Quality & Performance Report Agenda Item 12.1 (i) Public ......by reporting specialty, Aug-19...

Presented for: Governance

Presented by:Clare Smith

Chief Operating Officer

Author: Information Department

Previous Committees: None

Trust Goals

The best for patient safety, quality and experience ✓

The best place to work ✓

A centre for excellence for research, education and innovation ✓

Seamless integrated care across organisational boundaries ✓

Financial sustainability ✓

Key points

This report is presented to ensure the Board remains up-to-date with the areas the Trust is not achieving performance against the NHS Improvement(NHSI) frameworks, as well as measures stipulated within the NHS Standard Contract.

Governance

Quality & Performance Report

Public Board

September 2019

Agenda Item 12.1 (i)

1

2

Table of ContentsPerformance Summary Page 4,5

Non-Performing

Referral to Treatment Page 7

Emergency Care Standard Page 8

Delayed Transfer of Care and Repatriations Page 9

Diagnostic Test Waiting Time Page 10

Cancelled Operations Page 11

2 Week Cancer Waiting Times Page 12

31 Day Cancer Waiting Times Page 13

62 Day Cancer Waiting Times Page 14

Ambulance Handover Page 15

Incidence of MRSA Page 16

Incidents Page 17

Venous Thromboembolism (VTE) Risk Assessments Page 18

Performing

Mortality Indicator Reporting 0

Incidence of CDI Page 21

Electronic Discharge Advice Notes (eDANs) Page 22

Complaints Page 23

Patient satisfaction: Friends and Family Test Page 24

Harm Free Care Page 25/26

Outpatient Measures Page 27

Length of Stay Page 28

30 Day Emergency Readmission Rates Page 29

CQUIN Tracker Page 30/31/32

People Page 33/34

Finance

Finance: Accountability Framework Dashboard Page 35

Finance: In-year Delivery Page 36

Appendices

Appendix 1: Updates from Regulators Page 37

Appendix 2: Peer Groups Page 38

Appendix 3: Glossary Page 39

3

SummaryPerforming Non-Performing

Responsive • Outpatient Measures

• 31 Day Cancer First Definitive Treatment

• 31 Day Cancer Subsequent Drug Treatment

• 31 Day Cancer Subsequent Radiotherapy

• Referral to Treatment

• Emergency Care Standard

• Delayed Transfer of Care and Repatriations

• Diagnostic Test Waiting Times

• Cancelled Operations

• 2 Week Cancer Waiting Times

• 31 Day Cancer Subsequent Surgery

• 62 Day Cancer Waiting Times

• Ambulance Handover

Safe • Incidence of CDI

• Electronic Discharge Advice Notes (eDANs)

• Incidence of MRSA

• Incidents

• Venous Thromboembolism (VTE) Risk Assessments

Effective • Mortality Indicator Reporting

• 30 Day Emergency Readmission Rates

• Harm Free Care

Caring • Complaints

Well-Led • Patient Satisfaction: Friends and Family Test

• People

Other • Length of Stay

• CQUIN Tracker

Performance Summary

4

Performance Summary

5

Performance Measures Target Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Section C - NHSE Quality and Contract Requirements

Serious Incidents (SUIs) - 3 8 8 11 14 12 11 15 5 11 11 10

HCAI: MSSA <=59 8 8 5 10 7 3 6 10 5 6 8 3

Gynae Cytology 14 Day TATs >=98 0.29 0.32 0.51 0.45 2.87 0.79 0.67 1.40 1.04 -

Harm Free Care >=95 95.46 94.43 95.88 95.78 93.87 93.84 95.69 96.33 96.58 95.32 95.76 96.56

Readmissions to PICU Within 48 Hours <1 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.00 0.01 0.00 0.00 0.00

Section D - Local Quality and Contract Requirements

Cancer: 62 Day: Consultant Upgrade >=85 56.0 52.8 70.0 73.6 68.4 64.4 70.0 79.4 65.5 68.0 89.1

OP FUP Backlog: More Than 3 Months Overdue - 5,124 4,862 4,896 5,716 4,946 5,299 6,214 6,431 7,089 6,994 8,708 9,801

OP FUP Backlog: More Than 12 Months Overdue - 79 98 73 96 123 132 135 142 164 155 166 196

Section E - Internal Monitoring

Dementia Performance: Stage 1 >=90 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00



Pressure Ulcers (Grade 3) (developed) - 4 8 4 6 8 3 3 4 3 3 5 1

Pressure Ulcers (Grade 4) (developed) - 0 0 1 0 1 1 1 0 0 0 0 0

OP Appts Cancelled 2 or More Times (Total) - 2,026 2,336 2,214 2,024 2,602 2,125 2,324 2,301 2,519 2,302 2,639 2,404

OP Appts Cancelled 2 or More Times (By Hospital) - 882 993 951 854 1,093 956 1,096 1,062 1,118 918 1,134 977

Non performing areas

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7

CQC: Responsive Referral to Treatment Waiting Times

Standard(s): Ensure that a minimum of 92% of patients on incomplete pathways have been waiting no more than 18 weeksEnsure no patients wait over 52 weeks from referral to treatment

Owner(s): Chief Operating Officer and Clinical Directors

Commentary: The RTT reported position for August is 84.09%, a drop of 1.79% from July 2019.The TWL is currently 63,134 patients (against a trajectory of 65,727) and is expected to continue reducing over the remainder of the year.The reduction in RTT performance has been caused by the growth in non-admitted patients who have waited over 18 weeks. This is as a result of challenges in some specialties toaccommodate the rapid increase in referral numbers experienced between December 2018 and May 2019. These longer waits are associated with a small number of high volume specialties.Additional clinic capacity and alternative providers have been identified in a number of specialties to address this growth where possible. Actions taken to arrest this growth have exacerbatedthe reduction in performance as they have impacted on the denominator, but they are the right actions to take.There were 82 patients who waited over 52 weeks for treatment at the end of August 2019, with 81 patients in Adult Spines and 1 patient in Colorectal following the cancellation of theirplanned surgery due to Silver Command at the end of the month.A spinal summit will be held on 24th September bringing together LTHT, commissioners and NHSE/I to discuss the action plan to improve this position and the risks to delivery

Incomplete RTT performance

by reporting specialty, Aug-19Pathways Breaches Performance Monthly Trend

Cardiology 2,546 6 99.76%

Cardiothoracic Surgery 339 27 92.04%

Dermatology 3,812 463 87.85%

Ear Nose & Throat 1,872 431 76.98%

Elderly Medicine 144 0 100.00%

Gastroenterology 1,159 51 95.60%

General Medicine 1 0 100.00%

General Surgery 1,168 171 85.36%

Gynaecology 4,259 396 90.70%

Neurology 1,652 0 100.00%

Neurosurgery 321 44 86.29%

Ophthalmology 4,407 240 94.55%

Oral Surgery 1,510 147 90.26%

Plastic Surgery 2,031 446 78.04%

Respiratory Medicine 1,147 91 92.07%

Rheumatology 2,547 253 90.07%

Trauma & Orthopaedic Surgery 5,799 2,077 64.18%

Urology 3,241 954 70.56%

Other Specialties 25,179 4,248 83.13%

Trust 63,134 10,045 84.09%

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Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Incomplete Pathway Breach Date Passed

Outpatient Inpatient

65%

70%

75%

80%

85%

90%

95%

100%

Trusts

Peer comparison: % of patients on incomplete RTT pathways waiting no more than 18 weeks, July 2019

LTHT Peers Other Trusts England Target

Source: NHS England

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82%

84%

86%

88%

90%

92%

94%

96%

98%

100%


% of patients on incomplete RTT pathways waiting no more than 18 weeks

Breaches Total pathways % within 18 weeks Standard

CQC: Responsive Emergency Care Standard

Standard(s): Ensure at least 95% of attendees to A&E are admitted, transferred or discharged within 4 hours of arrival

Owner(s): Chief Operating Officer and Clinical Director of Urgent Care

Commentary: The NHSI trajectory target for August 2019 was 89.3%; LTHT achieved 88.28%. This is the best monthly reported position to date in 2019/20. LTHT was on trajectory to

achieve 89.3% up until Friday 23rd August. The impact of the bank holiday weekend exceeded what was anticipated. LTHT experienced an extended recovery period resulting

in the Trust being in Silver Command for four days. LTHT has reduced its bed base on the SJUH site by 36 beds over the last year and whilst compensated slightly by the

reduction in super stranded, there has been a loss of resilience.

An additional 1,112 patients attended LGI & SJUH in August 2019 compared to August 2018 (6.49% increase). Despite being below trajectory, LTHT’s August 2019

performance was 0.75% better than performance in August 2018, whilst maintaining a position of zero 12 hour breaches and zero patients being cared for in non-designated

areas.

Delivery against the Recovery Plan is managed through the Unplanned Care Improvement Programme. LGI non-admitted performance in August 2019 was 96.13%; at SJUH

non-admitted performance was 93.15%. LTHT overall non-admitted performance was 94.99%.

850%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Trusts

Peer comparison: Performance against the 95% 4 hour A&E access standard; August 2019

(Type 1 Departments - Major A&E)LTHT Peers Others Target

Source: NHS England

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Monthly Attendances and Breaches of the 4 Hour Access Standard

Attendances Breaches Allowed Breaches

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100

1 2 3 4 5 6 7 8 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 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Pe

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)

Week Number

Weekly ECS Performance2016-17 2017-18 2018-19 2019-20 Target

Site Aug-19 YTD

St James's 7,442 36,540

LGI 9,433 49,842

GP Stream 1,378 7,252

WGH 2,378 12,343

SHK 4,228 16,781

Trust 24,859 122,758

St James's 1,821 8,953

LGI 1,089 6,300

GP Stream 0 0

WGH 2 37

SHK 0 0

Trust 2,912 15,290

St James's 75.5% 75.5%

LGI 88.5% 87.4%

GP Stream 100% 100%

WGH 100% 100%

SHK 100% 100%

Trust 88.3% 87.5%

Indicator

Attendances

Breaches

Performance

> 95%

CQC: Responsive Delayed Transfer of Care and Repatriations

Standard(s): To reduce the length of stay in order to release capacity for other patients and provide an improved patient experience


Commentary: • From April 2017 to March 2018 LTHT lost 24,557 beds days due to DTOCs, this was equivalent to 67.3 beds not available for patient care, which is up from 64.8 beds in the previous year. For 2018/19 LTHT has lost 16,299 bed days which equates to 44.7 beds not available for patient care. During April - August 2019 LTHT lost 5083 bed days which equates to 33.2 beds demonstrating an improvement on the previous year. The largest category of delays was and continues to be Code G - NHS patient or Family choice.

• LTHT is working with partners following the diagnostic carried out by Newton Europe in June 2018 which demonstrated that 56% of people leaving hospital did not achieve their ideal outcome. A re audit in the summer of 2019 demonstrated an improvement with 41% of people leaving hospital not achieving their ideal outcome. Both audits suggest that we have an opportunity to increase the independence of service users, with many ending up in a more intensive care setting than they required.

• Since the diagnostic LTHT has worked with system partners to develop a programme of work focussing on the right pathway every time and responsive community services.

9

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1,200

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Delayed Transfers of Care: bed days lost, by month and delay source

NHS Social Services

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100

150

200

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300

Jun-17

Jul-1

7

Aug

-17

Sep

-17

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Dec-1

7

Jan-18

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Number of Patients MFFD Monthly Snapshot Audit

CQC: Responsive Diagnostic Test Waiting Times

Standard(s): Ensure at least 99% of patients wait no more than 6 weeks for a diagnostic test


Commentary: The diagnostic standard was consistently delivered 99% from September 2016, with the exception of January and December 2018 where LTHT did not achieve the standard due to reduced capacity over the Christmas & New Year periods. Since April 2019, the standard has not been achieved for a period of five months.Service delivery in August 2019 is at 98.83% which is 0.17% below the required standard of 99%. This 0.17% represents a total of 18 breaches of the 6 week standard. August position is a 0.5% improvement on July’s position. Underlying issues:• Replacement of the Bexley Wing scanner from March-June 2019. • CAH replacement scanner (University/ Leeds Cares joint funded) over the same period.• New Paediatric Hybrid MRI scanner not becoming fully operational until May (for Radiology MRI use). • Radiology staffing shortfalls

Number of

Patients on

Waiting List

Number Waiting

over 6 Weeks

% Waiting Less

Than 6 Weeks

- - 99%

Colonoscopy 202 2 99.0%

Flexi sigmoidoscopy 56 0 100.0%

Cystoscopy 141 1 99.3%

Gastroscopy 232 6 97.4%

Magnetic Resonance Imaging 2,542 94 96.3%

Computed Tomography 2,009 31 98.5%

Non-obstetric ultrasound 5,068 17 99.7%

Barium Enema 0 0 -

DEXA Scan 736 1 99.9%

Audiology - Audiology Assessments 179 0 100.0%

Cardiology - echocardiography 1,445 0 100.0%

Cardiology - electrophysiology 0 0 -

Neurophysiology - peripheral neurophysiology 344 0 100.0%

Respiratory physiology - sleep studies 262 2 99.2%

Urodynamics - pressures & flows 0 0 -

13,216 154 98.8%

Diagnostic Test

Target

Trust

Endoscopy

Imaging

Physiological

Measurement

Waiting list position as at 31-Aug-19

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000


Diagnostic waits: number of patients waiting for a diagnostic test at month end

90%

92%

94%

96%

98%

100%


Diagnostic waits: % patients waiting less than 6 weeks at month end

% Within 6 Weeks Target

10

80%

85%

90%

95%

100%

Trusts

Diagnostic waits - % of patients waiting less than 6 weeks at month-end, Jul-19

LTHT Peers Other Trusts England Target

Source: NHS England

CQC: Responsive Cancelled Operations

Standard(s): Ensure all patients who have operations cancelled at the last minute, for non-clinical reasons are offered another binding date to be treated within a maximum of 28 days (zero tolerance standard)


Commentary: This is a zero tolerance NHS contract standard and is reportable on a quarterly basis.

The volume of 28 day breaches has continued to reduce and remain below the mean of 23. The lowest monthly figure since October 2017 has been reported in June 2019.

For Q1 there were a total of 46 reported 28 day breaches in comparison to the same period last year of 82. Further work continues at CSU level to achieve the zero standard as part of CSU delivery contracts and there will be an increased focus on specific high volume CSU’s with an aim to further reducing the number of breaches against this standard.

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Assessment in Progress

0%

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10%

15%

20%

25%

30%

35%

Trusts

% of patients not treated within 28 days of last minute cancellations for non-clinical reasons

- Quarter 1, 2019-20 (April to June 2019)

LTHT Peers Others England

Source: NHS England

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Number of last minute elective operations cancelled for non clinical reasons

Patients not treated within 28 days of last minute cancellations for non-clinical reasons, Quarter 1, 2019-20

Average

2SD limits

3SD limits

LTHT

Other Trusts

Source: NHS England

497

559

454

383

48

95 102

46

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200

300

400

500

600

700

Q2 Q3 Q4 Q1

Quarterly Comparison of Last Minute Cancellations and Breaches of the 28 Day Standard

No. of LMCO in theQtr

No. of LMCO in thePrevious Years Qtr

No. of Breaches in theQtr

No. of Breaches in thePrevious Years Qtr

CQC: Responsive 2 Week Cancer Waiting Times

Standard(s): Ensure at least 93% of patients urgently referred with suspected cancer by their GP (GMP or GDP) are seen within 14 daysEnsure at least 93% of patients urgently referred for evaluation/investigation of “breast symptoms” by a primary or secondary care professional are seen within 14 days

Owner(s): Chief Operating Officer

Commentary: A 13% improvement in performance was reported in July although LTHT did not deliver the NHSE trajectory or constitutional standard with overall performance of 90.4%.An 8% growth in referrals was anticipated when the NHS Improvement trajectory was devised and this was broadly in line with actual volumes in Q1. However LTHT received the highestvolume of 2ww referrals in July with 545 additional referrals being received than that of the previous month. This constitutes a 20% increase in referral demand from July 2018. Increaseddemand within the skin, breast, head and neck and lower GI services in particular impacted on the Trust’s ability to meet the standard.Despite increased demand in the Breast service in July, the Breast service was able to clear the backlog of 2ww referrals through additional outpatient clinics and breast imaging to the pointwhere breast 2ww delivery for July was reported at 92.3%, which is the highest performance since October 2018.Although the constitutional standard was achieved in the skin service, a 4% reduction in performance was reported. As skin referrals form 30% of all 2WW referrals, this impacted on recoveryof the overall standard. 987 2ww skin referrals were received in July, the highest volume LTHT has reported (213 more than the previous month). Skin referral demand grew by 27% in July2019 when compared with July 2018. The service has been able to respond positively to this demand with August 2ww performance in the skin service expected to be reported above 96%.

12

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q2 2018/19 Q3 2018/19 Q4 2018/19 Q1 2019/20 Q2 2019/20(as at Jul-19)

Performance against the 2 week cancer standards

Suspected cancer Breast symptoms Threshold

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Cancer Benchmarking - 2 Week Wait, July 2019

Average

2SD limits

3SD limits

LTHT

Other Trusts

Source: NHS England

Tumour Type Jul-19 (%)Total Patients

Seen

Patients Seen

within Target

Suspected brain or central nervous system tumours 100.0% 12 12

Suspected breast cancer 92.3% 666 615

Suspected children's cancer 95.0% 20 19

Suspected gynaecological cancers 95.9% 242 232

Suspected haematological malignancies excluding acute leukaemia 85.0% 20 17

Suspected head and neck cancers 89.5% 370 331

Suspected lower gastrointestinal cancers 82.2% 490 403

Suspected lung cancer 82.9% 35 29

Suspected other cancer - 0 0

Suspected sarcomas 20.0% 10 2

Suspected skin cancers 93.0% 988 919

Suspected testicular cancer 100.0% 9 9

Suspected upper gastrointestinal cancers 88.9% 208 185

Suspected urological cancers (excluding testicular) 90.7% 236 214

Trust 90.4% 3,306 2,987

Cancer 2 Week Waits - Breast Symptoms 90.3% 154 77

Cancer 2 Week Waits - Suspected

CQC: Responsive 31 Day Cancer Waiting Times

Standard(s): Ensure at least 93% of patients urgently referred with suspected cancer by their GP (GMP or GDP) are seen within 14 days

Ensure at least 93% of patients urgently referred for evaluation/investigation of “breast symptoms” by a primary or secondary care professional are seen within 14 days


Commentary: The 31 Day First Definitive was achieved in April, June and July, with July performance of 96.6%. The standard was not achieved in May due to an increase in urology breaches as a consequence of increased demand with inadequate elective capacity to treat within target.

31 Day Subsequent Treatments - Of the 1041 patients receiving surgical, radiotherapy or drug subsequent treatments in July, 1028 were treated within 31 days in line with the constitutional standard. Of the 13 breaches, 12 were on a surgical pathway (of the 177 treated surgically) and therefore the 31 day Subsequent Surgery standard was 0.8% below the standard in July predominantly due to limited capacity within the bladder and skin service.

LTHT continues to meet the Subsequent Drug and Radiotherapy treatment standards.

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90%

92%

94%

96%

98%

100%

Q2 2018/19 Q3 2018/19 Q4 2018/19 Q1 2019/20 Q2 2019/20(as at Jul-19)

Performance against the 31 day cancer standard for first treatments

85%

90%

95%

100%

Q2 2018/19 Q3 2018/19 Q4 2018/19 Q1 2019/20 Q2 2019/20(as at Jul-19)

31 day cancer standard for second or subsequent treatment Drug Surg RT


Seen

Brain/Central Nervous System 100.0% 10

Breast 100.0% 64

Childrens cancer 100.0% 8

Gynaecological 100.0% 41

Haematological 100.0% 40

Head and Neck 91.7% 48

Lower Gastrointestinal 94.6% 56

Lung 97.6% 83

Other 100.0% 6

Sarcoma 100.0% 11

Skin 95.7% 47

Upper Gastrointestinal 96.1% 51

Urological 93.7% 95

Trust 96.6% 560

Cancer 31 Day Waits - Subsequent Surgery 93.2% 177

Cancer 31 Day Waits - Subsequent Drug Treatment 100.0% 369

Cancer 31 Day Waits - Subsequent Radiotherapy 99.8% 495

Cancer 31 Day Waits - First Definitive Treatment

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Cancer Benchmarking - 31 Day First Treatment, July 2019

Average

2SD limits

3SD limits

LTHT

Other Trusts

Source: NHS England

CQC: Responsive 62 Day Cancer Waiting Times

Standard(s): Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days of an urgent GP (GDP or GMP) referral for suspected cancer

Ensure at least 90% of patients receive their first definitive treatment for cancer within 62 days of referral from an NHS cancer screening service


Commentary: • July reported performance at 70.0%. This was a 0.4% improvement on June’s position of 69.6%.• Although the number of 62 day patients treated per working day increased slightly when compared to June, this was not sufficient to meet increased demand with a high volume of

breaches in urology, lung and lower GI and an increase in the volume of gynaecology and haematology breaches due to late referrals and patients requiring input from multiplespecialties. Only 46% of external patients treated in July were sent to LTHT by day 38.

• The number of patients awaiting treatment over day 62 in their pathway reduced from 242 in June to 160 in July, although this has increased over the summer with a current September

backlog of 199 patients (32 of these patients were sent to LTHT after day 62 of their pathway). Twice weekly review at individual patient level has commenced between the key CSUs andthe lead cancer team focused on actions to progress individual patients. Actions to recovery delivery will also be agreed through Level 1 and Level 2 escalation meetings with ADOP andDCOO.

14


Seen

Acute Leukaemia 100.0% 0.5

Brain/Central Nervous System - 0.0

Breast 83.8% 37.0

Childrens cancer - 0.0

Gynaecological 73.8% 21.0

Haematological (Excluding Acute Leukaemia) 44.4% 13.5

Head and Neck 58.0% 25.0

Lower Gastrointestinal 62.9% 17.5

Lung 75.0% 12.0

Other 50.0% 1.0

Sarcoma 57.1% 3.5

Skin 93.8% 32.0

Testicular 100.0% 3.0

Upper Gastrointestinal 46.4% 14.0

Urological (Excluding Testicular) 63.6% 53.5

Trust 70.0% 233.5

Cancer 62 Day Waits - GP Referral

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Cancer Benchmarking - 62 Day GP/Dentist, July 2019

Average

2SD limits

3SD limits

LTHT

Other Trusts

Source: NHS England

% of IPTs received

by day 38, Jul-19Trajectory By day 38 Total % by day 38

Airedale 70% from Apr-15 3 5 60.0%

Bradford 85% from May-15 5 13 38.5%

Calderdale 85% from Dec-14 9 14 64.3%

Harrogate 85% from Dec-14 7 12 58.3%

Mid Yorks 85% from end Q3 14/15 9 20 45.0%

York 75% by end Q4 14/15 7 17 41.2%

Sub Total 85% 40 81 49.4%

Total 85% 41 84 48.8%

60%

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80%

90%

100%

Q2 2018/19 Q3 2018/19 Q4 2018/19 Q1 2019/20 Q2 2019/20(as at Jul-19)

Performance against the 62 day cancer standard for GP/dentist referralsAll referrals Threshold

Internal referrals By Day 38

CQC: Responsive Ambulance Handover

Standard(s): All handovers should take place within 15 minutes

Owner(s): Chief Operating Officer and Clinical Director of Urgent Care

Commentary: Handover data is recorded by YAS staff on YAS software and submitted to NHSI/E directly. The ability for LTHT validation and challenge pre National submission ceased in November 2018. LTHT continue to locally validate the position and highlighted through to the CCG’s. Since the process for excluding challenges has changed, LTHT has seen a reduction in ambulance handover performance.

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Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19

LGI Ambulance Handover Times

>= 60 mins >= 30 mins

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100

120

140

160

180


SJUH Ambulance Handover Times

>= 60 mins >= 30 mins

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Trust Ambulance Handover Times

>= 60 mins >= 30 mins

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40%

Ambulance Handover % Longer Than 15 Minutes SJUH LGI

CQC: Safe Incidence of MRSA

Standard(s): Eliminate Trust-apportioned MRSA bacteraemia cases

Owner(s): Chief Medical Officer, Infection Control Team, and Clinical Directors

Commentary: For July 2019 there have been 0 cases attributed to LTHT. The total number of cases recorded for Q1 is 1 in comparison to 2 in Q1 last year.

The key finding from LTHT’s investigation is around the use of the appropriate decolonisation when a patient has resistance to Mupirocin (nasal treatment). The Trust is continuing with the HCAI faculty work on reducing bloodstream infections and have rolled out Trust wide “know your data” and “ Personal Protective Equipment” posters to encourage IPC practices.

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Trusts

Rate of trust-apportioned MRSA bacteraemia cases per 100,000 occupied bed days, Jul-18-Jul-19

Peers Other Trusts LTHT England

Source: Public Health England

44 Trust(s) reported no MRSA cases for the period. Rates calculated using 2018/19 bed day data.

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ys

Calculated Bed Days

MRSA Benchmarking, July 2018 - July 2019

Average

2SD limits

3SD limits

LTHT

Other Trusts

Source: NHS England

MRSA by CSU Aug-19 YTD

Abdominal Medicine and Surgery 0 0

Adult Critical Care 0 0

Cardio-Respiratory 0 0

Centre for Neurosciences 0 0

Emergency and Speciality Medicine 0 1

Institute of Oncology 0 0

Trauma and Related Services 0 0

Chapel Allerton 0 0

Children's 0 0

Ear Nose & Throat 0 0

Women's 0 0

Trust 0 1

CQC: Safe Incidents

Standard(s): The number of incidents occurring compared to the patients who receive our care.The number of never events, defined as serious harm to patients which should be avoided.

Owner(s): Chief Medical Officer

Commentary: A serious incident is defined where a patient, member of staff or member of the public has suffered serious injury, major permanent harm or unexpected death, or a significant near missthat may have led to serious harm (Serious Incident Framework, NHSE, March 2015). These are reported and investigated in line with the Trust’s Serious Incident Procedure (February 2016)to help us learn and take action to prevent recurrence. A detailed review of serious incidents and the associated learning from completed investigations is undertaken at the Trust’s QualityAssurance Committee.• The Trust reported 10 serious incidents to commissioners at NHS Leeds CCG in August 2019.• One Category 3 and two ungradeable pressure ulcers were reported to the commissioners in August 2019.• Three patient falls resulting in serious injury were reported to the commissioners in August 2019.• There was one Never Event in August 2019. A wrong tooth extraction (SUI 2019/18792) in Leeds Dental Institute.

17

0

1

2

3

Never Events

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Serious Incidents Per 1,000 Bed Days

*PU includes both admitted with and developed

No

. of

Inci

den

ts

0

50

100

150

200

250

300

350

400

450

500

Incidents by Risk Grade (August 2019)

Low Medium High

CQC: Safe Venous Thromboembolism (VTE) risk assessments

Standard(s): Ensure at least 95% of adult inpatients have a VTE risk assessment on admission to hospital

Owner(s): Chief Medical Officer and Clinical Directors

Commentary: Improving trajectory since current oversight system put in place (Feb 2019) 94.8% achieved for July 2019

Current actions being undertaken:1) Monthly review by clinical owner2) Work with CSUs that are below target, and with negative trajectories3) Work with wards to utilise Safety huddles for VTE review

18

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Trusts

% of eligible admitted patients risk assessed for VTE, Quarter 1 2019-20LTHT Peers Others Target

Source: NHS England

70%

75%

80%

85%

90%

95%

100%

VTE RCA Completion

90%

92%

94%

96%

98%

100%

Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19

% of eligible patients risk assessed for VTE

Performing areas

19

CQC: Effective Mortality Indicator Reporting

Standard(s): Improve the Trust’s Summary Hospital-level Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR)


Commentary: The Trust’s SHMI for April 2018 – March 2019 was 107.75, a increase from the previous releases. Relative to other providers LTHT remains within the expected range.

Observed Deaths are above Expected Deaths for the eighth consecutive period.

The Trust is currently ranked 98 out of 130 Trusts based on Observed Deaths vs. Spells at the last SHMI publication.

20

0

20

40

60

80

100

120

140

Apr-17 to Mar-18 Jul-17 to Jun-18 Oct-17 to Sep-18 Jan-18 to Dec-18 Feb-18 to Jan-19 Mar-18 to Feb-19 Apr-18 to Mar-19

Re

lati

ve

Ris

k

Fig. 3 Trust level SHMI and HSMR (basket of 56 diagnoses) by rolling 12 month period (source: Dr Foster / HSCIC)

SHMI HSMR (faded out is provisional) National average

3500

3600

3700

3800

3900

4000

4100

4200

4300

4400

Jan-15 toDec-15

Apr-15 toMar-16

Jul-15 toJun-16

Oct-15 toSep-16

Jan-16 toDec-16

Apr-16 toMar-17

Jul-16 toJun-17

Oct-16 toSep-17

Jan-17 toDec-17

Apr-17 toMar-18

Jul-17 toJun-18

Oct-17 toSep-18

Jan-18 toDec-18

Feb-18 toJan-19

Mar-18 toFeb-19

Apr-18 toMar-19

Observed Deaths vs Expected Deaths from SHMI Publications

Observed Deaths Expected DeathsFig. 1 Trust level mortality, Apr-18 to Mar-19 Spells ValueObserved

Deaths

Expected

Deaths

95%

Confidence

Interval

125,170 107.75 4,100 3,805 89.08-112.26

60,677 106.84 2,472 2,314 102.67-111.14

SHMI published banding (95% CL with over-dispersion)

HSMR

CQC: Safe Incidence of CDI

Standard(s): Reduce the number of Trust-attributed CDIs to no more than 118


Commentary: The CDI position for August is 12 against a trajectory of no more than 19. The Trust’s position for Q1 is a total of 32 cases against a trajectory of no more than 60. It is encouraging to note that we are continuing to see a downward trend in our CDI cases following the implementation of the CDI recovery plan during Q4 of 2018/19. Actions continue to be monitored via our current HCAI Annual Programme to ensure that the changes put in place are embedded in practice.

21

0

20

40

60

80

100

120

Trusts

Rate of trust-apportioned C.Difficile cases per 100,000 occupied bed days for patients aged > 2 years, May-17-May-18

Peers Other Trusts LTHT England

Source: Public Health England

3 Trust(s) reported no CDI cases for the period. Rates calculated using 2015/16 bed day data.

0

10

20

30

40

50

60

70

80

90

0 200000 400000 600000 800000

Ra

te p

er

100000 B

ed

Da

ys

Calculated Bed Days

CDI Benchmarking, July 2018 - July 2019

Average

2SD limits

3SD limits

LTHT

Other Trus ts

Source: NHS England

CDI by CSU Aug-19 YTD

Abdominal Medicine and Surgery 4 13

Adult Critical Care 0 4

Cardio-Respiratory 1 5

Centre for Neurosciences 1 1

Chapel Allerton Hospital 0 0

Childrens 0 2

Emergency and Speciality Medicine 3 17

Head & Neck 0 0

Institute of Oncology 3 13

Trauma and Related Services 0 1

Unassigned 0 0

Womens 0 2

Trust 12 63

63Trust (accounting for cases agreed with the CCG as unavoidable)

0

50

100

150

200

250

300Progress against the CDI target (split by annual trajectories)

CDI Cases Trajectory

Other: Local Electronic Discharge Advice Notes (eDANs)

Standard(s): Ensure at least 90% of eDANs comply with requirements and are received by GPs within 24 hours

Owner(s): Chief Medical Officer

Commentary: LTHT has been achieving this standard consistently since August 2018 with a steady improvement to 91.8% in August 2019.

22

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

65%

70%

75%

80%

85%

90%

95%

100%

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19

May-19

Jun-19

Jul-19

Aug-19

% of eDANs sent to GP within 24 hours of discharge

Applicable discharges % sent within 24 hours Target

0

1000

2000

3000

4000

5000

6000

Completed eDANs

Bluespier PPM+ Total

CQC: Caring Complaints

Standard(s): Work to reduce the number of complaints per 10,000 patient contactsReduce the number of complaints that are re-opened within 6 months of the initial response because concerns have not satisfactorily beenaddressed (internal indicator) through increasing the quality of complaint responses and reducing time to response issued.

Owner(s): Chief Nurse

Commentary: The number of complaints in August 2019 fell with the average number of complaints having risen from Feb 2019. Complaints appear to drop in the month of August with an assumption that it is holiday season and complaints are likely to rise in September as in previous years.The most frequently raised complaint in August 2019 relate to communication, treatment and administrative issues.

23

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

0

20

40

60

80

100


Number of complaints received and rate per 10,000 patient contacts

Received Rate per 10,000 patient contacts

0

5

10

15

20

25


Number of complaints re-opened

70%

75%

80%

85%

90%

95%

100%


Percentage of complaints acknowledged within 3 working days

Co

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0%

20%

40%

60%

80%

100%

0

5

10

15

20

25

30

35

40

Cu

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%

Co

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ts

Subject

Complaints by Subject (Aug-19)

Vital Few Useful Many Cumulative% Cut Off % [42]

Clinical Service Unit Received (YTD) Activity Rate/ 10k Activity

Theatres & Anaesthesia 11 10,825 10.2

Centre for Neurosciences 35 36,959 9.5

Women's 39 43,153 9.0

Emergency & Specialty Medicine 95 167,886 5.7

Trauma & Related Services 23 46,687 4.9

Children's 28 69,889 4.0

Cardio-Respiratory 22 60,489 3.6

Abdominal Medicine & Surgery 52 150,137 3.5

Leeds Dental Institute 6 27,621 2.2

Oncology 33 179,637 1.8

CQC: Well-led Patient satisfaction: Friends and Family Test

Standard(s): Ensure a high proportion of eligible patients respond to the Friends and Family Test (FFT) and that the Trust achieves high recommendation rates (2015/16 thresholds have not yet been specified by the TDA)

Owner(s): Chief Nurse

Commentary: The overall Response and Recommendation Rates includes those from Outpatients, Inpatients, Day Case, Maternity and Emergency Departments. The overall response rate in August 2019 was one of the highest the Trust has recorded.The overall recommended rate in August 2019 was above 90%. Both Emergency Departments continued to perform above the Trust response rate target of 20% with 50.4% SJUH ED patients providing feedback.All Inpatient/Daycase CSUs achieved a % recommended rate higher than the internal target of 90%.

24

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


FFT response rates (%)

A&E Inpatients Maternity

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


FFT recommendations (%)

A&E Inpatients Maternity Outpatients

Response

RateRecommendation

Response

RateRecommendation

Abdominal Medicine and Surgery 61.3% 96.4% 53.3% 96.7%

Cardio-Respiratory 45.0% 97.7% 37.1% 98.1%

Centre for Neurosciences 38.6% 97.8% 32.6% 96.7%

Chapel Allerton Hospital 39.3% 99.0% 31.5% 98.9%

Children's 47.0% 97.5% 37.8% 97.0%

Emergency and Specialty Medicine 54.3% 92.4% 49.4% 92.1%

Head & Neck 65.5% 95.9% 44.1% 97.2%

Institute of Oncology 29.4% 97.0% 23.5% 96.8%

Leeds Dental Institute 132.8% 98.1% 92.9% 98.6%

Theatres & Anaesthesia 39.6% 95.6% 32.9% 96.5%

Trauma and Related Services 97.5% 97.5% 61.0% 96.7%

Women's 4.4% 100.0% 11.3% 95.1%

Inpatient Total 48.2% 96.5% 39.5% 96.3%

Maternity Total 58.1% 99.1% 47.1% 97.9%

A&E Total 35.2% 87.8% 28.8% 87.8%

Outpatients Total n/app 95.4% n/app 95.5%

Combined Total 42.2% 93.1% 34.9% 93.3%

Aug-19 YTD

CSU

CQC: Effective Harm Free Care

Standard(s): Ensure at least 95% of patients receive harm free care in relation to pressure ulcers, falls, catheter-associated urinary tract infections (CUTIs)and venous thromboembolism (VTE)

Owner(s): Chief Nurse and Clinical Directors

Commentary: Performance related to Harm Free Care has been greater than 95% for six consecutive months during Q1/Q2 2019/20, with decreases reported in all domains from Q4 2018/19.During Q1 there were seven patients reported on the safety thermometer who fell in April 2019, 12 in May 2019 and six in June 2019. Of these 25 total falls, six were a fall with harm (twodefined as moderate occurred within LTHT). There were no falls with harm reported in June 2019. This is in comparison to Q4 2018/2019 where 37 patients fell, of which nine resulted in thepatient suffering harm. Since April 2017 falls with harm have seen a statistically significant reduction of 63%, with the mean recalculated from 0.38% to 0.14%.

During Q1 the prevalence of new hospital acquired pressure ulcers reported on safety thermometer totalled 48, with 0.71% (12 patients) in April 2019, 0.92% ( 15 patients) for May and1.33% (21 patients) in June 2019. Of these hospital acquired pressure ulcers 6 were identified as category 3, and one was a category 4 with moderate/severe harm. This is in comparison toQ4 2018/19 when 15 category 3 and two category 4 moderate/severe harms were reported for patients receiving care within the Trust.

25

0%

1%

2%

3%

4%

5%

6%


Ulcers Falls w Harm New VTEs CUTIs

Source: Safety Thermometer

90

91

92

93

94

95

96

97

98

% H

arm

Fre

e

Safety Thermometer - Harm Free Care Target (95%) Harm Free Care

90%

91%

92%

93%

94%

95%

96%

97%

98%Safety Thermometer - Harm Free Care

% Avg LCL UCL

CQC: Effective Harm Free Care

Standard(s): Ensure at least 95% of patients receive harm free care in relation to pressure ulcers, falls, catheter-associated urinary tract infections (CUTIs)and venous thromboembolism (VTE)


Commentary: • The Trust ‘Pressure Ulcer Collaborative’ remains active and the City Wide Pressure Ulcer Prevention Group continue to meet quarterly.• September 2019 has seen a change to Datix reporting for pressure ulcers, as a result of NHSi changes to definitions.• The online level 1 eLearning for pressure ulcer training compliance is currently at 91% (green) with level 2 learning currently at 76 % (amber). The eLearning package for level 2 is in the

final draft and should be ready for rollout in Q3 across the Trust. This is expected to improve compliance levels further and allow for easier access to training via the online training ratherthan a face to face competency.

• An SSKIN week to promote pressure ulcer awareness was organised by Tissue Viability in Beckett Wing.• The hybrid mattress trial continues on 2 wards

• The Trust ‘Falls Collaborative’ remains active along with a Trust Falls Prevention Group.• As part of the actions to reduce falls, a roll out programme for Stop the Line document for non STEIS reportable falls with moderate harm has been completed. Stop the Line focusses on

bringing key members of the multi-disciplinary team together at the bedside within six hours of detection of the incident to review the circumstances of the fall. If the fall is deemed avoidable then a full root cause analysis investigation will be undertaken. This will aid learning from incidents in a timely manner.

• The Senior Nurse for Patient Safety regularly reviews training compliance for falls prevention priority training and, where requested, undertakes bespoke training within CSU’s. Current compliance is 86% (green).

26

0

50

100

150

200

250

300

350

Ap

r-1

4

Jun-1

4

Au

g-1

4

Oct

-14

De

c-1

4

Fe

b-1

5

Ap

r-1

5

Jun-1

5

Au

g-1

5

Oct

-15

De

c-1

5

Fe

b-1

6

Ap

r-1

6

Jun-1

6

Au

g-1

6

Oct

-16

De

c-1

6

Fe

b-1

7

Ap

r-1

7

Jun-1

7

Au

g-1

7

Oct

-17

De

c-1

7

Fe

b-1

8

Ap

r-1

8

Jun-1

8

Au

g-1

8

Oct

-18

De

c-1

8

Fe

b-1

9

Ap

r-1

9

Jun-1

9

Au

g-1

9

Fa

lls

Month

All Falls

0

10

20

30

40

50

60

70

80

90

100

Apr-

14

Jun-1

4

Aug

-14

Oct-

14

Dec-1

4

Fe

b-1

5

Apr-

15

Jun-1

5

Aug

-15

Oct-

15

Dec-1

5

Fe

b-1

6

Apr-

16

Jun-1

6

Aug

-16

Oct-

16

Dec-1

6

Fe

b-1

7

Apr-

17

Jun-1

7

Aug

-17

Oct-

17

Dec-1

7

Fe

b-1

8

Apr-

18

Jun-1

8

Aug

-18

Oct-

18

Dec-1

8

Fe

b-1

9

Apr-

19

Jun-1

9

Aug

-19

Pre

ss

ure

Ulc

ers

Month

Developed Pressure Ulcers

CQC: Responsive Outpatient Measures

Standard(s): Ensure the Trust’s Did Not Attend (DNA) rate is below the peer averageReduce the number of appointments cancelled by hospital within 6 weeks of appointmentReduce the number of appointments cancelled by patient within 6 weeks of appointment

Owner(s): Director of Informatics and Clinical Directors

Commentary: Non Attendance rates (DNAs) for LTHT continue to be below our peer average and achieve the set standard. This is due to the continued use of LTHT automated Outpatient appointment reminder service managed by the RBS and the offering of choice of outpatient appointment to our patients.The rate of Outpatient appointment cancellations by both the hospital and patients still remains a challenge for LTHT. The Outpatient CSU, is continuing to support CSUs with reducing clinic cancellations under 6 weeks, increasing the number of Outpatients appointments booked through choice and the development of SLAs with CSUs. There has been an increasing number of patients waiting over 3 months for follow up since February 2019. Analysis has been undertaken and CSU’s have been requested to review their over 3 month follow up and provide a plan to reduce these waiting times. This measure will also be introduced into CSU Delivery Contracts by the end of Q2 2019/20.

27

0

5000

10000

15000

20000

25000

OP Appointment Cancellations Cancelled By Hospital Cancelled By Patient inc CND

0

2000

4000

6000

8000

10000

12000

OP Follow-Up Waiting List Patients >3 Months Over their Due Date

5.0%

5.5%

6.0%

6.5%

7.0%

7.5%

8.0%

8.5%

Outpatient DNA% LTHT Peer Avg

Source:Dr Foster

CQC: Other Length of Stay

Standard(s): To reduce the length of stay in order to release capacity for other patients and provide an improved patient experience


Commentary: When reviewing the SPC charts, 99% of data points should fall between the Lower and Upper Control Limit:• Elective LOS SPC Charts is within normal control• The Non Elective LOS SPC Charts is within normal control.

28

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

Non-Elective Length of Stay

LOS (Days) Average LCL UCL

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

Elective Length of Stay

LOS (Days) Average LCL UCL

2.00

2.50

3.00

3.50

4.00

4.50

Ave

rag

e L

OS

Da

ys

Elective LOS LTHT Peer Avg

3.50

4.00

4.50

5.00

5.50

6.00

Ave

ra

ge

LO

S D

ays

Non-Elective LOS LTHT Peer Avg

CQC: Effective 30 Day Emergency Readmission Rates

Standard(s): Ensure no more than 10.9% of patients are readmitted as an emergency within 30 days of discharge, following elective or non-elective treatment.

Owner(s): Chief Operating Officer and CSU Clinical Directors

Commentary: Readmission rates remain below peer in elective, non-elective and total categories..

29

0%

2%

4%

6%

8%

10%

12%

14%


% Readmissions - elective

% Readmissions Peer % Readmissions

0%

2%

4%

6%

8%

10%

12%

14%


% Readmissions - non-elective


0%

2%

4%

6%

8%

10%

12%

14%

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19

% Readmissions - total (elective and non-elective)


CQC: Other CQUIN Tracker – Page 1of 3

Standard(s): To ensure LTHT meets required CCG Nationally selected and locally agreed CQUIN requirements within defined timescales in order to access associated funding


Commentary: CCG & NHSE CQUINs 2019/20: IQPR 10 Sept 2019

30

CQC: Other CQUIN Tracker – Page 2 of 3




31

CQC: Other CQUIN Tracker – Page 3 of 3




32

Key

Not achieved Local assessment to be signed off

Partial achievement Achieved

CQC: Well-led People

Standard(s): Ensure staff turnover remains stableReduce sickness absence rates in line with the internally agreed trajectory

Owner(s): Director of Human Resources and Clinical Directors

Commentary: Turnover has reduced by 2% from November 17 to June 19 (latest available). The most common reasons for leaving (excluding training grade doctors) are “Voluntary Resignation - Other/NotKnown”, “Voluntary Resignation – Relocation” and “Voluntary Resignation – Promotion” which account for 62.8% of leavers.

33

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0

5

10

15

20

25

30

35

40

45

Cu

mu

lati

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%

FT

E

Reason

Leaving Reasons June2019


0%

2%

4%

6%

8%

10%

12%

14%

Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19

Turnover Rate (Jun-17 - Jun-19)

*Source iView – Not Comparable to internal figures due to counting some other organisations as part of the trust - This is the

last available data due to metric being retired.

Turnover May 2019

CQC: Well-led People

Standard(s): Ensure staff turnover remains stableReduce sickness absence rates in line with the internally agreed trajectory (AF and internal indicator)

Owner(s): Director of Human Resources and Clinical Directors

Commentary: A long term sickness is classed as any sickness over 28 consecutive days, a short term sickness is anything under this. The top 3 long term sickness absence reasons are “S10Anxiety/stress/depression/other psychiatric illnesses”, “S12 Other musculoskeletal problems” and “S98 Other known causes - not elsewhere classified” accounting for 55.4% of Long TermSickness Absence.The top 3 short term sickness absence reasons are “S25 Gastrointestinal problems”, “S10 Anxiety/stress/depression/other psychiatric illnesses” and “S13 Cold, Cough, Flu – Influenza”accounting for 43.6% of Short Term Sickness Absence.

34

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19

Sickness Rates (Jun-17 - Jun-19) Twelve Month Short Term % Twelve Month Long Term %

S10 A

nx

iety

/str

ess

/de

pre

ssi

on

/oth

er

psy

ch

iatr

ic

illn

ess

es

S12 O

the

r m

usc

ulo

ske

leta

l p

rob

lem

s

S98 O

the

r kn

ow

n c

au

ses

-n

ot

els

ew

he

re

cla

ssif

ied

S28 I

nju

ry,

fra

ctu

re

S99 U

nkn

ow

n c

au

ses

/ N

ot

spe

cif

ied

S11 B

ack P

rob

lem

s

S25 G

ast

roin

test

ina

l p

rob

lem

s

S17 B

en

ign

an

d m

ali

gn

an

t tu

mo

urs

, ca

nce

rs

S26 G

en

ito

uri

na

ry &

gyn

ae

co

log

ica

l d

iso

rde

rs

S13 C

old

, C

ou

gh

, F

lu -

Infl

ue

nza

S30 P

reg

na

ncy r

ela

ted

dis

ord

ers

S19 H

ea

rt,

ca

rdia

c &

cir

cu

lato

ry p

rob

lem

s

S15 C

he

st &

re

spir

ato

ry p

rob

lem

s

S16 H

ea

da

ch

e / m

igra

ine

S18 B

loo

d d

iso

rde

rs

S29 N

erv

ou

s sy

ste

m d

iso

rde

rs

S21 E

ar,

no

se,

thro

at

(EN

T)

S23 E

ye

pro

ble

ms

S31 S

kin

dis

ord

ers

S24 E

nd

ocri

ne

/ g

lan

du

lar

pro

ble

ms

S22 D

en

tal

an

d o

ral p

rob

lem

s

S27 I

nfe

cti

ou

s d

ise

ase

s

S14 A

sth

ma

0%

20%

40%

60%

80%

100%

0

1000

2000

3000

4000

5000

6000

7000

Cu

mu

lati

ve

%

Da

ys

Lo

st

Reason

Long Term Sickness Reasons June 2019


S25 G

ast

roin

test

ina

l p

rob

lem

s

S10 A

nx

iety

/str

ess

/de

pre

ssi

on

/oth

er

psy

ch

iatr

ic

illn

ess

es

S13 C

old

, C

ou

gh

, F

lu -

Infl

ue

nza

S99 U

nkn

ow

n c

au

ses

/ N

ot

spe

cif

ied

S98 O

the

r kn

ow

n c

au

ses

-n

ot

els

ew

he

re

cla

ssif

ied

S12 O

the

r m

usc

ulo

ske

leta

l p

rob

lem

s

S16 H

ea

da

ch

e / m

igra

ine

S11 B

ack P

rob

lem

s

S28 I

nju

ry,

fra

ctu

re

S21 E

ar,

no

se,

thro

at

(EN

T)

S30 P

reg

na

ncy r

ela

ted

dis

ord

ers

S26 G

en

ito

uri

na

ry &

gyn

ae

co

log

ica

l d

iso

rde

rs

S15 C

he

st &

re

spir

ato

ry p

rob

lem

s

S23 E

ye

pro

ble

ms

S22 D

en

tal

an

d o

ral p

rob

lem

s

S31 S

kin

dis

ord

ers

S27 I

nfe

cti

ou

s d

ise

ase

s

S19 H

ea

rt,

ca

rdia

c &

cir

cu

lato

ry p

rob

lem

s

S29 N

erv

ou

s sy

ste

m d

iso

rde

rs

S14 A

sth

ma

S24 E

nd

ocri

ne

/ g

lan

du

lar

pro

ble

ms

S17 B

en

ign

an

d m

ali

gn

an

t tu

mo

urs

, ca

nce

rs

S18 B

loo

d d

iso

rde

rs

0%

20%

40%

60%

80%

100%

0

200

400

600

800

1000

1200

1400

1600

Cu

mu

lati

ve

%

Da

ys

Lo

st

Reason

Short Term Sickness Reasons June 2019


Accountability

Framework Finance: Accountability Framework Dashboard

Owner(s): Director of Finance

35

Domain 2 - Finance

Aug-19

In-year financial delivery indicators Plan £'000 Actual £'000 Variance £'000

NHS Financial Performance

Year to Date, Actual compared to Plan (Control Total including PSF before the impact of gains on disposal of assets) (7,298) (5,654) 1,644

Forecast Outturn, Compared to Plan (Control Total including PSF before the impact of gains on disposal of assets) 12,007 12,007 0

Financial Efficiency

Actual Efficiency for Year to Date compared to Plan 13,142 13,172 30

Recurrent Efficiencies for Year to Date compared to Plan 10,776 9,231 (1,545)

Forecast Outturn Efficiency Compared to Plan 51,900 51,900 0

Recurrent Efficiencies for Forecast Outturn compared to Plan 41,051 35,824 (5,227)

Underlying Revenue Position

Forecast Outturn Underlying Revenue Position compared to plan (41,999) (47,226) (5,227)

Cash and Capital

Forecast Year End Charge to Capital Resource Limit (incl IFRS impact) 65,462 65,263 (199)

Temporary Working Capital Drawdown for Liquidity Purposes (cumulative sum) 0 0 0

Funding Accessed (cumulative sum) 0 0 0

Use of resources indicators Plan Actual Variance

Liquidity Days 4 4 0

Capital Services Capacity 4 4 0

I&E Margin 4 3 1

Variance from Control Total 1 1 0

Agency 1 1 0

Use of Resources Rating 3 3 0

SECTION A: NATIONAL KEY INDICATORS

In-Y

ea

r F

ina

nc

ial D

eliv

ery

Us

e o

f R

es

ou

rce

s

Ra

tin

g

36

Single Oversight

Framework Finance: In-year delivery

In-year Delivery The Trust delivered an operating deficit before Provider Sustainability Funding (PSF) and Marginal Rate Emergency Tariff (MRET) of £13.1 million for the fivemonths to 31st August 2019, £1.6m ahead of the plan. As the Trust has agreed to a control total with NHS England and NHS Improvement and has achievedits financial plan for August, it is eligible to receive PSF funding of £4.9 million in addition to MRET funding of £2.6 million which gives an overall deficit todate for the Trust of £5.7 million, ahead of plan by £1.6 million. Overall income at the end of August, £541.7 million, is ahead of plan by £7.8 million.Operating expenditure is £6.9 million behind plan with a £4.4 million adverse variance on pay and a £2.5 million adverse variance on non-pay. The non-payvariance includes an adverse variance against pass through drugs and blood of £3.8 million (offset in income), the non-pay non pass through is £1.3 millionfavourable to plan.

Savings of £2.3 million were delivered in August with savings to date of £13.2 million, which is slightly ahead of the plan by £0.1m. The savings plan for theyear is £51.9 million.

Accountability Framework

summary performance:In August the Trust reported a deficit of £5.7 million (including PSF and MRET) against a planned deficit of £7.3 million.

The Single Oversight Framework has four ratings/levels which are used by NHSI to determine which level of support would be of benefit to a trust:-1. No Concerns 2. Minor Concerns/Emerging Issues 3. Serious Issues 4. Critical Issues

The Trust achieved a use of resources risk rating of 3 in August.

Liquidity (weighting 20%) Liquidity at month end was -22 days which equates to a rating of 4 (against plan rating of 4)

Capital Servicing Capacity

(weighting 20%)Capital servicing capacity at month end was 0.93 which equates to a rating of 4 (against plan rating of 4).

I&E Margin (weighting 20%) I&E Margin at month end was (1.0%) which equates to a rating of 3 (against plan rating of 4).

Variance from Control Total

(weighting 20%)I&E Variance from control total at month end was 0.3% which equates to a rating of 1 (against plan rating of 1).

Agency Spend Distance

from Cap (weighting 20%)Agency Spend distance from capped plan at month end was (2.0%) which equates to a rating of 1 (against plan rating of 1).

Overall Use of Resources

(100%)Overall Use of Resources (after NHSI/NHSE overrides) at month end was rated at 3 (against plan rating of 3).

Appendix 1: Updates from Regulators

Provides a summary of important updates from regulatory and oversight bodies

Regulators Provider regulation – NHS Improvement regulates NHS foundation trusts and trusts on their financial stability, operational performance, care quality, leadership,

improvement capability and their ability to deliver strategic change. It does this through the Single Oversight Framework which combines powers previously exercised by

Monitor and the NHS Trust Development Authority (TDA).

Quality regulation – Quality regulation has risen up the agenda in recent years. As a result, the Care Quality Commission (CQC) has undergone significant reform. The CQC

sets the fundamental standards of quality and safety for healthcare services and monitors and inspects providers to ensure standards are upheld. The CQC's five year

strategy for 2016-21 sets out how its regulatory model will develop following the first inspection of all NHS providers.

NHS Improvement:

Join the conversation

on workforce

(February 2019)

NHS Improvement launched five discussion pages on Talk Health and Care asking:• How can we better support our clinical workforce?• How do we ensure the NHS is a great place to work?• How do we develop compassionate, effective and diverse leaders in the NHS?• The future medical workforce: How do we get the balance right?• How can we enable the delivery of the NHS Long Term Plan by improving skills and education in using new technology?Each week they post new questions via workforce bulletin.Share your views at: https://dhscworkforce.crowdicity.com/category/browse/

NHS Improvement

Provider Bulletins

Further in formation on the NHS Provider Bulletins is available on the NHS Improvement Website at:https://improvement.nhs.uk/news-alerts/?articletype=provider-bulletin

Care Quality

Commission: State of

Care 2017/18

(October 2018)

State of Care is our annual assessment of health and social care in England. This year's State of Care finds that most people receive a good quality of care, but that people’s experiences areoften determined by how well different parts of local systems work together.

Further information and the full report is available on the CQC Website at:https://www.cqc.org.uk/news/stories/state-care-201718-published

Care Quality

Commission: New

web resource on

effective staffing

(June 2019)

The CQC’s have published a new resource on the CQC’s website which explores the approaches taken by a range of health and social care providers to make effective use of their staff.

Further information and the full report is available on the CQC Website at:https://www.cqc.org.uk/news/stories/new-web-resource-effective-staffing

Care Quality

Commission: Latest

News

The latest news articles published by CQC can be found on the CQC Website at:http://www.cqc.org.uk/search/site/news

37

http://nhsproviders.org/topics/regulation/provider-regulation

http://nhsproviders.org/topics/regulation/quality-regulation

https://dmtrk.net/t/2J9J-1DCXY-AB3NOCAQBA/cr.aspx

https://dhscworkforce.crowdicity.com/category/browse/

https://improvement.nhs.uk/news-alerts/?articletype=provider-bulletin

https://www.cqc.org.uk/news/stories/state-care-201718-published

https://www.cqc.org.uk/news/stories/new-web-resource-effective-staffing

http://www.cqc.org.uk/search/site/news

38

Appendix 2: Peer GroupsLists the providers used to benchmark performance throughout the report

HCAIBrighton & Sussex University HospitalsCambridge University HospitalsCentral Manchester University HospitalsChelsea & Westminster HospitalGuy's & St. Thomas'Imperial College HealthcareKing's College HospitalManchester University NHS Foundation TrustNottingham University HospitalsOxford University HospitalsPlymouth HospitalsRoyal Free HampsteadRoyal Liverpool & Broadgreen University HospitalsSalford RoyalSheffield Teaching HospitalsSouth Tees HospitalsSt. George's HealthcareThe Newcastle upon Tyne HospitalsUniversity College London HospitalsUniversity Hospital BirminghamUniversity Hospital SouthamptonUniversity Hospitals BristolUniversity Hospitals Coventry & WarwickshireUniversity Hospitals of Leicester

Diagnostics, Harm Free Care, Friends and Family Test, Complaints, OP DNA, OP New to Review, Length of Stay and VTECambridge University Hospitals NHS Foundation TrustManchester University NHS Foundation TrustNottingham University Hospitals NHS TrustOxford University Hospitals NHS TrustRoyal Liverpool & Broadgreen University Hospitals NHS TrustSheffield Teaching Hospitals NHS Foundation TrustThe Newcastle upon Tyne Hospitals NHS Foundation TrustUniversity Hospital Southampton NHS Foundation TrustUniversity Hospitals Birmingham NHS Foundation TrustUniversity Hospitals Bristol NHS Foundation TrustUniversity Hospitals of Leicester NHS Trust

RTT (as above, plus the following)Guy’s and St Thomas’ NHS Foundation Trust

Imperial College Healthcare NHS Trust

King’s College Hospital NHS Foundation Trust

University College London Hospitals NHS Foundation Trust

A&ECambridge University Hospitals NHS Foundation Trust

Manchester University NHS Foundation TrustNottingham University Hospitals NHS Trust

Oxford University Hospitals NHS Trust

Royal Liverpool & Broadgreen University Hospitals NHS Trust

Sandwell And West Birmingham Hospitals NHS Trust

Sheffield Teaching Hospitals NHS Foundation Trust

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

University Hospitals Of Leicester NHS Trust

CancerCambridge University Hospitals NHS Foundation TrustManchester University NHS Foundation TrustNottingham University Hospitals NHS TrustSheffield Teaching Hospitals NHS Foundation TrustThe Christie NHS Foundation TrustThe Newcastle upon Tyne Hospitals NHS Foundation TrustThe Royal Marsden NHS Foundation TrustUniversity Hospitals Bristol NHS Foundation TrustUniversity Hospitals of Leicester NHS Trust

39

Appendix 3: GlossaryExplains any abbreviations used throughout the report

AFASICAHCASCCGCDICIPCEOCOOCQCCQUINCSUCUTIDBSDGHDHDNAEBITDAEDFFTFTGDPGMPHCAIHSMRI&EIMASIPTQPRKPILGILoSMDTMRSAMSSANIHR

Accountability FrameworkAppointment Slot IssueChapel Allerton HospitalCentral Alerting SystemClinical Commissioning GroupClostridium Difficile Infections Cost Improvement ProgrammeChief Executive OfficerChief Operating OfficerCare Quality CommissionCommissioning for Quality & InnovationClinical Service UnitCatheter-associated Urinary Tract Infection Directly Bookable ServicesDistrict General HospitalDepartment of HealthDid Not AttendEarnings Before Interest, Tax, Depreciation and AmortisationEmergency DepartmentFriends and Family TestFoundation TrustGeneral Dental PractitionersGeneral Medical PractitionersHealthcare Associated InfectionHospital Standardised Mortality RatioIncome & ExpenditureNHS Interim Management and SupportInter-Provider TransferQuality & Performance ReportKey Performance IndicatorLeeds General InfirmaryLength of StayMulti-Disciplinary TeamMeticillin Resistant Staphylococcus AureusMeticillin Sensitive Staphylococcus AureusNational Institute for Health Research

PDCR&IRAFRAGRCARTTSHMISJUHTBCTDAVTEWHOYASYTD

Public Dividend CapitalResearch & InnovationRisk Assessment FrameworkRed Amber GreenRoot Cause AnalysisReferral to TreatmentSummary Hospital-level Mortality IndicatorSt James's University HospitalTo Be ConfirmedTrust Development AuthorityVenous ThromboembolismWorld Health OrganisationYorkshire Ambulance ServiceYear to Date

In order to provide assurance of the quality ofdata presented in this report, a data qualitymatrix has been developed and appliedthroughout. The matrix is based on the 6dimensions of data quality (accuracy, validity,reliability, timeliness, relevance, andcompleteness), with indicators reviewed on anannual basis.

The icon displayed to the left is featured on pages whose content has been assessed and approved against the matrix.

Quality & Performance Report Agenda Item 12.1 (i) Public ......by reporting specialty, Aug-19...

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