34/12 Key Performance Indicator Dashboard - Surrey and Borders ...

Council of Governors: May 2012
Item Number: 34
Subject:
Author:
Purpose:
Key Issues:
Key Performance Indicators Dashboard
Jo Young, Director of Quality (Nurse Director)
Ann Stevenson, Associate Director of Performance and Information
For discussion
There are two Dashboards for the Council of Governors in May the
Trust position as at March 2012 and the new styled report for 2012/13.
For 2011/12 the Trust achieved 17 out of the 20 measures.
The following measures have not been achieved:
• Completion of Serious Incident action plans: target 95% actual
33%
• Percentage of staff with an up-to-date appraisal target 90%
actual 87%
• Improve the Trust’s performance within the national staff
survey to the next quartile for overall satisfaction and maintain
a return rate of over 69% of staff - actual 68.3%
The new styled Dashboard for 2012/13 includes benchmarking data
and performance trajectories.
Expert Report: provides an overview of insights and feedback of
people’s experience of the Trust.
Health/Social
Impact:
We continue to meet our Carers assessment target and deliver against
our safeguarding adults action plan.
Financial
Implications:
There is a risk that we will not achieve the CQUIN payments due the
non agreement of CQUIN for 2012/13 with NHS Surrey.
Diversity / Equality
Impact assessment
Recommendation to
the Council of
Governors:
The performance indicators address the diverse needs of the people
who use our services.
The Council are asked to note progress.

Surrey and Borders Partnership NHS Foundation Trust
Quality Directorate Report to the Council of Governors: March 2012
The following report provides further key information in relation to the performance of the
organisation as at year end 2011/12 and Month one for 2012/13.
1.Year end Report for 2011/12
The Trust is pleased to report that 17 out of the 20 measures were achieved at year end. Details
of the measures the Trust did not achieve are detailed below:
Risk and Safety
95% of Serious Incident Action Plans are completed on time (KPI 5): Completion of Serious
Incident action plans (target 95% actual 33% - the Trust recognises the work that needs to be
completed in order to achieve the target. It is envisaged that the new system for monitoring and
calling for completed action plans will begin to have an impact on improving performance during
2012/13.
Staff
90% of staff will have an appraisal (KPI 11): target 90% actual 87%. Unfortunately the Trust
were not able to achieve this at year end despite the additional attention paid to this target.
Retain a return rate of the staff survey at 69% (KPI 12): The national staff survey results
have now been received and the Leadership Forum and managers has now commenced work
on addressing the areas in the survey where the Trust need to improve.
1. Dashboard for 2012/13
Following a presentation earlier in the year to the Council of Governors on the format of the
Dashboard where possible it has been changed to reflect the discussions. The report has
benchmarking data, and performance trajectories to inform the Council on how the Trust is
performing.
2. Expert Report
The April’s edition of the ‘Expert Report’ has been circulated and provides information from a
wide variety of different sources. What is salient is that about 32000 people have been in
contact with our services in the past twelve months; people who have used our mental health
services, people with learning disabilities and people with drug alcohol needs. We have
engaged additionally with their carers, families and friends and we have connected with people
of all ages from babies to people who are at the end of their life.
Listening to people about their experience of our service is important to us as we are striving to
provide consistently excellent and responsive care, support and treatment to everyone who
comes in contact with Surrey and Borders Partnership NHS Foundation Trust. I think this
quarter’s Expert Report demonstrates the growing range of sources of feedback that we have
developed to try and capture people’s views. This includes the extended range of Peoples’
Key Performance Indicator Report to the Council of Governors March 2012 Page 2
JY / 12-Mar-12

Surrey and Borders Partnership NHS Foundation Trust
Experience Trackers, the Equality Delivery System programme and hearing from the Mental
Health Act Managers about their observations.
Improvements in the reported experience of people who use the service is demonstrated by the
Peoples’ Experience Trackers where 88% of people with learning disabilities said the staff look
after them well and 89% of people using mental health services rated care as excellent or
good. For the first time we are able to report from carers feedback. 32% of carers said they
were very or extremely satisfied with the service they received. The overall assessment that the
quality of our services continues to improve is reinforced by the Care Quality Commission visits
where all standards have been found to have being met in every service.
Looking forward to 2012/13, new programmes to enhance quality, safety and risk management
are underway as shown by the introduction of the Safety Thermometer and MISPER agreement
with Surrey Police. We will continue to strive towards our ambitious target to achieve 95%
completion of all action plans on time following serious incidents and fulfil the Equality Delivery
System objectives.
Jo Young
Director of Quality (Nurse Director)
Key Performance Indicator Report to the Council of Governors March 2012 Page 3
JY / 12-Mar-12

TRUST BOARD DASHBOARD - MAY 2012
Data: MARCH 2012
Quality and Culture
No, Measures Responsibility Target Measurement Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Benchmark
1 Visions and Values in our Periodic Service Review Colin Archer
100% of Services will achieve 85%
at year end
Quarter Actual
85% Avg of services
for each cluster.
2
Use Health of the Nation Outcome Scales (HoNOS) reporting as a
clinical outcome measure to monitor recovery progress for people
who use services
Marian DeRuiter 90% Monthly Actual 77% 77% 79% 81% 82% 85% 85% 88% 93% 93% 93% 92%
3
Use CAMHS Outcomes Research Consortia (CORC) results to
demonstrate improvements for people using CAMHS service
Mandy Dunn Completion of CORC Action Plan Quarterly
Risk and Safety
4 Serious Incidents: Assurance against “Never Events” Billy Hatifani Nil per month Monthly Actual 0 0 0 0 0 0 0 0 0 0 0 0
5
95% of the Action plans from the investigations of serious untoward
incidents are completed within the set timescale
Billy Hatifani => 95% Monthly Actual
Data Not
Available
Data Not
Available
Data Not Available Data Not Available Data Not Available Data Not Available Data Not Available 19% 19% 29% 39% 33%
6 Safeguarding- People at risk of abuse Samantha Symon
Compliance to the Safeguarding
Action Plan at year end
Yearly
7
95% of clinical staff are up to date with their clinical Risk
Assessment training
Pam Frost => 95%
Monthly Actual
95% 95% 95% 95.0% 95% 95% 95% 95% 95% 95% 95% 95%
Sustainability and Growth
8
Percentage of income at risk from under performance in
Commissioning for Quality and Innovation (CQUIN) targets
Dawn Hines
Monthly Actual
0% assumed in Q1
reporting
0% assumed in
m4 reporting
0% assumed in m5
reporting but risks
highlighted
0% assumed in m5
reporting but risks
highlighted
7.5% (115k) not
achieved included in
year end projections
7.5% (115k) not
achieved included
in year end
projections
7.5% (115k) not
achieved included
in year end
projections
8.2% (126k) not
achieved included
in year end
projections
8.2% (126k)
not
achieved
included in
year end
8.2% (126k)
not
achieved
included in
year end
9 Growth targets and Business Developments Andy Edeleanu £1m full year effect (fye) Monthly Actual £65K £33K circa £100K £Ok £304k £0K £0K £897k £0K £0K £0K £0K
18/06/2012

No, Measures Responsibility Target Measurement Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Benchmark
Staff
10 Use of temporary staffing Dawn Hines Reduction in costs of 20%
Monthly Actual -24% -22%
-30% in month, -
26% cumulative
-31% in month, -
27% cumulative
-23% in month, -
26% cumulative
-23% in month, -
25% cumulative
-23% in month, -25%
cumulative
-23% in month, -23% in month, -
-25% cumulative 23% cumulative
-14% in month,
-23% cumulative
-12.5% in
month, -
22%
cumulative
-12.5% in
month, -
22%
cumulative
11 Percentage of staff with an up-to-date appraisal Lynn Richardson
90% of staff with an appraisal held
at year end
Monthly Actual
82% 84% 82% 81% 81% 82% 82% 87% 87% 87% 85% 87.0%
12
Improve the Trust’s performance within the national staff survey to
the next quartile for overall satisfaction and maintain a return rate of
over 69% of staff
Lynn Richardson => 69% Yearly 69% 68.3% 68.3% 68.3% 68.3%
13 Performance against reducing staff sickness absence to 4% Lynn Richardson =< 4% at year end
Monthly Actual
4.2% 4.1% 4.1% 4.0% 4.01% 4.0% 3.9% 3.9% 3.80% 3.73% 3.78% 3.83%
Finance
14 Financial Risk Rating Dawn Hines 3
Monthly Actual 3 3 3 3 3 3 3 3 3 3 3 3
15 Achievement of plan Dawn Hines 0 Monthly Actual -£25k +£20k
16 Underlying performance Dawn Hines 0 Monthly Actual -£25k +£20k
-£72k excluding
redundancies
-£72k excluding
redundancies
Experience
-£66k excluding
redundancies
-£66k excluding
redundancies
-£274k excluding
redundancies
-£274k excluding
redundancies
-£652k against plan
excluding
redundancies
-£652k against plan
excluding
redundancies
-£615k against plan
excluding redundancies
-£615k against plan
excluding redundancies
-£539k against
plan excluding
redundancies
-£539k against
plan excluding
redundancies
-£426k against plan
excluding
redundancies
-£426k against plan
excluding
redundancies
-£315k against
plan excluding
redundancies
-£315k against
plan excluding
redundancies
-£158k
against plan
excluding
redundanci
es
-£158k
against plan
excluding
redundanci
es
-£253k
against plan
excluding
redundancie
s
-£253k
against plan
excluding
redundancie
s
17 Performance in Delivering Same Sex Accommodation Billy Hatifani 0
Quarter Actual
0 0 0 0 0 0 o 0 0 0 0 0
18
Improve the Trust’s performance with national service user survey to
the next quartile in the 3 areas that the Trust performance fell below
desired levels in 2010
Billy Hatifani
Quarter Actual
Data Not Available Data Not Available Data Not Available 69% 69% 69% 69% 69% 77% 77%
19
Carers assessments will be offered to at least the nominated carers
of 26% of ‘Adults on caseload’ (as per the clinical priorities in the
Annual Plan)
Eugene Jones => 26% Quarterly Actual 28.8% 34% 26% 28%
20
Ensure 97% of patients admitted under the Mental Health Act (MHA)
are assessed for their capacity to give consent to treatment on
admission and that the assessments are recorded within the
patients’ record
Billy Hatifani => 97%
Monthly Actual
81% 93% 98% 98% 95% 98% 100% 100% 96% 100% 98% 96%
A red light indicates poor performance and immediate action will be taken by the Trust to mitigate this.
Green indicates performance is on target and no remedial/additional action is currently required
Data Not Available
Quarterly/Annual Reporting
Year End Target
18/06/2012

TRUST BOARD KEY PERFORMANCE INDICATORS DASHBOARD - MAY 2012
Data: APRIL 2012
Quality and Culture
Risk and Safety
Sustainability and Growth
4
1
3
2
2
Staff
Finance
Experience
1
1
4
2
2
3
Achieved
Failed
Data Not Available
Quarterly/Annual Reporting