Health Board Report INTEGRATED PERFORMANCE DASHBOARD

AGENDA ITEM 4.4 2 nd March 2016 Health Board Report INTEGRATED PERFORMANCE DASHBOARD Executive Lead: Director of Planning and Performance Author: Assistant Director of Performance and Information Contact Details for further information: Deb Evans, Assistant Director of Performance and Information 01443 744800 or email debbie.evans2@wales.nhs.uk Purpose of the Health Board Report The purpose of this report is to provide the Health Board with a summary of current performance across a range of indicators and key issues, in particular where there are current organisational challenges and achievement and/or the organisation is under formal escalation with the Welsh Government. Governance Link to Health Board Strategic Objective(s) The Board s overarching role is to ensure its Strategy outlined within Cwm Taf Cares 3 Year Integrated Medium Term Plan 20-2018 and the related organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) Triple Aim are being progressed, these in summary are: To improve quality, safety and patient experience. To protect and improve population health. To ensure that the services provided are accessible and sustainable into the future. To provide strong governance and assurance. To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. Supporting evidence This report focuses on all of the above objectives. The Integrated Performance Dashboard is included as supporting evidence at Appendix 1. Integrated Performance Dashboard Page 1 of 13 University Health Board Meeting

Engagement Who has been involved in this work? The data and information contained within the Dashboard originates from a variety of sources which have a number of engagement processes associated with them. The Integrated Performance Dashboard is also discussed monthly at the Executive Board and Finance, Performance and Workforce Sub-Committee. Health Board Resolution To; APPROVE ENDORSE DISCUSS NOTE Recommendation DISCUSS and NOTE the Integrated Performance Dashboard, this report and performance actions outlined to support the achievement of targets. Summarise the Impact of the Health Board Report Equality and diversity There are no directly related Equality and Diversity implications as a result of this report. Legal implications A number of indicators monitor progress in relation to legislation, such as the Mental Health Measure. Population Health A number of indicators monitor progress in relation to Population Health, such as vaccination and immunisation uptake rates. Quality, Safety & A number of indicators monitor progress in Patient Experience relation to Quality, Safety and Patient Experience, such as Healthcare Acquired Infection Rates and Access rates. Resources There are no directly related resource implications as a result of this report. Risks and Assurance Within the Integrated Performance Dashboard, actions are listed where performance is not compliant with national or local targets. Standards for Health Services The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care; Dignified Care; Timely Care; Individual Care; Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1 064/24729_Health%20Standards%20Framework _20_E1.pdf The work reported in this summary and related annexes take into account many of the related quality themes. Workforce A number of indicators monitor progress in relation to Workforce, such as Sickness and Personal Development Review rates. Freedom of Open information status Integrated Performance Dashboard Page 2 of 13 University Health Board Meeting

INTEGRATED PERFORMANCE DASHBOARD 1. SITUATION / PURPOSE OF REPORT The purpose of this report is to provide the Health Board with a summary of performance against a number of key quality and performance indicators, including areas where the organisation has made significant improvements or has particular challenges, together with areas where the Health Board is under formal escalation measures from the Welsh Government and/or where local progress is being monitored. The Board is requested to discuss and note the contents of the report and the supporting actions to improve the achievement of national and local targets. 2. BACKGROUND / INTRODUCTION This report provides the Health Board with an update on progress across a number of key quality and performance targets. These relate to the following organisational objectives: o To improve quality, safety and patient experience. o To protect and improve population health. o To ensure that the services provided are accessible and sustainable into the future. o To provide strong governance and assurance. o To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. The report also sets out any issues affecting performance and associated actions underway to secure improvement. A number of new workforce indicators have been added to the Performance Dashboard and are referred to later on in this covering report. These include: Resourcing staff leavers, new starters and average turnover; ESR Self Service Roll-out figures; Recruitment Activity NWSSP measures. 3. ASSESSMENT / GOVERNANCE AND RISK ISSUES KEY ISSUES: Unscheduled Care (escalation level 2) Executive Lead, Chief Operating Officer and Director of Primary Care & Mental Health Performance against the 4 hour wait in A&E for January showed a drop in comparison with December s figures of 83.3% to 82.05%. The number of patients waiting longer than 12 hours increased significantly from 170 to 313, the highest number reported during the period April 2014 to January 2016, giving a performance of 97%. This performance is reflective of the Integrated Performance Dashboard Page 3 of 13 University Health Board Meeting

Red Call Responses Red Call Performance severe pressures experienced within the Emergency Departments and on the hospital wards during this month. By site the split was as follows: 4 hour Performance 12 hour Performance PCH 84.05% 143 (96.92%) RGH 76.87% 170 (96.58%) Despite the recent increase in the number of patients waiting over 12 hours, the Health Board maintains its strict and robust approach to waits in excess of 12 hours. Analysis of all patients waiting for over 12 hours to be seen, treated and admitted or discharged will continue, with each patient reported as a clinical incident, reviewed by senior clinicians and remedial actions implemented with immediate effect. Unfortunately due to the reduction in inpatient capacity at the Royal Glamorgan Hospital the required improvement is presenting some challenges, however further work is being undertaken to minimise the impact. In terms of emergency ambulance services, despite the internal hospital pressures, January data shows performance against the minute handover target dropped only slightly from 86.6% to 84.9% (80.6% at PCH and 88.8% at RGH). The number of ambulances delayed over one hour in remained low at just two, both at PCH. As members will be aware, from October onwards the measure for monitored ambulance response times changed and only Red1 calls are monitored against an 8 minute response time. Current information is received on a weekly basis (graph shown below) and shows that performance across the Cwm Taf UHB area has been variable. RED Calls - 8 minute performance Cwm Taf Health Board Area 100 100% 80 67.4% 77.0% 73.7% 71.1% 75.6% 83.7% 80% 60 40 20 56.4% 17 14 14 10 59.3% 11 13 11 8 66.7% 68.2% 14 58.3% 58.5% 63.4% 17 60% 40% 20% 0 22 29 47 28 16 32 34 41 30 30 21 24 26 01/11 08/11 /11 22/11 29/11 06/12 13/12 20/12 27/12 03/01 10/01 17/01 24/01 Week Ending 0% Hits (responses) <8 mins Responses >8 mins Cwm Taf Performance Target All Wales Performance The graph below shows the all Wales information at Health Board level for the first three months. As can be seen, the all Wales average for the period has been 70.6%, which was exceeded for Cwm Taf during December. Integrated Performance Dashboard Page 4 of 13 University Health Board Meeting

No. > 36 weeks Performance against target 63.5% 70.30% 75.70% 80.0% 60.0% RED Calls - 8 mins performance by health board area (target 65%) October to December 20 70.6% 65% 40.0% 20.0% 0.0% Betsi Cadwaladr Abertawe Bro Morgannwg Cardiff & Vale Aneurin Bevan Powys Cwm Taf Hywel Dda Oct- Nov- Dec- All Wales Average 70.6% Target Referral to Treatment Times (escalation level 1) Executive Lead, Chief Operating Officer Performance against the 36 week RTT target for January shows an overall reduction in the number of patients waiting over 36 weeks from 3091 patients waiting to 2944 patients. Due to the delay in the notification of patients being treated at other healthcare providers, this number will remain fluid and will change even once being reported. This figure remains below the submitted trajectory, which estimated the January figure to be 3100. Ophthalmology is now also below the predicted level and this figure includes the patients outsourced to other providers for treatment. 3500 Cwm Taf RTT 36 Week Profile 20/16 3000 2500 2000 00 1000 500 0 Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan-16 Feb-16 Mar-16 Cwm Taf 36 week Profile Cwm Taf 36 week Actual Ophthalmology Profile Ophthalmology Actual Integrated Performance Dashboard Page 5 of 13 University Health Board Meeting

The table below outlines the 36 week trend by speciality over the last 12 months: Specialty Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan 16 Orthopaedics 184 7 144 217 309 345 379 362 343 405 399 406 399 General Surgery 190 174 133 173 195 181 200 232 202 228 200 226 260 Urology 18 29 0 13 17 38 20 20 17 25 25 38 52 ENT 105 95 25 65 103 126 213 177 172 160 146 204 198 Ophthalmology 1324 1162 751 912 1032 1188 1356 1441 26 1603 24 18 1423 Oral Surgery 133 97 84 95 87 144 183 193 180 183 173 165 107 Gynaecology 71 52 0 35 114 173 210 185 114 181 109 117 122 Cardiology 8 48 9 12 25 16 19 16 12 14 12 11 10 Rest. Dentistry 3 14 7 20 27 48 10 26 26 41 66 79 32 Gastroenterology 18 20 2 0 1 6 17 16 9 14 17 25 33 Diagnostics 5 11 0 0 1 2 1 2 7 0 0 0 0 Respiratory 5 4 0 0 1 0 14 0 0 0 1 2 7 Anaesthetics 0 0 0 3 8 1 0 0 1 0 2 0 0 Dermatology 2 4 0 1 5 12 14 10 10 89 185 298 300 General Medicine 0 1 0 0 0 0 0 0 2 1 0 0 0 Rheumatology 0 1 0 0 0 0 0 16 18 2 3 2 1 Paediatrics 0 0 0 0 0 0 0 0 0 2 0 0 0 Haematology 0 0 0 1 2 0 0 0 3 2 0 0 0 Total 2066 1869 15 47 1927 2280 2636 2696 2642 2950 2862 3091 2944 The numbers above also include the patients currently awaiting treatment at other Healthcare providers which at the present time is 619 of the January cohort. In order to achieve our submitted trajectory, the Health Board is scheduling additional outpatient and surgical activity during February and March. However delivery is dependent upon the availability of elective beds, which has been problematic on occasions over recent months. The monitoring of both internal and external RTT treatments is ongoing via the weekly RTT meeting, chaired either by the Assistant Director of Operations (Scheduled Care) or the Assistant Director of Performance and Information. The Chief Executive and Executive Directors are also monitoring performance at their weekly catch-up meeting. A monitoring system has been developed within the Qlik system to enable an at a glance view of progress and issues. Diagnostic Waits Executive Lead, Chief Operating Officer In addition to general RTT waiting times, the Health Board monitors the number of patients awaiting diagnostic investigations. The maximum waiting times target is 8 weeks for the majority of the diagnostic modalities. The table below outlines the provisional position at the end of January, with a decrease to be noted from the December position last reported (3891 total). Integrated Performance Dashboard Page 6 of 13 University Health Board Meeting

Service Sub-Heading Total List < 8 weeks > 8 weeks 26+ 36+ Cardiology Echo Cardiogram 1058 755 303 1 0 Stress Test 123 110 13 1 0 Diagnostic Endoscopy Bronchoscopy 3 3 0 0 0 Colonoscopy 381 212 169 27 2 Cystoscopy 284 105 179 14 2 Flexible Sigmoidoscopy 440 201 239 47 5 Gastroscopy 824 363 461 73 0 Imaging Fluoroscopy 286 3 133 52 17 Physiological Measurement Urodynamic Tests 93 57 36 3 1 Radiology - Consultant Referral Barium Enema 138 113 25 1 0 C.T. 808 681 127 2 2 M.R. 03 1416 87 0 0 Non-Obstetric Ultrasound 2371 1305 1066 201 53 Nuclear Medicine 55 50 5 0 0 Radiology - GP Referral Barium Enema 46 40 6 0 0 C.T. 175 160 0 0 M.R. 148 138 10 0 0 Non-Obstetric Ultrasound 2282 1275 1007 2 69 Nuclear Medicine 9 8 1 0 0 11027 7145 3882 574 1 The main issue remains with non-obstetric ultrasound (NOUS), which relates to a national shortage of sonographers, although the number is starting to reduce. There is a local plan in place to provide additional capacity internally and to also outsource a number of procedures to an alternative healthcare, but it unfortunately remains unlikely that this will result in the Health Board achieving the target 8 week wait. Cancer 31 and 62 Day Target (escalation level 2) Executive Lead, Medical Director The 31 day target was achieved for December. The Health Board reported two breaches, both within Urology, with a performance of 98.5%. The 62 day target was unfortunately not achieved for December, although performance of over 90% was sustained at 91.5%. The Health Board reported four breaches; one each in Colorectal, Upper GI, Gynaecology and Urology. All four patients were treated at the tertiary centres but only one was referred by the Health Board by day 31 of the pathway. The table below shows the breaches by tumour site and the overall monthly performance over the last 12 months within this area Integrated Performance Dashboard Page 7 of 13 University Health Board Meeting

Urology Lung LGI H&N Gynae Haem Upper GI Breast Other No. Breaches Perfor mance January 0 0 2 0 1 1 0 0 0 4 91.5% February 3 2 3 1 0 0 1 0 0 10 81.5% March 0 0 0 2 0 0 0 0 0 2 96.3% April 2 3 0 1 1 0 0 0 0 7 89.3% May 1 1 1 0 0 0 0 0 0 3 93.6% June 5 2 0 1 2 0 0 0 0 10 82.8% July 2 3 0 0 1 0 0 0 0 6 89.5% August 2 2 1 1 0 0 0 0 0 6 88.0% September 1 1 0 0 1 1 0 0 1 5 91.7% October 1 0 1 1 2 0 1 0 0 6 86.4% November 1 1 2 0 0 0 0 0 0 4 93.4% December 1 0 1 0 1 0 1 0 0 4 91.5% Total 19 11 7 9 2 1 0 1 67 Stroke Quality Improvement Measures (QIMs) (escalation level 1) - Executive Lead, Director of Planning and Performance During January, the Health Board saw a record number of stroke patients admitted to its Stroke Unit; 61 patients were recorded within the stroke database. This is the second monthly submission with significantly increased numbers of patients recorded, with November s 60 patients being the next highest number of stroke patients recorded in one month since our submission to SSNAP commenced. Performance against the new QIMS is shown below: Quality Improvement Measures Bundle < 4 hours < 12 hours < 24 hours < 72 hours Oct 40 pts 50.0% 97.5% 60.0% 85.0% Nov 60 pts 48.3% 93.3% 58.3% 83.3% Dec 50 pts 60.0% 96.0% 62.0% 72.0% Jan 61 pts 47.5% 98.4% 55.7% 57.4% January 2016 Integrated Performance Dashboard Page 8 of 13 University Health Board Meeting

As can be seen, the main issue remains the direct admission to the stroke unit within the required timeframe and the subsequent swallow screening assessment. In particular the services of the Speech and Language Therapy Team are having a negative impact on bundle performance. This is due to current staff shortages, which the team is working to resolve. The 24 hour assessment by a stroke consultant and therapist has been problematic during January and will remain a challenge for patients presenting in particular over a weekend period until we are able to provide a comprehensive 24/7 service cover in these areas. During January, 14 of the 61 patients arrived at the hospital over the weekend period. Without a 24/7 service the maximum performance that could have been achieved for the 24 hour bundle is therefore 77%. The Health Board also reports lower than average percentage of patients being thrombolysed, although there has been a small increase in performance during January to 6.6%. Further work is being undertaken in this area to assess the reasons for this and to establish whether there are any process issues that need to be addressed to improve the number of patients thrombolysed. Mental Health Measure - Executive Lead, Director of Primary Care & Mental Health Part One of the Mental Health Measure relates to the primary care assessment and treatment and has a target for 80% of referrals to be assessed within 28 days. Prior to October 20, the treatment element of the pathway had a target of 56 days. The assessment performance dropped to 76.5% in December from 81.1% in November and remains non-compliant with the target. Performance for Part 1 Treatment target (28 days) also improved to 86.5%, despite receiving over 900 referrals during the month. The service is now fully recorded within the Myrddin system, which is having a positive effect on the patient pathway management. Part Two of the Mental Health Measure relates to patients having a valid care and treatment plan. Performance for December dropped slightly 81.2% to 80.5%. Workforce and Organisational Development Update Executive Lead, Director of Workforce and Organisational Development Analysis is carried out regularly within the Workforce and OD Directorate on sickness absence rates, personal development review (PDR) rates and Consultant Job Plans, which is included in detail in the attached Integrated Performance Dashboard. The source of data for this analysis is ESR Business Intelligence. Integrated Performance Dashboard Page 9 of 13 University Health Board Meeting

Sickness Absence Current sickness absence activity is focussed through the Directorate s five point activity plans which are agreed jointly with managers on a monthly basis and are used as the foundation for the CBM Reports. The Health Board target is 4.5% from 1st April 20. The table below shows data as at 18 January 2016 and illustrates a fairly static level of sickness absence from March 20 at 5.55% to December 20 at 5.91%. The more recent differences in data provided month on month are fairly negligible, refer to the end column [this has been updated from last month s report to show the differences in submissions for November and December]. This is mainly due to the increased rollout of weekly E-Rostering update feeding across in a more timely fashion, and also that the BI report for the most recent months has been run after the pay run has closed (so pay card data entered by payroll is included too). Data requested later in the month improves the accuracy of the data, as the variance becomes minor. From 1st to 31st December 20 the percentages of sickness entry by Self Service was 64%, by E-Rostering 18% and by pay cards 17%. The average time to enter absence has reduced from 23.24 days in January 20 to 13.04 days in December 20. This means that 61% of absences were entered within 11 days in December 20. The three year absence trend evidences that the absence rate for December 2013 was 5.66%, for December 2014 at 6.61% and for December 20 is 5.91%. The top three reasons for absence from 1 January 2014 to 31 December 2014 showed that anxiety/stress was the primary reason for staff to be absent with 25.2%. The second reason for absence was given in the Unknown category as 11.9%, and third was other musculoskeletal problems at 9.7%. In comparison, the primary reason for absence in the Integrated Performance Dashboard Page 10 of 13 University Health Board Meeting

year from 1 January 20 to 31 December 20 shows that anxiety/stress was still the major cause at 26%, with other musculoskeletal problems showing an increase at 11.9%, and gastrointestinal problems as the third reason. In comparing these two year periods, it is now strongly evident that the category Unknown causes/not specified is no longer appearing in the top three reasons for absence. Long Term Sickness for FTE was reported at 4.91% in December 2014 and 4.66% for December 20. Short Term Sickness in December 2014 was reported at 1.71% and peaked in January and February 20 at 2.1%, again there was a steady decline through the summer months down to 1.4%, and the rate in December 20 was 1.25%. The overview of occurrences of sickness absence over the past year show that the number of occurrences of Long Term absence has reduced from 592 in January 20 to 436 in December 20, and the number of Short Term occurrences has reduced from 904 in January 20 to 646 in December 20. Return to Work discussions are reported as 34.6% for the 12 month period January 20 to December 20, compared to 16.89% for the same period in 2014. Although the number of Return to Work discussions being entered onto ESR has increased in the last 12 months, efforts are currently being focussed on ensuring managers are entering the information onto ESR. We have implemented the new All Wales sickness absence policy, and training is being rolled out to managers across the organisation. This will be reviewed over the coming months to monitor compliance and impact of the changes. Resourcing Data for staff leaving the organisation shows the cumulative leavers by headcount is -75 and by FTE is -41.71. For new starters to the organisation, the cumulative starters by headcount is 62 and by FTE is 46.50. These figures are derived from 31st of December 20. This demonstrates a small increase in FTE numbers, with turnover relatively static. ESR Self Service Roll-out The current level of staff with Self Service accounts is 3,776. This represents 47.47% of the workforce. However 88% of the workforce is managed through a Manager Self Service account, which correlates with the general improvement in data being entered into ESR. We are currently planning to accelerate the Employee Self Service uptake, in advance of the upgrade to ESR enhance (a complete system upgrade) in October. This should see significant improvement in the data from April onwards. Integrated Performance Dashboard Page 11 of 13 University Health Board Meeting

Recruitment Activity Performance has decreased slightly regarding NWSSP measures and days to advert stage has decreased for Cwm Taf UHB from 36.5 days in November 20 to 34 days in December 20. For NHS Wales as a whole this figure is 29.2 days in December. Days to on-boarding stage has remained static at 24.1 days in December 20 and the NHS Wales average is 24.3 days. Significant recruitment activity is being undertaken to improve the vacancy position with our ward based nursing establishment. We are currently recruiting from our graduate recruitment programmes locally, nationally, in EU countries and internationally. We have recently had increased success rates with our graduate recruitment locally, and we are continuing to focus on upcoming graduate cohorts. We have also had significant success with International recruitment, and this activity is being prioritised over EU recruitment where we have had lesser success. The position is improving, but will remain challenging throughout the next financial year. Medical recruitment for Consultants and Doctors remains challenging. We have had recent successes with the recruitment to long term locum posts, but the position remains difficult. With the support of our Medacs managed service provision we have managed to fill our more fragile rotas, and have not had to implement our contingency plans. Training, PDR, Appraisal and Job Plan Compliance As at 1st February 2016 compliance is 65.61%, a decrease of 0.24% since the previous month and the fifth consecutive fall, meaning a total fall in compliance of 8.89% over the last five months. Whilst the majority of Directorates continue to perform above 60% compliance many have declined again this month. 13 Directorates have declined since last month. From the 1st April 31st December 20, a total of 51.94% of doctors have had a complete annual appraisal. This includes GPs for Merthyr Tydfil and RCT. The Directorate of General Surgery, Urology and T&O commenced their job plan cycle utilising the new e-system in October 20, starting with the teams in Trauma & Orthopaedics. The Directorate of Acute Medicine and A&E commenced their job plan review cycle in December 20, and are utilising the e-job plan system to undertake and record the job plan reviews. The Directorate of Radiology and ACT are due to start their next round of job plan meetings in the Spring of 2016, and have received their training to enable the reviews to be undertaken utilising the e-job plan system. e-job Plan training for the Directorate of Mental Health is scheduled for February 2016, in readiness for the next job plan cycle at the end of the month. Integrated Performance Dashboard Page 12 of 13 University Health Board Meeting

We are accelerating the roll out of the medical and dental e-systems. This will improve the % of medical staff with a signed off Job Plan. We should begin to see the improvements significantly materialise in the 1st quarter of the new financial year. Occupational Health The uptake rate for the Flu Campaign at 3rd February 2016 is 3767 (48%) overall, Cwm Taff have reached the WG target of 50% uptake amongst frontline staff at 50.1%. Insync agency use set to reduce further to 2 sessions / week from 1st March equating to a financial saving of 12,672 per month. The intention is to cease use of Insync from April 2016 although this will be monitored closely in terms of demand, capacity, waiting lists etc. 4. RECOMMENDATION The Health Board is asked to: - DISCUSS and NOTE the Integrated Performance Dashboard, this report and performance actions outlined to support the achievement of targets. Freedom of information status Open Integrated Performance Dashboard Page 13 of 13 University Health Board Meeting