Trust Board 30 January 2014 Public Section Paper ...€¦ · Public Section Paper Integrated...

Trust Board 30th January 2014

Public Section Paper

Integrated Quality & Performance Report

Presented for: Information

Presented by: Dr Mark Smith, Chief Operating Officer

Author: Information Department

Corporate objective: To achieve the best possible clinical outcomes for every patient, every time. To be the hospital of choice for patients and staff. To be a consistently high-performing and influential healthcare provider. To achieve academic excellence and expand the boundaries of healthcare.

Key points

This report is presented to ensure the Board remains up-to-date

with the Trust‟s performance in light of national requirements and

local developments.

Information

Agenda Item 24.1

THE LEEDS TEACHING HOSPITALS NHS TRUST

TRUST BOARD MEETING – JANUARY 2014

INTEGRATED QUALITY &

PERFORMANCE REPORT

PERIOD – DECEMBER 2013

Contents

Overview of Performance ............................................................................................................. 1

Summary ...................................................................................................................................... 2

AF Quality and Governance Dashboard ............................................................................ 3

Shadow Monitor Risk Assessment Framework ................................................................. 5

Narrative ...................................................................................................................................... 6

Referral To Treatment (RTT) ............................................................................................. 6

RTT Clearance Times ....................................................................................................... 8

Diagnostic Waits ................................................................................................................ 9

Cancelled Operations ...................................................................................................... 10

A&E Waiting Times (4 Hours) .......................................................................................... 11

A&E Measures ................................................................................................................ 12

Ambulance Handovers .................................................................................................... 14

Cancer 62 Days ............................................................................................................... 15

Cancer 31 Days ............................................................................................................... 17

Cancer 2 Week Wait ........................................................................................................ 18

Stroke Care ..................................................................................................................... 19

30 Day Emergency Readmissions................................................................................... 20

Outpatient Activity - New and Review.............................................................................. 21

Inpatient Activity - Elective and Non-elective ................................................................... 22

Length of Stay ................................................................................................................. 23

Flu Vaccinations .............................................................................................................. 24

Incidence of MRSA .......................................................................................................... 25

MRSA Screening ............................................................................................................. 26

Incidence of CDI .............................................................................................................. 27

Summary Hospital Mortality Index (SHMI) ....................................................................... 28

Hospital Standardised Mortality Rate (HSMR) ................................................................ 29

VTE Risk Assessment ..................................................................................................... 30

Never Events ................................................................................................................... 31

Harm Free Care............................................................................................................... 32

Pressure Ulcers ............................................................................................................... 33

Complaints ...................................................................................................................... 34

Patient Satisfaction – Friends & Family ........................................................................... 35

Outpatient Measures ....................................................................................................... 36

Choose and Book (CAB) - ASIs ...................................................................................... 38

CAB - Utilisation .............................................................................................................. 39

Workforce ........................................................................................................................ 40

Finance ...................................................................................................................................... 41

AF Finance Dashboard .................................................................................................... 41

Finance - In-Year Financial Delivery Indicators ............................................................... 42

Finance - Progress Towards Foundation Trust Status .................................................... 42

Internal Indicators Dashboard .................................................................................................... 43

Appendix 1 - Updates................................................................................................................. 45

Appendix 2 - Peer Groups .......................................................................................................... 46

Appendix 3 - Glossary ................................................................................................................ 47

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Overview of Performance

Overview:

The IQPR has been developed to include all measures contained within the NHS Trust Development Authority‟s (TDA) Accountability Framework (AF) and Monitor‟s Risk Assessment Framework (RAF) Service Performance Score. The latest performance against national and local CQUIN (Commissioning for Quality & Innovation) requirements, local contract quality requirements and key internal measures are also reported where appropriate.

In time, Trusts will be rated monthly against the 3 domains within the AF‟s Oversight Model (Quality & Governance, Finance and Delivering Sustainability). The methodology for rating overall performance as well as the detail behind the definition and thresholds for acceptable performance for a number of these metrics has yet to be confirmed by the TDA. The TDA has, however, intimated it will soon begin publishing the Oversight Model.

Access:

Trust level performance against the target for non-admitted patients treated within 18 weeks of referral was restored in December, having dipped below standard the previous month. The recovery trajectory for patients admitted to hospital within 18 weeks projects through to January 2014.

Capacity constraints and late referrals from other providers continue to impact on the Trust‟s ability to maintain the 62 day standard for urgent GP referral to cancer treatment. Performance in November was below standard for three of the cancer standards: 2 week wait for suspected cancer, 2 week wait for breast symptoms and 62 days from urgent GP referral to cancer treatment.

Outcomes:

The Trust has not had an MRSA case since September 2013. In addition, Trust level performance against the requirement to screen 95% of eligible patients for MRSA was restored in November and December, having fallen below standard in the previous two months.

There were 13 cases of C. difficile Infections (CDIs) at the Trust in December. Year-to-December there were 114 CDIs against the goal of no more than 101 for the full year.

The Trust achieved the „Safety Thermometer‟ (snapshot) measure in December for the sixth consecutive month.

Quality Governance:

The response rate for patients completing the Friends and Family Test remains above target at 21.2% in December. However, there are considerable differences between responses from inpatients and maternity patients (34.1% and 36.9% respectively) and A&E patients (5.7%).

The Friends and Family Test was rolled out in text message format to A&E attenders on the 1st January in an effort to address the poor response rate in this area.

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Indicator Group Group Description

National Indicators / Quality Requirements Indicators are included from the AF, which is used by the TDA to monitor the performance of non-Foundation Trusts (FTs), as well as Monitor‟s RAF Service Performance Score (this will be in shadow form until the Trust becomes an FT). These are national targets Trusts must achieve and incorporate indicators measuring access, quality, outcomes and finance. These include the MRSA and C. difficile (CDI) objective, A&E waiting times, referral to treatment (RTT) and cancer waits, patient experience and risk assessments of venous thromboembolism (VTE).

CQUIN Indicators

National and local CQUINs indicators are incorporated; these include indicators around the Safety Thermometer, dementia and patient discharge. The CQUIN summary dashboard is included on a quarterly basis.

Local Contractual Indicators Data indicators that form part of the Trust‟s Contract agreement with the Clinical Commissioning Groups (CCG).

Internal Indicators Internal indicators are metrics that are key to the Trust‟s success, that have not been incorporated previously. These include further information around RTT on clearance times, stroke care, inpatient and outpatient activity, and research and innovation (R&I) indicators.

Leeds Teaching Hospitals Trust (LTHT) Summary

This report covers national performance measures from the Trust Development Authority‟s (TDA) Accountability Framework (AF) and Monitor‟s Service Performance Score (part of the RAF). Relevant CQUIN indicators which are not already incorporated within the National Indicators are also included on a quarterly basis, as well as selected local contractual indicators and additional internal metrics. Updates from regulators are included in Appendix 1. (Please note this report is a work in progress, and there is not therefore a section for all indicators).

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AF Quality and Governance Dashboard

Category Indicator Oct-13 Nov-13 Dec-13 YTD

Referral to treatment within 18 weeks - admitted > 90% 86.0% 85.0% 87.3% 85.0%

Referral to treatment within 18 weeks - non-admitted > 95% 96.6% 94.4% 95.4% 95.1%

Referral to treatment within 18 weeks - incomplete > 92% 94.9% 94.4% 94.1% n/app

Referral to treatment within 18 weeks - over 52 week waiters (incomplete waits) 0 0 0 n/app

Diagnostic waits within 6 weeks > 99% 99.5% 99.5% 99.6% n/app

Last minute cancelled operations not re-booked within 28 days

Urgent operations cancelled for the second time 0 0Reported a month

in arrears0

A&E 4 hour > 95% 97.8% 97.2% 97.1% 96.6%

Cancer 62 days - GP referral > 85% 85.6% 77.9% 84.3%

Cancer 62 days - referral from screening service > 90% 91.8% 96.7% 95.9%

Cancer 31 days - first treatment > 96% 98.0% 97.7% 97.4%

Cancer 31 days - second or subsequent surgery > 94% 98.3% 97.8% 97.4%

Cancer 31 days - second or subsequent drug treatment > 98% 100.0% 100.0% 100.0%

Cancer 31 days - second or subsequent radiotherapy > 94% 99.6% 95.1% 98.9%

Cancer 2 week wait - suspected cancer > 93% 92.6% 92.3% 93.9%

Cancer 2 week wait - breast symptoms > 93% 95.0% 86.6% 91.9%

30 day emergency readmissions (Elective & non-elective) < 10.9% 6.6% 6.5%Reported a month

in arrears6.8%

Incidence of MRSA 0 0 0 5YTD: < 79

13/14: < 101

Medication errors causing serious harm - Number 0 0Reported a month

in arrears2

Harm free care (pressure sores, falls, CUTI and VTE) - Safety Thermometer (Snapshot) > 92% 92.5% 92.3% 93.2% n/app

Serious incidents - Number 3 3 4 26

Serious incidents - Rate per 1,000 bed days < 1.23 0.06 0.06 0.08 0.06

Never events 0 1 0 5

E. Coli cases 46 45 48 435

E. Coli cases - Rate per 100,000 bed days 3 < 94.9 87.2 87.7 93.4 94.0

MSSA cases - Rate per 100,000 bed days 3 < 9.02 3.8 17.5 1.9 9.9

Maternal deaths 0 0Reported a month

in arrears1

Summary Hospital-level Mortality Indicator (SHMI)

Hospital Standardised Mortality Ratio (HSMR) (2012/13 rebased)

Venous thromboembolism (VTE) risk assessment > 95% 96.2% 95.5%Reported a month

in arrears95.7%

Q1 > 15%

By Q4 > 20%

Nurse: bed ratio 5 1.90 : 1 1.94 : 1 - n/app

% of nurses registered nurses > 60% 69.6% 70.9% 71.1% -

Mixed sex accommodation 0 0 0 0

Apr 12-Mar 13: 92.8

National Indicators / Quality Requirements - AF Quality and Governance

TDA Thresholds

Acce

ss M

etr

ics

0

0

Reported a month

in arrears

18.2%

Ou

tco

me

s M

etr

ics

National Ave: 100

0

Incidence of C. Difficile

0

0

13/14: < 1

13 11414 14

n/app

n/app

20.8% 19.6%

National Ave: 100

Apr 12-Mar 13: 94 (Published Oct 13)

0.1 : 1 to 4.4 : 1

Q2: 7.4%0%

0

Qu

ality

Go

ve

rna

nce

Ind

ica

tors Patient satisfaction (friends and family) - Response rate¹ 20.6%

6

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Indicators Awaiting Clarification:

Category Indicator Oct-13 Nov-13 Dec-13 YTD

Warning notice None None None None

Civil and/or criminal action None None None None

Admissions of fullterm babies to neonatal care 2.2% 2.3% 2.7% 3.2%

YTD: < 42

13/14: < 60

C-section rates (Emergency and Elective LSCS) 18.1% 20.6%Reported a month

in arrears20.2%

Open CAS Alerts (Exceeding the deadline for action) 4 7 5 6 n/app

WHO surgical checklist compliance 95.5% 97.5% 97.6% n/app

3rd

Pa

rty

Re

po

rts

Any relevant report including safeguarding alerts, serious case reviews, ad hoc reports from MPs,

GMS, Ombudsman, Commissioners, litigation etc.

Patient satisfaction (friends and family) - Net Promoter Score (DH) ¹ 67.5 70.3 70.0 70.0

Patient and carer voice

Board turnover (12 months rolling average) 50.2% 50.5% 50.5% n/app

Sickness/absence rate (12 months rolling average) 4.3% 4.2% 4.2% n/app

Proportion temporary staff – clinical and non-clinical 8.3% 7.5% 7.4% n/app

Staff turnover (12 months rolling average) 10.4% 10.6% 10.8% n/app

Complaints - Rate per 10,000 occupied bed days 3 15.7 15.4 12.1 17.3

% staff appraised 47.7% 44.0% 49.9% n/app

1

2 Trajectory agreed with Clinical Commissioning Group (CCG).3

4

5

6

7

National Indicators / Quality Requirements - AF Quality and Governance

TDA Thresholds

CQ

C

Co

nce

rns

TBC

TBC

Meticillin Sensitive Staphylococcus Aureus (MSSA) cases

n/app

469 1

These figures show the number of full time equivalent (FTE) registered nurses (including midwives) as a proportion of all FTE nurses employed by the Trust at the end of each month.

TBC

For adult inpatients, A&E attenders and, from October 13, Maternity services.

Rate based on internal monthly overnight bed occupancy data.

Threshold not yet published by the TDA (although anticipated to be 0).

Figures shown for are based on snapshots of number of registered nurses (FTE) (excluding midwives) against the average number of available overnight General & Acute beds as reported in the

latest KH03 quarterly return.

n/app

TBC

Qu

ality

Go

ve

rna

nce

Ind

ica

tors

TBC

TBC

TBC

TBC

TBC

TBC

TBC

TBC

TBC

2

TBC

Percentage of staff who have an in date appraisal at month end.

Ou

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s M

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2

7

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Shadow Monitor Risk Assessment Framework

Qrt 1 Qrt 2 Qrt 3

A&E Waiting Times (4 hours) - LTHT (including Wharfedale) *1 94.6% 97.9% 97.4%

Patients treated within 18 weeks - admitted (%) *2 84.5% 84.4% 86.1%

Patients treated within 18 weeks - non-admitted (%) *2 95.0% 94.7% 95.5%

Patients awaiting treatment on the 18 weeks pathway - incomplete (%) *2 94.4% 94.9% 94.1%

Cancer 2 week wait - suspected cancer 95.9% 93.0% 92.5%

Cancer 2 week wait - breast symptoms (cancer not initially suspected) 94.4% 89.9% 90.9%

Cancer 31 Day Waits - first definitive treatment 97.8% 96.7% 97.9%

Cancer 31 Day Waits - subsequent surgery treatment 96.6% 97.9% 98.0%

Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment 99.8% 100% 100%

Cancer 31 Day Waits - subsequent radiotherapy treatment course 99.0% 99.6% 97.7%

Cancer 62 Day Waits - GP/Dentist referrals 85.1% 85.2% 81.8%

Cancer 62 Day Waits - cancer screening service referrals 98.0% 95.3% 94.3%

Q1 < 25 *3

51

76

Full year < 101

Compliance with requirements regarding access to healthcare for people with

learning disabilities (6 criteria)

Compliant on all 6

criteria

Compliant on all 6

criteria

Compliant on all 6

criteria

3.0 3.0 4.0 4.0 4.0 4.0 4.0 4.0

*1

*2

*3

Weighted

score

A&E: 1 Jul to 29 Sep-13

CDI: Apr to Sep-13

RTT Incomplete:

As at 30 Sep-13

Other: Jul to Sep-13

0.0

1.0

1.0

0.0

1.0

0.0

0.0

Projected

Weighted

score

Qrt 4

95%

Weighted

score

A&E: 30 Sep to 29 Dec-13

CDI: Apr to Dec-13

RTT Incomplete:

As at 31 Dec-13

Cancer: Oct to Nov-13

Other: Oct to Dec-13

1.0 0.0

Performance Indicator

National Indicators / Quality Requirements - Shadow Monitor Risk Assessment Framework (RAF) - Service Performance ScoreA

cce

ss M

etr

ics

92% 0.0

0.0

1.0

0.0

0.0

1.0

0.0

0.0

1.0

0.0

1.0

0.0

0.0

0.0

1.0

1.0

0.0

1.0

0.0

0.0

4.0

1.0

3.0

0.01.0

114 1.0 1.073

0.0

1.0

0.0

4.0

94%

90%1.0

0.0

Green

Risk Rating

93%1.0

93%

96%

Self certification

85%

94%

98%

0.0

General Notes

Failure to achieve any of the indicators with a weighting of 1 for three or more consecutive quarters may result in Monitor applying a governance concern and escalating the Trust for consideration as to whether it is in significant breach of its

Foundation Trust authorisation.

The CDI threshold used by Monitor is the greater of either: (a) a simple proportioning of the annual threshold (i.e. 25% of annual threshold at Q1, 50% at Q2 and 75% at Q3) or (b) 12 CDI cases.

A&E performance is derived from the weekly SITREP return figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters. Failure to meet this standard for any two quarters during the previous 12

month period and failing the indicator again during the subsequent 9 month period or full year may trigger a governance concern.

Whilst the RAF monitors performance quarterly, any monthly failure of the RTT standards must be reported to Monitor and represents a failure of that indicator for the quarter.

Weighted

score

2013/14

Thresholds

Red

0.095%

90%

Weighting

A&E: 1 Apr to 30 Jun-13

RTT Incomplete:

As at 30 Jun-13

Other: Apr to Jun-13

1.0

0.0

4.0

1.0

1.0

1.0

1.0

Ou

tco

me

s

Ma

tric

s

Rating Criteria

Service Performance Score

< 4.0

> 4.0

CDI 1.0 41 1.0YTD (@ Q2) <

YTD (@ Q3) <

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Narrative

Referral To Treatment (RTT) Admitted Non-Admitted Incomplete Admitted Non-Admitted

> 90% > 95% > 92% > 90% > 95%

99.1% 99.9% 100.0% 98.5% 99.4%

97.6% 96.4% 98.1% 85.4% 95.0%

91.4% 84.5% 84.8% 59.8% 94.0%

79.3% 95.6% 97.2% 76.2% 94.1%

0.0% 100.0% 100.0% 100.0% 100.0%

95.3% 91.1% 81.7% 94.7% 94.5%

0.0% 100.0% 100.0% 100.0% 100.0%

84.9% 97.1% 94.7% 86.4% 95.0%

92.5% 98.2% 99.5% 89.6% 98.8%

100.0% 99.0% 100.0% 98.4% 98.0%

81.8% 92.5% 98.1% 66.8% 83.0%

98.5% 98.1% 99.6% 96.0% 96.1%

94.7% 95.3% 97.7% 96.2% 96.2%

81.0% 78.8% 79.2% 82.7% 84.1%

100.0% 99.2% 100.0% 100.0% 99.9%

100.0% 97.5% 99.4% 100.0% 99.6%

89.6% 81.2% 91.8% 84.2% 85.0%

85.6% 97.0% 94.8% 79.7% 91.7%

74.1% 96.1% 93.9% 72.6% 94.1%

87.3% 95.4% 94.1% 85.0% 95.1%Trust

Target

Oral Surgery

Other Specialties

Plastic Surgery

Respiratory Medicine

Rheumatology

Trauma & Orthopaedic

Gastroenterology

General Medicine

Gynaecology

Neurology

Neurosurgery

Ophthalmology

General Surgery

Urology

Cardiology

Cardiothoracic Surgery

Dermatology

Ear Nose & Throat

Elderly Medicine

Dec-13RTT Reporting Specialties

YTD

National Indicator / Quality Requirement

Aims:

Ensure at least 90% of admitted patients are treated within 18 weeks of referral.

Ensure at least 95% of non-admitted patients are treated within 18 weeks of referral.

Ensure a minimum of 92% of patients on an incomplete pathway have been waiting no more than 18 weeks.

Ensure no patients wait over 52 weeks from referral to treatment. Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.

Appendix 2 lists the peer Trusts included in the benchmarking graphs. Four additional providers have been added to the Trust‟s RTT peer group.

Actions:

Admitted: The Trust remains non-compliant with the admitted RTT target due to the focus on over 18 week admitted backlog clearance, as agreed with the TDA. Although the Trust has slipped against this agreed trajectory, recovery plans have been put in place to ensure the trsut gets back on to a sustainable trajectory. Further modelling work is underway to to confirm a new trajectory.Non-admitted: The non-admitted target was failed in November due to the cancellation of a number of Dermatology clinics to accommodate registrar training. Performance is now back on to the expected trajectory.

70%

75%

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85%

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95%

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% o

f pa

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ting

targ

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% of Admitted Patients Seen within 18 Weeks

% Admitted Achieve Fail Trajectory

65%

70%

75%

80%

85%

90%

95%

100%

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Trusts

% of Admitted Patients Seen Within 18 Weeks - April to November 2013

LTHT Peers Other Trusts Target

Source: NHS England

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Referral To Treatment (RTT) (Continued)

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95%

100%

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% of Non-Admitted Patients Seen within 18 weeks

% Non-Admitted Achieve Fail

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% Incomplete Achieve Fail

% of Patients on an Incomplete Pathway Waiting no more than 18 Weeks

0

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Number of Patients Waiting Over 52 Weeks - Incomplete(As at month end)

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Trusts


Source: NHS England

% of Non-Admitted Patients Seen Within 18 Weeks - April to November 2013

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% of Patients on an Incomplete Pathway Waiting no More Than 18 Weeks - November 2013

Source: NHS England

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RTT Clearance Times Total Clearance

Times

>18 wk

Clearance times

Incompletes

>18wks

8 Wks 0.5 Wks -

16.6 0.0 0.0%

8.2 0.2 3.0%

10.3 1.0 9.6%

6.8 0.6 9.4%

- - -

24.1 2.1 8.9%

- - 0.0%

10.1 1.0 10.1%

9.8 0.3 2.9%

4.3 0.0 0.0%

7.4 0.7 9.3%

7.4 0.1 1.0%

8.3 0.7 8.2%

7.8 2.6 33.2%

1.2 0.0 0.0%

9.6 0.0 0.0%

10.8 0.8 7.2%

15.2 1.4 9.0%

11.0 1.7 15.5%

10.2 1.0 9.9%

General Medicine

Target

General Surgery

Cardiology

Cardiothoracic Surgery

Dermatology

Ear Nose & Throat

Elderly Medicine

Gastroenterology

RTT Reporting Specialties

Dec-13

Trust

Gynaecology

Neurology

Neurosurgery

Ophthalmology

Oral Surgery

Other Specialties

Plastic Surgery


Rheumatology

Trauma & Orthopaedic Surgery

Urology

Internal Indicator

Aims:

RTT clearance times aim to indicate how long, in weeks, it would take to clear current patients on incomplete pathways assuming that no new patients are added to the list. Although this is not a national target, a total clearance time of 8 weeks and an over 18 weeks clearance time of 0.5 weeks is deemed to indicate a sustainable waiting list according to the Department of Health (DH).

Reduce the number of patients waiting over 18 weeks at month-end (incomplete admitted) to 714 by the end of March 2014.

Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.

Actions:

Total: Total clearance times for RTT have been reduced from 12.3 weeks in September to 10.2 weeks in December, but are not yet at the 8 week target. Recovery plans are in place with teams to accelerate the RTT backlog removal and waiting times to support delivery of this internal standard. Over 18 weeks: The Trust continues to clear the patient backlog of those waiting over 18 weeks (917 at the end of December against a trajectory of 986). Slippage against agreed trajectories has been reviewed and formal recovery plans put in place in key areas. There were 11 failing specialties in November (not 8 as planned); however, this has been reduced to 7 for December.

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Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Cle

ara

nce

Tim

es

Referral to Treatment - Clearance Times

Total Clearance Times >18 wk Clearance Times

Total Clearance Times Target >18 wk Clearance Times Target

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

Ma

r-14

No

. o

f P

atie

nts

Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted

No. of Patients Trajectory

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51

No

. o

f P

atie

nts

Weeks Waiting

Number of Patients Waiting on an Incomplete Pathway - By Timeband December 2013 (As at month end)

of 47

Diagnostic Waits Number of

Patients on

Waiting List

Number

Waiting over 6

Weeks

% Waiting

Less Than 6

Weeks

Target - - 99%

Audiology - Audiology Assessments 5 1 80.0%

Barium Enema 2 0 100.0%

Cardiology - echocardiography 761 0 100.0%

Cardiology - electrophysiology 2 0 100.0%

Colonoscopy 557 18 96.8%

Computed Tomography 1,131 0 100.0%

Cystoscopy 297 0 100.0%

DEXA Scan 515 0 100.0%

Flexi sigmoidoscopy 301 3 99.0%

Gastroscopy 587 16 97.3%

Magnetic Resonance Imaging 1,944 1 99.9%

Neurophysiology - peripheral neurophysiology 1 0 100.0%

Non-obstetric ultrasound 4,751 0 100.0%

Respiratory physiology - sleep studies 122 0 100.0%

Urodynamics - pressures & flows 0 0 -

Trust 10,976 39 99.6%

Diagnostic Test

Waiting List Position As at 31/12/2013


Aim: Ensure at least 99% of patients wait no more than 6 weeks for a diagnostic test. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.

Appendix 2 lists the peer Trusts included in the benchmarking graphs.

Actions:

Additional in-house capacity available 6th January 2014.

Identify additional capacity from the independent sector.

90%

92%

94%

96%

98%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

% P

atie

nts

Wa

itin

g L

ess T

ha

n 6

we

eks

% Within 6 Weeks Target

Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-End

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000A

pr-

12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

No

. o

f p

atie

nts

wa

itin

g

Diagnostic Waits - Number of Patients Waiting for a Diagnostic Test at Month-End

70%

75%

80%

85%

90%

95%

100%

% P

atie

nts

Wa

itin

g L

ess T

ha

n 6

we

eks

Trusts


Source: NHS England

Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-EndNovember 2013

of 47

Cancelled Operations

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 Q2 Q3 Q4 Q1 Q2

% la

st m

inu

te c

an

ce

lla

tio

ns

% of Last Minute Cancelled Operations for Non-Clinical Reasons

2012/13 2013/14


Internal Indicator

Aims:

Ensure all patients who have operations cancelled at the last minute, for non-clinical reasons are offered another binding date to be treated within a maximum of 28 days.

Ensure no patient has their urgent operation cancelled for a second time. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalties.

Appendix 2 lists the peer Trusts included in the benchmarking graph. Actions:

Focus continues on removing this type of breach, although critical care bed issues have continued into Q3. Processes have been put in place to enhance planning of critical care capacity and timely escalation.

Cancelled operations breaches undergo a root cause analysis investigation at CSU level, with formally reported performance against this measure expected to improve in Q3 against the Q2 position (data currently not yet formally reported).

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 Q2 Q3 Q4 Q1 Q2

% p

atie

nts

bre

ach

ing

targ

et

Patients Cancelled at Last Minute for Non-Clinical Reasons: % Not Treated Within 28 Days

% 28 Day Breaches Achieve Fail

2012/13 2013/14

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% p

atie

nts

bre

ach

ing

targ

et

Trusts

% Patients Not Treated Within 28 Days of Last Minute Cancellation for Non-Clinical Reasons - Q2 2013-14

LTHT Peers Other Trusts

Source: NHS England(NB: 74 Trusts reported no breaches, including 4 peer Trusts)

of 47

A&E Waiting Times (4 Hours) Indicator Site Dec-13 YTD

St James's 6,497 64,097

LGI 8,281 83,612

Wharfedale 1,349 17,206

Trust 16,127 164,915

St James's 250 3,304

LGI 216 2,227

Wharfedale 0 0

Trust 466 5,531

St James's 96.2% 94.8%

LGI 97.4% 97.3%

Wharfedale 100% 100%

Trust 97.1% 96.6%

Target

A&E: Number of Attendances n/app

A&E: Performance > 95%

A&E: Number of Breaches n/app


Aim: Ensure at least 95% of A&E attendances are admitted, transferred or discharged within 4 hours of arrival. Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty.

Appendix 2 lists the peer Trusts included in the benchmarking graph.

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

07/0

4/2

013

14/0

4/2

013

21/0

4/2

013

28/0

4/2

013

05/0

5/2

013

12/0

5/2

013

19/0

5/2

013

26/0

5/2

013

02/0

6/2

013

09/0

6/2

013

16/0

6/2

013

23/0

6/2

013

30/0

6/2

013

07/0

7/2

013

14/0

7/2

013

21/0

7/2

013

28/0

7/2

013

04/0

8/2

013

11/0

8/2

013

18/0

8/2

013

25/0

8/2

013

01/0

9/2

013

08/0

9/2

013

15/0

9/2

013

22/0

9/2

013

29/0

9/2

013

06/1

0/2

013

13/1

0/2

013

20/1

0/2

013

27/1

0/2

013

03/1

1/2

013

10/1

1/2

013

17/1

1/2

013

24/1

1/2

013

01/1

2/2

013

08/1

2/2

013

15/1

2/2

013

22/1

2/2

013

29/1

2/2

013

05/0

1/2

014

12/0

1/2

014

% p

atie

nts

me

etin

g ta

rge

t

Week

A&E - 2012/13 and 2013/14 Performance Against the 4 Hour Access Standard (Including Wharfedale)

Standard 12/13 Performance 13/14 Performance

of 47

A&E Measures Indicator Site Dec-13 YTD

St James's 0 0

LGI 0 0

Trust 0 0

St James's 14 14

LGI 17 17

Trust 16 16

St James's 92 87

LGI 68 71

Trust 78 78

St James's 9.3% 9.9%

LGI 7.2% 6.4%

Trust 8.1% 7.9%

St James's 3.6% 4.2%

LGI 2.6% 2.7%

Trust 3.0% 3.4%

0

Target

A&E: % Unplanned Re-

Attendances Within 7 Days

A&E: % Patients Leaving A&E

Unseen

< 15

< 60

A&E: Time to Assessment

(95th Percentile)

A&E: Time to Treatment

(median)

< 5%

< 5%

A&E: Number of Trolley Waits

Greater Than 12 HoursLocal Contractual Indicator

Internal Indicator

Aims:

Ensure there are no A&E trolley waits greater than 12 hours.

Ensure 95th percentile for time of arrival at A&E to initial full assessment is no more than 15 minutes.

Ensure the median time spent from arrival at A&E to treatment is no more than 60 minutes.

Ensure the percentage of unplanned re-attendances within 7 days of discharge from A&E is no more than 5%.

Ensure percentage of patients who leave A&E without being seen is no more than 5%.

Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty.

0

5

10

15

20

25

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Tim

e to

Asse

ssm

en

t (m

ins)

A&E - Time To Assessment - 95th Percentile

Time To Assessment - 95th Percentile Target

0

20

40

60

80

100

120

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Tim

e to

Tre

atm

en

t (m

ins)

A&E - Time to Treatment - Median

Time To Treatment - Median Target

of 47

A&E Measures (Continued)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

% U

np

lan

ne

d R

ea

tte

nd

an

ce

s

A&E - Unplanned Re-Attendances Within 7 Days

Unplanned Re-Attendances Within 7 days Target

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

% P

atie

nts

Le

avin

g A

&E

Un

se

en

A&E - Patients Leaving A&E Unseen

Patients Leaving A&E Unseen Target

of 47

Ambulance Handovers

Indicator Site Dec-13 YTD

St James's 2,731 21,771

LGI 2,009 14,555

Trust 4,740 36,326

St James's 599 4,140

LGI 181 1,894

Trust 780 6,034

St James's 21 197

LGI 25 206

Trust 46 403

St James's 0 11

LGI 1 14

Trust 1 25

St James's 3,330 25,911

LGI 2,190 16,449

Trust 5,520 42,360

Target

Patient handovers taking longer than 15

minutes between ambulance and A&E0

Patient handovers taking longer than 30

minutes between ambulance and A&E

Patient handovers taking 15 minutes or

less between ambulance and A&E-

Total patient handovers between

ambulance and A&E-

0

0Patient handovers taking longer than 60

minutes between ambulance and A&E

Local Contractual Indicator

Aim: Ensure patient handovers between ambulance and A&E take no longer than 15 minutes. Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient safety, clinical outcomes, timely access to treatment, reputation & financial penalty.

Actions:

YAS are to visit the Trust on the 29th January to review the revised handover

process and agree improvements.

The Trust has requested that YAS review the current process for correcting errors identified in performance data.

0

100

200

300

400

500

600

700

800

900

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

No

. o

f h

an

do

ve

rs

Ambulance Handovers Taking Longer Than 15 Minutes

0

20

40

60

80

100

120

140

160

180

200


No

. o

f h

an

do

ve

rs


0

2

4

6

8

10

12

14

16

18

20


No

. o

f h

an

do

ve

rs


of 47

Cancer 62 Days Tumour Type Nov-13 (%)

Breast 89.5%

Gynaecological 57.9%

Haematological (Excluding Acute Leukaemia) 76.5%

Head & Neck 85.0%

Lower Gastrointestinal 86.2%

Lung 59.5%

Other 75.0%

Skin 87.5%

Upper Gastrointestinal 66.7%

Urological (Excluding Testicular) 89.0%

Trust 77.9%

Cancer 62 Day Waits - Screening Referrals 96.7%

Cancer 62 Day Waits - Consultant Upgrades (local contractual indicator) 50.0%

Cancer 62 Day Waits - GP Referral



Aims:

Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer.

Ensure at least 90% of patients receive their first definitive treatment for cancer within 62 days following referral from an NHS cancer screening service.

Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status (local contractual indicator).

Owner: Chief Operating Officer and Clinical Director of Leeds Cancer Centre. Consequence of failure: Timely access to treatment, patient experience, clinical outcomes, reputation & financial penalty.


The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline. Performance against the 62 day standard for referrals from consultant upgrade are liable to fluctuate due to the small numbers involved.

Actions:

This target was achieved for Q1, Q2 and October, but not for November. Internal capacity issues have arisen in Urology robotic surgery which are being addressed via recovery actions. Late referrals of patients past day 38 on a 62 day pathway from other providers to the Trust continue to worsen. A refreshed transfer process is in place, with improved performance by referring units having been requested via the Chief Operating Officer and commissioners. Due to these on-going internal issues and late referrals, it is unlikely that this target will be achieved for Q3.

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

% p

atie

nts

me

etin

g ta

rge

t

Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals

% Within 62 Days - GP/Dentist Target

40%

60%

80%

100%

Bre

ast

Gynaec

olo

gic

al

Haem

ato

logic

al (

Exc

ludin

gA

cute

Leuka

em

ia)

Head &

Neck

Low

er G

astroin

testin

al

Lung

Oth

er

Ski

n

Upper G

astroin

testin

al

Uro

logic

al (

Exc

ludin

gT

estic

ula

r)

% p

atie

nts

me

etin

g ta

rge

t

Cancer 62 Day Waits for GP Referrals by Tumour Type - Nov 2013

Performance Target

of 47

Cancer 62 Days (Continued)

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

% p

atie

nts

me

etin

g ta

rge

t

62 Day Upgrade 62 Day Upgrade Target

Performance Against the 62 Day Cancer Standard for Referrals from Consultant Upgrade

NB. Due to the small numbers involved, the above data are liable to fluctuate. In November 2013, for instance, 3.5 of just 7 accountable cases were treated within 62 days.

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

% p

atie

nts

me

etin

g ta

rge

t

62 Day Screening 62 Day Screening Target

Performance Against the 62 Day Cancer Standard for Referrals from Screening Service

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% W

ith

in 6

2 D

ays

Trusts

Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals - 2013-14 Q2


Source: NHS England

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% W

ith

in 6

2 D

ays

Trusts

Performance Against the 62 Day Cancer Standard for Referrals from Screening Service - 2013-14 Q2


Source: NHS England

of 47

Cancer 31 Days Tumour Type Nov-13 (%)

Brain/Central Nervous System 100.0%

Breast 98.1%

Children's 100.0%

Gynaecological 93.9%

Haematological 100.0%

Head & Neck 100.0%

Lower Gastrointestinal 100.0%

Lung 94.5%

Sarcoma 100.0%

Skin 92.1%

Upper Gastrointestinal 100.0%

Urological 100.0%

Other 100.0%

Trust 97.7%

Cancer 31 Day Waits - Subsequent Surgery 97.8%

Cancer 31 Day Waits - Subsequent Drug Treatment 100.0%

Cancer 31 Day Waits - Subsequent Radiotherapy 95.1%

Cancer 31 Day Waits - First Definitive Treatment


Aims:

Ensure at least 96% of patients receiving their first definitive treatment are treated within 31 days.

Ensure at least 94% of patients receiving subsequent surgery are treated within 31 days.

Ensure at least 98% of patients receiving a subsequent anti-cancer drug regimen are treated within 31 days.

Ensure at least 94% of patients receiving subsequent radiotherapy are treated within 31 days.


The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

% p

atie

nts

me

etin

g ta

rge

t

% Within 31 Days - First Treatments Target

Performance Against the 31 Day Cancer Standard for First Treatments

80%

85%

90%

95%

100%

Bra

in/C

ent

ral N

erv

ous

Sys

tem

Bre

ast

Child

ren's

Gynaec

olo

gic

al

Haem

ato

logic

al

Head &

Neck

Low

er G

astroin

testin

al

Lung

Sarc

om

a

Ski

n

Upper G

astroin

testin

al

Uro

logic

al

Oth

er

% p

atie

nts

me

etin

g ta

rge

t

Performance Target

Cancer 31 Day Waits for First Definitive Treatment by Tumour Type - Nov 2013

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

% p

atie

nts

me

etin

g ta

rge

t

Drug Drug Target

Surgery Surgery and Radiotherapy Target

Radiotherapy

Performance Against the 31 Day Cancer Standard for Second or Subsequent Treatment

of 47

Cancer 2 Week Wait

Tumour Type Nov-13 (%)

Suspected brain/central nervous system tumours 100.0%

Suspected breast cancer 76.3%

Suspected children's cancer 42.9%

Suspected gynaecological cancer 97.6%

Suspected haematological malignancies (excluding acute leukaemia) 100.0%

Suspected head & neck cancer 95.9%

Suspected lower gastrointestinal cancer 95.8%

Suspected lung cancer 97.4%

Suspected sarcoma 100.0%

Suspected skin cancer 97.0%

Suspected testicular cancer 100.0%

Suspected upper gastrointestinal cancer 96.2%

Suspected urological malignancies (excluding testicular) 93.5%

Trust 92.3%

Cancer 2 Week Waits - Breast Symptoms 86.6%

Cancer 2 Week Waits - Suspected


Aims:

Ensure at least 93% of patients urgently referred with suspected cancer by their GP (GMP or GDP) are seen within 14 days.

Ensure at least 93% of patients urgently referred for evaluation/investigation of “breast symptoms” by a primary or secondary care professional are seen within 14 days.


The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.

Actions:

The 2 week wait target was achieved for Q2 but not September or October, due mainly to breast capacity issues and the large number of cancelled Dermatology clinics in November. Provisional data suggests that performance has been restored for December.

Breast symptoms: The Trust failed this target in Q2, and will fail for November and likely Q3 due to on-going capacity issues in both breast surgical capacity, demand, and supporting radiology slots. Additional surgical capacity is however now in place and the Trust is expecting to achieve this target for January 2014.

80%

85%

90%

95%

100%

Ap

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Ma

y-1

2

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Ju

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Se

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2

Dec-1

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3

Ma

r-13

Ap

r-13

Ma

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Oct-

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% p

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% Within 14 Days - Suspected Cancer Target

Performance Against the 2 Week Cancer Standard for Suspected Cancer

80%

85%

90%

95%

100%

Susp

ecte

d b

rain

/centr

al

nerv

ous

syst

em

tum

ours

Susp

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d b

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cancer

Susp

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d c

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cancer

Susp

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d g

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Susp

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gast

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inal ca

nce

r

Susp

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d lung c

ance

r

Susp

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d s

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Susp

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d s

kin c

ance

r

Susp

ecte

d testic

ula

rca

ncer

Susp

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d u

pper

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inal ca

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test

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r)

% p

atie

nts

me

etin

g ta

rge

t

Cancer 2 Week Waits for Suspected Cancer by Tumour Type - Nov 2013

Performance Target

80%

85%

90%

95%

100%

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% Within 14 Days - Breast Symptoms Target

Performance Against the 2 Week Cancer Standard for Breast Symptoms

of 47

Stroke Care

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10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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Oct-

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Nov-1

3

% w

ith

in 2

4 h

ou

rs

Proportion of High-Risk TIA Patients Investigated and Treated within 24 Hours of First Contact with a Health Professional

Internal Indicator

Aims:

Ensure at least 80% of patients who have had a stroke spend at least 90% of their time in hospital on a stroke unit.

Ensure high-risk TIA patients are investigated and treated within 24 hours of first contact with a health professional.

Owner: Chief Operating Officer and Clinical Director of the Centre for Neurosciences Consequence of failure: Timely access to treatment, patient experience, clinical outcomes & financial penalty.

The stroke care indicator is monitored a month in arrears.

Actions:

Stroke coding is now being regularly reviewed by clinicians in order to reduce the incidence of non-stroke patients being assigned the stroke code.

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Stroke Discharges Spending at Least 90% of Spell on a Stroke Unit

90% of spell on stroke unit Target

of 47

30 Day Emergency Readmissions ElectiveNon-

ElectiveTotal Elective

Non-

ElectiveTotal Elective Non-Elective Total

Acute Medicine 2.7% 18.1% 16.1% 2.1% 19.0% 16.9% 4.0% 14.2% 12.7%

Adult Critical Care - 0.0% 0.0% - 7.1% 7.1% 2.0% 4.4% 2.2%

Adult Theatres & Anaesthesia 0.0% - 0.0% 0.0% - 0.0% 3.6% 8.6% 4.9%

Cardio-Respiratory 3.7% 12.8% 8.8% 3.7% 14.6% 10.0% 5.5% 15.5% 10.4%

Centre for Neurosciences 2.9% 8.8% 4.7% 2.6% 8.4% 4.4% 3.8% 10.7% 6.2%

Chapel Allerton Hospital 2.1% 14.3% 2.3% 1.7% 15.3% 1.9% 2.3% 11.2% 2.4%

Childrens 5.0% 6.7% 6.0% 4.4% 5.7% 5.2% 6.4% 9.7% 7.9%

Digestive Diseases 3.4% 15.5% 6.5% 3.5% 15.7% 7.1% 4.1% 14.5% 7.0%

Head & Neck 2.1% 6.3% 2.6% 2.2% 6.2% 2.7% 2.9% 6.8% 3.6%

Hepatorenal 3.2% 18.2% 7.4% 4.3% 15.7% 7.3% 5.9% 17.8% 8.6%

Leeds Cancer Centre - - - - - - 7.7% 19.3% 9.1%

Leeds Dental Institute 0.0% 0.0% 0.0% 0.4% 0.0% 0.4% 0.9% 1.6% 1.0%

Pathology - - - 0.0% - 0.0% 0.0% 0.0% 0.0%

Radiology - - - - - - 5.2% 10.6% 5.4%

Trauma and Related Services 2.6% 8.7% 4.9% 3.1% 8.2% 5.3% 3.7% 8.1% 5.7%

Urgent Care - 10.3% 10.3% - 10.9% 10.9% 3.0% 11.4% 11.4%

Womens 1.4% 1.1% 1.1% 2.0% 1.1% 1.3% 2.7% 2.3% 2.4%

Trust 3.7% 10.4% 6.5% 3.8% 10.9% 6.8% 4.7% 11.0% 7.2%

(NB: RAG ratings are based on thresholds set by the TDA)

CSU

Nov-13 YTD Total Peer - Feb-12 to Jan-13


Aim: Ensure no more than 10.9% of patients are readmitted as an emergency within 30 days of discharge, following elective or non-elective treatment. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, quality of care, reputation & financial penalty.


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Readmissions - Elective

% Readmissions Peer % Readmissions

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Readmissions - Non-Elective


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% R

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Readmissions - Total (Elective and Non-Elective)


of 47

Outpatient Activity - New and Review Plan Activity Variance Plan Activity Variance

Acute Medicine 1,908 1,554 -354 18,223 16,610 -1,613

Adult Critical Care 0 0 0 0 1 1

Adult Theatres & Anaesthesia 21 76 55 202 1,123 921

Adult Therapies 3,556 2,682 -874 33,958 35,148 1,190

Cardio-Respiratory 3,131 3,037 -94 29,904 31,382 1,478

Centre for Neurosciences 1,831 1,832 1 17,439 19,438 1,999

Chapel Allerton Hospital 6,359 6,429 70 60,155 59,824 -331

Childrens 2,853 2,913 60 26,797 28,570 1,773

Digestive Diseases 3,147 2,185 -962 27,953 24,047 -3,906

Head & Neck 7,260 7,611 351 68,082 68,872 790

Hepatorenal 4,140 4,159 19 39,535 38,080 -1,455

Leeds Cancer Centre 0 0 0 0 0 0

Leeds Dental Institute 3,238 2,834 -404 30,735 28,222 -2,513

Pathology 1 0 -1 7 8 1

Radiology 850 1,643 793 8,119 17,551 9,432

Trauma and Related Services 4,179 3,969 -210 39,839 38,166 -1,673

Urgent Care 2,138 0 -2,138 20,421 16,466 -3,955

Womens 1,702 2,113 411 16,250 15,907 -343

Trust 46,313 43,037 -3,276 437,619 439,415 1,796

CSUDec-13 YTD

Outpatient Activity - Review Attendances

Internal Indicator

Aim: Maintain financial viability through delivery of planned activity. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

New: Overall Trust activity year to-December was 1.5% below plan. Year-to-December, the following CSUs were more than 10% below their plan: Adult Critical Care, Digestive Diseases and Urgent Care (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan was only small numbers). Again the position shows marked variation against the plan which has previously been acknowledged to the board.

Review:

Overall Trust activity year to-December was 0.4% above plan.

Year-to-December, the following CSUs were more than 10% below their plan: Digestive Diseases and Urgent Care (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan was only small numbers).

Plan Activity Variance Plan Activity Variance

Acute Medicine 380 417 37 3,629 4,232 603

Adult Critical Care 4 0 -4 38 29 -9

Adult Theatres & Anaesthesia 0 1 1 0 2 2

Adult Therapies 1,376 1,170 -206 13,145 14,433 1,288

Cardio-Respiratory 1,844 1,706 -138 17,611 17,371 -240

Centre for Neurosciences 1,538 1,189 -349 14,589 13,961 -628

Chapel Allerton Hospital 1,935 1,832 -103 18,188 17,637 -551

Childrens 1,184 1,104 -80 11,061 11,262 201

Digestive Diseases 1,447 856 -591 13,226 10,457 -2,769

Head & Neck 2,734 4,087 1,353 25,552 25,691 139

Hepatorenal 887 1,008 121 8,470 9,315 845


Leeds Dental Institute 1,085 1,158 73 10,681 10,711 30

Pathology 3 6 3 25 23 -2

Radiology 260 323 63 2,481 3,552 1,071

Trauma and Related Services 2,111 1,934 -177 20,034 19,912 -122

Urgent Care 1,785 0 -1,785 17,047 13,757 -3,290

Womens 1,094 1,320 226 10,444 11,008 564

Trust 19,667 18,111 -1,556 186,220 183,353 -2,867

Outpatient Activity - New Attendances

CSUDec-13 YTD

of 47

Inpatient Activity - Elective and Non-elective Plan Activity Variance Plan Activity Variance

Acute Medicine 1,615 1,471 -144 14,324 12,844 -1,480

Adult Critical Care 6 7 1 51 56 5


Adult Therapies 0 0 0 0 0 0

Cardio-Respiratory 795 804 9 7,055 6,870 -185

Centre for Neurosciences 350 256 -94 3,101 2,259 -842

Chapel Allerton Hospital 18 11 -7 163 131 -32

Childrens 721 771 50 6,398 6,233 -165

Digestive Diseases 672 667 -5 5,965 6,208 243

Head & Neck 152 164 12 1,348 1,427 79

Hepatorenal 364 323 -41 3,228 3,233 5


Leeds Dental Institute 0 1 1 2 5 3

Pathology 0 0 0 0 1 1

Radiology 14 18 4 124 163 39

Trauma and Related Services 473 449 -24 4,197 4,451 254

Urgent Care 1,077 737 -340 9,549 7,111 -2,438

Womens 138 89 -49 1,221 1,077 -144

Awaiting CSU Allocation 0 0 0 0 5 5

Trust 6,395 5,768 -627 56,726 52,074 -4,652

CSUDec-13 YTD

Inpatient Activity - Non-Elective (Spells)

Internal Indicator

Aim: Maintain financial viability through delivery of planned activity Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

Elective:

Overall Trust activity year to-December was 1% below plan.

Year-to-December, only the Radiology CSU was more than 10% below its plan (with the exception of Adult Critical Care and Urgent Care, which involve very small numbers).

Non-elective:

Overall Trust activity year to-December was 8.2% below plan.

Year-to-December, the following CSUs were more than 10% below their plan: Acute Medicine, Centre for Neurosciences, Chapel Allerton Hospital, Urgent Care and Women‟s (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan was only small numbers).

Plan Activity Variance Plan Activity Variance

Acute Medicine 185 121 -64 1,768 1,665 -103

Adult Critical Care 0 0 0 2 0 -2


Adult Therapies 0 0 0 0 0 0

Cardio-Respiratory 505 432 -73 4,819 4,832 13

Centre for Neurosciences 561 494 -67 5,148 4,863 -285

Chapel Allerton Hospital 939 843 -96 8,941 8,382 -559

Childrens 846 885 39 7,860 8,677 817

Digestive Diseases 1,934 1,434 -500 15,956 14,947 -1,009

Head & Neck 1,090 1,096 6 10,217 10,267 50

Hepatorenal 879 856 -23 8,147 8,958 811


Leeds Dental Institute 130 100 -30 1,254 1,178 -76

Pathology 0 0 0 0 1 1

Radiology 13 6 -7 129 112 -17

Trauma and Related Services 691 598 -93 6,257 5,991 -266

Urgent Care 0 0 0 2 0 -2

Womens 281 219 -62 2,691 2,525 -166

Trust 8,055 7,093 -962 73,204 72,483 -721

Inpatient Activity - Elective (Spells)

CSUDec-13 YTD

of 47

Length of Stay

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iolo

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l Medic

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l Surg

ery

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l Surg

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tay

LTHT Peer Average

For peer listing, please see Appendix 2 Source: Dr Foster

Length of Stay: Selected Specialties - Nov-12 to Oct-13

Internal Indicator

Aim: To reduce the length of stay in order to release capacity for other patients and provide an improved patient experience. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, financial and clinical outcomes.

\

Specialty LTHT Peer Avg

Cardiology 3.2 4.4

Dermatology 5.1 6.4

Ear Nose & Throat 2.4 2.6

Elderly Medicine 11.5 13.5

Gastroenterology 7.4 7.9

General Medicine 6.6 6.1

General Surgery 4.9 4.6

Gynaecology 1.6 1.5

Neurology 10.8 9.4

Neurosurgery 10.6 8.1

Ophthalmology 0.9 1.6

Oral Surgery 2.0 2.3

Plastic Surgery 2.6 2.7

Respiratory Medicine 10.5 7.3

Rheumatology 4.4 5.8

Trauma & Orthopaedic Surgery 7.6 6.7

Urology 3.7 3.2

All Specialties 5.1 4.8

NB: For Length of Stay, Specialty level peer data is only available on Dr Foster for the

period Nov-12 to Oct-13. Please note that the Trust level (as shown in the ‘Other Key

Indicators’ dashboard) provides more up to date data: Dec-12 to Nov-13.

Length of Stay: Selected Specialties

Nov-12 to Oct-13

of 47

Flu Vaccinations Employees Vaccinated %

Acute Medicine 561 274 48.8%

Adult Critical Care 475 249 52.4%

Adult Theatres & Anaesthesia 714 351 49.2%

Adult Therapies 469 220 46.9%

Cardio-Respiratory 557 279 50.1%

Chapel Allerton 276 160 58.0%

Childrens 1,199 633 52.8%

Digestive Diseases 439 224 51.0%

Head Neck & Ophthalmology 208 104 50.0%

Hepatorenal 487 279 57.3%

Institute for Oncology/Leeds Cancer Centre 1,097 546 49.8%

Institute of Neurosciences 385 179 46.5%

Leeds Dental Institute 285 178 62.5%

Medicines Management and Pharmacy Services 521 359 68.9%

Outpatients 119 75 63.0%

Pathology 841 349 41.5%

Radiology 705 327 46.4%

Trauma and Related Services 364 172 47.3%

Urgent Care 412 264 64.1%

Womens 689 411 59.7%

Non Training Grade Doctors (Supporting Rotas) 59 19 32.2%

Training Grade Doctors 986 482 48.9%

Corporate Services 3,311 1,365 41.2%

Unknown - 1,733 -

Trust (including Unknown) 15,055 9,232 61.3%

Attainment by CSUDec-13

National Indicator

Aims:

To provide 75% of healthcare workers with a flu vaccination by January 2014. Owner: Chief Operating Officer, Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, patient safety, quality of care & financial penalty.

As at the 20th December 2013, 69.9% of healthcare workers had received a flu

vaccination.

Actions:

Managers of clinical areas are to encourage/challenge their staff to be vaccinated and to make best use of their peer vaccinators.

Peer vaccinators to return their completed forms immediately to OHS post each vaccine.

Staff who have been vaccinated at the GP surgery are being encouraged to tell OHS so their records can be updated.

Employees Vaccinated %

Add Prof Scientific and Technic 798 445 55.8%

Additional Clinical Services 2,368 1,233 52.1%

Administrative and Clerical 2,437 1,205 49.4%

Allied Health Professionals 821 423 51.5%

Estates and Ancillary 1,979 747 37.7%

Healthcare Scientists 737 318 43.1%

Medical and Dental 2,048 954 46.6%

Nursing and Midwifery Registered 3,959 2,170 54.8%

Students 12 4 33.3%

Unknown - 1,733 -

Trust (including Unknown) 15,055 9,232 61.3%

Attainment by staff groupDec-13

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Incidence of MRSA By month

MRSA Cases

(Trust-

Apportioned)

Achieve

Trajectory

( < )

Apr-13 1 0

May-13 2 0

Jun-13 0 0

Jul-13 0 0

Aug-13 1 0

Sep-13 1 0

Oct-13 0 0

Nov-13 0 0

Dec-13 0 0

By CSU Dec-13 YTD

Acute Medicine 0 1

Centre for Neurosciences 0 1

Digestive Diseases 0 2

Leeds Cancer Centre 0 1

All other CSU's 0 0

Trust 0 5


Aim: Eliminate Trust-apportioned MRSA bacteraemia cases in 2013/14. Owner: Chief Medical Officer, Infection Control Team, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.


As at 17 January, no MRSA bacteraemias have been provisionally recorded for January 2014.

Actions:

Continue to assess MRSA acquisition to ensure the appropriate Infection Control practices are in place.

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6

7

8

9

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se

s P

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Number of MRSA Bacteraemia Cases Per 100,000 Occupied Bed Days (Trust Apportioned) - April to November 2013


Source: HPA(NB: 42 Trusts reported no MRSA cases for the period, including 3 peer Trusts)

of 47

MRSA Screening Target > 95% > 95%

CSU Dec-13 YTD

Acute Medicine 97.4% 96.8%

Adult Critical Care 97.9% 95.6%

Adult Theatres & Anaesthesia 98.2% 96.8%

Cardio-Respiratory 95.5% 95.5%

Centre for Neurosciences 98.5% 97.3%

Chapel Allerton Hospital 99.2% 98.4%

Children's 86.7% 90.2%

Digestive Diseases 98.4% 96.1%

Head & Neck 92.9% 91.9%

Hepatorenal 98.4% 97.1%

Leeds Cancer Centre 96.4% 96.0%

Leeds Dental Institute* 0.0% 11.1%

Trauma & Related Services 92.0% 91.3%

Urgent Care 98.0% 91.9%

Women's 97.0% 95.4%

Trust 96.5% 95.6%

* Low numbers of eligible patients

MRSA Screening - % of Eligible Patients Screened


Aim: Ensure that at least 95% of eligible admitted patients are screened for MRSA. Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes & financial penalty.

Actions:

The MRSA Screening process was reinforced in October 2013. The Trust achieved the screening target in both November and December 2013.

80%

85%

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95%

100%

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MRSA Screening (Elective and Non Elective Admissions)

% Screened Target

of 47

Incidence of CDI

CSU Dec-13 YTD

Acute Medicine 3 25

Adult Critical Care 2 10

Cardio-Respiratory 0 11


Children's 0 15

Digestive Diseases 4 13

Head & Neck 0 1

Hepatorenal 3 12

Leeds Cancer Centre 0 11

Trauma & Related Services 0 7

Women's 0 1

All other CSU's 0 0

Trust 13 114

CDI Rate per 100,000 Bed Days 25.3 24.6

CDI



Aims:

Reduce the number of Trust-attributed CDIs in 2013/14 to no more than 101.

Reduce the CDI rate per 100,000 occupied bed days in line with the NHS Standard Contract.

Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.


As at 17 January, 4 CDIs have been recorded for January 2014. Actions:

CDI polymerase chain reaction testing introduced to allow better management of patients in source isolation and reduce the impact on bed capacity.

5 Clinical Service Units have attended an Executive-led CDI review meeting to discuss the root causes identified and the relevant actions that have taken place.

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Oct-

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Nov-1

3

Dec-1

3

No

. C

DI ca

se

s

Progress Against the CDI Target (Cumulative)

CDI Cases Achieve Trajectory

0

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3

Dec-1

3

CD

I R

ate

Pe

r 1

00

,00

0 O

ccu

pie

d B

ed

Da

ys

CDI Rate Per 100,000 Occupied Bed Days

NB: Denominator taken from internal Midnight Bed State data

0

5

10

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20

25

30

35

40

Ca

se

s p

er

10

0,0

00

Occu

pie

d B

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Da

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Trusts

Number of C.Difficile Cases Per 100,000 Occupied Bed Days for Patients Aged > 2 Years (Trust Apportioned) - April to November 2013


Source: HPA(NB: 7 Trusts reported no CDI cases for the period)

of 47

Summary Hospital Mortality Index (SHMI) SHMI Measure Spells SHMI

Observed

Deaths

Expected

Deaths

95%

Confidence

Interval

SHMI 127237 93.95 4003 4261 91.06-96.91

SHMI (adjusted for palliative care) 127237 96.15 4003 4163 93.20-99.18

SHMI (in hospital deaths) 127237 93.09 2868 3081 89.71-96.56

LTHT SHMI for Apr 12 to Mar 2013


The SHMI reports mortality at Trust level across the NHS in England using standard and transparent methodology. SHMI is the nationally recognised hospital level indicator of mortality.

Aim: Improve SHMI rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.

The Trust SHMI (source: Dr Foster) for the latest available period, April 2012 to March 2013 was 93.95 - better than expected. The Trust Relative Risk mortality for all CCS (Clinical Classification System) groups during the same period, were all either within or better than the expected range. The Trust has consistently maintained an overall SHMI within or better than the expected range over the latest available 3 year period.

of 47

Hospital Standardised Mortality Rate (HSMR)

Measure Spells HSMRObserved

Deaths

Expected

Deaths

95%

Confidence

Interval

HSMR 58790 92.78 2459 2650 89.15-96.52

LTHT HSMR for Apr 12 to Mar 2013


The HSMR reports mortality at Trust level across the NHS in England using standard and transparent methodology.

Aim: Improve HSMR rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.

The Trust HSMR (source: Dr Foster) for April 2012 to March 2013 was 92.78 – better than expected. The Trust has consistently maintained an overall HSMR within or better than the expected range over the latest available 4 year period.

80

85

90

95

100

105

2009/10 2010/11 2011/12 2012/13

HS

MR

(1

00

x O

bs

erv

ed

/Ex

pe

cte

d d

ea

ths

)

Financial Year

HSMR Trend

LTHT LTHT (rebased) England England (rebased)

Acute Trust HSMRs Apr-13 to Aug-13 (re-based)

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VTE Risk Assessment CSU Nov-13 YTD






Chapel Allerton 99.8% 99.4%



Head & Neck 97.8% 96.8%



Leeds Dental Institute 100.0% 99.7%



Women's 96.5% 95.8%

Trust 95.5% 95.7%

% VTE Risk Assessment


Aim: Ensure at least 95% of adult inpatients have a VTE risk assessment on admission to hospital. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, CQUIN & financial penalty.


The VTE risk assessment indicator is monitored a month in arrears due to the timing of the national reporting deadline.

Provisional Trust performance for December as at 17th January is 94%.

70%

75%

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

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n-1

2

Ju

l-1

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Au

g-1

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Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

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n-1

3

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Ma

r-13

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Oct-

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Nov-1

3

% p

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me

etin

g ta

rge

t

Venous Thromboembolism (VTE) Risk Assessments

% Patients Risk Assessed for VTE Target

70%

75%

80%

85%

90%

95%

100%

% P

atie

nts

Me

etin

g T

arg

et

Trusts


Source: NHS England

Venous Thromboembolism (VTE) Risk Assessments- April to October 2013

RRK University Hospitals Birmingham NHS Foundation Trust 99.2%

RGT Cambridge University Hospitals NHS Foundation Trust 98.8%

RA7 University Hospitals Bristol NHS Foundation Trust 97.5%

RTD The Newcastle Upon Tyne Hospitals NHS Foundation Trust 96.4%

RM2 University Hospital Of South Manchester NHS Foundation Trust 96.2%

Top 5 Performing Peer Trusts - April to October 2013:

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Never Events


Aim: Ensure that all Never Events are fully investigated and robust action plans put in place to prevent reoccurrence. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes & reputation.

As part of its commitment to be open and transparent about patient safety incident reporting, NHS England has begun publishing detailed data on never events – initially to cover incidents reported between April and September 2013. NHS England will continue to publish data at this level of detail quarterly, and then on a monthly basis from April 2014. Subsequent updates will be included in the IQPR at appropriate intervals.


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2

3

4

5

To

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nts

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Never events declared on STEIS at 21 October 2013, where reported date of incident is 1 April 2013 - 30 September 2013


Source: NHS England

NB. The above data is provisional and is subject to change.99 providers reported no Never Events for the period, including 3 peers.

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Harm Free Care

87

.8%

90

.0%

90

.8%

92

.9%

93

.2%

92

.9%

92

.5%

92

.3%

93

.2%

0%

10%

20%

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50%

60%

70%

80%

90%

100%

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% o

f P

atie

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With

Ha

rm F

ree

Ca

re

% of Patients With Harm Free Care

% of Patients With Harm Free Care Target

Source: Safety Thermometer


CQUIN Indicator

Internal Indicator

Aims:

Ensure at least 92% of patients receive harm free care in relation to pressure ulcers, falls, CUTIs & VTE).

Ensure that for the period October 2013 to March 2014 no more than 6.4% of patients have a pressure ulcer (between April and September 2013 this target stood at 7.2%, but was recently renegotiated with the CCG).

Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient safety, patient experience, clinical outcomes, quality of care, reputation and financial penalty.

Actions:

Data continues to be collected and entered at the point of care; this is reducing variation and improving data robustness.

Safety Thermometer data has been added to the developing internal “Ward Healthcheck” tool and is now displayed on every ward notice board to improve understanding and knowledge of harm free care.

0%

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lls R

esu

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arm

% of Patients With Falls Resulting in Harm

% Falls With Harm (LTHT) % Falls With Harm (National Acute Average)


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% o

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ressu

re U

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r (n

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an

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)

% of Patients With a Pressure Ulcer (New and Old)

% of Patients With a Pressure Ulcer (new and old) Target


0%

2%

4%

6%

8%

10%

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14%

Oct-

12

Nov-1

2

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Nov-1

3

Dec-1

3% o

f P

atie

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UIT

s (

Ne

w a

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Old

)

% of Patients With UTIs (New and Old)

% With UTIs (LTHT) % With UTIs (National Acute Average)


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Pressure Ulcers

CSU Dec-13 YTD

Acute Medicine 2 9

Adult Critical Care 0 2

Cardio-Respiratory 1 3


Hepatorenal 0 0

Trauma and Related Services 2 8

All other CSUs 2 8

Grade III Trust Total 7 36

Grade IV Trust Total 0 0

Pressure Ulcers - Grade III

Pressure Ulcers - Grade IV

CQUIN Indicator

Aims:

Reduce the number of grade III pressure ulcers developed in the Trust to no more than 36 for 2013/14.

Reduce the number of grade IV pressure ulcers developed in the Trust to no more than 2 for 2013/14.

Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, patient safety, clinical outcomes, quality of care, CQUIN & financial penalty.

Actions:

From January 2014, all Category 2 pressure ulcers will be subject to a „mini‟ Root Cause Analysis with subsequent improvement action plans.

The Nursing directorate team are currently undertaking independent assurance checks to review compliance against the required clinical standards for risk assessment, intervention and documentation.

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No

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Number of Grade III Pressure Ulcers

Grade III Target

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Number of Grade IV Pressure Ulcers

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of 47

Complaints

Complaints by CSU YTD

Acute Medicine 55

Adult Critical Care 6

Adult Theatres & Anaesthesia 14

Adult Therapies 7

Cardio-Respiratory 46

Centre for Neurosciences 78

Chapel Allerton Hospital 41

Children's 48

Digestive Diseases 71

Head & Neck 43

Hepatorenal 53

Leeds Cancer Centre 0

Leeds Dental Institute 9

Pathology 7

Radiology 11

Trauma & Related Services 61

Urgent Care 48

Women's 73

All Other CSU's 131

Trust 802

Top Complaints Subjects YTD

Medical Care 317

Communication 101

Nursing care 74

Waiting Lists 62

Attitude 61

Administration 45

Waiting Times 21

Discharge Planning 8

Equipment related issues 7

Policy and Procedural Issues 7

Sub Total 703

Trust 802


Internal Indicator

Aim: Improve patient experience and satisfaction through better understanding of the complaints received. Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, quality of care & financial penalty.

Actions:

A task and finish group has been established to implement the Trust‟s new Complaints Policy.

A new process has been put in place lead by the Deputy Chief Nurse and Director of Nursing Operations to review and initiate resolution for all complaints that have been open for over 6 months.

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om

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ints

Re

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ive

d

Complaints - Number of Complaints Received

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te p

er 1

0,0

00

Occu

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ays

Complaints - Rate per 10,000 Occupied Bed Days

of 47

Patient Satisfaction – Friends & Family

Response

Rate

Net Promoter

Score

Response

Rate

Net Promoter

Score

Acute Medicine 27.7% 48.3 33.3% 52.9

Cardio-Respiratory 25.7% 76.7 32.9% 78.4

Centre for Neurosciences 36.0% 80.0 27.9% 75.0

Chapel Allerton Hospital 55.6% 83.9 52.0% 87.3

Children's 0.0% - 15.8% 91.7

Digestive Diseases 52.4% 69.5 42.0% 70.1

Head & Neck 66.0% 64.1 21.8% 65.6

Hepatorenal 37.2% 69.7 37.0% 72.6

Leeds Cancer Centre 38.4% 82.2 34.4% 81.9

Trauma & Related Services 34.7% 72.2 22.2% 70.9

Urgent Care 1.0% 66.7 54.0% 68.9

Women's 10.1% 60.0 19.8% 66.1

All other CSUs - - - -

Inpatient Total 34.1% 70.4 30.7% 70.9

Maternity Total 36.9% 74.1 31.5% 73.0

A&E LGI 3.4% 34.2 7.0% 57.3

A&E SJUH 8.1% 71.7 8.5% 64.0

A&E Total 5.7% 60.0 7.7% 60.8

Combined Total 20.8% 70.0 49.4% 81.2

NB YTD Response Rate is not RAG rated as there is no YTD threshold.

Dec-13 YTD

CSU


Aims:

Ensure at least 15% of eligible patients respond to the Friends and Family test (FFT) question, with the aim to increase this to 20% by Quarter 4 in 2013/14.

Improve the number of positive recommendations to friends and family (Net Promoter Score) by people receiving NHS Treatment for the place where they received care.

Owner: Chief Nurse, Director of External Affairs & Communication Consequence of failure: Patient experience, reputation, CQUIN & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graph.

As of 1 October 2013, figures included Maternity services. The FFT will be extended to all NHS services in England, including Outpatient appointments, by the end of March 2015. The A&E return rate (for both the LGI and SJUH) is to be compliant (>20%) by 31 January 2013. Actions:

The Trust has signed up to the 'iWantGreatCare' gold package both to provide the FFT service and develop it to include the Staff FFT. Workshop meetings to plan implementation are to commence in January 2014.

A FFT text messaging service has been implemented in both of the Trust‟s A&E departments. The service went live on 1

st January 2014.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ja

n-1

3

Fe

b-1

3

Ma

r-13

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r-13

Ma

y-1

3

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3

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Se

p-1

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Oct-

13

Nov-1

3

Dec-1

3

% R

esp

on

se

Ra

te

Friends and Family Test - % Response Rate

Response Rate (%) Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Re

sp

on

se

Ra

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Trusts


Source: NHS England

Friends and Family Test Response Rates (A&E and inpatient)November 2013

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Friends and Family Test - Net Promoter Score

Net Promoter Score (LTHT) Net Promoter Score (Peer Avg)

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Outpatient Measures

CSU

Dec-13 YTD Dec-13 YTD

Radiology 201 3,032 9.0% 11.9%

Leeds Cancer Centre 1,543 20,183 14.7% 15.8%

Trauma and Related Services 1,243 14,460 17.7% 18.0%

Womens 1,303 15,310 17.3% 18.7%

Leeds Dental Institute 957 11,471 18.3% 20.7%

Adult Theatres & Anaesthesia 11 359 14.9% 22.2%

Head & Neck 3,853 36,899 25.3% 22.6%

Childrens 1,067 14,087 19.3% 22.9%

Cardio-Respiratory 1,363 16,541 20.1% 23.0%

Chapel Allerton Hospital 2,542 26,070 23.8% 23.5%

Hepatorenal 1,246 17,166 18.8% 23.8%

Digestive Diseases 985 13,635 22.4% 25.8%

Centre for Neurosciences 1,249 12,901 26.6% 25.8%

Acute Medicine 542 9,176 19.7% 26.7%

Pathology 0 18 0.0% 27.7%

Adult Therapies 84 1,149 25.8% 28.2%

Adult Critical Care - 25 - 30.5%

All other CSUs - 1 - 100.0%

Trust 18,189 212,483 20.3% 21.4%

Total Number of OP Appointment

Cancellations (By Patient and Hospital)

OP Appointment Cancellations (as a %

of Total Bookings)

Outpatients: Total Appointment Cancellations

Internal Indicator

Aims:

Ensure the Trust‟s Did Not Attend (DNA) rate is below the peer average.

Reduce the number of appointments cancelled by hospital within 6 weeks of appointment.

Reduce the number of appointments cancelled by patient within 6 weeks of appointment.

Owner: Director of Informatics and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

Actions:

To support improvements to RTT performance there will be a review of clinic templates and best practice in scheduling to enable the prioritisation of service improvement by the CSUs.

To identify patient pathways with more than one outpatient appointment before the decision to treat, and to review the referral triage process, outpatient to procedure ratio and Directory of Services.

Radiology 192 8.6% 2,887 11.4% 7 0.3% 138 0.5%

Leeds Dental Institute 504 9.6% 7,087 12.8% 190 3.6% 2,119 3.8%

Womens 713 9.5% 8,637 10.6% 418 5.6% 5,321 6.5%

Acute Medicine 277 10.1% 4,317 12.6% 121 4.4% 2,298 6.7%

Trauma and Related Services 518 7.4% 6,595 8.2% 506 7.2% 5,688 7.1%

Leeds Cancer Centre 732 7.0% 9,239 7.2% 672 6.4% 9,091 7.1%

Cardio-Respiratory 669 9.9% 8,750 12.2% 439 6.5% 5,476 7.6%

Childrens 445 8.1% 6,365 10.3% 387 7.0% 5,114 8.3%

Adult Therapies 52 16.0% 748 18.4% 29 8.9% 346 8.5%

Adult Theatres & Anaesthesia 5 6.8% 219 13.6% 6 8.1% 140 8.7%

Head & Neck 1,361 8.9% 16,318 10.0% 1,662 10.9% 14,330 8.8%

Chapel Allerton Hospital 1,068 10.0% 12,207 11.0% 1,192 11.1% 9,942 9.0%

Hepatorenal 633 9.5% 8,446 11.7% 477 7.2% 6,728 9.3%

Centre for Neurosciences 494 10.5% 6,179 12.4% 528 11.2% 4,763 9.5%

Adult Critical Care - - 16 19.5% - - 8 9.8%

Digestive Diseases 440 10.0% 6,786 12.8% 382 8.7% 5,453 10.3%

Pathology 0 0.0% 6 9.2% 0 0.0% 11 16.9%

All other CSUs - - - - - - - -

Trust 8,103 9.0% 104,802 10.5% 7,016 7.8% 76,966 7.7%

Outpatients: Appointments Cancelled Within 6 Weeks of Appointment

CSU

Cancelled by Patient (Number and as a

% of Total Bookings)

Cancelled by Hospital (Number and as a

% of Total Bookings)

Dec-13 YTD Dec-13 YTD

Specialty LTHT Peer Avg

General Medicine 1.0% 5.7%

General Surgery 8.4% 8.0%

Neurosurgery 8.4% 7.5%

Gynaecology 9.2% 7.1%

Cardiology 9.4% 8.8%

Elderly Medicine 9.5% 8.8%

Rheumatology 9.7% 9.3%

Urology 10.1% 8.6%

Ophthalmology 10.3% 9.1%

Respiratory Medicine 10.5% 10.4%

Dermatology 11.2% 8.3%

Trauma & Orthopaedic Surgery 11.3% 9.3%

Neurology 11.4% 9.9%

Gastroenterology 12.0% 10.7%

Ear Nose & Throat 12.1% 8.6%

Plastic Surgery 12.4% 9.8%

Oral Surgery 15.6% 11.7%

All Specialties 9.5% 8.6%

Outpatient Appointment DNA (%)

Selected Specialties - Nov-12 to Oct-13

0% 5% 10% 15% 20%

Cardiology

Dermatology

Ear Nose & Throat

Elderly Medicine

Gastroenterology

General Medicine

General Surgery

Gynaecology

Neurology

Neurosurgery

Ophthalmology

Oral Surgery

Plastic Surgery


Rheumatology

Trauma & Orthopaedic…

Urology

Ou

tpa

tie

nt A

pp

oin

tme

nt

DN

A (%

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LTHT Peer Average

For peer listing, please seeAppendix 2 Source: Dr Foster

Outpatient AppointmentDNA (%)Selected Specialties - Nov-12 to Oct-13

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Outpatient Measures (Continued)

Selected Specialties LTHT Peer Average

Cardiology 1.6 1.5

Dermatology 2.9 2.4

Ear Nose & Throat 1.1 1.4

Elderly Medicine 1.7 1.8

Gastroenterology 3.0 2.3

General Medicine 0.4 0.6

General Surgery 0.9 1.6

Gynaecology 1.1 1.1

Neurology 1.8 1.9

Neurosurgery 1.3 1.7

Ophthalmology 3.4 3.2

Oral Surgery 1.5 1.1

Plastic Surgery 1.8 2.7

Respiratory Medicine 1.9 2.5

Rheumatology 4.1 4.4

Trauma & Orthopaedic Surgery 1.9 2.0

Urology 3.2 2.4

All Specialties 2.0 2.3

New to Review Ratio: Selected Specialties

Nov-12 to Oct-13

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LTHT Peer Average

For peer listing, please see Appendix 2 Source: Dr Foster

Outpatient New to Review Ratio: Selected Specialties - Nov-12 to Oct-13

NB: For DNA Rate and New to Review Ratio, Specialty level peer data is only available on Dr

Foster for the period Nov-12 to Oct-13. Please note that the Trust level (as shown in the

‘Other Key Indicators’ dashboard) provides more up to date data: Dec-12 to Nov-13.

Actions:

At the end of December, there were 4,842 patients waiting more than 3 months over their due date for a review appointment; over half of these were waiting for appointments within the Digestive Diseases CSU. However, the number waiting more than 3 months over their due date has reduced from 1,895 at the end of August to 1,438 at the end of December in Colorectal Surgery.

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No of Colorectal Patients Waiting Over 3 Months Achieve Trajectory

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Choose and Book (CAB) – ASIs

Specialty Name ASIs

2 Week Wait Suspected Cancer 111

Cardiology 18

Children's & Adolescent Services 29

Dermatology 21

Diabetic Medicine 1

Diagnostic Physiological Measurement 41

Ear, Nose & Throat 22

Endocrinology and Metabolic Medicine 74

Geriatric Medicine 3

GI and Liver (Medicine and Surgery) 46

Gynaecology 9

Infectious Diseases 1

Neurology 53

Ophthalmology 11

Orthopaedics 8

Respiratory Medicine 5

Rheumatology 9

Surgery - Breast 70

Surgery - Not Otherwise Specified 5

Surgery - Plastic 3

Surgery - Vascular 13

Grand Total 553

ASIs - December 2013


Aim: Reduce the number of appointment slot issues (ASIs) to no worse than 2% above the national average. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes & financial penalty.

CAB ASIs is a percentage of ASIs generated from within Choose and Book out of all Directly Bookable Service (DBS) bookings.

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Choose and Book - Appointment Slot Issues (ASIs)

LTHT National Penalty Threshold

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CAB - Utilisation

Internal Indicator

Aim: Improve the percentage of appointments booked via CAB out of all first GP referrals to the target level of 90%. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes.

CAB utilisation is a national measure based on bookings made via the CAB system out of the estimated total number of GP referrals to first outpatient appointments.

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% Utilisation Target

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Workforce

CSU Dec-13

Medicines Management and Pharmacy Services 82.3%

Radiology 82.2%

Urgent Care 65.0%

Adult Therapies 62.5%

Leeds Dental Institute 61.0%

Cardio-Respiratory 57.0%

Digestive Diseases 54.5%

Hepatorenal 52.2%

Women's 50.8%

Adult Theatres & Anaesthesia 49.3%

Pathology 49.2%

Acute Medicine 45.2%

Head & Neck 44.8%

Leeds Cancer Centre 44.6%

Centre for Neurosciences 42.8%

Trauma & Related Services 42.7%

Adult Critical Care 42.3%

Children's 40.1%

Chapel Allerton 39.3%

Outpatients 38.1%

Trust 49.9%1 Percentage of staff who have an in date appraisal at month end.

Staff Appraised (Ranked by Attainment) 1


Aims:

Reduce sickness absence rates to be in line with the internally agreed trajectory. Current local target is 3.86%.

Meet local target: to ensure 95% of staff have a high quality annual appraisal. Owner: Director of Human Resources and CSU Clinical Directors Consequence of failure:

Sickness absence reduces productivity, places a greater reliance on variable staffing and adversely affects quality.

A failure to appraise staff has a negative impact on staff engagement, productivity and quality.

Actions:

Appraisals: Targeted interventions will be undertaken to ensure appraisals are completed by year end. In addition, the Trust‟s Appraisal Policy will be re-launched for 2014/15 as part of the on-going staff engagement work.

Sickness: Focused interventions will be undertaken by a dedicated Attendance Management Team, and a review of health and wellbeing activities completed in order to improve attendance. A review of the Firstcare solution will also take place to ensure that the Trust continues to achieves maximum benefits from the system.

CSU Dec-13Jan-13 to Dec-13

(12 Month Rolling Average)

Adult Therapies 3.0% 2.2%

Head & Neck 3.0% 3.5%





Radiology 6.9% 4.1%



Medicines Management and Pharmacy Services 5.0% 4.2%


Pathology 4.5% 4.3%




Women's 3.4% 5.2%




Outpatients 4.7% 5.7%

Trust 4.7% 4.2%

Sickness Absence Rate (Ranked by 12 Month Rolling Average)

CSU Dec-13Jan-13 to Dec-13

(12 Month Rolling Average)


Radiology 0.3% 7.2%



Medicines Management and Pharmacy Services 0.6% 8.0%



Pathology 1.0% 9.0%

Outpatients 0.0% 9.3%

Head & Neck 0.8% 9.8%


Women's 0.6% 11.0%





Adult Therapies 0.5% 15.1%




Trust 1.0% 10.8%2 Excluding Training Grade Doctors

Staff Turnover (Ranked by 12 Month Rolling Average) 2

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Finance

AF Finance D ashboard

In-Year Financial Delivery Indicators - December 2013

Category Indicator Plan £'000 Actual £'000 Variance £'000

NHS Financial Performance

Year to Date, Actual compared to Plan 12,412 (1,488) (13,900)

Forecast Outturn, Compared to Plan 1,418 609 (809)

Financial Efficiency

Actual Efficiency for Year to Date compared to Plan 24,698 22,021 (2,677)

Recurrent Efficiencies for Year to Date compared to Plan 11,991 10,163 (1,828)

Forecast Outturn Efficiency Compared to Plan 40,242 37,479 (2,763)

Recurrent Efficiencies for Forecast Outturn compared to Plan 20,448 18,604 (1,844)

Underlying Revenue Position

Forecast Outturn Underlying Revenue Position compared to plan (18,376) (6,074) 12,302

Cash and Capital

Forecast Year End Charge to Capital Resource Limit 27,312 22,262 5,050

Temporary PDC for Liquidity Purposes (cumulative sum) 0 0 0

Funding Accessed (cumulative sum) 0 0 0

Progress Towards Foundation Trust Status - December 2013


Progress Towards FT Status

EBITDA Margin Achieved: Year to Date 3 2 (1)

EBITDA Margin Achieved: Forecast Outturn 3 3 0

EBITDA Percentage of Plan: Year to Date 3 3 0

EBITDA Percentage of Plan: Forecast Outturn 3 3 0

Net Return After Financing: Year to Date 4 2 (2)

Net Return After Financing: Forecast Outturn 3 3 0

I&E Surplus Margin net of Dividend: Year to Date 3 2 (1)

I&E Surplus Margin net of Dividend: Forecast Outturn 2 2 0

Liquidity Ratio Days (including NWCF): Year to Date 3 3 0

Liquidity Ratio Days (including NWCF): Forecast Outturn 3 3 0

Combined Financial Risk Rating: Year to Date 3 2 (1)

Combined Financial Risk Rating: Forecast Outturn 3 3 0


Progress Towards FT Status

Liquidity Days 3 2 (1)

Capital Services Capacity 3 2 (1)

Combined Risk Rating

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Finance - In-Year Financial Delivery Indicators

Finance - Progress Towards Foundation Trust Status

National Indicator / Quality Requirement National Indicator / Quality Requirement

Income and Expenditure (I&E) is currently showing a significant adverse variance, but this is against the TDA submitted plan which is now phased differently to the Board reported plan. The actual reported I&E variance currently stands at £2.6 million adverse, and is primarily the result of under-trading against activity plans, and expenditure incurred in the independent sector. The Trust still has a forecast out-turn of £99k surplus as reported to the TDA as part of the 2014/15 annual financial plan submission on 13th January. The outturn included in this return is that reported after technical adjustments relating to income received from the Charitable Trustees. CIP performance is behind plan on a number of specific schemes, but is not forecast to significantly worsen between now and the end of the financial year. Forecast Capital Resource Limit (CRL) is showing an undershoot of £5 million as a result of the receipt from the Seacroft land sale. Capital receipts are a credit to the CRL charge. Accountability Framework Summary Performance

The Trust reported a year to date I&E deficit of £1,488k against a TDA planned surplus of £12,412k, resulting in an adverse variance of £13,900k.

The I&E variance is forecast to achieve a £99k surplus by the end of the year before technical adjustments which will result in a £809k deficit. CIPs are forecast to under achieve by £2,763k

Although there is an under-achievement against CIP plans of £2,677k year-to-date, a regular monthly process of reporting and managing savings plans should ensure that this does not get significantly worse by year-end.

The Trust is reporting an overall Financial Risk Rating of 2 for the end of December which will increase to 3 at the year end with I&E break even. The new Continuity of Service ratings are discussed individually below but the overall score is 2. Aspirant Trusts should aim for 3.

Indicator Comment

Monitor Combined - Liquidity

Liquidity at the month end was -13 days which equates to a rating of 2. Liquidity has improved from -16 days at the end of October but is forecast to remain at 2 at the year end.

Total Capital servicing capacity is 1.7 at the end of December compared to 1.56 at the end of October. This equates to a score of 2 where it is forecast to remain at the year end.

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Internal Indicators Dashboard

Indicator Oct-13 Nov-13 Dec-13 YTD

RTT clearance time: total (weeks) < 8 10.8 10.6 10.2 n/app

RTT clearance time: over 18 weeks (weeks) < 0.5 0.6 0.6 1.0 n/app

RTT: Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted 1,120 968 912 n/app

Cancelled Operations: Last Minute Cancellations for Non-Clinical Reasons

A&E: Time from arrival to initial full assessment (mins) - 95th percentile < 15 15 17 16 16

A&E: Time from arrival to treatment (mins) - median < 60 77 79 78 78

A&E: % Unplanned follow-up re-attendances within 7 days < 5% 7.9% 6.8% 8.1% 7.9%

A&E: % Patients leaving A&E unseen < 5% 3.1% 3.1% 3.0% 3.4%

A&E: Number of trolley waits greater than 12 hours 0 0 0 0

Patient handovers taking longer than 15 minutes between ambulance and A&E 790 709 780 6034



Cancer 62 days: referrals following consultant upgrade > 85% 87.9% 50.0%Reported a month

in arrears82.3%

Stroke patients spending at least 90% of their time in hospital on a stroke unit > 80% 79.4% 72.3%Reported a month

in arrears82.3%

Proportion of high-risk TIA patients investigated and treated within 24 hours of first contact with a health professional 70.6% 82.1%Reported a month

in arrears76.2%

MRSA Screening > 95% 92.9% 97.0% 96.5% 95.6%

CDI cases: Rate per 100,000 Occupied Bed Days 26.5 27.3 25.3 24.6

Harm Free Care: % of Patients With Falls Resulting in Harm (Snapshot) 1.2% 1.2% 0.5% n/app

Harm Free Care: % of Patients With UTIs (new and old) (Snapshot) 3.1% 3.9% 4.1% n/app

Number of complaints 83 79 62 802

OP Measure: DNA rate Peer ave: 8.6%

12,093 12,026 8,103 104,802

9.8% 10.5% 9.0% 10.5%

9,891 8,600 7,016 76,966

8.0% 7.5% 7.8% 7.7%

OP Measure: New to Review ratio Peer ave: 2.3 2.0

Dec-12 to Nov-13

Dec-12 to Nov-13

0

OP Measure: Number of OP Appointment Cancellations By Patient Within 6 Weeks of Appointment (and as % of Total

Bookings)

OP Measure: Number of OP Appointment Cancellations By Hospital Within 6 Weeks of Appointment (and as % of Total

Bookings)

Thresholds

As per NHS Standard

Contract

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9.5%

Key Indicators (not in other dashboards)

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Indicator Oct-13 Nov-13 Dec-13 YTD

OP Activity: New (Attendances) 25,033 23,697 18,111 183,353

OP Activity: Review (Attendances) 61,702 59,002 43,037 439,415

IP Activity: Elective (Spells) 11,371 10,529 7,093 72,483

IP Activity: Non-elective (Spells) 6,256 5,773 5,768 52,074

Length of Stay Peer ave: 4.9

Choose and Book: Appointment Slot Issues 10.7% 11.6% 10.8% 10.9%

Choose & Book utilisation > 90% 59.2% 60.6% 55.8% 59.4%

Research & Innovation (R&I): Activity - Research studies in NIHR portfolio (number) Q2: 343 (2nd) n/app

R&I: Participation - Participants recruited to NIHR Portfolio Studies (number) Q2: 6114 (6th) n/app

R&I: Initiation – all clinical trials should take 70 Days or less from receipt of a valid research application to 1st patient visit

(median) < 70 Q2: 75 days n/app

R&I: Delivery – all commercial clinical trials should recruit the agreed target number of patients within the agreed recruitment

period (%)> 80% Q2: 70% n/app

Dementia Stage 1: Find - % of all patients aged 75 and above admitted as emergency inpatients who are asked the

dementia case finding question within 72 hours of admission or who have a clinical diagnosis of delirium on initial

assessment or known diagnosis of dementia.

94.7% 94.3% 93.7%

Dementia Stage 2: Assess - % of all patients aged 75 and above admitted as emergency inpatients who have scored

positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into the exemption

categories reported as having had a dementia diagnostic assessment including investigations.

96.2% 92.0% 94.4%

Dementia Stage 3: Refer - % of all patients aged 75 and above, admitted as an emergency inpatient who have had a

diagnostic assessment (in whom the outcome is either “positive” or “inconclusive”) who are referred for further diagnostic

advice/follow up.

100.0% 94.1% 96.3%

No worse than 2%

above the national

average

Thresholds

Dec-12 to Nov-13 : 5.1

Reported a month

in arrears

Within top 5 Trusts in

England

> 90%

Within top 5 Trusts in

England

Reported quarterly

Key Indicators (not in other dashboards) (continued)

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Appendix 1 - Updates

Updates from Regulators

Everyone Counts: Planning for Patients 2014/15 to 2018/191

NHS England has published its planning guidance based on a five-year planning cycle. The focus is intended to be less on what is done for patients and more on the results of what is done. The report outlines the ambitions and outcomes expected, the planning process and the plans to be produced. Delivering the NHS Outcomes Framework and the following five offers remain the focus of the planning guidance:

• NHS Services, seven days a week. • More transparency, more choice. • Listening to patients and increasing their participation. • Better data, informed commissioning, driving improved outcomes. • Higher standards, safer care.

Securing Sustainability: Planning Guidance for Trust Boards 2014/15 to 2018/19

2

The NHS Trust Development Authority (TDA) has also published its planning guidance for Trusts. This guidance sets out, for the first time, a framework to enable NHS Trusts to look in more depth at how they plan to continue to deliver high quality services in a sustainable way over the next five years. In assessing the plans of NHS Trusts, the NHS TDA will consider the credibility of the assumptions made by NHS Trusts before determining whether to support their plan. Where the plan requires significant service change which has not yet been agreed with commissioners, the NHS TDA will support NHS Trusts to take those discussions forward.

Maternity Survey 20133

The Care Quality Commission‟s (CQC) latest survey into women‟s experiences of maternity care shows that improvements have been made over the last 3 years but further progress is needed in some areas. The survey received responses from more than 23,000 women who had a baby in February 2013. 286 women who had a baby at the Trust in February responded to the survey. The results showed that LTHT‟s results were “about the same” as other trusts for “labour and birth” and “staff” but that the Trust did not perform as well as other providers for “care in hospital after birth”.

NHS Waiting Times for Elective Care4

The National Audit Office (NAO) has published a study into the performance, recording and management of elective care waiting times in England. The NAO audited a sample of case files to look for errors in recording or processes. LTHT is mentioned in this report. The pathway that was reviewed by the NAO is one that is shared across provider units. As a result of this report, the Trust is investigating the related administration processes to ensure appropriate reporting is taking place across provider units.

1 Everyone Counts: Planning for Patients 2014/15 to 2018/19

2 Securing Sustainability: Planning Guidance for Trust Boards 2014/15 to 2018/19

3 CQC Maternity Survey 2013

4 NHS Waiting Times for Elective Care

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

http://www.ntda.nhs.uk/wp-content/uploads/2013/12/tda_planning_2013_final-4.pdf

http://www.cqc.org.uk/survey/maternity/RR8

http://www.nao.org.uk/wp-content/uploads/2014/01/NHS-waiting-times-for-elective-care-in-England.pdf

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Appendix 2 - Peer Groups

Peer Groups FFT, Complaints, Never Events, OP DNA, OP New to Review and LoS: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool and Broadgreen University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospital Southampton NHS Foundation Trust - University Hospitals Birmingham NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals Of Leicester NHS Trust RTT: As above, plus the following providers: - Guy‟s and St Thomas‟ NHS Foundation Trust - Imperial College Healthcare NHS Trust - King‟s College Hospital NHS Foundation Trust - University College London Hospitals NHS Foundation Trust A&E: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool And Broadgreen University Hospitals NHS Trust - Sandwell And West Birmingham Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospitals Of Leicester NHS Trust

Listed below are the Trusts used to benchmark performance. HCAI: - Brighton & Sussex University Hospitals - Cambridge University Hospitals - Central Manchester University Hospitals - Chelsea & Westminster Hospital - Guy's & St. Thomas' - Imperial College Healthcare - King's College Hospital - Nottingham University Hospitals - Oxford University Hospitals - Plymouth Hospitals - Royal Free Hampstead - Royal Liverpool & Broadgreen University Hospitals - Salford Royal - Sheffield Teaching Hospitals - South Tees Hospitals - St. George's Healthcare - The Newcastle upon Tyne Hospitals - University College London Hospitals - University Hospital Birmingham - University Hospital of South Manchester - University Hospital Southampton - University Hospitals Bristol - University Hospitals Coventry & Warwickshire - University Hospitals of Leicester Cancer: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Christie NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - The Royal Marsden NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals of Leicester NHS Trust

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Appendix 3 - Glossary

Glossary SJUH - St James's University Hospital TBC - To Be Confirmed TDA - Trust Development Authority VTE - Venous Thromboembolism WHO - World Health Organisation YAS - Yorkshire Ambulance Service YTD - Year to Date

AF - Accountability Framework ASI - Appointment Slot Issue CAB - Choose and Book CAS - Central Alerting System CCG - Clinical Commissioning Group CDI - Clostridium Difficile Infections CIP - Cost Improvement Programme CQC - Care Quality Commission CQUIN - Commissioning for Quality & Innovation CSU - Clinical Service Unit CUTI - Catheter-associated Urinary Tract Infection DBS - Directly Bookable Services DH - Department of Health DNA - Did Not Attend EBITDA - Earnings Before Interest, Tax, Depreciation and Amortisation ED - Emergency Department FFT - Friends and Family Test FT - Foundation Trust GDP - General Dental Practitioners GMP - General Medical Practitioners HCAI - Healthcare Associated Infection HSMR - Hospital Standardised Mortality Ratio I&E - Income & Expenditure IQPR - Integrated Quality & Performance Report KPI - Key Performance Indicator LGI - Leeds General Infirmary LoS - Length of Stay MRSA - Meticillin Resistant Staphylococcus Aureus MSSA - Meticillin Sensitive Staphylococcus Aureus NIHR - National Institute for Health Research R&I - Research & Innovation RAF - Risk Assessment Framework RAG - Red Amber Green RTT - Referral to Treatment SHMI - Summary Hospital-level Mortality Indicator

Trust Board 30 January 2014 Public Section Paper ...€¦ · Public Section Paper Integrated...

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Transcript of Trust Board 30 January 2014 Public Section Paper ...€¦ · Public Section Paper Integrated...