ORBIT Reporting
Trust Board Integrated
Performance Report
May 2014
At A Glance report
Escalation report
Data Quality Indicator
Graph Legend
The data quality rating has 2 components. The first component is a 5 point rating which
assesses the level and nature of assurance that is available in relation to a specific set of
data. The levels are described in the box below.
Rating
Required Evidence
1
Standard operating procedures and data definitions are in place.
2
As 1 plus: Staff recording the data have been appropriately trained.
3
As 2 plus: The department/service has undertaken its own audit.
4
As 2 plus: A corporate audit has been undertaken.
As 2 plus: An independent audit has been undertaken (e.g. by the Trust's internal
or external auditors).
5
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 2014-15
ORBIT Reporting
Operational
Access
Standards
Standard
YTD
Forecast
next
Data
Quality
90%
May-14
87.31%
86.7%
86.7%
3
RTT - non-admitted % within 18 weeks
95%
92%
NA
May-14
May-14
May-14
95.04%
92.42%
41563
94.9%
92%
94.9%
92%
41164.5
11.1
6.6
23
18.3
May-14
May-14
May-14
May-14
8.32
5.34
26.45
17.98
8.01
5.23
26.67
18.22
8
5.2
26.6
18.2
0
May-14
4
RTT - incomplete % within 18 weeks
RTT - #waiting on incomplete RTT pathway
RTT admitted - median wait
RTT - non-admitted - median wait
RTT 95th centile for admitted pathways
RTT - 95th percentile for non-admitted RTT
RTT - # specialties not delivering the admitted
standard
RTT - # specialties not delivering the nonadmitted standard
% Diagnostic waits waiting 6 weeks or more
0
May-14
2
0.5%
May-14
1.64%
Zero tolerance RTT waits AP
0
May-14
3
7
3.5
Zero tolerance RTT waits IP
0
May-14
26
43
21.5
0
May-14
3
3
1.5
Zero tolerance RTT waits NP
Ambulance Handovers within 15 minutes
0%
1.8%
1.8%
Quality
Outcomes
YTD
Forecast
next
689
62.55%
21.63%
1382
63%
21.1%
691
63%
21.1%
May-14
May-14
May-14
May-14
15.82%
0
3.71%
80.04%
15.9%
0
4%
80.8%
15.9%
0
May-14
0
1
Number of CAS Alerts received by Trust during
the month
Number of CAS Alerts with a deadline during
the month
Number of CAS alerts that were closed having
breached during the month
Dementia CQUIN patients admitted who have
had a dementia screen
Monthly numbers of complaints received
NA
May-14
7
16
5
NA
May-14
9
29
5
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Net promoter (friends & family -Inpatients)
Standard
NA
Sep-13
0.96
2
2
2
Total # of deliveries
NA
62%
23%
May-14
May-14
May-14
2
2
3
3
Proportion of Assisted deliveries
15%
NA
0%
80%
Proportion of normal deliveries
Proportion of C-Section deliveries
Maternal Deaths
30 day emergency readmission
Medication reconciliation completed within 24
hours of admission
Medication errors causing serious harm
2
Patient
Experience
No data available
0
0
62.23%
62.2%
NA
May-14
83
0%
May-14
22.65%
NA
May-14
78
0%
May-14
12.37%
19.6%
19.6%
NA
May-14
27
0
80%
Q1 14-15
May-14
11
85.07%
11
85.6%
11
85.6%
0%
May-14
87.5%
80.3%
80.3%
0
0
May-14
May-14
0
6
1
7
0.5
3.5
5
5
% adult inpatients have had a VTE risk assess
95%
Q1 14-15
91.54%
91.54%
91.54%
5
May-14
13482
23916
91.38%
91.4%
Last min cancellations - % of all EL admissions
0.5%
May-14
0.48%
0.5%
0.5%
2
Patient Satisfaction- Response rate (friends &
family -ED)
Net promoter (friends & family -ED)
0%
0
May-14
May-14
11.9%
0
9.3%
0
9.3%
0
2
Same sex accommodation breaches
Urgent cancellations
Total on Inpatient Waiting List
0
# patients spend >=90% of time on stroke unit
0
Time to Surgery (% patients having their
operation within the time specified according to
HCAI - MRSA bacteraemia
5
62.2%
2
173
86.5
4
25.6%
25.6%
77
43.5
2
5
NA
NA
May-14
May-14
10756
8920
NA
May-14
1264
NA
May-14
572
3
Number SIRIs
NA
May-14
4
10
5
5
May-14
May-14
May-14
27.65%
12693
17216
25534
33591
12767
16795.5
3
3
2
Number of Patient Falls with Harm
Total number of first outpatient attendances
NA
0
0
Incidents per 100 admissions
0
NA
NA
May-14
May-14
May-14
9
5.28
15.05
14
4.96
5.22
7
5
5.2
2
2
2
1st outpatient attends following GP referral
0
May-14
10075
19610
9805
2
# acquired, avoidable Grade 3/4 pressure Ulcers
NA
May-14
2
3
1.5
5
Other refs for a first outpatient appointment
0
May-14
8852
17493
8746.5
3
0%
May-14
92.6%
92.8%
92.8%
2
Non-elective FFCEs
0
0
May-14
May-14
5849
1861
11477
3714
5738.5
1857
2
3
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
NA
NA
May-14
May-14
0
91%
0
91.6%
0
91.6%
5
0
0
May-14
May-14
7002
104
13980
181
6990
90.5
3
2
# on Inpatient Waiting List dates less than 18
weeks
# on Inpatient Waiting List waiting between 18
and 35 weeks
# on Inpatient Waiting List waiting 35 weeks &
over
% Planned IP WL patients with a TCI date
No of GP written referrals
Number of Elective FFCEs - admissions
Number of Elective FFCEs - day cases
Delayed transfers of care: number (snapshot)
3
3
5
4
Apr-14
Q1 14-15
zero Urgent cancellations - 2nd time
4%
80.8%
3
May-14
NA
5
5
0
95%
2
Data
Quality
0%
% <=4 hours A&E from arrival/trans/discharge
11958
Current
Data Period Period Actual
Summary Hospital-level Mortality Indicator**
Number of attendances at A/E depts in a month
% patients not rebooked within 28 days
Activity
Current
Data Period Period Actual
RTT - admitted % within 18 weeks
Safety
HCAI - Cdiff
Patient Falls per 1000 bed days
Cleaning Scores- % of inpatient areas with initial
score >92%
Flu vaccine uptake
0%
0%
Operational
Activity
Standard
Delayed transfers of care as % of occupied beds
Theatre Utilisation - Total
3.5%
75%
Current
Data Period Period Actual
Q1 14-15
May-14
8.2%
72.77%
YTD
8.2%
72.9%
Forecast
next
Data
Quality
8.2%
73%
2
Finance
Capital
Financial
Risk
Theatre Utilisation - Elective
Theatre Utilisation - Emergency
Cancer
Waits
%patients cancer treatment <62-days urg GP ref
%patients cancer treatment <62-days - Screen
% patients treatment <62-days of upgrade
80%
May-14
76.91%
70%
May-14
57.82%
85%
Apr-14
74.68%
90%
Apr-14
91.67%
91.7%
0%
76.8%
76.8%
3
59%
59%
2
74.7%
74.7%
5
91.7%
5
0%
Standard
Capital Programme Compared to Plan
Capital servicing capacity (times)
Liquidity ratio (days) defined as Working Capital
balance *360/Annual Operating Expenses
Monitor Risk Rating
I&E
CIP Performance Compared to Plan
I&E Surplus Margin (%)
Current
Data Period Period Actual
YTD
90%
May-14
66.83%
90%
1.75
May-14
1.77
1.8
-7
May-14
-7.81
-7
3
May-14
3
3
95%
May-14
90.37%
95%
1%
May-14
-0.17%
1%
%patients subs cancer treatment <31days - Surg
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
%2WW of an urg GP ref for suspected cancer
%2WW urgent ref - breast symp
94%
Apr-14
Apr-14
92.92%
96.43%
Data
Quality
5
%patients 1st treatment <1 mth of cancer diag
96%
Forecast
next
92.9%
96.4%
92.9%
96.4%
5
5
98%
Apr-14
100%
100%
100%
5
94%
Apr-14
69.59%
69.6%
69.6%
5
93%
Apr-14
95.14%
95.1%
95.1%
5
93%
Apr-14
90.91%
90.9%
90.9%
5
Workforce
Head
count/Pay
costs
Standard
Worked WTE against Plan (displayed as a % of
total)**
Bank usage (displayed as a % of total)**
Agency usage (displayed as a % of total)**
Total cost of staff ( displayed as a %)**
Staff
Experience
Vacancy rate
Sickness absence**
Turnover rate
Current
Data Period Period Actual
101%
May-14
95.39%
0%
May-14
1.89%
0%
May-14
5.15%
101%
May-14
104.19%
0%
May-14
8.2%
3%
May-14
3.29%
10.5%
May-14
11.59%
YTD
Forecast
next
period
Data
Quality
3
11.6%
3
* 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
Year: 2014-15
Division: Division of Children's & Women's,Division of Clinical Support Services,Division of Corporate Services,Division of Medicine, Rehabilitation & Cardiac,Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Legacy Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal and
Rehabilitation,TRUST,Trust-wide only,Unknown
Directorate: Acute Medicine & Rehabilitaion ,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research,Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services,Chief Nurse Patient Services & Education,Children's ,Children’s,CRS Implementation,Division of Clinical Support Services,Division of Corporate Services,Division of Medicine, Rehabilitation & Cardiac,Division of Neuroscience,
Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Estates and Facilities,Finance and Procurement,Gastroenterology, Endoscopy and Churchill Theatres ,Gastroenterology, Endoscopy and Theatres (CH),Horton Management,Human Resources and Admin,Legacy Cardiac, Vascular & Thoracic Surgery,Legacy Cardiology,Legacy
Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal and Rehabilitation,Legacy Rehabilitation & Rheumatology,MARS -Research & Development,Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records,Oncology & Haematology ,Orthopaedics,Pathology & Laboratories,Pharmacy,Planning & Communications,Private Patients,Radiology & Imaging,Renal, Transplant & Urology,Specialist Surgery
,Strategic Change,Surgery ,Teaching Training and Research,Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
IPF Red Escalation Report FY 2014-15
Capital Programme Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve performance
Some of the Trust’s new capital
The capital programme is reviewed regularly by the
projects for 2014/15 are starting later Business Planning Group.
than originally anticipated.
Expected date to meet standard
Lead Director
The Trust expects to spend its planned Director of Finance & Procurement
capital funding in full by the end of
the year.
Standard
Current Data
Period
Period Actual
90%
May-14
66.83%
YTD
Forecast next
period
90%
IPF Red Escalation Report FY 2014-15
RTT 95th centile for admitted pathways
What is driving the reported
underperformance?
Across all services there was a
significant increase in activity,
an 11% increase on 2012/13
outturn.
High levels of emergency activity
within Neurosurgery caused a
loss of elective capacity.
May’s reporting period saw a
continued reduction in the 95th
percentile of admitted waits,
but a shallower drop than last
month. This would indicate that
there has been a slowing down
of the longer waiting patients
being treated, whilst also the
majority of the very long waiters
have already been treated.
What actions have we taken to improve
performance
Weekly meetings with divisional teams and
Director of Clinical Services to ensure recovery
plans are being implemented.
Specialties with significant challenges are:




Orthopaedics
Spinal
Ophthalmology
Neurosurgery
Additional capacity has opened in June to support
Orthopaedics, additional theatres lists are being
undertaken and external providers are being used
to support some surgical activity.
The recovery plans in plans continue to ensure
long term sustainability of the waiting times.
Expected date to meet standard Lead Director
Quarter 2 for Trust level
standard with risk limited to
orthopaedics and spinal.
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
May-14
26.45
26.67
26.65
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits AP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
3 admitted patients breached 52
weeks during May, one in each of
Paediatric Trauma &
Orthopaedics, Trauma &
Orthopaedics and Maxillo-facial
surgery.
All patients were treated in May 2014. Weekly
meetings with the Director of Clinical Services to
ensure recovery plans are being implemented to
reduce the number of patients waiting over 18
weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to orthopaedics
and spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
May-14
3
7
4
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits IP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
26 breaches of the 52 weeks
standard for incomplete pathways
in May. 14 of these were Trauma
& Orthopaedics, 3 Ophthalmology
and 9 in Spinal.
Weekly meetings with the Director of Clinical
Services to ensure recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to orthopaedics
and spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
May-14
26
43
21.5
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits NP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
3 breaches in total for the nonWeekly meetings with the Director of Clinical
admitted standard; 2 in Trauma & Services to ensure recovery plans are being
Orthopaedics and 1 Spinal patient implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Trust level standard achieved in
May
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
May-14
3
3
1.5
IPF Red Escalation Report FY 2014-15
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
What actions have we taken to improve performance
Q1 performance to date has seen The Urgent Care Working group meeting contuse to meet
a slight improvement in
weekly, with OCCG, OH, OCC and OUH colleagues to improve
performance compared to Q4.
patient flow across the system.
Daily Escalation in place with significant focus across all
Performance into June has
clinical teams to minimise the number of patients waiting
remained at a similar level to that over four hours.
of May. Performance remains
Additional Short Term Actions include:
challenging, with June’s
 All staffing reviewed each shift to ensure safe staffing
performance for the first 4 weeks
levels in all areas.
averaging at below 92%.
 Extended consultant presence in ED to 6am to 12
June has seen the highest number
midnight
of attenders all year.
 Additional Consultant led ward rounds, additional senior
decision makers in the Emergency
Department/Emergency Assessment Unit to ensure early
discharge or admission avoidance.
 Appointment of two Emergency Assessment Advisors
and an increase in ambulatory (chair space) capacity in
both the ED and Emergency Assessment Unit.
 Increased theatre capacity to manage trauma flow.
 Enhance diagnostic provision to SEU to same level of
ED/EAU
 GP expected patients admitted direct to appropriate
ward and not held in ED.
 Monitoring daily number of discharges from acute wards
to discharge lounge
Expected date to meet standard
Lead Director
July 2014 onwards
Director of Clinical Services
Standard
Current Data
Period
Period Actual
YTD
95%
Q1 14-15
91.38%
91.4%
Forecast next period
IPF Red Escalation Report FY 2014-15
Delayed transfers of care as % of occupied beds
What is driving the reported
underperformance?
May & June have seen a
worsening of the DToC position,
the snapshot of the 19th June has
101 patients as DToC, where the
actual number for May was 104.
This is better than the Q4 position
but still unacceptably high.
What actions have we taken to improve
performance
Daily whole system teleconference calls remain
in place, with further escalation when required
to Oxfordshire colleagues when system is on
RED.
Weekly Urgent Care Summit meeting with
OCCG, OH and OCC colleagues to manage whole
system and winter funding arrangements and
reprioritise where necessary.
Further work is progressing internally to
improve the discharge process for all patients
Expected date to meet standard Lead Director
The system has not agreed a date Director of Clinical Services
to achieve this the standard.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q1 14-15
8.2%
8.2%
8.2%
IPF Red Escalation Report FY 2014-15
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
Emergency theatre utilization
figures continue to be volatile.
What actions have we taken to improve
performance
Internal theatre meetings are in place to review
theatre utilization, work is progressing to develop
a standardised approach across the Trust to
manage the emergency lists which include:
 Developing & implementing a Standard
Operating procedure and flow chart for
all emergency lists
 Standardising the urgency category for all
procedures
Initial focus of this work will include Churchill,
West Wing Horton and JR2 emergency lists.
Expected date to meet standard Lead Director
Quarter 3 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
May-14
57.82%
59%
58.98%
IPF Red Escalation Report FY 2014-15
%patients cancer treatment <62-days urg GP ref
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Sustainable delivery of the 62 day A recovery plan is in place which includes:
target is challenging.
Relocation of the bronchoscopy unit is being
undertaken to the JR and additional scopes have
The main sub specialties
been purchased. Additional capacity sourced
predominately failing to achieve externally.
this standard are within Lung and
The Urology multidisciplinary team are
urology.
Lung: due to lack of thoracic
redesigning the pathway to reduce the average
theatre capacity and reduced
wait to definitive treatment decision. In
bronchoscopy capacity.
addition, the multiple treatment options offered
Urology: due to increased
are under review, giving the option for patients
referrals, complex pathways and to choose active surveillance.
multiple treatment options.
Expected date to meet standard Lead Director
August 2014
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
85%
Apr-14
74.68%
74.7%
74.68%
IPF Red Escalation Report FY 2014-15
%patients subs treatment <31days - Radio
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Problems with Radiotherapy
capacity and staffing have been
well documented. Performance is
however, increasingly adverse to
the trajectory within the recovery
plan.
A recovery plan is in place which includes:
Operating two of the five linacs on a seven day
basis to increase capacity
Extending the operating hours of the five linacs
Monday to Friday from 8am to 8pm
Expected date to meet standard
Lead Director
Performance expected to
deteriorate in the first quarter.
Sustainable achievement of the
standard from August 2014.
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
94%
Apr-14
69.59%
69.6%
69.59%
IPF Red Escalation Report FY 2014-15
Same sex accommodation breaches
What is driving the reported
underperformance?
What actions have we taken to improve
performance
7 non clinically justified breaches Training with both the operational management
and 4 clinically justified breaches Team and EAU will take place before the end of
EAU Co-ordinator on shift in
July.
conjunction with Operational
Team. It was believed at the time
that this would not be a same sex
breach because the patients were
on a separate side of the bay. The
bed bay area on the unit is a
dedicated male area. Foresight
and an understanding of what
constitutes a same sex breach
would avoided the incident
occurring; however this would
have created a chaotic ward
environment with a detriment to
patient care and experience.
Subsequently the decision to
breach same sex accommodation
was due to clinical reasoning and
the requirement to maintain
operational flow for emergency
admissions
Expected date to meet standard
Lead Director
Month 3
Interim Chief Nurse
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Q1 14-15
11
11
11
IPF Red Escalation Report FY 2014-15
Total cost of staff (displayed as a %)**
What is driving the reported
underperformance?
What actions have we taken to improve performance
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.
The Trust is introducing a number of workforce measures
to reduce the usage and cost of agency staff, and is
putting in place plans to improve the recruitment and
retention of permanent staff.
Expected date to meet standard
Lead Director
Pay is likely to continue to overspend Director for Finance & Procurement
in the short term while the Trust
improves its waiting list performance.
Standard
Current Data
Period
Period Actual
101%
May-14
104.19%
YTD
Forecast next
period
IPF Red Escalation Report FY 2014-15
Vacancy rate
What is driving the reported
underperformance?
The vacancy rate is currently 8.20%
which is above the KPI of 5%. Key
factors continuing to influence the
underperformance include: national
shortages in some professional groups;
turnover levels above the Trust KPI;
new additional posts associated with
agreed business cases and new posts
added to budgets at the start of the
new financial year, which will take
several months to fill .
What actions have we taken to improve performance
The recruitment processes have been reviewed to improve
the overall time to recruit . Implementation of the
candidate tracking system is having a beneficial effect.
A further International recruitment campaign is being
planned to recruit nurses across a number of specialties.
Attendance at trade and recruitment fairs will continue.
Consideration is being given to applying affordable
recruitment and retention incentives to some staff groups
within which turnover is a particular issue (e.g. therapeutic
radiography).
The development and implementation of a Recruitment and
Retention Strategy will aim to respond to/address the key
issues affecting retention and turnover.
Expected date to meet standard
Lead Director
September 2014
Director of Organizational Development & Workforce
Standard
Current Data
Period
Period Actual
5%
May-14
8.2%
YTD
Forecast next
period
IPF Red Escalation Report FY 2014-15
Turnover rate
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Staff turnover reduced
marginally from 11.79% in April
to 11.59% in May. The trend for
the previous twelve months has
been relatively constant,
although in excess of the KPI of
10.5%.
“PULSE” surveys have now been undertaken.
Results from the Picker institute will be
published in early July. This, in addition to the
Welcome questionnaire and the recently
revised exit questionnaire, will provide
important information upon which future
retention initiatives can be agreed.
Exit interviews and
questionnaires are providing a
useful source of information
regarding those principal factors
influencing individuals’ decisions
to leave the organisation:
Perceived limited opportunities
for career progression, and the
cost of relocation are
predominant.
In early July a recruitment and retention ‘risk’
summit will be jointly facilitated by the Director
of OD and Workforce and the Chief Nurse. A
range of professional leads and staff side
representatives will be in attendance. The
principal aim of the Summit is to gain a shared
understanding of the key issues influencing our
ability to attract, recruit and retain staff.
Attendees will also consider potential short,
medium and longer term responses to these
issues, as the basis for establishing a
Recruitment and Retention Strategy.
Standard
Current Data Period
Period Actual
10.5%
May-14
11.59%
YTD
Forecast next period
11.65%
Expected date to meet standard Lead Director
September 2014
Director of Organizational Development &
Workforce
Year: 2014-15
Directorate: Acute Medicine & Rehabilitation ,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research, Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services, Chief Nurse Patient Services & Education, Children’s ,Children’s,CRS Implementation, Division of Clinical Support
Services, Division of Corporate Services, Division of Medicine, Rehabilitation & Cardiac, Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery, Division of Operations & Service Improvement, Division of Research & Development, Division of Surgery & Oncology, Estates and Facilities, Finance and
Procurement, Gastroenterology, Endoscopy and Churchill Theatres ,Gastroenterology, Endoscopy and Theatres (CH),Horton Management, Human Resources and Admin, Legacy Cardiac, Vascular & Thoracic Surgery, Legacy Cardiology, Legacy Division of Cardiac, Vascular & Thoracic, Legacy Division of Musculoskeletal
and Rehabilitation, Legacy Rehabilitation & Rheumatology, MARS -Research & Development, Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records, Oncology & Haematology ,Orthopaedics, Pathology & Laboratories,Pharmacy,Planning & Communications, Private Patients, Radiology & Imaging,
Renal, Transplant & Urology, Specialist Surgery ,Strategic Change, Surgery ,Teaching Training and Research, Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
Division: Division of Children's & Women’s, Division of Clinical Support Services, Division of Corporate Services, Division of Medicine, Rehabilitation & Cardiac, Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery, Division of Operations & Service Improvement, Division of Research & Development,
Division of Surgery & Oncology, Legacy Division of Cardiac, Vascular & Thoracic, Legacy Division of Musculoskeletal and Rehabilitation,TRUST,Trust-wide only, Unknown
IPF Amber Escalation Report FY 2014-15
Liquidity ratio (days) defined as Working Capital balance *360/Annual Operating Expenses
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Although Cash and Current
Receivables were higher than
anticipated at the end of April,
Current Payables was also a little
higher and hence the ratio was
lower than planned. The original
plan assumes the Trust will meet
the target by the end of Q1.
None – timing issue only.
Expected date to meet standard
Lead Director
The financial plan for 2014/15
Director of Finance & Procurement
does not expect the Trust to
achieve the target ratio until the
end of the first quarter of the year
(June).
Standard
Current Data Period
Period Actual
-7
May-14
-7.8
YTD
Forecast next period
-7
IPF Amber Escalation Report FY 2014-15
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
There has been slippage on the
Divisions are aware they have to make up any
start of some Divisional and cross- slippage in the remainder of the year and their
Divisional schemes.
performance will be monitored monthly.
Expected date to meet standard
Lead Director
Q2 2014/15
Director of Finance & Procurement
Standard
Current Data Period
Period Actual
95%
May-14
90.37%
YTD
Forecast next period
95%
IPF Amber Escalation Report FY 2014-15
I&E Surplus Margin (%)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The Trust is reporting a small I&E
deficit in April. This is a timing
issue and only the reported
position is better than the
planned surplus.
None – timing issue only.
Expected date to meet standard
Lead Director
The financial plan for 2014/15 is Director of Finance & Procurement
phased such that the Trust is not
expected to generate a 1% surplus
until Month 4 (July).
Standard
Current Data Period
Period Actual
1%
May-14
-0.17%
YTD
Forecast next period
1%
IPF Amber Escalation Report FY 2014-15
RTT - admitted % within 18 weeks
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The improvement in
performance reported for April,
has continued into May,
however, this still remains
below the required 90% within
18 weeks. The backlog reduction
programme continues, but has
slowed a little, reflecting the
greater difficulty of finding
patients who are willing to move
their treatment to other
providers where capacity has
been secured.
Weekly meetings with services with Director of
Clinical Services to ensure recovery plans are
being implemented.
Expected date to meet
standard
Lead Director
Quarter 2 for Trust level
standard with risk limited to
orthopaedics and spinal.
Director of Clinical Services
Specialties with significant challenges are:




Orthopaedics
Spinal
Ophthalmology
Neurosurgery
Additional capacity has opened in June to support
Orthopaedics, additional theatres lists are being
undertaken and external providers are being used
to support some surgical activity.
The recovery plans in plans continue to ensure
long term sustainability of the waiting times.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
May-14
87.31%
86.7%
86.69%
IPF Amber Escalation Report FY 2014-15
RTT - # specialties not delivering the admitted standard
What is driving the reported
underperformance?
What actions have we taken to improve
performance
4 specialties failed to deliver the
admitted standard during May.
These were; Trauma and
Orthopaedics, Ophthalmology,
Neurosurgery and Cardiology.
Weekly meetings with the Director of Clinical
Services to ensure recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to orthopaedics
and spinal.
Standard
Current Data Period
Period Actual
0
May-14
4
YTD
Forecast next period
IPF Amber Escalation Report FY 2014-15
RTT - # specialties not delivering the non-admitted standard
What is driving the reported
underperformance?
What actions have we taken to improve
performance
2 services failed the Non-admitted
standard during May. These were;
Trauma and Orthopaedics and
Ophthalmology.
Weekly meetings with the Director of Clinical
Services to ensure recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Trust level standard achieved in
May
Director of Clinical Services
Standard
Current Data Period
Period Actual
0
May-14
2
YTD
Forecast next period
IPF Amber Escalation Report FY 2014-15
% Diagnostic waits waiting 6 weeks or more
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Performance on diagnostic waits
is still above the 0.5% target.
154 patients are waiting over 6
weeks, which equates to 1.6% of
the waiting list against the
national standard of 1%. There
are three main procedures where
patients are waiting above 6
weeks – nuclear cardiology &
echocardiography (39 patients),
Endoscopy (35 patients) and MRI
scans (61 patients reduction of 15
since last month).
Neurophysiology waits were
eliminated in May. Work is
progressing to reduce and sustain
waiting times.
Diagnostic recovery plans are in place:
Additional sessions provided in May, June & July
to undertake GA for children requiring an MRI.
Endoscopy are sourcing additional external
capacity.
Cardiology are putting on additional capacity.
Expected date to meet standard
Lead Director
August 2014
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0.5%
May-14
1.64%
1.8%
1.82%
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Total theatre utilisation remains Real time focus on theatre productivity with
lower than planned, and has done clinical teams both on the day and forward
since before Winter
booking of procedures.
Expected date to meet standard
Lead Director
Quarter 3 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
75%
May-14
72.77%
72.9%
72.95%
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Elective
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Similar to total theatre utilisation Real time focus on theatre productivity with
target, the elective utilisation is
clinical teams both on the day and forward
well below the target levels.
booking of procedures.
Deterioration of the utilised level
started before Winter.
Expected date to meet standard
Lead Director
Quarter 3 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
May-14
76.91%
76.8%
76.82%
IPF Amber Escalation Report FY 2014-15
%patients 1st treatment <1 mth of cancer diag
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Sustainable delivery of the 31 day
target is challenging. Loss of some
surgical capacity around Easter
and the May bank holidays didn’t
help this situation, as well as the
ongoing issues around patient’s
choosing to wait longer.
Expected date to meet standard Lead Director
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
96%
Apr-14
92.92%
92.9%
92.92%
IPF Amber Escalation Report FY 2014-15
%2WW urgent ref - breast symp
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Breast symptomatic performance This is thought to be a short-term blip cause by
has dipped below the standard for a temporary decrease in available capacity,
the first time since July 2013.
compounded by patient choice. This will be
resolved in May.
Expected date to meet standard
Lead Director
May 2014
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
93%
Apr-14
90.91%
90.9%
90.91%
IPF Amber Escalation Report FY 2014-15
Proportion of Assisted deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The caesarean section (LSCS) rates Continue to monitor and maintain LSCS rates.
correlates to the assisted delivery
rate, given the LSCS rate in the
Trust is low in comparison to
other units this will affect the
proportion of assisted births.
Expected date to meet standard
Lead Director
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
15%
May-14
15.82%
15.9%
15.92%
IPF Amber Escalation Report FY 2014-15
% adult inpatients have had a VTE risk assess
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Deterioration coincides with
switching off of assessment
functionality within the Casenotes
system on 09 April. EPR is now the
only route for assessment (apart
from NOC site where paper is still
used). It is likely that familiarity
with EPR - where the process for
VTE assessment is held by some
to be less intuitive and where
arrangements for real time
monitoring are less clear cut –
drives this deterioration.
Dr Altmann (CCIO) has been asked to prioritise
the development of real time dashboards by
Ward, if possible Lead Clinician, to facilitate a
snapshot of current performance in relation to
VTE risk assessment.
Expected date to meet standard
Lead Director
Q4 2014/15
Director of Clinical Services
Work ongoing on ‘closing the loop on tests’ may
act to enhance the access of Consultant staff to
EPR.
Electronic prescribing, when available, will be
associated with a step change in EPR use.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Q1 14-15
91.54%
91.54%
91.54%
IPF Amber Escalation Report FY 2014-15
Sickness absence**
What is driving the
reported
underperformance?
What actions have we taken to improve performance
There was no significant
change in the sickness
absence rate between
April and May.
FirstCare has now been in operation since April 2014. The benefits of
the absence management system in terms of better automation of
process and improved management information are being well
received by line managers
An Attendance Management Working group has been set up with
FirstCare and divisional representatives; this will focus on attendance
management at a Trust-wide level and will provide support and
guidance for managers. Examples of the group’s objectives include:
The profile for the
previous twelve months
shows a relatively stable
absence level. However
this is above the Key
Performance indicator of
3.0%
Standard
Current Data Period
Period Actual
3%
May-14
3.29%
YTD
Forecast next
period

developing initiatives to maintain sickness absence levels below
Trust target of 3%;
 monitoring the comparison of long-term and short-term
sickness levels and recommend action where required;
 implementing Trust-wide communications and initiatives to
improve the knowledge and understanding of the importance of
return to work interview completion;
 promoting and increasing the utilisation of information and
reports from the FirstCare system.
The initiatives associated with the Health and Wellbeing Strategy
continue to be applied. The Strategy is to be updated in Quarter 2.
The Occupational Health Team and HR Managers continue to work
closely with line managers to manage absence levels.
Expected date to meet
standard
Lead Director
September 2014
Director of Organizational Development & Workforce
Year: 2014-15
Directorate: Acute Medicine & Rehabilitation ,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research, Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services, Chief Nurse Patient Services & Education, Children’s ,Children’s,CRS Implementation, Division of Clinical Support Services,
Division of Corporate Services, Division of Medicine, Rehabilitation & Cardiac, Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery, Division of Operations & Service Improvement, Division of Research & Development, Division of Surgery & Oncology, Estates and Facilities, Finance and Procurement,
Gastroenterology, Endoscopy and Churchill Theatres ,Gastroenterology, Endoscopy and Theatres (CH),Horton Management, Human Resources and Admin, Legacy Cardiac, Vascular & Thoracic Surgery, Legacy Cardiology, Legacy Division of Cardiac, Vascular & Thoracic, Legacy Division of Musculoskeletal and Rehabilitation,
Legacy Rehabilitation & Rheumatology, MARS -Research & Development, Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records, Oncology & Haematology ,Orthopaedics, Pathology & Laboratories,Pharmacy,Planning & Communications, Private Patients, Radiology & Imaging, Renal, Transplant & Urology,
Specialist Surgery ,Strategic Change, Surgery ,Teaching Training and Research, Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
Division: Division of Children's & Women’s, Division of Clinical Support Services, Division of Corporate Services, Division of Medicine, Rehabilitation & Cardiac, Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery, Division of Operations & Service Improvement, Division of Research & Development, Division of
Surgery & Oncology, Legacy Division of Cardiac, Vascular & Thoracic, Legacy Division of Musculoskeletal and Rehabilitation,TRUST,Trust-wide only, Unknown