Trust Board Performance Report

Agenda item No. 9.2

Meeting / Committee: TRUST BOARD

Meeting Date:

13TH January 2009

Title: Performance Report

Purpose: To provide assurance and inform the Board in relation to performance and delivery of national and local targets.

Summary: The report highlights the following areas as risks relating to national standards, based on the year to date position:

Diagnostic Waiting Time Cancelled Operations Choose and Book slot availability % of patients offered retinal screening

In addition, there are a number of local measures which are at risk of underperforming against local agreements:

% of patients seen for retinal screening % of patients seen by GUM services

Prepared By: Mrs Ruth Potiphar, Deputy Director for Performance Management

Presented By:

Mrs Sue Watson, Director of Operational Services

Recommendation: Trust Board are asked to note overall performance and areas of risk.

Core Standard: Safety – C4a, Clinical and Cost Effectiveness; C5b and C5c, Governance; C7, Accessible and Responsive Care; C19.

Implications (Please mark an X)

Legal Financial

X

Clinical Strategic

X

Risk & Assurance

X

Performance Report Dashboard Summary of Performance against the Key National Targets

Performance Indicator Information

Ref

Ind

ica

tor

Pa

ge

Indicator Description Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth / Year

to date position

YTD Target (inc tolerance)

2008/09 Target (inc tolerance)

1.1 VS MRSA Bacteraemia Rates 4 1 4 3 4 2 1 1 20 23 32

1.2 VS Clostridium difficile Infections 22 17 14 28 28 33 22 16 180 236 354

2.1.1 VS 18 Week RTT for Admitted Patients 90.7% 91.9% 91.2% 93.1% 91.3% 93.3% 93.4% 92.2% 92.2% 89.4% 90.0%

2.1.2 VS 18 Week RTT for Non-Admitted Patients 96.5% 96.7% 97.5% 98.0% 96.9% 97.7% 97.7% 97.9% 97.9% 94.4% 95.0%

2.1.3 VS 7 Diagnostic waits - Over 6 Weeks 27 4 4 3 1 0 1 1 41 0 0

2.1.4 VS 18 week RTT Audiology Direct Access tba tba tba tba tba tba tba tba tba tba 95%

2.2.1 EC Cancer Waits - 2 Week Target 100.0% 99.7% 99.7% 100.0% 99.6% 99.8% 100.0% 99.8% 98% 98%

2.2.2 EC Cancer Waits - 31 Day Target 99.6% 99.6% 100.0% 99.6% 100.0% 100.0% 99.6% 99.9% 98% 98%

2.2.3 EC Cancer waits - 62 Day Target 94.9% 94.8% 94.0% 93.8% 98.3% 99.0% 100.0% 96.4% 95% 95%

2.2.4 VS 8 Two week wait for all referrals for breast symptoms 33.1% 44.0% 44.0% Profile tba n/a

2.2.4 VS 8 31 day target for subsequent treatments (chemo and surgery) 92.1% 92.6% 92.6% Profile tba 98%

2.2.4 VS 9 31 day target for subsequent treatments (radiotherapy) 86.8% 80.3% 80.3% Profile tba n/a

2.2.4 VS 9 62 day target for Screening Programme Referrals 46.1% 83.3% 83.3% Profile tba 86%

2.2.4 VS 10 62 day target for patients upgraded by clinician tba tba tba tba tba

2.3 VS % of stroke patients who spend at least 90% of time on a stroke unit - - - 78.9% 94.7% 92.5% 94.7% 96.9% 91.4% 65% 65%

2.3 VS % of high risk TIA patients who are treated within 24 hours - - - 38.5% 70.0% 45.5% 50.0% 47.1% 51.8% 25% 25%

2.4.1 EC Delayed Transfers of Care (as % occupied beds) 1.73% 1.39% 1.59% 1.31% 1.49% 1.92% 1.72% 1.27% 1.55% 3.50% 3.50%

2.4.2 EC 11 Short notice cancelled operations as a % of elective activity 0.45% 0.43% 0.41% 0.70% 0.70% 0.55% 0.73% 0.65% 0.58% 0.80% 0.80%

2.4.2 EC 11Cancelled Ops Not Re-admitted within 28 Days as a % of short notice cancelled operations

3.45% 3.70% 4.00% 10.87% 2.50% 0.00% 10.42% 10.00% 6.19% 5.00% 5.00%

2.4.3 EC A&E 4 Hour Maximum Wait 98.9% 98.9% 99.2% 99.01% 99.61% 99.80% 99.08% 99.30% 99.1% 98% 98%

Position as at November 2008

STHT Performance

Section One - SAFETY

Section Two - PATIENT FOCUS AND ACCESS2.1 Delivery of 18 Weeks Referral to treatment times

2.2 Implementation of the cancer strategy

2.3 Implementation of the stroke strategy

2.4 Maintaining existing commitments

. New cancer waiting time targets

Performance Reports / P Archman / Item 9.2 / Trust Board 13th January 20091

Performance Indicator Information STHT Performance

Ref

Ind

icat

or

Pag

e

Indicator Description Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth / Year

to date position

YTD Target (inc tolerance)

2008/09 Target (inc tolerance)

2.4.4 EC Outpatient 13 Week Maximum Wait Breaches 0 0 0 0 0 0 0 0 0 0 0

2.4.5 EC Inpatient 26 Week Maximum Wait Breaches 0 0 0 0 0 0 0 0 0 0 0

2.4.6 EC 3 Month Maximum wait for Revascularisation 100% 100% 100% 100% 100% 100% 100% 100% 100.0% 100% 100%

2.4.7 EC Rapid Access Chest Pain - 2 Week Wait 100% 100% 100% 100% 100% 100% 100% 100% 100.0% 100% 100%

Section Three - REDUCING HEALTH INEQUALITIES AND PROMOTING HEALTH AND WELL-BEING

3.1 EC 13 Access to GUM Services - appointments offered 97.2% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 99.0% 99%

3.1 LP 13 Access to GUM Services - patients seen within 48 hrs 70.7% 78.0% 80.1% 84.1% 82.9% 82.3% 71.5% 76.1% 78.2% 80% 80%

4.4 EC Data Quality on Ethnic Groups (vs HCC standard) 87.6% 88.7% 87.3% 87.9% 87.1% 89.6% 90.8% 95.6% 89.3% 80% 80%

Section Four - LOCAL LDP CONTRACT PERFORMANCE MEASURES

4.1 LP 14 Convenience and Choice - slot unavailability 0.20 0.30 0.31 0.36 0.35 0.27 0.27 0.33 0.33 0.16

4.2 EC 15 Retinal Screening - % offered over 12 month period 97.94% 97.90% 97.86% 96.77% 97.20% 97.3% 96.1%Data Not available

- 100% 100%

4.2 LP 15 Retinal Screening - % seen over 12 month period 78.12% 77.37% 77.43% 74.83% 74.79% 74.9% 76.3%Data Not available

- 80% 80%

5.1 16 Staff in post (WTE inc staff who are not directly employed 5974 5948 5955 5963 5985 6112 6088 6102 6102 6261

5.2 17 Sickness Absence 5.74% 5.83% 5.65% 5.79% 5.60% 5.64% 5.53% 5.31% 5.31% 6.00%

5.3 Turnover (provided quarterly)8.25% (Q1)

8.79% (Q2)

8.79%

5.4 18 Attendance at Mandatory Training 87% 87% 86% 86% 85% 84% 82% 80% 80% 80%

5.5 19 Appraisals completed 44.04% 43.68% 46.69% 47.76% 48.92% 50.57% 50.26% 48.98% 48.98% 80%

Key to indicator: VS = Vital signs National targets and standards; EC = existing commitments ; LP = Local priorities

Section five - HUMAN RESOURCE

2.4 Maintaining existing commitments (continued)


Trust Board Performance Report

Executive Summary

The Trust Board performance report provides a summary of current performance against key national and local targets identified in the Operating framework for the NHS in 2008/09 and provides further detail on risk areas highlighted in the summary.

Current risks relating to key national targets include:

Diagnostic Waits – From April 2008, there should be no patients waiting over six weeks for a diagnostic test. There was one patients waiting over 6 weeks for a diagnostic test in November due to administrative delay in sending the request. Year to date, 41 patients have waited over 6 weeks, the majority of these occurring in April.

Cancelled operations not readmitted within 28 days – In November, there were 4 cancelled operations that were not readmitted within 28 days due to capacity constraints within the respective service. This was from a total of 40 cancelled operations reported in November and is above the acceptable 5 per cent tolerance. Year to date we have reported 18 cancelled operations not readmitted within 28 days from a total of 291 short notice cancelled operations.

Access to GUM – in November, the Trust reported that 100% of patients were offered an appointment within 48 hours, a position which it has managed to sustain for the last six months. However, 76.1% of patients were seen within 48 hours which is below the local 80% target. The year to date position for patients seen within 48 hours is 78.2%. This position has come about mainly due to staffing issues relating to retirement and sickness. Evening clinics are now in place and having a positive impact in terms of choice for patients and staff cover is being provided at satellite clinics to alleviate the reduction in staffing levels.

Choose and Book – in November the Trust reported 0.33 slot issues per DBS compared to 0.11 locally and 0.16 nationally. This is an increase on previous months and the Trust has consistently reported more slot issues per booking than the national and local Northeast SHA position. To improve this position, the Trust is working through a number of initiatives aimed at reducing slot polling times, improving choose and book utilisation and supporting prospective planning through IT.

Retinal screening – for the period October 2007 to October 2008, 97.33% of eligible patients have been offered a retinal screen against a national target of 100%, and 74.91% of eligible patients have been seen against a local target of 80%. A recent review of the service undertaken by the national team has highlighted a number of areas for action. A project board has been established and key issues are being addressed with the support of PCTs, including replacement of vital equipment.

Other key areas of performance include:

MRSA Infection rates – Currently the Trust is within profile with 20 MRSA bacteraemias reported year to date against a November target of less than 23. This is a tremendous achievement given the number of MRSA bacteraemias reported in previous years. But this is still a significant challenge to the organisation and continuing efforts need to be maintained in order to stay within the target for this year which is to have no more than 32 MRSA bactereamias in 2008/09.

Clostridium difficile Infection rates – So far this year the Trust has reported 180 cases against a year to date target of having no more than 236 cases. Between June and September there was a steady increase in cases of C. difficile with 33 cases reported in September. In October and November the number of reported cases has reduced to 22 and 16 respectively. The infection prevention and control team believes this is probably due to reintroduction of the enhanced cleaning measures. Focus is now on early isolation of patients with symptoms. Seasonal trends indicate that numbers are likely to increase over the next few months. Although we remain below the current target trajectory, the Department of Health has recently requested additional data from 2007 with the suggestion that target baselines will be revised to reflect a fairer distribution between PCTs and acute trusts. No further information has been received yet.


Progress against the 18 week referral to treatment target for admitted and non-admitted pathways has been excellent over the last eight months with South Tees exceeding the national December 2008 targets since April (ie 90% for admitted pathways and 95% for non-admitted pathways). The effort now is in ensuring the Trust can achieve the target at a specialty level as well as driving down referral to treatment times to less than 16 weeks at an overall Trust level.

The existing cancer targets were achieved for October 2008 and the excellent performance against the 62 day target since August has now brought the Trust back into line in terms of the year to date position against the existing cancer target commitments. The 62 day target remains challenging though and clinical teams are being asked to continue to reduce delays in the patient pathways where possible. It is predicted the Trust will achieve the 31 and 62 day cancer target for November and December, but will have one breach of the 2 week wait referral received within 24 hours in November due to an admin error. From January 2009, the methodology for counting and reporting cancer pathways will be changed to align reporting with 18 weeks referral to treatment. In addition, a number of new cancer targets will be introduced, namely:

Maximum 31 days wait for patients receiving subsequent Chemotherapy or Surgery treatment from decision to treat date or earliest clinical appropriate date;

Maximum 62 day wait for patients referred following the detection of an abnormality by the NHS screening programme to treatment;

Maximum 62 day wait for patients not referred under the 2 week rule, who are then subsequently upgraded by a clinician, clock starts on upgrade date

The targets and tolerances have not yet been set by the Department of Health and will be published following submission of the 2008/09 Q4 data. Further information is included in this report.

Implementation of the stroke strategy – this is a comprehensive 10 year framework aimed at driving up the standards of care to reduce mortality and morbidity. Between July to November 2008 for South Tees, 91.4% of patients with stroke spent at least 90% of their time on stroke unit. This is significantly better than the national average of 56% and the 2008/09 milestone target of 65%. Similarly, for patients with a high risk transient ischaemic attack (TIA), 51.8% of patients seen at South Tees were treated within 24 hours. This is significantly better than the national average of 35% of high risk TIA patients treated within 7 days and the 2008/09 milestone target of 25%.

The remaining existing commitments were all achieved in November and have consistently been met month on month during 2008/09. These include:

delayed transfers of care, cancelled operations A&E maximum 4 hour waits national outpatient 13 week and inpatient 26 week maximum waits 3 month maximum wait for revascularisation 2 week wait for rapid access chest pain clinics Data quality on ethnic groups


Trust Board Performance Report

Introduction

This performance report provides summary detail on the range of indicators used to monitor and performance

manage acute trusts against the key national requirements as set out by the Department of Health in their

operating framework, and which will also form part of the Healthcare Commission performance rating scheme.

The operating framework for the NHS in 2008/2009 describes the national priority areas where PCTs (working

with providers) need to explicitly plan for delivery of local services in 2008/09. In addition to the national

measures, there are a number of other indicators which in part, reflect local priorities and which have been agreed

as part of the contract monitoring process. Further detail on risk areas highlighted in the executive summary are

reported by exception.

The performance measures are themed under the following headings:

Section one - SAFETY

Key areas of focus are:

Reducing MRSA bacteraemia rates

Reducing Clostridium difficile infection rates.

Section two - PATIENT FOCUS AND ACCESS

Key areas of focus include:

Delivery of 18 weeks referral to treatment times.

Supporting measures include reducing waits for diagnostic tests and direct access audiology waits.

Implementation of the cancer strategy

o Maintain existing cancer waiting time commitments:

A two-week maximum wait from urgent GP referral to first outpatient appointment;

A maximum waiting time of one month from diagnosis to treatment

A maximum waiting time of two months from urgent referral to treatment

o Implementing new cancer waiting time targets:

Proportion of patients with breast symptoms referred to a specialist who are seen within

two weeks of referral

Proportion of patients waiting no more than 31 days for second or subsequent cancer

treatments (surgery and drug treatments)

Proportion of patients waiting no more than 31 days for second or subsequent cancer

treatment (radiotherapy)


Proportion of patients with suspected cancer detected through national screening

programmes or by hospital specialist who wait less than 62 days from referral to

treatment;

Implementation of the stroke strategy

o Increase the number of patients who spend at least 90% of their time on a stroke unit;

o Increase % of higher risk TIA patients who are treated within 24 hours

Maintain existing commitments.

o Delayed transfers of care to be maintained at a minimum level;

o Cancelled operations for non-clinical reasons to be offered another binding date within 28 days;

o 4 hour maximum wait in A&E from arrival to admission, transfer or discharge;

o A maximum wait of 13 weeks for an outpatient appointment;

o A maximum wait of 26 weeks for in-patient appointments;

o Three month maximum wait for revascularisation;

o A maximum two-week wait standard for Rapid Access Chest Pain Clinics;

Note also that the Healthcare Commission will be assessing the quality of patient services and acute trusts

through a variety of clinical audits, patient and staff surveys and special data collections. These are generally

one-off exercises undertaken during the year.

Section three - REDUCING HEALTH INEQUALITIES AND PROMOTING HEALTH AND WELL-BEING

For acute Trusts, the main focus is:

Improving access to GUM services Data quality in ethnic groups.

Section four - LOCAL LDP CONTRACT PERFORMANCE MEASURES

The 2008/09 Operating Framework recognises the need for PCTs, acute trusts and other healthcare providers to

develop services appropriate to the needs of the local population. A number of performance measures, additional

to the national measures, have been included in the LDP contract to support the development of local priorities.

These include:

Choose and Book slot unavailability

Retinal screening

Section five - HUMAN RESOURCES

This section of the report covers the five main areas that are routinely monitored by the Human Resource

Directorate:

Staff in post

Sickness

Attendance at mandatory training

Appraisals completed

Turnover


2.1.3) Diagnostic Waits – Over 6 Weeks

Measure Description

There are two elements to the diagnostic waiting times target. The first incorporates the information relating to the 15 most common diagnostic tests which is reported monthly to the Department of Health. The second part is the quarterly census which assesses waiting times for all the remaining diagnostic tests. The diagnostic waits is a supporting measure to ensure delivery of the 18 weeks referral to treatment target.

Performance

Number of over 6 week waiters for Diagnostic Tests

Department of Health 15 key diagnostic testsTotal

patients seen

Patients waiting over 6 weeks

% seen within 6 weeks

Total patients

seen

Patients waiting over 6 weeks

% seen within 6 weeks

Magnetic Resonance Imaging 537 1 99.8% 499 0 100.0%Computed Tomography 340 0 100.0% 294 0 100.0%Non-obstetric ultrasound 775 0 100.0% 625 0 100.0%Barium Enema 12 0 100.0% 15 0 100.0%DEXA Scan 126 0 100.0% 132 0 100.0%Audiology - Audiology Assessments 256 0 100.0% 265 0 100.0%Cardiology - echocardiography 0 0 100.0% 10 0 100.0%Cardiology - electrophysiology 0 0 100.0% 2 0 100.0%Neurophysiology - peripheral neurophysiology 195 0 100.0% 150 1 99.3%Respiratory physiology - sleep studies 22 0 100.0% 24 0 100.0%Urodynamics - pressures & flows 91 0 100.0% 68 0 100.0%Colonoscopy 245 0 100.0% 215 0 100.0%Flexi sigmoidoscopy 72 0 100.0% 67 0 100.0%Cystoscopy 117 0 100.0% 112 0 100.0%Gastroscopy 179 0 100.0% 116 0 100.0%Total 2967 1 99.96% 2594 1 99.96%

Imaging

Physiological Measurement

Endoscopy

Oct-08 Nov-08

Year to date Summary Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonthly Over 6 week waits for 15 key Diagnostic tests 27 4 4 3 1 0 1 1Monthly Total patients seen in month 2777 2552 2752 2843 2879 2883 2967 2594Cumulative Over 6 week waits for 15 key Diagnostic tests 27 31 35 38 39 39 40 41Cumulative Total patients seen in month 2777 5329 8081 10924 13803 16686 19653 22247Cumulative % patients seen within 6 weeks for diagnostic test 99.0% 99.4% 99.6% 99.7% 99.7% 99.8% 99.8% 99.8%

Quarterly CensusPatients waiting over 6 weeks for additional diagnostic tests 4 4

Comments on Over/Under Performance

The 15 key diagnostic tests are monitored monthly by the Department of Health. During November 2008, there was 1 patient reported as waiting over 6 weeks for a diagnostic test in Neurophysiology. This was due to a delay in sending the request to the neurophysiology department.

Year to date there have been 41 breaches of the 6 week target for diagnostics from a total of 22,247 diagnostic tests, giving a compliance of 99.8%.

A weekly diagnostic PTL is now in place to monitor waiting times for diagnostic investigations.

Key Action Points

Requests for neurophysiology diagnostic tests will be sent on the same day the patient seen in clinic to avoid any unnecessary delays.

A root cause analysis is to be undertaken on any six week diagnostic breaches.


2.2.4 Extended Cancer Treatment Waiting Times

The following targets are new cancer targets that require compliance over the next three years. Data collection has recently commenced following the publication of the national dataset guidance.

The targets and tolerances have not yet been set by the Department of Health and will be published following submission of the 2008/09 Q4 data. In the meantime, the DH have undertaken a modelling exercise using the new cancer pathway ‘clock’ rules to estimate the effect of this on the current reported compliance levels. In summary, the comparison of current methodology versus new methodology for calculating length of waits indicate that the reported national averages will change (see table below) and this will be reflected in the new performance standards to be released in May 2009. As an interim, the estimated values should be used as the indicative targets until further guidance is available.

To give an indication of the Trust position for the new cancer targets, monthly analysis is now being undertaken. The system for tracking patients against the new targets was implemented in November (following publication of the national data set).

The months reported below are prior to the tracking process commencing and this date is provided for indicative purposes only.

BREAST SYMPTOMS 14 DAYS TO 1ST SEEN (VSA08) – Target implementation date December 2009

Maximum 14 day wait from Urgent GP Referral for investigation of breast symptoms (excluding those referred under cancer 2 week wait) to Date First Seen in the Trust – vital signs 08 (VSA08).

Breast SymptomsTotal Number Seen/Treated

Number seen over 14 Days

% ComplianceAssumed*

Target level for Dec 2009

Sep-08 181 121 33.1%Oct-08 209 117 44.0%

* Based on the DH cancer data modelling presented in October 2008. This is an estimate of the 2WW unadjusted national performance using the new cancer monitoring system rules.

93.0%

SUBSEQUENT CHEMOTHERAPY AND SURGICAL TREATMENTS (VSA11) – Target implementation date January 2009

Maximum 31 days wait for patients receiving subsequent Chemotherapy or Surgery treatment from decision to treat date or earliest clinical appropriate date – vital signs 11 (VSA11).

This new target combines subsequent treatment for Chemotherapy and Surgery. Assessment by the Healthcare Commission will be the overall aggregate level.

Summary of chemotherapy subsequent treatments

ChemotherapyTotal Number Seen/Treated

Number Treated over 31 Days


Target level for Jan 2009

Sep-08 446 26 94.2%Oct-08 441 20 95.1%

98.0%

* Based on the DH cancer data modelling presented in October 2008. This is an estimate of the 31 Day unadjusted national performance using the new cancer monitoring system rules.


Current national reported performance for patients receiving

first definitive treatment

Estimated national

performance under the new

monitoring system

2 WW Referrals 99+ % 93%31 Day 99+ % 98%62 Day 97% 86%

8

Summary of surgery subsequent treatments

SurgeryTotal Number Seen/Treated




Sep-08 139 20 85.6%Oct-08 127 20 84.3%

98.0%


Summary of combined chemo and surgery subsequent treatments

Chemotherapy & Surgery

Total Number Seen/Treated




Sep-08 585 46 92.1%Oct-08 538 40 92.6%


98.0%

SUBSEQUENT RADIOTHERAPY TREATMENTS (VSA12) – Target implementation date December 2010

Maximum 31 day wait for patients receiving subsequent Radiotherapy treatment from decision to treat date or earliest clinical appropriate date – vital signs 12 (VSA12).

Even though this target isn’t mandatory until December 2010, the Trust has committed to shadow monitoring this target in order that it can achieve this future deadline.

RadiotherapyTotal Number Seen/Treated



Target level for Dec 2010

Sep-08 106 14 86.8%Oct-08 76 15 80.3%


86.0%

NHS SCREENING 62 DAYS TO 1ST TREATMENT (VSA13A) – Target implementation date January 2009

Maximum 62 day wait for patients referred following the detection of an abnormality by the NHS screening programme to treatment – vital signs 13 part A (VSA13a). The current data refers to breast screening patients.

NHS Screening Referrals

Total Number Seen/Treated

Number Treated over 62 days



September-2008 13 7 46.1%Colorectal - - -

Breast 13 7 46.1%Gynaecology - - -October-2008 6 1 83.3%

Colorectal - - -Breast 6 1 83.3%

Gynaecology - - -

86.0%

86.0%



The methodology for recording and reporting of patients from screening programmes has only recently been introduced therefore there are no patients within the system identified as being referred from the colorectal or gynaecology screening programmes for September or October. It is anticipated the numbers will be relatively small and will start to be reported in the December 2008 cancer information onwards.

CONSULTANT UPGRADE (VSA13B) – Target implementation date January 2009

Maximum 62 day wait for patients not referred under the 2 week rule, who are then subsequently upgraded by a clinician, clock starts on upgrade date – vital signs 13 part B (VSA13b) .

Within the Trust’s patient administration system amendments have been put in place to allow data collection for non-2 week wait patients who are upgraded by a clinician and as such are then monitored against the 62 day target from the upgrade date.

The facility within the patient administration system has only recently gone live and the training is currently being rolled out across the Trust and therefore there is no data yet available. There are currently 2 patients with upgrade status being active from December 2008.

Key Action Points

National standards will not be released until May 2009. The estimated national averages will be used during the interim period as indicative targets.

Patient data is now being collected to track and monitor patients against the new targets. Data submission to the cancer target PTL commenced in November 2008. The PTL is a weekly

submission which provides a high level (patient numbers only) forward look of the number of patients that will be seen up to three weeks ahead and whether they will be seen within the target time or will have breached. It also provides a high level summary of the patients seen in the previous week.

Data submission using the new reporting methodology to commence January 2008. This is patient level information on patients that have had treatments (ie. retrospective) and is reported monthly. Currently this information is reported on the Open Exeter system which will be upgraded to facilitate the reporting of the extended cancer waiting times information. As yet, there is no release date from Open Exeter for this upgrade.


2.4.2) Cancelled Operations and those not re-admitted within 28 days

Measure DescriptionAll patients who have operations cancelled for non-clinical reasons to be offered another binding date within 28 days.

Performance

Short Notice (Same Day) Cancellations for Non-Clinical Reasons

0

10

20

30

40

50

60

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

Pati

en

t C

an

cellati

on

s

2008/09 Short notice cancellation Re-Admitted within 28 days

2008/09 Cancellations Not Re-admitted within 28 days

2007/08 Cancellations Not Re-admitted within 28 days

2007/08 Total short notice (same day) cancellations

Main Reasons for Non-Clinical Short Notice Cancellations April to November 2008

77

100

33

22 24

33

2

50

132

56

14

23

35

2

0

20

40

60

80

100

120

140

No bedavailable

Not enoughtheatre

session timefor case

Other Equipmentfailure

Consultantunavailable

No availableITU/CITU Bed

Anaesthetistunavailable

2008/09 (Cumulative to date) 2007/08 (same period)

Short notice cancellations: Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2006/07 Total short notice (same day) cancellations 27 59 47 54 24 48 32 64 17 55 49 532007/08 Total short notice (same day) cancellations 37 26 29 33 37 49 55 46 29 45 35 392007/08 Cancellations Not Re-admitted within 28 days 2 0 0 3 1 1 1 0 5 2 0 12008/09 Total short notice (same day) cancellations 29 27 25 46 40 36 48 402008/09 Short notice cancellation Re-Admitted within 28 days 28 26 24 41 39 36 43 362008/09 Cancellations Not Re-admitted within 28 days 1 1 1 5 1 0 5 4Short notice (same day) cancellations:as a % of Total Elective Activity 0.45% 0.43% 0.41% 0.70% 0.70% 0.57% 0.73% 0.65%YTD Cumulative position 0.45% 0.44% 0.43% 0.50% 0.54% 0.54% 0.57% 0.58%Healthcare Commission Tolerance* 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80%Total Elective Activity (includes daycases) 6507 6242 6084 6601 5736 6350 6573 6159Cancelled operations not readmitted within 28 days:as a % of short notice cancellations 3.45% 3.70% 4.00% 10.87% 2.50% 0.00% 10.42% 10.00%YTD Cumulative position 3.45% 3.57% 3.70% 6.30% 5.39% 4.43% 5.58% 6.19%Healthcare Commission Tolerance* 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%* Note- Healthcare Commission tolerance based on 2007/08 Annual Health Check


During November, there were 40 operations cancelled for non-clinical reasons including 4 breaches of the 28 day readmission target.

The four breaches of the 28 day target where patients could not be re-admitted within 28 days were: 1 in Cardiology where the initial cancellation was due to consultant/surgeon unavailability and because

of capacity issues with EP patients was unable to bring back with in the 28 days. 1 in orthopaedics where the initial cancellation was due to consultant/surgeon unavailability and the

patient was subsequently given the next available date. 2 in urology where the initial cancellations were due to a lack of theatre time for one patient and no

available bed for the second, both patients were subsequently given the next available dates.

The reasons for cancelled operations in November include: 9 x No Bed Available 16 x Insufficient Theatre Time 10 No available ITU/CITU/HDU bed 4 x Consultant/surgeon Unavailable 1 x Other

Where the reason for cancellation is insufficient theatre time, this is due mainly to complexities of prior cases booked into the same theatre session which then impacts on the available time left for remaining cases. When this occurs, if there is not enough available theatre time to do the surgery without impinging on other theatre lists, the operation is cancelled.


The three areas affected by bed shortages were general surgery (2 occasions) and urology (4 occasions) and ENT (3 occasions). All areas cite a busy elective programme and an increase in emergency admissions as the reason. Year to date there have been 291 short-notice cancelled operations of which 18 were not re-admitted within 28 days giving a compliance of 0.66% cancelled operations as a % of total elective activity (Healthcare Commission tolerance is 0.80%); and 6.19% of the total number of short notice cancelled operations not re-admitted within 28 days as a % of the total number of short-notice cancelled operations (Healthcare Commission tolerance is 5%).

For the same period last year, there were 312 short notice cancelled operations, of which 8 were not re-admitted within 28 days.

Short notice cancelled operations are also being monitored through the LDP commissioning process with an agreement between the Trust and the PCTs that the Trust will reduce 2008/09 short notice cancellations by 25% compared with the 2006/07 baseline of 529 cancellations. Year to date the Trust has seen a reduction of 18% which is 26 under the expected year to date local PCT target of 265 based on the 2006/07 baseline. The PCTs will not pay for short notice cancelled operations which exceed the local target level. Therefore, the current financial risk to this Trust is a penalty of approx. £13,000 (approx £500 per case below the target level). This will be assessed at the year end.

Key Action Points All divisional managers have been reminded of the importance of this target and asked to ensure that a zero

tolerance approach to the 28 day target is applied. Divisions are sent the patient detail for the cancellation and are asked to feedback on actions to reduce

these numbers through the monthly performance reviews. The Inpatient Cancellation Working Group has reconvened to review information around cancellations and

provide greater focus on the reasons behind cancellations in order to highlight areas for further improvement.

All funded additional theatre sessions identified at the beginning of the financial year are now available (orthopaedics, maxillo-facial, urology and plastic surgery).

Urology have one extra theatre session. Theatre capacity as a whole is being reviewed as part of the mid to long term plan to develop more theatres. Staffing levels on surgical wards have been reviewed and additional staff resources approved by the Formal

Management Group. Recruitment is underway but is expected to be completed by February 2009 when the next group of qualified nurses become available.

Theatres routinely undertake an analysis of the underlying reasons for the increase in cancelled ops due to lack of theatre time seen this month. The last audit indicated the main reason was due to complexity of patients requiring more time, rather than poor management of theatre time.

A daily bed meeting has been implemented with one of its objectives to avoid short notice cancellations.

Section Three - REDUCING HEALTH INEQUALITIES AND PROMOTING HEALTH AND WELL BEING

3.1) Access to GUM Services

Measure DescriptionAccess to GUM services: The target is that 100% of patients attending GUM clinics are offered an appointment within 48 hours of contacting a service by March 2008. The national expectation is that performance for patients seen within 48 hours should be no less than 80% of new patients seen. The focus this year is to reduce the gap between appointments offered and patients seen within 48 hours.


PerformanceSTHT GUM 48 Hour Access

0

10

20

30

40

50

60

70

80

90

100


2008/09

% f

irs

t a

tte

nd

an

ce

s

STHT % of First Attendances offered an appointment within 48 hrsSTHT % of First Attendances seen within 48 hours

GUM Target for patients seen within 48 hoursGUM Target for appointments offered an appointment within 48 hrs

GUM Activity monitoring Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

Overall First attendances 601 583 653 694 526 691 747 578 5073

Overall first attendances seen within 48 hours 425 455 523 584 436 569 534 440 3966

Overall first attendances offered an appointment within 48 hours 584 577 653 694 526 691 747 578 5050

STHT % of First Attendances seen within 48 hours 70.7 78.0 80.1 84.1 82.9 82.3 71.5 76.1 78.2

GUM Target for patients seen within 48 hours 80 80 80 80 80 80 80 80 80 80 80 80 80

STHT % of First Attendances offered an appointment within 48 hrs 97.2 99.0 100.0 100.0 100.0 100.0 100.0 100.0 99.5

GUM Target for appointments offered an appointment within 48 hrs 99 99 99 99 99 99 99 99 99 99 99 99 99


In November 100% of patients were offered an appointment within 48 hours (against a national target of 100%) and 76.1% of patients were seen within 48 hours (against a local target of 80%).

The drop below the 80% threshold for numbers of patients seen during the last two months is due to a combination of factors including: Retirement of the consultant covering the clinics at

JCUH, FHN and UHH resulting in a loss of capacity which the department has not been able to cover fully;

Sickness absence of staff across North Tees, Hartlepool and JCUH clinc sites. Where possible JCUH staff are covering clinic at the satellite sites.

Patients at the satellite sites who have been offered alternative appointments at James Cook University Hospital, but have preferred to wait for available appointment slots within their locality.

Year to date 5073 new patients have been seen of which 5073 were offered an appointment within 48 hours (99.5% YTD) and 3966 were seen within 48 hours (78.2% YTD).

As part of the financial incentive agreement with Tees PCTs it has been agreed that with effect from October there will be a financial penalty of £80,000 for each month in which the 100% offered target is not achieved (up to a maximum amount of £250,000) by the end of 2008/09.

Key Action Points Action plan produced in response to GUM

national support team visit. Evening clinics have been set up at all 3 sites

(JCUH, FHN and UHH). Early morning clinics between 8am and 9am have been trialled but no patients attended within the month trial period. This will be reassessed in the summer 2009.

GUM audit by Dr Tayal shows that on average male patients DNA on average 4 times with the exception of one patient 17 times. On average females DNA 1.3 times. The action now is that all patients are sent a text message for next appointment also reminding them to cancel

Action plan has been produced detailing steps to be taken to cover consultant time as well as future plans to improve staff resilience.

Section Four – Local LDP Contract Performance Measures

4.1) Convenience and Choice – Slot availability

Measure DescriptionPatients will be able to choose from at least four different healthcare providers for planned hospital care, paid for by the NHS. The success of this initiative will be judged through patient surveys.

This availability of slots is a reasonable indicator of how successfully patients are able to book into slots once they have made their choice.


PerformanceSTHT SUMMARY OF CHOOSE AND BOOK POSITION APRIL 2008 ONWARDS.OrganisationNational Position Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08OP CAB Referrals 392,373 378,870 384,619 421,304 378,335 431,364 456,228 398,868% OP CAB utilisation 49% 50% 48% 48% 48% 49% 50% 49%Slot issues (all reasons) 46,911 45,365 50,213 61,901 46,639 45,855 47,028 47,434DBS Bookings 284,032 277,452 280,892 309,979 282,598 326,890 348,387 305,062Issues per DBS booking 0.17 0.16 0.18 0.2 0.17 0.14 0.13 0.16Average slot poll length (weeks) 5.6 5.8 5.8 6.1 6.1 6.2 6.2 6.2

Northeast SHA Position Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08OP CAB Referrals 21,472 20,636 21,427 22,893 20,654 23,966 25,808 22,690% OP CAB utilisation 46% 48% 48% 47% 47% 50% 50% 51%Slot issues (all reasons) 2,224 2,776 3,382 4,627 3,580 2,657 3,094 3,059DBS Bookings 20,828 19,984 20,752 22,643 19,949 23,042 24,861 21,700Issues per DBS booking 0.11 0.14 0.16 0.20 0.18 0.12 0.12 0.11Average slot poll length (weeks) - - - - - - - -

South Tees Position Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08OP CAB Referrals 3,420 3,098 3,414 3,744 3,236 3,786 3,944 4,039% OP CAB utilisation 37% 37% 38% 39% 37% 40% 40% 40%Slot issues (all reasons) 682 910 1,045 1,318 1,112 997 1,058 1,129DBS Bookings 3,371 3,049 3,349 3,670 3,166 3,693 3,944 3,470Issues per DBS booking 0.2 0.3 0.31 0.36 0.35 0.27 0.27 0.33Average slot poll length (weeks) 7.1 7.2 7.4 7.8 7.5 7.7 7.9 8

Month

(Source of information: Department of Health weekly Choose and Book reports)


Patient convenience and choice are high on the DH agenda and consequently the utilisation of Choose and Book is being closely scrutinised. Utilisation of Choose and Book in the Northeast SHA is 51% compared to 49% nationally and providers and PCTs are being encouraged to look at ways to improve utilisation. The Trust and Tees PCTs have established a Choose and Book project group which has identified a number of work streams to improve choose and book utilisation over a 6 month period. The PCT has also provided funding to support the project.Key Action PointsTo date, progress has been made in the following areas: A project manager has been appointed and an action plan agreed. Middlesbrough PCT have agreed to

provide audit support to the Choose and Book project. An audit of redirected and rejected referrals has commenced to provide feedback to GPs when referrals are

received into the wrong service via the choose and book system. A group has been established to look at the feasibility of using choose and book for 2 week wait and other

urgent referrals. This includes a review of current routine, urgent and 2 week wait capacity and demand. It is planned to move to the use of choose and book for 2WW referrals by the end of March 2009. The project group is due to produce a first report in January 2009.

Specialties with high levels of slot unavailability are those which rely on ad hoc additional clinics to meet demand. These additional clinics are now being planned more in advance with the support of a predictive choose and book capacity tool. Additional clinics are being made available in the choose and book system. It is expected that this will reduce the slot issues per DBS booking to a ratio of less than 0.1.

Work is commencing to introduce the use of a key words search facility onto the choose and book system to improve GP utilisation of the system.

4.2) Retinal Screening

Measure DescriptionFrom December 2007, 100% of people with diabetes should be offered screening for the early detection (and treatment if needed) of diabetic retinopathy. In addition, the national screening programme for diabetic retinopathy recommends that at least 70% of eligible patients should take up of the offer of an initial screen and of these, at least 80% of patients should have regular repeat screens, ideally within 12 months of the previous screen but no longer than 15 months between screening. Locally, a target of 80% of all eligible patients to be screened within a 12 month period has been agreed, which exceeds this standard.


Performance

Diabetic Retinopathy Screening - Percentage offered and seen

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


12 Month periods (2007/08 to 2008/09)

Pe

rce

nt

Overall % of patients offered screeningOverall % of patients seenTarget for % offeredTarget for % seen

South Tees Diabetic Retinopathy SummaryFor period: From Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07

To Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08

Overall number of patients offered screening 13953 14069 14155 14122 14210 14414 14478Overall number of patients seen 11130 11119 11199 10921 10934 11093 11492

Diabetic population (minus exclusions) 14247 14371 14464 14594 14620 14809 15063Overall % of patients offered screening 97.94% 97.90% 97.86% 96.77% 97.20% 97.33% 96.12%

Target for % offered 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%Overall % of patients seen 78.12% 77.37% 77.43% 74.83% 74.79% 74.91% 76.29%

Target for % seen 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%

PCT splitsNorth Yorkshire & York PCT

% of patients offered screening 97.70% 97.59% 98.21% 96.95% 98.71% 98.51% 95.36%% of patients seen 78.97% 79.02% 79.87% 80.13% 79.66% 80.56% 82.28%

Middlesbrough PCT% of patients offered screening 97.88% 97.67% 97.32% 96.50% 96.85% 96.70% 95.59%

% of patients seen 75.63% 75.33% 75.05% 72.33% 72.22% 72.36% 73.76%Redcar & Cleveland PCT

% of patients offered screening 98.18% 98.38% 98.18% 96.91% 96.43% 97.13% 97.25%% of patients seen 80.17% 78.32% 78.13% 73.55% 73.90% 73.44% 74.62%


Data is not yet available for the period November 2007 to November 2008 due to technical problems with the system. An update will be issued as soon as this becomes available.

Long term sickness continues to affect clinic capacity. Temporary cover will be available from 15th December.

The project board is progressing the issues raised during the preliminary review by the ‘national team’ in preparation of the main visit in January 2009. Replacement cameras have been ordered and a replacement server is going through the tender process. A number of other actions are ongoing:

Funding of the retinal screening services is being reviewed through the LDP contract process. Continuing to undertake a review of the database, ensuring all patients are in the correct state. This is an

ongoing manual process to determine the reasons behind why patients have been ‘discharged’ from the retinal screening programme so the will take 3 – 6 months before impact of this work is realised.

Working with PCTs to encourage GPs to follow-up patients that repeatedly never reply to invitations. Working with PCTs to establish an up to date lists of diabetic patients based on information from GP practice

databases.

Section Five – HUMAN RESOURCES

This section of the report covers the main areas that are routinely monitored by the Human Resource Directorate:

5.1 Staff in Post

Measure Description


To monitor the Actual Whole Time Equivalent (WTE) against the Budgeted WTE position. Included in the chart is the position showing the directly employed (contracted) WTE.

Performance

Staff in Post

530054005500560057005800590060006100620063006400

Dec

-07

Jan-

08

Feb

-08

Mar

-08

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Budgeted WTE Actual WTE * Directly Employed Contracted WTE

Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08Budgeted WTE 5997 6015 6022 6014 5917 5941 6077 6112 6137 6193.8 6228.9 6260.92Actual WTE * 5827 5856 5891 5962 5974 5948 5955 5963 5985 6112.4 6087.6 6101.61Directly Employed Contracted WTE 5678 5703 5739 5746 5741 5772 5790 5803 5827 5890 5924 5956Extra Hours/Overtime (WTE) 97.1 99.1 126.5 157.5 150.9 116.1 114.6 117.1 127.72 166.73 142.52 139.687* Includes staff who are non-directly employed (i.e. Military & LET)


The data recorded by the HR system reports on the contracted WTE of those staff who are directly employed by the organisation. There are, of course, a number of other staff who contribute to the performance of the organisation (i.e. Military personnel and Medical and Dental staff employed through the Lead Employer Trust (Co Durham and Darlington Foundation Trust). These are reflected in the ‘Actual’ WTE staffing levels which are produced by the Finance Department. ‘Actual’ figures also include any additional hours or overtime, as described below.

The table also includes some data on the extra hours/overtime usage. It is worth noting that this information is based on those hours ‘paid’ in the current month and therefore are a reflection of those hours ‘worked’ in the previous month (i.e. figures represented in April 2008 reflect those hours worked in March 2008).

November sees an increase in the total staffing numbers, due to recruitment in line with business cases (Anaesthetics & Theatres, Women & Children and Information).

Key Action Points

Monitor staffing levels in line with agreed workforce profile for 2008/2009.

5.2 Sickness Absence

Measure Description

To monitor levels of sickness absence throughout the organisation.

Performance


Sickness Absence Rate

012

3456

78

Nov

-07

Dec

-07

Jan-

08

Feb

-08

Mar

-08

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Oct

-08

Nov

-08

% Absence % Short Term % Long Term

Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08% Absence 6.22 6.00 6.75 6.40 5.93 5.74 5.83 5.65 5.79 5.60 5.64 5.53 5.31% Short Term 3.19 2.69 3.89 3.01 2.85 2.99 2.76 2.75 2.69 2.62 2.97 2.95 2.86% Long Term 3.03 3.31 2.86 3.39 3.08 2.75 3.07 2.90 3.10 2.98 2.67 2.58 2.45


The month of November saw a further reduction in the Trust’s sickness rate (0.22%), in the main due to a decrease in Long-Term absence.

The Operational HR team continue to work with and support managers in the management of sickness absence across divisions.

Key Action Points

Continue to monitor sickness levels Manage compliance of the Sickness Absence

Policy

5.4 Attendance at Mandatory Training

Measure Description

To maintain attendance levels at Corporate Mandatory Training and Corporate Induction against the target of 80% to ensure compliance with Standards for Better Health (C11b).


Performance

Attendance at Mandatory Training

50

55

60

65

70

75

80

85

90

95

100

Per

cen

t

% Attendance Target (Healthcare Commission)

CH

IEF

EX

EC

UT

IVE

OP

ER

AT

ION

AL S

RV

CS

INF

OR

MA

TIO

N

PLA

NN

ING

HU

MA

N R

ES

OU

RC

ES

FIN

AN

CE

HC

GO

VE

RN

AN

CE

AC

UT

E M

ED

ICIN

E

SP

EC

IALT

Y M

ED

ICIN

E

SU

RG

ER

Y

NE

UR

OS

CIE

NC

ES

TR

AU

MA

WO

ME

N &

CH

ILDR

EN

PA

TH

OLO

GY

RA

DIO

LOG

Y

AN

AE

ST

HE

TIC

S &

TH

EA

TR

ES

CLIN

SU

PP

OR

T S

VC

S

CA

RD

IOT

HO

RA

CIC

AC

AD

EM

IC

TO

TA

L

% Attendance 80 64 100 100 100 85 82 98 90 54 86 64 76 71 78 76 81 72 100 80

Target (Healthcare Commission) 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80


The Trust continues to perform well against the target of 80% compliance with the November 2008 position showing that 80% of staff have attended either the Trust’s Corporate Induction or the Corporate Mandatory Awareness Training within the last 2 years. Whilst the position against the target is currently being maintained, closer monitoring of attendance levels is needed to ensure that levels of attendance do not fall beneath 80%.

The E-Learning module has been officially launched through a number of events held both on the James Cook University and Friarage Hospital sites. More than 500 staff have accessed the E-Learning module since the launch in October, which is excellent news.

Key Action Points

Monitor demand for 2008/2009 through Training Needs Analysis

Further development of other e-learning materials.

5.5 Appraisals Completed

Measure Description

To monitor the numbers of Staff Development Reviews (Appraisal) carried out using the Knowledge and Skills Framework (KSF) outlines.


Performance

Cumulative % of SDRs Completed at 30 November 2008

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Per

cen

t

Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08TRUST 61.95% 60.28% 57.28% 45.78% 44.04% 43.68% 46.69% 47.76% 48.92 50.57 50.26 48.98


November saw a disappointing drop in appraisal numbers. Divisions and Directorates must continue to adjust and monitor progress against their plans.

The E-KSF system, used to record details of appraisals, development plans and objectives is being piloted in a small number of Corporate Directorates. The benefits of using this system include less paperwork and consistent approach to conducting appraisals as being a mechanism to electronically store details pertaining to appraisals and any supporting evidence.

Key Action Points

Continue to monitor performance. Implement reviewed SDR Policy


Documents

Trust Board Performance Report