Are you satisfied with your integrated performance report?

GGI consultant Joe Roberts focuses on one of the most important and versatile tools available to any NHS board

Almost every NHS trust has an integrated performance report (IPR) showing how it is doing against its KPIs and, for any it is not achieving, the reason why that is, and what is being done to get back on track.

Many boards put a lot of time and effort into discussing what their IPR should contain and what it should look like – but they’re not always satisfied with the end result.

So, what key performance indicators should an IPR contain, how should it be structured, and what should it look like? The answer is that there is no single right answer – the holy grail does not exist. It all depends on the organisation and the challenges it faces. What we aim to do here is to provide a framework for developing an IPR that meets the board’s needs.

Start with why

The starting point is to establish the purpose of the integrated performance report. Why should you have one and what will it help you to achieve?

Put simply, it aims to ensure accountability through assurance and scrutiny in order to drive improvement. Improvement hardly needs to be explained, but what do we mean by accountability, assurance and scrutiny?

Accountability is a widely used term in public services but is not always well understood. The Nursing and Midwifery Council define it like this: “The principle that individuals and organisations are responsible for their actions and may be required to explain them to others”. The Nuffield Trust’s definition has a sharper edge: “Being responsible for success or failure and experiencing the consequences”.

NHS trusts are accountable firstly to their own board, but also to communities through their governors and members (for foundation trusts), to their local integrated care board, to local authorities and ultimately to Parliament. The primary audience for the IPR is the board, but it is a public document and other stakeholders may use it to hold a trust to account too.

Assurance is the use of facts and objective evidence from various sources – both internal and external – to show whether the organisation is achieving its objectives. It is often defined in contrast to reassurance, which is based on opinion, interpersonal trust and confidence in individuals’ professional expertise.

Scrutiny is defined in the Oxford English Dictionary as “critical observation or examination”. In the context of an NHS board, this means asking informed, focused questions and evaluating the answers.

Comprehensive and concise information

Delivering on all three of these concepts requires the board to be provided with timely, accurate information that is comprehensive but also reasonably concise, so it can put the right questions to the right people and hold individuals and teams to account.

After establishing first principles, the board needs to decide what must be measured and what to monitor. National targets are the focus of many IPRs, but they are not enough on their own, not least because they are skewed towards certain types of services, such as urgent and acute care, and towards access times rather than quality.

The board needs to ensure that it is monitoring progress against its own corporate objectives, as well as the contractual requirements set by the commissioners of its services. In this new world of partnership working, they also need to look outside their own organisation, to establish whether they are contributing to the objectives of their local integrated care system, for example by helping to reduce health inequalities within the local population.

Presentation matters

How the report is laid out and presented matters too. Some trusts group the indicators according to the strategic objective which they most closely relate to. Others structure the report around the Care Quality Commission’s five questions – whether services are safe, effective, caring, responsive and well led. Either approach is valid.

Depending on the size and complexity of an organisation, it may also be helpful to break down performance by divisions, care groups, or localities, because trust-wide data can sometimes mask local under-performance.

The IPR needs to balance detail with digestibility – so a well-written executive summary which guides the reader to the main issues is essential. Statistical process control charts are also very helpful in highlighting significant variations that require explanation. As the IPR is a public document, explanatory narratives should be written in plain English without excessive jargon.

The content and format of the report should be broadly consistent over time, demonstrating transparency and enabling performance to be tracked – boards should resist the temptation to ‘chop and change’ the report template in pursuit of perfection. There should also be consistency in presentation between different sections of the report – it needs to speak with one voice, and not read like four or five reports which have been stitched together.

IPR prerequisites

In our experience, there are a number of prerequisites for an IPR to be effective, regardless of how well it is designed and written. There needs to be a shared view among board members about what needs to be reported, and clarity about roles and responsibilities, e.g. ownership of KPIs by executive directors and committees. The trust needs a business intelligence function which has the right system and resources in place to produce timely and accurate data, and periodically the board needs to obtain assurance, for example from its internal or external auditors, about the quality of that data. Where statistical process control charts are used to present data, board members should be trained in the meaning of these charts and how to interpret them, in order that they do not draw the wrong conclusions.

Key takeaways

• The IQPR is one of the most important and versatile tools in the board’s toolbox – but is one of several, alongside the BAF, CEO’s report, patient stories, etc.

• There is no single right way of doing integrated reporting (although there are wrong ways).

• In designing an IPR, we often need to make trade-offs, for example between detail and conciseness.

• There needs to be agreement about what is reported and how.

• A new integrated performance report needs to be given time to embed without frequent changes to format and content that make it difficult to compare over time.

Contact us today to find out how we can help you with your integrated performance reporting.