Trust Board Meeting: Wednesday 11th March 2015
TB2015.29
Title
Integrated Performance Report – Month 10
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
TB2015.29_Integrated Performance Report M10
Assurance
Policy
Performance
Page 1 of 33
Oxford University Hospitals
TB2015.29
Integrated Performance Report Month 10
Executive Summary
1.
Key Highlights on performance
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2.
Areas of exception on performance
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3.
The percentage of adult inpatients that had a VTE risk assessment in January
achieved 95.25% against the standard of 95%.
Diagnostic waits over 6 weeks, 24 patients waited over 6 weeks at the end of
January, achieving the standard of no more than 1% waiting over 6 weeks.
The 18 week RTT Incomplete and Non-Admitted standards were achieved in
January at 92.66% and 95.03% against the standards of 90% and 95%
respectively.
Seven of the eight cancer standards were achieved in December and seven of
the eight standards were achieved overall in Q3 meaning the Trust achieved the
forecast Monitor score of 4.
Patients spending >=90% of time on stroke unit, achieved 73.44% against a
standard of 80% in January.
MRSA bacteraemia; one case reported in January.
Four same sex accommodation breaches reported for January.
A/E 4 hour standard of 95%, outturn for January was 83.45%.
The 62 day cancer standard was not achieved in December.
Delayed Transfers of Care as a percentage of occupied beds is at 11.91% for
January against the standard of 3.5%.
18 week RTT Admitted performance was 84.17% against the 90% standard as
expected due to the focus on reducing patients waiting over 18 weeks.
8 adult patients waited 52 weeks or more for treatment in January.
Staff turnover rate of 13.7%, 3.2% above the standard.
Staff sickness absence rate was 3.69%, 0.69% above the standard.
The vacancy rate was 7.01%, 2.01% above the standard.
Key Standards – in Month 10
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 January was 83.45%. February continued to be
challenging.
3.1.2. 18 Week Referral to Treatment [RTT] performance: The RTT admitted
standard failed in January with performance at 84.17% against the 90% target.
The incomplete standard was achieved at 92.66% against the 92% target and
the non-admitted standard was achieved at 95.03% against the 95% target.
3.1.3. Eight reported 52 week breaches; of which three patients were admitted in
January (two spinal and one plastic patient) and three had non-admitted clock
stops (three spinal patients). The remaining two patients, one was admitted in
February and one had a follow-up appointment to review treatment options in
February.
TB2015.29_Integrated Performance Report M10
Page 2 of 33
Oxford University Hospitals
TB2015.29
3.2. Activity
3.2.1. Delayed Transfers of Care continue to be a significant concern for the Trust
with performance for January at 11.91% against a target of 3.5%. The
monthly average for January was 188 delays across the system for
Oxfordshire residents.
3.3. Cancer Waits
3.3.1. Cancer waits: 62 day urgent GP referral and screening standard did not
achieve the standard in December however all other six cancer standards
were achieved.
3.3.2. With the exception of the 62 day standard overall performance for the seven
Cancer standards in Q3 was achieved.
4.
Monitor Assessment
4.1. The forecast score of 4 for Q3 was achieved.
5.
Capacity
5.1. As part of the Winter Plan the Trust was planning to increase acute bed capacity as
follows:
Bedford/Adams JR
4 beds
F Ward Horton
3 beds
OCE NOC
10 beds
John Warin CH
10 beds
7E
10 beds
5.2. The Bedford/Adams, F Ward and John Warin beds are operational.
5.3. In January staffing levels remained challenging an average of 24 beds per day were
closed due to safe staffing, and a decision was made to defer the opening of the
additional capacity on 7E.
5.4. In addition, the Tranche 2 Winter Funds (£560,000) have been used to commission
capacity in the private sector. Contracts with four nursing homes to procure 29 beds
to release beds on the Post-Acute Unit are in place until 31st March 2015. All beds
are operational and in use.
6.
Workforce
6.1. Turnover increased from 13.25% in December to 13.7% in January and is 3.2%
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;
mitigating high cost living;
development and implementation of multi-professional Education Training
Strategy;
implementation of the Leadership and Talent Development Strategic framework;
creating and sustaining the right environment.
TB2015.29_Integrated Performance Report M10
Page 3 of 33
Oxford University Hospitals
7.
TB2015.29
Recommendations
The Trust Board is asked to receive the Integrated Performance Report for Month 10.
Paul Brennan, Director of Clinical Services
Sara Randall, Deputy Director of Clinical Services
March 2015
TB2015.29_Integrated Performance Report M10
Page 4 of 33
ORBIT Reporting
Trust Board Integrated
Performance Report
January 2015
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 33
OUH -At A Glance 2014-15
ORBIT Reporting
Operational
Access
Standards
Standard
YTD
Forecast next Data
period
Quality
RTT - admitted % within 18 weeks
90%
Jan-15
84.17%
86.9%
85.2%
3
RTT - non-admitted % within 18 weeks
95%
92%
NA
Jan-15
Jan-15
Jan-15
95.03%
92.66%
38587
94.7%
91.6%
94.3%
92.5%
38479.3
11.1
6.6
23
18.3
Jan-15
Jan-15
Jan-15
Jan-15
8.67
5.85
27.06
17.98
7.86
5.14
26.1
18.46
8.1
5.3
26.7
18.9
0
Jan-15
10
0
Jan-15
5
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
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
NA
Mar-15
1
2
2
2
Total # of deliveries
NA
62%
23%
Jan-15
Jan-15
Jan-15
730
65.89%
20.27%
7029
62.9%
21.7%
685.7
64%
20.5%
3
3
5
2
2
3
3
Proportion of Assisted deliveries
15%
NA
0%
80%
Jan-15
Jan-15
Jan-15
Jan-15
13.84%
0
2.97%
81.58%
15.5%
0
3.7%
79.2%
15.6%
5
4
5
4
0
Jan-15
0
2
5
NA
Jan-15
13
112
5
NA
Jan-15
15
123
5
0
Jan-15
0
1
5
0%
Dec-14
71.12%
66%
69.2%
4
NA
0%
Jan-15
Jan-15
72
20.12%
826
25.1%
73
21.3%
5
2
NA
Jan-15
78
75.3
2
0%
Jan-15
8.22%
13%
8.1%
2
NA
Jan-15
76
52
2
0
80%
Q4 14-15
Jan-15
4
73.44%
25
82.8%
4.7
82.4%
3
5
0%
Jan-15
75.4%
77.5%
72.2%
3
0
5
Jan-15
Jan-15
1
4
7
50
0.7
5
5
5
1%
Jan-15
0.25%
1%
0.4%
2
0
Jan-15
3
60
7
4
Zero tolerance RTT waits IP
0
Jan-15
2
163
5.7
4
Zero tolerance RTT waits NP
0
NA
Jan-15
Jan-15
3
39
3
No data available
4
2
2
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
Patient
Experience
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
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Net promoter (friends & family -Inpatients)
5
3.4%
78.9%
Number of attendances at A/E depts in a
month
% <=4 hours A&E from arrival/trans/discharge
NA
Jan-15
11840
116724
95%
Q4 14-15
83.45%
90.4%
Last min cancellations - % of all EL admissions
0.5%
Jan-15
0.66%
0.5%
0.4%
2
Patient Satisfaction- Response rate (friends &
family -ED)
Net promoter (friends & family -ED)
0%
0
Jan-15
Jan-15
6.45%
0
5.1%
0
4.2%
0
2
Same sex accommodation breaches
0
Jan-15
0
0
0
NA
NA
Jan-15
Jan-15
11666
9778
2
3
NA
Jan-15
1235
4
% adult inpatients have had a VTE risk assess
95%
Q4 14-15
95.25%
94.1%
94.7%
5
NA
Jan-15
653
3
Number SIRIs
NA
Jan-15
7
46
6.3
5
Total number of first outpatient attendances
NA
0
0
Jan-15
Jan-15
Jan-15
29.58%
13692
17320
127305
175035
12653.7
16795.7
3
3
2
Number of Patient Falls with Harm
Incidents per 100 admissions
0
NA
NA
Jan-15
Jan-15
Jan-15
2
5.81
4.52
33
5.23
4.86
3.3
5.3
4.7
2
2
3
1st outpatient attends following GP referral
0
Jan-15
10153
101401
9961
2
# acquired, avoidable Grade 3/4 pressure Ulcers
NA
Jan-15
3
17
3.5
5
Other refs for a first outpatient appointment
0
Jan-15
9032
89393
8488.7
3
0%
Jan-15
94.53%
93.3%
93.5%
3
Non-elective FFCEs
0
0
Jan-15
Jan-15
5546
1773
57808
19106
5709.7
1850
2
3
% of Patients receiving Harm Free Care (Pressure
sores, falls, C-UTI and VTE)
Never Events
NA
NA
Jan-15
Jan-15
1
NA
4
55.6%
1.3
69.2%
5
5
0
0
Jan-15
Jan-15
7563
592
73787
1781
7255.7
326.7
3
3
NA
Jan-15
NA
NA
3.5%
Q4 14-15
11.91%
10.5%
11.2%
5
% patients not rebooked within 28 days
zero Urgent cancellations - 2nd time
Urgent cancellations
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
10966.7
Quality
Outcomes
Summary Hospital-level Mortality Indicator**
Zero tolerance RTT waits AP
Ambulance Handovers within 15 minutes
Activity
Current
Data Period Period Actual
5
# patients spend >=90% of time on stroke unit
Safety
Time to Surgery (% patients having their operation
within the time specified according to their clinical
categorisation)
HCAI - MRSA bacteraemia
HCAI - Cdiff
Patient Falls per 1000 bed days
Cleaning Scores- % of inpatient areas with initial
score >92%
Flu vaccine uptake
3
Page 6 of 33
Operational
Activity
Standard
Current
Data Period Period Actual
YTD
Forecast next Data
period
Quality
Theatre Utilisation - Total
75%
Jan-15
73.34%
72.2%
71.8%
2
Theatre Utilisation - Elective
80%
Jan-15
77.92%
76%
76.2%
3
Theatre Utilisation - Emergency
70%
Jan-15
59.05%
60.6%
59.8%
2
85%
Dec-14
82.71%
78%
80.9%
5
%patients cancer treatment <62-days - Screen
90%
Dec-14
89.29%
93.8%
95.5%
5
% patients treatment <62-days of upgrade
NA
Dec-14
%patients 1st treatment <1 mth of cancer diag
96%
Dec-14
96.69%
95.5%
96.7%
5
%patients subs cancer treatment <31days Surg
94%
Dec-14
96.55%
95.1%
95.6%
5
Cancer Waits %patients cancer treatment <62-days urg GP
Forecast
next
period
Data
Quality
75.83%
90%
5
Jan-15
1.78
1.8
5
-7
Jan-15
-5.54
-7
5
3
Jan-15
3
3
5
CIP Performance Compared to Plan
95%
Jan-15
90.13%
93%
5
I&E Surplus Margin (%)
1%
Jan-15
0.97%
1%
5
Forecast
next
period
Data
Quality
Current
Data Period Period Actual
Finance
Capital
Capital Programme Compared to Plan
90%
Jan-15
Financial Risk
Capital servicing capacity (times)
1.75
Liquidity ratio (days) defined as Working Capital
balance *360/Annual Operating Expenses
Monitor Risk Rating
ref
I&E
Standard
YTD
5
No data available
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
98%
Dec-14
100%
100%
100%
5
94%
Dec-14
98.7%
89.4%
99.1%
5
%2WW of an urg GP ref for suspected cancer
93%
Dec-14
96.05%
94%
94.6%
%2WW urgent ref - breast symp
93%
Dec-14
98.46%
94.8%
96.8%
Workforce
Head count/Pay Worked WTE against Plan (displayed as a % of
total)**
costs
Standard
Current
Data Period Period Actual
YTD
0%
Jan-15
96.46%
4
Bank usage (displayed as a % of total)**
0%
Jan-15
2.16%
5
5
Agency usage (displayed as a % of total)**
0%
Jan-15
5.53%
5
5
Total cost of staff ( displayed as a %)**
0%
5%
3%
10.5%
100%
0%
0%
Jan-15
Jan-15
Jan-15
Jan-15
Q3 14-15
Q3 14-15
Q3 14-15
102.74%
7.01%
3.69%
13.7%
11.69%
64.19%
80.2%
5
3
5
3
5
4
4
Staff Experience Vacancy rate
Sickness absence**
Turnover rate
Medical Appraisals
Non Medical Appraisals
Statutory and
Mandatory
Competence
Compliance
% staff with up to date Statutory and Mandatory
training
13.3%
100%
* 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: 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 & Rehabilitation ,Ambulatory Medicine ,Assurance,Biomedical Research,Cardiology, Cardiac & Thoracic Surgery ,Central Trust Services,Chief Nurse Patient Services & Education,Children's ,Children’s,Critical Care, Pre-operative Assessment, Pain Relief and Resuscitation,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,Legacy- Anaesthetics, Critical Care & Theatres,MARS -Research & Development,Medical Director,Networks,Neurosciences ,OHIS Telecoms & Med Records,Oncology & Haematology ,Oncology & Haematology ,Orthopaedics,Pathology & Laboratories,Pharmacy,Planning & Communications,Private
Patients,Radiology & Imaging,Renal, Transplant & Urology,Specialist Surgery ,Strategic Change,Surgery ,Teaching Training and Research,Theatres, Anaesthetics and Sterile Services,Trauma ,Trust wide R&D,Trust-wide only,Unknown,Women's
Page 7 of 33
IPF Red Escalation Report FY 2014-15
Capital Programme Compared to Plan
What is driving the reported
underperformance?
Some of the Trust’s capital
projects for 2014/15 are starting
later than originally anticipated.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
90%
Jan-15
75.83%
YTD
Forecast next period
90%
The capital programme is reviewed regularly by
the Business Planning Group.
Other schemes will be brought forward from
2015/16 to fill any gap caused by slippage in the
2014/15 projects.
Expected date to meet standard
Lead Director
The Trust expects to spend its
planned capital funding in full by
the end of the year.
Director of Finance & Procurement
Page 8 of 33
IPF Red Escalation Report FY 2014-15
RTT - admitted % within 18 weeks
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%
Jan-15
84.17%
86.9%
85.21%
Admitted performance continues Regular meetings are being held with Divisional
to be a challenge with January
Teams and the Director of Clinical Services.
performance deteriorating.
Specialties with significant challenges continue
Increase elective cancellations
to be:
due to emergency pressures as
 Orthopaedics
well as reduced theatre staffing.  Spinal
 Ophthalmology
 Ear Nose & Throat
 Urology
 Neurosurgery
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 February for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 9 of 33
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
23
Jan-15
27.06
26.1
26.72
January’s reporting period saw an Regular meetings with the Clinical Divisions and
increase in the 95th percentile of the Director of Clinical Services to ensure the
admitted waits.
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 February for Trust level
with risk limited to Orthopaedics
and Spinal.
Director of Clinical Services
Page 10 of 33
IPF Red 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
Jan-15
10
YTD
Forecast next period
Ten services did not achieve the Regular meetings are being held with the
admitted standard in January and Clinical Divisions and the Director of Clinical
are as follows:
Services to ensure the sustainable recovery
plans are being implemented to reduce and
1. Trauma & Orthopaedics
treat those patients waiting over 18 weeks.
2. Ear, Nose & Throat
3. Ophthalmology
4. Neurosurgery
5. Plastic Surgery
6. Urology
7. Gynaecology
8. Dermatology
9. cardiology
10.Other services
Expected date to meet standard
Lead Director
End of February for Trust level
standard with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 11 of 33
IPF Red 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
Standard
Current Data Period
Period Actual
0
Jan-15
5
YTD
Forecast next period
Five services did not achieve the The Trust-wide standard was met for January.
non- admitted standard in January
and are as follows:
Clinical Divisions do have recovery plans in
place to ensure all specialties reduce and treat
1. Trauma & Orthopaedics
those patients waiting over 18 weeks.
2. Ear, Nose & Throat
3. Ophthalmology
4. Neurosurgery
5. Cardiology
Expected date to meet standard
Lead Director
Trust-wide standard met.
Director of Clinical Services
Page 12 of 33
IPF Red Escalation Report FY 2014-15
Zero tolerance RTT waits AP
What is driving the reported
underperformance?
The reduction in patients waiting
over 52 weeks continued in
January.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Jan-15
3
60
7
There is an action plan in place to reduce the
number of patients waiting.
Three patients were admitted and
treated in January.
The services were:
 Spinal Surgery (2)
 Plastic
(1)
Expected date to meet standard
Lead Director
Quarter 4 with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 13 of 33
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
Jan-15
2
163
6
Reduction in the number of
There is an action plan in place to reduce the
incomplete pathways waiting over number of patients waiting.
52 weeks, this is to be expected
when clearing the longest waiting
patients as a priority. The services
were:
 Spinal Surgery Service (1)
 Clinical Genetics
(1)
Expected date to meet standard
Lead Director
Quarter 4 with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Page 14 of 33
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
A reduction in the non-admitted
patients treated over 52 weeks
during January.
The services were:
 Spinal Surgery Service (3)
There is an action plan in place to reduce the
number of patients waiting.
Expected date to meet standard
Lead Director
Quarter 4 with risk limited to
Orthopaedics and Spinal.
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Jan-15
3
39
3
Page 15 of 33
IPF Red Escalation Report FY 2014-15
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
95%
Q4 14-15
83.45%
90.4%
Forecast next period
January performance continues to The Urgent Care Working group continues to meet
weekly, with OCCG, OH, OCC and OUH colleagues to
be very challenging.
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
 Escalation beds opened
ECIST report has been received and action plans are
being implemented.
Expected date to meet standard
Lead Director
Quarter 4 onwards
Director of Clinical Services
Page 16 of 33
IPF Red Escalation Report FY 2014-15
% patients not rebooked within 28 days
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%
Jan-15
6.45%
5.1%
4.22%
Additional emergency pressures Clinical teams are focused on forward booking.
have imposed delays to rebooking
patients.
Recruitment of key critical theatre staff is ongoing.
Staff recruitment remains a
significant issue.
Expected date to meet standard
Lead Director
Quarter 4 2014/15
Director of Clinical Services
Page 17 of 33
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 January has
resulted in an overall
deterioration of the performance
to 11.91%, (145 patients).
Daily whole system teleconference calls remain
in place, with escalation to Oxfordshire
colleagues when system is on RED.
Weekly/Daily 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 patient flow and discharge process
for all patients.
Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Q4 14-15
11.91%
10.5%
11.15%
This system has not agreed a date Director of Clinical Services
to achieve this standard.
Page 18 of 33
IPF Red Escalation Report FY 2014-15
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
A 2.91% improvement on
December’s utilisation
performance during January.
Internal theatre meetings are in place to review
utilisation, work is progressing to develop a
standardized approach across the Trust to
manage the emergency lists.
Expected date to meet standard
Lead Director
Quarter 4 2014/15
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Jan-15
59.05%
60.6%
59.79%
Page 19 of 33
IPF Red Escalation Report FY 2014-15
Same sex accommodation breaches
What is driving the reported
underperformance?
A male patient (level 2 acuity) was
admitted via ED on the stroke
pathway. He needed to be
nursed, assessed and treated
within 4 hours on a Hyper Acute
Stroke Unit. The only bed space
available was within a female only
bay. It was clinically justifiable for
him to be nursed in a mixed bay.
The female patients were either
acuity level 1 or 0. It was
therefore not clinically justifiable
for the female patients to be in a
mixed bay. A UNIFY return of 4
DSSA breaches was submitted.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0
Q4 14-15
4
25
5
Reinforcement and clarification that it is not
clinically justifiable for patients with acuity level
1 or 0 to be in mixed sex accommodation during
the day. It is acceptable during the night
however.
Full DSSA RCA will be undertaken.
Expected date to meet standard Lead Director
This will be presented to the
Divisional Nurse and Chief Nurse
by 1 April 2015.
Chief Nurse
Page 20 of 33
IPF Red Escalation Report FY 2014-15
HCAI - MRSA bacteraemia
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
Jan-15
1
7
1
An OUH apportioned MRSA positive blood culture was reported in
January 2015 from within the MRC division (General Medicine).
Awaiting the final
agreed action plan
from the OCCG
A Post Infection Review (PIR) meeting was held on the 12/02/15
following the PIR
and it was agreed that the MRSA Bacteraemia was avoidable.
meeting held on
The likely source of this MRSA bacteraemia was agreed to be
12/02/15.This will be
chronic leg ulcers. The patient had multiple co-morbidities including reported in next
chronic peripheral vascular disease, STEMI Feb 2014, chronic MRSA month’s clinical
osteomyelitis on long term oral clindamycin suppression as
governance infection
recommended by the Bone Infection Unit, paraplegia secondary to control report.
a T12 spinal cord infarct and pressure sores to buttocks present on
admission.
The following learning points were identified:
 Prior to bilateral Angioplasty procedure undertaken in
interventional radiology, skin preparation was performed using
povidone iodine aqueous. This is not in line with Trust guidelines
which recommends the use of Chlorhexidine 2% in alcohol for
skin preparation.(povidone iodine alcohol is recommended as an
alternative to Chlorhexidine 2% for patients
allergic/contraindicated)
 The scheduled Angioplasty was cancelled on > 3 occasions,
delaying treatment of chronic MRSA colonised leg ulcers.
 The patient was receiving long term oral Clindamycin suppression
therapy for chronic MRSA osteomyelitis. However the MRSA was
confirmed to be resistant to Clindamycin, microbiology advised
the medical team no change in antibiotics was necessary.
Expected date to meet standard
Lead Director
The Trust objective of 0 avoidable MRSA bacteraemia has not been Medical Director
met, however measures are in place to reduce the likelihood of any
further avoidable MRSA bacteraemia for 2014-15.
Page 21 of 33
IPF Red Escalation Report FY 2014-15
Vacancy rate
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Vacancy rates have risen
marginally since the previous
month. Continued challenges
associated with the recruitment
and retention within particular
staff groups remain.
Actions being taken to reduce the vacancy rate
are consistent with those associated with
current recruitment and retention initiatives
(see Turnover rate section).
Expected date to meet standard
Lead Director
Q4 2014/15
Director of Organisational Development and
Workforce
Standard
Current Data Period
Period Actual
5%
Jan-15
7.01%
YTD
Forecast next period
Page 22 of 33
IPF Red Escalation Report FY 2014-15
Sickness absence**
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Sickness absence has risen
marginally when compared to
the previous month.
FirstCare, line managers, Occupational Health
and HR continue to work closely on day to day
absence management.
The introduction of First Care
absence management has
provided improved data quality,
which in turn has resulted in
higher recorded periods of
absence.
The appointment of FirstCare has improved the
flow and quality of information to line mangers,
who have also benefitted from the automation
of some of the process.
Standard
Current Data Period
Period Actual
3%
Jan-15
3.69%
YTD
Forecast next period
Regular meetings between FirstCare and
Divisional representatives have commenced so
that information can be reviewed and
actions/strategies agreed.
Return to work interviews are key in reducing
absence. Managers are now prompted to
undertake all reviews within seven days. This
monitored centrally and become a KPI.
Expected date to meet standard
Lead Director
Q1 2015/16
Director Of Organisational Development and
Workforce
Page 23 of 33
IPF Red Escalation Report FY 2014-15
Turnover rate
What is driving the reported
underperformance?
All staff groups with the exception
of Estates/Ancillary and
Healthcare Scientists have
experienced a rise in turnover
rates since the start of the
financial year.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
10.5%
Jan-15
13.7%
YTD
Forecast next period
13.34%
A range of actions is being taken to close the
vacancy gap. These include initiatives to apply
targeted recruitment and retention incentives,
assist staff with travel and access to work, and
to improve the opportunities for person al and
professional development.
Nursing and Midwifery have the
highest percentage of leavers (at
c38% of the total). The increase in
leaver rates for this staff group
will adversely affect those for the
Trust.
Expected date to meet standard
Lead Director
Q1 2015/16
Director Of Organisational Development and
Workforce
Page 24 of 33
IPF Red Escalation Report FY 2014-15
Medical Appraisals
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The medical appraisal system runs
for a 6 month period in Q3 and Q4
of each financial year rather than
on the rolling basis applied to
non-medical appraisal. This
means that reporting against a
target for a given quarter is
extremely difficult as the time
periods do not correlate. Whilst it
may therefore appear that the
medical appraisal indicator is
underperforming this is not in fact
the case. All doctors have been
assigned an appraiser and
progress is tracked centrally. The
Medical Director’s Office will be
able to report the appraisal status
of every doctor by 14th April 2014.
A compliance rate in excess of
90% is anticipated.
All doctors for whom an appraisal is not
submitted within the time period will be
followed up individually and remedial action
taken where necessary.
Expected date to meet standard
Lead Director
April 2014
Medical Director
Standard
Current Data Period
Period Actual
100%
Q3 14-15
11.69%
YTD
Forecast next period
100%
Page 25 of 33
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
Standard
Current Data Period
Period Actual
95%
Jan-15
90.13%
YTD
Forecast next period
93%
There has been slippage on the
Divisions are aware they have to make up any
start of some Divisional and cross- slippage in the remainder of the year and their
Divisional schemes.
performance is being monitored monthly.
Regular meetings are being held with Divisional
Directors and Divisional General Managers, and
a recovery plan is being agreed. Meetings were
also held with individual Divisions at the start of
November and stretch targets set to offset the
shortfall created by the slippage on schemes.
There will be significant cost pressures in
2015/16 and savings plans have been drawn up
to tackle these.
Expected date to meet standard
Lead Director
Q4 2014/15
Director of Finance & Procurement
Page 26 of 33
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
Standard
Current Data Period
Period Actual
1%
Jan-15
0.97%
YTD
Forecast next period
1%
The under-performance against
The Trust currently believes it will meet its key
the 1% target surplus is marginal. 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
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 27 of 33
IPF Amber Escalation Report FY 2014-15
Last min cancellations - % of all EL admissions
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Additional emergency pressures
and lack of bed capacity have
caused a number on elective
cancellations in January.
A huge amount of work is on-going to improve
patient flow and bed capacity throughout the
Trust. ECIST action plan is being implemented.
Expected date to meet standard
Lead Director
February 2015
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0.5%
Jan-15
0.66%
0.5%
0.45%
Page 28 of 33
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
75%
Jan-15
73.34%
72.2%
71.76%
January has seen a 4.66%
Focus continues on productivity for all clinical
increase in total theatre utilization teams both on the day and forward booking.
compared with December.
Recruitment of key critical theatre staff is ongoing.
Expected date to meet standard
Lead Director
Quarter 4 2014/15
Director of Clinical Services
Page 29 of 33
IPF Amber Escalation Report FY 2014-15
Theatre Utilisation - Elective
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Jan-15
77.92%
76%
76.24%
January has seen a 4.87% increase Clinical teams are focused on improving booking
in elective theatre utilization
procedures and maximizing productivity.
compared to December.
Expected date to meet standard
Lead Director
Quarter 4 2014/15
Director of Clinical Services
Page 30 of 33
IPF Amber 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 is quite often
limited, and demand is very often
hugely variable. Capacity and
variability in demand impacts on
delivery and reduces the time left
within the remaining days of the
pathway. Patients choosing to
wait longer also significantly
impacts on the delivery of this
particular target to delay which
can’t be adjusted for.
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
February 2015
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
85%
Dec-14
82.71%
78%
80.94%
Page 31 of 33
IPF Amber 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
The screening standard for
December failed due to a
data/reporting error which has
been rectified
The standard did achieve actively pursuing
change to Open Exeter.
Expected date to meet standard
Lead Director
Standard met
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Dec-14
89.29%
93.8%
95.49%
Page 32 of 33
IPF Amber Escalation Report FY 2014-15
# patients spend >=90% of time on stroke unit
What is driving the reported underperformance?
The figures largely reflect the very busy period of
December as many of the patients admitted that
month were not discharged until January. We had a
higher than average number of new admissions (56
vs. 44 in Nov) coupled with a lack of downstream bed
availability. There were also several patients from
out of area waiting some time to be repatriated.
What actions have we
taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Jan-15
73.44%
82.8%
82.39%
Plans are in the process of
being developed to
improve downstream
capacity and increase
capacity in ESD.
Regrettably, this meant that a significant number of
patients were moved to level 4 to accommodate new
admissions, thus reducing their time spent on a
stroke unit. Additionally, only 5 patients discharged
from 5B to ESD, which is a combination of more
severe strokes and the limited geographical reach of
the service.
Expected date to meet standard
Lead Director
February 2015
Director of Clinical Services
Page 33 of 33