ENC Bi Integrated Performance Report M6 2013/14 28 November 2013
Contents 1. Structure of the Document... 3 2. Southwark CCG and Providers Performance Summary Dashboard... 4 3. Southwark CCG Dashboard... 5 4. Provider Dashboards (M6 Performance Q2 Quality & Safety)... 6 a. King s College Hospital NHS Foundation Trust... 6 b. Guy s & St. Thomas NHS Foundation Trust... 7 c. Guy s & St. Thomas NHS Foundation Trust Community Health Services... 8 d. South London & Maudsley NHS Foundation Trust... 9 5. Performance and Quality and Safety Trackers... 10 a. Monthly Performance Tracker... 10 b. Quarterly Quality and Safety Tracker... 11 6. Performance Variance and Assurance Information... 12 7. Southwark CCG QIPP Performance... 23 a. Performance and Variance Tracker... 23 b. CCG-led New Outpatient QIPP... 24 c. CCG-led A&E QIPP... 25 d. CCG-led SLaM Risk Share QIPP... 26 8. Southwark CCG Finance Report (M7)... 27 9. Glossary of Performance Indicators... 28 2 P age
1. Structure of the Document The report is written to enable the CCG to review the key domains of finance, QIPP, performance, quality and safety in an assimilated format. The purpose of reporting in this way is to support the CCG s committees in their consideration of the current status of the above domains as well as the interdependencies between them. The report focuses on the current status of all key domains of quality & safety; finance & QIPP; and performance. It is structured to focus on the performance of the CCG but additionally provides a comprehensive overview of the range of indicators used to assess our main provider organsiations: King s College Hospital NHS Foundation Trust, Guy s & St. Thomas NHS Foundation Trust (including community health services) and South London & Maudsley NHS Foundation Trust. Performance dashboards are included in sections 2, 3 and 4 to provide a high-level overview of all performance domains, highlighting where performance is reported to have hit or exceeded target (green rated); where there is some variance from plan (amber rated) or where there is significant variance from plan (red rated). Dashboards are included for the CCG and for the four providers noted above. Performance and quality and safety indicator trackers are included in section 5 to provide on-going monitoring of key indicators. In Section 6, the report focuses in detail on those areas that are shown on the dashboards as having deviated from target. The tables included in Section 6 set out a description of these performance issues and include details of the forums the CCG uses to monitor and address these issues. An overview of the CCG s QIPP and current financial position is included in sections 7 & 8 and Appendix 1. CCG finance report. A glossary of all the performance indicators referred to in this report can be found in Section 9. The indicator definitions and targets have been taken from the Department of Health s Technical Guidance for the 2012/13 Operating Framework and the NHS Commissioning Boards Everyone Counts: Planning for Patients 2013/14 Technical Definitions document. Definitions for locally agreed targets have been taken from provider contract agreements. The data and information included in the Integrated Performance Report is sourced from provider contract monitoring and finance reports, CCG QIPP and finance reports and provider quality, safety and performance reports. The reporting period included varies as some reports are quarterly and others monthly, although the data included in this report is as follows unless otherwise stated in the report: Table 1: Integrated Performance Report Data Sources and Period Covered Data Source Period Covered Quality & Safety Finance Trust Quality & Safety reports SLCSU Acute Int Performance Report Community Contract Report SLaM Quality & Safety Report Serious Incidents Reports CCG Finance Report Acute Int Performance Report SLaM Finance Report Q2 2013/14 M6 Q2 Q2 Q2 M7 M6 Performance Indicators & Targets SLCSU Acute Int Performance Report SLCSU Performance Report M6 M6 3 P age
2. Southwark CCG and Providers Performance Summary Dashboard 4 P age
3. Southwark CCG Dashboard Amber and red-rated issues are reviewed in further detail in Section 6. 5 P age
4. Provider Dashboards (M6 Performance Q2 Quality & Safety) a. King s College Hospital NHS Foundation Trust 6 P age
b. Guy s & St. Thomas NHS Foundation Trust 7 P age
c. Guy s & St. Thomas NHS Foundation Trust Community Health Services 8 P age
d. South London & Maudsley NHS Foundation Trust 9 P age
5. Performance and Quality and Safety Trackers a. Monthly Performance Tracker 10 P age
b. Quarterly Quality and Safety Tracker 11 P age
RTT admitted Financial overperformance Issue CS SLaM ENC H 6. Performance Variance and Assurance Information The table below includes all key red- and amber-rated performance, quality & safety and financial domains included in the above dashboards. The table states the domain concerned, provides a synopsis of the matter arising and includes details of the forum in which the issue is addressed and monitored. This table is provided as a comprehensive overview and it is anticipated that CCG commissioners and committees should direct detailed questions to commissioning leads and and/or further reference the South East London Integrated Performance Reports or the reports listed in Section 1. Synopsis of Issue Finance Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Acute over-performance for M7 was - 2,710k. Likely YEP of - 7,455k (M7 report). Community services over-performance for M7 was - 759k (urgent care centre - 460; walk in centre - 290; other community services - 9). See finance report in appendix 1. Performance & Quality YTD (M7) Position Acute - 2,710k Comm. - 759k Client Groups - 829k Acute Contract Monitoring Meetings 6 Dec () 5 Dec () Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team A planned failure of the admitted performance target on a monthly basis is expected to support backlog clearance. The trust is using a combination of outsourcing to private providers and additional elective capacity on the PRUH and Orpington sites. The trust is transferring some existing orthopaedic waiters, subject to patient agreement, to for treatment. The trust should be in a sustainable position from April 2014. Progress against trajectory The admitted backlog figure at the end of October was 1451 compared to a trajectory of 1362-89 adrift of trajectory. Two main drivers behind this are bed availability and critical care availability. 87.3% 88.7% Target 90% Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5 December 21 November Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team By the end of November all 3 wards in Infill 4 will be open which will provide more inpatient bed capacity. There will be some additional critical care capacity coming on line in January 2014 and a 3rd theatre is opening in Orpington in January 2014. The phasing of the reduction of the backlog has shifted into Q4 2013/14, however the Trust is confident of meeting trajectory by the end of Q4 13/14. 12 P age
Cancelled Operations 28 days 52 weeks long waiters Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead There were 8 Southwark patients waiting more than 52 weeks on incomplete pathways in M6. All 8 of the long waiters are waiting at. 1 in general surgery/bariatric surgery and 7 gastroenterology for benign HpB surgery. There were 29 patients waiting more than 52 weeks on incomplete pathways in M6 compared to 36 in M5. The trust is outsourcing a cohort of the HpB patients to a private provider with the remaining patients being treated at. Infill Block 4, which has now been delayed until mid-november, will have additional bed and theatre capacity for HpB but the limiting factor is the availability of critical care beds. The service is relooking at the patients waiting to see if there is any further flexibility in terms of outsourcing, however a realistic assessment of when long waiters will be cleared is likely to be the end of the financial year. 8 29 Target 0 Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5 December 21 November Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team Tamsin Hooton and SLCSU Acute Contracting Team The number of cancelled operations (28 days) at has decreased in Q2 to 6 from 9 in Q1. The Trust have been a national outlier for cancelled operations. The Trust are looking at their processes for capturing data properly. 6 8 Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5 December 21 November Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team A Unify reporting review will be presented at the next performance meeting. The number of cancelled operations (28 days) at has increased in Q2 to 8 from 1 in Q1. The Trust are also querying the numbers of urgent cancellations. This will be reviewed at the next performance meeting. (Q2) Target 0 Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 6 December 22 November Tamsin Hooton and SLCSU Acute Contracting Team 13 P age
Cancer 62 days screening Cancer 62 days GP referral Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Performance in M5 has dropped to 83.3% from 96.3% in M4. This performance relates to 5 of 30 patients not being treated within the required performance threshold. 2 patients started their journey at and finished at, and the remaining 3 were internal to. Acute Contract Monitoring Meeting 6 December Performance in M5 improved slightly to 80.0% from 77.9% in M4. There were 17.5 breaches out of 87.5 pathways. Of the externally initiated referral pathways, 11 of the breaches were caused by late referrals and 3 were caused by delayed diagnostics (not necessarily at ). The internal referral pathway breaches were caused by patients transferring between services, patient choice to delay treatment and inadequate elective capacity. For internal referral pathways the trust has received, and is working to implement action plans from the DH Intensive Support Team (IST) review. 83.3% 80.0% 83.1% (M5) Target 85% Monthly Performance Meeting (for escalation) 22 November Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team The IST has recently reviewed all SEL providers. Agreed actions plans will be drawn up following the receipt of final IST reports in November 2013. Acute Contract Monitoring Meeting 5 December Performance in M5 dropped to 83.1% from 97.2% in M4. There were 6.5 breaches from 38.5 pathways. Monthly Performance Meeting (for escalation) 21 November Breaches were caused by admin errors, late referrals and delays in diagnostics. Performance has dropped from 80.0% in M4 to 71.4% in M5. Due to the low number of pathways, an evaluation of this performance indicator will take place with Q2 data. 71.4% (M5) Target 90% Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 6 December 22 November Tamsin Hooton and SLCSU Acute Contracting Team Performance has dropped from 97.1% in M4 to 86.1% in M5. Due to the low number of pathways, an evaluation of this performance indicator will take place with Q2 data. 86.1% (M5) Target 90% Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5 December 21 November Dr Jonty Heaversedge, Tamsin Hooton and SLCSU Acute Contracting Team 14 P age
Trust-Attributable Pressure Ulcers Ambulance HAS compliance Ambulance response 8 minutes Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Performance has dropped to 72.4% in M6 from 76.5% in M5 The drop in performance has been as a result of increased activity. In November a new intelligent conveyancing system will be introduced which will help manage flows of ambulances across the system and improve response times. 72.4% Target 75% Lambeth and Southwark Urgent Care Working Group 20 November Tamsin Hooton, Ali Young and Harprit Lally 90% of all patient handover times are recorded via the Patient Handover Button on the Hospital Based Alert and Handover System. Performance at has improved for a second month in a row from 84.6% in M5 to 86.5% in M6. HAS compliance has been part of the system wide assessment and is being monitored. 86.5% Target 90% Lambeth and Southwark recovery and improvement plan has been developed and will be pursued through the Lambeth and Southwark Urgent Care Network meetings Acute Contract Monitoring Meeting TBC 5 December Tamsin Hooton, Ali Young and Harprit Lally There were 2 grade 3 attributable pressure ulcers reported in Q2 13/14. Lambeth CCG are leading the review on these 2 incidents. There was 1 grade 3 attributable pressure ulcer reported in Q2 13/14 This will be reviewed in the December Serious Incident Committee meeting. SLaM 2 G3 1 G3 SLaM 4 G3 (Q2 13/14) Serious Incident Committee Meetings (5 Dec) (12 Dec) SLaM (11 Dec) Jacquie Foster There were 4 grade 3 attributable pressure ulcers reported in Q2 13/14 compared to 0 in Q1 13/14 (not Southwark patients). Target 0 These incidents will be reviewed at future Serious Incident Committee Meetings 15 P age
Diagnostic waits > 6 weeks Falls Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead There were 8 falls that resulted in major injury in Q2 13/14. These will be discussed at the Serious Incident Committee Meeting on 5 December. 8 major (Q2 13/14) Target 0 Serious Incident Committee Meeting 5 December There were 2 falls that resulted in death in Q2 13/14. 1 Incident involved a Croydon patient in August. This case will be reviewed in December s Serious Incident Committee meeting. 2 death (Q2 13/14) Jacquie Foster The second incident involved a Southwark patient. The investigation has been reviewed in September and the action plans will be reviewed in February 2014. Target 0 There were 4 falls that resulted in fractures in Q2 13/14 (not Southwark patients). Falls will soon be covered as a substantive agenda item in a CQRG meeting. Lambeth CCG will be leading the reviews of these incidents. 4 fractures (Q2 13/14) Target 0 Serious Incident Committee (fall resulting in death) and the joint acute and Community Health Services CQRG (falls resulting in major injury) 12 December During 2012/13 problems with waits for some diagnostic procedures emerged, as demand outstripped available diagnostic capacity - this has continued for some services into 13/14. Performance has dropped from 2.41% in M5 to 2.48% in M6. Under performance is mainly being driven by endoscopy at. Diagnostic waits at have improved from 5.13% in M5 to 4.44% in M6. The main driver for this under performance is endoscopy. Although has opened a new larger endoscopy suite, poor staffing levels has resulted in an increase in the number of waiters over 6 weeks. The trust has put additional sessions in place to increase staffing capacity using clinical fellows. The Trust anticipates it will take until December to fully clear the backlog of long waiters. Target <1% 2.48% 4.44% Target <1% Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 6 December 22 November Tamsin Hooton and SLCSU Acute Contracting Team 16 P age
Bookings<13 weeks (un-adjusted) Maternity Total C-section Births/midwife ratio Child safeguarding training Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Performance has been under the target of 80% for levels 2 and 3. Child safeguarding level 2 training compliance is 71% and level 3 compliance is 76%. This has been repeatedly addressed at the Southwark Safeguarding Executive Meeting. The Trust have commissioned extended training capacity to improve compliance. does not recognise staff who have completed the training at another trust as being compliant. This means all new recruits are classified as non-compliant which lowers compliance levels. This indicator will also be monitored at a newly created health sub-group of the Southwark Safeguarding Children Board which will focus on quality. Level 2 71% Level 3 76% M6 Target 80% Southwark Safeguarding Executive Meeting Health sub-group January TBC Gwen Kennedy The ratio has increased from 29.2 in M5 to 31.5 in M6. Maternity was covered as a substantial item at the September CQRG meeting and this indicator will continue to be monitored. 31.5 Target <27 CQRG Meeting Acute Contract Monitoring Meeting 12 December 6 December Jacquie Foster Tamsin Hooton and SLCSU Acute Contracting Team The total proportion of C-sections has increased slightly at to 30.2% in M6 from 32.4% in M5. The Trust attributes its high C-section rate to it s higher than average proportion of first time mothers. The total proportion of C-sections has increased slightly at to 26.2% in M6 from 23.4% in M5. 30.2% 26.2% Target 26% Joint acute and Community Health Services CQRG CQRG Meeting 12 December 18 December Jacquie Foster 72.0% Performance for M6 was 72.0% which was below the target of 90%. King s figures do not take into account the number of referrals of women who are already more than 13 weeks into their pregnancy. Target 90% CQRG Meeting 18 December Jacquie Foster 17 P age
Complaints Friends & Family test A&E Issue CS SLaM ENC H Synopsis of Issue A&E response rate Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead & In M6 and have recorded A&E response rates below the target of 15% (5.5% and 9.5% respectively). Commissioners are assured that every effort has been made to increase response rates at. has implemented the following means of collecting responses in A&E - Token box system in the to vote for scores - Text back system so patients can text responses - Volunteers asking patients with ipads - Online surveys - Cards to fill in responses A&E resp. rate 5.5% 9.5% Target 15% CQRG Meeting CQRG Meeting 12 December 18 December Jacquie Foster A&E score Denmark Hill A&E score The A&E score for M6 was 40 which is below the national average score of 52. Few patients report that they were unlikely or very unlikely to recommend. The Trust may be receiving a proportionately higher number of neutral responses which do not contribute towards the overall score. 40 204 complaints were received in Q2 13/14. Complaints are being continuously monitored during CQRG meetings. The Trust will soon be asked to provide an update on progress made in implementing improvements plans. There were 224 new formal complaints opened at in Q2 13/14 compared to 265 in Q1 13/14. Complaints are being continuously monitored at CQRG meetings. 204 224 (Q2 13/14) CQRG Meeting 18 December Jacquie Foster Joint acute and Community Health Services CQRG 12 December Jacquie Foster 18 P age
IAPT Coverage of NHS health checks Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead NHS Health Checks received % eligible people who have received an NHS Health Check in Q1 13/14 was 40.7% which was below the locally agreed target of 50% but higher than the Q4 12/13 performance position of 35.0%. The PH team are working with the DH and PHE to develop invitation letters and text messaging to improve take up and reduce DNAs. They are also working with clusters of practices to try to establish provider support i.e. by providing a mobile unit in a practice car park or at Greenwich hospital. 40.7% (Q1 13/14) Target 50% Joint Public Health Targets Meeting TBC Tamsin Hooton Referrals M6 performance position for the proportion of people with depression referred for psychological therapy is 0.92% against the M6 target of 1.06%. Mental health commissioners have visited practices to discuss service developments in mental health and used this opportunity to encourage GPs and practice managers to use the new referral form. Practices have been given notice that the model for commissioning IAPT services will be changed. It is unlikely that the target will be achieved in 13/14 despite the implementation of recovery plans and additional investment that has been made. This is due to variances in providers performance in recruitment and retention earlier in the year and a previous focus on high intensity clients. A task and finish group has been created to develop future commissioning models and future investment plans to meet the target in 14/15. 403 (0.96%) Target for M6 447 & 1.06% SLaM QIPP and Core Contract meeting 28 November Gwen Kennedy Moving to recovery Note: There have been a greater number of high intensity patients being seen by the IAPT service. This has resulted in fewer patients being seen overall due to the high number of appointments they require. The recovery rate has decreased slightly in M6 to 37.0% from 40.7% in M5. 2 additional psychological wellbeing practitioners were recently employed to focus on low intensity patients which will provide greater access to the service, increasing numbers of patients being seen and moving to recovery. 37.0% Target 50% 19 P age
DNAs Patient Facing Time Adult Community Nursing Patient Facing Time - Health Visiting Ethnicity at first contact Control of Medicines Issue CS SLaM ENC H Synopsis of Issue 31 incidents in total were reported across a range of settings. 17 of these were reported incidents within community health services directly. 14 incidents are attributable to other agencies but were reported by community staff. There were two incidents relating to a controlled drug. CH have provided a breakdown of all errors with improvement plans. The incidents will be discussed at the CHS Pharmacists meeting chaired by the Head of Nursing and attended by relevant service managers, to disseminate learning across the directorate. Current Status CH 31 (Q2 13/14) Forum Issue is Addressed Joint acute and Community Health Services CQRG (these incidents will be discussed at the next Community Health Patients Safety Forum and reported to the Medicines Safety Forum) Date 12 December TBC Responsible CCG Officer and CCG Clinical Lead Jean Young Performance has improved from 77.4% in M5 to 78% in M6. Commissioners are assured that performance is generally good. Under performance is generally due to ethnicity not being taken when first contact is made over the phone. Health Visiting and School Nursing identified as the two main areas of focus for improving performance. CH 78% Target 85% CH Contract Monitoring Meeting 17 December Jean Young Health visiting patient facing time is below this year s target of 40%. Performance has reduced slightly again in M6 to 25.0% from 26.7% in M5. There have been delays in registering agency staff on to RIO which has resulted in some patient facing time not being recorded. Also agency staff have not been as efficient as permanent staff at recording patient facing time. The Trust s recruitment and retention plans have also been discussed in light of on-going national health visitor shortages and will continue to be closely monitored. CH 25% Target 40% CH Contract Monitoring Meeting 17 December Jean Young Adult community nursing patient facing time has reduced from 41.3% in M5 to 38.0% in M6. Fall in performance has been attributed to a fall in recorded activity which is currently being investigated. CH 38.0% Target 40% CH Contract Monitoring Meeting 17 December Jean Young The DNA rate has increased in M6 to 5.5% which is slightly over the 5% target. An analysis of DNAs has taken place which showed that the rise in DNAs has occurred predominantly in orthotics. DNAs will again be monitored at the next Contract Monitoring Meeting on 17 December. CH 5.5% Target <5% CH Contract Monitoring Meeting 17 December Jean Young 20 P age
A&E breaches 6 hours (Mental Health) A&E breaches 4 hours (Mental Health) CPA 7 day follow up RTT - AHP % 18 wks Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Under performance was due to a number of breaches in the children's speech and language therapy service. These beaches were due to non adherence to admin procedures and steps are being taken to address these issues. CH 94.3% Target 95% CH Contract Monitoring Meeting 17 December Jean Young Performance has dropped to 94% in Q2 13/14, just below the target of 95%. The Mental Health team are currently querying the accuracy of this data with SLaM. Provisional performance data for October shows 100% delivery. 94% (Q2 13/14) Target 95% SLaM QIPP and Core Contract Meeting 28 November Gwen Kennedy There were 6 x 4 hour wait A&E breaches in M6, 2 less than in M5. A&E has experienced a greater than anticipated number of patient admissions. 50% of admissions are out of hours emergency admissions. High level discussions are underway with SLaM regarding creation of overspill capacity and enhancement of Home Treatment Teams contingent upon 4 borough agreement. The CCG has made additional investment to improve performance (see below regarding 6 hour breaches) SLaM 6 Target < 4 SLaM QIPP and Core Contract Meeting 28 November Gwen Kennedy There were 11 x 6 hour wait A&E breaches in M6 compared to 20 in M5. SLaM s in-patients is currently operating at full capacity and so they are struggling to find beds for patients being referred by the A&E Liaison Team. The CCG recently funded a pilot where an additional PLN and senior registrar or consultant psychiatrist were employed to cover the busy periods. Winter pressures funding has been approved to provide additional consultant and RMN cover during out of hours, 7 days a week. The impact of this will be reviewed in December 2013. SLaM 11 Target < 11 SLaM QIPP and Core Contract Meeting 28 November Gwen Kennedy 21 P age
Patient received copy of care plan Inpatient nutrition screen Issue CS SLaM ENC H Synopsis of Issue Current Status Forum Issue is Addressed Date Responsible CCG Officer and CCG Clinical Lead Performance has dropped in Q2 to 86% from 93% in Q1 This performance variance has been included in the commissioner s response requesting reasons for under performance and improvement plans. This will be reviewed at the next contract monitoring meeting on 28 November. SLaM 86% (Q2) Target 95% SLaM QIPP and Core Contract Meeting 28 November Gwen Kennedy Performance has been under target at 92% for both Q1 and Q2. The Trust has identified the patients that need to receive a copy of their care plan and will prioritise ensuring this happens. There is a sanction of 0.25% of contract associated with this indicator. SLaM 92% (Q2) Target 95% SLaM QIPP and Core Contract Meeting 28 November Gwen Kennedy 22 P age
7. Southwark CCG QIPP Performance a. Performance and Variance Tracker 23 P age
b. CCG-led New Outpatient QIPP 24 P age
c. CCG-led A&E QIPP 25 P age
d. CCG-led SLaM Risk Share QIPP 26 P age
8. Southwark CCG Finance Report (M7) See Appendix 1 for full M7 Finance Report Budget Annual Budget ( k) Variance to Month 7 ( k) Predicted End of Year ( k) Best Case F/cast Year End Var'ce ( k) Worst Case F/cast Year End Var'ce ( k) Total Acute 203,749-2,710-7,455-4,106-11,755 Client Groups 69,536-829 -1,580-1,000-3,953 Prescribing 31,617 263 446 600 200 Community and other Services 29,738-759 -1,300 0-1,300 Corporate Costs 4,078 42 40 60-8 Earmarked Budgets and reserves 14,137 3,993 9,849 4,446 7,200 Planned Surplus 3,972 2,317 3,972 3,972 3,972 Total 356,827 2,317 3,972 3,972 3,972 27 P age
9. Glossary of Performance Indicators % end of life (35%) - % of end of life patients on Southwark Gold Patient Register/CMC with a known preferred place of death. 2012/13 baseline 87/498 = 17.5%, 2013/14 annual target 293/836 = 35% - % smoking quitters (COPD) (10%) - % Confirmed Smokers on COPD Registers who quit smoking. 2012/13 baseline: No baseline (4,141 on COPD register, 1,659 smokers), 2013/14 annual target: 165 / 1,659 = 10% - % diabetes (21.3%) - % of patients on diabetes practice registers with a blood glucose level of 75 mmol/mol IFCC (HbA1C 9) or more (no exceptions). 2012/13 baseline (projected from current position): 3,316 / 13,020 = 25.4%, 2013/14 annual target: 2,816 / 13,200 = 21.3% (500 patients with better managed diabetes) - % Appointments Cancelled by Service (5%) The proportion of appointments cancelled by the service of the total number of appointments - CH 52 weeks long waiters (0) - The number of incomplete pathways greater than 52 weeks for patients on incomplete pathways at the end of the period Acute and A&E Attendance Avoidance (80%) - Percentage of patients who have been on a community matron caseload for 12 weeks or more without any A&E attendances in the last quarter - CH A&E breaches (4 hour wait) (3/month) - Number of breaches in the A&E 4-hour wait due to mental health services - SLaM A&E breaches (6 hour wait) (3/month) - Number of breaches in the A&E 6-hour wait due to mental health services - SLaM A&E waits (95%) - Percentage of patients who spent 4 hours or less in A&E - Acute Adult safeguarding training (80%) The proportion of staff who have achieved the required level of adult safeguarding training All providers AHP Goals (80%) - Percentage of rehabilitation goals achieved from an annual audit of 200 patients or equivalent - CH Alcohol Intervention - Alcohol Brief Intervention in Reproductive & Sexual Health - CH Ambulance HAS compliance (90%) - All acute trusts to ensure that patient handover times are recorded via the Patient Handover Button on the Hospital-based alert system (HAS) for 90% of all hospital turnarounds - Acute Ambulance Response 8 minutes Red 1 (75%) - Presenting conditions that may be immediately life threatening and the most time critical and should receive an emergency response within 8 minutes irrespective of location - Ambulance Response 8 minutes Red 2 (75%) - Presenting conditions that may be life threatening but less time critical than Red 1 and should receive an emergency response within 8 minutes irrespective of location - Ambulance Response 19 minutes (95%) - Presenting conditions, which may be immediately life threatening and should receive an ambulance response at the scene within 19 minutes irrespective of location in 95% of cases - Ambulance wait > 60 minutes (0) - The number of handover delays of longer than 60 minutes - Acute 28 P age
Assertive Outreach (TBC) - Number of new referrals to the Assertive Outreach service - SLaM Births/midwife (1:28) The Royal College of Midwives recommends a ratio for national planning (i.e. based upon expected national birth rate) of 28 births : 1 w.t.e. midwife for hospital births Acute Bookings<13 weeks (90%) - The percentage of women who have seen a midwife or a maternity healthcare professional for health and social care assessment of needs, risks and choices before 13 weeks of pregnancy - Acute figures do not take into account the number of referrals of women who are already more than 13 weeks into their pregnancy. measure their compliance with this target slightly differently to other trusts. They have a target booking number each month based on predicted births in 6 months time and hence if they exceed this target their performance is in excess of 100%. Due to their case mix and referrals of complex cases from elsewhere, this measurement has been agreed. C Diff (trajectory) - Number of Clostridium difficile infections for patients aged 2 or more on the date the specimen was taken - Acute CAMHS starting treatment < 12 weeks (90%) - Percentage of looked after children referred to CAMHS services to be assessed and start treatment within 12 weeks of referral - SLaM CAMHS Transition CPA - % of cases transitioned to AMH with CPA review 6 months prior to 18th birthday - SLaM CAMHS Transition Planning - % of cases with evidence of transition planning prior to 18th birthday - SLaM Cancelled Ops 28 days (0) - All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient s treatment to be funded at the time and hospital of the patient s choice - Acute Cancer 2 week GP referral (93%) - Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer - Acute and Cancer 2 weeks breast symptoms (93%) - Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer was not initially suspected - Acute and Cancer 31 days first definitive treatment (96%) - Percentage of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from date of decision to treat ) - Acute and Cancer 31 days subsequent treatment (drug) (98%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is an Anti-Cancer Drug Regimen - Acute and Cancer 31 days subsequent treatment (radiotherapy) (94%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is a Radiotherapy Treatment Course - Acute and Cancer 31 days subsequent treatment (surgery) (94%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is a Surgery - Acute and Cancer 62 days first definitive treatment by a Consultant (85%) - Percentage of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status - Acute and 29 P age
Cancer 62 days GP referral (85%) - Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer - Acute and Cancer 62 days referral NHS screening (90%) - Percentage of patients receiving first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service - Acute and Child safeguarding training (80%) The proportion of staff who have achieved the required level of children safeguarding training All providers Complaints (Trajectory) - Number of new formal complaints received in quarter - All providers Control of Medicines (0) The number of controlled drug incidents - CH Cost per Contact - Adult Nursing (-1% change) - Percentage change in cost per contact in the district nursing services - CH Cost per Contact - Health Visiting (-1% change) - Percentage change in cost per contact in the health visiting services - CH CPA 7 Day Follow Up (95%) The proportion of those patients on Care Programme Approach (CPA) discharged from inpatient care who are followed up within 7 days - Dementia - Ensure appropriate recording of the needs of people with Dementia referred to community services - CH Dementia diag rate (851 - a proportion of 53.2% against an expected prevalence of 1600) - Dementia diagnosis rate and SLaM Developing Standardised Care Plans - Care Planning for Patients with Long Term Conditions CH Diagnostic wait > 6 weeks (99%) - The percentage of patients waiting 6 weeks or more for a diagnostic test Acute and Discharge Plan in Place (100%) - An indicative discharge plan shall be agreed within 4 weeks of admission - SLaM DNAs (<5%) Proportion of patient appointments where the patient did not attend without providing adequate notice - CH Dressings (trajectory) - Adherence to dressings of those prescribed and recommended CH Early Intervention (TBC) - Number of new cases of psychosis served by Early Intervention teams - SLaM Easy in - Applies to discharges of patients from AMH (excluding triage). % of users when being discharged from secondary care have the following documentation sent to their GP within 7 working days of discharge - SLaM - Community - a completed Recovery and Support Plan. This support plan includes an advanced statement and is signed by the user. - Inpatients - an inpatient discharge summary detailing a summary of intervention. Easy out - Questionnaire sent to GPs to measure GP experience of referral, communication and discharge arrangements - SLaM 30 P age
Employment assessments (95%) - Percentage of service users on CPA to have an employment assessment - SLaM End of life care To show evidence of co-ordinated End of Life Care by the continued use of the Co-ordinate My Care electronic EOLC register. Patients who have chosen to die in their own home should routinely benefit from the sustained quality offered by the Liverpool Care Pathway - CH Ethnicity at First Contact (85%) - Percentage of new clients with one or more first contacts for whom ethnicity is known - CH Falls (minimal major falls are amber rated, falls resulting in death are red rated) Incidence of falls resulting in injury Acute and CH Falls (0) - Falls from unrestricted windows - SLaM Friends & Family - The Friends and Family Test (FFT) aims to provide a simple headline metric which, when combined with follow-up questions, can drive a culture change of continuous recognition of good practice and potential improvements in the quality of the care received by NHS patients and service users. The test asks the following standardised question: How likely are you to recommend our ward/a&e department to friends and family if they needed similar care or treatment? Patients will use a descriptive six-point response scale to answer the questions with the following response categories: 1. Extremely likely 2. Likely 3. Neither likely nor unlikely 4. Unlikely 5. Extremely unlikely 6. Don t know The scoring methodology being adopted will be based on the underlying Net Promoter Score calculation, which was considered to be the most effective at delivering the benefits of the Friends and Family Test outlined above. Proportion of respondents who would be extremely likely to recommend (response category: extremely likely ) MINUS Proportion of respondents who would not recommend (response categories: neither likely nor unlikely, unlikely & extremely unlikely ). Gate-kept (TBC) - Percentage of inpatient admissions gate-kept by the crisis resolution / home treatment team - SLaM Home Treatment Episodes YTD (TBC) - Number of episodes served by Home Treatment teams - SLaM Hospital Admission Avoidance (80%) - Percentage of patients who have been on a community matron caseload for 12 weeks or more and have avoided any emergency hospital admissions in the last quarter - CH IAPT % moving to recovery (50%) - The proportion of people who complete treatment who are moving to recovery SLAM and 31 P age
IAPT % receiving (5,241 against 41,929) - The proportion of people entering treatment (target 5,241 annually) against the level of need in the general population (the level of prevalence addressed or captured' by referral routes 41,929) SLAM and Inpatient Nutrition Screen (95%) - Percentage of inpatients who have had a full nutrition screen - SLaM Last Minute Cancelled Ops - Number of last minute cancelled elective operations for non clinical reasons - Acute Mixed-sex accommodation (0) - All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient, in accordance with the definitions set out in the Professional Letter CNO/2010/3 - Acute and SLaM MMR1 The proportion of children under the age of 5 who are unregistered or identified to not have had their MMR1 within 4 months of the recommended schedule date (13 months) who were subsequently identified and recorded as having a recorded MMR1 immunisation - CH Mortality - Summary Hospital-level Mortality Indicator (SHMI) (<1)- Gives an indication for each hospital trust in England whether the observed number of deaths within 30 days of discharge from hospital were higher than expected, lower than expected or as expected when compared to the national baseline. Higher than expected mortality rate > 1 As expected mortality rate = 1 Lower than expected mortality rate < 1 MRSA - Number of cases of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia - Acute and Near Time Patient Experience (TBC) - Replacement of annual patient experience survey with near time patient experience - CH Never Events (0) - Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. New Birth Visits (95%) - Percentage of new born babies who received a new birth visit or attempted visit between 10 and 14 days inclusive after birth CH New patients offered HIV test (30%) - Percentage of new patients with the ability to consent that are admitted to AMH and ADD inpatient services offered a HIV test - SLaM NHS Health Checks offered (20% of eligible population) - Percentage of eligible people who have been offered an NHS Health Check in 2012/13. The Department of Health target stipulated that the Health Check Programme was a five year rolling programme where 20% of the eligible population should be offered a Health Check each year - NHS Health Checks received (Locally agreed target of 40%)- Percentage of eligible people that have received an NHS Health Check in 2012/13. This is the proportion of people who received an NHS Health Check from 20% of the eligible population - NICE The number of NICE guidance awaiting response Acute Notified Serious Incidents (0) The total number of Serious Incidents notified to the CCG, a review of the SI investigation report may result in a de-escalation which may therefore result in an adjusted total figure All providers 32 P age
Obesity - Reduction in percentage of children who are obese or overweight - CH Patient Experience - This indicator seeks to assess and evaluate quality of inpatient services (both acute and rehab) through service user focus groups - SLaM Patient Facing Time (CQUIN) - Increase in reported Patient Facing Time in the Sickle Cell service - CH Patient received copy of care plan (95%) - Percentage of patients who have been given a copy of their CPA care plan - SLaM Patient Safety Thermometer 1. To collect data on pressure ulcers. 2. To develop a service development plan at Q2 outlining the work planned to reduce the number of pressure ulcers and report at Q4 on progress. PbR - 13/14 is a developing year for PbR for mental health. This CQUIN requires development of a shared understanding between commissioners and the provider on: Service specifications for each care package The relevant information to collect The quality of the information collected (accuracy and completeness) Related quality outcomes The quality assurance systems in place to monitor performance of PbR The cluster costs for each of the 21 clusters Benchmarking process identified to validate cluster costs - Payment will be awarded on successful completion of deliverables agreed at Q1 workshop - SLaM Percentage of delayed discharges (>7.5%) - Percentage of delayed discharges from inpatient care as per the monitor definition - SLaM Physical Health - Antipsychotics - Physical Health Checks for in-patients on anti-psychotic medication. This excludes triage only admissions - SLaM Physical Health - New Admissions - Physical Health Checks for new admission's. This excludes triage only admissions SLaM Pre-school booster The proportion of children who are unregistered or do not have a recorded DTaP/IPV or dtap/ipv (preschool booster) immunisation by four months from the recommended schedule date (3 years 4 months) who were subsequently identified and recorded as having a recorded DTaP/IPV or DTaP/IPV (preschool booster) immunisation - CH Pressure Ulcers (Grade 2 are not rated; Grade 3 are rated amber; Grade 4 are rated red) - Number of pressure ulcers in quarter All providers Pt Facing Time - Adult Comm Nursing CHS There is a new method of calculating performance for this indicator, details of which will be confirmed - CH Pt Facing Time - Health Visiting CHS There is a new method of calculating performance for this indicator, details of which will be confirmed - CH 33 P age
Pts with learning disabilities - Ensure appropriate treatment of patients with learning difficulties i.e. making reasonable adjustments where necessary and to ensure appropriate recording of the needs of people with learning disabilities referred to community services - CH Public and Pt Engagement - To show evidence of involving patients and the public in relation to service delivery including service changes or new service proposals - CH Recovery - The Recovery and Support plan is a recovery focussed plan that seeks to place the service user at the centre of the care/support planning process whereby they are supported to define their own goals based on their personal needs and aspirations - SLaM RTT - AHP % 18 wks Percentage of patients on Allied Health Professional-led pathways who received their first definitive treatment within 18 weeks in the Community - CH RTT admitted (90%) - The percentage of admitted pathways within 18 weeks for admitted patients whose clocks stopped during the period on an adjusted basis Acute and RTT incomplete pathway (92%) - The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period - Acute and RTT non-admitted (95%) - The percentage of non-admitted pathways within 18 weeks for non-admitted patients whose clocks stopped during the period - Acute and Safeguarding adults and children - To ensure that Community services comply with all relevant Safeguarding Acts for both vulnerable adults and children and comply with the Safeguarding policies as detailed in the contract - CH Smoking cessation training (33%) - Percentage of relevant inpatient & community staff working at SLaM for over 6 months to have undertaken smoking cessation level 1 training - SLaM Smoking quitters Number of clients of NHS Stop Smoking Services who report that they are not smoking four weeks after setting a quit date Summary care records - Number of patients on CPA where the summary care record has identified gaps in health screening in the last year or the patient is not registered with a GP SLaM Total C-section (<26% for and < 27% for ) Elective and non-elective caesarean sections as a percentage of all births - Acute Transition care plans - All young people aged 17 have transitional care plans indicating agreed clinical diagnosis and future treatment requirements and that the NHS and Local Authority commissioners are notified of transition patients in line with local protocol - CH VTE risk assessment (90%) - % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool Acute 34 P age