REPORT TO THE BOARD OF DIRECTORS (IN PUBLIC) … June 2020.pdfCarly West-Burnham Director of Strategy Strategic Operational Governance RELATED WORK: (PREVIOUS PEER ASSIST: PEER REVIEW:

REPORT TO THE BOARD OF DIRECTORS (IN PUBLIC)

RESPONSIBLE DIRECTOR: REPORT FOR: IMPACT ON BUSINESS:

Caroline Shaw Chief Executive Officer

Decision High Med Low

Discussion

Information

LEAD MANAGER: REPORT TYPE: BAF REFERENCES & RAG:

Carly West-Burnham Director of Strategy

Strategic

Operational

Governance RELATED WORK: (PREVIOUS PAPERS TO COMMITTEE) PEER ASSIST: PEER REVIEW:

Executive Directors

CQC Domain: (safe, caring, effective, responsive, well-led)

Well-led

Meeting Date: 2

June 2020

Report Title: Integrated Performance Report

PURPOSE:

This cover paper accompanies the attached Integrated Performance Report (IPR).

SUMMARY:

The Trust is required to provide assurance that its approach to performance management

is rigorous and appropriately identifies, escalates and deals with areas of performance

which are of concern in a timely manner.

This is the first month where Plot the Dots (Statistical Process Control) has been used

within the IPR.

Focusing on the data in this way, will enable greater visibility and oversight of areas which

require clear focus due to ongoing issues in relation to performance, rather than those

which are delivering within the parameters of agreed statistical variation.

RISK ASSESSMENT (CROSS-REFERENCE WITH RISK REGISTER WHERE APPROPRIATE):

Strategic / External

Operational/ Organisational

Financial Clinical Legal/ Regulatory

Reputational / Patient

Experience

RECOMMENDATION/S:

The Trust Board are asked to note the contents of this report, specifically the actions which

are being taken to maintain and to improve performance where appropriate. Author: Carly West-Burnham Date: 27

th May 2020

Version: 1.0

Agenda Item: 11

Page | 1

Integrated Performance Report

Trust Board

April 2020 data

Page | 2

Contents

1. 2.

Executive Summary Domain Reports

- Safe

Page 7

- Effective

Page 15

- Caring

Page 32

- Responsive

Page 39

- Well-led (Finance & Detailed Finance Report)

Page 50

- Well-led (People)

Page 53

Page | 3

Executive Summaries

Safe

There have been no never events in April 2020.

There were four new serious incidents reported to the Strategic Executive Information System (StEIS)

in April 2020.

There have been no cases of MRSA bacteraemia in April.

There have been two cases of Clostridiodes difficile in April.

There were sixteen hospital acquired pressure ulcers in April, an increase from the four reported last

month and eight of these were in the Intensive Care Unit (ICU).

The staffing fill rate for the Trust overall was above 95.86%.

VTE assessment compliance this month is below the Trust target of 97.24%.

Effective

Published standardised mortality rates remain as expected with no new alerts. A detailed review of

deaths following weekend admissions was presented at the Quality Committee and revealed no

lapses in care.

There were significantly more deaths in April due to COVID-19 in line with national reporting. A

detailed review of all COVID-19 related deaths is underway and will be presented in June.

Research activity has also been significantly higher in April due to an excellent response to the

national call to support COVID-19 related research.

Caring

There were 11 complaints received in April against a threshold of 20 per month

88.5% of complaints were responded to within 30 days.

Mixed sex accommodation (MSA) remains red this month following three occurrences which affected

nine patients.

The current Trust position (March 2020) with regard to dementia case finding is at 45.3 % which is

below the Trust target of 90%.

Responsive

Four hour Performance in April 2020 was 92.7% against the standard of 95% and the trajectory of

85.9%. 59% of ambulance handovers were completed within 15 minutes.

18-week referral to treatment (RTT) performance in April 2020 was 62.90% against the standard of

92%. At the end of April 2020, the total Trust waiting list was 12,160 and the total backlog of

patients waiting over 18 weeks was 4,609. There were 46 52-week breaches and 40 breaches of the

28-day readmission guarantee in April 2020.

Six-week diagnostic performance in April 2020 was 65.6% against the standard of 1%. The Trust

achieved all seven cancer waiting time standards in March 2020.

Well-led (Finance)

The Trust has reported a break-even position for month one following an assumption that the Trust

will receive reimbursement for all COVID-19 related costs. This is in line with the national guidance of

accounting for ‘block’ income, ‘top-up’ payments, taking account of COVID-19 reimbursements and

the retrospective ‘top-up’ mechanism, to bring the overall income and expenditure position back to a

Page | 4

balanced position.

An additional £0.597m of top-up income is required for month one to achieve this break-even

position.

Well-led (People)

Sickness absence has increased significantly and is now at 8.46% against a target of 4%; however,

38.8% of this sickness is related to COVID-19. If absences related to COVID-19 are excluded, then the

sickness absence rate would sit at 5.14%.

Due to COVID-19 the mandatory training requirements have been reduced to four courses only with

additional training provided for COVID-19. This is having a significant impact on the compliance for

all mandatory training with an 82% compliance rate against a target of 95%.

While the appraisal rate for medical staff sits at 94% against a target of 95%, appraisals for other

groups of staff is below target at 78% against a 90% target.

Page | 5

A note on SPC Charts

The report that follows uses the key below. A recap of using these descriptions is also included below

Page | 6

A note on SPC Charts continued

High level Key - Variation High level Key - Assurance

Common

Cause

Hit and miss

target

subject to

random

Consistently

pass target

Consistently

fail target

Variation Assurance

Special cause

Concerning variation

Special cause

Improving variation

Are we improving, declining

or staying the same

Blue = significant improvement

or low pressure

Grey = no

significant change

Orange = significant

concern or high pressure

Can we reliably hit

target?

Orange = system change

required to hit target

Blue = will reliably hit

target

Hit and miss target

Page | 7

1. DOMAIN REPORTS

Items in grey are awaiting the latest update.

Safe Dashboard

Apr-20 Falls Rate per 1000 beddays 0.98 0.36 Common Cause (expected) variation Capable

Apr-20 PUs Rate per 1000 beddays 0.00 2.14Special cause

(unexpected)

variation - Concern

(H)

Random

Apr-20 Overall Fill Rate % 80.0% 84.0%Special cause

(unexpected)

variation - Concern

(L)

Capable

Mar-20 Cleanliness - Very High Risk 95.0% 97.3% Common Cause (expected) variation Random

Mar-20 Cleanliness - High Risk 95.0% 96.3% Common Cause (expected) variation Random

Mar-20 Cleanliness - Significant Risk 95.0% 94.8%Special cause

(unexpected)

variation -

Improvement (H)

Random

Mar-20 Cleanliness - No. of audits complete 37.00 41 Common Cause (expected) variation Random

Apr-20 CDiff Rate per 100k beddays 17.60 31.54Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Apr-20 E Coli Rate per 100k beddays 0.00 10.51Special cause

(unexpected)

variation -

Improvement (L)

Not Capable

Apr-20 MSSA Rate per 100k beddays 0.00 6.31 Common Cause (expected) variation Not Capable

Apr-20 CHPPD 8.00 11.92Special cause

(unexpected)

variation -

Improvement (H)

Random

Mar-20 VTE Assessment Completeness 97.2% 93.6%Special cause

(unexpected)

variation - Concern

(L)

Random

Apr-20 Serious Incidents (DECLARED IN MONTH) 0 7

Apr-20 CDiff Actual 4 2

Apr-20 MRSA Actual 0 0

Apr-20 E Coli Actual 0 0

Apr-20 MSSA Actual 0 1

Apr-20Patient Safety Alerts not completed by

deadline0 0Mar-20 Cleanliness - Low Risk 95.0% 91.8%

Page | 8

Never Events

There have been no never events in April 2020.

Serious Incidents Issues: There were four new serious incidents reported to the Strategic Executive Information System (StEIS) in April 2020;

1. Delay in diagnosis

2. Two incidents of failure to act on adverse test results or images

3. Test results / images - available but inaccurate

Details of SI reported to STEIS in April 2020

SI Declared Date

Category SI RCA Due

Date

09/04/2020

Delay in diagnosis for no specified reason

Patient sustained a fractured neck of femur

08/07/2020

23/04/2020

Failure to act on adverse test results or images

Undetected deterioration in a patient with Glaucoma

24/07/2020

23/04/2020


Error identified through radiology discrepancy meeting; patient subsequently diagnosed with lung cancer

24/07/2020

27/04/2020

Test results/ images - available but inaccurate

Error identified through radiology discrepancy meeting, patient awaiting outcome of lymph node biopsy

24/07/2020

Actions;

Page | 9

Delay in diagnosis for no specified reason

Patient attended Theatre and underwent a left dynamic hip screw

Duty of Candour completed by Ward Sister.


Review of clinical notes

Medical Director has convened a meeting to establish if this is an isolated incident or a wider concern impacting on more than one

patient.

Test results/ images - available but inaccurate

Both of these SIs have been identified through the radiology discrepancy meeting where the individual cases have been peer discussed

and specific test learning shared with colleagues in the department.

All SI’s were reported to STEIS within the 48 hour period as required.

Page | 10

Pressure ulcers

Issues;

There were sixteen hospital acquired pressure ulcers reported in April

There has been a downward trend in pressure ulcer incidents over the last year, however, sixteen were reported in April which is an increase

from last month’s incident of four. Eight out 16 incidents were reported in ITU relating to COVID-19 patients who were put in the prone

position while the remaining eight were reported on ward areas. From the forum of Tissue Viability Nurses (TVN), the increase in pressure

ulcer incidents at QEH is consistent with the national trend and reporting. Some similar sized organisations have reported more pressure ulcer

incidents than the QEH.

In the last year, we have seen a reduction of 16% in the total number of pressure ulcer incidents. The reduction in pressure ulcers has been

achieved by the TVN team working collaboratively with the wards, maintaining a high level of visibility and availability on the wards, in

conjunction with taking over the delivery of mandatory training and continuing with the already well-established clinical induction, student

nurse induction, HCA teaching and bespoke ward-based teaching. This has then been further strengthened by the introduction of the ASKINS

Data To KPI Description TargetCurrent

ValueVariance Assurance

Trust

mmm yy

Decimel

Variation Comment Target Achievement

Special cause (unexpected) variation - Concern

(H)

Variation indicates inconsistently passing and

falling short of the target

0.0

0.5

1.0

1.5

2.0

May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20

Mean PUs Rate per 1000 beddays Process limits - 3σ Special cause - concern Special cause - improvement Target

PUs Rate per 1000 beddays - Trust starting 01/05/18

Apr-20 PUs Rate per 1000 beddays 0.00 2.14Special cause

(unexpected)

variation - Concern

(H)

Random

Page | 11

pressure ulcer prevention booklet, given to all staff aimed at supporting accurate pressure ulcer assessment and providing a point of

reference for further guidance. In addition, there was a relaunch of the 100 days free campaign in December 2019. This campaign monitors

and counts the number of hospital acquired pressure ulcers developed per ward and crucially, if any lapses in care were identified for each

incident. For every 100 consecutive days the ward goes without a pressure ulcer developing they are rewarded with cake to celebrate the

teams hard work and reinforce good practices. Eleven wards have now reached the first 100 days milestone including: ITU, Denver, Elm,

Gayton, Oxborough, Shouldham, Stanhoe, Tilney, West Newton, West Raynham and Windsor. Actions;

The Tissue Viability Team are supporting the ward areas by daily monitoring and working with the nursing staff. In particular, they are

working closely with the ITU team to find ways to reduce the occurrence of pressure ulcers in patients placed in the proning position.

In order to reduce harm associated with hospital acquired pressure ulcers, the team drafted a comprehensive work plan for this year

which will be reported to the Harm Free Care forum. The work plan will include supporting total bed management implementation, a

pressure ulcer summit, enhanced teaching sessions and raising the profile of 100 days free initiative.

Page | 12

Clostridium Difficile

Issues;

There have been two cases of C. diff in April against the Trust objective of between two and three a month. Root cause analysis meetings

have been scheduled to identify learning from these cases.

The total number of cases last year was 45 and the Trust’s year end trajectory was 44. Five cases are awaiting the appeals procedure, three

awaiting root cause analysis, 12 have been successfully appealed as there were no lapses in care identified therefore 25 cases currently count

towards the trajectory of 44.

Actions;

The IPAC team have been increasing staff awareness of the appropriate management of patients with diarrhoea and /or vomiting

through scheduled training.

One-to-one teaching with clinical staff on the wards.

The Antimicrobial Pharmacist is working closely with the Microbiology Team to ensure prudent use of antimirobials is embedded



Trust

mmm yy

Decimel



(H)

Variation indicates consistently (F)alling short

of the target

14.0

16.0

18.0

20.0

22.0

24.0

26.0

28.0

30.0

32.0


Mean CDiff Rate per 100k beddays Process limits - 3σ Special cause - concern Special cause - improvement Target

CDiff Rate per 100k beddays - Trust starting 01/05/18

Apr-20 CDiff Rate per 100k beddays 17.60 31.54Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Page | 13

VTE Assessment

Issues;

VTE assessment completeness has been declining over the past two quarters but has significantly deteriorated to 92.89% in quarter four.

Performance in March 2020 was 93.64 (with 349 patients missing their assessments).

The main drivers of this deterioration, particularly in the month of March, were reduced compliance in Ambulatory Care with 227 out of 349

patients missing their screening.

Clinical location Number of patients recorded as not assessed

AEC 227

AMU 32

SAU 37

SDEC 11



Trust

mmm yy

Percentage



(L)



87.5%

89.5%

91.5%

93.5%

95.5%

97.5%

99.5%

Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20

Mean VTE Assessment Completeness Process limits - 3σ Special cause - concern Special cause - improvement Target

VTE Assessment Completeness - Trust starting 01/04/18

Mar-20 VTE Assessment Completeness 97.2% 93.6%Special cause

(unexpected)

variation - Concern

(L)

Random

Page | 14

Multiple discussions have been had both by Medical and Deputy Medical Directors with the Divisional Leadership Teams to understand why

we are now failing the target and to reinforce the need for compliance with this process.

The documentation used in the surgical assessment unit (the SAU clerking booklets) had been changed late 2019. These abbreviated booklets

are quicker to complete but no longer include the section on VTE screening resulting in non-compliance in many surgical specialties and

Gynaecology. An assessment is still typically performed and this should always be checked by the onsultant at the time of senior review, but

the automatic prompt for this had been lost. This has now been rectified (May 2020).

The specific Ambulatory Emergency Care (AEC) unit paperwork is similarly abbreviated and does not provide a proforma for VTE assessment.

The new Same-Day Emergency Care Unit was also opened late in 2019 and blank sheets were initially used for assessment in this area. The

vast majority of the patients going through these units are ambulatory and their length of stay is between four and 12 hours and so they are

very low risk for VTE. However, clinicians do still need to undertake these assessments. The small number of higher risk patients who require

admission from these areas are transferred to the Acute Medicine Unit where the standard clerking booklets are in use. These do include the

VTE assessment, and this should also be checked on the post take round, but there is no robust system to ensure this takes place for the

ambulatory patients seen in these areas.

Finally, patients transferred directly to a COVID-19 Assessment Ward from the ED have their initial assessment recorded on the ED electronic

system, which is printed and filed in the notes with continuation sheets used thereafter. There has therefore been no reminder in place for

VTE (or dementia screening) for these patients.

Reinforcement of these reminders would certainly improve screening rates.

Actions;

The VTE sheets have been added to existing clerking proformas on SAU. Standard clerking booklets have been added to the notes for all

patients admitted to the COVID-19 assessment unit,s to be completed on admission to the ward with immediate effect.

The AEC and SDEC assessment sheets are also being redesigned to include both VTE and dementia screening proformas.

Mitigations;

Individual meetings have been held with the Clinical Directors of all specialties not complying with the target of 97.24%, to reinforce the

need for Consultants to always double-check that VTE assessment has been undertaken, on their post-take ward round or senior review. A

process change through the Senior Nursing Team to monitor and remind clinical teams to improve screening rates has also been made in AEC,

SDEC and AMU.

Page | 15

Items in grey are awaitng the latest update

Effective Dashboard

Mar-20 Stillbirth Rate 3.73 4.40Special cause

(unexpected)

variation - Concern

(H)

Random

Mar-20 Neonatal Deaths Rate 1.06 0.49Special cause

(unexpected)

variation - Concern

(H)

Capable

Mar-20 Extended Perinatal Deaths Rate 4.79 4.89Special cause

(unexpected)

variation - Concern

(H)

Capable

Mar-20 Total C Section Rate 25.0% 26.6% Common Cause (expected) variation Random

Mar-20 EL C Section Rate 10.0% 8.4% Common Cause (expected) variation Random

Mar-20 EM C Section Rate 15.0% 18.2% Common Cause (expected) variation Random

Jan-20 HSMR Crude Rate 3.18 2.79Special cause

(unexpected)

variation -

Improvement (L)

Random



Apr-20Rate per 1000 admissions of inpatient

cardiac arrests2.00 0.07 Common Cause (expected) variation Random

Apr-20 No. of patients recruited in NIHR studies 50 307Special cause

(unexpected)

variation -

Improvement (H)

Random

Apr-20 % "Term" admissions to the NNU 3.00% 8.64% Common Cause (expected) variation Random

Apr-20% "Avoidable Term" admissions to the

NNU0.00% 7.14% Common Cause (expected) variation Random



Apr-20 Maternal Deaths 0 0

Jan-20 HSMR Relative risk 100.00 102.34Special cause

(unexpected)

variation -

Improvement (L)

Not Capable

Jan-20 HSMR Weekend Relative risk 100.00 116.61Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Sep-19 SHMI 100.29 As Expected

Page | 16

Mortality

Issues;

The HSMR for January 2020 was 102.3. Although this is slightly higher than the previous month of 101.5 (December 2019) this is still with

expected levels.

Actions;

HSMR has been consistently within acceptable range for the year 2019-20.



Trust

mmm yy

Decimel


Special cause (unexpected) variation -

Improvement (L)


of the target

93.8

95.8

97.8

99.8

101.8

103.8

105.8

107.8

109.8

111.8

Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20

Mean HSMR Relative risk Process limits - 3σ Special cause - concern Special cause - improvement Target

HSMR Relative risk - Trust starting 01/02/18

Jan-20 HSMR Relative risk 100.00 102.34Special cause

(unexpected)

variation -

Improvement (L)

Not Capable

Page | 17

SHMI


Value

Sep-19 SHMI 100.29 As Expected

Page | 18

Issues;

SHMI was at 100.29 for September 2019. This is in the ‘as expected’ range. This is in line with HSMR.

Actions;

The revised Mortality Surveillance Group is providing enhanced insight into our mortalities. Its structure and reporting template have been

widely discussed with the bed-holding divisions, and engagement of the Divisional Leadership Teams has improved since the restructure. A

review process is now in place to scrutinise all deaths related to COVID-19 to understand any learning from these deaths and to identify any

examples of good practise or suboptimal care. A continuous update of learning from these deaths will be provided to the Quality Committee

from May 2020 onward.

Page | 19

Weekend mortality

Issues;

The mortality (HSMR) of patients initially admitted on weekends remains significantly higher (117.1) than that reported for patients admitted

on weekdays. Actions;

A full investigation has now been repeated.

No concerns in care have been identified, and good access to senior oversight and access to diagnostic tests

was noted within the case note reviews.

A detailed report on this exploring the difference in the case mix

of patients admitted on weekend days has presented to the Quality Committee in May 2020.



Trust

mmm yy

Decimel



(H)


of the target

95.0

100.0

105.0

110.0

115.0

120.0

Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20

Mean HSMR Weekend Relative risk Process limits - 3σ Special cause - concern Special cause - improvement Target

HSMR Weekend Relative risk - Trust starting 01/02/18

Jan-20 HSMR Weekend Relative risk 100.00 116.61Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Page | 20

Mitigations;

The Mortality Surveillance Group will continue to focus on ensuring the primary diagnosis and coding of co-morbidities is accurate paying

particular attention to COPD patients admitted at the weekend. All future weekend deaths will be subject to Structured Judgement Reviews,

as well as any deaths which have been identified by the Medical Examiner as being potentially preventable, or which may demonstrate

learning, and all deaths about which family members have expressed any concerns.

Number of deaths in April 2020

Issues;

There were 167 deaths in the hospital in April 2020. Figure six demonstrates that this is significantly higher than is typical for April – with a

mean of 98 deaths during this month over the last eight years. This equates to 45.7 deaths per 1,000 admissions as compared to 19.7 deaths

per 1,000 admissions in March 2020. The highest number of deaths occurred on the designated COVID-19 wards – (Stanhoe, Tilney, Windsor

and Oxborough). The Critical Care Unit designated for the care of patients with COVID-19 also recorded nine deaths.

There was significant reduction in planned activity during April 2020 compared to March 2020 (3608 admissions in April 2020 compared to

6089 admissions in March 2020) and so the case mix for this month is atypical compared to other years.

As expected, the highest number of deaths (89 out of 167) were recorded be against a diagnosis of COVID-19, however clinical coding of all

patient deaths has not yet been completed.

114 110

86 81 96

105 100 90

167

0

50

100

150

200

Apr-2012 Apr-2013 Apr-2014 Apr-2015 Apr-2016 Apr-2017 Apr-2018 Apr-2019 Apr-2020

Number of Deaths

Number of Deaths Mean UCL LCL

Page | 21

Actions;

Structured Judgement Reviews (SJR) are being undertaken on all deaths ascribed to COVID-19. 36 reviews (out of 126 deaths to date) have

been completed with no avoidable deaths identified to date. However, these reviews have identified some potential Hospital Acquired

Infections, and have identified that some patients might have been discharged prematurely (stable clinical condition at the time of discharge

but with a subsequent deterioration at home). A detailed analysis of this learning will be presented through the Quality Committee in June

2020. This will also include a detailed analysis of the age and comorbidity profiles of the patients who have died, benchmarked against

national data.

Mitigations;

There is continued scrutiny for any lapses in the clinical care provided to our patients as we adapt to a changing climate of national

treatment and infection prevention and control guidance. A detailed report on the learning from these deaths will be submitted to the

Quality Committee of the Trust Board in June 2020 and as required thereafter, to provide assurance on the quality of clinical care provided

for patients.

Page | 22

Clinical Audit

Issues;

The Trust participated in 88% (38 out of 43) Healthcare Quality Improvement Programme (HQIP) national audits during 19/20.

There is variance across audits in terms of % submission in order to meet the compliance requirements

Actions:

Under the leadership of the Director of Patient Safety supported by the Deputy Medical Director, a quality review of all clinical audits

has commenced to ensure data input is accurate and complete.

HQIP National Audits have been prioritised as the Quality Agenda for the Trust and the current process of data acquisition and

reporting is being revised to provide assurance to the Trust Board.

A recovery plan has been developed.

Page | 23

Clinical Research and Innovation

Issues;

Clinical research remains on track to exceed our recruitment target for this year although monthly accruals to individual studies varies.

We have also achieved our funding targets. During the pandemic, the Research Department was mandated by the Comprehensive Research

Network to focus on supporting clinical teams on the most urgent public health studies relating to COVID-19.

Actions;

We are working on five of these, while maintaining and following-up with patients already on clinical trials. Currently, QEH is enrolled for all

available national trials this includes a recovery trial (that has now been extended into six different treatment options). QEH has recruited 42

patients to date in this trial (JPUH has recruited 47 and NNUH 26 patients). In addition, we have recruited over 500 patients to four

observational COVID-19 studies in April. QEH has also submitted an expression of interest to join a study using Hydroxy/Chloroquine

prophylaxis and to be considered as a potential study site for vaccine testing – both of which seek to prevent COVID-19 in frontline NHS staff.



Trust

mmm yy

Integer



Improvement (H)



0

50

100

150

200

250

300


Mean No. of patients recruited in NIHR studies Process limits - 3σ Special cause - concern Special cause - improvement Target

No. of patients recruited in NIHR studies - Trust starting 01/05/18

Apr-20 No. of patients recruited in NIHR studies 50 307Special cause

(unexpected)

variation -

Improvement (H)

Random

Page | 24

Maternity - Caesarean Section rates



Trust

mmm yy

Percentage


Common Cause (expected) variationVariation indicates inconsistently passing and


19.1%

24.1%

29.1%

34.1%

39.1%

44.1%


Mean Total C Section Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Total C Section Rate - Trust starting 01/04/18

Mar-20 Total C Section Rate 25.0% 26.6% Common Cause (expected) variation Random

Page | 25



Trust

mmm yy

Percentage




5.5%

7.5%

9.5%

11.5%

13.5%

15.5%

17.5%

19.5%

21.5%


Mean EL C Section Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

EL C Section Rate - Trust starting 01/04/18

Mar-20 EL C Section Rate 10.0% 8.4% Common Cause (expected) variation Random



Trust

mmm yy

Percentage




8.6%

10.6%

12.6%

14.6%

16.6%

18.6%

20.6%

22.6%

24.6%

26.6%


Mean EM C Section Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

EM C Section Rate - Trust starting 01/04/18

Mar-20 EM C Section Rate 15.0% 18.2% Common Cause (expected) variation Random

Page | 26

Issues;

Caesarean section rates continue to remain above recommended rates of 25%.

Actions;

Over the last 12 months, consultant presence on the delivery suite has increased to 60 hours per week, compliance with CTG training has

improved, high risk antenatal clinics and instrumental delivery MDTs have all been introduced to address this.

Improvements have been achieved compared to 2018/2019 data, although these do not yet achieve statistical significance.

Between April 2018-March 2019, the mean caesarean rate was 33.3%. This has reduced to 28.8% in 2019-2020 – (see Figure 10). A new

consultant rota was also agreed, supported by the appointment of additional consultant staff.

Comparison between 2018-19 & 2019-2020 in caesarean section rates.

Mitigations;

The new consultant obstetrician rota was planned to start in March. However, its introduction was delayed due to COVID-19 related absence

within the directorate and this will now go live in June 2020. This will support tighter scrutiny on caesarean sections through MDT discussions,

weekly multidisciplinary CTG meetings, improved counselling for women who have had a previous caesarean section, more senior clinical

input into decision making, ongoing scrutiny and service improvements of high-risk clinical pregnancies. A detailed audit into caesarean

sections is being presented at the Quality Committee June 2020 to help understand which actions have been most effective and where future

work should focus to reduce preventable caesarean sections.

0

10

20

30

40

50

C/S rates Mean UCL LCL

0

10

20

30

40

C/S rates Mean UCL LCL

Page | 27

Admissions to NICU



Trust

mmm yy

Percentage




2.9%

3.9%

4.9%

5.9%

6.9%

7.9%

8.9%

9.9%

10.9%

11.9%

Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20

Mean % "Term" admissions to the NNU Process limits - 3σ Special cause - concern Special cause - improvement Target

% "Term" admissions to the NNU - Trust starting 01/04/19

Apr-20 % "Term" admissions to the NNU 3.00% 8.64% Common Cause (expected) variation Random



Trust

mmm yy

Percentage




0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20

Mean % "Avoidable Term" admissions to the NNU Process limits - 3σ Special cause - concern Special cause - improvement Target

% "Avoidable Term" admissions to the NNU - Trust starting 01/04/19

Apr-20% "Avoidable Term" admissions to the

NNU0.00% 7.14% Common Cause (expected) variation Random

Page | 28

Issues;

There were 14 admissions in month which equates to 8.6% of all births. This is consistently above the national target of 6% and our local

target of 3%. Trust level reporting will be revised in line with the national target from June 2020.

However, of these 14 admissions, only one was a potentially avoidable admission of a term infant in whom there was poor feed

documentation (7.1% of all term admissions). The review suggested that had the baby been fed in the first hour as per recommendations,

their consciousness and sugar levels might had been maintained and subsequent admission to NICU might have been avoided.

Actions;

The individuals involved in the care of this mother and the wider team has been reminded of the need to encourage feeding within the first

hour as well as for detailed monitoring and documentation.

We have completed the first MatNeo project which was linked to hypoxia and have sustained a low admission rate to NICU for hypoxia with

no cooling cases for the last 11 months. The next MatNeo project is smoking cessation which will commence in June/July once the Local

Maternity System (LMS) restarts. This aims to further reduce the number of term admissions

Previous admissions have also been due to neonatal jaundice with a failure to always monitor this closely and to intervene early enough. The

jaundice guideline has therefore been revised and updated in line with NICE guidance. Compliance with the pathway will then be audited

after six months. The postnatal readmission audit (which includes jaundice review) will be presented to the Quality Committee in June.

We have also updated the Transitional Care Guideline and once implemented this will also support alternative pathways to avoid admission

to NICU.

Mitigations;

ATAIN Reviews are undertaken monthly of all Neonatal Unit admissions to understand the reasons behind every admission. The national

ATAIN programme forms part of the Maternity Transformation Programme with the overall aim of achieving 50% reduction of stillbirths,

neonatal deaths and brain injury by 2025. The ATAIN action plan will be reported and a quarterly report will be presented through the

Maternity Safety and Strategy Forum (MSSF) and Clinical Governance Executive Group with the initial aim to meet the national target of 6%

consistently and then to aim for our local target of 3%.

Any changes to post-natal care pathways should have an immediate effect, but early pregnancy interventions e.g. smoking cessation are not

expected to impact outcomes until those women reach delivery.

Page | 29

Perinatal mortality



Trust

mmm yy

Decimel

Target AchievementVariation Comment

Variation indicates inconsistently passing

and falling short of the target


(H)

1.76

2.26

2.76

3.26

3.76

4.26


Mean Stillbirth Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Stillbirth Rate - Trust starting 01/04/18

Mar-20 Stillbirth Rate 3.73 4.40Special cause

(unexpected)

variation - Concern

(H)

Random



Trust

mmm yy

Decimel



(H)

Variation indicates consistently (P)assing the

target

0.0

0.2

0.4

0.6

0.8

1.0


Mean Neonatal Deaths Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Neonatal Deaths Rate - Trust starting 01/04/18

Mar-20 Neonatal Deaths Rate 1.06 0.49Special cause

(unexpected)

variation - Concern

(H)

Capable

Page | 30

Issues;

There has been a rise in perinatal death rates for three reasons. Firstly, the birth rate has fallen consistently since January 2019. Second, the

stillbirth in February was followed by a second stillbirth of 35+5-week twins in March. This case has also been reviewed extensively and was

found to be a delayed presentation of the mother to the delivery suite, by which time ultrasound confirmed intrauterine death of the 2nd

twin. The twins were then delivered by C/S but no care delivery concerns were identified. Thirdly, a neonatal death was reported in January

following discharge from our maternity unit. This has also been reviewed and classed as a Sudden Death in Childhood (SUDIC). This has been

escalated to the Child Death Overview Panel but there are currently no clinical concerns associated with this death. The Maternity

Transformation Programme is working towards a 50% reduction of stillbirths, neonatal deaths and brain injury. This formal programme is

currently suspended due to COVID-19, but we are still working towards this with LMS work stream meetings planned to restart in June. Any

lessons learnt from individual cases are shared with the team. No care concerns have been identified in the cases reported over the last year.

Actions;

Local Maternity System work stream meetings are planned to restart in June.



Trust

mmm yy

Decimel



(H)

Variation indicates consistently (P)assing the

target

1.76

2.26

2.76

3.26

3.76

4.26

4.76


Mean Extended Perinatal Deaths Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Extended Perinatal Deaths Rate - Trust starting 01/04/18

Mar-20 Extended Perinatal Deaths Rate 4.79 4.89Special cause

(unexpected)

variation - Concern

(H)

Capable

Page | 31

Caring Dashboard - Trust LevelItems in grey are awaiting the latest update

Apr-20 MSA Incidents 0 3 Common Cause (expected) variation Random

Apr-20 MSA Breaches 0 9 Common Cause (expected) variation Random

Apr-20 Total Clinical & Non_Clinical Complaints 20 11Special cause

(unexpected)

variation -

Improvement (L)

Random

Apr-20 Complaints - Rate per Staff In Post 0.60% 0.36%Special cause

(unexpected)

variation -

Improvement (L)

Random

Mar-20 Dementia Case Finding 90.0% 45.3% Common Cause (expected) variation Not Capable

Apr-20 FFT % Recommended (IP & DC) 95.00% 94.68% Common Cause (expected) variation Random

Apr-20 FFT Resp Rate (IP & DC) 30.00% 4.40%Special cause

(unexpected)

variation - Concern

(L)

Random

Apr-20 FFT % Recommended (AE) 95.00% 100.00%Special cause

(unexpected)

variation -

Improvement (H)

Random

Apr-20 FFT Resp Rate (AE) 20.00% 0.15%Special cause

(unexpected)

variation - Concern

(L)

Random

Apr-20 FFT % Recommended (OP) 95.00% 100.00%Special cause

(unexpected)

variation -

Improvement (H)

Capable

Apr-20 FFT Resp Rate (OP) 0.45%Special cause

(unexpected)

variation - Concern

(L)

Apr-20Complaints Rate per AE Atts, IP Adms & OP

Activity0.00% 0.04% Common Cause (expected) variation

Apr-20Complaints receiving a response within 30

working days %90.0% 88.5%

Special cause

(unexpected)

variation -

Improvement (H)

Not Capable

Apr-20 Complaints - Reopened (% of Total) 15.0% 0.0% Common Cause (expected) variation Random


ValueVariance AssuranceData To KPI Description Target

Current


Apr-20FFT % Recommended Mat Question 1

(Antenatal)95.00% 100.0% Common Cause (expected) variation Random


(Labour)95.00% 100.0% Common Cause (expected) variation Random


(Postnatal)95.00% 100.0%

Special cause

(unexpected)

variation -

Improvement (H)

Random


(Comm Postnatal)95.00% 100.0% Common Cause (expected) variation Capable

Apr-20 FFT Resp Rate Mat Question 2 (Labour) 15.00% 9.4% Common Cause (expected) variation Random

Page | 32

Mixed Sex Accommodation breaches



Trust

mmm yy

Integer



and falling short of the targetCommon Cause (expected) variation

0

2

4

6

8

10


Mean MSA Incidents Process limits - 3σ Special cause - concern Special cause - improvement Target

MSA Incidents - Trust starting 01/05/18

Apr-20 MSA Incidents 0 3 Common Cause (expected) variation Random Return to

Page | 33

Issues;

There have been three occurrences of same-sex accommodation breaches this month which affected nine patients. This is a reduction from

last month’s five. All occurrences were in the Hyper-Acute Stroke Unit. The main reason for the breaches was due to unavailability of suitable

beds when patients are ready to be stepped down from high level to ward level care.

The QEH reported breaches are in line with the national guidance.

Actions;

Continuous monitoring at the divisional governance meeting and escalation at the daily patient flow meeting.

There is now an increased awareness amongst the MDT to escalate and mitigate if breaches occur in the unit.

Active conversation with patients of the reason for breaches and maintaining their privacy and dignity.

There have been no concerns raised by patients or relatives with regard to same-sex accommodation breaches.



Trust

mmm yy

Integer




0.0

5.0

10.0

15.0

20.0

25.0


Mean MSA Breaches Process limits - 3σ Special cause - concern Special cause - improvement Target

MSA Breaches - Trust starting 01/05/18

Apr-20 MSA Breaches 0 9 Common Cause (expected) variation Random

Page | 34

Dementia Case Finding

Issues;

Dementia Case finding rates have been consistently falling short of recommended target levels of 90%. Performance in March was 45.3%.

Average performance over the year was 45.6%

The current screening process is unfit for purpose, exacerbated by the withdrawal of an incentive (CQUIN) two years ago. The current

screening process is confused (with different age ranges quoted in different areas), overly-complicated and requires completion of an

elaborate and outdated assessment process. Screening has also lost its clinical relevance as no clinical actions are taken in response to the

screen.

Actions;

Complete redesign of the screening process has been initiated and led by the Medical Director.



Trust

mmm yy

Percentage


Common Cause (expected) variationVariation indicates consistently (F)alling short

of the target

35.6%

45.6%

55.6%

65.6%

75.6%

85.6%


Mean Dementia Case Finding Process limits - 3σ Special cause - concern Special cause - improvement Target

Dementia Case Finding - Trust starting 01/04/18

Mar-20 Dementia Case Finding 90.0% 45.3% Common Cause (expected) variation Not Capable

Page | 35

Making the dementia screening process more relevant to clinicians by communicating the outcome clearly to GPs for action. This was

the original intent of the original CQUIN. The discharge letter will now have specific sections to provide the screening outcome and

the actions required to primary care. This has been actioned and in place.

Simplify the current process of screening. The clerking booklets have been redesigned to include a much simpler screening

questionaire for over 75s only, with more detailed assessment available to use for patients who have failed their initial screen. This

replaces the previous formal assessment of every patient and no longer relies on stickers being added to the clerking booklets. This has

been actioned and new booklets ordered.

Remind responsible consultants of the actions required. Daily emails to admitting consultants informing them of any admitted patient

over 75 years of age who requires dementia screening.

Longer term, these patient identifiers will go directly to the Integrated Care of Older People Team so that the patients are highlighted

for a screen if not done already, and to identify patients who require a Comprehensive Geriatric Assessment (CGA). This has been

shown to improve outcomes and reduce length of stay for patients with frailty, and forms part of the ICOP strategy pending a business

case.

Ultimately we are looking to automate these processes. When the electronic prescribing and adminstration system is introduced, a

forcing function can be introduced whereby no prescriptions can be made until every admission has had their VTE and dementia

screen (where appropriate) completed.

Page | 36

Complaints

Page | 37

Issues;

There were 11 complaints received in April 2020 which is below the target threshold of 20 complaints per month.

The complaint compliance response rate has increased from 76% in March to 88.5 % in April. Although the chart (variation) shows that it is

consistently failing the target, there has been a sustained improvement towards meeting the target of 90%. The reduction in the number of

complaints could be partly due to the low number of patients who have attended the hospital over recent weeks.

The backlog of eight overdue complaints at the end of March has been reduced to two overdue complaints at the start of April.

The main categories of complaints for April 2020 were:

Admissions and discharges

Clinical treatment

Re-opened complaints for April 2020

There were no complaints re-opened in April 2020.

PHSO

Due to the COVID-19 situation the PHSO have ceased investigating any new and existing complaints

De-escalated

There were in excess of 12 concerns resolved and closed in April that did not require escalation to complaints management process.

Actions;

The complaints team are increasing support to divisional teams with drafting of response letters.

Training is being developed for the divisional teams on the new process and this will be rolled out with support from the complaints

team.

The complaints team will continue to support divisional teams with their understanding of the new process and keeping focus on the

required deadlines.

Page | 38

Items in grey are awaiting the latest update

Responsive Dashboard - Trust Level

Apr-20 18 Weeks RTT - Incomplete Perf 92.0% 62.1%Special cause

(unexpected)

variation - Concern

(L)

Not Capable

Apr-2018 Weeks RTT - No. of Specialties failing

the target of 92%0 30

Apr-20 18 Weeks RTT - Over 52 Wk waiters 0 43

Apr-20 A&E 4 Hour Performance 95.0% 92.7%Special cause

(unexpected)

variation -

Improvement (H)

Not Capable

Apr-20 A&E 4 Hour Performance (Majors only) 95.0% 86.8% Common Cause (expected) variation Not Capable

Apr-20 A&E 4 Hour Performance (Minors only) 100.0% 98.6% Common Cause (expected) variation Not Capable

Apr-20 A&E 12 Hour Trolley Waits 0 0

Apr-20 Ambulance Handovers 100.0% 59.0% Common Cause (expected) variation Not Capable

Apr-20Last minute non-clinical cancelled elective

operations0.8% 1.29% Common Cause (expected) variation Random

Apr-20Breaches of the 28 day readmission

guarantee0 40

Apr-20Total non-clinical cancelled elective

operations3.2% 43.82%

Special cause

(unexpected)

variation - Concern

(H)

Random

Apr-20Urgent operations cancelled more than

once0 0

Mar-20Cancer Wait Times - Two Week Wait

Performance93.0% 95.7%

Special cause

(unexpected)

variation -

Improvement (H)

Random

Mar-20Cancer Wait Times - 31 Day Diag to

Treatment Performance96.0% 99.2%

Special cause

(unexpected)

variation -

Improvement (H)

Random

Mar-20Cancer Wait Times - 62 Day Ref to

Treatmemt Performance85.0% 92.9% Common Cause (expected) variation Random

Mar-20 Cancer Wait Times - 104 Day waiters 0 3


(Breast Symptomatic) Performance93.0% 100.0%

Special cause

(unexpected)

variation -

Improvement (H)

Random

Mar-20Cancer Wait Times - 31 Day Subsequent

Treatment - (Surgery) Performance94.0% 100.0% Common Cause (expected) variation Random

Mar-20Cancer Wait Times - 31 Day Subsequent

Treatment - (Drug) Performance98.0% 100.0% Common Cause (expected) variation Capable

Mar-20Cancer Wait Times - 62 Day Screening

Performance90.0% 95.8% Common Cause (expected) variation Random

Apr-20Diagnostic Wait Times - % of over 6 Week

Waiters1.0% 64.7%

Special cause

(unexpected)

variation - Concern

(H)

Random

Apr-20% of beds occupied by Delayed Transfers

of Care3.5% 0.1%

Special cause

(unexpected)

variation -

Improvement (L)

Random

Apr-20 Medically Fit For Discharge - Patients 71Special cause

(unexpected)

variation -

Improvement (L)

Apr-20 Medically Fit For Discharge - Days 100Special cause

(unexpected)

variation -

Improvement (L)

Mar-20 Stroke - 90% of time on a Stroke Unit 90.0% 81.3% Common Cause (expected) variation Random

Mar-20Stroke - Direct to Stroke Unit within 4

hours90.0% 64.6% Common Cause (expected) variation Not Capable

Mar-20Stroke - Patient scanned within 1 hour of

clock start48.0% 52.2% Common Cause (expected) variation Random

Mar-20Stroke - Patient scanned within 12 hours of

clock start95.0% 95.7% Common Cause (expected) variation Random

Mar-20TIA - High Risk, not admitted, treated

within 24 hrs60.0% 63.3% Common Cause (expected) variation Random

Apr-20No. of beds occ by inpatients >=21 days -

(Mthly average over rolling 3 mths)46 19

Special cause

(unexpected)

variation -

Improvement (L)

Random


ValueVariance AssuranceData To KPI Description Target

Current


Page | 39

Emergency Care

Four hour performance

Performance in April 2020 was 92.7% against the standard of 95% and trajectory of 85.9%.

Issues;

The main reasons for breaches occurring were patients awaiting a bed (28.0%) with the majority of these relating to COVID-19 bed

requirement and clinical deterioration of patients prior to transfer or discharge (15.7%)

21% of all attendances arrived between 8:00pm – 8:00am yet 42% of all breaches occurred during the same time period

61% of attendances were admitted (NB this includes same day emergency care) and admitted performance was 96.02%. 39% of

patients who attended were discharged home and non-admitted performance was 87.63%

Page | 40

Actions;

Daily analysis of all breaches to understand the root cause of delays and identify themes; this is shared at the weekly ED team meeting

Emergency Medicine Clinical Director is leading a case review of the non-admitted breaches where the root cause of the breach is

‘delay in decision making by ED doctor’. This will identify any learning and development opportunities together with any process

changes that need to be made

A change in process so that the Nurse in Charge and Lead Consultant on shift review the plans for all patients in department ≥ three

hours to resolve any delays in decision making

Page | 41

Ambulance Handover Performance

Performance in April 2020 was 59% against the standard of 100%.

Issues;

Ambulance handover and cohort capacity is limited due to changes to in the ED footprint in response to COVID-19

Actions;

Increased ambulance handover capacity through the relocation of acute medical and surgical assessment to the AEC/SDEC footprint

(implemented 18 May 2020)



Trust

mmm yy

Percentage


Common Cause (expected) variationVariation indicates consistently (F)alling short

of the target

33.7%

43.7%

53.7%

63.7%

73.7%

83.7%

93.7%


Mean Ambulance turnaround Process limits - 3σ Special cause - concern Special cause - improvement Target

Ambulance turnaround - Trust starting 01/05/18

Apr-20 Ambulance Handovers 100.0% 59.0% Common Cause (expected) variation Not Capable

Page | 42

Elective Care 18-week RTT

Performance in April 2020 was 62.90% against the standard of 92%. At the end of April 2020, the total Trust waiting list was 12,160 and the

total backlog of patients waiting over 18 weeks was 4,609.

Issues;

Routine, elective surgery was cancelled in response to COVID-19 and in line with national guidance.

The increase in backlog relates predominantly to the following specialties: Trauma & Orthopaedics (885), ENT (493) and Gynaecology

(420).

Actions;

Routine elective surgery restarted during week commencing 14 May 2020, it is noted that this is a phased return to routine, elective

surgery with specialty level plans in place.


ValueVariance Assurance Target AchievementVariation Comment

Variation indicates consistently (F)alling

short of the target


(L)

59.0%

64.0%

69.0%

74.0%

79.0%

84.0%

89.0%

94.0%


Mean RTT Incompletes % Process limits - 3σ Special cause - concern Special cause - improvement Target

RTT Incompletes % - Trust starting 01/05/18

Apr-20 18 Weeks RTT - Incomplete Perf 92.0% 62.1%Special cause

(unexpected)

variation - Concern

(L)

Not Capable

Page | 43

52-week breaches

There were 46 52-week breaches in April 2020, the majority of these occurred in Orthopaedics (19) and Gynaecology (14).

Issues;

Routine, elective surgery was cancelled in response to COVID-19 and in line with national guidance Actions;


surgery with specialty level plans in place. Long waiting patients will be prioritised for surgery where possible.

Breaches of the 28-day readmission guarantee

There were 40 breaches of the 28-day readmission guarantee in April 2020.

Issues;

All breaches were due to patients being cancelled in response to COVID-19 national guidance regarding cancellation of routine,

elective care. All patients were risk assessment by the relevant Consultant and determined to be routine elective cases. A further date

could not be offered within 28 days as suspension of routine, elective surgery remains in place

Actions;


surgery with specialty level plans in place.

Page | 44

Last minute non-clinical cancelled elective operations

Performance in April 2020 was 2.15% against the standard of 0.5%. There were 14 patients cancelled on the day of surgery across four

specialities with the majority of the cancellations (nine) were in TIU, Medical Oncology and Haematology, with the remaining five in

Ophthalmology.

Issues;

Eight patients were cancelled following a risk assessment undertaken by the consultant in line with COVID-19 guidelines and the

treatment was then subsequently deferred.

Five patients were cancelled due to consultant sickness.

One patient was cancelled due to blood results not being available on the day of treatment.

Actions;

Routine elective activity restarted during week commencing 14 May 2020, it is noted that this is a phased return to routine, elective

activity with specialty level plans in place.



Trust

mmm yy

Percentage



Concern (H)



0.0%

0.5%

1.0%

1.5%

2.0%


Mean Canc Ops as a % of EL Activity Process limits - 3σ Special cause - concern Special cause - improvement Target

Canc Ops as a % of EL Activity - Trust starting 01/04/18

Mar-20Last minute non-clinical cancelled elective

operations0.8% 2.15%

Special cause

(unexpected)

variation -

Concern (H)

Random

Page | 45

Diagnostic waiting times

Performance in April 2020 was 65.6% against the standard of 1%

Issues;

1,060 patients breached the standard, of which 1,056 breaches were due to cessation of routine activity as a result of COVID-19

The majority of breaches occurred in Echocardiography (47.4%), Audiology (29.7%) and Dexa Scans (12.1%). Actions;

Routine Radiology activity will restart from week commencing 25 May at 50% of pre-COVID-19 activity levels.

Endoscopy re-start plans are being finalised with a start date of early June expected.

Hysteroscopy and Urodynamic activity restarted on 18 May 2020 at 100% of pre-COVID-19 activity levels.



Trust

mmm yy

Percentage



Concern (H)



0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


Mean % Pats waiting >6 Wks Process limits - 3σ Special cause - concern Special cause - improvement Target

% Pats waiting >6 Wks - Trust starting 01/05/18

Apr-20Diagnostic Wait Times - % of over 6 Week

Waiters1.0% 65.6%

Special cause

(unexpected)

variation -

Concern (H)

Random

Page | 46

Cancer Care Two week referral to treatment

Performance in April 2020 was 95.7% against the standard of 93%.

Performance will be maintained by;

Planning to bring forward first appointment from 14 days to seven – 10 days.

Monitoring waiting times for first appointment at tumour site level.

Monitoring patient cancellations and ‘did not attend’ for first appointment.



Trust

mmm yy

Percentage



Improvement (H)



77.0%

82.0%

87.0%

92.0%

97.0%


Mean CWT - TWW % Process limits - 3σ Special cause - concern Special cause - improvement Target

CWT - TWW % - Trust starting 01/04/18


Performance93.0% 95.7%

Special cause

(unexpected)

variation -

Improvement (H)

Random

Page | 47

62-day referral to treatment

Performance in April 2020 was 92.9% against the standard of 85% and trajectory of 89.58%.

Issues;

During March 2020, the Trust treated 63 patients, of which five waited more than 62 days from referral to treatment (three colorectal,

one lung, one upper GI).

Root cause analysis shows the key breach reasons as delays in diagnostics and multiple diagnostic tests thereby delaying diagnosis and

treatment planning.

The Trust performs well against the two week referral standard and 31 day diagnosis to treatment standard is good, however only

c.60% of patients have a diagnosis by day 28.

Actions;

In order to improve performance against the 62-day cancer waiting time standard, significant improvements need to be made against

the 28-day faster diagnosis standard.



Trust

mmm yy

Percentage


Common Cause (expected) variationVariation indicates inconsistently passing


56.7%

61.7%

66.7%

71.7%

76.7%

81.7%

86.7%

91.7%

96.7%


Mean CWT - 62 Day % Process limits - 3σ Special cause - concern Special cause - improvement Target

CWT - 62 Day % - Trust starting 01/04/18

Mar-20Cancer Wait Times - 62 Day Ref to

Treatmemt Performance85.0% 92.9%

Common Cause

(expected)

variation

Random

Page | 48

These improvements will focus on reducing the waiting times for endoscopic and radiological diagnostic tests and improving reporting

turnaround times. Further analysis will to be undertaken at individual diagnostic test level to identify bottle necks and agree actions

for improvement

Page | 49

Page | 50

The Trust will report a break-even position or month one following an assumption that the Trust will receive reimbursement for all COVID-19

related costs. This is in line with the national guidance of accounting for ‘block’ income, ‘top-up’ payments, taking account of COVID-19

reimbursements and the retrospective ‘top-up’ mechanism to bring the overall income and expenditure position back to a balanced position.

An additional £0.597m of top-up income is required for month one to achieve this break-even position.

The budget is as per the four-month plan as prescribed by NHSE/I. This has been based on the average income and expenditure for months

one - nine of 2019/20 and updated for months eight, nine and 10 with an inflation adjustment of 2.8%.

Key drivers for the in-month position are:

The income from activities consists of the block payment for the month of £15.5m plus the top-up amount of £2.2m. The under-

performance is primarily driven by a reduction seen against non-contracted activity (i.e. out of area) by £0.2m.

Other operating income is under-performing through car park income, retail income and catering.

COVID-19 additional top-up income is a positive £0.6m; this is the amount that is needed to deliver a break-even income and

expenditure position. However, within this, a COVID-19 reimbursement amount of £1.1m implies an underlying cost base lower than

the block payment and top-up payment by £0.5m

Pay and non-pay (excluding COVID-19 related costs) are under plan by £0.3m and £0.6m respectively.

COVID-19 expenditure across pay and non-pay totals £1.1m and compares to a April claimed amount of £0.8m.

Agency expenditure is lower in April than in March.

Financing costs are under plan of £0.3m due to changes in the financial architecture (no interest charges on loans for first six months of year

prior to loan to PDC conversion).

Depreciation is above planned levels by £0.1m and is reflective of the significant capital expenditure in quarter four not included in the

budget calculations and is subject to depreciation in the first quarter.

Page | 51

Key Issues

2020/21 Capital Programme: The Trust has yet to finalise its capital plan for 2020/21. Work is on-going to agree this at a system-level within the

capital envelope allocated to the Norfolk and Waveney STP. This work will be finalised by 29 May 2020. A prioritisation process for capital

schemes is currently in progress which will include those schemes that were in progress as at 31 March 2020 and/or contractually committed to.

Capital spend in April 2020 amounted to £1.0m, with a further £0.2m of commitments recognised. This includes COVID-19 related expenditure.

Cash: The Trust’s cash balance increased from £14.0m as at 31 March 2020 to £28.0m at the end of April 2020. This reflects receipt of two

months’ worth of block payment in April to support cash-flow and prompter payment of suppliers. This is matched by a significant increase in

the Trust’s liabilities reflecting the receipt of this income in advance.

Trade and other payables: This balance has decreased by £4.0m from £24.0m as at 31 March 20 to £19.0m (30 April 2020). This reduction has

been driven by the requirement to reduce the number of payment days to seven. As a response to the Cabinet Office issuing a new

Procurement Policy Note in March 2020 new guidance was issued that required that we look to pay our suppliers more promptly. This

recognised that the NHS is an important customer to many businesses and it being vitally important that cash flows as promptly as possible

during COVID-19. As a response to this we have issued guidance around prompt receipting of goods and services and the authorisation of

invoices and extra resource has been brought into the finance team to support achievement against this target.

Current Borrowings: Current borrowings (loans repayable within the next 12 months) of £135.0m reflects the intention that all existing DHSC

interim revenue and capital loans as at 31 March 2020 will be extinguished and replaced with the issue of PDC to allow their repayment. This

will transact in September 2020. Until March 2020, these loans had been carried in the Statement of Financial Position (SOFP) as non-current

borrowings.

Page | 52

Well Led (People) Dashboard

Apr-20 Appraisal Rate 90.0% 78.0%Special cause

(unexpected)

variation - Concern

(L)

Not Capable

Apr-20 Appraisal Rate (Med Staff exc Jnr Drs) 95.0% 94.0% Common Cause (expected) variation Random

Apr-20 Sickness Absence Rate 4.0% 8.5%Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Apr-20 Turnover Rate 10.0% 11.6% Common Cause (expected) variation Not Capable

Apr-20 Mandatory Training Rate 95.0% 82.0%Special cause

(unexpected)

variation - Concern

(L)

Not Capable



Apr-20 CTG Training Compliance (Midwives) 90.0% 90.5% Common Cause (expected) variation Random

Apr-20 CTG Training Compliance (Doctors) 90.0% 95.0%Special cause

(unexpected)

variation -

Improvement (H)

Random

Page | 53

Staff in post

Issues;

As of April 2020, the Trust currently employs 3,536 substantive headcount, working a substantive whole time equivalent of 3,091.87. This is

against the 2020/21 funded establishment of 3499.03 FTE. Substantive FTE has increased this month, although headcount has remained the

same as March 2020. Bank usage increased by 36.37 FTE as did agency usage, by 14.75 FTE

Actions;

The additional increase in bank and agency usage and substantive staff includes the additional posts that have been recruited on a bank basis

to cover the increased requirement due to COVID-19. In particular we have implemented a Swabbing Team, a PPE Safety Officers Team and

recruited additional bank staff within Catering, Domestic Services, Registered and Unregistered staff during April 2020. There have also been

additional Medical and Nursing trainees recruited in response to COVID-19 in line with the national guidance in relation to their clinical

practice. A number of individuals who had retired in the last two years were contacted and have resumed working at the Trust on a

temporary basis.

Mitigation;

In response to COVID-19 additional triggers have been established within the medical and nursing workforce to ensure that safe staffing is

maintained at all times and at what stage there is a requirement to redeploy staff from other areas. As it stands we are now in the process of

looking how we either step down this additional resource or it becomes part of the agreed establishment. For example it is anticipated the

Swabbing Team (that covers employees, key workers and patients) and PPE Safety Officers will still be required.

Page | 54

Vacancy levels

Issues;

Trust vacancy rate has increased based on the increase in funded establishment. The vacancy levels remain in line with Trust target and has

remained fairly static in the last 12 months. The nursing vacancy rate for all areas currently sits at 9.66% and is below the target however we

had anticipated a greater decrease against the Trust target but international recruitment has been deferred for the last two months due to

COVID-19. Medical vacancy levels have fallen to 14.74% which is the lowest it has been over the last six months.

Actions;

We are currently developing a Better Hospital Medical workforce plan which will improve the medical workforce recruitment pipeline and

performance against recruitment KPIs, ensure robust grip and control for rostering and sickness management, align job plans and PA

allocation, and reduce the number of agency shifts by moving from locum to substantive post-holders.

We are currently developing a Better Hospital Nursing workforce plan which will improve the nursing recruitment pipeline and performance

against recruitment KPIs, ensure robust grip and control for rostering and sickness management, relaunch safer staffing systems, and reduce

the number of agency shifts by moving from temporary to substantive post-holders . A number of staff have returned and a number of

students have taken on band four posts. These individuals have expressed the desire to remain at QEH. We will use fast track and these

students will be offered a post provided their competencies are signed off.

Additional bank and substantive domestics have been recruited during April 2020.

Mitigation;

The workforce changes have taken place to address COVID-19 and we are in the process of stepping down the requirement for additional

staff and recruiting these individuals into substantive roles.

Page | 55

Appraisals

Issues;

The Trust appraisal rate (excluding bank staff) has decreased in April 2020. The number of appraisals completed in April halved in relation to

the previous months which had been approximately 200 per month. Due to COVID-19 the Trust is increasing the number of staff on the Trust

bank and therefore the compliance rate will continue to decrease with the additional staffing.

Actions;

New ways have been developed to ensure some appraisals are carried out during this time and this will be a key area for improvement within

the recovery plan. We have asked that those that are currently working from home are asked to complete appraisals during this

time. Trajectories for achievement of the Trust target will be revisited in June 2020 for all areas to bring the compliance to 90% by March

2021. This will continue to be monitored through Divisional Performance Review meetings. Further appraisal training has been undertaken

and we are looking at ways that appraisals can be undertaken by those that are currently self-isolating for 12 weeks via video conferencing.



Trust

mmm yy

Percentage


Variation indicates consistently (F)alling

short of the target


(L)

74.12%

79.12%

84.12%

89.12%

94.12%


Mean Appraisal Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Appraisal Rate - Trust starting 01/05/18

Apr-20 Appraisal Rate 90.0% 78.0%Special cause

(unexpected)

variation - Concern

(L)

Not Capable

Page | 56

Sickness

Issues;

Sickness has increased significantly during this month and is now at 8.46%. However 38.8% of this sickness is related to COVID-19. If these

are excluded, then the sickness absence rate would sit at 5.14%. The reason for absence as a result of stress and anxiety has decreased

further this month and has been declining for the last six months. We are also asking managers from this month to code any sickness that is

related to stress and anxiety caused by COVID-19 separately to COVID-19 sickness so this can be monitored, and appropriate actions put into

place. There has been a significant decline in absence that are recorded as unknown causes

Actions;

All long-term sickness cases have been reviewed and plans are in place to inform next steps which has shown a decrease in the number

of long-term cases. In line with national guidance, due to COVID-19 only cases which will have an impact on staff on an individual’s

health and well-being are being reviewed.



Trust

mmm yy

Percentage



(H)


of the target

3.8%

4.8%

5.8%

6.8%

7.8%

8.8%


Mean Sickness Absence Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Sickness Absence Rate - Trust starting 01/05/18

Apr-20 Sickness Absence Rate 4.0% 8.5%Special cause

(unexpected)

variation - Concern

(H)

Not Capable

Page | 57

A new sickness tracker has been developed for medical staff with clear actions highlighted. This has been further enhanced to

monitor absence and medical suspension due to COVID-19 as can be seen by the data further in the report.

Additional training to be provided to clinical leads in relation to absence management.

Our health and wellbeing offering, and staff engagement has been approved.

We will also be recruiting Mental Health First Aiders and providing additional mental health awareness and resilience training.

The Trust has engaged in a piece of work in partnership with MIND - The Time to Change. As part of this programme and to achieve

lasting change within the workplace, the Trust is developing a plan of tangible activity to break down mental health stigma. The plan

is designed to be a starting point which details the actions we are committed to as a Trust to tackle stigma and discrimination around

mental health.

Mitigation;

As part of the National response to COVID-19 NHS employers in partnership with staff side organisations have advised that employers will

pause disciplinary and other employment procedures (for example, sickness and capability triggers) while the crisis lasts, except where the

employee requests proceeding as it would otherwise cause additional anxiety, or where they are very serious or urgent. Additional virtual

meetings are taking place currently for long term sickness cases and some areas of poor performance.

Page | 58

Mandatory training

Issues;

Due to COVID-19 the mandatory training requirements have been reduced to four courses only and additional training for COVID-19. This

will have a significant impact on the compliance for mandatory training. There has been a decline this month as anticipated

Actions;

A formal letter has been sent to all staff shielding and working from home to advise that all mandatory training must be up-to-date. A

review of mandatory training is in the process of being undertaken which will ensure that there is a shift to e-learning. A new task and finish

group, being led by the Deputy Director of HR, has been established with support from the Regional ESR Account Manager to develop the

systems and processes to support the move to e-learning.



Trust

mmm yy

Percentage



(L)


of the target

77.9%

82.9%

87.9%

92.9%

97.9%


Mean Mandatory Training Rate Process limits - 3σ Special cause - concern Special cause - improvement Target

Mandatory Training Rate - Trust starting 01/05/18

Apr-20 Mandatory Training Rate 95.0% 82.0%Special cause

(unexpected)

variation - Concern

(L)

Not Capable

Documents

REPORT TO THE BOARD OF DIRECTORS (IN PUBLIC) … June 2020.pdfCarly West-Burnham Director of Strategy Strategic Operational Governance RELATED WORK: (PREVIOUS PEER ASSIST: PEER REVIEW: