Item - Moorfields Eye Hospital · Compared to 2014/15, November activity was up 7% (vs. November 2014) with the YTD up 9%. Cancer Performance For November 2015 '2 week wait' performance

Item

BOARD OF DIRECTORS OPERATIONAL PERFORMANCE REPORT

Presented By:

17th December 2015

Board of Directors

Produced By:

Stephen Chinn

Senior Performance Analyst

John Quinn

Chief Operating Officer

(Produced on 11th December 2015)

Month 8 (November 2015)

Action for Board: For information

For consideration

For decision

Board of Directors Performance Report - November 2015

Exception Report Page 2 - 3

Compliance Performance Summary Page 4

Access - Referral to Treatment Page 5 - 6

Access - A&E Page 7 - 8

Access - Cancer Waiting Times Page 9

Access - Other Page 10

Efficiency Page 11 -12

Effectiveness Page 13

Safety Page 13

Ward Staffing Levels Page 14

Patient Experience Page 15

Bank and Agency Staff Information Page 16

CONTENTS

For decision

Page 1


Exception Report - November 2015

RTT Performance

The October 2015 figures within this report are now confirmed, there were no significant changes to the provisional figures reported.

From October 2015, RTT reporting has changed to focus on open (incomplete) pathways or how long untreated patients are waiting. NHS Hospitals are no longer submitting 'closed' admitted and non-admitted data however this is still being monitored locally.

Two new RTT measures have been introduced nationally and are included in this report, these are: • 18 weeks Referral to Treatment -Incomplete (Pathways with DTA) • New RTT Periods - All Patients (Number of new Pathways)

RTT Incomplete Performance for November 2015 saw an increase to 95.1% (M7 - October 2015: 94.7%) with the Year to Date at 94.0%, remaining above the 92% target

18 weeks Referral to Treatment -Incomplete (Pathways with DTA) performance was at 87.1%, a decrease from 88.2% in October 2015. At this time figures prior to October 2015 are unavailable , this will be updated for the next report.

There were no 52 week breaches reported in November 2015. Accident and Emergency

In November 2015, the A&E department remained in a challenging position due to periods of high activity. November performance was achieved, however it was the second lowest recorded at 95.8% (M7: 95.7%), with 340 four hour breaches, however there was a reduction in the number of six hour breaches at 11 (M7: 30). The YTD four hour position is at 97.4%.

Three hour performance was also low, with the trust achieving 76.0% for the month (M6: 75.7%) with a YTD of 77.4%.

The challenges facing the A&E department have been recognised, and an A&E Active Triage pilot has been approved to allow A&E patients to be seen in different settings in order to ease the demand pressures on the department. This is due to commence early in the New Year.

Longer and more substantive changes are expected with the acceleration of the remainder of the A&E service review, with particular emphasis on medical staffing.

A&E Activity continues to remain high although not as high as the record levels experienced during Quarter 1. Compared to 2014/15, November activity was up 7% (vs. November 2014) with the YTD up 9%. Cancer Performance

For November 2015 '2 week wait' performance was at 80%; we had one breach for Ocular Oncology, due to patient choice. The YTD is at 90.9%, below the 93% target

'Cancer 31 day wait - diagnosis to first appointment' was at 89.5% for November 2015 with the YTD at 93.8%, both below the 96% target. Both breaches were for Ocular Oncology: • Patient 1: Patient choice first, then patient cancelled surgery because unwell. • Patient 2: The operation was cancelled because patient was admitted as an inpatient at North Middlesex Hospital for another condition.

'Cancer 31 day wait - subsequent treatment - surgery' was at 100% for the month, but remains below the 94% target for the YTD at 89.5%.

Page 2


Exception Report - November 2015 (Continued)

Choose and Book Performance Following the transition from the CAB system to e-Referral system the reports module of the new e-Referral system was not implemented before go-live. We have been informed by the e-Referral Team at HSCIC that the reports module which includes the Weekly ASI (Appointment Slot Issue) Report will be unavailable until further notice, therefore these figures will be unavailable until the reports module has been implemented by the HSCIC. This report contains data up to the last full month available (May 2015). Outpatient and Admission Activity First Appointment Activity remains high compared to the previous year, up 8% compared to November 2014 and 12% for the year to date . Follow up activity was at a similar level compared to November 2014 (per working day) and 3% up for the YTD.

Admission activity continues to see a decrease in admissions compared to last year, and is down 10% compared to November 2014, which is the equivalent of 15 less operations per working day. Year to date is down by 7%. Mixed Sex Accommodation Breaches Last month, Moorfields recorded 23 Mixed Sex Accommodation breaches, all of which occurred in one of our wards. The increase in MSA breaches was due to a number of patients admitted who required complex treatment, such as intensive treatment for eye infections (resulting in long term use of the two side rooms). There were also a number of patients admitted with longer term care needs that required admission and overnight stay. Work is underway to improve the current ward layout. Bank and Agency Staff Information At the time of the publication of this report the November Data is not yet available. The data contained in this report is therefore the latest graph from October's report.

Page 3


COMPLIANCE PERFORMANCE SUMMARY

Threshold Nov-15 YTD 15/16Monthly

TrendSource Threshold Nov-15 YTD 15/16

Monthly

TrendSource

≥ 90% 85.9% 89.96% CQC, Monitor,TDA ≥ 99% 100% 100% CQC, TDA

≥ 95% 95.5% 96.3% CQC, Monitor,TDA n/a 88.1% 88.0% Local

≥ 92% 95.1% 94.0% CQC, Monitor,TDA ≥ 96% n/a 85.3% Local

n/a 87.1% 87.6% * CQC, Monitor,TDA 0 0 1 CQC, TDA

n/a 11,407 22970 * CQC, Monitor,TDA n/a 2.1% 4.4% Monitor

0 0 0 CQC, Monitor,TDA n/a 2.6% 4.7% CQC, TDA, Outcomes

Framework

0 0 2 CQC, Monitor,TDA n/a 45.6% 51.3% Local

0 0 2 CQC, Monitor,TDA 0 0 0 CQC, Monitor,TDA

≥ 95% 95.8% 97.4% CQC, Monitor,TDA 0 0 0 CQC, Monitor,TDA

≥ 80% 76.0% 77.4% Local ≥ 95% 98.2% 98.3% CQC, TDA

≤ 5% 2.8% 2.5% CQC, TDA 0 23 30 CQC, TDA

≥ 30% 20.4% 22.8% Local n/a 103.0% 98.5% CQC, TDA

≤ 5% 0.3% 0.4% CQC, TDA ≥ 20% 14.7% 20.4% CQC,TDA, Outcomes

Framework

≥ 93% 80.0% 90.9% CQC, Monitor,TDA ≥ 30% 53.8% 54.4% CQC,TDA, Outcomes

Framework

≥ 96% 89.5% 93.8% CQC, Monitor,TDA ≥ 15% 10.7% 9.9% Local

≥ 94% 100.0% 89.5% CQC, Monitor,TDA

≥ 85% n/a 100.0% w CQC, Monitor,TDA

Key Reference:

w

Performance 2015/16Performance 2015/16

Percentage 18 weeks Non Admitted

Pathways

Emergency Readmissions within 28

days of discharge

Percentage 18 weeks Incomplete

Pathways

Emergency Readmissions within 30

days of discharge

Indicator Indicator

Percentage 18 weeks Admitted

Pathways

Cancelled Operations - 28 Days Re-

Book

18 weeks Referral to Treatment -

Incomplete (Pathways with DTA)

New RTT Periods - All Patients

18 weeks Admitted Pathways

52 Week Breaches

Choose & Book Appointment

Availability (April & May 15 Only)

Diagnostics 6 week waiting time

18 weeks Incomplete Pathways

52 Week BreachesNumber of MRSA cases

Outpatient appointment - Over 6

week waiters

Cancer 2 week wait - first

appointment urgent GP referral

% Cancer 31 day wait - diagnosis to

first appointment

A&E Left Before Treatment

A&E ENP Pathways

A&E Unplanned re-attendance

Friends & Family Test - Inpatients

(Response Rate)

18 weeks Non Admitted Pathways

52 Week Breaches

GP referrals first outpatient using

Choose & Book

VTE Screening - all admissions

Number of Mixed Sex

Accommodation Breaches

Friends & Family Test - A&E

(Response Rate)

A&E 3 hour waiting times

A&E 4 hour waiting time Number of C.Diff cases

Ward Staffing Levels

(Inpatient Wards Only)

Within tolerance and drop in figures

No target or N/A

On or above target

Stable on/above target

On target and drop in figures

Within tolerance and stable

Within tolerance and rise in figures

Friends & Family Test - Outpatients

(Response Rate - Estimated)

Below target and rise in figures

Below target and stable

Below target and fall in figures

Cancer 31 day wait - subsequent

treatment - surgery

Cancer 62 day from urgent GP

referral to first definitive treatment

* Incomplete (Pathways with DTA) & New RTT Periods

YTD from October 2015 as figures prior to this date available at this time

Page 4


18 Weeks Referral to Treatment (Provisional)

Year End YTD

Current

Month

Previous

Month Qtr1 Qtr2 Qtr3 Qtr4 YTD

≥ 90% 86.2% 83.7% 85.9% 88.5% 91.5% 90.2% 87.2% 89.96% Monitor, CQC,

TDA

≥ 95% 95.1% 94.8% 95.6% 96.0% 96.9% 96.1% 95.8% 96.3% Monitor, CQC,

TDA

≥ 92% 93.7% 92.9% 95.1% 94.7% 93.8% 93.5% 94.9% 94.0% Monitor, CQC,

TDA

N/A n/a n/a 87.1% 88.2% n/a n/a 87.7% 87.7% Monitor, CQC,

TDA

N/A n/a n/a 11,407 11,563 n/a n/a 22,970 22,970 Monitor, CQC,

TDA

Year End YTD

Current

Month

Previous


0 2 1 0 0 0 0 0 0

N/A 4,303 3,433 353 293 659 758 646 2,063

N/A -1,191 -1,329 -104 -40 118 16 -143 -8

0 3 2 0 0 1 1 0 2

N/A 3,719 2,633 333 316 638 817 649 2,104

N/A 77 -94 43 79 381 223 123 727

0 7 5 0 0 2 0 0 2

N/A 16,394 12,051 1,192 1,268 4,604 4,958 2,460 12,022

N/A 4,426 1,591 758 663 1,329 1,189 1,421 3,940

0 n/a n/a 0 0 n/a n/a 0 0 *

N/A n/a n/a 470 411 n/a n/a 881 881 *

* Incomplete (Pathways with DTA) & New RTT Periods: YTD from October 2015 as figures prior to this date available at this time

52 Week RTT Breaches

Non Admitted

Incomplete

(All Pathways)


18w(95%) Shortfall/Surplus

52 Week RTT BreachesIncomplete

(Pathways

with DTA) * Patients Waiting >18 weeks

Trust Total

18 weeks Referral to Treatment -Non

Admitted

18 weeks Referral to Treatment -Incomplete

(All Pathways)

Indicator

Patients Waiting >18 weeks



Indicator

18 weeks Referral to Treatment - Admitted

Admitted

18 weeks Referral to Treatment -Incomplete

(Pathways with DTA) *

New RTT Periods - All Patients *

Compliance

Source



Monthly

Trend

Monthly

TrendThreshold

Performance 2015/16

Threshold


Performance 2014/15


Compliance

Source

Page 5


18 Weeks Referral to Treatment (Provisional) (Cont.)

RTT Admitted Performance saw a slight decrease in performance, this was because of a concentrated focus applied due to the change of emphasis in RTT18 reporting on current

long waiters and closing their pathways. In November Performance was 85.9% (M7: 88.5%). Year to Date at 89.96%.

RTT Non-Admitted Performance saw an increase in performance in October achieving 95.5% (M7: 96.0%), with the Year to Date at 96.3%.

Trust Total

Page 6


Year End YTD

Current

Month

Previous


N/A95,951 64,862 8,400 9,024 27,233 26,070 17,424 70,727

N/A92,811 62,922 8,031 8,419 25,585 25,422 16,450 67,457

≥ 95% 99.2% 99.1% 95.8% 95.7% 98.0% 97.9% 95.7% 97.4% CQC, Monitor,

TDA

≥ 80% 81.8% 81.5% 76.0% 75.7% 76.1% 79.8% 75.9% 77.4% Local

N/A 605 459 340 383 489 543 723 1755

N/A 30 30 11 30 4 29 41 74

≤ 5% 1.2% 1.1% 2.8% 2.8% 2.6% 2.2% 2.8% 2.5% CQC, Monitor,

TDA

≤ 60 mins 25 21 32 30 29 25 31 0 CQC, TDA

≤ 240 mins 219 229 203 202 230 217 227 0 CQC, TDA

≤ 240 mins 227 221 237 236 229 228 237 0 CQC, TDA

≥ 30% 24.0% 24.6% 20.4% 19.8% 23.6% 23.9% 20.1% 22.8% Local

≤ 5% 0.6% 0.7% 0.3% 0.3% 0.5% 0.5% 0.3% 0.4% CQC, TDA

A&E Four Hour Performance

Threshold

Performance 2015/16

Total number of Arrivals in A&E

Total number of Expected Arrivals in A&E

Accident & Emergency

Indicator

Compliance

Source

Performance 2014/15

Monthly

Trend

A&E Three Hour Performance

Time to Treatment in Department - median

Total number of 4 hour breaches

Total number of 6 hour breaches

Left without being seen

Total time spent in A&E -Admitted 95th

Percentile

Total time spent in A&E - Non Admitted 95th

Percentile

A&E Unplanned Re-attendance

A&E ENP Pathway

Page 7


Percentage of Unplanned Re-Attendances and Left A&E Before Treatment remains stable compared to previous months.

Accident & Emergency (Cont.)

Page 8


Year End YTD

Current

Month

Previous


Cases 29 22 5 9 7 12 14 33 ≥ 93% 93.1% 90.9% 80.0% 77.8% 100.0% 100.0% 78.6% 90.9% Cases 15 10 19 18 4 56 37 97 ≥ 96% 100.0% 100.0% 89.5% 100.0% 100.0% 92.9% 94.6% 93.8% Cases 3 2 2 3 5 9 5 19 ≥ 94% 100.0% 100.0% 100.0% 100.0% 100.0% 77.8% 100.0% 89.5% Cases 0 0 0 0 0 1 0 1 ≥ 85% n/a n/a n/a n/a n/a 100.0% n/a n/a 100.0%

Cases 16 10 2 8 2 3 10 15 ≥ 93% 100.0% 100.0% 50.0% 75.0% 100.0% 100.0% 70.0% 80.0% Cases 0 0 17 18 3 50 35 88 ≥ 96% 88.2% 100.0% 100.0% 92.0% 94.3% 93.2% Cases 0 0 1 2 0 5 3 8 ≥ 94% 100.0% 100.0% n/a 60.0% 100.0% 75.0% Cases 0 0 0 0 0 0 0 0 ≥ 85%

Cases 13 12 3 1 5 9 4 18 ≥ 93% 84.6% 83.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cases 15 10 2 0 1 6 2 9 ≥ 96% 100.0% 100.0% 100.0% n/a 100.0% 100.0% 100.0% 100.0%

Cases 3 2 1 1 5 4 2 11 ≥ 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Cases 0 0 0 0 0 1 0 1 ≥ 85% 100.0% 100.0%

Cancer 31 day waits - subsequent treatment

CQC, Monitor,

TDA

Cancer 31 day waits - diagnosis to first

appointment

CQC, Monitor,

TDA

CQC, Monitor,

TDA

CQC, Monitor,

TDA

Cancer 62 days from urgent GP referral to first

definitive treatment

Cancer 31 day waits - subsequent treatment



CQC, Monitor,

TDA

Brain and Nervous System Tumours

Cancer 2 week waits - first appointment urgent

GP referral

CQC, Monitor,

TDA


appointment

CQC, Monitor,

TDA

Cancer 31 day waits - subsequent treatmentCQC, Monitor,

TDA



CQC, Monitor,

TDA

Skin Cancer


GP referral

CQC, Monitor,

TDA

CQC, Monitor,

TDA

CQC, Monitor,

TDA

Compliance

Source

Cancer Waiting Times

Indicator


appointment


GP referral

Threshold

Performance 2015/16

Monthly

Trend

Performance 2014/15

Page 9


Year End YTD

Current

Month

Previous


≥ 99% 100% 100% 100% 100% 100% 100% 100% 100% CQC, TDA

TBA 85.5% 85.6% 88.1% 87.9% 86.2% 89.7% 88.0% 88.0% Local

TBA 33.8% 39.6% 24.9% 22.4% 19.1% 23.8% 23.7% 22.1% Local

≥ 96% 87.3% 86.4% n/a n/a 85.3% * n/a n/a n/a 85.3% * Local

N/A 12.0% 12.8% n/a n/a 12.8% n/a n/a n/a 12.8% Local

N/A 0.7% 0.8% n/a n/a 1.8% n/a n/a n/a 1.8% Local

Access - Other (Cont.)

Choose and Book System Issue Rate

Indicator Threshold

* Quarter 1 and YTD figure are to May 2015 as unavailable (See notes below)

Diagnostic waiting times Performance remains at 100%.

Both the percentage of patients waiting 6 weeks for a first appointment and those waiting for admission within 13 weeks has increased compared to the previous month.

Following the transition from the CAB system to e-Referral system the reports module of the new e-Referral system was not implemented before go-live, therefore we are

unable to report any recent Choose and Book Performance figures. The figures within this report are to May 2015.

Choose and Book Capacity Issue Rate

First Outpatient Appointment Waiting more

than 6 weeks

Patients Waiting more than 13 weeks for

Admission

Diagnostic waiting times - 6 weeks

Choose and Book appointment availability

Access - Other

Monthly

Trend

Performance 2014/15

Compliance

Source

Performance 2015/16

Page 10


Year End YTD

Current

MonthPrevious


N/A 104,890 68,901 10,129 10,396 28,237 28,218 20,525 76,980 Local

N/A 403,657 270,814 34,988 37,002 102,411 104,088 71,990 278,489 Local

N/A 10.4% 9.4% 10.3% 10.5% 10.6% 10.5% 10.4% 10.5% Local

N/A 11.6% 11.4% 13.0% 12.6% 11.7% 12.4% 12.8% 12.3% Local

N/A 12.4% 12.2% 11.7% 11.9% 12.0% 12.3% 11.8% 12.0% Local

N/A 56.7% 55.7% 55.7% 57.9% 57.1% 59.6% 56.8% 57.9% Local

N/A 70.5% 70.2% 72.9% 72.2% 70.7% 72.6% 72.5% 71.9% Local

N/A 36,500 23,967 3,104 3,098 9,405 9,219 6,202 24,826 Local

N/A 37,232 25,577 2,877 2,977 8,987 8,929 5,854 23,770 Local

N/A 6.2% 6.0% 7.9% 9.2% 6.6% 7.5% 8.6% 7.4% Local

N/A 28.8% 26.7% 36.5% 37.3% 34.0% 33.6% 36.9% 34.6% Local

0 3 3 0 0 1 0 0 1 CQC, TDA

Efficiency

Trust Total

Outpatient DNA rate

- First Appointment

Theatre Sessions Starting Late

Clinic Journey Times Less Than 2 Hours

- Outpatient First Appointment

Clinic Journey Times Less Than 2 Hours

- Outpatient Follow Up Appointment

Outpatient DNA rate

- Follow Up Appointment

Theatre Cancellation Rate

Admission Demand

- Decision to Admit (DTA)

Admission Activity

Outpatient Cancellations

Outpatient Total Attendances

- First Appointment

Monthly

Trend

Compliance

Source


Outpatient Total Attendances

- Follow Up Appointment

Threshold

Cancelled Operations - 28 Days Re-Book

(Provisional)

Page 11


Key:

Efficiency (Cont.)

There has been an increasing trend of First

Appointment DNA Rate over the last 3

months, increasing from 12% to 13%. DNA

Rates for Follow Up Appointment have

remained stable compared to previous

months.

:4 Month Average:Monthly Trend

Page 12


Effectiveness

Year End YTD

Current

MonthPrevious


N/A 3.8% 3.7% 2.1% 4.6% 4.7% 4.6% 3.5% 4.4% Monitor

Cases 102 67 4 11 33 35 15 83

N/A 4.1% 4.0% 2.6% 5.0% 5.0% 4.8% 3.9% 4.7% CQC, TDA

Cases 109 71 5 12 35 37 17 89

N/A 54% 54% 45.6% 50.7% 53.8% 51.3% 48.1% 51.3% Local

Safety

Year End YTD

Current

MonthPrevious


0 0 0 0 0 0 0 0 0 CQC, TDA,

Monitor

0 0 0 0 0 0 0 0 0 CQC, Monitor,

TDA

≥ 95% 98.5% 98.4% 98.2% 96.7% 98.7% 98.5% 97.5% 98.3% CQC, TDA

0 0 0 23 4 3 0 27 30 CQC, TDA

Compliance

SourceThreshold

Monthly

Trend

Compliance

Source


Performance 2014/15

Number of C.Diff cases

Performance 2015/16

Number of MRSA cases

Indicator Threshold

Emergency Re-admission within 28 days of

discharge

Emergency Re-admission with 30 days for

elective and emergency cases

% GP referrals From Electronic Booking

(Choose & Book /E-referrals)

Indicator

VTE Screening

Mixed Sex Accommodation (Provisional)

Monthly

Trend

Page 13


Ward Staffing Levels (Only 'wards with inpatient beds' as per report requirement) - Provisional

Page 14


Patient Experience - Friends and Family Test (FFT) - November Provisional

Please note there have been a number of changes to the Friends and Family Test (FFT) response rate and scoring.

The scoring system has been replaced with a simpler percentage method, where patients who are ‘Extremely likely’ or ‘Likely’ to recommend Moorfields to friends and family

are listed as ‘Would Recommend’ the hospital, and patients who are ‘Unlikely’ or ‘Extremely Unlikely’ to recommend Moorfields are listed to ‘Would Not Recommend’ the

hospital.

The eligible patient population now includes under-16’s in all categories.

The ‘Inpatient’ FFT responses now include ‘day case’ patients as well as patients who stayed overnight, which has increased the number of results received in this category.

The ‘outpatient’ FFT scores and response rates are now also included in this report, covering most patients who attended an outpatient clinic.

Accident and Emergency FFT response rate method remains unchanged from last year (aside from the aforementioned inclusion of under-16s).

Page 15


Nursing Bank and Agency Staff Information (October Data)

Proportion of Nursing Bank and Agency Staff Hours filled, with total hours worked

Page 16

Item - Moorfields Eye Hospital · Compared to 2014/15, November activity was up 7% (vs. November 2014) with the YTD up 9%. Cancer Performance For November 2015 '2 week wait' performance

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