NLG(16)222

DATE

31 May 2016

REPORT FOR Trust Board of Directors – Public

REPORT FROM

Wendy Booth, Director of Performance Assurance & Tr ust Secretary

CONTACT OFFICER

Claire Jenkinson, Head of Performance

SUBJECT

Performance Compliance Report – April 2016

BACKGROUND DOCUMENT (IF ANY)

Monitor Risk Assessment Framework

REPORT PREVIOUSLY CONSIDERED BY & DATE(S)

Trust Governance and Assurance Committee – 19 May 2016

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

This report outlines the expected governance positi on against the standards set out in the Risk Assessment Framework for the year to date up to April 2016

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

NO

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

NO

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

YES

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

N/A

THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

Ensures compliances with the regulatory framework

ACTION REQUIRED BY THE BOARD The Board is asked to review key target performance and consider any further action required

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Monitor Risk Assessment Framework

Key Performance Measures

April 2016

This Report focuses solely on the Trust’s performance against key performance measures contained within

Monitor’s 2013 Risk Assessment Framework. Any performance risks relating to key performance indicators

contained within the Trust’s contract which could potentially result in the imposition of fines and penalties is

highlighted in both the integrated performance report and the monthly trading report.

Monitor, through its Risk Assessment Framework, continues to assign a governance risk rating to reflect the quality

of governance at the Trust. Monitor uses the governance rating below in order to gauge potential escalatory

measures:

• The sum of each metric’s weighting to calculate a service performance score

• Where the Trust breaches a target systematically, this will represent a governance concern

Indicator Red Rating may apply if the Trust:- Trust

Rating

C.Difficile

• Breaches the cumulative year-to-date trajectory for 3 successive

quarters

• Breaches its full year objective

• Reports important or significant outbreak

Referral to

Treatment

Waiting

• Breaches the 18 week RTT Incomplete waiting time measure for a third

successive quarter

A&E

• Fails to meet the target twice in any two quarters over a 12 month

period and fails the indicator in a quarter during the subsequent 9

month period or the full year

Cancer

Waiting Times

• Breaches the 31-day cancer waiting time for third successive quarter

• Breaches the 62-day cancer waiting time for third successive quarter

Community

Services Data

Completeness

• Fails to maintain the threshold for data completeness for any of the

following for a third successive quarter

- RTT information

- Service referral information

- Treatment activity information

Any Indicator

Weighted 1.0

• Breaches the indicator for three successive quarters

The governance rating assigned to an NHS Foundation Trust reflects Monitor’s views of its governance:

• a Green rating will be assigned by Monitor if no governance concern is evident;

• Where Monitor identifies potential material causes for concern with the Trust’s governance in one or more of

the categories (requiring further information or formal investigation), the Trust’s green rating will be replaced

with a description of the issue and the steps (formal or informal) to be taken to address it; or

• a Red rating will be assigned if Monitor take regulatory action.

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1. Summary Performance Against National Measures for April 2016

The final 18 week Referral to Treatment (RTT) incomplete waiting time performance fell short of the 92%

threshold for April 2016 at 89.40%.

The Trust has not achieved the 95% threshold for the A&E 4 hour wait target for the seventh consecutive

month, achieving 89.8% during April 2016.

There were no reported episodes of hospital acquired Clostridium Difficile during April 2016.

Current provisional cancer data indicates the Trust will achieve five of the seven cancer indicators for April 2015

presently breaching the 62 day referral to treatment and 31 day wait anti-cancer drugs measures. The Trust

failed the Post 62 day wait GP referral for the duration of 2015/16.

Individual Performance Risk Areas

1.1 Clostridium Difficile

Clostridium Difficile – YTD Total

During April 2016, there were no hospital acquired Clostridium Difficile episodes reported. The outstanding

DIPC review during March has now been completed and has confirmed there was no lapse in care, giving the

Trust a total of 10 episodes for 2015/16.

Response from DIPC:

Whilst the Trust is monitored on the number of ‘lapses in care’, given the overall number of cases of Clostridium

Difficile cases for the year to date, an internal improvement trajectory will be set for 2016/17 and will feature in

future reports.

Clostridium Difficile – Lapses in care

There were no hospital acquired Clostridium Difficile lapses in care during April 2016.

1.2 Cancer Waiting Times (provisional position)

April provisional cancer data indicates the Trust is on track to achieve five of the seven cancer indicators for the

month, presently breaching the post and pre 62 day GP referral at 78.19% and 81.72% respectively against an

85% threshold and the 31 day anti-cancer drug measure achieving 96.88% for the 98% threshold. Low numbers

for the 31 day anti-cancer indicator, currently reporting 1 patient breaching, has impacted on performance

compliance.

The final April cancer waiting times will be submitted to the national Open Exeter database on the 7 June 2016.

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Also included in this report is a breakdown of performance by tumour site (please refer to Appendix B)

Response from Chief Operating Officer:

As was anticipated from the expected planning trajectory, the Trust has failed two out of the seven National

Cancer Standards; Cancer 62 day wait for first treatment from urgent GP referral and the 62 day consultant

screening for first treatment. Cancer Performance continues to be monitored on a daily basis as well as

reporting/monitoring to the weekly Task & Finish Group and the weekly CEO Challenge Meeting. Key breach

themes have been identified through the weekly RCA Review Meetings and continue to be monitored through

an Action Plan which is taken to the monthly TGAC Meeting. Man marking of patients is a key action to support

and bottlenecks in pathways; diagnostic and reporting capacity and endoscopy are areas under significant

demand from referrals.

1.3 A&E 4 Hour Waiting Times

The Trust has not achieved the 95% threshold for the A&E 4 hour wait target for the seventh consecutive

month, achieving a Trust wide position of 89.8% for April 2016. Attendance and performance compliance is

slightly down on last month; however attendance in March spiked to their highest level during 2015/16.

Response from Chief Operating Officer:

During 2015/16 the Trust’s performance was 93.2% over the whole year (figure subject to final validation).

Performance through each of the quarter was as follows:

Q1 95.3%

Q2 95.2%

Q3 93.7%

Q4 88.5%

Actions to Support Recovery

Continued work on weekend discharges to even out the flow of patients through the 7 day week is ongoing as

well as development of the medical model at DPOW. Additional medical staff on both sites to focus on weekend

discharges is still in place and we await a third Acute Care Physician to take up post in the next few weeks for

DPOW. A Purple bed state is still prevalent at DPOW and work to look at the escalation bed availability on this

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site is supported by Strategy and Planning colleagues who are costing and working with relevant staff to

support associated compliance issues.

The graph below depicts attendance activity and performance measure for the last seven months.

1.4 18 Week Referral to Treatment Waiting Times

The final 18 week Referral to Treatment incomplete waiting time measure fell below the 92% threshold

reaching 89.40%. Therefore, In line with Monitor’s 18 week criteria the 18 week incomplete measure will not

achieve quarter one measure for the second consecutive quarter.

Response from the Chief Operation Officer:

Achievement of RTT remains extremely challenging for the Trust and there are a number of factors that are

inhibiting capacity and these are particular to surgery.

We continue to experience:

- Cancelled operations due to bed pressures, as we see medical patients cared for in surgical ward areas.

- The ongoing theatre refurbishment at DPOW that commenced in mid-January and has been planned in

two phases seeing disruption until June. Whilst work has been moved into some evenings and

weekends, the availability of anaesthetists to support evening realigned theatre sessions has been

difficult.

- Patient choice not to move to alternative site for operation during theatre refurbishment has been

noticeable as we have moved some activity to SGH and Goole.

- Continued medical workforce vacancies in General Surgery, Head and Neck, T&O, Urology & Pain

Service review work is now a key feature of the 2016/2017 sustainability programme and required to pull

together workforce, capacity and demand and job plans that inform and influence achievement of this target.

Performance is a regular standing agenda item to ET and capacity pressures are escalated.

1.6 Other

For information, the Trust’s position in relation to Delayed Transfers of care is provided within this report

(please refer to Appendix C) although it does not form part of the Monitor Risk Assessment Framework. April’s

performance information is currently not available due to the meeting schedule.

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Recommendations for Actions: Director of Performance Assurance

The following performance concerns will need to be progressed during the remainder of 2016/17 to ensure

performance is achieved / maintained:

I. Continued focus on ensuring achievement of the Incomplete 18 Week Referral to Treatment indicator

at specialty level, especially concentrating on improving the position of both North East Lincolnshire

and Lincolnshire East CCGs. The monitoring of 18 week Referral to Treatment recovery plans for failing

specialities by clinical groups.

II. Continued focus on A&E performance to ensure the Trust maintains achievement of this target over

the coming months and builds in sufficient capacity to improve achievement over the coming months.

As outlined above, a number of actions have already been taken and plans are in place including work with other local providers.

III. Continued focus on the achievement of all Cancer Waiting Time target with the ongoing

implementation of the Trust wide cancer performance improvement plan, including the continuation of

Root Cause Analysis for all patients breaching treatment targets. The Trust forecasts performance

below threshold for Q1.

Wendy Booth

Director of Performance Assurance & Trust Secretary

May 2016

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APPENDIX A

(PROVISIONAL POSITION AS AT 20.05.16)

2015/16 QTR 2 QTR 1 Qrt 1

WEIGHTING QTR 4 Threshold Apr-16 Actual To Date

FAILURE

WEIGHTING

1. Infection Control*

Total Hospital Acquired C.Difficile Cases Lapses in Care (YTD) 1.0 G 21 0 0 G

2. Referral to Treatment Waiting Times

Incomplete - Maximum waiting time of 18 weeks 1.0 R 92% 89.40% 89.40% R

3. Cancer ***

31 day wait diagnosis to treatment 1.0 G 96% 99.2% 99.2% G

i) 31 day wait for subsequent treatments - Surgery 1.0 G 94% 100% 100% G

ii) 31 day wait for subsequent treatments - Anti cancer drugs G 98% 96.9% 96.9% R

i) 62 day wait GP referral to treatment POST alloaction R 85% 78.2% 78.2% R

ii) 62 day wait GP referral to treatment PRE allocation 1.0 R 85% 81.7% 81.7% R

ii) 62 day wait Consultant screening service referrals allocation R 90% 100% 100% G

i) 2 week wait referral to consultation 1.0 G 93% 96.2% 96.2% G

ii) 2 week wait breast symptomatic referrals G 93% 98.1% 98.1% G

4. A&E

A&E 4 Hour Wait Compliance 1.0 R 95% 89.76% 89.76% R

5. Data Completeness Community Services **

5i) Referral to treatment information 1.0 G 50% 100% 100% G

5ii) Referral Information G 50% 100% 100% G

5iii) Treatment Activity Information G 50% 89% 89% G

6. Access **

Access to healthcare for people with learning disability 0.5 G Y/N Y Y G

* Quarterly Cumulative figures Total Monitor Compliance Score 4.0

** Forecast Position Amber

*** Provisional Data Red

Monitor Compliance Rating

Monitor Over ride Rating

PERFORMANCE METRIC

MONITOR COMPLIANCE FRAMEWORK SUMMARY

Performance Against Key Thresholds For The Period 1st April 2016 to 30th April 2016

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APPENDIX B

(Provisional position as at 10.05.16)

62 day Referral to treatment (standard 85%) - APR 16 Provisional

Tumour site Total treatments in

month

Total number of breaches that

have commenced 1st treatment

in Jan (Post Allocation)

Current Post %

(Monitor)

Breast 19 0 100%

Colorectal 8.5 3 64.71%

Gynaecology 2 1.5 25.00%

Haematology 4 1 75.00%

Head & Neck 1.5 0 100%

Lung 9.5 4.5 52.63%

Other (Surgery) 0 0 100%

Skin 13 1 92.31%

Upper GI (Medicine) 2 0 100%

Upper GI (Surgery) 3 1.5 50.00%

Urology 31.5 8 84.62%

Trust Total 94 20.5 78.19%

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APPENDIX C

Delay Transfer of Care

Site Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

DPoW 10283 9983 10211 10,374 10,152 9,933 10,462 10,085 10,475 11,000 10149 10898

443 305 315 341 223 282 299 302 358 385 271 289

4.3% 3.1% 3.1% 3.3% 2.2% 2.8% 2.9% 3.0% 3.4% 3.5% 2.7% 2.7%

SGH 8867 9577 8871 8,862 9399 8,820 9,433 8,775 9,144 9,566 8970 9328

109 139 163 287 159 204 134 173 231 149 216 271

1.2% 1.5% 1.8% 3.2% 1.7% 2.3% 1.4% 2.0% 2.5% 1.6% 2.4% 2.9%

GDH 539 657 620 627 644 684 678 572 586 644 550 570

36 28 24 57 38 39 56 63 64 35 10 17

6.7% 4.3% 3.9% 9.1% 5.9% 5.7% 8.3% 11.0% 10.9% 5.4% 1.8% 3.0%

Trust 19689 20217 19702 19,863 20,195 19,437 20,573 19,432 20,205 21,210 19669 20796

588 472 502 685 420 525 489 538 653 569 497 577

3.0% 2.3% 2.5% 3.4% 2.1% 2.7% 2.4% 2.8% 3.2% 2.7% 2.5% 2.8%