Integrated Performance & Quality Report - West London … integrated performanc… · 1 West London CCG The West London CCG Integrated Performance & Quality Report is aimed at providing

West London CCG

Integrated Performance & Quality Report

February 2017 (M11) FINAL

Reporting on February 2017 (M11) mandated performance metrics, with narrative updates by exception up to March 2017 (M12)

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West London CCG

The West London CCG Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the CCG based on the latest performance information available, and reporting on actions being taken to address any performance issues with progress to date. The contents of the report are defined by the CCG’s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution and Everyone Counts Guidance for 2014-15 to 2018-19 (operating framework). The report is split into 2 sections. Section 1 of the report provides an update on CCG and related providers’ operational performance against national standards. This includes 18 weeks RTT, cancer waits , A&E waits and ambulance handover times etc. This section also includes performance in key indicators for mental health and community services. Detailed information on underachieving indicators including trends and action log are also provided. Provider Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Serious Incidents, Never Events, SHMI, maternity services, complaints and patient experience. These are presented in trend charts and tables with commentary and actions for areas of concern. This section is broken down into 2.1 (acute), 2.2 (community) and 2.3 (mental health).

Introduction

West London CCG

Section 1: Performance Exception Report

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West London CCG Performance Overview

London Ambulance Service (LAS) Frequency ThresholdPrev.

MonthMonth 11 YTD Other Measures* Frequency

Threshold

(Month)

Threshold

(YTD)Prev. Month Month 11 YTD Community Services Frequency Threshold Prev. Month Month 11 YTD

1.1 LAS – Cat A Red 1 responses within 8min Monthly 75% 67.30% 71.66% 68.56% 5.1 Cancelled Ops - 28 Day Guarantee breaches Monthly 0 8 3 19CC22

7.1CLA - Children placed out of Borough health plans

monitored by a named lead CLA Monthly 98% 100.0% 100.0% 100.0%

1.2 LAS – Cat A Red 2 responses within 8min Monthly 75% 62.20% 67.70% 65.61% 5.2 Urgent Cancellations for the 2nd time Monthly 0 0 0 0CC231

7.2CLA - IHAs & RHAs forwarded within 3 working days of

receipt Monthly 100% No Activity 100.0% 100.0%

1.3 LAS - Cat A 19 transportation within 19min Monthly 95% 91.40% 93.31% 93.30% CB_B17_n5.3 Mixed Sex Accommodation Breaches (MSA) Monthly 0 0 1 1 7CCC06

7.3CLA - RHAs completed within agreed timescales

Monthly 100% No Activity 100.0% 100.0% Manual update figurtes - amend so formula update

HQU01 5.4 HCAI - MRSA Monthly 0 0 0 1 6CCC55

7.4 Diabetes - First appointments offered within 4 weeks Monthly 90% 42.9% 40.0% 42.1% RAG rate manually

A&E / LAS* Frequency ThresholdPrev.

MonthMonth 11 YTD HQU02 5.5 HCAI - CDIFF Monthly 4 47 7 3 62

CC37.5

District Nursing urgent referrals responded to within 4

hours Monthly 98% Not Reported 32.7% 83.4%

2.1 Total time spent in A & E < 4 hours (all activity types) Monthly 95% 86.8% 90.4% 92.5% RV3CC311

7.6District Nursing non-urgent referrals responded to

within 24 hours Monthly 98% Not Reported 34.6% 93.1%

2.2 Trolley Waits in A&E Monthly 0 1 0 2 Mental Health FrequencyThreshold

(Month)

Threshold

(YTD)Prev. Month Month 11 YTD

16

N_

CO7.7

DNA rates all relevant services - first appointmentsMonthly 4% 2.2% 2.2% 2.8%

2.3 No. of LAS arrival to handover > 30mins Monthly 0 274 153 1545 MH_2 6.1 IAPT - Access Monthly 1.25% 13.75% 1.46% 1.21% 14.35%

16

N_

CO7.8

DNA rates all relevant services - follow up appointmentsMonthly 2.2% 2.2% 2.3% DQIP

2.4 No. of LAS arrival to handover >60mins Monthly 0 11 3 25 MH_3 6.2 IAPT - Recovery Monthly 50% 50.3% 53.7% 51.7%CCC03

7.9Delayed Transfer of Care (DTOC)

Monthly 7.5% 0.0% 9.1% 0.4% DQIP

IAPT_9 6.3 IAPT waiting times - 6 weeks Monthly 75% 94.0% 94.6% 96.0%

Access Frequency ThresholdPrev.

MonthMonth 11 YTD IAPT_8 6.4 IAPT waiting times - 18 weeks Monthly 95% 99.6% 98.8% 99.6% Urgent Care ** Frequency Threshold Prev. Month Month 11 YTD

3.1 18 weeks RTT - Admitted Pathway Monthly 90% 64.0% 72.3% 69.3% MH_8 6.5 CPA Reviews within 12 months Monthly 95% 95.5% 95.7% 96.4% 8.1 NHS 111 - % calls answered in 60 secs Monthly 95% 95.4% 94.2% DQIP

3.2 18 weeks RTT - Non-admitted Pathway Monthly 95% 89.0% 89.9% 89.9% MH_A7 6.6 Outcomes Data Completeness - CPA Patients Monthly 50% 99.5% 99.8% 97.1% 8.2 NHS 111 - % calls abandoned in 30secs Monthly 5% 0.6% 0.8%

3.3 18 weeks RTT - Incomplete Pathway Monthly 92% 87.3% 87.5% 87.5% MH_12 6.7 CPA Follow-Ups within 7 days Monthly 95% 96.9% 100.0% 99.2% 8.3 NHS 111 - % calls where call back was offered Monthly 5% 0.7% 6.3%

3.4 52 week RTT Waiters - Incomplete pathway Monthly 0 60 46 MH_13 6.8 Inpatient gates kept by CRHT Teams Monthly 95% 100.0% 100.0% 98.8% 8.4 GP Out of Hours Monthly

3.5 6 Weeks Diagnostics Monthly 1% 0.8% 0.2% 0.6% MH_A18 6.9 New psychosis cases served by EIS (breach by YTD) Monthly 95% 100.0% 100.0% 148.6% 8.5 UCC Access KPIS Monthly

16N_MH_PSYC_196.10

EIS- 1st episode psychosis or at 'risk mental state' that

start a NICE-recommended care package in the reporting

period within 2 weeks of referral.

Monthly 50% No Activity 100.0% 72.2%Yellow shading indicates figures have not been updated

for M11

Cancer Waits Frequency ThresholdPrev.

MonthMonth 11 YTD MH_14 6.11 Delayed Transfers of Care Monthly <7.5% 3.2% 4.1% 2.8%

4.1 2 weeks of an urgent GP referral Monthly 93% 87.0% 91.4% 91.7% MH_15 6.12 DNA - 1st Appointments Monthly <15% 16.8% 15.5% 12.4%

4.2 2 weeks of an urgent referral for breast symptoms Monthly 93% 98.5% 94.4% 94.1% MH_16 6.13 DNA - Follow-Ups Appointments Monthly <15% 9.5% 9.4% 9.7%

4.3 31 Day - 1st definitive treatment Monthly 96% 95.3% 97.6% 95.8% MH_A136.14 Carers offered assessment Quarterly 75% Not Reported Not Reported 40.6%

4.4 31 Day Subsequent treatment (Surgery) Monthly 94% 100.0% 93.3% 93.9%16N_MH_CAMH_01

6.15 Outcome measure completed on acceptance Monthly 80% 100.0% 96.8% 93.2%

4.5 31 Day Subsequent treatment (Drugs) Monthly 98% 96.7% 100.0% 99.6%16N_MH_CAMH_02

6.16 Outcome measure completed on discharges Monthly 80% 69.2% 90.9% 62.4%

4.6 31 Day Subsequent treatment (Radiotherapy) Monthly 94% 94.1% 88.9% 97.3%CAMHS_1

6.17 CAMHS - 1st Appt. DNA Rates Monthly <15% 10.3% 15.7% 14.4%

4.7 62 Day - 1st definitive treatment (Urgent GP Referral) Monthly 85% 79.3% 66.7% 79.6%CAMHS_2

6.18 CAMHS -FU Appt. DNA Rates Monthly <15% 9.5% 12.6% 11.2%

4.8 62 Day - 1st definitive treatment (Screening Service) Monthly 90% 70.0% 60.0% 81.5%

4.9 62 Day - 1st definitive treatment (Cons. Upgrade) Monthly 85% 100.0% 100.0% 96.6%

* "A&E / LAS" and "Other Measures": Lead provider (CW) figures only indicated

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West London CCG 1.1 – 1.3) Exception Report – LAS

Root Cause: • Demand has started to gradually increase going

into 2017/18, but appears to be stable around 1500/1550 incidents per day on average.

• Cat A demand is currently reported a 7.4% above plan and Cat C 5.7% above plan.

• JCT has not met trajectory, although improvements are being delivered.

• Hospital Handover delays continue to account for approx.1000 hours lost per week, with handover to green delays reporting at circa 500 hours lost.

Mitigating Actions: • Capacity is being monitored on a daily basis through

Sector Delivery Group. All areas are covered. • Overtime is being offered, but the uptake is less than

the previous week, however substantive hours almost close to full amount expected at this time of year.

• Demand Management workshop s are underway across each of the local STP footprint areas, with full engagement from the LAS.

Assurances: • Capacity is strong particularly within substantive

hours . • DCA and FRU resource available, reported at

7.5% above plan. • M12 performance for 2016/17 was strong

despite coming in at just under plan for year end. This level of performance has continued into M1 of 2017/18 .

• LAS is currently reported nationally nationally as the 2nd highest performer against Cat A.

• JCT has seen continued improvement reporting 82.2 mins overall which equates to a reduction of circa5 mins over the last quarter.

• MAR is currently better than trajectory at 1.28 against a target of 1.29.

Gaps in Assurance: • NETS just missed target for the year-end. Internal work

is on-going to ensure that NETS vehicles are when the NE work is there .

• Specific areas of focus have been identified as key drivers of demand . LAS are currently undertaking a data analysis exercise to breakdown this data in detail to provide root cause for CCG focus.

Description Threshold M11- Feb YTD (28th February)

Cat A Red 1 responses within 8 mins 75% 71.66% 68.56%

Cat A Red 2 responses within 8 mins 75% 67.70% 65.61%

Cat A 19 transportation within 19 mins

95% 93.31% 93.30%

CCG Allocated (Cat A 8 Performance)

75% 64.7% 62.0%

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West London CCG

Issue Provider Update on Actions Action Status

Plan in Place?

CCG Owner Provider Owner

On Track Original Delivery

Date

Revised Delivery Date

Contract Status

Contract Penalties to date

Vehicle downtime

LAS

The zero tolerance maintenance work continues to be carried out. The volume of vehicles out of service has reduced. The most common cause for vehicles OOS relate to facilities and cleaning.

Green Yes Elizabeth Ogunoye

Andrew Grimshaw

Yes Ongoing Ongoing Not yet applicable

Staff sickness rates

LAS

Staff sickness rates have increased slightly. HR continue to work closely with management teams to support on-going improvement in absence levels. LAS have conducted a review of sickness reported and have concluded this is within seasonal expectations.

Green Yes Elizabeth Ogunoye

Karen Broughton

Yes Ongoing N/A Not yet applicable

1.1 – 1.3) Exception Report – LAS

Issue Provider Update on Actions Action Status

Plan in Place?



Date


Contract Status


Demand Management

LAS

LAS to finalise refinements to the demand management analysis toolkit and share pan-London LAS to circulate underpinning data concerning: • 111 referred incidents • HCP calls • Metropolitan Police Service (MPS) calls to facilitate a revised focus on demand management and inform next stage local implementation plans

Amber Yes Elizabeth Ogunoye

Andrew Grimshaw

Yes Sept Currently ongoing

Not yet applicable

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West London CCG 2.1 – 2.4) Exception Report – A&E & LAS Handover Delays (Imperial College Healthcare Trust)

Root Cause:

In M11: • ICHT M11 all type performance was 87.8% which is below the

M11 performance improvement trajectory but is an improvement from M10 position

• SMH did not meet A&E all types performance (including Western Eye) 88.5%. Top type 1 breach reasons were as follows: bed management (28%), clinical (17%) and waiting for specialist opinion (13%)

• SMH UCC performance was 98.9% • CXH performance was 81.4%. Top type 1 breach reasons were

wait for first clinician (27%), bed management (25%) and wait for specialist opinion (18%)

In M12: • ICHT M12 all type performance was 88.4% (unvalidated)

which is below the M12 performance improvement trajectory but is an improvement from M11 position

• SMH did not meet A&E all types performance (including Western Eye) 89.7%. Top type 1 breach reasons were as follows: bed management (17%), clinical (17%) and waiting for specialist opinion (15%)

• SMH UCC performance was 96.7% • CXH performance was 81.7%. Top type 1 breach reasons were

wait for first clinician (26%), bed management (23%) and wait for specialist opinion (21%)

Gaps in Assurance • National A&E standard not achieved and performance

improvement trajectory not met in M12 although an improvement compared to M11.

• Increased 12 hour trolley breaches in 2016/17 due to delays in accessing mental health beds with 1 case in M11 & 6 in M12.

• Increase in total number of 30 mins LAS breaches in M12 (230) compared to M11 (210)

Assurances: • A&E delivery board in place with senior whole system

representation • CXH and SMH UCCs met targets in M11 and M12. • A&E All types performance improved over the last three

months to 88.43% (M12) compared to 84.63% (M9)

Mitigating actions: • 2017/18 performance trajectory and actions have been

reviewed at the A&E delivery board. All healthcare partners have been asked to review supporting actions to be included within a whole system plan and impact on the improvement trajectory to be assessed. CCGs will have further discussion with the Trust in line with the new national guidance requiring achievement of the 95% standard by at least March 2018.

• SMH A&E and paediatric A&E refurbishment started in June 2016 and is due to be completed by July 2017. This will create new paediatrics CDU with 4 bays, 2 x new resuscitation bays, while Adult CDU will remain at 8 bays

• New role of Patient Flow Co-ordinator introduced Jan 17 in A&E to support delivery of rapid and efficient treatment pathways and reduce avoidable breaches

• Extended opening hours of the ambulatory emergency care (AEC) service at SMH to 08:00-22:00 (Mon to Fri) and 08:00-20:00 at weekends

• 12-space surgical assessment unit opened in January 17 in SMH to enable faster access to a specialist surgical opinion where required, to be fully optimised from April 17

• Co-locating acute emergency care on the ground floor at Charing Cross Hospital completed in Jan 17 and operating at maximum capacity. New South Green acute assessment unit (AAU) has 13 bays.

• 36-bed Marjory Warren acute medical unit (AMU) for people who may need further assessment and a short stay - bringing together services that were on ward 5 west and ward 5 south to reduce demand on A&E by rationalising resources

• Trust wide plan in place focussing on streaming and avoiding unnecessary hospital admissions through alternative pathways, streamlining ambulance handover process, implementing real time bed state dashboard and improving ward processes to improve rate of discharges before noon. Trust established 4-hour A&E performance steering group, chaired and attended by senior management to oversee the aforementioned work streams

• Escalation capacity identified on both sites to support resilience over the weekend (10 at SMH, 20 at CXH).

• Review in April 17 of the first six months of PATCH (Providing Assessment & Treatment to Children at Home). PATCH is a 12 month pilot service that started in September 16. Paediatric A&E aiming to secure funding to implement this model in Sept 17

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West London CCG 2.1 – 2.4) Exception Report – A&E & LAS Handover Delays (Imperial College Healthcare Trust)

Issue Provider Action Action Status

Plan in Place?

CCG Owner

Provider Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status

Contract Penalties to

date

A&E performance not meeting revised trajectory.

ICHT • 2017/18 performance trajectory and action plan to be agreed with

contract team and further system wide initiatives to be identified to deliver M12 trajectory.

Open Yes DH TO Yes 4/05/17 N/A N/A N/A

210 (M11) & 230 (M12) breaches - LAS >30mins handover waits 0 (M11) & 4 (M12) breaches – LAS>60mins handover waits

ICHT • No contract action required and assessed through STF N/A N/A DH TO N/A N/A N/A N/A N/A

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West London CCG 2.1 – 2.4) A&E & LAS Handover Delays (Chelsea and Westminster Hospitals Foundation Trust)

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West London CCG 2.1 – 2.4) A&E & LAS Handover Delays (Chelsea and Westminster Hospitals Foundation Trust) Cont’d

Mitigating Actions: A&E delivery board in place for CWHFT with senior whole system representation. 2017/18 performance trajectory and actions agreed with contract team as part of STF process. West Middlesex site • Programme across both sites to expedite discharges before noon in place, “2 before 12:00”. “Red to green” role

out on both sites following pilot. This scheme aims to identify and tackle any delays which lead to a patient being in hospital for longer than they need with full implementation by the end of May 2017.

• Frailty/Care of the Elderly units expanded and consultant recruitment to be completed for both sites by September 2017

• Additional escalation areas identified for WMUH (15) and CWH (10) for M1 (17/18) • Community Independence Service to operate at full capacity from June 2017 • Separate reception for ambulances, with two triage areas at the front door to speed up LAS handover. • Daily tracking of medically optimised patients and DTOCs to commence in March, to improve discharge process. Chelsea and Westminster site • Plastics ‘hot and cold’ clinic to be opened in M3 (17/18) which will receive tertiary / CWH referrals and will be

consultant led. This will reduce the need for patients to wait in A&E and is expected to improve decision making • Trust opened gynaecological assessment unit (12 beds) in March, to improve the patient pathway and release

acute bed provision. It is also being used for the electives pathway. Full review of speciality pathways to be completed by June 2017

• Improved pathways for end of life care (EOLC) to be implemented by August 2017 • Pharmacy and therapy interventions in care homes to be in place by April 2017 and will assist with demand

management • Whole system workshop in place to review how continuing health care screenings and assessments can be

undertaking outside of acute settings. Improved discharge processes for the trust expected by June 2017 • A&E refurbishment completed in January that has improved facilities and increased resuscitation capacity.

Improvements include new waiting areas for paediatrics and adults and increase of 9 cubicles in UCC. “See and treat” chairs are being used at points of pressure when trolley cubicles are needed.

• Retendering of liaison psychiatric services by CCG to improve delivery of mental health support to be completed by June 17.

• Trusted assessor arrangements in place with social care and independent care sector providers

Root Cause: M11: • CWHFT (including WMUH) did not meet performance in M11 - 90.39% . • CW site did not meet performance in M11, achieving 91.5% (unvalidated). Top

type 1 breach reasons were bed management (50%), clinical (22%) and wait for specialist opinion (15%)

• CW reported three 60 minute LAS handover delays in M11 • WMUH did not meet performance in M11, achieving 89.5% (unvalidated). Top

type 1 breach reasons were bed management (29%) and wait for specialist opinion (15%)

M12: • CWHFT (including WMUH) did not meet performance in M12 - 92.10%

(unvalidated) • CW site did not meet performance in M12, achieving 92.1% (unvalidated). Top

type 1 breach reasons were bed management (38%), clinical (29%) and wait for specialist opinion (17%)

• CW reported two 60 minute LAS handover delays in M12 which are being validated by the Trust

• WMUH did not meet performance in M12, achieving 92.1% (unvalidated). Top type 1 breach reasons were bed management (23%) and wait for specialist opinion (18%) and wait for first clinician (12%)

• WMUH reported one 60 minute LAS handover delay in M12 which is being validated by the Trust

Assurances: • WMUH & CWH UCCs delivered 98.92% and 97.92% (unvalidated) in M12 respectively • A&E All types performance for the trust improved from 90.39% in M11 to 92.10% in M12 (unvalidated). • Reduction in number of 30 and 60 mins breaches for the trust from 153 in M11 to 80 in M12 • Continued low level of delayed transfers of care in M11

Gaps in Assurance: • Trust did not meet the STF trajectory in M11 or M12 2016/17. Trust’s reported

trajectory for April 17 is 94.5% • Site reporting that low availability of beds leads to unplaced DTAs in the

morning across the two sites on a regular basis, averaging 6 for CWH and 12 for WMUH in M12

• WMUH unable to open additional A&E cubicles every day due to staffing numbers

• Bed pressures continue to be reported as main reason for breach on both sites, in M12

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West London CCG 2.1 – 2.4) A&E & LAS Handover Delays (Chelsea and Westminster Hospitals Foundation Trust) Cont’d


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


date

Not meeting A&E all type national standard across both West Middlesex and Chelsea & Westminster site

CWHFT • 2016/17 performance trajectory and action plan

to be agreed with contract team. Closed

To be confirmed

SS/AM RH Yes 27/02/17 To be

confirmed

Review at next A&E delivery board

N/A

153 (M11) & 80 (M12) breaches - LAS >30mins handover waits 3 (M11) & 3 (M12) breaches - LAS >60mins handover waits

CWHFT • No contract action required and assessed

through STF N/A N/A SS KM N/A N/A N/A N/A N/A

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West London CCG 3.1 – 3.3) Exception Report – 18 Weeks RTT

Root Cause: West London CCG is not meeting the incomplete standard overall with performance at 87.5% in M11. There has been a decrease in the CCG incomplete RTT backlog (patients waiting > 18 weeks) from 2255 in M10 to 2148 in M11. 18 Weeks incomplete RTT performance was largely driven by Imperial College Healthcare Trust (ICHT) and Chelsea and Westminster (CW). In total the proportion of number of the CCG backlog comprises of 71.5% at ICHT, 23.2% at CW and 5.3% at other organisations. • ICHT: Backlog for WL CCG has decreased from

1612 in M10 to 1535 in M11. The Trust backlog remains at an unsustainable level and ICHT is not meeting the incomplete performance overall (82.2%). The Trust met their STF trajectory (agreed in November 2016) in M11. However, ICHT did not meet their 52 week wait reduction target. Trust report performance in 2016/17 has been impacted by data quality issue within the Trust’s inpatient and outpatient waiting lists (PTL), long waits for first outpatient appointments due to capacity and capacity constraints on specialist pathways.

• CW: Backlog for WL CCG has decreased from 535 in M10 to 498 in M11. CW is meeting the incomplete pathway standard overall (92.0%). The Trust met their STF trajectory in M11.

Mitigating Actions: • 2017/18 trajectories have been agreed with all providers as part of

sustainability and transformation funding (STF) for 2017/18. • ICHT– STF trajectory has been developed based on the estimated

impact from the on-going data quality review and planned capacity boost both internally and through outsourcing

• ICHT : The Trust has established a programme steering group with NHSI, NHSE, IST and CCGs. RTT action plan, improvement team in place with IST support. Action plan has been refreshed

• Waiting list audits are completed across inpatient, and planned waiting lists and final specialty review largely completed. Outpatient waiting list sample audits of high risk specialties completed. Audits underway on other outpatient areas, active monitoring, and “appointment to be made at a later date”

• Trust implemented a new outcome form to be completed following outpatient appointments and supported by audit work that identifies areas where further training is required. There is a programme in place to improve the business as usual (BAU) processes to ensure that RTT pathways are accurately reported. Progress can be evidenced through some key DQ metrics

o Trust initiated outsourcing process with three independent sector providers. A total of 1,872 patients have been contacted to date, 902 agreed to be transferred and 271 treated to date

o Trust developing IP demand and capacity plans and shared with CCGs and NHS IST by the end of April . CCGs have requested that specialty level trajectories are developed by mid May 2017

• CW: CW has stated that demand and capacity plans are being developed and review meetings with CCGs to be organised

Gaps in Assurance: • Withdrawal of link between achievement of the RTT trajectories and

STF funding could potentially de-incentivise achievement • ICHT – The incomplete backlog remains at an unsustainable level.

Trust has not yet completed outpatient demand and capacity plans which impacts on the Trusts ability to produce robust trajectories.

• Business as usual processes are being improved and while these are not optimised the Trust are reporting that this is impacting on the Trust backlog

• CW –Detailed specialty recovery plans have not been shared with commissioners therefore the robustness of these plans is unknown

Assurances: • ICHT – Action plan and programme steering group in

place. Trust meeting backlog reduction target and reduced 52 week breaches in M11. Agreed 2017/18 STF trajectory estimates compliance by March 18

• CW – Met incomplete RTT performance from M2 to M8 16/17 and M11 16/17. Agreed 2017/18 STF trajectory confirms compliance for the year

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West London CCG 3.1 – 3.3) Exception Report – 18 Weeks RTT


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


date

M11 incomplete RTT performance not met ICHT

Weekly monitoring in place to monitor impact of validation programme. Specialty demand and capacity plans to be shared with CCGs for outpatients

Open

Open

Yes

Yes

DH

DH

ML

ML

Yes

Yes

In place

24/2/17

N/A

28/4/17

N/A N/A

M9 incomplete RTT performance not met CW

CCGs have formally requested specialty plans in August 2016. CW has agreed to arrange joint meeting to review plans for challenged specialties.

Open Yes SS SA Yes 14/04/17 To be

confirmed N/A N/A

13

West London CCG 3.4) Exception Report – RTT 52 Week Waiters

Root Cause: ICHT: Forty-five breaches reported; Trauma and Orthopaedics (30), ENT (4), plastic surgery (4), general surgery (3), other (3) and gastroenterology (1). ICHT reported 316 patients in total who were waiting over 52 weeks for treatment in February. Root cause is due to the data quality issues identified on inpatient and outpatients waiting lists and an issue between patient administration system and reporting system . KCH: One breach reported in other.

Mitigating Actions: ICHT –Eight cases of potential clinical harm have been identified in total. Two have been downgraded, two completed with moderate harm confirmed and four are going through the investigation process: • SI declared in October 2016 – patient’s eyesight

deteriorated while awaiting an ophthalmic procedure. The patient has since had surgery and visual field tests are encouraging . The SI panel has been scheduled for 7th March 2017

• SI declared in December 2016 – patient who has been lost to follow-up under plastic surgery despite numerous ED attendances. The patient has been offered two plastics outpatient appointments and has DNA’d both. The Trust is currently following this up with the patient’s GP. The SI panel is scheduled for 14th March 2017

• Two internal (level 1) incidents in Orthopaedics declared in November 2016; these have completed with moderate harm confirmed

• Two internal (level 1) incidents in ophthalmology (one initially declared as an SI in November 2016);

Two incidents reported and subsequently down-graded after review have been confirmed as showing no harm (plastics and orthopaedics). Of the 75 patients (53 NWL CCG, 22 other CCG) where a plan is in process these include: • 41 patients require TCI • Of the 34 remaining, 12 patients have been contacted to

clarify their requirements, 12 await outcome of pre-assessment and 10 have agreed outsourcing

KCH – Trust completed demand and capacity models for the most challenged specialties.

Gaps in Assurance:

ICHT - Continued 52 week breaches. High levels of 52 week waits reported following increase “pop ons” identified through the audit of the Trusts inpatient waiting lists. Trust did not meet M11 trajectory and M12 unlikely to be met. Provider trajectory does not fully resolve until Q4 2017/18. On-going data quality issues at ICHT resulting in difficulties to manage RTT waiting lists. KCH – the number of patients waiting over 52 weeks increased from 158 in M10 to 183 in M11.

Assurances: ICHT – Trust provided a breakdown of the reasons for breaches and treatment plans in place. Gender pathway- Plan in place to reduce long waiters on the gender pathway with 15 cases reported in M11 2016/17. This does not impact NWL CCGs. NHSI has requested a trajectory for 2017/18, this has been shared with CCGs. H&F CCG has requested that all patients are “shadow” booked to ensure capacity issues are identified early, and that outsourcing for any non specialist pathways are fully explored. KCH - The Trust has updated the assessment tool used in risk reviews of clinical harm to patients waiting over 52 weeks. The new process provides adequate assessment and, where necessary, swift access to medical intervention.

Table 3.4.1

Table 3.4.2

Plan in Process Plan Treated Grand Total

NHS BRENT CCG 16 30 21 67

NHS CENTRAL LONDON CCG 8 15 6 29

NHS EALING CCG 11 20 14 45

NHS HAMMERSMITH AND FULHAM CCG 6 18 16 40

NHS HARROW CCG 2 6 2 10

NHS HILLINGDON CCG 4 4

NHS HOUNSLOW CCG 2 5 8 15

NHS WEST LONDON CCG 8 22 15 45

Grand Total 53 120 82 255

CCG Gender Non-Gender Pop-ons Grand Total

NWLCCG 153 102 255

Plan in Process 33 20 53

Plan 63 57 120

Treated 57 25 82

OTHER 11 27 23 61

Plan in Process 3 14 5 22

Plan 6 9 11 26

Treated 2 4 7 13

Grand Total 11 180 125 316

14

West London CCG 3.4) Exception Report – RTT 52 Week Waiters

Issue Provider Action Action Status Plan in Place?



Date Revised

Delivery Date Contract

Status Contract Penalties to

date

M11 52 week waits reported

ICHT ICHT to provide treatment plan for each 52 week breach.

Closed Yes DH KL Yes 28/03/2017 N/A N/A N/A

15

West London CCG 4.1) Exception Report – Cancer Waits: two weeks urgent GP referral

Root Cause: WL CCG did not achieve the two-week wait standard (91.4%) in M11. This was due to 49 breaches at CW (29), ICHT (18) and RMH (2). Breaches were due to administrative delays (1), capacity issues (20), other medical conditions prioritised (1) and patient choice (27).

Gaps in Assurance: WL CCG’s performance is at 91.4% in M11 against the standard (93%). CW did not meet performance in M11, in-line with action plan trajectory.

Assurances: All NWL providers except CW are meeting the standard in M11. CW, improvement in categorisation of breaches within Open Exeter report; improved understanding of issues effecting performance.

Mitigating Actions: All NWL providers except CW are meeting the standard in M11. CW are completing breach investigation reports for those patients who did not meet the standard. Due to on-going non-compliance at CW, an action plan is in place to support delivery from M11.


Plan in Place?

CCG Owner

Provider Owner


Date


Contract Status


date

Two-week wait urgent GP referral standard (93%)

CW Breach investigation reports to be completed for non-compliant patients

Open Yes BD CF Yes 10/04/17 N/A N/A N/A

18

West London CCG 4.4) Exception Report – 31 Day Surgery

Root Cause: WL CCG did not achieve the 31-day subsequent treatment surgery standard (93.3%) in M11. This was due to 1 breach at ICHT due to patient choice.

Gaps in Assurance: WL CCG’s performance is at 93.3% in M11 against the standard (94%).

Assurances:

All NWLproviders except RBH are achieving the standard in M11.

Mitigating Actions: All NWLproviders except RBH are achieving the standard in M11. RBH are completing breach investigation reports for those patients who did not achieve the standard.


Plan in Place?

CCG Owner

Provider Owner


Date


Contract Status


date

31 day subsequent treatment surgery standard (94%)

RBH Breach investigation reports to be completed non-compliant patients

Open Yes BD JP Yes 10/04/17 N/A N/A N/A

20

West London CCG 4.1) Exception Report – 31 Day Radiotherapy

Root Cause: WL CCG did not achieve the 31-day subsequent treatment radiotherapy standard (88.9%) in M11. This was due to 2 breaches at ICHT (1) and RMH (1). Breaches were due to patient choice .

Gaps in Assurance: WL CCG’s performance is at 88.9% in M11 against the standard (94%).

Assurances:

All NWL providers are achieving the standard in M11.

Mitigating Actions: All NWL providers are achieving the standard in M11 therefore no action required.


Plan in Place?

CCG Owner

Provider Owner


Date


Contract Status


date

31 Day subsequent treatment radiotherapy standard (94%)

N/A All NWL providers are meeting the standard -no action required.

N/A N/A N/A N/A N/A N/A N/A N/A N/A

21

West London CCG 4.1) Exception Report – Cancer Waits: 62 Days NHS Cancer Screening Service

Root cause: WL CCG did not achieve the 62-day NHS screening standard (60%) in M11. This was due to 2 breaches at ICHT. Breaches were due to patient choice and complex diagnosis.

Mitigating Actions: CW and THH both met the 62-day screening standard in M11. ICHT and LWNHT are completing breach reports for patients who did not meet the standard.

Gaps in Assurance: WL CCG’s performance is at 60% in M11 against the standard (90%).

Assurances: CW and THH both met the 62-day screening standard in M11.


Plan in Place?

CCG Owner

Provider Owner


Date


Contract Status


date

62 Day screening services standard (90%)

ICHT/ LNWHT

Breach report to be completed for non-compliant patient

Open Yes BD GG/JMcF Yes 10/04/17 N/A N/A N/A

22

West London CCG 4.7) Exception Report – Cancer waits: 62 days urgent GP referral

Single trust 100+ day breaches Lowest level of 100+ day breaches for 3 months ICHT (2): 1) delay within initial colonoscopy which then had to be abandoned. There was a further delay for a CTC due to the patient not being contactable, further colonoscopy before treatment decision (LGI, 107 days, Hounslow CCG), 2) patient had a cardiac event and needed an ECHO and assessment by Geriatrics before proceeding (LGI, 111 days, Ealing CCG) CW (1): 1) the planned surgery was cancelled twice due to the patients ill-health (LGI, 104 days, H&F CCG)

Provider Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

Imperial College Healthcare 77.50% 81.90% 82.20% 82.80% 76.20% 75.60%

London North West Healthcare 77.00% 74.10% 91.00% 85.10% 75.20% 82.40%

The Hillingdon Hospitals 78.40% 85.20% 85.30% 93.60% 86.80% 92.00%

Chelsea And Westminster 88.30% 83.30% 81.40% 91.80% 86.40% 86.20%

Royal Brompton & Harefield 53.80% 80.00% 45.00% 81.80% 20.00% 75.00%

NWL performance 79.10% 80.00% 83.30% 87.00% 78.80% 82.40%

Providers with s igni ficant activi ty outts ide NWL commiss ioning:

The Royal Marsden 73.60% 75.40% 78.20% 79.20% 66.70% 78.00%

University College London Hospitals 73.20% 68.50% 73.70% 76.30% 61.60% 70.10%

Royal Free Hospitals 78.00% 73.70% 82.10% 82.70% 81.80% 79.80%

London performance 79.60% 79.40% 81.40% 84.00% 79.20% 79.90%

National performance 81.40% 81.00% 82.20% 83.00% 79.60% 79.80%

62 Day Standard Compliance

100+ day breaches for

NWL Providers (Feb)

First Seen Provider CW ICHT LNWHT THH RBH Other Total

CW 1 2 1 4

ICHT 2 1 3

LNWHT 1 1

THH 0

Other 0

Total 1 5 1 0 0 1 8

Treatment Provider

23

West London CCG 4.7) Exception Report – Cancer waits: 62 days urgent GP referral cont’d

Performance summary: WL CCG did not achieve the 62-day urgent GP referral standard in M11. This was due to 3 breaches at ICHT (1), CW (1) and RMH (1). Breaches were due to patient choice (2) and a delay in work-up. There were no patients waiting over 104 days.

Assurances: • THH and CW meeting the 62 day standard in month. • ICHT Details of elective cancellations to be shared with the ICHT/CCG PCE

meeting with an update on qualitative impact on patients at April CQG. • LNWHT Additional senior support for waiting list tracking and management has

been put in place from March. • RBH Internal NWL performance not effecting RBH position; improvement in 24

day treatment delivery (88% in M11) reflected in reallocation position (88.9%). • NWL Cancer Waiting Time agreement signed by two of the five Trusts in March,

remaining are being followed up. • Weekly monitoring of performance across Trusts continuing with good

engagement from each organisation. • NWL have seen a 30% reduction from March 2016 to March 2017 in the total PTL

backlog (patients waiting > 62 days).

Mitigating Actions: • ICHT, LNWHT and RBH to submit individual breach and exception reports by

10/04/17 for 62-day breach patients. • LNWHT Breakdown of cancer waiting list (PTL) and an update of the Trust action

plan has been requested by CCG to be reviewed by the Elective System Resilience Operational Group (SROG).

• ICHT Weekly identification of late referrals shared with referring Trusts for discussion each week to support shared learning and improved pathways.

• CW On-going monitoring of action plan to reduce PTL and improve 2WW performance; Trust report compliance in March (M12) for 2WW standard. PTL recovery plan requested to reduce the number of patients waiting > 62 days.

• RBH Continued engagement with RBH, NHSE specialised commissioning and NWL CCG cancer manager to review actions to improve performance.

• NWL Trusts Development of weekly intertrust referral database to monitor late referrals; and document agreed improvement actions.

• NWL 104 day breach trend analysis to be undertaken

NWL Cancer Performance Monitoring against key cancer waiting time standards: • ICHT – Performance remains below the standard in M11 (75.6%), the Trust did not

meet their proposed trajectory position (85.4%). ICHTs reallocation performance was at 82.3% which is an improvement on their position. Internal performance was at 78.1% in M11 due to a high number of internal breaches especially on the LGI pathway.

• LNWHT – The Trust did not meet performance in M11 (82.4%) and did not meet their proposed trajectory (85.1%). Reallocation performance was 78.6% indicating delays in referrals to other Trusts. Due to the increase in the patient waiting list (PTL), and high “tip over” rate, the Trust have been asked to provide a breakdown of the PTL by pathway. Actions to reduce the high number of patients without a decision to treat will be discussed at the System Resilience Operational Group.

• CW – The Trust met performance in M11 (86.2%), the Trust did not meet their trajectory (86.3%). Reallocation performance saw the Trust become non-compliant (83.7%) indicating late referrals for treatments. Review of the cancer waiting list (PTL) has been requested, following concern over the increase in the number of patients waiting on the colorectal pathway and 104 day breaches on the Urology pathway in Q4. The Trust are being asked to provide a waiting list reduction trajectory and target. The Trust are implementing a new cancer database (Somerset) during Q1 which merges systems across sites.

• THH - The Trust has met the 62 day standard in M11 (92.0%). Update awaited from NHSI review following delays on the three provider pathway between, THH, LNWH and ENHT (Mount Vernon Cancer Centre).

• RBH – The Trust did not meet the 62 day standard in M11 (75.0%) however with reallocation rules applied the Trust became compliant at 88.9% This is assurance that treatments are being completed within 24 days of referral. All late referrals were made from non NW London providers, RBH has been supporting referring providers and NHSE are raising concerns with relevant area teams.

• NWL Recovery plan and actions being drawn up to support the delivery of the cancer waiting time standards in 2017/18 with individual Trust actions to support delivery to be agreed.

Gaps in Assurance: • Delayed submission of provider breach and quality standard reports. • Lack of review of 104 day breaches and actions at CQGs. • Reduction in PTLs at Trust level especially in gynaecology at LNWH and colorectal

at CW. • Impact of non-NWL Trusts on performance especially at RBH. • Trust cancellation of patients due to emergency pressures, updates outstanding to

understand number of patients effected.

24


Reallocation Reallocation is based upon the timely referral and treatment of patients (referral by day 38 and treatment by day 24 – breach awarded against Trusts timely action). The reallocation position for M11 is shown below. ICHT and RBH would see an improvement in their overall position if the new rules were applied. Performance at the other Trusts would decline. This indicates the ICHT and RBH are treating within 24 days and the other Trusts have not referred patients within 38 days for treatment.

During February, 53% of the ITTs sent by the Trusts were after day 38.. When the treatment was provided by a NWL trust, 84% were completed within 24 days.

Internal/Inter-Trust Performance Across NWL, internal performance was above 85% at except at ICHT in M11. The intertrust performance at LNWHT saw their overall position become non-compliant.

Performance Trends In M11, all providers except CW met the two-week wait standard. CW have not met the standard for 7 months, action plan in place and the Trust indicate performance is now compliant in March (M12) 2017. NWL sector performance was at 93.1% in M11, recovering the overall compliance for the sector.

Across NWL, all providers except for RBH have met performance in M11 against the 31 day first treatment standard; this was due to 3 breaches. RBH’s performance was effected by capacity and patient choice. As a sector, performance is at 96.9%, maintaining compliance with the standard.

Trust Sep Oct Nov Dec Jan Feb Trust Sep Oct Nov Dec Jan Feb

CW 88.3% 83.3% 81.4% 91.8% 86.4% 86.2% CW 87.9% 80.4% 79.4% 92.8% 84.3% 83.7%

LNWHT 77.0% 74.1% 90.8% 85.1% 75.2% 82.4% LNWHT 77.6% 72.5% 89.8% 80.9% 71.8% 78.6%

ICHT 77.5% 81.9% 82.2% 82.8% 76.2% 75.6% ICHT 82.0% 86.5% 85.1% 88.7% 82.3% 82.3%

RBH 53.8% 80.0% 45.0% 81.8% 20.0% 75.0% RBH 68.8% 100% 60.9% 84.6% 16.7% 88.9%

THH 78.4% 85.2% 85.3% 93.6% 86.8% 92.0% THH 77.8% 84.6% 85.3% 92.3% 85.8% 90.5%

Actual CWT Position Reallocation Position (National Model - Frozen)

Trust NameTotal

Breaches

Single

Trust

Breaches

Intertrust

Breaches

% Single

Trust

%

IntertrustOverall

ChelWest 6.0 3.0 3.0 91.4 60.0 85.9

LNWHT 10.5 6.0 4.5 88.0 52.6 82.4

ICHT 19.5 14.0 5.5 78.1 60.7 75.0

RBH 1.0 0.0 1.0 75.0 75.0

THH 3.5 3.0 0.5 91.9 92.3 92.0

Provider

First Seen

No. of

ITTs sent

No. of

late ITTs% late ITTs Provider

Total ITTs

Rec.

Treated >

24 days

Treated <

24 days

% Treated

< 24 days

LNWH 15 8 53% RBH 8 1 7 88%

CW 15 9 60% ICHT 26 4 22 85%

THH 13 5 38% LNWH 4 1 3 75%

ICHT 2 2 100%

ITT Summary: Referred onto another Trust Treatment by a NWL Trust

Provider Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

Chelsea And Westminster 93.8% 91.2% 92.4% 91.1% 90.7% 91.7% 89.8% 90.8%

London North West Healthcare 95.1% 95.4% 93.6% 95.0% 94.7% 93.6% 93.0% 93.0%

Imperial College Healthcare 93.2% 93.0% 91.2% 93.5% 93.2% 93.1% 87.2% 93.2%

Royal Brompton & Harefield 100.0% 100.0% 100.0% 100.0%

The Hillingdon Hospitals 97.4% 95.3% 93.5% 94.7% 94.8% 93.0% 93.4% 97.1%

NWL performance 94.5% 93.7% 92.6% 93.6% 93.3% 93.0% 90.5% 93.1%

Two Week Wait Standard Compliance (93%)

Provider Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

Chelsea And Westminster 97.3% 100.0% 100.0% 98.7% 97.0% 100.0% 100.0% 96.8%

London North West Healthcare 95.6% 94.9% 97.1% 94.5% 98.1% 97.1% 99.0% 100.0%

Imperial College Healthcare 97.3% 96.9% 96.1% 96.7% 97.6% 98.6% 96.0% 96.3%

Royal Brompton & Harefield 100.0% 97.5% 96.3% 93.1% 95.2% 93.9% 80.0% 88.0%

The Hillingdon Hospitals 98.4% 98.6% 98.3% 98.5% 98.5% 98.7% 97.6% 98.4%

NWL performance 97.2% 97.1% 97.2% 96.5% 97.6% 98.2% 96.3% 96.9%

31 Day First Treatment Standard Compliance (96%)

25



Plan in Place?

CCG Owner

Provider Owner

On Track

Original Delivery Date

Revised Delivery

Date

Contract Status


date

62 day standard (85%) ICHT

/LNWH/ RBH

Trusts to submit individual breach reports with performance team review

Open Yes BD All Yes 10/04/17 N/A N/A N/A

62 day standard (85%) LNWHT Action plan delivery being monitored at elective SROG.

Open Yes HWJ AM Yes 20/02/17 11/04/17 N/A N/A

62 day standard (85%) CW

Monitoring of action plan for reduction of PTL and improvement to 2WW pathways

Open Yes BD CF Yes 30/11/16 On-going N/A N/A

62 day standard (85%) ICHT Update to backlog action plan to be completed

Open Yes DH GG Yes 11/01/17 19/04/17 N/A N/A

62 day standard (85%) All

Providers

Weekly performance of current/previous month to monitor early performance

Open Yes BD Cancer

Managers Yes 05/12/16 On-going N/A N/A

62 day standard (85%) ICHT

Weekly list requested of referrals to ICHT including ITR day for early breach monitoring

Open Yes BD GG Yes 22/02/17 On-going N/A N/A

62 day standard (85%) CW/LNWHT Action plan & timeline for reduction of PTL backlogs

Open Yes BD CF/JMcF Yes 30/04/17 N/A N/A N/A

26

West London CCG 5.1) Exception Report – Cancelled Ops

Root Cause: CW – 3 breaches reported in M11 2016/17. Breach reasons requested. ICHT – 6 breaches reported in M11 2016/17. Full review of breach reason scheduled at the April CQG.

Mitigating Actions: CW – Dependant on the outcome of the review of Q4 breach analysis. ICHT– Review is scheduled for presentation to the CQG meeting on 22 April 2017. This paper will cover: trends in cancellations and repeat cancellations; actions in place to reduce cancellations and ensure compliance with the 28-day rebooking guarantee; management of clinical risks; and patient experience.

Assurances:

CW – limited based on continued breaches to this standard

ICHT– CCG review at CQG on the 22nd April.

Gaps in Assurance:

CW / ICHT – Continued breaches to standard.


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Three breaches to the 28 day guarantee (cancelled operations)

CW Review of Q4 breaches and actions Open Yes SS PH Yes 24/05/17 N/A N/A N/A

Six breaches to the 28 day guarantee (cancelled operations)

ICHT Action plan to be reviewed at CQG. Note – The Trust has requested this report to be deferred to June CQG.

Open Yes DH KH Yes 22/04/17 N/A N/A N/A

27

West London CCG 5.3) Exception Report – MSA

Root Cause:

One breach in M11 which was reported at:

UCLH (1): Thirteen breaches reported in total. All breaches due to delay in step down from critical care/ITU.

Mitigating Actions: UCLH: Reducing delayed step downs from ITU is a CQUIN and an group has been tasked to develop an action plan to improve the position.

Assurances: UCLH: Developing patient flow modelling underway. Gaps in Assurance:

ULCH: On-going breaches against this standard


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Thirteen MSA breaches (1 WL patient)

UCLH To monitor progress against action plan

Open Yes NELCSU TBC Yes 28/04/17 N/A N/A N/A

28

West London CCG 5.4 & 5.5) Exception Report – HCAI

Root Cause: C.Diff - WL CCG did meet M11 C.Diff tolerance with 3 cases against a trajectory of 4 cases. Two cases out of three was apportioned to ICHT (2), and one of the cases were not apportioned to an acute site. WL CCG is not meeting year to date (YTD) tolerance with 62 cases against a requirement of 47. One case of MRSA bacteraemia reported.

Mitigating Actions:

• Dedicated infection control resource within

CWHHE that support on-going review of infection control and anti-microbial stewardship programmes across all providers

• Quarterly joint provider-commissioner review of Clostridium difficile (C diff) cases to determine if there were any lapses in the quality of care provided . No significant issues identified in Q3 16/17.

• MRSA post infection reviews (PIRs) for all cases • On-going assurance of the national Healthcare

Associated Infection (HCAI) agenda and compliance with the Health and Social Care Act 2008 through quarterly meetings to review: o mandatory training compliance o anti-microbial stewardship programme o Hand hygiene audits o Implementation of the Sepsis toolkit o Management of multi-resistant organisms

such as carbapenemase-producing Enterobacteriaceae (CPE), E Coli bloodstream infections

Assurances: • Joint review of C.Diff cases at CWHHE providers

have provided assurances that robust processes are in place. Where lapses in care identified actions are agreed with IC leads

• On-going monitoring of Hygiene Code compliance for all providers , reviewed quarterly at CCG quality and patient safety committees and CQGs

• Six month trial period of a dedicated anti-microbial pharmacist form the medicines management team to support the IPC Lead with C diff case reviews and also link in with primary care anti-microbial work

Gaps in Assurance: • Antimicrobial resistance/on-going threat of multi-resistant

microorganisms (CPE & Gram negative bacteria including E. coli). Awaiting national guidance on the proposed changes to manage and monitor E. coli bloodstream infections


Plan in Place?

CCG Owner

Provider Owner

On Track Original

Delivery Date Revised


Status


date

Inconsistent C.diff performance through 2016/17

NWL providers

Review of Q4 C.Diff with CWHHE providers Open Yes PK Infection control

lead Yes 28/4/17 N/A N/A N/A

Month Comment Apportioned

Apr-16 Contaminant patient not impacted CWHFT

Jul-16

Complex medical history, with long hospital

stays in across providers across NWL.

Improvements in line management (vascular

access) were identified and an action plan has

been requested. LNWHT

Oct-16

Non UK resident (WL CCG allocation based on

provider). Contaminated sample within the

cardiothoracic ITU. Ward training programme

including vascular access, decolonisation and

infection control protocols in place. Royal Brompton

Oct-16

Non UK resident (WL CCG allocation based on

provider). Patient RTA with probable source from

a wound infection following spinal surgery. Ward

have reviewed improvements to wound

management processes. ICHT

Nov-16

Following the PIR meeting, CCG and Royal

Brompton agreed that the case should be

assigned to third party due to the following

reasons: Non UK resident and strong evidence

from the reference lab that the strain was

specific to Queensland Australia. 3rd party

Feb-17

Patient admitted to St Marys A&E with a two day

history of chest pain. Diagnosed with necrotising

pneumonia and possible endocarditis. MRSA

isolated from the blood cultures taken on

admission. MRSA BSI treatment and

decolonisation commenced in a timely manner.

No suboptimal care identified. WL CCG

29

West London CCG 6.1 & 6.2) Exception Report – Mental Health IAPT

Root Cause: With February being the shortest calendar month of the year, referrals were down to 591 against an average of 645 monthly for the year. Team Leads had anticipated this reduction occurring and have ensured that the run rate for the quarter and YTD has been achieved.

Mitigating Actions: Trust have recruited a new team manager to oversee recruitment issues. Close working between CCG and Trust. IAPT recovery plan in place. Trust have weekly Team Leads meetings to allow team leads to act on low access numbers and plan for forthcoming weeks. Trust to continue to deliver and monitor effectiveness of recovery rate improvement plan. Trust to monitor implementation of plan in performance support meetings; patient suitability for IAPT Treatment in supervision and data quality in weekly data quality checks by Clinical Lead. Trust performance analyst is working with Team and performance leads on a daily basis to ensure the correct capacity is available to meet demand. Assurance:

CNWL IAPT performance meeting involving IAPT Service leads, CCG Commissioners, Contracting & Performance leads to review performance and agree appropriate actions. Trust confirmed IAPT Access rate target will be achieved in M08. 2016-17 M11 YTD IAPT Access and Recovery targets achieved.

Gaps in Assurance: No identified gaps in assurance.


Plan in Place?

CCG Owner

Provider Owner

On Track

Original Delivery

Date


Contract Status


date

IAPT Access & Recovery

CNWL On-going monitoring of IAPT target and CCG support to sustain performance improvement in 2016/17.

Open Yes GM/AN ROB Yes On-going

until 30/04/17

N/A N/A N/A

30

West London CCG Exception Report – DNA First Appointment

Root Cause: Multiple attempts were made to contact patient following referral and in all breaches patients were hard to engage due to history of poor contact with mental health services.

Mitigating Actions: Trust have started calling patients and reminding them to attend their appointments the day before, and rearrange the appointment if they say they cannot attend.

Assurances: 2016-17 YTD target achieved by Trust. YTD performance at 12.4% against a target of 15%. Slight improvement in M11 performance.



Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Under performance against F2F assessment undertaken within 4 hours

CNWL Weekly meetings are being carried out by CNWL to ensure reason for breaches are discussed and tracked on a weekly basis in the team.

Open Yes AN TW Yes On-going

until 30/04/17

N/A N/A N/A

31

West London CCG Exception Report – Face to Face (F2F) Assessments – emergency and urgent

Root Cause: Assessments undertaken with 4 hours M11 breach relates to one patient who was not seen with 4 hours. CNWL were unable to reach the patient despite multiple attempts. Assessments undertaken with 24 hours M11 breach relates to two patient not seen with 24 hours. CNWL were unable to reach the patient despite multiple attempts.

Mitigating Actions:

Weekly update discussions are held by Trust to ensure data is captured and that emergency referrals are tracked and responded to within this timescale where possible. Trust is holding monthly team briefings to update staff on issues from exception report.

Team manager and Senior staff to monitor performance weekly .

Assurances: On-going monitoring via CQG. Report and Action Plan presented to commissioners at PFIG in March.

Gaps in Assurance: 2016-17 YTD target not achieved.


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Under performance against F2F assessment undertaken within 4 hours and 24 hours

CNWL

Staff are informed that all recording must reflect the accurate time of contact with service users .


until 30/04/17

N/A N/A N/A

Trust to ensure emergency referrals are tracked and responded to within this timescale where possible.


until 31/04/17

N/A N/A N/A

Trust to develop a recording guidance and standardised approach to recording.

Open Yes AN TW Yes 30/04/17 N/A N/A N/A

Trust to roll out standard referral management template.


32

West London CCG Exception Report – Face to Face (F2F) Assessments

Root Cause: Underperformance in M11 due to: 1. Inconsistent process for managing new referrals. 2. Data Quality issues with recording appointments accurately on the clinical system.

Mitigating Actions: Trust to review incoming referrals on a daily basis for allocation to appropriate clinician and clinic. Teams are attending monthly Borough Accountability meetings with Borough director to address performance issues Teams working with Performance Lead to address Data Quality Issues.

Assurances: On-going monitoring via CQG. Report and Action Plan presented to commissioners at PFIG in March.

Gaps in Assurance: Underperformance throughout 2016-17.


Plan in Place?

CCG Owner

Provider Owner

On Track Original

Delivery Date

Revised Delivery

Date

Contract Status


Under performance against F2F assessment undertaken within 7 day s and 28 days.

CNWL

RAG rating tracker system to identify potential breaches to enable proactive action before breach

Closed Yes AN TW Yes 30/11/16 On-going

Until 31/03/17

N/A N/A

New system for tracking referral and assessment and data capture has been implemented by Trust

Closed Yes AN TW Yes On-going

Until 31/03/17

N/A N/A N/A

Trust to develop a recording guidance and standardised approach to recording.


Trust to roll out standard referral management template. Open Yes AN TW Yes 30/04/17 N/A N/A N/A

33

West London CCG Exception Report – Urgent and Crisis

Root Cause: Underperformance in M11 due to patients assessments not being carried out in home or community settings. CNWL assess patients in the most clinically appropriate setting at the time of the referral.

Mitigating Actions: Trust to ensure emergency referrals are tracked and responded to within this timescale where possible.

Assurances: On-going monitoring via CQG. Report and Action Plan presented to commissioners at PFIG in March. Further improvement at M11.

Gaps in Assurance: Performance below trajectory. Underperformance throughout 2016-17.


Plan in Place?

CCG Owner

Provider Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status


Under performance against Urgent assessments carried out in Home or Community setting

CNWL

Monthly team briefings being held to ensure staff enter contacts they have with patients accurately onto clinical systems at the correct date, time and location

Open Yes AN TW No

On-going Until

31/03/16

On-going Until

30/04/17 N/A N/A

At CQG Trust requested for a trajectory to address data quality issues and meet target. Update: Trust to provide update on issues, actions and trajectory to meet performance at March FIG . Update: Action Plan provided by Trust however trajectory not provided due to long-stop negotiations and agreement of KPI inclusion in for 2017-18..

Closed Yes AN TW Yes 31/12/16 31/03/17 N/A N/A

34

West London CCG Exception Report – DNA 1st appointments

Root Cause: M11 underperformance equates to 14 DNA’s. Analysis undertaken by the Trust has identified Half Term holiday impacted M11 performance.

Mitigating Actions: Trust monitor performance on a weekly basis in M12 to ensure target is met.

Assurances: On going monitoring via PFIG. M11 YTD target at 14.4% against a target of 15%.



Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Underperformance against DNA 1st Appointments

CWNL New reporting system being implemented across CNWL to enable performance to be monitored on a daily basis at team and staff level

Open Yes AN TW No

On-going Until

31/03/17

On-going

Until 30/04/17

N/A N/A

35

West London CCG Waiting Times- 18 Weeks RTT

Root Cause: Underperformance in M11 due to demand exceeding capacity, clinical issues and difficulties with patient engagement. Referral levels have continued to increase in 2016/17 with a 7% growth across all boroughs.

Mitigating Actions: Service is actively recruiting staff to the teams. Weekly review of waiting list by clinical staff.

Assurances: On-going monitoring via CQG and PFIG. Additional funding received by NHS England to deal with demand and capacity issues. Further improvement in M11 performance.

Gaps in Assurance: 2016-17 YTD target not achieved.


Plan in Place?

CCG Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


Underperformance against CAMHS 18 weeks RTT

CNWL

Service to keep a log of types of referral to demonstrate increase in demand which will be discussed with commissioners.

Closed Yes AN TW Yes On-going 31/3/17

N/A N/A N/A

Trust to review data entry processes in conjunction with the development of the SPA and new clinical systems.

Open Yes AN TW Yes 31/3/17 30/04/17 N/A N/A

CNWL are working with commissioners to develop a single point of access for all CAMHS referrals providing onward referral and redirection to other services where appropriate.


36

West London CCG Exception Report – Adult Community Nursing – Urgent and non-urgent referrals

Root Cause: Underperformance in M11 due to data issues arising from the Trust move to an automated reported function through BIPA (Business Intelligence and Performance Analysis).

Mitigating Actions: Trust to review root cause of underperformance and develop an action plan.

Assurances: On going monitoring via CQG. Service has confirmed all patients are seen within the required timeframe.



Plan in Place?

CCG Owner

Provider

Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status


Underperformance against Adult Community Nursing.

CLCH Trust to develop action plan and timetable to work through data issues.

Open Yes LC PB Yes

30/04/17 N/A N/A N/A

37

West London CCG Exception Report – Continuing Care Annual Reviews Completed

Root Cause: Underperformance in M11 due to capacity issues and increase backlog.

Mitigating Actions: CLCH to escalate to the CCG any unexpected surges in demand or reduction in staffing capacity at monthly performance meeting Trust to have regular data cleansing to ensure accuracy of data. Trust to streamline the process for clearing backlog. Weekly monitoring of assessments in panel

Assurances: On-going monitoring via CQG. Contract Performance Notice issued.

Gaps in Assurance: In month and YTD target not achieved.

Issue Provide

r Action

Action Status

Plan in Place?

CCG Owner

Provider

Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status


Underperformance against Continuing Care

CLCH

Trust to develop trajectory plan with clear target of reducing outstanding reviews .

Closed Yes LC PB Yes 28/02/17 31/03/17 CPN in Place

N/A

Trust to streamline process for backlog clearing through allocation of specific responsibilities to staff.

Open Yes LC PB Yes 31/03/17 30/04/17 CPN in Place

N/A

Trust to offer additional overtime/bank shifts to staff over the next 4 months to complete outstanding reviews

Open Yes LC PB Yes 31/07/17 N/A CPN in Place

N/A

CLCH to source temporary assessor to complete outstanding reviews.

Open Yes LC PB Yes 13/07/17 N/A CPN in Place

N/A

38

West London CCG 7.4) Exception Report – Diabetes

Root Cause: Underperformance in M11 due to data and referral pathway issues arising from the Trust move to an automated reported function through BIPA(Business Intelligence and Performance Analysis). Trust cannot report on appointment offered date and first appointments are being linked to incorrect referrals.

Mitigating Actions: Clinical leads are reviewing records to ensure data is correct and a single operating procedure is being drawn up to ensure correct data capture.

Assurances: On-going monitoring via CQG. Trust have reviewed next available appointment across CCGs and services within diabetes has indicated that there are currently available appointments within 4 weeks for all services.

Gaps in Assurance: Under performance throughout 2016-17.


Plan in Place?

CCG Owner

Provider

Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status


Underperformance against Diabetes: Appointments offered within 4 weeks

CLCH

Patient demand and capacity to be monitored to ensure there are always appointments available within 28 days.

Open Yes LC PB Yes On-going

until 31/03/17

On-going until

30/04/17 N/A N/A

Twice monthly review of additional BIPA ( Trust Business Intelligence Function) exception report.


until 31/03/17

On-going until

30/04/17 N/A N/A

Twice monthly review of available new appointment slots. Additional slots to be added to established clinics if demand increases


until 31/03/17

On-going until

30/04/17 N/A N/A

39

West London CCG 7.4) Exception Report – DTOC – Occupied beds as the result of a delay

Root Cause: Underperformance in M11 due to there not being suitable nursing homes.

Mitigating Actions: Trust continues to monitor performance. Weekly DTOC conference with CCG and adult social care in place.

Assurances: On-going monitoring via CQG. M11 YTD performance at 0.4% against a target 7.5%.

Gaps in Assurance: CLCH have low number of beds, a small number of DTOC bed days skew performance.


Plan in Place?

CCG Owner

Provider

Owner

On Track

Original Delivery

Date

Revised Delivery

Date

Contract Status


Underperformance against DTOC

CLCH

On-going monitoring of DTOC target and CCG support to sustain performance improvement in 2016/17. Update on actions to be provided if target is breached in M11.

Open Yes LC PB Yes 30/04/17 N/A N/A N/A

40

West London CCG Exception Report – Podiatry: Non-Urgent First Appointments seen within 28 days

Root Cause: Underperformance in M11 due to high level DNA, patient choice -appointments are rescheduled outside the 28 day target as per patient choice and SystmOne issues.

Mitigating Actions: SMS text messaging and reminding patients of appointments. Trust to ensure telephone reminder process is working as agreed with within the service. Podiatry DNA rates are monitored and being addressed by Trust.

Assurances: On-going monitoring via CQG. Action Plan in place to resolve SystmOne issues.

Gaps in Assurance: Under performance throughout 2016-17.


Plan in Place?

CCG Owner

Provider Owner

On Track


Revised Delivery

Date Contract Status


date

Under performance against Podiatry: non-urgent referrals seen within 28 days of referral

CLCH

Trust to re-configure the system to have a drop down list so recording is consistent and easily reportable. Update: Trust anticipate SystmOne issues will be resolved by April 2017

Open Yes LC PB Yes 19/08/16 30/04/17 N/A N/A

As part of the wider QIPP/Transformation work, Trust and CCGs are- -reviewing access to the service with the aim to reduce patients who are at high risk. -working to confirm if low risk diabetic basic nail care patients continue to be seen by CLCH podiatry Services

Open Yes LC PB Yes 31/03/17 On-going

until 31/05/17

N/A N/A

Service is looking at a process where cancelled clinic slots can be reassigned to a cohort of patients that are willing to be seen at very short notice.

Open Yes LC PB Yes 31/03/17 30/04/17 N/A N/A

41

West London CCG Exception Report – NHS 111


Plan in Place?

CCG Owner

CSU Owner Provider Owner


Date

Revised Delivery

Date

Contract Status


N/A

Root Cause: • Calls answered in 60 seconds dipped slightly

in M11. This is being addressed through contract monitoring meetings and is due to demand exceeding capacity.

• Calls requiring a call back continues to be below target, however this is in line with national performance.

• Note: calls transferred to/answered by a clinical advisor has been added to the call standards.

• Calls which led to ambulance dispatch have dropped and are now at the 10% target.

• Provider is running a number of pilots in addition to the core service which may be impacting on performance.

Mitigating Actions: • Addressing under-performance through

contract monitoring meetings. • The provide is continuing with their

recruitment drive for call handlers and clinical advisors.

Assurances: • Contract monitoring meetings. • Joint 111 and GP OOH CQRG chaired by

quality A.D. and clinical lead. • Monthly call reviews. • Robust clinical leadership.

Gaps in Assurance: • n/a.

February 2017

INWL* - LCW

Call standards No. calls %

Number of calls offered 10,059 N/A

Number of calls answered 9,744 N/A

Calls answered in 60 secs 9,182 94.23%

Calls abandoned in 30 secs 73 0.75%

Calls transferred to / answered

by a Clinical Advisor 1,975 20.27%

Calls triaged 8,270 84.47%

Calls where a call back was

offered 610 6.26%

Call backs within 10 minutes 186 30.49%

Led to ambulance dispatches 811 10.65%

Recommended to attend A&E 860 10.40%

Recommended to attend

primary/community care 4579 55.37%

Recommended to attend other

services 281 3.40%

Did not recommend to attend

other service 1,669 20.18%

* Central London, West London, Hammersmith & Fulham

Data source: UNIFY2

42

West London CCG Exception Report – GP Out of Hours


Plan in Place?

CCG Owner Contract Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


N/A

National Quality Requirements Target

Central/ West London & H&F CCGs

% calls triaged within 20 minutes (urgent) 95% 97%

% calls triaged within 60 minutes (routine) 95% 97%

% walk-ins triage complete within 20 minutes (urgent)

95% 100%

% walk-ins triage complete within 60 minutes (routine)

95% 100%

GP cons available at all times & places 100% 100%

% emergencies consulted within 1 hour 95% 100%

% urgent consulted within 2 hours 95% 100%

% routines consulted within 6 hours 95% 99%

% emergencies visited within 1 hour 95% 100%

% urgent visited within 2 hours 95% 96%

% routines visited within 6 hours 95% 99%

Root Cause: • Provider performing well and all targets are

green-rated.

Mitigating Actions: • N/A

Assurances: • Monthly performance reporting. • Quarterly contract meetings. • The calls waiting for HV are reviewed regularly

and patients are kept informed. • Joint 111 and GP OOH CQRG established in

November.

Gaps in Assurance: None.

43

West London CCG Exception Report – West Middlesex UCC

KPI Description Result

Ambulance Handovers Percentage of non-emergency handovers by LAS taking under 15 mins 100.0%

Adult Clinical Assessment Percentage of adult patients who have their clinical triage and

navigation within 20 mins 89.6%

Child Clinical Assessment Percentage of children who have their initial brief clinical assessment

and navigation within 15 mins. 85.5%

GP Information Transfer

Percentage of patients who are registered with a GP who have

information regarding their access of the UCC sent to their GP by 8am

the next working day (where the patient consents to this) 100.0%

Unregistered patient

assistance to register Percentage of non-registered patients helped to register with a GP 100.0%

Generic prescribing Adherence with the agreed UCC formulary 0.0%

A&E 4 hour wait Percentage of patients redirected from UCC to ED with no diagnostic

tests within 1 hour 89.5%

A&E 4 hour wait Percentage of patients redirected from UCC to ED with diagnostic tests

within 2 hours 44.8%

A&E 4 hour wait Percentage of patients treated and discharged from UCC within 4 hours 96.6%

Root Cause: • Streaming and redirection

performance within the UCC continues to be affected by the building works.

• The provider believes triage times may have been recorded incorrectly and are investigating this.

Mitigating Actions: • The UCC has employed a lead shift

worker to review diversions and recognise early problems that occur in triaging or streaming.

• The UCC are ensuring 100% rota fill at all times.

• A performance rectification action plan will be requested at next contract meeting if under-performance continues in M12.

Assurances: • Monthly KPI reporting. • Bi-monthly contract meetings. • Daily reporting of attendance and

performance figures. • Daily late referral analysis.

Gaps in Assurance: None.


Plan in Place?

CCG Owner Contract Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status

Triage rates below target for both adults and paediatrics. HRCH/

Greenbrook

Provider continuing to review staff streaming competencies. Provider investigating possible system issues affecting measurement of triage times.

In progress

Yes Geralyn Wynne

Candice Clark

Parmjit Rai

No 31/03/15 31/03/17 Expires

31/01/18

44

West London CCG Exception Report – Hammersmith UCC

KPI Description partnership LCW and Imperial Result

Unplanned re-attendance Unplanned re-attendance at UCC within 7 days of original attendance 4.2%

4 hour wait Percentage of patients treated and discharged from UCC within 4 hours 3 Breaches

Left without being seen Percentage of patients who left without being seen 4%

Service experience Patient satisfaction (Friends & Family Test) 99%

Time to treatment Median time to treatment (<60 minutes wait) 90%

Mitigating Actions: • n/a

Gaps in Assurance: • None.


Plan in Place?

CCG Owner

Contract Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


date

N/A N/A

Root Cause: • All targets are green-rated in

M111.

Assurances: • Quarterly contract meetings. • Monthly performance reporting.

45

West London CCG Exception Report – Charing Cross UCC

KPI Description Result

Unplanned re-attendance Unplanned re-attendance at UCC within 7 days of original attendance 4.5%

4 hour wait Percentage of patients treated and discharged from UCC within 4 hours 6 Breaches

Left without being seen Percentage of patients who left without being seen 3.1%

Service experience Patient satisfaction (Friends & Family Test) 96%

Time to treatment Median time to treatment (<60 minutes wait) 57.1%

Mitigating Actions: • The provider has set an action

to ensure that all staff are aware of the difference between planned and unplanned re –attendance. A request has been made for this to be on an action plan to be monitored at meetings.

Gaps in Assurance: • n/a


Plan in Place?

CCG Owner

Contract Owner

Provider Owner


Date

Revised Delivery

Date

Contract Status


date

N/A N/A

Assurances: • Quarterly contract meetings. • Monthly performance reporting.

Root Cause: • All targets are green-rated in

M11.

46

West London CCG Quality Premium

CCG funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for constitutional gateway measures breaches.

£1,227,285

Quality Premium Measures2016/17

Target Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

ytd

16/17Weight

Reward

Achievement

Cancers diagnosed at early stages 40% 20% £ -

Cancer Proxy measure - number of Emergency

Presentations of Cancer resulting in Inpatient spell24 13 12 18 22 21 11 10

Increase in proportion of E-referrals 53.1% 28.6% 25.3% 26.0% 27.8% 24.9% 29.1% 23.6% 23.6% 20% £ -

Overall experience of making a GP appointment 79% 20% £ -

Reduction in antibiotics prescribed in primary care 1.161 0.696 0.697 0.699 0.700 0.703 0.706 0.700 0.700 5% £ 61,364.25

Reduction in broad spectrum antibiotics in primary

care10.0% 10.1% 10.1% 10.1% 10.0% 10.2% 10.2% 10.2% 10.2% 5% £ -

Circulation - Reported prevalence of CHD on GP

registers as % of estimated prevalence60% 46.9% 47.1% 47.3% 47.5% 47.8% 48.0% 48.2% 47.9% 48.6% 48.6% 10% £ -

Mental health admissions to hospital: Rate per

100,000 population aged 18+85 27 22 27 32 32 10% £ 122,728.50

Cross-cutting - % of patients aged 17+ with

diabetes, as recorded on practice disease registers5% 4.4% 4.5% 4.6% 4.7% 4.7% 4.8% 4.7% 4.8% 4.8% 5% 10% £ -

Constitutional Measures2016/17

Target Ap

r-1

6

Ma

y-1

6

Jun

-16

Jul-

16

Au

g-1

6

Se

p-1

6

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Fe

b-1

7

Ma

r-1

7

ytd

16/17Weight

Potential

Adjustment

18 Week RTT (Incomplete) 92% 89.7% 89.6% 88.6% 87.2% 86.4% 86.0% 87.2% 87.3% 86.2% 87.3% 87.5% . 87.5% -25% £ 46,023.19

A&E waits <4hr waits 95% 94.5% 94.8% 95.0% 95.3% 95.3% 95.2% 95.0% 94.8% 94.8% 94.1% 93.4% . 93.4% -25% £ 46,023.19

62-day wait from urgent GP referral to first

definitive treatment for cancer85% 89.5% 66.7% 78.1% 78.1% 95.7% 68.8% 77.3% 82.4% 95.2% 79.3% 66.7% . 66.7% -25% £ 46,023.19

Cat A red 1 ambulance calls (LAS performance) 75% 70.0% 70.2% 70.9% 70.2% 69.9% 70.1% 69.4% 68.1% 66.2% 67.3% 71.7% . 71.7% -25% £ 46,023.19

Maximum Possible Reward

1,227,285£

E-referrals - latest available published data is September

Mental Health Admissions to Hospital: Rate per 100,000 - This has been derived from the number of Hospital admissions given on MHMDS for the

month divided by the GP registered list size (active GMS Patients) for West London CCG aged 18+ as of October 4th 2016 (202300)

Please note however, that as the Weighted GP registered list size is not provided by age-band, 82% of the registered population has been used as a

proxy for patients aged 18+ as this has been the average proportion over the past two years.

Cancer Proxy - Still in development; provided is the number of emergency admissions to hospital with Primary Diagnosis of Cancer, excluding those

patients who presented at A&E and were admitted with a Primary Diagnosis of Cancer at any time over the last financial year. The 'Target' is currently the

monthly average of 2015-16.

1,043,192£ 184,093£ 184,093£ -£ Please note that Local Measures relating to GP register sizes may vary retrospectively each month as patients registered during a certain time period may be recorded as being registered at a date after their registration. For this

reason the figures will be retrospectively updated every month.

Notes

Loca

l Mea

sure

sCo

nsti

tuti

on

Mea

sure

s

Quality Premium Deductions Remaining Reward Performance Deductions Overall Reward

CCG Population: 245,457 Total Maximum Funding Available:

Nat

iona

l Mea

sure

s

2014 performance is latest available figure: 41.9%

77% is latest achievement as per July 2016 survey. Next survey released in July 2017 agiainst which July

2016 performance will be compared to.

West London CCG

Section 2: Quality & Safety Exception Report

48

West London CCG Quality and Safety Overview

1 Maternity Target CWHFT ICHT RBHFT 6 Safeguarding Training Target CWHFT ICHT RBHFT 19 Patient Safety All CCGs Target CNWL

1.1 12 Weeks assessment 95% 96.9% 96.1% 6.1 Children's Safguarding training Level 1 90% 89.7% 79.6% 79.2% 19.1 SIs reported within 48 hours 95% 100%

1.2 Breast Feeding initiation rate 90% 87.5% 93.8%N

E 6.2 Children's Safguarding training Level 2 90% 73.7% 86.4% 69.9%C

C 19.2 RCA reports submitted within deadline 100% 37.5%

1.3 1:1 midwife care in established labour 95% 100% 95.8% 6.3 Children's Safguarding training Level 3 90% 79.7% 84.9% 73.6%C

C 19.3 Never Events 0 0

1.4 Pregnant women with named midwife 100% 87.1% 141.7%C

B6.4 Children's Safguarding training Level 4 90% NR NR 50.0%

C

C 19.4 Timeliness of NRLS uploads (M1, M7) ≤ 28 days M1

1.5 Homebirths 1% 2.1% 1.2% 6.5 Adults' Safeguarding training 90% 46.4% 84.9% 76.5%C

C 19.5 Top 25% Reporters (M7, M12) Yes M12

1.6 Births at midwifery-led units 14% 30.4% 17.2% 6.6 PREVENT training (Q3, Q4) 50% Q4 Q4 N/AC

C 19.6 PU prevention and mngt. Training (M3, M9)(WL CCG) 90% M3

1.7 Smoking cessation offered prior to delivery 95% 100% 100% 7 Complaints Target CWHFT ICHT RBHFT 19.7 Actioned Patient Safety Alerts (CAS) within deadline(WL CCG) 100% 100%

1.8 Elective C-Sections < 13% 12.9% 13.2% 7.1 Complaints acknowledged 100% 89.9% 100% 20 Friends and Family Test All CCGs Target CNWL

1.9 Non-Elective C-Sections < 16% 16.8% 13.8%M

H7.2 Complaints responded to 95% 26.3% 98.9%

C

C 20.1 FFT - Response Rate (Q3, Q4) 6% Q4

1.10 Post Partum Haemorrhaging > 1.5 L < 2.4% 2.7% 2.4%M

H8 End of Life Target CWHFT ICHT RBHFT

C

C 20.2 FFT - Recommended (Q3, Q4) 94% Q4

1.11 Midwife to birth ratio 1:30CW 1:30

WM 1:32

SMH 1:30

QCCH 1:30

I

A8.1 Patients died in their preferred place (quarterly) 90% Q4 Q4 N/A

C

C 21 Complaints WL CCG Target CNWL

1.12 3rd or 4th degree tear < 6% 2.2% 1.8% 9 Stroke Target CWHFT ICHT RBHFT 21.1 Complaints acknowledged 100% 100%

1.13 Consultant Ward Coverage (hrs) 168 hrsCW 115

WM 156

SMH 98

QCCH 118 9.1 HASU thrombolysis within 45 minutes 90% N/A 100% 21.2 Complaints responded to 95% 100%

1.14 Babies born before arrival None 0.6% 0.7% 9.2 TIA treated within 24 hours (M1, M7) 90% M1 M1 22 Safeguarding Training WL CCG Target CNWL

1.15 Instrumental births None 7.5% 14.5%M

H9.3 90% time on stroke ward (quarterly) 90% Q4 Q4

C

C 22.1 Children's Safguarding training Level 1 90% 91.7%

1.16 Stillbirths None 1 6M

H10 Venous Thromboembolism Target CWHFT ICHT RBHFT 22.2 Children's Safguarding training Level 3 90% 96.0%

1.17 Puerperal sepsis (quarterly) None Q4 Q4M

H10.1 VTE Risk Assessments (quarterly) 95% Q4 Q4 Q4 22.3 Children's Safguarding training Level 4 90% 100%

1.18 Maternity diverts or closures None 0 0M

H11 Colposcopy Target CWHFT ICHT RBHFT 22.4 Adults' Safeguarding training 90% 95.7%

1.19 Number of women diverted None 0 0M

H11.1 Colposcopy result sent within 4 weeks (quarterly) 90% Q4 Q4 N/A 22.6 PREVENT training (quarterly) 60% Q4

1.20 Length of time diverted or closed None 0 0M

H12 Tuberculosis Target CWHFT ICHT RBHFT

2 Patient Safety Target CWHFT ICHT RBHFT

M

H 12.1 TB appointment within 2 weeks (quarterly) 90% Q4 Q4 N/A

2.1 SIs reported within 48 hours 95% 83.3% 100% No Activity

M

H

2.2 RCA reports submitted within deadline 100% 62.5% 81.3% No Activity

C

A 13 Patient Safety Target CLCH

2.3 Never Events 0 0 0 0 13.1 SIs reported within 48 hours 95% 100%

2.4 Timeliness of NRLS uploads (M1, M7) ≤ 28 days M1 M1 M1 13.2 RCA reports submitted within deadline 100% 100%

2.5 Top 25% Reporters (M7, M12) Yes M12 M12 M12 13.3 Never Events 0 0

2.6 PU prevention and mngt. training (quarterly) 100% Q4 Q4 N/AC

A 13.4 Timeliness of NRLS uploads (M1, M7) ≤ 28 days M1

2.7 Actioned Patient Safety Alerts (CAS) within deadline 100% 100% 50.0% 50.0%

2.8 Number of incidents of clinical harm due to RTT 30+ weeks 0 N/A 0 N/A

3 HSMR Target CWHFT ICHT RBHFT 13.6 PU prevention and mngt. Training (quarterly) 90% Q4

3.1 HSMR reporting result (quarterly) None Q4 Q4 13.7 Actioned Patient Safety Alerts (CAS) within deadline 100% 100%

3.2 HSMR weekend mortality (quarterly) None Q4 Q4 14 Friends and Family Test Target CLCH

4 Friends and Family Test Target CWHFT ICHT RBHFT 14.1 FFT - Response Rate (Q3, Q4) 4% Q4

4.1 FFT - Inpatient Response Rate 30% 22.9% 34.7% 41.1% 14.2 FFT - Recommended 94% 91.6%

4.2 FFT - Inpatient Recommended 94% 87.9% 96.5% 96.0% 15 Complaints WL CCG Target CLCH

4.3 FFT - Outpatient Response Rate 6% 8.2% 10.9% 15.2 Complaints acknowledged 100% 100%

4.4 FFT - Outpatient Recommended 94% 89.5% 90.6% 15.3 Complaints responded to 95% 100%

4.5 FFT - A&E Response Rate 20% 14.3% 12.5% 16 Safeguarding Training Target CLCH

4.6 FFT - A&E Recommended 85% 89.4% 94.2% 16.1 Children's Safguarding training Level 1 90% 95.8%

4.7 FFT - Maternity Q1 (Antenatal) Recommended 94% 89.4% 92.3% 16.2 Children's Safguarding training Level 2 90% 89.5% Key

4.8 FFT - Maternity Q2 (Birth) Response Rate 20% 17.6% 26.0% 16.3 Children's Safguarding training Level 3 90% 84.0% Performance within threshold/ target met

4.9 FFT - Maternity Q2 (Birth) Recommended 94% 95.6% 95.3% 16.4 Children's Safguarding training Level 4 90% 89.3% Performance close to threshold / target met

4.10 FFT - Maternity Q3 (Postnatal Ward) Recommended 94% 84.8% 85.0%

4.11 FFT - Maternity Q4 (Postnatal Community) Recommended 94% 88.1% 98.5%

5 Dementia Target CWHFT ICHT RBHFT 16.6 PREVENT training (quarterly) 50% Q4

17 End of Life WL CCG Target CLCH

17.1 Patients died in their preferred place (quarterly) 90% Q4 Data for indicator was not submitted NR

17.2 80% Q4

18 Venous Leg Ulcers WL CCG Target CLCH

18.1 Simple VLUs healed within 12 weeks (quarterly) 60% Q4 Indicator is not applicable to provider N/A

16.5 Adults' Safeguarding training 90% 89.3% Performance outside of threshold/ target met

N/A

Acute Providers Acute Providers

All CCGs

M12

N/A

13.5 Top 25% Reporters (M7, 12) Yes

Community Provider - CLCH

Mental Health Provider - CNWL

N/A

No

Activity

5.2Emergency inpatients 75+ years identified as potentially

having dementia or delirium who are appropriately assessed.

N/A

5.1Patients 75+ years to whom case finding is applied after

emergency, unplanned care90% 87.1%

All CCGs

DQIP

SDIP

90% 87.1% 89.8%

All CCGs

There were no instances in month/quarter of the numerator/denominator which the

indicator measures No Activity

N/A

93.0%

Data Quality Improvement Plan (DQIP)/

Service Development and Improvement Plan (SDIP)

Patients on CMC with a recorded place of death (quarterly)

49

West London CCG Maternity Dashboard 1

50

West London CCG Maternity Dashboard 2

West London CCG

Section 2.1: Acute

West London CCG

Chelsea and Westminster Hospital NHS Foundation Trust

53

West London CCG 1.2 Exception Report: CW – Breastfeeding initiation rate

Root Cause: Staffing issues cross site have been linked to decline. Some concerns expressed by Infant Feeding Team that data not capturing all women.

Mitigating Actions: • Tertiary NICU status of the service • Maternal choice • Vacancy rates at Chelsea site reduced • Recruitment and retention action plan

devised for West Mid site ( 20 new Midwives starting May and June 2017)

• IFT and Data team reviewing data capture • Volunteers being trained to support

mothers with breastfeeding (Piloting at West Mid site)

Assurances: UNICEF full accreditation and audit of data demonstrates that 98% of all clinically well babies received skin to skin contact. NB. West Mid site due for reaccreditation visit March 2017

Gaps in Assurance: On-going monitoring of the situation with the Trust will continue through the CQG.



On Track



Contract Status


date

The breast feeding rate has dropped below the expected target of 90%

CWHFT To be discussed at next CQG. Open Yes Michael Roach

Simon Mehigan

No 30/11/2015 31/03/2017 On-going Nil

NB: In Feb, 752 (of 859) mothers initiated breast feeding.

54

West London CCG 1.4 Exception Report: CW – Pregnant women with a named midwife/ named team

Root Cause: High risk women having purely obstetric care. This needs to be verified with the performance team. Named Midwife is static and the Trust struggle to place women from out of area using their service. This pathway in under review.

Mitigating Actions: All women have a named Midwife allocated to them. Measures in place to introduce link Obstetrician. 2 Midwives recruited to provide Antenatal continuity to high risk out of are women at Chelsea NWL Better Births pilot is focussing on continuity.

Assurances: All women have a named clinician appropriate for their plan of care. West Mid site have “linked” obstetrician for all women Chelsea site introducing from March 2017

Gaps in Assurance: Consultant midwife under taking audit.



On Track



Contract Status


date

Number of women with a

named midwife below 100%

CWFT Discussion to continue. Open Yes Michael Roach

Simon Mehigan

Yes 31/05/2016 31/03/2017 On-going Nil

NB: In Feb, 748 (of 859) mothers had a named midwife/ team.

55

West London CCG 1.9 Exception Report: CW – C-Sections (Non-Elective)

NB: In Feb, 144 (of 859) women had non elective C-sections.

Root Cause: • The issue seems to predominantly concern

elective LSCS rates. This has been a long-running issue.

• Patient Demographics has impacted the Trust’s performance with this indicator.

Mitigating Actions: • The Trust has previously informed that

recruitment of Consultant Midwife posts to review the models of care should result in an increase the births in the birth centre to 20%.

• Consultant Midwife for Public Health is leading on cross site pathway for women requesting elective LSCS.

Assurances: • Quarterly Deep Dive presented at CQG in

February 2017 and explored / included an audit into the cases behind the numbers.

Gaps in Assurance: None as indicated from a 2015 Public Health report, however the situation will require on-going monitoring through the CQG.


CCG Owner

Provider Owner

On Track Original



Status


Demographic differences of local

population contribute to

increased rates

CWHFT Discussion to continue. Open No Michael Roach

Simon Mehigan

No 31/12/2014 31/03/2017 On-going Nil

56

West London CCG 1.10 Exception Report: CW – % Post Partum Haemorrhage 1.5L (PPH)

Root Cause: Caesarean Sections and inductions of labour have been identified as a contributory factor.

Mitigating Actions: • Induction of labour audit undertaken by

Consultant Midwife and is due for completion March 2017 alongside with proposals for changes to the induction pathway.

• ELCS (maternal request) is being introduced • All PPH’s will be reviewed by the Risk team

and themes highlighted and brought to site specific forums.

Assurances: The Trust has increased Consultant cover on the labour ward through the appointment of 2 new Consultants. This should ensure decision making is made at a senior level.



CCG Owner

Provider Owner

On Track Original



Status


Consultant Labour Ward cover

CWHFT Discussion to continue. Open TBA Michael Roach

Simon Mehigan

No 01/04/2015 31/03/2017 On-going Nil

NB: Threshold <2.4%. In Feb, 23 (of 859) mothers experienced PPH.

57

West London CCG 1.13 Exception Report: CW – Consultant ward coverage

Root Cause: The SaHF target for Consultant hours has been increased from 98 to 168 hours per week. NB. RCOG has recently published guidance highlighting lack of evidence to support 24 hour resident consultant cover

Mitigating Actions: • The birth rate and Consultant Obstetric hours

are being monitored through the SaHF maternity programme board.

• The Trust will also consider the increase in consultants required in relation to the increased birth rate.

Assurances: • The Trust has increased Consultant cover on

labour ward through the appointment of 2 new Consultants.

• New consultant has started in Foetal medicine which enables the Trust to provide medicine across the two sites.

Gaps in Assurance: • Small increase in Consultant hours require

further details of plans to increase to 168 hours.

• On-going monitoring of the situation with the Trust will continue through the CQG.

• Part of the NWL maternity transition was to aim get to 168hrs Labour Ward cover.


CCG Owner

Provider Owner

On Track Original



Status


Consultant Labour Ward cover

CWHFT

Discussion with the Trust regarding plans for recruitment to reach the trajectory of 168 hours per week

Consultant cover.

Open TBA Michael Roach

Simon Mehigan

No 01/04/2015 31/03/2017 On-going Nil

58

West London CCG 2.1 Exception Report: CW – Serious Incidents (SIs Reported on STEIS within two working days)

Root Cause: • This is an SI that was identified as a result of

the Trust ‘s new Mortality review process and was retrospectively reported.

.

Mitigating Actions: The Trust has added a section to DATIX to highlight reasons for delay outside of 48 hours if there is one and will include this on StEIS.

Assurances: Datix system has now been implemented Trust-wide, providing a reliable system for reporting and investigating incidents.

Gaps in Assurance: On-going monitoring of the situation


CCG Owner Provid

er Owner

On Track Original



Status


Serious Incidents not reported within

timeframe CWHFT Continue to monitor. Open No

Michael Roach

Shan Jones

TBA 30/04/2016 31/07/2017 On-going Nil

NB: In Feb, 5 (of 6) SIs were reported within deadline on STEIS.

59

West London CCG 2.2 Exception Report: CW – Serious Incidents (RCA Reports submitted within deadline)

Root Cause: • 2 were submitted a day late • 1 was as a result of on-going discussions

between the CWHHE Patient Safety Team and the Trust as to whether the incident occurred or not. Since then a report has been done and submitted.

.

Mitigating Actions: • Trust has changed the internal SI policy to

require reports to be finalised internally in 45 days.

• Trust Director of Quality Improvement review all incidents due with in the next 2 weeks.

• A system on Datix has also been set up to give a Dashboard to aid the process

Assurances: Datix system has now been implemented Trust-wide, providing a reliable system for reporting and investigating incidents.

Gaps in Assurance: On-going monitoring of the situation



On Track Original



Status


Serious Incidents not reported within

timeframe CWHFT Continue to monitor. Open No

Michael Roach

TBA TBA 30/04/2016 31/07/2017 On-going Nil

NB: In Feb, 5 (of 8) RCAs were submitted within deadline.

60

West London CCG 4.1, 4.2 Exception Report: CW – FFT Inpatient Services – Response Rate & Recommended

Root Cause: An increase in the target from 15% to 30% has meant the target is being missed.

Mitigating Actions: Trust planning to recruit volunteers to support FFT by handing out paper surveys prior to discharge. Trust is currently retendering FFT process with a view to use online surveys accessed through trust website and tablets.

Assurances: The Trust’s Patient Experience Report for 2015/16 states that there will be closer working with multi-disciplinary teams to understand themes from FFT data and action plan for improvements. Action planning workshops will support this.

Gaps in Assurance: Trust will update on the anticipated completion date for the re-Tendering process next March 2017.



On Track Original



Status


date

Inpatient FFT response and

recommended rate

CWHFT To be discussed Open No Michael Roach

TBA No 30/09/2016 31/03/2017 On-going Nil

61

West London CCG 4.4 Exception Report: CW – FFT Outpatients Services - Recommended



On Track Original



Status


date

Outpatient FFT recommended

rate CWHFT To be discussed Open No

Michael Roach


Root Cause: Last ten months figure is fluctuating between 88% to 90% has meant the target is being missed.




62

West London CCG 4.5 Exception Report: CW – FFT A&E – Response Rate



On Track Original



Status


date

Inpatient FFT response rate

CWHFT To be discussed Open No Michael Roach



Root Cause: An increase in the target from 15% to 20% has meant the target is being missed however in October it could not meet previous target of 15%.



63

West London CCG 4.7 Exception Report: CW – FFT – Maternity Services (Q1. Antenatal) – Recommended



On Track Original



Status


date

Maternity FFT recommended


Michael Roach

Simon Mehigan

No 30/09/2016 31/03/2017 On-going Nil


Root Cause: Last ten months figure is fluctuating between 88% to 93% has meant the target is being missed. Started to monitor by individual question rather than average of Questions 1,2 and 3 from this months.


Gaps in Assurance: Trust will update on the anticipated completion date for the re-Tendering process next March 2017. On-going concerns about the discrepancies in data.

64

West London CCG 4.8 Exception Report: CW – FFT – Maternity Service (Q.2 Birth) – Response Rate

Root Cause: New indicator.

Mitigating Actions:

Assurances: To be clarified

Gaps in Assurance: There is a discrepancy about this KPI which will be clarified by March 2017 with the Trust.



On Track Original



Status


date

Inpatient FFT response rate

CWHFT To be discussed Open No

Michael Roach

Simon Mehigan

No 31/07/2016 N/A On-going Nil

65

West London CCG 4.10 Exception Report: CW – FFT – Maternity Services (Q3. Postnatal Ward) – Recommended



On Track Original



Status


date



Michael Roach

Simon Mehigan

No 30/09/2016 31/03/2017 On-going Nil


Root Cause: Last ten months figure is fluctuating between 86% to 91% has meant the target is being missed. Started to monitor by individual question rather than average of Questions 1,2 and 3 from this months.



66

West London CCG 4.11 Exception Report: CW – FFT – Maternity Services (Q4. Postnatal Community) – Recommended



On Track Original



Status


date



Michael Roach

Simon Mehigan

No 30/09/2016 31/03/2017 On-going Nil


Root Cause: Last ten months figure is fluctuating between 88% to 92% has meant the target is being missed.



67

West London CCG 5.1, 5.2 Exception Report: CW – Patients over 75 who had dementia screening & diagnostic assessment

Root Cause: • Dementia Case Manager has identified

patients that are admitted on a Friday late afternoon and discharged early on a Monday are often missed.

• Yet to identify another member of staff to screen in dementia case managers absence.

• Patients transferred from AAU without screening completed.

Mitigating Actions: • A last -word pop up already exists which

alerts staff to the need for assessment. • Dementia case manager reviews Qlikview on

a daily basis when available and where possible carries out any outstanding assessments.

• Educating staff on this issue will be key to achieving our target and this is now incorporated in tier 2 dementia training.

Assurances: The Acute Assessment Unit routinely screen patients that are 75 years and above consultant Phillip Lee will reiterate this to junior Doctors.

Gaps in Assurance: • Identifying a member of staff to deputise in

the absence of Dementia Case Manager. • Ensuring junior doctors are aware of the need

for screening.



On Track Original



Status


Dementia screening CWHFT To be discussed at CQG Open TBA Michael Roach


NB: In Feb, 399 (of 458) & 399 (of 458) patients had screening & diagnostic assessment.

68

West London CCG 6.1 Exception Report: CW – Children’s Safeguarding Training Level 1



On Track Original



Status


Children’s Safeguarding

Training remains below standard

CWHFT Safeguarding Nurses to discuss

issues at CQG meeting. Open Yes

Designated Nurses

Mak Inayat

Kerry Heyes

TBA 30/09/2015 31/03/2017 On-going Nil

Root Cause: The Trusts training figures for Level 1 have decreased and are marginally below 90% compliance for the first time in last few months.

Mitigating Actions: The Trust have identified and are working on solutions of rectifying inaccuracies in recording on the computer system. The Trust are working on more robust ways of recording training and targeting staff who are non-compliant.

Assurances: The Named Nurses are working with the DON to identify staff not meeting their mandatory obligations. The deep dive in 2016 identified that staff understood child safeguarding & responding appropriately.

Gaps in Assurance:

The Trust to complete their actions following recommendations from the Deep Dive. The Trust to continue to monitor non-compliant and errors in computer recording to mitigate against reductions in training figures.

NB: In Feb 4574 (of 5100) staff received Safeguarding Children’s Level 1 Training to date.

69




On Track Original



Status






Designated Nurses

Mak Inayat

Kerry Heyes

TBA 30/09/2015 31/03/2017 On-going Nil

Root Cause: The Trusts training figures for Level 2 have decreased.

Mitigating Actions: The Trust have identified and are working on solutions of rectifying inaccuracies in recording on the computer system. The Trust are working on more robust ways of recording training and targeting staff who are non-compliant.

Assurances: The Named Nurses are working with the DON to identify staff not meeting their mandatory obligations. The deep dive in 2016 identified that staff understood child safeguarding & responding appropriately.

Gaps in Assurance:

The Trust to complete their actions following recommendations from the Deep Dive. The Trust to continue to monitor non-compliant and errors in computer recording to mitigate against reductions in training figures.

NB: In Feb 2531 (of 3435) staff received Safeguarding Children’s Level 2 Training to date.

70




On Track Original



Status






Designated Nurses

Mak Inayat

Kerry Heyes

TBA 30/09/2015 31/03/2017 On-going Nil

Root Cause: The Trust compliance for Level 3 safeguarding training has not achieved the 90% target and are likely to reduce due to a cohort of staff (midwives) not identified in the training strategy to require Level 3 training.

Mitigating Actions: The cohort of staff (midwives) have now been identified and been booked onto level 3 training. The Trust has identified staff who require level 3 due to their role are less compliant than other members of staff. The Trust are working with managers to target the non-compliant members.

Assurances: The Trust are working with Learning and Development and managers to make sure staff have been booked on their level 3 safeguarding training which is delivered in-house and assure the CCG figures should improve by Q4.

The deep dive in 2016 identified that staff understood child safeguarding & responding appropriately

Gaps in Assurance:

The Trust to complete their actions following recommendations from the Deep Dive. The Trust to continue to monitor non-compliant staff to mitigate against reductions in training figures.

NB: In Feb 613 (of 769)staff received Safeguarding Children’s Level 3 Training to date.

71

West London CCG 6.5 Exception Report: CW – Adult’s Safeguarding Training



On Track Original



Status


Adult’s Safeguarding Training

CWHFT Continue to monitor. Open Yes Designated

Nurses LA TBA 30/09/2015 31/03/2017 On-going Nil

Root Cause: The process of the two former Trusts joining forces has positively increased the safeguarding expertise within the workforce; the challenge is ensuring harmonisation of the safeguarding associated policy and guidance documentation and ultimately practice.

Mitigating Actions:

There is a discussion within the Trust around the figure of 46.4 % Compliance. The Director of Nursing has confirmed that Level 1 adult safeguarding is 87%.

Assurances: During September 2016, the Safeguarding team have undertaken a clinical safeguarding audit involving visits to both Chelsea and Westminster Hospital and West Middlesex University Hospital. The preliminary findings are that the team are assured by the Trust. In all components of the safeguarding portfolio and a final report has been shared on 17.11.2016 with the Trust annual Safeguarding Board & during December this was presented to CQRG. In March 2017 the Trust shared a improved work plan which needs final details to show how they will become compliant in respect of contractual training compliance.

Gaps in Assurance: The trust is continuing to work with the CCG in finalising a robust action plan. Close monitoring will ensure that the trust continue to work in partnership to drive up standards in respect of safeguarding. The Findings report was shared with the Trust during Q3 and the recommendations were accepted by the Trust.

NB: In Feb 4416 (of 9516) staff received Adult’s Safeguarding training.

72

West London CCG 7.1 Exception Report: CW – Complaints - Acknowledge

Root Cause: Systems and processes for responding to complaints within the organisation is not as robust as it could be.

Mitigating Actions: • The default position is now to telephone all

complainants as the complaint comes in. Where they cannot be reached an acknowledgement letter or email is sent.

• The complainant is asked how they would like for their complaint to be addressed.

Assurances: • All staff working in complaints team are now

fully aware and compliant with acknowledgement of complaints.

• The Trust will be offering more local resolution meetings to address complaints.

• Additional staffing resource has been brought in to support responding to complaints.



CCG Owner

Provider Owner

On Track Original



Status


Complaints process CWHFT Discussion with Trust Open No Michael Roach

Shan Jones

No 31/03/2016 28/02/2017 On-going Nil

NB: In Feb, 62 (of 69) complaints were acknowledged within deadline. There were no return for month June.

73

West London CCG 7.2 Exception Report: CW – Complaints - Response

Root Cause: Systems and processes for responding to complaints within the organisation is not as robust as it could be.

Mitigating Actions: • Weekly meetings take place with

complaints managers and divisional directors of nursing and divisional teams.

• Each complaint is reviewed for progress with timeframes set by the Divisional Directors.

• The Trust has invested in additional support to clear the outstanding backlog on an interim basis.

• Where the complaint is complex in nature a reasonable timeframe will be a set at the outset between the Trust and complainant

• A review will take place of the complaints policy to amend timeframe in line with benchmarking across 6 London Trusts

Assurances: • The patient experience team is now almost

fully recruited. • Complaints management is now

standardised on both hospital sites.

Gaps in Assurance: • There are still breaches in the 25 working day

internal target.


CCG Owner

Provider Owner

On Track Original



Status


Complaints process CWHFT Discussion with Trust Open No Michael Roach

Shan Jones

No 31/03/2016 31/03/2017 On-going Nil

NB: In Feb, 21 (of 80)complaints were responded within deadline. There were no return for months June, July & August.

West London CCG

Imperial College Healthcare NHS Trust

75

West London CCG 1.8 Exception Report: ICHT – C-sections (Elective)

Root Cause: Complex client group of preterm, IUGR and multiple pregnancies causes monthly fluctuation in the adherence to the threshold.

Mitigating Actions: The trust reviews all C-sections on a monthly basis – there is discussion with the trust as to whether the themes and trends can be reported on a quarterly basis with any mitigating actions.

Assurances: C sections are reviewed by senior consultant on a monthly basis.

Gaps in Assurance: Nil. Agreement of a tolerance either side of the target.


Plan in Place?


On Track Original



Status


Complex client group ICHT On-going monitoring On-going Yes Liam

Edwards

Shona Maxwell /

Scott Johnson

Yes 30/04/2016 31/03/2017 On-going Nil

NB: In Feb, 88 (of 666) women had elective c-sections.

76

West London CCG 2.2 Exception Report: ICHT – Serious Incidents (RCA Reports submitted within deadline)

Root Cause: ICHT have experienced late submissions due to extra work being required for quality improvement.

Mitigating Actions:

Weekly meetings in place with the Provider to monitor compliance. This is additionally discussed at CQG on a monthly basis.

Assurances:

Although not best practice this has ensured a

good quality of RCA return. Additionally ICHT

have restructured their patient safety team.

Another dimension to this is the strenthening of

the si process and ensuring the appropriate

person is conducting the SI with in depth key

lines of enquiry.

Gaps in Assurance: Previous months have been unstable in compliance.


Plan in Place?


On Track Original



Status


Oversight of SI process in relation to

complex cases ICHT Ongoing dialogue Open Yes

Liam Edwards

Shona Maxwell

Yes 31/6/2016 31/03/2017 On-going Nil

NB: In Feb, 13 (of 16) RCAs were submitted within deadline

77

West London CCG 2.7 Exception Report: ICHT – Overdue Patient Safety Alerts

Root Cause: Two alerts reported in February. One relating to infusion devices which was closed two weeks late. Unable to obtain reason from the trust at time or report.

Mitigating Actions: Nil.

Assurances: This alert was superseeded by MDA/2017/003 which is on track for being closed in time and addresses the same pump issue.

Gaps in Assurance: Nil.


Plan in Place?

CCG Owner

Provider Owner

On Track



Contract Status


Reported error in CAS system

ICHT On-going monitoring Open Yes Liam

Edwards Shona

Maxwell TBA 31/01/2017 N/A On-going Nil

NB: In Feb, 1 of 2 alerts were actioned within dead line. There were no activity on Aug & Nov.

78

West London CCG 4.4 Exception Report: ICHT – FFT - Outpatient Services - Recommended

Root Cause: Large scale redesign of outpatient in progress. There has been a recent change in the collection method of responses allowing patients to complete this at home giving a more ‘honest’ appraisal of the service.

Mitigating Actions: Continued challenge at CQG and ongoing transformation work relating to outpatients.

Assurances: Large scale outpatients redesign project in place to increase satisfaction. Waiting times in outpatients are being addressed through a workstream including consultant allocation. Although metric is not ideal there is recognition that this is a more accurate picture of satisfaction.

Gaps in Assurance: The trust has been unable to show consistent improvement in percentage recommending outpatient services.


Plan in Place?

CCG Owner

Provider Owner

On Track



Contract Status


Redesign work in place

ICHT Continue to monitor – update

expected at CQG following CQC report

Open Yes Liam

Edwards Guy Young Yes 30/06/2016 31/03/2017 On-going Nil

79

West London CCG 4.5 Exception Report: ICHT – FFT - A&E - Response Rate

Root Cause: Due to the increased pressure upon bed capacity in light of Accident and Emergency performance the focus on this metric has slipped slightly.

Mitigating Actions: Continued monitoring through CQG.

Assurances: Ongoing work into increasing compliance with metric.

Gaps in Assurance: Assurances from the provider with relation to the trajectory have not materialised at present as this should already be compliant. There is a lack of assurance that figures will continue on an upwards trajectory. Additionally there has been limited compliance across the sector.


Plan in Place?

CCG Owner

Provider Owner

On Track



Contract Status


Decrease in FFT response rate for

A&E ICHT

Request revised trajectory for improvement

Open Yes Liam

Edwards Guy Young Yes 30/06/2016 31/03/2017 On-going Nil

80

West London CCG 4.7 Exception Report: ICHT – FFT - Maternity Services (Q1. Antenatal) - Recommended

Root Cause: Unable to ascertain at present due to small percentage of not achieving target i.e. 1.7%

Mitigating Actions: Continued monitoring of target and exploration of reasons.

Assurances: Comparing last year to this shows increasing compliance with metric. This will also be raised at CQG.

Gaps in Assurance: Consistent explanation by the trust of variation in recommendation of maternity services.


Plan in Place?

CCG Owner

Provider Owner

On Track



Contract Status


Disaggregation of previous maternity metric into specific

domains

ICHT Further discussion taking place with

Trust Open Yes

Liam Edwards

Guy Young Yes 30/06/2016 31/03/2017 On-going Nil

81

West London CCG 4.10 Exception Report: ICHT – FFT – Maternity Services (Q3. Postnatal Ward) – Recommended

Root Cause: Provider is unable to ascertain why this dip has occurred but provisional figures for March show compliance is back to above 90%.

Mitigating Actions: Continued monitoring of target and exploration of reasons.

Assurances: Comparing last year to this shows increasing compliance with metric. This will also be raised at CQG.

Gaps in Assurance: Consistent explanation by the trust of variation in recommendation of maternity services.


Plan in Place?

CCG Owner

Provider Owner

On Track



Contract Status


Disaggregation of previous maternity metric into specific

domains

ICHT Further discussion taking place with

Trust Open Yes

Liam Edwards

Guy Young Yes 30/06/2016 31/03/2017 On-going Nil

82

West London CCG 5.2 Exception Report: ICHT – Patients over 75 who had dementia diagnostic assessment

Root Cause: • ICHT have missed this target by 0.2% but

have achieved this through the year. Dialogue has not been entered with the Trust in light of the very small margin.

Mitigating Actions: • Nil

Assurances: • Previous months compliance.

Gaps in Assurance: • Nil



On Track Original



Status


Dementia screening ICHT To be discussed at CQG Open TBA Liam

Edwards TBA No 31/07/2016 31/03/2017 On-going Nil

NB: In Feb, 132 (of 147) patients had diagnostic assessment.

83

West London CCG 6.1 Exception Report: ICHT – Children’s Safeguarding Training Level 1

NB: In Feb, 1990 (of 2501) eligible staff persons received training.

Root Cause: The Trust has reported on-going difficulties with high staff turnover and new starters inconsistencies in the accuracy of the number of staff who require training (eg. Doctors who have left the Trust or move to other roles that do not require level 3 training are being counted as being non compliant)

Mitigating Actions: The Trust’s safeguarding team is working with the training and development team to improve the accuracy of the training denominator and compliance of medical staff.

Assurances: There is good evidence of safeguarding practices across the organisation, the referral rate to children’s services for safeguarding concerns has increased which highlights a good understanding of safeguarding issues.

Gaps in Assurance: None identified currently, a period of monitoring is required to show any increase in compliance levels.



On Track Original



Status


date

Staff training ICHT Continued monitoring Open Yes Designated

Nurse

Guy Young / Senga Steel

Yes 30/06/2016 31/03/2017 On-going Nil

84

West London CCG 6.2, 6.3 Exception Report: ICHT – Children’s Safeguarding Training Levels 2 and 3

NB: In Feb, 4746 (of 5491) and 943 (of 1111) eligible staff persons received levels 2 and 3 training respectively.

Root Cause: Junior doctors who move into new roles in the Trust are allocated a new staff number, and their core training will be reset to non-compliant which in turn affects the compliance rate.

Mitigating Actions: The team is now offering 3 training sessions on a monthly basis as well as additional bespoke sessions. Staff who are non-compliant are being targeted and their managers informed. Monthly compliance reports of junior doctors will be submitted to Divisional Directors and reported to the safeguarding children and young people committee.

Assurances: A safeguarding training delivery plan has been shared with the Designated Nurse Development of a standard operating procedures is being developed to make the process for undertaking and recording doctors in training compliance clear.

Gaps in Assurance: None identified currently, a period of monitoring is required to show any increase in compliance levels.



On Track Original



Status


date

Staff training ICHT Continued monitoring Open Yes Designated

Nurse


Yes 30/06/2016 31/03/2017 On-going Nil

85

West London CCG 6.5 Exception Report: ICHT – Adults’ Safeguarding Training

NB: In Feb, 7747 (of 9112) eligible staff persons received training.

Root Cause: There is a challenge releasing time for clinicians to attend training. This is exacerbated by a high turn over of some staff groups such as junior doctors.

Mitigating Actions: The Trust has reviewed its training safeguarding strategy and they are working openly with the CCG who continue to supportively monitor.

Assurances: The Trust are engaged with the CCG and meet regularly. They are a member of the Tri Borough adult safeguarding executive Board. There is a positive dialogue between the CCG and the Safeguarding Lead.

Gaps in Assurance: This slide shows a .5% decrease from the previous month


CCG Owner

Provider Owner

On Track Original



Status


date

Staff training ICHT Continued monitoring Open Yes Liam

Edwards


Yes 30/06/2016 31/03/2017 On-going Nil

West London CCG

Royal Brompton and Harefield NHS Foundation Trust (Specialist commissioning – NHSE)

87

West London CCG The Royal Brompton and Harefield FT: Serious Incident Reporting (Dashboard ref 2.1)

No SIs were reported on to StEIS in February. The Trust performance of SIs is

overseen by NHS England.

88

West London CCG The Royal Brompton and Harefield FT: Children’s Safeguarding Training (Dashboard ref 6.1, 6.2, 6.3 and 6.4)

Issue Provider Action Action

Status

Plan in

Place?

CCG

Owner

Provider

Owner

On

Track

Original

Delivery

Date

Revised

Delivery

Date

Contract

Status

Contract

Penalties

to date

Safeguarding

children’s training RBH

Safeguarding Children’s leads

from Central London and

Hillingdon CCGs to liaise with the

Trust in relation to their

performance.

Complete Yes Jenny

Reid

Joy

Godden Yes 31/10/16 -

On-

going Nil

The Safeguarding Advisor is leading on training, as well as the development of the annual

training programme, in conjunction with the Named Nurse.

Support services are being supported to access Level 1 face to face and through eLearning

training.

Increased awareness of safeguarding children and vulnerable adults through a series of planned

promotional events, as well as information folders, cards and pens to all departments.

Audit to be completed by end of January 2017 to review new training programme, this will be

presented to the CQRG in the next couple of months.

For the 2017/18 contract, safeguarding training has been added to the Service Development

Improvement plan with a trajectory to meet compliance by end of Q4 2017/18.

89

West London CCG The Royal Brompton and Harefield FT: Adult’s Safeguarding Training (Dashboard ref 6.5)


Status

Plan in

Place?

CCG

Owner

Provider

Owner

On

Track

Original

Delivery

Date

Revised

Delivery

Date

Contract

Status

Contract

Penalties

to date

Adult’s

safeguarding

training

RBH

Confirm with Trust their

trajectory for improving

compliance with the training.

Complete Yes

Stephen

Dixon /

Julie Hall

Joy Godden Yes 31/12/16 - On-

going Nil

Training is provided at two levels within the Trust. Level 1 training is for all staff to

ensure that they have an understanding of what constitutes a safeguarding issue

and know how to report incidents. Level 2 training is for staff who may need to

investigate safeguarding concerns.

The newly appointed Hillingdon CCG Designated Nurse for Safeguarding adults is

meeting this the Trust to understand their training arrangements.

For the 2017/18 contract, safeguarding training has been added to the Service

Development Improvement plan with a trajectory to meet compliance by end of Q4

2017/18.

West London CCG

Section 2.2: Community Health

West London CCG

Central London Community Healthcare Trust

92

West London CCG 14.2 Exception Report: CLCH – FFT – Recommendation


Plan in Place?

CCG Owner

Provider Owner

On Track Original



Status


date

Root cause unknown CLCH Discuss with provider at regular

meetings and CQG. Open TBA Ash Khan

Trish Stewart

TBA 30/06/2016 31/03/2017 On-

going Nil

Root Cause: On-going work to improve metric. Root cause unknown at present.

Assurances: Quality action team in place which has demonstrated a reduction in complaints and PALS queries. The team has targeted staff attitude and clinical performance issues to increase FFT

to introduce a more blended and

innovative approach to delivery of all

training (including safeguarding training),

utilising resources such as e-

learning/workbook/face-to-face sessions.

Gaps in Assurance: Provider has been unable to reach target in the preceding twelve months.

Mitigating Actions: As per assurances

93

West London CCG 16.2 Exception Report: CLCH – Children’s Safeguarding training (Level 2 )


Plan in Place?

CCG Owner

Provider Owner

On Track Original



Status


date

Training compliance for safeguarding

training CLCH

Discuss with provider at regular meetings and CQG.

Open TBA Mak

Inayat Trish

Stewart TBA 30/06/2016 31/03/2017

On-going

Nil

Root Cause: The Trust Level 2 compliance dropped below 90%

Assurances:

Trish Stewart (HoS) continues to meet regularly with the DON and training and development to identify target groups and their managers who will be penalised for non-compliance. Gaps in Assurance:

The Trust to continue to monitor non-compliant staff to mitigate against reductions in training figures.

Mitigating Actions:

There has been a slight increase from the previous month. The Trust produced an exception report and are working with learning and development to target members of staff who are not compliant. This is challenged monthly at the CQG.

NB: In Feb, 496 (of 554) staff were trained for Children’s Safeguarding Training Level 2.

94

West London CCG 16.3. Exception Report: CLCH – Children’s Safeguarding training (Level 3)


Plan in Place?

CCG Owner

Provider Owner

On Track Original



Status


date


training CLCH


Open TBA Mak

Inayat Trish

Stewart TBA 30/06/2016 31/03/2017

On-going

Nil

Root Cause: The Trust are non-compliant with Level 3 training compliance with figures.

Assurances: Trish Stewart (HoS) continues to meet regularly with the DON and training and development to identify target groups and their managers who will be penalised for non-compliance.

Gaps in Assurance: The Trust to continue to monitor non-compliant staff to mitigate against reductions in training figures.

Mitigating Actions: Trish Stewart the HoS is resourcing alternative approaches to accessing level 3 training for staff and although the Trust remain non-compliant their has been a significant uptake of staff accessing and attending level 3 training. LSCB have a trainer in post therefore there will be more level 3 courses for staff to access.

In Feb, 337 (of 401) staff were trained for Children’s Safeguarding Training Level 3.

95

West London CCG 16.4. Exception Report: CLCH – Children’s Safeguarding training (Level 4)


Plan in Place?

CCG Owner

Provider Owner

On Track Original



Status


date


training CLCH


Open TBA Mak

Inayat Trish

Stewart TBA 30/06/2016 31/03/2017

On-going

Nil

Root Cause: The Trust are now compliant with their Level 4 safeguarding training.

Assurances: Trish Stewart (HoS) continues to meet regularly with the DON and training and development to identify target groups and their managers who will be penalised for non-compliance.

Gaps in Assurance: The Trust to continue to monitor non-compliant staff to mitigate against reductions in training figures and monitor the IT recording system.

Mitigating Actions: The HoS meets regularly with Learning and Development to target staff and managers that are not compliant and has identified errors. The Trusts IT system was incorrectly recording level 4 training this has now been addressed therefore the Trust are compliant with their level 4 safeguarding training.

In Feb, 25 (of 28) staff were trained for Children’s Safeguarding Training Level 4.

96

West London CCG 16.5 Exception Report: CLCH – Adult’s Safeguarding training

NB: In Feb, 1179 (of 1321) eligible staff were trained.

Root Cause: Not determined

Mitigating Actions: The Trust has a safeguarding training strategy and work plan in place which is monitored by Trust the Head of Safeguarding.

Assurances: Provider has made slight progress for the second sequential month in the right direction. The trust has assured the CCG that they have a plan to continue this positive momentum.

Gaps in Assurance: During each month of Quarter 3 training compliance improved from Red to amber: above 90%. In February 2017 it has increased by 5.5% however remains just short of amber.



On Track Original



Status


Adults Safeguarding Training below

standard CLCH

Safeguarding Nurses to discuss issues at CQG meeting.

Open Yes Designated

Nurses LA TBA 31/08/2016 31/03/2017 On-going Nil

West London CCG

Section 2.3: Mental Health

West London CCG

Central and North West London NHS Foundation Trust

99

West London CCG CNWL Mental Health (All boroughs): Serious Incidents (Dashboard ref 19.1 & 19.2)


Status

Plan in

Place?

CCG

Owner

Provider

Owner

On

Track

Original

Delivery

Date

Revised

Delivery

Date

Contract

Status

Contract

Penalties

to date

RCA reports

submitted on time. CNWL

For the CCG AD for Patient Safety

to explore why the Trust are not

meeting their deadline and look at

their internal processes

On-

going Yes

Nicky

Brownjohn

Andy

Mattin Yes 30/09/14 30/04/17 None Nil

3 of 3 SIs were declared within the timeframe. This shows a distinct improvement in the

response times for the Trust and they are now compliant.

3 of 8 RCA reports due for submission in M11 were received on time.

Although this is improving, the Trust is reliant on a sign off process by individual

Directors, one of whom was off sick for 2 weeks.

The AD for Quality and Safety for Harrow CCG and the Patient Safety team are working

closely with CNWL to address any delays in submission and meeting with the Trust to

gain assurance regarding the implementation of learning whilst awaiting the RCAs.

West London CCG

Data Quality, Glossary and Definitions

101

West London CCG Data Quality

Information management process – SC28

Data submitted by the Trust is quality assured by

the performance team

Gaps are addressed with the Trust for resolution

within 2 days (stage 1)

If gaps in data still exist after 2 days, then this is

escalated to the contract team

Contract team write formally to the Trust

requesting an action plan/timeline for data

submission (stage 2)

Information breach notice issued (stage 3) by

contract team if no response or if an

unacceptable response received to stage 2

request.

Stage 1 Informal contact with Trust via performance team

Stage 2 Escalate to contractual process

Stage 3 Information breach notice issued

Status key

KPI Performance

/ Quality Frequency Sector Trust Status

The Trust is not submitting a combined MIR (including West Middlesex) as agreed contractually. On a separate MIR tab, the Trust should report site level figures for West Middlesex. This was agreed by the contract team and is not being adhered to.

Performance Monthly Acute CWHFT Stage 2

Number of urgent operations cancelled for a second time Performance Monthly Acute CWHFT Stage 2

Complaints responded to Quality Monthly Acute CWHFT Stage 2

Childrens’ safeguarding L4 Quality Monthly Acute CWHFT,

LNWHT & ICHT Stage 2

% of patients on Coordinate my Care who died in their preferred place of death

Quality Quarterly Acute LNWHT &

CWHFT Stage 2

Pressure ulcer prevention and management training Quality Quarterly Acute LNWHT &

THHFT Stage 2

% of eligible staff across the organisation who are compliant with Children’s safeguarding training (Levels 4)

Quality Monthly Community LNW Stage 1

Diabetes- % of patients who achieved their target on discharge

Performance Monthly Community LNW: Ealing Stage 1

Agreeing DNA Rate Threshold - pre-booked first/ follow up contact appointments

Performance Monthly Community HRCH Stage 2

102

West London CCG Performance overview slide explained

This slide provides further explanatory text for the performance overview slide. This slide is located at the beginning of

section 1, showing a summary dashboard for the performance section KPIs.

2.1 – 2.4 A&E / LAS : RAG rated cells without data indicate under performance at one or more of CCG’s acute providers.

3.1 18 weeks RTT - Admitted pathway: As per Department of Health guidance, Trusts are no longer required to submit

adjusted figures for their admitted pathway. Therefore, the RAG rating has been removed for this KPI.

3.4 52 week RTT Waiters - Incomplete pathway : This is a snapshot figure of numbers waiting at month end. Therefore, we

would not expect a YTD measure. This is the reason why the YTD column is greyed out.

4.9 62 Day - 1st definitive treatment (Cons. Upgrade) : There is no national standard for this KPI. 85% is a locally agreed

standard with the providers . This is the reason why this KPI is not RAG rated.

5.1 & 5.2 Cancelled Ops : RAG rated cells without data indicate under performance at one or more of CCG’s acute

providers.

8.1 UCC Access : This is based on the multiple KPIs in the UCC slides - Adult Clinical Assessment, Child Clinical

Assessment, A&E 4 hour waits and Expected activity. The performance overview dashboard for UCC access will show red if

any these KPIs are below threshold.

8.4 GP out of hours : This is based on all the GP out of hours KPIs. Underperformance in any of these will show a red in the

performance overview dashboard for GP out of hours.

103

West London CCG Provider Glossary

Acute

CWHFT – Chelsea & Westminster Hospital Foundation Trust

ICHT – Imperial College Healthcare Trust

LNWHT – London North West Healthcare Trust

RBHFT – Royal Brompton Hospital Foundation Trust

THHFT – The Hillingdon Hospital Foundation Trust

WMUH – West Middlesex University Hospital

ENHT – East and North Hertfordshire Trust

For out of area hospitals:

MEH( Moorfield Eye Hospital); RFH (Royal Free Hospital); UCLH (University College Hospital); GST (Guys & St

Thomas); ASPH (Ashford & St Peters Hospital); RMH (Royal Marsden Hospital)

STF – sustainable transformation fund

DToC – delayed transfers of care

Community

CLCH – Central London Community Healthcare

HRCH – Hounslow & Richmond Community Healthcare

LNWHT CS – London North West Healthcare Trust Community Services

CNWL HCH – Central & North West London Hillingdon Community Healthcare

Mental Health

CNWL MHT – Central & North West London Mental Health Trust

WLMHT – West London Mental Health Trust

104

West London CCG Definitions

National cancer breach allocation guidance

This is for shared pathways and only relevant to the 62 day standard. It sets out the expectation that a patient should be transferred from one

provider to the treating Trust by day 38 on the 62 day pathway, which gives the treating Trust 24 days to complete treatment. Prior to this

guidance being published, local agreements used day 42 and 20 days to complete treatment as the timeline guidance when a transfer was late.

This national guidance will result in a re-allocation of shared pathways, so that if one part of the pathway is delivered, that Trust is not

disadvantaged if the patients breaches the 62 day standard.

Timeline:

On 03 August a new input cell in Open Exeter will allow the internal Trust transfer (ITT) date to be submitted for all pathways, both breached and

compliant pathways.

From October 2016, Local Breach Allocation process fully aligned to National Guidance, underpinned by system operating models to support

timely ITTs including compliance with 3 Trust pathways.

April 2017, shadow CWT data will be published with breaches and compliant pathways allocation based on ITT day of 38 and treatment within

24 days.

Scenario Referral timeframe Total timeframe Allocation 1 > 38 days ≤ 62 days 100% of success allocated

to the

treating provider

2 ≤ 38 days ≤ 62 days 50% of success allocated to

the

referring provider and 50%

allocated to the treating

provider

3 ≤ 38 days >62 days 100% of breach allocated to

the

treating provider

4 > 38 days > 62 days, but

treating trust treats within 24

days

100% of breach allocated to

the

referring provider

5 > 38 days > 62 days and

treating trust treats in >24

days

50% of breach allocated to

the referring

provider and 50% allocated

to the treating provider

105


Indicator Definition Data Source

A&E Performance Percentage of patients who spent 4 hours or less in A&E Unify2

Trolley Waits in A&E Patients who have waited over 12 hours in A&E from decision to admit to admission. Unify2

18 Weeks RTT Percentage of all NHS patients receiving treatment within 18 weeks of referral for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways.

Unify2

52 Week RTT Waiters The number of Referral to Treatment (RTT) pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways.

Unify2

6 Weeks Diagnostic Waits Percentage of NHS patients waiting 6 weeks or more for diagnostic tests Unify2

No. of LAS arrival to handover times

Ambulance handover delays of over 30 minutes and over 1 hour LAS

Database

Cancelled Ops - 28 Day Guarantee breaches

Number of breaches of the cancelled operations standard: number patients who have their operations cancelled, on or after the day of admission (including the day of the surgery), for non-clinical reasons

Unify2

Cancer 2 week waits Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer and percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer was not initially suspected .

National Cancer

Database

Cancer 31 day Waits

Percentage of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from ‘date of decision to treat’). Percentage of patients receiving subsequent treatment for cancer within 31-days, where that treatment is a Surgery, an Anti-Cancer Drug Regimen or a Radiotherapy Treatment Course.

National Cancer

Database

Cancer 62 day Waits

Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer. Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service. Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status.

National Cancer

Database

HCAI – MRSA & CDIFF Health Care Acquired Infections – Number of MRSA bacteraemia and C. difficile cases reported by providers Health

Protection Agency

Mixed sex Accommodation Breaches (MSA)

The number of occurrences of patients receiving care that is in breach of sleeping accommodation guidelines i.e. in mixed accommodation that is not in their overall best interests, or does not reflect their personal choice.

Unify2

Cancelled Ops – 28 Day Guarantee breaches

Number of breaches NHS operational standard for cancelled operations: All patients who have operation cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of their choice.

Provider Monthly

Information Returns

106



Urgent Ops Cancellations for the 2nd Time

Number of Urgent operation cancelled for the 2nd time

Provider Monthly

Information Returns

IAPT

Access - proportion of people that enter treatment against the level of need in the general population (the level of prevalence addressed or ‘captured’ by referral routes). Recovery - The number of people who have completed treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness” and at final session did not) as a proportion of the number of people who have completed treatment within the reporting quarter, having attended at least two treatment contacts) minus (The number of people who have completed treatment not at clinical caseness at initial assessment).

Provider Monthly

Information Returns

IAPT The number of people who had their first IAPT treatment programme appointment within 6 weeks or 18 weeks of referral.

Provider Monthly

Information Returns

New psychosis cases served by EIS

Number of new psychosis cases served by Early Intervention Team as proportion of estimated CCG target new cases

Provider Monthly

Information Returns

CPA Reviews within 12 months

Percentage of patients on CPA whose care plans have been reviewed within 12 months

Provider Monthly

Information Returns

Outcomes Data Completeness - CPA Patients

Percentage of service users who are on Care Programme Approach (CPA) for 12 months or more, with valid data entries across core outcome fields in their records.

Provider Monthly

Information Returns

CPA Follow-Ups within 7 days

Percentage of patients on enhanced CPA who were discharged from psychiatric in-patient care during who were followed up either by face to face contact or by a phone discussion within 7 days of discharge

Provider Monthly

Information Returns

Delayed Transfers of Care Total number of Delayed Transfers of Care (DToC) as a proportion of occupied bed days for the same period

Provider Monthly

Information Returns

107



CLA Initial Health Assessments (IHA) conducted within 20 operational days

Number of Initial Health Assessments (IHAs) of Children Looked After (CLA) that were completed within 20 operational days.

Provider Monthly

Information Returns

CLA Review Health Assessments (RHA) conducted within 6 wks

Number of Review Health Assessments (RHAs) of Children Looked After (CLA) that were completed within 6 weeks.

Provider Monthly

Information Returns

Referrals responded to during the day, twilight or night service periods within 24 hrs

Percentage of non-urgent referrals that were responded to during the day or twilight service period within 24 hours or on the date stipulated for the visit on the referral letter

Provider Monthly

Information Returns

Number of Rapid Response referrals responded to with 2 hrs

Percentage of referrals to Rapid Response Service that were responded to within 2 hours. Response include a clinical acknowledgement of the referral and a plan of proposed clinical action.

Provider Monthly

Information Returns

Pre-booked appointments DNA or UTA rate

Percentage of appointments where service user did not attend (DNA) or was unable to attend (UTA)

Provider Monthly

Information Returns

Palliative care patients with a recorded of preferred place of death

Patients under the care of palliative care teams who have a record of their preferred place of death

Provider Monthly

Information Returns

Palliative care patients who died in their preferred place of death

Patients under the care of palliative care teams who achieve their preferred place of death

Provider Monthly

Information Returns

108



LAS – Cat A Red 1 & 2 responses within 8min

The number of Category A (Red 1/Red 2) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes LAS

LAS - Cat A 19 transportation within 19min

The number of Category A calls (Red 1 and Red 2) resulting in an ambulance arriving at the scene of the incident within 19 minutes. LAS

NHS 111 • % calls answered in 60 secs • % calls abandoned in 30secs • % calls where call was offered

Unify2

GP OOH – Patient Communication

• Call Triages – Percentage of calls received that were triages within 20 minutes (urgent) or 60 minutes (routine) • Patient Consultations – Percentage of consultations within 1 hour (emergencies) or 2 hours (urgents), routine (6 hours) • Visits – Percentage of patient visits within 2 hours (urgents) or 6 hours (routines) • Patient Communication – Meeting special needs

GP OOH Service

Critical care transfers for non-clinical reasons

Number of critical care transfer forms completed including evidence of risk assessment and pre transfer stabilisation

Provider Monthly

Information Returns

Access to Rapid Access Chest Pain Clinics

Percentage of patients seen in Rapid Access Chest Pain Clinics (RACPC) within 14 days after a decision to refer

Provider Monthly

Information Returns

HASU thrombolysis treatment within 45 mins

Measures the door to needle time (DTNT) at Hyper Acute Stroke Units (HASU) between patients entering the service and the time thrombolysis starts. Indicator is a standard in the Stroke Improvement National Audit Programme (SINAP) and is part of the NICE Stroke Quality Standards.

Provider Monthly

Information Returns

109



Stroke Care The percentage of patients that had access to specialised stroke services within an appropriate setting, having been admitted due to a diagnosed cerebral vascular accident

Provider Monthly

Information Returns

TIA treated within 24 hours

NICE guideline 68 specifies that people who have had a suspected TIA should have specialist assessment and investigation within 24 hours of onset of symptoms. TIA diagnosis should be made on clinical symptoms and higher risk TIA cases risk stratified using the ABCD2 score of 4 or above. The time frame begins at the time of the patient’s first contact with any health‐care professional (including a paramedic, GP, stroke physician, A&E staff and district nurse etc.) and ends 24 hours later. Recurrent TIA after investigation and treatment should be considered as a new episode

Provider Monthly

Information Returns

TB access within 2 weeks The percentage of GP referrals for suspected pulmonary tuberculosis that were offered an appointment date within 2 weeks of referral.

Provider Monthly

Information Returns

Colposcopy

Percentage of women who have been sent notification of their colposcopy test result within 4 weeks of their test date with next steps as applicable

Provider MIR

Overdue safety alerts The number of Central Alerting System Patient Safety Alerts and Medical Device Alerts that were implemented and completed within deadline. NHS England

Serious Incidents reported within 48 hours of identification

The number of serious incidents that were reported within 48 hours of occurrence.

Strategic Executive

Information System (StEIS)

Serious Incident Root Cause Analysis Reports submitted within deadline

The number of serious incident root cause analysis investigation reports that were received within the 45/60 day deadline for Grade 1 and 2 serious incidents respectively.

Strategic Executive

Information System (StEIS)

Friends & Family Tests Response Rates (A&E, IP, OP, Maternity, Mental Health & Community)

The response rate for the Friends and Family Test based on the number of patients accessing the service in the month against the number of responses that were received.

NHS England

Complaints Acknowledged in 3 days

The percentage of complaints that were acknowledged within 3 days of being received, which is a patient right enshrined in the NHS Constitution.

Provider Monthly

Information Returns

Complaints Responded to within agreed timescales

Number of complaints responded to within the agreed timescale

Provider Monthly

Information Returns

110



Breast feeding A mother is defined as having initiated breastfeeding if, within the first 48 hours of birth, either she puts the baby to the breast or the baby is given any of the mothers breast milk

Provider Monthly

Information Returns

12 Weeks assessment First booking appointments completed by 12 weeks + days as a percentage of total booking appointments in month excluding late referrals (women referred after 10 weeks + 6 days)

Provider Monthly

Information Returns

Smoking cessation The percentage of women offered and recorded smoking cessation therapy at booking

Provider Monthly

Information Returns

1:1 Maternity Care Number of women having 1:1 maternity care in established labour. The indicator takes into account exclusion of elective C-sections and BBA as this KPI measures 1:1 midwife care in established labour.

Provider Monthly

Information Returns

Homebirths The percentage of maternal deliveries at home. The indicator includes still births and shows the percentage of women giving birth at home rather than the number of babies born at home.

Provider Monthly

Information Returns

Midwifery led unit The number of babies given birth to, including live or still-born babies of at least 24 weeks gestation, at midwifery led units.

Provider Monthly

Information Returns

Births before arrival The number of babies given birth to, including live or still born babies of at least 24 weeks gestation where the baby is born before arrival.

Provider Monthly

Information Returns

Instrumental deliveries The number of instrumental deliveries, including live or still-born babies of at least 24 weeks gestation.

Provider Monthly

Information Returns

Elective C-Sections A caesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s abdomen and womb. A planned (elective) procedure, when a medical need for the operation becomes apparent during pregnancy

Provider Monthly

Information Returns

111

West London CCG


Non-Elective C-Sections A caesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s abdomen and womb. A non-elective caesarean procedure is an emergency procedure, when circumstances during labour call for urgent delivery of the baby

Provider Monthly

Information Returns

3rd degree tear A 3rd degree tear is a tear or laceration through the perineal muscles and the muscle layer that surrounds the anal canal. This requires stitches and can take a similar time to a 2nd degree tear (two months or so), if not longer, before the wound is healed and the area comfortable.

Provider Monthly

Information Returns

Post Partum Haemorrhaging Number of women experiencing a Post-Partum Haemorrhage of 1.5 litres and above.

Provider Monthly

Information Returns

Definitions

Documents

Integrated Performance & Quality Report - West London … integrated performanc… · 1 West London CCG The West London CCG Integrated Performance & Quality Report is aimed at providing