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  • 1. TRUST BOARD – 1 NOVEMBER 2007 Title of the Paper: OBJECTIVE 2 PERFORMANCE REPORT Reference No: NUH 408 Jenny Leggott – Director of Nursing, Midwifery and Service Author/Sponsor: Improvement Objective 2 – Further improve our performance against Trust Objective: existing national healthcare standards and work towards developmental standards. Key issues: Currently some key targets are not being achieved and they continue to be the focus of further work to improve performance to national / local requirements. Risk Implications for NUH (including any Mitigating Actions (Controls): clinical and financial consequences): Achieving national waiting time guarantees – Trust-wide and Directorate specific no inpatients waiting more than 20 weeks. Action plans have been developed and implemented. Progress towards 18 weeks Referral to Services are implementing identified Treatment targets – despite significantly over actions from reworked capacity plans to performing on activity against plans, NUH did resolve ongoing pressures. Support has not achieve the targets to ensure 0 patients been confirmed with commissioners in were waiting more than 7-weeks for an the form of increased service level outpatient appointment and 15-weeks for agreements for a number of services. elective inpatient care by the end of March 07. We have now had formal confirmation from commissioners that they wish us to Recent Strategic Health Authority guidance achieve slightly faster access times this on access to diagnostic tests requires further year from those originally planned and progress in reducing waiting times. we are working with services to assess whether they can be achieved. Currently significant over performance continues as extra capacity is added. Rapid access to thrombolytic therapy – Increasing capacity and enhancing currently we are not achieving the national communications along the patient service framework standard as assessed pathway. through the Annual Healthcheck Access to genito – urinary clinics – An action plan has been developed to performance is improving but primary care increase capacity over the short and trusts are being challenged as to the level medium term and to improve data and being achieved. administrative processes. Access to cancer services – performance on A tumour specific action plan has been the 62 day referral to treatment target is not developed and is being implemented. yet consistently on target Page 1 of 12
  • 2. Hospital Acquired Infections – achieving A Trust Action Plan is being developed reductions in MRSA and c difficile infections and a senior project manager has been is challenging. appointed. Level of Assurance that can be given to the Trust Board from the report [significant, sufficient, limited, none]: SUFFICIENT Recommendation to the Trust Board: Members of the Trust Board are asked to note the position on key performance targets. Page 2 of 12
  • 3. Overview of performance The attached summary sheet shows the Trust with a number of key targets with significant performance issues. The exceptions are in similar areas to previously reported:  Ensuring that no patient waits more than 26 weeks from being added to the waiting list to treatment for an elective procedure  Working towards the target of no patients waiting more than 18 weeks from GP referral to hospital treatment by 2008 with a focus on outpatients, inpatients and diagnostics  Achieving diagnostic waiting time targets  Ensuring rapid access to thrombolytic therapy for people suffering a heart attack  Access to genito-urinary medicine (GUM) appointments  Ensuring rapid access to cancer care An additional area has been identified where there are particular pressures.  Ensuring achievement of infection control targets Further details are contained in the rest of the report. Page 3 of 12
  • 4. Maintain achievement of national waiting time guarantees Standard up to end Mar 07 No Inpatient/Daycase patients to wait more than 26 weeks (at month end or in month) Standard from April 07 - No Inpatient/Daycase patients to wait more than 20 weeks (at month end or in month) Area Performance Actions Impact – Responsibility Challenges Measures of Success 7 breaches April- A patient was seen in Action plan to deal with immediate causes has No future breaches Deputy Director of Operations August – previously outpatients and was been implemented. An investigation has taken for same Directorate leads noted. incorrectly outcomed as place as to whether same situation might have underlying A Dermatology breach “refer to another occurred for other patients. Given its nature the reasons. was reported in hospital” instead of to incident is also being investigated as a Serious September. the other site. As a Untoward Incident. result they were missed off various checks. Work towards the target of no patients waiting more than 18-weeks from GP referral to hospital treatment by 2008 Maximum wait of 7-weeks for outpatients, 11-weeks for diagnostics and 15-weeks for day-cases/inpatients by March 2007 Maximum wait of 5-weeks for outpatients, 6-weeks for diagnostics and 11-weeks for day-cases/inpatients by March 2008 Area Performance Impact – Responsibility Challenges Measures of Success At end of September a) Deliver 06/7 target We have agreed with commissioners Achievement of Deputy Director of 193 inpatient/day case shortfall. increases to planned activity levels in a milestones and Operations, Acting Assistant patients waiting 15 b) Progress to number of areas in order to achieve waiting profiles as Director of Finance weeks or longer. successful achievement time targets. With this PCT support we identified in the (Commissioning), (Main area of of 07/8 agreed targets continue to implement additional in house re-worked Directorates Leads. challenge: c) Ensure progression initiatives and place a number of patients in specialty plans. Orthopaedics = 96) to 07/8 targets enables the private sector. The number of patients (Clear responsibilities to be sufficient progress to who choose us but are unable to book slots derived in specialty-specific Page 4 of 12
  • 5. achieve 18 week directly is reducing as we increase capacity action plans.) 1432 outpatients targets by Dec 2008. and continue to over perform. waiting 7 weeks or d) Work with longer. commissioners to Commissioners have now formally informed (Main areas of manage demand. In us that they wish us to aim to achieve faster challenge: Cardiology 06/7 activity plans were access times of 4 weeks outpatients, 4 = 226 exceeded by 3% (more weeks diagnostics and 10 weeks inpatients Orthopaedics = 149 elective spells than by the end of this financial year. Services are Neurology = 89) planned) yet local assessing the operational requirements to targets were not meet these. Further discussions will then achieved. Continued take place with services and commissioners increases in demand if any gaps arise. will present significant challenges to achievement of targets in 07/8. The graphs below show the position for the whole trust and highlight the numbers of patients waiting over 7-weeks for their outpatient appointment as well as the number of patients waiting more than 15 weeks for elective treatment. There is also an element of patient choice where patients choose to wait beyond the targets established. Patients Waiting 7 weeks & over for an Outpatient Attendance Patients waiting 15 weeks & over for an Elective Inpatient or Daycase following GP or Other Referral Admission 4000 2000 3000 3246 3208 2517 2847 2759 2776 2928 2748 1500 1404 1351 1436 1200 1233 2169 2352 2452 1202 1237 1186 1138 1220 1241 1287 1125 1012 2000 1882 1320 1432 1000 1000 1998 1334 1414 1531 1227 1,064 500 1075 405 243 258 268 178 204 193 0 0 Jan- Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Feb Mar Apr- May Jun Jul Aug Sept Jan- Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Feb Mar Apr- May Jun Jul Aug Sept 06 07 07 06 07 07 NUH_7 & over wk OP Tgt NUH_15 & over w k IP/DC Tgt Page 5 of 12
  • 6. Work towards the target of no patients waiting more than 18-weeks from GP referral to hospital treatment by 2008 Maximum wait of 13 weeks for diagnostic tests by end of September 07 and 6 weeks by end of March 08 Area Performance Actions Impact – Responsibility Challenges Measures of Success The latest available The key challenges are The main over 13 week challenge remains in No over 13 wk Deputy Director of data across the 15 neurophysiology (188) neurophysiology. Following close collaboration waiters and Operations, Acting Assistant tests reported on the and echocardiography with the PCTs we have added significant extra reducing numbers Director of Finance monthly return shows (17). capacity in neurophysiology halving waiting over 4 weeks. (Commissioning), 207 over 13 wk waiters lists. However the number of over 13 week Directorates Leads. as at end Sept. waiters did not fall substantially as we were unable to contact some patients at short notice or they chose not to attend at such short notice. Any remaining patients waiting over 13 weeks for any test will be treated through October and November. Further work will take place to develop action plans to ensure we achieve the new 4 week milestone. Where extra activity is identified as required we will work internally and with PCTs to determine possible solutions. The Primary Care Trusts (PCTs) are required by the Strategic Health Authority (SHA) to ensure there are no patients waiting over 13 weeks by the end of September. This is an additional milestone to the target we are working towards of no patients waiting over 4 weeks by the end of March 2008. There are a further set of tests which are reported on a quarterly return and we are reviewing those as well to identify any problem areas. Page 6 of 12
  • 7. Achieving call to needle times for thrombolysis Standard to achieve 65% of patients receiving thrombolysis within 60 minutes of calling for professional help. This target has been updated from 56% previously set to reflect the level set in the Annual Healthcheck assessment. Area Performance Actions Impact – Responsibility Challenges Measures of Success The National Service This target relates to a Joint work is being undertaken with the East Midlands Improved Directorate leads Framework standard is small number of Ambulance Service (EMAS) as this target is shared performance. that people suffering patients (approx 11) a between NUH and EMAS. from heart attack month. should receive The new directorate management team are putting in thrombolytic therapy Performance in any place a number of actions over the next few months. within 60 minutes of individual month can • QMC thrombolysis nurse team providing 70% calling for professional therefore vary quite cover in ED as from August 27th, to date all shifts help. significantly but on have been covered. average it is 56% • First performance review meeting arranged for against a target of 65%. October 23rd to look through September performance with representation from EMAS and NUH teams. • Training dates for paramedics being arranged. • Support audit officer post to be advertised, will allow senior audit officer to meet with EMAS monthly to answer queries regarding call to door times as this area has the most potential to improve our data collection. Page 7 of 12
  • 8. Thrombolysis - Numbers eligible and % within 60 mins 100% 18 % receiving within 60 mins Call to 16 75% 14 Numbers eligible 12 10 Needle 50% 8 6 25% 4 2 0% 0 Jan Feb Mar Apr- May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept 06 Eligible Thromb_60 min % Tgt_60 min Access to genito-urinary medicine (GUM) services Standard to achieve 100% access to GUM clinic within 48 hours by March 08 Area Performance Actions Impact – Responsibility Challenges Measures of Success Performance has been Further significant Increased staffing – including extra nurse Action plan Directorate leads improving from 65-70% improvements are practioners for start of Oct and additional delivered per to over 70% in June, required to reach the consultant by March 08. timescale. July and August. 100% target. Increasing capacity from current establishment. Improved 48 hr performance. An audit of the data collection and reporting system has been undertaken. Page 8 of 12
  • 9. Currently the service is meeting the profile set internally as steps towards ensuring we meet the required target of 100% access by March 2008. However the PCTs are being assessed against a different profile and they are being challenged to improve performance. As the only provider of specialist genito urinary services within Nottingham we are key to the PCT’s plans. The health community sees this as a key risk area and therefore it was felt necessary to bring this to the Board’s attention. Speed of access to cancer services Maximum two month wait from urgent GP referral for suspected cancer to first definitive treatment for all cancers (“62 day target”) Performance Challenges Actions Impact – Responsibility Measures of Success Performance is not yet Improved Director of Nursing and A tumour-site specific action plan has been agreed following consistently above the 95% performance Operations pressure over the last couple of months. Performance is target level. Directorate leads beginning to shows signs of improvement as the plan is There are four main factors implemented. behind the current deterioration in performance Although September’s performance will be confirmed at below 95%, October is likely to be above and we anticipate that this  Capacity difficulties in should continue as the new management and administrative radiotherapy support structures become established. Discussions are taking  Management changes place with Sheffield on the options for referring patients for within NUH Radiotherapy when peaks of demand require that we do.  Impact of a review of The Lung team are meeting on the 8th November to review administration and clerical their current diagnostic process and look at further options to provision reduce the time taken  Impact of holidays on capacity Page 9 of 12
  • 10. Cancer 62 day target - from urgent referral to first definitive treatment 100.0% 90.0% 80.0% Total Tgt 70.0% 60.0% 50.0% Apr- May June Jul Aug Sep Oct Nov Dec- Jan Feb Mar Apr- May June Jul Aug Sep Oct Nov Dec- Jan Feb Mar Apr- May Jun Jul Aug 05 05 06 06 07 Page 10 of 12
  • 11. Hospital Acquired Infections - Achieving Infection Control Targets MRSA – target of 51 for 2007/8 C difficile - rate per 000 bed days in over 65s – target of 2.2 for 2007 based on Health Protection Agency estimate of bed days Performance Challenges Actions Impact – Measures of Responsibility Success The MRSA target is a year-on-year Actions include (from 1 November) much increased It has been agreed with A Deputy Director of Infection year 25% reduction. This is now 4 skin decolonisation in high risk areas, increased IP PCTs and SHA that Prevention and Control and cases per month. The trajectory has screening, and invigorated root cause analysis and NUH will aim to meet Governance has been consistently been exceeded (5-8 pr audit improvement cycles after cases. The hand the target in each appointed (to commence month since Jan 07). ) The target hygiene campaign continues. We are exploring month from October (ie week beginning 12 includes community acquired cases with PCTs increased health-community out-of-hospital the 'run-rate' to March November). The performance (currently around 25%). actions (notable screening and decolonisation). 08 will be in keeping management of HAI has with target levels of been revitalised by a weekly performance). meeting of IPC Team and Directorate Leads, chaired by the Director of Infection The C Diff target agreed (and recently The HAI action plan includes measures designed to Reducing rate to 2.2 on Prevention and Control, and confirmed) with PCTs is a 5% allow the trajectory to be regained (though to meet the average. monthly reporting to the reduction from 735 cases in those year's target number will require a stepped reduction Turnaround Team against the aged 65 and over Jan - Dec 2006 to in the number of cases to approx 36 per targets and the HAI Action 698 cases this calendar year month). These include the hand hygiene campaign, Plan (to be presented for the (equivalent to a reduction from 2.4 to increased use of F22 and single rooms for rapid Board's consideration Dec 2.2 per 1000 bed days). This target isolation, prompt treatment of cases, acceleration of 07) which has been informed trajectory has not been met this year the peroxide decontamination programme, attention to by the DoH Improvement (the trend line is on-the-whole overall antibiotic use, and the use of probiotics in at risk Team visit of late August. flat, as the graph shows). Since Jan patients. Invigorated root cause analysis and audit 07 144 of the 592 cases (to end Sept) improvement cycles after cases will be done as for have been community acquired. MRSA bacteraemia. We are working with the health community to develop actions (notably around reducing antibiotic use) to reduce community acquired C Diff.' Page 11 of 12
  • 12. Number of MRSA infections (as per Annual Healthcheck measure) 10 9 9 9 8 8 8 8 8 8 7 7 7 7 7 7 7 7 7 6 6 6 6 6 6 6 6 6 5 5 5 5 5 5 4 4 4 4 4 2 0 Apr May June Jul Aug Sep Oct Nov Dec-06 Jan Feb Mar Apr-07 May June Jul Aug Sept NUH_actual NUH target Total C. difficile Cases (in over 65s) - rate per 000 bed days (HPA est) 3.5 3 2.9 2.8 2.8 2.7 2.6 2.6 2.5 2.5 2 1.8 1.7 1.5 1 0.5 0 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Target Rate Page 12 of 12