ENC NO 3
Information
TRUST BOARD
6 SEPTEMBER 2007
Executive Director : Name: Sarah Jane Marsh
Designation: Director of Pla...
WALSALL HOSPITALS NHS TRUST
PERFORMANCE MANAGEMENT REPORT TO 31st JULY 2007
1. Introduction
This performance management re...
The team continue to ensure that all patients are seen within the shortest timescale. As can be
seen below 42% are seen wi...
 Clostridium Difficile (Cdif)
The Trust has agreed a target with Walsall tPCT, of no more than 334 cases of C diff during...
Ip/Dc Waiting List Laryngoscopy 2
Ip/Dc Waiting List Hysteroscopy 1
Ip/Dc Waiting List Laparoscopy 5
Ip/Dc Waiting List Ar...
PART 1B COMPLETED PATHWAYS - NON-ADMITTED PATIENTS
Length of RTT period for patients whose 18 week clock stopped during th...
There has been a significant amount of work undertaken to reduce the number of patients with an
unknown clock start date a...
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NHS Trust

  1. 1. ENC NO 3 Information TRUST BOARD 6 SEPTEMBER 2007 Executive Director : Name: Sarah Jane Marsh Designation: Director of Planning & Productivity PERFORMANCE MANAGEMENT REPORT TO 31st July 2007 The Trust Board is asked to note the performance management report covering the period July 2007, which identifies the level of compliance with the Health Care Commission targets. (HCC) for 2007/08. Summary of the Key Points: 1. There continues to be many challenges to meeting the individual targets for inpatient. outpatient and diagnostic waiting times relating to 18 weeks RTT milestones. 2. There have been no cases of MRSA and 8 cases of C.diff. 3. There has been an increase in the number of cancelled operations for non clinical reasons. 4. Thrombolysis indicators and quality of ethnic data continue to prove challenge as a result of issues around the data collection and submission. Key Risks (if yes explain risk and proposed management) Clinical Risks , Business Risks , Environmental risks , Finance & Performance risks , Reputation risks  1. The18 week RTT milestones and individual waiting time targets continue to require concerted effort by all divisions in order to ensure the Trust is able to demonstrate success and patients are seen without unnecessary delays. Legal Issues e.g. Human Resources: Y/N Resources required: None Report discussed with: Chief Executive Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 1 Walsall Hospitals NHS Trust
  2. 2. WALSALL HOSPITALS NHS TRUST PERFORMANCE MANAGEMENT REPORT TO 31st JULY 2007 1. Introduction This performance management report identifies the level of compliance with the Health Care Commission Targets (HCC targets) during July 2007. It outlines progress to date, areas of concern and actions planned or taken to rectify risks. 2. Key Updates on Targets  Cancer Targets There were no breaches to the cancer targets.  Cancelled Operations There were 11 cancelled operations this month for non clinical reasons bringing the year to date figure to 32; 0.35% of all operations carried out. This compares to 14 cancellations in June last year and 62 year to date. The eleven cancellations this month were:- o 5 General surgery – 3 due to equipment failure/unavailability, 1 list overrun, 1 surgeon unavailable o 5 Trauma & Orthopaedic – 3 due to equipment failure/ unavailability, 2 list overrun o 1 ENT due to an admin error o  Delayed Transfers of Care There were 33 (2.09%) delayed transfers of care in July making the year to date position 137 delays (2.01%) compared to 34 in the previous month and 91 year to date in 2006. We are working closely with the PCT to try to reduce the number of delays.  Total Time in A&E: 4 hours or less There were a total of 7069 attendances during the month, an average of 228 per day compared to 235.6 during July 2006. 1316 of the total attendances converted into a hospital admission and 150 patients breached the 4 hour target leading to an overall performance of 97.88% for the month and 98.50% for the year to date. Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 2
  3. 3. The team continue to ensure that all patients are seen within the shortest timescale. As can be seen below 42% are seen within one hour and almost 91% by the third hour. Treatment Wait 2007 Apr % of Total 2007 May % of Total 2007 Jun % of Total 2007 Jul % of Total 1 Hr or less 2932 42.72% 3117 43.88% 3240 47.79% 3001 42.45% >1 to 2 Hrs 2590 37.73% 2632 37.05% 2341 34.53% 2593 36.68% >2 to 3 Hrs 872 12.70% 821 11.56% 722 10.65% 861 12.18% >3 to 4 Hrs 418 6.09% 452 6.36% 341 5.03% 464 6.56% >4 to 5 Hrs 30 0.44% 42 0.59% 43 0.63% 62 0.88% >5 to 6 Hrs 9 0.13% 24 0.34% 46 0.68% 47 0.66% >6 to 7 Hrs 10 0.15% 10 0.14% 21 0.31% 27 0.38% >7 to 8 Hrs 2 0.03% 0 0.00% 20 0.30% 5 0.07% >8 to 9 Hrs 1 0.01% 2 0.03% 4 0.06% 2 0.03% >9 to 10 Hrs 0 0.00% 3 0.04% 0 0.00% 4 0.06% >10 to 11 Hrs 0 0.00% 0 0.00% 0 0.00% 3 0.04% >11 to 12 Hrs 0 0.00% 0 0.00% 1 0.01% 0 0.00% Total 6864 7103 6779 7069  Access to GUM Services The department continues to improve its access to patients with July showing 99.5% of patients being offered an appointment within 48hours. During July 77.2% of those offered were actually seen within the same time period which is a slight reduction on last month. There continues to be a discrepancy between the target set by the Department of Health and the Healthcare Commission and so the department continue to work towards the local target of 100% to ensure that all patients are offered appropriate access to services.  MRSA Bacteraemia. The target for 2007/08 is 12. There were no reported cases in July. MRSA Bacteraemia 07/08 April May June July August Sept. Oct. Nov. Dec. Jan. Feb. March Month 0 1 1 0 Cumulative 0 1 2 2 Target Trajectory 1 2 3 4 5 6 7 8 9 10 11 12 Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 3
  4. 4.  Clostridium Difficile (Cdif) The Trust has agreed a target with Walsall tPCT, of no more than 334 cases of C diff during the course of the year which equates to less than 28 cases per month. During June there were 8 recorded cases bringing the year to date position to 55. This is the lowest number of cases in one month since March 2005. Clostridium Difficile Data 2005 to 2008 April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. March Month 07/08 17 15 13 8 Cum 07/08 17 32 45 55 Month 06/07 41 49 44 22 31 25 33 32 22 28 32 23 Cum. 06/07 41 90 134 156 187 212 245 277 299 327 359 382 Month 05/06 23 30 16 11 13 11 13 16 13 12 28 36 Cum. 05/06 23 53 69 80 93 104 117 133 146 158 186 222  Waiting Times for Diagnostic Tests The reporting requirements for the Trust in relation to diagnostic waiting time has moved from the original 15 key tests to all tests in order to improve the overall services to patients. All departments have been working towards achieving the desired 6 week position and the table below identifies that in the majority of cases the target has been achieved; 56 investigations remained outstanding at the end of the month. There remain some issues with the availability of information for those investigations occurring within Clinical Measurement Unit which are currently being addressed by the department. The departments are now working to reduce the waiting time further towards 2 weeks for all but an agreed suite of investigations. Data Source Diagnostic Total who would breach without TCI before the end of the current month CRIS - Imaging System Magnetic Resonance Imaging 0 CRIS - Imaging System Computed Tomography 0 CRIS - Imaging System Non-obstetric ultrasound 0 CRIS - Imaging System Barium Enema 0 - DEXA Scan - Data Collection Spreadsheet Audiology - Audiology Assessments 3 Data Collection Spreadsheet Cardiology - echocardiography 0 - Cardiology - electrophysiology - Data Collection Spreadsheet Neurophysiology - peripheral neurophysiology 5 Data Collection Spreadsheet Respiratory physiology - sleep studies 0 Op Scheduling Urodynamics - pressures & flows 0 Ip/Dc Waiting List Colonoscopy 0 Ip/Dc Waiting List Flexi sigmoidoscopy 0 Ip/Dc Waiting List Cystoscopy 3 Ip/Dc Waiting List Gastroscopy 0 Subtotal for 15 tests 11 Other Diagnostic Tests Ip/Dc Waiting List Bronchoscopy 1 Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 4
  5. 5. Ip/Dc Waiting List Laryngoscopy 2 Ip/Dc Waiting List Hysteroscopy 1 Ip/Dc Waiting List Laparoscopy 5 Ip/Dc Waiting List Arthroscopy 28 Ip/Dc Waiting List CardiacCaths 8 Ip/Dc Waiting List Pharyngoscopy 0 Ip/Dc Waiting List Oesophagoscopy 0 Ip/Dc Waiting List Breath Tests 0 Op Scheduling Colposcopy 0 Ip/Dc Waiting List Ercp 0 Data Collection Spreadsheet Cmu Tests (other than in 15 key tests above) CRIS - Imaging System Imaging Tests (other than in 15 key tests above) 0 Subtotal for others 45 Pathology system Pathology Tests 0 Grand Total 56  18 Weeks Referral to Treatment (RTT) All divisions continue to implement their specific action plans in order to ensure that the Trust is best placed to meet the required milestones. Below are the data submissions relating to the target which demonstrates that there is some improvement across all areas coinciding with the reductions in the waiting times for the varying stages of the patients’ journey. PART 1A COMPLETED PATHWAYS - ADMITTED PATIENTS Length of RTT period for patients whose 18 week clock stopped during the month with an inpatient/day case admission Code Treatment function Number of patients whose 18 week clock stopped during the month with an inpatient/day case admission - length of period from referral to treatment (weeks): Treatment Line Number >0-18 >18-52 52 plus Patients with unknown clock start date Total % within 18 weeks 100 General Surgery AP100 247 78 6 51 382 64.66% 101 Urology AP101 59 9 1 1 70 84.29% 110 Trauma & Orthopaedics AP110 143 141 22 7 313 45.69% 120 Ear, Nose & Throat (ENT) AP120 85 45 7 1 138 61.59% 130 Ophthalmology AP130 38 16 2 0 56 67.86% 140 Oral Surgery AP140 7 14 0 0 21 33.33% 150 Neurosurgery AP150 0 0 0 0 0 - 160 Plastic Surgery AP160 0 0 0 0 0 - 170 Cardiothoracic Surgery AP170 0 0 0 0 0 - 300 General Medicine AP300 121 30 15 257 423 28.61% 301 Gastroenterology AP301 0 0 0 0 0 - 320 Cardiology AP320 14 2 0 2 18 77.78% 330 Dermatology AP330 0 0 0 0 0 - 340 Thoracic Medicine AP340 0 0 0 0 0 - 400 Neurology AP400 0 0 0 0 0 - 410 Rheumatology AP410 0 0 0 0 0 - 430 Geriatric Medicine AP430 2 0 0 12 14 14.29% 502 Gynaecology AP502 128 27 1 2 158 81.01% X01 Other APX01 204 78 11 99 392 52.04% 999 Total AP999 1048 440 65 432 1985 52.80% Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 5
  6. 6. PART 1B COMPLETED PATHWAYS - NON-ADMITTED PATIENTS Length of RTT period for patients whose 18 week clock stopped during the month for reasons other than an inpatient/ day case admission Code Treatment function Number of patients whose 18 week clock stopped during the month for reasons other than an inpatient/day case admission - length of period from referral to treatment (weeks): Treatment Line Number >0-18 >18-52 52 plus Patients with unknown clock start date Total % within 18 weeks 100 General Surgery NP100 244 47 11 18 320 76.25% 101 Urology NP101 26 12 0 1 39 66.67% 110 Trauma & Orthopaedics NP110 92 13 2 1 108 85.19% 120 Ear, Nose & Throat (ENT) NP120 259 49 10 13 331 78.25% 130 Ophthalmology NP130 167 44 7 4 222 75.23% 140 Oral Surgery NP140 49 25 3 1 78 62.82% 150 Neurosurgery NP150 0 0 0 0 0 - 160 Plastic Surgery NP160 7 1 0 6 14 50.00% 170 Cardiothoracic Surgery NP170 1 0 0 0 1 100.00% 300 General Medicine NP300 213 75 10 23 321 66.36% 301 Gastroenterology NP301 0 0 0 0 0 - 320 Cardiology NP320 0 0 0 0 0 - 330 Dermatology NP330 207 25 8 5 245 84.49% 340 Thoracic Medicine NP340 0 0 0 0 0 - 400 Neurology NP400 0 0 0 0 0 - 410 Rheumatology NP410 0 0 0 0 0 - 430 Geriatric Medicine NP430 29 11 3 3 46 63.04% 502 Gynaecology NP502 138 55 11 7 211 65.40% X01 Other NPX01 191 56 16 5 268 71.27% 999 Total NP999 1623 413 81 87 2204 73.64% PART 2 INCOMPLETE PATHWAYS - ALL PATIENTS Length of RTT period for patients whose 18 week clock is still running Code Treatment function Treatment Line Number Patients whose 18 week clock is still running at month end - length of RTT period so far (in weeks): >0-18 >18-52 52 plus Patients with unknown clock start date Total % within 18 weeks 100 General Surgery IP100 716 79 12 807 88.72% 101 Urology IP101 256 23 2 281 91.10% 110 Trauma & Orthopaedics IP110 983 220 50 1253 78.45% 120 Ear, Nose & Throat (ENT) IP120 769 64 22 855 89.94% 130 Ophthalmology IP130 581 62 7 650 89.38% 140 Oral Surgery IP140 124 10 1 135 91.85% 150 Neurosurgery IP150 0 0 0 0 - 160 Plastic Surgery IP160 63 1 0 64 98.44% 170 Cardiothoracic Surgery IP170 4 0 0 4 100.00% 300 General Medicine IP300 802 25 8 835 96.05% 301 Gastroenterology IP301 0 0 0 0 - 320 Cardiology IP320 57 9 0 66 86.36% 330 Dermatology IP330 440 7 0 447 98.43% 340 Thoracic Medicine IP340 0 0 0 0 - 400 Neurology IP400 0 0 0 0 - 410 Rheumatology IP410 0 0 0 0 - 430 Geriatric Medicine IP430 35 0 1 36 97.22% 502 Gynaecology IP502 500 23 8 531 94.16% X01 Other IPX01 463 37 9 509 90.96% 999 Total IP999 5793 560 120 0 6473 89.49% As can be seen 57% of admitted patients are currently seen within an 18 week period which increases to 71% for none admitted patients and 89% for patients whose treatment plans are ongoing. Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 6
  7. 7. There has been a significant amount of work undertaken to reduce the number of patients with an unknown clock start date and the divisional teams are making more extensive use of the available data.  Data Quality on Ethnic Groups The position on data quality in relation to ethnicity is slightly better than the previous two months but continues to remain a problem as a result of information submissions to Secondary Uses Services (SUS) and Hospital Episode Statistics (HES) data as previously reported. All efforts are continuing to resolve this situation.  Thrombolysis improvement score and call to needle time The July position remains unsatisfactory in terms of data collection related to thrombolysis scores. The team are actively working with the clinical team to improve the method of capture and improve the overall position. 2. Summary The first month in the second quarter shows some encouraging trends in relation to the national performance targets in particular around the number of new cases of C.diff and MRSA. There continues to be some concern relating to the individual milestones for inpatients, outpatient sand diagnostics which the divisions are working towards resolving. Cancelled operations for non- clinical reasons increased during the month. Data collection and submission for thrombolysis and ethnicity continue to prove difficult to resolve, every effort is being made by all those involved. Trust Board 6 September 2007 Performance Management Report to 31 July 2007 sb Building Better Health for Walsall 7

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