UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST Trust Key Performance Indicators October 2011 Report to: Trust Board 29 th November 2011 Report from: Sponsoring Executive: Aim of Report / Principle Topic: Review History to date: Recommendation(s): Andy Hyett, Head of Performance and Capacity Management Steve McManus, Chief Operating Officer Provides a summary of the Trust s performance against a range of high level key performance indicators as agreed by Trust Board. Regular report to Trust Board Trust Board are asked to note the Key Performance Indicators Report and consider whether there is appropriate assurance regarding current and future performance. 1. Strategic Context A range of high-level indicators to give an overview of performance within the Trust and to support the development of the Intelligent Board principles within the organisation. 1.1 The key performance indicators and individual scorecards have been realigned to more closely reflect the newly agreed Strategic Objectives. The scorecards will continue to be included within this report to provide monthly trends and additional detail to Board. 2. Supporting Guidance A supporting document which provides guidance on the information contained within this report, and how it should be interpreted, is available upon request. Such information has been removed from the monthly report in order to reduce its length, and to enable better focus on the reported performance / actions. 3. Executive Summary 3.1 Monitor Compliance Framework In line with the Monitor performance reporting requirements, this report provides a four quarter predictive performance based on the known Monitor Compliance Standards. These predictions are based on known seasonality, historical performance and proximity to the published thresholds. Actual Predicted Month Quarter to Date Year to Date 2011/12 Qtr 3 2011/12 Qtr 4 2012/13 Qtr 1 2012/13 Qtr 2 Service Performance Aggregate Score RAG Score RAG Score RAG Score RAG Score RAG Score RAG Score RAG Score 0.0 0.0 Financial Indicators Red 2.0 Red 2.0 Red 2.0 3.0 3.0 3.1.1 Monitor Service Performance Aggregate Score Areas of concern Admitted RTT Waiting Times A&E Indicators (across the winter months) More detailed scorecards are included in Appendix 1 Key Performance Indicators Report Page 1 of 5
3.1.2 Financial Indicators Areas of concern EBITDA margin Return on Assets Income & Expenditure surplus margin Liquid ratio (Days) More detailed scorecards are included in Appendix 1 3.2 Quality Indicator Pyramid Early Alert Monthly Measures Patient Experience How would you rate the care you received? Patient Safety Serious Incidents Requiring Investigation (SIRI) Patient Outcomes Unadjusted Mortality Rate Clinical Effectiveness Readmission Rate (28 days) Staff Experience Sickness Absence Clinical Efficiency Trust Inpatient Bed Occupancy (%) Financial Efficiency Cost Improvement Plan Financial Management Income and Expenditure Patient Experience Patient Safety Patient Outcomes Clinical Effectiveness Staff Experience Clinical Efficiency Financial Efficiency Financial Management Service initiative impact on quality is monitored on an ongoing basis. Key measures of quality are summarised in the early alert tool. These are analysed using statistical process control to improve sensitivity to identifying change. Occupancy levels are above target as a result of the sustained level of activity over-performance versus funded bed capacity. On a daily basis this position is in part mitigated through the targeted use of unfunded capacity. This, however, has an adverse effect on Divisional / Trust financial performance. A separate paper will be presented to Trust Board outlining the opportunity to provide additional planned bed capacity during Quarters 3 and 4 in order to mitigate the current forecast outturn occupancy level. This will be in the context of also managing an improvement in the forecast financial cost of the current use of ad hoc unfunded bed capacity. 4. Scorecard and Indicator Changes 4.1 Operating Framework 2012/2013 The 2012/2013 Operating Framework is expected to be published by the end of 2011. Any early indicators within this publication of changes to nationally mandated performance measures will be highlighted via the KPI report. Monitor will also circulate a draft Compliance Framework once the national position is published. Trust Board should be aware however of the recent position taken by the Secretary of State for Health regarding elective waiting times. it is possible that there will be an increase to the current 18 week admitted target from 90% to 92%. Currently Monitor do not reflect this within the Service Performance Aggregate Score. However any alteration will have a contractual consequence for 2012/2013. Key Performance Indicators Report Page 2 of 5
4.2 Forecast Year End Position (all scorecards and summaries) Given the increasing move towards regulatory monitoring on a quarterly basis, it is proposed that the Forecast Year End (fye) on all scorecards and summaries within this report be amended to show Forecast Final Year Position (fyp) rather than a full year forecast. This change has been implemented from the September report. 4.3 Timeliness of Care - Emergency Department Measures In a letter dated 23 June the Department of Health gave clarity to how NHS Trusts will be held to account in 2011/12 in relation to the A&E clinical quality indicators. The 5 indicators have been divided into 2 groups: timeliness and patient impact as below: Indicators Unplanned re-attendance A rate above 5% Left without being seen A rate above 5% Total time spent in A&E department Time to initial assessment Time to treatment Performance Trigger A 95 th percentile wait above 4 hours for admitted patients and with the same threshold for non-admitted A 95 th percentile time to assessment above 15 minutes A median time to treatment above 60 minutes Patient Impact Timeliness Organisations will be regarded as achieving the required minimal level of performance if they achieve at least one indicator in each of the 2 groups. Trusts will continue to also be monitored against the old standard of the percentage of patients treated within 4 hours. Monitor have now revised their compliance measure for A&E for Quarter 2 onwards back to a single performance standard of 95% of patients seen within 4 hours. The KPI Board Report will reflect this position and continue to publish the 5 new measures for type 1 and 2 A&E activity. 4.4 Patient Safety Serious Incidents Requiring Investigation (SIRI) As the reporting of SIRIs has become more robust through the Root Cause Analysis (RCA) panels, avoidable clinical outcome SIRIs have now been included in the reported figures. Current data shows a monthly reporting rate of around 2 Grade 3 or 4 Pressure Ulcers, 2 High Harm Falls and 4 avoidable VTE s. The suggested target for SIRI reporting is therefore less than 13 per month. 4.5 Productivity Indicators - Infrastructure The target tolerances for the Statutory and Mandatory Planned Maintenance and the Damage / Misuse have been adjusted from October, the new tolerances are as follows: Statutory and Mandatory <88% Red, 89-94% Amber, >95%, and Damage/ misuse >450 Red, 256-459 Amber, <255. 5. Performance as at the end of October 2011 (Appendices 1, 2 and 3) The scorecards showing current performance can be found in Appendices 1, 2 and 3. The summary action plans to support the Red Indicators are included as Appendix 4. Key Performance Indicators Report Page 3 of 5
5.1 18 Weeks RTT (admitted) For October UHS has reported delivery against 7 of the RTT measures. In addition to sustaining delivery of the Incomplete 95 th percentile standard first achieved in September the Trust has also delivered against the Admitted 95 th percentile target. The Trust s admitted backlog has also decreased to 1300. Milestones Trust delivers 95 th percentile performance for incompletes from October (achieved) Backlog size drops to below 1400 by end of October (achieved) Backlog size drops to bellow 1100 by the end of November Backlog size drops below 1000 by the end of December October and November run rate > 2800 (achieved for October) December run rate >2000 (reduced to reflect Christmas period) Risks, Impact and Mitigation Risk Impact Mitigation Non Elective / Urgent Elective demand reduces routine elective run rate 44% of backlog is attributed to 9 consultants Seasonal impact on capacity available ie Norovirus, Christmas run rate Capacity that was planned to be used to treat elective patients and clear backlog is absorbed As the backlog decreases it becomes increasingly specific to specialties and individual clinicians. Managing this bottleneck is dependant upon specific capacity This plan has been developed based on normal capacity. Any loss of capacity will impact on the Trusts ability to deliver to this plan. Based on treating approximately 125 patients per day stopping the elective program completely for 4 days will jeopardise this plan. Where ever possible ring fence elective capacity through use of offsite facilities ie Lymington / commercial sector. Capacity already identified in ISTC Monitor referrals trends for non elective and urgent referrals Expedite as a system non elective QUIPP actions Limit referrals to consultants with the biggest waiting list / capacity restrictions Review waiting lists for consultants with the biggest backlog to see if patients can be transferred to colleagues Book further ahead thus allowing better management of scarce capacity A detailed mitigations plan has been documented in the UHS Winter Capacity Plan. System funds have been identified to source additional capacity if necessary Maintain elective capacity for Quarters 3 and 4 at least as 2010/2011 outturn Maximise bed capacity through use of ESD to release elective bed capacity Key Performance Indicators Report Page 4 of 5
5.2 A&E performance The Trust has achieved the Monitor ED standard of 95% for the whole of Quarter 2, however this has deteriorated in October due to the continued level of non-elective demand and impact upon patient flow within the hospital. Performance against the five new A&E Clinical Quality Indicators has seen an improvement against Time to Initial Assessment. This area of performance is forecast to be delivering from October. It is also important to recognise the ongoing risk against ED performance going into Quarters 3 and 4. Non elective demand both in terms of ED attendances and non elective admissions are running significantly above plan. The forecast for ED performance in Quarters 3 and 4 has been maintained as at risk of underperforming. Further actions to mitigate this position and support delivery of the ED performance in Quarters 3 and 4 are identified in Appendix 4. 6. Conclusions Trust Board are asked to note the Key Performance Indicators Report and consider whether there is appropriate assurance regarding current and future performance. Key Performance Indicators Report Page 5 of 5