Integrated Quality & Performance Report
Public Board
27th March 2014
Presented for: Information
Presented by: Dr Mark Smith, Chief Operating Officer
Author: Information Department
Previous Committees:
None
Trust Goals
The best for patient safety, quality and experience
The best place to work
A centre for excellence for research, education and innovation
Seamless integrated care across organisational boundaries
Financial sustainability
Key points
This report is presented to ensure the Board remains up-to-date with the Trust’s performance in light of national requirements and local developments.
Information
Agenda Item 22.1
THE LEEDS TEACHING HOSPITALS NHS TRUST
TRUST BOARD MEETING – MARCH 2014
INTEGRATED QUALITY &
PERFORMANCE REPORT
PERIOD – FEBRUARY 2014
Contents
Overview of Performance ............................................................................................................. 1
Summary ...................................................................................................................................... 2
AF Quality and Governance Dashboard ............................................................................ 3
Shadow Monitor Risk Assessment Framework ................................................................. 5
Narrative ...................................................................................................................................... 6
Referral To Treatment (RTT) ............................................................................................. 6
RTT Clearance Times ....................................................................................................... 8
Diagnostic Waits ................................................................................................................ 9
Cancelled Operations ...................................................................................................... 10
A&E Waiting Times (4 Hours) .......................................................................................... 11
A&E Measures ................................................................................................................ 12
Cancer 62 Days ............................................................................................................... 14
Cancer 31 Days ............................................................................................................... 16
Cancer 2 Week Wait ........................................................................................................ 17
Stroke Care ..................................................................................................................... 18
30 Day Emergency Readmissions................................................................................... 19
Outpatient Activity - New and Review.............................................................................. 20
Inpatient Activity - Elective and Non-elective ................................................................... 21
Length of Stay ................................................................................................................. 22
Incidence of MRSA .......................................................................................................... 23
MRSA Screening ............................................................................................................. 24
Incidence of CDI .............................................................................................................. 25
Summary Hospital Mortality Index (SHMI) ....................................................................... 26
Hospital Standardised Mortality Rate (HSMR) ................................................................ 27
VTE Risk Assessment ..................................................................................................... 28
Harm Free Care............................................................................................................... 29
Pressure Ulcers ............................................................................................................... 30
Complaints ...................................................................................................................... 31
Patient Satisfaction – Friends & Family ........................................................................... 32
Outpatient Measures ....................................................................................................... 33
Outpatient Measures (Continued).................................................................................... 34
Choose and Book (CAB) – ASIs ...................................................................................... 35
CAB - Utilisation .............................................................................................................. 36
Workforce ........................................................................................................................ 37
Finance ...................................................................................................................................... 38
AF Finance Dashboard .................................................................................................... 38
Finance - In-Year Financial Delivery Indicators ............................................................... 39
Finance - Progress Towards Foundation Trust Status .................................................... 39
Internal Indicators Dashboard .................................................................................................... 40
Appendix 1 - Updates................................................................................................................. 42
Appendix 2 - Peer Groups .......................................................................................................... 43
Appendix 3 - Glossary ................................................................................................................ 44
Page 1 of 44
Overview of Performance
Overview:
The IQPR has been developed to include all measures contained within the NHS Trust Development Authority’s (TDA) Accountability Framework (AF) and Monitor’s Risk Assessment Framework (RAF) Service Performance Score. The latest performance against national and local CQUIN (Commissioning for Quality & Innovation) requirements, local contract quality requirements and key internal measures are also reported where appropriate.
In time, Trusts will be rated monthly against the 3 domains within the AF’s Oversight Model (Quality & Governance, Finance and Delivering Sustainability). The methodology for rating overall performance as well as the detail behind the definition and thresholds for acceptable performance for a number of these metrics has yet to be confirmed by the TDA. The TDA has, however, intimated it will soon begin publishing the Oversight Model.
Access:
Trust compliance with the target to treat 95% of non-admitted patients within 18 weeks, and for 92% of patients on incomplete pathways to have waited less than 18 weeks, was maintained in February. The Trust remains non-compliant with the standard to treat 90% of admitted patients within 18 weeks.
The Trust level 4 hour A&E access standard was failed in February, having previously been achieved each month since June 2013. Performance against this indicator was however restored for the first 2 weeks of March (as reported on page 11).
Capacity constraints and late referrals from other providers continue to impact on the Trust’s ability to maintain the 62 day standard for urgent GP referral to cancer treatment. Performance in January was also below standard for two of the other cancer standards: the 2 week wait target for suspected cancer, and the 31 day target for subsequent radiotherapy.
Outcomes:
There were no cases of MRSA apportioned to the Trust in February. In addition, Trust level performance against the requirement to screen 95% of eligible patients was maintained for the fourth consecutive month.
There were 9 cases of C. difficile infections (CDIs) at the Trust in February. Year-to-February there were 135 CDIs against the goal of no more than 101 for the full year.
The rate of E. Coli and MSSA cases per 100,000 bed days rose above the thresholds set by the TDA in February, at 95.5 (against a threshold of 94.9) and 10.2 (against a threshold of 9.02) respectively.
The Trust continues to maintain an overall Summary Hospital Mortality Index (SHMI) and Hospital Standardised Mortality Rate (HSMR) within or better than the expected range, as of the latest available position from Dr Foster (July 2012 to June 2013).
Quality Governance:
The Trust continues to achieve against the targeted response rate for the Friends and Family Test (FFT), with the overall response rate for February reported at 26.5% against a TDA threshold of 20%.
In January, the Trust’s FFT Net Promoter Score (which evaluates the proportion of respondents who would be extremely likely to recommend services minus the proportion who would not) matched the national average of 65. The Trust’s overall score for February was 62.1.
Page 2 of 44
Indicator Group Group Description
National Indicators / Quality Requirements Indicators are included from the AF, which is used by the TDA to monitor the performance of non-Foundation Trusts (FTs), as well as Monitor’s RAF Service Performance Score (this will be in shadow form until the Trust becomes an FT). These are national targets Trusts must achieve and incorporate indicators measuring access, quality, outcomes and finance. These include the MRSA and C. difficile (CDI) objective, A&E waiting times, referral to treatment (RTT) and cancer waits, patient experience and risk assessments of venous thromboembolism (VTE).
CQUIN Indicators
National and local CQUINs indicators are incorporated; these include indicators around the Safety Thermometer, dementia and patient discharge. The CQUIN summary dashboard is included on a quarterly basis.
Local Contractual Indicators Data indicators that form part of the Trust’s Contract agreement with the Clinical Commissioning Groups (CCG).
Internal Indicators Internal indicators are metrics that are key to the Trust’s success, that have not been incorporated previously. These include further information around RTT on clearance times, stroke care, inpatient and outpatient activity, and research and innovation (R&I) indicators.
Leeds Teaching Hospitals Trust (LTHT) Summary
This report covers national performance measures from the Trust Development Authority’s (TDA) Accountability Framework (AF) and Monitor’s Service Performance Score (part of the RAF). Relevant CQUIN indicators which are not already incorporated within the National Indicators are also included on a quarterly basis, as well as selected local contractual indicators and additional internal metrics. Updates from regulators are included in Appendix 1. (Please note this report is a work in progress, and there is not therefore a section for all indicators).
Page 3 of 44
AF Quality and Governance Dashboard
Category Indicator Dec-13 Jan-14 Feb-14 YTD
Referral to treatment within 18 weeks - admitted > 90% 87.3% 86.0% 88.7% 85.4%
Referral to treatment within 18 weeks - non-admitted > 95% 95.4% 95.0% 95.5% 95.5%
Referral to treatment within 18 weeks - incomplete > 92% 94.1% 94.6% 95.2% n/app
Referral to treatment within 18 weeks - over 52 week waiters (incomplete waits) 0 0 0 n/app
Diagnostic waits within 6 weeks > 99% 99.6% 99.0% 99.2% n/app
Last minute cancelled operations not re-booked within 28 days
Urgent operations cancelled for the second time
A&E 4 hour > 95% 97.1% 96.1% 93.9% 96.4%
Cancer 62 days - GP referral > 85% 76.3% 78.5% 83.0%
Cancer 62 days - referral from screening service > 90% 90.2% 100.0% 95.7%
Cancer 31 days - first treatment > 96% 97.3% 96.2% 97.3%
Cancer 31 days - second or subsequent surgery > 94% 91.9% 94.3% 96.7%
Cancer 31 days - second or subsequent drug treatment > 98% 100.0% 100.0% 100.0%
Cancer 31 days - second or subsequent radiotherapy > 94% 92.6% 93.3% 97.7%
Cancer 2 week wait - suspected cancer > 93% 94.9% 87.0% 93.2%
Cancer 2 week wait - breast symptoms > 93% 92.0% 93.8% 92.1%
30 day emergency readmissions (Elective & non-elective) < 10.9% 7.2% 6.8%Reported a month
in arrears6.9%
Incidence of MRSA 0 1 0 6YTD: < 94
13/14: < 101
Medication errors causing serious harm - Number 1 0Reported a month
in arrears3
Harm free care (pressure sores, falls, CUTI and VTE) - Safety Thermometer (Snapshot) > 92% 93.2% 93.8% 93.7% n/app
Serious incidents - Number 4 6 12 44
Serious incidents - Rate per 1,000 bed days < 1.23 0.08 0.11 0.24 0.08
Never events 0 0 1 6
E. Coli cases 48 44 47 526
E. Coli cases - Rate per 100,000 bed days 3 < 94.9 93.4 79.9 95.5 92.7
MSSA cases - Rate per 100,000 bed days 3 < 9.02 1.9 10.9 10.2 10.0
Maternal deaths 0 0Reported a month
in arrears1
Summary Hospital-level Mortality Indicator (SHMI)
Hospital Standardised Mortality Ratio (HSMR) (2012/13 rebased)
Venous thromboembolism (VTE) risk assessment > 95% 95.2% 96.1%Reported a month
in arrears95.7%
Q1 > 15%
By Q4 > 20%
Nurse: bed ratio 5 1.92 : 1 1.92 : 1 1.92 : 1 n/app
% of nurses registered nurses > 60% 71.1% 70.3% 70.2% -
Mixed sex accommodation 0 0 0 0
Unavailable 8
Q3: 3.0%0%
0
Qu
ality
Go
ve
rna
nce
Ind
ica
tors Patient satisfaction (friends and family) - Response rate¹ 22.4% 26.5% 20.5%
National Ave: 100
July 2012 to June 2013: 95.15
0.1 : 1 to 4.4 : 1
0
0
13/14: < 1
9 13513 12
n/app
n/app
July 2012 to June 2013: 91.17
National Indicators / Quality Requirements - AF Quality and Governance
TDA Thresholds
Acce
ss M
etr
ics
0
0
Reported a month
in arrears
20.8%
Ou
tco
me
s M
etr
ics
National Ave: 100
0
Incidence of C. Difficile
6
Page 4 of 44
Indicators Awaiting Clarification:
Category Indicator Dec-13 Jan-14 Feb-14 YTD
Warning notice None None None None
Civil and/or criminal action None None None None
Admissions of fullterm babies to neonatal care 2.7% 3.9% 2.3% 3.2%
YTD: < 54
13/14: < 60
C-section rates (Emergency and Elective LSCS) 18.3% 21.4%Reported a month
in arrears20.2%
Open CAS Alerts (Exceeding the deadline for action) 4 6 5 5 n/app
WHO surgical checklist compliance 97.6% 97.3% 97.8% n/app
3rd
Pa
rty
Re
po
rts
Any relevant report including safeguarding alerts, serious case reviews, ad hoc reports from MPs,
GMS, Ombudsman, Commissioners, litigation etc.
Patient satisfaction (friends and family) - Net Promoter Score (DH) ¹ 70.0 65.0 62.1 68.0
Patient and carer voice
Board turnover (12 months rolling average) 50.5% 44.0% 44.0% n/app
Sickness/absence rate (12 months rolling average) 4.2% 4.1% 4.1% n/app
Proportion temporary staff – clinical and non-clinical 7.4% 8.7% 8.5% n/app
Staff turnover (12 months rolling average) 10.8% 10.8% 10.6% n/app
Complaints - Rate per 10,000 occupied bed days 3 12.1 14.7 18.7 17.2
% staff appraised 49.9% 52.0% 57.4% n/app
1
2 Trajectory agreed with Clinical Commissioning Group (CCG).3
4
5
6
7
8
Percentage of staff who have an in date appraisal at month end.
Ou
tco
me
s M
etr
ics
TBC
1
TBC
Qu
alit
y G
ove
rna
nce
Ind
ica
tors
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
National Indicators / Quality Requirements - AF Quality and Governance
TDA Thresholds
CQ
C
Co
nce
rns
TBC
TBC
Meticillin Sensitive Staphylococcus Aureus (MSSA) cases 576
Data currently under review.
n/app
5
These figures show the number of full time equivalent (FTE) registered nurses (including midwives) as a proportion of all FTE nurses employed by the Trust at the end of each month.
TBC
For adult inpatients, A&E attenders and Maternity services.
Rate based on internal monthly overnight bed occupancy data.
Threshold not yet published by the TDA (although anticipated to be 0).
Figures shown for are based on snapshots of number of registered nurses (FTE) (excluding midwives) against the average number of available overnight General & Acute beds as reported in the
latest KH03 quarterly return.
n/app
TBC
2
7
Page 5 of 44
Shadow Monitor Risk Assessment Framework
Qrt 1 Qrt 2 Qrt 3 Qrt 4
(To date)
A&E Waiting Times (4 hours) - LTHT (including Wharfedale) *1 94.6% 97.9% 97.4% 95.2%
Patients treated within 18 weeks - admitted (%) *2 84.5% 84.4% 86.1% 87.2%
Patients treated within 18 weeks - non-admitted (%) *2 95.0% 94.7% 95.5% 95.2%
Patients awaiting treatment on the 18 weeks pathway - incomplete (%) *2 94.4% 94.9% 94.1% 95.2%
Cancer 2 week wait - suspected cancer 95.9% 93.0% 93.2% 87.0%
Cancer 2 week wait - breast symptoms (cancer not initially suspected) 94.4% 89.9% 91.3% 93.8%
Cancer 31 Day Waits - first definitive treatment 97.8% 96.7% 97.8% 96.2%
Cancer 31 Day Waits - subsequent surgery treatment 96.6% 97.9% 96.5% 94.3%
Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment 99.8% 100% 100% 100%
Cancer 31 Day Waits - subsequent radiotherapy treatment course 99.0% 99.6% 96.0% 93.3%
Cancer 62 Day Waits - GP/Dentist referrals 85.1% 85.2% 80.5% 78.5%
Cancer 62 Day Waits - cancer screening service referrals 98.0% 95.3% 93.4% 100.0%
Q1 < 25 *3
51
76
Full year < 101
Compliance with requirements regarding access to healthcare for people with
learning disabilities (6 criteria)
Compliant on all 6
criteria
Compliant on all 6
criteria
Compliant on all 6
criteria
Compliant on all 6
criteria
3.0 3.0 4.0 4.0 4.0 4.0 5.0 5.0
*1
*2
*3
Weighted
score
A&E: 1 Jul to 29 Sep-13
CDI: Apr to Sep-13
RTT Incomplete:
As at 30 Sep-13
Other: Jul to Sep-13
0.0
1.0
1.0
0.0
1.0
0.0
0.0
95%
Weighted
score
A&E: 30 Sep to 29 Dec-13
CDI: Apr to Dec-13
RTT Incomplete:
As at 31 Dec-13
Other: Oct to Dec-13
1.0
Weighted
score
A&E: 30 Dec-13 to 09 Mar-14
CDI: Apr-13 to Feb-14
RTT Incomplete:
As at 28 Feb-14
Cancer: Jan-14
Other: Jan to Feb-14
0.00.0
Performance Indicator
National Indicators / Quality Requirements - Shadow Monitor Risk Assessment Framework (RAF) - Service Performance ScoreA
cce
ss M
etr
ics
92% 0.0
0.0
1.0
0.0
0.0
1.0
1.0
0.0
1.0
1.0
0.0
0.0
0.0
0.0
1.0
0.01.0
3.0
0.01.0
5.0
0.0
114 1.0 135 1.0
1.0
73
0.0
1.0
0.0
4.0
1.0
94%
90%1.0
0.0
Green
Risk Rating
93%1.0
93%
96%
Self certification
85%
94%
98%
0.0
General Notes
Failure to achieve any of the indicators with a weighting of 1 for three or more consecutive quarters may result in Monitor applying a governance concern and escalating the Trust for consideration as to whether it is in significant breach of its Foundation Trust
authorisation.
The CDI threshold used by Monitor is the greater of either: (a) a simple proportioning of the annual threshold (i.e. 25% of annual threshold at Q1, 50% at Q2 and 75% at Q3) or (b) 12 CDI cases.
A&E performance is derived from the weekly SITREP return figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters. Failure to meet this standard for any two quarters during the previous 12 month period and
failing the indicator again during the subsequent 9 month period or full year may trigger a governance concern.
Whilst the RAF monitors performance quarterly, any monthly failure of the RTT standards must be reported to Monitor and represents a failure of that indicator for the quarter.
Weighted
score
2013/14
Thresholds
Red
0.095%
90%
Weighting
A&E: 1 Apr to 30 Jun-13
RTT Incomplete:
As at 30 Jun-13
Other: Apr to Jun-13
1.0
0.0
4.0
1.0
1.0
1.0
1.0
Ou
tco
me
s
Ma
tric
s
Rating Criteria
Service Performance Score
< 4.0
> 4.0
CDI 1.0 41 1.0YTD (@ Q2) <
YTD (@ Q3) <
Page 6 of 44
Narrative
Referral To Treatment (RTT) Admitted Non-Admitted Incomplete Admitted Non-Admitted
> 90% > 95% > 92% > 90% > 95%
100.0% 99.9% 99.8% 89.8% 98.8%
97.8% 99.1% 99.0% 90.7% 98.8%
89.7% 85.1% 92.3% 96.9% 98.2%
89.2% 96.9% 96.7% 77.3% 95.9%
100.0% 100.0% 100.0% - 99.4%
98.5% 88.2% 73.3% 96.0% 96.9%
- 100.0% 100.0% 100.0% 100.0%
87.1% 96.8% 96.4% 81.9% 92.1%
92.2% 99.2% 99.0% 87.4% 91.9%
100.0% 99.7% 100.0% 100.0% 96.2%
77.8% 98.7% 97.2% 76.7% 93.9%
97.5% 99.1% 99.7% 86.9% 95.5%
100.0% 97.0% 96.2% 96.4% 96.0%
83.0% 81.9% 81.2% 79.2% 91.0%
100.0% 100.0% 100.0% 100.0% 99.4%
100.0% 99.8% 98.9% 100.0% 99.7%
82.2% 86.3% 93.4% 82.4% 89.7%
76.6% 92.6% 95.1% 77.0% 96.2%
83.2% 95.6% 96.1% 78.8% 96.3%
88.7% 95.5% 95.2% 85.4% 95.5%
Feb-14RTT Reporting Specialties
YTD
Urology
Cardiology
Cardiothoracic Surgery
Dermatology
Ear Nose & Throat
Elderly Medicine
Trust
Target
Oral Surgery
Other Specialties
Plastic Surgery
Respiratory Medicine
Rheumatology
Trauma & Orthopaedic
Gastroenterology
General Medicine
Gynaecology
Neurology
Neurosurgery
Ophthalmology
General Surgery
National Indicator / Quality Requirement
Aims:
Ensure at least 90% of admitted patients are treated within 18 weeks of referral.
Ensure at least 95% of non-admitted patients are treated within 18 weeks of referral.
Ensure a minimum of 92% of patients on an incomplete pathway have been waiting no more than 18 weeks.
Ensure no patients wait over 52 weeks from referral to treatment. Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graphs.
Actions:
Admitted: The Trust remains non-compliant with the admitted RTT target due to the continued focus on delivery of the agreed backlog clearance. Following further discussions with the IST and the TDA the rust has revised its position and agreed to deliver this target in June 2014 reported in July.The trust is currently ahead of the planned trajectory position and.
Non-admitted: Non-admitted performance continues to be achieved. Work continues with CSUs on delivering sustainable non-admitted waiting times, which are key to delivery of the Admitted RTT target.
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Ma
r-14
Ap
r-14
Ma
y-1
4
Ju
n-1
4
No
. o
f P
atie
nts
Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted
No. of Patients Trajectory Revised Trajectory
65%
70%
75%
80%
85%
90%
95%
100%
% o
f p
atie
nts
me
etin
g ta
rge
t
Trusts
% of Admitted Patients Seen Within 18 Weeks - April to December 2013
LTHT Peers Other Trusts Target
Source: NHS England
Page 7 of 44
Referral To Treatment (RTT) (Continued)
70%
75%
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% o
f p
atie
nts
me
etin
g ta
rge
t
% of Non-Admitted Patients Seen within 18 weeks
% Non-Admitted Achieve Fail
70%
75%
80%
85%
90%
95%
100%
% o
f p
atie
nts
me
etin
g ta
rge
t
Trusts
LTHT Peers Other Trusts Target
Source: NHS England
% of Non-Admitted Patients Seen Within 18 Weeks - April to December 2013
70%
75%
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% o
f p
atie
nts
me
etin
g ta
rge
t
% Incomplete Achieve Fail
% of Patients on an Incomplete Pathway Waiting no more than 18 Weeks
70%
75%
80%
85%
90%
95%
100%
% o
f p
atie
nts
me
etin
g ta
rge
t
Trusts
LTHT Peers Other Trusts Target
% of Patients on an Incomplete Pathway Waiting no More Than 18 Weeks - December 2013
Source: NHS England
0
5
10
15
20
25
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
No
. o
f p
atie
nts
Number of Patients Waiting Over 52 Weeks - Incomplete(As at month end)
Page 8 of 44
RTT Clearance Times
Total Clearance
Times
>18 wk
Clearance times
Incompletes
>18wks
8 Wks 0.5 Wks -
14.0 0.0 0.2%
7.7 0.1 1.7%
9.8 0.4 4.5%
5.5 0.6 11.3%
0.0 0.0 -
33.9 3.8 11.1%
- - -
9.6 0.7 7.8%
14.6 0.8 5.3%
52.0 0.0 0.0%
7.7 0.8 10.0%
8.9 0.1 0.9%
7.7 0.3 4.0%
6.2 1.8 28.5%
0.7 0.0 0.0%
6.3 0.0 0.0%
12.3 0.7 5.7%
16.7 1.5 9.0%
8.2 0.8 10.0%
9.7 0.7 7.6%Trust
Gynaecology
Neurology
Neurosurgery
Ophthalmology
Oral Surgery
Other Specialties
Plastic Surgery
Respiratory Medicine
Rheumatology
Trauma & Orthopaedic Surgery
Urology
General Medicine
Target
General Surgery
Cardiology
Cardiothoracic Surgery
Dermatology
Ear Nose & Throat
Elderly Medicine
Gastroenterology
RTT Reporting Specialties
Feb-14
Internal Indicator
Aims:
RTT clearance times aim to indicate how long, in weeks, it would take to clear current patients on incomplete pathways assuming that no new patients are added to the list. Although this is not a national target, a total clearance time of 8 weeks and an over 18 weeks clearance time of 0.5 weeks is deemed to indicate a sustainable waiting list according to the Department of Health (DH).
Reduce the number of patients waiting over 18 weeks at month-end (incomplete admitted) to 714 by the end of March 2014.
Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.
Actions:
Total: Total RTT clearance times have risen to 9.7 for February from 8.6 in January. The aim remains to achieve an 8 week standard through delivery of the revised CSU trajectories for OP waits and over 18 week Admitted clearance.
Over 18 weeks: Over 18 week RTT clearance times have remained at 0.7 weeks, against the 0.5 week internal target. It is expected that this standard will be delivered alongside the achievement of the 18 week admitted target in June 2014, in line with the revised CSU trajectories.
0
2
4
6
8
10
12
14
16
18
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Cle
ara
nce
Tim
es
Referral to Treatment - Clearance Times
Total Clearance Times >18 wk Clearance Times
Total Clearance Times Target >18 wk Clearance Times Target
0
100
200
300
400
500
600
700
800
0 1 2 3 4 5 6 7 8 9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52+
Unkn
ow
n
No
. o
f P
atie
nts
Weeks Waiting
Number of Patients Waiting on an Incomplete Admitted Pathway - By TimebandComparison between April 2013 and February 2014
Apr-13 Feb-14
Page 9 of 44
Diagnostic Waits
Number of
Patients on
Waiting List
Number
Waiting over 6
Weeks
% Waiting
Less Than 6
Weeks
Target - - 99%
Audiology - Audiology Assessments 0 0 -
Barium Enema 3 0 100.0%
Cardiology - echocardiography 891 0 100.0%
Cardiology - electrophysiology 0 0 -
Colonoscopy 526 33 93.7%
Computed Tomography 1,471 0 100.0%
Cystoscopy 307 3 99.0%
DEXA Scan 569 1 99.8%
Flexi sigmoidoscopy 316 17 94.6%
Gastroscopy 607 28 95.4%
Magnetic Resonance Imaging 2,095 5 99.8%
Neurophysiology - peripheral neurophysiology 0 0 -
Non-obstetric ultrasound 4,647 0 100.0%
Respiratory physiology - sleep studies 113 0 100.0%
Urodynamics - pressures & flows 0 0 -
Trust 11,545 87 99.2%
Diagnostic Test
Waiting List Position As at 28/02/2014
National Indicator / Quality Requirement
Aim: Ensure at least 99% of patients wait no more than 6 weeks for a diagnostic test. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.
Appendix 2 lists the peer Trusts included in the benchmarking graphs.
90%
92%
94%
96%
98%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% P
atie
nts
Wa
itin
g L
ess T
ha
n 6
we
eks
% Within 6 Weeks Target
Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-End
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000A
pr-
12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
No
. o
f p
atie
nts
wa
itin
g
Diagnostic Waits - Number of Patients Waiting for a Diagnostic Test at Month-End
70%
75%
80%
85%
90%
95%
100%
% P
atie
nts
Wa
itin
g L
ess T
ha
n 6
we
eks
Trusts
LTHT Peers Other Trusts Target
Source: NHS England
Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-EndJanuary 2014
Page 10 of 44
Cancelled Operations
0%
2%
4%
6%
8%
10%
12%
14%
16%
Q1 Q2 Q3 Q4 Q1 Q2 Q3
% la
st m
inu
te c
an
ce
lla
tio
ns
% of Last Minute Cancelled Operations for Non-Clinical Reasons
2012/13 2013/14
National Indicator / Quality Requirement
Internal Indicator
Aims:
Ensure all patients who have operations cancelled at the last minute, for non-clinical reasons are offered another binding date to be treated within a maximum of 28 days.
Ensure no patient has their urgent operation cancelled for a second time. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalties.
Appendix 2 lists the peer Trusts included in the benchmarking graph.
Actions:
The quarter 3 position against the indicator for cancelled operations not rebooked within 28 days demonstrated significant improvement on quarter 2 performance, and focus continues on reducing such breaches in Q4 (recognising the impact of winter pressures).
Root cause analyses of all Q3 and January breaches have been returned and are being analysed for themes to support further reductions in Q4.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
% p
atie
nts
bre
ach
ing
targ
et
Trusts
% Patients Not Treated Within 28 Days of Last Minute Cancellation for Non-Clinical Reasons - Q3 2013-14
LTHT Peers Other Trusts
Source: NHS England(NB: 75 Trusts reported no breaches, including 4 peer Trusts)
0%
2%
4%
6%
8%
10%
12%
14%
16%
Q1 Q2 Q3 Q4 Q1 Q2 Q3
% p
atie
nts
bre
ach
ing
targ
et
Patients Cancelled at Last Minute for Non-Clinical Reasons: % Not Treated Within 28 Days
% 28 Day Breaches Achieve Fail
2012/13 2013/14
Page 11 of 44
A&E Waiting Times (4 Hours)
Indicator Site Feb-14 YTD
St James's 6,771 79,125
LGI 8,978 102,548
Wharfedale 1,503 20,441
Trust 17,252 202,114
St James's 729 4,604
LGI 321 2,751
Wharfedale 0 0
Trust 1,050 7,355
St James's 89.2% 94.2%
LGI 96.4% 97.3%
Wharfedale 100% 100%
Trust 93.9% 96.4%
Target
A&E: Number of Attendances n/app
A&E: Performance > 95%
A&E: Number of Breaches n/app
National Indicator / Quality Requirement
Aim: Ensure at least 95% of A&E attendances are admitted, transferred or discharged within 4 hours of arrival. Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graph.
Actions:
Departmental outflow is being closely managed through daily operational planning and Silver Command meetings.
Daily breach reviews are also being undertaken.
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
07/0
4/2
013
14/0
4/2
013
21/0
4/2
013
28/0
4/2
013
05/0
5/2
013
12/0
5/2
013
19/0
5/2
013
26/0
5/2
013
02/0
6/2
013
09/0
6/2
013
16/0
6/2
013
23/0
6/2
013
30/0
6/2
013
07/0
7/2
013
14/0
7/2
013
21/0
7/2
013
28/0
7/2
013
04/0
8/2
013
11/0
8/2
013
18/0
8/2
013
25/0
8/2
013
01/0
9/2
013
08/0
9/2
013
15/0
9/2
013
22/0
9/2
013
29/0
9/2
013
06/1
0/2
013
13/1
0/2
013
20/1
0/2
013
27/1
0/2
013
03/1
1/2
013
10/1
1/2
013
17/1
1/2
013
24/1
1/2
013
01/1
2/2
013
08/1
2/2
013
15/1
2/2
013
22/1
2/2
013
29/1
2/2
013
05/0
1/2
014
12/0
1/2
014
19/0
1/2
014
26/0
1/2
014
02/0
2/2
014
09/0
2/2
014
16/0
2/2
014
23/0
2/2
014
02/0
3/2
014
09/0
3/2
014
16/0
3/2
014
% p
atie
nts
me
etin
g ta
rge
t
Week
A&E - 2012/13 and 2013/14 Performance Against the 4 Hour Access Standard (Including Wharfedale)
Standard 12/13 Performance 13/14 Performance
Page 12 of 44
A&E Measures
Indicator Site Feb-14 YTD
St James's 0 0
LGI 0 0
Trust 0 0
St James's 12 14
LGI 17 17
Trust 16 15
St James's 97 88
LGI 75 71
Trust 84 78
St James's 9.6% 9.9%
LGI 6.9% 6.4%
Trust 8.0% 7.9%
St James's 4.4% 4.1%
LGI 3.0% 2.7%
Trust 3.6% 3.3%
0
Target
A&E: % Unplanned Re-
Attendances Within 7 Days
A&E: % Patients Leaving A&E
Unseen
< 15
< 60
A&E: Time to Assessment
(95th Percentile)
A&E: Time to Treatment
(median)
< 5%
< 5%
A&E: Number of Trolley Waits
Greater Than 12 Hours
Local Contractual Indicator
Internal Indicator
Aims:
Ensure there are no A&E trolley waits greater than 12 hours.
Ensure 95th percentile for time of arrival at A&E to initial full assessment is no more than 15 minutes.
Ensure the median time spent from arrival at A&E to treatment is no more than 60 minutes.
Ensure the percentage of unplanned re-attendances within 7 days of discharge from A&E is no more than 5%.
Ensure percentage of patients who leave A&E without being seen is no more than 5%.
Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty.
0
5
10
15
20
25
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Tim
e to
Asse
ssm
en
t (m
ins)
A&E - Time To Assessment - 95th Percentile
Time To Assessment - 95th Percentile Target
0
20
40
60
80
100
120
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Tim
e to
Tre
atm
en
t (m
ins)
A&E - Time to Treatment - Median
Time To Treatment - Median Target
Page 13 of 44
A&E Measures (Continued)
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% U
np
lan
ne
d R
ea
tte
nd
an
ce
s
A&E - Unplanned Re-Attendances Within 7 Days
Unplanned Re-Attendances Within 7 days Target
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% P
atie
nts
Le
avin
g A
&E
Un
se
en
A&E - Patients Leaving A&E Unseen
Patients Leaving A&E Unseen Target
Page 14 of 44
Cancer 62 Days
Tumour Type Jan-14 (%)
Breast 100.0%
Gynaecological 55.2%
Haematological (Excluding Acute Leukaemia) 88.0%
Head & Neck 68.4%
Lower Gastrointestinal 84.8%
Lung 57.6%
Other 50.0%
Sarcoma 100.0%
Skin 100.0%
Upper Gastrointestinal 82.8%
Urological (Excluding Testicular) 67.1%
Trust 78.5%
Cancer 62 Day Waits - Screening Referrals 100.0%
Cancer 62 Day Waits - Consultant Upgrades (local contractual indicator) 66.7%
Cancer 62 Day Waits - GP Referral
National Indicator / Quality Requirement
Local Contractual Indicator
Aims:
Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer.
Ensure at least 90% of patients receive their first definitive treatment for cancer within 62 days following referral from an NHS cancer screening service.
Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status (local contractual indicator).
Owner: Chief Operating Officer and Clinical Director of Leeds Cancer Centre. Consequence of failure: Timely access to treatment, patient experience, clinical outcomes, reputation & financial penalty.
Appendix 2 lists the peer Trusts included in the benchmarking graphs.
The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline. Performance against the 62 day standard for referrals from consultant upgrade are liable to fluctuate due to the small numbers involved.
Actions:
Capacity issues in Gynaecology and Urology, as well as delays in Pathology turnaround, remain concerns. Additional lists are in place in Gynaecology and Urology, and the backlog is being addressed, but will not deliver sustainable performance until Q1 2014/15. A Pathology recovery plan is to be presented by the end of March.
The late referral of patients (past day 38) from other organisations remains a concern. A request via the Chief Operating Officer and Commissioners to ensure timely referrals is now being further supported through meetings between the Trust Lead Cancer team and referring cancer teams in Q4. The Trust will continue to fail this standard in February and March, with action plans aiming to restore performance for Q1 2014/15.
40%
50%
60%
70%
80%
90%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals
% Within 62 Days - GP/Dentist Target
40%
60%
80%
100%
Bre
ast
Gynaec
olo
gic
al
Haem
ato
logic
al (
Exc
ludin
gA
cute
Leuka
em
ia)
Head &
Neck
Low
er G
astroin
testin
al
Lung
Oth
er
Sarc
om
a
Ski
n
Upper G
astroin
testin
al
Uro
logic
al (
Exc
ludin
gT
estic
ula
r)
% p
atie
nts
me
etin
g ta
rge
t
Cancer 62 Day Waits for GP Referrals by Tumour Type - Jan 2014
Performance Target
Page 15 of 44
Cancer 62 Days (Continued)
40%
50%
60%
70%
80%
90%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
62 Day Upgrade 62 Day Upgrade Target
Performance Against the 62 Day Cancer Standard for Referrals from Consultant Upgrade
NB. Due to the small numbers involved, the above data are liable to fluctuate. In January 2014, for instance, 3 of just 4.5 accountable cases were treated within 62 days.
40%
50%
60%
70%
80%
90%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
62 Day Screening 62 Day Screening Target
Performance Against the 62 Day Cancer Standard for Referrals from Screening Service
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% W
ith
in 6
2 D
ays
Trusts
Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals - 2013-14 Q3
LTHT Peers Other Trusts Target
Source: NHS England
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% W
ith
in 6
2 D
ays
Trusts
Performance Against the 62 Day Cancer Standard for Referrals from Screening Service - 2013-14 Q3
LTHT Peers Other Trusts Target
Source: NHS England
Page 16 of 44
Cancer 31 Days Tumour Type Jan-14 (%)
Brain/Central Nervous System 100.0%
Breast 100.0%
Children's 100.0%
Gynaecological 100.0%
Haematological 100.0%
Head & Neck 82.6%
Lower Gastrointestinal 95.0%
Lung 94.4%
Sarcoma 85.7%
Skin 96.2%
Upper Gastrointestinal 100.0%
Urological 94.5%
Other 100.0%
Trust 96.2%
Cancer 31 Day Waits - Subsequent Surgery 94.3%
Cancer 31 Day Waits - Subsequent Drug Treatment 100.0%
Cancer 31 Day Waits - Subsequent Radiotherapy 93.3%
Cancer 31 Day Waits - First Definitive Treatment
National Indicator / Quality Requirement
Aims:
Ensure at least 96% of patients receiving their first definitive treatment are treated within 31 days.
Ensure at least 94% of patients receiving subsequent surgery are treated within 31 days.
Ensure at least 98% of patients receiving a subsequent anti-cancer drug regimen are treated within 31 days.
Ensure at least 94% of patients receiving subsequent radiotherapy are treated within 31 days.
Owner: Chief Operating Officer and Clinical Director of Leeds Cancer Centre. Consequence of failure: Timely access to treatment, patient experience, clinical outcomes, reputation & financial penalty.
The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.
Actions:
Although overall compliance was achieved for Q3, the Trust failed the 31 day target for Subsequent Radiotherapy for both December and January; the main cause was an unexpected rise in demand at the same time as a planned machine upgrade.
The Trust is expecting to achieve the standard for Q4, with additional sessions and staff having been put in place in the short term to address the backlog.
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
% Within 31 Days - First Treatments Target
Performance Against the 31 Day Cancer Standard for First Treatments
80%
85%
90%
95%
100%
Bra
in/C
ent
ral N
erv
ous
Sys
tem
Bre
ast
Child
ren's
Gynaec
olo
gic
al
Haem
ato
logic
al
Head &
Neck
Low
er G
astroin
testin
al
Lung
Sarc
om
a
Ski
n
Upper G
astroin
testin
al
Uro
logic
al
Oth
er
% p
atie
nts
me
etin
g ta
rge
t
Performance Target
Cancer 31 Day Waits for First Definitive Treatment by Tumour Type - Jan 2014
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
Drug Drug Target
Surgery Surgery and Radiotherapy Target
Radiotherapy
Performance Against the 31 Day Cancer Standard for Second or Subsequent Treatment
Page 17 of 44
Cancer 2 Week Wait
Tumour Type Jan-14 (%)
Suspected brain/central nervous system tumours 90.9%
Suspected breast cancer 97.4%
Suspected children's cancer 78.6%
Suspected gynaecological cancer 90.7%
Suspected haematological malignancies (excluding acute leukaemia) 92.9%
Suspected head & neck cancer 72.6%
Suspected lower gastrointestinal cancer 87.5%
Suspected lung cancer 100.0%
Suspected sarcoma 100.0%
Suspected skin cancer 76.8%
Suspected testicular cancer 94.7%
Suspected upper gastrointestinal cancer 93.3%
Suspected urological malignancies (excluding testicular) 96.7%
Trust 87.0%
Cancer 2 Week Waits - Breast Symptoms 93.8%
Cancer 2 Week Waits - Suspected
National Indicator / Quality Requirement
Aims:
Ensure at least 93% of patients urgently referred with suspected cancer by their GP (GMP or GDP) are seen within 14 days.
Ensure at least 93% of patients urgently referred for evaluation/investigation of “breast symptoms” by a primary or secondary care professional are seen within 14 days.
Owner: Chief Operating Officer and Clinical Director of Leeds Cancer Centre. Consequence of failure: Timely access to treatment, patient experience, clinical outcomes, reputation & financial penalty.
The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.
Actions:
The Trust failed this standard in January and due to the scale of the problem in that month will fail the standard for Q4 2013/14. Action plans are in place for the Dermatology and Breast services in particular and the standard is being achieved in February and so far in March, but will not recover the overall position for the quarter.
Breast symptoms: This standard was met in January and is expected to achieve overall for Q4, due to the recovery plan in place for additional Radiology capacity as well as Breast Surgery clinic capacity.
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
% Within 14 Days - Suspected Cancer Target
Performance Against the 2 Week Cancer Standard for Suspected Cancer
80%
85%
90%
95%
100%
Susp
ecte
d b
rain
/centr
al
nerv
ous
syst
em
tum
ours
Susp
ecte
d b
reast
cancer
Susp
ecte
d c
hild
ren's
cancer
Susp
ecte
d g
ynaec
olo
gic
al
cancer
Susp
ecte
d h
aem
ato
logic
al
malig
nancie
s (e
xclu
din
g
acu
te le
ukaem
ia)
Susp
ecte
d h
ead &
neck
cancer
Susp
ecte
d low
er
gast
roin
test
inal ca
nce
r
Susp
ecte
d lung c
ance
r
Susp
ecte
d s
arc
oma
Susp
ecte
d s
kin c
ance
r
Susp
ecte
d testic
ula
rca
ncer
Susp
ecte
d u
pper
gast
roin
test
inal ca
nce
r
Susp
ecte
d u
rolo
gic
al
malig
nancie
s (e
xclu
din
g
test
icula
r)
% p
atie
nts
me
etin
g ta
rge
t
Cancer 2 Week Waits for Suspected Cancer by Tumour Type - Jan 2014
Performance Target
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
% Within 14 Days - Breast Symptoms Target
Performance Against the 2 Week Cancer Standard for Breast Symptoms
Page 18 of 44
Stroke Care
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% w
ith
in 2
4 h
ou
rs
Proportion of High-Risk TIA Patients Investigated and Treated within 24 Hours of First Contact with a Health Professional
Internal Indicator
Aims:
Ensure at least 80% of patients who have had a stroke spend at least 90% of their time in hospital on a stroke unit.
Ensure high-risk TIA patients are investigated and treated within 24 hours of first contact with a health professional.
Owner: Chief Operating Officer and Clinical Director of the Centre for Neurosciences Consequence of failure: Timely access to treatment, patient experience, clinical outcomes & financial penalty.
The Stroke and TIA indicators are monitored a month in arrears.
Actions:
Provisional data indicates that February performance against the 80% Stroke care threshold has been restored.
Further work is on-going to ensure all accountable patients are captured in the numerator for this indicator.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% m
ee
tin
g ta
rge
t
Stroke Discharges Spending at Least 90% of Spell on a Stroke Unit
90% of spell on stroke unit Target
Page 19 of 44
30 Day Emergency Readmissions
ElectiveNon-
ElectiveTotal Elective
Non-
ElectiveTotal Elective Non-Elective Total
Acute Medicine 1.0% 18.2% 16.2% 2.0% 18.8% 16.8% 4.0% 14.2% 12.7%
Adult Critical Care - 0.0% 0.0% - 5.9% 5.9% 2.0% 4.4% 2.2%
Adult Theatres & Anaesthesia 0.0% - 0.0% 0.0% - 0.0% 3.6% 8.6% 4.9%
Cardio-Respiratory 3.0% 16.0% 10.8% 3.6% 14.9% 10.2% 5.5% 15.5% 10.4%
Centre for Neurosciences 2.6% 8.0% 4.4% 2.7% 8.4% 4.6% 3.8% 10.7% 6.2%
Chapel Allerton Hospital 2.2% 7.1% 2.3% 1.7% 13.3% 1.9% 2.3% 11.2% 2.4%
Childrens 4.4% 5.5% 5.0% 4.5% 5.8% 5.3% 6.4% 9.7% 7.9%
Digestive Diseases 3.0% 17.3% 7.2% 3.5% 16.0% 7.2% 4.1% 14.5% 7.0%
Head & Neck 2.0% 9.7% 2.9% 2.2% 6.8% 2.7% 2.9% 6.8% 3.6%
Hepatorenal 4.5% 15.1% 7.3% 4.3% 15.6% 7.3% 5.9% 17.8% 8.6%
Leeds Cancer Centre - - - - - - 7.7% 19.3% 9.1%
Leeds Dental Institute 0.0% - 0.0% 0.3% 0.0% 0.3% 0.9% 1.6% 1.0%
Pathology - - - 0.0% - 0.0% 0.0% 0.0% 0.0%
Radiology - - - - - - 5.2% 10.6% 5.4%
Trauma and Related Services 2.2% 8.1% 4.4% 2.9% 8.3% 5.1% 3.7% 8.1% 5.7%
Urgent Care - 11.2% 11.2% - 10.9% 10.9% 3.0% 11.4% 11.4%
Womens 2.2% 1.8% 1.8% 2.0% 1.2% 1.3% 2.7% 2.3% 2.4%
Trust 3.6% 11.3% 6.8% 3.8% 11.0% 6.9% 4.7% 11.0% 7.2%
(NB: RAG ratings are based on thresholds set by the TDA)
CSU
Jan-14 YTD Total Peer - Feb-12 to Jan-13
National Indicator / Quality Requirement
Aim: Ensure no more than 10.9% of patients are readmitted as an emergency within 30 days of discharge, following elective or non-elective treatment. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, quality of care, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graphs.
0%
2%
4%
6%
8%
10%
12%
14%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% R
ea
dm
issio
ns
Readmissions - Elective
% Readmissions Peer % Readmissions
0%
2%
4%
6%
8%
10%
12%
14%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% R
ea
dm
issio
ns
Readmissions - Non-Elective
% Readmissions Peer % Readmissions
0%
2%
4%
6%
8%
10%
12%
14%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% R
ea
dm
issio
ns
Readmissions - Total (Elective and Non-Elective)
% Readmissions Peer % Readmissions
Page 20 of 44
Outpatient Activity - New and Review
Plan Activity Variance Plan Activity Variance
Acute Medicine 1,908 1,737 -171 22,231 19,971 -2,260
Adult Critical Care 0 0 0 0 1 1
Adult Theatres & Anaesthesia 21 95 74 246 1,344 1,098
Adult Therapies 1 3,556 2,930 -626 41,425 42,650 1,225
Cardio-Respiratory 3,131 3,382 251 36,479 38,552 2,073
Centre for Neurosciences 1,831 1,959 128 21,282 23,928 2,646
Chapel Allerton Hospital 6,359 6,729 370 73,493 74,974 1,481
Childrens 2,853 3,000 147 32,781 35,209 2,428
Digestive Diseases 3,147 2,544 -603 34,502 29,572 -4,930
Head & Neck 7,260 7,824 564 83,293 85,001 1,708
Hepatorenal 4,140 4,834 694 48,229 47,871 -358
Institute of Oncology 8,837 8,864 27 101,498 96,047 -5,451
Leeds Dental Institute 3,238 3,396 158 37,529 35,182 -2,347
Pathology 1 0 -1 9 8 -1
Radiology 850 2,013 1,163 9,904 21,669 11,765
Trauma and Related Services 4,179 4,108 -71 48,613 46,906 -1,707
Urgent Care 2 2,138 - -2,138 24,911 21,151 -3,760
Womens 1,702 2,223 521 19,823 19,504 -319
Trust 55,151 55,638 487 636,248 639,540 3,292
CSUFeb-14 YTD
Outpatient Activity - Review Attendances
Internal Indicator
Aim: Maintain financial viability through delivery of planned activity. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.
New:
Overall Trust activity year to-February was 2% below plan.
Year-to-February, the following CSUs were more than 10% below their plan: Digestive Diseases, and the Institute of Oncology (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers, and Urgent Care – as explained in footnote 2 below).
Review:
Overall Trust activity year to-February was 0.5% above plan.
Year-to-February, the following CSUs were more than 10% below their plan: Acute Medicine and Digestive Diseases (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers, and Urgent Care – as explained in footnote 2 below).
Plan Activity Variance Plan Activity Variance
Acute Medicine 380 457 77 4,427 5,222 795
Adult Critical Care 4 6 2 47 41 -6
Adult Theatres & Anaesthesia 0 0 0 0 2 2
Adult Therapies 1 1,376 1,226 -150 16,036 17,675 1,639
Cardio-Respiratory 1,844 1,838 -6 21,483 21,432 -51
Centre for Neurosciences 1,538 1,374 -164 17,816 16,958 -858
Chapel Allerton Hospital 1,935 1,937 2 22,243 21,837 -406
Childrens 1,184 1,200 16 13,544 13,793 249
Digestive Diseases 1,447 1,042 -405 16,247 12,738 -3,509
Head & Neck 2,734 4,212 1,478 31,278 30,917 -361
Hepatorenal 887 1,059 172 10,332 11,599 1,267
Institute of Oncology 1,907 1,974 67 21,749 18,837 -2,912
Leeds Dental Institute 1,085 1,250 165 12,969 13,247 278
Pathology 3 0 -3 31 31 0
Radiology 260 421 161 3,027 4,398 1,371
Trauma and Related Services 2,111 2,098 -13 24,464 24,344 -120
Urgent Care 2 1,785 - -1,785 20,795 17,559 -3,236
Womens 1,094 1,454 360 12,740 13,701 961
Trust 21,573 21,548 -25 249,227 244,331 -4,896
Outpatient Activity - New Attendances
CSUFeb-14 YTD
1 Activity for Psychology (within the Adult Therapies CSU) is not included for the reporting month in the above data. 2 Urgent Care activity for the reporting month is not included in the above data.
Page 21 of 44
Inpatient Activity - Elective and Non-elective
Plan Activity Variance Plan Activity Variance
Acute Medicine 1,458 1,355 -103 17,397 15,733 -1,664
Adult Critical Care 5 8 3 61 71 10
Adult Theatres & Anaesthesia 0 0 0 0 0 0
Adult Therapies 0 0 0 0 0 0
Cardio-Respiratory 718 824 106 8,568 8,550 -18
Centre for Neurosciences 316 237 -79 3,766 2,770 -996
Chapel Allerton Hospital 17 12 -5 197 156 -41
Childrens 651 664 13 7,771 7,658 -113
Digestive Diseases 607 610 3 7,245 7,526 281
Head & Neck 137 168 31 1,637 1,769 132
Hepatorenal 329 272 -57 3,921 3,851 -70
Institute of Oncology 318 311 -7 3,795 3,905 110
Leeds Dental Institute 0 0 0 2 5 3
Pathology 0 0 0 0 1 1
Radiology 13 11 -2 150 197 47
Trauma and Related Services 427 442 15 5,098 5,383 285
Urgent Care 972 674 -298 11,598 8,521 -3,077
Womens 124 90 -34 1,482 1,359 -123
Awaiting CSU Allocation 0 0 0 0 5 5
Trust 6,092 5,678 -414 72,690 67,460 -5,230
CSUFeb-14 YTD
Inpatient Activity - Non-Elective (Spells)
Internal Indicator
Aim: Maintain financial viability through delivery of planned activity Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.
Elective:
Overall Trust activity year to-February was 0.3% below plan.
Year-to-February, only the Radiology CSU was more than 10% below its plan (this excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers).
Non-elective:
Overall Trust activity year to-February was 7.2% below plan.
Year-to-February, the following CSUs were more than 10% below their plan: Centre for Neurosciences, Chapel Allerton Hospital, and Urgent Care (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers).
Plan Activity Variance Plan Activity Variance
Acute Medicine 185 170 -15 2,156 2,039 -117
Adult Critical Care 0 0 0 2 0 -2
Adult Theatres & Anaesthesia 1 8 7 8 103 95
Adult Therapies 0 0 0 0 0 0
Cardio-Respiratory 505 495 -10 5,879 5,940 61
Centre for Neurosciences 561 520 -41 6,320 5,997 -323
Chapel Allerton Hospital 939 827 -112 10,911 10,278 -633
Childrens 846 861 15 9,632 10,553 921
Digestive Diseases 1,934 1,479 -455 19,977 18,138 -1,839
Head & Neck 1,090 1,078 -12 12,501 12,671 170
Hepatorenal 879 940 61 9,986 10,922 936
Institute of Oncology 2,374 2,406 32 27,489 28,336 847
Leeds Dental Institute 130 134 4 1,527 1,469 -58
Pathology 0 0 0 0 1 1
Radiology 13 13 0 157 134 -23
Trauma and Related Services 691 654 -37 7,697 7,505 -192
Urgent Care 0 0 0 3 0 -3
Womens 281 217 -64 3,282 3,079 -203
Trust 10,429 9,802 -627 117,536 117,166 -370
Inpatient Activity - Elective (Spells)
CSUFeb-14 YTD
Page 22 of 44
Length of Stay
0
2
4
6
8
10
12
14
16
Ophth
alm
olo
gy
Gynaec
olo
gy
Ora
l Surg
ery
Ear
Nose
& T
hro
at
Pla
stic
Surg
ery
Card
iolo
gy
Uro
logy
Rheum
ato
logy
Derm
ato
logy
Tra
um
a &
Ort
hop
aedic
Surg
ery
Genera
l Medic
ine
Gastroente
rolo
gy
Genera
l Surg
ery
Neuro
logy
Neuro
surg
ery
Resp
irato
ry M
edic
ine
Eld
erly M
edic
ine
Le
ng
th o
f S
tay
LTHT Peer Average
For peer listing, please see Appendix 2 Source: Dr Foster
Length of Stay: Selected Specialties Jan 13 to Dec-13
Internal Indicator
Aim: To reduce the length of stay in order to release capacity for other patients and provide an improved patient experience. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, financial and clinical outcomes.
\
Specialty LTHT Peer Avg
Ophthalmology 0.8 1.6
Gynaecology 1.6 1.6
Oral Surgery 2.1 2.1
Ear Nose & Throat 2.5 2.6
Plastic Surgery 2.6 2.7
Cardiology 3.2 4.4
Urology 3.8 3.2
Rheumatology 4.3 5.7
Dermatology 4.8 6.3
Trauma & Orthopaedic Surgery 4.9 4.6
General Medicine 6.8 6.1
Gastroenterology 7.4 8.1
General Surgery 7.5 6.7
Neurology 9.5 9.2
Neurosurgery 10.5 8.1
Respiratory Medicine 10.5 7.6
Elderly Medicine 11.5 13.6
All Specialties 5.1 4.8
Length of Stay: Selected Specialties
Jan-13 to Dec-13
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Le
ng
th o
f S
tay
Length of Stay: Trust Level - Jan-13 to Dec-13
Length of Stay Expected Length of Stay
Source: Dr Foster
Page 23 of 44
Incidence of MRSA
By CSU Feb-14 YTD
Acute Medicine 0 1
Centre for Neurosciences 0 1
Digestive Diseases 0 2
Leeds Cancer Centre 0 2
Trust 0 6
National Indicator / Quality Requirement
Aim: Eliminate Trust-apportioned MRSA bacteraemia cases in 2013/14. Owner: Chief Medical Officer, Infection Control Team, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.
Appendix 2 lists the peer Trusts included in the benchmarking graph.
As at 14th February, no MRSA bacteraemias had been provisionally recorded for
February 2014. Actions:
A process to ensure clinical teams are able to rapidly identify Mupirocin resistance in MRSA-positive patients is currently being put in place.
By month
MRSA Cases
(Trust-
Apportioned)
Achieve
Trajectory
( < )
Apr-13 1 0
May-13 2 0
Jun-13 0 0
Jul-13 0 0
Aug-13 1 0
Sep-13 1 0
Oct-13 0 0
Nov-13 0 0
Dec-13 0 0
Jan-14 1 0
Feb-14 0 0
0
1
2
3
4
5
6
7
8
9
Ca
se
s P
er
10
0,0
00
Occu
pie
d B
ed
Da
ys
Trusts
Number of MRSA Bacteraemia Cases Per 100,000 Occupied Bed Days (Trust Apportioned) - April 2013 to January 2014
LTHT Peers Other Trusts
Source: HPA(NB: 36 Trusts reported no MRSA cases for the period, including 2 peer Trusts)
Page 24 of 44
MRSA Screening
Target > 95% > 95%
CSU Feb-14 YTD
Acute Medicine 97.1% 96.9%
Adult Critical Care 98.9% 96.3%
Adult Theatres & Anaesthesia 98.1% 96.9%
Cardio-Respiratory 96.3% 95.5%
Centre for Neurosciences 98.5% 97.5%
Chapel Allerton Hospital 99.7% 98.0%
Children's 91.0% 90.8%
Digestive Diseases 96.4% 96.3%
Head & Neck 94.4% 92.6%
Hepatorenal 99.3% 97.4%
Leeds Cancer Centre 94.9% 95.8%
Leeds Dental Institute * No eligible patients 11.1%
Trauma & Related Services 90.0% 91.3%
Urgent Care 95.2% 92.7%
Women's 97.0% 95.5%
Trust 96.1% 95.7%
* Low numbers of eligible patients
MRSA Screening - % of Eligible Patients Screened
Local Contractual Indicator
Aim: Ensure that at least 95% of eligible admitted patients are screened for MRSA. Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes & financial penalty.
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% o
f e
lig
ible
pa
tie
nts
scre
en
ed
MRSA Screening (Elective and Non Elective Admissions)
% Screened Target
Page 25 of 44
Incidence of CDI
By CSU Feb-14 YTD
Acute Medicine 5 34
Adult Critical Care 0 11
Cardio-Respiratory 0 12
Centre for Neurosciences 0 8
Children's 1 16
Digestive Diseases 1 19
Head & Neck 0 1
Hepatorenal 1 14
Leeds Cancer Centre 1 12
Trauma & Related Services 0 7
Women's 0 1
Trust 9 135
CDI Rate per 100,000 Bed Days 18.3 23.8
CDI
National Indicator / Quality Requirement
Local Contractual Indicator
Aims:
Reduce the number of Trust-attributed CDIs in 2013/14 to no more than 101.
Reduce the CDI rate per 100,000 occupied bed days in line with the NHS Standard Contract.
Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.
Appendix 2 lists the peer Trusts included in the benchmarking graph.
As at 14th February, 4 CDIs had been recorded for February 2014.
Actions:
Executive-led CDI review meetings with CSUs continue to take place.
A new root cause analysis investigation tool has been introduced.
0
20
40
60
80
100
120
140
160
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
No
. C
DI ca
se
s
Progress Against the CDI Target (Cumulative)
CDI Cases Achieve Trajectory
0
5
10
15
20
25
30
35
40
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
CD
I R
ate
Pe
r 1
00
,00
0 O
ccu
pie
d B
ed
Da
ys
CDI Rate Per 100,000 Occupied Bed Days
NB: Denominator taken from internal Midnight Bed State data
0
5
10
15
20
25
30
35
40
Ca
se
s p
er
10
0,0
00
Occu
pie
d B
ed
Da
ys
Trusts
Number of C.Difficile Cases Per 100,000 Occupied Bed Days for Patients Aged > 2 Years (Trust Apportioned) - April 2013 to January 2014
LTHT Peers Other Trusts
Source: HPA(NB: 4 Trusts reported no CDI cases for the period)
Page 26 of 44
Summary Hospital Mortality Index (SHMI)
SHMI Measure Spells SHMIObserved
Deaths
Expected
Deaths
95%
Confidence
Interval
SHMI 95% CI 126278 95.15 3982 4185 92.21-98.15
SHMI (adjusted for palliative care) 126278 96.93 3982 4108 93.95-99.99
SHMI (in hospital deaths) 126278 93.16 2824 3031 89.76-96.67
Trust Level SHMI (with adjustments) for July 2012 to June 2013
National Indicator / Quality Requirement
The SHMI reports mortality at Trust level across the NHS in England using standard and transparent methodology. SHMI is the nationally recognised hospital level indicator of mortality. Aim: Improve SHMI rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.
The Trust SHMI (source: Dr Foster) for the latest available period, July 2012 to June 2013, was 95.15 - better than expected. Relative Risk mortality was either within or better than the expected range for all Clinical Classification System (CCS) groups for in hospital deaths over the same period. The Trust has consistently maintained an overall SHMI within or better than the expected range over the latest available 3 year period.
Page 27 of 44
Hospital Standardised Mortality Rate (HSMR)
Measure Spells HSMRObserved
Deaths
Expected
Deaths
95%
Confidence
Interval
HSMR 59047 91.17 2412 2646 87.56-94.88
Trust Level HSMR for July 2012 to June 2013
National Indicator / Quality Requirement
The HSMR reports mortality at Trust level across the NHS in England using standard and transparent methodology.
Aim: Improve HSMR rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.
The Trust HSMR (source: Dr Foster) for July 2012 to June 2013 was 91.17 – better than expected. The Trust has consistently maintained an overall HSMR within or better than the expected range over the latest available 4 year period.
80
85
90
95
100
105
2009/10 2010/11 2011/12 2012/13 2013/14HS
MR
(1
00
x O
bs
erv
ed
/Ex
pe
cte
d d
ea
ths
)
Financial Year
HSMR Trend
LTHT LTHT (rebased) England England (rebased)
NB. "2013/14" accounts for the YTD period April 2013 to December 2013
Acute Trust HSMRs Apr-13 to Dec-13 (not rebased)
Page 28 of 44
VTE Risk Assessment
CSU Jan-14 YTD
Acute Medicine 95.8% 95.9%
Adult Critical Care 94.9% 95.3%
Adult Theatres & Anaesthesia 89.6% 87.9%
Cardio-Respiratory 94.0% 94.4%
Centre for Neurosciences 91.3% 91.6%
Chapel Allerton 98.1% 97.5%
Children's 85.4% 90.6%
Digestive Diseases 97.4% 96.4%
Head & Neck 98.0% 97.1%
Hepatorenal 97.1% 95.1%
Leeds Cancer Centre 98.4% 98.5%
Leeds Dental Institute 100.0% 99.7%
Trauma & Related Services 87.8% 88.8%
Urgent Care 96.8% 96.9%
Women's 97.4% 96.1%
Trust 96.1% 95.7%
% VTE Risk Assessment
National Indicator / Quality Requirement
Aim: Ensure at least 95% of adult inpatients have a VTE risk assessment on admission to hospital. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, CQUIN & financial penalty.
Appendix 2 lists the peer Trusts included in the benchmarking graph.
The VTE risk assessment indicator is monitored a month in arrears due to the timing of the national reporting deadline.
Provisional Trust performance for February as at 14th March was 96.02%.
70%
75%
80%
85%
90%
95%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
% p
atie
nts
me
etin
g ta
rge
t
Venous Thromboembolism (VTE) Risk Assessments
% Patients Risk Assessed for VTE Target
70%
75%
80%
85%
90%
95%
100%
% P
atie
nts
Me
etin
g T
arg
et
Trusts
LTHT Peers Other Trusts Target
Source: NHS England
Venous Thromboembolism (VTE) Risk Assessments - April to December 2013
RRK University Hospitals Birmingham NHS Foundation Trust 99.2%
RGT Cambridge University Hospitals NHS Foundation Trust 98.8%
RA7 University Hospitals Bristol NHS Foundation Trust 97.7%
RTD The Newcastle Upon Tyne Hospitals NHS Foundation Trust 96.5%
RM2 University Hospital Of South Manchester NHS Foundation Trust 96.2%
Top 5 Performing Peer Trusts - April to December 2013:
Page 29 of 44
Harm Free Care
87
.8%
90
.1%
90
.8%
92
.9%
93
.2%
92
.8%
92
.5%
92
.3%
93
.2%
93
.8%
93
.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4% o
f P
atie
nts
With
Ha
rm F
ree
Ca
re
% of Patients With Harm Free Care
% of Patients With Harm Free Care Target
Source: Safety Thermometer
National Indicator / Quality Requirement
CQUIN Indicator
Internal Indicator
Aims:
Ensure at least 92% of patients receive harm free care in relation to pressure ulcers, falls, CUTIs & VTE).
Ensure that for the period October 2013 to March 2014 no more than 6.4% of patients have a pressure ulcer (between April and September 2013 this target stood at 7.2%, but was recently renegotiated with the CCG).
Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient safety, patient experience, clinical outcomes, quality of care, reputation and financial penalty.
Actions:
Harm Free Care performance is to be displayed on every adult inpatient ward.
The multi-disciplinary team assessment booklet for falls is to be approved and rolled out across adult inpatient areas.
0%
1%
2%
3%
4%
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% o
f P
atie
nts
With
Fa
lls R
esu
ltin
g i
n H
arm
% of Patients With Falls Resulting in Harm
% Falls With Harm (LTHT) % Falls With Harm (National Acute Average)
Source: Safety Thermometer
0%
2%
4%
6%
8%
10%
12%
14%
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% o
f P
atie
nts
With
a P
ressu
re U
lce
r (n
ew
an
d
old
)
% of Patients With a Pressure Ulcer (New and Old)
% of Patients With a Pressure Ulcer (new and old) Target
Source: Safety Thermometer
0%
2%
4%
6%
8%
10%
12%
14%
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4% o
f P
atie
nts
With
UIT
s (
Ne
w a
nd
Old
)
% of Patients With UTIs (New and Old)
% With UTIs (LTHT) % With UTIs (National Acute Average)
Source: Safety Thermometer
Page 30 of 44
Pressure Ulcers
CQUIN Indicator
Aims:
Reduce the number of grade III pressure ulcers developed in the Trust to no more than 36 for 2013/14.
Reduce the number of grade IV pressure ulcers developed in the Trust to no more than 2 for 2013/14.
Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, patient safety, clinical outcomes, quality of care, CQUIN & financial penalty.
Actions:
The Trust-wide action plan for pressure ulcers is to be refreshed to take into account the CQUINs agreed for 2014/15.
Nursing teams are to continue to work with high risk or high prevalence areas, with audit findings to be included in CSU plans.
0
1
2
3
4
5
6
7
8
9
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
No
. o
f p
ressu
re u
lce
rs
Number of Grade III Pressure Ulcers
Grade III Target
0
1
2
3
4
5
6
7
8
9
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
No
. o
f p
ressu
re u
lce
rs
Number of Grade IV Pressure Ulcers
No. Grade IV
CSU Feb-14
Acute Medicine 4
Trauma and Related Services 2
Digestive Diseases 1
Institute of Oncology 1
Grade III Trust Total 8
Grade IV Trust Total 0
Pressure Ulcers - Grade III
Pressure Ulcers - Grade IV
Page 31 of 44
Complaints
Complaints by CSU YTD
Women's 100
Centre for Neurosciences 97
Digestive Diseases 95
Trauma & Related Services 83
Acute Medicine 80
Hepatorenal 71
Cardio-Respiratory 64
Urgent Care 59
Children's 56
Leeds Cancer Centre 55
Chapel Allerton Hospital 53
Head & Neck 52
Radiology 16
Adult Theatres & Anaesthesia 15
Leeds Dental Institute 12
Adult Therapies 11
Pathology 10
Adult Critical Care 8
All Other CSUs 39
Trust 976
Top Complaints Subjects YTD
Medical Care 421
Communication 133
Nursing care 98
Waiting Lists 78
Attitude 75
Administration 65
Waiting Times 26
Discharge Planning 13
Policy and Procedural Issues 10
Drug Issues 8
Sub Total 927
Trust 976
National Indicator / Quality Requirement
Internal Indicator
Aim: Improve patient experience and satisfaction through better understanding of the complaints received. Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, quality of care & financial penalty.
0
20
40
60
80
100
120
140
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4Nu
mb
er o
f C
om
pla
ints
Re
ce
ive
d
Complaints - Number of Complaints Received
0
5
10
15
20
25
30
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4Ra
te p
er 1
0,0
00
Occu
pie
d B
ed
D
ays
Complaints - Rate per 10,000 Occupied Bed Days
Page 32 of 44
Patient Satisfaction – Friends & Family
Response
Rate
Net Promoter
Score
Response
Rate
Net Promoter
Score
Acute Medicine 38.4% 46 33.8% 48
Cardio-Respiratory 33.2% 71 32.1% 74
Centre for Neurosciences 41.2% 72 29.7% 72
Chapel Allerton Hospital 55.7% 83 53.4% 85
Children's 0.0% - 12.0% 92
Digestive Diseases 44.4% 68 42.3% 67
Head & Neck 40.1% 75 26.9% 64
Hepatorenal 33.3% 65 36.7% 69
Leeds Cancer Centre 25.3% 78 33.0% 79
Trauma & Related Services 34.6% 69 25.1% 67
Urgent Care 56.0% 63 50.4% 65
Women's 16.1% 43 16.8% 59
Inpatient Total 37.0% 66 35.2% 67
Maternity Total 23.7% 71 27.3% 71
A&E LGI 20.8% 49 8.9% 54
A&E SJUH 18.5% 44 9.8% 56
A&E Total 19.7% 47 9.3% 55
Combined Total 26.5% 59 20.5% 64
NB YTD Response Rate is not RAG rated as there is no YTD threshold.
Feb-14 YTD
CSU
National Indicator / Quality Requirement
Aims:
Ensure at least 20% of eligible patients respond to the Friends and Family Test (FFT) question.
Improve the number of positive recommendations to friends and family (Net Promoter Score) by people receiving NHS Treatment for the place where they received care.
Owner: Chief Nurse, Director of External Affairs & Communication Consequence of failure: Patient experience, reputation, CQUIN & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graph.
The FFT will be extended to all NHS services in England, including Outpatient appointments, by the end of March 2015. Actions:
Work is underway to implement the iWantGreatCare "gold package" in existing areas, which will increase the depth of feedback available – above and beyond the standard FFT requirements.
Planning has commenced for the roll-out of the FFT to Daycases, Children's and Outpatients - ahead of the NHS England April 2015 deadline.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% R
esp
on
se
Ra
te
Friends and Family Test - % Response Rate
Response Rate (%) Target
0
10
20
30
40
50
60
70
80
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Ne
t P
rom
ote
r S
co
re
Friends and Family Test - Net Promoter Score
Net Promoter Score (LTHT) Net Promoter Score (National Avg)*
*Excludes Independent Sector providers. Reported a month in arrears.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Re
sp
on
se
Ra
te
Trusts
LTHT Peers Other Trusts
Source: NHS England
Friends and Family Test Response Rates (A&E and Inpatient)January 2014
Page 33 of 44
Outpatient Measures
Feb-14 YTD Feb-14 YTD
Radiology 374 3,861 12.5% 12.2%
Leeds Cancer Centre 2,259 25,650 16.3% 15.9%
Trauma and Related Services 1,499 18,201 17.5% 18.2%
Womens 1,735 19,431 19.5% 19.0%
Leeds Dental Institute 1,104 14,221 17.6% 20.6%
Adult Theatres & Anaesthesia 35 439 23.2% 22.1%
Head & Neck 3,373 45,404 20.0% 22.3%
Childrens 1,477 17,529 22.8% 22.9%
Chapel Allerton Hospital 2,661 32,639 21.7% 23.3%
Cardio-Respiratory 1,744 20,756 22.7% 23.4%
Hepatorenal 1,743 21,488 21.0% 23.6%
Pathology - 19 - 25.7%
Digestive Diseases 1,330 16,874 24.3% 25.9%
Centre for Neurosciences 1,539 16,440 29.1% 26.6%
Acute Medicine 743 11,076 22.9% 26.6%
Adult Therapies 88 1,364 24.3% 27.8%
Adult Critical Care 4 31 26.7% 28.4%
All other CSUs - 1 - 100.0%
Trust 21,708 265,424 20.3% 21.4%
Total Number of OP Appointment
Cancellations (By Patient and Hospital)
OP Appointment Cancellations (as a %
of Total Bookings)
Outpatients: Total Appointment Cancellations
CSU
Internal Indicator
Aims:
Ensure the Trust’s Did Not Attend (DNA) rate is below the peer average.
Reduce the number of appointments cancelled by hospital within 6 weeks of appointment.
Reduce the number of appointments cancelled by patient within 6 weeks of appointment.
Owner: Director of Informatics and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.
Actions:
A review of the automated appointment messaging service pilot is to be completed, with an aim to rollout the service to all booked Outpatients appointments in 2014/15.
The weekly Outpatient publication continues to highlight under 6 week hospital cancellations for CSUs to review and action.
Radiology 355 11.9% 3,672 11.6% 19 0.6% 182 0.6%
Leeds Dental Institute 720 11.5% 8,868 12.9% 198 3.2% 2,599 3.8%
Womens 973 10.9% 10,972 10.7% 654 7.3% 6,789 6.6%
Acute Medicine 408 12.6% 5,383 12.9% 195 6.0% 2,772 6.7%
Trauma and Related Services 780 9.1% 8,484 8.5% 524 6.1% 7,121 7.1%
Leeds Cancer Centre 927 6.7% 11,675 7.2% 1,163 8.4% 11,728 7.2%
Adult Critical Care 4 26.7% 22 20.2% 0 0.0% 8 7.3%
Cardio-Respiratory 1,011 13.2% 11,079 12.5% 471 6.1% 6,878 7.7%
Adult Therapies 62 17.1% 905 18.4% 23 6.4% 395 8.0%
Head & Neck 1,702 10.1% 20,629 10.1% 1,131 6.7% 16,928 8.3%
Childrens 672 10.4% 8,007 10.5% 607 9.4% 6,495 8.5%
Adult Theatres & Anaesthesia 15 9.9% 266 13.4% 20 13.2% 173 8.7%
Chapel Allerton Hospital 1,377 11.3% 15,619 11.2% 932 7.6% 12,275 8.8%
Hepatorenal 998 12.0% 11,064 12.2% 650 7.8% 8,166 9.0%
Digestive Diseases 718 13.1% 8,550 13.1% 504 9.2% 6,687 10.3%
Centre for Neurosciences 613 11.6% 7,650 12.4% 687 13.0% 6,356 10.3%
Pathology - - 7 9.5% - - 11 14.9%
All other CSUs - - - - - - - -
Trust 11,335 10.6% 132,852 10.7% 7,778 7.3% 95,563 7.7%
Outpatients: Appointments Cancelled Within 6 Weeks of Appointment
CSU
Cancelled by Patient (Number and as a
% of Total Bookings)
Cancelled by Hospital (Number and as a
% of Total Bookings)
Feb-14 YTD Feb-14 YTD
Specialty LTHT Peer Avg
General Medicine 1.2% 5.8%
Gastroenterology 8.1% 8.0%
Neurosurgery 8.4% 7.5%
Gynaecology 9.1% 6.9%
Cardiology 9.3% 8.7%
Rheumatology 9.6% 9.3%
Elderly Medicine 9.7% 9.4%
Urology 10.1% 8.5%
Ophthalmology 10.3% 9.0%
Respiratory Medicine 10.4% 10.2%
Dermatology 10.7% 8.3%
General Surgery 11.4% 9.8%
Trauma & Orthopaedic Surgery 11.5% 9.3%
Ear Nose & Throat 12.0% 8.7%
Neurology 12.2% 10.8%
Plastic Surgery 12.3% 9.6%
Oral Surgery 15.2% 11.6%
All Specialties 9.5% 8.6%
Outpatient Appointment DNA (%)
Selected Specialties - Jan-13 to Dec-13
0% 5% 10% 15% 20%
General Medicine
Gastroenterology
Neurosurgery
Gynaecology
Cardiology
Rheumatology
Elderly Medicine
Urology
Ophthalmology
Respiratory Medicine
Dermatology
General Surgery
Trauma & Orthopaedic…
Ear Nose & Throat
Neurology
Plastic Surgery
Oral Surgery
Ou
tpa
tie
nt A
pp
oin
tme
nt
DN
A (%
)
LTHT Peer Average
For peer listing, please see Appendix 2 Source: Dr Foster
Outpatient Appointment DNA (%)Selected Specialties - Jan-13 to Dec-13
Page 34 of 44
Outpatient Measures (Continued)
Specialty LTHT Peer Avg
General Medicine 0.4 0.6
Gastroenterology 0.9 1.6
Gynaecology 1.1 1.0
Ear Nose & Throat 1.1 1.4
Neurosurgery 1.3 1.6
Oral Surgery 1.5 1.1
Cardiology 1.6 1.5
Elderly Medicine 1.6 1.8
Plastic Surgery 1.8 2.6
General Surgery 1.9 1.9
Respiratory Medicine 1.9 2.5
Trauma & Orthopaedic Surgery 1.9 2.0
Dermatology 2.9 2.4
Urology 3.1 2.4
Neurology 3.1 2.3
Ophthalmology 3.4 3.1
Rheumatology 4.1 4.4
All Specialties 2.0 2.3
New to Review Ratio: Selected Specialties
Jan-13 to Dec-13
0
1
2
3
4
5
Genera
l Medic
ine
Gastroente
rolo
gy
Gynaec
olo
gy
Ear
Nose
& T
hro
at
Neuro
surg
ery
Ora
l Surg
ery
Card
iolo
gy
Eld
erly M
edic
ine
Pla
stic
Surg
ery
Genera
l Surg
ery
Resp
irato
ry M
edic
ine
Tra
um
a &
Ort
hop
aedic
Surg
ery
Derm
ato
logy
Uro
logy
Neuro
logy
Ophth
alm
olo
gy
Rheum
ato
logy
Ne
w to
Re
vie
w R
atio
LTHT Peer Average
For peer listing, please see Appendix 2 Source: Dr Foster
Outpatient New to Review Ratio: Selected Specialties - Jan-13 to Dec-13
Actions:
At the end of February, there were 4,578 patients waiting more than 3 months over their due date for a review appointment; over half of these were waiting for appointments within the Digestive Diseases CSU. Whilst the number waiting more than 3 months over their due date has reduced from 1,895 at the end of August to 1,514 at the end of February in Colorectal Surgery, the number overdue in Gastroenterology has risen over the same period from 961 to 1,226.
0
500
1000
1500
2000
2500
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Pa
tie
nts
Ove
rdu
e
Number of Colorectal Patients Waiting >3 Months Past their Due Date for a Review Appointment
No of Colorectal Patients Waiting >3 Months Achieve Trajectory
0
200
400
600
800
1000
1200
1400A
pr-
12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
Pa
tie
nts
Ove
rdu
eNumber of Gastroenterology Patients Waiting >3 Months Past their Due Date for a
Review Appointment
No of Gastroenterology Patients Waiting >3 Months Achieve Trajectory
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 *
Acute Medicine 201 3 0 0 0 0 1 0 q
Institute of Oncology 12 15 1 1 3 9 1 0 q
Radiology 0 0 1 0 0 0 0 0 u
Women's 4 1 0 2 1 0 23 29 p
Childrens 267 144 100 20 19 71 22 72 q
Cardio-Respiratory 5 2 10 71 248 43 45 84 p
Hepatorenal 668 555 582 620 658 569 439 95 q
Trauma and Related Services 225 173 38 196 409 230 200 102 q
Head & Neck 784 64 1 2 13 64 117 107 q
Leeds Dental Institute 142 164 88 57 147 300 446 350 p
Centre for Neurosciences 235 269 313 225 365 288 311 376 p
Chapel Allerton Hospital 534 262 332 445 1,220 1,116 533 499 q
Digestive Diseases 1,619 1,964 2,462 2,683 2,426 2,970 2,704 2,864 p
Trust 4,696 3,616 3,928 4,322 5,509 5,660 4,842 4,578 q
* As at 28/02/2014
NB. The "Trend" column indicates whether the number of patients waiting has risen, remained the same or fallen since the end of Q1 2012/13.
Trend
Outpatient Follow-Up Waiting List - Patients >3 Months Over their Due Date at Quarter End
CSU2012/13 2013/14
Page 35 of 44
Choose and Book (CAB) – ASIs
Specialty Name ASIs
Surgery - Breast 118
Cardiology 104
Dermatology 100
Children's & Adolescent Services 98
Endocrinology and Metabolic Medicine 90
Neurology 76
Diagnostic Physiological Measurement 74
Ear, Nose & Throat 65
GI and Liver (Medicine and Surgery) 50
Gynaecology 49
2 Week Wait Suspected Cancer 49
Respiratory Medicine 24
Surgery - Plastic 11
Pain Management 11
Orthopaedics 10
Rheumatology 4
Surgery - Not Otherwise Specified 4
Ophthalmology 3
Geriatric Medicine 2
Haematology 1
Urology 1
Surgery - Vascular 1
ASIs - February 2014
Local Contractual Indicator
Aim: Reduce the number of appointment slot issues (ASIs) to no worse than 2% above the national average. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes & financial penalty.
CAB ASIs is a percentage of ASIs generated from within Choose and Book out of all Directly Bookable Service (DBS) bookings. Actions:
ASIs are reviewed on a daily basis and are escalated to CSU meetings to review and increase capacity in line with demand.
ASIs are also reviewed at weekly access meetings with the Trust's central performance team.
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% A
SIs
Choose and Book - Appointment Slot Issues (ASIs)
LTHT National Penalty Threshold
Page 36 of 44
CAB - Utilisation
Internal Indicator
Aim: Improve the percentage of appointments booked via CAB out of all first GP referrals to the target level of 90%. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes.
CAB utilisation is a national measure based on bookings made via the CAB system out of the estimated total number of GP referrals to first outpatient appointments.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-1
2
Au
g-1
2
Se
p-1
2
Oct-
12
Nov-1
2
Dec-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-1
3
Au
g-1
3
Se
p-1
3
Oct-
13
Nov-1
3
Dec-1
3
Ja
n-1
4
Fe
b-1
4
% U
tilisa
tio
n
Choose and Book - % Utilisation
% Utilisation Target
Page 37 of 44
Workforce
CSU Feb-14
Adult Therapies 82.5%
Medicines Management and Pharmacy Services 74.0%
Radiology 73.2%
Urgent Care 70.8%
Leeds Dental Institute 70.6%
Adult Theatres & Anaesthesia 65.1%
Children's 62.0%
Acute Medicine 62.0%
Hepatorenal 61.9%
Centre for Neurosciences 60.3%
Women's 57.7%
Cardio-Respiratory 57.4%
Trauma & Related Services 56.0%
Adult Critical Care 54.0%
Chapel Allerton 52.1%
Pathology 48.8%
Digestive Diseases 48.3%
Leeds Cancer Centre 44.1%
Head & Neck 43.0%
Outpatients 41.3%
Trust 57.4%1 Percentage of staff who have an in date appraisal at month end.
Staff Appraised (Ranked by Attainment) 1
National Indicator / Quality Requirement
Aims:
Reduce sickness absence rates to be in line with the internally agreed trajectory. Current local target is 3.86%.
Meet local target: to ensure 95% of staff have a high quality annual appraisal. Owner: Director of Human Resources and CSU Clinical Directors Consequence of failure:
Sickness absence reduces productivity, places a greater reliance on variable staffing and adversely affects quality.
A failure to appraise staff has a negative impact on staff engagement, productivity and quality.
The Trust-level figures do not include Corporate Services.
CSU Feb-14Mar-13 to Feb-14
(12 Month Rolling Average)
Adult Therapies 3.0% 2.3%
Head & Neck 3.5% 3.1%
Trauma & Related Services 3.7% 3.3%
Leeds Cancer Centre 3.9% 3.7%
Children's 2.6% 3.8%
Leeds Dental Institute 2.5% 3.9%
Cardio-Respiratory 4.4% 3.9%
Centre for Neurosciences 4.8% 4.1%
Pathology 4.6% 4.2%
Urgent Care 4.4% 4.3%
Medicines Management and Pharmacy Services 5.6% 4.3%
Adult Critical Care 4.9% 4.4%
Radiology 6.4% 4.4%
Digestive Diseases 4.5% 4.5%
Acute Medicine 6.9% 4.7%
Women's 3.9% 5.0%
Hepatorenal 4.8% 5.2%
Chapel Allerton 5.6% 5.3%
Adult Theatres & Anaesthesia 4.7% 5.5%
Outpatients 6.2% 5.7%
Trust 4.4% 4.1%
Sickness Absence Rate (Ranked by 12 Month Rolling Average)
CSU Feb-14Mar-13 to Feb-14
(12 Month Rolling Average)
Hepatorenal 0.3% 6.4%
Adult Theatres & Anaesthesia 0.4% 6.8%
Radiology 0.2% 7.7%
Leeds Cancer Centre 0.9% 8.1%
Chapel Allerton 0.4% 8.1%
Adult Critical Care 1.7% 8.3%
Medicines Management and Pharmacy Services 0.6% 8.4%
Pathology 0.4% 8.6%
Outpatients 1.0% 9.6%
Cardio-Respiratory 0.2% 9.8%
Head & Neck 0.6% 10.1%
Digestive Diseases 0.4% 10.6%
Women's 0.1% 11.0%
Urgent Care 0.3% 11.1%
Children's 0.4% 11.1%
Centre for Neurosciences 0.5% 13.4%
Adult Therapies 1.2% 14.8%
Leeds Dental Institute 0.4% 15.5%
Trauma & Related Services 0.9% 16.8%
Acute Medicine 1.8% 17.2%
Trust 0.6% 10.6%2 Excluding Training Grade Doctors
Staff Turnover (Ranked by 12 Month Rolling Average) 2
Page 38 of 44
Finance
AF Finance D ashboard
In-Year Financial Delivery Indicators - February 2014
Category Indicator Plan £'000 Actual £'000 Variance £'000
NHS Financial Performance
Year to Date, Actual compared to Plan 14,908 1,072 (13,836)
Forecast Outturn, Compared to Plan 1,418 609 (809)
Financial Efficiency
Actual Efficiency for Year to Date compared to Plan 35,697 32,840 (2,857)
Recurrent Efficiencies for Year to Date compared to Plan 17,912 14,085 (3,827)
Forecast Outturn Efficiency Compared to Plan 40,242 40,111 (131)
Recurrent Efficiencies for Forecast Outturn compared to Plan 20,448 15,774 (4,674)
Underlying Revenue Position
Forecast Outturn Underlying Revenue Position compared to plan (18,376) (18,272) 104
Cash and Capital
Forecast Year End Charge to Capital Resource Limit 23,192 23,192 0
Temporary PDC for Liquidity Purposes (cumulative sum) 0 0 0
Funding Accessed (cumulative sum) 0 0 0
Progress Towards Foundation Trust Status - February 2014
Category Indicator Plan £'000 Actual £'000 Variance £'000
Progress Towards FT Status
EBITDA Margin Achieved: Year to Date 3 3 (1)
EBITDA Margin Achieved: Forecast Outturn 3 3 0
EBITDA Percentage of Plan: Year to Date 3 4 0
EBITDA Percentage of Plan: Forecast Outturn 3 3 0
Net Return After Financing: Year to Date 4 3 (2)
Net Return After Financing: Forecast Outturn 3 3 0
I&E Surplus Margin net of Dividend: Year to Date 3 2 (1)
I&E Surplus Margin net of Dividend: Forecast Outturn 2 2 0
Liquidity Ratio Days (including NWCF): Year to Date 3 3 0
Liquidity Ratio Days (including NWCF): Forecast Outturn 3 3 0
Combined Financial Risk Rating: Year to Date 3 3 (1)
Combined Financial Risk Rating: Forecast Outturn 3 3 0
Category Indicator Plan £'000 Actual £'000 Variance £'000
Progress Towards FT Status
Liquidity Days 3 1 (2)
Capital Services Capacity 3 3 (1)
Combined Risk Rating 3 2 (1)
Co
ntin
uity o
f
Se
rvic
es R
isk
Ra
tin
gs
Fin
an
cia
l R
isk R
atin
gs
In-Y
ea
r F
ina
ncia
l D
elive
ry
National Indicators / Quality Requirements - AF Finance
National Indicators / Quality Requirements - AF Finance
National Indicators / Quality Requirements - AF Finance
Page 39 of 44
Finance - In-Year Financial Delivery Indicators
Finance - Progress Towards Foundation Trust Status
National Indicator / Quality Requirement National Indicator / Quality Requirement
Income and expenditure is currently showing a significant adverse variance, but this is against the TDA submitted plan which is phased differently to the Board reported plan. The actual Income & Expenditure (I&E) variance reported to the Board currently stands at £7.1 million adverse, and is primarily the result of under-trading against activity plans, and expenditure incurred in the independent sector. The Trust still has a forecast out-turn of £99k surplus as reported to the TDA as part of the 2014/15 annual financial plan submission on 5
th March. The out-turn included in this return is
that reported after technical adjustments relating to income received from the Charitable Trustees. Cost Improvement Programme (CIP) performance is behind plan on a number of specific schemes, but is forecast to almost fully achieve by the year end as a result of non-recurrent income being used to substitute other non-recurrent expenditure schemes that have not delivered. Accountability Framework Summary Performance
The Trust reported a year to date adjusted I&E surplus of £1,072k against a TDA planned adjusted surplus of £14,908k, resulting in an adverse variance of £13,836k.
The I&E variance is forecast to achieve a £99k surplus by the end of the year before technical adjustments, which will result in a £609k deficit after technical adjustments. CIPs are forecast to under achieve by £131k.
Although there is an under-achievement against CIP plans of £2,857k year-to-date, this position is forecast to recover by the end of the financial year as per the comment above.
The Trust is reporting an overall Financial Risk Rating of 3 for the end of February, where it is forecast to remain at the year end with the I&E £99k forecast surplus. The new Continuity of Service ratings are discussed individually below but the overall score is 2. Aspirant foundation trusts should aim for 3.
Indicator Comment
Monitor Combined - Liquidity
Liquidity at the month end was -15.1 days, which equates to a rating of 1. Liquidity has deteriorated marginally from -15.2 days at the end of January but is forecast to remain at 1 at the year end.
Total Capital servicing capacity was 1.77 at the end of February: an improvement on the previous month. This equates to a score of 3, but it is forecast to reduce to 2 at the year end.
Page 40 of 44
Internal Indicators Dashboard
Indicator Dec-13 Jan-14 Feb-14 YTD
RTT clearance time: total (weeks) < 8 10.2 8.6 9.7 n/app
RTT clearance time: over 18 weeks (weeks) < 0.5 1.0 0.7 0.7 n/app
RTT: Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted 912 754 678 n/app
Cancelled Operations: Last Minute Cancellations for Non-Clinical Reasons
A&E: Time from arrival to initial full assessment (mins) - 95th percentile < 15 16 14 16 15
A&E: Time from arrival to treatment (mins) - median < 60 78 73 84 78
A&E: % Unplanned follow-up re-attendances within 7 days < 5% 8.2% 8.1% 8.0% 7.9%
A&E: % Patients leaving A&E unseen < 5% 3.0% 2.6% 3.6% 3.3%
A&E: Number of trolley waits greater than 12 hours 0 0 0 0
Patient handovers taking longer than 15 minutes between ambulance and A&E 780 816 732 7582
Patient handovers taking longer than 30 minutes between ambulance and A&E 46 49 44 496
Patient handovers taking longer than 60 minutes between ambulance and A&E 1 0 0 25
Cancer 62 days: referrals following consultant upgrade > 85% 61.5% 66.7%Reported a month
in arrears80.6%
Stroke patients spending at least 90% of their time in hospital on a stroke unit > 80% 72.0% 67.0%Reported a month
in arrears79.7%
Proportion of high-risk TIA patients investigated and treated within 24 hours of first contact with a health professional 71.1% 77.6%Reported a month
in arrears75.9%
MRSA Screening > 95% 96.5% 96.5% 96.1% 95.7%
CDI cases: Rate per 100,000 Occupied Bed Days 25.3 21.8 18.3 23.8
Harm Free Care: % of Patients With Falls Resulting in Harm (Snapshot) 0.5% 0.7% 0.4% n/app
Harm Free Care: % of Patients With UTIs (new and old) (Snapshot) 4.1% 4.0% 3.4% n/app
Number of complaints 62 81 92 976
OP Measure: DNA rate Peer ave: 8.6%
8,103 12,495 11,335 132,852
9.0% 10.1% 10.6% 10.7%
7,016 9,083 7,778 95,563
7.8% 7.3% 7.3% 7.7%
OP Measure: New to Review ratio Peer ave: 2.3 2.0
Jan-13 to Dec-13
Jan-13 to Dec-13
0
OP Measure: Number of OP Appointment Cancellations By Patient Within 6 Weeks of Appointment (and as % of Total
Bookings)
OP Measure: Number of OP Appointment Cancellations By Hospital Within 6 Weeks of Appointment (and as % of Total
Bookings)
Thresholds
As per NHS Standard
Contract
0
0
0
Q3: 1.3%
As per agreed trajectory
9.5%
Key Indicators (not in other dashboards)
Page 41 of 44
Indicator Dec-13 Jan-14 Feb-14 YTD
OP Activity: New (Attendances) 18,111 24,745 21,548 244,331
OP Activity: Review (Attendances) 43,037 63,650 55,638 639,540
IP Activity: Elective (Spells) 7,093 10,723 9,802 117,166
IP Activity: Non-elective (Spells) 5,768 6,393 5,678 67,461
Length of Stay Peer ave: 4.8
Choose and Book: Appointment Slot Issues 10.8% 6.7% 15.2% 10.9%
Choose & Book utilisation > 90% 55.8% 64.6% 63.1% 60.2%
Research & Innovation (R&I): Activity - Research studies in NIHR portfolio (number) Q3: 411 (2nd) n/app
R&I: Participation - Participants recruited to NIHR Portfolio Studies (number) Q3: 8374 (8th) n/app
R&I: Initiation – all clinical trials should take 70 Days or less from receipt of a valid research application to 1st patient visit
(median) < 70 Q3: 82 days n/app
R&I: Delivery – all commercial clinical trials should recruit the agreed target number of patients within the agreed recruitment
period (%)> 80% Q3: 60% n/app
Dementia Stage 1: Find - % of all patients aged 75 and above admitted as emergency inpatients who are asked the
dementia case finding question within 72 hours of admission or who have a clinical diagnosis of delirium on initial
assessment or known diagnosis of dementia.
95.3% 96.2% 94.1%
Dementia Stage 2: Assess - % of all patients aged 75 and above admitted as emergency inpatients who have scored
positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into the exemption
categories reported as having had a dementia diagnostic assessment including investigations.
96.9% 94.9% 94.7%
Dementia Stage 3: Refer - % of all patients aged 75 and above, admitted as an emergency inpatient who have had a
diagnostic assessment (in whom the outcome is either “positive” or “inconclusive”) who are referred for further diagnostic
advice/follow up.
98.0% 94.4% 96.2%
Reported a month
in arrears
Within top 5 Trusts in
England
> 90%
Within top 5 Trusts in
England
Reported quarterly
No worse than 2%
above the national
average
Thresholds
Jan-13 to Dec-13 : 5.1
Key Indicators (not in other dashboards) (continued)
Page 42 of 44
Appendix 1 - Updates
Updates from Regulators
CQC publishes findings from first wave of pilot inspections 1
The CQC has published its findings from the 18 pilot hospital inspections undertaken in 2013. Although the report concludes that compassionate care is alive and well, as well as a strong commitment to the NHS, inspectors found significant variations in quality between trusts and even between services within trusts. It also found that apart from critical care and maternity, most services cannot demonstrate whether they are delivering effective care or not. As a result of lessons learnt, the CQC has made a number of changes to its inspection methodology, including:
o Collection of more information, especially from national clinical audits, to enhance its assessments of effectiveness.
o Routinely asking for more specific information from trusts in advance of the site visits, so that it can incorporate this into the key lines of enquiry.
o A reduction in the number of information requests made to trusts during the site visit.
o An in depth, pilot assessment of complaints during the pre-inspection phase.
o Case tracking of a sample of recent patients with comorbidities or complex needs, a review of a sample of safety incidents, and a review of board minutes.
CQC publishes updates to Intelligent Monitoring reports 2
The CQC has published an updated set of Intelligent Monitoring reports, which include refreshed data and changes to the indicators used. The reports monitor a range of information, including patient experience, staff experience and performance, to cover the CQC’s five key domains: safe, effective, caring, responsive, and well-led.
2013 National Inpatient Survey Results published
3
The results of the National Inpatient Survey 2013, which are based on a sample of consecutively discharged inpatients who attended the Trust between June and August 2013, have been published. A total of 1,700 patients were sent the questionnaire, of which 715 were returned complete – giving a response rate of 43%. Although the results show improvement in some areas, performance has remained the same overall. The results are currently being analysed in full detail in order to identify priority areas for future development.
NHS England publishes reports into Leeds Children’s Heart Surgery Unit 4
NHS England has published two reports into the children’s heart services provided at the Trust, which were commissioned following the temporary suspension of services in 2013. They include a Mortality Case Review, which looks at 35 deaths identified by the National Institute for Cardiovascular Outcomes Research for the years 2009-2013, and a Family Experience Report, which tells the stories of 16 families' experience at the unit during the same time period. The Mortality Case Review concludes that on current evidence, services at Leeds are safe and running well; however, the Family Experience Report highlights issues with care and compassion. The Trust has stated that it will continue its commitment to improvement and learning by receiving the recommendations outlined in the Family Experience Report and developing and delivering tangible actions that will improve the service further.
1 The CQC’s new approach to inspecting NHS acute hospitals: Initial findings
2 Hospital intelligent monitoring: Summary of indicator changes
3 2013 National Inpatient Survey Results
4 Leeds children’s heart surgery services review
Page 43 of 44
Appendix 2 - Peer Groups
Peer Groups FFT, Complaints, Never Events, OP DNA, OP New to Review, LoS and VTE: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool and Broadgreen University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospital Southampton NHS Foundation Trust - University Hospitals Birmingham NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals Of Leicester NHS Trust RTT: As above, plus the following providers: - Guy’s and St Thomas’ NHS Foundation Trust - Imperial College Healthcare NHS Trust - King’s College Hospital NHS Foundation Trust - University College London Hospitals NHS Foundation Trust A&E: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool And Broadgreen University Hospitals NHS Trust - Sandwell And West Birmingham Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospitals Of Leicester NHS Trust
Listed below are the Trusts used to benchmark performance. HCAI: - Brighton & Sussex University Hospitals - Cambridge University Hospitals - Central Manchester University Hospitals - Chelsea & Westminster Hospital - Guy's & St. Thomas' - Imperial College Healthcare - King's College Hospital - Nottingham University Hospitals - Oxford University Hospitals - Plymouth Hospitals - Royal Free Hampstead - Royal Liverpool & Broadgreen University Hospitals - Salford Royal - Sheffield Teaching Hospitals - South Tees Hospitals - St. George's Healthcare - The Newcastle upon Tyne Hospitals - University College London Hospitals - University Hospital Birmingham - University Hospital of South Manchester - University Hospital Southampton - University Hospitals Bristol - University Hospitals Coventry & Warwickshire - University Hospitals of Leicester Cancer: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Christie NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - The Royal Marsden NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals of Leicester NHS Trust
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Appendix 3 - Glossary
Glossary SJUH - St James's University Hospital TBC - To Be Confirmed TDA - Trust Development Authority VTE - Venous Thromboembolism WHO - World Health Organisation YAS - Yorkshire Ambulance Service YTD - Year to Date
AF - Accountability Framework ASI - Appointment Slot Issue CAB - Choose and Book CAS - Central Alerting System CCG - Clinical Commissioning Group CDI - Clostridium Difficile Infections CIP - Cost Improvement Programme CQC - Care Quality Commission CQUIN - Commissioning for Quality & Innovation CSU - Clinical Service Unit CUTI - Catheter-associated Urinary Tract Infection DBS - Directly Bookable Services DH - Department of Health DNA - Did Not Attend EBITDA - Earnings Before Interest, Tax, Depreciation and Amortisation ED - Emergency Department FFT - Friends and Family Test FT - Foundation Trust GDP - General Dental Practitioners GMP - General Medical Practitioners HCAI - Healthcare Associated Infection HSMR - Hospital Standardised Mortality Ratio I&E - Income & Expenditure IQPR - Integrated Quality & Performance Report KPI - Key Performance Indicator LGI - Leeds General Infirmary LoS - Length of Stay MRSA - Meticillin Resistant Staphylococcus Aureus MSSA - Meticillin Sensitive Staphylococcus Aureus NIHR - National Institute for Health Research R&I - Research & Innovation RAF - Risk Assessment Framework RAG - Red Amber Green RTT - Referral to Treatment SHMI - Summary Hospital-level Mortality Indicator