Agenda and supporting papers - Plymouth Hospitals NHS Trust

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OTHER ACCESS & ACTIVITY Acting Chief Operating Officer WORKFORCE Human Resources Director SAFETY & QUALITY Medical Director & Acting Chief Nurse FINANCE & EFFICIENCY Acting Director of Finance A1 Summary performance dashboard - May 2013 Status Ranking Page Metric Status Page Safe Care Income & Expenditure Hospital Standardised Mortality Ratio (HSMR Relative Risk) 83.0 YTD 1/17 (SW YTD) £000s variance from plan (Month) (26) Summary Hospital-Level Mortality Indicator (SHMI ) 95.5 YTD 6/17 (SW YTD) £000s variance from plan (Year To Date) (54) D1 % Surgical safety checklist completion 98.0% M2 B1 Cost Improvement Programme Incidents Reporting Rate (per 100 admissions) 9.70 M2 Full year forecast variance from target (£000s) 1,700 % incidents leading to harm, loss or damage 32% M2 CIPs Delivered (£000s) 6,048 Effective Care CIPs Forecast as Green Risk (£000s) 10,937 D2 Readmissions (13 Month Avg Relative Risk) 97.0 YTD 12/17 (SW YTD) B2 CIPs Forecast as Amber Risk (£000s) 7,274 Patient Experience CIPs Forecast as Red Risk (£000s) 1,441 Friends and Family Test Response Rate (Inpatient) 13.7% M2 Capital Expenditure Friends and Family Test Response Rate (ED) 8.4% M2 % of capital programme spent 12% D3 Complaints closed within target (%) 85% M2 B3 Cash Management Non-clinically justified mixed sex breaches (No.) 0 M2 Revised Planned Closing Cash Balance (£'000s) 3,226 Cancelled operations (% of elective FFCEs) 1.96% YTD Actual Closing Cash Balance (£'000s) 8,761 Infection Control Cleared Balances (£'000s) 9,409 MRSA cases (hospital apportioned) 0 YTD 8 / 17 (SW YTD) BPPC - NHS Volume (% within target) 97% D4 B4 C-Diff cases (hospital apportioned) 4 YTD 4 / 17 (SW YTD) BPPC - NHS Value (% within target) 98% Other key safety & quality metrics BPPC - Non-NHS Volume (% within target) 95% % stroke patients >90% of time on stroke unit 62.6% YTD BPPC - Non-NHS Value (% within target) 90% B5 Follow-up backlog - actual (no.of patients) 24305 YTD Contract Penalties Accident & Emergency Contract Penalties - Year-to-Date (£000's) 427 D5 % of A&E patients waiting 30 mins) 1.7% YTD C1 Discretionary Spend (£000s) 1380 Delayed transfers of care (delayed days as % of occupied days) 1.7% YTD Vacancy % - Nursing 5.52% Cancer Services Vacancy % - Medical 7.07% E1 31 days from 'decision to treat' (%) 98.7% YTD 102/168 (Nat Q3) Vacancy % - Admin & Managers 6.60% 62 days from urgent GP referral (%) 83.1% YTD 153/167 (Nat Q3) Vacancy % - Other Staff 6.47% 62 days from screening referral to treat (%) 85.4% YTD 133/145 (Nat Q3) Training & Appraisals 62 days from consultant upgrade to treat (%) 95.7% YTD 64/154 (Nat Q3) Basic Life Support (% completed) 87% 31 days - DTT to subsequent - surgery (%) 95.6% YTD 140/162 (Nat Q3) C3 Manual Handling (% completed) 92% 31 days - DTT to subsequent - drugs (%) 99.2% YTD 4/152 (Nat Q3) Essential Skills (% completed) 95% E2 31 days - DTT to subsequent - rad'th'py (%) 97.8% YTD 69/78 (Nat Q3) Child Protection (% completed) 97% 2 weeks for breast symptom referral (%) 95.9% YTD 43/143 (Nat Q3) Appraisals (% completed) 82% 2 weeks from urgent GP referral (%) 94.1% YTD 150/170 (Nat Q3) Referral To Treatment (RTT) 18 weeks - Admitted patients (%) 88.3% M2 160/174 (Nat M12) 18 weeks - Non-admitted patients (%) 95.9% M2 195/207 (Nat M12) 18 weeks - Audiology Direct Access (%) 97.3% M2 C4 % Incomplete pathways within 18 weeks 90.3% M2 187/206 (Nat M12) Other key access & activity metrics % patients waiting >6 weeks for diagnostic test 2.8% M2 C6 Sickness Absence Trust Sickness Absence Rate (Average %) 3.63% E3 External Assessments Monitor's Governance Risk Rating Monitor's Financial Risk Rating Red 0% (4.0) 2 F1 F2 3
B1 Safe care Description Hospital Standardised Mortality Ratio (HSMR Relative Risk) Summary Hospital-Level Mortality Indicator (SHMI Relative Risk) % Surgical safety checklist completion Incidents Reporting Rate (per 100 admissions) % incidents leading to harm, loss or damage Never Events Overdue safety alerts PERFORMANCE INDICATORS Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Target RAG RAG Thresholds 85 83 83.0 100.0 Green R > 100 G < 100 95 96 95.5 100.0 Green R > 100 G < 100 96.8% 98.0% - 95% Green R < 92% G > 95% 9.8 9.7 - 7.5 Green R < 6.00 G > 7.50 33% 32% - 28% Red R > 28% G < 28% Q 0 0 0 0 Green R > 0 G < 1 3 3 - 0 Red R > 0 G < 1 120 100 80 60 Mortality (HSMR) (13 - Month Avg for Feb 12 - Feb 13) Actual Lower is better ANALYSIS OF KEY PERFORMANCE INDICATORS National Average 120 100 80 60 Summary Hospital Mortality Indicator (SHMI) (13 - Month Avg for Jan 12 - Jan 13) Lower is better COMMENTARY Mortality The Trust continues to perform well in respect of HSMR (17% better than expected) and the SHMI (4% better than expected). The mortality data presented is approx 4/5 months in arrears due to the lag time required for all UK Trusts to submit to the National database and results to be analysed. Individual diagnosis / procedure groups flagged as a concern are reviewed via the Clinical Effectiveness Group. 40 20 - Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Surgical safety checklist completion 100% Higher is better 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 40 20 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Incident Reporting Rate per 100 admissions 12.0 10.0 Higher is better 8.0 6.0 4.0 2.0 - Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Incident Reporting Our reporting rate sits firmly within the national upper quartile with a rate of 9.7 incidents per 100 admissions reported in May 2013. This reporting rate is significantly above the national average of ~7.5 and provides evidence that we have a good culture of openly reporting incidents. 4
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Trust Board Friday 5 July 2013, 9.0
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Members of Plymouth Hospitals NHS T
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Item 3 observer. The Chairman requi
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Item 3 Board oversight of contribut
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Item 3 the Board next month. • Th
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Item 3 been involved and there was
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Item 3 continuing to build. Mr Babe
Page 15 and 16: Item 3 to Norovirus, Professor Lewi
Page 17 and 18: Item 3 • Careful communication of
Page 19 and 20: Item 3 • Approved the writing off
Page 21 and 22: Updated: prior to July Board Item 4
Page 23 and 24: Updated: prior to July Board Item 4
Page 25 and 26: Item 8 Quality Impact Assessment Pa
Page 27 and 28: Item 8 3.2 Quarterly Summary Hospit
Page 29 and 30: Item 8 4.4 Monthly Proportion of Pa
Page 31 and 32: Item 8 Inpatient falls are currentl
Page 33 and 34: Item 8 REI signage PALS were contac
Page 35 and 36: Item 8 Complaints received listed b
Page 37 and 38: Item 8 The graphs below illustrate
Page 39 and 40: Item 8 5.5 Friends and Family Test
Page 41 and 42: Item 8 1. Pressure Ulcers (EoC) 2.
Page 43 and 44: Item 8 Observations The essence of
Page 45 and 46: Item 8a SUMMARY REPORT Trust Board
Page 47 and 48: Annex 2 Item 8a Summary of Serious
Page 49 and 50: Item 9 Key Recommendations The Trus
Page 51 and 52: Item 9 Effective Care (Section B2 o
Page 53 and 54: Item 9 Description 31 days from 'de
Page 55 and 56: Item 9 4.6 Non Elective Activity is
Page 57 and 58: Item 9 Summary of performance excep
Page 59 and 60: Item 9 Ensure that all patients adm
Page 61 and 62: Item 9 Forecast Significant progres
Page 63 and 64: Item 9 Update on previous actions C
Page 65: Contents EXECUTIVE SUMMARY D FINANC
Page 69 and 70: Response Rate Recommender Score B3
Page 71 and 72: B5 Other safety & quality metrics D
Page 73 and 74: C2 Non-Elective Activity Descriptio
Page 75 and 76: C4 Referral To Treatment (RTT) Desc
Page 77 and 78: C6 Other access & activity metrics
Page 79 and 80: D2 Cost improvement programme (CIP)
Page 81 and 82: D4 Cash Management Description Revi
Page 83 and 84: E1 Staffing numbers Description Est
Page 85 and 86: E3 Sickness absence PERFORMANCE IND
Page 87 and 88: Risk Rating F2 Monitor's Financial
Page 89 and 90: Item 10 DETAILED REPORT Trust Board
Page 91 and 92: Item 10 4. Key Issues for the Board
Page 93 and 94: Item 11 SUMMARY REPORT Trust Board
Page 95 and 96: Item 11 DETAILED REPORT Trust Board
Page 97 and 98: Item 11 • Challenge in respect of
Page 99 and 100: Item 11 Over the past two years, me
Page 101 and 102: Item 11 Getting it Right Charter An
Page 103 and 104: Item 11 Outcome of review with exte
Page 105 and 106: Item 11 Learning Disabilities Natio
Page 107 and 108: Item 11 Peer Review 2.5 Peer Review
Page 109 and 110: Item 12 Next Steps 1. Conversation
Page 111 and 112: Item 12 2. Board Inclusion Developm
Page 113 and 114: Item 12 EDS Grades and E & D Object
Page 115 and 116: Item 12 Plymouth Hospitals Trust -
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Item 12 3.6 The workforce is suppor
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Item 13 Key Recommendations The Tru
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Item 13 Telephone conversations.
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Item 13 19. The Medical Director ha
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Item 14 SUMMARY REPORT Trust Board
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Item 15 incident investigations to
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Item 15, Annex 1 3. Review of Actio
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Item 15, Annex 1 • Top three issu
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Item 15, Annex 1 The Chair asked SS
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Item 16 COMMITTEE MINUTES Finance,
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Item 16 pay and staffing, highlight
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Item 16 • PACS contract - likely
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Item 17 Terms and Conditions of Emp
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Item 17, Annex 1 29/2013 Minutes an
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Item 17, Annex 1 31/2013 Francis Re
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Item 18 SUMMARY REPORT Trust Board
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Item 18 Next Steps The Audit Commit
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Item 18, Annex 1 Matters arising 4/
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Item 18, Annex 1 time to embed and
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Item 18, Annex 1 Payroll & Expenses
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Item 18, Annex 1 The Committee note
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Item 18, Annex 1 Going Concern Revi
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Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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