Trust Board papers November 2012 - Barking Havering and ...

Effectiveness
GOVERNANCE RISK RATINGS
BHR University Hospitals NHS
Trust
See 'Notes' for further detail of each of the below indicators
Area Ref Indicator Sub Sections
Threshold
Referral to treatment information 50%
1a
Data completeness: Community services
comprising:
Referral information 50%
Treatment activity information 50%
Weighting
Historic Data
Qtr to Dec- Qtr to
11 Mar-12
1.0 N/a
Insert YES (target met in month), NO (not met in month) or N/A (as
appropriate)
See separate rule for A&E
Qtr to
Jun-12
N/a N/a N/a
Current Data
Jul 12 Aug-12 Sep-12
Patient identifier information 50% N/a N/a N/a N/a N/a N/a Yes
Data completeness, community services:
1b
(may be introduced later)
Patients dying at home / care
50% N/a N/a N/a N/a N/a N/a Yes
home
1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a Yes
N/a
N/a
Qtr to
Sep-12
Yes
Comments where target
not achieved
1c
2a
Data completeness: outcomes for patients
on CPA
From point of referral to treatment in
aggregate (RTT) – admitted
50% 0.5 N/a N/a N/a N/a N/a N/a Yes
Maximum time of 18 weeks 90% 1.0 N/a N/a Yes Yes Yes yes Yes
Patient Experience
2b
2c
2d
3a
From point of referral to treatment in
aggregate (RTT) – non-admitted
From point of referral to treatment in
aggregate (RTT) – patients on an
incomplete pathway
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
All cancers: 31-day wait for second or
subsequent treatment, comprising :
Maximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes yes yes Yes
Maximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes yes yes Yes
Surgery 94%
Anti cancer drug treatments 98%
Radiotherapy 94%
From urgent GP referral for
suspected cancer
85%
3b All cancers: 62-day wait for first treatment: 1.0 yes
From NHS Cancer Screening
90%
Service referral
N/A 0.5 no no no no no no No
1.0 yes
yes yes yes yes yes
yes
no
Yes
No yes yes No
the Trust is meeting meeting 5 of the 6
requirements . The area not yet fully
compliant 'audit of practice' against policy.
Business Units will review casenote for
patients with LD treated in the service during
October to meet this requirement
This measure was not met in July. The
underachievement was due to complex
pathways, endoscopy capacity and lack of
escalation across the pathways. The annual
trajectory was approved by the Trust
Executive Committee (TEC) with action plans
being provided by each specialty. In addition
the NHS Intensive Support Team provided
the Service with advice. Weekly specialtylevel
patient target list (PTL) meetings with
each Service Manager have been
introduced; a more robust escalation process
for delays in radiological and pathology
reporting has been implemented together
with a review of endoscopy capacity. The
Service is also recruiting additional MDT coordinators
a senior MDT coordinator and a
float MDT coordinator to provide cover for
leave. The target has been achieved since
August 2012.