2017/18 Trust Balanced Scorecard

Transcription

1 ITEM 8b ENC /18 Trust Balanced Scorecard Author: Performance Management Team March 2017 The purpose of this paper is to provide an update on the development of the 2017/18 Balanced Scorecard for Birmingham Community Healthcare Foundation Trust. This paper was presented to Executive Management Forum on 6 March 2017 for comment and approval prior to a planned presentation to Board Seminar on 7 March Comments received from Board seminar are indicated in this report and this final report is submitted to Trust Board for final approval. Once approved, this will be disseminated to the organisation. Introduction The overall purpose of the Trust Balanced Scorecard is to translate the vision and goals of the Trust into a comprehensive set of objectives and performance measures that can be quantified and appraised on a monthly basis to continuously improve strategic performance and results. The measures on the balanced scorecard are currently categorised across the five domains of: safety, quality, patient experience, workforce and efficiency and finance. Every performance measure on the scorecard is aligned to one of the Trust s strategic objectives around people, place, purpose, promotion, partnership and price thereby providing measurable indicators for strategic objectives. 1. Process for review of the scorecard The scorecard has been revised taking account of external guidance and internal advice and expertise from the Executive Director team and their indicator leads. 1.1 External guidance has been drawn from the following: The NHS Operational Planning and Contracting Guidance published by NHS England and NHS Improvement NHS Improvement Single Oversight Framework Delivering the Forward View: NHS Planning guidance 2016/ /21 describes the NHS Five Year Forward View which sets out the vision for the future of the NHS. Commissioner expectations confirmed through contract negotiations. 1.2 Internal revisions have also been made following: The Board Annual Planning meeting on 18 January 2017 Indicator performance review meetings between members of the Performance Management Team and Executive Directors and their leads held in February Summary of Revisions The revised Trust balance scorecard proposed has a total of 52 measures. Four new indicators have been proposed for addition whilst eight indicators have been suggested for removal. A V1.2 Updated following Board Seminar Page 1

2 number of indicators have had a new target value set or have been revised. All of the changes are summarised below. 2.1 Suggested new indicators for 2017/18 Workforce & Efficiency Domain Agency Spend relative to Cap (YTD cumulative) Following new targets from NHS Improvements relating to Agency Spend the Trust now has a financial cap. It is proposed to report the variation from this cap as a cumulative total throughout the year. This could be as a % variance or alternatively a financial value. The 16/17 KPI reported Agency spend as a percentage of total pay bill and was therefore compared with a moving target. The proposed amends will lead to greater clarity about performance against the cap. The overall Trust Target of this indicator will be devolved to Divisions based on their use of Agency in 16/17 as a proportion of the Trust total spend. Workforce & Efficiency Domain Delayed Transfers of Care NHS Reasons In addition to the current KPI reporting the overall percentage of Delayed Transfers of Care it is proposed to add a line showing the percentage of Delayed Transfers which were defined as NHS reasons. Workforce & Efficiency Domain Average Length of Stay In order to monitor efficient use of bed stock and achievement of contractual targets it is proposed to report the Average Length of Stay for in patients. Workforce & Efficiency Domain Reactive Estate Support Assurance The Estates reactive services provide a 24/7 operational service in ensuring maintenance repairs to property, clinical and patient areas and associated equipment, are suitably maintained to the highest standard possible and in a risk prioritised timeframe. The Reactive Estate Support Assurance target provides the Trust with compliance evidence of targeted, time constrained and prioritised repairs of the environment successfully being achieved against benchmarked targets and standards. A quarterly board assurance metric that is benchmarked at a target of 90% will be produced to demonstrate the reactive assurance of Priority 1 call outs. This priority is measured on same day urgent reactive estate calls to clinical/medical breakdown and repair to bed head services and patient care equipment and building environment. Updated following Board Seminar: Reactive Estates Support Assurance - 10% not achieved include in RAP and discuss at PPMB and where necessary escalate to FPAC. RAP to include response times and rationale for 10% none achievement. Consider development in year of a new measure of STP Admission Avoidance Measure as the STP s develop. V1.2 Updated following Board Seminar Page 2

3 2.2 Indicators with suggested revisions for 2017/18 Safety Domain VTE Risk Assessed on admission The current VTE KPI reports the percentage of patients offered appropriate prophylaxis following an assessment indicating high risk of VTE. It is proposed to replace this with a target reporting the percentage of patients who received an appropriate VTE risk assessment on admission. This amend is in accordance with the Single Oversight Framework. Workforce & Efficiency Domain Mandatory Training Contractual Mandatory Training Non-Contractual Contracts for the next two years show a reduction in the number of individual Mandatory Training courses included as contractual targets. Additionally divisions now have a greater number of contracts with different commissioners and targets, meaning that some training courses may be contractual for one group of staff but not for another. It is therefore proposed to report one single indicator for Mandatory Training Compliance and additionally work in year towards developing a further KPI describing wasted training spaces defined in the agreed Demand and Capacity plans with the L&D team at the start of the year. Full breakdowns of performance against individual mandatory training courses will continue to be reported on Divisional Scorecards. Finance Domain Contractual RAP process / financial penalty or Activity Management Plan Indicator renamed from Contractual RAP/financial penalty. The indicator will be expanded to report on individual services where formal Activity Management Plans (AMPs) are in place with Commissioners to manage over or underperformance in a specific service. The KPI will continue to report instances where a formal Remedial Activity Plan is agreed with Commissioners. Finance Domain Finance and Use of Resources Score This indicator has been amended following a change to the NHS Improvement methodology used to create the financial metric. Specifically a score reflecting the Provider s distance from Agency Spend Cap is now included in the methodology. 2.3 Indicators with a suggested amended target value Safety Domain Falls with Severe Injury or Death (cumulative) Following excellent performance, it is proposed to reduce the internal target from an annual total of no more than 22 cases in 16/17 to no more than 18 cases in 17/18. Safety Domain Grade 3 or 4 avoidable PUs Community (cumulative) Following excellent performance it is proposed to review the target which for 16/17 was no more than 28 cases. A clinical summit led by the service with input from the Director of Nursing & Therapies will meet on 30 th March 17 and will recommend a revised target. Quality Domain V1.2 Updated following Board Seminar Page 3

4 Percentage Compliance with CQUINs (forecast) CQUINs schemes have changed for 17/18 and onwards with all schemes now nationally mandated and Commissioners unable to amend targets for local agreement as in previous years. As a result it is proposed that the target for this indicator be reduced from 100% and instead be based on a realistic assessment from the CQUIN Board of what is possible to achieve. Patient Experience Domain Average response time to complaints (weeks) The 17/18 target for average response time to complaints will be standardised across all divisions with a reducing trajectory starting at 23 weeks in Q1 and reducing to 20 weeks by the end of the year. Some challenges are anticipated for individual divisions in meeting this target. Workforce & Efficiency Domain Average Length of Time to Recruit (Date Advertised to Offer) It is noted that this Indicator performs well and is particularly sensitive to individual breaches of target time, particularly at a Divisional level. The Board are asked to consider whether a reduction in target from the current 60 days would support a continued focus on recruitment or whether the current target provides sufficient challenge. Workforce & Efficiency Domain DNA Rates (Clinical Appointments) Noting that this KPI is no longer a contractual performance target it is proposed to standardise the DNA target across the Trust at 9% with the target applying to all Divisions. 2.4 Indicators suggested to be removed from the Scorecard Safety Domain MSSA bacteraemia new cases (cumulative) Noting strong historic performance of this indicator and lack of national targets it is proposed to remove this KPI from the Trust and Divisional scorecards. The indicator is not a statutory requirement and will continue to be reported to the Infection Control Committee. Safety Domain MRSA Screening with 24 hours The indicator has been established for a number of years with a strong performance throughout that time period. The indicator is ward focused and is not included in the Single Oversight Framework. It is then proposed to remove the KPI from the Trust Scorecard whilst leaving it as a Divisional level KPI on the Specialist, Rehab and Urgent Care scorecards. Quality Domain 18 week pathway consultant led (Admitted Patients) 18 week pathway consultant led (Non-Admitted Patients) Both national guidance and contractual frameworks have changed in order to focus on the key target of Incomplete Pathways (patients waiting for treatment). It is felt that the clock stop targets risk distorting clinical priorities as patients only record a breach once treated. In practice they can also cause confusion for a service who is attempting to manage both incomplete and clock stop targets. A focus will remain on incomplete waits with patients who have waited longer than 18 weeks breaching this target every month until treated. It is proposed to remove both the admitted and non-admitted pathways from the scorecards. Quality Domain Waiting Times for Diagnostic tests - % in 6 weeks As outlined in the Single Oversight Framework this indicator relates solely to Acute and Specialist Providers delivering defined procedures. It is therefore proposed to remove this KPI from the V1.2 Updated following Board Seminar Page 4

5 Trust Scorecard and also from the Children & Families Scorecard, whilst maintaining it on the Dental Divisional Scorecard as relevant to their activity. Updated following Board Seminar: Keep this measure Workforce & Efficiency Domain Turnover 12 month rolling total Noting that this KPI is stable and Green it is proposed for its removal from the Trust scorecard but retained on the divisional scorecards in the Human Resources domain. ESR will still be able to provide turnover information to services that require it for Business Planning. Workforce & Efficiency Domain Bank & Agency Spend as a % of Total Staff Spend It is proposed to remove this KPI as in practice having both this Indicator and one relating solely to Agency Spend has tended to generate two very similar narratives. In order to reflect the increased priority which is required for the management of Agency Spend a single KPI dedicated to this will generate a more focussed response. Workforce & Efficiency Domain Estates - % Occupancy It is proposed to remove this metric as it doesn t provide assurance to the board. 3.0 Proposed amendments to Divisional Scorecards Workforce & Efficiency Domain Percentage of sickness absence It is proposed to maintain the current target of 4.3% at a Trust level but following structural changes in 16/17 to review the individual allocation of targets to the Divisions. Finance Domain Contractual Activity Variance It is noted that in situations where a Division is facing both underperformance and overperformance against activity in different services this KPI can fail to give clarity on the nature of an issue. For example, significant over-performance in Community IMTs is not fully reflected on the scorecard due to underperformance in other areas. In addition over-performance against a cost and volume contract would normally be positive and generate additional resource whilst overperformance against a block contract involves additional work with no additional funding. It is proposed that two separate KPIs are reported to clarify this issue as follows: Finance Domain Contractual Activity Variance Block Contract (xx% of total planned income) This KPI is to report an aggregated divisional position comparing actual number of contacts (cumulative year to date) against the contractual activity plans for all Block service lines. A suggested tolerance of 5% is to be applied to this activity with over-performance above 5% being viewed as a breach suggesting additional activity for which the Trust is not receiving additional income. To provide context the KPI title will also state what percentage of planned divisional income for the year is included as part of the aggregated block position. V1.2 Updated following Board Seminar Page 5

6 Some concerns have been raised from Commercial Finance colleagues, specifically it is noted that some Block service lines do not have any targeted activity and would not therefore be reportable in this format. However it is noted that this is currently the case with the existing Contract Activity Variance KPI and additionally that this equates to less than 10% of the overall value of Block Contracts. It would be possible therefore to remove these service lines from the Indicator. In addition it is noted that some of the Block activity targets are historic and based on poor data. A rebasing exercise is taking place during 16/17 and this could lead to fluctuations in a service s target and performance. Finance Domain Contractual Activity Variance Cost and Volume (xx% of total planned income) This KPI is to report an aggregated divisional position comparing the financial value of contacts (cumulative year to date) against the contractual activity plans for all cost and volume or payment by results (PBR) tariff services. A tolerance would be applied to highlight the risk of marginal rates for activity (usually at 5% above or below target) with under-performance suggesting a loss of planned income. To provide context, the KPI title will also state what percentage of planned divisional income for the year is included as part of the aggregated Cost & Volume position. It has been noted that cap and collar arrangements in this area will present a challenge to reporting of this data. It is proposed to report this KPI as a financial value rather than based on units of activity in order to account for reduced or marginal tariff payments over a cap. 3.2 Proposed change of Executive Lead on Scorecard Safety Domain Percentage of Deaths Compared to all Discharges (excluding End of Life Care) In line with national guidance it is proposed to make the Medical Director the lead for this KPI (during 16/17 responsibility sat with the Director of Nursing and Therapies). The current definition of the indicator may also change due to work being undertaken on mortality governance nationwide and therefore may be amended in year. It is also proposed for the following Infection control KPIs to change from Medical Director to Director of Nursing and Therapies. C.diff new cases avoidable (cumulative) C.diff all cases (cumulative) MRSA bacteraemia new cases (cumulative) MRSA screening within 24 hours The workforce and governance KPIs currently have the Chief Executive as the Executive Lead. It is proposed that the Executive lead for workforce related indicators changes to the HR Director whilst the Complaints and Incidents related indicators lead changes to the Corporate Governance Director. The KPIs affected by these changes are listed below: % of SI and RCA action plans completed within agrees timescales Number of never events Number of serious incidents % complaints responded to in agreed timescales Average response time to complaints (weeks) Number of complaints per 10,000 activity contacts (1 month in arrears) Percentages of vacancies % sickness absence Average length of time to recruit Agency spend as % of total staff spend YTD Turnover 12 month rolling total V1.2 Updated following Board Seminar Page 6

7 3.3 Review of Alignment to Strategic Objectives Underneath each of the five domains are a range of indicators aligned to the six strategic objectives: People Price Promotion Place Partnerships To transform and deliver high-quality, efficient, integrated services that enable the best possible outcomes through our integrated delivery models To have a skilled, adaptable, innovative and diverse workforce that is valued and supported and empowered where compassionate and caring leadership are at the heart of our services. To secure our sustainability within the wider system through efficient use of resources and effective commercial relationship management. To promote the organisation and integrated care services that we and our partners deliver by engaging and effectively communicating with all of our stakeholders. To deliver services flexibly in the most appropriate patient centred location, supported by an effective and efficient fit for purpose shared estate. To develop effective partnerships, breaking down any barriers in order to provide integrated community care to maximise the benefits of expertise in the organisation to our partners and communities. Updated following Board Seminar: On Trust Scorecard, Data Quality Section in April s QPR, include plan on a page as to when the data quality indicators will be achieved in year. V1.2 Updated following Board Seminar Page 7

8 3 Trust Scorecard Quality Performance Domain - Safety Objective KPI Changes Historic Data Latest Data Trends Jan 2016 YTD Plan 17/18 Annual Annual Executive Data Quality 17/18 Oct 2016 Nov 2016 Dec 2016 Jan 2017 DoT Target FOT Lead D I A Safe staffing - % fill rate People 94.6% 97.8% 93.7% 91.8% 93.1% 100.0% GH C. diff new cases avoidable (cumulative)* GH MRSA bacteraemia new cases (cumulative) GH Falls with severe injury or death (cumulative) GH Falls with harm per 1000 OBDs GH Grade 3 or 4 avoidable PUs community (cumulative)* TBC GH Grade 3 or 4 avoidable PUs inpatients (cumulative)* GH Patient Safety Thermometer (harm-free care - new and old harms) Promotion 97.83% 97.35% 98.51% 97.95% 97.60% 95.00% GH Patient Safety Thermometer (harm-free care - NEW HARMS ONLY) Promotion 99.33% 99.15% 99.56% 99.37% 99.35% 95.00% GH Percentage of deaths compared to all discharges (excluding end of life care) Promotion % 2.22% 3.37% 2.39% 1.82% 5.40% AW % of SI and RCA action plans completed within agreed timescales People 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% TT C.diff - all cases (cumulative) N/A GH Number of never events Promotion TT Number of serious incidents Promotion N/A TT WHO surgical checklist compliance 100% 100% 100% 100% 100% 100% GH VTE risk assessed on admission % % % % % 95.00% GH Estates - compliance with statutory requirements for freehold property (quarterly) Place JT Domain - Quality Rapid response cases requiring onward admission to acute hospital - 1 month in arrears Ref 13.10% 7.40% 12.00% 9.90% 10.90% 15.00% JT Essential care indicators inpatients (aggregated measure) 97.90% 96.80% 96.60% 96.30% 93.20% 95.00% GH Essential care indicators community (aggregated measure) 96.10% 96.40% 96.50% 96.10% 95.10% 95.00% GH Essential care indicators - LD Inpatients 89.80% 98.20% 94.10% 98.50% 97.00% 95.00% GH Essential care indicators - LD community 69.50% 67.20% 74.70% 72.20% 35.00% 95.00% GH Early Warning Alerts - wards/units with 5 or more triggers GH 18 week pathway consultant led services (incomplete pathways) 94.21% 93.39% 94.10% 93.98% 93.78% 92.00% JT Zero tolerance RTT waits over 52 weeks JT % compliance with CQUINs (forecast) % 96.0% 96.0% 100.0% 97.8% TBC GH Cancer referrals (Urgent 2WW) % % % % % 93.00% JT CPA 12 month follow up 95.20% 93.65% 95.24% 95.90% 97.00% 95.00% JT *Data 2 months in arrears as RCAs are agreed with commissioners Cause / Health Outcome indicator KPI Changes 17/18 1. C.diff new cases avoidable (cumulative) - change in Exec Lead 2. MRSA bacteraemia new cases (cumulative) - change in Exec Lead 3. Change in target for Falls with severe injury or death (cumulative) 4. Target changing for Grade 3 or 4 avoidable PUs community (cumulative)* 5. Percentage of deaths compared to all discharges (excluding eol) - change in Exec Lead 6. C.diff all cases (cumulative) - change in Exec Lead 7. Proposed revised indicator VTE risk assessed on admission 8. Target changing for % compliance with CQUINs 8

9 Quality Performance Domain - Patient Experience Objective KPI Changes Historic Data Latest Data Trends Jan 2016 YTD Plan 17/18 Annual Annual Executive Data Quality 17/18 Oct 2016 Nov 2016 Dec 2016 Jan 2017 DoT Target FOT Lead D I A % Complaints responded to in agreed timescale People % % % % % % TT Average response time to complaints (weeks) People TT Customer Experience - % patients reporting very good or excellent Promotion 91.00% 90.00% 92.00% 92.00% 87.66% 85.00% GH Friends and family test Promotion 93.00% 93.00% 91.00% 94.00% 90.43% 85.00% GH Number of complaints per activity contacts (1 month in arrears) People N/A TT Use of Resources Performance Domain - Workforce & Efficiency YTD % CRES/ QIPP milestones achievement position Price 96.00% 96.07% 97.93% 97.74% 95.83% % LT DNA rates (clinical appointments) Price % 7.30% 7.26% 7.00% 7.20% 9.00% JT Mandatory Training Compliance People % GH & JT Percentage of vacancies People 9.29% 9.30% 8.90% 9.10% 12.10% 9.00% TT % sickness absence People 5.56% 5.53% 5.95% 6.23% 5.82% 4.30% TT % staff appraised (12 month rolling average) People 79.4% 81.7% 79.6% 82.0% 82.0% 90.0% JT Average length of time to recruit (date advertised to offer) People days 54 days 44 days 56 days 61 days TBC TT Agency spend as a % of total staff spend YTD 7.55% 7.52% 7.43% 7.31% 8.92% 4.94% TT Agency Spend relative to Cap (YTD cumulative) 13 TT Contractual RAP process / financial penalty or Activity Management Plan Partnership PA Total delayed transfer days as % of OBDs Price 9.65% 10.14% 10.98% 12.58% 11.82% 7.50% JT Delayed transfer days as % of OBDs - NHS reasons Price 15 JT Average length of stay Price 16 JT Environmental Cleanliness Assurance Place 17 TBC JT Reactive Estate Support Assurance Place 18 TBC JT Domain - Finance Net income and expenditure ( 000) Price 1, , , , , , PA CRES achievement - % YTD actual compared to YTD Plan Price 99.31% 98.20% 96.87% 95.94% 78.17% % PA Finance and Use of Resources Score Price PA Cash balance ( m) Price PA Capital programme - % achievement of plan Price 88.0% 91.3% 86.3% 76.8% 65.2% 90.0% PA Cause / Health Outcome indicator KPI Changes 17/18 9. Standardised target for Average response time to complaints (weeks) 10. A revised target for DNA rates (clinical appointments) 11. Revised training indicator - Mandatory Training Compliance 12. Proposed new target for Average length of time to recruit (date advertised to offer) 13. Agency spend relative to Cap (cumulative) - new indicator 14. Indicator renamed to include Activity Management Plan 15. Delayed transfer days as % of OBDs - NHS reasons - indicator added to the Trust scorecard 16. Average length of stay - indicator added to the Trust scorecard 17. Estates - Environmental Cleanliness Assurance - new indicator 18. Estates - Reactive Estate Support Assurance - new indicator 19. Indicator updated from Continuity of Service Risk Rating to Finance and Use of Resources Score 16/17 KPIs Removed 18 week pathway consultant led (admitted patients) 18 week pathway consultant led services (non-admitted patients) Bank and agency spend as a % of total staff spend YTD MRSA screening within 24 hours MSSA bacteraemia new cases (cumulative) Turnover - 12 month rolling total Waiting times for diagnostic tests - % in 6 weeks Estates - % occupancy (quarterly) 9

10 Document Title: Briefing on the 2017/18 Trust Balanced Scorecard The purpose of this paper is to provide Governors with the background to the 2017/18 Trust Balanced Scorecard and to provide some detail on the indicator measures. 1. Introduction The overall purpose of the Trust Balanced Scorecard is to translate the vision and goals of the Trust into a comprehensive set of objectives and performance measures that can be quantified and appraised on a monthly basis to continuously improve strategic performance and results. 2. Development of the scorecard Every year the scorecard is revised to take account of external guidance and internal advice and expertise. External guidance is drawn from NHS England and NHS Improvement requirements set out within the Single Oversight Framework and Commissioner expectations confirmed through contract negotiations. Internal revisions are proposed through the Annual Review Board session held in January each year and built upon through Executive Director and Management Team feedback. The balanced scorecard has a total of 52 measures. The measures on the balanced scorecard are categorised across the five domains of: Patient Safety, Patient Experience, Workforce and Efficiency, Clinical Quality and Finance. Every performance measure on the scorecard is aligned to one of the Trust s strategic goals around people, place, purpose, promotion, partnership and price. Trust balanced scorecard explainer The balanced scorecard for 2017/18 is arranged into 5 domains: 1. Safety 2. Quality 3. Patient Experience 4. Workforce and Efficiency 5. Finance Underneath each of these domains are a range of indicators aligned to the six strategic objectives: 1. People 4. Promotion 2. Place 5. Partnership Price 10

11 No Indicator Objective Description Data Classification Safety Domain 1 Safe staffing - % fill rate People Safe staffing levels are measured to give assurance that inpatient services are adequately staffed to provide safe and effective care. This indicator reports the overall fill rate for inpatient areas in the month. It is reported as the actual hours rostered expressed as a percentage of the required hours, taking into account number of patients and dependency in a twice-daily census. Annual Target RAG RATING In month 100% RED < 80% or >120% AMBER 80-<90% or > % GREEN % 2 Clostridium difficile new cases avoidable (cumulative) confirmed post RCA This indicator reports the total number of post 48 hour Clostridium difficile toxin positive cases attributable to BCHC confirmed as avoidable after a root cause analysis (RCA) review for the month. It demonstrates that our standard of practice in relation to Control of Infection is good; links to quality and safety of patient care and to managing our reputation as a healthcare provider. Furthermore it can affect our registration with the Care Quality Commission (CQC). Cumulative YTD 5 RED > 5 GREEN 5 3 MRSA bacteraemia new cases (cumulative) 4 Falls with severe injury or death (cumulative) Achievement of this target demonstrates our standard of practice in relation to Control of Infection, links to quality of patient care and to managing our reputation as a healthcare provider and our registration with the Care Quality Commission. The measure exclude patients discharged from acute settings already on suppressive therapy. All falls resulting in fracture, including those categorised as severe harm or death are reported and managed as serious incidents. This indicator reports the number of such incidents that occur. The target has been set based on 16/17 performance this presents a challenge as the acuity of patients in Trust inpatient units increases. The aim is to encourage active risk management in falls prevention and reducing harm from falls. This will in turn contribute to the Trust goal of delivering "harm free care" as part of the Safety Express project. Cumulative YTD Cumulative YTD 0 RED > 0 GREEN 0 18 RED > 2 per month GREEN 2 per month 11

12 No Indicator Objective Description Data Classification 5 Falls with harm per 1000 OBDs The rate of patient falls resulting in harm. Harm is defined using the NPSA measurement of harm. (Minor harm to severe harm and death) The indicator purpose is to aid the implementation of interventions to prevent falls and ensuring that individualised falls prevention care planning is embedded in practice will help to maximise patient safety, reducing the harm from a fall and also help to deliver efficient and effective clinical services. Annual RAG RATING Target In month 2.84 RED > 3.13 AMBER 3.13 and > 2.84 GREEN Grade 3 or 4 avoidable pressure ulcers community (cumulative) The cumulative number of avoidable pressure ulcers occurring in the community. The purpose of the indicator is a further reduction in grade 3 and 4 avoidable pressure ulcers occurring in the care of BCHC in the community. Data is 2 months in arrears to allow time for the Root Cause Analysis to confirm whether the ulcer was avoidable. Cumulative YTD TBC TBC 7 Grade 3 or 4 avoidable pressure ulcers inpatients (cumulative) The cumulative number of avoidable pressure ulcers occurring in BCHC inpatient units. The purpose of the indicator is a further reduction in grade 3 and 4 avoidable pressure ulcers occurring in the care of BCHC in inpatient units. Data is 2 months in arrears to allow time for the Root Cause Analysis to confirm whether the ulcer was avoidable. Avoidable inpatient pressure ulcers result in automatic penalties from Commissioners. Cumulative YTD 0 RED > 0 GREEN 0 8 Patient safety thermometer (harm free care new and old harms) Promotion The purpose of this indicator is to collect data at the point of care on the four outcomes - pressure ulcers, falls, urinary tract infections in patients with catheters and VTE and to use this information to measure patient safety improvement over time as a composite measure for the 4 harms. The measure is the number of patients experiencing harm-free care as a percentage of the number of patients surveyed on the sample day. In month 95% RED 94.7% AMBER >94.7% and <95% GREEN 95% 12

13 No Indicator Objective Description Data Annual RAG RATING Classification Target 9 Patient safety thermometer (harm free care NEW HARMS ONLY) Promotion In addition to the above indicator (Patient safety thermometer (harm free care new and old harms)) measures the number of new harms only. In month 95% RED 94.7% AMBER >94.7% and <95% GREEN 95% 10 Percentage of deaths compared to all discharges (excluding end of life care) Promotion In the absence of Hospital Standardised mortality rates for hospitals (which applies only to acute trusts) this will allow the Trust to review death rates compared to total discharges and allow better analysis of the data. The measure is the number of patient deaths (excluding end of life care patients) expressed as a percentage of all discharges. In month 5.4% RED 5.9% AMBER >5.4% and <5.9% GREEN 5.4% 11 Percentage of SI and RCA actions plans completed within agreed timescales 12 Clostridium difficile all cases (cumulative) People Demonstrates that actions are completed as agreed to improve care and reduce the possibility of similar incidents. This indicator reports the total number of post 48 hour Clostridium difficile toxin positive cases detected year to date whilst patients are in the Trust s care. In month 100% RED < 90% AMBER 90% and <100% GREEN 100% Cumulative YTD No target No target 13 Number of never events Promotion Never Events are incidents that are considered unacceptable and eminently preventable. 14 Number of serious Promotion This indicator is intended to monitor the number of SIs to enable incidents (SIs) trends analysis and lessons identified/learned to be recorded. 15 WHO surgical checklist This indicator reports results of a quarterly audit against the WHO compliance Checklist standard for each service i.e. compliance against the audit tool. The purpose is to ensure all areas of the Trust undertaking surgical procedures comply with the World Health Organisation checklist to prevent accidents and mistakes during surgery. The checklist is designed to prevent Never Events, serious clinical incidents which should not happen if proper procedures are followed. In month 0 RED > 0 GREEN 0 In month No target No target In quarter 100% RED < 100% GREEN 100% 13

14 No Indicator Objective Description Data Classification 16 VTE Risk assessed on admission This indicator is part of the Quality indicators in the NHS Improvement - Single Oversight Framework published Sept. 16. It measures the proportion of admitted adult patients in England who have been risk assessed for VTE. Annual RAG RATING Target In month 95% RED < 95% GREEN 95% 17 Estates - compliance with statutory requirements for freehold property (quarterly) Place This indicator reflects the quality and safety of properties owned by the Trust. Compliance is measured in 11 categories: Asbestos, Fire Risk, Pressure Systems, Decontamination, Gas Safety, Ventilation, Legionella, Piped Medical Gases, Electrical high voltage, Electrical low voltage and Managerial Risk Assessments. Each category is rated according to the following score: o Red = < 84% o Amber = 85% - 94% o Green = 95% -100% The Trust is then scored according to how many categories are green: 1. All green Trust rating Green ( score 3) amber Trust rating Amber (score 2) 3. 3 or more amber / 1 or more red Trust rating Red (score 1) In quarter All categories compliant (score of 3) RED = 1 AMBER = 2 GREEN = 3 18 Rapid Response cases requiring onward admission to acute hospital 1 month in arrears Proportion of Single Point of Access and Rapid Response cases accepted onto the service who go onto have an emergency admission to an acute hospital whilst still receiving the service expressed as a percentage of the total number of patients accepted by SPA and rapid response services. This determines the effectiveness of Single Point of Access and Rapid Response in preventing admissions to acute hospitals following community services assessment and development of a care package. In month 15% RED >15% GREEN 15% 14

15 No Indicator Objective Description Data Classification Quality Domain 19 Essential care indicators (aggregated measure) - inpatients 20 Essential care indicators (aggregated measure) community 21 Essential care indicators - LD inpatients 22 Essential care indicators - LD Community 23 Early Warning Alerts Escalation Assurance Number of wards / teams Annual Target RAG RATING In month 95% RED <85% AMBER 85% and <95% GREEN 95% Essential Care Indicators are a set of metrics recording quality of In month 95% RED <85% care. These indicators record the compliance with assessment and AMBER 85% and care planning for Essential Care in bedded areas and in Community Nursing Teams. Reporting is based on an audit of 5 sets of care plans per team in the Community and a percentage audit on each Ward. The assessments take place every month against an agreed set of care standards. The expectation is for 95% compliance with the standards. This demonstrates that appropriate care standards are followed. In month In month 95% 95% <95% GREEN 95% RED <85% AMBER 85% and <95% GREEN 95% RED <85% The EWA process has been designed to identify potential issues, early, and at team/ward level. It uses easily accessible information in the first instance to trigger a review, by the clinical team, where early discussion with front line staff can proactively resolve issues promptly. There is an escalation process for any triggers. This KPI will report the number of wards / teams which have triggered the alert for at least 5 consecutive months. AMBER 85% and <95% GREEN 95% In month 0 RED > 0 GREEN week pathway consultant led services (incomplete pathways) Incomplete pathways are waiting times for patients still waiting to start treatment at the end of the month. The measure is expressed as the percentage of patients waiting for first treatment who have waited more than 18 weeks. In month 92% RED < 92% GREEN 92% 15

16 No Indicator Objective Description Data Classification 25 Zero tolerance RTT waits over 52 weeks 26 Percentage compliance with CQUINs (forecast) Promotion The percentage of patients that wait more than 52 weeks. (Ref: NHS Commissioning Board guidance for FY13/14. Referral To Treatment waiting times for non-urgent consultant-led treatment. Zero tolerance of over 52 week waiters). This indicator is a statement on organisational compliance with the measures set out in the Commissioning for Quality and Innovation framework. It is a contractual requirement to achieve 100% against a number of agreed goals with 2.5% of income attached. It provides an indication of performance against the milestones throughout the year and gives assurance on the services ability to deliver improvements in quality efficiently. Annual RAG RATING Target In month 0% RED >0% GREEN 0% In month TBC TBC 27 Cancer referrals (urgent 2 week wait) The Cancer Reform Strategy (2007) introduced new and changed commitments in terms of service standards for cancer patients that must be met. A maximum two-week wait from an urgent GP referral for suspected cancer to date first seen by a specialist for all suspected cancers. Cancer referrals are received only by the Dental Hospital and so the indicator applies only in this division. In month 93% RED <93% GREEN 93% 28 CPA 12 months follow up Care Programme Approach patients having formal review in the last 12 months. Currently on the Monitor Risk Assurance Framework. Numerator = Number of adults in the denominator who have had at least one formal review in the last 12 months. In month 95% RED < 90% AMBER 90% and <95% GREEN 95% Denominator = total number of adults who have received secondary mental health services and who were on the CPA at the end of the reported period. 16

17 No Indicator Objective Description Data Classification Patient Experience Domain 29 % complaints responded People to within agreed timescales This indicator is intended to demonstrate a responsive customer focused complaints service and meet National regulatory targets. The Trust Complaints Team will write to the complainant to acknowledge receipt of the complaint and to provide information within 3 working days on how the complaint will be managed and respond within 6 months or as agreed. Annual Target RAG RATING In month 100% RED <90% AMBER 90% and <100% GREEN 100% 30 Average response time to complaints (weeks) People This indicator is also intended to demonstrate a responsive customer focused complaints service. It measures overall response time to complaints incorporating the most complex and lengthy cases. In month 20 weeks Baseline 23 weeks and then a reduction of 1 week in each quarter. 31 Customer experience - % Inpatients reporting very good and excellent Promotion This measure asks all inpatients who participate in the survey 'Overall how would you rate your experience?' Excellent / Very Good / Good / Fair / Poor / Very Poor / N/A. The figure is the percentage who responded very good or excellent. This question offers an additional measure which gives more information to support the Friends and Family Test (Net Promoter) question. In month 85% RED <76.5% AMBER 76.5% and <85% GREEN 85% 32 Friends and family test Promotion This indicator measures the percentage of patients responding either likely or very likely to the question: How likely is it that you would recommend this service to friends and family? 33 Number of complaints per 10,000 activity contacts (1 month in arrears) People This will show more accurately the level of dissatisfaction in those we provide services for as numbers alone can be misleading. This figure will take into account the number of patients that come into contact with services. In month 85% RED <76.5% AMBER 76.5% and <85% GREEN 85% In month No target No target 17

18 No Indicator Objective Description Data Classification Workforce and Efficiency Domain 34 Year to date (YTD) % Price The milestone achievement indictor relates to project deliverables Cumulative CRES/QIPP milestones within individual CRES / QIPP projects. Where a milestone is not met YTD achievement position the project manager reviews progress and records an update on Aspyre, the project management tool. Dependant on the milestone risk and the degree of impact to the project or other interdependent projects, a recovery plan will be drawn up and discussed at Divisional Confirm and Challenge and PPMB. Numerator: Green milestones for the year. Denominator: ALL milestones for the year. Annual Target RAG RATING 100% RED <90% AMBER 90% and <100% GREEN 100% 35 DNA rates (clinical appointments) Price The percentage of activity (community and outpatient) that has a recorded outcome of DNA based on the contractually agreed threshold. DNA rates lead to higher costs and can be avoided with better waiting list management (e.g. patient reminders, better choice of appointment). In month 9% RED >10% AMBER >9% and 10% GREEN 9% 36 Mandatory Training Compliance People This indicator comprises an aggregation of key training subjects which ensure workforce competency levels. This is presented by reporting the proportion of staff that is up-to-date with all internally mandated training courses on a rolling basis. In month 85% RED <76.5% AMBER 76.5% and <85% GREEN 85% 37 Percentage of vacancies An indicator of the balance between the opposing factors of turnover and time to recruit. Excludes newly established posts until funding flows are confirmed. In month 9% RED 9.5% AMBER >9% and <9.5% GREEN 9% 18

19 No Indicator Objective Description Data Classification 38 % sickness absence People The monitoring of sickness facilitates managers in achieving lower sickness absence levels and encourages tighter regimes around absence management. Sickness figures may give an indication of quality of care in terms of consistency in the workforce without the need for bank/agency cover and possibly staff satisfaction. They also confirm how well the organisation is managing sickness absence and taking the health and wellbeing of its employees seriously. The indicator is calculated as the WTE days lost to sickness as a percentage of all available WTE days, an established benchmark. 39 % of staff appraised (12 month rolling average) 40 Average length of time to recruit (working days from date advertised to offer) 41 Agency spend as a % of total staff spend YTD People People The purpose of this indicator is to provide assurance that all staff receive a PDR within a twelve month period, that work objectives are set in alignment with the Trust objectives (the 6 Ps) and that all staff have a personal development plan to support them in their current job role and future development. This aim is to minimise the length of time to recruit in order to ensure minimal negative impact on the effective use of resources and to ensure safe staffing levels and quality of core care. The length of time to recruit is impacted by the recruitment process and general NHS Preemployment checking such as Occupational Health checks, identity checks, professional registration checks and will also be impacted by employment checks which are out with internal control i.e. employment, reference checking and Disclosure and Barring Service (DBS) checking which is required for various posts. This measure is subsets of the overall temporary staffing spend KPI. It measures the spend on agency staff as a percentage of total staff spend. The purpose of this indicator is to monitor use of agency staff in order to ensure temporary staff cover is cost-effective and supports the delivery of high quality services in our clinical/operational divisions (excludes Corporate). The Trust has a preference to use internal bank staff rather than agency wherever possible. The justification for this is that the Trust has significant influence over the training and selection of Bank staff members and this helps to maintain high quality clinical services. Annual RAG RATING Target In month 4.3% RED 4.8% AMBER >4.3% and <4.8% GREEN 4.3% Rolling 12 months 90% RED <85% AMBER 85% and <90% GREEN 90% In month TBC TBC Cumulative YTD TBC TBC 19

20 No Indicator Objective Description Data Classification 42 Agency Spend relative to Following new targets from NHS Improvements relating to Agency Cumulative Cap (YTD cumulative) Spend the Trust now has a financial cap. It is proposed to report the YTD variation from this cap as a cumulative total throughout the year. 43 Contractual RAP Process / financial penalty or Activity Management Plan 44 Total delayed transfer days as % of occupied bed days (OBDs) Partnership Price This could be as a % variance or alternatively a financial value. The number of breaches in performance of contractual KPIs is measured to monitor the projected risk associated with KPI performance on a monthly basis. This indicator reports only breaches that incur at financial penalty or are subject to a Remedial Action Plan (RAP) process with commissioners. Total delayed occupied bed days all patients all reasons expressed as a percentage of total occupied bed days for the same month. The purpose of the indicator is to ensure the aim of discharging patients who no longer need to be in hospital in a timely manner is upheld as far as possible to prevent deterioration in their condition and to promote self-esteem. Annual Target TBC RAG RATING TBC In month 0 RED > 0 GREEN 0 In month 7.5% RED 8.5% AMBER >7.5% and <8.5% GREEN 7.5% 45 Delayed transfer days as % of OBDs NHS reasons Price Patients delayed transfer days for NHS reasons as % of Occupied Bed Days. Similar to indicator above. In month No Target 46 Average Length of stay Price The indicator measures the number of days between the dates a patient is discharged from hospital against their admission date. The mean is then calculated as sum of the inpatient days divided by the number of patients admitted. It is a useful indicator in predicting capacity and income. 47 Estates - Environmental Cleanliness Assurance Place Clinical space is to be environmentally maintained to the highest standards and is in line with NHS cleaning and environmental standard regulations. Annual Patient Lead Assessment of the Care Environment (PLACE) inspections provide an annual audit tool to review, assess and benchmark environmental and cleanliness standards. The Trust operates a mix of internal and external services within the facilities function to ensure that these environmental In month No Target In month TBC TBC 20

21 48 Estates - Reactive Estate Support Assurance Place standards are achieved. Continual audit inspections are undertaken to assess and score the quality and standard of our services in line with the NHS cleaning standards and our Trust Cleanliness Policy. The Environmental Cleanliness Assurance targets provide the Trust with compliance assurance of our environment in patient/clinical areas to ensure compliance. The Estates reactive services provide a 24/7 operational service in ensuring maintenance repairs to property, clinical and patient areas and associated equipment, are suitably maintained to the highest standard possible and in a risk prioritised timeframe. The Reactive Estate Support Assurance target provides the Trust with compliance evidence of targeted, time constrained and prioritised repairs of the environment successfully being achieved against benchmarked targets and standards. No Indicator Objective Description Data Classification Finance Domain 49 Net income and Price This indicator measures the total variance from budget. It is Cumulative expenditure ( 000) calculated by subtracting total expenditure (pay and non-pay) from YTD 50 CRES achievement - % Year to Date (YTD) actual compared to YTD Plan 51 Finance and Use of Resource Score Price Price total income. The Trust is required to make financial efficiency savings and this indicator will show the Board the progress being made throughout the year to deliver these savings. The indicator assesses CRES savings each month against the cumulative year to date (YTD) planned savings. The target is to achieve 100% of the YTD plan. It does not reflect amendments to the plan when schemes are revised and put into recovery. As per the Single Oversight Framework published Sept ; The new financial framework score is being used by NHSI to oversee and support providers in improving financial sustainability, efficiency and compliance with sector controls such as agency staffing and capital expenditure. The finance and use of resources score includes five metrics as shown below. The overall score is a mean average of the scores of the In month TBC TBC Cumulative YTD Annual Target Break even or surplus RAG RATING RED < 0 GREEN 0 100% RED <90% AMBER 90% and <100% GREEN 100% In month 2 RED 3 and 4 GREEN 1 and 2 21