Transcript Performance Management Summary December 2010

REPORT STATUS: OPEN
6.0
BOARD OF DIRECTORS’ MEETING – 26th September 2012
Report Title: Performance Management Report Summary
Report From: Robert Harrison, Director of Performance and Delivery
Report Purpose: For information
1.
Background
This report summarises HDFT’s latest performance position – based on key performance indicators used by the Department of
Health, Monitor and the Care Quality Commission. The report also looks at locally defined performance measures and presents a
summary of the latest activity position for August.
2.
Key messages for August 2012
Provisional data indicates that the Trust achieved all of the RTT 18 weeks standards and all Cancer Waiting Times standards in
August.
There was one additional case of hospital acquired C-difficile reported in August, bringing the year to date total to 6 cases. There
have been no further cases of MRSA recorded this year, following the 1 case reported in May.
SINAP (Stroke Improvement National Audit Programme) performance has improved with an overall score of 82.5% in August.
HPV immunisation remains on target and ahead of last year’s position.
3.
Recommendations/ Next Steps
That the Board of Directors note the information provided in the report.
Performance Framework 2012/13
•
The key performance indicators are based on the Department of Health 2012/13 performance framework, the 2012/13
Monitor Compliance Framework and a number of supporting performance measures.
Performance Highlights
•
Provisional data indicates that the Trust achieved all of the RTT 18 weeks standards in August.
•
Provisional data indicates the Trust has achieved all 8 Cancer Waiting Times standards in August and Q2 to date.
•
SINAP (Stroke Improvement National Audit Programme) performance continues to improve with an overall score of 82.5%
in August.
•
There was one additional case of hospital acquired C-difficile reported in August, bringing the year to date total to 6 cases.
There have been no further cases of MRSA recorded this year, following the 1 case reported in May.
•
Provisional data suggests that Stroke performance (the percentage of stroke patients who spend over 90% of their stay on
the Stroke unit) was at 96% in August against an 80% target.
•
HPV immunisation remains on target and ahead of last year’s position.
•
The Trust reported no mixed sex accommodation breaches for August.
•
The 5 key Emergency Department clinical quality indicators continue to be achieved.
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3
2012/13 Performance Framework
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Community Services Standards Focus
HPV Immunisation Cohort 9 (Year 8 11/12)
The percentage for Dose 1 remains at 92% and the percentage for Dose
2 has increased to 91%. As in 2011 Dose 3 began in March and this
month is at 88%, compared to 85% in August 2011.
Delivery of Community Equipment within 7 Working Days
The first graph shows the percentage of equipment delivered within 7
working days in the month for each store across both health and
social care (excluding non-standard equipment). The percentage
delivered in 7 working days increased in August for Harrogate and
decreased for York, Scarborough and Colburn stores. The second
graph compares the total volume of deliveries by store.
Out of Hours Service (OOH) Data Quality
Work continues with YAS (Yorkshire Ambulance Service) to resolve the
definitional issues with the data from the Adastra system, particularly
around the reporting of call start and stop times which affect the
performance calculations. In the meantime, the data reported this month
remains unvalidated and is reported as per the figures received from
YAS.
Although the data definitional issues are not resolved, the Trust is
working with the local CCG (Clinical Commissioning Group) to review
the performance against the national quality requirements and is putting
actions in place to address performance concerns.
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Acute Indicators
Referral to Treatment (RTT)
Performance
The Monitor compliance framework for 2012/13 has
amended the criteria for RTT performance reporting.
Trusts are now only required to report the aggregate
percentage for all admitted, non-admitted and open
pathways within 18 weeks, with the specified targets
for each pathway set at 90%, 95%, and 92%
respectively. The Trust continues to perform well
against each of these targets.
Delivery in all Specialties
As part of the Department of Health Performance
Framework for 2012/13, Trusts are required to report
on the number of specialties where standards are not
delivered. This covers admitted, non-admitted and
incomplete pathways. All specialties have achieved the
18 week standard in August.
Referral to Treatment (RTT) for Allied Health
Professionals (AHPs)
The scope of the 18 weeks target now includes
pathways delivered by AHPs, as well as consultant led
pathways. The Trust is working towards being able to
measure and monitor RTT waiting times for these
pathways.
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Acute Activity
New Outpatients
New outpatient attendances for August were below profile by
4.9%, (5,759 vs. 6,055). Consultant led attendances were 7.8%
below profile and non-consultant led attendances were 1.2%
over profile. However, the year to date position demonstrates
that all new outpatient activity is 1.1% above the profile (29,356
vs. 29,039).
Follow Up Outpatients
Overall, follow up outpatient attendances were 2.5% below
profile for August (12,868 vs. 13,202). Consultant led
attendances were 5.2% below profile and non-consultant led
attendances were 2.3% over profile. The total number of follow
up attendances in 2012/13 to date is 2.4% above profile
(64,863 vs. 63,319).
Elective Admissions
Elective admissions were 13.2% below plan in August (2,357
vs. 2,717) – inpatient admissions were 22.4% below profile and
day cases were 11.7% below profile. At the end of August the
total elective activity for 2012/13 is 8.6% below profile (11,912
vs. 13,029).
Non Elective Admissions
Non elective admissions were 1.1% above plan in August
(1,397 vs. 1,382). This year to date the total number of nonelective admissions is 3.7% above profile (7,450 vs. 7,182) and
continues to remain higher than last year’s admissions.
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National Cancer Patient Experience Survey 2011/12
• The results from this year’s National Cancer Patient Experience Survey were published in August. Out of the 160 hospitals taking part,
HDFT was ranked first in the country for the second year running.
• HDFT scored “significantly better than average” for 55 out of 63 questions and no questions were rated “significantly worse than
average”.
• In addition, the trust saw improvements on last year’s score for 30 out of 63 questions.
• The survey included all adult patients admitted with a primary diagnosis of cancer during the period September to November 2011. At
HDFT, 400 eligible patients were sent a survey and 281 patients responded, giving a response rate of 76%. The national response rate
was 67%.
• The table below provides a summary of HDFT’s scores in each section of the survey.
Number of questions where HDFT’s score compared
to the national average was:
Section
Total number
of questions
Significantly
worse
HDFT score this year
compared to last
year – number of
measures with
improvement
Significantly
better
About the same
Seeing your GP
Diagnostic tests
Finding out what was wrong
Deciding the best treatment for you
Clinical Nurse Specialist
Support for people with cancer
Cancer research
Operations
Hospital doctors
Ward nurses
Hospital care and treatment
3
4
4
5
4
3
3
4
4
4
8
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
2
0
0
0
3
3
4
4
5
3
3
1
4
4
4
5
1
2
4
2
3
3
n/a
1
0
4
2
Information given to you before leaving hospital
4
0
0
4
3
Hospital care as a day patient/ outpatient
6
0
0
6
3
Care from your general practice
2
0
1
1
1
5
0
1
4
1
63
0
8
55
30
Your overall NHS care
Total
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Clinical audits and studies
National healthcare acquired infection (HCAI) and Antimicrobial Prescribing Point Prevalence Survey, 2011
• In September 2011, HDFT participated in a European point prevalence study on healthcare-associated infection (HCAI) and
antimicrobial use, which included 264 inpatients at HDFT.
• HDFT performed well when compared to other similar Trusts.
• Older patients are at greater risk of HCAI: the median age of patients in the national survey was 69, but 73 years for HDFT patients.
• Despite this, the overall prevalence of HCAI at HDFT was 5.3%, compared with 6.5% overall for NHS Trusts and 5.6% for small
acute trusts.
• Presence of invasive devices (e.g. a catheter) increases HCAI risk. HDFT patients were significantly less likely to have central or
peripheral venous catheters, but were more likely to have urinary catheters than the national average.
• One in four HDFT patients were receiving antibiotics, compared with one in three patients nationally.
• The rationale for antibiotic therapy was recorded in patients’ notes in 97% of instances, compared with 85% nationally.
Central Line Infection Rates and the “Matching Michigan” initiative
• “Matching Michigan” is a quality improvement project based on a model developed in the United States which, over 18 months, saved
around 1,500 patient lives. It took place at Intensive Care Units in Michigan and introduced technical interventions (changes in clinical
practice) and non-technical interventions (linked to leadership, teamwork and culture change), which when applied together have been
shown to significantly reduce the incidences of Central Venous Catheter bloodstream infections.
• Following the introduction of the “Matching Michigan” initiative in the intensive care unit at HDFT, there have been no reported cases of
central line infections in intensive care over the last 12 months.
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Care and Quality – Hospital Mortality Information
• The NHS Information Centre published an update of its mortality measure, the Summary Hospital Mortality Index (SHMI), in late July. A
further update is expected in October.
• HDFT’s latest SHMI score is 95.5, a slight increase from last quarter but still below the national average (100).
• Dr. Foster continue to use the Hospital Standardised Mortality Ratio (HSMR). HDFT’s current score is 101.1.
• For both measures, the national score is set at 100 – a score significantly above 100 indicates higher than expected death rates,
whereas a score significantly below 100 indicates lower than expected death rates.
• The chart below compares local trusts’ scores on the latest publically available data for both measures.
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Monitor – 2012/13 compliance framework
The Compliance Framework, published by Monitor in
March 2012, outlines the approach that will be taken to
regulating NHS Foundation Trusts in 2012/13.
Service performance will be assessed on a quarterly basis
according to a matrix, the results for the year to date are
shown in the adjacent table, where:
• Green = a score of less than 1.0
• Amber-green = a score from 1.0 to 1.9
• Amber-red = a score from 2.0 to 3.9
• Red = a score of 4.0 or more
The Trust’s Monitor rating for Q2 to date is Green.
Three quarters’ successive failure of a national
requirement and other targets weighted 1.0: Where an
NHS foundation trust fails to meet the same national
requirement or the same target weighted 1.0 for three or
more consecutive quarters, Monitor will consider red-rating
the Trust and escalation for consideration of significant
breach.
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