TRUST BOARD – 1 NOVEMBER 2007

Title of the Paper: OBJECTIVE 2 PERFORMANCE REPORT

Reference No: NUH 408

Author/Sponsor:Jenny Leggott – Director of Nursing, Midwifery and Service Improvement

Trust Objective:Objective 2 – Further improve our performance against existing national healthcare standards and work towards developmental standards.

Key issues:Currently some key targets are not being achieved and they continue to be the focus of further work to improve performance to national / local requirements.

Risk Implications for NUH (including any clinical and financial consequences):

Mitigating Actions (Controls):

Achieving national waiting time guarantees – no inpatients waiting more than 20 weeks.

Trust-wide and Directorate specific Action plans have been developed and implemented.

Progress towards 18 weeks Referral to Treatment targets – despite significantly over performing on activity against plans, NUH did not achieve the targets to ensure 0 patients were waiting more than 7-weeks for an outpatient appointment and 15-weeks for elective inpatient care by the end of March 07.

Recent Strategic Health Authority guidance on access to diagnostic tests requires further progress in reducing waiting times.

Services are implementing identified actions from reworked capacity plans to resolve ongoing pressures. Support has been confirmed with commissioners in the form of increased service level agreements for a number of services.

We have now had formal confirmation from commissioners that they wish us to achieve slightly faster access times this year from those originally planned and we are working with services to assess whether they can be achieved. Currently significant over performance continues as extra capacity is added.

Rapid access to thrombolytic therapy – currently we are not achieving the national service framework standard as assessed through the Annual Healthcheck

Increasing capacity and enhancing communications along the patient pathway.

Access to genito – urinary clinics – performance is improving but primary care trusts are being challenged as to the level being achieved.

An action plan has been developed to increase capacity over the short and medium term and to improve data and administrative processes.

Access to cancer services – performance on the 62 day referral to treatment target is not yet consistently on target

A tumour specific action plan has been developed and is being implemented.

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Hospital Acquired Infections – achieving reductions in MRSA and c difficile infections is challenging.

A Trust Action Plan is being developed and a senior project manager has been appointed.

Level of Assurance that can be given to the Trust Board from the report [significant, sufficient, limited, none]: SUFFICIENTRecommendation to the Trust Board:Members of the Trust Board are asked to note the position on key performance targets.

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Overview of performance

The attached summary sheet shows the Trust with a number of key targets with significant performance issues.

The exceptions are in similar areas to previously reported:

Ensuring that no patient waits more than 26 weeks from being added to the waiting list to treatment for an elective procedure

Working towards the target of no patients waiting more than 18 weeks from GP referral to hospital treatment by 2008 with a focus on outpatients, inpatients and diagnostics

Achieving diagnostic waiting time targets

Ensuring rapid access to thrombolytic therapy for people suffering a heart attack

Access to genito-urinary medicine (GUM) appointments

Ensuring rapid access to cancer care

An additional area has been identified where there are particular pressures.

Ensuring achievement of infection control targets

Further details are contained in the rest of the report.

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Maintain achievement of national waiting time guarantees

Standard up to end Mar 07 No Inpatient/Daycase patients to wait more than 26 weeks (at month end or in month)Standard from April 07 - No Inpatient/Daycase patients to wait more than 20 weeks (at month end or in month)Area Performance

ChallengesActions Impact –

Measures of Success

Responsibility

7 breaches April-August – previously noted. A Dermatology breach was reported in September.

A patient was seen in outpatients and was incorrectly outcomed as “refer to another hospital” instead of to the other site. As a result they were missed off various checks.

Action plan to deal with immediate causes has been implemented. An investigation has taken place as to whether same situation might have occurred for other patients. Given its nature the incident is also being investigated as a Serious Untoward Incident.

No future breaches for same underlying reasons.

Deputy Director of OperationsDirectorate leads

Work towards the target of no patients waiting more than 18-weeks from GP referral to hospital treatment by 2008

Maximum wait of 7-weeks for outpatients, 11-weeks for diagnostics and 15-weeks for day-cases/inpatients by March 2007Maximum wait of 5-weeks for outpatients, 6-weeks for diagnostics and 11-weeks for day-cases/inpatients by March 2008Area Performance

ChallengesImpact – Measures of Success

Responsibility

At end of September193 inpatient/day case patients waiting 15 weeks or longer.(Main area of challenge: Orthopaedics = 96)

a) Deliver 06/7 target shortfall.b) Progress to successful achievement of 07/8 agreed targetsc) Ensure progression to 07/8 targets enables sufficient progress to

We have agreed with commissioners increases to planned activity levels in a number of areas in order to achieve waiting time targets. With this PCT support we continue to implement additional in house initiatives and place a number of patients in the private sector. The number of patients who choose us but are unable to book slots

Achievement of milestones and profiles as identified in the re-worked specialty plans.

Deputy Director of Operations, Acting Assistant Director of Finance (Commissioning), Directorates Leads.

(Clear responsibilities to be derived in specialty-specific

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1432 outpatients waiting 7 weeks or longer.(Main areas of challenge: Cardiology = 226Orthopaedics = 149Neurology = 89)

achieve 18 week targets by Dec 2008.d) Work with commissioners to manage demand. In 06/7 activity plans were exceeded by 3% (more elective spells than planned) yet local targets were not achieved. Continued increases in demand will present significant challenges to achievement of targets in 07/8.

directly is reducing as we increase capacity and continue to over perform.

Commissioners have now formally informed us that they wish us to aim to achieve faster access times of 4 weeks outpatients, 4 weeks diagnostics and 10 weeks inpatients by the end of this financial year. Services are assessing the operational requirements to meet these. Further discussions will then take place with services and commissioners if any gaps arise.

action plans.)

The graphs below show the position for the whole trust and highlight the numbers of patients waiting over 7-weeks for their outpatient appointment as well as the number of patients waiting more than 15 weeks for elective treatment. There is also an element of patient choice where patients choose to wait beyond the targets established.

Patients Waiting 7 weeks & over for an Outpatient Attendance following GP or Other Referral

3246

2169 2517 2847 32082759 2776 2928 2748 2352 1882

1334 1414 1531 1227 143213201075

1,06419982452

01000200030004000

Jan-06

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

Feb Mar Apr-07

May Jun Jul Aug Sept

NUH_7 & over wk OP Tgt

Patients waiting 15 weeks & over for an Elective Inpatient or Daycase Admission

1404 1351 1436 1202 1237 1186 1138 1220 1241 1287 1233 1012

405 243 258 268 178 204 193

12001125

0500

100015002000

Jan-06

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

Feb Mar Apr-07

May Jun Jul Aug Sept

NUH_15 & over w k IP/DC Tgt

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Work towards the target of no patients waiting more than 18-weeks from GP referral to hospital treatment by 2008

Maximum wait of 13 weeks for diagnostic tests by end of September 07 and 6 weeks by end of March 08Area Performance

ChallengesActions Impact –

Measures of Success

Responsibility

The latest available data across the 15 tests reported on the monthly return shows 207 over 13 wk waiters as at end Sept.

The key challenges are neurophysiology (188) and echocardiography (17).

The main over 13 week challenge remains in neurophysiology. Following close collaboration with the PCTs we have added significant extra capacity in neurophysiology halving waiting lists. However the number of over 13 week waiters did not fall substantially as we were unable to contact some patients at short notice or they chose not to attend at such short notice. Any remaining patients waiting over 13 weeks for any test will be treated through October and November.

Further work will take place to develop action plans to ensure we achieve the new 4 week milestone.

Where extra activity is identified as required we will work internally and with PCTs to determine possible solutions.

No over 13 wk waiters and reducing numbers over 4 weeks.

Deputy Director of Operations, Acting Assistant Director of Finance (Commissioning), Directorates Leads.

The Primary Care Trusts (PCTs) are required by the Strategic Health Authority (SHA) to ensure there are no patients waiting over 13 weeks by the end of September. This is an additional milestone to the target we are working towards of no patients waiting over 4 weeks by the end of March 2008. There are a further set of tests which are reported on a quarterly return and we are reviewing those as well to identify any problem areas.

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Achieving call to needle times for thrombolysis

Standard to achieve 65% of patients receiving thrombolysis within 60 minutes of calling for professional help. This target has been updated from 56% previously set to reflect the level set in the Annual Healthcheck assessment.Area Performance

ChallengesActions Impact –

Measures of Success

Responsibility

The National Service Framework standard is that people suffering from heart attack should receive thrombolytic therapy within 60 minutes of calling for professional help.

This target relates to a small number of patients (approx 11) a month.

Performance in any individual month can therefore vary quite significantly but on average it is 56% against a target of 65%.

Joint work is being undertaken with the East Midlands Ambulance Service (EMAS) as this target is shared between NUH and EMAS.

The new directorate management team are putting in place a number of actions over the next few months.

QMC thrombolysis nurse team providing 70% cover in ED as from August 27th, to date all shifts have been covered.

First performance review meeting arranged for October 23rd to look through September performance with representation from EMAS and NUH teams.

Training dates for paramedics being arranged. Support audit officer post to be advertised, will

allow senior audit officer to meet with EMAS monthly to answer queries regarding call to door times as this area has the most potential to improve our data collection.

Improved performance.

Directorate leads

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Thrombolysis - Numbers eligible and % within 60 mins

0%

25%

50%

75%

100%

Jan Feb Mar Apr-06

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

% r

ecei

ving

with

in 6

0 m

ins C

all t

o N

eedl

e

0

2

4

6

8

10

12

14

16

18

Num

bers

elig

ible

Eligible Thromb_60 min % Tgt_60 min

Access to genito-urinary medicine (GUM) services

Standard to achieve 100% access to GUM clinic within 48 hours by March 08Area Performance

ChallengesActions Impact –

Measures of Success

Responsibility

Performance has been improving from 65-70% to over 70% in June, July and August.

Further significant improvements are required to reach the 100% target.

Increased staffing – including extra nurse practioners for start of Oct and additional consultant by March 08.Increasing capacity from current establishment.

An audit of the data collection and reporting system has been undertaken.

Action plan delivered per timescale.

Improved 48 hr performance.

Directorate leads

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Currently the service is meeting the profile set internally as steps towards ensuring we meet the required target of 100% access by March 2008. However the PCTs are being assessed against a different profile and they are being challenged to improve performance. As the only provider of specialist genito urinary services within Nottingham we are key to the PCT’s plans. The health community sees this as a key risk area and therefore it was felt necessary to bring this to the Board’s attention.

Speed of access to cancer services

Maximum two month wait from urgent GP referral for suspected cancer to first definitive treatment for all cancers (“62 day target”)Performance Challenges Actions Impact –

Measures of Success

Responsibility

Performance is not yet consistently above the 95% target level.

There are four main factors behind the current deterioration in performance

Capacity difficulties in radiotherapy

Management changes within NUH

Impact of a review of administration and clerical provision

Impact of holidays on capacity

A tumour-site specific action plan has been agreed following pressure over the last couple of months. Performance is beginning to shows signs of improvement as the plan is implemented.

Although September’s performance will be confirmed at below 95%, October is likely to be above and we anticipate that this should continue as the new management and administrative support structures become established. Discussions are taking place with Sheffield on the options for referring patients for Radiotherapy when peaks of demand require that we do.

The Lung team are meeting on the 8th November to review their current diagnostic process and look at further options to reduce the time taken

Improved performance

Director of Nursing and OperationsDirectorate leads

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Cancer 62 day target - from urgent referral to first definitive treatment

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Apr-05

May June Jul Aug Sep Oct Nov Dec-05

Jan Feb Mar Apr-06

May June Jul Aug Sep Oct Nov Dec-06

Jan Feb Mar Apr-07

May Jun Jul Aug

TotalTgt

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Hospital Acquired Infections - Achieving Infection Control Targets

MRSA – target of 51 for 2007/8C difficile - rate per 000 bed days in over 65s – target of 2.2 for 2007 based on Health Protection Agency estimate of bed daysPerformance Challenges Actions Impact – Measures of

SuccessResponsibility

The MRSA target is a year-on-year year 25% reduction. This is now 4 cases per month. The trajectory has consistently been exceeded (5-8 pr month since Jan 07). ) The target includes community acquired cases (currently around 25%).

The C Diff target agreed (and recently confirmed) with PCTs is a 5% reduction from 735 cases in those aged 65 and over Jan - Dec 2006 to 698 cases this calendar year (equivalent to a reduction from 2.4 to 2.2 per 1000 bed days). This target trajectory has not been met this year (the trend line is on-the-whole overall flat, as the graph shows). Since Jan 07 144 of the 592 cases (to end Sept) have been community acquired.

Actions include (from 1 November) much increased skin decolonisation in high risk areas, increased IP screening, and invigorated root cause analysis and audit improvement cycles after cases. The hand hygiene campaign continues. We are exploring with PCTs increased health-community out-of-hospital actions (notable screening and decolonisation).

The HAI action plan includes measures designed to allow the trajectory to be regained (though to meet the year's target number will require a stepped reduction in the number of cases to approx 36 per month). These include the hand hygiene campaign, increased use of F22 and single rooms for rapid isolation, prompt treatment of cases, acceleration of the peroxide decontamination programme, attention to antibiotic use, and the use of probiotics in at risk patients. Invigorated root cause analysis and audit improvement cycles after cases will be done as for MRSA bacteraemia.  We are working with the health community to develop actions (notably around reducing antibiotic use) to reduce community acquired C Diff.'

It has been agreed with PCTs and SHA that NUH will aim to meet the target in each month from October (ie the 'run-rate' to March 08 will be in keeping with target levels of performance). 

Reducing rate to 2.2 on average.

A Deputy Director of Infection Prevention and Control and Governance has been appointed (to commence week beginning 12 November). The performance management of HAI has been revitalised by a weekly meeting of IPC Team and Directorate Leads, chaired by the Director of Infection Prevention and Control, and monthly reporting to the Turnaround Team against the targets and the HAI Action Plan (to be presented for the Board's consideration Dec 07) which has been informed by the DoH Improvement Team visit of late August.

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Number of MRSA infections (as per Annual Healthcheck measure)

5

7

9 98

6

87

8

4

6

87

67

6

89

7 7 7 7 7 76 6 6 6

5 5 5 5 54 4 4

0

2

4

6

8

10

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

NUH_actual NUH target

Total C. difficile Cases (in over 65s) - rate per 000 bed days (HPA est)

2.92.7 2.8 2.8 2.6

1.8

2.6 2.5

1.7

0

0.5

1

1.5

2

2.5

3

3.5

Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07Target Rate

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