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
Patient Experience
Effectiveness
1a
1b
Indicator
Data completeness: Community services
comprising:
Data completeness, community services:
(may be introduced later)
Referral to treatment information
50%
Qtr to
Dec-12
1.0
N/a
N/a
Current Data
Jul-13
Aug-13
Sep-13
Qtr to
Sep-13
N/a
N/a
N/a
N/a
N/a
Referral information
50%
50%
Patient identifier information
50%
N/a
N/a
N/a
N/a
N/a
N/a
N/a
Patients dying at home / care
home
50%
N/a
N/a
N/a
N/a
N/a
N/a
N/a
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
Maximum time of 18 weeks
90%
1.0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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
Yes
Yes
Yes
Yes
Yes
Yes
1.0
Yes
Yes
Yes
No
Yes
Yes
Yes
1.0
Yes
Yes
No
Yes
Yes
No
No
0.5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
0.5
Yes
Yes
Yes
No
Yes
Yes
Yes
1.0
Yes
No
No
Yes
No
Yes
Yes
1.0
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
2b
2d
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
3a
All cancers: 31-day wait for second or
subsequent treatment, comprising :
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
3g
Care Programme Approach (CPA)
patients, comprising:
Surgery
94%
Anti cancer drug treatments
98%
Radiotherapy
94%
From urgent GP referral for
suspected cancer
From NHS Cancer Screening
Service referral
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
93%
93%
95%
95%
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
3i
Meeting commitment to serve new
psychosis cases by early intervention
teams
95%
0.5
N/a
N/a
N/a
N/a
N/a
N/a
N/a
3j
Category A call – emergency response
within 8 minutes
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
Is the Trust below the de minimus
4a Clostridium Difficile
70
Is the Trust below the de minimus
0
4b MRSA
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1.0
Is the Trust below the YTD ceiling
A
No
Yes
1.0
Is the Trust below the YTD ceiling
CQC Registration
Non-Compliance with CQC Essential
Standards resulting in a Major Impact on
Patients
0
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
1.0
2.0
1.5
1.0
1.0
1.0
G
AG
AR
AG
AG
AG
AG
TOTAL
RAG RATING :
GREEN
= 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
Based on internally validated data
uncorrected for shared breaches.
Based on internally validated data
uncorrected for shared breaches.
Based on internally validated data
uncorrected for shared breaches.
Based on internally validated data
uncorrected for shared breaches.
97.41% in July, 94.30% in August and
95.32% in September.
95%
≤7.5%
Category A call – ambulance vehicle
arrives within 19 minutes
Board Action
85%
Admissions to inpatients services had
3h access to Crisis Resolution/Home
Treatment teams
3k
Safety
Historic Data
Qtr to
Qtr to
Mar-13
Jun-13
Weighting
Treatment activity information
1c Data completeness: identifiers MHMDS
1c
3b All cancers: 62-day wait for first treatment:
Quality
Threshold
Sub Sections
5 cases in August with 25 cases ytd against
a threshold of 35.
A single case in September was assessed
as unavoidable by Oxfordshire CCG and so
is not recorded against the zero avoidable
cases target.
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
Threshold
Weighting
Qtr to
Dec-12
Historic Data
Qtr to
Qtr to
Mar-13
Jun-13
Current Data
Jul-13
Aug-13
Sep-13
Qtr to
Sep-13
Board Action
Overriding Rules - Nature and Duration of Override at SHA's Discretion
i)
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
ii)
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
No
No
No
No
No
No
No
No
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
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
iv) A&E Clinical Quality Indicator
v)
Cancer Wait Times
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.
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
0.5
1.0
2.0
1.5
1.0
1.0
1.0
G
AG
AR
AG
AG
AG
AG
2 failures during a 12 month period (Qtr to
Jun-12 and Qtr to Mar-13) with a subsequent
failure Qtr to Jun-13. No override to be
applied at this stage follwing discussion with
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
4
4
4
4
Board Action
Net return after financing %
20%
>3
2
-0.5
-5
<-5
3
3
3
3
Financial
efficiency
I&E surplus margin %
20%
3
2
1
-2
<-2
2
2
2
2
Year to date surplus below 1%. Forecast surplus
of £8.4m is now just below 1% of turnover for the
year (0.96%).
Liquidity
Liquid ratio days
25%
60
25
15
10 <10
3
3
3
3
Liquidity ratio includes a modelled working capital
facility.
2.9
2.9
2.9
2.9
3
3
3
3
Weighted Average
100%
Overriding rules
Overall rating
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.
ORBIT Reporting
Trust Board Integrated
Performance Report
September 2013
At A Glance report
Escalation report
Data Quality Indicator
Graph Legend
The data quality rating has 2 components. The first component is a 5 point rating which
assesses the level and nature of assurance that is available in relation to a specific set of
data. The levels are described in the box below.
Rating
Required Evidence
1
Standard operating procedures and data definitions are in place.
2
As 1 plus: Staff recording the data have been appropriately trained.
3
As 2 plus: The department/service has undertaken its own audit.
4
As 2 plus: A corporate audit has been undertaken.
As 2 plus: An independent audit has been undertaken (e.g. by the Trust's internal
or external auditors).
5
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.
Underachieving
Standard
Plan/ Target
Performance
OUH At‐A‐Glance 2013‐14
ORBIT Reporting
Operational
Access
Standards
Standard
Period Actual
YTD
90%
11.1
Sep‐13
Sep‐13
90.9%
7.28
91.9%
6.93
91.2%
6.9
3
2
RTT 95th centile for admitted pathways
23
Sep‐13
23.83
22.24
23.2
3
RTT ‐ # specialties not delivering the admitted
standard
RTT ‐ non‐admitted % within 18 weeks
0
Sep‐13
5
95%
6.6
18.3
0
Sep‐13
Sep‐13
Sep‐13
Sep‐13
96.6%
5.39
17
1
96.8%
5.06
16.93
Sep‐13
Sep‐13
Sep‐13
92.1%
39935
2.4%
93.3%
% Diagnostic waits waiting 6 weeks or more
92%
NA
1%
% <=4 hours A&E from arrival/trans/discharge
95%
Q2 13‐14
95.6%
94.1%
Ambulance Handovers within 15 minutes
95%
Sep‐13
87.9%
82%
87%
Number of attendances at A/E depts in a month
NA
Sep‐13
10134
64167
11190.3
2
Last min cancellations ‐ % of all elec admissions
0.8%
Sep‐13
0.7%
0.6%
0.6%
2
5%
NA
Sep‐13
Sep‐13
3.3%
11760
10.9%
2.6%
2
3
NA
Sep‐13
9915
NA
Sep‐13
1249
NA
Sep‐13
596
NA
Sep‐13
26%
RTT ‐ admitted % within 18 weeks
RTT admitted ‐ median wait
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
% patients not rebooked within 28 days
Activity
Forecast
Data
next
period Quality
Current Data
Period
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
Quality
Outcomes
9.8%
2
2
3
93%
39998.7
2.8%
2
2
2
Hospital Standardised Mortality ratio*
92.49
100.64
5
5
Summary Hospital‐level Mortality Indicator**
NA
Dec‐12
0.96
5
Proportion of Assisted deliveries
15%
Sep‐13
12.6%
15.1%
14.6%
Proportion of C‐Section deliveries
23%
62%
NA
NA
Sep‐13
Sep‐13
Sep‐13
Sep‐13
20.1%
67.3%
706
0
22%
62.8%
4153
0
21.8%
63.6%
697
0
0%
0
NA
Sep‐13
Sep‐13
Sep‐13
3.4%
0
6
3.6%
1
90
3.6%
0
Sep‐13
0
6
5
NA
Sep‐13
13
95
5
90%
Aug‐13
49.3%
49.6%
50.14%
2
80%
Sep‐13
80.6%
76.8%
75.9%
4
NA
0%
Sep‐13
Sep‐13
84
9.1%
454
11.6%
76.7
11.3%
4
19.7%
20.4%
Total # of deliveries
Maternal Deaths
30 day emergency readmission
Medication errors causing serious harm
Number of CAS Alerts received by Trust during
the month
Number of CAS alerts that were closed having
breached during the month
Number of CAS Alerts with a deadline during
the month
Dementia CQUIN no of patients admitted to
each area who have had a dementia screening
Medications reconcilled within 24 hours of pt
admission
Patient
Experience
Data
Quality
Jul‐13
Jul‐13
Proportion of normal deliveries
5
YTD
Forecast
next
period
NA
NA
Monthly YTD HSMR at weekends for
emergency admission*
4.3
96.9%
5
16.9
1.3
Standard
Current
Data Period Period Actual
Monthly numbers of complaints received
3
5
5
Patient Satisfaction‐ Response rate (friends &
family ‐ED)
Patient Satisfaction ‐Response rate (friends &
family ‐Inpatients)
Net promoter (friends & family ‐ED)
0%
Sep‐13
18.8%
NA
Sep‐13
54
57.7
3
Net promoter (friends & family ‐Inpatients)
NA
Sep‐13
70
71
3
Same sex accommodation breaches
0
Q2 13‐14
0
0
0
2
# patients spend >=90% of time on stroke unit
80%
Sep‐13
95.8%
89.9%
92.1%
5
HCAI ‐ MRSA bacteraemia
0
Sep‐13
1
2
0.3
5
6
Sep‐13
5
25
3
5
3
No of GP written referrals
11689
Sep‐13
12852
76450
12832.7
3
Other refs for a first outpatient appointment
7812
Sep‐13
7376
46286
7660
3
1st outpatient attends following GP referral
8544
Sep‐13
10219
56797
9849.3
2
HCAI ‐ Cdiff
Total number of first outpatient attendances
15077
Sep‐13
17700
99839
17070.3
2
% adult inpatients have had a VTE risk assess
95%
Q2 13‐14
95.4%
95.5%
95.5%
5
Number SIRIs
NA
8
NA
NA
NA
Sep‐13
Sep‐13
Sep‐13
Sep‐13
Sep‐13
7
2
6.32
11.51
5
29
21
5.5
11.64
20
5.3
3.3
5.8
12
4
5
2
2
2
5
0%
Sep‐13
92.1%
91.7%
92.3%
2
NA
Sep‐13
1
2
0.7
5
Non‐elective FFCEs
Sep‐13
Sep‐13
Sep‐13
Sep‐13
Q2 13‐14
5461
1964
6619
128
11.2%
33200
12074
40356
685
10.8%
5622.3
2043.7
6909.3
115.7
10.8%
2
3
3
2
DTOCs as % of Occupied beds
5700
1959
6298
0
3.5%
Theatre Utilisation ‐ Total
75%
Sep‐13
76.6%
75.6%
75.8%
2
Theatre Utilisation ‐ Elective
80%
70%
Sep‐13
Sep‐13
79.2%
68.4%
78.4%
66.7%
78.8%
66.5%
3
2
Number of Elective FFCEs ‐ admissions
Number of Elective FFCEs ‐ daycases
Total number of delayed discharges
Theatre Utilisation ‐ Emergency
Safety
Number of Patient Falls with Harm
Patient Falls per 1000 bed days
Incidents per 100 admissions
# acquired, avoidable Grd 3/4 pressure Ulcers
% of Patients receiving Harm Free Care
(Pressure sores, falls, C‐UTI and VTE)
Never Events
Operational
Cancer Waits
Standard
Current Data
Period
Period Actual
YTD
Forecast
Data
next
period Quality
%patients cancer treatment <62‐days urgt GP
ref
85%
Aug‐13
86.3%
84.2%
86.2%
5
%patients cancer treatment <62‐days ‐ Screen
90%
Aug‐13
94.1%
94.2%
95.4%
5
% patients treatment <62‐days of upgrade
0%
%patients 1st treatment <1 mnth of cancer
diag
96%
Aug‐13
98.4%
97.7%
98.6%
5
%patients subs cancer treatment <31days ‐
Surg
94%
Aug‐13
97.6%
97.2%
98.7%
5
%patients subs cancer treatment <31‐days ‐
Drugs
98%
Aug‐13
100%
99.5%
99.2%
5
%patients subs treatment <31days ‐ Radio
94%
Aug‐13
94.7%
96.9%
96.6%
5
%2WW of an urgt GP ref for suspected cancer
93%
Aug‐13
93.9%
95%
94.4%
5
%2WW urgent ref ‐ breast symp
93%
Aug‐13
96%
95.1%
92.3%
5
0%
Finance
Balance Sheet
Standard
Staff
Experience
Period Actual
Agency usage (Displayed in 000s)
10065.38
NA
NA
Sep‐13
Sep‐13
Sep‐13
9639.06
£ ‐678
£ ‐1446
Total costs of staff (000s)
£ ‐39048
Sep‐13
£ ‐39415
8.9%
2.9%
11%
0%
80%
95%
Sep‐13
Sep‐13
Sep‐13
Q2 13‐14
Q2 13‐14
Q2 13‐14
7.8%
3.1%
11.4%
0%
66.4%
77.2%
Worked WTE against Plan
Bank usage (Displayed in 000s)
Vacancy rate
Sickness absence***
Turnover rate
Medical Appraisals
Non Medical Appraisals
Statutory and
Mandatory
Competence
Compliance
Overall Statutory and Madatory competence
Compliance
Data
Quality
Sep‐13
16%
BPPC by value (%) All
95%
Sep‐13
85.8%
86.3%
95%
Capital
Capital Programme Compared to Plan
1357
Sep‐13
1306.14
3372.67
1358
5
Cash &
Liquidity
Cash Held at Month End cf. Plan (£000s)
53287
Sep‐13
74005
65991
5
3
Sep‐13
3
3
5
Net Income Compared to Plan (Displayed in
£000s)
1105.01
Sep‐13
1189.5
2586.73
3191
5
Pay Compared to Plan (Displayed in £000s)
‐39048.03
Sep‐13
‐39415.1
‐38367
5
CIP Performance Compared to Plan
3634
Sep‐13
3477.83
4075
5
EBITDA Compared to Plan
6564
Sep‐13
6523.76
8621
5
Break Even Surplus Compared to Plan
1313
Sep‐13
1421.81
‐
239915.
19360.9
9
34274.7
6
3979.8
3399
5
3
5
Sep‐13
Sep‐13
3
4
3
4
5
5
3
2
Sep‐13
Sep‐13
3
2
3
2
5
5
5%
5
I&E
Current Data
Period
Forecast
next
period
5%
Liquidity Ratio (Score)
Standard
YTD
Debtors > 90 Days as % of Total debtors
EBITDA Margin (Score)
Workforce
Head
count/Pay
costs
Current
Data Period Period Actual
YTD
Forecast
Data
next
period Quality
£ ‐4007 £ ‐707
£ ‐10761 £ ‐2027
£ ‐38367
£‐
239915
3.1%
11.4%
0%
4
5
5
EBITDA Achieved (Score)
NRaF net return after financing
I&E Surplus Margin (Score)
5
3
3
3
5
4
* This measure is collected on a year to date basis and displays the latest available values
** This measure is collected for a 12 month period preceding the latest period shown
*** Sickness absence figures shown in period actual reflect the financial year to date
Year: 2013‐14
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,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,Estates and Facilities,Finance and Procurement,Gastroenterology, Endoscopy and Theatres (CH),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,Uknown,Unknown,Women's
IPF Red Escalation Report FY 2013‐14
Debtors > 90 Days as % of Total debtors
What is driving the reported
underperformance?
Steady progress has been made in
reducing the level of debt in
excess of 90 days with the
exception of Private Patient debt
which is now subject to a targeted
process and systems review.
What actions have we taken to improve
performance
Debt Recovery Clinic continues to maintain
finance team focus on historic debt and rigour in
process improvements.
Additional capacity has been brought in to
review processes and systems impacting on
private patient debt with capacity diverted from
the core finance team to support this action.
When compared with the same
period last financial year, the level
of debt in excess of 90 days with Efforts will continue with the aim of reducing
the exception of Private Patients the level of debt due to the Trust as low as
has reduced from £3.6m to
possible.
£2.3m.
Expected date to meet standard
Lead Director
Director of Finance and Procurement
The focus remains on steady
progress on historic debt whilst
maintaining low levels of current
debt, resulting in the standard not
being achieved until 2014/15
Standard
Current Data Period
Period Actual
5%
Sep‐13
16%
YTD
Forecast next period
5%
IPF Red Escalation Report FY 2013‐14
EBITDA Achieved (Score)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Although the Trust was slightly
behind plan for in the
achievement of its EBITDA target,
its year‐to‐date “bottom line”
position is on plan and “green”.
This is due to “technical” reasons
and it is believed that these
technical reasons will remain for
most of the rest of the year.
An in‐depth assessment of the forecast year‐
end position has been carried out as part of the
Month 3 Divisional performance reviews. The
Trust currently believes it will meet its key
financial targets for the year but that there are
key risks which, if they materialize, could change
this assessment. A further in‐depth review will
be held as part of the Month 6 Divisional
performance reviews.
Expected date to meet standard
Lead Director
Month 7 2013
Director for Finance & Procurement
Standard
Current Data Period
Period Actual
5
Sep‐13
4
YTD
Forecast next period
4
IPF Red Escalation Report FY 2013‐14
Ambulance Handovers within 15 minutes
What is driving the reported
underperformance?
The data is provided by South
Central Ambulance Service (SCAS)
and is currently not validated by
the OUH.
What actions have we taken to improve
performance
There have been a number of issues associated
with double verification. The Trust and SCAS
agreed and completed a pilot of Double
Verification on w/c 16th September, bother
organisations have reviewed the outcome and
are in the process of implementing the
recommendations.
Expected date to meet standard Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Sep‐13
87.9%
82%
86.95%
IPF Red Escalation Report FY 2013‐14
No of GP written referrals
What is driving the reported
underperformance?
What actions have we taken to improve
performance
GP referrals, whilst still above the The Trust is working with CCG colleagues to look
plan, are significantly reduced on at ways of reducing demand to outpatient
the level seen during July.
services.
September referrals were 1,163
above plan.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
11689
Sep‐13
12852
76450
12833
IPF Red Escalation Report FY 2013‐14
1st outpatient attends following GP referral
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The number of first attendances
is still tracking above plan, in line
with the increased (above plan)
levels of GP referrals being
received.
The Trust is working with CCG colleagues to look
at ways of reducing demand to outpatient
services.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
8544
Sep‐13
10219
56797
9849
IPF Red Escalation Report FY 2013‐14
Total number of first outpatient attendances
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The total number of first
The Trust is working closely with commissioner
attendances is still tracking 2,623 colleagues in looking at ways of reducing GP
patients attendances above plan, referrals.
in line with the increased (above
plan) levels of GP and other
referrals being received.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
15077
Sep‐13
17700
99839
17070
IPF Red Escalation Report FY 2013‐14
Number of Elective FFCEs ‐ daycases
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The overperformance in
outpatient activity is likely to be a
main driver in the continued
overperformance in elective
admissions, as well as the drive to
improve and maintain the 18
week performance at a specialty
level.
Significant demand analysis work is been
undertaken using the IMAS model across
surgical specialties to understand both current
waiting list size, backlogs and additional theatre
capacity requirements.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Additional theatres lists are being undertaken to
ensure patients are treated within 18 weeks.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
6298
Sep‐13
6619
40356
6909
IPF Red Escalation Report FY 2013‐14
DTOCs as % of Occupied beds
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Total number of delays have
remained constantly high through
September and are continuing to
increase. This is still unacceptably
high, and maintains the high
position of over 10% of occupied
beds for the second quarter of
the year. Problems still exist in
discharging patients from the
acute sites to community beds.
Supportive Hospital Discharge Scheme is open to
50 patients reviewing the establishment of team
to increase patient capacity over the coming
months.
Daily whole system teleconference calls remain
in place. Twice weekly discussions with COO s
Oxfordshire Urgent care Working group to
manage the winter plans and funding.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Further work is progressing internally to
improve the discharge process for all patients,
review of policy, standardized documentation,
improving training and competency skills at all
levels.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q2 13‐14
11.2%
10.8%
10.81%
IPF Red Escalation Report FY 2013‐14
Dementia CQUIN no of patients admitted to each area who have had a dementia screening
What is driving the reported
underperformance?
1.
2.
3.
Slight drop in levels of number
of screening in September, as
was the proportion of patients
having a recorded diagnostic
assessment. The changes in
team personnel and systems
had some impact on these
numbers, but an improvement
is expected to be shown in
October figures.
Electronic Cognitive Screening –
19 screenings were completed
on EPR in September, 6 of which
were repeats of manual
screening.
Compliance with standard is
dependent on clinical staff
undertaking screening within
72hours of admission
What actions have we taken to improve
performance
1.
2.
3.
4.
5.
6.
Expected date to meet standard
During September the two CQUIN administrators
have come on line to facilitate collection of data for
all patients.
The number of patients who were ‘sampled’ by the
team has increased from 75% in July and August was
maintained in September, but interim reporting has
October working at over 90%.
From October 1st patients admitted to the Churchill
Site have been included in the program.
EMTA CQUIN Specialist began in October to oversee
the Dementia process the following processes are
under review:
• Methodology for ‘sampling’ patients to:
• Create a more robust methodology regarding
timing of sampling of patients
• Change in local data set to allow for more
responsive ward / speciality based reporting of
compliance which has not been possible up to
this point
Electronic Cognitive Screening – the data collection
system and ability to pull information from ORBIT
are under review to ensure that the manual and
electronic systems can be fused in a coherent way
and adjust to the assumed increase in the use of EPR
Cognitive Screening
More responsive reporting to clinical specialties will
be tested in November for full rollout in December.
Lead Director
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Sep‐13
47.2%
49.6%
50.14%
IPF Red Escalation Report FY 2013‐14
HCAI ‐ MRSA bacteraemia
What is driving the reported
underperformance?
What actions have w e taken to improve
performance
It was agreed that this
None as the case was unavoidable.
contaminated blood culture was
unavoidable due to the patient’s
poor venous access, multiple
attempts to obtain the culture and
continuous movements from the
patient during the procedure.
Expected date to meet standard
Lead Director
N/A
Medical Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Sep‐13
1
2
0
IPF Red Escalation Report FY 2013‐14
Total costs of staff (000s)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Pay costs are being driven by the
continuing high use of bank &
agency staff, and additional
payments made to medical staff
to work weekend sessions that is
required to meet waiting list and
activity targets. Bank and agency
costs are £3.7m higher than for
the first five months of 2012/13,
whilst sessional payments and
overtime have cost £3.76m to
date.
The Trust has introduced a number of workforce
measures to reduce the usage and cost of
agency staff, and has also initiated recruitment
drives to replace temporary staff with
permanent employees.
Expected date to meet standard
Lead Director
Director for Finance & Procurement
Pay is likely to continue to
overspend while activity remains
above plan, with the funding from
over‐performance being used to
cover the additional cost incurred.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
£ ‐39048
Sep‐13
£ ‐39415
£ ‐239915
£ ‐38367
IPF Red Escalation Report FY 2013‐14
Sickness absence***
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Sickness levels for the financial
year to date are 3.1%. In the same
period last year the reported
sickness level was 3.0%. For the
month of September sickness was
higher in 2013 at 3.2% compared
to 2.9% in 2012.
Reducing absence levels during winter months
will be a challenge as sickness absence usually
increases during this period. However there are
several initiatives which it is anticipated will
influence this trend.
Expected date to meet standard
Lead Director
Third quarter
Director of Workforce
Targeted interventions continue e.g. Employee
Assistance Programme in the MARS division, Go
Operations and Service
Active Campaign, Healthy Eating and other
Improvement has the highest
H&WB initiatives. Stress management and other
divisional absence rate at 3.9%,
courses for managing absence are being
followed closely by Children’s and facilitated by the Occupational Health
Women’s at 3.8%. EMTA, Cardiac department and Human Resource Consultants.
and Critical Care are all above the
September trajectory and end of The Trust will be implementing a health care
year Key Performance Indicator. management system in the new year across all
divisions. This will play a key role in improving
The episodes of cold/flu April to
the management of absences, improve
September, as well as
monitoring and reporting which in turn will
headaches/migraine,
reduce absences.
musculoskeletal, Gastro intestinal
and Genitourinary conditions are The Flu campaign is underway within the Trust
all up on 2012.
with circa 2800 staff immunised in week one.
Standard
Current Data Period
Period Actual
2.9%
Sep‐13
3.1%
YTD
Forecast next period
3.1%
IPF Red Escalation Report FY 2013‐14
Turnover rate
What is driving the reported
underperformance?
Turnover has marginally fallen in comparison
with the previous month and is currently
11.4%.
There are circa 60 wte more leavers than at
the same point last year. Six out of eight staff
groups are showing higher turnover levels
than September 2012. These are
•
•
•
•
•
•
Allied Health Professionals
Nursing and Midwifery Registered
Administrative and Clerical
Estates and Ancillary
Healthcare Scientists
Medical and Dental
Leavers in Nursing/Midwifery,
Administrative and Clerical and healthcare
support roles account for circa 78% of
current leavers.
What actions have we taken to
improve performance
A Recruitment and Retention group
has been set up and a recruitment
strategy is in development. The
group will analyse data and develop
a retention strategy containing a
number of actions and strategies for
reducing turnover. Employee
engagement, Health and Wellbeing
strategy will also aid retention as
well as initiatives such as car parking
and accommodation reviews.
A welcome questionnaire has been
sent to all new starters since January
2012. A report will be produced by
April 2014. This with the results of
the staff survey (January 2014) could
potentially provide important
information for retention.
The potential benefits of Values
Based Interviewing (VBI) have been
reported previously. To date 190
interviews have taken place and 90
line managers have been trained.
Training will continue on a bi
monthly basis until November 2014.
Expected date to meet standard
Lead Director
Third quarter.
Director of Workforce
Standard
Current Data Period
Period Actual
11%
Sep‐13
11.4%
YTD
Forecast next period
11.43%
IPF Red Escalation Report FY 2013‐14
Non Medical Appraisals
What is driving the reported
underperformance?
Levels of compliance have
remained constant across
Divisions, in part due to the lack
of live reporting and management
information.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
80%
Q2 13‐14
66.4%
A new Electronic Appraisal System has been
developed, over the past two months the system
has been tested and piloted prior to launching in
November.
The system is due to be launched on the 7th
The new electronic appraisal
November 2013, this launch aims to address
system will give managers live
both the quantity and quality of appraisals, to
information to be able to manage ensure that staff leave their appraisals with
their compliance rates.
‐Clear objectives that are aligned to
organisational objectives and Trust values.
‐ Clear Personal Development Review (PDR) that
supports and motivates them to perform to the
best of their ability in their role.
‐ Enhanced management information to support
managers to identify those staff that are out of
date.
Managers have received communications
throughout October on the launch and further
demonstration days and training is scheduled for
November onwards.
Expected date to meet standard Lead Director
Director of Workforce
Year: 2013‐14
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
YTD
Forecast next period
IPF Amber Escalation Report FY 2013‐14
BPPC by value (%) All
What is driving the reported
underperformance?
Performance against NHS
Payables is driving the
underperformance with better
performance on Non‐NHS
Payables
What actions have we taken to improve
performance
The Trust has increased the use of purchase
orders which helps pay valid invoices more
quickly as they do not then need to be sent out
around the hospitals for approval.
When compared with the performance for the
last financial year, the performance has
improved from 83.8% to 86.3%.
The Trust will continue to aim toward the 95%
target by further extension of the use of
purchase orders and review at individual invoice
level with the divisions to improve the
authorization process.
Expected date to meet standard
Lead Director
Director of Finance and Procurement
Performance improved during
2012/13 and the aim is to build
further towards the target during
13/14.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Sep‐13
85.8%
86.3%
95%
IPF Amber Escalation Report FY 2013‐14
Pay Compared to Plan (Displayed in £000s)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Pay costs are being driven by the
continuing high use of bank &
agency staff, and additional
payments made to medical staff
to work weekend sessions that is
required to meet waiting list and
activity targets. Sessional
payments for medical staff, and
the cost of overtime, has been
£4.5m to date.
The Trust has introduced a number of workforce
measures to reduce the usage and cost of
agency staff, and has also initiated recruitment
drives to replace temporary staff with
permanent employees. While total spend on
bank and agency staff fell in September it is too
early to say whether this was a “one off”
adjustment or the start of a downwards trend.
Expected date to meet standard
Lead Director
Director for Finance & Procurement
Pay is likely to continue to
overspend while activity remains
above plan, with the funding from
over‐performance being used to
cover the additional cost incurred.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
‐39048
Sep‐13
‐39415.1
‐239915
‐38367
IPF Amber Escalation Report FY 2013‐14
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Higher than planned activity levels Performance is monitored regularly by the CIP
are resulting in slippage on some Programme Board. Where it is believed that
savings schemes
some schemes may not deliver the full level of
planned savings then schemes originally due to
start in 2014/15 are being re‐evaluated to see
whether they can be brought forward into
2013/14. The rating has remained “amber” in
September.
Expected date to meet standard
Lead Director
Q4 2013
Director for Finance & Procurement
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3634
Sep‐13
3477.8
19361
4075
IPF Amber Escalation Report FY 2013‐14
EBITDA Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Although the Trust was slightly
behind plan for in the
achievement of its EBITDA target,
its year‐to‐date “bottom line”
position is on plan and “green”.
This is due to “technical” reasons
and it is believed that these
technical reasons will remain for
most of the rest of the year.
An in‐depth assessment of the forecast year‐
end position has been carried out as part of the
Month 3 Divisional performance reviews. The
Trust currently believes it will meet its key
financial targets for the year but that there are
key risks which, if they materialise, could change
this assessment. This view remains unchanged
having considered the Trust’s Month 6 financial
performance although risks to the position still
exist.
Expected date to meet standard
Lead Director
Q3 2013
Director for Finance & Procurement
Standard
Current Data Period
Period Actual
YTD
Forecast next period
6564
Sep‐13
6523.8
34274.8
8621
IPF Amber Escalation Report FY 2013‐14
RTT 95th centile for admitted pathways
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The increase in the 95th percentile
of waits is a clear indication that
despite the high levels of elective
activity, the numbers of long
waiters is growing in a number of
services, which has been
corroborated by the results of the
recent service level IMAS capacity
and demand modelling showing
that there are a number of
services with growing elective
backlogs and with activity rates
not high enough to cope with the
demand coming in to the trust.
Divisional teams are reviewing the IMAS model
to understand the particular issues that are
relevant to each clinical service. Not all services
have a backlog. Plans are being progressed to
implementation to ensure the numbers of long
waiters are reduced over the coming months.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
Sep‐13
23.83
22.24
23.25
IPF Amber Escalation Report FY 2013‐14
RTT ‐ # specialties not delivering the admitted standard
What is driving the reported
underperformance?
ENT, Ophthalmology,
Neurosurgery, Plastic Surgery
and Gynaecology were the
services to fail August’s admitted
performance against the 90%
standard (87%, 74%, 86%, 84% &
85% respectively)
What actions have we taken to improve
performance
Weekly meetings are been held with Specialist
surgery and recovery plans are in place but are
not expected to achieve this target until end of
December . High level of demand, workforce
and capacity constraints have been the three
defining factors to achieving the standard.
Gynaecology has also recovery plans in place.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
0
Sep‐13
5
YTD
Forecast next period
4
IPF Amber Escalation Report FY 2013‐14
RTT ‐ # specialties not delivering the non‐admitted standard
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Trauma and Orthopaedics were Detailed analysis of the back log on the
the service to fail in September at incomplete pathways and implementation of the
93% against the 95% standard
recovery plans to improve the position has
resulted in a number of pathways being closed.
This has in turn had a direct impact on the non‐
admitted pathway.
Expected date to meet standard
Lead Director
30 November 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
0
Sep‐13
1
YTD
Forecast next period
1
IPF Amber Escalation Report FY 2013‐14
% Diagnostic waits waiting 6 weeks or more
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September shows a slowing down
of the reduction in over 6 week
waiters. At the end of September
there were 202 patients waiting
over 6 weeks for their diagnostic
test, with 104 of these waiting for
MRI scans.
Further reductions in patients waiting over 6
weeks are expected during October as the
department continue to provide a significant
amount of extra capacity.
Expected date to meet standard
Lead Director
30 November 2013
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
1%
Sep‐13
2.4%
9.8%
2.79%
IPF Amber Escalation Report FY 2013‐14
Number of Elective FFCEs ‐ admissions
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The overperformance in
outpatient activity is likely to be a
main driver in the continued
overperformance in elective
admissions, as well as the drive to
improve and maintain the 18
week performance at a specialty
level.
Significant demand analysis work is been
undertaken using the IMAS model across
surgical specialties to understand both current
waiting list size and backlogs. Plans are being
progressed to reduce backlogs, additional
theatres lists are being undertaken to ensure
patients are treated within 18 weeks, using
private sector capacity where appropriate.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
1959
Sep‐13
1964
12074
2044
IPF Amber Escalation Report FY 2013‐14
Theatre Utilisation ‐ Elective
What is driving the reported
underperformance?
Performance has continued to
stabilise. The emphasis placed on
lists starting on time by the whole
clinical team continues to be an
area of focus. Last minute
changes to lists and late
notifications of list contents and
‘running order’ are fairly common.
What actions have we taken to improve
performance
Clinical Teams are focused on real time
emphasis on booking procedures and start and
finish times ensuring maximum productivity.
The Project Board will remain in place to ensure
oversight and to ensure improvements are
sustained.
The reasons for this can be
entirely valid from a clinical
priority perspective. However,
poor list planning does contribute
adversely to the utilization figure.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Sep‐13
79.2%
78.4%
78.75%
IPF Amber Escalation Report FY 2013‐14
Theatre Utilisation ‐ Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
An improvement from last month Clinical Teams are focused on real time
just missing the standard by 1.6% emphasis on booking procedures and start and
finish times ensuring maximum productivity.
Daily monitoring of emergency lists is on‐going.
Expected date to meet standard
Lead Director
On‐going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Sep‐13
68.4%
66.7%
66.5%
IPF Amber Escalation Report FY 2013‐14
Overall Statutory and Mandatory competence Compliance
What is driving the reported
underperformance?
Currently all divisional compliance
is increasing daily with
compliance sitting between 95%
and 71%.
However, trust wide services
(Honorary Contracted staff
compliance is running at 21%
overall) .This is due to Honorary
Contracts sitting out with
Divisions for reporting
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
95%
Q2 13‐14
77.2%
Further discussions have taken place with
Divisional Directors to update the Statutory &
Mandatory Training Policy; these revisions will
be made during November to increase the
sophistication of the competence mapping.
A review of honorary contracts has taken place
and a plan has been developed to engage with
Honorary Contract Holders and align them to
Divisions for reporting.
Continuing to target areas of low compliance.
To date there has been little use of training
passports since this was approved; further
communications will be built into the induction
programme to promote awareness.
Expected date to meet standard Lead Director
Director of Workforce
Year: 2013‐14
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
YTD
Forecast next period