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Key Performance Indicator Definitions 2011/12 Data Dictionary

Version control April 2011 1st draft of document

Barnet, Enfield and Haringey Mental Health NHS Trust KPI Definitions 2010/11 v.2 January 2011

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INDEX

INTRODUCTION Trust Dashboard 1. Financial Risk Rating (Monitor)

1. Underlying Performance (EBITDA margin %) M 2. Achievement of Plan M

i) EBITDA % Achieved ii) Return on Assets %

3. Financial Efficiency (I&E Surplus %) M 4. Liquidity (Liquid Ratio) M

2. Mental Health Contractual Targets

1. Early Intervention 2. CPA 7-day contact 3. Treatment of drug misuser 4. Out-patient waiting 5. Delayed Transfers of Care 6. CR&HTT in-patient gatekeeping 7. Learning Disability Access 8. Mental Health Acti Monitoring 9. CQC Registration standards 10. Adult in-patient efficiency (ALoS and 28 day readmission rate) 11. Older adult in patient efficiency (ALoS) 12. Out-patient efficiency (Did not attend rates)

3. Enfield Community Services Contractual Targets 4. Monitor Compliance Framework targets 2011/12

1. CPA 7 day contact 2. Delayed Transfers of Care 3. CR&HTT in patient gatekeeping 4. Early Intervention 5. Data – Employment, Settled Accomodation and HoNOS 6. Learning Disability Access

5. Trust Targets 1. Adult in patient efficiency (ALoS) 2. Older adult in patient efficiency (ALoS) 3. CR&HTT productivity


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4. CMHT productivity 5. Out patient efficiency (DNA rates) 6. Recovery House Efficiency 7. NHS staff satisfaction survey 8. Service user experience survey 9. Trust strategic objectives 6.Mental Health CQUIN To be provided 7. Enfield Comminity Services CQUIN 8. Forensic CQUIN To be provided


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9. Introduction The Trust has identified its principal objectives for 2011/12 and monitors these at each public Board meeting. The objectives are cascaded down through the Trust in the business planning process and risks to achieving these is monitored through the Board Assurance Framework (BAF).The Board Assurance Framework provides a structure that enables the Trust to focus on the risks to achieving its principal objectives and be assured that adequate controls are operating to reduce these risks to acceptable levels. Linked to each principal objectives are a number of key performance indicators (KPIs) the definitions for which are contained in this data dictionary.

The KPI report contains a RAG (Red Amber Green) evaluation based on the current and year end forecast performance. The tolerances which determine whether a KPI is red, amber or green are given at the end of the criteria. The KPI RAG scores are displayed in a Trust “dashboard” which gives an “at a glance” view of how the Trust is performing (see below). The dashboard will be completed for each quarterley public Board meeting. Overleaf is an example. The majority of the KPIs relate to the Trust’s commissioning contracts and CQUINs and the definitions for these have been taken directly from the contract schedules. The most significant change in 2010/11 has been the Inclusion of KPIs for Enfield Community Services (ECS). The Trust have identified a number of KPIs related to achievement of key objectives which will ensure that the Board will be able to evaluate progress on the main areas of transformation. These have been benchmarked (using mental health

Business Planning and Performance Management Process

Trust Plan - Objectives

Individual objective setting, appraisal and PDP

Risk Register

Director’s Objectives

Performance & Risk SC

Board Assurance Framework

Performance Targets

Service Agreements

Service Lines

Commissioner Quality & Performance Review

Board

PerformanceReports

Governance & Risk CommitteeAudit Committee


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Benchmarking Club quartile reference points) with the aim of the Trust reaching best in class performance in 5 years. As the Trust aims to be a Foundation Trust a number of key performance indicators have been derived from Monitor's Compliance Framework .

KEY PERFORMANCE INDICATOR REPORTTRUST DASHBOARD - 2011/2012

Reference Key: Q CQC Compliance Monitor target IBP Transformation KPIs Contract/CQUINKeyCEO - Chief Executive COO - Chief Operating Officer Target not met/high riskFD - Finance Director Service Line Dir.s (SLD) Target at risk of not being metMD - Medical Director C&E Crisis & Emergency Lead May YE Target met/low riskDoN - Director of Nursing DCI Dementia & Cognitive impairment Jan Feb Mar Target not measured yetDS&P - Director of Strategy & Perform. P Psychosis Excellent Services and Staff variousPOD - People and Organisational Develop. CMH Common MH Problems Integrated and Holistic Service variousDEF - Director of Estates and Facilities S&C Severe & Complex non-psych. Developing New Opportunities various

HPh - Head Pharmacist F ForensicHIMT - Head of IM&T EC Enfield Community Lead May YE

MENTAL HEALTH Jan Feb Mar

CR&HTT C&E G G GLead May YE Lead May YE Early Intervention P R R R

Jan Feb Mar MENTAL HEALTH Jan Feb Mar CPA 7-day contact C&E G G GUnderlying Performance EBITDA margin% FD G G G Adult In-patient efficiency C&E A A A Treatment of drug misusers S&C G G GAchievment of Plan EBITDA achieved % FD G G G Older adult In-patient efficiency DCI R R R 13 week waiting OP assessment SLD A A A Return on assets % FD G G G NHS Staff Satisfaction survey POD G G G ENFIELD COMMUNITYFinancial Efficiency I&E surplus % FD A A A CR&HTT productivity C&E R R R 18 week RTT ECLiquidity Liquid ratio FD R R R CMHT productivity P R R R Urgent Response Times EC

Out Patient efficiency (DNA) SLD A A A Out Patient efficiency (DNA) ECRecovery House efficiency C&E New Birth Visits 0-14 days EC

ENFIELD COMMUNITY Access to GUM ECLead evious May YE Adult and OP service outcomes EC

Jan Feb Mar Children and YP service outcomes EC

Employment (outcomes) SLD G A ASettled accommodation (outcomes) DoN G A A Lead May YEDelayed Transfers of Care COO G A A MENTAL HEALTH Jan Feb MarCR&HTT in-patient gatekeeping C&E G G G Lead May YE CMHT transition planHoNOS Assessment SLDs Jan Feb Mar tbcLD Access SLDs CQC registration standards Q various G G G tbcMental Health Act monitoring Q C&E ENFIELD COMMUNITYService User Experience surveys SLDs Patient Experience

End of Life CarePhysical & MH wellbeing

Notes: HIV Testing at GU clinics1. Definitions of the above KPIs are contained in the KPI Data Definition 2011/12 Data Dictionary which was revised in April 2011 Bowel Cancer Diagnosis2. The Monitor targets are taken from Monitor's Compliance Framework 2011/12 FORENSICS3. The CQC have implemented a registration process and performance against these standards is reflected in the Clinical Quality Outcome section4. Mental Health Act Monitoring have now been added to the report under Service User Experience - a regular report will be provided in 2011/125. Transformation KPIs in the IBP have been added to the dashboard and are symbolised using

Financial Risk Rating (see Trust objective )Previous

Service User Experience (see Trust objective )

Service Access Targets (see Trust objective )Previous

Clinical Quality Outcomes (see Trust objective )Previous

Strategy (see Trusts Strategic objectives )Previous

CQUIN (see Trust objective )Previous

Efficiency and Productivity (see Trust objectives )Previous

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1. Financial Risk Rating (Monitor) (Organisational Objective 2.1) The targets and weighting taken from Monitor’s Compliance Framework are as follows: Financial Criteria

Weight %

Metric to be scored

Rating Categories 5 4 3 2 1

Achievement of Plan

10 EBITDA* achieved (% of Plan)

100 85 70 50 <50

Underlying Performance

25 EBITDA* margin (%) 11 9 5 1 <1

Financial Efficiency

20 Return on Assets excluding dividend (%)

6 5 3 -2 <-2

20 I&E surplus margin net of dividend (%)

3 2 1 -2 <-2

Liquidity 25 Liquidity ratio** (days)

60 25 15 10 <10

Financial risk rating is weighted average of financial criteria scores * EBITDA: Earnings before interest, taxes, depreciation and amortisation. EBITDA (and other financial metrics) may be adjusted by Monitor for any ‘one-off’ non recurring revenue, costs or ‘investment adjustments’ ** The liquidity ration is defined as cash plus trade debtors (including accrued income) plus unused working capital facility (up to a maximum of 30 days) minus (trade creditors plus other creditors plus accruals) expressed as the number of days operating expenses (excluding depreciation) that could be covered

Traffic light tolerance Overall rating 2 or below Overall rating 3 or above


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2. Mental Health Contractual Targets The attached is an extract from Schedule 3 Part 1: Quality Requirements of the Trust’s Mental Health commissioning contract SERVICE ACCESS TARGETS Technical Guidance Reference

Quality Requirement Threshold Method of Measurement

Consequence of breach

SQU13 Dashboard Ref: Early Intervention

The number of new cases of psychosis served by early intervention teams year to date

Target: Active cases B: 147 (3 yrs) E: 135 (3 yrs) H: 165 (3 yrs) (of which)New cases B: 49 E: 45 H: 55

Borough targets for:

• Total caseload

• Total early intervention caseload (active cases)

• Number of new cases accepted by early intervention services

Quarterly Vital Signs Monitoring Return (VSMR) Monitored through performance meeting

Performance Management Cl 32

Dashboard Ref: Early Intervention

Early Intervention services for 14-18 year olds Appropriate provision in Early Intervention services to meet needs of under 18’s

Approx. 10% of EIS users should be 14-18 years old

Breakdown of EIS user numbers by under/over 18s Evidence of appropriate provision in EIS to meet needs of under 18’s to include: • Appropriate

protocols (admission thresholds & criteria;

Develop action plan to realign performance Performance Management Cl 32


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SERVICE ACCESS TARGETS Technical Guidance Reference



interface with CAMHS and protocols between adult & CAMHS clinicians)

• Appropriate workforce

• Appropriate governance arrangements

• Appropriate child protection measures

Baseline to be established at Q1 Haringey & Barnet to reach 10% and provide evidence on protocols by Q2, Enfield to reach same by Q3 Monitored through performance meeting

SQU15 Dashboard Ref: CPA 7 day contact

The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the quarter

95% Performance Report Monitored through performance meeting


Dashboard Ref: Treatment of Drug Misusers

Problem Drug Users VSB14 No. of crack/opiate users in structured drug treatment who were

Barnet: 618 Enfield: Not applicable – do not

CQC Criteria Monthly National Drug Treatment Monitoring Service (NDTMS) Monitored through

Provision of exception report on why target has not been met


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SERVICE ACCESS TARGETS Technical Guidance Reference



discharged after 12 weeks or in a care planned way.

use BEHMHT drug services) Haringey: 954

performance meeting


Dashboard Ref: Outpatient Waiting (CAMHS)

All children and young people, including children with learning disabilities and/or ASC, should have access to a local comprehensive child and adolescent mental health service (CAMHS)

• Comprehensive coverage of the population by comprehensive CAMHS, which include access to 24-hour cover for urgent needs

Trust to review & redistribute its on-call rota each quarter to all PCTs, boroughs and acute trusts (including A&E) Waiting times for services (e.g. SCAN) for C&YP with MH and LD needs

Once service established, local targets to be agreed for reduction in waiting times from referral to assessment and assessment to treatment intervention:

• Length of wait for first access to CAMHS (CAMHS mapping)

Exception report on breaches, e.g. child not seen within 4 hours Exception report on waiting time breaches Review of on-call rota distribution to be monitored through governance meeting Monthly waiting times by specialist service by borough to be monitored through Performance meeting Performance Management Cl 32

SERVICE USER EXPERIENCE Dashboard Ref:

Delayed Transfers of

A reduction on baseline

Monthly on RIO Numbers to be split by borough

Trust to report on exceptions and


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Delayed Transfers of Care

Care VSC10 NI 131 Number of Delayed Transfers of Care attributable to: a) Health b) Social Care c) not determined % Days lost to delayed discharges

Baseline – Q3 2010/11

and specialty including CAMHS Monitored through performance meeting

develop action plan to realign performance Performance Management Cl 32

SQU14 Dashboard Ref: CR&HTT in-patient gatekeeping

Percentage of inpatient admissions that have been gatekept by crisis resolution/ home treatment team

95% Performance Report Monitored through performance meeting


Dashboard Reference: LD Access and care

People with learning disabilities and/or autistic spectrum conditions (ASC) should be able to access mainstream services when necessary • Reasonable

adjustments are made to services to allow access to mainstream mental health and other services as necessary

No less than 85% of the Greenlight Toolkit indicators to be assessed as ‘green’ at the end of the year

Comment: Primary and secondary diagnostic data will need to be collected to assess how people with learning disabilities and/or ASC access services. The capacity of local services to collect and report the required diagnostic data may need to be linked to the Data Quality Improvement Plan in order to collect: • Number of

people with mild or



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moderate learning disabilities/ASC using specialist mental health services with learning disability/ASC as a primary diagnosis – separate reporting on a) inpatients and b) service users in other settings

• Number of people with mild or moderate learning disabilities/ASC using specialist mental health services with learning disability/ASC as a secondary diagnosis - separate reporting on a) inpatients and b) service users in other settings

Monitored through


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governance meeting

Dashboard Reference: LD Access and care

People with a learning disability/ASC or long-term mental illness should receive appropriate physical health care

• All service users who have been in hospital/long- term health care for more than one year should have a physical health check at least annually

• 100% patients to have a physical health assessment & appropriate care plan within 2 weeks of admission

• 100% long-term in-patients will: a) have a 6mthly review by their Specialist b) be offered appropriate gender specific health screening in line with the National Screening Programme c) At risk long-stay patients will be offered flu and pneumococcal vaccination

100% of long-term inpatients that have received an annual health check. Six Monthly Report on Rates via 15min Clinical Audit at Q2 and Q4 Monitored through governance meeting.


Dashboard Ref: Mental Health Act Monitoring

External assurance Exception reporting and action plans relating to external accreditation e.g. Care Quality Commission Reviews – incl. peer reviews, NHS Litigation Authority

Corporate Risk Register Quarterly report on Performance Dashboard Monitored through governance meeting

Provide notice to BEH PCTs within 72hrs of any breach of standards monitored by such agencies Failure to resolve will result in decommissioning the service


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CLINICAL QUALITY OUTCOMES

CQC Registration To confirm registration and action plans relating to non-compliance or insufficient assurance

Quarterly report on Performance Dashboard Monitored through governance meeting

Exceptions and resulting actions to be provided quarterly Failure to resolve will result in decommissioning the service

EFFICIENCY AND PRODUCTIVITY Dashboard Ref: Adult In-patient efficiency

Length of Stay

Baseline: (Q3 10/11) Adults untrimmed B: 41 E: 51 H: 55 Additional measured agreed is RAG rating this using the following ratio 80-100% within 28 Days =Green, 75-80% = Amber, 0-74% Red. Adults trimmed B: 24 E: 31 H: 28 Target: Untrimmed

Monthly on RIO By Borough The PCT expects this data to be accurately tracked by borough and service throughout the year Monitored through performance meeting

Trust to report on exceptions and develop action plan to realign performance Performance Management Cl 32


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– 28 days Trimmed – 21 days Older Adults Untrimmed B: 34 E: 60 H: 83 Proposed Target 35 Days

Emergency re-admissions within 28 days Emergency re-admissions within 28 days

Baseline – Q2 10/11 B: 4% E: 3% H: 5% Target: 5% RAG Rating based on number of patients is 0-3 patients = Green, 4-6 patients = Amber and >5 patients = Red.

Monthly on RIO Monitored through performance meeting


Dashboard Ref: Out Patient efficiency (DNA)

Percentage DNA Rate News and Follow-ups Ratios to be measured across all services • CAMHS • Adults • Older People • Psychological

Therapies Personality Disorders

Target: As per Measure in Appendix 1 Targets to be reviewed after Q1

Monthly on RIO QMOP Benchmarking Monitored through performance meeting



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4. Monitor Compliance Framework Targets 2011/12 Those target indicators which are relevant for Mental Health Trusts. No Dashboard

Area Indicator Threshold Monitoring

period 1 Quality CPA patients comprising either:

a)Receiving follow-up within 7 days of discharge b)Having formal review within 12 months

95% 95%

Quarterly

2 Quality Minimising mental health delayed transfers of care

≤7.5% Quarterly

3 Quality Admissions to inpatients services had access to crisis resolution home treatment teams

90% Quarterly

4 Quality Meeting commitment to serve new psychosis cases by early intervention teams

95% Quarterly

5 Effect- iveness

Data completeness: identifiers 99% Quarterly

6 Effect- iveness

Data completeness: outcomes for patients on CPA

a) Employment Status b) In settled accommodation c) HoNOS assessment in last

12 months

50% Quarterly

7 Patient experience

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

N/A Quarterly

1a) 7-day follow up: Numerator: the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion) within seven days of discharge from psychiatric inpatient care. Denominator: the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care. Contact can include face-to-face or telephone contact. Guidance on what should and should not be counted when calculating the achievement of this target can be found on Unify2. 1b) For 12 month review (from MHMDS) Numerator: the number of adults in the denominator who have had at least one formal review in the last 12 months. Date last seen by care coordinator will be used as a proxy for formal CPA review during 2011/12. Denominator: The total number of adults who have received secondary mental health services and who were on the CPA at any point during the reporting period. For full details fo the changes to the CPA process pelase see the implementation guidance, Refocusing the Care Programme Approach on the DoH website. All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within seven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team. Exemptions from both the numerator and the denominator of the indicator include:


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• Patients who die within seven days of discharge; • Where legal precedence has forced the removal of a patient from the country; or • Patient discharged to another NHS psychiatric inpatient ward.

2. Minimising mental health delayed transfers of care Numerator: the number of non-acute patients(aged 18 and over) whose transfer of care was delayed averaged over the quarter. Denominator: number of non-acute patients (aged 18 and over) admitted to the trust, summed across the quarter. Delayed transfers of care attributable to social care are excluded.

1. Admissions to inpatient services had access to CR&HTT The following cases can be excluded:

• Admission to PICU; • Internal transfers of service users between wards in a trust and transfers from other

trusts; • Patients recalled on CTOs; or • Patients on leave under Section 17 of the Mental Health Act 1983.

An admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in admission. For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on the DoH website.

2. Meeting commitment to serve new psychosis cases by early intervention teams

Quarterly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance, rounded down. 3. Data completeness: identifiers

• Patient identity data completeness metrics (from MHMDS) to consist of: • NHS Number • Date of birth • Postcode (normal residence) • Current gender • Registered GP • GP practice organisation code • Commissioner organisation code

Numerator: count of valid entries for each data item above. Denominator: total number of entries.

4. Data completeness: outcomes for patients on CPA Outcomes for patients on CPA:

a) Employment status Numerator: the number of adults in the denominator in paid employment (i.e. those recorded as ‘employed’) at the time of their most recent assessment, formal review or other multi-


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disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during the reference period. The reference period is the last 12 months working back from the end of the reported quarter. Denominator: the total number of adults (adged 18 – 69) who have received secondary mental health services and who were on the CPA at any point during the reported quarter.

b) in settled accommodation c) Numerator: the number of adults in the denominator who were in settled

accommodation at the time of their most recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews were carried out during the reference period in the last 12 months working back from the end of the reported quarter.

Denominator: the total number of adults (aged 18 – 69) who have received secondary mental health services and who were on the CPA at any point during the reported quarter.

d) Having an HoNOS assessment in the past 12 months Numerator: The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months. NOTE: When implemented MHMDS v4 will allsow services to report all HoNOS variants, including those for young people and people on secure services. Until this time trusts should report standard HoNOS inclusive of all ages and ward types. Denominator: The total number of adults who have received secondary mental health services who were on the CPA during the reference period.


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5. Trust Target Definitions

6.

KPI Lower Quartile Median Upper

QuartileBest in class

Source

BEHMHT Position at

October 2009

BEHMHT Latest

position Q3 (2009/10)

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Adult annual bed occupancy excluding leave (%)

82% 88% 94% 68%Audit

Commission 90% 92% 92% 91% 90% 88% 86% 85%

Adult Average Length of stay (days) 28 35 42 16

Audit Commission 32 38 30 28 26 26 26 26

No of Adult admissions per 100k weighted population

50 65 76 23Audit

Commission 68 82 82 65 50 46 43 40

Recovery House annual occupancy (%) N/A 99% N/A N/A Turning Point N/A N/A 90% 90% 90% 90% 90% 90%

Recovery House Average Length of Stay N/A 7.5 DAYS N/A N/A Turning Point N/A N/A N/A 14 14 14 14 14

Older Adult bed occupancy excluding leave (%) 75% 81% 88% 56

Audit Commission 84% 85% 85% 85% 85% 85% 85% 85%

Older Adult Average Length of Stay (days) 55 77 88 34

Audit Commission 41 47 47 44 41 38 36 34

No of Older Adult admissions per 100k weighted population

65 78 90 22AC (5%

Reduction a year in targets)

70 84 84 70 65 60 55 50

Average CPA Caseload per CMHT WTE N/A N/A N/A N/A N/A N/A 15

Average Non CPA Caseload per CMHT WTE N/A N/A N/A N/A N/A N/A 15

Average face to face contacts per CMHT WTE per day

N/A N/A N/A N/A N/A N/A 1.5 2.0 3.0 4.0 4.0 5.0 5.0

Average telephone contacts per CMHT WTE per day

N/A N/A N/A N/A N/A N/A N/A

Average face to face contacts per HTT WTE per day

N/A N/A N/A N/A N/A N/A 2 2.0 2.2 2.4 2.6 2.8 3.0

Average caseloads per HTT WTE N/A N/A N/A N/A N/A N/A N/A

DNA's % Adults New6% 11% 15% 2%

AC (No Outpatients from

2012)20% 22% 22% 16% 6% 4% 3% 2%

DNA's % Adult Fup7% 9% 13% 2%


2012)14% 19% 19% 14% 7% 5% 3% 2%

DNA's % Older Adults New2% 5% 7% 0%


2012)10% 10% 10% 6% 2% 1% 1% 1%

DNA's % Older Adult Fup2% 4% 6% 1%


2012)7% 14% 14% 8% 2% 1% 1% 1%O

ut Patient Efficiency (Did Not

Attends)

Adu

lt Acute In

Patient Efficiency

Older Acute In

Patient

Efficiency

CMHT Prod

uctivity

CR&HTT

Prod

uctivity

National figuresBenchmarking Information from external sources BEHMHT Data/forecast


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7. Enfield Community Services CQUIN

Goal Number Indicator Number Indicator Name

Indicator Weighting (% of CQUIN scheme available)

Expected Financial Value of Indicator

Click to go to Indicator sheet

1 a Evidence of each service conducting 2 surveys a year and meeting the target improvements set out in detailed schedule

20.00% £56,703 1st Indicator

2 b Evidence of improved end of life care for patients through increasing the number of patients on an EOL care pathway dying in their preferred place and achieving the quality standards

20.00% £56,703 2nd Indicator

3 c Evidence of improved physical activity of patients through referrals of appropriate patients for exercises, Active Enfield Schemes and Social Networks

20.00% £56,703 3rd Indicator

4 d Evidence of increased uptake of HIV testing resulting in early detection in more patients and subsequently bettter management and re‐infection rates.

30.00% £85,055 4th Indicator

5 e Evidence of improved outcomes for housebound patients through bowel cancer screening.

10.00% £28,352 5th Indicator

Total 100.00% £283,515


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Local contract ref. RRP_5C1Goal number 1Goal name Patient Experience

Indicator number aIndicator name Evidence of each service conducting 2 surveys a year and meeting the target

improvements set out in detailed scheduleIndicator weighting (% of CQUIN scheme available)

20.00%

Description of indicator Composite indicator based on a postal self‐completion survey seeking patient responses to six questions:1. Have you been involved as much as you wanted to be in decisions about your care and treatment?2. Were you given enough time to discuss your condition with healthcare professionals?3. Did staff clearly explain the purpose of any medication and side effects in a way that you could understand?4. Do you know what number/who to contact if you need support out of hours (after 5pm)?5. Overall, have staff treated you with dignity and respect?6. Overall, are you satisfied with the personal care and treatment you have received from community services?

Numerator The indicator is a single measure calculated as the average of the six scored questions for all respondents. The result is a single composite indicator with a score between 0 and 100. Each question is scored according to a pre‐defined scoring regime, which is aligned to the NHS national patient survey programme (see guidance on http://www.nhssurveys.org/)

Denominator N/ARationale for inclusion The questions used are based on questions that are used in the NHS national

patient survey programme, so they have a track record of being tested and validated among different patient groups within the NHS. This goal will help ensure that the broad range of service activities and improvements are oriented towards improving the experience of patients.

Data source ECS Data sources Frequency of data collection twice a year collectionOrganisation responsible for data collection BEH‐MHT/ECSFrequency of reporting to commissioner QuarterlyBaseline period/date First Survey Conducted by end of Quarter 2Baseline value 20% of total CQUIN Value split for each service line based on financial value

of serviceFinal indicator period/date (on which payment is based)

31st March 2010 which is date by which second survey should be completed

Final indicator value (payment threshold) Performance against baseline should at least be maintaned or impoved on (based on level baseline) to qualify for payment

Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner)

1. 5% above Baseline (where baseline was <=70%)2. 3% above Baseline (where baseline was >70% and <=90%3. Same as Baseline (where baseline >90%)

Final indicator reporting date M12 Reporting Deadline as per Section 5 of contract


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Local contract ref. RRP_5C1Goal number 2Goal name End of Life Care

Indicator number bIndicator name Evidence of improved end of life care for patients through increasing the

number of patients on an EOL care pathway dying in their preferred place Indicator weighting (% of CQUIN scheme available)

20.00%

Description of indicator Improving end of life care for people with an increse in the number of people on an EOL care pathway dying in their preferred place* and achieving the quality standards:1) 95% of patients identified as end of life should be offered an EOL care planning discussion2) 80% of patients offered a discussion should have an advanced care plan3) 98% of patients who have an advanced care plan should have a record of the decision to resuscitate stated clearly in the notes4) 98% of patients should have evidence of sharing advanced care plans and decisions taken with primary, community and acute care clearly stated in the notes.5) 30% of patients who die in the community should die on an Liverpool care pathway or equivalent pathway for the dying

*Preferred place to be identified within care plan produced as part of the Liverpool care pathway.

Target percentage increase in deaths in preferred place ‐ to be agreed locally.

Numerator Number of deaths in a patients' preferred place (as stated in EOL care plan)

Denominator Total number of deaths for patients on EOL pathway with stated preferred place of death

Rationale for inclusion In England around half a million people die each year, nearly two thirds over the age of 75. For the majority, death is preceded by a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. In London there were 50,265 deaths in 2007, representing 0.66 per cent of the population.Nationally, the DH published the End of Life Care Strategy, implementation of which is an attempt to create a joined up service, encourage healthcare practitioners to adopt robust and tested procedures to ensure effective end of life care and to ensure that, wherever possible, peoples’ wishes as to the care they receive at the end of life are respected.

Data source Community provider electronic data systemsFrequency of data collection Quarterly

The CQUIN Goal and payment requires trusts to demonstrate:∙ That patients at the end of their life have been offered a care planning discussion and have an advanced care plan∙ That patients have been given a choice of where they would prefer to die ‐ The number of patients with an advanced care plan and evidence that this decision has been taken with primary, community & acute‐ That patients with an advanced care plan have a record of the decision to rescucitate clearly documented in the notes‐ The number of patients who are on a Liverpool care pathway or equivalent pathway for the dying∙ That patients have achieved death in their preferred place

Organisation responsible for data collection Community providersFrequency of reporting to commissioner QuarterlyBaseline period/date Q1 2011/12Baseline value To be agreed for all quality standardsFinal indicator period/date (on which payment is based)

Q4 2011/12

Final indicator value (payment threshold) Increase in deaths in preferred place to be agreed with commissioner. All other quality standards to be met.


Exclusions will need to be agreed before 30/04/2011



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Local contract ref. RRP_5C1Goal number 3Goal name Physical and Mental Health Well Being

Indicator number cIndicator name Evidence of improved physical activity of patients through referrals of

appropriate patients for exercises, Active Enfield Schemes and Social Indicator weighting (% of CQUIN scheme available)

20.00%

Description of indicator To improve the holistic delivery of health care with emphasis on long term health gain. To qualify for CQUIN payment under this indicator the provider will have to demonstrate that an agreed training programme has been developed and carried out for agreed key front line staff groups and show appropriate social referral outputs.

Numerator This will be in several parts1. number of staff trained2. number of people referred on to exercise scheme

Denominator This will be in several parts1. Total staff in agreed service line(s)2. number of people completing exercise scheme

Rationale for inclusion The purpose of this indicator is to not only encourage the provider to deliver the integration benefits of the merger but to maximise capacity in local community services that contribute to the overall health and well being of the community i.e. exercise referral, active enfield schemes, social networks

Data source BEMHT/ECS Data sourcesFrequency of data collection Twice a year collectionOrganisation responsible for data collection BEMHT/ECSFrequency of reporting to commissioner QuarterlyBaseline period/date 2010/11Baseline value 20% of total CQUIN Value based on financial value of service line (ECS)

Final indicator period/date (on which payment is based)

31st March 2012

Final indicator value (payment threshold) 1. 20% of indicator value for establishing baseline value of cardiac exercise referral (Q2) 2. 30% of indicator value for agreement of and development of baseline report (Q4) for overall social referral schemes 3. 20% paid on design of training programme for key staff groups(Q2)4. 30% for delivering more than 85% of training programme to agree front line (Q4) staff groups


Payment of element 4 will be as follows:50% trained; 50% of total element value (30%)65% trained 75% of total element value85% trained 100% of total element value

Final indicator reporting date M12 Reporting Deadline as per Section 5 of contract Local contract ref. RRP_5C1 Goal number 4 Goal name HIV Testing at GU clinics

Indicator number d Indicator name Evidence of increased uptake of HIV testing

resulting in early detection in more patients and subsequently bettter management and re‐infection rates.


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Indicator weighting (% of CQUIN scheme available)

30.00%

Description of indicator This indicator looks at increasing the number of patients being tested for HIV when attending GU clinic in Enfield by changing from an opt‐in to an opt‐out approach.

Numerator Number of tests in 11/12 Denominator Total of tests in 10/11 (baseline) Rationale for inclusion In 2009/10 Enfield had 635 HIV positive

patients which cost the NHS £6.2 million in treatment and care. Whilst people are undiagnosed we run the risk that they will infect others. Currently 60% of patients attending GU have an HIV test, with opt out testing this is likely to increase to about 90%. Anticipated first visit for 2010/11 8000; changing to opt out could mean an extra 2400 tests.

Data source BEMHT/ECS Data sources Frequency of data collection Quarterly Organisation responsible for data collection

BEMHT/ECS

Frequency of reporting to commissioner Quarterly Baseline period/date 2010/11 Baseline value 30% of total CQUIN Value based on financial

value of service line (ECS)


31st March 2012

Final indicator value (payment threshold)

Increased uptake of testing above baseline (10/11 level of update)


Payment will be based on percentage of the 2400 additional tests achieved: 0% for no improvement in baseline and 100% for achievement of the 2400 (100%) target.



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Local contract ref. RRP_5C1Goal number 5Goal name Bowel Cancer Diagnosis

Indicator number eIndicator name Evidence of improved outcomes for housebound patients through bowel

cancer screening.Indicator weighting (% of CQUIN scheme available)

10.00%

Description of indicator District Nurses and other communty health professionals to support housebound patients with completing bowel cancer screening kits. The health professional will also check that patients have received an invitation and/or kit and providing the necessary support in ensuring that it has been acted on.

Numerator It is estimated that 200 extra screens will be completed if this support is provided

Denominator NARationale for inclusion The aim of this CQUIN is to boost the Bowel cancer screening programme

which aims to detect bowel cancer at an early stage (in people with no symptoms) when treatment is more likely to be effective. Bowel cancer screening can also detect polyps. These are not cancers, but may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing

Data source BEHMT/ECS Data sourcesFrequency of data collection QuarterlyOrganisation responsible for data collection BEHMT/ECSFrequency of reporting to commissioner QuarterlyBaseline period/date 2010/11Baseline value 10% of total CQUIN Value based on financial value of service line (ECS)


31st March 2012

Final indicator value (payment threshold) Improvement on 10/11 total number of screensRules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner)

10% of the CQUIN allocation for every 20 patients screened above the baseline which will be 10/11 total screens


Documents

Key Performance Indicator Definitions 2011-12 Us/Priorities and performance... · Key Performance Indicator Definitions 2011/12 ... KPI Definitions 2010/11 v.2 January 2011 2