1

INTEGRATED PERFORMANCE REPORT

BOARD OF DIRECTORS

21 May 2019

2

S Section Page

Executive Summary 4

Trust Performance Overview 8

Trust Performance Report by Exception 10

HSMR 10

MRSA 10

MSSA 11

Serious Incidents reported in timescales 11

Incidents - % approved within 35 days 12

Average Length of Stay – Non-Elective 12

Never Events 13

Safety Thermometer 13

18 Weeks RTT – Non admitted pathways 14

18 Weeks RTT - Admitted pathways 14

A&E – 4 Hour Wait 15

Ambulance Turnaround Times 15

Cancelled Operations not re-dated within 28 days 16

Cancelled Outpatient Appointments - Hospital 16

Cancelled Outpatient Appointments - Patient 17

Cancer Waits – 62 days GP Referral to Treatment 17

Cancer Waits – 31 days Decision to Treat to Treatment 18

Cancer Waits - Screening 18

Cancer Waits – Subsequent Surgery 19

Capital Expenditure 19

Sickness Absence 20

Deep Dive – Electronic Referral Service (e RS) – Paper Switch Off Programme Update 21

Directorate Dashboards 30

REPO

3

RT TO THE BOARD OF DIRECTORS

Subject: Integrated Performance Report

Supporting Directors: Michael Harper, Chief Operating Officer; Neil Priestley, Director of Finance; Chris Morley, Chief Nurse; Mark Gwilliam, Director of

Human Resources and Staff Development; David Hughes, Medical Director; Anne Gibbs, Director of Strategy & Planning.

Author(s): Balbir Bhogal, Performance and Information Director; Joanne Weaver, Senior Information Analyst

Status (see footnote): A

PURPOSE OF THE REPORT: To provide the Board with a detailed assessment of performance against the agreed indicators and measures. The report describes

the specific actions that are under way to deliver the required standards.

RECOMMENDATIONS

The Board is asked to:

a) Receive the Integrated Performance Report for March 2019.

b) Note the performance standards that are being achieved.

c) Be assured that where performance standards are not currently met, a detailed analysis has been undertaken and actions are in place to ensure an improvement

is made.

IMPLICATIONS APPROVAL PROCESS

STH Strategic Aims Tick as

appropriate Meeting: Trust Executive Group

Finance and Performance Committee

Board of Directors

1 Deliver the best clinical outcomes Approved Y/N:

2 Provide patient centred services Date: 8 May 2019 13 May 2019 21 May 2019

3 Employ caring and cared for staff

A = Approval; A* = Approval and Requiring Board Approval; D = Debate; N = Note 4 Spend public money wisely

5 Deliver excellent research,

education and innovation

4

EXECUTIVE SUMMARY DELIVER THE BEST CLINICAL OUTCOMES

There was one case of Trust assigned MRSA bacteraemia recorded for the month of March. The year to date total is 2 cases.

There were 8 Trust attributable cases of MSSA bacteraemia recorded in March. The year to date total is 68 cases against an internal threshold of 57 cases.

The Trust recorded 7 cases of C.diff in March. The year to date performance is 84 cases against an internal threshold of 78 cases and an NHS Improvement threshold of 86 cases.

Hospital standardised mortality ratio is slightly higher than the ‘as expected’ range and the reason for this is being explored further.

There was one new never events reported in March. 83.02% of incidents were approved within 35 days, which is below the internal target of 95%.

The average length of stay for non-elective patients for the reportable period (December) was higher than the Dr Foster threshold.

The standard in the safety thermometer was 92.12% in March against a target of 95.0%

Summary of the Healthcare Governance Committee meeting held on 18 March 2019

The CQC Insight report was presented. The Trust had performed ‘better than’ or ‘much better than’ other trusts on 13 metrics and ‘worse than’ or ‘much worse than’ other

trusts on 14 metrics. The 12 ‘worse than’ and the two ‘much worse than’ metrics had been fo llowed up to ensure that plans or programmes of work are in place to address performance.

A presentation was given in relation to the Patient Pathway workstream. It was noted that the Breaks in Process report was developed for operational areas from 1st April

2019.

A presentation was given by the Nurse Director and the Operations Director for the MSK Care Group, providing an overview of c urrent performance and work across a number of key areas.

The CQC Compliance update was presented. The results of six recent inspection reports published for large, acute trusts nationally were noted.

The CQC Action Plan 2018 work plans were presented. The first update on progress against the action plan was due to the Commi ttee in May 2019. This would include the outstanding 2015 actions. It was noted that the work plans for the two actions regarding Use of Resources were currently under development and would be included in the 2018 CQC Action Plan once completed.

An update on incidents reported as Serious Incidents from 6 February to 27 February 2019 was presented. During this period nine new serious incidents were reported, and nine were on-going. It was highlighted that a number of SIs reported in February were historic incidents and it was also noted that the Patient Pathway workstream led by Balbir Bhogal would address issues relating to a number of the SIs.

The Staff, Student & Public Incidents, Public & Employers Liabilities Insurance Claims report was presented.

The Moving and Handling Annual Report was presented. It was noted that there was a decrease in RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) reportable incidents in 2018, compared to 2017.The RIDDOR reportable incidents were coded as ‘moderate’or ‘insignificant / no harm’ or ‘minor’.

The Quality Surveillance Programme Actions Plans for Key Specialised services 2018/19 was presented. Action plans were in place in order to work towards compliance

in those areas not meeting specific quality indicators.

The Outcome of Self-Declaration 2018/19 and notification of 2019/20 Quality Surveillance Programme was presented. All specialised services were current ly in the process of completing their 2019/20 annual self-declaration for the end of June 2018. The relevant Clinical Lead for the service would respond to the indicators available by declaring compliance or non-compliance with the quality indicators prior to submission.

The External Visits, Accreditations & Inspections report for November 2018 to January 2019 was presented. The joint inspection CQC with HM OFSTED Special Educational Needs & Disabilities (SEND) inspection was discussed. The Trust would lead on the action relating to specialist assessments for wheelchair services. Planned visits/inspections/accreditations registered Centrally for February 2019 –April 2019 were noted.

Hospital Mortality for Q3 was presented. SHMI for 1 October 2017 – 30 September 2018 (published 14 February 2019) 0.96 (0.89 - 1.12 over-dispersion control limits of 95%). This was in the ‘as expected’ range and rebased. HSMR for 1 December 2017 – 30 November 2018 (21st February 2019 update) was 110.8 (106.1-115.6) for all

admissions and was ‘higher than expected’ when compared with hospital trusts nationally. The Committee discussed the high HSM R and it was agreed that a more detailed update would be given to the April HCGC meeting.

5

PROVIDING PATIENT CENTRED SERVICES

Complaints – 94% of complaints met the agreed response timeframe.

FFT score inpatient – the score for March was 95% which is the same as the internal target of 95%.

FFT score A&E – the score for March was 89% which is better than the internal target of 86%.

FFT score community – the score for March was 91% which is better than the internal target of 90%.

FFT score maternity– the score for March was 96% which is better than the internal target of 95%.

Mixed sex accommodation – there were no breaches reported in March. The national standard is 0.

Referrals received during March 2019 were above the baseline level included in the Trust’s plan

New outpatient activity for March was 8.2% below the contract target. For the year, performance is 0.4% above target.

Follow up outpatient activity for March was 2.4% above the contract target. For the year, performance is 2.8% above target.

Accident and Emergency activity was 6.7% above the target in March 2019 and is 4.9% over target for the year.

Elective activity for March was at the contract target and is 1.4% below target for the year.

Non-elective activity for March 2019 was 0.2% below the contract target and is 0.2% over target for the year.

The average number of patients who had a delayed transfer of care in March was 50 compared to 62 in February.

71 operations were cancelled on the day for non-clinical reasons in March, compared to 96 in February.

1 patient had their operation cancelled on the day of admission in March for non-clinical reasons and were not readmitted within 28 days. This patient has subsequently had their operation.

In March, 87.15% of patients attending A&E were seen within 4 hours compared to a local target of 95% and the national target of 95%.

58.06% of ambulance handovers occurred within 15 minutes, compared to 56.76% in February. 2.79% of ambulance handovers took more than 30 minutes, compared to 3.05% in February.

The percentage of patients who had been waiting less than 18 weeks for their treatment at the end of March was 92.79% which meets the national target (92%). The percentage of patients who received treatment in March and had waited less than 18 weeks was 81.49% for admitted patients (local target 90%) and 89.73% for non-admitted patients (local target 95%).

At the end of March there were no patients waiting over 52 weeks for treatment.

At the end of March the percentage of patients waiting less than 6 weeks for their diagnostic test was 99.91% which is above the national target of 99%.

The percentage of outpatient appointments cancelled by the hospital and cancelled by patient’s remains higher than the national benchmark.

The percentage of patients that did not attend for their outpatient appointments was better than the national benchmark.

For Q4, the cancer waiting times were achieved for Two Week Wait, 31 Day Subsequent Treatment (Anti-Cancer Drug).

For Breast symptomatic referrals seen within two weeks, STH performance was 92.9% (threshold 93%).

With regard to 62 day referral to treatment (GP Referral), STH performance for non-shared pathways in Q4 was 75.9% (threshold 85%).The performance for Q4 2018/19, without reflecting the new Breach Allocation Guidance and reallocations, was 69.9% (threshold 85%).

For the pathway relating to 31 days from decision to treat, STH performance for Q4 was 92.1% (threshold 96%).

With regard to 31 day subsequent treatment (surgery), the Trust performance for Q4 2018/19 was 87.5% (threshold 94%).

For 62 day referral to treatment (Cancer Screening Service), STH performance for non-shared pathways in Q4 was 88.1% (threshold 90%). The performance for Q4 2018/19, without reflecting the new Breach Allocation Guidance and reallocations, was 84.8% (threshold 90%).

The percentage of referrals received from GPs through the e-Referrals Service in March was 99.95%.

6

EMPLOYING CARING AND CARED FOR STAFF

Sickness absence in March was above target at 4.1%. The full year sickness absence rate is 4.00%.

Short term absence has decreased from 2.0% in February to 1.8% in March.

Long term absence has decreased from 2.5% in February to 2.3% in March.

For the period March 2018 to February 2019, the Trust has achieved 90% for the number of appraisals which have been carried out. This met the target of 90%.

For the period April 2018 to March 2019, compliance levels for mandatory training are at 91.0% against a 90% target.

The staff group with the lowest leaver rates for March was for Healthcare Scientist staff (4%) and the staff group with the highest leaver rates was Administrative and Clerical roles (10%).

The proportion of temporary staff has reduced from 10.69% to 9.1%.

Retention figures for the Trust are at 90.3% which is above the target of 85%.

Safer staffing – overall, the percentage of care hours per patient day (CHPPD) for registered nurses was 89.2% and for all registered nurse and care staff was 96.7%. In any instances where the CHPPD was below 85% the reasons for this will be explored in detail at the Healthcare Governance Committee.

SPEND PUBLIC MONEY WISELY

The draft 2018/19 Annual Accounts show a £5,561.2k (0.5%) deficit. However, if “non-cash technical” items (impairments, donations and gains on asset disposals) are excluded there is a “cash-backed” surplus of £26.5m.

Within this sum there is £14.0m of additional Provider Sustainability Funding (PSF) discussed below, a £6.5m gain from the Estate Revaluation/Asset Lives Review and £3.5m of contingencies (net of commitments).

The balance of £2.5m reflects a £3.2m surplus against the original Financial Plan (£0.7m deficit). This represents an improvement of £0.7m on the Month 11 position and a £5.7m improvement on the Month 6 position.

There was an activity over-performance of £1.3m in March giving a cumulative over-performance of £8.65m for the year to-date. All of this over-performance has arisen in the second half of the year and has been a significant factor in the improved financial position. There were significant over-performances on non-elective and outpatient activity in month. However, the issues around the high level of income loss for MRET and Emergency Readmissions within 30 days (£2.6m above plan and £10.7m in total) remain. The high level of uncoded spells, for which estimated values have been used, also remains.

There was an increased pay overspend of £3.5m (0.5%) to the end of March, although Bank & Agency costs were still £0.5m below the equivalent 2017/18 position. Medical staffing remains the main pressure area with a £9.4m (5.2%) overspend, a deterioration of £1.2m in month.

There was ultimately a £10.3m over delivery against efficiency plans including the Estate Revaluation/Asset Lives Review gain noted above.

Overall, Directorates broadly delivered their aggregate plan. This is a significant improvement which has driven the positive financial outcome for the year.

The Financial Plan assumed receipt of all of the £26.1m of national PSF available to the Trust. Despite not receiving the £7.8m related to delivery of A&E trajectories, the Trust ultimately received an additional £14.0m (£40.1m in total) due to the various bonus and incentive PSF allocations notified in April by virtue of having improved on the Control Total by £8.4m.

Capital expenditure for the year totalled £24.4m which was a significant underspend. The underspent resources and relevant schemes will be carried-forward to 2019/20. The “cash-backed” surplus above will be used to supplement capital investment in future years.

The 2018/19 position is very encouraging but attention now needs to turn to meeting the 2019/20 Financial Plan.

7

DELIVER EXCELLENT RESEARCH, EDUCATION & INNOVATION

As previously reported, the number of patient accruals to portfolio adopted grant and commercial studies for 2018/19 Q3 was 2998. Cumulative recruitment up to Q3 was 7373; this was 107% of our Yorkshire and Humber Clinical Research Network (YHCRN) year to date target of 6875.

STH continues to maintain research performance as a result of several factors including shortened R&D setup times, active recruitment by researchers and on-going collaborative working between the Clinical Research & Innovation Office, YHCRN, and STH research facilities.

8

TRUST PERFORMANCE OVERVIEW

Indicator Measure Standard Target TypeCurrent Data

Month

Month

Actual YTD Trend

Data

Quality

CQC Compliance Outcome of CQC inspection Good in all five domains National March

NHSI Segmentation Compliance with Monitor defined targets Green/Amber or better National Q1 17/18

Hospital Mortality HSMR As expected or lower SOF Dec-17 to Nov-18 105.50

Hospital Mortality SHMI As expected or lower SOF Oct-17 to Sep-18 0.95

MRSA bacteraemia Trust Attributable / Assigned cases only Zero cases SOF March 1.00 2

MSSA bacteraemia Trust Attributable cases only Max 4.75 cases per month (57 per year) Local March 8 68

C.diff Trust Attributable cases only Max 7.16 cases per month (86 per year) SOF March 7 84

E.coli Trust Attributable cases only to be determined Local March 13 167

MSSA - infection rate MSSA bacteraemia rate per 100,000 bed days (Public Health England - national rate is 32.8) to be determined SOF 2016/17 33.9

C.diff - infection rate C.difficile infection rate per 100,000 bed days (Public Health England - national rate is 36.7) to be determined SOF 2016/17 49.2

E.coli - infection rate E.coli bacteraemia rate per 100,000 bed days (Public Health England - national rate is 115.9) to be determined SOF 2016/17 125.4

Serious Incidents Number of serious incidents (SI) Number Local March 5 37

Serious Incidents Approved SI Report submitted within timescales No overdue reports Local March 1

Incidents Number of finally approved incidents based on incident date Number of incidents Local March 1297 27034

Incidents Percentage of incidents approved within 35 days based on approval date 95% within 35 days Local March 0.8301967

Incidents Potential under reporting of patient safety incidents to be determined SOF March

Average LOS Elective 4.40 days (Dr Foster) Local Dec-18 to Jan-18 4.31

Average LOS Non Elective 4.79 days (Dr Foster) Local Dec-18 to Jan-18 5.02

C-Section rate Emergency Caesarean section rate as proportion of all births 15.5% SOF March 16.8% 18.4%

Patient Safety Alerts Number of outstanding Patient Safety Alerts Zero SOF March

Patient Falls Number of patient falls Local March 188 3833

Patient Falls Number of inpatient falls against nursing goals 216 per month (2586 per year) Local March 197 2907

Never Events Number of never events Zero SOF March 2 4

VTE VTE Risk Assessment completed as proportion of all inpatient admissions 95% SOF Q1 18/19 95.06%

Dementia Dementia Assessment and Referral 90% SOF Q1 18/19 92.00%

Safety Thermometer Harm free 95% harm free National March 0.9212

 A&E 4-hour wait Patients seen within 4 hours 95% SOF March 0.8715367 87.3%

>12 hr Trolley waits in A&E No. of patients waiting > 12 hours Zero National March 0 0

Ambulance turnaround Time taken for ambulance handover of patient 100% within 15 minutes National March 0.5806367 55.00%

Ambulance turnaround Time taken for ambulance handover of patient 0% in excess of 30 minutes National March 0.0279228 3.85%

Ambulance turnaround Time taken for ambulance handover of patient 0% in excess of 60 minutes Local March 0.0052192 0.41%

Percentage of admitted patients treated within 18 weeks 90% Local March 0.8148798

Percentage of non-admitted patients treated within 18 weeks 95% Local March 0.8972739

Percentage of patients on incomplete pathways waiting less than 18 weeks 92% SOF March 0.9278687

52 week waits Actual numbers Zero National March 0 0

6 week diagnostic waiting Percentage of patients seen within 6 weeks 99% SOF March 0.9991172

Number of operations cancelled on the day for non clinical reasons 75 per month Local March 71 1011

Number of patients cancelled on the day and not readmitted within 28 days Zero Local March 1 48

Percentage of out-patient appointments cancelled by hospital 7.01% (National figure 2016/17) Local March 0 11.45%

Percentage of out-patient appointments cancelled by patient 6.77% (National figure 2016/17) Local March 0 10.15%

Percentage of new out-patient appointments where patients DNA 7.56% (National figure 2016/17) Local March 0 6.12%

Percentage of follow-up out-patient appointments where patients DNA 7.82% (National figure 2016/17) Local March 0 6.78%

Patient seen within 2 weeks 93% National Q4 19/20 0.95

Breast symptomatic seen within 2 weeks 93% National Q4 19/20 0.934

62 days from referral to treatment (GP referral) 85% SOF Q4 19/20 0.707

62 days from referral to treatment (Cancer Screening Service) 90% SOF Q4 19/20 0.089

31 day first treatment 96% National Q4 19/20 0.929

31 day subsequent treatment (Surgery) 94% National Q4 19/20 0.884

31 day subsequent treatment (Radiotherapy) 94% National Q4 19/20 0.941

31 day subsequent treatment (Drugs) 98% National Q4 19/20 0.999

e-Referral Service Percentage of eligible GP referrals received through ERS 90% Local March 1 94.87%

Ethnic group data collection % valid ethnic group 85% National March 1 89.91%

Elective Inpatient activity Variance from contract schedules On plan Local March -0.03% -1.41%

Non elective inpatient activity Variance from contract schedules On plan Local March -0.16% 0.17%

A = Accuracy, V = Validity, R&C = Reliability & Consistency, T = Timeliness, R = Relevance, C&C = Completeness & Coverage

Provide Patient Centred Services

18 week waits referral to

treatment time

Cancelled Operations

Cancelled Outpatient

appointments

DNA rate

Cancer Waits

Deliver The Best Clinical Outcomes

Average Length of Stay (by

discharges)

9

New outpatient attendances Variance from contract schedules On plan Local March -8.21% 0.42%

Follow up op attendances Variance from contract schedules On plan Local March 2.37% 2.79%

A&E attendances Variance from contract schedules On plan Local March 0.0493168 4.85%

Complaints Percentage of complaints answered within 25 working days 90% answered within 25 days Local March 1 1

Written Complaints Rate Written complaints rate per 10,000 fces Total number upheld SOF 146

FFT Recommended Patients recommending STH for inpatient treatment 95% National March 1

FFT Recommended Patients recommending STH for A&E treatment 86% National March 0.8901961

FFT Recommended Patients recommending STH for Maternity treatment 95% SOF March 0.9638889

FFT Recommended Patients recommending STH for Community treatment 90% Local March 0.9058824

RTT information completeness 50% National 2017/18 @ Q3 64%

Referral information completeness 50% National 2017/18 @ Q3 100%

Activity information completeness 50% National 2017/18 @ Q3 100%

Day surgery rates Aggregate percentage of all BADS procedures recommended to be treated as day case or outpatient 88% Local March 1 91%

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard Zero SOF March 0 2

Sickness Absence All days lost as a percentage of those available 4.00% SOF March 0.0414508 4.02%

Appraisals Completed appraisals in last year 90% Local March 0.8952087

Mandatory Training Overall percentage of completed mandatory training 90% Local March 0.9065362

Care Hours per patient day (Registered Nurses) 85% of planned hours or greater Local March 0.8916763

Care Hours per patient day (Total) 85% of planned hours or greater Local March 0.9673348

Executive Team turnover to be determined SOF March 0.2857143

Number of leavers as a percentage of total head count (rolliing 12 months) to be determined SOF March 8.2%

Retention Rate 85% March 1

Temporary Staff Proportion of temporary staff to be determined SOF March 10.7%

Under/overspending against Agency Control Total <=0 SOF March -43.52%

Agency and bank spend as a percentage of total pay budget 8% Local March 2.95%

I & E YTD actual I & E surplus/deficit in comparison to YTD plan I & E surplus/deficit >=0 SOF March 1.90%

I & E Margin I & E surplus/deficit as a percentage of total revenue >=0 SOF March 2.45%

Contract performance Contracted Activity performance - variance from plan On plan Local March 1.22%

Efficiency Variance from plan On plan Local March 44.90%

Cash Actual Above profile Local March 32.15%

Liquidity Days of operating costs held in cash or cash equivalents >0 SOF March 12.60

Capital Service Capacity - degree to which the provider's generated income covers its financial obligations >2.5times SOF March 4.27

Expenditure - variance from plan On plan Local March 60.91%

Use of Resources Overall Use of Resources - NHSi weighted risk rating <=2 SOF March 100.00%

Total number of patient accruals to portfolio studies 7373 Regional -Y&H Q3 2018/19 107%

Quality recommendation % staff who would recommend STH to a friend / relative for treatment 69% SOF 2017 0.81

Work recommendation % staff who would recommend STH as a place to work 59% National 2017 0.68

Staff Engagement Staff engagement score 3.83 SOF 2017 3.83

CQC Inpatient Survey RAG rating for overall score determined by CQC to be determined SOF

A = Accuracy, V = Validity, R&C = Reliability & Consistency, T = Timeliness, R = Relevance, C&C = Completeness & Coverage

Deliver Excellent Research, Education & Innovation

Recruitment to trials

Annually Reported Indicators

Provide Patient Centred Services

Spend Public Money Wisely

Indicator Measure Standard Target Type Trend

Employ Caring & Cared for Staff

Community care –information

completeness

Agency spend

Safer Staffing

Capital

Month

Actual YTD

Current Data

Month

Staff Turnover

10

DELIVER THE BEST CLINICAL OUTCOMES

HSMR MRSA

Lead: David Hughes, Medical Director Timescale: Ongoing Lead: Chris Morley, Chief Nurse Timescale: Ongoing

Key Issues: The HSMR for the period February 18 – January 19 is ‘higher than expected’ at

104.8 (100.3-109.5) following the application of the updated benchmark (October 19), which is a reduction from last month’s HSMR of 108.1 (103.5-112.9).

Key Issues: During March 2019, The Trust recorded one case of MRSA.

Key Actions: Work continues to address issues around a number of indices which feed into the calculation of the ‘expected’ mortality and may be responsible for the decline in the expected deaths statistic. These include Admission Source, Admission Method, palliative

care and co-morbidity. Remedial action has been implemented to resolve any Admission Source inaccuracies currently and in the future. The amended data for the period July 2018 – March 2019 is yet to be uploaded and it is anticipated this will have some effect on reducing

the HSMR.

Key Actions: A root cause analysis carried out on this case identified that all appropriate actions were taken and the patient was isolated correctly on admission. Antibiotics were started promptly and appropriately, prior to blood cultures being

taken, based on the patient’s clinical condition. This means though that it is not possible to determine whether or not a true bacteraemia was identified.

95

97

99

101

103

105

107

109

111

113

115

Re

lati

ve

Ris

k

Diagnoses - HSMR | Mortality (in-hospital) | Feb 18 to Jan 19 | Trend

(rolling 12 months)

As expected Below Expected 95% Confidence interval

Above expected

0

1

2

11

E

MSSA SERIOUS INCIDENT REPORTS

Submitted within Timescales

Lead: Chris Morley, Chief Nurse Timescale: Ongoing Lead: David Hughes, Medical Director Timescale: Ongoing

Key Issues: During March 2019, the Trust recorded 8 cases of MSSA. Key Issues: During March 2019, one serious incident investigation report was not

submitted to the CCG within the 60 day timescale.

Key Actions: There is no nationally agreed threshold for MSSA. The Director of Infection Prevention and Control has reviewed our 2018/19 position with results from Trusts in our benchmarking group. This has demonstrated that STH have slightly improved in

numbers/rate this year compared to last year. The STH relative position against other Trusts has also improved.

The routine decolonisation of patients in appropriate clinical areas has now commenced.

Key Actions: An extension was requested from the CCG as additional information to support the investigation had been requested externally to the Trust.

This investigation is now complete and the report has now been submitted.

0

2

4

6

8

10

12

Cases Threshold

0

1

2

3

4

12

INCIDENTS

(% Approved Within 35 Days) NON-ELECTIVE LENGTH OF STAY

(Average LOS Non Elective)

Lead: David Hughes, Medical Director Timescale: Ongoing Lead: David Hughes, Medical Director Timescale: Ongoing

Key Issues: Performance continued to exceed 80% in March 2019, demonstrating a sustained improvement.

Key Issues: The average non-elective length of stay for the year ending December 2018 was 5.02 days, which is above the Dr Foster benchmark of 4.79.

Key Actions: Directorates continue to be provided with monthly performance reports to

assist them in monitoring their own performance and developing improvement plans. The

reports continue to be presented and discussed at the two Safety and Risk Committees,

enabling focussed discussion on key issues including performance against the 35 day

target.

The first meeting of the working group established to review the Trust Incident

Management Policy has taken place in April 2019. Discussions included the requirement

to review the stages and processes currently required to see an incident through from

reporting to approval and after completion of some baseline work, engagement with key

stakeholders will take place.

Key Actions: Ward and Organisational dashboards have been finalised showing key

ward and organisational performance metrics in collaboration with Information Services.

The Flow Working Group and Flow Operational Groups are now established and will lead

the discussion with directorates on performance at ward level.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Incidents approved within 35 days Target

4.20

4.30

4.40

4.50

4.60

4.70

4.80

4.90

5.00

5.10

5.20

5.30

Actual LOS Dr Foster target

13

NEVER EVENTS SAFETY THERMOMETER

Lead: David Hughes, Medical Director Timescale: May 2019 Lead: David Hughes, Medical Director Timescale: Ongoing

Key Issues: One Never Event was reported in March 2019. Key Issues: Data accuracy

Key Actions: The full investigation into these incidents is not yet complete and the

findings of this investigation will inform the actions required to ensure maximum learning and prevent recurrence.

Key Actions: All wards are fully compliant with submitting their Safety Thermometer

surveys and generally >95% of the surveys submitted are being validated each month (100% validation this month). Discussions and planning are on-going with regards to developing a robust automated data collection process as an alternative to the current

manual process.

0

1

2

87.00%

88.00%

89.00%

90.00%

91.00%

92.00%

93.00%

94.00%

95.00%

96.00%

% Harm Free Target

14

A&E 4 HOUR WAIT

(Patients Seen & Discharged or Seen & Admitted Within 4 Hours) AMBULANCE TURNAROUND

(Time Taken for Ambulance Handover of Patient)

Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing

Key Issues: The percentage of A&E attendances that were discharged or admitted within 4 hours in March was 87.15% against a local trajectory of 95.0%. This is compared to 86.62% in February.

Key Issues: The percentage of ambulance handovers completed within 15 minutes in March was 58.06% compared to 56.76% in February. The percentage of handovers that took longer than 30 minutes was 2.79% compared to 3.05% in February.

Key Actions: A number of actions are underway with Directorates to support an improved

performance. This includes actions to further reduce the waiting time for a bed or doctor as well as processes associated with emergency patients who do not require admission to a bed.

Key Actions: Action plans are being developed following the audit undertaken with the

Yorkshire Ambulance Service to reduce conveyance rate and improve data quality.

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

% seen within 4 hours PSF Trajectory National target

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Han

do

ver

> 3

0 m

ins

Han

do

ver

< 1

5 m

ins

Handover ≤ 15 Min Handover > 30 Min

15

18 WEEKS RTT % of Non-Admitted Patients Treated within 18 Weeks

18 WEEKS RTT

% of Admitted Patients Treated within 18 Weeks

Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing

Key Issues: The percentage of non-admitted patients treated within 18 weeks in March was 89.73% compared to 89.11% in February.

Key Issues: The percentage of admitted patients treated within 18 weeks in March was 81.49% compared to 84.38% in February.

Key Actions: Performance is reviewed on an individual specialty basis at the monthly Elective Care Working Group and escalated to the Waiting Times Performance Overview Group (WTPOG). Non-Admitted target recovery plans and trajectories have been provided

by all non-performing specialties.

Key Actions: Performance is reviewed on an individual specialty basis at the monthly Elective Care Working Group and escalated to the Waiting Times Performance Overview Group (WTPOG). Admitted target recovery plans and trajectories have been provided by

all non-performing specialties.

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

% <18 Weeks Non Admitted Pathways Target

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

% <18 Weeks Admitted Pathways Target

16

CANCELLED OPERATIONS

(Number of Operations Cancelled on the Day and Not Re-dated Within 28 Days)

CANCELLED OUTPATIENT APPOINTMENTS (% of Outpatient Appointments Cancelled by Patient)

Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing Lead: Michael Harper, Chief Operting Officer Timescale: Ongoing

Key Issues: In March, there was 1 operation cancelled on the day for non-clinical reasons and not redated within 28 days. This patient has now been admitted for surgery.

Key Issues: The percentage of outpatient appointments cancelled by the patient in March was 10.29%.

Key Actions: Daily monitoring is in place to ensure that those patients who have been cancelled on the day are dated as soon as possible.

The revised on-day cancellation policy will include a process for escalating patients who have been previously cancelled and are being rescheduled beyond 28 days.

Key Actions: The roll out of the patient booking hub will increase patient engagement in selecting an appointment date which is mutually convenient and less likely to be cancelled.

0123456789

101112

Not readmitted within 28 days

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Actual Target (6.77%)

17

CANCELLED OUTPATIENT APPOINTMENTS (% of Outpatient Appointments Cancelled by Hospital)

CANCER WAITS

(62 days from Referral to Treatment – GP referral)

Lead: Michael Harper, Chief Operating Officer Timescale: Ongoing Lead: Anne Gibbs, Executive Director for Cancer Timescale: Ongoing

Key Issues: The percentage of outpatient appointments cancelled by the hospital in March was 11.61%.

Key Issues: The Trust performance for all pathways Q4 2018/19 is 69.9% without reflecting the new Breach Allocation Guidance (threshold 85%). STHFT performance for non-shared

pathways in Q4 is 75.9%. Throughout the quarter there was a significant increase in performance, from 60% in January, to 76.5% in March for shared performance, and from 64.5% in January, to 83.7% in March for non-shared pathways.The current position for Q1

2018/19 (as at 8 May 2019) is 67.7% for shared pathways and 74.1% for non-shared pathways without reflecting the allocation guidance.

Key Actions:. Work continues to reduce ‘cancellations by hospital’ by managing annual

leave and a greater oversight by Operations Directors where decisions are made to cancel full clinics.

Key Actions: The Chief Executive, Executive Director for Cancer and Associate Medical

Director (Cancer) met with a number of the Cancer Site Lead Clinicians in February 2019 to discuss pathway management and performance. A PTL report is circulated to all teams showing all patients on a GP 62 day pathway without a decision to treat by day 50.

Performance is reported to the monthly Waiting Times Performance Overview Group and Elective Care Working Group.

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Actual Target (7.01%)

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2017-18 2017-18 2017-18 2017-18 2018-19 2018-19 2018-19 2018-19

STHFT National Average Target

18

CANCER WAITS

(31 days from Decision to Treat to Treatment)

CANCER WAITS

(Screening)

Lead: Anne Gibbs, Executive Director for Cancer Timescale: Ongoing Lead: Anne Gibbs, Executive Director for Cancer Timescale: Ongoing

Key Issues: The Trust performance for Q4 2018/19 is 92.1% (threshold 96%).

The current position for Q1 2018/19 (as at 8 May 2019) is 92.0%.

Key Issues: The Trust performance for Q4 2018/19 is 84.8% (threshold 90%). STHFT

performance for non-shared pathways in Q4 is 88.1%.Due to low treatment numbers a small number of breaches results in performance being below threshold. Throughout the quarter there was a noticable increase in performance, with only January being below the

performance threshold. The current position for Q1 2018/19 (at 8 May 2019) is 100.0% .

Key Actions:. Cancer Waiting Time (CWT) Performance is now reported to the monthly

Waiting Times Performance Overview Group and Elective Care Working Group. Head & Neck and Urology teams continue to work through an action plan for recovery of their CWT performance.

Key Actions: CWT Performance is now reported to the monthly Waiting Times Performance

Overview Group and Elective Care Working Group. .

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2017-18 2017-18 2017-18 2017-18 2018-19 2018-19 2018-19 2018-19

STHFT National Average Target

80.0%

85.0%

90.0%

95.0%

100.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2017-18 2017-18 2017-18 2017-18 2018-19 2018-19 2018-19 2018-19

STHFT National Average Target

19

CANCER WAITS

(Subsequent Surgery)

CAPITAL

(Expenditure - Variance from Plan)

Lead: Anne Gibbs, Executive Director for Cancer Timescale: Ongoing Lead: Neil Priestley, Director of Finance Timescale: Ongoing

Key Issues: The Trust performance for Q4 2018/19 is 87.5% (threshold 94%).

The current position for Q1 2018/19 (at 8 May 2019) is 93.1%.

Key Issues: During March, capital expenditure was £24,360k against a plan of £39,993k,

which is an under-spend of £15,633k. This is due to slippage on a number of capital schemes and is being managed through the Capital Investment Team (CIT)

Key Actions:. CWT Performance is now reported to the monthly Waiting Times Performance Overview Group and Elective Care Working Group. The Urology team

continues to work through an action plan for recovery of their CWT performance.

Key Actions: Specific schemes have been re-profiled to new dates. 2018/19 Capital programme underspend will be carried forward to 2019/20 for completion of

planned schemes.

85.0%

90.0%

95.0%

100.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2017-18 2017-18 2017-18 2017-18 2018-19 2018-19 2018-19 2018-19

STHFT National Average Target

-60.00%

-50.00%

-40.00%

-30.00%

-20.00%

-10.00%

0.00%

Variance from plan

20

EMPLOY CARING & CARED FOR STAFF

SICKNESS ABSENCE

Lead: Mark Gwilliam, Director of Human Resources Timescale: Ongoing

Key Issues: The monthly sickness absence figure is 4.1%.

Key Actions: All directorates have developed their own action plans which are

continuously reviewed; HR Business Partners continue to work with directorates to develop individual action plans for staff that have been off on long term sick. Based on previous years it is anticipated that sickness absence levels could well be affected by

seasonal variation; however we are monitoring sickness absence levels closely on a weekly basis.

0%

1%

2%

3%

4%

5%

6%

% Sickness Absence Target (4%)

21

APPENDIX 1: DEEP DIVE – ELECTRONIC REFERRAL SERVICE (e-RS) – PAPER SWITCH OFF PROGRAMME (PSO) UPDATE

1. Introduction

The NHS e-Referral Service (eRS) is a national system that replaced the national Choose and Book system in 2015. The system combines the electronic booking with a choice of place, date and time for first, hospital or clinic, appointments. Patients can choose their initial hospital or clinic appointment; booking it in their GP surgery at the point of referral, or later at home on the phone or online. NHS Digital has described the e-RS application as not just a technical process but a vehicle to facilitate Primary and Secondary care service redesign to improve the patient experience. The use of eRS was mandated through the NHS standard contract. The NHS Standard Contract: SC6.2A has introduced a new clause which states that: “With effect from 1 October 2018, and as provided for in NHS e-Referral Guidance and/or any subsequent guidance published by NHS England and/or NHS Digital, the Provider need not accept (and will not be paid for any first outpatient attendance resulting from) Referrals by GPs to Consultant-led acute outpatient Services made other than through the NHS e-Referral Service.” The scope of the contract clause covers GP to first consultant outpatient referrals only. The Trust was tasked with becoming paper free (in terms of GP referrals) by the end of April 2018. This was successfully achieved. 2. Sheffield Teaching Hospital (STH) Current Performance

The Trust stopped accepting paper GP routine referrals from the 1st May 2018. Urgent and two week wait paper referrals were switched off from September 2018. There is a list of excluded services where paper referrals are still received. These pathways have been agreed with the CCG and signed off by NHS England. Table 1 shows the referrals received by GP practices through eRS in February 2018. This is contrasted with Table 2 which shows the position in February 2019. Our eRS utilisation position from February 2018 to our current position has been a relatively smooth process and this has been accomplished with the full engagement from all STH specialties along with Sheffield CCG. However, the Trust has seen an increase in the demand in some services. This has been due to the visibility of the services within eRS and the ability for patients to more readily choose where they wish to be seen. There has also been an increase in patient cancellations and this has impacted on the Trust’s 18 week position due to the increase in demand coupled with the challenges of patients repeated cancellations.

22

Table 1 – eRS Sheffield GP Practice Utilisation March 2018

23

Table 2 – eRS Sheffield GP Practice Utilisation March 2019

The Trust has been monitoring the number of paper referrals that have been processed since Paper Switch Off (PSO) status was achieved. This data is reported monthly to NHS England. The number of paper referrals processed has drastically reduced since the deadline of the 1st October 2018. The Trust continues to monitor

24

the number of paper referrals that are processed within the Trust and as of February 2019, current utilisation for electronic referrals being processed stands at 99.98% with 2 paper referrals that were processed in error.

Table 3 – Paper Referrals Processed since 1st October 2018

3. National Update

In October 2018 the Trust was invited to attend the Northern eRS National Event. The Trust was asked to present the approach taken by the organisation to implement the paper switch off objectives and the Trust was asked to describe how it successfully worked with each speciality in the Trust to implement the revised processes. The Trust shared how the joint approach with the Sheffield Children’s Trust and CCG had made the transition easier for Sheffield GP’s. Following on from the successful implementation of Paper Switch Off, NHS England, NHS Improvement and NHS Digital are currently developing a new National Dashboard that will enable Trusts to review their use of eRS. This new dashboard will help identify areas where Trusts can improve or re-design services by using the extensive data that will be available through this dashboard. One area that the Trust is keen on exploring will be around the information on Appointment Slot Issues (ASI’s) and the timescales for these. Once the dashboard is fully available, this will enable the Trust to review a number of processes to ensure that eRS is being used effectively. This will also allow monitoring of timescales around reviewing and managing of GP referrals, referrals that are rejected back to the care of GP’s, ASI’s, Appointment cancellations, and redirecting referrals. This information will then be utilised and shared with our local CCG to ensure we work collaboratively and ensure we have the most robust processes in place for our patients. The electronic-Referral Service will continue to be developed nationally and some of these planned enhancements will be beneficial to our organisation. For example, NHS Digital has developed an Application Programming Interface (API), which will enable us to automatically upload the eRS referral letter into our Patient

545

24 7 5 3 2 6 0

100

200

300

400

500

600

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Paper Referrals Processed by STH 545 24 7 5 3 2 6

Paper Referrals Processed by STH

25

Administration System (PAS); Lorenzo. This is currently in the final stages of development and once released, this new functionality will bring many benefits to the organisation. This enhancement will save time with our administrative processes around the uploading of the referral letter into Lorenzo, but this will also enable our clinicians to refer back to these letters centrally within Lorenzo and manage the processing and administration of referrals electronically. 4. Paper Switch Off (PSO) Programme

Since PSO was achieved in 2018, the Trust has been reviewing and implementing additional functionality within eRS. The Referral Assessment Service (RAS) within eRS was developed in 2018. This functionality allows the referral to be clinically triaged ahead of the patient having an appointment booked. Following this triage, if the patient doesn’t need to be seen in an outpatient clinic, this functionality enables the clinician to send advice enabling the patient to be treated at the practice, or alternatively if the patient did need to be seen at STH, the patient would be booked into the most appropriate clinic first time. Unfortunately, STH were unable to fully utilise this new enhancement due to missing functionality within the system. Once this functionality has been fully developed, STH have a number of services that would benefit from using this and we will move these services onto the RAS as soon as it is fully operational. STH clinicians receive a number of paper requests from GP’s requesting Advice and Guidance (A & G) on patients. Currently these requests come into the organisation via paper and a response is sent via a dictated letter back to the GP. Within eRS there is the ability for GP’s to communicate with our clinicians to request advice on the treatment of their patients, without the need to send a referral. This could include advice regarding an ongoing condition or requesting additional clarification. The functionality in eRS facilitates an electronic conversation between GP and clinician giving a full audit trail on the requests and the response. This functionality is currently only being used by our Renal consultants and this has enabled a number of patients to be treated by the GP instead of having an appointment at the Trust. A number of clinicians and specialties have been identified to further test the electronic A & G system. We are currently in discussion with the local CCG around the usage of this functionality and once this has been fully approved, we will look at rolling this out within the organisation. Clinical Triaging of eRS referrals received has been primarily an administrative process where the electronic referral has been printed and given to the clinician for grading. This paper referral was then returned to the admin team for processing in eRS. The Patients’ Booking Hub opened at the beginning of December 2018 and this central team will deal with all referrals that come into the organisation both electronically and by paper. At this point, a clinical triage process has been adopted where clinicians are able to electronically triage their referrals in eRS, reducing paper, delays as letters move between hospital sites and an audit trail of decisions and actions. Further specialties will move to this system as their teams are consumed within the Patient Booking Hub. 5. Conclusions

The Trust worked collaboratively across specialties, with the CCG and Sheffield Children’s Trust to rollout the eRS and achieve the target to receive all GP referrals electronically from September 2018. Further work is required with GPs to ensure patients are fully engaged in electronically choosing their appointment, leading to reduced DNAs and cancellations. Roll-out of services into the Patient Booking Hub will extend the processes within the referral administration systems to move to ‘paper switch off’ and manage referrals, undertake clinical triage and offer Advice and Guidance in a more electronic manner.

26

APPENDIX 2: DIRECTORATES DASHBOARD

Indicator MeasureDiab &

Endo

Emerg

MedGastro Pharm

Resp

Med

Integ

Comm

Care

GSM

Prim

Care &

Int/Serv

Therap &

Pall CareCCDS ENT Neuro Ophthal

MRSA bacteraemia Actual numbers 1 0 0 0 0 0 0 0

MSSA bacteraemia Actual numbers 5 2 8 10 0 0 0 4

C Diff Actual numbers 7 2 6 21 1 0 4 7

Serious Incidents Approved SI Report submitted within timescales 1 6 0 0 0 1 0 0 0 0 0 0 0

Serious Incidents Number of serious incidents (SI) 1 6 0 0 2 3 2 0 0 0 0 3 0

Incidents Number of finally approved incidents based on incident date 39 272 27 22 48 43 159 25 22 18 10 30 7

Incidents Percentage of incidents approved within 35 days based on approval date 0.8833333 0.9511278 0.93181818 0.8510638 0.8139535 0.7421875 0.7655172 0.7719298 0.8461538 0.7173913 0.5 0.8533333 0.68965517

Average LOS Elective in days against Dr Foster expected -0.10 -1.02 -1.28 0.36 31.96 15.63 0.63 0.10 -1.63 -0.60

Average LOS Non Elective in days against Dr Foster expected 1.59 -2.48 0.85 1.06 4.91 13.33 -0.76 -0.32 -0.30 0.29

Patient Falls Number of inpatient falls against nursing goals 223 180 23

Never Events Number of never events 0 2 0 0 0 0 0 0 0 0 0 1 0

Percentage of admitted patients treated within 18 weeks (90%) 100.00% 96.00% 100.00% 81.71% 92.23% 90.00% 64.39%

Percentage of non-admitted patients treated within 18 weeks (95%) 99.36% 91.42% 96.77% 93.94% 100.00% 68.65% 96.98% 72.09% 93.47%

Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 99.89% 100.00% 98.86% 99.55% 99.26% 92.31% 90.08% 96.39% 89.22% 93.46%

52 week waits Actual numbers 0 0 0 0 0 0 0 0 0

6 week diagnostic waiting Percentage of patients seen within 6 weeks 100.00% 96.70% 100.00% 100.00%

Number of operations cancelled on the day for non clinical reasons 60 25 38 80

Number of patients cancelled on the day and not readmitted within 28 days 2 1 0 1

Percentage of out-patient appointments cancelled by hospital 5.66% 1.15% 11.59% 10.85% 13.55% 6.46% 12.95% 11.93% 16.81% 7.17%

Percentage of out-patient appointments cancelled by patient 10.32% 0.18% 9.49% 12.58% 15.84% 10.83% 14.18% 12.17% 12.12% 11.65%

Percentage of new out-patient appointments where patients DNA 7.80% 9.37% 12.22% 11.49% 7.80% 9.19% 5.34% 11.68% 5.55%

Percentage of follow-up out-patient appointments where patients DNA 7.88% 6.64% 7.17% 9.06% 7.44% 10.51% 7.54% 11.81% 4.38%

Patient seen within 2 weeks (93% compliance) 94.74% 93.75% 91.59% 91.59% 91.92% 91.59%

Breast symptomatic seen within 2 weeks (93% compliance)

62 days from referral to treatment (85% compliance) 57.75% 79.63% 25.00% 25.00% 31.82% 25.00%

31 day first treatment (96% compliance) 97.73% 94.95% 83.78% 83.78% 90.16% 83.78%

e-Referral Service Percentage of appointments booked through e-Referral 100.00% 96.34% 98.03% 89.83% 96.49% 95.97% 99.93% 95.86%

Ethnic group data collection % valid ethnic group (85%) 95.05% 93.68% 89.79% 95.76% 94.10% 90.00% 86.53% 88.76% 88.53% 91.53%

Elective Inpatient activity Variance from contract schedules 0.88% -100.00% -0.35% -2.56% 12.20% -6.95% -2.57% -11.07%

Non elective inpatient activity Variance from contract schedules -0.30% 3.67% 1.73% 1.65% 8.83% -29.79% 8.24% 16.52% 3.13% 32.96%

New outpatient attendances Variance from contract schedules 17.91% -11.44% -0.07% -9.65% 14.17% -0.66% -0.67%

Follow up op attendances Variance from contract schedules 12.54% -83.54% 5.43% 19.95% 3.06% -5.57% -7.68% 11.55% 8.30% 4.60%

Complaints Percentage of complaints answered within 25 working days 86% 87% 93% 100% 97% 100% 99% 100% 92% 100% 100% 99% 100%

FFT Recommended Patients recommending STH for treatment 87.37% 96.19% 97.20% 93.55% 97.14% 98.02%

Day surgery rates BADS - day surgery rates -1 99 -6 -18 658 -4 -10

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 2 0 0 0 0 0 0

Sickness Absence All days lost as a percentage of those available 4.69% 3.61% 3.00% 3.98% 3.56% 4.33% 4.81% 4.65% 3.00% 4.43% 5.47% 3.03% 4.47%

Appraisals Completed appraisal in last year 89.18% 91.04% 89.34% 98.82% 83.04% 89.09% 88.70% 92.62% 90.69% 92.18% 92.98% 87.40% 95.34%

Mandatory Training Overall percentage of completed mandatory training 88.80% 84.19% 90.72% 99.66% 86.39% 90.28% 86.46% 93.72% 95.44% 83.24% 91.33% 87.70% 95.23%

Agency spend Agency and bank spend as a percentage of total pay budget 8.19% 5.90% 5.47% 0.30% 8.37% 3.04% 10.64% 0.39% 1.01% 0.11% 5.47% 1.73% 3.01%

I & E Variance from plan -1.90% -1.27% 11.58% 1.50% -4.22% 0.35% 3.50% -1.84% -0.21% 0.88% 4.96% -4.76% 4.11%

Contract performance Variance from plan 2.00% 2.79% -1.61% 39.57% 1.80% 0.01% 3.42% 14.82% -0.36% -0.78% 3.91% 0.05% -2.03%

Productivity & Efficiency Variance from plan 5.29% 90.32% -59.91% -48.30% 55.50% -26.95% -77.13% 0.38% 1.61% -71.94% -13.27% 28.79% 0.91%

Cancer Waits

Average Length of Stay (by

discharges)

18 week waits referral to treatment

time

Cancelled Operations

Cancelled Outpatient appointments

DNA rate

27

Indicator Measure Lab Med MIMP OGN MSK OSSCA Cardiac Renal Vasc

Comm

Dis &

Spec

Med

Spec

Rehab

Spec

CancerGen Surg

Plastic

SurgUrology

MRSA bacteraemia Actual numbers 0 0 0 1 0 0 0 0 0 0 0 0

MSSA bacteraemia Actual numbers 2 3 2 8 6 4 2 1 4 5 0 0

C Diff Actual numbers 1 7 6 1 2 1 3 4 3 3 1 3

Serious Incidents Approved SI Report submitted within timescales 0 0 0 0 1 2 0 1 0 0 0 3 0 0

Serious Incidents Number of serious incidents (SI) 2 1 2 0 1 3 0 2 0 0 0 8 0 0

Incidents Number of finally approved incidents based on incident date 92 83 35 70 62 44 46 28 16 6 6 46 7 14

Incidents Percentage of incidents approved within 35 days based on approval date 0.9770115 0.9770115 0.7545455 0.85 0.9579832 0.8235294 0.9692308 0.8974359 0.6341463 0.875 0.4415584 0.9342105 0.8125 0.9565217

Average LOS Elective in days against Dr Foster expected -0.58 0.06 1.18 -4.05 0.00 -2.14 10.20 -1.37 1.39 -0.27 0.65

Average LOS Non Elective in days against Dr Foster expected 0.09 0.71 0.47 1.94 0.33 -0.16 57.46 -1.23 0.03 0.26 -0.85

Patient Falls Number of inpatient falls against nursing goals 158 134

Never Events Number of never events 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Percentage of admitted patients treated within 18 weeks (90%) 75.09% 70.45% 91.13% 100.00% 49.37% 96.48% 97.96% 86.83% 91.30% 91.48%

Percentage of non-admitted patients treated within 18 weeks (95%) 100.00% 96.91% 91.47% 0.00% 87.17% 100.00% 78.97% 94.06% 95.45% 98.36% 95.17% 97.91% 97.07%

Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 100.00% 92.02% 90.20% 95.00% 95.12% 100.00% 68.57% 93.80% 94.44% 99.45% 93.08% 95.05% 97.06%

52 week waits Actual numbers 0 0 0 0 0 0 0 0 0 0 0

6 week diagnostic waiting Percentage of patients seen within 6 weeks 100.00% 100.00% 99.67% 100.00% 100.00% 99.14%

Number of operations cancelled on the day for non clinical reasons 43 155 250 39 192 55 74

Number of patients cancelled on the day and not readmitted within 28 days 1 11 0 8 9 13 0 2

Percentage of out-patient appointments cancelled by hospital 5.66% 8.28% 11.62% 11.44% 14.75% 14.47% 14.69% 10.22% 19.28% 7.79% 8.09% 7.97%

Percentage of out-patient appointments cancelled by patient 22.64% 6.36% 10.67% 7.63% 7.87% 7.16% 10.11% 14.05% 4.80% 13.79% 11.13% 15.32%

Percentage of new out-patient appointments where patients DNA 19.61% 5.74% 4.05% 5.94% 12.48% 4.47% 9.02% 14.76% 2.80% 7.69% 6.28% 8.27%

Percentage of follow-up out-patient appointments where patients DNA 17.55% 3.45% 9.05% 4.18% 9.79% 3.80% 7.25% 8.81% 3.27% 5.40% 7.78% 6.11%

Patient seen within 2 weeks (93% compliance) 93.80% 93.75% 98.22% 95.05% 94.74% 96.02%

Breast symptomatic seen within 2 weeks (93% compliance) 93.16% 93.16%

62 days from referral to treatment (85% compliance) 77.27% 79.63% 95.45% 71.43% 57.75% 91.45%

31 day first treatment (96% compliance) 100.00% 94.95% 98.65% 93.45% 97.73% 98.25%

e-Referral Service Percentage of appointments booked through e-Referral 100.00% 98.92% 100.00% 100.00% 98.90% 99.49% 99.60% 100.00% 100.00% 98.66% 100.00%

Ethnic group data collection % valid ethnic group (85%)

Elective Inpatient activity Variance from contract schedules 3.17% -3.45% -0.54% 11.00% -18.37% -2.28% 1.36% -5.54% -5.13% -1.42%

Non elective inpatient activity Variance from contract schedules -3.88% -0.64% 3.02% -2.20% -7.89% 9.89% 1.94% -2.45% -2.70% -11.03%

New outpatient attendances Variance from contract schedules -5.83% 16.73% -2.16% -33.33% 7.13% 2.86% -9.09%

Follow up op attendances Variance from contract schedules -20.78% -20.78% -20.78% 1.67% 15.38% 1.81% 0.92% -1.45% -1.40% -2.36% 13.42% 6.12% 1.70% 8.49%

Complaints Percentage of complaints answered within 25 working days 100% 100% 92% 93% 96% 70% 77% 81% 98% 100% 100% 89% 91% 96%

FFT Recommended Patients recommending STH for treatment 96.77% 95.28% 100.00% 98.33% 100.00% 97.67% 97.16% 96.15% 93.06%

Day surgery rates BADS - day surgery rates 343 96 18 -18 -30 33 -32 17 -146 -14 340

Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0

Sickness Absence All days lost as a percentage of those available 3.10% 4.03% 4.34% 3.84% 4.42% 3.95% 5.12% 2.60% 3.61% 4.46% 3.34% 4.02% 2.52% 4.39%

Appraisals Completed appraisal in last year 90.11% 91.14% 87.53% 90.88% 81.62% 84.52% 87.59% 94.57% 80.79% 93.38% 86.84% 92.58% 94.68% 90.91%

Mandatory Training Overall percentage of completed mandatory training 90.11% 91.14% 87.53% 90.88% 81.62% 84.52% 87.59% 94.57% 80.79% 93.38% 86.84% 92.58% 94.68% 90.91%

Agency spend Agency and bank spend as a percentage of total pay budget 0.63% 0.45% 0.58% 5.30% 3.07% 4.81% 3.32% 7.19% 2.42% 10.11% 4.67% 5.21% 1.67% 2.26%

I & E Variance from plan -1.70% -1.18% 5.36% -0.67% 2.08% -1.40% 1.90% 4.54% -0.28% 1.16% 1.63% -1.45% -2.96% 0.29%

Contract performance Variance from plan 6.83% 19.19% -1.93% 0.72% 21.33% 2.59% 0.58% -0.55% 0.85% 4.06% 2.41% -0.34% 0.28% 1.56%

Productivity & Efficiency Variance from plan 42.82% 3.19% -31.92% 3.73% -63.94% 14.33% -61.90% 63.10% -77.53% -43.01% 42.75% -52.94% -30.06% -66.05%

Performance is YTD unless specified: Last complete month Rolling 12 months Last complete quarter

Average Length of Stay (by

discharges)

18 week waits referral to treatment

time

Cancelled Operations

Cancelled Outpatient appointments

DNA rate

Cancer Waits