Trust Board Meeting in Public: Wednesday 9th September 2015
TB2015.108
Title
Integrated Performance Report – Month 4
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
TB2015.108 Integrated Performance Report M4
Assurance
Policy
Performance
Page 1 of 31
Oxford University Hospitals
TB2015.108
Integrated Performance Report Month 4
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 July was
96.6% against the standard of 95%.
Performance against the 4 Hour standard was 96.5% in July.
Diagnostic waits over 6 weeks, 21 patients waited over 6 weeks at the end of
July, achieving 0.17% against the standard of no more than 1% waiting over 6
weeks.
The 18 week RTT Incomplete and Non-Admitted standards were achieved in July
at 92.09% and 95.03% against the standards of 92% and 95% respectively.
All eight cancer standards including the 62 day standard were achieved in June
2015.
MRSA bacteraemia; zero cases were reported in July.
Zero same sex accommodation breaches reported at end of July.
Patients spending >=90% of time on stroke unit was 95.59% against a standard
of 80% in July.
Eight adults waited 52 weeks or more for treatment in July.
Delayed Transfers of Care as a percentage of occupied beds is at 13.2% for July
against the standard of 3.5%.
18 week RTT Admitted performance was 88.08% against the 90% standard as
expected due to the focus on reducing patients waiting over 18 weeks.
Staff turnover rate is 13.71%, which is 3.21% above the standard.
Staff sickness absence rate was 3.68%, 0.68% above the standard.
CDifficile; eight cases were reported in July.
Key Standards
3.1. 18 Week RTT, A/E and Cancer
3.1.1. 4 Hour 95% of patients seen within 4 hours from arrival/transfer/
discharge: Performance at the end of July was 96.5%.
3.1.2. 18 Week Referral to Treatment [RTT] performance: The RTT admitted
standard was subject to an ag reed plan fail in July with performance at
88.08% against the 90% target. The incomplete standard was achieved at
92.09% against the 92% target and the non-admitted standard was achieved
at 95.03% against the 95% target.
3.1.3. All eight Cancer Standards were achieved in June 2015.
TB2015.108 Integrated Performance Report M4
Page 2 of 31
Oxford University Hospitals
TB2015.108
3.2. Activity
3.2.1. Delayed Transfers of Care continue to be a significant concern for the Trust
with performance for July at 13.2% against a t arget of 3.5%. The monthly
average for July was 174 delays across the system for Oxfordshire residents.
The monthly average within the OUH for July was 155.5.
4.
Monitor Assessment
4.1. Performance in June was better than the Trust’s trajectory with a score of 0 being
achieved. Performance in July is predicted to be 0 based on the cancer pre-check
data which is subject to the Open Exeter upload.
5.
Workforce
5.1. Turnover increased from 13.56% in June to 13.71% in July and is 3% 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 4.
Paul Brennan
Director of Clinical Services
August 2015
Report prepared by:
Sara Randall
Deputy Director of Clinical Services
TB2015.108 Integrated Performance Report M4
Page 3 of 31
ORBIT Reporting
Trust Board Integrated
Performance Report
July 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.
Page 4 of 31
Efficiency and Utilisation Report 2015-16
APPENDIX A: Efficiency and Utilisation IPR report Aug-15
Patients staying greater than 21 days and discharged in month
January
February
March
January
February
March
March
December
December
December
February
November
November
November
January
October
149
October
129
October
111
September
123
September
0.1
September
0.1
August
0.1
August
0.7
August
July
Average Number of ward transfers
Number of patients with more than 3 ward stays in one
spell
June
2015-16
May
OUH
April
* Excluding EAU,Discharge lounge, SEU, ITU( Adult, Neuro, Cardiac & Paeds)
This indicator records the number of ward moves that are
thought to be 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. July saw a more significant increase in patients with
over 3 ward moves during their spell.
July
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
These figures are sourced from the official Monthly
Activity Return (MAR) submitted to Unify each month.For
the first 4 months of 15/16 elective inpatients (2%) and
emergency (1.2% activity continues to grow compared
with the previous year. ED attendances are 1.5% lower
than for the same period last year.
Number of patients
April
May
June
July
Average LOS on Discharged Spells
0 to 2 Days
12429
13034
13727
14121
2 to 5 Days
1523
1604
1602
1571
5 to 7 Days
468
513
526
508
7 to 14 Days
741
731
687
681
14+ Days
Total number of patients
OUH
Number of bed days
Average LOS
626
611
602
640
15787
16493
17144
17521
0 to 2 Days
4870
4947
5084
5209
2 to 5 Days
5754
6043
6016
5970
5 to 7 Days
3024
3315
3390
3270
7 to 14 Days
7635
7501
7162
6975
14+ Days
18672
18345
19014
19248
Total number of Bed days
39955
40151
40666
40672
Average LOS Elective
3.93
4.30
4.30
4.12
Average LOS Non-elective
4.73
4.33
4.45
4.48
Average LOS Non-elective non- emergency
3.22
3.34
3.29
3.18
Day case
0.00
0.00
0.00
0.00
Average LOS (excluding daycases)
4.25
4.10
4.17
4.13
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 july, just under 4% of the
patients admitted to the hospitals accounts for
nearly 47% 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 two months of 15/16
compared with the same period for 14/15.
* bed days are counted for each midnight stay.
1
Page 5 of 31
Efficiency and Utilisation Report 2015-16
OUH
Average Number of
patients
486
423
586
589
594
626
613
623
Wednesday
623
642
665
627
Thursday
502
657
625
612
Friday
527
683
667
669
Saturday
329
338
357
331
Total number of Patients
234
229
234
222
14300
15644
16187
16595
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
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
July
669
623
627
589
612
Current Month as Chart
331
222
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
2
Sunday
Page 6 of 31
Efficiency and Utilisation Report 2015-16
OUH
Average Number of
patients
15
17
19
21
103
108
119
121
13:00 to 16:59 Hours
194
203
214
214
17:00 to 20:59 Hours
146
155
167
159
Total number of Patients
18
21
21
21
14300
15644
16187
16595
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 July 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. During July, only 23% of patients were
discharged during morning working hours.
Average Discharges by Hour
July
214
159
121
21
21
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
Page 7 of 31
Efficiency and Utilisation Report 2015-16
Delayed Discharges and Bed Utilisation
Total number of bed days available
*exclude:daycase wards, maty,well babies etc using
OPS team bedstock
4%
4%
5%
5%
Bed Utilisation - General & Acute
90%
91%
90%
89%
Bed Utilisation - Critical Care
75%
71%
76%
82%
30/04/2015
31/05/2015
30/06/2015
31/07/2015
Elective
31/08/2015
30/09/2015
31/10/2015
March
February
January
December
30/11/2015 31/12/2015 31/01/2016 29/02/2016 31/03/2016
March
1680
February
1834
January
1316
December
1484
November
159
October
159
September
135
August
134
Total number of Bed days used by patients Medically fit
and not discharged at month end
July
Number of patients Medically fit and not discharged at
month end
Delayed patients waiting for ongoing care continue
to be a major issue for the Trust and the wider
health economy. There has been no major
improvement in the numbers delayed since the end
of the winter months, and still remains excessively
high. The number of delayed patients remained at a
very high level during July.
June
36780
November
4983
October
4174
September
4177
August
July
4210
35554
POD / Admission Meth
2015-16
147
35970
Admissions
OUH
151
34771
% Bed days used by patients Medically fit and not
discharge at month end
2014-15
126
May
2015-16
132
April
OUH
June
Total Delayed bed days in month
May
Number of Delayed patients at month end
April
*for bed days:exclude:daycase wards, maty,well babies etc using OPS team bedstock
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
7405
7719
7890
7481
6977
7692
7351
8175
Day case
7123
7137
7559
8205
Elective
1993
1838
2094
2161
Non- Elective
5281
5662
5638
5532
Non- Elective non-emergency
1995
2155
2045
2036
Day case
6453
6712
7408
7673
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. As described above, elective and nonelective activity continue to grow compared with
the same period last year.
Page 8 of 31
Efficiency and Utilisation Report 2015-16
January
February
March
13908
94.3%
12282
96.5%
NA
NA
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
11291
92.4%
12010
96.2%
NA
NA
31/10/2014
31/10/2015
November
13482
91.9%
10673
96.4%
3
4
30/09/2014
30/09/2015
October
10434
90.8%
13517
91.1%
1
5
31/08/2014
31/08/2015
September
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
August
4 Hour standard by Month
*OUH Type 1 & OUH Type 2
10211
95.1%
10978
93.8%
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
NA
NA
Good performance continued during July 2015 and
has been much stronger than the same period last
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.
NA
NA
2686
2664
3094
5
March
2727
February
Total number of incompletes
January
989
2105
December
905
1759
November
245
2441
October
226
2501
September
July
On Admitted Pathway
Not on Admitted Pathway
August
June
2015-16
May
OUH
April
18 week incompletes over 18 weeks
There is still a large number of over 18 week wait
incomplete pathways. In light of the plans to
remove the admitted and non-admitted pathway
targets, and for the incomplete target to remain as
the only RTT target, the Trust will need to address
this figure of long waiting incomplete pathways.
Page 9 of 31
ORBIT Reporting
Operational
Standards
OUH - Quarterly Monitoring Report 2015-16
Standard
Q1
Q2
RTT - admitted % within 18 weeks
90%
87.13%
88.08%
87.4%
RTT - non-admitted % within 18 weeks
95%
95.07%
95.03%
95.1%
RTT - incomplete % within 18 weeks
92%
93.17%
92.09%
92.9%
% <=4 hours A&E from arrival/trans/discharge
95%
94.35%
96.47%
94.9%
%patients cancer treatment <62-days urg GP ref
85%
81.35%
81.4%
%patients cancer treatment <62-days - Screen
90%
91.07%
91.1%
%patients 1st treatment <1 mth of cancer diag
96%
97.73%
97.7%
%patients subs cancer treatment <31days - Surg
94%
95.98%
96%
%patients subs cancer treatment <31-days - Drugs
98%
100%
100%
%patients subs treatment <31days - Radio
94%
98.83%
98.8%
%2WW of an urg GP ref for suspected cancer
93%
94.86%
94.9%
%2WW urgent ref - breast symp
93%
98.17%
98.2%
69
15
HCAI - Cdiff
8
Q3
Q4
YTD
23
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,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 10 of 31
OUH At A Glance 2015 16
ORBIT Reporting
Operational
Standards
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
Quality
Outcomes
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
RTT - admitted % within 18 weeks
90%
Jul-15
88.08%
87.4%
87.7%
3
Summary Hospital-level Mortality Indicator**
NA
Dec-14
0.99
RTT - non-admitted % within 18 weeks
95%
92%
1%
Jul-15
Jul-15
Jul-15
95.03%
92.09%
0.17%
95.1%
92.9%
0.2%
95.1%
92.9%
0.2%
2
2
2
Total # of deliveries
NA
62%
23%
Jul-15
Jul-15
Jul-15
762
63.78%
20.08%
2910
64.8%
19.5%
739.3
64.1%
19.5%
3
3
5
0
0
0
NA
Jul-15
Jul-15
Jul-15
Jul-15
1
7
1
10794
4
20
2
46994
1
5.7
0.7
11159
4
4
4
2
Proportion of Assisted deliveries
15%
NA
0%
80%
Jul-15
Jul-15
Jul-15
Jul-15
15.88%
0
3.4%
64.74%
15.8%
0
3.7%
64.9%
16.3%
5
4
5
4
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
Number of attendances at A/E depts in a month
% <=4 hours A&E from arrival/trans/discharge
95%
Jul-15
96.47%
94.9%
Last min cancellations - % of all EL admissions
0.5%
Jun-15
0.53%
0.5%
0.5%
2
0%
Jun-15
12.24%
5.7%
5.7%
2
0
Jul-15
0
0
0
% patients not rebooked within 28 days
zero Urgent cancellations - 2nd time
0
Jul-15
Contract Variations Open
NA
Jul-15
7
Contract Notices Open
NA
Jul-15
1
Urgent cancellations
0
Jul-15
147
556
141.3
3
Jul-15
13.2%
12.4%
12.6%
5
80%
Jul-15
75.22%
76.2%
76.1%
3
Theatre Utilisation - Emergency
70%
Jul-15
59.69%
59.6%
58.8%
2
Theatre Utilisation - Total
75%
Jul-15
71.65%
72.1%
71.9%
2
Results Endorsed within 7 days
NA
Jul-15
52.83%
48.2%
%patients cancer treatment <62-days urg GP
ref
%patients cancer treatment <62-days - Screen
85%
Jun-15
84.96%
81.4%
81.4%
5
90%
Jun-15
91.67%
91.1%
91.1%
5
%patients 1st treatment <1 mth of cancer diag
96%
Jun-15
98.44%
97.7%
97.7%
5
%patients subs cancer treatment <31days - Surg
94%
Jun-15
97.59%
96%
96%
5
%patients subs cancer treatment <31-days Drugs
%patients subs treatment <31days - Radio
98%
Jun-15
100%
100%
100%
5
94%
Jun-15
98.97%
98.8%
98.8%
5
%2WW of an urg GP ref for suspected cancer
93%
Jun-15
94.98%
94.9%
94.9%
5
%2WW urgent ref - breast symp
93%
Jun-15
97.78%
98.2%
98.2%
5
0
Jul-15
0
0
0
3
80%
Jul-15
95.59%
87.2%
89.8%
5
# patients spend >=90% of time on stroke unit
Maternal Deaths
30 day emergency readmission
Medication reconciliation completed within 24
hours of admission
Medication errors causing serious harm
No data available
3.5%
Same sex accommodation breaches
Proportion of C-Section deliveries
5
Delayed transfers of care as % of occupied
beds*
Theatre Utilisation - Elective
Delayed transfers of care: number (snapshot)*
Proportion of normal deliveries
Patient
Experience
Safety
5
3.6%
64.9%
0
Jul-15
0
0
5
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
NA
Jul-15
8
24
5
Patient Satisfaction -Response rate (friends &
family -Inpatients)
Patient Satisfaction- Response rate (friends &
family -ED)
Patient Satisfaction- Response rate (friends &
family -Maternity)
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
Friends & Family test % likely to recommend Mat
Number SIRIs
% of Patients receiving Harm Free Care
(Pressure sores, falls, C-UTI and VTE)
Never Events
0
Jul-15
0
0
0%
Jun-15
72.86%
69.4%
69.4%
5
0%
Jun-15
92.34%
88.8%
88.8%
0%
Jun-15
100%
100%
100%
0%
Jul-15
7.48%
8.3%
8%
2
4
0%
Jul-15
27.63%
8.6%
10.8%
2
NA
Jul-15
26.92%
37.5%
33.4%
2
NA
Jul-15
6.55%
6.6%
6.6%
NA
Jul-15
1.1%
0.8%
0.8%
NA
Jul-15
0%
0.6%
0.3%
NA
Jul-15
87.46%
86.2%
86.1%
NA
Jul-15
96.15%
96.6%
96.7%
NA
Jul-15
95.16%
95%
95.6%
NA
Jul-15
19
53
15
5
0%
Jul-15
94.9%
94%
94.2%
3
NA
Jul-15
0
1
0
5
11.11%
28.1%
24%
Cleaning Scores- % of inpatient areas with initial
score >92%
Flu vaccine uptake
NA
Jul-15
0%
Jul-15
No data available
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
Jul-15
No data available
NA
Jul-15
1.77%
2.1%
NA
Jun-15
66
184
5
3
Page 11 of 31
Operational
Standards
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
Time to Surgery (% patients having their
operation within the time specified according
to their clinical categorisation)
0%
Jul-15
88.66%
82.8%
85.4%
3
HCAI - MRSA bacteraemia
0
6
95%
Jul-15
Jul-15
Jul-15
0
8
96.60%
2
23
97%
0.3
6.7
97.2%
5
5
5
YTD
Forecast
next
period
Data
Quality
13.7%
3
5
3
HCAI - Cdiff
% adult inpatients have had a VTE risk assess
Workforce
Vacancy rate
Workforce
Performance Sickness absence**
Turnover rate
Substantive staff in post against budget
Temporary Workforce expenditure as a total of
Workforce expenditure
Standard
5%
3%
10.5%
10932.68
5%
Current
Data Period Period Actual
Jul-15
Jul-15
Jul-15
Jul-15
3.68%
13.71%
10142.77
10.08%
Finance
Capital
Financial Risk
I&E
Standard
Current
Data Period Period Actual
YTD
Forecast
next
period
Data
Quality
Capital Programme Compared to Plan
90%
Jul-15
61.98%
5
Monitor Risk Rating
I&E Surplus Margin (%)
3
90%
1%
Jul-15
Jul-15
Jul-15
2
84.81%
-1.02%
5
5
5
Recurrent CIP Performance Compared to Plan
90%
Jul-15
82.17%
Total CIP Performance Compared to Plan
* 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,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 12 of 31
IPF Red Escalation Report FY 2015-16
Capital Programme Compared to Plan
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Some of the Trust’s new capital
projects for 2015/16 are starting
later than originally anticipated.
The capital programme is reviewed regularly by
the Business Planning Group.
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
Standard
Current Data Period
Period Actual
90%
Jul-15
61.98%
YTD
Forecast next period
Page 13 of 31
IPF Red Escalation Report FY 2015-16
I&E Surplus Margin (%)
What is driving the reported
underperformance?
What actions have we taken to improve
performance
The Trust is behind plan in the
achievement of its I&E target
surplus. This is partly due to
commissioning income being
lower than plan (but the figures
reported are based on only three
months’ data) and also because
Divisional expenditure is higher
than planned levels.
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. Divisions have been challenged at
their Q1 performance review meetings to take
effective mitigating actions and to achieve
agreed “stretch” targets.
Expected date to meet standard
Lead Director
Standard
Current Data Period
Period Actual
1%
Jul-15
-1.02%
YTD
Forecast next period
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.
Page 14 of 31
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
Forecast next period
0
Jul-15
7
20
6
52 week breaches of incomplete There is an action plan in place to reduce the
pathways have remained static for number of patients waiting.
the last 2 months.
Eight patients waited over 52 weeks or more for
treatment in July; five patients were treated;
one patient declined treatment and was
removed from the waiting list and two have
wait due to patient choice.
Expected date to meet standard
Lead Director
Quarter 2 2015/16
Director of Clinical Services
Page 15 of 31
IPF Red Escalation Report FY 2015-16
% 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%
Jun-15
12.24%
5.7%
5.69%
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.
*June’s data is still showing in this
report as well as the “At a glance
report”, this is due to an extended
validation process during July.
Figures will be updated as soon as
possible and a verbal update will
be provided.
Expected date to meet standard
Lead Director
Quarter 2 2015/16
Director of Clinical Services
Page 16 of 31
IPF Red Escalation Report FY 2015-16
Delayed transfers of care as % of occupied beds*
What is driving the reported
underperformance?
A minor improvement in
performance in July at 13.2%
compared to 13.36% in June.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
3.5%
Jul-15
13.2%
12.4%
12.57%
Daily whole system teleconference calls remain
in place, with escalation to Oxfordshire
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.
Page 17 of 31
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 very minor deterioration on
June utilisation performance
during July.
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 2 2015/16
Director of Clinical Services
Standard
Current Data Period
Period Actual
YTD
Forecast next period
70%
Jul-15
59.69%
59.6%
58.76%
Page 18 of 31
IPF Red Escalation Report FY 2015-16
HCAI - Cdiff
What is driving the reported
underperformance?
What actions have we taken to
improve performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
6
Jul-15
8
23
7
The limit set for OUH apportioned C.diff for the
month of July 2015 was 6 cases.
Though 5 cases were deemed unavoidable,
the following patient management issues
were identified as requiring action
A total of 8 OUH apportioned cases of C.diff were
• Improvements in the communication
reported by OUH Microbiology for July 2015.
between Nursing and Medical staff
All 8 OUH apportioned cases were discussed at the
when samples have been sent for C.diff
Monthly Health Economy meeting with the OCCG
testing.
and Oxford Health
• Improving awareness of the need for a
specific request on EPR for C.diff
Of the 8 cases, it was determined that 5 of the 8
testing if a C.diff infection is suspected,
cases were unavoidable. It was agreed that a
rather than a single request for MC&S
further review of the 1 remaining cases would be
testing.
required before avoidability could be determined.
The 2 further cases would be reviewed at the
September Health Economy meeting, as the Case
review documentation could not be made
th
available in time for the meeting on the 10
August 2015.
Expected date to meet standard
Lead Director
An upper limit of 6 OUH apportioned C.diff
infections has been set for August 2015 and the
Trust is expected to be within this upper limit for
the month.
Medical Director
The Trust Board is asked to note that for the
purposes of establishing a monthly
trajectory, indicative case numbers are
Overall, the Trust remains within its upper limit of allocated to each month. Stochastic
69 OUH apportioned cases for 2015-2016.
variation of actual cases through the year
means it is highly likely that on occasions,
the monthly target will not be met even
though the overall position is favourable.
Page 19 of 31
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
Standard
Current Data Period
Period Actual
YTD
Forecast next period
80%
Jul-15
64.74%
64.9%
64.93%
1. With the withdrawal of winter pressure
1. Recurrent funding has been
funding in April 2015 and the subsequent
approved to support seven day ward
removal of all ward based clinical
based pharmacy clinical services to a
pharmacy support on weekends this has
number of MRC areas across the
had a drastic effect on stage 2 medicines
Horton and JR sites from October
reconciliation figures. Medicines
2015. This should improve medicines
reconciliation now completed 5/7 days a
reconciliation figures for these areas.
week.
2. EPMA training for medical staff to
2. Stage 2 medicines reconciliation relies
highlight importance of completion
heavily on the completion of stage 1
of reconciling medication on
medicines reconciliation completed on
admission for all admitted patients.
admission by the clerking doctor on
Dr. Sudhir Singh leading on
ePMA. Currently 87% of stage 1 medicines
improving.
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.
Expected date to meet standard
Lead Director
November 2015
Medical Director
Page 20 of 31
IPF Red Escalation Report FY 2015-16
Sickness absence**
What is driving the reported
underperformance?
There is no single contributory
factor, but the most frequently
reported reason for absence is
stress/anxiety.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
3%
Jul-15
3.68%
YTD
Forecast next period
As predicted, reported absence levels are
continuing to plateau, with a slight reported
reduction during this period.
This is expected to continue during the
remainder of the year.
To enable further targeted interventions, it is
intended to refine some categories of absence
related to stress/anxiety. A number of new
categories will be introduced to provide more
precise descriptions of reasons for absence
related to mental health issues.
Expected date to meet standard
Lead Director
Q4 2015/2016
Director of Organisational Development and
Workforce
Page 21 of 31
IPF Red Escalation Report FY 2015-16
Turnover rate
What is driving the reported
underperformance?
Turnover has increased by 0.2%
during the reporting period and
remains above the Key
Performance Indicator.
Nursing and Midwifery leavers
remain they key contributing
factor, particularly band 5 staff.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
10.5%
Jul-15
13.71%
YTD
Forecast next period
13.66%
Two divisions have appointed to Lead Nurses
recruitment and retention roles and a new
recruitment nurse will begin in post in the
workforce directorate in September. As a group
they will be providing direct support to the main
retention interventions.
Expected date to meet standard
Lead Director
Q4 2015/2016
Director of Organisational Development and
Workforce
Page 22 of 31
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.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
5%
Jul-15
10.08%
YTD
Forecast next period
Recruitment of EU nurses to supplement
recruitment of UK based nurses continues. The
elimination of non-framework agencies is
almost complete. A review of longline agency
staff is underway.
Monthly monitoring of agency usage is
undertaken at the Workforce CIP meeting, with
a view to collaborating and controlling its use.
This month’s increase is
specifically related to the payment
of outstanding disputed Invoices.
This problem should not re-occur
as non-framework agencies are
removed from use.
Expected date to meet standard
Lead Director
Q4 2015/2016
Director of Organisational Development and
Workforce
Page 23 of 31
IPF Amber Escalation Report FY 2015-16
Monitor Risk Rating
What is driving the reported
underperformance?
The surplus from operating
activities is lower than the
surplus required to generate a
score of “2”.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
3
Jul-15
2
YTD
Forecast next period
None - timing issue only.
The risk rating is in line with the
plan for the first four months of
the year.
Expected date to meet
standard
Lead Director
Q4 2015/16
Director of Finance & Procurement
Page 24 of 31
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%
Jul-15
84.81%
YTD
Forecast next period
There has been slippage on the Divisions are aware they have to make up
start of some Divisional and
any slippage in the remainder of the year
cross-Divisional schemes.
and their performance is being
monitored monthly.
Expected date to meet
standard
Lead Director
Q3 2015/16
Director of Finance & Procurement
Page 25 of 31
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%
Jul-15
82.17%
YTD
Forecast next period
There has been slippage on the Divisions are aware they have to make up
start of some Divisional and
any slippage in the remainder of the year
cross-Divisional schemes.
and their performance is being
monitored monthly. They are also aware
that, if any schemes put in place for
2015/16 are non-recurrent, they will have
to identify additional recurrent savings
for 2016/17.
Expected date to meet
standard
Lead Director
Q3 2015/16
Director of Finance & Procurement
Page 26 of 31
IPF Amber Escalation Report FY 2015-16
RTT - admitted % within 18 weeks
What is driving the reported
underperformance?
Admitted performance
continues to be a challenge.
August is usually a difficult
months with holidays impacting
on available resource and
capacity.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
90%
Jul-15
88.08%
87.4%
87.73%
Regular meetings are being held with
Divisional Teams and the Director of
Clinical Services.
Specialties with significant challenges
continue to be:
• Orthopaedics
• Spinal
• Ophthalmology
• Ear Nose & Throat
• 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
Quarter 2 for Trust level
standard with risk limited to
Orthopaedics, Neurosurgery
and Spinal.
Director of Clinical Services
Page 27 of 31
IPF Amber Escalation Report FY 2015-16
Last min cancellations - % of all EL admissions
What is driving the reported
underperformance?
Additional emergency
pressures and lack of bed
capacity have caused a number
of elective cancellations in
June. Last minute cancellations
in June were 45% (15
cancellations) higher than they
were during May. Significant
numbers were seen in Cardiac
surgery, ENT and OMFS.
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
0.5%
*Jun-15
0.53%
0.5%
0.48%
A huge amount of work is on-going to
improve patient flow and bed capacity
throughout the Trust. The integrated
OUH urgent care plan also focuses on the
emergency/urgent pathway.
*June’s data is still showing in
this report as well as the “At a
glance report”, this is due to an
extended validation process
during July. Figures will be
updated as soon as possible
and a verbal update will be
provided.
Expected date to meet
standard
Lead Director
Quarter 2 2015/16
Director of Clinical Services
Page 28 of 31
IPF Amber Escalation Report FY 2015-16
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%
Jul-15
75.22%
76.2%
76.07%
July has seen a 1.13% decrease Clinical teams are focused on improving
in elective theatre utilization
booking procedures and maximizing
compared to June.
productivity. Actions plans are being
drawn up and implemented following the
“perfect theatre week” initiative.
Expected date to meet
standard
Lead Director
Quarter 2 2015/16
Director of Clinical Services
Page 29 of 31
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
Forecast next period
75%
Jul-15
71.65%
72.1%
71.87%
July has seen a 0.87% decrease Focus continues on productivity for all
in total theatre utilization
clinical teams both on the day and
compared with June.
forward booking.
Recruitment of key critical theatre staff is
on-going.
Actions plans are being drawn up and
implemented following the “perfect
theatre week” initiative.
Expected date to meet
standard
Lead Director
Quarter 2 2015/16
Director of Clinical Services
Page 30 of 31
IPF Amber Escalation Report FY 2015-16
Proportion of Assisted deliveries
What is driving the reported
underperformance?
What actions have we taken to improve
performance
Standard
Current Data Period
Period Actual
YTD
Forecast next period
15%
Jul-15
15.88%
15.8%
16.32%
The number of assisted
There will always be fluctuations in the
deliveries has fallen this month rate of assisted deliveries as it is
but remains above the
dependent on clinical need.
standard.
If LSCS rate is low the assisted delivery
The rates link closely to the
rate will be higher.
Induction of Labour and the
Caesarean Section (LSCS) rate.
The LSCS rate is below the
national average.
Expected date to meet
standard
Lead Director
n/a
Director of Clinical Services
Page 31 of 31