Summarise the Impact of the Health Board Report Equality and diversity

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1 AGENDA ITEM 4.1 Health Board Report INTEGRATED PERFORMANCE DASHBOARD Executive Lead: Director of Planning and Performance Author: Assistant Director of Performance and Information Contact Details for further information: Deb Evans, Assistant Director of Performance and Information. Tel: or Purpose of the Health Board Report The purpose of this report is to provide the Health Board with a summary of current performance across a range of indicators and key issues, in particular where there are current organisational challenges and achievement and/or the organisation is under formal escalation with the Welsh Government. Governance Link to Health Board Strategic Objective(s) The Board s overarching role is to ensure its Strategy outlined within Cwm Taf Cares 3 Year Integrated Medium Term Plan and the related organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) Triple Aim are being progressed, these in summary are; To improve quality, safety and patient experience. To protect and improve population health. To ensure that the services provided are accessible and sustainable into the future. To provide strong governance and assurance. To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. This report focuses on all of the above objectives. Supporting evidence The Integrated Performance Dashboard is included as supporting evidence. Integrated Performance Dashboard Page 1 of 11 University Health Board Meeting

2 Engagement Who has been involved in this work? The data and information contained within the dashboard originates from a variety of sources which have a number of engagement processes associated with them. The Integrated Performance Dashboard is also discussed monthly at the Executive Board and Finance and Performance Sub-Committee. Health Board Resolution To; APPROVE ENDORSE DISCUSS NOTE Recommendation To DISCUSS and NOTE the Integrated Performance Dashboard, this report and performance improvement actions outlined to support the achievement of targets. Summarise the Impact of the Health Board Report Equality and diversity There are no directly related Equality and Diversity implications as a result of this report. Legal implications A number of indicators monitor progress in relation to legislation, such as the Mental Health Measure. Population Health A number of indicators monitor progress in relation to Population Health, such as vaccination and immunisation uptake rates. Quality, Safety & Patient Experience A number of indicators monitor progress in relation to quality, safety and patient experience, such as healthcare acquired infection rates and access rates. Resources There are no directly related resource implications as a result of this report. Risks and Assurance Within the Integrated Performance Dashboard, actions are listed where performance is not compliant with national or local targets. Standards for Health Services The Integrated Performance Dashboard provides information on a range of key quality and performance indicators that will impact indirectly on a large number of the 26 Standards for Health Services in Wales. Workforce A number of indicators monitor progress in relation to Workforce, such as Sickness and Personal Development Review rates. Integrated Performance Dashboard Page 2 of 11 University Health Board Meeting

3 INTEGRATED PERFORMANCE DASHBOARD 1. SITUATION / PURPOSE OF REPORT The purpose of this report is to provide the Health Board with a summary of performance against a number of key quality and performance indicators, including areas where the organisation has made significant improvements or has particular challenges, together with areas where the Health Board is under formal escalation measures from the Welsh Government and/or where local progress is being monitored. The Board is requested to discuss and note the contents of the report and the supporting actions to improve the achievement of national and local targets. 2. BACKGROUND / INTRODUCTION This report provides the Health Board with an update on progress across a number of key quality and performance targets. These relate to the following organisational objectives: To improve quality, safety and patient experience; To protect and improve population health; To ensure that the services provided are accessible and sustainable into the future; To provide strong governance and assurance; To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. The report also sets out a number of issues affecting performance and associated actions underway to secure improvement. 3. ASSESSMENT / GOVERNANCE AND RISK ISSUES KEY ISSUES: Unscheduled Care (escalation level 2) Executive Lead, Chief Operating Officer and Director of Primary Care & Mental Health Performance against the 4 hour wait in A&E for July improved from 92.6% in June to 94.6%, which is the best monthly performance since November The number of patients waiting longer than 12 hours for completed treatment also improved significantly from 20 patients in June to 8 patients during July. This is the fewest number of 12 hour breaches ever recorded during one month. Despite the improving performance, the Health Board maintains its zero tolerance approach to patient waits in excess of 12 hours. The focus in this area is being led by the senior nurses and bed management teams. Analysis Integrated Performance Dashboard Page 3 of 11 University Health Board Meeting

4 of all 12 hour waits will continue with each reported as a clinical incident and remedial actions implemented with immediate effect. In terms of emergency ambulance services, July data shows against the fifteen minute handover target, performance has been sustained at 88%. However the number of ambulances delayed over one hour improved from ten in June to four during July, giving a monthly performance of 99.8%. The ambulance category A response time performance for July was 59.6%. Referral to Treatment Times (escalation level 1) Executive Lead, Chief Operating Officer Performance against the 36 week referral to treatment (RTT) target for July shows a further significant dip, with the number of patients waiting over 36 weeks increasing from 2280 to The table below gives the detailed breakdown by specialty. This number includes 1356 Ophthalmology patients. The number of patients waiting over 52 weeks for treatment is 358, 354 of which are within Ophthalmology, two in Orthopaedics and two in Dermatology. The main issue with delivery remains within the Ophthalmology service where there are currently 730 patients at stage 1 (first outpatients) and 626 at stage 4 (surgical treatment), giving a total of The table below outlines the 36 week trend over the last 12 months: Specialty July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Orthopaedics General Surgery Urology ENT Ophthalmology Oral Surgery Gynaecology Cardiology Rest. Dentistry Gastroenterology Diagnostics Respiratory Anaesthetics Dermatology General Medicine Rheumatology Haematology Total It should be noted that no procedures were cancelled during July due to the lack of availability of beds. However, analysis of theatre activity shows also that there has been a significant decrease in activity over recent months, in Integrated Performance Dashboard Page 4 of 11 University Health Board Meeting

5 comparison to previous years. The table below illustrates the variance with the high volume specialties. As can be seen, the number of procedures undertaken between April and July this year is 598 less than the same period of 20/ and there have been 101 fewer sessions undertaken. Further analysis is being undertaken with the Operations team to understand the reasons for this drop. Specialty Monthly Variance April to July Overall Variance April May June July 20/ 20/16 Anaesthetics Cases Number of Sessions ENT Surgery Cases Number of Sessions General Medicine Cases Number of Sessions General Surgery Cases Number of Sessions Gynaecology Cases Number of Sessions Ophthalmology Cases Number of Sessions Oral Surgery Cases Number of Sessions Orthopaedics Cases Number of Sessions Urology Cases Number of Sessions Total Cases Number of Sessions Cancer 31 and 62 Day Target (escalation level 2) Executive Lead, Medical Director Unfortunately the 31 day target was not achieved for June. The Health Board reported three breaches with a performance of 97.6%. All three patients were within the Lung tumour site area and were treated at the tertiary centres. There were no delays at Cwm Taf for these patients as the clock starts in terms of measuring performance at the tertiary centre. These breaches are classified as shared breaches between the Health Board and the tertiary unit, with the performance allocated to Cwm Taf in terms of reporting. In terms of the 62 day target, unfortunately this was also not achieved for June. The Health Board reported ten breaches and a performance of 82.8%. Five patients were treated at the tertiary centre but only one was referred by Integrated Performance Dashboard Page 5 of 11 University Health Board Meeting

6 Cwm Taf by day 31 of the pathway. The breaches were in Urology (5), Lung (2), Gynaecology (2) and Head & Neck (1). Both lung patients were complex cases. In terms of urology, patients experienced delays for outpatients appointments, biopsies and in-house surgery. The table below shows the number of breaches by tumour site and the overall monthly performance over the last 12 months within this area Urology Lung Lower GI Head & Neck Gynae Haem Upper GI Breast No Breaches Perform ance July % August % September % October % November % December % January % February % March % April % May % June % Total Stroke Bundles (escalation level 1) - Executive Lead, Director of Planning and Performance During June, 38 patients were recorded within the stroke database and performance improved in three out of four of the stroke care bundles, with one being compliant with the 95% target. The table below details the monthly performance since April 20. As can be seen, there has been an incremental improvement since this month in bundles 2, 3 and 4, with bundle 1 performing well, as has been seen in previous months. Bundle April - 38 Pts May - 31 Pts June - 38 Pts First Hours (1) 92.1% (35/38 pts) 96.1% (30/31 pts) 94.7% (36/38 pts) First Days (2) 52.6% (20/38 pts) 77.4% (24/31 pts) 86.8% (33/38 pts) First 3 Days (3) 76.3% (29/38 pts) 87.1% (27/31 pts) 92.1% (35/38 pts) First 7 Days (4) 86.8% (33/38 pts) 87.1% (27/31 pts) 97.4% (37/38 pts) The main issue for June was again with bundle 2, in particular direct access to the Stroke Unit (89.5%) and providing a timely swallow screening assessment (94.7%). It should be noted that 100% of patients had a CT scan, nutritional screening and were prescribed aspirin in time within this bundle. Only the manual handling assessment component of bundle 3 was non-compliant (94.7%). All elements of bundle 4 were compliant. Mental Health Measure - Executive Lead, Director of Primary Care & Mental Health Compliance with the Mental Health Measure has improved during June, in comparison to recent months. Integrated Performance Dashboard Page 6 of 11 University Health Board Meeting

7 Part One of the Mental Health Measure relates to the primary care assessment and treatment and has a target for 80% of referrals to be assessed within 28 days. Performance during June improved from 49.6% in May to 63%. Compliance has reduced slightly for the treatment element of the measure. During June 88.8% of patients received their treatment within 56 days of assessment against a target of 90%. Part Two of the Measure relates to patients with a current care treatment plan and has a target of 90%. Performance improved for June at 82.1%. The Directorate has revised its action plan with a view to achieving by September 20. Workforce and Organisational Development Update Executive Lead, Director of Workforce and Organisational Development Analysis is carried out on a regular basis within the Workforce and OD Directorate on sickness absence rates personal development review (PDR) rates and Consultant Job Plans, which is included in detail in the attached Integrated Performance Dashboard. The source of data for this analysis is the Electronic Staff Record (ESR). Sickness Absence Detailed reports on the sickness absence levels in the UHB are provided separately to the Executive Board and to the F&P Committee. The information currently remains up to two months behind which will not be resolved until the Health Board has completed the roll out of ESR which is due for completion by June Roll out of e-rostering will also help as it feeds sickness directly into ESR. The UHB target is 4.5% from 1 st April 20. Cwm Taf sickness percentage monthly, 13 months May 20 to May 20, shows that there has been a slight decrease from 5.23% in April 20 to 5.22% for May 20. Although representing a continued reduction, the absence rate is fairly static. There are continued, structured management actions and efforts to reduce absence, however the impact of the change to terms and conditions, restricting receipt of enhancements when on sick leave, may now be levelling off. Analysis of the seasonal trend demonstrates that sickness absence has normally levelled off or has started to increase. Long Term Absence for April 20 was 3.85% and remains fairly static at 3.84% in May 20. Short Term Absence remains static at 1.39% for May 20, the same as in April 20. In relation to reasons for absence, the instances of absence days lost for unknown causes has increased from 997 in April 20 to 1,099 in May 20 which is disappointing. Actions have been taken to remind managers not to use this code when recording sickness absence and the rate of unknowns is Integrated Performance Dashboard Page 7 of 11 University Health Board Meeting

8 reported at the CBM. Work is ongoing to reduce the recording of unknowns with the help of the roll-out of ESR Self Service. The number of absences attributed to anxiety/stress/depression has increased from 2,865 in April 20 to 3,071 in May 20. In addition, other MSK has increased from 1,5 in April 20 to 1,205 in May 20. There were a total of 5,375 days lost in May 20. The general trend is that sickness absence is progressing downwards across the UHB since January 20. Robust activity regarding the implementation of the sickness absence policy and other measures such as the review of Occupational Health services continue. Sickness absence is discussed at each Clinical Business meeting and work is continuing to analyse the various factors in each individual directorate and department, and to react and plan accordingly. All Wales Overview/Activity The new All Wales Sickness Absence Policy is due to be agreed and circulated by the Welsh Partnership Forum shortly and will need to be ratified by the Board. This will create an opportunity for the Workforce & OD team to reinvigorate and reinforce the application of the policy in terms of sickness absence monitoring in relation to trigger points and formal reviews. This will be undertaken by an intensive round of training sessions and communications, such as distribution of the policy flow chart. Key areas of focussed action for June / July 20 Activity to support managers to address sickness absence continues and is a high priority for WOD business partners. Reporting at CBMs is also given significant focus. The key areas of note for the reporting period are as follows. 1. Short term absence and RTWs Audits of compliance with the policy are being continued in areas of higher sickness absence and RTW compliance is now being routinely reported through CBMs; It is recognised that low compliance with RTW interviews are due to not being recorded on ESR, not because they are not taking place. This is being addressed in all areas and there should be a notable increase in compliance figures over the next few months. 2. Continue with Regular Audits The focus is on compliance with policy and triggers, targetting reduction on unknowns, promotion of ESR utilisation and Business Intelligence. 3. MSK and back problems Two areas of action include reviewing Manual Handling training compliance and improved access to physiotherapy services in OH. Staff can self refer. Additional capacity has been secured in discussions with Therapies directorate. Integrated Performance Dashboard Page 8 of 11 University Health Board Meeting

9 4. Analyse high % of stress, anxiety, depression Emerging analysis of stress/anxiety/depression as a reason for absence appears to be increasingly due to external and personal factors rather than work-related. This analysis is ongoing and is being considered by the OH sub-group Stress in the Workplace. Stress risk assessments are undertaken where necessary and acted upon with support from OH. The Counselling service is being used frequently by the departments. 5 Improved reporting and use of ESR Better use of ESR Business Intelligence is being promoted to provide managers with accurate real time data wherever possible. Managers are being trained to use ESR and ESR BI data is now being provided to CBMs which tracks the level of utilisation. Other issues being identified. Further emergent feedback is emanating from staff shortages and is evidenced as a factor in low morale and low productivity which in turn may result in sickness absence. It is acknowledged that recruitment is a high priority activity for the Health Board. Consideration is also being given to areas of organisational change and service redesign, where staff are uncertain about their future and services that may be provided in the future. Increased attention is being given to these areas regarding the management of change and ensuring open and transparent communications with staff and their representatives. Occupational Health OHWB Strategy The final draft of the OHWB Strategy has been submitted, complete with a full implementation plan and funds identified for the new structure. The Strategy is based on the Nurse Case Manager model. Physiotherapy service review The final draft of the physiotherapy service review will be submitted at the end of September. A new member of staff will commence in post at the beginning of August and it is hoped this will alleviate waiting lists at PCH Flu campaign Commencing 5 th October, additional nursing and A&C resources will be sought. Personal Development Reviews As at 1 st August 20 compliance is 73.36%. The upward trend continues with an overall increase of 13.22% since Oct 20. Integrated Performance Dashboard Page 9 of 11 University Health Board Meeting

10 The majority of Directorates continue to perform above 60% compliance with only 4 below 50% The number of Directorates declining or static remains unchanged at 11. However these decreases are marginal ranging from 0.2% to 4% The number of staff progressing through 2nd gateways without a PDR on a monthly basis has remained static at 56%. The volume of PDRs recorded via ESR Self Service continues to increase as Self Service training is rolled our for Managers/Supervisors L&D are working in close partnerships with Business Partner colleagues to support managers with persistent non-compliance issues and develop actions for improvement. Job Planning for Consultants and SAS staff Medical Appraisal and Revalidation The Medical appraisal year commences 1 st April each year. From the 1 st April 30 th June 20, a total of 21.20% of doctors have had a complete annual appraisal. This includes GPs for Merthyr Tydfil and RCT. Approval has been given to recruit to three Medical Appraisal Co-ordinator posts, to support the Quality Management Framework (approved at Wales Revalidation Delivery Board). Expressions of interest have been sought and interviews have been scheduled for 13 th August 20. Job Planning Progress continues with Consultant job planning in ACT with the number of consultants with a current signed job plan continuing to rise from 70.59% to 79.41%. Job plan meetings for all SAS doctors within the ACT Directorate have also been arranged. The Directorate of Radiology has almost completed the Consultant job plan cycle with just one remaining to be scheduled. However, there has been a significant delay in the completed signed job plans reaching Workforce and OD (these remain outstanding at time of reporting). Job plan meetings continue to be scheduled in other directorates including Obstetrics, Gynaecology & Sexual Health and Paediatrics. A reporting schedule has been developed with the Performance and Informatics team and will be available to individual Directorates via Sharepoint on a monthly basis to report the latest job planning compliance. The toolkit uses information from ESR BI and support the Directorates in identifying and prioritising lapsed job plan meetings and assist in improving compliance. This will also be made available for HR Business Partners to access. Implementation of the e-job planning system is on target to commence September 20 with formal training arranged for the Directorate Management team in General Surgery, Urology and T&O. Following the training, it is anticipated that the job plan cycle will commence within the Directorate in October 20. Integrated Performance Dashboard Page 10 of 11 University Health Board Meeting

11 4. RECOMMENDATION The Health Board is asked to: - DISCUSS and NOTE the Integrated Performance Dashboard, this report and performance actions outlined to support the achievement of targets. Integrated Performance Dashboard Page 11 of 11 University Health Board Meeting