BOARD OF DIRECTORS OPERATIONAL PERFORMANCE REPORT 7 - Operational... · Senior Performance Analyst...

Item 7

BOARD OF DIRECTORS OPERATIONAL PERFORMANCE REPORT

Presented By:

10th September 2015Board of Directors

Produced By:

Stephen ChinnSenior Performance Analyst

Steven DaviesNHS Finance Director

(Produced on 3rd September 2015)

Month 4 (July 2015)

Action for Board:

For information

For consideration

For decision

Board of Directors Performance Report ‐ July 2015

Exception Report - 3

Compliance Performance Summary Page 4

Access - Referral to Treatment Page 5 - 6

Access - A&E Page 7 - 8

Access - Cancer Waiting Times Page 9

Access - Other Page 10

Efficiency Page 11 -12

Effectiveness Page 13

Safety Page 13

Ward Staffing Levels Page 14

Patient Experience Page 15

Bank and Agency Staff Information Page 16

CONTENTS

Page 1

Board of Directors Performance Report - June 2015 and Quarter 1 2015/16

Item 7

Exception Report - July 2015

RTT Performance:

All three RTT performance measures achieved their respective targets for July 2015, however all measures saw a slight reduction on the previous month. Year to date figures also remain above target:

• RTT Admitted Performance for July was 91.9% (M3 (June 2015): 92.9%). YTD is 91.6%.

• RTT Non‐Admitted Performance for July was 96.5% (M3: 97.1%). YTD is 96.8%.

• RTT Incomplete Performance for July was 92.8% (M3: 93.1%). YTD is 93.5%.

There was one 52 week Non‐Admitted Breach reported. This was the closure of the Open Pathway breach reported in both May and June. The reasons established for the breach were that it was a complex medical pathway, but there were also a number of delays transferring the patient between subspecialty clinics. The incident was reviewed at the Serious Incident panel, where it was established no harm was caused as a result of delay.

Accident and Emergency:

Activity:After four successive months of record activity July activity saw a slight drop in arrivals into A&E, however activity remains high compared to the previous year, being 9% higher than July 2014 with year to date activity 11% on April to July 2014.

Performance:A&E four hour performance was achieved for the month at 97.0% (M4: 98.9%), with the year to date at 97.7%. However there was a significant increase in the number of four hour breaches compared to June 2015.

Our local three hour A&E performance increased to 79.7% from 77.9% but fell just short of the 80% target. Year to date is at 77.0%.

There were 3 six hour breaches in July with 7 now reported this financial year. These incidents, which occurred on the same day, were reported to NHS England as part of the A&E daily submission and commentary, and were due to a number of factors including some patients with complex conditions which required additional treatment so reducing capacity during a period of increased activity.

Page 2

Board of Directors Performance Report - June 2015 and Quarter 1 2015/16

Exception Report - July 2015Cancer Performance

On the 29th June, Moorfields Eye Hospital transferred ocular oncology from Barts Health.

For July there were five 'two week wait' cases which were all treated within target, our YTD remains at 100%.

There were 19 'patients receiving treatment within 31 days of decision to treat ‐ First Treatment' cases, however one of these cases was not treated within the 31 day target so the month was below the 96% target at 94.7%. Although the delay was due to patient choice, we were unable to apply a 'pause' as no records could be found to determine the original MDT discussion after the first outpatient appointment in February, therefore we were unable to date his original DTA. The YTD for this measure is also below target at 95.7%.

There were two 'patients receiving treatment within 31 days of decision to treat ‐ Subsequent Treatment' cases, however one of these cases was not treated within the 31 day target so the month was below the 94% target at 50%. This was a Health Care Provider initiated delay due to hospital staff failing to order this patient's graft ahead of surgery, therefore surgery was cancelled and rebooked to a later date. The YTD for this measure is also below target at 85.7%.

Choose and Book Performance:

Following the transition from the CAB system to e‐Referral system the reports module of the new e‐Referral system was not implemented before go‐live. We have been informed by the e‐Referral Team at HSCIC that the reports module which includes the Weekly ASI (Appointment Slot Issue) Report will be unavailable until further notice, therefore these figures will be unavailable until to the reports module has been implemented by the HSCIC. This report contains data up to the last full month available (May 2015).

28 Day Non‐Medical Cancellation Rebooking Breach

After the publication of the June/Quarter 1 board report, we identified a 28 day Cancellation breach in June 2015 where the rebooked operation took place 29 days after the original cancellation. This was submitted as part of the national QMCO return and this paper amended to reflect this change.

Outpatient and Admission Activity:

Outpatient Activity for July 2015 saw the second highest number of attendances ever seen at Moorfields at just over 46,000, with the highest month being June 2015. Activity by working day has decreased compared to previous months to 2,013 patients seen per working day.Compared to last year Outpatient Activity for July 2015 is up 5% on July 2014 (+9% First Appointments and +4% Follow Up Appointments) while the year to date is up 6% compared to April‐July 2014 (+12% First Appointments and +4% Follow Up Appointments).

Admission activity from July 2015 (per working day) saw an 8% decrease compared to June 2015, and is 10% down on July 2014.

'Emergency Readmission Rates' and '% GP referrals From Electronic Booking (Choose & Book /E‐referrals)'(the latter previously named 'GP referrals first outpatient using Choose & Book')

Due to an input error, these figures were not updated in the June /Quarter 1 board so both the current and previous figures related to May 2015, This has now been corrected. The Quarter 1 and Year to Date figures in the report were entered correctly so have not been updated.

Page 3


COMPLIANCE PERFORMANCE SUMMARY

Threshold Jul-15 YTD 15/16

Monthly Trend Source Threshold Jul-15 YTD

15/16Monthly Trend Source

≥ 90% 91.9% 91.6% CQC, Monitor,TDA ≥ 99% 100% 100% CQC, TDA

≥ 95% 96.5% 96.8% CQC, Monitor,TDA n/a 88.8% 86.9% Local

≥ 92% 92.8% 93.5% CQC, Monitor,TDA ≥ 96% n/a 85.3% Local

0 0 0 CQC, Monitor,TDA 0 0 1 CQC, TDA

0 1 2 CQC, Monitor,TDA n/a 2.6% 4.1% Monitor

0 0 2 CQC, Monitor,TDA n/a 3.0% 4.4% CQC, TDA, Outcomes Framework

≥ 95% 97.0% 97.7% CQC, Monitor,TDA n/a 48.5% 52.3% Local

≥ 80% 79.7% 77.0% Local 0 0 0 CQC, Monitor,TDA

≤ 5% 2.3% 2.5% CQC, TDA 0 0 0 CQC, Monitor,TDA

≥ 30% 26.3% 24.2% Local ≥ 95% 98.7% 98.7% CQC, TDA

≤ 5% 0.7% 0.5% CQC, TDA 0 0 3 CQC, TDA

≥ 93% 100.0% 100.0% CQC, Monitor,TDA n/a 100.3% 98.1% CQC, TDA

≥ 96% 94.7% 95.7% CQC, Monitor,TDA ≥ 20% 24.4% 27.7% CQC,TDA, Outcomes Framework

≥ 94% 50.0% 85.7% CQC, Monitor,TDA ≥ 30% 48.4% 54.7% CQC,TDA, Outcomes Framework

≥ 85% n/a n/a CQC, Monitor,TDA ≥ 15% 8.3% 10.0% Local

Key Reference:

Number of C.Diff cases

Ward Staffing Levels(Inpatient Wards Only)

Within tolerance and drop in figures

No target or N/A

On or above target

Stable on/above target

On target and drop in figures

Within tolerance and stable

Within tolerance and rise in figures

Friends & Family Test - Outpatients (Response Rate - Estimated)

Below target and rise in figures

Below target and stable

Below target and fall in figures

A&E 3 hour waiting times Number of MRSA cases

Outpatient appointment - Over 6 week waiters

Cancer 31 day wait - subsequent treatment - surgery

Cancer 62 day from urgent GP referral to first definitive treatment

A&E Unplanned re-attendance

Cancer 2 week wait - first appointment urgent GP referral

% Cancer 31 day wait - diagnosis to first appointment

Friends & Family Test - Inpatients (Response Rate)

A&E 4 hour waiting time GP referrals first outpatient using Choose & Book

VTE Screening - all admissions

Number of Mixed Sex Accommodation Breaches

Friends & Family Test - A&E (Response Rate)

A&E ENP Pathways

A&E Left Before Treatment

Emergency Readmissions within 30 days of discharge

Indicator Indicator

Percentage 18 weeks Admitted Pathways

Cancelled Operations - 28 Days Re-Book

18 weeks Admitted Pathways52 Week Breaches

18 weeks Non Admitted Pathways 52 Week Breaches

18 weeks Incomplete Pathways52 Week Breaches

Choose & Book Appointment Availability (April & May 15 Only)

Diagnostics 6 week waiting time

Performance 2015/16Performance 2015/16

Percentage 18 weeks Non Admitted Pathways

Emergency Readmissions within 28 days of discharge

Percentage 18 weeks Incomplete Pathways

Page 4


18 Weeks Referral to Treatment

Year End YTDCurrent Month

Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD

≥ 90% 86.2% 81.2% 91.9% 92.9% 91.5% 91.9% 91.6% Monitor, CQC, TDA

≥ 95% 95.1% 94.71% 96.5% 97.1% 96.9% 96.5% 96.8% Monitor, CQC, TDA

≥ 92% 93.7% 92.2% 92.8% 93.1% 93.8% 92.8% 93.5% Monitor, CQC, TDA



0 2 1 0 0 0 0 0 N/A 4,303 1,954 215 196 659 215 874 N/A -1,191 -916 49 81 118 49 167 0 3 0 1 1 1 1 2

N/A 3,719 1,327 250 217 638 250 888 N/A 77 -74 458 151 381 104 485 0 7 2 0 1 2 0 2

N/A 16,394 6,767 1,884 1,732 4,604 1,884 6,488 N/A 4,426 135 720 279 1,329 199 1,528

Compliance Source

Patients Waiting >18 weeks

18w(92%) Shortfall/Surplus

Monthly Trend

Monthly TrendThreshold

Performance 2015/16

Threshold


Performance 2014/15

Trust Total

18 weeks Referral to Treatment -Non Admitted

18 weeks Referral to Treatment -Incomplete

Indicator




Indicator

18 weeks Referral to Treatment - Admitted

Admitted

52 Week RTT Breaches


Non Admitted

Incomplete

Compliance Source



Page 5


18 Weeks Referral to Treatment (Cont.)Trust Total

Page 6




N/A 95,951 32,711 9,129 9,368 27,233 9,129 36,362 N/A 92,811 31,821 8,752 8,843 25,585 8,752 34,336 ≥ 95% 99.2% 99.2% 97.0% 98.9% 98.2% 97.0% 97.7% CQC, Monitor,

TDA

≥ 80% 81.8% 81.8% 79.7% 77.9% 76.1% 79.7% 77.0% Local

N/A 605 250 270 99 489 270 759 N/A 30 24 3 4 4 3 7 ≤ 5% 1.2% 1.3% 2.3% 2.6% 2.6% 2.3% 2.5% CQC, Monitor,

TDA

≤ 60 mins 25 mins 23 mins 24 mins 29 mins 29 mins 24 mins 28 mins CQC, TDA



≥ 30% 24.0% 24.2% 26.3% 22.9% 23.6% 26.3% 24.2% Local

≤ 5% 0.6% 1.0% 0.7% 0.7% 0.5% 0.7% 0.5% CQC, TDA

A&E Three Hour Performance

Time to Treatment in Department - median

Total number of 4 hour breaches

Total number of 6 hour breaches

Left without being seen

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

A&E Unplanned Re-attendance

A&E ENP Pathway

Compliance Source

Performance 2014/15

Accident & Emergency

IndicatorMonthly Trend

A&E Four Hour Performance

Threshold

Performance 2015/16

Total number of Arrivals in A&E

Total number of Expected Arrivals in A&E

Page 7


Accident & Emergency (Cont.)

In addition to the comments within the exception report: Unplanned re‐attendances and patients who left A&E before treatment remain below the 5% targets.

The percentage of patients who left before treatment has seen a recent increase which has now stabilised, this is due to a process change to improve the data quality of this metric.

A&E ENP Pathway performance remains below our local target of 30% at 26.3% for July 2015, but has increased on the previous month (M3: 22.9%).

Page 8




Cases 29 13 5 2 7 5 12 ≥ 93% 93.1% 92.3% 100.0% 100.0% 100.0% 100.0% 100.0% Cases 15 6 19 4 4 19 23 ≥ 96% 100.0% 100.0% 94.7% 100.0% 100.0% 94.7% 95.7% Cases 3 0 2 2 5 2 7 ≥ 94% 100.0% 50.0% 100.0% 100.0% 50.0% 85.7% Cases 0 0 0 0 0 0 0 ≥ 85%

Cancer 31 day waits - diagnosis to first appointment

CQC, Monitor, TDA

CQC, Monitor, TDA

CQC, Monitor, TDA

Compliance Source

Cancer Waiting Times

Indicator

Cancer 2 week waits - first appointment urgent GP referral

Threshold

Performance 2015/16Monthly Trend

Performance 2014/15

Cancer 62 days from urgent GP referral to first definitive treatment

In addition to the comments within the exception report:

There have been no '62 days from urgent GP referral to first definitive treatment' cases this financial year.

CQC, Monitor, TDA

Cancer 31 day waits - subsequent treatment

Page 9




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

TBA 85.5% 85.7% 88.8% 86.7% 86.2% 88.8% 86.9% Local

TBA 33.8% 41.3% 23.2% 19.1% 19.1% 23.2% 20.2% Local

≥ 96% 87.3% 87.8% n/a n/a 85.3% * n/a 85.3% * Local

N/A 12.0% 12.1% n/a n/a 12.8% * n/a 12.8% * Local

N/A 0.7% 0.5% n/a n/a 1.8% * n/a 1.8% * Local

Access - Other (Cont.)

First Outpatient Appointment Waiting more than 6 weeksPatients Waiting more than 13 weeks for Admission

Diagnostic waiting times - 6 weeks

Choose and Book appointment availability

Access - Other

Monthly Trend

Performance 2014/15Compliance

Source

Performance 2015/16

* Quarter 1 and YTD figure to May 2015 as unavailable (See notes below)

Diagnostic waiting times Performance remains at 100%.

The percentage of patients waiting for admission within 13 weeks has remained relatively stable compared to previous months, however the wait time of first appointments within 6 weeks continued to increase.

Following the transition from the CAB system to e‐Referral system the reports module of the new e‐Referral system was not implemented before go‐live, therefore we are unable to report any recent Choose and Book Performance figures. The figures within this report are to May 2015.

Choose and Book Capacity Issue Rate

Choose and Book System Issue Rate

Indicator Threshold

Page 10




N/A 104,890 33,965 9,850 10,179 28,237 9,850 38,087 Local

N/A 403,657 133,643 36,454 36,451 102,411 36,454 138,865 Local

N/A 10.4% 8.7% 10.3% 10.1% 10.6% 10.3% 10.6% Local

N/A 11.6% 11.1% 12.0% 11.7% 11.7% 12.0% 11.8% Local

N/A 12.4% 12.4% 12.0% 12.1% 12.0% 12.0% 12.0% Local

N/A 56.7% 55.4% 60.5% 58.4% 57.1% 60.5% 57.9% Local

N/A 70.5% 70.0% 73.9% 71.2% 70.7% 73.9% 71.6% Local

N/A 36,500 11,817 3,240 3,403 9,405 3,240 12,645 Local

N/A 37,232 12,549 3,065 3,174 8,987 3,065 12,052 Local

N/A 6.2% 5.9% 7.5% 6.4% 6.6% 7.5% 6.8% Local

N/A 28.8% 26.1% 33.0% 33.0% 34.0% 33.0% 33.7% Local

0 3 1 0 1 1 0 1 CQC, TDA

Outpatient Total Attendances - Follow Up Appointment

Threshold

Cancelled Operations - 28 Days Re-Book(Provisional)

Monthly Trend

Compliance Source


Efficiency

Trust Total

Outpatient DNA rate- First Appointment

Theatre Sessions Starting Late

Clinic Journey Times Less Than 2 Hours- Outpatient First AppointmentClinic Journey Times Less Than 2 Hours- Outpatient Follow Up Appointment

Outpatient DNA rate- Follow Up Appointment

Theatre Cancellation Rate

Admission Demand - Decision to Admit (DTA)

Admission Activity

Outpatient Cancellations

Outpatient Total Attendances - First Appointment

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Key:

Efficiency (Cont.)

In addition to the comments within the exception report:

Our Theatre Cancellation rate has seen a slight increase to 7.5%, while DNA rates (both first and follow up appointment) and Theatre Sessions starting late have remained stable.

:4 Month Average:Monthly Trend

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Effectiveness



N/A 3.8% 3.4% 2.6% 4.0% 4.7% 2.6% 4.1% Monitor

Cases 102 30 7 9 33 7 40 N/A 4.1% 3.5% 3.0% 4.0% 5.0% 3.0% 4.4% CQC, TDA

Cases 109 31 8 9 35 8 43 N/A 54% 52% 48.5% 46.8% 53.8% 48.5% 52.3% Local

Safety



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

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

≥ 95% 98.5% 98.4% 98.7% 98.6% 98.7% 98.7% 98.7% CQC, TDA

0 0 0 0 0 3 0 3 CQC, TDA

Emergency Re-admission within 28 days of discharge

Emergency Re-admission with 30 days for elective and emergency cases

% GP referrals From Electronic Booking (Choose & Book /E-referrals)

Indicator

VTE Screening

Mixed Sex Accommodation

There were no MRSA or C. Diff cases or Mixed Sex Accommodation Breaches recorded in July, and VTE performance remains stable above the 95% target.

Monthly Trend

Performance 2014/15

Number of C.Diff cases

Performance 2015/16

Number of MRSA cases

ThresholdMonthly Trend

Compliance Source


Compliance SourceThreshold

Indicator

Page 13


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

Page 14


Patient ExperienceFriends and Family Test (FFT)

Please note there have been a number of changes to the Friends and Family Test (FFT) response rate and scoring.

The scoring system has been replaced with a simpler percentage method, where patients who are ‘Extremely likely’ or ‘Likely’ to recommend Moorfields to friends and family are listed as ‘Would Recommend’ the hospital, and patients who are ‘Unlikely’ or ‘Extremely Unlikely’ to recommend Moorfields are listed to ‘Would Not Recommend’ the hospital.

The eligible patient population now includes under‐16’s in all categories.

The ‘Inpatient’ FFT responses now include ‘day case’ patients as well as patients who stayed overnight, which has increased the number of results received in this category.The ‘outpatient’ FFT scores and response rates are now also included in this report, covering most patients who attended an outpatient clinic.

Page 15


Nursing Bank and Agency Staff InformationProportion of Nursing Bank and Agency Staff Hours filled, with total hours worked

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