Performance Assessment Methodology The Scottish Government requires all Health Boards to attain a defined level of performance against a number of measures (known as Standards) which are included in the Local Delivery Plan (LDP). In addition, NHS Fife scrutinises its performance relating to Complaints. At initial assessment of performance, targets and Standards are grouped into three categories; those where performance always (or usually) achieves the required target (i.e. ‘on track’), those where performance has either ‘not met’ the required level or has dropped below it for a prolonged period (i.e. is ‘variable’) and those generally ‘not met’. Targets and Standards; On Track NHS Fife continues to meet or perform ahead of the following National Standards: Hospital Acquired Infection (HAI), Clostridium Difficile (C-Diff) target: We will achieve a maximum rate of C- Diff infection in the over 15 year olds of 0.32 Targets and Standards; Variable Performance NHS Fife has met the following National Standards for a sustained period however performance varies from month-to-month. If performance drops significantly below the Standard for 3 consecutive months, a drill-down process is instigated. N/A for Clinical Governance this month 3 Targets and Standards; Not Being Met - Drill-Down For each of the LDP Standards and targets not being met (or where performance is and key to the delivery of safe patient care), a more in-depth report is provided and is structured as follows: A summary box, describing the measure, current performance and the latest published performance and status (Scotland) A trend chart covering the last 12 months of local performance data A past performance box showing the last 3 data points (previous to the ‘current’ position) An improvements/benefits box, outlining key actions being taken, expected benefits and current status. HAI: SAB Drill Down Measure We will achieve a maximum rate of SAB (including MRSA) of 0.24 Current Performance 0.36 per 1,000 acute occupied bed days, for year ending Nov 2017 Scotland Performance 0.33 cases per 1,000 acute occupied bed days, for year ending Sep 2017 profile
Threshold has been clearly articulated to ensure children and people with complex, persistent and acute mental health issues (Tier 3) are accepted on a more equitable and consistent basis Clearer signposting for inappropriate referrals to alternative sources of support Robust screening process to ensure appropriate threshold is adhered to and equitable across Fife Developments are well underway to redesign the SCi-referral for GPs Psychological Therapies Waiting Times Drill Down Measure At least 90% of clients will wait no longer than 18 weeks from referral to treatment for Psychological Therapies (PT) Current Performance 71.3% of patients treated within 18 weeks for 3 months ending November Scotland Performance 76.6% of patients treated within 18 weeks for 3 months ending Sep 2017 Previous 3 Months 3 months to Aug 2017 3 months to Sep 2017 3 months to Oct 2017 69.5% ↑ 69.4% ↓ 70.2% ↑ Current Issues Delivery of PTs across services requires further integration to enhance efficiency; Psychology and Mental Health are in transition to TIARA and Trakcare which is likely to produce challenges in reporting for a limited period Context Never met Standard, although rolling 3-month performance is rising slightly; monthly performance normally between 65% and 75% Inconsistency across Health Boards in activity counted towards target – i.e. referrals for PT only / all mental health referrals. 5th out of the 11 Mainland Health Boards for the quarter ending September 2017 Key Actions for Improvement Planned Benefits Due By Status Development of Community Mental Health Teams across Fife being progressed through the Rebalancing Care work Allows comprehensive multidisciplinary approach to patients with complex needs including most efficient and effective use of highly specialist PTs within individual Care Programmes Mar 2018 (Teams Fully Functional) On Track Development of Community Mental Health Teams across Fife being progressed through the Rebalancing Care work Allows comprehensive multidisciplinary approach to patients with complex needs including most efficient and effective use of highly specialist PTs within individual Care Programmes Mar 2018 (Teams Fully Functional) On Track