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Last Year Last Month This Month
Jun-07 May-08 Jun-08
PERFORMANCE SCORECARD REPORT
FEBRUARY 2009 (JANUARY & FEBRUARY DATA)
Exception Report
Please note, some indicators are still under construction and additional indicators will continue to be developed as appropriate. It should be noted that trend
arrows demonstrate whether performance has improved (indicated by an up arrow), declined (indicated by a down arrow) or stayed the same (indicated by a
sideways arrow) between the month reported (Feb 08) and the previous month (Jan 08). The most recent data available is provided for all indicators wherever
possible.
It should be noted that due to the Board dates changing, data provided is now more up to date and instead of reporting just January data in the February report,
now February data is provided as well where possible.
To be the provider of choice
The service performance risk rating score covers the key access and choice targets we are required to report upon. The score is based upon NHS London Provider
Agency methodology and the indicators are listed in detail in the Glossary (page 11). A green rating would be a score of 1 or below, an amber from 1.0 to 2.9, and
red would be a score of 3 or greater. For February 2008, the trust has a rating of 2. This is due to the Outpatient 13 week target being breached by two patients in
February in Paediatrics. Data on cancelled operations has not been factored into the risk ratings for January 09 and February 09 as these months are still being
finally validated.
Additionally, performance against the Core standards for Better Health are incorporated into the service performance risk rating score, and each core standard that
we are not meeting or have insufficient assurance to demonstrate we are meeting is given a weighting of 0.5. The trust has two standards which are not being
met which are related to Personal Development Plans being in place and Mandatory training Programmes. The two project managers who are now in post
continue to work towards improving performance against these standard.
For the first time data is available around patient experience in maternity services. The data provided show overall scores from the Delivery Suite, Gwillim ward and
the Fetal Medicine Unit averaged together. Each patient is asked five questions tailored to the specific area/ward they attended related to their overall satisfaction
with their patient experience. This data is collected using the handheld Dr Foster patient experience trackers. The trust scored 89% in January and 92% in February.
To strengthen and expand flagship specialist services and network hubs
Updated information submitted to the Trauma Audit Research Network is included. The data, which has been collated from April 08 indicates the number of
patients who had an injury severity score (ISS) of greater than 15, and the mortality of these patients. Initial performance shows that of 73 patients since April
with an ISS of greater than 15, 70 survived which means 96% of the patients survived. More work will be carried out to refine this indicator and seek appropriate
benchmarks where possible through TARN.
To develop an Academic Healthcare Centre with St George's, University of London (SGUL)
The indicators related to developing an Academic Healthcare Centre have been altered so that they are now reported as cumulative figures rather than reporting each
month in isolation. Due to the lack of information previously available historically within R&D, it is hoped that this will start to build up a more useful picture of the
trends emerging.
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Exception Report Continued
To ensure financial sustainability
All indicators under the strategic aim of ensuring financial sustainability are given a risk rating on a scale from 1-5, where 5 is the best possible score. We report
on these indicators to the London Provider Agency monthly, and will be required to report on these to Monitor. These ratings also go to the monthly Finance
Committee with more detailed supporting information.
The financial risk rating for February 09 has deteriorated to a 2 as the trust is now scoring 2 on two of it's financial risk rating criteria which precludes the trust
scoring higher than a 2 for the financial risk rating. The two criteria are the Income & Expenditure Surplus Margin, and the Liquidity Ratio. The budget strategy
incorporates measures to deliver a rating of 3 for 2009/10 ahead of the trust's FT application.
To be an exemplary employer with career and development opportunities which attract, motivate and retain employee talent
The trust's sickness absence percentage is over the 4% target at 4.11% in February 09, however this is an improvement on the January figure of 4.14%. Turnover
and vacancy rate remain classified as amber.
Information from the staff bank is available for February regarding the ratio of bank to agency staff and the percentage fill rate for temporary staff requested.
The ratio of bank to agency staff in February was 1:0.16, with 85.4% of temporary staff coming from staff bank and 14.6% coming from agencies. The percentage
fill rate for temporary staff requested was 85.8% in February, i.e. 85.8% of requests for temporary staff were filled successfully. Performance against both
indicators has improved since reporting started in December 08.
The EWTD Project Plan was taken to the trust Clinical Management Board recently and it was reported there that we are 48% compliant with EWTD 2009. The
next ministerial return is as at the 31 March 2009, and these results should be available by the end of April.
The newly appointed Appraisal Project Manager has been working hard to improve performance against target regarding the number of staff who have been
appraised. Although still under the target of 85%, performance at 59.65% in February demonstrates marked improvement and is consistent with national p
performance.
A new indicator has also been included related to recruitment. The metric calculates the percentage of posts readvertised or open for greater than three months
as a percentage of all vacancies in a given month. For the month of February this figure was 7.5% a slight increase on the January position of 7.2%.
To provide an excellent physical environment fit for the delivery of modern healthcare
Information continues to be provided from Estates and Facilities department on the percentage of Planned Preventative Maintenance being taken out on a monthly
basis. The figure covers Planned Preventative Maintenance (PPM) work covered by contractors, the in-house team, and the PFI contractors in the Atkinson Morley
Wing. The percentage for February was 82%, this was an improvement on both December's figure and January's figure of 79% as we come out of the Christmas and New
holiday period.
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Strategic Aim: To be the provider of choice
Corporate Objective: Cancelled Operations
To achieve national targets priorities & requirements Numbers of cancelled operations and number of breaches of
the 28 day standard
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G) 300
Not
KPI-1.1.1 Service performance risk rating score † Score 3.5 2 <1 250
Avail
No. of patients
200
150
Corporate Objective: 100
50
To maintain and further improve clinical safety, clinical outcomes and the use of evidence-based medicine within
our services and reduce health care acquired infections 0
Q1 Q2 Q3
Month
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G) Number of cancellations on the day or after admission for non-clinical reasons
Number of breaches of the 28 day standard.
Not Q1 Q2
KPI-1.2.1 Severe incidents as a percentage of total incidents* % TBC
Avail 1.74% 2.70%
Not
KPI-1.2.2 Mortality Rate** % 0 0 TBC
Avail
KPI-1.2.3 Emergency readmissions rate % 6.4 7.6 N/A TBC
Percentage uptake of NICE technology appraisals Not
KPI-1.2.4 % 100%
guidance Avail
See note below
Percentage uptake of NICE interventional procedures Not
KPI-1.2.5 % 80% C. Difficile Cumulative Annual Target against Actual 2008/09
guidance Avail
KPI-1.2.6 MRSA bacteraemias No. 2 2.0 1.0 2 350
300
KPI-1.2.7 C.Diff numbers No. 21 5.0 8.0 25
250
200
150
Corporate Objective:
100
To make positive patient experience and the involvement of patients and the public a key focus of our organisation
50
0
Feb Jan Feb Status Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Units Benchmark Trend
08 09 09 (R/A/G)
Cumulative Target Cumulative Actual
Not
KPI-1.3.1 Patient experience on Maternity services for 2008/09 89% 92% 90%
Avail
* Data is provided quarterly. Severe incidents are those classified as Extreme or High, on a scale of: Extreme, High, Moderate, Low or No Harm
** This indicator is now defined related to the number of CRAM signals that occurred within the given month, i.e. No CRAM signals=0, One CRAM signal=1 etc
†
Detailed information about the key access and choice targets which make up the service performance calculator can be found in the glossary at the end of this document
NICE GUIDANCE
Information related to the uptake of technology appraisals and interventional procedures has not been included this month. The systems for ensuring these are adhered to are being strengthened so that
validation is more comprehensive. Therefore January data will not be available until the April report as this indicator will now take more time to process.
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2008 / 2009 Weekly SPC charts with average Year to Date figures displayed
Percentage of Patients Seen within 4hrs (incl WIC) Number of A&E Attendances
2500
100%
2000
98%
•
1500 •
96%
1000
94%
500
92%
YTD Average •
0
90%
Avg UCL LCL SPC special cause flag Avg UCL LCL SPC special cause flag
Number of WIC Attendances Number of Emergency Admissions
700
1400
1300
600
1200
•
1100
500
1000
900 •
800 400
700
600 300
500
400 200
300
200 100
100
0 0
Avg UCL LCL SPC special cause flag Avg UCL LCL SPC special cause flag
These statistical process control charts demonstrate weekly performance related to A&E attendances, emergency admission, WIC attendances and the A&E 4 hour wait
Strategic Aim: To strengthen and expand flagship specialist services and network hubs
Corporate Objective: Mortality for patients with Injury Severity Score >15
To be recognised as a trauma and emergency centre
16
Feb Jan Feb Status
Units Benchmark Trend 14
08 09 09 (R/A/G)
Improved mortality rates for patients with injury severity
KPI-2.1.1 % See chart opposite * 12
score >15
Number of patients
10
Died
8
Corporate Objective: Survived
To support the devolvement of consultant led services into community settings 6
4
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G)
2
First to follow up ratio
KPI-2.2.1 Ratio 1:3.13 1:2.89 1:3.05 TBC TBC 0
(Diabetes, Gastroenterology & Dermatology combined)
39539 39569 39600 39630 39661 39692 39722 39753
KPI-2.2.2 Consultant to consultant referral rates % 30.6% 28.3% 27.6% 26.6% Month
* This data is the initial cut of the data being collected since April as part of the work on becoming a trauma and emergency centre, which is submitted to TARN (Trauma Audit Research Network).
the July 07 result which rated the service as good, and indicates that the implementation of the Transport and Assessment Booking (TAB) Team is proving successful. Catering and Domestic services
are also being surveyed and the results will be reported soon.
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Strategic Aim: To develop an Academic Healthcare Centre with St George's, University of London (SGUL)
Corporate Objective:
To ensure the organisation promotes the best interests of its patients and the communities that it serves through
co-ordinated planning and development of clinical services, teaching, training and research, to improve patient
care and clinical outcomes
Feb Jan Feb Status
Units Benchmark
PLEASE NOTE ALL FIGURES ARE CUMULATIVE 08 09 09 (R/A/G)
KPI-3.1.1 Trust research income Income (£) TBC
No. of new clinical research projects approved (as host Not Not
KPI-3.1.2 No. N/A 204 220
or sponsor) on St George's site (SGUL+SGHT)† Avail Avail
Number of research projects on St George's site funded Not Not
KPI-3.1.3 No. N/A 36 40
by NIHR or partner organisations*† Avail Avail
Not Not
KPI-3.1.4 Number of new commercial contracts No. 22 35 37
Avail Avail
Corporate Objective:
To ensure all research activity complies with statutory requirements and best practice
Feb Jan Feb Status
* The starred indicator is currently under construction Units Benchmark
08 09 09 (R/A/G)
Number of clinical trials (SGH & SGUL) audited per
KPI-3.2.1 Ratio N/A 0 0 10%
year†
*Partner organisations include other areas of government, NIHR non-commercial partners (who award funds in open competition with high quality peer review, who fund research that is clear value to the NHS
and who take account of DH/NHS priorities and needs
†
Grant awards are attributed to the employer of the investigator - which does not reflect the true level of patient-related clinical research activity on the St George's site, so Trust and SGUL data are combined.
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Strategic Aim: To ensure financial sustainability
Corporate Objective:
To achieve our financial targets and improve financial risk rating
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G)
Not
KPI-4.1.1 Financial risk rating (Forecast Outturn) Score 3 2 3
Avail
Not 1.9m 0.3m
KPI-4.1.2 Variance from target £m 0
Avail Deficit Deficit
Corporate Objective:
To take the necessary steps to position the organisation for achievement of Foundation Trust status
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G)
Risk Not
KPI-4.2.1 Underlying Performance (EBITDA margin as %) 3 3 3
Rating Avail
Risk Not
KPI-4.2.2 Achievement of Plan (EBITDA achieved as a % of plan) 4 5 5
Rating Avail
Financial Efficiency (Return on assets excluding dividend Risk Not
KPI-4.2.3 3 3 3
(%) and I&E surplus margin net of dividend (%) Rating Avail
Risk Not
KPI-4.2.4 I&E Surplus Margin 2 2 2
Rating Avail
Liquidity Ratio (cash in hand expressed as number of days Risk Not
KPI-4.2.5 3 2 3
operating expenses) Rating Avail
KPI-4.2.6 Capital Expenditure* £ TBC*
* Regarding capital expenditure, the construction of this indicator is still being confirmed
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Strategic Aim: To be an exemplary employer with career and development opportunities which attract, motivate and retain employee talent
Corporate Objective: Appraisal rates against trajectory
To ensure we meet statutory employment duties, workforce targets and compliance with external assessments
Appraisal Rates (%)
Feb Jan Feb Status 100
Units Benchmark Trend
08 09 09 (R/A/G) 90
Sickness Absence Percentage* 80
KPI-5.1.1 % 4.41 4.14 4.11 <4%
(April 08 data)
% Appraisal completed
70
KPI-5.1.2 Turnover Rate % 13.25 13.85 13.82 <12% 60
50
KPI-5.1.3 Vacancy Rate** % 9.25 9.62 9.55 <7%
40
Not 30
KPI-5.1.4 Ratio of bank to agency staff Ratio 1:0.17 1:0.16 TBC
Avail 20
Not
KPI-5.1.5 Percentage fill rates for temporary staff requested % 86.8% 85.8% TBC 10
Avail
0
Percentage of rotas compliant with the European At April 08 - 97.4% compliant Apr- May- Jun- Jul-08 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
KPI-5.1.6 %
Working Time Directive (EWTD 2004 - 56 hours) At October 08 - 99.5% compliant 08 08 08 08 08 08 08 08 09 09 09
Percentage of rotas compliant with the European At April 08 - 32.4% compliant Month
KPI-5.1.7 %
Working Time Directive (EWTD 2009 - 48 hours) At October 08 - 44.9% compliant
Target Appraisal Rate
Corporate Objective:
To support our workforce through a challenging year
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G)
KPI-5.2.1 Non-medical appraisal rates % 25.71 56.77 59.65 85%
Not
KPI-5.2.2 Recruitment turnaround metric*** % 7.2 7.5 TBC
Avail
* Sickness absence percentage is reported one month in arrears to allow time for processing
** Vacancy rate is calculated as the difference between the overall trust establishment, and the number of staff in post
*** This metric looks at the % of posts readvertised or open for greater than 3 months as a percentage of all vacancies in a given month
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Strategic Aim: To provide an excellent physical environment fit for the delivery of modern healthcare
Corporate Objective:
To ensure compliance with statutory and mandatory duties, regulations and the requirements of external assessments
Catering Survey 2008
Feb Jan Feb Status
Units Benchmark Trend
08 09 09 (R/A/G) Key question "how would you score the catering service?
Percentage of Planned Preventative Maintenance Not
KPI-6.1.1 % 79 82 >90 Overall - How would you score the catering service?
completed* Avail
Not 25
KPI-6.1.2 Number of non-patient safety incidents No. 95 122 87 TBC TBC
Avail
Not 20
KPI-6.1.3 Number of estates related complaints No. 4 3 4 TBC
Avail
15
Not
(%)
KPI-6.1.4 Number of estates related SUIs reported in month No. 0 0 0
Avail
10
2008 Catering Survey Key Question - Overall how do
KPI-6.1.5 % Average response - "Good" 5
you rate the catering service? **
Trustwide percentage of mixed sex bays 0
KPI-6.1.6 % 23.35% 17.74% 17.74% 0%
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Trustwide percentage of mixed sex bays minus
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Ex
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KPI-6.1.7 exclusions - HDU, ICU, Paeds, Telemetry % 9.17% 4.90% 4.90% 0%
ar
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** Most recent survey results are still 2008 Catering survey: 988 in-patient surveys issued – 266 returned = 27% response rate
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Glossary
KPI 1.1.1 Service Performance Risk Rating Score Construction February 2009
Target Weighting Thresholds Relevant trusts Status Score
Maximum waiting time of 31 days from diagnosis to treatment for 1 98% Acute No breach 0
all cancers
Maximum waiting time of 62 days from urgent referral to treatment 1 95% Acute No breach 0
for all cancers
Maximum waiting time of 6 months for inpatients 1 99.97% Acute No breach 0
Maximum waiting time of 13 weeks for outpatients 1 99.97% Acute Breach 1
MRSA year-on-year reduction (year-end target) # 1 0 Acute No breach 0
18-week maximum wait by 2008 # 1 N/A Acute No breach 0
Sexual health - 48-hour access to GUM clinics by 2008 # 1 N/A Acute No breach 0
Implementation of choice and booking - convenience and choice - 1 100% Acute No breach 0
elective (inpatient and daycase) and outpatient booking
Maximum waiting time of 4 hours in A&E from arrival to admission, 0.5 98% Acute No breach 0
transfer or discharge
Patients with operations cancelled for non-clinical reasons to be 0.5 99% Acute Validated data not available for February 09
offered another binding date within 28 days
People suffering heart attack to receive thrombolysis within 60 0.5 68% Acute No breach Not relevant for this trust
minutes of call type - PPCI performed
Maximum waiting time of 3 months for revascularisation 0.5 99% Acute No breach 0
Maximum waiting time of 2 weeks from urgent GP referral to first 0.5 98% Acute No breach 0
outpatient appointment for all urgent suspect cancer referrals
Maximum waiting time of 2 weeks for rapid access chest pain clinics 0.5 98% Acute No breach 0
Minimising delayed transfers of care by 2008 0.5 No more than Acute No breach 0
3%
Each national core standard 0.5 N/A All 2 breaches 1
Total Score: 2
The service performance risk rating score is based on the above indicators listed. Each indicator has been given a weighting and if a breach
is incurred in the relevant month against an indicator this weighting consitutes the score for that indicator. Each national core standard for better
health that is breached is also given a weighting of 0.5.
The above weightings are the same as those used for the quarterly risk ratings submitted to the Provider Agency. Additionally, they were the same
as those outlined in Appendix B of the Monitor compliance framework. However it should be noted, that Monitor have recently changed their weightings
and hence St George's has also updated any weightings that were 0.4 to 0.5.
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