FOR DECISION AGENDA ITEM 2.1 26 October 2010 INTEGRATED

FOR DECISION

Performance Report 1/26 Performance Committee Meeting 26 October 2010

AGENDA ITEM 2.1

26 October 2010

INTEGRATED PERFORMANCE REPORT Report of

Director of Innovation & Improvement

Paper prepared by

Head of Performance

Purpose of Paper

To update the Committee on the UHB’s performance to date in 2010/11

Action/Decision required

To receive and consider the report and endorse and comment on the actions being taken to improve performance and recommend further measures that should be developed to monitor the UHB’s overall performance

Link to Health Care Standards:

Within this report there is a focus on areas relating to Standards for Health Services numbers 1, 3, 6, and 7.

Link to Health Board’s Strategic Direction and Corporate Objectives

To help ensure the University Health Board delivers its vision, achieves its objectives, meets Welsh Assembly Government targets and complies with the legislative and regulatory framework

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Acronyms and abbreviations

ALOS - Average Length of Stay AOF - Annual Operating Framework APC - Admitted Patient Care AWMSG - All Wales Medicines Strategy Group AWSSIC - All Wales Stroke Services Improvement Collaborative BADS - British Association of Day Surgery BSC - Business Services Centre CAMHS - Child and Adolescent Mental Health Services CANISC - Cancer Network Information System Cymru CAVOC - Cardiff and Vale Orthopaedic Centre CDIFF - Clostridium Difficile CHIP - Corporate Health Information Programme CMHT - Community Mental Health Team CRHT - Crisis Resolution Home Treatment Team CT - Computed tomography CVA - Cerebrovascular Accident DNA - Did Not Attend DSU - Delivery Support Unit DToCs - Delayed Transfers of Care EDDS - Emergency Department Data Set EMI - Elderly Mentally Infirm EU - Emergency Unit GI - Gastro Intestinal HCAI - Healthcare Associated Infection HIPO - Health Improvement Patient Outcome HPV - Human Papilloma Virus ICU - Intensive Care Unit MMR - Measles, Mumps, Rubella MRI - Magnetic Resonance Imaging MRSA - Methicillin Resistant Staphylococcus Aureus NLIAH - National Leadership and Innovation Agency for Healthcare NPSA - National Patient Safety Agency

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NRLS - National Reporting and Learning System PU - Prescribing Unit RAMI - Risk Adjusted Mortality Index RTT - Referral to Treatment SSI - Surgical Site Infection SSIP - Stroke Services Improvement Plan T&O - Trauma and Orthopaedics TIA - Transient Ischaemic Attack TOP - Termination of Pregnancy WAG - Welsh Assembly Government WHAIP - Welsh Healthcare Associated Infection Programme WHO - World Health Organisation WLIs - Waiting List Initiatives WTE - Whole Time Equivalents

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EXECUTIVE SUMMARY The key issues for the Committee to consider and the action being taken to improve performance are: Performance Domain/Area

Commentary Improvement Action

Quality and Safety: Risk adjusted hospital mortality

UHB overall index remains less deaths than expected. Medical Director reviewing individual cases weekly on a risk assessed basis CHKS last 3 months data (June – Aug) shows continuing rolling 3 month average improvement trend with RAMI 81 compared with peer group 72.

Divisional Q&S meetings report to Q&S Committee on implementation of appropriate remedial action. Medical Director advising Divisions on required changes in clinical practice when identified from review of cases

Healthcare Associated Infection

UHB CDiff numbers in September reduced to 34 cases (28 cases aged over 65), and rate v WAG seasonally adjusted profile has improved. The reducing trend needs to be maintained to achieve target of 20% reduction by 31/3/11 Cumulative number of cases for October to date indicates that the improved September position is being

Implementation of Divisional action plans having an impact from September. Four key action areas:

• Antimicrobial prescribing

• Hand hygiene • Ward cleanliness • Isolation

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maintained Mental Health Care Programme Approach (CPA)

Latest reported figures at 16/9/10 show that performance is improving: Standard CPA – 48% (last qtr 32%) Enhanced CPA – 64% (last qtr 60%)

Improvement plan in place and being implemented. Results of DSU/NLIAH audit expected shortly. Detailed report received by Q&S Committee on 12/10/10

Stroke Significant improvement in performance in August, further improved in September. UHL 100% compliant with all four care bundles and best performing unit in Wales. Main constraint remains ability to admit to UHW stroke ward within 24 hours, although very significant improvement in last 2 months.

Determination of the acute stroke pathway for non-thrombolysis patients is ongoing Determination of the stroke rehabilitation pathway is ongoing

Readmissions CHKS last 3 months data (June – Aug) shows continuing rolling 3 month average improvement trend, rate 5.8% and now close to peer group 5.7%. However readmission rates much higher than peer group in many specialties.

Top 40 hospital programme in place. Divisional Q&S meetings report to Q&S Committee on implementation of appropriate remedial action.

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Patient Experience:

Access to Elective Treatment

Performance for patients waiting under 26 weeks is now at 93%, and therefore does not meet the WAG tolerance target, entirely as a result of the increasing orthopaedics waiting list. The cumulative position, excluding orthopaedics is 99%. There were 980 Orthopaedic patients waiting longer than 36 weeks at 30/9/10. Numbers waiting for new outpatient appointments and for diagnostic tests including MRI tests are increasing rapidly, contributing to the deteriorating breach position.

Orthopaedics treatment productivity has recently increased to a maximum of 183 treatments per week, compared with expected mean activity of 163. This reflects seasonality and a concerted effort to increase theatre throughput. Outpatient utilisation is between 92-100% for elective clinics, suggesting only scope for further productivity gain is via template review and reducing follow up numbers Three sub specialty plans have been prepared in draft with design input from consultant body. These will articulate how balance between anticipated demand and capacity will be achieved in each sub specialty area. Challenge is being constructively input from DSU and Public Health. Additional progress made to increase capacity:

- 2 surgeons have agreed to provide

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additional theatre lists over their job plan.

- Hand surgeons have agreed to appoint a substantive surgeon

- An additional scoliosis list has been secured at UHW following theatre reconfiguration

Access to Cancer Treatment

Overall performance has improved in the second quarter, and the unvalidated position is 95% for the 62 day target and 98.5% for the 31 day target, meeting both WAG targets

Key risk identified is that there is no cover for the oral-maxillofacial surgeon who undertakes the cancer cases, and an additional appointment will be made in 2010-11 to address this. Discussions are underway to develop weekly psychology and psychiatry sessions. Implementation of additional breast clinics to reduce waits is being undertaken, along with the opening of the new breast unit. Additional theatre lists will be made available to address the urology backlog.

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Emergency Unit (EU) Waiting Time

Current performance has remained frustratingly at 86%, below the target of 95%. The key constraint to patient flow remains the lack of capacity of EU clinical decision makers. This issue plus minors and paediatrics performance are key areas for achieving improved levels of performance.

The Consultant Nurse will commence post on 1st November 2010 and will be reviewing the operational policy of the Minor and Paediatric streams. This is being prioritised with the aim of improving performance back to 99% in both streams. Additional emergency nurse practitioner capacity is being provided from 1/12/10. The new consultant job plan and rota has now been agreed by nearly all the consultants. The rapid assessment treatment zone (RATZ) is to recommence.

EU Ambulance Handover Time

Current performance has recently improved to 57% but still well below previous trend average of 70%. Reviewing potential to report turnaround time from WAST GPS system, rather than handover time

Previous meeting with WAST to discuss issues and to agree future joint improvement plan. Discussions ongoing

Patient Feedback Last report on the active complaints management position showed 121

Continued improvement in complaints management system. Summary of actions

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complaints (since reduced to 111) are active in the system:

taken in response to complaints to be reported to next Q&S Committee. Clinical audit resources to be allocated to investigating complaints about medical treatment.

Operational Efficiency: Emergency Average Length of Stay (ALOS)/DTOC

CHKS risk adjusted LOS v peer group average (Jun – Aug):

• Gen Med 113 v 83

• Geriatric Med 192 v 115

• Thoracic Med 110 v 83

• Cardiothoracic Surg 135 v 85

Trauma HRG codes with higher than average risk adjusted LOS: H04, H81, H99, H71, H84, H36, H39 DTOC – September bed days lost per monthly census: Mental Health 2078 (2292 last month). Non mental health 3602 (3573 last month)Main factors delaying discharge are:

• Lack of EMI residential capacity

• Very limited EMI nursing capacity

• Lack of general

Implementation of capacity/ward refurbishment plan and improving patient flow is key improvement project (also to improve performance in EU). Significant improvement in PDD recording compliance and ND needs to be maintained and then move to improving % of patients discharged on planned date, to ensure daily bed capacity is matched with predicted demand. Revised ACS strategy will reduce cardiac lengths of stay, with capacity already being released. Trauma review and management of complex elderly patients is key to reducing trauma length of stay as identified by HRG analysis DTOC and Timely

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nursing home beds in VOG

• Other choice issues

• Psychiatric assessment capacity

• Some issues with allocation of social workers from the Vale

Discharge Boards in place. Schedule of individual patients with LOS > 20 days needs to be produced and reviewed weekly to expedite quicker discharge where appropriate Medium term strategy for increasing EMI residential and nursing home capacity needs to be agreed with Local Authorities and Registered Social Landlords

Outpatient follow ups

The detailed monthly performance information for Outpatient follow up rates is included in Part One of the performance report, although WAG has acknowledged that the targets need to be amended. The UHB recognises that it needs to work with stakeholders to make significant reductions to outpatient volumes in order both to reduce avoidable hospital attendances and also to improve utilisation of clinical resources

The following actions are underway:

• Detailed monitoring of outpatient clinic utilisation by specialty/implementation of clinic productivity ‘tool’ to improve utilisation and create more slots to see new outpatients;

• Current work to identify targets based on specialty specific and peer comparison, which will lead to setting of more appropriate targets for 2010/11, which will be monitored

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within secondary care.

against in future reports.

• Increased quality assurance of coding

• Changing clinical practice to reduce inappropriate follow ups, through earlier discharge from secondary care

Outpatient DNAs DNA rates remain

particularly high across all specialties and show no signs of reducing.

An improvement group led by the Divisional Director for Clinical Diagnostics and Therapeutics UHB has been charged with addressing outpatient efficiency and improvement and is coordinating the work to reduce the rate of DNAs for outpatient clinics across the UHB. Improvements to the UHB’s telephone answering service are being made and an automatic reminder messaging service will be introduced shortly.

Theatres Utilisation of available sessions in theatres requires significant improvement, including reducing late starts. Performance has declined since May.

Divisional Management Team is leading major improvement workstream in Theatres. A new reporting system has been developed through the UHB’s

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‘intelligent warehouse’ to improve the analysis of theatre utilisation and to enable the reporting of turnaround times, so that the utilisation of available time within each session is maximised. This information will be provided within future performance reports. WAO are undertaking a national performance improvement review as part of 2010/11 audit programme

Day cases 4/18 WAG targets have been achieved during the year to date and an additional 3 targets have been met in recent months. Significant improvement is required for 4 out of the 18 procedures.

A standard operating procedure is being prepared with short stay surgery as the ‘default position’, unless this is clinically inappropriate for an individual patient.

Clinician/staff productivity

Report on progress with completion of and QA of consultant job plans discussed at last medical workforce group meeting and received by WOD Committee at its meeting on 21st October Nurse establishment review complete,

WOD Committee monitoring implementation of action plans to ensure financial savings plan targets are met.

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except for community nursing. Therapies review complete. AHP (pharmacists) review ongoing, paper discussed at OBD on 20/10/10

Use of Resources: Achievement of revenue and capital cash limit

Month 6 position is reporting a revenue deficit of £18.839m, with a declared year end forecast deficit of £28.4m. Even this position is not without considerable risk and the UHB continues to explore further savings opportunities.

Task and Finish Finance Group (TFFG) monitoring risk position and implementation of savings plans. Verbal update to be provided at meeting.

Cash position Cash expenditure within cash limit and UHB aiming to achieve best practice cash balance.

Cash flow review has been undertaken to ensure compliance with best practice in future months. There is a danger of a cash shortfall before the year end if the savings target is not met.

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INTRODUCTION The vision of the UHB, linked to its statement of intent, is to:

• become an exemplar healthcare organisation delivering top quartile world class performance;

• significantly improve the health and wellbeing of the citizens in

Cardiff and the Vale of Glamorgan and of Wales for tertiary services.

The performance report includes a broad range of performance indicators and measures to ensure that overall performance against the main objectives is being delivered. The performance report for the UHB has been developed to take account of the wider remit of the organisation. In addition, internal and external stakeholders have provided feedback on the content and style of the report. This performance report has two main objectives:

1. To present the performance of the UHB against the statutory targets set by Welsh Assembly Government (WAG) within the Annual Operating Framework (AOF) under which all Local Health Boards operate.

2. To present wider performance against a balanced range of

measures which provide a broader perspective on the services which the UHB provides for its residents and other patients.

This report sets out performance issues across a range of service areas within the UHB. As the new structures are put in place, the performance report will better reflect the divisional structure and show service and divisional performance metrics. This will enable the UHB to align its performance reporting mechanisms with the operational management of the organisation. As a result, the current performance report is still under refinement. Some indicators and measures are continuing to be developed and the report will therefore be amended over time. Community care metrics are included for the first time in part two of this report. Further, recent discussions with the University will enable the

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quality of student training to be included in the next report. Further iterations of the performance report will also link with the Social Care key performance indicators reported by the Local Authorities (e.g. Results Based Accountability (RBA) framework for frail elderly). LOCAL POPULATION CONTEXT Cardiff and Vale UHB is responsible for improving the health and wellbeing of its resident population. One of the major challenges in demonstrating such improvement is that changes in health status can often be difficult to measure quickly - they deal with long time delays between action and effect and sometimes the outcomes may be caused by several different factors. It is possible to demonstrate regular progress however, by developing a combination of outcome and process indicators for health protection and health improvement and then comparing monitoring data to baseline information.

Indicators for measuring our local population’s health and for tracking its improvement have been developed (using the criteria set out in the Department of Health and Association of Public Health Observatories Indicator Guide: Health Profiles 2010)* and this report provides a regular update on progress.

Snapshot of the Local Picture: Headline Indicators

The full list of public health indicators and our status against them is set out in section two of this report. A few headline indicators are reported here to provide a snapshot of the local picture.


Mortality from selected major causes, residents of Cardiff & Vale UHB area aged under 75, European age-standardised rate per 100,000, 2001-2008Source: Public Health Wales Observatory, using ONS data (ADDE, MYE)

101

8983

74

3025 25

123 126

111

129

2001-03 2002-04 2003-05 2004-06 2005-07 2006-08

all malignancies excluding 'other skin'

circulatory disease

respiratory disease

Figure 1 opposite shows the mortality figures for our local residents (aged under 75 years).

Since 2001, we can see a statistically significant reduction in the rate of early deaths from circulatory disease. Of concern is that deaths from cancer and respiratory

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disease do not show the same rate of decrease. The table below provides the local picture against six key headline indicators of health improvement, health protection and life expectancy. Headline Target Monitoring

Frequency Baseline Position Progress Status

First dose of MMR given in 2-year old children

95% Quarterly April 08 - March 09 Cardiff 87.1% Vale 91.3%

April-June 2010 Cardiff 90.2% Vale 92.5%

Improving

Uptake of the second MMR dose by 5 years of age

95% Quarterly April 08 - March 09 Cardiff 80.3% Vale 81.9%

Apr - June 2010 Cardiff 83.6% Vale 87.8%

Improving

Uptake of seasonal flu vaccinations in patients aged 65 years and over

70% in 2009-10 75% in 2010-11

Annually Winter 2008-09 Cardiff 60.5% Vale 57.3%

Winter 2009-10 Cardiff and Vale 64.7%

Improving

% of adults who smoke

n/a Annually 2008 Cardiff 23% Vale 26%

2009 - to be reported in 2011

n/a

% of adults who are overweight or obese

n/a Annually 2008 Cardiff 53% Vale 53%

2009 - to be reported in 2011

n/a

Life expectancy at birth

n/a Annually Rolling rate: 2006-08 Cardiff and Vale Males 76.6 years Females 81.7 years

Rolling rate: 2007-09 to be reported 2011

n/a

Health Protection: MMR vaccine protects against measles, mumps and rubella. The target is for 95% of children to have two doses of MMR vaccine to provide the best protection against measles. The uptake has increased from baseline but the target of two doses by age of 5 years has not yet been reached.

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Seasonal Flu: Flu vaccinations are aimed to reduce flu related morbidity, mortality and hospital admissions. Although the uptake has increased from the baseline period, the target has not yet been met. Delivery of the flu vaccination programme in 2009-10 sat within the context of the swine flu pandemic and its consequent effect on service provision. The target for uptake in the period 2010-11 has been raised to 75%. Health Improvement: smoking is the most important cause of preventable ill health and premature mortality in the UK and is a modifiable risk factor. Approximately a quarter of adults in our Health Board areas self report that they smoke. Recent data is not available at this time to compare to the baseline. Being overweight or obese are also important causes of morbidity and are modifiable risk factors. Half of adults in our Health Board area are overweight or obese (based on self reported data). Recent data is not available at this time to compare to the baseline. Childhood obesity is an important public health indicator and it is anticipated that this information will be available in the future. Life Expectancy: life expectancy at birth is a summary measure of the all cause mortality rates in a geographical area in a given period. The Cardiff and Vale measure is comparable to All- Wales and recent data is not available at this time to compare to the baseline. BALANCED SCORECARD The UHB integrated performance report has adopted four domains in order to report, manage and improve performance in a balanced and sustainable manner. The status of each indicator is summarised in this section, with more detail of performance trend in Parts One and Two of the Performance Report.

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Figure 1: Integrated Performance – 4 domains QUALITY AND SAFETY Quality and Patient Safety measures are an extract of the measures developed by the Quality and Safety Committee and reported in more detail in that Committee’s performance dashboard. Table 1: Quality & Safety

Target Key Metrics Target Frequency Prior period Current period Status

1 UHB Risk Adjusted Mortality Index (2010) <100 Monthly 94 94 Within target

2 AOF19 Healthcare Associated Infection - MRSA Nil Monthly 3 2 Within target

3 AOF19 C Difficile - cases in patients >65 468 Monthly 39 28 Improving

4 UHB Serious Adverse Incidents Nil Monthly 7 5 Improving

5 UHB Number of hospital falls Nil Monthly 267 308 Deteriorating

6 UHB Medication errors Nil Monthly 35 37 Stable

7 AOF15 Mental Health Care Programme Approacha Enhanced CPA 100% Quarterly 60% 68% Improvingb Standard CPA 100% Quarterly 32% 49% Improving

8 UHB Orthopaedic Surgical Site Infection (Qtrly) Nil Quarterly 0% 0% Within target

9 UHB WHO Surgical safety checklist - compliance 100% Monthly 93.5% 96.4% Improving

10 UHB Stroke Care Bundles

First 3 Hours 95% Monthly 79.0% 100.0% Within targetFirst 24 Hours 95% Monthly 25.0% 88.0% Below targetFirst 3 Days 95% Monthly 59.0% 95.0% Within targetFirst 7 Days 95% Monthly 75.0% 98.0% Within target

Quality and Safety

Operational Efficiency

Use of Resources

Patient Experience

Quality and Safety

VISION


Use of Resources

Patient Experience

Quality and Safety

VISION

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Commentary • The UHB’s overall risk adjusted mortality rate (RAMI) is better than

its Welsh peer group, but slightly higher than the CHKS peer group (12 month rolling average). The Quality and Safety Committee has the lead responsibility for the UHB and receives more detailed explanation and reporting of this area.

• Achievement of the CPA target for Mental Health remains

challenging, but performance has improved during the last quarter.

• Compliance with the WHO Surgical Safety Checklist has now improved and was in excess of 96% for September. The target remains to achieve 100% compliance for all planned cases.

• Part Two of the Performance Report outlines progress against

some of the stroke care bundle intelligent targets. National performance reporting has commenced against each of the four bundles and comparative feedback and All Wales comparisons will be provided in future reports. The UHL site is fully compliant with all four care bundles, and the best performing unit in Wales. The main constraint remains the ability to admit to the UHW stroke ward within 24 hours, although there has been a very significant improvement in the last 2 months.

OPERATIONAL EFFICIENCY Currently the majority of targets relate to hospital services provided by the UHB. Where there are available and relevant measures in Primary Care, Community, Mental Health and non clinical services these are included and will be developed further in future reports. The UHB needs to ensure it is making the best use of available resources. In addition to the specified efficiency and productivity measures referenced by WAG, the UHB includes information on the numbers of patients waiting for specific treatments in inpatient and outpatient settings. In addition, the level of referrals and the effectiveness of demand management are also included.

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Table 2: Operational efficiency


1 AOF 8 Day Case Rates (of elective surgery) 75% Monthly 56% 56% No change

2 AOF 8 Admission on Day of Surgery Monthly 60% 59% Stable

3 AOF 8 Outpatient Follow Up Rates Monthly 2.35 2.20 Improving

4 AOF 8 Outpatient DNA Rates Max 5% Monthly 10.9% 11.3% Deteriorating

5 UHB Theatres - Prompt starts Min 90% Monthly 75.4% 73.1% Deteriorating

6 UHB Number of patients waiting for Inpatient / Daycase treatment n/a Monthly 12,475 12,602 Deteriorating

7 UHB Number of patients waiting for an Outpatient consultation n/a Monthly 34,939 35,531 Deteriorating

8 AOF 8 Average Length of Stay - Emergency Care (AOF target specialties only) Monthly 9.16 9.41 Deteriorating

9 AOF 8 Average Length of Stay - Elective Care (AOF target specialties only) Monthly 3.39 3.64 Deteriorating

10 UHB All Referrals Specialty specific assumptions apply

Year to date comparison with

prior year 82,742 84,075 1.6% net

growth

Specialty specific targets apply

Specialty specific targets apply


Commentary

• There has been a small improvement in outpatient follow up rates,

but at a specialty level, this remains a major area for improvement. DNA Rates continue to remain at an unacceptably high level.

• Operational issues in theatres, the theatre ventilation programme

and surgical trays in particular, has led to a reduction in the number of theatre sessions starting promptly. The target remains to achieve 95% compliance for all planned sessions.

• The numbers of patients on the waiting lists for inpatient and

daycase treatment and new outpatient appointments are all increasing, and are now much higher than the start of 2010-11.

• Average lengths of stay are individually monitored and reported in

Part One of this report. The major areas of focus for improvement in 2010/11 are in emergency average lengths of stay in medical specialties, trauma and cardiac.

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RESOURCES The resource indicators include the effective application and use of finance, staff, facilities and other available resources of the UHB. Table 3: Use of resources


1 UHB Elective admissions n/a Year to date comparison with prior year 36,632 31,421 14% reduction

2 UHB Non Elective admissions n/a Year to date comparison with prior year 23,149 23,156 Stable

3 UHB Utilisation of available Theatre sessions 95% Monthly 79.2% 82.9% Stable

4 UHB Outpatients - New attendances n/a Monthly 65,337 76,180 17% Increase

5 AOF9 Revenue Expenditure Against Resource Limit 0 Monthly (16,559) (18,839) Above target

6 AOF9 Cash Expenditure Against Cash Limit n/a Monthly 1,069 445 Improving

7 AOF9 Payment of Non NHS Creditors within 30 Days 95% Monthly 94.0% 93.4% Stable

8 AOF8 Agency/Locum Expenditure 0.8% Monthly 1.2% 0.9% Improving9 AOF8 Sickness Absence <4.95% Monthly 4.95% 4.93% Target achieved

10 UHB Staff Turnover n/a Monthly 8.6% 8.1% Reducing

Resources

Commentary

• Elective admissions fell on a like for like basis for April to September between 2009 and 2010, with non elective admissions remaining stable. However, there has been an increase in the number of new outpatient attendances.

• Operational issues in theatres have led to a decrease in the

utilisation of theatre sessions, but the target remains 95% utilisation.

• The overall financial position continues to be a major challenge and

the UHB remains focussed on delivery of the Operational Plan and savings plans to support financial break even by the end of the financial year. However, at month 6 there is a deficit of £18.839m with a forecast declared year end deficit of £28.4m. Even this position is not without considerable risk and the UHB continues to explore further savings opportunities.

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• Agency and locum expenditure has decreased to 0.9% in September, which is close to the 0.8% target. It is anticipated that the review of the nursing establishment and additional financial controls to limit bank and agency expenditure will continue to have an impact through the remainder of 2010-11, to enable the UHB to meet the WAG target.

• Sickness absence has reduced to 4.93%, and the UHB is now

meeting the WAG target of 4.95%.

• Staff turnover has reduced to 8.08%. Although this still provides some opportunity to remodel the workforce towards new ways of working, it is diminishing with a continued downward trend. Turnover is higher than average for estates and ancillary staff, but lower for Allied Health Professionals. In volume terms, the highest turnover of staff is within the nursing and midwifery and administrative categories.

PATIENT EXPERIENCE

Patient experience measures have been developed to adopt a broad perspective on the patient and public experience of UHB services. It includes for example the Referral to Treatment targets for planned care as well as cancellations, complaints and waiting times in EU. Table 4: Patient Experience


1 AOF 10 Access to Elective Services – 26 Weeks 95% Monthly 94% 93% Deteriorating

2 AOF 10 Access to Elective Services – 36 Weeks Nil Monthly 743 980 Deteriorating

3 AOF 8 Operations Cancelled on Day or Day Before Surgery 2% Monthly 252 281 Reducing

since March4 AOF 14&17 Delayed Discharges Nil Monthly 104 121 Deteriorating

5 AOF 20 Access to Cancer Services – 62 Days Target 95% Monthly 96% 98% Improving

6 AOF 12 Access to Emergency Services – 4 Hours in EU 95% Monthly 86% 86% Stable

7 UHB Corridor Waits in the Emergency Unit Nil Monthly n/a n/a Data being

cleansed

8 UHB Number of Complaints – Primary Care - Monthly 26 n/a Stable

9 UHB Number of Complaints – Hospital & Community - Monthly 69 39 Decreasing

10 UHB Patient Survey - Monthly n/a n/aMeasures

being developed

Patient Experience

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Commentary

• Performance for patients waiting under 26 weeks is now at 93%, and therefore does not meet the WAG tolerance target, entirely as a result of the increasing orthopaedics waiting list. The cumulative position, excluding orthopaedics is 99%.

• Overall performance for access to cancer treatment has improved

in the second quarter, and the unvalidated position is 95% for the 62 day target and 98.5% for the 31 day target, meeting both WAG targets

• Current performance has remained frustratingly at circa 86%,

below the target of 95%. The key constraint to patient flow remains the lack of capacity of EU clinical decision makers. This issue plus minors and paediatrics performance are key areas for achieving improved levels of performance.

• There has been continued improvement in the complaints

management system. A summary of actions taken in response to complaints will be reported to the next Q&S Committee.

AOF AND STATUTORY TARGETS In relation to statutory performance, the NHS Performance Dashboard is no longer formally submitted to WAG, but still forms part of the UHB monitoring process. It covers a significant proportion of the AOF target areas. The dashboard for September 2010 is set out in Part One of this report. The UHB is currently preparing the formal AOF returns and progress reporting for quarter two to WAG. Feedback from WAG on the quarter one returns confirmed the following areas for improvement, which were already being addressed by the relevant Executive Lead:

1. Efficiency and Productivity 2. Unscheduled Care 3. Adult Mental Health

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4. Civil Contingencies 5. Substance Misuse

A summary of the quarter one and two positions is shown in section O of the part one report. FURTHER DEVELOPMENTS OF PERFORMANCE REPORTING AOF targets do not cover all aspects of the UHB’s performance sufficiently, in particular the quality and safety domain. Therefore the UHB is developing a series of additional measures, which when considered with the AOF targets, will provide a much more effective assessment of the UHB’s overall performance. The measures which have been developed to date are set out Part Two of this report. In order to demonstrate the UHB’s progress towards achieving its vision to become a world class healthcare organisation delivering top quartile performance, it is proposed to develop a weighted quality cost model so that progress can be monitored over time. Evidence of improvement in Cardiff and Vale citizens’ health and wellbeing can only be demonstrated in the medium and longer term. Nevertheless the UHB will need some mechanism to assess its progress in the same way as for the objective of becoming a world class health organisation. It is proposed therefore to develop a series of milestones (based on similar improvement methodology to the care bundles used on hospital services) which will need to be achieved as a pre-requisite to improving citizens’ health and well being. These milestones will need to be reflected in the Health Social Care and Well Being Strategy and associated Strategies and the Public Health Operational Plan. Parts One and Two are attached as addenda to this Executive Summary Report. CONCLUSION The high level measures in the balanced scorecard approach indicate that:

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• Quality and safety measures are showing significant improvement in most areas. The specific actions being taken to support reductions in the numbers of Hospital Acquired Infections (C Difficile) need to be maintained to achieve the WAG target profile.

• Most of the operational efficiency measures are not improving and

remedial actions need to be accelerated. Detailed reports have been prepared for the Performance Committee, a more specific timetable for implementation needs to be formulated.

• The use of resources section illustrates the pressures that the UHB

is facing on the financial targets whilst maintaining current activity and performance levels. The current financial position is not without considerable risk and the UHB continues to explore further savings opportunities. There is a danger of a cash shortfall before the year end if the savings target is not met. Workforce sickness absence target levels have already been achieved, but improving clinician/staff productivity remains a key challenge for the UHB in 2010/11.

• Performance in respect of patient experience shows a mixed

picture. Access to elective orthopaedic treatment and emergency treatment remains below expected levels, but there has been a significant improvement in access to cancer treatment, both WAG targets are currently being met and a significant improvement in administration of the complaints management system.

The actions to improve performance are set out in detail in the commentary in parts one and two of this report. The impact of these actions has been incorporated into the Divisional Plans and the UHB’s Operational Plan for 2010/11. RECOMMENDATIONS The Committee is asked to:

• NOTE the UHB’s current performance in 2010/11 • ENDORSE and COMMENT on the actions being taken to improve

performance

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• NOTE that further measures are being developed to monitor the UHB’s overall performance across the whole health and social care system.

IMPACT ASSESSMENT Health Improvement

The report will help to ensure that opportunities for improving citizen health and wellbeing, the quality and safety of patient care and resource utilisation are identified and realised.

Workforce

The report will help to ensure that all staff are aware of the contribution they make to achieving the UHB’s objectives and support and motivate them in their roles.

Financial

The report will help to ensure that the UHB delivers a high level of service within the resources available.

Legal

The report will help to ensure the UHB achieves its statutory duty to break-even

Equality

The report will help to ensure the UHB complies with equality legislation and ensure that services are delivered in an equitable manner relative to need and disability.

Environmental

The report will help to ensure that facilities and estates are operating as effectively and efficiently as possible.

RISK ASSESSMENT Clinical/Service

Opportunity to improve quality of care and patient safety may not be realised if improvement actions not implemented effectively.

Financial

Opportunity to improve resource utilisation may not be realised if improvement actions are not implemented effectively and targets not achieved.

Reputational

Stakeholder lack of confidence in UHB’s ability to manage its affairs if improvement actions not implemented and targets not achieved. Opportunity for earned autonomy lost.

INTEGRATED PERFORMANCE REPORT PART ONE NHS Wales National Performance Dashboard Measures - Contents

Introduction A. Access to Elective services B. Unscheduled care C. Cancer services D. Sexual Health E. Stroke services F. Adult Mental Health G. Child & Adolescent Mental Health H. Primary care services I. Healthcare Associated Infections J. Elective inpatients K. Emergency inpatients L. Outpatients M. Workforce N. Public Health Indicators O. Summary of performance to date in relation to all AOF targets

Performance Report Part One 1/41


Introduction The NHS Performance Dashboard is a monthly report of the key measures identified by the Welsh Assembly Government, which covers the majority of Annual Operating Framework targets. In summarising the performance of the UHB, a set of indicators using the approach set out in Figure 1 has been attached to each measure within the performance dashboard. This provides a useful summary explanation of the status of each measure and its relative position in relation to recent performance. Figure 1: Status indicators for NHS Performance Dashboard

Target not being achieved - Current performance not meeting target

Target not being achieved - Current performance level and actions satisfactory but worthy of note

Target being met or exceeded

↑ Performance level improving from prior period

↔ Performance unchanged (within tolerance level est. 1%) from prior period

↓ Performance deteriorating from prior period

↓↑Where data is reported for Cardiff and Vale localities separately and where the direction of travel differs between the two localities, Cardiff performance in respect of prior period is shown first.

Red and Deteriorating

It is recommended that areas marked as RED and which are also marked as

DETERIORATING ↓should be highlighted as agenda items for UHB performance Committee, unless specifically excluded.

Key:

A. Access to Elective Services – Performance up to and including September 2010 AOF

Reference Target measure Target Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being met

Risk rating and

rationale

Status (Last 3 periods) Comment

% admitted RTT patients (inc. Cardiac) who had waited less than 26 weeks (closed pathway) 95% 84% 81% 80% 82% 80% 79% No

Over 5% variance

from target ↓ Red and deteriorating

Number of admitted RTT patients (inc. Cardiac) who had waited over 36 weeks (closed pathway) 0 59 68 116 133 152 150 No Target is

zero ↓ Red and deteriorating

% non-admitted RTT patients (inc. Cardiac) who had waited less 26 weeks (closed pathway) 98% 96.2% 94.1% 93.5% 95.2% 94% 93% No

Over 5% variance


Number of non-admitted RTT patients (inc. Cardiac) who had waited over 36 weeks (closed pathway) 0 36 39 56 40 91 133 No Target is


% RTT patients (inc. Cardiac) on the open pathway who are waiting less than 26 weeks 95% 97% 96% 96% 95% 94% 93% No Within 5%

of target ↓Number of RTT patients (inc. Cardiac) on the open pathway who are waiting more than 36 weeks 0 41 60 136 272 743 980 No Target is


Number of patients waiting over 8 weeks for specified diagnostic tests who are not on a RTT pathway 0 10 39 102 164 191 204 No Target is


Number of patients waiting over 14 weeks for specified therapy services who are not on an RTT pathway

0 5 3 5 11 11 16 No Target is zero ↓ Red and

deteriorating

% of Cardiac RTT patients who received definitive treatment less than 26 weeks of receipt of the original referral by the referring Trust (closed pathway)

95% 84.2% 83.3% 86% 90% 87% 85% NoOver 5% variance


Number of Cardiac RTT patients who waited more than 36 weeks (closed pathway) 0 16 10 13 15 16 13 No Target is

zero ↔% of Cardiac RTT patients on the open pathway waiting less than 26 weeks 95% 95.7% 95.5% 96.7% 96% 95% 95% Yes

Operating better than

target ↔Number of Cardiac RTT patients on the open pathway who are waiting more than 36 weeks 0 0 0 2 0 2 0 Yes Target is

zero ↔

AOF Target 21

Acc

ess

to E

lect

ive

serv

ices

AOF Target 10


UHB Performance against Target Commentary on position and movement

• 980 patients were waiting in excess of 36 weeks at the end of September. The majority were waiting for Orthopaedic treatment.

• Performance for patients waiting under 26 weeks is now at 93%, and therefore does not meet the WAG tolerance target, entirely as a result of the increasing orthopaedics waiting list. The cumulative position, excluding orthopaedics is 99%.

• There are significant pressures facing the UHB in

maintaining current performance in respect of RTT waiting times, particularly in Orthopaedics, Neurosurgery and Cardiac Surgery

• The capacity of the UHB to immediately address the breaches at 36 weeks is constrained by the financial position of the UHB and resultant capacity deficits. Special measures are now in place, and weekly meetings are taking place with the DSU. However, the issue is one of resource prioritisation and availability. Within the resource envelope available for orthopaedics, a range of actions have been identified and are being implemented to address the backlog.

• Significant pressures remain in Cardiac, Neurosurgery,

Dermatology and Gynaecology. The challenge for gynaecology remains in the tertiary nature of a significant number of cases approaching 36 weeks, for which there is limited specialist capacity.

UHB Performance against Peers Current improvement work • Comparisons with peers in NHS England are not

straightforward as the RTT target is 18 weeks, albeit with greater tolerance for exceptions.

• Breaches are also occurring in one other UHB area – breaches are linked to tertiary and orthopaedic services.

• The UHB is one of three UHBs not meeting the 26 weeks tolerance target.

Immediate actions to improve the position include: • A plan for increasing capacity within orthopaedics to

meet demand which is cost and clinically effective • Review of the Orthopaedic Musculoskeletal triage team • Increased clinic and theatre utilisation across all

relevant Directorates


B. Unscheduled Care – Performance up to and including September 2010

AOF Reference Target measure 2009/10

Target2010/11 Target Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being

met

Risk rating and

rationale (AOF

2009/10)

Risk rating and

rationale (AOF

2010/11)

Status (Last 3 periods)

% of patients that spent no longer than 4 hours in a major A&E department from arrival until admission, transfer or discharge.

95% 95% 86% 88% 87% 88% 86% 86% NoOver 5%

distance from target

Over 5% distance from

target ↔% of patients that spent no longer than 8 hours in a major A&E department from arrival until admission, transfer or discharge.

99% 99% 96% 97% 97% 98% 97% 96% No Within 5% of target

Within 5% of target ↔

To achieve a handover of patients from an emergency ambulance to major accident and emergency departments within 15 minutes.

95% 100% 49.4% 58.8% 58.4% 67.6% 59.50% NoOver 5%



target ↔Rate of delayed transfers of care per 10,000 population for all specialties excluding mental health4

Cardiff - 13.99

Vale - 12.656.93

Cardiff - 20.05

Vale - 23.95

Cardiff - 20.72

Vale - 26.11

Cardiff - 21.24

Vale - 26.98

Cardiff - 21.50

Vale - 26.9

Cardiff - 21.43

Vale - 28.24

Cardiff - 21.46

Vale - 29.03No


target


target ↑↓Rate of cumulative days delayed per 10,000 population for all specialties excluding mental health4

Cardiff - 1144Vale - 817 137

Cardiff - 2307.03Vale -

1483.99

Cardiff -2313.30 Vale -

1474.22


1583.36


1505.66


1515.13

Cardiff - 2213.17 Vale -

1532.76

NoOver 5%



target ↔Rate of delayed transfers of care per 10,000 of population for mental health4

Cardiff - 0.54Vale -0.31 0.18 Cardiff - 0.60

Vale - 0.55 Cardiff - 0.55





Vale - 0.56 NoOver 5%



target ↔Rate of cumulative days delayed per 10,000 population for mental health4

Cardiff -90Vale - 28 9

Cardiff - 49.41

Vale - 35.12

Cardiff - 43.45

Vale - 38.42

Cardiff - 37.48

Vale - 40.54

Cardiff - 37.21

Vale - 42.90

Cardiff - 36.75

Vale - 46.53

Cardiff - 35.83

Vale - 48.51No


target


target ↑↓Emergency Average Length of Stay (all Specialities)1 8.7 8.7 8.8 8.8 8.9 8.9 No specific

target appliesNo specific

target applies ↓

AOF Target 14

AOF Target 17

Uns

ched

uled

Car

e

AOF Target 12



• Performance against the 4-hour and 8-hour target in the Emergency Unit has remained relatively static in recent months with a notable improvement in the however in the 15-minute handover target.

• Achievement of the 4 hour target continues to represent a

significant challenge with a static performance of 86-88% against the 4 hour target and 97-98% against the 8 hour target since April.

• Compliance with the 15 minute ambulance handover target has fallen back slightly in August. Discussions are ongoing with WAST to agree a joint improvement plan.

• Overall DToC patient numbers within the UHB have increased,

along with the number of bed days lost as follows:

• There were 121 DToC patients at the end of September compared to 104 at the end of August, an increase of 17.

• The most significant deterioration in the DToC position

was for non mental health patients with a total increase of 12 patients between August and September. However there was a reduction in the bed-days delay from 5,865 to 5,680 days.

• Overall emergency average lengths of stay have started to

deteriorate since July.

• There has been a reduction of approximately 90

beds from the acute hospitals’ bed capacity as part of the overall capacity plan. The key enabler is delivery of the new clinical model and the organisation delivering the capacity and processes to achieve a maximum 20 day length of stay for patients who are medically fit.

• The key constraint to flow remains the EU

clinical decision maker. This issue plus minors and paediatrics performance are key areas for achieving improved levels of performance.

• Patients’ awaiting treatment and discharge from

the EU for major treatment is highly variable and subject to a number of issues outside of the control of the emergency unit, such as access to beds.

• The DToC action plan identifies a range of

actions designed to address the issues around capacity gaps in the independent sector across the locality and for specialist placements and review of the choice protocol.


UHB Performance against Peers Current improvement work • The UHB performance for 4 hours in August (85.4%) based on

validated data was lower than the All Wales average of 87.3%. Similarly for the 8-hour performance, the UHB position was 97.4% against the All Wales average of 97.8%.

• Performance against the 15 minute handover target has

improved but is lower than the All Wales average.

• Revised reporting arrangements are being implemented for EU performance with effect from 1st October, and will be reported in future reports.

• The UHB is in the middle of a complex service modernisation and recruitment process of implementing a clinical re-design programme across the emergency patient stream, focusing upon 4 key issues as follows: 1. Timely access to an EU Clinician; 2. Minors stream improvement; 3. Paediatric stream improvement; 4. Discharge.

• The updated action plan contains the specific

actions being undertaken in order to improve performance.

• Unanticipated service and personnel changes have

presented new challenges, but the Division is responding pro-actively to these and using them as an opportunity to drive service change in order to deliver a safer, more sustainable service.


C. Cancer – Performance up to and including September 2010

AOF Reference Target measure Target Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being

met

Risk rating and

rationale


% of patients who were referred by their GP with urgent suspected cancer and subsequently diagnosed as such by a cancer specialist who started definitive

treatment no more than 62 days after receipt of referral

95% 85% 88% 83% 100% 97% 89% Yes Strategic priority ↑

% of patients not referred as urgent suspected cancer but subsequently diagnosed with cancer start definitive treatment no more than 31 days of

diagnosis, regardless of the referral route

98% 97% 96% 95.40% 98.30% 99.10% 98.50% Yes Strategic priority ↑

* Draft figures supplied for September 2010 position subject to final validation and may change

AOF Target 18

Can

cer



• Performance data for September is 89% for Urgent Suspected Cancer & 98% Non Urgent Suspected Cancer for September 2010, although the data is still not validated.

• Overall performance has improved in the second quarter, and

for the unvalidated position is 95% for the 62 day target and 98.5% for the 31 day target.

• The key constraint to achieving 31 day target remains

surgery.

• The measurement and communication process between the wider MDT has been improved.

• There have been delays in the month in the provision

of flexi cystoscopies, treatment times for max fax cancers and on the lower GI pathway which have impacted on September’s position.

• Radiotherapy access remains an issue, along with

other agreements in relation to South East Wales service provision for a range of site specific cancers.

UHB Performance against Peers Current improvement work

• Comparative performance for August indicates that the UHB is in line with other UHBs for the 31 day target, and one of the best in Wales for the 62 day target.

• Key risk identified is that there is no cover for the oral-

maxillofacial surgeon who undertakes the cancer cases, and an additional appointment will be made in 2010-11 to address this.

• Discussions are underway to develop weekly

psychology and psychiatry sessions.

• Implementation of additional breast clinics to reduce waits is being undertaken, along with the opening of the new breast unit.

• Additional theatre lists will be made available to

address the urology backlog.


D. Sexual Health – Performance up to and including September 2010


met

Risk rating and

rationale


% of patients who required access to core sexual health services (HIV, sexually transmitted infection testing and routine contraception advice) provided by appropriate specialists within 2 working days.

100% 97.3% 96.2% 95.2% 96.6% 96.7% 95.2% No ↓Number of patients who required access to core sexual health services (HIV, sexually transmitted infection testing and routine contraception advice) provided by appropriate specialists who had waited more than 2 working days

0 37 54 71 49 45 76 No Target is zero ↓AOF Target

24Sexu

al H

ealth


• 76 patients waited more than 2 days for access to services, resulting in the UHB not achieving the target for access.

• Overall performance is at 95.2% of patients being seen

within 2 days

• Higher performance than in 2009/10 is being sustained by the UHB and has been above 95% for 6 consecutive months.

UHB Performance against Peers Current improvement work • Not available • The sexual health service improvement group has led

to improvement and greater compliance with the targets. Training of the nursing team is underway to improve patient flows and reduce work pressures on the consultant body.

• Two new consultants are now in post and there


remains 1 consultant vacancy which is being progressed. It is planned for these posts to have an impact across the sexual health community including family planning and TOP services.


E. Stroke services – Performance up to and including September 2010 UHB Performance against target Commentary on position and movement

• The UHB action plan has been reviewed and resubmitted, setting out the actions required to comply with AOF requirements by the year end.

• Local guidance on measurement of the stroke care bundles

has been implemented to ensure consistent measurement across the UHB.

• Baseline measures have been recorded and reported

across both sites. Compliance has improved significantly and performance meets WAG targets for 3 care bundles and is just below target for admission to a stroke ward within 24 hours.

• The UHB has confirmed its intention to centralise acute

services at UHW and rehabilitation services at UHL and project workstreams have been established to oversee and implement these actions.

• The UHB has made funding available to allow the

remaining elements of the LDP to be progressed.

• Stroke ward capacity is being ‘protected’ whenever possible for stroke admissions

• Daily TIA clinics and Doppler diagnostic support is

now established across the UHB, with urgent referrals generally able to be seen within one working day. It is intended to begin populating the TIA database from November, as preparation for the relevant target reporting in 2011/12.

• The UHB has commenced the out of hours

thrombolysis pilot from September, in preparation for a future extended regional service, using a regional stroke physician on call rota and telemedicine links


• Comparative data for NHS Wales and in England is not currently available, but should be available later in 2010-11 in respect of the intelligent targets.

• Determination of the acute stroke pathway for non-

thrombolysis patients is ongoing • Determination of the stroke rehabilitation pathway is

ongoing


F. Adult Mental Health – Performance up to and including September 2010 AOF

Reference Target measure Target Frequency Jan-2010 Feb-2010 Mar-2010 Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being met

Risk rating and

rationale


% of service users on enhanced CPA who have an agreed care plan developed in accordance with the CPA and that specifically includes: all identified interventions and anticipated outcomes, a record of all actions necessary to achieved agreed goals, a record of unmet need, an assessment of risk and a record of how that risk is being managed, a crisis and contingency plan and the name and contact details of an allocated care co-ordinator.

100% (end year) Quarterly No


target ↑

% of service users of standard CPA who have an agreed care plan that includes an up to date assessment of their needs, all identified interventions and anticipated outcomes and the name and contact details of an allocated care co-ordinator

90% (end year) Quarterly No


target ↑% of service users of enhanced CPA who have been identified as having complex needs and/or have difficulty in engaging with services will receive an assessment to determined whether Assertive Outreach services are required.

100% (end year) Quarterly No ↔

% of services users who are admitted to a psychiatric hospital between 0900 and 2100 who have received a gate-keeping assessment by the CRHT prior to admission

95% Monthly 94% 87% 88% 94% 94% 100% 91% 90% 92% No ↔% of service users who are admitted to a psychiatric hospital, who did not receive a gate-keeping assessment by the CRHTs, who received a follow up assessment by the CRHTs within 24 hours of admission.

100% Monthly 100% 71% 67% 100% 67%No patients in this category

100% 100% 100% Yes ↑

68%

49%

n/aAdu

lt M

enta

l Hea

lth S

ervi

ces

AOF Target 15 (formerly

AOF 12)

AOF Target 16 (formerly

AOF 13)

60%

n/a

32%

72%

65%

n/a


UHB Performance against target Commentary on position and movement

• Performance in respect of compliance with the Care Programme Approach (CPA) is reported on a quarterly basis. Performance reduced in the first quarter of 2010-11 due to the inclusion of medical and PAMS professionals.

• Performance has improved in the second quarter, but is still some way from meeting the target.

• The UHB is close to meeting the target for patients are receiving an initial assessment by the Crisis Resolution service, and all patients are assessed within 24 hours.

Other performance issues • Outpatient waiting times currently have a maximum 9 week

wait for general mental health services. • However, substance misuse waiting times for drug and

alcohol treatment are longer • Average length of stay on acute wards is reported as 46

days in August, and the year to date average of 52 days compares favourably against the ALOS of 68 days for 2009-10.

• Bed occupancy remains high – from April to September overall the wards were running at 111% occupancy (including home leave) across all acute wards

Community • Referral rates to Adult CMHT teams remain relatively

constant compared to previous months, with 650 referrals for September.

• Outpatient DNA rates remain variable across the Community. With the exception of Gabalfa and Hafan Dawal, all other CMHTS are reporting DNA rates higher than 18%. However, there has been significant improvement in many CMHTs in September.

• There is also variation across teams in the new to follow up ratios. These variances reflect the outcome of the draft WAO report and feedback from the Adult Mental Health Strategic Review.

UHB Performance against Peers Current improvement work • Comparative performance data is not available for this

report.

• Partial booking arrangements have been put in place and an audit of DNAs is being undertaken to determine reasons etc. CMHT are also reviewing caseloads as part of New Ways of Working initiatives to ensure discharge back to primary care as appropriate.

• Funding has been approved to develop assertive outreach services

• Results are awaited from the latest DSU/NLIAH review to inform future improvement work.


G. Child & Adolescent Mental Health – Performance up to and including September 2010 AOF

Reference Target measure Target Frequency Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being met

Risk rating and rationale


WTE Primary Mental Care Workers per 100,000 population 2 Monthly Cardiff - 0.9

Vale - 0.8Cardiff - 0.9

Vale - 0.8 0.9 0.9 0.9 0.9 No Recommended staffing ↔

% of consultations and advice to professionals who deliver the functions of Tier 1 provided within 2 weeks of request

100% Monthly Cardiff - 100%Vale - 100%

Cardiff - 100%Vale - 100% 100% 97% 97% 100% No Achieved ↔

Number of consultations and advice to professionals who deliver the functions of Tier 1 not provided within 2 weeks of request

0 Monthly Cardiff - 0Vale - 0

Cardiff - 0Vale - 0 0 5 3 0 No Achieved ↔

% of patients referred to a Specialist CAMHS that are assessed and require intervention plans initiated within 16 weeks

100% Monthly Cardiff - 100%Vale - 100%

Cardiff - %Vale - % 100% 100% 100% 100% Yes Consistently at

target ↔Number of patients referred to a Specialist CAMHS that are assessed and require intervention plans not initiated within 16 weeks


Cardiff - 0Vale - 0 0 0 0 0 Yes Consistently at

target ↔% of patients who have sustained low mood of 6 weeks or more and suicidal ideation that are assessed and intervention plans required that are initiated within 4 weeks

100% Monthly

Cardiff - No Referrals received

during periodVale - 100%

Cardiff - 100%Vale - 100% 100% 100% 100% 100% Yes Achieved ↑

Number of patients who have sustained low mood of 6 weeks or more and suicidal ideation that are assessed and intervention plans required that are not initiated within 4 weeks


Cardiff - 0Vale - 0 0 0 0 0 Yes Achieved ↑

AOF Target 18

CA

MH

S


• The UHB is achieving 6 of the 7 AOF performance targets. • Staffing levels in respect of dedicated primary mental health

care workers per head of population continues to be below recommended levels.

• This service is provided to the UHB by Cwm Taf UHB.

UHB Performance against Peers Current improvement work • Comparable data for NHS Wales is not available, although

similar issues have been identified in respect of staffing levels in other UHB areas.

• This service is provided to the UHB by Cwm Taf UHB.


H. Primary Care indicators – Performance up to and including September 2010 AOF

Reference Target measure Target Frequency Dec-2009 Mar-2010 Jun-2010 Sep-2010 Target being met

Risk rating and

rationale

Status (Last 3 periods) Comment

% uptake rates of MMR at age 2 Quarterly Cardiff - 89.4 Vale - 91.5

Cardiff - 92.2 Vale - 94.9

Cardiff - 90.2 Vale - 92.5 n/a No ↔

% uptake rates of MMR at age 5 (1 dose) Quarterly Cardiff - 92.6 Vale - 90.9



% uptake rates of MMR at age 5 (2 doses) Quarterly Cardiff - 81.4 Vale - 84.1



% uptake rates of 5 in 1 vaccine at age 1 Quarterly Cardiff - 94.3 Vale - 96.8


Cardiff - 93.1 Vale - 94.6 n/a Yes Unchanged

(within 1%) ↔% uptake rates of 4 in 1 vaccine at age 5 Quarterly Cardiff - 84.8

Vale - 90.1Cardiff - 86.5 Vale - 91.2


% uptake rates for seasonal flu vaccinations in at risk groups 75% Quarterly 2010/11

measure2010/11 measure n/a n/a

% uptake rates of HPV for girls at age 12 to 13 90% Quarterly

CardiffHPV3 = 73.4ValeHPV3 = 78.3



n/a No ↑

% of GP practices opening times reviewed 100% Quarterly Cardiff - 91% Vale - 100%

Cardiff - 91% Vale - 100% 36% 98.5% Year end

target ↑ Annual Target - will be achieved

by year end

% of practices that are meeting the opening times contractual requirements 100% Quarterly Cardiff - 19%

Vale - 100%

Cardiff - 100% Vale - 100%

100% 100% Yes ↔AOF 5 % of contracted dental activity delivered 95% Quarterly

Cardiff - 103%Vale - 107%

Cardiff - 98%Vale - 100% 100% n/a Yes ↔

Commentary in Section N:

Public Health Indicators

AOF 6

Prim

ary

& C

omm

unity

Car

e

95%

AOF 2


I. Healthcare-Associated Infections – Performance up to and including September 2010


met

Risk rating and

rationale


Total number of MRSA bacteraemias reported by each DGH in the LHB for the period 4 5 5 3 3 2 Yes 22 Cases ↑Total number of C Difficile cases for patients above 65

468 (Target 219 September)

40 48 50 37 39 28 No Actual 242 cases ↑Pa

tient

Saf

ety

AOF 19


• MRSA cases have remained low since March. There is no specific target in place, but numbers remain below 2009-10 levels.

• C difficile cases are showing a downward trend • The AOF target is a 20% reduction in the numbers of c

difficile cases for patients aged over 65, and the cumulative target is 468, which equates to an average of 39 cases per month. Based on current performance the UHB is not meeting the target, but the gap between performance and the profiled target has narrowed in September and this trend has been maintained to date in October.

• This is a priority area for remedial action, which should also include an improvement in cleanliness audit scores.

• MRSA performance has improved. Central venous catheter care bundles on critical care have reduced the incidence of central line associated infections on ICU.

• Following the audit of Peripheral Intravenous Catheterisation, a review of practices and the business case for introducing Chloraprep disinfection is currently being progressed. These initiatives, together with the introduction of a care bundle, are aimed at tackling the whole range of bacteraemias, and solely restricted to MRSAs.

UHB Performance against Peers Current improvement work • Comparable performance is reported through the Welsh

Healthcare Associated Infection Programme. • Overall the All Wales performance is not achieving the

targets for C difficile cases, or MRSA bacteraemias, but is for MMSA cases.

• A comprehensive C Difficile improvement plan has been implemented across the Divisions, focused on antimicrobial stewardship, management of cases, clinical engagement, the environment and an isolation/cohort ward.

• Progress on implementation will continue to be monitored by the Quality and Safety Committee.


J. Elective Average Lengths of Inpatient Stay - Performance up to and including September 2010 AOF

Reference Data Requirement 2009/10 Target

2010/11 Target Frequency Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target Met

Risk rating and rationale (AOF 2009/10)


Change (last 3 months with 3%

tolerance)

Comment

General Surgery 3.8 3.4 Monthly 4.0 4.1 4.1 4.1 4.2 4.3 No Within 10% of target

Over 10% variance from

target ↓ Red and deteriorating

Urology 2.7 2.2 Monthly 2.6 2.5 2.4 2.4 2.4 2.3 YesOperating better than

target

Within 10% of target ↑

Trauma and Orthopaedics 4.5 3.8 Monthly 3.6 3.6 3.6 3.4 3.3 3.2 YesOperating better than

target


target ↑ENT 1.2 1.1 Monthly 1.5 1.6 1.6 1.6 1.6 1.6 No


target


target ↔Ophthalmology 1.4 Monthly 1.1 1.1 1.1 1.1 1.1 1.1 Yes


targetNot Applicable ↔ No longer an

AOF target for 2010/12

Oral Surgery 2.0 Monthly 2.8 2.7 2.9 2.9 3.1 2.9 NoOver 10%

variance from target


target ↑Neurosurgery 5.3 4.1 Monthly 4.1 4.1 4.2 4.1 4.1 4.2 Yes


target

Within 10% of target ↓

Gynaecology 2.8 2.6 Monthly 3.2 3.1 3.1 3.0 3.0 2.9 NoOver 10%



target ↑N.B. - There has been a change in the targets for 2010/11

Effic

ienc

y M

easu

res

- Ave

rage

Len

gth

of S

tay

(Ele

ctiv

e)

AOF 8 - Efficiency & Productivity measure 1



• The UHB has maintained its performance and is currently meeting 4 of the applicable national targets.

• The targets have changed since 2009-10 to reflect the best performance in Wales.

• UHB performance is excellent in relation to Urology, Orthopaedics, Ophthalmology and Neurosurgery where the time patients stay in hospital for planned care in these specialties is less than national targets and peers across NHS Wales. For General Surgery, ENT and Oral Surgery stays are significantly higher than the targets.

• Inpatient average length of stay needs to be reviewed in a wider context of performance including daycase rates and overall casemix.

• The UHB uses the CHKS risk adjusted length of stay analysis for elective activity comparisons and benchmarks well in the majority of specialties included in the WAG targets.

• Orthopaedics and Ophthalmology are high volume specialties with low average lengths of stay which makes a major contribution to the effective use of elective beds.

• UHB Performance against Peers Current improvement work

• The UHB continues to monitor performance against CHKS peers, as this may provide a better comparison of casemix.

• CHKS Upper Quartile indicators are being used to challenge current practice. CHKS indicators based on peer performance have more clinical acceptance and are in some cases particularly relevant to the services provided at University Hospital of Wales due to the specialist and tertiary nature of some services.

• Clinical Pathway redesign work is ongoing to review opportunities for standardising and improving the care provided across elective specialties.


K. Emergency Average Lengths of Inpatient Stay - Performance up to and including September 2010

AOF Reference Data Requirement 2009/10

Target2010/11 Target Frequency Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target

Being Met




tolerance)

Comment

General Surgery 6.1 5.9 Monthly 7.2 7.3 7.4 7.3 7.3 7.2 NoOver 10%



target ↑Urology 4.3 3.3 Monthly 4.8 4.7 4.7 4.4 4.4 4.4 No Within 10% of

target


target ↔Trauma and Orthopaedics 9.4 9.4 Monthly 9.7 9.9 10.2 10.2 10.4 10.4 No Within 10% of

target


target ↔ENT 2.8 Monthly 3.2 3.4 3.3 3.2 3.5 3.3 No


targetNot Applicable ↔ No longer an

AOF target for 2010/12

Ophthalmology 3.6 Monthly 5.5 5.2 5.3 5.7 5.4 5.3 NoOver 10%


Not Applicable ↑ No longer an AOF target for

2010/12

Oral Surgery 1.6 Monthly 2.9 2.9 2.8 2.7 2.9 2.9 NoOver 10%


Not Applicable ↔ No longer an AOF target for

2010/12

Neurosurgery 9.0 9.0 Monthly 9.9 9.7 9.8 10.0 10.1 10.2 NoOver 10%




Gynaecology 1.2 0.7 Monthly 0.5 0.5 0.5 0.5 0.5 0.5 YesOperating better than

target


target ↔Combined Medicine 9.3 9.3 Monthly 10.5 10.5 10.6 10.6 10.7 10.5 No


target


target ↑N.B. - There has been a change in the targets for 2010/11

Effic

ienc

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AOF 8 - Efficiency & Productivity measure 7



• The UHB currently only meets 1 of the 6 national targets, with 2 specialties within 0.5 days of the target.

• The targets have been amended in 2010-11 to reflect the

best performance in Wales, but may not include comparative casemix across all UHBs..

• When risk adjusting length of stay performance, the UHB has 4 specialties where length of stay is significantly greater than is expected against our peers: Integrated Medicine, Rehabilitation, Trauma and Cardiac.

• The predominant driver for the first 3 specialties listed is the management of the elderly complex group of patients.

• For integrated medicine the management of stroke patients and respiratory patients on the UHW site are identified as particular areas where improvements could be expected.

• In Cardiac, the two HRGs where performance appears poor are due to access to cardiac surgery, and therefore may require improved management of the pre-operative element of the pathway.

UHB Performance against Peers Current improvement work • On average, patients spend longer in hospital when

admitted as emergency admissions than in other parts of Wales.

• This is a position, which has many causes and as a consequence several potential improvement opportunities.

• However, the UHB also benchmarks performance against the Risk Adjusted length of stay for CHKS peers as this may provide a better comparison of casemix undertaken.

• Delivery of the new clinical service model and right sizing the capacity of the services in the community are essential to delivery of the 20 day maximum length of stay and driving down acute and rehab lengths of stay.

• Development of the stroke pathway. • Review of the emergency poisons pathway. • Implementation of the trauma review

recommendations. • Revised process for scheduling elective and cardiac

surgery in order to reduce pre-operative length of stay.


L. Outpatient services New to Follow Up Ratios - Performance up to and including September 2010

AOF Reference Target measure 2009/10

Target2010/11 Target Frequency Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being

met

Risk rating and

rationale (AOF

2009/10)

Risk rating and

rationale (AOF

2010/11)


tolerance)

Comment

General Surgery 1.2 1.2 Monthly 1.7 1.7 1.8 1.8 1.8 1.8 NoOver 25%



target ↔Urology 2.1 1.6 Monthly 2.7 2.6 2.6 2.6 2.6 2.6 No

Within 25% variance from

target


target ↔Trauma and Orthopaedics 1.9 1.9 Monthly 2.2 2.2 2.2 2.2 2.3 2.2 No


target


target ↔ENT 1.3 1.0 Monthly 1.6 1.6 1.6 1.7 1.7 1.7 No


target


target ↓ Local Target in place

Ophthalmology 2.2 2.0 Monthly 2.2 2.2 2.3 2.3 2.4 2.4 NoWithin 25%

variance from target ↓

Oral Surgery 1.3 1.3 Monthly 1.2 1.2 1.2 1.2 1.2 1.2 YesOperating better than

target


target ↔Neurosurgery 1.8 1.5 Monthly 1.9 1.9 1.9 1.9 1.9 1.9 No


target


target ↔General Medicine 2.2 2.0 Monthly 4.3 4.3 4.3 4.3 5.2 5.2 No


target



Dermatology 1.3 1.1 Monthly 2.7 2.6 2.6 2.7 2.6 2.6 NoOver 25%



target ↓Other Neurology 1.4 1.2 Monthly 2.0 2.1 2.1 2.1 2.2 2.2 No


target


target ↔ Red and deteriorating

Rheumatology 2.3 2.1 Monthly 7.9 7.8 7.7 7.8 7.4 7.2 NoOver 25%



target ↑Paediatrics 2.1 2.1 Monthly 4.3 4.3 4.2 4.2 4.1 4.1 No


target


target ↑Gynaecology 1.3 1.1 Monthly 1.6 1.6 1.6 1.6 1.6 1.6 No


target


target ↔N.B. - There has been a change in the targets for 2010/11

Effic

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AOF 8, Efficiency & Productivity measure 7


UHB Performance against Target Commentary on position and movement The UHB is meeting one of the targets. However, performance is deteriorating in other areas. WAG has acknowledged that the targets need to be amended (a separate paper on this issue has been provided for the Committee).

• The Rheumatology ratio is significantly above target and requires review, although there has been a significant improvement since August. It is anticipated that there could be opportunities through reviewing non tertiary out of area follow up patients.

• The Medicine Division has agreed to provide an options appraisal and impact analysis for their Caerphilly service and other out of area patients.


• Comparative data is not available for this report. Previously available information shows the UHB has higher rates of follow ups than other LHBs in Wales and higher rates of Did Not Attend (DNA) also.

The UHB recognises that it needs to work with stakeholders to make significant reductions to outpatient volumes in order both to reduce avoidable hospital attendances and also to improve utilisation of clinical resources within secondary care. The following actions are underway:


• Current work to identify targets based on specialty specific and peer comparison, which will lead to setting of more appropriate targets for 2010/11, which will be monitored against in future reports.

• Increased quality assurance of coding

• Changing clinical practice to reduce inappropriate follow ups, through earlier discharge from hospital


M. Workforce - Performance up to and including September 2010 AOF

Reference Target measure Target Frequency Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Target being met

Risk rating and

rationale


AOF 8, E&P 23

Agency/locum spend (amount spent on agency/locum staff as a % of total staffing costs) 0.8% Monthly N/A 1.10% 1.1% 1.4% 1.2% 0.9% No ↑

AOF 8, E&P 22

Sickness absence rate (total number of contracted days lost to sickness as a % of total contracted days) 4.95% Monthly 5.03% 4.98% 4.93% 4.96% 4.95% 4.93% Yes ↑

Wor

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• Agency locum expenditure increased in July, but has fallen since then, and is now close to the target of 0.8%.

• The UHB target sickness rate (as set by WAG) is 4.95%.Sickness Absence is at target since August with 4.93% for September.

• Facilities and Mental Health are the two major areas where sickness rates are persistently higher than target levels.

UHB Performance against Peers Current improvement work • Comparative performance data is not available for this

report. • Sickness data is now analysed between short and long

term to enable targeted action to address the causes of sickness.


N: Public Health Performance Indicators

Children and Young People Public Health

Indicator What is being

measured? Why it is being

measured? Data Baseline data Monitoring data

1 Intention of mother to breastfeed their newborn baby.

Percentage of babies for whom it was recorded after birth of baby that mother was intending to breast feed.

Breast feeding has well known health benefits for the child and for the mother in later life. It is amenable to change through public health interventions and midwife support.

UHB child health database Quarterly

Time period April 2007- March 2008 Cardiff and Vale UHB 67.7% (4041/5965)

Time period April - June 2010 Cardiff and Vale UHB 72.9 % (996/1502)

2 Percentage of babies who are being breastfed at 6 weeks of age.

The percentage of babies being breastfed at 6 weeks.

Breast feeding has well known health benefits for the child and for the mother in later life. It is amenable to change through public health intervention and midwife support.

UHB child health database Quarterly

Time period April 2007- March 2008 Cardiff and Vale UHB 22.4% (1338/5965)

Time period April – June 2010 Cardiff and Vale UHB 25% (336/1502)

3 Uptake of the first dose of MMR in two year old children.

Uptake of vaccine for children reaching their 2nd birthday in reported period. Target: 95% uptake.

MMR vaccine protects against measles, mumps and rubella infections. One dose of vaccine confers 90% immunity to measles.

Report prepared by PHW vaccine preventable disease programme: data from Health Solution Wales using the National Community Child Health Database.

Time period April 2008- March 2009 Cardiff: 87.1% (3662/4206) Vale of Glamorgan: 91.3% (1285/1407)

Time period: April-June 2010 Cardiff: 90.2% (997/1105) Vale of Glamorgan: 92.5% (368/398)


Public Health

Indicator What is being

measured Why it is being measured Data Source Baseline data Monitoring data

4 Uptake of the second MMR dose by five years of age.

Uptake of two does of vaccine for children reaching their 5th birthday in reported period. Target: 95% uptake.

MMR vaccine protects against measles, mumps and rubella infections. In order to eliminate measles, the World Health Organization (WHO) recommends two doses of a measles-containing vaccine.

As above Time period April 2008- March 2009 Cardiff: 80.3% (3058/3810) Vale of Glamorgan: 81.9% (1139/1391)

Time period: April-June 2010 Cardiff: 83.6% (763/913) Vale of Glamorgan: 87.8% (318/362)

5 Uptake of pre-school 4 in 1 booster in five year old children.

Uptake of vaccine for children reaching their 5th birthday in reported period. Target: 95% uptake.

Pre-school booster boosts protection against diphtheria, tetanus, pertussis and polio infection.

As above Uptake of pertussis is used as a proxy.

Time period April 2008- March 2009. Cardiff: 84.5% (3218/3810) Vale of Glamorgan 87.8% (1221/1391)

Time period: April-June 2010 Cardiff: 86.3% (763/913) Vale of Glamorgan 91.4% (318/362)

6

Uptake of HPV vaccination of girls aged 13 years old (routine campaign).

Uptake of vaccine for girls reaching their 13th birthday in the reported period.

HPV vaccination protects girls against cervical cancer associated with HPV types 16 and 18.

As above Time period September 2008-August 2009 Uptake of 3 doses. Cardiff 78.6% (1542/1963) Vale of Glamorgan 84.4% (656/777)

Time period: Sept 2009-August 2010 Uptake of 3 doses. (not complete data) Cardiff 83.8% (1642/1854) Vale of Glamorgan 86.8% (696/757)


UHB Performance Against Targets 1 to 6 Commentary on Position and Movement Target 1 Intention to Breastfeed Jan – March 66.3% April – June 72.9% Target 2 Breastfed at 6 weeks Jan – Mar 22% April – June 25%

Targets 1 & 2 • A slight increase is noted from the first quarter. However results over this

short time period are not necessarily reliable and the most indicative measure will be performance over the whole year. Target 3

• For MMR1 uptake, the current figure is an improvement against the baseline but not against the previous quarter.

UHB Performance Against Peers Current Improvement Work The last All Wales data comes from the UK Infant Feeding Survey 2005, which found that two thirds of mothers initiated breastfeeding at birth (intention to breastfeed was not recorded), and 37% were still breastfeeding at 6 weeks. The Infant Feeding Survey is carried out at 5 yearly intervals but results are not usually available until the following year or year after.

Targets 1 & 2 • Roll out of the Unicef Baby Friendly Initiative (BFI) training has

commenced with all relevant staff and will enable them to support breastfeeding mothers effectively. This will take time but is the foundation for achieving BFI accreditation (AOF target).

• UHL retained its full BFI award in October 2009 but this will be lost when the MLU transfers to UHW.

• UHW has achieved stage 1 accreditation and is due for stage 2 assessment (staff knowledge and skills) in March 2011.

• The Community service has signed up for BFI and will be working towards stage 1 in 2011.

Targets 3,4,5 • Targeted work on immunisation with Flying Start families, the gypsy

traveller communities and GP practices with low uptake.


Adult Health and Lifestyle

Public Health Indicator

What is being measured? Why it is being measured? Data Baseline data Monitoring data

7 Percentage of adults who smoke

The survey asked whether the adults smoked daily or occasionally (self reported).

Smoking is the most important cause of preventable ill health and premature mortality in the UK. It is linked to respiratory illness, cancer and coronary heart disease. Smoking is a modifiable lifestyle risk factor; effective tobacco control measures can reduce the prevalence of smoking in the population.

Welsh Health Survey Available annually (2 year delay)

Time period 2008 Cardiff: 23% Vale of Glamorgan:26%

Time period: 2009 To be reported in 2011

8 Percentage of adult smokers in Cardiff and Vale who accessed Stop Smoking Wales or UHB in house service

Percentage of adult smokers (18+ years) in Cardiff and Vale who accessed smoking cessation services. [Accessed=client attending at least one smoking cessation session (including the assessment session for SSW)].

Smoking is the most important cause of preventable ill health and premature mortality in the UK. It is linked to respiratory illness, cancer and coronary heart disease.

Annual report from Stop Smoking Wales and Cardiff and Vale UHB smoking cessation service. Available quarterly.

Time period April 2006-March 2007 Cardiff: 883 (1.6%) Vale of Glamorgan: 491 (2.0%)

Time period Jan-March 2010 Cardiff 204 (0.3%) Vale of Glamorgan 115 (0.5%)




9 Percentage of treated adult smokers who successfully quit at 4 weeks

Percentage of treated adult smokers in Cardiff and Vale (18+ years) who used either Stop Smoking Wales or UHB in house service and who had successfully quit at: 4 weeks (validated (CO) or non-validated) [Treated=client attended at least one smoking treatment session].

As above As above Time period April 2006-March 2007 Cardiff: 235 (38.4%) Vale of Glamorgan: 157 (52.9%)

Time period Jan-March 2010 Cardiff: 73 (61.3%) Vale of Glamorgan: 39 (54.9%)

10 Percentage of treated adult smokers who successfully quit at 52 weeks

Percentage of treated adult smokers in Cardiff and Vale (18+ years) who used either Stop Smoking Wales or UHB in house service and who had successfully quit at: 4 weeks and 52 weeks (validated (CO) and non-validated)

As above As above Time period April 2006-March 2007 Cardiff: 74 (30.8%) Vale of Glamorgan: 42 (26.7%)

Time period Jan-March 2010 Cardiff: 42 (57.5%) Vale of Glamorgan: 17(43.6%)




11 Percentage of adults who meet physical activity guidelines

Percentage of adults who report undertaking 30 minutes of moderate intensity exercise on at least 5 days in the previous week.

People who have a physically active lifestyle are at approximately half the risk of developing coronary heart disease compared to those who have a sedentary lifestyle. Regular physical activity is also associated with a reduced risk of diabetes, obesity, osteoporosis and colon cancer and with improved mental health.


Time period 2008 Cardiff: 27% Vale of Glamorgan: 29%

Time period:2008 + 2009 (Welsh Health Survey 2008+2009 published September 2010) Cardiff: 26% Vale of Glamorgan: 29% To be further reported in 2011

12 Number of referrals to the National Exercise Scheme

Number of referrals to the National Exercise Scheme made from UHB staff (secondary and primary care).

People who have a physically active lifestyle are at approximately half the risk of developing coronary heart disease compared to those who have a sedentary lifestyle. Regular physical activity is also associated with a reduced risk of diabetes, obesity, osteoporosis and colon cancer and with improved mental health.

Data collected for the scheme Available quarterly

Time period April 2008-March 2009 Cardiff: available for Nov 2010 report Vale of Glamorgan: 732

Time period April – September 2010 Cardiff: 1199 Time period April – June 2010 Vale of Glamorgan: 133




13 Percentage of adults who are overweight or obese

Percentage of adults who are defined as overweight or obese based on self reported height and weight Obesity in adults is defined for epidemiological purposes as body mass index (BMI) > 30 kg/m2.

There is an association between all cause mortality and obesity. Obesity decreases life expectancy by up to nine years. Obesity causes insulin insensitivity, which is an important causal factor in diabetes, heart disease, hypertension and stroke.


Time period: 2008 Cardiff 53% Vale of Glamorgan 53%


14 Percentage of adults who eat at least five portions of fruit and vegetables a day.

Percentage of adults who self report eating at least five portions of fruit and vegetables the previous day.

The indicator is a measure of a protective lifestyle factor. A diet rich in fruit and vegetables confers protective effects against development of heart disease and certain cancers. It has been estimated that eating at least 5 portions of a variety of fruit and vegetables a day could reduce the risk of deaths from chronic diseases such as heart disease, stroke, and cancer.


Time period: 2008 Cardiff 40% Vale of Glamorgan 35%






15 Uptake of seasonal flu vaccinations in people aged 65 and over.

Uptake for seasonal flu vaccinations in people aged 65 and over. Target 70% (Note target for 2010/11 will be 75%)

Flu vaccinations are aimed to minimise flu related morbidity, mortality and hospital admissions.

PHW annual seasonal flu vaccination uptake report based on data from GP data systems.

Winter 2008/09 Cardiff 60.5% (28481/47045) Vale of Glamorgan 57.3% (12483/21788)

Winter 2009/10 Cardiff and Vale UHB. 64.7% (43624/67375)

16 Hospital admissions attributable to alcohol.

Hospital admissions attributable to alcohol. This includes conditions that are entirely and partially due to alcohol. European Adjusted Standardised Rates per 100,000 are reported.

Hospital admissions data are an indicator of the level of alcohol associated harm in the population and an indicator of the burden place on health services.

Public Health Wales Annually (rolling rate)

4-year rolling rate (2004-2008) Cardiff Males: 2024 per 100,000 Females:1115 per 100,000 Vale of Glamorgan: Males: 1904 per 100,000 Females:1098 per 100,000

4-year rolling rate (2005-2009) Available in 2011

UHB Performance Against Targets 7 to 16 Commentary on Position and Movement Target 8 • Data relating to accessing smoking cessation services for the

period 1st June – 30th September 2010 will be available at the next quarterly reporting period.

Target 15 • Target figure for seasonal flu increased to 75% for 2010 -2011

season.

Target 11 • Recently produced Welsh Health Survey Report indicates that

the rate of engagement of the adult population in Cardiff in physical activity has reduced from 27% to 26% (no change in the Vale of Glamorgan). Information gathered is self reported and relates to the time period 2008 and 2009.

UHB Performance Against Peers Current Improvement Work Targets 7 to 14 • Cardiff and Vale UHB area reports 24% of adults who smoke – this

is the same as the All Wales figure. Powys reports the lowest figure at 18 and Cwm Taf and Aneurin Bevan the highest at 25%.

• The figure for smokers contacting Stop Smoking Wales is only 1% -

statistically significant worse than the All Wales position of 2.6%.Powys reports the highest at 4.9% and Cardiff and Vale reports the lowest.

• Cardiff and Vale UHB reports 28% of adults who meet physical

activity guidelines – this is statistically significantly worse than the All Wales figure of 30%.

• 53% of adults are reported as overweight or obese – which is

statistically significant better than the All Wales figure of 57%

Targets 7,8,9,10 • Cardiff and Vale Smoke Free UHB has been established with 3

Task and Finish groups taking forward a revised No Smoking Policy, Pre-operative Smoking Cessation Programme and the Maternity Smoking Cessation Project.

• Brief Intervention Training for Smoking Cessation has been arranged for staff in the Midwifery Unit, UHW for November 2011.

• Cardiff and Vale University Health Board - as part of Smoke Free UHB - are working to increase referrals to smoking cessation services for patients and staff. A data entry code has been added to the Clinical Outcome Form to enable a systematised approach to referrals from clinicians to smoking cessation services. Data will be available at the next quarterly report.

• Smoke Free Vale Strategic Action Plan 2010-2011 finalised and awaiting publication.

• Results Based Accountability (RBA) indicators agreed for the Cardiff Tobacco Free action plan and report card developed, contributing to the Cardiff Health, Social Care and Well-Being Strategy Delivery Plan (2011-2014).


Target 11 • Public health focus on physical activity with partners including

the UHB continues. • Cycle Training and Cycle Maintenance Workshops delivered with

UHB staff during September 2010. • Physical activity being included within the local strategic plans for

Cardiff and the Vale. • Results Based Accountability (RBA) indicators agreed for the

Cardiff Physical Activity action plan and report card developed, contributing to the Cardiff Health, Social Care and Well-Being Strategy Delivery Plan (2011-2014)

• RBA indicators agreed for physical activity and play and report card developed, contributing to the delivery plan of the Children and Young People’s Plan (2011-2014)

• Engagement with partners continues on adopting a healthy urban planning approach.

Target 12 • Referrals to exercise referral schemes continue. Target 13 • Healthy Weight Healthy City Strategic Framework endorsed by

Cardiff Health Alliance in August 2010. • RBA indicators agreed for overweight and obesity and report

card developed, contributing to the delivery plan of the Children and Young People’s Plan (2011-2014) and the Cardiff Health, Social Care and Well-Being Strategy Delivery Plan (2011-2014)

• Work underway to develop a proposal for UHB staff weight management service.

• Development of the Vale of Glamorgan Food and Fitness Strategy in progress


Target 15 • In 2009/10 the uptake of seasonal flu immunisation in people aged

65 and over was 63.5% across Wales as a whole. • Cardiff and Vale UHB ranked second only to Betsi Cadwaladr UHB

where the uptake rate was 65.5%. Target 16 • Cardiff and Vale reports statistically worse hospital admission rates

due to alcohol than the All Wales position. Powys and Hywel Dda report the lowest rates (better than the All Wales figure) and Cwm Taf and Abertawe Bro Morgannwg the highest.

Target 14 • Results Based Accountability (RBA) indicators have been

agreed for the Cardiff Food and Health action plan which include an indicator on fruit and vegetable consumption.

Target 15 • A seasonal flu information pack has been sent to all GPs. This

provides overall guidance including a reminder of the correct read codes for immunisation, and allows practices to see how their individual uptake rates compare with other (anonymised) practices in the UHB.

• Following discussions with older people’s groups in the area, an information leaflet has been developed & distributed which focuses on addressing the key reasons older people give for not having flu immunisation.

• Local efforts to improve immunisation rates are being supported nationally by an Assembly Government media campaign through TV, radio and bus shelter advertising.

Target 16 • An Alcohol Action Plan has been developed which includes

action at both primary and secondary prevention levels. The latter focuses on increasing the number of people offered help with problem drinking in primary care.


Life Expectancy and Causes of Death

Public Health

Indicator


17 Life expectancy at birth:

Life expectancy at birth is a summary measure of the all cause mortality rates in an area in a given period. It is the average number of years a new-born baby would survive, were he or she to experience the particular area’s age-specific mortality rates for that time period throughout his or her life.

To help reduce premature mortality and facilitate planning of health services at local level.

ONS data Annually ( 3 year rolling rate)

Rolling rate: 2006-08 Cardiff and Vale UHB: Males: 76.6 years Females 81.7 years

Rolling rate: 2007-09 Available 2011

18 Mortality from circulatory disease in under 75s European Adjusted Standardised Rates per 100,000 are reported.

Mortality is a direct measure of health care need reflecting the overall circulatory disease burden on the population, both the incidence of disease and the ability to treat it.

To estimate premature mortality due to circulatory diseases. To reduce premature deaths from circulatory diseases. Circulatory disease accounts for 40% of all deaths (30% under 75). The mortality rate may be improved by reducing the population’s risk.

Public Health Wales Annually ( 3 year rolling rate)

Rolling rate 2006-08 Cardiff and Vale UHB 74 per 100,000 Average annual deaths =320






19 Mortality from respiratory disease in under 75s European Adjusted Standardised Rates per 100,000 are reported.

Mortality is a direct measure of health care need reflecting the overall respiratory burden on the population, both the incidence of disease and the ability to treat it.

To estimate premature mortality due to respiratory disease. To reduce premature deaths from respiratory disease.

Public Health Wales Annually (3 year rolling rate)

Rolling rate 2006-08 Cardiff and Vale UHB 25 per 100,000 Average annual deaths = 111


20 Mortality from all cancers in under 75s European Adjusted Standardised Rates per 100,000 are reported.

Mortality is a direct measure of health care need reflecting the overall cancer on the population, both the incidence of disease and the ability to treat it.

To estimate premature mortality due to cancer. To reduce premature deaths from cancer.

Public Health Wales Annually ( 3 year rolling rate)

Rolling rate 2006-08 Cardiff and Vale UHB 126 per 100,000 Average annual deaths= 538


UHB Performance Against Targets 17 to 20 Commentary on Position and Movement

• No change from that cited above as rolling rate data next available in 2011

• No change from that cited above as rolling rate data next available

in 2011 UHB Performance Against Peers Current Improvement Work

• No change as rolling rate data next available in 2011 • As set out across this performance report

• Department of Health/Association of Public Health Observatories (2010) The Indicators Guide: Health Profiles 2010 http://www.apho.org.uk/resource/view.aspx?RID=50204] Accessed 12th August 2010.

O: Annual Operating Framework – Second Quarter Reporting Summary of Submission

AOF Target Programme Area Public Health

AOF 1 Green

Local Plan for implementing key actions identified within ‘Our Healthy Future’ Quarter 1 - Green; Quarter 2 – Green

AOF 2 Red

Vaccination Rate Targets Quarter 1 - Red; Quarter 2 – Red

Improving Patient Care in the Community AOF 3 Green

Chronic Conditions Management Quarter 1 - Amber; Quarter 2 – Green

AOF 4 Green

Rural Health Quarter 1 - Amber; Quarter 2 – Green

AOF 5 Data Only

Contracted Dental Activity Delivered Data collection only, not assessed by WAG to date

AOF 6 Data Only

GP Opening Times Data collection only, not assessed by WAG to date

AOF 7 Data Only

Community Pharmacy Contract Data collection only, not assessed by WAG to date

Efficiency and Productivity – revised for 2010/2011 AOF 8 Red

Core Efficiency and Productivity Measures Quarter 1 - Red; Quarter 2 – Red * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

Finance AOF 9 Financial Balance

Not reported through this process. Access - revised for 2010/2011 AOF 10 Red

RTT, Diagnostic and Therapy Waiting Time Targets RTT: Quarter 1 - Red; Quarter 2 – Red Diagnostic: Quarter 1 - Red; Quarter 2 – Red Therapy: Quarter 1 - Green; Quarter 2 – Red

AOF 11 No data

Health Needs of Veterans/Service Personnel No data collected to date



AOF Target Programme Area Unscheduled Care AOF 12 Red

A&E 4 hour and 8 hour targets and Ambulance Handover Targets Quarter 1 - Red; Quarter 2 – Red * Highlighted by WAG as requiring immediate actions

AOF 13 Red

Ambulance Response Times Welsh Ambulance Trust Target – Red for residents of the UHB

AOF 14 Red

To achieve the Year 3 reduction of the DToC programme Quarter 1 - Red; Quarter 2 – Red * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

Adult Mental Health Services AOF 15 Amber

Care Programme Approach Quarter 1 - Red; Quarter 2 – Amber * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

AOF 16 Green

Crisis Resolution Home Treatment Service Quarter 1 - Green; Quarter 2 – Green

AOF 17 Red

To achieve the Year 3 reduction of the DToC programme for mental health Quarter 1 - Red; Quarter 2 – Red * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

CAMHS AOF 18 Report not sent by Cwm Taf to date

Primary Mental Health Workers per 100,000 population; consultation and advice to professionals who deliver the functions of Tier 1 within 2 weeks of request; training course in each Unitary Local Authority and access targets for children and young people Quarter 1 - Amber; Quarter 2 – not yet received Data received for Quarter 2, but no document received as yet

Healthcare Associated Infections – revised for 2010/2011 AOF 19 Red

20% reduction in the number of cases of Clostridium difficile in patients over the age of 65 and over 95% compliance with mandatory HCAI surveillance schemes. Quarter 1 - Red; Quarter 2 – Red

Cancer Services AOF 20 Green

Implement plans to support the delivery of the Cancer Strategic Framework; 31 and 62 day targets for cancer referrals Quarter 1 - Red; Quarter 2 – Green


AOF Target Programme Area Cardiac Services AOF 21 Green

Implement plans to support the delivery of the Cardiac Disease Strategic Framework; cardiac RTT target Quarter 1 - Red; Quarter 2 – Green Green against the RTT target but Amber for progress against the LDP

Stroke Services AOF 22 Green

Implement plans to support the delivery of the Stroke Programme Quarter 1 - Green; Quarter 2 – Green

Renal Services AOF 23 Amber

Implement plans to support the delivery of the Renal Strategic Framework Quarter 1 - Amber; Quarter 2 – Amber

Sexual Health Services AOF 24 Amber

Access to core sexual health services within 2 working days Quarter 1 - Amber; Quarter 2 – Amber * Highlighted by WAG at the end of quarter 1 as requiring immediate actions – this was based however on incorrect data which has since been resolved

Critical Care AOF 25 Amber

Implement plans to support the delivery of the Critical Care Strategic Framework Quarter 1 - Amber; Quarter 2 – Amber

Other AOF Target Areas Other 1 Amber

Maternity Services Quarter 1 - Amber; Quarter 2 – Amber

Other 2 Amber

Civil Contingencies Quarter 1 - Amber; Quarter 2 – Amber * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

Other 3 Amber

Substance Misuse Quarter 1 - Amber; Quarter 2 – Amber * Highlighted by WAG at the end of quarter 1 as requiring immediate actions

Other 4 Amber

Healthcare Standards Quarter 1 - Amber; Quarter 2 – Amber


Performance Report Part Two 1/47

INTEGRATED PERFORMANCE REPORT – PART TWO CONTENTS Introduction 1. Quality and Safety

Core indicators

1.1. Risk Adjusted Mortality Index (RAMI) 1.2. Hospital Acquired Infection - MRSA 1.3. Hospital Acquired Infection – C Difficile 1.4. Serious Adverse Incidents 1.5. Falls 1.6. Medication Errors 1.7. Mental Health Care Programme Approach (CPA) 1.8. Orthopaedic Surgical Site Infection (SSI) 1.9. World Health Organisation (WHO) Surgical Safety

Checklist 1.10. Stroke Care Bundles Supplementary indicators 1.11. Readmission rates 1.12. Chronic Conditions Management 1.13. Prescribing 1.14. Ambulance Response Times 1.15. Primary and Community Care Reporting

2. Operational Efficiency Core indicators

2.1. Day Case Rates 2.2. Admission on Day of Surgery 2.3. Outpatient Follow Up Rates 2.4. Outpatient DNA Rates


2.5. Theatres 2.6. Average Length of Stay - Emergency Care 2.7. Average Length of Stay - Elective Care 2.8. Critical Care 2.9. GP Referrals

3. Use of Resources Core indicators

3.1. Elective Treatment Against Profile 3.2. Elective New Outpatient Activity Against Profile 3.3. Revenue Expenditure Against Resource Limit 3.4. Cash Expenditure Against Resource Limit 3.5. Payment of Non NHS Creditors within 30 Days 3.6. Agency/Locum Expenditure 3.7. Sickness Absence 3.8. Staff Turnover

4. Patient Experience Core indicators

4.1. Access to Elective Services – 26 Weeks 4.2. Access to Elective Services – 36 Weeks 4.3. Patients Waiting for Inpatient and Day Case Treatment 4.4. Patients Waiting for Outpatient Treatment 4.5. Operations Cancelled on Day or Day Before Surgery 4.6. Delayed Discharges 4.7. Access to Cancer Services 4.8. Access to Emergency Services – 4 Hours in EU 4.9. Corridor Waits in the Emergency Unit 4.10. Complaints – Primary Care 4.11. Complaints - Hospital 4.12. Patient survey

Supplementary indicators 4.13 University Teaching and Training 4.14 Cleanliness


INTRODUCTION In addition to the measures collected nationally and reported externally through the NHS Performance Dashboards set out in Part one, the UHB has identified core indicators within its balanced scorecard which are presented in the Executive Summary. These are provided in greater detail in this section, and are supplemented by additional measures, in order to highlight particular issues and are illustrative of the wider range of responsibilities of the UHB. 1. QUALITY AND SAFETY 1.1 Risk Adjusted Mortality Index (RAMI) The CHKS Risk Adjusted Mortality Index (RAMI) is an index which compares the deaths observed in a hospital or LHB with the number of deaths expected given the profile (case mix) of the patients being treated within the UHB. The calculation of the number of expected deaths is based on a statistical model developed by CHKS. An index score of 100 indicates that the observed deaths are in line with expected levels, an index of less than 100 shows that there are less observed deaths than would be expected and an index greater than 100 more deaths than expected. The RAMI compares the ratio of the actual number of deaths to the expected number of deaths. It is based on diagnosis groups that account for 80% of all deaths in acute care hospitals, and is adjusted for factors such as diagnosis group, age, sex, length of stay, admission category, co-morbidities, and transfers. The analysis excludes a range of specialties such as Mental Health sub-specialities and Palliative Care. Table 1: Risk Adjusted Mortality Index (2010) September 2009 to August 2010

UHB Welsh Peers

CHKS Peers

RAMI (2010) 94 101 87

Source: CHKS The index for the UHB is 94 which would suggest that the overall mortality rate is lower than expected, compared to Welsh Peers, but is higher than CHKS peers.


When interpreting risk adjusted mortality indices it should be noted that where the quality and detail of clinical coding are relatively low the RAMI is likely to appear relatively high as co-morbidities are less likely to be recorded in a patient’s record. As patients with co-morbidities will have a higher expected probability of death, under-recognition of co-morbidities will lead to a lower number of expected deaths and therefore a higher mortality index as this compares the observed deaths with the expected deaths. Figure 1: Risk adjusted mortality index September 2009 – August 2010

Source: CHKS Within the UHB, data is available through the CHKS system, and this information is cascaded through the organisation. The Medical Director is investigating individual cases weekly on a risk assessed basis, and the Quality and Safety Committee will monitor any specific areas of concern. As part of the CHKS Top 40 hospitals programme, there are a number of indicators which the UHB will need to achieve upper quartile performance, in order to achieve Top 40 status. The chart below outlines the UHB’s relative performance against the Peer group.


Figure 2: CHKS RAMI Peer Distribution

Source: CHKS 1.2 Healthcare Associated Infections (HCAI) - MRSA Healthcare Associated Infections (HCAI) refers to infections that occur as a result of contact with the healthcare system in its widest sense - from care provided in patients’ own homes, to general practice, nursing home care and care in acute hospitals.

HCAIs increase the time a patient takes to get better from surgery or other treatment and they can lead to severe disability or death in some cases. Also, patients who remain in hospital longer due to HCAI means that other patients cannot be treated as quickly and outbreaks of infection can cause severe disruption to a hospital or community healthcare service.

Information is reported by Public Health Wales (Welsh Healthcare Associated Infection Programme) on a monthly basis, and the chart below outlines cumulative progress against target. Based on the position to the end of September, the UHB is on course to meet the WAG target.


Figure 3: MRSA

Source: Public Health Wales 1.3 Healthcare Associated Infections (HCAI) – C Difficile The target for 2010-11 is to achieve a 20% reduction in the number of cases reported for patients aged over 65. For this community the numbers reported in the baseline year (July 2008 – June 2009) were 585 cases and therefore the cumulative target for 2010-11 is 468.

Information is reported by Public Health Wales (Welsh Healthcare Associated Infection Programme) on a monthly basis, and the chart below outlines cumulative progress against target. This demonstrates


that although the target is not currently being achieved, there was a reduction in cases in September, which has narrowed the difference between the UHB performance and the WAG target profile. The UHB is monitoring cases weekly and to date the reduction in cases has been maintained during October. Figure 4: Numbers of C Difficile Cases for patients over 65 years of age

Source: Public Health Wales A C Difficile improvement plan is being implemented in each Division to reduce the rate of infection. Key priority areas for improvement include:

• Antimicrobial Stewardship


• Management of cases using the C Difficile treatment algorithm • Clinical engagement through the Divisional Director structure • Environmental improvements, particularly in relation to chlorine

cleaning and increased hours • The prompt isolation of patients and the potential development of a

cohort ward. Progress against the improvement plans is being monitored by the Quality and Safety Committee. 1.4 Serious Adverse Incidents Serious adverse incidents are defined as any event or circumstance arising during NHS funded care that could have or did lead to unintended or unexpected harm, loss or damage to one or more patient. Serious incidents are reported to the National Patient Safety Agency (NPSA) through the National Reporting and Learning System (NRLS). Incidents are reported as part of the NHS Performance Dashboard, and the table below highlights the number of monthly incidents. This does highlight some variation between the months, although the numbers are small. Table 2: Serious Adverse Incidents April 2010

May 2010

June 2010

July 2010

August2010

Sept 2010

6 1 1 6 7 5

Source: Information Department 1.5 Falls Falls have been reported as part of the revised NHS Performance Dashboard, although there is not a specific target in place. Table 3: Hospital falls April 2010

May 2010

June 2010

July 2010

Aug 2010

Sept 2010

327 324 380 286 267 308 Source: Information Department


A significant number of falls are reported, the reducing trend in July and August has reversed in September. 1.6 Medication Errors Medication errors are reported in the NHS Performance Dashboard and relate to the wrong dose or medication given to the patient. These errors can cause harm to the patient and can delay discharge or lead to other treatment being required. The table below confirms the number of errors reported, and indicates performance is variable each month. Performance has deteriorated since May. Table 4: Medication Errors Reported

April 2010

May 2010

June 2010

July 2010

Aug 2010

Sept 2010

27 10 67 31 35 37 Source: Information Department The last Quality and Safety Committee meeting received a comprehensive integrated report on compliments, complaints, claims and incidents. The next report will set out what action has been taken in response to these issues. The UHB has established a complaints/claims review panel chaired by the UHB Chairman to scrutinise these matters. 1.7 Mental Health Care Programme Approach (CPA) The Performance Committee meeting will receive a comprehensive report in respect of Mental Health performance. The table overleaf outlines current performance. Overall, the numbers of patients on CPA continue to steadily increase. Following an apparent final quarter improvement the 2009/10 period, the reported figures for the 1st quarter of 2010/11 reduced due to the inclusion of medical and PAMS professionals in the reporting framework. Reported performance is now improving, and the Performance Committee will receive an update on the current position.


Table 5: CPA Report NHS Trust/ LHB Name: Cardiff and Vale University Health Board

Report period

01/10/09 to 31/12/09

Report period 01/01/10 to

31/03/10

Report period

01/04/10 to 31/07/10

Reported figures as of

16th September

2010 1. Number of patients on Standard CPA 3571 3616 3817 3862 2. Number of patients on Enhanced CPA 2184 2282 2778 2843 3. Total Number of patients on CPA 5755 5898 6595 6705 4. Number of patients with Standard Care Plan as defined in annex 2* 1100 (31%) 2348 (64%) 1221 (32%) 1853 (48%) 5. Number of patients with Enhanced Care Plan as defined in annex 2* 1300 (60%) 1635 (71%) 1667 (60%) 1819 (64%) 5a. Number of patients on Enhanced CPA who have received a assertive outreach assessment 6. TOTAL number of patients with Care Plan as defined in annex 2* 2400 (42%) 3983 (67.5%) 2888 (44%) 3672 (56%)

Source: Mental Health Divisional Report 1.8 Surgical Site Infections The UHB is required to submit information to the Welsh Healthcare Associated Infection Programme (WHAIP) in respect of Orthopaedic and Caesarean Section Surgical Site Infections. This data is then published quarterly by WHAIP. In line with AOF target 19, UHBs are required to achieve over 95% compliance with mandatory HCAI surveillance schemes. Figure 5 shows compliance with the requirement for completion of returns for orthopaedic surgical site infections and indicates that the UHB has low compliance compared with the rest of Wales. This issue has been referred to the T&O Directorate for resolution. Figure 6 shows the rate of surgical site infections reported on the valid returns.


Figure 5: UHB Return for Mandatory Procedures: 1 January 2010 to 30 June 2010

Source: Public Health Wales Figure 6: Overall SSI Rates between 1 January 2010 and 30 June 2010

Source: Public Health Wales There are no SSIs reported on the valid forms returned to WHAIP.


Tables 6 and 7 show compliance and performance for the Caesarean Section Infection rates. The overall infection and deep seated infection rates are slightly higher compared with the rest of Wales. Table 6: Caesarean Section Infection Rates 1 January 2010 to 31 March 2010

Source: Public Health Wales


Table 7: UHB Caesarean Section Infection Rate 1 January 2010 to 30 June 2010

Source: Public Health Wales 1.9 WHO Surgical Safety Checklist Figure 7 demonstrates compliance of the use of the WHO Surgical Safety Checklist. Compliance is a UHB specific target, and the target is to achieve 100% compliance.


Figure 7: WHO Checklist Compliance

WHO Checklist Compliance

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jul-10 Aug-10 Sep-10

Source: Theatre Information System The Theatre Improvement Project reviews monthly performance by specialty, some of which are achieving full compliance, and targeted work is taking place to improve compliance in specific specialty areas. Reported performance has improved significantly since July to a level of 95% compliance in September. 1.10 Stroke Care Current performance of stroke services compared with the AOF target is set out in Section E of Part one of the performance report. This section considers progress against the intelligent targets. Intelligent Targets Revised reporting arrangements have been developed in respect of the stroke targets, and performance against the stoke bundles for September are reported in the table 8 overleaf. Formal national reporting


was implemented from September across Wales, and future reports will include feedback from WAG and comparison across Wales. As part of the informal data collection process, concerns had previously been expressed to colleagues within NLIAH and the DSU regarding the interpretation and definition of some of the new intelligent targets that may result in inappropriate conclusions in respect of the treatment given to individual patients. Following discussions with both organisations, these concerns have now largely been resolved, and there now exists more of a shared understanding that careful interpretation of results, and further evolution of target requirements will be required in the future. It is the intention of the UHB’s stroke team to be fully involved in this evolving process. Table 8: Intelligent Target Performance September 2010

Intervention Total No. of patients within

the care bundle in this period

Of the total number of patients within the care

bundle, number that were compliant with every element

this period

% Compliance

Acute Stroke bundle – first 3 hours

42 42 100%

Acute Stroke bundle – first 24 hours

42 37 88%

Acute Stroke bundle – first 3 days

42 40 95%

Acute Stroke bundle – first 7 days

42 41 98%

Source: Medicine Division There has been a significant improvement in performance since July, the target of 95% compliance for each care bundle is now being achieved, except for procedures within the first 24 hours, which is just below the target. The main constraint remains the ability to admit to UHW stroke ward within 24 hours, and this is being addressed by the provision of additional nursing capacity. 1.11 Readmission Rates Readmission rates are an indicator of the quality of care and also patient experience. Lower readmission rates, particularly within a short timescale, are an indicator of good quality. Table 9 overleaf shows the readmission rate by specialty for emergency admissions within 28 days of discharge, over the September 2009 to August 2010 period for the UHB and the CHKS Peer Group (using CHKS data).


Table 9: Readmission rates

Source: CHKS The overall readmission rate for the UHB is 6.5% compared with a Peer Group rate of 5.6%. The Quality and Safety Committee has received a report outlining the specialties which have a readmission rate higher than the peer group. This Committee will be monitoring progress in reducing these rates through the Divisions monthly Quality and Safety meetings. 1.12 UHB performance – Chronic Conditions There is no detailed report on Chronic Conditions Management available for this performance report. 1.13 Prescribing Drug expenditure, both in the Acute and Primary Care setting, form a substantial proportion of the UHB non pay expenditure. Therefore, it is important to ensure the resources are maximised effectively.


1.13.1 Prescribing Units Cost Figure 8 below highlights the average monthly cost per 1,000 Astro Prescribing Units (PUs) plotted against the Townsend deprivation index. There is an opportunity to reduce costs in both the Cardiff and Vale localities, which are both above the all Wales regression line. Figure 8: Average Monthly Cost per 1,000 Astro Prescribing Units (PUs) Plotted Against the Townsend Deprivation Index

Source: NLIAH The All Wales Medicines Strategy Group (AWMSG) agrees a range of national indicators each year, and monitors UHB performance against these targets. Targets are related to achieving upper quartile performance or improving from current quartile. Each of these targets is also monitored on a practice by practice basis, by the Locality Prescribing Teams along with a range of other quality indicators. Cardiff and Vale localities’ performance against the most significant of these targets is shown in the following figures 9 to 11.


Figure 9: Simvastatin and Pravastatin as a Percentage of all Statins – June 2010 Quarter (Target is 76.14% or above)

Simvastatin and Pravastatin as % of all Statins - June 2010 Qtr (Target = 75.14% or Above)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

1 2 3

The

Vale

Of G

lam

orga

n 5 6 7 8 9 10 11 12 13 14 15 16 17

Car

diff 19 20 21 22

Nat

iona

l-GP

Source: NHS Wales Informatics Service The chart above indicates that the Cardiff locality is achieving the target but there is an improvement opportunity in the Vale of Glamorgan locality. The cost of simvastatin and pravastatin is considerably less than other statins and in AWMSG’s view, for the majority of patients, are just as effective.


Figure 10: Ibubrofen and Naproxen as a percentage of Non Steriodal Anti Inflammatory Drugs (NSAIDs) – June 2010 Quarter Target 49.91% or above

Ibuprofen And Naproxen as % of NSAIDs - June 2010 Qtr (Target = 49.91% or Above)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

1 2 3 4 5 6 7 8 9 10 11 12

The

Vale

Of G

lam

orga

n 14 15 16 17 18 19 20

Car

diff 22

Nat

iona

l-GP

Source: NHS Wales Informatics Service The chart above indicates that the Cardiff locality is one of the highest prescribers in Wales and that the Vale of Glamorgan locality is close to achieving the target, although not at the high performance level of Cardiff.


Figure 11: Top 9 Antibacterials as a Percentage of Antibacterials Items – June 2010 Quarter (Target 76.97% or above)

Top 9 Antibacterials as a % of Antibacterials Items - June 2010 Qtr (Target = 76.97% or Above)

62.00

64.00

66.00

68.00

70.00

72.00

74.00

76.00

78.00

80.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14

The

Vale

Of G

lam

orga

n 16 17 18 19 20

Car

diff 22

Nat

iona

l-GP

Source: NHS Wales Informatics Service The chart above indicates that the Cardiff locality is achieving the target and the Vale of Glamorgan locality is close to the target, although not at the high performance level of Cardiff. 1.14 Ambulance Response Times This target is not specifically a UHB target, but does impact on UHB residents in terms of speed of response to an emergency. Table 10 overleaf sets out the performance across Wales during August, for the 8 minute response target. The specific WAG target is the requirement to achieve: • a monthly all-Wales average performance of 65% of first responses to

Category A calls (immediately life threatening calls) arriving within 8 minutes


• a monthly minimum performance of 60% of first responses to Category A calls (immediately life threatening calls) arriving within 8 minutes in each Local Health Board area

• a monthly all-Wales average of 70% of first responses to Category A calls (immediately life threatening calls) within 9 minutes

• a monthly all-Wales average performance of 75% of first responses to Category A calls (immediately life threatening calls) within 10 minutes.

Table 10: Percentage of emergency responses arriving at the scene within 8 minutes, August 2010 by Unitary Authority

Source: WAG The 60% target was achieved in six of the seven Local Health Boards in August and has been consistently achieved for this community, and is higher than the All Wales average. 1.15 Primary and Community Care Reporting Primary and community care services such as Mental Health and District Nursing use the PARIS reporting system, and each month a series of reports are generated for operational managers. These reports are set out in figure 11 and tables 11 to 13 and cover a range of issues including:

• Source of referral into District Nursing • Categories of care required by clients accessing the services • Average length of stay while patients are cared by members of the

team • Review of specific areas such as pressure ulcers • Contacts and contact time for the teams


• Capacity planning comparing workloads where appropriate between the various teams.

Figure 12: Average Length of Stay for Community Nursing

Source: Paris Information System The chart above indicates that the average length of time that patients remain within the community nursing service is increasing over time. Table 11: Source of Referrals to the District Nursing Service – September 2010

Source: Paris Information System


The September 2010 report indicates that the District Nursing service receives close to 2,000 referrals every month, and that approximately half are directly from GPs and the other half from hospital services. Table 12: Active Cases within September 2010 Category of Care Cases Continence 2,583Continuing Care 91Curative 3,972Maintenance 4,354Palliative Care 313Rehabilitation/ Intermediate Care 155 Total 11,468Source: Paris Information System Reports were established on the basis of the draft All Wales categories of care, but these may be amended in future reports when the categories are formally agreed. Table 13: Community Nursing Contacts and Contact Time – By Team

Source: Paris Information System This report indicates that in excess of 25,000 attendances are undertaken each month by the Community Nursing service and the analysis of contact time and activity is used by the service to ensure that the resources are deployed most effectively across the teams.


The neighbourhood teams are currently working closely with social services colleagues to assess the scope for more effective utilisation of combined resources. 2. OPERATIONAL EFFICIENCY 2.1 Day Case Rates 2.1.1 Day Case Basket (Same Day Surgery) A new basket of procedures has been selected by WAG for performance monitoring in 2010/11. The listed procedures have been selected from the NHS Wales Short Stay Surgery Basket of 50 procedures*, derived from the British Association of Day Surgery (BADS) Directory of Procedures (3rd Edition 2009). The 18 procedures have been selected on the basis that relatively high volumes can reasonably be expected to be carried out against the targeted short stay delivery areas. This basis is further supported by the Wales Audit Office report ‘Making better use of Day Surgery in Wales’ (2006) which advocates the use of short stay surgery resources across a wider range of procedures and provides an incentive / challenge to practitioners to expand their scope. The targets set by WAG are specific to each procedure and since the target has been in place since April 2010, there are 6 months of data available. Table 14 overleaf shows that 4 targets have been achieved during this period and an additional 3 targets have been met in recent months. The national Acute Productivity Board is focussing its attention initially on 5 of these procedures and performance against these is included in a separate paper prepared for the Committee.


Table 14: Same Day Surgery Target Achievement Short Stay Surgery Basket of Procedures

2010/2011 April May June July August September6 month average Status

Simple mastectomy (inc axillary node biopsy) * 75% >/= 2-3 days 50% 44% 56% 62% 62% 70% 57% ImprovingSeptoplasty of nose * 95% >/= 1 day 100% 89% 94% 95% 100% 94% 95% Meeting targetTonsillectomy * 100% >/= 1 day 86% 83% 83% 85% 94% 86% 86% StableDiagnostic laparoscopy * 85% Same day 42% 56% 50% 38% 45% 65% 49% ImprovingLaparoscopic cholecystectomy 80% >/= 1 day 68% 81% 77% 71% 80% 81% 76% Target met Aug & SepPrimary repair of inguinal hernia 85% Same day 61% 48% 71% 65% 83% 70% 66% Improvement requiredRepair of umbilical hernia 80% Same day n/a n/a n/a n/a n/a 50% 50% Low patient numbersTherapeutic endoscopic operations on uterus (inc endometrial ablation) 90% Same day 57% 75% 68% 65% 82% 70% 70% StableTherapeutic laparoscopic procedures including laser, diathermy & destruction e.g. endometriosis, adhesiolysis, tubal surgery 70% Same day 50% 50% 55% 16% 17% 25% 36% Improvement requiredOperations to manage female incontinence 85% >/= 1 day 100% 50% 60% 67% 67% 86% 72% Target met SepAnterior colporrhaphy * 75% >/= 2-3 days 90% 75% 50% 100% 33% 80% 71% Target met SepCombined Procedures: Total / subtotal thyroidectomy & Hemithyroidectomy, lobectomy, partial thyroidectomy * 100% >/= 2-3 days 100% 100% 92% 87% 90% 88% 93%

Performance deteriorating

Arthroscopy of knee including menisectomy, meniscal or other repair 90% Same day 87% 85% 86% 79% 86% 81% 84% StableBunion operations with or without internal fixation and soft tissue correction 90% >/= 1 day 91% 88% 89% 100% 95% 94% 93% Target achieved

Endoscopic resection/destruction of lesion of bladder * 75% >/= 1 day 74% 71% 83% 69% 70% 89% 76% Target achievedEndoscopic resection of prostate (TUR) * 80% >/= 2-3 days 57% 93% 57% 67% 56% 67% 66% Improvement requiredOperations on foreskin - circumcision, division of adhesions 90% Same day 90% 64% 81% 60% 85% 76% 76% Improvement requiredVaricose vein surgery * 75% Same day 80% 91% 74% 67% 83% 86% 80% Target achieved

2010/11 Target

Source: Business Intelligence System, Information Department Significant improvement is required for 4 out of the 18 procedures. A standard operating procedure is being prepared with short stay surgery as the ‘default position’, unless this is clinically inappropriate for an individual patient. 2.2 Admission on Day of Surgery Where possible, admitting patients on the same day as their surgery can provide a better patient experience and reduce avoidable use of inpatient beds. The following table sets out current UHB performance to the end of September in relation to the national targets for the year. Table 15: Admission on Day of Surgery

Elective Operations Carried Out on Day of Admission

2010/11 target

Elective operations on

day of surgery

Total elective operations

2010/11 performance

to dateChange

General Surgery 58% 371 1,210 31% 3%Urology 71% 380 591 64% -2%T & O 56% 1,404 2,173 65% 1%ENT 96% 616 818 75% 1%Ophthalmology 90% 284 349 81%Oral Surgery 82% 58 149 39% -2%Gynaecology 62% 328 869 38% 2% Source: Business Intelligence System, Information Department Orthopaedics is the only specialty where the UHB is currently exceeding the national targets. When there is pressure on elective bed capacity, caused by medical outliers, clinicians will ‘tend’ to admit patients prior to day of surgery to ensure there is an available bed and avoid cancellation through lack of bed. A patient flow/discharge improvement project is in place to improve bed utilisation.


2.3 Outpatient Follow Up Rates The detailed monthly performance information for Outpatient follow up rates is included in Part One of the performance report, although WAG has acknowledged that the targets need to be amended (a separate paper on this issue has been provided for the Committee). The UHB recognises that it needs to work with stakeholders to make significant reductions to outpatient volumes in order both to reduce avoidable hospital attendances and also to improve utilisation of clinical resources within secondary care. The following actions are underway:


• Current work to identify targets based on specialty specific and peer comparison, which will lead to setting of more appropriate targets for 2010/11, which will be monitored against in future reports.

• Increased quality assurance of coding • Changing clinical practice to reduce inappropriate follow ups,

through earlier discharge from secondary care A particular focus is required in specialties where chronic conditions are a significant component. 2.4 Outpatient DNA Rates The WAG target for new and Follow up DNA rates for 2010/11 are: Mental Health – New 8.9% Follow Up 9.1% Other Specialties – New 5% Follow Up 5.7% Table 16 overleaf sets out monthly performance for the first 6 months of 2010/11


Table 16: DNAs by Directorate % DNAs April May June July August September

Child Health 14.5% 14.7% 16.0% 17.7% 15.3% 16.6%Obstetrics & Gynaecology 8.7% 9.3% 10.3% 9.8% 10.3% 10.9%Therapies 10.2% 11.4% 11.7% 10.7% 10.8% 10.8%Dental Hospital 9.1% 9.3% 9.2% 9.7% 9.9% 11.0%Clinical Oncology 6.1% 4.7% 9.3% 4.6% 7.7% 4.3%Dermatology 10.9% 9.5% 9.0% 9.1% 10.4% 11.5%Integrated Medicine 15.6% 15.8% 16.2% 14.8% 15.2% 15.2%Rehabiliatation 5.2% 7.5% 7.0% 8.5% 6.1% 5.9%Rheumatology 10.2% 11.0% 11.8% 9.2% 12.3% 10.5%Mental Health 22.0% 30.4% 16.7% 27.3% 28.6% 22.2%Cardiac Services 8.3% 9.1% 9.1% 8.9% 7.9% 9.6%Haematology 8.4% 9.8% 10.3% 9.5% 11.1% 9.9%Immunology 18.8% 18.3% 10.5% 16.4% 17.0% 21.1%Nephrology 13.0% 11.4% 13.1% 10.6% 9.0% 13.4%Neurosciences 10.1% 11.0% 12.5% 11.4% 12.1% 13.2%Anaesthetics 4.2% 1.8% 5.3% 4.6% 2.0% 4.3%General Surgery & Urology 11.6% 11.7% 11.4% 11.2% 11.5% 11.3%Ophthalmology & ENT 11.8% 11.2% 11.8% 11.8% 11.9% 11.6%Trauma & Orthopaedics 9.0% 8.2% 8.4% 9.1% 8.6% 9.1%Total 10.5% 10.7% 11.1% 10.8% 10.9% 11.3% Source: Business Intelligence System, Information Department DNA rates remain particularly high across all specialties and show no signs of reducing. An improvement group led by the Divisional Director for Clinical Diagnostics and Therapeutics UHB has been charged with addressing outpatient efficiency and improvement and is coordinating the work to reduce the rate of DNAs for outpatient clinics across the UHB. Improvements to the UHB’s telephone answering service are being made and an automatic reminder messaging service will be introduced shortly. 2.5 Theatres The Annual Operating Framework for 2010/11 sets out four specific measures for the efficient operation of Theatres:

• Late starts • Early finishes • Cancellations • Turnaround times.

In respect of late starts in Theatres, a specific change to the operational management process was established with patients being prepared and taken to theatre earlier so that pre operative anaesthetic and preparation was guaranteed to have taken place, to enable the session to start on time. This has led to sustainable improvement during 2010, although


performance has declined since May and is still well below the all Wales average. Figure 13: Prompt starts in Theatres

Prompt Starts

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10

Source: Theatre Information System Utilisation of available sessions in theatres requires significant improvement (table 17). Performance has declined since May. The target set for 2010/11 is 95%. Table 17: Planned session utilisation

April 2010

May 2010

June 2010

July 2010

August 2010

Sept 2010

Planned session utilisation

86.1% 92.5% 83.1%

80.6% 79.2%

82.9%

Source: Theatre Information System A new reporting system has been developed through the UHB’s ‘intelligent warehouse’ to improve the analysis of theatre utilisation and to enable the reporting of turnaround times, so that the utilisation of available time within each session is maximised. This information will be provided within future performance reports.


2.6 Average Length of Stay – Emergency Care Average Length of Stay for Emergency Care is included in Part One (Section K) of the performance report. Only one of the nine targets was achieved in 2009/10, only one of the targets is being met in 2010/11 and this is an area which requires significant improvement. Average length of stay is a crude high level measure and the UHB has undertaken a more detailed analysis based on risk adjusted length of stay and procedure bed day variation to identify the key improvement actions required. A summary is included in the part 1 report. The focus on case mix reported in table 18 below also helps in this respect. A separate more detailed paper on bed utilisation has been prepared for the Performance Committee. There is a major patient flow/discharge improvement project in place, which is starting to reduce length of stay for patients who have not exceeded 20 days in hospital. However, the UHB has a very significant constraint to discharging the large number of patients currently in hospital who exceed 20 days, who are medically fit for discharge but remain in hospital because of the severe shortage of EMI and nursing/residential home capacity in Cardiff and Vale. The UHB is working closely with the local authorities and registered social landlords to develop a future care home/supported housing strategy but this will take some time to come to fruition. 2.6.1 Focus On Casemix Average Length of Stay: Emergency A new measure for 2010/11 provides a more detailed focus on selected procedures beneath specialty level to drive through reductions in average length of stay and reduce variation in performance across organisations.


Table 18: Focus On – Emergency inpatient length of stay

Focus On Casemix Variance VarianceEmergency Average Length of Stay 2010-11 Inpatient Bed Average From Change

Target Stays Days LOS Target July

Respiratory 6.00 602 3,520 5.85 (0.15) (0.38)

5.35 (1.44)

Cardiovascular 7.00 943 9,453 10.02 3.02 0.03Musculoskeletal 6.00 232 2,069 8.92 2.92 0.12Diabetes 4.90 112 723 6.46 1.56 0.48CVA 11.20 262 4,335 16.55Atrial Fibrillation 3.90 199 1,101 5.53 1.63 0.72Fractured Neck of Femur 17.00 179 4,365 24.39 7.39 0.68

April - September 2010

Source: Business Intelligence System, Information Department The UHB has significant opportunities to reduce its average length of hospital stay for patients in the service areas set out above. The most significant opportunities are in fractured neck of femur, and cerebro-vascular accident (stroke). 2.7 Average Length of Stay – Elective Care Average Length of Stay for Elective Care is included in Part One (Section J) of the performance report. Four of the eight targets were achieved in 2009/10. Based on the more challenging targets which have been set for 2010/11, the UHB is meeting 4 of the targets for elective average length of stay, but is higher than 10% from the targets in the other 4 specialties. The reference in section 2.6 to average length of stay being a crude high level measure is equally applicable to elective average length of stay. The focus on case mix for elective care is reported in table 19. 2.7.1 Focus On Casemix Average Length of Stay: Elective A new measure for 2010/11 provides a more detailed focus on selected procedures beneath specialty level to drive through reductions in average length of stay and reduce variation in performance across organisations.


Table 19: Focus On – Elective Procedures

Focus On Casemix Average Length of Stay: Elective

Number of IP Stays

Cumulative LOS

2010/11 cumulative

average 10/11 TargetVariance

from targetHip Replacements 183 1152 6.30 7.40 (1.10)

0 (0.46)

Knee Replacements 302 2082 6.89 6.70 0.19Upper Genital Tract - Major 280 1185 4.23 4.20 0.03Large Intestine - Very Major 74 780 10.54 11.0 Source: Business Intelligence System, Information Department The UHB performs well against these measures, with hip replacement and large intestine procedures requiring a shorter length of stay in hospital in this UHB than the national target. For knee replacements and upper genital tract procedures, the local length of stay is almost at target, with less than 0.5 day variance in both. 2.8 Critical Care AOF 8 and AOF 25 include new targets in relation to Critical Care. There is a new target to ensure that 95% of patients identified for discharge are discharged within four hours. The aims of the target are to:

• Ensure patients with the most need have access to critical care

services and are transferred expediently at the most appropriate time

• Improve the timely transfer of patients and reduce the transfers of

care from critical care units in order to improve patient flow and patient safety thus ensuring patients are cared for in the most appropriate clinical setting

• Ensure the existing critical care resource is used to maximum

efficiency.

Figure 14 shows the average number of beds lost per day due to delayed discharges.


Figure 14: Average Beds Lost per Day to Delayed Discharges

Source: Critical Care Directorate The charts in figure 15 below analyse discharges and delays by speciality over the last 12 months and indicates that the most significant delays relate to surgical and neurosciences patients. Figure 15: Discharge Count and Discharge Delays for the last 12 Months

Source: Critical Care Directorate Reducing delayed discharges from critical care is largely connected with improving patient flow/ward discharge, already referred to in section 2.6.


2.9 GP Referrals The Demand Management Group is coordinating the monitoring of GP referrals, using information held corporately. Ongoing work with Informing Healthcare to introduce electronic referrals will lead to a more reliable and real time source of data in this area. The following summary tables provide a high level overview of current demand for the hospital services provided by the UHB. Table 20: Total referrals by source (year to date comparison for April – August 2010).

ReferralsApril - August

2009April - August

2010 Change % changeCardiff and Vale GP 35,250 37,114 1,864 5.3%Internal Consultant 10,164 9,740 424- -4.2%External Consultant 3,160 3,203 43 1.4%

Total 48,574 50,057 1,483 3.1%

Note 1: This excludes referrals designated as "External", which originate within CVUHB. These referrals are predominantly referrals between primary care triage services and the hospital service. Source: CVUHB Information Department

Total referrals include non elective as well as elective referrals. Table 21: Elective referrals only by source (year to date comparison for April to August).

ReferralsApril - Aug

2009April - Aug

2010 Change % changeCardiff and Vale GP 11,648 12,611 963 8.3%Internal Consultant 9,255 8,416 839- -9.1%External Consultant 306 307 1 0.3%

Total 21,209 21,334 125 0.6%

Note 1: This excludes referrals designated as "External", which originate within CVUHB. These referrals are predominantly referrals between primary care triage services and the hospital service. Source: CVUHB Information Department

3. USE OF RESOURCES 3.1. Elective Treatment Against Profile In 2009-10, there was a hybrid of LTA and local activity, and therefore overall monitoring of actual activity against planned has not been undertaken. However the Performance Team is working with colleagues


across the UHB to develop a system of monitoring actual activity for inpatients and day case treatments against profiled activity. This will be reported in detail in future performance reports. 3.2. Elective New Outpatient Activity Against Profile As with inpatients and day cases, there has been a hybrid of LTA and local activity being undertaken. The additional monitoring process being developed will also include outpatients. This will be reported in detail in future performance reports. 3.3 Expenditure Against Resource Limits The month 6 financial position is an in-year deficit of £18.839 million, against the financial plan. The UHB remains committed to delivering break-even by year end. However, given the scale of challenge and the very significant risks and constraints associated with the delivery of the savings plan, the declared forecast year end position of the UHB is a £28m adverse variance. Even this position is not without considerable risk and the UHB continues to explore further savings opportunities. Meeting the Capital Resource Limit is an additional statutory financial target for the UHB. The UHB is meeting this target, with expenditure in line with profile. 3.4 Cash Expenditure Against Cash Limit (Cashflow) In line with the forecast deficit, the UHB is forecasting a year-end cash flow shortfall in March. The UHB is aiming to deliver the best practice period end cash balance of 1/300th of the combined revenue and capital resources limits, and is taking action to ensure that this is achieved during 2010-11. For September, the cash balance of £0.445m was below target. 3.5 Payment of Non NHS Creditors within 30 Days Payment of non NHS creditors has improved in 2010-11, but has declined slightly to 93.94% at the end of September 2010, against the target of 95%. This is a significant improvement on the previous year. Action is also being taken to improve compliance against the 10 day target and this will be reported in future reports.


3.6 Agency/Locum Expenditure Locum and agency expenditure has decreased to 0.9% in September, which is slightly above the target of 0.8%. It is anticipated that expenditure will reduce as progress is made in delivering the UHB savings plans, particularly as the use of agency staffing is minimised. 3.7 Sickness Absence The sickness absence rate is improving at 4.93% in September and is below the WAG target of 4.95%. 3.8 Staff Turnover Staff turnover has reduced to 8.08%. Turnover is higher than average for estates and ancillary staff, and lower for Allied Health Professionals. In volume terms, the highest turnover of staff is within the nursing and midwifery and administrative categories. 4. PATIENT EXPERIENCE 4.1 Access to Elective Services – 26 Weeks

Figure 16 illustrates the overall position of the UHB in respect of waiting times and numbers of patients waiting for elective (non emergency and planned) treatment. This provides therefore a useful overview of all patients waiting and the stage at which they are in their pathway of care. Figure 16: Referral to Treatment Waiting Times – September 2010

Source: Business Intelligence System, Information Department


The overwhelming majority of patients continue to be seen and treated within 26 weeks. 93% of patients were waiting less than 26 weeks at the end of September which is now below the tolerance of 95% set by WAG, entirely as a result of the increasing orthopaedics waiting list. The cumulative position, excluding orthopaedics is 99%. These reports are available on an individual specialty basis and can be provided as required. Individual Consultant specific reports have been developed for Orthopaedics in order to support the process of the sustainable reduction of waiting times for patients. 4.2 Access to Elective Services – 36 Weeks

At the end of September, there were 980 patients waiting longer than 36 weeks for orthopaedic treatment, against a target of no breaches. Orthopaedics treatment productivity has recently increased to a maximum of 183 treatments per week, compared with expected mean activity of 163. This reflects seasonality and a concerted effort to increase theatre throughput. Outpatient utilisation is between 92-100% for elective clinics, suggesting only scope for further productivity gain is via template review and reducing follow up numbers Three sub specialty plans have been prepared in draft with design input from consultant body. These will articulate how balance between anticipated demand and capacity will be achieved in each sub specialty area. Challenge is being constructively input from DSU and Public Health. Additional progress made to increase capacity:

- 2 surgeons have agreed to provide additional theatre lists over their job plan.

- Hand surgeons have agreed to appoint a substantive surgeon - An additional scoliosis list has been secured at UHW following

theatre reconfiguration There are concerns about the increased numbers of patients on the waiting list in:

• Cardiac Services • Neurosurgery • Gastroenterology.


Action is being taken to prevent further breaches including specific action plans at specialty level including the detailed weekly monitoring of all long-waiting patients, performance monitoring of ‘treat in turn’ processes, and additional staffing appointments made. 4.3 Numbers of Patients Waiting for Inpatient and Day Case

Treatment As well as focussing on the length of time patients are waiting for treatment, the UHB constantly monitors the size of waiting lists in order to plan the delivery of capacity to treat these patients at the right time. The total number of patients waiting for planned treatment requiring inpatient or day case treatment was 12,602 at the end of September, which is an increase from 12,475 waiting at the end of August. 4.4 Numbers of Patients Waiting for Outpatient Treatment The total number of patients waiting for a new outpatient appointment is 35,531 at the end of September, an increase from 34,939 at the end of August 2010. Waiting times for specific components of a patient’s treatment have lengthened as the priority to complete all stages of treatment within 26 weeks for the majority of patients has been introduced.

• There were 15,636 patients waiting over 10 weeks at the end of September 2010 for a first outpatient appointment, compared to 14,445 patients at the end of August 2010.

• There were 4,724 patients waiting over 14 weeks at the end of

September 2010 for inpatient or day case treatment, compared to 4,620 patients at the end of August 2010.

4.5 Operations Cancelled on Day or Day Before Surgery

Data is reported for operations cancelled at short notice, either on the day or the day before surgery (figure 17)


Figure 17: Operations Cancelled on Day or Day before Surgery Theatre Cancellations at Short Notice

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There is a seasonal trend, cancellations increase during the winter months, as more beds are required for emergency admissions. A winter pressures plan has been prepared to try and minimise this impact during the coming months. 4.6 Delayed Discharges

Part One (Section B) of the performance report outlines progress against the AOF targets. The table overleaf outlines the numbers of patients delayed compared with the previous month. Table 22: Numbers of patients delayed Patients Delayed

August September Change

Non Mental Health 66 78 12Mental Health 38 43 5Total 104 121 17

Source:UHB DToC Census Report Figure 18 sets out the number of days delayed for patients.


Figure 18: Days delayed due to delayed discharges

Cardiff & Vale UHB: Days Delayed (Cardiff & Vale Residents)

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Source:UHB DToC Census Report The significant constraints associated with improving the DTOC position have already been reported in section 2.6.

4.7 Access to Cancer Services

Part one of the Performance report (section C) outlines performance against the AOF targets. Both targets have been achieved for the second quarter of 2010/11, which is a significant improvement from previous months, due to the implementation of a range of actions identified, to ensure that the targets are achieved.

Discussions are ongoing with colleagues in WAG and the Delivery Support Unit (DSU) around the perceived weaknesses in the Cancer Network Information System Cymru (CANISC) reporting system, in order to improve the tracking and accessing of information. 4.8 Access to Emergency Services – 4 Hours in EU

Part one (Section B) of the performance report outlines progress against the AOF targets. The chart overleaf shows the monthly 4 hour performance against the 95% target.


Figure 19: EU performance against the 4 hour target 4 Hour Target Performamce

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A separate update report on the implementation of the action plan and current performance has been prepared for the Performance Committee. The key issues which are fundamental to achieving compliance with the 4 and 8 hour targets are:

• Timely access to an EU clinician • “Minors” stream improvement • “Paediatric” stream improvement • Timely Discharge.

The report outlines progress against the detailed actions identified to deliver improvements in these key issues. Performance continues to be monitored on a weekly basis, through the Operational Performance Group.

4.9 Corridor Waits in the Emergency Unit

The UHB is committed to delivering high quality care for patients and in the Emergency Unit; it is seeking therefore to eliminate the treatment of patients on trolleys within the EU. This can occur when a patient requires


admission but there is no inpatient bed which is immediately (within 1 hour) available.

The EU action plan which will be supplemented by actions being taken to improved bed management discharge and patient flow will be part of the UHB strategy to eliminate the treatment of patients in such areas in future. The Business Intelligence Team has developed an EU dashboard, and this will enable the reporting of patients waiting on trolleys in future months. Additional reporting requirements have been mandated with effect from 1st October and will be reported in future performance reports.

4.10 Complaints – Primary Care

The Business Services Centre (BSC) manages primary care complaints on behalf of a number of Health Boards. Complaints are extremely important as they are a source of feedback of patients’ satisfaction related to the services that Health Boards commission. The BSC Complaints Department, on behalf of each UHB, works to the recommendations of the Welsh Assembly Government’s procedures ‘Complaints in the NHS – A guide to handling complaints in Wales’. Complaints are viewed positively, and where shortcomings are identified the aim is to learn from the lessons and make changes to improve the service. 4.11 Complaints – Hospital

There has been continued improvement in the complaints management system. The Q&S Committee received a detailed analysis of complaints at its meeting on 12th October 2010. A summary of actions taken in response to complaints will be reported to the next Q&S Committee meeting. The following table demonstrates the numbers of new complaints in July, August and September:


There has been a lot of work particularly in the medicine division to address the backlog of complaints and this work is not reflected in the tables but has had a significant impact on the numbers of active


complaints in the system. At the end of July 176 active complaints were displayed this has been reduced to 111 in September. Closer monitoring is also being undertaken with the numbers of patients who are satisfied with their response with the aim of ensuring a quality, timely and appropriate response to the initial complaint. There has been an increase in the numbers of meetings with complainants by clinical staff and these have proved to be effective in clarifying issues for patients and investigating staff. This table displays the response times in the surgery service group:


This table displays the response times in Medicine:

Data has also been collected for the past 2 months on the numbers of internet and phone enquiries. Internet enquiries range from 9 to 18 per week and all are responded to on the same working day –the numbers are being collated for those that become formal complaints but the aim is for local resolution. Detailed analysis of phone calls has been undertaken to identify and address the themes and information will be provided for future reports. Where themes are identified they are actioned such as problems with


telephone access to physiotherapy which was quickly addressed by the directorate and resolved. Many of the concerns are forwarded to the divisions and contact is made on the same day with the patient and concerns addressed quickly and effectively. Compliments –the Department receives approximately 8 letters per week , occasionally compliments are received via E-mail and this is being monitored. Departments are also being encouraged to send copies of the compliment letters and thank you cards that they receive to the complaints department so that they can be centrally collated to provide a balanced view of patient satisfaction. Detailed review of complaints, including lessons learnt, and actions taken is being monitored through the Complaints and Claims Panel, and the Quality and Safety Committee.

4.12 Patient Survey Survey results are discussed at the Divisional Health and Safety Committee meetings and progress on action plans will be monitored through the Quality and Safety Committee, with overviews provided to the Performance Committee and Board. There is no further update available at the time of this performance report. 4.13 University Teaching and Training Cardiff University reviews the quality of teaching and training provided to undergraduate and postgraduate medical students, who are required to submit online evaluations at the end of each training module. These evaluations provide detailed feedback on the student learning experience. Annual reports are provided to each UHB at the end of each academic year highlighting good practice and areas for improvement, as well as comparators against the All Wales position. Unfortunately the report is not available for the October meeting and will need to be considered at the next Committee meeting.


Feedback on the overall evaluation for 2009-10 will be used at Divisional level to improve the teaching and training, taking account of the specific issues identified at each Directorate level, and also will be used in the job planning process, to ensure that there is a commitment to high quality teaching and training. 4.14 Cleanliness The UHB completes the monthly Credits for Cleaning database which is a tool to manage cleaning standards and specifications in hospitals, monitor performance and compliance with national standards. All sites are audited on a weekly basis, and an overall site score is awarded, and this is compared to the overall UHB target of 88%. Monthly monitoring of scores takes place at Divisional level as well as the identified high risk areas across the organisation and some of the key areas identified as part of the audit process. The following charts show the weekly cleaning scores for the two acute sites and the remaining hospital sites. Figure 20: Cleaning Scores for UHW & UHL April – September 2010

Cleaning Scores - UHW and UHLApril - September 2010

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Source: Credits for Cleaning Database UHL is consistently achieving the target, but not UHW.


Figure 21: Cleaning Scores – Other Hospital Sites April – September 2010

Cleaning Scores - Other SitesApril - September 2010

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TargetWhitchurch West WingSt. Davids Rookwood Barry Target

Source: Credits for Cleaning Database The target is being achieved consistently at St Davids’, but performance is below target at Whitchurch. Overall staffing levels are well below establishment. The Operational Board of Directors has resolved that additional capacity is required, the Nursing Director is preparing a business case for consideration and approval in the light of the UHB’s current financial position.

Documents

FOR DECISION AGENDA ITEM 2.1 26 October 2010 INTEGRATED