Integrated Performance Report

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Integrated

Performance Report

M1 2013/14

27 June 2013

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

1. Structure of the Document ... 3

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

3. Southwark CCG Dashboard (M1) ... 5

4. Provider Dashboards (M1 Performance / Q4 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 and Variance Tracker ... 21

8. Southwark CCG Finance Report (M2) ... 21

9. Glossary of Performance Indicators ... 22

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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 CCG’s committees in their

consideration of the current status of 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 will be included in Sections 7 & 8 from M3 13/14.

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 other 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 Contract Report

Community Contract Report

SLaM Quality & Safety Report

CCG Complaints Report

Serious Incidents Reports

Q4 2012/13

Q4

Finance

CCG Finance Report

Acute Finance Report

SLaM Finance Report

M2

Performance Indicators & Targets

SLCSU Acute Contract Report

SLCSU Performance Report

M1

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2. Southwark CCG and Providers Performance Summary Dashboard

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3. Southwark CCG Dashboard (M1)

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

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4. Provider Dashboards

(M1 Performance / Q4 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

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5. Performance and Quality and Safety Trackers

a. Monthly Performance Tracker

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b. Quarterly Quality and Safety Tracker

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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.

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Synopsis of Issue Current Status

_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Responsible CCG Officer and CCG Clinical Lead

Performance & Quality

RTT

admitted

KCH  Performance dropped slightly in M1 13/14 to 88.8% from 89.3% in M12 12/13.  A planned failure of the admitted performance target on a monthly basis is expected to support backlog clearance until the trust is in a sustainable position.  KCH have a plan to manage their capacity as part of their plans to acquire PRUH through the TSA arrangements. If all goes to plan this should be operational from 1 October.  The Trust has supplied a trajectory for the first 2 quarters of 2013/14, which is currently being revised to take account of the April position. KCH 88.8% (M1 13/14) Target 90%

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KCH Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 4th July 20th June Dr Simon Fradd, Tamsin Hooton and SLCSU Acute Contracting Team.

52 weeks

long

waiters

KCH  There were 49 patients waiting more than 52 weeks on incomplete pathways in M1 13/14 compared to 57 in M12 12/13.  KCH reduced the number of 52 weeks waiters throughout 12/13. KCH 49 GST 14 (M1 13/14) Target 0

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KCH Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 4th July 20th June Dr Simon Fradd, Tamsin Hooton and SLCSU Acute Contracting Team GST  There were 14 patients waiting more than 52 weeks on incomplete pathways in M1 13/14 compared to 11 in M12 12/13.  GST reduced the number of 52 weeks waiters throughout 12/13. By March, GST did not report any 52 weeks waiters for Southwark, and this reflects a significant reduction trust wide. GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Cancer

2 weeks

‐

Breast

symptoms

_GST  Performance for M1 13/14 decreased to 92.3% from a performance position of 97.4% in M12 12/13.  The Trust missed the monthly target by 1 breach. The quarterly performance position will provide a more accurate gauge of performance due to the higher number of pathways GST 92.3% (M1 13/14) Target 93%

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GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June

Tamsin Hooton and SLCSU Acute Contracting Team

Cancer

31 day

s ‐

Drug

treatme

n

ts

SCCG  Performance for M1 13/14 decreased to 97.4% from a performance position of 100% in M12 12/13.  The SCCG performance position is based on 1 breach from 38 pathways. KCH  Performance for M1 13/14 decreased to 96.0% from a performance position of 100% in M12 12/13.  The KCH performance position is based on 2 breaches from 50 pathways. SCCG 97.4% KCH 96.0% (M1 13/14) Target 98%

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KCH Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 4th July 20th June Tamsin Hooton and SLCSU Acute Contracting Team

Cancer

62 day

s

–

GP

referral

SCCG  Performance for M1 13/14 decreased to 83.3% from a performance position of 87.5% in M12 12/13.  The SCCG performance position was based on 4 breaches from 24 pathways. SCCG 83.3% (M1 13/14) Target 85%

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GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team GST  Performance for M1 13/14 decreased to 68.6% from a performance position of 77.8%in M12 12/13.  The trust has invited the DH Intensive Support Team (IST) to review the pathways for 62 days, with particular focus on urology and lower GI.  Informal feedback from the IST indicates a need to address the management of the early part of the pathway, including diagnostics. Formal feedback is anticipated at the next Monthly Performance Report Meeting on the 21st June. GST 68.6% (M1 13/14) Target 85%

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Cancer

62 day

s

–

Screening

SCCG  Performance for M1 13/14 decreased to 80.0% from a performance position of 100% in M12 12/13.  M1 13/14 performance position was due to low numbers as there was 1 breach from 5 pathways. GST  Performance for M1 13/14 decreased to 83.3% from a performance position of 100% in M12 12/13.  M1 13/14 performance position was due to 1 shared breach from a total of 3 pathways. SCCG 80.0% GST 83.3% (M1 13/14) Target 90%

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GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team Ambulance HAS compliance 90% of all patient handover times are recorded via the Patient Handover Button on the Hospital Based Alert and Handover System. KCH Performance at KCH dropped in M1 13/14 to 79.3% from 81.9% in M12 12/13. KCH 79.3% GST 89.9% (M1 13/14) Target 90%

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Lambeth and Southwark recovery and improvement plan has been developed and will be pursued through the Lambeth and Southwark Urgent Care Network meetings 17th July Tamsin Hooton, Ali Young and Harprit Lally GST Performance at GST dropped in M1 13/14 to 89.9% from 92.4% in M12 12/13.

A&

E

waits

GST  Performance decreased in M1 13/14 to 94.6% from 95.3% in M12 12/13.  Nationally, over Q4 12/13 and into M1 13/14, the urgent and emergency care system has been experiencing pressure, and this is reflected in the local performance. GST 94.6% (M1 13/14) Target 95%

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Lambeth and Southwark recovery and improvement plan has been developed and will be pursued through the Lambeth and Southwark Urgent Care Network meetings 17th July Tamsin Hooton, Ali Young and Harprit Lally

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Trust ‐Attributab le Pressur e Ulcers GST  There was 1 grade 3 pressure ulcer reported in Q4 12/13.  Grade 3 and 4 pressure ulcers are reported as serious incidents and will be addressed at Serious Incident Committee meetings. SLaM  There were 2 grade 3 pressure ulcers reported in Q4 12/13 GST 1 G3 SLaM 2 G3 (Q4 12/13) Target 0

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GST Serious Incident Committee 20th June Jacquie Foster

SLaM Serious Incident Meeting 10th July Gwen Kennedy and Jacquie Foster SLaM  There were 3 grade 4 pressure ulcers reported in Q4 12/13  SLaM carries out root cause analysis for all serious pressure ulcers and these will be reviewed at SLaM Serious Incident Committee Meetings SLaM 3 G4 (Q4 12/13) Target 0

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SLaM Serious Incident Meeting 10th July Gwen Kennedy and Jacquie Foster

Falls

KCH  There were 2 falls that resulted in major injury in Q4 12/13.  Falls will be reviewed at the next CQRG meeting. GSTCHS  1 major fall was reported by GSTCHS in Q4 12/13  A Trust‐wide falls audit was undertaken in Q3 12/13, the results of which were due to be published in Q1 2013. Major: KCH 2 GSTCHS 1 (Q4 12/13) Target 0

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KCH Serious Incident Committee Meeting GSTCHS Serious Incident Committee Meeting Both meetings are on the 20th June Jacquie Foster GST  There was 1 fall that resulted in major injury and 1 fall that resulted in death in Q4 12/13.  The fall that resulted in death will be investigated through the serious incident root cause analysis process and should be reviewed at the next Serious Incident Committee meeting on the 20th June. GST 1 major and 1 death (Q4 12/13) Target 0 GST Serious Incident Committee (fall resulting in death) and the joint GST acute and Community Health Services CQRG (falls resulting in major injury) Both meetings are on the 20th June

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Mixed

‐sex

accommod

ation

KCH  There were 49 MSA breaches in M1 13/14 compared to 19 in M12 12/13  11 of the KCH breaches were SCCG patients.  KCH breaches are all related to ICU delayed discharge/step down.  KCH have declared that these breaches were due to the non‐availability of beds in general wards for patients who no longer required intensive care.  The medium term solution will be the implementation of additional general ward capacity which is due to come on stream during 2013/14. This will initially be when Infill Block 4 is fully operational later this year; this is currently in the process of being installed. Breaches: SCCG 12 KCH 49 GST 5 (M1 13/14) Target 0

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Mixed‐sex accommodation has been discussed at previous KCH Acute Contract Monitoring Meetings. An Improvement plan has been discussed and agreed. On‐going monitoring Dr Simon Fradd, Tamsin Hooton and SLCSU Acute Contracting Team. GST  There were 5 MSA breaches at GST in M1 13/14 compared to 0 in M12 12/13.  One of the GST breaches was a SCCG patient. GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team

Diagnosti

c

wai

ts

>

6 weeks

During 2012/13 problems with waits for some diagnostic procedures emerged, as demand outstripped available diagnostic capacity ‐ this has continued for some services into 13/14. SCCG 1.86% (M1 13/14) Target <1%

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KCH Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 4th July 20th June Dr Simon Fradd, Tamsin Hooton and SLCSU Acute Contracting Team KCH 3.00% GST 2.00% (M1 13/14) Target <1% GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Child Safeguardi ng Training

_KCH  Child safeguarding training levels at KCH for Q4 12/13 are: Level 2 – 74% Level 3 – 76%  Performance has remained at around 75% for Q3 and Q4 12/13 which is an improvement on the Q1 12/13 performance position (Level 2 49% and Level 3 61%).  Child safeguarding training levels will be raised at the next KCH CQRG meeting where improvement plans will be expected. KCH Level 2 – 74% Level 3 ‐ 76% (Q4 12/13) Target 80%

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KCH CQRG Meeting 21st June Jacquie Foster HCAIs ‐ MRSA SCCG There was 1 case of MRSA for SCCG patients in M1 13/14 against a target of 0. KCH and GST There were 2 cases of MRSA at both KCH and GST in M1 13/14 against a target of 0. The 12/13 outturn position for both Trusts was 2 cases of MRSA, so M1 13/14 performance is out of line with previous performance trends. SCCG 1 KCH 2 GST 2 (M1 13/14) Target 0

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KCH CQRG Meeting ₂₁st June Dr Simon Fradd and Gwen Kennedy (infection control lead) Joint GST acute and Community Health Services CQRG 18th June Dr Sian Howell and Gwen Kennedy (infection control lead) Complaints KCH  There were 155 new formal complaints opened at KCH for Q4 12/13 compared to 176 in Q3 12/13.  There were 155 complaints received, which is 20 over target for the quarter but a decrease of 21 compared to Q3.  Total complaints for 12/13 were 651 against a target of 540 and up 10% compared to 2011/12 when there were 590 complaints. GST  There were 322 new formal complaints opened at GST in December to March 12/13.  Women’s services (37), abdominal medicine and surgery (26), acute medicine (25) and surgery (20) are the directorates which regularly receive the most complaints. KCH 155 (Q4 12/13) GST 322 (Dec –Mar12/13)

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

4th July 20th June Dr Simon Fradd, Tamsin Hooton and SLCSU Acute Contracting Team GST Acute Contract Monitoring Meeting Monthly Performance Meeting (for escalation) 5th July 21st June Tamsin Hooton and SLCSU Acute Contracting Team

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Coverage of NHS health che cks NHS Health Checks offered  % people eligible for the NHS Health Check programme who have been offered an NHS Health Check. Performance has increased from 5.4% in Q3 to 6.6% in Q4.  The annual outturn performance position for health checks offered was 26.7% which is above the annual target of 20%. SCCG 6.6% (Q4 12/13) Target 6.9%

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Joint Public Health Targets _Meeting 18th June Tamsin Hooton NHS Health Checks received  % people eligible for the programme who have received an NHS Health Check. Performance has increased from 1.6% in Q3 to 1.7% in Q4.  The annual outturn performance position for health checks received was 8.2% which is above the annual target of 8%  % people who have received an NHS Health Check after being offered it was 26.0% which was below the locally agreed target of 40% % received from eligible SCCG 1.7% Target 2.7% % received from offered SCCG 26.0% Target 40% (Q4 13/14) IAPT Referrals  M1 13/14 performance position for the proportion of people with depression referred for psychological therapy is 0.79% against the M1 target of 0.93%.  The change in the definition of this indicator during Q3 12/13 led to a reduction in the numbers entering treatment affecting Q3 and Q4 by significantly reducing the numbers that could be counted towards the trajectory. 330 (0.79%) (M1 13/14) Target for M1 389 & 0.93%

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SLaM QIPP and Core Contract

meeting 27th June Gwen Kennedy Moving to recovery  M 1 13/14 performance position of the proportion who complete therapy who are moving to recovery was 42.1% against the end of year target of 50%.  The high levels of need of the Southwark population may be a contributing factor, where people may be better after therapy than they were before, but still meet the “caseness” definition. 42.1% (M1 13/14) Target 50% Control of Medicines __{22 Incidents in total were reported across a range of settings.}  13 of these were reported incidents within community health services directly.  9 incidents are attributable to other agencies but were reported by community staff. GSTCHS 22 (Q4 12/13)

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Transition care pl an s The Trust will report that the protocol is being followed and report any exceptions if the protocol is breached.  Lists have been shared of children requiring a transition plan. There are still discrepancies in the list and further work by social care needs to be done. The number of young people who are successfully transitioned from children’s to adults services.  18 children in Year 9 at a complex physical and learning difficulties school in Lambeth and Southwark do not have transition plans. GSTCHS (Q4 12/13)

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Joint GST acute and Community _{Health Services CQRG} 18th July Jean Young

Dressings – Tissu e viability A 2‐cycle audit of adherence to dressings of those prescribed and recommended is performed in year.  The Trust will try to improve performance by ensuring a preferred dressings list forms part of all tissue viability service training and advisory visits.  Service managers are to monitor epact data and compare it with the preferred list. They will meet on a one to one basis with all prescribers to discuss their prescribing practice. GSTCHS 65% (Feb 12/13) Target 80%

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Joint GST acute and Community _{Health Services CQRG} 18th July Jean Young

Ethnici ty at first contact _{In M1 13/14 76.1% of patients had their ethnicity recorded at first contact} compared to 75.8% in M12 12/13. Performance has remained slightly under target; however Adult Therapies and Foot Health will be targeted for improvement. GSTCHS 76.1% (M1 13/14) Target 85%

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Joint GST acute and Community Health Services CQRG 18th July Jean Young Pati ent Facing Time ‐ Adult Community Nursing  Adult community nursing patient facing time is below last year’s target of 42.5%.  There is a new method of calculating performance for this indicator which has impacted on the performance position.  The target for 13/14 is to be confirmed. GSTCHS 37.2% (M1 13/14) Target TBC

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GSTCHS Contract Monitoring Meeting 12 th July Jean Young

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_SCCG

GST

KCH

GSTCS

SLaM

Forum Issue is Addressed

Date

Pati ent Facing Time ‐ He alth Visit ing  Health visiting patient facing time is below last year’s target of 42.5%.  There is a new method of calculating performance for this indicator which has impacted on the performance position.  The target for 13/14 is to be confirmed. GSTCHS 26.8% (M1 13/14) Target TBC

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GSTCHS Contract Monitoring Meeting 12 th July Jean Young A&E breac h es (Mental He alth)  There were 7 x 6 hour wait A&E breaches in M1 13/14 which is significantly _{below the M12 12/13 performance position of 31}  The majority of these breaches are due to patients waiting for a bed to become available.  SLaM are putting caps on activity which will mean that Boroughs will no longer be able to use more occupied bed days than contractually agreed which will benefit Southwark patients as more beds will be available, which should improve performance. SLaM 7 (M1 13/14) Target < 4

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SLaM QIPP and Core Contract _Meeting 27th June Gwen Kennedy

Delayed discharges  12.7% of patients experienced a delayed discharge from inpatient care in M1 13/14 which increased from 0% in M12 12/13.  In M1 13/14 there were a greater number of discharges of 102 compared to 73 in M12 12/13.  The Mental Health team will be monitoring this to ensure that performance returns to below 7.5%.  Although the proportion of delayed discharges was high, the proportion of days lost due to delayed discharge was only 3.1% in M1 13/14 compared to 4.2% in M12 12/13.  The Mental Health team have asked for detailed explanations for all delayed discharges from inpatient care for 13/14. SLaM 12.7% (M1 13/14) Target <7.5%

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SLaM QIPP and Core Contract _Meeting 27th June Gwen Kennedy

Pati ent received copy of care plan  93.0% of patients have been given a copy of their care plan against a target of 95%.  The Trust continues its performance management process in respect of this indicator. Patient level data is monitored through the monthly Chief Executive Performance meetings to ensure that the relevant corrections are made at care coordinator level. SLaM 93.0% (M1 13/14) Target 95%

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7. Southwark CCG QIPP Performance and Variance Tracker

QIPP tracker tables will be included in this section from M3 13/14

8. Southwark CCG Finance Report (M2)

A summary table will be provided in this section from M3 13/14.

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9. Glossary of Performance Indicators

% 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 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 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 wait > 60 minutes (0) ‐ The number of handover delays of longer than 60 minutes ‐ Acute

Assertive Outreach (TBC) ‐ Number of new referrals to the Assertive Outreach service ‐ SLaM

C Diff (trajectory) ‐ Number of Clostridium difficile infections for patients aged 2 or more on the date the

specimen was taken ‐ Acute

CAMHS 3 months < 18th birthday (95%) ‐ Percentage patients to which a transfer CPA has been completed 3

months prior to their 18 birthday ‐ SLaM

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

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Cancelled Ops 28 days ‐ 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

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

Delayed Transfers of Care (OBDs) – GSTCHS – TBC

Delayed Transfers of Care (Patients) – GSTCHS – TBC

Dementia (851 ‐ a proportion of 53.2% against an expected prevalence of 1600) ‐ Dementia diagnosis rate

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

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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

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

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

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

SLaM

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.

(25)

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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”) likely would not recommend (response

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

Gatekept CR/HT ‐ The proportion of admissions to the Trust’s acute ward that were gatekept by the crisis

resolution home treatment teams ‐ 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

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

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 ‐ TBC

MRSA ‐ Number of cases of Methicillin‐resistant Staphylococcus aureus (MRSA) bacteraemia ‐ Acute and

SCCG

(26)

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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 ‐ Percentage of eligible people who have been offered an NHS Health Check in

2012/13 ‐ SCCG

NHS Health Checks received ‐ Percentage of eligible people that have received an NHS Health Check in

2012/13 ‐ SCCG

NICE – The number of NICE guidance awaiting response – Acute

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 ‐ 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.

Percentage Early Intervention (TBC) ‐ Percentage of patients receiving Early Intervention ‐ 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

(27)

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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

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

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

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

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

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Integrated

Performance Report

M1 2013/14

27 June 2013

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Contents

1. Structure of the Document ... 3

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

3. Southwark CCG Dashboard (M1) ... 5

4. Provider Dashboards (M1 Performance / Q4 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 and Variance Tracker ... 21

8. Southwark CCG Finance Report (M2) ... 21

9. Glossary of Performance Indicators ... 22

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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 CCG’s committees in their

consideration of the current status of 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 will be included in Sections 7 & 8 from M3 13/14.

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 other 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 Contract Report

Community Contract Report

SLaM Quality & Safety Report

CCG Complaints Report

Serious Incidents Reports

Q4 2012/13

Q4

Q4

Q4

Q4

Finance

CCG Finance Report

Acute Finance Report

SLaM Finance Report

M2

Performance Indicators & Targets

SLCSU Acute Contract Report

SLCSU Performance Report

M1

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