St George’s Healthcare NHS Trust Performance Report Trust Board Period ending 30 th April 2014

St George’s Healthcare NHS TrustPerformance Report

Trust BoardPeriod ending 30th April 2014

St George’s Healthcare NHS Trust

Performance Report to 30th April 2014

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Contents

Section Page

1 Executive Summary 3

2 The Performance Management Framework of the Trust 5

3 NTDA Accountability Framework 6

4 Monitor Compliance Framework 11

5 Exceptions and Actions 13

6 Definitions and Metrics 19

7 AppendicesTrends

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Benchmarking Data 27

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Section 1: Executive SummaryThe Performance Management FrameworkThe Trust is realigning its Performance Framework with the requirements of the NHS Trust Development Authority (TDA) and Monitor. The performance report is being updated to cover the new requirements of the TDA Accountability Framework for Trusts and to include greater visibility of performance at Divisional level, alongside Trust wide aggregate performance.

The TDA Accountability FrameworkThe accountability framework covers three domains – Quality, Finance and Delivering Sustainability. A set of indicators has been identified in each domain and delivery will be evaluated against a threshold and aggregated for each domain. Performance against these indicators will determine a score for each domain. These domain scores in turn contribute towards an overall Escalation score for the Trust. The Trusts will be rated using escalation levels 1 to 5 with Level 1 being the highest and 5 the lowest. The measurement and monitoring process will continue to place each trust in one of five Oversight categories, based on their scoring against the various oversight domains, relevant views of third parties such as the CQC, and the judgement of the TDA . Those categories will be:Standard Oversight with reduced frequency– The organisation has developed a sound FT application and received a ‘Good or Outstanding’ rating from CIHStandard Oversight with standard frequency: Limited or no delivery issuesSupporting Intervention: The organisation has some delivery issues including clinical and/or

financial challengesStrategic Intervention: The organisation has significant delivery issues clinical and/or financial

challengesSpecial Measures: The organisation has significant delivery issues, including serious

clinical and/or financial challenges or concerns.The Trust is also required to sign a self certifications on a monthly basis at Board level covering compliance with Monitor’s license requirements and a set of Board Statements .

The Monitor Compliance Framework

The Trust is reporting an AMBER/ GREEN Governance rating and a forecasted position on Continuity of Service Risks Rating of 3. The trust is forecasting that the Governance rating be Amber / Green or Green from Q1 once ED performance and remedial plans take full effect.

ExceptionsThe reportable areas of underperformance at month 1 are as follows :

A&E <4hrs:-In April performance for ED (Type 1) was 94% and ED & MIU (Type 1 & 3) was 94.7%.


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The Performance Management Framework of the Trust

The Trust continues to operate the Performance Framework presented to the Board and Finance and Performance Committee in April 2012. This is being refreshed to ensure the indicators included within the TDA Accountability Framework for NHS Trusts are reported against and to ensure that Divisional contributions to the Trusts aggregate reported performance are more visible.

The diagrams illustrate the components of the Trust’s Performance Management Framework. The Trust operates escalation processes with Divisions that reflect the national escalation processes and the recommendations in Monitor’s toolkits for implementing Service Line Management.

Quarterly Performance Reviews at Divisional Level, regular meetings with our commissioners, weekly Executive management Team meetings to address potential risks are all part of the Trusts Performance Management strategy.

- Escalation actions following Divisional reviews have focused on the action plan for recovering A&E 4 hour waits, financial performance within SNT and MedCard Divisions and Cancer performance to look at how delivery of the 62 day target can be improved and sustained.

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Section 2: Performance Management Framework of the Trust

Section 2: Performance Management Framework of the TrustThe Performance Management Framework of the Trust

The performance management arrangements includes quarterly reviews for each Division which review and challenge

Divisional progress, with an opportunity for Divisions to share with the Executive team issues of concern.

The Trust has extended this process by reporting divisional performance against the metrics within the TDA Accountability Framework, to the Finance and Performance committee on a monthly basis. The Trust reports on the vast majority of these metrics within the existing quarterly review process.

The Trust is also currently in the process of reviewing the indicators and thresholds in the scorecard in view of the most recently published TDA Accountability framework technical guidance , updated Monitor Compliance Framework and local Trust objectives.

This work is being undertaken in conjunction with the current Performance Framework review. A draft updated performance framework is being sent to the Executive Management Team Meeting on the 27th May after which a full suite of targets, thresholds and scoring methodology for the trust and divisional scorecards will be agreed and routinely reported on going forward.

Divisional Reports

Divisional rag ratings will be reported in the performance reports on a quarterly basis, however actions and escalation areas will be monitored and reported on a monthly basis and an overview provided. Any adjustments in rag rating will also be reported..

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Section 3: The NHS Trust Development Authority Accountability Framework for NHS Trusts

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The Accountability Framework

The TDA will assess delivery across three domains as shown in the diagram :

- Quality - Finance- Sustainability

Against each domain Trusts will report against a series of metrics. These are listed in detail in Section 6 : definitions and metrics

For 2014/15 trusts will be scored using escalation levels 1 to 5 with 1 being the highest risk rating and 5 the lowest. This is being done to ensure consistency with the CQC’s approach to assessing risk.

The measurement and monitoring process will continue to place eachNHS trust in one of five oversight categories, based on their scoring against the various oversight domains, relevant views of third parties such as the CQC, and the judgement of the TDA . Those categories are:-

The Trust is also required to sign off self certifications on a monthly basis at Board level covering progress against FT milestones, and compliance with Monitor’s license requirements


Section 3: TDA Accountability Framework

1. Special Measures

2. Intervention due to significant delivery issues

3. Intervention due to some delivery issues

4. Standard Oversight- limited or no delivery issues

5. Standard Oversight : Organisation has a developed a sound FT application and received a ‘Good or Outstanding rating from CIH.

Moderation including CQC Rating warning

notices and third party report

Moderation including CQC Rating warning

notices and third party report

Overall Escalation score (1 to 5)

Overall Escalation score (1 to 5)

Quality Score(1 to 5)

Quality Score(1 to 5)

Finance RAG Assessment

Finance RAG Assessment

SustainabilityScore (1-5)

Caring Score(1-5)

Caring Score(1-5)

Effective Score(1 to 5)reportEffective Score(1 to 5)report

Responsive Score(1 to 5)

Responsive Score(1 to 5)

Safe Score(1 to 5)

Safe Score(1 to 5)

Well-led(1to 5)

Well-led(1to 5)

Key Elements of the Oversight Model

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This section headed ‘Access’ indicates how effective the trust is at providing patients with the appointments and treatment they need and require in accordance with the national standards and the NHS Constitution.

The ED target is that 95% or more of patients should be seen and discharged within 4 hours of attending the Emergency Department. In April the Trust failed to meet this target with performance for ED (Type 1) at 94% and ED & MIU (Type 1 +3) at 94.7%. However for Qtr1, the trust is on track for Type 1+3 with performance as at the 22nd May at 95.2%. In April 1.3% of patients had their operation cancelled for non-clinical reasons against a target of 0.8% and 3.9% were not offered another binding date within 28 days against a target of 5%. The number of operations cancelled for non clinical reasons and rebooked within 28 days has fluctuated over the year due to bed pressures and an increase in the acuity of patients.

In April, 36.5% of LAS arrivals to patient handover times were within 15 minutes against the target of 100%. and 88.5% were within 60 minutes. St George's Hospital is not unusual in this regard as all trusts within the sector are underperforming. The trust will continue to monitor performance closely as fines will be applied where patient handovers exceed 30 and 60 minutes.


Section 3: TDA Accountability Framework : Access metrics

MetricName Units RAG (Mth)

Month

Trust CSW MED SN WC

YTD

Trust CSW MED SN WC

18 Weeks - Admitted waits % R ≤86 G ≥90

18 Weeks - Non Admitted waits % R ≤90, G ≥95

18 Weeks - Incomplete Waits % R ≤92, G ≥92

52 Week Waiters No. G 0, R >0

6 Week Diagnostic Waits % R ≤92, G ≥92

Operations cancelled for non-clinical reasons % G ≤0.8, R ≥1.5

Cancelled Operations re-booked within 28 days % G ≤5, R ≥15

A&E Waits (4 hours) % R ≤95, G ≥95

LAS handover within 15mins % R ≤95, G ≥99


LAS handover within 60mins No. G 0, R >0

2 week GP referral to 1st outpatient -breast symptoms * % R ≤93, G ≥93

2 week GP referral to 1st outpatient cancer * % R ≤93, G ≥93

31 day second or subsequent treatment (drugs) * % R ≤98, G ≥98

31 day second or subsequent treatment (surgery) * % R ≤94, G ≥94

31 day standard - from diagnosis to first treatment * % R ≤96, G ≥96

62 day urgent GP referral to treament for all cancers * % R ≤85, G ≥85

62 day urgent GP referral to treament from Screening * % R ≤90, G ≥90

n/a 93.490.990.1 86.8 n/a 93.490.990.1 86.8

n/an/an/an/an/a n/an/an/an/an/a



n/an/an/an/a99.3 n/an/an/an/a99.3

n/a 1.61.3 1.21.2 n/a 1.61.3 1.21.2

n/a 9.53.9 00 n/a 9.53.9 00

n/an/a99.994.7 94.0 n/an/a99.994.7 94.0

n/an/an/an/a36.5 n/an/an/an/an/a


n/an/an/an/a0 n/an/an/an/a0

n/an/an/a 99.399.3 n/an/a n/an/an/a


n/an/an/a 100100 n/an/a n/an/an/a

n/an/an/a 100100 n/an/a n/an/an/a




Access Metrics

Not yet available

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These indicators measure the outcomes resulting from treatment activity for which the Trust is responsible. The TDA framework includes monitoring Healthcare associated Infections and mortality.

The Trust has a target of no more than 40 Cdiff incidents in 2014/15 and the zero tolerance against MRSA continues. In April, the trust met both the CDiff and MRSA target. There were 3 Cdiff incidents against a trajectory of 5 and no MRSA blood stream infections. The trust will continue its programme of close monitoring and vigilance to ensure it remains complaint in 2014/15.

Prevention and education has been the focus throughout 2013/2014, with the trust aiming for zero tolerance of avoidable pressure ulcers. In April there were 15 reported Grade 3 Pressure Ulcers and no Grade 4’s. All grade 3 and 4 pressure ulcers acquired in our care are investigated as serious incidents, and a. full investigation and Root Cause Analysis is produced for each and reviewed at the Pressure Ulcer Strategy group, chaired by the Deputy Chief Nurse. The PU CQUIN for 14/15 has yet to be agreed.

The trust is reporting 1 Never Event. The incident took place in March, but was not reported on Datix until April when It was promptly declared as a SI . The incident was reported, following the retrieval of a throat swab in recovery following a dental procedure. The patient made a full recovery and did not come to any harm.

The WHO Surgical Checklist is a surgery safety checklist used prior to all surgical procedures. Compliance is just below target at 99%. Care group leads will continue to raise the profile through meetings and working with non compliant areas.


Section 3: TDA Accountability Framework : Outcome metrics


Month

Trust CSW MED SN WC

YTD

Trust CSW MED SN WC

Incidence of C.Difficile No. G ≤3, R ≥4

Incidence of MRSA No. G 0, R >0

Ecoli No. -

MSSA No. -

Medication Errors causing serious harm No. G 0, R >0

Trust Acquired Pressure Sores (G3/4) No. G 0, R >0

Serious Incidents No. G 0, R >0

Never Events No. G 0, R >0

C Sections (only applicable to Womens & Children) % G ≤28, R ≥30

Maternal Deaths No. G 0, R >0

Admission of full-term babies to neo-natal harm No. -

SHMI Rate G ≤100, R ≥1..

HSMR Rate G ≤100, R ≥1..

VTE Risk Assessment (data submitted to Unify) % R ≤95, G ≥95

CAS Alerts No. -

WHO Surgical Checklist (Qrtly audit: sign in/time-out/sig.. % R <100, G 100

Average LOS (elective) days -

Average LOS (non-elective) days -

30 Day emergency readmissions (fr elective) % -

30 Day emergency readmissions (fr non-elective) % -

3 11 10 3 11 10

00000 00000

21 17 4 00 21 17 4 00

77 000 77 000

00000 00000

15 6 53 1 15 6 53 1

21 96 33 21 96 33

11 000 11 000

n/an/an/a 22.522.5 n/an/an/a 22.522.5

n/an/an/a 00 n/an/an/a 00

n/an/an/a 44 n/an/an/a 44

n/an/an/an/a81 n/an/an/an/an/a


n/an/an/an/a96.3 n/an/an/an/a96.3

n/an/an/an/a9 n/an/an/an/a9

n/a 1009999 97 n/an/an/an/an/a

n/a 5.34.2 3.9 3.1 n/a 5.34.2 3.9 3.1

18.6 7.14.94.7 2.8 18.6 7.14.94.7 2.8

n/a 2.01.6 1.5 1.2 2.01.6 1.5 1.20

20 7.4 6.85.4 0.8 20 7.4 6.85.4 0.8

Outcome Metrics

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The Trust is required to respond to 85% of all complaints within 25 days and if this cannot be met, then an extension must be agreed with the complainant. The target then becomes 100% of all of those complaints should be responded to within 25 days or the agreed time In March 70% of all complaints were responded to within 25 working days and 87% were responded to when an agreed extensions was included.

The trust has seen an increase in the number of complaints received with 116 complaints in March compared to 103 in February. Complaints remains a key focus and priority for the Chief Nurse & DOO and is being monitored and focused on at divisional, governance and clinical leads meetings.

There were 4 EMSA breaches in April. A root cause analysis has been undertaken and reported to the CCG. system.

The trust is reporting research activity from the Research leadership with the aim of increasing its research activity.


Section 3: TDA Accountability Framework : Quality governance


Month

Trust CSW MED SN WC

YTD

Trust CSW MED SN WC

Patient satisfaction (friends and family) * NPS -

Mixed Sex accommodation No. G 0, R >0

Ward Staffing: Bank/Agency Usage % -

Ward Staffing: Unfilled Duty Hours % -

Staff Turnover % G ≤13, R >13

Voluntary Staff Turnover % G ≤10, R >10

Sickness/absence rate * % G ≤3.5, R >3.5

Vacancy rate % G ≤11, R >11

MAST attendance % R ≤85, G ≥85

Percentage of staff appraisal (medical) % R ≤85, G ≥85

Percentage of staff appraisal (non-medical) % R ≤85, G ≥85

Complaints - response within 25d * % R ≤85, G ≥85

n/an/an/a61 48 n/an/an/an/an/a

44 000 44 000

38.8 21.3 20.720.3 15.3 38.8 21.3 20.720.3 15.3

19.714.7 12.8 11.48.5 19.714.7 12.8 11.48.5

16.715.714.914.6 12.8 n/an/an/an/an/a

13.9 13.512.0 11.3 10.4 n/an/an/an/an/a

5.43.4 3.2 3.12.8 n/an/an/an/an/a

12.411.2 10.410.210.0 n/an/an/an/an/a

71.069.768.5 67.9 65.1 n/an/an/an/an/a

85.479.6 76.675.4 67 n/an/an/an/an/a

86.4 84.5 83.182.4 54 n/an/an/an/an/a

76.860.5 58.253.353.3 76.860.5 58.253.353.3

Quality Governance Indicators


Month

Trust CSW MED SN WC

YTD

Trust CSW MED SN WC

70 day - PI REPORT .. % R ≤30, G ≥70

Green Rated Time to target of all Open CLRN Studies % R ≤45, G ≥70

TIME TO TARGET - PD REPORT .. % R ≤45, G ≥70

Total recruitment at St Georges NHS - cumulative No. R ≤150, G ≥3..





Research

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Section 4: The Monitor Compliance Framework

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The Trust Rating as at 30th April 2014• The Trust Overall Rating is AMBER/GREEN for Performance and our forecasted position for 2014/15 for CoSRR is 3 at the

end of April.

The 62 Day target was met in Qtr 4 and for the month of March. In March performance was 85.5%, and for the quarter January to March performance was 85.2%

• For Qtr 1 to date, the trust is currently non-compliant against the ED target. ED (Type 1) is 94% and ED & MIU (Type 1 & 3) is 94.7%. Current monthly performance for Type 1 & 3 as at the 22nd May is 95.2%

Performance Rating

ForecastedCoSRR


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Section 4 : Monitor Compliance Framework

MONITOR COMPLIANCEDASHBOARD FOR ASPIRANT FINANCIAL TRUST

April 2014

Indicators Frequency PeriodCurrent /Recent

Performance(R/A/G)

ThresholdWeightingachieved

Indicators Frequency Period

Current /Recent Performance

(R/A/G)Threshold

Weightingachieved

Outcomes Access

Clostridium( C )difficile- meeting the C.difficile objective

Quarterly

Apr-Jun 14

3 incident in April

3 cases YTD

40 0

1

Maximum time of 18 weeks from point of referral to treatment in aggregate- admitted

Quarterly

Apr-Jun 14Data awaited predicting

compliance

90% 0

Data Completeness CSW Referral to Treatment Information

Quarterly Apr-Jun 14 50%0

2

Maximum time of 18 weeks from point of referral to treatment in aggregate- patients on an incomplete

pathwayQuarterly

Apr-Jun 14

Data awaited predicting compliance

92% 0

Referral InformationQuarterly Apr-Jun 14 50% Cancer first definitive treatment within 31 Day

Surgery Quarterly

Jan – Mar 14

100% (Mar 14)100% (Qtr to date)

YTD 99.2%94%

0

Treatment activity InformationQuarterly Apr-Jun 14 50%

1

Drug100% (Mar 14)

100% (Qtr to date)YTD 100%

98%

0

Cancer first definitive treatment within 62 Day

StandardQuarterly

Jan – Mar 14

85.5% Mar 14 )85.2% (Qtr4 )YTD 83.5%

85%

0Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these

patients?Yes

0

1

Screening90.9% (Mar14)93.4% (Qtr 4)YTD 94.5%

90%

Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria: · treatment options; · complaints procedures; and · appointments? Yes Cancer two week wait from referral to date first seen (2

ww)

2wwQuarterly

Jan – Mar 14

99.3% (Mar 14)98.2% (Qtr 4)YTD 97.7%

93%

0Does the trust have protocols in place to provide suitable support for family carers who support patients

with learning disabilitiesYes

1

Breast98.1% (Mar 14)98.9% (Qtr 4)

YTD 98%93%

Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?

Yes All cancer 31 day wait from diagnosis to Treatment StandardQuarterly

Jan – Mar 14

97.6% (Mar 14)97.1% (Qtr 4)YTD 97.6% 96%

0

Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?

Yes 1A&E maximum waiting time of four hours from arrival to

admission/transfer/discharge

Apr-Jun 14

94.7% (Qtr to date) as at end of April 95% 1

Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports?

Yes 1 Total for Access 1

Learning Disability 0 ## Total for Outcomes 0 Trust Overall Score for all Target and Indicators 1

* Unvalidated Green <1.0

Amber Green= ≥1 and ≤2

Amber/Red = ≥2 and ≤4

Red= ≥4

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Section 5 : Exceptions and Actions

Exceptions and ActionsThe following pages provide a summary of performance for the areas where the Trust is not meeting the required standards and the actions being taken to address the performance issues


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Performance : April – 94.7% all types within 4 hours

Actions

In April 94.7% of patients were seen within 4hours, for both Type 1 and Type 3 and for Type 1 only performance was 94.0%.

•The trust is continuing to be supported by the Emergency Care Intensive Support Team (ECIST) to implement the recommendations which developed over a number of visits over the last 6 months focusing on improving ED patient flow and flow through the organisation (in and out).

•Weekly recovery meetings continue to be held with the Exec team and the cross divisional leadership teams. This has identified further steps the Trust can be taking to improve performance including review of the current week, plans for the weekend, and a look to the week ahead. This will take note of any plans in place that would directly impact on improving ED performance and the overall flow of patients through the system.

•The ED continues to focus on any improvements that can be made to the emergency / urgent pathways. This includes the implementation of the Rapid Assessment and Treatment Service (RATS) 7 days per week to provide early senior intervention in the patients pathway reducing the time to treatment within the ED, the Clinical Director is now supervisory to support the ED team on the shop floor and to help facilitate smooth flow of patients between ED and admitting specialties. There have also been improvements made to the triage service and the flow of patients linked to this and a clearer focus on the shop floor leadership for the department.

•Following discussion with the TDA and ECIST virtual CDU and PDU patients are now counted in the breach numbers if they have waited more than 4 hours. Work is also underway with the mental health teams to improve response times and the patients experience.

•The Trust has achieved the 95% target for 4 weeks in a row – from week commencing 21st April to date.

A&E performanceSection 5: Exceptions and Actions

ED MIU ED & MIU

(Type 1) (Type 3) (Type 1+3)

Month of April 94.0% 99.9% 94.7%

Quarter to date (Q1) 94.0% 99.9% 94.7%

Year to date 94.0% 99.9% 94.7%

Where MIU data are not yet available average daily figures have been used and 100% performance assumed.

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Performance : 90.10% compliance in April against target of 90%

Actions

The trust is reworking and finalising the 18 week model for 14/15

• to include the final agreed SLA numbers per specialty andand• to allow ENT to increase its number of breaches to reduce its backlog and over 40 week waiters.

This will be completed for month 2 reporting and so the monthly targets will change slightly in the next report.

At the end of April t4 specialities failed to meet the standard.

Cardiology is not compliant for month 1 and will continue to be non-compliant until Q3 as the recovery plan is worked through. This is under discussion with commissioners. Any clinical risks in Cardiology will be reviewed at the June Patient Safety Committee. Particular focus is being paid to avoiding any 52 week waiters (after declaring 5 in March) and a weekly listing of all patients over 40 weeks is being sent to the Divisional Chairs and DDOs to address with their teams. The Admitted performance only is available at the time of the report being produced, a verbal update will be provided at the Finance & Performance meeting on Outpatients and Incompletes performance.

18 week Referral to Treatment (RTT) performance : Admitted pathwaySection 5: Exceptions and Actions

Reporting speciality Within Breach %General Surgery 165 18 90.2Urology 111 12 90.2Trauma & Orthopaedics 87 8 91.6Ear, Nose & Throat 139 24 85.3Maxillofacial Surgery 65 1 98.5Neurosurgery 55 6 90.2Plastic Surgery 215 18 92.3Cardiothoracic Surgery 76 9 89.4Gastroenterology 211 8 96.3Cardiology 115 46 71.4Neurology 53 0 100Dental 64 3 95.5Vascular Surgery 72 12 85.7Gynaecology 226 16 93.4Other 85 10 89.5Total 1739 191 90.1

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Performance : 5 patients waiting over 52 weeks in March

Actions

The trust recognises and acknowledges the recent increase in the number of patients waiting longer than 52weeks ,most recently five at the end of March. The reasons for the increase in long waiting patients is multi-factorial and include :•Technical issues affecting patient tracking lists (PTLs) following the Cerner PAS upgrade on 22nd February 2014, and subsequently the patient tracking process. Much effort has gone into the corrective work following this upgrade. •Multiple cancellations of the same patients where they have been unfit for surgery. A number of these have been complex patients such as high risk anaesthetic patients requiring repeat pre-op assessments prior to booking which adds to the patient journey •A number of patients requiring specialist OP review which have had delays in booking due to capacity constraints. •Clinician capacity constraints •Significant bed pressures experienced in Q4 2014, which resulted in a high number of elective cancellations, subsequently impacting on patient waits and also trust performance. This had considerable impact during February and March 2014.

RTT performance and reducing long waits is a key priority area for the trust, and we are taking pro-active measures to address this accordingly. Key actions include . Working through technical issues following the Cerner upgrade; some of which have been resolved and some are still underway. A project board is in place which is reviewing the implementation and monitoring progress/resolution of outstanding issues.

Weekly Referral to Treatment management meetings by care group are now in place which track the Patient Tracking List and review at patient level, review capacity and escalate long waits.

Weekly escalation email of long waiters is now sent by the Associate Director of Finance, Contracting and Performance to the Divisional Directors of Operations and Divisional Clinical Chairs to review personally and action those patients waiting for more than 40 weeks.

A monthly RTT Compliance meeting chaired by an Executive Director is held which reviews; performance by care group with a particular focus on patients waiting 40+ weeks to ensure treatment plans are in place, review/facilitate escalation, provide senior decision making support to drive actions forward, reviews and monitors elective cancellations, their rebooking to target and their impact on RTT performance. Recruitment of additional consultants in clinical areas of capacity constraints, such as ENT

The trust has recruited and now has in post a Director of Delivery and Improvement who is leading on service transformation, working closely with the divisions to ensure we implement our capacity plans and meet performance targets as we continue to improve our services.

Monthly meetings are being held with South London CSU reviewing RTT performance, and RCAs for long waiting patients.

18 week Referral to Treatment (RTT) performance : 52 Week WaitsSection 5: Exceptions and Actions

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Performance : Total of 3 Cdiff cases in April vs a monthly trajectory of 5 and a annual target of 40. A

total of zero MRSA cases year to date Actions

The Trust has a target of no more than 40 Cdiff incidents in 2014/15. There were 3 Cdiff incidents against a trajectory of 5 and no MRSA blood stream infections. The trust will continue its programme of close monitoring and vigilance to ensure it remains complaint in 2014/15.

The zero tolerance against MRSA continues in 2014/15. The trust can report that in April there were no MRSA bacteraemias

C.DifficileWith the annual total number of cases below trajectory thetrust is happy that it current strategy has reaped results with its lowest ever number of CDiff cases in three years.

The trust will continue to maintain its good performance as it faces an even more challenging target of 40 incidents in 2014/15 .which should be achievable

MRSA BacteraemiaThe root cause analysis for each bacteraemia is presented to

the HCAI taskforce, The Trust will continue its trust wide communication and

vigilance to improve compliance

The Infection control and the Vascular Access teams are also available to provide additional support. Weekly awareness sessions on line care continues

In 2014/15 the zero tolerance approach to MRSA bacteraemia (hence no national target) remains, and the trust will maintain its current strategy and continue to monitor this closely to avoid being non compliant

Following an appeals process, a 7th bacteraemia which occurred in March, has been assigned to St George’s bringing the total for 13/14 to 7. It was agreed that this did not cause a clinical infection but could have been a transient bacteraemia as the patient was on antibiotics sensitive to the bacteria. However the guidance does not accommodate this within its definitions and thus had to be assigned as a contaminant which is allocated to the organisation that took the blood culture (St George’s). The chair of the appeal panel will be writing to NHSE to raise this issue and suggest that the guidance is changed.

Section 5: Exceptions and Actions

Performance : 62 Day waits 85.5% compliance against target of 85%

Actions

The 62 Day target was met in March, with performance at 85.5%.

All other cancer targets were met for the full year 2013/14.

The 62 Day target was met in March , with performance at 85.5%. Despite not having met the target for 6 months out of the 12 months the Trust is happy to report that it also met the target for Quarter 4 with performance at 85.2%.

The trust will continue with the following plans to ensure the target is met and sustained:-

1. Implementation of single Cancer Management Team based at SGH, providing full visibility of the cancer performance for the whole organisation

•The scheduling and uploading contract would be transferred to SGH with effect from 1 July 2014 and KHT would take on the activity provided by their consultants.•Temporary staff have been recruited to the SGH TWR Office to manage the additional workload. Substantive staff will be recruited once the budget transfer takes place.•Meetings have been held and a new urology pathway will be implemented when new consultants come into post.

2. Development of a 62 day PTL capturing all TWR referrals received at SGH (not including QMH) to ensure performance against this target

• Work started in mid-February as planned and all tumour types are now receiving a PTL although there is more validation work required. Meetings have been set up with clinical leads, service teams and MDT co-ordinators to pro-actively manage pathways and take remedial action to avoid any breaches where possible

3. The transfer of the monitoring and reporting of QMH activity to St George’s enabling a direct feed from QMH PAS to the St George’s cancer informatics

•Awaiting resolution by IT before the Infoflex development work can begin• The development work and the commissioning of the new system is expected to be fully operational within 9 – 12 months.

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Section 5: Exceptions and Actions Cancer Performance- 62 Day

19

Section 6: Definitions and Metrics

20

Caring

Inpatient scores from Friends and Family Test

A&E scores from Friends and Family Test

Complaints – rate per bed days, MH contacts or calls to ambulance services

Inpatient Survey: Q68 Overall I had a very poor/good experience?

Mixed Sex Accommodation Breaches

Well-led

NHS England inpatients response rate from Friends and Family Test

NHS England A&E response rate from Friends and Family Test

Data Quality of trust returns to the HSCIC

NHS Staff Survey: Percentage of staff who would recommend the trust as a place of work

NHS Staff Survey: Percentage of staff who would recommend the trust as a place to receive treatment

Trust turnover rate

Trust level total sickness rate

Total trust vacancy rate

Temporary costs and overtime as % total pay bill

Percentage of staff with annual appraisal

Effective

Summary Hospital Mortality Indicator(HSCIC Published data)

Hospital Standardised Mortality Ratio(DFI Quarterly)

Hospital Standardised Mortality Ratio– weekend

Hospital Standardised Mortality Ratio– weekday

Deaths in low risk conditions

Emergency re-admissions within 30 daysfollowing an elective or emergency spell atthe trust

Safe

CDiff

MRSA

Never Event incidence

Medication errors causing serious harm

Maternal deaths

Proportion of patients risk assessed for Venous Thromboembolism (VTE)

Serious incidents

Proportion of reported patient safety incidents that are harmful

Admission to adult facilities for patients who are under 16 years of age (Number)

TDA Accountability FrameworkThe following pages provide details of the metrics included in the TDA performance framework applicable to

Acute Trusts.

Section 6: Definitions and metrics

21

Responsive

Proportion of patients spending more than 4 hours in A&E

RTT waiting times for admitted pathways: % within 18 weeks

RTT waiting times for non-admitted pathways: % within 18 weeks

RTT waiting times incomplete pathways

RTT over 52 week waiters

Diagnostic waiting times: patients waiting over 6 wks for a diagnostic test

Proportion of patients receiving first definitive treatment for cancer within 62 days of referral from GP

Proportion of patients receiving first definitive treatment for cancer within 62 days of referral from screening

Proportion of patients receiving first definitive treatment for cancer within 31 days of decision to treat

Proportion of patients receiving subsequent treatment within 31 days (Drug)

Proportion of patients receiving subsequent treatment within 31 days (Surgery)

Proportion of patients receiving subsequent treatment within 31 days (Radiotherapy

Proportion of patients receiving subsequent treatment within 31 days (Radiotherapy

Proportion of patients seen within 14 days of urgent GP referral

Proportion of patients with breast symptoms seen within 14 days of GP referral

Responsive contd

Urgent operations cancelled for a second time

Proportions of patients not treated within 28 days of last minute cancellation due to non clinical reasons

Certification against compliance regarding access to health care for people with a learning disability

12 hour trolley waits in A&E

Finance

Bottom line I&E position – Forecast compared to plan

Bottom line I&E position – Year to date actual compared to plan

Actual efficiency recurring/non recurring compared to plan- Year to date actual compared to plan

Actual efficiency recurring/non-recurring compared to plan – Forecast compared to plan

Forecast underlying surplus/deficit compared to plan

Forecast year end charge to capital resource limit

Is the Trust forecasting permanent PDC for liquidity purposes?

TDA Accountability FrameworkThe following pages provide details of the metrics included in the TDA performance framework applicable

to Acute Trusts

Section 6: Definitions and metrics

22

Section 7: Appendices

Trends


Month

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M114/15

18 Weeks - Admitted waits % R ≤86 G ≥90

18 Weeks - Non Admitted waits % R ≤90, G ≥95

18 Weeks - Incomplete Waits % R ≤92, G ≥92

52 Week Waiters No. G 0, R >0

6 Week Diagnostic Waits % R ≤92, G ≥92

Cancelled Operations re-booked within 28 days % G ≤5, R ≥15

Operations cancelled for non-clinical reasons % G ≤0.8, R ≥1.5

A&E Waits (4 hours) % R ≤95, G ≥95



LAS handover within 60mins No. G 0, R >0

2 week GP referral to 1st outpatient -breast symptoms * % R ≤93, G ≥93

2 week GP referral to 1st outpatient cancer * % R ≤93, G ≥93

31 day second or subsequent treatment (drugs) * % R ≤98, G ≥98

31 day second or subsequent treatment (surgery) * % R ≤94, G ≥94

31 day standard - from diagnosis to first treatment * % R ≤96, G ≥96

62 day urgent GP referral to treament for all cancers * % R ≤85, G ≥85

62 day urgent GP referral to treament from Screening * % R ≤90, G ≥90

92.692.6 91.991.8 91.7 91.6 91.4 91.390.5 90.390.3 90.190.1

98.1 97.997.9 97.7 97.697.6 97.597.597.597.5 97.096.8 n/a

95.195.194.9 94.294.1 94.0 93.8 92.4 92.392.392.3 n/an/a

5222111 00000 n/a

100.0100.0 99.999.999.9 99.899.899.8 99.799.799.799.7 99.3

12.1 10.9 8.78.3 8.07.75.6 3.93.3 2.1 000

2.6 2.01.8 1.51.51.5 1.4 1.31.31.2 0.90.8 0.7

95.094.8 94.794.4 93.8 93.793.793.6 91.396.8 96.1 96.0 95.4

81.875.869 46.240.2 36.536.2 32.432.4 30.129.9 26.3 3.4

94.4 88.588.5 88.487.883.4 8382.881.1 37.998.797.697.3

411 0000000000

99.6 99.599.599.5 99.398.9 98.7 97.897.296.9 96.393.1

98.898.3 98.198.1 98.097.697.5 97.297.2 97.097.096.3

100100100100100100100100100100100100

100100100100100100100100100 98.3 97.694.9

99.2 98.5 98.498.4 97.697.597.597.297.1 96.9 96.396.2

84.5 82.7 80.8 80.477.4 76.189.0 88.4 86.286.0 85.585.3

100100 97.295.7 95.6 94.794.491.7 91.4 90.990.990.9

Access Metrics

Monthly Trust PerformanceMonthly Trust Performance


Month

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M114/15

Incidence of C.Difficile No. G ≤3, R ≥4

Incidence of MRSA No. G 0, R >0

Ecoli No. -

MSSA No. -

Medication Errors causing serious harm No. G 0, R >0

Trust Acquired Pressure Sores (G3/4) No. G 0, R >0

Serious Incidents No. G 0, R >0

Never Events No. G 0, R >0

C Sections (only applicable to Womens & Children) % G ≤28, R ≥30

Maternal Deaths No. G 0, R >0

Admission of full-term babies to neo-natal harm No. -

SHMI Rate G ≤100, R ≥1..

HSMR Rate G ≤100, R ≥1..

VTE Risk Assessment (data submitted to Unify) % R ≤95, G ≥95

CAS Alerts No. -

WHO Surgical Checklist (Qrtly audit: sign in/time-out/sign-out) % R <100, G 100

Average LOS (elective) days -

Average LOS (non-elective) days -

30 Day emergency readmissions (fr elective) % -

30 Day emergency readmissions (fr non-elective) % -

9 4 333 2222 111 0

21111 00000000

2423 2121 2020 1818 1616161613

1111 10 9 7766 55 43 2

1 000000000000

20 16 1514 1312109 8 7765

29 212118 1514 13 1285 42 0

11111 00000000

27.126.824.8 24.324.324.3 24.1 23.4 22.522.521.020.8 17.5

0000000000000

9 666 55 420 n/an/an/an/a

8282828282 81818181818181n/a

85.885.885.885.385.3 84.684.6 79.579.579.579.579.5n/a

95.0 94.994.594.4 94.294.1 93.9 97.1 96.396.195.295.295.2

39 17 161515 1414 11 988 64

9999999999999999999999100n/a

4.4 4.24.04.0 3.93.83.83.7 3.63.63.6 3.53.5

6.0 5.3 5.1 4.8 4.74.74.74.7 4.64.6 4.54.54.4

1.71.7 1.61.6 1.51.5 1.41.31.31.31.3 1.21.2

6.7 6.3 6.26.26.16.16.1 5.9 5.75.65.6 5.45.4

Outcome Metrics



Month

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M114/15

Patient satisfaction (friends and family) * NPS -

Mixed Sex accommodation No. G 0, R >0

Nurse Bed Ratio % -

Ward Staffing: Bank/Agency Usage % -

Ward Staffing: Unfilled Duty Hours % -

Percentage of registered nurses % -

Proportion temporary staff on wards (Clinical and Non) % -

Staff Turnover % G ≤13, R >13

Voluntary Staff Turnover % G ≤10, R >10

Sickness/absence rate * % G ≤3.5, R >3.5

Vacancy rate % G ≤11, R >11

MAST attendance % R ≤85, G ≥85

Percentage of staff appraisal (medical) % R ≤85, G ≥85

Percentage of staff appraisal (non-medical) % R ≤85, G ≥85

Complaints - response within 25d * % R ≤85, G ≥85

6564 636262 616159595957 5648

22 15 433 00000000

1.0 0.90.90.90.90.9 0.80.80.80.8 n/an/an/a

20.3

14.7

85.4 80.480.1 79.076.2 75.875.775.7 75.4 75.233.8 33.6 n/a

19.917.517.4 17.016.9 16.215.114.8 n/an/an/an/an/a

14.9 14.614.414.113.613.5 13.413.413.413.4 13.213.1n/a

12.1 12.011.811.611.110.710.510.5 10.410.3 10.2

4.4 4.14.14.1 4.04.0 3.93.93.9 3.7 3.4n/an/a

11.210.910.8 10.710.7 10.510.3 10.110.0 9.99.99.4n/a

68.6 68.564.9 59.159.159.1 n/an/an/an/an/an/an/a

83.183.080.2 79.9 79.078.578.1 75.471.867.9 86.4 85.9n/a

82.481.980.5 80.480.2 80 79.6 76.7 76.274.1 7474

79.5 7574.2 68.56867.5 65.4 64.661.3 60.556.756.5n/a

Quality Governance Indicators


Month

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12M1

14/15

70 day - PI REPORT .. % R ≤30, G ≥70

Green Rated Time to target of all Open CLRN Studies % R ≤45, G ≥70

TIME TO TARGET - PD REPORT .. % R ≤45, G ≥70

Total recruitment at St Georges NHS - cumulative No. R ≤150, G ≥3..

24.524.523.623.612.9 12.812.8 505031.531.531.5n/a

44.8 44 434242 415149 4747 46 45n/a

40 39.339.335.935.918.518.5 18.218.2 46.846.846.8n/a

173115501306965670 263522961887 170366230782920n/a

Research


27

Appendix 1: Benchmark Data

28

Accident and Emergency (All type): 4 hour wait April 2014

29

Accident and Emergency (Type 1): 4 hour wait April 2014

30

Accident & Emergency: Week Ending 30th March 2014

All type A&E: 94.88%, up from 94.69% last weekType 1: 91.71%, up from 91.42% last week

For week ending: 11/5/2014London is ranked 2nd for All Types and 3rd for Type 1 performance. For QTD performance, London is ranked 2nd for All Types, and 4th for Type 1

(National ranking is based on the 4 commissioning regions)

31

MRSA Dashboard 2014-15 NB. Trajectories for 2014/15 are Zero for MRSA.

Sector Trust Name Total for last 12

months

Total for last 3 months

Number of cases last

month (April 2014)

Number of cases so far this month

(May 2014)

2014-15 YTD Position to

15th May 2014

2013-14 YTD position to the end of April

2013

NEL Barking, Havering And Redbridge Hospitals NHS Trust 2 0 0 0 0 0NEL Barnet And Chase Farm Hospitals NHS Trust 5 0 0 0 0 1NEL Barts Health Trust 12 3 1 1 2 0NEL Great Ormond Street Hospital For Children NHS Trust 1 0 0 0 0 0NEL Homerton University Hospital NHS Foundation Trust 5 2 1 0 1 1NEL North Middlesex University Hospital NHS Trust 4 0 0 0 0 2NEL Royal Free NHS Foundation Trust 0 0 0 0 0 0NEL Royal National Orthopaedic Hospital NHS Trust 0 0 0 0 0 0NEL University College London Hospitals NHS Foundation Trust 5 0 0 0 0 0NEL Whitti ngton Hospital NHS Trust 1 0 0 0 0 0

NEL TOTAL 35 5 2 1 3 4NWL Chelsea And Westminster Hospital NHS Foundation Trust 3 1 0 0 0 1NWL Ealing Hospital NHS Trust 1 0 0 0 0 0NWL Hillingdon Hospital NHS Trust 0 0 0 0 0 0NWL Imperial College Healthcare NHS Trust 10 2 1 0 1 0NWL North West London Hospitals NHS Trust 2 0 0 0 0 0NWL Royal Brompton And Harefield NHS Trust 1 0 0 0 0 0NWL West Middlesex University NHS Trust 5 1 0 0 0 0

NWL TOTAL 22 4 1 0 1 1SL Croydon Healthcare Services NHS Trust 2 2 0 0 0 0SL Epsom And St Helier NHS Trust 8 2 0 0 0 0SL Guy's and St Thomas's NHS Foundation Trust 4 1 0 0 0 2SL King's College Hospital NHS Trust 7 1 1 0 1 3SL Kingston Hospital NHS Trust 5 2 0 0 0 0SL Lewisham Healthcare NHS Trust 1 0 0 0 0 0SL Royal Marsden NHS Foundation Trust 1 0 0 0 0 0SL St George's Healthcare NHS Trust 5 0 0 0 0 0

SL TOTAL 33 8 1 0 1 5Total LONDON 90 17 4 1 5 10

1 Trust above 0 thresholdTrust achieving 0 threshold

32

C.Difficile Dashboard 2014-15

* Data in the body of the report may not reflect more recent updates

Sector

Trust Name

Annual Trajectory

Year to date Trajectory to

15th May

Total for last 12

months

Total for last 3

months

Number of cases last

month

Number of cases so far this month

Number of cases from 1st April 2014 -

15th May 2014 (Provisional)

2013-14 YTD number of cases to end April 2013

NEL Barking, Havering And Redbridge Hospitals NHS Trust 37 4.63 23 4 2 0 2 1NEL Barnet And Chase Farm Hospitals NHS Trust 20 2.50 34 11 5 0 5 3NEL Barts Health Trust 71 8.88 75 11 6 0 6 5NEL Great Ormond Street Hospital For Children NHS Trust 7 0.88 12 1 0 0 0 0NEL Homerton University Hospital NHS Foundation Trust 2 0.25 4 2 1 1 2 0NEL North Middlesex University Hospital NHS Trust 17 2.13 25 12 3 6 9 2NEL Royal Free NHS Foundation Trust 38 4.75 27 5 2 0 2 5NEL Royal National Orthopaedic Hospital NHS Trust 13 1.63 8 0 0 0 0 1NEL University College London Hospitals NHS Foundation Trust 57 7.13 89 15 4 2 6 10NEL Whitti ngton Hospital NHS Trust 19 2.38 20 5 2 0 2 3

NEL TOTAL 281 35.13 317 66 25 9 34 30NWL Chelsea And Westminster Hospital NHS Foundation Trust 8 1.00 11 2 2 0 2 0NWL Ealing Hospital NHS Trust 8 1.00 12 3 2 0 2 2NWL Hillingdon Hospital NHS Trust 16 2.00 10 0 0 0 0 0NWL Imperial College Healthcare NHS Trust 65 8.13 47 14 7 0 7 12NWL North West London Hospitals NHS Trust 18 2.25 20 2 1 0 1 2NWL Royal Brompton And Harefield NHS Trust 9 1.13 15 3 0 0 0 1NWL West Middlesex University NHS Trust 19 2.38 12 4 1 0 1 6

NWL TOTAL 143 17.88 127 28 13 0 13 23SL Croydon Healthcare Services NHS Trust 17 2.13 11 3 1 0 1 3SL Epsom And St Helier NHS Trust 40 5.00 41 9 2 2 4 2SL Guy's and St Thomas's NHS Foundation Trust 37 4.63 48 13 5 2 7 1SL King's College Hospital NHS Trust 58 7.25 66 12 6 0 6 5SL Kingston Hospital NHS Trust 24 3.00 18 1 1 0 1 2SL Lewisham Healthcare NHS Trust 39 4.88 40 5 1 0 1 4SL Royal Marsden NHS Foundation Trust 16 2.00 19 5 0 2 2 1SL St George's Healthcare NHS Trust 40 5.00 23 7 3 2 5 9

SL TOTAL 271 33.88 266 55 19 8 27 27Total LONDON 695 86.88 710 149 57 17 74 80

Note – The 2014/15 weekly C.diff numbers are aggregated at provider level but not attributed to the Trusts, therefore to avoid giving an inaccurate position we have omitted any comparison to plan and associated RAG rating.

Documents

St George’s Healthcare NHS Trust Performance Report Trust Board Period ending 30 th April 2014