BOARD OF DIRECTORS Subject/Title July (Month 4) Integrated Performance Report Executive Responsible Paper prepared by (if different from above) John Grinnell, Director of Finance Executive Directors Nature of Report Category of Item Context For Information For Discussion For Approval Strategic Direction and Development Performance and Governance Previous Board discussion Link to National Policy Link to Trust s Strategic Objectives Risk if no action taken Executive Summary The Trust s Month 4 Performance Report is detailed in the attached paper. Received or approved by Legal Implications None Recommendation It is recommended that the Board note: The performance during July 2015 (Month 4). Acronyms and Abbreviations VTE Venous Thromboembolism CQUIN Commissioning for Quality and Innovation Payment Programme RTT Referral to Treatment BRIC - Business, Risk and Investment Committee UCL Upper Confidence Limit LCL Lower Confidence Limit UTI Urinary Tract Infection BADS - British Association of Daycase Surgery PALS - Patient Advice and Liaison Service C. difficile Clostridium difficile (bacterial infection) MRSA Methicillin-resistant Staphylococcus aureus (bacterial infection) 1
BOARD OF DIRECTORS INTEGRATED PERFORMANCE REPORT JULY 2015 1. Introduction 1.1 The integrated performance report has been developed in order to assist the Board in monitoring the delivery of key performance metrics against local and national targets. 1.2 The report covers the five key domains of: - Patient Safety, Patient Experience, Resources, and External Perception. 1.3 Performance measurement targets within these domains are based on the following The core standards set nationally by Monitor, NHS England, Welsh Assembly Government and the Care Quality Commission Any locally agreed Commissioner driven targets including CQUIN quality improvement Internal performance targets in line with the Trust s Annual Operating Plan objectives. 1.4 The scorecard format provides an overview of the performance within each domain with further detail of specific metrics in graphical and tabular format. 1.5 The scorecard utilises two graphical presentation methods; line graphs and statistical process control (SPC) charts. SPC charts enable the analysis of the variability of a metric relative to average performance. Data points within the upper and lower limits are linked to natural variation in performance levels. 2. Chief Executive s Overview 2.1 The overall performance for July has demonstrated continued achievement across the key standards and scorecard metrics. 2.2 We continue to perform well across the quality domains and whilst our efficiency has shown improvement during the first quarter, activity levels in July were behind plan and we need to ensure continued focus on operational delivery through the summer months. 2.3 In resource terms we have delivered a 248K surplus in month and are cumulatively in surplus by 82K. However we are slightly behind plan cumulatively by 87K, supporting the need to focus operationally on delivery of activity levels which are key to overall sustainability in access levels. 2.4 The over performance on our contracts with Shropshire and with BCU are already significant and we have already committed to update the Board on these areas at out September meeting. The risk issues around QIPP for Shropshire CCG and the contract finalisation with BCU remain. 3. Performance Overview 3.1 Domain 1 Patient Safety 3.1.1 Overview There continues to be a strong performance within this domain, with seven of the nine key metrics rated as green in month. Although the level of incidents within the Trust remains low, we are scoping areas where we can reduce the level of incidents even further. 2
The following exceptions are noted for month 4. 3.1.2 Mortality Rates There were two patient deaths on the Care of the Elderly ward during July, the deaths were not unexpected. Following discussion at last month s Board meeting, the unexpected death tolerance will remain as zero. There were no unexpected deaths in July. 3.1.3 Hospital Acquired VTE (DVT or PE) A patient was diagnosed with hospital acquired deep vein thrombosis fourteen days following a spinal operation. A further two patients were diagnosed with a hospital acquired pulmonary embolism following joint replacement (hip and knee). These patients had been on prophylactic medication following risk assessment. Three incidents a month is in line with the monthly tolerance levels. 3.1.4 Hospital Acquired Pressure Ulcers Pressure Ulcers are graded on a scale from 1 to 4, with grade 1 relating to minimal harm and grade 4 being full skin loss and highest level of harm. There were four hospital acquired grade two pressure ulcers during July which is above the monthly tolerance of one case. Three patients were long stay rehabilitation patients on the Medicine wards and were found to have grade two sores by nursing staff. The patients care plans were updated to reflect changes to the frequency of turning patients, with ward staff linking with the Tissue Viability Nurse as appropriate. The fourth patient developed a pressure ulcer which has been linked to their orthotic appliance. 3.1.5 Clinical Quality Inpatient Falls (Harms) Nineteen inpatient falls occurred during July with five of the falls being the same patient who repeatedly refused to comply with advice given. In terms of activity this gives a fall rate of 2.62%. Five patients experienced low level harm as a result of their falls which were bruise (1), skin abrasion (1) and pain / restricted movement (3). Five incidents resulting in low level harm is above the monthly tolerance level but within the normal variation range. 3.1.6 Medication Errors (Harms) Seven medication incidents relating to patient care at the hospital were recorded during July which were categorised as Prescribing (4) and Administration (3). One patient required further observation as a result of a medication incident. No further harm was recorded. With a tolerance level of two incidents per month, the metric is rated as green in July. 3.1.7 28 day Readmission Rates to RJAH Seven patients were readmitted as an emergency within 28 day of initial discharge in June 2015 giving a readmission rate of 1.03% which is slightly above the target of less than 1%. Reasons for readmission were wound issues (4), pain management (1) administration of intravenous antibiotics (1) and review due to high temperature (1) 3.2 Domain 2 - Patient Experience 3.2.1 Overview The English 92% open pathway target was maintained at the end of July following return to compliance levels at the end of Quarter 1. As we focus on sustaining this performance we are reviewing our demand and capacity plans to ensure continued efficiency of our operational processes. 3
Patient feedback is important to us with responses now being received from patients via a number of different sources including social media and NHS choices. The responses remain positive with one hundred and seventy two formal compliments. The following exceptions are noted for month 4 3.2.2 NHS Friends & Family Test The Friends and Family metrics within the scorecard is a combined measure representing the percentage of both inpatient and outpatients that would and would not recommend the Trust. 99.49% of patients stated that they would recommend the Trust during July. Only 1 patient who responded during July stated that they wouldn t recommend the Trust to others with the reason given being the wait for an operation on day of surgery. The latest published national averages show that nationally 95% of inpatients recommend Trusts with 2% not recommending. 3.2.3 Complaints Ten complaints were received during July which is slightly above the monthly tolerance level of nine. There were three complaints regarding clinical care which related to care on the ward (1), outcome of operation (1) and Consultant s response at outpatient appointment (1). There was a further seven operational complaints which were all related to waiting times. Each complaint is currently under review in line with the Trust s Complaints Policy. 3.2.4 Access to Bone Tumour Services All three cancer targets were achieved during July with the performance in month being as follows: Metric Month 4 Performance Cancer Two Week Wait 93% 100% 31 Days First Treatment (Tumour) 96% N/A Cancer Plan 62 Days Standard (Tumour) 85% 100% The 31 Days First Treatment target was not applicable in month as there were no patients requiring treatment in month. 3.2.5 Access to Services - English The admitted and non-admitted metrics have now been removed from the scorecard as NHS England have abolished the metrics as national targets. We maintained the 92% open pathway performance target at the end of July with 92.74% of patients currently waiting 18 weeks or less to start their treatment. 3.2.6 Patients waiting over 52 weeks Both English and Welsh Commissioners have a zero tolerance policy on patients waiting over 52 weeks to start treatment. At the end of July there were three English Spinal Disorders patients waiting over 52 weeks with the previous Welsh breaches having been cleared in month. There is a continued pressure to meet the 52 weeks target especially within Spinal Disorders for all Commissioners as a result of the specialism of some of the cases. The Trust is keeping in regular contact with Commissioners regarding these concerns and will be working with them to develop an action plan to address current problems. 4
3.3 Domain 3 3.3.1 Overview Activity figures were lower than plan during July despite us utilising additional capacity within the private sector as part of the work to strive towards waiting list sustainability. Internal theatre throughput levels were below plan with 95.36% of theatre capacity being utilised against a target of 96%. Cases per session remained above the target of 2.2 with a ratio of 2.24 in July. With stepped improvement targets in a number of efficiency metrics between now and year end, further work is required to ensure that pathways are managed effectively. Exceptions to planned performance in July were as follows: 3.3.2 Demand for Services Although referral rates have remained fairly constant over the last few months, there has been a trend increase in the total number of open pathways. This is being reviewed and managed operationally and escalated as appropriate via weekly activity meetings. This will assist with ensuring that pressure points within the system are flagged up as early as possible in order to ensure bottlenecks don t appear in the RTT pathways over the next few months. 3.3.3 Daycase Performance The proportion of patients treated as daycase dipped slightly during July with 50.46% of patients being treated as daycase compared to a target of 51%. In addition, the performance against the composite target for BADS daycase also decreased with a rate of 81.82% compared to a target of 87%. Further work is being done by the Daycase Working Group to benchmark our performance against other Trusts with a view of linking together to exchange areas of good practice. 3.3.4 Average Length of Stay The average length of stay increased slightly to 4 days during July against a target of 3.8 days or less. The rate has been distorted by a small number of patients that required a longer period of inpatient rehabilitation. The enhanced recovery rate was maintained above the target level of 52% again in July with 55.67% of hip and knee patients discharged in 3 days or less. 3.3.5 Outpatient DNA Rate As part of the improved performance trajectory for the year, the Outpatient DNA rate target has reduced to 5.5% from the beginning of quarter 2. The rate of 5.58% for July is slightly above this reduced target, but within normal variation level. This will continue to be monitored over the next few months especially given the further reduction in the target towards year end. 3.3.6 New to Follow Up Ratio Despite there being a step decrease in the new to follow up ratio during July, the ratio of 1:2.08 remains slightly above, being worse than the target of 1:2.05. We are continuing to work with Commissioners regarding policies for follow up to ensure that patients are only brought back to hospital for review where clinically required. 3.4 Domain 4 Resources 3.4.1 Overview A surplus of 248k was achieved for July which was behind plan by 96k. The position was impacted by activity levels falling short of required levels and pay pressures driven by high levels of annual leave. 5
Year to date we have made a surplus of 82k. This is an averse variance of 87K from our plan of 169K. Our EBITDA margin is 4.6% and 0.4% beneath the expected level of 5%. Our CoSRR rating has returned to a level 4 (lowest risk) and is expected to remain at the lowest risk under Monitor s new risk framework that will reflect additional metrics focusing on sustainability. Our plan trajectory is as detailed below: -287,964-200,834 313,717 344,061-73,361 249,503 397,742 235,381-477,223 206,978 119,757 174,885 We continue to recognise the risk of commissioner affordability in funding contract performance that remains above formally contracted levels. For our host commissioner this is driven by QIPP shortfalls and the cost of reducing waiting times. We are also still to formally agree the BCU contract at a level that reflects the current levels of activity being delivered. The key features of the month 4 financial performance are detailed below: 3.4.2 Income - Overall clinical income fell short of plan by 0.13m driven by reduced surgical activity delivered through internal capacity. Private Patient income was strong over achieving plan by 0.11m and is back on plan year to date. Other income was slightly ahead of plan driven by increased RTA notifications. 3.4.3 Expenditure Overall pay costs were 28k under spent driven by corporate vacancies and reserves amounting to 61k. There was however a further overspend of 33k from clinical services driven by higher than planned Out of Job plan working to support theatre and outpatient activity during a period of high annual leave. Non pay costs exceeded budget by 139k driven by the costs of transferring work to the private sector. 3.4.4 Cost Improvements Cost efficiencies of 306k were recognised in month, which was 74k above plan. Cumulatively we have identified efficiencies of 910k which is 97k above plan. 6
These were delivered from a broad range of schemes (37 in total) with the most material areas being income generation, private patients, flexible bed management and productivity gains in Ultrasound following service redesign. The forecast shows we remain on target to deliver the full savings programme although this is contingent on a number of key deliverables that continue to be monitored closely as part of monthly review meetings with divisions. 3.4.5 Cash Balances increased in month by 0.1m to 5m which is 0.5m behind planned levels. The cash position continues to be impacted by commissioner over performance driven by differences between planned income assumptions and the formal contract arrangements from which we receive cash settlement. As of the end of July we have over performed by 0.76m for Shropshire CCG and 0.65m for BCU. The revised capital expenditure profile for our theatre development is currently providing an upside of 0.65m to our cash position and is offsetting the commissioner pressures. 3.4.6 Capital Expenditure - We spent 459k on capital during the month. On a cumulative basis we remain behind plan as a result of the revised cashflow received for our Theatre development. This revised cashflow does not alter the delivery programme of the scheme. 3.4.7 Sickness Absence Sickness absence for July increased to 3.15%, due to a sharp increase in short term sickness. It should be noted that this is the fourth consecutive year in which absence has risen in the summer months, therefore both patterns and reasons of absence are being reviewed in more detail. Benchmarking continued to rank the trust as the lowest 12 month rolling absence rates for the West Midlands region. 3.4.8 Staff Stability Index The stability index for July reduced to 91.76% which is slightly below (worse than) the 90% target. Leavers were drawn from across the Trust and due to a wide variety of reasons. 3.4.9 Staff Appraisal Staff appraisals decreased in July to 85.74% of staffing having undertaken an appraisal within the past 12 months and remains below the 90% target. Despite recent improvements, the lower performing departments remain Diagnostics and Theatres. 3.4.10 Staffing Establishment The Trust monitor staffing levels twice daily and this is reported to NHS England monthly. All escalation processes have been followed to ensure patient safety is maintained with the shift fill rate of 99.20 above the target of 90. The monthly Unify table is shown below. Ward name Registered midwives/nurses Total monthly planned staff hours Total monthly actual staff hours Day Night Day Night Total monthly planned staff hours Care Staff Total monthly actual staff hours Registered midwives/nurses Total monthly planned staff hours Total monthly actual staff hours Total monthly planned staff hours Care Staff Total monthly actual staff hours Average fill rate - registered nurses/ midwives (%) Average fill rate - care staff (%) Average fill rate - registered nurses/ midwives (%) Alice 1000 1008 378.5 366.5 744 744 168 168 100.8% 96.8% 100.0% 100.0% Clwyd 1164 1171.5 1068 1062 744 745.5 408 420 100.6% 99.4% 100.2% 102.9% Gladstone 1472 1472 1316 1316 804 794 672 672 100.0% 100.0% 98.8% 100.0% Wrekin 1656 1632 804 804 744 749 384 420 98.6% 100.0% 100.7% 109.4% Kenyon 1428 1399.5 1009.5 925.5 744 751 377 346 98.0% 91.7% 100.9% 91.8% Ludlow 943.5 940.5 744 739 744 745 372 344 99.7% 99.3% 100.1% 92.5% Powys 1164 1164 936 918 744 745 625 596 100.0% 98.1% 100.1% 95.4% Sheldon 1070 1072 1090 1071.5 744 746 744 708 100.2% 98.3% 100.3% 95.2% HDU 1170 1161.5 100 100 975 997.5 0 0 99.3% 100.0% 102.3% - Average fill rate - care staff (%) 7
3.5 Domain 5 External Perception 3.5.1 Our Continuity of Service Risk rating is rated at the highest level of 4. 3.5.2 Although we have now returned to compliance against the 92% target, whilst Monitor investigates governance concerns triggered by breaches of the referral to treatment targets our Governance Rating has been flagged as under review. For the purposes of the scorecard we have flagged this as amber. 4. Recommendation 4.1 It is recommended that the Board: Note the performance for July (Month 4) John Grinnell Director of Finance, Contracting and Performance 8
( ) 1,100,000 S u D 950,000 r e 800,000 p f l i 650,000 u c 500,000 s i t 350,000 / 200,000 50,000-100,000-250,000-400,000-550,000 Category Annual Plan Income and Expenditure Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Finance Dashboard 31st July 2015 Plan Variance Clinical Income from activity 83,908 28,254 28,389 135 (130) Private Patient income 4,855 1,480 1,503 24 109 Other income 5,756 1,934 1,945 11 35 Pay (53,424) (17,856) (17,784) 72 28 Non-pay (35,992) (12,234) (12,562) (328) (139) EBITDA 5,104 1,578 1,492 (86) (96) Finance Costs (4,101) (1,409) (1,409) (0) 0 Operational Surplus 1,003 169 82 (87) (96) EBITDA margin 5.4% 5.0% 4.6% -0.4% Debt Service Cover 4 I&E Margin 3 Liquidity (days) 4 Variance in I&E Margin 3 Overall FSRR 4 Monthly Surplus/Deficit Year To Date Position Movement In Variance From Prior Month YTD Debtor Days 25 26 Creditor Days 36 36 Plan Statement of Financial Position Category Movement Drivers Fixed Assets 53,388 53,642 254 Capital Investement. Non current receivables 482 466 (16) Total Non Current Assets 53,870 54,108 239 Inventories (Stocks) 1,113 1,075 (38) Receivables (Debtors) 6,169 6,769 600 Growth in commissioner debt. Cash at Bank and in hand 4,912 4,955 43 Total Current Assets 12,194 12,799 606 Education monies received quarterly and deferred. Payables (Creditors) (8,430) (9,029) (600) Specific commissioner underperformance. Borrowings (71) (67) 3 Current Provisions (288) (288) 0 Total Current Liabilities (8,788) (9,385) (596) Total Assets less Current Liabilities 57,275 57,523 248 Non Current Borrowings (75) (75) 0 Non Current Provisions (367) (367) 0 Non Current Liabilities (> 1 year) (442) (442) 0 Total Assets Employed 56,834 57,082 248 Public Dividend Capital (33,260) (33,260) 0 Revenue Position 165 (82) (248) In month surplus Retained Earnings (6,694) (6,694) 0 Revaluation Reserve (17,045) (17,045) 0 Total Taxpayers Equity (56,834) (57,082) (248) C a s h M 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Cash Flow V a r i a n c e -700,000 300 250 200 150 100 50 0 ( 50) ( 100) ( 150) Period Cumulative Variances Clinical Income from activity Private Patient income Other income Pay Non-pay Risks Income Risk Expenditure Risk CIP Risk 0.0 Monitor Plan M 4.9 5.1 5.0 5.5 8.3 6.1 5.1 6.9 5.8 5.0 7.4 5.5 M 4.9 5.5 4.9 5.0 9 Forecast M 4.9 5.5 4.9 5.0 7.3 5.2 4.6 5.7 5.4 4.6 6.2 5.5 Medium Medium Low Commentary Welsh income assumptions (37% of total) still to be covered by formal SLA Deliverability of QIPP Host Commissioner affordability to reimburse over performance Premium delivery costs in excess of planned levels remain a residual risk to plan Programme over identified and is being actively tracked through performance framework
Cost Improvement Programme Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Finance Dashboard 31st July 2015 In Month CIP Achievement 000's Year To Date CIP Achievement 000's Trust YTD Achievement Against YTD Plan 000's CIP by Theme Miscellaneous Income Workforce Redesign Transformation Procurement Productivity Capacity Alignment Bring Forward FYE 0 50 100 150 200 250 Jul Plan Jul Miscellaneous Income Workforce Redesign Transformation Procurement Productivity Capacity Alignment Bring Forward FYE 0 50 100 150 200 250 300 350 400 YTD Plan YTD 1,000 900 800 700 600 500 400 300 200 100 0 YTD Plan Total YTD In Month CIP Achievement 000's Year To Date CIP Achievement 000's CIP by Division Corporate Estates & Facilities Diagnostics Medicine Surgical Services Corporate Estates & Facilities Diagnostics Medicine Surgical Services RAG of Total Schemes Being Tracked 2,069 70% g 783 26% a 112 4% r 2,963 100% 0 50 100 150 Jul Plan Jul 0 50 100 150 200 250 300 350 400 450 YTD Plan YTD Year to date capital programme 000's Year To Date Commissioner Income against Plan m Project Annual Plan Year to date Plan Year to date Completed Year to date Variance In Month Forecast Outturn Outturn Variance Shropshire Capital Backlog Maintenance 400 159 106 53 46 300 100 Medical equipment 400 44 28 16 14 400 0 IT 280 95 96-1 34 280 0 Project Management 150 50 46 4 11 150 0 Charitable Purchases TBC 200 22 39-17 0 200 0 Contingency 300 0 0 0 0 173 127 Outpatients Refurbishment 400 80 4 76 2 400 0 Estates Rationalisation 100 33 3 30 1 100 0 Combined Heat and Pow er Plant 500 0 14-14 0 552-52 Theatre and Tumour Development 11,821 1,634 979 655 351 10,296 1,525 Theatre Chillers 0 0 0 0 0 175-175 NHS Capital Expenditure 14,551 2,118 1,315 803 459 13,026 1,525 Commissioner Performance BCU Specialist Other English Contracted Powys Telford Other Uncontracted - 2.00 4.00 6.00 8.00 1 12.00 YTD actual YTD plan 10
Patient Safety Patient Experience Overall Performance Overall Performance Month Key Metric YTD Change Forecast Month Key Metric YTD Change Forecast Infection Control g g same g Friends & Family Test g g same g Serious Incidents a a worse g of Complaints a g worse g Never Events g g same g Theatre Cancellations g g same g Unexpected Deaths g r better r Delayed Discharges a g worse g Clinical Quality a a worse g Access to Bone Tumour Services g g same g Medication Errors (Harms) g g same g Access to Services - English g a same g Pressure Ulcer Assessments g g same g Patients Waiting Over 52 Weeks r r worse a 28 Day Emergency Readmission Rate g g better g CQUIN g g same g VISION To be the leading centre for high quality, sustainable Orthopaedic and related care, achieving excellence in both experience and outcomes for our patients Resources Overall Performance Overall Performance Month Key Metric YTD Change Forecast Month Key Metric YTD Change Forecast Sickness Absence a g worse g Demand for Services g g same g Staff Stability Index a g worse g Activity - Surgery a a worse g Staff Appraisal a a same g Activity - Medicine a g worse g Safe Staffing - % Shift Fill Rate g g same g Daycase Performance a g worse g Overall CoSRR g g same g Admission on Day of Surgery g g same g Net Surplus a a worse g Theatre g g same g CIP Delivery g g same g Average Length of Stay g g same g Capital Expenditure g g better g Bed Utilisation r r worse a PSPP g g same g Outpatient Productivity a g worse g Cash Balance a a worse g New to Follow Up Ratio (Consultant Led Activity) a a better a External Perception Overall Performance Month Key Metric YTD Change Forecast Monitor Risk Rating - Finance g g same g Monitor Risk Rating - Organisational Health a a same g 11
Patient Safety Infection Control Hospital Acquired MRSA Bacteraemia Patient Safety Infection Control Hospital Acquired C.Difficile Patient Safety Serious Incidents 2.00 3.00 2.00 g g g g g g g g g 2.00 a g a 12
Patient Safety Never Events Patient Safety Unexpected Deaths Patient Safety Clinical Quality Hospital Acquired VTE (DVT or PE) 2.00 2.00 7.00 6.00 5.00 4.00 3.00 2.00 Mean UCL LCL g g g g r g r g 3.00 g 3.00 3.00 g 3.00 g 3.00 3.00 g 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 13
% Patient Safety Clinical Quality Inpatient Falls (Harms) Patient Safety Clinical Quality Hospital Acquired Pressure Ulcers - Grade 2 or Above Patient Safety Clinical Quality Safety Thermometer - % with no new harms 1 6.00 10 10 1 9.00 8.00 5.00 10 99.00 99.00 98.00 7.00 4.00 98.00 97.00 6.00 5.00 3.00 97.00 96.00 96.00 4.00 2.00 95.00 95.00 3.00 2.00 94.00 94.00 93.00 92.00 Mean UCL LCL 2.00 2.00 g 2.00 4.00 a 2.00 2.00 g 2.00 5.00 a 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 Mean UCL LCL g g g 4.00 r Mean UCL UCL LCL LCL 95.00 99.33 g 95.00 98.63 g 95.00 98.01 g 95.00 97.92 g 95.00 95.00 95.00 95.00 95.00 95.00 95.00 95.00 14
% % Patient Safety Medication Errors (Harms) Patient Safety Pressure Ulcer Assessments Patient Safety 28 Day Emergency Readmission Rate 28 Days Emergency Readmissions to RJAH Following an Overnight Stay 6.00 100.20 10 1.60 5.00 4.00 3.00 2.00 10 95.00 9 99.80 85.00 99.60 8 99.40 75.00 99.20 7 99.00 65.00 98.80 6 98.60 55.00 1.40 1.20 0.80 0.60 0.40 0.20 98.40 5 Mean UCL LCL Mean UCL LCL 2.00 g 2.00 3.00 a 2.00 g 2.00 g 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00 99.00 99.69 g 99.00 10 g 99.00 99.83 g 99.00 10 g 99.00 99.00 99.00 99.00 99.00 99.00 99.00 99.00 0.87 g 0.63 g 1.03 a No Data g 15
% Patient Safety CQUIN VTE Risk Assessments 102.00 10 10 95.00 9 98.00 85.00 96.00 8 94.00 75.00 92.00 7 9 65.00 88.00 6 86.00 55.00 84.00 5 9 99.91 g 9 10 g 9 99.77 g 9 99.92 g 9 9 9 9 9 9 9 9 16
% % Patient Experience Friends & Family Test Friends & Family - % Would Recommend (Inpatients and Outpatients) Patient Experience Friends & Family Test Friends & Family - % Would Not Recommend (Inpatients and Outpatients) Patient Experience of Complaints 102.00 10 10 95.00 9 98.00 85.00 96.00 8 94.00 75.00 92.00 7 9 65.00 88.00 6 86.00 55.00 84.00 5 1.20 2.00 1.80 1.60 1.40 0.80 1.20 0.60 0.80 0.40 0.60 0.40 0.20 0.20 2 18.00 16.00 14.00 12.00 1 8.00 6.00 4.00 2.00 Mean UCL LCL 9 99.26 g 9 98.84 g 9 98.76 g 9 99.49 g 9 9 9 9 9 9 9 9 0.74 a 0.14 a 0.37 a 0.17 a 9.00 g 9.00 1 a 9.00 6.00 g 9.00 1 a 9.00 9.00 9.00 9.00 9.00 9.00 9.00 9.00 17
% % Patient Experience Theatre Cancellations % Reportable Cancellations Patient Experience Theatre Cancellations Cancellations Not Rebooked within 28 Days Patient Experience Delayed Discharges % Delayed Discharges Against Occupied Beds on last Thursday of Month 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 6.00 5.00 4.00 3.00 2.00 Mean UCL LCL 0.80 0.54 g 0.80 0.54 g 0.80 0.53 g 0.80 0.71 g 0.80 0.80 0.80 0.80 0.80 0.80 0.80 0.80 g g g g 3.50 3.62 a 3.50 0.83 g 3.50 0.71 g 3.50 3.55 a 3.50 3.50 3.50 3.50 3.50 3.50 3.50 3.50 18
% % % Patient Experience Access to Bone Tumour Services Cancer Two Week Wait Patient Experience Access to Bone Tumour Services 31 Days First Treatment (Tumour) Patient Experience Access to Bone Tumour Services Cancer Plan 62 Days Standard (Tumour) 102.00 10 10 10 12 10 10 95.00 9 98.00 95.00 10 9 9 10 8 85.00 96.00 99.00 85.00 7 8 8 94.00 75.00 92.00 7 8 98.00 75.00 97.00 7 6 6 5 4 9 65.00 96.00 65.00 4 3 88.00 6 86.00 55.00 6 95.00 55.00 2 2 1 84.00 5 94.00 5 93.00 10 g 93.00 10 g 93.00 10 g 93.00 10 g 93.00 93.00 93.00 93.00 93.00 93.00 93.00 93.00 96.00 10 g 96.00 10 g 96.00 10 g 96.00 10 g 96.00 96.00 96.00 96.00 96.00 96.00 96.00 96.00 85.00 10 g 85.00 10 g 85.00 10 g 85.00 10 g 85.00 85.00 85.00 85.00 85.00 85.00 85.00 85.00 19
% % Patient Experience Access to Services - English 18 Weeks RTT Open Pathways Patient Experience Access to Services - English 6 Week Wait for Diagnostics - English Patients Patient Experience Patients Waiting Over 52 Weeks Patients Waiting Over 52 Weeks - English 10 94.00 95.00 92.00 9 9 85.00 88.00 8 86.00 75.00 7 84.00 65.00 82.00 6 8 55.00 78.00 5 10 95.00 99.80 9 99.60 85.00 99.40 8 99.20 75.00 7 99.00 65.00 98.80 6 98.60 55.00 98.40 5 3.50 3.00 2.50 2.00 1.50 0.50 92.00 86.02 r 92.00 89.10 r 92.00 92.05 g 92.00 92.74 g 92.00 92.00 92.00 92.00 92.00 92.00 92.00 92.00 99.00 99.47 g 99.00 99.77 g 99.00 99.69 g 99.00 99.85 g 99.00 99.00 99.00 99.00 99.00 99.00 99.00 99.00 r g g 3.00 r 20
Patient Experience Patients Waiting Over 52 Weeks Patients Waiting Over 52 Weeks - Welsh 20 18 16 14 12 10 8 6 4 2 5.00 r 2.00 r 7.00 r g 21
% % % Resources Resources Resources Sickness Absence Staff Stability Index Staff Appraisal 4.50 4.00 3.50 3.00 2.50 2.00 1.50 0.50 10 93.00 92.50 95.00 9 92.00 85.00 91.50 8 9 75.00 90.50 7 9 65.00 89.50 6 89.00 55.00 88.50 5 10 94.00 95.00 92.00 9 9 85.00 8 88.00 75.00 86.00 7 84.00 65.00 6 82.00 55.00 8 5 Mean UCL LCL 2.70 2.69 g 2.70 2.33 g 2.70 2.49 g 2.70 3.15 a 2.70 2.70 2.70 2.70 2.70 2.70 2.70 2.70 92.00 92.27 g 92.00 92.21 g 92.00 92.21 g 92.00 91.76 a 92.00 92.00 92.00 92.00 92.00 92.00 92.00 92.00 9 86.27 a 9 85.38 a 9 86.20 a 9 85.74 a 9 9 9 9 9 9 9 9 22
Resources Safe Staffing - % Shift Fill Rate 12 10 10 8 8 6 4 2 9 100.40 g 9 99.20 g 9 99.70 g 9 99.20 g 9 9 9 9 9 9 9 9 23
Demand for Services Total Open Pathways Demand for Services Referrals Received for Consultant Led Services Activity - Surgery Surgical Division Activity - Inpatient Contract 1000 400 140 900 9500.0 800 700 9000.0 600 500 8500.0 400 8000.0 300 200 7500.0 100 7000.0 350 300 250 200 150 100 50 120 120 100 100 80 80 60 40 20 850 8829.00 g 850 9029.00 g 850 9216.00 a 850 9474.00 a 850 850 850 850 850 850 850 850 2647.00 2619.00 a 2647.00 2803.00 g 2647.00 2774.00 g 2647.00 No Data g 2647.00 2647.00 2647.00 2647.00 2647.00 2647.00 2647.00 2647.00 1016.00 1013.00 a 1028.00 1044.00 g 1163.00 1184.00 g 1167.00 1135.00 a 1037.00 1137.00 114 1089.00 945.00 1096.00 1082.00 109 24
Activity - Surgery Surgical Division Activity - Outpatient Contract Activity - Medicine Medicine Division Activity - Inpatient Contract Activity - Medicine Medicine Division Activity - Outpatient Contract 800 800 700 700 600 600 500 500 400 400 300 300 200 200 100 20 20 18 16 14 15 12 10 10 8 6 5 4 2 180 180 160 160 140 140 120 120 100 100 80 80 60 60 40 40 20 6037.00 595 a 6109.00 614 g 6906.00 749 g 693 6845.00 a 616 6755.00 6775.00 6467.00 5612.00 6509.00 6426.00 6473.00 143.00 167.00 g 145.00 138.00 a 163.00 188.00 g 164.00 16 a 146.00 16 16 153.00 133.00 154.00 152.00 153.00 1279.00 138 g 1294.00 1486.00 g 1463.00 1685.00 g 1468.00 1422.00 a 1305.00 143 1435.00 137 1189.00 1379.00 1362.00 137 25
% % % Daycase Performance BADS Activity Daycase Performance Overall Daycase Rate Admission on Day of Surgery % of Elective NHS Inpatients Admitted on Day of Surgery 10 9 88.00 95.00 9 86.00 85.00 84.00 8 82.00 75.00 8 7 78.00 65.00 76.00 6 74.00 55.00 72.00 5 54.00 59.00 52.00 5 54.00 48.00 49.00 46.00 44.00 44.00 42.00 39.00 10 98.00 95.00 96.00 9 94.00 85.00 92.00 8 9 75.00 88.00 7 86.00 65.00 84.00 6 82.00 8 55.00 78.00 5 87.00 85.52 a 87.00 83.64 a 87.00 83.16 a 87.00 81.82 a 87.00 87.00 88.00 88.00 88.00 88.00 88.00 88.00 5 51.86 g 5 48.76 a 5 51.71 g 5 50.46 a 5 5 5 5 5 5 5 5 9 93.05 g 9 97.14 g 9 94.02 g 92.00 92.37 g 92.00 92.00 94.00 94.00 94.00 95.00 95.00 95.00 26
% Theatre % Staffed Theatre Lists Utilised Theatre Theatre Cases Per Session Average Length of Stay Average Length of Stay - Elective Excluding Daycase 10 95.00 95.00 9 85.00 9 8 75.00 85.00 7 65.00 8 6 55.00 75.00 5 2.35 4.00 3.50 2.30 3.00 2.25 2.50 2.20 2.00 1.50 2.15 2.10 0.50 2.05 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 0.50 95.00 96.66 g 95.00 96.84 g 95.00 97.53 g 96.00 95.36 a 96.00 96.00 97.00 97.00 97.00 98.00 98.00 98.00 2.20 2.16 a 2.20 2.20 g 2.20 2.25 g 2.20 2.24 g 2.20 2.20 2.20 2.20 2.20 2.20 2.20 2.20 4.00 3.88 g 4.00 4.10 a 4.00 3.88 g 3.80 4.00 a 3.80 3.80 3.60 3.60 3.60 3.50 3.50 3.50 27
% % Average Length of Stay % of Primary Hip and Knee Patients Discharged in 3 days or less Bed Utilisation Bed Occupancy - Adult Orthopaedic Wards Outpatient Productivity Outpatient DNA Rate 7 7 6 65.00 5 6 4 55.00 3 5 2 45.00 1 4 35.00 9 100.0 8 90.0 80.0 7 70.0 6 60.0 5 50.0 4 40.0 3 30.0 2 20.0 1 8.00 7.00 6.00 5.00 4.00 3.00 2.00 5 54.55 g 5 63.04 g 5 57.28 g 52.00 55.67 g 52.00 52.00 54.00 54.00 54.00 55.00 55.00 55.00 87.00 72.24 r 87.00 78.50 r 87.00 82.01 g 87.00 72.19 r 87.00 87.00 87.00 87.00 87.00 87.00 87.00 87.00 6.00 4.98 g 6.00 5.64 g 6.00 5.31 g 5.50 5.58 a 5.50 5.50 5.25 5.25 5.25 5.00 5.00 5.00 28
New to Follow Up Ratio (Consultant Led Activity) 3.00 2.50 2.00 1.50 0.50 2.10 2.23 r 2.10 2.12 a 2.10 2.35 r 2.05 2.08 a 2.05 2.05 2.02 2.02 2.02 2.00 2.00 2.00 29
Appendix 1 Declaration of risks against healthcare targets and indicators for 2015/16 or Indicator (per Risk Assessment Framework) Month 3 Achieved / Not Met Referral to treatment time, 18 weeks in aggregate, admitted patients 90% 1.0 Yes Not relevant Referral to treatment time, 18 weeks in aggregate, non-admitted patients 95% 1.0 Yes Not relevant Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 Yes Not met Cancer 62 Day Waits for first treatment (from urgent GP referral) 85% 1.0 No Not relevant Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) Threshold or target YTD Scoring Risk declared at Annual Plan 90% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No Not relevant Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No Not relevant Cancer 31 day wait from diagnosis to first treatment 96% 0.5 No Achieved Cancer 2 week (all cancers) 93% 0.5 No Achieved Clostridium Difficile -meeting the C.Diff objective 2 1.0 No Achieved Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No CQC enforcement action within last 12 months (as at 31 Mar 2015) N/A No No CQC enforcement action (including notices) currently in effect (as at 31 Mar 2015) N/A No No CQC enforcement action (including notices) currently in effect N/A No No Moderate CQC concerns or impacts regarding the safety of healthcare provision N/A Report by No No Exception Major CQC concerns or impacts regarding the safety of healthcare provision N/A No No Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements Score of 7 or less in standard 1 assessment at last NHSLA CNST inspection (maternity or all services) Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No N/A No No N/A No No Overall Score 1 Indicative Risk Rating GREEN 30