Poor performance can affect all aspects of the
organisation resulting in possible regulatory sanctions
and legal claims against the Trust.
The aim of the Integrated Performance Board Report is
to ensure that patient, public, and workforce safety is
maintained to the highest standards
As far as can be considered this paper has no
detrimental impact for the 9 protected characteristics
under the Equality Act 2010
Recommendations:The Board is asked to note this report and receive assurance
therefrom.
Agenda Item 96/13
N/A
Executive Summary: The Integrated Performance Board Report has been
reformatted to include recommended changes from the Board. Performance against
key indicators continues to be inconsistent with targets not met in Cancer and A&E.
Patient Focus – Keep Getting Better
BAF risk 1
Previously considered at
Related Trust Objective
Related Risk
Legal implications /
regulatory requirements
Quality impact
assessment
Equality impact
assessment
Board of Directors’ Meeting Report – 27/03/13
Integrated Performance Board Report
Rupert Wainwright
Information Team, Rupert Wainwright, Sandra le Blanc,
Sue Hardy
To provide assurance to the Board about the Trust’s
performance against national and local performance
measures.
Sponsoring Director
Authors
Purpose
Title
Page 1 of 50
F February - Month 11 - 2012/13
Best possible rating of 'Green' Lowest possible Risk Rating of 5 3
>=90% within 18 weeks 91.6% 84.57% q
>=95% within 18 weeks 98.0% 97.49% p
>=92% 95.90% p
(<= 100) 338 p
< 23 weeks 23.02 p
< 18.3 weeks 15.37 q
>=95% of all cases to be seen
within 4 hours. (SITREP data) 93.8% 89.9% q
Arrival to handover (>= 85% within
15 mins) 36% p
Handover to clear (>= 85% within
15 mins) 91% u
Arrival to clear (>= 85% within 15
mins) 73% p
<12.64% by end of year (<13.34%
before Jan 13) 14.0% 13.20% p
<0.8% FFCE's cancelled with short
notice. 1.15% 2.22% p
< 5% cancellations readmitted
outside 28 days. 4.91% 4.40% q
<1% 0.59% 0.45% q
all cancers (>93%) 94.9% 97.0% p
symptomatic breast (>93%) 92.8% 92.1% p
>96% 97.6% 97.7% p
anti cancer drug treatments (98%) 99.5% 100.0% p
surgery (>94%) 97.1% 100.0% p
radiotherapy (>94%) 97.9% 95.7% q
from urgent GP referral to
treatment. All Pathways (>85%) 85.1% 83.0% q
from urgent GP referral to
treatment. Southend Only (>90%) 90.6% 89.5% p
from cons screening service referral
(>90%) 95.2% 92.0% p
<6 22 q
>99% 99.81% p
85.4 69.2 q
Standard / TargetCompliance -
YTD
Compliance -
Report MonthMovement on previous over 13 month period
MonitorGovernance Risk Rating
Finance Risk Rating
18 Week RTT
(Referral to
treatment)
Admitted
Non - Admitted
Incomplete (not yet stopped)
Admitted Backlog
Admitted (95th percentile wait in
weeks)
Non - Admitted (95th percentile
wait in weeks)
A&E
Maximum 4 hour wait
Ambulance Turnaround * (Week
ending 10/2/12 covering 4 week
period, Jan 27th unavailable)
Cancellations
IP - All cancelled TCI (hospital %)
IP - Short notice (non-medical)
IP - Short Notice Readmitted
within 28 days
OP - Short notice clinic
cancellations
Diagnostics (6 Wk
Target)
DM01 - Waiting list 'as at' month
end for Unify
All Cancers: 62 Day wait for first
treatment comprising either:
Cancer
2 week wait from referral to date
first seen
All Cancers: 31 day wait
diagnosis to 1st treatment
All Cancers: 31 Day wait for 2nd
or subsequent treatment,
comprising either:
Cancer Backlog
HSMR (Latest available) Not to exceed national average of 100 (<100)
SUHFT Integrated Performance Report
Trustwide Overview
Frontsheet
Patient Access - Rupert Wainwright
Key: Red = Negative performance or non-compliant, Green = Positive or compliant. Arrow direction indicates movement from previous. Areas shaded Blue are not yet updated with the latest figures.
Southend University Hospital Foundation Trust Page 2 of 50
Standard / TargetCompliance -
YTD
Compliance -
Report MonthMovement on previous over 13 month period
MonitorGovernance Risk Rating
Number of measures compliant 21 p
Number in compliance range. 3 q
Number non-compliant 2 q
Data not provided/no target 7 q
<1:20 18 q
≥90% 79.0% q
4200(<350) 264 q
≤25% 28.0% p
≥75% 75.0% p
<8 8 q
<=12% (per Key Performance
Indicator collection) 12.1% q
93.5% 93.6% p
7.49% 8.78% p
< 3.25% (Top quartile University
Trusts) 3.96% 4.19% p
< 9.5% (Top Quartile University
Trusts) 10.40% 11.87% p
1.034 p
96.6% 98.0% q
Maternity
Dashboard
Various clinical and operational
Measures
Direct unexpected NICU
admissions from CDS
Maternity currently
failing or with a
failure of
compliance /
target in the last 6
Months
Supervisor to Midwife ratio
Bookings before 12+6
Total maternities
Total rate - All LSCS
Initiation of breast feeding
Non-Elective
KPI - Smoking at Delivery
MRSA Screening Screen 100% of relevant admissions
Pre-op Bed Days (Elective) Target of < 7.45% to be maintained
Summary Hospital-level
Mortality Indicator (SHMI)Not to exceed national average of 1 (<=1)
VTE Testing>=95% (Internal Target- Data shown from last complete
month)
Readmissions (30
Day)
Elective
Quality - Sue Hardy
Southend University Hospital Foundation Trust Page 3 of 50
Standard / TargetCompliance -
YTD
Compliance -
Report MonthMovement on previous over 13 month period
MonitorGovernance Risk Rating
Formal Complaints 10% reduction on last year -6.24% p
141 128 p
0.0% q
0.8% q
Internal Target of Top
Quartile
(>75%) benchmarked against NHS
Midlands and East Trusts 13.0% q
54 q
Average across
business units>=90% 90.0% 96.5% p
21 5 p
3 1 p
Extreme 0 0 u
High 2 2 p
Low & Moderate 426 55 p
0 0 u
National Top 20% 32.3% p
Average 50.0% q
National Bottom 20% 17.7% p
Zero Tolerance 71 6 p
Targets pending outcomes of Qtr 1
monitoring. 0.20% 0.19% p
Targets pending outcomes of Qtr 1
monitoring. 0.20% 0.41% q
No targetYTD is average of most recent 12
months.90.73% 88.93% p
30 3 q
3 2 p
(5,964) (466) q
(3,382) 144 q
874 141 q
(250) (116) q
(1,552) (55) q
5,759 498 q
15,104 p
592 (181) p
68.3% 68.5% p
Complaints
Falls
Internal Target - 10% reduction on last year, - YTD & chart
show number above/below trajectory) (<= 0)
Moderate Harm as % of All Falls
High/ Extreme Harm as % of All Falls
Trust wide <=1 hospital acquired per year (Monitor will not
fail until 6)
Medication ErrorsTarget not yet
determined
Friends & Family10 point improvement on Previous Year End (55) CQUIN
(Commissioning for quality and innovation) Target
Head Nurse Quality Indicators
(HNQI)
Incidents of C Diff Trust wide <=26 hospital acquired per year
Incidents of MRSA
Bacteraemia
Mixed Sex Accommodation Target is 0 Breaches
Patient Reported
Experience
Measures -
PREMS
Quarterly patient survey results,
benchmarked against national
scores.
Safety Thermometer
Serious Incidents Targets under review
Pressure Ulcers
(Grade 2 and
above)
Total Hospital Acquired
(Avoidable)
Hospital Acquired as % of Total
Admissions (Avoidable)
Hospital Acquired as % of Total
Admissions (Un-avoidable)
Outpatient F/up
Inpatient Elective
Inpatient Planned
Inpatient Non-Elective
Capital (NET)On Budget spending Under plan/(Over plan), variance
shown. £000
- of which Never Events Target of '0'
Activity vs. Plan
Outpatient New
Variance: Net (Surplus) / Deficit
Pay Related Cost 60% (YTD shows average)
Cash Flow StatementCompliant to FT Plan (Under)/Over, figure shown is
variance on plan. £000
Income & Expenditure Variance: Net Surplus / (Deficit) £000
Quality - Sue Hardy
Finance & Activity - Brian Shipley
Workforce - Sandra Le Blanc
21 24
+2 1
Southend University Hospital Foundation Trust Page 4 of 50
Standard / TargetCompliance -
YTD
Compliance -
Report MonthMovement on previous over 13 month period
MonitorGovernance Risk Rating
Trust Total 78.88% 59.35% p
100.0% p
3.29% 3.82% 1.84% q
11.22% 9.20% q
4597 q
3,969.84 4009.82 q
96% 96.69% p
- 4,439.31 p
- 9.93% 12.49% p
3.29% 3.55% 3.00% q
All Staff
(FTE)Overall
2 16.15% p
Overall2 11.67% p
Voluntary 9.26% q
Involuntary 2.41% p
Left within 1 Year 23.72% q
Fire, Inanimate Loads & Infection Control
Statutory
Mandatory
Training
Reach 85% for all staff to be trained
in each 12 month period - number
trained vs. a headcount 77.56% q
8 0 u
40 2 q
4% 3.31% q
No set targets 5.39% p
Appraisals 80%
Induction99% (permanent and fixed term temp staff only, excludes
doctors)
FTE (permanent, fixed term temp
and locum staff only)
FTE (permanent, fixed term temp
and locum staff plus bank)
Bank Staff Rate
Agency Spend as % of Pay Bill (Monthly)
Bank, Agency and *Additional Non-Contractual Payments Total
Staff Levels
Headcount (permanent, fixed
term temp and locum staff only)
Establishment (FTE)
Sickness Absence Rate (rolling 12 months)
Staff Turnover
Rate
10.1% for staff excluding junior
doctors for the Trust (based on
public sector 2012 in CIPD report)
Excluding
Junior
Doctors
(FTE)
Vacancy Rate
Based on Establishment minus In
Post
Based on Requisitions against
Establishment
Fire, Inanimate Loads & Infection
Control
Employment Tribunals No set targets
Grievances Raised No set targets
Workforce - Sandra Le Blanc
Clinical Outcomes/ Research & Development - Neil Rothnie
Southend University Hospital Foundation Trust Page 5 of 50
Standard / TargetCompliance -
YTD
Compliance -
Report MonthMovement on previous over 13 month period
MonitorGovernance Risk Rating
Number of measures compliant 29
Number measures non-compliant 6
Data not provided 15
Clinical
Oncology 56.25% p
Pathology 8.79% p
A&E 6.31% p
Stroke 43.47% q
Ortho 90.48% p
Urology 43.08% q
7.07 p
7.07 p
157 u
24 u
103 u
59 u To be included from March '13
39 u Development underway
4 u
Target 25 days 16 u
1 u
u
u
u
u
u
68279 6956 q
0.53 0.46 q
4.18 2.87 p
Clinical Outcomes
(Qtr.)Various Clinical Measures
Clinical Outcomes
currently failing or
with a failure of
compliance in the
last year
(Quarterly)
% Radiotherapy within 24hrs for Spinal Cord Compression
Post MRI (100% Target)
Borderline Nuclear Abnormality Rates for Cervical
Screening (<9% Target)
% OP Patients Seen and Discharged in a Single Visit i.e.
One Stop (>85% Target)
Obstetrics
Perinatal Mortality Rate (<5.6/1000 Target)
Still Birth Rate (<3.1/1000 Target)
All Unscheduled Reattendances Within 7 Days (<5%
Target)
Number of Patients who Return Home with Total
Independence (>50% Target)
% Patients with Hip Fractures Operated on within 36hrs
(>80% Target)
Research
Governance &
Facilitation
Number of projects approved
Median time to approval (days)
Grant applications
Publications
Research Activity
Total number of research studies
Industry sponsored research
NIHR portfolio studies
Number of patients screened for
participation in research
Number of patients recruited into
research projects
A&E Attendances No applicable target, total for month & YTD
Average Length of
Spell (Discharge
Spec)
ElectiveNo set targets, for monitoring
purposes only.
Research Income
Grant income
Commercial income
Other charity income
Network Income
Non-Elective
Clinical Outcomes/ Research & Development - Neil Rothnie
Southend University Hospital Foundation Trust Page 6 of 50
1) Currently failing target
2) =< 1% above target
3) => 2 consecutive months deteriorating trend
4) Where predicted trend will breach target within 3 months
5) Recent unstable or erratic performance
RAG Colours: Desired outcome not completed and past the date
Desired Outcome being progressed and has not passed the date
Desired Outcome achieved
Could all Executives ensure that all the sections are completed.
Indicators will be be analysed to assess whether or not they
represent a concern for the immediate future. Although
discretion will be used, indicators will generally be highlighted
as a concern if their performance meet one or more of the
following conditions:
Performance Matrix
Page 7 of 50
Concern
Failure
Patient AccessAdmitted
Non - Admitted
Incomplete
Admitted Backlog
Maximum 4 hour wait
Ambulance Turnaround (arrival to handover)
Ambulance Turnaround (arrival to clear)
IP - All cancelled TCI (hospital %)
IP - Short notice (non-medical)
IP - Short Notice Readmitted within 28 days
2 week wait from referral to date first seen (All)
2 week wait from referral to date first seen (Breast)
All Cancers: 31 Day wait for 2nd or subsequent treatment (surgery)
All Cancers: 31 Day wait for 2nd or subsequent treatment (radiotherapy)
All Cancers: 62 Day wait for first treatment (GP referral)
All Cancers: 62 Day wait for first treatment comprising either: from urgent GP referral to treatment. Southend Only (>90%)
All Cancers: 62 Day wait for first treatment (Cons screening referral)
Cancer Backlog
Breast Feeding Initiation
Smoking at Delivery
MRSA Screening
Pre-op Bed Days (Elective)
Elective
Non-Elective
SHMI
Patient QualityComplaints
Total Falls
High/ Exreme Harm
Benchmarked against NHS Midlands and East Trusts
10 point improvement on previous year
Incidents of MRSA
Pressure Ulcers Total Hospital Acquired (Avoidable)
Serious Incidents of which Never Events
Work ForceAgency Spend as % of Pay Bill (Monthly)
Establishment (FTE)
Sickness Absence Rate (rolling 12 months)
Overall (10-11%)
Statutory Mandatory Training
Staff Levels
Staff Turnover Rate (Excl. Junior Doctors)
18 Weeks RTT
A&E
Cancellations
Readmissions (30 Day)
Falls
Maternity
Friends & Family
Cancer
Concerns/ Failures for compliance month
Page 8 of 50
Executive Overview:
SUHFT Integrated Performance Report
Operational SMART Objectives
Patient Access Overview February has been another difficult month with a range of performance measures failing, or likely to fail. These can be grouped into the areas which have been affected by the management of Winter pressures, and areas which are not p erforming for unrelated reasons. Even in those unrelated areas it should be noted that the individuals under pressure for managing Winter pressures are often the same that must keep other areas running. Winter pressure issues Activity continues to be much higher than planned, as well as higher than previous years' activity yet even so the effect on Southend and the region has been more destabilising than previous years. The cost of managing the Winter pressures using temporary staff and catching up with lost operating lists is significant. The most obvious indicator is the A&E 95% 4 hour target which has been consistently missed since December. Action plans have been implemented to remove the least effective processess, the Intensive Support Team have provided a list of recommendations to provide a sustainable, joined up and effect ive service which will require considerable commitment to change by medical, nursing and the new management team in place from March. Elective activity has been reduced and expensively replaced during February to first stop the rise in the backlog of patients waiting more than 18 weeks for treatment, then secondly to bring it down as far as possible in the quarter to avoid repeated target failures in 2013 -14. This turnaround did not start to reduce the backlog until mid-February, thus leaving the forecast backlog between 250-300 patients rather than the 150-200 previously predicted. At mid-March the backlog reduction was 66 patients behind trajectory after 91 patients were cancelled during February. Cancer patient issues Winter pressures only indirectly impact on Cancer patients as they get priority over routine elective patients but there were still some delays in treatment due to staff shortages which caused breaches of the 90% Southend-only patient target set by the board. Haematology patients with very complex pathways breach ed in February which was enough to keep the Quarter to Date figure at 89.4%. March patient lists are being actively managed to ensure a higher than target compliance but this target is now in jeapardy for Q4, having been achieved for Q3. Summary The overrall picture is of a Trust which is performing poorly in a number of areas, and Southend has recently moved to 5th ou t of 5 in Essex in some weeks for A&E performance. Very few trusts are performing properly in the East of England region this year but the priority for Southend is to rapidly improv e patients' access to care to the best levels possible for a region under this pressure, even if that does not immediately meet national targets. Rapid changes in clinical commitment, management and processeses are underway to achieve that improvement, and to increase el ective activity during quarters 1-3 to ensure a much better foundation for next Winter.
Page 9 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
See narrative on 18 Wk - Incomplete. Percentage achievement (above) is only relevant with a
small and stable backlog, which has not been the case since December
Improvement AreaAdmitted
90% within 18 weeks
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
80%
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 10 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Agreed target in contract with PCT
of 95% at specialty level not
reached. Trust level performance
exhibiting a downward trend.
Specialty level compliance
of the non admitted target
30th April
2013
All Business Unit's
Buds and ABUDsSigned off?
Since January the focus has been on avoiding any future 52 week waiters by changing pathways
at the post-25 week stage to make them simpler and monitor tertiary hospital long delays.
The length and complexity of these long pathways means that solving problems for patients at
25 weeks will take many weeks change 52 week compliance, whilst dealing with those at later
stages in the pathway may be too late. In other words, there will be more 52 week breaches
over coming months, but the numbers of patients in the later stages of the pathway will be
checked each to ensure the numbers are dropping, and therefore the plans are effective.
Improvement AreaNon - Admitted
95% within 18 weeks
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
93%
95%
97%
99%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 11 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
An agreed limit of 100 backlog
patients and a stretch target of 16
weeks compliance by end October
were not achieved due to surgical
and theatre capacity. Winter
emergency demand and
cancellations completed the
problem
See - 18 week Admitted Backlog section for comments
Backlog reduced to 100
patients. Compliance with
90% admitted target, and
95% non-admitted target by
specialty.
end-March Rupert WainwrightSigned off?
Although all indicators are passing for RTT the backlog has increased in December and 95th percentile times have increased. This has resulted in the incompletes performance decreasing this month. This also means
that the admitted performance inparticular could be very low in the next couple of months and may miss the target. Recovery plans agreed with Business Units and currently being implemented.
Improvement AreaIncomplete (Not yet stopped)
92%
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
90%
92%
94%
96%
98%
100%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 12 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
February board update: Severe A&E and bed pressures are still causing restricted elective work and
therefore the backlog continues to rise. The new target for backlog reduction by the end of March is
now closer to 150, which is still low enough to be sustainable long term. However, without
improvement by the end of February, the backlog will be too high to allow target compliance in April,
and therefore Q1. The focus therefore remains on resolving A&E and emergency care to free up beds
for elective work. March Board update: A&E and bed pressures continued and deepened in February,
regionally and for Southend. The impact was an increase in the backlog of patients instead of the
necessary reduction. This increase turned to a decrease in mid-February which has been sustained for
the last 4 weeks, but leaving the trajectory 66 patients behind plan. 91 elective patients were
cancelled in February and a number of lists were not run because the bed capacity could not support
them. The situation is still very difficult but there are fewer outlying patients as March progresses.
Improvement AreaAdmitted backlog
<= 100
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
100
200
300
400
500
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 13 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Inability to create enough over-
performance to allow for Winter
peaks.Unusually high and erratic
demand across the region.
Basildon hospital required to stop
almost all elective work.
Achievement of 95% target
each week by end of Q4.
Achievement of Q1 and Q2
with enough margin to
allow for problems in Q3
and Q4 in 2013/14
End Q2 Rupert WainwrightSigned off?
Since the last board report the Intensive Support team have produced their report and
recommendations which have been put into a draft plan, with some quick actions and some
medium term actions which will require significant changes in process and working practice for
senior clinicians in A&E, AMU and wards to provide senior decision making to avoid times when
junior teams are over-pressured due to their reduced complement. A key corporate risk for the
last year has been the lack of the right numbers of junior doctors from the deanery and as
funded backfill for those gaps in the rota. An experienced professional A&E manager has been
recruited on an interim basis to stabilse the existing system and to implement the A&E parts of
the IST action plan. She started on 4th March. It is worth noting that the widespread failure
across the region is held to be partly the responsibility of the East of England ambulance
service, and the new Chief Executive has brought in an external reviewer to recommend
remedial measures. The board will receive a comprehensive update on the Emergency Care
pathway plans, the timetables, risks, and planned outcome to achieve national targets.
A&E targets failed for Q3 and likely to fail for Q4 and the year. The current system fails increasingly steeply when put under pressure and the high and erratic demand across the region has
exposed the weaknesses.
Improvement AreaA&E Maximum 4 hour wait
95% of all cases to be seen within 4 hours. (SITREP data)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 14 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Ambulance handovers are too
slow in the hospital unusual
volume peaks this year, slow
A&E systems to take the
patients, and a Southend bed
model that does not deliver the
right beds at the right time
Meet 15 minute handover
target, as part of overall
A&E plan. This is so very
much more than has been
achieved at Southend,
even when 95% 4 hour
target was being met, so
will have to follow
sustained 4 hour
compliance as a medium
term trajectory.
Q2 2013 Rupert WainwrightSigned off?
Note: The ambulance service was unable to provide handover times in February. There
are clearly delays at times at Southend A&E which cause ambulances to queue. An audit
has been carried out which showed large discrepancies between the times that the A&E
department had taken over patients and when the ambulance crews had stopped their
clocks, but resolution with the EoE ambulance service has not been conclusive. Since
the start of winter real delays have been obvious (strangely without much impact on the
performance figures), and the aim is to work on those controllable delays as part of the
overall A&E plan. Ensuring correct clock stops will be done after that. A new and
experienced A&E interim manager has been appointed with recent experience at
stopping both the real delays and the clock stop problems to move her trust from
second last to second best in that region.
Improvement AreaAmbulance Turnaround * (Week ending 10/2/12 covering 4 week period, Jan 27th unavailable)
Arrival to handover (>= 85% within 15 mins)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
10%
30%
50%
70%
90%
Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Page 15 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
Improvement AreaAmbulance Turnaround * (Week ending 10/2/12 covering 4 week period, Jan 27th unavailable)
Arrival to clear (>= 85% within 15 mins)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
50%
60%
70%
80%
90%
100%
Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
Improvement AreaIP - All cancelled TCI (hospital %)
<12.64% by end of year (<13.34% before Jan 13)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
10%
12%
14%
16%
18%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 17 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Peak in July reported to Board and
action requested to provide more
detail.In November and December
as emergency erratic demand
outstripped capacity in theatres
and beds
The key measure is
reduction in short term
cancellation rate to below
0.8 percent, in a consistent
way so the long term trend
line starts to move down
end-Feb Rupert WainwrightSigned off?
Cancellations have continued at a destabilising rate due largely to bed capacity but also due to
anaesthetist and theatre staffing issues where both planning and morale have been an issue.
The theatre clinical leaders and management team have been given additional support to help
plan proper staffing levels and to manage the day to day issues. This Business Unit is still
embryonic compared to the other Business Units and therefore performance is being more
closely managed, and structures changed where needed to deal with the pressures of
additional emergency activity over Winter and elective activity due to 18 week backlog
reduction.
After improving following the appointment of an new ABUD in August, cancellations have increased significantly due to emergency winter demand. This has affected most key indicators showing that
there was not sufficient marginal capacity set up, and the current culture is not used to making rapid changes in response to urgent pressures.
Improvement AreaCancellation - IP - Short notice (non-medical)
No more than 0.8% FFCE's cancelled with short notice.
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 18 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
See short notice cancellation narrative as the cancellation target figures are part of the same
issue. The only extra note on this particular issue are that the number are very small, therefore
erratic and readmissions are being booked in time, but subject to the same cancellations and
restrictions by the A&E issues.
Improvement AreaIP - Short Notice Readmitted within 28 days
Less than 5% cancellations readmitted outside 28 days.
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0%
5%
10%
15%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 19 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Failure to meet 2 week wait from
referral to date first seen, due to
reduced capacity over Christmas
period.
No continued failure
Feb-13 Rupert W.Signed off?
February recovered as expected from the last Board report
Improvement Area2 week wait from referral to date first seen
all cancers (93%)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 20 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Failure to meet 2 week wait from
referral to date first seen, due to
reduced capacity over Christmas
period
Quarter compliance
Mar-13 Rupert W.Signed off?
Q4 is now looking difficult to achieve due to the deep dip in January from Christmas referrals.
Better capacity put in place but the recovery relies very heavily on patients being willing to
come to clinic within 2 weeks, often without being aware that they are being referred for
suspect Cancer diagnosis.
Improvement Area2 week wait from referral to date first seen
symptomatic breast (93%)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 21 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Failure in compliance in January
due seasonal fail, reduced
capacity. 4 breaches - 1 clinical, 3
capacity
February Compliance
Feb-13 Rupert W.Signed off?
February compliant as expected from last Board report
Improvement AreaAll Cancers: 31 Day wait for 2nd or subsequent treatment, comprising either:
surgery (94%)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
80%
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 22 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
This is now being monitored more closely as patients have not had a problem accessing care in
time before now, and is included in this exception report as a warning flag to the department to
keep compliant.
Improvement AreaAll Cancers: 31 Day wait for 2nd or subsequent treatment, comprising either:
Radiotherapy (94%)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
90%
92%
94%
96%
98%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
See Cancer - 62Day Trt. SUHFT Only tab for comments.
Improvement AreaAll Cancers: 62 Day wait for first treatment (from urgent GP referral to treatment)
85%
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
70%
75%
80%
85%
90%
95%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 24 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
On-going issue Consistent achievement of
the 62 day target.
Consistent and monitored
improvement at all stages of
each pathway by new
tracking reports to ensure
62 days is likely to be met.
Reduction in number of late
referrals from other sites.
end-Feb Rupert WainwrightSigned off?
March board update: Key actions have been taken as described below, but achievement is now
a very high risk for the quarter. Key leadership changes are reducing current breaches but a new
and focussed approach is needed, and a clinically led structure has been proposed by the
Medical Director, which will be implemented and supported to provide longer term delivery.
February board update: Actions include
• A clear instruction from the Board to reach and maintain a level of 90% compliance for
patients who start and end at Southend
• Discussions with Basildon on an agreed turnaround time for EBUS reporting which is part of
the Lung pathway and currently ensuring a breach every time a referral is made. Basildon take
no share of the breach for these patients. The aim is to move the time from referral to
reporting from 3-4 weeks to 1-2.
• EBUS business case being prepared with an option currently being explored which would
provide the equipment to us leased at £15k per month.
Improvement AreaAll Cancers: 62 Day wait for first treatment from urgent GP referral to treatment. Southend Only
90%
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
80%
85%
90%
95%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 25 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Failure to target in January due to
2 breaches. 1 x patient choice. 1 x
clinical reasons
Action plan completed and
continued review
Feb-13 Rupert W.Signed off?
February compliant after simple recovery plan enacted.
Improvement AreaAll Cancers: 62 Day wait for first treatment (from cons screening service referral)
90%
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
75%
80%
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 26 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
See Cancer - 62 day Treatment tab for comments.
Improvement AreaCancer Backlog
<6
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
5
10
15
20
25
30
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 27 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
This remains a target which is monitored but is largely outside the trust control, and is a topic
of contractual discussion.
Improvement AreaBreast Feeding Initiation
>=75% (per maternity dashboard)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
60%
65%
70%
75%
80%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
Once again the success or failure of this target is largely outside the trust's control.
Improvement AreaSmoking at Delivery
<=12% (per Key Performance Indicator collection)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
5%
10%
15%
20%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
Progress has plateaud for a considerable period. As the Winter pressures recede this will be
moved up the priority list for full monitoring and compliance for the last few percent of patients
- either to screen them or show that they are not "relevant admissions".
Improvement AreaMRSA Screening
Screen 100% of relevant admissions
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
85%
90%
95%
100%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
This is affected by bed capacity and Winter pressures and will be re-examined as they reduce.
The key effort will be on a year-round plan to deal with these pressures at known times,
therefore reducing bed pressure impact on this indicator and others. In parallel there will be a
further look at any areas where pre-op admission has become clinical practice so that this can
be understood, and stopped where appropriate.
Improvement AreaPre-op Bed Days (Elective)
Target of < 7.45% to be maintained
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
5%
6%
7%
8%
9%
10%
11%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
This is dealt with largely as a contractual issue but there has been an audit of the
appropriateness of readmissions, following national guidance that suggested that only a very
small proportion of readmissions were in the control of acute trusts. Other reasons for
readmission are lack of consistent care in the community, co-morbities that make admission for
other reasons happen and frail patients who have reached a stage that frequent hospital
admissons become the norm - in the absence of a care plan that acknowledges the
inappropriate nature of some acute interventions when they are no longer helpful.
Improvement AreaElective
< 3.25% (Top quartile University Trusts)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0%
1%
2%
3%
4%
5%
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
See Elective readmission comments
Improvement AreaNon-Elective
< 9.5% (Top Quartile University Trusts)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
5%
7%
9%
11%
13%
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Signed off?
This is now a part of the regular board report and in subsequent months will be reported on in
more detail by the Medical Director, looking behind the average of all specialties to get a true
picture of areas that may be of concern, and reasons for any increase in the average figures
shown.
Improvement AreaSHMI
Not to exceed national average of 1
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0.950
Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12
Page 34 of 50
Executive Overview:
SUHFT Integrated Performance Report
Operational SMART Objectives
All elements in HNQI achieved the required level of performance, with 6/7 achieving stretch target of 95% An increase in compliance with falls prevention (98.4%) has not resulted in the desired decrease in the number of falls. Acti vity around emergency admissions remains high and it continues to be necessary to transfer more stable medical patients to wards outside medicine in order to accommodate acute ad missions. Nursing teams are reporting additional pressure around patient transfers and admissions. Patients continue to report being unsettled and unhappy with being transferred. A slight decline in PU prevention compliance was noted, with Medicine and Surgery not achieving 90% compliance and a slight i ncrease in avoidable pressure damage has been seen in some areas (reported separately). In some cases risk was not appropriately re -assessed, it was also identified that there was insufficient documentary evidence of appropriate levels of intervention. Additionally, demand on pressure relieving equipment has been high, resulting in the need to hire equipment whe n internal provision has been exhausted. The tissue viability team are reviewing the stock levels with MEMS service in order to identify procurement needs going forwards. The high level of emergency admissions has required additional beds, including the temporary ward, Ward 1 to remain open thro ughout February. It has been necessary to move some staff from medical wards to work in Ward 1 in order to ensure that the additional beds are safely staffed with the correct sk ill mix. In some cases back-fill cover with temporary (bank and agency) staff has been obtained to maintain staffing levels, but this can dilute the skill mix on the wards. In other cases i t has not been possible to secure back-fill for the wards providing staff to Ward 1, leaving some wards below optimum staffing levels. This continues to be monitored by the Matrons. Plans are i n place to close the additional beds by the end of March.
Page 35 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Increase in number of complaints
in January has taken us above the
trajectory to achieve a target of
10% reduction in complaints this
year.
10% reduction in the
number of complaints
compared to previous year
End March
2013 BUDsSigned off?
Business units are required to provide details of actions implemented to address issues raised
in complaints. Meetings with complainants are offered in order to discuss and resolve issues
and concerns. Ward Managers undertake ward rounds with patients and visitors during
supervisory time in order to identify any concerns at the earliest opportunity so that they can
be addressed in a timely fashion.
The seasonal trend of an increase in the number of complaints after the Christmas and New year period was noted, with an increase in the number of complaints received compared to the same period
last year. A similar pattern has been noted in another hospital within the area.
Improvement AreaFormal Complaints
10% reduction on last year
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
-15%
-10%
-5%
0%
5%
10%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Page 36 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Above target trajectory Compliance with falls
prevention care planning
≥90%. Reduction in falls
Mar-13
Ward Managers and
MatronsSigned off?
Matrons continue to monitor compliance with falls assessment and implementation of falls
prevention care plan. Ward Managers undertake spot checks of patients at risk of falls.
Improvement in compliance achieved across the wards. Falls prevention team provide specialist
advice and staff training in relation to patients at risk of fall.
We continue above the target trajectory within the year to date position. It is therefore unlikey we will achieve the 10% reduction in falls this year. Only 1 patient was reported to have severe injury. This is
considered unavoidable. Compliance with falls risk assessment and falls prevention care planning has improved across the trust (98.4%), though it has been noted that on occasions, some patients (with
full mental capacity) decline to follow falls prevention advice / intervention. Emergency and ward activity remains high, with a number of medical patients o continuing be transferred to wards outside of
speciality and resulting in an alteration in usual case mix on the wards.
Improvement AreaTotal Falls
Internal Target - 10% reduction on last year
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
25
50
75
100
125
150
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 37 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Review of the documentation and
the patient with a high severity fall
suggests that falls prevention
intervention was not necessary as
the patient was not considered at
risk of falling.
Appropriate care plans in
place for patients at risk of
falls. Reduction in high
severity falls
End March
2013
Matrons & Ward
Managers supported
by Falls prevention
practitionerSigned off?
Revised care plan document being trialled.
1 high severity fall occurred in February, which is considered to be unavoidable. The patient had been independent, safely mobilising and assessed as rehabilitation fit, with no risk of fall. A new falls
prevention care plan is being trialled in two wards that admit patients at a high risk of falls. If this is positively evaluated at the end of the trial it will be implemented across the trust.
Improvement AreaHigh/ Extreme Harm as % of All Falls
No Target
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0%
1%
2%
3%
4%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 38 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
See separate section "Friends and
Family".
Mar-13 BUDsSigned off?
Our internal target is for the Trust to be ranked in the top 25% Trusts when benchmarked against the Trusts within the Midlands and East. A poor NPS score in the third week of February
and an increase in detractor responses has adversely affected our over-all NPS score. Key areas of patient reported dissatisfaction are reported in separate section "Friends and Family".
Improvement AreaInternal Target of Top Quartile
(>75%) benchmarked against NHS Midlands and East Trusts
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0%
20%
40%
60%
80%
100%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13
Page 39 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Increase in Detractor responses
across the wards.
Increase in patients who
would recommend the
hospital
Mar-13 BUDsSigned off?
Ward Managers are receiving weekly reports on the NPS score and patients' comments to
enable them to identify and action issues in a timely manner. Though negative responses are
attributed to the ward receiving the transferred patient, it does not necessarily reflect poor
care on that ward. Ward staff are trying to make patients feel welcomed and settled on
transfer.
The over all Nett Promoter Score (NPS) for the Trust fell by one point in February. There was a slight increase (1%) in "promoter" responses and a 5% reduction in passive responses. However, detractor responses were more
than 3 times higher than in January at 4.6%. Some patients decline to provide a comment. The four areas of dissatisfaction most commonly reported are around: being unhappy about being moved to another ward (n.15);
ward perceived to be busy (n.15); Wait for TTA (n.5) and ward perceived to be understaffed (n.5). The continued high level of activity and pressures around accommodating emergency admissions is reflected in comments
around dissatisfaction with being moved to different wards.
Improvement AreaFriends And Family
Target +10 improvement by March 13
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
20
40
60
80
100
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 40 of 50
585 (15%)
+54
-1
+9 (Target +10 improvement by March '13)
NPS Score by Ward **
Ap
r
May
Jun
Jul
Au
g
Sep
Oct
No
v
Dec
Jan
Feb
Mar
Trust 45 68 69 64 57 81 75 80 82 55 54
CCU - - 59 90 67 79 89 96 100 60 92DAU - - 50 50 62 96 82 100 74 94 83Edmund Stone - - 88 83 63 70 94 86 90 70 78Hockley - - 96 39 77 64 96 81 88 44 78Elizabeth Loury - - 100 100 33 86 75 100 93 - 77Chalkwell - - - - - - 72 - - 61 76Balmoral - - 61 87 85 92 56 89 75 72 62
Eleanor Hobbs - - 41 74 41 88 68 73 88 31 62
Bedwell - - 78 20 71 73 80 68 78 94 60
Eastwood - - 72 33 60 94 76 92 90 47 60Benfleet - - -33 60 60 80 60 39 100 53 54Kitty Hubbard - - 75 25 85 67 89 88 100 50 53Estuary - - 50 40 58 91 60 63 70 52 52Rochford - - 60 33 67 82 56 71 82 64 50Gordon Hopkins - - 73 89 80 92 86 100 82 57 50 *a = no. of patients surveyed *b = % of patients surveyed of ward discharges (where % surveyed
Paglesham - - 67 33 -25 58 50 63 60 56 50 was 10% or more for latest reporting month/YTD respectively)
Castlepoint - - 72 59 42 75 71 83 76 43 46 ** where wards have a % survey sample of 10% or more of IP discharges YTD
Westcliff - - 0 88 50 90 69 74 63 47 44 allowing for significant and meaningful reporting comparisons
Blenheim - - 60 60 39 83 64 80 82 49 40 The overall Trust NPS (YTD) was made up from patients surveyed across 27 wards. 22 of the 27 wards
Windsor - - 87 76 62 83 83 88 95 23 31 sampled are shown in this report on the basis 10% or more of patients discharged from the ward (ytd)
Stambridge - - 57 65 46 77 39 36 71 50 26 were surveyed. The other 5 wards had very small sample sizes therefore not allowing a meaningful,
Southbourne - - 58 44 50 96 50 54 33 89 11 or significant, interpretation of their NPS within this report.
NPS Change from April 2012
Latest reporting month: Feb 2013 No. surveyed
Net Promoter Score (NPS)
NPS Change on Last Month
Top 5 Wards (*a,*b) Bottom 5 Wards (*a,*b)
This Month ** YTD *** This Month ** YTD ***
CCU (12, 24%) DAU (147, 38%) Southbourne (18, 34%) Paglesham (103, 23%)
DAU (29, 71%) CCU ( 139,28%) Stambridge (27, 44%) Stambridge (198, 32%)
While the positive comments far exceeded negative, 4 key areas of dissatisfaction were identified across the trust: unhappy with being moved to another ward; ward being busy; ward
appearing short staffed; and wait for TTAs. Whilst Ward Managers endeavour to address concerns raised in the weekly reports, the high level of activity and transfer of patients to
accommodate emergency admissions continues to create pressure on the ward and dissatisfaction among patients.
Edmund Stone (37, 24%) Edmund Stone (486, 32%) Windsor (29, 14%) Benfleet (97, 16%)
Hockley (18, 21%) Gordon Hopkins (220, 33%) Blenheim (48, 47%) Southbourne (134, 29%)
Elizabeth Loury (13, 12%) Elizabeth Loury (111, 11%) Westcliff (16, 20%) Blenheim (353, 36%)
ACTION PLANS AND RECOMMENDATIONS
Patient Revolution: The Friends and Family Test
0
10
20
30
40
50
60
70
80
90
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Net
Pro
mo
ter
Sco
re
Trust Net Promoter Score by Month (2012/13)
Target Trendline Trust NPS
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
1 reported case of an unavoidable
MRSA Bacteraemia
No further avoidable MRSA
bacteraemia
End March
2013 BUDsSigned off?
No concerns around practice or care identified. IPCT continue to promote and monitor
compliance with good IPC practice.
One new case of MRSA bacteraemia was reported in February. We are now 2 cases above our ceiling for the year of 1 case. RCA has been carried out and been reviewed by the Infection Prevention and Control Team (IPCT),
the Director of Infection Prevention and Control (DIPC), clinical team and our commissioners. It has been agreed that this was an unavoidable case in a patient with very complex clinical needs. No issues around practice or
care were identified.
Improvement AreaIncidents of MRSA
Trust wide 1 hospital acquired per year
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
1
2
3
4
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 42 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
6 cases of avoidable pressure
damage reported
Zero Tolerance of pressure
damage and reduction in
pressure damage.
End March
2013
Matrons & Tissue
Viability TeamSigned off?
Phase 1 of the SSKIN initiative is to be rolled out by the end of April 2013, supported by the
tissue viability team. Learning from RCAs continues to be shared and the implementation of
practice developments and improvements is being overseen by the Matrons. Issues around
availability of pressure relieving equipment are to be escalated and ward teams to ensure
additional proessure relieving intervention and position changes are to be put in place whilst
delivery of equipment is awaited.
6 cases of avoidable pressure damage were reported in February, comprising of 3 patients with Grade 2 skin damage and 3 patients with Grade 3 damage. RCAs have been carried out for 2 of the cases of
Grade 3 damage and the third RCA is in progress. Key learning from these cases is around insufficient documentation of pressure relieving intervention and position change. One patient should have been
reassessed for the risk of pressure damage following the deterioration in their clinical condition. The failure to reassess the risk meant that it was not identified that additional intervention needed to be
put in place. Increased activity and an increase in patients identified as at risk of pressure damage has increased demand on pressure relieving equipment. When the Trust's supply of pressure relieving
mattresses is in use, there can be a delay in obtaining specialist mattresses from an external supplier. Matrons are responsible for ensuring that positive action is in place to address the areas highlighted.
Improvement AreaGrade 2 and above - Total hospital acquired (avoidable)
Zero Tolerance
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
0
5
10
15
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 43 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
2 never events reported in
February (3 year to date)
No further reports of never
events
End March
2013
Clinical teams
undertaking
proceduresSigned off?
Additional checking procedures being implemented and work underway to standardise check-
lists for procedures performed outside of theatres. Staff communication / education campaign
commenced to raise awareness of learning points. Observational audits to be undertaken to
ensure compliance with checking procedures.
2 Never Events reported in February (1 eye unit, incorrect lens; 1 OPD wrong site surgery under local anaesthetic). Learning points from RCA being implemented.
Improvement Area - of which Never Events
Target of '0'
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
-1
0
1
2
3
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 44 of 50
Executive Overview:
SUHFT Integrated Performance Report
Operational SMART Objectives
The agency project group have implemented a number of central control measures to reduce agency spend . These include a further revision of the enhanced observation policy to reduce nursing and security agency requirements to 'special' patients. Guidance issued to the bank booking team and business units for booking medical agency staff, together with a reminder on consultant cover arrangements available under their contract of employment. The opening of Ward 1 to cope with w inter pressures has increased agency spend, however it is intended that the ward close on 21st March. Sickness absence is 3.5% for 12 months up to 28th February 2013, a slight increase of 0.03% from the previous month. Busines s Units are working towards achievement of their action plans. The Trust is marginally below trajectory at 77.56% for statutory mandatory training and has seen a slight drop from the previ ous month. The areas that are below 80% are Medicine (73.09%), Theatres and Critical Care (74.13%), Women's and Children (72.13%) and Central Services (75.51%). Staffing levels have decreased, however as reported to the Board last month, concerns have been raised in relation to data quality and a potential discrepancy between data held on ESR and the Finance system. The audit should be completed by end of March 2013. Turnover is based on staffing levels, therefore the audit may impact on the turnover data contained in this report. The audit should b e completed by end of March 2013.
Page 45 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Non achievement of target. On-going
On-going
Executive Team /
PMO
Director of HR / COO
/ Director of Finance
Signed off?
1. Continued monitoring of agency spend and delivery of CIPs through BU performance
framework.
2. Agency Project to review agency spend and identify and implement further central control
measures
Target of 2.68% based on Trust CIP plans submitted at the beginning of the financial year 2012/13. CIP plans have since been updated, and revised threshold is 3.29%. Despite central control measures
being implemented, agency spend is erratic.
Improvement AreaAgency Spend as % of Pay Bill (Monthly)
2.68%
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
2%
3%
4%
5%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 46 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Data shows that headcount is
above target level.
Assurance to the Board end of March
2013
Director of HR
Signed off?
Staffing levels data to be audited due to concerns in relation to data quality
Staffing levels have decreased, however as reported to the Board last month, concerns have been raised in relation to data quality and a potential discrepancy between data held on ESR and the Finance
system.
Improvement AreaEstablishment (FTE)
3969.84
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
3900
3950
4000
4050
4100
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 47 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Erratic performance, and
likelihood that we will not achieve
the stretch target of 3.3%
Progress towards achieving
3.3%.
On-going
June 2013
Executive Team
Associate Director of
HR
Signed off?
1.Continued monitoring of Business Unit action plans through performance management
meetings
2. Review effectiveness of revised sickness absence policy.
Sickness absence is 3.5% for 12 months up to 28th February 2013. Sickness absence increased slightly (up 0.03%) from the previous month. Business Units are working towards meeting their absence
plans . New policy on target for implementation.
Improvement AreaSickness Absence (rolling 12 months)
3.29% (trajectory)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
3%
4%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 48 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Data shows that we are above
benchmark levels for turnover.
Assurance to the Board
End of March Director of HRSigned off?
1. Staffing levels data to be audited due to concerns in relation to data quality.
Revised benchmark of 10.1% as previously agreed. Data shows that we are above the benchmark level, however this is subject to audit of staffing levels data.
Improvement AreaExcluding Junior Doctors (FTE): Overall
10.1% for staff excluding junior doctors for the Trust (based on public sector 2012 in CIPD report)
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
9%
10%
10%
11%
11%
12%
12%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 49 of 50
Executive Summary/Notes:
Area
Target
Reason/Source Desired Outcome By When? ResponsibilityR
A
G
Erratic performance against
trajectory.
Achievement of 85% End of March
2013
Business Unit
Directors / Executive
Team (through
performance
management
meetings)
Signed off?
Business Units to continue to monitor achievement of trajectory
The Trust is marginally below trajectory at 77.56% for statutory mandatory training and has seen a slight drop from the previous month. The areas that are below 80% are Medicine (73.09%), Theatres and
Critical Care (74.13%), Women's and Children (72.13%) and Central Services (75.51%).
Improvement AreaFire, Inanimate Loads & Infection Control
Reach 85% for all staff to be trained in each 12 month period - number trained vs. a headcount
Action
SUHFT Integrated Performance Report
Operational SMART Objectives
60%
70%
80%
90%
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Page 50 of 50
Top Related