Appendix 2 NHS South Gloucestershire CCG and North Bristol NHS Trust Performance Update 1. Introduction The purpose of the report is to provide a summary overview of current performance concerns at North Bristol NHS Trust (NBT) to inform discussions on performance at the NBT Integrated Contract Quality and Performance Management Board Meeting being held on 17 June 2014. 2. Executive Summary NBT Key Performance and quality issues summary and actions Ambulance handovers R 51.58% failed against 10% target (18/05/14). YTD 2014/15 stands at 52.08%. NBT will be exposed to handover fines from SWASFT. Improvement in performance is linked to improved patient flow. 4 Hour Wait R As of week ending 25 May 2014, NBT is failing at 90.34% against a target of 95%. YTD 2014/15 stands at 92.37% - failed. Improvement in performance is linked to improved patient flow. There is no indication of when this target will be sustainably met. Issues include high % occupied bed days and high levels of >14 day LOS. RTT A The Trust has underachieved the incomplete RTT standard at aggregate level in April 2014 and in the year to date for admitted and incomplete pathways. Specialty level performance is underperforming in the following areas: o Admitted pathways: Trauma & Orthopaedics; and Neurosurgery. o o Non-admitted pathways: Neurology; Neurosurgery and Trauma & Orthopaedics. Incomplete pathways: Trauma & Orthopaedics; Neurosurgery; Urology; Plastic Surgery. Diagnostic breaches A Underachieved in April 2014 with 98.90% patients seen in 6 weeks (target is 99%). Test level performance is underperforming in the following areas: o Cystoscopy; CT; MRI; and Urodynamics. Cancer A The Trust has underachieved against the <31 day 1 st treatment and <62 day urgent GP referrals standards in February 2014. The main issue was with the urology pathway and late referrals into the Trust. Also, shared breaches relating to lung and upper GI. C Diff G NBT has recorded 4 cases of CDIFF in April 2014. The annual limit is 79 cases. Never Events R 1 Wrong Site Surgery Never Event reported in April 2014 for a South Gloucestershire patient. South Gloucestershire CCG Leading you to Better Health Clinical Chair: Dr Jon Hayes Chief Officer: Jane Gibbs
3. Urgent Care Performance Ambulance Handover es Please note that the national contract standard for ambulance handovers remains at 15 minutes. However, in 2014/15, breaches will not have consequences in terms of penalties unless they take longer than 30 minutes. Achieved <= 10% Underachieved 15% to 10% Failed >15% No more than 10% of ambulance handovers to be completed in more than 15 minutes Current Performance 51.58% (w/e 18/05/2014) YTD 2014/15 52.08% The ambulance handover target (max 10% of all ambulance handovers to take longer than 15 minutes) is currently being failed with performance at 51.58% in the most recent week for which data is available at the time of writing (18/05/2014). Paper Page 2 of 21
Provider / Commissioner Actions? NBT and commissioners met at the end of May 2014 to agree a series of actions in order to recover ambulance handover performance in the new hospital. These are as follows: A small group within NBT to focus on technical handover improvements ie ED processes Development of a whole hospital response (operating policy) to ambulance delays. Agreement of a communications approach (Baton radio page) between NBT and SWASFT A recovery trajectory has been drafted for agreement in June 2014 Handover delays remain part of the agenda for NBT / CCG / TDA / Area Team escalation meetings. Given the continuing poor performance at NBT daily performance teleconferences are being instituted. Timeframe for Resolution? Dependant on agreement of trajectory as above. Paper Page 3 of 21
A&E 4 Hour Performance Achieved >= 95% Underachieved 94% to 95% Failed <94% 95% of all patients to be seen, treated, admitted or discharged within 4 Hours of arrival at A&E Current Performance 86.51% (w/e 25/05/2014) YTD 90.34% 2013/14 Full Year 92.37% Paper Page 4 of 21
Performance for the last 8 weeks Week ending Total A&E Attendances Waiting over 4 hours Decided to Admit/ Discharge within 4hrs % Compliant 06 Apr 14 1901 206 1695 89.16% 13 Apr 14 1747 160 1587 90.84% 20 Apr 14 1814 81 1733 95.53% 27 Apr 14 1857 164 1693 91.17% 04 May 14 1721 154 1567 91.05% 11 May 14 1848 291 1557 84.25% 18 May 14 1751 102 1649 94.17% 25 May 14 1638 221 1417 86.51% Total YTD 2014/15 14,277 1379 12,898 90.34% Paper Page 5 of 21
The Trust failed to meet the 95% standard in April 2014 with performance of 91.28% (673 breaches). There has been a further decline in performance across May and in to June 2014. Provider Actions? The Trust has developed an internal ED recovery action plan. This has been shared with the TDA. 5 distinct workstreams have been identified: Emergency & Acute Medicine Departments; Patient Flow; Discharge; Corporate; and Health System and other provider actions. Responsible staff and an Executive Lead have been identified against every action. The internal action plan is currently being revised and a whole system recovery plan being put together. Commissioner Actions? The following initiatives have been in place since December 2013 and are currently being evaluated. The GP rapid response at SWASFT; Communications Campaign; Additional non-acute bed capacity to provide interim social care/community placement; Enhanced Primary Care Capacity; Extended Front Door Pilot; Evolving Assessment Process; Enhanced operational capabilities for nursing and residential homes to care for more complex patients; 24/7 access to Professional Line by all health care professionals including nursing homes; and Elements of the 7 Day working programme. The System Flow Partnership Board is monitoring and tracking the delivery of these initiatives against agreed measures and KPIs Given the continuing poor performance against this standard in the new hospital, commissioners are escalating concerns through contractual means and working with the Trust, TDA and Area Team to secure a recovery trajectory. Timeframe for Resolution? The Trust is working to deliver all of the plans (ECIST, Recovery and Winter Plans) in place to meet the 95% standard on an ongoing basis. There is no indication of when this target will be sustainably met. The Trust forewarned that although progress continues on 4 hour performance, transfer to the new hospital would affect short term performance and this is proving to be the case. Paper Page 6 of 21
> 12 hour Trolley Waits Current Performance 1 in April 2014 YTD 1 There was 1 reported 12 hour trolley wait in April 2014. The incident occurred in March but was reported in April. The breach occurred due to pressure and difficulty creating capacity. A plan was formulated but not actions in a timely way with a delay in the patients being transferred from ED. The RCA has been shared with the emergency department and a discussion undertaken with the matron for department readiness of patients to leave in times of pressure. The accurate process for reporting a breach has been reiterated to the relevant staff. There have been 0 recorded breaches in May 2014. Paper Page 7 of 21
Planned Care Performance NBT Reported RTT Position Measure Jan-14 Feb-14 Mar-14 13/14 Apr-14 14/15 Admitted Pathways 88.01% 90.52% 90.48% 89.92% 90.87% 90.87% Non-Admitted Pathways 94.16% 94.65% 95.37% 96.13% 95.79% 95.79% Incomplete Pathways 88.42% 87.95% 89.29% 91.11% 89.07% 89.07% The Trust reported position has been taken from the Contract Monitoring information provided by the Trust Analysts. Non-commissioned activity is removed from all reported positions. The Trust has underachieved against one of the three pathway standards in April 2014 and for the full year of 2013/14 for admitted and incomplete pathways. The Trust has stated that this is principally due to issues in Trauma and Orthopaedics and Urology. Additional capacity is being planned in T&O, urology, neurology and plastic surgery. The Trust invited the Elective Care Intensive Support Team into the Trust for 3 days of diagnostics resulting in a report containing key recommendations for improvements. Commissioners had the opportunity to meet with the Intensive Support Team and share perspectives on 8 April 2014. The final report has been received by commissioners. The report includes 29 recommendations and the offer of further support from the IST to develop NBT s performance management systems. Full recovery plans which are robust, clear and analyse the case mix will be prepared by NBT by 9 July for commissioners where upon they will interrogate and challenge the analysis to agree with the Trust an improvement trajectory for both aggregate RTT and across 4 specific specialties that will deliver by 13 March 2015. The exception to this is complex spinal work which commissioners are supporting NBT to deliver through a new pathway however, it is not known when the impact of this will not be realised. Paper Page 8 of 21
18 Week Referral to Treatment Long Waiters 40-52 Week Waiters as at April 2014 Measure NBT Number 40-52 Weeks Admitted (unadjusted) Pathways 48 Non-Admitted Pathways 15 Incomplete Pathways 260 26 x Trauma and Orthopaedics 15 x Urology 3 x Plastic Surgery 3 x Neurosurgery 1 x Other 12 x Trauma and Orthopaedics 1 x Plastic Surgery 1 x Neurology 1 x Gynaecology 181 Trauma and Orthopaedics 30 x Urology 26 x Plastic Surgery 8 x Neurosurgery 6 x Other 4 x Thoracic Medicine 2 x Dermatology 1 x Cardiology 1 x Gastroenterology 1 x Neurology Over 52 Week Waiters as at April 2014 Fines only apply to over 52 week waiters on an incomplete pathway. Measure NBT Number Over 52 Weeks Admitted (unadjusted) Pathways 15 12 x Trauma and Orthopaedics 1 x Urology 1 x Plastic Surgery 1 x Neurosurgery Non-Admitted Pathways 2 2 x Trauma and Orthopaedics Incomplete Pathways 85 84 x Trauma and Orthopaedics 1 x Other The majority of long waiters in April are within the Trauma and Orthopaedics specialty (98) with nearly all on incomplete pathways waiting for spinal surgery. Paper Page 9 of 21
18 Week Referral to Treatment Admitted Pathways as at April 2014 Achieved >= 90% Underachieved 85% to 89.9% Failed <85% CCG By Provider for CCG % < Total 18 Weeks % < 18 Weeks By Provider for ALL Total YTD South Glos 92.39% 762 58 Bristol 90.76% 877 81 North Somerset 88.95% 362 40 Somerset 92.59% 108 8 Wiltshire 91.89% 74 6 BANES 89.89% 89 9 Swindon 100.00% 8 0 90.87% 2442 223 90.87% Gloucestershire 86.36% 88 12 North, East and West Devon South Devon and Torbay 80.00% 20 4 100.00% 5 0 Kernow 88.89% 9 1 Other 90.00 40 4 Note: NBT are not currently able to split out Specialised Commissioning activity, therefore it is recorded within other and the associate CCG lines. Paper Page 10 of 21
The speciality level exceptions are shown in the table below: Specialty % < 18 Weeks Total Trauma & Orthopaedics 80.11% 538 107 Revised trajectory to be provided by NBT to the CCG by 30 June 2014. Alongside a robust action plan for delivery current performance expected to decrease and treatment of urgent and long waiters has been prioritised in addition, performance will be affected by the move and reduction in theatre capacity in May 2014. Neurosurgery 88.07% 109 13 Neurosurgery has narrowly missed the 90% standard in April. The Trust has attributed underperformance to the reduced number of patients treated within the month. Commissioners have requested the Trust s trajectories to March 2015 and in particular the Quarter 1 plan to fail trajectories submitted to the TDA, which are for orthopaedics, urology and neurology. The Trust has stated that detailed plans will be completed by the end of quarter 1 2014/15. Commissioners are currently in discussion with the Area Team regarding the trajectories and has committed to sharing the Trust s plans and commissioner actions to support NBT in their future delivery of RTT performance. Paper Page 11 of 21
18 Week Referral to Treatment Non-Admitted Pathways as at April 2014 Achieved >= 95% Underachieved 90% to 94.9% Failed <90% Provider By Provider for CCG % < Total 18 Weeks % < 18 Weeks By Provider for ALL Total YTD South Glos 97.42% 2980 77 Bristol 95.78% 3577 151 North Somerset 93.69% 1126 71 Somerset 90.53% 285 27 Wiltshire 94.70% 151 8 BANES 94.27% 192 11 Swindon 94.59% 37 2 95.78% 8838 373 95.78% Gloucestershire 94.82% 251 13 North, East and West Devon South Devon and Torbay 94.44% 54 3 100.00% 15 0 Kernow 86.96% 23 3 Other 95.24% 147 7 Note: NBT are not currently able to split out Specialised Commissioning activity, therefore it is recorded within other and the associate CCG lines. Paper Page 12 of 21
The speciality level exceptions are shown in the table below: Specialty % < 18 Weeks Total Neurology 89.93% 427 43 There are outpatient capacity shortfalls which are being progressed through an action plan in conjunction with commissioners. Recruitment is underway for additional medical staff. Neurosurgery 93.24% 222 15 A business case is being prepared to increase capacity. Trauma & Orthopaedics 85.49% 1275 185 Revised trajectory to be provided by NBT to the CCG by 30 June 2014 alongside a robust action plan for delivery current performance expected to decrease and treatment of urgent and long waiters has been prioritised in addition, performance will be affected by the move and reduction in theatre capacity in May 2014. Paper Page 13 of 21
18 Week Referral to Treatment Incomplete Pathways as at April 2014 Achieved >= 92% Underachieved 87% to 91.9% Failed <87% Provider By Provider for CCG % < Total 18 Weeks % < 18 Weeks By Provider for ALL Total YTD South Glos 91.76% 9052 746 Bristol 88.41% 11600 1345 North Somerset 87.79% 4307 526 Somerset 88.06% 871 104 Wiltshire 88.71% 629 71 BANES 88.89% 765 85 Swindon 81.52% 92 17 89.03% 28951 3176 89.03% Gloucestershire 82.22% 821 146 North, East and West Devon South Devon and Torbay 82.89 % 187 32 83.10% 71 12 Kernow 85.59% 118 17 Other 92.88% 438 75 Note: It is not possible to identify Specialised Commissioning activity on an incomplete pathway; therefore it is recorded within other and the associate CCG lines. Paper Page 14 of 21
The speciality level exceptions are shown in the table below: Specialty % < 18 Weeks Total Trauma & Orthopaedics 68.71% 5181 1621 Revised trajectory to be provided by NBT to the CCG by 30 June 2014. Alongside a robust action plan for delivery current performance expected to decrease and treatment of urgent and long waiters has been prioritised in addition, performance will be affected by the move and reduction in theatre capacity in May 2014. Neurosurgery 87.57% 957 119 Spinal surgery capacity is at the root of the problem. The Trust is working with other providers and commissioners to identify additional capacity and streamline the pathways to help meet the target. Further work is being outsourced in order to target particular backlog problems. Progress is being made to clear the backlog, although emergency bed pressures within the speciality are preventing the level of progress needed. Urology 85.65% 4424 635 A detailed piece of work is being undertaken by the Trust to understand the recurrent levels of demand and capacity within the service. As a result of this review both staffing and process issues have been exposed. Significant training issues have been identified. There has been a knock on effect to the cancer pathways and meeting the wait time standards. The Trust has put in place additional capacity for 3 months and has experienced staff involved in resolving the issues. Urology is one of the services which were transferred from UHBT at the beginning of the year. An additional consultant is due to start in August. There will be a review of administrative process and further work to ensure correct application of the patient access policy. Commissioners will continue to support with ISTC utilisation. Plastic Surgery 87.22% 2050 262 Within the new hospital, plastic surgery will be working with dermatology to improve the timeliness for patient pathways. Both dermatology and plastic surgery have seen significant growth in skin cancer referrals in 2013/14. Paper Page 15 of 21
Diagnostic > 6 week waiters as at April 2014 Achieved >= 99% Underachieved 94% to 98.9% Failed <94% Provider By Provider for CCG % < Total 6 Weeks % < 6 Weeks By Provider for ALL Total YTD South Glos 98.25% 3021 53 Bristol 97.27% 2819 77 North Somerset 98.17% 874 16 Somerset 97.89% 95 2 Wiltshire 98.84% 86 1 BANES 97.20% 107 3 Swindon 100.00% 3 0 97.78% 7197 160 N/A Gloucestershire 95.38% 130 6 North, East and West Devon South Devon and Torbay 100.00% 10 0 100.00% 0 0 Kernow 80.00% 5 1 Other 97.87% 47 1 Note: NBT are not currently able to split out Specialised Commissioning activity, therefore it is recorded within other and the associate CCG lines. Paper Page 16 of 21
The exceptions by diagnostic test type are shown in the table below: Diagnostic Test % < 6 Weeks Total Cystoscopy 88.50% 200 23 The underperformance in cystoscopy is due to process issues within the Urology department (which have also manifested themselves in cancer concerns - please see relevant section). As part of the work to seek assurance on cancer concerns, commissioners have received a copy of an overall Urology action plan. Additional general anaesthetic sessions have been put in place to deal with the backlog of cystoscopies. There is only a small backlog still outstanding. The non-sedation procedures backlog has now been cleared. Urodynamics 94.64% 112 6 There has been an ongoing recruitment issue within Urodynamics, but this has now been resolved with the appointment of a Physiologist. The Trust has checked with commissioners and the ISTC is unable to take on urodynamics activity. Computed Tomography (CT) 96.97% 1714 52 Performance is expected to improve significantly with increased capacity at the new hospital coming online. Magnetic Resonance Imaging (MRI) 95.35% 1440 67 Performance is expected to improve significantly with increased capacity at the new hospital. Commissioners have reminded the Trust that the ISTC are able to support however, much of the pressure is with paediatric which the ISTC cannot support. Paper Page 17 of 21
Last Minute Cancelled Operations & 28-day Re-booking as at April 2014 <= 0.8% of operations cancelled on the same day for non-clinical reasons Achieved <= 0.8% Underachieved 1.5% to 0.81% Failed >1.5% <= 0.8% Total YTD 1.09% 4224 46 1.09% Performance has improved in April however was above the 0.8% threshold. 23 of the cancelled operations were due to theatre time over running, 10 were attributed to staffing levels and the remainder were for unavailability of theatre kit, unavailability of beds or where emergency patients needed to take precedence. 95% of last minute cancelled operations re-booked for within 28-days Achieved >= 95% Underachieved 85% to 94.9% Failed <85% >= 95% Total YTD 89.1% 46 5 89.1% 5 patients were not rebooked within 28 days in April 2014. This was due to capacity constraints with 2 patients in orthopaedics, 2 in urology and 1 in general surgery. Paper Page 18 of 21
4. Cancer Performance Urgent Referral to treatment < 62 days (GP referred) Current Performance 76.32% The Trust has not achieved against this standard for the 5th month in a row. The standard has not been met in March 2014 due to a number of patients being treated at another Trust that have not finally been validated for the March performance and are currently showing as a shard breach. This includes patients from upper GI Lung and Urology. There were a total of 27 breaches out of 114 patients Provider Actions? The Trust has confirmed that an additional urology consultant will start in August 2014, as the ongoing challenge to meeting this target relates to Urology. Commissioner Actions? Commissioners have asked if there is currently a locum in post as the urology cancer delivery action plan stated that this post should be enough to sustain performance. Commissioners have also asked the Trust if any complaints have been received from patients in relation to Urology. Timeframe for resolution? Early indications are that this indicator has been underachieved again in April 2014 and that the greatest issues are again as a result of capacity in Urology and late tertiary referrals. Paper Page 19 of 21
Urgent Referral to treatment < 62 days (National Screening Programme) Current Performance 84.00% The consultant screening target for March was not achieved due to four shared breaches with another provider. Provider Actions? NBT will be asked to provide an update on actions at the June ICQPMB meeting. Commissioner Actions? Commissioners are working to understand if any support can be offered in the recovery of this target. Timeframe for resolution? Early indications are that this indicator has been underachieved again in April 2014 5. Clinical Quality Eliminating Mixed Sex Accommodation (MSA) Zero tolerance of mixed sex accommodation breaches Current Performance 0 in April YTD 0 There have been 0 cases of MSA breaches in April 2014. The incident reported last month is not subject to financial penalty due to the exceptional circumstances that led to the incident. Paper Page 20 of 21
Healthcare Associated Infections Incidence of MRSA as at April 2014 Current Performance YTD 0 Cases against the national zero tolerance 0 Cases against the national zero tolerance The Trust is on track against the national zero tolerance with 0 cases reported in April 2014. Incidence of Clostridium Difficile as at April 2014 Current Performance 4 cases in April 2014 YTD 4 Cases against an annual limit of 79 Cases The annual limit for 14/15 has been set at 79 cases. 4 cases of CDiff have been recorded in April 2014. Each case will be reviewed by commissioners and only those that are found to have occurred due to a lapse in the quality of care will be subject to financial penalties. Provider Actions? The Trust has provided commissioners with the latest version of their action plan. NBT are considering the introduction of the Procalcitonin test. Commissioner Action? NHS South Gloucestershire CCG is attending NBT s monthly C Diff Review Group from June 2014 to ensure there is commissioner review of each case and the application of sanctions in 2014/15 Timeframe for Resolution? The Trust is currently developing its trajectory for meeting the 2014/15 plan of 79 cases. Never Events North Bristol NHS Trust has recorded 1 never event in April 2014. This related to a wrong site surgery that affected a South Gloucestershire patient. Paper Page 21 of 21