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INTEGRATED PERFORMANCE DASHBOARD

Lead Director – Director of Planning and Performance

6th July 2016 – Health Board Meeting

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MY LOCAL HEALTH SERVICE 5

STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH 10 INDICATOR 1: NUMBER OF EMERGENCY HOSPITAL ADMISSIONS FOR BASKET OF 8 CHRONIC CONDITIONS PER 100,000 OF POPULATION (ROLLING 12 MONTHS) .............................................................................. 10

STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH 11 INDICATOR 2: NUMBER OF EMERGENCY HOSPITAL RE-ADMISSIONS FOR BASKET OF 8 CHRONIC CONDITIONS PER 100,000 OF POPULATION (ROLLING 12 MONTHS) .......................................................................... 11

INDICATOR 3: UPTAKE OF INFLUENZA VACCINATION AMONG... A) 65 YEAR OLDS AND OVER B) UNDER 65’S IN RISK GROUPS C) PREGNANT WOMEN D) HEALTH CARE WORKERS ................................................. 12

INDICATOR 4: THE % OF SCHEDULED VACCINATION UPTAKE RATES FOR ALL CHILDREN UP TO AGE 4 ............................................................................................................................................................... 13

INDICATOR 5: THE % OF RECEPTION CLASS CHILDREN (AGED 4/5) CLASSIFIED AS OVERWEIGHT OR OBESE ....................................................................................................................................................... 14

INDICATOR 6: THE % OF ADULT SMOKERS MAKE A QUIT ATTEMPT VIA SMOKING CESSATION SERVICES ............................................................................................................................................................ 15

INDICATOR 7: THE % OF THOSE SMOKERS WHO ARE CO VALIDATED AS QUIT AT 4 WEEKS............................................................................................................................................................................ 16

INDICATOR 12 & 13: USE OF ‘MY HEALTH ON LINE’ ........................................................................................................................................................................................................................... 17

INDICATOR 15: NATIONAL PRESCRIBING INDICATOR RATE (INDICATOR IN DEVELOPMENT) ........................................................................................................................................................................... 18

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM 20 INDICATOR 16: DELAYED TRANSFER OF CARE DELIVERY PER 10,000 UHB POPULATION (DTOC) – MENTAL HEALTH (ALL AGES) ........................................................................................................................ 20

INDICATOR 17: DELAYED TRANSFER OF CARE DELIVERY PER 10,000 UHB POPULATION (DTOC) – NON MENTAL HEALTH (AGED 75+) ............................................................................................................... 21

CONTINUED: DELAYED BED DAYS TRANSFER OF CARE DELIVERY - MENTAL HEALTH..................................................................................................................................................................................... 22

CONTINUED: DELAYED BED DAYS TRANSFER OF CARE DELIVERY – NON MENTAL HEALTH ............................................................................................................................................................................ 23

CONTINUED: DELAYED TRANSFER OF CARE - CRITICAL CARE ............................................................................................................................................................................................................... 24

INDICATOR 18: THE NUMBER OF LABORATORY CONFIRMED CASES OF CLOSTRIDIUM DIFFICILE PER 100,000 OF THE POPULATION ...................................................................................................................... 25

INDICATOR 19: THE NUMBER OF LABORATORY CONFIRMED CASES OF STAPHYLOCOCCUS AUREUS PER 100,000 OF THE POPULATION ................................................................................................................. 26

INDICATOR 20: THE NUMBER OF PREVENTABLE HOSPITAL ACQUIRED THROMBOSIS .................................................................................................................................................................................... 27

INDICATOR 21: THE NUMBER OF HEALTHCARE ACQUIRED PRESSURE SORES .............................................................................................................................................................................................. 28

INDICATOR 22: IN DEVELOPMENT: IMPLEMENTATION OF THE UNIVERSAL CASE NOTE MORTALITY REVIEW PROCESS .......................................................................................................................................... 29

INDICATOR 23 TO 26: COMPLIANCE WITH THE PATIENT SAFETY REPORTING SYSTEM .................................................................................................................................................................................. 30

INDICATOR 27: OF THE SERIOUS INCIDENTS DUE FOR ASSURANCE WITHIN THE MONTH, % WHICH ASSURED IN AGREED TIMESCALE ...................................................................................................................... 31

INDICATOR 28: NUMBER OF NEVER EVENTS ....................................................................................................................................................................................................................................... 31

LOCAL MEASURE: COMPLAINTS ....................................................................................................................................................................................................................................................... 32

LOCAL MEASURE: INCIDENTS .......................................................................................................................................................................................................................................................... 33

EFFECTIVE CARE: I RECEIVE THE RIGHT CARE & SUPPORT AS LOCALLY AS POSSIBLE & I CONTRIBUTE TO MAKING THAT CARE SUCESSFUL 35 INDICATOR 30: PERCENTAGE OF PEOPLE AGED 50+ WHO HAVE A GP RECORD OF BLOOD PRESSURE MEASUREMENT IN THE PRECEDING 5 YEARS .................................................................................................... 35

INDICATOR 31 TO INDICATOR 32: NUMBER OF NISCHR CLINICAL RESEARCH PORTFOLIO STUDIES (CRP) & COMMERCIALLY SPONSORED STUDIES (CS) .......................................................................................... 36

INDICATOR 33 TO INDICATOR 34: NUMBER OF PATIENTS RECRUITED INTO NISCHR CLINICAL RESEARCH PORTFOLIO STUDIES & COMMERCIALLY SPONSORED STUDIES ....................................................................... 37

INDICATOR 36: CRUDE MORTALITY .................................................................................................................................................................................................................................................. 38

CONTENTS

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INDICATOR 36 CONTINUED: CONDITION SPECIFIC MORTALITY – DEATHS OF HEART ATTACK (MI) AGED 35 TO 74 WITHIN 30 DAYS OF EMERGENCY ADMISSION ....................................................................... 40

INDICATOR 36 CONTINUED: CONDITION SPECIFIC MORTALITY – DEATHS OF STROKE WITHIN 30 DAYS OF EMERGENCY ADMISSION............................................................................................................... 41

INDICATOR 36 CONTINUED: CONDITION SPECIFIC MORTALITY – DEATHS OF HIP FRACTURE (NOF) AGED >64 WITHIN 30 DAYS OF EMERGENCY ADMISSION ............................................................................. 42

INDICATOR 37: RISK ADJUSTED MORTALITY INDEX - RAMI 2014 ......................................................................................................................................................................................................... 43

INDICATOR 38: PERCENTAGE VALID PRINCIPLE DIAGNOSIS CODE 3 MONTHS AFTER EPISODE END DATE (MONTHLY) .......................................................................................................................................... 44

INDICATOR 39: PERCENTAGE VALID PRINCIPLE DIAGNOSIS CODE 3 MONTHS AFTER EPISODE END DATE (ROLLING 12 MONTHS) ........................................................................................................................... 44

LOCAL MEASURE: CLINICAL CODING QUALITY .................................................................................................................................................................................................................................... 45

DIGNIFIED CARE: I AM TREATED WITH DIGNITY & RESPECT & TREAT OTHERS THE SAME 47 INDICATOR 40: THE % OF PROCEDURES POSTPONED ON >1 OCCASION FOR NON-CLINICAL REASONS WITH LESS <8 DAYS NOTICE THAT ARE SUBSEQUENTLY CARRIED OUT WITHIN 14 CALENDAR DAYS OR AT THE PATIENT’S

EARLIEST CONVENIENCE ................................................................................................................................................................................................................................................................. 47

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE 49 INDICATOR 45: % OF GP PRACTICES OPEN DURING DAILY CORE HOURS OR WITHIN 1 HOUR OF DAILY CORE HOURS .......................................................................................................................................... 49

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE 50 STROKE QUALITY IMPROVEMENT MEASURES (QIMS) – EFFECTIVE FROM 1ST OCTOBER 2015 (INDICATIVE PERFORMANCE APRIL TO SEPTEMBER) ................................................................................................. 51

INDICATOR 52: THE % PATIENTS NEWLY DIAGNOSED WITH CANCER, NOT VIA THE URGENT ROUTE, THAT STARTED DEFINITIVE TREATMENT WITHIN (UP TO & INC.) 31 DAYS OF DIAGNOSIS (REGARDLESS OF REFERRAL

ROUTE) - NUSC ........................................................................................................................................................................................................................................................................... 52

INDICATOR 53: THE % PATIENTS NEWLY DIAGNOSED WITH CANCER, VIA THE URGENT ROUTE, THAT STARTED DEFINITIVE TREATMENT WITHIN (UP TO & INCLUDING) 62 DAYS OF RECEIPT OF REFERRAL - USC .................. 53

INDICATOR 54: THE % OF PATIENTS WAITING LESS THAN 26 WEEKS FOR TREATMENT (RTT) ........................................................................................................................................................................ 54

CONTINUED: LOCAL MEASURE: THE NUMBER OF CAMHS ADHD PATIENTS WAITING FOR TREATMENT 26 & 36 WEEKS .................................................................................................................................. 55

INDICATOR 55: THE NUMBER OF PATIENTS WAITING MORE THAN 36 WEEKS FOR TREATMENT (RTT) ............................................................................................................................................................ 56

INDICATOR 56: THE NUMBER OF PATIENTS WAITING MORE THAN 8 WEEKS FOR A SPECIFIED DIAGNOSTIC ....................................................................................................................................................... 58

LOCAL MEASURE: THERAPIES WAITING TIMES: THE NUMBER OF PATIENTS WAITING MORE THAN 14 WEEKS FOR A SPECIFIED THERAPIES .............................................................................................................. 59

INDICATOR 57: LOCAL MEASURE: CARDIAC PATHWAY (IN DEVELOPMENT) .............................................................................................................................................................................................. 60

INDICATOR 58: THE NUMBER OF PATIENTS WAITING FOR A FOLLOW-UP WHO ARE DELAYED PAST THEIR TARGET DATE ...................................................................................................................................... 62

INDICATOR 59: THE % OF PATIENTS WHO SPEND LESS THAN 4 HOURS IN ALL HOSPITAL MAJOR & MINOR EMERGENCY CARE (I.E. A&E) FACILITIES FROM ARRIVAL UNTIL ADMISSION, TRANSFER OR DISCHARGE ................. 64

INDICATOR 60: THE % OF EMERGENCY RESPONSES TO RED CALLS (IMMEDIATELY LIFE THREATENING) CALLS ARRIVING WITHIN (UP TO & INCLUDING) 8 MINUTES ............................................................................ 65

LOCAL MEASURE: NUMBER OF AMBULANCE HANDOVERS WITHIN 15 MINUTES ......................................................................................................................................................................................... 66

INDICATOR 61: NUMBER OF AMBULANCE HANDOVERS OVER ONE HOUR ................................................................................................................................................................................................. 67

INDICATOR 62: THE NUMBER OF PATIENTS WHO SPEND 12 HOURS OR MORE IN ALL HOSPITAL MAJOR & MINOR EMERGENCY CARE FACILITIES FROM ARRIVAL UNTIL ADMISSION, TRANSFER OR DISCHARGE ....................... 68

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES 70 INDICATOR 66: THE % OF ASSESSMENTS UNDERTAKEN WITHIN (UP TO & INCLUDING) 28 DAYS FROM THE DATE OF RECEIPT OF REFERRAL ............................................................................................................ 70

INDICATOR 67: THE % OF THERAPEUTIC INTERVENTIONS STARTED WITHIN (UP TO & INCLUDING) 28 DAYS FOLLOWING AN ASSESSMENT BY LPMHSS............................................................................................ 71

INDICATOR 68: THE % OF HB RESIDENTS IN RECEIPT OF SECONDARY MENTAL HEALTH SERVICES (ALL AGES) WHO HAVE A VALID CARE & TREATMENT PLAN (CTP) ............................................................................. 72

INDICATOR 70: THE % OF HOSPITALS WITHIN A HB WHICH HAVE ARRANGEMENTS IN PLACE TO ENSURE ADVOCACY IS AVAILABLE FOR ALL QUALIFYING PATIENTS .............................................................................. 73

INDICATOR 71: THE % OF REGISTERED OVER AGED 65 PATIENTS DIAGNOSED WITH DEMENTIA ..................................................................................................................................................................... 74

LOCAL MEASURE: THE % OF PATIENTS REGISTERED AS RECEIVING PALLIATIVE CARE WITH THEIR GP PRACTICE .................................................................................................................................................. 75

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OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM 77 INDICATOR 73: REDUCE WASTE IN SECONDARY & PRIMARY CARE THROUGH THE DELIVERY OF EFFICIENT & PRODUCTIVE SERVICES LOCAL MEASURE: THEATRE EFFICIENCY ................................................................. 77

LOCAL MEASURE: DELIVERED ACTIVITY ............................................................................................................................................................................................................................................. 78

LOCAL MEASURE: AVERAGE LENGTH OF STAY (AVLOS) MEDICINE ......................................................................................................................................................................................................... 80

INDICATOR 74: THE % OF FULL TIME EQUIVALENT (FTE) DAYS LOST TO SICKNESS ABSENCE.......................................................................................................................................................................... 82

INDICATOR 74: THE % OF FULL TIME EQUIVALENT (FTE) DAYS LOST TO SICKNESS ABSENCE.......................................................................................................................................................................... 83

INDICATOR 77: ESTIMATED RATE OF DID NOT ATTEND (DNA) FOR GP APPOINTMENTS PER GP CLUSTER ...................................................................................................................................................... 88

INDICATOR 78: ESTIMATED HIGHEST & LOWEST RATE OF DID NOT ATTEND (DNA) FOR GP APPOINTMENTS PER GP CLUSTER ........................................................................................................................... 88

INDICATOR 79: THE % OF PATIENTS WHO DID NOT ATTEND (DNA) A NEW OUTPATIENT APPOINTMENT ....................................................................................................................................................... 89

INDICATOR 80: THE % OF PATIENTS WHO DID NOT ATTEND (DNA) A FOLLOW-UP OUTPATIENT APPOINTMENT .............................................................................................................................................. 90

LOCAL MEASURE: OUTPATIENT CLINIC CANCELLATIONS ....................................................................................................................................................................................................................... 91

INDICATOR 83: % OF STAFF UNDERTAKING A PERFORMANCE APPRAISAL DEVELOPMENT REVIEW................................................................................................................................................................... 92

LOCAL MEASURE: CORE SKILLS – TRAINING COMPLIANCE .................................................................................................................................................................................................................... 93

INDICATOR 84: % OF TOTAL MEDICAL STAFF UNDERTAKING PERFORMANCE APPRAISALS - CONSULTANT JOB PLANNING .................................................................................................................................... 95

LOCAL MEASURE: FRACTURE NECK OF FEMUR (#NOF) - NUMBER OF PATIENTS ADMITTED TO ORTHOPAEDIC WARD WITHIN 4 HOURS 96

LOCAL MEASURE: FRACTURE NECK OF FEMUR (#NOF) - NUMBER OF PATIENTS WHO GO TO THEATRE FOR REPAIR WITHIN 36 HOURS 97

LOCAL MEASURE: HAND HYGIENE & NUTRITIONAL COMPLIANCE 98

LOCAL MEASURE: SURGICAL SITE INFECTION RATES (ARTHROPLASTY) 99

LOCAL MEASURE: CAESAREAN SECTION RATES & SURGICAL SITE INFECTION RATES (CAESAREAN SECTION) 100

COMMISSIONING 101

GLOSSARY 104

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My Local Health Service In addition to this internal performance report, Cwm Taf UHB also participates in the Welsh Government initiative which enables sharing of quality and

performance information with the public. My Local Health Service is designed to share more information about Cwm Taf with the general public than

ever before.

Cwm Taf UHB is responsible to the public for the health and social care that is provided within its boundaries. My Local Health Service will present

information on the workings of all these areas in a user friendly way so everyone can see how we are performing for our population.

This is a journey of honesty and increasing openness, with a lot more information to be provided over the coming months and then regularly updated.

My Local Health Service will publish various measures showing the quality of NHS services all over Wales. The information is provided where possible

with comparisons to be made between regions and organisations across Wales and not just within Cwm Taf. We encourage members of the public to

use this information to navigate the NHS and to challenge where improvement is needed.

The Website currently includes:

Bilingual access to performance measures for NHS Wales

The option to view information as a table or chart

Direct links to useful websites for further information A frequently asked questions tab

Future work

My Local Health Service is an evolving project with scope for the publication of a wide variety of performance data and useful public health service

information. The vision for My Local Health Service is to provide health care measures of success in more details on a local level. This will include

information about the performance of individual services within a hospital or General Practice.

http://mylocalhealthservice.wales.gov.uk/#/en/lhb/7a5

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At a Glance – part 1

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At a Glance – part 2

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Key Priorities

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 1: Number of emergency hospital admissions for basket of 8 chronic conditions per 100,000 of population (rolling 12 months) Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Medical Director

Period: May 2015 to Apr 2016 Target: Reduction Current Status: 1342

Current Trend & Benchmark How are we doing?

The chart illustrates the number of admissions for the basket of chronic conditions for all Welsh HB’s. Emergency admissions are acknowledged as being directly influenced by the availability and quality of a comprehensive package of services for Integrated Chronic Conditions Management in the community.

Current Trend & Benchmark What actions are we taking?

This target will be achieved by improving chronic conditions management

services in the community, thus stabilising acute capacity. Work is underway with Morlais medical practice to explore the reasons for the practice being an outlier in this area, data quality issues and potential pathway changes.

How do we compare with our peers? What are the main areas of risk?

Cwm Taf is an outlier in this area and further investigative work is required to look at the

reasons for this.

Source: NWIS/Welsh Government Delivery & Performance Website

0

200

400

600

800

1000

1200

1400

1600

1800

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

No.

of

ad

mis

sio

ns

Number of emergency admissions for basket of 8 chronic conditions per 100,000 of population (rolling 12 months)

Cwm Taf Abertawe Bro Morgannwg Aneurin Bevan

Betsi Cadwaladr Cardiff & Vale Hywel Dda

0

200

400

600

800

1000

1200

1400

1600

Cwm Taf Abertawe BroMorganwwg

Aneurin Bevan BetsiCadwaladr

Cardiff & Vale Hywel Dda

No.

of

ad

mis

sio

ns

Number of emergency admissions per 100,000 of population with one of the conditions specified in the basket of 8 chronic conditions in a

rolling 12 months to April 2016

Alzheimers Atrial Fibrillation Cardiovascular CVA

Diabetes Musculoskeletal Neurological Respiratory

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 2: Number of emergency hospital re-admissions for basket of 8 chronic conditions per 100,000 of population (rolling 12

months) Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Medical Director

Period: May 2015 to Apr 2016 Target: Reduction Current Status: 298


The chart illustrates the number of readmissions for the basket of chronic conditions for all Welsh HB’s. Emergency hospital readmissions are defined as the same patient being

admitted to the same LHB for the same chronic condition ‘category’

within a 12 month period (i.e. 365 days or less between the discharge date (from the original admission) and the admission date (of the subsequent admission). The chronic condition measure is based on primary diagnosis only.

Current Trend & Benchmark What actions are we taking?

Within A&E at Cwm Taf Health Board a multi professional clinical group regularly reviews patients with frequent attendance at A&E (more than 5 times per year) and a management plan is agreed to reduce further unplanned attendances and admissions.


Cwm Taf is an outlier in this area and further investigative work is required to look at the reasons for this.

Source: NWIS/Welsh Government Delivery & Performance Website

0

50

100

150

200

250

300

350

400


No.

of

ad

mis

sio

ns

Number of emergency re-admissions for basket of 8 chronic conditions per 100,000 of population (rolling 12 months)



0

50

100

150

200

250

300

350

Cwm Taf Abertawe BroMorganwwg

Aneurin Bevan BetsiCadwaladr

Cardiff & Vale Hywel Dda

No.

of

re-a

dm

issio

ns

Number of emergency re-admissions per 100,000 of population with one of the conditions specified in the basket of 8 chronic conditions in a

rolling 12 months to April 2016

Alzheimers Atrial Fibrillation Cardiovascular CVA

Diabetes Musculoskeletal Neurological Respiratory

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 3: Uptake of influenza vaccination among... a) 65 year olds and over b) Under 65’s in risk groups c) Pregnant women

d) Health care workers Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Public Health

Period: Season 2015/16 (as at 23/03/2016) Target: (a-c) 75% Target: (d) 50%

Current Trend How are we doing?

The level of staff uptake increases year on year. Latest figures indicate

that uptake is approaching 49% of front line staff compared to 46% last yr. It is important to note that this figure does not include the uptake by Bank staff, which if included would have achieved the target of 50%.

Uptake of flu immunisation in primary care for the over 65’s has slightly increased across Wales to 66.6%, Cwm Taf UHB uptake currently stands at 64.9%, 5 practices however have reached over 70% uptake.

There has been a slight decrease in the under 65 at risk group but this is seen across Wales, more work needs to be undertaken in Primary Care to increase uptake. 2, 3 yr. olds flu uptake has seen a 10% increase this yr. School flu vaccination programme has been very successful and has achieved 70% uptake, 2nd highest HB in Wales.

Benchmark: What actions are we taking?

Further work in Primary Care to increase uptake.

Immunisation coordinator has been working with community

facilitator’s undertaking immunisation talks to groups. Immunisation coordinator has been working with one cluster that has

chosen increasing flu vaccine uptake as a priority


None of the Health Boards meet the targets. Cwm Taf is not an outlier in this area and performs comparatively with some other Health Boards.

Immunisation capacity in general practice Flu Myth’s within our communities

Source: Public Health Wales Health Protection Division

0%

10%

20%

30%

40%

50%

60%

70%

80%

2012/13 2013/14 2014/15 2015/16 (CURRENTUPTAKE AS AT23/03/2016)

Perfo

rm

an

ce

Cwm Taf UHB % uptake of the influenza vaccine

Over 65'sUnder 65's in the at risk groupsPregnant womenHealthcare workers (current update Feb 2016)

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 4: The % of scheduled vaccination uptake rates for all children up to age 4 Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Public Health

Period: Apr 2015 to Mar 2016 Target: 95% Current Status: as per table


Quarter 4 of this year has seen an increase in uptake in the MMR1

age 2 and PCV age 2 childhood vaccines and only a small decrease in the other vaccines for children up to age 4. Cwm Taf’s performance continues to exceed the All Wales average.

Benchmark What actions are we taking?

Work is currently being planned to identify practices with lowest

uptake. Subsequent practice visits will be arranged.


Cwm Taf is one of only 4 Health Boards that meets the target for each type of vaccination. Immunisation capacity in general practice.

Source: Public Health Wales Health Protection Division

90%

95%

100%

Apr-Jun Jul-Sep Oct-Dec Jan-Mar

2015/16

Perfo

rm

an

ce

% uptake of scheduled vaccination uptake rates for all children up to age 4

5 in 1 age 1 MenC age 1 MMR1 age 2PCV age 2 HibMenC Booster age 2 Target

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 5: The % of reception class children (aged 4/5) classified as overweight or obese

(To be calculated for health boards where the participation standard of 85% has been achieved) Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Public Health

Period: 2012 to 2014 Target: Reduction Current Status: 28.1%


Cwm Taf UHB’s participation in the Child Measurement Programme (CMP) for Wales (2014/15) is the joint highest at 96.3% with Betsi Cadwaladr UHB.

Since the CMP was introduced there has been a reduction in overweight and obese 4/5 year old children in Cwm Taf.

The latest report shows that 71.9% of 4/5 year olds in Cwm Taf are a healthy weight. However, this is the lowest in Wales.

Cwm Taf has the highest rate of obesity in Wales at 13.2%, comprising 12.9% in Rhondda Cynon Taf and 14.7% in Merthyr Tydfil.

Participation 2013/14 What actions are we taking?

Multi agency Childhood Obesity Steering Group established to lead and coordinate the action locally.

The development of actions to support the prevention of childhood obesity using Public Health Wales 10 Steps to a healthy weight

approach. Following on from social marketing insight work, the information

resource Merthyr Babies: the breast start is being piloted in Merthyr Tydfil.

The Bump Start programme for pregnant women with a BMI of 35+,

covers Rhondda Cynon Taf and is funded by Families First. The external evaluation of Bump Start is expected imminently but

findings from clients who completed the service between Jan-May 2016 have shown that the average weight gain is now 5.6kgs (within recommended guidelines of 5-9 kg, Institute of Medicine).


Cwm Taf has improved its position year on year in relation to this measure. High rates of adult overweight and obesity

Uncertainty over funding of the Bump Start programme from April 2017. There is no programme in Merthyr Tydfil.

Source: Public Health Wales Child Development Programme

0%

5%

10%

15%

20%

25%

30%

35%

Cwm Taf Abertawe BroMorgannwg

AneurinBevan

BetsiCadwaladr

Cardiff &Vale

Hywel Dda Powys

% o

verw

eig

ht/

obese

% of reception class children (aged 4/5) classified as overweight or obese

2012/13 2013/14 2014/15

50%

75%

100%

Cwm Taf AbertaweBro

Morgannwg

AneurinBevan

BetsiCadwaladr

Cardiff &Vale

Hywel Dda Powys

% o

f p

arti

cip

ati

on

Proportion of children aged 4 to 5 years participating in a child measurement programme 2014/15

Wales 94.5%

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 6: The % of adult smokers make a quit attempt via smoking cessation services Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Public Health

Period: Q2 2015/16 Target: 5% Current Status: 1.82%

Current Trend: How are we doing?

The number of people accessing services to support a quit attempt increased in the last quarter. This was mainly due to increased numbers seen by the community pharmacy service, which reflects the increased

numbers of pharmacies providing this service. In addition, delivery of the MAMSS service for pregnant smokers in Rhondda, Cynon & Taf Ely is resulting in increased numbers accessing this support. The MAMSS service consistently treats not 5%, but 30% of pregnant smokers in Rhondda, Cynon and Taff.


Quarter 1

2015/160.86% 0.35% 0.52% 0.86% 0.36% 0.50% 0.47%

Quarter 2

2015/161.82% 0.83% 0.95% 1.83% 0.74% 1.03% 1.25%

Hywel Dda Powys

% Welsh resident smokers who make a quit attempt via smoking cessation services

(target 5% end of fin year)

Cwm Taf

Abertawe

Bro

Morgannwg

Aneurin

Bevan

Betsi

Cadwaladr

Cardiff &

Vale Period

Offering varenicline, as well as NRT, via our community pharmacy service.

Developing the role of health promotion champions within Cwm Taf community pharmacies.

Gaining access to text and remind service for community pharmacies delivering the Level 3 Stop Smoking Service.

Meeting monthly with Stop Smoking Wales (SSW) regarding

performance targets and establishing next steps in line with agreed actions.

Appointed a Stop Smoking Development Worker to work closely with Communities First teams in areas with high smoking prevalence rates. The post is initially based in Rhondda Fach.

Continuing to monitor the proportion of patients listed for surgery,

who want support to quit smoking. Maintaining support for the secondary care ‘no smoking ward

champions’.


Uptake in Cwm Taf of smoking cessation services is similar to that in Betsi Cadwaladr, and is

in excess of that achieved by other HBs.

Continuing low numbers accessing the Stop Smoking Wales service

provided by Public Health Wales. Funding to continue MAMSS and expand into Merthyr Tydfil.

Source: Smoking Cessation Services Data Collection, Welsh Government

0.0%

0.5%

1.0%

1.5%

2.0%


Cwm Taf UHB % smokers making a quit attempt

(Quarterly)

2013 2014 2015

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STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 7: The % of those smokers who are CO validated as quit at 4 weeks Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Public Health

Period: Q2 2015/16 Target: 40% Current Status: 34.13%


This quarter showed a decrease of smokers achieving a CO validated quit to 34.13% which is below the target, but this varies by service month on month.


Quarter 1

2015/1640.91% 44.76% 36.83% 32.26% 36.54% 50.17% 37.78%

Quarter 2

2015/1634.13% 41.57% 36.62% 32.02% 34.30% 47.77% 40.13%

% Welsh resident smokers who are CO validated as successfully quitting at 4 weeks

(target 40% end of fin year)

Hywel Dda PowysPeriod Cwm Taf

Abertawe

Bro

Morgannwg

Aneurin

Bevan

Betsi

Cadwaladr

Cardiff &

Vale

Availability of varenicline via community pharmacy service should

lead to an increased quit rate.

Access to CTUHB’s text and remind service for community pharmacies delivering the Level 3 Stop Smoking Service will enable community pharmacists to remind clients to attend appointments in a timely manner and will also help keep clients motivated. This should increase the quit rate beyond 40%.

SSW are contacting clients that DNA during their course to identify

reasons why and to remind them to return for their CO reading. SSW are trying to obtain the CO validation at the earliest time

within the Russell Standards parameters. SSW are developing a pathway for clients who receive telephone

support to be CO validated at a community pharmacy. SSW are interrogating their data to identify the reasons why clients

are not quit at 4 weeks, which lowers the number that can be CO

validated. MAMSS maternity support workers continue to make every effort to

CO verify at 4 weeks, including phone and text reminders.


The Health Board’s performance is second highest to that of Hywel Dda and exceeds the Tier 1 target of 40%.

Source: Smoking Cessation Services Data Collection, Welsh Government

0%

10%

20%

30%

40%

50%


Cwm Taf UHB % smokers who are CO validated as

successfully quitting (Quarterly)

2013 2014 2015

17

STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 12 & 13: Use of ‘My Health on Line’ Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: Mar 2015 to Feb 2016 Target: Improvement Current Status: as per table


There has been a small decrease in practices offering appointment booking in February. Overall there has an increase in practices offering the service during the last year but Cwm Taf still compares poorly with some Health Boards. There has been a significant increase in the number of practices

offering repeat prescriptions during February however Cwm Taf still remains an outlier in offering this service.

What actions are we taking?

The Primary Care team will promote and support the use of MHOL during the annual Practice Development Visits and ensure that

appropriate information is given to patients about the service.


Cwm Taf has 100% of practices able to use MHOL but is an outlier in offering repeat prescriptions and compares poorly with other Health Boards in offering appointment bookings.

Balancing the number of appointments released. Ensuring that paperwork is completed appropriately. A more robust infrastructure is required to deal with multiple

sites.

Source: Welsh Government Delivery & Performance Website

18

STAYING HEALTHY: I AM WELL INFORMED & SUPPORTED TO MANAGE MY OWN PHYSICAL & MENTAL HEALTH Indicator 15: National prescribing indicator rate (indicator in development)

ANTIBIOTIC PRESCRIBING (these will be linked to the national prescribing indicators) Antibacterial items per 1000 STAR -PU’s (2013

onwards) Cephalosporin’s & Fluoroquinolones items per 1000 patients Strategic Aim: Excellent Population Health Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: Oct 2015 to Dec 2015 Target: Improvement Current Status:



Prescribing Advisors working with practices across Cwm Taf. Specifically targeting those practices with high Antibiotic

prescribing to investigate and provide action plan to reduce rates.


Seasonal pressures in small practices. Patient demand. High use of Locum GPs due to recruitment problems.

Source: Local

0%

1%

2%

3%

4%

5%

0

100

200

300

400

500

Cynon Merthyr Tydfil Rhondda Taff Ely

% o

f C

ep

hals

po

rin

s/Q

uin

ole

ne

Nu

mb

er o

f A

nti

bacte

ria

l Ite

ms

Antibacterial Items Prescribed per 1000 STAR-PU(13)October to December 2015

Antibacterial Items Per 1000 STAR-PU(13)Cephalosporins Items % of Antibacterial ItemsQuinolone Items % of Antibacterial Items

Benchmark not available

20

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 16: Delayed transfer of care delivery per 10,000 UHB population (DToC) – Mental Health (all ages) Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: May 2015 to Apr 2016 Target: Reduction Current Status Rolling 12 months: as per table


Performance has declined during March and April and is poor across a number of specialties for the following reasons; Lack of availability of supported accommodation Lack of availability for specialist OPMH beds in the independent

sector; this has been exacerbated further by the recent closure of Rhondda Nursing Home (60 beds)

The LA process of SEWIC is causing delays in placements for some patients

Some internal ward efficiencies in following up referrals.


All DTOC patients escalated to LA service managers by ADO when

required Further delays escalated to Directors and we are proactively

working through a plan with RCT and introducing a new decision making Matrix for S117 placements

Strategic meeting with LA planned Ensure all Ward Managers follow through on referrals Active member of Gold Command


Cwm Taf’s performance in this area is average amongst its peers. Reduced patient flow.

Source: Local

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50


No

. o

f D

ela

yed

Tran

sfe

r o

f P

ati

en

ts

Delayed transfer of care delivery per 10,000 UHB population - mental health(all ages)

21

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 17: Delayed transfer of care delivery per 10,000 UHB population (DToC) – non Mental Health (aged 75+) Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: Reduction Current Status Rolling 12 months: as per table

Current Trend: How are we doing

Acute DTOC within the Health Board remains comparably low. There was a decrease in March from February with a slight increase in April

with a number of delays related to other Health Board repatriations. A small number of the delays that do exist are however lengthy delays as there are family and legal issues.


Continue joint working between Health and Local Authority colleagues.

Escalation to neighboring HBs continues.

Use of the All Wales transfer database remains in place.


Cwm Taf’s performance in this area is better than 3 of the other Health Boards. A delay due to other Health Boards remains challenging.

Delays in social worker assessments are monitored daily. Legal and family issues constitute the most challenging and lengthy

delays.

Source: Local

0

2

4

6

8

10

12

14

16

18


No

. o

f D

ela

yed

Tran

sfe

r o

f P

ati

en

ts

Delayed transfer of care delivery per 10,000 UHB population - non mental health(aged 75+)

Acute Community

22

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Continued: Delayed bed days transfer of care delivery - Mental Health Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: May 2015 to Apr 2016 Target: Reduction Current Status:


Performance is poor across a number of specialties for the following reasons;

Lack of availability of supported accommodation. Lack of availability for specialist OPMH beds in the independent

sector. Delays by LA in social worker allocation.

Lack of availability for specialist OPMH beds in the independent sector; this has been exacerbated further by the recent closure of Rhondda Nursing Home (60 beds)

The LA process of SEWIC is causing delays in placements. LA funding decisions delays. Some internal ward efficiencies in following up referrals.


All DTOC patients escalated to LA service managers by ADO when required.

Further delays escalated to Directors. Strategic meeting with LA planned. Ensure all Ward Managers follow through on referrals.

What are the main areas of risk?

Reduced patient flow.

Source: Local

0 200 400 600 800 1000 1200 1400 1600

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

Total Beddays

Mental Health Delayed Bed Days Transfers of Care

Merthyr RCT Other LHBs

23

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Continued: Delayed bed days transfer of care delivery – Non Mental Health Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: Reduction Current Status:


The DTOC measure stays with a patient throughout their entire stay and is attributed to the location of the patient at the point of census i.e.

acute or community. If a patient moves from the acute setting to community the DTOC previously associated with acute is then transferred to the community setting.

The increase in community delayed bed transfers of care, particularly in RCT has been exacerbated further by the recent closure of Rhondda

Nursing Home.


Improvements continue to be made in reducing the number of delayed

transfers of care


Availability of community placements remain a challenge.

Source: Local

0 100 200 300 400 500 600 700 800

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

Total Beddays

Acute Delayed Bed Days Transfers of Care


0 200 400 600 800 1000 1200 1400 1600

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

Total Beddays

Community Delayed Bed Days Transfers of Care


24

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Continued: Delayed Transfer of Care - Critical Care Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: COO

Period: Apr 2015 to Mar 2016 Target: 5% Current Status: PCH > 5%, RGH > 5%


From a critical care perspective the delays are calculated on a

basis of total number of delayed hours as a percentage of the

total number of hours used. The expected level of DToC by

the National Critical Care Network is no more than 5%.

The latest data demonstrates an improving picture in RGH of

just above the 5% target. However in PCH where the position has been relatively stable DTOC’s have increased to 15%. This is due to the unscheduled care pressures experienced in March. Moving into the summer period we would expect to see the position improve at both sites.


The main actions to be taken to keep DTOC’s @ 5% target is to ensure patient flow is working well. It is proven that when beds are available on the wards to discharge patients DTOC’s

reduces.


Ensuring that patient flow is maintained so that we do not

have any DTOC’s in the units.

Source: Local

0%

5%

10%

15%

20%

25%

30%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% D

To

C B

ed

Occu

pan

cy

Cwm Taf % DToC Bed Occupancy - Wales Target 5%

Prince Charles Hospital Royal Glamorgan Hospital Wales Target

0

300

600

900

1200

1500


Ho

urs L

ost

Number of hours lost compared to tolerance allowed to meet 5% target

RGH Hours Lost to DToC PCH Hours Lost to DToC

RGH DToC Tolerance PCH DToC Tolerance

25

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 18: The number of laboratory confirmed cases of Clostridium Difficile per 100,000 of the population Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Oct 2015 to May 2016 Target: Oct 2015 to Mar 2017 no more than 26 per 100,000 population Current Status: 4 / Oct- May 53


The lowest C.difficile rate currently in the major health boards is 18.2/100,000 population (Cwm Taf University Health Board). The rates in the other major health boards range from 18.7 to 43.97 per 100,000 of population.

There were 4 C.difficle cases in March of which only 1 was an in-patient.


Good Antimicrobial Stewardship – reducing the need for antibiotic

prescription where not indicated, targeting narrow spectrum therapy according to clinical findings & investigations; reviewing antibiotic prescription 24-48hrs after starting & de-escalating treatment where

appropriate. Multidisciplinary CDI RCAs are completed which have shown a recurring

theme of probable poor antimicrobial stewardship practices. Results are fed back to the clinical teams responsible for patients to ensure lessons learned. A second Antimicrobial Pharmacist has been appointed. Hand hygiene audits performed. The principles of bare below the elbow are encouraged.


Cwm Taf UHB maintains the lowest C.difficile rate in Wales apart from Powys. Poor antimicrobial stewardship. Poor hand hygiene

Source: Public Health Wales (WHAIP)

0

25

50

75

100

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Cu

mu

lati

ve

nu

mb

ers

of

C.d

Dif

ficil

e

Cumulative monthly numbers of C.difficile from October 2015 against the equivalent

period in 2014/15

Cumulative monthly numbers of C.difficile Oct 2014-Sep 2015

Cumulative monthly numbers of C.difficile Oct 2015

0

20

40

60

80

100

No

. o

f C

.dif

ficil

e

Monthly numbers of C. difficile from October 2015

Number of inpatient C.difficle Number of non-inpatient C.difficleCumulative target to achieve expected reduction Cumulative monthly numbers of C.difficile Oct 2015

26

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 19: The number of laboratory confirmed cases of Staphylococcus Aureus per 100,000 of the population Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Oct 2015 to May 2016 Target: Oct 2015 to Mar 2017 no more than 20 per 100,000 population. Current Status: 8 / Oct-May 70


There has been a change in reporting in that the measure now includes all S.aureus

bacteraemias (MRSA and MSSA) There was 0 MRSA cases in April or May. The MRSA cases for the YTD 8 which shows

improvement over the same period last year.

Cwm Taf has along with Betsi Cadwaladr the lowest MRSA bacteraemia rate currently in the major health boards at 0/100,000 population (Cwm Taf University Health Board).

There were 8 MSSA bacteraemia cases in May, 5 of which were in-patients. Cwm Taf

has the highest MSSA bacteraemia rate in

Wales.


Increase hand washing audits within effected clinical areas. Deliver education & training for IV line management

Implemented care bundles which will be monitored & audited. Good Antimicrobial Stewardship – reducing the need for antibiotic

prescription where not indicated, targeting narrow spectrum therapy according to clinical findings & investigations; reviewing antibiotic prescription 24-48 hrs. after starting & de-escalating treatment where appropriate. CDI RCAs (root cause analysis) have shown a recurring theme of probable poor antimicrobial stewardship practices.


Cwm Taf Health Board has the lowest MRSA bacteraemia rate in the major health boards but has the highest MSSA rate.

Poor antimicrobial stewardship. Poor hand hygiene.


0

2

4

6

8

10

12


Cu

mu

lati

ve n

um

bers o

f

MR

SA

Cumulative monthly numbers of MRSA from October

2015 against the equivalent period in 2014/15

Cumulative monthly numbers of MRSA Oct 2014-Sep 2015Cumulative monthly numbers of MRSA Oct 2015

0

50

100

150


Cu

mu

lati

ve n

um

bers o

f

MS

SA

Cumulative monthly numbers of MSSA from October

2015 against the equivalent period in 2014/15

Cumulative monthly numbers of MSSA Oct 2014-Sep…Cumulative monthly numbers of MSSA Oct 2015

0

20

40

60

80

Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17

No

. o

f S

.au

reu

s

bacte

raem

ia

Monthly numbers of S.aureus bacteraemia from October 2015

Total number of inpatient S.aureus bacteraemia Total number of non-inpatient S.aureus bacteraemia

Cumulative monthly numbers of S.aureus bacteraemia Oct 2015 Cumulative target to achieve expected reduction

27

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 20: The number of preventable hospital acquired thrombosis Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: Jun 2015 to May 2016 Target: Continuous Improvement Current Status: 18 (YTD 46)(rolling 12 months 292)


VTE risk assessment compliance is monitored via monthly Pharmacy audits with immediate feedback provide to the Ward

Sister. Ward based compliance results are presented at the quarterly VTE Steering group and shared with Directorates. The VTE compliance rates have decreased to 85% for February

2016, which is below the below the average of 91% for the last 6 months. Further improvement is required and actions are being taken via medical education and induction, local feedback and

sharing of data. The electronic VTE root cause analysis tool and process designed by CTUHB has been further developed to stream line the reporting and monitoring process.

The RCAs are informing learning and improvement with regards to prescribing and administration timeliness.


Clinical Directors with MDTs to ensure completion of the VTE

risk assessments and prophylaxis, prescribing and administration as per local guidelines. To monitor via local Quality and Safety meetings and feedback learning to the VTE Steering group.

The CTUHB VTE RCA tool is now being made available via a web based method to improve tracking and completion of the

RCAs by the lead consultants. Clinical Audit Clerical Officers will assist Medical Records in the

appropriate tracking of patient notes for RCAs to improve RCA compliance rates.


VTE Risk assessment compliance remains above the All Wales average due to the adoption

of CTUHB modified medication chart, which is under review for All Wales rollout.

Non-compliance with VTE risk assessment. Time for consultants to complete RCAs.

Source: Local

05

10152025303540

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

No

. o

f In

cid

en

ts

Potential Hospital Acquired Thromboses

40%

60%

80%

100%

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16%

Co

mp

lian

ce

Proportion of patients with the VTE risk assessment documented on the medication chart

Cwm Taf All Wales


28

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 21: The number of healthcare acquired pressure sores Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Apr 2016 Target: Reduction Current Status: 22 YTD 22


In April 2015 the healthboard adopted the all Wales guidelines for pressure ulcer reporting which increased the number of categories reported to six. These stages

are stage 1, 2, 3, 4, suspected deep tissue injury and unstageable/ungradeable. April 2016 saw 22 reported incidents of pressure ulcers which is above the target level for this year.

The graph illustrates the instances of HAPU broken down by the 4 grades of pressure ulcer.


Established monthly audits for compliance with the timely review and investigation of HAPU incidents.

Training on the Pressure Ulcer Investigation Tool for Senior Nurse Managers. Review of the issues affecting the measurement and monitoring of pressure

ulcers in community and accident and emergency areas

Engage WWIC research. Identifying the cost of improvements and/or cost of failure – working with

finance and PHW. Developing TVN Champion role within clinical areas. CTUHB is leading review of All Wales definitions for pressure damage at the

request of the Directors of Nursing for Wales, which will include making

recommendations for a standardized approach to management, reporting and monitoring of pressure damage across Wales.


Benchmarking demonstrates variability across Wales in how health boards capture,

monitor and measure pressure damage across Wales.

Timeliness of reporting Grade 3, 4 and multiple 2’s to WG.

Mis-categorisation and reporting of pressure ulcer incidents. Limited ownership of reviews, monitoring & investigation of pressure damage

incident.

Source: Fundamentals of Care/ Nursing Dashboard

3

13

3

3

0

50

100

150

200

250

300

0

5

10

15

20

25

30

35

40

Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17

Cu

mu

lati

ve R

ep

orte

d C

ases o

f S

ores

No

. o

f R

ep

orte

d C

ases

at

Sta

ge o

f S

ore

Pressure Sores (Local Data) - Target 20% Reduction on 2015/16 Baseline

Stage 1 Stage 2Stage 3 Stage 4Stage Unknown Cumulative 2015/16Target (20% Reduction on 15/16) Cumulative 2016/17

245

278

389

537

336

191

3815

0

100

200

300

400

500

600

Cwm Taf Abertawe

Bro

Morgannwg

Aneurin

Bevan

Betsi

Cadwaladr

Cardiff &

Vale

Hywel Dda Powys Velindre

To

tal

nu

mb

er o

f p

ressu

re s

ores

Total numbers of Pressure Sores for the 12 month period to April 2016

29

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 22: in development: Implementation of the universal case note mortality review process Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: Apr 2015 to Mar 2016 Target: Improvement Current Status: % completed reviews 71.1% (2015/16)

Current Trend: Please note Quarters 3 & 4 are only partially complete and figures will rise significantly once all reviews are completed

How are we doing?

These figures demonstrate that, for our acute hospitals, there

has a slight drop in performance since April 2015, as was predicted having identified the sub optimal cover from Primary Care at Stage 1 (some Stage 1 support is provided by attending Secondary Care clinicians). Some UMRs continue to

be completed as an ongoing pilot of the medical examiner system by two pathologists in accordance with the expected posts being funded from 2018 and the agreed role of the ME

in the Welsh Mortality Review process. Participation in Stage 2 remains reasonably stable. The numbers for community are probably too low to draw any particular conclusion. As sessions are held on a monthly

basis, any deviation from normal attendance impacts greatly on performance times.

We are putting in place a database developed in ABMU which will link with the QlikSense business intelligence tool to add value to our reporting mechanisms to Directorates and other clinical areas.


We have secured resource to fund additional sessions to review the backlog cases whilst using the existing resource to review recent cases to achieve a more “real time” service. We are vigilant about the threat of slippage in the months ahead

and continue to engage with the Medical Director accordingly.


There are continued risks to the performance, in particular, the support from primary care at Stage 1 is too patchy and

subject to staff shortages reported in that workforce. A significant number of Stage 2 reviews were conducted by a single clinician who has now returned to clinical practice The Post Stage 2 process needs further refining to ensure that lessons learned are translated into effective changes in clinical

practice

Source: Local Data

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM

0%

25%

50%

75%

100%

0

100

200

300

400

500

600

Q1 Q2 Q3 Q4

% c

om

ple

ted

revie

ws

To

tal n

um

ber o

f d

eath

s

Mortality Reviews (Acute & Community)April 2015 to January 2016

Stage 1 only Stage 2 only Stage 3 only Not reviewed % Completed reviews

30

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 23 to 26: Compliance with the patient safety reporting system Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Q4 2014/15 – Q3 2015/16 Target: 100% Current Status: as per Q3 in table


National Patient Safety Agency (NPSA) publications (prior to April 2014). The Health Board is 100% compliant with Patient Safety Alerts

and Patient Safety Rapid Response Reports, issued by the former National Patient Safety Agency (NPSA). No further Alerts in this category will be issued since the disbanding of the NPSA.

Patient Safety Solutions (after April 2014) Following the disbanding of the NPSA, Wales now issues its own safety notices, now known as Patient Safety Solutions – these include Alerts and Notices, which are reported

separately. Our current position is: Alerts. The Health Board is 100% compliant with the 2 Alerts issued. Notices. A total of 22 Notices have been now been issued. The

Health Board is compliant with 19 (86%) of these Notices. The four identified as non-compliant in the last report are now

complete.


Of the 3 outstanding, 1 is outside of the timescales for completion. Action

is being taken and is expected to be completed by the end of January 2016. Work is in progress to implement the 2 safety notices received during December:

Appropriate leads have been identified Risk assessments have been undertaken

Action plans are in place No barriers have been identified - Completion is therefore on course within the timescales.


Cwm Taf University Health Board’s overall compliance in among the best in Wales.


31

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Indicator 27: Of the serious incidents due for assurance within the month, % which assured in agreed timescale

Indicator 28: Number of never events Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Mar 2015 to Feb 2016 Target: Indicator 27 – 0% Target: Indicator 28 – Zero Current Status: as per tables

Current Trend & Benchmark Indicator 27 How are we doing?

The Health Board reports a 100% of serious incidents to Welsh Government and ensures robust investigation is undertaken which results in learning and improvement.

The Health Board currently has a significant backlog of closure forms awaiting submission to the Welsh Government. It should be

noted for the majority of these incidents the investigation has been completed and lessons identified. However the formal closure process has not been completed.

A never event was reported by the Health Board during December 2015. The incident related to the wrong size prosthesis being used during a left total hip arthroplasty for a Cwm Taf patient at the Spire Hospital. The incident has been fully investigated and lessons learned identified.

Current Trend & Benchmark Indicator 28 What actions are we taking?

An action plan relating to the never event in December has been developed and all actions completed by the 31/01/2016. Focused work is being undertaken by the Concerns Team to address the significant backlog of outstanding closure forms requiring

submission to the WG, which is monitored weekly. In order to reduce the risk of further backlog the closure form will be included as the end point of the investigation process.


The Welsh Government has identified the submission of closure forms as a specific risk for the Health Board which is being closely monitored to ensure improvement.

The main areas of clinical risk are being addressed through the Quality Delivery Plan. The remaining significant risk is that of organisational reputation in view of the percentage of overdue closures.


32

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Local Measure: Complaints Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Feb 2015 to Jan 2016 Target: Reduction Current Status: 69 Jan 2016 & (rolling 12 months) 850 (Feb 15 to Jan 16)


New complaints. The number of formal complaints being received continues to decrease. Many complaints which would have been managed

through the more protracted formal process are now being managed ‘on-the-spot’ or are being prevented in the first place through a more proactive approach by the Directorates.

Compliance with the 30 day target.

The number of complainants who received a final response within 30 days remained at 11% for December. Achieving better compliance in this area is dependent on both corporate management and the Directorates.

Compliance with 6 month target: Despite a slight improvement in compliance with the 6 month target during June, this has now fallen again to 81.82%. The current clinical pressures being experienced within the Clinical areas have impacted on the ability of staff to undertake investigations and provide information for complaint responses. In addition resources issues

within the Concerns Team have impacted on compliance with the response targets.

The Corporate Team continues to work with the Directorates to improve processes and provide responses in a timely manner, which will be reflected in future compliance.

Current Trend What are the main areas of risk?

Risk which results from these delays are: People raising the complaints become dissatisfied and in some cases

distressed waiting for responses,

Increased workload for who have to manage more queries from distressed patients and families.

Financial and reputational risks: Escalation to the press and local MPs / AMs Increased referrals to the Ombudsman Fines imposed for delays in managing complaints Increased likelihood of escalation to claims

Themes. The significant number of complaints relating to delays in

accessing treatment, which was previously reported as a risk particularly in Child & Adolescent Mental Health Services, Orthopaedics, and

Ophthalmology, has now improved as a result of more proactive management.

Source: Local

0

200

400

600

800

1000

1200

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Nu

mb

er o

f co

mp

lain

ts

Total number of new complaints (rolling 12 months)(inclusive of those managed by local resolution and on the spot)

Managed by local resolution Managed on the spot

0%

25%

50%

75%

100%


Perfo

rm

an

ce

Complaints managed by local resolution /Compliance within 30 day & 6 month response targets

Complaints responses - compliance with 30 day targetComplaints responses - compliance with 6 month target

33

SAFE CARE: I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOWN HARM Local Measure: Incidents Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Nursing

Period: Mar 2015 to Feb 2016 Target: Reduction Current Status: 8635 (rolling 12 months)


The majority of patient safety incidents reported result in no harm or low harm for the patient. High numbers in these categories are an

indication of a good safety culture. The main area of risk relates to the % of incidents that result in moderate harm to patients. The Health Board has a higher number of

incidents reported as causing moderate harm than the national average of 7.9% - the Health Board currently reports 12.5%. This has not reduced as it should have done since previous quarters.


Data quality issues identified within the information is being addressed through daily monitoring of moderate and severe incidents

is undertaken to identify inaccuracies and correct reported incidents targeted training continues to be provided to ensure accurate reporting and appropriate action is taken.


Inaccurate reporting, which results in being unable to identify trends and real risks which need urgent action to address.

Source: Local

0

2000

4000

6000

8000

10000

Nu

mb

er o

f In

cid

en

ts

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Death 4 5 5 5 6 6 6 6 6 6 6 2

Severe 71 72 71 63 70 52 45 32 34 33 30 20

Moderate 1126 1162 1202 1216 1194 1202 1202 1175 1139 1155 1158 1171

Low 2995 2980 3005 3021 3040 3067 3060 3054 2977 2914 2807 2898

No harm 4944 4994 5023 4988 4947 4861 4793 4692 4650 4571 4530 4544

Incidents Recorded by Level of Harm (rolling 12 months)

35

EFFECTIVE CARE: I RECEIVE THE RIGHT CARE & SUPPORT AS LOCALLY AS POSSIBLE & I CONTRIBUTE TO

MAKING THAT CARE SUCESSFUL Indicator 30: Percentage of people aged 50+ who have a GP record of blood pressure measurement in the preceding 5 years Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: April 1st 2016 Target: Improvement Current Status: as per chart


In addition to access information, Health Boards are also requested to

monitor numbers and percentages of patients recorded with Dementia or as being on a Palliative Care pathway and also those that have had a blood pressure recorded within the last five years.

There has been an overall increase in the percentage of patients with a BP reading, and as can be seen from the graph the Cynon cluster has the highest percentage closely followed by Rhondda.


A focus for action in the Cwm Taf UHB Tackling Inequalities in Health initiative.

Continuing to review through the QOF process. Part of the analysis by Locality Clinical Director identifying outliers

– this then to be used as part of the conversation in the clinical QOF visit.


Cwm Taf’s performance is currently the best in Wales. Registers come from QOF data – delays in applying the new year contract rules can be up to late October early November.

Read coding. QOF participation is voluntary.

Source: Local

89.5%

90.0%

90.5%

91.0%

91.5%

92.0%

92.5%

93.0%

93.5%

94.0%

94.5%


The % of patients aged 50+ who have a record of blood pressure in the preceding 5 years to April 1st 2016

36


MAKING THAT CARE SUCESSFUL Indicator 31 to Indicator 32: Number of NISCHR clinical research portfolio studies (CRP) & commercially sponsored studies (CS) Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: 2012 to 2015/16 (Q2) Target: Improvement Current Status: as per chart


Key performance indicators set by DSCHR, WG relate to increased research activity within Wales. Organisations are expected to increase the number of open CRP and

commercial studies by 10% pa. across all services in primary and secondary care. The DSCHR provides R&D funding to organisations to develop their own research infrastructure to encourage high quality research is undertaken. The funding is based

on research activity i.e. the no. of open CRP studies, the no. of participants recruited to CRP studies and the no. of Chief Investigators affiliated to the organisation The number of CRP studies open in CTUHB shows a 110% increase in 2014-15 from

the previous year. In 2014-15, CTUHB also exceeded the 10% KPI for the no. of Chief Investigators affiliated to CTUHB. As a result the R&D funding in 2015/16 was £792,707, an increase of £201,508 from the previous year. This allowed further development of Cwm Taf’s research infrastructure, providing Cwm Taf patients with the opportunity to undergo new therapies and treatment regimes.


Appointment of a Band 6 research nurse in July 2015 to support the development of commercial and non-commercial research. This has had a positive impact on the no. of clinicians in Cwm Taf expressing an interest in undertaking commercial research and completing the commercial feasibility questionnaires requested by the commercial companies. 2 further commercial research studies have opened for recruitment during 2015-16.

Discussions with the Health and Care Research Wales Support Centre to embed a

HCRW industry manager within the R&D Dept. to enhance measures put in place by

the HB to develop the CRP. Discussions with the Health and Care Research Wales Support Centre to embed

fulltime a Band 5 research nurse and a clinical research officer. The R&D dept. provides a fully equipped office in KHHP to facilitate primary care

and community research.


CT has low levels of CRPs & commercial activity compared to other HBs

Source: Local / Welsh Government Delivery & Performance Website

27 20 41 282 2 1 10

10

20

30

40

50

2012/13 2013/14 2014/15 2015/16 (Q1/Q2)

Nu

mb

er o

f S

tud

ies

Number of Clinical Research Portfolio & Commercially Sponsored Studies

Number of NISCHR Clinical Research Portfolio Studies

Number of commercially sponsored studies

37


MAKING THAT CARE SUCESSFUL Indicator 33 to Indicator 34: Number of patients recruited into NISCHR clinical research portfolio studies & commercially sponsored

studies Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: 2012 to 2015/16 (Q2) Target: Improvement Current Status: as per chart


The total number of participants recruited to CRP studies in 2012-13 to 2014-15 and shows a 97% increase in 2014-15 from the previous year. Cwm Taf did not meet the DSCHR’s KPIs to increase the no. of open

commercial research studies and no of participants recruited to commercial studies by 10%, which has predominantly been due to insufficient time for clinicians to undertake the research, as well as a lack of nursing support.

Increasing commercial activity is a priority for the R&D Department.


As above for indicators 31 & 32.


Although the total number of recruits for Cwm Taf is lower than some HBs, Cwm Taf had the best performance in terms of the increase in total number of recruits for CRP

studies (97%).

Increased research activity will necessitate the development of protocols and policies to meet MHRA requirements as well as development of a policy for

financial management of commercial research income.


279 419 823 3494 3 1

0

200

400

600

800

1000

2012/13 2013/14 2014/15 2015/16 (Q1/Q2)

Pati

en

ts r

ecru

ited

in

to C

RP

Number of Patients Recruited into Clinical Research Portfolio & Commercially Sponsored Studies

Number of patients recruited into NISCHR Clinical Research Portfolio Studies

Number of patients recruited into commercially sponsored studies

38


MAKING THAT CARE SUCESSFUL Indicator 36: Crude Mortality Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: May 2015 to Apr 2016 Target: Reduction Current Status: 2.96% (in month) 2.57% (rolling 12 months)


In order to provide a more up to date position for mortality index, the graphs represent the position from an extrapolation of local data from CHKS.

Mortality and RAMI rely heavily on the completeness of clinical coding, the standard for which is for Health Boards to work towards achieving currently

95% at a 12 week rolling scale and 98% on a rolling 12 month scale by 31st March 2016. Cwm Taf is presently at 95.5% against the 95% target and 98.5% against the 98% target.


There are currently a number of specific quality improvement projects being

undertaken: The systematic medical record reviews on the acute sites are continuing on a

weekly basis. The process is evolving in readiness for the medical examiner system when introduced.

The systematic reviews of deaths in community hospitals commenced on a fortnightly basis. (Currently a monthly basis due to small numbers).

Mortality reviews are regularly undertaken at both acute A&E depts. Mortality reviews follow a three stage process whereby stage 1 is to screen

out the expected deaths and stage 2 is for more detailed reviews of

unexpected deaths which could either prove to be unavoidable or proceed to stage 3 for potential learning and improvement.( figs 3 &4)

The All Wales Mortality Review Group is producing a new set of mortality indicators in line with the recommendations submitted to the Minister by Professor Stephen Palmer last year.

Fractured NOF peri-operative management, being led by the Clinical Director of Trauma & Orthopaedics.

Anticoagulation Review final recommendations were submitted to the Executive Board on 20th January 2016 and work is ongoing to implement the findings.


Cwm Taf does have both higher crude mortality rates and RAMI than Welsh Peers. For

a fuller explanation see Observations on the next page (p39).

Higher prevalence of chronic conditions in the Cwm Taf population.

Source: CHKS

1.00

1.50

2.00

2.50

3.00

3.50

Morta

lity

Rate

(%

)


Cwm Taf 2.65 2.10 2.09 2.67 2.21 2.27 2.45 2.84 3.08 2.73 2.87 2.96

Welsh Peers 1.75 1.54 1.42 1.53 1.54 1.62 1.67 1.74 1.91 1.83 1.99 1.70

Crude Mortality (in month)

1.25

1.50

1.75

2.00

2.25

2.50

2.75


Morta

lity

Rate

(%

)

Crude Mortality Rate - rolling 12 months



39


MAKING THAT CARE SUCESSFUL Indicator 36 continued: Crude Mortality (age bands) Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: May 2015 to Apr 2016 Target: Reduction Current Status: as per table below

Current Trend : Crude Mortality (age bands) Observations

Observations

0-15 years – the Health Board is on par with the All Wales mortality with very few deaths. 16-44 years – the Health Board reports higher % mortality than All Wales. Investigation of individual patients indicates this relates to those with a diagnosis of cancer. 45-64 years – the Health Board reports a more significantly higher level of mortality than other age group. This includes a case mix of cancer and drug & alcohol related deaths.

65-74 years – the Health Board reports a higher % than All of Wales. A high proportion of patients coded with palliative care, pneumonia, and stroke. 75+ years – the Health Board reports a high number of deaths. Age 75 to 90 deaths include pneumonias (lung diseases), stroke, heart failure, palliative care.

Age 91 to 100 again deaths include pneumonia, heart failure, palliative. Age 100+ pneumonia, sepsis and other age related diseases are observed. Cwm Taf’s population has higher rates of deprivation associated with higher rates of crude mortality as well as having greater rates of co-morbidities. Contributory

factors are lifestyle issues like obesity, smoking, alcohol and drug use which are more prevalent in the Cwm Taf population. Also life expectancy and healthy end of life years are shorter for the Cwm Taf population compared to Wales. The ratio of emergency care to elective care is higher in Cwm Taf and it is known that emergency care has higher risks and mortality. There are also a higher proportion of patients presenting with later stage cancer.65% of deaths in Cwm Taf take place in hospital compared to an All Wales average of 55.9% therefore further improvement is still required to support patients who wish to die outside of hospital. To address the contributory factors all Cwm Taf UHB local delivery plans have specific areas to address lifestyle issues and support early recognition and speedier management of illness particularly in cancer. These figures and factors should be interpreted in line with the CTUHB Risk Adjusted Mortality Index report which can be found at: http://www.cwmtafuhb.wales.nhs.uk/risk-adjusted-mortality-index-1

Source: CHKS

http://www.cwmtafuhb.wales.nhs.uk/risk-adjusted-mortality-index-1

40


MAKING THAT CARE SUCESSFUL Indicator 36 continued: Condition Specific Mortality – Deaths of Heart Attack (MI) aged 35 to 74 within 30 days of Emergency Admission Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: Feb 2015 to Jan 2016 Target: Reduction Current Status: 1.4%

Current Trend

How are we doing? What actions are we taking?

It should be noted that there is a Networking arrangement in place for acute coronary intervention for Cwm Taf patients. There has been some improvement regarding the transfer delay for Cwm Taf patients to access intervention in Cardiff however more improved is still required.

Younger patients with less comobidities are usually accepted for transfer to

Cardiff for intervention which means that the cohort of patients staying

within Cwm Taf tend to be older with more comobidities.

Unlike other Health Boards, there is no specific on-call service for Cardiology

at Cwm Taf. Cardiolgists form part of the General Medicine intake which

means there is no 24/7 cardiac service on either acute DGH.

Low numbers of cases can affect percentages.

Improvement is still required regarding consistency in defintion and coding for ACS and MI as shown by the decrepency in activity data between PEDW and MINAP.

There is a higher risk for CVD in Cwm Taf < 74 years old patients due to

higher incidence of smoking, high blood pressure, obesity and type 2

diabetes.

The Cwm Taf cardiac disease delivery plan aims to address underlying

risk factors for CVD across the whole pathway primary, community and

secondary care with emphasis on smoking cessation, weight

management and blood pressure control.

Cwm Taf UHB and ABUHB are working jointly on an inverse care law

programme to support improvement regarding prevention and reduction

of risk factors with regard to CVD.

Lead Cardiologists are looking into the pathology of MIs.

All in-patient deaths from MI are reviewed by a multi-disciplinary team

led by Jason Shannon, Assistant Medical Director.

Source: CHKS

0%

2%

4%

6%


Morta

lity

Rate

%

Deaths of Heart Attack (MI) aged 35 to 74 within 30 days of Emergency Admission (rolling 12 months)

Cwm Taf Welsh Peers

41


MAKING THAT CARE SUCESSFUL Indicator 36 continued: Condition Specific Mortality – Deaths of Stroke within 30 days of Emergency Admission Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director


Current Trend Issues Affecting Performance: Agreed Actions:


Small instances of deaths within stroke can cause signifcant fluctuations in the RAMI and can possibly be unreliable.

Low numbers of cases can affect percentages. There is still a requirement to develop 7 day stroke nurse coordinator input. There remain concerns on level of junior medical support.

Recent improvements in performance are as a result of improved patient

flow in general.

There is now a dedicated stroke bed on the ward, which has been

successfully ring-fenced.

There are now 24/7 thrombolysis services. (Networking arrangements).

Centralisation of acute stroke admission to Prince Charles Hospital was

completed in March 2015. All acute strokes are now admitted to the

single unit.

All nurses in the unit are trained and specialise in stroke care. There is

more robust and consistent stroke specialist therapist and senior medical

staffing.

All in-patient deaths from Stroke are reviewed by a multi-disciplinary

team led by Jason Shannon, Assistant Medical Director.

Source: CHKS

12%

13%

14%

15%

16%


Morta

lity

Rate

%

Deaths of Stroke within 30 days of Emergency Admission(rolling 12 months)

Cwm Taf Welsh Peers

42

EFFECTIVE CARE: I RECEIVE THE RIGHT CARE & SUPPORT AS LOCALLY AS POSSIBLE & I CONTRIBUTE TO MAKING

THAT CARE SUCESSFUL Indicator 36 continued: Condition Specific Mortality – Deaths of Hip Fracture (NoF) aged >64 within 30 days of Emergency Admission Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director


Current Trend Issues Affecting Performance: Agreed Actions:


Work is ongoing to improve outcomes in fractured neck of femur (#NOF), using an approach targeted at different elements of the pathway. This includes:

Work with WAST for pre admission elements e.g. improved analgesia. Monitoring of delays in A&E to reduce these. Prioritising these patients to enable speedy access to theatre. Determining how to improve Ortho-geriatric input.

Again, small numbers at a local level will result in more variation at UHB level than

would be seen at all Wales level.

Fracture Neck of femur is prioritised on the emergency list on Saturday and

Sunday (supported by the anaesthetic department).

Implement a ring fenced cubicle on the ward for Fracture Neck of femur

patients.

Improved rates of local block in A&E.

All in-patient deaths associated with #NOF are reviewed by a multi-

disciplinary team led by Jason Shannon, Assistant Medical Director.

Source: CHKS

0%

2%

4%

6%

8%


Morta

lity

Rate

%

Deaths of Hip Fracture (NoF) aged >64 - Major Trauma within 30 days of Emergency Admission (rolling 12 months)

Cwm Taf Welsh Peers

43


THAT CARE SUCESSFUL Indicator 37: Risk Adjusted Mortality Index - RAMI 2014 Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Medical Director

Period: Feb 2015 to Jan 2016 Target: Reduction Current Status: Index 123


Mortality and RAMI rely heavily on clinical coding completeness. Cwm Taf presently is 95.5% against the 95% target and 98.5% against the 98% target.

A review of the Q4 2014/15 was conducted and a report was sent to the Board in May 2015. The internal process of structured mortality review meetings & use of Warwick charts in A&E highlighted the rise in mortality cases from Nov 2014. The investigation found:

The ratio of Stage 1 mortality reviews to Stage 2 increased from 6:1 to 10:1 Increased cases of community acquired pneumonia as % of total deaths Dec 14 to Mar 15,

increased admissions during that period and patients from DSH moved to RGH. Re-examination of the RAMI model showed that; it is heavily influenced by clinical coding

which is in turn influenced by PBR, uncoded deaths and that small numbers of deaths in specialties & sites have an impact, some chronic conditions e.g. cancer by nature of frequent admissions are assigned low risk of death on each episode and the method of coding transfers between consultants/specialties during the episode of care has an impact on the calculation.

The conclusion, shared with Terry Gill, is that whilst RAMI is important and useful to continue

monitoring and publishing mortality data it is unhelpful in a number of ways. Cwm Taf believes

that the best way of monitoring and learning by mortality reviews is by multi professional review of every death rather than relying on statistical review e.g. across the UKK units have shown low RAMI but with negative quality of care reports. A separate report regarding the investigation will be sent to the Board.

RAMI 2013 vs. RAMI 2014 (April 2011 to Sep 2015) What actions are we taking?

There are currently a number of specific quality improvement projects being undertaken: The systematic medical record reviews on the acute sites are continuing on a weekly basis.

The process is evolving in readiness for the medical examiner system when introduced. Mortality reviews are regularly undertaken at both acute A&E departments. Mortality reviews follow a three stage process whereby stage 1 is to screen out the

expected deaths and stage 2 is for more detailed reviews of unexpected deaths which

could either prove to be unavoidable or go to stage 3 for potential learning and improvement.

Thrombosis risk assessment & prophylaxis has been rolled out an. In December 2015 the number of suspected HAT was 18.

Fractured NOF perioperative management, being led by the Clinical Director of Trauma & Orthopaedics.

Anticoagulation Review final recommendations were submitted to the Executive Board on 20th January 2016.


CTUHB has higher crude mortality rates and RAMI than Welsh Peers. Higher prevalence of chronic conditions in the Cwm Taf population.

Source: CHKS

100

105

110

115

120

125

130

In

dex


Cwm Taf 121 124 124 125 125 125 125 125 124 124 123 123

Welsh Peers 111 111 111 111 111 111 110 110 109 109 108 109

Risk Adjusted Mortality Index 2014(12 Monthly Rolling Index )

80

90

100

110

120

130

140

150

160

170

180

RA

MI S

core

RAMI 2013 & RAMI 2014

Prince Charles & Royal Glamorgan Hospitals (rolling 12 months)

PCH RAMI 13 RGH RAMI 13

44


THAT CARE SUCESSFUL Indicator 38: Percentage valid principle diagnosis code 3 months after

episode end date (monthly)

Indicator 39: Percentage valid principle diagnosis code 3

months after episode end date (rolling 12 months) Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Planning & Performance

Period: Apr to Jan 2016 Target: Indicator 38: (95%) Current Status 95.1% Target: Indicator 39: (98%) Current Status: 98.6%

Current Trend & Benchmark All Wales How are we doing?

The reported coded position for January 2016 is at 95.1%, which is

higher than the All Wales coded average of 88%, and maintains the return to achieving the 95% in month target.

This can be attributed to the department concentrating on coding the relevant case notes for the appropriate time period. This has involved a great deal of effort in tracking down the relevant case notes which are often distributed across the Health Board.

The rolling 12 month target of 98% currently stands at 98.6% for Cwm Taf which is an improvement on last month. Prioritizing workloads to reach targets will continue to maintain and

improve the current position.


The reporting position and the ongoing monitoring of productivity of the coding team are continuing on a weekly basis. This ensures that the coders code the case notes in turn.

One of the appointed clinical coders is now in post and will begin the in house training programme and will also be working on an e-learning package to support the Standards course run by Data Standards. The audit programme is embedded ensuring both quality and

completeness remains a priority to improve confidence in the coded

data. Previously overtime has been used to support compliance with targets but ceased from December 1st due to exhaustions of funds. Continuing promotion of Clinical Coding to Junior Doctors.


Cwm Taf’s position reported position demonstrates an average performance compared to its peers. A recent change to the central reporting algorithm is reflected in the performance trend.

Continuing sickness levels Availability of the case note

Information in the case note that is both legible and complete is an ongoing challenge.

Source: NWIS/Local

99.8 99.4 98.4 97.0 96.6 95.1 95.1 92.6

0

20

40

60

80

100

Powys Velindre Cwm Taf Aneurin Bevan Hywel Dda Abertawe Bro

Morgannwg

Betsi

Cadwaladr

Cardiff & Vale

Vali

d D

iag

nosis

%

Coding Completeness (reported position)April to January 2016

All WalesAverage 95.9%

45


THAT CARE SUCESSFUL Local Measure: Clinical Coding Quality Strategic Aim: Excellent Patient Outcomes Strategic Change Programme: Executive Lead: Director of Planning & Performance

Period: 2014/15 & Apr to Jan 2016 Target: Improvement Current Status: 94.6% (2015/16)

Current trend & All Wales Benchmark How are we doing?

The table outlines Cwm Taf’s position in comparison with rest of Wales in relation to some key data quality indicators. Coding completeness is the

main contributor to the quality index however the quality index is based on three elements :

Completeness – measured by the percentage of coding assigned, April 2015 to January 2016 we are 94.6% compared to the all Wales 91% Corrective – invalid diagnosis and procedure measures contribute to this,

for April 2015 to January 2016 CHKS reports all Cwm Taf Primary Diagnosis and Procedure codes are valid. Coding richness – Accuracy of Primary Diagnosis, Cwm Taf is still looking to improve the amount of Signs and Symptoms that are coded in a primary position, and to increase specificity.

Overall performance against the key quality elements is better than the Welsh peers. Two challenging areas are “Diagnosis Non-specific” and the “signs and symptoms” used as a primary diagnosis these two areas have deteriorated from last year and are higher than the Welsh peers.


Utilising CHKS reports, Cwm Taf’s position is compared to All Wales peer group. There is the ability within the reports to compare to wider peer groups e.g. the forty top performing organizations who submit data to CHKS.

In order to improve the use of “signs and symptoms” as a primary diagnosis Clinical Coding are working with Clinicians validating Information in the case note and on the Clinical Systems.


Currently Cwm Taf is performing well in relation to Percentage of Blank Primary Diagnosis, and Data Quality and Completeness Index.

The poor performance in relation to non-specific diagnoses and the use of signs and symptoms as a diagnosis highlights the importance of more focused work between clinical coding and the medical staffing body.

Source: CHKS

47

DIGNIFIED CARE: I AM TREATED WITH DIGNITY & RESPECT & TREAT OTHERS THE SAME Indicator 40: The % of procedures postponed on >1 occasion for non-clinical reasons with less <8 days notice that are subsequently

carried out within 14 calendar days or at the patient’s earliest convenience Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: Improvement Current Status: 56.9%


As part of WG’s manifesto, the Health Minister gave a commitment to patients that should their operations be cancelled on more than one occasion, with less than 8 days notice then they would receive treatment within 14 days of the second cancellation, or at the patient’s earliest convenience. This has now become a Tier 1 target on which Health Boards report monthly. The

data for this measure is extrapolated from the Health Board’s Myrddin

application at the end of each month. The graph opposite shows the level of procedures cancelled on more than one occasion recorded each month and whether the procedure is then carried out within 14 days of the second cancellation. The secondary axis (blue

dotted line) plots the % performance for the procedures carried out within 14 days. For example, in March 2015 56 patients had their procedure cancelled on more than one occasion and 18.2% were subsequently carried out within 14 days of the second cancellation. In April 2016 only 56.9% of 58 patients who had their appointments cancelled were seen within 14 days, which is a

marked decrease in performance.

The expectation is that this manifesto applies to 100% of patients to who it relates.


The Health Board is raising awareness of this measure amongst patient

booking staff and ensuring that data capture accurately reflects the discussions being undertaken with patients. This will ensure increased compliance with this measure.


Cwm Taf compares poorly against other Health Boards. Bed availability issues adversely affect this measure.

Periods of patient unavailability need to be accurately recorded for this measure to be calculated accurately.

Source: Local

0%

10%

20%

30%

40%

50%

60%

0

20

40

60

80

100

120

140

May-15 Jun-15 Jul-15 Aug-15Sep-15 Oct-15 Nov-15Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

% p

ati

en

ts s

een

wit

hin

14

days

No.o

f P

ati

en

ts

Postponed Admitted Procedures

Seen Within 14 Days Not Seen Within 14 days Not Seen Patient Choice

Medically Unfit % Seen Within 14 days

49

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN

DECISIONS ABOUT MY CARE Indicator 45: % of GP practices open during daily core hours or within 1 hour of

daily core hours

Indicator 46 : % of GP practices offering appointments

between 17:00 & 18:30 hours at least 2 nights per week Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Prim. Care & Mental Health

Period: April 2016 Target: Improvement Current Status: Indicator 45: 98% / Indicator 46: 100%


Under the domain of Timely Care, Health Boards are now to report on the following measures:

Percentages of GP Practices open during daily core hours or within one hour of

daily core hours.

Percentage of GP Practices offering appointments anytime between 17:00 and 18:30 hours at least two nights per week.

The charts show the distribution of registered patient’s between the four GP clusters and the appointment availability within each of the clusters. Within in Merthyr Tydfil locality the practice not meeting the requirement to open within one hour of daily core hours is a single hander working in an isolated and rural area of

the locality but to note they have good feedback on access from their patients.

Practices not offering appointments specifically between 18:00 and 18:30 hours it has been noted that in the majority of practices appointments run up to practice closing hours i.e. 18:30 hours. Depending on need the last appointment would be scheduled to conclude by closing hours 18:30 hours.


Regularly assessing if practices are meeting need by: Cluster Programme – all practices assessing patient satisfaction by survey and or

creation of patient participation group. Access Improvement Group (meet quarterly):

o Membership: Representatives from all localities, LMC, CHC, Clinical Director, OOH and Primary Care Team.

o Cwm Taf wide DNA policy. o Practices comply with opening and surgery times meeting the Contract

requirements. o Activity monitoring – seasonal planning. o OOH and A&E attendance.


The published position (above) shows the Health Board comparing favourably

with other Welsh Health Boards.

Single handers and small practices.

Recruitment issues leading to pressure and difficulty in sustaining appointments.

Demand fluctuations and seasonal pressures. High use of Locum GPs.

Source: Local

118

158

1

100%89%

100%

100%

0

5

10

15

20

Cynon Merthyr Tydfil Rhondda Taff ElyNo.

of

practi

ces

% of GP practices open during daily core hours or within 1 hour of the daily core hours

YES NO

11 915

8

100% 100%

100%

100%

0

5

10

15

20


No.

of

practi

ces

% of GP practices offering appointments between 17:00 & 18:30 at least 2 days a week

50


DECISIONS ABOUT MY CARE Local Measure: Number of GP referrals into Secondary Care Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Prim. Care & Mental Health

Period: Apr 2016 (rolling 12 months - May 2015 to Apr 2016 Target: Reduction Current Status: 7267 YTD 7267

Current Trend How are we doing? –April 2016

What actions are we taking? What are the main areas of risk?

Source: Local

Cynon,

18643,

22%

Merthyr ,

14326,

18%Rhondda,

19915,

26%

Taf, 26262,

34%

Total GP Cluster Referrals to

Secondary Care

April 2015 to March 2016

1309

1245

1645

2372

Cynon

1619

Merthyr

1355

Rhondda

1825

Taf

2468

GP Cluster Referrals to Secondary

Care

April 2015 vs April 2016(outside ring represents April 2016)

0

500

1000

1500

2000

2500

3000


Nu

mb

er o

f refe

rrals

GP Cluster Referrals to Secondary Care

Cynon Merthyr Rhondda Taf

51

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Stroke Quality Improvement Measures (QIMs) – effective from 1st October 2015 (indicative performance April to September)

Thrombolysis Care Performance Measures: Access & Time

72-hour Pathway Care Performance Indicators: <4 hours / <12 hours / <24 hours / <72 hours Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Planning & Performance

Period: May 2015 to Apr 2016 Target: as per table Current Status: as per table


The new Quality Improvement Measures came into force from October 2015 and include these bundles and Thrombolysis times. The main change is the more challenging timeline in which the interventions are to be delivered e.g. admission to the stroke ward within 4 hours rather than 24 hours. The table shows Cwm Taf's performance from April 2015 to April 2016.

Cwm Taf has seen a slight decline in compliance with bundle 2 to 94%,which is just below the target of 95%.The other bundles perform less well due to different challenges:

Bundle 1 – admissions to Stroke Ward Bundle 3 - weekend cover Bundle 4 – swallow/therapy assessment

There has been a decline in Performance in bundle 4 in comparison to the previous month, whilst there has been improvement in Bundles 1 and 3. There has been a large increase in the percentage of eligible patient’s thrombolysed from 25%. To 77.8%


There are now 24/7 thrombolysis services. (Networking arrangements). All acute strokes are admitted to the single unit. Nurses in the unit are trained and specialise in stroke care. There is more

robust and consistent stroke specialist therapist and senior medical staffing.


Specialist services with few staffing numbers. Ability to repatriate “false” strokes to RGH.

Source: SSNAP

0%

25%

50%

75%

100%

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16Perfo

rm

an

ce a

gain

st

targ

et

%

% Compliance with Stroke Quality Improvement measures (QIMs)

Bundle 1 - < 4 hours Bundle 2 - 12 hours Bundle 3 - < 24 hours

Bundle 4 - < 72 hours Target 95%

52

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Indicator 52: The % patients newly diagnosed with cancer, not via the urgent route, that started definitive treatment within (up to & inc.)

31 days of diagnosis (regardless of referral route) - NUSC Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: NUSC 98% Current Status: 95.9%


The target was missed in April 2016 (95.9%) with 4 breaches. The breaches were 3 Lung cancers and 1 Urology cancer. All 3 Lung breaches had the entire

wait from decision to treat at C&V and were treated with Surgery at Cardiff and Vale. The urology Breach had the entire wait from decision to treat in Velindre. On average 80% of Cwm Taf recorded breaches for this target occurred at C&V for treatment, with their entire wait in C&V. NUSC patients often have their decision to treat date (Clock Start Point) agreed at a networked MDT or at

tertiary centre MDTs. Cwm Taf has no input into the treatment plan for these patients and has little influence over the timeliness of treatment being delivered.

When the breach occurs it is attributed to the originating HB, even though all of the pathway events are managed within tertiary centres.


We continue to work with tertiary centres to ensure our patients are treated in time, with regular exchange of information on progress.

Ensuring delays for patients treated within Cwm Taf are minimised where possible.

We continue to raise with the cancer network and the WG the issue of

where the above beaches are counted. We believe that as all pathway clock

events occur outside of Cwm Taf, then we should not be owning and reporting this as our breach.

We have asked the new Wales cancer network manager to establish a monthly performance meeting between DGH and Tertiary centres to address the cancer patient issues across HB boundaries.

The two areas above are equally relevant for both NUSC and USC pathways and reporting.


The main cause of breaches is the tertiary centre capacity for treatment.

Source: CANISC / Welsh Government Delivery & Performance Website

94%

95%

96%

97%

98%

99%

100%


% P

ati

en

ts S

een

NUSC-31 Day Cancer Target (98%)

Cwm Taf All Wales

53


DECISIONS ABOUT MY CARE Indicator 53: The % patients newly diagnosed with cancer, via the urgent route, that started definitive treatment within (up to &

including) 62 days of receipt of referral - USC Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: USC 95% Current Status: 89.8%


Compliance with the 62 day target remains challenging for the Health Board due to the small number of patients treated. We are however, still maintaining around 90% cumulatively since October 2014.The breaches this month were 1 Lung, 1 UGI, 1

Colorectal and 3 Urological. 2 of the Urology breaches and the Colorectal breach were treated in Cwm Taf. Urology breaches – the 1 patient treated at C&V was referred to C&V in 26 days and the delay occurred in Surgery at C&V. no delay at Cwm Taf. The 2 remaining patients had delays in diagnostic pathways within Cwm Taf.

Lung breach – the 1 patient was referred to C&V on day 16 and the treatment delays occurred there.

UGI breach – this was a complex pathway with 5 diagnostic events resulting in a referral to Velindre on day 48. Further treatment delay of 39 days occurred there.

Colorectal breach – The patient was treated in Cwm Taf on day 67 following a 7 day delay for cancellation of first OP attendance due to Consultant sickness and 29 days for endoscopy appointment.


Weekly meetings with each MDT management team to

scrutinise suspected cancer patient lists. Detailed review of the Urology position with the MDT and

Directorate teams. Ensure capacity flexibility to prioritise cancer patient’s

appointments and treatments. Increase dialogue and escalation with tertiary centres to speed

up patient pathway events.


Our maintenance of approx 90% cumulatively since October 2014 puts us at the top of performance of

Welsh HB’s.

Ongoing Urological capacity and the large delays at Cardiff And

Vale for treatment.

Source: CANISC / Welsh Government Delivery & Performance Website

70%

80%

90%

100%


% P

ati

en

ts S

een

USC-62 Day Cancer Target (95%)

Cwm Taf All Wales

Head and neckUpper

Gastrointestinal

LowerGastrointestin

alLung Skin(c) Breast Urological

Haematological(d)

Other(f)

>62 days 0 2 1 0 0 0 3 0 0

<62 days 1 2 4 10 4 4 24 2 2

Performance 100.00% 50.00% 80.00% 100.00% 100.00% 100.00% 88.89% 100.00% 100.00%

0%

20%

40%

60%

80%

100%

0

5

10

15

20

25

30

Perfo

rm

an

ce

No

. P

ati

en

ts T

reate

d

62 day target by Tumour Site - April 2016

54


DECISIONS ABOUT MY CARE Indicator 54: The % of patients waiting less than 26 weeks for treatment (RTT) Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Dir. Primary Care & MH

Period: May 2015 to Apr 2016 Target: 95% Current Status: 86.6%


Cwm Taf’s RTT performance for 26 week waits is in line with the rest of Wales. The main area of concern remains Ophthalmology with 799 patients awaiting their first outpatient appointment and in total

there are 1407 patients waiting over 26 weeks.

Improvements can be expected within the non-surgical specialties.


Develop comprehensive demand and capacity plans for delivery in 2015/16. Improve the rate of back fill for lists not being utilised due to planned annual leave and study leave. Minimise use of additional theatre sessions at weekends.


Cwm Taf’s performance is comparable with other Health Boards. Poor compliance with treat in turn and clinic cancellation

processes. Lengthy waits for non-surgical specialties.


75%

77%

79%

81%

83%

85%

87%

89%

91%

93%

95%

97%

99%


Perfo

rm

an

ce

% of patients waiting <26 weeks for treatment (RTT) - all specialties

Target Cwm Taf RTT <26 Weeks - Total <26 Wks All Wales

55

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Continued: Local Measure: The number of CAMHS ADHD patients waiting for treatment 26 & 36 weeks Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: March 2016 Target: Current Status: 123 pts waiting


Cardiff and Vale

Anticipated 17 % reduction by 31/03/16 due to waiting list initiative.

Anticipated 13% reduction in av. waiting times for assessment

Cwm Taf Anticipated 32% reduction by 31/03/16 due to waiting list

initiative. Anticipated av. length of wait will decrease by 23% to under

26 wks ABM

Anticipated 25% reduction by 31/03/16 due to waiting list initiative.

Anticipated av. length of wait will decrease by 14% to under 26 wks

Network Waiting List Initiative The combined impact of the waiting list initiative will mean a 25%

reduction in the total waiting list (approximately 608 patients) and will bring the average length of wait for NDM assessments to the 26 week waiting time target.


Further work to predict how soon the overall targets will be met.

Recruit more staff from WG funding to reduce waiting lists for young people

Work towards reaching current waiting lists by Sept. 2016 and 28 days target by April 2017- this may vary according to

further funding decisions for 2016/17


High levels of additional activity

High levels of clinical risk

Source: Local

0

1

2

3

4

5

6

7

8

9

2 3 4 5 6 7 810

11

13

14

15

17

18

19

21

22

23

25

27

28

29

31

33

34

35

36

38

40

41

43

44

45

46

48

49

51

52

53

54

55

56

59

62

63

64

65

66

68

69

72

73

81

84

Nu

mb

er o

f P

ati

en

ts

Weeks Wait

CAMHS Waiting List - ADHD1st March 2016

Urgent Routine

56


DECISIONS ABOUT MY CARE Indicator 55: The number of patients waiting more than 36 weeks for treatment (RTT) Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: 0 Current Status: 1392


Reporting for March shows a decrease in the number of patients waiting over 36 weeks for treatment, from 2239 in January to 1120. The main area for concern remains Ophthalmology, with 184 patients at stage 1 and 425 at stage 4. Plans are in place to increase the

capacity for outpatients and ensure treatment of long waiting cataract

patients.


Develop comprehensive demand and capacity plans for delivery in 2015/16. Improve the rate of back fill for lists not being utilised due to planned annual leave and study leave. Minimise use of additional theatre sessions at weekends.


The Health Board’s performance has deteriorated more than peers in percentage terms since March 2014.However, focusing on overall patient numbers, Cwm Taf is still recording fewer 36 week breaches than neighbouring Health Boards

Poor compliance with treat in turn and clinic cancellation processes. Sickness absence of key clinicians in high volume specialties.


0

500

1000

1500

2000

2500

3000

3500


No

. o

f p

ati

en

ts

Number of patients waiting >36 weeks for treatment (RTT) - all specialties

RTT No Patient > 36 Weeks

57


DECISIONS ABOUT MY CARE RTT Continued – Performance Improvement Trajectories Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016

Current Trend: 26 Weeks Open Pathways RTT- 26 Weeks Trajectory

Current Trend: 36 Weeks Open Pathways RTT- 36 Weeks Trajectory

Source: Local

82%

84%

86%

88%

90%

92%

94%

96%


% <

26

weeks

Cwm Taf RTT 26 week 2016/17

Profile Actual

58


DECISIONS ABOUT MY CARE Indicator 56: The number of patients waiting more than 8 weeks for a specified diagnostic Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: Apr 2016 Target: 0 Current Status: 2848


Radiology The ultrasound lists remain high with 1324 patients waiting over 8

weeks. MRI – has increased to 7 patients > 8 weeks CT – has decreased to 40patients waiting over 8 weeks.

Fluoroscopy – 93 patients waiting over 8 weeks due to limited

MSK capacity. Cardiology and Endoscopy waits have both decreased from last month.


Ultrasound – seeking permission for funding additional capacity. Ultrasound – advert for sonographer out – no suitable applicants. MRI mobile scanner on site until October 2015. Fluoroscopy – MSK – additional lists being undertaken where

possible.


Cwm Taf is an outlier for Radiology waiting times, mainly within non-obstetric ultra sound scanning. MRI – demand exceeding core capacity.

Ultrasound – demand exceeding core capacity. Fluoroscopy increasing because of limited MSK capacity.


59

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Local Measure: Therapies waiting times: The number of patients waiting more than 14 weeks for a specified therapies Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: Apr 2016 Target: 0 Current Status: 6


Therapies generally perform well against the 14 week component wait

target and in March there are no patients waiting longer than the target period.

There are robust capacity and demand plans in place for the Physiotherapy service where historically there have been long term problems with extended waits and breaches for MSK services.


Each department is monitoring and managing waiting lists on a monthly basis at a minimum. The largest service Physiotherapy, is managing

their waiting lists by forecasting accurately using live capacity and demand tools.

In all services staff are mobilized and moved to cover periods of annual leave to ensure capacity is maintained.


Within Therapies standards of compliance with the target are comparable. Areas of risk are in Physio, Dietetics and SLT and relate to high staff

turnover recruitment delays and problems. We are endeavoring to aim for a 10 week position to ensure some safe headroom in waiting times

prior to winter period.

Source: Local / Welsh Government Statistics Website

60


DECISIONS ABOUT MY CARE Indicator 57: Local Measure: Cardiac Pathway (in development) Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Current Status: 857

Current Trend: Waiting Lists How are we doing?

The charts show that the total volume of patients waiting for cardiology review. There has been a slight decrease in the total volume waiting this

month to 855 patients waiting. The number of urgent patients waiting has decreased to 133 (15.6%).

Although the majority of patients are seen within 20 weeks (graph 2), there is a tail of patients waiting up to 35 weeks, which is of concern.


The main reason for the tail of long waits has been attributed to a capacity gap within some sub-specialty clinics due to long term staff absences and recent retirements. A full demand and capacity analysis of

the service is also being undertaken to redress the balance on a sustainable basis.


Capacity of sub specialty clinics.

Cardiac specific investigation capacity (MRI, CT and Echo).

Source: Local

1126 1178 1129 1168 1151 1053 987837 781 789 748 724

288 279248 220 173

194 210

196 188 191144 133

0

500

1000

1500


Pati

en

t N

um

bers

Cardiology Outpatient Waiting List Volumes

Routine Urgent

0

20

40

60

80

100

120

140

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Pati

en

t N

um

bers

Weeks Wait

Cardiology Outpatient Waiting List Profile: April 2016

Routine

Urgent


61


DECISIONS ABOUT MY CARE Continued Indicator 57: Local Measure: Cardiac Pathway (in development) Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: Apr 2014 to Dec 2015 Target: Current Status: as per charts

Current Trend: Waiting Lists How are we doing?

Exploratory work is currently ongoing to review the pathway for cardiology patients with the consideration of

a pathway that achieved a decision to treat by week 16 and treatment delivered for 100% of patients by week 26.

The charts represent the number of Cwm Taf residents waiting for cardiology services outside of this pathway at all Welsh providers; this includes those waiting at

tertiary providers.


The Health Board is working actively with Welsh

Government colleagues and neighbouring Health Board clinicians to measure and monitor compliance with this new indicator. Sub-specialty demand and capacity plans are being developed to facilitate delivery of this target.


High volume of demand for new outpatients and

diagnostic investigations. Capacity for more invasive investigations and

treatment at tertiary units.

Source: Local / Welsh Government

534605

574516 488

412 402

314

215

0

100

200

300

400

500

600

700


No

. o

f p

ati

en

ts

CTUHB resident cardiology stage 1-3 (excluding paediatric cardiology) 16+ weeks waiters at all providers

48

3329

21 22

14 1215

1824 26 27

0

10

20

30

40

50

60


No

. o

f p

ati

en

ts

CTUHB resident stage 4 cardiothoracic surgery 10+ weeks waiters at all providers

3847 42

38 36 3828

25 28

0

100

200


No

. o

f p

ati

en

ts

CTUHB resident cardioology stage 4 & cardiothoracic surgery (stages 1-4) 10+ weeks waiters at all providers

CT residents waiting for cardiothoracic surgery stages 1-4 over 10 weeks (all providers)

CT residents waiting at cardiolgy stage 4 over 10 Weeks (all providers) (ex paediatric cardiology)

62


DECISIONS ABOUT MY CARE Indicator 58: The number of patients waiting for a follow-up who are delayed past their target date Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Census Date: Apr 2016 Target: Reduction Current Status: 18243

Current Trend: Outpatient Follow-up Delays – NOT BOOKED How are we doing?

The Health Board is making good progress in the validation of patients showing as awaiting a follow-up review but with no indicated target date. The overall volume has dropped from 58,000 to 3509 which is a decrease from 3794 in March.

The volume of patients with a lapsed target date where there is no appointment booked is 18,243 where there is currently no booked appointment. This is a month on month increase since April 2015 when the total waiting was 14,311 (27% increase). Currently, the highest volumes of patients are

currently within Ophthalmology (5,069), ENT (2,124), T&O (1,879), General Medicine (1,290) & Gynaecology

(1,283).


Further work is being undertaken within the cohort of patients without an appointment date to manage the demand appropriately. It is anticipated that this

volume will reduce following this exercise. The backlog volumes have been incorporated into the

specialty demand and capacity plans and work is underway to remove the backlog by the end of March 2017.


The area of Ophthalmology is the main concern due to the risk to patients and the availability of staff to address the backlog.

Source: Local

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000

Ophthalmology

ENT

Trauma &…

General Medicine

Gynaecology

Child & Adolescent…

Urology

Gastroenterology

Thoracic Medicine

Rheumatology

Dermatology

Old Age Psychiatry

General Pathology

Paediatrics

Cardiology

Mental Illness

Oral Surgery

Rehabilitation

General Surgery

Anaesthetics

Psychotherapy

Nephrology

Clinical Haematology

Orthodontics

Restorative Dentistry

Neurology

Palliative Medicine

Clinical Oncology

Mental Handicap

Midwifery

Geriatric Medicine

Obstetrics - AN…

Total number of patients waiting for a follow-up who are delayed past their target date -NOT BOOKED

(census date April 2016)

0% up to 25%

delay

Over 26 up to 50%

delay

Over 50% up to 100%

delay

Over 100% delay

63


DECISIONS ABOUT MY CARE Continued Indicator 58: The number of patients waiting for a follow-up who are delayed past their target date Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Census Date: Apr 2016 Target: Reduction Current Status: 6347

Current Trend: Outpatient Follow-up Delays – BOOKED How are we doing?

The number of patients awaiting a follow up appointment with a lapsed target date is now 6347. Again this is has increased significantly since April 2015 when the total was 3,220. The main areas of concern are:

Ophthalmology – 887

Rheumatology – 633 General Medicine – 540 Gynaecology – 454 Mental Illness – 406 ENT – 384 T&O – 363 Paediatrics 332


The backlog volumes have been incorporated into the specialty demand and capacity plans and work is underway to remove

the backlog by the end of March 2017.


The area of Ophthalmology is the main concern due to the risk to patients and the availability of staff to address the backlog.

Source: Local

0 100 200 300 400 500 600 700 800 900 1,000

Ophthalmology

Rheumatology

General Medicine

Gynaecology

Mental Illness

ENT

Trauma &…

Paediatrics

Child & Adolescent…

Gastroenterology

Dermatology

Thoracic Medicine

Urology

General Surgery

Clinical Haematology

Cardiology

General Pathology

Oral Surgery

Anaesthetics

Neurology

Nephrology

Orthodontics

Old Age Psychiatry

Rehabilitation

Restorative Dentistry

Mental Handicap

Palliative Medicine

Total number of patients waiting for a follow-up who are delayed past their target date - BOOKED

(census date April 2016)

0% up to 25% delay 26% up to 50% delay Over 50% up to 100% delay Over 100% delay

64


DECISIONS ABOUT MY CARE Indicator 59: The % of patients who spend less than 4 hours in all hospital major & minor emergency care (i.e. A&E) facilities from arrival

until admission, transfer or discharge Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO



4, 8 and 12 hour performance across the Health Board remains challenging

although there is some improvement in April. The front door pressure

continues to reduce however both sites remain fragile due to the daily

variation in attendance numbers.

Patient flow continues to be monitored and appropriate actions are taken on a daily basis to balance elective and emergency admissions. Gold command meetings remain in place twice weekly and will be reviewed during April.


Daily deep dive work on all acute and community wards continues.

LA staff are fully engaged in all aspects of patient flow. Reduction in capacity to mitigate reduction in staffing levels. Daily review of actions to support patient flow.


CT performance has been in the main comparable with the best performance in Wales. Staffing issues have reduced following the actions taken this will continue

to be monitored closely.

Source: EDDS

0%

20%

40%

60%

80%

100%

2000

4000

6000

8000

10000

12000


Att

en

dan

ces

Perfo

rm

an

ce a

gain

st

targ

et

% of new patients spend no longer than 4 hours in A&E

Patients waiting <4 hours Patients waiting >4 hours Cwm Taf %

All Wales % 95% Target

65

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Indicator 60: The % of emergency responses to RED Calls (immediately life threatening) calls arriving within (up to & including) 8 minutes

Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: week ending 6th Mar to 29th May 2016 Target: 65% Current Monthly Status: 72.8% (Apr 2016)


Performance against the 8 minute response times for red category

calls continues to be above the 65% target. This is due to a number of factors which include:

Good ambulance turn around by DGH sites Ring fencing of vehicles Use of non-emergency vehicles for HCP arrivals

The Health Board continues to work closely with WAST to maintain this performance and develop further alternative pathways.


The UHB continue to work closely with WAST to maintain and

further improve this performance.


Source: WAST

17 25 29 24 16 26 28 29 21 35 31 23 35

27

8

1213

10

109 10

7

69

5

12

38.6%

75.8%70.7%

64.9%61.5%

72.2% 75.7% 74.4%75.0%

85.4%

77.5%

82.1%

74.5%

0%

20%

40%

60%

80%

100%

0

20

40

60

06/03 13/03 20/03 27/03 03/04 10/04 17/04 24/04 01/05 08/05 15/05 22/05 29/05

Red

Call

Perfo

rm

an

ce

Red

Call

Resp

on

ses

Week Ending

RED Calls - 8 minute performance Cwm Taf Health Board Area

Hits (responses) <8 mins Responses >8 mins Cwm Taf Performance

Target All Wales Performance

69.1%

45.0%

55.0%

65.0%

75.0%

85.0%

ABMU AB BCUHB C&V Cwm Taf HDda Powys

Perfo

rm

an

ce a

gain

st

targ

et

RED Calls - 8 mins performance by health board area (target 65%)October 2015 to April 2016

Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Mar-16 Apr-16 Target 65% All Wales average

66


DECISIONS ABOUT MY CARE Local Measure: Number of ambulance handovers within 15 minutes Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: Improvement Current Status: 83.86% YTD: 83.86%


Handover performance during March / April improved on both sites despite the continued capacity pressures.


Monitoring of the handover performance continues and alerts sent to

senior managers when delays occur so that they can be challenged.


CTUHB’s performance remains the best in Wales Handover performance during March / April improved on both sites despite the continued capacity pressures.

Source: WAST

75%

80%

85%

90%

95%

100%

0

500

1000

1500

2000

2500

May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16

Perfo

rm

an

ce

No

. o

f h

an

do

vers <

15

min

s

Number of Ambulance Handovers within 15 minutes

PCH RGH PCH RGH


67


DECISIONS ABOUT MY CARE Indicator 61: Number of ambulance handovers over one hour Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: Reduction Current Status: 4 YTD: 4


Handover performance has improved on both sites with RGH meeting the 100% target. Staff continue to be mindful of the need to ensure handover is timely and this continues to be monitored closely, with alerts in place to

senior managers when delays occur.


Monitoring of the handover performance continues and alerts are sent to senior managers when delays occur so that they can be

challenged.


CTUHB’s performance remains the best in Wales This area of performance is fairly stable and we do not anticipate any

problems.

Source: WAST

96%

97%

98%

99%

100%

0

2

4

6

8

10

12

May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16

Perfo

rm

an

ce

No

. o

f h

an

do

vers >

1 h

ou

r

Number of Ambulance Handovers over 1 hour

PCH RGH PCH RGH

68

TIMELY CARE: I HAVE TIMELY ACCESS TO SERVICES BASED ON CLINICAL NEED & AM ACTIVELY INVOLVED IN DECISIONS ABOUT MY CARE Indicator 62: The number of patients who spend 12 hours or more in all hospital major & minor emergency care facilities from arrival until

admission, transfer or discharge Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: COO

Period: May 2015 to Apr 2016 Target: 0 Current Status: 309 / YTD 309


12 hour performance has improved during April but still remains well

below UHB expectation.

12 hour breeches are in the main patients waiting admission or patients

who are awaiting senior review prior to discharge home. All patients are

seen on admission as per triage criteria and all 12 hour breeches are

reviewed to ensure all appropriate care is delivered in the department.

It is anticipated that this improvement will continue during May.


Daily deep dive work on all acute and community wards continues. LA staff are present on both community sites as routine and

patients waiting to transfer to community sites have reduced dramatically.

Concentrated effort is now being made to eradicate 12 hour waits.

In patient capacity has been reduced to mitigate the short term staffing shortages.


CT performance has in the main been below the best performance in Wales during December.

Lack of inpatient capacity remains the key reason for delays in the A&E department, this is particularly evident on the RGH site where beds have been closed due to nurse staffing levels.

Source: EDDS

140

19 8

76

183135

172 170

313446

623

309

90%

92%

94%

96%

98%

100%

8000

10000

12000


Perfo

rm

an

ce

Att

en

dan

ces

Number of patients spending 12 hours or more in A&E (eradication of >12 hr waits)

Patients waiting <12 hours Patients waiting >12 hours Cwm Taf % All Wales %

70

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Indicator 66: The % of assessments undertaken within (up to & including) 28 days from the date of receipt of referral Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health


Current Trend: How are we doing & what actions are we taking?

46.1% of referrals were assessed in April 2016; the target is 80%. There remains a continued high rate of referrals and we have slot clinic slots

due to staff sickness and the Bank Holidays. Availability of assessment slots continues to be closely monitored and clinic

utilization remains high. Pressure on the Service to absorb changes in referral rates and staff absence continues to present with difficulties.


Continued liaison with GP’s remains a priority for the Service to better manage referrals and ensure people receive a treatment at the earliest opportunity

We have now had confirmation of an investment of 120k and will progress with recruitment. This may take 3 months therefore we expect performance

to increase above current levels from August 2016.


A few other Health Boards in Wales are not achieving the 80% target for assessment.

The resilience of a relatively small number of teams to maintain performance when there is annual leave and sick leave. The volume of referrals from GPs is unsustainable.

Source: Local

167

216

176

144

257

304318

244

184

278

226

184

170

196

160

113

162 106

74

75

239131

116

215

0

50

100

150

200

250

300

350

400

450


0%

20%

40%

60%

80%

100%

To

tal

assessm

en

ts

Perfo

rm

an

ce

The % of assessments undertaken within 28 days of receipt of referral

Within 28 days > 28 days Performance against target Target

71

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Indicator 67: The % of therapeutic interventions started within (up to & including) 28 days following an assessment by LPMHSS Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health



Performance for Part 1 Treatment target (28 days) during April 2016 has decreased to 91.3% and this has been aided through the Valley Steps

programme and our efficiency drives to fill all available slots.


Myrddin is now fully operational since mid-September.


The resilience of a relatively small number of teams to maintain performance

when there is annual leave and sick leave. In terms of data quality there is one risk for audit. We are currently implementing more checking systems to ensure all available patient slots are filled.

Source: Local

125

224268

70

173

402366

276

368 393336

411168

12945

162

160

2…

108

43

4438

26

39

0

100

200

300

400

500

600

700


0%

25%

50%

75%

100%

To

tal

inte

rven

tio

ns

Perfo

rm

an

ce

The % of therapeutic interventions started within 28 days following an assessment by LPMHSS - new measure from

1st October 2015 (indicative performance May - September)

<28 days >28 days Performance against target

72

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Indicator 68: The % of HB residents in receipt of secondary mental health services (all ages) who have a valid care & treatment plan (CTP) Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health


Current Trend How are we doing

The 90% target was not met in April 2016 with compliance only being

83.4%. Two main issues affecting performance are: 1) there are still some

outstanding care plans needing to be completed 2) Care Plans have been

completed but have not received a CTP Review in the required timescale.

Psychiatrists remain the largest group of Care Co-ordinators as follows and

a request has been made for additional locum assistance to improve

compliance.

For April 2016 the compliance for CAMHs reduced which will require urgent addressing through a turnaround plan.


The plan to increase performance to 90% for Part 2 of the MHM is to examine the individual performance of each and every practitioner, including social worker care coordinators working in the local authority. This is being led by all professional heads including the local authority. The Directorate has also led an engagement on the definition of some

elements of current secondary care being discharged to GP shared care, following a paper to the May Executive Board. This will mainly affect the Consultant Psychiatrist compliance. Work has now begun on reviewing each case individually who meet the criteria and ensuring all relevant patients

understand the process under the measure. This stage has been more time consuming than anticipated.


All but 1 of the other health boards in Wales are compliant (> 90%) Sickness levels and resilience of teams to undertake increases in workload.

No issues with data quality.

Source: Local

70%

75%

80%

85%

90%

95%


% o

f p

ati

en

ts w

ith

vali

d C

TP

% of Cwm Taf residents who have a valid CTP completed by the end of each month

CTP Plan Target

73

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Indicator 70: The % of hospitals within a HB which have arrangements in place to ensure advocacy is available for all qualifying patients Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: Apr 2014 to Sep 2015 Target: 100% Current Status: 100%

Current Trend & Benchmark: Advocacy Arrangements How are we doing

We have consistently maintained this level of performance.


None


No risks at present

Source: Local

74

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Indicator 71: The % of registered over aged 65 patients diagnosed with dementia Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Prim. Care & Mental Health

Period: Apr 2016 Target: Current Status: 2.89%


In addition to access information, Health Boards are also requested to monitor

numbers and percentages of patients recorded with Dementia.

Benchmark: 2014/2015 What actions are we taking

Dementia Appointment of Dementia Nurse to work in Primary Care and Nursing homes Included as a priority in clinical QOF visits Part of the analysis by Locality Clinical Director identifying outliers – this then to

be used as part of the conversation in the clinical QOF visit on Dementia to

investigate the reasons Mental Health Directorate are working on developments and improvements in

Older Person’s Mental Health applicable to the Primary Care setting

Practices taking part in Mental Health DES have completed training in Dementia


Registers come from QOF data – delays in applying the new year contract rules can be up to late October early November

Read coding issues in collection of data Uncertainties about the diagnosis in some patients Practitioner concerns about coding being an inappropriate label

Practitioner concerns about the ethics and utility of coding QOF is voluntary and small practices may have very small registers

Source: Local

11637 10523 17172 16708

329

330

433528

2.83%

3.14%

2.52% 3.16%

8000

10000

12000

14000

16000

18000

Cynon Merthyr

Tydfil

Rhondda Taff Ely

Pati

en

ts r

eg

iste

red

ag

ed

65

plu

s

Of the registered patients aged over

65; the % diagnosed with dementia

Registered patients >65 diagnosed dementia

Registered patients >65

329 330 433 528

0.54%0.55%

0.49%

0.56%

0

100

200

300

400

500

600

Cynon Merthyr

Tydfil

Rhondda Taff Ely

No

. o

f p

ati

en

ts

Patients aged over 65 diagnosed with

dementia

as a % of total list size

Dementia

75

INDIVIDUAL CARE: I AM TREATED AS AN INDIVIDUAL, WITH MY OWN NEEDS & RESPONSIBILITIES Local measure: The % of patients registered as receiving palliative care with their GP practice Strategic Aim: Sustainable & Accessible Services Strategic Change Programme: Executive Lead: Director of Prim. Care & Mental Health



In addition to access information, Health Boards are also requested to monitor numbers and

percentages of patients recorded with Dementia or as being on a Palliative Care pathway and also those that have had a blood pressure recorded within the last five years. As can be seen from the graph opposite, the Merthyr Tydfil cluster has a higher percentage of patients recorded on both the dementia and palliative care register.

Benchmark What actions are we taking

Guidance and links the Welsh Palliative Care Website on the Primary Care Resource Portal Advanced Care Planning Resource Pack available on the Primary Care Portal Primary Care Macmillan GP Facilitator supporting practices with care pathways and

system templates to record data in patients notes


Registers come from QOF data – delays in applying the new year contract rules can be up to late October early November

Read coding issue in collection of data

Varying opinions amongst GPs about the purpose of a Palliative Care Register and the indications for including a patient on the Practice

GPs view is that a register is not a measure of quality but more around what care package is in place

Source: Local

60966 59955 88680 94619

0.17% 0.27%

0.18%

0.22%

40000

50000

60000

70000

80000

90000

100000


Reg

iste

red

pati

en

ts

Of the registered patients the % in need ofpalliative care / support

Registered patients % of Registered patients palliative care/support

77

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE

OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 73: Reduce waste in secondary & primary care through the delivery of efficient & productive services Local Measure: Theatre

Efficiency Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: COO

Period: May 2016 Local Target: Reduce cancellations using 2013/14 baseline Current Status: 504 YTD: 984

Current Trend: Theatre cancellations How are we doing?

There were 504 (22.26%) cancellations in May out of that 18.06% related

to no beds. The number of cancellations related to no beds has not improved greatly in April or May in total 165 to date. The other area is

the number of emergency cases undertaken which has meant electives have been cancelled which total 72, and some of these emergencies are much larger cases and require longer theatre time. Closure of 30 surgical beds in RGH due to nursing vacancies has had and

continues to have a major impact upon elective capacity. The pressure of unscheduled care continues to be a challenge upon the delivery of elective services.

Reasons for cancellation What actions are we taking?

The main action that can be taken is to invest in a a day surgery ward in

RGH. Ward 9 could accommodate this as it has previously operated as a day surgery unit until it closed 18 months ago. The other sustainable solution is investment in DSU in PCH to work 7 days a week. This would give flexibility in either providing a day case or 23/59 facility. Outsourcing these patients is not a sustainable solution as

we need to invest in our own facilities to ensure sustainability.

Cancellations by specialty – May 2016 What are the main areas of risk?

One of the risks we are now facing is that we have outsourced our fit & healthy patients ASA grades 1 & 2; leaving ASA grades 3 and above to be treated in the health board. These patients will usually have some co-morbidities and need more input from the anaesthetic pre-assessment

service to make them ready for surgery. These patients will also usually require a longer length of stay.

Source: Local

0

20

40

60

80

100

120

ENT Surgery General Surgery Gynaecology Ophthalmology Oral Surgery Orthopaedics Urology

Pati

en

ts

Patient Cancellations Clinical Cancellations Bed Cancellations Other Cancellations

78


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 73: Reduce waste in secondary & primary care through the

delivery of efficient & productive services (indicator in development)

Local Measure: Delivered Activity

The tables below a month by month and YTD comparison of activity delivered by Cwm Taf over 2015/16 and 2016/17. The inpatient activity includes both acute and community discharges and also emergency assessment admissions with a zero length of stay. It should be noted that the recording of assessment activity has been variable across these periods due to changes in clinical models at the Royal Glamorgan Hospital.

Source: Local

79


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 73: Reduce waste in secondary & primary care

through the delivery of efficient & productive services (indicator in

development) Local Measure: Admission on Day of Surgery

Target: To achieve

previously set

targets by specialty

Period: Feb 2015

to Jan 2016

Executive

Lead: COO

This indicator measures the percentage of patients, expected to have an overnight stay during their admission, who are admitted to hospital on the day of their intended operation. It should be noted that Ophthalmology inpatients are very small numbers. Central reporting of this measure ceased with the implementation of the 2013/14 Delivery Framework. However as it is a key indicator of efficiency in elective surgery, it will continue to be reported on a quarterly basis internally. All of the data for this measure is now sourced from CHKS which is more timely and reliable than data previously provided to the national repository.

How are we doing? What actions are we taking

Specialty TargetGeneral Surgery 62%Urology 75%Orthopaedics 55%ENT 81%Ophthalmology 79%Oral Surgery 46%Gynaecology 61%

General Surgery, Gynaecology and Urology have recently improved their performance in this area and are now achieving the expected targets. Orthopaedics improved on both sites achieving the agreed target in

December 2015.

Recent work undertaken with the Clinical Director of Orthopaedics has realised significant improvements in this area. Specific issues addressed were:

Anaesthetic Pre-assessment. Specialty specific pre-operative assessment –

including physio and OT input.

Nursing documentation.

Source: CHKS

20

40

60

80

100


Perfo

rm

an

ce %

Admission on Day of Surgery - General SurgeryTarget 62%

PCH RGH

40

60

80

100


Perfo

rm

an

ce %

Admission on Day of Surgery - UrologyTarget 75%

PCH RGH

0

20

40

60

80

100


Perfo

rm

an

ce %

Admission on Day of Surgery - Trauma & OrthopaedicsTarget 55%

PCH RGH

0

20

40

60

80

100

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15Sep-15 Oct-15 Nov-15Dec-15 Jan-16

Perfo

rm

an

ce %

Admission on Day of Surgery - GynaecologyTarget 61%

PCH RGH

80


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 73: Reduce waste in secondary &

primary care through the delivery of efficient & productive

services (indicator in development) Local Measure: Average Length of Stay (AvLoS) Medicine

Target: To achieve

previously set AQF

targets

Period: Jun 2015 to May 2016

Executive Lead:

COO

Central reporting of this measure ceased with the implementation of the 2013/14 Delivery Framework. However as it is a key indicator of efficiency in elective and emergency admissions, it will continue to be reported on a monthly basis internally. The charts illustrate the changes in average length of stay for medicine and how this length of stay is affected by the number of discharges with a zero length of stay.


Performance against these indicators remains around the level previously set by the WG targets. However work continues to make improvements wherever possible.

Recent increases in the numbers of patients being turned around on the day of admission has resulted in an overall drop in the average length of stay in acute medical admissions.

Efficiency indicators including LOS will be a focus of the work being undertaken by

directorates going forward with the Matrix.

Focus work on LOS for emergency admissions. Derive historic elective and emergency LOS data from CHKS and compare to

previous published information.

Source: Local

0

2

4

6

8

10

0

100

200

300

400

500

600

700

Em

erg

en

cy A

vLo

S

Zero

Lo

S

AvLoS & Zero LoS Activity - Acute Medicine

Acute Zero LoS Activity Acute Emergency AvLoS

0

2

4

6

8

10

0

100

200

300

400

Em

erg

en

cy A

vLo

S

Zero

Lo

S

PCH - AvLoS & Zero LoS Activity - Acute Medicine


0

2

4

6

8

10

0

100

200

300

400

Em

erg

en

cy A

vLo

S

Zero

Lo

S

RGH - AvLoS & Zero LoS Activity - Acute Medicine


81


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 73: Reduce waste in secondary & primary care

through the delivery of efficient & productive services (indicator in

development) Local Measure: Average Length of Stay (AvLoS) Surgery

Target: To achieve

previously set AQF

targets

Period: Jun 2015

to May 2016

Executive Lead:

COO

Source: Local

0

2

4

6

8

General Surgery AvLoS

Emergency Target - 6.0 / Elective Target - 3.3

Elective AvLoS TargetEmergency AvLoS Target

0

2

4

6

8PCH - General Surgery AvLoS

Elective AvLoS Target

Emergency AvLoS Target

0

2

4

6

8RGH - General Surgery AvLoS



0

10

20

30

40

50General Surgery - Vascular AvLoS

Elective AvLoS Emergency AvLoS

0

10

20

30

40

PCH - General Surgery - Vascular AvLoS


0

10

20

30

40

50

RGH - General Surgery - Vascular AvLoS


0

2

4

6

8

10

12

Orthopaedics AvLoS

Emergency Target - 10.2 / Elective Target - 3.6



0

5

10

15PCH - Orthopaedics AvLoS

Elective AvLoS TargetEmergency AvLoS Target

0

2

4

6

8

10

12RGH - Orthopaedics AvLoS



82

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 74: The % of full time equivalent (FTE) days lost to sickness absence Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: to Apr 2016 Target: Reduction (4.5%) Current Status: 5.16%


The graph shows data as at end of April at 5.16%, and illustrates a

fairly consistent level of sickness absence throughout the year. Analysis of the data reveals no specific reasons for the continual month by month fluctuations within individual Directorates. The three year absence trend evidences that the absence rate has improved,

with this year yielding the best performance overall. The WG target for the UHB is 4.5% from 1st April 2015. Whilst this remains a stretch target, realistically we need to target achieving monthly results at <5%. This has only occurred once in the last 3 years (4.94% in June 2103). In the rolling 12 months we have achieved 5.15% & 5.16% in 2 months, so this is viewed as an

achievable target. The table illustrates those departments currently above the WG targets. It is positive to note that more departments are beneath the target than above.

Directorate Absence Rates: Dec 2015 What actions are we taking?

A new All Wales Policy has been agreed and Sickness absence training to support the new policy has been commenced and is being rolled out jointly with Trade Union colleagues. We have already trained in excess of 250 supervisors and managers. The policy became effective on 1

December 2015. We will be monitoring the implementation and

compliance over the coming months. Sickness absence is discussed at each Clinical Business meeting and work is continuing to analyze the various factors in each individual directorate and department, and to react and plan accordingly.

We are reviewing the comparative data from across Wales, and

looking at a more in depth analysis of the data to understand whether there are other trends or impacts that we could identify.


We know that we are in the upper quartile in Wales, however we are making greater progress than most. Recent evidence presented at FP&W Committee meeting.

Source: ESR

4.0%

4.5%

5.0%

5.5%

6.0%

6.5%

7.0%

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

FT

E R

ate

Full Time Equivalent (FTE) Sickness Rate - 3 year trend

2013/14 2014/15 2015/16 Target

83


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 74: The % of full time equivalent (FTE) days lost to sickness absence Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: May 2015 to Apr 2016 Target: Reduction (4.5%) Current Status: 5.16%


Long Term Sickness per FTE was reported at 3.85% in April, which is in the

middle of the range of results. Short Term sickness per FTE was at 1.38% for April 2016. This is the lowest result achieved with short term sickness, and demonstrates real progress made.

The overview of occurrences of sickness absence over the past year show that the number of occurrences of Long Term absence is on a slight downward

trajectory. This is the opposite with Short term occurrences where these are on a rising trajectory. However the sharp drop in April to 596 occurrences is the lowest yet achieved. Further detailed analysis is being undertaken to look at the trend data. The Long term trend is marginally down, with short term being marginally increased. If we are able to continue the results going forward we will be able to achieve results at

sub 5%.

Current Trend: What actions are we taking?

Current sickness absence activity is focused through the Directorate’s five point

activity plans which are agreed jointly with managers on a monthly basis and are used as the foundation for the CBM Reports. These include: Improving the quality, accuracy and timeliness of sickness absence though

maximum utilisation of ESR, improved reporting and data cleansing. Improved analysis of reasons, patterns and trends to identify hot spot areas,

understand reasons to inform support and interventions

Auditing records in areas with high levels of sickness absence to ensure that managers are complying with the policy are managing the absence.

Delivering bespoke training for managers as required.


Source: ESR

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%


FT

E R

ate

Short Term / Long Term Sickness Rate - Full Time Equivalent (FTE)

Long Term FTE Sickness Rate Short Term FTE Sickness Rate

0

200

400

600

800

1,000

1,200


No

. O

f O

ccu

rren

ces

Short Term/Long Term Sickness - Number of occurrences

Long Term Sickness Occurrances Short Term Sickness Occurrances

84


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 74: The % of full time equivalent (FTE) days lost to sickness absence Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD



The top five reasons for absence from over the past year has seen a slight

shift in the order of top reasons recorded. In comparing these two year periods, it is now strongly evident that the category ‘Unknown causes / not specified’ is no longer appearing in the top 5 reasons for absence.

The work with Managers and employees to more accurately record the reasons for absence is allowing us more ready access to robust data. This

is demonstrated by the ‘Unknown causes / not specified’ category reducing from 17.86% in 2014 to below 5% now. This in part will account for some of the percentage increases seen in the top 2 reasons over. Return to Work discussions are reported as 46.21% for the 12 month period April 2016, compared to 22.02% for the same period a year ago. Although the number of Return to Work discussions being entered onto

ESR has increased in the last 12 months, efforts are currently being focused on ensuring managers are entering the information onto ESR. We are also now feeding data into ESR from the Electronic Rosters. We have discovered that due to a technical issue not all of the data is being captured, and a solution is being developed. This will in turn have a further positive impact on the trend in future months.

Current Trend:


Source: ESR

85

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 74: The % of full time equivalent (FTE) days lost to sickness absence Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD



The data is evidence that our average time taken to input

sickness data has improved significantly during the year, down from 25 days to 13.95 days. This has been achieved via the ongoing use of a cohesive use of our E-Systems including ESR

and Rostering systems. With the advent of an improved use of self service and the deployment of rostering software to further areas in the health board, we anticipate this trend being maintained. In addition the timeliness of the data being recorded on ESR has significantly improved over the last 12 months. We are now

seeing close 60% of sickness consistently being entered within

11 days, and have been in excess of 50% ongoing since July. This means that more timely data is available to managers and the health board, and we can make more effective use of our Business Intelligence reports.

From 1st to 31st March 2016 the percentages of sickness entry by Self Service was 48.75%, and E-Rostering at 27.60%. This means that 75% of the entries are now being input electronically, reducing the need for manual pay card entries. This is a positive trend as we seek to reduce and eliminate all

entries by pay cards in the new financial year.

Source: ESR

12

14

16

18

20

22

24

26

Averarag

e n

um

ber o

f d

ays


Average number of days 24.81 21.81 19.04 19.51 17.66 16.78 16.11 16.94 15.62 14.94 15.50 13.95

Average number of days taken to enter sickness into ESR

59.15% 54.20% 49.07% 48.19% 45.24% 41.83% 37.61% 41.93% 45.37% 42.88% 50.43% 47.98%

40.85% 45.80% 50.93% 51.81% 54.76% 58.17% 62.39% 58.07% 54.63% 57.12% 49.57% 52.02%

0%

50%

100%


% T

ime T

aken

% Time taken to enter sickness into ESR

>11 Days <11 Days

27.60%

23.65%

48.75%

Analysis of Sickness entry by system April 2016

E-Rostering Payroll Self Service

86


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Local Measure: ESR Self Service Rollout Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD



The current level of staff with Self Service accounts is 5,074. This represents 63.12% of the workforce. This has risen from 3,690 or 46.13% of the workforce in January. We have exceeded the 60% figure for the first time.

We have reviewed the delivery plan to accelerate progress, in advance of ESR Enhance deployment in November 2016. There are a number of

additional benefits to achieving the rollout as access to ESR Self Service underpins other activities e.g. Nurse Revalidation, Access to National and Local E-Learning, Electronic Pay Slips etc. that rely on self-service access. It is anticipated that we will achieve full deployment of self service by

the third quarter of the new financial year. This will require us to ensure that the hierarchies within ESR are drawn up in compliance with the

new Scheme of Delegation as approved by the audit committee. Employees from Workforce & Finance are working jointly to ensure this is delivered.

Source: ESR

87


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Local Measure: Resourcing Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: May 2015 to Apr 2016

Current Trend: Staff in Post & Recruitment Activity

The recruitment data is currently unavailable to be reported by Shared Services due to the switch between electronic systems and the move to TRac. The data is planned to be available next month.

Source: ESR

-300

-200

-100

0

100

200


FT

E

Starters / Leavers by month

Starters FTE Leavers FTE Cumulative FTE

88

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 77: Estimated rate of Did Not Attend (DNA) for GP

appointments per GP cluster

Indicator 78: Estimated highest & lowest rate of Did Not Attend

(DNA) for GP appointments per GP cluster Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Primary Care & Mental Health

Period: to February 2016 Target: Reduction Current Status:


Chart shows the activity over the given month: GP Face to Face. GP telephone contact. GP DNA.

We also collect

Practice Nurse Face to Face. Practice telephone contacts. Practice Nurse DNA.

To Note collection of activity data is not a requirement under the

GMS contact: Not all practices supply on a regular basis

Cynon, 60876

Merthyr , 59955

Rhondda, 88680

Taf, 94431

GP Cluster List Size

What action are we taking?

Access Group: Continue to encourage activity reporting by all practices on a

regular basis. Encouraging all practices to report DNA rates on a regular basis.

To drill down into Rhondda data in regard to the limited use of telephone triage.

Survey use of DNA policy and its impact. To help practices analyse reasons for a high DNA rates and offer

options to address.


Growing demand from patients. Seasonal pressures.

Recruitment of GPs. Impact of high use of Locum GPs.

Source: Local

1364

1,255

1,238

1082

360

258

166

300

927

755

797

690

53

39

28

28

36

24

49

33

0 500 1,000 1,500 2,000 2,500 3,000

Cynon

Merthyr Tydfil

Rhondda

Taff Ely

No. of contacts

GP Practice Contact Activity per 1,000 registered patients (September 2015 to February 2016)

Number of GP face to face cotacts (including home visits) Number of GP telephone ContactsNumber of Practice Nurse face to face contacts Number of Practice Nurse telephone contactsNumber of GP appointment DNA

89

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF

RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 79: The % of patients who Did Not Attend (DNA) a new outpatient appointment Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: COO

Period: Jun 2015 to May 2016 Target: Reduction (12 month trend) Current Status: 8%


Efficiency and activity measures will form part of the Health Board

Matrix at a strategic level and at an operational level the Consultant Dashboard, which will be utilised by CDs at directorate meetings.

Benchmark: Feb 2015 to Jan 2016 (12 month trend) What actions are we taking?

There are currently two initiatives about to come on board to improve attendance at clinical consultations: Text and Remind –This service was launched on 1st July 2015 and

reminds patients of their upcoming outpatient appointments. An initial

assessment of the impact of this service on DNA rates will take place

after 3 months of data has been collected.

Self Service Kiosk – this service will allow patients to update their own demographics as they attend for an appointment. It will ensure that we hold the right information for each patient and will aid

communication processes. This service was launched in August 2015.



0%

5%

10%

15%


% D

NA

Rate

New Outpatient DNA Rates



90

OUR STAFF & RESOURCES: I CAN FIND INFORMATION ABOUT HOW THE NHS IS OPEN & TRANSPARENT ON ITS USE OF

RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 80: The % of patients who Did Not Attend (DNA) a follow-up outpatient appointment Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: COO

Period: Jun 2015 to May 2016 Target: Reduction (12 month trend) Current Status: 15.2%


Good progress is being made in improving the booking

processes for follow-up appointments in line with RTT Rules or with previous Guide to Good Practice Guidance, It is anticipated that this will improve the number of DNAs experienced for follow-up appointments.

Currently the specialties are working on plans of how to address

their follow up backlogs through validation potentially through

case note review via virtual clinics.

Benchmark: Feb 2015 to Jan 2016 (12 month trend) What actions are we taking?

There are currently two initiatives about to come on board to

improve attendance at clinical consultations: Text and Remind –This service was launched on 1st July 2015

and reminds patients of their upcoming outpatient appointments. An initial assessment of the impact of this service on DNA rates will take place after 3 months of data has been collected.

Self Service Kiosk – this service will allow patients to update

their own demographics as they attend for an appointment. It will ensure that we hold the right information for each patient and will aid communication processes. This service was launched in August 2015.



0.0%

5.0%

10.0%

15.0%


% D

NA

Rate

s

Follow-up Outpatient DNA Rates



91


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Local Measure: Outpatient Clinic Cancellations Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: COO

Period: Oct 2015 Local Target: Continuous Improvement Current Status: 84 YTD 613

Current Trend: cancellations <6 weeks’ notice by reason How are we doing?

The charts are derived from data collected by medical records as a result of forms received requesting clinics to be cancelled. At present this only relates to

those clinics managed by the medical records department. It excludes clinics that are arranged and administered by specialty teams within surgical directorates. This work will progress to cover all outpatient clinics.

The largest reason for short notice cancellation of clinics is captured under “Other”. This needs to be explored so that more granularity is available. The

Performance and Information team will work with the directorates to improve reporting in this area. As can be seen from the graph opposite, the second biggest reason of short notice cancellations are due to annual leave, which contravenes the Health Board’s 6 week annual leave policy for clinical staff.

The charts illustrate the number of clinics cancelled during the month of October

with less than 6 weeks’ notice of cancellation. The cross-cutting theme for outpatient improvement is focusing on short notice clinic cancellations as a strand of the project. Improving in this area will be pivotal to the implementation of the Text & Remind service which was launched on 1st July 2015.

Current Trend: cancellations <6 weeks’ notice by site

Source: Local

0 5 10 15 20 25 30

Annual Leave

Other

Meeting

Study Leave

On call

Sickness Absence

Audit

Casualty/Emergency duty

Professional Leave

Number of cancelled Clinics

Clinic Cancellations < 6 weeks notice by reason for cancellation - October 2015

0 2 4 6 8 10 12 14

General Surgery

Paediatric

Respiratory

ENT

Orthodontics

Gynaecology

Dermatology

Urology

Nephrology

No. of clinic cancellations

Clinic Cancellations < 6 weeks notice by site - October 2015

North Locality

South Locality

92


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 83: % of staff undertaking a performance appraisal development review Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: Status May 2016 Target: Improvement Current Status: 63.98%


As at 1st June 2016 compliance is 63.98%, an increase of 2% on the previous month and the first significant increase recorded since August 2015.

The majority of Directorates continue to perform above 60% compliance. L&D continue to work in close partnerships with Business Partner colleagues

to support managers with persistent non-compliance issues and develop actions for improvement.

Using ESR Business Intelligence to report PDR compliance

ESR Business Intelligence (BI) continues to be used to report PDR compliance to Directorate Managers & Director of Nursing as part of their monthly PDR updates.

Managers are continually encouraged to access BI PDR Dashboards through their ESR Self Serve Accounts allowing them to view a full set of compliance data for their area of responsibility, accessible at any time and always less

than 24 hours old. Guides on “How to Access/Use BI Dashboards” are being developed by L&D

The Learning & Development Department continue to support Directorates in the following ways to improve PDR compliance:-

Providing a comprehensive suite of reports to DMs on a monthly basis providing the latest PDR compliance data, contextualising each Directorate’s performance; what to do to improve compliance; where to seek further help and guidance

Supporting the PDR agenda at the Clinical & Corporate Business Meetings

through preparation of summary reports in advance of each CBM and

attendance where necessary Training Reviewers to enable them to record PDRs via ESR Self Service;

offering on-going support and guidance. Providing a shortened, non-accredited PDR Awareness training course for

Managers, concentrating on How to improve compliance/impact of Pay Progression & Using ESR BI to monitor & report compliance. The 1-day

accredited PDR training for Reviewers has been temporarily suspended due to lack of available Training Officer resources within L&D.

Assigning L&D officers to individual Directorates to assist in the identification and rectifying of report anomalies; develop compliance plans;

provide 1:1 support to managers; raising awareness at briefing and department meetings

Key to chart below: % Improving or Static % Decreasing

Source: ESR

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2013/14 62.6% 60.4% 57.5% 53.7% 54.2% 49.1% 49.9% 50.3% 53.1% 56.4% 57.9% 59.4%

2014/15 60.1% 62.5% 65.2% 64.3% 62.8% 59.6% 60.1% 62.4% 63.0% 63.2% 63.8% 68.0%

2015/16 71.4% 71.9% 72.8% 73.4% 74.5% 72.1% 69.3% 66.8% 65.9% 65.6% 65.8% 63.6%

2016/17 61.98 63.98

40%

45%

50%

55%

60%

65%

70%

75%

80%

Co

mp

lian

ce R

ate

PDR Compliance - Non medical staff

96.00%93.18%

90.57%89.20%

84.48%77.27%76.92%76.40%

75.42%75.00%74.19%73.61%

72.38%72.38%

69.65%66.47%65.85%

55.12%53.23%

52.29%41.88%

40.50%35.29%

33.50%14.08%13.64%

0.00%0.00%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

EstatesCorporate Development

TherapiesMedicines Management

Performance & InformationFinance

PlanningLocalities

FacilitiesICT

PathologyMental HealthPrimary Care

Workforce & Organisational DevelopmentCAMHS Network

ACT and Medical Records & OutpatientsPaediatrics Acute & Community

Obstetrics & Gynaecology and Sexual HealthWelsh Health Specialist Services Committee

Patient Care & SafetyHead & Neck

General Surgery, Trauma & Orthopaedics and UrologyChief Executive

Acute Medicine and A&ERadiology

Operations ManagementContract and Commissioning Directorate

Innovation and Transformation Directorate

Non Medical Staff - PDR Compliance by Directorate

93


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Local Measure: Core Skills – Training Compliance Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: Status as at 27th April 2016 Target: Improvement Current Status: as per table


The new Core Skills Training Framework has been launched across the UHB. Reports are now being produced on a routine basis and supplied to Managers. This has also

been added to the performance data sets being reviewed at CBM’s. This should see a continuing trajectory of improvement. Whilst the majority of areas are in red, it is an improving picture. Our L&D colleagues are also supporting managers to import data records where these have previously been held locally. We are reviewing how we present that dashboard data in order that the trend is better displayed and able to be meaningful.

Source: ESR

94


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Continued: Indicator 83 continued: % of staff undertaking a performance appraisal development review Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: Apr 2016 Target: Improvement Current Status: 61.98%

Current Trend:

PDR % excludes Medical & Dental staff. Appraisal data for M&D staff is held on MARS (Medical Appraisal and Revalidation System) not on ESR. Percentage rates for M&D

staff is therefore included in the narrative on the next page

Source: ESR

95


OF RESOURCES & I CAN MAKE CAREFUL USE OF THEM Indicator 84: % of total medical staff undertaking performance appraisals - Consultant Job Planning Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Workforce & OD

Period: as at end of Apr 2016 Target: Improvement Current Status: Consultants 28.69% SAS Doctors 17.6%

Current Trend: Consultants How are we doing?

E-Job Planning There are 6 currently Directorates now fully trained and are utilising the e-job planning system in their recent rounds of job plan meetings.

The Directorate of General Surgery, Urology and T&O commenced their job plan cycle utilising the new e-system in October 2015,

starting with the teams in Trauma & Orthopaedics. 22 consultant reviews have now been undertaken, 11 of which have been signed off. ACT commenced their job plan cycle on 29th February 2016. 21 consultant reviews have been undertaken, 8 of which have received

full signed off. Remaining consultant reviews are scheduled to be undertaken prior to the end of April. The Directorate team due to commence SAS reviews, and a configuration meeting has been held on the 5th May. The Directorate of Acute Medicine and A&E commenced their job plan review cycle in

December 2015 and will continue through 2016. 20 consultant

reviews have been undertaken, 7 of which have been signed off.

Current Trend: SAS Doctors

The Mental Health Directorate commenced their job plan cycle on 22nd February 2016. 10 reviews have been undertaken, with 6 receiving full sign off. The remaining reviews are scheduled to be

completed by the end of May 2016. The Pathology Directorate have received their consultation meeting and training session to enable their reviews to be undertaken using

the e-job plan system. The Children and Young People Directorate implementation meeting

took place on the 6th May 2016 to enable 2016 reviews to be undertaken utilising the e-job plan system. It is intended that all directorates will have completed their job plans by the end of the financial year.


Source: ESR

96

Local Measure: Fracture Neck of Femur (#NoF) - Number of patients admitted to Orthopaedic Ward within 4 hours Strategic Aim: Strategic Change Programme: Executive Lead: Director of Public Health

Period: Apr 2015 to Mar 2016 Target: Improvement Current Status: 55% YTD 67%

Current Trend: Number of patients admitted to Orthopaedic ward within 4 hours How are we doing?

The graph demonstrates the performance each month against the 4 hour measure for admission to an Orthopaedic ward.


Following discussion with the Clinical Director for Trauma and Orthopaedics, it has been agreed that we will expand these metrics to also include those recommended by those bodies governing the National

Hip Fracture Database, which will allow benchmarking between Orthopaedic units nationally. Initially we will include:

Admission to an Orthopaedic ward within 4 hours,

In the longer term we will also seek to include the following, which will

give a complete view of the #NOF service at Cwm Taf:

Patients developing pressure ulcers Pre-operative assessment by an Ortho-geriatrician Discharged on bone protection medication, Received a falls assessment prior to discharge

Work has been undertaken to reduce overall length of stay, which improves outcomes, and eases bed pressures.

Current Trend: (per site)


Source: Local

0%

20%

40%

60%

80%

100%

0

10

20

30

40

50


Perfo

rm

an

ce

No.

of

pati

en

ts a

dm

itte

d t

oO

rth

op

aed

ic w

ard

Number of Fracture NoF patients admitted to Orthopaedic ward within 4 hours

< 4 hours wait in A&E > 4 hours wait in A&E % Achieved

1719

9

1413

812

9

93

7

8

4

4

10

11

65%

86%

56%

64%

76%

67%

55%45%

0

5

10

15

20

25

30

PCH RGH PCH RGH PCH RGH PCH RGH

Dec-15 Jan-16 Feb-16 Mar-16

No

. p

ati

en

ts a

dm

itte

d t

o

Orth

op

aed

ic W

ard

Number of Fractured NoF patients admitted to Orthopaedic Ward within 4 hours

< 4 hours wait in A&E > 4 hours wait in A&E

97

Local Measure: Fracture Neck of Femur (#NoF) - Number of patients who go to theatre for repair within 36 hours Strategic Aim: Strategic Change Programme: Executive Lead: Director of Public Health

Period: Apr 2015 to Mar 2016 Target: Improvement Current Status: 90% YTD 64%

Current Trend: Number of patients admitted to Orthopaedic ward within 4 hours How are we doing?

The graph demonstrates the performance each month against the 36 hour measure for patients who go to theatre.


Following discussion with the Clinical Director for Trauma and Orthopaedics, it has been agreed that we will expand the metrics to also include those recommended by those bodies governing the National Hip

Fracture Database, which will allow benchmarking between Orthopaedic units nationally. Initially we will include:

Surgery within 48 hours and during working hours - since the beginning of January the Health Board has achieved 85% against

this measure which is comparable to the national achievement of 86% in 2013. Further work will be done to produce this

information over the last two years for completeness.

Current Trend: (per site)


Source: Local

0%

20%

40%

60%

80%

100%

0

10

20

30

40

50

60


Perfo

rm

an

ce

No.

of

pati

en

ts w

ho

wen

tto

Th

eatr

e

Number of Fracture NoF patients who go to theatre for repair within 36 hours

< 36 hours to Theatre > 36 hours to Theatre % Achieved

1719

11

21

9 9 9

17

93

5

1

8

3

13

3

65%

86%

69%

95%

53%

75%

41%85%

0

5

10

15

20

25

30

PCH RGH PCH RGH PCH RGH PCH RGH

Dec-15 Jan-16 Feb-16 Mar-16

No

. p

ati

en

ts w

ho

wen

t

to T

heatr

e

Number of Fractured NoF patients who go to theatre for repair within 36 hours

< 36 hours to Theatre > 36 hours to Theatre

98

Local Measure: Hand Hygiene & Nutritional Compliance The recording of Hand Hygiene and Nutritional scroring compliance is now undertaken in the All Wales Nursing Dashboard Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Nursing

Period: May 2015 to Apr 2016 Target: Improvement Current Status: Hand Hygiene 96.4% / Nutrition Score 90.7%

Current Trend: Hand Hygiene How are we doing?

Hand hygiene performance improved again in April to 96.4% and remains above the All Wales average. During this period the largest single group of staff to be non-compliant were medical staff. However, there was also non-compliance noted with nursing and allied health professional staff.

The % compliance with Nutrition Score declined this month to 90.7% from 91.6% in March. This has continued a steady decline in compliance since January and is now below the All Wales average. The Chief Nursing Officer has directed that completion of the nutrition e-learning programme is mandatory for all nursing staff in Wales. CTUHB had committed to full compliance by July 2015 but currently compliance is only approximately 12%. There is

a need to consider alternative methods of support and/or delivery for this training in order to improve compliance and provide assurance.

Current Trend: Nutrition Score What actions are we taking?

100% complaince with nutrition e-learning by end of March 2016

HONs will be reminded of the CTUHB commitment that all nurses employed will

complete the nutrition e-learning programme. HONs will be supported to develop a

training strategy to improve compliance.

A MUST nutritional audit tool has been developed to monitor quality of documentation and actions taken following the admission assessment: the results will inform the quality assurance process.

The Infection Prevention and Control Team challenge staff who fail to perform hand

hygiene.

Hand hygiene awareness sessions are offered at ward level to improve staff

knowledge and understanding of the “WHO 5 Moments to Care”.

Non compliance with hand hygiene is reported and highlighted at Infection

Prevention and Control Directorate Group and Infection Prevention and Control

Operational/ Strategic Group meetings.

New signage is being sourced to encourage hand hygiene practices at ward level.


Hand hygiene - CTUHB remain above the All Wales average. Nursing staff not having time to complete the nutrition e-learning Non-compliance with hand hygiene increases infection risks to patients and staff.

Source: Fundamentals of Care/Nursing Dashboard

80%

85%

90%

95%

100%

May-15

Jun-15 Jul-15 Aug-15Sep-15 Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16 Apr-16

% C

om

pli

an

ce

% Compliance with Hand Hygiene (WHO 5 moments)

Cwm Taf All Wales

90%

93%

95%

98%

100%

May-15

Jun-15 Jul-15 Aug-15Sep-15Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16Apr-16

% C

om

pli

an

ce

% Compliance with Nutrition Score completed within 24 hrs of admission & appropriate action taken

Cwm Taf All Wales

99

Local Measure: Surgical Site Infection Rates (Arthroplasty) Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Nursing

Period: Jan 2011 to Dec 2014 Target: Reduction Current Status: as per table

Current Trend: Since 2003, Health Boards that carry out Orthopaedic procedures in Wales have been required by the Welsh Government to undertake continuous surveillance of surgical site infections (SSI) following Orthopaedic procedures. From 2007 onwards, surveillance has been restricted to just elective primary hip and elective primary knee arthroplasty.


Performance in this area has improved considerably over the last 3 years. Infection rates for both primary knee and primary hip replacements are now below the all Wales level. However there is a variance between the recorded primary arthroplasty carried out and the number of forms received by WHAIP.

To ensure all relevant procedures are recorded and an accurate infection rate derived: Establish accurate number of arthroplasty operations carried out across relevant

years.

Ensure all relevant procedures are cross reference with WHAIP infection

information.

Derive infection rates in line with accurate numbers and rationale.

This work will be on-going until a satisfactory rationale for compliant procedures is implemented


Elective

Primary Hip

Arthroplasty

Total

Procedures

Number

of forms

received

Number

of valid

forms

received

Number

of

inpatient

SSI

Number

of post-

discharge

SSI

Overall

SSI Rate Period

Elective

Primary Knee

Arthroplasty

Total

Procedures

Number

of forms

received

Number

of valid

forms

received

Number

of

inpatient

SSI

Number

of post-

discharge

SSI

Overall

SSI Rate

Cwm Taf 416 264 264 1 2 1.1% Cwm Taf 466 335 335 0 3 0.9%

All Wales no data 2003 1985 7 11 0.9% All Wales no data 2131 2119 8 29 1.7%

Cwm Taf 388 286 286 2 3 1.8% Cwm Taf 441 368 368 0 5 1.4%


Cwm Taf 427 353 353 4 1 1.4% Cwm Taf 561 543 543 3 6 1.7%


Cwm Taf 434 272 272 6 6 4.4% Cwm Taf 543 419 419 1 9 2.4%


Jan 2013 to Dec 2013




100

Local Measure: Caesarean Section Rates & Surgical Site Infection Rates (Caesarean Section) Strategic Aim: Excellent People Strategic Change Programme: Executive Lead: Director of Nursing

Period: May 2015 to Apr 2016 (infection rates: Apr 2015 to Mar 2016)

Target: Reduction – baseline to be established

Current Status: Rate of C Section: 26%/Infection Rate: 5.6

Current Trend: Caesarean Section Rates Current Trend: Surgical Site Infections (Caesarean Section)


All Health Boards in Wales have been required by the Welsh Assembly Government to

implement Caesarean Section surgical site infection surveillance since 01/01/2006, and to report these data to the WHAIP on a monthly basis. Previously reported high rates of infection within the Health Board have been reviewed and attributed to over reporting.

The directorate has since addressed these issues and the resulting drop in SSI rates reflects the accurate position going forward. Individual clinical practice and women’s choice have been identified as the main contributors to Cwm Taf’s high instances of Caesarean Section births. This is now being addressed by a Normal Birth Working Group with the aim of reducing by 1%

each year until the target rate is achieved.

Improved monitoring of reporting of C-sections and associated SSIs.

Established Multidisciplinary Normal Birth Working Group.

Audit of all CS performed in March 2014 to investigate peak.

Continuous audit of all Inductions of Labour.

Birth Environmental audit and refurbishment.

Cohort of Midwives trained to provide Aromatherapy.

Developing MDT Panel to review request for CS.

Developing Midwife Led VBAC Clinic.

Benchmarking practice across Wales.

Introduction of a standard operating procedure (SOP) for pre intra and post-

operative care.

Source: MITS / Public Health Wales (WHAIP)

32% 31%

27%28%

29%

27%

30% 29%

31%

33%

31% 31%

0%

5%

10%

15%

20%

25%

30%

35%

150

200

250

300

350


Caesarean

Rate

(%

)

To

tal

Deli

verie

s

Caesarean Section Rates

Grade 4 - Delivery timed to suit woman/team

Grade 3 - No maternal/fetal compromise but needs early delivery

Grade 2 - Maternal/fetal compromise-not immediately life threatening

Grade 1- Immediate threat to life of woman/fetus

Normal Deliveries

Caesarean Rate as a % of hospital births

6 6 6 4 7 3 8 4 3 3 0 50%

2%

4%

6%

8%

10%

12%

0

1

2

3

4

5

6

7

8

9

Apr-15May-15 Jun-15 Jul-15 Aug-15Sep-15 Oct-15 Nov-15Dec-15 Jan-16 Feb-16 Mar-16

SS

I R

ate

Nu

mb

er o

f In

fecti

on

s

Caesarean Section Surgical Site Infection

Number of Infections Cwm Taf Infection Rate All Wales Infection Rate

101

Commissioning

The Information below provides an update on the position at the end of June in relation to services commissioned by Cwm Taf UHB from Cardiff and Vale UHB and also those

services commissioned via WHSSC. The comments to the right of the figures provide a narrative of the current position.

Source: Local

Cwm Taf Commissioner Activity Monitoring- 2015-16 Month 11 Comments

Cardiff Summary

SpecialtyMonth 12

Forecast

Month 12 2014-

15

Increase/

(Decrease)

Plan Act Var Perf (£) Perf (£) Perf (£) Perf (£)

Inpatients 1,744 1,392 (352) (200,688) (190,642) (204,156) 13,514 Increase in elective inpatient activity being seen in Cardiff for surgical

specialties

Daycases/RDAs 2,492 2,653 162 180,539 407,955 348,438 59,516 Early data shows a significant reduction in daycase activity- CT aim to

repatriate haematology activity in 2015-16

Outpatients 18,473 17,458 (1,015) (89,466) (72,827) (69,067) (3,760) Underperformance on the Cardiff contract for medical specialties

CAVOC 95,455 163,133 226,161 (63,028) Underspend currently forecast compared to 14-15

AICU 124,576 124,576 124,576 - Lower AICU performance than in 2014-15 currently forecast

NICE 1,350,607 1,350,607 1,350,607 - Decrease in haematology drugs being offset by increase in MS drugs

Other High Cost 251,746 254,431 256,454 (2,023) Overspend driven by high cost activity

TOTAL 22,708 21,503 (1,205) 1,712,768 2,037,232 2,033,013 4,220

Cardiff Cost and Volume Contract by Specialty

Specialty

Plan Act Var Perf (£) Plan Act Var Perf (£) Plan Act Var Perf (£)

Haematology M11 2014-15 130 199 69 #REF! 352 #REF! #REF! #REF! 1,180 #REF! #REF! #REF!

Haematology M11 2015-16 130 100 (30) (21,348) 352 808 456 108,072 1,180 1,147 (33) (763)

Haematology Increase/(Decrease) 0 (99) (99) #REF! - #REF! #REF! #REF! (0) #REF! #REF! #REF!

Rheumatology M11 2014-15 16 3 (13) #REF! 12 #REF! #REF! #REF! 1,008 #REF! #REF! #REF!

Rheumatology M11 2015-16 16 2 (14) (26,812) 12 154 142 43,302 1,008 663 (345) (15,549)

Rheumatology Increase/(Decrease) (0) (1) (1) #REF! (0) #REF! #REF! #REF! - #REF! #REF! #REF!

WHSSC Monitoring

Plan

(£'000)

Actual

(£'000)

Variance

(£'000)

CT Share

(£'000)

Cardiff & Vale University Health Board 178,633 180,008 1,375 308

Abertawe Bro Morgannwg University Health Board 89,453 90,332 879 (11)

Cwm Taf University Health Board 5,803 5,637 (166) (16)

Aneurin Bevan Health Board 3,221 3,070 (151) (3)

Hywel Dda Health Board 285 285 - -

Betsi Cadwaladr University Health Board Provider 34,924 36,182 1,258 -

Velindre NHS Trust 30,538 31,198 660 122

Welsh Ambulance Service NHS Trust 129,299 129,299 - -

0 - - - -

Non Welsh SLAs 97,132 104,579 7,447 689

IPM & NCA 46,136 50,012 3,876 133

Renal 5,431 5,314 (117) (3)

Unallocated Development and Savings targets 5,081 4,537 (544) (91)

2015/16 Plan Developments 4,907 1,075 (3,832) (494)

Direct Running Costs 4,852 4,600 (252) (27)

Total Expenditure 635,694 646,127 10,433 608

Outpatients

Savings target in 2015-16 to repatriate rheumatology daycase activity looks

to be little progres after 11 months.

Savings target in 2015-16 to repatriate haematology daycase activity looks

to be making significant progres after 11 months

The WHSSC end of year position was significantly overspent at 608k above

the £1.1m that Cwm Taf invested in the WHSSC IMTP

Month 11

Month 12

Contract

Inpatients Daycases/RDAs

102

Commissioning (continued)

The information below provides an update on the position at the end of June in relation to services commissioned by neighbouring Health Boards from Cwm Taf UHB. The

comments to the right of the figures provide a narrative update on the current position.

Source: Local

Cwm Taf Provider Activity Monitoring- 2015-16 Month 11 Comments

Summary Contract Performance

Commissioner


Aneurin Bevan 5,778 5,620 (158) (275,188) 929 1,382 453 114,087 6,068 5,891 (177) (39,844)

The Health Board continue to overperform for AB against baseline, as expected,

although early indications are that the overperformance is falling as AB

repatriate outpatients to YYF

Cardiff and Vale 1,512 1,219 (298) (52,198) 383 418 35 825 2,052 1,844 (219) (37,527) Month 2 shows some underperformance for Cardiff and Vale

ABMU 582 416 (166) (209,367) 123 245 122 13,866 791 583 (208) (63,514) Both Health Boards aim to repatriate activity in 2015-16. 60% MR negotiated on

this contract

Powys 269 285 16 37,303 98 101 3 7,973 324 340 16 (4,404) The baseline will be updated for 2015-16 to include recurrent overperformance

Hywel Dda 52 46 (6) (3,535) 8 10 2 315 39 45 6 (826) Cwm Taf only have a small contract with Hywel Dda, some underperformance

showing

TOTAL 8,193 7,586 (612) (502,985) 1,541 2,156 615 137,066 9,274 8,703 (582) (146,115)

Contract Performance against RTT Specialties

Specialty


General surgery 1,367 292 (1,075) (59,141) 95 721 626 (2,300) 936 283 (653) (3,447) Inpatient underperformance primarily delivered for AB

Trauma & Orthopaedics 843 (31) (875) (102,544) 44 1,278 1,234 2,499 1,640 481 (1,159) (3,686) Significant underperformance for IP

ENT 339 55 (285) 2,886 41 454 413 3,421 725 245 (480) (2,999) Some overperformance coming through- AB and ABMU

Ophthalmology 33 13 (21) (14,862) 72 611 539 1,209 860 240 (620) (2,487) Significant daycase overperformance being delivered for AB

Oral Surgery 159 85 (73) (2,088) 45 487 442 3,344 643 163 (480) 8,719 Some overperformance coming through for AB

Cardiology 2 73 71 26,376 53 256 203 5,852 372 87 (285) 27,456 Some overperformance coming through for CV and AB

TOTAL 2,743 487 (2,257) (149,374) 350 3,806 3,456 14,026 5,176 1,499 (3,677) 23,556

Inpatients Daycases New Outpatients

Inpatients Daycases New Outpatients

103

Commissioning (continued) Cwm Taf Residents awaiting treatment at Cardiff and Vale UHB – RTT

(March 2016) Cwm Taf Residents awaiting treatment at Aneurin Bevan UHB – RTT

(April 2016)

The table above depicts the specialty level waiting lists for Cwm Taf patients at Cardiff and Vale University Health Board and also shows the percentage performance against the 36 week target.

It should be noted that the longest waiting & highest volume of patients are within Neurology, Ophthalmology, Neurosurgery, T&O. There are currently 10 patients waiting

>52 weeks- Neurosurgery (2), Ophthalmology (1), Paediatric Surgery (3), T&O (4).

The table above depicts the specialty level waiting lists for Cwm Taf patients at Aneurin Bevan University Health Board and also shows the percentage performance against the 36 week target.

It should be noted that the longest waiting patients are within Orthopaedics with 1 patient waiting 57 weeks and 2 patients in Ophthalmology waiting 53 & 55 weeks.

Source: C&V/AB

104

Glossary

Acronym Detail Explanation

AvLos Average Length of Stay A mean calculated by dividing the sum of inpatient days by the number of patients admissions

C.difficle Clostridium difficile

CHKS Caspe Healthcare Knowledge Systems A Limited Company that is a provider of Healthcare Intelligence.

CTP Care and Treatment Planning

New measure within Mental Health Services

DNA Did not attend outpatient clinic A count of patients that failed to attend an outpatient appointment and did not notify the

hospital in advance.

DSU Delivery and Support Unit The Welsh Government established the Delivery and Support Unit (DSU) to assist National

Health Service (NHS) Wales in delivering the key targets and levels of service expected by both

the Welsh Government and the public of Wales.

DTOC Delayed transfers of care A patient who continues to occupy a hospital bed after his/her ready-for transfer of care date

during the same inpatient episode.

EDDS Emergency Department Data Set A data set which is made up of both injury data and illness data received from each of the Major

Emergency Departments across Wales.

FCE Finished Consultant Episode A period of care under one consultant within one hospital

FTE Full Time Equivalent Number of employed persons as a whole unit

GP Cluster GP Practice Cluster Grouping of GP’s & Practices locally determined by individual Local Health Boards

HAI Hospital Acquired Infection Any infection that occurs during a patient's stay in hospital

HPV Human Papilloma Virus vaccination A vaccination to reduce the incidence of communicable diseases

HONS Heads of Nursing

KSF Knowledge & Skills Framework KSF defines & describes the knowledge & skills NHS staff need to apply in their work to deliver

quality services

LPMHSS Local Primary Mental Health Support

Services

Under provisions of section 2 of the Mental Health (Wales) Measure 2010, all local mental

health partners must work jointly to agree a scheme for the provision of mental health

services within the area.

MMR Mumps, Measles, Rubella vaccination A vaccination to reduce the incidence of communicable diseases

MRSA Methicillin Resistant Staphylococcus aureus

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Acronym Detail Explanation

MSSA Methicillin Sensitive Staphylococcus aureus

Mortality Measured as Crude Death Rate

The simplest death rate is the crude death rate & is usually calculated for periods of one year

NIHSS National Institute of Health Stroke Scale The NIH Stroke Scale/Score (NIHSS) quantifies stroke severity based on weighted evaluation

findings.

NISCHR National Institute for Social Care & Health

Research

Welsh Government body that develops, in consultation with partners, strategy and policy for

research in the NHS and social care in Wales.

NUSC Non Urgent Suspected Cancer Patients referred as non-urgent patients but subsequently diagnosed with cancer should start

definitive treatment within 31 days of diagnosis, regardless of the referral route

NWIS

NHS Wales Informatics Service

Have a national role to support NHS Wales to make better use of IT skills & resources

PDR Personal Development Review Process whereby an employee meets at least annually with their manager or nominated

deputy to discuss their performance for the last year, appraise objectives set for the previous

year and agree a Personal Development Plan (PDP) for the coming year

QOF

Quality Outcomes Framework The Quality and Outcomes Framework (QOF) is a voluntary system of financial incentives. It is

about rewarding GP's for good practice through participation in an annual quality improvement

cycle.

RAMI

Risk Adjusted Mortality Index

The NHS uses a number of indicators to measure the quality & safety of healthcare in Wales

RTT Referral to treatment 95% of patients referred to Secondary Care planned care services to receive their treatment within

26 weeks. All patients referred to RTT included services are to receive treatment within 36 weeks of

referral.

TOMS

Theatre Operating Management System Cwm Taf’s local electronic system for managing theatre activity.

UMR Universal Mortality Review Process of reviewing In-Hospital Deaths

USC Urgent Suspected Cancer Patients referred as urgent suspected cancer and subsequently diagnosed with malignant cancer

to start definitive treatment within 62 days of receipt of referral

YTD Year to Date Period commencing 1st April

integrated performance dashboard · integrated performance dashboard lead director ... my local...

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