NLG(15)329. DATE 28 July Trust Board of Directors Public REPORT FOR. Kathryn Helley, Deputy Director of Performance Assurance & Trust Secretary

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1 NLG(15)329 DATE 28 July 2015 REPORT FOR Trust Board of Directors Public REPORT FROM Kathryn Helley, Deputy Director of Performance Assurance & Trust Secretary CONTACT OFFICER Lisa Jamieson, Head of Performance SUBJECT Performance Compliance Report June 2015 BACKGROUND DOCUMENT (IF ANY) Monitor Risk Assessment Framework REPORT PREVIOUSLY CONSIDERED BY & DATE(S) Trust Governance and Assurance Committee 16 July 2015 EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) This report outlines the expected governance position against the standards set out in the Risk Assessment Framework for the first quarter HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? NO IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? NO WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? YES WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED Ensures compliances with the regulatory framework ACTION REQUIRED BY THE BOARD The Board is asked to review key target performance and consider any further action required

2 Monitor Risk Assessment Framework Key Performance Measures June 2015 This Report focuses solely on the Trust s performance against key performance measures contained within Monitor s 2013 Risk Assessment Framework. Any performance risks relating to key performance indicators contained within the Trust s contract which could potentially result in the imposition of fines and penalties is highlighted in both the integrated performance report and the monthly trading report. Monitor, through its Risk Assessment Framework, continues to assign a governance risk rating to reflect the quality of governance at the Trust. Monitor use the governance rating below in order to gauge potential escalatory measures: The sum of each metric s weighting to calculate a service performance score Where the Trust breaches a target systematically, this will represent a governance concern Indicator Red Rating may apply if the Trust:- Trust Rating C.Difficile Breaches the cumulative year-to-date trajectory for 3 successive quarters Breaches its full year objective Referral to Treatment Waiting Reports important or significant outbreak Breaches any 3 of the measures for a third successive quarter A&E Fails to meet the target twice in any two quarters over a 12month period and fails the indicator in a quarter during the subsequent 9 month period or the full year Cancer Waiting Times Community Services Data Completeness Any Indicator Weighted 1.0 Breaches the 31-day cancer waiting time for third successive quarter Breaches the 62-day cancer waiting time for third successive quarter Fails to maintain the threshold for data completeness for any of the following for a third successive quarter - RTT information - Service referral information - Treatment activity information Breaches the indicator for three successive quarters The governance rating assigned to an NHS Foundation Trust reflects Monitor s views of its governance: Green rating will be assigned by Monitor if no governance concern is evident; Where Monitor identifies potential material causes for concern with the Trust s governance in one or more of the categories (requiring further information or formal investigation), the Trust s green rating will be replaced with a description of the issue and the steps (formal or informal) to be taken to address it; or Red rating will be assigned if Monitor take regulatory action Page 1

3 1. Summary Performance Against National Measures for June 2015 The final 18 week RTT position demonstrates that the Trust has achieved all three indicators for June The A&E 4 hour wait target was achieved for June The Trust had three episodes of hospital acquired Clostridium Difficile during June The combined number of 8 cases during quarter one has taken the total over the quarter s threshold allowance of 5. Current provisional cancer data indicates the Trust will achieve six of the seven cancer indicators for June2015, however, the forecasted position suggests that quarter one will be compliant. 2. Individual Performance Risk Areas 2.1 Clostridium Difficile During June, the Trust reported a total of three Clostridium Difficile cases, two at DPoWH and one at SGH. This has taken quarter one total over the threshold allowance of 5 as we now have a combined total of 8 cases. The table below outlines episodes by site for : Site Apr-15 May-15 Jun-15 Quarter 1 DPOW SGH GDH Total Cancer Waiting Times (provisional position) The provisional cancer data suggests the Trust will achieve six of the seven cancer targets for June 2015, breaching the 62 day wait Urgent GP referral to treatment. The forecasted position for quarter one indicates the Trust will achieve all seven measures. The final cancer waiting times position for June 2015 will be submitted to the national Exeter database early August Page 2

4 18 Week Referral to Treatment Waiting Times The Trust achieved all three 18 week referral to treatment waiting time indicators in June 2015 and for quarter one.

4 2.3 A&E 4 Hour Waiting Times The Trust has met the A&E 4 Hour Waiting Times for June attaining 96.8% against the threshold of 95%. This demonstrates that the local improvement plans are having a positive impact on the Trust s performance. Attendance levels are comparable to last month and the same period last year Week Referral to Treatment Waiting Times The Trust achieved all three 18 week referral to treatment waiting time indicators in June 2015 and for quarter one. However, as the 18 week RTT admitted measure breached in April at 89.5%, this indicator will fail quarter one s target as set out in the Monitor Risk Assessment Framework. The Trust has now received confirmation from NHS England that the admitted and non-admitted targets have been retired although the Trust is still monitoring these indicators to abide to its contractual commitments until October We are awaiting confirmation from Monitor regarding whether we must continue to achieve the admitted and non-admitted indicators between now and October. Page 3

5 Note: In accordance with Monitor s Risk Assessment Framework, 18 week wait performance is measured on an aggregate (rather than specialty) basis and NHS Foundation Trusts are required to meet the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure. 2.5 Other For information, the Trust s position in relation to Delayed Transfers of care is provided on Appendix B, however this does not form part of the Monitor Risk Assessment Framework. 3. Recommendations for Actions The following performance concerns will need to be progressed during 2015/16 to ensure performance is achieved / maintained: I. Continued focus on ensuring achievement of 18 weeks at specialty level and across all 3 indicators, especially concentrating on improving the position of both North East Lincolnshire and Lincolnshire East CCGs. II. Continued focus on A&E performance to ensure the Trust maintains achievement of this target over the coming months and builds in sufficient capacity to ensure achievement over the winter months. A number of actions have already been taken and plans are in place including work with other local providers. Wendy Booth Director of Performance Assurance & Trust Secretary June 2015 Page 4

6 PERFORMANCE METRIC 1. Infection Control * APPENDIX A (PROVISIONAL POSITION AS AT ) 2014/ / /15 QTR 2 QTR 1 Qrt 1 QTR 2 QTR 3 QTR 4 Threshold Apr-15 May-14 Jun-14 Actual To Date WEIGHTING Total Hospital Acquired C.Difficile Cases (YTD) G G G R 2. Referral to Treatment Waiting Times*** Admitted - Maximum waiting time of 18 weeks R R G 90% 89.51% 92.90% 91.13% 91.12% R Non-admitted - Maximum waiting time of 18 weeks G G G 95% 95.66% 96.71% 96.30% 96.21% G Incomplete - Maximum waiting time of 18 weeks G G G 92% 96.75% 96.59% 96.17% 96.50% G 3. Cancer *** 31 day wait diagnosis to treatment G G G 96% 98.58% 100% 99.17% 99.23% G i) 31 day wait for subsequent treatments - Surgery G G G 94% 100% 100% 100% 100% G ii) 31 day wait for subsequent treatments - Anti cancer drugs G G G 98% 100% 100% 100% 100% G i) 62 day wait GP referral to treatment G G G 85% 86.54% 84.83% 83.44% 85.24% G ii) 62 day wait Consultant screening service referrals G G G 90% 87.50% 100% 100% 94.74% G i) 2 week wait referral to consultation G G G 93% 96.60% 97.17% 98.76% 97.56% G ii) 2 week wait breast symptom referrals G G G 93% 98.67% 98.82% 96.80% 97.89% G 4. A&E A&E 4 Hour Wait Compliance G R R 95% 93.33% 94.23% 96.83% 94.81% R 5. Data Completeness Community Services ** MONITOR COMPLIANCE FRAMEWORK SUMMARY Performance Against Key Thresholds For The Period 1st April 2015 To 30th June i) Referral to treatment information G G G 50% 100% 98% 98% 99% G 5ii) Referral Information G G G 50% 100% 98% 98% 99% G 5iii) Treatment Activity Information G G G 50% 79% 75% 80% 78% G 6. Access ** Access to healthcare for people with learning disability G G G Y/N Y Y Y Y G * Cumulative figures Total Monitor Compliance Score 3.0 ** Forecast Position Monitor Compliance Rating *** Provisional Data Monitor Over ride Rating Red Page 5

APPENDIX B All Sites Total Number of Bed Days Attributable to Delayed Transfers of Care A delayed transfer of care from acute or non-acute (including community and mental health) care occurs when a

7 APPENDIX B All Sites Total Number of Bed Days Attributable to Delayed Transfers of Care A delayed transfer of care from acute or non-acute (including community and mental health) care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready for transfer when: a. A clinical decision has been made that patient is ready for transfer AND b. A multi-disciplinary team decision has been made that patient is ready for transfer AND c. The patient is safe to discharge/transfer. d. Site Apr-14 May-14 Jun-14 Site Apr-14 May-14 Jun-14 DPoW GDH % 3.1% 3.1% 6.7% 4.3% 3.9% SGH Trust % 1.5% 1.8% 3.0% 2.3% 2.5% Page 6

Operational Performance. SaTH Overall Performance

Operational Performance. SaTH Overall Performance Balanced Scorecard Summary Operational Performance Previous This Year to Date Previous This Year to Date Number Number Number Number Number Green 17 17 15 Green 7 7 0 Amber 3 2 2 Amber 1 0 0 Red 2 4 5