Board Report May 2007 - West Herts College · The Trust utilises a risk-scoring matrix to conduct...

133/07

Board Report May 2007 Performance Report to April 2007 Including Performance Scorecard Report

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Key Messages 1.0 Safety

1.1 Infection control – Graham Ramsay 1.1.1 MRSA Bacteraemia The DH MRSA trajectory for 2007/2008 is 17, or an average of 1.5 per month. In April we have reported 3 bacteraemias and thus exceeded our target. A total of 42 MRSA bacteraemia isolates have been reported in the last twelve months, against the DH target for April 06-March 07 of 27. A further tightening of existing Infection Control measures is currently being implemented.

1.1.2 MRSA Internal Data (all in-patient isolates for the month of April 2007) In April 76 patients were identified with MRSA, of whom 13 (17%) are believed to have acquired their MRSA in WHHT during their admission (6% more than March), while the remaining 63 patients were already known to have MRSA or were identified as having MRSA on admission. 1.1.3 Clostridium difficile Internal Data - April 2007

(number of in-patient toxin-positive isolates) In March there were 58 in-patient C.difficile toxin-positive isolates.Of the 58 C.difficile isolates recorded in March 07, 30% of patients with diarrhoea were not isolated. This supports a need for “rapid isolation” of patients with diarrhoea, a vital key element in the prevention, control and management of C.difficile. In April there were 48 in-patient C difficile toxin positive isolates. Following the opening of isolation bays in the second week of April, we have succeeded in isolating all symptomatic cases. 1.2 Risk register and Assurance Framework – Gary Etheridge The strategic risks reported within this Performance Report comprise those risks that have a risk matrix score of 15 and above. As such, the table details 5 red risks out of a total of 8 strategic risks currently open on the Risk Register and also detailed in the Assurance Framework. The Trust utilises a risk-scoring matrix to conduct its risk assessments, scoring each risk on a scale of 1 to 5 in terms of both the consequence of impact and the likelihood of the risk occurring, and the overall score is produced by multiplying these together. This report shows the movement in this score over the last month. The majority of risks identified have been escalated to the appropriate sub-committee where progress against them is being monitored. New entries to the Register, which have not previously been escalated, will be escalated at the next opportunity. Below are descriptions of all those strategic risks that score 15 and above.

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Risk ID 729 Infection Control - MRSA Bacteraemias The Department of Health has set targets for Trusts to reduce their MRSA bacteraemia rates by 60% by 2007/8. It is envisaged that measures taken to achieve this target will also assist in the reduction of health care associated infections in general including Clostridium difficile Associated Diarrhoea (CDAD). Healthcare organizations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA).

Risk ID 848 Appraisal processes not effectively embedded in the organisation A review of the reporting arrangements related to appraisal has been undertaken and a proposal linked to the revised system of appraisal is in preparation for the Trust Executive. Two appraisal design sessions are being held in May and June to work with managers to learn from their experiences of linking KSF and appraisal. A revised system is planned to be issued during July and this will include monitoring of appraisal activity. Further work is also taking place with the national design team for e-KSF to see how this can support this process

Risk ID 905 Equal Pay Claims As at the 5th December 2006 the Trust has received two collective grievances relating to back pay under the Equal Pay Act 1970. The grievances cover a total of 10 employees. Using NHSLA approved solicitor to support the legal work related to the equal pay claims. Working with other Trusts in the East of England on managing equal pay claim process. Position paper presented to Directors in December 2006 to note financial risk. At present difficult to quantify level of potential financial risk involved but Finance team aware of the issues.

Risk ID 1009 Delivering a Healthy Future The Legal Challenge to the Service Reconfiguration leading to Judicial Review, means that delays could result in financial savings not being made.

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2.0 Clinical and cost effectiveness – Graham Ramsay

2.1 Emergency readmissions within 28 days Emergency readmission rates were 11.4%, 11.7% and 10.1% for February, March and April. This is against an England 2004 average of 9.2%.

2.2 Re-admissions within 28 days of treatment for fractured neck of femur Readmissions in this category were 21.6, 4.3% and 22.9% for February, March and April. The England average for 2004 was 9.9%. The surgical division is currently auditing the care of patients with fractured neck of femur and will be reporting back soon. 2.3 Deaths within 30 days of non-elective surgery Deaths within 30 days of non-elective surgery were 7.1%, 6.3% and 2.4% for February, March and April. The England average for 2004 was 4.5%.

3.0 Governance

3.1 Information governance – Anne Reilly Information Governance is the framework by which the NHS handles information about patients and employees – in particular, personal and sensitive information. It allows individuals and NHS and partner organisations to ensure that personal information is dealt with legally, securely, efficiently and effectively in order to deliver the best possible care. It provides a framework to bring together all the requirements, standards and best practice that apply to the handling of personal information to ensure:

• Compliance with the law • Implementation of Department of Health advice and guidance • Planned year on year improvement

The Governance Toolkit it is a web-based tool Incorporating initiatives such as Data Protection, Caldicott, Confidentiality, Freedom of Information, Information Security, Information Quality and Records Management. It requires NHS Acute Trusts to complete a baseline assessment of compliance by March each year. The tool kit does not allow us to compare results against other Trust's, however this may be feasible in the next version of the toolkit due to be released in June. Last years assessment highlighted the need for immediate action to improve Corporate Information Assurance and Information Governance Management This is high on the agenda for the Information Governance Committee, which meets again on 6th June to set the work programme for 2007/08.

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It aims: • To establish roles and responsibilities for each directorate • To develop action plans and set key performance indicators • To promote the development of effective & robust systems to improve data

quality and information management 3.2 Data completeness – Sue Gunn From 1 April 2006 the target for clinical coding is effectively 100%. In Quarter 4 the Trust had no uncoded episodes. This has been a remarkable achievement, given the on going staffing situation in the Clinical Coding Department. Much of the coding is being picked up through Infoflex, with clinicians entering the coding directly. The quality of this coded data is regularly improving thereby enabling the coders to use the Infoflex record as a source document when case notes have been unavailable. However, take up by clinicians needs to improve. Although the coding targets are being met, this is with the use of expensive agency coders and additional bank staff. A business case has been written which supports some increase in establishment and the creation of an internal clinical coding trainer/auditor to make the department more resilient to vacancies, sickness, etc.

3.3 Workforce – Sarah Childerstone 3.3.1 Sickness absence Sickness absence has decreased from 4.3% as at April 2006 to 4.2% in April 2007. The figure has remained constant over the last 5 months. Additional sickness reporting has been initiated to the Divisions over the last 3-4 months. This shows sickness rates and other data for all wards and departments, and lists all staff on long-term sick leave in order to help ensure prompt assistance in reducing sickness.

3.3.2 Labour turnover Labour turnover (measuring all non-medical staff) has decreased from 13.8% in April 2006 to 12.9% in April 2007. This means that based on this figure, each year around 400 - 450 non-medical staff leave the Trust. 3.3.3 Whole Time Equivalent (WTE) staff in post Contracted staffing as at March was 3,372 wte. This is a reduction of 110 wte since November 2006 when the current trust configuration (excluding plastic surgery and including paediatrics) was first reflected in our workforce figures. The most recent monthly change for April shows a reduction of 22 wte.

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3.3.4 WTE bank, agency and locum cover Agency Costs have decreased as a percentage of the payroll from 7.7% in April 2006 to around 0.7% in February 2007. Bank and Overtime costs have decreased as a percentage of the payroll from 7.7% in April 2006 to 4.6%. in February 2007. These changes reflect the controls placed on temporary staff. The most recent information for March has not been included as this has not been received for this report, however, there has been an increase in agency expenditure.

4.0 Patient focus – Gary Etheridge

4.1 Complaints The Trust received 35 formal complaints in March, a decrease of one from February. Although all complaints were acknowledged by the Quality Assurance Department within 48 hours, the Trust’s response rate fell for the second month in a row, down to 51% against the target of 85%. • Medicine failed to respond to 3 of their 8 complaints on time. Whilst the absence of

a Service Manager led to delays in 1 response, the other 2 responses were reviewed as part of the new process, to ensure that the responses are adequately addressing the needs of the complainant. On review, it was felt that further work needed to be done to the responses and in view of this, it was not possible to meet the 25-day response time.

• Within Surgery, delays in the internal approval process resulted in 1 response being sent out late. There is no specific identifiable reason for the failure to complete the four other responses that were late. This needs to be looked at further within the Division and will be brought to the attention of the Divisional Manager in order that this can be addressed..

• The 1 complaint that was not completed by Children’s & Women’s on time was in part due to difficulties in two divisions reaching agreement as to where the lead lay. Then changes to the response were required and this meant it was not possible to send the response out on time.

• There was also an issue with the Gynaecology complaints (currently recorded under Surgery on Datix). The combination of the absence of the Service Manager on both annual and sick leave, with no cover in place, and the higher than usual number of complaints received, resulted in a poor performance this month. Additionally, due to changes in staffing on Elizabeth ward the Service Manager no longer has the assistance of a Senior Nurse, who can assist with the investigation and drafting of nursing complaints.

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5.0 Accessible and responsive care – Nick Evans

5.1 A&E – patients spending less than 4 hours in A&E The Trust did not achieve the 98% target in April 2007. Staffing difficulties, particularly sustaining junior medical staff cover over weekend shifts have been a significant issue for the service. These have been exacerbated by sickness and the holiday period during April, which has made locum cover difficult to obtain where needed. The overall performance level during April means that the service must achieve good performance for the next few months if the overall target is to be delivered. A process of weekly performance reviews has been initiated.

5.2 Out patients At the end of March the trust achieved the new 11-week waiting time standard and this has been sustained through April. Achieving the March 2008 target of 5 weeks maximum wait will require treatment of almost 3000 additional patients over the next 11 months. Outpatient appointments cancelled by the hospital are currently running at 17 percent of the overall total. The largest single cause is the annual or study leave of the consultant or other key professional. This will become less of a problem as waiting times reduce and eventually fall below the 6-week threshold required for notice of absence on leave. In April the Rapid Access Chest Pain Clinic achieved the target level of 100% of patients seen within 2 weeks. The GUM services achieved 69% of patients seen within 48 hours. Although this is slightly short of the target level of 70%, it is above the England average and represents significant and sustained progress by the service over the last few months. 5.3 Choose and book The trust continues to achieve above the national average in the level of electronically booked appointments, although this remains below 30% of the total. Discussions with the PCT suggest that further improvements in the utility of the systems used by GPs will be required to deliver improvements.

5.4 Diagnostic waiting At the end of March the trust essentially achieved the new 13-week waiting time standard (with the exception of only 2 endoscopy patients whose admission had to be deferred due to consultant sickness). Changes to national guidance on recording patients has resulted in a significant rise in overall numbers, as patients waiting for audiology re-tests are now to be included. All trusts in Hertfordshire are addressing this issue, which will involve increasing capacity in order to offer appointments to this patient group.

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Delivery of the 6-week waiting time target for diagnostics by March 2008 will require treatment of almost 2,600 additional patients over the next 11 months. 5.5 Inpatients and day cases At the end of March the trust achieved the new 20-week waiting time standard and this has been sustained through April. Achieving the March 2008 target of 11 weeks maximum wait will require treatment of almost 2,000 additional patients over the next 11 months. 5.6 Cancer Against the14-day outpatient standard (target 100%), final data for March and provisional data for April show 1 breach in each month. The March breach was a colorectal patient whose clinic was cancelled, and due to an error in re-booking was offered a new appointment at 15 days. The April breach was a gynaecology patient and is thought to be due to a clerical error; this is being investigated.

Final data for March and provisional data for April indicate that the Trust achieved the operational standard for both the 31-day target and the 62-day target. 5.7 18 weeks Referral To Treatment (RTT) The 18-week national target requires trusts to ensure that by December 2008 the time elapsed from referral to the start of definitive treatment for each patient is less than 18 weeks. Trusts are expected to achieve a level of 85% for admitted patients and 90% for non-admitted patients by March 2008. Within these overall timescales the maximum wait targets for various elements in the pathway (outpatients, diagnostic and admitted care) still apply. Data capture remains a major challenge for the trust in pursuing this target. Manual systems are being implemented but are demanding of staff time, and prone to inaccuracy. Electronic data capture will become possible later in the year as developments within the Patient Administration System (PAS) come on line. Work is also going on within the trust to develop the use of the Infoflex system for this purpose.

6.0 Care environmental and amenities – Paul Mosley

6.1 PEAT scoring – hospital food The 2006 scores for the NPSA PEAT (food) results following the February 2006 self-assessments were: HHGH Good; SACH Acceptable; WGH Good. The 2007 figures have just been submitted from this year’s self-assessment and we await confirmation of the results. The April internal PEAT inspections scored food as: WGH Excellent (86%), HHGH Acceptable (78%) and SACH Acceptable (74%), ~ i-PEAT scores indicate a continuing overall Trust food score of Good.

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In order to further improve the target of excellent (95%) we need to achieve the implementation of Steamplicity on all our sites. The implications of doing so are now under review. 6.2 PEAT scoring – hospital cleanliness The NPSA PEAT (environment) 2006 results, part of which refers to cleanliness, are: HHGH Acceptable; SACH Poor; WGH Acceptable. The 2007 figures have just been submitted from this year’s self-assessment and we await confirmation of the results. The self-assessment has just been presented for this year and we currently await its acceptance. The April internal PEAT inspections scored cleanliness as: HHGH Acceptable (72%), SACH Good (78%), and WGH Acceptable (72%).

7.0 Public health – Alfa Saadu

The trust continues to perform above the national average.

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Summary of Performance Indicators – April 2007

Safety

Clinical &

Cost Effectiveness

Governance

Patient Focus

Accessibility

& Responsive Care

Care

Environment and

Amenities

Self-assessment (I-PEAT)

External assessment (HCC / NPSA-PEAT)

Public Health

1.1 Infection control

1.2 Risk Register

2.1 Emergency readmissions

2.2 Readmission after fractured hip

2.3 Deaths after emergency surgery

3.2 Data completeness3.1 Information Governance

3.3 Workforce

4.1 Complaints (Mar)

5.2 Outpatient targets 5.3 Choose & Book 5.1 4hr A&E wait

5.4 Diagnostic waiting 5.5.1 In-patient targets

5.5.6 Cancelled operations

5.5.8 Delayed transfers of care

5.6.1 Cancer 2-week wait

5.6.3 Cancer 31 and 62 day targets

5.6.2 Cancer data completeness

(Shaded = provisional)

5.7 18-week RTT target

6.1 PEAT – Hospital food 6.2 PEAT – Hospital cleanliness

6.2 PEAT – Hospital cleanliness (Feb 06) 6.1 PEAT – Hospital food (Feb 06)

7.2 Breast-feeding 7.1 Smoking in pregnancy

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1.0 First Domain – Safety

1.1 Infection control

1.1.1a MRSA bacteraemia isolates (all sources) - cumulative performance against plan

MRSA bacteraemias - cumulative in year

0

10

20

30

40

50

60

Apr-

05

Jun-

05

Aug-

05

Oct

-05

Dec

-05

Feb-

06

Apr-

06

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07

Jun-

07

Aug-

07

Oct

-07

Dec

-07

Feb-

08

BacteraemiasTarget

Source: National MRSA bacteraemia monitoring

1.1.1b Monthly MRSA bacteraemia isolates (all sources)

012345678 Bacteraemias

Trajectory


1.1.1c MRSA rate (bacteraemia isolates) Quarterly rate per 10,000 occupied bed-days

2004-05 Q4

2005-06 Q1

2005-06 Q2

2005-06 Q3

2005-06 Q4

2006-07 Q1

2006-07 Q2

2006-07 Q3

2006-07 Q4

Target England Apr 06 – Sep 06

MRSA rate 1.96 2.39 1.67 1.61 1.85 1.76 1.89 0.86 1.47 0.94 1.69 Source: National MRSA bacteraemia monitoring, and local input to this

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MRSA bacteraemia rate (all sources)

0.0

0.5

1.01.5

2.0

2.5

3.0

2004-05 Q4

2005-06 Q1

2005-06 Q2

2005-06 Q3

2005-06 Q4

2006-07 Q1

2006-07 Q2

2006-07 Q3

2006-07 Q4

Year and Quarter

Rat

e pe

r 10,

000

bed-

days

MRSA rate Target England average


1.1.2 MRSA infections

MRSA infections

020406080

100120140

Apr-

04M

ay-0

4Ju

n-04

Jul-0

4Au

g-04

Sep-

04O

ct-0

4N

ov-0

4D

ec-0

4Ja

n-05

Feb-

05M

ar-0

5Ap

r-05

May

-05

Jun-

05Ju

l-05

Aug-

05Se

p-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06Fe

b-06

Mar

-06

Apr-

06M

ay-0

6Ju

n-06

Jul-0

6Au

g-06

Sep-

06O

ct-0

6N

ov-0

6D

ec-0

6Ja

n-07

Feb-

07M

ar-0

7Ap

r-07

repo

rts b

y IC

Ns

Old & otherHospital acquired

Source: Trust internal reporting by Infection Control Nurses

1.1.3 Clostridium difficile infections

Clostridium difficile infections (all sources)

0

20

4060

80

100

120

Apr-

04M

ay-0

4Ju

n-04

Jul-0

4Au

g-04

Sep-

04O

ct-0

4N

ov-0

4D

ec-0

4Ja

n-05

Feb-

05M

ar-0

5Ap

r-05

May

-05

Jun-

05Ju

l-05

Aug-

05Se

p-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06Fe

b-06

Mar

-06

Apr-

06M

ay-0

6Ju

n-06

Jul-0

6Au

g-06

Sep-

06O

ct-0

6N

ov-0

6D

ec-0

6Ja

n-07

Feb-

07M

ar-0

7Ap

r-07

repo

rts b

y IC

Ns

Source: Trust internal reporting by Infection Control Nurses

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1.2 Risk Register - risks with a score of 15 or more

(movement from last month) STRATEGIC RISKS

Risks that directly threaten one or more of the Trust’s strategic objectives Description

Risk Score

Risk ID 729 Infection Control – MRSA bacteraemias 20 → Risk ID 848 Appraisal processes not effectively embedded in the organisation 16 → Risk ID 905 Equal Pay Claims 16 → Risk ID 1009 Delivering a Healthy Future 16 → Risk ID 401 Lack of access to level 2 HDU service closed

Source Local Datix information system2.0

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Second Domain – Clinical and cost effectiveness Figures for the latest month are still provisional 2.1 Emergency re-admissions within 28 days 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target

England 2004

Discharges 2751 2978 2802 2945 2775 2773 2602 2631 2391 2684 2426 2675 2384

Emergency re-admissions <=28 days 285 301 328 320 270 305 315 272 285 331 277 314 240 Emergency readmission rate (<=28 days of discharge) 10.4% 10.1% 11.7% 10.9% 9.7% 11.0% 12.1% 10.3% 11.9% 12.3% 11.4% 11.7% 10.1% n/a 9.2% Source: WHHT PAS Download (shaded figures = provisional) 2.2 Re-admissions within 28 days of treatment for fractured neck of femur 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target

England 2004

Discharges 41 40 35 33 49 45 41 48 54 60 37 47 35

Emergency re-admissions <=28 days 4 3 7 4 6 5 9 5 8 11 8 2 8 Emergency readmit rate (<=28 days of operation) 9.8% 7.5% 20.0% 12.1% 12.2% 11.1% 22.0% 10.4% 14.8% 18.3% 21.6% 4.3% 22.9% n/a 9.9% Source: WHHT PAS Download (shaded figures = provisional) 2.3 Deaths within 30 days of non-elective surgery 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target

England 2004

Selected emergency operations 214 234 214 232 237 229 177 170 189 210 184 192 165 Deaths within 30 days 15 6 8 13 8 9 9 8 13 13 13 12 4

Post-operative mortality rate (within 30 days of operation) 7.0% 2.6% 3.7% 5.6% 3.4% 3.9% 5.1% 4.7% 6.9% 6.2% 7.1% 6.3% 2.4% n/a 4.5%

Sources: WHHT PAS Download - England Healthcare Commission

(shaded figures = provisional) England comparison for 2.1-2.3 were taken from star ratings indicators. As the Healthcare Commission has now moved to Annual Health Checks, and these indicators are not included in the new set, there is no England comparison later than 2004.

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3.0 Third Domain – Governance 3.1 Information Governance Position as at March 2007 – self-assessment is undertaken annually Initiative Results

(based on requirements V4 )

Clinical Information Assurance 62% Confidentiality and Data Protection Assurance 63% Corporate Information Assurance 0% Information Governance Management 28% Information Security Assurance 53% Secondary Use Assurance 51%

3.2 Data Completeness 3.2.1 Completeness of FCE minimum datasets excl Maternity 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target England 2004-05

Ethnic group 33% 32% 31% 31% 31% 31% 31% 31% 28% 29% 30% 30% 30% 90% 76.5% NHS number 95% 96% 96% 96% 95% 96% 98% 97% 96% 96% 96% 97% 96% 95% 96.1% GP code 99% 99% 99% 99% 99% 100% 100% 100% 100% 100% 100% 100% 100% n/a n/a

Decided to admit date (elective admissions only) 88% 87% 87% 87% 83% 86% 85% 85% 80% 82% 82% 83% 85% n/a n/a Primary diagnosis 100% 100% 99% 100% 99% 99% 100% 100% 100% 100% 100% 100% 95% 95% 97.8% HRG code 100% 99% 99% 100% 99% 99% 100% 100% 100% 100% 100% 100% 95% n/a n/a

Source: WHHT PAS download - England HES

(shaded figures = provisional) (Maternity data are provided separately from CMIS system, and are essentially complete.)

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3.3 Workforce indicators

3.3.1 Sickness levels - accumulative percentage

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec England acute trusts

DoH Target

2005 4.5% 4.5% 4.3% 4.8% 4.7% 4.7% 4.8% 4.6% 4.6% 4.6% 4.5% 4.5% 4.4%2006 4.5% 4.4% 4.4% 4.3% 4.4% 4.3% 4.4% 4.4% 4.5% 4.2% 4.1% 4.2% 2007 4.2% 4.2% 4.2%

Source WHHT Workforce planning - England Sickness absence survey 3.3.2 Labour turnover - annual percentage 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Turnover 13.8% 13.7% 13.4% 12.8% 12.6% 13.4% 12.8% 12.2% 12.3% 12.4% 12.6% 12.3% 12.9%

Source WHHT Workforce planning 3.3.3 Numbers of staff (whole time equivalent) in post 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

DoH Target

Wte in post 3535 3528 3534 3515 3498 3379 3381 3482 3455 3435 3419 3394 3372 3338

Source WHHT Workforce planningThe increase shown in November is due to the transfer of paediatric staff from HPT. 3.3.4 Bank, agency and locum usage 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

DoH Target

Bank & Locum wte.

165 165 159 114 148 114 194 159 151 150 146 159

Agency wte 220 220 201 253 148 121 101 133 125 120 109 114 Total wte. 385 385 360 367 296 235 295 292 276 270 255 273 281

Source WHHT Workforce planning

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4.0 Fourth Domain – Patient Focus 4.1 Complaints 4.1.1 Response rate to complaints

2006 2007

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

Complaints to the trust 33 33 44 37 26 29 35 30 18 24 36 35 n/a

England median 2004-05

% answered in 25 days 64% 70% 66% 70% 92% 83% 89% 73% 94% 100% 67% 51% 85% 78.0%

% acknowledged in 2 days 100% 100% 100% 73% 92% 100% 100% 100% 100% 100% 100% 100% 100% n/a

Sources: WHHT internal reports - England Healthcare Commission

Replies to complaints within 25 days

0%

20%

40%

60%

80%

100%

Apr

-05

May

-05

Jun-

05

Jul-0

5

Aug

-05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

% replied within 25 days target % in 25 days

4.1.2 Complaints outstanding at end of month

2006 2007


From this month 8 9 10 4 1 4 2 7 0 0 8 12

From previous months (cum.) 11 13 9 4 6 4 3 1 3 2 0 2 Source: WHHT internal reports

Outstanding complaints at end of month

0

10

20

30

40

50

60

Apr-

05

May

-05

Jun-

05

Jul-0

5

Aug-

05

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Cumulative from previous months

From this month

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5.0 Fifth Domain – Accessibility and responsive care 5.1 Accident & Emergency week ended 01 Apr 07 08 Apr 07 15 Apr 07 22 Apr 07 29 Apr 07 06 May 07 13 May 07

Target

Oct-Dec 06A&E attendances 2483 2408 2448 2524 2352 2548 2390

% patients < 4 hours in A&E 94.0% 97.5% 94.8% 96.0% 96.9% 96.0% 96.1% 98% 98.2% Sources: WHHT SITREPS - England QMAE 5.1.1 A&E total attendances

A&E weekly attendances

1,800

2,000

2,2002,400

2,6002,800

3,0003,200

03-A

pr-0

5

01-M

ay-0

5

29-M

ay-0

5

26-J

un-0

5

24-J

ul-0

5

21-A

ug-0

5

18-S

ep-0

5

16-O

ct-0

5

13-N

ov-0

5

11-D

ec-0

5

08-J

an-0

6

05-F

eb-0

6

05-M

ar-0

6

02-A

pr-0

6

30-A

pr-0

6

28-M

ay-0

6

25-J

un-0

6

23-J

ul-0

6

20-A

ug-0

6

17-S

ep-0

6

15-O

ct-0

6

12-N

ov-0

6

10-D

ec-0

6

07-J

an-0

7

04-F

eb-0

7

04-M

ar-0

7

01-A

pr-0

7

29-A

pr-0

7

Source SITREPs

5.1.2 A&E 4-hour performance

A&E weekly performance against 4-hour target

84%

86%

88%

90%

92%

94%

96%

98%

100%

3-Ap

r-05

1-M

ay-0

5

29-M

ay-0

5

26-J

un-0

5

24-J

ul-0

5

21-A

ug-0

5

18-S

ep-0

5

16-O

ct-0

5

13-N

ov-0

5

11-D

ec-0

5

8-Ja

n-06

5-Fe

b-06

5-M

ar-0

6

2-Ap

r-06

30-A

pr-0

6

28-M

ay-0

6

25-J

un-0

6

23-J

ul-0

6

20-A

ug-0

6

17-S

ep-0

6

15-O

ct-0

6

12-N

ov-0

6

10-D

ec-0

6

7-Ja

n-07

4-Fe

b-07

4-M

ar-0

7

1-Ap

r-07

29-A

pr-0

7

A&E weekly 4hr % 4 week moving average Target

Source SITREPs

18

5.1.3 A&E performance against 4-hour target - Comparative Trust position within the SHA

Week ended 6 May 2007

WHHT 96.0% East of England average 98.6% Source: SITREPS 5.2 Outpatients 5.2.1 Performance against the 13-week outpatient standard and 11 week target (March 2007 onwards) 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

Breaches of 13 week standard 0 0 0 1 3 0 0 0 0 0 2 0 0 0 11 week waiters 261 235 208 156 191 212 161 138 170 218 216 0 0 0 Source QM08 5.2.2 In-month breaches of 13-week outpatient standard 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Breaches of 13+ weeks standard 241 329 266 186 169 201 216 155 118 214 201 232 95 Source QM08 5.2.3 Progress against the 5-week outpatient target (March 2008 onwards) 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

5-week waiters 3271 2876 2591 2106 2539 2357 2934 2838 3450 2798 2792 2896 2879 0 Trajectory 2900 2650 Source QM08

Patients waiting 5 weeks and over

0500

1000150020002500300035004000

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07 Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Waiting 5+ w eeks Suggested trajectory 5+ w eeks

Target 0 by Mar 2007

Source SITREPS

19

5.2.4 GP written referral requests

GP written referral requests

010002000300040005000600070008000

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Apr-

07

GP referrals (shaded = provisional) Last year

Source WHHT PAS download Delays in data entry mean that the latest month's figures under-count actual referrals

5.2.5 Outpatient appointments by outcome

Outpatient appointments by outcome April 2007

Patient attendedDid not attend

Cancelled by patient

Cancelled by hospital

Unrecorded

Source WHHT PAS download

5.2.6 Rapid Access Chest Pain Clinic 2006 2007



Seen in RACPC 64 79 84 64 67 69 76 58 78 90 96 99 75 Seen after 14+ days 9 3 2 5 5 7 1 2 0 2 2 1 0

% seen in RACPC within 2 weeks 86% 96% 98% 92% 93% 90% 99% 97% 100% 98% 98% 99% 100% 100% 97.5% Source: LDPR return

20

5.2.7 Genito-Urinary Medicine Clinics 2005 2006 2007

May Aug Nov Feb May Aug Nov Dec Jan Feb Mar Apr TargetEngland Mar 07

Seen in GUM clinics 954 1518 1268 1232 1011

Seen < 48 hours one-week sample data

602 831 805 855 702

% seen in GUM clinics <48 hours 62% 60% 62% 59% 65% 59% 52% 63% 55% 63% 69% 69% 70% 67% Source Health Protection Agency quarterly surveys and GUM monthly from Dec 06 5.3 Choose and Book 5.3.1 Choose and Book referrals as percentage of all outpatient referrals 2006 2007 April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

WHHT - Choose and book referrals = Electronically booked n/a 3.7% 5.9% 6.4% 8.3% 19.9% 21.9% 28.4% 18.7% 27.4% 25.8% 25.4% 21.1%

England - Electronically booked n/a 4.4% 6.2% 6.9% 7.5% 9.3% 11.1% 13.7% 11.1% 18.4% 18.2% 20.9% 20.1%

England - Choose and book referrals (electronic & other) n/a 12.7% 17.8% 19.2% 20.3% 23.7% 27.1% 30.8% 23.3% 34.9% 32.9% 36.9% 33.0% National data collection The apparent reduction in performance in December 2006 was partially because the nationally produced figures compare actual “choose and book” referrals to total referrals in an average month. December is not an average month, with referrals typically down by 18% compared to November.

21

5.4 Diagnostic waiting 5.4.1 Progress towards the 13-week diagnostic waiting target (March 2007)

2006 2007


Target England Mar 07

Actual 13 week waiters 662 677 712 577 577 547 610 369 398 375 212 2 1031 0

Trajectory 770 700 630 560 490 420 350 280 210 140 70 0 0

13+ as % all waiters 11% 11% 13% 10% 10% 10% 11% 7% 7% 7% 4% 0% 17% 15%

Source Monthly diagnostic waiting return The large apparent increase in April is a result of clarification recently issued by the SHA, which means that we are now counting patients waiting for audiology re-tests for digital hearing aids. Under our previous interpretation we would have had only 7 patients waiting more than 13 weeks.


0

200

400

600

800

1000

1200

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07

Actual 13 w eek w aiters Trajectory


5.4.2 Progress towards the 6-week diagnostic waiting target (March 2008)

2006 2007


Target England Mar 07

Actual 6 week waiters 2678 2630 2448 2121 2445 2105 2130 1896 2087 2173 1455 1345 2581 0

Trajectory 2600

6+ as % all waiters 43% 43% 43% 37% 44% 38% 39% 36% 39% 40% 29% 29% 43% 15%

Source Monthly diagnostic waiting return


0

500

1,000

1,500

2,000

2,500

3,000

Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08

6+ w eeks 6+ w eeks trajectory

Target 0 by Mar

22

5.4.3 Diagnostic waiting by type of test – April 2007

0

500

1,000

1,500

2,000

2,500

Mag

netic

Res

onan

ceIm

agin

gC

ompu

ter

Tom

ogra

phy

Non

-obs

tetri

cul

traso

und

Bariu

m E

nem

a

DEX

A Sc

an

Audi

olog

y - p

ure

tone

aud

iom

etry

Car

diol

ogy

-ec

hoca

rdio

grap

hyN

euro

phys

iolo

gy -

perip

hera

lne

urop

hysi

olog

yU

rody

nam

ics

-pr

essu

res

& flo

ws

Col

onos

copy

Flex

isi

gmoi

dosc

opy

Cys

tosc

opy

Gas

trosc

opy

MRI and CT Other imaging Physiological Measurement Endoscopy

<6 w eeks

6+ w eeks

Source Monthly diagnostic waiting return

23

5.5 Elective Inpatients 5.5.1 Performance against the 20-week inpatient target (March 2007 onwards) 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

20-week waiters at month end 647 428 464 300 489 417 359 233 194 254 246 0 0 Source KH075.5.2 In-month breaches of 20-week inpatient target 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Breaches of 20-week target 745 790 710 653 475 693 633 607 312 514 446 509 456 Source: WHHT PAS Download 5.5.3 All patients waiting for inpatient or day case admission

Total IP & DC waiters against plan

0

2000

4000

6000

8000

10000

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Apr-

07

Actual Trajectory

Source KH07

Note: from 1 October, Plastic Surgery and Burns transferred to Royal Free Hampstead 5.5.4 Performance against the 13-week PTCA standard 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

Breaches of 13-week standard 2 8 5 8 14 16 15 6 0 6 6 0 0 0 MMR return

24

5.5.5 Progress against the 11-week inpatient target (March 2008 onwards) 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Target

11-week waiters 3136 2919 2711 2435 2941 2869 2315 1945 2366 2314 2423 1984 1902 0 Trajectory 1980 1800 Source KH07


0500

10001500200025003000

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07 Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Actual Suggested trajectory


5.5.6 Cancelled Elective Admissions

2006 2007



Cancelled operations 60 66 49 79 42 87 49 139 80 90 98 90 65

Elective admissions 2721 3227 3255 3116 2520 3089 2861 3002 1962 2705 2474 2804 2507

% cancellations 2.2% 2.0% 1.5% 2.5% 1.7% 2.8% 1.7% 4.6% 4.1% 3.3% 4.0% 3.2% 2.6% <1% 1.0%

Source - QMCO 5.5.7 Proportion of Cancelled Elective Admissions admitted within 28 days

0%

20%

40%

60%

80%

100%

Jul-0

5

Aug-

05

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

% admitted w ithin 28 days % patients chose to w ait 28+ days Target

Source QMCO

25

5.5.8 Average general and acute length of inpatient spell (i.e. excluding maternity)

012345678

Apr-

04

Jun-

04

Aug-

04

Oct

-04

Dec

-04

Feb-

05

Apr-

05

Jun-

05

Aug-

05

Oct

-05

Dec

-05

Feb-

06

Apr-

06

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07

days


5.5.9 Delayed transfers of care 2006 2007


Target England Jan-Mar

06 Delayed transfers of care 30 30 32 35 37 11 31 29 25 37 23 27 41

% of occupied acute beds 5.2% 5.4% 5.8% 6.2% 7.9% 2.1% 5.8% 5.3% 4.6% 6.7% 4.2% 4.8% 7.7% n/a 2.1% Source SITREPS and MMR returns

Delayed transfers of care as % of occupied beds

0%1%2%3%4%5%6%7%8%9%

Apr-

04

Jun-

04

Aug-

04

Oct

-04

Dec

-04

Feb-

05

Apr-

05

Jun-

05

Aug-

05

Oct

-05

Dec

-05

Feb-

06

Apr-

06

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07

Source SITREPs

26

5.5.10 Emergency bed days trend (excluding Mount Vernon Hospital)

02,0004,0006,0008,000

10,00012,00014,00016,00018,00020,000

Apr-

04

Jun-

04

Aug-

04

Oct

-04

Dec

-04

Feb-

05

Apr-

05

Jun-

05

Aug-

05

Oct

-05

Dec

-05

Feb-

06

Apr-

06

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07

trend


5.5.11 Proportion of stroke patients treated in stroke unit

0%10%20%30%40%50%60%70%80%90%

100%

Apr-

04

Jun-

04

Aug-

04

Oct

-04

Dec

-04

Feb-

05

Apr-

05

Jun-

05

Aug-

05

Oct

-05

Dec

-05

Feb-

06

Apr-

06

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07


27

5.6 Cancer 5.6.1 Cancer 14 day standard for urgent referrals 2006 2007


Target England Jan-Mar

06

Urgent patients seen 306 395 370 406 345 352 348 347 342 349 347 377 395

not seen within 14 days 0 0 0 0 1 0 0 0 0 0 1 1 1

% seen within 14 days 100% 100% 100% 100% 99.7% 100% 100% 100% 100% 100% 99.7% 99.7% 99.7% 100% 99.9%

Source CWT national monitoring (shaded figures = provisional) 5.6.2 Cancer treatment data completeness (31 day standard) 2006 2007 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

DoH Target

Monthly activity 100 118 113 99 115 142 121 122 106 103 97 114 105 Refreshed final quarterly 339 356 355 314 350 Source CWT national monitoring (shaded figures = provisional) 5.6.3 Cancer compliance against the 31 and 62 day standards 2006 2007


Opera-tional

standard

England Oct-Dec

06

Patients treated 100 118 113 99 115 142 121 122 106 103 97 114 105

not treated within 31 days of diagnosis 0 0 0 0 0 0 0 0 0 0 0 0 1

31 day standard 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 98% 99.6%Urgent patients treated 47 48 40 42 50.5 55.5 49 54.5 38 37 38.5 45 41

not treated within 31 days of referral 1.5 3.5 1.5 0 0.5 0.5 0 1 0 0 0 0 1

62 day standard 97% 93% 96% 100% 99% 99% 100% 98% 100% 100% 100% 100% 98% 95% 96.3% Source CWT national monitoring (shaded figures = provisional)Shared cancer care between 2 providers counts as 0.5 for each 5.6.4 Patients receiving cancer treatment – 31 day standard

Cancer treatments

020406080

100120140160

Apr-

05

May

-05

Jun-

05

Jul-0

5

Aug-

05

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Apr-

07

Source CWT national monitoring (shaded column = provisional)

Overall performance achievement is reported 25 working days after the end of the month

28

5.6.5 Patients receiving urgent cancer treatment – 62 day standard

Urgent treatments

0

10

20

30

40

50

60

Apr-

05

May

-05

Jun-

05

Jul-0

5

Aug-

05

Sep-

05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr-

06

May

-06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Apr-

07

Source CWT national monitoring (shaded column = provisional)

5.7 Referral to Treatment (RTT) 18-week target 5.7.1 Referral-To-Treatment period for patients whose 18 week clock stopped during the month with an inpatient/day case admission 2006 2007

Oct Nov Dec Jan Feb Mar Apr

Target Mar 08

England

Treated < 18 weeks 432 349 224 343 275 339 273

Treated 18+ weeks 1236 1299 638 1156 1009 879 1086

Time to treatment not known 692 335 318 302 270 336 267

Total 2360 1983 1180 1801 1554 1554 1626

% <18 weeks 26% 21% 26% 23% 21% 28% 20% 85% n/a

% not known 29% 17% 27% 17% 17% 22% 16%

Source:Monthly RTT return

Distribution of admitted RTT times

010203040506070

0 13 26 39 5

weeks

Patie

nts

2

Nov-06

Apr-0718

wee

ks

Source: Monthly RTT return

29

5.7.2 Referral-To-Treatment period for patients whose 18 week clock stopped during the month for reasons other than an inpatient/ day case admission 2007

Jan Feb Mar Apr

Target Mar 08

England

Total 60 495 347 207 Treated < 18 weeks 49 476 340 202 % <18 weeks 82% 96% 98% 98% 90% n/a

Source:Monthly RTT return 5

.7.3 Referral-To-Treatment period so far for patients whose 18 week clock is still running

2007

Jan Feb Mar Apr

Target Mar 08

England

Total 304 1823 2728 3276 Waiting < 18 weeks 134 1348 1777 1657 % <18 weeks 44% 74% 65% 51% n/a n/a

Source:Monthly RTT return 6.0 Sixth Domain – Care Environment and Amenities 6.1 PEAT score for hospital food External (HCC / NPSA PEAT) 2005 (Jul 05) 2006 (Feb 06) Percentage score band 2 = 40-59% band 3 = 55-74% Outcome (PEAT) Poor Acceptable Outcome (HCC) Underachieved Achieved Source - External annual PEAT inspections Internal (Trust i-PEAT) Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 DoH Target Percentage score 76% 86% 85% 83% 80% 75% 79% band 5 = 94%+ Outcome (PEAT) Good Good Good Good Good Good Good Excellent Outcome (HCC) Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved Source - Internal monthly PEAT inspections 6.2 PEAT score for hospital cleanliness External (HCC / NPSA PEAT) 2005 (Jul 05) 2006 (Feb 06) Percentage score band 2 = 40-59% 66% Outcome (PEAT) Poor Acceptable Outcome (HCC) Underachieved Achieved Source - External annual PEAT inspections Internal (Trust i-PEAT) Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 DoH Target Percentage score 89% 74% 75% 72% 74% 73% 74% bands 4-5 = 75%+Outcome (PEAT) Good Acceptable Good Acceptable Acceptable Acceptable Acceptable Good Outcome (HCC) Achieved Achieved Achieved Achieved Achieved Achieved Achieved Achieved

30

7.0 Seventh Domain – Public Health 7.1 Smoking

2005-06

Q3 2005-06

Q4 2006-07

Q1 2006-07

Q2 2006-07

Q3 2006-07

Q4 Jan 07 Feb 07 Mar 07 Apr 07 Target

England 2005-06

Q3

Maternities 1164 1147 1356 902 1381 1323 459 409 455 405

smokers 194 162 191 139 163 181 65 64 52 47

% all mothers delivered who are smokers 17% 14% 14% 15% 12% 14% 14% 16% 11% 12% 17%

data recording % coverage 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 85%

Source LDPR return - England data exclude PCTs 5%+ not known 7.2 Breast feeding

2005-06

Q3 2005-06

Q4 2006-07

Q1 2006-07

Q2 2006-07

Q3 2006-07

Q4 Jan 07 Feb 07 Mar 07 Apr 07 Target

England 2005-06

Q3

Maternities 1173 1291 1164 1147 1356 902 459 409 455 405

known to initiate breast feeding 301 366 323 257 867 542 294 279 303 257

known not to initiate breast feeding 118 157 110 135 353 248 134 107 130 122

% new mothers breast feeding 66% 71% 69% 71% 70% 73% 69% 72% 70% 68% 67%

data recording % coverage n/a 90% 88% 86% 94% 82% 93% 94% 95% 94% 85%

Source LDPR return - England data exclude PCTs 5%+ not known Many of the figures in the report are provisional and unvalidated. The data were the most up-to-date at the time of writing of the report, and will be refreshed in any future report. Trevor Hill Head of Information and Performance Analysis 21 May 2007

Board Report May 2007 - West Herts College · The Trust utilises a risk-scoring matrix to conduct...

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