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Integrated Quality and Performance Report

December 2017

0.1 Executive summary December 2017

In this month (page 5) For the month of December, demand continued to grow when compared to the same period in the previous year, with GP referrals up by 2.7% and urgent cancer referrals up by 12.1%. Activity across all key areas was up slightly, most notably day case activity which rose by 6.2%. Are we safe? (pages 6-15)10 SIs were reported in December. There was 1 Never Event in December. All events will be investigated thoroughly within the national timeframes. The Trust continues to submit all Root Cause Analysis reports within the 60 day deadline set by the CCG.Are we effective? (pages 16-19)Although readmission rates remain above the level reported in 2016/17, the remain within the targets that have been set. The Caeserean section rate continues remain above the target however, it is worth noting that despite this it remains within national averages.Are we caring? (pages 20-30)Our Friends and Family Test results feedback remains positive and we are maintaining satisfactory response rates in many areas. Emergency Care has maintained a response rate of over 20% in December and response rates for admitted areas although stable are lower than response rates for the previous year. The month of December has seen an improvement in the response rate for community services, although response rates for patient transport and maternity services have dropped. “Recommend” scores are have remained stable and are improving in all areas of care this month. With the exception of Outpatients and Patient Transport not recommend scores have declined very slightly this month indicating fewer patients are reporting more negative experience. We are ensuring that more real time information is available to Directorates and continue to encourage teams to review key themes emerging from free text comments and identify actions for improvement.Are we responsive? (pages 31-45) A&E continued to experience surges in demand and high volumes of patients with mental health needs which resulted in the performance in December against the A&E 95% standard just falling short of the STF trajectory of 90% with a performance of 89.3%. The Trust’s performance against the internal 62 day cancer standard continued to demonstrate improvement with an internal performance of 84.4% for December which was above trajectory and only just fell short of the national operational standard of 85%. Overall performance for cancer 62 day was 71.5%. We continued to achieve the 2 week performance standard with December being the 5th

consecutive month we achieved this standard. In December we saw 67.2% of referrals within 7 days which is a significant improvement on the beginning of the year where were only managing to see 16% of patients within 7 days. In December our RTT performance was 87.2% which was on trajectory and patients waiting >52 weeks rose slightly to 18. The Diagnostic standard deteriorated significantly to 5.89% which was driven primarily by c. 350 breaches in non obstetric ultrasound and c.155 in MRI. These breaches were a result of a mixture increased demand, scheduling capacity issues and administrative pressures. A recovery plan has been developed and implemented and the breaches are expected to be cleared by February.Are we well-led? (pages 46-50)Our vacancy rate increased to 10.16% and remains above target. Agency spend decreased to 3.32% of the pay bill, and is below the Trust’s target of 4.3%. Usage continues to be monitored closely on a weekly basis. Turnover decreased to 12.29%. The number of completed personal development reviews (PDR) for December was 72.27%. Managers and staff have been reminded of the importance of undertaking and reporting PDRs.How effective are our enabling services? (pages 51-66) The annual plan is for a surplus of £10.2m. A loss of £1.6m has been recorded for December which is £4.3m worse than the planned surplus of £2.7m. Essentia Patient Services – who provide non-clinical support services across the Trust, have provided reports across its services. This enables a wider review of how it supports the Trust in its day to day activity.

0.2 Trust overviewDecember 2017

Domain Ref Theme PageManagement

priority (last month)

Management priority

(this month)Forecast status Briefings

1.1 Patient safety - incident reporting 8 Moderate Moderate Stable

1.2 Patient safety - harm-free care 9 Minor Minor Stable

1.3 Patient safety – patient falls 10 Minor Minor Stable

1.4 Infection Control and Cleanliness 11 Minor Minor Stable

1.5 Screening on admission 13 Excellent Excellent Stable

1.6 Mortality indicators 14 On Track On Track Stable

2.1 Quality Indicators 17 Minor Minor Stable

2.2 Clinical best practice (a) 18 Minor Minor Stable

2.9 Clinical Best Practice (b) 19 Minor Minor Stable

3.1.1 Admitted care (a) 21 Moderate Moderate Improving

3.1.2 Admitted care (b) 22 Moderate Moderate Improving

3.2 A&E Care 24 Moderate Moderate Improving

3.3 Maternity Care 25 Moderate Moderate Improving

3.4 3.4 Outpatient care 27 Moderate Moderate Improving

3.5 3.5 Community Care 28 Moderate Moderate Improving

3.6 3.6 Patient transport 29 Moderate Moderate Improving

3.7 3.7 General patient and carers’ experience 30 Moderate Moderate Improving

4.1 A&E Access 33 Significant Significant Stable A&E waits

4.2 A&E Performance 34 Significant Significant Stable

4.2.1 Elective access (a) 35 Significant Significant At risk

4.3.1 Cancer – 2-week waits 36 Moderate Moderate At risk

4.3.2 Cancer – 31-day waits 37 Moderate Moderate Stable

4.3.3 Cancer – 62-day waits 38 Moderate Moderate Stable

4.4 Diagnostic waits 39 Moderate Moderate Stable

4.5 Bed capacity and management 40 Moderate Significant At risk

4.6 Delayed Transfers of Care 41 Moderate Moderate Stable

4.7 Outpatient management 42 Moderate Moderate Stable

4.8 Theatre management 43 Moderate Moderate Stable

4.9 Complaints management 44 Moderate Moderate Stable

5.2 5.2 Staff experience 46 Minor Minor Stable

5.3.1 Workforce indicators (a) 47 Excellent Excellent Stable

5.3.2 Workforce indicators (b) 48 Minor Minor Improving

6.1 Overall financial position (a) 50 Moderate Moderate Stable

6.1 Overall financial position (b) 51 Moderate Moderate Stable

6.1 Overall financial position (c ) 52 Significant Significant Stable

6.2 Activity levels 53 On Track On Track Stable

6.3 Data quality and clinical coding 54 On Track On Track Stable

6.5 Essentia Patient Services 55-65 Minor Minor Stable

6 Enablers

1 Safe

2 Effective

3 Caring

5 Well-Led

4 Responsive

0.3 Key to scorecard assessments

Management priority Individual theme in 'Trust overview'

SignificantSignificant interventions are planned or in progress due to one or more factors: an externally-reported metric is off-track; multiple

internal metrics are off-track; qualitative experiences are raising significant concerns

ModerateModerate interventions are planned or in progress due to one or more factors: an important internal metric is off-track; qualitative

experiences are raising concerns; future projections are off-track

MinorSome interventions are planned or in progress: stretch targets are off-track; trends are adverse; qualitative experiences suggest

performance may be at risk

On track All areas within this theme on track

Excellent Amongst top performers nationally, with internal stretch targets consistently met

Forecast status Individual theme in 'Trust overview'

At risk Expected to worsen by next reporting period

Stable Not expected to change significantly by next reporting period

Improving Expected to improve by next reporting period

Indicator status Individual metric in 'Domain scorecard'

Achieving national standard or internal target (this reporting period)

Not achieving internal target (this reporting period)

Not achieving national standard (this reporting period)

Indicator only - not measured against a set target

December 2017

0.4 In this monthDecember 2017

December Same month Year so far

We received…

Referrals from GP's 16,598 2.7% 1.6%

Urgent cancer referrals 1,441 12.1% 11.4%

Referrals to @Home and ERR 354 48.7% 44.2%

We treated…

A&E attendances 15,081 1.4% 0.2%

Non-elective admissions 4,034 2.0% 1.0%

Outpatient attendances 82,820 2.5% 3.2%

Day cases 5,371 6.2% 5.8%

Elective inpatients 2,086 0.4% -0.8%

Compared to last year

1.0.1 Domain scorecard (1)1 SafeDecember 2017

Theme Ref Indicator Units Target R GPrior

yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

INC 06 Total incidents reported Number -M M

2,112 2,352 2,358 2,194 2,258 - - Y

INC 06S Incidents - Reported on STEIS (total number) Number -M M

9.8 4 9 10 8.4 - -

INC 06ST Incidents reported on Datix that are STEIS reportable (total number) Number -M M

8.1 4 6 10 6.8 - -

INC 07 Never Events Number ZeroR R

0.7 1 0 1 1.0 - - Y

INC 01 Incidents resulting in unexpected death Number -M M

2.8 3 3 6 3.4 - - Y

INC 02 Incidents resulting in severe harm Number -M M

3.9 1 6 6 4.3 - - Y

INC 03 Incidents resulting in moderate harm Number -M M

17.5 36 49 43 33.2 - - Y

INC 04 Incidents resulting in low harm Number -M M

305 385 360 338 328 - -

INC 05 Incidents resulting in no harm Number -M M

1,357 1,927 1,940 1,797 1,683 - -

INC 01S Incidents resulting in unexpected death - reported on STEIS Number -M M

2.4 0 3 1 1.4 - -

INC 02S Incidents resulting in severe harm - reported on STEIS Number -M M

3.5 0 1 3 2.8 - -

INC 03S Incidents resulting in moderate harm - reported on STEIS Number -M M

1.8 0 1 4 2.2 - -

INC 04S Incidents resulting in low harm - reported on STEIS Number -M M

0.7 1 2 0 0.4 - -

INC 05S Incidents resulting in no harm - reported on STEIS Number -M M

1.8 3 2 2 1.6 - -

INC 08P % incidents relating to patients Mthly % -M M

79.9% 100.0% 100.0% 99.8% 90.9% - -

305T Pressure ulcer acquisitions (grade 2 and above) attributable to Trust Number <5R R

3.7 3 7 5 3.6 -Y

Y

305TA Admissions with pressure ulcers (grade 2 and above) Cases -M M

39 49 50 50 41 Y

INC 22 Medication incidents reported Number -M M

266 239 299 224 265 - - Y

INC 21 Patient falls with moderate or severe harm Number -M M

3.1 1 4 1 2.0 - - Y

INC 20 Patient slips trips and falls Number -M M

156 157 157 139 154 ## ## Y

313BD Incidence of falls per 1000 bed days Number -0.00 0.00

5.2 4.0 4.7 4.7 4.2 0 0 Y

WHO WHO surgical safety checklist Ann % - 85%

1.1 Patient safety -

incident reporting

1.2 Patient safety -

harm-free care

1.0.2 Domain scorecard (2)1 SafeDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

324 MRSA screening of admissions Mthly % >95%R R

90% 90.0% 90.5% 90.9% 89.6% - 0 Y

301 MRSA bacteraemia (Trust-attributable) Number ZeroG G

0.3 0 0 0 0.6 - - Y

302L C-Diff acquisitions resulting from lapse in care Number ZeroG G

0.1 0 1 0 0.3Y

- Y

302T C-Diff acquisitions (Trust-attributable) Number <4 pmG G

2.7 3 2 2 2.6 - - Y

AMS Anti-microbial stewardship Score >85G G

88.8 85 86 90 84.0 - - Y

9936 VTE screening (externally reported) Mthly % >95%R R

96.6% 95.9% 95.1% 94.4% 96.2% - - Y

Dem75 Dementia screening (patients aged over 75) Mthly % >90%R R

88.9% 81.0% 80.2% 78.7% 84.0% - - Y

350 Deaths in hospital - number in month Number -M M

87.8 90 87 105 84.4 Y

HSMR Hospital standardised mortality ratio (HSMR) - most recent score Ratio <90G G

71.7 68.9 69.4 69.4 67.8 ## 0.0 Y

SHMI Standardised healthcare mortality index (SHMI) - most recent score Ratio <90G G

75.3 72.5 71.3 71.3 73.0 0 0 Y

1.6 Safe staffing SafeS Safe Staffing - ratio of actual to planned hours Mthly % -M M

100.0% 98.0% 100.8% 100.0% 99.6% 0 0

1.3 Infection

control and

cleanliness

1.5 Mortality

indicators

1.4 Screening on

admission

• 10 SIs were reported in December, 3 under the Acute Medicine and 3 under PCCP Directorates, 2 for Transplant, Renal and Urology and then 1 each for the Dental Services and Community Adult Directorates. This includes the 1 Never Event in December, for Dental Services which was a retained foreign object.

• Between 1st April and 31st December 2017 20,381 incidents were reported, representing a 9% increase in reporting over the same period for 2016. 15,732 of the reported incidents this year were patient related, where 13,931 of these have been reported to the NRLS, compared with 10,107 reported to NRLS for the same period last year.

• The top five highest reporting Directorates remain the same as last year: Acute Medicine, PCCP, Haem-Onc, Women’s Services and Adult Community. The top three highest reporting Incident Category Types are ‘Medication Incidents’, ‘Accident that may result in personal injury’ and ‘Implementation of care or ongoing monitoring/review’

1 Safe 1.1 Patient safety – incident reportingDecember 2017

0

1

2

3

4

5

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Never Events2017-182016-17Target

0

10

20

30

40

50

60

70


Patient incidents with moderate or severe harm or death2017-182016-17

1,2001,3001,4001,5001,6001,7001,8001,9002,0002,1002,2002,3002,4002,5002,600


Total incidents reported2017-182016-17

• There were higher than average acquired pressure ulcers this month 8 in total in PCCP, Haem Onc, cardiovascular, renal urology x2, GI x2 and children's. Each area has undertaken local reviews; themes and learning from each case and revised pressure prevention and management strategies based on this information, main areas are; review of skin integrity when patient condition deteriorates and clear documentation and communication between teams regards this. We will be closely monitoring this as part of the avoidable harm council reviews in January to ensure governance and clinical areas responding to lessons highlighted and maintenance of this.

• Admissions with pressure ulcers have increased this month, with the highest proportion being in acute medicine , we continue to review all of these patients and potential trends and work closely with community health and social care services.

• Medication incidents totalled 289 in December, 13% of all incidents reported. The reduction in reporting may reflect trust acuity and time to report over the holiday period. The 6% incidents with harm reported were all low harm.

• Drugs commonly involved in reports were opioids (14%), anticoagulants 10%, and insulins 4%. Consistently, around half opioid incidents relate to documentation not patient care, reflecting a strong surveillance culture. Opioid incident themes are consistent with national themes. The opioid patch monitoring used in community areas is being reviewed and an opioid patch patient held safety card is being developed with national collaborators.

• Two medication safety stalls were run in ‘Safety Connections’ week at the start of December.

• The December medication safety newsletter included changes to insulin choice, drug interactions (HIV medication), interruptions and medication safety, and advice to patients about their medicines.

1 Safe 1.2 Patient safety – harm-free careDecember 2017

0

2

4

6

8

10

12


Pressure ulcer acquisitions (grade 2 and above) attributable to Trust

2017-182016-17Target

0

50

100

150

200

250

300

350

400


Medication incidents reported2017-182016-17

0

10

20

30

40

50

60


Admissions with pressure ulcers (grade 2 and above)2017-182016-17

1 Safe 1.3 Patient safety – patient falls

• This month there was a reduction in the incidence of falls with 139 reported compared to 158 in November; this was primarily due to a reduction in Inpatient and Non-Ward falls. Looking further at the data there were 18 falls that involved a patient falling more than once; this is a reduction from last month where 23 falls involved patients falling more than once. There were 15 Assisted falls reported this month compared to 20 in November.

• The directorates with the highest incidence of falls are Acute Medicine, GI Medicine and Surgery, and Cardiovascular.• There was 1 fall resulting in Moderate harm or above this month, which occurred in PCCP.

December 2017

Page 5

0

1

2

3

4

5

6


Patient falls with moderate or severe harm2017-182016-17Target

0

1

2

3

4

5

6


Incidence of falls per 1000 bed days2017-182016-17

0

20

40

60

80

100

120

140

160

180

200


Patient slips trips and falls2017-182016-17

• C-diff performance remains good overall.

• There were zero cases of MRSA bacteraemia; the case from October was assigned by the arbitration panel to ‘Third Party’

• Recent performance in antimicrobial stewardship has improved back towards the levels seen before changes in data collection methodology.

1 Safe 1.4 Infection Control and Cleanliness

December 2017

0

1

2


MRSA bacteraemia (Trust-attributable)2017-182016-17Target

0

1

2

3


C-Diff acquisitions resulting from lapse in care2017-182016-17Target

0

1

2

3

4

5

6

7

8

9

10


C-Diff acquisitions (Trust-attributable)2017-182016-17Target

75

80

85

90

95

100


Anti-microbial stewardship2017-182016-17Target

HCAI

Figure 1. Cdiff cases 2017/18 compared with 2016/17 and 2015/16 with a linear trajectory to 51 cases.

Healthcare Associated Infection (HCAI)Information Owner: Neil Wigglesworth

Intelligence

triangulated

Root cause

understood

Action plan

set

Actions

underway

Actions

complete

Where we want to be. Targets and benchmarks:

• Clostridium difficile - The external objective for reportable cases of C. difficile (Cdiff) for 2017/18 is 51cases. Reportable cases are those that are ‘toxin positive’ (Enzyme-linked Immunoassay or ‘EIA’ positive)and are identified beyond three days of admission to the organisation (attributed). In addition the Trustmust determine and report to the commissioners any reportable cases that are deemed to be due to any‘lapse in care’.

• Meticillin Resistant Staphylococcus aureus (MRSA). The organisation has a zero tolerance threshold forMRSA bacteraemia.

• Other bacteraemia - The Trust is required to report all cases of MSSA E. coli, Klebsiella species andPseudomonas aeruginosa bacteraemia via the Public Health England (PHE) reporting system. The Trust isnot subject to a national objective for these bacteraemia at present.

Where we are: trends and patterns:

C. difficile - For December 2017 the Trust reported a total of 2 cases both of which were attributable. MRSA bacteraemia – Zero cases were reported in December 2017. The case from October was assigned by

the arbitration panel to ‘Third Party’

Other bacteraemia

•MSSA – For Decmber 2017 the Trust reported 7 cases of which 2 were deemed to be Trust attributable(identified > 48 hours after admission).

•E coli – For December 2017 the Trust reported 24 cases, of which 7 were attributable.

• Klebsiella species – for December 2017 the Trust reported 4 cases of which 1 was attributable to the Trust(new requirement to report from April 2017).

•Pseudomonas aeruginosa - for December 2017 the Trust reported 3 cases of which 1 was attributable tothe Trust (new requirement to report from April 2017).

Incidents and Investigations: Status

Mycobacterium chimera in heater/cooler units used in cardiac bypass machines – a retrofitted engineering solution from the manufacturer has been applied but is not yet fully operational

Actions underway

The Trust has established screening and preparedness for the threat of resistant Candia auris – no further cases in December 2017

Actions underway

The increased incidence of MRSA bacteraemia in the 1st 5 months of this year was a concern (total of 5 cases) an exceptional briefing paper was presented to Trust Board in September 2017. The range of actions put in place both prior to the TME briefing and those agreed by TME are in progress no further cases

Actions underway

There has been some Norovirus and Influenza activity, generally it has been well managed. Flu activity has been significant but the organisation has managed without recourse to escalation plans.

Actions underway

December 2017

Page 7

• The screening of patients over the age of 75 years for memory problems must meet a monthly compliance target of 90% or greater. This screening compliance was not met in December 2017 with a compliance figure of 78.7%. This was as a result of long holiday periods in the month of December 2017. There were also a number of patients being admitted to wards that normally do not normally have patients of this age group and not very familiar with screening. This is being addressed with bespoke training locally.

• A significant number of patients continue to be screened in the admission ward but the numbers continue to decline when they are transferred out within a short period of being in AAW. The AAW matron and DaD Clinical lead are supporting and reminding wards who receive patients from AAW about screening.

• The DAD clinical nurse specialists will continue to monitor screening as a priority and focus on the wards that the patients are transferred out to from the admission ward. They will continue to send daily emails to wards who have outstanding screens and will follow-up with phone calls to the wards where screening breaches are imminent. The Clinical lead will continue to support junior doctors.

• The DAD CNSs continue to offer teaching to wards who often have low compliance. Dementia screening is also covered in each Dementia Level 2 study day.

• The DaD CNSs continue to work closely with the specialist teams (STAT, OPAL. POPs). Assistance from STAT over the weekend has reduced due to capacity which will impact on the numbers of patients being screened at the weekend and over holidays.

1 Safe 1.5 Screening on admission December 2017

75%

80%

85%

90%

95%

100%


VTE screening (externally reported)2017-182016-17Target

75%

80%

85%

90%

95%

100%


Dementia screening (patients aged over 75)2017-182016-17Target

• Benchmarked mortality allows case-mix corrected risk of death to be compared across organisations. The Trust continues to perform exceptionally well, both against the England average and other London acute hospitals. Two measures are used: Hospital Standardised Mortality Rate (HSMR) shown in graph upper left; and Summary Hospital Mortality Indicator (SHMI) shown in graph upper right. SHMI includes deaths within 30 days of discharge. For both indicators a low score is good.

• Crude mortality for 2017/18 is lower than the previous year despite an overall increased activity including for emergency admissions where most deaths occur. The Learning from Deaths review process is established trust wide where all deaths are clinically reviewed for quality of care and peer reviewed where there are concerns or the patients are from a vulnerable group which will give more granular analysis. A quality theme has emerged from this process around transfer in of patients from other hospitals. Benchmarked mortality indices remain low compared to peers.

1 Safe 1.6 Mortality indicators December 2017

0

20

40

60

80

100

120


Deaths in hospital - number in month2017-182016-17

Trust level Nursing & Midwifery Safe Staffing (December 2017 data) Information Owner: Chief Nurse Office (Workforce Team)

Key highlights for December 2017

Average fill rates of planned hours for Registered Nurses (RNs) for days were 98.8%, with nights at 100.1%. Average fill rates for planned hours for NAs was 98.4% in the daytime and 119.3% for the night. Overall 100.6% of planned hours were used.

The vacancy rate in December 2017 was 11.0% with a turnover of 14.4%. On 5 January 2018 there were 346 external candidates in the Recruitment Pipeline, who are expected to join the Trust over the next few months.

The rate of spend on agency staff has decreased to 4.7%, 1% lower than the pervious month.

Staffing levels, activity and acuity

The number of bed days in December 2017 stood at 43,571. This is 3,716 more than the previous shorter month and significantly an additional 10,529 bed days from the same period in 2016. This represents a rise of 31.9% in activity from December 2016. From an acuity perspective, Level 1b (heavily dependent or acutely unwell) patients continue to be the most predominant across the Trust, this has been consistent over the past few years.

Actual hours for Registered Nurses were 1,584 below the planned hours for the month, which equates to 9.72 WTE, whilst Nursing Assistants were 3,503 above planned hours which equates to 21.50 WTE. This variation is driven by occasions where Nursing Assistants are employed in addition to the planned numbers to provide 1:1 care for those requiring enhanced care. There is also appropriate deployment of Nursing Assistants to cover a vacant shift for a Registered Nurse where patient acuity is lower.

A total of 86 Red Flags, highlighting potential concerns regarding safe staffing were raised in December 2017, an increase of 12 on the previous month. The numbers of red flags do fluctuate on a month by month basis and these were resolved within the Directorates without there being an impact upon patient care or patient safety. There were no reported quality incidents related to staffing reported in December 2017. All adult inpatient areas (with the exception of Howard Ward) are now using SafeCare to capture staffing and acuity data on a twice daily basis.

December 2017

2.0.1 Domain scorecard (1)2 Effective December 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

CQ1Aq CABG within 7 days of GSTT angiogram Qtly % >66%G G

81% 100.0% 80.0% 56.0% 67.8% - - Y

CQ1Bq CABG within 7 days of referral received (angiogram elsewhere) Qtly % >38%#### ####

65% 20.0% 8.0% 75.0% 35.5% - - Y

CQ1Cq CABG within 7 days - combined GSTT and external angiograms Qtly % >59%#### ####

71% 66.7% 41.0% 62.0% 51.2% - - Y

352 Emergency readmissions (within 28 days - in arrears) Cum % <5.8%R R

3.0% 5.9% 5.9% 5.8% - 0 Y

353 Emergency readmissions (within 14 days - in arrears) Cum % <3.8%R R

2.0% 3.7% 3.8% 3.8% - 0 Y

IC48 Critical Care Unplanned Readmissions within 48 Hours Mnthly (%) <=1.3G G

1.2% 1.1% 1.0% 1.7% 0.9% 0 0

913 % Caesarean sections Mthly % <28%R R

33% 35.4% 38.4% 34.7% 34.6% - -

ICNARC-STH Critical care mortality indicator-STH+VHDU Quarterly <=1.0G G

0.83 1.00 1.00 1.00 0.98 0 0

ICNARC-Guys Critical care mortality indicator-Guys CCU Quarterly <=1.0R R

0.80 1.15 1.15 1.15 1.14 0 0

EOL End of life care - % of deaths supported by Priorities for Care Mthly % >25%M M

42.8% 41.7% 49.0% 43.0% 47.0% 0 0

2.1 Quality

improvement

initiatives

2.2 Clinical best

practice

• A further 9 transfers (yellow cards) underwent operations in December who were not CABG and the continued struggle is to prioritise by patient need, not by operation type.

2.1 Quality improvement initiatives2 EffectiveDecember 2017

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


CABG within 7 days of GSTT angiogram2017-182016-17Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


CABG within 7 days - combined GSTT and external angiograms2017-182016-17Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


CABG within 7 days of referral received (angiogram elsewhere)2017-182016-17Target

• Readmission rates vary depending on the clinical service and by patient group. There is an Outcomes group to review the data and look for any trends as well as a

handover group to focus on improving the quality of discharge of patients from hospital and will take action if required.

• The caesarean section rate continues to be higher than target but remains in line with the 2016/17 average. Over the past two years we have been reporting the CS

rates under the Robson criteria, as per CCG and CQC agreement. We have identified an issue with multiparous women having emergency CS. Ongoing work has

identified high rates of comorbidities (2-12) and we are looking to see if quality of antenatal care can be improved in these women to mitigate this. We have used the

feedback from the ‘Getting it Right First Time’ team, and the analysis of our data to identify areas for focus. These have been explored and further work identified

through a recent multidisciplinary workshop, attended by a number of stakeholders.

• The Clinical Response Team (formerly the Critical Care Outreach Team) have been proactively reviewing all patients prior to admission to Critical Care and supporting

them after step down onto a general ward. The main area of focus for improvement is Guy’s Critical Care as there is no High Dependency Unit on the site.

2.2 Clinical best practice (a)2 EffectiveDecember 2017

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%


Emergency readmissions (within 28 days - in arrears)2017-182016-17Target

0%

1%

2%

3%

4%

5%


Emergency readmissions (within 14 days - in arrears)2017-182016-17Target

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%


Critical Care Unplanned Readmissions within 48 Hours2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


% Caesarean sections2017-182016-17Target

• The Trust continues to perform well in recognising people who go on to die in hospital. This recognition supports proactive communication as well as involvement of patients and those important to them in development and delivery of holistic care plans. We continue to audit practice and to integrate into the Trust mortality review process for all inpatient deaths.

2.2 Clinical best practice (b)2 EffectiveDecember 2017

0%

10%

20%

30%

40%

50%

60%


End of life care - % of deaths supported by Priorities for Care2017-182016-17Target

Domain scorecard3 CaringDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

258 Overall inpatient patient experience score Mthly % >89%R R

90% 89.3% 88.7% 88.5% 89.3% - Y

310 Single sex compliance - breaches (all types) Cases ZeroG G

4.1 0 0 0 0.0 - Y

501 Patients cancelled on day (in arrears) Cum % <0.8%M M

1.4% 1.8% 1.8% - 1.7% - Y

502 Cancelled patients not admitted within 28 days (in arrears) Number ZeroM M

8.1 16 20 15 8.9 - Y

FFT1W Friends and Family test (Ward) - Response rate Mthly % >=33%R R

23.4% 19.6% 19.7% 18.9% 20.3% - Y

FFT2W Friends and Family test - % Recommended (Ward) Mthly % >=97%R R

96.4% 95.4% 94.7% 95.1% 95.8% - Y

FFT3W Friends and Family test - % Not Recommended (Ward) Mthly % <=1%R R

1.3% 2.2% 2.3% 1.6% 1.6% - Y

FFT1AE Friends and family test (A&E) - Response rate Mthly % >=18%G G

15.3% 18.2% 22.6% 20.4% 21.9% - Y

FFT2AE Friends and Family test - % Recommended (A&E) Mthly % >=88%R R

85.2% 84.4% 83.6% 86.3% 83.6% - Y

FFT3AE Friends and Family test - % Not Recommended (A&E) Mthly % <=6%R R

6.9% 7.1% 7.0% 6.8% 7.0% Y

FFT1M Friends and Family test (Maternity) - Response rate overall Mthly % -M M

23.9% 15.7% 13.2% 9.9% 10.5% - Y

FFT2M Friends and Family test - % Recommended (Maternity) Mthly % -M M

91.3% 88.5% 85.0% 87.6% 89.9% Y

FFT3M Friends and Family test - % Not Recommended (Maternity) Mthly % -M M

3.2% 4.0% 4.7% 1.7% 2.7% Y

FFT2OP Friends and Family test - % Recommended (Outpatients) Mthly % -M M

92.8% 91.0% 91.7% 92.4% 91.6% Y

FFT3OP Friends and Family test - % Not Recommended (Outpatients) Mthly % -M M

3.2% 3.1% 3.5% 3.6% 3.5% Y

FFT1CS Friends and Family test (Community) - Response rate Mthly % -M M

4.6% 7.3% 5.9% 6.4% 5.8% - Y

FFT2CS Friends and Family test - % Recommended (Community) Mthly % -M M

95.3% 97.4% 96.2% 97.6% 96.7% Y

FFT3CS Friends and Family test - % Not Recommended (Community) Mthly % -M M

0.7% 0.4% 0.5% 0.0% 0.6% Y

FFT1PT Friends and Family test (Transport) - Response rate Mthly % -M M

2.4% 18.2% 22.6% 20.4% 21.9% - Y

FFT2PT Friends and Family test - % Recommended (Transport) Mthly % -M M

92.5% 84.4% 83.6% 86.3% 83.6% Y

FFT3PT Friends and Family test - % Not Recommended (Transport) Mthly % -M M

2.1% 7.1% 7.0% 6.8% 7.0% Y

3.7 General

patient and Food Satisfaction with food (PLACE) Mthly % >85%

G G92% 91.8% 91.8% 91.8% 91.8% Y

3.6 Patient

Transport

3.3 Maternity care

3.5 Community

care

3.1 Admitted care

3.2 A&E care

3.4 Outpatient

care

• Cancellations have increased in proportion to our increased levels of activity, so work to reduce cancellations is a key focus of the Fit for the Future work-stream that supports theatre productivity. We have also seen an increase in the number of patients not being rebooked within 28 days compared to last year. Although numbers are small we know that some are the result of patient’s choosing later dates as well as consultant specific procedures that cannot be booked within the time limit.

• Patient experience scores continue to reflect well on inpatient care, with an overall satisfaction rate of 88.5% although this has continued to decline since the October score of 89.3%.

• Single sex compliance is also reported a month in arrears.

3.1.1 Admitted care (a)3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Overall inpatient patient experience score2017-182016-17Target

0.0%

0.5%

1.0%

1.5%

2.0%


Patients cancelled on day (in arrears)2017-182016-17Target

0

3

6

9

12

15

18

21

24


Single sex compliance - breaches (all types)2017-182016-17Target

0

2

4

6

8

10

12

14

16

18

20

22


Cancelled patients not admitted within 28 days (in arrears)2017-182016-17Target

• Having reviewed the previous years data on inpatients and day case/surgery as a new area of care, the Trust has set itself a combined response rate of 30% for 2017-18. In December we achieved a response rate of 18.9%, a decline from 19.7% in November. Response rate for the day case areas has also declined. Monthly updates on recommend and not recommend scores together with response rates are now sent to all Directorate Management Teams for review and discussion.

• The proportion of patients who would recommend the Trust in December was 95.1% slight improvement on November’s score of 94.7%. The percentage of patients who would not make a recommendation also improved, falling from 2.3% in November to 1.6% in December.

• All responses have been reviewed and feedback to areas has been given so that actions can be taken to both improve response rates and patients’ experience.

• The briefing over leaf provides further analysis and detail of actions underway.

3.1.2 Admitted care (b)3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Ward)2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%

35%


Friends and Family test (Ward) - Response rate2017-182016-17Target

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


Friends and Family test - % Not Recommended (Ward)2017-182016-17Target

Where we want to be: targets and benchmarks• Work towards achieving a 30% response rate • Increase our FFT score/proportion of patients who would recommend us to 97%• Improve our response rate and the proportion of patients who would recommend the Trust when compared with Shelford Peers

Where we are: trends, patterns and causes• The response rate in December was 18.9% a slight decrease on the November figure of 19.7%.

• A review of underlying data showed that whilst the overall response rate has improved there is quite a bit of variation between individual ward response rates. Also the response rate for the day case areas has dipped slightly. Response rate targets have been set for ward areas so that teams are clear about the number of surveys they need to collect each month. The Chief Nurse has asked Directorate Management Teams to review scores and response rates and identify how response might be improved.

• The Patient Experience team will also be working with Directorates to review the inpatient and day case surveys to make these briefer and more focused. It is hoped that revised surveys will encourage more patients to respond.

• The recommend score for December is 95.1% which is a slight improvement on the November figure of 94.7%. The not recommend score has also improved falling from 2.3% in November to 1.6 in December.

• In November our response rate, placed us in the mid-range of the Shelford Group, whilst our “recommend” and “not recommend” scores placed us towards the bottom of the group. Our scores are in line with the London average and our recommend score is slightly lower than the national average.*NHS England have advised that there are some data quality issues with inpatient FFT results for November due to technical problems experienced by NHS Digital. Whilst have verified our own data it is not possible to do this for other Trusts.*

Risks or opportunities for the Trust

• It is important to ensure that we continue to capture patients’ feedback and that it is used to further improve the experience of patients staying on our wards

Trend –2017 Inpatient Friends and Family Test percentage Recommend v. Not recommend

Comparator – Shelford Group

Action and progress Owner Next review date

The Chief Nurse and Director of Patient Experience has contacted Directorate Management Teams and asked them to discuss and identify actions to improve response rates. The item is to go on monthly performance review meetings.

Patient Experience Team February 2018

The Patient Experience Team will be working with Directorates to revise both the inpatient and day case surveys to develop briefer and more focused surveys to help encourage completion.

Patient Experience Team Ongoing

The Patient Experience Team will carry out in ipad audit to verify the number of ipads in use, re-allocate unused ipads and identify areas of need and put in a bid for funding to purchase additional ipads if needed.

Patient Experience Team February 2018

Intelligence triangulated Root cause understood Action plan set Actions underway Actions complete

Trend – Inpatient Friends and Family Test response rate

3 Caring Inpatient and Daycase Friends and Family TestDecember 2017

0%

5%

10%

15%

20%

25%

30%

35%


Friends and Family test (Ward) - Response rate2017-182016-17Target

Shelford Group Response rate

November

Recommend % Not recommend % Inpatient

National Score for England 96% 2% 25.1%

London region score 94% 2% 26.2%

Guy's and St Thomas' NHS Foundation Trust 95% 2% 19.7%

University College London Hospitals NHS Foundation Trust 94% 3% 17.5%

Newcastle-Upon-Tyne Hospitals NHS Foundation Trust 99% 1% 13.7%

Sheffield Teaching Hospitals NHS Foundation Trust 96% 2% 30.9%

University Hospitals Birmingham NHS Foundation Trust 97% 2% 13.7%

Oxford University Hospitals NHS Trust 96% 2% 19.4%

King's College Hospital NHS Foundation Trust 94% 2% 19.8%

Cambridge University Hospitals NHS Foundation Trust 95% 2% 9.4%

Imperial College Healthcare NHS Trust 97% 1% 32.9%

Central Manchester University Hospitals NHS Foundation Trust 97% 1% 32.1%

NovemberTrust/Month

• The A&E Friends and Family Test (FFT) includes patients attending our A&E department at St Thomas’ Hospital and Minor Injuries Unit at Guy’s Hospital.

• Having reviewed local and national data for 2016-17 the Trust set itself a target response rate of 20% for 2017-18. The response rate for A&E has declined slightly falling from 22.6% in November to 20.4%, however this is still above the target of 20%. The team is continuing to take measures to increase the numbers of responses in the coming months.

• The proportion of patients who would recommend the service in December was 86.3% an improvement on November's score of 83.6% . Similarly the proportion of patients who said they would not recommend the service has also improved slightly, falling from 7.0% in November to 6.8% in December. Comments from patients continue to show frustration with delays and waits to be seen. There has however been a slight decline in the number of comments received from patients about long waiting times in December compared to those received in November. The team are reviewing themes from feedback to identify actions which can be put in place to improve patients experience.

3.2 A&E care3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (A&E)2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%


Friends and family test (A&E) - Response rate2017-182016-17Target

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%


Friends and Family test - % Not Recommended (A&E)2017-182016-17Target

• Having reviewed local and national data for 2016-17 the Trust has set itself a target response rate of 20% for 2017-18. The overall response rate for the Friends and Family Test for maternity services has fallen from 13.2% in November to 9.9% in December. Additional resources have been allocated to ensure that patients are continued to be surveyed on their experience.

• The proportion of women who would recommend the service has improved, increasing from 85.0% in November to 87.6% in December. The proportion of women who said they would not recommend the service has also improved dropping from 4.7% in November to 1.7% in December.

• The briefing on the following provides further analysis and detail of actions underway.

3.3 Maternity care3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Maternity)2017-182016-17

0%

5%

10%

15%

20%

25%

30%


Friends and Family test (Maternity) - Response rate overall2017-182016-17

0%

1%

2%

3%

4%

5%

6%


Friends and Family test - % Not Recommended (Maternity)2017-182016-17

Where we want to be: targets and benchmarks• Work towards achieving a 20% response rate • Increase our FFT score/proportion of patients who would recommend us to 97%• Improve our response rate and the proportion of patients who would recommend the Trust when compared with Shelford Peers

Where we are: trends, patterns and causesThe response rate dipped in November falling from 13.2% in November to 9.9% in December 2017.

• The unit continues to be extremely busy and continues to deliver much higher numbers of babies. This increase in birth rates has meant that there have been four additional women staying on the postnatal ward each week and the team have had to make additional use of the discharge lounge. The unit has experience a 20% increased in the number of babies delivered since April 2017.

• The overall recommend score has improved this month rising from 85% in November to 87.6% in December. The not recommend score has also improved markedly, falling from 4.7% in November to 1.7% in December. A review of the underlying data has shown that this is due to marked decline in the ratings given by women responding to the postnatal ward question.

• No comparative data for the Shelford Group was available for November 2017. Due to technical problems experienced by NHS Digital during the transition from the UNIFY2 portal to SDCS it was not possible to publish national results of the Friends and Family Test for maternity touchpoints for November

• Risks or opportunities for the TrustIt is important to ensure that we continue to capture patients’ feedback and that it is used to further improve the experience of patients staying on our wards

Trend – 2017 Maternity Friends and Family Test percentage Recommend v. Not recommend

Comparator – Shelford Group


Maternity Services will be consulting with women and their families on the practice of allowing partners to stay overnight. Following the consultation and any changes to be made the ‘Partners staying’ initiative will be re-launched in June (on Father’s day).

Maternity Services May 2018

Themes emerging from comments made by women giving negative responses to the postnatal ward touchpoint are similar to those emerging from the national survey. As part of the action plan all Band 7 midwives will be required to attend a bespoke programme on managing poor performance.

Maternity Services February 2018

Maternity Services will be working with the Patient Experience Team to review and revise the Labour, birth and postnatal care questionnaire in the light of the national maternity survey results. The aim will be to develop a shorter questionnaire on what matters the most to women during the hospital stay.

Patient Experience Team and Maternity

ServicesMarch 2018

Intelligence triangulated Root cause understood Action plan set Actions underway Actions complete

Trend – Maternity Friends and Family Test response rate

3 Caring Maternity Friends and Family TestDecember 2017

0%

5%

10%

15%

20%

25%

30%


Friends and Family test (Maternity) - Response rate overall2017-182016-17

Due technical problems experienced in in December NHS England was unable to release data for November 2017.

• We have reviewed local and national 2015-16 data and have set a response rate target of 7%.

• The proportion of outpatients who would recommend the Trust continues to improve from 91.7% in November to 92.4% in December. The proportion of patients who would not recommend the Trust remains stable, 3.5% in November and 3.6% in December.

• As part of the Fit for the Future outpatient work stream, directorates are improving communication with patients regarding their appointments through text messaging, where it is not currently in use and introducing a system for booking follow ups.“Partial booking” of follow up appointments allows patients to be involved in the choice of appointment date and time. As well as improving patient experience, these initiatives are also aimed at reducing non-attendance rates.

• This work stream is also looking at alternative pathways for outpatients to reduce unnecessary visits to the hospital. By reviewing discharge criteria, introducing more telephone appointments, and introducing more one-stop visits (where the consultation appointment and any associated diagnostic tests occur on the same day). Through improving patient experience some of these initiatives will improve new to follow-up ratios.

3.4 Outpatient care3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Outpatients)2017-182016-17

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%


Friends and Family test - % Not Recommended (Outpatients)2017-182016-17

• We have reviewed 2015-16 local and national data and set a response rate target of 7%.

• The response rate has slightly improved from 5.9% in November to 6.4% in December. The proportion of patients who would recommend community-based services is also up from 96.2% in November to 97.6% in December. The proportion of patients who would not recommend services has also seen an improvement, falling from 0.4% in November to 0.0%

3.5 Community care3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Community)2017-182016-17

0%

1%

2%

3%

4%

5%

6%

7%

8%


Friends and Family test (Community) - Response rate2017-182016-17

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


Friends and Family test - % Not Recommended (Community)2017-182016-17

• The proportion of patients recommending the transport continues to improve , rising from 93.5% in November to 93.8% in December. The not recommend score has worsened slightly, up from 2.2% in in November to 3.0% in December.

• The response rate has also dipped slightly, falling from 3.4% in November to 2.8% in December.

3.6 Patient transport3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Transport)2017-182016-17

0%

5%

10%

15%

20%

25%

30%


Friends and Family test (Transport) - Response rate2017-182016-17

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%


Friends and Family test - % Not Recommended (Transport)2017-182016-17

• The Trust has scored strongly for the quality of its catering as reflected in the National Inpatient Survey 2015, published by the Care Quality Commission (CQC). The Trust’s catering scores exceed those of other London Trusts.

• The catering team continue to work closely with both Nursing and Dietetic staff to consolidate and introduce further quality improvements, and the Trust is working towards full compliance with the Hospitals Food Standards Report.

3.7 General patient and carers’ experience3 CaringDecember 2017

75%

80%

85%

90%

95%

100%


Satisfaction with food (PLACE)2017-182016-17Target

4.0.1 Domain scorecard (1)4 ResponsiveDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

AE123 A&E stays less than 4 hours (type 1 2 3) Mthly % >95%R R

88.7% 90.4% 88.6% 89.3% 88.7%Y

- Y

AE1STH A&E stays less than 4 hours (type 1) Mthly % >95%R R

85.3% 87.5% 85.4% 86.0% 85.3% - Y

AE30 Ambulance handover times - breaches of 30 mins Number <3G G

3.8 5 2 0 3.0 Y

AE60 Ambulance handover times - breaches of 60 mins Number ZeroG G

0.0 0 0 0 0.0 Y

403M RTT - Incomplete pathways < 18 weeks (unadjusted) Mthly % >92%R R

90.4% 86.5% 87.1% 87.2% 87.5%Y

- Y

RTT 52I RTT - Incomplete pathways over 52 weeks Mthly ZeroR R

17.4 15 14 18 17.1 - 0 Y

RTT TQ RTT - Total incomplete pathways Mthly -M M

57,279 63,029 61,993 60,220 63,636 - 0 Y

RTT 18Q RTT - Incomplete pathways over 18 weeks Mthly -M M

5,534 8,521 7,993 7,714 7,979 Y

401M RTT - Non-admitted patients <18 weeks (unadjusted) Mthly % >95%R R

90.5% 88.2% 87.4% 88.6% 89.7% Y

402M RTT - Admitted patients < 18 weeks (unadjusted) Mthly % >90%R R

81.0% 79.2% 78.9% 79.2% 79.1%Y

- Y

RTT 52 RTT - Treatments over 52 weeks (unadjusted) Mthly ZeroR R

13.4 11 11 8 12.8 - 0 Y

451M Cancer - 2 week wait Qtly% >93%M M

91.4% 97.6% 97.7% 98.5% 95.3%Y

- Y

941 Cancer - breast symptomatic referrals <2 wks Qtly % >93%G G

89.3% 97.9% 96.3% 99.2% 95.6%Y

- Y

453M Cancer - 31 day first treatments Qtly% >96%M M

95.0% 97.0% 93.0% 93.8% 93.3%Y

- Y

459M Cancer - 31 day subs treatments - surgical Qtly% >94%M M

90.7% 90.6% 93.3% 91.2% 89.4%Y

- Y

943 Cancer - secondary chemotherapy <31 days Qtly % >98%G G

97.8% 99.5% 99.1% 100.0% 98.5%Y

- Y

942 Cancer - secondary radiotherapy <31 days Qtly % >94%R R

93.7% 94.6% 91.6% 93.6% 91.8%Y

- Y

454M Cancer - 62 day urgent GP referrals Qtly % >85%M M

67.1% 70.8% 70.1% 71.5% 67.5%Y

0 Y

Cancer - 62 day urgent GP referrals (LCA cases only) In devt#N/A #N/A

454I Cancer - internal 62-day referrals Qtly% >85%M M

78.4% 80.9% 78.7% 84.4% 79.2% - - Y

456M Cancer - 62 day screening Qtly % >90%M M

83.3% 50.0% 50.0% 80.0% 72.5%Y

0 Y

457 Cancer Backlogs - pathways over 62 days Number -M M

138 134 87 101 133 0 0

4.3 Cancer

access

4.1 A&E access

4.2 Elective

treatment access -

referral to

treatment (RTT)

performance

4.0.2 Domain scorecard (2)4 ResponsiveDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

Diag 6 Diagnostic waits - % over 6 weeks Mthly <1%R R

1.25% 1.7% 2.2% 5.9% 2.23% - - Y

FFF19 Turnaround time - inpatient MRI within 24 hours Mthly % >80%#### ####

63.8% 69.6% 68.0% 74.0% 66.0% 0 0 Y

FFF20 Turnaround time - inpatient CT within 24 hours Mthly % >80%#### ####

84.6% 87.5% 92.2% 88.5% 87.9% 0 0 Y

FFF21 Turnaround time - inpatient Ultrasound within 24 hours Mthly % >80%#### ####

76.5% 70.2% 77.6% 76.3% 73.4% 0 0 Y

531 Average length of stay (elective) Cum ALOS <last yrR R

3.54 3.85 3.84 3.91 3.91 - 0 Y

LOS>1 Non-elective average LOS >1 night Cum ALOS <last yrG G

8.7 8.7 8.7 8.7 8.7 - 0 Y

535 Discharges before noon Mthly % >25%R R

20.9% 20.6% 19.6% 20.5% 20.8% - 0 Y

Home GSTT referrals to @Home service Cases >100R R

69 77 77 67 66 0 0 Y

DToCDT DToC total delayed days Number - 543 379 460 419 463 0 0 Y

604 Appointments re-scheduled by hospital <6wks Cum % <4%R R

4.8% 5.2% 5.1% 5.1% 5.1% - 0 Y

FFF57 Gassiot House Room Utilisation Mthly % >75%M M

88.6% - - - - 0 0

618 Choose and Book - % slot unavailability Mthly % <5%M M

- - - Y

601R Follow-up ratio - adj cons appts (in arrears) Ratio 2.06R R

2.14 2.21 2.16 2.17 - 0 Y

602 Non-attendance rate (new appts) Mthly % <11%R R

10.9% 11.1% 11.5% 12.7% 11.0% -Y

Y

603 Non-attendance rate (f/up appts) Mthly % <9.8%R R

12.2% 10.8% 11.2% 12.8% 11.3% - 0 Y

533M Daycase rate - basket (in arrears) Mthly % >85%G G

84.3% 85.9% 86.0% 86.2% - 0 Y

505 Theatres Gross Cancellation Rate (in arrears) Mthly % <7%R R

7.4% 7.81% 7.87% 7.5% - - Y

COM1T Complaints opened in month (Trust total) Cases -M M

100.8 94 133 95 106 0 0 Y

COM2T Complaints re-opened in month (Trust total) Cases -M M

3.1 3 4 1 3 0 0 Y

COM6T Complaints CLOSED in month (total Trust) Cases -M M

98.0 112 113 60 104 0 0 Y

4.6 Outpatient

management

4.7 Theatre

management

4.4 Diagnostic

access

4.8 Complaints

mgt

4.5 Bed capacity

and management

• December saw a slight improvement in performance in the patient waiting time within our A&E services with 89.25% of patients with stays of less than 4 hours. The department continued to see surges in demand and high volumes of patients linked to seasonal period. Mental health attendances and outlier also continued to be a challenge for the department.

• A new ambulatory orthopaedic and frailty pathway was introduced to further support patient flow through the ED.

• A pilot of having the SNP based in A&E to support flow/bed allocation was commenced to support the department as part of winter pressures.

• Recruitment of new staff across all levels continues to improve, however the department experienced staffing gaps throughout the month and the junior doctor rotation day was a particularly challenge despite best efforts to fill any gaps.

4.1 A&E access4 ResponsiveDecember 2017

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


A&E stays less than 4 hours (all types)2017-182016-17Target

0

1

2

3

4

5

6

7

8

9

10


Ambulance handover times - breaches of 30 mins2017-182016-17Target

75%

80%

85%

90%

95%

100%


A&E stays less than 4 hours (type 1)2017-182016-17Target

0

1

2


Ambulance handover times - breaches of 60 mins2017-182016-17Target

A&E Performance4 Responsive

• Where we want to be: targets and benchmarks

• We are seeking to reduce the number of patients waiting over 4 hours to a level at which we can sustain performance against the national standards for incomplete pathways.

• We want to achieve our submitted performance trajectory for 4 hour performance for 2017/18.

• Where we are: trends and patterns

• In December, performance outturn was 89.25%, this being below the STF trajectory of 90%. Staffing levels continue to improve, with new staff joining from September-January.

• Risks or opportunities for the Trust

• Effective ambulatory pathways (including Frailty, Acute Assessment Unit & the Surgical Assessment Unit) remain key to improving flow through the Emergency Pathway and reducing demand on the ED capacity.

• Clinically safe Emergency Pathways for other specialties which avoid patients having to be seen in the Emergency Department are also in development.

• Work is ongoing with SLAM to improve the pathway for mental health patients in A&E

• Root cause analysis and insights

• The three key drivers for current A&E performance are:

1. A challenging physical environment due to the current temporary phase of the Emergency Care Pathway rebuild.

2. High number of complex patients with acute clinical requirements, including mental health conditions, and attendance surges creating a busy department.

3. Outflow in to Trust beds and external services can be challenging at times.


Action plan put in place for assisting efficient use of redirection options.Acute Medicine

January 2017

Winter pressure pilot of an SNP based within A&E to support flow/bed allocation. Acute Medicine January 2017

A weekly rapid change group is now being held to ensure decisions are made quickly and actions taken to improve the emergency pathway. This meeting will be chaired by the Chief Operating Officer and will include representatives from Acute Medicine, HR, IT and any other group who is required to enable rapid change. This group will also monitor flow across the Trust with a particular forward look to Winter.

Acute Medicine DMT January 2017

December 2017

90.3%

89.7%

86.6%

88.1%

87.2%86.6%

90.5%

88.1%

83.4%

90.7%

91.9%

88.5%

90.4%

88.6%89.3%

89.4%

83.0%

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

Q1 Q2 Q3 Q4 Apr-17 May-17 Jun-17 Q1 Jul-17 Aug-17 Sep-17 Q2 Oct-17 Nov-17 Dec-17 Q3

% of patients who have a total time in A&E over 4 hours All Types National STF target

4.2.1 Elective access (a)4 ResponsiveDecember 2017

75%

80%

85%

90%

95%

100%


RTT - Incomplete pathways < 18 weeks (unadjusted)2017-182016-17Target

30000

35000

40000

45000

50000

55000

60000

65000

70000


RTT - Total incomplete pathways2017-182016-17

0

5

10

15

20

25

30


RTT - Incomplete pathways over 52 weeks2017-182016-17Target

88.7%89.2%

88.5%88.0%

86.8%

85.3%

86.5%87.1%87.2%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

RTT Performance and Trajectory 2017-18

RTT Actual %

RTT Plan

RTT Target

• The Trust’s incomplete performance improved in December to 87.2%.

• The backlog decreased to 7714 which is due to the continued effort of validation through weekend validation initiatives and additional central validation.

• The Trust recognises there is a substantial amount of work required to be undertaken across all Directorates to ensure it achieves the planned recovery trajectory in 2018/19. To support this it is planning to manage the RTT recovery as a separate programme of work led by the COO team with the support of dedicated Programme Manager. One of the immediate areas of focus will be to improve data validation processes.

• The Trust achieved the 2 week wait target in December for the fifth consecutive month. We also achieved the 2 week breast symptomatic referral target for sixth consecutive month this financial year. We continue to see the positive impact of the move to the Electronic referral system (ERS) for all 2WW referrals.

• The median wait across all tumour groups in December has reduced to 6.5 days, which is an improvement of 12-13 days seen before the introduction of ERS. We have continued to see a positive impact on our 7 day performance following the move to the Electronic referral system (ERS) for 2WW referrals. In December, we managed to see 67.2% of all cancer referrals within 7 days. This is a significant improvement from 16% at the start of 2017-18. Going forward we would anticipate 7 day performance to remain around 65-70%. This would demonstrate that we are able to offer adequate appointment choice to our patients within the 14 day standard.

4.3.1 Cancer – 2-week waits4 ResponsiveDecember 2017

75%

80%

85%

90%

95%

100%


Cancer - 2 week wait2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - breast symptomatic referrals <2 wks2017-182016-17Target

• We achieved the 31 day subsequent treatment standard for Chemotherapy in December. However we remained below the target for 31 day first treatments, secondary Surgery and Radiotherapy for the month. The graph below illustrates our performance prior to a review of the breaches reported. Validation is being finalised.

• As with previous months, the majority of December breaches for 31 day first relate to surgical pathways. Initial analysis suggests capacity, medical reasons and patient choice all impacted our 31 day surgical pathways. More detailed analysis will be taking place to better under the underlying issues.

• As part of our Cancer Action Plan, we are creating a stand alone workstream to focus on specifically on 31 day performance to understand key drivers of poor performance across all 31 day standards. This will enable us to produce specific action plans with services to improve waiting times in the future. This work is in addition actions such as Red2Green and minimum Cancer Standards which have been implemented recently to support all cancer pathways.

4.3.2 Cancer – 31-day waits4 ResponsiveDecember 2017

75%

80%

85%

90%

95%

100%


Cancer - 31 day first treatments2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - secondary chemotherapy <31 days2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - secondary radiotherapy <31 days2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - 31 day subs treatments - surgical2017-182016-17Target

4.3.3 Cancer – 62-day waits4 Responsive

• Overall performance for 62-day maximum wait for first treatment remains below the 85% target. We are currently achieving 71.5% (unvalidated) overall which is above the trajectory set for December. We are also on target to achieve our internal trajectory for the third consecutive month.

• Our focus on the delivery of our cancer recovery action plan continues with weekly meetings chaired by the Chief Operating Officer and attended by the Chief Executive Officer. We also continue with intensified operational leadership across all cancer pathways. This is achieved through daily huddles chaired by our Chief of Cancer Services and Director of Operations and appropriate challenge at cancer PTL meetings. Our underlying metrics for cancer continue to demonstrate improvement for internal pathways. For example, we are continuing to meet our backlog targets.

• We continue to work with colleagues both in South East London (SEL) sector and South East England (SEE) to improve the quality and timeliness of referrals. We are working with them to support extra diagnostic capacity for CT and MRI which started in November and we are sharing key achievements across the sector to ensure we put in place best practice processes to support better pathways for patients. This is being supported by both the Accountable Cancer Network (ACN) and the monthly Member’s Board of Chief Executive Officers from all three SEL trusts.

December 2017

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Cancer - 62 day urgent GP referrals2017-182016-17Target

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Cancer - 62 day screening2017-182016-17Target

4.4 Diagnostic waits4 ResponsiveDecember 2017

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Turnaround time - inpatient Ultrasound within 24 hours2017-182016-17

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Turnaround time - inpatient MRI within 24 hours2017-182016-17

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Turnaround time - inpatient CT within 24 hours2017-182016-17

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

6.0%


Diagnostic waits - % over 6 weeks2017-182016-17Target

• Performance in December was 5.89%. From the table above the majority of the breaches for December, sit in MRI and Non-Obstetric Ultrasound, with a moderate amount in Endoscopy.

• The reasons for the substantial volume of breaches in imaging (MRI and Non-Obstetric Ultrasound) is multifactorial and related to increased referrals; increased volume of Cancer and Urgent referrals resulting in reduced capacity for routine appointments; Staffing shortages and administration issues which resulted in scheduling delays.

• Radiology has a plan to reduce the backlog in Q1 with the following actions: - Additional internal capacity to reduce the backlog in MRI and US; Outsouring to Alliance private sector provider (130 have been outsourced in January).

• The remaining modalities with high breaches (Endoscopy and Paeds MRI) were above trajectory for December (due to reduced clinics and patient choice), but have come back inline with trajectory in January.

• @home: overall accepted referrals have decreased from 234 in November to 213 in December. The service received 67 referrals from GSTT in December compared to 77 in November. The service is piloting an @home care home pathway to reduce emergency admissions and plans are being developed to expand into new pathways during 18/19.

• Average length of stay for elective and non-elective patients remains comparable to the previous year’s profile, which also had a slight increase in Dec. Directorates continue to work hard on their length of stay (LOS) improvement plans for the remainder of 17/18.

• Work continues on improving hospital discharges before noon, Directorates use their huddles to continue focusing on improvements to early discharge.

4.5 Bed capacity and management4 ResponsiveDecember 2017

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5


Average length of stay (elective)2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%


Discharges before noon2017-182016-17Target

0

1

2

3

4

5

6

7

8

9

10


Non-elective average LOS >1 night2017-182016-17Target

0

20

40

60

80

100

120

140


GSTT referrals to @Home service2017-182016-17Target

• The definition of a DTOC is when a clinical decision has been made that a patient is ready and safe to transfer from an acute hospital bed to an alternative care setting, but is prevented from doing so. The Number of DTOC days decreased in December, showing a return to a lower level following an anomalous spike in August. We continue to see an improvement vs prior year on average which is a positive outcome of multiple work streams.

• Strategic transformation plans are underway to address our long-standing causes of remaining DTOC (jointly across both GSTT/KCH and both Lambeth/Southwark):

• Assessment delays – Some patients are unable to safely return home after a spell in hospital, and delays can be encountered awaiting health and social care assessment to determine ongoing support needs prior to discharge.

• Action: CHC Discharge to Assess – A new model has been developed in Lambeth and Southwark to ensure that the majority of patients are assessed for ongoing health care needs in an alternative care setting outside of the acute hospital. This model fully launched in October 2017, and patients are now able to return home, or to a temporary care placement, for their Continuing Healthcare Assessments. This will also support achievement of a new national target which requires 85% of all Continuing Healthcare Assessments to be undertaken in a non-acute setting by March 2018. Both Lambeth and Southwark boroughs achieved their trajectory against this standard in December 17.

• Action: Expanded D2A / Trusted Assessment – A workshop is taking place on 30 January 2017 to discuss an expanded D2A pathway, alongside Trusted Assessment arrangements. This will involve GSTT Acute, GSTT Community, KCH, Lambeth LA/CCG, and Southwark LA/CCG, and will determine the next transformational work stream to take place in 2018/19.

• Patient/family choice – The process of choosing an alternative long term care setting (for example, a care home) can take a long time and currently patients are remaining in hospital whilst they, or their family/carer, make this decision.

• Action: Independent support for Choice – GSTT started a pilot scheme in December 2017 whereby an independent company now provides a bespoke ‘hand holding’ service to support patients/families who are making a decision about long term care. This aims to improve patient/family experience and reduce related transfer of care delays. Impact analysis will be undertaken in March 2018.

4.6 Delayed Transfers of Care (DTOC) 4 ResponsiveDecember 2017

0

100

200

300

400

500

600

700

800

APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR YTD Avg

DToC Days GSTT 17/18 GSTT 16/17

0

100

200

300

400

500

600

700

800

APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR YTD Avg

DToC Days by Responsible Organisation NHS Social Care Both

• Appointments re-scheduled by the hospital within 6 weeks –Work is ongoing to explore an improved system of managing clinician leave and outpatient clinic utilisation using a “6-4-2” principle. Under this system the clinician running a clinic must be confirmed 6 weeks in advance or cross cover / clinic reallocation arranged, to make better use of outpatient space and avoid late notice cancellations.

• e-RS (National Referral System) – Tranche 1 and 2 services are now live. Tranche 3 paper switch off commences on 1st February 2018. CQUIN report on e-RS and Advice & Guidance has been submitted internally and will be submitted to Commissioners soon. We reduced our ASIs to 9% in December. More specialities being scoped for Consultant Connect – Dermatology commenced a pilot in January.

• Non-attendance for new and follow up appointments – Dr Doctor reminders (level 1) continue to be embedded into new areas of the Trust, and a pilot of level 2 (appointment re-schedule, auto offer) functionality has been completed in Dental specialties, with encouraging anecdotal feedback on phone call volumes and patient and staff satisfaction. Following review a roll out plan for both level 2 and 3 (online booking) functionality by specialty is being put together under the Digital Patient Journey transformation programme, to run through 2017/18.

• Follow-up ratio – The new: follow up ratio has deteriorated, however the number of overdue follow ups has reduced slightly.

4.7 Outpatient management4 ResponsiveDecember 2017

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


Appointments re-scheduled by hospital <6wks2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Non-attendance rate (new appts)2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Non-attendance rate (f/up appts)2017-182016-17

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0


Follow-up ratio - adj cons appts (in arrears)2017-182016-17Target

4.8 Theatre management4 Responsive

• Day case rates continue to meet the target of 85% with continued focus on ensuring patients are recovered and discharged in line with national best practice.

• Cancellation rates were above the Trust target of 7% in November 2017 but significantly below 16-17 rates. Three reasons accounted for 53% of all cancellations on the day; patient did not attend, patient self-cancelled and patient medically unfit. Surgical and theatre services are working hard to reduce avoidable cancellations on the day.

December 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Daycase rate - basket (in arrears)2017-182016-17Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%


Theatres Gross Cancellation Rate (in arrears)2017-182016-17Target

4.9 Complaints management4 Responsive

The Trust’s ambition is to provide a complaints system which is open to complaints, supports patients, families, and staff through the process, and which delivers a timely apology, explanation and determination to learn from mistakes. The aim is to produce a service about which complainants are able to say: I felt confident to speak up; making my complaint was simple; I felt listened to and understood; I felt that my complaint made a difference.

• The complaints team continue to work hard with the directorates to provide good complaints management in line with the regulations and good quality standard of response.

• The number of complaints received in December 2017 was consistent with complaints received in December 2016. • The complaints team also logged 56 informal queries. This figure represents a further 56 contacts that were dealt with by the team quickly and efficiently

preventing them from becoming formal complaints.• 1 final report was received from the Parliamentary and Health Service Ombudsman in December and was not upheld.

December 2017

0

20

40

60

80

100

120

140


Complaints opened in month (Trust total)2017-182016-17

0

20

40

60

80

100

120

140


Complaints CLOSED in month (total Trust)2017-182016-17

0

1

2

3

4

5

6


Complaints re-opened in month (Trust total)2017-182016-17

5.0 Domain scorecard5 Well-ledDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

GOV Overall goverance rating (Monitor, in arrears) Rating Green#N/A g

Green Green Green Green Green

CQC Care Quality Commission (CQC) risk assessment Score >5G G

6 6 6 6 6 - - Y

FFTS1 Staff Friends and Family - recommend as place to work Qtly % >70%M M

77.1% 77% Y

FFTS2 Staff Friends and Family - recommend for care or treatment Qtly % >80%M M

93.6% 93% Y

VACTB Overall vacancy rate Mthly % <9%R R

11.4% 10.4% 10.1% 10.1% 11.1% Y

TEMPTB Agency staff (% of paybill) Mthly % <4.3%G G

4.2% 3.4% 3.8% 3.3% 3.6% - - Y

TURNTB Rolling annual turnover rate Mthly % <11%R R

12.2% 12.4% 12.7% 12.3% 12.5% - - Y

206TB Sickness and absence rate Mthly % <3.0%R R

3.2% 3.40% 3.57% 3.49% 3.26% - - Y

211TB Appraisal compliance (non-medical staff) Mthly % >95%R R

72.1% 72.1% 72.2% 71.9% 71.7% - - Y

MTTB Mandatory training compliance Mthly % >95%R R

84.7% 83.4% 84.0% 83.7% 84.0% Y

5.1 External

assessments

5.2 Staff

experience

5.3 Workforce

indicators

• Staff opinion on whether they would recommend a health care organisation for care or for work is statistically associated with the quality of care. Any fall in the positive opinion should be seen as a potential earlyindicator of a reduction in quality of care.

• The NHS National Staff Survey takes place in the third quarter of each year. 5128 staff members took time to respond in the 2016 NHS Staff Survey. The Survey asked for staff to share their experience of working in theTrust, including questions about their job, their managers, their personal development, their health and wellbeing and their safety at work. The Trust achieved the highest score at 4.03 (on a scale of 1-5) compared tothe national average of 3.80. Staff satisfied with the quality of work and patient care scored 4.11, against a national average of 3.92. The survey results show we are above average in 22 out of the 32 key findings in thesurvey. 94 % of staff, one of the highest scores agreed that their role makes a difference to patients and service users compared to a national average of 91%.

• The 2017 NHS Staff Survey closed on 1 December 2017 and the Trust opted to run a full census survey. The Staff Survey Co-ordination Centre has informed us that benchmark reports will be sent to all NHS Trusts w/c19 February 2018. There will be an embargo that will be placed until 6 March 2018 and the full results will be published on this day externally.

• The National Staff Survey asks similar but differently worded questions to the Staff Friends and Family Test (SFFT), which is open in quarters 1, 2 & 4. A total of 1,448 staff participated in the Quarter 2 2017/2018 StaffFriends and Family Test (SFFT), which was conducted in August 2017. The Quarter 2 results highlight the fact that our staff continue to give the Trust a huge vote of confidence as a provider of care. The results showthat 93% of our staff would recommend the Trust as a place to be treated, well above the national average of 80%. 77% of our staff said that they would recommend the Trust as a place to work, again a higher figurethan the national average of 63%. The Trust ranks 22nd out of 229 for best place to receive treatment and 17th out of 229 for the best place to work when compared with other Trusts in England.

• The Quarter 4 Staff Friends and Family Test survey will be administered in February/March 2018.

5.2 Staff experience 5 Well-ledDecember 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Staff Friends and Family - recommend as place to work2017-182016-17Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Staff Friends and Family - recommend for care or treatment2017-182016-17Target

• The overall vacancy rate (10.16%) increased in December and remains above the target. The Trust Staff in Post decreased by 10.74 WTE in December. The Substantive workforce is over 1014.75 WTE greater (7.5%) than the same month last year. l. . There are 836 external applicants in the recruitment pipeline scheduled to join the Trust over the next few months. With these new starters in the pipeline the 3 month forecasted vacancy rate shows a reduction to 10.34%.

• Agency spend as a proportion of paybill decreased in December to 3.32% and is below the Trust’s target of 4.3%. Agency usage continues to be monitored on a weekly basis, with price cap breaches reported to NHS Improvement and the Trust Board.

• Voluntary Staff Turnover decreased to 12.29%, but continues to trend above the target of 11%, however the Trust continues to benchmark favourably other London Trusts.

5.3.1 Workforce indicators (a)5 Well-ledDecember 2017

0%

2%

4%

6%

8%

10%

12%

14%


Overall vacancy rate2017-182016-17Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


Agency staff (% of paybill)2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Rolling annual turnover rate2017-182016-17Target

0%

1%

2%

3%

4%


Sickness and absence rate2017-182016-17Target

• Personal Development Review (appraisal) compliance rates increased to 72.27% and remains well below target. The Trust has yet to achieve its target of 95%.

• Mandatory training decreased slightly to 83.67% and is slightly lower than the December 2016 rate, with compliance remaining below Trust target level of 95%. Most directorates are now over 75% compliant, with five achieving over 90% compliance. Training data is updated weekly on WIRED which is available to all staff and managers.

5.3.2 Workforce indicators (b)5 Well-ledDecember 2017

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Appraisal compliance (non-medical staff)2017-182016-17Target

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Mandatory training compliance2017-182016-17Target

6.0 Domain scorecard6 EnablersDecember 2017


yearOct Nov Dec

YTD

avg Mo

nito

r

Qualit

y

prioritie

s

Trend

chart

MRRT Finance Use of Resources Score <=2G G

2.1 2.0 2.0 2.0 2.7Y

- Y

LQRT Liquidity ratio (in days) Days >0G G

15.5 5.8 6.0 4.6 11.3Y

- Y

DSCT Capital service cover Ratio >2.59R R

1.9 1.55 2.30 2.07 1.20Y

- Y

FIN01T Overall underlying financial surplus/(deficit) £M >£6.37mR R

-£0.5 -£13.8 -£1.3 -£1.6 -£10.9Y

- Y

CSHT Cash flow £M >£143mG G

£142.6 £159.8 £167.2 £154.8 £160.5 - - Y

CAPT Capital spend vs plan (year-to-date variance) Mthly % +/- 15%R R

-36.0% 52.5% 55.0% 57.1% 53.5% - - Y

VRPT Variance from Plan (year to date) Mthly % > 0R R

0.1% -1.41% -0.08% -0.29% -1.8%Y

- Y

UNPT Underlying Performance Mthly % > 0.6%R R

0.2% -0.9% 0.6% 0.6% -2.0%Y

- Y

560 Elective activity vs profiled plan - cumulative variance (month in arrears)Cum var % >0%R R

0.7% -4.6% -4.6% -1.5% - ## Y

606T New patients seen vs plan (all categories, in arrears) Mthly var >0R R

159 -1,196 -844 -2,407 0 0 Y

714 External cons referrals Number >last yrR R

2,314 2,499 2,399 1,583 2,246 -Y

Y

713 GP referrals Number >last yrR R

18,413 20,218 21,204 16,598 18,708 - 0 Y

6.3 Fit for the

Future CIPSTC Cost improvement plans (CIPs) - var to plan YTD £M >£0m

R R-£5.6 -£6.7 -£6.9 -£5.5 -£5.7 - - Y

CMI024 Community data completeness - % contacts outcomed Mthly % ≥ 95%G G

95.2% 96.8% 96.6% 96.5% 96.8%Y

- Y

712 NHS number coverage Cum % >98%R R

98.0% 98.5% 98.5% 98.0% 98.5% - ## Y

710x Clinical coding - diagnostic depth (in arrears) Ratio >4.5G G

5.06 5.35 5.18 5.17 - 0.0 Y

6.4 Data quality

and clinical

coding

6.2 Activity levels

(magic numbers)

6.1 Overall

financial position

6.1.1 Overall financial position (a)6 EnablersDecember 2017

Financial performance is assessed against the single oversight framework where the highest rating that can be achieved is a one and the lowest a four. The term “Finance and Use of Resources Rating “ has been amended to “Finance Score” to distinguish it from the new “Use of Resource Ratings”

At December a rating of two has been achieved which is behind the plan of one.

6.1.2 Overall financial position (b)6 EnablersDecember 2017

The annual plan is a surplus of £10.2m. A loss of £1.6M has been recorded at December, which is £4.3M worse than the planned surplus of £2.7M.

The CIP requirement for 17/18 is £99M. Current schemes have identified £91.5m of new savings or income growth. At month 9 £64.6m of savings or income growth has been achieved against a plan of £69.8m. The Trust plan assumes an increase in CIPs later in the year, this is reflected by a phasing adjustment of £1.7M in December.

The cash position at £155M is £24M ahead of plan of £131M. Capital expenditure as a percentage of plan has fallen below the threshold of 85% (to 57%) and a reforecast may be required

6.1.3 Overall financial position (c)6 Enablers December 2017

• Demand – Both GP referrals and External consultant (tertiary) referrals have reduced in December, which is down to normal seasonal variation seen at this time of year. However, it is worth noting that the reduction in December 2017 for external consultant referrals was greater than that seen in December 2016.

• Year to date until November17, the Trust’s overall elective activity levels continue to remain below plan. However there has been a reduction in variance from plan for new patients seen (in November) compared to previous months, which is a positive improvement.

6.2 Activity levels 6 EnablersDecember 2017

-4,000

-3,000

-2,000

-1,000

0

1,000

2,000

3,000

4,000

5,000


New patients seen vs plan (all categories, in arrears)2017-182016-17Target

0

500

1,000

1,500

2,000

2,500

3,000


External cons referrals2017-182016-17Target

-

5,000

10,000

15,000

20,000

25,000


GP referrals2017-182016-17Target

-6.0%-5.0%-4.0%-3.0%-2.0%-1.0%0.0%1.0%2.0%3.0%4.0%5.0%6.0%


Elective activity vs profiled plan - cumulative variance 2017-18

2016-17

• Accurate and complete clinical coding of our activity is important to ensure patient safety, accurate benchmarking and appropriate payment for the services we provide. Improving the quality of all of our data ensures that the information on which we base decisions is reliable.

• Diagnostic depth - the average number of diagnoses recorded per admitted episode – has increased to 5.3 diagnoses during 2017-18 (top left) and we have re-set targets for further improvements going forward. We are expecting to see further increases during 2017-18 as a result of more structured capture of patients’ underlying medical conditions within E-noting. Capture of smoking status is being used as a lead indicator for how well we are capturing co-morbidities, especially by non-medical staff (top right). We anticipate that the current level still understates the true prevalence of smoking amongst our admitted patients.

• Within the community setting, the capture of outcomes from patient contacts is our key indicator (bottom left). Levels are now exceeding 95% following a dip in performance linked to the introduction of Advanced Care Notes – the community clinical IT system.

• NHS number coverage (bottom right) is now ahead of the target level of 98% overall . Particular measures are in place to try to improve the capture of accurate demographic information amongst patients attending our A&E departments.

6.3 Data quality and clinical coding6 Enablers

Coded smokers

December 2017

75%

80%

85%

90%

95%

100%


Community data completeness - % contacts outcomed2017-182016-17Target

90%

92%

94%

96%

98%

100%


NHS number coverage2017-182016-17Target

6 EnablersMay 2015

6.5 Essentia Patient Services:Cleanliness

Summary:• Cleanliness scores continue to meet Trust performance targets.• Essentia’s team of specialist internal auditors assess cleanliness against a range of National Patient Safety authority (NPSA)

standards. The audit result is shown in the graph below. The NPSA score continues to track above target of 90%, with a score in November of 98.6%. The NPSA score of 98.40% was achieved against a target of 90%.

Action and Progress to Date:

• The monthly Inpatient Survey for cleanliness is conducted via ‘Meridian’. In December there were 1078 responses (for ward cleanliness and toilet/bathroom cleanliness), of which over 99.19% said that the cleanliness of their ward or room was ‘fairly clean’ or ‘very clean’.

• The decontamination activity in December was high, a total of 272 UV and 79 VHP at St Thomas’ and 96 UV and 13 VHP at Guy’s. In total 460 decontaminations were carried out across both sites compared to 189 in October 2016.

December 2017

6 EnablersMay 2015

Page 57

6.5 Essentia Patient Services:Catering

Summary: • Very strong performance in the 2016 Inpatient Survey (reported below) placing the Trust in the upper quartile in the Picker and Shelford Groups.• In the 2017 PLACE Assessment Guy’s and St Thomas’ performed above the national average for food and hydration (reported below).• No formal complaints received for patient catering in the last 12 months.


• The patient catering services continues to provide food that is highly rated by the patients. In December 5.38% rated the food as poor and there were no formal complaints received. This is against a background of in the region of 108,000 meals served per month.

• Catering and hospitality arrangements over the Christmas period performed well with no reported operational issues. This reflected the hard work and dedication of the catering team in putting in place special festive menus and delivering the service over what is a very busy period

• The National and Young Peoples Survey 2016 highlighted the Evelina amongst the lowest performers in London. This is not in line with the overall Trust performance but does highlight the need for some focused action for children and young adults. The catering and nursing teams have been working together to put in place actions aimed at improving performance. This is currently being reviewed to track progress and to ensure there is a robust plan in place, and that there is full engagement from all parties.

• In line with NHS England’s aims to reduce the sale of sugar-sweetened beverages (SSBs), the Trust has secured the commitment of all its retail operators, with the exception of Sainsbury’s, to commit to a voluntary sales reduction scheme for SSBs. Sainsbury’s position reflects that the Guy’s store is the only one they operate in the NHS, and whilst supportive of the scheme they are unable to adjust their operating model for such a small part of the overall business.

PLACE 2017

December 2017

Food Safety

Independent internal food safety compliance monitoring is carried out unannounced in all Trust catering venues. The audits are conducted to assure compliance with the food hygiene regulations and adherence to the Trust’s food safety policy and procedures. All areas inspected scored above target levels. Food venues are also inspected periodically by the Local Authority Environmental Health Department who issue a food safety rating between 0 and 5, with 5 representing full legal compliance with the food safety and hygiene regulations.

All areas that have undergone the inspection, including the main kitchen, are rated 5.

Trust Score

National

Average

Food 93.12% 89.70%

Organisation 92.74% 88.80%

Ward 93.16% 90.20%

Quality of Food (Good) 59.00% n/a

Choice of Food 90.10% n/a

Help with Eating 80.10% n/a

PLACE 2017 Food and

Hydration

2016 Inpatient Survey

6 EnablersMay 2015

6.5 Essentia Patient Services:Patient Transport Services

Summary:• The Patient Transport Service (PTS) undertakes around 22-25,000 journeys each month and 13,000 patient eligibility assessments.

• The main KPI's around arrival and departure times remain challenging. Arrival times are tracking below pre-contract levels.

• The Friends and Family test in December based on 597 responses, scored 93.13% for ‘would recommend’ and 0% for those that ‘wouldn’t’.

Action and Progress to Date:• Under the current contract enhanced performance standards were introduced;

patients are required to arrive no earlier than 45 minutes and no later than 15 minutes before their appointment time, and to depart within 30 minutes of being booked ready to travel. It soon became clear that these standards were unachievable within the operating environments of our main hospital sites and therefore unenforceable from a performance penalty perspective. The reality is that the current service has settled into a steady level of performance and has maintained standards achieved under the old contract, these being arrival times within 90 minutes of appointment and being booked ready to travel for the return journey. Market research carried out has indicated that these standards are fairly typical across the NHS. Within this report both the old and new KPIs are reported

• Kent and Medway PTS provided by G4S (commissioned by CCG), continues to experience operational issues. These problems have been repeatedly raised with the CCG who have now recognised that the activity volumes included in the contract specification were understated. This has led to the Commissioners asking G4S to re-base the contract as part of a ‘true-up’ exercise, the outcome of which was expected mid-December but has still not been received - it understood that the CCG and G4S are still in discussions. A meeting has been organised with Ian Ayres, the CCG Responsible Officer, which will be attended by Eileen Sills and Alastair Gourlay, the aim of which is to seek assurance on a sustained improvement to the service.

December 2017

6 EnablersMay 2015

6.5 Essentia Patient Services:Patient Transport Services

Performance Breakdown New KPI’s

December 2017

6 EnablersMay 2015

6.5 Essentia Patient Services:Telephony

Summary:In month there was an improvement in performance which in part reflects lower activity over the Christmas period. A recruitmentinitiative is in place which is expected to contribute to an overall improvement in performance early in the new year.


• The results of an intensive recruitment drive through November is now evident. In total 12.88 WTE positions have been offered, with nine having commenced in December and January. Further recruitment is on-going with the aim being to fill all vacant positions by the end of February.• A project plan is in place to address underlying organisational design issues. This is aimed at creating increased staff engagement and a working environment to support an improvement in overall performance.• GOSH has requested a draft proposal to extend the service currently provided for an additional year from July 2018.

December 2017

6 EnablersMay 2015

6.5 Essentia Services:Engineering & Building

December 2017

Summary: • Following additional revenue investment in an enhanced out of hours maintenance regime, lift availability on the two acute sites is once again

above target, with a score of 99% for December. Please note that currently 47.7% of our lift call outs are for misuse and abuse• Priority 2 calls (responded to within 4 hours) - November’s and Decembers performance of 69% falls just below target but is an improvement

on the 59% achieved in September. The Holiday period had a slight impact on P2 compliance. The Priority 2 KPI measures the time it takes to respond to calls, as full resolution and repair may require out of hours work or the procurement of additional parts.

Action and Progress to Date: • Recruitment continues to be an issue for key positions, with a high number

of vacancies. A review is currently underway. This will from time to time impact on reactive works but the focus will continue to reduce this impact as much as possible.

• Planned Preventative Maintenance (PPM’s) tasks are being completed, however the month-on-month completion rate is being affected by the increased number of PPM’s that are now in place. This is under review, looking at current use contractors against internal resourcing; this follows both the internal audit and the latest review of the CBRE contract specifications.

• New lifts following refurbishment are now available• Engineering and Building Compliance is progressing, with only 3.2% of the

600 questions remaining at red risk status.

6 EnablersMay 2015

6.5 Information Technology / Digital December 2017

Summary:

• Major improvement in the number of incidents resolved within target for December. For the first time in 8 months, the target of 75% was

exceeded for priority 2 tickets being resolved within 1 working day.

• The call answer time continues to be challenging for the Service Desk with a recorded average of over 5 and a half minutes for December.

• User satisfaction remains high at over 95% against a target of 85%.

Action and progress to Date:

•There were two P1, full outage incidents recorded in December, both relating

to the Trust’s Integration Engine, Biztalk.

•All requests targets were achieved for the third month in succession.

•Focus will be given to identifying areas of improvement with incident

resolution as the P3 target has not been met for some time.

•Five complaints and five compliments were received in December.

Complaints related to the length of time to deliver services and length of time

to get through to the Service Desk. Compliments related to the service offered

by the Service Desk, our End User Technology and Training teams.

•December saw a decrease in overall ward visits made by the Wards First

teams. This was primarily due to there being 5 ward closures over the

Christmas period.

•A complete review of the Service Improvement Plan will be carried out in

January/February with a focus on achieving the call answer target.

6 EnablersMay 2015

6.5 Essentia Services:Sterile Services

December 2017

Summary:• Non-conformity levels reported at 0.047% for the quarter equating to 1:2127. • Average activity volumes for the quarter September to December 2017 at 17,800 packs processed per week. • The current turnaround trends show an average of 7.2 hours against the agreed target of 24 hours.

Action and Progress to Date:• In October the North Middlesex contract reported issues with turnaround

times and some quality errors in October. Following implementation of a rectification plan a significant improvement has been recognised and performance overall is now back on track.

• Turnaround times (TAT) continue to perform below the industry norms of 12 hours, which enables good set utilisation.

• The preventative measures implemented by SSD have been successful with reports of a significant reduction in torn or damaged tray wrap. Measures include reinforced wrap, vacuum packs, protective cardboard and wider banding. An element of risk remains due to lack of theatre store shelving capacity, which can contribute to the damage of outer wraps by trays being stored on top of one another.

6 EnablersMay 2015

6.5 Essentia Services:Community

December 2017

Summary:

• Community teams are consistently achieving and exceeding their targets for reactive and PPM maintenance.

• Community cleanliness scores consistently exceed the 95% target for In-Patient sites.


• VHP cleaning continues within GSTT Community sites.• Reactive maintenance performance dipped from 89% in November to 76%

in December. This is due to a vacancy in the department not being successfully filled. Recruitment is underway with the intention of recruiting to the in the first quarter.

• All PPM tasks are currently under review, including activity codes, which will re-classify activities and reduce the number of codes. This review will include the categorisation of PPM’s, including statutory and mandatory tasks.

• Although within target, the slight dip in PPM compliance is due to Contractors operational times over the Christmas period. We will plan to review due times (for contractor works) in advance of Holiday periods.

Appendix: directorate-level heatmap (1 of 2)December 2017

Type Target Tru

st-w

ide

Acu

te M

edic

ine

Per

iop

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ive,

Cri

tica

l Car

e &

Pai

n

Surg

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Car

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Ab

do

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al M

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and

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On

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nd

Hae

mat

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Wo

men

's S

ervi

ces

Clin

ical

Imag

ing

& M

edic

al P

hys

ics

Med

ical

Sp

ecia

ltie

s

Den

tal S

ervi

ces

GR

IDA

Ther

apie

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Ad

ult

Co

mm

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ity

Serv

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Ch

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un

ity

Serv

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Ch

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Med

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Ser

vice

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Ch

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n's

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Mo

nit

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for

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Patient safety - Total incidents reported Number - 2,194 509 228 50 86 80 204 211 29 0 24 36 15 201 0 201 0 - - - -

Incident Reporting Incidents - Reported on STEIS (total number) Number - 10 3 3 0 0 2 0 0 0 0 1 0 0 1 0 0 0 - - - -

Incidents reported on Datix that are STEIS reportable (total number)Number - 10 3 3 0 0 2 0 0 0 0 1 0 0 1 0 0 0 - - - -

Never Events Number Zero 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 - - - y

Incidents resulting in unexpected death Number - 6 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 - - - -

Incidents resulting in severe harm Number - 6 0 2 0 0 2 0 0 0 0 0 0 0 0 0 1 0 - - - -

Incidents resulting in moderate harm Number - 43 4 9 2 1 3 3 2 2 0 1 1 0 8 0 2 0 - - - -

Incidents resulting in low harm Number - 338 54 30 8 15 15 27 24 7 0 5 9 7 62 0 33 0 - - - -

Incidents resulting in no harm Number - 1,797 450 185 40 69 59 173 185 20 0 18 26 8 130 0 164 0 - - - -

Incidents resulting in unexpected death - reported on STEIS Number - 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -

Incidents resulting in severe harm - reported on STEIS Number - 3 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -

Incidents resulting in moderate harm - reported on STEIS Number - 4 2 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 - - - -

Incidents resulting in low harm - reported on STEIS Number - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -

Incidents resulting in no harm - reported on STEIS Number - 2 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 - - - -

Patient safety Never events (confirmed) Cases Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0 0 Y

Harm Free Care Patient slips trips falls (DATIX) Cases - 140.0 51.0 2.0 9.0 13.0 6.0 15.0 0.0 0.0 0.0 0.0 0.0 3.0 0.0 0.0 1.0 0.0 - - - 0

Incidence of falls per 1000 bed days Number - 4.7 6.5 1.6 4.6 2.8 3.3 4.2 0.0 0.0 0.0 0.0 0.0 - 0.0 - 0.3 0.0 0 0 0 0

Falls with moderate or severe harm Cases 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -

Pressure ulcer acquisitions (grade 2 and above) Number 0 5.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 - - - -

Infection Control MRSA screening of admissions Mthly % >95% 91% 63% 91% 97% 96% 99% 92% 94% 86% 96% 100% 90% 0% - - - 87% - - - 0

and Cleanliness MRSA bacteraemia (Trust-attributable) Number Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -

C-Diff acquisitions Number 0 2.0 0.0 0.0 0.0 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Y - - -

Screening VTE screening (externally reported) Mthly % >95% 94% 89% 97% 78% 80% 98% 94% 92% 140% 96% 100% 100% 0% 100% - 88% 73% - Y - -

Dementia screening (patients aged over 75) Mthly % >90% 79% 86% - 32% 85% 40% 50% - - 100% - 100% - - - - - - Y - -

Mortality Deaths in hospital - number in month Number - 105.0 50.0 4.0 2.0 15.0 5.0 15.0 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 4.0 3.0 - - - -

Admitted care Friends and Family test (Ward) - Response rate Mthly % >=33% 19% 30% 27% 38% 22% 18% 44% 20% - - - - - 71% - 18% - - - - -

Friends and Family test - % Recommended (Ward) Mthly % >=97% 95% 94% 80% 97% 95% 97% 94% 100% - - - - - 80% - 98% - - - - -

Friends and Family test - % Not Recommended (Ward) Mthly % <=1% 2% 3% 10% 1% 0% 1% 1% 0% - - - - - 0% - 0% - - - - -

Overall inpatient patient experience score Mthly % >89% 89% 88% 73% 89% 90% 88% 88% 90% - - - - - - - - - - - - 0

Single sex compliance - breaches (all types) Cases Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -

Patients cancelled on day (in arrears) Cum % <0.8% 1.8% - 0.6% 1.3% 7.8% 4.2% 1.7% 2.4% 175.0% 1.9% 0.4% - 0.0% - - 3.6% 2.0% - - - 0

Overall outpatient patient experience score Mthly % >89% 91% 90% - 94% 88% 89% 89% 85% 88% 86% 94% 90% 93% - - - - - - - 0

Friends and Family test - % Recommended (Outpatients) Mthly % - 92% 94% 82% 91% 98% 95% 92% 91% 92% 89% 95% 91% 94% - - 100% 96% - - - -

Friends and Family test - % Not Recommended (Outpatients) Mthly % - 4% 5% 14% 4% 1% 3% 3% 6% 4% 5% 2% 4% 1% - - 0% 4% - - - -

Outpatient care

Appendix: directorate-level heatmap (2 of 2)December 2017

Type Target Tru

st-w

ide

Acu

te M

edic

ine

Per

iop

erat

ive,

Cri

tica

l Car

e &

Pai

n

Surg

ery

Car

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Ab

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and

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On

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Clin

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Med

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Sp

ecia

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Den

tal S

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ces

GR

IDA

Ther

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Ad

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Ch

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Co

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Ch

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Med

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Ch

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Mo

nit

or

CQ

UIN

Fit

for

Futu

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RTT RTT - Non-admitted patients <18 weeks (unadjusted) Mthly % >95% 89% 91% 55% 86% 76% 89% 86% 91% 74% 97% 94% 95% 80% 100% 100% 80% 80% Y - - -

RTT - Admitted patients < 18 weeks (unadjusted) Mthly % >90% 79% 100% 73% 74% 70% 85% 79% 69% 100% 85% 90% 90% 100% 100% - 84% 58% Y - - -

RTT - Incomplete pathways < 18 weeks (unadjusted) Mthly % >92% 87% 96% 85% 82% 84% 92% 81% 87% 72% 96% 92% 97% 88% 97% 75% 83% 74% Y - - -

RTT - Treatments over 52 weeks (unadjusted) Mthly Zero 8.0 0.0 0.0 6.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 1.0 - - - 0

RTT - Total incomplete pathways Mthly - 60,220 3,132 1,928 4,058 4,340 2,766 6,002 2,951 248 5,131 10,172 7,259 840 116 12 2,911 2,785 - - - 0

RTT - Incomplete pathways over 18 weeks Mthly - 7,714 129 297 744 703 233 1,128 377 70 230 862 236 100 3 3 483 717 - - - 0

Cancer access Cancer - 2 week wait Qtly% >93% Y - - -

Cancer - breast symptomatic referrals <2 wks Qtly % >93% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% Y - - -

Cancer - 31 day first treatments Qtly% >96% - - - - - - - - - - - - - - - - - Y - - -

Cancer - 31 day subs treatments - surgical Qtly% >94% Y - - -

Cancer - 62 day urgent GP referrals Qtly % >85% Y - - 0

Cancer - internal 62-day referrals Qtly% >85% - - - -

Cancer - 62 day screening Qtly % >90% Y - - 0

Diagnostics Diagnostic waits - % over 6 weeks Mthly <1% 6% 0% - - 3% 6% 0% - 6% 0% - - - - - 12% 13% - - - -

Bed management Average length of stay (elective) Cum ALOS <last yr 3.9 2.7 9.3 3.3 5.3 3.5 4.6 3.4 1.2 2.9 1.3 7.1 0.0 43.6 0.0 2.5 2.2 - - Y 0

Non-elective average LOS >1 night Cum ALOS <last yr 8.7 6.6 7.7 0.2 2.7 7.3 15.0 9.2 6.0 90.7 0.0 23.3 3.0 39.9 0.0 7.0 43.7 - - Y 0

Discharges before noon Mthly % >25% 20% 32% 17% 25% 12% 9% 18% 8% 64% 13% 50% 19% - 71% - 18% 25% - - - 0

Outpatient mgt Appointments re-scheduled by hospital <6wks Cum % <4% 5% 3% 6% 6% 6% 5% 8% 2% 1% 12% 4% 4% 2% 2% 0% 3% 4% - - Y 0

Follow-up ratio - adj cons appts (in arrears) Ratio 2.06 2.16 2.75 1.27 1.56 2.48 3.25 2.54 0.88 1.29 2.74 2.58 1.98 - - - 2.16 1.84 - - Y 0

Non-attendance rate (new appts) Mthly % <11% 13% 19% 10% 11% 35% 16% 12% 12% 20% 14% 7% 11% - - 0% 9% 11% - - Y Y

Theatre Daycase rate - basket (in arrears) Mthly % >85% 86% - - 90% 97% 53% 77% 90% - 100% - - - - - 88% 69% - - - 0

management Theatres Gross Cancellation Rate (in arrears) Mthly % <7% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% - - - -

Readmission mgt Emergency readmissions (within 28 days - in arrears) Cum % <5.8% 5.9% 11.3% 1.4% 2.8% 4.6% 5.5% 10.9% 2.2% 2.5% 1.9% 0.1% 1.8% 0.0% 3.0% 0.0% 3.8% 2.4% - - - 0

Emergency readmissions (within 14 days - in arrears) Cum % <3.8% 3.8% 8.1% 0.8% 2.2% 3.1% 3.0% 7.2% 1.7% 1.4% 1.4% 0.1% 1.2% 0.0% 1.5% 0.0% 2.6% 1.7% - - - 0

CQUIN - general Patients >75 asked dementia screening question Qtly % >90% 79% 86% - 32% 85% 40% 50% - - 100% - 100% - - - - - - Y - -

Data quality NHS number coverage Cum % >98% 98% 95% 100% 99% 100% 100% 100% 99% 100% 100% 96% 99% 99% 100% 100% 98% 100% - - - 0

Clinical coding - diagnostic depth (in arrears) Ratio >4.5 5.2 7.7 4.5 4.1 8.9 6.4 4.5 6.9 4.3 4.1 2.4 3.4 1.7 8.5 2.9 4.1 - - Y 0

Activity Elective activity vs profiled plan - cumulative variance (month in arrears)Cum var % >0% -5% 7% -6% -6% 0% 9% -4% -11% -12% -19% -8% 12% 0% 0% 0% -6% -15% - - - 0

(magic numbers) New patients seen vs plan (all categories, in arrears) Mthly var >0 -844 -8 24 -107 -110 213 -1 -156 -15 -511 221 -725 320 0 0 89 -119 0 0 0 0

External cons referrals Number >last yr 1,583 83 23 157 207 102 169 42 9 43 31 286 9 0 0 125 151 - - Y Y

GP referrals Number >last yr 16,598 539 139 505 736 524 1,440 2,487 25 1,176 1,933 1,815 3,794 0 0 277 193 - - Y 0

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