1. health and fitness
2. disease
3. cancer

Agenda Item 8.1(ii)
Trust Board
28th March 2013
Public Section Paper
Alison Dailly, Director of Informatics.
Report of
Information Department.
Paper prepared by
Integrated Quality & Performance Report.
Subject/Title
n/app
Background papers
Purpose of Paper
Action/Decision required
Link to:
NHS strategies and policy
Link to:
Trust’s Strategic Direction
Corporate objectives
To ensure that the Trust Board remains up to
date with the Trust’s performance in light of
national requirements and local
developments.
The Trust Board are asked to support the
actions in relation to each of the targets.
Everyone Counts: Planning for Patients
2013/14, Operating Framework 2012/13,
Monitor & Care Quality Commission
standards, QIPP, CQUINs, local contract, Dr
Foster.
To achieve the best possible clinical outcomes
for every patient, every time.
To be the hospital of choice for patients and
staff.
To be a consistently high-performing &
influential healthcare provider.
To achieve academic excellence & expand the
boundaries of healthcare.
n/app
Resource impact
Consideration of legal issues
Patient data is anonymised in line with
Department of Health guidance on publication
of small numbers.
Acronyms and abbreviations
Full titles used on first reference. Acronyms
used thereafter (see also Glossary in
Appendix 1).
THE LEEDS TEACHING HOSPITALS NHS TRUST
TRUST BOARD MEETING - 28 MARCH 2013
INTEGRATED QUALITY & PERFORMANCE REPORT
PERIOD - JANUARY / FEBRUARY 2013
TRUST PERFORMANCE
OVERVIEW
Page 1 of 44
Integrated Quality & Performance Report
March 2013
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Integrated Quality & Performance Report
March 2013
SUMMARY OF PERFORMANCE
Perspective of the Chief Operating Officer:
The overriding issue affecting the performance of the hospitals is the continuation of
“winter pressures”. This is demonstrated by the underperformance in A&E (ED) waiting
times, cancellation of elective surgery and delays in the flow of patients through beds.
These pressures have affected all hospitals in the area, and particularly in the cities such
as Sheffield and Manchester. In Leeds Teaching Hospitals’ (LTHT) case, we continue to
see high demand through March. We have taken compensating action by extending the
additional winter bed capacity through to mid-April and with additional weekend and
evening consultant medical staff assessing patients and avoiding admission for elderly
patients attending the ED.
Our staff are to be commended for the extended efforts (since mid-December) they have
made to maintain the quality of service to our patients.
We have agreed to undertake a review of this winter in April with our external partners. It
is clear that there are improvements which could be made in the overall health system
which would benefit patients and improve access to care.
A key element of our plan for 2012/13 was to provide a Multi-Specialty Assessment Area.
The Board will be aware that this proved not to be feasible or affordable in terms of a
capital scheme. We will develop an alternative proposal for 2013/14 in the next month.
The cancer performance in January was below the access standards. This was due to a
lack of capacity over the Christmas period, and later referrals from surrounding hospitals.
The performance has recovered in February and March, although a definitive position is
not available yet. In the case of two week wait patients referred with breast symptoms,
capacity was more than sufficient through this period, waiting times were solely the result
of patients’ choice of appointment date.
Page 3 of 44
Integrated Quality & Performance Report
March 2013
Summary Dashboard: April 2012 to January / February 2013
SECTION A - NATIONAL KEY INDICATORS
Provisional Performance - as at January / February 2013
Quarter 4-to-Date
1. NHS PERFORMANCE FRAMEWORK (PF)
2. MONITOR GOVERNANCE RISK RATING (GRR)
Quality of Service (QoS)
Integrated
Care Quality
Performance Commission
Measures
(CQC)
(IPM)
Registration
GRR Score: 4.5 (Red)
Finance
User
Experience
4.5
4.5
SECTION B - LOCAL KEY INDICATORS
These domains summarise performance based on a specific suite of indicators defined by the Trust.
3
1. QUALITY
2. PRODUCTIVITY & EFFICIENCY (P&E)
No. of indicators rated as:
No. of indicators rated as:
1
4
3
2
6
3. WORKFORCE
4. INFORMATION GOVERNANCE (IG)
No. of indicators rated as:
No. of indicators rated as:
2
2
2
1
1
5. FINANCE
No. of indicators rated as:
2
1
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Integrated Quality & Performance Report
March 2013
Areas of Risk Dashboard: April 2012 to January / February 2013
This dashboard shows the main indicators, within each domain, which are considered to be the key risk areas for the Trust.
SECTION A - NATIONAL KEY INDICATORS
Provisional Performance - as at January / February 2013
Quarter 4-to-Date
1. PERFORMANCE FRAMEWORK (PF)
2. MONITOR GOVERNANCE RISK RATING (GRR)
The main risk areas in this domain are:
A&E Waiting Times (4 hours) - LTHT (including Wharfedale)
MRSA
Patients treated within 18 weeks - admitted
Reporting specialties not achieving the referral to treatment (RTT) standards
Patients waiting more than 6 weeks for a diagnostic test (at month end)
Cancer 2 week waits - suspected cancer
Cancer 2 week waits - breast symptoms (cancer not initially suspected)
Cancer 62 Day Waits - GP/Dentist referrals
Cancer 62 Day Waits - cancer screening service referrals
EBITDA Margin (%)
Better Payment Practice Code Value %
Current Ratio
Payable Days
The main risk areas in this domain are:
A&E Waiting Times (4 hours) - LTHT (including Wharfedale)
MRSA
Patients treated within 18 weeks - admitted
Cancer 2 week waits - suspected cancer
Cancer 2 week waits - breast symptoms (cancer not initially suspected)
Cancer 62 Day Waits - GP/Dentist referrals
Cancer 62 Day Waits - cancer screening service referrals
SECTION B - LOCAL KEY INDICATORS
1. QUALITY
2. PRODUCTIVITY & EFFICIENCY (P&E)
The main risk areas in this domain are:
Pressure Ulcers - Grade III and Unstageable
Pressure Ulcers - Grade IV
Research & Innovation (R&I): Initiation (Year-to-Q3)
R&I: Delivery (Year-to-Q3)
Dementia
R&I: Participation (Year-to-Q3)
The main risk areas in this domain are:
Elective inpatient length of episode
Non-elective inpatient length of episode
Same day elective inpatient admissions
Theatre utilisation : In session
Theatre utilisation: Turnaround time
Outpatient appointment Did Not Attend (DNA) rate
3. WORKFORCE
4. INFORMATION GOVERNANCE (IG)
The main risk areas in this domain are:
Sickness Absence Rate (12 months rolling average)
Annual Staff Survey
The main risk areas in this domain are:
Admissions, Discharges & Transfers (ADT) - Activity Recorded within 30 days
5. FINANCE
The main risk areas in this domain are:
Income and Expenditure Against Plan
Cash Balance
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Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
Further Actions Required: April 2012 to January / February 2013
Indicator
A&E Waiting Times
MRSA
CDI
Patients Treated Within 18
Weeks - Admitted
Reporting Specialties Not
Achieving the RTT Standards
Patients waiting more than 6
weeks for a diagnostic test
Actions for Improvement
Continue recruitment to medical and advanced nurse practitioner posts (as per the agreed A&E
workforce strategy). In the meantime, continue to pursue all available options for the short term
covering of posts
Further improve A&E systems and processes; there is currently a 10 week service improvement
project underway.
A mini business case is currently being compiled which proposes the introduction of an extra nurseled line access list at St James’s (SJUH) with an associated centralised booking service.
Introduction of Polymerase Chain Reaction (PCR) testing (which reduces the time to get results) for
MRSA Screening swabs in high volume/risk areas is being reviewed in the Medicine Division.
A range of actions are currently in the process of being implemented and include:
• Stabilisation of cleaning input hours for the remainder of 2012/13 and a review of further enhanced
cleaning arrangements.
• Creation of permanent ward decant facilities for SJUH and Leeds General Infirmary (LGI) to be
considered as part of the Trust capital programme priorities.
• Testing of plans with the Medicine Division to use Hydrogen Peroxide Vaporisation (HPV) in side
rooms on patient discharge in the CDI cohort facility and also in designated areas (i.e. play rooms) in
the Women’s, Children’s, Head, Neck & Dental Division.
Owner
Action Completed
Chief Operating Officer
Ongoing into Quarter 1 2013/14
Chief Operating Officer
March 2013
Acting Divisional General Manager,
Diagnostic & Therapeutic Services
By April 2013
Acting Divisional General Manager,
Diagnostic & Therapeutic Services
By April 2013
Detailed action plans are being developed to minimise outpatient waiting times during Quarter 1 Chief Operating Officer
2013/14 in challenged specialties.
Quarter 1 2013/14
Continue to maximise delivery of elective activity to minimise the tip into over 18 week admitted Chief Operating Officer
pathways.
Ongoing
Detailed action plans are being developed to minimise outpatient waiting times during Quarter 1 Chief Operating Officer
2013/14 in challenged specialties.
Continue to maximise delivery of elective activity to minimise the tip into over 18 week admitted Chief Operating Officer
pathways.
Quarter 1 2013/14
Plans are in place for the further expansion of endoscopy capacity during 2013/14
By April 2013
Chief Operating Officer
Ongoing
Cancer 2 week wait - suspected Daily reports have been amended to show 2 week wait patients as they are booked outside the Divisional General Manager, Oncology & January 2013
Surgery
cancer
target timeframe so that they can be addressed / reviewed
Divisional General Manager, Oncology & February 2013
Surgery
Cancer 2 week wait - breast
symptoms
The Leeds Cancer Locality group has been asked to make all referring GPs aware of the need for
patients to attend within 2 weeks of referral.
Cancer 62 Day Waits GP/Dentist referrals
Plans are in place for additional capacity in renal, breast and lung surgery to support the 62 day wait Divisional General Manager, Oncology & February 2013
standard for GP/Dentist referrals
Surgery
Cancer 62 Day Waits - Cancer
Screening Service referrals
Year to Date Income and
Expenditure
Pathways have been reviewed and actions are underway to ensure improved prospective tracking of Divisional General Manager, Oncology & February 2013
Surgery
patients referred by the cancer screening service.
The Senior Management Team is monitoring the action plans necessary to ensure the continued Director of Finance
Ongoing
achievement of national key indicators.
Finance Processes & Balance
Sheet Efficiency
External Financing Limit (EFL) adjusted by £7 million to facilitate reduced balance at outturn.
Director of Finance
Capex reduced by £2 m and other working capital measures introduced.
The Trust will meet the EFL target for 2012/13 but will not achieve a cash balance of 10 days
operating expenditure (£25 m).
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March 2013
Integrated Quality & Performance Report
March 2013
SECTION B - LOCAL KEY INDICATORS
Further Actions Required: April 2012 to January / February 2013
Indicator
Pressure ulcers
Dementia Quality Goal
R&I: Participation, Initiation &
Delivery
P&E
Sickness absence
Staff Survey
ADT recording on PAS
Year to Date Income and
Expenditure against Plan
Cash balance
Actions for Improvement
All pressure ulcer root cause analysis (RCA) investigations are being reviewed as part of the
organisational restructure handover process.
Competency assessment of registered nursing staff continuing. To date, 1,563 staff have achieved
the assessment and recorded it on the Electronic Staff Record (ESR).
Owner
Action Completed
Acting Chief Nurse
End March 2013
Acting Chief Nurse
End March 2013
A review of the action plan and approach to delivering improvements in pressure ulcers is being
prepared for the Clinical Governance Committee and Trust Board.
Acting Chief Nurse
April 2013
Weekly performance reports now routinely produced for all wards/directorates providing status
updates against the CQUIN’s three sections.
Investigate the use of electronic data collection.
Increase engagement of clinical staff particularly in Medicine and Oncology & Surgery teams as the
two main Divisions by volume.
Introduce Nurse Specialist Assessment as a trigger for CQUIN completion. Nurse Specialist
Assessment to count as Stage 1 completion once completed.
New format key performance indicator (KPI) based Directorate performance report developed and
piloted. (Full roll out Quarter 4 - Quarter 3 data).
Introduction of quarterly performance management meetings to bring together performance
management of KPIs and core research staff funding. Initial meetings have taken place.
Clinical trial tracker to be launched on Trust Sharepoint to ensure recruitment to trials on time and to
target.
Complete the appointment text and voice messaging pilot and assess the impact within outpatients.
Patient flow programme undertaking work to enhance Board Rounds and act on identified delays to
reduce length of stay.
Roll out of theatre productivity boards continues
Director of Informatics
January 2013
Director of Informatics
Medical Director
By March 2013
By March 2013
Acting Chief Nurse
By April 2013
Medical Director
December 2012
Medical Director
End March 2013
Medical Director
End March 2013
Director of Informatics
Divisional General Manager, Specialist
Surgery
Divisional General Managers
July 2013
Ongoing
Director of Human Resources
Director of Human Resources
March 2013
March 2013
Director of Informatics
Director of Informatics
Ongoing
February 2013
Director of Informatics
By March 2013
Director of Finance
Ongoing
Director of Finance
March 2013
The rollout of Firstcare amongst nursing staff continues.
Report to Trust Board in March detailing individual time frames for interventions and work
programmes.
An intensive training programme is underway, with further staff being re-educated and trained.
A revised approach to ADT training providing more ward based training and follow up of staff
performance has been developed.
Set up a ward based administration model to ensure that all wards are covered 24/7 so that
performance can be maintained.
The Senior Management Team is monitoring the remedial action plans that have proved necessary
to achieve the financial targets, in particular their potential impact on quality and performance
targets.
EFL adjusted by £7 million to facilitate reduced balance at outturn. Capital expenditure (Capex)
reduced by £2 m and other working capital measures introduced. The Trust will meet the EFL target
for 2012/13 but will not achieve a cash balance of 10 days operating expenditure (£25 m).
Page 7 of 44
March 2013
Integrated Quality & Performance Report
March 2013
Page 8 of 44
Integrated Quality & Performance Report
March 2013
SECTION A-1:
NATIONAL KEY INDICATORS
- PERFORMANCE FRAMEWORK
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Integrated Quality & Performance Report
March 2013
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Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
1. NHS PERFORMANCE FRAMEWORK
QUALITY OF SERVICE: INTEGRATED PERFORMANCE MEASURES (IPM) - MARCH 2013 TRUST BOARD
Period
Monitored
Performance Indicator
A&E Waiting Times (4 hours) - LTHT (including Wharfedale)
1
MRSA
2
Month
Performing
September-12
(Nov IQPR)
Published
Weighted
Performance
Score
A&E: 1 Oct to 28 Oct-12
MRSA & CDI: Apr to Sep-12
Delayed Transfers:
Q2 2012/13
MSA: Oct-12
Other: Sep-12
October-12
(Dec IQPR)
Provisional
Weighted
Performance
Score
A&E: 29 Oct to 2 Dec 12
MRSA & CDI: Apr to Oct-12
Delayed Transfers:
Q2 2012/13
MSA: Nov-12
Other: Oct-12
November-12
(Jan IQPR)
Provisional
Weighted
Performance
Score
A&E: 3 Dec to 30 Dec
MRSA & CDI: Apr to Nov-12
Delayed Transfers:
Q2 2012/13
MSA: Dec-12
Other: Nov-12
December-12
(Feb IQPR)
Provisional
Weighted
Performance
Score
A&E: 31 Dec to 3 Feb
MRSA & CDI: Apr to Dec-12
Delayed Transfers:
Q3 2012/13
MSA: Jan-13
Other: Dec-12
January-13
(Mar IQPR)
Provisional
Weighted
Performance
Score
A&E: 4 Feb to 3 Mar
MRSA & CDI: Apr to Jan-13
Delayed Transfers:
Q3 2012/13
MSA: Feb-13
Other: Jan-13
Underperforming
Weighting
2012/13 Thresholds
1
93.7%
0.00
94.7%
2.00
88.1%
0.00
91.2%
0.00
91.0%
0.00
1
11
0.00
11
0.00
11
2.00
11
2.00
12
2.00
95%
94%
Year To
Jan13 < 10
Year To
Jan13 < 131
Year To
Jan13 > 13
Year To
Jan13 > 142
Monthly
Trend
01/01/00
2
CDI
YTD
YTD
1
79
2.00
93
2.00
108
2.00
120
2.00
131
3.00
Patients treated within 18 weeks - admitted (%)
Month
90%
85%
1
90.4%
3.00
84.8%
0.00
85.2%
2.00
86.8%
2.00
88.5%
2.00
Patients treated within 18 weeks - non-admitted (%)
Month
95%
90%
1
96.7%
3.00
96.6%
3.00
96.8%
3.00
96.5%
3.00
96.1%
3.00
Patients awaiting treatment on the 18 weeks pathway - incomplete (%)
Month
92%
87%
Number of reporting specialties not achieving the RTT standards
Month
0
Patients waiting more than 6 weeks for a diagnostic test (at month end)
Month
Cancer 2 week wait - suspected cancer
Cancer 2 week wait - breast symptoms (cancer not initially suspected)
1
94.4%
3.00
94.9%
3.00
95.0%
3.00
94.7%
3.00
94.7%
3.00
> 20
1
16
2.00
18
2.00
19
2.00
17
2.00
17
2.00
< 1%
5%
1
0.7%
3.00
0.8%
3.00
0.4%
3.00
0.41%
3.00
1.71%
2.00
Month
93%
88%
0.5
94.1%
1.50
95.3%
1.50
94.8%
1.50
95.2%
1.50
89.1%
1.00
Month
93%
88%
0.5
93.2%
1.50
94.8%
1.50
93.2%
1.50
93.3%
1.50
88.6%
1.00
Cancer 31 Day Waits - first definitive treatment
Month
96%
91%
0.25
97.5%
0.75
96.5%
0.75
98.8%
0.75
98.0%
0.75
96.2%
0.75
Cancer 31 Day Waits - subsequent surgery treatment
Month
94%
89%
0.25
95.2%
0.75
94.9%
0.75
95.6%
0.75
94.7%
0.75
94.6%
0.75
Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment
Month
98%
93%
0.25
100.0%
0.75
100.0%
0.75
100.0%
0.75
99.5%
0.75
100.0%
0.75
Cancer 31 Day Waits - subsequent radiotherapy treatment course
Month
94%
89%
0.25
95.9%
0.75
99.0%
0.75
99.2%
0.75
100.0%
0.75
98.8%
0.75
Cancer 62 Day Waits - GP/Dentist referrals
Month
85%
80%
0.50
85.6%
1.50
85.8%
1.50
86.8%
1.50
85.3%
1.50
80.7%
1.00
Cancer 62 Day Waits - cancer screening service referrals
Month
90%
85%
0.50
98.1%
1.50
95.5%
1.50
95.0%
1.50
87.5%
1.00
89.3%
1.00
Delayed transfers of care - % bed days lost (acute & non-acute)
Latest
Full Qtr
3.5%
5.0%
1
2.8%
3.00
2.8%
3.00
2.8%
3.00
3.2%
3.00
3.2%
3.00
Mixed Sex Accommodation (MSA) Breaches
Month
0.0%
0.5%
1
0.0%
3.00
0.0%
3.00
0.0%
3.00
0.0%
3.00
0.0%
3.00
VTE Risk Assessment
Month
90%
80%
1
91.9%
3.00
92.7%
3.00
93.0%
3.00
92.0%
3.00
92.5%
3.00
02/01/00
01/01/00
02/01/00
Performance Rating
Underperforming:
Performance under review:
Performing:
Indicator Scoring *
0
2
3
Total Weighted Score
Threshold
< 29.40
29.40 - 33.60
> 33.60
Overall Score
Threshold
< 2.1
2.1 - 2.4
> 2.4
35.00
34.50
33.00
2.36
2.50
2.46
2.36
●
●
●
●
●
06/01/00
03/01/00
04/01/00
05/01/00
06/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
02/01/00
02/01/00
02/01/00
03/01/00
03/01/00
03/01/00
03/01/00
04/01/00
04/01/00
04/01/00
04/01/00
05/01/00
06/01/00
05/01/00
05/01/00
05/01/00
06/01/00
06/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
02/01/00
03/01/00
04/01/00
05/01/00
06/01/00
01/01/00
33.00
05/01/00
06/01/00
06/01/00
02/01/00
01/01/00
2.43
04/01/00
05/01/00
05/01/00
02/01/00
01/01/00
34.00
03/01/00
04/01/00
04/01/00
01/01/00
01/01/00
14.00
03/01/00
03/01/00
01/01/00
01/01/00
Total Weighting:
02/01/00
01/01/00
01/01/00
01/01/00
02/01/00
02/01/00
02/01/00
02/01/00
03/01/00
03/01/00
04/01/00
04/01/00
03/01/00
04/01/00
03/01/00
04/01/00
05/01/00
05/01/00
05/01/00
05/01/00
06/01/00
06/01/00
06/01/00
06/01/00
* Multiplied by weighting to derive weighted score for each indicator.
1
2
A&E performance is derived from the weekly SITREP figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters.
Note that this is not the same methodology as in the Monitor Governance Risk Rating, in which a small numbers rule applies, and the trajectory is a simple proportion of the annual target.
Page 11 of 44
Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
1. NHS PERFORMANCE FRAMEWORK
FINANCE - MARCH 2013 TRUST BOARD
Performing
Performance Indicator
Planned Outturn as a proportion
Initial
Planning of Turnover
YTD Operating Performance
Year to
Date
YTD EBITDA
Forecast Operating Performance
Forecast
Forecast EBITDA
Outturn
Rate of Change in Forecast
Surplus or Deficit
Underlying Underlying Position %
Financial
Position EBITDA Margin (%)
Better Payment Practice Code
Value %
Better Payment Practice Code
Finance Volume %
Processes
& Balance Current Ratio
Sheet
Efficiency
Receivable Days
Payable Days
Performance under review
Weighting
2012/13 Rating Criteria
Underperforming
Planned operating breakeven or surplus that is either equal Any operating deficit less than 2% of income OR an operating
to or at variance to SHA expectations by no more than 3% of surplus/breakeven that is at variance to SHA expectations by Operating deficit more than or equal to 2% of planned income
income.
more than 3% of planned income.
Any operating deficit less than 2% of income OR an operating
YTD operating breakeven or surplus that is either equal to or
surplus/breakeven that is at variance to plan by more than Operating deficit more than or equal to 2% of forecast income
at variance to plan by no more than 3% of forecast income.
3% of forecast income.
Year to date EBITDA equal to or greater than 5% of actual
year to date income
Year to date EBITDA equal to or greater than 1% but less
than 5% of year to date income
Forecast operating breakeven or surplus that is either equal Any operating deficit less than 2% of income OR an operating
surplus/breakeven that is at variance to plan by more than
to or at variance to plan by no more than 3% of forecast
income.
3% of income.
Month of Publication
Current month
Performance
Weighted
Score
February 2013
5
3
15
20
3
60
Year to date EBITDA less than 1% of actual year to date
income.
5
3
15
Operating deficit more than or equal to 2% of income
20
3
60
Forecast EBITDA equal to or greater than 5% of forecast
income.
Forecast EBITDA equal to or greater than 1% but less than
5% of forecast income.
Forecast EBITDA less than 1% of forecast income.
5
3
15
Still forecasting an operating surplus with a movement equal
to or less than 3% of forecast income
Forecasting an operating deficit with a movement less than
2% of forecast income OR an operating surplus movement
more than 3% of income.
Forecasting an operating deficit with a movement of greater
than 2% of forecast income.
15
3
45
Underlying breakeven or Surplus
An underlying deficit that is less than 2% of underlying
income.
An underlying deficit that is greater than 2% of underlying
income
5
3
15
Underlying EBITDA equal to or greater than 5% of underlying Underlying EBITDA less than 5% but equal to or greater than
income
1% of underlying income
Underlying EBITDA less than 1% of underlying income
5
2
10
95% or more of the value of NHS and Non NHS bills are paid Less than 95% but more than or equal to 60% of the value of
within 30days
NHS and Non NHS bills are paid within 30days
Less than 60% of the value of NHS and Non NHS bills are
paid within 30 days
2.5
2
5
2.5
2
5
95% or more of the volume of NHS and Non NHS bills are
paid within 30days
Less than 95% but more than or equal to 60% of the volume Less than 60% of the volume of NHS and Non NHS bills are
of NHS and Non NHS bills are paid within 30days
paid within 30 days
Current Ratio is equal to or greater than 1.
Current ratio is anything less than 1 and greater than or equal
to 0.5
A current ratio of less than 0.5
5
2
10
Receivable days less than or equal to 30 days
Debtor days greater than 30 and less than or equal to 60
days
Debtor days greater than 60
5
3
15
Creditor days less than or equal to 30
Creditor days greater than 30 and less than or equal to 60
days
Creditor days greater than 60
5
2
10
100
Total Weighted
Score:
280
Overall Score:
2.80
Rating:
●
Total Weighting:
18-Jan-13
Performance Rating
Indicator Scoring *
Total Weighted Score Rating (Rounded)
Underperforming:
Performance under review:
Performing:
1
2
3
< 1.5
>=1.5 and <2.5
>= 2.5
* Multiplied by weighting to get weighted score for each indicator.
Page 12 of 44
Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
1 - NHS PERFORMANCE FRAMEWORK (PF)
The format of the NHS PF is similar to previous years in that Trusts will continue to be
awarded 2 separate equally weighted ratings for the overarching domains of Quality of
Service (QoS) and Finance.
The ratings applied for each of these domains at both overall domain level and also at
individual indicator level continue to be:
•
Performing (Green)
Performance Under Review (Amber)
•
•
Underperforming (Red)
QUALITY OF SERVICE (QoS)
QoS Summary
The QoS domain within the PF incorporates 3 separate elements, which combine to create an
overall rating for the domain:
1.1 Integrated Performance
Measures (IPM)
1.2 CQC Registration
1.3 User Experience
- With an overall score of 2.36, the Trust is categorised
as Performance Under Review (Amber) for the latest
period.
- As the Trust is compliant with all essential standards of
quality and safety, the current status is Performing
(Green).
- Overall performance shows that the Trust is
Performing (Green) against this element. As this is
assessed annually, the Trust is therefore rated as
Performing for the whole of 2012/13.
If the User Experience element is rated as Performing, the overall domain rating is based on
the lowest result for the other 2 elements. Therefore, due to the Integrated Performance
Measures, the overall QoS domain is Performance Under Review.
1.1 QoS INTEGRATED PERFORMANCE MEASURES
In terms of the 19 individual indicators, the Trust was rated as: Performing (Green) on 10,
Performance Under Review (Amber) on 8 and Underperforming (Red) on 1. Those standards
which are not currently classed as Performing are discussed in more detail in the following
section.
Page 13 of 44
Integrated Quality & Performance Report
March 2013
Actions for Improvement
Please note the data periods reported in the PF and the associated banner rating in the
following section reflect how the Department of Health (DH) assess the Trust. Where
more recent data is available, this has been incorporated in the narrative.
A&E Waiting Times (4 Hours)
Monthly
AIM: Ensure at least 95% of A&E attendances are admitted, transferred or discharged
within 4 hours of arrival.
Performance Against the A&E 4 Hour Access Standard
(Including Wharfedale)
Fail
Underachieve
Achieve
Provisional (As at 17/03/13)
A&E 4 Hour Performance - April 2012 to February 2013
% Seen in < 4 hrs
% patients meeting target
100%
90%
85%
80%
Feb data
Achieve Target
95%
90%
85%
80%
75%
University Hospitals of
Leicester
University Hospital of
South Manchester
Sandwell And West
Birmingham
Sheffield Teaching
Leeds Teaching
Oxford University
Nottingham University
Cambridge University
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
70%
Central Manchester
University
75%
Royal Liverpool &
Broadgreen
70%
Newcastle Upon Tyne
% patients m eeting target
95%
LTHT
Peers YTD
100%
• February performance is incorporated in the current PF. The period formally monitored by
the DH is from Monday 4 February to Sunday 3 March; 91% of patients met the 4 hour
target for the period.
• 1,552 patients attending A&E did not meet the target of being admitted, transferred or
discharged within 4 hours in the period.
• The two key issues impacting on performance are difficulties in recruiting to medical and
advanced nurse practitioner posts and a lack of available inpatient beds; the lack of beds
has particularly impacted on St James’s University Hospital (SJUH).
• February performance shows 88.3% of patients admitted, transferred or discharged within
4 hours of arrival at SJUH and 91.4% of patients at Leeds General Infirmary (LGI).
• Meeting and maintaining the A&E standard is also proving challenging for the Trust’s peers
with only The Newcastle Upon Tyne Hospitals NHS Foundation Trust and Cambridge
University Hospitals NHS Foundation Trust meeting the standard in February. Data for
acute trusts in the North of England (quarter 4 up to 3 March 2013) shows 28 of the 46
trusts failing this standard.
• For March, performance will be monitored from Monday 4 March to Sunday 31 March.
Provisional performance as at 17 March 2013 shows that 87.9% of patients have so far met
the target.
A&E Waiting Times: Actions for Improvement
Action
• Continue recruitment to medical and advanced nurse
practitioner posts (as per the agreed A&E workforce
strategy). In the meantime, continue to pursue all
available options for the short term covering of posts.
• Further improve A&E systems and processes; there
is currently a 10 week service improvement project
underway.
Page 14 of 44
Owner
Completed
Chief Operating Ongoing into
Quarter 1
Officer
2013/14
Chief Operating March 2013
Officer
Integrated Quality & Performance Report
March 2013
Meticillin Resistant Staphylococcus Aureus (MRSA)
YTD
AIM: Reduce the number of Trust-apportioned MRSA bacteraemia cases in 2012/13 to no
more than 13.
2012/13 Trust Level Cumulative MRSA Cases Versus Trajectory
Progress Against the MRSA Target
MRSA Cases
Achieve Trajectory
MRSA Cases
Achieve Trajectory
Provisional (As at 18/03/13)
4
Provisional (As at 18/03/13)
Fail Trajectory
20
18
16
14
No. MRSA Cases
No. MRSA cases
3
2
1
12
10
8
6
4
2
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
0
May-11
0
• The current PF monitors performance from April 2012 to January 2013; 12 cases have
been reported for the period. This equates to an average of 1 MRSA case per 15,000
admissions.
• During February, one further case of MRSA was reported. As at 18 March 2013, the Trust
has reported 13 MRSA cases for 2012/13, reaching the ceiling of no more than 13 for the
year.
• The Trust is currently rated as Performance Under Review for 2012/13; however if no
further MRSA cases are reported through the remainder of March, the Trust could still be
rated as Performing for the full year.
• Looking ahead to 2013/14, a zero-tolerance approach is being introduced nationally by the
NHS Commissioning Board.
MRSA: Actions for Improvement
Action
• A mini business case is currently being
compiled which proposes the introduction of an
extra nurse-led line access list at SJUH with an
associated centralised booking service.
• Introduction of Polymerase Chain Reaction
(PCR) testing (which reduces the time to get
results) for MRSA screening swabs in high
volume/risk areas is being reviewed in the
Medicine Division.
Page 15 of 44
Owner
Acting Divisional
General Manager,
Diagnostic &
Therapeutic Services
Completed
By April 2013
Integrated Quality & Performance Report
March 2013
Clostridium Difficile Infections (CDIs)
YTD
AIM: Reduce the number of Trust-attributed CDIs in 2012/13 to no more than 159.
Progress Against the CDI Target
CDI Cases
Achieve Trajectory
2012/13 Trust Level Cumulative CDI Cases Versus Trajectory
CDI Cases
Achieve Trajectory
Provisional (As at 18/03/13)
35
30
160
140
25
120
No. CDI Cases
No. CDI cases
Provisional (As at 18/03/13)
Fail Trajectory
180
20
15
10
100
80
60
40
5
20
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
May-11
Apr-12
0
0
• Performance is monitored in the current PF from April 2012 to January 2013; 131 CDIs
were reported for the period.
• In February, 13 CDI were reported; the year-to-February position of 144 cases means that
the Trust remains within the limits of the year to date trajectory (145) and on course to be
rated as Performing for 2012/13.
• To achieve this standard for the full year 2012/13, there needs to be no more than 15
cases in March, 5 cases have so far been reported (as at 18 March).
• The 2013/14 target for the Trust is to reduce the number of CDI’s to no more than 101; this
is a 36% reduction from the 2012/13 target.
CDI: Actions for Improvement
Action
A range of actions are currently in the process of being
implemented and include:
• Stabilisation of cleaning input hours for the remainder
of 2012/13 and a review of further enhanced cleaning
arrangements.
• Creation of permanent ward decant facilities for SJUH
and LGI to be considered as part of the Trust capital
programme priorities.
• Testing of plans with the Medicine Division to use
hydrogen peroxide vapourisation (HPV) in side rooms
on patient discharge in the CDI cohort facility and also
in designated areas (i.e. play rooms) in the Women’s,
Children’s, Head, Neck & Dental Division.
Page 16 of 44
Owner
Acting
Divisional
General
Manager,
Diagnostic &
Therapeutic
Services
Completed
By April 2013
Integrated Quality & Performance Report
March 2013
18 Week Referral to Treatment (RTT) Waiting Times
The Trust is monitored on 5 separate measures related to 18 week and diagnostic waiting
times in the PF:
• Admitted patients treated within 18 weeks
• Non-admitted patients treated within 18 weeks
• Patients awaiting treatment on the 18 weeks pathway (incomplete)
• Number of reporting specialties not achieving the RTT standards
• Patients waiting more than 6 weeks for a diagnostic test.
RTT performance for January 2013 is monitored in the current PF.
Further information on the 18 week Referral to Treatment waiting times standards is included
in the separate Trust Board Referral to Treatment Time report.
Patients Treated Within 18 Weeks - Admitted
Monthly
AIM: Ensure at least 90% of admitted patients are treated within 18 weeks of referral.
% of Admitted Patients Seen within 18 weeks
Fail
Underachieve
% of Admitted Patients Seen Within 18 Weeks - December 2012
Achieve
% Admitted
LTHT
100%
Peers
Other Trusts
Achieve
Fail
95%
90%
80%
% of patients meeting target
% of patients m eeting target
100%
90%
85%
80%
75%
70%
60%
50%
40%
30%
20%
Jan-13
10%
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
May-11
70%
0%
Trusts
Source: DH
• In January, 513 (88.5%) admitted patients were not treated within 18 weeks. This was due
in part, to the number of patients who deferred their surgery over the Christmas period and
were then treated in January. Other contributing factors included the pressure on bed
capacity, particularly on the SJUH site, which resulted in a number of elective patient
cancellations to enable acute patients to be admitted to wards safely from the Emergency
Department. This impacted on the overall number of elective patients being treated.
Latest available data nationally shows 9% of trusts either underachieved or failed this
standard in December.
• However, in February, the Trust achieved this standard for the first time since September
2012 with 90% of admitted patients being treated within 18 weeks.
Number of Patients Waiting Over 52 Weeks - Incomplete
Number of Patients Waiting Over 18 Weeks - Incomplete
(As at month end)
(As at month end)
180
3,000
160
2,500
No. of patients
1,500
1,000
120
100
80
60
40
500
20
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
Feb-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Jan-13
Page 17 of 44
May-11
0
0
Apr-12
No. of patients
140
2,000
Integrated Quality & Performance Report
March 2013
• Having decreased by 171 patients from the end of September 2012 to the end of January
2013, the total number of incomplete pathways for patients waiting over 18 weeks
increased in February 2013 by over 200 patients bringing the total to 2,626 patients. There
were increases in a number of specialties. These include elective specialties on the St
James’s site which have been affected by bed pressures, the mainly outpatient specialty of
paediatric immunology and allergy where the Clinical Commissioning Group has been
asked to initiate a capacity review and neurosurgery where there has been reduced
operating related to ward staffing.
• Ensuring that no patient waits over 52
weeks is a priority. At the end of February,
3 patients had been waiting over 52 weeks.
All 3 patients were particularly complex
cases who were either unavailable or unfit
for surgery.
• As at end of December 2012, Leeds
Teaching Hospitals was one of 66 (out of a
total of 207) trusts with patients waiting
over 52 weeks.
Number of Reporting Specialties Not Achieving the RTT Standards
Monthly
AIM: Ensure all specialties achieve the RTT standards (admitted, non-admitted &
incomplete).
Number of Reporting Specialties Not Achieving the RTT Standards
• In order to achieve the target, all reporting
specialties must achieve the admitted, non20
admitted and incomplete standards.
18
16
• 17 specialties did not achieve the RTT
14
standards for January 2013 and 18 for
12
February 2013.
10
• The areas which are not achieving on all
8
6
measures in February at specialty level are
4
Cardiothoracic Surgery, Plastic Surgery,
2
Trauma & Orthopaedics and Urology.
0
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Pressures from acute patients within
Cardiothoracic Surgery have impacted on earlier progress. More detail is included in the
separate Referral to Treatment Time paper.
Non-Admitted
Incomplete
No. Specialties
Admitted
18 Week RTT Waiting Times: Actions for Improvement
Action
• Detailed action plans are being developed to minimise
outpatient waiting times during Quarter 1 2013/14 in
challenged specialties.
• Continue to maximise delivery of elective activity to
minimise the tip into over 18 week admitted pathways.
Page 18 of 44
Owner
Chief
Operating
Officer
Completed
Quarter 1
2013/14
Ongoing
Integrated Quality & Performance Report
March 2013
Diagnostic Waits
Monthly
AIM: Ensure no patients wait more than 6 weeks for a diagnostic test
Diagnostic Waits: Actions for Improvement
Action
Owner
Plans are in place for further expansion of endoscopy Chief
capacity during 2013/14.
Operating
Officer
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
May-11
Apr-11
% Patients Waiting Over 6 weeks
Diagnostic Waits - % Patients Waiting Over 6 weeks at Month-End
• The Trust underachieved against the
Achieve
Underachieve
Fail
% waiting > 6 weeks
diagnostic waiting time target of no more 12%
than 1% of patients waiting more than 6
10%
weeks for a diagnostic test in January
8%
2013; this is the first time the standard has
not been achieved since January 2012.
6%
• 169 patients were waiting longer than 6
4%
weeks at the end of January. This was
2%
principally due to the high numbers of
0%
patients who chose to defer their tests
(particularly endoscopies) over the holiday
period.
• Following a difficult January, the Trust achieved the standard of no more than 1% of
patients waiting more than 6 weeks for a diagnostic test at the end of February 2013. High
demand in endoscopy in particular remains an issue and may impact on March
performance. Plans are in place for further expansion of endoscopy capacity during
2013/14.
Completed
By April 2013
Waiting Times for Cancer Diagnosis and Treatment
Cancer 2 Week Waits – Suspected Cancer
Monthly
AIM: Ensure at least 93% of patients urgently referred with suspected cancer by their
GP (GMP or GDP) are seen within 14 days
Performance Against the 14 Day Cancer Standard for Suspected Cancer
Fail
Underachieve
Achieve
% Within 14 Days - Suspected Cancer
100%
95%
Page 19 of 44
90%
85%
80%
75%
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
70%
Apr-11
% patients meeting target
• January was the first month in 2012/13 in
which the Trust has not achieved the 93%
standard. 89.1% of patients were seen
within 14 days. Prior to this, the Trust had
been able to maintain the standard for over
two years.
• The main cause of this was the impact of
cancelled capacity over the Christmas
period in the colorectal service.
• Of the 147 patients not seen within 14
days, 75% were seen within 21 days.
Integrated Quality & Performance Report
March 2013
Cancer 2 Week Waits – Breast Symptoms
Monthly
AIM: Ensure at least 93% of patients urgently referred for evaluation/investigation of
“breast symptoms” by a primary or secondary care professional are seen within
14 days.
Performance Against the 14 Day Cancer Standard for Breast Symptoms
Fail
Underachieve
Achieve
% Within 14 Days - Breast Symptoms
100%
95%
% patients meeting target
90%
85%
80%
75%
Cancer 62 Day Waits – GP/Dentist Referrals
Jan-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
70%
May-11
consistently
maintained
the
• Having
standard to see patients urgently referred
for evaluation / investigation of breast
symptoms within 14 days for over a year,
performance dipped to 88.6% during
January 2013.
• Analysis of patients breaching 14 days has
shown that all were due to patient choice.
• All 29 patients not seen within the standard
were seen within 28 days.
Monthly
AIM: Ensure at least 85% of patients receive their first definitive treatment for cancer
within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer
Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals
Fail
Underachieve
Achieve
% Within 62 Days - GP/Dentist
100%
95%
% patients meeting target
90%
85%
80%
75%
70%
65%
60%
55%
Cancer 62 Day Waits - Cancer Screening Service Referrals
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
Apr-11
50%
May-11
• Having struggled to maintain performance
against the 62 day referral to treatment
standard in previous years, the Trust had
shown consistent good performance for the
first 3 quarters of 2012/13.
• During January, however, the Trust
underachieved against this standard;
80.7% of accountable patients were
treated within 62 days. This was due to a
lack of capacity in renal, breast and lung
surgery.
Monthly
AIM: Ensure at least 90% of patients referred by the cancer screening service receive
their first definitive treatment within 62 days of referral.
• In January, 89.3% of patients referred by Performance Against the 62 Day Cancer Standard for Referrals from Screening Service
the cancer screening service were treated 100%
within the 62 day target.
95%
90%
• Due to the small number of patients
85%
referred in this way (there were only 38
80%
75%
people treated via this pathway in
70%
January), any breach of standard has a
65%
significant impact upon the overall
60%
55%
performance.
50%
• Where patients are seen/treated at two
trusts, each patient is counted as half a
breach against each trust. 6 shared
patients (3 accountable breaches) did not receive their first definitive treatment within 62
days of referral in January.
Underachieve
Achieve
% Within 62 Days - Screening Service
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
Apr-11
Page 20 of 44
May-11
% patients meeting target
Fail
Integrated Quality & Performance Report
March 2013
• Performance in December and January was impacted by both colorectal patients who were
referred late from both Calderdale and Huddersfield Foundation Trust and Bradford
Teaching Hospitals NHS Foundation Trust and those who were late receiving treatment at
Mid Yorkshire Hospitals NHS Trust following breast screening at Leeds Teaching
Hospitals.
Cancer waiting times: Actions for Improvement
Action
• Daily reports have been amended to show 2 week
wait patients as they are booked outside the target
timeframe so that they can be addressed /
reviewed
• The Leeds Cancer Locality group has been asked
to make all referring GPs aware of the need for
patients to attend within 2 weeks of referral.
• Pathways have been reviewed and actions are
underway to ensure improved prospective tracking
of patients referred by the cancer screening
service.
• Plans are in place for additional capacity in renal,
breast and lung surgery to support the 62 day wait
standard for GP/Dentist referrals.
Owner
Divisional General
Manager, Oncology
& Surgery
Completed
January 2013
February
2013
February
2013
February
2013
1.2 QoS CQC REGISTRATION
The Trust is currently rated as Performing (Green) for the CQC Registration element of the
QoS domain, as all essential standards of quality and safety have been met.
1.3 QoS USER EXPERIENCE
The User Experience element of the QoS domain is rated annually. A section will be
included in this report twice a year. Performance for 2012/13 shows that the Trust is
Performing (Green) against this element.
1.4 FINANCE
Finance Summary
At the end of February the Trust is performing overall against the national key indicators for
income and expenditure and expects to continue to do so until year end. Performance
against the Better Payment Practice Code (BPPC) is less than the 95% target due to cash
pressures following the suspension of research and development payments by the
Department of Health.
Page 21 of 44
Integrated Quality & Performance Report
March 2013
Year to Date Income and Expenditure (National Measures)
AIM:
YTD
To maintain income and expenditure within the agreed annual plan.
• The year to date income and expenditure surplus was held at £3.8m in February, but is
expected to deteriorate in March due to payment penalties linked to under performance
against certain targets. The forecast position is in the range between break even and a
surplus of £1.5m. The variance to plan improved from £9.7m in January to £8.5m in
February.
Year to Date Income and Expenditure against Plan: Actions for Improvement
Action
Owner
Completed
• The Senior Management Team is monitoring the action plans Director of Ongoing
necessary to ensure the continued achievement of national Finance
key indicators.
Finance Processes & Balance Sheet Efficiency
AIM:
YTD
To meet all ongoing payment obligations while meeting the statutory External
Financing Limit for the year.
• Cash, at the end of month 11, is £1.2 m below our revised plan. Forecast for the year end
has been further reduced to £17.9 m in light of the revised revenue position. BPPC for the
month is 79%, a small improvement in the reported YTD cumulative position represented
by a significant improvement in the monthly position.
Finance Processes & Balance Sheet Efficiency: Actions for Improvement
Action
Owner
Completed
• External Financing Limit (EFL) adjusted by £7 million to Director of March 2013
Finance
facilitate reduced balance at outturn.
• Capex reduced by £2 m and other working capital measures
introduced.
• The Trust will meet the EFL target for 2012/13 but will not
achieve a cash balance of 10 days operating expenditure
(£25 m).
Page 22 of 44
Integrated Quality & Performance Report
March 2013
SECTION A-2:
NATIONAL KEY INDICATORS
- Monitor Governance Risk Rating
Page 23 of 44
Integrated Quality & Performance Report
March 2013
Page 24 of 44
Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
2. MONITOR GOVERNANCE RISK RATING (GRR)
SHADOW MONITOR GOVERNANCE RISK RATING 2012/13 - SERVICE PERFORMANCE (HEALTHCARE TARGETS & STANDARDS) - MARCH 2013 TRUST BOARD
Qrt 1
Weighted
score
Qrt 2
Weighted
score
Qrt 4
Qrt 3
Weighted
score
Qrt 4
(To Date)
Weighted
score
Projected
Weighted
score
Qrt 4
2012/13
Thresholds
Performance Indicator
Weighting
A&E: 2 Apr to 1 Jul-12
MRSA & CDI: Apr to Jun-12
RTT admitted & non-admitted:
Apr to Jun-12
RTT Incomplete:
As at 30 Jun-12
Cancer: Apr to Jun-12
A&E: 2 Jul to 30 Sep-12
MRSA & CDI: Apr to Sep-12
RTT admitted & non-admitted:
Jul to Sep-12
RTT Incomplete:
As at 30 Sep-12
Cancer: Jul to Sep-12
A&E: 1 Oct to 30 Dec-12
MRSA & CDI: Apr to Dec-12
RTT admitted & non-admitted:
Oct to Dec-12
RTT Incomplete:
As at 31 Dec-12
Cancer: Oct to Dec-12
A&E: 31 Dec-12 to 17 Mar-13
MRSA & CDI: Apr-12 to Feb-13
RTT admitted & non-admitted:
Jan-13 to Feb-13
RTT Incomplete:
As at 28 Feb-13
Cancer: Jan-13
*1
1.0
94.8%
1.0
96.1%
0.0
92.4%
1.0
90.5%
1.0
1.0
1.0
9
1.0
11
1.0
11
1.0
13
1.0
0.0
1.0
42
1.0
79
0.0
120
1.0
144
0.0
0.0
90%
1.0
89.2%
1.0
90.5%
0.0
85.5%
1.0
89.2%
1.0
1.0
95%
1.0
97.8%
0.0
96.8%
0.0
96.7%
0.0
96.5%
0.0
0.0
92%
1.0
96.0%
0.0
94.4%
0.0
94.7%
0.0
94.4%
0.0
0.0
0.5
0.5
0.0
0.0
0.0
0.0
1.0
1.0
0.0
0.0
95%
A&E Waiting Times (4 hours) - LTHT (including Wharfedale)
Q1 <
YTD (@ Q2) <
YTD (@ Q3) <
Full year <
Q1 <
YTD (@ Q2) <
YTD (@ Q3) <
Full year <
MRSA
CDI
6
7
10
13
40
80
119
159
*2
10
*2
##
*3
Patients treated within 18 weeks - admitted (%)
*3
Patients treated within 18 weeks - non-admitted (%)
Patients awaiting treatment on the 18 weeks pathway - incomplete
(%)
*3
Cancer 2 week wait - suspected cancer
93%
Cancer 2 week wait - breast symptoms (cancer not initially suspected)
93%
Cancer 31 Day Waits - first definitive treatment
96%
Cancer 31 Day Waits - subsequent surgery treatment
94%
Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment
98%
Cancer 31 Day Waits - subsequent radiotherapy treatment course
94%
Cancer 62 Day Waits - GP/Dentist referrals
85%
95.8%
95.2%
0.5
0.5
98.4%
1.0
100.0%
Compliance with requirements regarding access to healthcare for
people with learning disabilities (6 criteria)
Self certification
0.0
98.3%
0.0
100.0%
93.9%
0.0
86.3%
*1
*2
*3
4.5
Service Performance Score
<1.0
> 1.0 , < 2.0
Amber - Green
> 2.0 , < 4.0
Amber - Red
> 4.0
Red
80.7%
0.0
96.1%
94.3%
Compliant on 4 criteria
Partial compliance on 2
criteria
89.3%
Compliant on 4 criteria
Partial compliance on 2
criteria
0.5
4.5
Rating Criteria
1.5
Compliant on all 6
criteria
0.5
4.5
1.5
4.5
100.0%
98.8%
0.0
0.5
0.0
94.6%
99.9%
85.9%
Compliant on 4 criteria
Partial compliance on 2
criteria
96.2%
99.2%
0.0
95.9%
0.0
95.2%
0.0
97.6%
87.6%
88.6%
97.8%
95.7%
99.3%
0.5
0.0
94.3%
96.4%
90%
89.1%
0.0
0.0
94.7%
1.0
Cancer 62 Day Waits - cancer screening service referrals
95.1%
1.5
4.5
4.5
4.5
4.5
3.5
4.5
3.5
3.5
Risk Rating
Green
A&E performance is derived from the weekly SITREP figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters.
The HCAI threshold used by Monitor is the greater of either: (a) a simple proportioning of the annual threshold (i.e. 25% of annual threshold at Q1, 50% at Q2 and 75% at Q3) or (b) 6 MRSA cases or 12 CDI cases. Note that this is not
the same methodolology as the DH Performance Framework which incorporates seasonality into the trajectory.
Whilst the GRR monitors performance quarterly, any monthly failure of the RTT standards must be reported to Monitor and represents a failure of that indicator for the quarter.
General Notes
Failure to achieve any of the indicators with a weighting of 1 for three or more consecutive quarters may result in Monitor giving the Trust a Governance risk rating of Red and escalating the Trust for consideration as to whether the Trust is in significant breach of its Foundation Trust
authorisation. It should be noted, however, that A&E performance is a special case; failure to meet this standard for any two quarters during the previous 12 month period and failing the indicator again during the subsequent 9 month period or full year may result in Monitor giving the
Trust a Governance risk rating of Red.
Page 25 of 44
Integrated Quality & Performance Report
March 2013
SECTION A - NATIONAL KEY INDICATORS
2 - MONITOR GOVERNANCE RISK RATING (GRR)
GRR Summary
A key component in the determination of the Trust’s GRR is performance against a set of
clearly defined ‘Service Performance’ measures. The scoring of these is based on a penalty
point system whereby Trusts score a penalty of either 1 or 0.5 points for each indicator not
achieved.
Indicators are discussed in detail in this section if they have not been achieved based on the
GRR criteria, and have not been discussed as part of the PF section of the report, or if the
measure is not incorporated within the PF.
GRR Summary Performance
• The Trust’s current Service Performance score for Quarter 4-to-date is 4.5, which gives a
GRR banding of ‘Red’.
GRR Indicator Performance
• The following indicators were not achieved for the period monitored, and were therefore
allocated penalty points.
Indicator
A&E Waiting Times
(1 Penalty Point)
Comment
The period monitored in the GRR is from Monday 31
December 2012 to Sunday 17 March 2013.
MRSA
(1 Penalty Point)
The GRR monitors performance from April 2012 to January
2013. Note the Monitor GRR measures performance
against a different threshold to the PF; this is based on a
simple proportioning of the annual target.
18 Weeks Admitted
(1 Penalty Point)
January to February 2013 performance is reported in the
GRR for Quarter 4 so far.
Cancer 2 week waits
(0.5 Penalty Point)
Encompasses two indicators with data for January 2013:
• Patients urgently referred with suspected cancer by their
GP (GMP/GDP) to be seen within 14 days.
• Patients urgently referred with “breast symptoms” to be
seen within 14 days.
A maximum of half a penalty point is attributed whether one
or both indicators are below standard. In January, the Trust
was below standard on both.
Encompasses two indicators with data for January 2013:
• Patients to receive their first definitive treatment within
62 days of referral by their GP (GMP/GDP).
Cancer 62 day waits
(1 Penalty Point)
Page 26 of 44
Integrated Quality & Performance Report
March 2013
• Patients to receive their first definitive treatment within
62 days of referral by the cancer screening service.
A maximum of one penalty point is attributed whether one
or both indicators are below standard. In January, the Trust
was below standard on both.
Page 27 of 44
Integrated Quality & Performance Report
March 2013
Page 28 of 44
Integrated Quality & Performance Report
March 2013
SECTION B:
- LOCAL KEY INDICATORS
Page 29 of 44
Integrated Quality & Performance Report
March 2013
Page 30 of 44
Integrated Quality & Performance Report
March 2013
SECTION B - LOCAL KEY INDICATORS
Core Indicator Performance Dashboard - April to January / February 2013
Trust priority indicators incorporate the Trust Goals, which are:
- To achieve the best possible clinical outcomes for every patient, every time.
- To be the hospital of choice for patients and staff.
- To be a consistently high-performing & influential healthcare provider.
- To achieve academic excellence & expand the boundaries of healthcare.
2011/12
Result
Indicator
Reduce the number of Grade III and unstageable pressure ulcers developed in the Trust by 50% from
the 2011/12 position.
Eliminate Grade 4 pressure ulcers in 2012/13.
1. QUALITY
Dementia Stage 1: Find - % of all patients aged 75 and above admitted as emergency inpatients who
are asked the dementia case finding question within 72 hours of admission or who have a clinical
diagnosis of delirium on initial assessment or known diagnosis of dementia.
Dementia Stage 2: Assess - % of all patients aged 75 and above admitted as emergency inpatients
who have scored positively on the case finding question, or who have a clinical diagnosis of delirium
and who do not fall into the exemption categories reported as having had a dementia diagnostic
assessment including investigations.
Dementia Stage 3: Refer - % of all patients aged 75 and above, admitted as an emergency inpatient
who have had a diagnostic assessment (in whom the outcome is either “positive” or “inconclusive”) who
are referred for further diagnostic advice/follow up.
Summary Hospital-level Mortality Indicator (SHMI)
Hospital Standardised Mortality Ratio (HSMR) (2012/13 rebased)
99
< 50
3
0
n/a
92.2
14 787 (3rd)
R&I: Initiation – all clinical trials should take 70 Days or less from receipt of a valid research application
to 1st patient visit (median)
R&I: Delivery – all commercial clinical trials should recruit the agreed target number of patients within
the agreed recruitment period (%)
Total Indicators
Green Indicators
Feb-13
Year to
date
> 60
10
10
88
>0
0
0
4
90.5%
n/a
n/a
90.7%
n/a
n/a
95.8%
n/a
n/a
> 90% for all 3 stages for 3
consecutive months in 2012/13
n/a
367 (2nd)
R&I: Participation - Participants recruited to NIHR Portfolio Studies (number)
Jan-13
n/a
92
R&I: Activity - Research studies in NIHR portfolio (number)
2012/13
2012/13 Thresholds¹
Achieve
Fail
New indicator
reported from Q2
12/13
New metric
reported from Q2
12/13
National Ave:
100
National Ave:
100
Jul 11-Jun 12:
91.54 (Published Jan-13)
Apr-Dec 12:
91
Ranked 16th or
Within top 5
below of Trusts in
Trusts in England
England
Ranked 16th or
Within top 5
below of Trusts in
Trusts in England
England
Year-to-Q3:
351 (2nd)
Year-to-Q3:
8380 (8th)
< 70 days
> 70 days
Year-to-Q3:
83 days
> 80%
< 60%
Year-to-Q3:
35%
11
3
Page 31 of 44
Integrated Quality & Performance Report
March 2013
2011/12
Result
Indicator
Elective inpatient length of episode
3.78
2. P&E
Non-elective inpatient length of episode
3.72
2012/13
2012/13 Thresholds¹
Achieve
Fail
Upper quartile:
< 3.06
Upper quartile:
< 3.22
Jan-13
Feb-13
Year to
date
> 3.06
3.51
3.78
3.79
> 3.22
4.53
4.50
4.23
< 85%
78.0%
77.6%
76.1%
< 73.4%
77.0%
78.4%
76.9%
Same day elective inpatient admissions
73.5%
> 85%
Daycase rate (including RDNAs)
74.8%
> 73.4%
Theatre utilisation : In session
83.8%
> 90%
< 90%
82.7%
83.7%
84.4%
Theatre utilisation: Turnaround time
13.1%
< 8%
> 8%
12.5%
11.8%
12.6%
First to Follow Up Outpatient Ratio (Source: Dr Foster as at 18/02/2013)
2.3
Outpatient Appointment DNA Rate (%) (Source: Dr Foster as at 18/02/2013)
10.0%
Feb12 - Jan13: Peer Ave: 2.3
Feb12 - Jan13: 2.0
Feb12 - Jan13: Peer Ave: 8.8%
Feb12 - Jan13: 9.6%
Total Indicators
Green Indicators
8
2
3. WORKFORCE
Staff In Post (FTE)
Mar12: 12987.4
< 13,874
> 13,874
13,105.9
13,077.5
n/app
Sickness Absence Rate (12 months rolling average)
Mar12: 4.17%
< 3.71%
> 4.21%
4.50%
4.46%
n/app
Turnover
Mar12: 9.4%
>8% & <10%
<8% or >10%
8.8%
9.0%
n/app
Variable Staffing Spend as proportion of overall Pay spend
Mar12: 7.2%
Target TBC
5.7%
N/A
n/app
2011 Result
Better than average on
key findings
Annual Staff Survey Result
Worse than average on
key findings
Staff Survey 2012 results
Total Indicators
Green Indicators
5
2
Information Governance Toolkit (Annual submission)
4. IG
ADT - Activity Recorded within 30 days
Health Record Flow - % current patients with multiple health records
Total Indicators
Green Indicators
Level 2
Level 2
< Level 2
99.70%
99.85%
< 99.5%
32%
< 25%
Level 2
99.82%
99.76%
99.75%
10.3%
9.5%
n/app
3
2
Page 32 of 44
Integrated Quality & Performance Report
March 2013
2011/12
Result
Indicator
Income and Expenditure Against Plan (£M)
- Patient Care Income (£M)
- Other Income (£M)
5. Finance
- Pay expenditure (£M)
- Non Pay Expenditure (£M)
- Financing Costs (£M)
Capital expenditure (£M)
Cash balance (£M)
2012/13
2012/13 Thresholds¹
Achieve
Fail
Jan-13
Feb-13
Year to
date
2.0
> £0
< £0
2.2
1.2
(8.5)
(2.7)
N/A
N/A
0.5
0.2
3.3
0.3
N/A
N/A
3.9
0.8
2.0
6.3
N/A
N/A
0.5
0.4
(1.3)
(2.6)
N/A
N/A
(2.6)
(0.1)
(12.8)
0.6
N/A
N/A
(0.0)
0.0
0.3
1.0
N/A
N/A
0.3
(0.2)
3.1
(3.9)
(1.2)
(1.2)
(3.5)
Cash balance > Cash balance <
plan
plan
Total Indicators
Green Indicators
3
0
Indicators currently in development:
Indicator
Section
Patients finding someone on the hospital staff to talk to about their worries and fears (% of those who had
worries and fears finding someone to talk to).
Patients finding someone on the hospital staff to tell them about their medication side effects to watch for when
they leave hospital (% of those who needed an explanation finding someone to talk to).
Page 33 of 44
1. QUALITY
1. QUALITY
Comments
These indicators will be included
once the results of the Inpatient
Survey
2012
have
been
published by the CQC.
Integrated Quality & Performance Report
March 2013
SECTION B - LOCAL KEY INDICATORS
1 - QUALITY
Actions for Improvement
Pressure Ulcers Quality Goal
• The reduction of Trust-attributed grade 3 pressure ulcers and the elimination of Trustattributed grade 4 pressure ulcers are key Quality Goals for 2012/13.
Pressure Ulcers - Grade III & Unstageable
YTD
AIM: Reduce the number of grade III and unstageable pressure ulcers developed in the
Trust to no more than 50 for 2012/13.
•
In February, 3 patients developed a grade
III pressure ulcer at the Trust, whilst 7
patients developed a pressure ulcer that
can not currently be graded; these are
therefore reported as ‘unstageable’
(Grade U1) for February.
For the year to February, there have been
88 grade III and unstageable pressure
ulcers in total.
Number of Grade III and Unstageable Pressure Ulcers
Grade U
Grade III
Achieve
Fail
14
12
No. of pressure ulcers
•
10
8
6
4
2
0
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Note: Grade U pressure ulcers reported on Qlikview have not yet been validated.
Pressure Ulcers - Grade IV
YTD
AIM: Eliminate Grade IV pressure ulcers in 2012/13.
•
It has been over 4 months since the Trust
last reported a Grade IV pressure ulcer.
The Trust has, however, failed the
2012/13 target of eliminating all Trustattributed Grade IV pressure ulcers, as 4
have been reported year-to-February.
Number of Grade IV Pressure Ulcers
3
No. of pressure ulcers
•
2
1
0
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
Pressure Ulcers: Actions for Improvement
Action
Owner
Completed
• All pressure ulcer root cause analysis (RCA) investigations Acting Chief End March
2013
are being reviewed as part of the organisational restructure Nurse
handover process.
1
Unstageable pressures ulcers reported on Qlikview (as at 14/03/2013) have not yet been validated.
Page 34 of 44
Integrated Quality & Performance Report
March 2013
•
•
End of March
2013
Competency assessment of registered nursing staff
continues. To date 1,563 staff have achieved the
assessment and recorded it on the Electronic Staff Record
(ESR).
A review of the action plan and approach to delivering
improvements in pressure ulcers is being prepared for the
Clinical Governance Committee and Trust Board.
April 2013
Dementia Quality Goal
Monthly
AIM: Improve the care and outcomes for patients with dementia, ensuring at least 90%
of applicable patients are screened, assessed and referred as necessary.
One of the Quality Goals identified by the Trust for 2012/13 focuses on improving the care of
people with dementia. This will be measured in line with the national CQUIN goal that has
been introduced, and this year applies to patients admitted acutely with a length of stay of 72
hours or more who are aged over 75. The CQUIN introduces a new set of processes for
implementation in acute Trusts, and is divided into 3 stages:
Stage 1: Find
- Patients are screened for dementia following admission to hospital,
Stage 2: Assess - Patients screened as at risk of dementia have a dementia risk
assessment within 72 hours of admission,
Stage 3: Refer
- Patients identified as at risk of having dementia are referred for
specialist diagnosis.
Based on CQUIN guidance, the Trust is required to achieve 90% compliance against all 3
stages for 3 consecutive months. Unlike other CQUINs, this spans across the entire patients’
length of stay, requiring input from various caregivers throughout the patients’ stay. Timely
presentation of data is regarded as important to ensure compliance can be encouraged and
engagement maintained.
The Trust successfully achieved the required 90% standard for each of the three stages in
January 2013. Performance for February and in-month performance for March continue to
maintain the steady progress demonstrated in January. The Trust is currently on course to
achieve compliance for the quarter.
Work with commissioners is currently underway preparing for changes to the CQUIN in
2013/2014. In addition to the assessment process, the Trust will also be delivering a
Dementia training plan and providing evidence that carers of this patient group are also being
supported.
Dementia: Actions for Improvement
Action
Owner
• Weekly performance reports now routinely produced Director of
for all wards/directorates providing status updates Informatics
against the CQUIN’s three sections.
Director of
• Investigate the use of electronic data collection.
Informatics
• Increase engagement of clinical staff particularly in Medical Director
Medicine and Oncology & Surgery teams as the two
main Divisions by volume.
• Introduce Nurse Specialist Assessment as a trigger for Acting Chief
CQUIN completion. Nurse Specialist Assessment to Nurse
count as Stage 1 completion once completed.
Page 35 of 44
Completed
January 2013
By March
2013
By March
2013
By April 2013
Integrated Quality & Performance Report
March 2013
2 - PRODUCTIVITY & EFFICIENCY
Actions for Improvement
P&E
Page 36 of 44
Integrated Quality & Performance Report
March 2013
• As the new acute theatre booking process becomes embedded, some improvements in
the pre-operative length of stay for non-elective patients have been noted.
• Reduced operating in Neurosurgery has impacted on theatre utilisation. The length of
sessions for this specialty is being managed on a daily basis.
• However, turnaround times are improving in most specialties reflecting the improvement
work from the “Efficiency Boards”.
• As part of the wider Transforming Outpatients project, the Trust began a pilot
implementation of text message reminders in mid-November 2012. The pilot is due to
end towards the end of June and the impact on DNA rates and other benefits will then
be assessed and recommendations made on any future Trust wide roll out.
• An online appointment cancellation form, launched in July 2012 was also initiated with
similar aims to the text message pilot. This has been a successful tool in managing
appointments with over 700 patients per month using it to cancel or request changes to
their appointment.
P&E: Actions for Improvement
Action
• Complete the appointment text and voice
messaging pilot and assess the impact within
outpatients.
• Patient flow programme undertaking work to
enhance Board Rounds and act on identified
delays to reduce length of stay.
• Roll out of theatre productivity boards continues.
Page 37 of 44
Owner
Director of Informatics
Completed
By July 2013
Divisional General
Manager, Specialist
Surgery
Divisional General
Managers
Ongoing
March 2013
Integrated Quality & Performance Report
March 2013
3 - WORKFORCE
Actions for Improvement
Sickness Absence
AIM:
Reduce sickness absence rates to be in line with the trajectory.
LTHT 12 Month Rolling Sickness Rate Against Target
Achieve
Underachieve
Fail
12m Rolling Sickness
In Month Sickness Absence
2010/11
In Month
2011/12
2012/13
5.5%
6.0%
5.8%
5.6%
5.0%
5.0%
4.8%
4.46%
4.6%
4.4%
4.2%
4.0%
In Month Sickness Rate
5.2%
4.5%
4.0%
3.96%
3.5%
Mar-13
12m Rolling Sickness Rate
5.4%
3.0%
3.8%
Sickness Absence: Actions for Improvement
Action
Owner
The rollout of Firstcare amongst nursing staff Director of Human
continues.
Resources
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Sep-11
Jul-11
Aug-11
Jun-11
Apr-11
May-11
Mar-11
3.6%
Completed
March 2013
Staff Survey
AIM:
•
•
To improve staff engagement and satisfaction.
The Trust Board and Workforce Committee received the results of the Staff Survey 2012
during February 2013. The need for alignment with the outcomes of the Patient Survey
2012, the Francis Report and the Compassion in Practice strategy was agreed.
The Board will receive a proposition in respect of staff engagement on 28th March
identifying a number of short term interventions and longer term organisational
development programmes.
Staff Survey: Actions for Improvement
Action
Owner
Director
of Human
• Report to Trust Board in March detailing
individual time frames for interventions and work Resources
programmes.
Page 38 of 44
Completed
March 2013
Integrated Quality & Performance Report
March 2013
4 - INFORMATION GOVERNANCE
Actions for Improvement
Admissions, Discharges & Transfers (ADT) - Activity Recorded Within 30 Days
YTD
AIM: Ensure at least 99.85% of admissions, discharges and transfers are recorded
within 30 days.
In February, out of over 44,000
admissions, discharges and transfers
recorded on the Patient Administration
System, 104 were not recorded within 30
days. The majority of these were in the
Directorate of Neurosciences & Cardiac
Surgery.
ADT - Activity Recorded Within 30 Days
Achieve
Fail
% Within 30 Days
100%
99%
% Within 30 Days
•
98%
97%
96%
95%
Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13
ADT - Activity Recorded Within 30 Days: Actions for Improvement
Action
Owner
Director
of
• An intensive training programme is underway, with further
Informatics
staff being re-educated and trained.
• A revised approach to ADT training providing more ward
based training and follow up of staff performance has been
developed.
• Set up a ward based administration model to ensure that
all wards are covered 24/7 so that performance can be
maintained.
Completed
Ongoing
February
2013
March 2013
5 - Finance
Actions for Improvement
Year to Date Income and Expenditure against Plan
AIM: To maintain income and expenditure within the agreed annual plan.
•
YTD
At the end of February, the Trust maintained its year to date actual surplus of £3.8 million,
but only due to the release of further pay provisions on top of those released last month.
Page 39 of 44
Integrated Quality & Performance Report
March 2013
•
•
There was a £1.2 million favourable movement in the variance against the year to date
plan, reducing the total year to date adverse variance to £8.5 million. This variance is
over-stated as unlike planned service agreements income, the phasing of variable costs
budgets cannot reflect the changes in working days due to the way in which expenditure
is recognised in the financial systems and because of the thousands of individual variable
cost budget lines. These budgets are therefore evenly spread across the year, hence in
months when working days are higher than the average the variance is over-stated and
conversely when working days are lower than the average the variance is under-stated.
As previously reported, the adverse variance against plan is being driven by the following
factors: expenditure on achieving access and quality standards in excess of that included
in the financial plan; increased expenditure on bank, agency and over-time payments
over and above vacancies on substantive posts; increased expenditure on drugs, blood
and devices outside of the contractual terms agreed with NHS Leeds on ‘pass through
costs’; unidentified non-pay Cost Improvement Programmes due to the inability of some
directorates to identify measures to pull back non-pay spend to 2011/12 forecast and
therefore budgeted levels.
Year to Date Income and Expenditure against Plan: Actions for Improvement
Action
Owner
Completed
Ongoing
• The Senior Management Team is monitoring the Director of
Finance
remedial action plans that have proved necessary to
achieve the financial targets, in particular their potential
impact on quality and performance targets.
Cash Balance
YTD
AIM: To meet all ongoing payment obligations while meeting the statutory External
Financing Limit for the year.
• Cash at the end of month 11 is £1.2 m below our revised plan. Forecast for the year end
has been further reduced to £17.9 m in light of the revised revenue position. BPPC for the
month is 79%, a small improvement in the reported year to date cumulative position
represented by a significant improvement in the monthly position.
Action
• EFL adjusted by £7 million to facilitate reduced balance
at outturn. Capex reduced by £2 m and other working
capital measures introduced. The Trust will meet the EFL
target for 2012/13 but will not achieve a cash balance of
10 days operating expenditure (£25 m).
Page 40 of 44
Owner
Director of
Finance
Completed
March 2013
Integrated Quality & Performance Report
March 2013
SECTION C:
UPDATES
Page 41 of 44
Integrated Quality & Performance Report
March 2013
Page 42 of 44
Integrated Quality & Performance Report
March 2013
SECTION C - UPDATES
Updates from Regulators
• Government report on the consultation on strengthening the NHS Constitution1
This report provides an overview of responses received to the consultation on strengthening
the NHS Constitution. The government is due to publish an updated NHS Constitution by
April 2013. The updated Constitution is intended to ensure that the Principles of the NHS
Constitution are consistent with relevant legislation. Changes are likely to strengthen
commitments to areas such as patient involvement, acting on feedback and protection of
patient information.
• Monitor’s new NHS provider licence2
The new provider licence is the new main tool with which Monitor will regulate providers of
NHS services. It has been agreed with ministers that Monitor will license foundation trusts
from April 2013, and other eligible NHS providers from April 2014. The licence contains
obligations for providers of NHS services that will allow Monitor to fulfil its new duties in
relation to: setting prices for NHS-funded care in partnership with the NHS Commissioning
Board; enabling integrated care; preventing anti-competitive behaviour; and supporting
commissioners in maintaining service continuity. It will also enable Monitor to continue to
oversee the way that foundation trusts are governed.
• The non-executive directors' guide to hospital data3
This briefing, published by the NHS Confederation and produced in association with CHKS,
will help non-executive directors better understand NHS data and how it can be used to
determine what is going on in their hospital. It introduces the scale of NHS activity, the range
of activity, the patient pathway and the major datasets. It is the first in a series of four
briefings - the 'Non-executive directors' guide to hospital data', which have been developed to
increase their understanding of NHS data and give them the confidence to ask the right
questions about it.
• Guidance on patient led assessments of the care environment (PLACE)4
The NHS Commissioning Board has published guidance on the new patient led assessments
of the care environment (PLACE) due to be introduced from April 2013. These are a
replacement for the Patient Environment Action Team (PEAT) inspections and will see local
people go into hospitals as part of teams to assess how the environment supports patient’s
privacy and dignity, food, cleanliness and general building maintenance. They will focus
entirely on the care environment and will not cover clinical care provision or how well staff are
doing their job. Results will be published to help drive up improvements to the care
environment.
1
www.wp.dh.gov.uk/publications/files/2013/02/Government-report-on-the-consultation-on-strengthening-theNHS-Constitution.pdf
2
www.monitor-nhsft.gov.uk/sites/default/files/publications/ToPublishLicenceDoc14February.pdf
3
www.nhsconfed.org/Publications/Documents/ned-guide-hospital-data.pdf
4
Patient-led assessments of the care environment (PLACE) | NHS Commissioning Board
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Integrated Quality & Performance Report
March 2013
APPENDIX 1
GLOSSARY
ADT
BPPC
Capex
CCG
CDI
CIP
CQC
CQUIN
DH
DNA
ED
EFL
FTE
GRR
HCAI
HPV
HSMR
IG
IPM
KPI
LGI
MRSA
NIHR
P&E
PCR
PF
PICU
QoS
R&I
RCA
RDNA
RTT
SHA
SHMI
SJUH
SMT
YTD
-
Admissions, Discharges & Transfers
Better Payment Practice Code
Capital Expenditure
Clinical Commissioning Group
Clostridium Difficile Infections
Cost Improvement Programme
Care Quality Commission
Commissioning for Quality & Innovation
Department of Health
Did Not Attend
Emergency Department
External Financing Limit
Full Time Equivalent
Governance Risk Rating
Healthcare Associated Infection
Hydrogen Peroxide Vaporisation
Hospital Standardised Mortality Ratio
Information Governance
Integrated Performance Measures
Key Performance Indicator
Leeds General Infirmary
Meticillin Resistant Staphylococcus Aureus
National Institute for Health Research
Productivity & Efficiency
Polymerase Chain Reaction
Performance Framework
Paediatric Intensive Care Unit
Quality of Services
Research & Innovation
Root Cause Analysis
Regular Day & Night Attenders
Referral to Treatment
Strategic Health Authority
Summary Hospital-level Mortality Indicator
St James's University Hospital
Senior Management Team
Year to Date
Page 44 of 44
Integrated Quality & Performance Report
March 2013