1. science
2. medicine
3. surgery

Trust Board — March 2011
Performance Report
Chair of Performance & Finance
Committee & Executive Lead:
Mark Oldham
Contains:1. Patient Quality & Safety focus (Jan '11 Data)
2. Finance focus (Jan '11 Data)
3. System delivery focus (Jan '11 Data)
4. Workforce focus (Jan '11 Data)
5. Learning/development focus (Jan '11 Data)
6. External focus & Service (Feb '11 Data)
Development/Planning
Page 1 of 90
Section 1 Patient Quality and Safety Focus
Accountable Office – Julie Smith
Page 2 of 90
Summary of Complaints – January 2011 (19 complaints received)
New Complaints by Division
16
14
12
10
8
6
4
2
0
Feb-10
Mar-10
Apr-10
Surgery & Cancer
May-10
Jun-10
Di agnostics & CSS
Jul-10
Aug-10
Sep-10
Emergency Care
Oct-10
Nov-10
Women, Chil dren & SH
Dec-10
Jan-11
Estates & Faci lities
The number of complaints received this month for Emergency Care has increased
again 8 to 12 but no clear trends were identified. The number of complaints
received this month by the Surgery and Cancer Division is again low (2).
Monthly Percentage of Inpatient and Day Case Activity for January 2011:
Division
Surgery and Cancer
Diagnostics and Clinical Support Services
Emergency Care
Women, Children and Sexual Health
Percentage
34%
2%
40%
24%
Percentage of Complaints responded to within Timescale
agreed with Complainants
120
100
80
60
40
20
0
Feb-10
M ar-10
A pr-10
M ay-10
Jun-10
Jul-10
A ug-10
Sep-10
Oct-10
No v-10
Surgery & Cancer
Diagno stics & CSS
Emergency Care
Wo men, Children & SH
Estates & Facilities
Target
Dec-10
Jan-11
Page 3 of 90
Risk Gr ading of Complaints
4
3
2
1
0
F e b-1 0
Mar- 10
Apr- 10
Ma y-1 0
Surg ery & C an cer
W ome n, Chi ldr en & SH
Note:
J un -10
Ju l-1 0
Au g-1 0
S ep -10
O c t-1 0
D ia gno sti cs & C SS
Es ta te s & F aci li ti es
1 = Minor, 2 = Moderate,
N ov -10
De c-1 0
Jan -1 1
Eme rgen cy C are
3 = Major/Catastrophic
The maximum risk grading of any complaint received in January 2011
was ‘moderate’. The grading of a complaint is calculated using the Trust’s
Risk Categorisation Matrix.
Number of Meetings
In addition to sending out formal written responses to complaints, the Trust
encourages meetings with complainants. During January meetings were held
with patients or their representatives as follows:
Division
Diagnostics & Clinical Support Services
Surgery & Cancer Division
Emergency Care Division
Women’s, Children’s & Sexual Health
Estates and Facilities
Total
Number
0
1
0
0
0
1
Complaints made to Central and Eastern Cheshire PCT
There were no complaints made to the PCT in January regarding the Trust’s
services.
Page 4 of 90
Complaints referred to the Ombudsman
No new complaints were referred to the Ombudsman in January
Complaints/Trends referred to Monitor
No complaints/trends were referred to Monitor in January
Top trends from past 3 months
Issues Raised Most Frequently in Complaints Received Between November 2010 January 2011 (65 complaints)
7
6
6
5
5
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2 2
2
2
2
1
1
1
1 1
1
1 1
1
1
0
0
0
0
Communic Communic
Attitude of Attitude of Treatment
ation with ation wit h
midwife
nurse
delay
patients
relatives
Nursing
care other
0
0
Discharge - Medical Medical Midwifery Privacy
inappropri medication
adverse
care
and dignity
ate
error/delay
outcome
0
Medical - Medical delay in diagnosis
treatment problems
Jan
0
2
3
3
3
3
2
1
2
1
0
3
6
Dec
4
3
0
1
1
0
2
1
1
1
1
0
0
Nov
1
4
5
3
3
2
3
3
4
3
2
4
3
Jan
Dec
Nov
Closed Complaints Summary Attached
Sections removed under S40 of the Freedom of Information Act
Ethnicity Data
Patients (n=19)
White British
Irish Ethnicity
White Other
Asian or Asian British
Mixed
Black or Black British
Other Ethnic Group
Undisclosed
Number
%
18
95%
0 Patients 0%
0
6%
0
0%
0
0%
0
0%
0
0%
1
5%
Number
%
12
63%
Complainants
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
7
37%
Page 5 of 90
Summary of Patient Advice and Liaison Service January 2011
Concerns by Division
PALS Concerns by Division
60
50
40
30
20
10
0
Feb10
Mar10
Apr10
May10
Jun- Jul-10 Aug10
10
Sep10
Oct10
Nov10
Dec10
Jan11
Surgery & Cancer
Diagnostics & CSS
Emergency Care
Women, Children & SH
Es tates & Facilities
Corporate
A total of 88 contacts for concerns (42%) were received for the above Divisions in
PALS from 208 contacts in January 2011.
Total contacts for the current month have decreased by 19% from the previous
month. This is probably due to the latter part of the Christmas period. PALS are
also continuing to receive fewer contacts for Face to Face interpreters, which is
impacting on the total number of contacts.
Contacts for concerns have decreased for all Divisions except Estates and
Facilities (+4). Three of these four concerns were regarding the cost of parking.
The two concerns for the Corporate Division were around communication in
Integrated Governance.
Page 16 of 90
Time to Resolve Concerns by Division
Perecentage of concerns resolved within 3 working days by
Division
120
100
80
60
40
20
0
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Surgery & Cancer
Diagnostics & CSS
Em ergency Care
Wom en, Children & SH
Estates & Facilities
Corporate
Dec-10
Jan-11
The number of issues resolved in 3 working days has decreased slightly for this
month, which is probably due to the latter part of the Christmas period and
annual leave being taken.
Compliments by Division
Complim ents by Division
12 0
10 0
80
60
40
20
0
Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Surgery & Cancer
Diagnostic s & CSS
Emergency Care
Women, Children & SH
Estates & Facilities
Corporate
Page 17 of 90
Compliments
There has been no return this month from Departments within Diagnostics and
Clinical Support Services. The three compliments for this Division have been
made direct to PALS.
PALS Top 5 Concerns
Top 5 Concerns - November 2010 to January 2011
140
120
100
80
60
40
20
0
Communication
Appointments
Care
Treatment
November
40
29
29
12
8
December
41
18
12
10
13
January
35
18
23
11
11
116
65
64
33
32
Total
Property
The above graph is based on the number of issues, not contacts.
Although the total numbers have decreased slightly for January, the total for
issues of Care have risen against the previous quarter by 8 (56). For January,
Emergency Care had the highest number of care issues, being 8, with the
Emergency Department having 3 of those issues. 2 were regarding Nursing care
and 1 Medical care
Sections removed under S40 of the Freedom of Information Act
Page 18 of 90
Patient Experience Report January 2011
Surveys carried out in January 2011 by Division
Survey
Name of
Division
Reason for survey
Number
Survey
CD089
PALS
Corporate
To evaluate the PALS service.
Service
CD087
Advance
Corporate
To gain patient feedback on their
Quality
experience whilst in hospital
SC090
Urology
Surgery &
To gain patient feedback on the
Nurse
Cancer
service currently provided.
Practitioner
Service
DC088
Waiting Time Diagnostics
To highlight issues regarding
Audit
& Clinical
communication
Services
of clinic delays to patients.
Evaluation Forms following patient surveys received to be reported to PEC:
Nutrition
Phlebotomy
Discharge Audit
NHS Choices postings – All postings reported they would recommend the
hospital
Surgery & Cancer Division
Breast Care Unit– positive -– prompt efficient and caring treatment received
Ward 9 – positive – Impressed with very clean and good food and good follow up
care
Orthopaedic Unit – positive – Staff were wonderful very caring with lots of
patience
Emergency Care Division
Accident and Emergency Department – positive – Care and kindness was
excellent
Women’s & Children’s Division
Maternity Unit – 2 positives – Excellent Care
To date 31 out of 50 patients would recommend the hospital
Page 22 of 90
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
Sep-10
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Falls
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↑95%
8594%
↓84%
↓84%
↓84%
↓84%
Falls Assessment
↓84%
↓84%
↓84%
Indicator Criterion
All patients will receive a falls risk on admission to the trust
which will be dated and signed by the assessing staff
member
Care Plans to minimize falls will be evident for all patients
assessed vas being at risk
A further assessment will be undertaken for all patients
identified as being at risk
All risk assessment documentation will provide details of
ward, patient name and date of birth, hospital identifier and
date
Care plans will identify actions following the use of the Risk
Balance Tool.
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Compliance for completion of bed rail assessments are
overall improving ward results.
Page 23 of 90
Feb-10
Jan-10
Dec-10
Nov-10
Oct-10
Sep-10
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Fluid Balance
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Fluid Balance Care Indicator
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Indicator Criterion:
Patients requiring Fluid Balance will be placed i=on the
appropriate chart – WPG319
All patient Fluid Balance Chart documentation will provide
details of ward, patient name, date of birth & hospital
number
All patients fluid balance charts will be dated.
24hr cumulative balances will be evident on all fluid
balance charts
Column totals will be calculated daily
Fluid Balance
There are only 10 patients per ward audited, these patients
may not be currently on fluid balance charts.
Further audits of fluid balance chart audits are currently
being undertaken by Consultants within the Trust
Page 24 of 90
Sep-10
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Bowels
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
↓84%
↓84%
↓84%
Bowels
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Bowels Care Indicator
All patients will receive an assessment of elimination
needs on admission to the Trust, which will be dated and
signed by the assessing staff member
All patients will have their bowel movement recorded and
documented on the vital observation chart once a day
All patients requiring analgesia will have an aperients
prescribed on their prescription chart
Aperient administration and efficacy will be documented in
the daily summary of care
↓84%
↓84%
↓84%
↓84%
↓84%
The results for the bowel indicator continue to improve
each month.
The implementation of the new Trust documentation will
further assist compliance
Short stay assessment documentation does not have
allocated section for initial bowel assessment hence this is
lowering scores
Page 25 of 90
Sep-10
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Nutritional Assessment
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Food & Nutrition
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Indicator Criterion
All patients will receive a nutritional assessment on
admission to the trust which will be dated and signed by
the assessing staff member
All patients will be weighed on admission to hospital
Care Plans demonstrating nutritional support interventions
will be evident for all patients identified at risk
Patients will be reassessed as required in accordance with
assessment documentation
All nutritional assessment documentation will provide
details of ward, patient name and date of birth, hospital
identifier and date
Nutritional assessment documentation will highlight
referrals to the dietetic dept as necessary
All wards are constantly completing nutritional
assessments, this is helped by ED weighing dependant
patients as they arrive
Page 26 of 90
Sep-10
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Cannula Care
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↑95%
8594%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Care Indicator – Cannula
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Indicator Criterion
Care Plan documentation will be evident for those patients
with venous access device
The VIP score will be carried out once per shift
Dressing Changes will be documented on the Care plan
All documentation will provide details of Ward, Patient
Name, Date of Birth, Hospital Identifier & date
The new cannula careplan is currently being trialled
throughout the Trust.
↓84%
Page 27 of 90
Sep-10
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Pressure Area Care
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
Pressure Area Care
Indicator Criterion
All patients will receive a waterlow risk assessment on
admission to the trust which will be dated and signed and
timed by the assessing member of staff
Waterlow Scoring will be reassessed on a daily basis.
All risk assessment documentation will provide details of
ward, patient name and date of birth, hospital identifier and
date
All patients identified as having a pressure ulcer will have
an IR1 form completed
Pressure Area prevention careplan to be evident for all
patients with a waterlow score of 10+
All patients with a pressure ulcer will have a careplan for
treatment of ulcer
Completion of question ‘pressure ulcer present on
admission? Will be completed
All patient indentified with pressure ulcer on admission to
be graded
The non-completion of pressure area prevention careplans
are causing reduced scores. The monthly data is submitted
to the Tissue Viability Nurses for ward followup/ education
input.
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Page 28 of 90
Sep-10
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Infection Control
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
↓84%
↓84%
↓84%
↓84%
Infection Prevention & Control
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Indicator Criterion:
Alcohol gel is available in line with Trust Guidance
Hand hygiene is completed in accordance with Trust policy
Care Plan documentation will be evident for those patients
who are identified with an alert/organism/ condition
Care Plan documentation will be evident for those patients
with invasive devices
Evidence of adherence to uniform policy and PPE worn
according to Trust guidance
↓84%
↓84%
↓84%
↓84%
This indicator has recently been re-introduced at the
request of the Matrons, results are improving monthly.
Reduction is results is caused by sideroom doors not being
closed when nursing an infectious patient and alcohol gel
not being at the end of each bed.
Page 29 of 90
Oct-10
Nov-10
Dec-10
Jan-10
Feb-10
↓84%
Sep-10
↓84%
Red =
Ambe
r=
Green
=
Trust Care Indicators
Wards with no results displayed were closed during the
audit period.
Medicine Management
Cardiac 1
↑95%
Respiratory
↑95%
Cardiac 3
↑95%
Gastroenterology 4
↑95%
Gastroenterology 5
↑95%
Complex Care
↑95%
Stroke Care
↑95%
Gastroenterology 7
↑95%
Orthopaedic Elective
↑95%
SAU
↑95%
Surgical Speciality
↑95%
Care of Older People
↑95%
General Surgery 12
↑95%
General Surgery 13
↑95%
Endocrinology
↑95%
Orthopaedic Trauma
↑95%
VIN Intermediate Care
↑95%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
8594%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
↓84%
Medicines Prescribing & Administration
Indicator Criterion
All patient prescription documentation will be legible.
All patient prescription documentation will provide details of
ward, patient name and date of birth, hospital identifier and
allergy status
The status of all patients with a potential / actual
medication allergy will be identified
Patients requiring antibiotics will be have a defined stop
date / review date.
This indicator was recently re-introduced for a 4 month
period to ensure sustained results
Page 30 of 90
Advancing Quality
The Trust joined the Regional Advancing Quality programme in 2008. The
programme went live in October 2008 with the Trust collecting and reporting on
clinical measures as well as service improvement work. The aim of this project is to
record and report on agreed clinical measures and improve outcomes for patients
with the following clinical conditions.
•
•
•
•
Acute Myocardial Infarction
Heart Failure
Hip & Knee Replacement Surgery
Community Acquired Pneumonia
In Year one, October 2008 – September 2009 the Trust was financially rewarded for
achieving top 50% in Heart Failure & Community Acquired Pneumonia. Year two
(October 2009- March 2010) earned the Trust achievement awards for Hip & Knee,
Heart Failure and AMI. AQ has now joined CQUIN.
Acute Myocardial Infarction
MI - Composite Scores 2010/11
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Apr
May
Jun
Jul
Rate
Aug
Sep
75th Percentile
Oct
Nov
Dec
Jan
50th Percentile
Feb
Mar
Apr
CQUIN
Oct 2010 Discharges
Acute Myocardial Infarction
Aspirin at arrival
Aspirin Prescribed at discharge
ACEI or ARB for LVSD
Adult Smoking Cessation Advice/Counselling
Beta Blocker prescribed at discharge
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI: Composite Process Score (CPS)
AMI: Appropriate Care Score (ACS)
Num
Den
Rate
32
26
4
4
22
1
0
89
32
32
26
4
5
25
2
0
94
37
100.00%
100.00%
100.00%
80.00%
88.00%
50.00%
N/A
94.68%
86.49%
Page 31 of 90
Heart Failure
Heart Failure - Composite Scores 2010/11
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Apr
May
Jun
Jul
Rate
Aug
75th Percentile
50th Percentile
CQUIN
Hospital
October 2010 discharges
Focus Area/Measure
Heart Failure
Discharge instructions
Evaluation of LV Function
ACEI or ARB for LVSD
Adult Smoking Cessation Advice/Counselling
HF: Composite Process Score (CPS)
HF: Appropriate Care Score (ACS)
Num
Den
Rate
14
21
9
0
44
15
20
23
12
1
56
23
70.00%
91.30%
75.00%
0.00%
78.57%
65.22%
Community Acquired Pneumonia
Community Acquired Pneumonia - Composite
Scores 2010/11
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Apr
Rate
May
Jun Jul Aug
75th Percentile
Sep
Oct Nov Dec
50th Percentile
Jan
Feb Mar
CQUIN
Apr
Hospital
October 2010 Discharges
Focus Area/Measure
Pneumonia
Oxygenation assessment
Blood Cultures Performed in the A&E Prior to Initial Abx Received in
Hospital
Adult Smoking Cessation Advice/Counselling
Initial antibiotic received within 6 hours of hospital arrival
Initial antibiotic selection for CAP in immunocompetent patients
PN: Composite Process Score (CPS)
PN: Appropriate Care Score (ACS)
Num
Den
Rate
39
40
97.50%
3
3
14
18
77
17
5
12
29
25
111
41
60.00%
25.00%
48.28%
72.00%
69.37%
41.46%
Page 32 of 90
Hip & Knee Surgery
Hip and Knees - Composite Scores 2010/11
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Apr
May
Jun
Rate
Jul
Aug
Sep
Oct
Nov
75th Percentile
Dec
Jan
Feb
Mar
50th Percentile
Apr
CQUIN
Hospital
October 2010 Discharges
Focus Area/Measure
Hip and Knee Replacement
Prophylactic antibiotic received within 1 hour prior to surgical incision
Prophylactic antibiotic selection for surgical patients
Prophylactic abx discontinued within 24 hours after surgery end time
Recommended venous thromboembolism prophylaxis ordered
Rcvd appropriate VTE Prophylaxis w/i 24 hrs Prior to surg to 24 hrs
After surg
H&K: Composite Process Score (CPS)
H&K: Appropriate Care Score (ACS)
Num
Den
Rate
36
45
46
43
47
46
46
45
76.60%
97.83%
100.00%
95.56%
31
201
24
45
229
47
68.89%
87.77%
51.06%
Stroke
Stroke joined the Advancing Quality programme with October 2010 discharges.
The formal period for assessment for the Stroke CQUIN is discharges between 1st
October 2010 – 31st March 2011
75% of the CQUINS award will be paid upon delivery of a cumulative composite
quality score which is equal to or exceeds 90%
25% of the CQUINS awards will be paid upon delivery of an appropriate care score
which equals or exceeds 50%
Stroke - Com posite Scores 2010/11
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
Apr
May
Jun
Jul
Aug
Rat e
Sep
Oct
75t h Percent ile
Nov
Dec
Jan
Feb
Mar
Apr
50t h Percent ile
Page 33 of 90
Hospital
October 2010 Discharges
Focus Area/Measure
Stroke
Stroke unit admission within 4 hours after hospital arrival
Swallowing disorder screening within 24 hours of hospital admission
Brain scan within 24 hours of hospital arrival
Aspirin or Antiplatelet received within 24 hours of hospital admission
Physiotherapy assessment received within 72 hours of hospital
admission
Occupational therapy assessment within 72 hours of hospital
admission
Weighed at least once during the admission process
STK: Composite Process Score (CPS)
STK: Appropriate Care Score (ACS)
Num
Den
Rate
10
31
32
34
34
37
39
35
29.41%
83.78%
82.05%
97.14%
30
34
88.24%
29
26
192
7
33
36
248
41
87.88%
72.22%
77.42%
17.07%
Year Three 1st April 2010 to 31st March 2011
Advancing Quality has joined the CQUIN programme from 1st April 2010
The incentive budgets for year three are based on a percentage of total contract
value, as advised by NHS North West. For Acute focus areas it is 0.01% of the total
contact value.
The CQUIN targets that have been set for each focus area have been set in
accordance with Trust improvement from Year 1 CQS.
Page 34 of 90
Patient Safety Monthly Performance Report
MCHFT want to deliver high quality, safe patient care. Despite their best efforts human factors, systems
and processes contribute to prevent this desire. We unintentionally harm patients in our care. In order to
understand this we need a diagnostic journey that moves the organisation to a model for improvement
and learning, away from a model of measuring for judgement (Institute for Innovation and Improvement
2009). Learning from the Leading Improvement in Patient Safety (LIPS) program, this paper has been
developed using Statistical Process Control (SPC) charts to measure the avoidable harm caused to
patients in Mid Cheshire Hospitals NHS Foundation Trust (MCHFT).
The Trust has a positive incident reporting culture and the aim is to:
• Reduce the severity of avoidable harm caused to patients by 10% year on year.
• Increase medication incident reporting by 10% 2010-2011.
• Increase no harm reporting by 1% 2010-2011.
This report presents the data in different formats with the inclusion of trend lines in some charts as an
alternative for consideration by the Board of Directors.
Definitions
Runs apply that identify special cause patterns on SPC charts.
•
Rule 2 or shift in the process is defined as 7 or more consecutive points above or below the
median. These are indicated by orange circles on the SPC charts within this report.
Serious incident
Serious harm is defined as any patient safety incident that appears to have caused major permanent
harm or contributed to the death of a patient (NPSA 2009).
Moderate harm
Moderate harm is defined as any patient safety incident that resulted in a moderate increase in
treatment and which significant but no permanent harm (NPSA 2009).
Low harm
Low harm is defined as any patient safety incident that required extra observation or minor treatment
and caused minimal harm (NPSA 2009).
References:
NHS Institute for Innovation and Improvement (2009) A guide to creating and interpreting run and
control charts, turning data into information for improvement.
National Patient Safety Agency (2009) Incident Categorisation Matrix.
Page 35 of 90
SPC 1
Clostridium
Difficile
outbreak on
Ward 5
Number of SIs
Temporal
Arteritis
Incident
3 months without SI
Patient Fall
resulting in
transfer to
neuro
surgery
Patient
suicide on
Orthopaedics
7 months without SI
3 months without SI
Misplaced naso
/ orogastric
tube not
detected prior
to use
Aimed Direction for Improvement
Serious Incidents by Month
April 2009 to January 2011 (Detail removed under S40 of FOI Act)
Information
Governance
incident at
VIN
Month
SPC 1 demonstrates the number of incidents that have resulted in a serious incident. In accordance with Trust policy a level 2 root cause analysis is performed
on all serious incidents reported with an Executive Lead review, this is to enable the Trust to learn and share lessons to prevent re-occurrence. Action plans
developed in response to these incidents are monitored at Operational Integrated Governance Committee (OIG). Following analysis of the incidents the severity
is reassessed and documented in the Operational Integrated Governance action points and on the incident reporting data base.
There have been no level 2 root cause analysis reviews since the last report.
Page 36 of 90
Run Chart 2
P atient F alls R es ulting in H arm by Month & Y ear
J anuary 2009 to J anuary 2011
System for
identifying
repeat patient
falls
introduced
50
Patient falls
strategy
implemented
40
30
Patient falls
documentation
audit completed
20
10
0
J an
F eb
Mar
A pr
May
J un
J ul
A ug
S ep
Oct
Nov
Dec
2009
39
41
42
39
53
51
33
23
23
31
45
42
2010
35
28
34
40
29
32
35
31
34
40
36
33
2011
37
Aimed Direction for Improvement
60
Run chart 2 demonstrates the number of patients who have fallen whilst in hospital which have resulted in harm. Of this data 96.6% (875) resulted in low harm,
3.3% (30) resulted in moderate harm and 0.1% (1) resulted in a serious incident. The majority of falls continue to result low harm. A patient fall that result in
moderate harm is subjected to a bespoke root cause analysis, this enables the Trust to learn and share lessons. The trend line for falls is slightly moving away
from the aimed direction of improvement.
Page 37 of 90
Run Chart 3
Direction for Improvement
Medic ation Inc idents R es ulting in H arm by Month & Y ear
J anuary 2009 to J anuary 2011
30
25
20
Introduction
of Pharmacy
Intervention Database
15
10
5
0
J an
F eb
Mar
A pr
May
J un
J ul
A ug
S ep
Oct
Nov
Dec
2009
6
12
4
5
6
15
17
7
8
19
26
10
2010
10
5
6
11
6
10
4
2
1
4
3
6
2011
3
Run chart 3 demonstrates the number of medication incidents that have occurred and resulted in harm. One rule 2 can be identified where the number of
medication incidents resulting in harm has been below the median line for 10 months. Of this data 99% (204) resulted in low harm and 1% (2) resulted in
moderate harm. There were no incidents reported graded moderate or above. Medication incidents are monitored at the Safer Medicines Practice Group and a
lesson’s learned document is issued following the meeting. The trend line for harm caused from medication incidents is moving towards the aimed direction of
improvement.
Page 38 of 90
Aimed Direction for Improvement
Run Chart 4
Run chart 4 demonstrates the number of patients who have developed either a Deep Vein Thrombosis (DVT or Pulmonary Embolism (PE) whilst
an inpatient. A bespoke root cause analysis’s is undertaken for any patient that experiences a Venous Thromboembolism (VTE) these are
monitored by the VTE working group chaired by the Consultant Lead for Patient Safety.
Page 39 of 90
Aimed Direction for Improvement
Run Chart 5
Run chart 5 shows the VTE data submitted to the Department of Health via their UNIFY system. The Trust is required to collect and submit this data on a
monthly basis and shows compliance towards achieving the CQUIN of 90%. The Trust is not achieving compliance with this.
Page 40 of 90
Run Chart 6
Crude Deaths by Month & Year
160
Aimed Direction for Improvement
140
120
100
80
60
40
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2009
139
104
119
125
100
97
104
83
109
114
96
109
2010
123
101
113
120
106
96
67
87
87
103
101
108
2011
143
Run chart 6 demonstrates the crude number of deaths for the Trust. The Hospital Mortality Reduction Group has initiated a number of actions throughout the
year aimed at reducing the Trust’s mortality rates. The Trust, along with 8 other Trusts in the region has signed up to a Mortality Collaborative in NHS North
West, this is a 12 month program aimed at reducing hospital standardised mortality rates by 10 points by March 2011. Whilst the numbers of deaths have
increased over the past month the trend line demonstates that the overall number of deaths is declining and that the Trust is moving towards the aimed direction
of improvement.
Page 41 of 90
Run Chart 7
Rolling 12 month Mortality Trending
Aimed Direction for Improvement
130
Mortality Index
120
110
100
90
80
70
60
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun09
09
09
09 09
09
09
09
09
10 10
10
10
10
10
Jul- Aug- Sep- Oct- Nov- Dec- Jan10 10
10
10
10
10
11
Mortality Index Month
Peer Average
Run Chart 7 demonstrates a reduction in the risk adjusted mortality rate against peer.
Page 42 of 90
Aimed Direction for Improvement
Run Chart 8
Page 43 of 90
Section 2 Finance Focus
Accountable Office - Mark Oldham
Page 44 of 90
1.
KEY FINANCIAL RISK RATINGS
Financial Risk Ratings
5
score
4
3
2
1
EBITDA EBITDA %
Margin achieved
ROA
I&E
surplus
margin
Cu m u l ati v e Rati ng
Liquidity
Overall
Rating
Forec as t Rati n g
EBITDA % achieved
EBITDA %age of turnover
170%
14.0%
12.0%
150%
lev 5
lev 4
10.0%
8.0%
Le v el 5
130%
Le v el 4
110%
Le v el 3
6.0%
lev 3
4.0%
90%
a c tu a l 0 9 /1 0
70%
a c tu a l 1 0 /1 1
2.0%
50%
30%
Bu d g e t (% )
a c t 0 8 /0 9 (% )
a c t 0 9 /1 0 (%)
Lev e l 3
a c t 1 0 /1 1 (% )
Return on Assets
I&E surplus %age of turnover
7.0%
6.0%
5.0%
Ac tu a l 1 0 /1 1
4.0%
Le v el 5
3.0%
Le v el 4
2.0%
Le v el 3
1.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
-1.0%
-2.0%
Le v el 5
Le v el 4
Le v el 3
Bu d g e t
Ac tu a l 0 9 /1 0
Ac tu a l 1 0 /1 1
0.0%
Plan
Actual
Days
Liquidity
40
35
30
25
20
15
10
5
0
Le v e l 5
Le v e l 4
Le v e l 3
Bu dg e t
Ac tua l 0 9/1 0
Ac tua l 1 0/1 1
Page 45 of 90
2.
OTHER KEY INDICATORS
Net Profit
Pay costs by month
5,000
4,000
3,000
2,000
1,000
0
(1,000)
(£'000)
(£'000)
11,100
10,600
10,100
9,600
9,100
8,600
8,100
7,600
7,100
Month
c u m u l a ti v e b u d g e t
c u m u l a ti v e a c tu a l 0 8 /0 9
c u m u l a ti v e a c tu a l 0 9 /1 0
c u m u l a ti v e a c tu a l 1 0 /1 1
a c tu a l 20 0 8 /09
a c tu a l 20 0 9 /1 0
a c tu a l 20 1 0 /11
Turnover by month
16,000
4,000
3,800
3,600
3,400
3,200
3,000
2,800
2,600
2,400
15,000
(£'000)
(£'000)
Non Pay Costs by Month
b ud g e t
14,000
13,000
12,000
11,000
10,000
bu dge t
ac tual 20 08/0 9
ac tua l 20 09 /10
a c tu al 2 010 /11
budget
a c tu a l 0 9 /1 0
a c tu a l 1 0 /1 1
Cash balance
6000
5000
4000
3000
2000
1000
0
(£'000)
(£'000)
Capital programme cumulative spend
a c tu a l 0 8 /0 9
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Bu dg et
Ac tu al 08 /09
Ac tu al 09 /10
Ac tu al 10 /11
Ba s e Pro gram m e
re v i s e d pro g ra m m e
c um u l a ti v e ac tu al 09 /1 0
100
95
90
85
80
Private Patient Cap
%age
%
Public Sector Payment Policy
1.60%
1.40%
1.20%
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
Ca p
Ac tu a l
Target
Ac tu al m on th
c u m u l ati v e av e rag e
Month
Cu m u l ati v e
Page 46 of 90
3.
INCOME & EXPENDITURE POSITION (see Appendix 1a, 1b)
A.
Summary Position for Quarter 4 and cumulative to 31st January 2011
Quarter
Actual Q4
to date
(£'000)
Cummulative
Var Q4 to
date (£'000)
Actual Apr Var Apr to
to January January
(£'000)
(£'000)
Var to
Last Year
(£'000)
Forecast
(£'000)
Income
Clinical revenue
Other
Expenditure
12,078
1,865
189
64
121,277
18,101
1,329
162
516
2,271
146,102
21,180
Pay
Non-pay
EBITDA
-9,813
-3,336
794
-284
285
254
-96,918
-34,026
8,434
-2,994
771
-732
-3,523
-1,055
-1,791
-116,023
-41,540
9,720
-464
3
-305
-15
-8
-14
-3
1
-3
-8
-4,333
29
-3,059
-175
-8
202
-37
1
68
-8
-58
-2
-55
39
-54
-5,189
44
-3,672
-220
0
5
227
888
-506
-1,921
683
Depreciation
Interest receivable
Dividend payable
Interest payments Leases
Profit on disposal of assets
Surplus/(Deficit)
A.1 Total contract income is £1,329K better than expected. The main reasons are:
i.
Non Elective income is (£17K) worse than plan. There is under-performance in short stay
activity of (£925K) and over-performance in standard tariff activity of £1,333K. Of note, are
positive variances in General Medicine £935K, Orthopaedics £419K, General Surgery
£198K & Paediatrics £255K and adverse variances in A&E of (£1,110K), Obstetrics
(£152K) and Gynae (£95K). This is offset by the impact of the cap agreement and
marginal rate being (£425K).
ii.
Day cases and elective inpatients are (£681K) worse than plan. Of which:
a. £201K is due to day case over-performance with notable variances of Clinical Haem
£94K, Ophthalmology £140K, Urology £100K and General Medicine (£133K).
b. (£882K) is due to under–performance in elective activity with notable adverse
variances in General Surgery (£473K), Orthopaedics (£259K), Gynaecology (£138K)
and Urology £87K. This has deteriorated by in month as a result of cancelled electives
(£223k) in regard of flu measures imposed by DoH.
iii.
Over performance on outpatients of £1,328K better than plan. Of which:
a. New patients are over-performing by £521K, most notably in General Surgery £306K,
Ophthalmology £120K and Gynaecology £87K.
b. Follow up patients are over-performing by £808K with variances being reported in
Ophthalmology £900K, Paediatrics £68K and General Surgery (£137K). However,
over-performance will be offset by (£313K) being the cap on the First:FollowUp ratio,
mainly in Gastroenterology, Orthopaedics and Ophthalmology.
c. Outpatient procedures are over-performing by £324K, mainly in Gynaecology,
Dermatology & ENT.
iv.
Over performance on A&E attendances of £309K.
v.
Other income is £390K better than plan relating in the main to High Cost Drugs £686K and
the rebate relating to the fixed contract value agreement of (£311K).
Page 47 of 90
The level of over-performance on the contract with CECPCT is £3.0M at Month 10, this being prior to the
rebate of £311K relating to the recent agreement to fix the value of the contract at £134.5M. This consisting
of contract base of £131.9M value plus £2.6M over-performance cap. The impact of the agreement is that
the forecast position of the Trust will reduce from £2M to £0.5M and is dependent upon expenditure being
controlled tightly throughout the remaining months of the financial year.
A.2 Overall Pay costs (£2,995K) worse than anticipated.
The cumulative position is primarily due to;
a. Medical staffing is over-spent by (£532K). Slippage on investments in medical staffing
and gaps in junior doctors has resulted in a £2,214K favourable variance which includes
locum costs of (£709K). This has been offset by agency costs of (£2,746K). There is a
need to review the level of vacancies in medical staff, however, the position has
improved in the last two months as a result of cessation of waiting list activity and
recruitment of some longstanding vacancies in Emergency Care Division. Use of
agency and locums is concerning due to the high cost and adverse productivity.
b. Nursing costs continue to overspend due to the ongoing high use of bank and agency to
cover vacancies and short term bed pressures. Detailed below is the position as at
month 10. Bank and agency spend has deteriorated against the previous month and is
higher than the levels experienced in the last financial year. The variance against
substantive posts has increased over last month. Close monitoring of the recruitment,
retention and use of bank and agency is required. A number of business cases to
reduce reliance on bank and agency have been agreed and are now implemented.
Nursing cost
Qtr 1
Variance
(£’000)
Qtr 2
Variance
(£’000)
Qtr 3
Variance
(£’000)
January
Variance
(£’000)
Cumulative
variance
(£'000)
Nurses in substantive posts
856
695
550
235
2,335
Agency Budget
250
250
250
83
833
Gaps covered through Nurse Bank
(728)
(757)
(764)
(264)
(2,513)
Gaps covered by Agency
(692)
(437)
(419)
(161)
(1,708)
Vacancy Target
(282)
(282)
(282)
(94)
(940)
Net unplanned spend
(595)
(531)
(665)
(201)
(1,992)
c.
The balance of the overspend is related to adverse variances attached to savings
targets not attributed to staff groups offset by underspends in admin and other staff
groups.
The table below highlights the position by division:
Qtr 1
Variance
(£'000)
Qtr 2
Variance
(£'000)
Qtr 3
Variance
(£'000)
January
Variance
(£'000)
Cumulative
Variance
(£'000)
Emergency Care
(425)
(613)
(531)
(250)
(1,819)
Surgery & Cancer
(406)
(649)
(602)
(76)
(1,733)
DIVISION
Women's & Children
55
11
45
(18)
94
Diagnostics & Clinical Support
85
(24)
(99)
(35)
(73)
Estates & Facilities
(74)
15
20
42
2
Corporate Services
TOTAL
281
(483)
18
(1,242)
181
(986)
54
(284)
534
(2,995)
Page 48 of 90
Emergency Care continues to overspend due in the main to ongoing medical and nursing
vacancies/staff turnover and the use of agency and bank staff. There is a continued pressure (£36k)
in A&E related to medical staffing vacancies and staffing CDU overnight to manage bed pressures.
Surgery and Cancer is overspent in month as a result of savings targets not being met in theatres
(£23k), the ward reconfiguration impact on rotas and staffing becoming embedded (£40k) and
additional shifts being worked in critical care as a result of the flu outbreak (£20k). However, this
continues the improvement shown in December.
Womens & Children is marginally overspent in month.
Diagnostics & Clinical is marginally overspent in month.
Estates & Facilities is underspent in month.
Corporate is underspent in month.
A.3 Non pay costs are under spent against plan to date by £771K. This is a movement of £285K in month
some of which is related to the previous month unusual overspend linked to stock movements over the
holiday period. Key variances include:
i. Drugs are adverse by (£287K), particularly in General Medicine, Clinical Haem, Paeds and
GUM. This is offset by the High Cost Drug income variance above.
ii. Clinical supplies is favourable by £973K, associated with Orthopaedic equipment and
appliances £374K, Ophthalmology lens £174K, pathology & imaging consumables £317K
and Blood products £85K.
iii. Non-clinical supplies is adverse by (£29K) as a result of a increased costs related to
disposable items on wards.
iv. Utilities are under-spent by £256K as a result of favourable prices compared to budget.
v. NHS Purchases & Professional fees are overspend by (£150k) as a result of recharges for
lens, sessions for oncology and radiology reporting.
B.
C.
Key Variance and Action Plans
Variance
Action Plan
Executive
Lead
Pay Costs
(£2,995)K
Close monitoring of recruitment to additional
establishment and impact on agency useage.
Support budget holders in management of
agency costs.
Vacancy freeze on non-clinical posts
introduced January 2011.
MO/JH
Understand vacancies in Medical staff and
expedite recruitment programme.
MO/RA
Forecast
The final column of Appendix 1a gives a forecast position of £0.7M. This assumes income and costs
continue with the current variance trend but that support of £1.3M is given to CECPCT to manage their
financial position. It also recognises risks around movement in incomplete spells, winter pressures and a
pending permanent injury claim.
The downside forecast would be break-even assuming the pay trend worsens by £100k per month and the
non-pay trend for under-spend reverts back to budget.
The upside forecast would be £1.3M which assumes income and non-pay costs continue with the current
variance trend and improvements in pay occur as a result of agency usage and efficiencies from theatres
redesign project are released.
Page 49 of 90
Cost Improvement Programme (CIP)
Following review of the impact of the Bed Reconfiguration project and analysis of current and revised
budgets, it has been necessary to reduce the expected level of budget savings as a result of ward closures
and moves. This has been offset by the positive settlement of the 2010-11 contract and additionally
identification of further schemes, most notably in Surgery around additional income from the AMD service of
£650k.
The table below gives an analysis of the original schemes, including the January position against target and
forecast position. In summary, current schemes have identified potential of £6.3m, of which the RAG rating
is £0.1m Amber Red, £1.7m Amber and £4.5m Green.
Target
2010/11
£'000
YTD
Target
£'000
YTD
Actual
£'000
Forecast
£'000
Bed Reconfiguration (AE Executive Lead)
281
127
-393
-251
Emergency Care
247
191
263
251
1472
1235
806
2047
CIP Summary Position
Surgery and Cancer
Women and Childrens
Diagnostics and clinical support
Estates and Facilities
924
755
750
914
1349
1010
1029
1317
498
415
460
535
Corporate teams
1546
1269
1299
1567
TOTAL
6317
5002
4214
6380
Savings identified and actions complete to deliver on time and within value
Green
Scheme identified but no evidence of delivery yet
Amber Red
Uncertainty remains as to the delivery date and the value but the scheme continues to be worked up
The scheme is no longer anticipated to deliver
4524
AR
126
Amber
1730
Red
0
6380
TOTAL
There are a number of schemes being supported by the Quality Matters Programme and these are now
entering implementation stage which will be vital for assurance on delivery in year. A summary of the KPI’s
for these schemes is included in Appendix 5.
Where there is a balance of CIP, the divisions are working on identifying alternative and further schemes to
meet the target level. An analysis of Amber Red schemes is available below.
Detailed Scheme
Closure of ward - QMP
Winter Ward ‐ QMP
Ward reconfiguration (Ward 18/19 to Surgical Corridor) ‐ QMP
Drugs spend on FP10's (Surgery Division)
Reduction in agency and bank useage (Surgery Division)
Admin Review (Surgery Division)
Community Paeds ‐ Admin Band 4 on hold Womens & Children Division ‐ Unidentified slippage
Selling aspetic products
Increase Car Parking fees
RAG
2010/11
Target £'000
YTD
Target
£'000
YTD
Actual
£'000
Forecast
£'000
AR
-235
-235
-366
-366
AR
322
76
81
302
AR
413
365
0
33
AR
67
50
39
67
AR
64
48
17
0
AR
100
50
0
0
AR
26
20
1
1
AR
0
0
0
28
AR
4
0
0
0
AR
90
68
38
60
851
441
‐191
125
Page 50 of 90
4.
BALANCE SHEET (see Appendix 3)
A.
Summary Position
A.1
Cash - balance is currently £4,078K, which is £1,585K less than planned at this stage in the year.
A.2
Current Assets
NHS Debtors are £ 4,645K which is £1,561K more than anticipated. This mainly due to
i)
East Cheshire NHS Trust. £462K is overdue, however only £330K has been
received in February.
University of North Staffordshire NHS Trust £160K with £134K relating to
Nephrology charges for a number of months
Salford Royal Foundation NHS Trust £40K for Radiology charges
Christies Foundation Trust £60k oncology drugs
CECPCT Bowel Screening £224K which has been paid in February
Western Cheshire Bowel Screening £180K which has been paid in February
ii)
iii)
iv)
v)
vi)
A.3
Creditors – Trade Creditors are now £1,162K more than anticipated. This is mainly due to
i)
ii)
iii)
iv)
B.
5.
CECPCT £330K Therapies Contract. This has now been paid in February
East Cheshire £100k
NHS Business Services £175K FP10 invoices which have queries on them
University of North Staffordshire NHS Trust £58K oncology invoice
Key Variances and Action Plans
Variance
Action Plan
£1,561K
Outstanding invoices pursued on a regular
basis
Over 4 month
Debts (464k)
East Cheshire - £365k These are being paid
and a resolution has been agreed to
Consultants recharge
Betsi Cadwaladar NCA £67k awaiting critical
care information. They have now received
information.
Executive
Lead
MO
MO
MO
CAPITAL PROGRAMME (see Appendix 6)
A.
Summary Position
A.1
The capital programme for 2010/11 is £6,250k, of which £750K for medical equipment replacement
is to be funded through lease arrangements. .
The spend to the end of January is £3,803K with £91K being paid in February leaving a variance of
£260K.
Page 51 of 90
B.
Key Variances and Action Plans
Variance
Action Plan
£262K
6.
Executive
Lead
To monitor capital spend
MO
CASH FLOW (see Appendix 3)
A.
Summary Position
A.1
Cash balance at the end of January is £4,078K, which is £1,585K less than anticipated at this stage
in the year, the material variances are due to:
i.
ii.
iii.
iv.
Movement in working capital (Debtors and Creditors)
Surplus
Financing activities
Investing activities
(1.3)M
(0.8)M
0.5M
0.0M
The chart below shows a cash flow forecast based on the 2010-11 plan with a rolling 12 month projection.
Cash Forecast
8000
7000
6000
5000
0
0 4000
'0
£
3000
Plan
Actual
2000
Forecast
1000
0
0
1
‐r
p
A
0
1
‐y
a
M
0
1
‐
n
Ju
0
1
l‐
u
J
0
1
‐g
u
A
0
1
‐
p
eS
0
1
t‐c
O
0
1
‐v
o
N
0
1
‐c
e
D
1
1
‐
n
aJ
1
1
‐
b
eF
1
1
‐r
a
M
1
1
‐r
p
A
1
1
‐y
a
M
1
1
‐
n
Ju
1
1
l‐
u
J
1
1
‐g
u
A
1
1
‐
p
eS
1
1
t‐c
O
1
1
‐v
o
N
1
1
‐c
e
D
2
1
‐
n
aJ
Page 52 of 90
Financial Institution Cash Balances 2010/11
Min
Balance
£'000
Max
Balance
£'000
Current
Interest
Rate
Interest
Received
Royal Bank of Scotland AA-
285
13,754
0.50%
23
GBS
419
14,189
0.25%
5
Financial Institution
Fitch LT
Risk
Rating
N/A
Investment Profile as at 31st January 2011
Period of Investment
On Call
1-5 Days
1 month
1-3 Months
£'000
4,076
-
Page 53 of 90
APPENDICES
Appendix
Board
1a.
Income and Expenditure Account
1b.
Monthly Income and Expenditure analysis for the quarter
2.
Balance Sheet – Statement of Position
3.
Cash Flow
4.
Forecast Income and Expenditure Account
5.
Cost Improvement Programme – QMP KPI’s
6.
Capital programme
Page 54 of 90
Appendix 1a
Income and expenditure report for the period April 2010 to January 2011
Quarter to Date
Year to Date
Actual
Plan Q4 Q4 to Var Q4 Plan Apr to Actual Apr Var Apr to
date
to date
January
to January
to date
January
(£'000)
(£'000)
(£'000) (£'000) (£'000)
(£'000)
Base
Budget
2010/11
£'000
Forecast
2010/11
(£'000)
Operating
N H S C linic a l R e v e nue
10,362
37
0
0
55,516
1,045
16,562
132
25,503
2,423
5,865
0
0
27062
144,507
0
144,507
1622
924
2,546
4,915
10,818
15,733
162,786
-8,269
-12,003
0
-2,148
- 109,814
-757
-18,434
-151,425
11,361
NHS Acute Activity Income
Elective revenue, long Stay
Elective revenue, Short Stay
Non-Elective Revenue
Planned Same day (day cases)
Outpatients
A&E
Other NHS
Tariff
Non Tariff
Tariff
Non Tariff
Tariff
Non Tariff
Tariff
Non Tariff
Tariff
Non Tariff
Tariff
Non Tariff
Tariff
Non Tariff
Sub Total
PbR Claw back
Total NHS Clinical Revenue
Non Mandatory/Non protected revenue
Private Patients revenue
Other Non Mandatory/Non protected clinical
Total
Other Operating Income
Research and Development Income
Education and training
Other
Total
TOTAL OPERATING INCOME
Operating Expenses
Drugs
Clinical Supplies
Decrease(increase) in inventories of finished
goods & WIP
Non Clinical Supplies
Employee Benefits Expenses (Pay)
Education and Training expense
Other operating expenses
TOTAL OPERATING EXPENSES COSTS
EBITDA
829
3
0
0
4,692
89
1,330
11
2,048
195
461
0
0
2,232
11,890
0
11,890
481
0
0
0
4,744
38
1,293
11
2,062
258
435
0
0
2,755
12,078
0
12,078
-348
-3
0
0
52
-51
-37
0
14
64
-26
0
0
523
189
0
189
8,569
31
0
0
46,122
865
13,702
109
21,099
2,004
4,925
0
0
22,521
119,948
0
119,948
7,694
28
0
0
46,235
735
13,856
152
21,871
2,562
5,234
0
0
22,911
121,277
0
121,277
-875
-3
0
0
113
-130
154
43
771
557
309
0
0
390
1,329
0
1,329
9,300
33
0
0
55,652
888
16,749
184
26,436
3,097
6,233
0
0
27,530
146,102
0
146,102
128
77
205
79
85
164
-49
8
-41
1,273
770
2,043
1,180
837
2,017
-93
67
-26
1,402
995
2,397
409
1,187
1,596
431
1,270
1,701
22
83
105
4,155
11,741
15,896
4,245
11,839
16,084
90
98
188
5,045
13,738
18,783
13,691
13,943
253
137,887
139,378
1,491
167,282
-701
-1,047
-688
-760
13
287
-6,591
-10,706
-6,878
-9,733
-287
973
-8,243
-11,664
0
-173
-9,529
-29
-1,671
0
-166
-9,813
-22
-1,700
0
7
-284
7
-29
0
-1,739
-93,924
-257
-15,504
0
-1,768
-96,918
-242
-15,405
0
-29
-2,994
15
99
-380
-2,119
-116,023
-290
-18,844
-13,150 -13,149
1
-128,721
-130,944
-2,223
-157,562
541
794
254
9,166
8,434
-732
9,720
6
3
-3
66
29
-37
0
-8
-8
0
-8
-8
44
0
0
-12
-303
-15
-317
-3
-14
-243
-2,961
-175
-2,759
68
202
-220
-2,721
-147
-147
0
-1,574
-1,574
0
-2,468
-305
0
5
0
1
0
227
0
-3,060
0
1,394
0
-3,059
0
888
0
1
0
-506
0
-3,672
0
683
Non Operating
82
0
-290
-3,164
-2,295
Non Operating Incom e
Finance Income
Interest Income
Other Non-Operating income
Proft(loss) on asset disposal
Non-Operating Expenses
Finance Cost
Interest Expense on Finance leases (non-PFI)
Depreciation & Amortisation - Ow ned Assets
Depreciation & Amortisation - assets held under
finance lease
Impairment
-3,670
PDC Dividend Expense
0
Taxation payable
2,024 Net Surplus/(deficit)
0
-306
0
-221
Comments
Page 55 of 90
Appendix 1b
Monthly I&E report for quarter 4
January
Actual
(£'000)
Plan
(£'000)
February
Variance
(£'000)
Plan
(£'000)
Variance
(£'000)
Actual
(£'000)
Quarter to date
March
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Plan
(£'000)
Actual
(£'000)
Variance
(£'000)
Inc o m e
NHS Clinical Inco me
Elective Income
Tariff
Non Tariff
Elective revenue, ShoTariff
Non Tariff
Non-Elective Income Tariff
Non Tariff
Planned Same day (d Tariff
Non Tariff
Outpatients
Tariff
829
481
-348
0
0
0
0
0
0
829
481
-348
3
0
-3
0
0
0
0
0
0
3
0
-3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4,692
4,744
52
0
0
0
0
0
0
4,692
4,744
52
89
38
-51
0
0
0
0
0
0
89
38
-51
1,330
1,293
-37
0
0
0
0
0
0
1,330
1,293
-37
11
11
0
0
0
0
0
0
0
11
11
0
2,048
2,062
14
0
0
0
0
0
0
2,048
2,062
14
Non Tariff
195
258
64
0
0
0
0
0
0
195
258
64
A&E
Tariff
461
435
-26
0
0
0
0
0
0
461
435
-26
Non Tariff
0
0
0
0
0
0
0
0
0
0
0
0
Other
Tariff
0
0
0
0
0
0
0
0
0
0
0
0
Non Tariff
Sub Total
PbR Claw back
Total NHS Clinical Incom e
2,232
2,755
523
0
0
0
0
0
0
2,232
2,755
523
11,890
12,078
189
0
0
0
0
0
0
11,890
12,078
189
0
0
0
0
0
0
0
0
0
0
0
0
11,890
12,078
189
0
0
0
0
0
0
11,890
12,078
189
128
79
-49
0
0
0
0
0
0
128
79
-49
77
85
8
0
0
0
0
0
0
77
85
8
205
164
-41
0
0
0
0
0
0
205
164
-41
Non NHS clinical Income
Private Patients revenue
Other clinical Income (RTA's)
Total
Other Income
Education and training
409
431
22
0
0
0
0
0
0
409
431
22
Other
1,187
1,270
83
0
0
0
0
0
0
1,187
1,270
83
Total
1,596
1,701
105
0
0
0
0
0
0
1,596
1,701
105
TOTAL INCOME
13,691
13,943
253
0
0
0
0
0
0
13,691
13,943
253
-9,529
-9,813
-284
0
0
0
0
0
0
-9,529
-9,813
-284
-701
-688
13
0
0
0
0
0
0
-701
-688
13
-1,047
-760
287
0
0
0
0
0
0
-1,047
-760
287
-173
-166
7
0
0
0
0
0
0
-173
-166
7
-29
-22
7
0
0
0
0
0
0
-29
-22
7
-29
Expenses
Pay Costs
Drug Costs
Clinical Supplies and services
Non Clinical Supplies
Education and Training expense
Other Costs
-1,671
-1,700
-29
0
0
0
0
0
0
-1,671
-1,700
-13,150
-13,149
1
0
0
0
0
0
0
-13,150
-13,149
1
541
794
254
0
0
0
0
0
0
541
794
254
profit/Loss on Asset Disposal
0
-8
-8
0
0
0
0
0
0
0
-8
-8
Impairments
0
0
0
0
0
0
0
0
0
0
0
0
Depreciation Ow ned Assets
-303
-317
-14
0
0
0
0
0
0
-303
-317
-14
Depreciation finance lease
-147
-147
0
0
0
0
0
0
0
-147
-147
0
6
3
-3
0
0
0
0
0
0
6
3
-3
-12
-15
-3
0
0
0
0
0
0
-12
-15
-3
0
0
0
0
0
0
0
0
0
0
0
0
Taxation payable
-306
-305
1
0
0
0
0
0
0
-306
-305
1
Net Surplus/(deficit)
-221
5
227
0
0
0
0
0
0
-221
5
227
-380
-380
0
0
-380
-380
0
0
0
0
0
0
0
0
0
0
-375
-153
TOTAL COSTS
EBITDA
Total Interest receivable/(Payable)
Total interest payable on Loans
and Leases
PDC Dividend
Exceptional item s
CECPCT Agreement
Norm alised position
-221
-375
-153
0
0
0
0
0
0
-221
Page 56 of 90
STATEMENT OF POSITION
Plan Apr Actual Apr
to January to January Variance
(£'000)
(£'000)
(£'000)
Forecast
2010/11 (£'000)
Assets
Assets, Non-Current
Intangible Assets, Net
Property, Plant and Equipment, Net
Trade and Other Receivables,Net,Non Current
NHS Trade Receivables, Non Current
Prepayments, Non -Current
Total Assets, Non-Current
Assets, Current
Inventories
Trade and other Receivables,Net,Current
NHS Trade Receivables, Current
Non NHS Trade Receivables, Current
Other Financial Assets, Current
Accrued income
Prepayments, Current
Non Current Assets held for sale
Cash and Cash Equivalents
Total Assets, Current
ASSETS, TOTAL
577
112,619
575
108,830
-2
-3,789
933
109,234
416
0
434
0
18
0
434
113,612
109,840
-3,772
110,601
3,131
2,980
-151
3,092
3,084
1,785
4,645
1,917
1,561
132
4,437
1,959
0
1,240
3
5,663
14,906
0
1,322
3
4,078
14,944
0
82
0
-1,585
38
1,025
0
2,285
12,798
128,518
124,784
-3,734
123,399
-104
-434
-91
-2,193
-162
-387
-176
-2,173
-58
47
-85
20
-1,435
-124
-201
-2,218
-3,820
-1,437
-717
-4,982
-1,409
-429
-1,162
28
288
-4,775
-1,287
-1,206
-2,769
-1,223
-12,788
-2,002
-1,223
-12,944
767
0
-156
-1,719
0
-12,965
2,118
2,000
-118
-167
-7,174
-1,423
-3,579
-1,368
3,595
55
-2,557
-1,518
-31
0
-31
0
0
0
0
-8,628
-4,978
3,650
-4,075
107,102
106,861
-241
106,359
49,946
11,629
2,010
49,946
11,154
2,405
0
-475
395
49,946
10,963
1,987
43,517
43,356
-161
43,463
107,102
106,861
-241
106,359
107,102
106,861
-241
106,359
Liabilities
Liabilities, Current
Finance Lease, Current
Deferred Income, Current
Provisions, Current
Current Tax Payables
Trade and Other Payables, Current
Trade Creditors, Current
Other Creditors, Current
Capital Creditors, Current
Other Financial Liabilities
Accruals, Current
PDC dividend creditor, Current
Total Liabilities, Current
Net Current Assets/(Liabilities)
Liabilities, Non Current
Non-Interest-Bearing Borrow ings, Non-Current
Provisions, Non-Current
Trade and Other Payables, Non-Current
Trade Creditors, Non-Current
Other Creditors, Non-Current
Total Liabilities Non-Current
TOTAL ASSETS EMPLOYED
Taxpayers' and Others' Equity
Taxpayers Equity
Public dividend capital
Retained Earnings
Donated asset reserve
Other reserves (government grant reserve etc)
Revaluation Reserve
TOTAL TAXPAYERS EQUITY
TOTAL FUNDS EMPLOYED
Comments
Page 57 of 90
Appendix 3
Cash flow statement to Period end 31st January 2011
Plan Apr Actual Apr
to January to January
(£'000)
(£'000)
Variance
Surplus/(deficit) after tax
1,454
888
-566
177
-87
146
-98
-31
-11
Non-cash flows in operating Surplus/(deficit)
- Finance Income/Charges
- Other operating non cash movements
- Impairments
- Depreciation and Amortisation
4,485
4,333
-152
Non-cash flows in operating Surplus/(deficit) total
4,575
4,381
-194
6,029
5,269
-760
Increase/(Decrease) in working capital
- Inventories
- NHS Trade receivables
- Non NHS Trade receivables
- Accrued Income
- Prepayments
- Deferred Income
- Provisions
- Tax payable
- Trade Creditors
- Other Creditors
- Accruals
- PDC Dividend Creditor
Increase/(Decrease) in working capital Total
-40
1,317
0
0
-488
0
-431
48
-1,925
32
0
1,210
-277
111
-244
-150
0
-570
-47
-401
28
-763
4
-767
1,210
-1,588
151
-1,561
-150
0
-82
-47
30
-20
1,162
-28
-767
0
-1,311
Net cash inflow /(outflow ) from operating activities
5,752
3,681
-2,071
Net cash inflow/(outflow) from investing activities
- Property, plant and equipment
-4,154
-3,833
321
-Movement in capital creditors
Net cash inflow/(outflow) from investing activities total
3
-4,151
-285
-4,118
-288
33
1,601
-436
-2,037
0
-243
-1,850
66
36
0
-1,991
0
-175
-1,471
29
57
23
-1,537
0
68
379
-37
21
23
454
-390
-1,973
-1,583
6,053
6,053
0
5,663
4,080
-1,583
Operating cash flow s before m ovem ents in w orking capital
Net Cash inflow /(outflow ) before financing
Net cash inflow/(outflow) from financing activities
- Public Dividend Capital received
- interest element of finance lease rental payments
- Capital element of finance lease rental payments
- Interest received on cash and cash eqivalents
- Cash flow s from other financing activities
- Cash receipt from asset sales
Net cash inflow/(outflow) from financing activities Total
Net increase/(decrease) in cash and cash equivalents
Opening cash balance
Closing cash balance
Comments
Page 58 of 90
Appendix 4
FORECAST INCOME AND EXPENDITURE ACCOUNT
See Forecast in 1a and narrative.
Page 59 of 90
C O S T IM P R O V E M E N T P R O G R A M M E
A p p e n d ix 5
Q M P T o p K e y P e r fo r m a n c e In d ic a t o r s
Ke y:
C o m p lian t w it h / E x ce e d s Tar g e t
W it h in 1 0 % o f Ta r g e t
F a ile d Tar g e t
K P I N o .
K P I 5
K P I 1 7 In d icat o r
Tar g e t
O v e r all % o f A & E p a t ie n t s D isch ar g e d / A d m it t e d (in clu d in g V IN ‐ M in o r s & M ajo r s)
75%
85%
95%
100%
08/09 B ase lin e
5 4 .1 %
7 9 .7 %
8 8 .3 %
9 8 .1 %
9 .4
1 0 .3
C u m m u lat iv e E m e r g e n cy C ar e L e n g t h o f st ay < 2 h r s
< 3 h r s
< 3 ½ h r s
< 4 h r s
N o t e : R e st at e d M t h 7 C H K S
Tr aje c t o r y A c t u al
V ar i an c e M o n t h y Tar g e t b e fo r e 1 1 am
M o n t h ly Tar g e t b e fo r e 3 p m
K P I 2 0
K P I 1 1
D isch ar g e s N o t e : R e st at e d M t h 9 t o In clu d e D isch ar g e s fr o m EA U
5 0 % R e d u ct io n in can ce llat io n s b y p at ie n t
M o n t h l y t ar g e t aft e r 3 p m
A c t u al M o n t h l y D i sc h ar g e s b e fo r e 1 1 am
V a r i e s p er V a r i e s p er m o n th
m o n th
A u g ‐1 0
6 3 .6 %
8 4 .4 %
9 1 .6 %
9 9 .0 %
S e p ‐1 0
5 8 .7 %
8 1 .5 %
8 8 .8 %
9 7 .1 %
O ct ‐1 0
5 5 .5 %
7 7 .7 %
8 5 .3 %
9 5 .7 %
N o v ‐1 0
5 7 .3 %
7 8 .5 %
8 6 .9 %
9 6 .3 %
D e c‐1 0
Ja n ‐1 1
5 3 .6 %
7 4 .5 %
8 2 .6 %
9 3 .1 %
5 9 .0 %
7 9 .8 %
8 6 .9 %
9 5 .9 %
9 .9
1 0 .3
‐0 .4
9 .8
1 0 .1
‐0 .3
9 .7
1 0 .0
‐0 .3
9 .7
9 .9
‐0 .2
9 .6
9 .7
‐0 .1
9 .5
9 .5
0 .0
9 .4
9 .4
0 .0
9 .3
9 .2
‐0 .1
9 .2
9 .1
‐0 .1
9 .2
9 .1
‐0 .1
534
531
534
543
559
556
552
556
578
562
266
261
266
269
269
266
261
266
277
344
0
0
0
0
0
0
0
0
0
156
165
168
170
167
282
279
313
364
359
337
357
366
386
379
A c t u al M o n t h l y D i sc h ar g e s aft e r 3 p m
471
476
494
565
531
543
520
583
627
562
260
474
214
260
430
170
260
547
287
260
536
276
260
522
262
260
511
251
260
489
229
260
498
238
260
473
213
260
423
163
260
494
227
533
306
227
453
226
227
468
241
227
508
281
227
446
219
227
521
294
227
370
143
227
480
253
227
489
262
227
458
231
227
227
98%
9 6 .0 %
98%
8 9 .7 %
9 8 .0 %
8 6 .4 %
‐1 1 .6 %
9 8 .0 %
8 6 .3 %
‐3 .7 %
9 8 .0 %
8 7 .9 %
‐1 0 .1 %
9 8 .0 %
8 9 .6 %
‐0 .4 %
9 8 .0 %
8 9 .8 %
‐8 .2 %
9 8 .0 %
8 9 .3 %
‐8 .8 %
9 8 .0 %
8 1 .3 %
‐1 6 .7 %
9 8 .0 %
8 0 .0 %
‐1 8 .0 %
9 8 .0 %
8 0 .1 %
‐1 7 .9 %
9 8 .0 %
7 9 .0 %
‐1 9 .0 %
9 8 .0 %
8 6 .8 %
‐1 1 .2 %
9 8 .0 %
8 8 .6 %
‐9 .4 %
9 8 .0 %
9 0 .2 %
‐7 .8 %
9 8 .0 %
8 7 .2 %
‐1 0 .8 %
9 8 .0 %
9 4 .4 %
‐3 .6 %
9 8 .0 %
9 0 .0 %
‐8 .0 %
9 8 .0 %
8 9 .8 %
‐8 .2 %
9 8 .0 %
9 1 .6 %
‐6 .4 %
9 8 .0 %
7 6 .4 %
‐2 1 .6 %
9 8 .0 %
9 1 .7 %
‐6 .3 %
85%
7 3 .6 %
85%
7 0 .0 %
8 5 .0 %
6 8 .8 %
‐1 6 .2 %
8 5 .0 %
6 7 .0 %
‐1 8 .0 %
8 5 .0 %
7 3 .3 %
‐1 1 .7 %
8 5 .0 %
7 0 .2 %
‐1 4 .8 %
8 5 .0 %
7 5 .6 %
‐9 .4 %
8 5 .0 %
6 8 .1 %
‐1 7 .0 %
8 5 .0 %
7 5 .8 %
‐9 .2 %
8 5 .0 %
6 5 .8 %
‐1 9 .2 %
8 5 .0 %
7 7 .8 %
‐7 .2 %
8 5 .0 %
6 8 .0 %
‐1 7 .0 %
8 5 .0 %
7 5 .8 %
‐9 .2 %
8 5 .0 %
7 0 .1 %
‐1 4 .9 %
8 5 .0 %
7 7 .1 %
‐7 .9 %
8 5 .0 %
7 2 .7 %
‐1 2 .3 %
8 5 .0 %
7 6 .0 %
‐9 .0 %
8 5 .0 %
7 0 .0 %
‐1 5 .0 %
8 5 .0 %
6 8 .7 %
‐1 6 .3 %
8 5 .0 %
7 3 .1 %
‐1 1 .9 %
8 5 .0 %
7 0 .7 %
‐1 4 .4 %
8 5 .0 %
7 2 .1 %
‐1 2 .9 %
V ar i an c e Tr aje c t o r y A c t u al
V ar i an c e Tr aje c t o r y A c t u al
V ar i an c e 9 .1
520
Tr aje c t o r y A c t u al
F e b ‐1 1
260
Tr aje c t o r y A c t u al
TC
6 1 .6 %
8 3 .4 %
9 1 .6 %
9 8 .7 %
164
A c t u al
I/ P
Ju l‐1 0
139
V ar i an c e K P I 2 1 8 5 % A v ailab le C lin ical C o n t act T h e at r e t im e U t ilisise d (ie e x clu d e lat e st ar t s, e ar ly fin ish e s, g ap s b e t w e e n ca se s a n d o v e r r u n s)
5 9 .4 %
8 2 .3 %
9 0 .3 %
9 8 .4 %
147
Tr aje c t o r y TC
Ju n ‐1 0
124
A c t u al
I/ P
6 3 .1 %
8 4 .9 %
9 2 .2 %
9 9 .0 %
164
V ar i an c e K P I 1 4 9 8 % o f fu n d e d list s u t ilise d (e x clu d e s W ait in g L ist s) M a y ‐1 0
144
Tr aje c t o r y 5 0 % R e d u ct io n in can ce llat io n s b y h o sp it al
5 9 .0 %
8 0 .9 %
8 7 .9 %
9 7 .5 %
A c t u al M o n t h l y D i sc h ar g e s b e fo r e 3 p m
V ar i an c e K P I 1 2
A p r ‐1 0
Page 60 of 90
Capital Programme as at 31st January 2011
Key Project
Original
Capital
Budget
£'000
98
CT/VT Mains
259
(Interim) Fire Measures
50
Fire Alarm System (Additional Capacity)
273
200
Appendix 6
Budget
to Date
£'000
Actual to Charged
in
Date
Next
£'000
Month
£'000
ONGOING W ORKS
72
0
Better /
(W orse)
than
Budget
£'000
%
Forecast
Carry Committed /
Completed
Not
£'000
Forw ard
to Date
to next Committed
year
£'000
Expected
Completion
Date
72
98
Yes
10
Mar-11
199
18
181
259
Yes
10
Mar-11
50
0
50
50
Yes
10
Street Refurbishment /Asbestos removal/containment
223
273
-50
273
Yes
100
CT phases 3 & 4
200
201
-1
200
Yes
100
Complete
0
-14
14
-14
Yes
100
Complete
Roads & Pavements
W ard (14) Refurbishment
0
0
0
Urgent Care Centre
0
0
0
VIN Car Park Drainage & OPD Carpark resurfacing
0
0
0
0
0
-13
13
-11
0
6
-6
6
Other under / Over 0910 Schemes
- Disability Discrimination Flat 25 & 26
Mar-11
Complete
NEW W ORKS
1220
W ard 5 & 3 Refurb
1220
1306
-86
1220
300
Outpatients
125
0
125
30
150
Consultant W ard 21 Offices
150
147
3
150
200
Additional W ard Siderooms
200
147
53
100
Breast Screening Extension
100
72
28
36
0
DSA / DDA
300 No
0
Jul-12
Yes
100
Complete
200
Yes
95
Feb-11
100
Yes
95
Feb-11
36
46
Yes
80
Mar-11
334
598
Part
40
Mar-11
0
82
Yes
100
Complete
Complete
BACKLOG
598
82
8
5
21
Backlog Maintenance
- Generators 1&2 synchrnisation unit
82
82
- VIN Enabling
17
17
0
8
Yes
100
5
5
0
5
Yes
90
Mar-11
19
19
0
21
Yes
100
Complete
100
100
0
148
Yes
95
Feb-11
13
0
13
13
Yes
100
Complete
Complete
- Rascals
- Mortuary Floor
148
- Gas Mains
13
- Boiler House Steam Meters
5
720
334
- W ater Softener
- Street Refurbishment
- Bulk Oil Store
- A&E Footpath
- W ard 6A Plate Heat Exchanger
5
5
0
5
Yes
100
629
629
0
720
Yes
85
Mar-11
11
11
0
Yes
100
Complete
Yes
100
Jan-11
6
5
1
29
29
0
Page 61 of 90
Key Project
Original
Capital
Budget
£'000
Budget Actual to Charged
to Date
Date
in
£'000
£'000
Next
Month
£'000
IM&T
Expected
Completion
Date
199
MIPLC
0
9
-100
139
Yes
50
112
Maternity Information System
0
59
-59
112
Yes
85
Apr-11
28
Digital Dictation
0
0
0
28
Yes
70
Mar-11
118
Business Continuity / Storage & Backup
0
72
-72
118
No
50
Mar-11
16
Integra
0
0
0
16
Yes
0
Jun-11
80
Replacement Hardware PAS
0
0
0
80
No
0
Mar-11
82
No
0
2011/12
82
91
%
Carry Committed /
Better / Forecast
Not
Completed
£'000
Forward
(Worse)
to Date
to next Committed
than
year
Budget
£'000
£'000
Theatre Scheduling
0
0
0
Colposcopy
0
0
0
Diabetic Retinopathy Module
0
9
-9
Computer Server Room Lease Buyout
0
14
ICS Lease Buyout
0
29
200
6
Dec-11
Yes
100
Oct-10
10
Yes
100
Dec-10
-14
14
Yes
100
Jan-11
-29
29
Yes
100
Dec-10
242
-42
240
Yes
83
Mar-11
6
0
6
Yes
100
Mar-11
40
12
52
Yes
100
OTHER
240
Design Team
52
Painting Division
52
Medical Contingency
52
36
NIV Equipment
36
25
11
36
Yes
100
Nov-11
0
39
-39
39
Yes
100
Nov-11
Meal Delivery Lease Buyout
5465
Electrolux Catering Lease Buyout
0
93
-93
93
Yes
100
Jan-11
Laundry Lease Buyout
0
29
-29
29
Yes
100
Jan-11
Computer Services Building Lease Buyout
0
56
-56
56
Yes
100
Dec-11
4119
3768
260
5386
Yes
100
Complete
TOTAL OWNED PROGRAMME
91
FINANCE LEASE AND OTHER SOURCES OF FUNDING
35
MA 12 Flat refurbishment
35
35
0
35
500
Medical Equipment Funded through Leasing Arrangements
0
0
0
500
250
Medical Contingency
0
0
0
250
4154
3803
260
6171
6250
TOTAL APPROVED PROGRAMME
91
N/A
Page 62 of 90
Section 3 System Delivery Focus
Accountable Office – Denise Frodsham
Page 63 of 90
ACTIVITY, TARGET AND STANDARDS
Summary of system focus section
Referrals & Activity from all Commissioners against Contract Target
In month performance against target for all referrals
up 1.5%
Cumulative performance against target for all referrals up 0.9%
In month activity for outpatients
New
Follow-up
Overall
down 1.3%
down 1.1%
down 1.1%
Cumulative activity for outpatients
New
Follow-up
Overall
up 3.1%
up 2.3%
up 2.6%
In month activity for admissions
Non-elective
Inpatients
Daycase
Overall
up 1.1%
down 46.3%
down 6.0%
down 4.5%
Cumulative activity for admissions
Non-elective
Inpatients
Daycase
Overall
up 2.6%
down 16.3%
down 0.3%
up 0.3%
Divisional Activity Summary
This shows a detailed breakdown of Activity By Division cumulatively against target and
against last year.
GP referrals are up against target and last year’s performance in all clinical divisions
except Women & Children.
First out-patient attendances are down in Diagnostics and Emergency Care against last
year’s performance and target. Surgery & Cancer and Women & Children are up against
both.
Follow-up out-patient attendances are down in Surgery & Cancer and Emergency Care
against last year’s performance. Emergency Care is the only division down against
target.
Non elective spells are up on last year’s performance and target in Surgery & Cancer,
Women & Children and Emergency Care. Diagnostic spells are to low to show a
realistic trend.
Elective activity is up on target in Diagnostics but down in Surgery & Cancer, Emergency
Care and Women & Children. Against last year’s performance only Surgery & Cancer is
down.
Page 64 of 90
Performance Targets & Standards
This gives the details behind the national, and some local, targets & standards
Tabular data in graphical form
Show performance against LDP targets and national Standards
Graph1
Graph 2
Graph 3
Graph 4
Graph 5
Graph 6
Graph 7
Graph 8
Graph 9
Graph 10
Graph 11
Graph 12
Graph 13
Graph 14
Graph 15
Graph 16
Graph 17
Graph 18
Inpatient Long waiters are up considerably on last month and waiting
lists in General Surgery, Orthopaedics and Urology have significant risks.
Outpatient long waiters are down overall but waiting lists in General
Surgery, Orthopaedics ENT, Ophthalmology, Dermatology and
Gastroenterology have significant risks.
18 week RTT (90% admitted and 95% non-admitted) - performance in
Jan ‘11 was 89.4% and 97.3% respectively and so the old 18 Week RTT
admitted target would have failed in month. In Jan ‘11 the following
specialties didn’t passed the old 18 Week RTT target: Orthopaedics
(Admitted & Non-Admitted), General Surgery (Admitted & Non-Admitted),
Urology (Admitted) and Gynaecology (Admitted).
4 hourly performance was above the new 95% target at approximately
96.18% in Jan ’11. Yearly performance is currently (20/2/11) above the
95% target at 97.43%.
RTT Median Waits (11.1 wks admitted and 6.6 wks non-admitted) –
achieved in Jan ’11 for both admitted (11 wks) and non-admitted waits (5
wks).
RTT 95 Percentile Waits (27.7 wks admitted and 18.3 wks non-admitted)
– achieved in Jan ’11 for both admitted (23 wks) and non-admitted waits
(17 wks). Please note the admitted RTT target from April ’11 onwards is
23 weeks and so at risk of failure.
Thrombolysis - Call to Needle – underachieved YTD up to Jan ‘11.
Cancer 14 day – Achieved in Jan ’11 and currently YTD.
Cancer 31 day – Failed in Jan ’11 but currently achieving YTD.
Cancer 62 day – Underachieved in Dec ’10 but currently achieving YTD.
Cancer 14 day breast – Achieved in Jan ’11 and currently YTD.
Cancer 31 days to subsequent treatment – Achieved in Jan ’11 and
currently YTD.
Cancer 62 day screen to treatment – Underachieved in Dec ’10 but
currently achieving YTD.
Cancelled Operations seen in 28 days – Achieved in Jan ’10 but
currently underachieving YTD.
Cancelled Operations on the Day – Underachieving YTD.
Occupied bed days – The monthly Medical Outliers are below the
average for last year but has risen since last month. The monthly Beds
occupied by Delayed Discharges are below the average for last year and
is down significantly since last month.
MRSA – Target for year is 5. No bacteraemia were reported in Jan ’11
and YTD.
C-Diff - Target for year is 106. 11 cases were reported in Jan ‘11 which
is above the monthly trajectory but just below the YTD trajectory.
Emergency Bed days – continues to be above the 03/04 baseline, red
rated.
GUM - 100% seen within 48 hours although national target is still
appointment given within 48 hours.
Page 65 of 90
MID CHESHIRE HOSPITALS FOUNDATION NHS TRUST
Referrals
Activity Measure
Monthly Performance
Target Actual Var'ce % Var
3767
3884
117
3.1%
3114
3099
-15
-0.5%
6881
6983
102
1.5%
Year to Date
Target Actual Var'ce % Var
39556 40151
595
1.5%
32692 32764
72
0.2%
72248 72915
667
0.9%
Activity Summary: Outpatients
Activity Measure
Annual
Monthly Performance
Target
Target Actual Var'ce % Var
New Attendances
73591
5911
5836
-75
-1.3%
Follow Up Atts
163782
13155 13013
-142
-1.1%
TOTAL ATTS
237373
19066 18849
-217
-1.1%
Year to Date
Target Actual Var'ce % Var
60883 62762
1879
3.1%
135498 138672
3174
2.3%
196381 201434
5053
2.6%
Activity Summary: Admitted Patient Care
Activity Measure
Annual
Monthly Performance
Target
Target Actual Var'ce % Var
Non Elective Spells
38486
3227
3263
36
1.1%
Elective IP Spells
4590
369
198
-171 -46.3%
Day Cases
23286
1870
1758
-112
-6.0%
TOTAL SPELLS
66362
5466
5219
-247
-4.5%
Year to Date
Target Actual Var'ce % Var
31914 32746
832
2.6%
3797
3179
-618 -16.3%
19265 19201
-64
-0.3%
54977 55126
149
0.3%
GP Referrals
Other Sources
TOTAL REFS
Annual
Target
47656
39386
87042
MONTH: January 2011
Average Percentage Bed Occupancy (at midnight)
Monthly Performance
Activity Measure 2009/10
Perf
2009/10 2010/11 Var'ce
Adult Medical
91.9%
92.2% 92.0%
-0.2%
Adult Surgical
88.8%
92.0% 83.7%
-8.3%
Adult Gen & Acute
90.8%
92.1% 89.2%
-2.9%
Year to Date
2009/10 2010/11 Var'ce
92.4% 89.9%
-2.5%
89.0% 85.2%
-3.8%
91.1% 88.3%
-2.8%
Page 66 of 90
Inpatient and Day Case Waiting Lists
Activity Measure
March
Oct
2010
2010
<2 weeks
790
689
2 to 4 weeks
1046
934
5 to 7 weeks
398
431
8 to 10 weeks
270
262
11 to 14 weeks
122
181
> 14 weeks
95
104
TOTAL
2721
2601
Nov
2010
759
810
456
305
156
111
2597
Dec
2010
437
1083
563
320
264
145
2812
Jan
2011
792
727
492
403
351
177
2942
11
11
12
13
5.6%
5.9%
6.4%
6.5%
4.3%
Outpatient Waiting Lists
Activity Measure
March
2010
< 1 week
730
1 to 2 weeks
830
2 to 3 weeks
603
3 to 4 weeks
558
4 to 5 weeks
468
> 5 weeks
1152
TOTAL
4341
Oct
2010
809
734
669
526
473
1567
4778
Nov
2010
584
766
629
559
412
1400
4350
Dec
2010
314
593
558
519
480
1588
4052
Jan
2011
644
742
669
448
214
1343
4060
8
8
8
8
18 week Referral to Treatment Times
Number of Open Pathways
Activity Measure
March
Oct
2010
2010
< 4 weeks
3782
3232
4 to 6 weeks
2635
2629
7 to 11 weeks
2660
2836
12 to 14 weeks
499
827
15 to 17 weeks
357
496
>= 18 weeks
232
484
TOTAL
10165
10504
Nov
2010
3325
2331
2864
729
592
417
10258
Dec
2010
3254
2355
2600
694
819
487
10209
Jan
2011
4223
1576
2526
602
774
550
10251
Monthly Performance
Pathways ending
Annual
with:
Target
Admission
90%
Non Admission
95%
Nov
2010
92.6%
98.0%
Dec
2010
93.8%
97.7%
Jan
2011
89.4%
97.3%
90th percentile waiting time(wks)
%age Suspended
90th percentile waiting time(wks)
Oct
2010
94.1%
97.8%
Page 67 of 90
CUMULATIVE ACTIVITY SUMMARY
MONTH: January 2011
GP Referrals
Annual
Target
25560
9227
7754
5115
47656
Year to Date Performance
09/10
10/11
10/11
YTD
Target
YTD
21038 21216 21703
7810
7659
8431
6385
6436
5737
4260
4246
4280
39493 39556 40151
Performance Variance
from Target
from 2009/10
Number
%
Number
%
487
2.3%
665
3.2%
772 10.1%
621
8.0%
-699 -10.9%
-648 -10.1%
34
0.8%
20
0.5%
595
1.5%
658
1.7%
First OP Attendances
Annual
Division
Target
Surgery & Cancer
35977
Emergency Care
10541
Women & Children
22035
Diagnostics
5038
TOTAL
73591
Year to Date Performance
09/10
10/11
10/11
YTD
Target
YTD
30457 29764 30867
8473
8721
8471
18233 18230 19362
4335
4168
4062
61498 60883 62762
Performance Variance
from Target
from 2009/10
Number
%
Number
%
1103
3.7%
410
1.3%
-250
-2.9%
-2
0.0%
1132
6.2%
1129
6.2%
-106
-2.5%
-273
-6.3%
1879
3.1%
1264
2.1%
Follow Up OP Attendances
Annual
Division
Target
Surgery & Cancer
70477
Emergency Care
27409
Women & Children
55131
Diagnostics
10765
TOTAL
163782
Year to Date Performance
09/10
10/11
10/11
YTD
Target
YTD
63508 58306 60218
22949 22676 22232
45400 45610 46209
9863
8906 10013
141720 135498 138672
Performance Variance
from Target
from 2009/10
Number
%
Number
%
1912
3.3%
-3290
-5.2%
-444
-2.0%
-717
-3.1%
599
1.3%
809
1.8%
1107 12.4%
150
1.5%
3174
2.3%
-3048
-2.2%
Non Elective Spells
Annual
Target
6261
19887
12338
0
38486
Year to Date Performance
09/10
10/11
10/11
YTD
Target
YTD
5496
5219
5845
15830 16495 16596
10050 10201 10305
1
0
0
31377 31914 32746
Performance Variance
from Target
from 2009/10
Number
%
Number
%
626 12.0%
349
6.4%
101
0.6%
766
4.8%
104
1.0%
255
2.5%
0 #DIV/0!
-1 -100.0%
832
2.6%
1369
4.4%
Annual
Target
18232
6210
2419
1015
27876
Year to Date Performance
09/10
10/11
10/11
YTD
Target
YTD
15382 15084 14594
4846
5138
4856
1838
2001
1882
826
840
1048
22892 23062 22380
Performance Variance
from Target
from 2009/10
Number
%
Number
%
-490
-3.2%
-788
-5.1%
-282
-5.5%
10
0.2%
-119
-6.0%
44
2.4%
208 24.8%
222 26.9%
-682
-3.0%
-512
-2.2%
Division
Surgery & Cancer
Emergency Care
Women & Children
Diagnostics
TOTAL
Division
Surgery & Cancer
Emergency Care
Women & Children
Diagnostics
TOTAL
Elective Spells
Division
Surgery & Cancer
Emergency Care
Women & Children
Diagnostics
TOTAL
Page 68 of 90
Non Elective Spells
Elective Spells
1000
200
100
800
0
-100
600
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
-200
400
-300
-400
200
-500
-600
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
-200
-700
-800
Monthly Activity
Cumulative Position
Monthly Activity
Cumulative Position
GP Referrals
Outpatients
7000
1500
6000
1000
5000
4000
500
3000
0
2000
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
1000
-500
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
-1000
-1000
Monthly Activity
Monthly Activity
Cumulative Position
Cumulative Position
Outpatient Waiting List (by wks waiting)
Waiting List (by weeks waiting)
3500
6000
3000
5000
2500
4000
2000
3000
1500
2000
1000
1000
500
0
0
Apr
May
<2 wks
Jun
Jul
2-4 wks
Aug
Sep
5-7 wks
Oct
Nov
8-10 wks
Dec
Jan
11-14 wks
Feb
Mar
Apr
May
< 1wk
> 14 wks
Open Referral to Treatment Pathways
Jul
Aug
1-2 wks
Sep
Oct
2-3 wks
Nov
Dec
3-4 wks
Jan
Feb
4-5 wks
Mar
> 5 wks
18 week RTT Performance
100.0%
98.0%
96.0%
94.0%
92.0%
90.0%
88.0%
86.0%
84.0%
14000
12000
10000
8000
6000
4000
2000
0
Apr
Apr
< 4 wks
Jun
May
4-6 wks
Jun
Jul
7-11 wks
Aug
Sep
Oct
12-14 wks
Nov
Dec
15-17 wks
Jan
Feb
>=18 wks
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Mar
Admitted Actual
Non Adm Actual
Admitted Target
Non Adm Target
Page 69 of 90
Performance Targets and Standards
MONTH: January 2011
1. Elective and Outpatient Waits
Status =
Red
IP Waits
Status =
Red
OP Waits
100.0%
98.0%
100% 1
99%
0.99
98%
0.98
97%
96%
0.97
95%
0.96
94%
96.0%
94.0%
92.0%
90.0%
88.0%
93%
0.95
92%
0.94
91%
0.93
90%
86.0%
84.0%
82.0%
80.0%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p10
O
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
0.92
0.91
Adm Actual
Non Adm Actual
Adm Target
Non Adm Target
0.9
1
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
OP Waits
1562
1731
1755
1640
1780
1621
1567
1400
1588
1343
0
0
Ap
r-1
0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
.C
IP Waits
280
273
223
253
274
299
285
267
409
528
0
0
3. A&E 4hr Waits
Achieve 95%; Underachieve 94%
Status = Green
M
Month
2. Referral to Treatment Times
Performance
Red
Data Completeness
Green
IP Target - 150 or fewer patients waiting > 10 weeks
OP target - 35 or fewer patients waiting > 5 weeks
4. Referral to Treatment Median Waiting Times
Admitted Pathways
Amber
Non Admitted Pathways
Green
12
95% of non-admitted patients achieve target
90% of admitted patients achieve target
5. Referral to Treatment 95th Percentile Waits
Admitted Pathways
Amber
Non Admitted Pathways
Amber
Monthly %age
Achieved
Underachieved
Within 4hrs
YTD Perf
#REF!
#REF!
6. Thrombolysis
Call to Needle - Achieve 68%; Underachieve 48%
Status = Amber
100.0%
25
90.0%
10
#REF!
20
80.0%
70.0%
8
15
60.0%
6
50.0%
10
40.0%
30.0%
There was one patient recorded on
the Door to Needle pathway and they
met the 30 minute target.
20.0%
10.0%
Adm Actual
Non Adm Actual
Adm Target
Non Adm Target
Achieve
1
0
Call to Needle (YTD)
Half of non-admitted patients seen within 6.6 weeks
Half of admitted patients seen within 11.1 weeks
Fe
b1
Non Adm Target
D
ec
-1
0
Adm Target
O
ct
-1
0
Non Adm Actual
0.0%
Ap
r-1
0
Adm Actual
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
0
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b11
M
ar
-1
1
0
Au
g1
2
10
5
Ju
n-
4
Underachieve
95% of non-admitted patients seen within 18.3 weeks
95% of admitted patients seen within 23 weeks
Page 70 of 90
Performance Targets and Standards
MONTH: January 2011
7. Cancer - 14 day
Achieve 93%; Underachieve 88%
Status = Green
8. Cancer - 31 day
Achieve 96%; Underachieve 91%
Status = Green
9. Cancer - 62 day
Achieve 85%; Underachieve 80%
Status = Green
100%
100%
99%
96%
97%
94%
95%
92%
93%
90%
91%
88%
Most recent
month is draft
local report
86%
84%
89%
87%
95%
90%
85%
80%
Most recent
month is draft
local report
75%
70%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
80%
65%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b11
M
ar
-1
1
85%
82%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
98%
Monthly %age
Achieve
Monthly %age
Achieve
Monthly %age
Achieve
YTD Perf
Underachieve
YTD Perf
Underachieve
YTD Perf
Underachieve
10. Cancer - 14 day Symptomatic Breast Referral
Achieve 93%; Underachieve 88%
Status = Green
11. Cancer - 31 day Diagnosis to Subs Treatment
Achieve 94%; Underachieve 89%
Status = Green
12. Cancer - 62 day Screening to Treatment
Achieve 90%; Underachieve 85%
Status = Green
100%
100%
99%
98%
95%
97%
94%
95%
92%
93%
90%
91%
88%
90%
85%
80%
89%
Most recent
month is draft
local report
84%
82%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
80%
Monthly %age
Achieve
YTD Perf
derachieve
Most recent month
is draft local report
87%
85%
75%
70%
65%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b11
M
ar
-1
1
86%
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
96%
Monthly %age
Achieve
Monthly %age
Achieve
YTD Perf
Underachieve
YTD Perf
Underachieve
Page 71 of 90
Performance Targets and Standards (Information removed under S43 of FOI Act)
13. Cancelled operations seen in 28 days
Achieve 95%; Underachieve 85%
Status = Amber
MONTH: January 2011
14. Cancelled Ops on Day of Admission
Achieve 99.2%; Underachieve 98.5%
Status = Amber
15. Beds Occupied by Dischargable Patients
Average Medical Outliers also shown
Red
Del Disch Status =
Green
Outlier Status =
350
60
60.0
95%
300
50
50.0
90%
250
40.0
40
85%
200
30.0
30
80%
150
75%
100
20.0
20
10.0
70%
50
Achieve
Underachieve
YTD Perf
0
Cumulative
16. MRSA
Target = <5 MRSA cases in year
Status = Green
20
Achieve
Ave Med
Delayed
Disch
Ave
Outliers
09/10
Ave Del
Del Disch
Disch 09/10
07/08
Ave
Underachieve
17. Clostridium difficile
Target = <106 c difficile cases in year
Status = Green
Ave Med
Outliers
Monthly
Delayed Disch
Ave Outliers
Monthly 07/08
Medical Outliers
18. Emergency Bed Days
Status =
Red
120
No MRSA bactaeremia reported
between April and January.
100
16
14
11 c difficile cases reported
in January.
40.0%
30.0%
80
12
10
20.0%
60
8
10.0%
0
0
0
1
0
0
1
0
0
1
0
0
0
0
r-1 y-1 n-1 ul-1 ug-1 ep-1 ct-1 ov-1 ec-1 an-1 eb-1 ar-1
J
O N
Ap Ma Ju
J
M
F
D
S
A
0
1
0
0
1
1
0
0
0
0
0
0
r-1 y-1 n-1 ul-1 ug-1 ep-1 ct-1 ov-1 ec-1 an-1 eb-1 ar-1
J
O
Ap Ma Ju
J
M
F
S
D
N
A
Reported Cumulative
Threshhold (<=12)"
Reported Cumulative
Threshhold (<=181)
% Month Change
Fe
b
-10.0%
D
ec
2
0.0%
O
ct
20
Au
g
4
There have been 7 deaths
this year where c diff was a
primary cause, and 3 where
it was a contributory factor
Ju
n
40
6
Ap
r
18
0
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b11
M
ar
-1
1
%seen in time
10
0.0
Ap A
r-1 prM 0 10
ay
-1 J
Ju 0 un
-1
n0
10
Ju
l-1 Au
Au 0 g -1
0
g1
Se 0O
p- ct
1 -1
0
O 0
ct
-1 D
N 0 ec
ov
-1 -10
D 0
ec
-1 Fe
Ja 0 b-1
1
n1
Fe 1
b1
M 1
ar
-1
1
Ap
r-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
Au 0
g1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
100%
% Cum've Change
Reduce emergency bed days by 5% by
2008 (from the 2003/2004 baseline)
Page 72 of 90
Performance Targets and Standards
MONTH: January 2011
19. Smoking in pregnancy
20. Breastfeeding
21. Supporting Information
Status =
Red
26%
Status =
Red
544 bed days (17.5 beds each day) were
unavailable for unplanned reasons during December.
This was mainly due to infections.
70%
24%
65%
22%
20%
60%
18%
55%
16%
14%
124 bed days (4.0 beds each day) were
opened above planned levels.
50%
12%
10%
Month 10/11
Target
Cumve 10/11
A comparison between the trusts 2009-10 and 201011 smoking during pregnancy rates
Month 10/11
Cumve 10/11
ar
M
Ja
n
Fe
b
ov
ec
D
O
ct
N
Se
p
Ju
l
Au
g
ay
Ju
n
Ap
r
40%
M
Ap
r
M
ay
Ju
n
Ju
l
Au
g
Se
p
O
ct
N
ov
D
ec
Ja
n
Fe
b
M
ar
45%
"Target"
A comparison between the trusts 2009-10 and
2010-11 breastfeeding initiation rates (joint measures
with 7. Smoking in pregnancy)
GUM Access
Status =
Green
Page 73 of 90
Monitoring the 18 week pathway 2010-11
Pathways not ending in an admission
Q1
Q2
%age ending pathway in < 18 wks
General Surgery
97.7% 96.6%
Urology
96.7% 97.5%
Orthopaedics
98.0% 97.8%
ENT
96.9% 97.7%
Ophthalmology
98.8% 99.3%
Pain Relief
Direct Access Audiology 100% 100%
Oct
Jan
YTD Target
Nov
Dec
Q3
95.3%
96.5%
95.8%
97.3%
99.3%
100%
100%
95.4%
95.2%
95.4%
97.3%
99.2%
100%
100%
94.8%
96.3%
92.7%
96.6%
99.2%
100%
100%
95.2%
96.0%
94.7%
97.1%
99.2%
100%
95%
95%
95%
95%
95%
95%
95%
99.2%
96.5%
95.5%
98.6%
100%
100%
99.3% 99.3% 99.3% 97.7% 98.4%
98.0% 98.2%
98.1%
98.7% 97.2% 97.1% 97.8% 97.8%
98.7% 100% 99.1% 100% 99.6%
100% 100%
100%
100% 100% 100% 100% 99.8%
95%
95%
95%
95%
95%
95%
94.3%
94.9%
95.3%
96.7%
98.0%
97%
100% 100%
96.3%
96.6%
96.8%
97.2%
99.0%
Gastroenterology
Diabetic Medicine
Cardiology
Respiratory Medicine
Care of the Elderly
Rheumatology
97.3% 98.9%
Gynaecology
Paediatric Medicine
Paediatric Audiology
99.0% 99.3%
98.4% 98.0% 98.8% 98.4% 96.8% 98.7%
99.1% 99.3% 100%
100%
100% 99.0% 100%
100%
95%
95%
95%
Dermatology
Clinical Haematology
Chemical Pathology
99.1% 99.3%
98.1% 98.3% 97.4% 98.0% 95.3% 98.5%
97.6% 94.7% 93.1%
100%
100% 100% 100%
100%
95%
95%
95%
Other Specialties
100%
99.6%
98.7% 97.5%
100% 100%
99.4%
100%
100%
TOTAL ALL SPECIALTIES 98.6% 98.6%
100%
100% 99.5% 100% 99.7%
97.8% 98.0% 97.7% 97.9% 97.3% 98.3%
95%
Page 74 of 90
Pathways ending in an admission
Q1
%age ending pathway in < 18 wks
General Surgery
96.0%
Urology
94.7%
Orthopaedics
96.6%
ENT
97.7%
Ophthalmology
98.8%
Pain Relief
Gastroenterology
Respiratory Medicine
99%
100%
Gynaecology
Q2
Oct
Nov
Dec
93.7%
94.8%
94.0%
98.3%
99.3%
90.9%
90.7%
88.9%
98.5%
98.6%
97.9%
99%
100%
97.6% 97.5% 96.7%
100% 100%
Q3
Jan
YTD Target
90.7% 92.1% 91.1% 84.2% 93.1%
93.7% 90.7% 92.0% 88.3% 93.5%
77.6% 85.9% 83.9% 78.4% 90.4%
98.1% 100% 98.6% 100% 98.3%
100%
97% 98.7% 97% 98.7%
100% 100%
97%
90%
90%
90%
90%
90%
90%
97% 100% 98.7%
100% 100% 100%
90%
90%
94.9% 96.5%
96.8% 97.6% 99.0% 97.6% 87.1% 95.5%
90%
Dermatology
Clinical Haematology
100%
100%
100%
100%
100%
100%
90%
90%
Other Specialties
100% 98.6%
100%
100%
TOTAL ALL SPECIALTIES 96.9% 96.2%
100%
100%
100% 99.5% 100% 99.2%
94.1% 92.6% 93.8% 93.5% 89.4% 95.1%
90%
** March and Q4 projected as at 6th April
Data Completeness
Q1
Q2
Oct
Nov
Dec
Q3
Jan
Non Admitted Pathways
Admitted Pathways
Sum All Pathways
93.0%
89.0%
90.9%
85.5%
79.3%
85.3%
87.5%
YTD
88.9%
88.0%
91.4%
85.5%
83.8%
75.5%
82.1%
87.5%
87.2%
91.8%
89.5%
89.5%
85.1%
78.5%
84.5%
87.5%
88.5%
Direct Access Audiology
52.0%
66.2%
81.5%
68.2%
272.9%
100.5%
99.1%
70.1%
Direct Access Audiology Data Completeness as understood by MCHFT and CECPCT
Page 75 of 90
95th percentile Wait Times
1. Pathways ending in an admission: threshold 23 weeks
April
May
June
July
Aug
General Surgery
19
18
18
18
20
Urology
19
19
18
18
16
Orthopaedics
18
18
18
20
18
ENT
18
18
18
17
18
Ophthalmology
18
17
17
17
17
Gastroenterology
15
15
15
15
14
Gynaecology
23
18
19
18
18
Other Specialties
18
17
18
18
17
Sum All Specialties
18
18
18
18
18
Oct
22
23
21
18
18
17
18
18
19
Nov
20
22
24
17
18
16
18
14
20
Dec
23
25
25
17
18
18
18
17
20
Jan
24
27
25
18
18
17
22
13
23
2. Pathways ending other than in an admission: threshold 18.3 weeks
April
May
June
July
Aug
Sep
Oct
General Surgery
16
16
17
17
17
18
18
Urology
18
17
18
17
17
16
15
Orthopaedics
17
15
16
16
17
16
17
ENT
17
16
18
17
16
17
16
Ophthalmology
14
13
14
15
13
14
14
General Medicine
13
12
10
14
12
11
9
Gastroenterology
18
17
18
18
18
17
18
Cardiology
15
18
17
17
18
18
18
Dermatology
15
16
17
16
17
17
18
Respiratory Medicine
9
15
12
16
12
14
15
Rheumatology
13
16
17
14
13
15
12
Geriatric Medicine
10
9
12
13
10
11
11
Gynaecology
15
17
15
15
16
15
16
Other
12
12
12
12
14
11
13
Sum All Specialties
13
15
16
15
16
16
16
Nov
17
18
18
17
15
11
17
15
17
12
12
11
17
10
16
Dec
19
17
21
18
15
11
17
17
18
12
15
10
15
12
17
Jan
20
19
18
18
15
10
17
18
18
12
12
9
17
13
17
3. Incomplete Pathways: threshold 28 weeks
April
May
June
General Surgery
15
17
17
Urology
18
17
16
Orthopaedics
15
15
16
ENT
17
18
14
Ophthalmology
12
13
14
General Medicine
10
11
11
Gastroenterology
13
14
13
Cardiology
13
13
14
Dermatology
12
13
12
Respiratory Medicine
10
10
11
Rheumatology
13
13
10
Geriatric Medicine
9
9
10
Gynaecology
15
15
15
Other
14
13
14
Sum All Specialties
15
15
15
Nov
22
18
19
17
15
10
15
13
15
9
10
9
17
15
18
Dec
23
18
20
18
15
12
15
14
16
10
11
9
19
16
18
Jan
25
18
21
17
15
13
16
14
17
9
11
9
17
15
19
July
18
16
16
15
14
11
15
15
13
10
11
10
15
15
16
Aug
18
19
17
17
14
11
13
14
16
11
12
10
17
16
17
Sep
22
21
20
18
17
16
20
18
19
Sep
19
17
18
17
13
13
14
14
15
11
11
9
18
15
17
Oct
20
17
20
18
14
11
15
12
15
9
10
10
18
15
17
Page 76 of 90
Median Wait Times
1. Pathways ending in an admission: Median threshold 11.1 weeks
April
May
June
July
Aug
Sep
General Surgery
9
9
9
7
12
11
Urology
8
10
8
7
8
11
Orthopaedics
11
11
12
12
14
13
ENT
12
8
10
10
10
9
Ophthalmology
10
9
8
8
8
9
Gastroenterology
6
6
5
3
3
3
Gynaecology
7
6
12
7
10
10
Other Specialties
13
10
13
13
12
14
Sum All Specialties
9
9
9
8
10
11
Oct
10
10
14
8
9
4
6
12
10
2. Pathways ending other than in an admission: Median threshold 6.6 weeks
April
May
June
July
Aug
Sep
Oct
General Surgery
5
6
5
5
7
6
5
Urology
7
7
7
7
7
8
8
Orthopaedics
6
6
6
7
7
7
7
ENT
8
7
8
6
7
10
7
Ophthalmology
7
4
8
6
7
7
5
General Medicine
6
6
5
7
4
5
3
Gastroenterology
9
9
11
11
11
10
11
Cardiology
7
8
7
8
8
8
7
Dermatology
9
10
10
8
10
10
10
Respiratory Medicine
6
6
7
7
8
7
5
Rheumatology
9
10
10
9
9
9
8
Geriatric Medicine
4
5
6
5
3
3
3
Gynaecology
5
5
5
4
5
4
5
Other
1
1
1
1
1
1
1
Sum All Specialties
5
5
6
5
6
6
5
3. Incomplete Pathways: Median threshold 7.2 weeks
April
May
June
July
General Surgery
5
5
6
6
Urology
6
5
5
5
Orthopaedics
5
5
6
6
ENT
6
6
5
6
Ophthalmology
5
5
5
5
General Medicine
4
3
5
5
Gastroenterology
6
6
6
6
Cardiology
5
5
6
6
Dermatology
5
5
5
6
Respiratory Medicine
4
4
4
5
Rheumatology
6
5
4
6
Geriatric Medicine
3
4
3
4
Gynaecology
6
6
6
6
Other
5
5
6
6
Sum All Specialties
5
5
5
6
Aug
Sep
6
6
7
6
6
4
6
5
6
4
5
3
6
6
6
Oct
6
5
6
5
5
4
5
5
6
4
5
2
7
5
6
Nov
10
8
14
7
9
6
7
8
9
Dec
Nov
Dec
5
8
7
6
5
4
9
7
9
5
7
3
5
1
5
Nov
7
6
6
6
5
5
5
5
6
3
5
4
6
5
6
6
11
13
7
9
5
6
9
9
Jan
5
8
7
7
5
5
10
8
11
5
7
2
4
1
5
Dec
7
7
7
6
5
4
5
4
6
3
4
3
6
5
6
Jan
11
13
15
8
11
6
7
8
11
5
9
7
8
6
5
10
9
11
6
8
2
3
1
5
Jan
8
7
8
7
7
5
6
6
7
4
5
3
7
6
7
Page 77 of 90
8
7
8
6
6
4
6
5
6
2
5
2
7
6
7
PCT PERFORMANCE SUMMARY: YEAR TO DATE
MONTH: January 2011
ADMITTED PATIENT CARE: Non Elective Acute FFCEs
PCT
Target
Actual
Difference
No
%age
Central & Eastern Cheshire
24468
25200
732
3.0%
West Cheshire
1058
994
-64
-6.0%
2009/10
23921
1065
Difference 09 to 10
No
%age
1279
5.3%
-71
-6.7%
North Staffordshire
Stoke on Trent
NORTH STAFFS
174
89
263
166
92
258
-8
3
-5
-4.6%
3.9%
-1.8%
189
81
270
-23
11
-12
-12.2%
13.6%
-4.4%
Shropshire County
Warrington
North Wales
67
31
50
63
28
0
-4
-3
-50
-5.8%
-8.4%
-100.0%
60
31
46
3
-3
-46
5.0%
-9.7%
-100.0%
639
4
26579
660
0
27203
21
3.2%
2.3%
63
-3
1210
10.6%
624
597
3
25993
ADMITTED PATIENT CARE: Elective Inpatients and Day Cases
Difference
PCT
Target
Actual
No
%age
Central & Eastern Cheshire
21034
20635
-399
-1.9%
West Cheshire
1127
1028
-99
-8.8%
2009/10
20950
1047
NCAs
Other
TOTAL
4.7%
Difference 09 to 10
No
%age
-315
-1.5%
-19
-1.8%
North Staffordshire
Stoke on Trent
NORTH STAFFS
462
234
696
379
198
577
-83
-36
-119
-17.9%
-15.4%
-17.1%
469
230
699
-90
-32
-122
-19.2%
-13.9%
-17.5%
Shropshire County
Warrington
North Wales
70
15
18
35
14
0
-35
-1
-18
-50.2%
-6.0%
-100.0%
65
13
19
-30
1
-19
-46.2%
7.7%
-100.0%
102
1
23062
91
0
22380
-11
-10.6%
99
-8
-8.1%
-682
-3.0%
22892
-512
-2.2%
Difference
No
%age
207
4.0%
-26
-20.9%
2009/10
5201
117
NCAs
Other
TOTAL
ADMITTED PATIENT CARE: Maternity
PCT
Target
Central & Eastern Cheshire
West Cheshire
Actual
Difference 09 to 10
No
%age
149
2.9%
-19
-16.2%
5143
124
5350
98
North Staffordshire
Stoke on Trent
NORTH STAFFS
19
12
31
32
19
51
13
7
20
65.1%
61.0%
63.5%
24
9
33
8
10
18
33.3%
111.1%
54.5%
Shropshire County
Warrington
North Wales
16
0
1
17
5
0
1
5
-1
6.2%
#DIV/0!
-100.0%
15
0
1
2
5
-1
13.3%
#DIV/0!
-100.0%
19
1
5335
22
0
5543
3
13.5%
3.9%
2
0
156
10.0%
208
20
0
5387
NCAs
Other
TOTAL
2.9%
Page 78 of 90
OUTPATIENT ATTENDANCES: Total Attendances
PCT
Target
Actual
Central & Eastern Cheshire
West Cheshire
Difference
No
%age
4973
2.7%
-330
-4.2%
2009/10
187854
8075
Difference 09 to 10
No
%age
-1065
-0.6%
-532
-6.6%
181816
7873
186789
7543
North Staffordshire
Stoke on Trent
NORTH STAFFS
3210
1416
4625
3205
1759
4964
-5
343
339
-0.2%
24.3%
7.3%
3326
1422
4748
-121
337
216
-3.6%
23.7%
4.5%
Shropshire County
Warrington
North Wales
603
192
89
562
152
110
-41
-40
21
-6.8%
-20.8%
24.3%
631
187
102
-69
-35
8
-10.9%
-18.7%
7.8%
1167
17
196381
1223
91
201434
56
4.8%
2.6%
25
-332
-1784
2.1%
5053
1198
423
203218
Difference
No
%age
-521
-15.1%
-39
-23.1%
2009/10
3378
177
NCAs
Other
TOTAL
ADMITTED PATIENT CARE: Elective Inpatients
PCT
Target
Actual
Central & Eastern Cheshire
West Cheshire
-0.9%
Difference 09 to 10
No
%age
-456
-13.5%
-46
-26.0%
3443
170
2922
131
North Staffordshire
Stoke on Trent
NORTH STAFFS
96
35
131
68
23
91
-28
-12
-40
-29.1%
-33.8%
-30.4%
91
37
128
-23
-14
-37
-25.3%
-37.8%
-28.9%
Shropshire County
Warrington
North Wales
7
2
9
6
2
0
-1
0
-9
-19.4%
-19.4%
-100.0%
7
3
10
-1
-1
-10
-14.3%
-33.3%
-100.0%
34
0
3797
27
0
3179
-7
-20.4%
-7
-20.6%
-618
-16.3%
34
0
3737
-558
-14.9%
Difference
No
%age
123
0.7%
-59
-6.2%
2009/10
17572
870
NCAs
Other
TOTAL
ADMITTED PATIENT CARE: Day Cases
PCT
Target
Actual
Central & Eastern Cheshire
West Cheshire
Difference 09 to 10
No
%age
141
0.8%
27
3.1%
17590
956
17713
897
North Staffordshire
Stoke on Trent
NORTH STAFFS
366
199
565
311
175
486
-55
-24
-79
-15.0%
-12.2%
-14.0%
378
193
571
-67
-18
-85
-17.7%
-9.3%
-14.9%
Shropshire County
Warrington
North Wales
63
12
9
29
12
0
-34
0
-9
-53.9%
-3.3%
-100.0%
58
10
9
-29
2
-9
-50.0%
20.0%
-100.0%
68
1
19265
64
0
19201
-4
-5.7%
-1
-1.5%
-64
-0.3%
65
4
19159
42
0.2%
NCAs
Other
TOTAL
Page 79 of 90
OUTPATIENT ATTENDANCES: First Attendances
PCT
Target
Actual
Central & Eastern Cheshire
West Cheshire
Difference
No
%age
1718
3.1%
-186
-7.6%
2009/10
56182
2488
Difference 09 to 10
No
%age
1372
2.4%
-208
-8.4%
55836
2466
57554
2280
North Staffordshire
Stoke on Trent
NORTH STAFFS
1142
564
1706
1195
872
2067
53
308
361
4.7%
54.5%
21.2%
1130
554
1684
65
318
383
5.8%
57.4%
22.7%
Shropshire County
Warrington
North Wales
227
91
23
197
50
27
-30
-41
4
-13.1%
-45.1%
16.6%
229
83
29
-32
-33
-2
-14.0%
-39.8%
-6.9%
523
11
60883
521
66
62762
-2
-0.4%
3.1%
-3
-213
1264
-0.6%
1879
524
279
61498
OUTPATIENT ATTENDANCES: Follow Up Attendances
PCT
Target
Actual
Difference
No
%age
Central & Eastern Cheshire
125980
129235
3255
2.6%
West Cheshire
5406
5263
-143
-2.7%
2009/10
131672
5587
NCAs
Other
TOTAL
2.1%
Difference 09 to 10
No
%age
-2437
-1.9%
-324
-5.8%
North Staffordshire
Stoke on Trent
NORTH STAFFS
2068
851
2920
2010
887
2897
-58
36
-23
-2.8%
4.2%
-0.8%
2196
868
3064
-186
19
-167
-8.5%
2.2%
-5.5%
Shropshire County
Warrington
North Wales
376
101
65
365
102
83
-11
1
18
-3.0%
1.1%
27.0%
402
104
73
-37
-2
10
-9.2%
-1.9%
13.7%
644
6
135498
702
25
138672
58
9.1%
2.3%
28
-119
-3048
4.2%
3174
674
144
141720
NCAs
Other
TOTAL
-2.2%
Page 80 of 90
REFERRALS: all referrals from General Practitioners
PCT
Target
Actual
Difference
No
%age
Central & Eastern Cheshire
36011
36392
381
1.1%
West Cheshire
1803
1624
-179
-9.9%
2009/10
36006
1811
Difference 09 to 10
No
%age
386
1.1%
-187
-10.3%
North Staffordshire
Stoke on Trent
NORTH STAFFS
879
554
1433
952
917
1869
73
363
436
8.3%
65.6%
30.5%
871
501
1372
81
416
497
9.3%
83.0%
36.2%
Shropshire County
Warrington
North Wales
159
18
6
121
19
2
-38
1
-4
-24.1%
4.0%
-65.6%
158
21
8
-37
-2
-6
-23.4%
-9.5%
-75.0%
120
6
39556
124
0
40151
4
3.0%
117
6.0%
595
1.5%
39493
7
0
658
Difference
No
%age
279
0.9%
-1
-0.1%
2009/10
30309
1437
NCAs
Other
TOTAL
REFERRALS: all referrals from Other Sources
PCT
Target
Actual
Central & Eastern Cheshire
West Cheshire
1.7%
Difference 09 to 10
No
%age
-186
-0.6%
-221
-15.4%
29844
1217
30123
1216
North Staffordshire
Stoke on Trent
NORTH STAFFS
493
210
703
448
205
653
-45
-5
-50
-9.1%
-2.4%
-7.1%
517
194
711
-69
11
-58
-13.3%
5.7%
-8.2%
Shropshire County
Warrington
North Wales
109
49
23
104
42
39
-5
-7
16
-4.4%
-14.2%
67.8%
112
69
31
-8
-27
8
-7.1%
-39.1%
25.8%
507
240
32692
587
0
32764
80
15.7%
0.2%
-27
1
-518
-4.4%
72
614
-1
33282
Difference
No
%age
660
1.0%
-180
-6.0%
2009/10
66315
3248
NCAs
Other
TOTAL
TOTAL REFERRALS
PCT
Central & Eastern Cheshire
West Cheshire
Target
Actual
-1.6%
Difference 09 to 10
No
%age
200
0.3%
-408
-12.6%
65855
3020
66515
2840
North Staffordshire
Stoke on Trent
NORTH STAFFS
1372
764
2136
1400
1122
2522
28
358
386
2.0%
46.9%
18.1%
1388
695
2083
12
427
439
0.9%
61.4%
21.1%
Shropshire County
Warrington
North Wales
268
67
29
225
61
41
-43
-6
12
-16.1%
-9.3%
41.1%
270
90
39
-45
-29
2
-16.7%
-32.2%
5.1%
628
246
72248
711
0
72915
83
13.3%
0.9%
-20
1
140
-2.7%
667
731
-1
72775
NCAs
Other
TOTAL
0.2%
Page 81 of 90
Turnaround Times for Clinic Letters, Discharge Summaries and Diagnostics Reporting
February 2011
OUTPATIENT CLINIC LETTERS (Days)
DIVISION / DEPARTMENT
SURGERY & CANCER
General Surgery
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
8
9
9
4
9
9
13
10
10
10
7
12
11
11
5
5
0
5
0
0
9
10
5
8
1
5
6
5
7
7
4
7
1
5
3
3
10
10
10
10
2
5
5
6
5
5
5
5
19
19
19
19
19
19
19
29
29
29
29
29
29
29
40
40
40
40
40
40
40
30
30
30
30
30
30
30
7
7
7
7
7
7
7
6
6
6
6
6
6
6
SRS
PPI
SM
15
15
15
10
10
10
20
25
25
15
15
15
2
9
9
5
5
5
Oral Surgery
2
2
2
2
2
2
DJC
JPS
AJG
MEH
CRS
AUK
VP
GKM
DIVISION / DEPARTMENT
EMERGENCY CARE
Urology
Endoscopy
NA
NA
NA
NA
NA
NA
Pain Clinic
2
2
2
2
2
2
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
7
4
8
17
12
3
4
3
5
18
18
6
8
8
10
15
3
3
5
7
5
7
5
3
9
9
9
11
11
6
9
9
12
12
3
4
3
3
3
5
3
3
10
7
9
9
10
3
7
7
6
6
3
4
3
3
3
3
12
3
5
4
6
6
6
3
9
9
9
9
3
3
3
4
4
3
10
3
7
8
7
7
8
3
7
10
9
9
3
5
3
3
3
5
5
3
9
8
4
12
3
4
5
4
7
7
3
6
Dr Thomson
Dr Burns
Dr Ellison
Dr Dowson
4
7
6
4
0
1
0
2
1
1
8
8
1
4
5
3
1
1
4
4
5
4
11
6
Dr Thirumurugan
0
2
8
3
1
7
Dr Sackey
0
4
8
2
0
1
8
0
8
JMST
Cardiology Locum
APM
RKK
Heart Failure Nurse
MDW
Locum (Care of Elderly)
MS (Care of Elderly)
LGA (Care of Elderly)
AHH
MZQ
JSM
IJL
KYY
KP (Rheumatology)
AJF (Rheumatology)
A&E Consultants
Acute Physicians
Orthopaedics
My Hyder
Mr Pegg
Mr Gilles
Mrs Luscombe
Mr Redfern
Mr Barnes
Miss Blanckley
Sep-10
9
WOMEN & CHILDREN
Paediatrics
Dr I Blakeborough
Audiology (Eagle bridge)
ENT
AFD
JAD
JED
AK
35
35
35
35
36
36
36
36
34
34
34
34
25
25
25
25
28
28
28
28
21
21
21
21
ADH
SW
MAN
27
27
27
23
23
23
21
21
21
21
21
21
19
19
19
14
14
14
SQ
27
23
21
21
19
14
BJM / VK
27
23
21
21
19
14
Ophthalmology
26
20
8
21
12
15
Obstetrics & Gynaecology
Mr Meekins
5
4
0
11
1
1
Mr Scott
Mr Armatage
Mr Lukas
Miss Heron
Miss Coughlin
Dr Cunningham
Miss Pinto
Miss R Sawyer
Sally Smith
7
5
7
6
11
0
0
7
12
10
11
4
0
12
2
11
12
0
0
0
0
0
0
0
0
0
0
1
8
9
8
12
0
9
0
0
4
0
14
5
0
0
0
1
2
0
2
3
2
0
26
19
21
25
21
25
12
16
10
7
11
22
0.6%
99%
86%
73%
0%
66%
82%
65%
61%
71%
33%
100%
43%
44%
86%
4%
86%
76%
25%
1.4%
87%
83%
81%
0%
82%
90%
67%
64%
78%
75%
100%
47%
44%
90%
0%
100%
83%
35%
100%
2.4%
96%
57%
73%
0%
83%
70%
61%
59%
78%
100%
100%
31%
47%
68%
0%
82%
86%
31%
4.1%
88%
67%
72%
11%
77%
92%
66%
60%
72%
67%
67%
45%
54%
90%
0%
75%
83%
32%
5.0%
98%
100%
78%
0%
77%
100%
62%
60%
77%
71%
100%
41%
56%
90%
0%
86%
87%
29%
100%
79%
81%
100%
67%
42%
100%
50%
30%
70%
100%
28%
80%
100%
60.3%
60.0%
59.9%
58.3%
DIAGNOSTICS
Dermatology
gy
Haematology
E-DISCHARGE & SIGMA (Maternity) SUMMARIES
SPECIALTY
Accident & Emergency
Anaesthetics
Cardiology
Clinical Oncology
Dental
Ear Nose & Throat
Gastro-Enterology
General Medicine
General Surgery
Gynaecology
Medical Oncology
Medicine for the Elderly
Obstetrics - Delivery
Opthalmology
Paediatrics
Radiology
Rheumatology
Trauma & Orthopaedics
Urology
Vascular Surgery
Z Not Used (Endocrinology)
Z Not Used (Haematology (Clinical)
Z Not Used (Nephrology)
Z Not Used (Rehabilitation)
Z Not Used (Thoracic Medicine)
Haematology
Genito-Urinary Medicine
Upper Gastrointestinal Surgery
SPECIALTY
33%
71%
67%
92%
0%
96%
43%
81%
84%
86%
100%
100%
100%
99%
77%
0%
75%
93%
90%
83%
91%
100%
62%
100%
100%
81%
100%
100%
0%
97%
89%
78%
89%
87%
67%
67%
100%
100%
78%
0%
100%
91%
75%
100%
89%
63%
75%
100%
0%
95%
100%
78%
87%
86%
100%
100%
100%
100%
72%
0%
100%
88%
89%
95%
71%
100%
90%
100%
92%
67%
79%
89%
87%
100%
100%
94%
100%
57%
0%
100%
94%
89%
88%
77%
100%
86%
0%
95%
83%
78%
87%
91%
100%
56%
100%
100%
51%
0%
100%
92%
86%
100%
90%
94%
100%
94%
73%
100%
100%
95%
43%
100%
92%
50%
100%
96%
64%
Accident & Emergency
Anaesthetics
Cardiology
Clinical Oncology
Dental
Ear Nose & Throat
Gastro-Enterology
General Medicine
General Surgery
Gynaecology
Medical Oncology
Medicine for the Elderly
Obstetrics - Delivery
Opthalmology
Paediatrics
Radiology
Rheumatology
Trauma & Orthopaedics
Urology
Vascular Surgery
Z Not Used (Endocrinology)
Z Not Used (Haematology (Clinica
Z Not Used (Nephrology)
Z Not Used (Rehabilitation)
Z Not Used (Thoracic Medicine)
Haematology
84.8%
85.4%
83.2%
80.6%
80.1%
% Within 48 Hours
88.9%
88.7%
87.2%
85.3%
85.6%
TRUST
DIAGNOSTIC WAITING TIMES (Days)
MEDICAL IMAGING
CARDIO RESPIRATORY
ECG
83%
22%
0%
TRUST
MRI
CT
Ultrasound
Barium
Dexa
86%
64%
100%
46%
100%
57.0%
DIAGNOSTIC REPORTING TIMES (Days)
Sep-10
28
21
28
7
7
Oct-10
28
28
21
7
7
Nov-10
28
35
21
14
7
Dec-10
28
35
21
14
7
Jan-11
28
35
28
21
7
Feb-11
28
35
28
7
7
Sep-10
0
Oct-10
0
Nov-10
0
Dec-10
0
Jan-11
7
Feb-11
1
MEDICAL IMAGING
MRI
CT
Ultrasound
Barium
Dexa
Plain Films: - GP's
- A&E
Exercise Tolerance Test GP
12
18
21
9
14
11
- Wards
Exercise Tolerance Test OPD
Echocardiogram urgent
Echocardiogram routine
Vascular Scan - urgent
Vascular Scan - routine
Varicose vein scan
24 ECG monitor
24 BP monitor
Lung Function Test Basic
Lung Function Test Full
Carotoid Scan - urgent
Carotoid Scan - routine
Cardiac event recorder -
12
5
5
10
10
10
4
5
5
3
4
4
19
18
4
4
4
7
7
4
7
4
2
4
7
25
21
5
12
5
5
5
12
13
5
6
1
5
5
9
2
2
1
9
9
9
2
9
3
1
3
38
14
1
5
7
7
7
13
7
7
6
1
7
30
11
3
14
3
20
20
14
5
14
8
3
20
35
- Outpatients
Sep-10
7
2
2
7
7
Oct-10
7
7
2
7
7
Nov-10
7
2
2
7
7
Dec-10
7
2
2
7
7
10
10
4
20
10
25
0
0
Back log of Backlog of 51 backlog of 98
42 days
days
days
Backlog of 40 Backlog of 63 backlog of
days
days
102 days
backlog of
122 days
Jan-11
7
2
2
7
7
Feb-11
7
2
2
7
7
10
10
15
10
Backlog of 98 backlog 109
days
days
Backlog of 28 Backlog of 43
days
days
Page 82 of 90
Membership Figures
as at 21 February 2011
Month
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr 12
Apr-
Staff
2,697
2,695
2,690
Patient
Public
Total
1,309
4,011
1,304
3,995
1,305
4,010
8,017
7,994
8,005
Required
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
Number
Membership Figures Required -v- Actual
8,020
8,015
8,010
8,005
8,000
7,995
7,990
7,985
7,980
Required
Breakdown of Total Figures
Class of Patient & Carer
Class of
Patient
Carer of Patient 16+
Carer of Patient 15 or less
Unknown
Total
Min Req. Jan-11
230
1227
10
21
10
10
0
46
250
1304
Feb-11
Target
1228
21
10
46
1305
1333
Min Req. Jan-11
189
604
22
117
121
776
179
670
57
190
10
8
30
148
0
182
608
2695
Feb-11
Target
604
117
775
667
189
8
148
182
2690
2667
Min Req. Jan-11
450
808
1100
1669
1200
1518
0
0
2750
3995
Feb-11
Target
812
1676
1524
0
4010
4000
Staff
Staff Category
Clinical support
Medical
Me
dical & Dental
Non Clinical
Nursing & Midwifery
Other Clinical Professional
Reps of Trade Unions
Volunteer
Unknown
Total
Public Constituency
Actual
Month
Borough of
Congleton
Crewe & Nantwich
Vale Royal
Unknown
Total
Page 83 of 90
Section 4 Workforce focus
Accountable Office – Rachel Alcock
Page 84 of 90
Workforce Focus: January 2011
Trust Summary
(Rolling performance except spend against budget, mandatory training and appraisal which are cumulative)
Trust : Jan 11
Attendance
T: 95.60%
100%
Attendance is above target overall but long term sickness
(musculo-skeletal, malignancy, stress & surgical
conditions) in Surgery & Cancer and Diagnostics may
impact upon attendance figures.
A: 95.66%
96%
91%
In Budget
Retention
87%
B: £93,924.4k
A: £96,918.3k
T: 91.48%
A: 90.13%
82%
Appraisal
T: 72.41%
Mand Training
T: 62.57%
A: 54.82%
A: 70.86%
Retention is 1.35% away from target. Improvements in
retention have been seen in Women & Children, Estates &
Facilities and Corporate Divisions.
Mandatory & essential training is 8% below target with
Surgery & Cancer (-28%) Diagnostics (-10%) and
Corporate (-18%) away from target.
The Trust is overspent against its pay budget. Surgery &
Cancer and Emergency Care have a £1.7M and £1.8M
YTD overspend respectively. Of these two divisions,
Emergency Care has a higher % of divisional overspend.
Both divisions have a high usage of bank and agency
nursing staff.
Emergency Care : Jan 11
Surgery & Cancer : Jan 11
Attendance
100%
90%
Attendance
100%
T: 95.73%
A: 94.92%
95%
80%
70%
In Budget
Retention
60%
B: £25,668.2k
A: £27,400.7k
50%
Appraisal
90%
In Budget
T: 92.00%
B: £19,399.3k
A: 91.84%
A: £21,217.9k
T: 89.11%
85%
A: 87.69%
Appraisal
T: 62.00%
A: 78.98%
A: 44.78%
Mand Training
T: 62.00%
A: 56.20%
Diagnostics : Jan 11
Women & Children : Jan 11
Attendance
100%
Attendance
T: 95.38%
A: 95.90%
100%
99%
B: £13,977.2k
A: £13,884.0k
Retention
Mand Training
T: 73.34%
T: 77.97%
A: 68.88%
In Budget
T: 95.20%
A: 95.21%
T: 96.26%
A: 95.94%
90%
98%
Retention
97%
T: 93.16%
A: 91.55%
In Budget
B: £18,804.7k
80%
Retention
70%
T: 90.75%
A: 88.88%
A: £18,877.3k
Appraisal
Mand Training
T: 65.00%
A: 65.97%
T: 50.00%
A: 56.81%
Appraisal
Mand Training
T: 73.64%
T: 75.93%
A: 78.79%
A: 63.70%
Corporate: Jan 11
Estates : Jan 11
Attendance
100%
T: 93.71%
A: 95.44%
Attendance
100%
T: 97.08%
A: 97.75%
90%
95%
80%
In Budget
B: £7,133.8k
A: £7,131.7k
Appraisal
T: 77.70%
A: 67.79%
90%
Retention
In Budget
85%
A: 93.30%
70%
60%
T: 94.50%
B: £8,941.3k
50%
Retention
T: 90.00%
A: 88.10%
A: £8,406.7k
Mand Training
T: 58.40%
A: 54.72%
Appraisal
T: 81.26%
A: 52.40%
Mand Training
T: 73.29%
A: 55.02%
Page 85 of 90
Key Monitoring Areas
Trust Attendance
Target
Rolling
The rolling 12 month attendance rate is above target.
In month
The in month (January ) position is 94.68% and has
improved.
97.0
%
96.5
The Trust lost 4466 FTE days through sickness
absence in January. This equated to £290,831 in
direct lost salary costs.
96.0
95.5
There were 593 sickness episodes in January, which
is an 18% decrease on the December position, with
cold and influenza still having an impact.
95.0
94.5
In month sickness has improved in Surgery &
Cancer, Diagnostics and Women & Children.
Surgery & Cancer had the highest in month sickness.
Critical Care, and Orthopaedics remain the main
hotspots both in month and rolling.
94.0
93.5
93.0
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan10
10 10 10
10
10 10
10 10
10 10
10
11
Emergency Care is now above trajectory.
Benchmarking Attendance
iView Northwest trusts Jan-Oct 10 is 95.61%.
MCHFT is 95.75% (better than average).
Vacancy and Bank/Agency Usage
Nursing Staff (WTE)
Vacancy
Graphs showing bank/locum and agency usage
against current vacancies for the three main groups of
staff – Nursing, Medical and A&C staff.
Bank and Agency
180
160
Use of nursing agency decreased in January but this
was offset by an increase in nurse bank usage.
140
120
Medical staff locum and agency usage has risen
slightly this month with increases in sickness and
covering vacancies. Surgery & Cancer continue to
reduce their agency medical staff usage.
100
80
60
The medical, and the administration staff groups
remains consistent with the level of vacancies but the
nursing staff group appears to be significantly in
excess of the vacancy levels. This is explored in more
detail overleaf.
40
20
0
May- Jun10
10
Jul10
Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10
10
10
10
10
11
11
11
Medical Staff (WTE)
Vacancy
Locum and Agency
A&C Staff (WTE)
180
180
160
160
140
140
120
120
100
100
80
80
60
60
40
40
20
20
0
0
May- Jun10
10
Jul10
Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10
10
10
10
10
11
11
11
Vacancy
Bank and Agency
May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10 10 10 10 10 10 10 10 11 11 11
Page 86 of 90
The graph below shows the bank and agency usage for the wards in January Generally, wards are staffed above budget with bank
and agency staff.
Jan 11 Nursing WTE
Able to Work
Sickness
B&A
Budget
90
80
70
60
50
40
30
20
Wd 26
Wd 24
Wd 23
Wd 17
Wd 13
Wd12 F
Wd 10 SSW
Wd 10 SAU
Theatres
TC Wd
TC Th
Ortho
ICU
Wd 7
Wd 6a
Pre Disch
Wd 5
Wd 4
Wd 3
Wd 2
Wd 14
Wd 1/CC
A&E
VIN
Elmhurst
0
EAU
10
The graph below shows bank and agency usage reasons (bars) and actual vacancies (line) for each ward.
A realignment of ward establishment has taken place. All wards are now staffed within budget. VIN, and SAU are using between
2-4 WTE more than needed to cover vacancies and sickness.
The audit that was undertaken in December has been discussed with lead nurses and actions to address issues raised agreed.
NB. Please be aware of the difference in scale when comparing the two graphs.
Sickness
Dependency
Jan 11 B&A Reasons WTE
Vacancy
Workload
All Leave
Actual Vacancy
14
12
10
8
6
4
Wd 26
Wd 24
Wd 23
Wd 17
Wd 13
Wd12 F
Wd 10 SSW
Wd 10 SAU
Theatres
TC Wd
T C Th
Ortho
ICU
Wd 7
Wd 6a
Pre Disch
Wd 5
Wd 4
Wd 3
Wd 2
Wd 14
Wd 1/CC
EAU
A&E
VIN
0
Elmhurst
2
Page 87 of 90
Section 5 Learning and development focus
Accountable Office – Rachel Alcock
Page 88 of 90
Appraisals
Information on appraisals is now shown in the Workforce Focus section.
Serious Incident Root Cause Analysis
Between April and January 11 there have been 17 meetings chaired by Executive Director.
After Action Reviews
Review
Increase In A&E Attendance following a cold spell
IT Virus
Cancer Peer Review : Internal Validation Process
High Dependency Patients on CAU in December 2009
Review to understand non elective admissions and reasons for high
levels of A & E breaches.
Clinical Service Strategy
Pharmacy Review
4 x Leadership Development Reviews: Estates & Facilities,
Diagnostics, Corporate and Women, Children and SH,
Victoria Infirmary Inpatient Wards Move to Ward 19 Leighton Hospital
Non Elective Patient Flow Model
Haematology at. ECHT - CPA Visit
Ward Reconfiguration – Financial Impact
Date Held
January 10
February 10
February 10
February 10
April 10
April 10
April 10
May 10
May 10
June 10
September 10
September 10
Page 89 of 90
Section 6 External focus
& Service Development/Planning
Accountable Office – Executive Director
(as appropriate)
Page 90 of 90