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APPENDIX B

CKW Cluster Partnership: 2011/12 NHS Operating Framework: Annual Accountability Agreement - Reporting of Q3 supporting measures and latest position for Headline measures where available (Quality, Resources & Reform) Calderdale & Huddersfield Foundation Trust Area

Ref No HQU01 HQU02

Quality (Safety, Effectiveness and Patient Experience)

HQU08

Healthcare Associated Infections Mixed Sex Accommodation (MSA)

MRSA Clostridium Difficile Number of unjustified breaches

Actual

YTD

FOT

Period Target/ 2011-12 Plan

Actual

YTD

FOT

Monthly

December

0/5

0

5

7

0/7

1

11

15

Monthly Monthly & Annually Monthly

December

43/58

4

30

40

76/101

6

85

113

December

0

6

38

51

0

5

146

195

December

90%

92.10%

91.97%

91.97%

90%

82.60%

76.6%

76.6%

HQU05a

RTT Admitted - 18 weeks

HQU06a

RTT Non Admitted - 18 weeks

Monthly

December

95%

99.28%

99.31%

99.31%

95%

95.03%

94.5%

94.5%

HQU05b

RTT Admitted - 95th percentile

Monthly

December

23 weeks

20.00

20.00

20.00

23 weeks

26.10

26.10

26.10

RTT Non Admitted - 95th percentile

Monthly

December

18.3 weeks

11.80

11.80

11.80

18.3 weeks

17.70

17.70

17.70

RTT Incomplete - 95th percentile

Monthly

December

28 weeks

20.10

20.10

20.10

28 weeks

21.80

21.80

21.80

SQU24

RTT Admitted - median

Monthly

December

11.1 weeks

9.2

9.2

9.2

11.1 weeks

10.20

10.20

10.20

SQU25

RTT Non-admitted - median

Monthly

December

6.6 weeks

2.6

2.6

2.6

6.6 weeks

3.70

3.70

3.70

SQU26

RTT incomplete - median

Monthly

7.2 weeks

6.5

6.5

6.5

7.2 weeks

6.4

6.4

6.4

Time spent in A & E 4 hour wait

Monthly

December w/e 12/02/12

95%

95.70%

96.37%

96.37%

95%

88.2%

91.6%

91.6%

Time spent in A & E - Admitted 95th percentile

Monthly

December

<4 hours

06:12:00

06:03:00

06:03:00

<4 hours

05:47:00

07:12:00 07:12:00

Time spent in A & E - Non -Admitted 95th percentile

Monthly

December

<4 hours

03:44:00

03:36:00

03:36:00

<4 hours

03:49:00

03:50:00 03:50:00

Time to initial assessment - 95th Percentile

Monthly

December

15 mins

00:15:00

00:20:00

00:20:00

15 mins

00:36:00

00:39:00 00:39:00

Time to treatment in department - median Unplanned re-attendance rate at A & E within 7 days of original attendance (including if referred back for another health professional Left department without being seen rate

Monthly

December

60 mins

00:44:00

00:44:00

00:44:00

60 mins

00:50:00

00:50:00 00:50:00

Monthly

December

<5%

4.8%

4.9%

4.9%

<5%

7.4%

7.7%

7.7%

Monthly

December

<5%

2.3%

2.2%

2.2%

<5%

3.1%

3.0%

3.0%

HQU14_01

% of patients seen within 2 weeks of an urgent GP referral for suspected cancer

Monthly & Quarterly

December

93%

98.8%

97.2%

97.2%

93%

99.9%

99.8%

99.8%

HQU14_02

% of patients seen within 2 weeks of an urgent referral for breast symptoms where cancer is not initially suspected

Monthly & Quarterly

December

93%

89.8%

95.7%

95.7%

93%

98.1%

98.9%

98.9%

SQU05_01

% of patients receiving first definitive treatment within 31 days (one month) of a cancer diagnosis

Monthly & Quarterly

December

96%

100%

99.9%

99.9%

96%

100.0%

99.4%

99.4%

SQU05_02

% of patients receiving subsequent treatment for cancer within 31 days where that treatment is Surgery

Monthly & Quarterly

December

94%

100%

100%

100%

94%

97.3%

100%

100%

SQU05_03

% of patients receiving subsequent treatment for cancer within 31 days where that treatment is an Anti-Cancer Drug Regime

Monthly & Quarterly

December

98%

100%

99.6%

99.6%

98%

100%

100%

100%

SQU05_04

% of patients receiving subsequent treatment for cancer within 31 days where that treatment is a Radiotherapy Treatment Course

Monthly & Quarterly

December

94%

HQU15_01

% of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer

Monthly & Quarterly

December

85%

91.9%

92%

92%

85%

91.0%

87.2%

87.2%

HQU15_02

% of patients receiving first definitive treatment for cancer within 62 days of referral from and NHS Cancer Screening Programme

Monthly & Quarterly

December

90%

100%

98.2%

98.2%

90%

100%

96.6%

96.6%

HQU15_03

% of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status

Monthly & Quarterly

December

85%

100%

93.8%

93.8%

85%

100%

87.1%

87.1%

HQU06b HQU07a

HQU09

Referral To Treatment Waits (including percentile and median)

A & E Quality Indicator

HQU09_10 HQU09_12 HQU09_13

A & E Quality Indicators (all other measures)

HQU09_09 HQU09_11

Quality (safety, Effectiveness and Patient Experience)

Data Reporting Period Target/ Availability period 2011-12 Plan

Outcome/Measure

Mid Yorkshire Hospital Trust

Cancer Waiting Time Standards: 2 week wait, 31 day wait, 62 day wait

Not appllicable to CHFT as they do not do Radiotherapy

94%

Not appllicable to MYHT as they do not do Radiotherapy

HQU16

Emergency Re-admissions

Emergency Re-admissions within 30 days

Monthly

December

11%/ <25%

12.65

13.86

13.86

<25%

SQU01

VTE Risk Assessment

% of all adult inpatients who have had a VTE risk assessment

Monthly

December

90%

90.61%

90.81%

90.81%

90%

97.8%

96.0%

96.0%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit

Quarterly

Quarter 3

80%

90.38%

87.94%

87.94%

80%

82.0%

75.0%

82.0%

Proportion of people at high risk of Stroke who experience an TIA are assessed and treated within 24 hours

Quarterly

Quarter 3

60%

41.67%

59.00%

59.00%

60%

22.0%

18.0%

18.0%

SQU06_01 Stroke Indicators SQU06_02

Data not available

SQU12

Access to Maternity Services

% of women who have seen a midwife by 12 weeks and 6 days of pregnancy

Quarterly

90%

Data not available

90%

Data not available

SQU29

Emergency admissions for Long Term Conditions

Number of emergency admissions to hospital for people who have a Long Term Condition each month

Monthly

%<

Data not available

N/A

Data not available

HRS05

Acute Bed Capacity

G & A Acute Beds

Quarterly

Quarter 2

841

730

730

730

1324

1221

1221

1221

HRS06

Non Elective FFCEs

Non-Elective FFCEs

Monthly

December

26,539

26,634

26,634

26,634

40,023

44,991

44,991

44,991

HRS07

Referral To Treatment Waits

Total number waiting at the end of the month on an incomplete Referral to Treatment pathway

Monthly

December

17,813

17,813

17,813

23,514

23,514

23,514

SRS02

Total workforce (WTEs)

Workforce

Monthly

SRS08_01

Length of Stay (Acute & MH)

Average spell for non-same day acute discharges

Monthly

SRS09

Day case Rate

Proportion of elective FFCEs which are for daycases.

Monthly

December

77.47%

79.94%

79.94%

SRS10

Delayed Transfer of Care (Acute, Non Acute & MH)

Delayed transfer of care - Commissioning measure is the number of delays per 100,000 population. Provider measure is the number delays as a proportion of a count of activity or beds.

Monthly

December

1.00%

0.00%

0.02%

Provider-Commissioner View

efficiency savings

Performance Reporting Period as at February 2012

Data not available

efficiency savings

Data not available

<2.58%

3.2

2.8

2.8

79.94%

74.06%

79.48%

79.48%

79.48%

0.02%

<3.5%

3.9%

3.9%

3.9%

Data not available

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APPENDIX B

Calderdale & Huddersfield Foundation Trust

Experience) and Patient Capacity & Activity) (Finance, (Safety, Effectiveness Quality Reform Resources

Area

Ref No

Outcome/Measure

SRS11

GP Written Associated Referrals toInfections hospital Healthcare

SRS12

Data Reporting Period Target/ Availability period 2011-12 Plan

Actual

YTD

FOT

Period Target/ 2011-12 Plan

Actual

YTD

FOT

Monthly

December

64,610

63,017

63,017

63,017

74,777

75,438

75,438

75,438

Other Referrals for a First Outpatient Number of other referrals for a first outpatient appointment Appointment

Monthly

December

16,455

13,992

13,992

13,992

36,400

40,883

40,883

40,883

SRS13

First Outpatient Attendance following Number of first outpatient appointments following GP GP Referral referral

Monthly

December

58,021

53,783

53,783

53,783

59,687

62,514

62,514

62,514

SRS14

All First Outpatient Attendances

Number of all first outpatient attendances

Monthly

December

104,347

91,531

91,531

91,531

84,661

94,329

94,329

94,329

SRS15

Elective FCEs

Number of FCEs (ordinary admissions and separately daycases)

Monthly

December

38,858

39,842

39,842

39,842

47,919

49,391

49,391

49,391

SRS16

A & E Attendances

Number of attendances at A & E departments in a month (total and type 1)

Quarterly (aggregated from weekly)

SRS19

Staff Absences

Workforce: Number of days sick as a proportion of number of days available.

Monthly

December

4%

3.50%

3.97%

3.97%

4%

5.44%

5.42%

5.42%

Bookings to services where named consultant led team was available even if not selected

Monthly

December

70%

97.5%

97.5%

97.5%

70%

92.6%

92.6%

92.6%

Proportion of GP referrals to first Outpatient appointment booked using Choose and Book

Monthly

90% guide

Not applicable

90% guide

Not applicable

Trend in value/volume of patients being treated at NHS hospitals

Monthly

%>

Not applicable

%>

Not applicable

SRF11 SRF12 SRF13

Choice

Number of GP written referrals

Mid Yorkshire Hospital Trust

%<

Data not available

%<

Data not available

NB:- The outcomes/measures highlighted in 'blue' are headlines measures/outcomes and are "must be dones".

Provider-Commissioner View

Performance Reporting Period as at February 2012

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