Quality Report for December 2011 (Month 9 and Quarter 3) and

Overview and headlines / p.1
Performance and Quality Priorities / p.2
Clinical Safety and Clinical Effectiveness / p.3
User & Carer Experience / p.4
Mental Health performance indicators / p.5
Drug & Alcohol and Productivity / p.6
PCT indicators / p.7
Community Health Services / p.8
Quality Dashboard / p.9-10
Performance Dashboard / p.11-13

Performance Report for January 2012 (month 10)

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  1. Overview:

This report covers:

  • Quality: October -December 2011 (Q3) of 2011-12
  • Performance: Month 10 (January) of 2011-12.

The December Quality Dashboard can be seen at p 9

The January Performance Dashboard can be seen at p10

1.1.Monitor:

The headline is that at month 10 we are achieving all Monitor Targets. However, it should be noted that there are areas of variable performance behind this and this is discussed at p 4.

• CPA 7 Day Follow-Up: January showed an improvement (97%) from December (94.5%) for this indicator.

• CPA Reviews in 12 months: The CPA Review position for January (95%) was achieved and this was maintained from December (also 95%).

A key element in maintaining our Monitor KPIs has been the availability of QIS reports to service line senior management each week, tracking performance and giving an early warning of areas in need of attention.

Consequence of not achieving Monitor targets:

These are key to our rating. If we fail on any Monitor target at the end of a quarter, this will lead to greater scrutiny and potentially be an obstacle to us winning new business or protecting our existing market share.

1.2.Quality Priorities:

The headline is that an analysis of these measures from Q1 to Q3 in shows a downward trend in performance against KPIs. The reasons for this are the subject of analysis and action plans. They include the move to Service Lines, reductions in staffing levels and challenges with Jade

A series of robust management plans have been put in place for all areas, and are set out in this report. Quality indicators are gathered into a dashboard each quarter (p10) and taken up with service lines at the monthly Quality and Performance Management Group, in local SMTs and through quarterly reviews, in one to one sessions and through a range of discussions with service line management.

On a positive note, the Trust’s QRP (Quality Risk Profile) is the best we have ever had, as a result of the outcomes of CQC visits. This is available via the CQC website to commissioners and other key stakeholders.

All of the Quality Priorities bar one are linked to the CQUIN and therefore the CQUIN income is at risk if the targets are not achieved by Quarter 4. This is discussed at 2.5 below.

  1. Quality – Trust and Directorate performance for Q3:

The indicators on the Quality Dashboard are comprised of a) Quality Priorities for Mental Health and Allied Specialties reported in CNWL’s Quality Account (indicators 1.1 – 1.11), and b) Board agreed indicators of quality (all remaining indicators)

The dashboard includes 35 indicators, structured as follows:

  • Section 1: Quality Priorities (12 indicators)
  • Section 2: Clinical Safety (14 indicators)
  • Section 3: Clinical Effectiveness (4 indicators)
  • Section 4: Service User Experience (5 indicators)

The chart below shows a comparison of the performance across all 35 indicators for quarters one, two and three:

2.1.Key highlights by section

2.1.1.Quality Priorities (QP)

Adult and older adult services are not meeting 5/12 of the Quality Priority indicators for quarter three (Red and Amber)

Most of these indicators are patient reported ones and data is collected via the quarterly user surveys. The methodology has been examined during Q3 and some changes have been made to improve the validity of this data. This has lead to a slight adjustment of recorded outcomes in 4 QP/CQUIN areas. These are indicated below and can be seen on the quality dashboard at p 10in indicators 1.2, 1.4, 1.6b and 1.7.

  • Areas for improvement:

a)(1.7). Community patients reported they were definitely involved as must as they wanted to be in decisions about their care plan. Target 65%. Q3 – 46% (Q2 – 84%, Q1 – 82%). We are investigating this change. The methodology has only made a 1% change so that is not the cause.

b)(1.6b). Community patients on CPA report they got enough advice and support for the physical health. Target 65%. Q3 – 63% (Q2 – 72%, Q1 69%). This is also a CQUIN.

c)Community patients reported that they were given (or offered) a written copy of their care plan. Target 85%. Q3 – 50% (Q2 – 60%, Q1 – 71%). This is also a CQUIN

d)Identified carers for patients. Target 55%. Q3 – 45% (Q2 – 55%, Q1 – target not set). CQUIN

e)Patients receiving a crisis card. Target 85%. Q3 – 52% (Q2 – 39%, Q1, 62%). Some improvement but still short of the target. CQUIN.

f)It should be noted that while response in a crisis has dropped slightly, the new methodology shows that the overall experience is positive:

(1.4). Patients stated that they received an informed response/help they wanted when contacting the CNWL crisis point. Target 65%. Q3 – 80% (Q2 – 83%, Q1 – 92%). CQUIN

Action:

  • The new Care and Support Plan has been rolled out since November, and should have animpact on both measures (a and c) above.
  • Local actions are being implemented by Business Managers to ensure that inpatients have a physical health assessment after admission and to ensure that more inpatients are offered a copy of their care plan (b and c)
  • The recording of carers is difficult on Jade, so a change request has been made to make it easier. There is also a cultural issue around recording carer information, which is being addressed locally.
  • Over 30,000 crisis cards have been sent out in Q3 so it is expected that this measure will improve by Q4 (e)
  • Clinical Safety

Some indicators do not have a fixed target, but must show a quarter on quarter reduction (QtQR)

Areas for improvement:

a)Completion of L5 SUI investigationstaking longer than 3 months (QtQR). Increased 3 cases from Q2 to 13 (Q3 – 13, Q2 – 10, Q1 – 13)

b)Inpatient risk assessments completed and linked to care plan. Target 95%. Q3 - 90%(Q2 – 91%, Q1 – 83%)

c)Community patient risk assessments completed and linked to care plan. Target 95%. Q3 – 89% (Q2 – 84%, Q1 – 84%)

d)All incidents of violence between patients (QtQR). Q3 - increased 3 cases from Q2 to 137 (Q2 – 134, Q1 –120)

e)All incidents of violence by patients on staff QtQR). Increased 36 cases from Q2 to 245 (Q2 – 209, Q1 – 164)

f)Incidents of violence by patients on staff (L3 upwards) (QtQR) increased from 1 case in Q2 to 8 (Q2 – 7, Q1- 2)

g)AWOLs and AWOLS reported to the CQC, both increased from Q2. Those reported to CQC - - Q3 – 62, Q2 – 50, Q1 – 26. Those not reported to CQC – Q3 – 94, Q2 – 90, Q1 – 57)

Action:

  • SUIs are now formally managed by the Associate Director for Governance and we are seeing delays reducing (a)
  • Risk assessments – This is an issue of training and communication at service line level and is being lead there (b - c).
  • Violence and AWOLs - This is also an issue of training and communication at service line level and is being lead there (e-f)
  • Clinical Effectiveness

These measures have remained stable

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2.1.4.User and Carer Experience

Areas for Improvement:

a)Inpatients recorded as having a copy of their care plan. Target 95%. Q3 – 73% (Q2 – 78%, Q1 – 74%)

b)Community patients recorded as having a copy of their care plan. Target – 95%. Q3 – 88% (Q2 – 78%, Q1 – 66%)

c)Service users on CPA who state that they definitely understand what is in their care plan. Target 75%. Q3 – 52% (Q2 – 53%, Q1 – baseline not set). This is a CQUIN.

Action:

  • For all these areas, the roll out of the new care and recovery plan is designed to improve performance (a-c)
  • There is also a significant issue about people on Lead Professional Care (LPC) recognizing their care plan. The issue of LPC has implications here, and in relation to PbR, and a separate piece of work is underway to address who should be on LPC and what the package should be for them (a-b)
  • CQUINs:

As above, these are aligned with quality priorities and this means that where we are seeing a drop, this has a financial implication. Action plans are in place in relation to all areas, particularly user and carer experience, response in a crisis, involvement in care planning and receipt of a care plan. The Trust has agreed to a project management resource for CQUINs for 2012-13, when the value rises from 1.5% of the contract, to 2.5%.

  1. Directorate Performance across the last 3 months

3.1.Mental Health:

3.1.1.7 Day follow up (97.2% in month, 95.4% cumulative): Target 95%

Two areas did not achieve the target this month.

Harrow Adults: This was one patient who was followed up, however the contact was not recorded appropriately on JADE. This has since been rectified and staff have been reminded of the data entry process.

Westminster Adults: One was a clinical breach were despite numerous attempts to contact the client, it was not possible to engage. The other is a result of incorrect CPA level recorded on the system, which has since been changed.

3.1.2.CRT Gatekeeping (98%) Target 90%.

All areas achieved the CRT gate-keeping target .

3.1.3.CPA Review within 12 months (95.1%): Target 95%

Three areas did not achieve the target this month:

Harrow OA– The Business manager will review and report weekly.

Eating Disorders- This is a Jade issue and patient allocation which is being addressed as part of the ICT strategy

Learning Disabilities- Recent changes to JADE for LD continue to be embedded operationally. A review meeting is scheduled f or February to assess impact of changes.

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3.2.Drug and Alcohol Services

NTA targets are set out in the dashboard at p11. Trustwide, all have achieved green scores at January 2012 although not always at borough level (see below). However, as these scores depend on a pathway and are not indicative of CNWL’s performance, a new set of KPIs will be developed for 2012-13 to give a truer picture of the Service Line’s performance.

A few headlines to indicate where the Trust sits in performance include:

For achieving patient abstinence or reliable improvement, CNWL’s performance was better than regional performance for opiates, crack, cocaine, alcohol, cannabis and injecting. For the last two, the difference with the regional average was 23% and 24% respectively.

CNWL is addressing new and emerging drug problems which are hard to treat. Access points to this include the Club Drug Clinic for which a research grant has been applied.

Detail of where the existing targets show some ambers and reds at Borough level are set out below for:

a)Completeness of TOP information at Review

b)Completeness of TOP information at Exit

c)Drug planned discharges

d)Alcohol planned discharges

  • Completeness of TOP Information at Review (Target >85%)

This target was not met in two boroughs – as last month: H&F and K&C:

H&F (72%): There were a number of factors involved including client disengagement and late data entry. Systems and processes are being reviewed in line with newly revised LES contract (with GPs), to ensure clear understanding of requirements There is a clear upward trend on performance,

K&C (66%):This was due to a data entry – the inclusion of national pilot clinic data. A tracker to monitor collection of this data is now being discussed in weekly MDT meetings.

  • Completeness of TOP information at Exit (Target >85%)

K&C (83%): Due to onereview being missed through staff error. A tracker to monitor collection of this data is now being discussed in weekly MDT meetings.

Drug Planned Discharges (Target 40%)

Brent (35%), K&C (35%), H&F (30%) and Ealing (36%): there is a pathway issue here as discharge may not be from CNWL, as reported in previous summaries. Actions include monitoring of DNA clients and follow up within 24 hours to encourage re-engagement. Re-profiling of patients most likely to re-engage, and those that are not is also taking place, to gain a better understanding and therefore devise appropriate strategies.

Alcohol Planned Discharges (Target 50%)

Brent (29%) H&F (38%) and Hounslow (43%):Data cleansing work is ongoing to address the data quality issues and recently developed and agreed care pathways are being implemented to ensure that only clients that begin a treatment pathway are entered onto DET.

New motivational recovery groups and peer support programmesare being put in place as part of the new pathway to reduce unplanned exits. Month on month improvement is expected.

3.3.Productivity Indicators –( locally defined): Trustwide Performance across last 3 months

KPI / Target / Nov / Dec / Jan
Emergency Readmissions / <=11% / 6.6% / 1.8% / 4.1%
DNAs - First / <=15% / 18.8% / 12.6% / 13.2%
DNAs - Follow up / <=15% / 16.7% / 13.8% / 14.4%
Inpatient diagnosis / 95% / 91.0% / 87.5% / 84.7%
Community diagnosis / 95% / 91.0% / 92.8% / 92.3%
Delayed Transfers of Care / <=7.5% / 3.7% / 5.6% / 5.2%
  • DNA First Appointment

Two areas are exceeding the 15% threshold for DNA First appointments. In Westminster OA (33%), this appears to be due to a data recording issue rather than a clinical problem. Further training is being provided as appropriate to the teams and the data is being investigated to identify anomalies. CAMHS Westminster (18%) are investigating why DNA rates continue to be high, though this month did see a slight improvement over December.

  • DNA Follow Up

Two areas are exceeding the 15% threshold for DNA F/Up appointments. In Hillingdon Adults (15.3%) this is due to a non-Hillingdon team being incorrectly attributed to their report, thus impacting performance. With this team excluded, performance is below the 15% threshold. In CAMHS Brent (15.3%) the DNA rate is attributable to parents not attending optional group sessions.

3.3.1.In-patient and Community Diagnosis

For Inpatient Diagnosis the Trust wide position has dropped significantly to 85% in January due to 5 areas not achieving the target. In K&C and Westminster Adults, the breaches are due to absence of members of staff, however processes are in place to now address the issues.

3.4.PCT Targets:

There are 2 key PCT targets which are not covered above: number of CRT home treatment episodes (HTEs) and number of Under 18s admissions on adult wards deemed to be clinically inappropriate. Both of these targets apply to adult services only.

3.4.1.Home Treatment Episodes: Harrow Adults under-achieved this target (353/356) and are taking action to ensure that the target is met by the end of the year. The plan includes following up all patients, as appropriate.

3.4.2.Under 18s inappropriately admitted to adult wards: In M10 there were no occupied bed nights attributable to inappropriate under 18s admissions to adult wards.

3.5.PbR Clustering

The Trust had set a deadline of the end of December to achieve 100% clustering of open patients. Performance has improved since last month from 95% to 96%.

  1. Community Services

4.1.Community Information Dataset (CIDs):

Summary Performance in Camden and Hillingdon against the newly proposed targets set by Monitor are included in the January report for the first time – although we are not performance managed against them

CIDs will be a Monitor requirement – originally set for 2014, there is now a proposal this be pulled forward to April 2012. CNWL has joined colleagues in Oxleas, Leeds and North East London FTs in submitting formal responses setting out why this is not achievable.

Performance by CPS and HCH is good against those areas where data is available.

4.2.Monitor:

All Monitor targets have been achieved for December by both provider services

4.3.CQUIN:

The position remains strong.

  • CPS – the challenge is around follow up contact with patients, and discussion about medication & side-effects
  • HCH – the challenge here is HPV vaccination where take-up is voluntary.
  • There are action plans in place and there is no significant financial exposure.

4.3.1.CPS

Camden provider services are showing significant improvement in relation to safeguarding training.

They continue to show reds in relation to Health Visitor reviews for children aged 2 and 3 years old, but these are voluntary for parents which has made this target a challenge

Activity in a number of areas exceeds the commissioned level, but is within a block payment system so this is a risk to CPS – similar to that in relation to MSK in HCH.

4.3.2.Hillingdon Community Health

  • MSK:

As in previous reports, HCH struggles with its MSK target of seeing 95% patients within 3 months. This is because of the high levels of referral – well over the target of 950. They are making progress with commissioners.

Action: The service is actively working with local GPs to manage referrals. There was a dip in referrals over December and the service managed to see 44% of patients within the timescale, although referrals shot back up in January.

  • Dental:

NHS Hillingdon commissioning have set Hillingdon Community Dental Service (CDS) a target of seeing all patients within 26 weeks. In January, some patients waited 40 weeks for initial assessment in the Adult Special Needs Service.

There has been an increase in the number of referrals, particularly from Old Bank House into the Adult Special Needs Dental Service, rising 23% in 2011-12 from 2010-11 and a rise in patients being recalled, whilst there has been no increase in capacity.

Action:

  • The service is writing to Old Bank House to request patients requiring an appointment contact the service
  • Dental's Clinical Director will meet with high referring GDP's to discuss referrals appropriateness
  • ASN patients with denture requirements are being redirected onto the Prosthetic waiting list
  • The service is reviewing the ASN eligibility criteria with a view to discussing with commissioners

Quality Dashboard Q3 (p1):

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Key
I / Internal Indicator
QP / Quality Priority
YoYR / Year on year reduction
Data not collected for these boroughs/directorates, data not applicable or data could not by borough/directorate (Quality Committee indicators only)

Quality Dashboard Q3 (p2):

Performance Dashboard M10 (p1)

Performance Dashboard M10 (p2)

Performance Dashboard M10 (p3)

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