NLG(16)491

DATE OF MEETING 29 November 2016

REPORT FOR Trust Board of Directors – Public

REPORT FROM Wendy Booth, Director of Performance Assurance & Tr ust Secretary

CONTACT OFFICER Maria Wingham, Head of Performance

SUBJECT Performance Compliance Report – October 2016

BACKGROUND DOCUMENT (IF ANY) NHS Improvement Risk Assessment Framework

REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Trust Governance and Assurance Committee – 17 Novem ber 2016 Resources Committee – 23 November 2016

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

This report outlines the expected governance positi on against the standards set out in the NHSI Risk Assessment Frame work for the year to date up to October 2016

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

NO

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

NO

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

YES

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

N/A

THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

Ensure compliances with the regulatory framework

ACTION REQUIRED BY THE BOARD The Trust Board is asked to review key target perfo rmance and consider any further action required

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NHS Improvement Risk Assessment Framework

Key Performance Measures

October 2016

This Report focuses solely on the Trust’s performance against key performance measures contained within NHS

Improvement’s (formally Monitor) 2013 Risk Assessment Framework. Any performance risks relating to key

performance indicators contained within the Trust’s contract which could potentially result in the imposition of fines

and penalties is highlighted in both the integrated performance report and the monthly trading report.

NHS Improvement, through its Risk Assessment Framework, continues to assign a governance risk rating to reflect

the quality of governance at the Trust. NHS Improvement uses the governance rating below in order to gauge

potential escalatory measures:

• The sum of each metric’s weighting to calculate a service performance score

• Where the Trust breaches a target systematically, this will represent a governance concern

Indicator Red Rating may apply if the Trust:- Trust

Rating

C.Difficile

• Breaches the cumulative year-to-date trajectory for 3 successive

quarters

• Breaches its full year objective

• Reports important or significant outbreak

Referral to

Treatment

Waiting

• Breaches the 18 week RTT Incomplete waiting time measure for a third

successive quarter

A&E

• Fails to meet the target twice in any two quarters over a 12 month

period and fails the indicator in a quarter during the subsequent 9

month period or the full year

Cancer

Waiting Times

• Breaches the 31-day cancer waiting time for third successive quarter

• Breaches the 62-day cancer waiting time for third successive quarter

Community

Services Data

Completeness

• Fails to maintain the threshold for data completeness for any of the

following for a third successive quarter

- RTT information

- Service referral information

- Treatment activity information

Any Indicator

Weighted 1.0

• Breaches the indicator for three successive quarters

The governance rating assigned to an NHS Foundation Trust reflects NHS Improvement’s views of its governance:

• a Green rating will be assigned by NHS Improvement if no governance concern is evident;

• Where NHS Improvement identifies potential material causes for concern with the Trust’s governance in one or

more of the categories (requiring further information or formal investigation), the Trust’s green rating will be

replaced with a description of the issue and the steps (formal or informal) to be taken to address it; or

• a Red rating will be assigned if NHS Improvement take regulatory action.

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1. Summary Performance Against National Measures for October 2016

The current provisional 18 week Referral to Treatment (RTT) incomplete waiting time performance is below the

92% threshold for October 2016 at 81.03% and the NHSI trajectory of 92.6%.

The Trust has not achieved the 95% threshold for the A&E 4 hour wait target achieving 87.9% during October

2016 and has also fallen short of the NHS Trajectory set at 94.18 this month.

There was one reported episode of hospital acquired Clostridium Difficile in October, which was not identified

as a lapse in care following the Post Infection Review, giving the Trust a total of two cases so far this year.

The current provisional cancer data indicates the Trust will achieve all of the seven cancer indicators for

October 2016, the 62 day wait Urgent GP Post referral will achieve the NHSI 85.71% trajectory and the Post

positon will be slightly below the target.

Individual Performance Risk Areas

1.1 Clostridium Difficile

Clostridium Difficile – YTD Total

There was one hospital acquired Clostridium Difficile episode reported in October 2016 on Ward B4, a surgical

ward at DPoW, giving the current accumulative yearly figure to thirteen episodes all of which have had a Post

Infection Review completed.

Clostridium Difficile – Lapses in care

The hospital acquired Clostridium Difficile lapse in care Post Infection Review has been undertaken for the

single episode in October which has concluded that there was no evidence of a lapse in care on ward B4, giving

the Trust at total of two so far this year.

1.2 Cancer Waiting Times (provisional position)

October provisional cancer data indicates the Trust is on track to achieve all of the seven cancer. In addition to

monitoring the actual monthly position, the monthly NHSI trajectory for the 62 day wait urgent GP referral

measure for October 2016 has been set at 85.71%. At 85.93%, the PRE position has reach the threshold and the

POST measure is slightly below at 85.43%.

The final October cancer waiting times will be submitted to the national Open Exeter database on the

5 December 2016.

Response from Interim Chief Operating Officer:

Cancer: Good progress has been maintained for cancer pathways during October, however the cancellation of

activity linked to the IT incident will add delays for some patients, though their reappointments have been

prioritised. Demand in some tumour sites is giving rise to some capacity pressures and specific focus to

Site Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16

DPOW 0 0 1 0 0 1 0

SGH 0 0 0 0 0 0 0

GDH 0 0 0 0 0 0 0

Total 0 0 1 0 0 1 0

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respond to this is in place. The next phase of the recovery will be to consolidate this improved performance to

ensure sustainable delivery; this will be over seen through the current governance structure.

Also included in this report is a breakdown of performance by tumour site (please refer to Appendix B)

Cancer Performance continues to be monitored on a daily basis as well as reporting/monitoring to the weekly

Task & Finish Group and the weekly CEO Challenge Meeting. A decision has been made to use the weekly RCA

Review Meetings to focus on more recent breaches so that we can identify actions which still need to be taken

or actions which have been taken but which need to be embedded.

1.3 A&E 4 Hour Waiting Times

The Trust has not achieved the 95% threshold for the A&E 4 hour wait target for October reaching 87.9%, the

lowest point so far this year. Compared to the same periods last year, attendance levels are increasing with an

accumulative total of 3227 additional patients since April, October attendance increasing by 613 additional

patients compared to October 2015 and 267 on last month. The trend for patient attendance mirrors those of

last year’s levels. This measure was last compliant in September 2015 at 95.5%. The Trust also fell short of the

new monthly trajectory threshold for October which has been set at 94.18%.

A single A&E action plan continues to be implemented - this includes increasing the hours of consultant

presence at a weekend, realigning the nurse establishment to match the peaks in activity and the

implementation of the Acute Care Physician model at DPOW to support patient flow through the acute phase.

Response from Interim Chief Operating Officer:

Accident & Emergency: The newly created health system Accident & Emergency Delivery Board will oversee

the development and implementation of cross organisational actions to improve delivery of the emergency

pathway standards. Review and update of current actions will take place to ensure consistency.

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1.4 18 Week Referral to Treatment Waiting Times

The 18 week Referral to Treatment incomplete waiting time measure is currently below the 92% threshold at

81.34% with quarter two also non-compliant at 83.46% . This measure was last compliant in June 2015. The

NHSI and Trust trajectory for September is 92.07%, with the final validation on 18 September it is forecast that

the Trust will not reach either the actual or trajectory measure.

Response from Interim Chief Operating Officer:

Referral to Treatment: In recent months the total size of waiting list and proportion of long waiting patients

have increased. As outlined in the graph above, there are multiple contributory factors to this which include

increasing demand, shortfalls in capacity as well as weaknesses in operational processes/systems which are

giving rise to poor data quality (please see appendix. The NHS Improvement Intensive Support Team are

working with the Trust to support the recovery agenda; a ‘stocktake’ has been completed, number of key areas

for intervention have been identified and initial actions are being put in place. The process will be iterative and

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a phased remedial action plan will be put in place, which will differentiate between generic and

specialty/service specific work.

1.5 Other

For information, the Trust’s position in relation to Delayed Transfers of care is provided within this report

(please refer to Appendix C) although it does not form part of the NHS Improvement Risk Assessment

Framework.

Recommendations for Actions: Director of Performance Assurance

The following performance concerns will need to be progressed during the remainder of 2016/17 to ensure

performance is achieved / maintained:

I. Continued focus on ensuring achievement of the Incomplete 18 Week Referral to Treatment indicator

at specialty level, especially concentrating on improving the position of both North East Lincolnshire

and Lincolnshire East CCGs. The monitoring of 18 week Referral to Treatment recovery plans for failing

specialities by clinical groups.

II. Continued focus on A&E performance to ensure the Trust maintains achievement of this target over

the coming months and builds in sufficient capacity to improve achievement over the coming months.

As outlined above, a number of actions have already been taken and plans are in place including work with other local providers.

III. Continued focus on the achievement of all Cancer Waiting Time target with the ongoing

implementation of the Trust wide cancer performance improvement plan, including the continuation of

Root Cause Analysis for all patients breaching treatment targets.

Wendy Booth

Director of Performance Assurance & Trust Secretary

November 2016

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APPENDIX A

(PROVISIONAL POSITION AS AT 16.11.16)

2015/16 2016/17 2016/17 QTR 2 QTR 3 Qrt 3

WEIGHTINGQTR 4 QTR 1 QTR 2

ThresholdSTP

Trajectory Oct-16 Actual To DateWEIGHTING

1. Infection Control*

Total Hospital Acquired C.Difficile Cases Lapses in Care (YTD) 1.0 G G G 21 0 2 G

2. Referral to Treatment Waiting Times

Incomplete - Maximum waiting time of 18 weeks 1.0 R R R 92% 92.6% 81.35% 81.35% R

3. Cancer ***

31 day wait diagnosis to treatment 1.0 G G G 96% 100% 100% G

i) 31 day wait for subsequent treatments - Surgery 1.0 G G G 94% 100% 100% G

ii) 31 day wait for subsequent treatments - Anti cancer drugs G G G 98% 100% 100% G

i) 62 day wait GP referral to treatment POST alloaction R R G 85% 85.71% 85.43% 85.43% G

ii) 62 day wait GP referral to treatment PRE allocation 1.0 R R G 85% 85.71% 85.93% 85.93% G

ii) 62 day wait Consultant screening service referrals allocation R G G 90% 100% 100% G

i) 2 week wait referral to consultation 1.0 G G G 93% 97.37% 97.37% G

ii) 2 week wait breast symptomatic referrals G G G 93% 97.96% 97.96% G

4. A&E

A&E 4 Hour Wait Compliance 1.0 R R R 95% 94.18% 87.90% 87.90% R

5. Data Completeness Community Services **

5i) Referral to treatment information 1.0 G G G 50% 99.8% 99.8% G

5ii) Referral Information G G G 50% 99.8% 99.8% G

5iii) Treatment Activity Information G G G 50% 89.3% 89.3% G

6. Access **

Access to healthcare for people with learning disability 0.5 G G G Y/N Y Y G

* Quarterly Cumulative figures Total NHS Improvement Compliance Score 2.0

** Forecast Position Green

*** Provisional Data Red

NHS Improvement Compliance Rating

NHS Improvment Over ride Rating

PERFORMANCE METRIC

NHS IMPROVEMENT COMPLIANCE FRAMEWORK SUMMARY

Performance Against Key Thresholds For The Period 1st April 2016 to 31st October 2016

Oct-16

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APPENDIX B

(Provisional position as at .16.11.16)

62 day Referral to treatment (standard 85%) - October 2016

Tumour site Total treatments in

October

Total number of breaches that have

commenced 1st treatment in October

(Post Allocation)

Current Post %

Breast 12.5 0 100.00%

Colorectal 13 0 100.00%

CUP 1.5 1 33.33%

Gynaecology 3.5 2 42.86%

Haematology 7 1 85.71%

Head & Neck 4 1 75.00%

Lung 19 3.5 81.58%

Other (Surgery) 0 0 100.00%

Sarcoma 0 0 100.00%

Skin 10.5 0 100.00%

Upper GI 3.5 0 100.00%

Urology 25 6 76.00%

Trust Total 99.5 14.5 85.43%

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APPENDIX C

Delay Transfer of Care

Bed Days attributable to

Delayed DischargeOct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

DPoW 299 302 358 385 271 289 390 258 300 372 242 218

SGH 134 173 231 149 216 271 227 145 165 190 215 191

GDH 56 63 36 35 10 17 30 20 27 37 37 49

All Sites 489 538 625 569 497 577 647 423 492 599 494 458