ORBIT Reporting
Trust Board Integrated
Performance Report
November 2014
At A Glance report
Escalation report
Data Quality Indicator
Graph Legend
The data quality rating has 2 components. The first component is a 5 point rating which
assesses the level and nature of assurance that is available in relation to a specific set of
data. The levels are described in the box below.
Rating
Required Evidence
1
Standard operating procedures and data definitions are in place.
2
As 1 plus: Staff recording the data have been appropriately trained.
3
As 2 plus: The department/service has undertaken its own audit.
4
As 2 plus: A corporate audit has been undertaken.
As 2 plus: An independent audit has been undertaken (e.g. by the Trust's internal
or external auditors).
5
Underachieving
Standard
Plan/ Target
Performance
The second component of the overall rating is a traffic-light rating to include the level of
data quality found through any auditing / benchmarking as below
Rating
Green
Data Quality
Satisfactory
Amber
Data can be relied upon but minor areas for improvement identified.
Red
Unsatisfactory/significant areas for improvement identified.
1
OUH -At A Glance 2014-15
ORBIT Reporting
Operational
Access
Standards
Standard
YTD
Forecast
next
period
Data
Quality
RTT - admitted % within 18 weeks
90%
Nov-14
82.79%
87%
85.9%
3
RTT - non-admitted % within 18 weeks
95%
92%
NA
Nov-14
Nov-14
Nov-14
92.88%
92.56%
39719
94.6%
91.4%
93.9%
92.2%
40181
2
2
2
11.1
6.6
23
18.3
Nov-14
Nov-14
Nov-14
Nov-14
8.7
5.18
29.44
20.59
7.86
5.09
26.21
18.59
8.4
5.2
26.9
19.4
2
2
3
3
0
Nov-14
9
0
Nov-14
8
RTT - incomplete % within 18 weeks
RTT - #waiting on incomplete RTT pathway
RTT admitted - median wait
RTT - non-admitted - median wait
RTT 95th centile for admitted pathways
RTT - 95th percentile for non-admitted RTT
RTT - # specialties not delivering the admitted
standard
RTT - # specialties not delivering the nonadmitted standard
% Diagnostic waits waiting 6 weeks or more
1%
Nov-14
0.6%
1.2%
0.8%
2
Zero tolerance RTT waits AP
0
Nov-14
14
53
8.7
4
Zero tolerance RTT waits IP
0
Nov-14
10
171
17
4
Zero tolerance RTT waits NP
0
Nov-14
4
34
6.7
4
11716.3
2
Ambulance Handovers within 15 minutes
0%
Nov-14
Number of attendances at A/E depts in a month
NA
Nov-14
10651
% <=4 hours A&E from arrival/trans/discharge
95%
Q3 14-15
89.09%
92%
Last min cancellations - % of all EL admissions
0.5%
Nov-14
0.62%
0.5%
0.3%
0%
0
Nov-14
Nov-14
3.45%
0
4.9%
0
3.5%
0
0
Nov-14
0
0
0
NA
NA
Nov-14
Nov-14
11325
9404
2
3
NA
Nov-14
1217
4
% patients not rebooked within 28 days
zero Urgent cancellations - 2nd time
Urgent cancellations
Activity
Current
Data Period Period Actual
Total on Inpatient Waiting List
# on Inpatient Waiting List dates less than 18
weeks
# on Inpatient Waiting List waiting between 18
and 35 weeks
# on Inpatient Waiting List waiting 35 weeks &
over
% Planned IP WL patients with a TCI date
2
No data available
94475
Quality
Outcomes
Standard
YTD
Forecast
next
period
Data
Quality
Summary Hospital-level Mortality Indicator**
NA
Sep-14
0.99
Total # of deliveries
NA
62%
23%
Nov-14
Nov-14
Nov-14
646
64.4%
19.81%
5618
62.6%
21.9%
706.3
63.8%
22%
3
3
5
15%
NA
0%
80%
Nov-14
Nov-14
Nov-14
Nov-14
15.79%
0
3.19%
80.04%
15.5%
0
3.8%
79.3%
14.1%
5
4
5
4
Proportion of normal deliveries
Proportion of C-Section deliveries
Proportion of Assisted deliveries
Maternal Deaths
30 day emergency readmission
Medication reconciliation completed within 24
hours of admission
Medication errors causing serious harm
Patient
Experience
Current
Data Period Period Actual
Number of CAS Alerts received by Trust during
the month
Number of CAS Alerts with a deadline during
the month
Number of CAS alerts that were closed having
breached during the month
Dementia CQUIN patients admitted who have
had a dementia screen
Monthly numbers of complaints received
5
3.4%
80.4%
0
Nov-14
0
2
5
NA
Nov-14
8
82
5
NA
Nov-14
15
98
5
0
Nov-14
0
1
5
0%
Oct-14
71.71%
65.5%
67.4%
4
NA
Nov-14
80
687
89.3
5
26.4%
25.1%
2
72.3
2
9.8%
2
52
2
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Net promoter (friends & family -Inpatients)
0%
Nov-14
25.1%
NA
Nov-14
71
Patient Satisfaction- Response rate (friends &
family -ED)
Net promoter (friends & family -ED)
0%
Nov-14
10.28%
2
NA
Nov-14
38
2
Same sex accommodation breaches
0
80%
Q3 14-15
Nov-14
10
86%
21
83.2%
7
86.7%
3
5
0%
Nov-14
64.95%
77.9%
77.2%
3
0
5
Nov-14
Nov-14
0
8
4
43
0.7
6.7
5
5
% adult inpatients have had a VTE risk assess
95%
Q3 14-15
94.61%
93.8%
93.8%
5
5
# patients spend >=90% of time on stroke unit
Time to Surgery (% patients having their
operation within the time specified according to
their clinical categorisation)
Safety
HCAI - MRSA bacteraemia
HCAI - Cdiff
14.4%
NA
Nov-14
704
3
Number SIRIs
NA
Nov-14
7
34
4.3
5
Nov-14
Nov-14
Nov-14
29.27%
12453
17261
101797
141909
12628
18085.3
3
3
2
Number of Patient Falls with Harm
Total number of first outpatient attendances
NA
0
0
0
NA
NA
Nov-14
Nov-14
Nov-14
5
4.85
4.73
28
5.15
4.91
2.7
5.6
4.7
2
2
3
1st outpatient attends following GP referral
0
Nov-14
10272
81790
10418
2
Other refs for a first outpatient appointment
0
Nov-14
8292
72219
9120.7
3
Non-elective FFCEs
0
0
Nov-14
Nov-14
5687
2068
46366
15624
5755.3
2005.7
2
3
# acquired, avoidable Grade 3/4 pressure
Ulcers
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
0
0
Nov-14
Nov-14
7333
112
59353
913
7543.7
124
3
3
3.5%
Q3 14-15
11.17%
10%
10%
5
No of GP written referrals
Number of Elective FFCEs - admissions
Number of Elective FFCEs - day cases
Delayed transfers of care: number (snapshot)
Delayed transfers of care as % of occupied beds
Patient Falls per 1000 bed days
Incidents per 100 admissions
Cleaning Scores- % of inpatient areas with initial
score >92%
NA
Oct-14
1
10
1.7
5
0%
Nov-14
93.32%
93.2%
93.5%
3
NA
NA
Nov-14
Nov-14
3
69.23%
3
54.5%
1
55.4%
5
5
2
Operational
Activity
Cancer
Waits
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
Theatre Utilisation - Total
75%
Nov-14
73.11%
72.5%
71.8%
2
Theatre Utilisation - Elective
80%
Nov-14
84.38%
76.1%
75.5%
3
Theatre Utilisation - Emergency
70%
Nov-14
64.58%
61.4%
61.3%
2
%patients cancer treatment <62-days urg GP ref
85%
Oct-14
80.49%
77.2%
75.8%
5
%patients cancer treatment <62-days - Screen
90%
Oct-14
100%
94.2%
93.8%
5
% patients treatment <62-days of upgrade
%patients 1st treatment <1 mth of cancer diag
0%
96%
0%
Oct-14
97.06%
Finance
Capital
Financial
Risk
I&E
5
95.2%
97%
Standard
Current
Data Period Period Actual
YTD
90%
Nov-14
93.91%
90%
5
Capital servicing capacity (times)
1.75
Nov-14
1.84
1.8
5
Liquidity ratio (days) defined as Working Capital
balance *360/Annual Operating Expenses
-7
Nov-14
-5.44
-7
5
Monitor Risk Rating
3
Nov-14
3
3
5
95%
Nov-14
91.96%
90%
5
1%
Nov-14
1.27%
1%
5
Forecast
next
period
Data
Quality
CIP Performance Compared to Plan
5
Standard
Nov-14
97.19%
4
Nov-14
2.11%
5
0%
Nov-14
5.56%
5
101%
Nov-14
101.49%
5
Nov-14
Nov-14
Nov-14
6.73%
3.61%
13.07%
3
5
3
Oct-14
95.88%
95%
95.7%
5
98%
Oct-14
100%
100%
100%
5
94%
Oct-14
98.7%
86.9%
97.2%
5
Agency usage (displayed as a % of total)**
%2WW of an urg GP ref for suspected cancer
93%
Oct-14
95.04%
93.9%
94.6%
5
Total cost of staff ( displayed as a %)**
%2WW urgent ref - breast symp
93%
Oct-14
96.3%
94.2%
96.1%
5
Vacancy rate
5%
3%
10.5%
Sickness absence**
Turnover rate
YTD
0%
94%
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
Worked WTE against Plan (displayed as a % of
total)**
Bank usage (displayed as a % of total)**
Current
Data Period Period Actual
101%
%patients subs cancer treatment <31days - Surg
Staff
Experience
Data
Quality
Capital Programme Compared to Plan
I&E Surplus Margin (%)
Workforce
Head
count/Pay
costs
Forecast
next
period
12.8%
* This measure is collected on a year to date basis and displays the latest available values
** This measure is collected for a 12 month period preceding the latest period shown
*** Sickness absence figures shown in period actual reflect the financial year to date
Year: 2014-15
Directorate: Acute Medicine & Rehabilitaion ,Acute Medicine & Rehabilitation,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research,Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services,Chief Nurse Patient Services & Education,Children's ,Children’s,CRS Implementation,Division of Clinical Support Services,Division of Corporate Services,Division of
Medicine, Rehabilitation & Cardiac,Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Estates and Facilities,Finance and Procurement,Gastroenterology, Endoscopy and Theatres (CH),Horton Management,Human Resources and Admin,Legacy Cardiac, Vascular &
Thoracic Surgery,Legacy Cardiology,Legacy Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal and Rehabilitation,Legacy Rehabilitation & Rheumatology,MARS -Research & Development,Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records,Oncology & Haematology ,Oncology & Haematology ,Orthopaedics,Pathology & Laboratories,Pharmacy,Planning &
Communications,Private Patients,Radiology & Imaging,Renal, Transplant & Urology,Specialist Surgery ,Strategic Change,Surgery ,Teaching Training and Research,Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
3
IPF Red Escalation Report FY 2014-15
RTT - admitted % within 18 weeks
What is driving the reported
underperformance?
Admitted performance
continues to be a challenge.
November performance has
deteriorated further but is not
attributable to a dip in activity.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Nov-14
82.79%
87%
85.86%
Weekly meetings continue to be held with
Divisional Teams and the Director of
Clinical Services.
Specialties with significant challenges
continue to be:
 Orthopaedics
 Spinal
 Ophthalmology
 Neurosurgery
Additional theatres lists are being
undertaken and external providers are
being used to support some surgical
activity.
Expected date to meet
standard
Lead Director
End of November for Trust
Director of Clinical Services
level standard with risk limited
to Orthopaedics and Spinal.
4
IPF Red Escalation Report FY 2014-15
RTT 95th centile for admitted pathways
What is driving the reported
underperformance?
What actions have we taken to improve
performance
November’s reporting period
saw a significant increase in the
95th percentile of admitted
waits. The 95th percentile wait
is likely to increase in the short
term whilst the services refocus the effort to treat the
longest waiting patients first.
Weekly meetings with the Clinical
Divisions and the Director of Clinical
Services to ensure the sustainable
recovery plans are being implemented to
reduce and treat those patients waiting
over 18 weeks.
Expected date to meet
standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
Nov-14
29.44
26.21
26.91
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
5
IPF Red Escalation Report FY 2014-15
RTT - 95th percentile for non-admitted RTT
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Due to the prolonged non
achievement of the nonadmitted target, the 95th
percentile waits have seen an
increase. This is expected to
increase further in the short
term, as services re-focus on
treating the longest waiting
patients.
Weekly 18 week performance meetings
are held with Divisional Teams and the
Director of Clinical Services.
Expected date to meet
standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
18.3
Nov-14
20.59
18.59
19.45
End of November for Trust level Director of Clinical Services
standard with risk limited to
Orthopaedics and Spinal.
6
IPF Red Escalation Report FY 2014-15
RTT - # specialties not delivering the admitted standard
What is driving the reported
underperformance?
Nine services did not achieve the
admitted standard in November
and are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Trauma & Orthopaedics
Ear, Nose & Throat
Ophthalmology
Neurosurgery
Plastic Surgery
Cardiology
Cardiac Surgery
Urology
Other services
What actions have we taken to
improve performance
Standard
Current Data Period
Period Actual
0
Nov-14
9
YTD
Forecast next period
8
Weekly meetings with the Clinical
Divisions and the Director of Clinical
Services to ensure the sustainable
recovery plans are being implemented
to reduce and treat those patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
7
IPF Red Escalation Report FY 2014-15
RTT - # specialties not delivering the non-admitted standard
What is driving the reported
underperformance?
Six services did not achieve the
non- admitted standard in
September and are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
Trauma & Orthopaedics
Ear, Nose & Throat
Ophthalmology
Plastic Surgery
Cardiology
Urology
Respiratory medicine
Other services
What actions have we taken to
improve performance
Standard
Current Data Period
Period Actual
0
Nov-14
8
YTD
Forecast next period
7
Weekly meetings with the Clinical
Divisions and the Director of Clinical
Services to ensure the sustainable
recovery plans are being implemented
to reduce and treat those patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
8
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits AP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Nov-14
14
53
9
Large increase in 52 week
There is an action plan in place to reduce
breaches treated within
the number of patients waiting.
November, this was planned as
the backlog clearance work
continues. The services were:
 Plastic Surgery (7)
 Spinal Surgery Service (2)
 Ophthalmology (2)
 Paediatric Plastic Surgery
(2)
 Neurosurgery (1)
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
9
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits IP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Nov-14
10
171
17
Large reduction in the number There is an action plan in place to reduce
of incomplete pathways waiting the number of patients waiting.
over 52 weeks, this is to be
expected when clearing the
longest waiting patients as a
priority. The services were:
 Spinal Surgery Service (8)
 Maxillo Facial Surgery (1)
 Physiotherapy (1)
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
10
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits NP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Nov-14
4
34
7
A reduction in the nonThere is an action plan in place to reduce
admitted patients treated over the number of patients waiting.
52 weeks during November.
The services were:
 Spinal Surgery Service (2)
 Ophthalmology (1)
 Physiotherapy (1)
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
11
IPF Red Escalation Report FY 2014-15
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Quarter 3 performance has
seen a deterioration in
performance since Quarter 2.
Q3 performance at the end of
October was 91.38%, but since
then this has dipped below
90% for the quarter. November
saw only one week where
performance was over 90%.
December continues to be very
challenging.
The Urgent Care Working group continues to
meet weekly, with OCCG, OH, OCC and OUH
colleagues to improve patient flow across the
system. Escalation is in place with significant
focus across all clinical teams to minimize the
number of patients waiting over four hours.
Additional short terms actions include:
 Staffing reviewed each shift to ensure safe
staffing
 Extended consultant presence in ED
 Additional consultant led ward rounds and
senior decision makers in ED.
 Increased theatre capacity to manage
trauma flow
 Enhanced diagnostic and Pharmacy
provision
 Monitoring number of admissions and
discharges to transfer lounge
 Escalation beds opened
Winter Plans have been agreed and being
implemented.
ECIST report has been received and action
plans being implemented.
Expected date to meet
standard
Lead Director
Quarter 4 onwards
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
95%
Q3 14-15
89.09%
92%
Forecast next period
12
IPF Red Escalation Report FY 2014-15
Delayed transfers of care as % of occupied beds
What is driving the reported
underperformance?
Performance in Q3 continues
to be extremely challenging,
although the actual monthly
position for November showed
a very marginal improvement
on the levels seen in October
(128 patients in November, 130
in October).
Performance on this metric is
very consistent with the levels
seen in the last financial year.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q3 14-15
11.17%
10%
10.03%
Daily whole system teleconference calls
remain in place, with escalation to
Oxfordshire colleagues when system is on
RED. Weekly Urgent Care Summit
meeting with OCCG, OH and OCC
colleagues to manage system and winter
funding arrangements and reprioritize
where necessary. Further work is
progressing internally to improve the
discharge process for all patients.
Expected date to meet
standard
Lead Director
This system has not agreed a
date to achieve this standard.
Director of Clinical Services
13
IPF Red Escalation Report FY 2014-15
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
A 4 percentage point
improvement on October’s
utilisation performance during
November.
Internal theatre meetings are in place to
review utilisation, work is progressing to
develop a standardized approach across
the Trust to manage the emergency lists
which include:
 Developing and implementing a
standard operating procedure and
flow chart for all emergency lists.
 Standardising the urgency category
for all procedures.
Expected date to meet
standard
Lead Director
Quarter 3 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Nov-14
64.58%
61.4%
61.26%
14
IPF Red Escalation Report FY 2014-15
Same sex accommodation breaches
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Q3 14-15
10
21
7
10 breaches in November 2014. There have been no breaches since
2 were justified and 8 were
November.
non-justified. The Emergency
Department was full and there
was no capacity in the hospital.
The Trust was required to
submit a Unify return of 10.
Expected date to meet
standard
Lead Director
December 2014
Chief Nurse
15
IPF Red Escalation Report FY 2014-15
HCAI - Cdiff
What is driving the reported
underperformance?
What actions have we taken to improve
performance
8 cases of C.diff were reported
in November 2014, against a
monthly limit set at 6 for the
month.
All 8 C.diff cases were discussed at the
monthly Health Economy meeting held in
December 2014 and it was agreed that all
cases were unavoidable. Further actions
were identified in terms of
documentation and patient review,
particularly within MRC.
Expected date to meet
standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
5
Nov-14
8
43
7
The OUH remained below the Medical Director
cumulative limit for November
2014 (45 cases) and remains on
track to meet the C.diff
objective for 2014/2015.
16
IPF Red Escalation Report FY 2014-15
Total cost of staff ( displayed as a %)**
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The pay overspend continues to
be driven by the on-going
payment of premium rates for
staff – the high use of bank &
agency staff, and additional
payments made to medical
staff to work weekend sessions
required to meet performance
targets.
The Trust is introducing further workforce
measures to reduce the usage and cost of
agency staff, and has also initiated
recruitment drives to replace temporary
staff with permanent employees. It has
improved the rate paid to bank staff as
part of its strategy to increase bank usage
and reduce the reliance on more
expensive agency workers. The controls
that were in place seemed to have
started to reduce agency spend as
planned (although not at the rate hoped).
However shortages in nursing staff in
December has meant that an emergency
removal of the controls was effected by
the Director of Clinical Services.
Therefore agency spend is expected to
grow once again over the rest of the year.
Expected date to meet
standard
Lead Director
Pay is likely to continue to
overspend until performance
targets are met and
performance is stabilised, and
until the policies to recruit &
retain permanent staff take
effect.
Director for Finance & Procurement
Standard
Current Data Period
Period Actual
101%
Nov-14
101.49%
YTD
Forecast next period
17
IPF Red Escalation Report FY 2014-15
Vacancy rate
What is driving the reported
underperformance?
Despite an increase in staff in
post, vacancy levels have risen
on the previous month from
6.1% to 6.7%. The is due in part
to increases in Budget wte .
The issues facing recruitment
and retention are well
documented and continue to
influence vacancy levels in a
variety of staff groups and
areas.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Nov-14
6.73%
YTD
Forecast next period
The Trust has set improving retention as
a key corporate objective. Six high impact
areas have been identified to facilitate
improved retention rates.






Increasing substantive workforce
capacity
Mitigating high cost of living
Applying targeted recruitment and
retention incentives
Widening participation
Improving professional development
opportunities and career
advancement
Creating and sustaining the right
environment
Expected date to meet
standard
Lead Director
Q4
Director of Organisational Development
and Workforce
18
IPF Red Escalation Report FY 2014-15
Sickness absence**
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
3%
Nov-14
3.61%
YTD
Forecast next period
Sickness absence is at 3.6%
The Trust continues to manage sickness
which is above the KPI of 3.0%. absence operationally by the close
working of Line Managers, Occupational
Improved data quality following Health and HR. The process is aided by
FirstCare’s introduction has
the improved flow of information to line
influenced the rise in reported managers from FirstCare data and the
sickness levels.
automation of process.
Flu vaccination for front line staff is at
58%. Occupational Health is now offering
a rapid Psychiatric assessment service to
appropriate users.
In 2015, FirstCare and Divisional
representatives will meet to review
Division specific data and trends. This will
assist in informing and agreeing
appropriate actions and strategies.
The procurement process is underway for
the introduction of an Employee
Assistance Programme.
Expected date to meet
standard
Lead Director
Q1 2015/16
Director of Organisational Development
and Workforce
19
IPF Red Escalation Report FY 2014-15
Turnover rate
What is driving the reported
underperformance?
Turnover has continued to
increase and is now 13.1%.
Since April 2014 the upward
trend is being driven by
increases in turnover for most
staff groups, with the exception
of Estates and Healthcare
Scientists.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
10.5%
Nov-14
13.07%
YTD
Forecast next period
12.79%
Actions taken to address turnover are
compatible with those for reducing
vacancy levels and are highlighted within
this report.
Nursing and Midwifery and
support staff (e.g. Health Care
Assistants), account for 58% of
current leavers, excluding
junior doctors. This figure rises
to 78% when Administrative
and Clerical staff are included.
Allied Health Professional whist
smaller in numbers are also
experiencing a marked increase
in turnover.
Expected date to meet
standard
Lead Director
Q1 205/16
Director of Organisational Development
and Workforce
20
IPF Amber Escalation Report FY 2014-15
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
95%
Nov-14
91.96%
YTD
Forecast next period
90%
There has been slippage on the
Divisions are aware they have to make up any
start of some Divisional and cross- slippage in the remainder of the year and their
Divisional schemes.
performance is being monitored monthly.
Regular meetings are being held with Divisional
Directors and Divisional General Managers, and
a recovery plan is being agreed. Meetings were
also held with individual Divisions at the start of
November and stretch targets set to offset the
shortfall created by the slippage on schemes.
Expected date to meet standard
Lead Director
Q4 2014/15
Director of Finance & Procurement
21
IPF Amber Escalation Report FY 2014-15
RTT - non-admitted % within 18 weeks
What is driving the reported
underperformance?
Non-admitted performance has
not seen an improvement and is
below the 95% standard for the
fourth month in a row.
Performance is likely to dip
further as the backlog clearance
gathers further momentum
throughout December.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Nov-14
92.88%
94.6%
93.91%
Weekly meetings continue to be held with
Divisional Teams and the Director of Clinical
Services.
Specialties with significant challenges continue to
be:
 Orthopaedics
 Spinal
 Ophthalmology
 Neurosurgery
Additional theatres lists are being undertaken
and external providers are being used to support
some surgical activity.
Expected date to meet standard Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal
Director of Clinical Services
22
IPF Amber Escalation Report FY 2014-15
Last min cancellations - % of all EL admissions
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0.5%
Nov-14
0.62%
0.5%
0.3%
A continuation of the worsening The number of elective cancellations increased
of cancellation performance
due to the number of emergency admissions
during November. An increase of directly leading to a lack of elective capacity.
0.1% above standard.
Expected date to meet standard
Lead Director
December 2015
Director of Clinical Services
23
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
November has seen has seen a 2
percentage point increase in total
theatre utilization compared with
October.
Focus continues on productivity for all clinical
teams both on the day and forward booking.
Recruitment of key critical theatre staff is ongoing.
Expected date to meet standard
Lead Director
Quarter 3 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
75%
Nov-14
73.11%
72.5%
71.77%
24
IPF Amber Escalation Report FY 2014-15
%patients cancer treatment <62-days urg GP ref
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Capacity at ‘front end’ of
pathways to see patients within
the 2 week target is quite often
limited, and demand is very often
hugely variable. Capacity and
variability in demand impacts on
delivery and reduces the time left
within the remaining days of the
pathway. Patients choosing to
wait longer also significantly
impacts on the delivery of this
particular target to delay which
can’t be adjusted for.
Plans in place to increase front end capacity.
Working with CCG to increase patient/GP
understanding of need to uptake appointments.
Working with radiology to match diagnostics to
demand.
Expected date to meet standard
Lead Director
January 2015
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
85%
Oct-14
80.49%
77.2%
75.75%
25
IPF Amber Escalation Report FY 2014-15
Proportion of Assisted deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
15%
Nov-14
15.79%
15.5%
14.11%
The Directorate has been
The rate has been below the target for the last 2
reviewing a number of issues
months, there is a level of on-going scrutiny
related to birth including assisted and review of pathways.
deliveries.
There is a link between Induction
of Labour (IOL) and assisted
deliveries. The IOL pathway is
currently being reviewed.
Expected date to meet standard
Lead Director
January 2015
Director of Clinical Services
26
IPF Amber Escalation Report FY 2014-15
% adult inpatients have had a VTE risk assess
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The electronic VTE risk assessment
was housed in CaseNotes and when it
was transferred to EPR (April 2014)
this led to a reduction in VTE risk
assessment performance. This was
due to the lack of familiarity of EPR
but also due to the fact that patients
were not being admitted quickly on
to EPR and therefore doctors were
unable to complete EPR VTE
assessments.
There have been many actions taken since the dip in
VTE risk assessment:
1) Information about how to complete a VTE risk
assessment on EPR has been made available to all
clinical staff – by the thromboprophylaxis team
distributing this information to in-patient wards
and a copy of this information has been cascaded
to each division, with the intention that it is sent
to all doctors.
2) Consultants have been sent a document to show
them how to make an in-patient list to evaluate
their performance in VTE risk assessments. This
was sent to divisions for cascading.
3) An e-mail and a short powerpoint presentation
was sent to all the divisions for cascading to
inform all doctors about the dip in VTE risk
assessment and that as a Trust this needed to
improve.
4) EPR informs clinicians at 6 hours and onwards
following admission that a VTE risk assessment
needs to be completed, if it hasn’t been done.
These measures saw a gradual improvement in
figures, but 95% has not been reached. This has led
to the decision that mandation of VTE risk
assessment will be implemented via EPR. This will
not take place until e-prescribing has been rolled out.
Expected date to meet standard
Lead Director
Dependent upon EPR e-Prescribing
roll-out.
Medical Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Q3 14-15
94.61%
93.8%
93.79%
27