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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 v n ne ne ly c ch ly il il t t eb t t ct ay ay ep ep us us o pr pr Ja e Ju Ju O N Ju Ju ar D M F M A A ug ug S S M A A 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