Transcript Document

Report to Board
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INTEGRATED
PERFORMANCE REPORT
September 2014
Stewart Messer, Chief Operating Officer
1
Trust Balance Scorecard
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2
Quality & Outcomes
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Effectiveness – HSMR / SHMI
HSMR- Whilst 2014/15 figures appear to
show an improving trend at this stage
this must be viewed with caution. Future
data uploads will add more complex
patients into the calculation which tends
to increase the HSMR figure. Trends in
the diagnostic groups contributing to the
2014/15 HSMR will continue to be
tracked and where indicated ‘deep dive’
reviews of patient groups will be
undertaken. Routine reviews of all
deaths will commence in November
2014.
SHMI- The SHMI profile continues to
mirror the HSMR profile with the
diagnostic groups contributing also
mirroring the HSMR groups indicating no
concerns with respect to post discharge
mortality risk.
3
Quality & Outcomes
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Safety - Falls
•Falls continue to reduce overall per 10,000 bed days .
4
Quality & Outcomes
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Experience – Friends & Family
•F&F responses will be available on
Hospedia as of 20 October to
improve response rates
•The Q2 quality report will cover
trends in the scores and relevant
actions taken to improve these
5
Performance & Efficiency
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4 Hour Emergency Access Standard (EAS)
•The Emergency Access Standard (EAS) was
achieved (95.21%) for September 2014 and for
Quarter 2 (95.39%) despite continued levels of
emergency demand and significant delays in
discharging patients.
•At the end of September there were 80 patients
within the Trust on the Fit to Go list.
•A broader selection of A&E quality standards
have been produced (below) which give a better
overall view of performance than simply
measuring the 4 hour standard. It can be seen that
the Trust achieved 3 out of 5 standards in
September.
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Performance & Efficiency
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Factors Affecting 4 Hour EAS
•Emergency admissions and delayed
discharges are two of the main factors that
influence the Trust’s ability to achieve the
95% standard.
•The chart shows the overall trends in total
emergency admissions over the last 3
years. As can be seen from the chart, the
Trust is still experiencing high levels of
demand in emergency admissions
compared to the same period previously.
This unplanned increased has left the Trust
in a position where it has had to cancel
elective work in order to prioritise patient
safety.
Growth in Emergency Admission
2014/15 compared with 2013/14
CCG
SW CCG
R & B CCG
WF CCG
Other CCG
Total
Financial Year to Date % Change
Under 75 Over 75
All
-1.5%
8.9%
1.6%
3.3%
-3.7%
1.2%
-1.7%
5.4%
0.3%
-0.5%
7.5%
1.7%
-0.1%
4.5%
1.3%
Site
WRH
Alex
Other
Total
Financial Year to Date % Change
Under 75 Over 75
All
-2.4%
8.4%
0.7%
3.7%
-0.5%
2.4%
0.0%
-17.4%
-12.9%
-0.1%
4.5%
1.3%
Weeks have been normalised to allow comparison of full weeks across years.
This Year is 31st March 2014 to 29th March 2015. Last year 1st April 2013 to 30 March 2014
•The trust has still had no respite in the
acuity of patients presenting with age
related illness. (Please refer to slide 10)
•Patients presenting as emergency is still
higher than expected for the period with
the majority presenting in the early and
late evening.
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Performance & Efficiency
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Factors Affecting 4 Hour EAS
•The Trust regularly has between 60-80
patients that are medically fit for discharge,
equating to between 3 and 4 wards. It
should be noted that 80 patients are
currently waiting (Sept). This is the highest
number of medically fit patients waiting for
discharge for a 12 month period in terms of
bed days.
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Performance & Efficiency
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A&E Attendances
Growth in A&E Attendancess 2014/15 compared with 2013/14
Financial Year to Date % Change
CCG
% Growth
SW CCG
9.5%
R & B CCG
5.9%
WF CCG
7.3%
Other CCG
3.7%
Total
7.2%
Financial Year to Date % Change
Site
%Growth
WRH
10.1%
Alex
4.5%
KGH
5.6%
Total
7.2%
•There has been no change in A&E attendances and
they continue to increase compared to the previous
year. A&E attendances have historically been relatively
static but since Nov 2013 attendances increased by 7%
compared to the same period in the previous year.
•The Trust is at present auditing the over 75 patient
admissions in line with the current spate of nursing
home closures across the county to see if there is a
correlation.
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Performance & Efficiency
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Referral to Treatment
% Referral
Growth on
Previous Year
13/14 to
Sept
General Surgery
Urology
Trauma & Orthopaedics
Ear, Nose & Throat (ENT)
Ophthalmology
Oral Surgery
Gynaecology
Other
Total
2.30%
-0.57%
8.53%
4.38%
6.37%
6.85%
6.02%
4.77%
5.25%
Patients Treated in September 2014
%
Within
Within
14/15 to
< 18 Wks 18 to 36 37 to 52 > 52 Wks Treated
Sept
< 18 wks
Wks
Wks
84.5%
0
3
46
267
0.07%
78.4%
0
8
36
160
0.79%
74.5%
0
12
132
421
-1.28%
63.9%
0
3
71
131
-10.63%
91.8%
0
0
49
548
0.51%
77.4%
0
4
53
195
18.09%
74.6%
0
0
57
167
-4.75%
93.2%
0
1
44
618
10.65%
82.8%
0
31
488
2507
3.69%
•Significant challenges remain on the admitted pathway and the Trust achieved 82.85% for September. It should be noted that the Trust continues to achieve the national targets for patients on the nonadmitted and incomplete pathways. The total backlog remains a challenge however the inpatient backlog is now showing signs of reducing. Conversely the outpatient referrals and backlog continue to
increase. Achieving the recovery trajectory is dependent on a reduction in both referrals and emergency demand which have not as yet materialised through delivery of the CCG QIPP schemes.
•Through the 18WRTT steering group (chaired by CEO) a number of work streams have been identified. This includes a weekly PTL meeting chaired by COO and DCOO. This approach ensures a
comprehensive, multi-faceted approach to sustainability and recover the Trust’s overall 18 week RTT performance. This will be achieved with Operational and Corporate Directorates through a structured
programme of work. Improvements in systems, processes, staff knowledge and consistency of approach will improve efficiency and effectiveness of pathways and in turn facilitate sustainable delivery of key
performance metrics. Use of the independent sector for targeted cohorts of activity will provide short term headroom whilst the transformation programme delivers the expected benefits.
• This programme of work has already commenced to deliver 13 projects to provide the improvements required and meet key stakeholders expectations to improve performance against these targets, in
particular the admitted target by November 2014. The programme will encapsulate both the administrative response needed and the clinical outcomes required. The proposed programme will deliver the
following projects:
 Leadership and management engagement & compliance ( 18WRTT Steering Group),
 Improving data quality and validation of admitted, incomplete and non-admitted pathways ( Central validation of waiting lists)
 PTL Management process review and redesign (Informatics and /Information)
 Migrating to Oasis RTT clocks from current reporting ( Information/ Informatics/ Validation)
 Comprehensive 18 RTT week reporting ( Information/ Informatics/ Validation)
 Retraining of all staff on 18 week RTT rules and standards ( Training commenced)
 Revision and implementation of the Trust’s Access Policy (TMC september2014)
 Clinical pathway review and redesign (Divisionally led)
 Analysis of capacity and demand ( working with 18 WRTT IST(IMAS))
 Development of recovery plans for all Directorates ( Supported by IMAS/ Validation/ IS Outsourcing/ theatre utilisation)
 Prediction of future performance ( Capacity and demand planning IMAS Modelling tool (T&0) Completed and ENT next speciality )
 Increased utilisation and further implementation of e-referrals (CAB linked to and overall LHE response to include primary care and re-launch of DOS)
 Access & Booking Services review and redesign.
• This is in line with the expectations of the Operational resilience and capacity planning document 2014/15 and the newly formed SRG
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Performance & Efficiency
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Referral to Treatment - Backlog
• The charts above show the number of patients waiting >18 weeks on the Inpatient and Outpatient waiting lists. The Trust has a target to bring backlog levels back down to January 13
levels by the end of November 2014.
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Performance & Efficiency
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Cancer Standards
•In line with the August performance it is the 62
day that remains a challenge and again in line
with August all areas apart from the 62 days are
achieving. The updated September figures show
the Trust in green for the 2ww symptomatic
breast patients (96.64% for the month and
90.48% year to date), green for the 31 day target
for first treatments (96.12% for the month and
95.54% year to date) , amber for the 62 day
target with 124 treatments recorded and 21
breaches (83.06% for the month and 82.16%
year to date), and amber for the 62 day
screening target (88.89% for the month and
86.35% year to date).
•The Trust has completed the diagnostic
proforma in regard of breaches and this
information has been fed back to the
directorates. The IST team has agreed with the
Trust on a 2 day visit to support the on going
work now being undertaken to support the ongoing improvement of patient pathway
processes.
•A meeting was convened with MDT clinical leads
and CNS, to discuss current performance and
improvements that could be initiated. It was
agreed that the group would meet every 3 weeks
to continue the following areas of improvement:
•Action plan to be developed and supported by
IMAS, this will include review of MDT meetings,
role of the MDT co-ordinator, discussion of
current performance and forward plans to
include delays in tertiary referrals and delays
from tertiary centres, in house processes and
where relevant reconfiguration of pathway.
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Workforce & Training - Overview
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Sickness
• The Trust’s sickness rate as reported in September 2014 was 4.09%. The cumulative sickness rate for the current year to date is marginally above
target at 3.78%. This is very slightly above the cumulative figure reported in September 13 of 3.73%
• Benchmarking the levels of absence within the West Midlands Region, the Trust is in the top 50% for Acute Trusts.
• There are local challenges within Divisions that are being managed with appropriate HR support. The detail is set out below.
Mandatory Training
• Monthly Mandatory Training Performance reports continue to be sent to Divisional Director of Operations, Nurse Directors and Medical Directors
to cascade to managers within their Division so that managers know who needs to attend training. All but 3 of the topics are now on trajectory to
meet the 95% target set for April 2015.
• The three topic areas that are not achieving 70% compliance are Medicines Management ,Venous Thrombosis and Safeguarding Children and
detailed action plans have been agreed with each of the topic leads and commenced implementation immediately, these include additional
resources to deliver extra training sessions.
• Corporate Induction Attendance declined to 83% in September 2014 as there were 22 DNA’s at corporate induction programme 9 of which were
junior doctors whose attendance has been followed up with the relevant clinical director to ensure that they complete the relevant e-learning
modules.
Staff Turnover
• Overall staff turnover reduced in September to 10.09% from 10.51% which is in line with normal range for Acute Trusts. The current overall
turnover (excluding medics) for the Arden, Hereford and Worcester LETC is 10.1%. Qualified Nursing Staff turnover has reduced by 0.92% from
11.10% to 10.18%. Turnover of unqualified Nursing Staff has reduced this month by 0.35% from 13.06% to 12.71% which is reversing the
upward trend, but is still an area for review.
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Workforce & Training - Overview
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Non Medical Staff Appraisals
•
The Trusts non medical appraisal rate only improved by 0.42% since August 2014 to 70.12%. Each Division has been asked to review their
performance and ensure appraisals are completed.
• All staff who are due an increment in the following month are sent a letter informing them unless they have had an up to date appraisal recorded
they will not receive their incremental progression, this action has prompted some activity.
• Closer monitoring of PDR performance is being undertaken and the Learning and Development Department are contacting all Department
achieving less than 70% completion to agree what support is required and an action plan to improve performance.
Medical Staff Appraisals
• The rate of appraisal for all medical staff (including consultants, SAS and other career grade medical staff) continues to improve increasing by
1.8% in September to 72.9% with the rate of consultant appraisal increasing by 2.6 % to 77.6%. Progress of appraisal is monitored and reviewed
on a monthly basis with Divisional Medical Directors (DMDs) provided with a RAG rated report on the appraisal status of doctors within their
division for review and action. Divisions are asked to produce action plans to address doctors with expired appraisals. The RAG report to be issued
to the DMDs in October will provide additional analysis on expired appraisals highlighting doctors with no progress over specific timeframes for
urgent attention.
• A revised Medical Appraisal Policy has been drafted and includes a process for non-engagement in appraisal. The draft policy mirrors the national
NHS England policy highlighting the importance of the Framework for Quality Assurance for Responsible Officers and process for postponement
and non-engagement in appraisal process and the potential consequences of referral to the GMC in cases classified and non-engagement. Once
ratified (anticipated to be following MMC Meeting 12 November 2014), implementation of the policy will ensure clear standards, expectations
and processes are established and maintained resulting in an expected increase in the rate of appraisal.
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Workforce & Training
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Sickness and Absence
• The Trust’s sickness rate has been increasing steadily from May 14 when the Trust met the target of 3.50%. The increase in rates is usually seen
from October through to February so the seasonal effect has commenced early this year and is likely to add to the absence levels in the coming
months.
• All the clinical Divisions are above target in September with the exception of Clinical Support Services and all Divisions saw an increase.
• The main reason for absence is September was gastrointestinal problems ( 158 episodes ( 20% of all absences)), followed by Muscular Skeletal
problems ( 116 episodes ( 18% of all absences )) and then coughs, cold ,flu ( 100 episodes ( 13% if all absences)) . This is reflective of the impact of
norovirus on staff.
• There has been progress in the Asset Management and WHITS Division over the last quarter where the rates have decreased by over 1% in 3
months.
• An impact has been made on the absence amongst the additional clinical services staff group with the trend showing a reduction in the last
quarter. This staff group remains challenging as it is predominantly Health Care Assistants and is the subject of more targeted actions within
Divisions.
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Workforce & Training
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Statutory and Mandatory Training
•All topics reported here are now on target to
meet the target set by the CCG’s contract query
of 95% by April 2015.
•IG training has improved from 88% to 90%.
•Please note that the thresholds for Mandatory
Training now reflect the required CCG reporting
trajectory of 95% by year end.
•76.6% of eligible staff have completed training
this month.
•Please note that the thresholds for Mandatory
Training now reflect the required CCG reporting
trajectory of 95% by year end.
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Workforce & Training
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Turnover
Overall staff turnover reduced in September to 10.09% from 10.51% which is in line with normal range for Acute
Trusts. The current overall turnover (excluding medics for the Arden, Hereford and Worcester LETC is 10.1%.
Qualified Nursing Staff turnover has reduced by 0.92% from 11.10% to 10.18%. Turnover of unqualified Nursing Staff
has reduced this month by 0.35% from 13.06% to 12.71% which is reversing the upward trend, but is still an area for
review within the Divisions.
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Finance & Contractual
Trust wide Position as at Month 6
•
Income for September has continued above Trust plan, at the highest rate for the year. Elective, Day Case and
Outpatient points of delivery were all significantly over plan, although some of this has come at considerable premium
cost. Additional activity for the A&E MIU and the ‘ramp up’ of the Oncology Centre has been included within the Trust
income for the first time, although this increased income is offset with equal additional costs.
•
Pay overspends are being driven by two main factors – firstly, the need to employ premium rate locum and agency staff
– in part to fill gaps in clinical rotas as a result of dual site working. This has been exacerbated by the continued
uncertainty around reconfiguration plans. Secondly, the current demand for both elective and emergency care has led to
the Trust having to put in place additional premium cost medical capacity through agency staff and additional waiting
list sessions, which are not allowed for within the standard tariff.
•
QIPP performance has started to fall behind plan (£0.3m) due primarily to an inability to reduce premium costs at
present due to the lack of substantive applicants The QIPP plan steps up in October which will require further savings to
be made.
•
In line with the performance management escalation framework, a number of monthly confirm and challenge sessions
have been held. Whilst assurance was received that 4 out of the 5 clinical divisions were on track to deliver their revised
forecast, it was clear that the Medicine division has an unrealistic forecast and the Executive team have agreed a range
of enhanced support measures to enable the division delivers better value for money.
•
On the back of concerns around the Medicine division’s current run rate and recovery trajectory, coupled with other
risks and pressures, it is now predicted that the £12.5m forecast deficit should be considered a best case position, with a
most likely position being a £15m forecast deficit after mitigations. In the meantime, discussions are on-going with the
TDA and CCGs about the support that can be provided to assist the Trust to maintain the required quality of care and to
deliver the expected access standards.
18
•
Based on a set of assumptions regarding activity levels and QIPP delivery, the Trust planned on a £9.8m deficit in 2014/15. Once
adjusted for the impact of non recurrent funding rebates, the Trust’s underlying deficit was £3.8m (circa 1% of turnover).
•
The Board will be aware that stepped improvements in the financial run rate were predicted from month 6, both in terms of
additional income and reductions in temporary staffing costs. However, the £1.1m variance from plan at Month 5 prompted a
series of mid year confirm and challenge meetings with divisions to assess the actions and controls to be put in place to recover
the position. As a result, plans for a revised forecast trajectory were produced for the September Trust Board, demonstrating how
the Trust could mitigate the revised ‘bottom up’ £15m forecast deficit back to a £12.5m deficit, pending any further support.
Therefore, when reviewing performance, it should be noted we are comparing to both the original TDA plan and also against the
revised trajectory.
•
The Trust had a £1.7m adverse variance in September, compared to a £0.85m original planned variance and a revised trajectory
variance of £1.5m. Therefore, as expected the Month 6 position was significantly worse than original plan and slightly worse than
the revised trajectory. This leaves the Trust with a year to date adverse variance of £2m, which can be explained as follows;
Premium costs of maintaining elective work & temporary medical staff related to vacancies and additional demand (£1.4m)
Under achievement of QIPP schemes (£0.3m)
Unfunded Governance Reviews (£0.3m)
•
•
•
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Finance & Contractual
Income & Expenditure Position
Current Month
Income & Expenditure
Operating Income
Operating Expenditure
EBITDA
Dep., Int. & Div.
Surplus/(Deficit)
Year to Date
Full Year
Full Year
Plan
Actual
Var
Plan
Actual
Var
TDA Plan
Plan
Forecast
Var
£000s
£000s
£000s
£000s
£000s
£000s
£000s
£000s
£000s
£000s
29,546
30,654
(28,423) (30,388)
1,123
266
(1,973) (1,972)
(850) (1,706)
1,108 175,986 179,444
(1,965) (172,101) (177,534)
(857)
3,885
1,910
1 (11,809) (11,808)
(856) (7,924) (9,899)
3,458 350,318 353,268 363,160
9,892
(5,434) (336,676) (339,436) (354,560) (15,124)
(1,976)
13,642
13,832
8,600 (5,231)
1 (23,412) (23,602) (23,601)
1
(1,975) (9,770) (9,770) (15,000) (5,230)
20
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Finance & Contractual
CIP Delivery
TACO
Clinical Support
Headroom
Target
5,539,714
3,456,974
2,410,270
3,461,516
2,246,331
Asset Mgmt, IT &
Corporate
2,885,196
Division
Medicine
Surgery
Women & Children
Trustwide
Total
20,000,000
Base Target
4,343,136
2,710,267
1,889,651
2,713,829
1,761,123
2,261,994
967,000
16,647,000
In year Plan
4,315,601
2,124,776
688,917
2,236,178
1,426,721
5,101,568
0
15,893,761
PIDs in Progress
1,866,982
100,001
301,210
42,000
402,500
118,750
1,345,000
4,176,442
YTD Plan
(M6)
1,503,321
700,844
292,823
961,165
510,916
2,455,115
0
6,424,185
YTD Actual
(M6)
1,021,736
884,708
313,712
1,004,746
497,267
2,450,116
0
6,172,284
Variance YTD
Actual to Plan
-481,585
183,863
20,889
43,581
-13,648
-5,000
0
-251,900
Full Year
Forecast
4,090,016
2,250,185
701,650
2,315,912
1,685,966
5,086,652
516,620
16,647,000
% Forecast v
Base Target
94%
83%
37%
85%
96%
225%
53%
100%
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Finance & Contractual
Activity
Daycase activity
Elective activity
Forecast based upon
activity up to 12th Oct
5,000
Forecast based upon
activity up to 12th Oct
1,200
1,100
4,500
1,000
4,000
900
3,500
800
3,000
700
600
2,500
Apr
May
Jun
2014/15 Actual - Private
Jul
Aug
Forecast
Sep
Oct
Nov
2014/15 Actual
Dec
Jan
2013/14 Actual
Non Elective - Emergency activity - Excluding Paed/Maternity
Feb
Apr
Mar
May
Jun
2014/15 Actual - Private
2014/15 Plan
Jul
Forecast
Sep
Oct
Nov
2014/15 Actual
Dec
Jan
2013/14 Actual
A&E activity
Forecast based upon
activity up to 12th Oct
4,100
Aug
Feb
Mar
2014/15 Plan
Forecast based upon
activity up to 12th Oct
14,000
3,700
12,000
3,300
10,000
2,900
8,000
2,500
Apr
May
Jun
2014/15 Actual
Jul
Aug
Forecast
Sep
Oct
Nov
2013/14 Actual
Dec
Jan
Feb
2014/15 Plan
Mar
Apr
May
Jun
2014/15 Actual
Jul
Aug
Forecast
Sep
Oct
Nov
2013/14 Actual
Dec
Jan
Feb
Mar
2014/15 Plan
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