Performance, Quality and Outcomes Report: Position Statement

Performance, Quality and Outcomes Report: Position Statement Update to Governing Body 5 April 2018 Item 1 Author(s) Sponsor Directors Purpose of Paper Jane Howcroft Programme and Performance Assurance Manager, Sheffield CCG Rachel Clewes Senior Programme and Performance Analyst Brian Hughes - Director of Commissioning and Performance, NHS Sheffield CCG Mandy Philbin Acting Chief Nurse, NHS Sheffield CCG To update Governing Body on key performance, quality and outcomes measures. Key Issues Areas of concern, which remain under review A&E 4 hour waits: The proportion of Sheffield CCG s adult patients admitted, transferred or discharged within 4 hours of arrival at A&E, remains below the national standard for 2017/18. Daily performance this Quarter has fluctuated, with some very challenging days when the Trust has been coping with high numbers of acutely ill patients, and high numbers of patients attending overall. The CCG and Sheffield Teaching Hospitals NHS FT (STH) are in ongoing dialogue around the complex factors which are contributing to high attendances and long waits, including recruitment, and improving flow through the hospital. Diagnostic Waits: The largest number of patients waiting over six weeks were requiring Echocardiography tests at STH. Work is under way across the Integrated Care System of South Yorkshire and Bassetlaw to identify additional capacity in neighbouring hospitals. There are vacancies in the STH service which are proving difficult to recruit to due to national shortages in this speciality. The waiting list had recently reduced due to support from surrounding DGHs, but in January the number of reported breaches significantly increased. This is entirely due to a reporting issue. STH use a bespoke system for echocardiography administration and identified that the wrong system breach report was being used. This has now been corrected which has led to the difference in volumes of numbers of patients reported and it is important to be clear that STH has assured us that they have always been actively managing all patients that are waiting. There have been no material changes in the numbers of patients waiting and no lost waiting lists. This was a data extract error and operational metrics used to manage delivery and patients remain unchanged. STH is managing this at a very senior level. Ambulance Response Programme: The previous Red 1 and Red 2 national standards have been replaced by a new call prioritisation system, which sets standards for all 999 calls to ambulance services. These new standards are now recorded at a provider level, so local data is not available. The Yorkshire wide performance statistics however show that currently none of the four new call categories are being met. Sheffield CCG will be working with Wakefield CCG, the lead commissioner, to look at how we can support

Yorkshire Ambulance Services (YAS) to deliver the new standards. Early Intervention In Psychosis: The proportion of people seen within two weeks of referral dropped in January to 32%, against a target of 50% (the service had previously been delivering to the standard for the last three months). Additional investment has been made into this service and new posts have been created, however staff have not yet joined the team. January also saw a very high level of patients who Did Not Attend (DNA); this is now being addressed by staff telephoning patients ahead of their appointment to encourage them to attend, and in some cases, home visits will be arranged. Performance and quality highlights Healthcare Acquired Infections: The number of Clostridium Difficile (C.Diff) infections occurring in hospital is below the threshold, at both STH and Sheffield Children s NHS FT (SCH). There were no MRSA bacteraemia infections in February. The number of C. Diff infections in the community is however above the plan of 178 cases; there have been 239 to date. The vast majority of cases are not lapses in care, and do not have modifiable risk factors. The CCG has however observed a slight increase in the number of recurrences / relapses, and this has been reported locally by colleagues also. We are currently discussing with the microbiology department at STH as to whether anything more can be done to try and prevent these recurrences. As happens every year, there will be an annual report which is a deep dive as to the nature of the community cases, with accompanying recommendations. Continuing Health Care (CHC): The CCG is making significant improvements in delivering the standard of ensuring that decisions made around eligibility for CHC are made outside a hospital setting. This is in line with national requirements. Is your report for Approval / Consideration / Noting Consideration Recommendations / Action Required by Governing Body The Governing Body is asked to discuss and note: Sheffield performance on delivery of the NHS Constitution Rights and Pledges Key issues relating to Quality, Safety and Patient Experience Governing Body Assurance Framework Which of the CCG s objectives does this paper support? 1. To improve patient experience and access to care 2. To improve the quality and equality of healthcare in Sheffield Specifically the risks: 2.1 Providers delivering poor quality care and not meeting quality targets 2.3 That the CCG fails to achieve Parity of Esteem for its citizens who experience mental health conditions, so reinforcing their health inequality and life expectancy

Are there any Resource Implications (including Financial, Staffing etc)? Not applicable at this time Have you carried out an Equality Impact Assessment and is it attached? Please attach if completed. Please explain if not, why not No - none necessary Have you involved patients, carers and the public in the preparation of the report? It does not directly support this but as a public facing document is part of keeping the public informed.

Performance, Quality & Outcomes Report 2017/18: Position statement using latest information for the April 2018 meeting of the Governing Body

Highest Quality Healthcare - NHS Constitution Measures Performance Dashboard Performance Indicator Target Reporting period (CCG) CCG Monthly Position CCG Performance against standard (latest 6 months) Sheffield Teaching Hospital Latest Provider Total Monthly Position Sheffield Children's Hospital Sheffield Health & Social Care Yorkshire Ambulance Service Referral To Treatment waiting times for non-urgent consultant-led treatment All patients wait less than 18 weeks for treatment to start No patients wait more than 52 weeks for treatment to start 92% Jan-18 95.78% 95.75% 93.39% 0 Jan-18 1 0 0 Diagnostic test waiting times A&E Waits Cancer Waits: From GP Referral to First Outpatient Appointment (YTD) Cancer Waits: From Diagnosis to Treatment (YTD) Cancer Waits: From Referral to First Treatment (YTD) Ambulance response times Patients wait 6 weeks or less from the date they were referred Patients are admitted, transferred or discharged within 4 hours of arrival at A&E (YTD position) No patients wait more than 12 hours from decision to admit to admission 2 week (14 day) wait from referral with suspicion of cancer 2 week (14 day) wait from referral with breast symptoms (cancer not initially suspected) 1 month (31 day) wait from referral with suspicion of cancer to first treatment 1 month (31 day) wait for second/subsequent treatment, where treatment is anti-cancer drug regimen 1 month (31 day) wait for second/subsequent treatment, where treatment is radiotherapy 1 month (31 day) wait for second/subsequent treatment, where treatment is surgery 2 month (62 day) wait from urgent GP referral 2 month (62 day) wait from referral from an NHS screening service 2 month (62 day) wait following a consultant's decision to upgrade the priority of the patient Category 1 (life threatening) calls resulting in an emergency response arriving within 7 minutes (average response time) Category 2 (emergency) calls resulting in an emergency response arriving within 18 minutes (average response time) Category 3 (urgent) calls resulting in an emergency response arriving within 120 minutes (90th percentile response time) Category 4 (less urgent) calls resulting in an emergency response arriving within 180 minutes (90th percentile response time) 99% Jan-18 88.02% 87.24% 98.16% 95% Feb18 YTD 90.37% 88.68% 97.23% 0 Feb-18 0 0 0 93% Jan-18 YTD 96.14% 96.10% 93% Jan-18 YTD 96.92% 96.99% 96% Jan-18 YTD 98.48% 96.94% 98% Jan-18 YTD 99.73% 99.77% 94% Jan-18 YTD 96.39% 95.68% 94% Jan-18 YTD 98.62% 98.59% 85% Jan-18 YTD 84.49% 78.02% 90% Jan-18 YTD 96.47% 93.56% (85% threshold) Jan-18 YTD 79.49% 73.90% 7 mins Feb-18 8 mins 7 sec 8 mins 7 sec 18 mins Feb-18 25 mins 7 secs 25 mins 7 secs 120 mins Feb-18 180 mins Feb-18 141 mins 57 secs 214 mins 44 secs 141 mins 57 secs 214 mins 44 secs Information and Intelligence Team, NHS Sheffield CCG Page 1

Highest Quality Healthcare - NHS Constitution Measures Performance Dashboard Performance Indicator Target Reporting period (CCG) CCG Monthly Position CCG Performance against standard (latest 6 months) Sheffield Teaching Hospital Latest Provider Total Monthly Position Sheffield Children's Hospital Sheffield Health & Social Care Yorkshire Ambulance Service Ambulance Handover - reduction in the number of delays over 30 minutes in clinical handover of patients to A&E Ambulance Handover - reduction in the number of delays over 1 hour in clinical handover of patients to A&E Ambulance handover times Crew Clear - reduction in the number of delays over 30 minutes from clinical handover of patients to A&E to vehicle being ready for next call Crew Clear - reduction in the number of delays over 1 hour from clinical handover of patients to A&E to vehicle being ready for next call Local Reduction Local Reduction Local Reduction Local Reduction Jan-18 12.57% 23.42% 0.00% 12.57% Jan-18 2.86% 2.68% 0.00% 2.86% Jan-18 2.90% 1.89% 1.44% 2.90% Jan-18 0.15% 0.15% 0.00% 0.15% Mixed Sex Accommodation (MSA) breaches Cancelled Operations Mental Health Zero instances of mixed sex accommodation which are not in the overall best interest of the patient Operations cancelled, on or after the day of admission, for non-clinical reasons to be offered another date within 28 days No urgent operation to be cancelled for a 2nd time or more People under adult mental illness specialties on CPA (Care Plan Approach) to be followed up within 7 days of discharge (YTD) 0 Jan-18 1 0 0 0 Local Q3 2017/18 3 2 1 Reduction Local Jan-18 0 0 0 Reduction 95% Feb-18 YTD 92.79% 92.79% Highest Quality Healthcare - Mental Health Measures Performance Dashboard Early Intervention in Psychosis (EIP) Crisis Resolution / Home Treatment Improved Access to Psychological Therapies (IAPT) Proportion of EIP patients seen in 2 weeks Number of episodes of home treatment provided to people experiencing mental health crisis as an alternative to hospital admission Number of patients receiving IAPT as a proportion of estimated need Proportion of IAPT patients moving to recovery Proportion of IAPT patients waiting 6 weeks or less from referral Proportion of IAPT patients waiting 18 weeks or less from referral 50% Jan-18 32.00% 100.00% 22.73% 1102 Feb-18 1394 1394 12.03% Nov-17 YTD 12.70% 12.75% 50.00% Nov-17 YTD 48.36% 48.13% 75.00% Nov-17 86.67% 87.64% 95.00% Nov-17 97.78% 98.88% Information and Intelligence Team, NHS Sheffield CCG Page 2

Highest Quality Health Care - NHS Constitution Measures Performance Dashboard: Actions Area Action being taken Expected timeframe for improvement Action requested of Governing Body RTT 52 week There has been one patient waiting over 52 weeks for Plastic Surgery at We will continue to monitor None waits Mid Essex Hospital since October; this patient was still waiting in January. The patient is waiting for a highly specialised plastic surgery procedure. There are a number of long waiters at this particular Trust; each patient has had a clinical harm review carried out, including psychological harm review. All the patients receive regular updates, and have been offered an alternative surgeon. The hospital has a clearance plan for the patients waiting over 52 weeks for this procedure, with the aim of clearing them all by May 2019. this patient at Mid Essex until they have been seen. Diagnostic Diagnostic waits continue to be monitored through monthly Contract The Cardiac Echo and DEXA To endorse the approach of Waits - STHFT Management Group (CMG) meetings and escalated to the Performance services are working hard to monitoring STHFT achievement and Contract Management Board (PCMB). There continue to be resolve the capacity issues of diagnostic waiting times and challenges in Cardiac Echo, and DEXA scanning. which have led to long waits; any necessary mitigating For Echocardiography, the Trust is working with neighbouring DGHs at present the Trust is not able actions, through monthly PCMB across the Integrated Care System to increase capacity and to attract staff to say exactly when they will meetings with the Trust. with the required skills. They are also investigating whether all the referrals be able to return to delivering into this service are clinically necessary at the present time, including the waiting time standard. checking that they are not repeat requests for this test, and assessing Clinical Neurophysiology is whether patients can be monitored or assessed using different tests. The expected to achieve the waiting list had recently reduced due to support from surrounding DGHs, standard from April 2018. but in January the number of reported breaches significantly increased. This is entirely due to a reporting issue. STH use a bespoke system for echocardiography administration and identified that the wrong system breach report was being used. Prior to January 2018 STH were reporting echocardiogram breaches for patients seen rather than patients waiting for Oct to Dec and prior to that only those that had a future date. This has now been corrected which has led to the difference in volumes of numbers of patients reported and it is important to be clear that STH has assured us that they have always been actively managing all patients that are waiting for an echo. STH has tracked the new and old reporting numbers and are clear that there have been no material changes in the numbers of patients waiting and no lost waiting lists. This was merely a data extract error and operational metrics used to manage delivery and patients remain unchanged.sth is managing this at a very senior level via the monthly elective care Working Group and at Trust Board level. For DEXA scanning, the number waiting has reduced, but the backlog is not being cleared as quickly as had originally planned, despite recruiting new staff. A recovery plan is under development A new issue has developed in Clinical Neurophysiology, caused by issues in recruiting Consultants. A recovery plan has been developed and the department expects to achieve the standard from April 2018. Diagnostic The performance at SCHFT for Diagnostic waits fell below target for SCHFT expect to be back To endorse the approach of Waits - SCHFT December (98.58%) against the target of 99%. This was a result of unusually high sickness in December which could not be covered, in the Urodynamic and Sleep Studies services. The small number of patients seen by SCHFT means that even a slight dip can lead to the Trust missing the percentage target. This problem has continued into January, however SCHFT are expecting to be back within target for February. within target by February. monitoring SCHFT achievement of diagnostic waiting times and any necessary mitigating actions, through monthly Contract Review Meetings with the Trust for escalation in Contract Management Boards if needed. Information and Intelligence Team, NHS Sheffield CCG Page 3

Highest Quality Health Care - NHS Constitution Measures Performance Dashboard: Actions Area Action being taken Expected timeframe for improvement Action requested of Governing Body A & E Waits The Urgent Care portfolio continues to monitor performance on a daily basis. Regular discussions regarding A&E performance are held with the Trust within formal contracting and performance meetings, and STH share their weekly action plans with the CCG. The level of dependency and acuity of illness of patients presenting is high and this is a factor in the longer waits. Significant focus has been placed on recruitment to address staffing gaps, as well as strengthening clinical leadership and cover at key points in the day and peaks of pressure in the week. STH provides weekly assurances around weekend cover, which has included: securing consultant and junior doctor locum cover, overall increase of middle grades; adjusting Emergency Nurse Practitioner shifts to manage the overnight shortfalls, and ensuring Nurse Consultant coverage between midnight and 7.00 am. STH also have a nurse co-ordinator day and night (weekends). Delivery of the target for Quarter 3 was not met due to challenges of winter pressures (87.68% delivered). The Trust is not expected to deliver the trajectory for Quarter 4. New Planning Guidance for 2018-19 highlights revised expectations regarding delivery of the four hour A&E target; we will be reporting according to these new guidelines in future months. To endorse the actions being taken and the continued monitoring of STHFT progress towards achievement of the A&E standard, via the Assurance Framework, and the delivery of any necessary mitigating actions agreed through the Performance Contract Management Board. Cancer Waiting STHFT 62 day performance has fallen since last month (75.0% for Funding has been secured To endorse the approach Times - 62 day January) mainly due to patient choice associated with the holiday session. from the Cancer Alliance to proposed by the Cancer Alliance waits Head & Neck, Upper and lower Gastro-intestinal pathways continue to have issues but there has been an improvement in Urology in the past month. Oncology resource remains a major issue and reflects the national shortage in this staff group and STHFT has experienced difficulty in recruiting these positions. Patients who start their pathway at a assist with capacity issues in Urology and Upper & Lower Gastro-intestinal and there is an expectation that performance will improve and to develop a common performance management framework for cancer waiting times across the region (aligned to the STF trajectory) whilst neighbouring hospital and then are referred to STHFT (these are known as hit the target by the end of Q4. continuing to monitor progress Inter Provider Transfers) continue to experience delays. This issue is being addressed by the Cancer Alliance, with support from NHS & Improvement who will be performing a "Deep Dive" into the 62 day delivery against internal improvement plans and escalate to the PCMB as appropriate. across the Alliance (Sheffield s will be held on 26th March 2018). Directors at STHFT have been assigned to lead the work on the two areas which are experiencing the highest number of delays, namely Head and Neck and Gastroenterology. Although 62 day consultant upgrade did not make the target it should be noted that the numbers were low but 5 patients breached due to late inter provider transfer. Ambulance Ambulance services are now working to new response times following Progress is being monitored None this month. Response extensive Ambulance Response Pilots (ARP) which took place across the by the Urgent Care Team, Times country, including in Yorkshire. New guidance has been released and YAS Urgent and Emergency Care are working to align all reports to that guidance, thereby replacing the previous way of measuring and reporting performance. The calls now split into 4 main categories with Health Care Practitioner (non-paramedic) calls monitored separately. Transformation Delivery Board and at the Yorkshire & Humber 999/111 Contract Management Board meeting. As agreed at the Contract Management Board, YAS will only be reporting the YAS response standard until further discussion take place at a regional level. The Inter-Facility Transfer performance measure may change in terms of how it is measured. As has been reported previously, ambulance response times have suffered in recent months due to the increased demand for responses that require an ambulance. The service demand is starting to rise in line with winter pressures (now above contract levels) and lost hours continue to increase as a result. Action being taken: YAS are still pursuing improvement of "Hear and Treat" rates by expanding the number of jobs in the clinical queue, which in turn reduces the demands on ambulance staff. Information and Intelligence Team, NHS Sheffield CCG Page 4

Highest Quality Health Care - NHS Constitution Measures Performance Dashboard: Actions Area Action being taken Expected timeframe for improvement Action requested of Governing Body Ambulance Ambulance handover performance for STH continued to decline in The CCG continues to To continue to endorse the Handover times February putting pressure on ability of YAS to respond in a timely way. facilitate meetings between approach of monitoring Action being taken: Local data on delayed handovers at STHFT is used to STH & YAS to discuss ambulance handover complement the YAS level data (which covers all Trusts served by YAS) measures to improve performance and the monitoring and supports the monitoring of performance, and any necessary mitigating performance moving forward. of any necessary mitigating actions, through monthly Contract Management Group meetings with the With regard to addressing actions through monthly Trust. Handover data is reported daily to the city-wide Chief Executive local pressures, YAS continue Contract Management Group group, and is a key system trigger for escalation. At times of pressure YAS to provide additional dedicated meetings with the Trust. continue to provide on-site senior manager support at the front door of the Intra Facility Transport crews emergency department to assist with the triaging and handover of patients. (between the Northern STH have also reviewed the front door triage process and have agreed to refresh the methodology. General and Royal Hallamshire sites). Mixed Sex A Mixed Sex Accommodation (MSA) breach has been reported for a This was a time specific issue, None requested. Accommodation Sheffield patient for January. This breach occurred at Imperial College limited to January 2018 only. breaches Healthcare NHS Trust, at St Mary's Hospital. The patient was a neurosurgery patient and there were unforeseen capacity problems in neurosurgery and stroke departments, which led to a number of MSA breaches in the department. Cancelled As reported last month, during Quarter 3, there were 3 cancelled Cancelled operations will Governing body are asked to Operations - (on operations reported (where the patient was not subsequently offered continue to be monitored acknowledge and be assured day of another binding appointment for surgery within 28 days) 2 for STHFT and 1 through Contract Management that processes that have been admission) for SCHFT. This is an increase from the 2 reported in Quarter 2. The detail Group (CMG) meetings and put in place to avoid future of these instances was reported to Governing Body in March 2018. Any cancelled operations will continue to be monitored through Contract Management Group (CMG) meetings and escalated to the Performance and Contract Management Board (PCMB) if required. No specific action is required at this time. escalated to the Performance and Contract Management Board (PCMB) if required. breaches, but note that patient choice was a contributing factor to the Q3 breach at SCHFT Mental Health SHSC FT achieved 91.30% follow up of Care Programme Approach (CPA) We continue to closely monitor To continue to receive CPA 7 day patients within 7 days of discharge in January and 81.25% in February. CPA 7 day follow up within monitoring reports on this follow up The year to date figure is 92.79%, against a target of 95%. The CCG's Clinical Director for Mental Health had discussions with the Clinical Contract Management Group (CMG). CPA was raised at the national target. Director of the Specialist Mental Health Directorate in SHSC. They agreed January CMG, and a further that the way that CPA is currently delivered had the potential to lead to delayed interventions, such as waiting for allocation of care co-ordinators and for clinical actions to be endorsed through CPA. Service re-design follow up and report back on clinical discussions is planned for February 2018. could be undertaken to address these issues. For Older Adult CPA the current clinical position is to develop, deliver and monitor a robust care plan. Further discussion were scheduled at Quality Review Meeting on 13th March, relating to whether process issues can be addressed by SHSC to reduce any potential negative impact, and so improve delivery of the standard. Work is under way to identify examples of good clinical practice which are taking place in the service, to give a more rounded picture of quality to offset the non- delivery of the 7 day follow up standard. Information and Intelligence Team, NHS Sheffield CCG Page 5

Highest Quality Health Care - NHS Constitution Measures Performance Dashboard: Actions Area Action being taken Expected timeframe for improvement Action requested of Governing Body Mental Health Measures Performance Dashboard: Actions Early Intervention in Psychosis (EIP) There were a number of factors which saw a reduction in activity for the month of January. A number of new posts have been recruited to, but these staff have not yet started in post. The service also had a higher than usual level of staff sickness in January. Other factors include Provider system errors, in terms of identifying breaches, and a Do Not Attend (DNA) rate which reached 50% (although a high DNA rate can be anticipated for this particular service user group). Action being taken: The service will prioritise staffing resource in order to undertake any outstanding assessments to ensure the target is achieved. The DNA rates will be addressed by telephoning clients in advance of their appointments, and where appropriate, home visits will be organised as part of the triage process to support those service users who are likely to DNA. Systems and processes are being reviewed and updated to ensure information is accessible in terms of reviewing referrals accurately in relation to the waiting time standard. The CCG will robustly monitor these actions via the formal Contract Management Group, to ensure they are being implemented. Additional investment from the Governing Body are asked to Trust is expected to impact endorse the actions being taken positively on the service in and agree to accept further Quarter 4 of 2017/18. The updates as required. CCG is however aware that referrals have significantly increased to this service, and therefore we will continue to monitor waiting times. Additional analysis as requested by Governing Body on EIP patients and the length of time they were waiting: Number of EIP patients YTD (Apr17- Jan18) 0-2 weeks 100 2-6 weeks 71 6-12 weeks 21 12 weeks+ 10 Total 202 % seen in 2 weeks YTD 49.50% Improved Access to Psychological Therapies (IAPT) It is noted that the recovery rate has recently slightly reduced. As previously reported over a number of months, the service does take referrals for people with more complex needs whose recovery trajectory impacts on the achievement of this national target. However, the service also over achieves on the number of people accessing the service within a 6 week period. We are therefore looking at whether the service could separate out date and report separately on the recovery rate for people with the most complex needs, in order to not negatively impact on the recovery target for the population as a whole. As reported last month, the IAPT service has been implementing major service redesign through the delivery of 10 new long term condition pathways within STH for people with additional physical health conditions. This is being extremely well received by patients and clinicians in primary and secondary care. However, it is noted that the recruitment to new posts within this pathway and the scale of this innovative new service model has had a slight impact on the core IAPT service, as experienced clinicians move into these new areas of work. The service is introducing enhanced supervision for new staff, and scrutiny of performance and caseloads on an individual practitioner level in order to mitigate the risk of the movement of experienced staff out of core IAPT service. We continue to work closely with the provider to monitor performance. An updated position will be presented to Governing Body until this measure is consistently achieving the national target of 50% (monthly as well as quarterly). Governing Body is asked to continue to receive these updated position statements, until this standard is delivered consistently. Information and Intelligence Team, NHS Sheffield CCG Page 6

Highest Quality Health Care - Quality Dashboard Performance Indicator Reporting period Sheffield CCG Sheffield Teaching Hospital Sheffield Children's Hospital Sheffield Health & Social Care Yorkshire Ambulance Service Target / Latest data Target / Latest data Target / Latest data Target / Latest data Target / Latest data PATIENT SAFETY Patients admitted to hospital who were risk assessed for venous thromboeombolism (VTE) Q3 17/18 Target 95% 95.19% Rate of reporting of patient safety incidents per 1000 bed days, using the National Reporting and Learning System (Trusts which report a higher number of incidents tend to have a more effective safelty culture) Oct16 - Mar17 Group (Acute) 40.14 37.60 Group (Specialist) 41.73 76.95 Group (Mental Health) 44.33 59.87 Proportion of patient safety incidents resulting in severe harm or death Oct16 - Mar17 Group (Acute) 0.38 0.09 Group (Specialist) 0.21 0.00 Group (Mental Health) 1.13 1.18 Group (Ambulance) 2.35 2.23 Incidence of Healthcare Associated Infections - MRSA Feb-18 Plan 0 0 Plan 0 0 Plan 0 0 Incidence of Healthcare Associated Infections - Clostridium Difficile (Cdiff) Feb-18 Plan 16 12 Plan 7 7 Plan 0 0 Feb-18 YTD Plan 178 239 Plan 80 76 Plan 3 2 Serious Incidents - Number opened in month Serious Incidents - Never Events Feb-18 No target 4 No target 1 No target 1 No target 1 No target 0 Feb-18 YTD Target 0 7 Target 0 0 Target 0 0 Target 0 0 PATIENT EXPERIENCE Patient Reported Outcome Measures (PROMS) Patient Reported Outcome Measures (PROMS) Health gain (EQ-5D Index) - hip replacement surgery (primary) Health gain (EQ-5D Index) - knee replacement surgery (primary) Apr16-Mar17 (Feb release) Apr16-Mar17 (Feb release) 0.445 0.417 0.324 0.317 Friends and Family Test Response rate - A & E Jan-18 Target 20% 17.5% Friends and Family Test Response rate - Inpatients Jan-18 Target 30% 28.0% Friends and Family Test Response rate - Mental Health Jan-18 Friends and Family Test Proportion recommended - A & E Jan-18 Friends and Family Test Proportion recommended - Inpatients Jan-18 Friends and Family Test Proportion recommended - Mental Health Jan-18 Staff Friends and Family Test Staff Friends and Family Test Patient Complaints Proportion recommended - as a place of work Q2 17-18 Proportion recommended - as a place of care Q2 17-18 Number of complaints responded to within agreed timescale Various Internal target 85% 86.4% 86.2% 95.7% 95.1% 62.3% 70.0% 79.6% 89.7% 94% (Dec17 YTD) Internal target 85% 12.2% 2.0% 23.3% 31.0% 2.9% 19.1% 86.4% 87.0% 95.7% 75.1% 88.5% 92.3% 62.3% 64.6% 79.6% 89.7% 82% (Q2 17/18) Internal target 85% 2.9% 0.9% 88.5% 94.77% 62.3% 54.2% 79.6% 65.1% 71% (Q2 17/18) Mixed Sex Accommodation Number of breaches Jan-18 Target 0 1 Target 0 0 Target 0 0 Target 0 0 Proportion of DST's (Decision Support Tool) Continuing Healthcare (CHC) completed on patients in an acute hospital setting Q3 17-18 Target 15% 0.00% Continuing Healthcare (CHC) Proportion of Referrals completed within 28 days Q3 17-18 Target 80% 59.00% Integrated Personal Commissioning (IPC) HOSPITAL MORTALITY Summary Hospital-Level Mortality Indicator (SHMI) CHILDREN & YOUNG PEOPLE Number of open Personal Health Budgets Q3 17-18 Target 283 331 delivery time for Education Healthcare Plans (EHCP) Jul16-Jun17 Up to Feb18 Target 20 wks 29 weeks 1.0050 0.9874 Number of children and young people with a statement to be converted to EHCP all to be completed by end of March18 145 conversions to Up to Feb18 121 finalise Information and Intelligence Team, NHS Sheffield CCG Page 7

Highest Quality Health Care - Quality Dashboard Actions Area Commentary / Action being taken Expected timeframes Action requested of Governing Body Patient Safety Healthcare Q3 Root Cause Analysis needs to be undertaken and discussed, STH are Weekly monitoring. None requested. Associated aware this is required. Infections For February, STHFT remains on target with 76 cases of Clostridium Difficile (C.Diff). The agreed threshold for the end of February was 80. SCHFT are also within target having had 2 cases to date (April & January) against an annual threshold of 3 cases. For community acquired infections, the vast majority of cases are not lapses in care with no modifiable risk factors. However we are seeing a slight increase in the number of recurrences/relapses and this has also been reported locally. There are ongoing discussions with microbiology as to whether anything more can be done to try and prevent these. As happens every year there will be an annual report which is a deep dive as to the nature of the community cases with recommendations. There were zero cases of MRSA Bacteraemia in February. Never Events No "never events" have been reported for February. The figure in the dashboard shows that there have been 7 "never events" so far this year at STHFT. Weekly monitoring. None requested. Patient Experience PROMS (Patient Patients undergoing elective inpatient surgery for hip and knee Ongoing None required. Reported replacement are asked to complete questionnaires before and after their Outcome operations to assess improvement in health as perceived by the patients Measures) themselves. This is measured using a methodology called PROMS. Provisional figures (Apr 16 Mar 17) for Hip Replacement show the EQ5D measure (a combination of 5 key criteria concerning general health) flagging as an outlier (below average). The Oxford Hip score (another questionnaire that is specific to the patient s condition for measuring outcomes) is not flagging as an issue, giving some assurance to the clinical teams. STH continue to review Trust level data and pathways to identify possible areas for improvement Moving forward, The directorate will begin trialling using PROMS measures electronically as part of the MSK MyPathway. This should increase participation and response rates. School of Health and Related Research, University of Sheffield, will be supporting the clinical team to analyse PROMS data to further inform local decision making and improvements in the care/services provided. STH will be working with the national team to confirm how this will then get processed through QualityHealth and NHS. Friends and STHFT: STH triangulates and analyses a wide range of patient experience Ongoing. None required. Family Test data and takes action in response to trends identified. Response rates for FFT are good. STH closely monitors FFT response and recommendation rates and takes action when rates drop. This includes ward level improvement plans for inpatient area where the proportion of people who would not recommend the service is higher than the national average. SCHFT: SCH s Currently SCH s formal reporting does not fully triangulate complaints data with other patient experience data, but there is a monthly Care Experience Group at which themes and trends are discussed. FFT response rates for A&E and outpatients are low. Different methods of promotion and collection are being trialled to try to improve this. The FFT response rate for inpatients dropped to 13% in December 2017 but improved to 31% in January 2018. The proportion of inpatients that would recommend the Trust is low at 75%. The CCG is currently undertaking a benchmarking SHSCFT: The Trust has a Service User Engagement Strategy with an emphasis on co-production and involvement of service-users at all levels. The strategy is supported by an appropriate action plan and recent staff appointments. Progress in implementing the strategy has been limited in some areas, particularly in relation to developing robust reporting and governance structures. As a result the Trust is not able to consistently evidence service improvements resulting from experience feedback. The Trust continues to receive low numbers of responses to FFT (153 responses were received in January 2018). Information and Intelligence Team, NHS Sheffield CCG Page 8

Highest Quality Health Care - Quality Dashboard Actions Area Commentary / Action being taken Expected timeframes Action requested of Governing Body Mixed Sex A Mixed Sex Accommodation (MSA) breach has been reported for a Time specific issue, limited to None requested. Accommodation Sheffield patient for January. This breach occurred at Imperial College January 2018 only. breaches Healthcare NHS Trust, at St Mary's Hospital. The patient was a neurosurgery patient and there were unforeseen capacity problems in the neurosurgery and stroke departments, which led to a number of MSA breaches in the department, including the Sheffield patient. Continuing Healthcare (CHC) Proportion of CHC assessments undertaken in hospital The CCG introduced a new pathway in June 2017, which avoids the Decision Support Tool (DST) being completed in hospital. National evidence points to this providing a more accurate assessment of the patient's ongoing care needs. Q3 quarterly return demonstrates that 0 assessments were completed in an acute setting from October to December and this continued into January. This is very encouraging in terms of ongoing effectiveness of the new pathway in relation to meeting the Quality Premium set by NHS. Referrals completed within in 28 days Compliance against 28 day process showed in Q3 that 59% of assessments completed between October and December were completed within 28 days. This is lower than the anticipated target set by NHS of 80%, with ongoing staffing absences including maternity leave, contributing towards this result. The CCG has agreed to recruit additional staff to work in this area, in order to improve performance. Local information shows that no DSTs were completed in hospital during February. No new official data is available, the most recent quarterly data (for Q3) was reported to Governing Body last month. The most recent in month local data on 28 day compliance showed that 97% of referrals were completed within 28 days. None required. Integrated Integrated Personalised Commissioning (IPC) is a key national initiative Further guidance from NHSE None required. Personal which aims to give people more choice and control over their care, and is awaited. Commissioning care which is personalised to them. A core element of this is expanding the (IPC) number of people who have Personal Health Budgets (PHBs), both in numbers and to different client groups. Sheffield is an early adopter site and as such has agreed a cumulative target with NHS that 560 Personal Health Budgets will be in place by 31 March 2018. Sheffield delivered 331 PHBs in Quarter 3, which was above the target we agreed with NHS of 283. This was however fewer than our internal performance target of 423, as a result of which the lead managers of the work streams have submitted action plans for assurance and performance management to Mandy Philbin, Senior Responsible Owner for the IPC Programme. We have taken the precautionary position of advising the NHSE IPC Site Advisor for Sheffield there is a risk that the Quarter 4 target of 560 PHBs may be not be achieved. We have been advised that a new offer of further support and funding from the NHSE IPC team is to be made to us for 2018/19, in recognition of our advancement made towards achieving model maturity for IPC. We are awaiting further feedback form NHSE as to whether there may be an impact on this offer, should we fail to meet the PHB target in March 2018. Information and Intelligence Team, NHS Sheffield CCG Page 9

Highest Quality Health Care - Quality Dashboard Actions Area Commentary / Action being taken Expected timeframes Action requested of Governing Body Children and Young People Education Education Health Care plans (EHC plan) have been established to replace All current Statements need to None requested. Healthcare Statements of Special Educational Needs, and Learning Difficulties be converted in to the new Plans (EHCP) Assessments, for children and young people with special educational needs. EHC plans should be completed within 20 weeks, however the current EHCPs by 31 March 2018. There were 622 conversions to finalise at the beginning of average delivery time for Sheffield has been 40 weeks. The Local Authority January. The Local Authority has appointed additional staff to improve this time frame and are have appointed additional staff introducing a graduated approach to EHCP so that a majority of the work is to clear the conversions. done prior to the statutory timeframe, this is being implemented and in the There are now 145 to finalise, last two months the average completion time has reduced to 25-30 weeks. of this 121 are with families in Now that conversions are almost cleared we are seeing an improved delivery time to first time EHCP s. draft and will be finalised by the end of the financial year, There are 24 currently being drafted which may not be completed by the end of the financial year. Safeguarding Safeguarding The CCG safeguarding team are continuing to review provision by all health providers within the city whether they are contracted with or not by SCCG, to then work with them to gain assurance from a safeguarding perspective. Ongoing Governing Body to note Information and Intelligence Team, NHS Sheffield CCG Page 10

Highest Quality Health Care - Provider CQC Ratings The following table provides an overview of CQC (Care Quality Commission) inspection ratings for providers within Sheffield CCG locality. The CQC monitors, inspects and regulates health and social care services. Only providers that are rated as 'Requires Improvement' or 'Inadequate' in the month will be displayed for information in the table below. Organisation Name Provider Name Organisation Inspection Directorate Specialism / Services Date of Insepection report Overall CQC Rating CQC Rating Report Darnall Grange S & S Healthcare Limited Adult social care Accommodation for persons who require nursing or personal care, Treatment of disease, disorder or injury, Caring for adults under 65 yrs, Caring for adults over 65 yrs 30/01/2018 Requires Improvement Is the service safe? Requires Improvement Is the service effective? Requires Improvement Is the service caring? Requires Improvement Is the service responsive? Requires Improvement Is the service well-led? Requires Improvement http://www.cqc.org.uk/location/1-119175302 Dr A I McKenzie Dr Kieran Pressley Dr A I McKenzie Dr Kieran Pressley (Totley Rise Medical Centre) Primary Medical Services Primary Medical Services Diagnostic and screening procedures, Mental health conditions, Physical disabilities, Services in slimming clinics, Treatment of disease, disorder or injury, Caring for children (0-18yrs), Caring for adults under 65 yrs, Caring for adults over 65 yrs Diagnostic and screening procedures, Family planning services, Maternity and midwifery services, Services for everyone, Surgical procedures, Treatment of disease, disorder or injury 05/02/2018 09/02/2018 Focussed Inspection Requires Improvement Is the service safe? Requires Improvement Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Requires Improvement http://www.cqc.org.uk/location/1-135025013 http://www.cqc.org.uk/location/1-513865945 Chapel Lodge Roseberry Care Centres GB Limited Adult Social Care Accommodation for persons who require nursing or personal care, Diagnostic and screening procedures, Treatment of disease, disorder or injury, Caring for adults over 65 yrs 23/02/2018 Requires Improvement Is the service safe? Requires Improvement Is the service effective? Requires Improvement Is the service caring? Requires Improvement Is the service responsive? Requires Improvement Is the service well-led? Requires Improvement http://www.cqc.org.uk/location/1-308166615 Ark Home Healthcare Sheffield Ark Home Healthcare Limited Adult Social Care Eating disorders, Learning disabilities, Mental health conditions, Personal care, Physical disabilities, Sensory impairments, Substance misuse problems, Caring for adults under 65 yrs, Caring for adults over 65 yrs 24/02/2018 Requires Improvement Is the service safe? Requires Improvement Is the service effective? Requires Improvement Is the service caring? Requires Improvement Is the service responsive? Requires Improvement Is the service well-led? Requires Improvement http://www.cqc.org.uk/location/1-3147779029 Cygnet Hospital Sheffield Cygnet NW Limited Hospitals Assessment or medical treatment for persons detained under the 1983 Act, Caring for people whose rights are restricted under the Mental Health Act, Diagnostic and screening procedures, Mental health conditions, Treatment of disease, disorder or injury, Caring for adults under 65 yrs, Caring for adults over 65 yrs 28/02/2018 Focussed Inspection http://www.cqc.org.uk/location/1-222659082 Millenium House Home Alternative Adult Social Care Dementia, Personal care, Caring for adults over 65 yrs 04/03/2018 Requires Improvement Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Requires Improvement Is the service well-led? Requires Improvement http://www.cqc.org.uk/location/1-108568449 Information and Intelligence Team, NHS Sheffield CCG Page 11