board of directors operational performance report … 9 - operational... · board of directors...

BOARD OF DIRECTORS OPERATIONAL PERFORMANCE REPORT

Month 9 (December 2014) and Quarter 3 (Oct-Dec 14)

Presented By:

22nd January 2015

Board of Directors

Rob Elek

Director of Strategy and Business Development

Produced By:

Stephen Chinn

Senior Performance AnalystAction for Board: For information

For consideration

For decision

Exception Report -3

Compliance Performance Summary Page 4

Access - Referral to Treatment Page 5 - 6

Access - A&E Page 7 - 8

Access - Cancer Waiting Times Page 9

Access - Other Page 10

Efficiency Page 11 -12

Effectiveness Page 13

Safety Page 13

Page 14

Page 15Patient Experience

Ward Staffing Levels

CONTENTS

Board of Directors Performance Report - December 2014 and Quarter 3

Exception Report - December 2014 and Quarter 3

18 Week RTT Performance: The Trust achieved referral to treatment (RTT) compliance in December for all three RTT measures. Admitted performance achieved the 90% target for the first time this financial year, with 92.1% of patients seen within 18 weeks (M8 88.9%). The Q3 position of 89.2% (Q2 83.4%) remained below target, as anticipated, following M7 and M8 performance. RTT Non Admitted Performance continued to achieve at 96.1% (M8 95.7%). The target was also achieved for Q3 with performance of 95.8% (Q2 94.1%). RTT Incomplete Pathways continues to achieve the target with performance of 95.1% (M8 95.6%), well above the 92% target. Q3 performance of 95.3% (Q2 92.1%) has resulted in compliance in our YTD position at 93.2%. The above is provisional pending final validation and submission on 20th January. Accident and Emergency: A&E 4 Hour performance continues to meet the national target of 95%, achieving 99.3% in December and 99.1% for Q3. A&E 3 hour performance continues to achieve the internal target of 80%, achieving 81.2% in December and 81.2% in Q3. Activity continues to increase, especially compared to the previous year where it has increased 10% compared to last December and 8.4% for the year to date. This represents an average increase of 20 A&E attendances every day. Percentage of A&E patients seen, treated and discharged by an Emergency Nurse Practitioner (ENP) remains below our local target of 30%, with 22.8% of patients treated in December and 23.8% of patients treated in Q3. Cancer For December and Q3 all cancer waiting time targets were achieved with no breaches, however year to date the ‘two week wait for first appointment’ remains just below the 93% target at 92% due to two missed cases in Q2.

Page 2


Exception Report - December 2014 and Quarter 3 (Continued.)

Choose and Book Performance Performance for Choose and Book (first appointment slot availability) has increased in December to 87.2% (M8: 82.3%), Q3 performance was 85.1% (Q2 84.4%). Efficiency Following the successful migration of data from Croydon’s to Moorfields’ information systems in December, all measures now include our activity – prior months currently exclude activity at Croydon University Hospital and Purley War Memorial Hospital. Compared to November total activity remains at a similar level for First Outpatient Attendances, there is an increase in admissions, and is lower for Follow up attendances, even with the inclusion of the Croydon data. However this is due to December containing less working days and an expected lower than normal activity level between the Christmas and New Year period. For Q3 compared to the previous year, excluding the additional Croydon data (for a like-for-like comparision), first appointment activity increased by 8%, follow up activity increased by 4% and admissions increased by 10%. First Attendances continues to increase with Q3 at 24,561, against 22,017 and 22,559 in Q1 and Q2 respectively. Follow up Attendances remain at a similar level to Q2. Did not attend (DNA) rates remain stable at around 11% for both first and follow up appointments compared to previous months. For December Outpatient Cancellations are at 13.7%, an increase of 3% from 10.9% in the previous month. For quarter 3 this has increased from 9.5% in quarter 2 to 11.6%. There were no reported 28 days breaches for inpatient cancellations in December 2014 or Quarter 3. VTE Performance The migration of data from Croydon, has (at present) resulted in the unavailability of the flag confirming whether a Venous thromboembolism (VTE) assessment had been completed prior to an admission. Therefore, these Croydon admissions are marked as not compliant. This has had a negative effect on the overall VTE performance, taking it below the 95% target to 89.9%, compared to 99.0% the previous month. For Q3, the trust remains above target at 95.8%.

Page 3


COMPLIANCE PERFORMANCE SUMMARY

Threshold Dec-14 Q3 14/15 YTD 14/15Quarterly

TrendSource Threshold Dec-14 Q3 14/15 YTD 14/15

Quarterly

TrendSource

≥ 90% 92.1% 89.2% 84.5% CQC, Monitor,TDA 0 0 0 3 CQC, TDA

≥ 95% 96.1% 95.8% 94.9% CQC, Monitor,TDA n/a 5.0% 3.3% 3.6% Monitor

≥ 92% 95.1% 95.3% 93.2% CQC, Monitor,TDA n/a 5.0% 3.6% 3.8% CQC, TDA, Outcomes

Framework

≥ 95% 99.3% 99.1% 99.2% CQC, Monitor,TDA n/a 50.4% 54.7% 53.2% Local

≥ 80% 82.9% 81.2% 81.6% Local 0 0 0 0 CQC, Monitor,TDA

≥ 5% 0.6% 0.9% 1.1% CQC, TDA 0 0 0 0 CQC, Monitor,TDA

≥ 30% 22.8% 23.8% 24.4% Local ≥ 95% 89.9% 95.8% 97.5% CQC, TDA

≥ 5% 0.5% 0.6% 0.7% CQC, TDA 0 0 0 0 CQC, TDA

≥ 93% 100% 100% 92.0% CQC, Monitor,TDA n/a 100% 100% 101% CQC, TDA

≥ 96% 100% 100% 100% CQC, Monitor,TDA ≥ 20% 74.7% 72.4% 70.3% CQC,TDA, Outcomes

Framework

≥ 94% 100% 100% 100% CQC, Monitor,TDA ≥ 30% 23.6% 25.9% 26.9% CQC,TDA, Outcomes

Framework

≥ 85% n/a n/a n/a CQC, Monitor,TDA

≥ 99% 100% 100% 100% CQC, TDA

n/a 87.4% 85.6% 85.9% Local

≥ 96% 87.0% 85.1% 86.5% Local

Key Reference:

Within tolerance and drop in figures

No target or N/A

On or above target

Stable on/above target

On target and drop in figures

Below target and rise in figures

Below target and stable

Below target and fall in figures

Within tolerance and stable

Within tolerance and rise in figures

A&E 4 hour waiting timeGP referrals first outpatient using

Choose & Book

VTE Screening - all admissions

Number of Mixed Sex

Accommodation Breaches

Friends & Family Test - Inpatients

(Response Rate)

A&E ENP Pathways

A&E Left Before Treatment Number of C.Diff cases

Ward Staffing Levels

(Inpatient Wards Only)

Choose & Book Appointment

Availability

A&E 3 hour waiting times Number of MRSA cases

Outpatient appointment - Over 6

week waiters

Cancer 31 day wait - subsequent

treatment - surgery

Cancer 62 day from urgent GP

referral to first definitive treatment

Diagnostics 6 week waiting time

A&E Unplanned re-attendance

Cancer 2 week wait - first

appointment urgent GP referral

% Cancer 31 day wait - diagnosis to

first appointment

Friends & Family Test - A&E

(Response Rate)

Performance 2014/15Performance 2014/15

Percentage 18 weeks Non Admitted

Pathways

Emergency Readmissions within 28

days of discharge

Percentage 18 weeks Incomplete

Pathways

Emergency Readmissions within 30

days of discharge

Indicator Indicator

Percentage 18 weeks Admitted

Pathways

Cancelled Operations - 28 Days Re-

Book

Page 4


18 Weeks Referral to Treatment (Provisional)

Performance

2013/14 Forecast

YTD

Current

Month

Previous

Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4

90% N/A 92.1% 88.9% 80.9% 83.4% 89.2% 84.5% Monitor, CQC,

TDA

95% N/A 96.1% 95.7% 94.95% 94.1% 95.8% 94.9% Monitor, CQC,

TDA

92% N/A 95.1% 95.6% 92.2% 92.1% 95.3% 93.2% Monitor, CQC,

TDA

Performance

2013/14 Forecast

YTD

Current

Month

Previous


N/A N/A 171 281 1,442 1,363 799 3,604

N/A N/A 44 -29 -686 -543 -56 -1,284

N/A N/A 207 290 934 1,097 809 2,840

N/A N/A 55 48 -9 -174 143 -39

N/A N/A 1,014 928 5,035 5,066 2,964 13,065

N/A N/A 649 750 116 73 3,305 6,067

Performance

2013/14 Forecast

YTD

Current

Month

Previous


90% N/A 100.0% 97.8% 86.3% 85.3% 98.5% 89.3% Monitor, CQC,

TDA

95% N/A 99.0% 98.0% 97.3% 95.1% 98.9% 97.0% Monitor, CQC,

TDA

92% N/A 95.0% 96.4% 94.3% 85.9% 96.7% 92.1% Monitor, CQC,

TDA

Performance

2013/14 Forecast

YTD

Current

Month

Previous


90% 91.2% 91.9% 88.4% 80.8% 83.3% 88.8% 84.2% Monitor, CQC,

TDA

95% 95.5% 95.8% 95.4% 94.6% 93.9% 95.4% 94.6% Monitor, CQC,

TDA

92% 92.4% 95.1% 95.5% 91.96% 92.6% 95.2% 93.3% Monitor, CQC,

TDA

Compliance

Source

Compliance

Source

Quarterly

Trend

Compliance

Source

Admitted

Incomplete

Patients Waiting >18 weeks

90% Shortfall / Surplus





Performance 2014/15

Quarterly

Trend

Trust Total

Croydon

Indicator

Indicator

18 weeks Referral to Treatment - Admitted

18 weeks Referral to Treatment -Non

Admitted

18 weeks Referral to Treatment -Incomplete


Admitted



Admitted


Indicator

Non Admitted

Monthly

Trend

Monthly

Trend

Monthly

Trend

Monthly

Trend

Indicator Threshold

Performance 2014/15

Threshold

Performance 2014/15


Threshold

Performance 2014/15

Compliance

Source


Threshold

Moorfields (excluding Croydon)

Quarterly

Trend

Quarterly

Trend

Page 5


18 Weeks Referral to Treatment (Cont.)

Trust Total

All RTT Targets were achieved for the Trust in December 2014.

Croydon Performance continues to remain high across all performance targets at 100%, 99% and 95% for Admitted, Non-Admitted and Incomplete performance respectively

Moorfields excluding Croydon Performance also achieved all three targets at 91.9%, 95.8% and 95.1% for Admitted, Non-Admitted and Incomplete performance respectively

Page 6


Performance

2013/14 Forecast

YTD

Current

Month

Previous


N/A66,400 7,147 7,869 24,338 24,268 23,402 72,008

N/AN/A 6,767 7,346 23,766 23,755 22,168 69,689

95% 99.6% 99.3% 98.5% 99.3% 99.1% 99.1% 99.2% CQC, Monitor,

TDA

80% 83.1% 82.9% 79.8% 82.0% 81.7% 81.2% 81.6% Local

N/A 190 37 97 139 190 167 496

N/A 2 0 0 20 10 0 30

5% 0.9% 0.6% 1.2% 1.2% 1.0% 0.9% 1.1% CQC, Monitor,

TDA

60 mins 10 mins 25 mins 23 mins 23 mins 24 mins 24 mins 20 mins CQC, TDA



30% 21.7% 22.8% 23.4% 22.8% 26.5% 23.8% 24.4% Local

5% 1.3% 0.5% 0.7% 1.1% 0.3% 0.6% 0.7% CQC, TDA

Compliance

Source

Quarterly

Trend

A&E Maximum waiting times - 3 hours

Time to Treatment in Department - median

Total number of 4 hour breaches

Total number of 6 hour breaches

Left without being seen

Total time spent in A&E -Admitted 95th

Percentile

Total time spent in A&E - Non Admitted 95th

Percentile

A&E Unplanned Re-attendance

A&E ENP Pathway

Accident & Emergency

Indicator

Monthly

Trend

A&E Maximum waiting times - 4 hours

Threshold

Performance 2014/15

Total number of attendances

Total number of expected attendances

Page 7


A&E 4 Hour performance continues to meet the national target of 95%, achieving 99.3% in December and 99.1% for Quarter 3.

A&E 3 hour performance continues to our target of 80%, achieving 81.2% in December and 81.2% in quarter 3.

Activity continues to increase, especially compared to the previous year where it has increased 10% compared to last December and 8.4% for the year to date. This represents an average

increase of 20 A&E attendances every day. The increase was seen for both working and non-working days activity compared to December 2013.

Percentage of A&E patients treated by an Emergency Nurse Practitioner (ENP) remains below our local target of 30%, with 22.8% of patients treated in December and 23.8% of patients treated

in quarter 3.

Percentage of Unplanned Re-Attendances and Left A&E before treatment remain well below their 5% targets.

Accident & Emergency (Cont.)

Page 8


Performance

2013/14 Forecast

YTD

Current

Month

Previous


Cases 24 3 0 8 13 4 25

93% 95.8% 100% n/a 100% 84.6% 100% 92.0%

Cases 9 3 1 2 7 4 13

96% 100% 100% 100% 100% 100% 100% 100%

Cases 1 1 1 0 1 2 3

94% 100% 100% 100% n/a 100% 100% 100%

Cases 0 0 0 0 0 0 0

85% n/a n/a n/a n/a n/a n/a n/a

Performance

2013/14 Forecast

YTD

Current

Month

Previous


99% 100% 100% 100% 100% 100% 100% 100% CQC, TDA

TBA 79.4% 87.4% 83.9% 84.5% 87.7% 85.6% 85.9% Local

TBA 58.0% 18.7% 22.0% 46.6% 37.6% 23.6% 37.6% Local

96% 94.8% 87.0% 82.3% 86.1% 84.4% 85.1% 86.5% Local

N/A 4.6% 11.6% 16.4% 13.4% 15.0% 13.4% 12.7% Local

N/A 0.6% 1.2% 1.3% 0.6% 0.6% 1.4% 0.8% Local

Compliance

Source

Cancer 31 day waits - diagnosis to first

appointment

Quarterly

Trend

CQC, Monitor,

TDA

CQC, Monitor,

TDA

CQC, Monitor,

TDA

Compliance

Source

Cancer Waiting Times

Indicator

Cancer 2 week waits - first appointment urgent

GP referral

Threshold

Performance 2014/15

Monthly

Trend

Choose and Book Capacity Issue Rate

Quarterly

Trend

Cancer 31 day waits - subsequent treatment

Choose and Book System Issue Rate

Indicator Threshold

Performance 2014/15

First Outpatient Appointment Waiting more

than 6 weeks

Patients Waiting more than 13 weeks for

Admission

Diagnostic waiting times - 6 weeks

Choose and Book appointment availability

Cancer 62 days from urgent GP referral to first

definitive treatment

For December and quarter 3 all cancer waiting time targets were achieved with no breaches, however year to date the ‘two week wait for first appointment remains just below the 93% target at

92% due to two missed cases in Quarter 2.

To achieve the 93% target for the financial year MEH will need 5 or more two week waits in quarter 4 and no further breaches.

Access - Other

CQC, Monitor,

TDA

Monthly

Trend

Page 9


Access - Other (Cont.)

Performance for Choose and Book (first appointment slot availability) as increased in December to 87.2% (M8: 82.3%), for quarter 3 performance was 85.1%, an increase on quarter 2

performance (84.4%). This is due to a percentage reduction in 'capacity issues' compared to November.

Patients waiting more than 6 weeks for a first appointment remains stable, while patient waiting more than 13 weeks for an admission continues to fall.

Diagnostics Waiting Times less than 6 weeks remains compliant at 100%

Page 10


Performance

2013/14 Forecast

YTD

Current

MonthPrevious


N/A 65,833 8,048 7,973 22,017 22,559 24,561 69,137 Local

N/A 273,355 29,906 30,906 92,666 95,094 95,593 283,353 Local

TBA 8.5% 13.7% 10.9% 8.5% 9.5% 11.6% 9.9% Local

TBA 10.6% 11.0% 11.7% 11.0% 11.6% 11.5% 11.4% Local

TBA 12.3% 11.5% 11.3% 12.4% 12.4% 11.6% 12.1% Local

TBA 62.2% 60.5% 57.1% 55.6% 54.9% 58.2% 56.2% Local

TBA 75.7% 73.0% 71.0% 69.9% 70.5% 71.0% 70.4% Local

N/A 27,148 2,921 3,180 8,787 8,931 9,096 26,814 Local

N/A 22,615 2,650 2,724 8,297 8,821 8,365 25,483 Local

TBA 6.7% 6.1% 6.3% 6.1% 5.8% 6.3% 6.0% Local

TBA 36.9% 28.5% 28.3% 27.1% 26.4% 27.3% 26.9% Local

0 2 0 0 1 2 0 3 CQC, TDA

Monthly

Trend

Outpatient Total Attendances

- Follow Up Appointment

Compliance

Source

Performance 2014/15

Quarterly

TrendThreshold

Cancelled Operations - 28 Days Re-Book

Efficiency

Indicator

Outpatient DNA rate

- First Appointment

Theatre Sessions Starting Late

Clinic Journey Times Less Than 2 Hours

- Outpatient First Appointment

Clinic Journey Times Less Than 2 Hours

- Outpatient Follow Up Appointment

Outpatient DNA rate

- Follow Up Appointment

Theatre Cancellation Rate

Admission Demand

- Decision to Admit (DTA)

Admission Activity

Outpatient Cancellations

Outpatient Total Attendances

- First Appointment

Page 11


Key: :4 Month Average:Monthly Trend

Efficiency (Cont.)

Page 12


Effectiveness

Performance

2013/14 Forecast

YTD

Current

MonthPrevious


N/A 3.70% 5.00% 2.10% 3.50% 4.00% 3.30% 3.60% Monitor

Cases 76 11 5 23 28 23 74

N/A 3.70% 5.00% 2.10% 3.60% 4.10% 3.60% 3.80% CQC, TDA

Cases 78 11 5 24 29 25 78

N/A 61% 50.4% 56.2% 51.8% 53.0% 54.7% 53.2% Local

Safety

Performance

2013/14 Forecast

YTD

Current

MonthPrevious


0 0 0 0 0 0 0 0 CQC, TDA,

Monitor

0 0 0 0 0 0 0 0 CQC, Monitor,

TDA

95% 97.2% 89.9% 99.0% 98.4% 98.3% 95.8% 97.5% CQC, TDA

0 0 0 0 0 0 0 0 CQC, TDA

Monthly

Trend

Monthly

Trend

Number of C.Diff cases

Performance 2014/15

Emergency Re-admission within 28 days of

discharge

Emergency Re-admission with 30 days for

elective and emergency cases

GP referrals first outpatient using Choose &

Book

Indicator

Number of MRSA cases

VTE Screening

Mixed Sex Accommodation

There remain zero MRSA, C.Diff Cases or Mixed Sex Accommodation breaches reported this financial year.

Compliance

SourceThreshold

Quarterly

Trend

Compliance

Source

Performance 2014/15

Quarterly

TrendIndicator Threshold

Page 13


Ward Staffing Levels (Only 'wards with inpatient beds' as per report requirement)

The fill rate during July for the Cumberlege Wing was of 54% and based on a small denominator - a total of 3 WTE care staff. During this time a member of staff was absent which resulted in the

reduction of the fill rate. This was mitigated by cover being provided by a registered nurse, giving adequate cover in the skill mix. It is not uncommon that whenever necessary, the absence of a

care worker can be substituted with a registered nurse to ensure safe standards are maintained on the wards.

Page 14


Patient Experience (A&E and Inpatient Wards Only)

Site: MoorfieldsExtremely

LikelyLikely Unlikely Not at all l ikely Don't Know

Total

responses

Ward Name: Duke Elder 11 1 0 0 0 1 13 13 100.00%

Ward Name: Observation Bay 38 5 0 0 0 0 63 43 68.25%

Cumbelege Wing (NHS Pts) 2 4 0 0 0 0 7 6 85.71%

51 10 0 0 0 1 83 62 74.69%

Accident and Emergency 1179 302 38 7 7 37 (+2 Blk) 6,655 1572 23.62%

Overnight Admissions Average

Total

Number of

people

el igible to

respond

Neither likely

or unlikely

Response

rate

Friends and family score: December 2014

Page 15

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