INTEGRATED GOVERNANCE COMMITTEE REPORT papers... · INTEGRATED GOVERNANCE COMMITTEE REPORT ... representative of the Medicines Management Team should attend the IGC and provide quarterly

Version: Final E - 1 Date: 25 06 13

GOVERNING BODY

LEAD: Phil Moore, Deputy Chair (Clinical) of Governing Body and Chair of Integrated Governance Committee

ATTACHMENT:

REPORT AUTHOR: Jill Pearse, Head of Governance & Business Support

AGENDA ITEM: 9

RECOMMENDATION: The Governing Body is asked to note this report

GOVERNING BODY MEETING DATE: 2nd July 2013

INTEGRATED GOVERNANCE COMMITTEE REPORT

EXECUTIVE SUMMARY:

This report highlights issues discussed at Integrated Governance Committee on 7th May 2013 and 18th June 2013. The Performance report and Risk register as presented to the June meeting are attached as appendices for further information

KEY SECTIONS FOR PARTICULAR NOTE: As identified in attached report

RECOMMENDATIONS: To note this report

RISKS IDENTIFIED: As per report

GOVERNING BODY OBJECTIVES for 2013/14:

Please indicate below all the domains which the paper provides evidence for:

Domain One: A strong clinical focus and multi professional focus which brings real added value

Domain Two: Meaningful engagement with patients, carers and their communities

Domain Three: Clear and credible plans which continue to deliver the QIPP challenge within financial resources, in line with national requirements (including outcomes) and the local joint health and wellbeing strategy

Domain Four: Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effectively commission all the services for which they are responsible.

Domain Five: Collaborative arrangements for commissioning with other CCGs, local authorities and NHS England as well as the appropriate external commissioning support

Domain Six: Great leaders who individually and collectively can make a real difference

EQUALITY IMPACT ASSESSMENT:

PRIVACY IMPACT ASSESSMENT: No patient identifiable information was used in the writing of the report.

E


Introduction

This report highlights issues discussed at Integrated Governance Committee on 7th May 2013 and 18th June 2013. The Performance report, Integrated Governance exception report and Risk register (as presented to the June meeting) are attached as appendices for further information.

Quality & Safety

Quality Surveillance Group (QSG) The Quality Surveillance Group (QSG) met on the 14th May 2013 and will meet again on 25th June. Serious Incidents

Mental Health: Management of SI’s by South West London and St Georges NHS Mental Health Trust has improved and better oversight established.

Surveillance needs to include Out of Hours /NHS 111 - The committee discussed who would take responsibility for monitoring this and whether the Clinical Quality Review Group would be the right forum to feed issues back to NHS England.

Child Safeguarding

The Office for Standards in Education, Children’s Services and Skills (Ofsted) commenced an unannounced safeguarding inspection for the local authority starting 3 June 2013. The Committee noted the resignation of the former leader of the Council.

Complaints Kingston CCG has invoked the Complaints Policy Section regarding persistent complainants on one occasion in the last month.

Adult Safeguarding A revised proposal for the introduction of a “corporate relative” to be discussed at the June Health & Wellbeing board. The current Safeguarding Adults Programme Board action plan includes proposed self-assessments for partners. National Institute for Health and Care Excellence (NICE) The Committee discussed how assurance regarding the dissemination and implementation of NICE Standards, Technology Appraisals and Guidance could be obtained. It was noted that this was within the remit of the Clinical Quality Review Groups; but it was agreed that this should be monitored by the Integrated Governance Committee.

Governance Conflict of Interests Conflict of Interests added to the risk register. Specific issues around the virtual angina project were discussed and a way forward agreed at the May meeting. A Conflict of Interests Policy is under development. Medicines Management Shared Care Prescribing Guidelines: The Chief Pharmacist presented a briefing paper on shared care prescribing. It was agreed that documents should be made available to be added to GPMail.net and that a representative of the Medicines Management Team should attend the IGC and provide quarterly reports.


Performance

A new performance reporting template was agreed by the IGC in May, which also approved the formation of the Performance Management Group subject to a 6 month review. The report, as presented to the meeting in June is attached (appendix A)

The chart below shows the overall year to date position as at by achievement level:

Areas of concern include:

Harmoni: - Patient Experience of GP Out of Hours Services The annual survey for 2011/12 shows Kingston as

having the third lowest satisfaction rate nationally, which does not accord with the current patient survey data supplied by Harmoni.

- Harmoni SPA 111: Calls answered within 60 seconds and Called back within 10 minutes Recent data shows improved position - Harmoni NHS 111 achieved the target with an average of 95.5%, but the year to date position is still below the 95%.

Incidence of healthcare associated infection: MRSA – One case occurred at the Royal Surrey County Hospital involving Kingston patient, against a CCG target of zero. The root cause analysis (RCA) report is awaited

Ambulance Handover time - London Ambulance Service (LAS). This is a new indicator for 2013-14 and performance is measured LAS-wide, with a target of 100% of patient handovers to be completed within 15 minutes. The CCG has written to the London Ambulance Service NHS Trust asking how they will ensure they will meet the expected outcome and expected timescale.

Improving Access to Psychological Therapies (IAPT) service - proportion of relevant population seen and proportion moving to recovery – The IAPT service was retendered during 2012 with Camden and Islington NHS Foundation Trust and Central and North West London NHS Foundation Trust being awarded the contract in October 2012. During the transition period (Oct 2012 - Mar 2013) there was a dip in the IAPT service performance; Commissioners have agreed a settling –in period and monthly performance meetings are being held to ensure that the new service achieves its goals in the 3rd and 4th quarter of the current financial year.

CMHT % of referrals not assessed within 28 days from referral and % of CPA caseload receiving face to face/ telephone contact in month

Proportion of patients delayed in a Your Healthcare bed for reasons related to non-health services DTOCs across the whole Kingston economy will be an area of focus for the urgent care board because any delays within the system impacts the throughput and transition of patients through care settings.

The IGC agreed that performance indicators should have identified trigger points and root cause analysis (RCA) reports required from the provider if these points were passed.


2013/14 Quality, Innovation, Productivity and Prevention (QIPP) Programme

Summary OF 2013/14 QIPP Schemes by projected outcome (achievement of saving target)

QIPP schemes (RAG based on project manager assessment of full year savings target deliverability; not reported = A)

G A R* Total

Service redesign projects 4 4 2 10

Contract / budget adjustments 23 0 0 23

Total 27 4 2 33

Brief commentary on schemes with identified full year financial risk

Scheme Project Manager comment Full year projected financial risk £k vs target

Patient centred angina management

Business case not yet approved and further work required. Review of CCG conflicts of interest requested. Significant risk to project. PM best estimate is now 6 months effect in 13/14.

-131

Community Cardiology

Project(s) and timescales not yet clearly defined so £50k saving target not linked to clear plan. Work progressing as planned to define scope and potential, max impact of change likely to be 6 months in 13/14

-50

Above risk = £195k against a full year programme target saving of £6.015m, = 3.2%,

Risk Register

There are currently 6 moderate risks, 10 high risks and 1 very high risk identified. The attached risk report and register details the current risks (appendix B).

Very high risks

Risk 314: Safeguarding children and looked after children services: This risk was escalated following the Ofsted/Care Quality Commission (CQC) report of their Inspection of Safeguarding & Looked after Children (July 2012) which identified gaps in in service, and also an increase in number of children subject to Child Protection Plan. The IGC debated the continued “very high” rating, and noted the progress of the action plan, but agreed that the rating remained appropriate. New Risks The following risks were added following the IGC meeting in May and are agreed at the June meeting:

Risk 621: Fraud and bribery - added on advice from Local Counter Fraud Service Risk 622: Conflicts of interest - added following IGC meeting in May 2013 It was agreed that a separate risk should be added regarding the limitations for sharing patient confidential data between NHS organisations for anything other than direct patient care and the potential impact of this on the implementation of projects such as risk stratification.


Appendix A: Performance Report

INTEGRATED GOVERNANCE COMMITTEE

Performance Report – June 2013

Overall Position As at the 14th June 2013, Kingston CCG is showing the overall position against the following areas:

Report Date: 11:00 14th June 2013

Indicator

1. Preventing people from dying prematurely G

2. Enhancing quality of life for people w ith long-term conditions G

3. Helping people to recover from episodes of ill health or follow ing injury A

4. Ensuring that people have a positive experience of care A

5. Treating and caring for people in a safe environment and protecting them from avoidable harm A

Acute Care G

Mental Health/ Non-Acute Care A

Everyone Counts - Local Priorities G

Kingston Hospital NHSFT G

South West London and St Georges MHT A

Your Healthcare CIC G

CCG National Measures

CCG Local Measures

CCG Outcomes Indicators

Fore-

cast

Below shows the position by achievement level:


KINGSTON CCG INTERGRATED PERFORMANCE REPORT EXCEPTIONS Report Date: 11:00 14th June 2013

Indicator Reporting Latest Latest YTD YTD

Frequency Actual target Actual Target

4. Ensuring that people have a positive experience of care

Patient experience of GP out of hours services (NHS OF 4a ii) Annual 57.65 70.30 57.65 70.30 2011/12 57.65 R

Patient experience of hospital care (NHS OF 4 b) - Kingston Hospital Annual 74.30 75.63 74.30 75.63 2011/12 74.30 A

Patient experience of outpatient services (NHS OF 4.1) - Kingston

HospitalAnnual 75.20 79.51 75.20 79.51 2011 75.20 A

Responsiveness to in-patients’ personal needs (NHS OF 4.2) -

Kingston HospitalAnnual 64.20 67.39 64.20 67.39 2011/12 64.20 A

Patient experience of A&E services (NHS OF 4.3) - Kingston Hospital Annual 74.70 78.60 74.70 78.60 2011 74.70 A

Patient experience of community mental health services (NHS OF

4.7) - South West London and St Georges MHTAnnual 83.93 86.64 83.93 86.64 2011 83.93 A

5. Treating and caring for people in a safe environment and protecting them from avoidable harm

Incidence of venous thromboembolism (VTE) (NHS OF 5.1) -

Kingston HospitalMonthly 92.0% 95.0% 92.0% 95.0% Apr-13 92.0% A

Incidence of healthcare associated infection: MRSA (NHS OF 5.2.i) Monthly 1 0 1 0 May-13 0 R

Acute Care

Ambulance handover time (w ithin 15 minutes) (LAS-w ide) Monthly 63.46% 100.00% 63.46% 100.00% Apr-13 63.46% R

Harmoni SPA 111: Calls answ ered w ithin 60 seconds Monthly 95.46% 95.00% 93.4% 95.00% May-13 88.80% R

Harmoni SPA 111: Called back w ithin 10 minutes Monthly 52.78% 90.00% 53.7% 90.00% May-13 54.88% R

Non-elective FFCEs (First Finished Consultant Episode) Monthly 1,081 1,060 1,081 1,060 Apr-13 12,816 A

All f irst outpatient attendances Monthly 4,042 3,936 4,042 3,936 Apr-13 47,628 A

Mental Health/ Non-Acute Care

IAPT - Patient numbers as % of Population w ith Depression etc Quarterly 2.67% 3.50% 10.86% 12.80% Q4 12-13 10.86% R

IAPT – proportion moving to recovery Quarterly 42.90% 40.77% 40.18% 40.19% Q4 12-13 40.18% A

South West London and St Georges MHT

CMHT % of referrals not assessed w ithin 28 days from referral Monthly 41.00% 22.00% 41.00% 22.00% Apr-13 20.00% R

CMHT % of CPA caseload receiving face to face/ telephone contact

in monthMonthly 72.00% 80.00% 72.00% 80.00% Apr-13 80.00% R

Your Healthcare CIC

Proportion of patients delayed in a bed for reasons related to non-

health servicesMonthly 16.60% 5.00% 16.60% 5.00% Apr-13 16.60% R


CCG Local Measures

Period Trend/ DirectionYear end

forecast

Fore-

cast


Areas of Concern The table below shows the exceptions on published data reported on or before 14th June 2013.

CCG Outcome Measures 1. Patient Experience of GP Out of Hours Services

The annual survey reported was for 2011/12, and shows Kingston as having the third lowest satisfaction rate, behind Hounslow and Richmond respectively. We receive monthly reports from Harmoni the shows a positive response from patients – see below example for April 2013.


The CCG is seeking assurance from Harmoni that measures will be put in place to improve performance, and that the local monthly patient survey questions reflect the national yearly questions, to enable demonstrable change. The CCG has also noted that Harmoni’s local survey return rate (of the 10% contracts sampled) is very low, and so has sought assurance on how the uptake rate could then also be improved. Kingston CCG is still investigating the remaining patient experience indicators with the respective leads.

2. Incidence of healthcare associated infection: MRSA The CCG has had one MRSA breach in May, against a target of no breaches for the entirety of 2013-14. As part of the 2013-14 Standard NHS contract, this breach is treated as having a zero tolerance, with the consequence of the breach being the non-payment of the inpatient episode in question. This breach is being investigated, as it appears to have not originated from a local acute trust.

CCG National Measures 1. Ambulance Handover time (London Ambulance Service)

This indicator is new for 2013-14, with the performance measured across the whole of the produced is LAS-wide, with a target of 100% of patient handovers to be completed within 15 minutes. The CCG has written to Martin McTigue, AOM Commissioning and Business Development, at the London Ambulance Service NHS Trust requesting their assurance to KCCG Board regarding how they will ensure they will put in place measures to meet the expected outcome and expected timescale.


2. Harmoni SPA 111: Calls answered within 60 seconds and Called back within 10 minutes

Kingston CCG is working closely with SL CSU to obtain reassurance from Harmoni that measures are being put in place to rectify this poor performance. Recent data shows that Harmoni NHS 111 achieved the target with an average of 95.5%, but the year to date position is still below the 95%. We will continue to monitor closely this target outcome to ensure its sustainability.

A key issue in the call back issue with Harmoni is the recruitment and retention of clinical advisors to deal with the demand for warm transfer – this have been put into their recovery and improvement plan which is being performance monitored and managed by SL CSU on the CCG’s behalf.

This is being reported back via the clinical governance group and contract performance meetings. Harmoni is also clarifying if it can remove call backs that are only for advice purposes, which become delayed due to Harmoni prioritising other calls above these.

3. Activity Measures

a. Non-elective FFCEs (First Finished Consultant Episodes) Kingston CCG is 1.98% (21 patients) above the planned figure for April 2013, which was based on the 2012-13 position, increased for demographic growth of 0.7%. Whilst this position is above planned levels, it is expected that this is a direct consequence of the issues around the national accident and emergency performance for April, and should then normalise in future months. b. All first outpatient attendances Kingston CCG is 2.69% above planned levels (based on the planning assumptions above), which equates to 106 patients above plan. Work is on-going to understand outlying specialties, comparing these with historical levels and benchmarking against similar CCGs, which will inform the CCG’s referral management strategy to contain growth.

4. IAPT proportion of relevant population seen and proportion moving to recovery

The IAPT service was retendered during 2012 with Camden and Islington NHS Foundation Trust and Central and North West London NHS Foundation Trust being awarded the tender in October 2012. During the transition period between October 2012 and March 2013 there was a dip in the IAPT service performance for the following reasons:

Two experienced Band 7 CBT Therapists resigned from the IAPT service in December 2012 who were key members of staff who had performed to a high standard. Although they were temporarily replaced with agency staff for some of the time they were inexperienced by comparison. There was consequently a dip in performance of the whole service.

During this period there were also two members of staff who went on maternity leave which caused further disruption to services, a WTE and a 0.4 WTE who did not return.

During the whole of this transition period staff were faced with uncertainty about their own jobs and the Senior Manager was required to lead the service through transition which resulted in a reduction in her clinical time.

Under the circumstances the IAPT service maintained its focus on clinical work and did well to keep the service at the level documented, albeit unable to achieve the targets set the previous year.


Since the implementation of the new service the IAPT team are adjusting to the new regime. Commissioners have agreed a settling –in period and are meeting with the service for monthly performance meetings to ensure that the new service achieves its goals in the 3rd and 4th quarter of the current financial year.

CCG Local Measures

1. CMHT % of referrals not assessed within 28 days from referral

While the performance of this target in May has improved on April, South West London & St Georges has experienced an increase in DNA rates over the last two months which is a key contributing factor to the underperformance. The CMHT Duty system is being reviewed to allow timely assessment and allocation of patients. This will be reinforced through improved admin systems that will be more responsive to reducing DNAs though the implementation of a patient reminder calling system.

2. CMHT % of CPA caseload receiving face to face/ telephone contact in month

There has been a large improvement on the 2012-13 position to 72%, against a target of 80%. However, the teams have not progressed to satisfactory levels as expected due to higher than expected DNA rates and a drop in discharges during the month due to absence of key staff/managers which further skew the figures. The discharge process in teams are currently being reviewed with a view to ensuring care coordinators undertake this task through appropriate governance arrangements. Any clients seen in outpatients for CPA reviews will be called through the patient reminder calling system.

3. Proportion of patients delayed in a Your Healthcare bed for reasons related to non-health services The CCG has seen an increasing number of Delayed Transfers of Care (DTOCs) in the community health beds at Cedars unit associated with non-health / social care delays e.g. patients awaiting funding decision on placement, telecare and equipment installation. A factor appears to be the lack of formal referral process with RBK. These delays have also contributed to an increasing average length of stay in the Cedars Unit. YHC have been asked to produce an action plan to improve discharge planning and management from the Cedars unit which will improve on the DTOC and ALOS positions. The action plan will be monitored via the YHC Performance Review Meetings. DTOCs across the whole Kingston economy will be an area of focus for the urgent care board because any delays within the system impacts the throughput and transition of patients through care settings.


Kingston CCG - QIPP Overall 13-14 Summary Report - To May 2013

Status Summary

QIPP schemes (RAG based on project manager assessment of full

year savings target deliverability; not reported = A)G A R Total

Service redesign projects 4 4 2 10

Contract / budget adjustments 23 0 0 23

Total 27 4 2 33

Apr-

13

May-1

3

Notes / Signif icant Risks

YTD net

saving

target

YTD net

saving

projection

YTD

variance

Full year

net saving

target

Full year

net saving

projection

FY

variance

Project manager overall assessment of

13/14 year to date progress G G

Project manager current assessment of

13/14 full year savings target deliverabilityG G


13/14 year to date progress R R


13/14 full year savings target deliverability R R


13/14 year to date progress A


13/14 full year savings target deliverability A




13/14 full year savings target deliverabilityA










13/14 year to date progress A A


13/14 full year savings target deliverability A A




13/14 full year savings target deliverability R R


13/14 year to date progress A G


13/14 full year savings target deliverability A G




13/14 full year savings target deliverability A

132 79 -53 1139 944 -195

813 813 0 4876 4876 0

945 892 -53 6015 5820 -195

Projected FY percentage variance -3.2%

0

0 0

9. Referral

management

No saving target currently associated w ith this project.

Project plan is to identify clear deliverables and process by end

June 13.

0 0 0 0 0

50 0 -50

8. SPA111

No saving target currently associated w ith this project.

Objectives are quality oriented; Project Manager's report indicates

after diff icult start in April 13 progress and Improvement has been

achieved in May 13.

0 0 0 0

7. Cardiology

RISK: project(s) and timescales not yet clearly defined so £50k

saving target not linked to clear plan.

Work progressing as planned to define scope and potential, max

impact of change likely to be 6 months in 13/14

8 0 -8

0

6. Rheumatology

ESP triaging implemented from Dec12.

RISK: No evidence yet of signif icant impact (FY expectation of 40%

reduction in acute activity (from 900 GP referrals to 540 and

associated outpatient activity).

Further w ork under w ay to review FYE for 13/14. Best estimate at

this stage is £37k saving

4 3 -1 50 36 -14

56 56 0 338 338

0

4. Direct access

audiology

Service live from 13/5/13 as planned. 1 1 0 32

3b. Risk

stratif ication

1st quarter = preparatory period - progressing according to plan,

though amber due to need to dovetail w ith new risk stratif ication

DES - being explored

0 0 0

32 0

0

3a. Telehealth

Initial group of patients (11) using telehealth but apparent

resistance from Community Matrons to extending - unable to

identify any more (target 50 by Dec13). Alternative sources

(specialist nurses) being explored.

Unable to attribute savings to date.

2 0 -2 70 70

Project delivering as planned.

1. Admission

avoidance

To May 2013 - £k

17 19 2

A. Service redesign Schemes

-131

208 208 0

To March 2014 - £k

B. Contract / budget adjustment schemes (23 schemes, YTD figs based on apportioning full year projection)

Service redesign schemes (10) totals

Kingston CCG Total

261 130

2. Patient centred

angina management

RIS: Business case not yet approved and further w ork required.

Review CCG CoI efforts requested. Next consideration at Gov

Body 4/7/13. Signif icant risk to project.

PM best estimate is now 6 months effect in 13/14.

44 0 -44

130 130

5. Kingston at Home

- community beds

£638k removed from YHC contract at start of year in lieu of bed

reductions (47 to 35).

£300k non-recurrent enabling funds provided - plan for expenditure

due.

RISK: Essential that YHC begin to reduce ave LOS in Cedars beds

to maintain throughput through few er beds; in turn may be some

dependence on right community services in place to facilitate

earlier discharge. No evidence yet of either

QIPP Programme for 2013-14 Below is the performance to date of the QIPP programme:

Version: Final D - 11

Date: 25 06 13




1. Preventing people from dying prematurely G

Potential years of life lost from causes considered amenable to healthcare: adults, children and

young people (NHS OF 1a i & ii)Annual 3,206.7 4,324.1 3,206.7 4,324.1 2011 3,206.7 G

People w ith severe mental illness w ho have received a list of physical checks

Antenatal assessment < 13 w eeks Quarterly 91.89% 90.00% 90.62% 90.00% Q4 12-13 90.62% G

Maternal smoking at delivery Quarterly 4.77% 10.00% 4.76% 10.00% Q4 12-13 4.76% G

Breastfeeding prevalence at 6-8 w eeks Quarterly 75.24% 75.00% 72.83% 75.00% Q4 12-13 72.83% A

Under 75 mortality from cardiovascular disease (NHS OF 1.1) Annual 57.72 67.68 57.72 67.68 2011 57.72 G

Myocardial infarction, stroke & stage 5 kidney disease in people w ith diabetes

Mortality w ithin 30 days of hospital admission for stroke

Under 75 mortality from respiratory disease (NHS OF 1.2) Annual 18.43 28.51 18.43 28.51 2011 18.43 G

Under 75 mortality from liver disease (NHS OF 1.3) Annual 13.68 16.37 13.68 13.68 2011 13.68 G

Emergency admissions for alcohol related liver disease Annual 17.63 25.68 17.63 25.68 2011/12 17.63 G

Under 75 mortality from cancer (NHS OF 1.4) Annual 102.80 122.99 102.80 122.99 2011 102.80 G

One and f ive year survival from all cancers (NHS OF 1.4.i and ii) Annual

One and f ive year survival from breast, lung & colorectal cancers (NHS OF 1.4 iii and iv) Annual

2. Enhancing quality of life for people w ith long-term conditions G

Health-related quality of life for people w ith long-term conditions (NHS OF 2) Bi-annual 92.66% 92.91% 92.66% 92.91% 2011/12 92.66% G

People feeling supported to manage their condition (NHS OF 2.1) Bi-annual 61.18% 64.08% 61.18% 64.08% 2011/12 61.18% A

People w ith COPD & Medical Research Council Dyspnoea scale ≤3 referred to a pulmonary

rehabilitation programme

People w ith diabetes w ho have received nine care processes

People w ith diabetes diagnosed less than one year referred to structured education

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) (NHS OF 2.3.i) Annual 543.60 792.55 543.60 792.55 2011/12 543.60 G

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s (NHS OF 2.3.ii) Annual 196.21 319.33 196.21 319.33 2011/12 196.21 G

Complications associated w ith diabetes including emergency admission for diabetic ketoacidosis

and low er limb amputation

Access to community mental health services by people from BME groups

Access to psychological therapy services by people from BME groups

Recovery follow ing talking therapies (all ages and older than 65)

Estimated diagnosis rate for people w ith dementia (NHS OF 2.6i) Annual 41.0% 39.2% 41.0% 39.2% Mar-13 41.0% G

People w ith dementia prescribed anti-psychotic medication

3. Helping people to recover from episodes of ill health or follow ing injury A

Emergency admissions for acute conditions that should not usually require hospital admission

(NHS OF 3a)Annual 764.50 1,040.29 764.50 1,040.29 201/12 764.50 G

Emergency readmissions w ithin 30 days of discharge from hospital (NHS OF 3b) Annual 11.44 11.76 11.44 11.76 2010/11 11.44 G

Patient-reported increased health gain as assessed by patients for elective procedures (NHS OF

3.1 i - iv)Annual 0.188 0.201 0.188 0.20 2011/12 0.19 A

a) hip replacement Annual 0.389 0.396 0.389 0.40 2011/12 0.39 G

b) knee replacement Annual 0.277 0.293 0.277 0.29 2011/12 0.28 A

c) groin hernia Annual 0.09 0.08 0.09 0.08 2011/12 0.09 G

d) varicose veins Annual 0.00 0.03 0.00 0.03 2011/12 0.00 A

Emergency admissions for children w ith low er respiratory tract infections (NHS OF 3.2) Annual 215.00 366.48 215.00 366.48 2011/12 215.00 G

People w ho have had a stroke w ho are admitted to an acute stroke unit w ithin four hours of

arrival to hospital

People w ho have had a stroke w ho receive thrombolysis follow ing an acute stroke

People w ho have had a stroke w ho are discharged from hospital w ith a joint health and social

care plan

People w ho have had a stroke w ho receive a follow -up assessment betw een 4-8 months after

initial admission

4. Ensuring that people have a positive experience of care A

Patient experience of GP out of hours services (NHS OF 4a ii) Annual 57.65 70.30 57.65 70.30 2011/12 57.65 R

Patient experience of hospital care (NHS OF 4 b) - Kingston Hospital Annual 74.30 75.63 74.30 75.63 2011/12 74.3 A

Friends and family test for acute inpatient care and A&E (NHS OF 4c)

Patient experience of outpatient services (NHS OF 4.1) - Kingston Hospital Annual 75.2 79.5 75.2 79.5 2011 75.2 A

Responsiveness to in-patients’ personal needs (NHS OF 4.2) - Kingston Hospital Annual 64.2 67.4 64.2 67.4 2011/12 64.2 A

Women’s experience of maternity services (NHS OF 4.5)

Patient experience of community mental health services (NHS OF 4.7) - South West London and St

Georges MHTAnnual 83.9 86.6 83.9 86.6 2012 83.9 A

Patient experience of A&E services (NHS OF 4.3) - Kingston Hospital Annual 74.7 78.6 74.7 78.6 2012 74.7 A


PeriodTrend/

Direction

Year end

forecast

Fore-

cast

Appendix 1: Total CCG Performance – by area and indicator


Date: 25 06 13




5. Treating and caring for people in a safe environment and protecting them from avoidable harm A

Patient safety incidents reported (NHS OF 5a) - Kingston Hospital Bi-annual 2.21 11.04 2.21 11.04 Mar-12 2.21 G

Incidence of venous thromboembolism (VTE) (NHS OF 5.1) - Kingston Hospital Monthly 92.0% 95.0% 92.0% 95.0% Apr-13 92.0% A

Incidence of healthcare associated infection: MRSA (NHS OF 5.2.i) Monthly 1 0 1 0 May-13 0 R

Incidence of healthcare associated infection: C diff icile (NHS OF 5.2.ii) Monthly 3 2 4 5 May-13 24 G

Acute Care G

Cancer 1st treatment 62 days: GP Urgent Referral Monthly 100.00% 86.0% 100.00% 86.0% Apr-13 100.0% G

Cancer 1st treatment 62 days: Screening Referral Monthly 100.00% 90.0% 100.00% 90.0% Apr-13 100.0% G

Cancer 1st treatment 62 days: Consultant upgrade Monthly 100.00% 90.0% 100.00% 90.0% Apr-13 100.0% G

Cancer 1st treatment 31 days Monthly 98.11% 96.0% 98.11% 96.0% Apr-13 98.1% G

Cancer subsequent treatment w ithin 31 days for surgery Monthly 100.00% 94.0% 100.00% 94.0% Apr-13 100.0% G

Cancer subsequent treatment w ithin 31 days for cancer drugs Monthly 100.00% 98.0% 100.00% 98.0% Apr-13 100.0% G

Cancer subsequent treatment w ithin 31 days for radiotherapy Monthly 95.00% 94.0% 95.00% 94.0% Apr-13 95.0% G

All cancer 2 w eek w aits Monthly 96.76% 93.0% 96.76% 93.0% Apr-13 96.8% G

Cancer 2 w eek for breast symptoms (cancer not initially suspected) Monthly 93.75% 93.0% 93.75% 93.0% Apr-13 93.8% G

A&E w aiting time >4 hours (Kingston Hospital) Monthly 95.56% 95.0% 95.59% 95.0% Apr-13 95.6% G

Trolley w aits in A&E Monthly 0.00% 0.0% 0.00% 0.0% May-13 0.0% G

Ambulance clinical quality – Category A (Red 1) 8 minute response time (LAS-w ide) Monthly 77.64% 75.0% 77.64% 75.0% Apr-13 77.6% G

Ambulance clinical quality – Category A (Red 2) 8 minute response time (LAS-w ide) Monthly 75.82% 75.0% 75.82% 75.0% Apr-13 75.8% G

Ambulance clinical quality - Category A 19 minute transportation time (LAS-w ide) Monthly 98.04% 95.0% 98.04% 95.0% Apr-13 98.0% G

Ambulance handover time (w ithin 15 minutes) (LAS-w ide) Monthly 63.46% 100.0% 63.46% 100.0% Apr-13 63.5% R

Crew Clear (LAS-w ide) Monthly

90% of stroke patients on stroke unit Quarterly 97.89% 80.0% 96.80% 80.0% Q4 12-13 96.8% G

Suspected TIA treated w ithin 24h Quarterly 55.56% 60.0% 68.75% 60.0% Q4 12-13 68.8% G

Cancelled Operations Quarterly 4.17% 21.7% 2.92% 21.7% Q4 12-13 2.9% G

Urgent operations cancelled for a second time Quarterly

12 w eek maternity Quarterly 91.89% 90.0% 90.62% 90.0% Q4 12-13 90.6% G

RTT 18 w eeks admitted Monthly 94.20% 90.0% 94.20% 90.0% Apr-13 94.2% G

RTT 18 w eeks non-admitted Monthly 96.95% 95.0% 96.62% 95.0% Apr-13 96.6% G

RTT 18 w eeks incomplete pathw ays Monthly 94.91% 92.0% 94.91% 92.0% Apr-13 94.9% G

Number of 52 w eek Referral to Treatment Pathw ays Monthly 0.03% 0.50% 0.03% 0.50% Apr-13 0.03% G

Diagnostic tests w aiting 6 w eeks or more Monthly 0.15% 1.00% 0.15% 1.00% Apr-13 0.15% G

Harmoni SPA 111: Calls answ ered w ithin 60 seconds Monthly 95.46% 95.00% 93.4% 95.00% May-13 93.39% A

Harmoni SPA 111: Calls abandoned Monthly 1.1% 5.0% 1.9% 5.0% May-13 1.88% G

Harmoni SPA 111: Called back w ithin 10 minutes Monthly 52.78% 90.00% 53.7% 90.00% May-13 53.72% R

Non-elective FFCEs (First Finished Consultant Episode) Monthly 1,081 1,060 1,081 1,060 Apr-13 12,816 A

All f irst outpatient attendances Monthly 4,042 3,936 4,042 3,936 Apr-13 47,628 A

Elective f inished f irst consultant episodes (FFCEs) Monthly 1,302 1,401 1,302 1,401 Apr-13 15,624 G

A&E Attendances Monthly 4,909 4,913 4,909 4,913 Apr-13 59,726 G

Mental Health/ Non-Acute Care A

Early Intervention in Psychosis Quarterly 3 6 31 22 Q4 12-13 31 G

Crisis Resolution Home Treatment Quarterly 107 75 308 224 Q4 12-13 413 G

Care Programme Approach Follow Up Quarterly 97.59% 95.0% 98.5% 95.0% Q4 12-13 98.7% G

IAPT - Patient numbers as % of Population w ith Depression etc Quarterly 2.7% 3.5% 10.9% 12.8% Q4 12-13 10.9% R

IAPT – proportion moving to recovery Quarterly 42.90% 40.8% 40.2% 40.2% Q4 12-13 40.2% A

Everyone Counts - Local Priorities G

Proportion of GP-registered population covered by the Risk Stratif ication Scheme Quarterly 0.00% 0.0% 0.0% 0.0% May-13 85.00% G

Number of nursing/ care homes under the nursing/ care home support scheme. Quarterly 100.0% 60.0% 100.0% 60.0% May-13 100.0% G

Kingston at Home Project - SPA and intergrated team by 2013-14 (three key deliverables) Quarterly 0 0 0 0 May-13 3 G



PeriodTrend/

Direction

Year end

forecast

Fore-

cast


Date: 25 06 13

Appendix B: Risk Register

INTEGRATED GOVERNANCE COMMITTEE

Risk Register Summary of Risks There are currently 6 moderate risks, 10 high risks and 1 very high risk identified. The attached risk register details the current risks. The heat map below indicates the risk ratings by impact and likelihood.

Commentary

Risk Register system changes

Kingston CCG uses the RSM Tenon Risk Management product 4Risk to manage the risk register. The following system changes are noted:

The top risk category is now called “very high” as opposed to “extreme”

An additional field has been added to record the “target” risk rating – this is not yet reflected in the standard report generated by 4Risk

Very high risks

Risk 314: Safeguarding children and looked after children services: This risk was escalated following the Ofsted/CQC report of Inspection of Safeguarding & Looked after Children (July 2012) which identified gaps in in service, and also an increase in number of children subject to Child Protection Plan. The IGC debated the continued “very high” rating, and noted the progress of the action plan, but agreed that the rating remained appropriate. New Risks The following risks have been added following the IGC meeting and are recorded as draft as they have yet to be formally agreed: Risk 621: Fraud and bribery - added on advice from Local Counter Fraud Service Risk 622: Conflicts of interest - added following IGC meeting in May 2013 Recommendation: The Committee is asked to review the Risk Register and agree risk scores.

CONSEQUENCE or IMPACT

LIK

ELIH

OO

D

SCORES

Negligible Minor Moderate Major Catastrophic

1 2 3 4 5

Rare 1

334

Unlikely 2

163 166 608

Possible 3

393 571 613 614 615

621

173 611

314

Likely 4

609 610 612 622

Almost certain 5

Documents

INTEGRATED GOVERNANCE COMMITTEE REPORT papers... · INTEGRATED GOVERNANCE COMMITTEE REPORT ... representative of the Medicines Management Team should attend the IGC and provide quarterly