Quality & Performance Report. Public Board

Transcription

1 Agenda Item 12.1 Quality & Performance Report Public Board 27 th November 2014 Presented for: Presented by: Author: Previous Committees: Governance Professor Suzanne Hinchliffe CBE Chief Nurse / Interim Chief Operating Officer Information Department None Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points This report is presented to ensure the Board remains up-to-date with the Trust s performance in light of national requirements and local developments. Governance

2 Table of contents Overview... 1 Overview... 1 Accountability Framework dashboard... 2 Risk Assessment Framework dashboard... 4 Performance summary... 5 Performance summary by month... 5 Performance summary by CSU... 7 Responsive... 9 A&E waiting times... 9 Referral to treatment waiting times Cancelled operations day cancer waiting times day cancer waiting times Effective Summary Hospital Mortality Index (SHMI) Hospital Standardised Mortality Rate (HSMR) Safe Incidence of MRSA Harm free care Caring Complaints Well-led Workforce: appraisals, sickness absence and turnover Workforce: mandatory training Internal Activity and income Finance Finance: Accountability Framework dashboard Finance: in-year delivery and progress towards Foundation Trust status.. 23 Appendices Appendix 1: CQUIN dashboard Appendix 2: activity and income data Appendix 3: updates from regulators Appendix 4: peer groups Appendix 5: glossary... 29

3 Overview Overview Provides an overview of the format of the report and headline statements regarding Trust performance Overview: This report covers Trust performance against national performance measures from the Trust Development Authority (TDA) s Accountability Framework (AF) and Monitor s Risk Assessment Framework (RAF). Performance against any Commissioning for Quality and Innovation (CQUIN) indicators not contained within the national frameworks, as well as indicators stipulated within the Trust s contract with NHS England and the relevant Clinical Commissioning Groups, is also included on a quarterly basis. Detailed performance reports are provided by exception after the national dashboards. An overview of performance against indicators contained within the Quality Score section of the TDA s AF, which is aligned with the Care Quality Commission (CQC) s five key domains of Caring, Effective, Responsive, Safe, and Well-led, is provided below. Data quality: In order to provide assurance that the data reported herein can be relied upon to accurately describe the Trust s performance, a data quality matrix has been developed and applied throughout. The matrix is based on the 6 dimensions of data quality (accuracy, validity, reliability, timeliness, relevance, and completeness). The icon displayed to the right is featured on pages whose content has been assessed and approved against the matrix. Responsive: The Trust achieved the 90% admitted referral to treatment standard for October, in spite of nationally mandated efforts to increase the volume of long waiters treated. However, in line with these efforts (which will continue during November), the 95% non-admitted standard was not met. The Trust continues to achieve the 92% incomplete standard. Effective: The latest available data from Dr Foster, which covers the period April 2013 to March 2014, reports the Trust s overall SHMI as which remains within the expected range and is largely unchanged from the SHMI of reported for the previous period (January to December 2013). Safe: There were 12 cases of C. difficile (CDI) at the Trust in October against a TDA threshold of 10. However, the Trust remains in line with the cumulative year to date threshold of 73, with 72 cases occurring since the beginning of April. Of these, 13 cases have since been confirmed by the CCG as nonaccountable (split by 11 for the first quarter, and 2 for the second). As at the end of October, there have not been any cases of MRSA bloodstream infection under the Trust s care since June. In addition, the Trust continues to comply with the requirement to screen 95% of eligible patients. Caring: The Trust achieved the mixed sex accommodation standard and the Friends and Family Test Net Promoter Score for inpatients for October. The Net Promoter Score for A&E, reported at 45.7, did not meet the TDA threshold of 46, although the year to date position remains above standard. Well-led: The Trust continues to achieve against the targeted response rate for the Friends and Family Test (FFT) for inpatients, with performance for October reported at 44.4% (against a threshold of 25%), although the rate for A&E was 14.5% against a threshold of 15%. Page 1 of 29

4 Caring Safe Effective Responsive Accountability Framework dashboard Accountability Framework dashboard (1 of 2) Detailed performance reports, by exception, follow the dashboards Domain Indicator TDA Thresholds Aug-14 Sep-14 Oct-14 YTD A&E: 4 hour standard > 95% 95.6% 95.5% 94.4% 95.6% A&E: 12 hour trolley waits Referral to treatment within 18 weeks: admitted > 90% 89.33% 89.96% 90.21% 90.05% Referral to treatment within 18 weeks: non-admitted > 95% 96.2% 94.7% 94.7% 95.8% Referral to treatment within 18 weeks: incomplete > 92% 95.4% 95.6% 95.4% n/app Referral to treatment within 18 weeks: over 52 week waiters (incomplete waits) n/app Diagnostic waits within 6 weeks > 99% 97.3% 99.7% 99.7% n/app Last minute cancelled operations not re-booked within 28 days 0% Q2 2014/15: 4.2% Urgent operations cancelled for a second time Cancer 62 days: GP referral > 85% 78.0% 71.5% 77.7% Cancer 62 days: referral from screening service > 90% 90.4% 91.4% 94.2% Cancer 31 days: first treatment > 96% 96.2% 95.7% 96.7% Cancer 31 days: second or subsequent surgery > 94% 95.5% 92.1% Reported a month in arrears 94.7% Cancer 31 days: second or subsequent drug treatment > 98% 100.0% 99.6% 99.9% Cancer 31 days: second or subsequent radiotherapy > 94% 99.7% 99.3% 99.3% Cancer 2 week wait: suspected cancer > 93% 93.3% 94.5% 94.0% Cancer 2 week wait: breast symptoms > 93% 93.3% 93.6% 89.9% Certification against compliance with requirements regarding access to health care for people with a learning disability Self-certification Compliant Compliant Compliant n/app Summary Hospital-level Mortality Indicator (SHMI) Hospital Standardised Mortality Ratio (HSMR) (2013/14 rebased) National Ave: 100 National Ave: Apr-13 to Mar-14: Apr-13 to Mar-14: day emergency readmissions (Elective & non-elective) < 10.9% 7.0% 6.3% Reported a month in arrears Delayed transfers of care < 3.5% 4.3% 3.6% 3.5% n/app Incidence of C. Difficile National Indicators / Quality Requirements - AF Quality and Governance YTD: < 73 14/15: < Incidence of MRSA Medication errors causing serious harm Reported a month in arrears Harm Free Care (pressure sores, falls, CUTI and VTE): Safety Thermometer (snapshot) > 95% 93.7% 92.2% 94.1% n/app Serious incidents: number n/app Serious incidents: rate per 1,000 bed days < Never events Maternal deaths 14/15: < Reported a month in arrears 6.6% Venous thromboembolism (VTE) risk assessment > 95% 95.9% 96.6% Reported a month in arrears Open CAS Alerts (exceeding the deadline for action) n/app Friends and Family Test: Inpatient Net Promoter Score > Friends and Family Test: A&E Net Promoter Score > Mixed sex accommodation breaches % Page 2 of 29

5 Well-led Caring Safe Well-led Accountability Framework dashboard (2 of 2) Detailed performance reports, by exception, follow the dashboards National Indicators / Quality Requirements - AF Quality and Governance Category Indicator TDA Thresholds Aug-14 Sep-14 Oct-14 YTD Friends and Family Test: Inpatient response rate By Q1: > 25% By Q4: > 30% 45.0% 36.5% 44.4% 41.0% Friends and Family Test: A&E response rate By Q1: > 15% By Q4: > 20% 16.6% 16.4% 14.5% 17.7% NHS Staff Survey: Percentage of staff who would recommend the trust as a place of work > 61% 2013: 51.0% NHS Staff Survey: Percentage of staff who would recommend the trust as a place to receive treatment > 67% 2013: 58.0% Staff turnover (12 months rolling average) n/app 10.9% 10.2% 10.7% n/app Sickness/absence rate (12 months rolling average) n/app 4.1% 4.1% 4.1% n/app Staff In Post (FTE) n/app 13,121 13,380 13,491 n/app 3 % staff appraised n/app 89.1% 90.3% 95.4% n/app Indicators Awaiting Clarification: Domain Indicator TDA Thresholds Aug-14 Sep-14 Oct-14 YTD Patient Safety events that are harmful TBC Complaints: rate per 10,000 occupied bed days 4 TBC Inpatient Survey 2013, Q68: Overall, I had a very poor/good experience TBC 7.9 ("average") Data quality of returns to HSCIC TBC Variable staffing spend as proportion of overall pay spend TBC 9.3% 9.4% 9.7% n/app Although above the national index, performance remains within the expected range. The 2 Never Events occurring in September were attributed to the Chapel Allerton CSU. Percentage of staff who have an in date appraisal at month end, excluding Medical and Dental staff. Rate based on internal monthly overnight bed occupancy data. Page 3 of 29

6 Outcomes Matrics Access Metrics Risk Assessment Framework dashboard Displays Trust performance against metrics contained within Monitor s Risk Assessment Framework National Indicators / Quality Requirements - Shadow Monitor Risk Assessment Framework (RAF) - Service Performance Score Qrt 4 (13-14) Weighted score Qrt 1 (14-15) Weighted score Qrt 2 (14-15) Weighted score Qrt 3 (14-15) Weighted score Performance Indicator 2014/15 Thresholds Weighting A&E: 30 Dec-13 to 30 Mar-14 CDI: Apr-13 to Mar-14 RTT Incomplete: As at 31 Mar-14 Other: Jan to Mar-14 A&E: 31 Mar-14 to 29 Jun-14 RTT Incomplete: As at 30 Jun-14 Other: Apr-14 to Jun-14 A&E: 30 Jun-14 to 28 Sep-14 RTT Incomplete: As at 30 Sep-14 CDI: Apr-14 to Sep-14 Other: Jul-14 to Sep-14 *1 A&E Waiting Times (4 hours) - LTHT (including Wharfedale) 95% % % % % *2 Patients treated within 18 weeks - admitted (%) 90% % % % % A&E: 29 Sep-14 to 26 Oct-14 RTT Incomplete: As at 31 Oct-14 Cancer: Qrt 2 position CDI: Apr-14 to Oct-14 Other: Jul-14 to Oct *2 Patients treated within 18 weeks - non-admitted (%) 95% % % % % 1.0 *2 Patients awaiting treatment on the 18 weeks pathway - incomplete (%) 92% % % % % Cancer 2 week wait - suspected cancer 93% % % % % Cancer 2 week wait - breast symptoms (cancer not initially suspected) 93% 93.6% 86.7% 93.4% 93.4% Cancer 31 Day Waits - first definitive treatment 96% % % % % Cancer 31 Day Waits - subsequent surgery treatment 94% 95.0% 95.0% 94.4% 94.4% Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment 98% % % % % Cancer 31 Day Waits - subsequent radiotherapy treatment course 94% 95.4% 99.2% 99.4% 99.4% Cancer 62 Day Waits - GP/Dentist referrals 85% % % % % Cancer 62 Day Waits - cancer screening service referrals 90% 98.2% 97.0% 92.1% 92.1% Q1 < 32 *3 CDI Q2 < 64 Q3 < 95 Full year < Compliance with requirements regarding access to healthcare for people with learning disabilities (6 criteria) Self certification 1.0 Compliant on all 6 criteria Compliant on all 6 criteria Compliant on all 6 criteria Compliant on all 6 criteria Rating Criteria Service Performance Score < 4.0 > 4.0 Risk Rating Green Red *1 A&E performance is derived from the weekly SITREP return figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters. Failure to meet this standard for any two quarters during the previous 12 month period and failing the indicator again during the subsequent 9 month period or full year may trigger a governance concern. *2 Whilst the RAF monitors performance quarterly, any monthly failure of the RTT standards must be reported to Monitor and represents a failure of that indicator for the quarter. *3 The CDI threshold used by Monitor is the greater of either: (a) a simple proportioning of the annual threshold (i.e. 25% of annual threshold at Q1, 50% at Q2 and 75% at Q3) or (b) 12 CDI cases. General Notes Failure to achieve any of the indicators with a weighting of 1 for three or more consecutive quarters may result in Monitor applying a governance concern and escalating the Trust for consideration as to whether it is in significant breach of its Foundation Trust authorisation. Page 4 of 29

7 CQUIN Indicators Never Events National Quality Requirements Operational Standards Performance summary Performance summary by month Performance summary by month (1 of 2) Summarises performance, at Trust level, for the most recent 13 months Measure Threshold Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Referral to treatment within 18 weeks: admitted > 90% 86.00% 85.00% 87.31% 86.00% 88.66% 89.26% 88.02% 88.11% 91.81% 92.59% 89.33% 89.96% 90.21% Referral to treatment within 18 weeks: non-admitted > 95% 95.05% 94.41% 95.35% 95.00% 95.52% 96.04% 96.08% 96.53% 96.63% 96.18% 96.15% 94.74% 94.72% Referral to treatment within 18 weeks: incomplete > 92% 94.45% 94.38% 94.12% 94.58% 95.22% 95.43% 95.60% 95.78% 95.62% 95.56% 95.39% 95.63% 95.35% Number of specialties failing the RTT complete admitted standard Number of specialties failing the RTT complete non-admitted standard Number of specialties failing the RTT incomplete standard Diagnostic waits within 6 weeks > 99% 99.5% 99.5% 99.6% 99.0% 99.2% 97.8% 96.8% 96.1% 97.9% 97.8% 97.3% 99.7% 99.7% A&E: 4 hour standard > 95% 97.8% 97.4% 96.8% 96.2% 94.1% 96.5% 94.4% 96.4% 96.3% 96.6% 95.6% 95.1% 95.3% Cancer 2 week wait: suspected cancer > 93% 92.6% 92.3% 94.9% 87.0% 95.0% 95.0% 93.3% 93.9% 93.8% 94.8% 93.3% 94.5% Cancer 2 week wait: breast symptoms > 93% 95.0% 86.6% 92.0% 93.8% 94.4% 92.5% 79.8% 89.6% 91.3% 93.4% 93.3% 93.6% Cancer 31 days: first treatment > 96% 98.0% 97.7% 97.3% 96.2% 97.8% 96.9% 97.4% 97.4% 97.4% 96.5% 96.2% 95.7% Cancer 31 days: second or subsequent surgery > 94% 98.3% 97.8% 91.9% 94.3% 97.4% 94.1% 98.5% 94.2% 94.5% 95.6% 95.5% 92.1% Cancer 31 days: second or subsequent drug treatment > 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6% Cancer 31 days: second or subsequent radiotherapy > 94% 99.6% 95.1% 92.6% 93.3% 97.8% 96.8% 98.5% 99.5% 99.8% 99.5% 99.7% 99.3% Cancer 62 days: GP referral > 85% 85.6% 77.9% 76.3% 78.5% 79.3% 75.2% 81.3% 78.3% 79.0% 78.7% 78.0% 71.5% Cancer 62 days: referral from screening service > 90% 91.8% 96.7% 90.2% 100.0% 97.0% 97.9% 94.7% 100.0% 97.1% 93.8% 90.4% 91.4% Cancer 62 days: clinical upgrade > 85% 87.9% 50.0% 61.5% 66.7% 72.7% 65.5% 92.9% 83.8% 77.8% 80.7% 81.3% 93.3% Mixed sex accommodation breaches Reported in arrears Last minute cancelled operations not re-booked within 28 days Reported quarterly Incidence of MRSA Incidence of C. Difficile 2014/15: < Referral to treatment within 18 weeks: over 52 week waiters (incomplete waits) Ambulance handovers taking between 30 and 60 minutes Ambulance handovers taking longer than 60 minutes A&E: 12 hour trolley waits Urgent operations cancelled for a second time Eligible inpatients undergoing a VTE risk assessment > 95% 96.2% 95.5% 95.2% 96.1% 96.5% 96.5% 95.5% 95.4% 96.1% 96.3% 95.9% 96.6% Formulary to be published Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Duty of candour: failure to notify relevant person of patient safety incident Completion of valid NHS number field in acute commissioning datasets submitted via SUS > 99% 99.5% 99.2% 99.1% 99.4% 99.6% % 99.3% 99.2% 99.3% 99.0% Completion of valid NHS number field in A&E commissioning datasets submitted via SUS > 95% 96.5% 95.3% 96.6% 96.1% 95.6% % 96.5% 96.4% 94.8% 95.9% Reported in arrears Reported two months in arrears Incidence of never events Dementia performance: stage 1 (find) > 90% 94.7% 94.3% 95.3% 96.2% 95.4% 96.4% 96.3% 98.5% 100.0% 99.2% 100.0% 100.0% Dementia performance: stage 2 (assess) > 90% 96.2% 92.0% 96.9% 94.9% 95.2% 100.0% 96.5% 97.4% 98.3% 100.0% 100.0% 100.0% Dementia performance: stage 3 (refer) > 90% 100.0% 94.1% 98.0% 94.4% 96.1% 98.4% 95.3% 100.0% 97.2% 100.0% 100.0% 100.0% Prevalence of new and old grade 2, 3 and 4 pressure ulcers (Safety Thermometer snapshot) Oct-14: 6.1% 5.6% 5.0% 5.1% 3.9% 4.9% 3.6% 4.1% 4.7% 4.8% 4.5% 4.8% 5.2% 4.3% Incidence of new grade 2, 3 and 4 pressure ulcers Oct-14: 0.75% 0.7% 0.7% 0.6% 0.7% 0.6% 0.6% 0.6% 0.6% 0.7% 0.5% 0.6% 0.5% 0.8% Prevalence of falls with harm (Safety Thermometer snapshot) Oct-14: 1.07% 1.2% 1.2% 0.5% 0.7% 0.4% 0.4% 0.4% 0.1% 0.3% 0.4% 0.3% 1.1% 0.3% Reported in arrears Key: Not met - externally reported Not met - internally reported Achieved - externally reported Achieved - internally reported * In development Page 5 of 29

8 Research & Innovation Other Quality Requirements Local Quality Requirements Performance summary by month (2 of 2) Summarises performance, at Trust level, for the most recent 13 months Measure Threshold Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Histopathology: %age of cancer resection cases reported using template or proforma 50% by Q3 * * * * * * * * * * * * * Histopathology: % of diagnostic biopsies turned around within 7 days of biopsy 45% by Q3 59.4% 55.3% 48.2% 44.8% 36.4% 37.3% 43.5% 38.4% 62.1% 52.4% 49.1% 41.4% 52.8% Histopathology: % of reports available within 10 calendar days of procedure 50% by Q3 72.8% 65.0% 56.5% 54.9% 52.9% 50.8% 58.4% 56.8% 75.6% 72.6% 64.2% 62.8% 70.3% % of Stroke patients admitted to a Stroke unit within 4 hours of clock start > 60% 41.3% 53.4% 63.0% 52.6% 57.3% 53.9% In arrears % of eligible patients participating in Patient Reported Outcome Measures (PROMs) 75% by Mar /14: 72.7% Apr-14 to Jun-14: 59.4% Apr-14 to Sep-14: 76.3% Consultant to consultant referrals to adhere to criteria Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Provision of edans completed from A&E to comply with requirements Medication on discharge to comply with requirements Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Specialties not meeting baseline for outpatient follow-ups that are over 3 months overdue Outpatient appointments cancelled two or more times (by hospital) 1,283 1,094 1,067 1, ,199 1, , ,214 1,235 Reduce the number of patients waiting more than 13 weeks for a first appointment Oct-14: 1, Compliance with all NICE Guidance & Technology Appraisals Compliance with local Safeguarding requirements of adults and children All quarterly complaints reports to be submitted to deadline % of eligible patients screened for MRSA > 95% 92.9% 97.0% 96.5% 96.5% 96.1% 97.0% 96.5% 96.6% 96.9% 97.0% 96.8% 96.9% 96.4% Reduction in cases of MSSA 2014/15: < Incidents reported to the commissioner within 1 working day of being assessed as serious 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Timely implementation of national patient safety alerts Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved % of edans complying with requirements and received by GP within 24 hours > 90% 79.0% 79.8% 80.2% 79.9% 81.9% 81.5% 81.3% 81.2% 81.5% 81.8% 77.2% 78.7% 79.7% Plan submitted Q1 submitted Q1 submitted Q1 submitted Q2 achieved Q2 submitted Q2 submitted Q2 submitted Quarterly Reported quarterly Provision of assurance for "Basics of Care" Q2 submitted Reported quarterly Workforce assurance to comply with requirements Activity and finance plan to be updated in line with agreed change notices Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved No alterations to be made to activity and finance plan without a signed contract variation Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved A&E: % unplanned follow-up reattendances within 7 days < 5% 7.9% 6.8% 8.2% 8.1% 8.0% 7.5% 8.4% 8.5% 7.8% 7.9% 8.4% 7.7% 7.7% A&E: % of patients leaving unseen < 5% 3.1% 3.1% 3.0% 2.6% 3.6% 3.5% 3.8% 4.0% 3.9% 3.4% 3.6% 4.1% 4.2% Fractured neck of femur: % operated on within 48 hours (excluding medically unfit patients) > 88% 81.4% 92.3% 90.9% 75.6% 90.2% Friends and Family Test: combined response rate (inpatients, A&E and maternity) 18.2% 20.6% 20.8% 22.4% 26.5% 25.9% 24.5% 23.7% 29.2% 25.0% 24.9% 22.1% 24.4% Complaints - % responded to within 40 days > 80% % 23.0% 47.5% 58.2% 67.6% 100.0% 100.0% Complaints: % re-opened following initial resolution (at any time) 12.8% 13.8% 17.5% 13.1% 9.9% 6.5% 10.5% 11.1% 5.1% 3.3% 1.4% 1.2% 0.0% Prevalence of old and new catheter-associated UTIs (Safety Thermometer snapshot) 0.7% 1.0% 1.0% 0.9% 0.9% 0.7% 0.9% 1.4% 0.8% 0.9% 0.8% 1.6% 0.9% Nurse to bed ratio 1.88 : : : : : : : : : : : : : 1 CQC Intelligent Monitoring Overall Risk Score Incidence of falls Deteriorating patients: number of 2222 calls % of full term babies admitted to neonatal care 2.9% 3.1% 2.9% 4.5% 2.4% 4.3% 5.3% 3.6% 2.8% 3.3% 4.3% 3.1% In arrears C-section rates 18.1% 20.6% 18.3% 21.2% 21.8% 19.0% 17.5% 19.2% 19.1% 20.3% 18.9% 19.9% In arrears Joint review of discharge experience (number of incidents) Unplanned readmissions to PICU within 48 hours Activity: research studies in NIHR portfolio (number) Participation: participants recruited to NIHR portfolio studies (number) Within top 5 in England Initiation: all clinical trials should take 70 days or less from receipt of a valid research application to 1st patient visit (median) < 70 Delivery: all commercial clinical trials should recruit the agreed target number of patients within the agreed recruitment period (%) > 80% 411 (2nd) (2nd) 67 until Apr-15 60% 61% 52% 11% 0.0% 257 (2nd) 8374 (8th) (6th) 3196 (6th) /15 data currently unavailable 0.6% 348 (2nd) 6580 (9th) 44 Reported quarterly Key: Not met - externally reported Not met - internally reported Achieved - externally reported Achieved - internally reported * In development Page 6 of 29

9 CQUIN Indicators Never Events National Quality Requirements Operational Standards Acute Medicine Adult Critical Care Adult Therapies Cardio-Respiratory Centre for Neurosciences Chapel Allerton Hospital Childrens Digestive Diseases Head & Neck Hepatorenal Institute of Oncology Leeds Dental Institute Pathology Radiology Theatres & Anaesthesia Trauma and Related Services Urgent Care Womens Performance summary by CSU Performance summary by CSU (Oct-14 position; 1 of 2) Summarises performance, by CSU, for the most recent reporting month (note that any indicators reported in arrears on the previous page will be a month behind) Measure Threshold Referral to treatment within 18 weeks: admitted > 90% 100.0% % 86.4% 88.3% 96.5% 88.9% 92.5% 84.3% 94.9% 96.0% % 100.0% 84.8% % Referral to treatment within 18 weeks: non-admitted > 95% 100.0% % 97.9% 90.4% 97.4% 79.1% 97.0% 96.7% 99.0% 86.9% 98.7% 91.3% % % Referral to treatment within 18 weeks: incomplete > 92% 100.0% % 95.4% 94.0% 95.5% 90.1% 97.1% 94.5% 97.1% 96.5% 99.9% 100.0% 0.0% 86.9% % Number of specialties failing the RTT complete admitted standard Number of specialties failing the RTT complete non-admitted standard Number of specialties failing the RTT incomplete standard Diagnostic waits within 6 weeks > 99% % 100.0% % 99.1% 99.3% 100.0% % % A&E: 4 hour standard > 95% % - Cancer 2 week wait: suspected cancer > 93% % 100.0% 97.3% % 91.7% 96.1% 95.8% Cancer 2 week wait: breast symptoms > 93% % Cancer 31 days: first treatment > 96% % 100.0% 97.8% % 90.6% 97.1% 96.1% Cancer 31 days: second or subsequent surgery > 94% % 97.2% 94.0% % 83.3% 91.7% 88.0% Cancer 31 days: second or subsequent drug treatment > 98% % 100.0% 100.0% % 100.0% 100.0% 100.0% Cancer 31 days: second or subsequent radiotherapy > 94% % 100.0% 100.0% % 98.8% 100.0% 100.0% Cancer 62 days: GP referral > 85% % 85.4% 74.2% % 67.5% 60.5% Cancer 62 days: referral from screening service > 90% % 33.3% Cancer 62 days: clinical upgrade > 85% % 85.0% 100.0% Mixed sex accommodation breaches Last minute cancelled operations not re-booked within 28 days Incidence of MRSA Incidence of C. Difficile 2014/15: < Referral to treatment within 18 weeks: over 52 week waiters (incomplete waits) Ambulance handovers taking between 30 and 60 minutes Ambulance handovers taking longer than 60 minutes A&E: 12 hour trolley waits Urgent operations cancelled for a second time Eligible inpatients undergoing a VTE risk assessment > 95% 98.3% 100.0% % 95.1% 96.4% 89.3% 98.3% 98.9% 97.2% 98.5% 100.0% % 90.0% 98.7% 93.4% Formulary to be published Duty of candour: failure to notify relevant person of patient safety incident 0 Completion of valid NHS number field in acute commissioning datasets submitted via SUS > 99% at CSU level Completion of valid NHS number field in A&E commissioning datasets submitted via SUS > 95% Incidence of never events Dementia performance: stage 1 (find) > 90% 100.0% % 100.0% 100.0% % 100.0% 100.0% 100.0% % 100.0% - Dementia performance: stage 2 (assess) > 90% 100.0% % 100.0% % % 100.0% % - - Dementia performance: stage 3 (refer) > 90% 100.0% % 100.0% % % % - - Prevalence of new and old grade 2, 3 and 4 pressure ulcers (Safety Thermometer snapshot) Oct-14: 6.1% Incidence of new grade 2, 3 and 4 pressure ulcers Prevalence of falls with harm (Safety Thermometer snapshot) Oct-14: 0.75% Oct-14: 1.07% at CSU level Key: Not met - externally reported Not met - internally reported Achieved - externally reported Achieved - internally reported * In development Page 7 of 29

10 Research & Innovation Other Quality Requirements Local Quality Requirements Acute Medicine Adult Critical Care Adult Therapies Cardio-Respiratory Centre for Neurosciences Chapel Allerton Hospital Childrens Digestive Diseases Head & Neck Hepatorenal Institute of Oncology Leeds Dental Institute Pathology Radiology Theatres & Anaesthesia Trauma and Related Services Urgent Care Womens Performance summary by CSU (Oct-14 position; 2 of 2) Summarises performance, by CSU, for the most recent reporting month (note that any indicators reported in arrears on the previous page will be a month behind) Measure Threshold Histopathology: %age of cancer resection cases reported using template or proforma 50% by Q3 * * * * * * * * * * * * * * * * * * Histopathology: % of diagnostic biopsies turned around within 7 days of biopsy 45% by Q % Histopathology: % of reports available within 10 calendar days of procedure 50% by Q % % of Stroke patients admitted to a Stroke unit within 4 hours of clock start > 60% % % of eligible patients participating in Patient Reported Outcome Measures (PROMs) Consultant to consultant referrals to adhere to criteria Provision of edans completed from A&E to comply with requirements - Achieved Medication on discharge to comply with requirements Specialties not meeting baseline for outpatient follow-ups that are over 3 months overdue Outpatient appointments cancelled two or more times (by hospital) Reduce the number of patients waiting more than 13 weeks for a first appointment Oct-14: 1, Compliance with all NICE Guidance & Technology Appraisals Compliance with local Safeguarding requirements of adults and children All quarterly complaints reports to be submitted to deadline % of eligible patients screened for MRSA > 95% 96.9% 96.6% % 97.5% 98.9% 89.4% 97.0% 95.8% 99.7% 97.0% % 92.4% 96.4% 96.5% Reduction in cases of MSSA 2014/15: < Incidents reported to the commissioner within 1 working day of being assessed as serious 100% Timely implementation of national patient safety alerts % of edans complying with requirements and received by GP within 24 hours > 90% 83.9% % 74.4% 85.1% 73.9% 79.6% 94.4% 73.1% 79.9% % % Provision of assurance for "Basics of Care" Workforce assurance to comply with requirements Activity and finance plan to be updated in line with agreed change notices No alterations to be made to activity and finance plan without a signed contract variation A&E: % unplanned follow-up reattendances within 7 days < 5% - 7.7% A&E: % of patients leaving unseen < 5% - 4.2% Fractured neck of femur: % operated on within 48 hours (excluding medically unfit patients) > 88% Friends and Family Test: combined response rate (inpatients, A&E and maternity) Complaints - % responded to within 40 days > 80% Complaints - % reopened Prevalence of old and new catheter-associated UTIs (Safety Thermometer snapshot) Nurse to bed ratio CQC Intelligent Monitoring Overall Risk Score Incidence of falls Deteriorating patients: number of 2222 calls % of full term babies admitted to neonatal care % C-section rates % Improving the patient experience of discharge Unplanned readmissions to PICU within 48 hours % Activity: research studies in NIHR portfolio (number) Participation: participants recruited to NIHR portfolio studies (number) 75% by Mar-15 Within top 5 in England Initiation: all clinical trials should take 70 days or less from receipt of a valid research application to 1st patient visit (median) < 70 Delivery: all commercial clinical trials should recruit the agreed target number of patients within the agreed recruitment period (%) > 80% at CSU level at CSU level at CSU level at CSU level at CSU level at CSU level at CSU level at CSU level at CSU level at CSU level Key: Not met - externally reported Not met - internally reported Achieved - externally reported Achieved - internally reported * In development Page 8 of 29

11 06/04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /06/ /06/ /06/ /06/ /06/ /07/ /07/ /07/ /07/ /08/ /08/ /08/ /08/ /08/ /09/ /09/ /09/ /09/ /10/ /10/ /10/ /10/ /11/ /11/2014 Accountability Framework Responsive A&E waiting times Standard(s): Owner(s): Consequence of failure: Notes: Commentary: Ensure at least 95% of A&E attendances are admitted, transferred or discharged within 4 hours of arrival Chief Operating Officer and Clinical Director of Urgent Care Patient experience, clinical outcomes, timely access to treatment, reputation and financial penalty Appendix 2 lists the peer Trusts included in the benchmarking graph Performance against the 4 hour standard has deteriorated in 2014, although the year to date position remains above 95%. The Trust did not meet the 95% 4 hour A&E standard for the reporting period set for October by the TDA and Monitor (29th September to 26th October), but achieved for the full calendar month, with performance reported at 95.3%. There have been significant pressures on the service due to increased attendances which, due to the additional resource required at the SJUH site, has reduced the ability of the service to flex to cover cross site issues, and impacted on flow and bed availability. Additional resources to support flow have been put in place and efforts will be focussed on achieving the standard for Q3. Performance: Indicator Attendances Site Oct-14 YTD St James's 6,585 50,275 LGI 9,447 67,043 Wharfedale 1,772 14, % Weekly performance against the 95% 4 hour A&E access standard (including Wharfedale) Current performance Performance at same point last year Standard Trust 17, ,500 95% St James's 518 3,108 Breaches LGI 477 2,722 Wharfedale % Trust 995 5,830 85% St James's 92.1% 93.8% Performance > 95% LGI 95.0% 95.9% Wharfedale 100% 100% 80% Trust 94.4% 95.6% Page 9 of 29

12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Accountability Framework Responsive Referral to treatment waiting times Standard(s): Ensure at least 90% of admitted patients are treated within 18 weeks of referral Ensure at least 95% of non-admitted patients are treated within 18 weeks of referral Ensure a minimum of 92% of patients on an incomplete pathway have been waiting no more than 18 weeks Ensure no patients wait over 52 weeks from referral to treatment Owner(s): Consequence of failure: Notes: Commentary: Chief Operating Officer and Clinical Directors Patient experience, timely access to treatment, quality of care, reputation and financial penalty The benchmarking graph is derived from data published by NHS England, which is 2 months in arrears. Appendix 2 lists the peer Trusts included. The Trust achieved the 90% admitted referral to treatment standard for October, in spite of nationally mandated efforts to increase the volume of long waiters treated. However, in line with these efforts (which will continue during November), the 95% non-admitted standard was not met. The Trust continues to achieve the 92% incomplete standard. Performance: 100% 80% 60% 40% 20% 0% 100% 95% 90% 85% 80% 75% 70% 65% Admitted performance and backlog of patients waiting over 18 weeks Oct-14 YTD RTT Reporting Specialties Performance (%) Performance target (%) Backlog Admitted Non-Admitted Incomplete Admitted Non-Admitted Target > 90% > 95% > 92% > 90% > 95% 2,000 Cardiology % % 99.86% 99.91% 99.89% 1,600 Cardiothoracic Surgery 95.39% 97.96% 97.69% 97.58% 98.38% 1,200 Dermatology 76.27% 93.64% 96.53% 78.20% 93.30% Ear Nose & Throat 93.75% 96.46% 95.04% 91.84% 97.46% 800 Elderly Medicine % % % % % 400 Gastroenterology 81.82% 69.95% 83.80% 86.99% 70.95% 0 General Medicine % % % % % General Surgery 90.00% 94.60% 95.80% 85.69% 96.63% Gynaecology 92.00% 98.55% 98.87% 90.17% 98.85% % of admitted patients seen within 18 weeks - Sep-14 Neurology % % % % 99.68% LTHT Peers Other Trusts Target Neurosurgery 83.72% 96.72% 95.04% 84.13% 97.13% Ophthalmology 94.80% 98.89% 99.26% 96.73% 99.00% Oral Surgery 92.73% 86.58% 96.35% 95.75% 93.59% Plastic Surgery 85.52% 86.93% 83.49% 84.96% 79.82% Respiratory Medicine % % % % % Rheumatology % 95.99% 98.34% % 98.76% Trauma & Orthopaedic Surgery 85.06% 83.08% 89.67% 84.91% 83.05% Urology 78.79% 95.42% 91.45% 85.39% 96.19% Other Specialties 89.98% 95.51% 95.39% 88.21% 96.66% Trusts Source: NHS England Trust 90.21% 94.72% 95.35% 90.05% 95.83% Page 10 of 29

13 Accountability Framework Responsive Cancelled operations Assessment in progress Standard(s): Owner(s): Consequence of failure: Notes: Commentary: Ensure all patients who have operations cancelled at the last minute, for non-clinical reasons are offered another binding date to be treated within a maximum of 28 days (zero tolerance standard) Chief Operating Officer and Clinical Directors Patient experience, clinical outcomes, timely access to treatment, reputation and financial penalties Appendix 2 lists the peer Trusts included in the benchmarking graph. Performance against the 28 day cancelled operations standard is reported quarterly. There were 15 breaches of the 28 day standard in Q2 2014/15 against a TDA threshold of 0. Risks are monitored on a weekly basis through CSU access meetings, and reviews undertaken when breaches occur. Reasons for last minute cancellations in Thoracic Surgery (part of the Leeds Cancer Centre), which accounted for nearly half of the 28 day breaches, have been identified - with all occurring either due to non-availability of beds or theatre lists overrunning. The CSU is expected to improve its position in Q3. An assessment against the newly introduced data quality matrix is currently underway. Performance: Number of operations cancelled at last minute for non-clinical reasons and number not subsequently treated within 28 days 28 day breaches 28 day breaches target (0) Last minute cancellations Number of patients not treated within 28 days of last minute cancellations for non-clinical reasons Jul-14 to Sep Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/ Trauma and Related Services 2 Centre for Neurosciences 3 % of patients not treated within 28 days of last minute cancellations for non-clinical reasons - Quarter 2, (July to September 2014) 40% 35% 30% 25% 20% 15% 10% 5% 0% LTHT Peers Other Trusts Trusts Leeds Cancer Centre 7 Children's 2 Hepatorenal 1 73 Trust(s) reported no breaches for the period, including 4 peer(s). Source: NHS England Page 11 of 29

14 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Accountability Framework Responsive 31 day cancer waiting times Standard(s): Ensure at least 96% of patients receiving their first definitive treatment are treated within 31 days Ensure at least 94% of patients receiving subsequent surgery are treated within 31 days Ensure at least 98% of patients receiving a subsequent anti-cancer drug regimen are treated within 31 days Ensure at least 94% of patients receiving subsequent radiotherapy are treated within 31 days Owner(s): Consequence of failure: Notes: Commentary: Chief Operating Officer Timely access to treatment, patient experience, clinical outcomes, reputation and financial penalty The cancer indicators are monitored 2 months in arrears due to the timing of the national reporting deadline. The Trust did not meet the 31 day first definitive treatment September due to lung cancer surgery capacity being much reduced in the independent sector. The Q2 formally reported position was achieved. There are some issues with Urology performance in October due to clearance of backlog patients, but Q3 is expected to achieve. The subsequent surgery target for September was also not met due to short notice absence of a Skin Plastic Surgeon for 6 weeks. The Q2 formally reported position was achieved and the Trust is expected to achieve for Q3. CSUs have developed 62 day recovery plans which include supporting 31 day performance and an update will be presented to the November Board. Performance: 100% Performance against the 31 day cancer standard for first treatments % Within 31 Days - First Treatments Target Tumour Type Sep-14 (%) Total Treated Brain/Central Nervous System 100.0% 4 95% Breast 96.6% 58 Children's 100.0% 12 90% Gynaecological 92.5% 40 85% Haematological 100.0% 43 80% Head & Neck 100.0% 33 Lower Gastrointestinal 97.8% 46 Lung 91.3% % 98% 96% 94% 92% Performance against the 31 day cancer standard for second or subsequent treatment Drug Drug Target Surgery Radiotherapy Surgery and Radiotherapy Target Sarcoma 94.1% 17 Skin 90.6% 32 Upper Gastrointestinal 97.7% 43 Urological 98.1% 53 Other 87.5% 8 Trust 95.7% 469 Cancer 31 Day Waits - Subsequent Surgery 92.1% % Cancer 31 Day Waits - Subsequent Drug Treatment 99.6% 252 Cancer 31 Day Waits - Subsequent Radiotherapy 99.3% 401 Page 12 of 29

15 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Accountability Framework Responsive 62 day cancer waiting times Standard(s): Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer. Ensure at least 90% of patients receive their first definitive treatment for cancer within 62 days following referral from an NHS cancer screening service. Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status (local contractual indicator). Owner(s): Consequence of failure: Notes: Commentary: Chief Operating Officer Timely access to treatment, patient experience, clinical outcomes, reputation and financial penalty Appendix 2 lists the peer Trusts included in the benchmarking graphs. The cancer indicators are monitored 2 months in arrears due to the timing of the national reporting deadline. Performance against the 62 day standard for referrals from consultant upgrade is liable to fluctuate due to the small numbers involved. The 85% standard was not met in September. As previously detailed, the non-compliance with this standard is attributed to under-diagnosis of the scale of pathway problems in some services, and the continued late referral of patients (past day 38) from other organisations. The requested trajectories for improved positions regarding transfers by day 38 have been received from Harrogate and York trusts; Airedale have responded but due to their small number of cases are unable to confirm a trajectory, and although a meeting has been held with Mid Yorks, a trajectory has not yet been received. A response to the letter from the COO to the remaining organisations (Bradford and Calderdale) is awaited. The TDA have agreed that supplementary reporting of internal and by day 38 performance separated from external post day 38 performance against the 62 day standard would be beneficial. This does not affect the nationally reported overall position shown in this report. CSUs have developed recovery plans and an update will be presented to the November Board, but as forecast, performance against the standard was not achieved for Q2 and is not expected until quarter 4 (dependent on an improvement in late referrals from other organisations). Performance: 100% 90% 80% 70% 60% 50% Performance against the 62 day cancer standard for GP/dentist referrals % Within 62 Days - GP/Dentist Target Tumour Type Sep-14 (%) Accountable Total Treated Breast 85.7% 21 Gynaecological 57.1% 18 Haematological (Excluding Acute Leukaemia) 72.7% 11 Head & Neck 51.7% 15 Lower Gastrointestinal 81.3% 16 Lung 60.5% 19 Other 60.0% 3 Sarcoma 81.3% 8 Skin 85.4% 21 Upper Gastrointestinal 73.9% 12 Urological (Excluding Testicular) 67.5% 20 Trust 71.5% % Cancer 62 Day Waits - Screening Referrals 91.4% 29 Cancer 62 Day Waits - Consultant Upgrades (local contractual indicator) 93.3% 15 Page 13 of 29

16 Accountability Framework Effective Summary Hospital Mortality Index (SHMI) Standard(s): Owner(s): Consequence of failure: Improve SHMI Chief Medical Officer and Clinical Directors Patient safety, patient outcomes and reputation The SHMI reports mortality at Trust level across the NHS in England using standard and transparent methodology. SHMI is the nationally recognised hospital level indicator of mortality. Commentary: The latest available data from Dr Foster, which covers the period April 2013 to March 2014, reports the Trust s overall SHMI as which remains within the expected range and is largely unchanged from the SHMI of reported for the previous period (January to December 2013). Performance: Trust Level SHMI (with adjustments), Apr-13 to Mar-14 Spells Value Observed Deaths Expected Deaths 95% Confidence Interval SHMI 95% CI 125, ,842 3, SHMI published banding (95% CL with over-dispersion) 125, ,842 3, SHMI (adjusted for palliative care) 125, ,842 3, SHMI (in hospital deaths) 125, ,692 2, Worse than expected Within expected range Better than expected Page 14 of 29

17 Relative Risk Accountability Framework Effective Hospital Standardised Mortality Rate (HSMR) Standard(s): Owner(s): Consequence of failure: Notes: Commentary: Improve HSMR Chief Medical Officer and Clinical Directors Patient safety, patient outcomes and reputation The HSMR reports mortality at Trust level across the NHS in England using standard and transparent methodology. The latest available data from Dr Foster, which covers the period April 2013 to March 2014, reports the Trust s overall HSMR as which remains within the expected range and is largely unchanged from the HSMR of reported for the previous period (January to December 2013). As displayed on the funnel chart below, the Trust remains amongst the top performers when compared to other non-london acute teaching hospitals. Performance: Trust Level HSMR, Apr-13 to Mar-14 Spells Value Observed Deaths Expected Deaths 95% Confidence Interval HSMR 58, ,292 2, Trust level HSMR (basket of 56 diagnoses) by data period Jan-12 to Dec-12 Apr-12 to Mar-13 Jul-12 to Jun-13 Oct-12 to Sep-13 Jan-13 to Dec-13 Apr-13 to Mar-14 Worse than expected Within expected range Better than expected Page 15 of 29

18 Accountability Framework Safe Incidence of MRSA Standard(s): Eliminate Trust-apportioned MRSA bacteraemia cases in 2014/15 Owner(s): Consequence of failure: Notes: Commentary: Chief Medical Officer, Infection Control Team, and Clinical Directors Patient safety, patient experience, quality of care, clinical outcomes, reputation and financial penalty Appendix 2 lists the peer Trusts included in the benchmarking graph. As at the end of October, there have not been any cases of MRSA bloodstream infection under the Trust s care since June. Performance: MRSA by CSU Oct-14 YTD Acute Medicine 0 2 Cardio-Respiratory 0 1 Digestive Diseases 0 1 Adult Critical Care 0 0 Children's 0 0 Hepatorenal 0 0 Leeds Cancer Centre 0 0 Urgent Care 0 0 Women's 0 0 Trauma and Related Services 0 0 Chapel Allerton 0 0 Centre for Neurosciences 0 0 Trust Number of trust-apportioned MRSA bacteraemia cases per 100,000 occupied bed days, Sep-13-Sep Trust(s) reported no MRSA cases for the period. Other Trusts Peers LTHT Trusts Source: Public Health England Page 16 of 29

19 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Accountability Framework Safe Harm free care Standard(s): Owner(s): Consequence of failure: Notes: Commentary: Ensure at least 95% of patients receive harm free care in relation to pressure ulcers, falls, CUTIs and VTE. Chief Nurse and Clinical Directors Patient safety, patient experience, clinical outcomes, quality of care and reputation n/app The improvement collaboratives to reduce falls and cardiac arrest calls are progressing. Work is on-going to clarify harms that happen within the Trust s care and to ensure ward teams fully understand information supplied to them, to support focussed planned interventions. The electronic collection of observations and calculation of Early Warning Scores is being piloted, which will improve the early recognition of deteriorating patients, and work continues to support the roll out of the catheter passport across the Trust and Leeds Community Healthcare, which will ensure details relating to care are accurately transferred between providers. The roll-out of a new assessment tool for pressure area assessment has been completed at SJUH and is underway at the LGI and CAH. The revised MDT falls booklet is being rolled out across the Trust to support more robust risk assessment and intervention planning to reduce the risk of falls. Performance: 100% % of Patients With Harm Free Care % of Patients With Harm Free Care Target 14% % of Patients With UTIs (New and Old) % With UTIs (LTHT) National mean for 13 month period (acute wards only) 95% 90% 94.12% 12% 10% 8% 85% 6% 80% 4% 2% 75% 0% Source: Safety Thermometer Source: Safety Thermometer Page 17 of 29