REPORT TO TRUST BOARD Date: 2nd December 2015 Paper Title: Croydon Health Services NHS Trust Performance Summary September (M6 plus Month 7 Draft KPI Dashboard) Sponsoring Director: Lisa Chesser, Director of Planning & Informatics Author: Sharon Hamilton, Trust Performance Manager Decision Required: Trust Board to note: The Trust position against the KPIs for Month 6 The update relating to the Trusts Data Quality Objectives The NHS Trust Development Authority’s (TDA) Accountability Framework Quality self-assessment score for the month of September 2015 Reputational implications of non-achievement Impact on Patient Experience: Impact on staff and patient experience Impact on Financial Improvement Financial penalties and loss of income from non-achievement of performance standards. History: This paper has been to the Finance & Performance Committee and the Quality & Oversight Executive Management Board. Executive Summary The Trust has continued to review the Performance Dashboard. Reporting is aligned with the Care Quality Commission’s (CQC) five domains and is based on indicators set out in the TDA Accountability Framework and Oversight model with local indicators identified as a priority by key stakeholders. Performance against key quality, operational and finance measures is reviewed at the Trust Board, Board Committees, within Clinical Directorates and at Performance Reviews. The Trust position remains positive across a range of measures with action plans in place to support the delivery of those measures below target. The Trusts continues to proactively benchmark across South West London and Greater London, delivering enhanced dashboards to drive the transparency of performance and subsequent improvements across the Trust from Ward to Board. Additional work has begun in supporting business units with service level dashboards to ensure there is visibility in their contributions to overall directorate performance. Page |1 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 The key points to note for September 2015: Overall, the Trust is meeting the standards for three of the five CQC quality domains – Caring, Safe and Effective. The key performance challenges for the Trust are: The A&E 4 hour target for all types declined to 90.64% in September below the standard of 95%. A recovery plan and trajectory to meet year end compliance has been agreed with the Clinical Commissioning Group. The national incomplete referral to treatment pathway standard continues to be met. However, the Trust reported two 52 week breaches in month, with a total of 9 year to date. In month, the Trust met all cancer waiting standards with the exception of Referral to First Appointment for Breast Symptoms (14 days) and Referral to Treatment for Urgent Suspected Cancer (62 days). The Friends & Family Test Response Rates for A&E and Daycase are below expected, and significantly below target for Outpatients. The Core Skills Training Framework (CSTF) previously MAST and Appraisal compliance remains a concern. Trust Data Quality - CHS aggregate SUS data quality performance for M6 2015/16 is 97.9% against a national average of 96.2%. Related CQC 5 Key Areas of Care: X Safe X Effective X Responsive X X Well-Led Caring Has an equality impact assessment form been completed? This report has been written within the Trust current internal Performance Framework which is the mechanism to hold all Directorates to account for the key quality, performance and financial standards and the TDA Accountability Oversight and Escalation model. The model of service is not impacted. Has legal advice been taken? Does this report have any financial implication? No No If so, has the report been approved by the Financial Department? Reviewed by Director of Finance Page |2 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Performance Summary Areas of Positive Performance - Month 6 RTT 18 Weeks Incomplete Pathways - The Trust successfully achieved the RTT Incomplete pathway standard for September 2015 reporting 93.70% against a standard of 92%. FFT Score (Recommended) - Performance remains above YTD target across A&E, Maternity, Inpatient, Outpatient, Day cases and Community, all reporting above the expected standard of 90%. Friends & Family Response Rate Inpatients and Maternity - Performance across both standards remain strong and above target in month and at year to date. Mixed Sex Accommodation – The Trust continues to report zero breaches. Delayed Transfers of Care – The rate remains below the tolerance of 3.50%. Never Events - Zero cases reported. Harm Free Care - Standards continue to be met on a consistent and improving basis for Harm Free Care. New Birth Visits at 10-14 Days - The Trust reported a positive position of 92.70% in month a significant improvement on previous months against a standard of 90%. Patient Safety Thermometer - % of Harm Free Care - remains positive reporting 97.04% against a 95% standard. Timely Response to Complaints - the service has performed well for timely response to complaints both in month and at year to date, reporting 87% against a standard of 80%. SUS Data Quality - CHS aggregate SUS data quality performance for M6 2015/16 is 97.9% against a national average of 96.2%. Data Quality/London Comparison - Due to data quality improvement initiatives, CHS is now ranked 12th out of 35 providers in London compared to 30th out of 35 at the start of 2015/16. Page |3 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Performance Issues - Month 6 A&E 4 Hour All Types - Reported 90.64% against a standard of 95%. Whilst below the standard, this is above the trajectory agreed with Croydon Clinical Commissioning Group. A&E 4 Hour Type 1 - Performance declined on previous month reporting 86.88% against a standard of 95%. Trust Vacancy Rate - The rate remains higher than expected reporting 14.80% against the expected tolerance of 11.50%. Cancer Waits - Referral to First Appointment for Breast Symptoms (14 Days) reported 89.80% in month against a standard of 93% but the year to date position remains strong at 93.33%. Referral to Treatment 52 Week Waits - Trust reported two cases in month 6 and a year to date position of nine against a tolerance of zero. FFT - Response Rate - A&E, Day cases and Outpatients - The percentage of A&E respondents was low in month reporting only 17.14% against a standard of 20% with a year to date position of 13.37%. Response rate for day cases had declined reporting a year to date position of 19.87% against the standard of 30% and Outpatients 9.98% (YTD) against a standard of 25%. PDR Compliance - The percentage of all Trust Staff with an Annual Appraisal remains below the expected standard of 85% reporting only 63% for month 6. Integrated Women’s, Children’s and Sexual Health Services contributed to the decline in the overall result reporting only 59% for month 6. Core Skills Training - continues to remain below expected standards at month 6. Performance Risks - Month 6 Referral to Treatment 18 Weeks Admitted and Non-admitted Pathways - Whilst the Trust is no longer measured nationally it continues to monitor reported results. Referral to Treatment - Admitted for month 6 showed only a slight increase on the previous month reporting 80.23% with Non-admitted reporting 92.44%, a small increase in month 6. Page |4 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Exception Reports Responsiveness Domain 4 Hour Total Time in A&E Department - All Types and Type 1 In month the Trust reported a decrease in A&E All Types from 94.52% to 90.64%. Type 1 also decreased from a previous month position of 92.03% to 86.88%. A comprehensive action plan which can be seen in fig 1 has been put in place to improve performance with a focus on the implementation of front-end service redesign to ensure that patients are managed appropriately. Performance during November has significantly improved within Safer Faster week and the introduction of the Edgecombe Unit - although the organisation must sustain performance over 96% each month to achieve the year-end target of 95%. The trajectory has been shared with the Clinical commissioning Group. A&E All Types Monthly Performance Trajectory 2015/16 Page |5 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Fig 1- Emergency Care Programme Action Plan Emergency Care Programme - Progress Update November 2015 Completed Nov-15 Dec-15 Jan-15 Feb-15 Daily Telephone Conference call in place Roving GP Recruitment of 2 ED Consultants Recruitment of 2 ED Consultants Recruitment of 2 ED Consultants Roving GP Impact Analysis of Roving GP 3 Additional Band 8a Nurses New allocation of Middle Grades from Deanary Development of ED Standards, Emergency Floor SOP and Escalation processes Emergency Department Pathways and Models of Community Care Plans in A&E Expansion of Coordinate My Care Development of ED Standards, Emergency Floor SOP and Escalation processes Emergency Department Pathways and Models of Emergency Department Pathways and Models of Emergency Department Workstream Clinical Streaming Model agreed for rollout on 9th November ‘On call’ staffing at UCC Rapid Response staff in ED Rapid response Staff in Nursing and Care Homes Development of ED Standards, Emergency Floor SOP and Escalation processes Staffing templates signed off and agreed Workforce requirements mapped against activity LAS consistent usage of alternative provision Consultant Workforce Mapping A&E Consultant rotas overlapping Co-location of AMU, Adult Early Assessment at Front Direct Referrals from GPs, Consultant only Admission Care of the Elderly + of House to Rapid Ambulance and A&E to Ambulatory Care Response/Community Assessment Areas Discharge Flow Consultant Geriatricians in A&E Increased Psychiatric Liaison Allocate and agree capital costs for build of Allocate and agree Winter Resillience funds for staffing of Edgecombe Unit Pefect Ward across to pilot ward areas Earlier MDT + Identification of Patients Discharge before mid-day Utilisation of Whiteboards to drive flow across all ward areas Complete Discharge Lounge Audit Review of Nursing, OT care and rehabilitation Informatics Define what Information needs to be gathered Define what infomtion needs to be shared Carry out capacity modelling across health economy Carry out bed mapping across heatlh economy Blue Green Amber Red Grey Joint working with the CCG to agree tariffs associated with existing and new services Joint working with the Joint working with the CCG Joint working with the CCG to agree tariffs to agree tariffs associated CCG to agree tariffs associated with existing with existing and new associated with existing and new services services and new services Perfect Ward across all Wards Therapy and OT Assessments over Perfect Ward across all Wards Standardised Discharge Planning with Expected Perfect Ward across all Wards Standardised Discharge Planning with Expected Perfect Ward across all Wards Standardised Discharge Planning with Expected Relaunch of Workstream of Four Eyes Ward Work with Medical DirectorCompletion at chair Audit to measure Increase in Intermediate timeliness and quality of Care Beds discharge summaries Increase in Intermediate Care Services Improved performance of Agreement with Bromley NHSE Specialist Stroke on Stroke Patients Beds Ensure access is delivered Ensure access is Explore methods for Explore methods for as required to operational delivered as required to sharing information across sharing information staff driving flow through operational staff driving health economy across health economy the organisation flow through the Monitor useage and Monitor useage and compliance of infotmation compliance of and IT systems internal to infotmation and IT CHS (CERNER and systems internal to CHS Increase user capacity Explore mobile platforms Explore mobile platforms internally and externally for information sharing for information sharing to useful Information Explore "REATLIME" Explore "REATLIME" information reporting out information reporting out of CERNER of CERNER Completed On Track Slow progress/ work in Outstanding/ significant work required Not applicable Page |6 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Referral to Treatment The national incomplete pathway standard continues to be met. However, the Trust reported two 52 week breaches in month, with a total of 9 year to date. This is largely as a result of the Patient Tracking List (PTL) review, ensuring that long all long waiting patients are seen as soon as possible. Whilst no longer national targets; the Trust continues to monitor performance against admitted and non-admitted 18 week pathways. Performance has deteriorated against these two standards since May with a 10% and 3% reduction in performance for admitted and non-admitted pathways respectively. Demand and capacity analysis has been undertaken with key constraints identified across Urology and General Surgery. Action plans to increase capacity and review pathways have been developed with a trajectory to meet the standards by December 2015. Cancer Waiting Times Inc. South West London Cancer Network Provider Results September 2015 - Month 6 Summaries In month, the Trust met all cancer waiting standards with the exception of Referral to First Appointment for Breast Symptoms (14 days) and Referral to Treatment for Urgent Suspected Cancer (62 days). Comprehensive action plans have been developed and implemented to ensure compliance with all standards. For example, 14 day referrals will be logged on the system within 24 hours from receipt, clinically triaged and appointments offered within 48 hours where possible. Performance against the 62 day standard was met in October 2015 and will be reported in December. The breach review panel will now have formal presentations of pathways from co-ordinators and clinical leads where possible and also review the service level 62 day performance, which will be communicated to board level. The team also produce Root Cause Analysis for all 100 day patients and breaches for 14, 31 and 62 days. Staff Friends & Family Test Results July 2015 to September 2015 (Q2) 2015 The Trusts Staff Friends & Family Test results for July 2015 to September 2015 (Q2) showed a slight improvement on the previous quarter. The Trust has made positive progress on both the response rate and the survey findings over the last two years. To support the continued progress a number of Listening into Action teams are developing action plans from the Staff Big Conversations that will address some of the key issues and resonating themes highlighted throughout the staff FFT. Action: The Trust needs to set and agree an internal target for the two indicators. Page |7 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Well-Led Domain Core Skills Training and PDR Compliance The Trust aspirations for achieving the stretch targets for Core Skills Training (CST) and PDR’s was not realised at the end of September. Support has continued with the production of detailed data at business unit level in order to identify any failing areas. The overall Trust PDR compliance remained below the locally set standard of 90% at 63.00% in month. An action plan to support the delivery of CST followed from the CQC inspection in June with the Trust making an internal commitment to significantly improve PDR and Core Skills Training compliance to 98% by Quarter 3. Following the Quality Summit, HR & OD have continued to work closely with Trust Senior Managers on developing and implementing action plans to improve the current compliance status but equally look to see how this can be maintained. HR and OD have identified significant challenges to meeting this with staff not being able to attend training sessions, winter pressures or being given time to complete e-learning. Directorate performance additionally continues to be monitored through monthly performance meetings with compliance trajectories and plans to deliver performance requested by the Chief Operating Officer within month. Trust Data Quality The Trust has made significant improvements over a number of data quality metrics across Admitted Patient Care, Outpatients and A&E. Key metrics include Patient Pathway, NHS Number, Ethnicity, Procedure, Diagnostic code and HRG compliance. Current Performance: CHS aggregate SUS data quality performance for M6 2015/16 is 97.9% against a national average of 96.2% Due to data quality improvement initiatives, CHS is now ranked 12th out of 35 providers in London compared to 30th out of 35 at the start of 2015/16 Actions Taken: The ‘Site of Treatment’ reporting issues have now been completely resolved and CHS is rated 100% across all three data sets Significant improvement in the outpatient ‘Priority Type’ indicator Page |8 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6 Resolved the technical issues affecting the ‘Outcome of Attendance’ indicator, further improvement in this indicator will be delivered through increasing operational compliance with Cerner work flows Developed the Trust DQ dashboard for admitted patient care; now in final testing before rollout Progressed development of the Trust DQ dashboard for outpatient data Rolled out the Trust A&E DQ Dashboard, the DQ team are now working with the A&E department to understand how best to resolve the remaining DQ issues Planned Actions: Our biggest issue from the SUS DQ Dashboard is now patient demographic data (including NHS number and postcode), improvements will be made there by: Working with the Application Support Team to streamline the process for patient record merging Data Warehouse development to correctly use appropriate default codes where information is not available Identify and support areas or individuals who are registering patients without linking to the national Patient Demographic Service Rollout the Trust DQ dashboards for admitted patient care and outpatients Targeted data correction by the DQ team in priority areas and continued support to operational teams Progress issues with Cerner data feeds, assisting with investigations and escalating where appropriate Recommendations/Actions Trust Board to note: The Trust position against all KPI standards, including those indicators where there has been improvement, those below target and the associated actions to address, and areas where focussed effort is required to ensure the target continues to be met. The Trust continued proactive development in benchmarking across South West London and Greater London and delivering enhanced dashboards to drive the transparency of performance and subsequent improvements across the Trust from Ward to Board. Page |9 Croydon Health Services NHS Trust Performance Summary September 2015 Month 6