Trust Board Meeting: Wednesday 12 November 2014
TB2014.118
Title
Integrated Performance Report – Month 6
Status
For report
History
The report provides a summary of the Trust’s performance
against a range of key performance indicators as agreed by the
Trust Board.
Board Lead(s)
Mr Paul Brennan, Director of Clinical Services
Key purpose
Strategy
TB2014.118_Integrated Performance Report M6
Assurance
Policy
Performance
Page 1 of 36
Oxford University Hospitals
TB2014.118
Integrated Performance Report Month 6
Executive Summary
1.
Key Highlights on performance
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2.
Areas of exception on performance
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3.
Zero same sex accommodation breaches reported for Quarter 2.
Zero medication errors causing serious harm in September
Diagnostic waits over 6 weeks, 87 patients waited over 6 weeks at the end of
September, achieving the standard of no more than 1% waiting over 6 weeks.
18 week RTT Incomplete standard was achieved in September.
Last minute cancellations for elective surgery, was below the standard of 0.5% by
0.38% for September.
Patients spending >=90% of time on stroke unit, achieved 85.25% against a
standard of 80% in September.
Five of the eight cancer standards were achieved in August.
MRSA bacteraemia; one case was reported in September which has been
reviewed and reported as unavoidable.
A/E 4 hour standard of 95%, for Quarter 2 outturn was 94.31%.
The percentage of adult inpatients that have had a VTE risk assessment in
September was 94.67%, which represents an improvement from August
(94.31%) but is still below the required standard of 95%.
The cancer standards of 62 day urgent GP and 62 day screening remain below
the targets of 85% and 90% at 73.53% and 79.31% respectively, with 2 week
wait urgent breast at 90.74% against the target of 93%.
Delayed Transfers of Care is 6.8% above the 3.5% target in September.
18 week RTT for the Admitted target was 87.29% against the 90% standard,
Non-Admitted target was 94.48% against a standard of 95%.
21 adult patients waited 52 weeks or more for treatment in September, which
represents a further reduction.
Staff turnover rate of 12.5%, 2% above the standard.
Staff sickness absence rate was 3.55%, 0.55% above the standard.
The vacancy rate was 5.76%, 0.76% above the standard.
Key Standards – in Month 6
3.1. 18 Week RTT, A/E & Cancelled Operations
3.1.1. A/E 95% of patients seen within 4 hours from arrival/transfer/ discharge:
Performance at the end of September was 93.61%. Quarter 2 performance
94.31%. There was a planned 24 hour EPR downtime for a major upgrade on
the last weekend of September, which has impacted on reporting. The
reported performance for September is therefore subject to review and will be
re-submitted when the UNIFY window reopens in January 2015.
3.1.2. 18 Week Referral to Treatment [RTT] performance: The RTT admitted and
non-admitted standards failed in September, with performance at 87.29% and
94.48% against the 90% and 95% targets respectively. The incomplete
standard was achieved at 92.03% against the 90% target.
TB2014.118_Integrated Performance Report M6
Page 2 of 36
Oxford University Hospitals
TB2014.118
3.1.3. Twenty-one reported 52 week breaches; in September four patients were
admitted (one plastics and three spinal patients) and six had non-admitted
clock stops (one maxillofacial, one clinical genetics and four spinal patients).
Of the remaining eleven patients; three have admission dates and eight have
follow-ups. An action plan is in place to eliminate 52 week waits by the end of
November 2015.
3.2. Activity
3.2.1. Delayed Transfers of Care remain a major cause of concern for the Trust, at
the end of September the number of delays was at 10.3% against a target of
3.5%. The monthly average for September was 136 delays across the system
for Oxfordshire residents.
3.3. Cancer Waits
3.3.1. Cancer waits: 62 day urgent GP referral, 62 day screening and 2ww urgent
breast did not achieve the standard in August. Pre-check data for September
indicates all cancer standards, excluding the 62 day urgent, will be achieved.
4.
Update on Performance Delivery
4.1. Diagnostic 6ww: the Trust is delivering against this standard and this is expected to
be maintained.
4.2. 4 Hour: the Trust achieved the standard in August, September is subject to review
linked to the EPR upgrade, however the standard was not achieved in October. The
Trust trajectory is expected to be below the standard in November but sustainably
achieved from December onwards.
4.3. Cancer standards: the Trust performance has improved and it is anticipated that
seven of the eight standards will be consistently achieved from September onwards.
The 62 day treatment standard will be achieved from January 2015.
4.4. 52 week waits: the Trust expected to eliminate 52 week waits in March 2015,
however, performance has improved and it is now forecast that no patient will wait
beyond 52 weeks from the end of November 2014.
4.5. RTT: the Trust has signed a contract variation with NHS England and the Clinical
Commissioning Group (CCG) to treat additional patients during the period August to
November inclusive and during October and November 2014 to focus on 18 week
waits. The Trust has therefore agreed a ‘managed fail’ of the RTT standards in
October and November with the TDA, NHS England and the CCG.
5.
Workforce
5.1. Turnover Rates
5.1.1. Turnover increased from 12.2% in August to 12.5% in September and is 2%
above the KPI target. Reducing staff turnover is a key area of focus. In
addition to current recruitment activity, other interventions concerned with
improving staff retention include:
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staff engagement and involvement initiatives;
staff recognition and reward;
development and implementation of multi-professional Education Training
Strategy;
TB2014.118_Integrated Performance Report M6
Page 3 of 36
Oxford University Hospitals
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6.
TB2014.118
implementation of the Leadership and Talent Development Strategic
framework.
Indicator Scoring
6.1. The red and amber Exception Reports which form the Integrated Performance Report
shows detailed performance of each indicator and the narrative explains the key
issues and actions taken for resolution.
6.2. As part of the Trust’s data quality assurance process, each indicator has a data
quality assessment completed by each of the data quality indicators. Each
assessment comprises of two elements:
6.2.1. A rating of 1 to 5 to identify the level of assurance available as per the table
below:
Table 1: Rating Required Evidence
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.
5
As 2 plus: An independent audit has been undertaken (e.g. by the Trust’s
internal or external auditors).
6.2.2. A traffic-light rating to assess the quality of the data as per the table below:
Rating Data Quality
7.
Rating
Data Quality
Green
Satisfactory
Amber
Data can be relied upon but minor areas for improvement identified.
Red
Unsatisfactory/significant areas for improvement identified.
Recommendations
The Trust Board is asked to receive the Integrated Performance Report for Month 6.
Paul Brennan, Director of Clinical Services
Sara Randall, Deputy Director of Clinical Services
October 2014
TB2014.118_Integrated Performance Report M6
Page 4 of 36
ORBIT Reporting
Trust Board Integrated
Performance Report
September 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
Underachieving
Standard
Plan/ Target
Performance
The second component of the overall rating is a traffic-light rating to include the level of
data quality found through any auditing / benchmarking as below
Rating
Green
Data Quality
Satisfactory
Amber
Data can be relied upon but minor areas for improvement identified.
Red
Unsatisfactory/significant areas for improvement identified.
Page 5 of 36
OUH -At A Glance 2014-15
ORBIT Reporting
YTD
Forecast
next
period
90%
Sep-14
87.29%
87.7%
88.4%
3
95%
92%
NA
Sep-14
Sep-14
Sep-14
94.48%
92.03%
40201
94.9%
91.1%
94.9%
90.3%
42288
RTT - 95th percentile for admitted pathways
11.1
6.6
23
Sep-14
Sep-14
Sep-14
7.99
5.49
25.18
7.65
5.11
25.75
RTT - 95th percentile for non-admitted RTT
18.3
Sep-14
18.81
18.14
0
Sep-14
8
0
Sep-14
7
1%
Sep-14
0.94%
Zero tolerance RTT waits AP
0
Sep-14
Zero tolerance RTT waits IP
0
Sep-14
Zero tolerance RTT waits NP
0
Sep-14
6
Operational
RTT - admitted % within 18 weeks
Access
Standards
RTT - non-admitted % within 18 weeks
RTT - incomplete % within 18 weeks
RTT - #waiting on incomplete RTT pathway
RTT admitted - median wait
RTT - non-admitted - median wait
RTT - # specialties not delivering the admitted
standard
RTT - # specialties not delivering the nonadmitted standard
% Diagnostic waits waiting 6 weeks or more
Period
Actual
Data
Quality
0.99
2
2
2
Total # of deliveries
NA
62%
23%
Sep-14
Sep-14
Sep-14
700
62%
24.71%
4199
61.9%
22.3%
708.7
60.3%
24%
3
3
5
7.3
5
25
2
2
3
Proportion of Assisted deliveries
15%
NA
0%
Sep-14
Sep-14
Sep-14
13.29%
0
3.17%
15.8%
0
3.9%
15.7%
3.8%
5
4
5
18.4
3
Medication reconciliation completed within 24
hours of admission
Medication errors causing serious harm
80%
Sep-14
80.91%
79.2%
79%
4
0
Sep-14
0
2
3
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
Sep-14
8
60
5
NA
Sep-14
18
76
5
1.3%
0.9%
2
4
31
5.3
4
11
131
19
4
20
5
4
Sep-14
NA
Sep-14
10978
95%
Q2 14-15
94.31%
93%
Last min cancellations - % of all EL admissions
0.5%
Sep-14
0.12%
0.5%
0.4%
0%
0
Sep-14
Sep-14
2.86%
0
5.4%
0
5.8%
0
0
Sep-14
0
0
0
NA
NA
Sep-14
Sep-14
10432
8572
2
3
NA
Sep-14
1224
4
NA
Sep-14
636
3
Total number of first outpatient attendances
NA
0
0
Sep-14
Sep-14
Sep-14
29.36%
11845
18712
75758 12222.3
106365 18070.3
1st outpatient attends following GP referral
0
Sep-14
10522
61058
Other refs for a first outpatient appointment
0
Sep-14
9702
54559
Non-elective FFCEs
0
0
Sep-14
Sep-14
5706
1909
0
0
Sep-14
Sep-14
3.5%
Q2 14-15
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 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)
Delayed transfers of care as % of occupied
beds
Proportion of normal deliveries
Proportion of C-Section deliveries
Maternal Deaths
30 day emergency readmission
Patient Experience
0
Sep-14
0
1
Aug-14
63.09%
63.9%
64.6%
2
NA
Sep-14
82
501
84.3
4
26.6%
24.7%
2
74
2
0%
Sep-14
23.32%
NA
Sep-14
73
Patient Satisfaction- Response rate (friends &
family -ED)
Net promoter (friends & family -ED)
0%
Sep-14
12.65%
2
NA
Sep-14
57
2
Same sex accommodation breaches
0
80%
Q2 14-15
Sep-14
0
85.25%
0%
Sep-14
0
6
% adult inpatients have had a VTE risk assess
Number SIRIs
3
3
2
Number of Patient Falls with Harm
10293.7
2
9175
3
34806
11516
5794.3
1932
2
3
# acquired, avoidable Grade 3/4 pressure
Ulcers
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
7581
113
44303
654
7644
116.7
3
2
10.3%
9.6%
9.6%
3
2
No data available
11699
2
5
# patients spend >=90% of time on stroke unit
Time to Surgery (% patients having their
operation within the time specified according
to their clinical categorisation)
Safety
HCAI - MRSA bacteraemia
HCAI - Cdiff
Patient Falls per 1000 bed days
Incidents per 100 admissions
Cleaning Scores- % of inpatient areas with
initial score >92%
Flu vaccine uptake
5
0%
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Net promoter (friends & family -Inpatients)
70304
YTD
Forecast
Data
next
period Quality
Mar-14
NA
Urgent cancellations
Period
Actual
NA
Number of attendances at A/E depts in a
month
% <=4 hours A&E from arrival/trans/discharge
zero Urgent cancellations - 2nd time
Quality
Outcomes
Current
Standard Data Period
Summary Hospital-level Mortality Indicator**
Ambulance Handovers within 15 minutes
% patients not rebooked within 28 days
Activity
Current
Standard Data Period
14.4%
2
63.3
2
11
82%
5.5
82.6%
3
5
75.64%
78%
77.1%
Sep-14
Sep-14
1
6
3
31
0.3
5.7
5
5
95%
Q2 14-15
94.28%
93.5%
93.5%
5
NA
Sep-14
2
23
3.3
5
0
NA
NA
Sep-14
Sep-14
Sep-14
1
5.84
4.5
21
5.05
4.94
2
5.4
4.7
2
2
2
NA
Sep-14
2
9
2
5
0%
Sep-14
93.8%
93.2%
93.4%
2
NA
NA
Sep-14
Sep-14
0
46.27%
0
52.5%
0
44.1%
5
5
0%
0%
16.4%
5
3
Page 6 of 36
Operational
Theatre Utilisation - Total
Activity
Cancer
Waits
Current
Standard Data Period
Period
Actual
YTD
Forecast
next
period
Data
Quality
75%
Sep-14
71.19%
72.7%
71.8%
2
Finance
Capital
Theatre Utilisation - Elective
80%
Sep-14
74.79%
76.1%
75.3%
3
Financial Risk
Theatre Utilisation - Emergency
70%
Sep-14
60.16%
61.2%
61%
2
%patients cancer treatment <62-days urg GP
ref
85%
Aug-14
73.53%
77.2%
77.1%
5
%patients cancer treatment <62-days - Screen
90%
Aug-14
79.31%
92.5%
91.3%
5
% patients treatment <62-days of upgrade
N/A
Aug-14
%patients 1st treatment <1 mth of cancer diag
96%
Aug-14
97.2%
94.6%
95.4%
5
%patients subs cancer treatment <31days Surg
94%
Aug-14
96.77%
94.8%
94.3%
5
No data available
I&E
98%
Aug-14
100%
100%
100%
5
94%
Aug-14
97.21%
83.2%
89.1%
5
%2WW of an urg GP ref for suspected cancer
93%
Aug-14
93.91%
93.6%
93.3%
5
%2WW urgent ref - breast symp
93%
Aug-14
90.74%
92.5%
93.6%
5
Workforce
Head count/Pay
costs
105.74%
90%
5
Capital servicing capacity (times)
1.75
Sep-14
1.71
1.8
5
-7
Sep-14
-7.07
-7.5
5
3
Sep-14
2
3
5
CIP Performance Compared to Plan
95%
Sep-14
89.56%
90%
5
I&E Surplus Margin (%)
1%
Sep-14
0.76%
0.8%
5
Current
Standard Data Period
Worked WTE against Plan (displayed as a % of
total)**
Bank usage (displayed as a % of total)**
Vacancy rate
Sickness absence**
Turnover rate
Medical Appraisals
Non Medical Appraisals
Statutory and
Mandatory
Competence
Compliance
Forecast
Data
next
period Quality
Sep-14
Total cost of staff ( displayed as a %)**
* 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
YTD
90%
Agency usage (displayed as a % of total)**
Staff Experience
Period
Actual
Capital Programme Compared to Plan
Liquidity ratio (days) defined as Working
Capital balance *360/Annual Operating
Expenses
Monitor Risk Rating
5
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
Current
Standard Data Period
% staff with up to date Statutory and
Mandatory training
Period
Actual
YTD
Forecast
next
Data
period Quality
101%
Sep-14
96.39%
0%
Sep-14
2.02%
5
0%
Sep-14
5.5%
5
101%
5%
3%
10.5%
0%
0%
0%
Sep-14 103.04%
Sep-14
5.76%
Sep-14
3.55%
Sep-14
12.5%
Q2 14-15
NA
Q2 14-15 56.8%
Q2 14-15 79.4%
4
12.2%
5
3
5
3
5
4
4
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 ,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 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
Page 7 of 36
IPF Red Escalation Report FY 2014-15
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
95%
Sep-14
89.56%
YTD
Forecast next period
90%
There has been slippage on the Divisions are aware they have to make up
start of some Divisional and
any slippage in the remainder of the year
cross-Divisional schemes.
and their performance is being
monitored monthly.
Regular meetings are being held with
Divisional Directors and Divisional
General Managers, and a recovery plan is
being agreed. The latest meeting took
place on 30 October at which all
mitigating actions were reviewed to see if
further delivery of savings can be
realised.
Expected date to meet
standard
Lead Director
Q4 2014/15
Director of Finance & Procurement
Page 8 of 36
IPF Red Escalation Report FY 2014-15
RTT 95th centile for admitted pathways
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September’s reporting period
saw a slight decrease in the 95th
percentile of admitted waits.
The 95th percentile wait is likely
to increase in the short term
whilst the services re-focus the
effort to treat the longest
waiting patients first.
Weekly meetings with the Clinical
Divisions and the Director of Clinical
Services to ensure the sustainable
recovery plans are being implemented to
reduce and treat those patients waiting
over 18 weeks
Expected date to meet
standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
Sep-14
25.18
25.75
25.03
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
Page 9 of 36
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Sep-14
4
31
5
September saw a continued
There is an action plan in place to reduce
reduction in the number of
the number of patients waiting.
admitted patients whose clock
was stopped having waited
over 52 weeks. 3 Spinal and 1
Plastic Surgery patient waited
over 52 weeks.
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
Page 10 of 36
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Sep-14
11
131
19
A significant reduction in
There is an action plan in place to reduce
number of incomplete patients the number of patients waiting.
waiting over 52 weeks at the
end of September, compared
with June, July and August. 6
spinal, 3 Trauma and
Orthopaedics, 1 Ophthalmology
and 1 Physiotherapy patients
were the 11 patients over 52
weeks.
It is expected that this will
continue to reduce.
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
Page 11 of 36
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Sep-14
6
20
5
Non-admitted performance
There is an action plan in place to reduce
against the 52 week target
the number of patients waiting.
remains volatile, and saw a
slight increase in September. 1
Trauma and Orthopaedic, 2
Spinal, 1 Physiotherapy, 1
Maxillo-Facial Surgery and 1
clinical genetics patient were
the patients who had waited
over 52 weeks.
Expected date to meet
standard
Lead Director
End of November for Trust level Director of Clinical Services
with risk limited to
Orthopaedics and Spinal.
Page 12 of 36
IPF Red Escalation Report FY 2014-15
Delayed transfers of care as % of occupied beds
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Performance in Q2 continues
to deteriorate, although the
actual monthly position for
September showed a very
marginal improvement on the
levels seen in August (113
patients in September, 121 in
August). October has seen the
highest number of delays this
year.
Daily whole system teleconference calls
remain in place, with escalation to
Oxfordshire colleagues when system is on
RED. Weekly Urgent Care Summit
meeting with OCCG, OH and OCC
colleagues to manage system and winter
funding arrangements and reprioritize
where necessary. Further work is
progressing internally to improve the
discharge process for all patients.
Expected date to meet
standard
Lead Director
This system has not agreed a
date to achieve this standard.
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q2 14-15
10.3%
9.6%
9.64%
Page 13 of 36
IPF Red Escalation Report FY 2014-15
Theatre Utilisation - Elective
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September has seen a slight
increase in utilisation following
the resumption of normal
levels of activity.
Focus continues on productivity for all
clinical teams both on the day and
forward booking.
Recruitment of critical theatres staff ongoing.
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%
Sep-14
74.79%
76.1%
75.32%
Page 14 of 36
IPF Red Escalation Report FY 2014-15
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
A very slight decrease in
utilisation rates during
September in emergency
theatres.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Sep-14
60.16%
61.2%
61.05%
Internal theatre meetings are in place to
review utilization, work is progressing to
develop a standardized approach across
the Trust to manage the emergency lists
which include:


Developing and implementing a
standard operating procedure and
flow chart for all emergency lists.
Standardising the urgency category for
all procedures.
Expected date to meet
standard
Lead Director
Quarter 3 2014/15
Director of Clinical Services
Page 15 of 36
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
Capacity at ‘front end’ of
pathways to see patients
within the 2 week target. This
impacts on reducing time left
within the remaining 62 days.
Patient choice to delay
pathway for holidays, take
’thinking time’.
Plans in place to increase front end
capacity. Working with CCG to increase
patient/GP understanding of need to
uptake appointments. Working with
radiology to match diagnostics to
demand.
Expected date to meet
standard
Lead Director
January 2015
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
85%
Aug-14
73.53%
77.2%
77.15%
Page 16 of 36
IPF Red Escalation Report FY 2014-15
%patients cancer treatment <62-days - Screen
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Aug-14
79.31%
92.5%
91.27%
This relates to only 3 patients N/A
from a total of 15 which shows
a marked deficit despite low
numbers.
Expected date to meet
standard
Lead Director
September 2014
Director of Clinical Services
Page 17 of 36
IPF Red Escalation Report FY 2014-15
HCAI - MRSA bacteraemia
What is driving the reported
underperformance?
Though there was 1 MRSA Bacteraemia
from Cardiothoracic Critical Care that was
apportioned to the OUH in September
2014, it was agreed with the
Commissioners at the Post Infective Review
(PIR) meeting, that though the
bacteraemia was hospital acquired, it was
unavoidable .
What actions have we taken
to improve performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Sep-14
1
3
0
The case was thought to be
well managed in accordance
with Trust guidelines and
protocols i.e. VAP care
bundle, Antibiotic guidelines
and there were no further
learning outcomes identified.
Additionally the patient’s early postoperative course was complicated by AF,
surgical emphysema and concurrently
severe sepsis due to Acalculous
Cholecystitis. The careful management of
the biliary sepsis was thought to be lifesaving.
The OUH has an upper limit of 0 avoidable
MRSA Bacteraemia for FY 2014 – 2015 and
to date has reported 0 avoidable MRSA
Bacteraemia for the FY 2014-2015 .
The OUH is therefore not underperforming
for this IPF.
Expected date to meet standard
Lead Director
The Trust aims to achieve its objective of 0 Medical Director
avoidable MRSA Bacteraemia 2014-15.
Page 18 of 36
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
The pay overspend continues to
be driven by the on-going
payment of premium rates for
staff – the high use of bank &
agency staff, and additional
payments made to medical
staff to work weekend sessions
required to meet performance
targets.
The Trust is introducing further workforce
measures to reduce the usage and cost of
agency staff, and has also initiated
recruitment drives to replace temporary
staff with permanent employees. It has
improved the rate paid to bank staff as
part of its strategy to increase bank usage
and reduce the reliance on more
expensive agency workers.
Expected date to meet
standard
Lead Director
Standard
Current Data Period
Period Actual
101%
Sep-14
103.04%
YTD
Forecast next period
Pay is likely to continue to
Director for Finance & Procurement
overspend until performance
targets are met and
performance is stabilized, and
until the policies to recruit &
retain permanent staff become
effective.
Page 19 of 36
IPF Red Escalation Report FY 2014-15
Sickness absence**
What is driving the
reported
underperformance?
What actions have we taken to improve
performance
The Trust’s absence rate is
at 3.55% in September and
is an increase from the
previous month which was
3.48%.
FirstCare, the absence management system,
has been introduced and is working well across
the Trust. The automation of much of the
absence process has greatly enhanced the
service for line managers, although sickness
absence levels have risen as data quality has
improved. To strengthen the operational
management of sickness further, a post has
been allocated to help support Divisions case
manage long term sickness cases.
Standard
Current Data Period
Period Actual
3%
Sep-14
3.55%
YTD
Forecast next period
Most staff groups and all
clinical divisions have
experienced increases in
absence rates when
compared to the previous
To help prevent sickness absence and support
month.
the FirstCare initiative, TME recently supported
the move to introduce a Trust wide Employee
The increase in absence
rates over the short term Assistance Programme (EAP).This will provide
support to staff and their families in helping to
were predicted at the
introduction of FirstCare, deal with non-work related issues which in turn
due to increased accuracy should reduce the need for absence during
periods of family crisis.
of data capture.
The Occupational Health Service has
commenced the annual flu immunization
programme at the end of September. Currently,
34% of front line staff have been inoculated.
Expected date to meet
standard
Lead Director
Q4
Director of Organisational Development and
Workforce
Page 20 of 36
IPF Red Escalation Report FY 2014-15
Turnover rate
What is driving the
reported
underperformance?
What actions have we taken to improve
performance
Turnover is at 12.5%
which is in excess of the
KPI of 10.5%.
The Trust has set improving retention as a key
corporate objective.
Standard
Current Data Period
Period Actual
10.5%
Sep-14
12.5%
YTD
Forecast next period
12.15%
Actions associated with reducing the turnover
rate apply equally to reducing vacancy levels
Turnover reasons are
multi factorial and include within the Trust and are noted within the vacancy
section.
cost of living, staff
satisfaction, local market A recruitment and retention action group has
forces, pay staff
been established to recommend and implement
satisfaction.
the high impact interventions that emerged from
the R and R summit held in July .
Staff engagement, recognition and reward are all
important factors in reducing turnover. Actions
for these e.g. Staff recognition awards 2014 and
the various workstreams associated with
engagement e.g. Values Based Interviewing, staff
surveys etc. are on-going.
Other actions include:


development and implementation of multiprofessional Education Training Strategy;
implementation of the Leadership and Talent
Development Strategic framework.
Expected date to meet
standard
Lead Director
Q4
Director of Organisational Development and
Workforce
Page 21 of 36
IPF Amber Escalation Report FY 2014-15
Capital servicing capacity (times)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
2
Sep-14
1.7
YTD
Forecast next period
2
The EBITDA was fractionally below It is expected that the ratio will go above 1.75
the amount needed to maintain by the end of the next quarter.
the key ratio so the overall score
remained “2”. The ratio has to be
1.75 and it was 1.71 in September.
Expected date to meet standard
Lead Director
December 2014
Director of Finance & Procurement
Page 22 of 36
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
Standard
Current Data Period
Period Actual
-7
Sep-14
-7.1
YTD
Forecast next period
-8
The fall in cash, and balance held None – timing issue only.
at the end of the month, were in
line with the Month 5 forecast
because it was known that the
Trust would be making its halfyearly payments for PDC dividend
and interest.
Expected date to meet standard
Lead Director
October 2014
Director of Finance & Procurement
Page 23 of 36
IPF Amber Escalation Report FY 2014-15
Monitor Risk Rating
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
3
Sep-14
2
YTD
Forecast next period
3
The ratios for both liquidity and
None – timing issue only. It is expected that one
capital servicing scores are
of the two key ratios will change.
fractionally below the values
needed for one of them to score a
“3” and hence push this score
from “2” to “3”. (It only needs one
score to become a “3”, not both,
for this overall score to go from
“2” to “3”.)
Expected date to meet standard
Lead Director
October 2014
Director of Finance & Procurement
Page 24 of 36
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
Although the Trust was slightly
behind plan in the achievement of
its I&E target surplus, its position
against its break even duty is on
plan. This is due to “technical”
reasons and it is believed that
these technical reasons will
remain for most of the rest of the
year.
The Trust currently believes it will meet its key
financial targets for the year but it will be
important for the Trust to maintain a tight grip
on its expenditure and for Divisional mitigating
actions to be implemented effectively.
Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
1%
Sep-14
0.76%
YTD
Forecast next period
0.75%
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 towards the end of the year.
Page 25 of 36
IPF Amber Escalation Report FY 2014-15
RTT - admitted % within 18 weeks
What is driving the reported
underperformance?
Admitted performance continues
to be challenge. September’s
performance has deteriorated
further but is not attributable to
a dip in activity.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Sep-14
87.29%
87.7%
88.4%
Weekly meetings continue to be held with
Divisional Teams and the Director of Clinical
Services.
Specialties with significant challenges continue to
be:




Orthopaedics
Spinal
Ophthalmology
Neurosurgery
Additional capacity has opened support
Orthopaedics, additional theatres lists are being
undertaken and external providers are being
used to support some surgical activity.
Expected date to meet standard Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 26 of 36
IPF Amber Escalation Report FY 2014-15
RTT - non-admitted % within 18 weeks
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Non-admitted performance has
not seen an improvement and is
below the 95% standard for the
second month in a row.
Performance is likely to dip
further as the backlog clearance
gathers further momentum
throughout October and
November.
Weekly 18 week performance meetings are
held with Divisional Teams and the Director of
Clinical Services.
Expected date to meet standard
Lead Director
End of November 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
95%
Sep-14
94.48%
94.9%
94.88%
Page 27 of 36
IPF Amber Escalation Report FY 2014-15
RTT - 95th percentile for non-admitted RTT
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
18.3
Sep-14
18.81
18.14
18.35
Due to the prolonged non
Weekly 18 week performance meetings are
achievement of the non-admitted held with Divisional Teams and the Director of
target, the 95th percentile waits Clinical Services.
have seen an increase. This is
expected to increase further in
the short term, as services refocus on treating the longest
waiting patients.
Expected date to meet standard
Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 28 of 36
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
Standard
Current Data Period
Period Actual
0
Sep-14
8
YTD
Forecast next period
Eight services did not achieve the
Weekly meetings with the Clinical Divisions
admitted standard in September and and the Director of Clinical Services to ensure
are as follows:
the sustainable recovery plans are being
implemented to reduce and treat those
1. Urology
patients waiting over 18 weeks.
2. Trauma & Orthopaedics
3. Ear, Nose & Throat
4. Ophthalmology
5. Neurosurgery
6. Plastic Surgery
7. Cardiology
8. Other services
Expected date to meet standard
Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 29 of 36
IPF Amber Escalation Report FY 2014-15
RTT - # specialties not delivering the non-admitted standard
What is driving the reported
underperformance?
Seven services did not achieve the
non- admitted standard in
September and are as follows:
1.
2.
3.
4.
5.
6.
7.
Trauma & Orthopaedics
Ear, Nose & Throat
Ophthalmology
Neurosurgery
Plastic Surgery
Cardiology
Other services
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
0
Sep-14
7
YTD
Forecast next period
Weekly meetings with the Clinical Divisions
and the Director of Clinical Services to ensure
the sustainable recovery plans are being
implemented to reduce and treat those
patients waiting over 18 weeks.
Expected date to meet standard
Lead Director
End of November for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 30 of 36
IPF Amber Escalation Report FY 2014-15
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
The end of quarter position
reflected is due to the nonachievement of the 95% standard
in July and September. Q2 has
seen a steady increase in
performance as compared to
quarter one. Year to date
performance up to the end of
26/10/2014 is 92.81%.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
95%
Q2 14-15
94.31%
93%
Forecast next period
The Urgent Care Working group continues to
meet weekly, with OCCG, OH, OCC and OUH
colleagues to improve patient flow across the
system. Escalation is in place with significant
focus across all clinical teams to minimize the
number of patients waiting over four hours.
Additional short terms actions include:
 Staffing reviewed each shift to ensure safe
staffing
 Extended consultant presence in ED
 Additional consultant led ward rounds and
senior decision makers in ED.
 Increased theatre capacity to manage
trauma flow
 Enhanced diagnostic and Pharmacy
provision
 Monitoring number of admissions and
discharges to transfer lounge
Winter Plans have been agreed and being
implemented.
Expected date to meet standard
Lead Director
Quarter 3 onwards
Director of Clinical Services
Page 31 of 36
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September has seen a marginal
increase in utilisation with the
resumption of normal levels of
activity following the August
holiday month.
Focus continues on productivity for all clinical
teams both on the day and forward booking.
Recruitment of key critical theatre staff is ongoing.
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%
Sep-14
71.19%
72.7%
71.79%
Page 32 of 36
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
93%
Aug-14
90.74%
92.5%
93.55%
The dip in performance is due to 5 Changes are being made to pre-check reporting.
breaches that occurred in August.
This is due to a validation error
which has been corrected with
potential recovery, that will be
visible at end of quarter.
Expected date to meet standard
Lead Director
September 2014
Director of Clinical Services
Page 33 of 36
IPF Amber Escalation Report FY 2014-15
Proportion of C-Section deliveries
What is driving the reported
underperformance?
The LSCS rate fluctuates each
month as it is in part dependent
upon case mix. 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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23%
Sep-14
24.71%
22.3%
24.04%
LSCS rate has been reviewed by the Head of
Midwifery, Clinical Lead for Intrapartum Care
and Clinical Director for Women’s Services.
Further discussion involving Midwives and
Consultant to raise awareness of the rate. It is
noted that the year to date rate is within the
target range.
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
Ongoing
Director of Clinical Services
Page 34 of 36
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
The Trust has been collecting VTE 
risk assessment date in a number
of different ways to date,

including paper –based (clinical
Services-NOC) via the case notes 
system and latterly, via EPR.
Until 9th April 2014 risk
assessment carried out in either 
case notes or EPR was adequate.

On the 9th April 2014, Casenotes
functionality (including VTE risk 
assessment) was switched off.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Q2 14-15
94.28%
93.5%
93.51%
Monthly auditing of data via ORBIT-reports
sent to Clinical Leads
Quick Reference Guides/How to complete eVTE Risk Assessment via Tasklist and Adhoc.
Education of Junior doctors in how to
complete e-VTE Risk Assessment via EPR
completed in August 2014- will be repeated
every 6 months.
Education of Consultant Body- Checking VTE
Assessment Compliance through EPR.
Mandate VTE Risk Assessment –Link the Risk
Assessment with e-PMA.
2x Quality Improvement Projects will run for
2014/15 with Junior Doctors in Thrombosis
and Thromboprophylaxis.
Trust Wide Audit (VTE Quality Standard 3)
demonstrated that a drop in VTE Risk Assessment
has not had an adverse impact upon the
prescription of Thromboprophylaxis (the
clinical/quality endpoint of VTE assessment
processes).
Expected date to meet standard Lead Director
December 2014
Medical Director
Page 35 of 36
IPF Amber Escalation Report FY 2014-15
Vacancy rate
What is driving the reported
underperformance?
The vacancy rate in September
has reduced further to 5.76%.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Sep-14
5.76%
YTD
Forecast next period
Vacancy rates have reduced in September as the
Trust has increased its staff in post. The number of
new starters continue to exceeded leavers however
whilst that is a positive, the number of new nurses
and midwives has matched leavers indicating that
further intensive support is required.
This is above the KPI target of
5.0%, with current vacancies
being influenced by national
shortages for certain occupations The recruitment process is under continuous review
to ensure that there are no unnecessary blockages
and turnover within the Trust.
within the system and any temporary issues are
resolved. TRAC the Trust’s recruitment management
system has been rolled out across the Trust and
automated large parts of the process for line
managers.
Recruitment literature is being revised and the Trust
continues to attend trade and employment fairs.
Other initiatives being pursued include the
application of targeted recruitment and retention
payments, fast-track progression and targeted Nurse
support.
Notice periods for all new non-medical staff, bands
5,6 and 7, have already been extended, this will
st
apply to substantive staff from 1 January 2015. This
will provide managers with an extended time period
recruit replacement staff also positions the Trust in
line with many other Trusts.
Expected date to meet standard
Lead Director
Q4
Director of Organisational Development and
the Workforce
The Workforce Optimisation Group has commissioned a proposal to create an internal band five
bureau which will assist in the internal transfer of such staff between departments and also offer an
alternative to resignation for staff who considering a change of specialty.
In February 2015 a further cohort of international recruits is planned to arrive at the Trust with
additional cohorts joining monthly into Spring.
Page 36 of 36