TB2014.54 - Appendix A
ORBIT Reporting Trust Board Integrated Performance Report March 2014 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. OUH ‐At A Glance 2013‐14
ORBIT Reporting
Operational
Access Standards
Standard
RTT ‐ admitted % within 18 weeks
YTD Data Quality
90% 11.1 Mar‐14
Mar‐14
79.92% 9.21 88.8% 7.56 3
2
RTT 95th centile for admitted pathways
23 Mar‐14
32.21 25.69 3
RTT ‐ # specialties not delivering the admitted standard
RTT ‐ non‐admitted % within 18 weeks
0 Mar‐14
7 95% 6.6 18.3 Mar‐14
Mar‐14
Mar‐14
93.45% 4.79 20.29 95.6% 5.2 17.67 0 Mar‐14
4 RTT ‐ #waiting on incomplete RTT pathway
92% NA
Mar‐14
Mar‐14
91.19% 39594 91.9% % Diagnostic waits waiting 6 weeks or more
1% Mar‐14
1.66% % <=4 hours A&E from arrival/trans/discharge
95% Q4 13‐14
90.65% Ambulance Handovers within 15 minutes
95% Mar‐14
Number of attendances at A/E depts in a month
NA
Mar‐14
10675 130478 2
Last min cancellations ‐ % of all elec admissions
0.8% Mar‐14
0.23% 0.6% 2
% patients not rebooked within 28 days
5% Mar‐14
4.76% 7.9% 2
Total on Inpatient Waiting List
NA
Mar‐14
9184 3
# 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
NA
Mar‐14
7673 3
NA
Mar‐14
1085 NA
Mar‐14
426 NA
Mar‐14
22.1% No of GP written referrals
11162 Mar‐14
Other refs for a first outpatient appointment 7456 1st outpatient attends following GP referral 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
Activity Current Data Period Period Actual
Quality
Outcomes
Standard
Hospital Standardised Mortality ratio*
Current Data Period Period Actual
YTD Data Quality
NA
NA
Jan‐14
Jan‐14
92.56 97.98 5
5
NA
Jun‐13
0.95
5
Proportion of Assisted deliveries
15% Mar‐14
15.31% 15.4% Proportion of C‐Section deliveries
Total # of deliveries
23% 62% NA
Mar‐14
Mar‐14
Mar‐14
21.54% 63.14% 738 22.7% 61.8% 8315 Maternal Deaths
NA
Mar‐14
0 2 2
2
30 day emergency readmission
0% 0 Mar‐14
Mar‐14
3.44% 1 3.7% 2 5
6.2% 2
NA
Mar‐14
25 180 5
93.2% 5
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 patients admitted who have had a dementia screen
Medication reconciliation completed within 24 hours of admission Monthly numbers of complaints received
0 Mar‐14
0 6 5
NA
Mar‐14
11 167 5
90% Feb‐14
62.68% 54.6% 2
80% Mar‐14
85.53% 78.1% 4
NA
Mar‐14
80 889 4
0% Mar‐14
27.1% 12.3% Monthly YTD HSMR at weekends for emergency admission*
Summary Hospital‐level Mortality Indicator**
2
2
3
Proportion of normal deliveries
Medication errors causing serious harm
Not available
Patient Experience
3
Patient Satisfaction‐ Response rate (friends & family ‐ED)
Patient Satisfaction ‐Response rate (friends & family ‐Inpatients)
Net promoter (friends & family ‐ED)
0% Mar‐14
28.42% 23.5% NA
Mar‐14
60 3
Net promoter (friends & family ‐Inpatients)
NA
Mar‐14
76 3
Same sex accommodation breaches 0 Q4 13‐14
13 17 2
13111 152008 3
# patients spend >=90% of time on stroke unit
80% Mar‐14
89.87% 90.2% 5
Mar‐14
8621 94743 3
HCAI ‐ MRSA bacteraemia
0 Mar‐14
0 5 5
8155 Mar‐14
9933 116022 2
HCAI ‐ Cdiff
5 Mar‐14
9 64 5
Total number of first outpatient attendances 14402 Mar‐14
17385 201574 2
% adult inpatients have had a VTE risk assess
95% Q4 13‐14
95.55% 95.5% 5
Non‐elective FFCEs
Mar‐14
Mar‐14
Mar‐14
Mar‐14
5785 1980 7561 107 66919 23557 82824 1319 2
3
3
2
Number SIRIs
Delayed transfers of care: number (snapshot)
5894 1876 6019 0 Incidents per 100 admissions
NA
8 NA
NA
Mar‐14
Mar‐14
Mar‐14
Mar‐14
2 1 4.56 11.65 57 47 5.4 1.23 5
2
2
2
Delayed transfers of care as % of occupied beds
3.5% Q4 13‐14
9.63% 10.5% # acquired, avoidable Grd 3/4 pressure Ulcers
NA
Feb‐14
6 37 5
Theatre Utilisation ‐ Total
75% Mar‐14
73.33% 74.9% 2
0% Mar‐14
93.02% 92.4% 2
Theatre Utilisation ‐ Elective
80% 70% Mar‐14
Mar‐14
76.33% 62.48% 77.9% 64.9% 3
2
% of Patients receiving Harm Free Care (Pressure sores, falls, C‐UTI and VTE)
Never Events
NA
Mar‐14
0 3 5
Number of Elective FFCEs ‐ admissions
Number of Elective FFCEs ‐ daycases
Theatre Utilisation ‐ Emergency
Safety
Number of Patient Falls with Harm
Patient Falls per 1000 bed days
Operational
Cancer Waits
Standard
Current Data Period Period Actual
YTD Data Quality
%patients cancer treatment <62‐days urgt GP ref
85% Feb‐14
73.95% 80.5% 5
%patients cancer treatment <62‐days ‐ Screen
90% Feb‐14
100% 93.8% 5
% patients treatment <62‐days of upgrade
0% %patients 1st treatment <1 mnth of cancer diag
96% Feb‐14
96.34% 96.9% 5
%patients subs cancer treatment <31days ‐ Surg 94% Feb‐14
94.34% 95.8% 5
%patients subs cancer treatment <31‐days ‐ Drugs
98% Feb‐14
100% 99.8% 5
%patients subs treatment <31days ‐ Radio
94% Feb‐14
81.64% 88.6% 5
%2WW of an urgt GP ref for suspected cancer 93% Feb‐14
97.25% 95.5% 5
%2WW urgent ref ‐ breast symp 93% Feb‐14
96% 96.6% 5
0% Finance
Balance Sheet
Standard
Mar‐14
25% BPPC by value (%) All
95% Mar‐14
93.41% 91.6% Capital
Capital Programme Compared to Plan
4984 Mar‐14
Cash & Liquidity
Cash Held at Month End cf. Plan (£000s)
74221 Mar‐14
86448 5
4 Mar‐14
3 5
Net Income Compared to Plan (Displayed in £000s)
1088.99 Mar‐14
9662.45 17430.59 5
Pay Compared to Plan (Displayed in £000s)
‐38347 Mar‐14
‐38507.3 5
CIP Performance Compared to Plan 4070 Mar‐14
3972 ‐
481379.9
42696 5
EBITDA Compared to Plan
6545 Mar‐14
6947.57 73264.86 5
Break Even Surplus Compared to Plan 1302 Mar‐14
1215.97 10893.72 5
3 5 Mar‐14
Mar‐14
3 4 5
5
3 2 Mar‐14
Mar‐14
3 2 5
5
EBITDA Margin (Score)
EBITDA Achieved (Score)
Staff Experience
Worked WTE against Plan
YTD Agency usage (Displayed in 000s)
Mar‐14
Mar‐14
Mar‐14
10042.75 £ ‐827 £ ‐8489 £ ‐2711 £ ‐23720 4
5
5
Total costs of staff (000s)
£ ‐38347 Mar‐14
£ ‐38507 5
5% 3% 10% 100% 0% 0% Mar‐14
Mar‐14
Mar‐14
Q4 13‐14
Q4 13‐14
Q4 13‐14
5.51% 3.27% 11.35% 86.91% 66.47% 77% Vacancy rate
Sickness absence***
Turnover rate
Medical Appraisals
Non Medical Appraisals
Statutory and % staff with up to date Statutory and Mandatory training
Mandatory Competence Compliance
5
Data Quality
10148.97 NA
NA
Bank usage (Displayed in 000s)
11826.38 22137.82 5
Current Data Period Period Actual
Data Quality
5% I&E
Standard
YTD Debtors > 90 Days as % of Total debtors
Liquidity Ratio (Score)
Workforce
Head count/Pay costs
Current Data Period Period Actual
£ ‐
481380 NRaF net return after financing
I&E Surplus Margin (Score)
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 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 IPF Red Escalation Report FY 2013‐14
Debtors > 90 Days as % of Total debtors
What is driving the reported underperformance?
What actions have we taken to improve performance?
There has been progress in reducing debtors greater than 90 days across all categories, with an overall year on year reduction of £1m. NHS Debtors were expected in increase at the close of 2013/14, as practice returned to estimated bills which would be settled in the new financial year, compared to the successful drive by the Trust for settlements in 2013/14 with PCTs and SHAs demising. In terms NHS debt rose from £3.8m at the close of 12/13 to £10.8m at the close of 13/14, making year on year comparison on this measure difficult. The high level at the start of the year was due to exceptionally low in terms debt. The underlying position after adjusting for year‐end distortion has moved down to 15%. Progress on overdue debt will be maintained during 2014/15. 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 further improvement during 2014/15.
Standard
Current Data Period
Period Actual
YTD 5% Mar‐14
25% Forecast next period
IPF Red Escalation Report FY 2013‐14
Capital Programme Compared to Plan
What is driving the reported underperformance?
What actions have we taken to improve performance?
There has been an overachievement in month, resulting in action taken to mitigate the previous shortfalls. An assessment of key milestones is taking place across all 2014/15 projects to ensure the forward programme risk assessment is clear and documented. Expected date to meet standard
Lead Director
2014/15
Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 4984 Mar‐14
11826.4 22137.8 Forecast next period
IPF Red Escalation Report FY 2013‐14
Liquidity Ratio (Score)
What is driving the reported underperformance?
What actions have we taken to improve performance?
The cash held by the Trust at the end of the year was higher than planned but, as reported previously, the higher level of operating expenditure meant that the Trust would need yet more cash than originally anticipated to achieve the higher score of “4”. None. A score of “3” still indicates a level of liquidity sufficient to support the day‐to‐day operations of the Trust. Expected date to meet standard
Lead Director
As forecast, the score was “3” at the end of the financial year.
Director of Finance and Procurement
Standard
Current Data Period
Period Actual
YTD 4 Mar‐14
3 Forecast next period
IPF Red Escalation Report FY 2013‐14
Break Even Surplus Compared to Plan What is driving the reported underperformance?
What actions have we taken to improve performance?
Although the Trust’s performance The Trust met its key financial targets for the in the month of March was year. slightly behind, the Trust generated its break even target surplus for the year. Expected date to meet standard
Lead Director
N/A – a new plan, and target, has Director for Finance and Procurement
been agreed for the new financial year.
Standard
Current Data Period
Period Actual
YTD 1302 Mar‐14
1216 10893.7 Forecast next period
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 The Trust met its key financial targets for the behind plan in the achievement of year. its EBITDA target at the end of the year, it met all its financial duties. The shortfall on EBITDA was due to “technical” reasons identified, and reported on, earlier in the year. Expected date to meet standard
Lead Director
As forecast, this score remained at “4” at 31 March 2014.
Director for Finance and Procurement
Standard
Current Data Period
Period Actual
YTD 5 Mar‐14
4 Forecast next period
IPF Red Escalation Report FY 2013‐14
RTT ‐ admitted % within 18 weeks
What is driving the reported underperformance?
March’s admitted RTT position for the Trust has continued to show a decline, now at 79.92%. This reflects the significant numbers of long waiters that services have cleared during the month. The admitted waiting list has reduced by approximately 3,000 through treatments and validation during the period of late January to end of February. What actions have we taken to improve performance?
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced
by the end of March. Additional theatres lists are being undertaken over six days per week and external providers are been used to support some surgical activity.
This work continues in Q1 2014/15 to ensure sustainability. Expected date to meet standard Lead Director Trust‐wide standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 90% Mar‐14
79.92% 88.8% Forecast next period
IPF Red Escalation Report FY 2013‐14
RTT 95th centile for admitted pathways
What is driving the reported underperformance?
The growing trend in the 95th percentile of admitted waits is a clear indication that, patients who have been waiting longer are being treated through the backlog clearance plan. There is still more work to be done on backlog clearance, which is likely to continue into the new financial year. What actions have we taken to improve performance?
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced
by the end of March. Additional theatres lists are being undertaken over six days per week and external providers are been used to support some surgical activity.
This work continues in Q1 2014/15 to ensure sustainability. Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 23 Mar‐14
32.21 25.69 Forecast next period
IPF Red Escalation Report FY 2013‐14
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported underperformance?
Q4 performance has seen a further deterioration in performance compared to Q3. March performance (93.2%) was at a higher level to that of February. Performance for the first few weeks of April has continued to be challenging. Most weeks have been above 90%, but none achieving the required standard of 95%. The year end position was 93.23% compared to 92.89% in 2012/13. What actions have we taken to improve performance?
The Urgent Care Working group Summit meeting chaired by the Interim CEO for OCCG continues to meet weekly, with OH, OCC & OUH colleagues to improve patient flow across the system. The Trust’s internal urgent care group meets every 2 weeks to ensure the ED/winter action plan is completed. Key focus areas continue to be: • Admission avoidance • Implementing rapid nurse assessment • Increase medical workforce & senior decision making • Improving access to diagnostics & pharmacy 24/7 • Expanding EAU • Improving patient flow • Timely escalation • Delays to patients being discharged. A more detailed review of impact of the ED/winter action plan is under way. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 95% Q4 13‐14
90.65% 93.2% Forecast next period
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?
March’s received referrals levels were around 2,000 above the plan. A very similar pattern to the rest of the last quarter of the year. Joint work with the OCCG is ongoing to identify where and why these elevated levels are occurring. The Trust is meeting with OCCG clinical colleagues in May to look at ways of reducing demand. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services No of GP written referrals
Standard
Current Data Period
Period Actual
YTD 11162 Mar‐14
13111 152008 Forecast next period
IPF Red Escalation Report FY 2013‐14
Other refs for a first outpatient appointment What is driving the reported underperformance?
Other referrals, which will include consultant referrals showed as being significantly above plan (~1,100) during March. This is a very similar pattern to what was seen in the last quarter. What actions have we taken to improve performance?
The Trust is working closely with commissioner colleagues to understand the reasons for the increase in referrals. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 7456 Mar‐14
8621 94743 Forecast next period
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 The Trust is working with CCG clinical still tracking above plan, in line colleagues to look with the increased (above plan) at ways of reducing demand to outpatient levels of GP referrals being services. received. As part of the Outpatient Reprofiling Project new clinic profiles have now started to be implemented, with the remainer being built by March is has increased a little more due to the 18 week backlog the end of May 2014. clearance plan for non‐admitted In addition, implementing the 18 weeks RTT care. action plan will mean that more patients will be
seen over the next few months. Expected date to meet standard Lead Director Quarter 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 8155 Mar‐14
9933 116022 Forecast next period
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 number of first attendances is The Trust is working with CCG clinical still tracking above plan, in line colleagues to look with the increased (above plan) at ways of reducing demand to outpatient levels of referrals being received. services. As part of the Outpatient Reprofiling Project March has increased a little more new clinic profiles have now started to be implemented, with the remainer being built by due to the 18 week backlog clearance plan for non‐admitted the end of May 2014. care. In addition, implementing the 18 weeks RTT action plan will mean that more patients will be
seen over the next few months. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 14402 Mar‐14
17385 201574 Forecast next period
IPF Red Escalation Report FY 2013‐14
Number of Elective FFCEs ‐ admissions
What is driving the reported underperformance?
The over performance in outpatient activity is likely to be a significant driver in the continued over performance in elective admissions, as well as the drive to improve the 18 week performance at a specialty level for patients on an admitted pathway. Oversized waiting lists are being experienced in a significant proportion of the clinical services. The backlog clearance plan has had an impact on activity during March as this was at one of its highest points above plan during the whole 13/14 financial year. This is likely to continue into 2014/15, until backlogs have been reduced. What actions have we taken to improve performance?
As expected significant elective activity continued throughout March to improve waiting times. 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. Additional theatres lists are being undertaken to
ensure patients are treated within 18 weeks. External providers are being used to support some surgical activity and this is likely to continue into Q1 2014/15 for some specialities. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 1876 Mar‐14
1980 23557 Forecast next period
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 over performance in As expected significant elective activity outpatient activity is likely to be a continued throughout March to improve waiting significant driver in the continued times. over performance in elective admissions, as well as the drive to Significant demand analysis work is been undertaken using the IMAS model across improve the 18 week performance at a specialty level surgical specialties to understand both current for patients on an admitted waiting list size, backlogs and additional theatre
pathway. capacity requirements. Oversized waiting lists are being Additional theatres lists are being undertaken to
ensure patients are treated within 18 weeks. experienced in a significant proportion of the clinical services. External providers are being used to support some surgical activity and this is likely to The backlog clearance plan has had an impact on activity during continue into Q1 2014/15 for some specialities. March as this was at the highest point above plan during the whole 13/14 financial year. This is likely to continue into 2014/15, until backlogs have been reduced. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 6019 Mar‐14
7561 82824 Forecast next period
IPF Red Escalation Report FY 2013‐14
Delayed transfers of care as % of occupied beds
What is driving the reported underperformance?
Total number of delays has remained constantly high through the whole year. Quarter 4 averaged below 10% for the first time in the year, but this is still significantly adverse from the standard. The most recent figures for April (24th April snapshot) show that levels have significantly reduced from the 107 patients recorded at the end of March to 70 patients. What actions have we taken to improve performance?
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. Weekly Urgent Care Summit with OH,OCC and OCCG colleagues to manage the winter plans and funding and reprioritise where necessary. Escalation to Oxfordshire colleagues when system is on RED. 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. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 3.5% Q4 13‐14
9.63% 10.5% Forecast next period
IPF Red Escalation Report FY 2013‐14
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?
Clinical Teams are focused on real time emphasis on booking procedures and start and finish times ensuring maximum productivity. Daily monitoring of emergency lists is on‐going. The last three months of 2013/14 remained the greatest challenge due to reduced inpatient capacity as increased pressures on A/E. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 70% Mar‐14
62.48% 64.9% Forecast next period
IPF Red Escalation Report FY 2013‐14
%patients cancer treatment <62‐days urgt GP ref
What is driving the reported underperformance?
The main reasons for the under performance in 62 day pathway treatments are late receiving of referrals, patient choice to delay appointments and complex treatments and the scheduling. What actions have we taken to improve performance?
The Trust are working closely with the OCCG and have produced a joint agreed Cancer Action
plan to achieve all the cancer standards over the
next few months. Patient Choice issues; Work with CCG to raise awareness of CWT to GP's ‐2WW/62 day pathways. Joint CCG/OUH Education sessions to: •Re launch TWEEK leaflets to GP Practices •Improve use of clinical referral proformas •Raise awareness of CWT to GP's ‐2WW/62 day pathways. Working with other trusts to reduce late referrals on 62 day pathway. Expected date to meet standard Lead Director Quarter 2 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 85% Feb‐14
73.95% 80.5% Forecast next period
IPF Red Escalation Report FY 2013‐14
%patients subs treatment <31days ‐ Radio
What is driving the reported underperformance?
Upgrades to the Radiotherapy equipment has resulted in delays to planning and treatment of patients, and this has had a knock on effect. Additionally, staff recruitment and therefore available resource remains an issue, however, this is not a unique problem being experienced by the OUH as there is a national shortage of therapeutic radiographers What actions have we taken to improve performance?
Summary of actions : • Implementing the short term action of utilising the 6th linac from April 2014 plus either continued weekend working or extending the day on two linacs would reduce the backlog of fractions by 1692 to 402 by the end of the week of 2 June. By June there should also be an expected positive impact of RapidArc . • Re‐negotiating the software contract so that it can be upgraded out of hours. Expected date to meet standard Lead Director Quarter 2 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 94% Feb‐14
81.64% 88.6% Forecast next period
IPF Red Escalation Report FY 2013‐14
Medication errors causing serious harm
What is driving the reported underperformance?
What actions have we taken to improve performance?
1 medication incident reported as A divisional investigation has been initiated, major harm reported to the Datix which will produce a formal report for both the incident management system, and family and the coroner. is related to a patient fall and Warfarin medication. Expected date to meet standard Lead Director Quarter 1 2014/2015 Interim Medical Director Standard
Current Data Period
Period Actual
YTD 0 Mar‐14
1 2 Forecast next period
IPF Red Escalation Report FY 2013‐14
Dementia CQUIN patients admitted who have had a dementia screen
What is driving the reported underperformance?
Reporting by clinical teams is not consistent across the Trust. 90‐95% of case notes are reviewed and EPR screening included in the figures. What actions have we taken to improve performance?
This standard has been monitored by the Senior management throughout the year and reported through exception reporting. Increased education of Junior doctor grades has been initiated. Dementia Steering Group has been established to lead on this and wider Dementia issues, including developing a Dementia Strategy. Methodology for data collection has been refined throughout the year with an assurance review of process being undertaken. Appointment of CQUIN administrators (x2) to facilitate the robust collection of data. Appointment of Service Improvement & CQUIN Manager to provide oversight. Expected date to meet standard Lead Director Quarter 2 2014/2015 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 90% Feb‐14
62.68% 54.6% Forecast next period
IPF Red Escalation Report FY 2013‐14
Same sex accommodation breaches What is driving the reported underperformance?
What actions have we taken to improve performance?
In February, this was a single sex Confusion within the ward – now resolved. breach event in Cardiology Ward Rapid Access Unit (RAU) ‐ whereby two bed bays were reversed resulting in female patients having to walk through a male bay to access their
bathrooms and vice versa. There were 2 empty beds available at the time of breach and staffing levels were optimum. There were
11 new admissions throughout the day; however the day started with 9 empty beds, therefore it is likely that this breach could have been avoided. There were no breaches in March
Expected date to meet standard Lead Director Quarter 1 2014/2015 Acting Chief Nurse Standard
Current Data Period
Period Actual
YTD 0 Q4 13‐14
13 17 Forecast next period
IPF Red Escalation Report FY 2013‐14
HCAI ‐ Cdiff
What is driving the reported underperformance?
The OUH Trust had 9 cases of C. diff in March 2014. However, the OUH Trust has met its C. diff objective for 2013/2014. What actions have we taken to improve performance?
The focus continues to be on minimizing antibiotic usage i.e. reducing duration and early conversion from broad spectrum to narrow. This is to reduce the number of cases that have developed secondary to antibiotics. Expected date to meet standard Lead Director C. diff objective met in 2013/2014 Interim Medical Director Standard
Current Data Period
Period Actual
YTD 5 Mar‐14
9 64 Forecast next period
IPF Red Escalation Report FY 2013‐14
Vacancy rate
What is driving the reported underperformance?
What actions have we taken to improve performance?
The vacancy rate has reduced The recruitment processes have been reviewed consistently throughout the year to improve time to recruit. To support this, a as the number of substantive staff new candidate tracking system, TRAC has been in post has increased. Despite this, introduced. the vacancy rate is marginally Exit questionnaires are now sent to every leaver above the KPI of 5%. with an e mail address and exit interviews are There are a number of reasons for arranged on demand. this; difficult to recruit areas, national shortages in some The Staff Survey, Welcome Questionnaire and the revised Leaver’s Questionnaire will provide professional groups, turnover information to help target retention initiatives. levels above the Trust KPI, and new additional posts associated A recruitment and retention summit is with agreed business cases. scheduled for July. The outcomes from this event will further inform the Trust’s recruitment and retention strategies. Further International nurse recruitment programmes are planned. Attendance at trade and recruitment fairs will continue. Expected date to meet standard
Lead Director
June 2014 Director of Organisational Development and Workforce Standard
Current Data Period
Period Actual
YTD 5% Mar‐14
5.51% Forecast next period
IPF Red Escalation Report FY 2013‐14
Sickness absence***
What is driving the reported underperformance?
What actions have we taken to improve performance?
Absence levels have been marginally above the KPI throughout the financial year but always within 0.3%. Sickness absence has risen during Autumn and Winter, as anticipated. The FirstCare absence management system has been introduced and went live from 1st April. As well as training new managers in FirstCare, over 700 existing managers were also trained in the new absence procedure. More efficient processes and better information for managers will assist in reducing absence levels. Absence continues to be managed via HR, line managers and Occupational Health staff. Health and Wellbeing is a priority for the Trust. Key initiatives include: a) Introduction of divisional Health Champions and Trust application to become an accredited training centre; b) Stress busting workshops running March – May; c) Healthier Eating Survey – 2,335 people responded to an online survey. The results will be used by the Healthy Eating Group to inform discussion with on‐site caterers with a view to improving the food options available to staff throughout the Trust. Expected date to meet standard
Lead Director
June 2014 Director of Organisational Development and Workforce Standard
Current Data Period
Period Actual
YTD 3% Mar‐14
3.27% Forecast next period
IPF Red Escalation Report FY 2013‐14
Turnover rate
What is driving the reported underperformance?
What actions have we taken to improve performance?
Turnover has fallen marginally against the previous month, (11.45% to 11.35%), although has remained relatively constant throughout the last twelve months. Feedback from staff, both formal and anecdotal, suggests personal decisions and local factors such as cost of living, travel costs and car parking are major factors influencing employees’ decisions to leave. A recruitment and retention strategy is currently being developed. Following the annual staff survey, focus groups have been conducted and Divisional action plans will be finalised in May. In addition, quarterly “pulse” surveys of staff will begin in June; these will provide important feedback on the level of staff engagement. The results of the Welcome Questionnaire, sent to new starters, will also be available and evaluated. The Exit Questionnaire has been revised and strengthened. Expected date to meet standard
Lead Director
June 2014
Director of Organisational Development and Workforce Standard
Current Data Period
Period Actual
YTD 10% Mar‐14
11.35% Forecast next period
IPF Red Escalation Report FY 2013‐14
Medical Appraisals
What is driving the reported underperformance?
The medical appraisal window for 2013‐14 has now closed. To date 87% of required appraisals have been submitted. Of the remaining 13% (119 appraisals) 76 have been accounted for as delayed for a variety of reasons. The remaining 43 doctors are unaccounted for. What actions have we taken to improve performance?
All doctors who did not conduct their meeting by 31st March 2014 will be followed up as part of the missed appraisal audit to establish more detailed reasons for the delays. One of the biggest challenges faced by the Medical Director’s Office this year has been the emergence of a large cohort of honorary contract holders who had not previously aligned themselves with the Trust for revalidation and appraisal purposes. These doctors have, in general, been poorly prepared for appraisal, difficult to contact, and have required additional time and support to comply with Trust processes. This group accounts for a significant proportion of the delays. The Responsible Officer’s team remains confident that every appraisal due in 2013‐14 will be accounted for; appropriate action will be taken in respect of missed appraisals, according to the reason established.
Expected date to meet standard
Lead Director
2014/2015
Interim Medical Director
Standard
Current Data Period
Period Actual
YTD 100% Q4 13‐14
86.91% Forecast next period
IPF Amber Escalation Report FY 2013‐14
BPPC by value (%) All
What is driving the reported underperformance?
What actions have we taken to improve performance
The calculation methodology has been reviewed following an external audit recommendation and a new approach in accordance with that used by other NHS organisations was considered and approved by the Audit Committee. This has changed the reported performance The Trust had an external audit finding to review of the calculation methodology, this work is complete and was reported to the Audit Committee as part of the year end accounts planning in February 2014. The calculation which has now been applied across the full year and follows precisely the same methodology as is used by NHS Shared Business Services who provide Finance & Accounting to all 243 NHS Commissioning organisations, and have 70 NHS Trusts accessing their full contract portfolio. By value NHS payables achieved the 95% target and progress will be made to bring the other measures up now the base calculation is settled
Expected date to meet standard
Lead Director
A further review of legacy on hold Director of Finance and Procurement
invoices will be undertaken in 2014/15 with aim to meet the target alongside expansion of Purchase Orders.
Standard
Current Data Period
Period Actual
YTD 95% Mar‐14
93.41% 91.6% Forecast next period
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
Throughout 2013/14 pay costs were 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 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
N/A – a new plan, and set of Director of Finance and Procurement
targets, will be agreed for the new financial year.
Standard
Current Data Period
Period Actual
YTD ‐38347 Mar‐14
‐38507.3 ‐481380 Forecast next period
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 has been monitored regularly by resulted in slippage on some the CIP Programme Board. Other than where it savings schemes was identified part‐way through the year that some schemes would not deliver the full level of planned the programme delivered the full level of expected savings for the year. Expected date to meet standard
Lead Director
As forecast, this measure ended Director of Finance and Procurement
the year as “amber” due to slippage on schemes. A new plan, and set of targets, has been agreed for the new financial year.
Standard
Current Data Period
Period Actual
YTD 4070 Mar‐14
3972 42696 Forecast next period
IPF Amber Escalation Report FY 2013‐14
RTT ‐ # specialties not delivering the admitted standard
What is driving the reported underperformance?
ENT (71.13%), Ophthalmology (66.43%), Neurosurgery (67.24%), Plastic Surgery (66.48%), Gynaecology (85.53%), Trauma and Orthopaedics (64.93%) and other (83.10%) are the services that failed the admitted standard of 90% admitted within 18 weeks.
What actions have we taken to improve performance
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced by the end of March. Additional theatres lists are being undertaken over six days per week and external providers are been used to support some surgical activity. This work has continued into Q1 2014/15 to ensure sustainability. Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 0 Mar‐14
7 Forecast next period
IPF Amber Escalation Report FY 2013‐14
RTT ‐ non‐admitted % within 18 weeks
What is driving the reported underperformance?
Trust wide performance recovered slightly in March to 93.45%. What actions have we taken to improve performance
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced by the end of March. Additional outpatient sessions are being undertaken and external providers are been used to support some of this work. This work continues in Q1 2014/15 to ensure sustainability. Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 95% Mar‐14
93.45% 95.6% Forecast next period
IPF Amber Escalation Report FY 2013‐14
RTT ‐ 95th percentile for non‐admitted RTT
What is driving the reported underperformance?
A slight reduction in the 95th percentile wait for non‐admitted. This is a reflection of the huge amount of backlog clearance of long waiting patients during February, and has continued into March for the slightly shorter waiting patients, bringing down the percentile. This should reduce further in April. What actions have we taken to improve performance
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced
by the end of March. Additional outpatient sessions are being undertaken and external providers are been used to support some of this work. This work continues in Q1 2014/15 to ensure sustainability. Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 18.3 Mar‐14
20.29 17.67 Forecast next period
IPF Amber Escalation Report FY 2013‐14
RTT ‐ # specialties not delivering the non‐admitted standard
What is driving the reported underperformance?
The four specialties that didn’t achieve the non‐admitted standard in March were Trauma and Orthopaedics (7.3%), ENT (72.73%), Ophthalmology (87.32%) and Plastic Surgery (93.64%). What actions have we taken to improve performance
The Trust has agreed a planned failure of the RTT admitted standard for the last quarter whilst patients who have waited over 18 weeks are seen and treated. Recovery plans are being implemented to ensure the numbers of long waiters are reduced
by the end of March. Additional outpatient sessions are being undertaken and external providers are been used to support some of this work. This work continues in Q1 2014/15 to ensure sustainability Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 0 Mar‐14
4 Forecast next period
IPF Amber Escalation Report FY 2013‐14
RTT ‐ incomplete % within 18 weeks
What is driving the reported underperformance?
A 2% point improvement is this metric during March. As described above, a reflection of the significant backlog clearance work undertaken for both admitted and non‐admitted pathways. What actions have we taken to improve performance
Detailed analysis of the back log on the incomplete pathways, validation of patient waiting and implementation of the recovery plans to improve the position has resulted in the
incomplete pathways becoming transparent. Plans to recover the trust‐wide position are in place. Expected date to meet standard Lead Director Trust‐wide RTT standard April 2014 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 92% Mar‐14
91.19% 91.9% Forecast next period
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
Diagnostic waiting times continue 152 patients are waiting over 6 weeks, a to be challenging, and at the end decrease of 16 since February. The three main of March there were 152 patients areas of increased waits are; Nuclear cardiology waiting over 6 weeks, 48 of which & echocardiography (17 patients) due to an had been waiting over 13 weeks. increase of referrals from Milton Keynes & Half of the long waiters are Northampton and clearing down remaining waiting for an MRI scan, with backlog of echo patients; Neurophysiology (24 other significant contributors to patients) additional capacity is being provided in April; MRI scan (88 patients) additional Saturday the number being GA lists continue. Echocardiography, Neurophysiology and Endoscopy.
Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 1% Mar‐14
1.66% 6.2% Forecast next period
IPF Amber Escalation Report FY 2013‐14
Theatre Utilisation ‐ Total
What is driving the reported underperformance?
March saw a continued marginal decline in overall theatre utilization. This is still well below the levels that were being achieved before December. 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. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 75% Mar‐14
73.33% 74.9% Forecast next period
IPF Amber Escalation Report FY 2013‐14
Theatre Utilisation ‐ Elective
What is driving the reported underperformance?
A very marginal improvement in elective theatre utilization during March. Still well below the levels being achieved before the winter.
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. Expected date to meet standard Lead Director Quarter 1 2014/15 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 80% Mar‐14
76.33% 77.9% Forecast next period
IPF Amber Escalation Report FY 2013‐14
Proportion of Assisted deliveries
What is driving the reported underperformance?
There is a direct correlation between higher instrumental (assisted) deliveries, caesarean sections and normal births. This is reflected for the reporting period.
A number of these were complex deliveries reflecting the Trust’s role as a Tertiary Centre for high risk deliveries. What actions have we taken to improve performance
M12 performance is slightly (0.31%) above the required standard of performance, has reduced from the M11 position (16.91%) and is lower than the M11 forecast (16.04%). Performance is monitored closely at Directorate, Divisional and Executive Committees via Performance Management and Clinical Governance reports together with validation and review of the Children’s and Women’s Division Maternity Dashboard. Expected date to meet standard Lead Director Quarter 1 2014/2015 Director of Clinical Services Standard
Current Data Period
Period Actual
YTD 15% Mar‐14
15.31% 15.4% Forecast next period
IPF Amber Escalation Report FY 2013‐14
Total costs of staff (000s)
What is driving the reported underperformance?
What actions have we taken to improve performance
Throughout 2013/14 pay costs were 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 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
N/A – a new plan, and set of Director of Finance and Procurement
targets, will be agreed for the new financial year.
Standard
Current Data Period
Period Actual
YTD £ ‐38347 Mar‐14
£ ‐38507 £ ‐481380 Forecast next period