ORBIT Reporting
Trust Board Integrated
Performance Report
July 2014
At A Glance report
Escalation report
Data Quality Indicator
The data quality rating has 2 components. The first component is a 5 point rating which
assesses the level and nature of assurance that is available in relation to a specific set of
data. The levels are described in the box below.
Rating
Required Evidence
1
Standard operating procedures and data definitions are in place.
2
As 1 plus: Staff recording the data have been appropriately trained.
3
As 2 plus: The department/service has undertaken its own audit.
4
As 2 plus: A corporate audit has been undertaken.
As 2 plus: An independent audit has been undertaken (e.g. by the Trust's internal
or external auditors).
5
The second component of the overall rating is a traffic-light rating to include the level of
data quality found through any auditing / benchmarking as below
Rating
Green
Data Quality
Satisfactory
Amber
Data can be relied upon but minor areas for improvement identified.
Red
Unsatisfactory/significant areas for improvement identified.
Graph Legend
Underachieving
Standard
Plan/ Target
Current Year Performance
Previous Year Performance
OUH -At A Glance 2014-15
ORBIT Reporting
Operational
Access
Standards
Standard
YTD
Forecast
next
period
Data
Quality
Quality
Outcomes
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
RTT - admitted % within 18 weeks
90%
Jul-14
89.36%
87.5%
88%
3
Summary Hospital-level Mortality Indicator**
NA
Dec-13
0.98
RTT - non-admitted % within 18 weeks
95%
92%
NA
Jul-14
Jul-14
Jul-14
95.41%
89.49%
43826
95.1%
91.4%
95.2%
91.3%
42019
2
2
2
Total # of deliveries
NA
62%
23%
Jul-14
Jul-14
Jul-14
721
58.25%
23.44%
2794
62.2%
21.3%
700.3
61.8%
21.5%
11.1
6.6
23
18.3
Jul-14
Jul-14
Jul-14
Jul-14
6.69
4.67
24.5
17.72
7.67
5.04
26.01
17.95
7.7
5
25.6
17.9
2
2
3
3
Proportion of Assisted deliveries
15%
NA
0%
80%
Jul-14
Jul-14
Jul-14
Jul-14
18.31%
0
3.85%
77.39%
16.5%
0
4%
78.9%
16.7%
0
Jul-14
4
0
Jul-14
3
1%
Jul-14
0.99%
1.5%
1.3%
Zero tolerance RTT waits AP
0
Jul-14
7
22
6
Zero tolerance RTT waits IP
0
Jul-14
27
101
28
0
Jul-14
5
10
3.3
RTT - incomplete % within 18 weeks
RTT - #waiting on incomplete RTT pathway
RTT admitted - median wait
RTT - non-admitted - median wait
RTT 95th centile for admitted pathways
RTT - 95th percentile for non-admitted RTT
RTT - # specialties not delivering the admitted
standard
RTT - # specialties not delivering the nonadmitted standard
% Diagnostic waits waiting 6 weeks or more
Zero tolerance RTT waits NP
Proportion of normal deliveries
Proportion of C-Section deliveries
Maternal Deaths
30 day emergency readmission
Medication reconciliation completed within 24
hours of admission
Medication errors causing serious harm
2
Patient
Experience
1
2
3
Jul-14
12
41
5
NA
Jul-14
9
48
5
0
Jul-14
0
0
0%
Jun-14
67.88%
64.4%
NA
Jul-14
92
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Net promoter (friends & family -Inpatients)
0%
Jul-14
26.31%
NA
Jul-14
73
0%
Jul-14
16.8%
NA
Jul-14
64
0
80%
Q2 14-15
Jul-14
0
85.25%
11
82.2%
0%
Jul-14
78.49%
78.7%
80.6%
0
6
Jul-14
Jul-14
0
6
2
25
0.3
8
5
5
Jul-14
13908
49115
% <=4 hours A&E from arrival/trans/discharge
95%
Q2 14-15
94.28%
92.5%
Last min cancellations - % of all EL admissions
0.5%
Jul-14
0.46%
0.5%
0.4%
2
Patient Satisfaction- Response rate (friends &
family -ED)
Net promoter (friends & family -ED)
0%
0
Jul-14
Jul-14
2.17%
0
4.3%
0
5.8%
0
2
Same sex accommodation breaches
Urgent cancellations
0
11314
9506
NA
Jul-14
1211
NA
Jul-14
597
Total number of first outpatient attendances
NA
0
0
Jul-14
Jul-14
Jul-14
24.76%
13507
19686
52598
71840
1st outpatient attends following GP referral
0
Jul-14
11241
Other refs for a first outpatient appointment
0
Jul-14
Non-elective FFCEs
0
0
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
# patients spend >=90% of time on stroke unit
Time to Surgery (% patients having their
operation within the time specified according to
their clinical categorisation)
Jul-14
Jul-14
# 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
5
0
NA
NA
Total on Inpatient Waiting List
2
2
3
Safety
4
5
4
Jul-14
NA
12893.7
3.9%
78.1%
3
0
Number of attendances at A/E depts in a month
zero Urgent cancellations - 2nd time
2
5
NA
0%
No data available
Data
Quality
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
Ambulance Handovers within 15 minutes
% patients not rebooked within 28 days
Activity
Current
Data Period Period Actual
HCAI - MRSA bacteraemia
HCAI - Cdiff
5
64.4%
2
340
83.3
4
28%
27.8%
2
75.7
2
15.2%
2
51.7
2
5.5
81.1%
2
5
18%
% adult inpatients have had a VTE risk assess
95%
Q2 14-15
93.79%
93%
93%
5
3
Number SIRIs
NA
Jul-14
2
15
3
5
3
3
2
Number of Patient Falls with Harm
13252.3
18488.3
Incidents per 100 admissions
0
NA
NA
Jul-14
Jul-14
Jul-14
3
4.81
4.86
20
4.76
5.09
5
4.8
6.4
2
2
2
41418
10627.7
2
# acquired, avoidable Grade 3/4 pressure Ulcers
NA
Jun-14
2
5
1.7
5
10099
37133
9497.3
3
0%
Jul-14
93.63%
93.1%
93.2%
2
Jul-14
Jul-14
6062
2023
23485
7743
5952.3
1963.3
2
3
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
NA
NA
Jul-14
Jul-14
0
44.23%
0
56%
0
52.1%
5
5
0
0
Jul-14
Jul-14
8059
116
29430
413
7484
112
3
2
3.5%
Q2 14-15
10.29%
9.3%
9.3%
3
Patient Falls per 1000 bed days
Cleaning Scores- % of inpatient areas with initial
score >92%
Flu vaccine uptake
0%
0%
Operational
Activity
Cancer
Waits
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
Finance
Capital
Standard
Theatre Utilisation - Total
75%
Jul-14
73.83%
73.7%
73.9%
2
Theatre Utilisation - Elective
80%
Jul-14
77.44%
77.1%
77.2%
3
Theatre Utilisation - Emergency
70%
Jul-14
61.39%
61.4%
61.8%
2
Liquidity ratio (days) defined as Working Capital
balance *360/Annual Operating Expenses
%patients cancer treatment <62-days urg GP ref
85%
Jun-14
78.74%
77.8%
77.8%
5
Monitor Risk Rating
%patients cancer treatment <62-days - Screen
90%
Jun-14
96.15%
94.8%
94.8%
5
% patients treatment <62-days of upgrade
0%
%patients 1st treatment <1 mth of cancer diag
96%
Jun-14
92.96%
93.1%
93.1%
5
%patients subs cancer treatment <31days - Surg
94%
Jun-14
94.67%
95.4%
95.4%
5
0%
%patients subs cancer treatment <31-days Drugs
98%
Jun-14
%patients subs treatment <31days - Radio
94%
%2WW of an urg GP ref for suspected cancer
93%
%2WW urgent ref - breast symp
93%
Financial
Risk
I&E
5
Workforce
Head
count/Pay
costs
YTD
Forecast
next
period
Data
Quality
5
Capital Programme Compared to Plan
90%
Jul-14
97.16%
90%
Capital servicing capacity (times)
1.75
Jul-14
2.08
1.8
-7
Jul-14
-6.22
-7
3
Jul-14
3
3
CIP Performance Compared to Plan
95%
Jul-14
90.01%
95%
5
I&E Surplus Margin (%)
1%
Jul-14
1.31%
1%
5
Forecast
next
period
Data
Quality
Standard
100%
100%
100%
5
Jun-14
84.8%
77.5%
77.5%
5
Jun-14
92.97%
93.6%
93.6%
5
Jun-14
90.91%
91.4%
91.4%
5
Total cost of staff ( displayed as a %)**
Staff
Experience
Current
Data Period Period Actual
Current
Data Period Period Actual
YTD
101%
Jul-14
96.37%
5
Bank usage (displayed as a % of total)**
0%
Jul-14
1.97%
5
Agency usage (displayed as a % of total)**
0%
Jul-14
5.43%
5
101%
5%
Jul-14
Jul-14
103.24%
8.2%
5
3
3%
10.5%
Jul-14
Jul-14
3.44%
11.97%
Worked WTE against Plan (displayed as a % of
total)**
Vacancy rate
Sickness absence**
Turnover rate
11.8%
5
3
* This measure is collected on a year to date basis and displays the latest available values
** This measure is collected for a 12 month period preceding the latest period shown
** Sickness absence figures shown in period actual reflect the financial year to date
Division: Division of Children's & Women's,Division of Clinical Support Services,Division of Corporate Services,Division of Medicine, Rehabilitation & Cardiac,Division of Neuroscience, Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Legacy Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal
and Rehabilitation,TRUST,Trust-wide only,Unknown
Directorate: Acute Medicine & Rehabilitaion ,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research,Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services,Chief Nurse Patient Services & Education,Children's ,Children’s,CRS Implementation,Division of Clinical Support Services,Division of Corporate Services,Division of Medicine, Rehabilitation & Cardiac,Division of Neuroscience,
Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Estates and Facilities,Finance and Procurement,Gastroenterology, Endoscopy and Churchill Theatres ,Gastroenterology, Endoscopy and Theatres (CH),Horton Management,Human Resources and Admin,Legacy Cardiac, Vascular & Thoracic Surgery,Legacy
Cardiology,Legacy Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal and Rehabilitation,Legacy Rehabilitation & Rheumatology,MARS -Research & Development,Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records,Oncology & Haematology ,Orthopaedics,Pathology & Laboratories,Pharmacy,Planning & Communications,Private Patients,Radiology & Imaging,Renal, Transplant &
Urology,Specialist Surgery ,Strategic Change,Surgery ,Teaching Training and Research,Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
Zero tolerance RTT waits AP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Admitted breaches of the 52 week An action plan is in place to reduce the number
standard decreased to 7 during
of patients waiting.
July. 5 were Spinal and 2 were
Ophthalmology.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Jul-14
7
22
6
Zero tolerance RTT waits IP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The number of 52 week breaches An action plan is in place to reduce the number
on the incomplete pathway list
of patients waiting.
has reduced to 26 Spinal patients.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Jul-14
27
101
28
Zero tolerance RTT waits NP
What is driving the reported
underperformance?
What actions have we taken to improve
performance
6 Spinal patients breached 52
weeks on the non-admitted
pathway during July.
An action plan is in place to reduce the number
of patients waiting.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to orthopaedics
and spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Jul-14
5
10
3
Delayed transfers of care as % of occupied beds
What is driving the reported
underperformance?
Performance in Q1 showed a
slight improvement from the
position in Q4 of 2013/14, but this
is marginal. Performance
continues to be significantly
above the standard.
What actions have we taken to improve
performance
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
The system has not agreed a date Director of Clinical Services
to achieve this standard.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q2 14-15
10.29%
9.3%
9.3%
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Emergency theatre utilisation
Internal theatre meetings are in place to review
remains very volatile, as would be utilization, work is progressing to develop a
expected.
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Jul-14
61.39%
61.4%
61.81%
%patients cancer treatment <62-days urg GP ref
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Sustainable delivery of the 62 day
target is challenging. Loss of
some surgical capacity around the
Easter holidays, as well as the
ongoing issues around patient’s
exercising their right to wait
longer. Further loss of surgical
capacity during the coming
holiday season is likely to make
the current performance levels
difficult to improve upon.
A recovery plan is in place which includes:
Expected date to meet standard
Lead Director
August 2014
Director of Clinical Services



Relocation of the bronchoscopy unit
Additional capacity being sourced externally
Urology are redesigning the pathway to
reduce the average wait to definitive
treatment decision.
Multiple treatment options are under review,
giving the option to patients to choose active
surveillance.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
85%
Jun-14
78.74%
77.8%
77.8%
%patients subs treatment <31days - Radio
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Problems with Radiotherapy
A recovery plan is in place which includes:
capacity and staffing have been
well documented. Performance is  Operating two of the five linacs on a seven
now improving.
day basis to increase capacity.
 Extending the operating hours of the five
linacs Monday to Friday from 8am to 8pm.
Expected date to meet standard
Lead Director
Performance is expected to
deteriorate in the first quarter.
Sustainable achievement of the
standard from August 2014.
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
94%
Jun-14
84.8%
77.5%
77.46%
Total cost of staff ( displayed as a %)**
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The continued high use of bank
and agency staff and the
additional payments made to
medical staff to work weekend
sessions in order to meet waiting
list and activity targets are driving
the pay costs.
The Trust is introducing a number of workforce
measures to reduce the usage and cost of
agency staff, and is putting in place plans to
improve the recruitment and retention of
permanent staff.
Expected date to meet standard
Lead Director
Pay is likely to continue to
Director of Finance & Procurement
overspend in the short term while
the Trust improves its waiting list
performance.
Standard
Current Data Period
Period Actual
101%
Jul-14
103.24%
YTD
Forecast next period
Vacancy rate
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The vacancy rate is 8.2%, which is The outcomes of the Recruitment and Retention
greater than the Trust’s KPI of 5%. Summit i.e. strategy and action plan will assist in
addressing some of the key recruitment and
There are a number of nationally retention issues. This will include a review of pay
recognised difficult to recruit
and consider targeted pay premia to selected
shortage occupations, revised
staff groups in order to address excessive
establishments and additional
turnover. A paper will be presented to Trust
posts will have all contributed to Board in September detailing the action plan
and will contain key milestones.
the Trust’s vacancy rate.
Increased turnover also impacts
significantly on the number of
reported vacancies.
A further assessment of the recruitment process
is underway, led by the Deputy Director of
Workforce. This is to ensure that there are no
unnecessary remaining barriers which may
influence the time to recruit.
Clinical Divisions are also developing local
targeted initiatives. In Clinical Support Services a
“find a friend” scheme has been introduced.
In September the Trust will commence its
overseas recruitment campaign for qualified
nurses. Attendance at recruitment and trade
fairs is ongoing and recruitment literature is
being reviewed. The expansion of “one stop”
recruitment shops is also being evaluated.
Expected date to meet standard Lead Director
Q4 2014/15
Director of Organizational Development &
Workforce
Standard
Current Data Period
Period Actual
5%
Jul-14
8.2%
YTD
Forecast next period
Turnover rate
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Turnover continues to rise and is Staff have been invited to contribute to the
now 11.97% compared to 11.87% second “PULSE” survey, the results of which will
in June 2014.
be published towards the end of September.
The data collected from this survey along with
The most recent information
results from the Welcome and exit
available from exit questionnaire questionnaires will provide important
indicates “relocation” and “career information upon which future retention
advancement” as the two
initiatives can be agreed.
principle reasons contributing to
the Trust’s turnover.
A Recruitment and Retention Summit was held
in July where short, medium and long term
solutions were considered. Attendees obtained
a shared understanding of the issues affecting
recruitment and retention within the Trust. Key
outcomes were the development of a
Recruitment and Retention strategy and related
action plan. A paper will be presented to Trust
Board in September detailing the action plan
and will contain key milestones.
A Trust Leadership Strategy has been approved
and is now in the implementation stage, this will
address a number of concerns relating to career
advancement .
Expected date to meet standard
Lead Director
Q4 2014/15
Director of Organizational Development &
Workforce
Standard
Current Data Period
Period Actual
10.5%
Jul-14
11.97%
YTD
Forecast next period
11.85%
IPF Amber Escalation Report FY 2014-15
CIP Performance Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
There has been slippage on the
In the performance review meetings, Divisions
start of some Divisional and cross- have been asked to identify new schemes to
Divisional schemes
make up any shortfall resulting from slippage in
the schemes they identified. Their performance
is being monitored monthly.
Expected date to meet standard
Lead Director
Q2 2014/15
Director of Finance & Procurement
Standard
Current Data Period
Period Actual
95%
Jul-14
90.01%
YTD
Forecast next period
95%
IPF Amber Escalation Report FY 2014-15
RTT - admitted % within 18 weeks
What is driving the reported
underperformance?
Performance has started to
improve in July, and still remains
below the required 90% within 18
weeks. The backlog reduction
programme continues, but has
slowed a little, reflecting the
greater difficulty of finding
patients who are willing to move
their treatment to other
providers where capacity has
been secured. Trust capacity is
also starting to be impacted by
the start of the holiday season.
What actions have we taken to improve
performance
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 in June to
support Orthopaedics, additional theatres lists
are being undertaken and external providers are
being used to support some surgical activity.
The recovery plans continue to ensure long term
sustainability of the waiting times.
Expected date to meet standard Lead Director
Quarter 2
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Jul-14
89.36%
87.5%
87.96%
IPF Amber Escalation Report FY 2014-15
RTT - incomplete % within 18 weeks
What is driving the reported
underperformance?
What actions have we taken to improve
performance
6 specialties failed to deliver the
incomplete standard during July.
These were; Trauma and
Orthopaedics, Ophthalmology,
Ear Nose & Throat, Neurosurgery,
Plastic Surgery and Other.
Weekly meetings with the Clinical Divisions and
the Director of Clinical Services to ensure the
sustainable recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
92%
Jul-14
89.49%
91.4%
91.28%
IPF Amber 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
Increased number of patients
waiting to be treated.
Weekly meetings with the Clinical Divisions and
the Director of Clinical Services to ensure the
sustainable recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
Jul-14
24.5
26.01
25.58
IPF Amber Escalation Report FY 2014-15
RTT - # specialties not delivering the admitted standard
What is driving the reported
underperformance?
What actions have we taken to improve
performance
4 specialties failed to deliver the
admitted standard during July.
These were; Trauma and
Orthopaedics, Ophthalmology,
Cardiology and Other.
Weekly meetings with the Clinical Divisions and
the Director of Clinical Services to ensure the
sustainable recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
0
Jul-14
4
YTD
Forecast next period
IPF Amber Escalation Report FY 2014-15
RTT - # specialties not delivering the non-admitted standard
What is driving the reported
underperformance?
What actions have we taken to improve
performance
3 specialties failed to deliver the
admitted standard during July.
These were; Trauma and
Orthopaedics, Ophthalmology and
Ear Nose & Throat (ENT).
Weekly meetings with the Clinical Divisions and
the Director of Clinical Services to ensure the
sustainable recovery plans are being
implemented to reduce the number of patients
waiting over 18 weeks.
Expected date to meet standard
Lead Director
Quarter 2 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics
and Spinal.
Standard
Current Data Period
Period Actual
0
Jul-14
3
YTD
Forecast next period
IPF Amber Escalation Report FY 2014-15
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
Performance in July improved
and just missed the standard,
August continued to improve and
ensured the standard was
achieved.
What actions have we taken to improve
performance
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.
An increase in patients waiting to
Additional short terms actions include:
go home – delayed transfers of
care has had a significant impact  Staffing reviewed each shift to ensure safe
on patient flow from ED.
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.
Expected date to meet standard
Lead Director
Quarter 2 onwards
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
95%
Q2 14-15
94.28%
92.5%
Forecast next period
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Total theatre utilisation target, is
below the target levels of 75%.
Focus continues on productivity for all clinical
teams both on the day and forward booking.
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%
Jul-14
73.83%
73.7%
73.89%
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Elective
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Similar to total theatre utilisation Focus continues on productivity for all clinical
target, the elective utilisation is
teams both on the day and forward booking.
well below the target levels of
80%. Deterioration of the utilised
level started before Winter, but is
recovering slowly and for July
remains above 77%.
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%
Jul-14
77.44%
77.1%
77.19%
IPF Amber Escalation Report FY 2014-15
%patients 1st treatment <1 mth of cancer diag
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Lack of surgical capacity, complex
patient pathways and patient
choice are driving the
underperformance in a number of
tumour sites.
The Director of Clinical Services and Trust-wide
Cancer Lead are due to review all tumour sites.
Expected date to meet standard
Lead Director
Q2 2014/2015
Director of Clinical Services
Additional surgical capacity has been created to
support treatment.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
96%
Jun-14
92.96%
93.1%
93.12%
IPF Amber Escalation Report FY 2014-15
%2WW of an urg GP ref for suspected cancer
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Lack of capacity within Lower and Additional Endoscopy capacity has been
Upper GI specifically for
created.
Endoscopy.
Expected date to meet standard
Lead Director
Q2 2014/2015
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
93%
Jun-14
92.97%
93.6%
93.59%
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
Increased number of outpatient
referrals and capacity to see the
patients in a timely way.
Increased capacity in the short term but there
needs to be a longer term review of capacity to
meet need and managing the patient pathway.
Expected date to meet standard
Lead Director
July 2014
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
93%
Jun-14
90.91%
91.4%
91.43%
IPF Amber Escalation Report FY 2014-15
Proportion of normal deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Normal births are related to a
number of factors including
Induction of Labour and LSCS
rates.
Continue to monitor.
Expected date to meet standard
Lead Director
On-going
Director of Clinical Services
Encourage women with low risk pregnancies to
birth in the Midwifery Led units.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
62%
Jul-14
58.25%
62.2%
61.78%
IPF Amber Escalation Report FY 2014-15
Proportion of C-Section deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The LSCS rate within OUHT is one Monitor rate monthly.
of the lowest in the country.
However there are times when
Case reviews being undertaken by the Clinical
due to the clinical needs of the
Lead and Consultant Midwife.
woman the rate will rise.
Expected date to meet standard
Lead Director
On-going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23%
Jul-14
23.44%
21.3%
21.51%
IPF Amber Escalation Report FY 2014-15
Proportion of Assisted deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The assisted birth rate links to the Continue to monitor.
LSCS rate. The LSCS rate in OUHT
is low in comparison to other units Review individual cases as appropriate.
and this will impact on the
assisted birth rate.
Expected date to meet standard
Lead Director
On going
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
15%
Jul-14
18.31%
16.5%
16.71%
IPF Amber Escalation Report FY 2014-15
Medication reconciliation completed within 24 hours of admission
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Medicines reconciliation is
completed by a ward based
clinical pharmacist or trained
technician five days a week.
Introduction of an enhanced pharmacy
weekend service for medical wards on the John
Radcliffe site has seen a 33% improvement in
compliance with results in the mid-90%. Of all
the patients admitted on these wards over 90%
Audit is currently completed on a have had medicines reconciliation completed
Monday resulting in lower
within 24 hours.
compliance rates as wards have
not had a clinical pharmacy visit Recent approval via winter pressure monies will
during the two days of the
see the extension of this service on the John
weekend. Results are always
Radcliffe and Horton sites. It is expected to have
higher when the audit is
the same effect as the introduction on the
completed later in the working
medical wards.
week. Audit days are set to rotate
from September.
Recruitment for band 5 ward
based pharmacy technicians to
support clinical pharmacy activity
on wards is especially difficult in
Oxford
Expected date to meet standard
Lead Director
April 2015
Interim Medical Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Jul-14
77.39%
78.9%
78.11%
IPF Amber Escalation Report FY 2014-15
% adult inpatients have had a VTE risk assess
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Deterioration coincides with
switching off of assessment
functionality within Casenotes
system on 09 April. EPR is now the
only route for assessment (apart
from NOC site where paper is still
used) decline is due to the
practice change.
A number of strategies have been employed to
improve results including education and training
of medical staff as well as increasing the
awareness of the requirement to complete an
assessment of patients.
Expected date to meet standard
Lead Director
Q4 2014/2015
Director of Clinical Services
Circulation of a quick reference guide for
completion of assessments using EPR system.
Standard
Current Data Period
Period Actual
YTD
Forecast next period
95%
Q2 14-15
93.79%
93%
92.99%
IPF Amber Escalation Report FY 2014-15
Sickness absence**
What is driving the reported
underperformance?
The July sickness absence rate is
3.44% which is an increase on
June of 0.1%.
Whilst current absence rates are
above the 3.0% KPI, the rise in
absence levels were anticipated
following the introduction of the
FirstCare Absence Management
system, and are attributed to
improved data quality and
reporting.
What actions have we taken to improve
performance
Line managers, FirstCare, HR and Occupational
Health continue to work closely together to
manage sickness operationally. The introduction
of FirstCare has resulted in a number of service
improvements:
 Data quality.
 Line managers are being sent automated
reminders to undertake return to work
interviews.
 FirstCare are open twenty four hours a day
for staff to report sickness.
 Nurse Triage service is available.
FirstCare have now loaded historical absence
data into their system, and this will further
improve the quality of data that is available to
line managers.
An Attendance Management Group has been set
up to support the work detailed above and to
ensure absence is managed appropriately across
the Trust. This group will meet monthly and
consists of divisional, FirstCare, Occupational
Health and Workforce Directorate
representatives.
The Health and Wellbeing Strategy is currently
being reviewed. Consideration is being given to
the Trust training its own “Health Champions”
Standard
Current Data Period
Period Actual
3%
Jul-14
3.44%
YTD
Forecast next period
IPF Amber Escalation Report FY 2014-15
and becoming a Public Health (RSPH) accredited
centre for delivery of the Level 2 award
“Understanding Health Improvement”.
Expected date to meet standard Lead Director
Q4 2014/154
Director of Organizational Development &
Workforce
Year: 2014-15
Directorate: Acute Medicine & Rehabilitaion ,Ambulatory Medicine ,Anaesthetics, Critical Care & Theatres,Assurance,Biomedical Research,Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services,Chief
Nurse Patient Services & Education,Children's ,Children’s,CRS Implementation,Division of Clinical Support Services,Division of Corporate Services,Division of Medicine, Rehabilitation & Cardiac,Division of
Neuroscience, Orthopaedics, Trauma & Specialist Surgery,Division of Operations & Service Improvement,Division of Research & Development,Division of Surgery & Oncology,Estates and Facilities,Finance and
Procurement,Gastroenterology, Endoscopy and Churchill Theatres ,Gastroenterology, Endoscopy and Theatres (CH),Horton Management,Human Resources and Admin,Legacy Cardiac, Vascular & Thoracic
Surgery,Legacy Cardiology,Legacy Division of Cardiac, Vascular & Thoracic,Legacy Division of Musculoskeletal and Rehabilitation,Legacy Rehabilitation & Rheumatology,MARS -Research & Development,Medical
Director,Networks,Neurosciences ,OHIS Telecoms & Med Records,Oncology & Haematology ,Orthopaedics,Pathology & Laboratories,Pharmacy,Planning & Communications,Private Patients,Radiology &
Imaging,Renal, Transplant & Urology,Specialist Surgery ,Strategic Change,Surgery ,Teaching Training and Research,Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
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