Integrated Performance Report - Southwark CCG · ENC Bii The best possible outcomes for Southwark people 3 | P a g e 1. Structure of the Document The report is written to enable the

ENC Bi

Integrated

Performance Report M9 2013/14

27 February 2014

Bii

ENC Bii

The best possible outcomes for Southwark people 2 | P a g e

Contents 1. Structure of the Document ........................................................................................................ 3

2. Southwark CCG and Providers Performance Summary Dashboard ........................................... 4

3. Southwark CCG Dashboard (M9) ................................................................................................ 5

4. Provider Dashboards (M8 Performance Q3 Quality & Safety) .................................................. 6

a. King’s College Hospital NHS Foundation Trust .................................................................................... 6

b. Guy’s & St. Thomas’ NHS Foundation Trust ........................................................................................ 7

c. Guy’s & St. Thomas’ NHS Foundation Trust – Community Health Services ........................................ 8

d. South London & Maudsley NHS Foundation Trust .............................................................................. 9

5. Performance and Quality and Safety Trackers ......................................................................... 10

a. Monthly Performance Tracker ........................................................................................................... 10

b. Quarterly Quality and Safety Tracker ................................................................................................ 11

6. Performance Variance and Assurance Information ................................................................. 12

7. Southwark CCG QIPP Performance .......................................................................................... 25

a. Performance and Variance Tracker ................................................................................................... 25

b. CCG-led New Outpatient QIPP .......................................................................................................... 26

c. CCG-led A&E QIPP .............................................................................................................................. 27

d. CCG-led SLaM Risk Share QIPP .......................................................................................................... 28

8. Southwark CCG Finance Report (M10) ..................................................................................... 29

9. Glossary of Performance Indicators ......................................................................................... 30

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1. Structure of the Document

The report is written to enable the CCG to review the key domains of finance, QIPP, performance, quality and safety in an assimilated format. The purpose of reporting in this way is to support the CCG’s committees in their consideration of the current status of the above domains as well as the interdependencies between them. The report focuses on the current status of all key domains of quality & safety; finance & QIPP; and performance. It is structured to focus on the performance of the CCG but additionally provides a comprehensive overview of the range of indicators used to assess our main provider organsiations: King’s College Hospital NHS Foundation Trust, Guy’s & St. Thomas’ NHS Foundation Trust (including community health services) and South London & Maudsley NHS Foundation Trust. Performance dashboards are included in sections 2, 3 and 4 to provide a high-level overview of all performance domains, highlighting where performance is reported to have hit or exceeded target (green rated); where there is some variance from plan (amber rated) or where there is significant variance from plan (red rated). Dashboards are included for the CCG and for the four providers noted above. Performance and quality and safety indicator trackers are included in section 5 to provide on-going monitoring of key indicators. In Section 6, the report focuses in detail on those areas that are shown on the dashboards as having deviated from target. The tables included in Section 6 set out a description of these performance issues and include details of the forums the CCG uses to monitor and address these issues. An overview of the CCG’s QIPP and current financial position is included in sections 7 & 8 and Appendix 1. CCG finance report. A glossary of all the performance indicators referred to in this report can be found in Section 9. The indicator definitions and targets have been taken from the Department of Health’s Technical Guidance for the 2012/13 Operating Framework and the NHS Commissioning Boards Everyone Counts: Planning for Patients 2013/14 Technical Definitions document. Definitions for locally agreed targets have been taken from provider contract agreements. The data and information included in the Integrated Performance Report is sourced from provider contract monitoring and finance reports, CCG QIPP and finance reports and provider quality, safety and performance reports. The reporting period included varies as some reports are quarterly and others monthly, although the data included in this report is as follows unless otherwise stated in the report: Table 1: Integrated Performance Report Data Sources and Period Covered

Data Source Period Covered

Quality & Safety

Trust Quality & Safety reports SLCSU Acute Int Performance Report Community Contract Report SLaM Quality & Safety Report Serious Incidents Reports

Q3 2013/14 M9 Q3 Q3 Q3

Finance CCG Finance Report Acute Int Performance Report SLaM Finance Report

M10 M9

Performance Indicators & Targets SLCSU Acute Int Performance Report SLCSU Performance Report

M9 M9

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2. Southwark CCG and Providers Performance Summary Dashboard

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3. Southwark CCG Dashboard (M9)

Amber and red-rated issues are reviewed in further detail in Section 6.

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4. Provider Dashboards (M8 Performance Q3 Quality & Safety)

a. King’s College Hospital NHS Foundation Trust

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b. Guy’s & St. Thomas’ NHS Foundation Trust

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c. Guy’s & St. Thomas’ NHS Foundation Trust – Community Health Services

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d. South London & Maudsley NHS Foundation Trust


5. Performance and Quality and Safety Trackers

a. Monthly Performance Tracker


b. Quarterly Quality and Safety Tracker


6. Performance Variance and Assurance Information

The table below includes all key red- and amber-rated performance, quality & safety and financial domains included in the above dashboards. The table states the domain concerned, provides a synopsis of the matter arising and includes details of the forum in which the issue is addressed and monitored. This table is provided as a comprehensive overview and it is anticipated that CCG commissioners and committees should direct detailed questions to commissioning leads and and/or further reference the South East London Integrated Performance Reports or the reports listed in Section 1.

Issu

e

Synopsis of Issue Current Status SC

CG

GST

KC

H

GST

CS

SLaM

Forum Issue is Addressed Date Responsible CCG Officer and CCG

Clinical Lead

Finance

Fin

anci

al o

ver-

per

form

ance

Acute over-performance for M10 was -£4,884k.

Likely YEP of -£7,229k (M10 report).

Community services over-performance for M10 was -£1,063k (urgent care

centre -£655; walk in centre -£408).

Client group over-performance for M10 was -£1,199.

Corporate costs over-performance for M10 was -£39.

See finance report in appendix 1.

YTD (M10) Position

Acute -£4,884k

Comm. -£1,063k

Client -£1,199

Corp -£39

Acute Contract Monitoring Meetings

7 Mar (GST)

6 Feb (KCH)

Dr Jonty Heaversedge,

Tamsin Hooton and SLCSU Acute Contracting Team

Performance & Quality

A&

E

KCH (Denmark Hill): Refer to the highlight report for more detail The Denmark Hill site has not achieved the A&E target for the last three

months.

With effect from 1 October, PRUH became part of the KCH trust, the figures for

KCH reflect this.

Additional funding to support A&E was announced by NHSE for winter. Some of

this funding is now available for Denmark Hill.

KCH Denmark Hill

93.6%

KCH 87.9%

(M9)

Target 95%

KCH Acute Contract Monitoring

Meeting

Monthly Performance Meeting (for escalation)

6 February

28 February





Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

RTT

ad

mit

ted

Refer to the highlight report for more detail

SCCG

Admitted performance for Southwark CCG patients has been below the 90%

target for the last five months.

KCH

A planned failure of the admitted performance target on a monthly basis is

expected to support backlog clearance.

KCH are below the performance threshold. They are however within the

planned improvement trajectory of 87% agreed with the trust and therefore

amber rated.

The trust is using a combination of outsourcing to private providers and

additional elective capacity on the PRUH and Orpington sites. The trust is

transferring some existing orthopaedic waiters, subject to patient agreement,

to GST for treatment.

Progress against trajectory

Backlog increased to 1483 in December 2013.

Action plans have been put in place for specialties missing their revised

trajectories.

Neurosurgery was expected to get slightly worse over the Christmas period but

then return to trajectory by the end of January. Further patients will receive

their care at Harley Street.

SCCG 89.0%

(M9)

Target 90%

KCH Acute Contract Monitoring

Meeting

Monthly Performance Meeting

(for escalation)

6 February

28 February



KCH 87.8%

(M9)

Planned

improvement

trajectory

target

87%


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

52

we

eks

lon

g w

aite

rs

Refer to the highlight report for more detail SCCG There were 14 Southwark patients waiting more than 52 weeks on incomplete

pathways in M9.

KCH There were 78 patients waiting more than 52 weeks on incomplete pathways

in M9 compared to 27 in M8.

For bariatrics, some activity continues to be outsourced to private providers

and additional ring-fenced beds are available in the Centenary Wing.

A cohort of HpB patients are being outsourced to private providers and ring-

fenced beds are available in the Centenary Wing. Weekend lists occurred in

December and January.

The trust keeps long waiters under regular clinical review to ensure there is no

clinical risk to patients.

The CCG applies a contractual financial penalty each month for patients still

waiting over 52 weeks. This has been implemented since April 2013 in line with

national arrangements.

SCCG 14

KCH 78

(M9)

Target 0

KCH Acute Contract Monitoring Meeting


6 February

28 February




Can

celle

d O

per

atio

ns

– 2

8 d

ays

KCH

The number of cancelled operations (28 days) at KCH has increased in Q3to 45

from 6 in Q2. Figures have increased dramatically in Q3 because figures now

include the PRUH.

The Trust has been a national outlier for cancelled operations.

The Trust is looking at their processes for capturing data properly.

A Unify reporting review will be presented at the next performance meeting.

GST

The number of cancelled operations (28 days) at GST has increased in Q3 to 9

from 8 in Q2.

The Trust is also querying the numbers of urgent cancellations.

This will be reviewed at the next performance meeting.

KCH 45

GST 9

(Q3)

Target 0



6 February

28 February



GST Acute Contract Monitoring Meeting


7 March

28 February



Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Can

cer

31

day

s –

Firs

t d

efi

nit

ive

SCCG

Performance has improved from 94.5% in M7 to 95.9% in M8.

GST

Performance has dropped from 95.5% in M7 to 93.3% in M8.

There were 18 breaches from 270 pathways. This indicator will be further

reviewed when Q3 data is available.

SCCG 95.9%

GST 93.3%

(M8)

Target 96%

GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation)

7 March

28 February


Can

cer

31

day

s –

Firs

t d

efi

nit

ive

–

sub

seq

uen

t tr

eatm

ent

– su

rger

y

GST




KCH




GST 84.4%

(M8)

Target 94%



6 February

28 February



KCH 92.5%

(M8)

Target 94%



7 March

28 February


Can

cer

62

day

s –

GP

re

ferr

al

KCH


GST

Performance has improved from 71.0% in M7 to 78.0% in M8.

62 day pathway performance at GST is associated with receipt of tertiary

referrals as well as some patients with pathways within the trust.

The IST has reviewed processes at GST for patients whose total journey is

within the Trust.

The IST has also recently separately reviewed all old SLHT providers focussing

on pathway access issues for 62 day patients who start their journey at the old

SLHT and are referred to GST.

The final report was received by trusts in December 2013 and the SLCSU is now

organising a review group to ensure recommendations from the report are

taken forward. This will be held in mid-January.

GST does not expect to meet this target before the end of the year.

KCH 84.0%

(M8)

Target 85%



6 February

28 February



GST 78.0%

(M8)

Target 85%



7 March

28 February



Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Can

cer

62

day

s –

Scre

enin

g GST

Performance has dropped from 100% in M7 to 80% in M8.

M8 performance is based on one breach from five pathways. This indicator will

be further reviewed when Q3 data is available.

GST 80.0%

(M8)

Target 90%



7 March

28 February


Am

bu

lan

ce r

esp

on

se 8

m

inu

tes

SCCG

Performance has dropped to 74.2% in M8 from 75.0% in M7.

The drop in performance has been as a result of increased activity.

In November a new intelligent conveyancing system was introduced which has

help manage flows of ambulances across the system and will reduce

ambulance surges.

Provisional data shows improved performance in January.

SCCG 74.2%

(M8)

Target 75%

Lambeth and Southwark Urgent Care Working Group

5 March Tamsin Hooton,

Ali Young and Harprit Lally

Mix

ed-s

ex a

cco

mm

od

atio

n


SCCG

There were 32 breaches in M9 compared to 36 in M8.

All Southwark breaches in M7, M8 and M9 occurred at KCH Denmark Hill.

KCH

There were 85 breaches in M9 compared to 99 in M8.

All breaches were in the Clinical Decision Unit (CDU) at Denmark Hill.

KCH opened a new 8 bedded CDU at the end of December, and now has 16

CDU beds in total. Although this is only a net increase of 2 beds, the new

configuration will allow males and females to be more easily separated.

Contractual penalties are being applied to breaches.

A clinically-led assurance visit is scheduled to take place on 5 March 2014.

SCCG 32

KCH 85

(M9)

Target 0



6 February

28 February




Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

HC

AIs

- C

.dif

f


KCH

At M9, there were 40 infections YTD against a planned trajectory of 37. At the

current rate, the Trust will not meet the C.diff target for 13/14.

Following the transfer of community services to GST, GST provide community

infection control support to primary care through training and C.diff

surveillance (currently based on GST lab data). It is planned that King’s lab data

will also soon be included for the purpose of enhanced surveillance.

The Lambeth and Southwark Public Health Team review local HCAI data

regularly. Following a local C.diff summit, a multiagency C.diff Task and Finish

Group is addressing surveillance, raising awareness, antibiotic prescribing and

care pathway development.

Southwark CCG is undertaking a deep-dive review into infection control within

its local acute and community providers. It will include recommendations on

how to improve local infection control arrangements.

KCH 40

(M9)

Target 37

KCH CQRG Meeting 20 March Gwen Kennedy

(Infection Control Lead)

HC

AIs

– M

RSA


SCCG

There was 1 CCG assigned MRSA infection in M9.

KCH

There was 1 trust assigned MRSA infection in M9.

Post Infection Reviews of MRSA bacteraemias are producing information on

the detail of local cases and learning. Most cases are very complex with

numerous healthcare contacts.

Southwark CCG is undertaking a deep-dive review into infection control within

its local acute and community providers. It will include recommendations on

how to improve local infection control arrangements.

SCCG 1 KCH 1

(M9)

Target 0

KCH CQRG Meeting 20 March Gwen Kennedy

(Infection Control Lead)


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Tru

st-A

ttri

bu

tab

le P

ress

ure

Ulc

ers

GST

There were 3 grade 3 attributable pressure ulcers reported in Q3 13/14.

Lambeth CCG are leading the review on these 3 incidents.

KCH

There were 5 grade 3 attributable pressure ulcers reported in Q3 13/14

This was reviewed in detail in the February CQRG meeting.

GST 3 G3 KCH 5 G3

(Q3 13/14)

Target 0

Serious Incident Committee Meetings

KCH 27 Feb GST 20 March

Jacquie Foster KCH – Denmark Hill

There were 2 grade 4 attributable pressure ulcers reported in Q3 13/14.

A pressure ulcer awareness event for staff is being held to raise awareness.

A Safer Care Forum has been setup which will review pressure ulcer RCAs to

ensure that actions are being implemented to reduce incidence.

Pilot work is being done on two wards around nursing culture and decision

making and how hearts and minds can be captured to ensure zero-harm care is

delivered.

KCH 2 G4

(Q3 13/14)

Target 0

Falls

KCH

There were 5 falls that resulted in major injury in Q3 13/14.

Three of these were discussed at January’s Serious Incident Committee

meeting and action plans will be reviewed in April. The remaining two will be

discussed in the February Serious Incident Committee meeting and action plans

will be reviewed in May.

GST

There were 3 falls that resulted in fractures in Q3 13/14.

Lambeth CCG will be leading the reviews of these incidents.

KCH 5 major

GST 3 fractures

(Q2 13/14)

Target 0

KCH Serious Incident Committee Meeting 27 February

Jacquie Foster

GST Serious Incident Committee (fall resulting in death) and the joint GST acute and Community Health Services CQRG (falls resulting in major injury)

20 March


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Dia

gno

stic

wai

ts >

6 w

eek

s


SCCG

In M8 performance was under target at 1.71% and has remained under target in M9 at 2.02%.

Under performance is mainly being driven by endoscopy at GST.

GST

Diagnostic waits performance has deteriorated slightly at GST from 2.46% in M8 to 3.17% in M9.

The main driver for this under performance is endoscopy.

The Trust has put additional sessions in place to increase staffing capacity

KCH Denmark Hill

Performance has deteriorated slightly at KCH Denmark Hill from 1.40 in M8 to

1.6% in M9.

KCH Denmark Hill had an issue with sleep studies in M8 due to the loss of a

staff member. Activity has now restarted with additional sessions arranged to

clear the backlog, this is expected to be cleared by late January 2014 and the

CCG will receive the performance outturn in late February.

SCCG 2.02% GST 3.17%

KCH Den. Hill 1.6%

(M9)

Target <1%

GST Acute Contract Monitoring Meeting Monthly Performance Meeting

(for escalation)

7 March

28 February




6 February

28 February



Ch

ild s

afeg

uar

din

g tr

ain

ing

KCH

Q3 data is not currently available for King’s due to the launch of their new training monitoring system. This is expected to be resolved by 21 February.

Performance has been under the target of 80% for levels 2 and 3.

Child safeguarding level 2 training compliance is 71% and level 3 compliance is 76%.

This has been repeatedly addressed at the Southwark Safeguarding Executive Meeting.

The Trust have commissioned extended training capacity to improve compliance.

KCH does not recognise staff who have completed the training at another trust as being compliant. This means all new recruits are classified as non-compliant which lowers compliance levels.

This indicator will also be monitored at a newly created health sub-group of the Southwark Safeguarding Children Board which will focus on quality.

KCH Level 2 – 71% Level 3 – 76%

Q2

Target 80%

Southwark Safeguarding Executive Meeting

Health sub-group

12 March

12 March

Gwen Kennedy


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Bir

ths/

mid

wif

e ra

tio

GST

The ratio has reduced from 30.4 in M8 to 29.6 in M9.

Maternity was covered as a substantial item at the September CQRG meeting and this indicator will continue to be monitored.

GST 29.6

(M9)

Target <27

GST CQRG Meeting GST Acute Contract Monitoring Meeting

20 March

7 March

Jacquie Foster


Mat

ern

ity

– To

tal

C

-sec

tio

n

GST

The total proportion of C-sections has increased slightly at GST from 27.6% in M8 to 30.4% in M9.

The Trust attributes its high C-section rate to it’s higher than average proportion of first time mothers.

KCH

The total proportion of C-sections has reduced slightly at KCH from 27.0% in M8 to 26.5% in M9.

GST 30.4% KCH 26.5%

(M9)

Target 26%

Joint GST acute and Community Health Services CQRG KCH CQRG Meeting

20 March

20 March

Jacquie Foster

Bo

oki

ngs

<13

wee

ks (

un

-ad

just

ed

)

KCH

Performance for M9 was 78.6% which was below the target of 90%.

King’s figures do not take into account the number of referrals of women who are already more than 13 weeks into their pregnancy.

KCH 78.6%

(M9)

Target 90%

GST CQRG Meeting

KCH CQRG Meeting

20 March

20 March

Jacquie Foster

GST

Performance for M9 was 85.1% which was below the target of 90%.

GST 85.1%

(M9)

Target 90%


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Frie

nd

s &

Fam

ily t

est

– A

&E

A&E response rate

KCH – Denmark Hill

In M9 KCH Denmark Hill recorded A&E response rates below the target of 15%.

Achieving target A&E response rates at KCH continues to be challenging on both sites and presents a risk to achieving linked CQUIN targets.

Work is ongoing with teams on both sites to raise response rates. From January 2014 SMS text messaging was planned to be introduced, which has proved successful in other trusts.

A&E resp. rate

Denmark Hill

9.6%

(M9)

Target 15%

GST CQRG Meeting

KCH CQRG Meeting

20 March

20 March

Jacquie Foster

A&E score


The A&E score for M9 was 49 which is below the national average score of 56.

Few patients report that they were unlikely or very unlikely to recommend KCH. The Trust may be receiving a proportionately higher number of neutral responses which do not contribute towards the overall score.

A&E score

Denmark Hill 49

(M9)

Target 56

Frie

nd

s &

Fam

ily t

est

–

Inp

atie

nts

Inpatients score


The inpatients score for M9 was 63 compared to a national average of 71.

There is a wide variation in the scores for wards on both sites and this is an area for improvement and will be monitored at future CQRG meetings.

Inpat. score

Denmark Hill 63

(M9)

Target 71

KCH CQRG Meeting 20 March Jacquie Foster

Co

mp

lain

ts

KCH

182 complaints were received in Q3 13/14.

Complaints are being continuously monitored during CQRG meetings.

The Trust will be asked to provide an update on progress made in implementing improvements plans at the CQRG meeting on 19 February.

KCH 182 GST 208

(Q3 13/14)

KCH CQRG Meeting

20 March Jacquie Foster


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

GST

There were 208 new formal complaints opened at GST in Q3 13/14 compared to 224 in Q2 13/14.

Complaints are being continuously monitored at CQRG meetings.

Joint GST acute and Community Health Services CQRG 20 March Jacquie Foster

IAP

T –

Mo

vin

g to

Rec

ove

ry Refer to the highlight report for more detail

Moving to recovery

Note: There have been a greater number of high intensity patients being seen by the IAPT service. This has resulted in fewer patients being seen overall due to the high number of appointments they require.

The recovery rate has decreased from 40.7% in M8 to 36.5% in M9. 2 additional psychological wellbeing practitioners were recently employed to

focus on low intensity patients which will provide greater access to the service, increasing numbers of patients being seen and moving to recovery.

SLaM 36.5%

(M9)

Target 50%

SLaM QIPP and Core Contract meeting 27 February Gwen Kennedy

IAP

T –

Firs

t co

nta

cts Refer to the highlight report for more detail

First contacts

The number of first contacts dropped in M9 to 308 from 465 in M8. This is probably due to a seasonal variation and because there are less working days in December.

Data for January shows there were 488 first contacts which is above the trajectory of 454.

SLaM 308

(M9)

Target 436

SLaM QIPP and Core Contract meeting 27 February Gwen Kennedy

Loca

lly a

gree

d t

arge

t -

Smo

kin

g q

uit

ters

(C

OP

D)

SCCG

92 people were recorded to have stopped smoking by M8 against a target of 110.

The Integrated Respiratory Service has carried out a virtual clinic/practice support session with nearly all Southwark practices emphasising the importance of reinforcing the message around smoking cessation.

Local COPD guidelines have been developed to support practices.

SCCG 92

(M8)

Target 110

- - Jean Young


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

Co

ntr

ol o

f M

edic

ines

25 incidents in total were reported across a range of settings. 13 of these were reported incidents within community health services directly. 12incidents are attributable to other agencies but were reported by

community staff. There were five incidents relating to a controlled drug. GSTCH have provided a breakdown of all errors with improvement plans. The incidents will be discussed at the CHS Pharmacists meeting chaired by the

Head of Nursing and attended by relevant service managers, to disseminate learning across the directorate.

GSTCH 25

(Q3 13/14)

Joint GST acute and Community Health Services CQRG

(these incidents will be discussed at the next Community Health Patients Safety Forum and reported to the GST Medicines Safety Forum)

20 March

TBC Jean Young

Eth

nic

ity

at f

irst

co

nta

ct

Performance has improved from 80.2% in M8 to 81.8% in M9. Performance improvement is due to the child health team starting to receive

information from Kings Maternity. Similar information is expected to be received from GST shortly and further

work to capture parents ethnicity in Health Visiting is ongoing.

GSTCH 81.8%

(M9)

Target 85%

GSTCH Contract Monitoring Meeting

11 March Jean Young

Pat

ien

t Fa

cin

g Ti

me

- H

ealt

h

Vis

itin

g

Health visiting patient facing time is below this year’s target of 40%. Performance has reduced slightly again in M9 to 23.1% from 24.5% in M8. There have been delays in registering agency staff on to RIO which has resulted

in some patient facing time not being recorded. Also agency staff have not been as efficient as permanent staff at recording patient facing time.

The Trust’s recruitment and retention plans have also been discussed in light of on-going national health visitor shortages and will continue to be closely monitored.

A standardised process for the booking of clinics and home visits is now being implemented and is expected to positively impact performance in Q4 2013/14.

GSTCH 23.1%

(M9)

Target 40%


11 March Jean Young

Pat

ien

t Fa

cin

g Ti

me

– A

du

lt C

om

mu

nit

y N

urs

ing

Adult community nursing patient facing time has increased from 36.1% in M8 to 38.8% in M9.

The Dulwich locality remains an outlier and the other 3 Southwark localities have an average PFT of 42.6% in December

GSTCH 38.8%

(M9)

Target 40%

GSTCH Contract Monitoring Meeting 11 March Jean Young


Issu

e


CG

GST

KC

H

GST

CS

SLaM


Clinical Lead

DN

As

The DNA rate has decreased in M9 to 5.5% which is slightly over the 5% target. An analysis of DNAs has taken place which showed that the rise in DNAs has

occurred predominantly in orthotics. DNAs will again be monitored at the next Contract Monitoring Meeting on 11

March.

GSTCH 5.5%

(M9)

Target <5%


11 March Jean Young

New

pat

ien

ts

off

ered

HIV

tes

t

Performance in Q3 was 14% which is below the target of 30%. SLaM will incorporate this into physical health tests offered as standard to all

patients on admission and so performance is expected to improve in Q4.

SLaM 14%

(Q3)

Target 30%

SLaM QIPP and Core Contract Meeting 27 February Gwen Kennedy

Pat

ien

t re

ceiv

ed

cop

y o

f ca

re p

lan

Performance is under target at 93% for Q3. The Trust has identified the patients that need to receive a copy of their care

plan and will prioritise ensuring this happens. There is a sanction of 0.25% of contract associated with this indicator.

SLaM 93%

(Q3)

Target 95%


A&

E b

reac

he

s –

6

ho

urs

There have been 12 x 6 hour breaches in M9. 5 of these patients were from Southwark.

This could be due to seasonal fluctuation as mental health related activity usually increases in December.

SLaM 12

(M9)

Target 11


Emp

loym

ent

Ass

ess

me

nts

Performance for Q3 is 92% against a target of 95%. Performance has been impacted by staffing issues. As part of the enhanced assessment project a re-ablement team has been

established in the Community Mental Health team. Part of their role will be to look at patient employment as they take a more holistic approach to assessing and treating patients.

SLaM 92%

(Q3)

Target 95


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7. Southwark CCG QIPP Performance

a. Performance and Variance Tracker

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b. CCG-led New Outpatient QIPP

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c. CCG-led A&E QIPP

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d. CCG-led SLaM Risk Share QIPP

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8. Southwark CCG Finance Report (M10)

See Appendix 1 for full M10 Finance Report

Budget Annual Budget

(£k) Variance to

Month 10 (£k) Predicted End

of Year (£k)

Best Case F/cast Year

End Var'ce (£k)

Worst Case F/cast Year End

Var'ce (£k)

Total Acute 208,566 -4,884 -7,299 -6,970 -7,916

Client Groups 66,824 -1,199 -1,623 -1,322 -1,924

Prescribing 31,617 547 645 715 300

Community and other Services

29,738 -1,063 -1,500 -200 -1,793

Corporate Costs 4,920 -39 0 60 -20

Earmarked Budgets and reserves

11,335 6,637 9,777 7,717 11,053

Planned Surplus 3,972 3,310 3,972 3,972 3,972

Total 356,972 3,310 3,972 3,972 3,672

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9. Glossary of Performance Indicators

% end of life (35%) - % of end of life patients on Southwark Gold Patient Register/CMC with a known

preferred place of death. 2012/13 baseline 87/498 = 17.5%, 2013/14 annual target 293/836 = 35% - SCCG % smoking quitters (COPD) (10%) - % Confirmed Smokers on COPD Registers who quit smoking.

2012/13 baseline: No baseline (4,141 on COPD register, 1,659 smokers), 2013/14 annual target: 165 / 1,659 = 10% - SCCG

% diabetes (21.3%) - % of patients on diabetes practice registers with a blood glucose level of 75 mmol/mol IFCC (HbA1C 9) or more (no exceptions). 2012/13 baseline (projected from current position): 3,316 / 13,020 = 25.4%, 2013/14 annual target: 2,816 / 13,200 = 21.3% (500 patients with better managed diabetes) - SCCG

% Appointments Cancelled by Service (5%) – The proportion of appointments cancelled by the service of the

total number of appointments - GSTCH

52 weeks long waiters (0) - The number of incomplete pathways greater than 52 weeks for patients on

incomplete pathways at the end of the period – Acute and SCCG

A&E Attendance Avoidance (80%) - Percentage of patients who have been on a community matron caseload

for 12 weeks or more without any A&E attendances in the last quarter - GSTCH

A&E breaches (4 hour wait) (3/month) - Number of breaches in the A&E 4-hour wait due to mental health

services - SLaM

A&E breaches (6 hour wait) (3/month) - Number of breaches in the A&E 6-hour wait due to mental health

services - SLaM

A&E waits (95%) - Percentage of patients who spent 4 hours or less in A&E - Acute

Adult safeguarding training (80%) – The proportion of staff who have achieved the required level of adult

safeguarding training – All providers

AHP Goals (80%) - Percentage of rehabilitation goals achieved from an annual audit of 200 patients or

equivalent - GSTCH

Alcohol Intervention - Alcohol Brief Intervention in Reproductive & Sexual Health - GSTCH

Ambulance HAS compliance (90%) - All acute trusts to ensure that patient handover times are recorded via the Patient Handover Button on the Hospital-based alert system (HAS) for 90% of all hospital turnarounds - Acute Ambulance Response 8 minutes Red 1 (75%) - Presenting conditions that may be immediately life threatening and the most time critical and should receive an emergency response within 8 minutes irrespective of location - SCCG Ambulance Response 8 minutes Red 2 (75%) - Presenting conditions that may be life threatening but less time critical than Red 1 and should receive an emergency response within 8 minutes irrespective of location - SCCG Ambulance Response 19 minutes (95%) - Presenting conditions, which may be immediately life threatening and should receive an ambulance response at the scene within 19 minutes irrespective of location in 95% of cases - SCCG Ambulance wait > 60 minutes (0) - The number of handover delays of longer than 60 minutes - Acute

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Assertive Outreach (TBC) - Number of new referrals to the Assertive Outreach service - SLaM Births/midwife (1:28) – The Royal College of Midwives recommends a ratio for national planning (i.e. based upon expected national birth rate) of 28 births : 1 w.t.e. midwife for hospital births – Acute Bookings<13 weeks (90%) - The percentage of women who have seen a midwife or a maternity healthcare professional for health and social care assessment of needs, risks and choices before 13 weeks of pregnancy - Acute KCH figures do not take into account the number of referrals of women who are already more than 13 weeks into their pregnancy. GST measure their compliance with this target slightly differently to other trusts. They have a target booking number each month based on predicted births in 6 months time and hence if they exceed this target their performance is in excess of 100%. Due to their case mix and referrals of complex cases from elsewhere, this measurement has been agreed. C Diff (trajectory) - Number of Clostridium difficile infections for patients aged 2 or more on the date the specimen was taken - Acute CAMHS starting treatment < 12 weeks (90%) - Percentage of looked after children referred to CAMHS

services to be assessed and start treatment within 12 weeks of referral - SLaM

CAMHS Transition CPA - % of cases transitioned to AMH with CPA review 6 months prior to 18th birthday -

SLaM

CAMHS Transition Planning - % of cases with evidence of transition planning prior to 18th birthday - SLaM

Cancelled Ops 28 days (0) - All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice - Acute Cancer 2 week GP referral (93%) - Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer - Acute and SCCG Cancer 2 weeks breast symptoms (93%) - Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer was not initially suspected - Acute and SCCG Cancer 31 days first definitive treatment (96%) - Percentage of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from ‘date of decision to treat’) - Acute and SCCG Cancer 31 days subsequent treatment (drug) (98%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is an Anti-Cancer Drug Regimen - Acute and SCCG Cancer 31 days subsequent treatment (radiotherapy) (94%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is a Radiotherapy Treatment Course - Acute and SCCG Cancer 31 days subsequent treatment (surgery) (94%) - Percentage of patients receiving subsequent treatment for cancer within 31 days, where that treatment is a Surgery - Acute and SCCG Cancer 62 days first definitive treatment by a Consultant (85%) - Percentage of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status - Acute and SCCG

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Cancer 62 days GP referral (85%) - Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer - Acute and SCCG Cancer 62 days referral NHS screening (90%) - Percentage of patients receiving first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service - Acute and SCCG Child safeguarding training (80%) – The proportion of staff who have achieved the required level of children

safeguarding training – All providers

Complaints (Trajectory) - Number of new formal complaints received in quarter - All providers

Control of Medicines (0) – The number of controlled drug incidents - GSTCH

Cost per Contact - Adult Nursing (-1% change) - Percentage change in cost per contact in the district nursing

services - GSTCH

Cost per Contact - Health Visiting (-1% change) - Percentage change in cost per contact in the health visiting

services - GSTCH

CPA 7 Day Follow Up (95%) – The proportion of those patients on Care Programme Approach (CPA)

discharged from inpatient care who are followed up within 7 days - SCCG

Dementia - Ensure appropriate recording of the needs of people with Dementia referred to community

services - GSTCH

Dementia diag rate (851 - a proportion of 53.2% against an expected prevalence of 1600) - Dementia

diagnosis rate – SCCG and SLaM

Developing Standardised Care Plans - Care Planning for Patients with Long Term Conditions – GSTCH

Diagnostic wait > 6 weeks (99%) - The percentage of patients waiting 6 weeks or more for a diagnostic test – Acute and SCCG Discharge Plan in Place (100%) - An indicative discharge plan shall be agreed within 4 weeks of admission -

SLaM

DNAs (<5%) – Proportion of patient appointments where the patient did not attend without providing

adequate notice - GSTCH

Dressings (trajectory) - Adherence to dressings of those prescribed and recommended – GSTCH

Early Intervention (TBC) - Number of new cases of psychosis served by Early Intervention teams - SLaM

Easy in - Applies to discharges of patients from AMH (excluding triage). % of users when being discharged

from secondary care have the following documentation sent to their GP within 7 working days of discharge -

SLaM

- Community - a completed Recovery and Support Plan. This support plan includes an advanced statement

and is signed by the user.

- Inpatients - an inpatient discharge summary detailing a summary of intervention.

Easy out - Questionnaire sent to GPs to measure GP experience of referral, communication and discharge

arrangements - SLaM

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Employment assessments (95%) - Percentage of service users on CPA to have an employment assessment -

SLaM

End of life care –

To show evidence of co-ordinated End of Life Care by the continued use of the Co-ordinate My Care

electronic EOLC register.

Patients who have chosen to die in their own home should routinely benefit from the sustained quality

offered by the Liverpool Care Pathway - GSTCH

Ethnicity at First Contact (85%) - Percentage of new clients with one or more first contacts for whom

ethnicity is known - GSTCH

Falls (minimal – major falls are amber rated, falls resulting in death are red rated) – Incidence of falls

resulting in injury – Acute and GSTCH

Falls (0) - Falls from unrestricted windows - SLaM

Friends & Family - The Friends and Family Test (FFT) aims to provide a simple headline metric which, when

combined with follow-up questions, can drive a culture change of continuous recognition of good practice

and potential improvements in the quality of the care received by NHS patients and service users.

The test asks the following standardised question: “How likely are you to recommend our ward/A&E

department to friends and family if they needed similar care or treatment?”

Patients will use a descriptive six-point response scale to answer the questions with the following response

categories:

1. Extremely likely 2. Likely 3. Neither likely nor unlikely 4. Unlikely 5. Extremely unlikely 6. Don’t know The scoring methodology being adopted will be based on the underlying ‘Net Promoter Score’ calculation, which was considered to be the most effective at delivering the benefits of the Friends and Family Test outlined above. Proportion of respondents who would be extremely likely to recommend (response category: “extremely likely”) MINUS Proportion of respondents who would not recommend (response categories: “neither likely nor unlikely”, “unlikely” & “extremely unlikely”). Gate-kept (TBC) - Percentage of inpatient admissions gate-kept by the crisis resolution / home treatment

team - SLaM

Home Treatment Episodes YTD (TBC) - Number of episodes served by Home Treatment teams - SLaM

Hospital Admission Avoidance (80%) - Percentage of patients who have been on a community matron

caseload for 12 weeks or more and have avoided any emergency hospital admissions in the last quarter -

GSTCH

IAPT % moving to recovery (50%) - The proportion of people who complete treatment who are moving to recovery – SLAM and SCCG

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IAPT % receiving (5,241 against 41,929) - The proportion of people entering treatment (target 5,241 annually) against the level of need in the general population (the level of prevalence addressed or ‘captured' by referral routes 41,929) – SLAM and SCCG Inpatient Nutrition Screen (95%) - Percentage of inpatients who have had a full nutrition screen - SLaM

Last Minute Cancelled Ops - Number of last minute cancelled elective operations for non clinical reasons -

Acute

Mixed-sex accommodation (0) - All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient, in accordance with the definitions set out in the Professional Letter CNO/2010/3 - Acute and SLaM MMR1 – The proportion of children under the age of 5 who are unregistered or identified to not have had

their MMR1 within 4 months of the recommended schedule date (13 months) who were subsequently

identified and recorded as having a recorded MMR1 immunisation - GSTCH

Mortality - Summary Hospital-level Mortality Indicator (SHMI) (<1)- Gives an indication for each hospital

trust in England whether the observed number of deaths within 30 days of discharge from hospital were

higher than expected, lower than expected or as expected when compared to the national baseline.

Higher than expected mortality rate > 1 As expected mortality rate = 1 Lower than expected mortality rate < 1 MRSA - Number of cases of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia - Acute and SCCG Near Time Patient Experience (TBC) - Replacement of annual patient experience survey with near time

patient experience - GSTCH

Never Events (0) - Never Events are serious, largely preventable patient safety incidents that should not

occur if the available preventative measures have been implemented.

New Birth Visits (95%) - Percentage of new born babies who received a new birth visit or attempted visit

between 10 and 14 days inclusive after birth – GSTCH

New patients offered HIV test (30%) - Percentage of new patients with the ability to consent that are

admitted to AMH and ADD inpatient services offered a HIV test - SLaM

NHS Health Checks offered (20% of eligible population) - Percentage of eligible people who have been

offered an NHS Health Check in 2012/13. The Department of Health target stipulated that the Health Check

Programme was a five year rolling programme where 20% of the eligible population should be offered a

Health Check each year - SCCG

NHS Health Checks received (Locally agreed target of 40%)- Percentage of eligible people that have received

an NHS Health Check in 2012/13. This is the proportion of people who received an NHS Health Check from

20% of the eligible population - SCCG

NICE – The number of NICE guidance awaiting response – Acute

Notified Serious Incidents (0) – The total number of Serious Incidents notified to the CCG, a review of the SI

investigation report may result in a de-escalation which may therefore result in an adjusted total figure – All

providers

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Obesity - Reduction in percentage of children who are obese or overweight - GSTCH

Patient Experience - This indicator seeks to assess and evaluate quality of inpatient services (both acute and

rehab) through service user focus groups - SLaM

Patient Facing Time (CQUIN) - Increase in reported Patient Facing Time in the Sickle Cell service - GSTCH

Patient received copy of care plan (95%) - Percentage of patients who have been given a copy of their CPA

care plan - SLaM

Patient Safety Thermometer –

1. To collect data on pressure ulcers.

2. To develop a service development plan at Q2 outlining the work planned to reduce the number of

pressure ulcers and report at Q4 on progress.

PbR - 13/14 is a developing year for PbR for mental health. This CQUIN requires development of a shared understanding between commissioners and the provider on: • Service specifications for each care package • The relevant information to collect

• The quality of the information collected (accuracy and completeness)

• Related quality outcomes

• The quality assurance systems in place to monitor performance of PbR

• The cluster costs for each of the 21 clusters

• Benchmarking process identified to validate cluster costs - Payment will be awarded on successful

completion of deliverables agreed at Q1 workshop - SLaM

Percentage of delayed discharges (>7.5%) - Percentage of delayed discharges from inpatient care as per the

monitor definition - SLaM

Physical Health - Antipsychotics - Physical Health Checks for in-patients on anti-psychotic medication. This

excludes triage only admissions - SLaM

Physical Health - New Admissions - Physical Health Checks for new admission's. This excludes triage only

admissions – SLaM

Pre-school booster – The proportion of children who are unregistered or do not have a recorded DTaP/IPV or

dTaP/IPV (preschool booster) immunisation by four months from the recommended schedule date (3 years 4

months) who were subsequently identified and recorded as having a recorded DTaP/IPV or DTaP/IPV

(preschool booster) immunisation - GSTCH

Pressure Ulcers (Grade 2 are not rated; Grade 3 are rated amber; Grade 4 are rated red) - Number of

pressure ulcers in quarter – All providers

Pt Facing Time - Adult Comm Nursing – GSTCHS – There is a new method of calculating performance for this

indicator, details of which will be confirmed - GSTCH

Pt Facing Time - Health Visiting – GSTCHS – There is a new method of calculating performance for this

indicator, details of which will be confirmed - GSTCH

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Pts with learning disabilities - Ensure appropriate treatment of patients with learning difficulties i.e. making

reasonable adjustments where necessary and to ensure appropriate recording of the needs of people with

learning disabilities referred to community services - GSTCH

Public and Pt Engagement - To show evidence of involving patients and the public in relation to service

delivery including service changes or new service proposals - GSTCH

Recovery - The Recovery and Support plan is a recovery focussed plan that seeks to place the service user at

the centre of the care/support planning process whereby they are supported to define their own goals based

on their personal needs and aspirations - SLaM

RTT - AHP % 18 wks – Percentage of patients on Allied Health Professional-led pathways who received their

first definitive treatment within 18 weeks in the Community - GSTCH

RTT admitted (90%) - The percentage of admitted pathways within 18 weeks for admitted patients whose clocks stopped during the period on an adjusted basis – Acute and SCCG RTT incomplete pathway (92%) - The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period - Acute and SCCG RTT non-admitted (95%) - The percentage of non-admitted pathways within 18 weeks for non-admitted patients whose clocks stopped during the period - Acute and SCCG Safeguarding adults and children - To ensure that Community services comply with all relevant Safeguarding

Acts for both vulnerable adults and children and comply with the Safeguarding policies as detailed in the

contract - GSTCH

Smoking cessation training (33%) - Percentage of relevant inpatient & community staff working at SLaM for

over 6 months to have undertaken smoking cessation level 1 training - SLaM

Smoking quitters – Number of clients of NHS Stop Smoking Services who report that they are not smoking

four weeks after setting a quit date – SCCG

Summary care records - Proportion of patients on CPA where the summary care record has identified gaps in

health screening in the last year or the patient is not registered with a GP – SLaM

Total C-section (<26% for KCH and < 27% for GST) – Elective and non-elective caesarean sections as a

percentage of all births - Acute

Transition care plans - All young people aged 17 have transitional care plans indicating agreed clinical

diagnosis and future treatment requirements and that the NHS and Local Authority commissioners are

notified of transition patients in line with local protocol - GSTCH

VTE risk assessment (90%) - % of all adult inpatients who have had a VTE risk assessment on admission to

hospital using the clinical criteria of the national tool – Acute

Integrated Performance Report - Southwark CCG · ENC Bii The best possible outcomes for Southwark people 3 | P a g e 1. Structure of the Document The report is written to enable the

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