INTEGRATED PERFORMANCE REPORT BOARD OF DIRECTORS 20 September 2017 1
S Section Page Executive Summary 4 Trust Performance Overview 7 Trust Performance Report by Exception 9 MSSA Bacteraemia - Actual numbers 9 C DIFF - Actual numbers 9 Serious Incidents not approved within the timescale 10 Incidents - Incidents not approved after 35 days 10 Average Length of Stay (by discharges) - Average LoS Non Elective 11 Safety Thermometer Harm free 11 A&E 4-hour wait Percentage of Patients seen within 4 hours 12 Ambulance Turnaround - Time taken for ambulance handover of patient 15 & 30 minutes 12 18 week waits referral to treatment time Percentage of admitted patients treated within 18 weeks 13 18 week waits referral to treatment time Percentage of non-admitted patients treated within 18 weeks 13 Diagnostic waits 14 Cancelled Outpatient Appointments - Percentage of outpatient appointments cancelled by hospital 14 Cancelled Outpatient Appointments - Percentage of outpatient appointments cancelled by patient 15 e-referrals Service Utilisation - Percentage appointments booked through e-referrals Service 15 Appraisals - Completed appraisals last year 16 Directorate Dashboards 17 2
REPORT TO THE BOARD OF DIRECTORS Subject: Supporting Directors: Author(s): Status (see footnote): A* Integrated Performance Report Kirsten Major, Deputy Chief Executive; Neil Priestley, Director of Finance; Hilary Chapman, Chief Nurse; Mark Gwilliam, Director of Human Resources and Organisational Development; David Throssell, Medical Director. Balbir Bhogal, Performance and Information Director; Joanne Weaver, Senior Information Analyst; PURPOSE OF THE REPORT: To provide the Board with a detailed assessment of performance against the agreed indicators and measures. The report describes the specific actions that are under way to deliver the required standards. Note that due to the absence of a Board meeting or Finance and Performance Sub- Committee during August, this IPR does not include a Deep Dive Report. KEY POINTS: RECOMMENDATIONS The Board is asked to: a) Receive the Integrated Performance Report for June 2017. b) Note the performance standards that are being achieved. c) Be assured that where performance standards are not currently met, a detailed analysis has been undertaken and actions are in place to ensure an improvement is made. STH Strategic Aims IMPLICATIONS Tick as appropriate Meeting: 1 Deliver the best clinical outcomes Approved Y/N: Trust Executive Group APPROVAL PROCESS Finance and Performance Committee Board of Directors 2 Provide patient centred services Date: 2 August 2017 11 September 2017 20 September 2017 3 Employ caring and cared for staff 4 Spend public money wisely 5 Deliver excellent research, education and innovation A = Approval; A* = Approval and Requiring Board Approval; D = Debate; N = Note 3
EXECUTIVE SUMMARY DELIVER THE BEST CLINICAL OUTCOMES There have been 0 cases of Trust assigned MRSA bacteraemia recorded for the month of June. The year to date total is 1 case. There were 7 Trust attributable case of MSSA bacteraemia recorded in June. The full year performance is 24 cases of MSSA against an internal threshold of 10.5 cases. The Trust recorded 11 cases of C.diff for May. The full year performance is 25 cases of C.diff against an internal threshold of 20 and a NHS Improvement threshold of 22. Summary of the Healthcare Governance Committee meeting held on 19 June 2017 The Committee received a monthly update in relation to CQC compliance. No new Information of Concern (IoC) notifications had been received and there were no outstanding responses to IoC notifications. The CQC action plan continued to be monitored. An overview was provided of the CQC Celebrating Good Care leaflet, which highlighted examples of outstanding practice from CQC inspections. Two new serious incidents were reported and were currently under investigation. Seven incidents were on going, five incident reports had been completed and submitted to the CCG and no incidents were closed during the period. The six-monthly Patient Incidents, Concerns, Claims and Inquests report was presented to the Committee. It was noted that work was currently underway to align more closely the management of incidents, concerns claims and inquests and to review the management structures which support this work. The Mental Health Act Annual Update was presented to the Committee. Two of the three actions identified in the 360 Assurance audit report in February 2015 had now been completed. The third action related to training and this work was ongoing. The Committee received a presentation relating to Maternity Services. Of note was the use of the Birthrate Plus acuity tool in midwifery and the development of a Band 3 Maternity Support Worker role from September 2017. A Fire Safety update was provided to the Committee, providing assurances that there was no high-risk cladding on any of the Trust s buildings and that there are robust systems and processes in place in relation to fire prevention and management. The quarterly External Visits, Accreditations and Inspections report was presented to the Committee. During the period covered, three new action plans had been received following reports from external visits and eight action plans had been confirmed as completed. The External Visits Policy had recently been reviewed and updated. The Quarterly Trust Mortality Report was presented to the Committee and. The Trust s most recent rolling 12 month HSMR (March 2016-February 2017) was higher than expected when compared with hospital trusts nationally, however the improvement in the monthly HSMR figures was noted, and on this basis it was anticipated that the rolling 12 month metric would return to as expected with the next update. The 12-month rolling SHMI was in the as expected range and rebased. The 12-month rolling Crude Mortality rate was 3.25 for this Trust, comparable with the national rate of 3.21. A further update was to be presented to the Committee in July 2017. The 2016/17 Cancer Services Improvement Report was presented to the Committee. It was noted that this was the first year of a new process for assessment and that from next year, it was expected that there would be further alignment between the Trust s self-assessment, the Quality Surveillance Team assessment and the Peer Review schedule of visits. The Trust Clinical Audit Programme (TCAP) 2017/18 report was presented to the Committee. There were currently 311 clinical audit projects within the TCAP underway across the Trust. Local projects were a strong feature of the programme, alongside national projects. 4
PROVIDING PATIENT CENTRED SERVICES Complaints 93% of complaints were responded to within 25 working days. FFT score inpatient the score for June was 96% which is better than the internal target of 95%. FFT score A&E the score for June was 88% which is better than the internal target of 86%. Maternity score the score for June was 97% which is better than the internal target of 96%. Mixed sex the Trust reported 0 breaches in May. The internal target is 0. Referrals received during June 2017 were below the baseline level included in the Trust s plan New outpatient activity for June 2017 was 5.9% below the contract target Follow up outpatient activity for June 2017 was 1.2% below the contract target Accident and Emergency activity was on target in June 2017 Elective activity for June 2017 was 2.8% below the contract target Non-elective activity for June 2017 was 0.6% below the contract target The average number of patients who had a delayed transfer of care in June was 88 compared to 87 in May and 100 in April. The number of operations cancelled on the day for non-clinical reasons in June 2017 was 75 compared to 56 in May and 73 in April. This is the third consecutive month that the number of cancellations has been better than the threshold of 75 per month. The average length of stay for non-elective patients remains above the bench mark. In June 2017 93.13% of patients attending A&E were seen within 4 hours compared to the Sustainability & Transformation Fund agreed trajectory of 90% and the national target of 95%. There were 14 days when the Trust exceeded the 95% target. The turnaround time taken for the handover of ambulance patients improved with 80.0% occurring within 15 minutes compared to 71.0% in May. For patients where the handover time was more than 30 minutes, this indicator improved to be only 0.5% of patients. The percentage of patients who have been waiting less than 18 weeks for their treatment was 96.0% which is better than the national target (92%). The percentage of patients receiving their treatment within 18 weeks was slightly below the local targets at 87.2% for admitted patients and 94.8% for non admitted patients (compared to the targets of 90% and 95% respectively). At the end of June there were no patients waiting over 52 weeks for treatment. At the end of June the number of patients who were waiting more than 6 weeks for their diagnostic test was 96.99% which is slightly below the target of 99%. The percentage of outpatient appointments cancelled by the hospital and cancelled by patients, remain higher than the national bench mark. The percentage of patients that did not attend for their outpatient appointments was better than the national bench mark. As reported last month the Cancer Waiting Time Targets were achieved for Q4 of 2016/17 apart from the 62 days from referral to treatment (GP referral). For Q1 2017/18 the latest position (as at 21 July 2017) is 78.3% for all pathways, including those originated in other hospitals, and 85.1% for STH pathways. The percentage of appointments booked by GPs through the e-referrals service remains at around 30%. EMPLOYING CARING AND CARED FOR STAFF Sickness absence was better than target at 3.71 % this figure has improved from 3.73% in May 2017. In June short term absence has improved slightly from 1.66 % to 1.61% and long term absence has increased slightly from 2.07% to 2.10%. The Trust saw an increase over the past 4 weeks in the number of appraisals which have been carried out rising to 87.4%. The HR Operations Director is reviewing this monthly. Directorate level action plans are being established. Compliance levels for mandatory training are at 90.1%. Annual turnover rate was 7.96% and the lowest turnover rate was 5.87% amongst Healthcare Scientists. Proportion of temporary staff is 9.51%. Safer staffing overall, the actual fill rate for day shifts for registered nurses was 91.6% and for other care staff against the planned levels was 113.6%. At 5
night these fill rates were 93.9% for registered nurses and 118.7% for other care staff. In any instances where the fill rate falls below 85% the reasons for this are explored in detail at the Healthcare Governance Committee. SPEND PUBLIC MONEY WISELY The Month 3 position shows a 4,098.4k (1.6%) deficit against plan. This maintains the disappointing start to the year. There was a cumulative activity over-performance of 0.2m at Month 3 which is broadly unchanged from Month 2. There was an overspend of 0.9m (0.6%) on pay to the end of June. Medical staffing remains the main pressure area, largely due to agency costs to fill vacancies. These are in specialties where there are national workforce challenges and not unique to STH. Bank and Agency costs are 0.7m lower than for the same period last year. There was a 0.3m under delivery against efficiency plans for the first 3 months of the year. Overall, Directorates reported positions 3.2m worse than their plans at Month 3. The Financial Plan and current position assume receipt of all of the 18.6m of national Sustainability and Transformation funding (STF) available to the Trust. To receive this the Trust has to deliver a financial Control Total and, if this is met, then 30% of the STF depends on achieving A&E 4 hour target trajectories and other plans. The Control Total is a 4.2m deficit (equating to the Financial Plan deficit of 6m). The position will again be assessed on a quarterly basis but with a greater weighting placed on the later quarters. The Quarter 1 STF is likely to be achieved but this is only 15% of the annual sum. There are no issues of concern at this stage in respect of the working capital position, balance sheet or capital programme, although NHS Receivables still remain exceptionally high. The key risks for 2017/18 relate to internal delivery of activity, efficiency and financial plans; residual tariff/contracting issues; receipt of CQUIN and System Resilience funding; financial, workforce, service and infrastructure pressures; and receipt of the STF. Work is therefore required to drive activity delivery, control expenditure, mitigate possible contract income losses, improve efficiency and maximise contingencies. DELIVER EXCELLENT RESEARCH, EDUCATION & INNOVATION STH performance for 2016/17 for recruitment to trials was completed on target, as demonstrated by both the total number of patient accruals to portfolio studies and the percentage of clinical trials meeting the NIHR 70 day benchmark, which is used nationally as an indicator of efficient study setup. The number of patient accruals to portfolio adopted grant and commercial studies for 2016/17 was 11490. This was 127% of our Yorkshire and Humber Clinical Research Network target of 9000, with STH remaining one of the Network s top performers. Performance for clinical trials meeting the NIHR 70 day benchmark (from receipt of a Valid Research Application to Recruitment of First Eligible Patient) for 2016/17 was 87%. This is significantly above the NIHR national target of 80%. STH continues to maintain and excel in research performance as a result of several factors including shortened research and development setup times, active recruitment by researchers and collaborative working between the Clinical Research Office, YHCRN, and STH research facilities. 6
TRUST PERFORMANCE OVERVIEW Indicator Measure Standard Target Type CQC Compliance Outcome of CQC inspection Good in all five domains National June NHSI Segmentation Compliance with Monitor defined targets Green/Amber or better National Q1 16/17 Deliver The Best Clinical Outcomes Current Data Month Hospital Mortality HSMR As expected or lower SOF Apr-16 to Mar-17 Hospital Mortality SHMI As expected or lower SOF Oct-15 to Sep-17 Hospital Mortality HSMR (weekend only) As expected or lower SOF Apr-16 to Mar-17 MRSA bacteraemia Actual numbers Zero cases SOF June 0.00 2 MSSA bacteraemia Actual numbers Max 3.5 case a month Local June 7 24 C Diff Actual numbers June = 7 SOF June 11 25 C Diff - infection rate to be determined to be determined SOF June Serious Incidents Number of serious incidents (SI) Number Local June 5 11 Serious Incidents Approved SI Report submitted within timescales No overdue reports Local June 2 Incidents Total number of incidents reported Number of incidents reported Local June 1276 4749 Incidents Incidents not approved after 35 days Zero Local June 806 Incidents Potential under reporting of patient safety incidents to be determined SOF June Average Length of Stay (by discharges) Average LOS Elective 4.22 days (Dr Foster) Local Apr-16 to Mar-17 4.16 Average LOS Non Elective 4.90 days (Dr Foster) Local Apr-16 to Mar-17 5.39 C-Section rate Emergency Caesarean section rate as proportion of all births to be determined SOF June 17.9% 19.2% Patient Safety Alerts Number of outstanding Patient Safety Alerts Zero SOF June Patient Falls Number of patient falls 331 per month (5% reduction from 14/15) Local June 256 861 Never Events Number of never events Zero SOF June 0 3 Readmissions within 30 days Readmissions as proportion of all emergency admissions to be determined SOF June 18.2% 17.6% VTE VTE Risk Assessment completed as proportion of all inpatient admissions 95% SOF Q4 16/17 0.9521 Safety Thermometer Harm free 95% harm free National June 0.9264 Provide Patient Centred Services A&E 4-hour wait Patients seen within 4 hours 95% SOF June 0.9312982 92.0% >12 hr Trolley waits in A&E No. of patients waiting > 12 hours Zero National June 0 0 Ambulance turnaround Time taken for ambulance handover of patient 100% within 15 minutes National June 0.7797224 71.77% Ambulance turnaround Time taken for ambulance handover of patient 0% in excess of 30 minutes National June 0.0054315 0.53% 18 week waits referral to treatment time Percentage of admitted (un-adjusted) patients treated within 18 weeks 90% Local June 0.8761019 Percentage of non-admitted patients treated within 18 weeks 95% Local June 0.9477352 Percentage of patients on incomplete pathways waiting less than 18 weeks 92% SOF June 0.9595053 52 week waits Actual numbers Zero National June 0 0 6 week diagnostic waiting Percentage of patients seen within 6 weeks 99% SOF June 0.9699155 Cancelled Operations Cancelled Outpatient appointments DNA rate Cancer Waits Number of operations cancelled on the day for non clinical reasons 75 per month Local June 75 204 Number of patients cancelled on the day and not readmitted within 28 days Zero Local June 0 0 Percentage of out-patient appointments cancelled by hospital 6.64% (National figure 2014/15) Local June 0 13.14% Percentage of out-patient appointments cancelled by patient 6.20% (National figure 2014/15) Local June 0 9.73% Percentage of new out-patient appointments where patients DNA 7.72% (National figure 2014/15) Local June 0 5.86% Percentage of follow-up out-patient appointments where patients DNA 7.97% (National figure 2014/15) Local June 0 6.70% Patient seen within 2 weeks 93% National Q4 16/17 0.9632721 Breast symptomatic seen within 2 weeks 93% National Q4 16/17 0.9337349 62 days from referral to treatment (GP referral) 85% SOF Q4 16/17 0.7891738 62 days from referral to treatment (Cancer Screening Service) 90% SOF Q4 16/17 0.9318182 31 day first treatment 96% National Q4 16/17 0.9665354 31 day subsequent treatment (Surgery) 94% National Q4 16/17 0.9973118 31 day subsequent treatment (Radiotherapy) 94% National Q4 16/17 0.9476813 31 day subsequent treatment (Drugs) 98% National Q4 16/17 0.9892473 e-referral Service Percentage of appointments booked through e-referral 50% Local June 0 30.34% Ethnic Origin data collection % valid ethnic group 85% National June 1 89.29% Elective Inpatient activity Variance from contract schedules On plan Local June -2.78% -0.21% Non elective inpatient activity Variance from contract schedules On plan Local June -0.0060044-1.52% Month Actual YTD Trend Data Quality 7
TRUST PERFORMANCE OVERVIEW - continued Current Data Month Indicator Measure Standard Target Type YTD Trend Month Actual Data Quality Provide Patient Centred Services New outpatient attendances Variance from contract schedules On plan Local June -0.0585194-2.52% Follow up op attendances Variance from contract schedules On plan Local June -0.0118149 3.13% A&E attendances Variance from contract schedules On plan Local June 0.0004447-0.96% Complaints Percentage of complaints answered within 25 working days 85% answered within 25 days Local June 1 89.97% Written Complaints Rate Written complaints rate per 10,000 fces Total number upheld SOF Q2 16/17 146 FFT Recommended Patients recommending STH for inpatient treatment 95% National June 1 FFT Recommended Patients recommending STH for A&E treatment 86% National June 0.8841555 FFT Recommended Patients recommending STH for Maternity treatment 95% SOF June 0.9681093 FFT Recommended Patients recommending STH for Community treatment 95% Local June n/a Community care information completeness RTT information completeness 50% National 2016/17 64% Referral information completeness 50% National 2016/17 100% Activity information completeness 50% National 2016/17 100% Day surgery rates BADS - day surgery rates 88% Local June 0.8929106 90% Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard Zero SOF June 0 0 Employ Caring & Cared for Staff Sickness Absence All days lost as a percentage of those available 4.00% SOF June 0.0370669 3.72% Appraisals Completed appraisals in last year 90% Local June 0.8738425 Mandatory Training Overall percentage of completed mandatory training 90% Local June 0.9009113 Safer Staffing Staff Turnover Percentage of planned shifts worked by Registered Nurses/midwives during the day 85% of planned hours or greater worked Local June 0.9162636 Percentage of planned shifts worked by Registered Nurses/midwives during the night 85% of planned hours or greater worked Local June 0.9390759 Percentage of planned shifts worked by Clinical Support Workers during the day 85% of planned hours or greater worked Local June 1.1330621 Percentage of planned shifts worked by Clinical Support Workers during the night 85% of planned hours or greater worked Local June 1.1871593 Executive Team turnover to be determined SOF June 0 Number of leavers as a percentage of total head count (rolliing 12 months) to be determined SOF June 7.96% Temporary Staff Proportion of temporary staff to be determined SOF June 9.51% Agency spend Spend Public Money Wisely Distance from provider cap <=0% SOF June Agency and bank spend as a percentage of total pay budget 8% Local June 3.52% I & E YTD actual I & E surplus/deficit in comparison to YTD plan I & E surplus/deficit >=0% SOF June 1.65% I & E Margin I & E surplus or deficit asa percentage of total revenue >1% SOF June 1.65% Cost Reduction Aggressive cost reduction plans Under development SOF June Contract performance Variance from plan On plan Local June 0.08% Efficiency Variance from plan On plan Local June -7.65% Cash Actual Above profile Local June -24.20% Liquidity Days of operating costs held in cash or cash equivalents including wholly committted lines of credit available for drawdown >0 SOF June 0.40 Capital Capital Service Capacity - degree to which provider's generated income covers its financial obligations >2.5times SOF June 0.16 Expenditure - variance from plan On plan Local Q2 16/17-22.52% Distance from Plan Distance from control total or financial plan On Plan Local Q2 16/17 0.35% Deliver Excellent Research, Education & Innovation Recruitment to trials Annually Reported Indicators Total number of patient accruals to portfolio studies 9000 Regional -Y&H 2016/17 255% 70 Day Benchmark for recruitment of first patient to a clinical trial 80% National 2016/17 87% Quality recommendation % staff who would recommend STH to a friend / relative for treatment 69% SOF 2016 0.76 Work recommendation % staff who would recommend STH as a place to work 61% National 2016 0.64 Staff Engagement Staff engagement score 3.80 SOF 2016 3.82 CQC Inpatient Survey RAG rating for overall score determined by CQC to be determined SOF A = Accuracy, V = Validity, R&C = Reliability & Consistency, T = Timeliness, R = Relevance, C&C = Completeness & Coverage 8
DELIVER THE BEST CLINICAL OUTCOMES MSSA (Number) C diff (Number) 14 12 10 8 6 4 2 0 16 14 12 10 8 6 4 2 0 Cases Threshold Cases STH Threshold Lead: Hilary Chapman, Chief Nurse Timescale: March 2018 Lead: Hilary Chapman, Chief Nurse Timescale: March 2018 Key Issues: During June 2017, the Trust recorded 7 cases of MSSA. Key Issues: During June 2017, the Trust recoded 11 cases of C.diff. Key Actions: The Trust performance on rates of MSSA bacteraemia are discussed by the Infection Control Team at the monthly Infection Control Operational Group. A root cause analysis tool is being trialled to gain further information about each individual bacteraemia. Key Actions: The actions to prevent and reduce C.diff are contained within the Infection,Prevention and Control Programme. The Infection Control Operational Group have discussed the rise in cases of C.diff identified by the Trust and have considered the findings from the root cause analyses undertaken. 9
SERIOUS INCIDENT REPORTS NOT APPROVED WITHIN THE TIMESCALE (Number) INCIDENTS (Incidents Not Approved After 35 Days) 3 2 1 0 1500 1400 1300 1200 1100 1000 900 800 700 600 500 Incidents not approved within 35 days Lead: David Throssell, Medical Director Timescale: August 2017 Lead: David Throssell, Medical Director Timescale: March 2018 Key Issues: There are two incident investigations which have not been completed within the CCG 60 day timescale due to the complexity of the investigation. The CCG are aware of the delayed responses. Key Issues: There has been a small rise in the number incidents not approved within 35 days during June. The data will continue to be monitored. Key Actions: The reports are in the process of being finalised. Key Actions: Directorates continue to be provided with both weekly and monthly performance reports, to assist them in monitoring their own performance and developing improvement plans. The monthly reports are presented and discussed at each Senior Risk Management Board meeting and directorates with low compliance are required to provide detailed improvement plans. New arrangements for managing incidents not approved within 35 days were discussed at the last Safety and Risk Management Board meeting. These are now being considered at Board level and, if approved, will be implemented from September 2017. 10
NON-ELECTIVE LENGTH OF STAY (Average LOS Non Elective) SAFETY THERMOMETER (Harm Free) 6.00 5.80 5.60 5.40 5.20 5.00 4.80 4.60 4.40 0.96 0.95 0.94 0.93 0.92 0.91 0.9 0.89 0.88 0.87 Actual LOS Dr Foster Target % Harm Free Target Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Lead: David Throssell, Medical Director Timescale: September 2017 Key Issues: The average LOS continues to be above the Dr Foster target and the rolling 12 month position has varied between between 5.40 and 5.34 days for the past 12 months. Key Issues: Work is on-going to ensure consistency and accuracy of reporting across all areas Key Actions: Continued reduced volumes of delayed transfers of care are supporting efforts to bring non-elective length of stay in line with Dr Foster benchmarks. These changes are not yet apparent in the Dr Foster data due to time-lags. Analysis of the results of 78 Trust service improvement initiatives which were tested as part of Give it a Go Week 2017 during the week commencing 26th June 2017, is underway. Those initiatives which successfully improved patient flow will be further developed with a view to broader implementation into daily working patterns. The initial focus of this will be to ensure all wards have a senior clinical review of all patients every day. Key Actions: Safety Thermometer data continues to be presented and reviewed at the monthly Safer Care Committee meeting. A monthly Care Group summary of Safety Thermometer results is sent to the Nurse Directors and their deputies. Specialists of the specific harms review the reported harms each month to verify their accuracy. Any descrepancies are amended and the clinical areas that have entered the incorrect data are informed. Email reminders are sent to clinical staff to collect the data in a timely manner and to the Matron to validate. A Safety Thermometer flow chart has been created and distributed to clarify harm definitions, ongoing discussions with community based teams to standardise their practice where possible. Safety Thermometer data is also compared to available data from the Nursing and Midwifery Quality Dashboard to confirm consistency. 11
PROVIDE PATIENT CENTRED SERVICES A&E 4 HOUR WAIT (Patients Seen & Discharged or Seen & Admitted Within 4 Hours) AMBULANCE TURNAROUND (Time Taken for Ambulance Handover of Patient) Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Key Issues: The percentage of A&E attendances that were seen within 4 hours in June was 93.14%. This is above the agreed trajectrory of 90%. There were 14 days when the Trust exceeded the 95% target. Key Actions: Performance is managed daily through the Morning Operational Group Meeting. A weekly score card is now in use and discussed at a weekly performance meeting between the A&E team and the Chief Operating Officer and the Performance and Information Director. Key Issues: The percentage of ambulance patients where handover was completed within 15 minutes improved again in June to 77.97% compared to 70.98% in May and 66.59% in April. This is the highest level since September 2016. There was a slight improvement in the percentage of handovers that took longer than 30 minutes; 0.54% of patient arrivals in June compared to 0.61% in May. Key Actions: Performance is managed daily through the Morning Operational Group Meeting. A weekly score card is now in use and discussed at a weekly performance meeting between the A&E team and the Chief Operating Officer and the Performance and Information Director. The department continues to work closely with the Ambulance Service to develop and improve handover processes. 12
18 WEEKS RTT % of Admitted Patients Treated within 18 Weeks 18 WEEKS RTT % of Non Admitted Patients Treated within 18 Weeks 92.0% 90.0% 88.0% 86.0% 84.0% 82.0% 80.0% 78.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% % <18 Weeks Admitted Pathways Target % <18 Weeks Non Admitted Pathways Target Lead: Kirsten Major, Deputy Chief Executive Timescale: September 2017 Lead: Kirsten Major, Deputy Chief Executive Timescale: September 2017 Key Issues: The percentage of admitted patients treated within 18 weeks of referral in May was 87.2% which is similar to that in pervious months. Key Actions: All areas not currently meeting the required waiting times have produced revised delivery trajectories to the Waiting Times Performance Overview Group. The Group monitors progress against recovery plans on a monthly basis. Performance across all directorates is managed and maintained by the RTT (Referral to Treatment) Action Group. The utilisation of clinic and theatre capacity is monitored on a weekly basis to ensure the effective use of resources to help achieve this local target. Key Issues: The percentage of non-admitted patients treated within the 18 weeks in June was 94.8% which is a slight improvement on the Mayperfromance of 94.5%. Key Actions: All areas not meeting the required waiting time have produced delivery trajectories for the Waiting Times Performance Overview Group. The Group monitors progress against recovery plans on a monthly basis. Performance across all directorates is managed and maintained by the RTT (Referral to Treatment) Action Group. The utilisation of clinic capacity is monitored on a weekly basis to ensure the effective use of resources to help achieve this local target. In addition discussions contiune with local commissioners to ensure the appropriateness of the referrals received from primary care. 13
DIAGNOSTIC WAITS (% waiting more than 6 weeks) CANCELLED OUTPATIENT APPOINTMENTS (% of Outpatient Appointments Cancelled by Hospital) 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Seen in 6 weeks Target Actual Target (6.64%) Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Key Issues: In June 96.99% of patients were waiting less than 6 weeks for their diagnostic test compared to the target of 99%. The modalities that did not achieve the target were Echocardiography, DEXA scans and Flexible Sigmoidoscopy. Key Issues: The percentage of outpatient appointments cancelled by the hospital in June was 11.69% which is higher than the 11.18% in May. Key Actions: For Flexible Sigmoidoscopy and DEXA scans there was a temporary short fall in capacity that is being addressed. In the case of Echocardiography, an action plan is being developed to address the issue.. Key Actions: Directorates are currently reviewing the information that is now available for their areas to understand what is contributing to cancellation rates at a speciality/clinic level. 14
CANCELLED OUTPATIENT APPOINTMENTS (% of Outpatient Appointments Cancelled by Patient) e-referral SERVICE (% of Appointments Booked Through e-referral) 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Actual Target (6.20%) Actual Target (50%) Lead: Kirsten Major, Deputy Chief Executive Timescale: March 2018 Lead: Kirsten Major, Deputy Chief Executive Timescale: October 2018 Key Issues: The percentage of outpatient appointments cancelled by the patient in June was10.30% which is higher than the 10.02% in May. Key Actions: Individual care groups are investigating the reasons that patients cancel their appointments. The use of the remind system is being reviewed to ensure that requests from patients to rearrange their appointment are followed up. Further analysis is to be undertaken at a specialty level to determine what impact communication with patients regarding appointments has on the rate of cancellations. Key Issues: The percentage of outpatient appointments that took place in June that were booked through the e-referral Services (e-rs) was 30.85% compared to 30.19% in May Overall the level has remained steady at around 30% for the past 12 months. Key Actions: The Trust has established a task and finish group to understand current baselines and specific actions to increase utilisation. The first meeting of the group was held in May. Directorates have completed a template indicating when they expect all of their clinic slots to be released to e-rs. The CQUIN requires that the Trust has all of its consultant-led first outpatient services available on the e-referral Service for GPs to book into. There are plans in place for this to be achieved by March 2018 in line with the CQUIN timetable. 15
EMPLOY CARING AND CARED FOR STAFF APPRAISALS (Completed Appraisals in Last 12 months) 92.00% 90.00% 88.00% 86.00% 84.00% 82.00% 80.00% 78.00% % Staff with Appraisals Target (90%) Lead: Mark Gwilliam, Director of Human Resources Timescale: March 2018 Key Issues: The cumulative position for completed appraisals during the past twelve months at the end of June is 87.4 % compared to the target of 90%; focus will continue on the achievement of this target. Key Actions: Directorates have developed action plans in conjunction with their HR Business Partners in order that they can achieve compliance of the target in 2017/18 this will include the need to realign the timing of appraisals. 16
APPENDIX 2: DIRECTORATES DASHBOARD Indicator Measure Diab & Endo Emerg Med Gastro Pharm Resp Med Integ Comm Care GSM Prim Care & Int/Serv Therap & Pall Care CCDS ENT Neuro Ophthal MRSA bacteraemia Actual numbers 0 0 0 0 1 0 0 0 0 MSSA bacteraemia Actual numbers 3 2 3 3 2 0 0 0 0 C Diff Actual numbers 2 0 3 2 7 1 0 0 0 Serious Incidents Approved SI Report submitted within timescales 0 0 0 0 0 0 0 0 0 1 0 0 0 Serious Incidents Number of serious incidents (SI) 0 0 0 0 0 0 1 0 0 0 1 0 2 Incidents Number of Incidents 131 128 106 100 163 183 619 99 76 122 73 190 42 Incidents Incidents not approved after 35 days 15 194 10 17 27 63 57 9 3 22 18 17 9 Average Length of Stay (by discharges) Average LOS Elective -1.14-13.26-1.41 0.96 34.61 22.28 0.59 0.40-1.80-0.44 Average LOS Non Elective 1.92-2.81 0.94 0.28 5.94 16.67-1.15-0.49-0.61-0.48 Patient Falls Number of patient falls 63 11 35 0 56 7 258 8 17 0 17 55 2 Never Events Number of never events 0 0 0 0 0 0 0 0 0 0 0 0 2 18 week waits referral to treatment time Percentage of admitted (unadjusted) patients treated within 18 weeks (90%) 100.00% 100.00% 96.97% 100.00% 79.32% 96.41% 93.48% 82.68% Percentage of non-admitted patients treated within 18 weeks (95%) 98.86% 100.00% 92.86% 100.00% 95.95% 89.47% 97.94% 95.30% 93.97% Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 99.56% 100.00% 99.45% 100.00% 100.00% 94.58% 98.79% 97.51% 95.34% 52 week waits Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 6 week diagnostic waiting Percentage of patients seen within 6 weeks 99.18% 99.28% 100.00% Cancelled Operations Number of operations cancelled on the day for non clinical reasons 9 2 10 41 Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 Percentage of out-patient appointments cancelled by hospital Cancelled Outpatient appointments 6.53% 0.05% 19.54% 14.28% 9.46% 9.11% 13.08% 12.98% 11.93% 6.57% Percentage of out-patient appointments cancelled by patient 11.62% 0.16% 9.06% 12.87% 15.91% 11.98% 14.05% 12.20% 12.46% 10.80% DNA rate Cancer Waits Percentage of new out-patient appointments where patients DNA 9.60% 7.42% 12.01% 11.08% 10.83% 10.42% 4.93% 9.47% 5.22% Percentage of follow-up out-patient appointments where patients DNA 8.10% 6.24% 8.22% 12.62% 7.20% 10.53% 7.29% 11.81% 4.05% Patient seen within 2 weeks (93% compliance) 50.00% 100.00% 100.00% 100.00% 100.00% 100.00% Breast symptomatic seen within 2 weeks (93% compliance) 62 days from referral to treatment (85% compliance) 0.00% 0.00% 0.00% 0.00% 50.00% 0.00% 31 day first treatment (96% compliance) 100.00% 100.00% 0.00% 0.00% 50.00% 0.00% e-referral Service Percentage of appointments booked through e-referral 12.37% 22.09% 19.69% 15.83% 0.32% 55.96% 1.95% 36.58% Ethnic Origin data collection % valid ethnic group (85%) 95.10% 92.78% 89.29% 96.00% 85.47% 88.34% 86.05% 88.00% Elective Inpatient activity Variance from contract schedules -34.56% -100.00% 0.15% 2.69% -1000.00% -7.28% -4.98% 10.07% 4.16% Non elective inpatient activity Variance from contract schedules 4.88% -16.06% -6.90% -9.92% 10.29% 39.03% 14.49% 36.30% -12.56% -21.19% New outpatient attendances Variance from contract schedules 2.14% 1.29% 20.55% 13.58% -4.65% -3.13% -2.85% -14.87% -9.67% 7.10% Follow up op attendances Variance from contract schedules 10.82% 86.60% 0.35% 24.06% -5.04% -1.65% 5.65% 3.73% 14.14% 6.76% Complaints Percentage of complaints answered within 25 working days 100% 64% 77% 100% 93% 100% 94% 100% 100% 83% 88% 95% 100% FFT Recommended Patients recommending STH for treatment n/a n/a n/a n/a n/a n/a Day surgery rates BADS - day surgery rates 1 0 0 0 0 0 Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0 0 Sickness Absence All days lost as a percentage of those available 5.08% 3.24% 3.91% 2.78% 4.22% 4.37% 5.24% 4.13% 3.38% 3.83% 4.75% 3.61% 3.21% Appraisals Completed appraisal in last year 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% 88.89% Mandatory Training Overall percentage of completed mandatory training 88.38% 76.16% 87.40% 98.04% 87.97% 84.05% 84.29% 88.95% 93.19% 88.48% 91.45% 91.55% 93.26% Agency spend Agency and bank spend as a percentage of total pay budget 7.84% 8.95% 4.94% 0.22% 9.43% 3.23% 9.54% 1.10% 0.49% 0.12% 7.19% 1.04% 7.65% I & E Variance from plan -3.56% 2.19% -5.24% 0.16% -6.45% 2.76% 0.31% 1.58% 1.38% 3.83% 12.58% 7.78% -3.02% Contract performance Variance from plan 4.06% -1.35% 2.18% -860.13% 0.17% 0.00% 7.84% -3205.38% 3.28% -0.75% -1.56% 0.06% 1.71% Productivity & Efficiency Variance from plan 145.19% 15.14% 8.38% -7.36% -36.72% -88.24% -6.47% -2.70% -2.56% -30.64% -70.64% -67.21% -42.90% Performance is YTD unless specified: Last complete month Rolling 12 months Current quarter to date 17
APPENDIX 2: DIRECTORATES DASHBOARD - continued Indicator Measure Lab Med MIMP OGN MSK OSSCA Cardiac Renal Vasc Comm Dis & Spec Med Spec Rehab Spec Cancer Gen Surg Plastic Surg MRSA bacteraemia Actual numbers 0 0 0 0 0 1 0 0 0 0 0 0 MSSA bacteraemia Actual numbers 1 2 1 1 2 2 0 0 0 2 0 0 C Diff Actual numbers 0 1 0 1 1 0 0 2 1 4 0 0 Serious Incidents Approved SI Report submitted within timescales 0 0 3 0 0 1 0 0 0 0 0 0 0 0 Serious Incidents Number of serious incidents (SI) 0 0 1 0 0 2 0 0 0 0 0 4 0 0 Incidents Number of Incidents 314 176 336 374 322 237 133 70 188 74 156 176 19 44 Incidents Incidents not approved after 35 days 25 2 38 35 21 5 2 4 51 19 34 46 7 4 Average Length of Stay (by discharges) Average LOS Elective -0.31-0.20 0.00 0.83-4.79-0.39-1.43 11.02-0.87 1.13-0.03 0.59 Average LOS Non Elective 0.08 1.51 6.91 0.59 0.65 2.22 0.82 91.16-1.67-0.23-0.04-1.06 Patient Falls Number of patient falls 0 3 14 100 4 39 27 22 28 10 40 31 4 10 Never Events Number of never events 0 0 0 0 0 1 0 0 0 0 0 0 0 0 18 week waits referral to treatment time Percentage of admitted patients treated within 18 weeks (90%) 80.40% 89.55% 71.89% 100.00% 80.26% 91.57% 98.86% 86.35% 97.91% 96.70% Percentage of non-admitted patients treated within 18 weeks (95%) 100.00% 96.58% 94.02% 100.00% 83.90% 100.00% 87.26% 96.19% 99.15% 95.51% 99.06% 98.35% Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 97.39% 100.00% 93.24% 93.82% 71.43% 93.28% 96.65% 99.44% 94.68% 99.63% 52 week waits Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 week diagnostic waiting Percentage of patients seen within 6 weeks 100.00% 95.25% 67.31% 98.88% Cancelled Operations Number of operations cancelled on the day for non clinical reasons 48 47 5 22 10 4 Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 0 0 0 0 Percentage of out-patient appointments cancelled by hospital Cancelled Outpatient appointments 6.32% 7.48% 11.57% 9.91% 17.87% 15.37% 15.28% 9.67% 14.33% 8.76% 12.95% Percentage of out-patient appointments cancelled by patient 15.52% 6.98% 9.84% 6.08% 8.84% 10.49% 8.72% 16.83% 13.52% 10.74% 15.05% DNA rate Cancer Waits Percentage of new out-patient appointments where patients DNA 15.29% 6.05% 3.85% 5.79% 12.22% 4.68% 10.72% 7.78% 7.03% 3.81% 10.61% Percentage of follow-up out-patient appointments where patients DNA 9.80% 3.10% 9.15% 4.23% 9.42% 4.37% 6.34% 9.08% 5.48% 7.27% 6.32% Patient seen within 2 weeks (93% compliance) 100.00% 100.00% 33.33% 100.00% 66.67% 100.00% Breast symptomatic seen within 2 weeks (93% compliance) 100.00% 62 days from referral to treatment (85% compliance) 100.00% 0.00% 66.67% 38.46% 0.00% 66.67% 0.00% 31 day first treatment (96% compliance) 0.00% 100.00% 66.67% 69.23% 100.00% 100.00% 50.00% e-referral Service Percentage of appointments booked through e-referral 16.82% 28.64% 20.38% 65.32% 35.76% 53.17% Ethnic Origin data collection % valid ethnic group (85%) 94.08% 90.46% 83.58% 88.77% 90.00% 90.36% Elective Inpatient activity Variance from contract schedules 18.74% -1.81% -3.01% -11.19% -6.89% -5.84% -0.29% -8.65% 0.70% -6.89% Non elective inpatient activity Variance from contract schedules -1.73% 3.00% -0.34% -6.53% -2.00% 13.13% 3.79% 0.46% -24.05% 16.53% New outpatient attendances Variance from contract schedules 8.05% -5.10% -0.33% -69.39% -1.19% -17.59% -5.02% -7.52% 8.68% 2.99% -2.84% 1.82% -11.47% Follow up op attendances Variance from contract schedules -24.29% 5.75% 1.90% 32.10% -3.73% -6.04% -2.13% -0.31% -2.97% 3.87% -12.21% 0.54% -2.75% Complaints Percentage of complaints answered within 25 working days 100% 100% 100% 96% 80% 93% 100% 80% 100% 100% 100% 83% 83% 86% FFT Recommended Patients recommending STH for treatment n/a n/a n/a n/a n/a n/a Day surgery rates BADS - day surgery rates 0 0 0 0 0 0 0 0 0 0 0 Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0 Sickness Absence All days lost as a percentage of those available 2.78% 3.33% 4.35% 3.23% 4.38% 3.10% 3.19% 2.91% 3.34% 6.31% 4.32% 3.18% 1.92% 3.06% Appraisals Completed appraisal in last year 88.00% 94.89% 84.97% 87.33% 90.02% 72.25% 83.39% 77.38% 89.14% 92.36% 82.02% 88.26% 94.57% 95.65% Mandatory Training Overall percentage of completed mandatory training 95.01% 96.02% 88.68% 91.83% 91.17% 86.53% 89.98% 91.02% 92.08% 86.87% 90.20% 93.35% 87.81% 89.39% Agency spend Agency and bank spend as a percentage of total pay budget 0.35% 0.72% 2.16% 4.45% 3.73% 4.37% 1.45% 6.75% 3.50% 8.43% 9.86% 5.64% 0.09% 3.80% I & E Variance from plan -3.12% -3.59% 2.89% -1.98% 6.17% 4.93% 3.16% 8.34% 7.65% 8.85% 5.09% 11.40% 0.51% 2.00% Contract performance Variance from plan 3.17% 22.28% -1.11% -0.22% 13.58% 1.38% 0.36% -2.45% 0.09% -1.03% 0.92% -2.97% -0.22% -1.54% Productivity & Efficiency Variance from plan -1.33% 15.79% 52.92% 56.39% -0.89% -14.72% 3.53% -21.68% -76.61% 2.55% 268.97% 0.50% 227.49% 43.81% Urology Performance is YTD unless specified: Last complete month Rolling 12 months Current quarter to date 18