Integrated Performance & Quality Report

(1)

Central London CCG

Integrated Performance

& Quality Report

(2)

Central London CCG

The Central London CCG Integrated Performance & Quality Report is aimed at providing a monthly update on the performance of the CCG based on

the latest performance information available, and reporting on actions being taken to address any performance issues with progress to date. The

contents of the report are defined by the CCG’s priorities which are informed by nationally defined objectives for commissioners - the NHS Constitution

and Everyone Counts Guidance for 2014-15 (operating framework).

The report is split into 3 sections. Section 1 of the report provides an update on CCG and related providers’ operational performance against national

standards. This includes 18 weeks RTT, cancer waits , A&E waits and ambulance handover times. Detailed information on underachieving indicators

including trends and action log are also provided.

Provider Quality and Safety issues are covered in section 2 of the report. The key areas highlighted in this section are Serious Incidents, Never Events,

SHMI, maternity services, complaints and patient experience. These are presented in trend charts and tables with commentary and actions for areas of

concern.

Section 3 provides an update on CCG local priority indicator measures.

Introduction

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Central London CCG

Performance Overview

Access MonthPrev. Month 7 Other Measures MonthPrev. Month 7 Community Services MonthPrev. Month 7

18 weeks RTT - Admitted Pathway 83.5% 80.7% Cancelled Ops - 28 Day Guarantee breaches CLA - Review Health Assessments (RHA) conducted _{within 6 wks} 100.0% 100.0% 18 weeks RTT - Non-admitted Pathway 94.2% 94.7% Urgent Cancellations for the 2nd time Referrals responded to during the day, twilight or night _{service periods within 24 hrs} 97.8% 98.2% 18 weeks RTT - Incomplete Pathway 88.9% 87.3% CB_BMixed Sex Accommodation Breaches (MSA) 2 0 Number of Rapid Response referrals responded to with

2 hrs 99.1% 99.1%

52 week RTT Waiters - Incomplete pathway 2 1 HQU0HCAI - MRSA 0 0 Palliative care patients achieving preferred place of _death 100.0% 100.0%

6 Weeks Diagnostics 1.2% 1.5% HQU0HCAI - CDIFF 1 4 Venous leg ulcers healed within 12 weeks 38.0%

Pre-booked appointments DNA or UTA rate 2.6% 2.4%

Cancer Waits MonthPrev. Month 7 Mental Health* MonthPrev. Month 7

2 weeks of an urgent GP referral 93.2% 93.1% IAPT - Access 0.7% 0.7% Out of Hospital Services _MonthPrev. Month 7

2 weeks of an urgent referral for breast symptoms 93.7% 91.3% IAPT - Recovery (YTD) 36.2% 36.8% LAS – Cat A Red 1 responses within 8min 61.9% 64.1%

31 Day - 1st definitive treatment 100.0% 100.0% CPA Reviews with 12 months 95.8% 95.5% LAS – Cat A Red 2 responses within 8min 54.0% 57.5%

31 Day Subsequent treatment (Surgery) 90.9% 100.0% Outcomes Data Completeness - CPA Patients 62.3% 62.2% LAS - Cat A 19 transportation within 19min 90.5% 91.5% 31 Day Subsequent treatment (Drugs) 100.0% 95.8% CPA Follow-Ups within 7 days 100.0% 100.0% NHS 111 - % calls answered in 60 secs 96.1% 98.3% 31 Day Subsequent treatment (Radiotherapy) 100.0% 100.0% Inpatient gates kept by CRHT Teams 100.0% 95.5% NHS 111 - % calls abandoned in 30secs 0.9% 0.2% 62 Day - 1st definitive treatment (Urgent GP Referral) 92.3% 100.0% New psychosis cases served by EIS (YTD) 85.7% 81.3% NHS 111 - % calls where call back was offered 5.4% 4.0% 62 Day - 1st definitive treatment (Screening Service) 100.0% 75.0% Delayed Transfers of Care 5.3% 3.8% GP Out of Hours

62 Day - 1st definitive treatment (Cons. Upgrade) 100.0% 100.0% DNA - 1st Appointments 6.9% 9.0%

DNA - Follow-Ups Appointments 9.2% 9.3%

A&E / LAS Prev.

Month Month 7 Carers offered assessment 84.8% 84.8%

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Central London CCG

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Central London CCG

Exception Report – 18 Weeks RTT

Root Cause:

18 Weeks RTT performance was largely driven by Imperial College Healthcare Trust (ICHT) and to a lesser extent Chelsea and Westminster (CW) and University College Hospitals (UCLH ). Performance due to the inability to forecast and manage excess demand exacerbated by data quality issues across all Trusts.

Mitigating Actions:

Contract query (CQN) in place at ICHT and UCLH. At Dec PCE Trust advised that CQN RAP would not be met for 30/11 timeline, and that RTT trajectory for

December would not be met. Subsequent to the PCE meetings have taken place between NHSE and the Trust. On the 12/12 a revised trajectory has been agreed whereby the Trust will deliver an aggregate 90% in M10, 11 and 12.

The CQN will be amended and confirmed to the CW associate Committee.

The lead CCG and associate's to the ICHT contract have agreed a similar approach and plan to retract CQN at ICHT. ICHT and UCLH have agreed

improvement trajectories with NHSE to achieve admitted RTT standard in M8. In additional RTT backlog reduction trajectories have also been agreed with all Trusts.

CW has agreed a revised RTT trajectory with NHSE to meet all standards in M9.

Gaps in Assurance:

Contract action taken but limited assurance in Trusts ability to deliver M8 performance:

• ICHT has agreed an improvement trajectory however the RTT backlog continues to increases and therefore potential risk to achievement of admitted / non-admitted RTT standard overall in M8.

• CW not meeting specialty level trajectories and reporting Paediatric Dentistry breaches in M8 will

Assurances:

• CW – Action plan reviewed at CQG and weekly monitoring of backlog clearance in place and a reduction in overall backlog reduction in line with expectations. IST assessment provides assurance of Trust processes .

• ICHT – Action plan in place with the Trust confirming performance will be met in M8 but dependant on Trusts’ data quality issues being resolved by M8 as planned.

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Central London CCG

Issue Provider Action Action Status Plan in Place? CCG Owner Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

RTT standards not met due to:

• Performance reporting issues following PAS implementation. • Demand and capacity

imbalance.

ICHT Weekly review of performance based on backlog reduction

trajectory agreed with NHSE. Open Yes

PJ NG Unknown 20/12/14 N/A Contract query in place - RTT standards not met

due to

• identified capacity issues within specific specialties

• demand within Paediatric Dentistry

CW Monitoring against agreed _{trajectories.} Open Yes LP RH Except for Paediatric

Dentistry 31/12/14 N/A

Contract Query retracted - Not meeting 18 week

RTT standards. Excess demand over capacity and poor waiting list management.

UCLH

Camden CCG / NEL CSU are monitoring against agreed trajectories with NWL CCGs at a bi weekly review meeting.

Open Yes MB AK Unknown 31/12/14 N/A Contract query in place -

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Central London CCG

Root Cause:

18 Weeks RTT 52 week breach – One case in the neurosurgery specialty at UCLH

Trust requested to confirm treatment plan in place.

Gaps in Assurance:

•On-going data quality issues at ICHT resulting in difficulties to manage RTT waiting lists.

Assurances:

• Reduced number of 52 week breaches at ICHT.

Issue Provider Action Action _Status Plan in Place? CCG _Owner Provider _Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

RTT standards not met due to:

• Data quality issues UCLH

Trust to provide details of

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Central London CCG

Exception Report – Diagnostic Waits

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Original Delivery Date Delivery Revised Date Contract Status Contract Penalties to date

Diagnostic breaches within

neurophysiology ICHT Trust requested to confirm fully resolved Open Yes PJ NG Yes 19/12/14 N/A N/A N/A

Root Cause:

Diagnostic performance was driven by ICHT due to a data quality issue that resulted in some neuro physiology referrals not included on the diagnostic waiting list.

Mitigating Actions:

Action plan provided to CCGs to expedite neurophysiology diagnostic tests.

Assurances:

Trust reviewed all diagnostic pathways and have confirmed no other pathways impacted.

Awaiting confirmation that all patients waiting over 6 weeks are now treated.

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Central London CCG

Exception Report – Cancer Waits

Issue Provider Action Action Status Plan in _Place? _OwnerCCG Provider _Owner On Track Original _{Delivery Date} Delivery Revised Date Contract Status Contract Penalties to date No current action as Root Cause:

2ww Breast symptomatic standard (91.3%) due to 7 patient breaches due to patient choice. Patients breached at ICHT (3), UCLH (1), Lewisham and Greenwich (1), Guy’s and St Thomas’ (1) and The Royal Marsden (1).

Mitigating Actions:

NWL provider joint action plan includes actions on engagement between primary and secondary care and developing a

communication strategy to ensure patient availability for review and investigations are maximised.

Assurances:

YTD performance impacted by Q1 underperformance at ICHT. ICHT is in a sustainable position to achieving 2ww Breast symptomatic standard.

Gaps in Assurance:

Primary care process in encouraging patients referred on the Breast symptomatic pathway to be available for review and investigations.

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Central London CCG

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Original Delivery Date Delivery Revised Date Contract Status Contract Penalties to date

No current action as relevant NWL providers meeting standards

Root Cause:

31 day subsequent treatment (chemotherapy) standard (95.8%) due to one patient at UCLH who chose to delayed the start of treatment.

Mitigating Actions: No action required Assurances: CCG performance is 99.2% YTD. Gaps in Assurance: No gaps in assurance

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Central London CCG

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Original Delivery Date Delivery Revised Date Contract Status Contract Penalties to date

No current action as relevant

Root Cause:

62 days screening standard (75.0%) was not achieved due to one patient breach on the Breast pathway. The patient was repatriated to the Royal Marsden from ICHT screening service. The patient was referred late, but was also unfit for treatment within the 62 day standard.

NWL provider joint action plan includes actions on improving repatriation pathways specific to breast screening patients.

Assurances:

• CCG is 95.2% YTD • ICHT are achieving

Patients that are repatriated to a non-NWL provider.

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Central London CCG

Exception Report – A&E & LAS (ICHT)

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Original Delivery Date Delivery Revised Date Contract Status Contract Penalties to date

Not meeting A&E all type

national standard ICHT

•Share revised NHSE trajectory to March 2015 •Audit inpatients and

agree improved process to expedite discharges and repatriations. •Fully utilise community

capacity

Open Yes PJ NG Yes 18/12/14 N/A Review at _{next CQG} None

Root Cause:

A&E all type national standard • Capacity issues at St Marys and

Charing Cross

• Trust report increased variation in attendances at St Marys particularly in the evening

Assurances:

• Limited based on recent deteriorating performance.

• Reason for deterioration not fully understood and performance has not recovered.

In response to recent issues the Trust has:

o opened an additional 35 escalation beds and in addition 18 community beds provided by CLCH has been opened.

o increased managerial and clinical support in the ED departments to 22:00

At St Mary’s theTrust has;

o increased cubicle space in ED in their majors area and UCC;

o opened additional ambulatory care area and opened an addition 6 surgical beds.

At Charing Cross the Trust are increasing ambulatory care capacity with building work underway

The Trust is also planning to increase GP cover within St Marys and Charing Cross UCC to a 24/7 hour basis.

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Central London CCG

Exception Report – A&E

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

251 breaches of the LAS >30mins handover waits 9 breaches of the LAS >60mins handover waits

ICHT

Contract penalties of £200 per 30 minute breach and £1000 per 60 minute breach being applied.

Open audit in Trust

place PJ NG Yes 31/12/14 N/A

Review at next CQG

£200 / £1000 per

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Central London CCG

Exception Report – LAS Chelwest

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

67 breaches of the LAS >30mins handover waits 4 breaches of the LAS >60mins handover waits

CW

Contract penalties of £200 per 30 minute breach and £1000 per 60 minute breach being applied.

Open No, other than escalatio n plans

LP LG N/A 31/12/14 N/A Review at _{next CQG} £1000 per £200 / case

Root Cause:

• CW reported increased pressure from from LAS conveyances and Type 1 attendances.

Mitigating Actions:

• Trust escalation processes in place

Assurances:

• Overall waiting ambulance total time at A&E’s not changed.

• Trust escalation processes

• Reason for deterioration through 2014/15 not fully understood.

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Central London CCG

Exception Report – Cancelled Operations

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Cancelled operation standards not met due to poor escalation processes and poor waiting list management

ICHT Trust requested to provide an assessment of current

issues and actions in place. Open Yes PJ NG

No trajecto ry 31/12/14 N/A Review at next CQG Breaches to guarante e not paid for Root Cause:

ICHT reported one patient that was not treated within 28 days of a non-clinical cancellation of their operation .

Trust requested to provide an assessment of issues and actions.

Mitigating Actions:

ICHT – Trust reported improvement in

performance from quarter 1 with improved escalation and bed management processes.

Assurances:

ICHT – Improved performance from Q1 Gaps in Assurance: ICHT – Trust has reported an increase in the

total number of non-clinical cancellations in M7

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Central London CCG

Exception Report – HCAI

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Improvement infection control and prescribing practice

All providers in CWHHE

On-going review of infection control and anti

microbial prescribing. Open Yes JB All Yes 31/12/14 N/A N/A N/A Benchmarked CCG position

unknown N/A

Review of CWHHE CCG

benchmarked prevalence Open Yes JP N/A Yes 31/12/14 N/A N/A N/A

Root Cause:

Increased prevalence of C.Diff within elderly population, longer hospital length of stays and increased antibiotic / proton pump inhibitor usage.

4 cases in October with 2 attributed to acute Trusts, UCLH (1) and ICHT (1).

• Dedicated infection control resource within CWHHE that support on-going review of infection control and anti microbial prescribing across all provider.

• Continuous system to review GP prescribing. • Training provided to 161 care home staff

from Q2.

Assurances:

Low level of cases within community and mental health providers.

Prescribing analysis demonstrates good clinical practice within primary care.

Dedicated infection control support not replicated across London.

CCG benchmarked prevalence rates currently unavailable.

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Central London CCG

Exception Report – Venous Leg Ulcers (CLCH: All CCGs)

This is the first month that the trust have reported on this KPI this year . The trust have developed a manual process for data collection and have reported backdated data from June 2014. Performance is reported at trust level.

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Patients with venous leg ulcers

Increase data coverage by ensuring teams are compliant with the new process.

Open Yes LC AB Yes 31/03/15 N/A N/A N/A

Root Cause: The Trust has reported that this is

the first month that teams have collected data for this indicator and hence data quality is currently low. Further data quality assurance work is therefore needed before firm

conclusions can be drawn from the information. This is best done when there is more

comprehensive data to review.

Mitigating Actions:

The Trust is increasing data coverage by ensuring teams completed new process.

Assurances:

Trust has achieved 100% for first three months of reporting and have a plan in place.

Data quality concerns and low numbers reported likely to be skewing actual performance.

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Central London CCG

Exception Report – IAPT

Root Cause:

Referral levels, staff capacity and accommodation have been identified as key contributors to underperformance across both IAPT Access and Recovery.

The Trust also reported that October is a transition month in most IAPT services with new trainees taking on less cases at the beginning of their training, which has led to a dip in delivery in October 2014.

CNWL is working closely with CLCCG to improve appropriate referral rates into the service, specifically focusing on increasing appropriate referrals for older adults, carers and hard to reach groups.

This is a collaborative action which will result in a communications strategy for referrers. A poster campaign has been developed and will commence in new year targeting GP ‘s and other professionals in the first instance. An extensive programme of direct contact with other health professionals and 3rd sector groups is underway.

Assurances:

NHS England IST is currently undertaking an IAPT Desktop Review across CWHHE. The outcomes of which will be used to build upon the action plan developed following the IAPT Desktop Review in BHH.

A comprehensive clinical programme to review recovery monitoring has been undertaken by CNWL. Clinicians have been informed of national guidance and are adhering to it.

Performance remains below target and

significant improvement is required to meet the end of year target.

In mth YTD In mth YTD In mth YTD In mth YTD In mth YTD

Annual Target In mth/ YTD Target 1.2% 6.6% 0.9% 4.2% - - - -Actual 0.69% 5.52% 0.52% 3.90% 0.07% 0.58% 0.08% 0.95% 0.01% 0.08% Local Target 50.0% 50.0% 50.0% 50.0% - - - -Actual 36.8% 41.8% 41.8% 41.8% 35.0% 30.9% 23.1% 41.5% - 30.0% Description Threshold NHS CENTRAL

LONDON CCG CNWL LES COUNSELLORS

PRIMARY CARE

COUNSELLORS MIND

- -

-IAPT Access: % of people with common mental illness (CMI) receiving psychological therapy Recovery rate IAPT: % of people who complete treatment and are moving to recovery

12.9% 8.7%

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner Track On Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Under performance against IAPT Access and IAPT

Recovery targets CNWL

•CNWL to work with CLCCG to improve referral rates into service

•CNWL to continue with recruitment campaign. •Accommodation provision to be finalised. •_{Comprehensive exception report and update on}

actions above requested from Trust.

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Central London CCG

Exception Report – Early Intervention Service

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner Track On Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date Root Cause:

The team receives referrals from Central London CCG residents who are not registered with an in-borough GP and therefore can not be included in Brent activity.

The Trust expected to see 2 cases in month however 1 case was seen.

Teams are working closely with individuals to encourage them to register with practices locally.

Assurances:

The service is actively engaging with the referring teams to ensure clarity regarding the criteria for the service in order to improve referrals.

No gaps identified

Month Target Number of New Psychosis Cases (Cumulative)

No. of New Psychosis Cases Served by Early Intervention Teams (Cumulative) April - 2014 2 5 May- 2014 4 5 Jun - 2014 6 6 Jul - 2014 9 7 Aug-2014 11 11 Sep-2014 14 12 Oct-2014 16 13

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Central London CCG

Exception Report – HoNOSCA

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner Track On Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

% HoNOSCA completion rate on acceptance into service. CNWL

Team Manager to ensure staff update clinical system within appropriate

timeframes. Open Yes ER TW Yes 31/12/14 N/A N/A N/A

Root Cause:

Data entry errors on the clinical system have been identified as the key contributors to

underperformance. These include:

• Clinicians not recording all contacts with clients

• Clinicians not recording contacts within agreed timeframes

• Contacts not being recorded correctly.

Assurances: Gaps in Assurance:

Staff to be made aware of recording errors on clinical system and undertake training.

This is the first month this year that the Trust has dipped below the 80% threshold.

The Contracts & Performance team will continue to monitor through the FIG and CQG meetings.

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Central London CCG

Exception Report – LAS

Issue Provider Action Action Status Plan in Place? Owner NWL Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

LAS unable to meet established staffing levels

LAS

New EAC staff recruited Open Yes

Rob

Larkman Elizabeth Ogunoye Woodrow Paul

Yes 28/02/15

(Cohort 1) N/A

Signed -

National Paramedic

recruitment Open Yes

Yes 31/03/15

(Cohort 1) N/A International Paramedic

recruitment Open Yes Yes 31/03/15 N/A

Staff retention difficult Create new senior paramedic _{role to aid retention} Open Yes _LarkmanRob Elizabeth _Ogunoye _WoodrowPaul Yes 31/03/15 N/A Signed -

Rob Elizabeth Paul No On-going On-going Signed

Root Cause:

• Paramedics under established levels • LAS is unable to meet the required levels

of shift cover

• Ambulance utilisation rates high, meaning LAS is unable to cope with surges in demand in the system.

• Whilst activity is broadly in line with plan, the acuity of cases has increased

Mitigating Actions:

• Increased overtime payments to incentivise workers to fill shifts

• Increased use of the Hear & Treat model • Recruitment drive (longer term mitigation) • Drive to reduce multiple attendance ratio • External consultants have been brought in

to examine capacity & capability.

Assurances:

• Weekly assurance meetings between LAS and Commissioners, TDA and NHS England • Daily and weekly performance updates

showing updated performance against plan • LAS have provided recovery trajectory

Gaps in Assurance:

• Trajectory not signed off formally; does not recover Cat A by year end.

• Red 1 likely to be missed, affecting CCG quality premium.

• Trajectory based on unsustainable recovery methods.

Description Threshold In Month YTD (31_October)st

Cat A Red 1 responses within 8 mins 75% 64.12 % 69.42 %

Cat A Red 2 responses within 8 mins 75% 57.49 % 62.60 %

Cat A 19 transportation within 19

mins 95% 91.48 % 93.73 %

CCG Cat A 8:45 Performance In Month 65.91 %

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Central London CCG

Exception Report – LAS

Issue Provider Action Action Status Plan in Place? Owner NWL Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Demand on LAS increasing LAS

LAS increasing use of Hear &

Treat Open Yes Larkman Rob Elizabeth Ogunoye Woodrow Paul Yes On-going N/A Signed -

LAS expanding operation

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Central London CCG

Quality Premium

CCG funding achievement will be based on year-end performance against the pre-qualifying criteria, national and local measures with adjustments for

constitutional gateway measures breaches. Please note IAPT performance is measured against CCG plans submitted to NHSE.

Financial Gateway

2014/15 Target YTD/Qtrly Targets YTD M7/Qtrly Performance Maximum Available Potential Deductions Reporting Frequency 1743 (per 100k population) 1743 (per 100k population) Available in summer 2015 £145,108 Annual 12.89% 2.75% 2.17% £145,108 -£145,108 Quarterly 1735 (admissions per 100k pop.) 1735 (admissions per 100k pop.) Available in summer 2015 £241,846 Annual

(i) Supporting roll-out of Friends and

Family Test (FFT) by local providers Evidence of engagement Evidence of engagement tbc (ii) Improvement in 'Patient Experience of

Hospital Care' Improvement on 2013/14 score of 72.1 Improvement on 2013/14 score of 72.1 Available in summer 2015

Local Providers Target Local Providers Target tbc £145,108 Monthly

Central London CCG Local Measure 4000 4000 tbc £145,108 tbc £967,385 -£145,108 £822,277

Target YTD Target YTD M7 Performance

Potential % Adjustment to Funding Potential Adjustment to Funding Reporting Frequency Improving Patient Experience: £145,108 Annual

Operate in a manner consistent with Managing Public Money in

2014/15 Not Incur Unplanned deficit in 2014/15, or require financial support to avoid unplanned deficit Not incur a qualified audit report in respect of 2014/15

Quality Premium Measures

Improving the reporting of medication-related safety incidents

Total

Total Maximum Funding Available

Constitutional Measures

Number of new health and social care related plans (as defined by NHS Choices) created in year

National measures

Reducing Potential Years of Life Lost (PYLL) through causes considered amenable to healthcare and including addressing locally agreed priorities for reducing premature mortality Improving Access to Psychological Therapies (IAPT) (Quarterly Performance - Q2)

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Central London CCG

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Central London CCG

Quality and Safety Overview

Maternity Indicators ICHT CW RBH

Breast feeding N/A

12 Weeks assessment N/A

Smoking at delivery N/A

Homebirths N/A

Elective C-Sections N/A

Non-Elective C-Sections N/A

3rd degree tear N/A

Post Partum Haemorrhaging N/A

1:1 midwife care in established labour No data N/A

Midwife to birth ratio N/A

Obstetric Consultant Ward Coverage N/A

Serious Incidents M07

Serious Incidents reported within 48 hours of identification

Serious Incident Root Cause Analysis Reports submitted within deadline

Falls M07

Falls per 1000 bed days

Safeguarding Training M07

Adult Safeguarding Children Safeguarding

Complaints M07

Acknowledged in 3 days

Responded to within agreed timescales

Serious Incidents indicators ICHT CW RBH

Serious Incident Root Cause Analysis Reports

submitted within deadline N/A

Serious Incidents M07

Serious Incident Root Cause Analysis Reports submitted within deadline

Complaints M07

Acknowledged in 3 days

Responded to within agreed timescales

Acute Providers

Community Provider - CLCH

Mental Health Provider - CNWL

Quality Indicators ICHT CW RBH

HASU thrombolysis treatment within 45 mins N/A N/A

90% time on stroke ward N/A

TIA treated within 24 hours N/A

TB access within 2 weeks No data N/A

VTE Risk Assessments NRLS uploads Overdue safety alerts

Friends and Family Test Indicators ICHT CW RBH

Inpatient Response Rate

A&E Response Rate N/A

Safety M07

Under 18s admitted to adult psychiatric wards

Patients feeling safe on an inpatient unit

Key

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Central London CCG

Exception Report: ICHT –

% of Serious Incidents reported within 2 working days of identification

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Late reporting of SIs

onto STEIS ICHT Review meetings held with Trust Joint action to be formulated with TDA Completed Dec/January - MM Maxwell Shona - December 14 February 15 - -

Root Cause:

The Trust has implemented a system for management of reporting of Serious incidents whereby the incidents are reviewed by the Medical director on a weekly basis prior to being entered onto STEIS this has resulted in only 60% of the incidents being reported within 49 hours

Mitigating Actions:

• Three meetings have taken place with the Trust to understand internal reporting mechanisms and concerns.

• Discussion with the TDA regarding concerns – formulating strategy to address this jointly TDA and CCG with Imperial

• The internal review of Serious Incidents is rigorous

Assurances:

• Internal review of Serious Incidents

Gaps in Assurance:

• Willingness to review internal processes to address 48 hour reporting requirements. • Any change in reporting of SIs within

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Central London CCG

% of complaints responded to within timeframes

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Complaints response Trust to respond to further requests for

Root Cause: Mitigating Actions:

• Raised with the trust at CQG.

• Discussed outside CQG – trust has not implemented extensions - this is to be considered

Will be scheduled for discussion at CQG in future months

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Central London CCG

% first booking maternity appointments completed by 12 weeks 6 days excluding late referrals

Issue Provider Action Action Status Plan in _Place? _OwnerCCG Provider _Owner On Track _{Delivery Date}Original Delivery Revised Date Contract Status Contract Penalties to date Attributed to

Cerner data issue ICHT Trust to resubmit data Open Yes MM

Jacqui

Dunkley-Bent No Jan 15 N/A - -

Root Cause:

• Possible Cerner data quality issue – trust does not report this as below threshold

To be revised following data resubmission

Persistent issue since April 2014 – trust has preciously given assurance that this would resolve

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Central London CCG

Home births

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Home births below

Root Cause:

• London wide issue

• Part of SaHF strategy to increase home births

Assurances:

On-going monitoring Gaps in Assurance: • Continually below threshold throughout the year

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Central London CCG

% of women that have non-elective caesarean sections

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Non -Elective sections

above thresholds ICHT Review as part of Maternity Network Open No MM JDB - - - - -

Root Cause:

• London wide issue

• Part wider Maternity Network consideration for 2015/16 to address across NWL sector

Assurances:

Review as part of Maternity Network

Gaps in Assurance:

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Central London CCG

Consultant Ward Coverage at St Mary’s Hospital (SMH) and Queen Charlotte's and Chelsea Hospital (QCCH)

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Consultant obstetric Plan or business case to achieve 168

Root Cause:

• Difference in data reported to CCG

performance team and trust reported data. • Trust reports currently at 98 hours however

should be reporting 168 hours from month 7

Discussed with Director of Children’s and Women’s Services who advised that the increase in consultant hours is linked to Ealing closure. Advised to develop trajectory for delivery of additional consultant hours

Assurances:

• Discussed with Director of Children’s and Women’s Services

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Central London CCG

Midwife to birth ratio at St Mary’s Hospital (SMH) and Queen Charlotte's and Chelsea Hospital

(QCCH)

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Midwife to birth ratio above expected threshold

ICHT International recruitment has taken place.

Confirmation of numbers and start dates Open Yes MM JDB Unknown - - - -

Root Cause:

Requirement to recruit additional midwives – international recruitment has taken place

Mitigating Actions:

Use of agency and bank midwifery to address shortfall

Assurances:

Focus CQG on maternity services in Jan / Feb 2015

Confirmation of numbers of staff recruited, start dates and induction processes

(33)

Central London CCG

Exception Report: ChelWest –

Serious Incidents indicators

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Serious incident Trust to provide update on action plan at To

Root Cause:

The organisation recognises that its Clinical Governance and associated reporting structures can be significantly improved.

The Trust is still using a paper based reporting system which contributes to delays in externally reporting incidents.

Mitigating Actions:

External Audit of clinical governance processes commissioned at the Trust and a plan is in place to restructure the governance team and to update the reporting to an electronic system. Improvements have been seen over the last year in the reporting culture.

Assurances:

The Trust has an action plan in place.

The CQC also identified gaps in the assurance processes regarding reporting and governance at the Trust.

(34)

Central London CCG

Breastfeeding initiation rate

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

To be identified CW Review process and improve breast _{feeding initiation rate} Open Yes LW TBC Yes Jan 15 N/A - -

Root Cause:

To be identified Mitigating Actions: To review process and update CQG in Jan

Assurances:

To be assessed after review at CQG

(35)

Central London CCG

% of women that non-elective caesarean sections

Issue Provider Action Action Status Plan in _Place? _OwnerCCG Provider _Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date Demographic

differences of local Trust to feedback at next CQG the

Root Cause:

Chair of CQG has met with the medical director and divisional medical director to discuss. The issue seems to predominantly concern elective LSCS rates. This has been a long-running issue and lots of work has been done with hospital clinicians of many types and a variety of clinical audits and reviews have been undertaken which will be reviewed by the Chair and a view to potentially commission an external review.

Trust meeting with Public Health England to review the demographic differences for the Trust.

Assurances:

(36)

Central London CCG

Midwife to birth ratio

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date Root Cause:

Numbers of midwives available

On-going recruitment plan.

(37)

Central London CCG

Exception Report: CLCH: All CCGs –

% of Serious Incidents reported within 2 working days of identification

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Serious incident Trust to provide update on action plan at To

Root Cause:

The organisation recognises that its Clinical Governance and associated reporting structures can be significantly improved.

The Trust is still using a paper based reporting system which contributes to delays in externally reporting incidents.

Mitigating Actions:

External Audit of clinical governance processes commissioned at the Trust and a plan is in place to restructure the governance team and to update the reporting to an electronic system. Improvements have been seen over the last year in the reporting culture.

Assurances:

The Trust has an action plan in place.

The CQC also identified gaps in the assurance processes regarding reporting and governance at the Trust.

(38)

Central London CCG

Exception Report: CNWL MH: All CCGs – Serious Incident Indicators

Issue Provider Action Action Status Plan in Place? Owner CCG Provider Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date

Late reporting of SIs ICHT To be explored with trust at CQG Open No MM AM

Root Cause:

To be identified at CQG Mitigating Actions: To be discussed at CQG

Assurances:

Root cause analysis reporting has improved

Unclear as to cause of failure to report within 48 hours.

(39)

Central London CCG

Exception Report: CNWL: Central London – % of complaints responded to within agreed timescales

Issue Provider Action Action Status Plan in _Place? _OwnerCCG Provider _Owner On Track Delivery Original Date Revised Delivery Date Contract Status Contract Penalties to date Inconsistent response Root Cause:

Unclear – trust reviewing complaints system Mitigating Actions: To be addressed at CQG in January

(40)

Central London CCG

(41)

Central London CCG

Local Priorities

Place Holder for:

•

Dementia Diagnosis Rates

•

Number of new health and social care related care plans (as defined

(42)

Central London CCG

(43)

Central London CCG

Definitions

Indicator Definition Data Source

A&E Performance Percentage of patients who spent 4 hours or less in A&E Unify2 Trolley Waits in A&E Patients who have waited over 12 hours in A&E from decision to admit to admission. Unify2 18 Weeks RTT Percentage of all NHS patients receiving treatment within 18 weeks of referral for completed admitted pathways (un-adjusted), completed _{non-admitted pathways and incomplete pathways.} Unify2 52 Week RTT Waiters The number of Referral to Treatment (RTT) pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed _{non-admitted pathways and incomplete pathways.} Unify2 6 Weeks Diagnostic Waits Percentage of NHS patients waiting 6 weeks or more for diagnostic tests Unify2 No. of LAS arrival to

handover times Ambulance handover delays of over 30 minutes and over 1 hour Database LAS Cancelled Ops - 28 Day

Guarantee breaches Number of breaches of the cancelled operations standard: number patients who have their operations cancelled, on or after the day of admission (including the day of the surgery), for non-clinical reasons Unify2 Cancer 2 week waits Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer and percentage of patients seen within two _{weeks of an urgent referral for breast symptoms where cancer was not initially suspected .} National Cancer

Database Cancer 31 day Waits

Percentage of patients receiving first definitive treatment within one month (31-days) of a cancer diagnosis (measured from ‘date of decision to treat’).

Percentage of patients receiving subsequent treatment for cancer within 31-days, where that treatment is a Surgery, an Anti-Cancer Drug Regimen or a Radiotherapy Treatment Course.

National Cancer Database

Cancer 62 day Waits

Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer.

Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service. Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status.

National Cancer Database HCAI – MRSA & CDIFF Health Care Acquired Infections – Number of MRSA bacteraemia and C. difficile cases reported by providers Protection Health

Agency Mixed sex

(44)

Central London CCG

Definitions

Urgent Ops Cancellations

for the 2nd_Time Number of Urgent operation cancelled for the 2nd time

Provider Monthly Information

Returns

IAPT

Access - proportion of people that enter treatment against the level of need in the general population (the level of prevalence addressed or ‘captured’ by referral routes).

Recovery - The number of people who have completed treatment having attended at least two treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness” and at final session did not) as a proportion of the number of people who have

completed treatment within the reporting quarter, having attended at least two treatment contacts) minus (The number of people who have completed treatment not at clinical caseness at initial assessment).

Returns

New psychosis cases served

by EIS Number of new psychosis cases served by Early Intervention Team as proportion of estimated CCG target new cases

Provider Monthly Information Returns CAMHS - % of patients showing improved HoNOSCA Score

Percentage of CAHMS patients discharged from service where the paired HoNOSCA shows improvement between acceptance and discharge (paired scores)

Returns CPA Reviews within 12

months Percentage of patients on CPA whose care plans have been reviewed within 12 months

Provider Monthly Information Returns Outcomes Data Completeness - CPA Patients

Percentage of service users who are on Care Programme Approach (CPA) for 12 months or more, with valid data entries across core outcome fields in their records.

Returns CPA Follow-Ups within 7

days Percentage of patients on enhanced CPA who were discharged from psychiatric in-patient care during who were followed up either by face to face contact or by a phone discussion within 7 days of discharge

Returns Delayed Transfers of Care Total number of Delayed Transfers of Care (DToC) as a proportion of occupied bed days for the same period

(45)

Central London CCG

Definitions

CLA Initial Health

Assessments (IHA) conducted

within 20 operational days Number of Initial Health Assessments (IHAs) of Children Looked After (CLA) that were completed within 20 operational days.

Returns CLA Review Health

Assessments (RHA) conducted within 6 wks

Number of Review Health Assessments (RHAs) of Children Looked After (CLA) that were completed within 6 weeks. Provider Monthly Information

Returns Referrals responded to

during the day, twilight or night service periods within 24 hrs

Percentage of non-urgent referrals that were responded to during the day or twilight service period within 24 hours or on the date stipulated for the visit on the referral letter

Returns Number of Rapid Response

referrals responded to with 2 hrs

Percentage of referrals to Rapid Response Service that were responded to within 2 hours. Response include a clinical acknowledgement of the referral and a plan of proposed clinical action.

Returns Pre-booked appointments

DNA or UTA rate Percentage of appointments where service user did not attend (DNA) or was unable to attend (UTA)

Returns Palliative care patients with a

recorded of preferred place

of death Patients under the care of palliative care teams who have a record of their preferred place of death

Returns Palliative care patients who

died in their preferred place

of death Patients under the care of palliative care teams who achieve their preferred place of death

(46)

Central London CCG

Definitions

LAS – Cat A Red 1 & 2

responses within 8min The number of Category A (Red 1/Red 2) calls resulting in an emergency response arriving at the scene of the incident within 8 minutes LAS LAS - Cat A 19 transportation

within 19min The number of Category A calls (Red 1 and Red 2) resulting in an ambulance arriving at the scene of the incident within 19 minutes. LAS NHS 111

• % calls answered in 60 secs • % calls abandoned in 30secs • % calls where call was offered

Unify2

GP OOH – Patient Communication

• Call Triages – Percentage of calls received that were triages within 20 minutes (urgent) or 60 minutes (routine) • Patient Consultations – Percentage of consultations within 1 hour (emergencies) or 2 hours (urgents), routine (6 hours) • Visits – Percentage of patient visits within 2 hours (urgents) or 6 hours (routines)

• Patient Communication – Meeting special needs

GP OOH Service

Critical care transfers for

non-clinical reasons Number of inter-trust transfers of critical care patients for non-clinical reasons as a proportion of all inter-trust critical care transfers

Returns Access to Rapid Access Chest

Pain Clinics Percentage of patients seen in Rapid Access Chest Pain Clinics (RACPC) within 14 days after a decision to refer

Returns HASU thrombolysis

treatment within 45 mins Measures the door to needle time (DTNT) at Hyper Acute Stroke Units (HASU) between patients entering the service and the time thrombolysis starts. Indicator is a standard in the Stroke Improvement National Audit Programme (SINAP) and is part of the NICE Stroke Quality Standards.

(47)

Central London CCG

Definitions

90% time on stroke ward As defined by the National Sentinel Stroke Audit a Stroke unit is a multidisciplinary team including specialist nursing staff based in a discrete _{ward which has been designated for stroke patients.}

Returns TIA treated within 24 hours

NICE guideline 68 specifies that people who have had a suspected TIA should have specialist assessment and investigation within 24 hours of onset of symptoms. TIA diagnosis should be made on clinical symptoms and higher risk TIA cases risk stratified using the ABCD2 score of 4 or above. The time frame begins at the time of the patient’s first contact with any health-care professional (including a paramedic, GP, stroke physician, A&E staff and district nurse etc.) and ends 24 hours later. Recurrent TIA after investigation and treatment should be considered as a new episode

Returns TB access within 2 weeks The percentage of GP referrals for suspected pulmonary tuberculosis that were offered an appointment date within 2 weeks of referral.

Returns NRLS uploads The number of National Reporting and Learning System (NRLS) uploads that were submitted within the deadline. NHS England Overdue safety alerts The number of Central Alerting System Patient Safety Alerts and Medical Device Alerts that were implemented and completed within deadline. NHS England Serious Incidents reported

within 48 hours of

identification The number of serious incidents that were reported within 24 hours of being identified, as recorded by the Provider.

Strategic Executive Information System (StEIS) Serious Incident Root Cause

Analysis Reports submitted within deadline

The number of serious incident root cause analysis investigation reports that were received within the 45/60 day deadline for Grade 1 and 2 serious incidents respectively.

Strategic Executive Information System (StEIS) Friends & Family Tests

Response Rates (A&E, IP & Maternity)

The response rate for the Friends and Family Test based on the number of patients accessing the service in the month against the number of

responses that were received. NHS England

(48)

Central London CCG

Definitions

Breast feeding A mother is defined as having initiated breastfeeding if, within the first 48 hours of birth, either she puts the baby to the breast or the baby _{is given any of the mothers breast milk}

Returns 12 Weeks assessment First booking appointments completed by 12 weeks + days as a percentage of total booking appointments in month excluding late referrals _{(women referred after 10 weeks + 6 days)}

Returns Smoking at delivery The smoking status at time of delivery indicator measures the number of women smoking at time of delivery (child birth) compared to the _{total number of women that gave birth to children in month.}

Returns Homebirths The percentage of maternal deliveries at home. The indicator includes still births and shows the percentage of women giving birth at home _{rather than the number of babies born at home.}

Returns Elective C-Sections A caesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s abdomen and womb. A planned _{(elective) procedure, when a medical need for the operation becomes apparent during pregnancy}

Returns Non-Elective C-Sections A caesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s abdomen and womb. A non-_{elective caesarean procedure is an emergency procedure, when circumstances during labour call for urgent delivery of the baby}

Returns 3rd degree tear A 3rd degree tear is a tear or laceration through the perineal muscles and the muscle layer that surrounds the anal canal. This requires stitches and can take a similar time to a 2nd degree tear (two months or so), if not longer, before the wound is healed and the area

comfortable.

Returns Post Partum Haemorrhaging Number of women experiencing a Post-Partum Haemorrhage of 2 litres and above.