171214 TB Item 07 October IPR.pdf - moorfields.nhs.uk TB Item 07... · Report to Trust Board Report...

Report to Trust Board

Report Title Integrated Performance Report - October 2017

Report from John Quinn, Chief Operating Officer

Prepared by Performance And Information Department

Previously discussed at Management Executive

Attachments

Brief Summary of Report

This Integrated Performance Report highlights a series of metrics regarded as the Key Indicators of Trust Performance and cover a variety of

organisational activities within Operations, Quality and Safety, Workforce, Finance, Research, Commercial and Private Patients . The report

uses a number of mechanisms to put performance into context, showing achievement against target, in comparison to previous periods and

as a trend. The source of each KPI is also shown, namely; the Single Oversight Framework (SOF); NHS England (NHSE); NHS

Improvement (NHSI); Care Quality Commission (CQC); Trust derived (Local) or a Strategic Objective (SO, followed by a number to indicate

which objective). Importantly, the report also identifies additional information and Remedial Action Plans for those KPIs falling short of target

and requiring improvement.

The following is a brief domain summary;

Responsive

• Of the 18 KPIs within this section, 9 are achieving target (shaded green) with 8 Red. There is also one KPI (Cancer 62-day waits) as there

were no patients recorded in this category this month. All those breaching their respective targets are reported on through the Remedial

Action Plans. There are two changes from the previous month; 18 Week RTT Closed Non-Admitted has improved from September and is

achieving the target this month while Electronic Booking Appointment Slot Issue (ASI) Rate has increased and is above target.

• The KPI for 52 Week RTT Incomplete Breaches remain rated as Red due to it breaching the annual target but there has also been one one

reported breach this month.

• Performance against the 14-Day target for NHS England Ocular Oncology remains below the monthly threshold of 93.0%, achieving 92.4%

for October.

X To Note

Well Led

Safe

Effective

• For the 10 KPIs within the Effective section, 6 are achieving their respective targets this month with two being rated 'Amber' and the

remaining two 'Red'.

• Of the two Amber KPIs, the Outpatient Cancellation Rate (Patient Cancellations) has marginally breached the target (3.18% achieved

against the 3.15% target) and the Theatre Cancellation Rate (Non-Medical Cancellations) has achieved it's best level of performance this

month.

• Of the two Red KPIs, operations which were cancelled for non-medical reasons which were not rebooked within 28 days has again reported

2 for the month which has prompted a review of the administrative and escalation processes. Similarly the Emergency Re-admission

percentage breach has also triggered work to ensure accurate recording of data.

Caring

• Of the six metrics within this domain, all are achieving target this month. This is an improvement on the previous month with Written

Complaints now meeting the monthly target.

• This domain contains 19 reportable KPIs for this month, of which 18 are achieving target. The only KPI breaching target this month is

'Adenovirus cases that were possibly MEH acquired', for which a Remedial Action Plan has been completed. The RAP identifies that whilst

there have been four cases, each has been reviewed and there are no specific causes for concern with infection control or for patient safety.

The report is primarily for information purposes but will inform discussion regarding how the Trust is performing against its key organisational measures.

This may in turn generate subsequent action. As this is the first Integrated Performance Report produced in this format, the Board is also asked to provide

feedback on the style and content of the report, so that these can be considered for future iterations.

For Assurance For decision For discussion

• The 17 KPIs within this domain reflect 9 measures achieving target with the remainder falling short, with 2 Amber and 6 Red. Remedial

Action Plans are supplied for 6 of these KPIs, the temporary staffing details can be found within the Boards Finance Report

• Appraisal Compliance has achieved the 80% target this month for the first time this financial year.

Use Of Resources

• The 15 KPIs within this domain reflect 12 measures achieving target with 3 falling short (1 Amber and 2 Red). Further detail can be found in

the Board Financial Report.

Action Required/Recommendation

The report is primarily for information purposes but will inform discussion regarding how the Trust is performing against its key organisational measures.

This may in turn generate subsequent action. As this is the first Integrated Performance Report produced in this format, the Board is also asked to provide

feedback on the style and content of the report, so that these can be considered for future iterations.

Action Required/Recommendation

G A R G A R

Referral To Treatment 2 0 2 Patient Experience 5 0 0

Accident & Emergency 3 0 1 Organisational Health 1 0 0

Cancer 3 0 1

Clinic Management 0 0 4

Diagnostics 1 0 0 Organisational Health 5 2 2

Staff Experience 1 0 1

Infection Control 6 0 1 Training Compliance 2 0 0

Patient Safety 8 0 0 Research 1 0 3

Safer Staffing (WHO) Checklist 5 0 0

Non-Attendances 2 0 0

Cancellations 3 2 1

Re-admissions 0 0 1

Mortality 1 0 0

'Current Rating' Key 'Monthly Trend' Key

* Red, Amber, Green ratings are used to identify whether or not a KPI is achieving target. Where there are

data issues, these are highlighted in blue.

Colour of symbol shows Red, Amber Green rating of

current month against target.

* Grey ratings represent zero return and therefore a percentage can not be calculated, or where a target has

not been set or is 'tbc'

* Metrics for which data is either not available or are not applicable to reporting period (i.e. Quarterly figures)

are shown as black.

* If metric is aligned to a strategy objective, this objective is listed in the 'KPI Source' column denoted SO1 -

SO8

0

Financial Metrics 6 1 2Effective

Use of

Resources

Financial Resources 6 0

Trust Executive Summary - October 2017

Responsive

Caring

Well-led

Safe

Intergrated Performance Report - October 2017 Page 2

Executive Summary - Domain Trends

0

2

4

6

8

10

12

Apr May Jun Jul Aug Sep Oct

KP

I RA

G S

tatu

s


Green 7 8 9 9 10 10 9

Amber 0 1 2 1 1 1 0

Red 10 8 6 6 7 7 8

Responsive

0

5

10

15

20


KP

I RA

G S

tatu

s


Green 16 16 18 17 18 19 19

Amber 0 0 0 0 0 0 0

Red 3 3 2 1 0 1 1

Safe

0

2

4

6

8

10


KP

I RA

G S

tatu

s


Green 6 5 5 6 5 8 6

Amber 2 3 0 2 1 1 2

Red 2 2 5 2 4 0 2

Effective

0

1

2

3

4

5

6

7


KP

I RA

G S

tatu

s


Green 5 5 5 6 5 5 6

Amber 0 0 0 0 0 0 0

Red 1 1 1 0 1 1 0

Caring

0

2

4

6

8

10

12


KP

I RA

G S

tatu

s


Green 11 10 10 11 8 7 9

Amber 2 2 3 2 3 3 2

Red 3 4 4 4 6 7 6

Well-Led

0

2

4

6

8

10

12

14


KP

I RA

G S

tatu

s


Green 10 12 12 12 9 11 12

Amber 1 0 0 1 0 0 1

Red 4 3 3 2 6 4 2

Use of Resources

Integrated Performance Report - October 2017 Page 3

2016/17 2017/18 2016/17 2017/18

A&E Arrivals (All Type 2) 8,613 8,401 - 2.5% 62,044 59,807 - 3.6%

Number of 4 hour breaches 281 43 - 84.7% 1,327 999 - 24.7%

Number of Referrals Received 11,163 11,889 + 6.5% 75,776 76,019 + 0.3%

Total Attendances 47,215 50,556 + 7.1% 324,207 329,513 + 1.6%

First Appointment Attendances 10,888 11,429 + 5.0% 72,313 73,906 + 2.2%

Follow Up (Subsequent) Attendances 36,327 39,127 + 7.7% 251,894 255,607 + 1.5%

Total Admissions 3,195 3,337 + 4.4% 22,069 21,780 - 1.3%

Day Case Elective Admissions 2,817 3,004 + 6.6% 19,829 19,395 - 2.2%

Inpatient Elective Admissions 125 83 - 33.6% 670 621 - 7.3%

Non-Elective (Emergency) Admissions 253 250 - 1.2% 1,570 1,764 + 12.4%

These figures are not subject to any finance or commissioning business logic. They present all activity, whether chargeable or not

Outpatient

Activity

Admission

Activity

Context - Overall Activity - October 2017October 2017 Monthly

Variance

Year To Date YTD

Variance

Accident &

Emergency

Intergrated Performance Report - October 2017 Page 4

Domain: Responsive

Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3 13 Month Month

18 Week RTT Incomplete Performance SOF ≥92% G 96.0% 95.7% 95.3% 94.7% 97.7% 96.7% 95.6% 94.7%

52 Week RTT Incomplete Breaches NHSEZero

BreachesR 7 5 0 0 1 6 4 0 1

18 Week RTT Closed Admitted Performance NHSE ≥90% R 8 83.7% 83.2% 83.6% 83.5% 86.3% 84.1% 83.3% 83.5%

18 Week RTT Closed Non-Admitted Performance NHSE ≥95% G 95.3% 95.2% 95.1% 95.5% 96.0% 95.8% 94.8% 95.5%

A&E Four Hour Performance SOF ≥95% G 98.3% 98.1% 99.4% 99.5% 98.0% 97.5% 98.7% 99.5%

Time to Treatment In Department - median Local ≤60 Mins G 31 33 36 40 35 31 34 40

A&E Left Without Being Seen Local ≤5% G 2.4% 1.9% 2.1% 2.7% 2.3% 2.4% 2.2% 2.7%

A&E Unplanned Reattendance Local ≤5% R 9 5.5% 5.6% 5.7% 5.6% 5.4% 5.5% 5.6% 5.6%

Cancer 2 week waits - first appointment urgent GP referral NHSE ≥93% G 97.9% 93.3% 100.0% 100.0% 100.0% 97.0% 97.7% 100.0%

Cancer 14 Day Target - NHS England Referrals (Ocular Oncology) NHSE ≥93% R 10 92.2% 92.6% 91.5% 92.4% 89.1% 91.8% 92.6% 92.4%

Cancer 31 day waits - diagnosis to first appointment NHSE ≥96% G 90.8% 100.0% 100.0% 100.0% 93.2% 79.1% 100.0% 100.0%

Cancer 31 day waits - subsequent treatment NHSE ≥94% G 96.3% 100.0% 100.0% 100.0% 100.0% 88.9% 100.0% 100.0%

Cancer 62 days from urgent GP referral to first definitive treatment SOF ≥85% 100.0% 100.0% n/a n/a 100.0% n/a 100.0% n/a

Outpatient Clinic Journey times - New Appointments (Minutes): Trajectory

target of 105.7 mins by March 2018SO1 YTD: ≤ 110.6 R 11 117.9 116.3 116.6 116.3 116.3 117.9 118.4 116.3

Outpatient Clinic Journey times - Follow Up Appointments (Minutes):

Trajectory target of 93.1 mins by March 2018SO1 YTD: ≤ 97.4 R 12 102.0 102.7 100.6 100.6 102.6 102.9 101.6 100.6

Electronic Booking Appointment Slot Issue (ASI) Rate - trajectory target

of ≥ 4% by March 2018NHSI Mth: ≤ 13.1% R 13 22.1% 17.2% 12.4% 22.5% 19.8% 26.9% 17.4% 22.5%

Percentage of GP referrals From Electronic Booking - trajectory target of

80% by Q3NHSI Mth: ≥83.3% R 14 56.8% 58.9% 62.0% 60.5% 57.7% 53.8% 58.4% 60.5%

Diagnostics Percentage of Diagnostic waiting times less than 6 weeks NHSE ≥99% G 100% 100% 100% 100% 100% 100% 100% 100%

Referral To

Treatment

Accident &

Emergency

Cancer

Clinic

Management

October 2017

Theme Metric DescriptionKPI

SourceTarget

Cu

rre

nt

RA

P P

g Current

Year to

Date

Month Quarter Trends

Where issued for a metric, the page number of the Remedial Action Plan (RAP) can be found in column 'RAP Pg'


Remedial Action Plans for Responsive


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Referral To TreatmentZero

BreachesR 5 0 0 1 6 4 0 1

Lead Manager

A paper internal referral from Glaucoma to the Adnexal

service was not processed

The patient has now been seen by the Adnexal service with

further appointments arranged. The internal referral process is

now being managed electronically through the Windip system.

30/10/2017

Divisional Managers Responsible Director John Quinn

Reasons for Underperformance? Action Plan(s) to Improve Performance Date Expected

Remedial Action Plan 52 Week RTT Incomplete Breaches

Domain: Theme Target

Cu

rren

t

Current

Year to

Date

Month Quarter

0.0%

200.0%

400.0%

600.0%

800.0%

1000.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Referral To Treatment ≥90% R 83.7% 83.2% 83.6% 83.5% 86.3% 84.1% 83.3% 83.5%

Lead Manager

North West - Issues with cover at Northwick Park and Ealing

Hospital are affecting performance. Cover both in terms of senior

medical cover and anaesthetic cover.

Team continue to book locum anaesthetic cover for sessions. Divisional

Manager has met with City Road to discuss what options are available

and will enter into discussions with Ealing about SLA agreement and

anaesthetic cover.

30/11/2017

South - Additional referrals loaded March/April 2017 (450 Referrals)

impacting bottle neck 18-24 weeks.

Maximising lists - Ensuring we utilise full day of theatre lists. Increase

Injection list from an average of 11 to 13. Additional Cataract list on

Saturdays leading to January 2017

01/02/2018

Cancellation rates for patients particularly New patients noted to be

much higher at Darent Valley and Watford; 7-8%.

Divisional Manager to meet with team doing bookings to understand

issues and draw up plan to reduce patient cancellations.30/11/2017

North East - Issues with capacity at Darent Valley Hospital

insufficient for current demand. Main other underperformance is

Cataract at St Ann's and Mile End.

Darent Valley Hospital expansion plan underway. Cataract lists have

been increased to 7 per session at Mile End and St Ann's to help

performance although Barts move has affected Theatres.

30/11/2017



Remedial Action Plan 18 Week RTT Closed Admitted Performance


Cu

rren

t

Current

Year to

Date

Month Quarter

75%

80%

85%

90%

95%

100%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Accident & Emergency ≤5% R 5.5% 5.6% 5.7% 5.6% 5.4% 5.5% 5.6% 5.6%

Lead Manager

Ealing experiencing high cancellations due to lack of

available anaesthetic cover.

Team continue to try and book locum anaesthetic cover for

sessions. Divisional Manager has met with City Road to discuss

what options are available and will enter into discussions with

Ealing about SLA agreement and anaesthetic cover.

30/11/2017

Sean Briggs/Alison McGirr Responsible Director John Quinn


Remedial Action Plan A&E Unplanned Reattendance


Cu

rren

t

Current

Year to

Date

Month Quarter

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Cancer ≥93% R 92.2% 92.6% 91.5% 92.4% 89.1% 91.8% 92.6% 92.4%

Lead Manager

14 day Ocular oncology performance of 92.4% was due to

patient choice. Out of 79 attendance 6 patients did not

want their appointment within the 14 day timeframe

All patients who request a date for their appointment outside the

breach date are escalated to the service manager . All patients

are telephoned and offered dates within the 14 day time frame

30/11/2017

Katie Goodwin Responsible Director John Quinn


Remedial Action Plan Cancer 14 Day Target - NHS England Referrals (Ocular Oncology)


Cu

rren

t

Current

Year to

Date

Month Quarter

70%

75%

80%

85%

90%

95%

100%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Clinic Management YTD: ≤ 110.6 R 117.9 116.3 116.6 116.3 116.3 117.9 118.4 116.3

Lead Manager

Booking profiles: Clinic profiles are front loaded with

patients resulting in more patients attending clinics per slot

then capacity to see them. Meaning that journey times are

inflated as patients will be waiting longer.

Clinic profiles are being systematically amended clinic by clinic.

The first clinics being reviewed are in Glaucoma at City Road.

The first rollout of newly re-profiled Glaucoma clinics at City

Road was carried out in October for 2 clinics. Initial results have

shown a 5-48% reduction in those 2 clinics, and we have rollout

to an additional 3 clinics in November. Depending on success

there will then be a rolling programme of re-profiling of clinics.

We are currently not anticipating an adverse effect on delivery

by March 2018.

30/11/2017

Komal Whittaker-Axon Responsible Director John Quinn


Remedial Action PlanOutpatient Clinic Journey times - New Appointments (Minutes):

Trajectory target of 105.7 mins by March 2018


Cu

rren

t

Current

Year to

Date

Month Quarter

105

110

115

120

125


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Clinic Management YTD: ≤ 97.4 R 102.0 102.7 100.6 100.6 102.6 102.9 101.6 100.6

Lead Manager

Booking profiles: Clinic profiles are front loaded with

patients resulting in more patients attending clinics per slot

then capacity to see them. Meaning that journey times are

inflated as patients will be waiting longer.

Clinic profiles are being systematically amended clinic by clinic.

The first clinics being reviewed are in Glaucoma at City Road.

The first rollout of newly re-profiled Glaucoma clinics at City

Road was carried out in October for 2 clinics. Initial results have

shown a 5-48% reduction in those 2 clinics, and we have rollout

to an additional 3 clinics in November. Depending on success

there will then be a rolling programme of re-profiling of clinics.

We are currently not anticipating an adverse effect on delivery

by March 2018.

30/11/2017

Komal Whittaker-Axon Responsible Director John Quinn


Remedial Action PlanOutpatient Clinic Journey times - Follow Up Appointments (Minutes):

Trajectory target of 93.1 mins by March 2018


Cu

rren

t

Current

Year to

Date

Month Quarter

90

95

100

105

110


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Clinic Management Mth: ≤ 13.1% R 22.1% 17.2% 12.4% 22.5% 19.8% 26.9% 17.4% 22.5%

Lead Manager

Remedial Action PlanElectronic Booking Appointment Slot Issue (ASI) Rate - trajectory target

of ≥ 4% by March 2018


Cu

rren

t

Current

Year to

Date

Month Quarter

Sean Briggs Responsible Director John Quinn


Actual clinic slots now available stands at 93%. MEH are

working with commissioners to change the data we are

currently reporting as we are on track to meet the CQUIN.

High demand for new CAB slots.

Demand and capacity project looking to ensure all choose and

book slots have capacity. 01/01/2018

0.0%

10.0%

20.0%

30.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Responsive Clinic Management Mth: ≥83.3% R 56.8% 58.9% 62.0% 60.5% 57.7% 53.8% 58.4% 60.5%

Lead Manager

01/01/2018

Actual clinic slots now available stands at 93%. MEH are

working with commissioners to change the data we are

currently reporting as we are on track to meet the CQUIN.

High demand for new CAB slots.

Demand and capacity project looking to ensure all choose and

book slots have capacity.

Sean Briggs Responsible Director John Quinn


Remedial Action PlanPercentage of GP referrals From Electronic Booking - trajectory target

of 80% by Q3


Cu

rren

t

Current

Year to

Date

Month Quarter

50%

60%

70%

80%

90%

100%


Domain: Safe


Endopthalmitis Rates - Cataract (per 1000 incidents) CQC ≤0.83 G 0.08 0.00 0.00 0.00 0.17 0.17 0.00 0.00

Endopthalmitis Rates - Intravitreal (per 1000 incidents) CQC ≤0.5 G 0.13 0.00 0.62 0.00 0.00 0.00 0.31 0.00

MRSA Bacteraemias Cases SOF Zero Cases G 0 0 0 0 0 0 0 0

Clostridium Difficile Cases SOF Zero Cases G 0 0 0 0 0 0 0 0

Percentage of Adenovirus positive cases which were possible MEH

acquiredCQC

< Previous

QtrR 17 2.4% 0.0% 0.0% 9.1% 1.2% 1.9% 0.0% 9.1%

Hand Hygiene Audit Compliance CQC ≥95% G 98.7% 99.0% 99.0% 99.0% 98.3% 98.3% 99.0% 99.0%

Cleanliness Audit Compliance CQC ≥95% G 99.7% 99.9% 99.4% 99.8% 99.7% 99.6% 99.8% 99.8%

Duty of Candour (Percentage of conversations informing family/carer that

a patient safety incident has ocurred within 10 working days of the

incident being reported to local risk management systems)

CQC 100% G 97.9% 100.0% 100.0% 83.0% n/a 100.0% 100.0% 83.0%

Inpatient (Overnight) Ward Staffing Fill Rate CQC ≥90% G 95.5% 94.0% 100.1% 103.7% 93.6% 91.8% 96.3% 103.7%

Occurrence of any Never events SOF Zero Events G 2 0 0 0 0 2 0 0

Occurrence of any Serious Incidents SOF Zero Events G 1 0 0 0 3 0 1 0

NHS England/NHS Improvement Patient Safety Alerts breached SOF Zero Alerts G 0 0 0

VTE Risk Assessment SOF ≥95% G 98.7% 99.1% 97.9% 98.5% 99.0% 98.8% 98.7% 98.5%

Posterior Capsular Rupture rates Local ≤1.95% G 0.95% 0.82% 1.30% 0.97% 1.06% 0.97% 0.93% 0.97%

Safeguarding - Mandatory Training Compliance CQC ≥80% G 85.6% 86.8% 86.9%

Safer Surgery Checklist: Percentage of audited "Team Briefing" stage

elements compliant with requirements SO1 ≥90% G 93.2% 100.0% 96.3% 96.9% 94.0% 90.1% 95.6% 96.9%

Safer Surgery Checklist: Percentage of audited "Sign In" stage elements

compliant with requirementsSO1 ≥90% G 99.5% 100.0% 100.0% 100.0% 95.3% 98.8% 99.9% 100.0%

Safer Surgery Checklist: Percentage of audited "Time Out" stage

elements compliant with requirementsSO1 ≥90% G 98.5% 100.0% 97.5% 98.7% 94.8% 98.1% 98.7% 98.7%

Safer Surgery Checklist: Percentage of audited "Sign Out" stage


Safer Surgery Checklist: Percentage of audited "Team Debrief" stage


October 2017


SourceTarget

TrendsCurrent

Year to

Date

Month Quarter

Infection

Control

Patient Safety

Safer Staffing

(WHO)

ChecklistC

urr

en

t

RA

P P

g



Remedial Action Plans for Safe


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Safe Infection Control< Previous

QtrR 2.4% 0.0% 0.0% 9.1% 1.2% 1.9% 0.0% 9.1%

Lead Manager

Remedial Action PlanPercentage of Adenovirus positive cases which were possible MEH

acquired


Cu

rren

t

Current

Year to

Date

Month Quarter

Catherine Wagland Responsible Director Tracy Luckett


There is no particular indication for the increase in

numbers of adenovirous for the month of October. All four

cases occurred in different department and on different

dates and were seen by different practitioners. However,

appropriate actions were taken.

The Infection Control Nurses conducted a walkabout in the units

that had the cases to observe practice. All the areas had the

appropriate wipes present which were in every cubicle and slit-

lamps were observed to be cleaned between patients. Staff

were reminded to clean medical devices between patients and

practice good hand hygiene.Continued surveillance of

adenovirus is being conducted by the infection control team.

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%


Domain: Effective


Outpatients DNA rate - 1st appointment - trajectory target of 12.7% by

March 2018Local YTD:≤13.3% G 12.3% 12.6% 12.5% 11.6% 13.8% 12.5% 12.5% 11.6%

Outpatients DNA rate - follow up appointment - trajectory target of 10.9%

by March 2018Local YTD:≤11.3% G 10.7% 11.0% 11.2% 10.6% 12.0% 10.5% 10.9% 10.6%

Outpatient Cancellation rate (Hospital cancellations) Local ≤2.85% G 2.86% 3.09% 2.54% 2.63% 2.70% 2.99% 2.83% 2.63%

Outpatient Cancellation Rate (Patient cancellations) Local ≤3.15% A 20 3.26% 3.41% 3.05% 3.18% 3.20% 3.28% 3.28% 3.18%

Theatre Cancellation Rate Local ≤7.6% G 7.0% 6.7% 6.3% 6.9% 8.0% 7.4% 6.6% 6.9%

Theatre Cancellation Rate (Non-Medical Cancellations) Local ≤0.8% A 21 1.35% 0.98% 1.09% 0.95% 1.22% 1.73% 1.12% 0.95%

Theatre Sessions starting late Local ≤35.8% G 32.2% 27.7% 27.6% 30.5% 38.5% 37.4% 27.7% 30.5%

Number of non-medical cancelled operations not treated within 28 days * CQCZero

BreachesR 22 9 1 2 2 1 4 3 2

Re-AdmissionsPercentage of Emergency re-admissions within 30 days following an

elective or emergency spell at the ProviderSOF ≤3.77% R 23 4.07% 5.36% 3.51% 6.20% 3.35% 3.44% 3.79% 6.20%

Mortality Summary Hospital Mortality Indicator SOF Zero Cases G 0 0 0 0 1 0 0 0

Non-

Attendances

Cancellations

October 2017


SourceTarget

Cu

rre

nt

RA

P P

g Current

Year to

Date


* Figures for Current quarter and YTD are provisional



Remedial Action Plans for Effective


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Effective Cancellations ≤3.15% A 3.26% 3.41% 3.05% 3.18% 3.20% 3.28% 3.28% 3.18%

Lead Manager

Patients contacted over the past three months to reminding

them of their upcoming appointment. This has resulted in

more patient cancellations

All out patient activity is being monitored weekly including

patient cancellations. All patients are telephoned by the booking

centre staff before their appointment date to confirm

attendance.

30/11/2017

Cancellation rates for patients particularly New patients

noted to be much higher at Darent Valley and Watford - 7-

8%.

Divisional Manager to meet with team doing bookings to

understand issues and try to draw up plan to reduce patient

cancellations.

30/11/2017



Remedial Action Plan Outpatient Cancellation Rate (Patient cancellations)


Cu

rren

t

Current

Year to

Date

Month Quarter

2.0%

2.5%

3.0%

3.5%

4.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Effective Cancellations ≤0.8% A 1.35% 0.98% 1.09% 0.95% 1.22% 1.73% 1.12% 0.95%

Lead Manager

Increased patient contact confirming planned surgery. A

reduction in DNA numbers supporting overall cancellation

rate.

The performance has improved from 1.09% down to 0.95 % in

the past month. The admission teams are calling patients to

confirm their attendance

30/11/2017

Ealing experiencing high cancellations due to lack of

available anaesthetic cover.

Team continue to try and book locum anaesthetic cover for

sessions. Divisional Manager has met with City Road to discuss

what options are available and will try to enter into discussions

with Ealing about SLA agreement and anaesthetic cover.

30/11/2017



Remedial Action Plan Theatre Cancellation Rate (Non-Medical Cancellations)


Cu

rren

t

Current

Year to

Date

Month Quarter

0.0%

1.0%

2.0%

3.0%

4.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Effective CancellationsZero

BreachesR 9 1 2 2 1 4 3 2

Lead Manager

One patient cancelled and then delayed due to patient

choice. One patient was cancelled due to a lack of theatre

time and then not re-booked in time.

Strengthened data capture and escalation process for non-

medical cancellations. 01/11/2017



Remedial Action Plan Number of non-medical cancelled operations not treated within 28 days


Cu

rren

t

Current

Year to

Date

Month Quarter

0

1

2

3


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Effective Re-Admissions ≤3.77% R 4.07% 5.36% 3.51% 6.20% 3.35% 3.44% 3.79% 6.20%

Lead Manager

A high number of patients returning to A/E are planned and

not captured as so but rather as unplanned.

A designated clinic has been set up for planned reattendance

for patients who attend A/E to record planned returning

patients. In addition the new ECDS electronic system which

will go live on Dec 6th should capture the data more accurately.

Returning patients bookings will be reviewed weekly to ensure

are coded accurately.

30/11/2017

General Managers Responsible Director John Quinn


Remedial Action PlanPercentage of Emergency re-admissions within 30 days following an

elective or emergency spell at the Provider


Cu

rren

t

Current

Year to

Date

Month Quarter

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%


Domain: Caring


Written Complaints – rate per 10,000 attendances SOF ≤2.943 G 2.95 3.08 3.22 1.60 3.67 3.44 2.95 1.60

Mixed Sex Accommodation Breaches SOFZero

BreachesG 2 0 0 0 0 2 0 0

Inpatient Scores from Friends and Family Test - % positive SOF ≥90% G 99.3% 99.3% 99.1% 99.2% 99.2% 99.3% 99.3% 99.2%

A&E Scores from Friends and Family Test - % positive SOF ≥90% G 95.0% 95.5% 95.6% 93.4% 93.9% 95.2% 95.3% 93.4%

Outpatient Scores from Friends and Family Test - % positive SOF ≥90% G 96.6% 97.1% 96.4% 95.7% 96.9% 97.0% 96.7% 95.7%

Organisational

Health

Percentage of Staff agreeing with the staff survey statement "Care of

patients / service users is my organisation's top priority"Local ≥86% G 86.0%

Patient

Experience

October 2017


SourceTarget

Cu

rre

nt

RA

P P

g Current

Year to

Date




Remedial Action Plans for Caring

NO REMEDIAL ACTION PLANS ARE REQUIRED FOR THIS DOMAIN THIS MONTH


Domain: Well Led


Staff Sickness (Month Figure) SOF ≤4% G 4.2% 4.0% 3.1%

Staff Sickness (Rolling Annual Figure) SOF ≤4% G 3.9% 3.9% 3.9%

Staff Turnover (Rolling Annual Figure) SOF ≤15% A 28 19.7% 19.5% 19.0%

Executive team turnover SO5/SOF ≤20% G 0.0% 11.8% 11.8%

NHS Staff Survey SO5/SOF 3.98 G 4.02

Proportion of Temporary Staff SOFRAG as per

spendR ** 14.7% 15.8% 13.9% 15.7% n/a 14.1% 15.0% 15.7%

Staff Stability Local ≥80% G 83.0% 83.5% 84.0%

Staff Vacancy Rates SO5 ≤10% A 29 14.1% 12.8% 13.2%

Temporary Staff Spend SOF ≤ Plan (£) R ** 667 182 29 255 n/a -244 297 255

Percentage of Staff agreeing with the staff survey statement "If a friend or

relative needed treatment, I would be happy with the standard of care

provided by this organisation"

SO3 ≥90% G 95.4% 94.5% 96.3% 95.4%Due

Jan 18

Percentage of Staff agreeing with the staff survey statement "I would

recommend my organisation as a place to work"Local ≥70% R 30 66.8% 77.8% 70.3% 66.8%

Due

Jan 18

Mandatory Training Compliance Local ≥80% G 81.7% 80.2% 81.1%

Appraisal Compliance Local ≥80% G 75.4% 79.8% 80.9%

70 Day To Recruit First Research Patient SO2 ≥80% R 31 77.4% 66.7% 75.0% 75.0% 85.7% 82.4% 70.0% 75.0%

Percentage of Patients Recruited Against Target (Studies Closed In

Month)SO2 100% G 114.2% 128.7% 80.0% 117.7% 85.0% 82.7% 125.1% 117.7%

Percentage of Research Projects Achieving Time and Target SO2 ≥80% R 32 64.7% 66.7% 66.7% 66.7% 60.0% 61.9% 66.7% 66.7%

Total patient recruitment to all studies (YTD cumulative) - trajectory target

for the year end of 6000SO2 ≥3500 R 33 2354 150 394 432 n/a 1088 834 432

Organisational

Health

Staff

Experience

Training

Compliance

Research

October 2017


SourceTarget

Cu

rre

nt

RA

P P

g Current

Year to

Date




Remedial Action Plans for Well Led


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Organisational Health ≤15% A n/a 19.7% 19.5% 19.0% n/a n/a n/a n/a

Lead Manager

Remedial Action Plan Staff Turnover (Rolling Annual Figure)


Cu

rren

t

Current

Year to

Date

Month Quarter

Emral Jarrold Responsible Director Helen Rushworth


Turnover within the trust has been identified as a

significant challenge. The reasons are only partially

understood and hard evidence is limited. Trainees change

over month is August and this is reflected in shown spike in

figures. A target reduction to 15% or lower has been set to

be achieved by Q4 2017-18.

A detailed analysis of the issues affecting retention has been

conducted. A proposed action plan is being drafted. Action in

the meantime to address known issues include workshops and

assistance to staff on Brexit, improving onboarding processes,

and career development clinics.

31/03/2018

10.0%

15.0%

20.0%

25.0%

30.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Organisational Health ≤10% A n/a 14.1% 12.8% 13.2% n/a n/a n/a n/a

Lead Manager

Refresh our presence in the recruitment market, positioning

Moorfields attractively within social media to ensure the widest

possible reach.

31/03/2018

Hot spots are understood and include parts of Moorfields

South and theatres at City Road.

Modernise recruitment processes to ensure we attract talent to

the organisation from the widest possible pool, improving our on-

boarding processes to optimise the experience of new recruits.

31/12/2017

Recruitment initiatives as described within the Nursing Strategy. 31/12/2017

Sean Martin/Asli Asim Responsible Director Helen Rushworth


Remedial Action Plan Staff Vacancy Rates


Cu

rren

t

Current

Year to

Date

Month Quarter

5.0%

10.0%

15.0%

20.0%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Staff Experience ≥70% R n/a n/a n/a n/a 77.8% 70.3% 66.8% Due Jan 18

Lead Manager

Remedial Action PlanPercentage of Staff agreeing with the staff survey statement "I would

recommend my organisation as a place to work"


Cu

rren

t

Current

Year to

Date

Month Quarter

Emral Jarrold Responsible Director Helen Rushworth


The reasons are currently unknown. The staff survey is

currently underway and results will be available early

December. This will give an indication as to reasons for

underperformance.

Once the reasons are better understood a detailed action will be

developed. Local action plans have been produced and there is

focusing on improving areas previously identified in the 2016/17

staff survey. We are currently implementing a staff engagement

platform that will provide a more forensic analysis.

01/12/2017

60%

65%

70%

75%

80%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Research ≥80% R 77.4% 66.7% 75.0% 75.0% 85.7% 82.4% 70.0% 75.0%

Lead Manager

Rare event where staff required for patient consent were

unavailable (sickness and annual leave) to recruit in time to

meet the benchmark.

Research and Development staff will ensure a greater number

of staff are available to consent patients during the benchmark

window, including drafting staff from other studies during this

time.

01/12/2017

Maria Hassard Responsible Director Peng Khaw


Remedial Action Plan 70 Day To Recruit First Research Patient


Cu

rren

t

Current

Year to

Date

Month Quarter

50%

60%

70%

80%

90%

100%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Research ≥80% R 64.7% 66.7% 66.7% 66.7% 60.0% 61.9% 66.7% 66.7%

Lead Manager

1. Global project target met, closing the study early, before

the MEH had the opportunity to achieve its proportion of

that global target. 2. Study had very stringent eligibility

criteria which made the study difficult to recruit to and/or it

was a rare disease study with few eligible patients seen in

clinic to recruit in time.

Internal feasibility analysis will enable the setting of better

targets in difficult to recruit to studies. Negotiations with partners

will in future develop target ranges which will allows us to report

against both the lower and upper ends of that range. This will

cater for those occasions where we are opening as a site later

than most other international sites and avoid the risk of having

studies close early before we have been able to meet our

agreed target locally. We are also looking at predicted closure

dates 6 months in advance and engaging with sponsors early to

try to avoid this happening so often

01/12/2017



Remedial Action Plan Percentage of Research Projects Achieving Time and Target


Cu

rren

t

Current

Year to

Date

Month Quarter

50%

60%

70%

80%

90%


Aug-17 Sep-17 Oct-17 16/17 Q4 17/18 Q1 17/18 Q2 17/18 Q3

Well-Led Research ≥3500 R 2354 150 394 432 n/a 1088 834 432

Lead Manager

Our researchers are currently engaged in studies that recruit small

numbers of patients, typically being high intensity or advanced

therapy studies and/or early phase clinical trials. It should be noted

that around £6 million per annum of R&D income from NIHR is

linked to our ability to deliver studies of this type (BRC, CRF,

Research Capability Funding). In previous years, researchers were

undertaking a greater number of larger studies such as genotyping

studies, which have ended and have not been replaced by studies

of a similar size (in terms of patient numbers). The study number

overall has not fallen; the reduction in patient recruitment, relative

to previous years, is due to the above changes in the study

portfolio.

Pump priming, with internal investment, of larger low intensity and

observational studies that are relevant to the Moorfields patient

population.

Access to IT systems for improved patient screening and recruitment

have the potential to increase study throughput.

Greater Trust investment in research PAs and/or research training

fellowships to increase study number.



Remedial Action PlanTotal patient recruitment to all studies (YTD cumulative) - trajectory

target for the year end of 6000


Cu

rren

t

Current

Year to

Date

Month Quarter

0

2,000

4,000

6,000


Domain: Use of Resources


Capital Service Capacity SOF 1 G 1 1 1 1

Liquidity (days) SOF 1 G 1 1 1 1

I&E Margin (Current in Trust Metric : Overall Position) SOF 1 G 1 2 2 1

Distance from Financial Plan (Current in Trust Metric : Trust Underlying

Overall Position - Surplus / Deficit)SO7 1 G 1 2 2 1

Agency Spend v trajectory SOF 1 G 1 1 1 1

Use of resources risk rating - combines all of above measures SOF 1 G 1 1 1 1

Overall financial performance (In Month Var. £m) SOF ≥0 G 2.18 -0.24 0.81 0.83

NHS Performance (In Month Var. £m) SOF ≥0 G 1.93 -0.53 1.00 1.01

Research & Development Position (In Month Var. £m) SOF ≥0 A 0.33 0.03 -0.05 -0.1

Commercial Trading Unit Position (In Month Var. £m) SOF ≥0 R 0.30 0.27 -0.14 -0.08

Efficiency Scheme Performance (YTD Percentage) SO7 100% G 100% 80% 91% 85%

Efficiency Scheme Performance (YTD Var. £m) SO7 ≥0 R -0.59 -0.45 -0.27 -0.59

Cash Flow (In Month Variation) SOF ≥0 G 6.56 -1.17 1.91 6.56

Capital Expenditure (Variation To Plan forecast) SOF ≥0 G 16.45 1.48 15.30 16.45

Outstanding debtors (Total £m) SOF ≤ Plan G 9.9 9.3 9.8 9.9

Please note there are no Remedial Action Plan generated from this page. For commentary, please refer to the Finance Report presented to board

Financial

Resources

Financial

Metrics

October 2017


SourceTarget

Cu

rre

nt

RA

P P

g Current

Year to

Date



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