Trust Board Meeting: Wednesday 11th November 2015
TB2015.129
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
TB2015.129 Integrated Performance Report M6
Assurance
Policy
Performance
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Oxford University Hospitals NHS FT
TB2015.129
Integrated Performance Report Month 6
Executive Summary
1.
Key Highlights on performance
•
•
•
•
•
•
•
•
2.
Areas of exception on performance
•
•
•
•
•
•
3.
The percentage of adult inpatients that had a VTE risk assessment in September
was 96.47% against the standard of 95%.
Diagnostic waits over 6 weeks, 27 patients waited over 6 weeks at the end of
September, achieving 0.23% against the standard of no more than 1% waiting
over 6 weeks.
The 18 week RTT Incomplete and Non-Admitted standards were achieved in
September at 92.1% and 95.11% against the standards of 92% and 95%
respectively.
All eight cancer standards including the 62 day standard were achieved in August
2015.
MRSA bacteraemia; zero cases were reported in September.
Zero same sex accommodation breaches reported at end of September.
Patients spending >=90% of time on stroke unit was 89.47% against a standard
of 80% in September.
C Difficile, four cases were reported in September.
Performance against the 4 Hour standard was 90.6% in September.
Four adult waited 52 weeks or more for treatment in September.
Delayed Transfers of Care as a percentage of occupied beds is at 12.78% for
September against the standard of 3.5%.
18 week RTT Admitted performance was 86.04% against the 90% standard as
expected due to the focus on reducing patients waiting over 18 weeks.
Staff turnover rate is 13.58%, which is 3.08% above the standard.
Staff sickness absence rate was 3.56%, 0.56% above the standard.
Key Standards
3.1. 18 Week RTT, A/E and Cancer
3.1.1. 4 Hour 95% standard: Performance in September was 90.59%.
3.1.2. 18 Week Referral to Treatment [RTT] performance: The RTT admitted
standard was subject to an agreed plan fail in September with performance at
86.04% against the 90% target. The incomplete standard was achieved at
92.1% against the 92% target and the non-admitted standard was achieved at
95.11% against the 95% target.
3.1.3. All eight Cancer Standards were achieved in August 2015.
3.2. Activity
3.2.1. Delayed Transfers of Care continue to be a significant concern for the Trust
with performance for September at 12.78% against a target of 3.5%. The
monthly average within the OUH for September was 164 for the System.
TB2015.129 Integrated Performance Report M6
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Oxford University Hospitals NHS FT
4.
TB2015.129
Monitor Assessment
4.1. Whilst Monitor’s Access and Outcomes matrix operates on a quarterly basis (except
for RTT) the Trust monitors performance against this matrix on a monthly basis. The
Trust monthly score to date is set out below.
April
May
June
July
August
September
Score
2
1
0
0
1
1
Standards Not
Achieved
62 day
cancer
4 hour
62 day
cancer
-
-
4 hour
4 hour
Note: Target score is zero.
Note: September figures exclude Cancer as figures awaited from Open Exeter.
5.
Workforce
5.1. Turnover decreased from 13.75% in August to 13.58% in September and is 3.08%
above the KPI target. Reducing staff turnover remains a key area of focus.
6.
Additional Appendices
6.1. There are two new reports attached in appendix 2 and 3 respectively, the Efficiency
and Utilisation report focusing on length of stay, patient flow and detail on the
delayed discharges. The Quarterly monitoring report has been added for
completeness.
7.
Recommendations
The Trust Board is asked to receive the Integrated Performance Report for Month 6.
Paul Brennan
Director of Clinical Services
November 2015
TB2015.129 Integrated Performance Report M6
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ORBIT Reporting
Trust Board Integrated
Performance Report
September 2015
At A Glance 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
Escalation report
Graph Legend
Underachieving
Standard
Plan/ Target
Current Year Performance
Previous Year 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.
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Efficiency and Utilisation Report 2015-16
APPENDIX A: Efficiency and Utilisation IPR report Oct-15
Patients staying greater than 21 days and discharged in month
March
March
March
February
February
February
January
January
January
December
0.1
140
December
0.1
126
December
0.1
149
November
0.1
129
November
0.1
111
November
September
August
July
June
0.7
123
October
Average Number of ward transfers
Number of patients with more than 3 ward stays in one
spell
October
2015-16
October
OUH
May
April
* Excluding EAU,Discharge lounge, SEU, ITU( Adult, Neuro, Cardiac & Paeds)
This indicator records the number of ward moves that are
less clinically appropriate. Wards where a definitive
clinical decision has been made to move the patient to,
such as ITUs, Transfer Lounge, Emergency Admissions
Units have been removed. September saw a slight
increase to the levels August, but slightly below those of
July.
July
August
September
Total number of first outpatient attendances
1st outpatient attends following GP referral
Other refs for a first outpatient appointment
Admissions and Day Cases
Non-elective FFCEs
June
2015-16
May
OUH
April
Number of Elective FFCEs - Admissions and Day Cases
18247
10362
9066
8172
5730
17556
9942
8384
8504
5873
20263
11536
9712
9221
5923
20394
11725
9689
9675
5896
17985
10122
8656
8479
5649
20784
11915
9636
9313
5792
These figures are sourced from the official Monthly
Activity Return (MAR) submitted to Unify each month.For
the first 6 months of 15/16 elective inpatients (2.2%)
continue to grow, however, non-elective spells are
consistent with last year, and ED attendances are 3%
lower than for the same period last year.
Number of patients
April
May
June
July
August
September
Average LOS on Discharged Spells
0 to 2 Days
12429
13034
13727
14121
12674
13710
2 to 5 Days
1523
1604
1602
1571
1538
1505
5 to 7 Days
468
513
526
508
524
482
7 to 14 Days
741
731
687
681
652
683
14+ Days
Total number of patients
OUH
Number of bed days
Average LOS
626
611
602
640
603
634
15787
16493
17144
17521
15991
17014
0 to 2 Days
4870
4947
5084
5209
4848
4983
2 to 5 Days
5754
6043
6016
5970
5821
5697
5 to 7 Days
3024
3315
3390
3270
3390
3090
7 to 14 Days
7635
7501
7162
6975
6810
7130
14+ Days
18672
18345
19014
19248
19288
20083
Total number of Bed days
39955
40151
40666
40672
40157
40983
Average LOS Elective
3.93
4.30
4.30
4.12
4.11
4.70
Average LOS Non-elective
4.73
4.33
4.45
4.48
4.71
4.53
Average LOS Non-elective non- emergency
3.22
3.34
3.29
3.18
3.29
3.37
Day case
0.00
0.00
0.00
0.00
0.00
0.00
Average LOS (excluding daycases)
4.25
4.10
4.17
4.13
4.28
4.32
1
The table shows the profile of stays for all
admitted patients to all sites of the hospitals
across the OUH. It is quite stark that in August,
just under 4% of the patients admitted to the
hospitals accounts for nearly 48% of all bed
days* consumed. Conversely, 80% of admitted
patients account for 12% of all bed days
consumed.The trend on length of stay is
generally down. All PODs are showing a
reduced length of stay for the first few months
of 15/16 compared with the same period for
14/15.
* bed days are counted for each midnight stay.
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Efficiency and Utilisation Report 2015-16
OUH
Average Number of
patients
486
423
586
589
493
565
594
626
613
623
625
608
Wednesday
623
642
665
627
603
659
Thursday
502
657
625
612
636
627
Friday
527
683
667
669
629
658
Saturday
329
338
357
331
333
363
Total number of Patients
234
229
234
222
218
237
14300
15644
16187
16595
15184
16132
The table and chart show the profile of
discharges by day of the week by month. It is
clear from the information, that the drop off in
discharges over the weekends, and through
Monday, will be a contributory factor in there
often being a capacity and patient flow
problem at the start of the working week.
Average Discharges by day of the week
September
659
608
627
March
February
January
December
November
October
September
August
July
Monday
Tuesday
Sunday
Total
June
Day of the week
May
April
Discharge Profile
Average number of Discharges in Month by Day of Discharge
658
565
Current Month as Chart
363
237
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
2
Sunday
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Efficiency and Utilisation Report 2015-16
OUH
Average Number of
patients
15
17
19
21
18
17
103
108
119
121
106
116
13:00 to 16:59 Hours
194
203
214
214
199
213
17:00 to 20:59 Hours
146
155
167
159
147
169
Total number of Patients
18
21
21
21
20
21
14300
15644
16187
16595
15184
16132
March
February
January
December
November
October
September
August
July
00:00 to 08:59 Hours
09:00 to 12:59 Hours
21:00 to 23:59 Hours
Total
June
Hour
May
April
Average number of Discharges in Month by Hour of Discharge
Level: Trust
The chart and table show the profile of
discharges within the month by grouped hour
of day. The days have been split into grouped
hours of day giving 5 broader categories, which
generally represent overnight, morning
(working hours), afternoon (working hours),
early evening and late evening. 70% of
discharges during September fell into the
afternoon and early evening brackets. The
Transformation Team are currently leading a
project to ensure that discharges happen
generally much earlier in the day.
Average Discharges by Hour
September
213
169
116
21
17
00:00 to 08:59 Hours
09:00 to 12:59 Hours
13:00 to 16:59 Hours
17:00 to 20:59 Hours
3
21:00 to 23:59 Hours
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Efficiency and Utilisation Report 2015-16
Delayed Discharges and Bed Utilisation
36780
35554
2015-16
Number of patients Medically fit and not discharged at
month end
134
135
159
160
137
184
Total number of Bed days used by patients Medically fit
and not discharged at month end
1484
1316
1834
1680
1701
1901
4%
4%
5%
5%
5%
5%
Bed Utilisation - General & Acute
90%
91%
90%
89%
86%
89%
Bed Utilisation - Critical Care
75%
71%
76%
82%
79%
79%
30/04/2015
31/05/2015
30/06/2015
31/07/2015
31/08/2015
30/09/2015
% Bed days used by patients Medically fit and not
discharge at month end
Admissions
POD / Admission Meth
2014-15
OUH
2015-16
August
OUH
March
36780
Delayed patients waiting for ongoing care
continue to be a major issue for the Trust and
the wider health economy. There was a 27%
increase in the number of DToCS reported
during September compared with August.
31/10/2015
30/11/2015 31/12/2015 31/01/2016 29/02/2016 31/03/2016
March
35554
February
35970
February
34771
Total number of bed days available
*exclude:daycase wards, maty,well babies etc using
OPS team bedstock
January
4634
January
4367
December
4939
December
4090
November
4164
November
4140
Total Delayed bed days in month
October
September
146
October
August
115
September
July
147
July
June
149
June
May
123
May
129
Number of Delayed patients at month end
April
April
*for bed days:exclude:daycase wards, maty,well babies etc using OPS team bedstock
Elective
1904
1874
2102
2095
1824
2046
2124
2025
1706
1925
1828
2110
Non- Elective
5284
5536
5460
5761
5451
5342
5625
5512
5652
5216
4727
5303
Non- Elective non-emergency
2077
2144
2053
2086
1991
2022
2193
1942
2022
2109
1802
2112
Day case
7123
7137
7559
8205
7405
7719
7890
7481
6977
7692
7351
8175
Elective
1994
1843
2104
2174
1919
2002
Non- Elective
5283
5672
5652
5596
5369
5339
Non- Elective non-emergency
1997
2167
2058
2066
2000
2021
Day case
6456
6723
7420
7678
6619
7517
4
Daycase activity looks to have reduced, but
this is artificial and as a result of chemotherapy
now being booked as regular attendances from
April 15 onwards.
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Efficiency and Utilisation Report 2015-16
10211
95.1%
11542
93.8%
NA
NA
10978
93.8%
11823
90.6%
NA
NA
March
13908
94.3%
12282
96.5%
NA
NA
February
11291
92.4%
12010
96.2%
NA
NA
January
13482
91.9%
10673
96.4%
3
4
30/11/2014 31/12/2014 31/01/2015 28/02/2015 31/03/2015
30/11/2015 31/12/2015 31/01/2016 29/02/2016 31/03/2016
December
10434
90.8%
13517
91.1%
1
5
31/10/2014
31/10/2015
November
September
30/09/2014
30/09/2015
August
31/08/2014
31/08/2015
July
2015-16
31/07/2014
31/07/2015
June
OUH Type
1&2
# of Attendances
Performance
# of Attendances
Performance
# of weeks in which 95% was achieved
# Of weeks in Month
30/06/2014
30/06/2015
May
2014-15
31/05/2014
31/05/2015
April
30/04/2014
30/04/2015
October
4 Hour standard by Month
*OUH Type 1 & OUH Type 2
13520
91.4%
10651
86.2%
10409
83.8%
11840
83.5%
10191
88.3%
10968
84.9%
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Performance dipped in September, despite a strong
performance during the earlier part of the year.
*The statutory sitrep reporting has changed from
weeks to calendar months during June, therefore
the number of weeks during the month performing
above 95% will no longer be reported.
1014
1935
1103
1972
Total number of incompletes
2727
2686
2664
3094
2949
3075
5
March
989
2105
February
905
1759
January
September
245
2441
December
August
226
2501
November
July
On Admitted Pathway
Not on Admitted Pathway
October
June
2015-16
May
OUH
April
18 week incompletes over 18 weeks
There are still a large number of over 18 week wait
incomplete pathways, which is growing. In light of the
plans to remove the financial penalties for the admitted
and non-admitted pathway targets, and for the
incomplete target to remain as the only sanctionable RTT
target, the Trust will need to address this figure of long
waiting incomplete pathways.
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ORBIT
Reporting
OUH - Quarterly Monitoring Report 2015-16
Operational
Standards RTT - admitted % within 18 weeks
RTT - non-admitted % within 18 weeks
RTT - incomplete % within 18 weeks
% <=4 hours A&E from arrival/trans/discharge
%patients cancer treatment <62-days urg GP ref
%patients cancer treatment <62-days - Screen
%patients 1st treatment <1 mth of cancer diag
%patients subs cancer treatment <31days - Surg
%patients subs cancer treatment <31-days - Drugs
%patients subs treatment <31days - Radio
%2WW of an urg GP ref for suspected cancer
%2WW urgent ref - breast symp
HCAI - Cdiff
Standard
Q1
Q2
YTD
90%
95%
92%
95%
85%
90%
96%
94%
98%
94%
93%
93%
69
87.13%
95.07%
93.17%
94.35%
81.35%
91.07%
97.73%
95.98%
100%
98.83%
94.86%
98.17%
15
87.33%
95.07%
92.22%
93.67%
86.03%
94.44%
97.72%
96.27%
99.08%
98.41%
94.54%
93.55%
15
87.2%
95.1%
92.7%
94%
83.2%
92.4%
97.7%
96.1%
99.7%
98.6%
94.7%
95.9%
30
Year: 2015-16
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 &
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
10 of 28
OUH -At A Glance 2015-16
ORBIT Reporting
Operational
Standards
Standard
Current
Data Period Period Actual
YTD
Data
Quality
Quality
Outcomes
Standard
Current
Data Period Period Actual
YTD
Data
Quality
RTT - admitted % within 18 weeks
90%
Sep-15
86.04%
87.2%
3
Summary Hospital-level Mortality Indicator**
NA
Dec-14
0.99
RTT - non-admitted % within 18 weeks
95%
92%
1%
Sep-15
Sep-15
Sep-15
95.11%
92.1%
0.23%
95.1%
92.7%
0.2%
2
2
2
Total # of deliveries
NA
62%
23%
Sep-15
Sep-15
Sep-15
719
63.42%
22.67%
4321
64.2%
20.8%
3
3
5
Sep-15
Sep-15
Sep-15
Sep-15
0
4
0
11823
8
19
3
71847
4
4
4
2
Proportion of Assisted deliveries
Number of attendances at A/E depts in a month
0
0
0
NA
15%
NA
0%
80%
Sep-15
Sep-15
Sep-15
Sep-15
13.91%
0
3%
62.93%
15.6%
0
3.6%
65%
5
4
5
4
% <=4 hours A&E from arrival/trans/discharge
95%
Sep-15
90.59%
94%
5
0
Sep-15
0
0
5
Last min cancellations - % of all EL admissions
0.5%
Sep-15
0.4%
0.5%
2
NA
Sep-15
7
51
5
0%
Sep-15
0%
5.7%
2
0
Sep-15
0
0
20
RTT - incomplete % within 18 weeks
% Diagnostic waits waiting 6 weeks or more
Zero tolerance RTT waits AP
Zero tolerance RTT waits IP
Zero tolerance RTT waits NP
% patients not rebooked within 28 days
zero Urgent cancellations - 2nd time
0
Sep-15
20
Contract Variations Open
NA
Sep-15
7
Contract Notices Open
NA
Sep-15
1
0
Sep-15
146
Urgent cancellations
Delayed transfers of care: number (snapshot)*
809
3
Delayed transfers of care as % of occupied
beds*
Theatre Utilisation - Elective
3.5%
Sep-15
12.78%
12%
5
80%
Sep-15
75.91%
75.9%
3
Theatre Utilisation - Emergency
70%
Sep-15
57.48%
59.9%
2
Theatre Utilisation - Total
75%
Sep-15
71.45%
72%
2
Results Endorsed within 7 days
NA
Sep-15
59.36%
51.1%
%patients cancer treatment <62-days urg GP ref
85%
Aug-15
85.75%
83.2%
5
%patients cancer treatment <62-days - Screen
90%
Aug-15
93.33%
92.4%
5
%patients 1st treatment <1 mth of cancer diag
96%
Aug-15
97.14%
97.7%
5
%patients subs cancer treatment <31days - Surg
94%
Aug-15
97.06%
96.1%
5
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
98%
Aug-15
100%
99.7%
5
94%
Aug-15
99.05%
98.6%
5
%2WW of an urg GP ref for suspected cancer
93%
Aug-15
93.78%
94.7%
5
%2WW urgent ref - breast symp
93%
Aug-15
93.33%
95.9%
5
0
Sep-15
0
0
3
80%
Sep-15
89.47%
88.7%
5
Same sex accommodation breaches
# patients spend >=90% of time on stroke unit
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
Number of CAS Alerts received by Trust 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
Dementia diagnostic assessment and
investigation
Dementia :Referral for specialist diagnosis
Patient
Experience
Safety
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Patient Satisfaction- Response rate (friends &
family -Maternity)
Patient Satisfaction- Response rate (friends &
family -ED)
Friends & Family test % not likely to
recommend - ED
Friends & Family test % not likely to
recommend - IP
Friends & Family test % not likely to
recommend - Mat
Friends & Family test % likely to recommend ED
Friends & Family test % likely to recommend - IP
5
0
Sep-15
0
0
5
0%
Aug-15
82.81%
72.9%
4
0%
Aug-15
91.48%
89.4%
0%
Aug-15
100%
100%
0%
Sep-15
15.49%
10%
2
NA
Sep-15
9.78%
28.2%
2
2
0%
Sep-15
30.93%
16.3%
NA
Sep-15
8.82%
7.5%
NA
Sep-15
1.17%
1%
NA
Sep-15
0.75%
0.8%
NA
Sep-15
84.42%
85.8%
NA
Sep-15
95.99%
96.5%
Friends & Family test % likely to recommend Mat
Number SIRIs
NA
Sep-15
95.52%
95%
NA
Sep-15
13
81
5
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
0%
Sep-15
92.22%
93.6%
3
NA
Sep-15
3
6
5
Cleaning Scores- % of inpatient areas with initial
score >92%
Flu vaccine uptake
NA
Sep-15
25.81%
28%
5
0%
Sep-15
No data available
3
Falls with moderate harm or greater as a
percentage of total harms
% of incidents associated with moderate harm
or greater
# newly acquired pressure ulcers (category 2,3
and 4)
NA
Sep-15
No data available
NA
Sep-15
1.9%
2.1%
NA
Aug-15
67
322
11 of 28
Operational
Standards
YTD
Data
Quality
0%
Sep-15
83.65%
82.9%
3
0
6
Sep-15
Sep-15
0
4
2
30
5
5
Standard
Time to Surgery (% patients having their
operation within the time specified according to
their clinical categorisation)
HCAI - MRSA bacteraemia
HCAI - Cdiff
% adult inpatients have had a VTE risk assess
95%
Current
Data Period Period Actual
Aug-15
96.91%
97%
5
Finance
Capital
Financial Risk
I&E
Standard
Standard
5%
3%
Turnover rate
10.5%
Substantive staff in post against budget
10977.25
Temporary Workforce expenditure as a total of
5%
Vacancy rate
Sickness absence**
Workforce expenditure
Current
Data Period Period Actual
Sep-15
Sep-15
Sep-15
Sep-15
Sep-15
5.37%
3.56%
13.58%
10387.31
8.78%
YTD
YTD
Data
Quality
90%
Sep-15
104.63%
5
Monitor Risk Rating
3
90%
1%
90%
Sep-15
Sep-15
Sep-15
Sep-15
2
87.51%
-1.49%
84.09%
5
5
5
Total CIP Performance Compared to Plan
I&E Surplus Margin (%)
Recurrent CIP Performance Compared to Plan
Workforce
Workforce
Performance
Current
Data Period Period Actual
Capital Programme Compared to Plan
Data
Quality
3
5
3
* The figures include acute hospital transfers which are not reported at a National Level
** This measure is collected for a 12 month period preceding the latest period shown Year: 2015-16
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,Medicine, Rehabilitation & Cardiac,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,Education and Training,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,Medicine, Rehabilitation & Cardiac 2,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
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IPF Red Escalation Report FY 2015-16
I&E Surplus Margin (%)
What is driving the reported
underperformance?
The Trust is behind plan in the
achievement of its I&E target
surplus. This is because (i)
Divisional expenditure is higher
than plan and (ii) commissioning
income remains below planned
levels.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
1%
Sep-15
-1.49%
YTD
TME has agreed a number of control measures
and other mitigations to rectify the financial
position, and the forecast year-end position for
the Trust has improved.
The Trust 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.
The Trust Development Authority (TDA) has
asked the Trust to improve its year-end surplus
position by £5m. The financial pressures on the
organisation mean that meeting this revised
target will be challenging. Monitor will also
want the Trust to meet this new target.
Expected date to meet standard
Lead Director
The Trust is not planning to make Director of Finance & Procurement
a 1% I&E surplus in 2015/16.
An I&E deficit of £3.6m, or 0.4% of
turnover, is planned for the year
but the TDA/Monitor want the
Trust to improve this planned
outturn position by £5m.
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IPF Red Escalation Report FY 2015-16
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
0
Sep-15
4
19
52 week breaches of incomplete There is an action plan in place to reduce the
pathways went down in July and number of patients waiting.
August but have increased to 4 in
September.
Four patients waited over 52 weeks or more for
treatment in September; 2 patients were
admitted and treated in October; 1 patient
attended clinic and clocked stopped in October
and one waited due to patient choice.
Expected date to meet standard
Lead Director
Quarter 3 2015/16
Director of Clinical Services
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IPF Red Escalation Report FY 2015-16
% <=4 hours A&E from arrival/trans/discharge
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September performance has
remained below the 95%
standard. There have been some
staffing issues with late absences
due to sickness. High levels of
patients who are delayed
transfers of care remain a
significant concern for the Trust.
The System Resilience 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.
Expected date to meet standard
Lead Director
Quarter 3 2015/16
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
95%
Sep-15
90.59%
94%
An integrated Urgent care Improvement Plan is
being implemented.
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IPF Red Escalation Report FY 2015-16
Delayed transfers of care as % of occupied beds*
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
3.5%
Sep-15
12.78%
12%
A deterioration in performance in Daily whole system teleconference calls remain
September at 12.78% compared in place, with escalation to Oxfordshire
to 10.46% in August.
colleagues when system is on RED.
Weekly meeting with OCCG, OH and OCC
colleagues to manage Oxfordshire system
issues.
Further work is progressing internally to
improve the patient flow and discharge process
for all patients.
Expected date to meet standard
Lead Director
This system has not agreed a date Director of Clinical Services
to achieve this standard.
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IPF Red Escalation Report FY 2015-16
Theatre Utilisation - Emergency
What is driving the reported
underperformance?
What actions have we taken to improve
performance
A 5.93% deterioration on August
utilisation performance during
September.
Work is progressing internally to review and
improve theatre utilization, developing a
standardized approach across the Trust to
manage emergency lists.
Expected date to meet standard
Lead Director
Quarter 3 2015/16
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
70%
Sep-15
57.48%
59.9%
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IPF Red Escalation Report FY 2015-16
Medication reconciliation completed within 24 hours of admission
What is driving the reported
underperformance?
•
•
What actions have we taken to
improve performance
With the withdrawal of winter
•
pressure funding in April 2015 and the
subsequent removal of all ward based
clinical pharmacy support on
weekends this has had a drastic effect
on stage 2 medicines reconciliation
figures. Medicines reconciliation now
completed 5/7 days a week in most
clinical areas.
Stage 2 medicines reconciliation relies
heavily on the completion of stage 1
medicines reconciliation completed on
admission by the clerking doctor on
ePMA. Currently 87% of stage 1
•
medicines reconciliations are being
completed by ward based clinical
pharmacy staff and not medical staff.
This has placed a significant new
burden on pharmacy staff that was
not there prior to ePMA introduction •
and significantly reduced the time
available to complete stage 2
medicines reconciliation.
Standard
Current Data Period
Period Actual
YTD
80%
Sep-15
62.93%
65%
Recurrent funding has been
approved to support seven day
ward based pharmacy clinical
services to a number of MRC
divisional areas across the Horton
and JR sites from October 2015.
Furthermore reconfiguration of
weekend working at the CH site has
released pharmacists on weekends
to support a number of clinical
areas. This should improve
medicines reconciliation figures for
these areas.
EPMA training for medical staff to
highlight importance of completion
of reconciling medication on
admission for all admitted patients.
Dr Sudhir Singh leading on
improving.
Dr Sudhir Singh to identify a
medical team to champion
identified medication admission
reconciliation.
Expected date to meet standard
Lead Director
January 2016
Medical Director
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IPF Red Escalation Report FY 2015-16
Sickness absence**
What is driving the reported
underperformance?
Following an initial rise in absence
rates the overall sickness absence
level continues a recent trend of
decline, which is consistent with
the introduction of the FirstCare
management system. In March
sickness peaked at 3.75%.
There is no single contributory
factor, but the greatest time lost
is due to mental health issues.
This is consistent with the longer
term nature of the illnesses
concerned.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
3%
Sep-15
3.56%
YTD
The introduction of an absence management
module in the ‘line managers’ toolkit’ training
should assist the absence management process.
The close operational working between the
Workforce Directorate, line managers and the
Occupational Health Service will continue.
The further sub-categorisation of stress/anxietyrelated absence into subsidiary reasons will
provide improved management information and
enable better targeted interventions.
Expected date to meet standard
Lead Director
Q1 2016/17
Director of Organisational Development and
Workforce
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IPF Red Escalation Report FY 2015-16
Turnover rate
What is driving the reported
underperformance?
Overall staff turnover has
stabilised, but remains below
target.
The numbers of leavers amongst
nursing and midwifery staff, and
care support workers, is a key
contributory factor. Combined,
these staff categories account for
c.56% of all wte leavers.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
10.5%
Sep-15
13.58%
YTD
Whilst turnover rates for band 5 nursing and
midwifery posts have improved, increasing
retention amongst this staff group remains
challenging. A retention incentive, linked to
length of service, is being scoped.
One corporate and two divisional lead
recruitment and retention nurses have been
appointed. These key posts will provide direct
advice and support in the recruitment and
retention of nursing staff and undertake
detailed analysis to further inform local
retention strategies.
Expected date to meet standard
Lead Director
Q2 2016/17
Director of Organisational Development and
Workforce
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IPF Red Escalation Report FY 2015-16
Temporary Workforce expenditure as a total of Workforce expenditure
What is driving the reported
underperformance?
Reliance on the use of temporary
staff (bank and agency) is largely
driven by vacancies in the
substantive staff establishment.
Other contributory factors include
sickness absence, maternity leave
and the requirement to provide
intensive “specialty” care to
certain categories of patients.
Performance remains below
target, although expenditure has
reduced for the second month in
succession.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Sep-15
8.78%
YTD
From October the recruitment of EU nurses to
supplement recruitment of UK based nurses
increased, with approximately 25 nurses arriving
every two weeks. The recruitment of such
nurses is likely to continue into the new year.
The elimination of non-framework agencies is
almost complete. A review of long line agency
staff is underway.
All trusts have been mandated by Monitor and
the TDA to reduce nurse agency expenditure to
a prescribed ceiling in Q3, Q4 and beyond. The
level of reduction is dependent upon current
expenditure and the cap for OUH is 8% for the
remainder of this financial year. Further
national measures to introduce an absolute cap
on hourly rates are expected in November.
Current controls will remain in force and
additional measures are being scoped, should
these be required.
Monthly monitoring of agency usage is
undertaken at the Workforce CIP meetings and
via the dissemination of workforce information
to divisional teams.
Expected date to meet standard
Lead Director
Q2 2016/17
Director of Organisational Development and
Workforce
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IPF Amber Escalation Report FY 2015-16
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-15
2
YTD
The risk rating is in line with the
None - timing issue only.
plan for the first six months of the
year.
Expected date to meet standard
Lead Director
Q4 2015/16
Director of Finance & Procurement
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IPF Amber Escalation Report FY 2015-16
Total 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
90%
Sep-15
87.51%
YTD
There has been slippage on some Divisions are aware they have to make up any
Divisional and cross-Divisional
slippage in the remainder of the year and their
schemes.
performance is being monitored monthly.
Performance against all schemes is monitored at
monthly meetings of the Transformation & CIP
Steering Group, and Divisions and project
managers are required to identify alternative
savings when it appears that current projects
are not expected to deliver the full level of
savings in the year.
Mitigating actions have been identified and are
now improving CIP performance.
Expected date to meet standard
Lead Director
Q4 2015/16
Director of Finance & Procurement
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IPF Amber Escalation Report FY 2015-16
Recurrent 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
90%
Sep-15
84.09%
YTD
There has been slippage on some Divisions are aware they have to make up any
Divisional and cross-Divisional
slippage in the remainder of the year and their
schemes.
performance is being monitored monthly.
Performance against all schemes is monitored at
monthly meetings of the Transformation & CIP
Steering Group, and Divisions and project
managers are required to identify alternative
savings when it appears that current projects
are not expected to deliver the full level of
savings in the year.
Mitigating actions have been identified and are
now improving CIP performance although some
of these will only realise a non-recurrent
benefit.
Expected date to meet standard
Lead Director
Q4 2015/16
Director of Finance & Procurement
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IPF Amber Escalation Report FY 2015-16
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
90%
Sep-15
86.04%
87.2%
Admitted performance continues Regular meetings are being held with Divisional
to be a challenge in September
Teams and the Director of Clinical Services.
due to workforce and capacity
constraints.
Specialties with significant challenges continue
to be:
• Orthopaedics
• Plastic Surgery
• Ophthalmology
• Ear Nose & Throat
• Neurosurgery
• Gynaecology
Additional theatres lists are being undertaken
and external providers are being used to
support some surgical activity.
Expected date to meet standard
Lead Director
Quarter 3 for Trust level standard Director of Clinical Services
with risk limited to Orthopaedics,
Neurosurgery and Spinal.
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IPF Amber Escalation Report FY 2015-16
Theatre Utilisation - Elective
What is driving the reported
underperformance?
What actions have we taken to improve
performance
September has seen a 0.92%
increase in elective theatre
utilization compared to August.
Clinical teams are focused on improving booking
procedures and maximizing productivity.
Actions plans are being drawn up and
implemented following the “perfect theatre
week” initiative.
Expected date to meet standard
Lead Director
Quarter 3 2015/16
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
80%
Sep-15
75.91%
75.9%
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IPF Amber Escalation Report FY 2015-16
Theatre Utilisation - Total
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
75%
Sep-15
71.45%
72%
September has seen a 0.63%
Focus continues on productivity for all clinical
decrease in total theatre
teams both on the day and forward booking.
utilization compared with August.
Recruitment of key critical theatre staff is ongoing.
Actions plans are being drawn up and
implemented following the “perfect theatre
week” initiative.
Expected date to meet standard
Lead Director
Quarter 3 2015/16
Director of Clinical Services
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IPF Amber Escalation Report FY 2015-16
Vacancy rate
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Sep-15
5.37%
YTD
Whilst still below target, the
Actions taken to reduce the vacancy rate are
overall vacancy rate reduced in
consistent with those associated with current
month. This further reduction was recruitment and retention initiatives.
as a consequence of increased
recruitment activity in September.
Between August and September,
substantive staff in post increased
by 180 wte.
Expected date to meet standard
Lead Director
Q3 2015/16
Director of Organisational Development and
Workforce
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