1. real estate

Agenda Item: Enclosure
Board of Directors
Meeting
Report
Subject: Integrated Performance Report - Exception Summary Report
Date: 5th September 2013
Author:
Lead Director: Jacqui Tuffnell, Director of Operations
Executive Summary
Performance Summary: July 2013
Monitor Compliance
Performance for July 2013 has resulted in the Trust reporting zero Monitor compliance
points with indicators meeting the required standards. However, the Trust has reported a
further confirmed MRSA case for the month of July. Monitor guidance states it has an annual
de minimis limit for cases of MRSA reflecting a governance concern being set at 6.
As a consequence of the Trusts financial and governance risk ratings the Trust remains in
breach of its authorisation with automatic over-ride applying a red governance risk rating.
Acute Contract
RTT
The Trust has continued to achieve the bottom-line position for all three RTT standards in
July 2013. 92% Incomplete Pathways and 90% Admitted had all reportable grouped
specialties achieve the respective targets, it should be noted that the Trust has reported two
patients on an Incomplete Pathway waiting over 52 weeks this will result in a financial
penalty, both patients are being actively managed on their pathway.
The Trust is reporting in-month specialty breaches of the 95% non-admitted standard. As per
the previous month July 2013 has seen same four specialties underachieving against the
95% target. Further specialty level recovery action plans and trajectories are being produced
and shared with the commissioners following the CCG specifying the Trust target for delivery
of the non-admitted standard must be achieved during Quarter 3 2013/14.
The current central RTT Team continue to actively track patients and work closely with the
Trust PPCs with the focus on being patient’s pathways being progressed in a timely and
proactive manner. The recruitment process is being followed for recruiting an additional
10Wte staff whose function will be to track all specialties for patients with an RTT wait of 6
weeks and above, validate weekly ‘clock stops’ on all patient pathways, progress patients on
an Incomplete RTT pathway and review all ‘clock stops’ from the past 12 months to provide
a high assurance on the Trusts RTT patients.
ED
The number of ED un-planned re-attendances for a further month is above 5% for July 2013;
this is deterioration from the previous month. The department is continuing to reiterate
messages to patients regarding when to return, displaying messages to patients in the
waiting room, working with high volume service users and revisiting advice leaflets to offer
more specific advice.
Specific work continues to being undertaken with CCG/Primary Care around paediatric
emergency attendances and reinforcing communication regarding the use of Out of Hours
Primary Care Services before re-attending at the Childrens Emergency Department.
Un-coded Activity
The level of un-coded admitted patient care spells at the 5th working day of the month has
increased decreased from 39.66% to 27.92% (-11.74%) against the Clinical Commissioning
Group target of 20%. The decrease has been a result of reviewing departmental process
and implementing lean ways of working. The Clinical Coding Team is continuing to assess
processes in place to further improve the un-coded position.
Following recruitment in July the Trust has appointed four substantive trainee Clinical Data
Capture Coders. The successful candidates will be joining the department late September
and early October but will require full Clinical Data Capture Coding foundation course
training; the Trust will begin to see the benefit of the appointments from December 2013
onwards.
ASI Rates
During the month of July 2013 the Trust reported a Choose and Book Available Slot Issue
(ASI) rate of 8% against a target of 5%; this is an improved position from June 2013.
Dermatology, Endocrine, Pain Management, Respiratory Medicine, Paediatric Allergy and
Vascular Surgery were the main contributing specialties, current performance for August
2013 indicates the Trust being at an ASI rate of 8%. The Divisional teams following
instruction to resolve the ASI issue are working closely with the Booking and Access Team
to provide remedial actions for reducing the ASI rate to an acceptable level.
Quality
The monthly Quality and Safety Report written by the Executive Director of Nursing and
Executive Medical Director will cover key quality domains.
HR/Workforce
A summary of the key workforce issues are grouped below, these will be expressed in more
detail within the HR paper:
Workforce Numbers & Cost
The budgeted establishment in month was 3687.56 wte an increase of 9.56 wte and staff in
post was 3437.74 wte an increase of 3.88 wte. Pay spend in month was £13.77m, of which
£11.78m was fixed pay spend and £1.68m was variable pay spend (increase since last
month) which equates to 12.20%.
Sickness Absence
Staff absence levels remain high, decreasing only slightly since last month from 4.71% in
June 13 to 4.69% in July 13. Short term absence has decreased from 2.66% to 2.48%
(0.18%) and long term has increased from 2.05% to 2.21% (0.16%). The month rate is
4.69% with the rolling 12-13 12 month rate at 4.86% which is 0.30% higher than 11-12
(4.56%). Absence must be effectively managed in order to ensure levels of care are
maintained and cost levels are reduced.
Agenda for Change Appraisal Completion
The current appraisal rate is 64.19% which has increased since last month by 3.68%. The
appraisal coordinator has worked rigorously to the number of records which have no
appraisal date reported. Since April 13, appraisal rates have increased by 9.59% from
54.60%. A validation check of all divisions’ appraisal information is taking place with
escalation to achieve 85% by the end of September.
July 2013 Successes
The Trust continues to achieve the ED 4 hour target with performance in July 2013 being
96.37%, this being despite of high volume attendances and capacity and flow issues during
July 2013.
The Trust continues to receive ‘excellent’ for the NHS Friends and Family Test, remaining at
4.6 star rating and 60 for proportional score.
Q2 13/14 Forecast Risks
Achievement of the Choose and Book appointment slot issues (ASI) continues to rely heavily
on waiting list initiatives to meet shortfalls in capacity. The target agreed with commissioners
is 5%.
Non-Admitted RTT Trust bottom-line 95% achievement is a potential risk due the patients
breaching their RTT pathway being tightly progressed for treatment outcomes and lower
activity volumes due to annual leave.
Cancer 62 Day Cancer has been flagged as potential risk with projected Quarter 2
performance as at 23rd August 2013 deteriorating to 86.9% (against a target of 85%). This
has been raised and managed at the Patient Waiting Times meeting and Cancer PTL
meeting. The Cancer Pathway team and Booking and Access Manager are micro-managing
individual patients who we have identified as being potential breaches within Q2. Significant
attention is being focused on this target as this is not the care we wish to provide to our
patients and underachievement would result in a Monitor Compliance point.
Recommendation
For the Executive Board to receive this high level summary report for information and to
raise any queries for clarification.
Relevant Strategic Objectives (please mark in bold)
Achieve the best patient experience
Improve patient safety and provide high
quality care
Attract, develop and motivate effective
teams
Achieve financial sustainability
Build successful relationships with
external organisations and regulators
Links to the BAF and Corporate
Risk Register
Details of additional risks
associated with this paper (may
include CQC Essential Standards,
NHSLA, NHS Constitution)
Links to NHS Constitution
Key Quality and Performance Indicators provides
assurances on delivery of rights of patients accessing
NHS care.
Financial Implications/Impact
Legal Implications/Impact
The financial implications associated with any
performance indicators underachieving against the
standards are identified.
Failure to deliver key indicators results in Monitor
placing the trust in breach of its authorisation
Partnership working & Public
Engagement Implications/Impact
Committees/groups where this
item has been presented before
Monitoring and Review
Is a QIA required/been
completed? If yes provide brief
details
The Board receives monthly updates on the reporting
areas identified with the IPR.
Workforce Performance Indicators
Key Issues - July 13
1.0 Overview
1.1 Summary Messages
a. Workforce Numbers & Cost – The budgeted establishment in month was 3687.56 wte an
increase of 9.56 wte and staff in post was 3437.74 wte an increase of 3.88 wte. Pay spend
in month was £13.77m, of which £11.78m was fixed pay spend and £1.68m was variable
pay spend (increase since last month) which equates to 12.20%.
b. Sickness Absence – Staff absence levels remain high, decreasing only slightly since last
month from 4.71% in June 13 to 4.69% in July 13. Short term absence has decreased from
2.66% to 2.48% (0.18%) and long term has increased from 2.05% to 2.21% (0.16%). The
month rate is 4.69% with the rolling 12-13 12 month rate at 4.86% which is 0.30% higher
than 11-12 (4.56%). Absence must be effectively managed in order to ensure levels of care
are maintained and cost levels are reduced.
c. Agenda for Change Appraisal Completion – The current appraisal rate is 64.19% which has
increased since last month by 3.68%. The appraisal coordinator has worked rigorously to
improve data quality. Since April 13, appraisal rates have increased by 9.59% from 54.60%.
1.2 Key Issues – July 13
1.2.1 Staff Numbers & Pay Spend (Source – Integra System - Finance)
Key points to note:
• Since last month there has been an
increase in the budgeted establishment
by 9.56 wte to 3687.56 wte.
• Staff in post has increased by 3.88 wte
to 3437.74 wte in July 13.
• The number of vacant posts is currently
249.82 wte which is a slight increase of
5.68 wte since June 13. The Trust
vacancy rate is 6.77%, the majority of
vacancies continue to be in Registered
Nursing (108.11 wte/43.40%). This is an
increase since last month by 4.71 wte.
Since last month there have been
significant increases in the number of
administrative and clerical vacancies
(increase of 11.25 wte) and slight
increases in Unregistered Nursing.
Workforce Numbers
(WTE)
April 13
May 13
June 13
July 13
12 month rolling
average
Budgeted
Establishment
3653.84
3668.10
3678.00
3687.56
3549.82
Budgeted
Reserves
64.20
68.20
68.20
69.20
1
Staff in Post
3389.19
3412.90
3433.86
3437.74
3369.90
Vacancies excluding
reserves
264.65
255.20
244.14
249.82
179.92
Key points to note:
• In month total pay expenditure was £13.77m, which is above the 12 month rolling average of £13.59m.
This continues to remain static since the April 13.
• Variable pay has increased since last month by £0.40m with an expenditure of £1.68m and is below the 12
month rolling average of £1.73m by £0.05m. The majority of variable pay increase is attributed to
increased spend in nursing staff group in Emergency Care & Medicine for additional capacity and
outcomes of Keogh review.
• Variable pay accounts for 12.20% of total pay spend which is below the rolling 12 month average of
13.50%.
Pay Spend
Planned
Spend
Fixed Pay
Spend
Variable
Pay
Spend
Reserves
Spend
Total Pay
Spend
Variance
against plan
April 13
May 13
June 13
July 13
12 month
rolling avg
(inclusive of
reserves)
£14.01m
£14.12m
£14.08m
£13.95m
£11.86m
£11.89m
£11.93m
£11.78m
£11.66m
£1.77m
£1.77m
£1.28m
£1.68m
£1.84m
£44k
£68k
£428k
£310k
£84k
£13.77m
£14.05m
£13.93m
£13.77m
£13.59m
£234k
£64k
£152k
£180k
Variable
Pay as a %
of total Pay
Spend.
12.82%
12.57%
9.22%
12.20%
13.50%
The graphs overleaf demonstrate pay spend for 13/14 against plan, followed by a graph illustrating variable
pay % of total pay spend.
2
Summary – Staff Numbers and Pay Spend
Progress - Pay Spend plan and staff numbers have been finalised in conjunction with Finance &
HR to enable effective reporting.
Risk – % of Variable pay against total pay spend has increased since last month
Action Required - Recruit to posts substantively where possible to avoid use of variable pay.
Ensure that pay spend is closely monitored against plan in future months to ensure CIP delivery.
3
1.2.2 Sickness Absence (Source – ESR System – HR)
•
•
•
•
•
•
In month absence rate
4.69%
Remains static from June
13 decreasing slightly by
by 0.02% from 4.71%.
Short
term
absence
accounts for 2.48%
Long term absence is
currently 2.21%.
The 12 month rolling
absence rate is currently
4.83% which is above the
same period last year by
0.34% (4.49% 12-13). The
June 13 position (4.70%) is
0.36% above the June 12
position of 4.34%.
The cost of paying absent
staff in July 13 was £404k.
Summary – Sickness Absence
Progress - Absence total rate (4.69%) remains high since last month decreasing slightly by
0.02%; short term absence (2.48%) has decreased by 0.18% since last month and long term
(2.21%) has increased by 0.16%.
Risk - Absence continues at the rate of last year this impacts on clinical care and cost, despite an
increase in support to managers and performance management meetings.
1.2.3 Staff Appraisal Completion – Agenda for Change (Source – ESR System – HR)
•
•
•
Agenda
for
Change
appraisal rate is 64.19%
(Aug 12 – Jul 13), an
increase of 3.68%.
178 appraisals were
completed in July 13,
compared
with
102
appraisals in July 12.
The target for appraisal
completion is 79% and
the current rate is 15%
below target. The chart
details
appraisal
progress from last month.
Corporate division has been the first division to achieve the 79% target at 80.74% following intensive work with
the Managers within the division. Emergency Care & Medicine and Diagnostics & Rehabilitation both had
increases in appraisal rate. Planned Care & Surgery had a slight decrease in their appraisal rate from 66.73%
to 66.10%.
For the purposes of this analysis, bank staff have been removed (although not exempt from taking part in
appraisals) due to being employed on an irregular/unplanned basis.
4
Focus continues to drive down data issues, and where managers raise concerns a meeting will be held with
them to address the issue and implement any changes to support process improvement. Over the next month
managers who have low appraisal performance and fail to make a return of information for July position will be
contacted directly from divisions and asked to make the return. In the meantime, appraisal dates will be
uploaded directly into ESR, followed by a final data validation in which managers will be required to
authenticate the validity of the data.
Summary – Appraisal Completion
Progress - Appraisal rate has increased from 60.51% in June 13 to 64.19% in July 13 by 3.68%
Risk - Appraisal rate is still significantly below the target of 79% by 15%.
Action Required) Managers need to ensure they have appraisals completed & reported and future
appraisals scheduled. HR to continue to assist managers with the return of information to enable
a fuller reporting picture.
5
TRUST KEY PERFORMANCE INDICATORS
Monitor compliance
July 2013 as at 18th August 2013
Target
Apr-13
May-13
Jun-13
Jul-13
In month
Change
Q2
2013/14
Q1
2013/14
YTD
13/14
Q4
2012/13
Q3
2012/13
Q2
2012/13
Q1
2012/13
2012/13
Admitted Patient Care (90% of
patients treated within 18 weeks)
>=90%
94.37%
94.83%
97.22%
94.39%

94.39%
95.49%
95.22%
93.34%
86.44%
84.89%
90.72%
88.86%
Non Admitted Patient Care (95% of
patients treated within 18 weeks)
>=95%
95.18%
95.88%
95.89%
96.07%

96.07%
95.65%
95.77%
95.52%
93.91%
93.47%
96.03%
94.71%
Incomplete Pathways (92% of patients
complete pathway within 18 weeks)
93.51%
89.88%
90.06%
95.24%
95.52%
95.71%
95.11%
95.06%

95.24%
>=92%
-
June 13
Snapshot
position
-
March 13
Snapshot
position
December 12
Snapshot
position
September 12
Snapshot
position
June 12
Snapshot
position
March 13
Snapshot
position
SFHFT (% <4 hour wait)
>=95%
93.50%
98.20%
98.47%
96.37%

96.37%
96.73%
96.64%
93.43%
92.74%
95.53%
95.71%
94.34%
Kings Mill (% <4 hour wait)
>=95%
91.20%
97.74%
98.11%
95.26%

95.26%
95.67%
95.56%
91.13%
90.66%
94.58%
94.82%
92.85%
Newark (% <4 hour wait)
>=95%
98.42%
98.67%
98.80%
97.99%

97.99%
98.63%
98.46%
98.78%
99.13%
99.43%
99.39%
99.20%
2 week wait: All Cancers
>=93%
93.59%
94.25%
94.55%
(95.54%)

(95.59%)
94.13%
(94.87%)
95.48%
96.23%
95.69%
95.89%
95.83%
2 week wait: Breast Symptomatic
>=93%
97.67%
97.67%
97.44%
(95.35%)

(96.42%)
97.60%
(97.04%)
95.08%
94.87%
95.50%
96.97%
95.54%
31 day wait: from diagnosis to first
treatment
>=96%
100.00%
100.00%
99.15%
(100.00%)

(99.65%)
99.70%
(99.68%)
99.30%
99.39%
99.66%
99.39%
99.43%
31 day wait: for subsequent treatment surgery
>=94%
100.00%
100.00%
88.89%
(100.00%)

(100.00%)
96.67%
(98.25%)
100.00%
100.00%
98.04%
97.67%
98.65%
31 day wait: for subsequent treatment drugs
>=98%
100.00%
100.00%
100.00%
(100.00%)

(100.00%)
100.00% (100.00%) 100.00%
100.00%
100.00%
100.00%
100.00%
62 day wait: urgent referral to
treatment
>=85%
89.66%
88.06%
95.83%
(89.80%)

(87.59%)
91.37%
(89.65%)
89.29%
89.56%
93.01%
91.35%
90.78%
62 day wait: for first treatment screening
>=90%
100.00%
100.00%
100.00%
(100.00%)

(100.00%)
100.00% (100.00%)
97.67%
90.57%
92.98%
100.00%
94.95%
Community Referral to Treatment
information
>=50%
78.47%
82.42%
84.31%
86.41%

86.41%
81.81%
82.98%
78.46%
72.94%
75.38%
63.44%
74.35%
Community Referral information
>=50%
54.00%
54.12%
54.34%
53.82%

53.82%
57.42%
54.08%
54.28%
54.03%
54.18%
54.86%
54.37%
Community Treatment activity - and
care contact
MONITOR COMPLIANCE FRAMEWORK
Ref.
Referral to Treatment:
A&E Clinical Quality:
Total Time in A&E Dept
Cancer
Data Completeness:
Infection Prevention Control:
>=50%
76.38%
76.58%
77.08%
77.11%

77.11%
76.69%
76.79%
67.82%
68.54%
69.45%
69.18%
68.77%
MRSA Bacteraemia (No. of cases
attributed to Trust)
0
0
1
0
1

1/0
1/0
2/0
0
0
0
0
0
Clostridium Difficile Infections (No. of
cases attributed to Trust)
3
2
4
2
2

2/2
8/6
10/25
12/9
8/9
3/9
6/9
29/36
0.0
0.0
Access to Healthcare for people with learning disabilities
CQC Compliance
95.11%
compliance points relative to site visits
Compliance
0
Compliant


Monitor Compliance Points
N/A
1.0
2.0
3.0
2.0
1.0
RED
RED
RED
RED
AMBER GREEN
Governance Risk Rating (GRR)
N/A
TRUST KEY PERFORMANCE INDICATORS
Acute Contract Performance
July 2013
Target
Mar-13
Apr-13
May-13
Jun-13
Jul-13
In month
change
Q2
2013/14
Q1
2013/14
YTD
2013/14
Q4
2012/13
Q3
2012/13
Full Year
2012/13
SFHFT (% <4 hour wait) Total Time in A&E
Dept
>=95%
92.25%
93.50%
98.20%
98.47%
96.37%

96.37%
96.73%
96.64%
93.43%
92.74%
94.34%
Unplanned re-attendance rate within 7 days
of original attendance
<=5%
4.87%
6.24%
4.93%
5.44%
5.51%

5.51%
5.53%
5.53%
5.02%
5.94%
5.70%
Left without being seen rate
<=5%
2.18%
1.70%
1.63%
1.63%
2.10%

2.10%
1.67%
1.78%
1.73%
2.11%
2.08%
Time to Initial Assessment for patients arriving
by emergency ambulance (95th percentile Mins)
<=15
31
35
27
26
29

29
29
29
33
42
39
Time to Initial Assessment for patients arriving
by emergency ambulance (Median Minutes)
<=16
4
4
4
4
4

4
4
4
5
7
6
Time to Treatment (Median minutes wait from
arrival to treatment)
<=60
136
54
51
50
57

57
52
53
55
57
56
CONTRACTUAL PERFORMANCE METRICS
Ref
A&E Clinical Quality:
Ambulance Turnaround
Times
Average Clinical Handover Time (%)
>=65%
51.43%
55.84%
65.34%
63.80%
59.72%

59.72%
61.52%
61.06%
54.69%
51.17%
55.64%
Delayed Transfer of Care
Trust Total % (at snapshot position)
3.50%
5.40%
3.54%
4.78%
5.38%
4.65%

4.65%
4.54%
4.57%
3.63%
6.75%
5.97%
% Of elective admissions
<=0.8%
0.91%
0.43%
0.36%
0.48%
0.40%

0.40%
0.42%
0.41%
0.82%
0.98%
0.71%
% Breached 28 day guarantee
<=5%
0.00%
0.00%
0.00%
0.00%
0.00%

0.00%
0.00%
0.00%
0.00%
0.95%
0.75%
Diagnostic waiting times
<6weeks
%
>=99%
99.42%
99.49%
99.64%
99.49%
99.84%

-
-
-
-
-
-
Choose & Book:
Ratio: Slot issues per booking
<0.05
0.05
0.05
0.09
0.09
0.08

-
-
-
0.08
SUS data:
% uncoded within 5 days of month end
<20%
34.28%
36.51%
26.53%
39.66%
27.92%

-
-
-
-
-
Admitted Patient Care (90% of patients
treated within 18 weeks)
>=90%
93.88%
94.37%
94.83%
97.22%
94.39%

94.39%
95.49%
95.22%
93.34%
86.44%
88.86%
Non Admitted Patient Care (95% of patients
treated within 18 weeks)
>=95%
95.69%
95.18%
95.88%
95.89%
96.07%

96.07%
95.65%
95.77%
95.52%
93.91%
94.71%
Incomplete Pathways (92% of patients
complete pathway within 18 weeks)
>=92%
95.24%
95.52%
95.71%
95.11%
95.06%

-
-
-
-
-
-
18week RTT for direct access audiology
completed pathways (treated)
>=95%
99.59%
99.68%
99.63%
99.64%
99.47%

99.47%
99.65%
99.59%
99.35%
99.75%
99.69%
0
2
2
1
1
2

-
-
-
-
-
-
2 week wait: All Cancers
>=93%
95.16%
93.59%
94.25%
94.55%
(95.54%)

(95.59%)
94.13%
(94.87%)
95.48%
96.23%
95.83%
2 week wait: Breast Symptomatic
>=93%
91.11%
97.67%
97.67%
97.44%
(95.35%)

(96.42%)
97.60%
(97.04%)
95.08%
94.87%
95.54%
31 day wait: from diagnosis to first treatment
>=96%
100.00%
100.00%
100.00%
99.15%
(100.00%)

(99.65%)
99.70%
(99.68%)
99.30%
99.39%
99.43%
31 day wait: for subsequent treatment surgery
>=94%
100.00%
100.00%
100.00%
88.89%
(100.00%)

(100.00%)
96.67%
(98.25%)
100.00%
100.00%
98.65%
31 day wait: for subsequent treatment - drugs
>=98%
100.00%
100.00%
100.00%
100.00%
(100.00%)

(100.00%)
100.00%
(100.00%)
100.00%
100.00%
100.00%
62 day wait: urgent referral to treatment
>=85%
95.40%
89.66%
88.06%
95.83%
(89.80%)

(87.59%)
91.37%
(89.65%)
89.29%
89.56%
90.78%
62 day wait: for first treatment - screening
>=90%
100.00%
100.00%
100.00%
100.00%
(100.00%)

(100.00%)
100.00%
(100.00%)
97.67%
90.57%
94.95%
62 day wait: consultant upgrade
>=91%
100.00%
100.00%
100.00%
100.00%
(100.00%)

(93.24%)
100.00%
(96.47%)
86.36%
91.67%
93.64%
MRSA Bacteraemia (No. of cases attributed to
Trust)
0
0
0
1
0
1

1/0
1/0
2/0
0
0
0
Clostridium Difficile Infections (No. of cases
attributed to Trust)
3
4
2
4
2
2

2/2
8/6
10/25
12/9
8/9
29/36
Cancelled Operations:
Referral to Treatment:
Patients on an Incomplete Pathway waiting 52
weeks & Over
Cancer
Infection Prevention
Control:
denotes when the target is a contractual and Monitor performance target that
is replicated in the Monitor compliance dashboard
TRUST KEY PERFORMANCE INDICATORS
18 Weeks
July 2013
REFERRAL TO TREATMENT (RTT) - 18 WEEKS
Monitor Compliance
For the month of June 2013 all three RTT targets achieved the required standard for Monitor compliance, however there are in-month specialty breaches.
Quality
For the month of July 2013 two patients an Incomplete Pathway are waiting beyond 52 weeks, both patients are being actively managed. The commissioners have been notified of these
delays and the Trust is regular contact ensuring an uptodate picture of progress is shared along with an RCA for each patient. The access policy has been streamlined to aid administrative
and clinical understanding of the guidance, including patients choosing to delay their treatment for a significant period of time. This has been circulated for consultation, commentry and
ratification within the Trust and CCG with an expectation receiving final approval at September 2013 Board following the policy being presented at Hospital Management Board, Trust and
CCG Executive Meetings. The Trust attended the CCG Clinical Executive Meetings held 25th July and 8th August where CCG sign off was gained. An implementation plan is being developed
once final approval has been received to support the roll out of the revised arrangements to clinical, administrative and management teams that will be supported by monitoring
arrangements which are set out within the policy. A programme of training is being developed to support roll out.
Operational
Management to achieve the 92% target continues to impact upon delivery of the 95% non-admitted target for particular
specialties as evidenced in the adjacent table, as such the CCG have requested further additional specialty specific trajectories
and action plans for delivery which indicate delivery of the non-admitted target in Qtr3 13/14. The volume of non-admitted
specialties underachieving against the 95% standard remained as per the June 2013 performance at the same four specialties General Surgery, Urology, T&O and Gastoenterology. July 2013 saw all reportable grouped specialties achieve the 92% RTT
Incomplete Pathways target and 90% RTT Admitted Target. RTT meetings continue to monitor progress and drive delivery
including; weekly performance meetings with the CCGs, weekly waiting list management group, patient waiting times
meeting and departmental communication cells. The weekly Patient Waiting Times meeting attended by operational teams
representing all points across a patients pathway track and progress patients on their RTT pathway, currently the focus is at
an individual patient for those waiting 35 weeks and over. This will continue to reduce over the coming weeks. The RTT
validation team review every incomplete patient pathway for patients waiting beyond 18 weeks with a view to prevent
extensive waits and take any potential issues to the weekly patient waiting times meeting for resolution. The team has also
introduced reviewing patients between 12 and 17 weeks on specialties which have potentially multiple diagnostics to ensure
patients are being progressed. The CCG continue to monitor with the Trust patients waiting 42 weeks and beyond to establish
the actions being taken on individual patient pathways.
Referral to Treatment July 2013 Summary
RTT Specialty
General Surgery
Urology
T&O
ENT
Ophthalmology
MaxFax
Plastic Surgery
Cardiothoracic
Gastroenterology
Cardiology
Dermatology
Respiratory Medicine
Neurology
Rheumatology
Geriatrics
Gynaecology
Others
Total
Incomplete
92.57%
93.52%
92.01%
96.39%
98.29%
95.38%
94.79%
100%
92.28%
96.18%
98.53%
96.53%
97.65%
97.96%
99.81%
95.61%
94.23%
95.06%
RTT Standard
Admitted
Non-Admitted
91.02%
92.83%
93.16%
93.67%
90.00%
90.14%
91.43%
97.78%
97.44%
98.19%
94.87%
97.40%
95.12%
100%
100%
100%
98.99%
100%
98.67%
95.00%
94.39%
92.80%
95.74%
99.67%
95.50%
98.88%
98.33%
99.69%
95.20%
97.03%
96.07%
Acute Contract
The Trust has failed to deliver the national quality standard for non-admitted patients at a speciality level and will incur penalties. The total RTT penality as at July 2013 is £41,334 which
includes £20,000 for patients waiting 52 weeks and over.
TRUST KEY PERFORMANCE INDICATORS
Quality & Safety
July 2013
Target
Ref.
Apr-13
May-13
Jun-13
Jul-13
In month
change
Q2
2013/14
2.5
1
1
4
0

0
6/2.5
3
4
2
7
1
2

2
10/12
13
0
12
1
2
0
0

0
3/12
1
0
1
1
1
0
0

0
2/1
1
0
1
0
0
0
0

0
0/1
0
0

0
QUALITY & SAFETY METRICS
Infection Prevention
Control:
G
A
R
MSSA Bacteraemia (No. of hospital acquired cases)
0
0
E Coli bacteraemia (No. of Hospital acquired cases)
0
2
E. Coli Urinary Catheter Associated Bacteraemia (No. of
hospital acquired cases)
0
Other Urinary Catheter Associated Bacteraemia (No. of
hospital acquired cases)
0
Surgical Site Infections (Total Knee Replacement
surgery)
0
0
0
1
1
0
0
Medication, storage and custody
>90%
>85%
<85%
94%
79%
96%
Infection control/privacy & dignity
>90%
>85%
<85%
97%
93%
94%
Patient observations/ACAT
>90%
>85%
<85%
89%
85%
90%
Pain Management
>90%
>85%
<85%
89%
86%
93%
Nutritional Assessment
>90%
>85%
<85%
97%
82%
91%
Tissue Viability
>90%
>85%
<85%
92%
95%
97%
Falls Assessment
>90%
>85%
<85%
97%
92%
91%
Continence Assessment
>90%
>85%
<85%
97%
93%
92%
0
-
>0
0
0
0
1

<21
21-27
>28
14
14
6
9
Catastrophic-Death *(Live reporting system-updates can
affect numbers on daily basis)
0%
-
0%
0 (0%)
0 (0%)
0 (0%)
Severe harm *(Live reporting system-updates can affect
numbers on daily basis)
0%
-
0%
0 (0%)
0 (0%)
1 (<1%)
Moderate harm *(Live reporting system-updates can
affect numbers on daily basis)
<=5%
-
>5%
20 (4%)
21 (4%)
Low harm *(Live reporting system-updates can affect
numbers on daily basis)
<=23%
-
>23%
62 (12%)
80 (14%)
No harm *(Live reporting system-updates can affect
numbers on daily basis)
>=72%
-
<72%
Number of medication errors per 1000 occupied bed
days resulting in serious harm
-
-
-
0.00
0.00
0.00
Falls rate per 1000 occupied bed days
-
-
-
7.90
7.77
6.64
Surgical Site Infections (Total Hip Replacement surgery)
Serious Incidents (reported externally to CCG)
Patient Safety Incidents
Medication related
incidents
Q4
2012/13
Q3
2012/13
Q2
2012/13
2012/13
YTD
2013/14
6
2
13
6/2.5
19
Data now
split,
Qtr1/2 to
32
12/12
0
0
2
3/12
0
0
3
2/1
0
0
0
0/1
1/1
0
0
1
2
1/1
90%
94%
93%
97%
94%
90%
95%
98%
95%
94%
96%
95%
88%
90%
88%
86%
87%
88%
90%
86%
89%
88%
88%
90%
90%
82%
87%
86%
86%
90%
94%
94%
96%
93%
94%
94%
93%
94%
96%
95%
96%
93%
94%
93%
94%
91%
93%
94%
1
0
0
0
0
0
1

9
34
32
31
20
98
43
1 (<1%)

1
0
2
3
1
6
1
1 (<1%)

1
1
0
1
0
3
2
19 (4%)
22 (4%)

22
60
20
52
38
154
82
86 (17%)
82 (14%)

82
228
90
240
222
787
310
437 (84%) 458 (82%) 398 (79%) 488 (82%)

488
1293
473
1325
1170
4152
1781
0.00

0.00
0.00
New methodology agreed for 2013/14
0.00
7.90

7.90
7.46
New methodology agreed for 2013/14
7.46
New methodology agreed for 2013/14
1.30
Nursing Metrics:
Never Event (number of reported events)
Q1
2013/14

Data
collection
method
and source
has been
updated to
FOCUS IT.
Pilot in July
2013, new
data
format will
be
provided
for August
2013
period






Data
collection
method
and source
has been
updated to
FOCUS IT.
Pilot in
July 2013,
new data
format will
be
provided
for August
2013
period

Slips, trips and falls
-
-
-
1.17
1.29
1.44
1.85

1.85
1.30
Grade 2 *(Live reporting system-updates can affect
numbers on daily basis)
<5
>=5<=10
> 10
14
13
16
8

8
43
54
30
17
135
43
Grade 3 *(Live reporting system-updates can affect
numbers on daily basis)
<2
>=2<=4
>4
5
4
2
0

0
11
9
6
8
23
11
Grade 4 *(Live reporting system-updates can affect
numbers on daily basis)
0
-
>=1
0
0
0
0

0
0
0
1
0
2
0
1.28
1.30
>1:30
N/A
N/A
1.28
01:34
01:33
01:32.0
01:32.1
Falls rate per 1000 occupied bed days resulting in harm
Pressure Ulcer (post
admission/avoidable
*from April 2012)
Midwife to birth ratio
Number of Calls to
Outreach Team
<3.5 per >3.5 per
1000
1000
1.7
2.5
2.2
1.3

1.3
2.2
2.1
3.1
2.9
3.0
2.1
-
-
-
131
108
102
111

111
341
362
359
317
1309
341
Acute
-
-
-
101
71
70
73

73
242
258
233
182
844
242
Follow Up (seen by critical care on discharge from ICCU
-
-
-
30
37
32
38

38
99
104
126
135
465
99
>=70%
scored at
Level 2
-
<70%
scored at
Level 2
72%
72%
72%
72%

72%
72%
72%
49%
72%
64%
72%
0
-
>=1
Information Governance (Scores for IG Toolkit)
Eliminating Same Sex Accommodation Breaches (No of breaches)
No of complaints received in month
<=0.10%
Improving Patient
Experience
0.11% >=0.20%
0.19%
0
0
0
0

0
0
0
0
0
0
0
59
57
53
60

60
169
219
174
153
683
169
0.15%
0.14%
0.13%
0.13%

0.13%
0.14%
>=96%
81-95%
<=80%
94%
33%
79%
100%

100%
69%
77%
84%
87%
89%
69%
No of contacts
-
-
-
660
613
569
649

649
1842
1933
2141
1992
8531
2491
Compliments
-
-
-
140
98
79
58

58
317
240
246
148
915
375
Comments
-
-
-
249
228
211
247

247
688
847
788
938
3593
935
263
278
259
347

347
800
779
1052
867
3822
1147
0.65%
0.66%
0.66%
0.77%

0.77%
0.66%
17
15
25
12

12
57
0.04%
0.04%
0.06%
0.03%

0.03%
0.05%
% against activity complaints received in month
(Acknowledgement)
PALs
>5 per
1000
Total
Cardiac Arrest Calls (outside of ICCU)- 1-5 per 1000 admission)
Concerns - volume received
<=0.10%
0.11% >=0.20%
0.19%
Concerns - % against activity
First Line Complaints - volume received
<=0.10%
0.11% >=0.20%
0.19%
Complaints - % against activity
New methodology agreed for 2013/14
New methodology agreed for 2013/14
67
55
39
201
New methodology agreed for 2013/14
0.14%
0.64%
69
0.05%
NHS Friends and Family Test (5 start rating scoring)
>=4
>=3.5
<3.5
4.6
4.6
4.6
4.6

4.6
4.6
2012/13 data not collected in Five
Star rating method
N/A
N/A
NHS Friends and Family Test (proportional score) (DH
deem above 50 as excellent)
50
45
40
61
63
61
60

60
61
2012/13 data not collected in
proportional score method
N/A
N/A
Heart Attacks Secondary Prevention
>90%
90%
<90%
N/A
HSMR
<=100
-
>100
N/A
Net Promoter
Denotes not applicable at time of report
Not available at time of report publication
Monthly Trend



Improved Performance
In line with previous period
Deterioration in Performance




Achieving threshold improving performance
Achieving threshold deteriorating performance
Failing threshold improving performance
Failing threshold deteriorating performance
96.32%
98.42%
99.60%
99.33%
N/A
N/A
96.8
118.5
111.2
N/A
N/A
TRUST KEY PERFORMANCE INDICATORS
HR/Workforce
July 2013
Code
HR WORKFORCE METRICS
Target effective from 1st April 13 (establishment target based on
end of year target requirement)
G
A
Mar-13
Apr-13
May-13
Jun-13
Jul-13
In month
change
Q2 2013/14
Q1 2013/14
Q4 2012/13
Q3 2012/13
Q2 2012/13
YTD 2013/14
R
>3666.58
3483.88
3653.84
3668.10
3678.00
3687.56
9.56
3687.56
3666.65
3484.59
3489.59
3490.96
3671.88
-
-
-
3358.23
3389.19
3412.90
3433.86
3437.74
3.88
3437.74
3411.98
3346.16
3352.58
3337.64
3418.42
< or = 7.50%
> 7.50% & < 10.00%
>10.00%
-125.65
-264.65
-255.20
-244.14
-249.82
-5.68
-249.82
-254.66
-138.44
-137.01
-153.32
-253.45
<9.45%
>9.45% & <10.40%
>10.40%
9.73%
0.95%
1.46%
2.33%
3.09%
0.76%
3.09%
2.33%
9.73%
7.35%
4.96%
1.96%
<1.52%
>1.52% & <1.68%
>1.68%
2.46%
3.02%
2.48%
2.66%
2.48%
-0.18%
2.48%
2.72%
2.73%
2.63%
2.23%
2.66%
<1.64%
>1.64% & <1.82%
>1.82%
2.37%
1.81%
2.15%
2.05%
2.21%
0.16%
2.21%
2.00%
2.44%
2.56%
2.00%
2.06%
<3.51%
>3.51% & <3.85%
>3.85%
4.83%
4.83%
4.63%
4.71%
4.69%
-0.02%
4.69%
4.72%
5.17%
5.19%
4.23%
4.72%
-
-
-
£219,990
£264,339
£220,772
£175,504
£208,591
£33,087
£208,591
£660,615
£658,287
£654,933
£548,542
£869,206
-
-
-
£225,795
£161,228
£189,457
£209,172
£195,879
-£13,293
£195,879
£559,857
£613,486
£660,186
£476,994
£755,736
-
-
-
£445,785
£425,567
£410,229
£384,676
£404,470
£19,794
£404,470
£1,220,472
£1,271,773
£1,315,119
£1,025,536
£1,624,942
Absence 12 month rolling rate (%) - Short
Term
<1.52%
>1.52% & <1.68%
>1.68%
2.45%
2.51%
2.56%
2.58%
2.59%
0.01%
2.59%
2.55%
2.43%
2.33%
2.20%
2.56%
Absence 12 month rolling rate (%) - Long
Term
<1.64%
>1.64% & <1.82%
>1.82%
2.29%
2.27%
2.24%
2.25%
2.27%
0.02%
2.27%
2.25%
2.28%
2.29%
2.38%
2.26%
<3.51%
>3.51% & <3.85%
>3.85%
4.73%
4.78%
4.80%
4.83%
4.86%
0.03%
4.86%
4.80%
4.70%
4.62%
4.58%
4.82%
-
-
-
83.59
88.24
89.85
87.51
85.86
-1.65
85.86
88.53
87.33
88.50
88.82
87.86
-
-
-
£62,676
£61,866
£62,106
£62,232
£62,713
£481
£62,713
£62,068
£62,514
£62,187
£61,917
£62,229
Establishment
Staff in Post
< or = 3666.58
Workforce Numbers
Vacancies
(Diff between Bud. Est. & SIP)
Turnover Rate (%)
Sickness Absence (%) - Short Term
Sickness Absence (%) - Long Term
Sickness Absence (%) - Total
Absence Cost (£) - Short Term*
Absence Cost (£) - Long Term*
Attendance and Wellbeing - * This is the cost
of salary paid to those who were absent due to
Absence Cost (£) - Total*
sickness.
Absence 12 month rolling rate (%) - Total
Maternity (WTE on maternity in month)
Annual Clinical Income per WTE (£)
Income and Staff Costs
Staff Performance
Annual Average Salary per WTE (£)
AFC Rolling 12 month Appraisal
completion rate
Mandatory Training Completion
-
-
-
£45,958
£46,483
£46,263
£45,907
£46,099
£192
£46,099
£46,218
£45,752
£45,221
£45,672
£46,188
>79%
>79% & <71%
<71%
52.93%
57.40%
57.41%
62.03%
64.19%
2.16%
64.19%
62.03%
46.81%
48.00%
47.00%
64.19%
>98%
>88% & <98%
<88%
75%
75.00%
75.00%
75.00%
75.00%
0%
75.00%
75.00%
74.00%
71.00%
73.00%
75.00%
TRUST KEY PERFORMANCE INDICATORS
Workforce/Human Resources
July 2013
Workforce Summary
Key Issues:a. Workforce Numbers & Cost – The budgeted establishment in month was 3687.56 wte an increase of 9.56 wte and staff in post was 3437.74 wte an increase of 3.88 wte. Pay spend in month was £13.77m,
of which £11.78m was fixed pay spend and £1.68m was variable pay spend (increase since last month) which equates to 12.20%.
b. Sickness Absence – Staff absence levels remain high, decreasing only slightly since last month from 4.71% in June 13 to 4.69% in July 13. Short term absence has decreased from 2.66% to 2.48% (0.18%)
and long term has increased from 2.05% to 2.21% (0.16%). The month rate is 4.69% with the rolling 12-13 12 month rate at 4.86% which is 0.30% higher than 11-12 (4.56%). Absence must be effectively
managed in order to ensure levels of care are maintained and cost levels are reduced.
c. Agenda for Change Appraisal Completion – The current appraisal rate is 64.19% which has increased since last month by 3.68%. The appraisal coordinator has worked rigorously to the number of records
which have no appraisal date reported. Since April 13, appraisal rates have increased by 9.59% from 54.60%.
Workforce Numbers
a) Budgeted Establishment - In comparison to last month, budgeted establishment has increased by 9.56 wte to 3687.56 wte. Planned establishments remain stable until October 13 where CIPs are
expected to be achieved.
b) Staff in post - has increased by 3.88 wte to 3437.74 wte in July 13 from 3433.86 wte in June 13.
c) The number of vacant posts is currently 249.82 wte which is a decrease of 5.68 wte since June 13. The Trust vacancy rate is 6.77%, the majority of vacancies continue to be in registered Nursing (108.11
wte/43% of all vacancies).
d) Comparison with 12/13 - The current budgeted establishment is 3687.56 wte which is 202.49 wte above than the budgeted establishment position of 3485.07 wte at July 12. When comparing current
staff in post 3437.74 wte is 93.74 wte above July 12, 3344.00 wte.
e) Against Annual Plan - In terms of annual plan, we are above the projections of 3716.83 by 37.93 wte.
f) Turnover - current FYTD turnover is 3.09% which is below the rate for the same period 12/13 of 3.19%. This does not include junior doctors leaving for rotation.
Attendance & Wellbeing
a) In Month - Trust absence levels have decreased slightly since last month by 0.02% to 4.69%. When comparing against July 12, the absence rate was 4.32%, with absence for July 13 0.37% above the same
period last year.
b) Rolling 12 Months Absence - The rolling 12 month period absence is currently 4.86% which is 1.36% above the target of 3.50%. This is 0.30% above the same period for August 11 to July 12 of 4.56%
c) Absence Cost - The cost of salary paid to absent staff for July was £404k, for the 12 month rolling year this equates to £4.86m. This is the direct cost of paying staff whilst they are on sick leave and does
not account for additional hours/overtime/bank/agency used.
d) Occupational Health activity - During July 13 there have been a total of 69 referrals to Occupational Health to support staff at work/returning to work, this is a decrease since last month by 10.39%.
e) Sickness Actions - Monthly confirm and challenge sessions are being held on a monthly basis with managers of high absence areas to present challenge and also receive feedback on issues preventing the
effective management of absence. All managers are now in receipt of a sickness absence dashboard to assist them in the management of sickness absence within their area of responsibility.
f) The top three absence reasons for all staff : 1) Anxiety/stress/depression/other psychiatric illnesses (22.52%), 2) Other musculoskeletal problems (14.21%) 3) Gastrointestinal problems (11.47%).
Workforce Productivity & Staff Costs
a)
b)
c)
d)
Clinical Income - Current financial year to date clinical income is £63k per WTE which is a slight increase from June 13 by £1k.
Average Salary - Average salary per WTE of £46k in July 13 which remains static from June 13.
Pay Spend - In month the total pay spend was £13.77m, of which £11.78m was fixed pay spend.
Variable Pay - spend was £1.68m for July 13 (12.20% of total pay spend), which is an increase against last month, and remains below the 12 month rolling variable pay spend of £1.84m.
Staff Training & Development
a) Mandatory training - the current rate is 75%, which is no change since last month.
b) National annual junior doctors changeover has taken place with 152 new junior doctors and higher level trainees joining the organisation has now taken place.
Recruitment & Selection
a) New Consultants:
- Dr P Paul starting substantively in Anaesthetics on 9th September 2013 (11 PA)
- Dr Esther Corker starting as a Consultant Community Paediatrician starting on 19th September 2013. (8 PA)
- Mr Raphael Layiemo starting as a Consultant in Obstetrics and Gynaecology (Laparoscopic Surgery and Medical Education) 10 PA post – starting on 9th September 2013 (10 PA)
- Miss J Rajeswary starting as a Consultant in Obstetrics and Gynaecology (9 PA) – start date 9th September 2013
- Dr Sharon Tao consultant in Obstetrics and Gynaecology (8 PA) – start date 9th September 2013
- Dr Tyria Siddiq, Locum Consultant in Obstetrics and Gynaecology working 8 PA and starting on 16th September 2013 for a 12 month period
- Dr Seepathy Speciality Doctor in Ophthalmology start date to be confirmed
b) Consultants Leaving:
- Dr Liz Topley Community Paediatrician retiring around December – waiting for the official notification.
Workforce Change
a) The CIP target of £13.3m requires workforce savings of £9.6m. There are approximately 90 schemes in progress in terms of workforce related CIP schemes. There is still a requirement for more CIP
schemes relating to workforce to be scoped and these need to be commenced through the workforce change cycle to ensure they are implemented to meet the saving requirement; variances of those plans
scoped against the annual plan will be analysed to understand where more schemes are required to close this gap.
b) GMB Unions have balloted members of the Trust who are in favour of strike action and action short of a strike. Members return votes and 18 staff were in favour of action short of a strike and 17 in
favour of strike action our of a total of 56 members balloted. An action short of a strike took place on Thursday 15th August 2013. A day of strike action was planned for Tuesday 27th August 2013, however
this will now not go ahead.
Health & Safety
a) There has been no formal contact between the Trust and the HSE this month.
b) On 3rd July 2013 the Trust provided training to 12 people on respirator face fit testing. This is to help prepare for any necessary use of respirators in the event of a flu pandemic.
c) Training for managers and supervisors on their health and safety responsibilities and how these should be discharged recommenced during July 2013 and these courses will continue to run throughout
2013/14.
Serious Disciplinary & Tribunal Cases
a) Activity Summary - As at the end of July 2013 there are 17 formal cases in process with HR under Trust Policies, of which 8 have been disciplinary related, 1, are related to employee grievances, 1 case
relates to capability issues, 3 harassment case, 3 referrals and 1 whistleblowing.