KPMG Full Page Talkbook Template

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SUFFICIENT
Note the Trust Performance to September 09
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Contents

• 1. Key Performance Indicator Dashboard
• 2. Introduction
• 3. Emergency Care
• 4. 18 Weeks
• Cancelled Operations
• LOS
• New to Follow Up Ratios
• Infection Control
• Conclusion

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1. Key Performance Indicators
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2. 3. Introduction Emergency Care
1. Introduction This report provides a
briefing to the Board members on the
performance against key targets up to
September 2009. The paper focuses on the main
targets, identified by the Department of
Health and the Care Quality Commission.

• 2. Emergency Care Accident and Emergency
• Target 98 of patients seen/treated/discharged
  within 4 hours
• The Trust did not meet the 98 Target for the
  month of September (96.65).
• The Trust has seen a 21 YTD increase in
  emergency admissions, predominately via GP
  Referrals. Key Actions-
• Local GP reviewing out of hours admissions.
• Discussions with TCN re involvement of GPs in
  AE department.
• Consultation with AE staff ongoing.
• Decision to recruit additional (approved) 5th
  Consultant.
• Introduction of board rounds every morning.

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4. 18 Weeks
Target 90 admitted patients and 95 non
admitted patients to be seen in 18 weeks. Target
has to be achieved by each specialty. The charts
show the Trusts overall position.
All Specialities are achieving the 90 and 95
targets and the Trust are currently the best
performing in the East of England. There are no
financial penalties attached to this target.
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4.1 - 18 Weeks
NON ADMITTED
ADMISSIONS
THESE ARE INDICATIVE FIGURES ONLY FOR THE MONTH
OF OCTOBER
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5. Cancelled Operations

• The red alert on the performance summary was due
  to 1 patient who breached due to specialist
  equipment needed.
• The number of cancelled operations has shown an
  increase from August to September 09 from 18
  to 44.
• The cancellations continue to arise as a result
  of -
•  
• Out of Theatre Time
• Late session start is the predominate
  cancellation reason. This has a knock on effect
  throughout the day which causes the last patient
  to be cancelled as "out of theatre time" . The
  theatre start times have been  adjusted to allow
  for those consultants that have essential
  meetings e.g. Cancer MDT, which affects their
  ability to start the theatre session at the
  default time to prevent over-runs.
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• The Directorate is currently auditing avoidable
  i.e. late session starts, equipment issues,
  versus unavoidable I.e. surgeon sick, bed
  pressures, cancellations. Avoidable
  cancellations will be discussed at the surgical
  specialty meetings or with individual consultants
  for remedial action.
• Work to analyse the reasons behind the
  cancellations continues drilling to consultant
  level.
• A review of the opera management system is also
  underway with regard to the booking of patients.
  This is being managed via the transformation
  process.

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6. Length of Stay
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7. New to Follow Up Ratio
Most Specialties are doing well against the PCT
contracted New to Follow Up ratio targets with
the exceptions of Anaesthetics, Plastic Surgery
and Paediatrics. Performance management and
review for the specialties where performance
needs to improve is undertaken at the monthly
performance meetings Excluded from the
Contract
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8. Infection Control

• For C-difficile we are below the trajectory
  position by 8 cumulatively as at end of September
  2009.

• For MRSA bacteraemias we are currently on
  trajectory with 3 cases as at end of September.

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9. Conclusion

• An action plan is in place to enhance the AE
  waiting time and ensure that performance
  improves for 2009/10.
• Performance management of cancelled operations
  will be enhanced at the surgical directorate
  performance review meeting, focussing on
  reasons, speciality and individual if required.
• Length of Stay has reduced across Directorates
  and specialties. The Trust is focussing on
  improving Length of Stay with the redesign of
  F7,F8 G8 wards as part of its transformation
  projects.