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									                                       Key Performance Indicators
                                               August 2009
                                             Reporting on July 2009




                                                   Our Vision

                             To improve the health and well being of the communities we serve




Key Performance Indicators
Aug 2009                                                                                        1]
Monitor Compliance                        Title                         Director Lead    Jul-09     Jun-09      May-09
       KPI 2         7 day follow up rates by locality                  Angie Mason                              
       KPI 3         Delayed Discharges / transfer of care by           Angie Mason                              
                     locality Sex accommodation
       KPI 19        Single                                                  All                                 
 Key Performance
                                          Title                         Director Lead    Jul-09     Jun-09      May-09
     Indicator
       KPI 1         Outpatient waiting time by locality                Angie Mason                              
      KPI 4          % carers with a care plan by locality              Angie Mason     TBD 09/09   TBD 09/09   TBD 09/09
      KPI 5          Cost Improvement Plan                               Peter King                              
      KPI 6                                                              Peter King
                                                                                                                 
      KPI 7          Cash flow                                           Peter King                              
      KPI 8          Debtors and creditors                               Peter King                              
                     Gross margin and earnings before interest,
      KPI 9                                                              Peter King                               
                     taxes depreciation and amortisation                                   
     KPI 10          Financial risk forecasts                            Peter King                              
     KPI 11          Capital Programme                                   Peter King                              
     KPI 12          % PDR completion                                   Kate Truscott                            
      KPI 13         Uptake of training                                 Kate Truscott                            
      KPI 14         Sickness/Absence Levels                            Kate Truscott                            
                     Market share of services linked to marketing
      KPI 15
                     strategy
                                                                        Richard Hill                             

      KPI 16         Annual Health Check Update                              All                                 
                     Admission to inpatient services had access to
      KPI 17                                                                 All                                 
                     crisis resolution home treatment teams
                     Maintain level of crisis resolution set in 03/06
      KPI 18         planning round (or subsequently contracted              All                                 
                     with PCT)
KPI 1 Outpatient waiting time


Strategic Goal

To provide services that are safe, person centred, delivered in appropriate environments and sensitive to the needs of the individual          Trend

                                                                                                                                        July           
Measure/Key Performance Indicator - Target 100% seen within 11 weeks                            Outpatient waiting time                 June           
                                                                                                                                        May            


KPI supplied by: Information Management Team                           Lead Director : Director of Nursing Service Delivery

No GP written referrals for outpatient appointments were received in June 2009.

There have been no breaches of the 11 week wait from GP referral for outpatient appointments with Consultants.




Forecast
Systems are well established to ensure that the 11 week target will be met into the future



Monitor Service Line                                                   Traffic Light rating -
Clinical quality and patient satisfaction
KPI 2 7 day follow up rates by locality


Strategic Goal

To provide services that are safe, person centered, delivered in appropriate environments and sensitive to the needs of the individual          Trend

Measure / Key Performance Indicator - Target 95%                                        7 day follow up rates by locality                July           
                                                                                                                                         June           
Final figures for June 2009                Figures for July 2009                                                                         May            
Hull Business Unit                  93.18% Hull Business Unit                      95.83%
East Riding Business Unit          100.00% East Riding Business Unit              100.00%
Trustwide                           96.00% Trustwide                               97.87%

Hull Business Unit - 95.83%
Improvement from last month. One breach from AOT in Hull. The Team Manager has produced an Adverse Incident and has
undertaken a root cause analysis to reduce the risk of future breaches. An Action Plan is in place.
Forecast
See front sheet for recommendations




Scoring Threshold                                                    Traffic Light Rating
< 95% = 1
> 95% = 3
KPI 3 Delayed Discharges / transfer

Strategic Goal

To retain the confidence of patients, carers and commissoners by upholding the principles of the NHS                                         Trend

Measure / Key Performance Indicator - Below 7.5%                     Delayed discharges/transfer of care                                  July       
                                                                                                                                          June       
KPI supplied by: In patient unit managers                            Lead Director : Director of Nursing Service Delivery                 May        


During July 2009 14 people experienced a delay in their discharge within the Trust, 11 people in the Hull Business Unit and 3 people in
the East Riding Unit.
This equates to a rate of 6.5%
Care Quality Commission will only use the NHS data for Annual Healthcheck and this equates to 0.46 % (1 divided by 214 )

Forecast : See PIP page 7


Scoring Threshold                                                    Traffic Light Rating
<7.0 = 3
7.0 - 7.4 = 2
>7.5 = 1



See Performance Improvement Plan
Performance Improvement Plan - KPI 3: Delayed Discharges



Definition:          A delayed transfer of care from acute or non-acute (including PCT and mental health) care    Rating
                     occurs when a patient is ready to depart from such care and is still occupying a bed. A
                     patient is ready for discharge/transfer when:
                     a) A clinical decision has been made that the patient is ready for discharge/transfer AND
                     b) a multi-disciplinary team decision has been made that the patient is ready for
                     discharge/transfer AND
                     c) the patient is safe to discharge/transfer and no longer requires inpatient treatment.

Rationale:           There is an expectation that delays in discharges will be kept to a minimum
Target               Below 7.5%                  actual 6.5%
Monitored by:                               Source                                                  Trust Lead: Angie Mason
                              1 None
Performance Issues

Commentary /         A definition of delayed discharge is in the process of being agreed by the Modern Matron Group following which
Narrative :          this definition will be used in a consistent manner across the whole Trust.
                                                                                                     Start date     Completion date
                              1 All people in Learning Disability facilities who are ready
                                for discharge have an action plan to enable their
Action(s) required              discharge                                                                              01/03/10
                              2 Re-provision plans for named individuals to keep to
                                agreed project plan timescale                                                          ongoing
                              3 Performance team to co-ordinate review of all delayed
                                discharges, ensuring that they fit the DoH criteria                    01/07/09        ongoing
Responsibility       UGM'S
Timescales           This PIP will be removed if recorded as a green indicator next month.
KPI 4 % carers with a care plan

Strategic Goal

To provide services that are safe, person centred, delivered in appropriate environments and sensitive to the needs of the individual

Measure / Key Performance Indicator = TBD 31/7/09                    % carers with a care plan

KPI supplied by : iPM                                                  Lead Director : Director of Nursing Service Delivery
For the period of July 2009 the East Riding Business Unit approached a total of 25 carers with a view to a carers' assessment. (6 adult
Carers' meet criteria - 25 met the criteria = 100%
Assessments offered - 5 were not offered, therefore 20 carers were offered an assessment = 80%
Assessments accepted - 9 (45%) ( 1 in adult and 8 in Old Age Psychiatry .)
Assessments declined - 11 (55%) ( 11 in Old Age Psychiatry)
For Hull only there are some Carers Assessments that have to be inputted but these go back over a year . The Performance Advisor for
Hull will be inputting this data and will be reported on in the September report.

Total number of carers offered  714                                  work to raise awareness with
Carers with assessments on iPM 187                                   clinicians via UGMs will be on-




Forecast - : Please see PIP - Page 9


Scoring threshold                                                    Traffic Light rating :
< 85% = 1
85 - 89% = 2
90 - 95% = 3
                                                                                              TBD by 09/09


See Performance Improvement Plan
Performance Improvement Plan - KPI 4: Carers Assessments


                     Number of assessments carried out for people who give substantial input into a service
Definition:          users care and who accepts the offer of an assessment                                       Rating       TBD
                     The Carers (Recognition and Services) Act 1995 and the Carers (Equal Opportunities) Act 2004 state a carers
Rationale:           assessment must be offered to carers who provide "substantial and regular " care.
Target               95% or over            Actual : 100%
Monitored by:                               Source                                                   Trust Lead: Head of Patient
                              1 iPM has been developed to collect carer assessment information
Performance Issues            2 Confusion as to who is lead agency for the assessments
                              3 Definition of 'carer' needed to enable performance to be reported
Commentary /         Operating framework refers to a new national carer's strategy being developed.
Narrative :          Newly updated Care Programme Approach identifies importance of carers assessment and care planning.
                                                                                                    Start date    Completion date
                              1 Training Lead to develop training guide for admin to                                Completed
Action(s) required            2 Work with Head of Patient Experience to raise profile of              01/08/09       30/09/09


Responsibility       UGM's and Head of Patient Experience
Timescales           see above
Trend:
KPI 5, 6, 7, 8, 9, 10, 11             Finance


Strategic Goal

To provide and develop services that are efficient and cost effective and responsive to the needs of the people who use them             Trend

Measure / Key Performance Indicator                                 KP1 5 - Cost Improvement Plan                              Good   July       
                                                                    KPI 6 - Income and expenditure by Business Unit            Fair   June       
                                                                    KP1 7 - Cash Flow                                          Good   May        
                                                                    KP1 8 - Debtors and creditors                              Good
                                                                    KP1 9 - Gross margin and earnings before interest,         Good
                                                                    KPI 10 - financial risk and forecasts                      Good
                                                                    KPI 11 - Capital Programme                                 Good

KPI supplied by : Peter King                                        Lead Director : Director of Finance

Forecast : See Finance Report




                                                                    Traffic Light rating -
5% ahead of target = 4
On target = 3
<= 10% off target = 2
> 10% off target = 1
KPI 12 % PDR completion

Strategic Goal

To be an excellent employer maximising the skills and talents of our staff with a workforce that feels valued                                 Trend

Measure / Key Performance Indicator - Target 100%                     % PDR completion                                                 July      
                                                                                                                                      June       
KPI supplied by : HCC Staff Survey 2007                            Lead Director - Director of Human Resources and Diversity          May        
55% of staff have now had a PDR linked to KSF, and a reduction of 4% to 30% of these recorded PDRs are currently out of date @ 31st
July 2009. 88% of staff now have an agreed KSF Outline, with additional Outlines now in draft form/dates in diaries for others.

A PDR census is currently underway to establish a benchmark of actual PDR activity - refer to PIP




Forecast - Please see PIP



Scoring Threshold                                                     Traffic Light Rating -
<75% = 1
75 - 84% = 2
85 - 95% = 3



See Performance Improvement Plan
Performance Improvement Plan - KPI 12: PDR completion


                      The number of completed Personal developmental plans against the number of staff
Definition:           expressed as a percentage                                                                       Rating
                      Annual personal development planning is essential to maintain a skilled workforce which can deliver high quality
Rationale:            services both clinical and non-clinical. This is also linked to the use of Knowledge Skills Framework
Target
Monitored by:                              Source                                                   Trust Lead: Kate Truscott
                               1 Non compliance with system notifying training department of completed PDR's
Performance Issues

Commentary /
                      Results of PDR census to be reported to the September Board with Action Plan.
Narrative :

                                                                                                        Start date    Completion date
                               1 There is a need to report on the number of all Personal
                                 Development Plans agreed, not just those with KSF.                                       ongoing

                               2 All new job descriptions are competency based and all
                                 current clinical and administration job descriptions are                                31/12/09
                                 being updated to competency based job descriptions.
Action('s) required            3 The Organisational Development Team within the new
                                 structure will be tasked in focusing on completions of                                  31/12/09
                                 The and PDR activity
                                 KSF Organisational Development Team to lead on a
                               4 high profile launch of the reviewed PDR Policy,
                                 Workforce Consistency Protocol, new Standard                                            31/12/09
                                 Paragraphs and New Competency based Job
                                 Descriptions.
Responsibility        All Trust Managers
KPI 13         Uptake of Mandatory Training


Strategic Goal

To be an excellent employer maximising the skills and talents of our staff with a workforce that feels valued                                  Trend

Measure / Key performance Indicator - Target 85%                                                        Uptake of training                  July       
                                                                                                                                            June       
KPI supplied by: Carey Mason                                                    Lead Director : Director of Human Resources and Diversity   May        
                         Apr-09 Movement                      May-09 Movement      Jun-09 Movement                   Jul-09 Movement
Infection Control          37%  1%                             45%  8%             46%  1%                          44%  2%
Fire                       60%  1%                             66%  6%             65%  1%                          70%  5%
Manual Handling            83%    2%                           83%   0%            83%      0%                      85%  2%
Health & Safety            64%  1%                             68%  4%             70%  2%                          72%  2%



Forecast - Please see PIP



Scoring Threshold                                                               Traffic Light Rating
> 85% = 4
>75% = 3
<75% with improvement plan = 2
< 75% without an improvement plan = 1


See Performance Improvement Plan




                                                             MANDATORY TRAINING - PERCENTAGE COMPLIANCE
                                        r attending




                                                      1600
                                                      1400
                                                      1200
                                                      1000
                                                       800
                                                       600
Performance Improvement Plan - KPI 13: Uptake of mandatory training


Definition:                                                                                                                                                          Rating


Rationale:
Target                                                      85%                                   70% for Fire                                             72%
                                                                                                                                  44% Infection 85% Man & Hand Health & Safety
Monitored by:                                                       Source                        Training Team                                 Trust Lead: Kate Truscott
                                    1 Mandatory Training
Performance Issues
                                    2 Lack of clarity around what training is mandatory for different professional groups
                                                                     MANDATORY TRAINING - PERCENTAGE COMPLIANCE
                                        Number attending




                                                           1600
                                                           1400
                                                           1200
                                                           1000
                                                            800
                                                            600
                                                            400
                                                            200
                                                              0                                                                                             May-09
                                                                                                                   Manual          Health & Safety
                                                                                          Infection Control
                                                                      Fire (Annually)                           Handling (every          (on                Jun-09
                                                                                             (Annually)
                                                                                                                   3 years)         appointment)
                                                                                                                                                            Jul-09
                                                           May-09            1178               802                  1485               1217
                                                           Jun-09            1164               829                  1485               1245
                                                           Jul-09            1244               780                  1509               1286



                                   Topic                                Refresher Period                      Compliance              Movement on previous month
                                    Fire                                      Annually                           70%                                  5%
Commentary / Narrative :      Infection Control                               Annually                           44%                                  2%
                              Manual Handling                                  3 yearly                          85%                                  2%
                               Health & Safety                           on appointment                          72%                                  2%
                                      Additional provision of training to be timetabled if there is a high                                           Start date        Completion date
                                      uptake for Training is now
                                    1 Mandatorytraining courses.mandated in the standard paragraphs of all                                                                ongoing
                                    2 job descriptions                                                                                                                    31/03/09
Action('s) required



Responsibility             UGM's and Heads of Departments
Timescales
KPI 14 Sickness / Absence Levels

Strategic Goal

To be an excellent employer maximising the skills and talents of our staff with a workforce that feels valued                                    Trend

Measure / Key Performance Indicator - Target 4.5%                                 Sickness/Absence levels Trust wide = 5.24%                  July       
                                                                                                                                              June       
KPI supplied by : ESR reporting                                                   Lead Director : Director of Human Resources and Diversity   May        
                                                                  Sickness Trends 2007 -2009
                              8.00


                              7.00


                              6.00


                              5.00


                              4.00                                                                                                Target
                                                                                                                                  2008
                              3.00                                                                                                2009


                              2.00


                              1.00


                              0.00
                                      Jan    Feb    Mar    Apr     May     Jun       Jul   Aug    Sep    Oct      Nov      Dec
                             Target   4.50   4.50   4.50   4.50    4.50    4.50     4.50   4.50   4.50   4.50     4.50     4.50
                             2008     7.44   6.53   6.38   6.56    5.55    6.09     5.55   4.73   5.82   6.17     5.84     5.77
                             2009     6.29   5.67   5.49   5.02    5.14    5.24




                                                                              % Movement                        Actual %
           Staff Group (Trust)                                                  0.11%                           5.25%
           Hull Business Unit                                                   0.40%                           5.49%
           East Riding Business Unit                                            0.58%                           6.45%
           Specialist                                                           1.61%                           6.76%
           Chief Executive Directorate                                          0.55%                           0.14%
           Finance (Directorate)                                                0.32%                           2.33%
           Medical (Directorate)                                                0.18%                           0.75%
           Nursing and Service Delivery (Directorate)                           0.61%                           6.00%
           Performance and Service Improvement
           (Directorate)                                                           0.90%                        3.57%

           Human Resources and Diversity Directorate                               0.14%                        1.35%

< 4.5% = 4                                                                        Traffic Light Rating
Following trajectory to 4.5% = 3
One off increase above trajectory = 2
More than one month above trajectory = 1
Performance Improvement Plan - KPI 14: Sickness / Absence levels



Definition:                     Whole time equivalent staff off sick against whole time equivalent staff employed                  Rating
                                Sickness absence rates are nationally set targets. The monitoring of the rate can be used to establish where
Rationale:                      there may be stressors and action plans can be developed to alleviate
Target                                           4.5% Actual                       5.25%
Monitored by:                                             Source                   ESR                                Trust Lead: Kate Truscott
                                          1 Effectiveness of the implementation of Trust absence management policy
Performance Issues                        2 Availability of absence data at all necessary organisation levels
                                          3 Impact on Trust ability to deliver its services
Commentary /                    The overall trend is in line with the trajectory to the 4.5% target level. Figures reported have not been updated
Narrative :                     from last month's KPI due to Payroll being unable to supply July's figures.
                                                              Sickness Trajectory - April 2008 to September 2009

                     7

                     6

                     5

                     4                                                                                                                                   Trajectory
                                                                                                                                                         Actual
                     3

                     2

                     1

                     0
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                                                                                                                            Start date           Completion date
                                         1 Long term absence cases have been reviewed by
                                           Director of Human Resources and the Human Resource
                                           Advisors.                                                                                                ongoing
Action(s) required                       2 A review of the reporting from Payroll to be undertaken                          01/09/2009              ongoing
                                         3 Capability Policy needs to be implemented if a                                           8/1/2008        ongoing

                                         Old Directorates still on ESR to be refreshed by
                                       4 31 August 2009                                                                                             31/08/09
Responsibility                  UGM's and Heads of Departments
Timescales
KPI 15 Market share of services linked to marketing strategy

Strategic Goal
To provide and develop services that are efficient, cost effective and responsive to the needs of the people who use them.
                                                                                                                                              Trend

Measure / Key Performance Indicator                                      Market share of services linked to marketing strategy
                                                                                                                                           July       
KPI supplied by: Business and Planning                                   Lead Director : Associate Director of Business and Marketing      June       
                                                                                                                                           May        
    ▪      YAS - agreed to amend current contract £ to reflect last years use and correct recent overpayments. We with then sign the
           contract. YAS - to supply split contract values to reflect partner use - we push ER to pay fair amount.
    ▪      YAS - patient survey completed, results presented, average 5 users/month. Used to drive programme above.
    ▪      Share Services - 2008/09 contracts issued, 2009/10 to follow with actual costs. Will push to split Block Contracts to isolate
           shared services and facilitate efficient management and increase funding where needed.
    ▪      New KPI's for reporting purposes to be developed in relation to market share
    ▪      Potential income from various commissioning organisations to be formally researched and mapped out as opportunities.
    ▪      Initial discussion with Bradford MH Trust re tender opportunity for N Yorks MH Services - Joint Team and follow-up to follow

Smart Objectives:
         Quantify the Regional Market for MH Funding: £/by source
          Assess our market share %
          Investigate and quantify service initiatives for innovation
          Formalise business cases to support
          Assess services and create a market position to indicate new offering, expansion, extension, contraction
          Investigate and position competitors
          Make recommendations for cooperation and/or acquisition

Forecast:
Current prospects look promising. Tender review meeting held. Associate Director post now filled.
Monitors Service Line                                                    Traffic Light Rating -
Clinical and administrative efficiency
KPI to be developed in line with Marketing plans
KPI 16 Annual Health Check update
Strategic Goal
To provide services that are safe, person centred, delivered in appropriate environments and sensitive to the needs of the individual.
Through the use of evidence based practice provide high quality services, to establish a reputation for exceptional standards of care.                    Trend

Measure: Key Performance Indicator                                          Annual Health Check Update
                                                                                                                                                    July          
KPI supplied by:                                              Lead Directors : Medical Director                                                     June          
ALE : ALE data has now been ratified and the Trust has maintained a strong rating of 3
                                                                                                                                                    May           
Health Care Standards - We have submitted our declaration within the timescale. The Declaration has now been published on our website as per
the required timescale and Care Quality Commission will check on 22nd May 2009 . The Trust is currently going through the ratification process of
the evidence submitted for the Health Care Standards and this will be completed week commencing 3 August 2009.

The verification process started on 20 May 2009
The following evidence has been verified so far:
Learning Disability
100% of people with care plan
Mental Health - NHS Trust Staff Satisfaction
Trust percentage is 3.576 against national average of 3.549. Total number of respondents 391
Experience of Patients/survey
Trust scored above the national average in all areas and the number of respondents was 107
Data Quality on ethnic Group
Following email from CQC, revalidated data quality on ethnic group now stands at 98.02% compared to 97.576% previously recorded
Drug Users in effective treatment
Trust achieved green in all areas




Forecast : Expectation of maintaining ratings of excellent and good ( Quality of Service and use of resources respectively)



Monitors Service Line                                                       Traffic Light Rating
                                                                                 Quality of Services                    Use of Resources
KPI 17 Admissions to inpatient services had access to crisis resolution home treatment teams

Strategic Goal

To provide and develop services that are efficient, cost effective and responsive to the needs of the people who use them                    Trend

Measure: Key Performance Indicator                                  Have a fully compliant PIG model team in Hull with DoH Fidelity and
                                                                                                                                          July       
KPI supplied by: Dr Denise Brown and iPM                            Lead Director : Director of Nursing Service Delivery                  June       
                                                                                                                                          May        
July 2009


East Riding Business Unit had 96% Gatekept in the month and Hull Business Unit had 97%. Trustwide the figure is 96.5%. We have
rated on Trustwide figure.


Forecast: Processes in place to ensure compliance into the future


Monitors Service Line                                               Traffic Light Rating
Gate-kept admissions
95-100% Gate-kept = 3
90-94% Gate-kept = 2
<90%Gate-kept = 1


See Performance Improvement Plan - Page 19
           Maintain level of crisis resolution teams set in 03/06 planning round (or subsequently contracted
KP18       with PCT)


Strategic Goal

To provide and develop services that are efficient, cost effective and responsive to the needs of the people who use them                        Trend

Measure: TAB                                                                                                                                  July       
                                                                                                                                              June       
KPI supplied by:                                               Lead Director : Director of Nursing Service Delivery                           May        
All CRH teams meet the PIG Model compliance requirements or has Fidelity and Flexibility with an agreed plan with PCT to be fully compliant
within this year.




Forecast: This target is met and will continue to be met in the future


Compliance to PIG Model = Excellent                                      Traffic Light Rating -
Non- compliance to PIG Model = Weak
KP19       Single Sex Accommodation



Strategic Goal
Through the use of evidence based practice provide high quality services that are safe, person centred, delivered in appropriate
environments and sensitive to the individual needs.                                                                                          Trend

Measure: Number of Units meeting the requirements                                                                                         July       
                                                                                                                                          June       
KPI supplied by: Dave Knapp                                          Lead Director : Director of Nursing Service Delivery                 May        

Privacy and Dignity - Bid to the SHA has been successful £105K. Work completed by mid July 2009. Work required involves minor
structural changes to 6 in patient areas to enhance privacy, dignity and safety plus a review of accommodation of acute treatment
accommodation in Hull which led to single sex units being developed. Review of and placement (where needed) of a single gender
signage across all in patient facilities also occurred. SHA visited to review patch wide (PCT/Acute Trust/Mental Health Trust) progress
July and were positive about the progress made.

All Trusts must be compliant with single sex accommodation requirements by 2010. Patch wide meetings with Acute Trust and PCT's
including patient and user involvement.
* Department of Health Minimum Standards
      ▪     No shared sleeping accommodation
      ▪     No shared toilets
      ▪     Patients do not have to pass through opposite sex facilities to access their own.

Forecast: The Delivering Same Sex Accommodation (DSSA) programme is expanding with further guidance & toolkits for Trusts to
          utilise in support of meeting this policy initiative. This will focus on ensuring ongoing progress especially around the
          organisational cultures in relation to delivering services that promote privacy and dignity.

Compliance with DoH minimum standards* plus progress                 Traffic Light Rating -
on plans to improve privacy & dignity = 4
Compliance with DoH minimum standards* = 3
Non-compliance (anywhere) with DoH minimum standards* = 1

								
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