Report to Trust Board 26/01/2017. Report Title Operational Performance Report - December 2016 & Quarter /17 Report from

Transcription

1 Item 10 Report to Trust Board 26/01/2017 Report Title Operational Performance Report - December 2016 & Quarter /17 Report from John Quinn, Director of Operations Prepared by Stephen Chinn, Senior Performance Analyst (Produced on 19/01/2017) Previously discussed at Attachments Brief Summary of Report This report highlights a series of metrics regarded as the Key Indicators of Operational Performance. They cover a variety of activities covering including the management of Referral to Treatment waiting times, Accident & Emergency accessibility, cancer treatment, access to services, efficiency (including activity levels, attendance and cancellation rates and journey times), effectiveness and safety measures, patient feedback and information relating to staffing levels. The report uses a number of mechanisms to put performance in context, showing achievement against target, in comparison to previous periods and as a trend. The first section of the document also contains an exception report which explains the current position with those indicators which fall short of target and outlines the corrective action being taken to improve that position. Action Required/Recommendation The report is primarily for information purposes but will inform discussion regarding how the Trust is performing against its Operational measures. This may in turn generate subsequent action. For Assurance For decision For discussion To Note

2 CONTENTS Executive Report Page 2 Exception Report Page 3-4 Compliance Performance Overview Page 5 Access - Referral to Treatment Pages 6-7 Access - A&E Pages 8-9 Access - Cancer Waiting Times Pages Access - Other Page 12 Efficiency Pages Effectiveness Page 16 Safety Page 16 Ward Staffing Levels Page 17 Patient Experience Page 18 Bank and Agency Staff Information Page 19 Page 1

3 Executive Report - December 2016 and Quarter /17 Indicator Threshold Current Month Current Quarter Year To Date Exception Summary Year Forecast 18 weeks Referral to Treatment - Incomplete Pathways (All) 52 Week RTT Breaches - Incomplete Pathways (All) A&E Four Hour Performance % Cancer 2 week waits - first appointment urgent GP referral % Cancer 14 Day Target - NHS England Referrals (Ocular Oncology) % Cancer 31 day waits - diagnosis to first appointment National: 92% STF: 96.5% All Pathways Within 52 Weeks National: 95% STF: 97.6% Thresholds Achieved 2 Breaches Recorded Thresholds Achieved Thresholds Achieved 3 Breaches Recorded Thresholds Achieved Thresholds Achieved 3 Breaches Recorded Thresholds Achieved 93% Seen No Breaches No Breaches Above Threshold 93% Seen Above Threshold Above Threshold Below Threshold 96% Treated No Breaches Above Threshold Above Threshold % Cancer 31 day waits - subsequent treatment 94% Treated Below Threshold Below Threshold Below Threshold % Cancer 62 days from urgent GP referral to first definitive treatment Diagnostic waiting times - 6 weeks 85% Treated No Cases No Breaches Below Threshold National: 99% STF: 100% All Seen Within 6 Weeks All Seen Within 6 Weeks All Seen Within 6 Weeks One Breach in October and Two Breaches in December. See Exception Report for further details Recent improvements and achieved for Quarter, however unlikely to achieve threshold for the year One breach from three cases in December, and 10 cases in the quarter YTD down due to one breach in September, but on course to achieve for year Cancelled Operations - 28 Days Re-Book Zero Cases No Breaches No Breaches No Breaches Number of MRSA cases Zero Cases No Cases No Cases No Cases Number of C.Diff cases Zero Cases No Cases No Cases No Cases VTE Screening - all admissions 95% Above Threshold Above Threshold Above Threshold Friends & Family Test - A&E (Response Rate) 20% Below Threshold Below Threshold Below Threshold Friends & Family Test - Inpatients (Response Rate) Friends & Family Test - Outpatients (Response Rate - Estimated) * STF = 'Sustainability and Transformation Fund' trajectory 30% Above Threshold Above Threshold Above Threshold 15% Below Threshold Below Threshold Below Threshold Difficulties in establishing and maintaining engagement, this is under review. Difficulties in establishing and maintaining engagement, this is under review. Page 2

4 Exception Report - December 2016 and Quarter /17 Referral To Treatment (RTT) 52 Week Pathway Breaches In December we recorded two 52 week Incomplete Pathway Breaches. Board of Directors Operational Performance Report - December 2016 and Quarter /17 The first patient was intended to be listed for Adnexal surgery in May 2015, however an incorrect RTT status was entered on the outcome form. This hid the patient from reporting and the surgery was not scheduled. This was found by the consultant s secretary and highlighted to the service manager. The patient is at 87 weeks wait and has a provisional date for surgery on 27/01/2017. The second patient was referred from Glaucoma to Medical Retinal but did not attend their first appointment in The patient was given another appointment but this was cancelled by the trust using the wrong RTT code and never rebooked. The patient was discovered as part of an investigation regarding to a serious incident. The patient is at 73 weeks and will be seen on 20/01/2017. For the quarter there were three Incomplete Pathway Breaches in total, the third patient was paediatric patient who was originally discharged from Moorfields A&E with an action to book an appointment in an outpatient service; however no appointment was made, and due to changes in reporting this was identified and not actioned until October This patient was reported as an incomplete breach in October, and then as a closed admitted breach in November when they were treated. There were four Closed Non-Admitted Breaches for quarter, all in October. The reasons for these breaches are as follows: Two paediatric patients who were discharged from Moorfields A&E with an action to book an appointment in an outpatient service, however no appointment was made. Due to changes in reporting, this was not picked up in failsafe reporting and not actioned until October A cataract patient was referred from the Medical Retinal sub-speciality to cataract, however this referral was lost until it arrived at the booking centre in October A neuro-ophthalmology patient was referred to this sub-speciality in May 2016 from Glaucoma (the patient had been referred previously in Aug 2015 but this was not registered), this was an internal referral delay which resulted in a 61 week wait. Page 3

5 Exception Report - December 2016 and Quarter /17 (Continued) Cancer performance - % 31 day breach (Subsequent Treatment): There was one breach recorded in December, performance for the month was 67% (from three cases) and 90% for the quarter. This was due to patient's original offer date for treatment being cancelled due to anaesthetic complications. Friends & Family Test - A&E & Outpatients Response Rate Response rates for December in of these have fallen more than 5% below their respective targets (to 12.4% and 8.4% respective ly). For the Quarter performance was at 14.8% and 10%, with the YTD at 15.7% and 11.6% respectively. The performance reflects the difficulties the clerical management teams at City Road and Moorfields South (though notably not Moorfields North), and the A&E staff have had in establishing and maintaining engagement with the process within their teams. The recent changes to the trust management structure will hopefully address this. The Day Care response rate continues to perform well at all sites. Of the responses received, both A&E and Outpatients maintain a high satisfaction rate with 96% of patients recommending Moorf ields, and 99% recommending the inpatient services. Page 4

6 COMPLIANCE PERFORMANCE OVERVIEW Key Reference: Indicator 18 weeks Referral to Treatment - Incomplete 18 weeks Referral to Treatment - Incomplete With DTA 18 weeks Referral to Treatment - Admitted 18 weeks Referral to Treatment - Non Admitted New RTT Periods (Clock Starts) - All Patients 52 Week RTT Breaches - Incomplete 52 Week RTT Breaches - Admitted Left without being seen A&E ENP Pathway A&E Unplanned Re-attendance % Cancer 31 day waits - diagnosis to first appointment % Cancer 31 day waits - subsequent treatment % Cancer 62 days from urgent GP referral to first definitive treatment Threshold N: 92.0% L: 96.5% Dec-16 Q3 2016/17 YTD 2016/17 Source Indicator Threshold Dec-16 Q3 2016/17 YTD 2016/ % 97.7% 97.8% Monitor, CQC, TDA Diagnostic waiting times - 6 weeks 99% 100% 100% 100% Source CQC, TDA, NHSI n/a 92.3% 93.6% 94.1% Monitor, CQC, TDA n/a 92.2% 90.1% 90.5% 90% 87.5% 88.9% 89.5% 95% 96.2% 96.2% 96.4% from October 2015 from October % 79.5% 82.0% 80.4% n/a 10,442 34, ,517 Monitor, CQC, TDA n/a 7.3% 5.8% 5.5% Monitor Monitor, CQC, TDA Emergency Readmissions within 30 days of discharge n/a 7.3% 6.2% 5.7% CQC, TDA CQC, TDA, Outcomes Framework, NHSI Monitor, CQC, TDA n/a 56.0% 58.9% 59.4% 52 Week RTT Breaches - Non Admitted Number of MRSA cases A&E Four Hour Performance A&E Three Hour Performance % Cancer 2 week waits - first appointment urgent GP referral % Cancer 14 Day Target - NHS England Referrals (Ocular Oncology) Monitor, CQC, TDA CQC, Monitor, 99.3% 98.4% 98.1% Number of C.Diff cases TDA, NHSI 80% 87.2% 81.7% 80.3% VTE Screening - all admissions 95% 97.8% 98.4% 98.9% N: 95.0% L: 97.6% Performance 2016/17 CQC, Monitor,TDA, NHSI CQC, Monitor, TDA, NHSI CQC, TDA, NHSI 5% 1.2% 1.7% 2.3% CQC, TDA NHSI 30% 24.1% 24.2% 24.2% Friends & Family Test - A&E (Response Rate) 20% 12.4% 14.8% 15.7% 5% 5.9% 6.2% 6.4% CQC, TDA Friends & Family Test - Inpatients (Response Rate) 30% 60.2% 58.3% 59.1% CQC,TDA, Outcomes Framework CQC,TDA, Outcomes Framework 93% 100.0% 100.0% 97.6% CQC, Monitor,TDA 15% 8.4% 10.0% 11.6% 93% 95.5% 95.5% 90.1% CQC, Monitor,TDA Ward Staffing Levels (Inpatient Wards Only) n/a 92.3% 91.9% 97.5% 96% 100.0% 98.5% 97.8% CQC, Monitor,TDA 94% 66.7% 90.0% 92.0% CQC, Monitor,TDA 85% 100.0% 83.3% CQC, Monitor, TDA, NHSI On or above target Below target and rise in figures Stable on/above target Below target and stable On target and drop in figures Below target and fall in figures Outpatient appointment - Over 6 week waiters Electronic Booking Appointment Availability Cancelled Operations - 28 Days Re- Book * Emergency Readmissions within 28 days of discharge % GP referrals From Electronic Booking Number of Mixed Sex Accommodation Breaches Friends & Family Test - Outpatients (Response Rate - Estimated) * Figures are provisional since as of the time of production of this report they have not been submitted as final Within tolerance and rise in figures Within tolerance and stable Within tolerance and drop in figures Performance 2016/17 No target or N/A CQC, TDA Page 5

7 18 Weeks Referral to Treatment Trust Total Indicator 18 weeks Referral to Treatment -Incomplete (All Pathways) 18 weeks Referral to Treatment -Incomplete (Pathways with DTA) * 18 weeks Referral to Treatment - Admitted 18 weeks Referral to Treatment -Non Admitted New RTT Periods - All Patients * Threshold N: 92.0% L: 96.5% Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD 94.7% 94.2% 97.6% 97.9% 97.9% 97.8% 97.7% n/a 97.8% n/a 89.0% 87.5% 92.3% 94.3% 93.7% 94.8% 93.6% n/a 94.1% 90% 88.9% 89.6% 87.5% 89.5% 89.1% 90.3% 88.9% n/a 89.5% 95% 96.3% 96.3% 96.2% 96.2% 96.6% 96.5% 96.2% n/a 96.4% n/a 66,658 33,232 10,442 12,185 34,260 35,609 34,648 n/a 104,517 Compliance Source Monitor, CQC, TDA, NHSI Monitor, CQC, TDA from October 2015 from October 2015 Monitor, CQC, TDA Incomplete (All Pathways) Incomplete (Pathways with DTA) * Admitted Non Admitted Indicator 52 Week RTT Breaches Patients Waiting >18 weeks 18w(92%) Shortfall/Surplus 52 Week RTT Breaches Patients Waiting >18 weeks 52 Week RTT Breaches Patients Waiting >18 weeks 18w(90%) Shortfall/Surplus 52 Week RTT Breaches Patients Waiting >18 weeks 18w(95%) Shortfall/Surplus Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD n/a 3 Monitor, CQC, TDA N/A 15,683 13, ,487 1,629 1,801 n/a 4,917 N/A 7,917 4,820 1,455 1,502 4,229 4,363 4,382 n/a 12, n/a 0 Monitor, CQC, TDA N/A 2,374 1, n/a 2, n/a 1 Monitor, CQC, TDA N/A 3,454 2, n/a 2,619 N/A n/a n/a 5 Monitor, CQC, TDA N/A 3,181 2, n/a 2,509 N/A 1, n/a 1,022 * Incomplete (Pathways with DTA) & New RTT Periods: 2015/16 YTD from October 2015 as figures prior to this date not available at this time Compliance Source Page 6

8 18 Weeks Referral to Treatment (Cont.) All RTT figures are final, including November s figures which were previously listed as provisional. 18 weeks Referral to Treatment for all incomplete pathways the trust achieved 97.6% in December, a slight decrease from 97.9% in November, so remaining above 92% national target and the 96.5% Sustainability and Transformation Fund trajectory. The 18 week performance maintains a run of 28 months above the 92% target with the YTD at 97.8%. There were two 52 week breaches this month, both have been highlight in the exception report. For the quarter, performance was 97.7% with three 52 week breaches. 18 weeks Referral to Treatment - Incomplete (Pathways with DTA) recorded 92.3%, a drop from 94.3% recorded in November. Admitted performance dropped to 87.5% from 89.5% in November, while Non-Admitted Performance remained stable at 96.2%. Page 7

9 Accident & Emergency Total number of 4 hour breaches Total number of 6 hour breaches Left without being seen Indicator Total number of Arrivals in A&E Total number of Expected Arrivals in A&E A&E Four Hour Performance A&E Three Hour Performance Time to Treatment in Department - median Total time spent in A&E -Admitted 95th Percentile Total time spent in A&E - Non Admitted 95th Percentile A&E ENP Pathway A&E Unplanned Re-attendance Threshold N/A N/A N: 95.0% L: 97.6% Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD 103,922 78,539 7,340 8,203 26,874 26,563 24,157 n/a 77,594 99,313 74,658 8,008 8,895 28,532 27,981 26,253 n/a 82, % 97.5% 99.3% 99.3% 97.5% 98.5% 98.4% n/a 98.1% Compliance Source, NHSI 80% 78.1% 77.7% 87.2% 82.1% 77.1% 82.3% 81.7% n/a 80.3% N/A n/a 1433 N/A n/a 93 5% 2.5% 2.5% 1.2% 1.5% 2.7% 2.4% 1.7% n/a 2.3% 60 mins n/a 35 CQC, TDA 240 mins n/a 233 CQC, TDA 240 mins n/a 226 CQC, TDA 30% 22.3% 22.8% 24.1% 24.0% 23.9% 24.5% 24.2% n/a 24.2% 5% 0.4% 0.4% 5.9% 5.9% 6.5% 6.5% 6.2% n/a 6.4% CQC, TDA Page 8

10 Accident & Emergency (Cont.) A&E Four Hour Performance remained stable at 99.3% for the month, so is above both the 95% national target and the Sustainability and Transformation Fund trajectory set at 97.6%. performance was at 98.4% and YTD at 98.1%. No days in December fell below the 95% target, there were 47 four hour breaches in total. 27 out of 31 days achieving the STF trajectory, however there were four six hour breaches recorded with two each on the morning of the 6th and 7th. Three hour performance also saw a month increase from 82.1% to 87.2%, above the 80% local target. The quarterly performance was at 81.7% with the YTD at 80.3%. Total A&E monthly arrivals were at 7,340 which represents a drop of 6% compared to December 2015, or 25 less patients per working day (Monday to Friday, weekends are at a similar level). YTD activity is down 1.2% over the same period last year. Page 9

11 Cancer Waiting Times Indicator Cancer 2 week waits - first appointment urgent GP referral % Cancer 14 Day Target - NHS England Referrals (Ocular Oncology) Cancer 31 day waits - diagnosis to first appointment Cancer 31 day waits - subsequent treatment Cancer 62 days from urgent GP referral to first definitive treatment Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Trust Summary (All Cancer Cases) Cases n/a 42 93% 91.0% 92.7% 100.0% 100.0% 94.7% 100.0% 100.0% n/a 97.6% Cases n/a % 81.3% 77.9% 95.5% 98.5% 86.1% 89.8% 95.5% n/a 90.1% Cases n/a % 91.5% 94.9% 100.0% 95.0% 98.2% 96.6% 98.5% n/a 97.8% Cases n/a 25 94% 89.7% 85.7% 66.7% 100.0% 90.9% 100.0% 90.0% n/a 92.0% Cases n/a 6 85% 100.0% 100.0% n/a n/a 100.0% 0.0% 100.0% n/a 83.3% Compliance Source As mentioned in the exception report, in December there were three 'Cancer 31 day wait - subsequent treatment cases with a single breach. The quarter finished at 90% (1 breach in 10 cases) with the YTD performance now below the 94% target to 92.0%., NHSI In quarter 3 there were 13 2 week waits - first appointment urgent GP referral cases, of which 7 were in December, none of which breached, so the YTD remains above the 92% target at 97.6%. There were 66 'Cancer 31 day wait - first treatment in quarter 3 with just one breach (in November), so quarter performance was above the 96% target at 98.5%. YTD remains above target at 97.8%. There were no Cancer 62 days from urgent GP referral to first definitive treatment cases in December, therefore we remain below the 85% target at 83.3%, however we expect to achieve this before the end of the financial year. NHS England requires that all referrals of suspected cancers from whatever source will be seen by a senior doctor within 14 days, with a target of 93%. For the first time since the service started in late June 2015 we achieved the 93% target for the quarter, performing at 95.5%. The YTD remains below target at 90.1%. Page 10

12 Cancer Waiting Times (Continued) Indicator Cancer 2 week waits - first appointment urgent GP referral Cancer 31 day waits - diagnosis to first appointment Cancer 31 day waits - subsequent treatment Cancer 62 days from urgent GP referral to first definitive treatment Cancer 2 week waits - first appointment urgent GP referral Cancer 31 day waits - diagnosis to first appointment Cancer 31 day waits - subsequent treatment Cancer 62 days from urgent GP referral to first definitive treatment Threshold 2015/16 Performance 2016/17 Year End YTD Current Month Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Ocular Oncology (Brain and Nervous System Tumours - see Trust Sumary for 14 Day Performance) Cases n/a 19 93% 85.7% 85.7% n/a n/a 91.7% 100.0% n/a n/a 94.7% Cases n/a % 90.7% 94.4% 100.0% 95.0% 98.2% 96.5% 98.4% n/a 97.7% Cases n/a 21 94% 86.7% 77.8% 50.0% 100.0% 87.5% 100.0% 88.9% n/a 90.5% Cases n/a 5 85% n/a n/a n/a n/a 100.0% 0.0% 100.0% n/a 80.0% Skin Cancer Cases n/a 23 93% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% n/a 100.0% Cases n/a 6 96% 100.0% 100.0% 100.0% n/a 100.0% 100.0% 100.0% n/a 100.0% t Cases n/a 4 94% 92.9% 91.7% 100.0% n/a 100.0% n/a 100.0% n/a 100.0% t t Cases n/a 1 85% 100.0% 100.0% n/a n/a n/a n/a 100.0% n/a 100.0% t Compliance Source, NHSI, NHSI Page 11

13 Access - Other Indicator Diagnostic waiting times - 6 weeks First Outpatient Appointment Waiting more than 6 weeks Patients Waiting more than 13 weeks for Admission Electronic Booking appointment availability Electronic Booking Capacity Issue Rate * Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD 99% 100% 100% 100% 100% 100% 100% 100% n/a 100% Compliance Source CQC, TDA, NHSI TBA 89.1% 88.5% 92.2% 89.2% 90.9% 90.5% 90.1% n/a 90.5% TBA 23.3% 22.6% 20.1% 16.6% 21.4% 17.6% 17.1% n/a 18.7% 96% 78.2% 78.6% 79.5% 85.7% 74.0% 84.8% 82.0% n/a 80.4% N/A 21.1% 20.5% n/a 14.3% 25.9% 15.1% 12.5% n/a 17.7% Electronic Booking System Issue Rate * * Some December 2016 Electronic Booking Figures unavailable (See notes below) N/A 0.8% 1.0% n/a 0.2% 0.1% 0.1% 0.1% n/a 0.1% An indicator of diagnostic waiting time performance has also been included in the Sustainability and Transformation Fund trajectories for this financial year. The agreed target, of 100% within 6 weeks, has been achieved for both month and Quarter, and remains at 100% for the YTD. Electronic Bookings performance for December was at 79.5%, a decrease from 85.7% in November, with the quarter at 82.0% and YTD at 80.4%. This is being investigated as part of the booking centre action plan and linked to the directory of service work we are undertaking, and will be reported on in future meetings. At this time we are unable to report for December on the breakdown between capacity and system issue rates due to ongoing reporting functionality development by the national E-Referral development team. Page 12

14 Efficiency Trust Total Outpatient Total Attendances - First Appointment Outpatient Total Attendances - Follow Up Appointment Outpatient Cancellations Outpatient DNA rate - First Appointment Outpatient DNA rate - Follow Up Appointment Clinic Journey Times Less Than 2 Hours - Outpatient First Appointment Clinic Journey Times Less Than 2 Hours - Outpatient Follow Up Appointment Admission Demand - Decision to Admit (DTA) Admission Activity Theatre Cancellation Rate Theatre Sessions Starting Late Cancelled Operations - 28 Days Re-Book (Provisional - submitted quarterly) Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Compliance Source N/A 116,152 86,219 8,768 11,255 30,152 31,273 30,911 n/a 92,336 N/A 412, ,569 30,872 37, , , ,103 n/a 320,665 N/A 10.9% 10.6% 12.0% 12.3% 11.5% 12.1% 12.1% n/a 11.9% N/A 12.7% 12.4% 15.1% 14.5% 13.5% 14.2% 14.4% n/a 14.1% N/A 12.1% 12.0% 11.8% 12.9% 11.7% 11.9% 12.1% n/a 11.9% N/A 58.1% 58.4% 59.4% 58.3% 58.8% 58.5% 58.7% n/a 58.7% N/A 71.2% 72.0% 67.1% 65.5% 67.6% 67.6% 67.0% n/a 67.4% N/A 36,956 27,588 2,638 3,420 9,901 10,025 9,471 n/a 29,397 N/A 35,864 26,373 2,504 3,323 9,355 9,520 9,021 n/a 27,896 N/A 7.8% 7.4% 6.8% 7.3% 7.9% 7.5% 7.3% n/a 7.6% N/A 35.8% 34.7% 40.5% 39.4% 42.5% 39.2% 37.1% n/a 39.6% n/a 0 CQC, TDA Page 13

15 Efficiency (Cont.) Outpatient Activity continues to remain high, especially against the same period during 2015/16, Average outpatient activity was at 1,982 attendances per working day compared to 1,920 in December Year to date, first appointment activity is 7.1% up on the previous year while follow up appointment YTD activity is up 3.7%. First appointment DNA rates continue to increase to 15.1% in December from 14.5% in November, with the YTD at 14.1%. Follow up DNA rates also saw a decrease from 12.9% in November to 11.8% in December with the YTD at 11.9%. Cost improvement programmes are being implemented to address this across a number of sites. Admission activity is at a similar level to the previous month with 125 admissions completed per working day, with a 5.8% YTD increase compared to the same period last year. The theatre cancellation rate saw a decrease from 7.3% last month to 6.8% this month, with the YTD at 7.7%. Theatre sessions starting late saw an increase with 40.5% starting more than 15 minutes after the scheduled start time compared to 39.4% last month, the YTD is at 39.6%. Both these previously identified issues will be addressed as part of the Theatre Improvement Programme. Page 14

16 Efficiency (Cont.) Key: : :4 Month Average Page 15

17 Effectiveness Indicator Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD Compliance Source Emergency Re-admission within 28 days of discharge Emergency Re-admission with 30 days for elective and emergency cases % GP referrals From Electronic Booking (Choose & Book /E-referrals) N/A 4.0% 4.1% 7.3% 6.6% 4.8% 5.9% 5.8% n/a 5.5% Monitor Cases n/a 130 N/A 4.2% 4.4% 7.3% 7.3% 5.1% 5.9% 6.2% n/a 5.7% Cases n/a 135 CQC, TDA, NHSI N/A 51.8% 51.1% 56.0% 61.0% 58.4% 60.8% 58.9% n/a 59.4% Safety Indicator Number of MRSA cases Number of C.Diff cases VTE Screening Threshold Year End 2015/16 YTD Current Month Performance 2016/17 Previous Month Qtr1 Qtr2 Qtr3 Qtr4 YTD n/a n/a 0 95% 98.4% 98.3% 97.8% 98.6% 99.2% 99.0% 98.4% n/a 98.9% Compliance Source CQC, TDA, Monitor, NHSI CQC, Monitor, TDA, NHSI CQC, TDA, NHSI Mixed Sex Accommodation n/a 23 NHSI There were no MRSA or C.Diff Cases recorded at Moorfields this financial year. VTE Screening Performance remains above the 95% target. There were no Mixed Sex Accomodation breaches in December, however three were reported during the quarter in October. Page 16

18 Ward Staffing Levels (Only 'wards with inpatient beds' as per report requirement) The fill rate for December 2016 was generally within expected bounds for all wards with the exception of OBS s Bay where the Average (day) rate was 78.3%. This may be due to the higher than normal levels of sickness and Annual Leave during the month. The figures for Cumberlege Ward and Duke Elder Ward are in line with previous months, in the case of Duke Elder Ward, the Average Fill Rate (Day) has increased to 95.4% which is in line with previous (pre e-roaster) submissions. Page 17

19 Patient Experience - Friends and Family Test (FFT) The scoring system is represented as a simple percentage method, where patients who are Extremely likely or Likely to recommend Moorfields to friends and family are listed as Would Recommend the hospital, and patients who are Unlikely or Extremely Unlikely to recommend Moorfields are listed to Would Not Recommend the hospital. The eligible patient population includes under-16 s in all categories. The Inpatient FFT responses include day case patients as well as patients who stayed overnight, which has increased the number of results received in this category. The outpatient FFT scores and response rates are also included in this report, covering most patients who attended an outpatient clinic. Accident and Emergency FFT response rate method remains unchanged from last year (aside from the aforementioned inclusion of under-16s). Page 18

20 Nursing Bank and Agency Staff Information Proportion of Nursing Bank and Agency Staff Hours filled, with total hours worked Page 19