Integrated Performance & Quality Report

Integrated Performance & Quality Report October 2014 (Month 7)

Introduction The Hounslow Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the based on the latest performance information available, and reporting on actions being taken to address any performance issues with progress. The contents of the report are defined by the s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution and Everyone Counts Guidance for 2014-15 (operating framework). The report is split into 3 sections. Section 1 of the report provides an update on and related providers operational performance against national standards. This includes 18 weeks RTT, cancer waits, A&E waits and ambulance handover times. Detailed information on underachieving indicators including trends and action log are also provided. Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Serious Incidents, Never Events, SHMI, maternity services, complaints and patient experience. These are presented in trend charts and tables with commentary and actions for areas of concern. Section 3 provides an update on local priority indicator measures. 1

Performance Overview Access Prev. Month Month 7 Other Measures 18 weeks RTT - Admitted Pathway 90.3% 91.3% Cancelled Ops - 28 Day Guarantee breaches 18 weeks RTT - Non-admitted Pathway 95.9% 95.3% Urgent Cancellations for the 2nd time Prev. Month 18 weeks RTT - Incomplete Pathway 92.8% 91.6% CB_B Mixed Sex Accommodation Breaches (MSA) 0 1 52 week RTT Waiters - Incomplete pathway 0 0 HQU0HCAI - MRSA 0 0 Month 7 Community Services CLA - Initial Health Assessments (IHA) conducted within 20 operational days CLA - Review Health Assessments (RHA) conducted within 6 wks Referrals responded to during the day, twilight or night service periods within 24 hrs Number of Rapid Response referrals responded to with 4 hrs Prev. Month Month 7 0.0% 0.0% 16.7% 29.4% 6 Weeks Diagnostics 0.2% 0.5% HQU0HCAI - CDIFF 2 4 Pre-booked appointments DNA or UTA rate 6.2% 6.4% 96.0% 100.0% Cancer Waits Prev. Month Month 7 Mental Health (WLMHT) Prev. Month Month 7 Out of Hospital Services 2 weeks of an urgent GP referral 94.3% 94.9% IAPT - Access 0.7% 0.9% LAS Cat A Red 1 responses within 8min 61.9% 64.1% 2 weeks of an urgent referral for breast symptoms 95.5% 97.5% IAPT - Recovery (YTD) 45.3% 45.0% LAS Cat A Red 2 responses within 8min 54.0% 57.5% 31 Day - 1st definitive treatment 96.6% 95.2% CPA Reviews with 12 months 99.7% 99.7% LAS - Cat A 19 transportation within 19min 90.5% 91.5% 31 Day Subsequent treatment (Surgery) 96.0% 100.0% Outcomes Data Completeness - CPA Patients 100.0% 100.0% NHS 111 - % calls answered in 60 secs 98.7% 96.7% 31 Day Subsequent treatment (Drugs) 100.0% 100.0% CPA Follow-Ups within 7 days 90.9% 95.0% NHS 111 - % calls abandoned in 30secs 0.2% 0.5% 31 Day Subsequent treatment (Radiotherapy) 94.1% 100.0% Inpatient gates kept by CRHT Teams 89.5% 86.7% NHS 111 - % calls where call back was offered 4.8% 5.0% 62 Day - 1st definitive treatment (Urgent GP Referral) 85.2% 85.7% New psychosis cases served by EIS (YTD) 102.0% 99.4% GP Out of Hours 62 Day - 1st definitive treatment (Screening Service) 81.8% 83.3% Delayed Transfers of Care 16.5% 14.4% 62 Day - 1st definitive treatment (Cons. Upgrade) 100.0% 100.0% DNA - 1st Appointments 15.5% 17.1% Prev. Month Month 7 A&E / LAS Total time spent in A & E < 4 hours (all activity types) Prev. Month DNA - Follow-Ups Appointments 10.6% 11.7% Month 7 Carers offered assessment 78.6% 82.4% Mental Health Tariffs Trolley Waits in A&E HoNOSCA Completion rates on acceptance 53.8% 63.6% No. of LAS arrival to handover > 30mins HoNOSCA Completion rates on discharge 5.1% 6.7% No. of LAS arrival to handover >60mins CAMHS - 1st Appt. DNA Rates 11.9% 5.4% CAMHS -FU Appt. DNA Rates 15.9% 15.8% RAG rated cells without data indicate under performance at one or more of s key providers WMUH, ASPH, ICHT 2

Performance Exception Report

Exception Report 18 Weeks RTT 18 Weeks RTT performance was largely driven by Imperial College Healthcare Trust (ICHT). Performance due to the inability to forecast and manage excess demand exacerbated by data quality issues across both Trusts. query in place at ICHT. Trust using addition national resilience funds and agreed improvement trajectories with NHSE. An additional RTT backlog reduction trajectory has been agreed. Based on the NHSE requirement to treat additional RTT backlog patients which superseded the original ICHT remedial action plan, the lead and associate's to the ICHT contract have agreed to retract CQN. ICHT Action plan in place with the Trust confirming performance will be met in M8 but dependant on Trusts data quality issues. action taken but limited assurance in Trusts ability to deliver M8 performance. ICHT RTT backlog continues to increases and therefore potential risk to achievement of admitted / nonadmitted RTT standard overall in M8. Issue Action Action RTT standards not met due to: Performance reporting issues following PAS implementation. Demand and capacity imbalance. ICHT Weekly review of performance based on backlog reduction trajectory agreed with NHSE. Open Yes PJ NG Unknow n 20/12/14 - query in place - 4

Exception Report Cancer Waits 31 day standard (95.2%): due to 3 breaches. 2 at ICHT as a result of a delay in workup (1) and another medical condition prioritised (1). One breach at WMUH as a result of patient choice. NWL performance team have reviewed and no identifiable trend in breach reasons. achieving performance year-to-date. All NWL providers achieving 31 day standard in M7. Not applicable based on current year performance Issue Action Action CSU - - All provides have achieved the 31 day standard performance - - - - - - - - - - 5

Exception Report Cancer Waits 62 days screening standard (83.3%): was not achieved because of 1 breach at ICHT on the Breast pathway. The breach was due to a delay in workup. ICHT requested to provide detailed breach reports for screening breaches. NWL Performance Team will agree appropriate actions with ICHT s across NWL have committed to a joint action plan to improve inter provider transfer on the Breast Screening pathways. CWHHE performance committee received assurance from providers they are developing joint actions to improve breast screening performance To be determined following a review of progress against the joint action plan. Issue Action Action 62 day Screening standard (89.7%) achieving standard YTD ICHT ICHT requested to provide detailed breach reports for screening breaches. NWL Performance Team will agree appropriate actions with ICHT Open Yes DH NG Yes 19/12/14 N/A - - 6

Exception Report A&E A&E all type national standard due to: Capacity issues including paediatrics Out of hours skill mix to ensure prompt clinical decision making. Limited assurance based on deteriorating performance. In response to recent issues the Trust has: o Deployment of more senior nursing leadership in the A&E department o Intensive coaching to support Band 7 team in A&E to improve shift coordination o Planned introduction of rapid assessment with an additional A&E consultant in post o Additional clinical space within A&E o operational triggers for management of surges of demand o Transformation work in progress to enhance timely discharge o Collaborative work with Hounslow to ensure maximum benefit from 7 day social work service Performance deteriorated compared to last year and not met M8 performance. Issue Action Action A&E all type national standard: A&E processes and capacity issues WMUH Review of A&E performance issues and progress in implementing winter initiatives at CQG. Open Yes SJ GA Yes 17/12/14 N/A considerin g contract action following review at next CQG None 7

Exception Report Mixed Sex Accommodation There was one mixed sex accommodation breach in October. This breach occurred at ICHT. Root cause currently unknown, the trust has been requested to provide a detailed breach analysis. ICHT have been requested to provide detailed breach report First MSA breach in 2014/15 All providers continue to reduce incidence of MSA breaches in 2014/15 against previous years. Do not currently full understand the reasons for the MSA breach Issue Action Action Mixed sex accommodation breaches ICHT Trust requested to confirm fully resolved Open Yes PJ NG Yes 19/12/14 N/A N/A N/A 8

Exception Report HCAI C.Diff - Increased prevalence of C.Diff within elderly population, longer hospital length of stays and increased antibiotic / proton pump inhibitor usage. 4 C.Diff cases in October with 1 attributed to acute Trusts, ICHT (1). Dedicated infection control resource within CWHHE that support on-going review of infection control and anti microbial prescribing across all provider. Continuous system to review GP prescribing. Training provided to 161 care home staff from Q2. Low level of cases within community and mental health providers. Prescribing analysis demonstrates good clinical practice within primary care. Dedicated infection control support not replicated across London. benchmarked prevalence rates currently unavailable. Issue Action Action Improvement infection control and prescribing practice All providers in CWHHE On-going review of infection control and anti microbial prescribing. Open Yes JB All Yes 31/12/14 N/A N/A N/A Benchmarked position unknown N/A Review of CWHHE benchmarked prevalence Open Yes JP N/A Yes 31/12/14 N/A N/A N/A 9

Exception Report HRCH Looked After Children (LAC) Indicators. Delay in practitioner being able to undertake assessments due to 3 CLA posts vacant including CLA medical officer and LAC Nurse posts. Local Authority (LA) delays to notify service as soon as a child becomes looked after. Looked after children (Teenagers) often DNA for appointments and a number have been offered up to 6 appointments before the CLA Nurse has been able to see them. Work with the LA to develop LAC services in Hounslow commenced. Regular meetings held and all issue being addressed. Interim medical advisor undertaking medicals to ensure children & young people are offered appointments within set timescale. LAC Nurse posts recruited to. place to address capacity issues and work with LA commenced. LAC (Teenagers) DNA ing appointments remains an issue. Issue Action Action 0 out of 3 LAC IHAs were conducted within 20 days. 5 out of 17 LAC RHAs were conducted within 6 calendar weeks HRCH Consultant now in post and is reviewing all LAC appointing processes to ensure all children are seen within the statutory timescales Closed Yes CH HM Yes 31/12/14 N/A N/A N/A 10

Exception Report HRCH - Referrals responded to during the day, twilight or night service periods within 24 hours Data quality issues and inconsistent processes are identified as the main causes for not being able to achieve this KPI. Clear pathways have been drafted and a new standard operating procedure is currently being written to clarify and standardise the referral/triage process. The pathways have been signed off and training provided to all teams Relevant referral response time codes and associated criteria have been agreed to reduce choice and improve consistency. & Performance teams to continue to monitor performance through CQG meetings. This is the first month that the trust have reported on the referral response time KPIs. Issue Action Action Referrals responded to within 24 hours. HRCH District Nursing staff to receive on going training on amending referral urgency codes in light of triage decision Open Yes CH HM Yes 31/12/14 N/A N/A N/A 11

Exception Report HRCH - Pre-booked appointments DNA or UTA rate Children within the Child Development Services often have complex health needs and become poorly quickly and therefore there are often DNAs on the day of appointment. Within the Dietetics Service the largest group who DNA are those referred to Oral Nutrition Support assessment.. There is a concern that patient s DNA their appointment as they feel their supplement use may be reviewed and removed. The trust has reported that the majority of Musculoskeletal (MSK) Service patients are now invited to a set appointment slot, rather than through the previous system of partial booking. Although patients can ring and re-schedule if the time they have been sent is not convenient, it had taken away an element of patient choice which has impacted on DNA rates. In order to meet the on-going increase in demand the MSK Team have temporarily cancelled the fortnightly clinically based team teaching sessions to run an additional new patient clinic. Initial telephone audit to ascertain reasons for DNAs indicated: 50% felt better,40% forgot to attend 10% couldn t get through to cancel/re-book. Trust are implementing action plan by service area to address issues affecting DNA rates DNA rates are continuing on an upward trend. Under performance against DNA s for pre-booked appointments Issue Action Action HRCH The MSK team have carried out a Telephone audit with patients who DNA d to ascertain the reason for non-attendance. Re-audit will be more comprehensive completed by February Open Yes CH HM Yes 09/12/14 31/01/14 N/A N/A 12

Exception Report HRCH - Pre-booked appointments DNA or UTA rate Issue Action Action Under performance against DNA s for pre-booked appointments HRCH The MSK team are carrying out survey to identify patient preference around service opening times and times of rehab classes Trust have replace the phone system in the Therapy Block, West Middlesex Hospital, so that communicating with the department is more straightforward. In order to meet the on-going increase in demand the MSK Team have temporarily cancelled the fortnightly clinically based team teaching sessions to run an additional new patient clinic. Open Yes CH HM Yes 09/12/14 31/01/15 N/A N/A Closed Yes CH HM Yes 17/11/14 12/12/14 N/A N/A Closed Yes CH HM Yes 21/11/14 N/A N/A N/A 13

Exception Report Mental Health IAPT IAPT Access- Trust requested to confirm root cause for under performance. Exception reports have not been provided by the trust due to recent change in target through contract variation. IAPT Recovery- Under performance is attributed to a rise in complex cases due to increased thresholds in secondary care. Data Quality Issues. The trust have met the IAPT Access target each month leading up to October. Action plan in place to address recovery under performance. Data Quality check to be completed to ensure amendments are ready ahead of the data refresh submission date. Work on going to Increase referrals for more treatable conditions (i.e. phobias ) that are underrepresented in IAPT services. To date the trust have not achieved the 50% recovery target this year. Significant improvement in performance is required to recover performance. NHS England IST is currently undertaking an IAPT desktop review across CWHHE. The outcomes of which will be used to build upon the action plan developed following the IAPT desktop review in BHH Issue Action Under performance against IAPT Access target Under performance against IAPT Recovery target WLMHT WLMHT Trust requested to provide update on actions to meet revised target. Work with Anchor Counselling service to improve monitoring of their counsellors' recovery rates as their counsellors contribute to the IAPT recovery rate. Action On Track to date Open No MC AT Yes 31/12/14 N/A N/A N/A Open Yes MC AT Yes 31/12/14 N/A N/A N/A Recruitment campaigns to take place to complete to address extra capacity required to treat clients to wellness. 14

Exception Report Mental Health Crisis Resolution Home Treatment Two breaches in month. CRHT not informed that one patient was secluded on arrival to ward and subsequently assessed and agreed to informal admission and one patient was detained in police custody which CRHT were also not made aware of. A short term solution concerning direct contact in to local Police teams has been identified and implemented and a longer term solution is in development which will be available in early 2015. & Performance teams to continue to monitor performance through CQG and FIG meetings. Trust have only met the target in June and July this year and since then there has been a gradual decrease in performance. Issue Action The M7 figures relate to 2 out of 15 admissions that were not Gatekept by CRHT. WLMT Both cases in October are due to Unit Co-ordinators (UC's) not contacting CRHT, so the Senior Nurse Manager will meet with all UC to instruct them to contact CRHT for all admissions. WLMHT Approved Mental Health Professionals (AMPHs) to use direct contact number to local police rather than central command.. Action On Track to date Open Yes MC AT Yes 31/12/14 N/A N/A N/A Closed Yes MC AT Yes 30/11/14 N/A N/A N/A 15

Exception Report Mental Health Delayed Transfers of Care The reasons for the delays are: -Awaiting completion of assessment -Awaiting public funding -Awaiting nursing home placement or availability -Awaiting care package in own home - Housing - patients not covered by NHS and Community Care Act (G) Patient or Family Choice A DToC overview group met towards the end of October and have agreed an action plan to address the under performance within Ealing and Hounslow. Action plan in place which focuses on both actions for the trust and joint actions with Social Care/ Local Authority to address DTOCs through Social Care Panel and monthly escalation meetings Although performance has gradually been improving since July the <7.5% target has only been met once this year which was in April. Issue Action Action On Track to date escalated DToC meeting to be set up to discuss cases that are not moving (to include LA staff). Open Yes MC AT Yes 31/12/14 N/A N/A N/A DTOC equates for 14 patients with a Hounslow GP who are responsible for 190 bed nights lost in month. WLMHT Audit on patients with a length of stay of over 50 days to identify the reasons for the long stay commenced. Open Yes MC AT Yes 31/12/14 N/A N/A N/A 16

Exception Report Mental Health % Readmissions within 30 days For M7- - Readmission was offered to try and break the cycle of detentions under S136 (including alcohol, threatening self harm or actual self harm, and contacting emergency services). - Patient was initially discharged but subsequently admitted to Private hospital. Family ran out of funding, patient was not medically ready for discharge so patient accepted back on Grosvenor Ward. - Patient self discharged and was readmitted after few days in vulnerable state. - Following discharge patient has shown a very rapid decline in mental health as is the nature of illness which could not be supported by CRHT or family at home. Performance for readmissions within 30 days has been 0% against 8% target until September when it increased to 4%. & Performance teams to continue to monitor performance through CQG and FIG meetings. Trust has process in place to ensure patients are discharged appropriately. Some patients are readmitted within 30 days for reason out of control of the service and sometimes this will account for more that 8.0% of patients admitted. Issue Action Action On Track to date 4 out of 25 readmissions were within 30 days in October WLMHT Trust requested for update on actions if performance has not recovered in M8. Open No MC AT Yes 31/12/14 N/A N/A N/A 17

Exception Report Mental Health DNA Rates Key reasons for DNA s ascertained from audit include- - lack of appointment reminders sent (either by text or a telephone call) - appointment dates / times not communicated effectively - not offered a choice of appointment date or time, instead just sent a letter containing the appointment date (Choice Booking) Action Plan developed and being implemented to address audit findings Action Plan submitted to for on going monitoring. & Performance teams to continue to monitor performance through CQG and FIG meetings. No gaps in assurance identified Issue Action Action On Track to date 1 st appointment DNA s above <15% target at M7 WLMHT Actions from DNA Audit to be implemented to ensure more consistent communication with patients about their appointment dates and times including reminders (whether by text, phone call or letter). Open Yes MC AT Yes 31/12/14 N/A N/A N/A 18

Exception Report Mental Health Tariffs Low staff awareness about clustering accurately and within agreed timeframes. Newly appointed Clinical Directors are in post and leading the service lines. They will be responsible for ensuring that clustering accuracy is on their SMT/ Governance meeting agendas. The Data Quality Improvement Manager to send regular reports relating to these targets to team managers to ensure they are aware of their performance during the month A MH Tariff Group has recently been reestablished with a remit to ensure adequate reporting is in place and that the CQUIN, quality schedule and DQiP targets are met. & Performance teams to continue to monitor performance through CQG and FIG meetings. % of patients receiving their initial clustering assessment within DH guidelines - 2nd face-toface/ 2nd bed night performance has not been achieved since month 1 and is on a downward trajectory. Issue Action Action Under performance across Mental Health Tariff KPIs WLMHT The Clinical Lead for MH Tariff will provide updated MH Tariff training to clinical teams across Local Services. RiO integration of predictive algorithm for red rules to be implemented to ensure accurate clustering. Trust have reported that this work is behind schedule as the RiO team have a backlog of changes to make to the new system. Open Yes MC AT Yes 31/12/14 N/A N/A N/A Open Yes MC AT No 30/10/14 31/12/14 N/A N/A 19

Exception Report CAMHS DNA Rates Lack of clarity amongst clinical staff regarding how to accurately record DNA on RiO Staff reminded to capture all activity and outcome appointments. Trust Informatics now send routine weekly DNA reports showing the breakdown by team. Hounslow have made improvements for the second consecutive month on both types of DNA. & Performance teams to continue to monitor performance through CQG and FIG meetings The trust has not met the target for CAMHS Follow Up DNA rates this year Issue Action Action On Track Under performance against CAMHS Follow Up DNA Rates WLMHT DNA Audit Results to be tabled at Trusts December SMT to inform further action planning. Open Yes MC AT Yes 31/12/14 N/A N/A N/A 20

Exception Report HoNOSCA Under performance has been attributed to data quality as staff begin to use HONOSCA to record completion rate on acceptance, completion rate on discharge and paired scores. The Assistant Psychologists from each borough are in the process of undertaking a piece of work with the Informatics Team to ensure that the data being reported accurately reflects the HoNOSCA completion rates by analysing MIR data against what is recorded on the patient s RiO record. At month 7 the trust have not provided any assurance that Hounslow will meet the target by year end. & Performance teams to continue to monitor performance through CQG and FIG meetings Trust has reported that Time 2 completion rates remain poor and are likely to remain poor until January/February 2015 because most of the cohort of patients who were seen for the first time since July 2014 and had a HoNOSCA completed will not reach Time 2 until early 2015. Issue Action Under performance against CAMHS HoNOSCA KPIs WLMHT WLMHT s CORC lead to regularly monitor and audit staff compliance with HoNOSCA. A quarterly meeting is being established to review missing measures which will include HoNOSCA auditing. Action On Track Open Yes MC AT No 31/10/14 31/12/14 N/A N/A to date 21

Exception Report LAS Description Threshold In Month YTD (31 st October) Cat A Red 1 responses within 8 mins 75% 64.12 % 69.42 % Cat A Red 2 responses within 8 mins 75% 57.49 % 62.60 % Cat A 19 transportation within 19 mins 95% 91.48 % 93.73 % Cat A 8:45 Performance In Month 65.91 % Hounslow 61.3% Paramedic levels under established levels LAS unable to meet required levels of shift cover Ambulance utilisation rates high, meaning LAS are unable to cope with surges in demand in the system. Whilst activity is broadly in line with plan, the acuity of cases has increased Weekly assurance meetings between LAS and Commissioners, TDA and NHS England Daily and weekly performance updates showing updated performance against plan LAS have provided recovery trajectory Increased overtime payments to incentivise workers to fill shifts Increased use of the Hear & Treat model Recruitment drive (longer term mitigation) Drive to reduce multiple attendance ratio External consultants have been brought in to examine capacity & capability Trajectory not signed off formally; does not recover Cat A by year end Red 1 likely to be missed, affecting quality premium Trajectory based on unsustainable recovery methods Issue Action Action NWL LAS unable to meet established staffing levels Staff retention difficult LAS unable to fill shifts to required levels LAS New EAC staff recruited Open Yes National Paramedic recruitment International Paramedic recruitment Create new senior paramedic role to aid retention LAS offering incentive payments & double time to incentivise uptake LAS increasing PAS usage to fill shifts LAS to use taxis for low priority HCP journeys Open Yes Rob Larkman Elizabeth Ogunoye Paul Woodrow Yes 28/2/15 (Cohort 1) Yes 31/03/15 (Cohort 1) Open Yes Yes 31/03/15 N/A Open Open Open Open Yes Yes Yes Yes Rob Larkman Rob Larkman Rob Larkman Rob Larkman Elizabeth Ogunoye Elizabeth Ogunoye Elizabeth Ogunoye Elizabeth Ogunoye Paul Woodrow Paul Woodrow Paul Woodrow Paul Woodrow N/A N/A Signed - Yes 31/03/15 N/A Signed - No On-going On-going Signed - No On-going On-going Signed - Yes On-going On-going Signed - 22

Exception Report LAS Issue Action Action NWL Demand on LAS increasing LAS LAS increasing use of Hear & Treat LAS expanding operation hours of METDG Open Open Yes Yes Rob Larkman Rob Larkman Elizabeth Ogunoye Elizabeth Ogunoye Paul Woodrow Paul Woodrow Yes On-going N/A Signed - Yes On-going N/A Signed - 23

Exception Report NHS 111 October 2014 ONWL* Call standards No. calls % Number of calls offered 9723 N/A Insufficient number of clinical staff available leading to higher than contracted proportion of calls offered a call back Recruitment of new clinical staff is ongoing Number of calls answered 9678 N/A Calls answered in 60 secs 9361 96.7% Calls abandoned in 30 secs 45 0.5% Calls triaged 7391 76.4% Calls where a call back was offered 483 5.0% contract meetings Daily exception reporting of all call backs over 10 minutes None Call backs within 10 minutes 221 45.8% Led to ambulance dispatches 827 11.2% Recommended to attend A&E 670 9.1% * Brent, Ealing, Harrow, Hounslow Data source: UNIFY2 Recommended to attend primary/community care Recommended to attend other services Did not recommend to attend other service 4614 62.4% 154 2.1% 1126 15.2% Issue Action Action NWL s Insufficient clinician staffing level Care UK Recruitment of additional clinical staff On-going Yes Angela Stephanie McKenzie Grant Caralyn Tettmar N/A N/A N/A Expires 18/02/15 79,205 24

Exception Report GP Out of Hours National Quality Requirements Target Hounslow % calls triaged within 20 minutes (urgent) 100% 94.00% % calls triaged within 60 minutes (routine) 100% 75.63% % walk-ins triage complete within 20 minutes 100% 96.23% % walk-ins triage complete within 60 minutes 100% 99.60% GP cons available at all times & places 100% 100% % emergencies consulted within 1 hour 100% 100% % urgents consulted within 2 hours 100% 96.23% % routines consulted within 6 hours 100% 99.60% % emergencies visited within 1 hour 100% 100% % urgents visited within 2 hours 100% 86.05% % routines visited within 6 hours 100% 98.23% Patient communication - special needs met 100% 100% NQRs 9b and 9c (Urgent/Routine triage within 20/60 minutes) 12 urgent and 106 routine breaches in month due to increase in activity and insufficient number of GPs to complete all calls within 60 minutes. Shortage of GPs leading to some breaches of NQR 12e (Urgent visits within 2 hours); 6 breaches in month. General shift in pattern of surges; less predictable than previously, more patients accessing OOH with in hours primary care needs. contract reporting Quarterly contract meetings (final meeting for this contract on 18/12) Care UK looking to increase number of GPs who contract directly with them to increase level of cover and provide more control over when GPs take annual leave. Working with NHS 111 on management of surges to try to spread demand more evenly across the day. Occasional lateness from provider in submissions of data Issue Action Action NWL s Insufficient number of GPs Care UK On-going recruitment of GPs contracted directly with provider On-going Yes Janet Cree Stephanie Grant Kevin Barnett Yes N/A N/A Expired 30/11/14 N/A 25

Quality Premium funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for constitutional gateway measures breaches. Please note IAPT performance is measured against plans submitted to NHSE. Financial Gateway Operate in a manner consistent with Managing Public Money in 2014/15 Not Incur Unplanned deficit in 2014/15, or require financial support to avoid unplanned deficit Not incur a qualified audit report in respect of 2014/15 Quality Premium Measures Reducing Potential Years of Life Lost (PYLL) through causes considered amenable to healthcare and including addressing locally agreed priorities for reducing premature mortality 2014/15 Target YTD/Qtrly Targets 1868 (per 100k population) 1868 (per 100k population) YTD M7/Qtrly Performance Available in summer 2015 Maximum Available Potential Deductions Reporting Frequency 222,276 Annual Improving Access to Psychological Therapies (IAPT) (Quarterly Performance - Q2) 13.16% 3.10% 2.65% 222,276 Quarterly National measures Reducing avoidable emergency admissions (Composite Measure) Improving Patient Experience: (i) Supporting roll-out of Friends and Family Test (FFT) by local providers (ii) Improvement in 'Patient Experience of Hospital Care' 1831 (admissions per 100k pop.) 1831 (admissions per 100k pop.) Available in summer 2015 Evidence of engagement Evidence of engagement tbc Improvement on 2013/14 score of 70.7 Improvement on 2013/14 score of 70.7 Available in summer 2015 370,460 Annual 222,276 Annual Improving the reporting of medication-related safety incidents Local s Target Local s Target tbc 222,276 Hounslow Local Measure Total People with diabetes diagnosed less than a year who are referred to structured education Total Maximum Funding Available 69.78% 70% tbc 222,276 tbc 1,481,840 0 1,481,840 Gateway measures (Penalty) Constitutional Measures 18 Week RTT (Incomplete Pathway) A&E waits ( mapped from HES provider data) Cancer waits - 14 days (Urgent GP referral for Suspected Cancer) Cat A red 1 ambulance calls (LAS performance) Potential Year End Achievement (after Gateway Measures Performance Adjustments) Target YTD Target YTD M7 Performance Potential % Adjustment to Funding Potential Adjustment to Funding Reporting Frequency 92% 92% 93.7% - 95% 95% 97.0% - 93% 93% 95.3% - 75% 75% 69.4% 25% - 370,460 1,111,380 26

Quality & Safety

Quality and Safety Overview Acute s Community - HRCH Mental Health - WLMHT Serious Incidents indicators WMUH ICHT Serious Incidents M07 Serious Incidents M07 Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Maternity Indicators WMUH ICHT Complaints M07 Complaints M07 Breast feeding Acknowledged in 3 days Acknowledged in 3 days 12 Weeks assessment Smoking at delivery Responded to within agreed timescales Responded to within agreed timescales Homebirths Elective C-Sections Non-Elective C-Sections 3rd degree tear Post Partum Haemorrhaging Safeguarding Training Adult Safeguarding District Nurses Children Safeguarding Community medical staff M07 Safety Under 18s admitted to adult psychiatric wards Patients feeling safe on an inpatient unit M07 1:1 midwife care in established labour No data Midwife to birth ratio Obstetric Consultant Ward Coverage Quality Indicators WMUH ICHT HASU thrombolysis treatment within 45 mins N/A 90% time on stroke ward N/A TIA treated within 24 hours TB access within 2 weeks N/A VTE Risk Assessments NRLS uploads Overdue safety alerts Friends and Family Test Indicators WMUH ICHT Inpatient Response Rate A&E Response Rate Mat Response Rate Complaints Indicators WMUH ICHT Acknowledged in 3 days Responded to within agreed timescales Key In month/quarter performance within threshold In month/quarter performance outside of threshold Data for indicator was not submitted in month/quarter There were no instances in month/quarter of the numerator/denominator which the indicator measures Indicator is not applicable to provider No data No activity N/A 28

Exception Report: WMUH Complaints Issue with the data return. Local complaints report, Director of Nursing and NWL Acute performance manager have agreed on solution and implemented the solution. Lag in data return as resolution within month, metric will improve in M8. Issue Action Action Data issue WMUH Have reviewed process and implemented mitigating actions Open Yes Leigh Forsyth Charlotte Hall Yes January - - - 29

Exception Report: WMUH Friends and Family Test Maternity Q2 Response Rate All patients are offered the opportunity to respond. However, the system for capturing data across the pathway (the same question at three different points in the pathway) relies on new mothers responding. Trust to send reminder texts at the three stages in the pathway. Trust has completed the maternity plus audit, Trust to share these results. Nil Issue Action Action Receiving responses from patients WMUH Trust to send reminder texts at the 3 stages in the pathway that require a response. Open Yes Leigh Forsyth Shan Jones Yes M9 N/A - - 30

Exception Report: WMUH Breastfeeding initiation rate The trust has identified challenges with the data collection with this metric. To review process and update CQG in Jan. Improvement in reporting since discussion in Sept. Issue Action Action Data collection WMUH Review process and improve reporting rate Open Yes Leigh Forsyth Shan Jones Yes January - - - 31

Exception Report: WMUH 1:1 midwife care in established labour Maternity recruitment plans On-going recruitment plan. After review of data submission there has been a marked improvement in the overall position. The Trust are now within 0.5% of threshold and benchmark in line with similar trusts within NWL. Nil. Issue Action Action 1:1 midwife care in established labour below threshold WMUH Midwife recruitment plan Open Yes Leigh Forsyth Shan Jones Yes January - - - 32

Exception Report: WMUH Percentage of women that have non-elective caesarean sections Acuity of deliveries Trust has completed Birth Rate Plus Audit earlier this year. Trust Benchmarks favourably amongst other maternity units in North West London. Results of Birth Rate plus Audit Issue Action Action has not seen the results of the Birth rate Plus Audit WMUH Trust to share audit results. Open Yes CQG Shan Jones Yes January 2015 n/a - - 33

Exception Report: WMUH Midwife to birth ratio Numbers of midwives available On-going recruitment plan. 1:1 midwife care in established labour is 94.5%, there is an on-going recruitment plan. Clinical outcomes as evidenced in the birth rate plus audit. Issue Action Action Evidence of clinical audit outcome WMUH To provide most recent birth rate plus audit at the next CQG Open Yes Leigh Forsyth Shan Jones Yes January - - - 34

Exception Report: ICHT % of Serious Incidents reported within 2 working days of identification The Trust has implemented a system for management of reporting of Serious incidents whereby the incidents are reviewed by the Medical director on a weekly basis prior to being entered onto STEIS this has resulted in only 60% of the incidents being reported within 49 hours Internal review of Serious Incidents Three meetings have taken place with the Trust to understand internal reporting mechanisms and concerns. Discussion with the TDA regarding concerns formulating strategy to address this jointly TDA and with Imperial The internal review of Serious Incidents is rigorous Willingness to review internal processes to address 48 hour reporting requirements. Any change in reporting of SIs within timescales Issue Action Action Late reporting of SIs onto STEIS ICHT Review meetings held with Trust Joint action to be formulated with TDA Completed Dec/January - MM Shona Maxwell - December 14 February 15 - - 35

Exception Report: ICHT % of complaints responded to within timeframes Raised with the trust at CQG. Discussed outside CQG trust has not implemented extensions this is to be considered Will be scheduled for discussion at CQG in future months Issue Action Action Complaints response process ICHT Trust to respond to further requests for explanation as to the reason for the late response Open No MM SS/CR - - - - - 36

Exception Report: ICHT % first booking maternity appointments completed by 12 weeks 6 days excluding late referrals Possible Cerner data quality issue trust does not report this as below threshold To be revised following data resubmission. Persistent issue since April 2014 trust has preciously given assurance that this would be resolved. Issue Action Action Attributed to Cerner data issue ICHT Trust to resubmit data Open Yes MM Jacqui Dunkley- Bent No - Jan 15 - - 37

Exception Report: ICHT Home births London-wide issue Part of SaHF strategy to increase home births Continually below threshold throughout the year Issue Action Action Home births below trajectory ICHT Implement SaHF strategy Open Yes MM JDB - - - - - 38

Exception Report: ICHT % of women that have non-elective caesarean sections London wide issue Part wider Maternity Network consideration for 2015/16 to address across NWL sector Issue Action Action Non -Elective sections above thresholds ICHT Review as part of Maternity Network Open No MM JDB - - - - - 39

Exception Report: ICHT Consultant Ward Coverage at St Mary s Hospital (SMH) and Queen Charlotte's and Chelsea Hospital (QCCH) Difference in data reported to performance team and trust reported data. Trust reports currently at 98 hours however should be reporting 168 hours from month 7 Discussed with Director of Children s and Women s Services who advised that the increase in consultant hours is linked to Ealing closure. Advised to develop trajectory for delivery of additional consultant hours Discussed with Director of Children s and Women s Services No firm trajectory with business case planned Issue Action Action Consultant obstetric labour ward cover ICHT Plan or business case to achieve 168 hours cover Open N MM ICHT - - - - - 40

Exception Report: ICHT Midwife to birth ratio at St Mary s Hospital (SMH) and Queen Charlotte's and Chelsea Hospital (QCCH) Requirement to recruit additional midwives international recruitment has taken place. Use of agency and bank midwifery to address shortfall. Focus CQG on maternity services in Jan / Feb 2015. Confirmation of numbers of staff recruited, start dates and induction processes. Issue Action Action Midwife to birth ratio above expected threshold ICHT International recruitment has taken place. Confirmation of numbers and start dates Open Yes MM JDB tbc - - - - 41

Exception Report: HRCH: Hounslow Community Services Serious Incidents Indicators Serious Incident internal process. Trust to review process and improve KPI tracking. Greater clinical discussions and visibility of SI s through standardised format and agenda in meetings. n/a Issue Action Action Serious Incident Internal Process HRCH To review process and improve KPI tracking Open Yes Leigh Forsyth Siobhan Gregory Yes Feb (M9 report) - - - 42

Exception Report: HRCH The number of Safety Alerts (excluding estates and facilities alerts) that were not implemented within deadline Trust late in responding to close the alerts. Trust to review process of closure and communication. We can see that all alerts are closed but there is a delay in closing them. The specific reason is unclear. Issue Action Action Trust late in responding to alerts HRCH Trust to identify and report back the specific reason for the delays. Open yes Leigh Forsyth Siobhan Gregory Yes January - - - 43

Exception Report: WLMHT: All s % of Serious Incidents reported within 48 hours Delay in reporting on StEIS. Incidents are reported locally and are discussed at CQG via the trust report. The overall process in regards to RCA reporting has improved over the year. The level of discussion has increased within the CQG. The change to StEIS uploads. Issue Action Action Serious Incidents not being uploaded onto StEIS in a timely manner WLMHT Trust to review processes and improve timeliness Open Yes Leigh Forsyth Angela Middleton Yes February (M9 report) - - - 44

Local Priorities

Local Priorities Place Holder for: Dementia Diagnosis Rates People with diabetes diagnosed less than a year who are referred to structured education. 46

Definitions

Definitions Indicator Definition Data Source A&E Performance Percentage of patients who spent 4 hours or less in A&E Unify2 Trolley Waits in A&E Patients who have waited over 12 hours in A&E from decision to admit to admission. Unify2 18 Weeks RTT 52 Week RTT Waiters Percentage of all NHS patients receiving treatment within 18 weeks of referral for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways. The number of Referral to Treatment (RTT) pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways. 6 Weeks Diagnostic Waits Percentage of NHS patients waiting 6 weeks or more for diagnostic tests Unify2 No. of LAS arrival to handover times Cancelled Ops - 28 Day Guarantee breaches Cancer 2 week waits Cancer 31 day Waits Cancer 62 day Waits HCAI MRSA & CDIFF Mixed sex Accommodation Breaches (MSA) Cancelled Ops 28 Day Guarantee breaches Ambulance handover delays of over 30 minutes and over 1 hour Number of breaches of the cancelled operations standard: number patients who have their operations cancelled, on or after the day of admission (including the day of the surgery), for non-clinical reasons Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer and percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer was not initially suspected. Percentage of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from date of decision to treat ). Percentage of patients receiving subsequent treatment for cancer within 31-days, where that treatment is a Surgery, an Anti-Cancer Drug Regimen or a Radiotherapy Treatment Course. Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer. Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service. Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status. Health Care Acquired Infections Number of MRSA bacteraemia and C. difficile cases reported by providers The number of occurrences of patients receiving care that is in breach of sleeping accommodation guidelines i.e. in mixed accommodation that is not in their overall best interests, or does not reflect their personal choice. Number of breaches NHS operational standard for cancelled operations: All patients who have operation 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 their choice. Unify2 Unify2 LAS Database Unify2 National Cancer Database National Cancer Database National Cancer Database Health Protection Agency Unify2 48

Definitions Indicator Definition Data Source Urgent Ops Cancellations for the 2 nd Time IAPT New psychosis cases served by EIS CAMHS - % of patients showing improved HoNOSCA Score CPA Reviews within 12 months Outcomes Data Completeness - CPA Patients CPA Follow-Ups within 7 days Delayed Transfers of Care Number of Urgent operation cancelled for the 2 nd time Access - proportion of people that enter treatment against the level of need in the general population (the level of prevalence addressed or captured by referral routes). Recovery - The number of people who have completed treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness and at final session did not) as a proportion of the number of people who have completed treatment within the reporting quarter, having attended at least two treatment contacts) minus (The number of people who have completed treatment not at clinical caseness at initial assessment). Number of new psychosis cases served by Early Intervention Team as proportion of estimated target new cases Percentage of CAHMS patients discharged from service where the paired HoNOSCA shows improvement between acceptance and discharge (paired scores) Percentage of patients on CPA whose care plans have been reviewed within 12 months Percentage of service users who are on Care Programme Approach (CPA) for 12 months or more, with valid data entries across core outcome fields in their records. Percentage of patients on enhanced CPA who were discharged from psychiatric in-patient care during who were followed up either by face to face contact or by a phone discussion within 7 days of discharge Total number of Delayed Transfers of Care (DToC) as a proportion of occupied bed days for the same period 49

Definitions Indicator Definition Data Source CLA Initial Health Assessments (IHA) conducted within 20 operational days CLA Review Health Assessments (RHA) conducted within 6 wks Referrals responded to during the day, twilight or night service periods within 24 hrs Number of Rapid Response referrals responded to with 2 hrs Pre-booked appointments DNA or UTA rate Palliative care patients with a recorded of preferred place of death Palliative care patients who died in their preferred place of death Number of Initial Health Assessments (IHAs) of Children Looked After (CLA) that were completed within 20 operational days. Number of Review Health Assessments (RHAs) of Children Looked After (CLA) that were completed within 6 weeks. Percentage of non-urgent referrals that were responded to during the day or twilight service period within 24 hours or on the date stipulated for the visit on the referral letter Percentage of referrals to Rapid Response Service that were responded to within 2 hours. Response include a clinical acknowledgement of the referral and a plan of proposed clinical action. Percentage of appointments where service user did not attend (DNA) or was unable to attend (UTA) Patients under the care of palliative care teams who have a record of their preferred place of death Patients under the care of palliative care teams who achieve their preferred place of death 50

Definitions Indicator Definition Data Source LAS Cat A Red 1 & 2 responses within 8min LAS - Cat A 19 transportation within 19min NHS 111 GP OOH Patient Communication Critical care transfers for non-clinical reasons Access to Rapid Access Chest Pain Clinics HASU thrombolysis treatment within 45 mins The number of Category A (Red 1/Red 2) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes The number of Category A calls (Red 1 and Red 2) resulting in an ambulance arriving at the scene of the incident within 19 minutes. % calls answered in 60 secs % calls abandoned in 30secs % calls where call was offered Call Triages Percentage of calls received that were triages within 20 minutes (urgent) or 60 minutes (routine) Patient Consultations Percentage of consultations within 1 hour (emergencies) or 2 hours (urgents), routine (6 hours) Visits Percentage of patient visits within 2 hours (urgents) or 6 hours (routines) Patient Communication Meeting special needs Number of inter-trust transfers of critical care patients for non-clinical reasons as a proportion of all inter-trust critical care transfers Percentage of patients seen in Rapid Access Chest Pain Clinics (RACPC) within 14 days after a decision to refer Measures the door to needle time (DTNT) at Hyper Acute Stroke Units (HASU) between patients entering the service and the time thrombolysis starts. Indicator is a standard in the Stroke Improvement National Audit Programme (SINAP) and is part of the NICE Stroke Quality Standards. LAS LAS Unify2 GP OOH Service 51

Definitions Indicator Definition Data Source 90% time on stroke ward TIA treated within 24 hours TB access within 2 weeks As defined by the National Sentinel Stroke Audit a Stroke unit is a multidisciplinary team including specialist nursing staff based in a discrete ward which has been designated for stroke patients. NICE guideline 68 specifies that people who have had a suspected TIA should have specialist assessment and investigation within 24 hours of onset of symptoms. TIA diagnosis should be made on clinical symptoms and higher risk TIA cases risk stratified using the ABCD2 score of 4 or above. The time frame begins at the time of the patient s first contact with any health care professional (including a paramedic, GP, stroke physician, A&E staff and district nurse etc.) and ends 24 hours later. Recurrent TIA after investigation and treatment should be considered as a new episode The percentage of GP referrals for suspected pulmonary tuberculosis that were offered an appointment date within 2 weeks of referral. NRLS uploads The number of National Reporting and Learning System (NRLS) uploads that were submitted within the deadline. NHS England Overdue safety alerts The number of Central Alerting System Patient Safety Alerts and Medical Device Alerts that were implemented and completed within deadline. NHS England Serious Incidents reported within 48 hours of identification Serious Incident Root Cause Analysis Reports submitted within deadline Friends & Family Tests Response Rates (A&E, IP & Maternity) Complaints Acknowledged in 3 days Complaints Responded to within agreed timescales The number of serious incidents that were reported within 24 hours of being identified, as recorded by the. The number of serious incident root cause analysis investigation reports that were received within the 45/60 day deadline for Grade 1 and 2 serious incidents respectively. The response rate for the Friends and Family Test based on the number of patients accessing the service in the month against the number of responses that were received. The percentage of complaints that were acknowledged within 3 days of being received, which is a patient right enshrined in the NHS Constitution. The percentage of complaints that were investigated and responded to within the timeframes agreed with the complainant, which is a patient right enshrined in the NHS Constitution. Strategic Executive System (StEIS) Strategic Executive System (StEIS) NHS England 52