AGENDA ITEM 4.2 4 May 2016 Health Board Report INTEGRATED ... · ambulance response times changed and only Red1 calls are monitored against an 8 minute response time. Current information

Integrated Performance Dashboard Page 1 of 18 University Health Board Meeting 4 May 2016

AGENDA ITEM 4.2

4th May 2016

Health Board Report

INTEGRATED PERFORMANCE DASHBOARD

Executive Lead: Director of Planning and Performance

Author: Assistant Director of Performance and Information

Contact Details for further information: Deb Evans, Assistant Director of Performance and Information 01443 744800 or email

[email protected]

Purpose of the Health Board Report

The purpose of this report is to provide the Health Board with a summary

of current performance across a range of indicators and key issues, in particular where there are current organisational challenges and

achievement and/or the organisation is under formal escalation with the

Welsh Government.

Governance

Link to Health

Board Strategic Objective(s)

The Board’s overarching role is to ensure its Strategy

outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related

organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being

progressed, these in summary are: To improve quality, safety and patient experience.

To protect and improve population health. To ensure that the services provided are accessible

and sustainable into the future. To provide strong governance and assurance.

To ensure good value based care and treatment

for our patients in line with the resources made available to the Health Board.

This report focuses on all of the above objectives.

Supporting

evidence

The Integrated Performance Dashboard is included as

supporting evidence.

Engagement – Who has been involved in this work?

The data and information contained within the dashboard originates from a variety of sources which have a number of engagement processes

associated with them. The Integrated Performance Dashboard is also

mailto:[email protected]


discussed monthly at the Executive Board and Finance, Performance and

Workforce Sub-Committee.

Health Board Resolution (insert √) To;

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation DISCUSS and NOTE the Integrated Performance

Dashboard, this report and performance actions

outlined to support the achievement of targets.

Summarise the Impact of the Health Board Report

Equality and

diversity

There are no directly related Equality and

Diversity implications as a result of this report.

Legal implications A number of indicators monitor progress in

relation to legislation, such as the Mental Health Measure.

Population Health A number of indicators monitor progress in

relation to Population Health, such as vaccination and immunisation uptake rates.

Quality, Safety & Patient Experience

A number of indicators monitor progress in relation to Quality, Safety and Patient

Experience, such as Healthcare Acquired

Infection Rates and Access rates.

Resources There are no directly related resource

implications as a result of this report.

Risks and Assurance Within the Integrated Performance Dashboard,

actions are listed where performance is not

compliant with national or local targets.

Health and Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care;

Dignified Care; Timely Care; Individual Care; Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework

_2015_E1.pdf The work reported in this summary and related

annexes take into account many of the related

quality themes.

Workforce A number of indicators monitor progress in

relation to Workforce, such as Sickness and Personal Development Review rates.

Freedom of

information status

Open

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdf




INTEGRATED PERFORMANCE DASHBOARD

1. SITUATION / PURPOSE OF REPORT

The purpose of this report is to provide the Health Board with a summary of

performance against a number of key quality and performance indicators, including areas where the organisation has made significant improvements or

has particular challenges, together with areas where the Health Board is under formal escalation measures from the Welsh Government and/or where local

progress is being monitored.

The Board is requested to DISCUSS and NOTE the contents of the report and

the supporting actions to improve the achievement of national and local targets.

2. BACKGROUND / INTRODUCTION

This report provides the Health Board with an update on progress across a number of key quality and performance targets. These relate to the following

organisational objectives: o To improve quality, safety and patient experience.

o To protect and improve population health. o To ensure that the services provided are accessible and sustainable

into the future. o To provide strong governance and assurance.

o To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board.

The report also sets out any issues affecting performance and associated

actions underway to secure improvement.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

KEY ISSUES:

Unscheduled Care – Executive Lead, Chief Operating Officer and

Director of Primary Care & Mental Health

The pressures in the unscheduled care system during March has resulted in

performance against the unscheduled care access targets being the worst since reporting commenced in October 2009. Performance against the 4 hour wait in

A&E was just 74.6%. At a site level performance was 72% at PCH and 69.8% at RGH. On 6 separate days a performance of less than 60% was recorded on

one of both of the units. The graph below outlines the daily performance by the Health Board as a whole against the 4 and 12 hour targets.


50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

A&E Performance March 2016

4Hr % Achieved 12Hr % Achieved

The number of patients waiting longer than 12 hours also increased significantly from 446 in February to 623, giving a performance of 94.9%. This is again the

worst performance reported by the Health Board.

Further analysis of the data shows that numbers of attendances on a daily basis

have been higher during March than over recent months. An average of 370 patients presented each day across the Health Board, in comparison to an

average of 316 per day during January to December 2015. Ambulance arrivals have been fairly static at an average of 42 per day at each acute site.

Whilst the recent performance against the Unscheduled Care targets has been

poor in comparison to previous months, this has not previously been related to any increase in the number of patients attending our A&E departments.

However, the graph below shows the marked increase in numbers attending the both A&E departments during March. However, it is felt that the drop in

performance is more related to the increased acuity of patients presenting and being admitted and the reduction in bed availability at RGH due to staffing

constraints. Further work will be undertaken to review this in more detail.


For PCH it is also worth noting that the increase in stroke admissions since

September has continued, with a monthly increase of up to 50%. Of particular note is the increase in admissions to the stroke ward from Aneurin Bevan UHB

and Powys tHB, as shown below:

Admissions from Aneurin Bevan UHB

Admissions from Powys tHB

In terms of emergency ambulance services, March data shows performance against the 15 minute handover target dropped from 83.8% in February to

80.2% (79% at PCH and 84.5% at RGH). The number of ambulances delayed over one hour rose to 11, 7 at PCH and 4 at RGH.

As members will be aware, from October onwards the measure for monitored

ambulance response times changed and only Red1 calls are monitored against an 8 minute response time. Current information is received on a weekly basis

(graph shown below) and shows that performance across the Cwm Taf UHB area remains variable. Although performance improved during the middle of

March, this has since reduced.


The graph below shows the all Wales information at Health Board level for the

last five months. As can be seen, the all Wales average for the period has been 69.4%, which was exceeded for Cwm Taf during the first three months, has not

been achieved during February or March.

Referral to Treatment Times (escalation level 1) – Executive Lead, Chief Operating Officer

Reporting of performance against the 36 week RTT target for March shows that

the unscheduled care pressures have had a significant impact on the delivery of planned care. The Health Board had profiled the number of 36 week breaches

to be in the region of 1,050 but a final figure of 1120 patients waiting over 36 weeks was reported. It should be noted that this is a slight improvement on

the 1155 patient reported waiting as at the end of 2014/15.

There were also unfortunately 230 patients waiting longer than 52 weeks for

treatment, mainly within Ophthalmology (194) but also small numbers in Orthopaedics (26), Oral Surgery (5), General Surgery (4) and Gynaecology (1).

All non-Ophthalmology patients had been given dates for treatment before the


end of the financial year, but unfortunately had to be cancelled due to bed unavailability.

The table below outlines the 36 week trend by speciality over the last 12

months, with the end of year position:

Specialty Mar

15 Apr 15

May 15

June 15

July 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Orthopaedics 144 217 309 345 379 362 343 405 386 406 400 276 133

General Surgery 133 173 195 181 200 231 202 227 196 226 261 235 134

Urology 0 13 17 38 20 20 17 25 24 38 52 36 11

ENT 25 65 103 126 213 177 171 160 147 204 198 183 120

Ophthalmology 751 912 1032 1188 1356 1439 1350 1603 1509 1518 1424 1227 609

Oral Surgery 84 95 87 144 183 192 180 183 170 166 107 51 32

Gynaecology 0 35 114 173 210 185 114 181 105 117 122 105 55

Cardiology 9 12 25 16 19 15 12 14 8 11 10 7 0

Rest. Dentistry 7 20 27 48 10 26 26 41 65 79 32 1 0

Gastroenterology 2 0 1 6 17 16 9 14 16 26 33 22 3

Respiratory 0 0 1 0 14 0 0 0 1 2 7 1 0

Anaesthetics 0 3 8 1 0 0 1 0 2 0 0 1 0

Dermatology 0 1 5 12 14 10 10 89 183 298 300 63 20

General Medicine 0 0 0 0 0 0 2 1 0 0 0 2 0

Rheumatology 0 0 0 0 0 16 18 2 2 2 1 0 0

Paediatrics 0 0 0 0 0 0 0 2 0 0 0 0 0

Haematology 0 1 2 0 0 0 2 2 0 0 0 0 0

Diagnostic Services 0 0 1 2 1 2 6 0 16 24 72 30 3

Total 1155 1547 1927 2280 2636 2691 2645 2949 2830 3117 3019 2240 1120

The Health Board is committed to delivering the best position it can against the

RTT target, however it should be noted that the ability to schedule sufficient core surgical activity throughout March 2016 has been restricted due to

unprecedented levels of unscheduled care pressure on both acute and

community sites.

During the financial year, a total of 1417 procedures were cancelled due to bed unavailability and during the last quarter alone, the figure was 886 procedures

cancelled. This is the highest number reported for a year and for a combined quarter, with the previous highest being 2012/13 when 1269 procedures were

reported for the year and 779 for the last quarter.

The majority of cancellations during the year, due to bed unavailability, were within Orthopaedics at the RGH with 293 patients cancelled. A further 153

were affected at PCH given a total 446 procedures; 406 were cancelled in General Surgery and 254 in Gynaecology. These figures are reflected in the

end of year breaches seen above.

The monitoring of both internal and external RTT treatments will remain

ongoing as a priority, via the weekly RTT meeting, chaired either by the Assistant Director of Operations (Scheduled Care) or the Assistant Director of

Performance and Information. However, the process will be revised to capture and report performance on a quarterly basis. It is anticipated that this will


remove some of the end of year pressure but will mean that capacity will need to be streamed equitably throughout the year.

Diagnostic Waits – Executive Lead, Chief Operating Officer

In addition to general RTT waiting times, the Health Board also monitors waiting times for patients awaiting diagnostic investigations. The maximum

waiting times target is 8 weeks for the majority of the diagnostic modalities. The table below outlines the reported position at the end of March, with a

reduction of 208 to be noted in the number waiting over 8 weeks from the February position last reported. The overall waiting list volume has also

dropped from 9921 to 8966, a reduction of 955 patients.

Service Sub-Heading

Total

List

Within

Target

Over

Target

Over 16

Weeks

Over 26

Weeks

Over 36

Weeks

Cardiology Echo Cardiogram 840 821 19 2 2 1

Stress Test 138 127 11 2 1 0

Diagnostic Endoscopy Bronchoscopy 4 4 0 0 0 0

Colonoscopy 356 218 138 38 2 0

Cystoscopy 196 123 73 27 8 1

Flexible Sigmoidoscopy 353 196 157 48 3 0

Gastroscopy 662 362 300 105 8 0

Imaging Fluoroscopy 275 161 114 58 21 6

Phys iologica l MeasurementUrodynamic Tests 83 52 31 23 3 0

Barium Enema 127 124 3 0 0 0

C.T. 664 645 19 8 3 0

M.R. 420 413 7 0 0 0

Non-Obstetric Ultrasound 2302 1527 775 213 17 3

Nuclear Medicine 40 40 0 0 0 0

Radiology - GP Referra l Barium Enema 39 39 0 0 0 0

C.T. 142 142 0 0 0 0

M.R. 77 77 0 0 0 0

Non-Obstetric Ultrasound 2244 1435 809 144 9 2

Nuclear Medicine 4 4 0 0 0 0

Total 8966 6510 2456 668 77 13

% > Target 73% 27% 7% 1% 0.1%

Radiology - Consultant

Referra l

Cancer 31 and 62 Day Target (escalation level 2) – Executive Lead,

Medical Director

The 31 day target was narrowly missed in February. The Health Board reported two breaches, one in Head and Neck and one in Lung, with a performance of

97.9%.

The 62 day target was also unfortunately not achieved for February and dropped to below 90% at 88.9%. The Health Board reported six breaches;

three in Gynaecology (one was a complex pathway), two in Lung and one within Urology. All six patients were treated at the tertiary centres but none

being referred by day 31 of the pathway.

The table below shows the breaches by tumour site and the overall monthly

performance over the last 12 months within this area.


Urology Lung LGI H&N Gynae Haem Upper Breast Other No. Breaches

Performance

GI

March 0 0 0 2 0 0 0 0 0 2 96.30%

April 2 3 0 1 1 0 0 0 0 7 89.30%

May 1 1 1 0 0 0 0 0 0 3 93.60%

June 5 2 0 1 2 0 0 0 0 10 82.80%

July 2 3 0 0 1 0 0 0 0 6 89.50%

August 2 2 1 1 0 0 0 0 0 6 88.00%

September 1 1 0 0 1 1 0 0 1 5 91.70%

October 1 0 1 1 2 0 1 0 0 6 86.40%

November 1 1 2 0 0 0 0 0 0 4 93.40%

December 1 0 1 0 1 0 1 0 0 4 91.50%

January 6 0 0 0 2 0 0 0 1 9 83.30%

February 1 2 0 0 3 0 0 0 0 6 88.9%

Total 23 15 6 6 13 1 2 0 2 68

Stroke Quality Improvement Measures (QIMs) (escalation level 1) - Executive Lead, Director of Planning and Performance

During February, 50 patients have been recorded within the stroke database.

This is the fourth monthly submission with significantly increased numbers of patients recorded. Performance against the new QIMS is shown below:

Quality Improvement Measures

Bundle < 4 hours < 12 hours < 24 hours < 72 hours

Oct – 40 pts 50.0% 97.5% 60.0% 85.0%

Nov – 60 pts 48.3% 93.3% 58.3% 83.3%

Dec – 50 pts 60.0% 96.0% 62.0% 72.0%

Jan - 60 pts 48.3% 98.3% 55.0% 56.7%

Feb – 50 pts 32.0% 100% 52.0% 76.0%


February 2016

As can be seen from the information above, the main issue remains the direct

admission to the stroke unit within the required timeframe and the subsequent swallow screening assessment. The assessment by a stroke consultant and

therapist also remains an issue although, it should also be noted that with the current level of cover available to the stroke service then the assessment by a

stroke consultant within 24 hours will remain challenging for patients admitted over the weekend period.

As was mentioned within the RTT section, the Health Board has seen an

increase in Stroke presentations from Aneurin Bevan UHB and Powys tHB over recent months. The increase in Powys activity was expected as an agreed

service change has been put in place. Further clarity is required on the increased flow of Aneurin Bevan patients.

The Stroke clinical team has recently undertaken an audit of all cases to establish suitability for thrombolysis. This work will be analysed and presented

to the April meeting of the Stroke Task and Finish Group. It will be included as an update in May’s Performance Report.

Mental Health Measure - Executive Lead, Director of Primary Care &

Mental Health

Part One of the Mental Health Measure relates to the primary care assessment and treatment, and has a target for 80% of referrals to be assessed within 28

days. The assessment performance improved from 43.5% in January to 68% in February but remains non-compliant with the target. Performance for Part 1


Treatment target (28 days) improved again to 91.2%, in spite of the high volume of referrals the service is receiving each month. The service is now

fully recorded within the Myrddin system, which is having a positive effect on the patient pathway management.

Part Two of the Mental Health Measure relates to patients having a valid care and treatment plan. Performance for February dropped slightly from 84.2%

from 83.8%.

Workforce and Organisational Development Update – Executive Lead, Director of Workforce and Organisational Development

Analysis is carried out regularly within the Workforce and OD Directorate on

sickness absence rates personal development review (PDR) rates and Consultant Job Plans, which is included in detail in the attached Integrated

Performance Dashboard. The source of data for this analysis is ESR Business Intelligence.

Sickness Absence

Current sickness absence activity is focussed through the Directorate’s five point activity plans which are agreed jointly with managers on a monthly basis

and are used as the foundation for the CBM Reports.

The Health Board target is 4.5% from 1st April 2015. The table below shows

data as at 29 February 2016, and illustrates a further downward trend to a fairly static level of sickness absence throughout the year from March 2015 at

5.62% to February 2016 at 5.47%.

Current data as at 29/02/2016

Data provided

21/12/15

Data provided

26/11/15

Data provided

20/10/2015

Data provided

4/09/15

Data provided

03/06/2015

Month Abs FTE % Abs FTE % Abs FTE % Abs FTE % Abs FTE % Abs FTE %

Difference in data

provided Dec 2015

& Feb 2016

2015 / 03 5.62 5.54 5.55 5.55 5.55 5.63 0.08

2015 / 04 5.22 5.2 5.2 5.22 5.22 5.17 0.02

2015 / 05 5.19 5.15 5.15 5.17 5.17 4.65 0.04

2015 / 06 5.41 5.38 5.39 5.38 5.38 0.03

2015 / 07 5.64 5.61 5.64 5.64 5.6 0.03

2015 / 08 5.63 5.56 5.6 5.61 5.69 0.07

2015/ 09 5.46 5.36 5.39 5.38 0.10

2015/ 10 5.47 5.45 5.39 0.02

2015/ 11 5.66 5.73 -0.07

2015/ 12 5.71 5.73 -0.02

2016/01 5.74

2016/ 02 5.47

The more recent differences in data provided month on month are fairly

negligible, refer to the end column [this has been updated from last month’s report to show the differences in submissions for December 2015 and February

2016]. This is mainly due to the increased rollout of weekly E-Rostering update feeding across in a more timely fashion, and also that the BI report for the

most recent months has been run after the pay run has closed (so pay card


data entered by payroll is included too). Data requested later in the month improves the accuracy of the data, as the variance becomes minor.

From 1st to 29th February 2016 the percentages of sickness entry by Self

Service was 56.87%, this figure was 56.87% in January 2016, by E-Rostering

24.490% and this was 20.60% in January, and by pay cards 21.34%, which was 22.53% in January.

The average time to enter absence has reduced from 25.51 days in March 2015

to 11.87 days in February 2016. This means that 62% of absences were entered within 11 days in January 2016.

The three year absence trend evidences that the absence rate for February

2014 was 5.91%, for February 2015 at 6.21% and for February 2016 is 5.47%.

The top three reasons for absence from 1 March 2014 to 28 February 2015 showed that ‘anxiety/stress’ was the primary reason for staff to be absent with

24.8%. The second reason for absence was given in the ‘Unknown’ category as 11.1%, and third was ‘other musculoskeletal problems’ at 10.1%. In

comparison, the primary reason for absence in the year from 1 March 2015 to 29 February 2016 shows that ‘anxiety/stress’ was still the major cause and an

increase of 2% at 26.4%, with ‘other musculoskeletal problems’ showing an

increase at 12.8%, and ‘gastrointestinal problems’ as the third reason at 8.1%. In comparing these two year periods, it is now strongly evident that the

category ‘Unknown causes / not specified’ is no longer appearing in the top three reasons for absence.

Long Term Sickness for FTE was reported at 4.21% in February 2015 and

3.81% for February 2016. Short Term Sickness in February 2015 was reported at 2.06%. Following a drop to the lowest level of 1.4% in April 2015, the rate

in February 2016 was 1.67%.

The overview of occurrences of sickness absence over the past year show that the number of occurrences of Long Term absence has reduced from 445 in

February 2015 to 393 in February 2016, and the number of Short Term occurrences has reduced from 831 in February 2015 to 751 in February 2016.

Return to Work discussions are reported as 39% for the 12 month period March 2015 to February 2016, compared to 20% for the same period March 2014 to

February 2015. Although the number of Return to Work discussions being entered onto ESR has increased in the last 12 months, efforts are currently

being focussed on ensuring managers are entering the information onto ESR.

Resourcing Regarding staff leaving the organisation the cumulative leavers by headcount is

-36 and by FTE is -29.05. For new starters to the organisation, the cumulative starters by headcount is 69 and by FTE is 57.95. These figures are derived

from 29 February 2016.


ESR Self Service Roll-out The current level of staff with Self Service accounts is 4,345. This represents

54.37% of the workforce.

Recruitment Activity

Performance has decreased slightly regarding NWSSP measures and days to advert stage has decreased for Cwm Taf UHB from 36.6 days in January 2016

to 30.2 days in February 2016. For NHS Wales as a whole this figure is 30.8 days in January.

Days to on-boarding stage has also decreased at 19.7 days in February 2016

and the NHS Wales average is 23.9 days.

Training, PDR, Appraisal and Job Plan Compliance As at 1st April 2016 compliance is 63.57%, a decrease of 2.21% since the

previous month and an overall decrease of 9.41 in the last 6 months. The majority of Directorates continue to perform above 60% compliance. Thirteen

Directorates have declined/remained static since last month. L&D continue to work in close partnerships with Business Partner colleagues to support

managers with persistent non-compliance issues and develop actions for improvement.

The Medical appraisal year commences 1st April each year. From the 1st April – 29th February, a total of 80 % of doctors have had a complete annual

appraisal. This includes GPs for Merthyr Tydfil and RCT.

e-Job Planning Update Four Directorates are now fully trained and are utilising the e-job planning

system in their recent rounds of job plan meetings.

The Directorate of General Surgery, Urology and T&O commenced their job plan cycle utilising the new e-system in October 2015, starting with the teams in

Trauma & Orthopaedics. 19 consultant reviews have now been undertaken, 9 of which have been signed off.

Anaesthetics, critical care and theatres (ACT) commenced their job plan cycle

on 29th February 2016. 14 consultant reviews have been undertaken, 5 of

which have received full signed off.

The Directorate of Acute Medicine and A&E commenced their job plan review cycle in December 2015, and will continue through 2016. 14 consultant

reviews have been undertaken, 7 of which have been signed off.

The Mental Health Directorate commenced their job plan cycle on 22nd February 2016. 4 consultant reviews have been undertaken, with 3 receiving

full sign off.

The Directorate of Radiology are due to start their next round of job plan meetings in the Spring of 2016. The Directorate Management Teams have


received their training to enable the reviews to be undertaken utilising the e-job plan system.

The Pathology and Head and Neck Directorates are next on the implementation

plan. Consultation meetings have been scheduled with the Directorate

Management teams and training is to be arranged.

Occupational Health OHWB leads continue to work on existing and potentially new SLAs as

highlighted last month.

Draft organisational and Directorate OH activity reports have been presented within W&OD for comments, with a view of sharing reports at Directorate level

via appropriate forums/discussion.

NHS Outcomes Framework

At the beginning of April, Welsh Government issued its final version of an NHS Outcomes Framework (WHC (2016) 023 the NHS Outcomes Framework for

2016-17). The focus for this revised version has been on ensuring links with the Francis Inquiry (achieved via engagement between staff and local

residents), with the Wellbeing of Future Generations (Wales) Act 2015 and with

the Public Health outcomes Framework. The framework includes outcome indicators that will provide an annual view of the impact health services are

having on improving outcomes at a population level. These indicators are supported by the delivery element of the framework that will measure

performance of the organisation throughout the year.

There are small changes noted in the measures required for 2016/17 against those used in 2015/16. The measures no longer included are:

o Percentage of reception class children (aged 4/5) classified as overweight or obese

o National prescribing indicator rate o Number of healthcare acquired pressure ulcers (incorporated into

“performance against key health and care standard themes”) o Primary care clusters demonstrating rolling improvement against

agreed plans

o Percentage of people aged 50+ who have a record of blood pressure measurement in the preceding 5 years

o Risk adjusted mortality rate and data quality standards attainment level

o Participation in the National Clinical Audit programme o Results of the Fundamentals of Care audit (incorporated into

“performance against key health and care standard themes”) o Improvement in the cardiac pathway

o The gap between the least and most deprived of the percentage of people with hypertension whose GP latest recorded blood pressure is

150/90 or less


o Evidence of compliance against the Welsh Language Act 1993 as assessed through the Welsh Quality Standards

o Reduce waste in secondary and primary care through the delivery of efficient and productive services (included as an outcome indicator

with a different form of measurement)

o Primary and community spending as a percentage of total spend o Results of actions from the staff survey to improve the organisation’s

staff engagement o Percentage of medical staff undertaking a performance appraisal

(incorporated into percentage of staff undertaking performance appraisal)

o Percentage of patients who left without being seen in A&E

Work has commenced to ensure the performance report reflects the changes outlined in the document and it is anticipated that the May report will be

fully compliant with the needs of the document.

Welsh Audit Office – Review of Health Board Performance Reports

As part of Welsh Audit Office’s Structured Assessment for 2015, a review of how effectively NHS bodies report their performance at Board level was

undertaken. The results of the review were fed back to Board Secretaries at

the end of February.

The reports reviewed covered the period July to November 2015 and the criteria used was:

o Attributes – do performance reports adhere to good practice criteria including, for example, exception reporting, use of charts and

benchmarking? o Coverage – do performance reports provide sufficient functional

coverage, including areas such as finance, patient outcomes and patient experience?

The findings include a web-analysis covering key attributes at an all Wales level

and for each individual health board. The all Wales review includes a comparison over previous years and is shown below:


The full report is included as an appendix to this report but summary findings for Cwm Taf are outlined below.

The report used for the review was the September report submitted to the

Health Board. As can be seen from the diagram below, Cwm Taf’s report scores higher than the all Wales score on most indicators.


The narrative provided with the analysis outlines the following positive areas and those where WAO feels improvements could be made:

What is good or appears to have

improved?

What could be better?

The report’s summary focuses on a number

of key areas where the organisation has

made significant improvements or has

particular challenges.

There is a summary, but a scorecard and/or

exception reporting would further help direct

readers’ attention.

There is a reasonable mix of narrative and

data within the boundaries of what is

reported.

There is potential to widen the summary’s

coverage because it focuses heavily on

access and pathway indicators.

The performance report has a mix of

qualitative and quantitative information,

with charts and graphics showing current

and trend performance.

There is potential to widen the performance

report’s coverage because it does not cover

the totality of the health board’s activity.

The summary focuses heavily on access and

pathway indicators.

Generally, most indicators have targets

attached. Those local performance

measures that have been defined include

targets.

There is potential to make clearer linkages

between performance and IMTP priorities.

The performance report narrative identifies

corrective action across most functions.

The main performance report would benefit

from more use of RAG rating/ colour coding

to help the reader quickly gauge

performance against target.

The performance report uses comparative

information in specific areas, but no

widespread benchmarking.

Identified actions within the performance

report would benefit from unambiguous

assigned responsibilities.

There are some local indicators reported,

based around improving efficiency e.g.

theatre efficiency, DNA rates, length of

stay.

The performance report would benefit from

a more insightful narrative

It is worth noting that since the publication of the September 2015 Integrated

Performance Report the format has been revised and many of the issues highlighted by this review have already been addressed.

The report now includes benchmark for all measures where they are available

and the summary at the beginning of each chapter contains a scorecard function to enable easier reading of progress. Work is continuing to explore the

breadth of the report to ensure we are covering the totality of the Health

Board’s activity but this is limited to the availability of appropriate datasets.


4. RECOMMENDATION

The Health Board is asked to: -

DISCUSS and NOTE the Integrated Performance Dashboard, this

report and performance actions outlined to support the achievement of targets.

Freedom of information status

Open

Documents

AGENDA ITEM 4.2 4 May 2016 Health Board Report INTEGRATED ... · ambulance response times changed and only Red1 calls are monitored against an 8 minute response time. Current information