SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Perfrmance Indicatrs December 2010 Reprt t: Trust Bard 31 January 2011 Reprt frm: Spnsring Executive: Aim f Reprt / Principle Tpic: Review Histry t date: Steve McManus, Chief Operating Officer Steve McManus, Chief Operating Officer Prvides a summary f the Trust s perfrmance against a range f high level key perfrmance indicatrs as agreed by Trust Bard. Regular reprt t Trust Bard Recmmendatin(s): Trust Bard are asked t nte the Key Perfrmance Indicatrs Reprt and cnsider whether there is apprpriate assurance regarding current and future perfrmance. 1. Strategic Cntext Detailed summary f KPI revisin as set ut in 2011/2012 Operating Framewrk and draft Mnitr cmpliance Framewrk t be presented t Trust Bard in February. Rapid review f reduced elective inpatient waiting time target fr 2011/2012 n required level f cmmissined activity frm PCT. A range f high-level indicatrs t give an verview f perfrmance within the Trust and t supprt the develpment f the Intelligent Bard principles within the rganisatin. 1.1 The key perfrmance indicatrs and individual screcards have been realigned t mre clsely reflect the newly agreed Strategic Objectives. The screcards will cntinue t be included within this reprt t prvide mnthly trends and additinal detail t Bard. 1.2 A number f new metrics will need t be included r develped t mnitr the new Strategic Objectives, fr example: PROMS Medicatin errrs Falls Staff utilisatin (incme per wte k) Reference csts Market psitin It shuld be nted hwever, that a number f these indicatrs (specifically thse within CQUIN) are new fr this year and mnitring infrmatin may nt be available until Quarter 4 f 2010/11. 2. Supprting Guidance A supprting dcument which prvides guidance n the infrmatin cntained within this reprt, and hw it shuld be interpreted, is available upn request. Such infrmatin has been remved frm the mnthly reprt in rder t reduce it's length, and t enable better fcus n the reprted perfrmance / actins. 3. Executive Summary 3.1 Regulatry Aggregate Scring The fllwing sectins summarise the impact f perfrmance (which is reprted within the detail f this dcument) upn aggregate scring tls used by Regulatry rganisatins. Key Perfrmance Indicatrs Reprt Page 1 f 5
3.1.1 NHS Perfrmance Framewrk (Department f Health Indicatrs) Actual Year t Date Predicted YTD at end Qtr 4 2010/11 Published 2010/11 Qtr2 Perfrmance PF Scre Perfrmance PF Scre Perfrmance PF Scre Operatinal Standards and Targets Perfrming 2.79 Perfrming 2.65 Perfrming 2.79 The 2010/11 Quarter 2 results fr the NHS Perfrmance Framewrk were published n the 12 th January 2011 (summary attached as Appendix 5). The results were bradly in line with earlier predictins with under-perfrmance in delayed transfers f care, strke and PPCI. The Trust s wn internal screcard is included in Appendix 1 and includes frecast perfrmance fr Quarter 4 2010/11 based n the new guidance and threshlds. The Department f health published the NHS Operating Framewrk fr 2011/2012 in December 2010. A number f revisins t the service quality indicatrs are set ut within this dcument, cvering a range f perfrmance measures including elective referral t treatment times (RTT), emergency access, cancer waiting times, strke care etc. The KPI Bard Reprt will be updated in shadw frm fr the February Trust Bard t reflect these changes in service perfrmance indicatrs. These changes are als reflected within the Mnitr Cmpliance Framewrk as detailed in sectin 3.1.3. 3.1.2 Annual Health Check 2009/10 (Care Quality Cmmissin (CQC) Due t revisins t the NHS Operating Framewrk the CQC will nt be publishing aggregated scres fr trusts fr 2009/10, this will be replaced by benchmarking data. The CQC have yet t advise n hw this will impact n 2010/11 and will update rganisatins as discussins prgress with the Department f Health. 3.1.3 Mnitr Cmpliance Framewrk (Fundatin Trust Indicatrs) In line with the Mnitr perfrmance reprting requirements, this reprt nw prvides a fur quarter predictive perfrmance based n the knwn Mnitr Cmpliance Standards. These predictins are based n knwn seasnality, histrical perfrmance and prximity t the published threshlds. Mnitr published a cnsultatin dcument n 21 st December 2010 regarding its Cmpliance Framewrk fr 2011/12. Key issues are: Revised self-certificatin t incrprate a regard by the Bard fr the Quality Gvernance Framewrk. This clinical quality self-certificatin becmes a quarterly rather than annual return. Further t this, it is prpsed that each NHS Fundatin Trust s annual Statement n Internal Cntrl shuld include a specific cmment n arrangements fr quality gvernance Revisin t gvernance indicatrs as indicated in sectin 3.1.1: Re-intrductin f indicatrs fr referral t treatment times (inpatients and utpatients) based n the 95 th percentile measure Inclusin f five emergency access indicatrs t reflect the new A&E related perfrmance targets Inclusin f tw new cancer targets that have been measured in shadw frm during 2010 Mnitr prpses t amend the gvernance risk rating and service perfrmance scres t reflect a Red rating at 4.0 rather than 3.0. Key Perfrmance Indicatrs Reprt Page 2 f 5
Actual Mnth Quarter t Date Year t Date Predicted 2010/11 Qtr 4 Predicted Predicted Predicted 2011/12 Qtr 1 2011/12 Qtr 2 2011/12 Qtr 3 Service Perfrmance Aggregate Scre RAG Scre RAG Scre RAG Scre RAG Scre RAG Scre RAG Scre RAG Scre Amber / Green 1.5 Green 0.0 Green 0.0 Green 0.0 Green 0.0 Green 0.0 Green 0.0 Financial Indicatrs Red 3.0 Areas f cncern Finance Indicatrs (all indicatrs) A&E 4 hur wait Cancer waits (secnd r subsequent treatment (surgery)) Mre detailed screcards are included in Appendix 1 3.2 Quality Indicatr Pyramid Early Alert Mnthly Measures Patient Experience Hw wuld yu rate the care yu received? Patient Safety Serius Untward Incidents (SUIs) Patient Outcmes Unadjusted Mrtality Rate Clinical Effectiveness Readmissin Rate (28 days) Staff Experience Sickness Absence Clinical Efficiency Trust Inpatient Bed Occupancy (%) Financial Efficiency Cst Imprvement Plan Financial Management Incme and Expenditure Patient Experience Patient Safety Patient Outcmes Clinical Effectiveness Staff Experience Clinical Efficiency Financial Efficiency Financial Management In additin t Financial indicatrs, the measure related t clinical efficiency (percentage inpatient bed ccupancy) whilst nt appearing t have deterirated, is f cncern given the issues identified belw. The measures fr Staff Experience and Patient Outcmes have als deterirated but these are expected seasnal variatins. Please nte that deterirating measures are nw being shwn with a dwnward arrw. December saw a severe challenge fr the hspital regarding the impact f bth increases in seasnal flu-related nn-elective admissins and a viral diarrhea utbreak impacting n hspital capacity and patient flws. At the height f the viral utbreak, 10 wards were clsed t new admissins with a resultant lss in bed capacity tgether with the need t chrt cnfirmed and suspected flu patients. The seasnal flu demand had a particular impact n the yung adult ppulatin, with a high level f acuity leading t increased critical care requirements. Thrughut this perid the HIMT (Hspital Incident Management Team) was instigated n a daily basis with an executive lead in rder t versee the clinical and peratinal requirements f the hspital at that time. Daily telecnferencing was held with PCT and ther cmmunity clleagues. A detailed reprt n the management f the hspital during this perid has been presented t NHS Suthamptn at the request f their CEO. Sectins 1.1 and 1.2 f appendix 4 sets ut a number f the actins taken t recver the hspital s peratinal perfrmance during this perid. Key Perfrmance Indicatrs Reprt Page 3 f 5
4. Screcard and Indicatr Changes 4.1 18 Week RTT Milestnes The KPI reprt nw cntains updated infrmatin regarding elective access perfrmance as measure in median waits and 95 th percentile f referral t treatment time. Further details f the inpatient / utpatient RTT measures will be included in the KPI reprt t Bard in February. Hwever, there are sme key cnsideratins regarding these indicatr changes: RTT 95 th percentile and median waits appear t fully replace the previus 90% / 95% 18 week targets 4.2 Patient Safety Measures appear t be at Trust aggregate level rather than by specialty 95 th percentile target has reduced frm 27.7 weeks t 23 weeks. This needs t be mdelled in terms f cntracted activity levels in 2011/2012 t ensure delivery f this headline measure is cntracted fr by PCTs These measures are reflected in the Mnitr Service Perfrmance Aggregate scre fr elective care. The patient indicatrs fr the perfrmance reprt have increased t apprpriately reflect the measures cntained within the Trust s Patient Imprvement Framewrk and the quality indicatrs as utlined in the Quality Cntract and CQUIN by which we are mnitred. 4.2.1 Grade III and IV Hspital Acquired Pressure Ulcers We have changed the indicatr t measure Grades III and IV rather than just Grade IV t reflect the cntract and the natinal nurse indicatr. Fr 2010/11 the target has been a 25% reductin in Grade III and IV pressure ulcers frm baseline set frm Dec March 2010 with an verall annual trajectry f 81. 4.2.2 Avidable Falls T reduce avidable falls t under 5% f ttal falls. 4.2.3 Falls - SIRFIT Cmpliance T maintain SIRFIT cmpliance abve 95%. 4.2.4 Nutritin MUST Assessment Internal Trust target t achieve a 20% imprvement in the use f MUST. 4.2.5 Medicatin Errrs Quality Cntract target fr 2010/11 t reduce serius medicatin errrs by 10% i.e. 8 r less, fr 2011/12 the target will be 6 r less. 4.2.6 Thrmbprphylaxis (VTE) Assessment 90% risk assessment (CQUIN). CQUIN fr 2011/12 yet t be set ut by the DH. 4.2.7 Thrmbprphylaxis (VTE) Patients receiving apprpriate Pharmaclgical Prphylaxis 90% apprpriate treatment (Trust Target) CQUIN fr 2011/12 yet t be set ut by the DH. Key Perfrmance Indicatrs Reprt Page 4 f 5
4.3 Prductivity Indicatrs Definitins 4.3.1 Outpatient Indicatrs New t fllw up rate: The number f fllw up attendances fr each new attendance Outpatient discharge rate: The percentage f patients discharged back t their GP after a new utpatient attendance (n fllw-up r waiting list additin) Outpatient DNA rate: The percentage f patients (new and fllw-up) wh d nt attend (DNA) their utpatient appintment. (This des nt include cancellatins) 4.3.2 Elective Inpatient Indicatrs Day f Surgery Admissins: Percentage f elective inpatients wh were admitted n the same day as their first prcedure/peratin (this excludes day case patients) Day Case Rates: Percentage f elective patients wh did nt have an vernight stay (ie were admitted and discharged n the same day) Pre-Operative Length f Stay: The average number f days (vernights) that elective inpatients spend in hspital befre their first prcedure/peratin (this excludes day case patients) Theatre Utilisatin: The amunt f theatre time actually used as a percentage f ttal theatre time available (Centre Blck Theatres nly) Elective Length f Stay: The average number f days elective inpatients (discharged in the perid) stay in hspital (frm admissin t discharge). Nte that day cases are excluded. 4.3.3 Nn-elective Indicatrs Nn-elective Length f Stay: The average number f days nn-elective patients (discharged in the perid) stay in hspital (frm admissin t discharge) Trust Inpatient Bed Occupancy: The percentage f ccupied beds (excluding maternity, Cuntess Muntbatten Huse, Bursledn Huse, all HDU and ICU beds) at midnight averaged acrss the mnth. Medical Outliers: The number f acute general medical / elderly care patients residing in beds utside cmmissined Divisin B bed stck. Pre-11am Discharges: The number f patients discharged befre 11am as a percentage f all inpatient discharges in the perid (patients with a zer length f stay are excluded frm this analysis) 5. Perfrmance as at the end f December 2010 (Appendices 1, 2 and 3) The screcards shwing current perfrmance can be fund in Appendices 1, 2 and 3. The summary actin plans t supprt the Red Indicatrs are included as Appendix 4. 5.1 Educatin and Training As reprted in Quarter 2 - the system fr recrding and generating reprts against the educatin KPI's was migrated t OLM (the learning management cmpnent f ESR) in December 2010 and lcal database maintenance stpped. Due t functinality issues the reprts aggregating activity fr Quarter 3 will nt be available until February 2011 and will be presented as part f the KPI reprts at the March bard meeting. 6. Cnclusins 6.1 Trust Bard are asked t nte the Key Perfrmance Indicatrs Reprt and cnsider whether there is apprpriate assurance regarding current and future perfrmance. Key Perfrmance Indicatrs Reprt Page 5 f 5