Performance Management Dashboard May 2015 Paper No: SET/43/15
May 2015 Performance Summary Overview Of 78 performance measures, 37 were status red in April, 13 Amber and 28 Green. Increase of 372 new and unplanned attendances to the Ulster ED in May 15 in comparison to May 14 Ulster Hospital - busiest Emergency Department in the region however 84.3% of attendees who did not require admission were treated and discharged within the 4 hour target. Position of Psychological therapies has improved slightly in spite of capacity and demand issues with 474 patients waiting longer than 13 weeks. Number of clients waiting for assessment for Autism continues to be a challenge with 63 clients waiting >13 wks, however the Trust has the lowest number of waits regionally. Complex delays discharging complex patients from hospital remains a challenge however performance has improved again this month. Of 563 complex discharges in SET beds, 74.4% were discharged within 48 hours
Activity and Performance Summary May 2015 N&UP Attendances Seen < 4hrs Waited > 12 hrs ULSTER Hosp Emergency Dept Mar 7394 71.0% (5249) 1.3% (97) Apr 7458 68.2% (5086) 2.0% (147) May 7587 73.1% (5543) 1.3% (100) Emergency Admissions* Elective Admissions Total Admissions* ULSTER Hosp Adult Wards (non-maternity) Mar 1963 299 2262 Apr 1920 282 2202 May 1922 333 2255 *Excludes Emergency Admissions via A&E discharged under AE specialty HOSP. Services (All sites. Cons.-led) (New) Outpatients New Patients Sent For DNA (or cancelled on day) DNA Rate Mar 7117 474 6.7% Apr 6775 449 6.6% May 6375 416 6.5% CANCER Services (incl. breast) Referrals (GP Red Flags) Pats. begun Treatment %Started <62 days (Number not Started) Mar 1440 (863) 62 60% 25 Apr 1425 (928) 53 61% 20.5 May 1382(859) 50.5 54% 23
Activity and Performance Summary May 2015 In SET Hospital Beds Discharged < 48hrs Delayed > 7days COMPLEX Discharges Mar 514 66.3% (341) 16.1% (83) Apr 522 73.2% (360) 9.1% (48) May 563 74.4% (419) 8% (45)
CHILD PROTECTION Activity and Performance Summary May 2015 Referrals received (allocated <24hrs) Initial assessments completed in month No. (%) completed within 15 days of receipt of referral Mar 91 (100%) 75 74 (98.7%) 10 day target Apr 69 (98.6%) 63 62 (98.4%) 15 day target May 112 (100%) 101 101 (100%) 15 day target LOOKED-AFTER Children Initial assessments completed in month No. (%) completed within 14 days of the date of the child becoming looked after Mar 22 16 (72.7%) 10 day target Apr 30 26 (86.7%) 14 day target May 14 13 (92.9%) 14 day target
AVERAGE LENGTH OF STAY Ulster Hospital General Medicine, Care of the Elderly and All Adult Non Maternity Specialties Length of Stay 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 May- 14 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May General Medicine 5.5 6.0 5.2 6.0 5.6 5.9 5.5 5.9 5.7 6.3 6.7 6.4 6.3 Care of Elderly 12.0 11.3 13.1 12.3 10.4 10.2 11.5 12.1 13.4 9.8 12.0 12.1 11.6 Ave LOS All Specialties 5.7 5.6 5.4 6.1 5.9 5.5 5.5 6.0 6.1 5.8 6.1 6.2 6.1 General Medicine Care of Elderly Ave LOS All Specialties Page 14 of Scorecard
72.4 76 74 73.6 71.9 69.1 67.4 66.6 75.3 71.0 68.2 73 84.8 90.7 84.8 90.6 80.1 86.5 91.9 87.7 91.6 88.7 86.8 92.1 90.2 91.5 93.6 91.4 91.6 84.9 90.3 85.1 86.5 89.0 88.2 88.9 92.3 91.8 91.9 LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES TARGET: 95% of patients attending any Type 1, 2 or 3 Emergency Department are either treated and discharged home, or admitted, within 4 hours of their arrival in the department. May attendances: Ulster 7588 LVH 1827 Downe 1581-73% 4 hr - 91.8% 4 hr - 91.9% 4 hr Regional Comparison April 2015 78% 80% 64% 79% 72% 100 90 80 70 60 50 40 30 20 10 0 Performance against 4hr target A&E May-14 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May-15 Ulster Lagan Valley Downe Target SITE 4 HOUR MONTHLY POSITION MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR 15 MAY 15 SET 80.4% 82.8% 85.5% 81.7% 81.5% 81.1% 82.8% 78.4% 76.8% 76.2% 79.6% 75.3% 81.6% UHD 72.4% 76% 80.1% 74% 73.6% 71.9% 75.3% 69.1% 67.4% 66.6% 71% 68.2% 73% LVH 84.8% 84.8% 86.5% 87.7% 88.7% 92.1% 91.5% 91.4% 84.9% 85.1% 88.2% 88.9% 91.8% DH 90.7% 90.6% 91.9% 91.6% 86.8% 90.2% 93.6% 91.6% 90.3% 86.5% 89% 92.2% 91.9% Page 17 of Scorecard
May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May-15 LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES TARGET: NO PATIENT SHOULD WAIT LONGER THAN 12 HOURS IN A&E DEPT TO BE TREATED, DISCHARGED HOME OR ADMITTED There were 100 12 hour breaches in May, all in the Ulster Hospital. Regional Comparison April 2015 250 Ulster Hospital 12hr Breaches 200 150 78 100 6 223 50 0 1 149 May 14 - Apr 15 May 13 - Apr 14 MONTHLY POSITION SITE MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR 15 MAY 15 SET 2 6 1 1 28 22 3 45 237 229 100 149 100 UHD 1 6 1 1 28 22 3 45 237 210 97 147 100 LVH 0 0 0 0 0 0 0 0 0 3 1 0 0 DH 1 0 0 0 0 0 0 0 0 16 2 2 0 Page 17 of Scorecard
LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES Target: 95% of patients should, where clinically appropriate, wait no longer than 48 hours for inpatient treatment of hip fractures Compliance - 85% in May. 138 fracture cases in total 33 neck of femur with treated > 48 hours. Regional Performance - April 12 th June15 2015 92% N/A 92% 79% 98% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hip Fractures Target Line Page 18 of Scorecard
LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES Target: All urgent breast cancer referrals should be seen within 14 days Compliance 81.6% in May, with 30 breaches. Regional Performance April 2015 100% 90% 80% 70% 60% Regional comparison (Dec 14 most recent available) : 100% 16% 50% 40% 30% 100% 20% 10% 100% 95% 0% April May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May % Seen Target Page 20 of Scorecard
LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES TARGET: At least 98% of patients diagnosed with cancer should receive their first definitive treatment within 31 days of a decision to treat. May performance was 92% with 8 breaches. Regional comparison April 2015 100.0% 90.0% 80.0% 100% 98% 94% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 100% 96% 10.0% 0.0% % Receiving 1st Treatment Target % RECEIVING FIRST TREATMENT - MONTHLY POSITION MAY 14 JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR 15 MAY 96.0% 97.0% 98.9% 96.0% 96.0% 98.0% 94.0% 95.0% 91.0% 98.0% 99.0% 96.0% 92.0% Page 20 of Scorecard
Apr-14 May Jun Jul Aug Sep Oct Nov Dec Jan-15 Feb Mar Apr May 53.8 59.5 54 55 54 56 54 60 61 71.3 72.1 73.4 70.5 74.5 LEAD DIRECTOR: SEAMUS MCGORAN, DIRECTOR OF HOSPITAL SERVICES TARGET: At least 95% of patients urgently referred with a suspected cancer should begin their first definitive treatment within 62 days May performance was 54% with 23 breaches Regional comparison April 2015 100 90 80 70 60 92% 80% 70% 50 40 30 20 10 91% 60% 0 62 DayTarget Target Line 62 day Trend Page 20 of Scorecard SUSPECT CANCER REFERRALS MAR MAY 13 MAR MAY 14 % INC MAR MAY 13 VS 14 MAR MAY 15 %INC MAR MAY 14 VS 15 GP Red Flag 1862 2131 14.4% 2652 24.4% Other Red Flag 1443 1700 17.8% 1603-5.7% Total 3305 3831 15.9% 4255 11.1%
LEAD DIRECTOR: BRIA MONGAN, DIRECTOR OF ADULT SERVICES Target: No patient of any age to wait longer than 13 weeks from referral to assessment and commencement of treatment in Psychological Therapies The service attained 47.4% against the target in May which is an improvement on the April position. This service has an acknowledged capacity and demand shortfall 100 90 80 Regional Performance April 2015 Regional comparison (Mar 15 most recent available) : 70 60 68.6 64.5 66.4 58 57.8 55.7 55.5 50 45.3 44.9 47 43.5 47.2 47.4 108 96 142 40 30 20 66 509 10 0 May Jun Jul Aug Sep Oct Nov Dec Jan-15 Feb Mar Apr May-15 % waiting < 13 wks Target Page 43 of Scorecard
LEAD DIRECTOR: BRENDAN WHITTLE, DIRECTOR OF CHILDRENS SERVICES Target: All Child Protection Referrals to be Investigated and an Initial Assessment Completed within 15 days CHILD PROTECTION REFERRALS INVESTIGATED AND ASSESSED WITHIN 15 WORKING DAYS OF RECEIPT Regional Referral Trend QE March 2015 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 16% 19% 21% 15% 28% % Within 15 Days Target Page 48 of Scorecard
LEAD DIRECTOR: BRENDAN WHITTLE, DIRECTOR OF CHILDRENS SERVICES Target: Monitor the number of unallocated cases >20 days in Children s Services 200 Unallocated Cases Over 20 Days Regional Performance March 2015 180 160 140 120 100 100 125 104 115 133 149 101 116 150 167 184 98 82 45 80 82 81 60 40 27 150 20 0 Pages 48-50 of Scorecard Regional (March) Child Protection Family Support Disability Total Belfast 0 45 0 45 Northern 0 70 12 82 South Eastern 0 150 0 150 Southern 0 22 5 27 Western 0 73 25 98 Total 0 360 39 399