Handover deliverable · 1 of 6 · Target M2

Agreed KPI and definitions register

Layered definitions from service reality through system capture, data logic and sign-off.

DRH migration context: Legendary Care (case-based) → PathwayOne (action-based). Parallel run Dec 2025–Jan 2026; Mar 2026 definition crunch.

Definition chain: A measure is only safe to use when we can trace it from the real service event, through system capture and data logic, into the final report and the action taken from it.

I would not just ask BI to fix the report. I would help the service, BI, IM&T and performance colleagues agree what the report now needs to mean.

Service realitySystem captureSource dataWarehouse logicKPI / reportValidation & sign-offManagement action

Featured example — referrals (KPI-01)

KPI-01 — Referrals received

Status: Agreed pending workshop N/L: Both Phase: D

Service definition: A request for the service to consider accepting a patient onto the MH access pathway.
System / workflow capture: Old (Legendary Care): staff open a case and record referral received date. New (PathwayOne): access actions — referral sent, received, accepted or rejected.
Data / fact-table definition: Pre-migration: count Legendary case records with referral_received_datetime in month. Post-migration: count derived referral episodes where agreed access-action rule identifies a valid referral.
Reporting use: Local demand monitoring and MHSDS-like mandatory reporting — inclusion rules documented separately for each.
Exclusions / caveats: Rejected referrals may still count as received depending on rejection reason (e.g. DRH-PAT-002896). Duplicates and admin actions excluded from demand but monitored in DQ.
Validation check: Compare monthly counts against old case extract during parallel running; sample rejected referrals with service leads; monitor unmapped rejection reasons.
Owner / sign-off: Service lead (operational); BI (implementation); Performance (reporting use); directorate lead (final sign-off).

Anchor patient DRH-PAT-002896 shows why the chain matters: old case counts rejected referral as received; new default excludes unless clinical triage. See definition migration vignette. Source-to-report map: referral received preset · MHSDS-like submission.

Register at a glance

KPI	Measure	Service question	Status	Sign-off
KPI-01	Referrals received	A request for the service to consider accepting a patient onto the MH access pat…	Agreed pending workshop	Directorate lead
KPI-02	Pathway start	The point at which the patient begins active care on the pathway after acceptanc…	Agreed	CMHT clinical lead
KPI-03	Waiting list stock	Patients accepted onto the pathway but not yet had first contact — waiting for a…	Draft	Service manager
KPI-04	First contact rate	Proportion of referrals where the patient is seen within 14 days of referral rec…	Agreed	Clinical lead
KPI-05	Activity contacts	Clinical contacts delivered to patients — assessments, interventions, ongoing ca…	Pending reconciliation	CSDS owner
KPI-06	DNA rate	Patients who did not attend a scheduled clinical contact.	Agreed	Service manager
KPI-07	Open caseload	Patients actively on the pathway at month end — accepted and not yet closed.	Draft	Performance lead
KPI-08	Agency cost per contact	Cost of agency staff per clinical contact delivered — workforce pressure indicat…	Agreed	Finance directorate
KPI-09	Pathway closure	Patient pathway formally closed — discharged, transferred or otherwise ended.	Draft	Clinical lead
KPI-10	Outcome	What happened to the patient at end of pathway — recovery, transfer, decline, et…	Draft	Clinical lead
KPI-11	Reporting month allocation	When a service event counts for monthly performance — not always obvious after m…	Agreed	Performance lead
KPI-12	Team ownership	Which CMHT or access team owns the patient for performance and capacity purposes…	Agreed	Service manager

Full definition chains

KPI-02 — Pathway start (Agreed)

KPI-02 — Pathway start

Status: Agreed N/L: Local Phase: D

Service definition: The point at which the patient begins active care on the pathway after acceptance.
System / workflow capture: Old: PathwayStartDate on case (often same as referral). New: first CARE_FIRST_CONTACT action after ACCESS_ACCEPTED.
Data / fact-table definition: Derive pathway_start_date from first qualifying CARE_FIRST_CONTACT linked to accepted access episode.
Reporting use: Waiting time from referral to pathway start; local performance and waiting-list risk reports.
Exclusions / caveats: Gap between access accepted and first contact affects waiting metrics — 12-day gaps flagged in vignettes.
Validation check: Compare old PathwayStartDate vs new first-contact rule for sample patients during parallel run.
Owner / sign-off: CMHT clinical lead (operational); service manager; BI lead.

KPI-03 — Waiting list stock (Draft)

KPI-03 — Waiting list stock

Status: Draft N/L: Local Phase: D

Service definition: Patients accepted onto the pathway but not yet had first contact — waiting for access.
System / workflow capture: Old: case status Waiting on Legendary. New: ACCESS_WAITING action open at month end.
Data / fact-table definition: Count ACCESS_WAITING actions where action_end is null or after month-end; join dim_team excluding INVALID_TEAM.
Reporting use: Local waiting-list risk report and capacity planning meetings.
Exclusions / caveats: INVALID_TEAM rows excluded; team remap failures can inflate or deflate stock.
Validation check: Compare old case Waiting stock vs new action stock by team for Mar 2026.
Owner / sign-off: Service manager (operational); performance lead (reporting).

KPI-04 — First contact rate (Agreed)

KPI-04 — First contact rate

Status: Agreed N/L: Both Phase: C

Service definition: Proportion of referrals where the patient is seen within 14 days of referral received.
System / workflow capture: Referral date from agreed KPI-01; first contact from CARE_FIRST_CONTACT action.
Data / fact-table definition: Numerator: count referrals with days_to_first_contact <= 14. Denominator: fact_referral_agreed (KPI-01).
Reporting use: Local and national access standards; senior performance brief headline.
Exclusions / caveats: Denominator must use agreed referral definition — not dashboard count. Rejected-referral rule affects both.
Validation check: Test against known patients pre-embed; reconcile numerator/denominator monthly.
Owner / sign-off: Clinical lead (standard); performance lead (reporting).

KPI-05 — Activity contacts (Pending reconciliation)

KPI-05 — Activity contacts

Status: Pending reconciliation N/L: National Phase: D

Service definition: Clinical contacts delivered to patients — assessments, interventions, ongoing care.
System / workflow capture: Old: ContactCount on case. New: CARE_ONGOING and CARE_FIRST_CONTACT actions (admin actions separate).
Data / fact-table definition: Count care actions in month from fact_activity; exclude ADMIN_CANCEL, duplicate ActionId, non-clinical action types.
Reporting use: CSDS-like mandatory community activity return and local productivity pack.
Exclusions / caveats: Admin actions can inflate counts if not excluded — vignette DRH-PAT-003201. National rules may differ from local.
Validation check: CSDS-like cross-check; weekly DQ on ActionId duplicates and admin flags.
Owner / sign-off: CSDS owner (mandatory); service manager (local); BI lead (implementation).

KPI-06 — DNA rate (Agreed)

KPI-06 — DNA rate

Status: Agreed N/L: Local Phase: F

Service definition: Patients who did not attend a scheduled clinical contact.
System / workflow capture: Old: DNA recorded on case contact. New: CARE_DNA action or DNA flag on scheduled CARE_* action.
Data / fact-table definition: Numerator: DNA-flagged care actions. Denominator: scheduled care actions in reporting month.
Reporting use: Local demand-capacity pack and service recovery meetings.
Exclusions / caveats: Cancelled vs DNA must be distinguished; admin cancellations excluded from denominator.
Validation check: Weekly DQ check; compare DNA rate trend before and after migration.
Owner / sign-off: Service manager (operational and reporting).

KPI-07 — Open caseload (Draft)

KPI-07 — Open caseload

Status: Draft N/L: Local Phase: D

Service definition: Patients actively on the pathway at month end — accepted and not yet closed.
System / workflow capture: Old: open case count on Legendary. New: accepted access without outcome closure in period.
Data / fact-table definition: Hybrid: pre-Feb use case open logic; post-Feb derive from access/outcome action pairs.
Reporting use: Local caseload management and workforce planning.
Exclusions / caveats: Definition of open differs from waiting stock — includes post-first-contact patients.
Validation check: Monthly stock reconcile against service manager caseload review.
Owner / sign-off: Performance lead; service manager (operational validation).

KPI-08 — Agency cost per contact (Agreed)

KPI-08 — Agency cost per contact

Status: Agreed N/L: Local Phase: F

Service definition: Cost of agency staff per clinical contact delivered — workforce pressure indicator.
System / workflow capture: Finance: agency postings in LedgerWise. Activity: agreed KPI-05 contacts from PathwayOne.
Data / fact-table definition: Sum agency ledger lines in month / count fact_activity contacts (KPI-05 rules).
Reporting use: Local demand-capacity pack and finance-directorate review.
Exclusions / caveats: Activity definition must match KPI-05 — admin inflation affects cost-per-contact.
Validation check: Finance review of ledger mapping; cross-check activity denominator monthly.
Owner / sign-off: Finance BP (cost); service manager (activity); finance directorate (sign-off).

KPI-09 — Pathway closure (Draft)

KPI-09 — Pathway closure

Status: Draft N/L: Local Phase: D

Service definition: Patient pathway formally closed — discharged, transferred or otherwise ended.
System / workflow capture: Old: ClosureDate and outcome on case. New: OUTCOME_CLOSED action with outcome type.
Data / fact-table definition: Count OUTCOME_CLOSED actions in reporting month; map outcome types to agreed categories.
Reporting use: Local throughput and caseload turnover; supports waiting-list interpretation.
Exclusions / caveats: Admin closures vs clinical closures must be distinguished; transfer-out rules differ local vs national.
Validation check: Sample closed cases with service leads; compare old closure count vs new for parallel months.
Owner / sign-off: Clinical lead (outcome meaning); service manager; BI lead.

KPI-10 — Outcome (Draft)

KPI-10 — Outcome

Status: Draft N/L: Both Phase: D

Service definition: What happened to the patient at end of pathway — recovery, transfer, decline, etc.
System / workflow capture: Old: OutcomeText on case. New: outcome type on OUTCOME_CLOSED or OUTCOME_* actions.
Data / fact-table definition: Derive outcome_category from action outcome type via pathway_status_map crosswalk.
Reporting use: Local service quality review; may feed mandatory returns where outcome fields required.
Exclusions / caveats: Free-text outcomes on old system do not map 1:1 to new coded types — manual review for edge cases.
Validation check: Review unmapped outcome codes monthly; sample with clinical lead.
Owner / sign-off: Clinical lead (categories); mandatory reporting owner where national fields apply.

KPI-11 — Reporting month allocation (Agreed)

KPI-11 — Reporting month allocation

Status: Agreed N/L: Both Phase: D

Service definition: When a service event counts for monthly performance — not always obvious after migration.
System / workflow capture: Old: ReportingMonth field on case. New: ActionDate per event — no single case field.
Data / fact-table definition: Per-KPI allocation rules in register; warehouse applies reporting_month dimension consistently.
Reporting use: All monthly KPIs and mandatory returns — underpins reconciliation.
Exclusions / caveats: Events near month boundary can shift counts; parallel-run months need explicit rules.
Validation check: Reconcile month-boundary vignettes; compare old ReportingMonth vs new rules.
Owner / sign-off: Performance lead (facilitation); BI lead (implementation); mandatory reporting owner.

KPI-12 — Team ownership (Agreed)

KPI-12 — Team ownership

Status: Agreed N/L: Local Phase: D

Service definition: Which CMHT or access team owns the patient for performance and capacity purposes.
System / workflow capture: Old: ResponsibleTeam on case. New: TeamCode on each action — can change mid-pathway.
Data / fact-table definition: Join actions to dim_team via team_service_code_map; flag INVALID_TEAM for DQ not reporting.
Reporting use: All team-level local reports, waiting lists, productivity and demand packs.
Exclusions / caveats: Team remap failures (DRH-PAT-000874) break team-level reporting; transfers change ownership mid-month.
Validation check: Crosswalk completeness check; compare old ResponsibleTeam vs new TeamCode for sample cases.
Owner / sign-off: Service manager (operational teams); BI lead (crosswalk); performance lead (reporting).

Sign-off: KPI-01 Mar 2026 referrals — agreed pending directorate workshop (2026-03-25). Performance lead + mandatory reporting owner.

kpi_definitions_register.csv · data dictionary

In plain English

This is the agreed dictionary of what we count and what it means. When someone asks “how many referrals did we have?”, this register records the answer everyone has signed up to — starting in everyday service language, not computer jargon. During a system change, the biggest risk is that the number still updates but means something different. This document is how we stop that happening.