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NORTHERN HEALTH AND SOCIAL

CARE TRUST

TRUST BOARD

Performance Report

August 2013

Date Issued: 19/09/13

2

Contents

1.0 Executive Summary 2.0 Summary of Commissioning Plan, Commissioning Direction Targets 3.0 Governance 4.0 Commissioner Targets and Associated Activity 5.0 Access / Waiting Time Targets 6.0 Community Care and Associated Targets 7.0 Improving Productivity APPENDIX 1: LIST OF TABLES APPENDIX 2: LIST OF GRAPHS

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SECTION 1

1.0 Executive Summary – Reporting on Performance at End of August 2013

The Executive Summary highlights areas of improved performance, key challenges or changing trends. Please see full report for comprehensive performance overview and details. Emergency Department (A&E)

Positive progress has been made in the number of patients being seen and treated within 4hrs and 12 hrs in the acute Emergency Departments. Antrim Hospital achieved an improvement from the July position of 68.6% with Causeway Hospital showing a slight decrease on July’s position of 80.7%

Under 4hrs

Antrim Hosp 77.3%

Causeway Hosp

77.9%

The number of patients waiting over 12 hrs for the completion of their treatment in the ED has seen a sustained improved position during August with virtually no 12 hour breeches.

Over 12 hrs

Antrim 0 Causeway 1

Benchmark: The regional picture has been encouraging too with improvements in the 4 hours target achievement. The 12 hour regional position has also improved.

4 hrs Regionally Jun-13 81.5% Jul-13 80.1%

12 hrs Regionally

Jun-13 – 247 Jul-13 - 198

Discharge of Complex Cases from Hospital

It’s important that patients who are medically fit but require ongoing care in the community after leaving hospital are supported to do so in a timely way. The regional target is that 90% should be discharged in 48 hrs with the appropriate community care in place and no-one delayed more than 7 days. The Complex Discharge target has been met since May 2013.

93% complex cases

discharged within 48 hours

There remain challenges for some complex cases and 6 cases were delayed over 7 days mainly due to training needs, family resistance to discharge and equipment needs.

6 cases delayed over 7 days

Cancer

95% of urgent patients with a suspected cancer should begin treatment within 62 days of referral, 79% has been achieved in July and August. At the end of August 4 patients were exceeding 85 days, with the longest waiter waiting 136 days.

79% commenced

treatment within 62 days

All urgent breast cancer referrals should be seen within 14 days. August position has returned to 100% being seen within 2 weeks, however the situation remains challenging.

100% Referrals seen within 14 days

Elective (Planned) Wating Times for Hospital Services

70% of patients to wait within 13 weeks for Inpatient / Day Case treatment increasing to 80% by March 2014. Whilst August’s position presents a 3% reduction from that of July, it remains 6% above target.

76% within 13 weeks

70% of patients to wait within 9 weeks for 1st outpatient appointment, increasing to 80% by March 2014. The end of August position is 7% below target compared to 6% below target at the end of July.

63% within 9 weeks

4

Elective (Planned) Hospital Services – Reporting Against SBA Volumes

The position at 8th September in respect of the combined Elective Inpatients and Daycases, shows an under performance of - 849 (-10%) admissions. General Surgery is presenting an under performance of -25% (607 patients) & Urology -10% (155 patients). Complex General Surgery cannot be carried out at Whiteabbey & Mid Ulster hospitals for patient safety reasons and this has resulted in vacant slots on both theatre lists. The under performance in Urology has been affected by Consultant vacancies in Causeway hospital. The overall position at the end of July, (excluding endoscopy) was -10%. The Endoscopy position at 31st August shows an under performance of -14% (658 patients). July’s position was -12% (462 Patients).

-10% compared to SBA Volume

The position for 8th September New Outpatient services shows an under performance of -9% attendances. New General Surgery attendances shows an under performance of -12% (466 patients), and Gynae -12% (294 patients). The overall position at the end of July was -6%. Performance for Outpatient Reviews was above draft target by 2949 (8%) attendances. July’s position was 13% above draft target.

-9% compared

to New SBA Volume

8% above Review SBA

Volume

Control of Infection

25 cases of C Difficile have been reported from April to August compared to 24 over the same period last year. Target for year is no more than 56.

25 cases

8 cases of MRSA have been reported from April to August, compared to 6 cases over the same period last year. April to July’s position was 7 cases. Target for year is no more than 8.

8 cases

Unallocated Cases

Planned reduction in unallocated cases has been impacted on by increased demand and fluctuating staff levels. Positive progress has been made on reducing the number of unallocated cases from the position in June of 131 cases. All child protection cases are allocated within 24 hrs.

101 Unallocated Cases

Corporate Performance Absence

The cumulative 2013/14 absence position at the end of July was 5.12%, which is above the target of 5.0% for 13/14. This is however an improvement on the 12 /13 cumulative position of 5.75%. August position is not yet available.

5.12%

The Performance Management Department has recognised for some time that the format of the Trust Board Performance Report was in need of an overhaul. We have taken into consideration comments from Trust Board members and will implement a number of changes on a phased approach. Such changes will include the redesign of the summary section, providing trend and narrative explaining performance and noting actions. A final phase will include improving our use of available technology and contributing to a paper lighter environment. Targets have been realigned to Key Service areas outlined in the Commissioning Plan.

SECTION 2: Measurable Performance against Commissioning Plan, Commissioning Direction, and Additional Targets Period: 1 April 2013 – 31 August 2013

(Note in some cases information is cumulative in others a ‘snapshot’ position is provided eg number patients waiting over 13 weeks is a snapshot at the end of the period, whereas the number of waits over 12 hrs in A&E is a cumulative count of how many times that situation occurred in the period)

NOTE: 2013/14 Targets are from the Commissioning Plan Direction Target Areas. A number of additional indicators are also included in support of these target areas. Some are still in development stage and some do not have specific targets confirmed. PMSI are liaising with Trusts on these.

Key for Trend on previous month

Red arrow pointing down indicates a performance worse than previous month and below target.

Red arrow pointing up indicates a performance better than previous month though below target.

Red side to side arrow indicates no significant movement and is below target

Monthly Key

Achieving Target

Amber arrow pointing down indicates a performance worse than previous month almost on target

Amber arrow pointing up indicates a performance better than previous month almost on target

Amber side to side arrow indicates no significant movement and is almost on target

Almost Achieving Target

Not Achieving Target

Green arrow pointing down indicates a performance worse than previous month yet still above target.

Green arrow pointing up indicates a performance better than previous month and also above target.

Green side to side arrow indicates no significant movement though is achieving target

Not Applicable / Available

Not comparable to previous month

Dir. Target

Description Comments and Actions Recent 3 month Perf.

Assessment Trend on

prev. month

Trend Analysis

June July Aug

Elective Care AHS From April 2013,

70% of patients wait within 9 weeks for 1

st

outpatient appointment, increasing to 80% by March 2014

6,015 NHSCT Patients >9 weeks at 29/08/13, 647of which are IS transfers New backstops applied for quarter 1 & 2 2013/14

Core & Independent Sector Patients seen

within 9 weeks

0%

20%

40%

60%

80%

100%

A M J J A S O N D J F M

% within 9 wks 12/13 % within 9 wks 13/14Target 13/14

68% 64% 63%

Core & Independent Sector backstop breaches

2,091 2,490 2,725

AHS From April 2013, no patient to wait > 18 weeks for 1

st outpatient

appointment decreasing to 15 weeks by March 2014

494 of the 2,246 NHSCT patients >15 weeks at 29/8/13 are IS transfers.

Core & Independent Sector patients > 15

weeks

0

750

1500

2250


0

5000

10000

15000

20000

Pats > 15 wks 12/13 Pats > 15 wks 13/14

Target 13/14 Total Waits 13/14

1,683 2,052 2,246

Total Core & Independent OP Waiters

16,418 16,255 16,583

AHS From April 2013, no patient to wait > 9 weeks for a diagnostic test

Breaches in cardiac echo and MPI – action plan in place to bring both back in line to 9 weeks. MPI performance to be at 9 weeks by 30 Sep

0

400

800

1200

1600


No pats > 9 wks 12/13 No pats > 9 wks 13/14Target 13/14

544 533 420

Dir. Target Description

Comments and Actions Recent 3 month Perf. Assessment

Trend on prev.

month Trend Analysis

June July Aug

AHS From April 2013, no patient to wait > 9 weeks for a day case endoscopy.

Actions - Endoscopy templates reviewed - Pre-assessment implemented to

reduce DNA rate

75 of the 190 patients >9 weeks at 29th

August are IS transfers.

Core & Independent Patients > 9 weeks

0

150

300

450

600


500

1000

1500

2000

No pats > 9 wks 12/13 No pats > 9 wks 13/14


268 227 190

Total Core & Independent Endoscopy Patients

Waiting

1,590 1,363 1,153

AHS From April 2013, 100% of all Urgent diagnostic tests to be reported on within 2 days

33 patients waited > 2 days for July ‘13 29 in Imaging 4 in Physiological Measurement

0%

20%

40%

60%

80%

100%


% within 2 days 12/13 % within 2 days 13/14Target 13/14

99% 99% 99%

AHS From April 2013, 70% of patients wait within 13 weeks for Inpatient / Day Case treatment increasing to 80% by March 2014

932 (24%) NHSCT Patients (Inc IS)>13 weeks at 29/08/13 New backstops applied for quarter 1 & 2 2013/14 Excludes scopes who are solely within 9 weeks position

0%

20%

40%

60%

80%

100%


% within 13 wks 12/13 % within 13 wks 13/14 Target 13/14

Core & Independent Sector Patients within 13

weeks

80% 79% 76%

Core & Independent

Sector backstop breaches

179 210 262



Trend on prev.


June July Aug

AHS From April 2013, no patient to wait longer than 30 weeks for Inpatient / Day Case treatment decreasing to 26 weeks by March 2014

Excludes scopes who are solely within 9 weeks position

Core & Independent Sector patients > 26

weeks

0

50

100

150

200

250

300


2000

3000

4000

5000

No pats > 26 wks 12/13 No pats > 26 wks 13/14


143 169 199

Total Core & Independent IPDC Waiters

4,022 3,961 3,822

AHS From April 2013, no patient to wait longer than 9 weeks from referral to commencement of AHP treatment

OT – 3 new peripatetic community OT’s have commenced and a further 1 has been appointed. Paediatric OT is currently recruiting 2 peripatetic staff. LD have recruited 1 permanent & 1 agency OT. Draft action plan & IPT completed for non recurring resources to support waiting list. SLT – continued pressure in the SLT service. Vacancies in the adult service are being recruited to, in the interim 2 temporary staff have been employed.

0

250

500

750

1000

1250

1500


No pats > 9 wks 12/13 No pats > 9 wks 13/14 Target 13/14

718 782 1,218

OT – 723 Orthoptics - 24

SLT - 94 Physio – 296 Dietetics - 81

Unscheduled Care (Including Delayed Discharges) AHS From Apr 13,

95% of patients attending any A&E dept to be treated, discharged home or admitted within 4 hrs of arrival in Dept

There are numerous work streams in operation working to reduce the number of patients with a completed ED journey time of 12 hours. ED teams on both sites meet fortnightly as ED Improvement Teams to focus on patient journey in ED. This has led to a renewed focus on key performance indicators, for example working to ensure patients are triaged within 15 minutes of registration. There has been further work to extend Assessment Unit operations, which have reduced the number of GP referrals to ED.

Antrim

0%

20%

40%

60%

80%

100%


Antrim 12/13 Antrim 13/14 C'way 12/13

C'way 13/14 Target 13/14

78% 69% 77%

Attendances

5,889 6,474 5,989

Causeway

82% 81% 78%

Attendances

3,543 4,162 3,832



Trend on prev.


June July Aug

AHS From April 13 no patient should wait longer than 12 hours in A&E dept to be treated, discharged home or admitted

There are numerous work streams in operation working to reduce the number of patients with a completed ED journey time of 12 hours. Further to the above, when the system is under times of pressure, the ED has been very proactive in ensuring consultants are available to review and progress patients through the system. The Turnaround Team, led by M Hinds has brought a renewed focus on unscheduled care and significant effort from across clinical and managerial structure has moved to improve flow and active management of all patients in hospital.

Antrim

0

100

200

300

400


Antrim 12/13 Antrim 13/14 Cway 12/13 Cway 13/14 Target 13/14

0 19 0

Causeway

14 3 1

AHS/ PCCOPS

From April 13 90% of complex discharges take place within 48 hours of decision to discharge

August Discharges Antrim Hosp Dsch = 93% Causeway Hosp Dsch = 93.7% Mid Ulster Hosp Dsch = 100% Whiteabbey Hosp Dsch = 87.5% Not all wards / specialties are included

Monthly Position

40%

60%

80%

100%


Monthly 12/13 Monthly 13/14Target 13/14

94% 90% 93%

AHS/ PCCOPS

From April 13 all non-complex discharges take place within 6 hours of decision to discharge

August Discharges Antrim Hosp Dsch = 95.2% Causeway Hosp Dsch = 96.5% Mid Ulster Hosp Dsch = n/a Whiteabbey Hosp Dsch = 95.5% Not all wards / specialties are included

Monthly Position

40%

60%

80%

100%


Monthly 12/13 Monthly 13/14 Target 13/14

96% 97% 96%



Trend on prev.


June July Aug

AHS/ PCCOPS

From April 13 no complex discharge from an acute hospital setting takes longer than 7 days

6 patients waited over 7 days during the month of August (3 ANT, longest wait 38 days, 2 CAU, longest wait 10 days & 1 WHA longest wait 7 days). Not all wards / specialties are included Non Complex Discharges included in 2012/13 target monitoring, excluded from April 13 onwards. (Only Complex Discharges shown in graph for 2012/13)

Number of Patients discharged > 7 days

0

7

14

21

28

35


Dsch >7 days 12/13 Dsch >7 days 13/14Target 13/14

5 10 6

% discharged within 7 days

99% 99% 99%

AHS From April 13 95% of patients wait no longer than 48 hours for inpatient hip fracture treatment

August Fractures Transferred 1 patient transferred to RVH > 2 nights.

0%

20%

40%

60%

80%

100%


% Cum <48 hrs 12/13 % Cum <48 hrs 13/14Target 13/14

43% 56% 46%

AHS/ PCCOPS

By March 2013 secure a 10% reduction in the number of emergency readmissions within 30 days

Interim Target = 3076 readmissions (Ant – 2230 Cau – 846) Target is 10% below 10/11 baseline, as per HSCB guidance. Monitored activity is from CHKS 30 day Re-Admissions performance indicator. Information excludes regular day attenders, obstetrics and < 14 years of age. Local information based on HSCB definitions in development. Information presented one month in arrears.

Readmissions Antrim (Cumulative)

0

50

100

150

200

250

300

350

400


Readm 12/13 Readm 13/14

Target 13/14

751 1011

Readmissions Causeway (Cumulative)

290 404



Trend on prev.


June July Aug

AHS/ PCCOPS

By March 2014 reduce the number of unplanned admissions to hospital by 10% for adults with specified long term conditions

Interim Cum Target 1644 (10/11 baseline) Included: Diabetes, Heart Failure, Asthma and COPD to be monitored. Target of 137 per month. Figures presented are dependent on completeness of clinical coding. Current month information will be subject to change and updated in future reports

0

50

100

150

200


Unplanned Admissions 12/13Unplanned Admissions 13/14Target 13/14

Monthly

148 115 119

Cumulative

442 557 676

AHS By March 2014 reduce the number of excess bed days for the acute programme of care by 10%

Information is being developed. Currently presented amber as per TDP. Target to be achieved in partnership with community and primary care services, in addition to considering hospital internal processes and development of managing new models of LTC.

Health and Social Wellbeing Improvement, Health Protection and Screening (& HCAI)

AHS

By March 14, extend the bowel cancer screening programme to invite 50% of all eligible men and women aged 60-71, with a screening uptake of at least 55% of those invited.

Achieving this target is outside Trusts control as it is centrally administered by PHA. The target is scored green in that all actions within the Trusts control can be achieved.



Trend on prev.


June July Aug

MG By March 13, reduce MRSA infections by 29% (regionally), compared to 2011/12 (all ages) NHSCT target of 12 cases for 12/13

Target now confirmed for 2013/14 as 8 MRSA cases

Cumulative Cases

0

3

6

9

12

15


Cumul Position 12/13 Cumul Position 13/14

Target 13/14

4 7 8

MG By March 13, reduce CDiff infections by 29% (regionally), compared to 2011/12 (> 2 years). NHSCT target of 59 cases for 12/13

Target now confirmed for 2013/14 as 56 C. Difficile cases

Cumulative Cases

0

25

50

75

100


Cumul Position 12/13 Cumul Position 13/14Target 13/14

9 14 25

Cancer Care AHS From April 2013

95% of urgent patients with a suspected cancer will begin treatment within 62 days

Delays are mainly at outpatients and endoscopy. Actions: - Templates reviewed to ensure adequate capacity for suspect cancer referrals. - Additional activity being carried out to eliminate backlogs.

0%

20%

40%

60%

80%

100%



80% 79% 79%



Trend on prev.


June July Aug

Long Term Conditions AHS From April 2013,

ensure that 10% of patients with confirmed Ischaemic stroke receive thrombolysis

Total of 51 patients presented with stroke during August ’13, 7 of which received thrombolysis.

FAST campaign continuing in media.

0%

5%

10%

15%

20%


% Bolus Admin 12/13 % Bolus Admin 13/14Target 13/14

7% 13% 14%

AHS/ PCCOPS

By March 2014 deliver 121,500 Telehealth monitored days (equival to 680 patients) from the provision of remote telemonitoring services through Tele-monitoring NI

Monitored Days shows a steady increase. Currently 95% achievement against target. Implementation plan has been submitted. * Actual patients currently being monitored as at month end.

0

20000

40000

60000

80000

100000

120000


Cumul Position 13/14 Target 13/14

Patients*

157 186 217

Monitored Days

27,421 37,680 47,961

AHS/ PCCOPS

By March 2014, deliver 187,475 Telecare Monitored Patient Days (equival 545 patients), from the provision of telecare services through Tele-monitoring NI

Implementation plan has been submitted. * Actual patients currently being monitored as at month end.

Patients*

0

40000

80000

120000

160000

200000


Cumul Position 13/14 Target 13/14

260 266 273

Monitored Days

20,989 29,098 30,239



Trend on prev.


June July Aug

AHS/ PCCOPS

By 2014, develop and secure a range of quality assured education, information and support programmes to help people manage their long term conditions effectively.

First education programme commenced 3

rd June for people with Type 1 diabetes.

Trust will deliver 3 programmes over forthcoming months to approx 50 people. Other planned programmes include Chest Heart & Stroke Association Taking Control programme. Planned to deliver across 4 localities 2013/14. Discussions ongoing regarding identification of & funding for programme for people with Type 2 Diabetes.

Specialist Services

MG / AHS

From April 2013 no waits > 13 weeks to commence NICE approved specialist therapies for rheumatoid & psoriatic arthritis or ankylosing sponylitis

Target achieved from June ‘12

0

2

4

6

8

10


No pat >13 wks 12/13 No pat >13 wks 13/14

Target 13/14

0 0 0

MG / AHS

From April 2013 no waits > 39 weeks to commence NICE approved specialist therapies for psoriasis, decreasing to 13 weeks by Sept 13

0 > 13 weeks August 2013

0

2

4

6

8

10


No pat >39 wks 12/13 No pat >39 wks 13/14Target 13/14

0 0 0



Trend on prev.


June July Aug

Mental Health & Learning Disability MHD A. From April

2013, ensure that 99% of all Learning Disability Discharges take places within 7 days of the patient being assessed as medically fit for discharge

5 Patients discharged July 2013 5 = 0 – 7 days

40%

60%

80%

100%



Monthly

100% 67% 100%

Cumulative

92% 88% 91%

MHD B. No Learning Disability discharge to take more than 28 days of the patient being assessed as medically fit for discharge

12/13 target, no patient > 7 days

0

1

2

3

4

5


Dsch >28 days 13/14 Target 13/14

0 1 0

MHD A. From April 2013 99% of patients admitted as Mental Health inpatients for assessment & treatment are discharged within 7 days of decision to discharge

50%

75%

100%



Monthly

88% 97% 97%

Cumulative

93% 94% 95%



Trend on prev.


June July Aug

MHD

B. No Mental Health discharge to take more than 28 days of the patient being assessed as medically fit for discharge

1 patients discharged > 28 days Figures in graph relate to patients waiting > 7 days

0

2

4

6

8


Dsch >7 days 12/13 Dsch >7 days 13/14

Target 13/14

1

MHD Resettle an additional 12 Learning Disability patients by March 2015

The Trust is committed to the resettlement of all patients and is working as part of regional arrangements to achieve this objective. There are significant challenges given the complexity of patients. Resettlement Target Achieved for 12/13 Graph shows total resettlements for previous years.

0

10

20

30

40


Concluded Resettlement 12/13 Concluded Resettlement 13/14

Pats still in hosp 12/13 Pats still in hosp 13/14

11 11 12

12 resettled from April ‘12

MHD Resettle an additional 7 Mental Health patients by March 2015

The Trust is committed to the resettlement of all patients and is working as part of regional arrangements to achieve this objective. There are significant challenges given the complexity of patients.

Resettlement Target Achieved for 12/13 Graph shows total resettlements for previous years.

0

15

30

45


Concluded Resettlement 12/13 Concluded Resettlement 13/14

Pats still in hosp 12/13 Pats still in hosp 13/14

1 1 1

1 resettled from April ‘12



Trend on prev.


June July Aug

MHD From April 2013 no patient waits longer than 9 weeks to Access mental health services (Adult)

0

2

4

6

8

10


No pat > 9 wks 12/13 No pat > 9 wks 13/14

Target 13/14

1 0 0

MHD From April 2013 no patient waits longer than 13 weeks for psychological therapies (any age)

0

10

20

30

40

50

60


No pat >13 wks 12/13 No pat >13 wks 13/14Target 13/14

13 34 52

Children’s Services CS From April 2013

no patient waits longer than 9 weeks to Access child and adolescent mental health services

- Breach position remains fragile - Referral rates and referral accepted rates have increased significantly - Contact NI continue recruitment processes and hope to renew service delivery in coming weeks

0

50

100

150

200


No pat >9 wks 12/13 No pat >9 wks 13/14

Target 13/14

16 50 45



Trend on prev.


June July Aug

CS From April 2013 increase the number of children in care for 12 month or longer with no placement change to 85%

Information reported annually. Amber as per TDP.

CS By March 2014 increase the number of care leavers aged 19 in education, training or employment to 75%.

Aged 19 years old at month end 54 care leavers 10 ineligible

30%

60%

90%


% 19 yr old Care Leavers 12/13 % 19 yr old Care Leavers 13/14

Target 13/14

care leaver aged 19 years

80% 80% 81%


78% 82% 78%


76% 78% 67%

CS From April 2013 ensure a 3 year time-frame for 90% of all children to be adopted from care

Information reported annually. Green as per TDP.



Trend on prev.


June July Aug

Community Care – Older People & Physical Disability PCCOPS

From April 2013 no waits > 5 weeks for a completed assessment

12/13 target – 8 weeks

Monthly

60%

80%

100%


% waits <8 wks 12/13 % waits <5 wks 13/14

Target 13/14

99% 95% 100%

Cumulative

97% 97% 97%

PCCOPS

From April 2013 all components of care needs to be met within 8 weeks

12/13 target – 12 weeks

Monthly

60%

80%

100%


% waits <12 wks 12/13 % waits <8 wks 13/14Target 13/14

96% 98% 100%

Cumulative

96% 96% 97%

Transforming Your Care PPMSSS

During 2013/14, implement integrated Care Partnerships in support of Transforming Your Care.

Planning infrastructure is in place across the Trust and LCG. This will be taken forward jointly.

The following trends are for Indicators of Performance which are in support of the Commissioning Direction Targets. (This section is new to the 2013/14 report and will be developed over the coming months)

MINISTERIAL PRIORITY: TO IMPROVE AND PROTECT HEALTH AND WELL-BEING AND REDUCE INEQUALITIES; THROUGH A FOCUS ON PREVENTION, HEALTH PROMOTION AND EARLIER INTERVENTION

A Area Indicator Jan Feb Mar Apr May Jun Jul Aug Sept

Self Harm A10. Number of new & unplanned review attendances at A&E due to deliberate self harm

139 120 131 139 129 140 142 116

Alcohol-related Admissions

A15. Reduction in the rate of alcohol-related admissions to hospital

Information being developed

Seasonal Flu Vaccine

A22. Uptake of the seasonal flu vaccine by frontline Health and Social Care workers.

Reporting to commence Oct ‘13

Admissions for Venous Thromboembolism

A23. Number of emergency readmissions within 3 months (90 days) with a diagnosis of venous thromboembolism in 2013/14, regardless of the diagnosis related to the original (initial) admission.


Maternity Child Health POC

A24. Level of activity in maternity and child health programme of care including average length of stay.

KH03A returned quarterly

Caesarean Sections A25. Percentage of babies born by caesarean section and number of babies born in midwife-led units, either freestanding or alongside.

30% (Antrim/Causeway) 31% (Antrim/Causeway) KP19 returned quarterly

Intervention Rates A28. Percentage reduction in intervention rates (including caesarean sections) benchmarked against comparable units in UK and Ireland.

44% (Antrim/Causeway) 43% (Antrim/Causeway) KP19 returned quarterly

MINISTERIAL PRIORITY: TO IMPROVE THE QUALITY OF SERVICES AND OUTCOMES FOR PATIENTS, CLIENTS AND CARERS

Cancer Services B1. From April 2012 98% of patients should commence treatment within 31 days of decision to treat

96.8% 98.8% 99% 96.8% 98.9% 99.2% 100% 99%

B2. Number of patients given a red flag referral for suspect cancer by a GP for a first OP appointment with a cancer specialist (inc. consultant upgrades)

796 811 761 821 932 880 979 913

B3. From April 2012 all urgent breast cancer referrals should be seen within 14 days (Red Flag)

100% 100% 100% 78% 98% 53% 51% 100%

Attendances At A&E Department

B5. Number of new & unplanned attendances at A&E departments Types 1 & 2 (Antrim & Causeway)

9176 8661 9386 9506 9388 9432 10636 9821

Attendances At A&E Department

B6. Percentage of new & unplanned review A&E attendances by time band (<30mins, 30mins – 1 hr, 1-2 hours etc.)

A&E Information presented in Section 4


Review Outpatient DNA's

B8. Rate of review outpatient appointments where the patient did not attend.

10.6% 8.8% 11.1% 10.5% 9.3% 9.8% 9.9% 9.6%

New Outpatient Appointments cancelled by hospital

B9. Rate of New outpatient appointments cancelled by the hospital.

5.4% 7.7% 9.0% 7.8% 6.5% 6.7% 6.3% 8.0%

GP Referrals B10. Number of GP referrals to consultant-led outpatient services.

7053 6418 6586 6822 6935 6377 6547 6444

OP Appointments B11. Number of outpatient appointments with procedures (for selected specialties)

Outpatient coding currently on hold until additional funding is received

Radiology Tests B12. Number of radiology tests carried out for a discrete list of tests

Awaiting guidance from Department

Stroke B13. Number of emergency admissions with a primary diagnosis of stroke.

36 49 55 63 58 43 40 52

Pressure Ulcers B15. The number of incidents (i.e. forms) of hospital acquired pressure ulcers (grade 2 and above) within all programmes of care.

28 (Jan – Mar) 28 (Apr – Jun) Reported Quarterly

Falls B16. Number of falls in hospital settings

471 (Jan – Mar) 464 (Apr – Jun) Reported Quarterly

Hearing Aids B17. Number of hearing aids fitted within 3 months as a percentage of completed waits. (figures shown relate to those waiting < 13 wks)

97% waiting

< 13 wks

98% waiting

< 13 wks

95% waiting

< 13 wks

91% waiting

< 13 wks

92% waiting

< 13 wks

93% waiting

< 13 wks

92% waiting

< 13 wks

73% waiting

< 13 wks

Wheelchairs B18. Percentage of patients waiting over 13 weeks for any wheelchair (basic and specialised).

87% waited < 13 wks

87% waited < 13 wks

83% waited < 13 wks

80% waited < 13 wks

84% waited < 13 wks

86% waited < 13 wks

86% waited < 13 wks

93% waited < 13 wks

Housing Adaptations

B19. Percentage of patients who have lifts and ceiling track hoists installed within 16 weeks of the OT assessment and options appraisal.

89% within 15 wks

86% within 15 wks

65% within 15 wks

100% within

15 weeks

100% within

16 weeks

96% within

16 weeks

100% within

16 weeks

88% within

16 weeks

Emergency Admissions for Specific Acute Conditions

B26. Emergency Admissions for acute conditions which should not usually require hospital admission



Emergency Admissions & Readmissions

B27. Number and proportion of emergency admissions and readmissions for people aged 0-64 and 65+, (i) with and (ii) without a recorded long term condition, in which medicines were considered to have been the primary or contributing factor.


MINISTERIAL PRIORITY: TO DEVELOP MORE INNOVATIVE, ACCESSIBLE AND RESPONSIVE SERVICES: PROMOTING CHOICE AND BY MAKING MORE SERVICES AVAILABLE TO THE COMMUNITY

Pharmaceutical Services within TYC

C1(b) (i) Number and proportion of Health and Care Centres in each Trust active in pharmaceutical services provision currently and in future. (ii) Number and proportion of Health and Care Centres in each Trust without active pharmaceutical services currently but with plans to introduce in the next 6 months.

Reporting Frequency – Half Yearly

Remote Telemonitoring

C5. Number of patients benefiting from remote telemonitoring

13/14 information presented in Target Section above

Telecare Services C6. Number of patients benefiting from the provision of telecare services

13/14 information presented in Target Section above

Occupational Therapy Waiters

C7. Number of patients waiting longer than nine weeks from referral to commencement of Occupational Therapy treatment.

36 13 0 37 222 352 481 723

Speech & Language Therapy Waiters

C8. Number of patients waiting longer than nine weeks from referral to commencement of Speech & Language Therapy treatment.

2 0 0 22 51 93 87 94

Dementia Waiters C9. Number of patients waiting longer than 9 weeks to access dementia services

Dementia Patients previously included in Community MH Teams

0 0

MINISTERIAL PRIORITY: TO IMPROVE THE DESIGN, DELIVERY AND EVALUATION OF HEALTH AND SOCIAL CARE SERVICES THROUGH INVOLVEMENT OF INDIVIDUALS, COMMUNITIES AND THE INDEPENDENT SECTOR

Direct Payments D2. Number of direct payment cases by programme of care

524 514 518 516 520 523 531 533

MINISTERIAL PRIORITY: TO IMPROVE THE PRODUCTIVITY BY ENSURING EFFECTIVE AND EFFICIENT ALLOCATION AND UTILISATION OF ALL AVAILABLE RESOURCES IN LINE WITH MINISTERIAL PRIORITIES

Pre-operative stay

E1. Elective average pre-operative stay. 0.76 0.39 0.46 0.51 0.48

Elective LOS E2. Elective average length of stay in acute programme of care.

2.9 3.1 3.3 3.3 3.4

Stroke LOS E3. Average length of stay for stroke patients within the acute & elderly programme of care.

13.8 18.0 22.0 15.3 9.7


Day Surgery Rates E4. Day surgery rate for each of a basket of elective procedures. (Figures shown are cumulative)

62% 61% 62% 73% 68% 68% 63% 63%

Cancelled Ops E5. Percentage of operations cancelled for non-clinical reasons.

1.1% 1.9% 3.7% 3.6% 1.0% 1.5% 1.8% 1.4%

Elective Admissions E6. Percentage of patients admitted electively who have their surgery on the same day as admission. (Indicator – 75%)

79% 81% 77% 72% 76% 81%

Diagnostic Tests E7. Percentage of routine diagnostic tests reported on within 2 weeks of the test being undertaken.

98.9% 94.8% 97.8% 96.1% 95.7% 91.9% 93.5% 93.8%

Diagnostic Tests E8. Percentage of routine diagnostic tests reported within 4 weeks of the test being undertaken.

100% 99.7% 99.7% 99.4% 99% 99.1% 99.1% 99.1%

Nurse / Bed Staffing Ranges

E9. (a) Initiate the use of existing normative nurse to bed staffing ranges (b) normative staffing ranges to be developed within specific community settings

Reporting frequency - Annually

New / Review OP Ratio

E10. Ratio of new to review outpatient appointments scheduled by speciality and Trust. (All specialties)

1.55 1.66 1.74 1.72 1.60 1.61 1.61 1.61

MINISTERIAL PRIORITY: TO ENSURE THE MOST VULNERABLE IN OUR SOCIETY, INCLUDING CHILDREN AND ADULTS AT RISK OF HARM, ARE LOOKED AFTER ACROSS ALL OUR SERVICES

Foster Care F1. Percentage of all foster care placements that are kinship care placements.

29% 29% 30% 29% 30% 31% 31%

Care Leavers F2. Number of care leavers in education, training and employment by placement type. Reporting frequency – Annually

Adoption F3. The % of children with an adoption best-interests decision that are notified to the (ARIS) within 4 weeks of the HSC Trust approving the adoption panel’s recommendation that adoption is in the best interest of the child.

100% (2 of 2) 100% (4 of 4) Reported Quarterly

Lost School Days

F4. Number of school-age children in care for 12 months or longer who have missed 25 or more school days

Reporting frequency – half yearly

Adoption Decision F5. Length of time it takes for the decision to be made that adoption is in the best interests of a child

Reporting frequency – Annually

Children in MH Wards

F6. Children in Adult Mental Health Wards (Quarterly Info)

4 Jan ‘13 – Mar ‘13 1 Apr ’13 – Jun ‘13 Reported Quarterly

ADDITIONAL INDICATORS IN SUPPORT OF TARGETS / INDICATORS ABOVE


Patient Client Experience

Outcomes against the patient client experience standards in the settings agreed for the formal work plan.

Quarterly reports produced & submitted for each area to PHA

Absenteeism

The HSCB and PHA should ensure that Trusts achieve a level of performance that they reduce the rate of absenteeism to 5% across HSC Trusts.

5.7% 5.74% 5.75% 5.64% 5.32% 5.22% 5.12%

Children

From April 2011 the Trust should maintain the standard that all children admitted to residential care will have, prior to their admission. (a) been subject to a formal assessment

100% 100% 100% 100% 100% 100% 100% 100%

From April 2011 the Trust should maintain the standard that all children admitted to residential care will have, prior to their admission. (b) have their placement matched

100% (2of2)

100% (4of4)

100% (4of4)

100% (4of4)

100% (2of2)

100% (4of4)

100% (3of3)

100% (5of5)

Child Protection (allocation of referrals) – From April 11 100% of all child protection referrals are allocated to a social worker within 24 hours of receipt of referral

100% 100% 100% 100% 100% 100% 100% 100%

Child Protection (initial assessment) – From April 11 all Child Protection referrals are investigated and an initial assessment completed within 10 working days

100% 100% 100% 100% 100% 100% 100% 100%

Child Protection (pathway assessment) – From April 11, following completion of Initial Assessment a Case Conference is held with 15 working days of original referral

85% 100% 77% 87% 97% 96% 93%

Level of usage of advocacy services by Looked After Children – number of contacts made with advocacy services

Reporting frequency – Annually

Looked After Children (initial assessment) - From April 2011, an initial assessment completed within 10 working days from date of child becoming looked after

100% 100% 100% 91% 96% 100% 100%

Family Support (Referrals) – From April 2011, 90% of family support referrals to be allocated to a social worker within 20 working days for initial assessment

42% 67% 66% 89% 89% 81% 69%


Family Support (initial assessment) – From April 2011 all FSR must have an initial assessment completed within 10 working days from date referral allocated to the SW

31% 34% 42% 43% 45% 49% 58%

Family Support – From April 2011 on completion of the initial assessment 90% of cases requiring a family support pathway assessment should be allocated within 20 working days

53% 55% 71% 38% 64% 49% 37%

Unallocated Cases Unallocated Cases - All Family Support or Disability Referrals must be allocated to a social worker within 20 working days

126 129 91 98 117 131 101

Autism Autism – Children wait < 13 weeks for assessment following referral, and a further 13 weeks for specialised intervention

Assess185 >

13 wks Inter

0 > 13 wks

Assess145 >

13 wks Inter

0 > 13 wks

Assess26 >

13 wks Inter

0 > 13 wks

Assess0 > 13 wks Inter

0 > 13 wks


0 > 13 wks


0 > 13 wks


0 > 13 wks

Assess 4 > 13 wks Inter

0 > 13 wks

Pre-op Assessment From Apr 11, all surgical patients should have a pre-op assessment

76% 74% 74% (Info from PMSI)

Housing Adaptations From April 11, maintain 95% standard for minor urgent housing adaptations completed within 10 working days.

95% (53 of

56)

98% (81 of 83)

97% (37 of 38)

100% (48 of 48)

100% (43 of 43)

98% (47 of 48)

100% (36 of 36)

100% (60 of 60)

Acquired Brain Injury From April 11, maintain 13 wk maximum waiting time from referral to assessment & commencement of treatment

0 > 13 wks

0 > 13 wks

0 > 13 wks

0 > 13 wks

0 > 13 wks

0 > 13 wks

0 > 13 wks

0> 13 wks

Care Management Assessments

From April 11, the Trust should achieve a performance level of 48% of care management assessments completed in relation to nursing home, residential or domiciliary care, recommend domiciliary care provision.

66% 66% 66% 67% 67% 67% 67% 67%

Elective Care – Consultant Led Outpatient Waiting Times (Reviews)

All Outpatient Reviews to be completed within the clinical indicated time. Excludes patients waiting for independent sector.

5,419 7,404 8,446 6,939 7,037 6,087 5,387 5,590

New Outpatient DNA’s

Rate of new outpatient appointments where the patient did not attend.

8.0% 6.0% 7.7% 6.3% 5.8% 6.3% 7.1% 6.8%

Mortality From Sept 10 Trust to put in place arrangements to routinely review mortality rates, over time and against NI & GB comparator organisations.

Reporting continuing on a monthly basis via CHKS analysis. CHKS providing web based Benchmarking service. The RAMI for the Trust for 11/12 was 81, better than the expected range.


Complaints Respond within 20 days of receipt (complaints received and % responded to within 20 days)

56% 74% 70% 50% 53% 76% 44%

Acute Environmental Cleanliness

Comply with 85% cleanliness target 93% 91% 93% 94% 94% 94% 94%

Clinical Coding 95% coding within 31 days 98% @ 8/1/13

98% @ 13/2/1

3

99% @ 4/3/13

99% @ 3/5/13

99% @ 6/6/13

100% @

5/7/13

99% @ 6/8/13

99% @ 2/9/13

Clinical Coding 100% coding within 62 days

99% 8

th Jan

99% 13

th

Feb

99% 4

th Mar

99% @ 3

rd May

99% @ 6/6/13

100% @

5/7/13

100% @

6/8/13

99% @ 2/9/13

Nursing Skill Mix By Mar 11, achieve a reduction of one point in the ratio of qualified nurses to unqualified nurses.

78:22 78:22 78.22 78.22 78:22

AHP Skill Mix By Mar 11, achieve a reduction of one point in the ratio of qualified AHP’s to unqualified AHP’s

86:14 85:15 85:15 85:15 85:15

7 Day Follow up Trusts should ensure that, from April 2011, all mental health patients discharged from hospital who are to receive a continuing care plan in the community should receive a follow-up visit within 7 days of discharge

98.4% 98.4% 98.6% 100% 100% 100% 100% 100%

Directorate Codes: AHS Acute Hospital Services CS Childrens Services PCCOPS Primary & Community Care for Older Peoples Services MG Medical Governance PPMSS Planning, Performance Management and Support Services F Finance MHD Mental Health & Disabilities

Governance

Including Patient Safety Quality Improvement Plan Progress Report (July 2013)

& HCAI Performance Report

(July 2013)

PATIENT SAFETY QUALITY IMPROVEMENT PLAN (PSQIP) PROGRESS REPORT JULY 2013

28

TABLE 1: New Commissioning Priorities for 2013-14

Target Apr 13 May 13 Jun 13 Jul 13 Comments

Pressure Ulcer (SKIN

bundle)

Compliance with bundle (%) 95% 85 85 88 91 Pressure Ulcer bundle introduced to Antrim pilot wards in early 2013. Spread to 9 wards in April - May Spread to a further ward in June (10 wards) July – 12 wards, but no data was received for 2 of these wards Not yet introduced to Causeway

Number of PU ≥ grade 2 (hospital acquired)

N/A

1 1 7 5

Number of PU ≥ grade 2 (admitted with)

38 41 24 26

Pressure Ulcer Rate (per 1000 beddays)

6.76 7.54 5.47 4.04

Acute Falls Number of Falls

N/A 68 60 59 61 Falls Walking Stick introduced to wards in early 2013.

Data received from Antrim, Mid-Ulster and Whiteabbey. Awaiting data from Causeway.

Falls Rate (per 1000 beddays)

8.32 6.88 7.29 7.05

WHO Checklist

Trustwide (General Theatres, Maternity Theatres, DSUs & DPUs) (%)

95% 100 100 99 100 Target changed from 85% to 95% from April 13 July - No data received from 2 wards

VTE

Compliance with Risk Assessment (%)

95%

32 54 51 68 Audits being carried out by Local Medical Governance Groups across 10 wards in Antrim.

Appropriate prophylaxis prescribed in line with VTE Risk Assessment (%)

100 93 99 98

Crash Call Rate

Trust-wide (per 1000 beddays)

N/A 1.73 0.82 0.71 1.04

Compliance with SSI

Surveillance (C-Sections)

SSI Rate Trust-wide

N/A 19.0 13.4 12.5 17.9

Data received quarterly from PHA. Figures shown are for Quarters 2, 3 & 4 2012; and Quarter 1 2013. Quarter 2 2013 figures will not be available until mid-October 2013.

NI Aggregate 10.8 9.8 9.7 8.6

Return of surveillance forms (%)

Trust-wide 95%

79 82 85 79

NI Aggregate 78 76 76 74

Compliance with device-associated

surveillance

Ventilator Acquired Pneumonia (rate)

Antrim

N/A 8.62 0 0 ND

Data received from PHA. Figures are monthly. July 2013 data not yet available.

Causeway 0 0 0 ND NI Aggregate 1.37 0 0 ND

Central Line Blood Stream Infections (rate)

Antrim

N/A 0 0 0 ND

Causeway 0 0 0 ND NI Aggregate 0.53 0 0 ND

Catheter Associated Urinary Tract Infections

(rate)

Antrim

N/A 4.81 0 0 ND

Causeway 0 0 0 ND NI Aggregate 0.39 0.77 0.41 ND

29

TABLE 2: Other Patient Safety Initiatives (Non-Commissioning)

Target Apr 13

May 13

Jun 13

Jul 13

Comments

Leadership Walkrounds

Number of Walkrounds held per month

4 4 2 2 --- July – no Leadership Walkrounds held this month due to leave

Mental Health

Weekly team review (WTR) (%) 95% 100 70 95 100

Joint Risk Assessment (JRA)

(%) 95% 100 95 95 100

Treatment/ care plan (TCP) (%)

95% 100 100 100 100

Surgical Site bundle (Maternity C-Sections)

Trust-wide (%) 95% 100 100 99 100

Central Line bundle (Antrim & Causeway)

Trust-wide (%) 95% 100 100 100 100

Ventilator bundle (Antrim & Causeway)

Trust-wide (%) 95% 100 100 100 100

PEWS Compliance Trust-wide (%) 95% 95 93 94 96 July – no data received from Causeway wards

Medication Safety Meds Rec within 48 hours

(Antrim) (%) 95% 82 85 87 100

B1 reverted back to being the only admission ward, therefore data more centralised

ED Measures

Stroke

Assessment within 30 minutes (%)

95%

100 100 100 100

July - CT scans delayed for 3 patients - Lysis delayed for 1 patient due to requirement for MRI; and another patient required treatment for high blood pressure

CT scan within 45 minutes (%)

60 60 67 50

Lysis bolus within 60 minutes (%)

20 50 67 0

Appropriate ward within 90 minutes (%)

60 100 100 100

Number of stroke patients presenting

per month N/A 5 5 3 6

Unscheduled reattenders

Within 7 days (%)

1 – 5% 6.06 6.03 6.50 ND Data not yet received for July 2013

Left before treatment (%) <5% 4.26 3.19 3.21 ND Data not yet received for July 2013

SECTION 3.1 HCAI Performance Report The following indicators are included in this section; Clostridium Difficile / MRSA Targets 2013/14 MRSA: 8 per year C DIFF: 56 per year (please note that MRSA relates to all ages, CDiff target for 2013/14 relates to aged >2 Environmental Target INDICATOR – Compliance with 85% Cleanliness target A steering group has been set up to implement the Regional strategy “Cleanliness Matter”. This will be implemented where possible, within existing resources, as no additional funding is available. Hand Hygiene Target INDICATOR – 95% Overall Compliance

31

TABLE 1: SUMMARY TABLE 2013-14

Actual activity 12/13

12/13 Target

Apr-13 May-13 Jun-13 Jul-13 Monthly target 13/14*

Cumulative position as at

31 Jul 13

Cumulative target

(Jul 13)

13/14 Target

Comments

PERFORMANCE REPORT

C DIFFInfections ≥2 years 80 N/A 2 1 6 5 4.92 14 18.68 56

Deaths associated with C Diff Primary = (P) / Secondary = (S)

21 N/A 1 0 3 1 N/A 5 N/A N/A Please note figures include toxin negative cases

MRSA Infections 13 12 2 1 1 3 0.67 7 2.68 8

LOCAL IPC PERFORMANCE INDICATORS

Compliance with Hand Hygiene Policy (%) 99 95 98 96 97 97 95 97 95 95

Compliance with Antimicrobial Prescribing Policy (%)

94 90 94 92 93 92 90 93 90 90

Antimicrobial exemptions (appropriateness) 91 95 88 86 90 91 95 89 95 95

HIGH IMPACT INTERVENTIONS (HII)

HII 1 Central venous catheter bundle (%)

Insertion 100 95 100 100 95 100 95 99 95 95

July - HII 4 (Peri-op) awaiting data for 2 wards.

Ongoing 100 95 95 100 100 100 95 99 95 95

HII 2 Peripheral line bundle (%) Insertion 99 95 100 100 94 95 95 97 95 95

Ongoing 100 95 99 100 99 99 95 99 95 95

HII 3 Renal bundle (%) Insertion 100 95 100 NIL NIL NIL 95 100 95 95

Ongoing 99 95 100 99 99 100 95 100 95 95

HII 4 Surgical Site bundle (%) Maternity 100 95 100 100 99 100 95 100 95 95

Peri-op 98 95 99 99 99 87 95 96 95 95

HII 5 Ventilator care bundle (%) 100 95 100 100 100 100 95 100 95 95

HII 6 Urinary catheter care bundle (%)

Insertion 100 95 100 97 100 100 95 99 95 95

Ongoing 100 95 100 100 100 100 95 100 95 95

HII 7 C Diff bundle (%) 100 95 100 100 NIL 100 95 100 95 95

ENVIRONMENTAL CLEANLINESS

Trust-wide compliance (%) Acute 93 85 94 94 94 94 85 94 85 85

Trust-wide compliance (%) Community 91 85 90 92 91 89 85 91 85 85

C Diff death figures are accurate at the time of report production. Figures may change if subsequent cases are reported by laboratory services. Subsequent changes will be reflected in the next issue of the performance report. Includes Community figures (Dalriada, Moyle and Robinson). Figures relate to only those cases which are included in Target Monitoring NIL = no patients requiring intervention/bundle

32

TABLE 2: Summary of Infection Prevention & Control Validation Audits (carried out by IPCNs) – July 2013

ANTRIM Total number of audits carried out: 24

CAUSEWAY Total number of audits carried out:

Audit Number of audits in each compliance category


Hand Hygiene Full compliance Partial compliance Minimal compliance

5 1 ---

Hand Hygiene Not audited

Management of Peripheral Lines

Full compliance Partial compliance Minimal compliance

7 2 ---



--- --- 2

Management of Urinary Catheters


4 1 ---



--- --- 2

C Diff Validation Audits Full compliance Partial compliance Minimal compliance

2 2 ---

C Diff Validation Audits


3 --- ---

Venepuncture Management


--- 1 ---

MRSA Management Full compliance Partial compliance Minimal compliance

1 --- ---

HOLYWELL, MID-ULSTER & WHITEABBEY Total number of audits carried out:

DALRIADA, ROBINSON & INVER Total number of audits carried out:



Hand Hygiene Full compliance Partial compliance Minimal compliance

--- --- 1

Hand Hygiene Not audited


Not audited


Not audited



--- 1 1


Not audited

C Diff Validation Audits Not audited

C Diff Validation Audits


2 --- ---

MRSA Management


1 --- ---

MRSA Management Not audited

NB: Wards / Depts falling below 90% compliance with Hand Hygiene, Management of Urinary Catheters or Management of Peripheral Lines are required to carry out weekly audits for a period of 3 months.

Compliance Scores: Compliant = 95% or above Partial Compliance = 90% - 94% Minimal Compliance = 89% or below

33

TABLE 3: Regional Healthcare Hygiene Cleanliness Audit Tool

entre – 3 July 2013 Average Compliance

Section 2 - General Environment 85%

Section 4 - Waste and Sharps 100%

Section 5 - Patient Equipment 99%

Section 6 - Hygiene Factors 93%

Section 7 - Hygiene Practices (observed) 96%

Inver 3 Holywell Hospital – 16 July 2013 Average Compliance


Section 3 - Patient Linen 94%




Section 7 - Hygiene Practices (observed) 92%

Wilson House Day Centre – 24 July 2013 Average Compliance


Section 3 - Patient Linen 38%




An action plan is put in place for any areas which fall below compliance.

Compliance Scores: Compliant = 95% or above Partial Compliance = 90% - 94% Minimal Compliance = 89% or below

SECTION 3.2 COMPLAINTS

INDICATOR – Respond to complaints within 20 working days TABLE 1: COMPLAINTS - April 12 – July 13

MonthComplaints

Received

Number replied to within

20 working daysPercentage

Apr-12 50 39 78%

May-12 58 34 59%

Jun-12 47 26 55%

Jul-12 50 29 58%

Aug-12 49 31 63%

Sept-12 44 24 55%

Oct-12 70 59 84%

Nov-12 75 47 63%

Dec-12 28 15 54%

Jan -13 59 33 56%

Feb -13 54 40 74%

Mar-13 50 35 70%

TOTAL TO DATE 634 412 65%

MonthComplaints

Received

Number replied to within

20 working daysPercentage

Apr-13 56 28 50%

May - 13 62 33 53%

June - 13 54 41 76%

July - 13 61 27 44%

TOTAL TO DATE 233 129 55% (Source: Governance Dept; Monthly Complaints Report)

GRAPH 1: COMPARATIVE GRAPH – COMPLAINTS 2012/13 – 2013/14

Complaints Responded to within 20 DaysApril 12 - July 13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar

Month

Perc

en

tag

e

2012/13 2013/14

35

SECTION 3.3 HOSPITAL STANDARDISED MORTALITY RATIOS (HSMRs)

Hospital Standardised Mortality Ratios (HSMRs) = the ratio of the number of deaths in hospital within a given time period, to the number that might be expected if the hospital had the same death rates as some reference population i.e. using CHKS's national database containing more than 7 million episodes received annually from over 150 hospitals representative of DGH and Teaching hospitals in the United Kingdom. Of these, 146 English acute hospitals were used as the comparator group for NI. Step 1: The risk of dying with each given combination of age, sex, diagnosis and other risk factors is worked out for a ‘standard’ population. This process calculates the risk for particular patient subgroups within the standard population. In the HSMR for example, there are more than 2,000 different combinations of age, sex, deprivation, admission type, diagnosis and co-morbidity. Step 2: This risk is then applied to the corresponding subgroups in the local hospital in order to calculate how many deaths would be expected to occur in that trust if the standard level of risk applied locally. The expected number of deaths is therefore a locally-weighted count of deaths. For some local hospitals, there may be none or very few patients and deaths in some of the subgroups. Step 3: This ‘expected’ figure is then compared with the observed (actual) number of deaths that occurred in the hospital to give a ratio. The ratio between the number of expected deaths and the number of actual deaths is known as a standardised mortality ratio (SMR). It represents the number of actual deaths divided by the number of expected deaths x 100. Hospital Standardised Mortality Ratio (HSMR) = the number of actual deaths divided by the number of expected deaths x 100. When using mortality ratios, it is usual practice to set the SMR in the standard population at the value of 100. This simply means that there is an exact match between the observed deaths and the expected deaths - hence it is the ‘standard’. Using 100 also makes it easier to express local Trust HSMRs in terms of a percentage difference to this standard. Example: If a trust’s HSMR is 85, it has 15% fewer deaths than expected. Similarly an HSMR of 120 would indicate 20% more deaths than expected. The information on HSMRs is provided to the Trust through the work of CHKS (health care benchmarking service provider) which uses clinically coded data sourced from the Trust’s Patient Administration Systems. This data is then risk adjusted using the CHKS Risk Adjusted Mortality Index (RAMI) methodology. The HSMR for the Trust is therefore presented in the form of a Risk Adjusted Mortality Index (RAMI) score.

Performance against HSCB Trusts has been Benchmarked against 146 acute hospitals in England,

which are in the CHKS database.

The Trust stats have been published in the Trust Board Performance Report at March 2013.

36

Commissioner Targets and Associated

Activity

37

SECTION 4 4.0 COMMISSIONER TARGETS AND ASSOCIATED ACTIVITY

The following section presents detailed progress against our Service and Budget Agreement activity. This section also presents additional supporting hospital services activity. SERVICE AND BUDGET AGREEMENTS

4.1.1 ACTIVITY: Inpatients, Day Cases and Outpatient

INDICATOR – Elective targets have now almost all been agreed between the Trust and HSCB. This includes Inpatients, Day case and New Outpatients. Review Outpatients have not yet been agreed.

4.1.2 ACTIVITY: AHP and Community Health Services

INDICATOR – To maintain a level of activity consistent with volumes set out in the New Health and Social Care Board Service and Budget Agreement. (These have not yet been formally agreed for 13/14). Tables 9A, 9C & 9D presents the combined NHSCT position for AHP and Community Health Services. The currency used is Face to Face Contacts and the comparison shown for AHP is against 11/12 outturn and additional investment for 12/13.

(Note that the provision of this information continues to require development)

Table 1a:

Cumulative Period 23

NHSCT

Specialty

Core

expected

Target / Vol

Actual Cum

ActivityVariance % Variance

Core

expected

Target / Vol

Actual Cum

ActivityVariance % Variance

Core

expected

Target / Vol

Actual Cum

Activity

Variance % Variance

Cardiology 32 30 -2 -7.1% 98 88 -10 -10.0% 130 118 -12 -9.3%

Dermatology 14 0 -14 -100.0% 256 310 54 21.0% 270 310 40 14.9%

ENT 517 393 -124 -23.9% 521 624 103 19.8% 1038 1017 -21 -2.0%

Gastroenterology 123 38 -85 -69.2% 290 244 -46 -15.8% 413 282 -131 -31.7%

General Medicine 18 45 27 154.3% 40 18 -22 -54.8% 58 63 6 9.6%

General Surgery (includes paed surg) 837 569 -268 -32.0% 1586 1247 -339 -21.4% 2423 1816 -607 -25.1%

Breast Surgery 119 120 1 0.5% 30 27 -3 -10.2% 150 147 -3 -1.7%

Geriatric Medicine 4 4 0 13.0% 0 0 - n/a 4 4 0 13.0%

Haematology 0 45 45 n/a 109 89 -20 -18.2% 109 134 25 23.2%

Nephrology 27 33 6 22.3% 4 1 -3 -74.9% 31 34 3 9.8%

Neurology (excludes VC C'way & PNeur) 0 0 0 n/a 6 7 1 13.0% 6 7 1 13.0%

Obs and Gyn (Gynaecology) 552 440 -112 -20.2% 831 831 -0 0.0% 1383 1271 -112 -8.1%

Paed Med (excludes MUH amb) 71 66 -5 -6.7% 2 0 -2 -100.0% 73 66 -7 -9.0%

Pain Management 2 5 3 182.6% 264 266 2 0.9% 265 271 6 2.1%

Rheumatology 33 18 -15 -45.7% 307 366 59 19.1% 341 384 43 12.7%

Thoracic Medicine 4 61 57 - 219 234 16 7.1% 222 295 73 32.9%

Urology (incl Nurse Led Activity) 228 284 56 24.7% 1276 1065 -211 -16.5% 1504 1349 -155 -10.3%

Total for listed specialties 2580 2151 -429 -17% 5838 5417 -421 -7% 8417 7568 -849 -10%

NOTE: The following specialties exclude scopes: Gastro, GS & Medicine, which have been identified by procedure code on PAS

Elective Inpatients Daycases Combined Elective and Daycase

1st April 2013 - 8th September 2013 (23 weeks)

Elective Inpatient activity is based on Admissions (1st FCE only)13/14 Activity Comparison for NHSCT Inpatient and Daycase compared to 13/14 HSCB volumes. (Based on HSCB monitoring)

(Source: Acute Hospital Information Services; Cumulative Weekly SBA Activity Report)

Above table now includes Dr Valko WLIO (ENT) activity & Dr Riddell WLIO (Rheu) activity. Chemical Pathology now included in Endocrinology.

Table 1b: Endoscopy performance against HSCT target: 01/04/2013 – 31/8/2013 (5 months)

NHSCT April May June July August Cumulative

Actual Activity to Date 741 883 794 846 733 3997

Expected SBA Monthly Volume 931 931 931 931 931 4655

Monthly Variance -190 -48 -137 -85 -198 -658

% Variance -20.4% -5.2% -14.7% -9.1% -21.3% -14.1% (Source: Acute Hospital Information Services; Cumulative Weekly SBA Activity Report)

39

TABLE 1c:

(Based on HSCB monitoring)

Cumulative Period 23 1st April 2013 - 8th September 2013 (23 weeks)

NHSCT

Specialty

Core

expected

Target / Vol

Actual Cum

Activity

Variance%

Variance

Core

expected

Target / Vol

Actual Cum

Activity

Variance % Variance

Cardiology 1607 1923 316 19.6% 1671 2060 389 23.2%

Dermatology 1945 1842 -103 -5.3% 2587 2475 -112 -4.3%

Diabetes / Endocrinology 587 587 -0 -0.1% 960 2825 1865 194.2%

ENT 2752 2698 -54 -2.0% 2752 3410 658 23.9%

Gastroenterology 1327 1040 -287 -21.6% 2654 1993 -661 -24.9%

General Medicine 1095 529 -566 -51.7% 2190 1157 -1033 -47.2%

General Surgery (includes paed surg) 3753 3287 -466 -12.4% 4841 4416 -425 -8.8%

Breast Surgery 1211 1165 -46 -3.8% 1477 1121 -356 -24.1%

Geriatric Medicine 445 457 12 2.7% 445 666 221 49.7%

Haematology 203 250 47 22.9% 1650 2889 1239 75.1%

Nephrology 271 210 -61 -22.4% 1083 1677 594 54.9%

Neurology (excludes VC C'way & PNeur) 222 208 -14 -6.3% 278 472 194 69.9%

Obs and Gyn (Gynaecology) 2415 2121 -294 -12.2% 2415 2901 486 20.1%

Gynae - Colposcopy 748 724 -24 -3.3% 0 0 - n/a

Gynae - Urodynamics 129 123 -6 -4.8% 0 0 - n/a

Orthodontics 133 108 -25 -18.6% 1327 1117 -210 -15.8%

Paed Med (excludes MUH amb) 1534 1267 -267 -17.4% 3559 3226 -333 -9.4%

Pain Management 274 270 -4 -1.5% 576 380 -196 -34.0%

Rheumatology 771 768 -3 -0.4% 2700 3128 428 15.9%

Thoracic Medicine 1057 1015 -42 -4.0% 2114 2745 631 29.8%

Urology (incl Nurse Led Activity) 1296 1000 -296 -22.8% 1944 1514 -430 -22.1%

Total for listed specialties 23777 21592 -2185 -9% 37223 40172 2949 8%

13/14 Comparison for NHSCT Outpatient Activity compared to 13/14 HSCB volumes

New Outpatients Review Outpatients

(Source: Acute Hospital Information Services; Cumulative Weekly SBA Activity Report)

40

Table 2:

Northern Health and Social Care Trust SBA Volume Breakdown

Specialty Total Elect Adms Total Day Cases

Combined Elect

Adms & DC New Outs Review outs

Cardiology 73 221 294 3,634 3,779

Dermatology 31 579 610 4,398 5,849

Diabetes / Endocrinology 0 0 0 1,328 2,171

ENT 1168 1178 2346 6,222 6,222

Gastroenterology 279 655 934 3,000 6,000

General Medicine 40 90 130 2,476 4,952

General Surgery (includes paed surg) 1893 3585 5478 8,484 10,944

Breast Surgery 270 68 338 2,738 3,340

Geriatric Medicine 8 0 8 1,006 1,006Haematology 0 246 246 460 3,731

Nephrology 61 9 70 612 2,448

Neurology (excludes VC C'way & PNeur) 0 14 14 502 628

Obs and Gyn (Gynaecology) 1247 1879 3126 5,460 5,460Gynae - Colposcopy 0 0 0 1,692 0Gynae - Urodynamics 0 0 0 292 0

Orthodontics 0 0 0 300 3,000

Paed Med (excludes MUH amb) 160 4 164 3,468 8,046

Pain Management 4 596 600 620 1,302

Palliative Medicine 0 0 0 0 0

Rheumatology 75 695 770 1,744 6,104

Thoracic Medicine 8 494 502 2,390 4,780

Urology (incl Nurse Led Activity) 515 2885 3400 2,930 4,395

Total 5,832 13,198 19,030 53,756 84,157not yet agreed with HSCB

Endoscopes 11,167

(Source: HSCB; Based on NHSCT Capacity & Demand Report)

- The 2013 / 14 volumes are based mainly on 2012/13 volumes with a 2% increase for productivity.

- The majority of Elective activity volumes for 2013/14 have been agreed with HSCB for inpatients, day cases and new outpatients. Draft volumes are used in the

interim for review outpatients until 2013/14 volumes have been confirmed. Inpatient / Day Case volume split has not yet been agreed, HSCB draft percentage

split has been used in the interim.

41

AHP Activity TABLE 3a - Service & Budget Agreement (SBA) for New AHP Face to Face (FTF) Contacts CUMULATIVE POSITION: 1st April – 31st July 2013 (Update for August not yet available) (Commissioning targets have been agreed for new FTF contacts only. These have been based on 11/12 activity and include any additional investment received within the current year)

Dietetics 4,481 3,586 335 3,921 560 1,680 14%

Occupational Therapy 7,224 6,305 0 6,305 919 2,756 15%

Orthoptics 1,381 1,177 0 1,177 204 613 17%

Physiotherapy 14,301 12,745 0 12,745 1,556 4,667 12%

Podiatry 3,465 3,284 0 3,284 181 544 6%

Speech & Language Therapy 1,837 1,704 126 1,830 7 20 0%

% Year

End

Variance

Year End

Variance

Projected

AHPs (New)

13/14 New FTF

Contacts

Activity

13/14 SBA

New FTF

Target

Variance

Additional

Investment

FTF Target

(New)

Total 13/14

New FTF

Target

TABLE 3b – Additional Investment 2013/14 Additionality - Full Year Effect New Review

SLT New Post from 12/13 recurrent 378 756

Dietetics Elective Funding recurrent 1005 3205

To be Confirmed

Dietetics DAFNE - - -

Dietetics CAWT - - - Performance Notes: Speech & Language Therapy

SLT staff have relocated from Community Services to Antrim Hospital which impacts on elective target. Staff are endeavouring to balance the needs of new referrals and meeting targets with managing the risks with

delayed reviews. Adult Services have recruited to 1 vacancy, and one maternity leave, a further maternity leave vacancy remains

to be covered, in the interim 2 temporary staff (1 agency) have been employed and additional hours have been made available to other staff to minimise risk and endeavour to reduce numbers waiting in excess of 9 weeks to access the service.

Pressure continues on SLT services in both scheduled and unscheduled aspects. Occupational Therapy

Community, Dementia and Learning Disability OT services are all breaching 9 week target. 3 new peripatetic OT’s have been employed in the Community OT service and a further one has been appointed

and should start in the next few weeks. The Paediatric OT service is also currently recruiting 2 peripatetic OT staff.

The Trust is currently negotiating some additional temporary staff to help manage the waiting list position. Learning Disability have recruited a permanent OT to their service and 1 temporary agency OT. OT waiting list position is unlikely to improve over the next few months unless significant additional help is

provided with immediate effect. Physiotherapy

Demand for the service continues to increase. Physiotherapy does not have the funded capacity to service this increase in referrals. An IPT is presently being prepared to secure additional funding.

Dietetics

Additionality to be confirmed. Unusually high rate of absence in some areas of service Staff has been utilised to cover these areas to minimise breaches Staff contracts temporarily extended to cover absenteeism Dietetics waiting list is expected to improve by end of October

42

TABLE 3c - AHP Supporting Information - Review Face to Face (FTF) Contacts CUMULATIVE POSITION: 1st April – 31st July 2013 (Update for August not yet available)

(Review activity is not part of SBA activity however the following activity is provided in support of the new activity in the table above. Review targets have been based on 11/12 activity and include any additional investment received within the current year)

Dietetics 6,863 5,580 1,068 6,648 215 645 3%

Occupational Therapy 16,129 13,045 0 13,045 3,084 9,251 24%

Orthoptics 3,276 3,504 0 3,504 -228 -683 -6%

Physiotherapy 54,425 54,663 0 54,663 -238 -713 0%

Podiatry 26,130 28,141 0 28,141 -2,011 -6,034 -7%

Speech & Language Therapy 13,915 14,330 252 14,582 -667 -2,000 -5%

OT Contacts (Mental Health) (New)

(excluding Dementia)* 333

OT Contacts (Mental Health) (Review)

(excluding Dementia)* 11,446

% Year

End

Variance

Year End

Variance

ProjectedAdditional

Investment

FTF Target

(Review)AHPs (Review)

13/14 Review

FTF Contacts

Activity

13/14

Review FTF

Target

Total 13/14

Review FTF

Target

Variance

TABLE 3d - Community Health Services The following table is for information only and details at a high level Community Health Services. Activity provided is for 1st April – 31st July 2013 (Update for August not yet available)

Health Visitors 9,469

District Nurses 98,776

Community Midwifery 26,977

Community Nurses Learning Disability 1,549

Community Psychiatric Nurses 16,060

Community Dental 7,423

Clinical Psychology 7,013

Family Planning 2,663

Public Health Staff Nurses 806

Care Managed Nursing 1,906

Community Health Services

13/14 FTF

Contacts

Note: Health Visitor activity is now child health only. (TABLES 3a, b, c & d - Source: Corporate Information Services; AHP & Community Health Service Monthly (FTF Contact) Activity)

43

A&E Target INDICATOR – 95% of people who attend A&E are treated, admitted or discharged home within 4 hours; no patient should wait longer than 12 hours. Trusts should ensure that the 95% standard is achieved in individual hospital sites. TABLE 4: NEW AND UNPLANNED REVIEW PATIENTS WHO DEPART FROM A&E IN THE MONTH of August 2013

Antrim*

New/ Unpl

Rev 4627 77.3% 1362 22.7% 0 0.0% 5989

Causeway*

New/ Unpl

Rev 2985 77.9% 846 22.1% 1 0.0% 3832

Mid Ulster**

New/ Unpl

Rev 630 100.0% 0 0.0% 0 0.0% 630

Whiteabbey**

New/ Unpl

Rev 687 100.0% 0 0.0% 0 0.0% 687

Trust Total

New/ Unpl

Rev 8929 80.2% 2208 19.8% 1 0.0% 11138

Total

Attendances

(exc incorrect

DT)Department

Attendance

Type

Total 0-4

hours

%0-4

hours

Total 4-12

hours

% 4-12

hours

Total 12

hours +

% 12

hours +

(Source: Acute Hospital Information Services; Monthly AE Performance Report)

Includes unplanned review patients, Please note Planned reviews (Clinic Reviews) are excluded. 12 hr+ breaches include ambulance breaches which are attributed to NHSCT. Excludes those attributed to the Ambulance Service.

Mid Ulster and Whiteabbey Hospitals are Nurse-led Minor Injuries Units.

TABLE 5: ANTRIM HOSPITAL NEW AND UNPLANNED REVIEW PATIENTS WHO DEPART FROM A&E – April 12 – August 13

Fiscal Year April May June July Aug Sept Oct Nov Dec Jan Feb Mar

2012 / 13 5892 6225 5902 5748 6224 5952 6106 5776 5730 5769 5568 5967

2013 / 14 5894 5787 5889 6474 5989

Variance 2 -438 -13 726 -235 (Source: Acute Hospital Information Services; Monthly AE Performance Report)

TABLE 6: A&E 12 HOUR BREACHES September 12 – August 13 (Number of Patients Waiting >12 Hours)

NHSCT

Breaches

Sept

12

Oct

12

Nov

12

Dec

12

Jan

13

Feb

13

Mar

13

Apr

13

May

13

Jun

13

Jul

13

Aug

13

A&E 97 150 210 238 337 225 417 448 76 13 18 0

A&E /

Transport12 4 9 14 19 4 16 18 6 1 4 1

TOTAL 109 154 219 252 356 229 433 466 82 14 22 1

(Source: Acute Hospital Information Services; Monthly AE Performance Report)

*A&E Transport breaches for which NHSCT is responsible are shown separately.

44

Graph 1: Monthly % Departing A&E within 4 hours – Antrim & Causeway Hospital Sites

ED - % Seen 0- 4 Hours

68

.5%

61

.7%

61

.5%

60

.5%

59

.7%

62

.8%

77

.3%

68

.6%

77

.8%

75

.3%

67

.1%

63

.9%

78

.2%

82

.2%

85

.0%

78

.3%

70

.2%7

7.9

%

70

.9%

71

.9%

71

.1%

82

.4%

80

.7%

77

.9%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

%

ANT CAU Target

Accident and Emergency services continue to fall short of the 4 hour waiting target for 95% of attendances.

Graph 2: ANTRIM HOSPITAL A&E NEW AND UNPLANNED REVIEW PATIENT ATTENDANCES FOR AMBULANCE SOURCE OF REFERRAL: February 13 – August 13

ANTRIM & CAUSEWAY HOSPITAL A&E NEW & UNPLANNED REVIEW PATIENT

ATTENDANCES FOR MODE OF ARRIVAL EMERGENCY AMBULANCE

9321206 1111 1095 1206 1390 1261

496530 566 458

498653

577

0

500

1000

1500

2000

2500

Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13Arr

ivals

by E

merg

en

cy A

mb

ula

nce

Antrim Causeway

(Source: Acute Hospital Information Services)

Table 7: ADMISSIONS INTO HOSPITAL VIA A&E: August 12 – August 13

Month

ANT CAU MID WHA ANT CAU MID WHA

Aug-12 6224 4154 598 801 11777 1611 634 0 0 2245 19.1%

Sep-12 5952 3597 587 690 10826 1675 586 0 0 2261 20.9%

Oct-12 6106 3573 684 808 11171 1850 609 1 0 2460 22.0%

Nov-12 5776 3328 608 757 10469 1815 586 0 0 2401 22.9%

Dec-12 5730 3362 432 504 10028 1910 591 0 0 2501 24.9%

Jan-13 5769 3407 609 621 10406 2044 628 0 0 2672 25.7%

Feb-13 5568 3093 583 711 9955 1801 495 0 0 2296 23.1%

Mar-13 5967 3419 616 610 10612 1928 597 0 0 2525 23.8%

Apr-13 5894 3612 699 623 10828 1826 579 0 0 2405 22.2%

May-13 5787 3601 752 680 10820 1855 582 0 0 2437 22.5%

Jun-13 5889 3543 707 691 10830 1777 610 0 0 2387 22.0%

Jul-13 6474 4162 780 795 12211 1780 672 0 0 2452 20.1%

Aug-13 5989 3832 630 687 11138 1744 680 0 0 2424 21.8%

% AdmittedNo. of New & Unplanned Reattenders

TOTALNo of Patients Admitted via A&E from PAS

TOTAL

(Source: Acute Hospital Information Services; 2010-13 Admissions via AE Trust Position Report)

45

4.3 CANCELLED OPERATIONS INDICATOR – No more than 2% of operations should be cancelled for non-clinical reasons on the day. All surgical patients should have appropriate pre-operative assessment. This section of the report replaces the cancelled admissions section and is based on the monthly PMSI return monitoring the number of operations cancelled for non-clinical reasons.

GRAPH 3: Total Hospital Cancellations for Non-Clinical Reasons (Sept 12 – Aug 13)

Non Clinical Cancelled Operations Target

from Sept 12 - Aug 13

1.8%1.4%

1.1%

2.1%

1.8%2.2% 1.9%

1.1%

3.7%3.6%

1.0%

1.5%

0.0%

1.0%

2.0%

3.0%

4.0%

Sep

t 12

Oct

12

Nov

12

Dec

12

Jan

13

Feb

13

Mar

13

Apr

13

May

13

Jun

13

Jul 1

3

Aug

13

Month

% C

ance

lled

% Non Clinical Cancellations on day or later Target %

GRAPH 4: % of Admissions that had a valid corresponding Pre-Op Assessment Attendance

% of Admissions that had a valid corresponding Pre-Op Assessment Attendance - BY MONTH,

Admissions during Jun 12 - Mar 13

(See notes for exclusions)

76% 76% 72% 72% 76% 77% 77% 76% 74%

24% 24% 28% 28% 24% 23% 23% 24% 26% 26%

74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Yes No

Notes: Information based on coded Admissions only. Information includes Day Cases. Current levels of coding have contributed to the percentage in the graph above. Updated positions not yet available.

46

4.4 CLINICAL CODING INDICATOR – Trust to work towards 95% of all diagnosis/procedure coded activity to be carried out within 31 days of the end date of the relevant FCE/Day case or the OP Attendance. 100% should be achieved within 62 days. TABLE 8: CLINICAL CODING TIMELINESS

As at

Total

Episodes

Coded

Episodes % Coded Target

Total

Episodes

Coded

Episodes % Coded Target

03/05/2013 110243 109341 99% 95% 101239 100563 99% 100%

06/06/2013 120642 119792 99% 95% 111046 110337 99% 100%

05/07/2013 129072 128444 100% 95% 120258 119661 100% 100%

06/08/2013 139243 138412 99% 95% 129661 129046 100% 100%

02/09/2013 147168 146220 99% 95% 137965 137241 99% 100%

31 Day Target 62 Day Target

(Source: Acute Hospital Information Services; 2013 – 14 Clinical Coding Target Report)

This report shows the level of clinical coding completed within the 31 and 62 day target dates and excludes Independent Hospital Activity. It is not yet possible to calculate the % completed for OP Clinical coding as there is no way at present of accurately identifying those OP attendances where procedures have taken place.

47

Access / Waiting Time

Targets

48

SECTION 5 5.1 WAITING TIMES – Inpatient / Daycase Waiters INDICATOR – 70% of inpatients and daycases to be treated within 13 weeks, increasing to 80% by March 14, with no patient to wait longer than 30 weeks for treatment decreasing to 26 weeks by March 14. Table 1a below shows the numbers waiting against HSCB July Backstop positions.

As at 29/08/2013 there were; 932 NHSCT patients (Inc IS) waiting over 13 weeks (Inpatient / Daycase) 262 NHSCT (Inc IS) patients breached the backstop positions 199 NHSCT patients (Inc IS) waiting over 26 weeks

Table 1a: IP/DC Patients by Weeks Waiting at 29/08/13 (exc. Endoscopy) Patients waiting in the >13 week column are waiting 92 – 97 days, 14 weeks: 98 – 104 days etc.

>13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

36-

44 > 44

Total > 13

Weeks

CARDIOLOGY (C) 2 1 3 16

DENT LEARN DIS/SPEC NEEDS (C) 5 1 1 1 1 9 22

DENTAL CHILDRENS (C) 3 5 2 1 2 1 2 16 22

EAR, NOSE & THROAT- ADULT (C) 2 2 1 1 1 7 19

EAR, NOSE & THROAT - ADULT (WLIO) 1 1 15

EAR, NOSE & THROAT – PAEDIATRIC (C) 1 1 2 2 1 7 18

EAR, NOSE & THROAT (IS) 1 1 1 3 21

GENERAL SURGERY ( C) IS 4 2 2 3 1 1 4 1 1 1 2 1 3 26 41

GENERAL SURGERY (C) 20 19 35 28 14 8 14 13 4 5 3 6 3 1 3 3 1 2 1 183 34

GENERAL SURGERY (WLIO) 1 1 1 1 4 31

GYNAECOLOGY (C ) IS 2 1 4 1 1 1 5 1 6 3 5 3 1 10 4 4 3 2 2 3 62 39

GYNAECOLOGY (C) 3 15 20 13 11 16 14 2 1 4 1 2 3 1 4 1 1 1 113 46

OBS & GYN (GYNAECOLOGY) (WLIO) 1 5 6 17

PAIN MANAGEMENT (IS) 1 1 2 15

UROLOGY (C) 4 9 7 8 6 3 1 2 1 5 6 6 4 5 10 3 2 82 43

INPATIENTS >13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

36-

44 > 44

Total > 13

Weeks

EAR, NOSE & THROAT- ADULT (C) 3 1 1 1 7 2 4 1 1 1 22 28

EAR, NOSE & THROAT – PAEDIATRIC (C) 1 1 19

GENERAL SURGERY ( C) IS 4 2 1 2 1 3 3 1 1 1 5 24 42

GENERAL SURGERY (C) 4 9 9 8 18 7 4 9 3 1 1 2 3 2 1 2 2 1 1 1 1 3 3 95 45

GENERAL SURGERY (WLIO) 2 2 22

GENERAL SURGERY BREAST (C ) IS 1 1 1 1 2 1 3 10 48

GENERAL SURGERY BREAST (C) 1 1 2 3 7 41

GYNAECOLOGY (C ) IS 2 6 1 4 1 2 6 2 2 1 1 2 1 3 1 10 45 44

GYNAECOLOGY (C) 3 12 11 6 8 12 12 6 3 1 5 4 5 1 5 2 2 6 2 3 1 1 10 121 43

OBS & GYN (GYNAECOLOGY) (WLIO) 1 1 19

UROLOGY (C ) IS 1 1 49

UROLOGY (C) 5 6 6 5 5 3 3 9 4 4 4 4 3 6 3 2 3 1 1 1 78 34

UROLOGY (WLIO) 1 1 19

TOTAL IP/DC 55 82 97 80 76 64 69 51 19 35 23 37 31 21 20 38 26 19 10 8 13 6 3 41 8 932

DAYCASES

Longest

Wait

(Weeks)

WEEKS

(Source: Information Services – Acute, PTLIPDC – run date 29/08/2013)

NOTES: = 13 wk PFA target or agreed backstop for certain specialties.

- Patients are grouped into weeks waiting, ie. 18 weeks equals 126 – 132 days. Patients waiting >18 weeks (127-132 days) will therefore be included in the 18 week group. Only those waiting exactly 18 weeks in this column are not breaches.

- Waiting list figures are validated weekly by operational staff. Table 1a excludes Visiting Consultant waiters.

49

Table 1b: Endoscopy Patients by Weeks Waiting at 29/08/2013

190 NHSCT Endoscopy patients (Inc. IS) waiting over 9 weeks

>9 10 11 12 13 14 15 16 17 18 19 20 21 22 24 26 27 28 29

Total > 9

Weeks

GASTROENTEROLOGY ( C) IS 1 1 2 3 1 4 1 2 15

GASTROENTEROLOGY (C) 2 8 9 1 1 1 1 1 1 25

GENERAL SURGERY (C ) IS 1 3 8 6 2 2 2 1 4 9 3 1 4 2 3 1 1 5 1 59

GENERAL SURGERY (C) 12 23 15 21 4 4 3 1 1 2 1 1 1 89

GS ENDOSCOPY (C ) IS 1 1

GS ENDOSCOPY (C) 1 1

Total 15 34 32 29 8 8 7 2 9 11 9 3 4 3 6 2 1 6 1 190

Specialty

WEEKS

(Source: Information Services – Acute, PTLIPDC _ run date 29/08/2013) Table 1c: Visiting Consultant IP/DC Patients by Weeks Waiting at 29/08/2013

14 18 21 24 26 27

Total > 13

Weeks

OPHTHALMOLOGY (C) 2 1 1 1 5

UROLOGY BHSCT (C) 4 1 1 6

UROLOGY BHSCT (WLI) 1 1

Total 2 5 1 1 1 2 12

Specialty

WEEKS

(Source: Information Services – Acute, PTLIPDC – run date 29/08/2013)

Table 2: Waiting Times for Inpatients / Daycase Backstop Specialties – August 2013

Specialty WEEKS Specialty WEEKS

Breast Surgery 26 General Surgery 26

Dermatology 11 ENT 18

Endoscopy 9 Gynae 26

Urology 26 All Other Specialties 13

50

5.2 WAITING TIMES – Outpatient Waiters INDICATOR – 70% patients should wait no longer than 9 weeks for a 1st outpatient appointment, increasing to 80% by March 14, and all

patients to be seen within 18 weeks for a 1st outpatient appointment, decreasing to 15 weeks by March 14. Table 3a shows the numbers waiting against HSCB May backstop positions.

As at 29/08/13 there were

6,015 NHSCT patients waiting over 9 weeks Outpatients (inc. IS Transfers) 2,725 NHSCT patients breached the backstop positions (inc. IS Transfers) 2,246 NHSCT patients waiting over 15 weeks (inc. IS Transfers)

Table 3a: OP Patients by Weeks Waiting at 29/08/13 Patients waiting in the >9 week column are waiting 64 – 69 days, 10 weeks: 70 – 76 days etc.

>9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Total > 9

Weeks

CARDIOLOGY (C) 46 49 53 46 22 33 8 3 1 261

CHEMICAL PATHOLOGY (C) 1 3 1 3 1 1 10

COLPOSCOPY - GYNAE (C) 2 26 48 3 22 30 36 3 36 32 14 22 10 21 2 307

DERMATOLOGY (C) 36 68 39 34 14 16 7 4 1 3 3 3 2 6 4 5 8 2 2 4 3 4 2 1 271

DERMATOLOGY (IS) 7 16 20 10 1 2 11 6 12 3 1 9 3 5 4 2 4 4 3 2 2 5 132

DIABETIC (C) 1 1

DIABETIC/LIPID (C) 2 2

EAR, NOSE & THROAT (C) 86 121 144 134 105 159 115 87 78 52 29 10 7 5 1132

EAR, NOSE & THROAT (IS) 1 29 14 5 27 2 24 10 3 115

ENDOCRINOLOGY (C) 6 13 19 16 12 16 9 9 10 7 4 6 3 1 2 1 1 1 136

GASTROENTEROLOGY (C) 54 65 94 81 57 89 76 67 85 74 74 75 24 53 29 10 17 5 2 1 1032

GASTROENTEROLOGY (IS) 2 3 28 7 7 2 3 52

GENERAL MEDICINE (C) 3 4 1 3 1 12

GENERAL SURGERY (C) 92 113 80 98 48 54 24 9 8 3 1 1 1 532

GENERAL SURGERY (IS) 1 3 17 9 21 19 9 3 1 83

GENERAL SURGERY BREAST (C) 14 25 19 5 7 14 22 13 28 12 12 6 1 178

GERIATRIC ASSESSMENT (C) 2 1 4 1 5 13

GERIATRIC/CC (C) 1 1

GYNAECOLOGY (C) 64 119 103 94 40 58 17 12 4 1 512

GYNAECOLOGY (IS) 6 8 7 24 2 3 18 13 1 82

HAEMATOLOGY (C) 1 3 4

MIRENA - GYNAE (C) 1 1

NEPHROLOGY (C) 8 9 9 4 3 11 6 2 52

NEUROLOGY (C) 11 28 14 13 6 3 2 2 1 80

NEUROLOGY (IS) 1 2 1 1 5

ORTHODONTICS (C) 1 3 3 15 1 2 3 5 6 1 3 43

PAEDIATRIC MEDICINE (C) 30 24 21 14 6 12 5 7 5 7 4 12 4 3 3 157

PAIN MANAGEMENT (C) 19 24 34 32 2 5 6 4 4 5 2 1 1 139

PAIN MANAGEMENT (IS) 1 3 21 15 11 13 11 12 5 1 1 2 1 1 1 3 1 103

RHEUMATOLOGY (C) 22 25 21 29 8 11 1 2 3 1 1 124

RHEUMATOLOGY (IS) 2 12 8 3 2 8 11 15 6 4 2 1 1 75

THORACIC MEDICINE (C) 6 5 5 5 2 4 1 7 2 37

URACYST (C) 1 1

URODYNAMICS - GYNAE (C) 12 11 22 7 6 10 8 3 1 1 81

UROLOGY (C) 11 25 15 19 19 15 13 7 18 16 16 19 6 13 9 9 6 7 2 3 1 249

Total 529 766 771 681 437 585 399 278 387 299 192 198 64 123 85 86 53 27 12 9 16 7 4 7 6015

Specialty Description

WEEKS

(Source: Information Services – Acute OP PTL – run date 29/08/2013)

NOTES: = 9 wk PFA target or agreed backstop for certain specialties.

- Patients are grouped into weeks waiting, ie. 15 weeks equals 105 – 111 days. Patients waiting >15 weeks (106-111 days) will therefore be included in the 15 week group. Only those waiting exactly 15 weeks in this column are not breaches. - Waiting list figures are validated weekly by operational staff. Table 3 excludes ICATS and Visiting Consultant waiters. Community Paediatric (non PAS) included from 31

st March 2013

51

Table 3b: Visiting Consultant OP Patients by Weeks Waiting at 29/08/13

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 40 41 42

Total > 9

Weeks

DENTAL SURGERY (C) 4 12 15 6 15 17 5 5 12 11 8 6 11 9 14 5 5 4 6 5 12 7 10 6 10 2 3 5 1 2 2 2 237

NEUROLOGY (C) 4 7 8 9 8 3 2 1 1 1 4 1 4 1 3 2 1 60

OPHTHALMOLOGY (C) 16 12 4 1 33

ORTHOPAEDICS (C) 1 1 1 1 4

TRAUMA & ORTHOPAEDICS (C) 3 1 3 2 9

Grand Total 27 32 30 19 24 20 5 5 12 13 9 7 12 14 15 9 6 7 9 6 12 7 10 6 10 2 3 5 1 2 2 2 343

Specialty Description

WEEKS

(Source: Information Services – Acute OP PTL – run date 29/08/2013)

Table 4: Waiting Times for Outpatient Backstop Specialties – August 2013

Specialty WEEKS Specialty WEEKS Specialty WEEKS

Breast Surgery 13 Cardiology 15 Chem Path/Diabetic/Lipid 15

Dermatology 15 Endocrinology 15 ENT 15

Gastro 15 General Surgery 15 Gynae 15

Gynae - Colposcopy 10 Nephrology 10 Neurology (Dr Esmonde) 15

Orthodontics 15 Pain Management 15 Rheumatology 12

Urology 15 All Other Specialties 9

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5.3 WAITING TIMES – Mental Health Outpatient Waiters INDICATOR –No patient to wait longer than 9 weeks from referral to assessment and commencement of treatment for mental health issues, 13 weeks for psychological therapies. TABLE 5: Waiting List Position as of 06/09/2013

All Non Consultant-led Services0-3 Weeks (0-21

days)

>3 to 6 weeks (22-

42 days)

> 6 to 9 weeks

(43 -63 days)

> 9 to 13 weeks

(64 -91 days)

> 13 weeks (>91

days)Total waiters

Community Mental Health Teams 264 191 53 0 0 508

Psychiatry of Old Age (Non Consultant Led) / Community

Mental Health Teams for Older People

Forensic Services 4 0 0 0 0 4

Eating Disorder Services 4 1 0 0 0 5

Addictions 138 84 11 0 0 233

Child and Adolescent Mental Health Services (CAMHS) Tier 3

services 72 46 34 38 7 197

Dementia Services 86 106 15 0 0 207

Personality Disorder Services

Consultant Led Psychosexual Services*

TOTAL 568 428 113 38 7 1154

All Non Consultant-led Services0-3 Weeks (0-21

days)

>3 to 6 weeks (22-

42 days)

> 6 to 9 weeks

(43 -63 days)

> 9 to 13 weeks

(64 -91 days)

> 13 weeks (>91

days)Total waiters

Adult Mental Health Service (including victims of sexual

violence and trauma) 97 111 91 91 49 439

Adult Health Psychology Services (including long term

conditions management) 5 11 7 1 0 24

Children's Psychology Services (including paediatric

psychology and therapeutic services for looked after children 0 2 0 0 0 2

Adult and Children's Learning Disability Services 32 18 28 7 0 85

Psychology Led Psychosexual Services

TOTAL 134 142 126 99 49 550 (Source: Corporate Information Services; Priority 6 – Weekly Mental Health Services Waiting Times HSCB Return 2013-14) As at 31/08/13 there were 45 CAMHS patients breaching the 9 week target, and 52 Psych Therapies patients breaching the 13 wk target.

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5.4 WAITING TIMES – Diagnostics

INDICATOR – No patient to wait longer than 9 weeks for a Diagnostic Test.

TABLE 6: Waiting List Position as of 31/08/2013

0-3 Weeks

(0 - 21 days)

>3 to 6 weeks

(22 - 42 days)

>6 to 9 weeks

(43 - 63 days)

>9 to 13 weeks

(64 - 91 days)

>13 to 21 weeks

(92 - 147 days)

> 21 to 26 weeks

(148 - 182 days)

> 26 weeks

(183 days +)Total waiters

Imaging 3814 1941 899 58 2 0 0 6714

Cardiology 797 542 341 127 70 26 0 1903

GI Physiology 1 0 0 1 0 0 0 2

Respiratory Physiology 199 140 75 43 3 0 0 460

Urodynamics 25 40 24 64 26 0 0 179

Audiology 81 90 79 0 0 0 0 250

TOTAL 4917 2753 1418 293 101 26 0 9508

(Source: Acute Hospital Information Services; Priority 2 – Diagnostic Tests WL Monthly 2013-14)

As at the 31/08/13 there were 60 Imaging, 223 Cardiology, 1 GI Physiology, 46 Respiratory Physiology and 90 Urodynamic patients waiting over 9 weeks for a diagnostic test. (There are 39 tests, these are grouped in the headings shown above). Figures not yet validated.

* Cardiology Perfusion Studies – MPI breaches due to (i) A sharp rise in demand over several months, (ii) Limited reporting capacity due to having a single NHSCT cardiologist competent in MPI reporting.

Other Diagnostic Day cases and Outpatients are included in the IPDC / OP Waiting list figures and are subject to the 13 and 9 week targets.

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5.5 WAITING TIMES – Allied Health Professionals

INDICATOR – No patient should wait longer than 9 weeks from referral to commencement of AHP treatment. TABLE 7: Waiting List Position as at 06/09/2013

0-3 Weeks (0-

21 days)

>3 to 6 weeks

(22-42 days)

>6 to 9 weeks

(43 - 63 days)

> 9 to 13 weeks

(64 - 91 days)

> 13 weeks (>

91 days)Total waiters

Longest Wait in

Days

Dietetics 372 419 134 51 39 1015 130

Occupational Therapy 760 608 445 407 344 2564 149

Orthoptics 198 234 71 38 5 546 137

Physiotherapy 1359 1491 795 266 9 3920 105

Podiatry 514 471 113 0 0 1098 59

Speech and Language Therapy 198 180 89 65 23 555 166

Multi-Disciplinary Teams 0

TOTAL 3401 3403 1647 827 420 9698

Patients still waiting to be seen/treatedWaiting List as at Fri 6/09/13

(Source: Corporate Information Services; Priority 2 – AHP Waiting Times Fortnightly Return 2013-14)

Notes – As at 31/08/13 there were 1,218 patients waiting over 9 weeks. - Part of the data for Dietetics, Orthoptics and Physio is reported one week behind due to restricted reporting mechanisms, these restrictions are being addressed.

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5.6 CANCER TARGETS The Trust is required to monitor and deliver on targets for the timeliness of referral, diagnosis and treatment (where applicable) of suspect cancer patients.

INDICATOR – 98% of patients diagnosed with cancer (decision to treat) should begin their treatment within a maximum of 31 days.

TABLE 8: Patients with Confirmed Cancers with completed waits over 31 day target as at 09/09/13

Patients

DATE START FIRST

TREATMENTWithin Target NHSCT Breach Grand Total

% within

target% target

Sep-12 112 0 112 100% 98%

Oct-12 115 1 116 99% 98%

Nov-12 104 0 104 100% 98%

Dec-12 98 1 99 99% 98%

Jan-13 123 4 127 97% 98%

Feb-13 82 1 83 99% 98%

Mar-13 105 1 106 99% 98%

Apr-13 93 3 96 97% 98%

May-13 95 1 96 99% 98%

Jun-13 131 1 132 99% 98%

Jul-13 87 1 88 99% 98%

Aug-13 86 1 87 99% 98%

31 Day Target

(Source: Cancer Services; Completed Waits – 31 days)

From CaPPs & Cancer Waits Database Patients shared with another Trust count as 0.5 These figures are subject to change as patient notes are updated HSCNI official figures exclude the latest month.

INDICATOR – 95% of patients referred with a suspected cancer should begin their first definitive treatment within 62 days (of referral).

TABLE 9: Patients with Confirmed Cancers with completed waits over 62 day target as at 09/09/13

Patients

DATE STARTED FIRST

TREATMENT Within Target Breachers Total

% Within

Target % Target

Sep-12 44.5 10.5 55 81% 95%

Oct-12 38.5 9.5 48 80% 95%

Nov-12 37 5.5 42.5 87% 95%

Dec-12 37 5 42 88% 95%

Jan-13 51.5 12 63.5 81% 95%

Feb-13 33 11.5 44.5 74% 95%

Mar-13 47 12 59 80% 95%

Apr-13 30.5 12.5 43 71% 95%

May-13 37.5 7.5 45 83% 95%

Jun-13 56 14 70 80% 95%

Jul-13 40 10.5 50.5 79% 95%

Aug-13 40.5 11 51.5 79% 95%

62 Day Target

(Source: Cancer Services; Completed Waits – 62 days)

From CaPPs & Cancer Waits Database Patients shared with another Trust count as 0.5 These figures are subject to change as patient notes are updated The main reasons for Breach of the cancer target are due to Delay in TRUS biopsy, Endoscopic investigation, Hysteroscopy diagnostic test and complex cases.

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SUSPECTED BREAST CANCER INDICATOR – All Breast referrals, deemed urgent according to regionally agreed guidelines, for suspected breast cancer, should be seen within 14 days of receipt of GP referral. At present there are weekly reports prepared for Service Delivery Unit, DHSSPS. A summary of Performance (by month) for breast “urgent” referral waiting times is set out below.

TABLE 10: % OF “URGENTLY” REFERRED PATIENTS SEEN AT BREAST CLINIC WITHIN 2 WEEKS OF REFERRAL AT 12/09/13

Month

No of "Urgent"

Breast Clinic

Attendances seen

No of Patients Seen

within 2 Weeks of

Referral

Target 100% to be

seen within 2 weeks

% seen within 2

Weeks of

Referral

September 12 117 117 100% 100%October 12 190 190 100% 100%November 12 131 131 100% 100%December 12 145 145 100% 100%January 13 106 106 100% 100%February 13 115 115 100% 100%March 13 151 151 100% 100%

April 13 121 94 100% 78%

May13 179 175 100% 98%

Jun 13 137 73 100% 53%

Jul 13 225 114 100% 51%

Aug 13 185 185 100% 100% (Source: Corporate Information Services; Breast Cancer – SDR2BC Return)

Notes: Performance based on those referred to Breast Clinic and flagged as "BC" or "CAS" on PAS.

"Urgent" based on the Patient having a Priority Type = 2

57

Community Care and Associated Targets

58

SECTION 6 6.1 DELAYED DISCHARGES – MENTAL HEALTH & LEARNING DISABILITY

INDICATOR – From April 13, 99% of patients admitted for assessment and treatment are discharged within 7 days of the decision to discharge.

TABLE 1: MENTAL HEALTH – COMPLETED WAITS

Month End 0 - 7 days8 to 90

days

91 to 365

days>365 days Total

% Discharged

within 0-7 days

30/04/2013 68 2 2 0 72 94.4%

31/05/2013 50 1 0 0 51 98.0%

30/06/2013 50 4 3 0 57 87.7%

31/07/2013 59 2 0 0 61 96.7%

31/08/2013 60 1 1 0 62 96.8% (Source: Corporate Information Services; Priority 6 – Mental Health Services Monthly Return to HSCB 12/13 & 13/14)

TABLE 2: LEARNING DISABILITY – COMPLETED WAITS

Month End 0 - 7 days8 to 28

days

29 to 90

days

91 to 365

days>365 days Total

% Discharged

within 0-7 days

30/04/2013 7 0 0 1 0 8 88%

31/05/2013 4 0 0 0 0 4 100%

30/06/2013 1 0 0 0 0 1 100%

31/07/2013 2 0 0 0 1 3 67%

31/08/2013 5 0 0 0 0 5 100%

(Source: Corporate Information Services; Priority 6 – Learning Disability Monthly Return to HSCB 12/13 & 13/14)

Figures in above tables are based on Patients where a decision to discharge has been taken and who have been discharged (Completed Waits = Length of Time between Decision to Discharge date and Date of Discharge)

6.2 OLDER PEOPLE

INDICATOR – From April 13, people with continuing care needs should wait no longer than 5 weeks for assessment to be completed and have the main components of their care needs met within a further 8 weeks.

TABLE 3: CARE IN THE COMMUNITY – COMPLETED 5 WEEK TARGET (100%) The following table provides an indication of the NHSCT progress to meet the 5 week target for assessments.

30/04/2013 179 2 181 99%

31/05/2013 156 11 167 93%

30/06/2013 143 1 144 99%

31/07/2013 149 8 157 95%

31/08/2013 137 0 137 100%

April 13 - July

13 Total764 22 786 97%

Completed > 5

weeks

Assessments

CompletedMonth

% Waiting <5

weeks

Completed < 5

weeks

(Source: Corporate Information Services; Priority 3 / 4 - HSCB Monthly Return on Care Assessment / Management /

Direct Payments Performance Issues 2013 – 14)

Information is based on clients who have had an assessment completed within the month and how long it has taken this assessment to be completed.

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TABLE 4: CARE IN THE COMMUNITY – 8 WEEK TARGET (100%) The following table provides an indication of the NHSCT progress to have the main components of care met within the 8 week target.

30/04/2013 89 5 94 95%

31/05/2013 99 4 103 96%

30/06/2013 79 2 81 98%

31/07/2013 84 2 86 98%

31/08/2013 88 0 88 100%

April 13 - July

13 Total439 13 452 97%

Components Met >

8 weeks

Total Components

MetMonth

% Components

Met <8 weeks

Components Met

< 8 weeks

(Source: Corporate Information Services; Priority 3 / 4 - HSCB Monthly Return on Care Assessment / Management /

Direct Payments Performance Issues 2013-14)

Information is based on the completed wait. NB Figures for PFA target include Nursing, Residential and Domiciliary Care (Dom figures include Care Managed Full packages Critical and Substantial bandings only), Elderly and Dementia Programmes of Care only. Patients waiting >5 and >8 weeks require validation as some patients are becoming ‘Medically Unfit’ and this assessment time is not currently being removed from the total time waiting. A validation mechanism is to be put in place to avoid recording of invalid breachers.

FULLY INTEGRATED CARE AND SUPPORT IN THE COMMUNITY

6.3 CARE MANAGED PACKAGES INDICATOR – From April 2011, the Trust should achieve a performance level of 48% of care management assessments completed in relation to nursing home, residential or domiciliary care, recommend domiciliary care provision. TABLE 5: COMBINED CARE MANAGEMENT (Target – 48%)

The following table is the combined NHSCT position. Please note Domiciliary Care now includes Care managed and non care managed figures. For reference purposes, Supported Living, Respite and Direct payments are presented separately fro ‘Domiciliary Care Packages’. They are however included in the ‘Total DC’ as they are also methods of care and support which are provided outside of ‘residential/nursing home care.

MONTH ENDING 30/04/2013 31/05/2013 30/06/2013 31/07/2013 31/08/2013

961 947 957 957 957

1829 1834 1850 1860 1857

Domiciliary Care Supported Living: MH 107 109 109 106 107

Supported Living: LD 194 194 194 194 195

SubTotal: Supp Liv 301 303 303 300 302

Respite 65 58 48 65 50

Temporary Care 39 40 48 41 46

Direct Payments 516 520 523 531 533

Domiciliary Care (soscare) 4650 4639 4673 4671 4692

5571 5560 5595 5608 5623

8361 8341 8402 8425 8437

67% 67% 67% 67% 67%% Domiciliary - 48% Target

Residential Care

Nursing Home Care

Total Domiciliary Care including SL , Respite &

Direct Payments

Total Receiving Care Packages

(Source: Corporate Information Services; Priority 3 / 4 – Breakdown of Domiciliary Care (Packages) 2013 – 14)

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6.4 DIRECT PAYMENT CASES INDICATOR – Increase the number of direct payment cases from 2011/12 outturn of 527.

TABLE 6: DIRECT PAYMENT CASES – August 2013

Directorate POC

Internal

POC target Mar-13

13/14

Target Aug-13

MHLD Dementia 14% 129 74 132

EPCOP Eldercare 32% 125 169 133

MHLD Learning Disability 4% 64 21 63

MHLD Mental Health 1% 5 5 7

MHLD Physical Disability 41% 143 216 148

CW Children's 8% 52 42 50

Total 100% 518 527 533 (Source: Corporate Information Services; Priority 3 / 4 - HSCB Monthly Return on Care Assessment / Management /

Direct Payments Performance Issues 2013 – 14)

Note: (i) The above table refers to all Direct Payment Cases which are open as at the end of July 2013. While there

have been additions, some clients have died during the year and therefore these cases have ceased. (ii) A number of Direct Payment Cases have changed to a “Caring Hands” contract and are not included in the above figures.

(iii) The Target split of 527 is under review within the Trust. This split is for internal purposes and is only a guide to assist achieving Trust target.

CHILDRENS TARGET Unallocated Cases

Indicator - All family support or disability referrals must be allocated to a named social worker within 20 working days.

TABLE 7: Unallocated Cases by Category > 20 Working Days

Category Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

Gateway 18 29 33 41 100 39 43 0 0 0 8 3

Family Support / Family

Intervention Team 68 65 80 85 121 86 86 87 92 111 115 88

Disability 7 1 0 1 1 1 0 4 6 6 8 10

Total 93 95 113 127 222 126 129 91 98 117 131 101

100 % of Child Protection referrals to be allocated to a social worker within 24 hours of receipt of referral. April – July ‘13 = 100%

Planned reduction in unallocated cases has been impacted on by increased demand and fluctuating staff levels. Interviews have been completed to refresh the Social Worker waiting list and ways to escalate recruitment to vacant posts has been agreed with Human Resources. Analysis of caseload weighting measures indicates potential to temporarily redirect staff to reduce further the level of unallocated cases.

Notes - Figures include assessed cases not yet allocated to a named social worker but allocated to other staff

(e.g. family support workers) and in receipt of services. - Includes Initial Assessments completed within Gateway but not yet allocated to a named social worker

for Pathway Assessment etc.

APPENDIX 1: TABLE LIST

Section Table No Table Name Governance 3.0 1 Clinical Dashboard PfA Targets

2 Patient Safety Clinical Dashboard

Governance 3.1 HCAI Performance Report

1 HCAI Performance Dashboard

2 Infection Prevention & Control Validation Audits (carried out by IPCNs)

Governance 3.2 1 Complaints

Commissioner Targets and Associated Activity

1a , 1b, 1c SBA Activity Comparison

2 NHSCT SBA Volume Breakdown

3a,3b, 3c & 3d AHP New SBA, Additional Investment, Review Contacts and

Community Contacts

4 New & Unplanned Review Patients who depart A&E for the month

5 Antrim Hospital New & Unplanned Review Patients by Month

6 A&E 12 Hour Breachers

7 Admissions into Hospital via A&E

8 Clinical Coding Timeliness

Access / Waiting Time Targets

1a, 1b IP / DC & Endoscopy Core Patients by weeks waiting at month end

1c, 1d IP / DC & Endoscopy Independent Sector Patients by weeks waiting at month end

2 Waiting Times for IP/DC Backstop Specialties

3a OP Core by weeks waiting at month end

3b Visiting Consultant OP by weeks waiting at month end

4 Waiting Times for Outpatient Backstop Specialties

5 Mental Health Outpatient Waiters

6 Diagnostic Waiting List

7 Allied Health Professional Waiting List

8 Patients with confirmed Cancers with completed waits > 31 Day Target

9 Patients with confirmed Cancers with completed waits > 62 Day Target

10 % of "Urgently" referred patients seen at Breast Clinic within 2 weeks

Community Care & Associated Targets

1 Mental Health - Completed Waits

2 Learning Disability - Completed Waits

3 Care in the Community - Completed 8 week Target

4 Care in the Community - Completed 12 week Target

5 Combined Care Management

6 Direct Payment Cases

7 Unallocated Cases

APPENDIX 2: GRAPH LIST

Section Graph

No Graph Name

Governance 3.2 Complaints

1 Complaints Comparative Graph 2012/13 - 2013/14

Commissioner Targets and Associated Activity

1 Monthly % Departing A&E within 4 hours – All Hospital Sites

2 Antrim Hospital A&E New & Unplanned review attendances by source of referral

3 Total Hospital Cancellations for Non Clinical Reasons

4 % Admissions with valid PreOP Assessment Attendances

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