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1 of 21 Board Integrated Performance Report - June 2017
1.2 NHS Improvement
Segment
Provisional
Board Integrated Performance Report
29 June 2017
May 2017 Data
Good
1.1 CQC Rating 1.3 NHS Improvement
Use of Resources
Provisional
1
Agenda Item: 13
Lead Director: Director of Finance,
Contracting and Facilities
Presented For: Assurance
1
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
2 of 21 Board Integrated Performance Report - June 2017
The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in
delivery of a broad range of key targets and indicators.
Board Action Key Highlights Slides
NHS Improvement Indicators
Assurance • NHS Improvement indicators have been met for May 2017, for those indicators where final data is available. 4 - 5
Quality
Information
Exceptions
• In line with the agreed changes to the Integrated Performance Reporting cycle, summary data only is provided
this month. Full data and narrative focusing on actions and their impacts will be provided quarterly.
• Reasons for and actions to address the reduction in Information Governance training compliance and staff
receiving appraisal will be discussed at the June performance meetings for business units and corporate
functions. Information Governance training compliance is likely to have been impacted by the decision at the
last Information Governance Steering Group Meeting to review the staff that were previously classed as
exceptions for compliance purposes and to include all staff groups on ESR.
7 – 12
8
Business Unit
Information • A new service dashboard is included. This will be provided quarterly to support the Board’s holistic
understanding of performance, with increased visibility of performance at service level and to support
scheduling in-year of Board quality and safety visits. Board members’ feedback on the initial content is
welcomed. A quarterly activity report is also being developed, for inclusion from September 2017.
• The correlation of quality, workforce, activity and finance information by service does not suggest any new
themes or trends.
13
Change Programme
Exceptions
• The 2017/18 Change Programme provides governance, monitoring and assurance for eight transformation
projects delivering significant service transformation and change. Of the eight projects:
- Four are rated red (corporate benchmarking; roster savings; mental health acute and community; Trust
procurement);
- Four are rated green (adult physical health; estates and facilities; specialist inpatients, dental &
administration; children’s services).
14
Enablers
Information • New slides are included for Informatics and Estates and Facilities for Board discussion and consideration.
Comments would be especially welcomed for Informatics indicators. Both enabling areas will be reported
quarterly to support the ‘strategy’ focus of the Board meeting. Board feedback is sought on the draft content.
18 - 21
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
3 of 21 Board Integrated Performance Report - June 2017
The purpose of this Integrated Performance Report is to assist the Board in assessing the Trust’s performance and progress in
delivery of a broad range of key targets and indictors.
Board Action Key Highlights Slides
Finance
Assurance
Exceptions
• Control Total Performance – 2017/18 Performance: Surplus/(Deficit) Position: A year to date surplus of
£22k compared to a plan deficit of (£665k) gives a favourable £687k variance. A number of Commissioning
for Quality and Innovation (CQUIN) requirements and CIPs are profiled to deliver in the latter part of the
financial year with some implementation plans still being finalised. CIP and CQUIN delivery therefore remain
high risk. The majority of operational pay under spending at month 2 is assessed to be non recurrent with
recruitment activities and increased medical locum costs expected. The 2017/18 forecast is that the Trust will
meet its Control Total of £826k surplus allowing access to a further £752k Sustainability and Transformation
Funding. The executive team agreed to retain a number of financial controls during Quarter 1 pending a
detailed forecast, risk and efficiency review.
• Cash: Cash balances are £3.5m above plan reflecting £0.7m favourable Control Total performance and NHS
Property Services outstanding debts which have now been settled in May 2017 (following full and final
agreement in April 2017).
• Use of Resources (UoR): The actual UoR at month 2 is ‘1’ compared to plan of ‘3’ and reflecting delivery of
an in month surplus rather than deficit plan position.
• CIPs: Detailed project plans are still being finalised for a number of CIP schemes that are profiled to deliver in
the last 6 months of the year. At month 2 CIPs are £310k above plan. Forecast risks of £679k (before high
risk reserve) are expected to require particularly close management.
• Workforce – Agency Controls: All agency expenditure caps have been achieved in month 2 and are
forecast to achieve but with elevated medical locum cost and hourly rate risks flagged. There were 182 price
cap and 198 wage cap breaches during May (5 week month).
• Capital: Capital expenditure was £154k lower than plan in month 2 driven mainly by IM&T, however all
capital schemes are forecast to deliver in full. A £500k capital contingency is available to mitigate in-year
applications and priorities, a number of which are already being considered.
15 - 17
Summary and Recommendations
The report shows good performance in May 2017, including further improvement in sickness absence rate, though with under-performance in
relation to appraisals and information governance training compliance. Whilst year to date financial performance is good we anticipate
elevated financial challenges in quarters 3 and 4 due to phasing of efficiencies and CQUIN targets and as recruitment activities impact.
Correlation of quality (including patient experience and safety related measures), performance, finance, workforce and health & safety
information took place at the Directors’ Business & Transformation meeting and did not identify any themes or trends for Board escalation.
The Board is recommended to consider the exceptions highlighted and note the proposed actions.
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
4 of 21 Board Integrated Performance Report - June 2017
Single Oversight Framework Operational Performance Metrics
Indicator M7: Data is provided in relation to the waiting time element of the new standard for Early Intervention in Psychosis (EIP). This
shows patients who started treatment in May 2017 within two weeks of referral. The number of incomplete pathways (patients waiting) at the
end of May 2017 was 13; 5 of these patients have been waiting for more than two weeks.
Indicator M19: Performance against this standard was assessed as part of the 2016/17 national Commissioning for Quality and Innovation
(CQUIN) indicator, via local and national audits in quarter 4 of 2016/17. The national audit results for inpatient wards and community mental
health services were published in June 2017: the Trust performance significantly exceeded the national target.
Measure
Target
England
Benchmarking
figure
Graph Key
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
80.0%
85.0%
90.0%
95.0%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
90.0%
92.5%
95.0%
97.5%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q1 17/18 Q1 17/18
Outturn Outturn OutturnNumerator
Outturn
Denominator
OutturnOutturn
M3
Maximum time of 18 weeks from point of referral to
treatment (RTT) in aggregate − patients on an incomplete
pathway
92.0% 100.0% 100.0% 657 657 100.0% 89.9 % as of April 17
M5
Patients requiring acute care who received a gatekeeping
assessment by a crisis resolution and
home treatment team in line with best practice standards
95.0% 100.0% 100.0% 118 118 100.0%
98.7% as of
Q3 - 16/17
Next publication date:
TBC
M7
People with a first episode of psychosis begin treatment
with a NICE-recommended package of care within 2
weeks of referral
50.0% 64.2% 75.3% 69.5% 90.0% 70.8% 35 44 79.5%
Ensure that cardio-metabolic assessment and treatment
for people with psychosis is delivered routinely in the
following service areas:
a) Inpatient Wards 90.0% 98.0%
b) Early Intervention in psychosis services 90.0% 94.0%
c) Community mental health services (people on Care
Programme Approach)65.0% 96.0%
National
Benchmark
Indicator
No.
Indicator
Target Apr May Jun Graph
M19
80.0%
85.0%
90.0%
95.0%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
90.0%
92.5%
95.0%
97.5%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
5 of 21 Board Integrated Performance Report - June 2017
Indicator M20a: This Mental Health Services Data Set (MHSDS) data completeness indicator comprises NHS number, date of birth,
postcode, gender, GP and commissioner. The Trust is still awaiting clarification from NHS Improvement and NHS Digital about the data
definitions to be used to calculate performance. Pending this, data has been provided based on internal calculations from the MHSDS.
Indicator M20b: In January 2017, NHS Improvement confirmed that the MHSDS indicator for priority metrics will only assess performance
on three elements – ethnicity, accommodation status and employment status. The Trust is still awaiting clarification from NHS Improvement
and NHS Digital about the data definitions to be used to calculate performance for these three elements.
Indicators M21, M10, M11: Within the Single Oversight Framework, Trust performance for Improving Access to Psychological Therapies
(IAPT) is assessed quarterly, based on final data published by NHS Digital. NHS Digital is due to publish final data for 2016/17 quarter 4 on
22 June 2017.
Single Oversight Framework Operational Performance Metrics
Measure
Target
England
Benchmarking
figure
Graph Key
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Q2 16/17 Q3 16/17 Q4 16/17 Apr May Jun Q1 17/18 Q1 17/18 Q1 17/18
Outturn Outturn OutturnNumerator
Outturn
Denominator
OutturnOutturn
M20a
Complete and valid submissions of metrics in the monthly
Mental Health Services Data Set Submissions to NHS
Digital:
* Identifier metrics
95.0%
99.5%
June Final
data
99.5%
September
Final data
99.5%
December
Final data
97.1%
Jan Provisional
Next publication date:
22/06/2017
M20b
Complete and valid submissions of metrics in the monthly
Mental Health Services Data Set Submissions to NHS
Digital:
* Priority metrics
85.0%
M21Proportion of people completing treatment who move to
recovery (from IAPT minimum dataset)50.0% 52.8% 51.8%
55.6%
(Provisional)
53.6%
(Provisional)210 470 44.7%
51.1% as of Feb 17:
Next pub,ication date
22/06/17
M10
waiting time to begin treatment (from IAPT minimum data
set)
- within 6 weeks
75.0%94.2% 94.4%
96.3%
(Provisional)
95.6%
(Provisional)
98.3% as at
Feb 17
Next publication date:
22/06/17
M11
waiting time to begin treatment (from IAPT minimum data
set)
- within 18 weeks
95.0%98.4% 99.3%
99.1%
(Provisional)
99.1%
(Provisional)
98.7% as at
Feb 17
Next publication date:
22/06/17
TBC
TargetNational
BenchmarkGraph
Indicator
No.
Indicator
60.0%
70.0%
80.0%
90.0%
100.0%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
85.0%
87.5%
90.0%
92.5%
95.0%
97.5%
100.0%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
40.0%
45.0%
50.0%
55.0%
60.0%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
6 of 21 Board Integrated Performance Report - June 2017
Airedale NHS Foundation Trust and Bradford Teaching Hospitals NHS Foundation Trust performance against the national standard for
Accident and Emergency (A&E) waits is provided to the Board for information. The Trust contributes to delivery of the target through a range
of services and interventions. The Trust is working actively with both Airedale NHS Foundation Trust and Bradford Teaching Hospitals
Foundation Trust on providing support within A&E departments and developing pathways designed to avoid admissions.
NHS England and NHS Improvement designated the West Yorkshire system as an urgent and emergency care ‘Acceleration Zone’. The key
requirement of this is to deliver transformation and interventions will which support delivery of urgent and emergency care targets across
West Yorkshire, including the A&E 4 hour target. National funding allocated to deliver transformation and interventions has been extended
into quarter 1 of 2017/18.
Accident and Emergency Waiting Times
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Indicator
No. Indicator TargetQ1
16/17
Q2
16/17
Q3
16/17
Q4
16/17July Aug Sep Oct Nov Dec Jan Feb Mar Apr
Total attendances within 4 hours 13,368 13,174 13,180 13,840 4,628 4,232 4,314 4,375 4,164 4641 4,416 4,323 5,101 4,960
M18a% of A&E attendances where service
user was admitted, transferred or
discharged within 4 hours
95% 93.3% 90.2% 89.2% 91.9% 90.3% 88.8% 91.3% 90.2% 90.8% 90.1% 88.4% 94.5% 93.1% 93.3%
Total attendances within 4 hours 31,297 30,250 28,941 29,091 10,714 9,774 9,762 9,792 9,516 9,633 9,612 8,981 10,498 9,709
M18b% of A&E attendances where service
user was admitted, transferred or
discharged within 4 hours
95% 90.8% 89.4% 84.0% 89.8% 89.8% 90.1% 88.2% 85.0% 85.1% 82.1% 86.8% 90.1% 92.4% 87.4%
Airedale NHS Foundation Trust
Bradford Teaching Hospitals NHS Foundation Trust
7 of 21 Board Integrated Performance Report - June 2017
Indicator No.
16/17 Out-turn
This month's performance 17/18 Year
to Date
Q3 96 1 5
Serious Incident Numbers
0
2
4
6
8
10
12
14
16
May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17 Apr - 17 May - 17
May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17 Apr - 17 May - 17
Under age admission 0 1 0 0 1 0 0 0 0 0 0 0 0
Suspected Suicides 4 0 6 1 4 4 3 3 1 2 0 1 1
Homicides 0 0 0 0 0 0 0 0 0 0 0 0 0
Absconders/escape/AWOLs 0 0 0 0 0 0 0 0 0 0 0 0 0
Pressure Ulcers 8 4 6 5 5 7 6 1 0 0 0 0 0
Serious incidents Other 2 1 3 0 0 0 1 2 0 0 0 3 0
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
8 of 21 Board Integrated Performance Report - June 2017
Workforce – Appraisal & Mandatory Training
Indicator
No. Indicator
16/17
outturn
17/18
Target Numerator Denominator
Current
Performance
FOT
17/18 Graph
Q17
% Mandatory training
(excl. Information
Governance
Compliance)
88.96% 80.00% 6414 7772 82.53%
Q17a
% Information
Governance Training
- Substantive Staff
Only
98.46% 95.00% 2083 2423 85.97%
Q17b % Information
Governance Training
- Tertiary Staff Only
96.51% 95.00% 286 307 93.16%
Q17c
% Information
Governance Training
- Substantive and
Tertiary Staff
Combined
98.28% 95.00% 2369 2730 86.78%
Q18 % Staff Receiving
Appraisal 83.77% 80.00% 1854 2391 77.54%
80.0%
85.0%
90.0%
95.0%
100.0%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
80.00%
85.00%
90.00%
95.00%
100.00%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
80.0%
85.0%
90.0%
95.0%
100.0%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
80.0%
85.0%
90.0%
95.0%
100.0%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
9 of 21 Board Integrated Performance Report - June 2017
Workforce – Labour Turnover, Vacancy and Absence
Indicator
No. Indicator
16/17
outturn
17/18
Target
Current
Performance
FOT
17/18 Graph
Q19 % Labour Turnover 13.04% 10.00% 12.07%
Q20 % Sickness absence rate 5.12% 4.00% 4.69%
Q21 % Vacancy rate 7.17% 10.00% 8.76%
Staff Sickness Absence Total Number
Total days lost 38963
Total staff 2561
Average working days lost 15.22
Bradford Factor Score Points Previous Month Current Month
Informal process: 20 - 99 points 422 433
Informal process: 100 - 299 points 137 128
Formal process: 300 points and above 69 82
8.00%
9.00%
10.00%
11.00%
12.00%
13.00%
14.00%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
LTO (YTD) Target
0.00%
5.00%
10.00%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Long Term Short Term
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Mar-17
Apr-17
May-17
Vacancy Target
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
10 of 21 Board Integrated Performance Report - June 2017
Q23a - Safer Staffing: Inpatient Services - May 2017
Risks:
- Hotspot areas in terms of vacancies (in DAU, Thornton, Bracken and
Ashbrook) meaning safe staffing levels cannot be sustained long term
without posts being permanently recruited to.
Contingency/ Mitigating Actions:
- Roster review / risk assessment in place on a daily basis
- Weekly ward meetings continue to be held to forward plan rosters and
re-distribute staff across services as required. Redeployment of staff
is now recorded in the system to provide audit trail.
- The SafeCare module has being reviewed with further work planned
to pilot this on DAU
- Programme of recruitment fayres being attended in next 12 months.
Rolling recruitment ongoing with specialist programmes and potential
new roles/ career pathways being explored – e.g. Associate
Physician, and Apprenticeships.
Narrative on data extracts regarding staffing levels on 13 wards
during May 2017
Exact/over compliant shifts - Over compliant shifts continue to reduce
across all wards due to the weekly planning meetings held within the
services. The hotspots during May however, were mainly attributed to
Ashbrook, Dementia Assessment Unit (DAU), and Clover (PICU) wards
due to the acuity (complexity of need) and the requirement for skill mix
within the units. 52% (4% increase from April) of all shifts worked were
bank or agency filled, with 86% of these shifts requesting unregistered
staff. The main reason for bank and agency is due to Vacancy which has
decreased by 3% from last month (55% to 52%, with hotspot areas being
DAU, Thornton, Bracken and Ashbrook.
Under compliant shifts - There were 59 incidents reported relating to
staffing shortages in May 2017 (an increase of 30 from the previous
month), with the majority (41) submitted by Specialist inpatient services;
and particularly DAU (21). There are planned controls being introduced to
track Bank staff who DNA; this could help to reduce the number of under-
compliant shifts by being forewarned of remaining gaps in rosters and the
need to rebook. Another contributing factor to under compliance is
sickness, of which 15% of bank and agency bookings in April were
attributed to long term sickness (an increase of 3% from previous month),
particularly across Assessment and Treatment Unit (ATU), Ashbrook
Heather, and Bracken wards.
Non-compliant shifts – Two night shifts were identified as being non-
compliant in May. One shift on ATU was mitigated by the registered nurse
on the late shift working overtime to complete the medication round and
the Duty Nurse on Low Secure overseeing the rest of the nightshift. The
second night shift was on Step Forward, which was mitigated in part
without incident arising, and action has been taken to avoid recurrence.
No. shifts
Exact/ Over Compliance 1957
Under Compliance 312
Non Compliance 2
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
11 of 21 Board Integrated Performance Report - June 2017
Q23a - Safer Staffing: Inpatient Services – May 2017
Main 2 Specialties on
each ward
Specialty 1
Total
monthly
planned staff
hours
Total
monthly
actual staff
hours
Total
monthly
planned staff
hours
Total
monthly
actual staff
hours
Total
monthly
planned staff
hours
Total
monthly
actual staff
hours
Total
monthly
planned staff
hours
Total
monthly
actual staff
hours
Fern710 - ADULT MENTAL
ILLNESS975 997.5 885 810 306.9 353.4 846.3 744 102.3% 91.5% 115.2% 87.9%
Heather710 - ADULT MENTAL
ILLNESS937.5 1012.5 1154.5 1200 288.3 372 864.9 790.5 108.0% 103.9% 129.0% 91.4%
Bracken710 - ADULT MENTAL
ILLNESS937.5 855 1387.5 1380 288.3 279 864.9 883.5 91.2% 99.5% 96.8% 102.2%
Ashbrook710 - ADULT MENTAL
ILLNESS930 1005 1395 1740 288.3 288.3 864.9 1246.2 108.1% 124.7% 100.0% 144.1%
Maplebeck710 - ADULT MENTAL
ILLNESS930 870 1395 1207.5 288.3 288.3 864.9 864.9 93.5% 86.6% 100.0% 100.0%
Oakburn710 - ADULT MENTAL
ILLNESS937.5 1027.5 1387.5 1162.5 288.3 325.5 864.9 827.7 109.6% 83.8% 112.9% 95.7%
Baildon710 - ADULT MENTAL
ILLNESS952.5 877.5 1140 915 288.3 288.3 576.6 576.6 92.1% 80.3% 100.0% 100.0%
Ilkley710 - ADULT MENTAL
ILLNESS930 690 1162.5 952.5 288.3 288.3 576.6 576.6 74.2% 81.9% 100.0% 100.0%
Thornton710 - ADULT MENTAL
ILLNESS930 915 1627.5 1845 288.3 288.3 1153.2 1125.3 98.4% 113.4% 100.0% 97.6%
Assessment &
Treatment Unit (LD)700- LEARNING DISABILITY 930 877.5 1395 2062.5 288.3 288.3 864.9 1199.7 94.4% 147.8% 100.0% 138.7%
Clover (PICU)710 - ADULT MENTAL
ILLNESS930 960 1860 3052.5 288.3 316.2 1153.2 2027.4 103.2% 164.1% 109.7% 175.8%
Step Forward (Rehab)710 - ADULT MENTAL
ILLNESS532.5 547.5 622.5 622.5 288.3 288.3 288.3 362.7 102.8% 100.0% 100.0% 125.8%
Dementia Assessment
Unit (DAU)
710 - ADULT MENTAL
ILLNESS930 877.5 2790 3157.5 576.6 530.1 1441.5 1887.9 94.4% 113.2% 91.9% 131.0%
Staffing: Nursing, midwifery and care staff
Fill rate indicator return
Average fill
rate -
registered
nurses/midwiv
es (%)
Average fill
rate - care
staff (%)
Average fill
rate -
registered
nurses/midwiv
es (%)
Average fill
rate - care
staff (%)
Day Night
Ward name
Registered
midwives/nursesCare Staff
Registered
midwives/nursesCare Staff
Day Night
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
12 of 21 Board Integrated Performance Report - June 2017
Quality Assurance
Indicator
Number Target
Target met this
month Yes/No
Q5 Never Events Y
Q7 Meet Central Alert System (CAS) timelines Y
Q10 No MRSA bacteraemia cases Y
Q11 No Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia cases Y
Q12 No Clostridium difficile (C.diff) cases Y
Q15 Meet nationally mandated Commissioning for Quality and Innovation (CQUINs) – Forecast 2017/18. Y
Q15 Meet CCG Commissioning for Quality and Innovation (CQUINs) – current quarter Y
Q16 Meet NHS England Commissioning for Quality and Innovation (CQUINs) – current quarter Y
Q32 No Complaints to Information Commissioners Office (ICO) Y
Q33 No Information Governance Serious Incidents (STEIS) Y
Q34 Maintain Mixed sex accommodation status Y
Q35 Meet Dental Referral To Treatment within 52 weeks Y
Q37 Maintain Publication of the Formulary on Provider’s website Y
Q38a Meet duty of candour requirement to notify the relevant person of a suspected or actual reportable patient safety
incident Y
Q38b Number of duty of candour incidents 0
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
13 of 21 Board Integrated Performance Report - June 2017
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Indicator
Reporting
Period Co
mm
un
ity N
urs
ing
Sp
ecia
list
Serv
ices:
Co
nti
nen
ce,
Tis
su
e V
iab
ilit
y,
Fall
s
Pall
iati
ve C
are
, H
osp
ice a
t
Ho
me,
Fast
Tra
ck
Po
dia
try
Sp
eech
& L
an
gu
ag
e T
hera
py
Su
bsta
nce M
isu
se
Safe
gu
ard
ing
, L
oo
ked
Aft
er
Ch
ild
ren
, Y
ou
th O
ffen
din
g
Bra
dfo
rd S
ch
oo
l N
urs
ing
Bra
dfo
rd H
ealt
h V
isit
ing
Bra
dfo
rd F
am
ily N
urs
e
Part
ners
hip
Wakefi
eld
Sch
oo
l N
urs
ing
Wakefi
eld
Healt
h V
isit
ing
Wakefi
eld
Fam
ily N
urs
e
Part
ners
hip
Ad
ult
Co
mm
un
ity M
en
tal
Healt
h
Ch
ild
& A
do
lescen
t M
en
tal
Healt
h
Earl
y I
nte
rven
tio
n i
n P
sych
osis
Psych
olo
gic
al
Th
era
pie
s
In-p
ati
en
t -
Acu
te C
are
Serv
ices
(Ward
s,
Fir
st
Resp
on
se,
IHT
T)
Learn
ing
Dis
ab
ilit
ies
(Co
mm
un
ity)
Old
er
Peo
ple
Co
mm
un
ity
Men
tal
Healt
h
Ad
min
istr
ati
on
Serv
ices
Inp
ati
en
ts -
Sp
ecia
list
Serv
ices
Den
tal
Serv
ices
Number of incidents2016/17
quarter 4 392 3 9 4 6 17 13 13 3 103 5 16 4 848 10 77 13 522 45
Number of near misses2016/17
quarter 4 6 0 1 0 0 0 0 0 0 3 1 0 0 41 1 1 1 15 1
Number of serious incidents2016/17
quarter 4 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0
Number of compliments2016/17
quarter 4 37 0 8 40 5 0 0 0 4 0 10 3 2 3 30 1 6 0 2 1
Number of complaints2016/17
quarter 4 0 0 0 0 0 0 0 0 0 0 2 2 0 1 2 0 0 0 0 0
Number of Friends and Family
Test responses
2016/17
quarter 4 151 18 13 54 64 261 44 17 3 14 145 16 32 59 13
Friends & Family Test
'recommend' score (out of 5)
2016/17
quarter 4 4.87 4.94 4.92 4.54 4.70 4.59 4.91 4.76 5.00 4.36 4.06 4.63 4.84 4.27 5.00
Whole time equivalents
(budgeted)May-17 301 29 32 43 58 31 22 85 189 12 38 103 9 109 100 53 136 288 56 81 185 206 93
Safer staffing compliance/
staffing ratioApr-17
From
Oct 17
From
Oct 17
From
Oct 17
From
Oct 17
See
slides
See
slides
Sickness absence May-17
Turnover12 months to
May 17
Mandatory training May-17
Information governance
trainingMay-17
Staff receiving appraisal May-17
Vacancy rate May-17
Bank spend (% of pay) May-17
Agency spend (% of pay) May-17
Finance year to date variance2017/18
year to date
Finance forecast outturn
variance
2017/18
forecast
Cost improvement plan
variance (Business Unit level)
2017/18
year to date
2016/17 Q4 83,592 2,976 4,132 20,063 7,430 18,778 5,790 407 4,514
Change ↓ ↓ ↑ ↑ ↑ ↑ ↑ ↓ ↓
Achievement of contractual
indicators
2016/17
quarter 4
Board walkabout visit(s) to
service in 2016/172016/17 Yes No Yes Yes No Yes No No No No Yes Yes Yes Yes Yes Yes Yes Yes No No
Board walkabout visit(s) to
service in 2017/182017/18 Yes Jun-17 No No Mar-18 No No No Sep-17 No Yes Yes Yes Nov-17 No No No No No Feb-18 No Jun-17 Dec-17
Contacts
Adult Physical Health Children's Services Mental Health Acute and Community Specialist/Admin/Dental
To be added from Aug 17
To be added from Aug 17
To be added from Aug 17
Service Dashboard
14 of 21 Board Integrated Performance Report - June 2017
Directors Business & Transformation Programme Monthly Summary
The 2017/18 Directors Business & Transformation Programme is providing governance, monitoring and assurance for 8 transformation
projects delivering significant service transformation and change. In addition there are 60 corporate transactional Cost Improvement savings
being monitored across the Trust. The scale of these savings and change activities required is expected to deliver budget reductions totaling
£7.975m during 2017/18 to achieve the Trust objectives to become financially sustainable and digitally capable.
In month 2 the overall programme is rated red, though with improvement from month 1 following development of delivery plans and
completion of quality impact assessments. Given the scale of transformation and thorough planning and engagement with stakeholders the
project initiation and plans have required some re-modelling. The shortfall expected (net of mitigations but before taking into account the high
risk reserve) is currently £679k. This includes a combination of recurrent and non-recurrent slippage. The summary at month 2 is:
1. Control Total including Corporate Benchmarking – Plan and CIP partially QIA’d but expect in-year CIP target to be achieved.
2. Roster savings – Paper agreed by Executive Management Team and QIA now scheduled for July.
3. Mental Health Acute & Community – Service model approved at QIA. Inpatient occupancy plan now scheduled for July QIA.
4. Trust Procurement – Plan received for forward work plan and now being reviewed. Initial CIP challenge assessed to be 50%.
5. Adult Physical Health - Non recurrent funding put forward to mitigate and now on track for 17/18; recurrent actions underway.
6. Estates and Facilities - Plans partially approved at QIA and planning underway at a number of key sites.
7. Specialist Inpatients, Dental, Admin – Plan partially QIA’d but work still underway to review agency CIP.
8. Children’s Services – Both Bradford and Wakefield on track.
9. Transactional (Corporate) Schemes – All on track.
The purpose of the Directors Business & Transformation Programme is to ensure effective project governance, delivery, monitor and
approve Project Initiation and risks, issues and exceptions and ensure a consistent approach to Quality Impact Assessments (QIA).
Feb-17 Mar-17 Apr-17 May-17
All Service AreasNumber of
Schemes Value (£,000)
QIA Yes 77 5,802£
QIA No* 25 2,161£
Total Schemes 102 7,963£
Green 89
Amber 2
Red 10
Total Scemes 101
* note - "QIA No" icludes those with partial QIA
All Service Areas Financial status and Quality Impact Assessment (QIA) Completed
RAG Status
77
25
Num
be
£5,802
£2,161
Project Value (£,000)
QIA Yes
QIA No*
89
210
Financial RAG Status
Green
Amber
Red
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
15 of 21 Board Integrated Performance Report - June 2017
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Finance Key Measures
Plan ActualVariance
(Adv)/FavRAG Plan Actual
Variance
(Adv)/FavRAG
Net Surplus/(Deficit) (665) 22 687 1,578 1,578 0
Technical Adjustments 0 0 0 0 0 0
Performance against the Control Total (665) 22 687 1,578 1,578 0
CIPs (before High Risk Reserve) 805 1,115 310 7,973 7,294 (679)
Capital Expenditure 399 245 154 3,528 3,528 0
Cash Balance 11,120 14,575 3,455 11,485 11,485 0
Use of Resources 3 1 2 1 1 0
Forecast Outturn
£000's
Year to Date
16 of 21 Board Integrated Performance Report - June 2017
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
(2,000)
(1,500)
(1,000)
(500)
0
500
1,000
1,500
2,000
(800)
(600)
(400)
(200)
0
200
400
600
800
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Ye
ar
to D
ate
Pla
n a
& A
ctu
al -
£0
00
's
In M
onth
Pla
n &
Actu
al -
£0
00
's
Control Total Performance
In Month Plan In Month Actual YTD Plan YTD Actual
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
0
100
200
300
400
500
600
700
800
900
1,000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
YT
D P
lan &
A
ctu
al -
£0
00
's
In M
onth
Pla
n &
Actu
al -
£0
00
's
Cost Improvement Programmes
In Month Plan In Month Actual YTD Actual YTD Plan
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
0
100
200
300
400
500
600
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
YT
D P
lan &
Actu
al -
£0
00
's
In M
onth
Pla
n &
Actu
al -
£0
00
's
Capital Expenditure
In Month Plan In Month Actual YTD Actual YTD Plan
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
In Month Cash Balances
Plan Actual 2016/17
Workforce KPIs - Agency Expenditure Cap
(Adv)/Fav
Variance
from Cap
£000's
YTD
RAG
Change in
month
Total Agency Expenditure Cap in Month 368 Improvement
Medical Agency Expenditure Cap in Month 35 Deterioration
Workforce KPIs - Agency Expenditure Cap
(Adv)/Fav
Variance
from Cap
%
YTD
RAG
Change in
month
Qualified Nursing Expenditure Cap - In Month 1.94% Improvement
Qualified Nursing Expenditure Cap - YTD 1.56% Improvement
Workforce KPIs - Price & Wage Cap BreachesNo. of
Shifts
YTD
RAG
Change in
month
Price Cap Breaches in Month - Medical 182 Increase
Wage Cap Breaches in Month - Medical 198 Increase
Price Cap Breaches in Month - Non Medical 0 Same
Wage Cap Breaches in Month - Non Medical 0 Same
Workforce KPIs - Average cost per WTE £000'sYTD
RAG
Change in
month
Average cost per WTE 40 Increase
17 of 21 Board Integrated Performance Report - June 2017
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Trust CIP Exceptions and Substitutions
Plan ActualVariance
(Adv)/FavPlan Actual
Variance
(Adv)/Fav
Green 708 708 0 5,800 5,800 0
Amber 2 0 (2) 12 0 (12)
Red/Blue 95 59 (36) 2,161 761 (1,400)
Mitigations 348 348 0 733 733
Total CIPs 805 1,115 310 7,973 7,294 (679)
High Risk Reserves (83) 0 83 (500) 0 500
Total CIPs net of Reserves 722 1,115 393 7,473 7,294 (179)
Year to Date - £000's Forecast Outturn - £000's
QIA RAG Status
Reason for Variance & Mitigating Actions
• Note – of the £2,161k planned Red/Blue CIP schemes, £1,476k (15 schemes) have gone to QIA in June and July.
During July the Trust is reviewing:-
1. Human Resources - £150k forecast risk
2. Procurement (too early to fully risk assess) - £225k initial risk assessment (50%)
3. Further progress on Corporate Benchmarking and potential in-year and recurrent opportunities
The projected shortfall includes the following, with work now underway to review non-recurrent / recurrent mitigations:-
1. Projected inpatient occupancy reductions (non recurrent) - £84k
2. Projected in-year roster saving shortfall (recurrent) subject to 13.7.17 QIA - £274k
18 of 21 Board Integrated Performance Report - June 2017
Informatics
Activity Number Activities Quarterly Target
(Capacity) Quarter 4 2016/17
Quarter 1 2017/18
to date (May 2017)
1 – Clinical Systems Total systems training (number of staff trained) 436 397
2 – Service Desk Number of tickets logged by Service Desk for all teams 7,785 6,414
3 – Service Desk Number of tickets resolved by all Informatics teams 10,830 7,301
4 – Service Desk % of customer feedback falling in the ‘excellent’ and
‘good’ category for all tickets via service desk Data collection
commenced May
2017
42 out of 54
78% - May 2017
5 – Service Desk Did we complete the work you requested? – Yes result
%
50 out of 55
91% - May 2017
6 - Service Desk Total number of computer devices Total: 3,149 May 2017
(1,048 Desktops & 2,101 Laptops)
7 – Information Governance
& Records Management
Number of requests for personal information received
(police/courts requesting personal patient related
information) 104 71
8 – Information Governance
& Records Management
Number of requests for information received under the
Freedom of Information Act 117 41
9 – Projects * Total number of agreed Informatics Projects that are
‘On Track’ or ‘Completed’ 37 out of 38* 28 out of 29*
10 – Cyber Security**
11 - Telephony
12 – Response rates
13 - Workforce
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
This is the first presentation to Board of key Informatics activity indicators. Oversight and scrutiny of Informatics performance and activity is
supported by various reports to Informatics Board and key performance indicator dashboards to both the Information Governance Group and
the Informatics Steering Group. Comments are welcomed on which indicators should be included to support Board oversight.
* 9 – Projects: Craven Podiatry Transfer - Amber: Due to short rapid delivery deadline. Service has WorkSmart solution in place now, but
requires more robust connectivity given the rural Craven locality. Capital Planning Investment Group has approved related capital resources.
** 10 – Cyber Security: A review of Trust cyber security arrangements will identify key performance indicators so this section remains in
development.
19 of 21 Board Integrated Performance Report - June 2017
Hotel Services – Cleanliness audits
Food Services – Mealtime Assessments
Estate Maintenance – Response Rates
Patient Transport, Removal & Pest Control – Response Rates
Cleanliness audits within in-patient sites are undertaken on a monthly
basis. All cleanliness audits achieved the performance target of >90%.
The chart shows target achievement of lower priorities although currently
below target achievement for higher priority tasks. The implementation of
response targets is a recent innovation within Estate Maintenance and
team meetings have a continued focus on their achievement, particularly
higher priority tasks. Recent issues have impacted upon performance
including a data-flow problem within Concept Evolution and the cyber-
attack. Estate Maintenance are involved in ward huddles and ward
environment meetings to more quickly identify and remedy potential
response issues within the wards.
All tasks are achieving performance target for response rates due to
proactive time sheet management within Concept Evolution.
Maplebeck did not achieve the performance target as on the date of the
assessment one service user did not order their meal with their
housekeeper. They were therefore brought the main menu choice for that
mealtime with which they were not happy. This impacted the mealtime
assessment score for that month.
0%
50%
100%
PTS Pest Control Removals
Operational Services
Operational Services
93% 85%
75%
90% 85%
80% 85%
0%
20%
40%
60%
80%
100%
4 hrs 12hrs 1 WD % 3 WD % 1 WK % 2 WK % 4+ WK %
Key:
Target performance Achieving target
< 25% off target > 25% off target
Response rate: the % of reactive tasks completed by the deadline set
and agreed within Concept Evolution
0%
20%
40%
60%
80%
100%
Mealtime Assessments scores , May 2017
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Estates and Facilities Service Performance for Operational Services – In-Patient Sites
20 of 21 Board Integrated Performance Report - June 2017
Hotel Services – Cleanliness audits Estate Maintenance – Response Rates
Patient Transport, Removal & Pest Control – Response Rates
Cleanliness audits within BDCFT community properties are undertaken
on a quarterly basis. Cleaning services are provided by NHS Property
Services (NHSPS). Every 6 months BDCFT undertakes either an
Infection Prevention Audit or a Cleanliness audit to ensure cleaning
standards are being achieved. BDCFT minimum performance pass is
set at 90% (National Specifications for Cleanliness [NSC] suggest trusts
set their own targets for cleanliness). The ‘indicative aim’ defined in NSC
for Significant risk areas is set at 85%. NHSPS have been alerted to the
shortfall in standard and rectification actions have been programmed.
Weekly meetings are diarised between Facilities Service Desk and
Estate Maintenance to ensure quality assurance checks are completed
relating to task performance.
Recent issues have impacted upon reported levels of performance
including a data-flow problem within Concept Evolution and the recent
cyber-attack.
0%
20%
40%
60%
80%
100%
PTS Pest Control Removals
Operational Services
100%
86% 92%
73% 75%
62%
86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
4 hrs 12hrs 1 WD % 3 WD % 1 WK % 2 WK % 4+ WK %
Key:
Target performance Achieving target
< 25% off target > 25% off target
Response rate: the % of tasks completed by the deadline set
and agreed within Concept Evolution
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Estates and Facilities Service Performance for Operational Services – Community Properties
21 of 21 Board Integrated Performance Report - June 2017
Health and Safety – reporting Fire Safety – Fire Incidents
105 88 102 71 98
55 19 20
444
137
0
100
200
300
400
500
600
No. RIDDOR reportable incidents
No. H&S Incidents withsmoking as a causal factor
Total no. H&S Incidents(without smoking related incidents)
3 5 4
2
6
33
29 29
26
33
9 10 11
2
10
0
5
10
15
20
25
30
35
No. Needlestick Injuries
No. Slips, Trips & Falls
No. reported Near Misses
The tally system for reporting smoking related incidents was reintroduced in
April 2017 on a 3 month basis, with ongoing review via Trust Smoke-Free
Group. This accounts for the increase in health and safety incidents with
smoking as a causal factor. The Corporate Manslaughter & Corporate
Homicide Task & Finish Group are monitoring via Trust Action Plan the
implementation of a reviewed Restricted Items Protocol to include cigarettes.
Slips, trips and falls incidents have increased from April 2017 to May 2017
although remain 49.5% lower than in May 2016. The majority of these
incidents are within ward areas and involve clinical rather than environmental
factors.
Date Location Cause
12.3.1
7
Step Forward Toaster was left unattended by
housekeeper
25.4.1
7
Westbourne
Green
Member of public doused themselves
in petrol & threatened to ignite
himself with lighter
26.4.1
7 Ashbrook
Service user set fire to bed. Staff
extinguished, fire service attended
26.4.1
7 Clover Steam from shower
1.5.17 Heather Steam from shower bed 2 (1am)
1.5.17 Heather Steam from shower bed 2 (4am)
2.5.17 Heather Steam from shower
6.5.17 Fern Service user burnt edges of
pillowcase
10.5.1
7 Ashbrook
Service user hit manual call point
repeatedly with shampoo bottle
There have been 7 reported incidents related to fire, such as fire
alarm activations from 1 March to 31 May 2017. There have been
2 fire incidents in this period.
32 fire risk assessments have been completed between 1 March
and 31 May 2017. Assessments are carried out as per the
departmental fire safety schedule. There are no overdue risk
assessments and currently there are zero outstanding actions that
require escalation.
Fire Safety – Fire Risk Assessments
Lessons learned following incidents are shared with teams
involved in the incident to support service improvement and
continued safety of staff and service users.
Summary NHS
Improvement Quality
Business Unit
Change Programme
Finance Enablers
Well Led
Estates and Facilities: Health and Safety - Advisory Services