GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

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1 GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Appendix A PERFORMANCE MANAGEMENT FRAMEWORK Corporate Performance Document PATIENT EXPERIENCE CSF 1: Measure and exceed patient expectations, improving the patient experience 1.1 Percentage of patients that would recommend this trust / hospital to A Jan G family and friends (>80%) (1) 1.2 Percentage of patients rating care overall as good, very good or A Jan G excellent (.80%) (1) 1.3 Percentage of patients that would recommend this ward to family and friends (1) Nov/ Dec Nov+ Dec G CSF 2: Ensure patients experience no unnecessary delays 2.1M 18 week performance (1) M Nov R R 2.2M Waits in Accident and Emergency (1) M Dec R R 2.3 Ambulance delays over 30 minutes (1) M Dec R R 2.4 Patients waiting over standard (1) M Dec R R 2.5 Diagnostic waits over standard (1) M Nov R R 2.6 Cancelled operations (1) M Dec G G 2.7M Cancer waits (1) M Nov A A CSF 3: Involve patients and their carers in decisions about their care 3.1 Percentage of patients reporting they were definitely involved as A Jan R much as they wanted to be in decisions about their care (>80%) (1) 3.2 Percentage of patients reporting they were definitely involved in decisions about their discharge (1) A Jan R CSF 4: Provide an environment that exceeds patient expectations KEY PERFORMANCE INDICATOR Freq Month Current Last Report 4.1 Provide and maintain a clean environment (1) M Dec G G 4.2 Supplies of Clean Linen TBA(1) Bi Nov G N/A mthly 4.3 Efficiency of telephone service (1) Q Oct G G 4.4 Condition and use of estate (1) Bi- May A A Annual 4.5 Compliance with Statutory Duties (1) Q Oct R R 4.6 Maintenance Performance TBA (1) M N/A N/A CSF 5: Ensure patients are treated with dignity and respect 5.1 Compliance with essence of care, privacy and dignity standard (1) A Jan G 5.2 Percentage of patients reporting they were always treated with dignity A Jan G and respect (>80%) (1) 5.3 Percentage of patients admitted to single sex accommodation (1) Q N/A PMF Corporate Performance Document Page 1 of 8

2 CSF 6: Improve the quality, availability and communication of information to patients, carers and the public 6.1 Percentage of patients who reported they definitely were given A Jan R enough information about ward routines (>80%) (1) 6.2 Percentage of patients who reported they definitely could find a A Jan R member of staff to talk with about worries and fears (>80%) (1) 6.3 Percentage of complaints responded to within 25 days (95%) (1) M Dec A A PMF Corporate Performance Document Page 2 of 8

3 CLINICAL EXCELLENCE CSF 7: Deliver an improvement in measurable clinical outcomes 7.1 Hospital Standardised Mortality Ratio (2) A Dec G G 7.2 Crude Mortality Rates (2) Q July G 7.3 Readmission rates within 28 days of discharge (2) Q N/A 7.4 Stroke time to scan M N/A 7.5 Stroke percentage admitted to stroke unit (1) M Nov R R 7.6 M Thrombolysis pain to needle time (1) M Dec R R CSF 8: Deliver a comprehensive strategic clinical audit programme 8.1 Data completeness of key fields in MINAP (1) Q Q2 G G 8.2 Participation in heart disease audits (1) Q Q2 G G 8.3 Engagement in local and national clinical audits (1) Q Q2 G G 8.4 Clinical Audit Strategy (1) Q Q2 G G 8.5 Submission of Cancer Data Sets (1) Q Q2 G G CSF 9: Ensure a culture which promotes high quality research and innovation 9.1 Cumulative number of portfolio trials approved (2) M Dec G G 9.2 Cumulative number of accruals to portfolio trials (2) M Dec G G 9.3 Status of new products and technologies (3) A March G CSF 10: Be compliant with national standards for clinical care 10.1 Nationally issued alerts actioned within deadline (1) Q Q2 A A 10.2 Maternity standards (1) M Dec A R 10.3 Data Quality on Ethnic group (1) M Dec R R 10.4 Daycase Rates M Dec A CSF 11: Maximise the safety of patients, staff and visitors 11.1 The Global Trigger Tool (3) Q Q2 G 11.2 Never Events Reports (1) M Nov R G 11.3 Cumulative number of executive visits (3) M Nov G G 11.4 Infection control compliance with Saving Lives Audit (2) M N/A 11.5 M Infection control number of post 48hour MRSA bacteraemia (1) M Nov/ ytd A A 11.6 M Infection control total number of C Diff cases (1) M Nov G G 11.7 M Infection control number of post 48 hour C Diff cases (1) M ytd G G 11.8 Hand washing compliance (1) M Nov A A 11.9 Rate of patient falls per 1000 bed days (1) Q Q2 A A Rate of confirmed cases of venous thromboembolism (VTE) per Q Q2 G G 1000 discharges (2) Compliance with risk assessment for VTE(orthopaedics) (2) Q Q2 G G Compliance with treatment protocol for VTE (orthopaedics) (2) Q Q2 G G WHO surgical safety checklist (3) N/A Medication incidents per 1000 bed days (2) Q Q2 G G Discharge summaries sent within 3 days (1) M Dec A R Number of staff falls per 1000 staff (2) Q Q2 G G Number of sharps related incidents per 1000 staff (2) Q Q2 G G Number of RIDDOR reportable incidents (2) Q Q2 G G Incidents of violence & aggression towards staff per 1000 staff (2) Q Q2 G G Incidents of injury as a consequence of lifting and handling per 1000 staff (2) Q Q2 G G PMF Corporate Performance Document Page 3 of 8

4 STAFF CSF 12: Provide and promote a proposition that attracts, retains and engages staff 12.1 Staff perception of pay and benefits as a key factor in their N/A decision to join the Trust 12.2 Staff perception of pay and benefits as a key factor in their N/A decision to leave the Trust 12.3 Staff perception of pay and benefits in their continuing employment with the Trust (1) A March G G CSF 13: Recognise and Celebrate Success 13.1 Staff reporting - Recognition for good work (1) A March A A 13.2 Staff reporting on work valued by Trust (1) A March R R CSF 14: Enable staff to meet agreed individual and team objectives 14.1 Individuals and teams have the human resources required to enable them to achieve their objectives and deadlines (1) Vacancy Rate (1) Q Aug G G Absence Rate (sickness only) (1) Q Nov G G 08 to Oct Overtime Worked (1) N/A Temporary Staff Usage (1) Q Oct A A Turnover Rate (1) Q Nov A A 08 to Oct Stability Rate N/A Compliance with EWTD N/A 14.2 Individuals work in well structured teams that have agreed objectives and deadlines linked to the Trust s strategic objectives (1) Team structure (1) A March R R Staff know how their role contributes to what their team is trying to A March A A achieve (1) Staff goals and objectives for their job (1) A March A A 14.3 Individuals and teams have the physical resources required to enable them to achieve their objectives and deadlines [i.e. right equipment and environment] Equipment & environmental deficits: Reported at appraisal relevant to RIDDOR relevant to ACI reporting identified through Environmental Audit identified through Medical Engineering N/A PMF Corporate Performance Document Page 4 of 8

5 CSF 15: Develop high performing leaders and managers 15.1 Leadership and accountability project progress (3) Q Dec G G 15.2 Indicators of leadership performance in the annual staff survey (1) A March A A 15.3 Achievement of IIP award N/A CSF 16: Optimise personal competence through effective learning and development Period 16.1 Percentage of staff who have a personal development plan agreed A R R at appraisal within the last 12 months (1) 16.2 Percentage of Staff who have completed the mandatory training Q R R required for their role (1) 16.3 Percentage of staff who report they have received Personal A G G development and access to training relevant to their jobs (1) 16.4 Percentage of staff who have agreed competencies for their role (1) N/A 16.5 Percentage of staff recorded as having achieved the agreed competencies for their role (1) N/A PMF Corporate Performance Document Page 5 of 8

6 PARTNERSHIPS CSF 17: Be perceived as an excellent corporate partner 17.1 Partner organisation reputation audit N/A 17.2 Evidence of Partner Working N/A 17.3 Corporate Citizenship (3) A June G 17.4 Environmental sustainability (3) A April G CSF 18: Communicate effectively with a wide range of stakeholders 18.1 Partner Organisation reputable audit - communication N/A 18.2 Score from members and Governors annual survey N/A CSF 19: Be responsive to commissioner intentions 19.1 Services provided compared to those specified (1) A April G 19.2 Annual commissioner survey A N/A due Jan Market share with NHSG (3) A April G PMF Corporate Performance Document Page 6 of 8

7 FINANCE AND EFFICIENCY CSF 20: Generate a surplus to reinvest 20.1 M Planned financial outturn (1) A 09/10 * * 20.2 M Current position against plan (1) M Dec * * 20.3 M Projected outturn at year end (1) M Dec * * * reported separately in the Financial Performance Report CSF 21: Optimise the use of resources through continuous improvement 21.1 Activity to Plan (1) M Dec R R 21.2 Theatre Utilisation (1) M Dec A A 21.3 Length of Stay (1) M Dec R R 21.4 Occupancy (1) M Dec R R 21.5 Clinic Utilisation (1) M Nov A A 21.6 Delayed Discharges (1) M Dec A G CSF 22: Develop and maintain governance arrangements that are fit for purpose KEY PERFORMANCE INDICATOR Freq Month Current Last Report 22.1 M Governance Risk Rating (1) Q Oct R A 22.2 Board Declaration (1) A May A A 22.3 FT Membership Targets (1) Q Oct R R 22.4 Governor Vacancies (1) M Dec G G 22.5 Independent Non-Executive Vacancies (1) M Dec G G 22.6 Care Quality Commission Registration (1) A April G G 22.7 CQC Hygiene Code (1) A July G G 22.8 NHSLA Standards (1) A Feb G G 22.9 Other Regulatory Bodies Enforcement action (1) M Dec R G * denotes that there are planned reports on at least an annual basis but unannounced visits and issues can arise at any time during the year CSF 23: Achieve the highest rating by external bodies 23.1 M Financial risk rating (1) Q Q2 A A 23.2 Prudential Borrowing Code Ratios (1) Q Q2 G G 23.3 Overriding rules (1) Q Q2 A A PMF Corporate Performance Document Page 7 of 8

8 Legend RAG Status The approach to the Red- Amber- Green (RAG) status is set out below. Each KPI is annotated with the approach used. 1. Where the indicator is quantitative and a clear target has been agreed, the status is driven by a set of rules which has been defined by the owner. This is the approach used for those indicators which are also national performance targets 2. For some quantitative indicators it is not appropriate to identify a target but it is important to identify if there is an abnormal variation in the indicator. In most cases Statistical Process Control (SPC) techniques have been used to understand the nature of the variation and the following approach applied: Normal variation - green Abnormal adverse variation detected, under investigation amber Abnormal adverse variation with special cause identified red 3. For other indicators the ranking represents the judgement of the indicator owner, agreed by the executive owner for the CSF to which the indicator relates, applying the following approach: Performance satisfactory green Performance less than satisfactory but action plan improving position amber Performance less than satisfactory and action plan not improving position red M: These KPIs most likely to lead to concerns within Monitor regarding compliance with terms of authorisation PMF Corporate Performance Document Page 8 of 8

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