ODT Performance
Report
Monthly - November 2014
Data production date: December 08, 2014
Publication date: December 15, 2014
1. EXECUTIVE SUMMARY FOR DECEMBER ODT SMT MEETING
a. Key achievements
•
•
•
•
•
•
•
A significant number of ODT staff (individuals and teams) were acknowledged in the recent staff awards. The North West team won fundraising team of the year,
Angela Ditchfield from the North West team won employee of the year, the Nottingham based ODT team were recognised as team of the year, Trish Collins was
recognised for exceptional customer service, Susan Hannah and Rachel Stoddard-Murden were acknowledged for their personal contributions to the bright ideas
scheme and for health and safety work.
There was a great level of staff engagement in the recent ‘Your Voice’ survey. The overall response rate was 65%, but ODT achieved 82% - the highest of the
operational directorates.
All regions have facilitated their St. John awards which have stimulated positive local publicity. A meeting will be held early in February to review the lessons learnt
and plan for next year. All regions have also facilitated their autumn regional collaborative meetings.
The negotiating and influencing courses, monthly action learning set consent training and actor based consent training sessions continue to be rolled out as per plan.
The current annual consent course has finished; 209 SNODS have received this training since January 2014 and a new annual consent course is being developed
for roll out in February 2015.
The ‘values’ based cohort recruitment selection days are nearing completion, with the final day to be held on 16 December. The majority of posts have been
successfully recruited into with plans to source candidates for the remaining roles to be assessed and recruited in line with the start date for Block Training
commencing in April 2015.
In October there were just two occasions when the NORS teams stood down before three hours, one for clinical reasons and the other data entry error.
The number of incidents open over 90 days has decreased considerably since the start of the quarter.
b. Challenges
•
•
•
•
•
•
Despite targeted training for consent, the rate remains stubbornly low at 57.9% (combined consent rate). The consent pilot continues to provide targeted training,
and evaluation of the consent core values workshop is underway to identify common themes/underlying values of the 'top consenters'.
The number of DCD donors remains well below target, impacting on the resulting number of transplants. On average, five donors per day (DBD and DCD combined)
are now needed if we are to meet the original 2014/15 target of 1439 donors.
Practice Development Specialists (PDS) have not met the target of dedicating 60% of time on local work this month, with 51% of time spent locally. This is due in part
to national work on consent taking priority. Additional PDSs have been recruited to back fill any vacancies to increase current resource.
Living Donation remains slightly behind target, although altruistic donation is likely to ensure targets are met.
There is a degree of under reporting of complaints centrally. QA are working with ODS Teams and Regional Managers to improve this. It is therefore expected that
complaint numbers will start to rise as a result.
Sickness absence has an increasing trend, especially in the Organ Donation area. HR to continue to work closely with managers to manage absence and facilitate
return to work at the earliest opportunity.
c. Major risks and issues
•
•
•
•
It remains unlikely that the end of year targets will be met and a risk that the donor numbers and moreover the resulting number of transplants will be below that
achieved in 2013/14.
There is a risk that the values based cohort recruitment fails to recruit the number of staff required (n=23).
Management of complaints may be impacted on if the level of reporting increases significantly due to the limited resources available for managing complaints.
There is a risk that absence levels may impact on service delivery across the organ donation teams.
2. ODT PERFORMANCE SUMMARY
Table 1: ODT Strategic Objectives – Summary of performance to date
Final Target
Performance
2014/15 performance
+
Objective
Target
Target date
2012/13
2013/14
Target
Aug
Sep
Oct
Nov
Year to
Date
1
80%
31-Mar-2020
57.0%
59.4%
61.5%
56.7%
62.4%
59.6%
57.1%
57.9%
2#
26 pmp
31-Mar-2020
19.1 pmp
20.8 pmp
22.5 pmp
NA
20.2
NA
NA
20.5
3
Increase of
5%
31-Mar-2020
Baseline
year 0%
3.1%
1.3%
-1.7%
4.9%
-1.7%
-2.6%
-0.4%
4#
74 pmp
31-Mar-2020
49 pmp
55.4 pmp
59.0 pmp
NA
53.7
NA
NA
53.7
+
1 Consent/authorisation for organ donation – aim for consent/authorisation rate above 80%.
2 Deceased organ donation – aim for 26 deceased donors per million population.
3 Organ utilisation – aim to transplant 5% more of the organs offered from consented, actual donors.
4 Patients transplanted – aim for a deceased donor transplant rate of 74 pmp.
#
based on rolling 12 month period.
3. ODT SMT KEY PERFORMANCE MEASURES MONTHLY SUMMARY
Table 2: ODT SMT Key Performance Measures – Strategic
Strategic
Measure
Performance
Code
Description
2012/13
2013/14
Aug
YTD
Sep
YTD
Oct
YTD
Nov
YTD
YTD
Target
YE
Target
Increase the no.
deceased organ
donors
1212
1320
506
629
749
862
959
1439
23
11.4%#
8.9%#
é
é
ê
ê
Increase the no. living
kidney/liver donations
1098
1142
462
554
651
22
4.9%#
4.0%#
ê
é
é
There are more organ
transplants from
deceased donors
3113
3514
1321
1645
1948
2244
21
6.9%#
12.9%#
é
é
ê
ê
#
9.0%#
667
1143
0.1%#
2505
% increase on previous 12 months
NB: Although YTD numbers are provided, the arrows indicate progress against the previous month
3758
6.9%#
YTD Slider chart
Table 3: ODT SMT Key Performance Measures – Donor and Recipient Safety
Donor and Recipient Safety
Measure
Code
Description
20
Reduce the damage rate of
retrieved organs (DBD)
19
% of incidents that are SAE/SARs
18
Performance
2012/13 2013/14
Aug
Sep
Oct
11.23%
5.21%
4.79%
ê
é
é
5.9%
3.4%
2.0%
2.3%
Number of Duty Office incidents
per thousand offers
0.00
2.47
1.13
1.15
17
Number of offering incidents per
thousand offers
3.62
1.76
2.26
0.77
16
Number of referral incidents per
thousand referrals
0.00
4.67
3.08
1.77
15
Number of retrieval incidents per
thousand retrievals
113
211
100
106
14
Number of transplant incidents
per thousand transplants
17.48
9.26
13.20
0.00
8.58%
6.81%
10.1%
NB: The arrows indicate progress against the previous month
Nov
YE
Target
9.00%
YTD Slider chart
Table 4: ODT SMT Key Performance Measures – Operational Performance
Operational Performance
Measure
Code
13
12
11
Performance
Description
Increase the
approach rate
Increase
deceased donor
family consent /
authorisation
Work effectively
(% of Trusts /
Boards
achieving
national targets)
2012/13
2013/14
Overall
67.8%
59.1%
DBD
92.5%
93.1%
DCD
58.4%
48.1%
Overall
57.4%
59.4%
DBD
67.6%
68.1%
DCD
51.3%
53.8%
DBD
30.9%
36.4%
DCD
34.8%
Aug
YTD
Sep
YTD
Oct
YTD
Nov
YTD
56.6%
57.6%
57.9%
58.4%
ê
é
ê
é
92.8%
93.2%
92.9%
93.1%
é
é
ê
é
45.1%
46.1%
46.5%
46.7%
ê
é
ê
ê
56.6%
57.7%
57.9%
57.9%
é
é
ê
ê
65.5%
67.2%
67.5%
67.4%
é
é
ê
ê
50.7%
51.4%
51.7%
51.5%
é
é
ê
ê
41.2%
38.3%
34.2%
35.2%
é
ê
ê
é
32.0%
30.5%
32.4%
31.8%
é
ê
é
ê
YTD
Target
YE
Target
57.9%
57.9%
93.5%
93.5%
46.4%
46.4%
61.5%
61.5%
72.5%
72.5%
55.0%
55.0%
50.0%
50.0%
50.0%
50.0%
YTD Slider chart
Operational Performance - continued
Measure
Code
10
Performance
Description
Increase SNODs
involvement
during consent /
authorisation
2012/13
2013/14
Overall
71.4%
76.4%
DBD
78.9%
84.4%
DCD
66.8%
71.4%
9
More people have
registered to be an organ
donor
8
Sep
YTD
Oct
YTD
Nov
YTD
77.3%
77.8%
77.9%
77.8%
é
é
ê
ê
83.7%
85.1%
85.4%
85.5%
ê
é
ê
ê
73.1%
73.1%
73.1%
72.7%
é
ê
ê
ê
508941
587221
689524
é
ê
ê
é
83.7%
83.2%
84.1%
é
ê
é
20
20
14
8
ê
çè
é
é
88.9%
88.9%
90.8%
91.8%
é
ê
é
çè
1011929 1060642 414975
-6.1%#
4.8%#
Maximise DCD Organ
Retrieval
70.0%
84.0%
7
Effectively deal with
Clinical Governance
incidents*
25
18
6
Effectively deal with
complaints
92.5%
82.7%
#
Aug
YTD
YTD
Target
YE
Target
78.0%
78.0%
85.0%
85.0%
73.0%
73.0%
666667 1000000
-5.7%#
95.0%
95.0%
0
0
90.0%
90.0%
% increase on previous 12 months
* In-month not YTD
NB: Although YTD numbers and percentages are provided, the arrows indicate progress against the previous month
YTD Slider chart
Table 5: ODT SMT Key Performance Measures – Resourcing/Infrastructure
Resourcing/Infrastructure
Measure
Performance
2012/13
2013/14
Aug
YTD
Sep
YTD
Oct
YTD
Nov
YTD
52.3%
53.3%
58.1%
58.1%
65.7%
10.12%
10.05%
9.96%
9.89%
ê
é
é
é
3.07%
3.28%
3.51%
3.79%
é
ê
ê
ê
91.0%
94.1%
94.8%
95.9%
é
é
é
é
94.6%
94.6%
95.1%
96.2%
ê
é
é
ê
Code
Description
5
Develop SNODs
(consent training)
4
Right number of
staff
12.08%
9.76%
3
Reduce and
manage absence
3.77%
4.20%
2
Develop our staff*
86.9%
1
Meet budgets+
101.5%
102.7%
YTD
Target
YE
Target
90.0%
10.00%
10.00%
4.00%
4.00%
95.0%
95.0%
100.0%
100.0%
* In-month not YTD
+
% YTD expenditure compared with YTD budget
NB: Although YTD percentages are provided, the arrows indicate progress against the previous month
YTD Slider chart
4. OD KEY PERFORMANCE MEASURES MONTHLY SUMMARY
Table 6: OD Regional Performance Dashboard
ODT Regional Dashboard (in-month)
BSD
Testing
Combined
DBD
DCD
Combined
Eastern
DBD
DCD
Combined
London
DBD
DCD
Combined
Midlands
DBD
DCD
Combined
North West DBD
DCD
Combined
Northern
DBD
DCD
Combined
N Ireland
DBD
DCD
Combined
Scotland
DBD
DCD
Combined
South Central DBD
DCD
Combined
South East
DBD
DCD
Combined
South Wales DBD
DCD
Combined
South West DBD
DCD
Combined
Yorkshire
DBD
DCD
Combined
National
DBD
DCD
Targets
Month Reported: Novem ber 2014
Referral
81.0%
95.0%
75.0%
80.0%
100.0%
85.4%
81.5%
96.3%
81.7%
68.8%
93.8%
74.6%
94.4%
100.0%
75.0%
100.0%
100.0%
91.7%
0.0%
100.0%
68.8%
93.3%
80.0%
75.0%
63.6%
90.9%
69.4%
77.8%
94.4%
58.3%
87.5%
100.0%
85.7%
100.0%
100.0%
89.5%
80.0%
100.0%
68.0%
82.7%
95.5%
76.6%
Approach
SNOD
Present
Consent
57.9%
93.5%
46.4%
65.2%
100.0%
57.9%
61.8%
94.7%
44.4%
59.1%
90.0%
50.0%
42.0%
100.0%
17.1%
64.5%
90.0%
52.4%
77.8%
78.0%
85.0%
73.0%
63.3%
62.5%
63.6%
85.3%
88.9%
81.3%
50.0%
66.7%
41.2%
100.0%
100.0%
100.0%
85.0%
100.0%
72.7%
85.7%
61.5%
72.5%
55.0%
60.0%
62.5%
59.1%
47.1%
50.0%
43.8%
50.0%
66.7%
41.2%
66.7%
73.3%
50.0%
35.0%
33.3%
36.4%
85.7%
77.8%
75.9%
84.6%
68.8%
65.4%
100.0%
52.6%
62.2%
91.7%
48.0%
76.5%
100.0%
60.0%
76.2%
90.0%
63.6%
55.2%
100.0%
40.9%
62.2%
94.1%
48.6%
85.7%
59.1%
72.7%
45.5%
70.6%
85.7%
60.0%
87.0%
90.9%
83.3%
100.0%
100.0%
100.0%
81.3%
88.9%
71.4%
81.3%
85.7%
77.8%
77.1%
86.5%
69.4%
85.7%
45.5%
54.5%
36.4%
52.9%
85.7%
30.0%
78.3%
81.8%
75.0%
61.5%
100.0%
16.7%
75.0%
66.7%
85.7%
56.3%
85.7%
33.3%
57.1%
66.7%
49.3%
Donors
YTD
Organs per
Donor
959
556
403
85
45
40
96
69
27
94
60
34
84
56
28
60
35
25
32
23
9
76
50
26
60
45
15
81
53
28
44
20
24
72
42
30
78
40
38
862
538
324
3.40
3.94
2.66
3.00
4.00
2.29
3.40
4.00
2.50
3.46
3.86
3.00
3.18
3.30
2.00
3.00
4.50
2.25
3.75
Indicators in Bold are used to calculate monthly performance score
Score is calculated using: Green = +1; Am ber = 0; Red = -1
Consent for Eyes is last reported Quarterly figure. If not known, assumes Green (i.e., until June)
Note: Northern Ireland had no eligible DBD donors in November.
3.75
4.00
4.00
4.00
3.13
2.71
6.00
3.17
3.63
2.25
3.88
4.00
3.00
3.45
4.00
2.50
3.22
3.43
2.50
3.36
3.68
2.78
Consent
for Eyes
(Quarterly
in Arrears)
Apr
May
Jun
Jul
Aug Sep
Oct
Nov
Dec
Jan
Feb
Mar
7
7
7
7
8
8
8
8
8
8
8
8
3
2
7
2
5
5
4
4
7
4
3
3
3
4
5
4
-1
2
1
3
3
1
-3
1
4
3
3
1
4
3
0
3
7
7
3
-1
8
7
6
4
0
6
-2
1
3
7
4
5
3
4
5
3
-1
2
-2
0
4
2
2
1
3
0
4
1
6
5
4
5
7
6
3
3
1
-2
-1
1
-1
2
-2
6
3
3
4
7
7
8
4
8
4
1
3
6
4
5
4
5
4
4
6
8
3
5
40%
52%
33%
37%
27%
40%
38%
35%
44%
33%
30%
48%
39%
38%
Trend
5. SLIDER KPI CHARTS EXAMPLE
Slider KPI charts display a bar divided into segments according to the boundary values that are specified. The actual value of the KPI is indicated
with a triangle pointer on the top (for a horizontal slider) or the left (for a vertical slider). This actual value indicator is the same colour as the
segment that contains the actual KPI value. The target value is displayed as a smaller triangle on the bottom (or right side) of the slider. See
below: