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BOARD OF DIRECTORS OPERATIONAL PERFORMANCE REPORT
Month 9 (December 2014) and Quarter 3 (Oct-Dec 14)
Presented By:
22nd January 2015
Board of Directors
Rob Elek
Director of Strategy and Business Development
Produced By:
Stephen Chinn
Senior Performance AnalystAction for Board: For information
For consideration
For decision
Exception Report Page 2 -3
Compliance Performance Summary Page 4
Access - Referral to Treatment Page 5 - 6
Access - A&E Page 7 - 8
Access - Cancer Waiting Times Page 9
Access - Other Page 10
Efficiency Page 11 -12
Effectiveness Page 13
Safety Page 13
Page 14
Page 15Patient Experience
Ward Staffing Levels
CONTENTS
Board of Directors Performance Report - December 2014 and Quarter 3
Exception Report - December 2014 and Quarter 3
18 Week RTT Performance: The Trust achieved referral to treatment (RTT) compliance in December for all three RTT measures. Admitted performance achieved the 90% target for the first time this financial year, with 92.1% of patients seen within 18 weeks (M8 88.9%). The Q3 position of 89.2% (Q2 83.4%) remained below target, as anticipated, following M7 and M8 performance. RTT Non Admitted Performance continued to achieve at 96.1% (M8 95.7%). The target was also achieved for Q3 with performance of 95.8% (Q2 94.1%). RTT Incomplete Pathways continues to achieve the target with performance of 95.1% (M8 95.6%), well above the 92% target. Q3 performance of 95.3% (Q2 92.1%) has resulted in compliance in our YTD position at 93.2%. The above is provisional pending final validation and submission on 20th January. Accident and Emergency: A&E 4 Hour performance continues to meet the national target of 95%, achieving 99.3% in December and 99.1% for Q3. A&E 3 hour performance continues to achieve the internal target of 80%, achieving 81.2% in December and 81.2% in Q3. Activity continues to increase, especially compared to the previous year where it has increased 10% compared to last December and 8.4% for the year to date. This represents an average increase of 20 A&E attendances every day. Percentage of A&E patients seen, treated and discharged by an Emergency Nurse Practitioner (ENP) remains below our local target of 30%, with 22.8% of patients treated in December and 23.8% of patients treated in Q3. Cancer For December and Q3 all cancer waiting time targets were achieved with no breaches, however year to date the ‘two week wait for first appointment’ remains just below the 93% target at 92% due to two missed cases in Q2.
Page 2
Board of Directors Performance Report - December 2014 and Quarter 3
Exception Report - December 2014 and Quarter 3 (Continued.)
Choose and Book Performance Performance for Choose and Book (first appointment slot availability) has increased in December to 87.2% (M8: 82.3%), Q3 performance was 85.1% (Q2 84.4%). Efficiency Following the successful migration of data from Croydon’s to Moorfields’ information systems in December, all measures now include our activity – prior months currently exclude activity at Croydon University Hospital and Purley War Memorial Hospital. Compared to November total activity remains at a similar level for First Outpatient Attendances, there is an increase in admissions, and is lower for Follow up attendances, even with the inclusion of the Croydon data. However this is due to December containing less working days and an expected lower than normal activity level between the Christmas and New Year period. For Q3 compared to the previous year, excluding the additional Croydon data (for a like-for-like comparision), first appointment activity increased by 8%, follow up activity increased by 4% and admissions increased by 10%. First Attendances continues to increase with Q3 at 24,561, against 22,017 and 22,559 in Q1 and Q2 respectively. Follow up Attendances remain at a similar level to Q2. Did not attend (DNA) rates remain stable at around 11% for both first and follow up appointments compared to previous months. For December Outpatient Cancellations are at 13.7%, an increase of 3% from 10.9% in the previous month. For quarter 3 this has increased from 9.5% in quarter 2 to 11.6%. There were no reported 28 days breaches for inpatient cancellations in December 2014 or Quarter 3. VTE Performance The migration of data from Croydon, has (at present) resulted in the unavailability of the flag confirming whether a Venous thromboembolism (VTE) assessment had been completed prior to an admission. Therefore, these Croydon admissions are marked as not compliant. This has had a negative effect on the overall VTE performance, taking it below the 95% target to 89.9%, compared to 99.0% the previous month. For Q3, the trust remains above target at 95.8%.
Page 3
Board of Directors Performance Report - December 2014 and Quarter 3
COMPLIANCE PERFORMANCE SUMMARY
Threshold Dec-14 Q3 14/15 YTD 14/15Quarterly
TrendSource Threshold Dec-14 Q3 14/15 YTD 14/15
Quarterly
TrendSource
≥ 90% 92.1% 89.2% 84.5% CQC, Monitor,TDA 0 0 0 3 CQC, TDA
≥ 95% 96.1% 95.8% 94.9% CQC, Monitor,TDA n/a 5.0% 3.3% 3.6% Monitor
≥ 92% 95.1% 95.3% 93.2% CQC, Monitor,TDA n/a 5.0% 3.6% 3.8% CQC, TDA, Outcomes
Framework
≥ 95% 99.3% 99.1% 99.2% CQC, Monitor,TDA n/a 50.4% 54.7% 53.2% Local
≥ 80% 82.9% 81.2% 81.6% Local 0 0 0 0 CQC, Monitor,TDA
≥ 5% 0.6% 0.9% 1.1% CQC, TDA 0 0 0 0 CQC, Monitor,TDA
≥ 30% 22.8% 23.8% 24.4% Local ≥ 95% 89.9% 95.8% 97.5% CQC, TDA
≥ 5% 0.5% 0.6% 0.7% CQC, TDA 0 0 0 0 CQC, TDA
≥ 93% 100% 100% 92.0% CQC, Monitor,TDA n/a 100% 100% 101% CQC, TDA
≥ 96% 100% 100% 100% CQC, Monitor,TDA ≥ 20% 74.7% 72.4% 70.3% CQC,TDA, Outcomes
Framework
≥ 94% 100% 100% 100% CQC, Monitor,TDA ≥ 30% 23.6% 25.9% 26.9% CQC,TDA, Outcomes
Framework
≥ 85% n/a n/a n/a CQC, Monitor,TDA
≥ 99% 100% 100% 100% CQC, TDA
n/a 87.4% 85.6% 85.9% Local
≥ 96% 87.0% 85.1% 86.5% Local
Key Reference:
Within tolerance and drop in figures
No target or N/A
On or above target
Stable on/above target
On target and drop in figures
Below target and rise in figures
Below target and stable
Below target and fall in figures
Within tolerance and stable
Within tolerance and rise in figures
A&E 4 hour waiting timeGP referrals first outpatient using
Choose & Book
VTE Screening - all admissions
Number of Mixed Sex
Accommodation Breaches
Friends & Family Test - Inpatients
(Response Rate)
A&E ENP Pathways
A&E Left Before Treatment Number of C.Diff cases
Ward Staffing Levels
(Inpatient Wards Only)
Choose & Book Appointment
Availability
A&E 3 hour waiting times Number of MRSA cases
Outpatient appointment - Over 6
week waiters
Cancer 31 day wait - subsequent
treatment - surgery
Cancer 62 day from urgent GP
referral to first definitive treatment
Diagnostics 6 week waiting time
A&E Unplanned re-attendance
Cancer 2 week wait - first
appointment urgent GP referral
% Cancer 31 day wait - diagnosis to
first appointment
Friends & Family Test - A&E
(Response Rate)
Performance 2014/15Performance 2014/15
Percentage 18 weeks Non Admitted
Pathways
Emergency Readmissions within 28
days of discharge
Percentage 18 weeks Incomplete
Pathways
Emergency Readmissions within 30
days of discharge
Indicator Indicator
Percentage 18 weeks Admitted
Pathways
Cancelled Operations - 28 Days Re-
Book
Page 4
Board of Directors Performance Report - December 2014 and Quarter 3
18 Weeks Referral to Treatment (Provisional)
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
90% N/A 92.1% 88.9% 80.9% 83.4% 89.2% 84.5% Monitor, CQC,
TDA
95% N/A 96.1% 95.7% 94.95% 94.1% 95.8% 94.9% Monitor, CQC,
TDA
92% N/A 95.1% 95.6% 92.2% 92.1% 95.3% 93.2% Monitor, CQC,
TDA
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
N/A N/A 171 281 1,442 1,363 799 3,604
N/A N/A 44 -29 -686 -543 -56 -1,284
N/A N/A 207 290 934 1,097 809 2,840
N/A N/A 55 48 -9 -174 143 -39
N/A N/A 1,014 928 5,035 5,066 2,964 13,065
N/A N/A 649 750 116 73 3,305 6,067
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
90% N/A 100.0% 97.8% 86.3% 85.3% 98.5% 89.3% Monitor, CQC,
TDA
95% N/A 99.0% 98.0% 97.3% 95.1% 98.9% 97.0% Monitor, CQC,
TDA
92% N/A 95.0% 96.4% 94.3% 85.9% 96.7% 92.1% Monitor, CQC,
TDA
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
90% 91.2% 91.9% 88.4% 80.8% 83.3% 88.8% 84.2% Monitor, CQC,
TDA
95% 95.5% 95.8% 95.4% 94.6% 93.9% 95.4% 94.6% Monitor, CQC,
TDA
92% 92.4% 95.1% 95.5% 91.96% 92.6% 95.2% 93.3% Monitor, CQC,
TDA
Compliance
Source
Compliance
Source
Quarterly
Trend
Compliance
Source
Admitted
Incomplete
Patients Waiting >18 weeks
90% Shortfall / Surplus
Patients Waiting >18 weeks
95% Shortfall / Surplus
Patients Waiting >18 weeks
92% Shortfall / Surplus
Performance 2014/15
Quarterly
Trend
Trust Total
Croydon
Indicator
Indicator
18 weeks Referral to Treatment - Admitted
18 weeks Referral to Treatment -Non
Admitted
18 weeks Referral to Treatment -Incomplete
18 weeks Referral to Treatment -Non
Admitted
18 weeks Referral to Treatment -Incomplete
18 weeks Referral to Treatment -Non
Admitted
18 weeks Referral to Treatment -Incomplete
Indicator
Non Admitted
Monthly
Trend
Monthly
Trend
Monthly
Trend
Monthly
Trend
Indicator Threshold
Performance 2014/15
Threshold
Performance 2014/15
18 weeks Referral to Treatment - Admitted
Threshold
Performance 2014/15
Compliance
Source
18 weeks Referral to Treatment - Admitted
Threshold
Moorfields (excluding Croydon)
Quarterly
Trend
Quarterly
Trend
Page 5
Board of Directors Performance Report - December 2014 and Quarter 3
18 Weeks Referral to Treatment (Cont.)
Trust Total
All RTT Targets were achieved for the Trust in December 2014.
Croydon Performance continues to remain high across all performance targets at 100%, 99% and 95% for Admitted, Non-Admitted and Incomplete performance respectively
Moorfields excluding Croydon Performance also achieved all three targets at 91.9%, 95.8% and 95.1% for Admitted, Non-Admitted and Incomplete performance respectively
Page 6
Board of Directors Performance Report - December 2014 and Quarter 3
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
N/A66,400 7,147 7,869 24,338 24,268 23,402 72,008
N/AN/A 6,767 7,346 23,766 23,755 22,168 69,689
95% 99.6% 99.3% 98.5% 99.3% 99.1% 99.1% 99.2% CQC, Monitor,
TDA
80% 83.1% 82.9% 79.8% 82.0% 81.7% 81.2% 81.6% Local
N/A 190 37 97 139 190 167 496
N/A 2 0 0 20 10 0 30
5% 0.9% 0.6% 1.2% 1.2% 1.0% 0.9% 1.1% CQC, Monitor,
TDA
60 mins 10 mins 25 mins 23 mins 23 mins 24 mins 24 mins 20 mins CQC, TDA
240 mins 216 mins 222 mins 262 mins 224 mins 191 mins 234 mins 226 mins CQC, TDA
240 mins 215 mins 217 mins 223 mins 220 mins 221 mins 220 mins 221 mins CQC, TDA
30% 21.7% 22.8% 23.4% 22.8% 26.5% 23.8% 24.4% Local
5% 1.3% 0.5% 0.7% 1.1% 0.3% 0.6% 0.7% CQC, TDA
Compliance
Source
Quarterly
Trend
A&E Maximum waiting times - 3 hours
Time to Treatment in Department - median
Total number of 4 hour breaches
Total number of 6 hour breaches
Left without being seen
Total time spent in A&E -Admitted 95th
Percentile
Total time spent in A&E - Non Admitted 95th
Percentile
A&E Unplanned Re-attendance
A&E ENP Pathway
Accident & Emergency
Indicator
Monthly
Trend
A&E Maximum waiting times - 4 hours
Threshold
Performance 2014/15
Total number of attendances
Total number of expected attendances
Page 7
Board of Directors Performance Report - December 2014 and Quarter 3
A&E 4 Hour performance continues to meet the national target of 95%, achieving 99.3% in December and 99.1% for Quarter 3.
A&E 3 hour performance continues to our target of 80%, achieving 81.2% in December and 81.2% in quarter 3.
Activity continues to increase, especially compared to the previous year where it has increased 10% compared to last December and 8.4% for the year to date. This represents an average
increase of 20 A&E attendances every day. The increase was seen for both working and non-working days activity compared to December 2013.
Percentage of A&E patients treated by an Emergency Nurse Practitioner (ENP) remains below our local target of 30%, with 22.8% of patients treated in December and 23.8% of patients treated
in quarter 3.
Percentage of Unplanned Re-Attendances and Left A&E before treatment remain well below their 5% targets.
Accident & Emergency (Cont.)
Page 8
Board of Directors Performance Report - December 2014 and Quarter 3
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
Cases 24 3 0 8 13 4 25
93% 95.8% 100% n/a 100% 84.6% 100% 92.0%
Cases 9 3 1 2 7 4 13
96% 100% 100% 100% 100% 100% 100% 100%
Cases 1 1 1 0 1 2 3
94% 100% 100% 100% n/a 100% 100% 100%
Cases 0 0 0 0 0 0 0
85% n/a n/a n/a n/a n/a n/a n/a
Performance
2013/14 Forecast
YTD
Current
Month
Previous
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
99% 100% 100% 100% 100% 100% 100% 100% CQC, TDA
TBA 79.4% 87.4% 83.9% 84.5% 87.7% 85.6% 85.9% Local
TBA 58.0% 18.7% 22.0% 46.6% 37.6% 23.6% 37.6% Local
96% 94.8% 87.0% 82.3% 86.1% 84.4% 85.1% 86.5% Local
N/A 4.6% 11.6% 16.4% 13.4% 15.0% 13.4% 12.7% Local
N/A 0.6% 1.2% 1.3% 0.6% 0.6% 1.4% 0.8% Local
Compliance
Source
Cancer 31 day waits - diagnosis to first
appointment
Quarterly
Trend
CQC, Monitor,
TDA
CQC, Monitor,
TDA
CQC, Monitor,
TDA
Compliance
Source
Cancer Waiting Times
Indicator
Cancer 2 week waits - first appointment urgent
GP referral
Threshold
Performance 2014/15
Monthly
Trend
Choose and Book Capacity Issue Rate
Quarterly
Trend
Cancer 31 day waits - subsequent treatment
Choose and Book System Issue Rate
Indicator Threshold
Performance 2014/15
First Outpatient Appointment Waiting more
than 6 weeks
Patients Waiting more than 13 weeks for
Admission
Diagnostic waiting times - 6 weeks
Choose and Book appointment availability
Cancer 62 days from urgent GP referral to first
definitive treatment
For December and quarter 3 all cancer waiting time targets were achieved with no breaches, however year to date the ‘two week wait for first appointment remains just below the 93% target at
92% due to two missed cases in Quarter 2.
To achieve the 93% target for the financial year MEH will need 5 or more two week waits in quarter 4 and no further breaches.
Access - Other
CQC, Monitor,
TDA
Monthly
Trend
Page 9
Board of Directors Performance Report - December 2014 and Quarter 3
Access - Other (Cont.)
Performance for Choose and Book (first appointment slot availability) as increased in December to 87.2% (M8: 82.3%), for quarter 3 performance was 85.1%, an increase on quarter 2
performance (84.4%). This is due to a percentage reduction in 'capacity issues' compared to November.
Patients waiting more than 6 weeks for a first appointment remains stable, while patient waiting more than 13 weeks for an admission continues to fall.
Diagnostics Waiting Times less than 6 weeks remains compliant at 100%
Page 10
Board of Directors Performance Report - December 2014 and Quarter 3
Performance
2013/14 Forecast
YTD
Current
MonthPrevious
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
N/A 65,833 8,048 7,973 22,017 22,559 24,561 69,137 Local
N/A 273,355 29,906 30,906 92,666 95,094 95,593 283,353 Local
TBA 8.5% 13.7% 10.9% 8.5% 9.5% 11.6% 9.9% Local
TBA 10.6% 11.0% 11.7% 11.0% 11.6% 11.5% 11.4% Local
TBA 12.3% 11.5% 11.3% 12.4% 12.4% 11.6% 12.1% Local
TBA 62.2% 60.5% 57.1% 55.6% 54.9% 58.2% 56.2% Local
TBA 75.7% 73.0% 71.0% 69.9% 70.5% 71.0% 70.4% Local
N/A 27,148 2,921 3,180 8,787 8,931 9,096 26,814 Local
N/A 22,615 2,650 2,724 8,297 8,821 8,365 25,483 Local
TBA 6.7% 6.1% 6.3% 6.1% 5.8% 6.3% 6.0% Local
TBA 36.9% 28.5% 28.3% 27.1% 26.4% 27.3% 26.9% Local
0 2 0 0 1 2 0 3 CQC, TDA
Monthly
Trend
Outpatient Total Attendances
- Follow Up Appointment
Compliance
Source
Performance 2014/15
Quarterly
TrendThreshold
Cancelled Operations - 28 Days Re-Book
Efficiency
Indicator
Outpatient DNA rate
- First Appointment
Theatre Sessions Starting Late
Clinic Journey Times Less Than 2 Hours
- Outpatient First Appointment
Clinic Journey Times Less Than 2 Hours
- Outpatient Follow Up Appointment
Outpatient DNA rate
- Follow Up Appointment
Theatre Cancellation Rate
Admission Demand
- Decision to Admit (DTA)
Admission Activity
Outpatient Cancellations
Outpatient Total Attendances
- First Appointment
Page 11
Board of Directors Performance Report - December 2014 and Quarter 3
Key: :4 Month Average:Monthly Trend
Efficiency (Cont.)
Page 12
Board of Directors Performance Report - December 2014 and Quarter 3
Effectiveness
Performance
2013/14 Forecast
YTD
Current
MonthPrevious
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
N/A 3.70% 5.00% 2.10% 3.50% 4.00% 3.30% 3.60% Monitor
Cases 76 11 5 23 28 23 74
N/A 3.70% 5.00% 2.10% 3.60% 4.10% 3.60% 3.80% CQC, TDA
Cases 78 11 5 24 29 25 78
N/A 61% 50.4% 56.2% 51.8% 53.0% 54.7% 53.2% Local
Safety
Performance
2013/14 Forecast
YTD
Current
MonthPrevious
Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Qtr4
0 0 0 0 0 0 0 0 CQC, TDA,
Monitor
0 0 0 0 0 0 0 0 CQC, Monitor,
TDA
95% 97.2% 89.9% 99.0% 98.4% 98.3% 95.8% 97.5% CQC, TDA
0 0 0 0 0 0 0 0 CQC, TDA
Monthly
Trend
Monthly
Trend
Number of C.Diff cases
Performance 2014/15
Emergency Re-admission within 28 days of
discharge
Emergency Re-admission with 30 days for
elective and emergency cases
GP referrals first outpatient using Choose &
Book
Indicator
Number of MRSA cases
VTE Screening
Mixed Sex Accommodation
There remain zero MRSA, C.Diff Cases or Mixed Sex Accommodation breaches reported this financial year.
Compliance
SourceThreshold
Quarterly
Trend
Compliance
Source
Performance 2014/15
Quarterly
TrendIndicator Threshold
Page 13
Board of Directors Performance Report - December 2014 and Quarter 3
Ward Staffing Levels (Only 'wards with inpatient beds' as per report requirement)
The fill rate during July for the Cumberlege Wing was of 54% and based on a small denominator - a total of 3 WTE care staff. During this time a member of staff was absent which resulted in the
reduction of the fill rate. This was mitigated by cover being provided by a registered nurse, giving adequate cover in the skill mix. It is not uncommon that whenever necessary, the absence of a
care worker can be substituted with a registered nurse to ensure safe standards are maintained on the wards.
Page 14
Board of Directors Performance Report - December 2014 and Quarter 3
Patient Experience (A&E and Inpatient Wards Only)
Site: MoorfieldsExtremely
LikelyLikely Unlikely Not at all l ikely Don't Know
Total
responses
Ward Name: Duke Elder 11 1 0 0 0 1 13 13 100.00%
Ward Name: Observation Bay 38 5 0 0 0 0 63 43 68.25%
Cumbelege Wing (NHS Pts) 2 4 0 0 0 0 7 6 85.71%
51 10 0 0 0 1 83 62 74.69%
Accident and Emergency 1179 302 38 7 7 37 (+2 Blk) 6,655 1572 23.62%
Overnight Admissions Average
Total
Number of
people
el igible to
respond
Neither likely
or unlikely
Response
rate
Friends and family score: December 2014
Page 15