Board Integrated Performance Report 29 June 2017 May 2017 Data · Board Integrated Performance...

1 of 21 Board Integrated Performance Report - June 2017

1.2 NHS Improvement

Segment

Provisional

Board Integrated Performance Report

29 June 2017

May 2017 Data

Good

1.1 CQC Rating 1.3 NHS Improvement

Use of Resources

Provisional

1

Agenda Item: 13

Lead Director: Director of Finance,

Contracting and Facilities

Presented For: Assurance

1

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in

delivery of a broad range of key targets and indicators.

Board Action Key Highlights Slides

NHS Improvement Indicators

Assurance • NHS Improvement indicators have been met for May 2017, for those indicators where final data is available. 4 - 5

Quality

Information

Exceptions

• In line with the agreed changes to the Integrated Performance Reporting cycle, summary data only is provided

this month. Full data and narrative focusing on actions and their impacts will be provided quarterly.

• Reasons for and actions to address the reduction in Information Governance training compliance and staff

receiving appraisal will be discussed at the June performance meetings for business units and corporate

functions. Information Governance training compliance is likely to have been impacted by the decision at the

last Information Governance Steering Group Meeting to review the staff that were previously classed as

exceptions for compliance purposes and to include all staff groups on ESR.

7 – 12

8

Business Unit

Information • A new service dashboard is included. This will be provided quarterly to support the Board’s holistic

understanding of performance, with increased visibility of performance at service level and to support

scheduling in-year of Board quality and safety visits. Board members’ feedback on the initial content is

welcomed. A quarterly activity report is also being developed, for inclusion from September 2017.

• The correlation of quality, workforce, activity and finance information by service does not suggest any new

themes or trends.

13

Change Programme

Exceptions

• The 2017/18 Change Programme provides governance, monitoring and assurance for eight transformation

projects delivering significant service transformation and change. Of the eight projects:

- Four are rated red (corporate benchmarking; roster savings; mental health acute and community; Trust

procurement);

- Four are rated green (adult physical health; estates and facilities; specialist inpatients, dental &

administration; children’s services).

14

Enablers

Information • New slides are included for Informatics and Estates and Facilities for Board discussion and consideration.

Comments would be especially welcomed for Informatics indicators. Both enabling areas will be reported

quarterly to support the ‘strategy’ focus of the Board meeting. Board feedback is sought on the draft content.

18 - 21

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in

delivery of a broad range of key targets and indictors.

Board Action Key Highlights Slides

Finance

Assurance

Exceptions

• Control Total Performance – 2017/18 Performance: Surplus/(Deficit) Position: A year to date surplus of

£22k compared to a plan deficit of (£665k) gives a favourable £687k variance. A number of Commissioning

for Quality and Innovation (CQUIN) requirements and CIPs are profiled to deliver in the latter part of the

financial year with some implementation plans still being finalised. CIP and CQUIN delivery therefore remain

high risk. The majority of operational pay under spending at month 2 is assessed to be non recurrent with

recruitment activities and increased medical locum costs expected. The 2017/18 forecast is that the Trust will

meet its Control Total of £826k surplus allowing access to a further £752k Sustainability and Transformation

Funding. The executive team agreed to retain a number of financial controls during Quarter 1 pending a

detailed forecast, risk and efficiency review.

• Cash: Cash balances are £3.5m above plan reflecting £0.7m favourable Control Total performance and NHS

Property Services outstanding debts which have now been settled in May 2017 (following full and final

agreement in April 2017).

• Use of Resources (UoR): The actual UoR at month 2 is ‘1’ compared to plan of ‘3’ and reflecting delivery of

an in month surplus rather than deficit plan position.

• CIPs: Detailed project plans are still being finalised for a number of CIP schemes that are profiled to deliver in

the last 6 months of the year. At month 2 CIPs are £310k above plan. Forecast risks of £679k (before high

risk reserve) are expected to require particularly close management.

• Workforce – Agency Controls: All agency expenditure caps have been achieved in month 2 and are

forecast to achieve but with elevated medical locum cost and hourly rate risks flagged. There were 182 price

cap and 198 wage cap breaches during May (5 week month).

• Capital: Capital expenditure was £154k lower than plan in month 2 driven mainly by IM&T, however all

capital schemes are forecast to deliver in full. A £500k capital contingency is available to mitigate in-year

applications and priorities, a number of which are already being considered.

15 - 17

Summary and Recommendations

The report shows good performance in May 2017, including further improvement in sickness absence rate, though with under-performance in

relation to appraisals and information governance training compliance. Whilst year to date financial performance is good we anticipate

elevated financial challenges in quarters 3 and 4 due to phasing of efficiencies and CQUIN targets and as recruitment activities impact.

Correlation of quality (including patient experience and safety related measures), performance, finance, workforce and health & safety

information took place at the Directors’ Business & Transformation meeting and did not identify any themes or trends for Board escalation.

The Board is recommended to consider the exceptions highlighted and note the proposed actions.

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Single Oversight Framework Operational Performance Metrics

Indicator M7: Data is provided in relation to the waiting time element of the new standard for Early Intervention in Psychosis (EIP). This

shows patients who started treatment in May 2017 within two weeks of referral. The number of incomplete pathways (patients waiting) at the

end of May 2017 was 13; 5 of these patients have been waiting for more than two weeks.

Indicator M19: Performance against this standard was assessed as part of the 2016/17 national Commissioning for Quality and Innovation

(CQUIN) indicator, via local and national audits in quarter 4 of 2016/17. The national audit results for inpatient wards and community mental

health services were published in June 2017: the Trust performance significantly exceeded the national target.

Measure

Target

England

Benchmarking

figure

Graph Key

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

80.0%

85.0%

90.0%

95.0%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

90.0%

92.5%

95.0%

97.5%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q1 17/18 Q1 17/18

Outturn Outturn OutturnNumerator

Outturn

Denominator

OutturnOutturn

M3

Maximum time of 18 weeks from point of referral to

treatment (RTT) in aggregate − patients on an incomplete

pathway

92.0% 100.0% 100.0% 657 657 100.0% 89.9 % as of April 17

M5

Patients requiring acute care who received a gatekeeping

assessment by a crisis resolution and

home treatment team in line with best practice standards

95.0% 100.0% 100.0% 118 118 100.0%

98.7% as of

Q3 - 16/17

Next publication date:

TBC

M7

People with a first episode of psychosis begin treatment

with a NICE-recommended package of care within 2

weeks of referral

50.0% 64.2% 75.3% 69.5% 90.0% 70.8% 35 44 79.5%

Ensure that cardio-metabolic assessment and treatment

for people with psychosis is delivered routinely in the

following service areas:

a) Inpatient Wards 90.0% 98.0%

b) Early Intervention in psychosis services 90.0% 94.0%

c) Community mental health services (people on Care

Programme Approach)65.0% 96.0%

National

Benchmark

Indicator

No.

Indicator

Target Apr May Jun Graph

M19

80.0%

85.0%

90.0%

95.0%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

90.0%

92.5%

95.0%

97.5%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17


Indicator M20a: This Mental Health Services Data Set (MHSDS) data completeness indicator comprises NHS number, date of birth,

postcode, gender, GP and commissioner. The Trust is still awaiting clarification from NHS Improvement and NHS Digital about the data

definitions to be used to calculate performance. Pending this, data has been provided based on internal calculations from the MHSDS.

Indicator M20b: In January 2017, NHS Improvement confirmed that the MHSDS indicator for priority metrics will only assess performance

on three elements – ethnicity, accommodation status and employment status. The Trust is still awaiting clarification from NHS Improvement

and NHS Digital about the data definitions to be used to calculate performance for these three elements.

Indicators M21, M10, M11: Within the Single Oversight Framework, Trust performance for Improving Access to Psychological Therapies

(IAPT) is assessed quarterly, based on final data published by NHS Digital. NHS Digital is due to publish final data for 2016/17 quarter 4 on

22 June 2017.

Single Oversight Framework Operational Performance Metrics

Measure

Target

England

Benchmarking

figure

Graph Key

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Q2 16/17 Q3 16/17 Q4 16/17 Apr May Jun Q1 17/18 Q1 17/18 Q1 17/18

Outturn Outturn OutturnNumerator

Outturn

Denominator

OutturnOutturn

M20a

Complete and valid submissions of metrics in the monthly

Mental Health Services Data Set Submissions to NHS

Digital:

* Identifier metrics

95.0%

99.5%

June Final

data

99.5%

September

Final data

99.5%

December

Final data

97.1%

Jan Provisional


22/06/2017

M20b

Complete and valid submissions of metrics in the monthly

Mental Health Services Data Set Submissions to NHS

Digital:

* Priority metrics

85.0%

M21Proportion of people completing treatment who move to

recovery (from IAPT minimum dataset)50.0% 52.8% 51.8%

55.6%

(Provisional)

53.6%

(Provisional)210 470 44.7%

51.1% as of Feb 17:

Next pub,ication date

22/06/17

M10

waiting time to begin treatment (from IAPT minimum data

set)

- within 6 weeks

75.0%94.2% 94.4%

96.3%

(Provisional)

95.6%

(Provisional)

98.3% as at

Feb 17


22/06/17

M11

waiting time to begin treatment (from IAPT minimum data

set)

- within 18 weeks

95.0%98.4% 99.3%

99.1%

(Provisional)

99.1%

(Provisional)

98.7% as at

Feb 17


22/06/17

TBC

TargetNational

BenchmarkGraph

Indicator

No.

Indicator

60.0%

70.0%

80.0%

90.0%

100.0%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

85.0%

87.5%

90.0%

92.5%

95.0%

97.5%

100.0%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

40.0%

45.0%

50.0%

55.0%

60.0%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17


Airedale NHS Foundation Trust and Bradford Teaching Hospitals NHS Foundation Trust performance against the national standard for

Accident and Emergency (A&E) waits is provided to the Board for information. The Trust contributes to delivery of the target through a range

of services and interventions. The Trust is working actively with both Airedale NHS Foundation Trust and Bradford Teaching Hospitals

Foundation Trust on providing support within A&E departments and developing pathways designed to avoid admissions.

NHS England and NHS Improvement designated the West Yorkshire system as an urgent and emergency care ‘Acceleration Zone’. The key

requirement of this is to deliver transformation and interventions will which support delivery of urgent and emergency care targets across

West Yorkshire, including the A&E 4 hour target. National funding allocated to deliver transformation and interventions has been extended

into quarter 1 of 2017/18.

Accident and Emergency Waiting Times

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Indicator

No. Indicator TargetQ1

16/17

Q2

16/17

Q3

16/17

Q4

16/17July Aug Sep Oct Nov Dec Jan Feb Mar Apr

Total attendances within 4 hours 13,368 13,174 13,180 13,840 4,628 4,232 4,314 4,375 4,164 4641 4,416 4,323 5,101 4,960

M18a% of A&E attendances where service

user was admitted, transferred or

discharged within 4 hours

95% 93.3% 90.2% 89.2% 91.9% 90.3% 88.8% 91.3% 90.2% 90.8% 90.1% 88.4% 94.5% 93.1% 93.3%

Total attendances within 4 hours 31,297 30,250 28,941 29,091 10,714 9,774 9,762 9,792 9,516 9,633 9,612 8,981 10,498 9,709

M18b% of A&E attendances where service

user was admitted, transferred or

discharged within 4 hours

95% 90.8% 89.4% 84.0% 89.8% 89.8% 90.1% 88.2% 85.0% 85.1% 82.1% 86.8% 90.1% 92.4% 87.4%

Airedale NHS Foundation Trust

Bradford Teaching Hospitals NHS Foundation Trust


Indicator No.

16/17 Out-turn

This month's performance 17/18 Year

to Date

Q3 96 1 5

Serious Incident Numbers

0

2

4

6

8

10

12

14

16

May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17 Apr - 17 May - 17

May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17 Apr - 17 May - 17

Under age admission 0 1 0 0 1 0 0 0 0 0 0 0 0

Suspected Suicides 4 0 6 1 4 4 3 3 1 2 0 1 1

Homicides 0 0 0 0 0 0 0 0 0 0 0 0 0

Absconders/escape/AWOLs 0 0 0 0 0 0 0 0 0 0 0 0 0

Pressure Ulcers 8 4 6 5 5 7 6 1 0 0 0 0 0

Serious incidents Other 2 1 3 0 0 0 1 2 0 0 0 3 0

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Workforce – Appraisal & Mandatory Training

Indicator

No. Indicator

16/17

outturn

17/18

Target Numerator Denominator

Current

Performance

FOT

17/18 Graph

Q17

% Mandatory training

(excl. Information

Governance

Compliance)

88.96% 80.00% 6414 7772 82.53%

Q17a

% Information

Governance Training

- Substantive Staff

Only

98.46% 95.00% 2083 2423 85.97%

Q17b % Information

Governance Training

- Tertiary Staff Only

96.51% 95.00% 286 307 93.16%

Q17c

% Information

Governance Training

- Substantive and

Tertiary Staff

Combined

98.28% 95.00% 2369 2730 86.78%

Q18 % Staff Receiving

Appraisal 83.77% 80.00% 1854 2391 77.54%

80.0%

85.0%

90.0%

95.0%

100.0%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

80.00%

85.00%

90.00%

95.00%

100.00%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

80.0%

85.0%

90.0%

95.0%

100.0%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

80.0%

85.0%

90.0%

95.0%

100.0%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Workforce – Labour Turnover, Vacancy and Absence

Indicator

No. Indicator

16/17

outturn

17/18

Target

Current

Performance

FOT

17/18 Graph

Q19 % Labour Turnover 13.04% 10.00% 12.07%

Q20 % Sickness absence rate 5.12% 4.00% 4.69%

Q21 % Vacancy rate 7.17% 10.00% 8.76%

Staff Sickness Absence Total Number

Total days lost 38963

Total staff 2561

Average working days lost 15.22

Bradford Factor Score Points Previous Month Current Month

Informal process: 20 - 99 points 422 433

Informal process: 100 - 299 points 137 128

Formal process: 300 points and above 69 82

8.00%

9.00%

10.00%

11.00%

12.00%

13.00%

14.00%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

LTO (YTD) Target

0.00%

5.00%

10.00%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Long Term Short Term

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Vacancy Target

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Q23a - Safer Staffing: Inpatient Services - May 2017

Risks:

- Hotspot areas in terms of vacancies (in DAU, Thornton, Bracken and

Ashbrook) meaning safe staffing levels cannot be sustained long term

without posts being permanently recruited to.

Contingency/ Mitigating Actions:

- Roster review / risk assessment in place on a daily basis

- Weekly ward meetings continue to be held to forward plan rosters and

re-distribute staff across services as required. Redeployment of staff

is now recorded in the system to provide audit trail.

- The SafeCare module has being reviewed with further work planned

to pilot this on DAU

- Programme of recruitment fayres being attended in next 12 months.

Rolling recruitment ongoing with specialist programmes and potential

new roles/ career pathways being explored – e.g. Associate

Physician, and Apprenticeships.

Narrative on data extracts regarding staffing levels on 13 wards

during May 2017

Exact/over compliant shifts - Over compliant shifts continue to reduce

across all wards due to the weekly planning meetings held within the

services. The hotspots during May however, were mainly attributed to

Ashbrook, Dementia Assessment Unit (DAU), and Clover (PICU) wards

due to the acuity (complexity of need) and the requirement for skill mix

within the units. 52% (4% increase from April) of all shifts worked were

bank or agency filled, with 86% of these shifts requesting unregistered

staff. The main reason for bank and agency is due to Vacancy which has

decreased by 3% from last month (55% to 52%, with hotspot areas being

DAU, Thornton, Bracken and Ashbrook.

Under compliant shifts - There were 59 incidents reported relating to

staffing shortages in May 2017 (an increase of 30 from the previous

month), with the majority (41) submitted by Specialist inpatient services;

and particularly DAU (21). There are planned controls being introduced to

track Bank staff who DNA; this could help to reduce the number of under-

compliant shifts by being forewarned of remaining gaps in rosters and the

need to rebook. Another contributing factor to under compliance is

sickness, of which 15% of bank and agency bookings in April were

attributed to long term sickness (an increase of 3% from previous month),

particularly across Assessment and Treatment Unit (ATU), Ashbrook

Heather, and Bracken wards.

Non-compliant shifts – Two night shifts were identified as being non-

compliant in May. One shift on ATU was mitigated by the registered nurse

on the late shift working overtime to complete the medication round and

the Duty Nurse on Low Secure overseeing the rest of the nightshift. The

second night shift was on Step Forward, which was mitigated in part

without incident arising, and action has been taken to avoid recurrence.

No. shifts

Exact/ Over Compliance 1957

Under Compliance 312

Non Compliance 2

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Q23a - Safer Staffing: Inpatient Services – May 2017

Main 2 Specialties on

each ward

Specialty 1

Total

monthly

planned staff

hours

Total

monthly

actual staff

hours

Total

monthly

planned staff

hours

Total

monthly

actual staff

hours

Total

monthly

planned staff

hours

Total

monthly

actual staff

hours

Total

monthly

planned staff

hours

Total

monthly

actual staff

hours

Fern710 - ADULT MENTAL

ILLNESS975 997.5 885 810 306.9 353.4 846.3 744 102.3% 91.5% 115.2% 87.9%

Heather710 - ADULT MENTAL

ILLNESS937.5 1012.5 1154.5 1200 288.3 372 864.9 790.5 108.0% 103.9% 129.0% 91.4%

Bracken710 - ADULT MENTAL

ILLNESS937.5 855 1387.5 1380 288.3 279 864.9 883.5 91.2% 99.5% 96.8% 102.2%

Ashbrook710 - ADULT MENTAL

ILLNESS930 1005 1395 1740 288.3 288.3 864.9 1246.2 108.1% 124.7% 100.0% 144.1%

Maplebeck710 - ADULT MENTAL

ILLNESS930 870 1395 1207.5 288.3 288.3 864.9 864.9 93.5% 86.6% 100.0% 100.0%

Oakburn710 - ADULT MENTAL

ILLNESS937.5 1027.5 1387.5 1162.5 288.3 325.5 864.9 827.7 109.6% 83.8% 112.9% 95.7%

Baildon710 - ADULT MENTAL

ILLNESS952.5 877.5 1140 915 288.3 288.3 576.6 576.6 92.1% 80.3% 100.0% 100.0%

Ilkley710 - ADULT MENTAL

ILLNESS930 690 1162.5 952.5 288.3 288.3 576.6 576.6 74.2% 81.9% 100.0% 100.0%

Thornton710 - ADULT MENTAL

ILLNESS930 915 1627.5 1845 288.3 288.3 1153.2 1125.3 98.4% 113.4% 100.0% 97.6%

Assessment &

Treatment Unit (LD)700- LEARNING DISABILITY 930 877.5 1395 2062.5 288.3 288.3 864.9 1199.7 94.4% 147.8% 100.0% 138.7%

Clover (PICU)710 - ADULT MENTAL

ILLNESS930 960 1860 3052.5 288.3 316.2 1153.2 2027.4 103.2% 164.1% 109.7% 175.8%

Step Forward (Rehab)710 - ADULT MENTAL

ILLNESS532.5 547.5 622.5 622.5 288.3 288.3 288.3 362.7 102.8% 100.0% 100.0% 125.8%

Dementia Assessment

Unit (DAU)

710 - ADULT MENTAL

ILLNESS930 877.5 2790 3157.5 576.6 530.1 1441.5 1887.9 94.4% 113.2% 91.9% 131.0%

Staffing: Nursing, midwifery and care staff

Fill rate indicator return

Average fill

rate -

registered

nurses/midwiv

es (%)

Average fill

rate - care

staff (%)

Average fill

rate -

registered

nurses/midwiv

es (%)

Average fill

rate - care

staff (%)

Day Night

Ward name

Registered

midwives/nursesCare Staff

Registered

midwives/nursesCare Staff

Day Night

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Quality Assurance

Indicator

Number Target

Target met this

month Yes/No

Q5 Never Events Y

Q7 Meet Central Alert System (CAS) timelines Y

Q10 No MRSA bacteraemia cases Y

Q11 No Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia cases Y

Q12 No Clostridium difficile (C.diff) cases Y

Q15 Meet nationally mandated Commissioning for Quality and Innovation (CQUINs) – Forecast 2017/18. Y

Q15 Meet CCG Commissioning for Quality and Innovation (CQUINs) – current quarter Y

Q16 Meet NHS England Commissioning for Quality and Innovation (CQUINs) – current quarter Y

Q32 No Complaints to Information Commissioners Office (ICO) Y

Q33 No Information Governance Serious Incidents (STEIS) Y

Q34 Maintain Mixed sex accommodation status Y

Q35 Meet Dental Referral To Treatment within 52 weeks Y

Q37 Maintain Publication of the Formulary on Provider’s website Y

Q38a Meet duty of candour requirement to notify the relevant person of a suspected or actual reportable patient safety

incident Y

Q38b Number of duty of candour incidents 0

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Indicator

Reporting

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dfo

rd H

ealt

h V

isit

ing

Bra

dfo

rd F

am

ily N

urs

e

Part

ners

hip

Wakefi

eld

Sch

oo

l N

urs

ing

Wakefi

eld

Healt

h V

isit

ing

Wakefi

eld

Fam

ily N

urs

e

Part

ners

hip

Ad

ult

Co

mm

un

ity M

en

tal

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h

Ch

ild

& A

do

lescen

t M

en

tal

Healt

h

Earl

y I

nte

rven

tio

n i

n P

sych

osis

Psych

olo

gic

al

Th

era

pie

s

In-p

ati

en

t -

Acu

te C

are

Serv

ices

(Ward

s,

Fir

st

Resp

on

se,

IHT

T)

Learn

ing

Dis

ab

ilit

ies

(Co

mm

un

ity)

Old

er

Peo

ple

Co

mm

un

ity

Men

tal

Healt

h

Ad

min

istr

ati

on

Serv

ices

Inp

ati

en

ts -

Sp

ecia

list

Serv

ices

Den

tal

Serv

ices

Number of incidents2016/17

quarter 4 392 3 9 4 6 17 13 13 3 103 5 16 4 848 10 77 13 522 45

Number of near misses2016/17

quarter 4 6 0 1 0 0 0 0 0 0 3 1 0 0 41 1 1 1 15 1

Number of serious incidents2016/17

quarter 4 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0

Number of compliments2016/17

quarter 4 37 0 8 40 5 0 0 0 4 0 10 3 2 3 30 1 6 0 2 1

Number of complaints2016/17

quarter 4 0 0 0 0 0 0 0 0 0 0 2 2 0 1 2 0 0 0 0 0

Number of Friends and Family

Test responses

2016/17

quarter 4 151 18 13 54 64 261 44 17 3 14 145 16 32 59 13

Friends & Family Test

'recommend' score (out of 5)

2016/17

quarter 4 4.87 4.94 4.92 4.54 4.70 4.59 4.91 4.76 5.00 4.36 4.06 4.63 4.84 4.27 5.00

Whole time equivalents

(budgeted)May-17 301 29 32 43 58 31 22 85 189 12 38 103 9 109 100 53 136 288 56 81 185 206 93

Safer staffing compliance/

staffing ratioApr-17

From

Oct 17

From

Oct 17

From

Oct 17

From

Oct 17

See

slides

See

slides

Sickness absence May-17

Turnover12 months to

May 17

Mandatory training May-17

Information governance

trainingMay-17

Staff receiving appraisal May-17

Vacancy rate May-17

Bank spend (% of pay) May-17

Agency spend (% of pay) May-17

Finance year to date variance2017/18

year to date

Finance forecast outturn

variance

2017/18

forecast

Cost improvement plan

variance (Business Unit level)

2017/18

year to date

2016/17 Q4 83,592 2,976 4,132 20,063 7,430 18,778 5,790 407 4,514

Change ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓

Achievement of contractual

indicators

2016/17

quarter 4

Board walkabout visit(s) to

service in 2016/172016/17 Yes No Yes Yes No Yes No No No No Yes Yes Yes Yes Yes Yes Yes Yes No No

Board walkabout visit(s) to

service in 2017/182017/18 Yes Jun-17 No No Mar-18 No No No Sep-17 No Yes Yes Yes Nov-17 No No No No No Feb-18 No Jun-17 Dec-17

Contacts

Adult Physical Health Children's Services Mental Health Acute and Community Specialist/Admin/Dental

To be added from Aug 17



Service Dashboard


Directors Business & Transformation Programme Monthly Summary

The 2017/18 Directors Business & Transformation Programme is providing governance, monitoring and assurance for 8 transformation

projects delivering significant service transformation and change. In addition there are 60 corporate transactional Cost Improvement savings

being monitored across the Trust. The scale of these savings and change activities required is expected to deliver budget reductions totaling

£7.975m during 2017/18 to achieve the Trust objectives to become financially sustainable and digitally capable.

In month 2 the overall programme is rated red, though with improvement from month 1 following development of delivery plans and

completion of quality impact assessments. Given the scale of transformation and thorough planning and engagement with stakeholders the

project initiation and plans have required some re-modelling. The shortfall expected (net of mitigations but before taking into account the high

risk reserve) is currently £679k. This includes a combination of recurrent and non-recurrent slippage. The summary at month 2 is:

1. Control Total including Corporate Benchmarking – Plan and CIP partially QIA’d but expect in-year CIP target to be achieved.

2. Roster savings – Paper agreed by Executive Management Team and QIA now scheduled for July.

3. Mental Health Acute & Community – Service model approved at QIA. Inpatient occupancy plan now scheduled for July QIA.

4. Trust Procurement – Plan received for forward work plan and now being reviewed. Initial CIP challenge assessed to be 50%.

5. Adult Physical Health - Non recurrent funding put forward to mitigate and now on track for 17/18; recurrent actions underway.

6. Estates and Facilities - Plans partially approved at QIA and planning underway at a number of key sites.

7. Specialist Inpatients, Dental, Admin – Plan partially QIA’d but work still underway to review agency CIP.

8. Children’s Services – Both Bradford and Wakefield on track.

9. Transactional (Corporate) Schemes – All on track.

The purpose of the Directors Business & Transformation Programme is to ensure effective project governance, delivery, monitor and

approve Project Initiation and risks, issues and exceptions and ensure a consistent approach to Quality Impact Assessments (QIA).

Feb-17 Mar-17 Apr-17 May-17

All Service AreasNumber of

Schemes Value (£,000)

QIA Yes 77 5,802£

QIA No* 25 2,161£

Total Schemes 102 7,963£

Green 89

Amber 2

Red 10

Total Scemes 101

* note - "QIA No" icludes those with partial QIA

All Service Areas Financial status and Quality Impact Assessment (QIA) Completed

RAG Status

77

25

Num

be

£5,802

£2,161

Project Value (£,000)

QIA Yes

QIA No*

89

210

Financial RAG Status

Green

Amber

Red

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led


Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Finance Key Measures

Plan ActualVariance

(Adv)/FavRAG Plan Actual

Variance

(Adv)/FavRAG

Net Surplus/(Deficit) (665) 22 687 1,578 1,578 0

Technical Adjustments 0 0 0 0 0 0

Performance against the Control Total (665) 22 687 1,578 1,578 0

CIPs (before High Risk Reserve) 805 1,115 310 7,973 7,294 (679)

Capital Expenditure 399 245 154 3,528 3,528 0

Cash Balance 11,120 14,575 3,455 11,485 11,485 0

Use of Resources 3 1 2 1 1 0

Forecast Outturn

£000's

Year to Date


Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

(2,000)

(1,500)

(1,000)

(500)

0

500

1,000

1,500

2,000

(800)

(600)

(400)

(200)

0

200

400

600

800

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

Ye

ar

to D

ate

Pla

n a

& A

ctu

al -

£0

00

's

In M

onth

Pla

n &

Actu

al -

£0

00

's

Control Total Performance

In Month Plan In Month Actual YTD Plan YTD Actual

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

0

100

200

300

400

500

600

700

800

900

1,000


YT

D P

lan &

A

ctu

al -

£0

00

's

In M

onth

Pla

n &

Actu

al -

£0

00

's

Cost Improvement Programmes

In Month Plan In Month Actual YTD Actual YTD Plan

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

0

100

200

300

400

500

600


YT

D P

lan &

Actu

al -

£0

00

's

In M

onth

Pla

n &

Actu

al -

£0

00

's

Capital Expenditure

In Month Plan In Month Actual YTD Actual YTD Plan

8,000

9,000

10,000

11,000

12,000

13,000

14,000

15,000


In Month Cash Balances

Plan Actual 2016/17

Workforce KPIs - Agency Expenditure Cap

(Adv)/Fav

Variance

from Cap

£000's

YTD

RAG

Change in

month

Total Agency Expenditure Cap in Month 368 Improvement

Medical Agency Expenditure Cap in Month 35 Deterioration

Workforce KPIs - Agency Expenditure Cap

(Adv)/Fav

Variance

from Cap

%

YTD

RAG

Change in

month

Qualified Nursing Expenditure Cap - In Month 1.94% Improvement

Qualified Nursing Expenditure Cap - YTD 1.56% Improvement

Workforce KPIs - Price & Wage Cap BreachesNo. of

Shifts

YTD

RAG

Change in

month

Price Cap Breaches in Month - Medical 182 Increase

Wage Cap Breaches in Month - Medical 198 Increase

Price Cap Breaches in Month - Non Medical 0 Same

Wage Cap Breaches in Month - Non Medical 0 Same

Workforce KPIs - Average cost per WTE £000'sYTD

RAG

Change in

month

Average cost per WTE 40 Increase


Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Trust CIP Exceptions and Substitutions

Plan ActualVariance

(Adv)/FavPlan Actual

Variance

(Adv)/Fav

Green 708 708 0 5,800 5,800 0

Amber 2 0 (2) 12 0 (12)

Red/Blue 95 59 (36) 2,161 761 (1,400)

Mitigations 348 348 0 733 733

Total CIPs 805 1,115 310 7,973 7,294 (679)

High Risk Reserves (83) 0 83 (500) 0 500

Total CIPs net of Reserves 722 1,115 393 7,473 7,294 (179)

Year to Date - £000's Forecast Outturn - £000's

QIA RAG Status

Reason for Variance & Mitigating Actions

• Note – of the £2,161k planned Red/Blue CIP schemes, £1,476k (15 schemes) have gone to QIA in June and July.

During July the Trust is reviewing:-

1. Human Resources - £150k forecast risk

2. Procurement (too early to fully risk assess) - £225k initial risk assessment (50%)

3. Further progress on Corporate Benchmarking and potential in-year and recurrent opportunities

The projected shortfall includes the following, with work now underway to review non-recurrent / recurrent mitigations:-

1. Projected inpatient occupancy reductions (non recurrent) - £84k

2. Projected in-year roster saving shortfall (recurrent) subject to 13.7.17 QIA - £274k


Informatics

Activity Number Activities Quarterly Target

(Capacity) Quarter 4 2016/17

Quarter 1 2017/18

to date (May 2017)

1 – Clinical Systems Total systems training (number of staff trained) 436 397

2 – Service Desk Number of tickets logged by Service Desk for all teams 7,785 6,414

3 – Service Desk Number of tickets resolved by all Informatics teams 10,830 7,301

4 – Service Desk % of customer feedback falling in the ‘excellent’ and

‘good’ category for all tickets via service desk Data collection

commenced May

2017

42 out of 54

78% - May 2017

5 – Service Desk Did we complete the work you requested? – Yes result

%

50 out of 55

91% - May 2017

6 - Service Desk Total number of computer devices Total: 3,149 May 2017

(1,048 Desktops & 2,101 Laptops)

7 – Information Governance

& Records Management

Number of requests for personal information received

(police/courts requesting personal patient related

information) 104 71

8 – Information Governance

& Records Management

Number of requests for information received under the

Freedom of Information Act 117 41

9 – Projects * Total number of agreed Informatics Projects that are

‘On Track’ or ‘Completed’ 37 out of 38* 28 out of 29*

10 – Cyber Security**

11 - Telephony

12 – Response rates

13 - Workforce

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

This is the first presentation to Board of key Informatics activity indicators. Oversight and scrutiny of Informatics performance and activity is

supported by various reports to Informatics Board and key performance indicator dashboards to both the Information Governance Group and

the Informatics Steering Group. Comments are welcomed on which indicators should be included to support Board oversight.

* 9 – Projects: Craven Podiatry Transfer - Amber: Due to short rapid delivery deadline. Service has WorkSmart solution in place now, but

requires more robust connectivity given the rural Craven locality. Capital Planning Investment Group has approved related capital resources.

** 10 – Cyber Security: A review of Trust cyber security arrangements will identify key performance indicators so this section remains in

development.


Hotel Services – Cleanliness audits

Food Services – Mealtime Assessments

Estate Maintenance – Response Rates

Patient Transport, Removal & Pest Control – Response Rates

Cleanliness audits within in-patient sites are undertaken on a monthly

basis. All cleanliness audits achieved the performance target of >90%.

The chart shows target achievement of lower priorities although currently

below target achievement for higher priority tasks. The implementation of

response targets is a recent innovation within Estate Maintenance and

team meetings have a continued focus on their achievement, particularly

higher priority tasks. Recent issues have impacted upon performance

including a data-flow problem within Concept Evolution and the cyber-

attack. Estate Maintenance are involved in ward huddles and ward

environment meetings to more quickly identify and remedy potential

response issues within the wards.

All tasks are achieving performance target for response rates due to

proactive time sheet management within Concept Evolution.

Maplebeck did not achieve the performance target as on the date of the

assessment one service user did not order their meal with their

housekeeper. They were therefore brought the main menu choice for that

mealtime with which they were not happy. This impacted the mealtime

assessment score for that month.

0%

50%

100%

PTS Pest Control Removals

Operational Services


93% 85%

75%

90% 85%

80% 85%

0%

20%

40%

60%

80%

100%

4 hrs 12hrs 1 WD % 3 WD % 1 WK % 2 WK % 4+ WK %

Key:

Target performance Achieving target

< 25% off target > 25% off target

Response rate: the % of reactive tasks completed by the deadline set

and agreed within Concept Evolution

0%

20%

40%

60%

80%

100%

Mealtime Assessments scores , May 2017

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Estates and Facilities Service Performance for Operational Services – In-Patient Sites


Hotel Services – Cleanliness audits Estate Maintenance – Response Rates

Patient Transport, Removal & Pest Control – Response Rates

Cleanliness audits within BDCFT community properties are undertaken

on a quarterly basis. Cleaning services are provided by NHS Property

Services (NHSPS). Every 6 months BDCFT undertakes either an

Infection Prevention Audit or a Cleanliness audit to ensure cleaning

standards are being achieved. BDCFT minimum performance pass is

set at 90% (National Specifications for Cleanliness [NSC] suggest trusts

set their own targets for cleanliness). The ‘indicative aim’ defined in NSC

for Significant risk areas is set at 85%. NHSPS have been alerted to the

shortfall in standard and rectification actions have been programmed.

Weekly meetings are diarised between Facilities Service Desk and

Estate Maintenance to ensure quality assurance checks are completed

relating to task performance.

Recent issues have impacted upon reported levels of performance

including a data-flow problem within Concept Evolution and the recent

cyber-attack.

0%

20%

40%

60%

80%

100%

PTS Pest Control Removals


100%

86% 92%

73% 75%

62%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4 hrs 12hrs 1 WD % 3 WD % 1 WK % 2 WK % 4+ WK %

Key:

Target performance Achieving target

< 25% off target > 25% off target

Response rate: the % of tasks completed by the deadline set

and agreed within Concept Evolution

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Estates and Facilities Service Performance for Operational Services – Community Properties


Health and Safety – reporting Fire Safety – Fire Incidents

105 88 102 71 98

55 19 20

444

137

0

100

200

300

400

500

600

No. RIDDOR reportable incidents

No. H&S Incidents withsmoking as a causal factor

Total no. H&S Incidents(without smoking related incidents)

3 5 4

2

6

33

29 29

26

33

9 10 11

2

10

0

5

10

15

20

25

30

35

No. Needlestick Injuries

No. Slips, Trips & Falls

No. reported Near Misses

The tally system for reporting smoking related incidents was reintroduced in

April 2017 on a 3 month basis, with ongoing review via Trust Smoke-Free

Group. This accounts for the increase in health and safety incidents with

smoking as a causal factor. The Corporate Manslaughter & Corporate

Homicide Task & Finish Group are monitoring via Trust Action Plan the

implementation of a reviewed Restricted Items Protocol to include cigarettes.

Slips, trips and falls incidents have increased from April 2017 to May 2017

although remain 49.5% lower than in May 2016. The majority of these

incidents are within ward areas and involve clinical rather than environmental

factors.

Date Location Cause

12.3.1

7

Step Forward Toaster was left unattended by

housekeeper

25.4.1

7

Westbourne

Green

Member of public doused themselves

in petrol & threatened to ignite

himself with lighter

26.4.1

7 Ashbrook

Service user set fire to bed. Staff

extinguished, fire service attended

26.4.1

7 Clover Steam from shower

1.5.17 Heather Steam from shower bed 2 (1am)

1.5.17 Heather Steam from shower bed 2 (4am)

2.5.17 Heather Steam from shower

6.5.17 Fern Service user burnt edges of

pillowcase

10.5.1

7 Ashbrook

Service user hit manual call point

repeatedly with shampoo bottle

There have been 7 reported incidents related to fire, such as fire

alarm activations from 1 March to 31 May 2017. There have been

2 fire incidents in this period.

32 fire risk assessments have been completed between 1 March

and 31 May 2017. Assessments are carried out as per the

departmental fire safety schedule. There are no overdue risk

assessments and currently there are zero outstanding actions that

require escalation.

Fire Safety – Fire Risk Assessments

Lessons learned following incidents are shared with teams

involved in the incident to support service improvement and

continued safety of staff and service users.

Summary NHS

Improvement Quality

Business Unit

Change Programme

Finance Enablers

Well Led

Estates and Facilities: Health and Safety - Advisory Services

Board Integrated Performance Report 29 June 2017 May 2017 Data · Board Integrated Performance...

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