Monthly - February 2007 Patient Experience Length of Stay - Overall A Mortality Rate G Cancelled Operations R Elective A Peri-operative Mortality Rate Cancelled Operations (28 day reschedule) A Non-elective A Re-admission Rate G Cancelled / Rescheduled Clinic Appointments Pre-operative (elective) A Hospital Acquired Infection A A&E (4 hour) R Delayed Transfers of Care A MRSA R Inpatients (15 weeks) R Additional Capacity Open A CDiff A Outpatients (11 weeks) G Closed Beds G Total Complaints A Cancer Waits A Day Case Rates A Complaints Response Times R 2 weeks G Basket G Referred to Healthcare Commission 31 day G Trolley G Referred back for Local Resolution 62 day R New to Follow up Outpatient Rate A Serious Untoward Incidents Diagnostic Waits A Outpatient DNA Rate A Thrombolysis - door to needle A Progress towards 18 weeks A Theatres A Convenience and Choice G Percentage Utilisation A Market Share Operations Performed GP Referrals Frequent Emergency Admissions Tertiary Referrals Other Referrals Waiting List Size Clinical Research and Development Productivity Indicators Financial Position Research Funding Cashflow G Staff in Post (WTE) G Commercial Research Income - network Income and Expenditure G Vacancy G Commercial Research Income - independent Debtors G Turnover G Service Support Costs Paybill G Sickness Absence A External Income Savings Programme G Agency Expenditure R SLA Activity G Overtime/Excess Hours Expenditure R A&E Attendances G Spell Activity G Outpatient Activity G ICU and HDU bed day usage G Education and Training SLA Income G Citizen Experience Key good performance (target achieved) G poor performance R on the Corporate Risk Register acceptable performance A to be developed improving / deteriorating performance (no change shown as a blank) 29/03/2007 Trust Key Performance Indicators Page 1 of 5 (r)
Quarterly and Annual - Updated February 2007 Education and Training National Patient Surveys Standards for Better Health (05/06 assessment) FAIR Staff Appraisals and PDPs Hospital Cleanliness (PEAT) Standards for Better Health (Qrtly progress) Mandatory Training - percentage compliance Hospital Food (PEAT) Core Standards Compliance Fire Safety Single Sex Accommodation (Qrtly) Areas of Concern Moving and Handling Developmental Standards Compliance Infection Control Areas of Concern Serious Untoward Incidents Basic Life Support Medical Equipment Training response times by severity by theme Child Protection Induction Claims Report number by theme Pressure Ulcer Prevalence Education Plans External Accrediation Visits Effective use of Education Budgets SIFT WDD Internal Evaluation of Clinical Placements Citizen Experience Financial Position Clinical Research and Development Foundation Trust Status ALE (annual Auditors Local Evaluation) Research Funding Public Engagement (as required - service change) SLA Income Transition Funding Trust Board (PPI representation and involvement) G Efficiency Savings Stranded Costs Contribution Analysis Historic Debt Working Capital Capital Programme Market Share New Partnerships Service Support Costs Commercial Income Grant Income Project and Programme Grants Technology and Platform Funding R&D Annual Report Wellcome Trust Annual Report Research Governance Staff Surveys MHRA Diversity (quarterly) Clinical Staff Achieving Research Degrees Key good performance (target achieved) G poor performance R on the Corporate Risk Register (r) acceptable performance A to be developed improving / deteriorating performance (no change shown as a blank) 29/03/2007 Trust Key Performance Indicators Page 2 of 5
High Level Action Plans Issue Action Timescale Impact or Financial Value Cancelled Operations Current performance above national Healthcare Commission targets, SUHT performance also routinely exceeds performance of other Trusts across South Central. Short notice cancellation of patients significantly impacts upon patient experience. Cancellations reduced over Christmas and into January but have increased in February due to bed capacity pressures. Total Wait in A&E Current performance (weekly, monthly and year to date) below the Healthcare Commission target of 98%. Reduction in number of breaches over last two weeks (March). Inpatients 15 weeks The Trust aimed for a maximum wait of 15 weeks by the end of December. There were 257 patients waiting over 15 weeks at the end of February. Orthopaedics is not now expected to achieve 15 weeks across the board by the end of March despite targeted increased activity. The Trust now has standards in place that requires all cases to be cleared with the Care Group Manager before the patient is cancelled. work to reduce length of stay will free up ward beds and reduce cancellations. The Trust will open 6 more HDU beds in Medicine at the start of April, freeing up capacity for elective patients. A detailed bed modelling tool has been developed to predict the number of beds needed at all times for both Elective and Non-elective patients. Detailed action plan in place. A series of meetings with the PCT in place to review emergency pressures. Hospital at Night project includes recommendations for CDU and medical staffing changes. A specific target has been set for the Trauma and Orthopaedic Care Group. This has been achieved and less than 40 patients will wait more than 15 weeks. All other areas will achieve the 15-week target. This will provide headroom on the way to 18 weeks. April 2007 May 2007 April/May 2007 August 2007 Improved patient experience Improved utilisation of theatre time Improved waiting list management Improved bed management 29/03/2007 Trust Key Performance Indicators Page 3 of 5
Cancer 62-day Wait Cancer Action Plan in place and reviewed monthly at Delivery Group. Weekly meeting has also been established to review all cancer patients, check treatment dates and smooth any pathway delays. Detailed information is circulated twice a week and the number of potential breaches has reduced. Profile of patients not diagnosed by day 42 to be raised (single most important indicator of success in delivering the 62-day pathway). A single manager to be responsible for each pathway. Improved patient pathway Achievement of target MRSA Trust currently exceeding monthly MRSA target numbers Complaints Response Times The Trust achieved 45% compliance against the 25-day target in January 2007 (latest available data). This was against an increased number of complaints for the month (seasonal trend). Thrombolysis Door to Needle Door to Needle performance in quarter 3 was 45% against a 68% target. Quarter 3 performance an improvement on Quarter 2 Trust Infection Prevention and Control Plan is in place. Currently being refocused and updated. New model of complaints management being introduced across the Trust, addressing quality issues as well as overall performance. New indicators also being developed as part of the Governance Performance Report to give more detailed information on: Corporate performance for acknowledging written complaints within 24 hours Divisional response times for first response to a written complaint Complainants that are dissatisfied with their first response Referrals to and from the Healthcare Commission including compliance with timescales Joint Standard with the Ambulance Trust and joint actions already being taken to enable them to provide pre-hospital thrombolysis. Emergency Department and Cardiac actions being developed to deliver improvement (currently with Medical Director, Divisional Clinical Leads and Divisional Directors of Operation. Completed April 2007 Reduced length of stay Reduced cost of prescribing Improved bed flexibility Improved Door to Needle performance in Quarter 4 (and ongoing thereafter) 29/03/2007 Trust Key Performance Indicators Page 4 of 5
Agency Expenditure Linked to additional capacity, increased sickness levels and FRP Overtime / Excess Hours Expenditure Linked to additional capacity, increased sickness levels and FRP Affordable and appropriate staffing levels to meet funded activity and capacity in 07/08 will be agreed with Divisions to help to reduce flexible staffing expenditure (including overtime and excess hours). As above Improved patient experience Reduced agency/excess hours and overtime expenditure Increased headcount 29/03/2007 Trust Key Performance Indicators Page 5 of 5