AGENDA ITEM 4.1 15 Title of the Health Board Report...

Integrated Performance Dashboard of 27 University Health Board Meeting 15 July 2015

AGENDA ITEM 4.1

15th July 2015

Title of the Health Board Report

INTEGRATED PERFORMANCE DASHBOARD

Executive Lead: Director of Planning and Performance

Author: Assistant Director of Performance and Information

Contact Details for further information: Deb Evans, Assistant Director of Performance and Information 01443 744800 or email

[email protected]

Purpose of the Health Board Report

The purpose of this report is to provide the Health Board with a summary

of current performance across a range of indicators and key issues, in particular where there are current organisational challenges and

achievement and/or the organisation is under formal escalation with the

Welsh Government. This particular report also presents a look back on performance achievement during 2014/2015.

Governance

Link to Health Board Strategic

Objective(s)

The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated

Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of

Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are;

To improve quality, safety and patient experience.

To protect and improve population health. To ensure that the services provided are accessible

and sustainable into the future.

To provide strong governance and assurance. To ensure good value based care and treatment

for our patients in line with the resources made available to the Health Board.

This report focuses on all of the above objectives.

Supporting evidence

The Integrated Performance Dashboard is included as supporting evidence.

mailto:[email protected]


Engagement – Who has been involved in this work?

The data and information contained within the Dashboard originates from

a variety of sources which have a number of engagement processes associated with them. The Integrated Performance Dashboard is also

discussed on a bi-monthly at Health Board and monthly at the Executive Board and Finance and Performance Committee. The Annual Performance

Report for 2014/2015 has been received and discussed at Executive Board and the Finance and Performance Sub-Committee.

Health Board / Committee Resolution (insert √) To;

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation To NOTE and DISCUSS the latest

Integrated Performance Dashboard, the Annual Performance Report 2014/2015 and

performance actions outlined to support the achievement of targets.

Summarise the Impact of the Health Board Report

Equality and

diversity

There are no directly related Equality and

Diversity implications as a result of this report.

Legal implications A number of indicators monitor progress in

relation to legislation, such as the Mental Health Measure.

Population Health A number of indicators monitor progress in

relation to Population Health, such as vaccination and immunisation uptake rates.

Quality, Safety & Patient Experience

A number of indicators monitor progress in relation to Quality, Safety and Patient

Experience, such as Healthcare Acquired Infection Rates and Access rates.

Resources There are no directly related resource

implications as a result of this report.

Risks and Assurance Within the Integrated Performance Dashboard,

actions are listed where performance is not compliant with national or local targets.

Health & Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes.

Issues within this report relate to Theme 2; Safe Care; Theme 3; Effective Care and Theme 5;

Timely Care.

Workforce A number of indicators monitor progress in relation to workforce, such as sickness and

Personal Development Review rates.


INTEGRATED PERFORMANCE DASHBOARD

1. SITUATION / PURPOSE OF REPORT

This report is comprised this month of two main parts:

Part One - Integrated Performance Dashboard: the purpose of part one of this

report is to provide the Health Board with the latest summary of key quality and performance indicators, including areas where the organisation has made

significant improvements or has particular challenges, together with areas where the Health Board is under formal escalation measures from the Welsh

Government and/or where performance is under close scrutiny locally within

the organisation.

Part Two - Annual Performance Report 2014/2015: the purpose of part two of this report is to provide the Board with a review of performance during the

financial year 2014/15 on key quality and performance indicators. This includes areas where the organisation has made significant improvements or has had

particular challenges, together with areas where the Health Board has been under formal escalation measures from the Welsh Government and/or where

performance has been under close scrutiny locally within the organisation.

2. PART ONE – INTEGRATED PERFORMANCE DASHBOARD

This report provides the Health Board with an update on latest progress across a number of key quality and performance targets. The report also sets out any

issues affecting performance and associated actions underway to secure

improvement.

NEW INDICATORS

New Indicators for the July report are:

Fractured Neck of Femur (#NOF) – although information on #NOF has been included for some months, it is now sourced from the National Hip Fracture

Database (NHFD) and reflects the targets set by the NHFD, which are: o Patients admitted to an orthopaedic ward within 4 hours.

o Patients are transferred to theatres within 36 hours of presentation. Emergency admission and re-admission rates for eight chronic conditions.

Performance on follow-up outpatient appointments. Primary care indicators.

KEY ISSUES:

Unscheduled Care (escalation level 2) – Executive Lead, Chief Operating Officer and Director of Primary Care & Mental Health

Performance against the 4 hour wait in A&E for May improved from 86.7% to

88.2%. The number of patients waiting longer than 12 hours for completed


treatment improved significantly from 241 in April to 140 in May with a performance attainment of 98.71%. Of the 140 patients who waited 12

hours or more the split across sites was fairly even with 72 patients recorded at the Royal Glamorgan Hospital (RGH) and 68 patients at Princes Charles

Hospital (PCH). The operational team is carrying out focussed work to

identify the recent issues with the 4 and 12 hour performance and implement remedial action.

The Health Board maintains its zero tolerance approach to patient waits in

excess of 12 hours and focus in this area is being led by senior nurses and bed management teams. Analysis of all patient 12 hour waits will continue,

with each reported as a clinical incident and remedial actions implemented with immediate effect.

In terms of emergency ambulance services, May 2015 data shows that

against the 15 minute handover target, performance improved from 85.8% in April to 87.8%. The number of ambulances delayed over one hour

dropped to just one in May 2015 from three in April. Performance however is sustained at 99.9%.

Category A response time performance for May 2015 has improved from

62.5% in April to 63.5%. The further improvement is as a consequence of

the pilot with WAST being sustained. This has seen Cwm Taf ambulance resources ring-fenced to Cwm Taf boundaries where possible.

The graphs below are produced by WAST and show by way of example, for

the period 1st to 7th June 2015, the Category A 8 minute percentage response times, by Health Board and Operational Area. Performance for

Rhondda Cynon Taff during this period was 58%, whilst performance in the Merthyr Tydfil area was 81%.


From the same dataset, the 15 minute handover performance shows considerable variation across Wales during the same period. At a hospital

level, performance ranged from 39% (Royal Gwent and Princess of Wales) to 87% at Withybush. Cwm Taf’s performance was 82% at Prince Charles and

86% at Royal Glamorgan. At a Health Board level, Cwm Taf achieved an

overall ambulance handover rate of 84%. Other Health Board performance was as follows:

Health Board 15 minute (%) > 1 hour (No)

Cwm Taf 84% 3

Hywel Dda 73% 42

Cardiff & Vale 68% 17

BCU 53% 52

ABHB 49% 31

ABMU 41% 153

The continued work to improve patient flow within the organisation, complimented by the above joint working initiatives, is anticipated to

maintain and further improve our ambulance handover rates within the next three months so that we can aim to achieve the 95% target.

Referral to Treatment Times (escalation level 1) – Executive Lead,

Chief Operating Officer

Unfortunately performance against the 36 week and 52 week referral to treatment (RTT) targets for May 2015 shows a significant dip. The number

of patients waiting over 52 weeks for treatment is 297, all of which are

within Ophthalmology. The number of patients waiting over 36 weeks has increased from 1547 in April to 1927 in May, with the table below providing

a detailed breakdown by specialty. This number now includes more than 1,000 Ophthalmology patients waiting.

The main issue with delivery remains within Ophthalmology where there are

currently 432 patients at stage 1 (first outpatients) and 600 at stage 4 (surgical treatment), giving a total of 1032.

The table below outlines the 36 week trend over the last 12 months:

Specialty June

14 July 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Orthopaedics 175 170 204 134 109 74 112 184 157 144 217 309

General Surgery 125 112 174 165 173 133 167 190 174 133 173 195

Urology 12 13 27 4 9 4 12 18 29 0 13 17

ENT 89 83 69 59 44 25 65 105 95 25 65 103

Ophthalmology 313 533 802 940 1113 1074 1165 1324 1162 751 912 1032

Oral Surgery 135 127 146 145 143 128 137 133 97 84 95 87

Gynaecology 26 111 106 60 16 0 20 71 52 0 35 114

Cardiology 8 15 16 16 16 13 15 8 48 9 12 25

Rest. Dentistry 0 0 1 1 0 0 3 3 14 7 20 27

Gastroenterology 5 9 14 16 5 13 18 18 20 2 0 1


Specialty June 14

July 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

Diagnostics 5 5 3 0 4 4 1 5 11

0 0 1

Respiratory 0 0 2 1 0 9 8 5 4 0 0 1

Anaesthetics 0 0 0 0 0 1 0 0 0 0 3 8

Dermatology 0 0 0 0 0 1 1 2 4 0 1 5

General Medicine 0 0 0 0 0 7 18 0 1 0 0 0

Rheumatology 1 0 1 0 0 0

Haematology 0 0 0 0 0 0 0 0 0 0 1 2

Total 893 1179 1564 1541 1632 1487 1742 2066 1869 1155 1547 1927

It should be noted that numbers of procedures cancelled during May 2015

due to the lack of availability of beds remained high at 93, with 97 in April.

Cancer 31 and 62 Day Target (escalation level 2) – Executive Lead, Medical Director

Unfortunately the 31 day cancer access target was not achieved for April 2015. The Health Board reported two patient breaches, with an overall

performance of 97.9%. Both patients were treated at the tertiary centres. There were no delays at Cwm Taf for these patients as the ‘clock starts’ in

terms of waiting times at the tertiary centre. These will be classified as “shared breaches” between the Health Board and the tertiary unit, with the

performance allocated to Cwm Taf.

The 62 day target was also unfortunately not achieved for April 2015. The Health Board reported seven breaches and a performance of 87.5%. All

seven patients were treated at the tertiary centre, three of which were referred by the Health Board by day 31 of the pathway. Three of the patient

breaches were in Lung, two in Urology, one in Head and Neck and one in Gynaecology. Of the patients not referred by day 31 of the pathway, all

experienced delays at the ‘front end’ of the pathway, waiting for their first

appointment in Cwm Taf.

The table below shows the breaches by tumour site and the overall monthly performance over the last 12 months within this area

Urology Lung Lower

GI Head

& Neck Gynae Haem Upper

GI Breast No

Breaches Performance

May 1 1 0 0 1 0 1 0 4 90.9%

June 3 2 1 0 2 0 0 0 8 85.7%

July 2 0 1 0 2 0 0 0 5 92.4%

August 2 0 1 0 4 0 0 0 7 86.8%

September 4 1 1 1 2 0 0 0 9 84.2%

October 0 1 0 0 2 0 0 0 3 92.9%

November 0 0 0 0 1 0 0 0 1 97.7%

December 1 2 1 0 0 0 0 0 4 94.1%

January 0 0 2 0 1 1 0 0 4 91.5%

February 3 2 3 1 0 0 1 0 10 81.5%

March 0 0 0 2 0 0 0 0 0 96.3%

April 2 3 0 1 1 0 0 0 7 89.3%

Total 18 12 10 5 16 1 2 0 62


Cancer Single Cancer Pathway Pilot– Executive Lead, Medical Director

Over the last 12 months, the Welsh Government has been considering the development and implementation of a single cancer pathway. Cwm Taf has

been invited to pilot the single cancer pathway for a three month period due

to the internal development of a cancer tracking system. It is anticipated that the tracking system will then be adopted by NWIS and rolled out across

NHS Wales, where other Health Boards will ‘shadow run’ the pathway for a further six month period. A meeting to finalise plans and funding support

will take place between Cwm Taf and Welsh Government colleagues during June.

Stroke Bundles (escalation level 1) - Executive Lead, Director of

Planning and Performance

During May 2015, 31 patients have been recorded within the stroke database and performance has improved from that achieved in April for all

four care bundles, with bundle one being compliant with the 95% target. The following outcomes were recorded:

Bundle 31 Pts

First Hours (1) 96.1% (30/31 pts)

First Days (2) 77.4% (24/31 pts)

First 3 Days (3) 87.1% (27/31 pts)

First 7 Days (4) 87.1% (27/31 pts)

The main issue for May was again with bundle 2, in particular, direct access

to the Stroke Unit and swallow screening assessments being carried out. 100% of patients had a CT scan in time and were prescribed aspirin within

this bundle. For bundles 3 and 4 - four out of five elements were compliant

with the 95% target.

For the reporting of the shadow bundles, May’s performance has not yet been reported but April is included in the table below:

May

14 Jun 14

Jul 14

Aug 14

Sep 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

< 4 hrs 24.3% 17.4% 30.6% 21.4% 33.3% 34.2% 28.3% 19.4% 35% 26.2% 40% 17.9%

< 12 hrs 91.9% 87% 97.2% 95.2% 84.8% 97.4% 95.7% 86% 92.5% 95.2% 100% 89.7%

< 24 hrs 43.2% 47.8% 47.2% 40.5% 57.6% 63.2% 39.1% 19.4% 42.5% 50% 60% 59%

< 72 hrs 75.7% 78.3% 86.1% 85.7% 69.7% 71.1% 63% 58.3% 62.5% 78.6% 80% 64.1%

Although the commissioning of the single site Stroke Unit only took place at the beginning of April, feedback from staff and patients to date has been

positive. It is anticipated that performance against the bundles will improve further over the coming months.


Mental Health Measure - Executive Lead, Director of Primary Care & Mental Health

Unfortunately compliance in all areas of the Mental Health Measure has

dropped during April 2015. Part One of the Mental Health Measure relates

to the primary care assessment and treatment, and has a target for 80% of referrals to be assessed within 28 days. Performance during April has

dropped to 47.5% from 69% in March. An action plan for improvement has been submitted to Welsh Government for full compliance by June 2015.

Compliance has also dropped for the treatment element of this measure.

During April only 83.3% of patients received their treatment within 56 days of assessment, against a target of 90%. The Health Board has previously

been compliant with this element. During the year 2014/15 there was an incremental increase in demand, with the service typically receiving 550

referrals a month, an increase of 100 referrals compared to the original of 450. This has meant that the achievement of reaching 80% compliance for

assessment is challenging.

It should be noted that from October 2015, the treatment target will change from 56 to 28 days, which will be difficult to achieve. The Directorate is

planning on the following actions to address the performance gap:

o work with General Practice to find alternatives to full assessment and

improve liaison; o introduce Myrddin to ensure a systematic approach and reduce DNAs;

o submit a prioritisation bid as part of the IMTP to increase the workforce to meet current and future demand.

Part Two of the Measure relates to patients with a current care treatment

plan and has a target of 90%. Performance has dropped from 83.2% for March to 78.6% in April 2015. The Directorate has revised its action plan

with a view to achieving the target by September 2015. Two main issues affecting performance are:

o There are still some outstanding care plans needing to be completed.

o Care plans have been completed but have not received a CTP Review

in the required timescale.

3. PART TWO – ANNUAL PERFORMANCE REPORT 2014/2015

This report provides the Board with an overview of performance across a range of indicators during the last financial year of 2014/2015.

Unscheduled Care (escalation level 2) – Executive Lead, Chief

Operating Officer and Director of Primary Care & Mental Health

Performance against the A&E 4 hour target improved during the latter months of 2013/14 and the average across the 12 month period was 89.6%.


The improvement was sustained for the first eight months of 2014/15 and for that period the average performance improved to 90.4%. However

performance dropped to 84.6% during December during the increased unscheduled care pressures. This was the lowest performance achieved

since April 2013. Performance recovered slowly during the last quarter of

2014/15 with 89.3% achieved for March 2015. This gave an average performance across the year of 89.5%, slightly lower than the previous year.

The performance against the 12 hour target has been similar to that of the 4 hour target. The overall number of patients waiting more than 12 hours in

the Emergency Departments increased for the year 2014/15 (1384) against that for 2013/14 (1282). The highest volume of these occurred during

December 2014 where the number was 319 and the average for the quarter November to March was 177, against an average of 71 for the previous

seven months and 115 for the full year. From a percentage perspective the average for the year was 98.9% which was the same for 2013/14. The

equitable performance in spite of increased number of breaches is due to the variation in the number of patients attending the departments 111,198 for

2013/14 and 125,170 for 2014/15, an increase of 12.5%.

0

500

1000

1500

2000

2500

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

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

No

> 4

Hrs

Att

en

da

nce

s

Patients waiting > 4 hours

14/15 nos 13/14 Nos 13/14 % 14/15 %

0

50

100

150

200

250

300

350

400

450

95.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%


No

> 1

2H

rs

Att

en

da

nce

s

Patients waiting > 12 hours

14/15 nos 13/14 Nos 13/14 % 14/15 %


In terms of emergency ambulance services, performance against the 15 minute handover improved significantly in May 2013 and has been sustained

each month since, with the exception of December 2014, where performance dropped to below 80% for the first time at PCH and reduced the Health

Board performance to just 80.95%. The comparable averages for the two

years has been as follows:

As can be seen above, even with April 2013 figures removed, there has been an overall improvement in the performance in this measure. The monthly

breakdown can be seen in the graphs below:

0

200

400

600

800

1000

1200

1400

1600

40%

50%

60%

70%

80%

90%

100%

No

ove

r 1

5 m

ins

% w

ith

in 1

5 m

ins

Ambulance 15 Minute Handover - 2013/14

No > 15 mins (RGH) No > 15 mins (PCH) Cwm Taf RGH PCH

0

100

200

300

400

500

600

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%N

o >

15

min

s

% w

ith

in 1

5 m

ins

Ambulance 15 Minute Handover - 2014/15

> 15 mins RGH > 15 mins PCH RGH PCH Cwm Taf

2013/14 2013/14

(without Apr-13)

2014/15

Cwm Taf 81% 85% 86.3%

PCH 82% 85% 84.9%

RGH 81% 85% 87.7%


Performance against the Category A ambulance response times target unfortunately dropped during 2014/15. The average performance for

2013/14 was 51.8% but only 43.9% was achieved for 2014/15. As can be seen from the graphs below performance began to drop in December 2013

(Nov 13 – 56.7%, Dec 13 – 47.0%) and did not recover during the period to

March 2015, although the implementation of the Explorer project has since seen a significant rise in performance in 2015/2016 to date.

Referral to Treatment Times (escalation level 1) – Executive Lead,

Chief Operating Officer

The Health Board entered 2014/15 with 638 patients waiting over 36 weeks

for treatment within RTT specialties. The Health Board set a target to achieve a zero position in relation to 36 week breaches but unfortunately

pressures within individual specialties and within unscheduled care resulted in that not being achievable.

The graph below plots the monthly performance for 2013/14 and 2014/15

and as can be seen, the increase in 36 week breaches coincides with the unscheduled care pressures seen in the previous graphs (as a consequence

of April 2013 and December 2014).

20%

30%

40%

50%

60%

70%

80%

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Ambulance Cat A Response Time - 2014/15 (43.9%)

Cwm Taf Ambulance Cat A in 8 mins Target All Wales Ambulance Cat A in 8 mins

20%

30%

40%

50%

60%

70%

80%


Ambulance Cat A Response Time - 2013/2014 (51.8%)

Cwm Taf Ambulance Cat A in 8 mins Target All Wales Ambulance Cat A in 8 mins


However, the end of year achievement improved considerably on the expectation set out in January 2015, where the Health Board indicated that

it expected to have 1,500 patients waiting over 36 weeks at the end of March, 900 of which would be within Ophthalmology. The final position of

1,156 included 750 Ophthalmology patients. The table below shows the month by month position by specialty:

Specialty Apr

14 May 14

June 14

July 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Mar 15

Orthopaedics 141 182 175 170 204 134 109 74 112 184 157 144

General Surgery 156 189 125 112 174 165 173 133 167 190 174 133

Urology 3 6 12 13 27 4 9 4 12 18 29 0

ENT 94 94 89 83 69 59 44 25 65 105 95 25

Ophthalmology 151 238 313 533 802 940 1113 1074 1165 1324 1162 751

Oral Surgery 168 163 135 127 146 145 143 128 137 133 97 84

Gynaecology 10 13 26 111 106 60 16 0 20 71 52 0

Cardiology 1 4 8 15 16 16 16 13 15 8 48 9

Rest. Dentistry 0 0 0 0 1 1 0 0 3 3 14 7

Gastroenterology 11 11 5 9 14 16 5 13 18 18 20 2

Diagnostics 2 4 5 5 3 0 4 4 1 5 11

0

Respiratory 0 0 0 0 2 1 0 9 8 5 4 0

Anaesthetics 0 0 0 0 0 0 0 1 0 0 0 0

Dermatology 0 0 0 0 0 0 0 1 1 2 4 0

General Medicine 0 0 0 0 0 0 0 7 18 0 1 0

Rheumatology 1 0 1 0

Total 735 904 893 1179 1564 1541 1632 1487 1742 2066 1869 1155

Due to the pressures within Ophthalmology, there were unfortunately patients remaining who waited more than 52 weeks for treatment (262). All

were awaiting surgical intervention.

The Health Board has committed to achieving all RTT targets by the end of 2015/2016, but is mindful that this is dependent upon delivering the

required service improvements in particular within Ophthalmology.

50.0%

60.0%

70.0%

80.0%

90.0%

0

500

1,000

1,500

2,000

2,500


RTT Performance Apr 2013 to March 2015

2013/14 36 wk Nos 2014/15 36 wk Nos

2013/14 26 wk % 2014/15 26 wk %


Cancer 31 and 62 Day Target (escalation level 2) – Executive Lead,

Medical Director

Sustained delivery of the 62 day target has historically proven to be difficult

for the Health Board to achieve. This is due in part to the small numbers of patients diagnosed via this pathway and also the number of complex

pathways within this cohort of patients. However, the Health Board strives to achieve the 95% wherever possible and also to maintain a monthly

performance of 90% or above. As can be seen from the graphs below, the overall performance for 2013/14 was 85%, which improved during 2014/15

to 90%.

The table below shows the breaches by tumour site and the overall monthly

performance over the last 12 months within this area. As can be seen, the 95% target was achieved for two months during the year and a 90%

performance was achieved for a further five months.

70%

75%

80%

85%

90%

95%

100%

0

10

20

30

40

50

60

70

80

62 Day Cancer Target - 2014/15 (90%)

< 62 days >62 days Target %

0%

20%

40%

60%

80%

100%

0

10

20

30

40

50

60

70%

< 6

2 d

ay

s

No

of

Pa

tie

nts

Tre

ate

d

62 Day Cancer Target - 2013/14 (85%)

< 62 days > 62 days % Target


Urology Lung Lower

GI Head & Neck

Gynae Haem’ Upper GI

Breast No Breaches

Performance

April 2 3 2 0 2 0 0 0 9 82.4%

May 1 1 0 0 1 0 1 0 4 90.9%

June 3 2 1 0 2 0 0 0 8 85.7%

July 2 0 1 0 2 0 0 0 5 92.4%

August 2 0 1 0 4 0 0 0 7 86.8%

September 4 1 1 1 2 0 0 0 9 84.2%

October 0 1 0 0 2 0 0 0 3 92.9%

November 0 0 0 0 1 0 0 0 1 97.7%

December 1 2 1 0 0 0 0 0 4 94.1%

January 0 0 2 0 1 1 0 0 4 91.5%

February 3 2 3 1 0 0 1 0 10 81.5%

March 0 0 0 2 0 0 0 0 2 96.5%

Total 18 12 12 4 17 1 2 0 66

Analysis of the breaches recorded during 2014/15 shows that 43 of the 66 patients were treated at the tertiary units. However, only six of these

patients were referred onwards by day 31 of the pathway.

The position for the 31 day Cancer Target is more positive, with the target being achieved for the year (98.3%) and for six months of the year. The

annual performance is an improvement on the 98.1% for the full year 2013/14.

During 2014/15 the Health Board reported 21 breaches out of a total of 1,249 patients treated. Of the 21 patients not treated within 31 days of the

decision to treat, 15 were within the Urological tumour site, two within Colorectal, one within Upper GI and three within Lung. Analysis of the 15

Urology patients show that 11 were treated at the tertiary units, where the full 31 day pathway is recorded. All four patients treated at Cwm Taf

received surgery, the date for which was delayed beyond 31 days.

The Health Board has committed to achieving all Cancer targets by year end

but is conscious that this is not always feasible due to small numbers of patients treated on the 62 day pathway. Where this is not possible then a

90% commitment for this target has been reiterated.

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

0

20

40

60

80

100

120

140%

< 3

1 D

ays

No

of

Pat

ien

ts T

reat

ed

31 Day Cancer Target - 2014/15 (98.3%)

< 31 days > 31 days Performance Target


Stroke Bundles (escalation level 1) - Executive Lead, Director of Planning and Performance

During 2014/15, 443 patients have been recorded within the stroke

database with the following outcomes:

Unfortunately, as can be seen from the table above the Health Board was

not able to achieve compliance with all four bundles for any month during the year. This is primarily due to the difficulties in achieving bundle 2, which

is adversely affected in particular when the direct admission to the stroke ward is not possible, on occasion due to unscheduled care pressures. For

three months of the year, the remaining bundles were achieved and two bundles were achieved for seven months, six in succession (May to October).

At a site level, the table below highlights the range of performance against

the bundles. It shows that PCH has a higher average performance in

bundles 1 to 3 but RGH has performed better in bundle 4.

Month Compliant Breaches % Month Compliant Breaches %

Apr-14 39 0 100.0% Apr-14 27 12 69.2%

May-14 37 0 100.0% May-14 18 19 48.6%

Jun-14 23 0 100.0% Jun-14 13 10 56.5%

Jul-14 34 2 94.4% Jul-14 22 14 61.1%

Aug-14 42 0 100.0% Aug-14 29 13 69.0%

Sep-14 33 0 100.0% Sep-14 26 7 78.8%

Oct-14 37 1 97.4% Oct-14 33 5 86.8%

Nov-14 44 2 95.7% Nov-14 29 17 63.0%

Dec-14 33 3 91.7% Dec-14 19 17 52.8%

Jan-15 35 6 85.4% Jan-15 28 13 68.3%

Feb-15 42 0 100.0% Feb-15 28 14 66.7%

Mar-15 32 0 100.0% Mar-15 21 11 65.6%

Bundle 2Bundle 1

Month Compliant Breaches % Month Compliant Breaches %

Apr-14 37 2 94.9% Apr-14 35 2 94.6%

May-14 27 10 73.0% May-14 37 0 100.0%

Jun-14 22 1 95.7% Jun-14 23 0 100.0%

Jul-14 33 3 91.7% Jul-14 36 0 100.0%

Aug-14 39 3 92.9% Aug-14 40 2 95.2%

Sep-14 32 1 97.0% Sep-14 33 0 100.0%

Oct-14 36 2 94.7% Oct-14 37 1 97.4%

Nov-14 36 10 78.3% Nov-14 39 7 84.8%

Dec-14 30 6 83.3% Dec-14 32 4 88.9%

Jan-15 29 12 70.7% Jan-15 34 7 82.9%

Feb-15 41 1 97.6% Feb-15 41 1 97.6%

Mar-15 26 6 81.3% Mar-15 26 6 81.3%

Bundle 3 Bundle 4


The Health Board has committed to achieving all components of the Stroke Bundles target by year end.

Mental Health Measure - Executive Lead, Director of Primary Care &

Mental Health

Unfortunately, as can be seen from the graph below, compliance for patients with a current care treatment plan has not been achieved for January,

although performance has increased from 81% to 85.9%. Throughout the year the Directorate stated that it was on track to delivery by the end of

March 2015 but unfortunately this has not been achieved.

Two main issues affecting performance are:

o There are still some outstanding care plans needing to be completed. o Care plans have been completed but have not received a CTP Review

in the required timescale.

Month RGH PCH RGH PCH RGH PCH RGH PCH

Apr-14 96.4% 100.0% 53.6% 83.3% 85.7% 91.7% 89.3% 100.0%

May-14 100.0% 100.0% 41.7% 69.2% 62.5% 92.3% 91.7% 84.6%

Jun-14 100.0% 100.0% 35.7% 100.0% 93.8% 100.0% 100.0% 100.0%

Jul-14 94.7% 94.1% 63.2% 58.8% 94.7% 88.2% 100.0% 100.0%

Aug-14 100.0% 90.9% 82.6% 50.0% 91.3% 81.8% 100.0% 81.8%

Sep-14 100.0% 100.0% 78.6% 84.2% 92.9% 100.0% 100.0% 100.0%

Oct-14 94.4% 100.0% 77.8% 90.0% 100.0% 90.0% 100.0% 95.0%

Nov-14 93.1% 100.0% 51.7% 82.4% 75.9% 82.4% 86.2% 88.2%

Dec-14 80.0% 95.5% 33.3% 63.6% 66.7% 86.4% 93.3% 81.8%

Jan-15 100.0% 90.9% 52.6% 86.4% 84.2% 63.6% 100.0% 81.8%

Feb-15 100.0% 95.5% 40.9% 86.4% 90.9% 95.5% 90.9% 86.4%

Mar-15 100.0% 100.0% 55.6% 78.6% 83.3% 78.6% 83.3% 78.6%

Average 96.6% 97.2% 55.6% 77.7% 85.2% 87.5% 94.6% 89.9%

Bundle 1 Bundle 2 Bundle 3 Bundle 4


Part One of the Mental Health Measure relates to the primary care assessment and treatment and has a target for 80% of referrals to be

assessed within 28 days and also 90% target for the treatment to commence within 56 days. As can be seen from the graphs below, the

Health Board has achieved 69% compliance over the year with the first part

of this measure and 97.7% for the second part. An action plan to address the shortfall in the assessment target has been developed and shared with

Welsh Government. It is estimated by the Directorate that compliance will be achieved by the end of June 2015.

The Health Board has committed to achieving all components of the Mental

Health Measure by year end.

Theatre Cancellations

The Health Board records and reports all procedures scheduled to take place

that are subsequently cancelled. Each cancellation is allocated a category for the ‘reason of cancellation’ from the following:

o No beds available.

o Cancelled by patient. o Cancelled for clinical reasons.

o Cancelled for other reason.

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Total Assessments during the month 346 254 285 359 270 307 339 318 259 369 271 411

Waiting upto and inc 28 days 120 88 115 91 99 95 144 110 129 134 127 102

% 28 day target 69.4 71.7 80.4 66.3 76.7 74.9 69.6 64.5 66.4 48.2 76.8 61.6

% Target

LPMHSS - Assessments - 2014/15 & 2015/2016

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Total Therapeutic Interventions during the month 200 180 184 154 173 174 222 213 183 245 164 158

Total Therapeutic Interventions within 56 days 193 175 180 151 170 164 210 201 174 229 164 155

% ofTherapeutic Interventions within 56 days 96.5 97.2 97.8 98.1 98.3 94.3 94.6 94.4 95.1 93.5 100.0 98.1

% Target 90 90 90 90 90 90 90 90 90 90 90 90

LPMHSS - Therapeutic Interventions - 2014/15 & 2015/2016


The first three categories are self explanatory. However, the “other reason” category requires further clarity and definition. Within this cohort of

procedures are those patients unfortunately cancelled due to the unavailability of staff and equipment, or when the planned theatre list

overruns. As can be seen from the graphs below, the split between

cancellation categories has changed over the periods 2013/14 and 2014/15, particularly with the number of procedures cancelled due to bed availability.

During 2013/14, an average of 101 procedures were cancelled each month

due to the unscheduled care pressures and the subsequent impact on bed availability for elective cases, with a total of 1210 over the full year. During

2014/15 this reduced to 56 procedures per month, a total of 444 over the full year.

It would therefore be logical to expect a considerable drop in the overall

number of procedures cancelled between the two periods. However, there was a considerable increase during 2014/15 in the number of procedures

cancelled for “other” reasons, from 1785 (149 per month) to 2242 (182 per month). This resulted in the overall monthly average for cancelled

procedures to reduce from 494 to 468.

Some work has already been undertaken to understand the reasons behind

the “other” cancellations and to minimise the impact each month. This includes a further development of the TOMS system to allow Directorates to

visualise the scheduling of procedures and more proactively manage the under and over-utilisation of theatre lists. More focussed work will be driven

by individual Directorates throughout this year. Unsurprisingly, the pattern illustrated by the graphs below mirror that of the unscheduled care

performance for the same periods.

0.00100.00200.00300.00400.00500.00600.00700.00800.00900.00

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Theatre Cancellations 2013/14

Cancelled for Other Reason Cancelled by Patient Clincal Cancellation No Beds


The Health Board has committed to significantly improving the level of procedures cancelled by the end of the year.

Fractured Neck of Femur (#NOF)

The Health Board has been formally monitoring its performance against the

#NOF pathway for the last two years. The metrics used were those developed by the Delivery Unit:

% of patients admitted to a #NOF bed within two hours of arrival at A&E (set by the Delivery Unit).

% of patients to receive surgery within 24 hours of discharge from A&E (set by the Delivery Unit).

% of patients to receive surgery within 48 hours of discharge from A&E (set by NICE).

As can been seen from the graph below, performance over the last 12

months has been variable. There is unfortunately a negative trend line for performance against the 2 hour target. Over the twelve month period, an

average of 31% of patients have been discharged from A&E within the two hour window.

Performance against the 24 hour target for the patient to arrive in theatres

has been better, although with a rather static trend line. The average for

the year has been 57%. When this target was implemented, it was the intention that this would only include patients suitable for surgery within 24

hours. However, the 57% figure includes all known #NOF patients irrespective of their fitness to proceed for surgery.

The same cohort of patients are included within the 48 hour target, which

should be 100% of patients. The target is 85% and as can be seen, the Health Board performs more closely to this level, with the average for the

year being 78%.

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Theatre Cancellations 2014/15

Cancelled for Other Reason Cancelled by Patient Clincal Cancellation No Beds


In order for the Health Board to maintain focus in this important service area, the measure for 2015/16 will be to achieve 85% of patients to theatre

within 36 hours. This is the target set by the National Hip Fracture Database.

Going forward, the Health Board will also be expanding the reporting of outcomes for #NOF patients by including the following measures:

o Patients developing pressure ulcers. o Pre-operative assessment by an orthogeriatrician.

o Patients discharged on bone protection medication. o Patients that receive a falls assessment prior to discharge.

The Health Board has committed to significantly improving the pathway for

patients suffering with a fractured neck of femur. This should improve the performance against the measures by the end of the year.

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Performance Against #NOF Targets 2014/15

No of Patients 2 hr Target 24 hr Target 48 hr Target Linear (48 hr Target)

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Fracture Neck of Femur (#NOF) - 48 Hour Target

Total Patients < 48hours Theatre Target


Clinical Coding

Measuring performance within clinical coding is undertaken by various metrics which cover both the timeliness and the quality of the coding being

carried out.

From a timeliness perspective, the expectation is that 95% of coding is

complete each month, within 12 weeks of the episode completing. Reporting at present is complete up to the end of November and as can be seen from

the graph below, the Health Board is now 96.6% complete for that month.

In addition Health Boards are also required to achieve 98% completeness for a full financial year, again with a backlog of 12 weeks. This is not formally

reported until the end of June (for full year 2014/15) but currently the Health Board is achieving 98.2%. It is anticipated that this will be sustained

comfortably with some progress to reducing the backlog to 8 weeks, which is a local stretch target.

As can be seen from the graph below, the Health Board is now in a very positive position in comparison to the rest of Wales at individual Health

Board level and it is reassuring to note that the work undertaken over the

last 12 months is having a positive impact.

96.6%

6,500.00

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Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14

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Clinical Coding Performance 2014/15

Coded Uncoded Cwm Taf All Wales


With regards to clinical coding quality, the table below outlines the key

performance indicators (KPIs) used and shows the Health Board position in comparison to the All Wales position. As can be seen, the Health Board is

achieving 94.2% against the overall Data Quality and Completeness Index,

which exceeds the All Wales position of 92.4%. The performance for the blank primary diagnosis indictor is also significantly better than the all Wales

position (1.73%, which is positive, against 4.14%).

The main area of concern relates to the “Sign and Symptom as a Primary Diagnosis” area which relates to how the clinicians are recording an actual

diagnosis rather than a symptom. For example, an outcome of chest pain is a sign and symptom, an outcome of acute MI is a diagnosis. The

department continues to work closely with clinical leads to improve awareness of the need for accurate record keeping and the detrimental

impact on clinical coding performance where it is non-specific.

The Health Board is committed to sustaining the improvements made in the

area of clinical coding and striving to achieve a stretch target of compliance within 8 weeks, rather than the designated 12 weeks.

Day of Surgery Admission

One area of focus for performance improvement during 2014/15 was the

rate of admission on day of surgery within orthopaedics. A benchmarking exercise undertaken via CHKS identified Cwm Taf as an outlier in day of

surgery admission rate data, particularly within the specialty of Orthopaedics. This is an important efficiency measure that had historically

been reported as a Tier 1 target but that has been reported internally only since April 2014.

(source:CHKS) CTUHB Welsh Peers CTUHB Welsh Peers

Data Quality &

Completeness Index94.9% 94.7% 95.2% 91.7%

Blank Primary Diagnosis 1.05% 1.46% 0.76% 4.93%

Invalid Primary

Diagnosis0.00% 0.00% 0.00% 0.00%

Unacceptable Primary

Diagnosis0.04% 0.05% 0.06% 0.04%

Diagnosis Non-specific 15.54% 14.82% 15.38% 15.44%

Procedure Code Invalid 0.00% 0.00%

Sign & Symptom as a

Primary Diagnosis11.92% 11.74% 13.48% 11.49%

(April to February 2015)

2013/14DATA QUALITY

INDICATOR

2014/15


The benchmarking report showed that at Cwm Taf only 39% of elective procedures were undertaken on the day of admission against a peer mean of

88.8% and an upper quartile of 96.6%. the graph below shows the Cwm Taf position within the peer group.

In order to improve this position a task and finish group was set up, which focussed on the admission procedure for patient admitted the Clinical

Director for Trauma and Orthopaedics. Performance has since improved significantly from August 2014 and has been sustained with an average of

73% since then.

Work now needs to progress to see this service change implemented across this and other relevant specialties.

Sickness Absence

The rate of sickness absence has unfortunately not improved throughout the year 2014/15. The rolling 12 month rate has increased each month from

5.57% in April to 5.91% in October. The graph below illustrates the increase in trend from December 2013:


The range of sickness at Directorate level is from 0.38% to 7.42%. There are currently 11 directorates achieving the 4.5% target or better. However

a further 16 are not compliant. The latest figure for the Health Board as a whole is 5.91%.

The Health Board has committed to achieving the sickness target by the end

of the year.

Flu Vaccine – Executive Lead, Nicola John, Director of Public Health

October 1st 2014 saw the launch of this year’s Flu Vaccination Programme.

The Health Board is dedicated to improving the uptake of the flu vaccination amongst staff and patients. During 2013/14, 44% of Cwm Taf staff received

the vaccine, which equates to more than 3,500 staff members.

The actual target for flu vaccination levels is 75% of at risk groups. However, internally the Health Board is aspiring to achieve 50% amongst

staff groups this year. Although, no staff group achieved the 50% uptake last year, the evaluation undertaken showed the following staff groups with

the highest uptake:

Allied health professionals (48%). Additional clinical services (47%).

Medical and dental (45%). Nursing and midwifery registered (41%).

Administrative and clerical (40%).

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

Rolling Average % 5.34% 5.34% 5.38% 5.46% 5.54% 5.57% 5.63% 5.70% 5.76% 5.82% 5.85% 5.91%

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Cwm Taf Sickness % 12-month Rolling Average - Nov 2013 to Oct 2014

Rolling Average % Trendline


Our lowest uptake within staff groups were:

Healthcare scientists (30%). Additional professional, scientific and technical (23%).

It is worth noting that the first week of this campaign saw more than 1,000 staff receive the vaccine. Figures for January showed an increase in update

of the flu vaccination for staff from 41.1% in 2013/14 to almost 45% this year.

Healthcare Associated Infections (HCAIs)

The method of reporting HCAIs on a monthly basis changed in 2014/15.

Prior to April 2014 the performance was gauged over a 12 monthly period with an expected cumulative reduction of 20% (minimum) with the previous

year. From the 1st April 2014, the performance was measured over an 18 month period (to September 2015) with each Health Board set a maximum

incidence level per 100,000 population. For Cwm Taf the maximum expected levels of infection incidences are as follows:

o C-difficile – 139 o MRSA – 12

As can be seen from the graph below, the Health Board has recorded 101

cases of Healthcare Associated C-difficile from April 2104 to March 2015. This is eight more than expected at this point in the 18 month reporting

period. Although it is possible that the Health Board may achieve the range expected, based on the trend so far, current predictions show that there

may be an increase in these numbers by the end of September 2015.


Chart 1. Cwm Taf University Health Board maximum cumulative monthly

numbers of C. difficile to achieve the 18 month (Apr 14 to Sep 15) target and

current cumulative monthly numbers for Apr 14 to Mar 15

The Control of Infection Team report that there has been a 25% increase in cases, from 81 in the previous year to 101, with 2014/15 being the first year

which we have seen a significant rise in number of cases since 2010/11. Work is ongoing within the Health Board to improve this position and remain

within the tolerance level by the end of the 18 month period.

In terms of MRSA cases, to date the Health Board has reported 15 cases, with the tolerance for the 18 month period being only 12 cases. Current

predictions estimated a potential final figure of around 23 cases by September 2015.

Chart 2. Cwm Taf University Health Board maximum cumulative monthly

numbers of MRSA bacteraemia to achieve the 18 month (Apr 14 to Sep 15)

target and current cumulative monthly numbers for Apr 14 to Mar 15

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4. RECOMMENDATION

The Health Board is asked to: -

NOTE and DISCUSS the latest Integrated Performance Dashboard, the Annual Performance Report and performance actions outlined to

support the achievement of targets.

AGENDA ITEM 4.1 15 Title of the Health Board Report...

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