Integrated Performance Report - May 2009

Integrated Performance Report: Strategic Overview

Introduction... 3

Integrated Performance Report: Strategic Overview... 4

Trust Board Performance Dashboard... 1

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Trust Board Key Performance Indicators (KPIs): Rationale & Construction –updated for 2009/2010 ... 1

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Dear Board Member/Reader

Welcome to the Trust’s Integrated Performance Report: Strategic Overview for month 1 2009/2010 (April 2009 information).

The integrated performance strategic overview report is a key tool to provide assurance to the Board that the strategic objectives are

being delivered and to direct the Board’s attention to significant risks, issues and exceptions. The Trust has defined a set of Key

Performance Indicators (KPIs), to help assess how well the Trust is performing against the strategic objectives. These KPIs have been

woven into a performance dashboard based on the 4 plus 2 model (Strategy, execution, culture, structure, innovation, partnerships),

providing a high level view of actual performance against target and assurance to the Board about the delivery of the strategic

objectives.

The Trust Board has agreed a revised set of KPIs for 2009/2010 which will be incrementally incorporated into the performance reports

from month 2 onwards (see page 15 for details).

Strategy:

Develop our services to meet local

expectations and make the most of opportunities to progress and improve

Overview

The Trust continues to be successful in achieving the stated intention of strengthening and maintaining its market share in line with the position set out in the Integrated Business Plan (IBP), supported by 3 year contracts with all Commissioners. (KPI 1.2.1) The Trust continues to work with SHA and PCTs to clarify the CQUIN indicators, the headline indicators have been agreed however there is still considerable work taking place to finalise the data definitions and the submission dates.

The relationships with PCTs remain very positive, with a willingness to continue with a “co-production” approach. Each of the PCTs are exploring options for closer working relationships with the Trust through executive team to team meetings, this approach is setting out a framework for ongoing engagement and partnership working for the future. There is increasing recognition that the PCTs financial position is becoming increasingly pressured as the impact of global financial position emerges, this may have an impact on any future developments.

The Trust continues to explore a variety of differing partnering arrangements with 3rd and Independent Sector providers. For example in partnership with Mental Health Matters, a Third Sector organisation, the Trust is developing a bid for the NHS Wakefield District IAPT service. The final

submission date for the tender is the 26th May 2009.

Work is ongoing to refresh the Integrated Business Plan and Long Term Financial Model as agreed at the Trust Board development session in February and discussed further at the Trust Board development session on the 19th May .

Risks

• World Class Commissioning (WCC) – Primary Care Trusts (PCTs) are continuing to develop their procurement arrangements to demonstrate value for money through increasing levels of contestability.

• Requirements linked to the 0.5% Quality Improvement uplift are not met.

Mitigation

• Relationship management with Commissioners remains key, with an emphasis on delivering key performance targets in line with contracts. Where appropriate, joint implementation plans have been agreed with Commissioners. Independent advice has been sought, linked to marketing strategy development, to mitigate the potential impact of contestability.

• Robust action being developed to ensure the requirements linked to the 0.5% CQUIN initiative are met.

• The Trust Board approved a Marketing strategy in January 2009; marketing plans are now being developed in each of the Service Delivery Groups.

Services for Adults of a Working Age

• Current market share (63%) remains healthy and in line with IBP( KPI 1.1.1)

• The strategic intent to sub specialise is progressing well with agreement being reached with Commissioners in Kirklees and Wakefield to the development of an Adult Attention Deficit Hyperactivity Disorder (ADHD) service, staff are now in post and undergoing an induction period, they will commence with transitional cases from the end of April.

• The IAPT service in Kirklees commenced on the 1st April, the service is in development, with the majority of staff undergoing training, the service will have an official launch on the 1st June 09.

• The Trust is submitting a joint bid with mental Health Matters for the IAPT service in Wakefield.

• Discussions are ongoing with NHS Calderdale to understand their approach to IAPT development, and to explore how the Trust can work collaboratively with the PCT’s existing primary care mental health provider to ensure that a seamless service offer is made to service users in Calderdale.

• Proposals for the re-engineering of services in line with Pathways and Packages are developing, subject to stakeholder approval, and will support the transition to Business Delivery Units.

Strategy

continued

Risks

• Failure to submit an appropriate bid for the IAPT service in Wakefield could undermine ability to expand further in this area. • Delays in reengineering may impact on the ability of the SDG to deliver the CIP for 2009/10.

Mitigation

• The Director of Business Development & Planning is exploring opportunities to work collaboratively with Third and Independent Sector providers to support IAPT bids

• Detailed project plans for reengineering are being developed with full engagement of all stakeholders to ensure sign up and agreed implementation.

Older People’s Services

• Current market share (85%) remains healthy and in line with IBP ( KPI 1.1.2)

• The increasing ageing profile of local populations could trigger changing commissioning intentions in line with WCC, though as yet these have not materialised.

• The changing regulatory frameworks to residential and nursing home care could impact on the Trust’s ability to manage resulting changes to demand and capacity.

• The publication of the Dementia Strategy provides opportunities for strengthening the Trusts position in the delivery of services for dementia and provides further information to support the debate regarding the Trusts position regarding the development of “needs led, age

appropriate” services. Work is developing with partners to understand the implications of the Dementia Strategy and to develop actions plans for implementation.

Risks

• That individuals are discriminated against on the ground of age

Mitigation

• A transition protocol is in the process of being implemented.

• Discussions are taking place with Commissioners and other key stakeholders regarding the implications of the Dementia Strategy

Forensic Services

• Current market share (32%) remains healthy and in line with IBP. ( KPI 1.1.4)

• The independent sector remains active in the market at a local level, however there has been increased demand for Medium Secure beds and the previous over provision is now being fully utilised

• The bed day price of the service remains competitive, especially when compared with the independent sector. • The Trust maintains a strong reputation for quality with Specialist Commissioners.

• Commissioners have agreed to a reduction in bed occupancy level to 90% from April 2009, this will assist in the managing length of stay issues.

• The financial profile of the Trust remains strong allowing for longer term involvement in service configuration (2011/12, 2012/13) to enhance service quality/market position in line with IBP, the Director of Business Development & Planning and the interim Care Group Director has begun discussions with Commissioners to explore how the Trusts position in the Forensic pathway can be enhanced and also to ensure that any estate development is commensurate with commissioning intentions.

• The Trust has submitted an initial business case to NHS Wakefield District in response to the revised specification for both prisons. As a consequence negotiations are ongoing led by the Director of Business Development & Planning and the interim Care Group Director to agree a final position with NHS Wakefield.

Strategy

continued

Risks

• Potential for independent sector to contest Trust contract in longer term, particularly.

• The reduction in bed occupancy rate is welcomed however it could still present the Trust with challenges in providing adequate throughput in the service.

• NHS Wakefield District do not agree to fully resource the Trust Business case for prison healthcare

Mitigation

• Advice sought re contestability/contractual issues through FT network connections.

• The Chief Executive, Director Business Development and Planning and the interim Care Group Director are continuing discussions with Commissioners to resolve issues regarding the provision of service to the prisons and to develop an action plan to address.

Services for People with a Learning Disability

• Current market share (32%) remains healthy and in line with IBP. ( KPI 1.1.3)

• Emphasis remains on maintaining existing position in terms of specialist assessment and treatment to NHS care. This is going well.

• The transfer of Newhaven from St Luke’s hospital site is projected for 2009 with the resultant opportunity to enhance the Trust’s Low Secure provision in this area as per IBP through the development of a sub regional PLD Low Secure service. Commissioners have given

agreement in principle to commissioning all the additional beds as an addition to the block contract.

• Discussions have commenced with NHS Calderdale to understand their investment position in PLD services in Calderdale, acknowledging that current investment challenges the ability to deliver a viable service.

Risks

• Changes to Local Authority funding profiles could impact on investment in community Learning Disability Services impacting on the specialist healthcare element.

• Calderdale PLD service become less viable and unable to deliver its CIP

Mitigation

• As part of annual planning, assessment is being made by the SDG of the potential impact of Local Authority investment. • Joint working to agree a revised health and social care pathway that clarifies the role of specialist health services.

• Work in place to agree model of service in Calderdale linked to clarity about the pathway, which will support discussions around future investment.

Other Developments

• Opportunities exist to enhance the Trust’s market share through sub specialisation in areas such as Child and Adolescent Mental Health Services (CAMHS) at a specialist level, as well as the potential for eating disorder developments through innovative partnership with Affinity Healthcare.

• The Operating Framework identifies the requirements for PCTs to divest their provider functions which will provide opportunities for geographical expansion.

Risks

• Failure to gain Foundation Trust status will significantly hamper ability to deliver on such developments.

• The Trust does not position itself effectively to make the most of the geographical expansion opportunities available.

Mitigation

• Clear marketing strategy and position agreed by Trust Board to support scoping and response to the available geographical expansion opportunities.

Flawless

Execution:

Ensure we have effective systems in place to support service delivery & development

Estate Strategy

• Future options for the delivery of services presently being delivered at St Luke’s Hospital are being considered by the Trust Board. • The Trust has a significant capital programme based on a consultation process, the delivery of which supports the implementation of the

IBP.

• The Estate strategy will be reviewed following the review of the Integrated Business Plan and service strategies during 2009.

Risks

• Non delivery of the capital program will effect the reputation of the Trust and the ability to deliver the service changes identified in the IBP

• Failure to achieve Foundation Status may put surplus at risk which would have an impact on the capital programme • That the quality of the environment on the St Luke’s site continues to deteriorate

• That recurrent CIPs in future years are not delivered

Mitigation

• Achieving Foundation Trust status.

• St Luke’s Site management board established under the leadership of the Director of Human Resources and Workforce Development.

Healthcare Commission Annual Rating Quality of Services

• Although we achieved excellent for 2007/08 the criteria for 2008/09 is more stretching. (KPI 2.1.10, 2.2.7)

Risks

• That the Trust does not sustain an excellent rating in 2008/09

Mitigation

• Process in place led by Director of Nursing, Compliance and Innovation supported by appropriate director leads to achieve excellent rating in 2009/2010.

Monitor Compliance

• The Trust is achieving the mandatory service risk rating (KPI 2.1.9 = Green). Performance against the Monitor governance risk rating is assessed as amber as at month 1 as a result of underperformance against one of the service performance targets (see below)

• The Trust has achieved 3 out of the 4 Monitor service targets (crisis team size, admission of patients with access to crisis teams, Minimising delayed transfers of care) ( KPI 2.2.1, 2.2.2, 6.2.1). The % patients followed up in 7 days target (KPI 2.2.3) was not achieved in month 1. Four service users out of 69 discharged on CPA in month 1, were not followed up within 7 days (94% against a target of 95%). This indicator is monitored quarterly by Monitor. The expectation is that this target will be met at Quarter 1 and in future quarters.

Risks

• That the Trust does not maintain the action needed to ensure full achievement of monitor risk ratings. • That the Trust does not meet all the Monitor service targets

Mitigation

• Robust performance management arrangements in place to ensure continued compliance. Implementation of action plans where potential non compliance is identified.

Flawless

Execution

continued

National PCT Indicators

• Number of new cases of psychosis for EIP teams Month 1 = 24 (Month 12 = 22; target = 13). The target for all 3 PCT’s was achieved for Month 1 2009/2010. (KPI 6.7.4)

• Number currently receiving EIP services = 315 (303 month 12) 3 year cumulative target = 454: plan in place to achieve this by March 2010. Neither Kirklees, Calderdale or Wakefield PCT monthly targets were achieved for Month 1 2009/2010 (only one PCT in SHA area presently achieving this)

• In Month 1, 137 qualifying Intensive Home Based Treatment Episodes were delivered against a Trust target of 168 (Month 12 = 173). Monthly PCT target was achieved for Wakefield (64 episodes; target = 62) but not for Calderdale (29 episodes; target = 36) or Kirklees (44 episodes; target = 71) (KPI 6.7.1)

• Number on Assertive Outreach team caseload Month 1 = 335 (Month 12 = 334; target = 404). Wakefield monthly PCT target was achieved in Month 1 (151 on caseload; target = 148). Kirklees & Calderdale monthly PCT targets were not achieved in Month 1 (Kirklees caseload = 113; target = 170), Calderdale caseload = 71; target = 86)

Risks

• The Trust will loose credibility with its Commissioners if it fails to achieve national targets.

• Contract with NHS Kirklees has a financial penalty if and agreed action plan is not delivered for each of these indicators

• Care coordinator capacity in AOT team in Kirklees and Calderdale does not appear adequate to meet the national target which could compromise our ability to achieve it.

Mitigation

• Action plans are in place to achieve these indicators • Work is being developed for these indicators for 2009/2010.

Other Trust KPIs

• 2 SUIs have been reported to the SHA in month 1. (KPI 2.2.4)

• At Month 1 the percentage of people recorded as being given or offered a copy of their care plan was (rounded) 79% for adult services and 72% for older peoples services.

• Independent inquiry action plans continue to be on track at month 1. (KPI 3.2.3) • There have been no hospital acquired infections in month 1 (KPI 2.2.6)

• The Trust continues to maintain a positive dialogue with all three overview and scrutiny committees and update them of service changes and developments. (KPI 6.1.1)

Risks

• Care planning is at the heart of service provision; there is a risk to organisational reputation, potential HCC quality rating and the perception of quality of services by Commissioners

• An increase in the level of SUIs could effect the reputation of the organisation

• Hospital acquired infections will reduce the quality of the service and the reputation of the organisation.

Mitigation

• Strong Trust drive to ensure CPA compliance led by Director of Nursing, Compliance and Innovation • Detailed action planning in place in both AWA and OPS services to improve practice

• All SUIs have a robust review to ensure that the root cause is understood and lessons learnt to improve systems and reduce the level of future incidents.

• Robust Infection prevention and control processes are in place.

Flawless

Execution

continued

HR and Workforce

• The sickness rate continues to fall with the rate for the first month April 2009 being 3.8%. • The year to date fire lecture attendance is slightly below the 80% target and is 79.6%. • Appraisal rate is being reported at 85% above the 80% Trust target.

• Turnover for the first month is 9%. • Agency costs for the first month is 1.4%.

Risks

• Middle grade doctors remains a risk from a service perspective due to a national shortage but this risk is reducing.

Mitigation

• Reviewing the middle grade role with a view to develop into consultant grades that could by recruited to.

Culture:

Develop the Trust’s culture so that it reflects our values and helps to provide services that are sensitive to the needs of a diverse population

Foundation Trust Membership

• Foundation Trust Membership and engagement remains strong with almost 11,000 members; representative of the population served. (KPI 3.1.1, 3.1.2)

Risks

• Need to ensure that we capitalise on opportunities to engage members now that we are an FT.

Mitigation

• Engagement events are planned for June.

• Members’ Council work stream in place focused on developing member communications and engagement

Diversity

• Revised strategy for involvement and inclusion has been approved and work is underway to roll out across the organisation.

Risks

• Services are not responsive to the needs of individuals • Non compliance with equality and Human Rights legislation

Mitigation

• Compliance lead for diversity and inclusion recruited and rolling out programme of work across the organisation

Mutual Respect

• Work on the pilot project in the low secure service to promote a culture of mutual respect is progressing well. • Work on the second pilot to examine how mutual respect can be tested through HR processes completed.

Risks

• Mutual respect is central to a customer focused culture

• Momentum and involvement of stakeholders reduced during a critical period, with a diminished focus on the development of a culture of mutual respect

Mitigation

• New Leadership and Management arrangements are being developed to support the engagement of key stakeholders and a culture of ‘mutual respect’.

• Customer care and communications training are being introduced across the trust with an expectation that a need to attend such training would be identified through training needs analysis.

Culture

continued

Complaints

• New national complaints procedure came into effect in April 2009, which changes requirements in terms of response times. • The Trust responded to all complaints within 25 days or an agreed extended period in month 1. (KPI 3.1.5)

Risks

• New procedure requires stronger emphasis on informal resolution which is more resource intensive

Mitigation

• Some additional capacity put into complaints function from PALS team

• Reorientation of complaints team to customer services planned to better describe role of team in resolving issues rather than investigation.

Structure:

Develop a clear organisational structure which promotes accountability and responsibility at all levels

Leadership and Management - Service Line Management

• The Trust continues to develop business delivery units (which are the Trust’s approach to service line management) through an

organisational development programme linked to a competency framework assessment and development centres. This will be incorporated in to the Trust’s Leadership and Management strategy. (KPI 4.1.2)

Risks

• Failure to gain appropriate clinical engagement in the development of leadership and management arrangements that link to the quality strategy

• Delay in FT authorisation could divert capacity from core cultural initiatives and undermine credibility in the workforce.

• Delays in payment by results for mental health and changes to commissioning arrangements which impact on service line management.

Mitigation

• Clinical networks are being established under the leadership of the Medical Director to advise on service and related quality issues with a view to underpinning service strategy and associated leadership and management developments. Reviewed at a meeting of Strategic EMT on 12th March

• Dr Adrian Berry has agreed to move into the role of Interim Care Group Director for Forensic Services subject to formal process in the longer term

• Robust communication and workforce development approach, including progression of Leadership and Management strategy

Managing the Workforce

• Developing significant change to service whilst maintaining staff morale and support requires effective workforce development arrangements.

Risks

• Staff morale is affected resulting in reduced support for change and difficulties with recruitment and retention

Mitigation

• Effective HR strategy and workforce plan, with workforce development linked into annual planning cycle. • Effective communication with staff and involvement of staff side organisations.

• Wellbeing and Engagement Programme developed in partnership with Bradford District Care Trust.

Innovation:

Find opportunities to develop new services and ways of working which help us to maintain our reputation as a lead provider

Pathways and Packages

• The Trust is part of the Care Pathways and Packages (CPPP) Consortium and is arguably the lead player from a clinical perspective. The embedding of this approach into practice including integration with CPA continues. (KPI 5.1.1, 5.1.2)

• The Trust is proposing to use the INPAC methodology to re-structure its service within AWA and OPS to support greater efficiency and effectiveness.

• The InPaC methodology is being used to inform the development of the Service Strategy within the review Integrated business plan through the Trust Board.

Risks

• Due to the complexity of the project across the Consortium there may be issues in delivering to the DoH timescale.

• Stakeholders may not sign up to the re-structuring proposals which also support the development of IAPT and the delivery of the CIP • The introduction of SARN2 and future developments of SARN may conflict with the continued DoH requirements to record and report

HONOS

Mitigation

• Letter from the DoH has confirmed that the national mental health currency will be based on the Care Pathways and Packages methodology.

• Detailed proposals now being discussed with stakeholders with regard to the remodelling of services in AWA in Wakefield and Kirklees. • Discussions with respect to HONOS requirements are being picked up through the Consortium Board and with the SHA.

Partnerships:

Ensure

partnerships are developed which help us to achieve our vision and brings benefits for the communities we serve

World Class Commissioning (WCC)

• Relationships with PCTs remain positive with very little evidence of changes to procurement arrangements. The principles of co production remain strong with each of the PCTs exploring options for closer collaborative working with the Trust, for example exploring how the Community Hospitals initiative can be used to enhance service provision and consequently the use of estate.

Risks

• Through the process PCTs may be encouraged to develop a pluralistic market through increased contestability.

Mitigation

• Relationships with Commissioners are being maintained to ensure the Trust is well placed to understand the implications for PCTs and to understand the response that may be required from the Trust.

Pathways and Packages

• The Trust is part of the Care Pathways and Packages (CPPP) Consortium and has commenced the local work stream on currency development with its partners. Engagement with partners remains crucial, The Chief Operating Officer and Director of Business

Development and Planning are ensuring that clear transparent communication is taking place with PCTs and Local Authorities to facilitate local implementation of the project. To facilitate this a Transformational Programme Board has been established ensuring that all partners are offered an opportunity to fully understand the key issues related to the programme and to have a forum to deal with the interface with Putting People First from a Local Authority perspective and World Class Commissioning from a PCT perspective.

Risks

• Poor local engagement in the development of currency at a national level results in lack of partnership engagement and ownership

Mitigation

• Engagement of partners through the development of a Transformational Programme Board and through specific locality focussed groups continues, ensuring that partners remain fully engaged in local implementation issues.

Goal:

Strategy - Develop our services to meet local expectations and make the most of opportunities to progress and improve

Key Issues/questions:

What is our market position and is it growing? Are we developing new market opportunities?

Do we have 3 year contracts in place with all our customers?

Rpt_Strategy: Key Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

1.1.1 Percentage of existing market (Adults of Working Age ) Annual 63% 63%

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4

1.1.2 Percentage of existing market (Older People Services) Annual 85% 85%

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4

1.1.3 Percentage of existing market (Learning Disabilities) Annual 32% 32%

9

4

1.1.4 Percentage of existing market (Forensic Services) Annual 32% 32%

9

4

1.2.1 Number of 3 year contracts in place Annual 5 5

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4

Goal:

Flawless Execution - Ensure we have effective systems to support service development/delivery

Key Issues/questions:

Do we provide the best quality of care to our Service Users? Do we achieve our compliance requirements?

Are we financially viable?

Do we use our resources in the most efficient way? Are our staff motivated and competent to deliver the service?

Rpt_Flawless_ExecutionKey Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

2.1.0 £2.6m Surplus on Income and Expenditure Monthly tbd Not available month 1

2.1.1 External Financing Limit Monthly tbd Not available month 1

2.1.2 Capital Resource Limit Monthly tbd Not available month 1

2.1.3 Capital Cost Absorption Monthly tbd Not available month 1

2.1.4 Better Payment Practice Code Monthly tbd Not available month 1

2.1.5 Use of Resources FY 2007-08 Monthly tbd Not available month 1

2.1.6 Delivery of CIPs (Trust) Monthly tbd Not available month 1

2.1.7 Monitor risk rating finance 2008/2009 Monthly tbd Not available month 1

2.1.8 Monitor risk rating governance 2008/2009 Monthly Green Amber U 3

2.1.9 Monitor risk rating mandatory services 2008/2009 Annual Green Green

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2.1.10 HCC quality of service (National benchmark) 2008/2009 Quarterly* Excellent Good/Excellent U 3

2.2.1 Crisis Equivalent Team Size (National benchmark) (FT) Monthly 6.9 8.2

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2.2.2 % Admissions with access to Crisis teams (FT) Monthly 90% 93.8%

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4

2.2.3 % patients followed up within 7 days of discharge (enhanced CPA) (FT) Monthly 95% 94% U 3

2.2.4 SUIs reported to SHA (SHA benchmark) Monthly N/A 2 3

2.2.5 % service users on CPA offered a care plan (AWA & OPS) Monthly 80% 76.6% U 3

2.2.6 Number of hospital acquired infections/1000 days (SHA) (FT) Monthly 0 0

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3

2.2.7 HCC data quality - ethnic coding (NAT) Quarterly* >= 85% 91.8% (2007/08)

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2.3.1 Sickness absence rate (YTD) Monthly <= 5.5% 3.8%

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4

2.3.2 Use of agency staff Monthly 2.3% of Pay Bill 1.4%

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4

2.3.3 Annual attendance at fire lecture Monthly > 80% 79.6% U 3

2.3.4 Vacancy rate (Active Vacancies) Monthly < 10% 2.1%

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4

Key Issues/questions:

Do we embrace diversity? Are we locally involved?

Do we treat people with dignity and respect? Do we have zero tolerance to abuse for Service Users and staff?

Key Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

3.1.1 Total Trust membership (FT) Monthly 8,000 (March) 10893

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3.1.2 Is our membership representative of the local population? Monthly Yes Yes

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3.1.3 Ethnicity of compulsory admissions Monthly <=8.5% 19% U 2

3.1.4 % of complaints upheld with staff attitude as an issue Monthly < 45% 15%

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3.1.5 % complaints replied to within agreed deadlines (SHA) Monthly 100% 100%

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3.2.1 Physical violence - against staff by patient Monthly < 70 67

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3.2.2 Physical violence - against patient by patient Monthly < 26 20

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3.2.3 Independent Inquiries: plans on track Monthly Yes Yes 3

Goal:

Structure - Develop a clear organisational structure which promotes accountability and responsibility at all levels

Key Issues/questions:

Does the structure support service line management Do we have competent managers and leaders?

Do we have clear accountability in place?

Rpt_Structure: Key Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

4.1.1 % of staff who have had an appraisal in the last 12 months Monthly 80% 85%

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4.1.2 Development of BDUs/service line management against plan Quarterly* Yes Yes

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Goal:

Innovation - Find opportunities to develop new services and ways of working which help us to maintain our reputation as a lead provider

Key Issues/questions:

Are we compliant with the implementation of NICE guidance Are we developing innovative approaches to practice?

Rpt_Innovation Key Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

5.1.1 Number of staff trained in INPAC (AWA & OPS) Monthly 80% 60.4% U 2

Key Issues/questions:

Are we delivering the business developments agreed Do we have legal partnership agreements in place where appropriate e.g. section 75?

Does partnership working ensure movement through the care pathway (e.g. timely discharge)?

Are we working partnership to delivery national priorities (e.g. 18 week wait Psychological Therapy Services)?

Do we have an effective working relationship with our partners e.g.(O&S committee)?

Rpt_Partnerships: Key Performance Indicators: Frequency Target Current Position Status Trend Assurance Further Details in

6.1.1 Overview & Scrutiny Committee approval (major projects) Quarterly* Yes 100%

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6.1.2 Are business developments agreed with commissioners on track:

Low Secure Annual Yes Yes

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PICU Annual Yes Yes

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3

136 Annual Yes Yes

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6.2.1 Delayed Transfers of Care (FT) Monthly <=7.5% 3.5%

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3

6.2.2 % seen within 18 weeks referral to treatment (APT) Monthly >=85% 38% U 3

6.2.3 Bed Occupancy (Forensic) Monthly 90% 93%

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6.7.1 Crisis - No. of intensive home based treatment episodes (IHBT) Monthly 168 137 U 3

6.7.4 Early Intervention in Psychosis service - New cases Monthly 13 24

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KEY

Performance is on or above target - No assurance level assigned

Performance is not meeting target 1 No plan in place

Performance has improved 2 Plan in place but progress insufficient

Performance maintained or target met and assurance 4 3 Plan in place and progress satisfactory

Performance has declined 4 On target, no plan required at this stage

NAT National Benchmark N/A Not Applicable

IBP Integrated Business Plan 6 Month Reporting Period

IPR Integrated Performance Report 12 Month Reporting Period

* Information updated every quarter SHA SHA Benchmark

FT Foundation Trust Service Target MAV Management of Aggression and Violence

APT Adult Psychological Therapies tbd To Be Determined

Trust Board Key Performance Indicators (KPIs): Rationale & Construction –updated for 2009/2010

Descriptor Freq Target Rationale KPI, target & frequency Construction Responsible Director

1. STRATEGY –

Develop our services to meet local expectations and make the most of opportunities to progress and improve

Maintain or increase market share

A To be

determined

Market assessment is a key element of the Trust’s integrated Business Plan.

Introduced from month 2 2009/10. KPI to be split by Adults of Working Age; Older People Services; Learning Disabilities; Forensic Services

Percentage calculated from: Numerator = total contract value Denominator = total commissioner spend2008/09 by care group

Director of Business Development and Planning

2. FLAWLESS EXECUTION –

Ensure we have effective systems to support service development/delivery

Cash Position M projected monthly cash position

Projected monthly cash position defined in LTFP. KPI shows actual against plan.

Director of

Finance

Delivery of CIPs M Monthly target

Trust target. Monthly and cumulative annually. KPI re-defined in IPR dashboard from month 5 2008/9 Proposed change from month 2 -2009/2010 to Monthly actual against monthly target

Actual performance of delivery of each CIP each month compared to plan

Director of Finance

Monitor Finance Risk Rating

A, M 4.3 Trust target. Annual Target, monthly assessment of achievement. KPI re-defined in IPR dashboard from month 5 2008/9 (see ‘Monitors risk rating this month (finance’)

Calculated monthly using current months I&E and Balance Sheet data applied to Monitor’s calculations.

Director of Finance

Monitor Governance risk rating

M Green Required to meet Monitor compliance framework. Introduced month 1 2008/9 Internal self-

assessment against the 7 elements included in Monitor’s assessment of governance & risk: Legality of constitution; Growing a representative

membership; appropriate board roles 7 structures; service performance; clinical quality; effective risk & performance management; co-operation with NHS bodies & local authorities Service performance: relates to the current reporting period and assesses performance against the core standards and Monitor mental health targets at that point in time. Clinical Quality relates to the current reporting period in terms of compliance with various internal and external requirements

Responsible Directors for each of the 7 elements conduct the assessment against identified criteria. Lead Director Overall assessment validated by Performance EMT Service

performance: All existing targets met & no more than 2 core standards not met = GREEN (Monitor score = <1) No more than 2 existing targets not met plus no more than 2 core standards not met = AMBER (score = from 1.0 – 2.9) More than 2 targets not met OR 3rd consecutive amber rated quarter from a failure to achieve the same national requirement) = RED (score = 3.0 or more) Clinical quality:

Director of Nursing, Compliance and Innovation

of red/amber or green against the following criteria:

• Failure to comply with HCC Indicators

• Assurance levels of 1 or 2 against Quality of Service, SUI, Infection control KPIs

• Identified breaches or lack of assurance against Core Standards; NHSLARMs

• Clinical quality

• Limited assurance levels in any relevant internal audit

assessments reported within the period

• Score of 1 or 2 in any HCC review reported in the period

• Weak or equivalent other 3rd party review score reported in the period

• Delayed implementation of

identified actions in respect of HCC or other 3rd party review action plans due within the period Significant deficits in respect of national surveys completed within the period

Monitor risk rating mandatory services

M Green Required to meet Monitor compliance framework Assessment of: mandatory service. Introduced month 1 2008/9 •Changes to mandatory service provision •Disposals of protected assets

Lead Director Assessment, validated by Performance EMT

Director of Business Development and Planning National Quality Standards M 0 Number of significant lapses against National

Standards. This forms part of the Trust Board declaration to the new CQC.

Lead Director Assessment, validated by Performance EMT

Director of Nursing, Compliance and Innovation % service users on NEW

CPA offered a care plan (AWA & OPS)

M 80% NSF target (AWA). Month 9, 10,11 KPI under development. Introduced month 12 with target of 80%. Originally related to service users on standard and enhanced CPA and to service users given a copy of their care plan

Data available from month 12 Changed to

enhanced & service users offered a care plan from month 12

Data source = RiO Percentage calculated for AWA & OPS service users using: Numerator = number of service users on enhanced CPA offered a care plan.

Denominator = number of service users on enhanced CPA

Director of Nursing, Compliance and Innovation

Sickness absence rate (YTD)

M 5% Introduced from month 9. Month 9, 10,11,12 – target = <5%

Target revised from 5.0 to 5.5 from month 1 following Trust Board agreement and in light of comparative benchmarking data. Part of monthly WIMS (Workforce Information Management system) collection to SHA/DoH.

Data source: ESR The sickness absence rate is calculated as FTE days lost to sickness absence as a percentage of FTE staff in post. Reported cumulatively from April to March each financial year,

Director of HR and Workforce Development

Vacancy rate M Needs to be

determined

Introduced from month 9. Part of annual NHS Vacancy Survey reported to DoH

Propose change to staff in post against funded establishment from month 2-2009/2010

Data source: Recruitment System/ESR Director of HR and Workforce Development

Data Quality

completeness of mental health minimum data set

Q 80% The mental health minimum data set (MHMDS) is a nationally defined framework of data held locally by mental health trusts on their adult and older people services patients. Completeness of the MHMDS is a new mental health indicator introduced in 2008/09 as one of the 11 indicators used in the 2008/09 annual health check

Numerator count of valid entries for each of eight selected data fields (patient ID, date of birth, gender, marital status, NHS number, GP code, post code, commissioner code) Denominator = total number of records submitted

Indicator = is the numerator divided by the denominator expressed as a percentage

Chief Operating Officer

3. CULTURE –

Maintain and develop the Trust’s culture so that it reflects our values and helps us provide services that are sensitive to the needs of a diverse

population

% of complaints upheld with staff attitude as an issue

M <45% Introduced as a result of concerns about the high proportion of complaints relating to staff attitude. KPI enables the Trust Board to measure the effectiveness of mutual respect work aimed at Improving the interface between staff and service users. Introduced from month 9. Quarterly month 9, 10 . Monthly from month 11 Target set at 46% month 9; target <45% from month 10 (= below or equal to the 07/08 average)

Data source = DATIX Director of Corporate Development

Physical violence against patient by patient

M <26 Introduced from month 9. Quarterly month 9; Monthly from month 10 Target set from month 12. Set to be less than monthly average for reported incidents in 2007/8. KPI originally named Violent assault - patient on patient. KPI name changed to physical violence against patient by patient from month 3 2008/9

Data source = DATIX Chief Operating Officer

introduced from July 2008. Target set at 5% less than the average number of incidents July - Dec

Control and restraint M To be determined

Percentage of Patients experiencing one or more incidents of control and restraint.

Proposed National Indicator out for consultation

Manual collection Director of Nursing, Compliance and Innovation

Seclusion M To be

determined

Percentage of inpatients experience of one or more incidents of seclusion

Proposed Nation ional Indicator out for consultation

Manual collection Director of Nursing, Compliance and Innovation Absconded formal

patients

Q 0 The proportion of inpatients who have absconded within the last 3 months

Proposed Nation ional Indicator out for consultation Datix Director of Nursing, Compliance and Innovation Single rooms Q To be determined

Percentage of single rooms for patients National standard out for consultation

Manual collection Director of Business Development and Planning

4. STRUCTURE –

Develop a clear organisational structure which promotes accountability and responsibility at all levels

% of staff who have had an appraisal in the last 12 months

Q 80% Introduced from month 9. Quarterly month 9,10 Incremental target month 9, 10, 11- Included in annual Staff Opinion Survey

Data source: manual count/ESR Numbers of staff who have had an appraisal/KSF review in a rolling twelve month period expressed as a

percentage of current staff in post (Headcount)

Director of HR and Workforce Development

% of Service Users with INPAC assessment (WAA & OPS)

M 80% Under development month 9, 10, 11. . Target TBD month 9, 10,11; set at 80% from month 12

Data source = RiO Percentage calculated for AWA & OPS service users Numerator = number of currently active service users with INPAC assessment Denominator = total number of currently active service users NB Currently active service users have an open referral and have been seen by at least one team within the Trust

Chief Operating Officer NICE guidance implementation Q To be determined

Part of compliance with national standards in annual declaration

Quarterly assessment of

implementation of published guidance and level of reported compliance.

Medical Director

6. PARTNERSHIPS –

Ensure partnerships are developed which help us to achieve our vision and brings benefits for the communities we serve

% waiting less than 18 weeks Referral to Assessment (APT)

M >= 85% Improving Access to Psychological Therapies (IAPT) programme Target TBD month 9, 10, 11; set at 85% from month 12 KPI changes from % waiting over 18 weeks referral to assessment (Month 9, 10, 11) - to % waiting less than 18 weeks from month 12 KPI changed from % waiting less than 18 weeks referral to assessment to % waiting over 18 weeks referral to treatment from month 4. Target changed to < or = 15% from month 4. KPI changed from % waiting less than 18 weeks Referral to Assessment (APT) to % seen within 18 weeks referral to treatment (APT) from month 7. Target set at >=85% from month 7

From month 2 KPI split by PCT

Data source; provided by service Data will be taken from RiO by the end of the financial year

Director of Business Development and Planning

Crisis Teams - Number of intensive home based treatments episodes

M 168 Directly relates to an NHS Plan key deliverable. PCT vital signs target. SWYMHT performance assessed as part of the NSF autumn assessment. SWYMHT required by SHA/PCT to set recovery trajectories to meet target by Mar 09 Historically reported via service level. Introduced in Trust Board dashboard from month 3 Target =

SWYMHT share of national DoH (NHS Plan) target

Data source = RiO Number of intensive home based treatment episodes in the period as calculated using DoH guidance for counting episodes

Chief Operating Officer

Early Intervention in Psychosis – New cases of psychosis

M Monthly target

Directly relates to an NHS Plan key deliverable. Historically reported via service level. Introduced in Trust Board dashboard from month 3 2008/9 Incremental target calculated from the recovery trajectory set by the SHA from 2007/08

Data source = RiO Number of cases of First Episode Psychosis which have been taken on by Early Intervention teams for treatment and support in the period (from April) since 1 April 2007.

Chief Operating Officer

quarterly activity report. Key PCT performance indicator monitored via the SHA and the DoH.

Teams. Officer

25 Hours activity –Forensic services

M To be determined

New target in National Standards guidelines and in Contract for Forensic Services. Financial penalty if not achieved.

Method of data collection being developed Chief Operating Officer Improving Access to Psychological Therapy Service- IAPT - Kirklees

Q To be determined

The number of people who are moving to recovery as a proportion of those who have completed a course of psychological therapy

RIO Chief

Operating officer Waiting time for

assessment -urgent

M !00% The percentage of face to face assessments by crisis service within 4 hours of referral

SHA standard within contract

RIO Chief

Operating Officer Waiting time for

assessment –non urgent

M To be determined

The percentage of service users requiring non urgent assessment who were offered a face to face assessment by a qualified practitioner within 14 days of referral.

SHA standard within contract

RIO Chief

Operating Officer

Wellbeing care plan – PLD Q To be determined

Percentage of Learning Disability service users who have a had a documented health and wellbeing plan

SHA standard within contract

Manual collection until supported on RIO

Chief Operating Officer

KEY

Will require some development

136/136 Suite Section 136 Place of Safety

ADHD Attention Deficit Hyperactivity Disorder

ALE Auditors Local Evaluation – Use of Resources

ALOS Average Length of Stay

AOT Assertive Outreach Team

APT Adult Psychological Therapies

AWA Adults of Working Age

BDU Business Delivery Unit

CAMHS Child and Adolescent Mental Health Services

CIP Cost Improvement Programme

CPA Care Programme Approach

CRHT Crisis Resolution Home Treatment Team DTOC Delayed Transfers of Care

EBITDA Earnings before Interest Taxes Depreciation and Amortisation

EIP Early Intervention in Psychosis

FY For year

FT Foundation Trust

HCC Healthcare Commission

HR Human Resources

IAPT Improving Access for Psychological Therapies IHBT Intensive Home Based Treatment

INPAC Integrated packages of Care

LA Local Authority

NACRO National Association for the Care and Resettlement of Offenders

NAT National benchmark

NHSLARMS NHS Litigation Authority Risk Management Standards

OPS Older Peoples Services

PBL Prudential Borrowing Limit

PCT Primary Care Trust

PICU Psychiatric Intensive Care Unit

PLD People with Learning Disabilities

SARN 17 Summary Assessments of Risk and Need

SDG Service Delivery Group

SHA Strategic Health Authority

SWYPFT South West Yorkshire Partnership NHS Foundation Trust

VFM Value for Money

WCC World Class Commissioning