Integrated Quality and Performance Report · 73.65%. Managers and staff have been reminded of the importance of undertaking and reporting PDRs. How effective are our enabling services?

Integrated Quality and Performance Report

January 2018

0.1 Executive summary January 2017

Page 2

In this month (page 5) In January, there was a significant rise in GP referrals and urgent cancer referrals when compared to the same month in the previous year, up 16.8% and 30.8% respectively, some of which is driven by seasonal demand following the Christmas break. All activity remains higher for the year with the exception of elective inpatients, which is down by 0.8% for the year. Are we safe? (pages 6-15)10 SIs were reported in January. All events will be investigated thoroughly within the national timeframes. The Trust continues to submit all Root Cause Analysis reports within the 60 day deadline set by the CCG.Are we effective? (pages 16-19)Although readmission rates remain above the level reported in 2016/17, the remain within the targets that have been set. The Caeserean section rate continues remain above the target however, it is worth noting that despite this it remains within national averages.Are we caring? (pages 20-30)Our Friends and Family Test results feedback remains positive and we are maintaining satisfactory response rates in many areas. Emergency Care has maintained a response rate of over 20% in January and response rates are improving across all areas of care with maternity care seeing a particularly notable increase in responses. “Recommend” scores have improved across all areas of care with the exception of community and outpatient areas which have seen a slight dip. With the exception of community and Maternity Care “not recommend” scores have declined this month indicating fewer patients are reporting more negative experience. We are ensuring that more real time information is available to Directorates and continue to encourage teams to review key themes emerging from free text comments and identify actions for improvement.Are we responsive? (pages 31-45) In January A&E fell short of the national 95% standard but exceeded the STF trajectory of 90% with a performance of 92%. The Trust’s performance against the internal 62 day cancer standard continued to demonstrate improvement with 90.6%, which exceeds both our trajectory and the national operational standard of 85%. Although below trajectory our overall performance for cancer 62 day further improved to 73.4%. We continued to achieve the 2 week performance standard for the 6th

consecutive month. RTT performance is showing a steady improvement with 88.5%, in January which is above trajectory and patients waiting >52 weeks decreased to 9. The Diagnostic standard also improved to 3.6% which related to the recovery actions within non-obstetric Ultrasound to outsource to Alliance Heath Care and MRI by scheduling additional clinic sessions, to clear the backlog. Are we well-led? (pages 46-50)Our vacancy rate increased to 10.45% and remains above target. Agency spend decreased to 3.23% of the pay bill, and is below the Trust’s target of 4.3%. Usage continues to be monitored closely on a weekly basis. Turnover increased to 12.90%. The number of completed personal development reviews (PDR) for January was 73.65%. Managers and staff have been reminded of the importance of undertaking and reporting PDRs.How effective are our enabling services? (pages 51-66) The annual plan is a surplus of £10.2m. A surplus of £0.3M has been recorded at January, which is £5.0M worse than the planned surplus of £5.3M. Essentia Patient Services – who provide non-clinical support services across the Trust, have provided reports across its services. This enables a wider review of how it supports the Trust in its day to day activity.

0.2 Trust overview January 2018

Page 3

Domain Ref Theme PageManagement priority

(last month)Management priority

(this month)Forecast status Briefings

1.1 Patient safety - incident reporting 8 Moderate Moderate Stable1.2 Patient safety - harm-free care 9 Minor Minor Stable1.3 Patient safety – patient falls 10 Minor Minor Stable1.4 Infection Control and Cleanliness 11 Minor Minor Stable1.5 Screening on admission 13 Excellent Excellent Stable1.6 Mortality indicators 14 On Track On Track Stable

2.1 Quality Indicators 17 Minor Minor Stable2.2 Clinical best practice (a) 18 Minor Minor Stable2.9 Clinical Best Practice (b) 19 Minor Minor Stable

3.1.1 Admitted care (a) 21 Moderate Moderate Improving3.1.2 Admitted care (b) 22 Moderate Moderate Improving3.2 A&E Care 24 Moderate Moderate Improving3.3 Maternity Care 25 Moderate Moderate Improving3.4 3.4 Outpatient care 27 Moderate Moderate Improving3.5 3.5 Community Care 28 Moderate Moderate Improving3.6 3.6 Patient transport 29 Moderate Moderate Improving3.7 3.7 General patient and carers’ experience 30 Moderate Moderate Improving

4.1 A&E Access 33 Significant Significant Stable A&E waits4.2 A&E Performance 34 Significant Significant Stable

4.2.1 Elective access (a) 35 Significant Significant At risk4.3.1 Cancer – 2-week waits 36 Moderate Moderate At risk4.3.2 Cancer – 31-day waits 37 Moderate Moderate Stable4.3.3 Cancer – 62-day waits 38 Moderate Moderate Stable4.4 Diagnostic waits 39 Moderate Moderate Stable4.5 Bed capacity and management 40 Moderate Significant At risk4.6 Delayed Transfers of Care 41 Moderate Moderate Stable4.7 Outpatient management 42 Moderate Moderate Stable4.8 Theatre management 43 Moderate Moderate Stable4.9 Complaints management 44 Moderate Moderate Stable

5.2 5.2 Staff experience 46 Minor Minor Stable5.3.1 Workforce indicators (a) 47 Excellent Excellent Stable5.3.2 Workforce indicators (b) 48 Minor Minor Improving5.4 Workforce exception report 49 Moderate Moderate Improving

6.1 Overall financial position (a) 50 Moderate Moderate Stable6.1 Overall financial position (b) 51 Moderate Moderate Stable6.1 Overall financial position (c ) 52 Significant Significant Stable6.2 Activity levels 53 On Track On Track Stable6.3 Data quality and clinical coding 54 On Track On Track Stable6.5 Essentia Patient Services 55-65 Minor Minor Stable

6 Enablers

1 Safe

2 Effective

3 Caring

5 Well-Led

4 Responsive

0.3 Key to scorecard assessments

Management priority Individual theme in 'Trust overview'

Significant Significant interventions are planned or in progress due to one or more factors: an externally-reported metric is off-track; multiple internal metrics are off-track; qualitative experiences are raising significant concerns

Moderate Moderate interventions are planned or in progress due to one or more factors: an important internal metric is off-track; qualitative experiences are raising concerns; future projections are off-track

Minor Some interventions are planned or in progress: stretch targets are off-track; trends are adverse; qualitative experiences suggest performance may be at risk

On track All areas within this theme on track

Excellent Amongst top performers nationally, with internal stretch targets consistently met

Forecast status Individual theme in 'Trust overview'

At risk Expected to worsen by next reporting period

Stable Not expected to change significantly by next reporting period

Improving Expected to improve by next reporting period

Indicator status Individual metric in 'Domain scorecard'

Achieving national standard or internal target (this reporting period)

Not achieving internal target (this reporting period)

Not achieving national standard (this reporting period)

Indicator only - not measured against a set target

January 2018

Page 4

0.4 In this month January 2018

Page 5

January Same month Year so far

We received…Referrals from GP's 21,992 16.8% 2.7%

Urgent cancer referrals 1,521 30.8% 11.7%

Referrals to @Home and ERR 398 1.3% -2.5%

We treated…A&E attendances 15,620 6.5% 0.5%

Non-elective admissions 4,072 5.4% 1.6%

Outpatient attendances 106,670 11.7% 4.4%

Day cases 6,810 17.2% 7.1%

Elective inpatients 2,228 4.2% -0.8%

Compared to last year

1.0.1 Domain scorecard (1)1 Safe January 2018

Page 6

Theme Ref Indicator Units Target R G Prior year Nov Dec Jan YTD

avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

INC 06 Total incidents reported Number - M M 2,112 2,358 2,194 2,462 2,278 - - Y

INC 06S Incidents - Reported on STEIS (total number) Number - M M 9.8 9 10 10 8.6 - -

INC 06ST Incidents reported on Datix that are STEIS reportable (total number) Number - M M 8.1 6 10 10 7.1 - -

INC 07 Never Events Number Zero G G 0.7 0 1 0 0.9 - - Y

INC 01 Incidents resulting in unexpected death Number - M M 2.8 3 6 3 3.4 - - Y

INC 02 Incidents resulting in severe harm Number - M M 3.9 6 6 4 4.3 - - Y

INC 03 Incidents resulting in moderate harm Number - M M 17.5 49 43 38 33.7 - - Y

INC 04 Incidents resulting in low harm Number - M M 305 360 338 346 330 - -

INC 05 Incidents resulting in no harm Number - M M 1,357 1,940 1,797 2,070 1,721 - -

INC 01S Incidents resulting in unexpected death - reported on STEIS Number - M M 2.4 3 1 0 1.3 - -

INC 02S Incidents resulting in severe harm - reported on STEIS Number - M M 3.5 1 3 3 2.8 - -

INC 03S Incidents resulting in moderate harm - reported on STEIS Number - M M 1.8 1 4 6 2.6 - -

INC 04S Incidents resulting in low harm - reported on STEIS Number - M M 0.7 2 0 0 0.4 - -

INC 05S Incidents resulting in no harm - reported on STEIS Number - M M 1.8 2 2 1 1.5 - -

INC 08P % incidents relating to patients Mthly % - M M 79.9% 100.0% 99.8% 100.0% 91.9% - -

305T Pressure ulcer acquisitions (grade 2 and above) attributable to Trust Number <5 R R 3.7 7 5 5 3.7 - Y Y

305TA Admissions with pressure ulcers (grade 2 and above) Cases - M M 39 50 50 51 42 Y

INC 22 Medication incidents reported Number - M M 266 299 224 239 263 - - Y

INC 21 Patient falls with moderate or severe harm Number - M M 3.1 4 1 4 2.0 - - Y

INC 20 Patient slips trips and falls Number - M M 156 157 139 185 157 ## ## Y

313BD Incidence of falls per 1000 bed days Number - 0.00 0.00 5.2 5.3 5.1 4.3 4.6 0 0 Y

WHO WHO surgical safety checklist Ann % - 85%

1.1 Patient safety - incident reporting

1.2 Patient safety - harm-free care

1.0.2 Domain scorecard (2)1 Safe January 2018

Page 7


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

324 MRSA screening of admissions Mthly % >95% R R 90% 90.5% 90.9% 90.6% 89.7% - 0 Y

301 MRSA bacteraemia (Trust-attributable) Number Zero R R 0.3 0 0 1 0.6 - - Y

302L C-Diff acquisitions resulting from lapse in care Number Zero M M 0.1 1 0 0 1.0 Y - Y

302T C-Diff acquisitions (Trust-attributable) Number <4 pm M M 2.7 2 2 1 2.0 - - Y

AMS Anti-microbial stewardship Score >85 R R 88.8 86 90 0 67.2 - - Y

9936 VTE screening (externally reported) Mthly % >95% R R 96.6% 94.8% 94.2% 91.1% 95.1% - - Y

Dem75 Dementia screening (patients aged over 75) Mthly % >90% R R 88.9% 80.2% 77.2% 81.0% 83.4% - - Y

350 Deaths in hospital - number in month Number - M M 87.8 88 106 108 87.0 Y

HSMR Hospital standardised mortality ratio (HSMR) - most recent score Ratio <90 G G 71.7 69.4 69.4 71.6 68.2 ## 0.0 Y

SHMI Standardised healthcare mortality index (SHMI) - most recent score Ratio <90 G G 75.3 71.3 71.3 72.8 73.0 0 0 Y

1.6 Safe staffing SafeS Safe Staffing - ratio of actual to planned hours Mthly % - M M 100.0% 100.8% 100.0% 94.8% 99.0% 0 0

1.3 Infection control and cleanliness

1.5 Mortality indicators

1.4 Screening on admission

• 9 SIs were reported in January, 3 under the Acute Medicine, 2 under the Viapath Directorate and then 1 each for the Medical Specialties, Women’s Services, Haematology and Oncology and a shared SI with Gastrointestinal Medicine and Surgery and Transplant, Renal and Urology Directorates. There were no reported Never Events in January.

• Between 1st April and 31st January 2018 22,843 incidents were reported, representing a 9% increase in reporting over the same period for 2016. 17,651 of the reported incidents this year were patient related, where 16,250 of these have been reported to the NRLS, compared with 11,702 reported to NRLS for the same period last year.

• The top five highest reporting Directorates remain the same as last year: Acute Medicine, PCCP, Haem-Onc, Women’s Services and Adult Community. The top three highest reporting Incident Category Types are ‘Medication Incidents’, ‘Accident that may result in personal injury’ and ‘Implementation of care or ongoing monitoring/review’

1 Safe 1.1 Patient safety – incident reportingJanuary 2018

Page 8

0

1

2

3

4

5

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

Never Events 2017-182016-17Target

1,2001,3001,4001,5001,6001,7001,8001,9002,0002,1002,2002,300


Total incidents reported 2017-182016-17

0

10

20

30

40

50

60

70


Patient incidents with moderate or severe harm or death 2017-182016-17

• In January there were 5 avoidable acquired pressure ulcers. Each area has undertaken local reviews; themes and learning from each case and revised pressure prevention and management strategies based on this information, main areas are; review of skin integrity when patient condition deteriorates and clear documentation and communication between teams regards this. We will be closely monitoring this as part of the avoidable harm council reviews in January to ensure governance and clinical areas responding to lessons highlighted and maintenance of this.

• Admissions with pressure ulcers have increased this month, with the highest proportion being in acute medicine , we continue to review all of these patients and potential trends and work closely with community health and social care services.

1 Safe 1.2 Patient safety – harm-free careJanuary 2018

Page 9

0

2

4

6

8

10

12


Pressure ulcer acquisitions (grade 2 and above) attributable to Trust

2017-182016-17Target

0

50

100

150

200

250

300

350

400


Medication incidents reported 2017-182016-17

0

10

20

30

40

50

60


Admissions with pressure ulcers (grade 2 and above) 2017-182016-17

1 Safe 1.3 Patient safety – patient falls

• This month there was an increase in the incidence of falls with 185 reported compared to 139 in December; this was primarily due to a increase in Inpatient and Non-Ward falls. Looking further at the data, the increase in Inpatient falls was due to a large increase in falls in Acute Medicine as well as smaller increases innumbers of falls in a number of other directorates. There were 26 falls that involved a patient falling more than once; this is an increase from last month where 18 falls involved patients falling more than once. There were 15 Assisted falls reported this month which is the same amount as in December.

• The directorates with the highest incidence of falls are Acute Medicine, Cardiovascular, Haematology & Oncology and Transplant, Renal & Urology.• There were 4 falls resulting in Moderate harm or above this month, which occurred in Acute Medicine, Specialist Ambulatory Services and Community Adult

Services.

January 2018

Page 10

0

1

2

3

4

5

6


Patient falls with moderate or severe harm 2017-182016-17Target

0

1

2

3

4

5

6


Incidence of falls per 1000 bed days 2017-182016-17

020406080

100120140160180200


Patient slips trips and falls 2017-182016-17

• C-diff performance remains good overall.

• The January 2018 case of MRSA bacteramia has been referred to the arbitration panel, with a recommendation for ‘Third Party’ assignment, awaiting confirmation.

• Recent performance in antimicrobial stewardship has improved back towards the levels seen before changes in data collection methodology.

1 Safe1.4 Infection Control and

Cleanliness

75

80

85

90

95

100


Anti-microbial stewardship 2017-182016-17Target

January 2018

Page 11

0

1

2

3

4

5


MRSA bacteraemia (Trust-attributable) 2017-182016-17Target

0

1

2

3


C-Diff acquisitions resulting from lapse in care 2017-182016-17Target

0123456789

10


C-Diff acquisitions (Trust-attributable) 2017-182016-17Target

HCAI

Figure 1. Cdiff cases 2017/18 compared with 2016/17 and 2015/16 with a linear trajectory to 51 cases.

Healthcare Associated Infection (HCAI)Information Owner: Neil Wigglesworth

Intelligence triangulated

Root cause understood

Action plan set

Actions underway

Actions complete

Where we want to be. Targets and benchmarks:• Clostridium difficile - The external objective for reportable cases of C. difficile (Cdiff) for 2017/18 is 51

cases. Reportable cases are those that are ‘toxin positive’ (Enzyme-linked Immunoassay or ‘EIA’ positive)and are identified beyond three days of admission to the organisation (attributed). In addition the Trustmust determine and report to the commissioners any reportable cases that are deemed to be due to any‘lapse in care’.

• Meticillin Resistant Staphylococcus aureus (MRSA). The organisation has a zero tolerance threshold forMRSA bacteraemia.

• Other bacteraemia - The Trust is required to report all cases of MSSA E. coli, Klebsiella species andPseudomonas aeruginosa bacteraemia via the Public Health England (PHE) reporting system. The Trust isnot subject to a national objective for these bacteraemia at present.

Where we are: trends and patterns:C. difficile - For January 2018 the Trust reported a total of 4 cases both of which 1 was attributable. MRSA bacteraemia – A case was reported for January 2017, this was initially Trust assigned, but following

Post Infection Review (PIR) there was agreement to refer the case to the arbitration panel with a recommendation for ‘Third Party’ assignment – awaiting the panel’s response.

Other bacteraemia •MSSA – For January 2018 the Trust reported 6 cases of which 1 was deemed to be Trust attributable(identified > 48 hours after admission).•E coli – For January 2018 the Trust reported 17 cases, of which 7 were attributable.• Klebsiella species – for January 2018 the Trust reported 10 cases of which 5 were attributable to the Trust(new requirement to report from April 2017).•Pseudomonas aeruginosa - for January 2017 the Trust reported 4 cases of which 1 was attributable to theTrust (new requirement to report from April 2017).

Incidents and Investigations: Status

Mycobacterium chimera in heater/cooler units used in cardiac bypass machines – a retrofitted engineering solution from the manufacturer has been applied but is not yet fully operational – awaiting update on engineering issues

Actions underway

A serious incident has been declared following the identification of an increase in post procedure urinary tract infections following ureteroscopy. Actions and investigations are in place. Low harm.

Actions underway

The increased incidence of MRSA bacteraemia in the 1st 5 months of this year was a concern (total of 5 cases) an exceptional briefing paper was presented to Trust Board in September 2017. The range of actions put in place both prior to the TME briefing and those agreed by TME are in progress, the case in January 2018 has been referred for ‘Third Party’ assignment.

Actions underway

There has been some Norovirus and Influenza activity, generally it has been well managed. Flu activity has been significant but the organisation has managed without recourse to escalation plans.

Actions underway

January 2018

Page 12

• The screening of patients over the age of 75 years for memory problems must meet a monthly compliance target of 90% or greater. This screening compliance was not met in January 2018 2017 with a compliance figure of 81.0%. The trend of elderly patients being admitted to wards that normally do not have patients of this age group and the DaD have been supporting staff on these areas with information and training

• A significant number of patients continue to be screened in the admission ward but the numbers continue to decline when they are transferred out within a short period of being in AAW. Many patients are screened on the wards they are transferred to but outside of the 72hour window and therefore not taken into account. The AAW matron and DaD Clinical lead and Clinical Nurse Specialists are supporting and reminding wards who receive patients from AAW about screening within 72 hours of admission.

• The DAD clinical nurse specialists have continued to monitor screening as a priority and focus on the wards that the patients are transferred out to from the admission ward. They will continue to send daily emails to wards who have outstanding screens and will follow-up with phone calls to the wards where screening breaches are imminent. The Clinical lead will continue to support junior doctors.

• The DAD CNSs continue to offer teaching to wards who often have low compliance and escalate for further support. Dementia screening is also covered in each Dementia Level 2 study day.

• The DaD CNSs continue to work closely with the specialist teams (STAT, OPAL. POPs). There is no additional support over the weekends and this increases the number of breaches.

1 Safe 1.5 Screening on admission January 2018

Page 13

75%

80%

85%

90%

95%

100%


VTE screening (externally reported) 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Dementia screening (patients aged over 75) 2017-182016-17Target

• Benchmarked mortality allows case-mix corrected risk of death to be compared across organisations. The Trust continues to perform exceptionally well, both against the England average and other London acute hospitals. Two measures are used: Hospital Standardised Mortality Rate (HSMR) shown in graph upper left; and Summary Hospital Mortality Indicator (SHMI) shown in graph upper right. SHMI includes deaths within 30 days of discharge. For both indicators a low score is good.

• Crude mortality for 2017/18 is lower than the previous year despite an overall increased activity including for emergency admissions where most deaths occur. The Learning from Deaths review process is established trust wide where all deaths are clinically reviewed for quality of care and peer reviewed where there are concerns or the patients are from a vulnerable group which will give more granular analysis. A quality theme has emerged from this process around transfer in of patients from other hospitals. Benchmarked mortality indices remain low compared to peers.

1 Safe 1.6 Mortality indicators January 2018

Page 14

0

20

40

60

80

100

120


Deaths in hospital - number in month 2017-182016-17

Trust level Nursing & Midwifery Safe Staffing (January 2018 data) Information Owner: Chief Nurse Office (Workforce Team)

Key highlights for January 2018Vacancy rate for January 2018 was 12.2%, a slight increase from December 2017. This is partly driven by a rise in establishment as a result of increased posts required within PCCP to support the opening of EW6.

On 2nd February 2018 there were a further 390 external candidates in the Recruitment Pipeline, who are expected to join the Trust over the next few months.

The rate of spend on agency staff has reduced by 1% from the previous month to 3.7%.

Staffing levels, activity and acuityThe number of bed days in January 2018 stood at 8,824. This is 2,791 more than the previous month and an additional 4,907 bed days from the same period in 2017. This represents a rise of 11% in activity from January 2017. From an acuity perspective, Level 1b (heavily dependent or acutely unwell) patients in non-critical care beds, continue to be the most predominant across the Trust, this has been consistent over the past few years.

Actual hours for Registered Nurses were 21,567 below the planned hours for the month, whilst Nursing Assistants were 3,636 above planned hours. There are occasions where Nursing Assistants are employed in addition to the planned numbers to provide 1:1 care for those requiring enhanced care. There is also appropriate deployment of Nursing Assistants to cover a vacant shift for a Registered Nurse where patient acuity is lower. In January 2018, 80 red flags were raised by staff highlighting concerns with staffing. All 80 were resolved. The numbers of red flags do fluctuate on a month by month basis and these were resolved within the Directorates without there being an impact upon patient care or patient safety.

With the implementation of SafeCare across the adult inpatient areas there is now visibility, in real time, throughout the organisation, of areas who potentially do not have the appropriate levels of staffing for the patients. This highlights and supports decision making as to prioritising deployment of temporary staff or the need to move staff to support patient needs in other areas.

January 2018

Page 15

2.0.1 Domain scorecard (1)2 Effective January 2018

Page 16


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

CQ1Aq CABG within 7 days of GSTT angiogram Qtly % >66% G G 81% 80.0% 55.6% 100.0% 68.4% - - Y

CQ1Bq CABG within 7 days of referral received (angiogram elsewhere) Qtly % >38% G G 65% 8.3% 75.0% 100.0% 34.2% - - Y

CQ1Cq CABG within 7 days - combined GSTT and external angiograms Qtly % >59% R R 71% 40.9% 61.5% 44.4% 51.3% - - Y

352 Emergency readmissions (within 28 days - in arrears) Cum % <5.8% R R 3.0% 5.9% 5.9% 5.8% - 0 Y

353 Emergency readmissions (within 14 days - in arrears) Cum % <3.8% R R 2.0% 3.8% 3.8% 3.7% - 0 Y

IC48 Critical Care Unplanned Readmissions within 48 Hours Mnthly (%) <=1.3 G G 1.2% 1.0% 1.7% 1.5% 1.0% 0 0

913 % Caesarean sections Mthly % <28% R R 33% 38.4% 34.7% 36.3% 34.8% - -

ICNARC-STH Critical care mortality indicator-STH+VHDU Quarterly <=1.0 G G 0.83 1.00 1.00 1.00 0.98 0 0

ICNARC-Guys Critical care mortality indicator-Guys CCU Quarterly <=1.0 R R 0.80 1.15 1.15 1.15 1.14 0 0

EOL End of life care - % of deaths supported by Priorities for Care Mthly % >25% M M 42.8% 49.0% 43.0% - 47.0% 0 0

2.2 Clinical best practice

2.1 Quality improvement

initiatives

• CABG within 7 days of GSTT angiogram 100% (2/2)

• CABG within 7 days of received (angiogram elsewhere) as 22% (2/9)

• CABG within 7 days – combined GSTT and external angiograms as 4/11 = 36%

• The demands on OIR and ITU due to winter bed capacity have been huge. This has resulted in lists being cancelled in advance due to no OIR capacity as well as patients being cancelled on the day. Whilst OIR is full there are also issues with transferring patients to our wards in a timely fashion from the referring DGH. This is an issue across the South east and is ongoing. There are daily meetings about which patients need to go to OIR as a trust rather than just the cardiac surgery patients. The Trust then prioritise ALL patients needing OIR base on clinical urgency not procedure type. There have been days when ALL cardiac surgery has been cancelled. For January there were 19 cancellations due to no beds on OIR.

2.1 Quality improvement initiatives2 Effective January 2018

Page 17

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%


CABG within 7 days of GSTT angiogram 2017-182016-17Target

0%10%20%30%40%50%60%70%80%90%

100%


CABG within 7 days of referral received (angiogram elsewhere) 2017-182016-17Target

0%10%20%30%40%50%60%70%80%90%

100%


CABG within 7 days - combined GSTT and external angiograms 2017-182016-17Target

• Readmission rates vary depending on the clinical service and by patient group. There is an Outcomes group to review the data and look for any trends as well as a handover group to focus on improving the quality of discharge of patients from hospital and will take action if required.

• The caesarean section rate continues to be higher than target but remains in line with the 2016/17 average. Over the past two years we have been reporting the CS rates under the Robson criteria, as per CCG and CQC agreement. We have identified an issue with multiparous women having emergency CS. Ongoing work has identified high rates of comorbidities (2-12) and we are looking to see if quality of antenatal care can be improved in these women to mitigate this. We have used the feedback from the ‘Getting it Right First Time’ team, and the analysis of our data to identify areas for focus. These have been explored and further work identified through a recent multidisciplinary workshop, attended by a number of stakeholders.

• The Clinical Response Team (formerly the Critical Care Outreach Team) have been proactively reviewing all patients prior to admission to Critical Care and supporting them after step down onto a general ward. The main area of focus for improvement is Guy’s Critical Care as there is no High Dependency Unit on the site.

2.2 Clinical best practice (a)2 Effective January 2018

Page 18

0%1%2%3%4%5%6%7%8%9%

10%


Emergency readmissions (within 28 days - in arrears) 2017-182016-17Target

0%

1%

2%

3%

4%

5%


Emergency readmissions (within 14 days - in arrears) 2017-182016-17Target

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%


Critical Care Unplanned Readmissions within 48 Hours 2017-182016-17Target

0%5%

10%15%20%25%30%35%40%45%50%


% Caesarean sections 2017-182016-17Target

• The Trust continues to perform well in recognising people who go on to die in hospital. This recognition supports proactive communication as well as involvement of patients and those important to them in development and delivery of holistic care plans. We continue to audit practice and to integrate into the Trust mortality review process for all inpatient deaths.

2.2 Clinical best practice (b)2 Effective January 2018

Page 19

0%

10%

20%

30%

40%

50%

60%


End of life care - % of deaths supported by Priorities for Care 2017-182016-17

Domain scorecard3 Caring January 2018

Page 20


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

258 Overall inpatient patient experience score Mthly % >89% G G 90% 88.7% 88.5% 89.3% 89.3% - Y

310 Single sex compliance - breaches (all types) Cases Zero G G 4.1 0 0 0 0.0 - Y

501 Patients cancelled on day (in arrears) Cum % <0.8% R R 1.4% 1.8% 1.8% 1.7% - Y

502 Cancelled patients not admitted within 28 days (in arrears) Number Zero R R 8.1 20 15 - 11.3 - Y

FFT1W Friends and Family test (Ward) - Response rate Mthly % >=33% R R 23.4% 19.7% 18.9% 21.9% 20.5% - Y

FFT2W Friends and Family test - % Recommended (Ward) Mthly % >=97% R R 96.4% 94.7% 95.1% 96.1% 95.8% - Y

FFT3W Friends and Family test - % Not Recommended (Ward) Mthly % <=1% R R 1.3% 2.3% 1.6% 1.3% 1.5% - Y

FFT1AE Friends and family test (A&E) - Response rate Mthly % >=18% G G 15.3% 22.6% 20.4% 22.4% 21.9% - Y

FFT2AE Friends and Family test - % Recommended (A&E) Mthly % >=88% R R 85.2% 83.6% 86.3% 86.6% 83.9% - Y

FFT3AE Friends and Family test - % Not Recommended (A&E) Mthly % <=6% R R 6.9% 7.0% 6.8% 6.1% 6.9% Y

FFT1M Friends and Family test (Maternity) - Response rate overall Mthly % - M M 23.9% 13.2% 9.9% 17.0% 11.2% - Y

FFT2M Friends and Family test - % Recommended (Maternity) Mthly % - M M 91.3% 85.0% 87.6% 90.3% 89.9% Y

FFT3M Friends and Family test - % Not Recommended (Maternity) Mthly % - M M 3.2% 4.7% 1.7% 3.3% 2.8% Y

FFT2OP Friends and Family test - % Recommended (Outpatients) Mthly % - M M 92.8% 91.7% 92.4% 91.9% 91.7% Y

FFT3OP Friends and Family test - % Not Recommended (Outpatients) Mthly % - M M 3.2% 3.5% 3.6% 3.5% 3.5% Y

FFT1CS Friends and Family test (Community) - Response rate Mthly % - M M 4.6% 5.9% 6.4% 9.8% 6.2% - Y

FFT2CS Friends and Family test - % Recommended (Community) Mthly % - M M 95.3% 96.2% 97.6% 95.6% 96.6% Y

FFT3CS Friends and Family test - % Not Recommended (Community) Mthly % - M M 0.7% 0.5% 0.0% 0.5% 0.6% Y

FFT1PT Friends and Family test (Transport) - Response rate Mthly % - M M 2.4% 3.4% 2.8% 3.8% 4.2% - Y

FFT2PT Friends and Family test - % Recommended (Transport) Mthly % - M M 92.5% 93.5% 93.8% 94.7% 91.1% Y

FFT3PT Friends and Family test - % Not Recommended (Transport) Mthly % - M M 2.1% 2.2% 3.0% 1.0% 2.9% Y

3.7 General patient and

Food Satisfaction with food (PLACE) Mthly % >85%G G

92% 91.8% 91.8% 91.8% 91.8% Y

3.5 Community care

3.1 Admitted care

3.2 A&E care

3.4 Outpatient care

3.6 Patient Transport

3.3 Maternity care

• Cancellations have increased in proportion to our increased levels of activity, so work to reduce cancellations is a key focus of the Fit for the Future work-stream that supports theatre productivity. We have also seen an increase in the number of patients not being rebooked within 28 days compared to last year. Although numbers are small we know that some are the result of patient’s choosing later dates as well as consultant specific procedures that cannot be booked within the time limit.

• Patient experience scores continue to reflect well on inpatient care, with an overall satisfaction rate of 89.3% which is a slight increase on the December figure of 88.5%.

• Single sex compliance is also reported a month in arrears.

3.1.1 Admitted care (a)3 Caring January 2018

Page 21

75%

80%

85%

90%

95%

100%


Overall inpatient patient experience score 2017-182016-17Target

0.0%

0.5%

1.0%

1.5%

2.0%


Patients cancelled on day (in arrears) 2017-182016-17Target

0

3

6

9

12

15

18

21

24


Single sex compliance - breaches (all types) 2017-182016-17Target

02468

10121416182022


Cancelled patients not admitted within 28 days (in arrears) 2017-182016-17Target

• Having reviewed the previous years data on inpatients and day case/surgery as a new area of care, the Trust has set itself a combined response rate of 30% for 2017-18. In January we achieved a response rate of 21.9% which is an improvement upon the December figure of 18.9%. Monthly updates on recommend and not recommend scores together with response rates are now sent to all Directorate Management Teams for review and discussion.

• The proportion of patients who would recommend the Trust in January was 21.9%, slight improvement on December’s score of 95.0%. The percentage of patients who would not make a recommendation also improved, falling from 1.6% in December to 1.3% in January.

• All responses have been reviewed and feedback to areas has been given so that actions can be taken to both improve response rates and patients’ experience.

• The briefing over leaf provides further analysis and detail of actions underway.

3.1.2 Admitted care (b)3 Caring January 2018

Page 22

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Ward) 2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%

35%


Friends and Family test (Ward) - Response rate 2017-182016-17Target

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


Friends and Family test - % Not Recommended (Ward) 2017-182016-17Target

Where we want to be: targets and benchmarks• Work towards achieving a 30% response rate • Increase our FFT score/proportion of patients who would recommend us to 97%• Improve our response rate and the proportion of patients who would recommend the Trust when compared with Shelford Peers

Where we are: trends, patterns and causes• The response rate in January was 21.9% an improvement on the December figures of 18.9%.

• Response rates have improved across both wards and day case/surgery areas, however we are still below the national and regional average for this touchpoint. Response rate targets have been set for ward areas so that teams are clear about the number of surveys they need to collect each month. The Chief Nurse has asked Directorate Management Teams to review scores and response rates and identify how response might be improved.

• The Patient Experience team will also be working with Directorates to review the inpatient and day case surveys to make these briefer and more focused. It is hoped that revised surveys will encourage more patients to respond.

• The recommend score for January is 96.1% which is an improvement on the November figure of 95.1%. The not recommend score has also improved falling from 1.6% in December to 1.3% in January.

• In November our response rate, placed us in the mid-range of the Shelford Group, whilst our “recommend” and “not recommend” scores placed us towards the bottom of the group. Our scores are in line with the London average and our recommend score is slightly lower than the national average.

Risks or opportunities for the Trust

• It is important to ensure that we continue to capture patients’ feedback and that it is used to further improve the experience of patients staying on our wards

Trend –2017 Inpatient Friends and Family Test percentage Recommend v. Not recommend

Comparator – Shelford Group

Action and progress Owner Next review date

The Chief Nurse and Director of Patient Experience has contacted Directorate Management Teams and asked them to discuss and identify actions to improve response rates. The item is to go on monthly performance review meetings.

Patient Experience Team February 2018

The Patient Experience Team will be working with Directorates to revise both the inpatient and day case surveys to develop briefer and more focused surveys to help encourage completion.

Patient Experience Team April 2018

The Patient Experience Team will carry out in ipad audit to verify the number of ipads in use, re-allocate unused ipads and identify areas of need and put in a bid for funding to purchase additional ipads if needed.

Patient Experience Team March 2018

Intelligence triangulated Root cause understood Action plan set Actions underway Actions complete

3 Caring Inpatient and Daycase Friends and Family Test January 2018

Page 23

0%

5%

10%

15%

20%

25%

30%

35%


Friends and Family test (Ward) - Response rate 2017-182016-17Target

Shelford Group Response rateDecember

Recommend % Not recommend % InpatientNational Score for England 95% 2% 21.4%

London region score 94% 3% 22.7%Guy's and St Thomas' NHS Foundation Trust 95% 2% 18.9%University College London Hospitals NHS Foundation Trust 94% 3% 15.1%Newcastle-Upon-Tyne Hospitals NHS Foundation Trust 98% 1% 12.6%Sheffield Teaching Hospitals NHS Foundation Trust 96% 2% 27.2%University Hospitals Birmingham NHS Foundation Trust 97% 1% 17.5%Oxford University Hospitals NHS Trust 96% 2% 19.8%King's College Hospital NHS Foundation Trust 93% 3% 21.6%Cambridge University Hospitals NHS Foundation Trust 95% 2% 7.8%Imperial College Healthcare NHS Trust 98% 1% 29.9%Central Manchester University Hospitals NHS Foundation Trust 96% 2% 25.1%

Trust/Month December

• The A&E Friends and Family Test (FFT) includes patients attending our A&E department at St Thomas’ Hospital and Minor Injuries Unit at Guy’s Hospital.

• Having reviewed local and national data for 2016-17 the Trust set itself a target response rate of 20% for 2017-18. The response rate for A&E has increased, rising from 20.4% in December to 22.4% in January. The team is continuing to take measures to a robust response rate is achieved each month.

• The proportion of patients who would recommend the service in January has increased slightly rising form the December figure of 86.3% to 86.6% in January. Similarly the proportion of patients who said they would not recommend the service has also improved slightly, falling from 6.8% in December to 6.1% in January. Comments from patients continue to show frustration with delays and waits to be seen. The team are reviewing themes from feedback to identify actions which can be put in place to improve patients experience.

3.2 A&E care3 Caring January 2018

Page 24

0%

5%

10%

15%

20%

25%

30%


Friends and family test (A&E) - Response rate 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (A&E) 2017-182016-17Target

0%1%2%3%4%5%6%7%8%9%

10%


Friends and Family test - % Not Recommended (A&E) 2017-182016-17Target

• Having reviewed local and national data for 2016-17 the Trust has set itself a target response rate of 20% for 2017-18. The overall response rate for the Friends and Family Test for maternity services has improved significantly in January rising from 9.9% in December to 17% in January. Additional resources have been allocated to ensure that patients are continued to be surveyed on their experience.

• The proportion of women who would recommend the service has improved, increasing from 87.6% in December to 90.3%. The proportion of women who said they would not recommend the service has increased rising from 1.7% in December to 3.3% in January.

• The briefing on the following provides further analysis and detail of actions underway.

3.3 Maternity care3 Caring January 2018

Page 25

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Maternity) 2017-182016-17

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family test (Maternity) - Response rate overall 2017-182016-17

0%

1%

2%

3%

4%

5%

6%


Friends and Family test - % Not Recommended (Maternity) 2017-182016-17

Where we want to be: targets and benchmarks• Work towards achieving a 20% response rate • Increase our FFT score/proportion of patients who would recommend us to 97%• Improve our response rate and the proportion of patients who would recommend the Trust when compared with Shelford Peers

Where we are: trends, patterns and causesThe response rate improved significantly in January rising from 9.9% in December 2017 to 17%.

• The unit remains extremely busy and continues to experience periods of very high acuity and activity. The increase in birth rate hasmeant that there have been an average of four additional women staying on the postnatal ward each week and the team have had to make additional use of the discharge lounge.

• The overall recommend score has continued to improve rising from 87.6% in December to 90.3% in January. The not recommend score has declined, rising from 1.7% in December to 3.3% in January. A review of the underlying data has shown that this is due to a marked increase in the number of not recommend ratings given by women staying on our postnatal ward. A review of themes emerging from comments made by women highlight concerns regarding noise at night, staff attitude and delays in receiving some aspects of care.

• In December our “recommend” score places us in the lower half of the Shelford Group and our not recommend scores in the upper half. Our recommend score is above the national average and above the London regional score. Please note that we are only able to use the Labour and Birth touchpoint as this is the only touchpoint that NHS England can accurately estimate a response rate for.

• Risks or opportunities for the TrustIt is important to ensure that we continue to capture patients’ feedback and that it is used to further improve the experience of patients staying on our wards

Trend – 2017 Maternity Friends and Family Test percentage Recommend v. Not recommend

Comparator – Shelford Group


Maternity Services will be consulting with women and their families on the practice of allowing partners to stay overnight. Following the consultation and any changes to be made the ‘Partners staying’ initiative will be re-launched in June (on Father’s day).

Maternity Services May 2018

Themes emerging from comments made by women giving negative responses to the postnatal ward touchpoint are similar to those emerging from the national survey. As part of the action plan all Band 7 midwives will be required to attend a bespoke programme on managing poor performance.

Maternity Services February 2018

Maternity Services will be working with the Patient Experience Team to review and revise the Labour, birth and postnatal care questionnaire in the light of the national maternity survey results. The aim will be to develop a shorter questionnaire on what matters the most to women during the hospital stay.

Patient Experience Team and Maternity

ServicesMarch 2018

Intelligence triangulated Root cause understood Action plan set Actions underway Actions complete

Trend – Maternity Friends and Family Test response rate

3 Caring Maternity Friends and Family Test January 2018

Page 26

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%


Friends and Family test (Maternity) - Response rate overall 2017-182016-17

Recommend % Not recommend %

National Score for England 95% 2%London region score 91% 3%

Guy's and St Thomas' NHS Foundation Trust 82% 1%King's College Hospital NHS Foundation Trust 87% 5%University College London Hospitals NHS Foundation Trust 99% 1%Imperial College Healthcare NHS Trust 86% 6%

University Hospitals Birmingham NHS Foundation Trust No Data No Data

Sheffield Teaching Hospitals NHS Foundation Trust 94% 1%Oxford University Hospitals NHS Trust 100% 0%Newcastle-Upon-Tyne Hospitals NHS Foundation Trust 98% 0%Central Manchester University Hospitals NHS Foundation Trust No Data No DataCambridge University Hospitals NHS Foundation Trust 90% 2%

Shelford Trust/MonthPostnatal Ward

• We have reviewed local and national 2015-16 data and have set a response rate target of 7%.

• The proportion of outpatients who would recommend the Trust in December is 91.9% which is similar to the figure of 91.7% in November. The proportion of patients who would not recommend the Trust remains stable, at 3.6% which is the same as the December figure.

• As part of the Fit for the Future outpatient work stream, directorates are improving communication with patients regarding their appointments through text messaging, where it is not currently in use and introducing a system for booking follow ups. “Partial booking” of follow up appointments allows patients to be involved in the choice of appointment date and time. As well as improving patient experience, these initiatives are also aimed at reducing non-attendance rates.

• This work stream is also looking at alternative pathways for outpatients to reduce unnecessary visits to the hospital. By reviewing discharge criteria, introducing more telephone appointments, and introducing more one-stop visits (where the consultation appointment and any associated diagnostic tests occur on the same day). Through improving patient experience some of these initiatives will improve new to follow-up ratios.

3.4 Outpatient care3 Caring January 2018

Page 27

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Outpatients) 2017-182016-17

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%


Friends and Family test - % Not Recommended (Outpatients) 2017-182016-17

• We have reviewed 2015-16 local and national data and set a response rate target of 7%.

• The response rate has improved rising from 6.4% in December to 9.8% in January. The proportion of patients who would recommend community-based services has dipped slightly falling from 97.6% in December to 95.6% in January. The proportion of patients who would not recommend services has also declined slightly rising from November to 0.0% to 0.5% in December.

3.5 Community care3 Caring January 2018

Page 28

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Community) 2017-182016-17

0%

2%

4%

6%

8%

10%

12%


Friends and Family test (Community) - Response rate 2017-182016-17

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


Friends and Family test - % Not Recommended (Community) 2017-182016-17

• The proportion of patients recommending the transport continues to improve , rising from 93.8% in December to 94.7%. The not recommend score has improved, down from 3.0% in December to 1% in January.

• The response rate has also improved, rising from 2.8% in December to 3.8% in January.

3.6 Patient transport3 Caring January 2018

Page 290

0%

5%

10%

15%

20%

25%

30%


Friends and Family test (Transport) - Response rate 2017-182016-17

75%

80%

85%

90%

95%

100%


Friends and Family test - % Recommended (Transport) 2017-182016-17

0%

1%

2%

3%

4%

5%

6%


Friends and Family test - % Not Recommended (Transport) 2017-182016-17

• The Trust has scored strongly for the quality of its catering as reflected in the National Inpatient Survey 2015, published by the Care Quality Commission (CQC). The Trust’s catering scores exceed those of other London Trusts.

• The catering team continue to work closely with both Nursing and Dietetic staff to consolidate and introduce further quality improvements, and the Trust is working towards full compliance with the Hospitals Food Standards Report.

3.7 General patient and carers’ experience3 Caring January 2018

Page 30

75%

80%

85%

90%

95%

100%


Satisfaction with food (PLACE) 2017-182016-17Target

4.0.1 Domain scorecard (1)4 ResponsiveJanuary 2018

Page 31


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

AE123 A&E stays less than 4 hours (type 1 2 3) Mthly % >95% R R 88.7% 88.6% 89.3% 92.0% 89.1% Y - Y

AE1STH A&E stays less than 4 hours (type 1) Mthly % >95% R R 85.3% 85.4% 86.0% 89.1% 85.7% - Y

AE30 Ambulance handover times - breaches of 30 mins Number <3 G G 3.8 2 0 0 3.0 Y

AE60 Ambulance handover times - breaches of 60 mins Number Zero G G 0.0 0 0 0 0.0 Y

403M RTT - Incomplete pathways < 18 weeks (unadjusted) Mthly % >92% R R 90.4% 87.1% 87.2% 88.5% 87.6% Y - Y

RTT 52I RTT - Incomplete pathways over 52 weeks Mthly Zero R R 17.4 14 18 9 16.3 - 0 Y

RTT TQ RTT - Total incomplete pathways Mthly - M M 57,279 61,993 60,220 61,408 63,413 - 0 Y

RTT 18Q RTT - Incomplete pathways over 18 weeks Mthly - M M 5,534 7,993 7,714 7,061 7,887 Y

401M RTT - Non-admitted patients <18 weeks (unadjusted) Mthly % >95% R R 90.5% 87.4% 88.6% 89.3% 89.6% Y

402M RTT - Admitted patients < 18 weeks (unadjusted) Mthly % >90% R R 81.0% 78.9% 79.2% 78.9% 79.1% Y - Y

RTT 52 RTT - Treatments over 52 weeks (unadjusted) Mthly Zero R R 13.4 11 8 15 13.0 - 0 Y

451M Cancer - 2 week wait Qtly% >93% G G 91.4% 97.7% 98.5% 97.9% 95.5% Y - Y

941 Cancer - breast symptomatic referrals <2 wks Qtly % >93% G G 89.3% 96.3% 99.2% 94.1% 95.5% Y - Y

453M Cancer - 31 day first treatments Qtly% >96% R R 95.0% 93.1% 93.8% 89.8% 93.7% Y - Y

459M Cancer - 31 day subs treatments - surgical Qtly% >94% G G 90.7% 93.4% 90.7% 94.1% 89.7% Y - Y

943 Cancer - secondary chemotherapy <31 days Qtly % >98% G G 97.8% 99.3% 100.0% 98.4% 98.6% Y - Y

942 Cancer - secondary radiotherapy <31 days Qtly % >94% R R 93.7% 91.6% 93.9% 92.9% 91.9% Y - Y

454M Cancer - 62 day urgent GP referrals Qtly % >85% R R 67.1% 69.2% 71.5% 73.4% 68.1% Y 0 Y

Cancer - 62 day urgent GP referrals (LCA cases only) In devt #N/A #N/A454I Cancer - internal 62-day referrals Qtly% >85% G G 78.4% 78.7% 84.4% 90.6% 79.6% - - Y

456M Cancer - 62 day screening Qtly % >90% R R 83.3% 55.6% 77.8% 25.0% 71.6% Y 0 Y

457 Cancer Backlogs - pathways over 62 days Number - M M 138 87 101 88 133 0 0

458 Cancer Backlogs - pathways over 62 days Number - M M 48.3% 47.9%

4.3 Cancer access

4.1 A&E access

4.2 Elective treatment access -

referral to treatment (RTT)

performance

4.0.2 Domain scorecard (2)4 ResponsiveJanuary 2018

Page 32


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

Diag 6 Diagnostic waits - % over 6 weeks Mthly <1% R R 1.25% 2.2% 5.9% 3.6% 2.38% - - Y

FFF19 Turnaround time - inpatient MRI within 24 hours Mthly % >80% R R 63.8% 68.0% 74.0% 56.1% 65.2% 0 0 Y

FFF20 Turnaround time - inpatient CT within 24 hours Mthly % >80% G G 84.6% 92.2% 88.5% 89.2% 88.1% 0 0 Y

FFF21 Turnaround time - inpatient Ultrasound within 24 hours Mthly % >80% R R 76.5% 77.6% 76.3% 73.7% 73.4% 0 0 Y

531 Average length of stay (elective) Cum ALOS <last yr R R 3.54 3.84 3.91 3.90 3.90 - 0 Y

LOS>1 Non-elective average LOS >1 night Cum ALOS <last yr G G 8.7 8.7 8.7 8.7 8.7 - 0 Y

535 Discharges before noon Mthly % >25% R R 20.9% 19.7% 20.6% 21.3% 20.9% - 0 Y

Home GSTT referrals to @Home service Cases >100 R R 69 77 67 82 68 0 0 Y

DToCDT DToC total delayed days Number - 543 460 419 287 0 0 Y

604 Appointments re-scheduled by hospital <6wks Cum % <4% R R 4.8% 5.1% 5.1% 5.1% 5.1% - 0 Y

FFF57 Gassiot House Room Utilisation Mthly % >75% M M 88.6% - - - - 0 0

618 Choose and Book - % slot unavailability Mthly % <5% M M - - - Y

601R Follow-up ratio - adj cons appts (in arrears) Ratio 2.06 R R 2.14 2.17 2.20 2.17 - 0 Y

602 Non-attendance rate (new appts) Mthly % <11% R R 10.9% 11.2% 12.0% 12.2% 11.1% - Y Y

603 Non-attendance rate (f/up appts) Mthly % <9.8% R R 12.2% 11.1% 12.4% 12.3% 11.3% - 0 Y

533M Daycase rate - basket (in arrears) Mthly % >85% G G 84.3% 86.1% 86.4% 86.1% - 0 Y

505 Theatres Gross Cancellation Rate (in arrears) Mthly % <7% R R 7.4% 7.87% 8.36% 7.6% - - Y

COM1T Complaints opened in month (Trust total) Cases - M M 100.8 133 95 118 108 0 0 Y

COM2T Complaints re-opened in month (Trust total) Cases - M M 3.1 4 1 3 0 0 Y

COM6T Complaints CLOSED in month (total Trust) Cases - M M 98.0 113 60 120 106 0 0 Y

4.6 Outpatient management

4.7 Theatre management

4.4 Diagnostic access

4.8 Complaints mgt

4.5 Bed capacity and management

• January saw a significant improvement in performance within our A&E services with 92% of patients with stays of less than 4 hours, exceeding our planned trajectory of 90%. The department continued to see surges in demand and high volumes of patients but managed this well. Mental health attendances and outlier also continued to be a challenge for the department.

• Clinical and Operational Management team members began an internal Care Redesign Programme to review and create a new acute ambulatory pathway.• A mental health project board commenced, one area of focus is the management of mental health patients presenting to the ED.• Substantive recruitment was approved for the role of Patient Flow Coordinator dedicated to the Urgent Care Centre and a new consultant commenced in post.

4.1 A&E access4 ResponsiveJanuary 2018

Page 33

0123456789

1011121314151617


Ambulance handover times - breaches of 30 mins 2017-182016-17Target

0

1

2


Ambulance handover times - breaches of 60 mins 2017-182016-17Target

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


A&E stays less than 4 hours (all types) 2017-182016-17Target

75%

80%

85%

90%

95%

100%


A&E stays less than 4 hours (type 1) 2017-182016-17Target

A&E Performance4 Responsive

• Where we want to be: targets and benchmarks• We are seeking to reduce the number of patients waiting over 4 hours to a level at which we can

sustain performance against the national standards for incomplete pathways. • We want to achieve our submitted performance trajectory for 4 hour performance for 2017/18.

• Where we are: trends and patterns

• In January, performance outturn was 92%, this being above the STF trajectory of 90%. Staffing levels continue to improve, with new staff joining between February-April.

• Risks or opportunities for the Trust• Effective ambulatory pathways (including Frailty, Acute Assessment Unit & the Surgical

Assessment Unit) remain key to improving flow through the Emergency Pathway and reducing demand on the ED capacity.

• Clinically safe Emergency Pathways for other specialties which avoid patients having to be seen in the Emergency Department are also in development.

• Work is ongoing with SLAM to improve the pathway for mental health patients in A&E• Root cause analysis and insights • The three key drivers for current A&E performance are:1. A challenging physical environment due to the current temporary phase of the Emergency Care Pathway rebuild. 2. High number of complex patients with acute clinical requirements, including mental health conditions, and attendance surges creating a busy department.3. Outflow in to Trust beds and external services can be challenging at times.


Plan to review time between patient ready to be transferred and time patient leaves department to identify opportunities to improve patient flow.

Acute Medicine March 2018

Review underway of pathways for escalating at times of high mental health attendances and admissions, to ensure flow through the ED and ward beds is maintained. Acute Medicine March 2018

A weekly rapid change group is now being held to ensure decisions are made quickly and actions taken to improve the emergency pathway. This meeting will be chaired by the Chief Operating Officer and will include representatives from Acute Medicine, HR, IT and any other group who is required to enable rapid change. This group will also monitor flow across the Trust with a particular forward look to Winter.

Acute Medicine DMT March 2018

January 2018

Page 34

90.3%89.7%

86.6%

88.1%

87.2% 86.6%

90.5%

88.1%

83.4%

90.7%

91.9%

88.5%

90.4%

88.6%89.3%

89.4%

92.0% 92.0%

83.0%

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

Q1 Q2 Q3 Q4 Apr-17 May-17 Jun-17 Q1 Jul-17 Aug-17 Sep-17 Q2 Oct-17 Nov-17 Dec-17 Q3 Jan-18 Feb-18 Mar-18 Q4

% of patients who have a total time in A&E over 4 hours All Types National STF target

4.2.1 Elective access (a)4 Responsive

• The Trust’s RTT performance exceeded the 87.4% trajectory for January 2018, achieving 88.50%.

• The backlog decreased further in January from December’s position of 7714 to 7061. As stated in the previous IQPR, this is related to the continued effort of validation through weekend validation initiatives and additional central validation.

• The Trust recognises there is a substantial amount of work required to be undertaken across all Directorates to ensure it achieves the planned recovery trajectory in 2018/19. To support this there is a new elective care pathway programme that will cover all areas of elective care management, performance, digital patient journey, data quality, with executive and clinical oversight.

January 2018

Page 35

75%

80%

85%

90%

95%

100%


RTT - Incomplete pathways < 18 weeks (unadjusted) 2017-182016-17Target

30000

35000

40000

45000

50000

55000

60000

65000

70000


RTT - Total incomplete pathways 2017-182016-17

0

5

10

15

20

25

30


RTT - Incomplete pathways over 52 weeks 2017-182016-17Target

• The Trust achieved the 2 week wait target in December for the 6th consecutive month. We also achieved the 2 week breast symptomatic referral target for sixth consecutive month this financial year.

• The median wait across all tumour groups in December has reduced to 6.5 days, which is an improvement of 12-13 days seen before the introduction of ERS. We have continued to see a positive impact on our 7 day performance following the move to the Electronic referral system (ERS) for 2WW referrals. In December, we managed to see 67.2% of all cancer referrals within 7 days. This is a significant improvement from 16% at the start of 2017-18. Going forward we would anticipate 7 day performance to remain around 65-70%. This would demonstrate that we are able to offer adequate appointment choice to our patients within the 14 day standard.

4.3.1 Cancer – 2-week waits4 ResponsiveJanuary 2018

Page 36

75%

80%

85%

90%

95%

100%


Cancer - 2 week wait 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - breast symptomatic referrals <2 wks 2017-182016-17Target

• We achieved the 31 day subsequent treatment standard for Chemotherapy in December. However we remained below the target for 31 day first treatments, secondary Surgery and Radiotherapy for the month. The graph below illustrates our performance prior to a review of the breaches reported. Validation is being finalised.

• As with previous months, the majority of December breaches for 31 day first relate to surgical pathways. Initial analysis suggests capacity, medical reasons and patient choice all impacted our 31 day surgical pathways. More detailed analysis will be taking place to better under the underlying issues.

• As part of our Cancer Action Plan, we are creating a stand alone workstream to focus on specifically on 31 day performance to understand key drivers of poor performance across all 31 day standards. This will enable us to produce specific action plans with services to improve waiting times in the future. This work is in addition actions such as Red2Green and minimum Cancer Standards which have been implemented recently to support all cancer pathways.

4.3.2 Cancer – 31-day waits4 ResponsiveJanuary 2018

Page 37

75%

80%

85%

90%

95%

100%


Cancer - 31 day first treatments 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - 31 day subs treatments - surgical 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - secondary chemotherapy <31 days 2017-182016-17Target

75%

80%

85%

90%

95%

100%


Cancer - secondary radiotherapy <31 days 2017-182016-17Target

4.3.3 Cancer – 62-day waits4 Responsive• Overall performance for 62-day maximum wait for first treatment remains below the 85% target. We are currently achieving 73.4% (unvalidated) overall which is

below the trajectory set for January. We are also on target to achieve our internal trajectory for the third consecutive month, with a performance of 90.6% (unvalidated).

• Our focus on the delivery of our cancer recovery action plan continues with weekly meetings chaired by the Chief Operating Officer and attended by the Chief Executive Officer. We also continue with intensified operational leadership across all cancer pathways. This is achieved through daily huddles chaired by our Chief of Cancer Services and Director of Operations and appropriate challenge at cancer PTL meetings. Our underlying metrics for cancer continue to demonstrate improvement for internal pathways. For example, we are continuing to meet our backlog targets.

• We continue to work with colleagues both in South East London (SEL) and South East England (SEE) sectors to improve the quality and timeliness of referrals. We are working with them to support extra diagnostic capacity for CT and MRI, which started in November, and are sharing key achievements across the sector to ensure we put in place best practice processes to support better pathways for patients. This is being supported by both the Accountable Cancer Network (ACN) and the monthly Member’s Board of Chief Executive Officers from all three SEL trusts.

January 2018

Page 38

50%55%60%65%70%75%80%85%90%95%

100%


Cancer - 62 day urgent GP referrals 2017-182016-17Target

40%45%50%55%60%65%70%75%80%85%90%95%

100%


Cancer - 62 day screening 2017-182016-17Target

4.4 Diagnostic waits4 Responsive• January’s performance was 96.4%, which although is below trajectory, shows a marked improvement from December. This is related to the outsourcing of non-obstetric US

and additional in-house lists (MRI and US) within radiology, to recover performance.

• The reasons for the substantial volume of breaches in imaging (MRI and Non-Obstetric Ultrasound) is multifactorial and related to increased referrals; increased volume of Cancer and Urgent referrals resulting in reduced capacity for routine appointments; Staffing shortages and administration issues which resulted in scheduling delays.

• Endoscopy, Paeds MRI (GA) were above trajectory for December (due to reduced clinics and patient choice), but in January the position has recovered, and is back under trajectory with predicted breach value of 19 for January.

• Paediatric Sleep Studies, have had an increase in demand and this has resulted in a backlog, which will take a while to recover, due to limited capacity that cannot be increased. This is highly specialised and there is limited availability of paeds sleep studies nationwide, so outsourcing is not an option. The service clinical triaging, managing DNAs.

January 2018

Page 39

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%5.5%6.0%6.5%


Diagnostic waits - % over 6 weeks 2017-182016-17Target

50%55%60%65%70%75%80%85%90%95%

100%


Turnaround time - inpatient Ultrasound within 24 hours 2017-182016-17

50%55%60%65%70%75%80%85%90%95%

100%


Turnaround time - inpatient MRI within 24 hours 2017-182016-17

50%55%60%65%70%75%80%85%90%95%

100%


Turnaround time - inpatient CT within 24 hours 2017-182016-17

• @home: overall accepted referrals have increased from 213 in December to 259 in January. The service received 82 referrals from GSTT in January compared to 67 in November. The service is piloting an @home care home pathway to reduce emergency admissions and plans are being developed to expand into new pathways during 18/19.

• Average length of stay (LOS) for elective and non-elective patients remains comparable to the previous year’s profile. Directorates continue to work hard on their LOS improvement plans for the remainder of 17/18; and to set the conditions for further improvement in FY18/19.

• Work continues on improving hospital discharges before noon, Directorates use their huddles to continue focusing on improvements to early discharge.

4.5 Bed capacity and management4 ResponsiveJanuary 2018

Page 40

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5


Average length of stay (elective) 2017-182016-17Target

0%

5%

10%

15%

20%

25%

30%


Discharges before noon 2017-182016-17Target

0123456789

10


Non-elective average LOS >1 night 2017-182016-17Target

0

20

40

60

80

100

120

140


GSTT referrals to @Home service 2017-182016-17Target

• The definition of a DTOC is when a clinical decision has been made that a patient is ready and safe to transfer from an acute hospital bed to an alternative care setting, but is prevented from doing so. The Number of DTOC days increased slightly in January – this will be monitored to determine whether it is a trend and whether our action plan remains sufficient. Overall however we continue to see an improvement vs prior year on average which is a positive outcome of multiple work streams.

• Strategic transformation plans are underway to address our long-standing causes of remaining DTOC (jointly across both GSTT/KCH and both Lambeth/Southwark):• Assessment delays – Some patients are unable to safely return home after a spell in hospital, and delays can be encountered awaiting health and social care

assessment to determine ongoing support needs prior to discharge.• Action: CHC Discharge to Assess – A new model has been developed in Lambeth and Southwark to ensure that the majority of patients are assessed for

ongoing health care needs in an alternative care setting outside of the acute hospital. This model fully launched in October 2017, and patients are now able to return home, or to a temporary care placement, for their Continuing Healthcare Assessments. This will also support achievement of a new national target which requires 85% of all Continuing Healthcare Assessments to be undertaken in a non-acute setting by March 2018.

• Action: Expanded D2A / Trusted Assessment – A new programme of work launched in January 2018 which aims to expand our D2A pathways in Lambeth and Southwark, alongside considering Trusted Assessment arrangements. This involves GSTT Acute, GSTT Community, KCH, Lambeth LA/CCG, and Southwark LA/CCG – project objectives, milestones, and resourcing TBC in March/April 2018.

• Patient/family choice – The process of choosing an alternative long term care setting (for example, a care home) can take a long time and currently patients are remaining in hospital whilst they, or their family/carer, make this decision.

• Action: Independent support for Choice – GSTT started a pilot scheme in December 2017 whereby an independent company now provides a bespoke ‘hand holding’ service to support patients/families who are making a decision about long term care. This aims to improve patient/family experience and reduce related transfer of care delays. Impact analysis will be undertaken in March 2018.

4.6 Delayed Transfers of Care (DTOC) 4 ResponsiveJanuary 2018

Page 41

0

100

200

300

400

500

600

700

800

APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR YTD Avg

DToC Days GSTT 17/18 GSTT 16/17

0

100

200

300

400

500

600

700

800

APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR YTD Avg

DToC Days by Responsible Organisation NHS Social Care Both

• Appointments re-scheduled by the hospital within 6 weeks –Work is ongoing to explore an improved system of managing clinician leave and outpatient clinic utilisation using a “6-4-2” principle. Under this system the clinician running a clinic must be confirmed 6 weeks in advance or cross cover / clinic reallocation arranged, to make better use of outpatient space and avoid late notice cancellations.

• e-RS (National Referral System) – Tranche 1 and 2 services are now live. Tranche 3 paper switch off commences on 1st February 2018. CQUIN report on e-RS and Advice & Guidance has been submitted internally and will be submitted to Commissioners soon. We reduced our ASIs to 9% in December. More specialities being scoped for Consultant Connect – Dermatology commenced a pilot in January.

• Non-attendance for new and follow up appointments – Dr Doctor reminders (level 1) continue to be embedded into new areas of the Trust, and a pilot of level 2 (appointment re-schedule, auto offer) functionality has been completed in Dental specialties, with encouraging anecdotal feedback on phone call volumes and patient and staff satisfaction. Following review a roll out plan for both level 2 and 3 (online booking) functionality by specialty is being put together under the Digital Patient Journey transformation programme, to run through 2017/18.

• Follow-up ratio – The new: follow up ratio has deteriorated, however the number of overdue follow ups has reduced slightly.

4.7 Outpatient management4 ResponsiveJanuary 2018

Page 42

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0


Follow-up ratio - adj cons appts (in arrears) 2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Non-attendance rate (new appts) 2017-182016-17Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


Appointments re-scheduled by hospital <6wks 2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Non-attendance rate (f/up appts) 2017-182016-17

4.8 Theatre management4 Responsive

• Day case rates continue to meet the target of 85% with continued focus on ensuring patients are recovered and discharged in line with national best practice.

• Cancellation rates were above the Trust target of 7% in December 2017. Three reasons accounted for 54% of all cancellations on the day; patient did not attend, patient self-cancelled and patient medically unfit. Surgical and theatre services are working hard to reduce avoidable cancellations on the day.

January 2018

Page 43

0%10%20%30%40%50%60%70%80%90%

100%


Daycase rate - basket (in arrears) 2017-182016-17Target

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

10.0%


Theatres Gross Cancellation Rate (in arrears) 2017-182016-17Target

4.9 Complaints management4 Responsive

The Trust’s ambition is to provide a complaints system which is open to complaints, supports patients, families, and staff through the process, and which delivers a timely apology, explanation and determination to learn from mistakes. The aim is to produce a service about which complainants are able to say: I felt confident to speak up; making my complaint was simple; I felt listened to and understood; I felt that my complaint made a difference.

• The complaints team continue to work hard with the directorates to provide good complaints management in line with the regulations and good quality standard of response.

• In addition to the numbers of formal complaints logged, the team also logged 65 informal queries. This figure represents a further 65 contacts that were dealt with by the team quickly and efficiently preventing them from becoming formal complaints.

• 1 final report was received from the Parliamentary and Health Service Ombudsman in January and this was partly upheld.

January 2018

Page 44

0

20

40

60

80

100

120

140


Complaints opened in month (Trust total) 2017-182016-17

0

20

40

60

80

100

120

140


Complaints CLOSED in month (total Trust) 2017-182016-17

0

1

2

3

4

5

6


Complaints re-opened in month (Trust total) 2017-182016-17

5.0 Domain scorecard5 Well-led January 2018

Page 45


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

GOV Overall goverance rating (Monitor, in arrears) Rating Green #N/A g Green Green Green Green Green

CQC Care Quality Commission (CQC) risk assessment Score >5 G G 6 6 6 6 6 - - Y

FFTS1 Staff Friends and Family - recommend as place to work Qtly % >70% M M 77.1% 77% Y

FFTS2 Staff Friends and Family - recommend for care or treatment Qtly % >80% M M 93.6% 93% Y

VACTB Overall vacancy rate Mthly % <9% R R 11.4% 10.1% 10.1% 10.4% 11.0% Y

TEMPTB Agency staff (% of paybill) Mthly % <4.3% G G 4.2% 3.8% 3.3% 3.2% 3.6% - - Y

TURNTB Rolling annual turnover rate Mthly % <11% R R 12.2% 12.7% 12.3% 12.9% 12.5% - - Y

206TB Sickness and absence rate Mthly % <3.0% R R 3.2% 3.57% 3.49% 3.81% 3.32% - - Y

211TB Appraisal compliance (non-medical staff) Mthly % >95% R R 72.1% 72.2% 71.9% 73.7% 71.9% - - Y

MTTB Mandatory training compliance Mthly % >95% R R 84.7% 84.0% 83.7% 83.7% 83.9% Y

5.1 External assessments

5.2 Staff experience

5.3 Workforce indicators

• Staff opinion on whether they would recommend a health care organisation for care or for work is statistically associated with the quality of care. Any fall in the positive opinion should be seen as a potential earlyindicator of a reduction in quality of care.

• The NHS National Staff Survey takes place in the third quarter of each year. The 2017 NHS Staff Survey closed on 1 December 2017 and the Trust opted to run a full census survey.

• 5,392 staff members took time to respond in the 2017 NHS Staff Survey. The Survey asked for staff to share their experience of working in the Trust, including questions about their job, their managers, their personal development, their health and wellbeing and their safety at work. When comparing to our comparator group ‘combined acute and community trusts’, the Trust achieved a high staff engagement score at 3.99 (on a scale of 1-5) compared to the national average of 3.78. Staff satisfied with the quality of work and patient care scored 4.07, against a national average of 3.90.

• The survey results show we are above average in 23 out of the 32 key findings in the 2017 NHS Staff Survey. We achieved the best score nationally in eight, out of 32, key areas. A total of 88% of our staff who responded are happy with the standard of care we provide, compared to the national average of 69%. 78% of staff would recommend the Trust as a place to work, compared to the average of 59%.

• We’ve seen a significant decrease in the number of staff witnessing potentially harmful errors, near misses or incidents, as well as an improvement in staff reporting any experience of violence.

• The Trust scored below than national average on four key findings and there are key areas for improvement which will be addressed through Trustwide and local directorate action plans.

• The National Staff Survey asks similar but differently worded questions to the Staff Friends and Family Test (SFFT), which is open in quarters 1, 2 & 4. A total of 1,448 staff participated in the Quarter 2 2017/2018 StaffFriends and Family Test (SFFT), which was conducted in August 2017. The Quarter 2 results highlight the fact that our staff continue to give the Trust a huge vote of confidence as a provider of care. The results showthat 93% of our staff would recommend the Trust as a place to be treated, well above the national average of 80%. 77% of our staff said that they would recommend the Trust as a place to work, again a higher figurethan the national average of 63%. The Trust ranks 22nd out of 229 for best place to receive treatment and 17th out of 229 for the best place to work when compared with other Trusts in England.

• Quarter 4 Staff FFT Survey is currently underway and the results will be available in April/May 2018.

5.2 Staff experience 5 Well-led

0%10%20%30%40%50%60%70%80%90%

100%


Staff Friends and Family - recommend as place to work 2017-182016-17Target

0%10%20%30%40%50%60%70%80%90%

100%


Staff Friends and Family - recommend for care or treatment 2017-182016-17Target

January 2018

Page 46

• The overall vacancy rate (10.45%) increased in January and remains above the target. The Trust Staff in Post increased by 44 WTE in January. The Substantive workforce is over 939.99 WTE greater (6.9%) than the same month last year. There are 864 external applicants in the recruitment pipeline scheduled to join the Trust over the next few months. With these new starters in the pipeline the 3 month forecasted vacancy rate shows a reduction to 10.34%.

• Agency spend as a proportion of paybill decreased in January to 3.23% and is below the Trust’s target of 4.3%. Agency usage continues to be monitored on a weekly basis, with price cap breaches reported to NHS Improvement and the Trust Board.

• Voluntary Staff Turnover increased to 12.90%, but continues to trend above the target of 11%, however the Trust continues to benchmark favourably other London Trusts.

5.3.1 Workforce indicators (a)5 Well-led January 2018

Page 47

0%

1%

2%

3%

4%


Sickness and absence rate 2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Overall vacancy rate 2017-182016-17Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


Agency staff (% of paybill) 2017-182016-17Target

0%

2%

4%

6%

8%

10%

12%

14%


Rolling annual turnover rate 2017-182016-17Target

• Personal Development Review (appraisal) compliance rates increased to 73.65% and remains well below target. The Trust has yet to achieve its target of 95%.

• Mandatory training decreased slightly to 83.65% and is slightly lower than the January 2017 rate, with compliance remaining below Trust target level of 95%. Most directorates are now over 75% compliant, with five achieving over 90% compliance. Training data is updated weekly on WIRED which is available to all staff and managers.

5.3.2 Workforce indicators (b)5 Well-led January 2018

Page 48

50%55%60%65%70%75%80%85%90%95%

100%


Appraisal compliance (non-medical staff) 2017-182016-17Target

50%55%60%65%70%75%80%85%90%95%

100%


Mandatory training compliance 2017-182016-17Target

Where we want to be: targets and benchmarks• The Trust is currently reporting a 73.7% compliance rate for PDR and has remained below 75% since

January 2017. • The Trust has set an internal stretch target of 95%. • PDR compliance excludes Medical and Dental staff. Compliance rates for M&D staff was 92.8 in Jan 2018• Benchmark data (where available) through AUKUH London Trusts ranges between 66% to 83%, but rates

through the Shelford Group show higher compliance rates.

Trends and patterns• Over the past 12 months the average PDR compliance rate is 72.12%, remaining stable on a monthly basis. • The table shows compliance rates for the 20 Directorates with largest number staff . • A&C staff are reported as having the lowest PDR compliance at 66.65% and Estates/Ancillary staff the

highest at 80.40%• 84% of our staff have reported that they have received an appraisal review in the last 12 months in our staff

survey. This is lower than the national average of 86% and the trust score in 2016 (87%). This will be a focus of the Trust action plan. The quality of appraisals remains above the national average.

Root cause analysis and insights • There is potential that PDRs are taking place but not being reported centrally via the HR Portal and therefore

communication will be going out to remind managers and provide guidance on how to report this

Risks or opportunities for the Trust• An increase in PDR rates ensure that employees feel engaged and continue to develop in their role which will

improve on retention, performance and patient care

Actions set and progress to date• A multi-disciplinary group is reviewing the PDR process and paperwork as well as training offered to

manager. All actions aim to improve compliance rates as well as the quality of PDRs• Non-compliance is discussed at regular performance review meetings• Improved communication about the importance of carrying out PDR and reporting these centrally.

5. Exception report

Intelligence triangulated

Root cause understood Action plan set Actions

underwayActions

complete

White – Not started Red – Not successfully completed / facing significant issuesGreen – Successfully underway/completed Amber – Underway / completed with minor risks or issues 49

Directorate Headcount PDR Rate % No Current PDR - HeadcountPCCP 1,459 63.39% 534Evelina Medicine & Neonatology 836 62.66% 312Oncology & Haematology 941 69.31% 289Acute Medicine 809 68.88% 252Womens Services 671 64.96% 235Clinical Imaging & Med Physics 498 61.79% 190Cardiovascular Services 481 64.89% 169Community Adults 881 82.52% 154Dental Services 537 72.98% 145Transplant, Renal and Urology 450 68.34% 142Medical Specialties 617 77.10% 141Evelina Surgery & PICU 459 72.47% 126Specialist Ambulatory Services 555 79.82% 112Pharmacy 396 73.08% 107Finance Director 232 59.54% 94R&D : NIHR 295 70.53% 87Therapies 513 85.33% 75Evelina Community Services 637 88.70% 72Gastrointestinal Medicine & Surgery 310 77.17% 71Surgery 258 74.52% 66

5 Well-led

6.0 Domain scorecard6 Enablers January 2018

Page 50


avg Mon

itor

Qua

lity

prio

ritie

s Trend chart

MRRT Finance Use of Resources Score <=2 G G 2.1 2.0 2.0 2.0 2.6 Y - Y

LQRT Liquidity ratio (in days) Days >0 G G 15.5 6.0 4.6 4.0 10.6 Y - Y

DSCT Capital service cover Ratio >2.59 R R 1.9 2.30 2.07 2.22 1.30 Y - Y

FIN01T Overall underlying financial surplus/(deficit) £M >£6.37m R R -£0.5 -£1.3 -£1.6 £0.3 -£9.8 Y - Y

CSHT Cash flow £M >£143m G G £142.6 £167.2 £154.8 £143.5 £158.8 - - Y

CAPT Capital spend vs plan (year-to-date variance) Mthly % +/- 15% R R -36.0% 55.0% 57.1% 58.3% 53.9% - - Y

VRPT Variance from Plan (year to date) Mthly % > 0 R R 0.1% -0.08% -0.29% -0.28% -1.7% Y - Y

UNPT Underlying Performance Mthly % > 0.6% R R 0.2% 0.6% 0.6% 0.8% -1.7% Y - Y

560 Elective activity vs profiled plan - cumulative variance (month in arrearCum var % >0% R R 0.7% -4.6% -4.8% -1.5% - ## Y

606T New patients seen vs plan (all categories, in arrears) Mthly var >0 R R 159 -804 -3,270 -2,498 0 0 Y

714 External cons referrals Number >last yr R R 2,314 2,408 1,838 2,141 2,257 - Y Y

713 GP referrals Number >last yr G G 18,413 20,740 16,567 21,992 18,908 - 0 Y

6.3 Fit for the Future

CIPSTC Cost improvement plans (CIPs) - var to plan YTD £M >£0mR R

-£5.6 -£6.9 -£5.5 -£7.5 -£5.9 - - Y

CMI024 Community data completeness - % contacts outcomed Mthly % ≥ 95% M M 95.2% 96.6% 96.5% 87.1% Y - Y

712 NHS number coverage Cum % >98% G G 98.0% 98.6% 98.5% 98.6% 98.6% - ## Y

710x Clinical coding - diagnostic depth (in arrears) Ratio >4.5 G G 5.06 5.41 5.52 5.24 - 0.0 Y

6.4 Data quality and clinical

coding

6.2 Activity levels (magic numbers)

6.1 Overall financial position

6.1.1 Overall financial position (a)6 Enablers January 2018

Page 50

Financial performance is assessed against the single oversight framework where the highest rating that can be achieved is a one and the lowest a four. The term “Finance and Use of Resources Rating “ has been amended to “Finance Score” to distinguish it from the new “Use of Resource Ratings”

At January a rating of two has been achieved which is behind the plan of one.

6.1.2 Overall financial position (b)6 Enablers January 2018

Page 51

The annual plan is a surplus of £10.2m. A surplus of £0.3M has been recorded at January, which is £5.0M worse than the planned surplus of £5.3M.

The CIP requirement for 17/18 is £99M. Current schemes have identified £91.5m of new savings or income growth. At month 10 £72.3m of savings or income growth has been achieved against a plan of £80.8m. The Trust plan assumes an increase in CIPs later in the year, this is reflected by a phasing adjustment of £1.1M in January

The cash position at £144M is £11M ahead of plan of £133M. Capital expenditure as a percentage of plan has fallen below the threshold of 85% (to 58%) and a reforecast may be required.

6.1.3 Overall financial position (c)6 Enablers January 2018

Page 52

• Demand – GP referrals and external consultant (tertiary) referrals have increased in January, which is down to normal seasonal variation. However, it is worth noting that the increase in January 2018 GP referrals has exceed target planned levels and that what was seen this time last year.

• Year to date until December 17, the Trust’s overall elective activity levels continue to remain below plan with lower activity over the Christmas period. The Christmas effect was also reflected in new patients seen vs plan (graph on bottom left).

6.2 Activity levels 6 Enablers January 2018

Page 53

-4,000

-3,000

-2,000

-1,000

0

1,000

2,000

3,000

4,000

5,000


New patients seen vs plan (all categories, in arrears) 2017-182016-17Target

-

5,000

10,000

15,000

20,000

25,000


GP referrals 2017-182016-17Target

-4.0%-3.0%-2.0%-1.0%0.0%1.0%2.0%3.0%4.0%5.0%6.0%


Elective activity vs profiled plan - cumulative variance 2017-182016-17Target

0

500

1,000

1,500

2,000

2,500

3,000


External cons referrals 2017-182016-17Target

• Accurate and complete clinical coding of our activity is important to ensure patient safety, accurate benchmarking and appropriate payment for the services we provide. Improving the quality of all of our data ensures that the information on which we base decisions is reliable.

• Diagnostic depth - the average number of diagnoses recorded per admitted episode – has increased to 5.3 diagnoses during 2017-18 (top left) and we have re-set targets for further improvements going forward. We are expecting to see further increases during 2017-18 as a result of more structured capture of patients’ underlying medical conditions within E-noting. Capture of smoking status is being used as a lead indicator for how well we are capturing co-morbidities, especially by non-medical staff (top right). We anticipate that the current level still understates the true prevalence of smoking amongst our admitted patients.

• Within the community setting, the capture of outcomes from patient contacts is our key indicator (bottom left). Levels are now exceeding 95% following a dip in performance linked to the introduction of Advanced Care Notes – the community clinical IT system.

• NHS number coverage (bottom right) is now ahead of the target level of 98% overall . Particular measures are in place to try to improve the capture of accurate demographic information amongst patients attending our A&E departments.

6.3 Data quality and clinical coding6 Enablers

Coded smokers

75%

80%

85%

90%

95%

100%


Community data completeness - % contacts outcomed 2017-182016-17Target

January 2018

Page 6

90%

92%

94%

96%

98%

100%


NHS number coverage 2017-182016-17Target

6 Enablers May 2015

Page 566.5 Essentia Patient Services:

CleanlinessSummary:• Cleanliness scores continue to meet Trust performance targets.• Essentia’s team of specialist internal auditors assess cleanliness against a range of National Patient Safety authority (NPSA) standards. The audit result is shown

in the graph below. The NPSA score continues to track above target of 90%, with a score in November of 98.6%. The NPSA score of 98.0% was achieved against a target of 90%.

Action and Progress to Date:

• The monthly Inpatient Survey for cleanliness is conducted via ‘Meridian’. In January there were 1078 responses (for ward cleanliness and toilet/bathroom cleanliness), of which over 99.19% said that the cleanliness of their ward or room was ‘fairly clean’ or ‘very clean’.

• The decontamination activity in January was high. In total 542 decontaminations were carried out across both sites compared to 245 in January 2016.

January 2018

6 Enablers May 2015


CateringSummary: • Very strong performance in the 2016 Inpatient Survey (reported below) placing the Trust in the upper quartile in the Picker and Shelford Groups.• In the 2017 PLACE Assessment Guy’s and St Thomas’ performed above the national average for food and hydration (reported below).• No formal complaints received for patient catering in the last 12 months.

Action and Progress to Date:• The patient catering services continues to provide food that is highly rated by

the patients. In January 6.98% rated the food as poor and there were no formal complaints received. This is against a background of in the region of 108,000 meals served per month.

• The catering team were selected as the January Team of the Month. This reflected the hard work and dedication of the catering team in putting in place special festive menus and delivering the service over what is a very busy period.

• The National and Young Peoples Survey 2016 highlighted the Evelina amongst the lowest performers in London. This is not in line with the overall Trust performance but does highlight the need for some focused action for children and young adults. The catering and nursing teams have been working together to put in place actions aimed at improving performance. This is currently being reviewed to track progress and to ensure there is a robust plan in place, and that there is full engagement from all parties.

PLACE 2017

January 2018

Food Safety

Independent internal food safety compliance monitoring is carried out unannounced in all Trust catering venues. The audits are conducted to assure compliance with the food hygiene regulations and adherence to the Trust’s food safety policy and procedures. All areas inspected scored above target levels. Food venues are also inspected periodically by the Local Authority Environmental Health Department who issue a food safety rating between 0 and 5, with 5 representing full legal compliance with the food safety and hygiene regulations.

All areas that have undergone the inspection, including the main kitchen, are rated 5.

Trust ScoreNational Average

Food 93.12% 89.70%Organisation 92.74% 88.80%Ward 93.16% 90.20%Quality of Food (Good) 59.00% n/aChoice of Food 90.10% n/aHelp with Eating 80.10% n/a

PLACE 2017 Food and Hydration

2016 Inpatient Survey

6 Enablers May 2015


Patient Transport ServicesSummary:• The Patient Transport Service (PTS) undertakes around 22-25,000 journeys each month and 13,000 patient eligibility assessments.• The main KPI's around arrival and departure times remain challenging. Arrival times are tracking below pre-contract levels.• The Friends and Family test in January, based on 875 responses, scored 94.7% for ‘would recommend’ and 0% for those that ‘wouldn’t’.

Action and Progress to Date:• Under the current contract enhanced performance standards were introduced;

patients are required to arrive no earlier than 45 minutes and no later than 15 minutes before their appointment time, and to depart within 30 minutes of being booked ready to travel. It soon became clear that these standards were unachievable within the operating environments of our main hospital sites and therefore unenforceable from a performance penalty perspective. The reality is that the current service has settled into a steady level of performance and has maintained standards achieved under the old contract, these being arrival times within 90 minutes of appointment and being booked ready to travel for the return journey. Market research carried out has indicated that these standards are fairly typical across the NHS. Within this report both the old and new KPIs are reported.

• A management consultancy organisation, Neller Davies, was appointment to advise on the future provision of patient transport. Having taken the report’s findings into account, in addition to patient engagement feedback and recommendations in an internal audit report, it is clear that in depth consideration and review is required to scope a service that will meet the expectations of patient users. The options emerging would fundamentally change the delivery and service arrangements and need full stakeholder support. For these reasons a paper was taken to the 1st February TME to seek approval for an extension to the current contract of one year in order to create sufficient time for a project based approach to delivering the optimum service outcomes. The approach was approved by TME.

January 2018

6 Enablers May 2015

Page 59

6.5 Essentia Patient Services:Patient Transport Services

Performance Breakdown New KPI’s

January 2018

6 Enablers May 2015


TelephonySummary:Following the recent recruitment campaign all front-line vacancies have been successfully filled leaving only two ‘cover’ positions outstanding. In total 12.88 WTEs have been recruited.


• Although the recruitment of staff is expected to increase overall performance in the coming months there has been a drop in performance this month, mainly attributable to management focussing on the training of new staff. This is also against a background of a continuing increase in call volumes

• GOSH has requested a draft proposal to extend the switchboard service provided by the Trust for up to two years from July 2018. A draft proposal has been submitted ahead of further discussions. Lewisham have requested an extension to their contract until April 2019. Both these contracts demonstrate the benefit GSTT customer services can offer externally whilst delivering an important income stream to the Trust.

January 2018

6 Enablers May 2015

Page 616.5 Essentia Services:

Engineering & BuildingJanuary 2018

Summary: • Following additional revenue investment in an enhanced out of hours maintenance regime, lift availability on the two acute sites is once again above target,

with a score of 99% for December. Please note that currently 47.7% of our lift call outs are for misuse and abuse• Priority 2 calls (responded to within 4 hours) – Decembers performance of 69% and Januarys 67%, falls just below target but is an improvement on the 59%

achieved in September. The Priority 2 KPI measures the time it takes to respond to calls, as full resolution and repair may require out of hours work or the procurement of additional parts.

Action and Progress to Date: • Recruitment continues to be an issue for key positions, with a high number

of vacancies. A review is currently underway. This will from time to time impact on reactive works but the focus will continue to reduce this impact as much as possible.

• Planned Preventative Maintenance (PPM’s) tasks are being completed, however the month-on-month completion rate is being affected by the increased number of PPM’s that are now in place. This is under review, looking at current use contractors against internal resourcing; this follows both the internal audit and the latest review of the CBRE contract specifications.

• New lifts following refurbishment are now available• Engineering and Building Compliance is progressing, with only 3.2% of the

600 questions remaining at red risk status.

6 Enablers May 2015

Page 626.5 Information Technology /

DigitalJanuary 2018

Summary:• The average call answer time continues to be a challenge for the Service Desk and this is primarily due to a lack of resources due to leave, sickness and

turnover.• Despite the challenges in the call answer time, the Service Desk continues to perform well with the first time fix rate maintaining at 66% and the customer

satisfaction at 88%.• The overall incident resolution target was achieved and all requests were resolves within target at nearly 90%

Action and progress to Date:• The call answer time for January was averaging 6 minutes and primarily due to resourcing issues. A plan is being developed to bridge the gap between staff leaving and the time taken to on board and train new team members. •We continue to focus on aged tickets and this is steadily reducing month on month. •There were six P1 incidents in January which included issues with user profiles, Patnet unavailability, CareVue and Datix accessibility.•There was only one full outage which impacted Pathnet and the connection to EPR.•The Wards First team have extended into new areas and initial walk arounds and audits have been conducted.•The Samaritan Ward move scheduled for January has been delayed until February.

6 Enablers May 2015


Sterile ServicesJanuary 2018

Summary:• Non-conformity levels reported at 0.04% for the quarter equating to 1:2222. • Average activity volumes for the quarter November to January 2017 reported at 13,5252 instruments processed per week. • The current turnaround trends show an average of 7.97 hours against the agreed target of 24 hours.

Action and Progress to Date:• North Middlesex contract continues to maintain improvement to meet

required turnaround and quality standards. • Non conformances maintain at target levels. The recovery of this remains

significantly better than trade standards.• Activity levels for the quarter are in line with expected seasonal volumes• Damage wrap issues is controlled and SSD has also responded to recent

failures in Evelina. SSD will introduce the same preventative measures. However, SSD continue to incur cost pressures as theatre storage issues still remain.

6 Enablers May 2015


CommunityJanuary 2018

Summary:• Community teams are consistently achieving and exceeding their targets for reactive and PPM maintenance.• Community cleanliness scores consistently exceed the 95% target for In-Patient sites.


• VHP cleaning continues within GSTT Community sites.• Reactive maintenance performance has increased from 76% in December

to 89% in January following a review of priority calls and categorisation.• All PPM tasks are currently under review, including activity codes, which

will re-classify activities and reduce the number of codes. This review will include the categorisation of PPM’s, including statutory and mandatory tasks.

• Although within target, the slight dip in PPM compliance is mainly due to recruitment, which is underway.

Appendix: directorate-level heatmap (1 of 2)January 2017

Page 65

Type Target Trus

t-w

ide

Acut

e M

edici

ne

Perio

pera

tive,

Crit

ical C

are

& P

ain

Surg

ery

Card

iova

scul

ar S

ervi

ces

Abdo

min

al M

edici

ne a

nd S

urge

ry

Onc

olog

y An

d Ha

emat

olog

y

Wom

en's

Serv

ices

Clin

ical I

mag

ing

& M

edica

l Phy

sics

Med

ical S

pecia

lties

Dent

al S

ervi

ces

GRID

A

Ther

apie

s

Adul

t Com

mun

ity S

ervi

ces

Child

ren'

s Com

mun

ity S

ervi

ces

Child

ren'

s Med

ical S

ervi

ces

Child

ren'

s Sur

gica

l Ser

vice

s

Mon

itor

CQU

INFi

t for

Fut

ure

wor

kstr

eam

Qua

lity

prio

ritie

sLo

cal

Patient safety - Total incidents reported Number - 2,194 509 228 50 86 80 204 211 29 0 24 36 15 201 0 201 0 - - - -Incident Reporting Incidents - Reported on STEIS (total number) Number - 10 3 3 0 0 2 0 0 0 0 1 0 0 1 0 0 0 - - - -

Incidents reported on Datix that are STEIS reportable (total n Number - 10 3 3 0 0 2 0 0 0 0 1 0 0 1 0 0 0 - - - -Never Events Number Zero 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 - - - yIncidents resulting in unexpected death Number - 6 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 - - - -Incidents resulting in severe harm Number - 6 0 2 0 0 2 0 0 0 0 0 0 0 0 0 1 0 - - - -Incidents resulting in moderate harm Number - 43 4 9 2 1 3 3 2 2 0 1 1 0 8 0 2 0 - - - -Incidents resulting in low harm Number - 338 54 30 8 15 15 27 24 7 0 5 9 7 62 0 33 0 - - - -Incidents resulting in no harm Number - 1,797 450 185 40 69 59 173 185 20 0 18 26 8 130 0 164 0 - - - -Incidents resulting in unexpected death - reported on STEIS Number - 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -Incidents resulting in severe harm - reported on STEIS Number - 3 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -Incidents resulting in moderate harm - reported on STEIS Number - 4 2 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 - - - -Incidents resulting in low harm - reported on STEIS Number - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - - - -Incidents resulting in no harm - reported on STEIS Number - 2 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 - - - -

Patient safety Never events (confirmed) Cases Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0 0 YHarm Free Care Patient slips trips falls (DATIX) Cases - 140.0 51.0 2.0 9.0 13.0 6.0 15.0 0.0 0.0 0.0 0.0 0.0 3.0 0.0 0.0 1.0 0.0 - - - 0

Incidence of falls per 1000 bed days Number - 4.7 6.5 1.6 4.6 2.8 3.3 4.2 0.0 0.0 0.0 0.0 0.0 - 0.0 - 0.3 0.0 0 0 0 0Falls with moderate or severe harm Cases 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -Pressure ulcer acquisitions (grade 2 and above) Number 0 5.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 - - - -

Infection Control MRSA screening of admissions Mthly % >95% 91% 63% 91% 97% 96% 99% 92% 94% 86% 96% 100% 90% 0% - - - 87% - - - 0and Cleanliness MRSA bacteraemia (Trust-attributable) Number Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -

C-Diff acquisitions Number 0 2.0 0.0 0.0 0.0 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Y - - -Screening VTE screening (externally reported) Mthly % >95% 94% 89% 97% 78% 80% 98% 94% 92% 140% 96% 100% 100% 0% 100% - 88% 73% - Y - -

Dementia screening (patients aged over 75) Mthly % >90% 79% 86% - 32% 85% 40% 50% - - 100% - 100% - - - - - - Y - -Mortality Deaths in hospital - number in month Number - 105.0 50.0 4.0 2.0 15.0 5.0 15.0 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 4.0 3.0 - - - -Admitted care Friends and Family test (Ward) - Response rate Mthly % >=33% 19% 30% 27% 38% 22% 18% 44% 20% - - - - - 71% - 18% - - - - -

Friends and Family test - % Recommended (Ward) Mthly % >=97% 95% 94% 80% 97% 95% 97% 94% 100% - - - - - 80% - 98% - - - - -Friends and Family test - % Not Recommended (Ward) Mthly % <=1% 2% 3% 10% 1% 0% 1% 1% 0% - - - - - 0% - 0% - - - - -Overall inpatient patient experience score Mthly % >89% 89% 88% 73% 89% 90% 88% 88% 90% - - - - - - - - - - - - 0Single sex compliance - breaches (all types) Cases Zero 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - - - -Patients cancelled on day (in arrears) Cum % <0.8% 1.8% - 0.6% 1.3% 7.8% 4.2% 1.7% 2.4% 175.0% 1.9% 0.4% - 0.0% - - 3.6% 2.0% - - - 0Overall outpatient patient experience score Mthly % >89% 91% 90% - 94% 88% 89% 89% 85% 88% 86% 94% 90% 93% - - - - - - - 0Friends and Family test - % Recommended (Outpatients) Mthly % - 92% 94% 82% 91% 98% 95% 92% 91% 92% 89% 95% 91% 94% - - 100% 96% - - - -Friends and Family test - % Not Recommended (Outpatients) Mthly % - 4% 5% 14% 4% 1% 3% 3% 6% 4% 5% 2% 4% 1% - - 0% 4% - - - -

Outpatient care

Appendix: directorate-level heatmap (2 of 2)January 2017

Page 66

Type Target Trus

t-w

ide

Acut

e M

edici

ne

Perio

pera

tive,

Crit

ical C

are

& P

ain

Surg

ery

Card

iova

scul

ar S

ervi

ces

Abdo

min

al M

edici

ne a

nd S

urge

ry

Onc

olog

y An

d Ha

emat

olog

y

Wom

en's

Serv

ices

Clin

ical I

mag

ing

& M

edica

l Phy

sics

Med

ical S

pecia

lties

Dent

al S

ervi

ces

GRID

A

Ther

apie

s

Adul

t Com

mun

ity S

ervi

ces

Child

ren'

s Com

mun

ity S

ervi

ces

Child

ren'

s Med

ical S

ervi

ces

Child

ren'

s Sur

gica

l Ser

vice

s

Mon

itor

CQU

INFi

t for

Fut

ure

wor

kstr

eam

Qua

lity

prio

ritie

sLo

cal

RTT RTT - Non-admitted patients <18 weeks (unadjusted) Mthly % >95% 89% 91% 55% 86% 76% 89% 86% 91% 74% 97% 94% 95% 80% 100% 100% 80% 80% Y - - -RTT - Admitted patients < 18 weeks (unadjusted) Mthly % >90% 79% 100% 73% 74% 70% 85% 79% 69% 100% 85% 90% 90% 100% 100% - 84% 58% Y - - -RTT - Incomplete pathways < 18 weeks (unadjusted) Mthly % >92% 87% 96% 85% 82% 84% 92% 81% 87% 72% 96% 92% 97% 88% 97% 75% 83% 74% Y - - -RTT - Treatments over 52 weeks (unadjusted) Mthly Zero 8.0 0.0 0.0 6.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 1.0 - - - 0RTT - Total incomplete pathways Mthly - 60,220 3,132 1,928 4,058 4,340 2,766 6,002 2,951 248 5,131 10,172 7,259 840 116 12 2,911 2,785 - - - 0RTT - Incomplete pathways over 18 weeks Mthly - 7,714 129 297 744 703 233 1,128 377 70 230 862 236 100 3 3 483 717 - - - 0

Cancer access Cancer - 2 week wait Qtly% >93% Y - - -Cancer - breast symptomatic referrals <2 wks Qtly % >93% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% Y - - -Cancer - 31 day first treatments Qtly% >96% - - - - - - - - - - - - - - - - - Y - - -Cancer - 31 day subs treatments - surgical Qtly% >94% Y - - -Cancer - 62 day urgent GP referrals Qtly % >85% Y - - 0Cancer - internal 62-day referrals Qtly% >85% - - - -Cancer - 62 day screening Qtly % >90% Y - - 0

Diagnostics Diagnostic waits - % over 6 weeks Mthly <1% 6% 0% - - 3% 6% 0% - 6% 0% - - - - - 12% 13% - - - -Bed management Average length of stay (elective) Cum ALOS <last yr 3.9 2.7 9.3 3.3 5.3 3.5 4.6 3.4 1.2 2.9 1.3 7.1 0.0 43.6 0.0 2.5 2.2 - - Y 0

Non-elective average LOS >1 night Cum ALOS <last yr 8.7 6.6 7.7 0.2 2.7 7.3 15.0 9.2 6.0 90.7 0.0 23.3 3.0 39.9 0.0 7.0 43.7 - - Y 0Discharges before noon Mthly % >25% 20% 32% 17% 25% 12% 9% 18% 8% 64% 13% 50% 19% - 71% - 18% 25% - - - 0

Outpatient mgt Appointments re-scheduled by hospital <6wks Cum % <4% 5% 3% 6% 6% 6% 5% 8% 2% 1% 12% 4% 4% 2% 2% 0% 3% 4% - - Y 0Follow-up ratio - adj cons appts (in arrears) Ratio 2.06 2.16 2.75 1.27 1.56 2.48 3.25 2.54 0.88 1.29 2.74 2.58 1.98 - - - 2.16 1.84 - - Y 0Non-attendance rate (new appts) Mthly % <11% 13% 19% 10% 11% 35% 16% 12% 12% 20% 14% 7% 11% - - 0% 9% 11% - - Y Y

Theatre Daycase rate - basket (in arrears) Mthly % >85% 86% - - 90% 97% 53% 77% 90% - 100% - - - - - 88% 69% - - - 0management Theatres Gross Cancellation Rate (in arrears) Mthly % <7% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% 8% - - - -Readmission mgt Emergency readmissions (within 28 days - in arrears) Cum % <5.8% 5.9% 11.3% 1.4% 2.8% 4.6% 5.5% 10.9% 2.2% 2.5% 1.9% 0.1% 1.8% 0.0% 3.0% 0.0% 3.8% 2.4% - - - 0

Emergency readmissions (within 14 days - in arrears) Cum % <3.8% 3.8% 8.1% 0.8% 2.2% 3.1% 3.0% 7.2% 1.7% 1.4% 1.4% 0.1% 1.2% 0.0% 1.5% 0.0% 2.6% 1.7% - - - 0CQUIN - general Patients >75 asked dementia screening question Qtly % >90% 79% 86% - 32% 85% 40% 50% - - 100% - 100% - - - - - - Y - -Data quality NHS number coverage Cum % >98% 98% 95% 100% 99% 100% 100% 100% 99% 100% 100% 96% 99% 99% 100% 100% 98% 100% - - - 0

Clinical coding - diagnostic depth (in arrears) Ratio >4.5 5.2 7.7 4.5 4.1 8.9 6.4 4.5 6.9 4.3 4.1 2.4 3.4 1.7 8.5 2.9 4.1 - - Y 0Activity Elective activity vs profiled plan - cumulative variance (mont Cum var % >0% -5% 7% -6% -6% 0% 9% -4% -11% -12% -19% -8% 12% 0% 0% 0% -6% -15% - - - 0(magic numbers) New patients seen vs plan (all categories, in arrears) Mthly var >0 -844 -8 24 -107 -110 213 -1 -156 -15 -511 221 -725 320 0 0 89 -119 0 0 0 0

External cons referrals Number >last yr 1,583 83 23 157 207 102 169 42 9 43 31 286 9 0 0 125 151 - - Y YGP referrals Number >last yr 16,598 539 139 505 736 524 1,440 2,487 25 1,176 1,933 1,815 3,794 0 0 277 193 - - Y 0

Documents

Integrated Quality and Performance Report · 73.65%. Managers and staff have been reminded of the importance of undertaking and reporting PDRs. How effective are our enabling services?