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NLG(16)490

DATE OF MEETING 29 November 2016

REPORT FOR Trust Board of Directors – Public

REPORT FROM Wendy Booth, Director of Performance Assurance & Tr ust Secretary

CONTACT OFFICER Maria Wingham, Head of Performance

SUBJECT Integrated Performance/KPI Framework Report – Septe mber 2016

BACKGROUND DOCUMENT (IF ANY) Performance Reporting Framework

REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Trust Governance and Assurance Committee – 17 Novem ber 2016 Resources Committee – 23 November 2016

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

The attached report outlines the position against t he Trust’s key performance indicators as at September 2016. This includes the NHS Improvement Framework, Contract KPI requirements an d the Internal Performance Summary

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

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

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

NO

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

N/A

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

NO

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

YES

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

N/A

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

Ensure compliances with the key performance indicat ors

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

DIRECTORATE OF PERFORMANCE

INTEGRATED PERFORMANCE REPORT

September 2016

Author: Maria Wingham

Head of Performance

Date: September 2016

SECTION 1 MONITOR COMPLIANCE FRAMEWORK

SECTION 2 CONTRACTUAL COMPLIANCE

SECTION 3 TRUST KEY QUALITY & PERFORMANCE INDICATORS

CONTENTS

2015/16 2016/17 QTR 2 QTR 2 Qrt 2

WEIGHTINGQTR 4 QTR 1

ThresholdSTP

TrajectoryActual STP

TrajectoryActual STP

TrajectoryActual Actual To Date WEIGHTING

1. Infection Control*

Total Hospital Acquired C.Difficile Cases Lapses in Care (YTD) 1.0 G G 21 0 0 1 2 G

2. Referral to Treatment Waiting Times

Incomplete - Maximum waiting time of 18 weeks 1.0 R R 92% 92.00% 85.5% 92.24% 83.7% 92.07% 81.9% 83.6% R

3. Cancer ***

31 day wait diagnosis to treatment 1.0 G G 96% 100% 100% 100% 100% G

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

ii) 31 day wait for subsequent treatments - Anti cancer drugs G G 98% 100% 98.2% 100% 99.1% G

i) 62 day wait GP referral to treatment POST alloaction R R 85% 85.9% 82.3% 85.61% 86.5% 85.5% 88.1% 85.2% G

ii) 62 day wait GP referral to treatment PRE allocation 1.0 R R 85% 89.9% 85.1% 85.61% 90.5% 85.5% 90.3% 88.3% G

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

i) 2 week wait referral to consultation 1.0 G G 93% 98.5% 96.9% 97.2% 97.5% G

ii) 2 week wait breast symptomatic referrals G G 93% 94.9% 96.7% 95.7% 95.9% G

4. A&E

A&E 4 Hour Wait Compliance 1.0 R R 95% 95.01% 91.5% 94.35% 90.2% 95.08% 92.3% 91.3% R

5. Data Completeness Community Services **

5i) Referral to treatment information 1.0 G G 50% 99.9% 100% 100% 100% G

5ii) Referral Information G G 50% 99.9% 100% 100% 100% G

5iii) Treatment Activity Information G G 50% 90.5% 85.1% 88.7% 88.0% G

6. Access **

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

* Quarterly Cumulative figures Total NHS Improvement Compliance Score 2.0

** Forecast Position Green

*** Provisional Data Red

NHS Improvement Compliance Rating

NHS Improvment Over ride Rating

PERFORMANCE METRIC

NHS IMPROVEMENT COMPLIANCE FRAMEWORK SUMMARY

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

Jul-16 Aug-16 Sep-16

Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

Referral to Treatment

E.B.3 Patients on incomplete RTT pathways waiting no more than 18 weeks from referral 92% 89.4% 88.7% 86.8% 85.5% 83.7% 81.9%

A range of proactive improvement measures have been instigated across the Trust to

regularly manage and monitor the 18 week performance position. Service review

work is a key feature of the 2016/17 sustainability programme.

E.B.4 Patients waiting less than 6 weeks from Referral for a diagnostic test 99% 97.5% 97.9% 99.0% 99.5% 98.7% 99.3%

Increased referrals has resulted in reduced capacity, to help improve the position

MRI has been outsourced however, this has been hampered by the breakdown of

MRI equipment. A lack of Endoscopists has resulted in Endoscopy diagnostic

breaches, a rescheduling of sessions is planed and additional weekend working to

help alleviate waiting times.

E.B.S.2Patients who have operations cancelled, on or after the day of admission, for non-clinical reasons to be offered

another binding date within 28 days0 0 1 0 0 0 0

Due to the transfer of theatre data from ORMIS to Web V a new data set is being

compiled that will be completed at the end of November.

E.B.S.4 Zero tolerance RTT waits over 52 weeks for incomplete pathways 0 0 0 0 0 0 0

E.B.S.6 No urgent operation should be cancelled for a second time 0 0 0 0 0 0 0

A&E

E.B.5 Patient admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 89.8% 93.2% 93.5% 91.5% 90.2% 92.3%

A high dependency cohort of patients and bed availability is an ongoing occurrence

within the department. Operationally various processes have been instigated

including shift leaders regulating staffing levels to meet capacity demands, the Trust

has continued enhanced medical support across 7 days to support patient reviews

and decision making.

E.B.S.5 Trolley waits in A&E no longer than 12 hours 0 0 0 0 0 0 0

*Cancer

E.B.6 2ww - urgent GP referrals (cancer suspected) 93% 96.2% 95.9% 98.2% 98.5% 96.9% 97.2%

E.B.7 2ww - urgent symptomatic breast referrals (cancer not initially suspected) 93% 98.1% 92.8% 99.1% 94.9% 96.7% 95.7%

E.B.8 Patient waiting no more than 31 days from diagnosis to first definitive treatment for all cancers 96% 99.3% 99% 100% 100% 100% 100%

E.B.9 Patient waiting no more than 31 days for subsequent treatment (surgery) 94% 100% 100% 100% 100% 100% 100%

E.B.10 Patient waiting no more than 31 days for subsequent treatment (anti-cancer drug regime) 98% 97.9% 100% 100% 100% 98.2% 100%

A Trust wide Action Plan has been developed which includes all aspects of pathway

management, breach review and reporting to support improved performance. In

addition a new detailed report monitoring performance, Trust wide and by tumour

site, has been introduced and deployed on a weekly basis. RCA for all patients

breaching treatment targets is undertaken.

E.B.12 Patient waiting no more than 62 days from urgent GP referral to first definitive treatment 85% 81.5% 81.6% 83.3% 85.1% 90.5% 90.3%

A Trust wide Action Plan has been developed which includes all aspects of pathway

management, breach review and reporting to support improved performance. In

addition a new detailed report monitoring performance, Trust wide and by tumour

site, has been introduced and deployed on a weekly basis. RCA for all patients

breaching treatment targets is undertaken.

E.B.13Patient waiting no more than 62 days referral from an NHS screening service to first definitive treatment (all

cancers)90% 100% 100% 100% 100% 100% 100%

Infection Control

E.A.S.4 Zero Tolerance MRSA 0 0 0 0 0 0 0

E.A.S.5 Minimise rates of Clostridium Difficile Lapse in Care (YTD) 21 0 0 1 1 1 2

Clostridium Difficile (YTD) 0 3 6 7 9 12

3 Hospital Acquired MRSA bacteraemia cases to be notified to commissioner within 2 working days 100% n/a n/a n/a n/a n/a n/a No episodes of MRSA bacteraemia cases year to date

4 MRSA bacteraemia PIR report provided to commissioner within 14 working days of case being identified 100% n/a n/a n/a n/a n/a n/a No episodes of MRSA bacteraemia cases year to date

5 Appropriate elective admissions screened for MRSA prior to admission 95% 100% 100% 98.9% 95.5% 100% 97.5%

6 Appropriate emergency admissions screened for MRSA within 24 hours of admission 95% 87.9% 88.5% 91.0% 92.3% 90.4% 91.9%Performance is being monitored at Infection Control site meetings, matrons have

been asked to review and improve their screening processes.

7 In-patients with MRSA are on MRSA Care Pathway 100% 100% 100% 100% 100% 100% 100%

Performance Metric Comments

SECTION 2

CONTRACTUAL COMPLIANCE SUMMARY

For The Period 1st April 2016 to 30th September 2016

Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16Performance Metric Comments

SECTION 2

CONTRACTUAL COMPLIANCE SUMMARY

For The Period 1st April 2016 to 30th September 2016

8 Notification to commissioners of C. Difficile toxin positive cases within 1 working day 100% n/a 100% 100% 100% 100% 100%

9 RCA undertaken for all NLAG acquired C. Diff cases - key issues submitted to Commissioner 100% n/a 100% 100% 100% 100% 100%

Ambulance Handover

E.B.S.7a All handovers between ambulance & A&E must take place within 15 mins (no more than 30 mins) 0 834 429 227 248 292 317

E.B.S.7b All handovers between ambulance & A&E must take place within 15 mins (no more than 60 mins) 0 161 43 34 18 38 50

National Quality & Governance

** VTE 95% 93.9% 94.7% 95.1% 96.1% 94.2% 95.5%

Weekly reports detailing the VTE status are sent to ward managers, matrons and

senior managers highlighting the number of patients that are outstanding a VTE

assessment to enable proactive management

Duty of Candour - SUIs - met in all relevant instances 0 0 0 0 0 0 0

Duty of Candour - Moderate Harm (non SUIs) - met in all relevant instances 0 0 0 0 0 0 0

NHS Number in SUS (Acute) 99% 100% 99.9% 99.9% 99.9% 100% 0.0%

NHS Number in SUS (A&E) 95% 98.8% 98.6% 98.6% 98.6% 100% 0.0%

Never Events 0 0 0 0 0 0 0

E.B.S.1 MSA - sleeping breaches 0 0 0 0 0 0 0

Maternity

1 Maternity - women recorded as smoking by 12 weeks & 6 days referred to smoking cessation 95% 100% 100% 100% 100% 100% 100%

2 Maternity - women who have seen a midwife by 12 weeks and 6 days 90% 96.1% 94.0% 95.6% 96.3% 96.6% 97.9%

Local Quality & Governance

10 Serious incidents reported to commissioners within 48 hours of SI being identified 100% 100% 100% 100% 100% 100% 100%

11 Completed serious incident reports to be submitted within 60 days for both Grade 1 & Grade 2 100% 100% 100% 100% 100% 100%

* September Provisional

** Qrt 2 Provisional

A bi weekly task group has been implemented to review the new Ambulance Arrival

Screen Project. Early indications are that this group has had a positive impact on

performance which is demonstrated June's figures. A dedicated handover nurse

team has been implemented at SGH and DPoW. There are a number of ongoing

issues regarding EMAS data quality being worked through with EMAS.

September data is currently being validated.

Performance MetricIndicator

TypeCommittee Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Trend Analysis

Effectiveness

KPI01 SHMI - hospital within expected range MPAC TGAC 95109

(Dec - 15)

104

(Jan - 16)

107

(Feb - 16)

107

(Mar - 16)

108

(Apr - 16)

107

(Sep - 16)

KPI02 SHMI - weekend within expected range MPAC TGAC 95114

(Dec - 15)

106

(Jan - 16)

110

(Feb - 16)

109

(Mar - 16)

112

(Apr - 16)

112

(Sep - 16)

KPI03 Adherence to NICE guidance (all guidance) QDP QPEC 90% 83.4% 76.5% 77.6% 79.9% 82.2% 85.7%

Work streams implemented to support healthcare professionals to assess the

increasing numbers of guidelines within the required timescales. TGAC monitoring

monthly performance.

KPI03a Adherence to NICE guidance TAG QDP QPEC 100% 92.3% 93.2% 90.0% 88.9% 91.0% 93.5%

KPI03b Adherence to NICE guidance - CG & NG QDP QPEC 90% 76.5% 75.7% 80.8% 68.4% 68.1%

KPI183 Documents in compliance within the Document Control System PERF TGAC 90% 78.6% 79.3% 77.9% 79.5% 81.2% 79.9%

Operational groups have implemented various work streams to improve such as using

trackers, dedicated section on governance agenda and general management direct

control.

KPI343Documents in compliance within the Document Control System - Patient Group Directions for

Medicaton within EDCQC TGAC/QPEC 90% 100% 100% 100% 100% 83.7% 88.5%

KPI342 Documents in compliance within the Document Control System - Maternity CQC TGAC/QPEC 90% 91.1% 93.4% 94.9% 94.1%

KPI350 Number of service reviews undertaken CQC RES 14.3% 14.3% 14.3% 0.0%

KPI351 Number of services with capacity plans CQC RES 46.2% 46.2% 46.2% 0.0%

Safety

KPI04 Inpatient discharge summary to GP within 24 hours. PERF QPEC 98% 72.2% 73.7% 71.2% 72.3% 73.9% 72.6% Trend analysis process created to identify problem areas.

KPI05 Safety Thermometer - Acute PERF TGAC 95% 89.8% 91.3% 89.6% 91.5% 89.5% 92.6%

KPI06 Safety Thermometer - Community PERF TGAC 95% 97.4% 95.7% 98.5% 97.8% 96.9% 95.0%

KPI08 5% reduction in incidents with a common theme PERF TGAC 855 1157 1143 1170 1220 1390 1229

KPI09 50% reduction in incidents with same theme (Pressure Ulcers) PERF TGAC 16 33 23 30 31 34 29

Trust wide action plans created from RCAs and individual action plans for any grade 3

and 4 pressure ulcers. Mandatory pressure area management & documentation

training introduced in July 15.

KPI368 Pressure Ulcers - Theatres harm free care QDP QPEC 0 0 0 0 0 0 0

KPI11 Incidents coded & graded within 5 working days PERF TGAC 95% 78.0% 79.3% 72.7% 90.3% 73.6% 63.8%The additional coding and grading sessions delivered over the past few months are

having a positive impact on this KPI.

KPI12 CCG Incidents responded to within 20 working days PERF TGAC 100% 44.0% 56.3% 39.5% 52.2% 53.3% 75.6%Risk Governance Facilitators currently reviewing processes to improve response times.

KPI341 Learning lessons - Feedback on incidents to be provided CQC TGAC 100% 86.0% 79.9% 76.3% 84.8%This KPI is measuring requested feedback from incidents provided to reporter. Datux

has been modified to capture this data from June 16 onwards.

KPI332 Emergency Care Incidents - no anaesthetic staff CQC RES 0 1 0 0 0 0 0

KPI13 Groups achieved publication of quarterly learning lessons newsletter PERF TGAC 100% 100% 100% 100% 100% 100% 100%

3.1 Dementia & Delirium - Screening over 75s CQUIN TGAC 90% 91.9% 95.1% 95.1% 92.6% 91.8% 93.7%

3.2 Dementia & Delirium - Assessment CQUIN TGAC 90% 100% 100% 100% 100% 100% 100%

KPI184 Serious Incident Action Plans completed within required timescales TGAC 100% 100% 100% 100% 100% 100% 100%

KPI185 Confidential enquires to have gap analysis TGAC 90% 84.2% 100% 100% 100% 93.0% 93.0%

KPI186 Patient safety alerts have been actioned by the specified deadlines TGAC 100% 100% 100% 100% 100% 100% 100%

KPI187 SUI responded to within the required 12 week timescale TGAC 100% 100% n/a 100% 100% 100% 100%

KPI188 SUI responded to within the re-negotiated timescale TGAC 100% 100% n/a n/a n/a n/a n/a

KPI334 Nursing Capacity incidents - ED CQC RES 7 2 1 2 3 19 15

KPI335 Nursing Capacity incidents - Medicine CQC RES 41 10 7 3 63 77 52

KPI336 Nursing Capacity incidents - Surgery CQC RES 2 6 1 2 13 16 10

KPI337 Midwife Capacity incidents CQC RES 5 10 0 2 29 41 27

KPI344 Complaints/PALS - Midwifery CQC RES 5 8 2 3 5 2 2

KPI348 Community buildings where PAT testing is completed CQC TGAC 70% 26.9% 38.5% 100% 91.3%August reported 100% of building were tested, however the contractors missed 2

properties that have been scheduled for testing in October.

KPI352 Sis in A&E Department - anti-liagture risks CQC TGAC/QPEC 0 0 0 0 0 0 0

KPI353 Incidents in A&E Department - anti-liagture risks CQC TGAC/QPEC 0 0 0 0 0 1 0

Patient Flows

KPI14 Elective Length of Stay at or below national benchmark rate PERF TGAC 3.3 2.4 3.3 2.4 2.6 2.1 2.9

KPI15 Non-elective Length of Stay at or below national benchmark rate PERF TGAC 4.7 5.3 4.6 4.6 4.9 4.6 4.7

KPI16 Ward transfers due to capacity reasons QDP QPEC 20% 11.0% 8.0% 11.0% 9.0% 11.0% 10.0%

KPI17 Delayed transfer of care at or below national benchmark rate PERF TGAC 3.8% 3.3% 2.1% 2.5% 3.1% 2.6% 2.5%

SECTION 3

TRUST KEY QUALITY PERFORMANCE INDICATORS

For The Period 1st April 2016 to 30 September 2016

Comments

This is a Trust quality priority which is monitored at monthly QPEC and MPAC

meetings. A range of work streams have been implemented focusing on: care for

patients at the end of life, accuracy of information and coding, 6 clinical led Multi

Disciplinary Teams looking at quality/morality agenda. Case note reviews are also

looking at care quality and a monthly detailed Mortality report is overseen by MPAC

and Trust Board.

Pam Clipson is revising the KPI’s, given that Service Reviews are continuous and a

measure which quantifies how many are completed does not indicate delivery of

output. No data was supplied for September.



SECTION 3



Comments

KPI339 Delay Discharges Intensive Thearpy Unit DPoW - Intensive Care Unit SGH CQC QPEC 67.8% 50.0% 43.9% 44.4% 0.0%

Performance is based on patients that are medically fit to be stepped down to ward

level that have a delayed discharge of more that 4 hours. This data is extracted

quarterly and presented to the Critical Care Provision Group. Data is rebased each

quarter to capture historic data.

KPI 18 Outliers on adult wards QDP QPEC 3% 5.6% 4.4% 4.3% 4.3% 3.8% 4.1%

KPI 182 Trust DNA Rate QDP QPEC 6% 8.6% 9.2% 9.9% 9.7% 9.2% 9.6%

Call reminder service resources allocated to specific specialities to be rolled out to all

specialities following implementation of the new clinical admin structure. Monthly

data is rebased to reflect historic changes.

KPI338 DNA Rate Goole CQC TGAC 6% 7.1% 8.5% 9.5% 8.4% 8.5% 7.8% Monthly data is rebased to reflect historic changes.

KPI19 Fractured Neck of Femur patients to be operated on within 36 hours QDP QPEC 75% 64.3% 60.0% 73.7% 52.9% 56.1% 73.5%

There is discrepancy currently an issue around conciliating data on the National Hip

Fracture Database compared to PAS. The operation group is in the process of

procuring more administration support into #NOF validation. The performance is

representative of the current information available.

* KPI19b Fracture neck of Femur Best Practice Tariff PERF TGAC 39.3% 36.0% 47.4% 35.3% 41.5% 52.9%

KPI20 30 day emergency readmissions at or below national benchmark rate PERF 6.6% 5.8% 4.1% 4.2% 3.9% 5.7% 4.9%

KPI21 New to review ratio at or below national benchmark rate PERF 1:9 2.0 2.0 1.9 1.9 2.1 2.3

KPI191 QA and NCAPOP National Audit on Target for Completion PERF TGAC 100% 96.5% 96.7% 95.1% 96.7% 96.7% 96.0%

KPI192 QA and NCAPOP National Audits have in place a signed action plan agreed at Governance PERF TGAC 100% 100% 100% 100% 100% 100% 100%

KPI193 QA and NCAPOP action plans are on target PERF TGAC 100% 60.0% 76.5% 76.5% 76.5% 88.3% 68.8%

KPI195 Reduction in Hospital Outpatient Cancelled Appointments rates by Patients PERF QPEC 1% 0.1% 0.5% (-0.2%)

KPI322 Hospital Out Patient Cancelled Appointment Rate - Trustwide CQC QPEC 5% 13.1% 8.5% 8.5% 10.3% 8.9% 7.7%

KPI361 Out Patient Clinical Slot Utilisation Rate CQC QPEC 94% 82.8% 85.3% 84.4% 83.3% 85.1% 86.4% This KPI is measuring the percentage of allocated time that is utilized to see patients

KPI323 Hospital Outpatient Cancelled Appointments - GDH CQC QPEC 5% 15.2% 8.3% 8.5% 14.4% 10.5% 11.5%

KPI320 Theatre 'On the Day' Cancellation Rate (Hospital only for clinical reason) CQC QPEC 4.3% 3.9% 4.5% 3.4% 0.0% 0.0% 0.0%

KPI321 Theatre 'On the Day' Cancellation Rate (Hospital only for non-clinical reason) CQC QPEC 2.5% 2.2% 2.6% 3.1% 0.0% 0.0% 0.0%

KPI362 Theatre 'On the Day' Cancellation Rate - Surgery CQC QPEC 5% 8.9% 11.5% 8.9% 0.0% 0.0%

Data is not currently available due to the transition of theatre systems from ORMIS to

WEBV which is impaction on the majority of hospital in-patient reporting. The

Information service is creating a new data set that will be back dated to identify

historic information.

KPI367(a) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Elective Surgery CQC QPEC 0 0 0 0 0 0

KPI367(b) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Emergency Surgery CQC QPEC 0 0 0 0 0 0

KPI367(c) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Urgent Surgery CQC QPEC 0 0 0 0 0 0

KPI367(d) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Elective Surgery CQC QPEC 0 0 5 2 0 0

KPI367(e) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Emergency Surgery CQC QPEC 0 8 4 1 0 0

KPI367(f) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Urgent Surgery CQC QPEC 0 0 0 0 0 0

KPI326 Rdlgy Reporting times Urgent CT/MRI GP Referrals within 72 hours CQC RES 90% 32.1% 28.9% 41.9% 31.5% 29.9% 26.7%

KPI327 Rdlgy Reporting times Urgent CT/MRI Outpatients within 72 hours CQC RES 90% 27.4% 30.9% 43.1% 44.9% 46.3% 33.4%

KPI328 Rdlgy Reporting times CT/MRI Inpatient within 24 hours CQC RES 90% 91.1% 91.7% 92.7% 93.4% 93.3% 92.5%

KPI329 Rdlgy Reporting times 31/62 GP Referrals within 24 hours CQC RES 90% 54.1% 60.5% 66.3% 65.0% 74.3% 62.6%

KPI330 Rdlgy Reporting times Outpatients within 24 hours CQC RES 90% 43.2% 50.1% 53.1% 67.2% 75.6% 55.9%

KPI331 Rdlgy Reporting times Routine within 168 Hours (7 days) CQC RES 90% 68.3% 73.4% 78.1% 87.0% 79.4% 73.0%

KPI356(a) Reduction in the number of Cardiology Referrals NE Lincolnshire CQC RES 5% 2.3% (-12%) 7.6% 5.7% 16.5% 16.6%

KPI356(b) Reduction in the number of Cardiology Referrals North Lincolnshire CQC RES 5% 32.6% 35.9% 24.3% 22.8% 46.0% 35.3%

KPI357(a) Reduction in the number of Respiratory Referrals NE Lincolnshire CQC RES 5% (-8.9%) (-27%) 1.8% 15.5% 22.0% 0.0%

KPI357(b) Reduction in the number of Respiratory Referrals NorthLincolnshire CQC RES 5% 7.6% 34.2% 18.6% (-11.1%) 47.3% 34.4%

KPI196 Hospital Followup appointments - Over Due PERF 18266 18190 19742 21204 16461 13618

KPI203 Hospital Followup appointments - Due date not known PERF 12838 13095 12433 12990 12914 10470

KPI197 18 wk Pathway validation numbers - Active to inactive PERF 1593 3147 4205 6585 4307 6524 This is an accumulative number April 16 to September 16

KPI198 Cancelled Clinic Rate PERF 12.7% 6.7% 6.1% 8.3% 6.0% 4.8%

A review of the appointment cancellation reasons in CAMIS PAS to make them more

informative has been undertaken. Therefore historic data has been rebased to reflect

the comprehensive recording of appointment cancellations reasons in CAMIS.

Stroke

KPI22 Stroke patients spending time on stroke unit PERF TGAC 80% 100% 88.0% 87.0% 87.0% 90.0% 95.0%

KPI23 TIA with high risk of stroke - assessed & treated within 24 hours PERF TGAC 60% 88.0% 100% 83.0% 100% 92.3% 89.0%

KPI24 Stroke patients scanned within 1 hour of hospital arrival PERF TGAC 50% 72.0% 54.0% 64.0% 67.0% 80.4% 64.0%

KPI25 Stroke patients scanned within 24 hours of hospital arrival PERF TGAC 100% 100% 100% 100% 100% 100% 100%

KPI26 Stroke patients & carers with joint care plans PERF TGAC 85% 100% 100% 100% 100% 100% 100%

KPI27 Stroke patients support from Early Supported Discharge Team PERF TGAC 40% 60.0% 70.0% 56.0% 73.0% 75.6% 55.0%

Quality Accounts and National Clinical Audit Patient Outcomes Programme are

National Audits that the Trust must take part in. Group performance of these

QA/NCAPOP audits is monitored through the Quality & Audit Department.

This measure is monitoring the reduction of referrals based on the same monthly

period the previous year to allow for seasonal variations - This data is rebased each

month to capture back logged activity. Currently historic data is only captured from

July 2015.

These measures are to monitor any theatre lists that have been stood down due to

lack of medical cover in Surgery for Elective, Emergency and Urgent operations. July

data is not currently available - Transition of theatre systems from ORMIS to WEBV is

impacting on monthly reporting

New referrals only include accepted referrals in the data set. This measure is

monitoring the reduction of referrals based on the same monthly period the previous

year to allow for seasonal variations to determine the impact the GP referral protocol

is having on referral numbers. Negative numbers signify a reduced number of referrals

from the previous year. There were 48 respiratory referrals for both 2015 and 2016



SECTION 3



Comments

Patient Experience

KPI28 (a) In patient Friends & Family Test response rate FFT (all) QPEC TGAC 40% 19.3% 17.0% 16.4% 20.7% 18.4% 18.8%

KPI28 (b) In patient Friends & Family Test response rate FFT (inpatients) QPEC TGAC 40% 41.6% 39.0% 40.0% 41.1% 44.3% 41.3%

KPI29 A&E Friends & Family Test response rate QPEC TGAC 20% 8.9% 7.7% 11.8% 7.9% 7.4% 7.3%

KPI30 Complaints acknowledged within 3 working days PERF TGAC 100% 100% 100% 100% 100% 100% 100%

KPI31 Complaint action plans drafted PERF TGAC 90% 100% 100% 100% 100% 100% 100%

KPI32 Complaints action plans implemented PERF TGAC 90% 100% 100% 100% 100% 100% 100%

KPI189 PALS concerns responded to within 5 working days QDP QPEC 90% 62.0% 62.2% 52.5% 49.8% 70.1% 60.0%

Complexity of the concern raised can require additional time to be allocated to the

PALs concern. PALS daily prioritization monitor report being developed. Other issues

can be due to the groups not dealing with the concern within the agreed timescales.

Groups are prompted to deal with concerns via the weekly PALs report which is to

prompt / escalate concerns.

KPI190 Complaints investigated within timescale agreed with complainant QDP QPEC 95% 100% 100% 100% 100% 100% 100%

KPI33 5% reduction in complaints received with same theme PERF TGAC 52 76 80 68 78 78 47

KPI34 Performance across 5 areas contained within menu card survey PERF TGAC 90% 96.7% 97.4% 96.8% 97.4% 97.3% 97.0%

KPI35 Patient Experience across the nursing care indicators PERF TGAC 95% 99.6% 99.9% 99.5% 97.7% 97.2% 97.9%

KPI36 Patients involved in decisions about their care & treatment PERF TGAC 95% 98.8% 100% 100% 97.9% 94.7% 96.2%

KPI44 Appropriate action was taken in response to NEWS score in accordance with Trust policy PERF TGAC 95% 100% 100% 100% 99.7% 100% 99.7%

KPI345 End of life Care (Complaints) CQC QPEC 1 0 0 0 1 2 0

KPI324 Complaints relating to delays or cancellations in Angiography Catherization Lab SGH CQC QPEC 1 0 0 0 0 0 0

KPI325 Incidents relating to delays or cancellations in Angiography Catherization Lab SGH CQC QPEC 1 0 0 0 0 0 0

Maternity

KPI45 Rate for stillbirths at or below national benchmark rate PERF TGAC 4.7 4.8 4.6 3.7 3.9 3.7 3.7From June this year, this measure is reporting on 12 month rolling figure to be

consistent with the new maternity dashboard.

KPI46 Neonatal deaths less than 28 days at or below national benchmark rate PERF TGAC TBC 0 0 0 1 0 0

KPI47 Caesarean Rate - Overall PERF TGAC 26.2% 23.3% 26.3% 24.5% 24.8% 21.7% 22.5%

KPI48 Induction Rate PERF TGAC 25.0% 29.0% 27.4% 27.9% 26.0% 22.7% 30.5%Induction rates nationally are increasing due to recent work around still births and

neonatal deaths.

KPI49 Unexpected Admissions to NICU PERF TGAC TBC 4 0 5 2 4 1

KPI82 No gynaecology patient outliers on maternity (admissions and transfers) PERF TGAC 0 0 0 0 0 0 0

KPI333 Maternity Incidents that have an RCA CQC RES 5 11 12 12 7 5 8

KPI364 (a) Ratio of midwives to births - DPoW CQC RES 1.28 1.34 1.34 1.34

KPI364 (b) Ratio of midwives to births - SGH CQC RES 1.28 1.30 1.30 1.30

KPI365 1:1 figures for births CQC RES 100% 100% 99.5% 98.7% 100% 98.5% 99.2%

Staffing & Roistering

KPI50 Staff turnover rates 15.2% 14.7% 14.4% 14.6% 14.0% 13.8%

KPI51 Reduction in nursing vacancy rate (Registered) QDP RES 6% 9.7% 10.0% 10.4% 10.4% 10.9% 9.5%

Review meetings held every week. Recruitment incentive packages developed and

agreed, European recruitment ongoing, University partnerships developed, Retention

plan progression including band 5+, Nursing academies and return to practice,

Enhanced pay for bank staff within ‘specialist areas’.

KPI318 Reduction in nursing vacancy rate - Un Registered CQC RES 6% (1.62%) (1.65%) (1.44%) 0.9% 1.5% (2.51%)

KPI310 Nursing Vacancy Rates - ED registered CQC RES 6% 16.8% 6.9% 10.3% 14.5% 9.8% 9.1%

WORKFORCE INDICATORS

Clinical Group have implemented measures to improve response rate. NHS

England FFT Lead stipulated the team have implemented amble measure for

promotion, provision of cards and staff awareness. Ongoing monitoring by

department managers. Card collection and data entry capacity issues has

impacted on low response rates Going forward a robust web based data entry

system will go live in February. A budget has been allocated for an NHS

Apprentice who will lead on card collection and data in put.



SECTION 3



Comments

KPI311 Nursing Vacancy Rates - ED Un registered CQC RES 6% (12%) (17.6%) (28.76%) (24.45%) (21.48%) (27.77%)

KPI312 Nursing Vacancy Rates - CC Registered CQC RES 6% 3.0% 6.9% 4.3% (0.72%) (0.72%) 1.9%

KPI313 Nursing Vacancy Rates - CC Un registered CQC RES 6% 33.6% 33.6% (0.14%) 19.4% 13.0% 3.9%

KPI314 Nursing Vacancy Rates - Surgery Registered CQC RES 6% 10.6% 11.0% 12.2% 13.2% 14.2% 13.7%

KPI315 Nursing Vacancy Rates - Surgery Un Registered CQC RES 6% (6.68%) (16.53%) (5.76%) (3.89%) (3%) (4.5%)

KPI316 Nursing Vacancy Rates - Medicine Registered CQC RES 6% 15.0% 15.3% 15.8% 17.1% 16.5% 13.3%

KPI317 Nursing Vacancy Rates - Medicine Un registered CQC RES 6% (2.58%) (2.07%) (2.23%) (0.26%) 1.1% 6.3%

KPI319 Midwife Vacancy Rates CQC RES 6% (0.75%) 3.2% 2.6% 2.3% 3.5%

KPI363 Radiologist vacancy rate CQC RES 14.17% 45.7% 41.1% 41.1% 36.5% 36.5% 36.5%

KPI52 Reduction in medical staffing vacancy rate QDP RES 14.17% 16.3% 18.9% 19.1% 19.8% 20.7% 21.2%

KPI302 Doctors Vacancy Rates - ED CQC RES 14.17% 28.9% 33.9% 31.9% 34.0% 34.4% 36.6%

KPI303 Doctors Vacancy Rates - CC CQC RES 14.17% 1.7% 1.5% 3.6% 1.9% (10.3%) -(10%)

KPI53 Reduction in AHP vacancy rate QDP RES 6.86% 6.9% 7.4% 6.1% 6.1% 6.1% 4.2%

This data is extracted from the monthly Safer Staffing Unity submission with the

exception of ED which isn't a requisite for the submission therefore the data is from E

Rostering. The performance target is the actual percentage where as the Unify return

is the average percentage of day and night shifts.

KPI304 Nursing unfilled shifts - Medicine CQC RES 80% 91.6% 90.6% 87.9% 87.8% 101.2% 90.6%

KPI305 Nursing unfilled shifts - Surgery CQC RES 80% 96.7% 95.0% 93.8% 92.5% 109.7% 93.8%

KPI306 Nursing unfilled shifts - ED CQC RES 80% 92.4% 91.3% 88.4% 88.4% 87.9% 90.5%

KPI307 Midwife unfilled shifts CQC RES 80% 94.9% 94.5% 93.2% 92.7% 98.4% 91.4%

KPI300 Drs Unfilled Shifts - Medicine CQC RES 0 61 42 38 0

KPI301 Dr Unfilled Shifts - Surgery CQC RES 0 0 7 9 9

KPI302 Drs Unfilled Shifts - ED CQC RES 0 13 22 32 13

KPI303 Drs Unfilled Shifts - CC CQC RES 0 0 0 4 0

KPI54 Reduction in average monthly spend on nursing locum & agency staff QDP QPEC £476,000 £747,000 £741,000 £685,000 £702,000 £743,000 £703,000

Increased spend due to use of high cost agency. Controlled system in place to use

cost effective agencies, enhancement schemed commenced to increase use of hospital

bank staff.

KPI55 Reduction in average monthly spend on locum & agency medical staff QDP QPEC £1,467,000 £1,508,000 £1,436,000 £1,682,000 £1,754,000 £1,902,000 £1,902,000

KPI56 Sickness levels at or below national benchmark rate QDP QPEC 4% 4.4% 4.3% 4.5% 4.9% 4.7% 4.6%

KPI207 No Band 4s are rostered to RN shifts at roster approval stage’ CQC RES 0 0 0 0

KPI349 Number of wards with dedicated management time CQC QPEC 100% 42.9% 26.0% 46.9% 37.3% 29.4% 45.1%

KPI349 (a) Provision of protected management time for ward charge nurses CQC QPEC 75% 90.2% 71.1% 61.6% 73.8%

KPI349 (b) Dedicated shift leader on days CQC QPEC 80% 0 0 0 0 0 100%

KPI368 Locum's completed a local induction MPAC QPEC 95%

A new process to collate information to evidence that NLAG Locum induction policy

has recently been implemented. The data collection process is being implemented

and it is anticpated that this KPI will be reported on from November onwards.

Staff Experience

KPI59 Staff FFT - would be happy for friend or family member to receive care on this ward PERF TGAC 80% 100% 100% 97.4% 81.1% 75.5% 81.3%

KPI60 Staff are satisfied with care that they provide PERF TGAC 80% 100% 100% 95.3% 80.6% 75.8% 79.9%

KPI61 Director visit evaluation forms received from every visit PERF TGAC 75% 100% 100% 100% 76.9% 88.9% 83.3%

Training & Development

KPI62Relevant staff have received dementia awareness training

(by 31 Dec 16)QDP QPEC 60% 67.6% 68.7% 70.0% 71.1% 84.4% 72.0%

KPI63 Mandatory training compliance rate QDP QPEC 95% 93.3% 93.1% 91.8% 91.6% 92.3% 89.2%

Failure to achieve this indicator has been escalated to and discussed at the Trust's

Governance & Assurance Committee. A range of actions were identified and these will

be undertaken over the coming months. Monthly reports are distributed to group

managers highlighting staff who are nearing the cut off point for training compliance.

KPI64 Staff to have undertaken an annual Vision & Values PADR QDP QPEC 95% 85.3% 77.9% 78.4% 76.3% 76.3% 79.0%

This continues to be monitored at all levels of the Trust. Monthly reports are

distributed to group managers highlighting staff who are nearing the cut off point for

PADR compliance.

KPI65 Nurses have received supervision (by 31 Dec 16) QDP QPEC 75% 76.7% 77.4% 76.5% 78.0% 77.4% 74.2%

KPI340 Health Visitors - 3 monthly safeguarding peer supervision TGAC 92% 88.9% 86.1% 88.9% 84.7% 74.3% 97.4%

KPI335 Relevant staff have received training in managing patients with a learning disability CQC QPEC 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

A local Education and Training Strategy for LD care to reflect the new Health

Education England training for learning disability guidance is currently being

developed. Once this has been sanctioned a training programme with be delivered

Trust wide.

KPI66 All relevant wards & departments to have a nominated LD champion QDP QPEC 100% 97.9% 97.9% 97.9% 97.9% 97.9% 97.9%

KPI67 All LD champions to have received relevant training QDP QPEC 100% 52.2% 52.2% 52.2% 52.2% 52.2% 52.2%

The new LD training and Education Strategy is to be launched imminently therefore

performance compliance rates should improve going forward.

This measure is monitoring the number of wards that have utilised their full allocation

of their dedicated management time. All wards have variant degrees of dedicated

management time built into their rotas which takes into account shift patterns and the

size of area.



SECTION 3



Comments

Clinical Indicators

KPI68 Clinical lead roles appointed to QDP QPEC 90% 97.4% 97.4% 97.1% 96.5% 97.1% 97.1%

KPI69 Mandatory training target for clinicians QDP QPEC 95% 69.1% 70.9% 71.5% 70.9% 76.7% 73.0%

Failure to achieve this indicator has been escalated to and discussed at the Trust's

Governance & Assurance Committee. Monthly reports are distributed to group

managers highlighting staff who are nearing the cut off point for training compliance.

KPI70 Relevant doctors have a refreshed and reviewed job plan QDP QPEC 100% 22.0% 28.0% 38.9% 72.0% 85.0% 86.0%

KPI71 Completed job plans recorded on the central database QDP QPEC 100% 100% 100% 100% 100% 100% 100%

KPI72 Job plan clearly differentiates between DCC and SPA activity QDP QPEC 100% 100% 100% 100% 100% 100% 100%

KPI73 All PAs > 10 to be clearly identified as additional PAs on a fixed term basis QDP QPEC 100% N N N N N NProcess is currently being developed to differentiate between the 10 PA contract and

the fixed term additional PA's on the e-job planning system.

KPI74 Doctors have undertaken annual appraisal QDP QPEC 95% 96.8% 97.9% 97.6% 76.5% 88.7% 96.1%

This continues to be monitored at all levels of the Trust. Monthly reports are

distributed to group managers highlighting staff who are nearing the cut off point for

PADR compliance.

KPI75 Doctors have undertaken revalidation PERF TGAC 95% 80.0% 0.0% 100% 100% 100% 100%

KPI76 Job plans are Quality Assured annually by AMDs QDP QPEC 100% N N N N N NRobust process is currently being developed. Audit meeting will be scheduled

following the release of e job plans.

KPI77Appropriate AMDs & Clinical Leads have attended development programme within 6 months of being

in postQDP QPEC 90% 82.9% 82.9% 80.0% 80.0% 76.5% 76.5%

Work is ongoing to provide a new Development Programme which will review the

programme content and forward delivery.

KPI204 Antimicrobial Stewardship within 48-72 hours - Quarterly CQUIN

Qrt 1 25%

Qrt 2 50%

Qrt 3 75%

Qrt 4 90%

48.0% 40.0% 32.0% 22.0% 22.0% 38.0%

This KPI is an audit of 50 representative sample taken from antibiotic prescriptions.

The threshold is an progressive quarterly target. September's performance improved

due to the validation being taken from patients notes, historically validation was

extracted from the survey monitor forms that were completed sporadically.

KPI204 a Antimicrobial Stewardship within 48-72 hours - Monthly CQUIN 48.0% 32.0% 16.0% 22.0% 22.0% 70.0%

This performance is a point of reference to monitor the monthly position for the 50

representative samples taken from antibiotic prescriptions and to identify the monthly

audit trend.

Estates and Facilities Indicators

KPI78 Patient satisfaction with hospital food PERF QPEC 90% 89.1% 89.3% 89.6% 91.9% 91.8% 92.4%Patient comments to be discussed at the Catering Sub Group meeting and menu

update. Wards to inform kitchen and Trust dietician regarding specialist diet requests.

KPI79 Patient satisfaction with ward/hospital cleanliness PERF QPEC 90% 99.6% 99.5% 99.8% 99.6% 99.9% 99.9%

KPI80 Preventative Maintenance PERF RES 90% 90.4% 88.4% 88.2% 87.3% 82.7% 88.8%

KPI81 Reactive Maintenance PERF RES 90% 73.2% 82.1% 76.7% 76.2% 76.8% 79.4%

Administration Indicators

KPI199 Percentage of letters on Dictate IT system PERF 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

KPI200 Percentage of letters completed over 10 Days PERF 10 Days 65.7% 51.5% 36.4% 0 0

KPI201 Percentage of abandoned telephone PERF 7.1% 6.3% 6.3% 7.7% 8.1% 7.1%This KPI is measuring the percentage of telephone calls from patients to the SAT team

that are abandoned.

KPI202 Number of abandoned letters PERF 0 0 0 0 0This new indicator will be reporting on the number of letters that have been dictated

onto the Dictate IT system but no letter have been produced.

* Included within the Performance KPIs to demonstrate the 2 ~NOF measures reported on by the Trust.

Currently reviewing all existing planned preventative maintenances. A portion of

maintenance delays can be attributed waiting for delivery of parts and spares. Impact

of additional new plant and equipment installations with no additional in house

workforce.