Oxford University Hospitals NHS Trust
GOVERNANCE RISK RATINGS
Insert YES, NO or N/A (as appropriate)
See 'Notes' for further detail of each of the below indicators
Area Ref
Indicator
Sub Sections
Patient Experience
Effectiveness
Referral to treatment information
Data completeness: Community services
1a
comprising:
1b
Data completeness, community services:
(may be introduced later)
Referral information
50%
Treatment activity information
50%
Patient identifier information
Patients dying at home / care
home
1c Data completeness: identifiers MHMDS
Weighting
Nov-12
Dec-12
Qtr to
Dec-12
N/a
N/a
N/a
N/a
N/a
N/a
N/a
50%
N/a
N/a
N/a
N/a
N/a
N/a
N/a
50%
N/a
N/a
N/a
N/a
N/a
N/a
N/a
1.0
97%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
50%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
Board Action
Data completeness: outcomes for patients
on CPA
2a
From point of referral to treatment in
aggregate (RTT) – admitted
Maximum time of 18 weeks
90%
1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
From point of referral to treatment in
2b
aggregate (RTT) – non-admitted
Maximum time of 18 weeks
95%
1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
From point of referral to treatment in
2c aggregate (RTT) – patients on an
incomplete pathway
Maximum time of 18 weeks
92%
1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/A
0.5
No
No
No
No
No
Surgery
Anti cancer drug treatments
Radiotherapy
94%
98%
94%
1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
December position is based on internally
validated data uncorrected for shared
breaches.
1.0
Yes
Yes
No
Yes
Yes
Yes
Yes
December position is based on internally
validated data uncorrected for shared
breaches.
0.5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
0.5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
December position is based on internally
validated data uncorrected for shared
breaches.
No
Yes
Yes
Yes
No
Yes
Performance marginally under target for Dec
at 94.58% although delivered for the quarter
at 95.86%.
N/a
N/a
N/a
N/a
N/a
N/a
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
All cancers: 31-day wait for second or
3a
subsequent treatment, comprising :
3b All cancers: 62-day wait for first treatment:
3c
All Cancers: 31-day wait from diagnosis to
first treatment
3d
Cancer: 2 week wait from referral to date
first seen, comprising:
3e
A&E: From arrival to
admission/transfer/discharge
3f
Care Programme Approach (CPA) patients,
comprising:
3g
From urgent GP referral for
suspected cancer
From NHS Cancer Screening
Service referral
3i
3j
3k
85%
90%
96%
all urgent referrals
for symptomatic breast patients
(cancer not initially suspected)
Maximum waiting time of four
hours
Receiving follow-up contact within
7 days of discharge
Having formal review
within 12 months
Minimising mental health delayed transfers
of care
Admissions to inpatients services had
3h access to Crisis Resolution/Home
Treatment teams
Meeting commitment to serve new
psychosis cases by early intervention
teams
Category A call – emergency response
within 8 minutes
93%
93%
95%
95%
1.0
N/a
≤7.5%
1.0
N/a
N/a
N/a
N/a
N/a
N/a
N/a
95%
1.0
N/a
N/a
N/a
N/a
N/a
N/a
N/a
95%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
Red 1
80%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
Red 2
75%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
95%
1.0
N/a
N/a
N/a
N/a
N/a
N/a
N/a
Category A call – ambulance vehicle
arrives within 19 minutes
Is the Trust below the de minimus
12
No
No
No
No
No
No
No
Is the Trust below the YTD ceiling
88
Yes
No
Yes
Yes
Yes
Yes
Yes
Is the Trust below the de minimus
6
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Is the Trust below the YTD ceiling
7
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1.0
4b MRSA
A
1.0
95%
4a Clostridium Difficile
Safety
Current Data
Oct-12
1c
2d
Quality
Threshold
50%
Historic Data
Qtr to
Qtr to
Qtr to
Mar-12
Jun-12
Sep-12
1.0
CQC Registration
Non-Compliance with CQC Essential
Standards resulting in a Major Impact on
Patients
0
2.0
No
No
No
No
No
No
No
B
Non-Compliance with CQC Essential
Standards resulting in Enforcement Action
0
4.0
No
No
No
No
No
No
No
C
NHS Litigation Authority – Failure to
maintain, or certify a minimum published
CNST level of 1.0 or have in place
appropriate alternative arrangements
0
2.0
No
No
No
No
No
No
No
0.5
2.5
1.5
0.5
0.5
1.0
0.0
G
AR
AG
G
G
AG
G
TOTAL
RAG RATING :
GREEN
Returns based on historical data from Oct
2011 sourced from OXPAS for former ORH
sites from Oct 2011 due to data quality
issues within Cerner Millennium.
December position is based on internally
validated data uncorrected for shared
breaches.
65 cases of C Diff YTD against a ceiling of
67 with 8 cases in December.
One case of MRSA in December and 3 for
YTD against a trajectory of 4.
= Score less than 1
AMBER/GREEN
= Score greater than or equal to 1, but less than 2
AMBER / RED
= Score greater than or equal to 2, but less than 4
RED
= Score greater than or equal to 4
Overriding Rules - Nature and Duration of Override at SHA's Discretion
Meeting the MRSA Objective
Greater than six cases in the year to date, and breaches
the cumulative year-to-date trajectory for three successive
quarters
No
No
No
No
No
No
No
Meeting the C-Diff Objective
Greater than 12 cases in the year to date, and either:
Breaches the cumulative year-to-date trajectory for three
successive quarters
Reports important or signficant outbreaks of C.difficile, as
defined by the Health Protection Agency.
No
No
No
No
No
No
No
iii) RTT Waiting Times
Breaches:
The admitted patients 18 weeks waiting time measure for a
third successive quarter
The non-admitted patients 18 weeks waiting time measure
for a third successive quarter
The incomplete pathway 18 weeks waiting time measure
for a third successive quarter
No
No
No
No
No
No
No
iv) A&E Clinical Quality Indicator
Fails to meet the A&E target twice in any two quarters over
a 12-month period and fails the indicator in a quarter during
the subsequent nine-month period or the full year.
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
N/a
i)
ii)
v)
Cancer Wait Times
Breaches either:
the 31-day cancer waiting time target for a third successive
quarter
For Qtr to Jun-12: 2 failures during a 12
month period (Qtr to Dec-10, Qtr to Mar-11)
and a failure in following 9 months (Qtr to
Jun-12)
the 62-day cancer waiting time target for a third successive
quarter
Breaches:
the category A 8-minute response time target for a third
successive quarter
vi) Ambulance Response Times
the category A 19-minute response time target for a third
successive quarter
either Red 1 or Red 2 targets for a third successive quarter
vii) Community Services data completeness
Fails to maintain the threshold for data completeness for:
referral to treatment information for a third successive
quarter;
service referral information for a third successive quarter,
or;
treatment activity information for a third successive quarter
viii) Any other Indicator weighted 1.0
Breaches the indicator for three successive quarters.
No
No
No
No
No
No
No
Adjusted Governance Risk Rating
0.5
4.0
1.5
0.5
0.5
1.0
0.0
G
R
AG
G
G
AG
G
Page 5 of 34
Page 6 of 34
FINANCIAL RISK RATING
Oxford University Hospitals NHS Trust
Insert the Score (1-5) Achieved for each
Criteria Per Month
Reported
Position
Risk Ratings
Normalised
Position*
Criteria
Indicator
Weight
5
4
3
2
1
Year to
Date
Forecast
Outturn
Year to
Date
Forecast
Outturn
Underlying
performance
EBITDA margin %
25%
11
9
5
1
<1
3
3
3
3
Achievement
of plan
EBITDA achieved %
10%
100 85
70
50 <50
5
5
5
5
Net return after financing %
20%
>3
2
-0.5
-5
<-5
3
3
3
3
I&E surplus margin %
20%
3
2
1
-2
<-2
2
2
2
2
Planned surplus for the year is less than 1%,
therefore this scores a 2.
Liquid ratio days
25%
60
25
15
10 <10
3
2
3
2
IBP assumes a DH loan to deliver an FRR of 3 at
year end but this is not currently included in the
forecast.
3.0
2.8
3.0
2.8
Financial
efficiency
Liquidity
Weighted Average
100%
Overriding rules
3
3
Overall rating
3
Board Action
3
3
3
Overriding Rules :
Max Rating
3
3
2
2
2
3
1
2
Rule
Plan not submitted on time
Plan not submitted complete and correct
PDC dividend not paid in full
Unplanned breach of PBC
One Financial Criterion at "1"
One Financial Criterion at "2"
Two Financial Criteria at "1"
Two Financial Criteria at "2"
No
No
No
No
3
3
* Trust should detail the normalising adjustments made to calculate this rating within the comments box.
Page 7 of 34
Page 8 of 34
ORBIT Reporting Trust Board Integrated Performance Report November 2012 At A Glance report Data Quality Indicator Escalation report 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. Page 9 of 34
ORBIT Reporting
OUH ‐At A Glance 2012‐13
Operational
Access Standards
Standard
NA
Dec
19 19 Creditor Days
NA
Dec
55 55 5
3
Debtors > 90 Days as % of Total NHS
5% Dec
0% 0.1% 0% 5
90% Dec
92.4% 91.4% 92.4% 3
RTT admitted ‐ median wait
11.1 Dec
6.78 7.33 7 2
RTT 95th centile for admitted pathways
23 Dec
21.97 22.77 22 RTT ‐ # specialties not delivering the admitted standard
Period Actual
YTD Forecast next Data period Quality
Debtor Days
Standard
RTT ‐ admitted % within 18 weeks
Finance
Balance Sheet
Period Actual
YTD 5
0 Dec
1 1.3 3
Debtors > 90 Days as % of Total Non‐NHS
5% Dec
35% 36.3% 35% 5
RTT ‐ non‐admitted % within 18 weeks
95% Dec
97.9% 97.5% 97.8% 2
BPPC by value (%) All
95% Dec
88.6% 84.9% 89% 5
RTT ‐ non‐admitted ‐ median wait 6.6 Dec
2.66 4 4.2 2
Capital
Capital Programme Compared to Plan
1367 Dec
1769 11433 3158 5
RTT ‐ 95th percentile for non‐admitted RTT
18.3 Dec
15.59 15.99 16.1 3
40755 Dec
63622 54805 5
0 Dec
0 0 2
Cash & Liquidity
Cash Held at Month End cf. Plan (£000s)
Liquidity Ratio (Score)
2 Dec
3 3 5
92% Dec
94.6% 95.3% 94.9% 2
I&E
Net Income Compared to Plan (Displayed in £000s)
57 Dec
338.7 3575.8 145 5
RTT ‐ #waiting on incomplete RTT pathway
NA
Dec
35008 34958.7 2
Commissioning Income Compared to Plan (£000s)
51730 Dec
% Diagnostic waits waiting 6 weeks or more
1% Dec
10.6% 4.6% 7% 3
1153 Dec
% <=4 hours A&E from arrival/trans/discharge
95% Q3 95.9% 94% 95% 2
PPs/Overseas and RTA Income Compared to Plan (£000s)
Other Income Compared to Plan (£000s)
11811 Number of attendances at A/E depts in a month
NA
Dec
12221 96360 10873 2
Pay Compared to Plan (Displayed in £000s)
‐38580 Last min cancellations ‐ % of all elec admissions
0.8% Dec
1.2% 10.2% 1.4% 3
Non‐Pay Compared to Plan (Displayed in £000s)
‐20743 Dec
% patients not rebooked within 28 days
5% Dec
90.6% 34.7% 60.7% 3
CIP Performance Compared to Plan 5044 Dec
4600.8 32423.1 4119 5
Total on Inpatient Waiting List
NA
Dec
11512 11512 3
EBITDA Compared to Plan
5371 Dec
5705.9 52282.5 5459 5
# on Inpatient Waiting List dates less than 18 weeks
NA
Dec
9059 9059 3
Break Even Surplus Compared to Plan 229 Dec
247.4 3427.6 316 5
# on Inpatient Waiting List waiting between 18 and 35 weeks
# on Inpatient Waiting List waiting 35 weeks & over
NA
Dec
1770 1770 3
EBITDA Margin (Score)
3 Dec
3 3 5
NA
Dec
683 683 3
EBITDA Achieved (Score)
5 Dec
5 5 5
% Planned Inpat WL patients with a TCI date
NA
Dec
23.5% 23.5% 3
NRaF net return after financing
3 Dec
3 3 5
No of GP written referrals
NA
Dec
9876 107756 12028.3 3
I&E Surplus Margin (Score)
2 Dec
2 2 5
Other refs for a first outpatient appointment NA
Dec
6662 72266 7812 3
1st outpatient attends following GP referral NA
Dec
7534 79697 9026 2
Total number of first outpatient attendances NA
Dec
12589 133467 14864 2
Non‐elective FFCEs
NA
Dec
5654 51859 5680.7 2
Number of Elective FFCEs ‐ admissions
1904 Dec
1586 15704 1787.3 3
Number of Elective FFCEs ‐ daycases
5396 Dec
4382 42802 5397.7 3
Total number of delayed discharges
39 Dec
78 801 74.3 2
DTOCs as % of Occupied beds
3.5% Q3 7.5% 8.5% 8.5% 2
Theatre Utilisation ‐ Total
80% Dec
72.7% 74.7% 74.6% Theatre Utilisation ‐ Elective
80% Dec
77.5% 79.2% 78.8% Theatre Utilisation ‐ Emergency
80% Dec
60.4% 62.2% 62.3% RTT ‐ # specialties not delivering the non‐admitted standard
RTT ‐ incomplete % within 18 weeks
Activity Current Data Period
Forecast next Data period
Quality
Current Data Period
55866.4 504468.5 55523 974.6 5
9788.6 1258 5
Dec
11137.4 92515.6 11097 5
Dec
‐37522.4 ‐37017 ‐
329738 1
‐24750.1 ‐224752 ‐25402 5
5
Page 10 of 34
Operational
Cancer Waits
Forecast next Data period
Quality
Standard
Current Data Period
%patients cancer treatment <62‐days urgt GP ref
85% Nov
86.5% 86% 85.8% 5
%patients cancer treatment <62‐days ‐ Screen
90% Nov
100% 96.4% 100% 5
% patients treatment <62‐days of upgrade
NA
NA %patients 1st treatment <1 mnth of cancer diag
96% Nov
96.8% 96.8% 96.6% 5
%patients subs cancer treatment <31days ‐ Surg 94% Nov
97% 95.6% 95.6% 5
%patients subs cancer treatment <31‐days ‐ Drugs
98% Nov
100% 99.7% 100% 5
%patients subs treatment <31days ‐ Radio
94% Nov
94.1% 96.4% 94% 5
%2WW of an urgt GP ref for suspected cancer 93% Nov
97.1% 95.5% 96.7% 2
%2WW urgent ref ‐ breast symp 93% Nov
94.4% 96.9% 94.6% 2
Period Actual
YTD Quality
Outcomes
Standard
Hospital Standardised Mortality ratio
100 Sep
96.2 93.9 95.2 4
Summary Hospital‐level Mortality Indicator
1.13 Aug
1 1 1 4
ANTT Injectables
90% Dec
96.8% 96.7% 97.4% Proportion of Assisted deliveries
15% Dec
13.6% 14.6% 14.8% 2
Proportion of Assisted deliveries
23% Dec
22.6% 21.5% 21.7% 2
Proportion of normal deliveries
62% Dec
63.9% 63.9% 63.5% 2
Total # of deliveries
NA
Dec
700 6487 731 2
Monthly numbers of complaints received
NA
Nov
57 570 64.3 2
0 Q3 8 8 2.7 2
80% Dec
97% 89.8% 94.6% 5
0 7 Dec
Dec
1 8 3 65 0.7 7 5
5
Patient Experience
# patients spend >=90% of time on stroke unit
Safety
YTD Forecast next Data period
Quality
HCAI ‐ MRSA bacteraemia
HCAI ‐ Cdiff
Standard
Current Data Period
Period Actual
9442 Dec
8914.5 8889 4
% adult inpatients have had a VTE risk assess
90% Q3 93.1% 92.1% 92.1% 5
Bank usage (Displayed in 000s)
NA
Dec
£ ‐545 £ ‐4957 £ ‐570 5
Number SIRIs
NA
Dec
1 33 4.3 2
Agency usage (Displayed in 000s)
NA
Dec
£ ‐1550 £ ‐12301 £ ‐1462 5
Number of Patient Falls with Harm
NA
Dec
1 10 1 2
£ ‐38580 Dec
£ ‐37522 Patient Falls per 1000 bed days
NA
Dec
5.7 19.1 5.6 3
2
Contracted WTE against Plan
Total costs of staff (000s)
Staff Experience
Period Actual
5
Same sex accommodation breaches Workforce
Head count/Pay costs
Forecast next Data period Quality
Current Data Period
Vacancy rate
YTD £ ‐
£ ‐37294 329738
5.5% 5% Dec
5.6% 2
Incidents per 100 admissions
NA
Oct
8.2 47 9.2 Sickness absence
3.2% Dec
3.2% 3.1% 3.3% 2
# acquired, avoidable Grd 3/4 pressure Ulcers
NA
Dec
2 24 3.3 3
Turnover rate
11% Dec
11% 10.9% 2
Never Events
NA
Dec
0 1 0 2
Medical Appraisals
NA
Q3 1.6% 100% Non Medical Appraisals
90% Q3 70.1% 71.5% 80% Q3 64% 80% Statutory and Overall Statutory and Madatory competence Compliance
Mandatory Competence Compliance
4
Page 11 of 34
Debtors > 90 Days as % of Total Non-NHS
What is driving the reported
underperformance?
There are some very old non-NHS and
private patient debts which have
been a matter of on-going discussions
between the Trust and the third
parties which, once resolved, will
improve the performance measure
quickly.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
5%
Dec
35%
36.3%
35%
The amount of debt owed as recorded on the
Accounts Receivable system (A/R) has reduced
consistently since July.
The Trust has resolved almost all disputes with other
NHS bodies that are more than 90 days old.
£0.8m of the amount owed by non-NHS
organisations and over 90 days old is owed by the
University of Oxford. A meeting was held with
University representatives on 13 December with the
aim of resolving these debts. The Trust continues to
manage payments due to the University and will do
so until the disputes over the aged debt are resolved.
In January 2013 Jersey General Hospital settled most
of the old debt attributed to them.
The amount of total debt over 90 days old was 22.5%
at the start of the year and has been brought down
to 15.2% at the end of December.
50% of the debts greater than 90 days relate to
private patient (PP) disputes. The main Finance
Department has taken over responsibility for
managing the private patient A/R team from January
2013 with one goal being to reduce the amount of
old PP debt.
Expected date to meet standard
Lead Director
Not until 2013/14 at the earliest
Director of Finance & Procurement
Page 12 of 34
PPs/Overseas and RTA Income Compared to Plan (£000s)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Although private patient income
remains below plan year-to-date,
there has been an upward trend
in the monthly income earned
since July 2012 and the variance is
now less than 1.5% below plan.
All Divisions are examining their processes to
ensure private patients are correctly &
separately identified. It is currently planned that
the administrative functions for PP will be
transferred from being within a central
corporate department to one where
responsibilities sit in the Divisions in February
2013. Debt collection will move to the central
Finance Department at the same time.
Expected date to meet standard
Lead Director
Before 31 March 2012
Director of Finance & Procurement
Standard
Current Data Period
Period Actual
YTD
Forecast next period
1153
Dec
974.6
9788.6
1258
Page 13 of 34
Other Income Compared to Plan (£000s)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
11811
Dec
11137.4
92515.6
11097
The year-to-date adverse variance None required – if R&D is excluded then other
occurs because of slippage on
income would be £1.4m better than plan and
R&D projects and is offset by
risk rated as “green”.
compensating underspends on
pay and non-pay budgets
Expected date to meet standard
Lead Director
N/A
Director of Finance & Procurement
Page 14 of 34
Non-Pay Compared to Plan (Displayed in £000s)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The Trust’s level of activity overperformance is generating
additional non-pay expenditure,
which represents approximately
one third of cost and are variable
to a significant degree. The overperformance on elective, nonelective and out-patient activities
would result in £5.0m additional
non-pay spend on a proportionate
basis. Expenditure on “pass
through” drugs and devices was
£3.6m greater than plan after the
first nine months of the year
Expenditure targets have been set for all
Divisions and their year-end forecasts against
these targets are reviewed at monthly
performance management meetings.
Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
-20743
Dec
-24750.1
-224752
-25402
It is likely that the overDirector of Finance & Procurement
performance on activity will mean
that non-pay expenditure remains
above plan for the remainder of
the year, with Divisions focusing
on achieving the stretch targets
set for them.
Page 15 of 34
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
As previously reported the high
level of bed occupancy within the
Trust means that the full level of
planned savings from ward
closures will not be realised in the
current year. Other than this only
£0.1m of the original savings plan
is currently categorised as being
high risk and which is considered
still to be possibly deliverable in
2012/13.
Performance against savings is monitored at
Divisional monthly performance reviews. KPMG
have been asked to strengthen the process for
identifying and delivering CIP plans for 2013/14
and 2014/15.
Expected date to meet standard
Lead Director
31 March 2013
Director of Finance & Procurement
Standard
Current Data Period
Period Actual
YTD
Forecast next period
5044
Dec
4600.8
32423.1
4119
Page 16 of 34
% Diagnostic waits waiting 6 weeks or more
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
1%
Dec
10.6%
4.6%
7.03%
The Trust is now reporting a full
return to the Department of
Health. This has been in place
since the November submission
(submitted in December),
though some of the patient
waiting time validations being
carried out cannot be
undertaken within the
Millennium system.
Recovery plans have been revised to ensure
performance has improved by end of December
2012.
Non -Obstetric Ultrasound below 6 weeks at the
end of December, the exception is MSK
ultrasound recovery plan is being progressed.
Cardiology
Echo - end January at 5 weeks & below
Ambulatory ECG – at 6 weeks by end of
February
Nuclear – holding at 7 weeks unable to
There are still significant waiting
get below this without additional
times problems in MRI,
resource for a new camera this is
orthopaedics MRI, CT, nonreported on the quarterly submission
obstetric ultrasound,
only.
echocardiography and
cystoscopy with large numbers MRI – demand currently exceeds supply,
(1,031) of patients still waiting
reviewing the way patients are scheduled, moving
(at the end of December 2012) to earliest slot available across all sites. Note 20%
over 6 weeks across all the tests vacancies for radiographers.
highlighted above. .
Expected date to meet standard Lead Director
Director of Clinical Services
Page 17 of 34
% patients not rebooked within 28 days
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Data has not been validated since
implementation of EPR. Year to
date performance means that the
Trust is unable to recovery the
position in this financial year. Due
to the ongoing data quality
problems this quarterly
submission has not been made
since go-live.
Validation had commenced from January with
weekly validation by divisions, additional
corporate support providing individual
validation. Expect to achieve target from April
2013.
Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
5%
Dec
90.6%
34.7%
60.68%
Page 18 of 34
Total number of delayed discharges
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
39
Dec
78
801
74
Total number of delays has
Additional escalation beds have been opened
increased from 64 in November to across all sites.
78 in December.
Whole system Director level meetings to
increase capacity within community hospitals
Direct impact of Christmas & New and social services
Year holidays and high number of Applied for additional winter pressure funding
attendances in ED during
to support escalation beds and staffing.
December has exacerbated the
problems. Problems still exist in
discharging patients from the
Acute sites to community beds.
Since the month of December
submission the DToC position has
worsened, and at the snapshot
date of 23rd January there were
125 delayed patients in the OUH
hospitals.
Expected date to meet standard
Lead Director
Director of Clinical Services
Page 19 of 34
DTOCs as % of Occupied beds
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The trend for the DToCs as a
percentage of occupied beds is
reducing, it is still unacceptably
high and well above the 3.5% set
standard.
Additional escalation beds have been opened
across all sites.
Whole system Director level meetings to
increase capacity within community hospitals
and social services
Applied for additional winter pressure funding
to support escalation beds and staffing.
Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q3
7.5%
8.5%
8.53%
Director of Clinical Services
Page 20 of 34
Theatre Utilisation - Total
What is driving the reported
underperformance?
The emphasis placed on lists
starting on time by the whole
clinical team is not optimal. For
example, last minute changes to
lists and late notifications of list
contents and ‘running order’ are
fairly common. The reasons for
this can be entirely valid from a
clinical priority perspective.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Dec
72.7%
74.7%
74.57%
Newton Europe and external consultancy group
has been engaged and is actively working to
improve sessional activity.
Repatriation of theatres lists back from Ramsay
will happen by end of March.
However, poor list planning does
contribute adversely to the
utilization figure.
Expected date to meet standard
Lead Director
March 2013
Director of Clinical Services
Page 21 of 34
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Dec
60.4%
62.2%
62.29%
Lack of standardised start and
Newton Europe and external consultancy group
finish times in theatres trust wide. has been engaged and is actively working to
Expected lower utilization due to improve sessional activity.
type of theatre activity.
Additional bank holidays in
December.
Perhaps we need to alter the
emergency theatre utilization
target? 80% target is not
appropriate for emergency
theatre utilization.
Expected date to meet standard
Lead Director
Director of Clinical Services
Page 22 of 34
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
8
8
3
This is the position for quarter A trust wide review of Mixed Sex
three, there have been no further accommodation has started.
reportable breaches in November
or December.
Expected date to meet standard Lead Director
Chief Nurse
Page 23 of 34
HCAI - MRSA bacteraemia
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
Dec
1
3
1
The objective is 7 MRSA
The OUH Trust is within its MRSA bacteremia
bacteremia for 2012/2013 and the objective for this financial year.
OUH Trust has had 3 all of which
were unavoidable.
Expected date to meet standard
Lead Director
Meeting standard
Medical Director
Page 24 of 34
HCAI - Cdiff
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The C. diff objective is 88 cases
for 2012/2013 and as a trust we
remain within this Objective.
Focusing on reducing the duration of antibiotics
and early switch from broad spectrum to
narrow.
Expected date to meet standard
Lead Director
Meeting standard
Medical Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
7
Dec
8
65
7
Page 25 of 34
Vacancy rate
What is driving the reported
underperformance?
The vacancy rate does not
represent an absolute position of
staffing levels as temporary
workforce employed to part cover
vacant posts.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Dec
5.6%
YTD
Forecast next period
5.52%
Vacancies continue to be filled as quickly as
possible.
A new KPI has been introduced within
recruitment setting a 13 week turnaround
period to bring a candidate into post. A
specialist recruitment service is being developed
for areas/positions with difficulties in recruiting
to vacant posts.
2013/14 will see a reduction in the turnover
target to 9.5% from 11.0%. Less leavers will
have a positive effect on vacancy rates. The staff
survey and on line leaver questionnaire will
provide valuable information to allow targeted
intervention to reduce leaver rates. Values
based interviewing will provide a better “fit” of
candidate to position thus further minimizing
turnover
Expected date to meet standard
Lead Director
Director of Workforce
Page 26 of 34
Sickness absence
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.2%
Dec
3.2%
3.1%
3.29%
Seasonal trends, sickness levels
Variable targets to be set in next financial year
for winter months are higher than to recognise seasonality.
at any other time in the year.
Sickness will continue to be managed
Sickness levels in month are
proactively between line managers, HR staff and
higher than Trust Target but year Occupational Health. Targeted interventions
to date is below the required
will continue.
performance level.
The appointment of a Health and Wellbeing
It is recommended that the
Specialist will aid the health and wellbeing of
compliance tolerance is amended staff. The sickness procedure is currently being
to reflect year to date against
revised and training planned. Participation in a
target. This will then show
Department of Health funded project will
performance as green.
highlight good practice in 60 Trust to inform
future action.
Expected date to meet standard
Lead Director
March 2013
Director of Workforce
Page 27 of 34
Non Medical Appraisals
What is driving the reported
underperformance?
Managers and employees not
prioritising appraisals.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
90%
Q3
70.1%
YTD
Forecast next period
71.47%
Staff survey results in 2012 highlighted the need
to improve the number of non-medical
appraisals being undertaken.
Activity pressures in some areas
forcing cancellation of
There has been a spotlight on appraisals, with
appraisals.
particular focus at divisional performance
compact meetings. Divisions have developed
Absence of a single
plans to improve in year.
comprehensive system to
record appraisals
There has also been a significant push on
recording appraisals electronically. This is
currently on ESR but will progress to the new ELMS. E-LMS will greatly enhance current levels of
accessibility to recording the required
information. Planned roll out date is
February/March 2013 subject to success of
initial testing.
Expected date to meet standard Lead Director
Director of Workforce
Page 28 of 34
BPPC by value (%) All
What is driving the reported underperformance?
What actions have we taken to improve performance
The Trust has not achieved this standard for many years over the recent past A review of processes within the Accounts Payable department has led to a steady improvement in performance over the past six months Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
YTD Forecast next period
95% Dec
88.6% 84.9% 89% It is not likely that the Trust will meet Director of Finance & Procurement
this target until 2013/14 at the earliest
Page 29 of 34
RTT ‐ # specialties not delivering the admitted standard
What is driving the reported underperformance?
The Trust achieved all its Trust wide targets for December. However at an individual specialty level for ‘admitted’ patients, General Surgery performed below 90% for the month. This was specifically due to lack of capacity both in terms of manpower and theatre lists. What actions have we taken to improve performance
Standard
Current Data Period
Period Actual
YTD Forecast next period
0 Dec
1 1 A review of the recovery plan has been undertaken with the specialty, additional fully resourced lists have been booked for February and March at the Churchill plus additional operating at Horton will achieve the required 90% by end of March 2013. Expected date to meet standard
Lead Director
31 March2013
Director of Clinical Services
Page 30 of 34
Last min cancellations ‐ % of all elec 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
0.8% Dec
1.2% 10.2% 1.38% Technical reporting issues of last Weekly validation by divisions, additional minute cancellations have now corporate support providing individual been resolved, and validation validation, seeing monthly reduction. Expect to work plan has been agreed on an achieve target from April 2013.
ongoing basis. The figure presented for December data (1.2%) is considered to be of much better data quality and a slight reduction on last month of 1.44%.
Historic validation has not happened for previous three quarters and therefore means that the Q3 return will not be submitted.
Expected date to meet standard
Lead Director
April 2013 Director of Clinical Services Page 31 of 34
Theatre Utilisation ‐ Elective
What is driving the reported underperformance?
What actions have we taken to improve performance
The emphasis placed on lists starting on time by the whole clinical team is not optimal. For example, last minute changes to lists and late notifications of list contents and ‘running order’ are fairly common. The reasons for this can be entirely valid from a clinical priority perspective. However, poor list planning does contribute adversely to the utilization figure. Newton Europe and external consultancy group has been engaged and is actively working to improve sessional activity. Repatriation of theatres lists back from Ramsay will happen by end of March. Expected date to meet standard
Lead Director
End of March 2013 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD Forecast next period
80% Dec
77.5% 79.2% 78.76% Page 32 of 34
Overall Statutory and Mandatory competence Compliance
What is driving the reported underperformance?
There are a number of staff that have yet to register on the new E‐
LMS and complete their competencies. Compliance levels across the Divisions is varied. What actions have we taken to improve performance
Standard
Current Data Period
Period Actual
YTD Forecast next period
80% Q3 64% 80% Divisions will be supported to directly target those that have not engaged in the process ( 3,000 ) Drop in facilitated e‐assessment sessions are currently being piloted, if successful they will be made available to staff in all Divisions. This supports enhanced IT usage and familiarises staff with the framework. Further training sessions are now being rolled out to managers to enhance the use of the compliance manager reporting suite for monitoring purposes. Review options to report by staff group and the use of a ‘client’ portal to manage staff groups who are not substantive employees (Junior Docs / Hon Contracts etc) Expected date to meet standard
Lead Director
March 2013
Director of Workforce
Page 33 of 34
Page 34 of 34