executive summary report to the board of directors b2... · 2015-09-11 · executive summary report...

EXECUTIVE SUMMARY

REPORT TO THE BOARD OF DIRECTORS

RECOMMENDATIONS

Tick as appropriate MeetingFinance, Performance &

Workforce CommitteeBoard of Directors

1 Approved Y/N Y

2 Date 7 September 2015 16 September 2015

3

4

5

IMPLICATIONS APPROVAL PROCESS

Subject: Integrated Performance Report

Supporting Directors:Kirsten Major, Director of Strategy & Operations; Neil Priestley, Director of Finance; Hilary Chapman, Chief Nurse; Mark Gwilliam, Director of Human Resources & OD;

David Throssell, Medical Director.

Author(s): Paul Buckley, Deputy Director of Strategy & Planning; Annette Peck, Head of Information.

Status (see footnote): D & A

PURPOSE OF THE REPORT

STH Strategic AimsTrust Executive Group

Deliver the best clinical outcomes Y

Provide patient centred services 9 September 2015

Employ caring and cared for staff

Spend public money wiselyA = Approval; A* = Approval & Requiring Board Approval; D = Debate; N = Note.

Deliver excellent research, education & innovation

To provide the Board with a detailed assessment of the performance against the agreed indicators and describe the specific actions that are under way to deliver the required standards. Supplementary to this report is the Integrated Performance Report for August, which is included because no Board meeting was held in that month.

The Board is asked to: a) Receive the Integrated Performance Reports for August and September. b) Debate the current performance against the agreed indicators. c) Review the detailed actions described within the exception reports and be assured that improvements are being made where performance is not at the required level. c) Note the deep dive topic for the October Board meeting will be Cancellations (covering operations and out-patients appointments - whether initiated by patients or the Trust).

1

BOARD OF DIRECTORS

16 SEPTEMBER 2015

2

Contents

Page

4

7

10

MSSA bacteraemia - Actual numbers 10

10

11

11

12

12

13

A&E 4 hour wait - Patients seen within 4 hours 13

14

14

Cancelled Operations - Number of operations cancelled on the day for non clinical reasons 15

Cancelled Operations - Number of patients cancelled on the day and not readmitted within 28 days 15

Cancelled Outpatients - Percentage of out-patient appointments cancelled by hospital 16

Cancelled Outpatients - Percentage of out-patient appointments cancelled by patient 16

Cancer Waits - Patients seen within 2 weeks 17

Cancer Waits - 62 days from referral to treatment (GP referral) 17

Cancer Waits - 31 day subsequent treatment (Surgery) 18

Choose & Book Utilisation - Percentage appointments booked through C&B 18

Elective inpatient activity - Variance from contract schedules 19

New outpatient attendances - Variance from contract schedules 19

Follow up op attendances - Variance from contract schedules 20

FFT Response Rates - Increased response rates for A&E 20

21

Trust Performance Report by Exception

Section

Executive Summary

Trust Performance Overview

Serious Untoward Incidents - Approved SUI report submitted within timescales

Incidents - Incidents not approved after 35 days

Average Length of Stay by Discharges - Average LOS Non Elective

Sickness Absence - All days lost as a percentage of those available

Appraisals - Completed appraisals last year

Efficiency - Variance from plan

Ambulance Turnaround - Time taken for ambulance handover of patient 15 & 30 minutes

52 week waits - Actual numbers

Directorate Dashboard

3

Executive Summary

Deliver The Best Clinical Outcomes

Employ Caring & Cared For Staff

There have been 0 cases of Trust assigned MRSA bacteraemia recorded for the month of July. The year to date total remains nil. There were 5 Trust attributable cases of MSSA bacteraemia recorded in June, which is worse than the monthly trajectory that the Trust has set itself. The

year to date performance is 17 cases of MSSA against an internal threshold of 14 cases. The Trust recorded 5 cases of C.diff for July. This is better than the monthly target of 7.25 cases. The year to date performance is 20 cases of C.diff against

an internal threshold of 26 cases and a Monitor threshold of 29. Safer staffing – overall, the actual fill rate for day shifts for Registered Nurses was 91.7% and for other care staff against t he planned levels was 101.4%. At

night these fill rates were 90.2% for registered nurses and 111.0% for other care staff. On a number of individual wards the fill rate fell below 85%. The main reasons for this are vacant posts, sickness and parenting leave above the planned level. The fill rates for Registered Nurses at night continue to be carefully monitored. The Trust, in partnership with NHS Professionals, has offered 11 Spanish nurses posts for a year on a bank only c ontract.

4 new SUIs had been reported during the period 9th June to 13th July 2015 with 9 currently being investigated. Saving Lives, Improving Mothers’ Care: the enquiry identified key topic-specific messages for care, namely: Think Sepsis; Prevention and treatment of

haemorrhage; Caring for women with Amniotic Fluid Embolism; Learning from neurological complications; Lessons for Anaesthesia ; and Caring for women with other medical and surgical complications

The report contained a gap analysis of the current position within the Trust's Maternity Services. An action plan with named responsible officers and timescales for completion of the actions has been developed. This would be monitored through the Directorate Healthcare Gove rnance Group.

The Trust was notified on 8th July 2015 of concerns regarding staffing and the impact on patient care and safety at A&E over the weekend of 4th/5th July 2015. The CQC had asked that concerns were reviewed and that they were informed of the outcome of the Trust investigation. N o patient safety concerns have been identified at this stage of the investigation.

The Health and Safety Annual Report highlighted that no enforcement actions were served on the Trust for 2014/15 and that the Health and Safety Executive (HSE) had not investigated any RIDDOR incidents reported to them. The Sharps Incident Group continued to review incidents an d ongoing improvement work continues to reduce these incidents. Two RIDDOR incidents were being investigated following a patient falls and one had been escalated as a Serious Untoward Incident (SUI). A review of the process for RIDDOR reporting was currently underway.

The Trust was recently identified as one of the top 100 Best Places to Work in the NHS by the HSJ (and one of 40 Acute Trusts). Using data compiled from the recent NHS staff survey, independent research firm Best Companies Group identified 120 top performing NHS organisations. Data was categorised into seven core areas: leadership and planning; corporate culture and communication; role satisfaction; work environment; relationship with s upervisor; training, development and resources; employee engagement and satisfaction.

Phase 2 of Listening into Action has been launched with 26 schemes in place. The recent Pass it On event from Phase 1 was fel t to be successful and market stalls from that event will be showcased at the Annual members meeting in September.

Sickness absence in July 2015 continued to rise and was 4.37% as compared with 4.31% in June resulting in a year end position as at end July of 4.27% against a target of 4%. This figure was 0.35% worse than the same period in 2014/15. Long term sickness absence continues to be of conc ern at a monthly figure of 2.59% and a year to date position of 2.68%.

The number of appraisals which have been carried out in the preceding 12 month period continue to be around 84% with the rate at the end of July 2015 standing at 83.7%. At the recent summit directorates were encouraged to ensure that all outstanding appraisals are scheduled and plans in place over the coming months to ensure that performance levels can be maintained.

Compliance with mandatory training requirements continues to improve with a level of 72.7% compliance being reported as at th e end of July against a target of 70% for quarter 1. Directorates are working towards the next quarterly target of 90%. This training is taking place at the same t ime as training associated with T3 and good progress appears to be being made.

Bank and agency spend continues to rise. The development of a standard operating procedure for the approval of agency spend h as been agreed with TEG.

4

Executive Summary

Spend Public Money Wisely

Provide Patient Centred Services

The Month 4 position shows a £6.2m (2.0%) deficit against plan. This represents a significant deterioration on the month 3 position in both value and

percentage terms. There is a significant year to-date activity under-performance of £3.6m, which is a deterioration of £1.5m in July. The under-performance is largely in

respect of elective activity, out-patients and a significantly larger than expected deduction for the MRET and emergency readmissions within 30 days. There is an over performance on non-elective activity.

There was a pay overspend of £2.2m (1.1%) in the first 4 months of the year, largely due to medical staffing pressures, and a £2.2m under delivery against efficiency plans.

Overall, Clinical Directorates reported positions £6.4m worse than their plans. With regard to Patient Service contracts, the CCG and NHS England contracts are now signed. The contract with Sheffield City Council is not agreed given

that the council has now requested further savings from the Sexual Health Service. Discussions are on-going. The key risks for the year remain contract challenges, performance penalties, delivery of the Local Quality Incentive Schemes, delivery of

activity/efficiency/financial plans, service/cost pressures and consequences of the T3 Electronic Patient Record project. There are no issues of concern at this stage in respect of the working capital position, balance sheet or capital programme. The position at the end of Month 4 is of considerable concern and action is required to improve delivery of activity, efficiency and financial plans and to

mitigate risks and maximise contingencies. The Trust wide Action Plan is largely formulated. All Directorates have submitted Recovery Plans which, if delivered, will return the Trust to at least a balanced position against plan. However, there are clearly many risks to be overcome to achieve this position.

91% of complaints were responded to within 25 working days. This is the first time the Trust target of 85% has been met in a single month since September 2014. This issue is covered in more detail as part of a deep dive.

FFT response rates for inpatients in July was 35.8%. FFT response rates for A&E in July was 19.4%. New outpatient activity was 6.5% below target in July and is 2.6% below target for the year to date. Follow up activity was 7.3% below target in July and is 2.4% below for the year to date The level of elective inpatient activity was 5.3% below target in July and is 0.6% below for the year to date. Non elective activity was 3.1% above target in July and is 1.8% above for the year to date. Accident and Emergency activity was 2.0% above target in July and is 0.9% above for the year to date. At any one time in July there were, on average, 47 patients whose discharge from hospital was delayed for non clinical reasons compared to 60 during

June. There were 85 operations cancelled on the day in July compared to 76 in June. There were 2 patients who were cancelled on the day and not readmitted

within 28 days, both were in ENT. The percentage of A&E attendances seen within 4 hours was 92.84% in July compared to 95.33% in June. The targets for Cancer waiting times are not currently being met for 2 week wait and 62 day GP referrals and for the 31 day subsequent treatment

(surgery). The percentage of first outpatient appointments made through the e-Referral Service was 24.9%.

5

Executive Summary

Deliver Excellent Research, Education & Innovation

STH performance for 2014/15 for recruitment to trials completed on target, as demonstrated by both the total number of patient accruals to our portfolio studies and the percentage of clinical trials meeting the NIHR 70 day benchmark, which is used nationally as an indicator of efficient study setup.

The number of patient accruals to portfolio adopted grant and commercial studies for 2014/15 was 7786. This was 98% of our Yo rkshire and Humber Clinical Research Network target of 7977, making STH one of the Networks top performers.

Performance for clinical trials meeting the NIHR 70 day benchmark (from receipt of a Valid Research Application to Recruitmen t of First Eligible Patient) for 2014/15 was 89%. This is significantly above the NIHR national target of 80%.

The metrics in this report reflect the overall improvement in our research performance over the last year which is the result of several factors, including; shortened R&D setup times, increased researcher awareness of the deadline to recruit the first patient to each clinical trial and researchers identifying potential participants in trials in advance of NHS permission.

Further steps to improve and maintain our research performance include the:

o implementation of the new STH Research Strategy and Performance & Operating Framework to monitor the research performance of each directorate

o award of Academic Directorate status to a total of 13 directorates based on their research strategies and research performance

o implementation of a Clinical Research Academy with University of Sheffield to increase the Trust’s research profile, with 3 f ellows from STH awarded to commence in September 2015

o implementation of a new innovation infrastructure for STH providing greater integration of our research and innovation servic es for researchers within the Trust and for improved engagement with external partners

6

Indicator Measure Standard Target Type

Current Data

Month

Month

Actual YTD Trend

Data

Quality

CQC Compliance Number of high risk indicators Actual (increase or decrease) National July H

CQC Compliance Priority banding for inspection Category 5 or 6 by CQC National August H

Monitor Compliance Continuity of Services Risk Rating Category 3 or 4 National September H

Monitor Governance Rating Compliance with Monitor defined targets Green/Amber or better National Q1 15/16 H

Hospital Mortality HSMR As expected or lower Local Jun14 - May15 H

Hospital Mortality SHMI As expected or lower Local Jan14 - Dec14 H

MRSA bacteraemia Actual numbers Zero cases Local July 0.00 0 H

MSSA bacteraemia Actual numbers Max 3.5 case a month Local July 5 17 H

C Diff Actual numbers 7.25 cases or less per month National July 5 20 H

Serious Untoward Incidents Number of serious untoward incidents (SUI) Number Local July 0 13

Serious Untoward Incidents Approved SUI Report submitted within timescales No overdue reports Local July 3

Incidents Increase in incident reporting levels Monthly increases in reporting Local July 1.50% H

Incidents Incidents not approved after 35 days Zero Local July 1010

Average LOS Elective 4.09 days (Dr Foster) Local Jun 14 to May 15 -0.40

Average LOS Non Elective 5.32 days (Dr Foster) Local Jun 14 to May 15 0.19

Staff Friends & Family Recommend as a place to be treated National Average Local Q4 14/15 78.00%

Patient Falls Number of patient falls 331 (5% reduction from 14/15) Local July 168 916 H

Never Events Number of never events Zero National July 0 2 H

Sickness Absence All days lost as a percentage of those available 4.00% Local July 4.37% 4.27% M

Appraisals Completed appraisals in last year 85% Local July 83.74% M

Mandatory Training Overall percentage of completed mandatory training 70% Local July 72.74% M

Percentage of planned shifts worked by Registered Nurses/midwives during the day 85% of planned hours or greater worked Local July 91.70% M

Percentage of planned shifts worked by Registered Nurses/midwives during the night 85% of planned hours or greater worked Local July 90.20% M

Percentage of planned shifts worked by Clinical Support Workers during the day 85% of planned hours or greater worked Local July 101.40% M

Percentage of planned shifts worked by Clinical Support Workers during the night 85% of planned hours or greater worked Local July 111.00% M

Staff Friends & Family Recommend as a place to work National Average Local Q4 14/15 70.00%

Agency spend Agency and bank spend as a percentage of total pay budget 8% Local July 6.39% M

I & E Variance from plan On plan Local July 1.99% H

Contract performance Variance from plan (£) On plan Local July -1.30% H

Efficiency Variance from plan On plan Local July -31.48% M

Cash Actual Above profile Local July H

Capital expenditure Variance from plan On plan Local Q1 15/16 1.0630155 H

Spend Public Money Wisely

Average Length of Stay (by

discharges)


Deliver The Best Clinical Outcomes

Employ Caring & Cared for Staff

Safer Staffing

7


Current Data

Month

Month

Actual YTD Trend

Data

Quality


A&E 4-hour wait Patients seen within 4 hours 95% National July 92.84% 94.1% H

>12 hr Trolley waits in A&E No. of patients waiting > 12 hours Zero National July 0 0 H

Ambulance turnaround Time taken for ambulance handover of patient 100% within 15 minutes National July 65.73% 69.40% H

Ambulance turnaround Time taken for ambulance handover of patient 0% in excess of 30 minutes National July 0.55% 0.45% H

Percentage of admitted patients treated within 18 weeks 90% National July 90.07% M

Percentage of non-admitted patients treated within 18 weeks 95% National July 96.59% M

Percentage of patients on incomplete pathways waiting less than 18 weeks 92% National July 93.66% M

52 week waits Actual numbers Zero National July 3 6 M

6 week diagnostic waiting Percentage of patients seen within 6 weeks 99% National July 99.08% M

Number of operations cancelled on the day for non clinical reasons 75 per month Local July 85 324 H

Number of patients cancelled on the day and not readmitted within 28 days Zero Local July 2 7 H

Percentage of out-patient appointments cancelled by hospital 6.1% (Nat aver 13/14) Local July 10.00% 9.86% H

Percentage of out-patient appointments cancelled by patient 6.0%(Nat aver 13/14) Local July 12.09% 12.08% H

Percentage of new out-patient appointments where patients DNA 7.0% (Nat aver 13/14) Local July 6.48% 6.54% H

Percentage of follow-up out-patient appointments where patients DNA 7.0% (Nat aver 13/14) Local July 6.21% 6.00% H

Patient seen within 2 weeks 93% National Q2 to date 92.88% H

Breast symptomatic seen within 2 weeks 93% National Q2 to date 94.59% H

62 days from referral to treatment (GP referral) 85% National Q2 to date 78.62% H

31 day first treatment 96% National Q2 to date 96.18% H

31 day subsequent treatment (Surgery) 94% National Q2 to date 93.43% H

31 day subsequent treatment (Radiotherapy) 94% National Q2 to date 99.45%

31 day subsequent treatment (Drugs) 98% National Q2 to date 100.00%

Choose & Book Utilisation Percentage appointments booked through C&B 50% Local July 24.94% 24.92%

Ethnic Origin data collection % valid ethnic group 85% National July 94.44% 94.63% H

Elective Inpatient activity Variance from contract schedules On plan Local July -5.30% -0.60% H

Non elective inpatient activity Variance from contract schedules On plan Local July 3.10% 1.80% H

New outpatient attendances Variance from contract schedules On plan Local July -6.50% -2.60% H

Follow up op attendances Variance from contract schedules On plan Local July -7.30% -2.40% H

A&E attendances Variance from contract schedules On plan Local July 1.97% 0.95% H

Complaints Percentage of complaints answered within 25 working days 85% answered within 25 days Local July 91% 75.72% M

FFT Response Rates Increased response rates for inpatient areas 30% National July 35.82% M

FFT Response Rates Increased response rates for A&E 20% National July 19.40% M

RTT information completeness 50% National Q1 15/16

Referral information completeness 50% National Q1 15/16

Activity information completeness 50% National Q1 15/16

Day surgery rates BADS - day surgery rates 88% Local July 90.28% 91% M

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard Zero National July 0 0

Community care –information

completeness

Provide Patient Centred Services

18 week waits referral to

treatment time

Cancelled Operations

Cancelled Outpatient

appointments

DNA rate

Cancer Waits

8


Current Data

Month

Month

Actual YTD Trend

Data

Quality


Total number of patient accruals to portfolio studies 7977 Regional -Y&H 14/15

70 Day Benchmark for recruitment of first patient to a clinical trial 80% National 14/15

Safety Thermometer Harm free 95% harm free National 2014 75%

Quality recommendation % staff who would recommend STH to a friend / relative for treatment 67% National 2014 0.78 M

Work recommendation % staff who would recommend STH as a place to work 61% National 2014 0.70 M

Staff Engagement Staff engagement score 3.69 weighted National 2014 3.81

Deliver Excellent Research, Education & Innovation

Recruitment to trials

Annually Reported Indicators

9


Deliver The Best Clinical Outcomes Deliver The Best Clinical Outcomes M

SS

A B

acte

raem

ia -

Actu

al num

bers

Serio

us U

nto

ward

Incid

ents

- A

ppro

ved S

UI

Report

subm

itte

d w

ithin

tim

escale

s

Key Issues During July 2015, the Trust did not meet its monthly target for MSSA, recording 5 cases against a target of 3.5. Key Actions There were no clusters of infections in individual areas. The monthly number of cases can vary; so far this year we have had 7 cases during April but only 2 during May. The actions to prevent and reduce MSSA bacteraemia are contained within the Infection, Prevention and Control Programme. Timescale October Lead Hilary Chapman, Chief Nurse

Key Issues Key Actions Timescale Ongoing Lead David Throssell, Medical Director

Key Issues In July there were 3 SUI that had not been submitted within the agreed timescale. Key Actions Two of the reports are within Cardiothoracic services and one within Respiratory medicine. Drafts of the 2 Cardiac investigations have been produced by the Clinical Director and some further changes are being made. The other report has been referred to the Clinical Director for Respiratory Medicine to consider the recommendations and actions prior to final submission

Timescale October Lead David Throssell, Medical Director

0

1

2

3

4

5

6

7

8

Apr-15 May-15 Jun-15 Jul-15

No of MSSA cases

Actual Monthly threshold

0

0.5

1

1.5

2

2.5

3

3.5

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

Approved SUI Report not submitted within timescales

Approved SUI Report not submitted within timescales

10


Deliver The Best Clinical Outcomes Deliver The Best Clinical Outcomes In

cid

ents

- I

ncid

ents

not

appro

ved a

fter

35 d

ays

Avera

ge L

ength

of

Sta

y (

LoS

) -

Avera

ge L

oS

Non E

lective

Key Issues The number of incidents reported in May and June showed two successive months of improvement. July however saw a substantial fall off. This is being investigated with individual Directorates, as the combined decline in reporting is marked. Key Actions The July figures are being interrogated to try identify the underlying cause for the months variance. Actions are ongoing to encourage reporting of incidents in a timely way. Timescale October Lead David Throssell, Medical Director

Key Issues The number of incidents not approved within 35 days has fallen significantly but remains high. Key Actions Directorates have been tasked with reducing the backlog of incidents requiring approval and have developed action plans in response Following the last SRMB a summit was held with Risk Leads from all directorates to assist them in reducing the backlog of incidents requiring approval. Many areas have diverted resources to ensure that the backlogs are managed and reduced and whilst there is a reduction progress remains very slow. Timescale October Lead David Throssell, Medical Director

-50.0%

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

% Change in incident reporting


0

500

1000

1500

2000

2500

3000

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

Incidents not approved after 35 days


Key Issues The number of incidents not approved within 35 days has fallen significantly but remains high. Key Actions Directorates have been tasked with reducing the backlog of incidents requiring approval and have developed action plans in response Following the last SRMB a summit was held with Risk Leads from all directorates to assist them in reducing the backlog of incidents requiring approval. Many areas have diverted resources to ensure that the backlogs are managed and reduced and whilst there is a reduction progress remains very slow. Timescale October Lead David Throssell, Medical Director

0

500

1000

1500

2000

2500

3000

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15



Key Issues The number of incidents reported in April was 5.2% lower than those reported in March. However, in terms of incidents reported per day - there were 68 reported per day in April compared to 69 reported per day in March. Key Actions A number of actions are underway to continue to encourage the reporting of incidents in a timely way. Timescale Ongoing Lead David Throssell, Medical Director

-0.1

-0.05

0

0.05

0.1

0.15

0.2

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15



Key Issues The non elective LoS of was 5.51 days compared to the Dr Foster benchmark of 5.32 days (based on the period June 14 to May 2015).

Key Actions

Significant and complex programmes of improvement are underway supported by Service Improvement, in priority non-elective areas with the greatest variance against Dr. Foster. Good results are being demonstrated particularly in Respiratory where LOS now continues to drop below Dr. Foster and show significantly lower than expected HSMR. Six pathway teams have now been selected for the Health Foundation Flow Programme, including COPD, Fractured Neck of Femur, and Stroke. This aims to build improvement capability at pathway level and support teams to make improvements . The Service Improvement team are facilitating the evaluation of the "Give it A Go" and "Right Good Week" where many more ward teams tested Board Rounds, Bed Wizards and other ideas that have delivered proven improvement elsewhere. The learning will be shared more widely in September and October. Operational improvements to flow, prompted through the CEO led Emergency Care Pathway Review are being progressed, including a review of the MAU model across the Trust.

Timescale October

Lead

Kirsten Major, Director of Strategy & Operations

4.95

5.15.25.35.45.55.65.75.85.9

Average LOS for non elective

Actual Target

11


Employ Caring & Cared for Staff Employ Caring & Cared for StaffS

ickness A

bsence -

All

days lo

st

as a

perc

enta

ge o

f th

ose a

vaila

ble

Appra

isals

- C

om

ple

ted a

ppra

isals

in

last

year

Key Issues The number of incidents reported in April was 5.2% lower than those reported in March. However, in terms of incidents reported per day - there were 68 reported per day in April compared to 69 reported per day in March. Key Actions A number of actions are underway to continue to encourage the reporting of incidents in a timely way. Timescale Ongoing Lead David Throssell, Medical Director

-0.1

-0.05

0

0.05

0.1

0.15

0.2

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15



Key issues The level of sickness absence continues to increase and was 4.37% in July as compared with 4.31% in June resulting in a year end position as at end July of 4.27% against a target of 4%. This figure was 0.35% worse than the same period in 2014/15. Long term sickness absence continues to be of concern at a monthly figure of 2.59% and a year to date position of 2.68%. Key Actions A review of the action plan has been shared with TEG with specific focus on whether the policy on Managing Attendance is being adhered to. Directorate action plans have also been developed with those directorates above the Trust target of 4%. These continue to be monitored through the meetings the HR team has with Care Groups each quarter. Timescale October Lead Mark Gwilliam, Director of Human Resources & OD

Key Issues The non elective LoS of was 5.51 days compared to the Dr Foster benchmark of 5.32 days (based on the period June 14 to May 2015).

Key Actions

Significant and complex programmes of improvement are underway supported by Service Improvement, in priority non-elective areas with the greatest variance against Dr. Foster. Good results are being demonstrated particularly in Respiratory where LOS now continues to drop below Dr. Foster and show significantly lower than expected HSMR. Six pathway teams have now been selected for the Health Foundation Flow Programme, including COPD, Fractured Neck of Femur, and Stroke. This aims to build improvement capability at pathway level and support teams to make improvements . The Service Improvement team are facilitating the evaluation of the "Give it A Go" and "Right Good Week" where many more ward teams tested Board Rounds, Bed Wizards and other ideas that have delivered proven improvement elsewhere. The learning will be shared more widely in September and October. Operational improvements to flow, prompted through the CEO led Emergency Care Pathway Review are being progressed, including a review of the MAU model across the Trust.

Timescale October

Lead


0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Sickness Absence

Actual Target

4.95

5.15.25.35.45.55.65.75.85.9

Average LOS for non elective

Actual Target

Key issues The level of sickness absence continues to increase and was 4.37% in July as compared with 4.31% in June resulting in a year end position as at end July of 4.27% against a target of 4%. This figure was 0.35% worse than the same period in 2014/15. Long term sickness absence continues to be of concern at a monthly figure of 2.59% and a year to date position of 2.68%. Key Actions A review of the action plan has been shared with TEG with specific focus on whether the policy on Managing Attendance is being adhered to. Directorate action plans have also been developed with those directorates above the Trust target of 4%. These continue to be monitored through the meetings the HR team has with Care Groups each quarter. Timescale October Lead Mark Gwilliam, Director of Human Resources & OD

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Sickness Absence

Actual Target

Key Issues

The cumulative position for the past twelve months at the end of July 2015 is 83.7%.

Key Actions

The target for quarter 1 was 85%, 90% by the end of quarter 2 and thereafter on an ongoing basis with a stretch target of 95%. Monthly summits continue to be held with members of the Operational Board and their representatives led by the Chief Executive with specific focus being given to directorates setting trajectories for the coming months as to how they will achieve the target position. Timescale

October

Lead

Mark Gwilliam, Director of Human Resources & OD

70.0%72.0%74.0%76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%

Appraisals

Actual Target

12


Spend Public Money Wisely Provide Patient Centred ServicesE

ffic

iency -

Varia

nce f

rom

pla

n

A&

E 4

-hour

wait -

Patie

nts

seen w

ithin

4 h

ours

Key Issues

The cumulative position for the past twelve months at the end of July 2015 is 83.7%.

Key Actions

The target for quarter 1 was 85%, 90% by the end of quarter 2 and thereafter on an ongoing basis with a stretch target of 95%. Monthly summits continue to be held with members of the Operational Board and their representatives led by the Chief Executive with specific focus being given to directorates setting trajectories for the coming months as to how they will achieve the target position. Timescale

October

Lead

Mark Gwilliam, Director of Human Resources & OD

Key Issues

Directorates have underperformed significantly at M4, with a position of £2.23m or 27% behind plan. Directorates continue to forecast a better year end position, with less than 3% under-delivery expected.

Key Actions All 4 Workstream Executive Directors and Leads are progressing the following actions: • Improved support to aid pace of delivery on specific cross Trust projects • Increased work with directorates to improve local rigour of local PMOs • Increased focus on benefits realisations for big win areas • Promotion of a bolder mind-set, a more experimental culture and additional

focus on unwarranted variation • Series of supporting activities are planned for 16/17 planning, building on the

evaluation of activities during 15/16. All directorates have submitted recovery plans and directorate control totals have been agreed. Special Measures Performance meetings continue with Directorates as part of the Performance Management Framework. Timescale

September

Lead

Neil Priestley, Director of Finance

70.0%72.0%74.0%76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%

Appraisals

Actual Target

0

5000

10000

15000

20000

25000

30000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Efficiency Programme

F/Outturn Actual to Date 2014/15 Plan Forecast Outturn Tracker

Key Issues

Directorates have underperformed significantly at M4, with a position of £2.23m or 27% behind plan. Directorates continue to forecast a better year end position, with less than 3% under-delivery expected.

Key Actions All 4 Workstream Executive Directors and Leads are progressing the following actions: • Improved support to aid pace of delivery on specific cross Trust projects • Increased work with directorates to improve local rigour of local PMOs • Increased focus on benefits realisations for big win areas • Promotion of a bolder mind-set, a more experimental culture and additional

focus on unwarranted variation • Series of supporting activities are planned for 16/17 planning, building on the

evaluation of activities during 15/16. All directorates have submitted recovery plans and directorate control totals have been agreed. Special Measures Performance meetings continue with Directorates as part of the Performance Management Framework. Timescale

September

Lead

Neil Priestley, Director of Finance

0

5000

10000

15000

20000

25000

30000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Efficiency Programme

F/Outturn Actual to Date 2014/15 Plan Forecast Outturn Tracker

Key Issues In July performance was 94.49%, which is the lowest since April 15. The percentage of patients which take more than 4 hours from arrival to admission or discharge has increased since last month. The delay in managing patients through the department can be linked to departmental crowding, extremely high numbers of attendances with high levels of acuity, increases in frailty patients admissions via A&E, high numbers of ambulance arrivals and shortages in clinical capacity. Key Actions The key actions are being developed through the Emergency Care Pathway Workstreams. These are reviewing ED staffing levels and deployment, how the Trust provides assessment and ambulatory care services and treatment and discharge. The recommendations from the workstreams will be described in a summary document in September. In the meantime all specialties and Clinical Operations continue to maximise efforts to maintain flow. Timescale September Lead Kirsten Major, Director of Strategy & Operations

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%

A&E 4 hour wait

% seen within 4 hours Target

13


Provide Patient Centred Services Provide Patient Centred ServicesA

mb

ula

nce T

urn

aro

und -

Tim

e t

aken f

or

am

bula

nce h

andover

of

patie

nt

- 15 m

inute

s &

30 m

inute

s

52 w

eek w

aits -

Actu

al num

bers

Key Issues In July performance was 94.49%, which is the lowest since April 15. The percentage of patients which take more than 4 hours from arrival to admission or discharge has increased since last month. The delay in managing patients through the department can be linked to departmental crowding, extremely high numbers of attendances with high levels of acuity, increases in frailty patients admissions via A&E, high numbers of ambulance arrivals and shortages in clinical capacity. Key Actions The key actions are being developed through the Emergency Care Pathway Workstreams. These are reviewing ED staffing levels and deployment, how the Trust provides assessment and ambulatory care services and treatment and discharge. The recommendations from the workstreams will be described in a summary document in September. In the meantime all specialties and Clinical Operations continue to maximise efforts to maintain flow. Timescale September Lead Kirsten Major, Director of Strategy & Operations

Key Issues

Key Actions

Timescale September

Lead


78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

18 week wait - admitted pathways

Actual Target

Key Issues The percentage of 999 arrivals that are clinically handed over within 15 minutes of arriving in the Emergency Department has decreased over the last two months with July ending on 66.28%. The number of clinical handovers which take more than 30 minutes has significantly fallen since the winter but has slightly increased from June which finished on 0.36% to July 0.55%. The delay in clinical handover times, in excess of 30 minutes can be linked to crowding in the Emergency Department and inability to create trolley space for new arrivals. Key Actions There is continued audit and challenge of C3 data for all clinical handovers in excess of 30 minutes to ensure data is robust. Wider work on flow both within the Emergency Department and on the admitting units will link into creating capacity for prompt handover at point of arrival. A re-focus on the clinical handover times, lead from the Emergency Medicine Directorate group is ongoing together with regular attendance at YAS joint forum meetings Timescale September Lead Kirsten Major, Director of Strategy & Operations

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

60.0%

62.0%

64.0%

66.0%

68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

YAS/STHFT 999 Turnaround performance

%age handover in 15m %age handovers over 30 min

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%

A&E 4 hour wait

% seen within 4 hours Target

Key Issues

Key Actions

Timescale September

Lead


78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

18 week wait - admitted pathways

Actual Target

Key Issues The percentage of 999 arrivals that are clinically handed over within 15 minutes of arriving in the Emergency Department has decreased over the last two months with July ending on 66.28%. The number of clinical handovers which take more than 30 minutes has significantly fallen since the winter but has slightly increased from June which finished on 0.36% to July 0.55%. The delay in clinical handover times, in excess of 30 minutes can be linked to crowding in the Emergency Department and inability to create trolley space for new arrivals. Key Actions There is continued audit and challenge of C3 data for all clinical handovers in excess of 30 minutes to ensure data is robust. Wider work on flow both within the Emergency Department and on the admitting units will link into creating capacity for prompt handover at point of arrival. A re-focus on the clinical handover times, lead from the Emergency Medicine Directorate group is ongoing together with regular attendance at YAS joint forum meetings Timescale September Lead Kirsten Major, Director of Strategy & Operations

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

60.0%

62.0%

64.0%

66.0%

68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

YAS/STHFT 999 Turnaround performance

%age handover in 15m %age handovers over 30 min

Key Issues At the end of July there were 3 patients who were waiting over 52 weeks. These were in General Surgery, Spinal Surgery and Upper GI. The Spinal Surgery patient was referred from Rotherham when their waiting time was already at 70 weeks. The patient's pathway ended on 3/9/15. The General Surgery patient is the same one as was reported at the end of July and had asked for their treatment to be delayed. The Upper GI patient had an incorrect clock stop which was then removed. The patient has a complex pathway and does not yet have a date for treatment. Key Actions Directorates are now required to provide detailed information on all patients who are waiting longer than 26 weeks and highlight the action that is being taken. The majority of the long waiters that are now being reported are due to previous errors in recording the status of the patient's pathway. Now that directorates have been charged with checking all clock stops on an ongoing basis the number of long waiters revealed in this way should disappear. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0

5

10

15

20

25

No of 52 week waiters


14


Provide Patient Centred Services Provide Patient Centred ServicesC

ancelle

d O

pera

tio

ns -

Num

ber

of

opera

tio

ns c

ancelle

d o

n t

he d

ay f

or

non-c

linic

al re

asons

Cancelle

d O

pera

tio

ns -

Num

ber

of

patie

nts

cancelle

d o

n t

he d

ay a

nd n

ot

readm

itte

d w

ithin

28 d

ays

Key Issues At the end of July there were 3 patients who were waiting over 52 weeks. These were in General Surgery, Spinal Surgery and Upper GI. The Spinal Surgery patient was referred from Rotherham when their waiting time was already at 70 weeks. The patient's pathway ended on 3/9/15. The General Surgery patient is the same one as was reported at the end of July and had asked for their treatment to be delayed. The Upper GI patient had an incorrect clock stop which was then removed. The patient has a complex pathway and does not yet have a date for treatment. Key Actions Directorates are now required to provide detailed information on all patients who are waiting longer than 26 weeks and highlight the action that is being taken. The majority of the long waiters that are now being reported are due to previous errors in recording the status of the patient's pathway. Now that directorates have been charged with checking all clock stops on an ongoing basis the number of long waiters revealed in this way should disappear. Timescale October Lead Kirsten Major, Director of Strategy & Operations

Key Issues In July there were 85 operations cancelled on the day for non clinical reasons compared to 76 in June, 89 in May, 74 in April and 120 in July 2014. This is 0.68% of all operations. Key Actions There have been 324 operations cancelled on the day for non clinical reasons so far this year compared to 334 in the same period last year. The specialities that accounted for more than 5% of the total cancellations were the same as last month; Cardiology, Cardiothoracic, Ophthalmology, Orthopaedics, Gastroenterology and Urology. The main reasons again were a lack of beds (general & critical care), lack of theatre time and more urgent case took precedence. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0

5

10

15

20

25



0

20

40

60

80

100

120

140

Operations cancelled on the day for non clinical reasons

Actual Target

Key Issues In July there were 85 operations cancelled on the day for non clinical reasons compared to 76 in June, 89 in May, 74 in April and 120 in July 2014. This is 0.68% of all operations. Key Actions There have been 324 operations cancelled on the day for non clinical reasons so far this year compared to 334 in the same period last year. The specialities that accounted for more than 5% of the total cancellations were the same as last month; Cardiology, Cardiothoracic, Ophthalmology, Orthopaedics, Gastroenterology and Urology. The main reasons again were a lack of beds (general & critical care), lack of theatre time and more urgent case took precedence. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0

20

40

60

80

100

120

140

Operations cancelled on the day for non clinical reasons

Actual Target

Key Issues In July there was 1 operation cancelled on the day for non clinical reasons that was not readmitted within 28 days. This was in ENT. The patient could not be readmitted within 28 days as they were a robot case and the list is only available to ENT once a month. The patient was cancelled in May and the robot list in June was already booked with a cancer case, so the patient had to be booked into the list in July. Key Actions The Robot User Group have been made aware of this and will be reviewing the capacity required for robotic cases to ensure that cancellations are minimised and where they do occur all are readmitted within 28 days. Timescale October Lead Kirsten Major, Director of Strategy & Operations

15



ancelle

d O

utp

atie

nt

Appoin

tments

- P

erc

enta

ge o

f outp

atie

nt

appoin

tments

cancelle

d b

y h

ospital

Cancelle

d O

utp

atie

nt

Appoin

tments

- P

erc

enta

ge o

f outp

atie

nt

appoin

tments

cancelle

d b

y p

atie

nt

Key Issues In July there was 1 operation cancelled on the day for non clinical reasons that was not readmitted within 28 days. This was in ENT. The patient could not be readmitted within 28 days as they were a robot case and the list is only available to ENT once a month. The patient was cancelled in May and the robot list in June was already booked with a cancer case, so the patient had to be booked into the list in July. Key Actions The Robot User Group have been made aware of this and will be reviewing the capacity required for robotic cases to ensure that cancellations are minimised and where they do occur all are readmitted within 28 days. Timescale October Lead Kirsten Major, Director of Strategy & Operations

Key Issues The percentage of outpatient appointments cancelled by the hospital rose slightly in July to 10.0% compared to 9.53% in June. As in previous months the reasons for the cancellations are that no doctors were available either through annual leave or changes in staffing levels or rotas. There were 17,464 clinic lists planned for July of which 3,034 were cancelled. Key Actions The continued implementation of the Access Policy will help to reduce cancellations due to clinical staff leave. Directorates will be asked to investigate the reasons for cancellations outside of the policy in more detail. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Outpatient Appointments cancelled by hospital

Actual Target

Key Issues The percentage of outpatient appointments cancelled by the hospital rose slightly in July to 10.0% compared to 9.53% in June. As in previous months the reasons for the cancellations are that no doctors were available either through annual leave or changes in staffing levels or rotas. There were 17,464 clinic lists planned for July of which 3,034 were cancelled. Key Actions The continued implementation of the Access Policy will help to reduce cancellations due to clinical staff leave. Directorates will be asked to investigate the reasons for cancellations outside of the policy in more detail. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Outpatient Appointments cancelled by hospital

Actual Target

Key Issues The number of outpatient appointments cancelled by the patient fell slightly in July to 12.09% compared to 12.27% in June. Key Actions The increased use of the e-Referrals service and the continued implementation of the Access Policy, which states that the date and time of the appointment should be agreed with the patient will help to reduce the number of cancellations. Directorates will be asked to provide a briefing on the extent to which full and partial booking has been implemented in their areas. Timescale October Lead Kirsten Major, Director of Strategy & Operations

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Outpatient Appointments cancelled by patient

Actual Target

16



ancer

Waits -

Patie

nts

seen w

ithin

2 w

eeks

Cancer

Waits -

62 d

ays f

rom

refe

rral to

tre

atm

ent

(GP

refe

rral)

Key Issues The number of outpatient appointments cancelled by the patient fell slightly in July to 12.09% compared to 12.27% in June. Key Actions The increased use of the e-Referrals service and the continued implementation of the Access Policy, which states that the date and time of the appointment should be agreed with the patient will help to reduce the number of cancellations. Directorates will be asked to provide a briefing on the extent to which full and partial booking has been implemented in their areas. Timescale October Lead Kirsten Major, Director of Strategy & Operations

Key Issues The performance for Q2 2015/16 (as at 01/09/15) is 92.9% (threshold 93%) and consists of 2921 closed pathways of which 207 are breaches . The main cancer sites below the threshold are Gynaecology, Lower GI, Skin, and Upper GI. The reason for the breaches in Q2 2015/16 is attributed to patient choice Key Actions All teams have been asked to offer a first 2 Week Wait appointment by day 7 in the pathway. The offer of a first appointment is monitored by the Cancer Management Team on a weekly basis and flagged to site specific teams who are underperforming for action which includes a requirement for a review of capacity. Administrative staff have been reminder to offer multiple appointments to patients within 14 days of receipt of referral. All cancer waiting times performance is circulated throughout the organisation on a weekly basis. Teams have been asked to ensure cancer tracking is up to date on InfoFlex to ensure an accurate performance is communicated. Timescale September Lead Kirsten Major, Director of Strategy & Operations

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Outpatient Appointments cancelled by patient

Actual Target

Key Issues The performance for Q2 2015/16 (as at 01/09/15) is 92.9% (threshold 93%) and consists of 2921 closed pathways of which 207 are breaches . The main cancer sites below the threshold are Gynaecology, Lower GI, Skin, and Upper GI. The reason for the breaches in Q2 2015/16 is attributed to patient choice Key Actions All teams have been asked to offer a first 2 Week Wait appointment by day 7 in the pathway. The offer of a first appointment is monitored by the Cancer Management Team on a weekly basis and flagged to site specific teams who are underperforming for action which includes a requirement for a review of capacity. Administrative staff have been reminder to offer multiple appointments to patients within 14 days of receipt of referral. All cancer waiting times performance is circulated throughout the organisation on a weekly basis. Teams have been asked to ensure cancer tracking is up to date on InfoFlex to ensure an accurate performance is communicated. Timescale September Lead Kirsten Major, Director of Strategy & Operations

Key Issues The performance for Q2 2015/16 (as at 01/09/15) is 80.6% (threshold 85%) and consists of 281.5 closed pathways of which 54.5 are breaches. The cancer sites that are currently below the threshold are, Head & Neck, Lower GI, Lung, Sarcoma, Upper GI, other & Urology. The main reasons for the breaches in Q2 2015/16 are attributed to: 1. Inter-Trust referrals received late (day 39 onwards). The Trusts performance for non-shared pathways in Q2 to date is 89.9%. 2. Health care provider initiated delay to diagnostic tests. The majority of these delays were attributed to referring providers. 3. Complex diagnostic pathways. Key Actions All teams have been asked to expedite all pathways and provide an analysis of performance as well as a remedial action plan. A 'Surgical cancellations on the day policy' is operational across the Trust. All cancer waiting times performance is circulated throughout the organisation on a weekly basis for information and action. Timescale September Lead Kirsten Major, Director of Strategy & Operations

17



ancer

Waits -

31 d

ay s

ubsequent

treatm

ent

(surg

ery

)

Choose &

Book U

tilis

atio

n -

Perc

enta

ge a

ppoin

tments

booked t

hro

ugh C

&B

Key Issues The performance for Q2 2015/16 (as at 01/09/15) is 80.6% (threshold 85%) and consists of 281.5 closed pathways of which 54.5 are breaches. The cancer sites that are currently below the threshold are, Head & Neck, Lower GI, Lung, Sarcoma, Upper GI, other & Urology. The main reasons for the breaches in Q2 2015/16 are attributed to: 1. Inter-Trust referrals received late (day 39 onwards). The Trusts performance for non-shared pathways in Q2 to date is 89.9%. 2. Health care provider initiated delay to diagnostic tests. The majority of these delays were attributed to referring providers. 3. Complex diagnostic pathways. Key Actions All teams have been asked to expedite all pathways and provide an analysis of performance as well as a remedial action plan. A 'Surgical cancellations on the day policy' is operational across the Trust. All cancer waiting times performance is circulated throughout the organisation on a weekly basis for information and action. Timescale September Lead Kirsten Major, Director of Strategy & Operations

Key Issues The utilisation rate of Choose and Book in Sheffield is currently one of the lowest in the country. The number of referrals being sent to the Trust through Choose and Book (C&B) by Sheffield GPs is gradually increasing. It was at 12.9% in April and had increased to 18.9% in January and again in February to 20.62%. This is still a long way short of the overall aim to achieve all referrals being sent through C&B. Key Actions A joint project between the Trust and Sheffield CCG has been underway since June with the aim of increasing the utilisation rate to 85% by June 15. All GP practices have produced a plan to increase their use of C&B. Refresher training has been provided for practices. Within the Trust all directorates have reviewed their entries on the Directory of Services except Urology, Gastroenterology and Colorectal Surgery. Refresher training has been given to all areas and work is nearly completed to ensure that all available slots are released to C&B for GPs to book into. All of the Trust's outpatient services will be available through C&B by April. The new arrangements for the MSK service will require GPs to refer through C&B and this will significantly increase the utilisation rate. Timescale On going Lead

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

% appointments made through Choose & Book

Actual Target

Key Issues

The performance for Q2 2015/16 as at 07/09/15 is 94.3% (threshold 94%) and consists of 211 closed pathways of which 12 are breaches The main cancer site below the threshold is Urology. Sarcoma and Lower GI cancer sites contribute to a small degree. A report has been included due to the fragile position. The main reasons for the breaches in Q2 2015/16 include: Elective capacity inadequate (Urology) and treatment delayed due to medical reasons.

Key Actions

Urology are working through a recovery plan which includes a pilot of 3 case day theatre lists and fortnightly Saturday operating lists. All Cancer Teams are required to submit a contingency plan for activity and MDT planning for public holidays. A 'Surgical cancellations on the day policy' is operational across the Trust. Staff continue to be vigilant regarding escalation of potential breaches; the prompt recording of treatments and production of breach reports. Cancer waiting times performance is circulated on a weekly basis throughout the organisation. Teams have been asked to ensure cancer tracking is up to date on InfoFlex to ensure an accurate performance is communicated.

Timescale

September

Lead



0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Actual Target

Key Issues

The performance for Q2 2015/16 as at 07/09/15 is 94.3% (threshold 94%) and consists of 211 closed pathways of which 12 are breaches The main cancer site below the threshold is Urology. Sarcoma and Lower GI cancer sites contribute to a small degree. A report has been included due to the fragile position. The main reasons for the breaches in Q2 2015/16 include: Elective capacity inadequate (Urology) and treatment delayed due to medical reasons.

Key Actions

Urology are working through a recovery plan which includes a pilot of 3 case day theatre lists and fortnightly Saturday operating lists. All Cancer Teams are required to submit a contingency plan for activity and MDT planning for public holidays. A 'Surgical cancellations on the day policy' is operational across the Trust. Staff continue to be vigilant regarding escalation of potential breaches; the prompt recording of treatments and production of breach reports. Cancer waiting times performance is circulated on a weekly basis throughout the organisation. Teams have been asked to ensure cancer tracking is up to date on InfoFlex to ensure an accurate performance is communicated.

Timescale

September

Lead


Key Issues The percentage of appointments made through C&B fell slightly from 26% in June to 24.9% in July. There were significant 'teething problems 'with the introduction of the new e-Referrals service (C&B replacement) that made it difficult for GPs to use the system. Key Actions The initial problems have been resolved but there are still issues with the new system. Two workshops are being held in September with representatives from GP practices and NHS Sheffield to look at progress so far in increasing the usage of the e-Referrals system , to look at the lessons learnt and agree the next steps. Timescale October Lead Kirsten Major, Director of Strategy and Operations

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


Actual Target

18


Provide Patient Centred Services Provide Patient Centred ServicesE

lective I

npatie

nt

Activity -

Varia

nce f

rom

contr

act

schedule

s

New

Outp

atie

nt

Att

endances -

Varia

nce f

rom

pla

n

Key Issues The percentage of appointments made through C&B fell slightly from 26% in June to 24.9% in July. There were significant 'teething problems 'with the introduction of the new e-Referrals service (C&B replacement) that made it difficult for GPs to use the system. Key Actions The initial problems have been resolved but there are still issues with the new system. Two workshops are being held in September with representatives from GP practices and NHS Sheffield to look at progress so far in increasing the usage of the e-Referrals system , to look at the lessons learnt and agree the next steps. Timescale October Lead Kirsten Major, Director of Strategy and Operations


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Actual Target

Key Issues Elective activity was 5.3% below target in July but remains above target (0.6%)for the year to date. Key Actions The pattern of activity across the months this year is similar to last. The target for July is the highest for any month of the year as it is based on working days and there were 23 in July. One of the reasons for under performance is that level of consultant leave was high this has a significant impact on activity levels. Directorates are expecting to recover the position towards the end of the quarter. Timescale September Lead Kirsten Major, Director of Strategy and Operations

8000

9000

10000

11000

12000

13000

14000

Elective Spells

Actual Target

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


Actual Target


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Actual Target

Key Issues Elective activity was 5.3% below target in July but remains above target (0.6%)for the year to date. Key Actions The pattern of activity across the months this year is similar to last. The target for July is the highest for any month of the year as it is based on working days and there were 23 in July. One of the reasons for under performance is that level of consultant leave was high this has a significant impact on activity levels. Directorates are expecting to recover the position towards the end of the quarter. Timescale September Lead Kirsten Major, Director of Strategy and Operations

8000

9000

10000

11000

12000

13000

14000

Elective Spells

Actual Target

Key Issues New outpatient attendances were 6.5% below target in July and are 2.6% below target for the year to date. Key Actions The target for July is the highest for any month in the year due to the high number of working days (23). The target per working day has risen from 1,168 in 14/15 to 1,259 this year. The delivery of some this increase is dependent on additional consultant appointments scheduled for later in the year. Directorates are anticipating recovering the position towards the end of the quarter. Timescale September Lead Kirsten Major, Director of Strategy and Operations

20000

21000

22000

23000

24000

25000

26000

27000

28000

29000

30000

New attendances

Actual Target

19


Provide Patient Centred Services Provide Patient Centred ServicesF

ollo

w U

p O

utp

atie

nt

Att

endances -

Varia

nce f

rom

pla

n

FF

T R

esponse R

ate

s -

Incre

ase r

esponse r

ate

s f

or

A&

E

Key Issues New outpatient attendances were 6.5% below target in July and are 2.6% below target for the year to date. Key Actions The target for July is the highest for any month in the year due to the high number of working days (23). The target per working day has risen from 1,168 in 14/15 to 1,259 this year. The delivery of some this increase is dependent on additional consultant appointments scheduled for later in the year. Directorates are anticipating recovering the position towards the end of the quarter. Timescale September Lead Kirsten Major, Director of Strategy and Operations


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Actual Target

Key Issues The Trust failed to achieve the internal response rate target for Friends and Family Test for Accident and Emergency by 0.6%. Key Actions The response rate for Accident and Emergency has been consistently above 20% for many months. There are no issues identified to explain why the response rate has fallen below 20%. The response rate will be monitored over the next few months. If it continues to fall we will work with our survey partner, Healthcare Communications, on ways to increase the response rate. Timescale October Lead Hilary Chapman, Chief Nurse

2000021000220002300024000250002600027000280002900030000

New attendances

Actual Target


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%



Actual Target

Key Issues Follow up outpatient attendances were 7.3% below target in July and are 2.4% below for the year to date. Key Actions As with new attendances the target for July is the highest for any month in the year. The target per working day has risen from 2,972 in 14/15 to 3,073 this year. Directorates are anticipating recovering the position towards the end of the quarter. Timescale September Lead Kirsten Major, Director of Strategy and Operations

30000

35000

40000

45000

50000

55000

60000

65000

70000

75000

Follow up attendances

Actual Target17

18

19

20

21

22

23

24

January February March April May June July

A&E Response Rate %

20


Indicator MeasureDiab &

Endo

Emerg

MedGastro Pharm Resp Med

Integ

Comm

Care

GSMPrim Care

& Int/Serv

Rehab &

Pall Care

Oral &

Dental ENT Neuro Ophthal

MRSA bacteraemia Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0

MSSA bacteraemia Actual numbers 0 0 0 0 0 0 1 0 0 0 0 0 0

C Diff Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0

Serious Untoward Incidents Approved SUI Report submitted within timescales 0 0 0 0 0 0 0 0 0 0 0 0 0

Serious Untoward Incidents Number of Serious Untoward Incidents 0 0 0 0 0 0 0 0 0 0 0 0 0

Incidents Increase in incident reporting levels (increase or decrease from previous month) -32 -156 -31 -15 -56 -153 -143 -5 -11 -22 -12

Incidents Incidents not approved after 35 days 22 129 40 25 65 140 100 13 12 48 21

Average LOS Elective 1.15 -2.60 -1.80 -0.86 14.10 0.33 -0.10 -2.32 -0.50

Average LOS Non Elective 0.90 -2.78 1.18 -0.23 3.60 -0.61 -0.30 -0.15 -0.50

Patient Falls Number of patient falls 0 0 0 0 0 9 57 1 2 17 1

Never Events Number of never events 0 0 0 0 0 0 0 0 0 0 0

Sickness Absence All days lost as a percentage of those available 5.51% 3.57% 4.28% 3.73% 6.17% 3.89% 5.28% 3.57% 4.43% 3.30% 3.81% 4.03%

Appraisals Completed appraisal in last year 84.62% 76.71% 88.24% 93.24% 74.81% 85.44% 60.34% 88.20% 94.12% 79.55% 83.70% 90.32%

Mandatory Training Overall percentage of completed mandatory training 71.00% 60.53% 63.35% 81.89% 66.69% 67.66% 50.17% 74.31% 73.09% 67.98% 76.55% 85.66%

Agency spend Agency and bank spend as a percentage of total pay budget 4.10% 17.11% 10.12% 4.77% 8.85% 5.50% 7.85% 5.70% 4.04% 2.49% 8.43% 4.91% 16.49%

I & E Variance from plan 9.65% 3.22% 1.52% 6.84% 0.17% 2.50% 7.60% 2.09% 3.13% -2.77% 2.65% 3.38% 5.83%

Contract performance Variance from plan -1.30% 0.68% 1.30% -42.83% 0.00% -0.03% 3.63% 0.80% -1.34% 1.13% -6.32% -1.97% 2.98%

Productivity & Efficiency Variance from plan -17.11% 6.90% -25.00% -0.78% -48.60% -21.69% -34.43% -17.10% -75.78% -50.04% -36.36% -41.54% -0.10%

Percentage of admitted patients treated within 18 weeks (90%) 100.00% 97.20% 98.97% 100.00% 95.22% 90.66% 97.17% 93.25%

Percentage of non-admitted patients treated within 18 weeks (95%) 99.09% 100.00% 92.15% 97.56% 100.00% 95.71% 96.82% 96.60% 95.94% 99.06%

Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 98.77% 69.61% 92.98% 97.39% 86.20% 98.91% 97.96% 95.54% 95.34% 98.09%

52 week waits Actual numbers 0 0 0 0 0 0 0 0 0 0

6 week diagnostic waiting Percentage of patients seen within 6 weeks 99.22% 98.36% 99.06% 100.00%

Number of operations cancelled on the day for non clinical reasons -2.2222222 -0.1481481 -1.3333333 -0.5185185 -0.5925926 -2.962963

Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 0 0 0 0 0 2 0 0

Percentage of out-patient appointments cancelled by hospital 8.23% 0.00% 21.56% 17.53% 2.70% 18.40% 3.49% 8.01% 7.48% 11.90% 5.20%

Percentage of out-patient appointments cancelled by patient 12.34% 1.44% 12.41% 13.70% 11.16% 14.01% 4.51% 15.51% 12.70% 15.73% 15.63%

Percentage of new out-patient appointments where patients DNA 10.95% 0.12% 9.37% 8.51% 9.83% 10.41% 3.13% 9.00% 5.62% 6.87% 5.02%

Percentage of follow-up out-patient appointments where patients DNA 9.88% 7.07% 8.96% 8.74% 6.78% 5.85% 2.23% 8.81% 3.83% 6.71% 4.81%

Patient seen within 2 weeks (93% compliance)

Breast symptomatic seen within 2 weeks (93% compliance)

62 days from referral to treatment (85% compliance)

31 day first treatment (96% compliance)

Choose & Book Utilisation Percentage appointments booked through C&B 15.62% 13.16% 28.83% 22.65% 19.64% 0.00% 1.84% 48.30% 24.39% 25.09%

Ethnic Origin data collection % valid ethnic group (85%) 98.71% 97.06% 93.40% 97.95% 100.00% 98.15% 94.12% 86.49% 91.35% 90.83%

Elective Inpatient activity Variance from contract schedules -8.27% 7.14% 4.57% -16.29% 48.81% 16.05% -17.95% -4.22% 3.04%

Non elective inpatient activity Variance from contract schedules -3.61% -11.05% 8.38% -5.21% 4.57% 10.31% -11.89% 34.20% -1.25% -26.56%

New outpatient attendances Variance from contract schedules 4.75% 16.77% -8.32% 17.24% -8.28% -7.12% -28.57% -5.85% -11.80% -8.47% -1.80%

Follow up op attendances Variance from contract schedules -4.32% 296.83% -18.83% 3.16% 9.95% -9.36% -5.69% 6.58% -12.67% 3.65% 6.22%

Complaints Percentage of complaints answered within 25 working days 100% 92% 50% 100% 83% 100% 100% 100% 100%

FFT Response Rates Increased response rates for inpatient areas 43.65% 42.04% 46.78% 30.99% 45.22% 69.69%

FFT Response Rates Increased response rates for A&E 19.40%

Day surgery rates BADS - day surgery rates 104.00% 50.00% 94.58% 114.06% 100.00% 94.59%

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0

Performance is YTD unless specified: Directorates in Special Measures

Last complete month

Rolling 12 months

Current quarter to date


discharges)

Cancer Waits

18 week waits referral to treatment

time


Cancelled Outpatient appointments

DNA rate

21


Indicator Measure Lab Med MIMP OGN MSK OSSCA Cardiac Renal Vasc

Comm

Dis &

Spec Med

Spec

Rehab

Spec

CancerGen Surg

Plastic

SurgUrology

MRSA bacteraemia Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MSSA bacteraemia Actual numbers 0 0 0 0 2 0 0 0 0 0 0 0 0 0

C Diff Actual numbers 0 0 0 0 0 0 0 0 0 1 1 3 0 0

Serious Untoward Incidents Approved SUI Report submitted within timescales 0 0 0 1 1 0 0 0 0 0 1 0 0 0

Serious Untoward Incidents Number of Serious Untoward Incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Incidents Increase in incident reporting levels (increase or decrease from previous month) -5 0 -12 2 -21 -25 -6 -6 -74 8 -21 -19 -6 -20

Incidents Incidents not approved after 35 days 0 0 0 0 0 0 0 0 0 0 0 0 0

Average LOS Elective -0.43 -0.19 0.20 -2.40 -0.90 3.13 5.40 -1.58 1.10 -0.61 -0.50

Average LOS Non Elective -0.03 -0.17 0.73 1.80 -1.60 1.43 75.50 -2.36 -0.08 0.09 -1.40

Patient Falls Number of patient falls 0 0 3 25 2 6 4 4 8.00 12.00 15 1 1

Never Events Number of never events 0 0 0 0 0 0 0 0 0 0 0 0 0

Sickness Absence All days lost as a percentage of those available 2.81% 3.05% 6.13% 5.14% 5.85% 4.07% 6.36% 3.80% 2.85% 2.87% 4.48% 2.62% 5.18%

Appraisals Completed appraisal in last year 87.12% 91.73% 76.74% 76.96% 78.89% 65.91% 81.00% 46.43% 78.59% #DIV/0! 90.98% 81.70% 87.23% 86.84%

Mandatory Training Overall percentage of completed mandatory training 91.09% 91.74% 71.48% 66.39% 67.20% 49.93% 80.38% 49.36% 65.45% #DIV/0! 77.02% 66.93% 63.83% 60.10%

Agency spend Agency and bank spend as a percentage of total pay budget 1.64% 4.52% 1.24% 8.69% 7.48% 6.03% 1.38% 4.16% 3.11% 11.70% 5.32% 3.98% 2.97% 2.92%

I & E Variance from plan 0.18% 2.25% 5.20% 6.40% 7.77% 3.14% -0.84% 6.34% 1.21% 0.00% -1.81% 0.73% -2.47% 1.10%

Contract performance Variance from plan -0.36% 5.35% -0.30% -7.62% -75.38% 1.95% 0.22% -2.90% -0.30% 0.10% 1.01% -0.40% -0.87% -1.23%

Productivity & Efficiency Variance from plan -35.90% -40.33% -55.69% -29.73% -42.37% -10.64% -8.27% -36.69% -2.67% -33.70% -22.30% -23.18% -20.32% 151.00%

Percentage of admitted patients treated within 18 weeks (90%) 95.64% 84.80% 71.64% 100.00% 95.97% 98.45% 100.00% 99.10% 83.33% 90.09% 78.79%

Percentage of non-admitted patients treated within 18 weeks (95%) 97.93% 96.38% 89.77% 100.00% 98.95% 97.63% 100.00% 98.39% 86.56% 98.39% 92.89%

Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 95.64% 93.04% 82.41% 100.00% 95.65% 96.66% 98.89% 94.27% 89.17% 90.46% 89.73%

52 week waits Actual numbers 0 1 0 0 0 0 0 0 2 0 0

6 week diagnostic waiting Percentage of patients seen within 6 weeks 100.00% 100.00% 99.80% 97% 52.73%

Number of operations cancelled on the day for non clinical reasons -0.8888889 -3.037037 -5.4814815 -0.5185185 -0.1481481 -0.2962963 -2.5185185 -0.8888889 -2.4444444

Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Percentage of out-patient appointments cancelled by hospital 6.49% 15.70% 7.17% 10.14% 10.95% 9.37% 11.36% 9.37% 10.27% 12.19% 7.45% 11.44%

Percentage of out-patient appointments cancelled by patient 9.09% 12.99% 17.38% 14.48% 12.11% 11.55% 9.98% 12.70% 5.25% 14.11% 12.54% 13.37%

Percentage of new out-patient appointments where patients DNA 6.26% 7.51% 8.37% 9.08% 10.34% 4.89% 8.36% 13.04% 6.05% 7.61% 4.53% 8.51%

Percentage of follow-up out-patient appointments where patients DNA 2.84% 7.98% 7.36% 8.02% 9.43% 4.60% 5.61% 5.97% 4.46% 5.35% 6.82% 5.40%

Patient seen within 2 weeks (93% compliance)

Breast symptomatic seen within 2 weeks (93% compliance)

62 days from referral to treatment (85% compliance)

31 day first treatment (96% compliance)

Choose & Book Utilisation Percentage appointments booked through C&B 17.95% 33.08% 0.00% 18.06% 39.46% 40.31% 38.16% 0.00% 0.00% 26.46% 25.10% 18.44%

Ethnic Origin data collection % valid ethnic group (85%) 98.02% 95.71% 89.17% 96.63% 94.09% 95.53% 79.57% 90.16% 95.37% 97.11% 96.30%

Elective Inpatient activity Variance from contract schedules -3.04% -11.68% 3.11% -16.50% -3.84% 4.47% 6.09% -12.79% -14.92% -10.71%

Non elective inpatient activity Variance from contract schedules -100.00% 9.41% -5.54% 6.18% -8.99% -1.41% -2.78% 2.68% -3.94% 18.33% 1.59%

New outpatient attendances Variance from contract schedules 28.01% -2.56% -4.86% -89.56% -2.01% -5.02% -13.02% -7.52% 8.89% 1.36% -5.12% -1.94% 3.62%

Follow up op attendances Variance from contract schedules -41.33% 4.25% -8.72% 7.81% -3.76% -17.80% -8.04% -11.62% 2.70% -15.58% -3.76% -8.47%

Complaints Percentage of complaints answered within 25 working days 100% 67% 92% 100% 75% 100% 100% 100% 100% 67% 100%

FFT Response Rates Increased response rates for inpatient areas 23.20% 0.4902913 0.4504951 53.13% 28.95% 17.54% 25.85% 33.00%

FFT Response Rates Increased response rates for A&E

Day surgery rates BADS - day surgery rates 104.73% 86.75% 100.00% 93.88% 86.44% 100.00% 98.59% 50.00% 125.00% 87.93%

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Performance is YTD unless specified:

Last complete month

Rolling 12 months

Current quarter to date


discharges)

Directorates in Special Measures

18 week waits referral to treatment

time


Cancelled Outpatient appointments

DNA rate

Cancer Waits

22

Deep Dive Topic - Complaint response timesSummary: The Trust target is to respond to a minimum of 85% of complaints within 25 working days. The chart below shows, by month, our performance against this target. Since April 2013 onwards, the target was met on only one occasion, in September 2014. Prior to May 2013, the target had been consistently met. However, since May 2013 a decline in response times has been seen. This ‘deep dive’ summarises how the decline in performance occurred, the actions taken, and the impact that these have had, which is reflected in the 91% response rate in July 2015. Trust response times by month: Causes of the decline in response times Complaints backlog Towards the end of 2013, it was identified that a backlog of overdue complaints had built up. It was not possible to pinpoint precisely when the backlog began. There was a significant increase in the number of complaints received in March 2013, which is likely to have impacted significantly on our ability to respond to complaints on time. Once work commenced to close these complaints and clear the backlog, this affected response times negatively. Managing and closing the backlog of overdue complaints also had a knock-on effect on other complaints in the system. As resources were directed to closing complaints which were already overdue, this meant that complaints which would have been closed on time also became overdue. This in turn perpetuated the backlog affecting our ability to achieve the response time target

Managing concerns informally In addition to the backlog, the graph below shows that there has been an ongoing increase in the number of concerns being managed informally and a corresponding decrease in the number of complaints managed formally. Since January 2015, the Trust has been managing more complaints as informal concerns rather than as formal complaints. This means only the more complex and resource intensive complaints are being managed through the formal complaints process and these complaints typically take longer to complete. Only complaints managed formally contribute to the response time percentage. Formal complaints and informal concerns received by month: Actions taken When the backlog of complaints was first identified towards the end of 2013, this was picked up by the Patient Experience Committee and a complaints recovery plan was implemented throughout 2014. A number of changes in working practice were introduced to help reduce the backlog such as protected time for staff to draft and check complaint final responses, and the reallocation of some administration requirements to increase the capacity of complaints staff. Reporting was also amended to show the number of open and overdue complaints in the system, as previously we only reported on the number of complaints closed each month. A significant piece of work was also undertaken to review the complaints process. This resulted in a 6 month pilot project, which commenced in May 2015, in Urology and General Surgery to trial new ways of working and improve complaint responses. As part of the review of the complaints process, and results from the Patients Association complaints survey, it was identified that complainants are happy for their complaint to take longer than 25 working days, as long as they are kept well informed and receive a high quality response to their concerns.

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New formal complaints received New informal concerns received All concerns combined

23

Deep Dive Topic - Complaint response timesNew tiered response time targets have been introduced as part of the pilot to identify the appropriate timescale for a response, taking into account the complexity and seriousness of the complaint. The timescale is agreed with the complainant from the outset and includes a 10 day response target for complaints which can be resolved more quickly, a 25 day target for complaints of medium complexity, a 40 day target for highly complex complaints and a 60 day target will be in place for the small number of complaints where the response cannot be sent until other due processes have been completed, such as inquests. Should the pilot in Urology and General Surgery prove successful, this will be rolled out across the Trust. Additional intervention The actions outlined above were essential in terms of addressing the longer term concerns with the complaints process and tackling the initial backlog. However, as mentioned previously, managing and closing the backlog of overdue complaints had a negative impact on the response time performance. As the backlog started to reduce and the complaints caseload became more manageable, the following acute actions have recently been implemented to ensure the 85% response time target is achieved: Weekly reporting Since May 2015, weekly complaint caseload reports and meetings have been implemented. These meetings focus on identifying those complaints that are due to be responded to within the next 5 working days and the next 10 working days and confirming that all the necessary information is available to enable the complaint to be answered in time. Escalation process Where a complaint is identified as potentially becoming overdue, a process was implemented during June and July 2015 whereby these are escalated to the Deputy Chief Nurse, Deputy Medical Director or Chief Operating Officer to ensure, where possible, that the necessary information is available to respond to the complaint on time. Daily monitoring Since July 2015, daily monitoring of all complaints due to be closed has been undertaken. This enables all complaints due to be closed on or by that day to be reviewed and actions to be taken if these complaints have not been closed. Regular updates are sent to the Deputy Chief Nurse, Nurse Directors, Deputy Nurse Directors and Complaint Co-ordinators. Impact The interventions outlined above are resource intensive but have added a sharper focus on the complaints caseload and resulted in achieving a response rate of 91% for July 2015. In addition to this, the graph below shows that the number of open and overdue complaints which make up the backlog has reduced to 9 at the end of July 2015, from a peak of 118 in December 2013.

Number of open and overdue complaints at end of month: The current position of less than 10 overdue complaints makes achieving the target much easier. The focus is now on maintaining the current response time and further reducing the backlog position. The aim is now is to achieve the 85% response time target for firstly August, then the quarter July to September 2015 and then to maintain this performance for the remainder of this year and beyond that.

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executive summary report to the board of directors b2... · 2015-09-11 · executive summary report...

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