Board of Directors’ Meeting Report – 27/03/13 · Board of Directors’ Meeting Report – 27/03/13 Integrated Performance Board Report Rupert Wainwright Information Team, Rupert

Poor performance can affect all aspects of the

organisation resulting in possible regulatory sanctions

and legal claims against the Trust.

The aim of the Integrated Performance Board Report is

to ensure that patient, public, and workforce safety is

maintained to the highest standards

As far as can be considered this paper has no

detrimental impact for the 9 protected characteristics

under the Equality Act 2010

Recommendations:The Board is asked to note this report and receive assurance

therefrom.

Agenda Item 96/13

N/A

Executive Summary: The Integrated Performance Board Report has been

reformatted to include recommended changes from the Board. Performance against

key indicators continues to be inconsistent with targets not met in Cancer and A&E.

Patient Focus – Keep Getting Better

BAF risk 1

Previously considered at

Related Trust Objective

Related Risk

Legal implications /

regulatory requirements

Quality impact

assessment

Equality impact

assessment

Board of Directors’ Meeting Report – 27/03/13

Integrated Performance Board Report

Rupert Wainwright

Information Team, Rupert Wainwright, Sandra le Blanc,

Sue Hardy

To provide assurance to the Board about the Trust’s

performance against national and local performance

measures.

Sponsoring Director

Authors

Purpose

Title

Page 1 of 50

F February - Month 11 - 2012/13

Best possible rating of 'Green' Lowest possible Risk Rating of 5 3

>=90% within 18 weeks 91.6% 84.57% q

>=95% within 18 weeks 98.0% 97.49% p

>=92% 95.90% p

(<= 100) 338 p

< 23 weeks 23.02 p

< 18.3 weeks 15.37 q

>=95% of all cases to be seen

within 4 hours. (SITREP data) 93.8% 89.9% q

Arrival to handover (>= 85% within

15 mins) 36% p

Handover to clear (>= 85% within

15 mins) 91% u

Arrival to clear (>= 85% within 15

mins) 73% p

<12.64% by end of year (<13.34%

before Jan 13) 14.0% 13.20% p

<0.8% FFCE's cancelled with short

notice. 1.15% 2.22% p

< 5% cancellations readmitted

outside 28 days. 4.91% 4.40% q

<1% 0.59% 0.45% q

all cancers (>93%) 94.9% 97.0% p

symptomatic breast (>93%) 92.8% 92.1% p

>96% 97.6% 97.7% p

anti cancer drug treatments (98%) 99.5% 100.0% p

surgery (>94%) 97.1% 100.0% p

radiotherapy (>94%) 97.9% 95.7% q

from urgent GP referral to

treatment. All Pathways (>85%) 85.1% 83.0% q

from urgent GP referral to

treatment. Southend Only (>90%) 90.6% 89.5% p

from cons screening service referral

(>90%) 95.2% 92.0% p

<6 22 q

>99% 99.81% p

85.4 69.2 q

Standard / TargetCompliance -

YTD

Compliance -

Report MonthMovement on previous over 13 month period

MonitorGovernance Risk Rating

Finance Risk Rating

18 Week RTT

(Referral to

treatment)

Admitted

Non - Admitted

Incomplete (not yet stopped)

Admitted Backlog

Admitted (95th percentile wait in

weeks)

Non - Admitted (95th percentile

wait in weeks)

A&E

Maximum 4 hour wait

Ambulance Turnaround * (Week

ending 10/2/12 covering 4 week

period, Jan 27th unavailable)

Cancellations

IP - All cancelled TCI (hospital %)

IP - Short notice (non-medical)

IP - Short Notice Readmitted

within 28 days

OP - Short notice clinic

cancellations

Diagnostics (6 Wk

Target)

DM01 - Waiting list 'as at' month

end for Unify

All Cancers: 62 Day wait for first

treatment comprising either:

Cancer

2 week wait from referral to date

first seen

All Cancers: 31 day wait

diagnosis to 1st treatment

All Cancers: 31 Day wait for 2nd

or subsequent treatment,

comprising either:

Cancer Backlog

HSMR (Latest available) Not to exceed national average of 100 (<100)

SUHFT Integrated Performance Report

Trustwide Overview

Frontsheet

Patient Access - Rupert Wainwright

Key: Red = Negative performance or non-compliant, Green = Positive or compliant. Arrow direction indicates movement from previous. Areas shaded Blue are not yet updated with the latest figures.

Southend University Hospital Foundation Trust Page 2 of 50

http://www.monitor-nhsft.gov.uk/home/about-nhs-foundation-trusts/nhs-foundation-trust-directory/southend-university-hospital-nhs-fou

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YTD

Compliance -



Number of measures compliant 21 p

Number in compliance range. 3 q

Number non-compliant 2 q

Data not provided/no target 7 q

<1:20 18 q

≥90% 79.0% q

4200(<350) 264 q

≤25% 28.0% p

≥75% 75.0% p

<8 8 q

<=12% (per Key Performance

Indicator collection) 12.1% q

93.5% 93.6% p

7.49% 8.78% p

< 3.25% (Top quartile University

Trusts) 3.96% 4.19% p

< 9.5% (Top Quartile University

Trusts) 10.40% 11.87% p

1.034 p

96.6% 98.0% q

Maternity

Dashboard

Various clinical and operational

Measures

Direct unexpected NICU

admissions from CDS

Maternity currently

failing or with a

failure of

compliance /

target in the last 6

Months

Supervisor to Midwife ratio

Bookings before 12+6

Total maternities

Total rate - All LSCS

Initiation of breast feeding

Non-Elective

KPI - Smoking at Delivery

MRSA Screening Screen 100% of relevant admissions

Pre-op Bed Days (Elective) Target of < 7.45% to be maintained

Summary Hospital-level

Mortality Indicator (SHMI)Not to exceed national average of 1 (<=1)

VTE Testing>=95% (Internal Target- Data shown from last complete

month)

Readmissions (30

Day)

Elective

Quality - Sue Hardy



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YTD

Compliance -



Formal Complaints 10% reduction on last year -6.24% p

141 128 p

0.0% q

0.8% q

Internal Target of Top

Quartile

(>75%) benchmarked against NHS

Midlands and East Trusts 13.0% q

54 q

Average across

business units>=90% 90.0% 96.5% p

21 5 p

3 1 p

Extreme 0 0 u

High 2 2 p

Low & Moderate 426 55 p

0 0 u

National Top 20% 32.3% p

Average 50.0% q

National Bottom 20% 17.7% p

Zero Tolerance 71 6 p

Targets pending outcomes of Qtr 1

monitoring. 0.20% 0.19% p

Targets pending outcomes of Qtr 1

monitoring. 0.20% 0.41% q

No targetYTD is average of most recent 12

months.90.73% 88.93% p

30 3 q

3 2 p

(5,964) (466) q

(3,382) 144 q

874 141 q

(250) (116) q

(1,552) (55) q

5,759 498 q

15,104 p

592 (181) p

68.3% 68.5% p

Complaints

Falls

Internal Target - 10% reduction on last year, - YTD & chart

show number above/below trajectory) (<= 0)

Moderate Harm as % of All Falls

High/ Extreme Harm as % of All Falls

Trust wide <=1 hospital acquired per year (Monitor will not

fail until 6)

Medication ErrorsTarget not yet

determined

Friends & Family10 point improvement on Previous Year End (55) CQUIN

(Commissioning for quality and innovation) Target

Head Nurse Quality Indicators

(HNQI)

Incidents of C Diff Trust wide <=26 hospital acquired per year

Incidents of MRSA

Bacteraemia

Mixed Sex Accommodation Target is 0 Breaches

Patient Reported

Experience

Measures -

PREMS

Quarterly patient survey results,

benchmarked against national

scores.

Safety Thermometer

Serious Incidents Targets under review

Pressure Ulcers

(Grade 2 and

above)

Total Hospital Acquired

(Avoidable)

Hospital Acquired as % of Total

Admissions (Avoidable)

Hospital Acquired as % of Total

Admissions (Un-avoidable)

Outpatient F/up

Inpatient Elective

Inpatient Planned

Inpatient Non-Elective

Capital (NET)On Budget spending Under plan/(Over plan), variance

shown. £000

- of which Never Events Target of '0'

Activity vs. Plan

Outpatient New

Variance: Net (Surplus) / Deficit

Pay Related Cost 60% (YTD shows average)

Cash Flow StatementCompliant to FT Plan (Under)/Over, figure shown is

variance on plan. £000

Income & Expenditure Variance: Net Surplus / (Deficit) £000

Quality - Sue Hardy

Finance & Activity - Brian Shipley

Workforce - Sandra Le Blanc

21 24

+2 1



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YTD

Compliance -



Trust Total 78.88% 59.35% p

100.0% p

3.29% 3.82% 1.84% q

11.22% 9.20% q

4597 q

3,969.84 4009.82 q

96% 96.69% p

- 4,439.31 p

- 9.93% 12.49% p

3.29% 3.55% 3.00% q

All Staff

(FTE)Overall

2 16.15% p

Overall2 11.67% p

Voluntary 9.26% q

Involuntary 2.41% p

Left within 1 Year 23.72% q

Fire, Inanimate Loads & Infection Control

Statutory

Mandatory

Training

Reach 85% for all staff to be trained

in each 12 month period - number

trained vs. a headcount 77.56% q

8 0 u

40 2 q

4% 3.31% q

No set targets 5.39% p

Appraisals 80%

Induction99% (permanent and fixed term temp staff only, excludes

doctors)

FTE (permanent, fixed term temp

and locum staff only)

FTE (permanent, fixed term temp

and locum staff plus bank)

Bank Staff Rate

Agency Spend as % of Pay Bill (Monthly)

Bank, Agency and *Additional Non-Contractual Payments Total

Staff Levels

Headcount (permanent, fixed

term temp and locum staff only)

Establishment (FTE)

Sickness Absence Rate (rolling 12 months)

Staff Turnover

Rate

10.1% for staff excluding junior

doctors for the Trust (based on

public sector 2012 in CIPD report)

Excluding

Junior

Doctors

(FTE)

Vacancy Rate

Based on Establishment minus In

Post

Based on Requisitions against

Establishment

Fire, Inanimate Loads & Infection

Control

Employment Tribunals No set targets

Grievances Raised No set targets

Workforce - Sandra Le Blanc

Clinical Outcomes/ Research & Development - Neil Rothnie



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YTD

Compliance -



Number of measures compliant 29

Number measures non-compliant 6

Data not provided 15

Clinical

Oncology 56.25% p

Pathology 8.79% p

A&E 6.31% p

Stroke 43.47% q

Ortho 90.48% p

Urology 43.08% q

7.07 p

7.07 p

157 u

24 u

103 u

59 u To be included from March '13

39 u Development underway

4 u

Target 25 days 16 u

1 u

u

u

u

u

u

68279 6956 q

0.53 0.46 q

4.18 2.87 p

Clinical Outcomes

(Qtr.)Various Clinical Measures

Clinical Outcomes

currently failing or

with a failure of

compliance in the

last year

(Quarterly)

% Radiotherapy within 24hrs for Spinal Cord Compression

Post MRI (100% Target)

Borderline Nuclear Abnormality Rates for Cervical

Screening (<9% Target)

% OP Patients Seen and Discharged in a Single Visit i.e.

One Stop (>85% Target)

Obstetrics

Perinatal Mortality Rate (<5.6/1000 Target)

Still Birth Rate (<3.1/1000 Target)

All Unscheduled Reattendances Within 7 Days (<5%

Target)

Number of Patients who Return Home with Total

Independence (>50% Target)

% Patients with Hip Fractures Operated on within 36hrs

(>80% Target)

Research

Governance &

Facilitation

Number of projects approved

Median time to approval (days)

Grant applications

Publications

Research Activity

Total number of research studies

Industry sponsored research

NIHR portfolio studies

Number of patients screened for

participation in research

Number of patients recruited into

research projects

A&E Attendances No applicable target, total for month & YTD

Average Length of

Spell (Discharge

Spec)

ElectiveNo set targets, for monitoring

purposes only.

Research Income

Grant income

Commercial income

Other charity income

Network Income

Non-Elective

Clinical Outcomes/ Research & Development - Neil Rothnie



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1) Currently failing target

2) =< 1% above target

3) => 2 consecutive months deteriorating trend

4) Where predicted trend will breach target within 3 months

5) Recent unstable or erratic performance

RAG Colours: Desired outcome not completed and past the date

Desired Outcome being progressed and has not passed the date

Desired Outcome achieved

Could all Executives ensure that all the sections are completed.

Indicators will be be analysed to assess whether or not they

represent a concern for the immediate future. Although

discretion will be used, indicators will generally be highlighted

as a concern if their performance meet one or more of the

following conditions:

Performance Matrix

Page 7 of 50

Concern

Failure

Patient AccessAdmitted

Non - Admitted

Incomplete

Admitted Backlog

Maximum 4 hour wait

Ambulance Turnaround (arrival to handover)

Ambulance Turnaround (arrival to clear)

IP - All cancelled TCI (hospital %)

IP - Short notice (non-medical)

IP - Short Notice Readmitted within 28 days

2 week wait from referral to date first seen (All)

2 week wait from referral to date first seen (Breast)

All Cancers: 31 Day wait for 2nd or subsequent treatment (surgery)

All Cancers: 31 Day wait for 2nd or subsequent treatment (radiotherapy)

All Cancers: 62 Day wait for first treatment (GP referral)

All Cancers: 62 Day wait for first treatment comprising either: from urgent GP referral to treatment. Southend Only (>90%)

All Cancers: 62 Day wait for first treatment (Cons screening referral)

Cancer Backlog

Breast Feeding Initiation

Smoking at Delivery

MRSA Screening

Pre-op Bed Days (Elective)

Elective

Non-Elective

SHMI

Patient QualityComplaints

Total Falls

High/ Exreme Harm

Benchmarked against NHS Midlands and East Trusts

10 point improvement on previous year

Incidents of MRSA

Pressure Ulcers Total Hospital Acquired (Avoidable)

Serious Incidents of which Never Events

Work ForceAgency Spend as % of Pay Bill (Monthly)

Establishment (FTE)

Sickness Absence Rate (rolling 12 months)

Overall (10-11%)

Statutory Mandatory Training

Staff Levels

Staff Turnover Rate (Excl. Junior Doctors)

18 Weeks RTT

A&E

Cancellations

Readmissions (30 Day)

Falls

Maternity

Friends & Family

Cancer

Concerns/ Failures for compliance month

Page 8 of 50

Executive Overview:


Operational SMART Objectives

Patient Access Overview February has been another difficult month with a range of performance measures failing, or likely to fail. These can be grouped into the areas which have been affected by the management of Winter pressures, and areas which are not p erforming for unrelated reasons. Even in those unrelated areas it should be noted that the individuals under pressure for managing Winter pressures are often the same that must keep other areas running. Winter pressure issues Activity continues to be much higher than planned, as well as higher than previous years' activity yet even so the effect on Southend and the region has been more destabilising than previous years. The cost of managing the Winter pressures using temporary staff and catching up with lost operating lists is significant. The most obvious indicator is the A&E 95% 4 hour target which has been consistently missed since December. Action plans have been implemented to remove the least effective processess, the Intensive Support Team have provided a list of recommendations to provide a sustainable, joined up and effect ive service which will require considerable commitment to change by medical, nursing and the new management team in place from March. Elective activity has been reduced and expensively replaced during February to first stop the rise in the backlog of patients waiting more than 18 weeks for treatment, then secondly to bring it down as far as possible in the quarter to avoid repeated target failures in 2013 -14. This turnaround did not start to reduce the backlog until mid-February, thus leaving the forecast backlog between 250-300 patients rather than the 150-200 previously predicted. At mid-March the backlog reduction was 66 patients behind trajectory after 91 patients were cancelled during February. Cancer patient issues Winter pressures only indirectly impact on Cancer patients as they get priority over routine elective patients but there were still some delays in treatment due to staff shortages which caused breaches of the 90% Southend-only patient target set by the board. Haematology patients with very complex pathways breach ed in February which was enough to keep the Quarter to Date figure at 89.4%. March patient lists are being actively managed to ensure a higher than target compliance but this target is now in jeapardy for Q4, having been achieved for Q3. Summary The overrall picture is of a Trust which is performing poorly in a number of areas, and Southend has recently moved to 5th ou t of 5 in Essex in some weeks for A&E performance. Very few trusts are performing properly in the East of England region this year but the priority for Southend is to rapidly improv e patients' access to care to the best levels possible for a region under this pressure, even if that does not immediately meet national targets. Rapid changes in clinical commitment, management and processeses are underway to achieve that improvement, and to increase el ective activity during quarters 1-3 to ensure a much better foundation for next Winter.

Page 9 of 50

Executive Summary/Notes:

Area

Target

Reason/Source Desired Outcome By When? ResponsibilityR

A

G

Signed off?

See narrative on 18 Wk - Incomplete. Percentage achievement (above) is only relevant with a

small and stable backlog, which has not been the case since December

Improvement AreaAdmitted

90% within 18 weeks

Action



80%

85%

90%

95%

100%

Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Page 10 of 50


Area

Target


A

G

Agreed target in contract with PCT

of 95% at specialty level not

reached. Trust level performance

exhibiting a downward trend.

Specialty level compliance

of the non admitted target

30th April

2013

All Business Unit's

Buds and ABUDsSigned off?

Since January the focus has been on avoiding any future 52 week waiters by changing pathways

at the post-25 week stage to make them simpler and monitor tertiary hospital long delays.

The length and complexity of these long pathways means that solving problems for patients at

25 weeks will take many weeks change 52 week compliance, whilst dealing with those at later

stages in the pathway may be too late. In other words, there will be more 52 week breaches

over coming months, but the numbers of patients in the later stages of the pathway will be

checked each to ensure the numbers are dropping, and therefore the plans are effective.

Improvement AreaNon - Admitted

95% within 18 weeks

Action



93%

95%

97%

99%


Page 11 of 50


Area

Target


A

G

An agreed limit of 100 backlog

patients and a stretch target of 16

weeks compliance by end October

were not achieved due to surgical

and theatre capacity. Winter

emergency demand and

cancellations completed the

problem

See - 18 week Admitted Backlog section for comments

Backlog reduced to 100

patients. Compliance with

90% admitted target, and

95% non-admitted target by

specialty.

end-March Rupert WainwrightSigned off?

Although all indicators are passing for RTT the backlog has increased in December and 95th percentile times have increased. This has resulted in the incompletes performance decreasing this month. This also means

that the admitted performance inparticular could be very low in the next couple of months and may miss the target. Recovery plans agreed with Business Units and currently being implemented.

Improvement AreaIncomplete (Not yet stopped)

92%

Action



90%

92%

94%

96%

98%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Page 12 of 50


Area

Target


A

G

Signed off?

February board update: Severe A&E and bed pressures are still causing restricted elective work and

therefore the backlog continues to rise. The new target for backlog reduction by the end of March is

now closer to 150, which is still low enough to be sustainable long term. However, without

improvement by the end of February, the backlog will be too high to allow target compliance in April,

and therefore Q1. The focus therefore remains on resolving A&E and emergency care to free up beds

for elective work. March Board update: A&E and bed pressures continued and deepened in February,

regionally and for Southend. The impact was an increase in the backlog of patients instead of the

necessary reduction. This increase turned to a decrease in mid-February which has been sustained for

the last 4 weeks, but leaving the trajectory 66 patients behind plan. 91 elective patients were

cancelled in February and a number of lists were not run because the bed capacity could not support

them. The situation is still very difficult but there are fewer outlying patients as March progresses.

Improvement AreaAdmitted backlog

<= 100

Action



0

100

200

300

400

500


Page 13 of 50


Area

Target


A

G

Inability to create enough over-

performance to allow for Winter

peaks.Unusually high and erratic

demand across the region.

Basildon hospital required to stop

almost all elective work.

Achievement of 95% target

each week by end of Q4.

Achievement of Q1 and Q2

with enough margin to

allow for problems in Q3

and Q4 in 2013/14

End Q2 Rupert WainwrightSigned off?

Since the last board report the Intensive Support team have produced their report and

recommendations which have been put into a draft plan, with some quick actions and some

medium term actions which will require significant changes in process and working practice for

senior clinicians in A&E, AMU and wards to provide senior decision making to avoid times when

junior teams are over-pressured due to their reduced complement. A key corporate risk for the

last year has been the lack of the right numbers of junior doctors from the deanery and as

funded backfill for those gaps in the rota. An experienced professional A&E manager has been

recruited on an interim basis to stabilse the existing system and to implement the A&E parts of

the IST action plan. She started on 4th March. It is worth noting that the widespread failure

across the region is held to be partly the responsibility of the East of England ambulance

service, and the new Chief Executive has brought in an external reviewer to recommend

remedial measures. The board will receive a comprehensive update on the Emergency Care

pathway plans, the timetables, risks, and planned outcome to achieve national targets.

A&E targets failed for Q3 and likely to fail for Q4 and the year. The current system fails increasingly steeply when put under pressure and the high and erratic demand across the region has

exposed the weaknesses.

Improvement AreaA&E Maximum 4 hour wait

95% of all cases to be seen within 4 hours. (SITREP data)

Action



85%

90%

95%

100%


Page 14 of 50


Area

Target


A

G

Ambulance handovers are too

slow in the hospital unusual

volume peaks this year, slow

A&E systems to take the

patients, and a Southend bed

model that does not deliver the

right beds at the right time

Meet 15 minute handover

target, as part of overall

A&E plan. This is so very

much more than has been

achieved at Southend,

even when 95% 4 hour

target was being met, so

will have to follow

sustained 4 hour

compliance as a medium

term trajectory.

Q2 2013 Rupert WainwrightSigned off?

Note: The ambulance service was unable to provide handover times in February. There

are clearly delays at times at Southend A&E which cause ambulances to queue. An audit

has been carried out which showed large discrepancies between the times that the A&E

department had taken over patients and when the ambulance crews had stopped their

clocks, but resolution with the EoE ambulance service has not been conclusive. Since

the start of winter real delays have been obvious (strangely without much impact on the

performance figures), and the aim is to work on those controllable delays as part of the

overall A&E plan. Ensuring correct clock stops will be done after that. A new and

experienced A&E interim manager has been appointed with recent experience at

stopping both the real delays and the clock stop problems to move her trust from

second last to second best in that region.

Improvement AreaAmbulance Turnaround * (Week ending 10/2/12 covering 4 week period, Jan 27th unavailable)

Arrival to handover (>= 85% within 15 mins)

Action



10%

30%

50%

70%

90%

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13

Page 15 of 50


Area

Target


A

G

Signed off?

Improvement AreaAmbulance Turnaround * (Week ending 10/2/12 covering 4 week period, Jan 27th unavailable)

Arrival to clear (>= 85% within 15 mins)

Action



50%

60%

70%

80%

90%

100%

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13


Area

Target


A

G

Signed off?

Improvement AreaIP - All cancelled TCI (hospital %)

<12.64% by end of year (<13.34% before Jan 13)

Action



10%

12%

14%

16%

18%


Page 17 of 50


Area

Target


A

G

Peak in July reported to Board and

action requested to provide more

detail.In November and December

as emergency erratic demand

outstripped capacity in theatres

and beds

The key measure is

reduction in short term

cancellation rate to below

0.8 percent, in a consistent

way so the long term trend

line starts to move down

end-Feb Rupert WainwrightSigned off?

Cancellations have continued at a destabilising rate due largely to bed capacity but also due to

anaesthetist and theatre staffing issues where both planning and morale have been an issue.

The theatre clinical leaders and management team have been given additional support to help

plan proper staffing levels and to manage the day to day issues. This Business Unit is still

embryonic compared to the other Business Units and therefore performance is being more

closely managed, and structures changed where needed to deal with the pressures of

additional emergency activity over Winter and elective activity due to 18 week backlog

reduction.

After improving following the appointment of an new ABUD in August, cancellations have increased significantly due to emergency winter demand. This has affected most key indicators showing that

there was not sufficient marginal capacity set up, and the current culture is not used to making rapid changes in response to urgent pressures.

Improvement AreaCancellation - IP - Short notice (non-medical)

No more than 0.8% FFCE's cancelled with short notice.

Action



0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


Page 18 of 50


Area

Target


A

G

Signed off?

See short notice cancellation narrative as the cancellation target figures are part of the same

issue. The only extra note on this particular issue are that the number are very small, therefore

erratic and readmissions are being booked in time, but subject to the same cancellations and

restrictions by the A&E issues.

Improvement AreaIP - Short Notice Readmitted within 28 days

Less than 5% cancellations readmitted outside 28 days.

Action



0%

5%

10%

15%


Page 19 of 50


Area

Target


A

G

Failure to meet 2 week wait from

referral to date first seen, due to

reduced capacity over Christmas

period.

No continued failure

Feb-13 Rupert W.Signed off?

February recovered as expected from the last Board report

Improvement Area2 week wait from referral to date first seen

all cancers (93%)

Action



85%

90%

95%

100%


Page 20 of 50


Area

Target


A

G

Failure to meet 2 week wait from

referral to date first seen, due to

reduced capacity over Christmas

period

Quarter compliance

Mar-13 Rupert W.Signed off?

Q4 is now looking difficult to achieve due to the deep dip in January from Christmas referrals.

Better capacity put in place but the recovery relies very heavily on patients being willing to

come to clinic within 2 weeks, often without being aware that they are being referred for

suspect Cancer diagnosis.

Improvement Area2 week wait from referral to date first seen

symptomatic breast (93%)

Action



85%

90%

95%

100%


Page 21 of 50


Area

Target


A

G

Failure in compliance in January

due seasonal fail, reduced

capacity. 4 breaches - 1 clinical, 3

capacity

February Compliance


February compliant as expected from last Board report

Improvement AreaAll Cancers: 31 Day wait for 2nd or subsequent treatment, comprising either:

surgery (94%)

Action



80%

85%

90%

95%

100%


Page 22 of 50


Area

Target


A

G

Signed off?

This is now being monitored more closely as patients have not had a problem accessing care in

time before now, and is included in this exception report as a warning flag to the department to

keep compliant.

Improvement AreaAll Cancers: 31 Day wait for 2nd or subsequent treatment, comprising either:

Radiotherapy (94%)

Action



90%

92%

94%

96%

98%

100%



Area

Target


A

G

Signed off?

See Cancer - 62Day Trt. SUHFT Only tab for comments.

Improvement AreaAll Cancers: 62 Day wait for first treatment (from urgent GP referral to treatment)

85%

Action



70%

75%

80%

85%

90%

95%


Page 24 of 50


Area

Target


A

G

On-going issue Consistent achievement of

the 62 day target.

Consistent and monitored

improvement at all stages of

each pathway by new

tracking reports to ensure

62 days is likely to be met.

Reduction in number of late

referrals from other sites.

end-Feb Rupert WainwrightSigned off?

March board update: Key actions have been taken as described below, but achievement is now

a very high risk for the quarter. Key leadership changes are reducing current breaches but a new

and focussed approach is needed, and a clinically led structure has been proposed by the

Medical Director, which will be implemented and supported to provide longer term delivery.

February board update: Actions include

• A clear instruction from the Board to reach and maintain a level of 90% compliance for

patients who start and end at Southend

• Discussions with Basildon on an agreed turnaround time for EBUS reporting which is part of

the Lung pathway and currently ensuring a breach every time a referral is made. Basildon take

no share of the breach for these patients. The aim is to move the time from referral to

reporting from 3-4 weeks to 1-2.

• EBUS business case being prepared with an option currently being explored which would

provide the equipment to us leased at £15k per month.

Improvement AreaAll Cancers: 62 Day wait for first treatment from urgent GP referral to treatment. Southend Only

90%

Action



80%

85%

90%

95%


Page 25 of 50


Area

Target


A

G

Failure to target in January due to

2 breaches. 1 x patient choice. 1 x

clinical reasons

Action plan completed and

continued review


February compliant after simple recovery plan enacted.

Improvement AreaAll Cancers: 62 Day wait for first treatment (from cons screening service referral)

90%

Action



75%

80%

85%

90%

95%

100%


Page 26 of 50


Area

Target


A

G

Signed off?

See Cancer - 62 day Treatment tab for comments.

Improvement AreaCancer Backlog

<6

Action



0

5

10

15

20

25

30


Page 27 of 50


Area

Target


A

G

Signed off?

This remains a target which is monitored but is largely outside the trust control, and is a topic

of contractual discussion.

Improvement AreaBreast Feeding Initiation

>=75% (per maternity dashboard)

Action



60%

65%

70%

75%

80%



Area

Target


A

G

Signed off?

Once again the success or failure of this target is largely outside the trust's control.

Improvement AreaSmoking at Delivery

<=12% (per Key Performance Indicator collection)

Action



5%

10%

15%

20%



Area

Target


A

G

Signed off?

Progress has plateaud for a considerable period. As the Winter pressures recede this will be

moved up the priority list for full monitoring and compliance for the last few percent of patients

- either to screen them or show that they are not "relevant admissions".

Improvement AreaMRSA Screening

Screen 100% of relevant admissions

Action



85%

90%

95%

100%



Area

Target


A

G

Signed off?

This is affected by bed capacity and Winter pressures and will be re-examined as they reduce.

The key effort will be on a year-round plan to deal with these pressures at known times,

therefore reducing bed pressure impact on this indicator and others. In parallel there will be a

further look at any areas where pre-op admission has become clinical practice so that this can

be understood, and stopped where appropriate.

Improvement AreaPre-op Bed Days (Elective)

Target of < 7.45% to be maintained

Action



5%

6%

7%

8%

9%

10%

11%



Area

Target


A

G

Signed off?

This is dealt with largely as a contractual issue but there has been an audit of the

appropriateness of readmissions, following national guidance that suggested that only a very

small proportion of readmissions were in the control of acute trusts. Other reasons for

readmission are lack of consistent care in the community, co-morbities that make admission for

other reasons happen and frail patients who have reached a stage that frequent hospital

admissons become the norm - in the absence of a care plan that acknowledges the

inappropriate nature of some acute interventions when they are no longer helpful.

Improvement AreaElective

< 3.25% (Top quartile University Trusts)

Action



0%

1%

2%

3%

4%

5%

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13


Area

Target


A

G

Signed off?

See Elective readmission comments

Improvement AreaNon-Elective

< 9.5% (Top Quartile University Trusts)

Action



5%

7%

9%

11%

13%

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13


Area

Target


A

G

Signed off?

This is now a part of the regular board report and in subsequent months will be reported on in

more detail by the Medical Director, looking behind the average of all specialties to get a true

picture of areas that may be of concern, and reasons for any increase in the average figures

shown.

Improvement AreaSHMI

Not to exceed national average of 1

Action



0.950

Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12

Page 34 of 50

Executive Overview:



All elements in HNQI achieved the required level of performance, with 6/7 achieving stretch target of 95% An increase in compliance with falls prevention (98.4%) has not resulted in the desired decrease in the number of falls. Acti vity around emergency admissions remains high and it continues to be necessary to transfer more stable medical patients to wards outside medicine in order to accommodate acute ad missions. Nursing teams are reporting additional pressure around patient transfers and admissions. Patients continue to report being unsettled and unhappy with being transferred. A slight decline in PU prevention compliance was noted, with Medicine and Surgery not achieving 90% compliance and a slight i ncrease in avoidable pressure damage has been seen in some areas (reported separately). In some cases risk was not appropriately re -assessed, it was also identified that there was insufficient documentary evidence of appropriate levels of intervention. Additionally, demand on pressure relieving equipment has been high, resulting in the need to hire equipment whe n internal provision has been exhausted. The tissue viability team are reviewing the stock levels with MEMS service in order to identify procurement needs going forwards. The high level of emergency admissions has required additional beds, including the temporary ward, Ward 1 to remain open thro ughout February. It has been necessary to move some staff from medical wards to work in Ward 1 in order to ensure that the additional beds are safely staffed with the correct sk ill mix. In some cases back-fill cover with temporary (bank and agency) staff has been obtained to maintain staffing levels, but this can dilute the skill mix on the wards. In other cases i t has not been possible to secure back-fill for the wards providing staff to Ward 1, leaving some wards below optimum staffing levels. This continues to be monitored by the Matrons. Plans are i n place to close the additional beds by the end of March.

Page 35 of 50


Area

Target


A

G

Increase in number of complaints

in January has taken us above the

trajectory to achieve a target of

10% reduction in complaints this

year.

10% reduction in the

number of complaints

compared to previous year

End March

2013 BUDsSigned off?

Business units are required to provide details of actions implemented to address issues raised

in complaints. Meetings with complainants are offered in order to discuss and resolve issues

and concerns. Ward Managers undertake ward rounds with patients and visitors during

supervisory time in order to identify any concerns at the earliest opportunity so that they can

be addressed in a timely fashion.

The seasonal trend of an increase in the number of complaints after the Christmas and New year period was noted, with an increase in the number of complaints received compared to the same period

last year. A similar pattern has been noted in another hospital within the area.

Improvement AreaFormal Complaints

10% reduction on last year

Action



-15%

-10%

-5%

0%

5%

10%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13

Page 36 of 50


Area

Target


A

G

Above target trajectory Compliance with falls

prevention care planning

≥90%. Reduction in falls

Mar-13

Ward Managers and

MatronsSigned off?

Matrons continue to monitor compliance with falls assessment and implementation of falls

prevention care plan. Ward Managers undertake spot checks of patients at risk of falls.

Improvement in compliance achieved across the wards. Falls prevention team provide specialist

advice and staff training in relation to patients at risk of fall.

We continue above the target trajectory within the year to date position. It is therefore unlikey we will achieve the 10% reduction in falls this year. Only 1 patient was reported to have severe injury. This is

considered unavoidable. Compliance with falls risk assessment and falls prevention care planning has improved across the trust (98.4%), though it has been noted that on occasions, some patients (with

full mental capacity) decline to follow falls prevention advice / intervention. Emergency and ward activity remains high, with a number of medical patients o continuing be transferred to wards outside of

speciality and resulting in an alteration in usual case mix on the wards.

Improvement AreaTotal Falls

Internal Target - 10% reduction on last year

Action



0

25

50

75

100

125

150


Page 37 of 50


Area

Target


A

G

Review of the documentation and

the patient with a high severity fall

suggests that falls prevention

intervention was not necessary as

the patient was not considered at

risk of falling.

Appropriate care plans in

place for patients at risk of

falls. Reduction in high

severity falls

End March

2013

Matrons & Ward

Managers supported

by Falls prevention

practitionerSigned off?

Revised care plan document being trialled.

1 high severity fall occurred in February, which is considered to be unavoidable. The patient had been independent, safely mobilising and assessed as rehabilitation fit, with no risk of fall. A new falls

prevention care plan is being trialled in two wards that admit patients at a high risk of falls. If this is positively evaluated at the end of the trial it will be implemented across the trust.

Improvement AreaHigh/ Extreme Harm as % of All Falls

No Target

Action



0%

1%

2%

3%

4%


Page 38 of 50


Area

Target


A

G

See separate section "Friends and

Family".

Mar-13 BUDsSigned off?

Our internal target is for the Trust to be ranked in the top 25% Trusts when benchmarked against the Trusts within the Midlands and East. A poor NPS score in the third week of February

and an increase in detractor responses has adversely affected our over-all NPS score. Key areas of patient reported dissatisfaction are reported in separate section "Friends and Family".

Improvement AreaInternal Target of Top Quartile

(>75%) benchmarked against NHS Midlands and East Trusts

Action



0%

20%

40%

60%

80%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13

Page 39 of 50


Area

Target


A

G

Increase in Detractor responses

across the wards.

Increase in patients who

would recommend the

hospital

Mar-13 BUDsSigned off?

Ward Managers are receiving weekly reports on the NPS score and patients' comments to

enable them to identify and action issues in a timely manner. Though negative responses are

attributed to the ward receiving the transferred patient, it does not necessarily reflect poor

care on that ward. Ward staff are trying to make patients feel welcomed and settled on

transfer.

The over all Nett Promoter Score (NPS) for the Trust fell by one point in February. There was a slight increase (1%) in "promoter" responses and a 5% reduction in passive responses. However, detractor responses were more

than 3 times higher than in January at 4.6%. Some patients decline to provide a comment. The four areas of dissatisfaction most commonly reported are around: being unhappy about being moved to another ward (n.15);

ward perceived to be busy (n.15); Wait for TTA (n.5) and ward perceived to be understaffed (n.5). The continued high level of activity and pressures around accommodating emergency admissions is reflected in comments

around dissatisfaction with being moved to different wards.

Improvement AreaFriends And Family

Target +10 improvement by March 13

Action



0

20

40

60

80

100


Page 40 of 50

585 (15%)

+54

-1

+9 (Target +10 improvement by March '13)

NPS Score by Ward **

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Trust 45 68 69 64 57 81 75 80 82 55 54

CCU - - 59 90 67 79 89 96 100 60 92DAU - - 50 50 62 96 82 100 74 94 83Edmund Stone - - 88 83 63 70 94 86 90 70 78Hockley - - 96 39 77 64 96 81 88 44 78Elizabeth Loury - - 100 100 33 86 75 100 93 - 77Chalkwell - - - - - - 72 - - 61 76Balmoral - - 61 87 85 92 56 89 75 72 62

Eleanor Hobbs - - 41 74 41 88 68 73 88 31 62

Bedwell - - 78 20 71 73 80 68 78 94 60

Eastwood - - 72 33 60 94 76 92 90 47 60Benfleet - - -33 60 60 80 60 39 100 53 54Kitty Hubbard - - 75 25 85 67 89 88 100 50 53Estuary - - 50 40 58 91 60 63 70 52 52Rochford - - 60 33 67 82 56 71 82 64 50Gordon Hopkins - - 73 89 80 92 86 100 82 57 50 *a = no. of patients surveyed *b = % of patients surveyed of ward discharges (where % surveyed

Paglesham - - 67 33 -25 58 50 63 60 56 50 was 10% or more for latest reporting month/YTD respectively)

Castlepoint - - 72 59 42 75 71 83 76 43 46 ** where wards have a % survey sample of 10% or more of IP discharges YTD

Westcliff - - 0 88 50 90 69 74 63 47 44 allowing for significant and meaningful reporting comparisons

Blenheim - - 60 60 39 83 64 80 82 49 40 The overall Trust NPS (YTD) was made up from patients surveyed across 27 wards. 22 of the 27 wards

Windsor - - 87 76 62 83 83 88 95 23 31 sampled are shown in this report on the basis 10% or more of patients discharged from the ward (ytd)

Stambridge - - 57 65 46 77 39 36 71 50 26 were surveyed. The other 5 wards had very small sample sizes therefore not allowing a meaningful,

Southbourne - - 58 44 50 96 50 54 33 89 11 or significant, interpretation of their NPS within this report.

NPS Change from April 2012

Latest reporting month: Feb 2013 No. surveyed

Net Promoter Score (NPS)

NPS Change on Last Month

Top 5 Wards (*a,*b) Bottom 5 Wards (*a,*b)

This Month ** YTD *** This Month ** YTD ***

CCU (12, 24%) DAU (147, 38%) Southbourne (18, 34%) Paglesham (103, 23%)

DAU (29, 71%) CCU ( 139,28%) Stambridge (27, 44%) Stambridge (198, 32%)

While the positive comments far exceeded negative, 4 key areas of dissatisfaction were identified across the trust: unhappy with being moved to another ward; ward being busy; ward

appearing short staffed; and wait for TTAs. Whilst Ward Managers endeavour to address concerns raised in the weekly reports, the high level of activity and transfer of patients to

accommodate emergency admissions continues to create pressure on the ward and dissatisfaction among patients.

Edmund Stone (37, 24%) Edmund Stone (486, 32%) Windsor (29, 14%) Benfleet (97, 16%)

Hockley (18, 21%) Gordon Hopkins (220, 33%) Blenheim (48, 47%) Southbourne (134, 29%)

Elizabeth Loury (13, 12%) Elizabeth Loury (111, 11%) Westcliff (16, 20%) Blenheim (353, 36%)

ACTION PLANS AND RECOMMENDATIONS

Patient Revolution: The Friends and Family Test

0

10

20

30

40

50

60

70

80

90

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

Net

Pro

mo

ter

Sco

re

Trust Net Promoter Score by Month (2012/13)

Target Trendline Trust NPS


Area

Target


A

G

1 reported case of an unavoidable

MRSA Bacteraemia

No further avoidable MRSA

bacteraemia

End March

2013 BUDsSigned off?

No concerns around practice or care identified. IPCT continue to promote and monitor

compliance with good IPC practice.

One new case of MRSA bacteraemia was reported in February. We are now 2 cases above our ceiling for the year of 1 case. RCA has been carried out and been reviewed by the Infection Prevention and Control Team (IPCT),

the Director of Infection Prevention and Control (DIPC), clinical team and our commissioners. It has been agreed that this was an unavoidable case in a patient with very complex clinical needs. No issues around practice or

care were identified.

Improvement AreaIncidents of MRSA

Trust wide 1 hospital acquired per year

Action



0

1

2

3

4


Page 42 of 50


Area

Target


A

G

6 cases of avoidable pressure

damage reported

Zero Tolerance of pressure

damage and reduction in

pressure damage.

End March

2013

Matrons & Tissue

Viability TeamSigned off?

Phase 1 of the SSKIN initiative is to be rolled out by the end of April 2013, supported by the

tissue viability team. Learning from RCAs continues to be shared and the implementation of

practice developments and improvements is being overseen by the Matrons. Issues around

availability of pressure relieving equipment are to be escalated and ward teams to ensure

additional proessure relieving intervention and position changes are to be put in place whilst

delivery of equipment is awaited.

6 cases of avoidable pressure damage were reported in February, comprising of 3 patients with Grade 2 skin damage and 3 patients with Grade 3 damage. RCAs have been carried out for 2 of the cases of

Grade 3 damage and the third RCA is in progress. Key learning from these cases is around insufficient documentation of pressure relieving intervention and position change. One patient should have been

reassessed for the risk of pressure damage following the deterioration in their clinical condition. The failure to reassess the risk meant that it was not identified that additional intervention needed to be

put in place. Increased activity and an increase in patients identified as at risk of pressure damage has increased demand on pressure relieving equipment. When the Trust's supply of pressure relieving

mattresses is in use, there can be a delay in obtaining specialist mattresses from an external supplier. Matrons are responsible for ensuring that positive action is in place to address the areas highlighted.

Improvement AreaGrade 2 and above - Total hospital acquired (avoidable)

Zero Tolerance

Action



0

5

10

15


Page 43 of 50


Area

Target


A

G

2 never events reported in

February (3 year to date)

No further reports of never

events

End March

2013

Clinical teams

undertaking

proceduresSigned off?

Additional checking procedures being implemented and work underway to standardise check-

lists for procedures performed outside of theatres. Staff communication / education campaign

commenced to raise awareness of learning points. Observational audits to be undertaken to

ensure compliance with checking procedures.

2 Never Events reported in February (1 eye unit, incorrect lens; 1 OPD wrong site surgery under local anaesthetic). Learning points from RCA being implemented.

Improvement Area - of which Never Events

Target of '0'

Action



-1

0

1

2

3


Page 44 of 50

Executive Overview:



The agency project group have implemented a number of central control measures to reduce agency spend . These include a further revision of the enhanced observation policy to reduce nursing and security agency requirements to 'special' patients. Guidance issued to the bank booking team and business units for booking medical agency staff, together with a reminder on consultant cover arrangements available under their contract of employment. The opening of Ward 1 to cope with w inter pressures has increased agency spend, however it is intended that the ward close on 21st March. Sickness absence is 3.5% for 12 months up to 28th February 2013, a slight increase of 0.03% from the previous month. Busines s Units are working towards achievement of their action plans. The Trust is marginally below trajectory at 77.56% for statutory mandatory training and has seen a slight drop from the previ ous month. The areas that are below 80% are Medicine (73.09%), Theatres and Critical Care (74.13%), Women's and Children (72.13%) and Central Services (75.51%). Staffing levels have decreased, however as reported to the Board last month, concerns have been raised in relation to data quality and a potential discrepancy between data held on ESR and the Finance system. The audit should be completed by end of March 2013. Turnover is based on staffing levels, therefore the audit may impact on the turnover data contained in this report. The audit should b e completed by end of March 2013.

Page 45 of 50


Area

Target


A

G

Non achievement of target. On-going

On-going

Executive Team /

PMO

Director of HR / COO

/ Director of Finance

Signed off?

1. Continued monitoring of agency spend and delivery of CIPs through BU performance

framework.

2. Agency Project to review agency spend and identify and implement further central control

measures

Target of 2.68% based on Trust CIP plans submitted at the beginning of the financial year 2012/13. CIP plans have since been updated, and revised threshold is 3.29%. Despite central control measures

being implemented, agency spend is erratic.

Improvement AreaAgency Spend as % of Pay Bill (Monthly)

2.68%

Action



2%

3%

4%

5%


Page 46 of 50


Area

Target


A

G

Data shows that headcount is

above target level.

Assurance to the Board end of March

2013

Director of HR

Signed off?

Staffing levels data to be audited due to concerns in relation to data quality

Staffing levels have decreased, however as reported to the Board last month, concerns have been raised in relation to data quality and a potential discrepancy between data held on ESR and the Finance

system.

Improvement AreaEstablishment (FTE)

3969.84

Action



3900

3950

4000

4050

4100


Page 47 of 50


Area

Target


A

G

Erratic performance, and

likelihood that we will not achieve

the stretch target of 3.3%

Progress towards achieving

3.3%.

On-going

June 2013

Executive Team

Associate Director of

HR

Signed off?

1.Continued monitoring of Business Unit action plans through performance management

meetings

2. Review effectiveness of revised sickness absence policy.

Sickness absence is 3.5% for 12 months up to 28th February 2013. Sickness absence increased slightly (up 0.03%) from the previous month. Business Units are working towards meeting their absence

plans . New policy on target for implementation.

Improvement AreaSickness Absence (rolling 12 months)

3.29% (trajectory)

Action



3%

4%


Page 48 of 50


Area

Target


A

G

Data shows that we are above

benchmark levels for turnover.

Assurance to the Board

End of March Director of HRSigned off?

1. Staffing levels data to be audited due to concerns in relation to data quality.

Revised benchmark of 10.1% as previously agreed. Data shows that we are above the benchmark level, however this is subject to audit of staffing levels data.

Improvement AreaExcluding Junior Doctors (FTE): Overall

10.1% for staff excluding junior doctors for the Trust (based on public sector 2012 in CIPD report)

Action



9%

10%

10%

11%

11%

12%

12%


Page 49 of 50


Area

Target


A

G

Erratic performance against

trajectory.

Achievement of 85% End of March

2013

Business Unit

Directors / Executive

Team (through

performance

management

meetings)

Signed off?

Business Units to continue to monitor achievement of trajectory

The Trust is marginally below trajectory at 77.56% for statutory mandatory training and has seen a slight drop from the previous month. The areas that are below 80% are Medicine (73.09%), Theatres and

Critical Care (74.13%), Women's and Children (72.13%) and Central Services (75.51%).

Improvement AreaFire, Inanimate Loads & Infection Control

Reach 85% for all staff to be trained in each 12 month period - number trained vs. a headcount

Action



60%

70%

80%

90%


Page 50 of 50

Documents

Board of Directors’ Meeting Report – 27/03/13 · Board of Directors’ Meeting Report – 27/03/13 Integrated Performance Board Report Rupert Wainwright Information Team, Rupert