TRUST BOARD. Document is for: (indicate with an x) Assurance X Information Decision. Executive Summary

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1 Document Title: Presenter: Author: Contact details for further information: Performance Report TRUST BOARD Chris Sands, Director of Finance, Performance & Information Amanda Rawlings, Director of People and Organisational Effectiveness Ben Lobo, Medical Director William Jones, Director of Operations David Caddy, Management Accountant, Performance & Costing Kate Davis, Head of Costing and Performance Date of Meeting: 27 June 2013 Agenda Item No: 190/13 Document is for: (indicate with an x) Assurance X Information Decision Executive Summary No of pages inc. this one: 28 The Board Performance Report sets out a summary of DCHS performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2013/14. There are 81 green, 11 amber, 13 red and 30 unrated indicators this month. The Overview of Measures at page 7 gives further details. Changes Since last Month (ytd) Key Red rated Amber rated Green rated Not measured Unrated Measure Fire Training (% compliance) Staff with appraisal completed (% compliance) Number of formal compliments reported per 1,000 direct/face-to-face contacts (no.) Complaints Received - Number of formal complaints reported per 1,000 direct/face-to-face contacts (no.) A&E Targets (rating) April 13 May 13

2 Patients who have operations cancelled for non clinical reasons on the day (%) New or revised policies/procedures/strategies supported by EIAs (%) Total Harm Free C are, in accordance with Safety Express (%) Medication Errors causing Serious Harm (no.) Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) MIU Activity (no.) OPMH Inpatient Excess Bed Days Activity (no.) Podiatric Surgery Activity (no.) Speech and Language Therapy Activity (no.) Leicester County & Rutland Elective Servs Activity (no.) Chlamydia Screening Activity (no.) Total pay cost per wte community nurse ( ) Financial Impact The report contains a number of issues and risks that have a financial impact on the organisation. These are detailed clearly within the report including, where appropriate, any mitigation plans and strategies that are in place. Links to DCHS Strategy Performance management is a fundamental part of monitoring our delivery against our overarching strategy and objectives. Recommendations Note and comment

3 Monitoring Information Brief Summary CQC Compliance A number of the performance targets e.g. top X and mixed sex accommodation The source of the target e.g. national.internal is clearly identified Monitor Compliance Reporting all of the applicable elements of the compliance framework. High quality performance reporting is fundamental to board assurance around the effective management of the business NHSLA Compliance Assurance Framework Ref: Underpins delivery of our whole assurance framework Other Are there Equality & Diversity implications? Are there Patient and Public Involvement implications? (If no, why) No No

4 Board Performance Report June 2013 Background The Board Performance Report sets out a summary of DCHS performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page No s Summary Document 1-5 Overview of Measures 7 DCHS Balanced Scorecard 8-11 HCAI Scorecard 13 CQUIN Scorecard 14 Exception Reports Glossary Key for RAG, arrows and Data Quality Kitemark 25 OVERVIEW Future plans: Incorporation of Performance Reporting into the Business Intelligence solution to facilitate consolidation of measures, improved efficiency in the collection of information, and greater sophistication in the rating of measures. Business Intelligence is being used to provide flash reports in this report and will increase as BI is developed. Summary Overview There are 81 green, 11 amber, 13 red, and 30 unrated indicators this month. The Overview of Measures at page 7 gives further details. New measures have been included and will be developed as new information becomes available. Aspirant FT Benchmarking data will be revised on a monthly basis, as ratings and information become more accurate. Ratings have been made against the Aspirant FT Benchmark, rather than the Aspirant FT average. IM&T Strategy Delivery of the IM&T programme is continuing as planned. An electronic system for the Clinical Navigation Service is due to be delivered this month. Significant functionality has now been added to our Business Intelligence system. The roll out of TPP Community Nurses and Therapists continues. Erewash has now been closed off. TPP is live in almost all South Dales. The next phase will be Amber Valley. Network coverage in South Dales is not good and

5 further work is being carried out both to change network providers and to use Briefcase which allows working offline. The overall plan remains challenging as a result of the on-going consultation with GPs and capacity within the project team. These two issues are being addressed through continuing dialogue and recruitment. Data Quality Kitemark The Data Quality Kitemark ratings have been included in the Balanced Scorecard where available, with a key to the ratings provided at page 25. Additional ratings are being added as outstanding issues are cleared. QUALITY PEOPLE: (page 8) Key Issues Total Workforce Costs ( 000) the year to date costs are below plan by 182k (0.9%) Agency & Bank Spend (Clinical) as a % of total Workforce Costs (%) spend has increased in month (2% in month 1, 3% in month 2) however year to date it is 2.5% against the Benchmarking Club target of 5% and is green rated. Staff Turnover (%) year to date is 10.6% against a target of <14% and is green rated. Essential Learning (% Compliance) This indicator remains amber rated, at 94% year to date against a target of 95%. The measure now indicates monthly compliance, rather than cumulative achievement. Information Governance Training (% Compliance) Has been given an amber rating. The actual score of 92% is behind the year to date plan of 95%. The measure now indicates monthly compliance, rather than cumulative achievement. Staff Attendance (%) The attendance rate is 95.7% year to date, against a target of 97%. This target has been amber rated. The absence rate for May was 3.59% which is below the current East Midlands rate of 4.90% and also below the National NHS rate of 4.80% Long term sickness (over 30 days) is 2.24% and short term is 1.35%. Anxiety, Musculoskeletal, and Injury & Fracture were the main reasons given for absence this month.

6 Fire Training (% Compliance) This measure has been red rated with an actual of 89% against a target of 95%. Compliance measurement has resulted in a drop in the measure. An exception report is included at page 16. Staff with Appraisal Completed (% Compliance) Actual performance is 87% as recorded on ESR, against a target of 95%. This has been red rated. The measure now indicates monthly compliance, rather than cumulative achievement. An exception report is included at page 17. QUALITY SERVICE : (pages 8-10) The HCAI scorecard is shown on page 13. All measures are green rated apart from MRSA Screenings - non elective admissions, which is amber rated at 99% ytd. The CQUIN scorecard is shown at page 14. All measures are green rated. Key Issues Compliments (no) The number of compliments year to date is 1,205 against a target of 1,147 and is green rated. Diagnostics - Patients exceeding 6 weeks wait (%) In May, 6 patients waited for a tests over 6 weeks. This equates 0.6% for the month, giving a year to date average of 0.5% against a target of 1%. It remains green rated. Delayed Transfer of Care for OPMH (%) Currently stands at 3.5%, year to date, which is under the Monitor threshold of 7.5%. It maintains its green rating. CQC Registration (Internal) The score continues to be 0. Avoidable grade 2, 3 & 4 Pressure Ulcers In May 0 instances were recorded. This has been green rated. Healthcare Acquired Infections (HCAI) (no) MRSA Bacteraemia is again 0 for May. Clostridium Difficile is again 0 for May. The new E Coli & MSSA measure also remains at 0 for May. Total Harm Free Care, in accordance with Safety Express (%) This measure has improved this month and is 90.2% for May which is above the target of 90% and therefore the in-month target becomes green rated. The year to date target remains amber rated at 89.8% which is just below the target.

7 Inpatients Average Length of Stay (no) Is 20.0 in May a slight reduction from 20.2 in April & is green rated. The year to date rolling three month measure is This has been red rated against. An exception report is included at page 18. Smoking Quitter Targets (rating) Tobacco Control attendances increased to 297 in May from 244, giving a year to date figure of 541. However despite this improvement the measure is still below the year to date target of 767 and remains red rated. A quarterly exception report will be presented to the Board in the July report. Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) Year to date performance has dipped to 76% and now becomes red rated. A separate report is provided to Quality Business Committee. An exception report is provided at page 19. Falls resulting in severe injury or death (no.) There was one fall in May, year to date there have been 2 falls against a 0 target. This measure is red rated and an exception report is provided at page 20. QUALITY BUSINESS: (pages 10 and 11) The activity data is the latest data available for May of 2013/14. Key Issues Better Payment Practice Code (%) The Trust continued to achieve its BPP targets in May and is green rated for both measures. Activity Performance (no.) The majority of service lines are either overperforming against their year to date profiled activity plans, or have very low and therefore recoverable, levels of underperformance. FT Membership (no.) Membership is now at 11,825 against a target of 11,300 and is green rated. Inpatient Activity-Block (no.) Spells activity is amber rated for the block contract, with 552 contacts against a target of 574. An exception report for Inpatients Excess Bed Days (C&V) is provided at page 21. Chlamydia Screening - Activity has reduced to 58 in month giving a year to date figure of 172 which is below the target of 216 and therefore becomes red rated. The diagnostic rate has also deteriorated to 1.9% year to date

8 . against a target of 2.4% and also becomes red rates. An exception report is provided at page 22. ASPIRANT COMMUNITY BENCHMARKS : (page 11) The activity data is the latest data available month (May) of 2013/14. Ratings are made against the benchmarking target. This information should be used with caution until the robustness of these measures has been developed. Key Issues C.Difficile Cases (per 1,000 OBDs) (no.) is again green rated with a year to date score of 0 against a target of Face to Face Contacts per wte Community Nurse Working Day (no.) The year to date figure of 9.9 is green rated against the year to date target of 6.9. Total Pay Cost per wte Community Nurse ( ) Pay costs are 3,150 year to date, against a target of 3,128 and is green rated. Average Length of Stay (days) Is again green rated with a year to date of 21.0 against a year to date target of Total Pay Cost per wte Health Visitor ( ) Is amber rated with a year to date actual of 3,275 against a year to date target of 3,155. Injurious Falls per 1,000 Inpatient Occupied Bed Days (no.) This is again red rated, with an actual year to date of 6.7 against a target of Face to Face Contacts per wte Health Visitor Working Day (no.) - The year to date figure of 3.5 is red rated against the year to date target of 5.3. Activity investigations continue.

9 DCHS Scorecards June 2013

10 Derbyshire Community Health Services Board Performance Overview of Measures Month June-13 Measure Total Number of Measures Total Number of YTD Measures Rated Green Total Number of YTD Measures Rated Amber Total Number of YTD Measures Rated Red Total Number of YTD Unrated Measures Quality People 23 (23) 7 (7) 3 (5) 2 (0) 11 (11) Quality Service - Service User Experience Quality Service - Service User Safety Quality Service - Clinical Effectiveness & Planning 22 (22) 15 (10) 1 (0) 1 (3) 5 (9) 20 (20) 12 (9) 0 (1) 4 (3) 4 (7) 3 (3) 0 (0) 0 (0) 2 (1) 1 (2) Quality Business - Finance 4 (4) 2 (2) 0 (0) 0 (0) 2 (2) Quality Business - Business & Marketing 23 (23) 12 (12) 3 (2) 2 (3) 6 (6) Quality Business - IM&T 4 (4) 3 (3) 0 (0) 0 (0) 1 (1) Quality Business - FT Regime 7 (7) 7 (7) 0 (0) 0 (0) 0 (0) Aspirant Community FT Benchmmarks Healthcare Associated Infection 13 (13) 8 (9) 3 (2) 2 (2) 0 (0) 16 (16) 15 (15) 1 (1) 0 (0) 0 (0) Totals 135 (135) 81 (74) 11 (11) 13 (12) 30 (38) Percentages Allocated 100% 100% 60% 55% 8% 8% 10% 9% 22% 28% The previous month totals are shown in brackets

11 DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD Focus Area Measure Benchmark Reference Data Quality Score Director Benchmark Target-Apr 2013 Benchmark Average-Apr / 14 Full Year Target YTD Target Apr-13 May-13 Trend YTD 2013/14 Forecast Outturn Narrative Total Workforce Cost ( 000s) DoHR 114,081 20,064 9,758 10,124 19, ,081 Includes Agency & Bank Temporary Staffing Costs - Agency ( 000's) 12 DoHR Funded by vacancies budget Temporary Staffing Costs - Bank ( 000's) 12 DoHR Funded by vacancies budget Agency & Bank Spend (Clinical) as a % of total workforce costs (%) P13 DoHR 5.0% 5.0% 2.0% 3.0% 2.5% Total WTE (no.) 18 DoHR 3,554 3,559 3,334 3,331 3,331 3,554 Headcount (no.) 18 DoHR 4,363 4,362 4,362 QUALITY PEOPLE TRAINING WORKFORCE METRICS Health Visitor WTE (no.) 18 DoHR Family Nurse Partnership & Specialist Nurses (no.) DoHR Staff Attendance (%) W1 18 DoHR 97.0% 97.0% 96.0% 96.4% 95.7% Ytd is rolling 12 month average Absence rate over past 12 months is 4.42% NHS absence rate is 4.8% (4.9% East Midlands) Staff Turnover (%) W4 18 DoHR <14% <14% 9.7% 10.8% 10.6% Board Turnover (no.) DoHR 2 or less in 6 months Nurse/Bed Ratio (no.) Registered Nurses (%) Redundancy (no.) DoHR Turnover Per WTE ( 's) DoHR 4,472 4,498 4,498 Advertised Vacancies (no.) 18 DoHR Essential Learning completed (% compliance) W2 18 DoHR 95% 95% 93% 94% 94% Information Governance Training (% compliance) 18 DoHR 95% 95% 91% 92% 92% Under development Under development Fire Training (% compliance) 18 DoHR 95% 95% 90% 89% 89% Targeted communication to be sent to Managers. Exception Report at page Family Nurse Partnership Specialist Nurse WTE contribute to the overall WTE for Health Visiting and have been added as a separate line & now include FNP IMH & Specialist Nurses New starters attending induction (compliance) (%) 18 DoHR 95% 95% 96% 98% 96% Staff with appraisal completed (% compliance) W3 18 DoHR 100% 100% 83% 87% 87% Leaders to be contacted & further classes arranged. Exception Report at page 17. Improvement in Staff Survey participation rates (%) DoHR 64.0% 64.0% Annual FEEDBACK Improvement in Staff Survey engagement and staff satisfaction scores (no.) DoHR Annual Staff Net Promoter Question Result (no.) DoHR Annual Patient Revolution Fiends & Familily Test (no.) QR10 DoNQ >71 > Patient experience of hospital care, as reported by patients in responses to the Care Quality Commission Inpatient Survey Under development Compliments Received (no.) DoNQ 6,882 1, ,205 PATIENT SATISFACTION Number of formal compliments reported per 1,000 direct/face-to-face contacts (no.) QR9 DoNQ Complaints Received (no.) DoNQ Complaints Received - Number of formal complaints reported per 1,000 direct/face-to-face contacts (no.) QR8 DoNQ PEAT / PACE (score) DoSD 95% 0% Quarterly measure Certification against compliance with requirements regarding access to healthcare for people with a learning disability DoNQ Yes Yes Yes Yes Yes To be reported to EDS & quarterly to QSC

12 DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD Focus Area Measure Benchmark Reference Data Quality Score Director Benchmark Target-Apr 2013 Benchmark Average-Apr / 14 Full Year Target YTD Target Apr-13 May-13 Trend YTD 2013/14 Forecast Outturn Narrative A&E A&E Targets (rating) 18 DoSD RTT Targets (rating) 18 DoSD SERVICE USER EXPERIENCE REFERRAL TO TREATMENT Choose and Book Targets (rating) DoSD Diagnostics - Patients exceeding 6 weeks wait (%) DoSD <1% <1% 0.4% 0.6% 0..5% Patients who have operations cancelled for non clinical reasons on the day (%) DoSD <0.8% <0.8% 2.5% 0.0% 0.0% Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%) DoSD 100% 100% 100% 100% 100% Mixed Sex Accommodation Breach Rate (%) DoSD Delayed Transfer of Care (%) QR4 DoSD <12.5% <12.5% 7.8% 7.9% 7.9% DTOC contract calculation for Inpatients & OPMH INPATIENT SERVICES Delayed Transfer of Care for Rehabilitation and Urgent Care - contract calculation (%) DoSD 9.9% 9.1% 9.9% Delayed Transfer of Care for OPMH - contract calculation (%) DoSD <7.5% <7.5% 2.4% 4.9% 3.5% Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) DoSD <7.5% <7.5% Inpatient Average Length of Stay (days) 18 DoSD Changes to inpatient complexity. Exception Report at page 18. QUALITY SERVICE EQUALITY Achievement of consultation /involvement/engagement inclusion priorities (%) DoHR 100% 100% 100% 100% 100% New or revised policies/procedures/strategies supported by EIAs (%) DoHR 87% 87% 87% 87% Under review CQC Registration - Internal (rating) DoNQ CQC Registration - Impact Governance Scores (rating) DoNQ Impact on SHA Performance Report and Compliance Framework GRRs CQC Warning Notices DoNQ CQC Civil and/or criminal action DoNQ Total Harm Free C are, in accordance with Safety Express (%) QR11 DoNQ 90% 90% 89% 90% 90% Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 DoNQ No exception report-total for month = 0 Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 DoNQ SERVICE USER SAFETY Incidence of Newly Acquired Pressure Ulcers (no.) Under development - discussion taking place Medication Errors causing Serious Harm (no.) Under review NHSLA Rating (no.) DoNQ Expected to be 1 until next assessment April 2014 Falls resulting in severe injury or death (no.) DoNQ Anxious and unsettled patient. Exception Report at page 20. Duty of Candour - Failure to notify relevant person of a reportable incident (no) All reporting requirements are met Safeguarding alerts, serious case reviews, Ad-hoc reports from MPs, GMC, the Ombudsman, Commissioners, etc. Under development Healthcare Care Associated Infections - MRSA bacteraemia (no.) 16 DoNQ YTD target of 6 has been issued by the SHA in the SOM report. Healthcare Care Associated Infections - Clostridium difficile (no.) 16 DoNQ See HCAI shedule for details. Healthcare Care Associated Infections - Clostridium Difficile/1000 Occupied Bed Days (no) DoNQ Healthcare Care Associated Infections - E Coli & MSSA (no) NESS & Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) DoSD 84% 84% 80% 72% 76% Separate report to go to QBC Exception report at page 19

13 DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD Focus Area Measure Benchmark Reference Data Quality Score Director Benchmark Target-Apr 2013 Benchmark Average-Apr / 14 Full Year Target YTD Target Apr-13 May-13 Trend YTD 2013/14 Forecast Outturn Narrative CLINICAL EFFECTIVE- PLANNING Breastfeeding prevalence 6-8 weeks after birth (%) DoSD 40% 37% 39% Separate report to go to QBC. Exception report at page 19. Smoking Quitter Targets (rating) 12 DoSD Tobacco Control - Next set of data to be for June 2013 CIP Achieved-Recurrent(%) FIN 3 DoFPI 100% FINANCE CIP Achieved-Non Recurrent (%) FIN3 DoFPI Better Payment Practice Code - by value (%) FIN2 DoFPI >95% >95% 98% 97% 98% Discussed in the Finance Report Better Payment Practice Code - by volume (%) FIN1 DoFPI >95% >95% 96% 98% 97% Discussed in the Finance Report Positive media stories (no.) DoSD Facilities Unutilised Space (%) DoSD Not currently available Available Beds (no.) 18 DoSD Inpatient beds MIU Activity (no.) DoSD 56,755 9,459 4,669 5,049 9,718 56,755 Inpatient Spells Activity-C&V (no.) 18 DoSD Inpatient Excess Bed Days Activity-C&V (no.) 18 DoSD Patient flow strategy meetings to be upgraded. Exception report at page 21. Inpatient Spells Activity-Block (no.) 18 DoSD 3, ,444 Inpatient Excess Bed Days Activity-Block (no.) 18 DoSD 3, ,782 OPMH Inpatient Spells Activity (no.) 18 DoSD OPMH Inpatient Excess Bed Days Activity (no.) 18 DoSD 3, ,462 BUSINESS & MARKETING ACTIVITY METRICS Outpatient and Daycase Activity (no.) 18 DoSD 39,457 6,538 3,447 3,414 6,861 39,457 Vasectomy Service Activity (no.) 18 DoSD Podiatric Surgery Activity (no.) 18 DoSD 13,732 2,432 1,276 1,075 2,351 13,732 Community Podiatry Activity (no.) 14 DoSD 126,089 22,076 11,715 11,509 23, ,089 QUALITY BUSINESS Physiotherapy Activity (no.) 15 DoSD 116,421 16,982 9,078 9,291 18, ,421 Speech and Language Therapy Activity (no.) 14 DoSD 16,066 2,554 1,206 1,427 2,633 16,066 Health Visiting Activity (no.) 18 DoSD 9,431 9,061 18,492 Health visiting - overall contractual performance (rating) 18 DoSD Community Nursing Activity (no.) 10 DoSD 508,814 84,802 41,871 47,289 89,160 Community Matron Activity (no.) 15 DoSD 1,019 1,334 2,353 TPP Amber Valley, Erewash, NED & SD & DD only. Rehabilitation and Intermediate Care Activity (no.) 9 DoSD 6,393 7,723 14,116 January's figure now includes Amber Valley & Erewash, South DD TPP data for the year. Both ecsac & TPP data now includes NFTF data. Leicester County & Rutland Elective Servs Activity (no.) DoSD 191,562 32,100 15,272 16,334 31,606 OP & DC & Radiology Chlamydia Screening Activity (no.) DoSD 2, GP training to continue & further performance meetings in place. Exception Report at page 22. Community Information Dataset Completeness-Referral to treatment information (%) DoFPI >50% >50% 67% 67% 67% Community Information Dataset Completeness-Referral information (%) DoFPI >50% >50% 67% 69% 69% IM&T Community Information Dataset Completeness-Treatment activity information (%) DoFPI >50% >50% 59% 61% 61%

14 DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD Focus Area Measure Benchmark Reference Data Quality Score Director Benchmark Target-Apr 2013 Benchmark Average-Apr / 14 Full Year Target YTD Target Apr-13 May-13 Trend YTD 2013/14 Forecast Outturn Narrative Information Governance Toolkit Achievement - measures scoring 2 or better (no.) DoFPI Awaiting release of new toolkit for 13/14 Shadow Monitor Governance Risk Rating (score) All SHA Performance Management Regime-New (score) All Financial Risk Rating (FRR) DoFPI FT REGIME Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format) DoFPI Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format) DoFPI FT Membership (no.) DoSt 11,792 11,825 11,825 Progress against Tripartite Formal Agreement Trajectory (rating) All QP Sickness & Absence Rates (%) W1 18 DoHR 3.5% 4.4% 4.0% 3.6% 3.6% New SIRIs reported per month (excluding pressure ulcers) (no.) QR2 DoNQ New Grade 3 and above Pressure Ulcers reported per month (no.) QR3 DoNQ QUALITY SERVICE Percentage of deaths compared to all discharges (%) QR5 DoNQ 10.0% 6.2% 10.0% 6.5% 5.4% 4.6% 5.4% Inpatient Wards Injurous Falls per 1,000 inpatient occupied bed days (no.) QR6 DoNQ Rehab Inpatients Only-injurious falls-ytd represents current month ASPIRANT COMMUNITY FT BENCHMARKS Rate of Incidents (Injurious and non-injurious) per 1,000 Contacts (no.) QR7 DoNQ Investigating contacts data. 95% of patients seen within 18 weeks of referral (%) A1 DoSD 95% 96% 95% 95% 99% 99% 99% Face to face contacts per whole time equivalent (wte) community nurse per working day (no.) P1 DoSD Total pay cost per wte community nurse ( ) P3 DoSD 3,128 3,128 3,126 3,173 3,150 QUALITY BUSINESS Face to face contacts per whole time equivalent (wte) health visitor per working day (no.) P4 DoSD Investigating contacts data Total pay cost per wte health visitor ( ) P6 DoSD 3,155 3,155 3,213 3,335 3,275 Average length of stay (days) P7 DoSD Inpatient OPMH Wards & LD Wards Percentage occupancy of community hospital beds (%) P8 DoSD 88.0% 84.1% 88% 88% 90% 88% 89% Inpatient OPMH Wards & LD Wards

15 DCHS Healthcare Acquired Infections and CQUIN Scorecards June 2013

16 HEALTHCARE ASSOCIATED INFECTION SCORECARD Focus Area Measure Type Frequency Director 2013/14 Full Year Target YTD Target YTD Q1 YTD Q2 YTD Q3 Apr-13 May-13 Trend YTD Forecast Outturn QUALITY SERVICE SERVICE USER SAFETY & EXPERIENCE MRSA Infections - Avoidable (No.) Internal Monthly DoNQ MRSA Infections - Possible (No.) Internal Monthly DoNQ MRSA Infections - Unavoidable (No.) Internal Monthly DoNQ ESBL - Avoidable (No.) Internal Monthly DoNQ ESBL - Possible (No.) Internal Monthly DoNQ ESBL - Unavoidable (No.) Internal Monthly DoNQ Norovirus outbreaks (No.) Internal Monthly DoNQ MRSA Bacteriaemia - Avoidable (No.) National Monthly DoNQ MRSA Bacteriaemia - Possible (No.) National Monthly DoNQ MRSA Bacteriaemia - Unavoidable (No.) National Monthly DoNQ MRSA Screenings - Elective Surgery (%) Internal Monthly DoNQ 100% 100% 100% 100% 100% 100% MRSA Screenings - Non Elective Admissions (%) Internal Monthly DoNQ 100% 100% 96% 96% 99% 98% MRSA Screenings - Sexual Health (%) Internal Monthly DoNQ 100% 100% 100% 100% 100% 100% Clostridium Difficile - Avoidable (No.) National Monthly DoNQ Clostridium Difficile - Possible (No.) National Monthly DoNQ Clostridium Difficile - Unavoidable (No.) National Monthly DoNQ Avoidable Infections There were no avoidable infections to report. Possible Avoidable Infections There were no possible avoidable infections to report. Unavoidable Infection ESBL infection There was one patient with an unavoidable ESBL infection during May. The patient had a positive urine sample result shortly after transfer from Chesterfield Royal Hospital Foundation Trust and 2 weeks later whilst still an inpatient on Derwent Ward, Walton Hospital. The patient has underlying kidney function disease which will increase their susceptibility to urinary tract infections. The patient was treated with antibiotics on both occasions due to increased incontinence and confusion. Treatment was successful and advice was sought from microbiology regarding antibiotic choice and duration of treatment due to avoid promoting increasingly resistant strains of ESBL for this patient. MRSA Screening The MRSA screening score for May is 98.9% for the following reasons: - 1 patient was transferred to an acute provider less than 24 hours from admission - 1 ward could not establish whether the screening had taken place on admission as documentation incomplete so screening repeated - 1 patient was not screened within the accepted time frame

17 CQUIN INDICATORS NHS DERBYSHIRE COUNTY PCT AND ASSOCIATES CONTRACT Focus Area Measure Type Frequency of Reporting Annual Value,000 Director 2012/13 Full Year Target YTD Target Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trend YTD Forecast Outturn Narrative Friends and Family Test - Phased Expansion - Adult Emergency Departments National 1.1 Annually DoNQ Demonstrate that milestones have been met April 2013 Adult ED = phase 1. Second phase is Maternity Services which does not apply to DCHS. All DCHS services are adopting the FFT however as part of CQUIN Friends and Family Test - Increased Response Rate National 1.2 Quarterly 160 DoNQ Provider having a response rate that places them in the top quartile and also shows an improvement on the average of returns for Q1 Top Quartile Baseline period to be Q1 13/14. Check on implementation at end of October 2013 and end of January 2014 Friends and Family Test Improved performance on the Staff Friends and Family Test National 1.3 Annually DoHR DCHS having a better result in 2013/14 compared with 2012/13 NHS Safety Thermometer - Data Collection National 2 Monthly 160 DoFPI 12 Timely Submissions > Timely Submission(s) Also a CQUIN. Data submitted for April and May submitted in May. Confirm named lead clinician and the planned training Dementia - Clinical Leadership National 3.2 Quarterly DoSD programme as identified in the Trust Action Plan. 160 Demonstrate a monthly audit of Carers of people with dementia Dementia - Supporting Carers National 3.3 Monthly DoSD on DCHS OPMH wards VTE - Risk Assessment National 4.1 Monthly DoSD 95% 95% 100% Awaiting clarification of VTE submissions from Loughborough. 160 Achievement of at least 95% and achievement of the quarterly VTE - Root Cause Analyses National 4.2 Quarterly DoSD thematic review for root cause analyses of hospital associated thrombosis, as reported to the commissioner QUALITY SERVICE EXPERIENCE, SAFETY & CLINICAL EFFECTIVENESS Local safety thermometer -Pressure Ulcers (%) Breastfeeding - Knowledge and Training - Education Audit Breastfeeding - Knowledge and Training - Team Training Breastfeeding - Knowledge and Training - Policy Orientation Local 5 Quarterly 128 DoSD Achievement of 7.5% average prevalence as per safety thermometer data by Q4 TBA Local Annually DoNQ Achieve 80% for the UNICEF education audit 100% of Health Visiting teams to have received baby friendly Local Annually DoNQ training within 6 months of joining the Trust % of Health Visiting teams to have been orientated with the Local Quarterly DoNQ Breastfeeding policy within 2 weeks of joining the Trust Q1 Baseline Report Breastfeeding - Mothers Audit Local 6.2 Quarterly DoNQ Q3 Re-audit Report Baseline data to be March Incidence data to be reported Q1. PU prevalence data to be reported quarterly as average for the quarter. Build on the work undertaken in 2012/13 in embedding a Nutrition Local 7 Quarterly 511 DoSD Nutritional assessment tool; audit of MUST and appropriate care planning Q1 baseline data on use of MUST tool Q4 2012/13. Also a CQUIN. Q1 training delivery plan Q2 records audit and update on training plan Q3 records audit and update on training plan Q4 records audit and final report on training with action plan going forward 2014/15 Improve standards of care by implementing the Dignity in Dignity in Care Local 8 Quarterly 511 DoNQ Care Bronze and Silver award initiative and evidence actions taken against the Francis Report recommendations Q1 Baseline report of activity to date. Q2/3 Update on progress Q4 Final report on awards achieved Improve transfer & admission, flow of relevant medical and Hospital Discharge Local 9 Quarterly 384 DoSD nursing information from acute to rehab and urgent care inpatient wards & joint working initiatives Q1 data baseline report of transfers and incidents. Also a CQUIN Q2/3/4 data report patient transfers and incidents Q2/4 report on activities to demonstrate partnership working and updates on action plans Making Every Contact Count Local 10 Quarterly DoSD Undertake evaluation of staff MECC training within Planned Care Quarterly report on progress and or update against action plan. Quarterly data report on training Annual staff survey report 384 Making Every Contact Count Local 10 Quarterly DoSD Embed principles of MECC in the staff survey Making Every Contact Count Local 10 Quarterly DoSD Demonstrate improvement of Staff Health and Wellbeing

18 DCHS Performance Exception Reports June 2013

19 Exception Report Analysis Measure Type Frequency Director 2013/14 Full Year Target YTD Target Q2 Apr-13 May-13 Jun-13 YTD Fire Training (% compliance) External Monthly DoHR 95% 95% 90.0% 89.0% 89.0% Fire Training (% compliance) - May 96% 95% 94% 93% 92% 91% 90% 89% 88% 87% % of Staff Attending Training % Target Profile % Staff Actually Completed Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Month ACTION PLAN: Fire Training needs to be completed annually and can be undertaken by attending the Essential Learning day, special Fire Safety Training sessions (class room or ward based) completing a workbook or an e-learning programme, 3650 Staff have completed the Fire Training during the last twelve months years which is 89% compliance. Compliance has dipped further this month due to the new way of recording. Detailed monitoring dashboard and reports are now available for each Directorate and Division, clearly identifying when staff compliance expires and need to complete all their Essential Learning including Fire Safety Training. Particular areas of concern are the corporate functions in Finance and IMT, Quality, Strategy and certain teams in ICBS North. Further targeted communication has been sent to Managers in the areas. 86%

20 Exception Report Analysis Measure Type Frequency Director 2013/14 Full Year Target YTD Target Q1 Apr-13 May-13 Jun-13 YTD Staff with appraisal completed (% compliance) External Monthly DoHR 95% 95.0% 83.0% 87.0% 87.0% Staff With Appraisals Completed (% compliance) - May 96.0% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 ACTION PLAN: Appraisal Completion is a measure Appraisals of available staff in the last twelve months. According to the information on ESR; there were 3698 (87%) staff that have had an Appraisal in the last 12 months and 292 (7%) of staff didn't have their Appraisal as planned in April or May Leaders are being contacted to ascertain the reasons for the appraisals not being completed to plan and ESR updated accordingly, areas of concern are the Corporate directorates of Finance & IMT and Quality and certain teams in ICBS North and Health Wellbeing and Inclusion Further Appraisal Master classes have been arranged & communicated, some managers are awaiting training before completing this years appraisals. Month 94.0% 92.0% 90.0% 88.0% 86.0% 84.0% 82.0% 80.0% 78.0% 76.0% % of Staff % Target Profile % Staff With Appraisal Completed

21 Exception Report Analysis Measure Type Frequency Director 2013/14 Full Year Target YTD Target Q2 Feb-13 Mar-13 Apr-13 YTD Inpatient Average Length of Stay (days) External Monthly DoSD Inpatient Average Length of Stay (days) 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 Month Days Monthly Length of Stay (days) Average Length of Stay (3 month rolling ave) Target ACTION PLAN: There has been a significant improvement during last year of the average length of stay performance from 24 to a sustained performance at days for the majority of the year. There have been significant pressures in the health economy during the last quarter of 2012/13 and the first month of 2012/13 which have led to an increase in the average length of stay in the Inpatient service. There are several factors which have contributed to this: - The patient cohort has changed due to feeder acute services being in escalation which has increased the complexity of cases. - There have been delays in the discharge process due to the transfer of the Continuing Care Assessment completion to the centralised team forming part of the commissioning function which is expected to improve as the transfer is fully completed and processes are fully embedded. The target of 20 days was set and based on the assumption that Integrated Business Plan changes would be implemented during the year, there has been some delay in implementing these initiatives due to factors outside the control of DCHS. In order to mitigate this deviation from plan the following initiatives have been implemented: - Twice weekly JONAH meetings led by General Managers - Daily ward rounds - Continued partnership working with DCC Social Care and other partner agencies - Action plans are being developed at locality level by General Managers to map changes required to meet the target LoS of 20 days - A review of bed capacity is being undertaken which includes review of the complexity of cases

22 Exception Report Analysis Measure Type Frequency Director 2013/14 Full Year Target YTD Target Q1 Apr-13 May-13 Jun-13 YTD Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) External Monthly DoSD 84% 84% 80% 72% 76% Breast Feeding Sustainment- 10 Days to 6-8 Weeks - May 90% 85% 80% 75% 70% % Sustainment Actual In Month Sustainment (%) Cumulative Sustainment (%) 65% Target 80% 72% Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Month 60% ACTION PLAN: This month there has been a further decrease across the service in the number of babies who have sustained being breast fed from 10 days until 6 weeks. As a service we have looked at the reasons for non-sustainment on every baby that has stopped breast feeding after 10 days. 51% of all the 90 babies that stopped breast feeding by 6 weeks had been partially In particular we have looked at High Peak and Dales locality which has seen a significant decline in sustainment. At a recent meeting attended by the locality manager with partner agencies it was highlighted by all that there are changing demographics in this area and these could be affecting our sustainment rates. The future plan in High Peak is to work in collaboration with partner agencies (DCC children s Centres), Midwives, Breast mate volunteers to provide more support and information in the antenatal period to ensure women are prepared and have the correct information to enable informed choices to sustain breast feeding. An initial meeting has taken place and an action plan to start and roll a programme of support is being written.

23 Exception Report Analysis 2013/14 Full YTD Target Q1 Apr-13 May-13 Jun-13 YTD Measure Type Frequency Director Year Target Falls resulting in severe injury or death (no.) External Monthly DoNQ Falls Resulting in Severe Injury or Death - May 2 1 No Falls Resulting in Severe Injury (no) Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Month ACTION PLAN: On investigation the patient was found on the floor with the wheeled zimmer frame. The patient was able to stand with the assistance of staff. 0 The patient was reviewed by the ward doctor due to pain and swelling in right ankle and calf. An urgent X-ray was requested of right leg and ankle to exclude a fracture. The incident was escalated to the General Manager as soon as X-ray results were obtained. The patient s previous medical history included short term memory loss. On admission a Personal Handling Risk Assessment (PHRA) and Fall Prevention, Intervention Plan was completed within 4 hours. The patient had been seen by the Physiotherapist and on the 26th April 2013 & had been assessed as mobile with wheeled Zimmer Frame and 1 person. The patient had remained compliant with mobility treatment plan up to the 6th May 2013, when documentation showed that the patient had been getting up unaided/unsupervised. Staff tried to explain the risks of falling to the patient. The following factors were identified as contributing to the fall occurring; Short term memory loss the patient was unable to retain information given to her. The patient not following instructions in treatment plan Was told not to mobilize independently but due to short term memory loss did not always follow these instructions. On the evening of the fall, the patient was anxious and unsettled. A chair sensor was not in use on the patient at the time of the fall; however, a chair sensor will not prevent a fall occurring it only indicates that someone has left their seat. There were a high number of patients with confusion and risk of falls on the ward at the time and too many chair sensors in use at any one time negates their effective use.

24 Exception Report Analysis Measure Type Frequency Director 2013/14 Full Year Target YTD Target Apr-13 May-13 Jun-13 YTD Inpatient Excess Bed Days Activity-C&V (no.) External Monthly DoSD Inpatients Excess Bed Days C&V - May Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Site ACTION PLAN: Whilst the activity for this financial year is on a block contract and the performance does not affect the income associated with the activity. Contacts (no) Cumulative Actual (no) Cumulative Target (no) - It should be noted that length of stay has been stable for some time which demonstrates the embedding of more proactive discharge planning and closer working relationships between Inpatient Services and Social Care services. This has had a negative impact on the excess bed days performance but an improvement in the quality aspects of the service has also been demonstrated. - Performance is below the year to date plan currently, but the position is expected to recover through the year. - Work is being undertaken to re-invigorate the Patient Flow Strategy Meetings which should help to manage excess bed days to within the plan.

25 Exception Report Analysis Measure Type Frequency Director 2012/13 Full Year Target YTD Target Q1 Apr-13 May-13 Jun-13 YTD Chlamydia Screening (no.) External Monthly DoSD 2, Chlamydia Screening (no.) - May Positive Screens No. of Planned Screens (Cumulative) No. of Actual Screens (Cumulative) Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Month 80 ACTION PLAN: Target number of positives required end May positive results received with a deficit of 20%. Action plan in place including scheduled performance meetings. GP scheme 3C's training planned in May to be undertaken in July which is expected to increase uptake of Chlamydia screening within primary care. Still awaiting national release of performance data for last years programme. The achievement of the number of positive results is linked directly to the diagnosis rate and all work is being focussed in this area.

26 DCHS COMMITTEE PERFORMANCE REPORT BALANCED SCORECARD Focus Area Measure Type Frequency Director New / Revised / Description Total Workforce Cost ( 000s) Internal Monthly DoHR Total workforce costs including Bank & Agency Costs Temporary Staffing Costs - Agency ( 000's) External Monthly DoHR Temporary Staffing Costs - Bank ( 000's) External Monthly DoHR Agency & Bank Spend (Clinical) as a % of total workforce costs (%) External Monthly DoHR New QUALITY PEOPLE A&E PATIENT SATISFACTION FEEDBACK TRAINING WORKFORCE METRICS Total WTE (no.) External Monthly DoHR Headcount (no.) Internal Monthly DoHR Health Visitor WTE (no.) External Monthly DoHR Family Nurse Partnership & Specialist Nurses (no.) External Monthly DoHR Staff Attendance (%) Internal Monthly DoHR Staff Attendance in month & on a ytd 12 month average Staff Turnover (%) Internal Monthly DoHR Board Turnover (no.) Internal Monthly DoHR New Redundancy (no.) External Monthly DoHR Turnover Per WTE ( 's) Internal Monthly DoHR Advertised Vacancies (no.) Internal Monthly DoHR Essential Learning completed (% compliance) Internal Monthly DoHR Revised Information Governance Training (% compliance) External Monthly DoHR Fire Training (% compliance) External Monthly DoHR Revised New starters attending induction (%) Internal Monthly DoHR New starters attending induction within 3 months / new starters requiring induction Staff with appraisal completed (% complaince) Internal Annually DoHR Revised Improvement in Staff Survey participation rates (%) Internal Annually DoHR Total staff participating / Total staff Improvement in Staff Survey engagement and staff satisfaction scores Internal Annually DoHR (no.) Staff Net Promoter Question Result (no.) Internal Quarterly DoHR Patient Revolution Net Promoter Score (no.) External Monthly DoNQ Compliments Received (no.) Internal Monthly DoNQ Complaints Received (no.) External Monthly DoNQ PEAT / PACE (score) External Monthly DoNQ Certification against compliance with requirements regarding access to External Monthly DoNQ healthcare for people with a learning disability Certification against compliance with requirements regarding access to External Monthly DoNQ healthcare for people with a learning disability New A&E 4 Hour Wait for A&E Attendances (%) External Monthly DoSD The percentage of people who are seen within A&E in under 4 hours A&E Unplanned Re-attendance Rate (%) External Monthly DoSD Unplanned attendances within 7 days of discharge / total attendances A&E Left Without Being Seen Rate (%) External Monthly DoSD The percentage of people who leave the A&E without being seen A&E Time to Initial Assessment - 95th percentile (mins) External Monthly DoSD The time below which 95% of patients arriving by emergency ambulance are assesed A&E Time to Treatment - Median (mins) External Monthly DoSD The time below which 50% of attendances were treated QUALITY SERVICE SERVICE USER EXPERIENCE CHOOSE & BOOK REFERRAL TO TREATMENT A&E Total Time in the A&E Department (non admitted) - Longest (mins) External Monthly DoSD A&E Total Time in the A&E Department (non admitted)-95th percentile External Monthly DoSD (mins) New RTT Waits - incomplete pathway 92nd percentile (weeks) External Monthly DoSD RTT Waits - admitted patients 90th percentile (weeks) External Monthly DoSD RTT Waits - non admitted patients 95th percentile (weeks) External Monthly DoSD RTT pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete External Monthly DoSD pathways. New Re Admission Rates (%) External Monthly DoSD New First Outpatient Attendances (consultant-led) in general and acute External Monthly DoSD specialties (no) New General & Acute (G&A) elective admissions FFCEs External Monthly DoSD New Diagnostics - Patients exceeding 6 weeks wait (%) External Monthly DoSD New Appointment slots available on the Choose and Book - no of patients External Monthly DoSD unable to book (%) Eligible Services Directly Bookable via Choose and Book(%) External Monthly DoSD Choose & Book-Unpublished Services in Directory of Services (%) External Monthly DoSD Choose & Book-Minimise Number of "Do Not Use" or "Test" Services in Directory Of Services (No) External Monthly DoSD Choose & Book-Age range added to all services in the Directory Of External Monthly DoSD Services (%) Choose & Book-Provide advice & guidance for all included services (%) External Monthly DoSD Choose & Book-Requests for Advice and Guidance to be responded to External Monthly DoSD within 3 working days of request (%) Patients who have operations cancelled for non clinical reasons on the External Monthly DoSD day (%) Patients who have operations cancelled for non clinical reasons receiving External Monthly DoSD treatment within 28 days (%) Single longest time recorded from arrival at A&E to transfer or discharge 90th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis Mixed Sex Accommodation Breach Rate (%) External Monthly DoSD Number of breaches / number of Finished Consultant Episodes EQUALITY & INPATIENTS DIVERSITY Delayed Transfer of Care (%) External Monthly DoSD Delayed Transfer of Care for Rehabilitation and Urgent Care - contract calculation (%) External Monthly DoSD Delayed Transfer of Care for OPMH - contract calculation (%) External Monthly DoSD Delayed Transfer of Care for OPMH - Monitor compliance framework External Monthly DoSD calculation (%) Rehabilitation Inpatient Average Length of Stay (days) External Monthly DoSD Urgent Care Inpatient Average Length of Stay (days) External Monthly DoSD Older Peoples Mental Health Average Length of Stay (days) Internal Monthly DoSD Achievement of consultation /involvement/engagement inclusion Internal Monthly DoHR priorities (%) New or revised policies/procedures/strategies supported by EIAs (%) Internal Monthly DoHR Number of delayed transfers of care as a proportion of the number of occupied beds SERVICE USER SAFETY CQC Registration (rating) External Monthly DoNQ CQC Registration - Impact Governance Scores (rating) External Monthly DoNQ CQC Warning Notices External Monthly DoNQ new CQC Civil and/or criminal action External Monthly DoNQ New Total Harm free care (patients suffering none of 4 harms in accordance External Monthly DoNQ with Safety Express) (%) New Avoidable Grade 2, 3 & 4 Pressure Ulcers (no.) External Monthly DoNQ Total Grade 3 & 4 Pressure Ulcers (no.) External Monthly DoNQ Incidence of Newly Aquired Pressure Ulcers (no.) External Monthly DoNQ New Medication Errors causing Serious Harm (no.) External Monthly DoNQ New Open Serious Incidents Requiring Investigation (SIRI) (no.) External Monthly DoNQ Never Events (no.) External Monthly DoNQ NHSLA Rating (no.) External Monthly DoNQ Falls resulting in severe injury or death (no.) External Monthly DoNQ Healthcare Care Associated Infections - MRSA bacteraemia (no.) External Monthly DoNQ Healthcare Care Associated Infections - Clostridium difficile (no.) External Monthly DoNQ Healthcare Care Associated Infections - Clostridium Difficile/1000 External Monthly DoNQ Occupied Bed Days (no) New Healthcare Care Associated Infections - E Coli & MSSA (no) External Monthly DoNQ New CLINICAL EFFECTIVENESS & PLANNING Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) External Monthly DoSD Breastfeeding prevalence 6-8 weeks after birth (%) External Monthly DoSD 4 Week Smoking Quitters Attended NHS Stop Smoking Services (no.) External Monthly DoSD 4 Week Smoking Quit Rate (%) External Monthly DoSD New 52 Week Smoking Quit Rate Follow Up (%) External Monthly DoSD New Number of partially and fully breastfed infants / total infants due a 6-8 week check Number of partially, fully and none breastfed infants / total infants due a 6-8 week check