The measures undertaken as part of the Whittington Health A&E Improvement Plan and the Islington A&E Delivery Board Plan have not resulted in the performance predicted. WH/Islington CCG, this main commissioner, together with NEL CSU produced a report for the February A&E Delivery Board which identified the factors (internal and external to WH) which have contributed to the performance. 6 week Diagnostic waits There was a slight improvement in diagnostic performance in January 2017, from 1.4% in December 2016 to 1.3 for Haringey CCG. However, the standard is less than 1% of patients waiting more than 6 weeks, therefore performance is below the standard by 0.1% and has been now for four months. Staffing and capacity issues within endoscopy and colonoscopy at NMUH impacted on the delivery of the operational standard for diagnostics. Commissioners have received assurance that actions are being taken to improve and sustain performance and close monitoring will continue until such time as the standard is achieved and on a stable trajectory. 4

5 Haringey CCG Performance Summary Key Messages Cancer access standards Haringey CCG achieved all but one of the national cancer standards in December, which was the 62 Day Cancer Wait: Screening service standard Performance was at 83.3% against the standard of 90%, this was a slight improvement on the November performance, and was due predominantly to NMUH. The Trust s December 2016 performance was 66.67%. None of the other NCL providers failed this target. NMUH also failed the 2 week wait breast symptomatic target for December but achieved the quarter target which is the national measure. NMUH informed commissioners that there was a slight increase in demand and they had difficulty trying to coordinate consultants in radiology to deliver the one stop service. There were also issues regarding patient choice over the festive period. The Trust confirmed the percentage for performance for breast symptomatic was 88.5%, however the expect to deliver the standard in January Haringey has previously had underachieved against the 62 Day GP Referral national standard. However, NMUH achieved the 62 Day GP Referral national standard and the STF for the second month running. NMUH provider performance was at 88.14% in December However, Royal Free London has not delivered their STF trajectory for the 62 day standard in December Compliance is now expected in February Previously identified data quality issues have now been resolved. UCLH have proposed an information sharing solution to support the inter-trust referrals which is under consideration. All providers are now expected to complete RCAs for all 62 day breaches and not just for the long waiters. RTT Performance against the RTT incomplete pathways standard remains strong for HCCG, the RRT standard was achieved in December. Performance stood at 93.5% against a standard of 92%. NMUH the main provider achieved the trajectory for the 18-week Referral to Treatment standard in December Performance stood at % against a standard or 92%. In January 2017 there were nine Admitted 52 weeks waiters at Haringey CCG for Royal Free Hospital. Out of these, six were General Surgery and one was Gynaecology. There were five Non-Admitted 52 weeks waiters at Haringey CCG for Royal Free hospital. Out of these, two were General Surgery and one was Plastic Surgery. There was one Incomplete 52 weeks waiters at Haringey for Imperial College London under Trauma & Orthopaedics. 5

6 North Middlesex University Hospital Performance Dashboard KPI/Threshold NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST Dec Weeks RTT Admitted % 92.77% YTD KPI/Threshold NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST Dec-16 YTD 18 Weeks RTT Non-Admitted % 95.86% A&E All Types Performance 95% 79.37% 82.22% 18 Weeks RTT Incomplete Pathways 92% 97.10% 96.74% >52 week waits Admitted >52 week waits Non Admitted KPI/Threshold NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST Jan-17 YTD >52 week waits Incomplete Weeks Diagnostic Waits 1% 2.87% 1.34% Cancelled Operations ( Q2) 100% 97.73% 98.80% KPI/Threshold 2 Week Cancer Wait 93% 95.20% 94.84% 2 Week Cancer Wait: Breast Symptoms 31 day Cancer Wait: 1st definitive treatment 31 Day Cancer Wait: Subsequent treatment (Surgery) NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST Dec-16 YTD 93% 88.54% 93.94% 96% % 99.32% 94% % % No of waits from decision to admit to admission (Trolley waits - over 12 hours) % Ambulance Handovers within 15 mins: KPI 1 % Ambulance Handovers within 30 mins: KPI 2 Number of Ambulance Handover - 30 minute breaches Number of Ambulance Handover - 60 minute breaches % Patient Records Captured Electronically: KPI % 24.20% 22.00% 100% 85.90% 83.70% % 89.90% 90.80% 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 98% % % 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 62 Day Cancer Wait: GP Referral 62 Day Cancer Wait: Screening service 62 Day Cancer Wait: Consultant Upgrade 94% % 99.17% 85% 88.14% 74.12% 90% 66.67% 89.71% % 93.10% 6

7 Whittington Health Trust Performance Dashboard Elective Care (RTT, Diagnostics & CWT); Non Elective (A&E & LAS) KPI/Threshold THE WHITTINGTON HOSPITAL NHS TRUST KPI/Threshold THE WHITTINGTON HOSPITAL NHS TRUST Nov-16 YTD Nov-16 YTD 18 Weeks RTT Admitted % 74.99% A&E All Types Performance 95% 85.10% 88.08% 18 Weeks RTT Non-Admitted % 90.63% 18 Weeks RTT Incomplete Pathways 92% 92.64% 93.27% >52 week waits Admitted >52 week waits Non Admitted >52 week waits Incomplete Weeks Diagnostic Waits 1% 0.16% 0.40% Cancelled Operations ( Q2) 100% % % KPI/Threshold THE WHITTINGTON HOSPITAL NHS TRUST Nov-16 YTD 2 Week Cancer Wait 93% 97.24% 97.30% No of waits from decision to admit to admission (Trolley waits - over 12 hours) KPI/Threshold % Ambulance Handovers within 15 mins: KPI 1 % Ambulance Handovers within 30 mins: KPI 2 Number of Ambulance Handover - 30 minute breaches Number of Ambulance Handover - 60 minute breaches % Patient Records Captured Electronically: KPI THE WHITTINGTON HOSPITAL NHS TRUST Dec-16 YTD 100% 23.30% 30.24% 100% 92.10% 96.98% % 87.00% 90.16% 2 Week Cancer Wait: Breast Symptoms 31 day Cancer Wait: 1st definitive treatment 93% % 98.87% 96% % % KPI/Threshold LONDON AMBULANCE SERVICE NHS TRUST Nov-16 YTD 31 Day Cancer Wait: Subsequent treatment (Surgery) 94% % % 31 Day Cancer Wait: Subsequent treatment (Chemotherapy) 98% % % 31 Day Cancer Wait: Subsequent treatment (Radiotherapy) 94% 62 Day Cancer Wait: GP Referral 85% 84.21% 85.83% 62 Day Cancer Wait: Screening service 62 Day Cancer Wait: Consultant Upgrade 90% % % % 7

8 Whittington Health Trust Performance Key Messages Key Messages Accident and Emergency WH performance, as with most other Providers nationally and within London, is well below the 95% 4 hour standard in January 83% of patients were treated, admitted or discharged within 4 hours. The measures undertaken as part of the WH A&E Improvement Plan and the Islington A&E Delivery Board Plan have not resulted in the performance predicted. WH/Islington CCG and NEL CSU are preparing a report for the February A&E Delivery Board which aims to identify the factors (internal and external to WH) which have contributed to the performance. Referral to Treatment Time and Diagnostics The percentage of patients waiting for treatment at WH who have waited less than 18 weeks for treatment remains above the operational standard of 92%. WH also achieved the standard of 99% of patients waiting less than 6 weeks for a diagnostic test in November Cancer Services In November 2016 WH achieved all cancer targets apart from the 85% 62 day GP referral to treatment target. This was missed by 0.5 cases from a caseload of 19. The reasons for breaches were patient choice/clinical delays or delays with inter-trust transfers of care. The London Cancer Alliance is leading work with London providers to improve inter-trust pathways and WH is fully engaged with this work. Cancer Services Whittington Health achieved all of the relevant 8 cancer operational standards for January 2016 and is on track to achieve all standards apart from the 2 week wait suspected cancer and 2 week wait breast symptomatic referral standards where performance is expected to be around 92% for the year against the 93% standard. (See later Cancer section in this report for more details) 8

9 Whittington Health Provider Performance Summary Community Services Area Current Position/Risks Mitigating Actions Assurance/ Recommendations MSK, Gynaecology & Podiatry Contract Performance Notices (CPNs) issued this financial year due to poor performance regarding Waiting Times, Access and DNA rates. Remedial Action Plans (RAP) agreed and being monitored monthly. Monitoring of progress against agreed actions within RAPs for Gynae & Podiatry continue. Recommended closure of RAP MSK as actions complete; Further work to be taken forward through Wellbeing Partnership. Waiting Times Waiting times for access to services remain a cause of significant concern. Patient experience, quality and clinical harm consequences of the poor performance in terms of access have been raised by the CCG Quality and Performance Committee and at Clinical Quality Review Group (CQRG) and Contract Management Group (CMG). Contract Management Group (CMG) (January 2017) agreed to: a) Prioritise and focus on Performance at future monthly meetings with a focus on community performance b) Establish a Task & Finish Performance Group comprising of commissioner and provider representatives to address key services with poor performance. Initial areas of focus to be agreed. Key Performance Indicators for 2017/2018 are at the final stage of negotiation between commissioners and Trust. Prioritising Performance at CMG has raised profile and Trust has acknowledged commissioner concerns. Task & Finish Group terms of reference circulated; First meeting date due end March/start April Community Services Disaggregation Work continues in regards to the Community Services Disaggregation work stream. Commissioner representative on Project Team include Islington, Haringey, Camden and City & Hackney CCG s. Trust have provided a second iteration of the financial split by service line and appointed Deloitte to support them to progress this project. Commissioners and CSU reviewing the data. Commissioners have been asked to agree in principle that no financial changes are to be made to Community Services budget for a fixed period of time, to support delivery of disaggregation project. This would be linked to targeted performance improvement. Next meeting set for end May-17, at which point 12 months of data will be available for review and scrutiny. 9

10 Haringey CCG Quality Summary Quality Issues & Priorities Below is a summary of the key provider quality issues for this reporting period: North Middlesex university Hospital (NMUH) risks due to increased patient numbers in ED and wards: NMUH have opened additional beds in response to high demand since mid-december This consists of a 28 bedded winter ward, 59 escalation beds, used as required, and 8 additional patients lodged on five identified wards. To understand risk to patients safety and potential deterioration of quality of services NMUH undertook a quality impact assessment to understand if the additional activity is resulting in a deterioration of the performance on a range of quality indicators. The analysis showed a raised incidence of pressure ulcers which the Trust is addressing through a number of initiatives. NMUH mortality rates: The fifth and final CQC mortality alert to date, on senility and organic mental disorders has been de-escalated to local monitoring. FFT scores in the Emergency Department (ED): Positive FFT satisfaction scores for ED continue to remain below 50% and are the lowest in London. NMUH recognises the need to change the perception of the quality of the ED services and have invited Healthwatch Haringey to undertake a feedback and engagement exercise with patients in ED. Whittington influenza outbreak: As of 6 February 2017, WH have reported 162 cases of positive influenza with 145 cases community acquired and a possibility of 17 cases acquired in hospital. Nine of the above acquired cases were identified on Cloudesley ward acquired as inpatients. Public Health England has been informed and The IPCT are visiting the wards daily and affected ward has been closed to admissions. 79.5% of WH staff vaccinated against flu and is in the top centile in the country. Whittington Community Services: SI s: District Nursing being investigated, along with responsiveness and adherence to process. Pressure Ulcers Deep Dive Report highlighted decrease in avoidable Grade 2, increase in Grade 3 (5%) and no change in Grade 4. BEH MHT Adult Acute Mental Health Inpatient Capacity: The lack of sufficient availability of acute adult inpatient admission beds causing delays across the local health system with an impact on patient experience and outcomes. In order to better understand the underlying issues a deep dive has been agreed and the proposal to be shared with commissioners and BEHMHT at JPQ. The CSU has recommended the adaptation of the ECIST Emergency Admission Capacity and Demand modelling tool and application to BEH services. BEH MHT Haringey Memory Services: Significant numbers of patients waiting over 6 weeks for referral to assessment and assessment to diagnosis. Haringey Commissioners and BEHMHT have developed and implemented an action plan to understand and refine the clinical pathway, match resources to demand and improve referral processes. Initial Capacity and Demand modelling has been completed. CQC Cost Improvement Plan: Barnet, Enfield and Haringey CCGs have agreed subject to receiving a trajectory for reduced length of stay, the investment and changes for PICU services. Commissioners are considering the proposals for their respective CAMHS services in the light of capacity and demand models and national funding bids. 10 BEH Psychiatry liaison services at NMUH: NCL STP has submitted a bid for national funding to support the provision of a Core 24 Psychiatric Liaison Service by BEHMHT at NMUH. The Team are expecting a response from NHSE in March 2017.

11 Barnet, Enfield and Haringey MH Trust Quality and Performance Summary Key Priorities The Deep Dive Task and Finish Group are continuing to collate and analyse information about the Crisis Resolution and Home Treatment Team and inpatient admissions. The group have received the final batch of activity data. Staffing information is still outstanding CQC Cost Improvement Plan: Enfield CCG have agreed, subject to recruitment, the funding for the additional psychology posts. Barnet, Enfield and Haringey CCGs have agreed subject to receiving a trajectory for reduced length of stay, the investment and changes for PICU services. Commissioners are considering the proposals for their respective CAMHS services in the light of capacity and demand models and national funding bids. In December 2016 the Trust received verbal notification from CQC that there will be another comprehensive inspection of services in quarter one of 2017/18. NCL STP has submitted a bid for national funding to support the provision of a Core 24 Psychiatric Liaison Service by BEHMHT at North Middlesex Hospital. The Team are expecting a response from NHSE in early March Commissioners are working with BEHMHT to understand the impact of the proposed 800k investment in EIP services in terms of NICE compliant treatments and timely access. 11

12 12 Key Messages NCL Integrated Urgent Care Service (IUC) M10 Summary London Central West Unscheduled Care Collaborative (LCW) Key Messages There were 26,399 calls to the NCL IUC service in January. This is a reduction of 1,372 on the previous month of December NCLs STP (service transformation plan) The NCL IUC Programme team have submitted a very robust delivery plan for the continued and future development of IUC across NCL. This includes the merger of IUC with the Urgent and Emergency Care (UEC) workstream of the STP as well as the growth of IUC to bring more UC services under the IUC brand across NCL. The plan has been submitted to the STP/UEC Board for consideration. Commissioners will be made aware of the Board s decisions in due course through individual CCGs. IUC Team Resourcing the funding for the IUC Programme Team expires at the end of March The team have submitted papers to NCL COs requesting additional funding for the team through to the transition of the new NCL CCG organisational structure. Winter pilots - The IUC Programme Team and LCW secured additional funding from NHSE for winter pilots around workforce development. These initiatives went live on the 23 January 2017 and run until the end of March A full evaluation will be completed and presented to commissioners. 30% Clinical call target - This is a nationally mandated target for all IUC and 111 services. A minimum of 30% of calls must be handled by a clinician or have clinical input by the end of March NCL are way ahead of other providers both across London and Nationally at an impressive 58%. LCW have achieved this through a number of initiatives supported by the NCL IUC Programme team 111 Online As reported last month, NCL went live with a new NHS111 Online pilot at the beginning of February It has now been operational for a month and increased from a phased start to full 24/7 operation on 1 st March For more information on the pilot and the press releases, please visit LCW have a CQC inspection on the 2 nd /3 rd March 2017 Commissioners and Patient Representatives are involved in this and will be interviewed by CQC colleagues. This inspection is for LCW s 111 element of the IUC service and not GP OOHs. LCW have planned significantly for the inspection and the results will be shared with Commissioners as soon as they are available.

13 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 LAS Summary Haringey LAS Performance Dashboard Target Monthly Trajectory Jan 2017 Performance Year to Date Trajectory Year to Date Performance Red 1 Performance (8 minutes) 75% 75.9% 63.9% 70.3% 61.2% Red Red 2 Performance (8 minutes) 75% 72.3% 53.0% 66.7% 54.4% Red Cat A Performance (19 minutes) 95% 93.0% 90.3% 93.0% 93.3% Amber Green 1 Performance (45 minutes) 50% 79.2% 48.6% 79.5% 63.7% Green Green 1 Performance (60 minutes) 75% 85.1% 56.4% 85.5% 70.2% Amber Green2 Performance (60 minutes) 50% 81.1% 52.3% 80.7% 66.1% Green Green 2 Performance (90 minutes) 75% 89.7% 62.4% 89.5% 76.5% Green Green 3 Performance (60 minutes) 50% 80.3% 59.5% 79.1% 68.7% Green Green 3 Performance (90 minutes) 75% 89.3% 71.0% 88.8% 78.5% Green Key Messages Haringey Red 1(conditions which may be immediately life threatening) performance increased in month at 63.9%. London (as a whole) Red 1 performance is currently at 67.1%. Haringey's YTD performance at 61.2% remains below the London average (currently 68.2%). Red 2 (life threatening but less time critical) performance has decreased by 0.3% to 53% Other categories have shifted marginally either way. Green 4 Performance (60 minutes) 50% 60.4% 35.0% 60.3% 46.9% Amber Green 4 Performance (90 minutes) 75% 73.9% 48.1% 74.1% 60.1% Red Cat A (8 minute) PerformanceVs. Target NHS Haringey CCG 80% 70% 60% 50% 58.09% 62.07% 59.31% 59.03% 58.31% 57.57% 57.53% 58.24% 56.03% 56.14% 40% 44.41% 45.70% 30% 20% 10% 0% There were 1,670 conveyances to an Emergency Department in January, a decrease of 35 in month. 927 conveyances within Haringey went to NMUHT and 574 to WHITT. This equates to 90% of all ambulance conveyances from Haringey to an Emergency Department Care Pathway location. Full information is available in the monthly LAS CCG performance pack. LAS 16/17 Performance(Red 1 & Red 2 combined) Cat A8% Cat A8% YTD Target LAS 15/16 Performance(Red 1 & Red 2 Combined) 13

14 Data Sources and Glossary of Terms Part 1 of 2 Data sources Appendices Finance & Performance Unify2 - RTT, Diagnostic Waits, A&E, LAS Data, FFT, VTE, MSA As listed here. LAS Portal - LAS Data Open Exeter - Cancer Waits Provider returns IAPT STEIS System - Serious Incidents HSCIC - NHS Safety Thermometer Public Health England - C.Difficile & MRSA Provider returns / Omnibus and Unify - Mental Health Data Provider returns - Community Data Abbreviation Term Definition A&E/ED Accident and Emergency Accident and Emergency department. C.Diff Clostridium Difficile Clostridium Difficile is an infection that may occur within a healthcare environment, leading to diarrhoea. CCG Clinical Commissioning Group Clinical Commissioning Groups (CCGs) are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. CSU Commissioning Support Unit The CSU provide services such as contract management, service redesign, finance & analytical support & other professional services. FOT Forecast Outturn An assumption at a point in time of what the end of year position will be. FY Financial Year The financial year runs from 1st April until 31st March, every year. HCAI Healthcare Associated Infections Healthcare-Associated Infections (HCAI) are those infections that develop as a direct result of any contact in a healthcare setting. HAS Hospital Alert System The Hospital Alert System is an electronic replacement to the paper forms used for documenting patient handover. KPI Key Performance Indicator KPIs help you define and measure progress towards organisational goals. MRSA Methicillin-resistant Staphylococcus aureus MRSA is a type of bacterial infection that is resistant to a number of widely used antibiotics. MSA Mixed Sex Accommodation Mixed sex accommodation is when members of the opposite sex are placed on the same ward/unit. This should not occur. NELIE North East London Information Exchange NELIE is the system and process of information exchange between personnel across various organisations within North East London. NHS Constitution The NHS constitution for England is a formal constitution which, in one document, lays down the objectives of the National Health Service. Full details can be found at NHSI NHS Improvement NHS Improvement support foundation trusts and NHS trusts to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. OP Outpatients A patient who receives medical treatment without being admitted to a hospital: "attending a clinic as an outpatient". PAS Patient Administration System A PAS records the patient's demographics (e.g. name, home address, date of birth) and details all patient contact with the hospital. 14

15 Data Sources and Glossary of Terms Part 2 of 2 Abbreviation Term Definition PIR Post Infection Review As of 1 April 2013, all NHS organisations reporting positive cases of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia via the Healthcare Associated Infections Data capture system (HCAI DCS) will be required to complete a Post Infection Review (PIR). QIPP Quality, Innovation, Productivity and Quality, Innovation, Productivity and Prevention (QIPP) is a set of 'stretch' targets, varying from Trust to Trust, which aim to achieve more Prevention efficient commissioning and higher levels of productivity Quality Premium The quality premium is intended to reward Clinical Commissioning Groups (CCGs) for improvements in the quality of the services that they commission. RTT Referral to Treatment The RTT data measures referral to treatment (RTT) waiting times in weeks, split by treatment function. The length of the RTT period is reported for patients whose RTT clock stopped during the month. SI Serious Incident A serious incident is defined by the National Patient Safety Agency as an incident that occurs in NHS-funded services and care resulting in various levels of harm. SLA Service Level Agreement A Service Level Agreement outlines specific services and products delivered by the CSU. SUS Secondary Users Service The Secondary User Service is designed to provide anonymous patient based data for purposes including direct clinical care. VTE Venous Thromboembolism Venous Thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). YTD Year to Date Year-to-date is a period, starting from the beginning of the current financial year. Abbreviations of Trust Names BCF BEH BARTS C&I CLCH CNWL CHEL WEST ELFT GOS HOM LAS MEH NORTH MID RFL RNOH T&P UCLH WHITT Barnet and Chase Farm Hospitals NHS Trust Barnet, Enfield and Haringey Mental Health Trust Barts Health NHS Trust Camden and Islington NHS Foundation Trust Central London Community Healthcare NHS Trust Central and North West London NHS Foundation Trust Chelsea and Westminster Hospital NHS Foundation Trust East London NHS Foundation Trust Great Ormond Street Hospital for Children NHS Foundation Trust Homerton University Hospital NHS Foundation Trust London Ambulance Service NHS Trust Moorfields Eye Hospital NHS Trust North Middlesex University Hospital NHS Trust Royal Free London NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust The Tavistock and Portman NHS Foundation Trust University College London Hospitals NHS Foundation Trust The Whittington Hospital NHS Trust 15

16 Appendix A: Barnet, Enfield and Haringey MH Trust Mental Health Performance Dashboard Theme KPI/Measure Source Reporting Period Actual Standard Current Month and Previous Month's Trend Blue = NHS Digital Green = Local Data Red = Target BEH IAPT SERVICES (NHS DIGITAL DATA VIA THE WHITTINGTON HOSPITAL NHS TRUST) BEH IAPT SERVICES BEH IAPT SERVICES BEH: OTHER MENTAL HEALTH STANDARDS % Waited less than 6 weeks for a course of treatment (for those finishing a course of treatment) % Waited less than 18 weeks for a course of treatment (for those finishing a course of treatment) NHS Digital Nov % Local Data Jan % NHS Digital Nov % Local Data Jan % 75% 95% Recovery Rate Local Data Jan % 50% Numbers entering into Treatment Local Data Jan The percentage of RTT First Episode Psychosis (FEP) periods within 2 weeks of referral. NHS Digital Dec % 50% Local Data Jan % 50% Proportion of patients on CPA who were followed up within 7 days after NHS Digital discharge from psychiatric inpatient Q % 95% care Proportion of admissions to acute wards that were gate kept by the CRHT teams NHS Digital Q % 95% 93.00% 91.88% 92.00% 90.00% 89.40% 94.35% 93.39% 91.00% 97.30% 96.60% 95.90% Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan % 99.57% 98.00% % 98.90% 98.87% 99.56% 99.00% % 99.30% 98.90% Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan % 46.41% 46.86% 47.52% 50.00% 47.20% 49.30% 46.20% 50.58% 49.30% 43.10% Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan % 56.76% 56.41% 66.67% 66.67% 70.83% 62.50% 63.64% 69.23% 66.67% 71.43% 64.71% 64.71% 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 % 98.87% 98.80% 99.36% 98.73% 99.01% 99.12% 99.42% 99.46% 99.47% Q Q Q Q Q Q Q Q Q Q % 99.07% 99.52% 98.57% 97.41% 94.89% 97.87% 99.69% % 98.13% Q Q Q Q Q Q Q Q Q Q3 Theme KPI 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 % Assessments begun within 1 hour in RAID Mental Health A&E Liaison Service (North % Assessments begun within 4 hours in Middlesex Univeristy AMU Hospital NHS Trust) % Assessments begun within 24 hours on wards Barnet Enfield and Haringey MH Trust Psychiatric Liaison national Target 89% 93% 92% 82% 80% 71% 81% 86% 83% 84% 86% 85% 85% 95% 86% 69% 83% 70% 71% 73% 61% 62% 71% 52% 73% 63% 91% 95% 79% 84% 79% 80% 80% 80% 82% 82% 84% 84% 66% 88% 92% 95% 16

17 Appendix A: Barnet, Enfield and Haringey MH Trust Quality Dashboard Theme KPI/Measure Reporting Period Actual YTD Current Month and Previous 12 Months Trend Blue = Actual Red = Target Friends & Family test (FFT) - % Recommend (Mental Health) Dec % 81.20% 84.46% 81.67% 81.31% 80.71% 82.99% 86.40% 83.71% Friends & Family test (FFT) - Response Rate (Mental Health) Dec % 9.93% 8.26% 7.50% 8.97% 7.36% 7.34% 7.56% 7.78% Friends & Family test (FFT) - % Recommend (Community) Dec % 96.92% 98.23% 98.26% 99.22% 89.27% 97.11% 91.34% 99.24% Patient experience Friends & Family test (FFT) - Response Rate (Community) Dec % Staff Friends & Family test (FFT) - % Recommended as a place to work Q % Staff Friends & Family test (FFT) - % Not Recommended as a place to work Q % 2.18% 1.97% 2.58% 2.86% 2.01% 2.31% 2.30% 2.77% 52.31% 46.72% 60.22% 67.98% 53.37% 30.00% 28.47% 24.54% 17.74% 16.26% Staff Friends & Family test (FFT) - % Recommended as a place for Care Q % 51.54% 48.18% 74.73% 70.44% 60.74% Staff Friends & Family test (FFT) - % Not Recommended as a place for Care Q % 23.85% 26.28% 8.06% 10.34% 15.34% Complaints - Number of formal complaints Jan Mixed sex Accommodation - breaches Jan

18 Appendix B: NCL Integrated Urgent Care Service (IUC) M10 Performance against performance KPIs In line with the IUC contract LCW are reporting performance of local and National KPIs but are not being formally performance managed against these in the first year of the contract, Work is underway to formally agree the final suite of national and local KPIs through the IUC CQRG/CRM meetings. These KPIs will be monitored and revised throughout the first year of the contract. From the second year of the contract 20% of the block contract value will be apportioned against an agreed number of KPIs and the LCW will be liable for performance management should the agreed KPIs not be met. The table below shows performance against KPIs for January The majority of performance KPIs were achieved with one just slightly under. Those that are grey and state TBA refer to national KPIs where agreement has still not been reached at a local or national level. Work is underway across London to monitor and improve re-triage rates to LAS (green ambulances only) and ED. LCW are performing well within London and are working with commissioners to improve further. The two red KPIs are again a topic being discussed both regionally and nationally these targets have not been achieved by any Provider of 111/IUC Quality and Performance Indicators KPI Type Target Target What does this mean Engaged calls Performance <0.1% 0.05% Abandoned calls Performance <5% 0.05% A call that abandons after queuing Answer Time Performance 95% 100% Call waiting time Performance 95% 94.85% % of calls answered in 60 seconds Life threatening referrals Quality 100% 100% Meeting individuals needs Quality 100% 100% Safeguarding Quality 100% 100% Triage rate Quality TBA 97.80% A division of Number of calls received by the number triaged Transfer to 999 Performance TBA 12.60% Cases with an outcome to a 999 emergency service Attend Accident & Emergency Department Performance TBA 9.00% A patient given a final disposition to attend an emergency department Referred to Primary Care and other dispositions Performance TBA 52.00% A patient given a final disposition to attend a primary care or other service Warm Transfers Performance 98% 59.30% A call warm transferred to a skill set as per the case disposition Time taken for call back Performance 100% 9.80% The time taken from the end of a case assessment to the point the skill set makes successful contact Notifications Quality 100% 99% Post Event Message Patient Education Quality 100% 100% Data Source: LCW Reports

19 To know more If you would like to discuss any element of this presentation, please contact: Shana Vijayan Tel: Report Version: 1.74 Template Last Updated: 05/01/15