Performance Framework (Trust Summary) ORBIT Reporting Integrated Performance Framework
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ORBIT Reporting Performance Framework (Trust Summary) Integrated Performance Framework Access Quality Activity Outcomes Cancer Waits Safety 18 weeks, A/E and cancelled operations Patient Experience Colour Description Green Target Achieved Amber Target Under-achieved Red Target Failed Grey No Target NA No Data Available/ Not Applicable Finance I&E Workforce Head count/Pay costs Staff Experience Performance Framework (Divisional Summary) ORBIT Reporting Divisions Division of Cardiac, Vascular & Thoracic Access Access Domain Summary A&E Activity Cancellations Cancer 2 week waits Cancer 31 day waits Cancer 62 day waits Elective Access RTT - Admitted RTT Incompletes RTT - Nonadmitted Theatre Utilisation Total number of delayed discharges Finance Finance Domain Summary I&E Quality Quality Domain Summary ANTT Emergency Admissions Falls HCAI Maternity Never Events Number SIRIs Pressure Ulcers Same sex accommodatio n breaches Stroke Indicator VTE risk assessment Workforce Workforce Domain Summary Agency usage Bank usage Contracted WTE against Plan Sickness absence Total pay costs Total workforce (FTEs) Turnover rate Vacancy rate Colour Description Green Target Achieved Amber Target Under-achieved Red Target Failed Grey No Target NA No Data Available/ Not Applicable Division of Children's & Women's Division of Critical Care, Theatres, Diagnostics and Pharmacy Division of Emergency, Medicine, Therapies & Ambulatory Division of Musculoskeletal and Rehabilitation Division of Neurosciences, Trauma & Specialist Surgery Division of Surgery & Oncology Trust-wide only Division of Corporate Services Division of Operations & Service Improvement ORBIT Reporting Performance Framework Access 18 weeks, A/E and cancelled operations Indicator Information In Period Included in (Framework) Year To Date Latest Actual Period A&E Q067 % of patients who spent 4 hours or less in A&E from arrival, transfer or discharge AESitrep4 Operating Framework, Monitor Framework & Outcomes Framework Activity Q069 Number of attendances at A/E depts in a month - AEAttend Operating Framework May 10096 Cancellations A033 Last minute elective cancellations for treatment/surgery as a percentage of all elective None admissions - CancelRate May A036 % patients rebooked within 28 days - CancelFail None Elective Access Q064 % Diagnostic waits waiting 6 weeks or more - DiagWaits2 RTT - Admitted Q050 RTT Incompletes RTT - Nonadmitted Elective Access Theatre Utilisation R 89.2% 12.18% 0.5% 11.68% R May 34.24% 5% 29.24% Operating Framework May 3.18% 1% RTT - admitted % within 18 weeks - 18Adm Operating Framework & Monitor Framework May 90.5% 90% Q051 admitted - median wait - RTTAdmM None May 7.98 Q052 95th percentile for admitted waiting no longer - RTTAdm95 None May 24.4 23 1.4 A 23.29 Q056 RTT - incomplete % within 18 weeks - 18Incomp Operating Framework May 92.53% 92% 0.53% G 95.33% Q058 Numbers waiting on incomplete referral to treatment pathway - InCompPath Operating Framework & Monitor Framework May 34130 Q053 RTT - non-admitted % within 18 weeks - 18NonAdm Operating Framework & Monitor Framework May 97.23% 95% 2.23% G 96.93% Q054 95th percentile for non-admitted no longer than - RTTNonAdm95 None May 15.69 18.3 -2.61 G 15.75 Q055 non-admitted - median wait - RTTNonAdmM None May 3.57 Included in (Framework) No of GP written referrals - GPRefWrit Operating Framework May A002 Other referrals for a first outpatient appointment - FAOther Operating Framework A003 First outpatient attendances following GP referral - FAGP Operating Framework A004 Total number of first outpatient attendances - FA A016 R 95% G 12.57% 0.5% 12.07% R 0.5% G R 36.97% 5% 31.97% R 5% G 2.18% A 2.18% 1% 1.18% A 1% G 0.5% G 90.52% 90% 0.52% G 90% G 23 0.29 A 23 G 92% 3.33% G 92% G 95% 1.93% G 95% G 18.3 -2.55 G 18.3 G 19606 7.75 3.23 Plan Variance Actual Plan Forecast Outturn Variance Variance From Plan R 24855 15684 9171 R 94103 G May 9178 5371 3807 R 17116 10741 6375 R 64447 G May 10295 7497 2798 R 18264 14994 3270 R 89962 G Operating Framework May 17017 12659 4358 R 30769 25317 5452 R 151903 G Non-elective FFCEs - FFCENE Operating Framework May 5591 4309 1282 R 11375 8617 2758 R 51703 G A017 Number of Elective FFCEs - admissions - FFCEAdm Operating Framework May 1830 1904 -74 G 3414 3808 -394 G 22850 G A018 Number of Elective FFCEs - daycases - FFCEDC Operating Framework May 4606 5396 -790 G 8359 10791 -2432 G 64747 G Q060 Total on Inpatient Waiting List - EALTotal None May 21006 Q061 Total on Inpatient Waiting List dates within 17 weeks - EAL17 None May 10229 Q062 Total on Inpatient Waiting List waiting over 35 weeks - EAL35 None May 1434 Q063 % of Planned Inpatient Waiting List patients with a TCI date - EALTCI None May 17.57% A029 Total Utilisation rate - TURate None May 76.52% 80% -3.48% A 74.89% 80% -5.11% R 80% G A030 Elective - TUEL None May 80.73% 80% 0.73% G 79.65% 80% -0.35% A 80% G A031 Emergency - TUEM None May 64.62% 80% -15.38% R 62.01% 80% -17.99% R 80% G A032 Labour Theatre - TULT None NA Total number of delayed discharges - DelPat None 87 39 210 78 432 G 48 R In Period Included in (Framework) Operating Framework, Monitor Framework & Outcomes Framework Operating Framework, Monitor Framework & Outcomes Framework Operating Framework, Monitor Percentage of patients receiving first definitive treatment within one month of a Framework & Outcomes cancer diagnosis - CancerAll0 Framework Operating Framework, Monitor Percentage of patients receiving subsequent treatment for cancer within 31-days Framework & Outcomes where that treatment is Surgery - CancerSurgery0 Framework Operating Framework, Monitor Percentage of patients receiving subsequent treatment for cancer within 31-days Framework & Outcomes where that treatment is an Anti-Cancer Drug Regime - Canceranti0 Framework Operating Framework, Monitor Percentage of patients receiving subsequent treatment for cancer within 31-days Framework & Outcomes where that treatment is a Radiotherapy Treatment Course - CancerRadio0 Framework Percentage of patients receiving first definitive treatment for cancer within 62-days of Operating Framework, Monitor Framework & Outcomes an urgent GP referral for suspected cancer - CancerUrgTreat0 Framework Percentage of patients receiving first definitive treatment for cancer within 62-days of Operating Framework, Monitor Framework & Outcomes referral from an NHS Cancer Screening Service - CancerNatScr0 Framework Percentage of patients receiving first definitive treatment for cancer within 62-days of Operating Framework & Outcomes Framework a consultant decision to upgrade their priority status - CancerCons0 132 R Year To Date Latest Actual Period Plan Variance Actual Plan Forecast Outturn Variance Variance From Plan Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer - CancerUrgFirst0 Apr 91.67% 93% -1.33% A 91.67% 93% -1.33% A 93% G Q073 Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer is not initially suspected - CancerBreast0 Apr 98.65% 93% 5.65% G 98.65% 93% 5.65% G 94% G Apr 96.77% 96% 0.77% G 96.77% 96% 0.77% G 96% G Apr 93.94% 94% -0.06% A 93.94% 94% -0.06% A 94% G Apr 100% 98% 2% G 100% 98% 2% G 98% G Apr 96.97% 94% 2.97% G 96.97% 94% 2.97% G 94% G Apr 87.93% 85% 2.93% G 87.93% 85% 2.93% G 85% G Apr 95.65% 90% 5.65% G 95.65% 90% 5.65% G 90% G Q006 Q007 Q001 Q002 Q003 Data Quality Process Quality Ref Q072 Q004 Data Quality Process Quality Ref 5713 May Data Quality Process Quality Ref -5.8% 7842 Q005 Cancer 62 day waits Variance From Plan 13555 Indicator Information Cancer 31 day waits Forecast Outturn Variance Year To Date Latest Actual Period A001 Plan 95% In Period Total number of A023 delayed discharges Cancer Waits Cancer 2 week waits Actual -5.8% Indicator Information Activity 89.2% Variance 95% Activity Q1 Plan NA Finance I&E In Period Indicator Information I&E Included in (Framework) Year To Date Latest Actual Period Plan Variance Actual F031 Commissioning Income as % of Plan (Displayed in £000s) - CommInc None May 56541.7 F032 PP & Overseas Income as % of Plan (Displayed in £000s) - PPOInc None May 1011.6 850 F033 Other Income as % of Plan (Displayed in £000s) - Oinc None May 8983.4 10227 -12.16% R F034 Pay as % of Plan (Displayed in £000s) - Pay None May -35524.5 -35430 F035 Non-Pay as % of Plan (Displayed in £000s) - NonPay None May -27248.5 -26453 54567 3.62% G 19.04% G Plan 108111 Forecast Outturn Variance 106256 1.75% G Variance From Plan Process Quality Ref 646072 G 1872.4 1936 -3.29% R 11578 G 19372.9 21470 -9.77% R 129433 G -0.27% A -71207.3 -71079 -0.18% A -422724 G -3.01% R -56121 0.54% G -362806 G -55817.7 Data Quality Quality Outcomes In Period Year To Date Indicator Information Included in (Framework) ANTT Q135 ANTT Injectables - ANTT None May 93.57% Emergency Admissions Q014 Emergency admissions for acute conditions that should not usually require hospital admission - EmerAdm Operating Framework & Outcomes Framework May 361 HSMR Q133 Hospital Standardised Mortality ratio - HSMR Operating Framework & Outcomes Framework NA Maternity Q107 Breast Feeding initiation (BFI) - BFI None NA Q108 Breast Feeding initiation (BFI) - not known - BFIU None NA Q109 Proportion of normal deliveries - NormalDel None May Q020 Hip replacement - PROMSHip Operating Framework & Outcomes Framework NA Q021 Knee replacement - PROMSKnee Operating Framework & Outcomes Framework NA Q022 Groin hernia - PROMSGroin Operating Framework & Outcomes Framework NA Q023 Varicose - PROMSVar Operating Framework & Outcomes Framework NA Q134 Summary Hospital-level Mortality Indicator - SHIMI Operating Framework & Outcomes Framework PROMS for elective procedures SHIMI Patient Experience Latest Actual Period 62.63% Plan Variance 90% 3.57% Actual G Included in (Framework) 94.03% Forecast Outturn Variance 90% 4.03% G 60% 2.71% G 90% Variance From Plan Data Quality Process Quality Ref G 743 60% 2.63% G 62.71% NA In Period Indicator Information Plan Year To Date Latest Actual Period Cleaning Scores Q136 Cleaning Scores - CleanScore None Complaints Q132 Monthly numbers received - CompNo None NA Same sex Q075 Same sex accommodation breaches - AccBreach Operating Framework & Outcomes Q1 Plan Variance Actual Plan Forecast Outturn Variance Variance From Plan Process Quality Ref NA 0 0 0 G 0 0 0 G 0 Data Quality G PROMS for elective procedures SHIMI Q109 Proportion of normal deliveries - NormalDel None Q020 Hip replacement - PROMSHip Operating Framework & Outcomes Framework NA Q021 Knee replacement - PROMSKnee Operating Framework & Outcomes Framework NA Q022 Groin hernia - PROMSGroin Operating Framework & Outcomes Framework NA Q023 Varicose - PROMSVar Operating Framework & Outcomes Framework NA Q134 Summary Hospital-level Mortality Indicator - SHIMI Operating Framework & Outcomes Framework Patient Experience May 62.63% 60% 2.63% G Included in (Framework) 60% 2.71% G NA In Period Indicator Information 62.71% Year To Date Latest Actual Period Plan Variance Actual Plan Forecast Outturn Variance Variance From Plan Process Quality Ref Cleaning Scores Q136 Cleaning Scores - CleanScore None Complaints Monthly numbers received - CompNo None NA Same sex accommodation breaches - AccBreach Operating Framework & Outcomes Framework Q1 0 0 0 G 0 0 0 G 0 G Number of patients who spend at least 90% of their time on a stroke unit StrokeOnUnitM Operating Framework & Outcomes Framework May 87.8% 80% 7.8% G 87.59% 80% 7.59% G 80% G Q132 Same sex Q075 accommodation breaches Stroke Indicator Q085 Safety NA In Period Indicator Information Included in (Framework) Year To Date Latest Actual Period Plan Variance Actual Plan Forecast Outturn Variance Variance From Plan Number of Patient Falls with Harm - Falls None Q096 Patient Falls per 1000 bed days - Fall1000 None Q076 MRSA bacteraemia - MRSAInc May 0 1 -1 G 0 1 -1 G 7 G Q077 CDI - CDiff May 13 8 5 R 24 16 8 R 88 G Incidents Q097 Incidents per 100 admissions - Inci100 Operating Framework, Monitor Framework & Outcomes Framework Operating Framework, Monitor Framework & Outcomes Framework Operating Framework & Outcomes Framework Never Events Q131 Never Events - Never None May 0 0 Number SIRIs Q094 Number SIRIs - SIRI None May 5 11 Pressure Ulcers Q101 Number of newly acquired, avoidable Grade 3 or 4 pressure Ulcers - PU3and4 Operating Framework & Outcomes Framework Apr 5 VTE risk assessment % of all adult inpatients who have had a VTE risk assessment - VTE Operating Framework & Outcomes Framework Q1 91.05% 90% 1.05% G 90% G HCAI Q078 Apr 0 0 0 Data Quality Process Quality Ref Q095 Falls Data Quality 0 NA NA 5 90% 1.05% G 91.05% Workforce Head count/Pay costs In Period Year To Date Indicator Information Included in (Framework) Agency usage W003 Agency usage (Displayed in WTEs) - AgencyUs None May Bank usage W002 Bank usage (Displayed in WTEs) - BankUs None May 157 Contracted WTE W001 against Plan Contracted WTE against Plan - WTE None May 8670.6 9452 -782 G Total pay costs Total costs of staff (to include cost of staff within provider contracts) (Displayed in£000s) - PayCost Operating Framework May -35524.5 -35430 -0.27% R All Hospital and Community Health Services (HCHS) workforce by FTE - WFFTE Operating Framework Apr 9037.5 W011 Total workforce W013 (FTEs) Staff Experience Latest Actual Period Plan Variance Actual Included in (Framework) Forecast Outturn Variance Variance From Plan Data Quality Process Quality Ref 251.4 -71207.3 -71079 -0.18% R Year To Date Latest Actual Period -850775 R 9037.5 In Period Indicator Information Plan Plan Sickness absence W006 Sickness absence - SickAbs None May 3.05% 3.2% Turnover rate W007 Turnover rate - TurnORate None May 10.8% Vacancy rate W005 Vacancy rate - VacRate None May 8.27% Variance Actual Plan -0.15% G 3.07% 3.2% 11% -0.2% G 10.8% 5% 3.27% R 8.16% Forecast Outturn Variance Variance From Plan Process Quality Ref -0.13% G 3.07% G 11% -0.2% G 10.8% G 5% 3.16% R 8.16% R Year: 2012-13 Division: Division of Cardiac, Vascular & Thoracic,Division of Children's & Women's,Division of Corporate Services,Division of Critical Care, Theatres, Diagnostics and Pharmacy,Division of Emergency, Medicine, Therapies & Ambulatory,Division of Musculoskeletal and Rehabilitation,Division of Neurosciences, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Trust-wide only,Unknown Directorate: Ambulatory,Anaesthetics, Critical care & Theatres,Biomedical Research,Cardiac Medicine,Cardiac, Vascular & Thoracic Surgery,Central Trust Services,Children's,CRS Implementation,Division of Cardiac, Vascular & Thoracic,Division of Children's & Women's,Division of Corporate Services,Division of Critical Care, Theatres, Diagnostics and Pharmacy,Division of Emergency, Medicine, Therapies & Ambulatory,Division of Musculoskeletal and Rehabilitation,Division of Neurosciences, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Emergency Medicine & Therapies,Estates and Facilities,Finance and Data Quality Narrative Domain Ref Issue Action Access Q067 A/E Reporting sourced from Millennium has continued throughout May. Achieving the 95% standard has remained challenging through May. Q1 performance at the end of May was at 89%. During June, this has improved slightly. W/E 17.6.12 91.65%, 10.6.12 95.4% respectively. Access A033 Cancellations (Hospital) The figures detailed here are, as yet, unvalidated. The clinical service have a large validation agenda and thus far these have not yet been verified. Access A036 % of cancellations rebooked with 28 days The clinical service have a large validation agenda and thus far these have not yet been verified. Access Q050 & Q052 Elective Access Access Q056 & Q058 Access Q060 – 62 Elective Access Access Q063 Elective Access Access Access Incompletes RTT pathways The Trust is achieving 18 weeks for admitted & non-admitted at a Trust-wide level, by quarter 1 contractually the Trust needs to achieve this target by speciality. Divisional plans are in place & are being monitored. The figures presented here are the re-run from the October RTT submission. There are data quality issues with the incomplete RTT pathway numbers, that are being addressed. For transparency it was consider better to present what has been externally reported. Numbers on the waiting list(EAL): Data Quality issues persist with the waiting list numbers, plans in place for on-going validation & training. % Planned waiting list is also subject to on-going validation with services. Diagnostic waits over 6 weeks: There are ongoing data quality issues with the diagnostic waiting position. These are extricably linked to the data % Diagnostic waits quality of the waiting lists, and are being Q064 waiting 6 weeks or addressed as a top priority. The May position was more a continuation of the partial return for just the diagnostic tests covering Radiology and Audiology. Following implementation of EPR, there have been a number of data quality issues with the activity figures for both outpatient and inpatients. A001 – A017 Activity A001 and A002: GP and Other referrals: Data Timescale Exec Owner 30/06/2012 Director of Clinical Services 30/06/2012 Director of Clinical Services Director of Clinical Services 30/06/2012 Director of Clinical Services 30/06/2012 Director of Clinical Services 30/06/2012 30/06/2012 30/06/2012 30/06/2012 Director of Clinical Services Director of Clinical Services Director of Clinical Services Director of Clinical Access Access Access position. These are extricably linked to the data % Diagnostic waits quality of the waiting lists, and are being Q064 waiting 6 weeks or addressed as a top priority. The May position was more a continuation of the partial return for just the diagnostic tests covering Radiology and Audiology. Following implementation of EPR, there have been a number of data quality issues with the activity figures for both outpatient and inpatients. A001 – A017 Activity A001 and A002: GP and Other referrals: Data quality issues exist with this, and are being addressed. The numbers here reflect the external submission of activity. A029-A32 Theatre Utilisation Relevant data to calculate the utilisation rate for labour theatre is not currently available 30/06/2012 Director of Clinical Services 30/06/2012 Director of Clinical Services 30/06/2012 Director of Clinical Services Access A023 Delayed Discharges Delayed discharges remain a major concern for the Trust. However the Provider action plans are now being implemented and the system wide delays have reduced from 201 in March to 159 at 20/5/12. Access Q004 Cancer 31 day waits This is the signed off performance from Open Exeter for April. NA Access Q005 Cancer 62 day waits This is the signed off performance from Open Exeter for April. NA Workforce W005 Vacancy rate distorts finanacial position Vacancy rate, does not represent gap in service delivery as temporary workforce employed to part cover vacant posts. NA Director of Workforce Finance F031 Under-achievement Better than plan - no comment required of income v. plan Finance F032 Under-achievement None - close enough to plan not to be of concern of income v. plan at present Review at Q1 Director of Finance Finance F033 £0.52m of the under-achievement of “other” Under-achievement income relates to recharges to third parties and is of income v. plan offset by matching underspends on pay and on drugs; some of this will be resolved in Month 3 Review at Q1 Director of Finance Finance F034 Marginal overspend Finance F035 Underspend of nonBetter than plan - no comment required pay v. plan None - close enough to plan not to be of concern at present Director of Clinical Services Director of Clinical Services Director of Clinical Services
