TAUNTON & SOMERSET NHS OUNDATION TRUST INTEGRATED PERORMANCE REPORT Report to: Trust Board on 24 ebruary 2016 Purpose of the Report: (Please type in Bold) To provide an overview of high level performance reporting for ebruary 2016 in the areas of inance, Clinical Quality, Performance and Workforce. Sponsor: Author: Contact Details: inancial/resource Implications: All Executives Kelvin Grabham, Associate Director of Performance and Information Helen Stapleton, Head of People & Systems Reporting Lynn Pearson, Corporate Performance Manager N/A Indicative Timings (Mins) Risk Implications Link to Assurance ramework or Corporate Risk Register: Legal Implications: Link to CQC Essential Standards reedom of Information Status: Previous Considerations: Action Required: (Please type in Bold) Linked to key risks on finance, performance and quality RTT 18 weeks is a legal right for patients from 1 April 2010 and part of the national contractual requirement. Outcome 16 - Assessing & monitoring the quality of service provision. Tick if one of the following apply: Data protection staff or patient detail Commercially sensitive Stakeholder management Early stage of discussion Potentially prejudicial to staff morale or partnership working Report presented at each Trust board The Board is asked to note the report TSTA/02.16 Page 1 of 22
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Integrated Board Report ebruary 2016 TSTA/02.16 Page 3 of 22
1. BACKGROUND The board is receiving the integrated performance report in this revised format for the second time this month and as requested the KPI sheet has been updated so that regulatory targets (as well as those measures which are new ) have been highlighted for easier interpretation for members of the Board. The use of the updated scorecard at Directorate PA is helping to ensure a robust and balanced review of performance with clear actions aimed at performance improvement covering all aspects of the scorecard. This is further being strengthened in ebruary with an enhanced financial performance committee feeding into the PA process. 2. PERORMANCE OVERVIEW Overall performance against the range of Scorecard measures fell slightly this month, with three less indicators rated as green in January than in December. However, there was continued good performance against patient focused indicators, particularly for hospital cleanliness (where all three measures were above target) and patient feedback through the riends and amily Test. Performance against Operational Delivery indicators was more mixed with the majority of cancer targets being met and agency usage remaining lower, although further progress is required against indicators linked to waiting times performance (A&E, RTT and diagnostic waiting times) and measures related to urgent care (increased emergency admissions, non-elective length of stay and medical outliers). People measures are consistent with previous months, although there has been progress against measures related to the annual review process. Performance against a number of finance measures has improved slightly this month although the majority remain below target. In addition having reviewed the (RAG) thresholds for a number of the finance indicators these have been further strengthened. Summary of Indicator Scores Area Green Change from previous month Amber Red Total Patients 18 0 17 7 42 People 0 0 9 3 12 Operational Delivery 9-2 8 14 31 inance & Value 2-1 2 8 12 Total 29-3 36 32 97 TSTA/02.16 Page 4 of 22
3. PATIENTS 3.1 Overview Performance remains positive against the majority of patientfocused indicators, with particularly good performance on a clean and welcoming environment, help and information, and listening to patients. Numbers of pressure ulcers have decreased again to the lowest number this financial year and significant improvement is shown in complaints management. Specific areas for continued focus for improvement include timeliness of incident management, end of life care planning, falls, dementia screening and out of hours transfers. 3.2 Detailed Review of Indicators 3.2.1 The care we provide is safe alls: The number of falls continues to be a concern, although there were less falls in December (75) than in the each of the previous 3 months. Significant focus is being given to on-going improvement work linked to Sign Up to Safety (SUTS). The run-chart below (fig. 1) shows the latest position for high consequence falls, one of several key measures being monitored by the SUTS falls work-stream. The falls safety programme has been concentrating on interventions using improvement methodology on a small number of wards, with roll-out to a second wave of wards planned. ig. 1 CAUTI: Another area of focus for SUTS is catheter acquired urinary tract infections (CAUTI) and performance in this area is showing improvement although only slowly. The process for assessing and recording the daily need for a catheter had identified poor compliance, and use of a daily sticker has been rolled out across the Trust to ensure the ongoing need for a catheter is assessed daily. The Trust s Infection Prevention and Control Committee is overseeing delivery of the action plan. C Diff: In January, there was a further case of Clostridium difficile infection (although not due to a lapse in care), bringing the year to date position to 20. This is another area being overseen by the Infection Prevention and Control Committee. The cumulative position is shown overleaf (fig. 2). The target for the year was 12, but (as previously reported) the Trust, Monitor and the CCG are particularly focussing on cases due to lapses in care (currently four for the year to date). Three of the lapses in care were related to antimicrobial prescribing TSTA/02.16 Page 5 of 22
and one related to cleaning and decontamination issues in AMU. eedback was given to the appropriate clinicians regarding antimicrobial prescribing and an action plan is in place to address the cleaning and decontamination issues on AMU, with progress and improvement already noted. ig. 2 Pressure Ulcers: The chart below (fig. 3) demonstrates progress against one of the key measures, number of Grade 2 pressure ulcers per 1,000 bed days. There has been improved performance on this month by month since October, with this metric now scoring as green (7 pressure ulcers in January). In December 2015 the Trust participated in the CCG Somerset Pressure Ulcer Peer Review; the results of this review were reported to the Governance Committee in ebruary 2016. ig. 3 Management of Incidents: The Trust has recently introduced a new performance indicator on the management of incidents, focussing on ensuring incidents are responded to by the responsible manager within 10 working days. Despite the Governance Support Unit (GSU) working closely with teams to improve on this performance deteriorated in January, with only 43.6% of incidents managed within 10 days. The Women & Children s Directorate needs particular focus (27.8% performance for January). This will be discussed with the team at their performance review meeting later in the month. Two other indicators under the patient safety section showed as red or amber for the first time in January: Still-births: There were two still-births in January. This is disappointing for the Maternity Team as these were the first since August, but both have been reviewed and assessed as unavoidable and due to medical factors. TSTA/02.16 Page 6 of 22
Door to needle time for neutropenic sepsis patients: The Trust dipped below the 90% target for this key indicator in January after 15 months consecutively of excellent performance. Each miss in January has been reviewed and discussed with the clinical area and staff concerned, and formal training is being provided to the AMU nursing team by the Acute Oncology Team this month to ensure that the target can be recovered promptly. 3.2.2 The care we provide is clinically effective HSMR & SHMI: A number of the indicators for clinical effectiveness are currently amber, including HSMR and SHMI. Although 3-month rolling HSMR is currently above 100 (100.7), the confidence interval is 88.1 to 114.6 (see fig. 4 below) so it remains within the expected range. The 3-month rolling SHMI is currently at 90.6 up to October 2015 (confidence intervals 82.2 to 99.9). ig. 4 The rolling 3 month HSMR for November 2015 for non-elective (emergency) patients admitted on a weekend was 102.4 compared to 101.0 for those patients admitted on a weekday (see fig. 5), elevated but again within the expected range. The divergence between weekend and weekday mortality persists. The Trust has extensively reviewed deaths in weekend admissions for the period October to November 2012 and also as part of the January 2015 deaths review. All departments are now regularly reviewing their inpatient deaths. ig. 5 The Trust s Data Outlier Review Group meets monthly to review all diagnosis groups in which the Trust is an outlier within HSMR or SHMI trees as highlighted below (note, HSMR data covers the period December 2014 to November 2015 and SHMI November 2014 to October 2015). TSTA/02.16 Page 7 of 22
ig. 6 Looking at other indicators within this section of the report the new indicators developed relating to the management of policies and best practice guidance continue to show improvement. 3.2.3 Compassion and Respect Three of the seven Scorecard indicators for compassion and respect are red rated this month, an improvement on last month (where four were red). End of Life Care: The focus on End of Life Care on a monthly basis has begun to have an effect on the percentage of Treatment Escalation Plans (TEPs) clearly evidenced in patient notes. 93.5% of the notes audited in January contained TEPS, against 77.8% in December, although there is still work required to return to the levels seen earlier in the year. The percentage of notes with evidence of End of Life Care Planning guidance improved a little in January but is still red at 44.1% (the target is 60%). The End of Life Steering Group is leading the improvement programme, with Executive Leadership from Dr Sam Barrell, and the new End of Life Strategy and work plan was supported for implementation by the Trust Executive Board in ebruary. Dementia: The local dementia screening CQUIN requires patients who are 75 years and above to be screened before the point of discharge and the Trust has consistently achieved 90% for this throughout 2015. The national target, however, requires the screening to occur within 72 hours of admission. With the new EPR in place supporting the screening process, there is greater visibility and focus on achieving this although the latest figures do not show an improvement (27.5% of patients screened within 72 hours in December, down from 34.8% in November). Karen Holden, Dementia and rail Elderly Projects Lead, is supporting the directorate teams by preparing a briefing of key actions required for improvement. This will be discussed at the ebruary performance review meetings. Transfers out of hours: Performance has improved a little since December (63 patients moved at night in January, 74 in December) but improvement is still required. The number of patients moved after hours is related to increased emergency activity and the need to move medical, surgical and orthopaedic patients to create capacity in acute medicine. These patients are cared for under the buddy ward arrangement. All attempts to minimise out of hours patient moves are taken, and patients who are moved receive a full explanation and apology. TSTA/02.16 Page 8 of 22
3.2.4 Listening to patients Six of the seven indicators under this section were green in January, with just one amber, a significant improvement on last month. riends and amily indicators continue to be positive (see chart below): ig. 7 rom the in-house patient surveys, the percentage of patients rating care as very good / excellent continues to be high, as does those stating they were always treated with dignity and respect: Patients Rating Care as Very Good / Excellent ig. 8 Patients who felt they were always treated with respect & dignity ig. 9 Managing Complaints It was recognised some months ago that the performance of complaint response times required significant improvement as this had been challenging for some time. To take this forward a Trust workshop was held in July 2015 with a range of staff and a revised improvement strategy was agreed by the Trust Executive Board in November 2015. These revised plans are now in place and are starting to realise benefit and deliver real improvement. The Trust is aiming to deliver 90% compliance by the end of Q4 2015/16 TSTA/02.16 Page 9 of 22
and the January position (now amber) shows that we are well on our way to delivering this (85% complaints closed within the agreed deadline in January). 4. PEOPLE 4.2 Areas for improvement 4.2.1 Our colleagues know how they are doing 4.1 Overview As reported last month many of the indicators within the people quadrant are taken from the Pulse Check questionnaire. The next update to this will be published in the March report and from then on there will be a monthly phased programme of pulse checks which will provide a cumulative 12 month rolling position. We have now received confirmation of our national staff survey results, which are showing extremely positive improvement over the previous year, and place us in the top 20% of all acute trusts for overall staff engagement, and recommendation of the trust both as a place to work and as a place to receive care and treatment. The report is embargoed until national release on the 23 rd ebruary and so this will be tabled at the board meeting on the 24 th as part of the integrated performance presentation. All three red People indicators remain against the principle which is designed to measure if colleagues know how they are performing at an individual level. Two of the three relate to the annual review process where improvement has been seen in January, particularly against the measure looking at completion of 6 month reviews which has increased from 29.8% to 40.8%. Performance against these indicators was a key focus in the January performance review meetings and the People team have been working with colleagues to ensure the annual and 6-month reviews are recorded accurately and in a timely manner. As we are now drawing close to the time for end of year reviews (for colleagues who are band 7 and above) significant effort will be dedicated to ensuring high levels of compliance for these reviews which will take place during April and early May. 4.22 Other areas of focus As the first step in our revised directorate deep dive pulse check approach (where each directorate will complete an all colleague pulse check on a 6 monthly basis) we have completed a pulse check in the Women and Children Directorate. This revised approach has enabled a deeper understanding of variances in engagement across teams within the directorate and therefore more targeted action planning, which has now taken place within this directorate. Directorate specific results and action plans are available to board members upon request. TSTA/02.16 Page 10 of 22
5. OPERATIONAL DELIVERY 5.1 Overview The number of green indicators fell by two in January, with the performance wheel principle related to minimising waiting times moving from amber to red whilst the other three principals within Operational Delivery remained amber. Underperformances against key national waiting time targets remain the main concern. RTT performance continued to be below the national incomplete pathway standard falling from 91.8% in November to 90.2% in December against the 92% target. Performance also fell against the 6-week diagnostic wait target primarily because of delays in patients receiving audiology tests. The percentage of patients seen within 4-hours in A&E improved in January but remains slightly below target. A&E attendances and emergency admissions continue to be higher than expected, whilst medical outliers and delayed discharges are both above planned levels. 5.2 National Targets Accident and Emergency 4 hour target (95%) Performance against the 4-hour waiting time standard improved from 92.3% in December to 93.8% in January. A&E attendances have fallen in January but continue to be significantly higher than the same period last year (around 13%), whilst emergency admissions have also increased sharply this year (9.6%). Given the continued demand pressure the existing action plan for improvement has been revised and key actions to improve performance in quarter four include: Implementation of 24/7 middle grade rota in A&E (in place from 3 rd ebruary); To improve ambulance handover times the adoption of an agreed standard operating process with the Ambulance Trust (from 31 January 2016) and a review of the use of handover bays (by March 2016); Establishment of a longer term strategy for patients with minor conditions (by May 2016). The plan also includes commissioner actions for understanding and reducing the drivers of demand on A&E and other urgent care services in Somerset, including a joint communications plan to encourage the most appropriate use of services plus a set of actions to be taken forward by the Somerset Urgent Care Programme Board. A&E 4-hour performance A&E attendances ig. 10 Cancer Targets Six of the eight national cancer targets were provisionally achieved in January. The 62 day target was met for the second subsequent month, with performance exceeding the agreed improvement trajectory (see chart below) and rollover of breaches reducing month-on-month. More detail on 62 day performance by speciality is included in the cancer exception report in appendix A. TSTA/02.16 Page 11 of 22
ig. 11 Some specialities are still finding it challenging to meet the 62-day target (urology, lung and head & neck in particular) but all specialties have improvement action plans in place that are being reviewed in fortnightly meetings chaired by the Deputy Director of Operations. Colorectal cancer performance is currently good after some difficult months for this speciality, but long waits for endoscopy may impact on future performance as there is a risk that patients will be diagnosed too late in their pathway for treatment within the target. A plan to increase endoscopy capacity is being produced to mitigate against this risk. Performance against the 2 week wait from GP referral target dipped again in January, with performance at 90.2% against the 93% target. This under-performance occurred primarily early in the month, with patients seen early in January rather than within target at the end of December. Some of this was due to patients wishing to delay until after Christmas, but also because the arrangements for more staff to be trained to process the fast-track referrals did not take full effect until mid-january. There was also a CT scanner breakdown at the end of December that caused some delays to colorectal first appointments. There is some confidence that the 2 week wait target will be recovered in ebruary, although meeting the target for the quarter will be challenging because of the poor early start. 2 week wait referral growth remains high, with an 8% increase on numbers referred in April to January 2015-16 when compared with the same period last year (amounting to an additional 671 patients requiring fast-track appointments for suspected cancer). The other cancer target that was not met in January was the 31 day target for patients requiring subsequent surgery for a confirmed cancer. Numbers are small for this group of patients so performance is always volatile; the four cases in January were all skin patients where some communication issues between the clinical team and the cancer services team meant that the patients were not correctly tracked and brought forward accordingly. These communication issues are being worked through with the clinical team and not expected to re-occur. Referral to Treatment (92% target) Performance against the national incomplete pathway standard (92% of patients waiting under 18 weeks) fell further below target in December primarily due to an increase in the waiting list size caused by growing demand in a number of key specialties, plus a reduction in activity taking place in the independent sector or as waiting list initiatives. In December 90.2% of patients were waiting under 18 weeks, with the largest number of breaches being seen in general surgery (337), orthopaedics (303), ENT (296) and ophthalmology (247). The chart overleaf shows performance since January 2015. ig. 12 TSTA/02.16 Page 12 of 22
A further deterioration in performance against this target in expected in ebruary (to around 89% of pathways within 18 weeks). The Trust is working closely with commissioners on a plan and trajectory to recover performance back above the 92% target during 2016/17. Given the number of breach patients that need to be seen and the continued referral demand growth for specialties such as general surgery and ENT this is likely to show recovery back above the 92% target taking up to 12 months. The plan, which will be based on achieving sustainable waiting list sizes, is expected to be completed during ebruary 2016. Diagnostic 6-week wait (99% target) The number of 6-week breaches rose significantly in December, from 164 to 350, with audiology and neurophysiology breaches accounting for the majority of breaches (236). The increase in neurophysiology breaches, which rose from 48 in November to 106 in December, was highlighted as a risk in last month s report and was related to an unexpected consultant capacity gap. A locum has been in place since the beginning of ebruary and will help to reduce the backlog back to minimal levels by May 2016. The increase in the audiology breaches (from 34 to 130) was caused by a combination of a gap in administrative booking capacity and a high level of patient choice. A draft action plan to reduce the breaches is currently being produced, although the backlog is likely to increase in the short term before reducing from the end of quarter four and into early 2016/17. The increased breaches seen in neurophysiology and audiology have caused the Trust to fall behind its trajectory for improvement as shown in the chart below. A revised trajectory will be produced to reflect the actions set out for these modalities, although achieving the 99% target (which allows for less than 50 breaches per month from a waiting list of around 4,800 patients) will remain very challenging. ig. 13 5.3 Right staff in the right place at the right time The average WTE worked for the three months to the end of January was consistent with previous months across all staff groups, with an increase in nursing due to winter capacity. Contracted staff in post has remained stable across all staff groups. Temporary staff use was better than plan in January due to lower than anticipated activity for some of the month. Average WTE worked (3 month rolling) People utilisation - WTE worked Aug 15- Oct 15 Sep 15- Nov 15 TSTA/02.16 Page 13 of 22 Oct 15 Dec 15 Nov 15 - Jan 15 Movement Nursing 1,676 1,691 1,703 1,711 8 Medical 489 483 483 483 0 Other Clinical 442 442 441 436-5 Non-Clinical 1,255 1,259 1,263 1,251-12 WTE contracted medical and other clinical staff in post was reasonably consistent with previous months. There was a further drop in non-clinical people in post (administrative and estates staff), reflecting tighter recruitment controls for this staff group.
Compliance with the nursing roster rules continues to be a challenge. Roster management plans are being reviewed through the monthly performance review process and significant challenge is being applied, with ward level reviews to support optimal deployment of ward based colleagues. 5.4 Other areas for improvement Other than waiting times measures, the majority of red rated indicators in the Operational Delivery section of the Scorecard are related to urgent care pressures. Non-elective activity remains significantly above planned levels (14.9% in January) and a high level of delayed discharges and medical outliers continues to impact on flow through the hospital (see chart below). ig. 14 The length of stay for non-elective patients has also increased in January from an average of 3.6 days to 4.1 days, whilst ambulance handover delays, related to A&E capacity, have increased from 6.8% to 9.3%. The joint A&E action plan referred to in section 5.2 above includes wider community measures, for instance approaches to reducing delayed discharges, which should relieve pressure on the Trust. However, the sustained increase in emergency demand continues to affect the Trust s ability to achieve national targets including the A&E 4-hour wait and the RTT incomplete standard. The DNA rate for outpatient attendances remains a concern (see the chart overleaf), although the rate has started to decrease for the first time since the Trust moved to MAXIMS. The DNA reminder service was partially opened (to T&O) at the end of January and the Trust has been working closely with the supplier of the system to roll out to all specialties in ebruary. ig. 15 TSTA/02.16 Page 14 of 22
6. INANCE AND IMPROVEMENT 6.1 Overview Performance against financial measures is covered in more detail in the separate finance board report. In the Scorecard eight of the twelve finance indicators are red, with the current and forecast overspend and under-delivery of CIP savings accounting for six of these. Please note that the year to date and forecast over/underspend performance shown in the Scorecard is based on the original 2015/16 financial targets rather than revised year end positions. As mentioned previously, following the completion of the detailed budget review meetings in January we have taken the opportunity to enhance the focus applied at a directorate level through the inance Performance Committee (which is part of the PA process). TSTA/02.16 Page 15 of 22
APPENDIX A CANCER EXCEPTION REPORT Cancer 62 days The table below shows overall performance since April 2015 (January data remains provisional until formal upload). Standard Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan 62 day from urgent GP referral to treatment 85% 83.8% 81.7% 79.9% 81.0% 85.5% 78.8% 82.3% 77.6% 92.7% 85.1% In January there were 13 breaches against a threshold of approximately 12. The breakdown of performance at cancer site is shown in the table below. It shows that there are still challenges for lung and urology where there are shared care pathways with other Trusts. Haematology and head & neck both dipped below target in month but numbers are low for these specialities, and head & neck cancer treatment is particularly complex. Directorate Cancer site Patients Breaches % Acute Surgery & Gastro Lower GI (colorectal) 7 1 85.7% Upper GI 9 1 88.9% Breast 3 0 100% Head/Neck & Specialist Head and Neck 4.5 1 77.8% Surgery Skin 22 2 90.9% Urological (inc. Testicular) 25 5 80.0% Women and Children Gynaecology 6 0 100% Paediatrics 0 0 - Cancer of Unknown 0 0 - Primary HOPE Haematology 5 2 60.0% Sarcoma 0 0 - Acute Medicine Lung 5.5 1 81.8% Trust Total Total 87 13 85.1% Performance was better than anticipated for January and rollover of breaches has also improved, indicating that the continued focus on improving pathways and tracking patients has begun to have a more sustained impact. The table below shows the rollover rates since April 2015. Breaches carried into month Main specialties (from previous month) April 15 17.5 Urology (4), skin (3.5) May 14 Urology (6) June 21.5 Urology (7.5), upper GI (4.5) July 23 Urology (9.5), upper GI (5), colorectal (4) Aug 15 Urology (6), colorectal (4), lung (3) Sep 24 Urology (7), colorectal (6.5), skin (4) Oct 20.5 Urology (7), skin (3.5), lung (3.5) Nov 13.5 Colorectal (3), lung (3) Dec 10.5 Urology (5) Jan 16 18.5 Urology (6.5), colorectal (3) eb 10.5* Urology (2.5), head & neck (2.5), lung (1.5) * this includes 6 patients (3 shared breaches) waiting for dates at Bristol or RDE TSTA/02.16 Page 16 of 22
APPENDIX B - LIST O INDICATORS Patients (* denotes new indicator, # denotes national target) Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red Cleanliness audit Cleanliness audit 96.0% 96.0% 96.0% 96.0% 94.0% 94.0% 95.0% 95.0% 95.0% 96.0% 95.0% 90.0% Our environment is clean and welcoming Patient reported experience (2 questions from quarterly surveys) Our patients and their carers get the help and information they need Patient reported experience (3 questions from quarterly surveys) % Patients with evidence of discharge plans Patient reported experience (2 questions from quarterly surveys) % Patients who rate the hospital as very clean* % Patients who report staff treating & examining them always introduce themselves* % Patients who were given the help they needed at mealtimes* % Patients who always found staff to discuss worries & fears* % Patients who were happy with the level of involvment in decisions about care & treatment* % Patients with evidence of discharge plans* % Patients who felt always treated with respect & dignity* % Patients who report staff are always kind & sensitive to their needs* 86.0% 86.0% 86.0% 92.0% 92.0% 92.0% 94.0% 91.0% 91.0% 94.0% 90.0% 80.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 98.0% 92.0% 96.0% 95.0% 85.0% 84.0% 96.0% 89.0% 88.0% 96.0% 85.0% 89.0% 86.0% 93.0% 85.0% 90.0% 75.0% 73.0% 79.0% 78.0% 83.0% 85.0% 78.0% 81.0% 88.0% 81.0% 82.0% 90.0% 75.0% 93.0% 93.0% 93.0% 95.0% 95.0% 95.0% 93.0% 95.0% 92.0% 90.0% 95.0% 80.0% - 91.7% 88.8% 86.7% 82.7% 83.7% 100.0% 86.8% 70.4% 86.6% 85.0% 75.0% 97.0% 98.0% 96.0% 93.0% 96.0% 94.0% 97.0% 97.0% 91.0% 94.0% 95.0% 80.0% 92.0% 93.0% 94.0% 92.0% 92.0% 92.0% 93.0% 93.0% 87.0% 91.0% 90.0% 80.0% Our patients and their carers are treated with compassion and respect Mixed sex accommodation breaches End of Life Care Planning (2 metrics from EoL dashboard) Mixed sex accommodation breaches # 0 0 0 0 0 0 0 0 0 0 0 1 % Deceased patients with End of Life Care Planning guidance in notes* % Deceased patients who had a Treatment Escalation Plan in place* 47.8% 49.5% 53.8% 72.6% 50.5% 43.0% 53.8% 49.4% 36.7% 44.1% 60.0% 50.0% 83.0% 91.0% 92.0% 95.0% 92.0% 97.0% 95.0% 91.6% 77.8% 93.5% 90.0% 80.0% No. patients transferred between wards after 10pm No. patients transferred between wards after 10pm* % Patients who were screened for % Patients who were screened for dementia within 72 hours dementia within 72 hours Emergency readmissions within 30 days - after elective Emergency readmissions within 30 days - after elective - - - - - - 39 66 74 63 30 49 60.1% 63.5% 63.1% 63.6% 64.8% 52.0% 23.5% 34.8% 27.5% - 90.0% 90.0% 3.6% 3.6% 3.1% 3.0% 3.7% 2.9% 3.4% 3.0% 3.2% - 2.4% 3.5% The care we provide is clinically effective Emergency readmissions within 30 days - after emergency % Stroke Patients direct admission to stroke ward in 4 hours Emergency readmissions within 30 days - after emergency % Stroke Patients direct admission to stroke ward in 4 hours # 12.3% 12.1% 11.6% 13.0% 13.6% 12.1% 12.0% 11.7% 12.1% - 11.4% 12.5% 72.7% 75.4% 71.1% 69.6% 67.5% 75.0% 73.6% 72.9% 65.3% 82.7% 90.0% 75.0% HSMR HSMR # 116.3 117.5 106.7 103.3 103.0 108.0 104.9 100.7 - - 95 105 SHMI SHMI # 101.0 103.2 100.5 95.2 89.2 91.3 90.6 - - - 95 105 Policy & guidelines management (NICE & local) NICE process compliance* - - - - - 45 37 40 32 27 25 40 Policies and guidelines process compliance* 64.5% - 64.5% 64.7% 68.0% 68.7% 70.7% 70.6% 72.8% 76.3% 75.0% 60.0% (Patients metrics continued on next page) TSTA/02.16 Page 17 of 22
Patients (continued) Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red No of SUIs/Never Events No of SUIs/Never Events 3 4 2 0 0 2 0 2 0 1 0 5 Management of incidents with a score of 3 or more Reported incidents managed within 10 days* - 55.9% 50.1% 53.7% 48.8% 47.6% 57.3% 51.6% 48.3% 43.6% 80.0% 50.0% IC - Clostridium Difficile cases (post) IC - Clostridium Difficile cases (post) # 3 3 1 2 1 0 2 5 2 1 0 1 IC - MRSA bacteraemias (post) IC - MRSA bacteraemias (post) # 0 0 0 0 0 0 0 0 0 0 0 0 SUTS - CAUTI - % of patients % Patients where ongoing need for where ongoing need for catheter catheter has been assessed and recorded has been assessed and recorded daily* daily - - - - - - 75.0% 59.0% 73.0% 74.0% 80.0% 70.0% SUTS - No. of patient falls SUTS - No. of patient falls 85 77 65 85 71 80 92 81 75-43 50 The care we provide is safe SUTS - No. of pressure ulcers grade 2 & above SUTS - No. of pressure ulcers grade 2 & above 13 17 14 15 14 12 14 11 10 7 7 14 SUTS - Care of Deteriorating Patient - No. ward-based cardiac No. ward-based cardiac arrests* 1 5 4 1 4 5 1 3 3 5 0 6 arrests SUTS - Sepsis - % of patients receiving antibiotics within 60 mins Neutropenic Sepsis - Antibiotics received within 60 mins* % Patients receiving antibiotics within 60 mins 90.0% 100.0% 92.0% 92.0% - 91.0% 90.0% 90.0% 93.0% 89.0% 90.0% 80.0% - - - 30.4% 54.5% - - - - - 90.0% 49.0% SUTS - Maternity - no. of stillbirths and/or babies born in unexpectedly poor condition SUTS - No. of still births* 0 0 2 0 1 0 0 0 0 2 0 0 SUTS - No. of babies born in unexpectedly poor condition* 0 0 0 0 0 1 0 0 0 0 0 0 Medicines Management (dispensing errors & missed doses) Medicines Management - % patients with missed doses* - 2.6% 2.0% 2.1% 2.0% 2.4% 2.4% 2.5% 2.4% 2.2% 1.0% 3.0% Pharmacy - no. of dispensing errors* - 0 0 0 0 0 0 0 0 0 0 1 riends & amily Test (patients likely to recommend) 97.3% 98.7% 98.2% 97.9% 98.1% 97.2% 98.0% 98.2% 95.4% 97.6% 95.0% 94.0% riends & amily Test (4 sources: inpatients, outpatients, maternity & A&E) riends & amily Test - Maternity 98.1% 98.9% 99.4% 78.4% 95.8% 100.0% 98.3% 97.0% 98.5% 97.1% 93.0% 91.0% riends & amily Test - Outpatients* - 93.6% 95.2% 96.8% 96.7% 93.0% 90.1% 97.1% 89.5% 92.1% 91.0% 86.9% We listen to our patients and their carers and learn from them riends & amily Test - Accident & Emergency* Patient survey - rate care received Patient survey - rate care received as as excellent excellent - 89.4% 91.0% 91.3% 91.4% 94.3% 89.8% 93.4% 95.1% 94.5% 91.0% 86.9% 69.1% 76.0% 66.5% 70.8% 71.9% 65.2% 75.5% 73.0% 70.6% 77.6% 75.0% 60.0% Catering satisfaction scores Catering satisfaction scores 85.1% 92.2% 86.0% 80.0% 88.8% 82.0% 81.0% 84.0% 86.0% 86.0% 80.0% 75.0% Complaints handling (process & actions identified) Complaints breached against deadline 40.6% 56.0% 48.2% 52.0% 18.0% 32.0% 64.0% 40.0% 39.0% 15.0% 10.0% 25.0% % Closed complaints with actions identified that are completed* - - - - - - - - - - 10.0% 25.0% TSTA/02.16 Page 18 of 22
People Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red We provide opportunity to learn % Mandatory training completed % Mandatory training completed 86.1% 87.2% 86.7% 86.6% 85.0% 85.4% 85.5% 85.7% 86.4% 87.8% 95.0% 85.0% and develop Pulse Check - I think that it is safe Pulse check - I think that it is safe to speak to speak up & challenge the way up & challenge the way things are done* things are done 65.6% 65.6% 65.6% 64.6% 64.6% 64.6% - - - - 90.0% 64.0% Our colleagues speak up and share ideas and concerns Pulse Check - When we get things Pulse check - when we get things wrong I wrong I feel that we learn & make feel that we learn & make changes to changes to improve improve* 75.5% 75.5% 75.5% 77.6% 77.6% 77.6% - - - - 90.0% 64.0% % Staff completing Pulse Check % Staff completing Pulse Check 27.6% 27.6% 27.6% 25.2% 25.2% 25.2% - - - - 50.0% 24.0% % Annual performance reviews completed % Annual performance reviews completed 83.4% 74.5% 77.4% 78.6% 79.1% 78.4% 80.0% 79.3% 82.8% 84.0% 92.0% 85.0% Our colleagues know how they are doing Our managers provide strong leadership We care about the wellbeing and safety of our colleagues % Staff given a rating in their performance review % Performance 6 month reviews completed for bands 7 & above Pulse Check - I receive regular & constructive feedback on my performance Pulse Check - Leadership capability index % Staff given a rating in their performance review* % Performance 6 month reviews completed for bands 7 & above* Pulse Check - I receive regular & constructive feedback on my performance* - - - - - - 65.0% 67.0% 68.7% 70.1% 90.0% 64.0% - - - - - - 13.0% 20.0% 29.8% 40.8% 90.0% 79.0% 61.0% 61.0% 61.0% 62.2% 62.2% 62.2% - - - - 90.0% 64.0% Pulse Check - Leadership capability index 69.8% 69.8% 69.8% 70.8% 70.8% 70.8% - - - - 90.0% 64.0% Pulse Check - My immediate Pulse Check - My immediate manager manager places a strong emphasis places a strong emphasis on promoting on promoting safety & wellbeing safety & wellbeing of colleagues* of colleagues Pulse Check - I feel respected & valued as a member of my team Pulse Check - I feel respected & valued as a member of my team* 72.7% 72.7% 72.7% 74.8% 74.8% 74.8% - - - - 90.0% 64.0% 76.3% 76.3% 76.3% 76.8% 76.8% 76.8% - - - - 90.0% 64.0% Pulse Check - Great place to work Pulse Check - Great place to work 80.4% 80.4% 80.4% 81.1% 81.1% 81.1% - - - - 90.0% 64.0% TSTA/02.16 Page 19 of 22
Operational Delivery Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red % Nursing rosters non-compliant with rules % Nursing rosters non-compliant with rules 51.6% 46.8% 46.2% 47.1% 53.6% 57.4% 53.7% 44.6% 49.3% 50.7% 25.0% 35.0% We have the right staff in the right place at the right time Agency, bank & overtime as % of total worked Vacancy - % difference contracted TE in post vs budgeted establishment Agency, bank & overtime as % of total worked Vacancy - % difference contracted TE in post vs budgeted establishment 10.2% 9.9% 9.7% 8.8% 9.0% 8.4% 8.5% 7.9% 7.0% 7.3% 7.5% 10.0% -6.3% -6.2% -5.0% -5.9% -4.4% -3.6% -2.9% -3.5% -4.2% -4.4% 5.0% 7.5% % Sickness levels % Sickness levels 3.8% 3.8% 3.7% 3.6% 3.6% 3.6% 3.6% 3.6% 3.6% 3.6% 3.3% 3.8% Cancelled Operations Cancelled Operations 41 37 29 34 20 52 40 36 22 28 35 36 DNA Rate - Outpatients DNA Rate - Outpatients 6.7% 7.0% 6.9% 7.0% 7.0% 7.7% 9.5% 9.8% 10.5% 10.2% 5.0% 7.5% No. of medical outliers No. of medical outliers 25 25 14 18 19 30 30 26 24 30 15 25 We plan and manage our activity well Referrals variance Referrals variance* - - - - - - - - - - 5.0% 10.0% Elective activity variance Elective activity variance -4.6% -10.8% -2.4% -9.6% -12.4% -10.3% -11.1% -7.6% -13.2% -7.5% 5.0% 10.0% Non-elective activity variance Non-elective activity variance 2.9% -2.2% -0.4% -2.0% 1.2% 10.4% 13.1% 11.7% 11.8% 14.9% 5.0% 10.0% Outpatient activity variance Outpatient activity variance* - - - - - - - - - - 5.0% 10.0% Elective average length of stay Elective average length of stay 2.8 3.3 2.8 2.8 2.5 2.5 2.3 3.0 3.0 2.1 2.6 2.6 Non-elective average length of stay Non-elective average length of stay 4.0 3.9 3.9 4.0 3.7 3.8 4.0 3.7 3.6 4.1 3.8 3.8 Daycase rate Daycase rate 84.8% 86.0% 83.9% 84.8% 82.8% 78.8% 72.8% 80.7% 79.9% 81.1% 78.0% 75.0% No-one stays in hospital longer than they need to Morning discharge rate - before 2pm Morning discharge rate - before 2pm 34.9% 35.1% 33.7% 33.3% 33.2% 32.6% 33.6% 34.9% 34.2% 33.7% 40.0% 30.0% Weekend discharge rate Weekend discharge rate 17.7% 25.3% 17.9% 17.0% 24.5% 19.2% 20.0% 21.5% 18.2% 23.2% 20.0% 15.0% % Patients who have been spoken % Patients who have been spoken to by a to by a member of staff about member of staff about plans for discharge* plans for discharge 54.0% 43.0% 49.0% 53.0% 49.0% 57.0% 64.0% 50.0% 59.0% 57.0% 60.0% 50.0% No. Patients with delayed discharge No. Patients with delayed discharge* 13 24 17 27 24 47 34 44 52 35 20 30 (Operational Delivery metrics continued on next page) TSTA/02.16 Page 20 of 22
Operational Delivery (continued) Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red A&E 4hr performance A&E 4 hour performance # 97.4% 96.9% 97.3% 96.4% 93.9% 93.8% 88.6% 93.9% 92.2% 93.8% 96.0% 95.0% Ambulance turnaround - breach of Ambulance turnaround - breach of 30 mins 30 mins # Cancer - compliance with Monitor 2 week wait target (suspected cancer & breast symptomatic) Cancer - max. 2 week wait from GP referral (suspected cancer) # Cancer - max 2. week wait from GP (symptomatic breast) # Cancer - compliance with Monitor first treatment target (max. 31 day Cancer - max. 31 day wait from diagnosis to wait from diagnosis to first 1st treatment # treatment) 3.8% 5.7% 3.9% 6.0% 4.8% 6.9% 12.5% 6.5% 6.8% 9.3% 0.0% 3.5% 90.8% 94.0% 91.8% 89.0% 92.6% 94.6% 93.2% 89.4% 92.6% 90.2% 94.0% 93.0% 98.3% 98.7% 94.8% 90.7% 93.8% 98.7% 98.1% 95.5% 94.4% 93.6% 94.0% 93.0% 97.6% 99.4% 99.4% 99.4% 96.5% 97.9% 97.8% 98.9% 97.8% 96.6% 97.0% 96.0% Cancer - compliance with Monitor 62 day targets (GP referrals & screening patients) Cancer - max. 62 day wait # 83.8% 81.7% 79.9% 81.0% 85.5% 78.8% 82.3% 77.6% 92.7% 85.1% 86.0% 85.0% Cancer - max. 62 day wait referral from NHS screening service # 84.6% 94.1% 97.8% 100.0% 74.2% 92.7% 91.7% 94.4% 92.1% 94.6% 91.0% 90.0% We minimise how long patients have to wait Cancer - compliance with Monitor subsequent treatment targets (drugs, radiotherapy & surgery) Cancer - max. 31 day wait for subsequent treatment - drug # Cancer - max. 31 day wait for subsequent treatment - radiotherapy # Cancer - max. 31 day wait for subsequent treatment - surgery # 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 97.0% 98.5% 98.6% 100.0% 98.8% 93.0% 98.2% 95.1% 94.9% 97.8% 100.0% 95.0% 94.0% 93.3% 96.9% 100.0% 100.0% 100.0% 100.0% 95.8% 100.0% 100.0% 83.3% 94.0% 93.0% Diagnostic outpatient six week breaches Diagnostic outpatient six week breaches # 334 314 522 451 418 300 164 160 350-0 40 Imaging - % of inpatients scanned within 24 hours Histopathology - % cases turned around in 7 days (receipt to results) Average time in weeks to first OPA RTT incomplete pathway performance % Inpatient scan requests turned around in <24 hrs* Histopathology - % cases turned around in 7 days (receipt to results)* - - - - - - - 92.1% 75.6% 73.5% 96.0% 90.0% - - - - - - - - 48.0% 55.0% 71.0% 50.0% Average time in weeks to first OPA* - - - - - - - - - - - - RTT incomplete pathway performance # 92.3% 92.9% 93.0% 92.5% 92.4% 92.5% 92.1% 91.8% 90.2% - 92.0% 92.0% No. of RTT patients in backlog waited 40 weeks or more No. of RTT patients in backlog waited 40 weeks or more* 29 23 25 20 22 23 33 24 49-6 15 TSTA/02.16 Page 21 of 22
inance and Improvement Principle Board Metric Metric Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Target (Green) Red YTD under or over spent YTD under or over spent - - - - - - 2.7% 2.7% 2.7% 2.5% 0.0% 0.0% We spend our money wisely to meet our patients' needs orecast under or over spend orecast under or over spend - - - - - - 2.3% 2.1% 2.4% 2.8% 0.0% 0.0% % Budgets overspent % Budgets overspent* - - - - - - 43.0% 57.0% 55.0% 38.0% 10.0% 20.0% We make good use of our assets Non-invoiced income YTD as proportion of income Agency use as a % of establishment Non-invoiced income YTD as proportion of income 45.9% 31.4% 30.4% 0.8% 15.0% - 22.2% 20.2% 19.6% 18.6% 5.0% 10.0% Agency use as a % of establishment* - - - - - - 2.0% 1.5% 1.5% 1.6% 5.0% 10.0% YTD CIP achievement YTD CIP achievement 42.4% 83.1% 85.0% 87.7% 83.3% - 54.1% 51.0% 54.0% 56.0% 100.0% 85.0% orecast CIP achievement orecast CIP achievement 72.3% 65.1% 64.7% 83.9% 74.8% - 66.8% 63.0% 64.0% 66.0% 100.0% 85.0% We work hard to maximise value ull year effect of CIP ull year effect of CIP* - 100.0% 67.0% 67.0% 67.0% - - 57.0% 57.0% 57.0% 90.0% 80.0% Quarterly Service Line Reporting profitability Quarterly Service Line Reporting profitability* - - - - - - - - - - - - Reference cost index Reference cost index* - - - - - - 95.6 96.46 96.46 96.46 95 100 One month forecast accuracy One month forecast accuracy* - - - - - - 0.5% 0.5% 1.1% -1.6% 2.5% 5.0% We understand our business Three month forecast accuracy Three month forecast accuracy* - - - - - - 4.8% 0.4% -0.2% -2.7% 2.5% 5.0% % Budget holder checklists returned % Budget holder checklists returned* - - - - - - - 61.0% 48.0% 61.0% 100.0% 85.0% TSTA/02.16 Page 22 of 22