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
Feb-13
Mar-13
Qtr to
Mar-13
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
N/a
1.0
97%
0.5
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
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
2b
From point of referral to treatment in
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
Yes
Yes
Yes
Yes
Surgery
94%
Anti cancer drug treatments
98%
1.0
Yes
Yes
Yes
Yes
Yes
Radiotherapy
94%
1.0
Yes
No
Yes
Yes
Yes
3a
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
All cancers: 31-day wait for second or
subsequent treatment, comprising :
3b All cancers: 62-day wait for first treatment:
From urgent GP referral for
suspected cancer
From NHS Cancer Screening
Service referral
All Cancers: 31-day wait from diagnosis to
3c
first treatment
3d
Cancer: 2 week wait from referral to date
first seen, comprising:
A&E: From arrival to
3e
admission/transfer/discharge
3f
Care Programme Approach (CPA) patients,
comprising:
Maximum waiting time of four
hours
Receiving follow-up contact within
7 days of discharge
Having formal review
within 12 months
Admissions to inpatients services had
3h access to Crisis Resolution/Home
Treatment teams
3i
Meeting commitment to serve new
psychosis cases by early intervention
teams
3j
Category A call – emergency response
within 8 minutes
Based on internally validated data
uncorrected for shared breaches.
90%
0.5
Yes
Yes
Yes
Yes
Yes
0.5
Yes
Yes
Yes
Yes
Yes
93%
93%
95%
95%
Based on internally validated data
uncorrected for shared breaches.
Based on internally validated data
uncorrected for shared breaches.
1.0
No
Yes
Yes
No
No
No
No
1.0
N/a
N/a
N/a
N/a
N/a
N/a
N/a
95%
≤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
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
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Is the Trust below the de minimus
12
Is the Trust below the YTD ceiling
88
Is the Trust below the de minimus
6
Is the Trust below the YTD ceiling
7
4a Clostridium Difficile
1.0
4b MRSA
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
2.5
1.5
0.5
1.0
1.0
2.0
2.0
AR
AG
G
AG
AG
AR
AR
A
TOTAL
RAG RATING :
GREEN
Returns based on historical data from Oct
2011 sourced from OXPAS for former ORH
sites since Oct 2011 due to data quality
issues within Cerner Millennium. Live data
to be reintroduced in April 2013.
Based on internally validated data
uncorrected for shared breaches.
Red 1
Category A call – ambulance vehicle
3k
arrives within 19 minutes
Board Action
85%
96%
all urgent referrals
for symptomatic breast patients
(cancer not initially suspected)
Minimising mental health delayed transfers
3g
of care
Safety
Current Data
Jan-13
1c
2d
Quality
Threshold
50%
Historic Data
Qtr to
Qtr to
Qtr to
Jun-12
Sep-12
Dec-12
85.73% in March and 89.67% for Q4 as a
whole. Action plan for improvement
trajectory in development.
92 cases in year to date against a ceiling of
88, with 10 cases in March.
One cases in March. 4 cases in year against
a trajectory of 7.
= 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.
Yes
No
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
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
4.0
1.5
0.5
1.0
1.0
2.0
2.0
R
AG
G
AG
AG
AR
AR
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)
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.
This includes the modelled working capital
facility. The IBP assumed a DH loan to deliver
an FRR of 3 at year end but this cannot be drawn
down until the point of licence.
Financial
efficiency
Liquidity
2
2
2
2
2.8
2.8
2.8
2.8
Overriding rules
3
3
3
3
Overall rating
3
3
3
3
3
3
3
3
Liquid ratio days
Weighted Average
25%
60
25
15
10 <10
100%
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
* Trust should detail the normalising adjustments made to calculate this rating within the comments box.
Board Action
ORBIT Reporting Trust Board Integrated Performance Report March 2013 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. ORBIT Reporting
OUH ‐At A Glance 2012‐13
Operational
Access Standards
RTT ‐ admitted % within 18 weeks
RTT admitted ‐ median wait
RTT 95th centile for admitted pathways
RTT ‐ # specialties not delivering the admitted standard
RTT ‐ non‐admitted % within 18 weeks
RTT ‐ non‐admitted ‐ median wait RTT ‐ 95th percentile for non‐admitted RTT
RTT ‐ # specialties not delivering the non‐admitted standard
RTT ‐ incomplete % within 18 weeks
RTT ‐ #waiting on incomplete RTT pathway
% Diagnostic waits waiting 6 weeks or more
% <=4 hours A&E from arrival/trans/discharge
Number of attendances at A/E depts in a month
Last min cancellations ‐ % of all elec admissions
% patients not rebooked within 28 days
Activity 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 Inpat WL patients with a TCI date
No of GP written referrals
Other refs for a first outpatient appointment 1st outpatient attends following GP referral Total number of first outpatient attendances Non‐elective FFCEs
Number of Elective FFCEs ‐ admissions
Number of Elective FFCEs ‐ daycases
Total number of delayed discharges
DTOCs as % of Occupied beds
Theatre Utilisation ‐ Total
Theatre Utilisation ‐ Elective
Theatre Utilisation ‐ Emergency
Forecast next Data period Quality
Standard
Current Data Period
Period Actual
YTD 90% 11.1 23 Mar
Mar
Mar
92.7% 6.5 21.64 91.9% 7.15 22.26 93.2% 6.6 20.8 3
2
3
0 Mar
0 0 3
95% 6.6 18.3 Mar
Mar
Mar
97.9% 2.77 16.18 97.6% 3.73 16.05 97.6% 2.9 16.2 2
2
3
0 Mar
0 0.3 92% Mar
NA
Mar
93.6% 34237 95% 94.1% 34638.3 2
2
3
95% Q4 89.7% 92.9% 95% 2
2
0.8% Mar
1.7% 7.9% 1.6% 3
5% NA
Mar
Mar
47.6% 11502 35.6% 50.9% 11502 3
3
NA
Mar
8401 8401 3
NA
Mar
1840 1840 3
NA
Mar
742 742 BPPC by value (%) All
Net Income Compared to Plan (Displayed in £000s)
17% 10544.3 Debtors > 90 Days as % of Total Non‐NHS
I&E
8.6% 127993 Debtors > 90 Days as % of Total NHS
2
17.7% 12436 Creditor Days
Capital Programme Compared to Plan
Mar
Mar
Debtor Days
Capital
Cash & Liquidity
1% NA
Finance
Balance Sheet
3
NA
Mar
24.8% 24.8% 3
NA
Mar
11781 143847 12030.3 3
NA
Mar
7096 94870 7534.7 3
NA
Mar
8399 105081 8461.3 2
NA
Mar
14858 177039 14524 2
NA
1904 5396 39 3.5% 80% 80% 80% Mar
Mar
Mar
Mar
Q4 Mar
Mar
Mar
5542 1973 6512 138 12.5% 73.4% 76.8% 62.9% 67883 21139 59728 1222 9.6% 74.5% 78.8% 62.2% 5341.3 1811.7 5642 140.3 9.5% 73.8% 77.6% 62% 2
3
3
2
2
Cash Held at Month End cf. Plan (£000s)
Liquidity Ratio (Score)
Commissioning Income Compared to Plan (£000s)
PPs/Overseas and RTA Income Compared to Plan (£000s)
Other Income Compared to Plan (£000s)
Pay Compared to Plan (Displayed in £000s)
Non‐Pay Compared to Plan (Displayed in £000s)
CIP Performance Compared to Plan EBITDA Compared to Plan
Break Even Surplus Compared to Plan EBITDA Margin (Score)
EBITDA Achieved (Score)
NRaF net return after financing
I&E Surplus Margin (Score)
Standard
Current Data Period
Period Actual
Forecast next Data period Quality
YTD NA
NA
5% Mar
Mar
Mar
12 50 20% 5.4% 5
5
5
5% Mar
43% 38% 5
95% 7503 23483 Mar
Mar
Mar
89.6% 7576.8 65657 84.7% 22894.5 5
5
5
2 Mar
2 5
‐161 Mar
‐4738.3 ‐1316.2 5
5
53773 Mar
53477.2 672334 1216 Mar
593.8 12027.5 5
9285 Mar
20674 137342.2 5
‐41987 Mar
‐46989.9 ‐450411.4 5
‐16934 Mar
‐22469.4 ‐302523.6 5
4595 5353 Mar
Mar
4808.5 5285.6 45520.3 68768.5 5
5
11 Mar
‐62.9 3646.9 5
3 Mar
3 5
5 Mar
5 5
3 Mar
3 5
2 Mar
2 5
Operational
Cancer Waits
Standard
Current Data Period
Period Actual
YTD Forecast next Data period Quality
%patients cancer treatment <62‐days urgt GP ref
85% Feb
86.6% 86.2% 86.9% Quality
Outcomes
Hospital Standardised Mortality ratio*
5
Summary Hospital‐level Mortality Indicator**
%patients cancer treatment <62‐days ‐ Screen
% patients treatment <62‐days of upgrade
%patients 1st treatment <1 mnth of cancer diag
%patients subs cancer treatment <31days ‐ Surg %patients subs cancer treatment <31‐days ‐ Drugs
%patients subs treatment <31days ‐ Radio
%2WW of an urgt GP ref for suspected cancer %2WW urgent ref ‐ breast symp 90% Feb
100% 96% 94.7% 5
NA
NA 96% Feb
97.7% 96.8% 96.8% 5
94% Feb
98.2% 96.2% 98.2% 5
98% Feb
100% 99.8% 100% 5
94% Feb
94.9% 95.9% 94.5% 5
93% Feb
96.7% 95.7% 96.4% 2
93% Feb
95.9% 97% 97.3% 2
Contracted WTE against Plan
Bank usage (Displayed in 000s)
Agency usage (Displayed in 000s)
Total costs of staff (000s)
Staff Experience
Vacancy rate
Sickness absence
Turnover rate
Medical Appraisals
Non Medical Appraisals
Statutory and Mandatory Competence Compliance
Proportion of Assisted deliveries
Proportion of C‐Section deliveries
Proportion of normal deliveries
Total # of deliveries
Patient Experience
Forecast next Data period Quality
Standard
Current Data Period
Period Actual
YTD 9578 Mar
9061.4 9024.1 4
NA
NA
Mar
Mar
£ ‐923 £ ‐6974 £ ‐672 £ ‐2740 £ ‐17629 £ ‐1776 5
5
£ ‐41987 Mar
£ ‐46990 £ ‐450411 £ ‐40224 5% Mar
5.4% 5.6% 2
3.2% Mar
3% 3.1% 3.4% 2
11% 100% 90% Mar
Q4 Q4 11.3% 92.3% 65.1% 11.2% 95.2% 70.1% 2
90% Q4 74% Monthly numbers of complaints received
Same sex accommodation breaches # patients spend >=90% of time on stroke unit
Safety
Workforce
Head count/Pay costs
ANTT Injectables
5
HCAI ‐ MRSA bacteraemia
Standard
Current Data Period
Period Actual
Forecast next Data period Quality
YTD 100 Dec
98.1 4
1 Sep
1 4
90% Mar
98.8% 96.9% 97.6% 15% Mar
15.5% 14.5% 14.3% 2
23% Mar
21% 21.2% 20.4% 2
62% Mar
63.6% 64.2% 65.3% 2
NA
Mar
730 8593 702 2
NA
Mar
85 869 80.3 2
0 Q4 5 13 4.3 2
80% Mar
87.5% 89.3% 87.5% 5
1 Mar
1 4 0.3 5
7 Mar
10 92 8.7 5
90% Q4 93.1% 92.4% 92.7% 5
NA
NA
Mar
Mar
3 0 44 10 3.7 0 2
2
NA
Mar
5.1 44.8 8.6 3
NA
Mar
10.2 89.9 8.1 2
NA
Mar
6 34 3.3 3
NA
Mar
0 2 0.3 2
HCAI ‐ Cdiff
% adult inpatients have had a VTE risk assess
Number SIRIs
Number of Patient Falls with Harm
Patient Falls per 1000 bed days
Incidents per 100 admissions
# acquired, avoidable Grd 3/4 pressure Ulcers
Never Events
* 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
Overall Statutory and Madatory competence Compliance
4
IPF Red Escalation Report
Debtors > 90 Days as % of Total NHS
What is driving the reported underperformance?
What actions have we taken to improve performance
The percentage of NHS debts has The total amount owed to the Trust by third parties increased because the overall value has fallen by £9.4m over the past year. owed by NHS bodies has fallen significantly in March 2013 (and therefore the denominator in the calculation is markedly smaller than it was). This is because many NHS bodies have wanted to settle outstanding amounts prior to their legal cessation on 31 March. Expected date to meet standard
Lead Director
All disputes relating to amounts owed Director of Finance & Procurement
by NHS bodies that no longer exist in 2013/14 must be resolved by 30 June 2013. Standard
Current Data Period
Period Actual
YTD 5% Mar
20% 5.4% Forecast next period
Debtors > 90 Days as % of Total Non‐NHS
What is driving the reported underperformance?
What actions have we taken to improve performance
There are some very old non‐NHS and The total amount owed to the Trust by third parties private patient debts which have has fallen by £9.4m over the past year. The Trust been a matter of on‐going discussions continues to manage payments due to the University between the Trust and the third of Oxford, and will do so until the disputes over the parties which, once resolved, will aged debt of £0.9m are resolved. improve the performance measure quickly. Expected date to meet standard
Lead Director
The University is likely to want to Director of Finance & Procurement
resolve any outstanding matters before its own financial year end (on 31 July 2013). Standard
Current Data Period
Period Actual
YTD 5% Mar
43% 38% Forecast next period
Net Income Compared to Plan (Displayed in £000s)
What is driving the reported underperformance?
What actions have we taken to improve performance
Although the Trust is reporting a retained deficit on its Income & Expenditure account, it has achieved the required surplus against its break even target and therefore met its financial duty for 2012/13. N/A
Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD ‐161 Mar
‐4738.3 ‐1316.2 Forecast next period
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 (PP) income remained below plan for the year, the Trust achieved its overall financial targets. The chart shows how erratic this source of funding can be. All Divisions are examining their processes to ensure private patients are correctly & separately identified. In February the administrative functions for PP were transferred from being within a central corporate department to one where responsibilities sit in the Divisions. Debt collection moved to the central Finance Department at the same time. It is expected that debt collection will improve over the coming months now it is part of a centralized function. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD 1216 Mar
593.8 12027.5 Forecast next period
Pay Compared to Plan (Displayed in £000s)
What is driving the reported underperformance?
What actions have we taken to improve performance
The main reason for the N/A overspend is the Trust’s over‐
performance against contracted levels of activity – the level of activity for patient services ended the year £26.5m, or 4.1%, higher than plan with non‐elective activity in particular over‐
performing. This led to an increase in staff costs, particularly for bank & agency staff where the Trust spent £6.2m more than it did in 2011/12. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD ‐41987 Mar
‐46989.9 ‐450411.4 Forecast next period
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 over‐ N/A performance is generating additional non‐pay expenditure, which represents approximately one third of cost and are variable to a significant degree. The over‐
performance on elective, non‐
elective and out‐patient activities would result in £9.0m additional non‐pay spend on a proportionate basis. Expenditure on “pass through” drugs and devices was £5.9m greater than plan to the end of the year. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD ‐16934 Mar
‐22469.4 ‐302523.6 Forecast next period
Break Even Surplus Compared to Plan What is driving the reported underperformance?
What actions have we taken to improve performance
The Trust ended the year £44,000 better than plan and therefore met its financial duty to break even. N/A Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD 11 Mar
‐62.9 3646.9 Forecast next period
% Diagnostic waits waiting 6 weeks or more
What is driving the reported underperformance?
What actions have we taken to improve performance
There are two areas of significant numbers waiting over 6 weeks, these are, MRI and non‐obstetric ultrasound. The overall number of over 6 week waiters has increased significantly since the end of February (increase of 447 patients 26%). This increase is almost entirely down to a growth in the numbers waiting for MRI scans. The numbers of over 6 week waiters in non‐obstetric ultrasound are high (636 patients) but this shows only a minor increase on the February figures. Non‐obstetric ultrasound MSK – improving daily sessional productivity, additional fully resourced capacity in month. Agreeing internal referral criteria to increase capacity. OCCG has written to GPs to review criteria for referral to help reduce demand on service. MRI – review of capacity within current job plans, prioritizing work load within diagnostics, ensuring adherence to current clinical referral protocols, reviewing direct referrals from OCCG to MSK Hub rather than direct to radiology
Expected date to meet standard
Lead Director
June 2013
Director of Clinical Services
Both recovery plans remain on track to deliver early June Standard
Current Data Period
Period Actual
YTD Forecast next period
1% Mar
17.7% 8.6% 17.05% % <=4 hours A&E from arrival/trans/discharge
What is driving the reported underperformance?
What actions have we taken to improve performance
ED performance against the four hour standard continues to be challenging. Weekly performance during quarter 4 to date has ranged from 78% to 95%, with only 1 week, out of the 8 weeks reported quarter to date, seeing the achievement of the 4 hour standard. More recent weeks performance (into April) has continued to be challenged with performances fluctuating around an average of 88% within 4 hours. A significant increase in the number of DToCs will be contributing to the slowing of pathways through the hospital during the winter months. A high level of ED attendances is a contributing factor.
Clinical staffing reviewed on a daily basis to ensure all shifts are filled. Access to agency staffing is variable. Discussions have been had with NHSP to support in medium to long term long lines to support vacancies. Medical staffing has been increased in ED, with additional senior physician support from 3‐8pm daily. Appointments panel has been held for new ED consultant posts. ED escalation area has been opened since January 2013.
Over 100 escalation beds have been open since December rising to a maximum of 121 beds in February. Escalation beds remain open into 2013/14. Internal teleconference calls at weekend to support urgent care pathway, flow and bed management. OUH attendance at Urgent Care taskforce led by OCCG. CEO and COO discussions held with Oxford Health to review ED attendances/admissions/delayed discharges & escalate additional actions to reduce demand. Discussion held with Directors at OUH & OCCG Expected date to meet standard
Lead Director
Q1 2013/14
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
95% Q4 89.7% 92.9% 95% % patients not rebooked within 28 days
What is driving the reported underperformance?
What actions have we taken to improve performance
Data has been partly validated A new validation database has been developed from January, but as yet, no and is now operational and this will help method is yet available to enable deliver the resumption of reporting for this this validation to be fed measure April 2013.
back into Millennium. The numbers presented in this report therefore reflect an un‐
validated position. Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
5% Mar
47.6% 35.6% 50.86% Number of Elective FFCEs ‐ daycases
What is driving the reported underperformance?
What actions have we taken to improve performance
March day case activity has increase significantly compared to January and February levels. However, this increase is usually expected (based on history) during March and compares to a non‐ profiled target level. Daycase activity is expected to return to within contracted levels in April. Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
5396 Mar
6512 59728 5642 Total number of delayed discharges
What is driving the reported underperformance?
What actions have we taken to improve performance
Total number of delays has decreased marginally from 145 at the end of February to 138 at the end of March. Extended cold periods of weather seem to have extended the impact of winter pressures and a high number of attendances continued into March exacerbating the problems. Problems still exist in discharging patients from the Acute sites to community beds. Since the end of March the DToC position has slightly improved further, and at the snapshot date of 18th April there were 120 delayed patients in the OUH hospitals.
Over 90 escalation beds have been open since December rising to a maximum of 121 beds in February to improve patient flow, with over 100 escalation beds remained open in March. Additional clinical decision makers have been funded for ED/EAU Additional discharge planners have been funded and recruited in AGM Supportive Hospital Discharge Scheme is open to 60 patients Some elective work is been done within the private sector to maintain flow. Daily whole system teleconference calls remain in place Weekly discussions with COO continue Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
39 Mar
138 1222 140 DTOCs as % of Occupied beds
What is driving the reported underperformance?
What actions have we taken to improve performance
The marginal decrease in DToCs during March has lead to a marginal decrease in the Q4 overall average to 12.5% compared to the quarter to date figure at the end of February of 12.6%.
Over 90 escalation beds have been open since December rising to a maximum of 121 beds in February to improve patient flow, with over 100 escalation beds remained open in March. Additional clinical decision makers have been funded for ED/EAU Additional discharge planners have been funded and recruited in AGM Supportive Hospital Discharge Scheme is open to 60 patients Some elective work is been done within the private sector to maintain flow. Daily whole system teleconference calls remain in place Weekly discussions with COO continue Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
3.5% Q4 12.5% 9.6% 9.49% Theatre Utilization ‐ Total
What is driving the reported underperformance?
What actions have we taken to improve performance
Last minute cancellations are one Newton Europe an external consultancy group has significant reason driving theatre been engaged and is actively working to improve list utilization underperformance sessional activity across all sites. Real time emphasis against the planned level of 80%. on booking procedures and start and finish times ensuring maximum productivity. Project Board will remain in place to ensure The emphasis placed on lists oversight and to ensure improvements are starting on time by the whole embedded and sustained. clinical team continues to be Escalation beds open across the trust to reduce suboptimal, though is being impact of non‐elective admissions and delayed tackled. discharges on elective activity. Quarter 4 has been For example, last minute changes extremely challenging. Additional elective capacity to lists and late notifications of list has been resourced at weekends and within the private sector. 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.
Additional impact pressured bed capacity makes this standard an extremely difficult one to achieve particularly in winter months.
Expected date to meet standard
Lead Director
Q1 2013/14
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
80% Mar
73.4% 74.5% 73.84% Theatre Utilization ‐ Emergency
What is driving the reported underperformance?
What actions have we taken to improve performance
Utilisation trend is fairly Newton Europe an external consultancy group consistent and varies usually has been engaged and is actively working to between 60% and 65%. Lower improve sessional activity across all sites. Real utilization is desirable in time emphasis on booking procedures and start emergency theatres, as flexibility and finish times ensuring maximum is required to be able productivity. book patients at short notice. The target for emergency theatres utilization probably needs to be reset to around 65%, which will be changed for the reporting year 13/14.
Expected date to meet standard
Lead Director
Q1 2013/14
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
80% Mar
62.9% 62.2% 62.02% Same sex accommodation breaches What is driving the reported underperformance?
This breach was at EAU at HGH on 29 January 2013. A male patient could not be discharged as too unwell and 4 female patients were admitted to EAU. What actions have we taken to improve performance
1.
2.
Each collection of clinical unjustified breaches within a clinical areas completes an RCA. These are reviewed within the Trust at a meeting chaired by the Chief Nurse or her Deputy, to which commissioners are invited, to establish environment, patient flow and training/education resolutions to the breaches. The revised Delivering Single Sex Accommodation policy and associated Trust work plan was presented at Clinical Governance Meeting in April 2013 and progress will be monitored through this group. Expected date to meet standard Lead Director
On‐going Chief Nurse Standard
Current Data Period
Period Actual
YTD Forecast next period
0 Q4 5 13 4 HCAI ‐ Cdiff
What is driving the reported underperformance?
It is unclear as to why there are more cases of C. diff in March 2013. What actions have we taken to improve performance
In March, all patients who had stool samples were reviewed as to the appropriateness of the sample. If it was appropriate it was processed by the lab otherwise the medical/surgical team were informed and asked to review the patient to assess if the sample was required. Expected date to meet standard Lead Director May 2013 following local review Medical Director of all C. diff cases from April 2012 to March 2013 with Oxfordshire Commissioning group who are aiming to remove cases that were unavoidable. Standard
Current Data Period
Period Actual
YTD Forecast next period
7 Mar
10 92 9 Total costs of staff (000s)
What is driving the reported underperformance?
What actions have we taken to improve performance
The main reason for the N/A overspend is the Trust’s over‐
performance against contracted levels of activity – the level of activity for patient services ended the year £26.5m, or 4.1%, higher than plan with non‐elective activity in particular over‐
performing. This led to an increase in staff costs, particularly for bank & agency staff where the Trust spent £6.2m more than it did in 2011/12. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD Forecast next period
£ ‐41987 Mar
£ ‐46990 £ ‐450411 £ ‐40224 Vacancy rate
What is driving the reported underperformance?
Turnover levels and the decision to increase AGM staffing levels at the start of the financial year. What actions have we taken to improve performance
Vacancy levels are closer to KPI threshold of 5% after falling from start of year position of 8%. Vacancies continue to be filled as quickly as possible – a KPI of 8 weeks from notice has been introduced. Focused work is also underway on retention – as outlined in previous workforce reports to Trust Board. Expected date to meet standard Lead Director First quarter 2013/2014. Director of Workforce Standard
Current Data Period
Period Actual
YTD Forecast next period
5% Mar
5.4% 5.55% Turnover rate
What is driving the reported underperformance?
What actions have we taken to improve performance
Increased volume of leavers. Taking into account all leavers over the last 12 months, turnover is 11.3% against a KPI of 11%. The underlying rate of turnover is 11.0% once leavers via ‘managed exit’ programmes are removed. Staff survey results and exit interview analysis have provided insight into reasons for leaving. Focused work continues on retention. A KPI of 10% has been agreed for the new financial year with differential KPIs across the Divisions to reflect the current variances. Expected date to meet standard Lead Director Second quarter 2013/2014 Director of Workforce Standard
Current Data Period
Period Actual
YTD Forecast next period
11% Mar
11.3% 11.18% Medical Appraisals
What is driving the reported underperformance?
Constantly fluctuating numbers – starters and leavers and daily changes. Non‐compliance of 30 (4%) of expected appraisals. What actions have we taken to improve performance
The remaining 30 (4%) are being contacted by the Medical Director to ascertain why they have failed to complete an appraisal. This will enable a procedural review and individual intervention to take place as required. Expected date to meet standard Lead Director 30 April 2013 Medical Director Standard
Current Data Period
Period Actual
YTD Forecast next period
100% Q4 92.3% 95.16% Non Medical Appraisals
What is driving the reported underperformance?
Managers and employees not prioritizing appraisals. Activity pressures in some areas forcing cancellation of appraisals.
Absence of a single comprehensive system to record appraisals. What actions have we taken to improve performance
Standard
Current Data Period
Period Actual
YTD Forecast next period
90% Q4 65.1% 70.14% A new e‐based appraisal linked to the Trust values is being piloted and will be rolled out during the first quarter, supported by comprehensive training. It is envisaged the new process, developed with staff and managers, will increase take up and will also improve reporting.
In addition, appraisal compliance will continue to be a key feature of performance review meetings with Divisions. Expected date to meet standard Lead Director September 2013 Director of Workforce Year 2012‐13 Directorate: Ambulatory,Anaesthetics, Critical care & Theatres,Assurance,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,Emergency Medicine and Therapies ,Estates and Facilities,Finance and Procurement,Generic Strategic Change,Generic Teaching Training and Research,Horton Management,Human Resources and Admin,MARS ‐Research & Development,Medical Director,Networks,Neurosciences,Nursing Midwifery,OHIS Telecoms & Med Records,Oncology,Orthopaedics,Pathology & Laboratories,Pharmacy ,Planning & Communications,Private Patients,Radiology & Imaging,Rehabilitation & Rheumatology,Renal, Transplant & Urology,Specialist Surgery,Strategic Change,Surgery,Teaching Training and Research,Trauma,Trust wide R&D,Trust‐wide only,Unknown,Women's 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
IPF Amber Escalation Report
BPPC by value (%) All
What is driving the reported underperformance?
The Trust has not achieved this standard for some considerable time and hence a review of the “cradle to grave” processes involving Procurement, Accounts Payable and the spending departments is being undertaken to see what the underlying issues may be. What actions have we taken to improve performance
A review of processes within the Accounts Payable department has been initiated and due to be finished in April/May. It is expected that the results will set out recommendations as to how performance can be improved in 2013/14. Expected date to meet standard Lead Director
It is not likely that the Trust will meet this target until some months into 2013/14 at the earliest
Director of Finance & Procurement
Standard
Current Data Period
Period Actual
YTD 95% Mar
89.6% 84.7% Forecast next period
Capital Programme Compared to Plan
What is driving the reported underperformance?
What actions have we taken to improve performance
Although marked as “amber” this N/A is technical only. The Trust has a financial duty not to exceed its Capital Resource Limit and it undershot the limit by £40,000. It therefore met this financial duty in 2012/13 and, at the same time, minimized the underspend. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD 7503 Mar
7576.8 22894.5 Forecast next period
Commissioning Income Compared to Plan (£000s)
What is driving the reported underperformance?
What actions have we taken to improve performance
The Trust ended the year £26.5m N/A better than plan. This was largely driven by over‐performance on non‐elective activity compared to the levels contracted by commissioners. Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD 53773 Mar
53477.2 672334 Forecast next period
EBITDA Compared to Plan
What is driving the reported underperformance?
What actions have we taken to improve performance
The Trust ended the year £3.3m better than plan with the over‐
performance on non‐elective activity resulting in additional expenditure being incurred. N/A Expected date to meet standard
Lead Director
N/A
N/A
Standard
Current Data Period
Period Actual
YTD 5353 Mar
5285.6 68768.5 Forecast next period
Last min cancellations ‐ % of all elec admissions
What is driving the reported underperformance?
What actions have we taken to improve performance
The figure presented for March Weekly validation of the cancellations is (1.7%) is slightly higher than the on‐going, additional escalation beds have been figure for February (1.4%). Some kept open to avoid cancelling surgery. patients have been cancelled due to limited bed capacity. Considerable effort has been spent in minimising the number of cancellations during the period of extreme emergency pressures the Trust is under. Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
0.8% Mar
1.7% 7.9% 1.6% Number of Elective FFCEs ‐ admissions
What is driving the reported underperformance?
What actions have we taken to improve performance
March Elective activity has The number of elective admissions are expected increase significantly compared to to be within agreed contract levels in April. January and February levels. However, this increase is usually expected (based on history) and compares to a non‐ profiled target level. Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
1904 Mar
1973 21139 1812 Theatre Utilization ‐ Elective
What is driving the reported underperformance?
What actions have we taken to improve performance
Last minute cancellations are one Newton Europe an external consultancy group significant reason driving the has been engaged and is actively working to elective theatre list utilization improve sessional activity across all sites. Real underperformance against the time emphasis on booking procedures and start planned level of 80%. The and finish times ensuring maximum emphasis placed on lists starting productivity. on time by the whole clinical team Escalation beds remained open across the trust continues to be suboptimal. For to reduce impact of non‐elective admissions and example, last minute changes to delayed discharges on elective activity. Quarter lists and late notifications of list 4 have been extremely challenging. Additional contents and ‘running order’ are elective capacity has been resourced at fairly weekends and within the private sector. 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. The additional impact of pressured bed capacity makes this standard extremely difficult to achieve particularly in winter months.
Expected date to meet standard
Lead Director
April 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD Forecast next period
80% Mar
76.8% 78.8% 77.58% Proportion of Assisted deliveries
What is driving the reported underperformance?
The assisted delivery rate is linked closely to the Caesarean Section rate and if CS rates are low the assisted delivery rate is often higher. The LSCS rates are lower than many similar units. The rates of assisted deliveries fluctuate depending upon the clinical needs of the women as demonstrated in the table. The overall rate for the year is below the standard. What actions have we taken to improve performance
The assisted delivery rate is monitored using the Dashboard. Year to date the rate remains 0.5% below standard. The total number of deliveries this month is 730 the highest number delivered this quarter. Expected date to meet standard Lead Director See above. Director of Clinical Services Standard
Current Data Period
Period Actual
YTD Forecast next period
15% Mar
15.5% 14.5% 14.34% Overall Statutory and Mandatory Competence Compliance
What is driving the reported underperformance?
What actions have we taken to improve performance
Standard
Current Data Period
Period Actual
YTD 90% Q4 74% Forecast next period
On the new system circa 1,500 Mailshots have been undertaken to target staff have still to register including individuals that have not registered as well as new starters (this has reduced by those that have not completed their core 50% during the last quarter). statutory and mandatory training. Also there has been significant Going forward we will be: discussion regarding the Statutory • Targeting directly those that have not and Mandatory Policy which is engaged in the process (the 1,500 that have currently being reviewed so not not engaged); all staff have completed their • Targeting the competencies that have lower competencies due to the ongoing levels of compliance against the overall discussion. trajectory; • Continuing engagement with Divisions and sharing best practice, for example the highest performing Division currently has 85% compliance. Expected date to meet standard Lead Director Director of Workforce July/Aug based on the average increase of compliance per month of 5.5%. Year: 2012‐13 Directorate: Ambulatory,Anaesthetics, Critical care & Theatres,Assurance,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,Emergency Medicine and Therapies ,Estates and Facilities,Finance and Procurement,Generic Strategic Change,Generic Teaching Training and Research,Horton Management,Human Resources and Admin,MARS ‐Research & Development,Medical Director,Networks,Neurosciences,Nursing Midwifery,OHIS Telecoms & Med Records,Oncology,Orthopaedics,Pathology & Laboratories,Pharmacy ,Planning & Communications,Private Patients,Radiology & Imaging,Rehabilitation & Rheumatology,Renal, Transplant & Urology,Specialist Surgery,Strategic Change,Surgery,Teaching Training and Research,Trauma,Trust wide R&D,Trust‐wide only,Unknown,Women's 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