NLG(16)222
DATE
31 May 2016
REPORT FOR Trust Board of Directors – Public
REPORT FROM
Wendy Booth, Director of Performance Assurance & Tr ust Secretary
CONTACT OFFICER
Claire Jenkinson, Head of Performance
SUBJECT
Performance Compliance Report – April 2016
BACKGROUND DOCUMENT (IF ANY)
Monitor Risk Assessment Framework
REPORT PREVIOUSLY CONSIDERED BY & DATE(S)
Trust Governance and Assurance Committee – 19 May 2016
EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)
This report outlines the expected governance positi on against the standards set out in the Risk Assessment Framework for the year to date up to April 2016
HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?
N/A
HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?
N/A
ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?
NO
IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?
N/A
ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?
NO
WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?
YES
WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?
N/A
THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED
Ensures compliances with the regulatory framework
ACTION REQUIRED BY THE BOARD The Board is asked to review key target performance and consider any further action required
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Monitor Risk Assessment Framework
Key Performance Measures
April 2016
This Report focuses solely on the Trust’s performance against key performance measures contained within
Monitor’s 2013 Risk Assessment Framework. Any performance risks relating to key performance indicators
contained within the Trust’s contract which could potentially result in the imposition of fines and penalties is
highlighted in both the integrated performance report and the monthly trading report.
Monitor, through its Risk Assessment Framework, continues to assign a governance risk rating to reflect the quality
of governance at the Trust. Monitor uses the governance rating below in order to gauge potential escalatory
measures:
• The sum of each metric’s weighting to calculate a service performance score
• Where the Trust breaches a target systematically, this will represent a governance concern
Indicator Red Rating may apply if the Trust:- Trust
Rating
C.Difficile
• Breaches the cumulative year-to-date trajectory for 3 successive
quarters
• Breaches its full year objective
• Reports important or significant outbreak
Referral to
Treatment
Waiting
• Breaches the 18 week RTT Incomplete waiting time measure for a third
successive quarter
A&E
• Fails to meet the target twice in any two quarters over a 12 month
period and fails the indicator in a quarter during the subsequent 9
month period or the full year
Cancer
Waiting Times
• Breaches the 31-day cancer waiting time for third successive quarter
• Breaches the 62-day cancer waiting time for third successive quarter
Community
Services Data
Completeness
• Fails to maintain the threshold for data completeness for any of the
following for a third successive quarter
- RTT information
- Service referral information
- Treatment activity information
Any Indicator
Weighted 1.0
• Breaches the indicator for three successive quarters
The governance rating assigned to an NHS Foundation Trust reflects Monitor’s views of its governance:
• a Green rating will be assigned by Monitor if no governance concern is evident;
• Where Monitor identifies potential material causes for concern with the Trust’s governance in one or more of
the categories (requiring further information or formal investigation), the Trust’s green rating will be replaced
with a description of the issue and the steps (formal or informal) to be taken to address it; or
• a Red rating will be assigned if Monitor take regulatory action.
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1. Summary Performance Against National Measures for April 2016
The final 18 week Referral to Treatment (RTT) incomplete waiting time performance fell short of the 92%
threshold for April 2016 at 89.40%.
The Trust has not achieved the 95% threshold for the A&E 4 hour wait target for the seventh consecutive
month, achieving 89.8% during April 2016.
There were no reported episodes of hospital acquired Clostridium Difficile during April 2016.
Current provisional cancer data indicates the Trust will achieve five of the seven cancer indicators for April 2015
presently breaching the 62 day referral to treatment and 31 day wait anti-cancer drugs measures. The Trust
failed the Post 62 day wait GP referral for the duration of 2015/16.
Individual Performance Risk Areas
1.1 Clostridium Difficile
Clostridium Difficile – YTD Total
During April 2016, there were no hospital acquired Clostridium Difficile episodes reported. The outstanding
DIPC review during March has now been completed and has confirmed there was no lapse in care, giving the
Trust a total of 10 episodes for 2015/16.
Response from DIPC:
Whilst the Trust is monitored on the number of ‘lapses in care’, given the overall number of cases of Clostridium
Difficile cases for the year to date, an internal improvement trajectory will be set for 2016/17 and will feature in
future reports.
Clostridium Difficile – Lapses in care
There were no hospital acquired Clostridium Difficile lapses in care during April 2016.
1.2 Cancer Waiting Times (provisional position)
April provisional cancer data indicates the Trust is on track to achieve five of the seven cancer indicators for the
month, presently breaching the post and pre 62 day GP referral at 78.19% and 81.72% respectively against an
85% threshold and the 31 day anti-cancer drug measure achieving 96.88% for the 98% threshold. Low numbers
for the 31 day anti-cancer indicator, currently reporting 1 patient breaching, has impacted on performance
compliance.
The final April cancer waiting times will be submitted to the national Open Exeter database on the 7 June 2016.
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Also included in this report is a breakdown of performance by tumour site (please refer to Appendix B)
Response from Chief Operating Officer:
As was anticipated from the expected planning trajectory, the Trust has failed two out of the seven National
Cancer Standards; Cancer 62 day wait for first treatment from urgent GP referral and the 62 day consultant
screening for first treatment. Cancer Performance continues to be monitored on a daily basis as well as
reporting/monitoring to the weekly Task & Finish Group and the weekly CEO Challenge Meeting. Key breach
themes have been identified through the weekly RCA Review Meetings and continue to be monitored through
an Action Plan which is taken to the monthly TGAC Meeting. Man marking of patients is a key action to support
and bottlenecks in pathways; diagnostic and reporting capacity and endoscopy are areas under significant
demand from referrals.
1.3 A&E 4 Hour Waiting Times
The Trust has not achieved the 95% threshold for the A&E 4 hour wait target for the seventh consecutive
month, achieving a Trust wide position of 89.8% for April 2016. Attendance and performance compliance is
slightly down on last month; however attendance in March spiked to their highest level during 2015/16.
Response from Chief Operating Officer:
During 2015/16 the Trust’s performance was 93.2% over the whole year (figure subject to final validation).
Performance through each of the quarter was as follows:
Q1 95.3%
Q2 95.2%
Q3 93.7%
Q4 88.5%
Actions to Support Recovery
Continued work on weekend discharges to even out the flow of patients through the 7 day week is ongoing as
well as development of the medical model at DPOW. Additional medical staff on both sites to focus on weekend
discharges is still in place and we await a third Acute Care Physician to take up post in the next few weeks for
DPOW. A Purple bed state is still prevalent at DPOW and work to look at the escalation bed availability on this
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site is supported by Strategy and Planning colleagues who are costing and working with relevant staff to
support associated compliance issues.
The graph below depicts attendance activity and performance measure for the last seven months.
1.4 18 Week Referral to Treatment Waiting Times
The final 18 week Referral to Treatment incomplete waiting time measure fell below the 92% threshold
reaching 89.40%. Therefore, In line with Monitor’s 18 week criteria the 18 week incomplete measure will not
achieve quarter one measure for the second consecutive quarter.
Response from the Chief Operation Officer:
Achievement of RTT remains extremely challenging for the Trust and there are a number of factors that are
inhibiting capacity and these are particular to surgery.
We continue to experience:
- Cancelled operations due to bed pressures, as we see medical patients cared for in surgical ward areas.
- The ongoing theatre refurbishment at DPOW that commenced in mid-January and has been planned in
two phases seeing disruption until June. Whilst work has been moved into some evenings and
weekends, the availability of anaesthetists to support evening realigned theatre sessions has been
difficult.
- Patient choice not to move to alternative site for operation during theatre refurbishment has been
noticeable as we have moved some activity to SGH and Goole.
- Continued medical workforce vacancies in General Surgery, Head and Neck, T&O, Urology & Pain
Service review work is now a key feature of the 2016/2017 sustainability programme and required to pull
together workforce, capacity and demand and job plans that inform and influence achievement of this target.
Performance is a regular standing agenda item to ET and capacity pressures are escalated.
1.6 Other
For information, the Trust’s position in relation to Delayed Transfers of care is provided within this report
(please refer to Appendix C) although it does not form part of the Monitor Risk Assessment Framework. April’s
performance information is currently not available due to the meeting schedule.
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Recommendations for Actions: Director of Performance Assurance
The following performance concerns will need to be progressed during the remainder of 2016/17 to ensure
performance is achieved / maintained:
I. Continued focus on ensuring achievement of the Incomplete 18 Week Referral to Treatment indicator
at specialty level, especially concentrating on improving the position of both North East Lincolnshire
and Lincolnshire East CCGs. The monitoring of 18 week Referral to Treatment recovery plans for failing
specialities by clinical groups.
II. Continued focus on A&E performance to ensure the Trust maintains achievement of this target over
the coming months and builds in sufficient capacity to improve achievement over the coming months.
As outlined above, a number of actions have already been taken and plans are in place including work with other local providers.
III. Continued focus on the achievement of all Cancer Waiting Time target with the ongoing
implementation of the Trust wide cancer performance improvement plan, including the continuation of
Root Cause Analysis for all patients breaching treatment targets. The Trust forecasts performance
below threshold for Q1.
Wendy Booth
Director of Performance Assurance & Trust Secretary
May 2016
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APPENDIX A
(PROVISIONAL POSITION AS AT 20.05.16)
2015/16 QTR 2 QTR 1 Qrt 1
WEIGHTING QTR 4 Threshold Apr-16 Actual To Date
FAILURE
WEIGHTING
1. Infection Control*
Total Hospital Acquired C.Difficile Cases Lapses in Care (YTD) 1.0 G 21 0 0 G
2. Referral to Treatment Waiting Times
Incomplete - Maximum waiting time of 18 weeks 1.0 R 92% 89.40% 89.40% R
3. Cancer ***
31 day wait diagnosis to treatment 1.0 G 96% 99.2% 99.2% G
i) 31 day wait for subsequent treatments - Surgery 1.0 G 94% 100% 100% G
ii) 31 day wait for subsequent treatments - Anti cancer drugs G 98% 96.9% 96.9% R
i) 62 day wait GP referral to treatment POST alloaction R 85% 78.2% 78.2% R
ii) 62 day wait GP referral to treatment PRE allocation 1.0 R 85% 81.7% 81.7% R
ii) 62 day wait Consultant screening service referrals allocation R 90% 100% 100% G
i) 2 week wait referral to consultation 1.0 G 93% 96.2% 96.2% G
ii) 2 week wait breast symptomatic referrals G 93% 98.1% 98.1% G
4. A&E
A&E 4 Hour Wait Compliance 1.0 R 95% 89.76% 89.76% R
5. Data Completeness Community Services **
5i) Referral to treatment information 1.0 G 50% 100% 100% G
5ii) Referral Information G 50% 100% 100% G
5iii) Treatment Activity Information G 50% 89% 89% G
6. Access **
Access to healthcare for people with learning disability 0.5 G Y/N Y Y G
* Quarterly Cumulative figures Total Monitor Compliance Score 4.0
** Forecast Position Amber
*** Provisional Data Red
Monitor Compliance Rating
Monitor Over ride Rating
PERFORMANCE METRIC
MONITOR COMPLIANCE FRAMEWORK SUMMARY
Performance Against Key Thresholds For The Period 1st April 2016 to 30th April 2016
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APPENDIX B
(Provisional position as at 10.05.16)
62 day Referral to treatment (standard 85%) - APR 16 Provisional
Tumour site Total treatments in
month
Total number of breaches that
have commenced 1st treatment
in Jan (Post Allocation)
Current Post %
(Monitor)
Breast 19 0 100%
Colorectal 8.5 3 64.71%
Gynaecology 2 1.5 25.00%
Haematology 4 1 75.00%
Head & Neck 1.5 0 100%
Lung 9.5 4.5 52.63%
Other (Surgery) 0 0 100%
Skin 13 1 92.31%
Upper GI (Medicine) 2 0 100%
Upper GI (Surgery) 3 1.5 50.00%
Urology 31.5 8 84.62%
Trust Total 94 20.5 78.19%
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APPENDIX C
Delay Transfer of Care
Site Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
DPoW 10283 9983 10211 10,374 10,152 9,933 10,462 10,085 10,475 11,000 10149 10898
443 305 315 341 223 282 299 302 358 385 271 289
4.3% 3.1% 3.1% 3.3% 2.2% 2.8% 2.9% 3.0% 3.4% 3.5% 2.7% 2.7%
SGH 8867 9577 8871 8,862 9399 8,820 9,433 8,775 9,144 9,566 8970 9328
109 139 163 287 159 204 134 173 231 149 216 271
1.2% 1.5% 1.8% 3.2% 1.7% 2.3% 1.4% 2.0% 2.5% 1.6% 2.4% 2.9%
GDH 539 657 620 627 644 684 678 572 586 644 550 570
36 28 24 57 38 39 56 63 64 35 10 17
6.7% 4.3% 3.9% 9.1% 5.9% 5.7% 8.3% 11.0% 10.9% 5.4% 1.8% 3.0%
Trust 19689 20217 19702 19,863 20,195 19,437 20,573 19,432 20,205 21,210 19669 20796
588 472 502 685 420 525 489 538 653 569 497 577
3.0% 2.3% 2.5% 3.4% 2.1% 2.7% 2.4% 2.8% 3.2% 2.7% 2.5% 2.8%