CORPORATE PERFORMANCE DASHBOARD. August 2010

Transcription

1 Quality care for you, with you CORPORATE PERFORMANCE DASHBOARD August 21 Approved by the Board of Directors on 3 th September 21 1

2 CONTENT: Page Introduction 3 Targets: 1 st OP Appointment 4 Diagnostic Test 4 IP/DC Treatment 5 A&E 5 AHP 6 Autism 6 Primary MH Assessment & Treatment 7 Fractures 7 Renal 8 HCAI 8 Unallocated Child Care Cases 9 Outpatient Review Backlog 9 Approved by the Board of Directors on 3 th September 21 2

3 Introduction The Corporate Performance Dashboard is a new report which will supplement the Corporate Performance Management Report. It will included trend analysis and narrative update on key performance indicators of particular interest to the SMT, Board and public. Whilst primarily an exception reporting tool for targets or performance at risk it can also be used by SMT as a source document to include areas of particular interest or sensitivity which require discussion and monitoring Areas for inclusion will fall into the following areas: Area identified in red risk status on the Corporate Performance Report Areas identified by SMT for close monitoring Areas identified as sensitive and of particular interest to the SMT The content of the dashboard will change frequently to reflect the areas of essential review. Indicators and reporting will be removed as risk alleviates and others added on as required and agreed via SMT. It is intended to include key issues regarding Finance and HR into future reports. Approved by the Board of Directors on 3 th September 21 3

4 Key Areas Target: 1 st OP Appointment - By March 211 no patient should wait longer than nine weeks for a first outpatient appointment No. of OPs N o s. O f O P s W a i t i n g > 9 w e e k s A p r il M a y J u n e J u ly A u g M o n t h At the end of August 556 patients waited longer than 9 weeks. Where capacity gaps have been defined bids have been prepared and submitted to the HSCB with a view to securing funding for the provision of additional in-house sessions. Areas where specialty gaps have been defined include: Respiratory/Thoracic, Gastroenterology, Gynaecology, Rheumatology, Symptomatic Breast, Urology & Orthopaedics. In addition capacity gaps have also been defined for Ophthalmology and Oral Surgery for which a regional solution is required as these are visiting services. For specialty areas breaching 9 weeks, for whom no defined capacity gap has been agreed, Service Delivery Plans are being prepared which detail necessary steps to bring performance on to profile to ensure 9 weeks delivery by March 211 these include Cardiology, Dermatology and Paediatrics. Target: Diagnostic Test - By March 211 no patient should wait longer than nine weeks for a diagnostic test Nos. of patients waiting a diagnostic test >9 weeks Aug 453 July 343 June 23 May 81 April No. of Pts At the end of August 453 patients waited longer than 9 weeks. A capacity gap has been defined for Neurophysiology for which a regional solution is required as this is a visiting service. MRI and Dexa proposals have been prepared and submitted to the HSCB with a view to securing funding for the provision of additional sessions. All other areas, where a gap has not been identified, must ensure performance remains on profile to deliver services within 9 weeks. Service Delivery Plans must be prepared for any area where this is not the case. Approved by the Board of Directors on 3 th September 21 4

5 Target: IP/DC Treatment - By March 211 the majority of IP/DC should be treated within 13 weeks and no patient waits longer than 36 weeks for treatment No. of Pts. N o. o f p a t i e n t s w a i t i n g f o r I P / D C T r e a t m e n t > 1 3 w e e k s Where capacity gaps have been defined bids have been prepared, to secure funding for the provision of additional in-house sessions, and submitted to the HSCB to bring the access waiting times closer to a 13 week position. Areas where specialty gaps have been defined include: Cardiology, Endoscopy, General Surgery, Orthopaedics, Pain Management, Rheumatology and Urology. For specialty areas breaching 13 weeks, for which no defined capacity gap has been agreed, Service Delivery Plans are being prepared which detail necessary steps to ensure the specialty area remains on target to deliver services within 13 weeks. A p r il M a y J u n e J u ly A u g M o n t h Target: A&E - From April 21 95% of patients attending any A&E Dept should be either treated and discharged home, or admitted within 4 hours of their arrival in the department. No patient should wait longer than 12 hours. S H S C T E m e rg e n c y C a re 4 H o u r T a rg e t 1. % % within 4 Hours 9 5. % 9. % 8 5. % C A H AE 8. % D H H A E 7 5. % S H S C T R E G IO N A L 7. % T AR G E T Jan-1 Feb-1 Mar-1 Apr-1 May-1 Jun-1 Jul-1 Aug-1 Jan- 1 Feb- 1 Mar - 1 A pr - 1 May - 1 Jun- 1 Jul- 1 A ug- 1 CA H A E % % % % 8 6. % 8 6. % % % DHH A E % 9 2. % % % % % % % S H S CT 9.7 % 9.8 % % 9.1 % % % % % REG IO N A L 8.3 % % % 8 9. % 7 7. % % % 8 5. % TA RG ET 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % M o n t h N o te : M in o r In ju r y Un its a t S o u th T y r o n e a n d A r m a g h s ite s a r e in c lu d e d in S H S CT f ig u r e b u t n o t r e p o r te d in d iv id u a lly d u e to s u s ta in m e n t o f 1%. Regional Figure is s ourc ed from HSC Information Management Portal and Inc ludes all Emergenc y Care Departments. CAH AE - Key issues impacting on performance include manpower issues associated with 3 middle grade staff vacancies and the loss of the expeditor role. Steps being taken by the directorate to turn around this performance include the continuation of the 4hour team meeting as well as the introduction of measures to streamline the process for admissions moving to the ward. 1 breach of 12 hr target in August due to ambulance delay issue discussed at Patient Flow Meeting. Approved by the Board of Directors on 3 th September 21 5

6 Target: AHP From April 21, no patient waits longer than 9 weeks from referral to commencement of AHP treatment N o. o f p atien ts w aitin g fo r A H P tre atm en t >9 w ee ks A ug 85 July 7 June 71 M ay 93 A pril No. o f P ts. Staff absences and summer leave have in part contributed to this performance. Processes are currently being put in place to guarantee AHP services are back on profile to deliver within the 9 week target by March 211. No regional capacity gap has been identified for this area. SDP plans are in place for return to profile for OT and SLT children s services. Target: Autism From April 21 all children wait no longer than 13 weeks for assessment following referral and a further 13 weeks for commencement of specialised intervention. No. of children waiting No. of Children waiting for Assessment and Commencement of Treatment for Autism >13 weeks May June July Aug >13 wks - Assessment >13 wks - Comm. Treatment 5 Capacity gap identified and included in Trust bid to HSBC. Approved by the Board of Directors on 3 th September 21 6

7 Target: Primary Mental Health Assessment & Treatment from April 21 no patient waits longer than 9 weeks from referral to assessment and commencement of treatment (exception psychological therapies for which no patient should wait longer than 13 weeks) N o. o f p a tie n ts w a itin g fo r P rim a ry M H A s s e s s m e n t & T re a tm e n t A u g Ju ly Ju n e M a y Service Delivery Plans prepared to profile return to 9/52 position for PMHC. Analysis of the step model is underway with retard to PMHC to assess the capacity that can be sustained in the absence of year 3 funding. A p ril N o s W a i tin g > 9 > 1 3 Fractures: From April 21 95%, where clinically appropriate should wait no longer than 48 hours for IP fracture treatment. S H S C T - F r a c t u r e A c c e s s ( % 4 8 H o u r T a r g e t ) % within 48 Hours 1. % 8. % 6. % 4. % 2. %. % S H S C T 9 5 % T A R G E T ( J A N U A R Y 1 A N D M A R C H 1 1 ) 7 5 % H O L D IN G T A R G E T 6th consultant model implemented with 2 additional trauma lists in place. This should see improvements in performance generally. J a n - 1 F e b - 1 M a r - 1 A p r - 1 M a y - 1 J u n - 1 J u l - 1 A u g - 1 S H S C T % 8 5. % % % 8. 6 % % 8. 5 % 9. 6 % 9 5 % T A R G E T 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % 9 5. % ( J A N U A R Y 1 A N D M A R C H 1 1 ) 7 5 % H O L D IN G 7 5 % 7 5 % 7 5 % 7 5 % 7 5 % 7 5 % 7 5 % 7 5 % T A R G E T N I R E G IO N A L 6 5 % 7 2 % 7 5 % 7 6 % 8 1 % 8 1 % 8 1 % 8 9 % P O S IT IO N Approved by the Board of Directors on 3 th September 21 7

8 Target: Renal Services From April 21 at least 6% of patients should receive dialysis via a fistula. 65.% 6.% 55.% 5.% 45.% 4.% 35.% 4.9% 38.1%38.1% 38.8%38.9% 39.8% 37.% SOUTHERN HEALTH AND SOCIAL CARE TRUST % Patients Receiving Dialysis via Fistula 35.1% 35.7%36.5% 34.9% 39.8% 36.8% 38.5% 35.8%35.7% 36.2% 34.3% 34.% 33.3% 32.7% 33.7% 38.1% 36.7% % Target % March 29 Target % March % 4.6% 39.8% 39.% 4.% 42.7% The number of in-house fistulas has increased as this surgery is now undertaken locally. There should be a resulting increase in performance as fistulas mature and patients start to receive dialysis through these. Work is ongoing to increase patient uptake via education and support. 3.% Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan-1 Feb-1 Mar-1 Apr-1 May-1 Jun-1 Jul-1 Aug-1 Health Care Associated Infections: In year to March 211 Trust should secure further reduction of 2% in MRSA and C Difficile C Diff infections compared to position in 29/1 MRSA C Diff MRSA Approved by the Board of Directors on 3 th September 21 8

9 Target: Unallocated Child Care Cases: Total number of Unallocated cases by Service type as at end August' This relates to cases not yet allocated to a named social worker. However the child has been seen and the case is subject to ongoing management review Action taken to mitigate risks and strengthen our system: Apr-1 May-1 Jun-1 Jul-1 Aug-1 Number of Family Support Unallocated cases Number of CW D unallocated cases Number of Child Protection unallocated cases Data Number of Family Support Unallocated cases Number of CWD unallocated cases Number of Child Protection unallocated cases There are no unallocated child protection cases. All such cases are allocated and responded to. Heads of Service, the APSW for Gateway and Team Managers regularly monitor, review and prioritise unallocated cases for allocation. Across Gateway and FIT Services there are still currently a number of staff vacancies. Target: OP Review Backlog: 25 2 No. of Patients who require OP Review Appointment - ly Position April Sept The Trust is currently focusing on the longest waiters and the most urgent patients are being prioritised. Additional resources are being sought from HSCB to assist with clearing the 28 and 29 review backlog. No. of Pts Work is also ongoing with medical teams to ensure the most appropriate clinical practice in relation to reviewing patients is applied. A validation exercise on all review waiters has commenced. April '1 May '1 June '1 July '1 August '1 Incs. Acute Directorate plus Paeds Approved by the Board of Directors on 3 th September 21 9