Integrated Performance Report 2012-13 1
CONTENTS - Performance Executive Summary Key Performance s Overview Areas of Escalation Single Sex Compliance A&E 4 Hour Standard A&E Timeliness s Never Events CQC Visits Contract Performance Metrics & National Benchmarking Workforce KPIs Executive Overview Trend Graphs 3 4 5 6 8 9 10 11 12 13 2
1. Executive Summary - Key Priority Areas 2012/13 The above shows an overview of current months performance for key areas within each domain and references where the Trust may not be meeting 1 or more related targets and provide page numbers to navigate to analysis and further details for areas of escalation. 3
2. Key Performance s Overview (Page 1 of 1) Quality - A&E Quality - Maternity and Stroke Care Outturn Outturn Total time in A&E - 95% of patients should be seen within 4hrs 96.0% 96.9% 93.2% 95% % Maternities Breastfeeding 86% 86% 87% 78.0% Timeliness: A&E: Time to initial assessment (95th percentile) N/A 31.00 <= 15 minutes % Maternities not Smoking 92% 93% 94% 90.0% Timeliness: A&E: Time to treatment decision (median) N/A 76.00 <= 60 minutes % Patients spending at least 90% of their time on the stroke unit 95% 96.0% 94% 80% Patient Impact: A&E: Unplanned reattendance rate N/A 1.68% <= 5% Percentage of high risk TIA patients who are treated within 24hrs 74% 71% 87% 60% Patient Impact: A&E: Left without being seen N/A 0.31% < 5% Percentage of low risk TIA patients who are treated within 7 days 83% 88% 90% 80% A&E Ambulatory Care Pathways - DVT % Admitted Patients 24.7 26% 31.25% <30% A&E Ambulatory Care Pathways - Cellulitis % Admitted Patients 30.4 15% 40% <15% A&E - LAS Handover > 60 mins 6 0 0 Quality - Cancer Outturn Quality and Safety - Infection Control Outturn % Urgent Referrals seen within 14 days 95.4% % Urgent Referrals seen within 14 days - Breast Symptomatic 95.9% % Cancers treated within 31 days of Decision to treat 98.4% % Cancers treated within 62 days of Referral 89.5% % Consultant Upgrades treated within 62 days 99.4% % Screening Services treated within 62 days 96.6% 93.9% 93.8% 93% No. Clostridium Difficile Hospital Acquired 33 10 0 33 93.8% 94.7% 93% No. Clostridium Difficile Community + GP Acquired 36 10 3 99.1% 96.2% 96% No. MRSA Hospital Acquired 6 0 0 4 90.1% 89.4 % 85% No. MRSA Community Acquired 7 7 0 99.6% 96.0% 90% Clostridium Difficile Hospital Acquired Per 1000 OBD 0.126 0.078 0 0.1259 96.8% 90.9% 90% MRSA Hospital Acquired Per 1000 occupied bed days 0.023 0 0 0.0230 % Subsequent treatments treated within 31 days of DTT - Drugs 100.0% 100.0% 100.0% 98% Clostridium Difficile Hospital Acquired Per 1000 attendances 0.217 0.16 0 0.0250 % Subsequent treatments treated within 31 days of DTT - Surgery 97.2% Note : Aug Cancer performance detailed as Sep data currently undervalidation. 99.3% 100.0% 94% MRSA Hospital Acquired Per 1000 attendances 0.039 0 0 0.0048 Access - RTT Outturn Quality and Safety - Patient Experience Outturn % Diag. Tests. Excl Audiol. waiting > 6 weeks 0.35% 0.10% 0.00% < = 1% % Ops. Canc. at last minute* 0.79% 0.69% 0.61% 0.80% % Audiology tests waiting > 6 weeks 0.00% 0% 0% < = 1% % Canc.Ops not Re-Admitted within 28 days 0.57% 0.00% 0.00% 5.00% RTT Waiting Times 95th Percentile - Incomplete N/A 20.37 36 Weeks Number of Same Sex Breaches 89 22 0 RTT Waiting Times 95th Percentile - Admitted N/A 19.43 27.7 Weeks Number of Never Events 1 3 1 0 RTT Waiting Times 95th Percentile - Non-Admitted N/A 13.99 18.3 Weeks % Delayed Discharges 3% 2.90% 2.87% 3.50% RTT Waiting Times Median - Incomplete N/A 5.73 7.2 Weeks % VTE Assesment 91.76% 92.54% 93.78% 90% RTT Waiting Times Median - Admitted N/A 8.59 11.1 Weeks RTT Waiting Times Median - Non-Admitted N/A 6.25 6.6 Weeks 18 Weeks - Admitted 90% N/A 94% 90% 18 Weeks - Non-Admitted 95% N/A 99% 95% 4
3. Performance Areas of Escalation (Page 1 of 5) - Single Sex Compliance Lead Director Single Sex Compliance : Number of Same Sex Breaches August 2011/2012 Forecast Date expected to meet standard Peer Performance 2012 Latest Data Published BCFH UCLH Whittington NMUH Royal Free SP 20 22 0 A Nov -12 22 1 0 0 0 Note: There were 22 breaches of single sex compliance in, with all the breaches occurring within ITU/HDU as a result of not meeting the step-down criteria which is due to shortage in bed availability. performance has not met the performance improvement trajectory. This is being addressed as per the action plan submitted to commissioners and work being undertaken with regards to the new medical model and revised bed management pathways, hence Amber RAG rating. The action plan is currently being reviewed to identify if additional areas need to be addressed. 5
3. Performance Areas of Escalation (Page 2 of 5) - A&E - 4 Hour Standard Lead Director Total time in A&E - 95% of patients should be seen within 4hrs August 2011/2012 Forecast Date expected to meet standard SP 97.5% 93.2% 95% G Oct -12 The Trust has been achieving the A&E operational standard of 95% throughout 2012/13 and continues to do so. However, the Trust has observed some variance in performance by site and in particular has not attained the 95% operational standard for particular weeks in 2012, in particular at Chase Farm Hospital. Investigations into breach reasons for underperformance have highlighted the following key root causes: Higher attendances at both sites Greater acuity, in particular majors/minors split Discharge performance Staff sickness Delayed transfers of care An action to recover performance has been drawn and is being implemented. Performance recovery is being seen in early October with both sites meeting the standard in the 1 st week. Further work is being undertaken as part of the new medical model and review of Emergency Care pathways, which will additionally address a number of the root causes identified. 6
3. Performance Areas of Escalation (Page 3 of 5) - A&E - 4 Hour Standard Action Plan Actions Actions required Lead Outcome Timeframe Implementation of the new medical model for the Deputy Director Earlier senior review in 1 st November Medical directorate - involves changing job plans and of Operations A&E, speedier discharge proposed start ways of working for all the medical consultants and and improved pathways date acute physicians using ambulatory care Early consultant review and timely input from Medics Manage delayed discharges Manage sickness Weekly delayed discharge meetings to progress patients through the processes One week bed clearance exercise with social services reviewing patients and clearing beds of those that are medically fit for discharge Robust sickness management of nursing staff in line with Trust policy Robust sickness management of medical staff in line Head of Nursing Deputy Director of Operations Matrons Clinical Director Focus on all patients medically fit for discharge Beds cleared, freeing up capacity for acute patients requiring admission Reduced staff sickness, therefore more cover on the shopfloor with Trust policy Length of stay Individual focus on pts not meeting PDD Head of Nursing Clearer discharge planning and understanding of future capacity Hot validation process PDD monitored before 12 midday Head of Nursing Ensure sufficient bed capacity Sufficient beds by time of day Development ambulatory care protocols Use of discharge lounge Matrons, ward sisters and Site team to continue to pull patients to discharge lounge to clear beds earlier in the day Process of 'hot validation' for all breaches to understand the causes, particularly for speciality delays - Director of Operations Head of Nursing Senior Business Manager Emergency Care Admission avoidance In place w/c 8 th October In place and ongoing October 2012 In place Ongoing additional pathways in development Beds cleared earlier in the day October 2012 Ownership of patients and breaches onto the individual teams October 2012 7
3. Performance Areas of Escalation (Page 4 of 5) - A&E - Timeliness s Lead Director Timeliness: A&E: Time to initial assessment (95th percentile) August 2011/2012 Forecast June 2012 SP 23 31 <= 15 minutes A Lead Director Timeliness: A&E: Time to treatment decision (median) August 2011/2012 Forecast June 2012 SP 64 76 <= 60 minutes A Date expected to meet standard Peer Performance 2012 August Data Published BCFH UCLH Whittington NMUH Royal Free Sep - 12 27 N/A N/A 6 22 Date expected to meet standard N/A = data not available Peer Performance 2012 August Data Published BCFH UCLH Whittington NMUH Royal Free TBC 89 N/A N/A 60 46 The Trust has not met timeliness indicators performance in. A deep dive review of these indicators is currently being undertaken to establish key reasons for this and variation in practice between the Trust sites with an action plan to follow. However improvements at site level have been observed. BH has seen a month on month improvement with time to initial assessment with performance being 20 minutes. However, CFH is a key target area with performance of 31 minutes. With regards to the time to treatment indicator, CFH has met the indicator in August and with performance of 41 and 50 minutes respectively. BH remains a key target area here with August and performance of 86 and 98 minutes respectively. Peer analysis of performance against indicators has shown variable performance comparable to the Trust. The Royal Free have highlighted similar issues to the Trust with regards to the time to initial assessment performance not being indicative of real performance as the initial assessment would be undertaken, but clinical staff often wait until the patient is stabilised before entering this data. The Trust is working with peers to share best practice and approaches to similar issues. 8
3. Performance Areas of Escalation (Page 5 of 5) - Never Events Lead Director Patient Experience Never Events 2011/2012 Forecast Date expected to meet standard TR 3 1 0 G Sep - 12 The Trust has had 3 never events : 1 in June pertaining to a retained swab post-surgery in maternity. 1 in August pertaining to a medication administration error (Methotrexate Incident) on Montreal Ward. 1 in pertaining to incorrect administration of a gas. This is attributed to the directorate of Critical Care and Anaesthetics. Root cause analysis investigations are currently being undertaken with findings to be presented to the Trust panel and a report to be sent to NHS London in due course. 9
3. CQC Unannounced Compliance Reviews - Update (Page 1 of 1) Barnet Hospital - 26 th 2012 The CQC issued the Trust with a Judgement of non-compliance against Outcome 9 Management of medicines following a unannounced visit at Barnet Hospital on 25th April 2012. An action plan to improve and achieve compliance was draw up, agreed with the CQC and implemented. The CQC has since then carried out an additional unannounced compliance review at Barnet Hospital on 26 th 2012 to check whether the Trust had taken action in relation to: Outcome 09 - Management of medicines. Overall, the CQC found that the Trust had made key improvements in relation to this standard and gave a judgement of Compliant. Chase Farm Hospital - 26 th August 2012 On 20 th August 2012 the CQC carried out an unannounced compliance review at Chase Farm Hospital. The CQC assessed compliance against four essential standards of quality and safety. The CQC provided the Trust with a draft compliance report for review and factual accuracy feedback. The report detailed judgements of compliant with two of the four standards. The remaining two standards have been judged to be non-compliant as follows: Outcome 13: Staffing non-compliant with a moderate impact on people who use the service. Outcome 21: Records non-compliant with a moderate impact on people who use the service The Trust have acknowledged and accepted the findings against outcome 21. However, the Trust raised concerns with the findings presented against outcome 13 in the report and find it to be inaccurate with an inappropriate judgement of noncompliant. The Trust challenged this via the factual accuracy process, providing additional evidence and commentary detailing the reasons. Following a review of the Trusts response, the CQC have made some minor amendments to the narrative within their report. However, based on their observations and feedback from staff on the day, the CQC have upheld their judgement of non-compliant and issued a final report. The Trust is now in the process of undertaking a root cause analysis investigation into both standards, with a remedial action plan in order to achieve compliance being drawn up. 10
4. Contract Metrics and National Benchmarking (Page 1 of 2) Contract Metrics National Benchmarking Metrics Efficiency s Dr Foster - Clinical Quality Baseline Position August Observed Expected Relative Risk Peer Casemix Average SHA Average Emergency Re-admissions OP First to Follow Up 1.41 Daycase to OP Procedures This indicator is currently being finalised following clinical audit 1.65 1.62 1.65 68.62% 70.2% 75.51% 74.65% 1.37 80% Mortality - HSMR (3 mths May 12 - July 12) 297 371 Consultant to Consultant Referrals 16.90% 19.8% 23.20% 24.42% 14% Re-admissions 28 days ( Feb 12 - Apr 12 ) A&E Conversion Rate 9.17% 6.46% 6.58% 7.00% 6.92% Cervical Screening <2 Weeks (Test Turnaround) 100% 100% 100% 98% 80 95.2 87.4 Mortality - SHMI ( Jan 11 - Dec 11 ) 88.3 89.64 Length of Stay (3 mths May 12 - July 12) 3555 4039 88 90.7 90.7 2132 1887 113.8 102.9 97.9 Activity Metrcis - April - Dr Foster - Clinical Efficiency ( May 12 - Jul 12) Apr - Sep Activity Activity Plan Variance to Plan Activity Variance to Plan Rate National Average SHA Rate Peer Trusts Rate Trust Rank % Nationally Elective Planned Activity Variance to Plan 21808 25115 26820-6.36% 4134-7.90% First to follow-up Emergency Activity Variance to Plan 19061 22014 19905 10.60% 3500 7.26% DNA Rates New Outpatient Activity Variance to Plan 71194 65152 77420-15.85% 10933-15.62% Excess bed days Follow up outpatient activity variance to plan 132309 152452 164502-7.33% 25726-6.56% Re-admissions crude 30- day rate 33.21% 30.96% 31.30% 28.00% 27th 7.32% 7.87% 11.35% 12.39% 35th 13.31% 12.82% 14.76% 14.67% 56th 7.04% 6.82% 6.75% 7.32% 55th Note: With regards to efficiency indicators Directorates are working through their prioritiy areas and action plans for performance improvement being drawn up for implementation. A contract metrics working group is also being set-up to drive forward performance improvements and to monitor the implementation of these action plans Day Case Rate 85.82% 81.50% 80.15% 83.58% 14th Day of Surgery Admission 99.00% 97.64% 95.43% 95.21% 12th 11
6. Workforce KPIs - Overview (Page 1 of 2) Workforce Performance Outturn on previous month Vacancy Rate 12.55% 11.18% 11.18% 0.38% 10% Turnover Rate 12.80% 12.02% 12.02% 0.06% only Sickness Absence 3.6% 3.49% 3.73% 0.05% 3.25% Appraisals 73% 80% 80% 1% 85% Statutory and Mandatory Training 70% 81% 81% 4% 85% (95% NHSLA IG & B/Care ) Staff Experience 3.66 staff engagement score - - on previous year Maintain above average staff engagement score Key Messages: Enablers Revision of the weekly Establishment Control Group (ECG) including a review of all vacancies New BankStaff system implemented - further functionality being implemented e.g. employee online. Dedicated resource in place is increasing availability of shifts on the bank. Review of agency invoice payments. Exit interview policy approved and being implemented Weekly meetings within the recruitment and bank teams to address any blockers to processes and ensure robust communication with managers using these services of appropriate protocols. Sickness league tables now going to HMB, and HRAC to distribute these to Trust managers Top e-learning completions in London for 3 rd month running and in the top 6 nationally 756 e-learning courses completed in 2012 with over 650 unique users. Employee Assistance Programme launched. Online support service being promoted New TRAC recruitment system in place to enable efficient time to hire E-rostering (improved sickness reporting & resource allocation) Bradford Score report 2 week absence sickness reports & intervention of absence at 2+ weeks Increased sickness absence hearings in line with Managing Attendance policy Operational Implementation Directorates are completing the 2012 National Staff Survey Director of Ops /Nursing weekly meeting with matrons re: B&A usage and effective use of e-rostering Continued performance management by Directors of Ops re: appraisals, statutory and mandatory compliance Directorate Staff Survey focus groups completed and actions are being implemented. JSC Taskforce Partners scrutinising Staff Survey (SS) action plans with GMs 12
6. Workforce KPIs - Trend Graphs (Page 2 of 2) 15.00% 14.00% 13.00% 12.00% 11.00% 10.00% 9.00% 8.00% 7.00% 6.00% % Vacancies Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 4.50% 4.00% 3.50% 3.00% 2.50% 2.00% Sickenss Monthly Percentage Absence (FTE days absent / FTE days available) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2012/13 2012/13 90% % Appraisals 90% Total Statutory and Mandatory Training 13.50% Staff Turnover 80% 70% 60% 50% 80% 70% 60% 50% 13.00% 12.50% 12.00% 40% 40% 11.50% 30% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 30% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 11.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2012/13 2012/13 2012/13 Band 5 recruitment update: 157wte band 5 vacancies in Nine Band 5 recruitment campaigns currently at advert, shortlisting and interview stage 71 conditional offers at pre-employment checks stage Impact of current and forthcoming ward closures will enable further reduction with the redeployment of 33.87wte band 5 nurses Ward closures will remove the Band 5 challenge within Planned Care however, there will remain a recruitment challenge within Emergency Care therefore re-marketing of the Medical Band 5 posts is being undertaken to attract more applicants locally Monthly variations in numbers of applicants and leavers should be noted. 13