AGENDA ITEM 4.2 27 th January 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) Supporting evidence 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. This report focuses on all of the above objectives. The Integrated Performance Dashboard is included as supporting evidence. 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 Integrated Performance Dashboard Page 1 of 11 University Health Board Meeting
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 (insert ) To; APPROVE ENDORSE DISCUSS NOTE 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. 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. Health and Care Standards 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 11 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 Integrated Performance Dashboard is attached as Appendix 1. The Board is requested to note and discuss 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: 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. The report also sets out a number of issues affecting performance and associated actions underway to secure improvement. 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 December showed an improvement on November figures 80.7% to 83.3%. The number of patients waiting longer than 12 hours also improved slightly from 172 in November to 170, giving a performance of 98.17%. By site the split was as follows: 4 hour Performance 12 hour Performance PCH 87.58% 46 (98.97%) RGH 79.39% 124 (97.43%) Integrated Performance Dashboard Page 3 of 11 University Health Board Meeting
Red Call Responses Red Call Performance 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, December data shows performance against the minute handover target dropped slightly from 87.3% in November to 86.6% (83.98% at PCH and 89.2% at RGH). The number of ambulances delayed over one hour 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 very variable. 100 80 76.7% RED Calls - 8 minute performance Cwm Taf Health Board Area 67.4% 77.0% 73.7% 71.1% 75.6% 83.7% 68.2% 100% 80% 60 40 20 64.3% 10 10 52.8% 17 63.5% 19 56.4% 17 14 14 10 59.3% 11 13 11 8 66.7% 14 60% 40% 20% 0 18 33 19 33 22 29 47 28 16 32 34 41 30 30 04/10 11/10 18/10 25/10 01/11 08/11 /11 22/11 29/11 06/12 13/12 20/12 27/12 03/01 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 two months. As can be seen, the all Wales average for the period has been 68.7%, which was exceeded for Cwm Taf during November. Red Calls - 8 Min Performance by HB Area 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ABMU ABHB BCU C&V CT HDd Powys All Wales Oct- Nov- Target All Wales Average (68.7%) Integrated Performance Dashboard Page 4 of 11 University Health Board Meeting
No. > 36 weeks Referral to Treatment Times (escalation level 1) Executive Lead, Chief Operating Officer Performance against the 36 week RTT target for December shows an increase in the number of patients waiting over 36 weeks from 2950 to 3091 (the table below gives the detailed breakdown by specialty). This figure remains below the submitted trajectory, which estimated the December figure to be 3200. Ophthalmology remains above the predicted level currently, but this figure includes the patients outsourced to other providers for treatment. There is a slight change to the figures reported at Executive Board due to the notification of patients treated at the alternative providers. 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 Profile Cwm Taf Actual Profile minus Ophth Actual minus Ophth The table below outlines the 36 week trend by speciality over the last 12 months: Specialty Dec 14 Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec Orthopaedics 112 184 7 144 217 309 345 379 362 343 405 399 406 General Surgery 167 190 174 133 173 195 181 200 232 202 228 200 226 Urology 12 18 29 0 13 17 38 20 20 17 25 25 38 ENT 65 105 95 25 65 103 126 213 177 172 160 146 204 Ophthalmology 1165 1324 1162 751 912 1032 1188 1356 1441 26 1603 24 18 Oral Surgery 137 133 97 84 95 87 144 183 193 180 183 173 165 Gynaecology 20 71 52 0 35 114 173 210 185 114 181 109 117 Cardiology 8 48 9 12 25 16 19 16 12 14 12 11 Rest. Dentistry 3 3 14 7 20 27 48 10 26 26 41 66 79 Gastroenterology 18 18 20 2 0 1 6 17 16 9 14 17 25 Diagnostics 1 5 11 0 0 1 2 1 2 7 0 0 0 Respiratory 8 5 4 0 0 1 0 14 0 0 0 1 2 Anaesthetics 0 0 0 0 3 8 1 0 0 1 0 2 0 Dermatology 1 2 4 0 1 5 12 14 10 10 89 185 298 General Medicine 18 0 1 0 0 0 0 0 0 2 1 0 0 Rheumatology 0 0 1 0 0 0 0 0 16 18 2 3 2 Paediatrics 0 0 0 0 0 0 0 0 0 0 2 0 0 Haematology 0 0 0 0 1 2 0 0 0 3 2 0 0 Total 1742 2066 1869 15 47 1927 2280 2636 2696 2642 2950 2862 3091 Integrated Performance Dashboard Page 5 of 11 University Health Board Meeting
The Health Board has commenced its outsourcing programme offering patients the opportunity to be treated by alternative service providers and is monitoring uptake closely. Further work is also underway to maximise internal capacity as far as is possible. 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 also monitors waiting times for patients awaiting diagnostic investigations. The maximum waiting times target is 8 weeks for the majority of the diagnostic modalities. The table below outlines the reported position at the end of December with an increase to be noted from the November position last reported. Service Investigation Total < 8 > 8 List weeks weeks 26+ 36+ Cardiology Echo Cardiogram 15 734 421 2 2 Stress Test 112 107 5 1 0 Diagnostic Endoscopy Bronchoscopy 4 2 2 1 0 Colonoscopy 392 233 9 14 0 Cystoscopy 327 128 199 45 2 Flexible Sigmoidoscopy 462 200 262 46 2 Gastroscopy 812 414 398 36 0 Imaging Fluoroscopy 296 170 126 34 12 Physiological Measurement Urodynamic Tests 95 73 22 3 0 Radiology - Consultant Referral Barium Enema 133 129 4 0 0 C.T. 810 706 104 2 2 M.R. 1241 10 226 0 0 Non-Obstetric Ultrasound 2476 1446 1030 282 53 Nuclear Medicine 44 42 2 0 0 Radiology - GP Referral Barium Enema 46 46 0 0 0 C.T. 149 137 12 0 0 M.R. 318 256 62 0 0 Non-Obstetric Ultrasound 2345 1488 857 7 24 Nuclear Medicine 4 4 0 0 0 11221 7330 3891 623 97 Although there have been increases within most modalities during December, the main issue remains with non-obstetric ultrasound (NOUS), which relates to a national shortage of sonographers. There is a local plan in place to address this issue in advance of the 31 st March but it is unlikely that this will result in the Health Board achieving the target 8 week wait in this modality. Integrated Performance Dashboard Page 6 of 11 University Health Board Meeting
Cancer 31 and 62 Day Target (escalation level 2) Executive Lead, Medical Director Unfortunately, the 31 day target was not achieved for November. The Health Board reported four breaches, three within Urology, one in Lung and one in Colorectal, with a performance of 96.4%. Two patients were treated at the tertiary centre on days 35 and 40 and one patient was treated at the Royal Glamorgan Hospital on day 46. The 62 day target was also unfortunately not achieved for November, although performance improved from the previous month at 93.4%. The Health Board reported four breaches; two were in Colorectal and one each in Urology and Lung. Two patients were treated at the tertiary centres. The table below shows the breaches by tumour site and the overall monthly performance over the last 12 months within this area: Urology Lung LGI H&N Gynae Haem Upper GI Breast Other No. Breaches Perfor mance December 1 2 1 0 0 0 0 0 0 4 94.1% 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% Total 19 17 11 7 8 2 1 0 1 67 Stroke Quality Improvement Measures (QIMs) (escalation level 1) - Executive Lead, Director of Planning and Performance During December, 50 patients have been 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 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 50.0% 97.5% 60.0% 85.0% pts Nov 60 pts 48.3% 93.3% 58.3% 83.3% Dec 50 pts 60.0% 96.0% 62.0% 72.0% Integrated Performance Dashboard Page 7 of 11 University Health Board Meeting
As can be seen from the data above, the main issues include the direct admission to the stroke unit within the required timeframe and the subsequent swallow screening assessment. The assessment by a stroke consultant and therapist also remains an issue although, it should also be noted that with the current level of cover available to the stroke service then the assessment by a stroke consultant within 24 hours will remain more problematic for patients admitted over the weekend period. Work is currently underway to investigate options for providing a more enhanced service. The Health Board also reports lower than average percentage of patients being thrombolysed. 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 improved to 81.1% in November and is compliant with the target. Performance for Part 1 Treatment target (28 days) also improved to 77.2%, despite receiving over 900 referrals during the month of November. The service is now fully recorded within the Myrddin system, which is having a positive effect on the patient pathway management. Integrated Performance Dashboard Page 8 of 11 University Health Board Meeting
Part Two of the Mental Health Measure relates to patients having a valid care and treatment plan. Performance for November improved from 79.6% to 81.2%. 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. 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 1 st April 20. The table below shows data as at 21 December 20, and illustrates a fairly static level of sickness absence from March 20 at 5.54% to November 20 at 5.73%. The more recent differences in data provided month on month are fairly negligible, refer to the end column (this information has been updated 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 days in December 2014 to 10 days in November 20. In addition, 55% of absences were entered within 7 days in November 20. Integrated Performance Dashboard Page 9 of 11 University Health Board Meeting
The three year absence trend evidences that the absence rates are lower than 2013, and since July 20 are closely mirroring the figures for 2014. Whilst the figures have increased slightly in November to 5.73%, this remains at its lowest point for the last 3 years in the comparable month of November. The comparison for the top three reasons for absence from 1 December 2014 to 30 November 20 show that anxiety/stress is the primary reason for staff to be absent with 25.57%. This has been fairly static at around this level over the last 3 years. In terms of other musculoskeletal problems, there has been an increase from 9.3% to 11.69% of staff absent. In comparing these two year period, there has been a significant decrease in the use of Unknown causes / not specified from 12.9% to 7.66% - this figure has almost halved in the last 12 months and is the result of a concerted, and very successful, effort in educating managers not to use this category when recording sickness absence. Long Term Sickness for FTE was reported at 4.6% in November 2014 and peaked in December 2014 at 5.0%, however, there was a steady decline throughout the year to 4.29% at November 20. Short Term Sickness in November 2014 was reported at 1.9% and peaked in January and February 20 at 2.1%, again there was a steady decline through the summer months down to 1.6%, and the rate in November 20 was 1.44%. Return to Work discussions are reported as 33% for the 12 month period to end of November 20, compared to 13.83% for the same period in 2013 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. Resourcing Regarding staff leaving the organisation the cumulative leavers by headcount is -79 and by FTE is -52.07. For new starters to the organisation, the cumulative starters by headcount is 67 and by FTE is 49.50. These figures are derived from 31 November 20. Average turnover for the Health Board is currently 8.3%. ESR Self Service Roll-out The current level of staff with Self Service accounts is 3,690. This represents 46.13% of the workforce. We are currently progressing with an implementation plan that would see all employees live with a self service account in the 1 st quarter of the new financial year. Recruitment Activity Performance has decreased slightly regarding NWSSP measures and days to advert stage has increased for Cwm Taf UHB from 29.9 days in October 20 to 36.5 days in November 20. For NHS Wales as a whole this figure is 24.7 days in November. Days to on-boarding stage has remained static at 24.5 days in November 20 and the NHS Wales average is 24 days. Integrated Performance Dashboard Page 10 of 11 University Health Board Meeting
Training, PDR, Appraisal and Job Plan Compliance As at 1 st January 2016 PDR compliance is 65.85%, a decrease of 1.9% since the previous month and the fourth consecutive fall, meaning a total fall in compliance of 8.2% (=606 staff) over the last four months. Whilst the majority of Directorates continue to perform above 60% compliance many have declined again this month. Directorates have declined since last month as much as 16% From the 1 st April 30 th November 20, a total of 48.91 % of doctors have had a complete annual appraisal. This includes GPs for Merthyr Tydfil and RCT. Wales Audit Office visited the UHB in November 20 as an early adopter of their Consultant Contract Benefit Realisation work. The results of the review are expected in the Spring of 2016. Occupational Health The uptake rate for the Flu Campaign at 6 January 2016 is 3759 (47.95%). Due to additional OH nurses now sufficiently skilled to undertake case management, the Insync doctor agency clinic sessions will be reduced to 3 per week from beginning of February equating to a financial saving of 2,880 per month. 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 11 of 11 University Health Board Meeting