Board of Directors - Basildon and Thurrock University Hospitals

Board of Directors
agenda
Date
27 October 2010
Time
3:30pm
Place
Committee Rooms 1 and 2
Level G, Tower Block
Basildon University Hospital
Contact
Angus Wyatt
Basildon and Thurrock
University Hospitals NHS
Foundation Trust
Nethermayne
Basildon
Essex
SS16 5NL
Tel: 0845 155 3111
Extension
3874
Email:
Angus.wyatt@btuh.nhs.uk
1
Members of the Board of Directors
Chairman
Mr M Large
Non Executive Directors
Mrs J Gibson
Mr R Holmes
Mr J Kent
Mr T Parks
Mr P Sheldrake
Ms H Sturgess
Mr P Wardle
Executive Directors
Mr A R Whittle
Mrs J Galpin
Mr M Magrath
Dr S Morgan
Mr A Ray
Mrs D Sarkar
Mr A Sewell-Jones
Mr N Taylor
Chief Executive
Director of Estates and Facilities
Director of Operations and Service Development
Medical Director
Acting Director of Finance
Interim Director of Nursing
Programme Director and Director of Continuous
Improvement
Director of Personnel and Organisational Development
Quorum
No business shall be transacted at a meeting of the Board of Directors unless at least
five Directors including not less than two executive and not less than two nonexecutive Directors are present.
2
PART ONE – PUBLIC MEETING
AGENDA
Item No
Page
No
SECTION 1 – Administration
(1) 1
(1) 2
(1) 3
(1) 4
Chairman’s Welcome and Note of Apologies for Absence
Minutes of the Meeting held on 29 September 2010
Matters Arising from the Minutes of the Meeting held on 29 September 2010
Evaluation of the Meeting held on 29 September 2010
5
17
SECTION 2 - Operational Performance
(2) 5
(2) 6
(2) 7
Performance Report for September 2010
Report from the Programme Management Office and KPI Schedule
Items considered by the Board of Clinical Directors
19
69
79
SECTION 3 – Contemporary Reports from Executive Directors
(3) 8
(3) 9
Chief Executive - Verbal report
Chairman - Verbal Report
SECTION 4 – Reports on Committee meetings since 28 July 2010
(4) 10
(4) 11
Clinical Governance Committee (11 October 2010 - verbal)
Finance & Performance Committee (25 October 2010 – verbal)
SECTION 5 – Regulatory Matters – Report from Corporate Secretary
(5) 12
(5) 13
81
83
Compliance with CQC Conditions (attached)
Contact with Regulators (attached)
SECTION 6
(6) 14
Questions from Governors - to respond to written questions from Governors
(6) 15
Public Questions - to respond to written questions from members of the
public
(6) 16
Use of the Corporate Seal - to note the occasions on which the Corporate
Seal has been used since the last meeting
(6) 17
Date, Time and Venue of next Meeting
The next meeting is scheduled for Wednesday 24 November, at 1.30pm,
Rooms B2/B3, Education Centre, Basildon Hospital
(6) 18
Any Other Business
Exclusion of the Press and Public: To Resolve
“That representatives of the Press and other Members of the Public be excluded from
the remainder of this meeting, having regard to the confidential nature of the
business to be transacted, publicity on which would be prejudicial to the Public
Interest” (Section 1(2) Public Bodies (Admission to Meetings) Act 1960)
3
4
BOARD OF DIRECTORS
MINUTES OF THE MEETING
HELD ON WEDNESDAY 29th SEPTEMBER 2010
PART 1
Present:Non Executive
Directors:
Executive
Directors:
Mr M Large
Mrs J Gibson
Mr R Holmes
Mr J Kent
Mr T Parks
Mr P Sheldrake
Ms H Sturgess
Chairman
Mr A Whittle
Mrs J Galpin
Mr M Magrath
Dr S Morgan
Mr A Ray
Mrs D Sarkar
Mr A Sewell-Jones
Chief Executive
Director of Estates and Facilities
Director of Operations and Service Development
Medical Director
Acting Director of Finance (non-voting member)
Interim Director of Nursing
Programme Director and Director of Continuous
Improvement
Director of Personnel and Organisational
Development
Mr N Taylor
Governors in
Attendance:
Mr I Clifton
Mrs J Coleman
Cllr. Mrs S Hillier
Mr D Sydney
Mr B Wellman
Mr K Wright
In Attendance:
Ms A Saville
Mrs P Trinnaman
Mr A Wyatt
Mrs S Lawton
Ms A Drury
Ms A Hall
Ms A Latham
94/10
Corporate Secretary
Associate Director – Communications
Board Secretary
Deputy Director of Personnel (for item 94/10)
Health & Safety Executive (for item 94/10)
Health & Safety Executive (for item 94/10)
Staff
HEALTH AND SAFETY EXECUTIVE PRESENTATION
The Board welcomed Annette Hall and Antonia Drury from the Health and Safety
Executive, who gave a brief presentation entitled ‘Past, Present and The Way
Forward’ which highlighted key aspects of the relationship between the Health and
Safety Executive and the Trust in recent years. By way of background, the Board
was advised that the Health and Safety Executive investigated according to
published criteria and that its primary function was to work to improve Health and
Safety Standards. More recently, the Health and Safety Executive had begun
5
working closely with the Care Quality Commission (CQC) and Monitor and proactively engaged with the Trust’s regulators to investigate areas of concern as
appropriate.
The Board was advised of 4 areas where the Health and Safety Executive had
focused its attention as follows:•
•
•
•
The death of Kyle Flack.
Investigations in relation to the management of Legionella.
The management of manual handling at the Trust.
The Care Quality Commission’s review in relation to the management of
violence and aggression at the Trust.
The Board noted that the joint inspection with the CQC had led to the serving of 4
improvement notices on the Trust, 2 of which had now been complied with, with
extensions of time having been agreed in relation to link co-ordinators and the
management of violence and aggression within Accident and Emergency. It was the
Health and Safety Executive’s view that robust processes should be in place to
ensure that health and safety was managed centrally and implemented on a ward by
ward basis and that health and safety was not managed in an uncoordinated manner
by individual departments and directorates.
The Board was advised that the Health and Safety Executive was now moving
towards focusing on qualitative assessments with the quality of risk management
being at the centre.
During discussion the following points were noted:•
The Board advised the Health and Safety Executive representatives that
the issue of Risk Management was currently under review. It was
questioned whether the Health and Safety Executive could identify
exemplar sites within the NHS for Risk Management and the Trust was
advised to cast its net wider to consider the private sector, including British
Sugar, whose processes in relation to Risk Management had been redefined with the assistance of the Health and Safety Executive.
•
In relation to the Health and Safety Executive Improvement Notice
regarding Board competence,the Health and Safety Executive Inspectors
were advised of the composition of the Health and Safety Committee and
of the Trust’s focus in relation to the management of Health and Safety
which did not appear to be recognised within the Enforcement Notice. In
response, the Board was advised that the Trust was not being treated
differently to other organisations and that a number of other Trusts
throughout the region had received a similar amount of attention more
recently from the Health and Safety Executive.
•
The methodology of the Health and Safety Executive Inspections and
subsequent serving of Enforcement Notices was questioned with the
perception that the Health and Safety Executive assumed there were short
comings at the Trust and the onus was therefore on the Trust to disprove
the detail of the Enforcement Notice. In response, the Health and Safety
Executive advised that they visited for between 4 and 5 days and that
through a process of intense interview, discussion with ward based staff, a
review of documentation and post inspection deliberation had led to
Enforcement Notices being issued.
6
•
The Health and Safety Executive Improvement Notice in relation to
violence and aggression within Accident and Emergency had been
debated at the Health and Safety Committee where it had been noted that
of the 125 assaults recorded for the last financial year, only 2 related to the
Accident and Emergency Department. It was questioned whether the
Enforcement Notice related to a perceived risk although in response, the
Board was advised that the notice had been served following an in depth
investigation and discussion with Accident and Emergency staff.
In conclusion, the Board thanked the representatives of the Health and Safety
Executive for their attendance at the Board Meeting and they then left the meeting.
95/10
APOLOGIES
Apologies for absence were received from Mr P Wardle, Non-Executive Director.
96/10
MINUTES
The minutes of the Part 1 meeting held on Wednesday 28th July 2010 were
approved as a correct record subject to the amendment of Minute 81/10 –
Performance Report for June 2010, first line to read “The Board considered the
Performance Report for June 2010………………”.
97/10
MATTERS ARISING
The Board satisfied itself that all necessary action had been taken in relation to the
action log appended to the minutes. The Board also noted the detail of the
evaluation of the Board Meeting held on 28th July 2010, in particular, the revised
overall evaluation of the meeting comments which were tabled by the Corporate
Secretary. The Board discussed the comments and suggestions which had been
made for future meetings and noted the earlier circulation of Board papers to
Governors as detailed within the minute action log.
The Board was advised that a benefits realisation paper in relation to the electronic
medical records project was due to be presented to the December meeting of the
Board.
With reference to the suggestion for microphones to be provided for Board
meetings, the Board agreed that Board members should speak clearly but the
Governors should also position themselves so as to be in the optimum position to
hear the discussion.
98/10
PERFORMANCE REPORT FOR AUGUST 2010
The Board considered the Performance Report for August 2010 against the key
themes of Patient Safety, Patient Experience, Efficiency and Effectiveness and Look
and Feel. During discussion the following points were noted:•
The Trust had recorded no cases of MRSA or Clostridium Difficile within
the month.
•
A full review of patient falls was in progress, with the Trust looking to
decrease the number of preventable falls.
•
The re-based Hospital Standardised Mortality Ratio for the 2009/10
financial year was 107. The rolling 12 month average to June 2010 was
7
99.9 with the HSMR for the first 3 months of the current financial year at
88.
•
The Board noted that whilst all access standards had been achieved within
the month, going forward there were risks as follows:There was a risk in relation to the 62 day screening to treatment standard
for cancer going forward.
Whilst the Trust had recorded 100%
performance in July, since that time the Trust had been advised of a
second treatment at a tertiary centre which had exceeded the 62 day
standard. Two further treatments had also been advised from tertiary
centres which had been treated within 62 days, taking the Trust’s
performance to 75% for July. In September the Trust expected two
breaches recording 2.5 breaches for Quarter 2. The result of this would be
the Trust recording 1 breach point against Monitor’s compliance
framework. The Director of Operations and Service Development advised
the Board that the cause of delay in relation to the failure to achieve the
standard related to one patient on a complex pathway and two relating to
Patient Choice compounded by a complex pathway.
The Board was also advised of the risk of failure to achieve the 18 week
referral to treatment standard which, whilst it had been achieved in the
month of August, in September a significant number of elective operations
had been cancelled due to electrical problems and as a result, the backlog
of patients waiting over 18 weeks had increased as had the volume of
patients approaching the 18 week deadline. It was anticipated that the
number of patients who would breach the standard would plateau at 200
which was higher than the threshold under which the Trust could treat all
patients and maintain achievement of this standard going forward. As a
consequence of this, the Board was advised that the Trust would be
looking to increase where possible, clinical activity in order to expedite the
treatment of those patients with long waits.
The Board was advised that whilst the 18 week referral to treatment
standard was no longer measured as part of Monitor’s compliance
framework, its principles were enshrined within the NHS constitution and
formed part of the contract with Commissioners. Failure to achieve the
standard could impose a financial penalty on the Trust. In conclusion, the
Director of Operations and Service Development advised the Board that at
the present time, the situation was being managed appropriately.
The Board noted the Trust’s performance in relation to the 4 hour standard
in A&E with the Trust recording the second best result in the country for the
year to date. In contrast, the Trust had faced significant difficulties in
September with maintaining this performance due to capacity constraints.
The Board noted that the seasonal winter pressures had started early
although the Trust’s performance in managing the A&E standard over the
summer months had indicated significantly improved control on the
emergency care pathway. The Board of Clinical Directors had discussed
an action plan to improve the management of capacity at its most recent
meeting.
•
The Board was advised that the number of complaints received by the
Trust continued to increase in number and, anecdotally, in complexity.
Compliance with the response time standard was below expected and the
Board was advised that the Interim Director of Nursing was currently
8
reviewing the complaints management process at the Trust and reporting
progress through the Clinical Governance Committee.
•
The Board noted the net income and expenditure position of break even in
August with a £0.4 million deficit for the year to date. The full year forecast
remained at break even. However, the Trust was still aiming for a small
surplus. A £5.1m cost improvement programme had been delivered
against a plan of £5.8m. The total Trust agency costs of £0.4m in August
were lower than 2009/10 average.
•
The Board noted that the Cardiothoracic Centre was £2m behind income
plan but was also advised that weekly monitoring had indicated an upturn
in the number of referrals through the Centre. It was noted that Specialist
Commissioners were keen to repatriate activity from London to the Essex
Cardiothoracic Centre and whilst the Trust would not catch up the £2m
deficit, in its entirety, it was anticipated that it would achieve its planned
income at year end. The Board was advised that the Cardiothoracic
Centre was good at reducing its cost base and had generated over £1m of
cost savings in the current year. Given the significant impact the success
or failure the Essex Cardiothoracic Centre would have on the overall
finances of the Trust, it was agreed that a detailed recovery plan should be
presented to the next meeting of the Finance and Performance Committee
for ongoing monitoring.
Action 5: Acting Director of Finance
•
The Board was advised that private patient income and activity had begun
to rise and was now at the level being recorded by Ramsay Healthcare
prior to the Trust serving notice to terminate the contract.
The Board discussed the need for the Trust to raise the profile of the Essex
Cardiothoracic Centre to establish it as the Centre of Choice for patients requiring
cardiothoracic surgery within Essex and further afield. There was a proposal being
considered by South West Essex Primary Care Trust to introduce an outreach clinic
in Brentwood to attract additional referrals to the centre. It was noted that with the
Brentwood Community Hospital Cardiology service not being provided by BTUH, a
significant number of Brentwood referrals were currently moving to London.
The Board discussed the ongoing expenditure in relation to Bank and Agency staff
and noted that whilst the Trust had made significant improvements in relation to the
spend on nursing, there was a need to improve performance in relation to the use of
middle grade medical locum cover throughout the Trust. Whilst it was inevitable
there would be some locum usage, the continuing high spend in this area was of
concern and it was agreed that the matter would be considered further at the
Finance and Performance Committee. The Board also noted the forecast spend in
relation to the Capital programme with the Trust forecasting a £22.6m spend against
a plan of £30m.
99/10
REPORT FROM THE PROGRAMME MANAGEMENT OFFICE AND KEY
PERFORMANCE INDICATOR (KPI) SCHEDULE
The Board noted the report of the Programme Director/Director of Continuous
Improvement which presented an update on progress and achievements of the
projects overseen by the Programme Management Office (PMO) since the last
meeting. The Board noted the summary key issues:
9
•
The PMO was currently overseeing 24 projects.
•
At present there were 2 projects in the pipeline.
•
Of the 1113 milestones (or actions) that were due for completion since
the start of the programme, 20 were outstanding (2%).
•
At the current time there were 50 key performance indicators (KPIs)
being monitored by the Programme Board and of these 17 or 34% were
not being fully met.
•
2 projects (A&E Improvements and Releasing Time to Care) were
currently temporarily suspended from the programme pending major
revision to the projects and were therefore not currently being measured.
•
The project for reducing length of stay had been reinstated due to the
ongoing capacity problems being experienced by the Trust. The Board
was advised that the Trust currently had 9 patients with a length of stay
of over 100 days with 23 patients unable to move on to the next stage of
care due to the lack of availability of intermediate care beds within the
community.
100/10 ITEMS CONSIDERED BY THE BOARD OF CLINICAL DIRECTORS
The Board noted the report of the Chief Executive which presented the list of items
considered by the Board of Clinical Directors since the last Board of Director’s
meeting.
101/10 REPORT OF THE CHIEF EXECUTIVE
The Board received a verbal report from the Chief Executive which advised on the
following matters.
PCT Financial Performance
The Board was advised that the Primary Care Trust Board had met earlier in the day
to approve a forecast recovery plan to achieve savings of £52m in the current
financial year. The Board noted that these savings were over and above the plan to
reduce expenditure for 2011/12 and 2012/13 by £32m per year.
Regulatory Interest
The Board was reminded of the attendance at Monitor by members of the Board of
Directors. The next meeting with Monitor was scheduled for 10th November 2010
where Monitor would consider progress which might lead to de-escalate the
significant breach of terms of authorisation by the Trust.
•
The Care Quality Commission had recently lifted two additional registration
conditions and had advised the Trust verbally that the Trust had complied
with the condition in relation to the management of Legionella and that that
condition would be lifted in due course. The Board was advised during
discussion of the recent visit by the Care Quality Commission where a
number of concerns had been raised particularly in relation to the
production of action plans following Serious Incidents..
10
102/10 REPORT OF THE CHAIRMAN
The Board received a verbal report from the Chairman which updated
Members on his recent teleconference with the Chairman of the Care Quality
Commission.
103/10 REPORT OF THE DIRECTOR OF OPERATIONS AND SERVICE DEVELOPMENT
Annual Plan Timescale
The Board considered the report of the Director of Operations and Service
Development which presented proposed milestones which would lead to the
completion of the annual plan 2011/12 to 2013/14 before the end of the current
financial year. The Director of Operations and Service Development advised the
Board of the intention to review the final annual plan at the March meeting of the
Board of Directors. The Programme Director/Director of Continuous Improvement
advised it was the intention for the January Board of Directors meeting to agree the
objectives to be included within the annual plan, identify the key risks and begin the
Board Assurance Framework process to cover the life of the plan. The Board was
advised however, that the system QIPP plan was not yet signed off due to the
financial difficulties currently being experienced by NHS South West Essex.
104/10 REPORT OF THE INTERIM DIRECTOR OF NURSING
Review of Serious Incident Procedure
The Board noted the report of the Interim Director of Nursing which presented a
proposal to strengthen the serious incident reporting and management mechanism
by ensuring the appropriate actions were taken by the most appropriate persons at
the right time. The Board noted the intension for the new procedure to be piloted for
the next 2 serious incidents with the process being reviewed after this time to ensure
it was fit for purpose. The significant improvement which had been made to the
process for managing and reporting serious incidents was acknowledged.
Airedale Report
The Board considered the report of the Interim Director of Nursing which advised of
the Trust’s review of its services in light of the Airedale enquiry. The Board noted
that the matter had been considered at the last Clinical Governance Committee and
would be subject to further consideration by that Committee going forward. It was
noted that all actions relating to the key findings from the report were in progress and
that a full update would be presented to the Clinical Governance Committee in due
course.
Action 6: Interim Director of Nursing
105/10 REGULATORY MATTERS – REPORT FROM THE CORPORATE SECRETARY
The Board noted the report of the Corporate Secretary which informed the Board on
progress with the action plans developed to ensure compliance with the conditions to
the Trust’s registration with the Care Quality Commission.
Contact with Regulators
11
The Board noted the report of the Corporate Secretary which provided a summary of
contacts with regulators and external agencies between 28th July 2010 and 21st
September 2010 and an update on feedback from visits where received. The Board
was reminded of the recent unannounced inspection visit undertaken by the Care
Quality Commission where the Interim Director of Nursing had been interviewed for a
considerable length of time. It was noted that the visit had been triggered by
correspondence from the Strategic Health Authority in relation to the management of
serious incidents and the Board was mindful of the review of serious incidents which
was currently being overseen by the Clinical Governance Committee. The 2 serious
incidents of interest to the Care Quality Commission related to gynaecology
oncology and a faulty infusion pump.
106/10 REPORT OF THE ACTING DIRECTOR OR FINANANCE
Corporate Governance Manual
The Board considered the report of the Corporate Secretary and Financial Controller
which advised of the proposed changes to the Trust’s Corporate Governance
manual following a recent review. The Board noted the summary of key changes
required which had been considered and agreed at the Audit Committee on 8th
September 2010.
107/10 REPORT OF THE MEDICAL DIRECTOR
Medical Director’s Report
The Board received a verbal report from the Medical Director which advised of the
following matters:Clinical Director – Medicine and Emergency Care
Dr David Gertner had resigned as Clinical Director for the Medicine and Emergency
Care Directorate on 1st August 2010 and had taken up the role of Clinical
Effectiveness Lead within the Medical Director’s Office. Dr Tayyab Haider had been
appointed to the position of Clinical Director, Medicine and Emergency Care,
supported by 4 Clinical sub Directors.
The Board was advised that a review of the management role of Clinical Directors
had recently been completed..
The Board added its sincere thanks to Dr Ian Barton for his contribution and hard
work during his time as Clinical Tutor for the Trust. The Board was advised that Dr
Barton was now Associate Post Graduate Dean for the Eastern Deanery and Dr
Johnson Samuel had been appointed as Clinical Tutor for the Trust. The Board was
advised of four recent consultant appointments to the Obstetrics and Gynaecology
Department.
The Board was advised that the Department of Health and Strategic Health Authority
would be undertaking a VTE assessment visit in October.
The Board also received an update in relation to the appointments to the “Medical
Directors’ Office”. The Board noted that Mr Chris Welch had already been appointed
as Associate Medical Director for Patient Safety and that a Candidate had been
identified for the 2nd Associate Medical Director role.
12
In conclusion the Board was advised of the new integrated working arrangements
which had been introduced between the Medical Director’s Office and the Directorate
of Nursing.
Annual Report 2009/10 – Hospital Standardised Mortality Ratio
The Board noted the report of the Medical Director which presented an update on
progress made during 2009/10 in relation to Hospital Standardised Mortality Ratio
(HSMR), the impact of the annual rebasing undertaken by Dr Foster and which
informed the Board of the current position as at 1st September 2010. The Board
was advised that the HSMR for the financial year 2009/10 was 106.9 which would be
rounded up to 107. There had been a 24 point (or 18%) reduction on the HSMR in
comparison to 2008/9. The early results for Quarter 1 2010/11 indicated the HSMR
was at 88. Of the original top 5 HRG diagnoses identified in 2009 as requiring
attention, none were currently significantly higher than average and the 12 month
rolling HSMR from July 2009 to June 2010 was 99.9.
108/10 REPORT OF THE DIRECTOR OF PERSONNEL AND ORGANISATIONAL
DEVELOPMENT
Progress Report on the Staff Survey
The Board noted the report of the Director of Personnel and Organisational
Development which presented progress with actions taken as a result of the 2009
National Staff Opinion Survey.
109/10 REPORT OF THE GOVERNOR LIAISON NED
Feedback from Governors’ Strategic Planning Event
The Board received a verbal report from the Governor Liaison Non Executive
Director which advised of the recent Governor Strategic Planning Event which would
feed into the Trust’s annual planning process. The Board was advised that the
process undertaken had worked well although only 14 Governors had attended the
event.
110/10 REPORTS ON COMMITTEE MEETINGS SINCE 28th JULY 2010
Clinical Governance Committee
The Board received an update in relation to the matters discussed at the Clinical
Governance Committee at its meetings held on 9th August and 13th September
2010. The Chair of the Committee advised of the robust discussion which had taken
place in relation to the Trust’s quality strategy and of early discussion in relation to
the presentation of patient stories to the Committee on a regular basis. The
Committee had also focused its discussion on HSMR, Serious Incidents, Complaints
and the achievement of the NHSLA Risk Management Standards for both maternity
and general services.
Health and Safety Committee
The Board received a verbal report advising on the matters considered by the Health
and Safety Committee at its meeting on 7th September 2010. The Board was
advised that the Health and Safety Report which had been agreed by the Health and
Safety Committee had been accepted on its fourth draft, that the report had
presented adequate assurance to the Trust and that no high risk actions had been
identified during that audit.
13
Audit Committee
The Board received a verbal update on the matters considered by the Audit
Committee at its last meeting. The Complaints Report had been presented by the
Trust’s internal auditors and the Trust had received adequate assurance in relation
to its processes for the management of complaints. The Audit Committee had also
considered the report in relation to the Trust’s quality accounts and noted a number
of recommendations which required completion by the end of the financial year in
order to achieve an unqualified opinion in relation to the Trust’s quality accounts.
Data quality on PAS was also discussed.
111/10 QUESTIONS FROM GOVERNORS
There were no questions from Governors.
112/10 PUBLIC QUESTIONS
There were no public questions.
113/10 USE OF THE CORPORATE SEAL
The Corporate Seal had not been used since the last meeting.
114/10 DATE, TIME AND VENUE OF NEXT MEETING
The next meeting was scheduled for Wednesday 27th October 2010 at 3:30 pm in
Committee Rooms 1 and 2, Level G, Tower Block, Basildon Hospital.
115/10 ANY OTHER BUSINESS
There was no other items of business.
Signed …………………………………………………
(Chairman)
Date………………………..……………………………
14
BOARD OF DIRECTORS (PART 1) MEETING 2010
ACTION LOG - PUBLIC
Minute Ref
and subject
Action
No
Action required
Action
Owner
Date
raised
Date Due and
Report to
Action Status/ Progress
Outcome/ Impact for patients
(date action
Agreed)
98/10
Performance
Report
5
104/10
Airedale
Report
6
Present detailed financial recovery plan
for the Essex Cardiothoracic Centre to
the next meeting of the Finance and
Performance Committee for ongoing
monitoring.
Present a full update on all actions
relating to the key findings from the
Airedale report to the Clinical
Governance Committee
Acting
Director of
Finance
29
25 October 2010
September
2010
Completed – On Agenda for meeting
25 October 2010
Interim
Director of
Nursing
11 October 2010
29
September
2010
Completed – On Agenda for meeting
11October 2010
15
This page is left blank intentionally
16
Evaluation of Board of Directors meeting held on 29 September 2010
29-Sep-10
ORGANISATION
You had sufficient time in advance of
the meeting to review Board
materials.
4.8
Background material provided was
adequate to make informed decisions.
4.8
The source of data was known and
was complete and accurate.
4.4
AGENDA
The meeting discussions were
valuable and focused.
4.4
The meeting agenda included relevant
topics and focused on key priorities.
4.6
The impact on quality was given
appropriate consideration in the
making of decisions.
4.6
PARTICIPATION
Robust discussion and debate of
proposals took place prior to
decisions being made.
4.5
Board members are encouraged to
and feel free to participate in the
meeting.
4.8
Your time was well spent
participating in this meeting.
5.0
Board members clearly understand
the aims of the Trust and role of the
Board.
4.9
CHAIRMANSHIP
The chairman ensured that actions
were assigned and executive
directors were held to account for
delivery.
The extent of the chairman’s own
contribution allowed executive
directors were held to account for
their own areas of responsibility.
4.5
4.7
17
Evaluation of Board of Directors meeting held on 29 September 2010
Good meeting
The number of matters to be discussed resulted in Parts 1 and 2 taking longer than is ldeal. We should aim to
finish both these agendas by 6.00pm
Lengthy - but the time was needed
Too long. Too much emphasis placed on documents that were clearly defined e.g. Performance Report
Comments Overall evaluation of the Valuable but a little too long
meeting
Quite good – all participated. Still some difficulty hearing 1 or 2
Definite positive comment and explanation of all subjects
Very interesting and productive. It was my first time and I was amazed how in most subjects my profession
was involved – from H&S to CTC recovery plan. The reports to hand were very informative and useful.
The meeting continued until quite late resulting in several Governors leaving before it concluded and a change
the sequence of items.
Start at 11.00 - 12.00 then 13.00 - 17.00 (max)
Comments Suggestions for future
More publicity so more members of staff or public can attend. I would certainly come again
meetings
Consider starting the public part of the meeting earlier.
Made to feel very welcome at first meeting
? Inclusion of clinical presentation routinely for max 30 mins
Poor report on H&S – appeared to try to justify their wage
Other Comments Positive attitude on the visit last November
Good to see list of full titles of acronyms
Well delivered, very clear and concise. All topics were relevant and timely. I did not know a lot of the Board
and some had quite an input and most were quite challenging.
18
Performance Report
September 2010
Board of Directors
October 2010
19
Section A: Performance Dashboard – September 2010
Patient Safety
Previous
month
RAG
Hospital Standardised Mortality Ratio (HSMR)
Hospital Acquired MRSA bacteraemia Hospital Acquired Clostridium difficile episodes Hospital acquired pressure ulcers
Patient falls
98.3
2
23
6
832
12 mth
YTD
YTD
In mth
YTD
Efficiency and Effectiveness
RAG
Monitor Financial Risk Rating
Cost Improvement Plan surplus/(deficit)
% of relevant staff with documented appraisals
Vacancy factor
Sickness absence
YTD
YTD
12 mth
In mth %
In mth %
3
(£1,040k)
73
8.2
3.06
99.9
2
20
11
683
Previous
month
3
(£723k)
71 9.25 2.98 Patient Experience
Previous
month
RAG
< 18 wks referral to treatment (admitted)
< 18 wks referral to treatment (non‐admitted) A&E 4hr to admission or discharge All cancer targets being met
Overall satisfaction score (Patient Tracker) Would you recommend this hospital? (Patient Tracker)
In mth %
In mth %
In mth %
In mth
In mth %
In mth %
90.5
96.5
98.0
6 of 7
88
96
Look and Feel
Previous
month
RAG
Cleaning scores ‐ Very High Risk Areas
Cleaning scores ‐ High Risk Areas
Statutory maintenance completed
Water systems maintenance completed
Planned preventative maintenance completed
In mth %
In mth %
In mth %
In mth %
In mth %
92.5 97.6 99.7 7 of 7 89 97 98
97
87
96
80
20
98 97 91 97 84 Section B: Executive Summary
Patient Safety
Measures to improve Patient Safety in 2010/11 will continue to include the effectiveness of actions to reduce Inpatient Falls, Medication Incidents and Pressure Ulcers. A further observational audit is planned to assess compliance with the World Health Organisation (WHO) Surgical Checklist.
Only 60% of emergency patients were screened for MRSA in September, which is down from August when the Trust achieved 69%. This was discussed at the Infection Control Committee in September to identify actions which can be taken to improve this result. Patient Experience
The number of complaints has reduced slightly with 39 received in September (43 in August). There are no identifiable trends developing, however “every aspect of medical care/treatment”
continues to be the primary theme, with a high number this month (9) being received in the Accident and Emergency Department.
The overall Patient Tracker satisfaction score was 88%. The number of responses again exceeded the monthly target (3,500) with 3,886 in September. The number of formal plaudits (acknowledged by the Chief Executive) reduced with 17 received in September (35 in August),
however an increased number of plaudits were received via the “Get It Right” comment cards, PALS contacts, NHS Choices and written expressions of appreciation directly to the wards. The collated number of plaudits for September was 145.
The A&E and 18 week standards were achieved in September. However, the 62 day cancer screening to treatment standard was not achieved in September or quarter 2, due to patient initiated
delays to diagnosis, complex pathways and small volumes (9 treatments in total for the quarter). Achievement of the 18 week
admitted standard is at risk in future months, as explained on page 35.
21
Section B: Executive Summary
Efficiency and Effectiveness
The Trust has a £0.6m cumulative net deficit for the six months to the end of September. There was a small deficit for September. The year‐end net forecast is revised to a £1m deficit, but the target is still a £1m surplus and at minimum break‐even. The current FRR is 3, as assessed by Monitor. The forecast for the year‐end is a FRR of 3.
Look and Feel
Delivery of the capital programme is progressing. During September preparations were made for the handover of the first phase of the Accident and Emergency Department and Fracture Clinic project. The new offices and new minors department were nearing completion ready for occupation during October in line with the project programme. The financial position includes £0.9m income at risk due to non‐elective activity above the 30% threshold. This increased £0.3m in the month.
Cleaning scores have been maintained at or above the target level. During September there were no occasions when the cleaning scores were reported to be below the Trust trigger point of 96% for very high risk areas and 93% for high risk areas. The Trust achieved its stretch targets of 98% and 95% respectively in the month.
The Trust has delivered a £5.9m CIP to date against a plan of £7.0m. New schemes have been added to meet the shortfall.
Pay Expenditure continues to be lower than last year, this is a result of successful management action to reduce agency and increase bank usage.
The first phase of the ward kitchen refurbishment was completed and approval has been gained for refurbishment of the restaurant to support the introduction of a steam cuisine style food service for patients.
The CTC activity improved for the last two weeks of September, the Directorate has started to implement the activity recovery plan.
A Financial Recovery Plan has been implemented to ensure achievement of the financial targets. This plan was presented to the Board of Clinical Directors in October.
22
Section C: Patient safety ‐ Mortality
•
•
•
•
The 12 month rolling average for the period August 2009 – July 2010 is 98.3 after being re‐based.
The combined HSMR for quarter 1 of 2010/11 is 88. There are no diagnosis groups which are showing as significantly above average (red) in the 12 month rolling position from August 2009‐July 2010. One mortality alert has been generated in the last three months and that is for skin and tissue. An investigation of the cause of this alert has been generated and will be managed through the Programme Board. 23
Source of data: Dr Foster Intelligence
Section C: Patient safety – Mortality Comparison data
•
•
•
Chart A
•
Chart B
Data source: Dr Foster Intelligence HSMR Comparison Report as of 02/08/2010
In April 2010, Dr Foster added additional functionality to the mortality system which enables trusts to “re‐base” their HSMR data. Whilst this is not wholly accurate, it does show estimated performance in relation to other trusts. Chart A shows the HSMR for 2009/10 and the re‐based position as of 1 September 2010. This now also includes the April – June quarter of 2010/11
Chart B shows the relative position of the Trust following re‐basing for the first quarter of the year (blue dot) The grey dots in the funnel represent all other acute trusts following re‐basing. This funnel chart will be updated at the end of quarter 2. 24
Month
Trust Total Absolute No.
of Deaths
Discharges
% of Trust Absolute Rolling 12 months HSMR 09/10 Trajectory Rolling
Deaths
(Basket of 56)
HSMR (Basket of 56)
Jul-07
110
5500
2.0%
137.2
Aug-07
111
5412
2.1%
136.6
Sep-07
138
5252
2.6%
137.7
Oct-07
131
5723
2.3%
137.1
Nov-07
138
5689
2.4%
135.6
Dec-07
167
5197
3.2%
137.5
Jan-08
168
5605
3.0%
136.4
Feb-08
155
5353
2.9%
136.4
Mar-08
182
5408
3.4%
136.3
Apr-08
142
5881
2.4%
136.8
May-08
163
5717
2.9%
139.1
Jun-08
139
5732
2.4%
141.4
Jul-08
121
6071
2.0%
140.4
Aug-08
110
5525
2.0%
140.1
Sep-08
106
5622
1.9%
139.0
Oct-08
142
5781
2.5%
139.2
Nov-08
139
5568
2.5%
139.3
Dec-08
155
5484
2.8%
136.6
Jan-09
192
5809
3.3%
136.5
Feb-09
145
5563
2.6%
135.0
Mar-09
143
6218
2.3%
133.0
Apr-09
126
5687
2.2%
129.3
May-09
114
5599
2.0%
124.3
Jun-09
140
5885
2.4%
122.5
Jul-09
100
6151
1.6%
120.1
Aug-09
100
5338
1.9%
118.6
Sep-09
142
6006
2.4%
117.5
Oct-09
131
6358
2.1%
114.3
Nov-09
138
6043
2.3%
110.9
Dec-09
119
5791
2.1%
107.8
Jan-10
173
5466
3.2%
105.6
Feb-10
136
5400
2.5%
102.5
Mar-10
134
6411
2.1%
97.7
Apr-10
139
5780
2.4%
95.9
May-10
108
6026
1.8%
93.1
Jun-10
103
6157
1.7%
99.9
Jul-10
101
6176
1.6%
98.3
Aug-10
113
5927
1.9%
Sep-10
125
6065
2.1%
119
119
119
The number of actual deaths in hospital continues to decrease. Whilst this could be concluded to coincide with seasonal variation, it should be noted that the period April – September 2010 saw a 4.5% reduction in the number of deaths in hospital when compared to same period in 2009. 116
108
113
116
120
The continued use of care pathways in a number of key areas, and
improvements in the recognition of patients who are at risk of deteriorating is considered to be reflected in this reduction. 115
117
115
Source of Data:
110
Dr Foster
106
104
102
HSMR monthly trend (August 2009 – July 2010)
100
Trust Actual Deaths*:
98
AQUIP/MD_DEATHS_1
Discharges: Ardentia/md_spells_drfoster
25
Section C: Patient safety ‐ Infection control
In September there were 3 cases of hospital acquired C. Diff. Year to date, the Trust has had 23 cases against a ceiling of 36. 90
80
70
60
50
40
30
20
10
Cumulative C-Diff
Performance Trajectory
2009/10 Cumulative CDiff
Incentive trajectory
The performance ceiling trajectory for MRSA bacteraemia for 2010/11 is 4 hospital acquired cases per year, equating to one per quarter. In September there were no new cases, the total for the year to date therefore remains at 2. 100%
Hand Hygiene scores , as observed by patients, achieved 89%. The aim is to achieve the levels of compliance realised at the end of the 2009/10. The Trust also monitors compliance with hand hygiene standards through the Saving Lives audits, which for September, indicates an overall compliance of 98%. 75%
A p r ‐1 0
M a y ‐1 0
Ju n ‐ 1 0
Ju l‐ 1 0
A u g ‐1 0
S ep ‐1 0
O c t‐ 1 0
N o v ‐1 0
D ec ‐1 0
Ja n ‐ 1 1
F eb ‐1 1
M a r ‐1 1
‐
MRSA Bacteraemia
Hand Hygiene
(data source: Dr Foster Intelligence PET 3.0)
95%
2009/10
90%
2010/11
Standard
85%
80%
Apr
M ay
Ju n
Ju l
Aug
Sep
O ct
Nov
D ec
Ja n
Feb
M ar
Clostridium Difficile
5
4
Cumulative MRSA
Bacteraemia
3
2
Performance Trajectory
1
A p r ‐1 0
M ay ‐1 0
Ju n ‐1 0
Ju l‐1 0
A u g ‐1 0
S ep ‐1 0
O c t‐1 0
N o v ‐1 0
D ec ‐1 0
Jan ‐1 1
F eb ‐1 1
M ar ‐1 1
‐
Data source for HCAI: Laboratory results.
2009/10 Cumulative
MRSA Bacteraemia
MRSA screening of emergency patients continues within A&E and the admission units. In September, only 60% of emergency patients were screened for MRSA, which is a reduction from August when the Trust achieved 69%. This continues to be discussed at the Infection Control Committee and actions have been identified to achieve a consistent and sustained improvement in the results in order to continue to achieve against trajectory. 26
MRSA screening for elective admissions has been a national requirement since April 2009 with the aim of reducing the burden of MRSA in the community. Whilst this Trust has been compliant with this requirement, the system for screening has recently changed to ensure full capture of all day case patients. The information is Source of data: Laboratory results
reported monthly to the PCT and is monitored through the quality contract monitoring meetings.
Section C: Patient safety – Patient Falls
Inpatient Falls
The 10% reduction target for this year remains challenging, with 149 inpatient falls reported in September, affecting 114 patients. (144 falls in August affecting 107 patients). There was a small rise in the number of “clinical” falls (8 in September, 2 in August and 2 in July). Mobility and Slips and Trips are unchanged.
(data source: Incident Reporting on Ulysses Safeguard System)
1,800
1,600
1,400
1,200
1,000
800
600
400
200
‐
Cummulative Inpatient Falls
Performance Improvement
Trajectory
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
2009/10 Cumulative Patient falls
The Falls Group categorise falls into three areas:
•
Mobility
•
Clinical
•
Slips and Trips
The number of falls for the year to date (April‐September) was 832 which is 9.5% above the trajectory of 754. The majority of incidents relate to patients who experience a first fall and then no other. Even with robust assessment, it is not always possible to predict these events. The Falls Group is developing new measures to ensure that the 10% reduction in falls is achieved this year. Monitoring the detail of patient falls (see chart below) will help focus on the
appropriate actions to reduce 2nd and 3rd falls. An immediate robust action plan and data review is being developed to establish additional causal factors of these falls.
There was one RIDDOR reportable fall in September. No. of Patients reported to have 1, 2 and 3+ falls
Patient Falls
(data source: Incident Reporting on Ulysses Safeguard System)
(data source: Incident Reporting on Ulysses Safeguard System)
100
120
80
100
1 Fall
60
80
2 Falls
Clinical
40
60
3+ Falls
Mobility
20
40
Slips & Trips
20
Se p‐1 0
Aug‐1 0
Jul‐1 0
Jun‐1 0
May‐1 0
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
Oct‐09
‐
Apr‐1 0
0
27
Section C: Patient safety – Medication Incidents
Medication Incidents
(data source: Ulysses Safeguard @ 13/09/10)
30
Administration
25
20
Dispensing
15
10
Prescribing
5
0
Apr‐10 May‐10 Jun‐10
Jul ‐10
Aug‐10
Sep‐10
Medication Incidents
(data source: Incident Reporting on Ullysses Safeguard System)
60
50
40
30
20
10
2009/10
The Safe Handling of Medicines Policy will be reviewed and lessons learnt from previous incidents will be reflected in changes in practice within the updated policy.
The frequency of checking Controlled Drug stock levels will be reviewed and new guidance issues.
To be completed by end of October 2010
The NRLS report for the period October 2009 to March 2010 is due in early September and it is planned to share the key points at the CGMG in September 2010 with a formal report the following month. The Directorates continue to produce action plans to reduce incidents and improve learning.
Ongoing and reported monthly to the CGMG
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
Oct‐09
Sep‐09
Aug‐09
Jul‐09
Jun‐09
May‐09
2010/11
Apr‐09
‐
•The use of an adapted medication matrix is being considered for medical staff. Nursing and Midwifery staff continue to follow the medication matrix should a medication incident occur.
• Current performance indicates a 33.47% reduction in medication incidents compared to the same period (April – September) in 2009/10 . August
September
Clinical Sciences
0
0
CTC
3
1
Medicine and Emergency Care
13
7
Outpatients
0
0
Surgical Services
8
5
Women & Children’s
5
5
There was a reduction in the number of medication incidents reported during September (18) compared to August (30) and July (27). The data shows a continuing downward trend of administration incidents.
The breakdown of medication incidents by directorate for September, compared to August, is shown in the table to the left. 28
Section C: Patient safety – Principles of Care (data source: Audit data compiled by the Clinical Effectiveness Unit)
Principles of Care Audit
(6 Essential Standards ‐ CQC Conditions) 100%
95%
90%
Principles of Care Audit ‐
Trust Totals
85%
Performance Improvement
Trajectory
S e p ‐1 0
A u g ‐1 0
J u l ‐1 0
J u n ‐1 0
A p r ‐1 0
M a y ‐1 0
M a r ‐1 0
F e b ‐1 0
J a n ‐1 0
D e c ‐0 9
80%
• A random sample of 10 healthcare records were audited during September 2010.
• To ensure that questions are relevant to appropriate areas, the audit tool was reviewed and refined in relation to the Medical Admissions Unit (MAU) resulting in 9 of the standards assessed as not appropriate to the clinical area. Since the establishment of monthly auditing, the target for each of the standards has been reviewed and 6 standards have been identified as being essential to meet the needs of all patients and to ensure the welfare and safety of the patient. The target will remain at 90%. For the remaining standards, a trajectory has been set in order to achieve the 90% target across all standards by November 2010.
• In September the overall average (of all standards) was 93% (92% in August). The improvement trajectory target of 88% was exceeded, with 15 individual standards achieving against their target. Of these, 14 standards achieved over 90% compliance. For the 6 essential standards, the average performance for August was 96% against the 90% trajectory
• Principles of Care Standard 12 relating to documentation containing relevant demographics shows an improvement from 59% in August to 67% in September.
Principles of Care Audit
Principles of Care Audit (All Standards)
(Monthly Result by Directorate)
(Total average for all standards) 100%
100%
95%
95%
Total average for all
standards
90%
Performance Improvement
Trajectory
85%
N o v ‐1 0
O c t ‐1 0
S e p ‐1 0
A u g ‐1 0
J u l ‐1 0
J u n ‐1 0
M a y ‐1 0
A p r ‐1 0
80%
90%
85%
80%
Cardiothoracic Centre Medicine & Emergency
Care
Sep-10
Surgical Specialties
Women & Children's
29
P erfo rmance Impro vement Trajecto ry
Source of data: Internal Systems
Section C: Patient safety – Pressure Ulcers
Pressure Ulcers
(data source: Tissue Viability Team & Incident Reports)
Grade 2
Grade 3
70
60
Grade 4
50
40
Total
30
20
Patients
10
S ep ‐1 0
A u g ‐1 0
Ju l‐1 0
Ju n ‐1 0
M a y ‐1 0
A p r ‐1 0
M a r ‐1 0
F eb ‐1 0
Ja n ‐1 0
D ec ‐0 9
‐
Community
Acquired The graph (above left) shows the pressure ulcer rates from December 2009. There were 6 hospital acquired pressure ulcers reported in September 2010 (9 in August). The number of patients affected was 6. Performance continues to surpass trajectory.
In September there were 45 community acquired pressure ulcers reported, involving 39 patients (42 ulcers, 34 patients in August). Reporting of this continue to the PCT for their action.
The incidence of pressure ulcers (as shown above right) is calculated as the rate of ulcers per 1000 occupied bed days. As can be seen, there has been a significant reduction from 1.4 per 1000 bed days in January 2010 to 0.33 in August 2010.
The Tissue Viability Group is implementing robust systems to ensure shared learning from Root Cause Analysis (RCAs).
30
Section C: Patient safety – Other
Vulnerable Patients
Safeguarding
The Named Nurse for Adult Safeguarding has commenced a secondment to the Directorate of Nursing for a period of 6‐months. The terms of reference for the secondment are to review the robustness of policies and procedures for the management of safeguarding
referrals and investigations, and with regard to the robustness of evidence in relation to NHSLA and CQC standards. The review will incorporate elements specific to those with a learning disability or altered mental state (such as dementia) for example the Mental Capacity Act and Deprivation of Liberties. It is anticipated that the review of safeguarding children and young people policy and procedures will follow suit.
Learning Disabilities A project initiation document was presented to the Project Management Board on 7 October 2010 with regard to the 70k funding received from the East of England Strategic Health Authority. The board agreed for the project ‘person centred pathways for better health outcomes – working together’ to be managed through the PMO process. The Deputy Director of Nursing and Nurse Advisor for Learning Disabilities are meeting with representatives from the Regional Valuing People Team and the East of England to determine the project plan. Population of the PMO workbook has commenced in anticipation of the first PMO set up meeting and in advance of appointment of a project manager and clinical support post which formed part of the bid.
Dementia
A performance measure relating to dementia has been agreed with the Commissioning PCT. This relates to the number of patients with dementia that are referred to specialist services for assessment. A review of the NICE standards for dementia services is being undertaken and a work stream determined to improve the care and environment provided for this patient group. This is being led by the Service Manager for Elderly Medicine in association with consultant colleagues and the Matron for Elderly Care. An action plan has been produced which, along with a project initiation document, will be presented to the Project Management Board for consideration of its inclusion within their portfolio of managed projects.
31
Section C: Patient safety – Emergency preparedness
Ensure clear plans are in place to deal with a Flu Pandemic and for business continuity in the event of an unexpected incident or event. Evidenced by successful completion of 2 communication tests and 1 tabletop exercise (or incident) by March 2011.
Business Continuity Management.
On 21st September an auditor from the British standards Institute (BSI) undertook a pre audit assessment as part of the
Trust’s accreditation process towards the business continuity standard BS 25999. The Trust’s Emergency Planning Liaison Officer, provided evidence of the contingencies and plans currently in place. The auditor’s assessment was very positive and he has recommended we proceed to the next stage. The next stage assessment is due to take place in December. Leading up to this date the Trust will raise awareness amongst staff by including articles in newsletters, the
hub and other means. Major Incident Communications Exercise.
Every six months, the Trust is required to undertake a test of it’s major incident alert cascade system. However the Trust has planned to undertake the test on a more regular basis during working hours and out of hours. This will ensure the system is fully tested and robust, and will build confidence in the staff involved in the cascade. On 29th September a test of the cascade system was carried out. The feedback from departments throughout the Trust was very positive. The test was extended to include a range of departments and services including Orsett hospital. Planned Drinking Water Shutdown – 2nd September 2010 Essential planned maintenance work was carried out on the Trust’s Drinking Water system over a period of 20:00hrs –
24:00hrs (midnight) on 2nd September 2010. The drinking water shutdown impacted on only a limited number of clinical wards and services. The affected departments were notified in advance of the shutdown which allowed for
contingencies to be put in place over the period of the shutdown.
Olympic Games 2012
The Trust attended its first meeting in Essex regarding the planning for the summer Olympic games in 2012. A
presentation was given by Essex Police which highlighted the impact the games will have on the Essex County and it’s communities.
32
Section D: Patient experience – Background and context
•
•
•
•
Measuring patient experience is challenging in that there is no single metric which will provide robust information on all aspects of patient experience.
As can be seen from the reports in the following pages, this Trust measures a suite of metrics designed to provide assurance in a number of areas which patients have indicated are important to them. The metrics chosen are centred on a number of themes:
– Access to services, including waiting times for cancer and performance against the NHS Constitutional right not to wait longer than 18 weeks to treatment. – Performance against the A&E standard of discharge, transfer or admission within 4 hours of arrival
– Privacy and Dignity through compliance with Delivering Single Sex Accommodation standards. – Results of National Patient Surveys with their associated actions. – Content and volume of complaints. – Content and volume of PALS contacts.
– Patient Feedback from comments cards, NHS Choices website postings, plaudits and the results from the Dr Foster Patient Experience Tracker. To provide evidence of the aspiration to improve the patient experience score year on year, the Trust strives to achieve the following:
‰ No avoidable breaches of the cancer waiting time standards. ‰ No avoidable breaches of the 18 week referral to treatment standard. ‰ 98% of patients seen and discharged from A&E within 4 hours of arrival. ‰ No non clinically justified breaches of the single sex accommodation standard.
‰ 70% of complaints responded to within the timeframe agreed with the complainant
‰ Over 90% of PALS contacts resolved within 5 working days
‰ Over 90% overall satisfaction with the care provided in hospital, with 95% or more of patients stating that they would recommend this hospital to others. 33
Section D: Patient experience ‐ Cancer •
September results are provisional and awaiting ratification.
•
6 of 7 cancer targets were met in the month (there is no threshold for the 8th). As predicted in the previous month’s performance report, the 62 day screening to treatment target was not achieved during Q2. In Q2 there were 2.5 breaches from 9 treatments (72.2% within 62 days) due to patient initiated delays in diagnosis and complex pathways.
•
Source of all data: National Cancer Waiting Times Database.
34
Section D: Patient experience ‐ 18 week access
The September admitted position for the Trust was 90.5%, which is above the 90% threshold. The non admitted position was 96.5%, above the
95% threshold.
In August and September a significant number of elective operations were cancelled due to electrical problems affecting theatres, and as a
result the backlog of patients waiting over 18 weeks has increased, as has the volume of patients coming up to 18 weeks, as shown in the table
below. Future deliver of the 18 week admitted target is therefore at risk, as the backlog of patients waiting over 18 weeks has increased from
the typical position of 120.
Source of all data: Patient Administration System
Patients awaiting admission for treatment
Waiting time from referral (weeks)
>18
17‐18
16‐17
08/08/2010
115
22
23
15/08/2010
115
26
27
22/08/2010
135
29
34
29/08/2010
149
30
37
05/09/2010
152
26
32
12/09/2010
162
35
43
19/09/2010
188
41
52
26/09/2010
197
48
28
03/10/2010
217
28
36
10/10/2010
221
41
36
14‐16
70
78
98
111
126
112
113
107
80
103
35
Section D: Patient experience – A&E
•
Performance in September reduced to 98.04% within 4 hours. Use of escalation beds increased slightly in September to 3.7, compared to 1.1 per day in August.
•
The revision to the NHS Operating Framework reduced the threshold for this target to 95%. Monitor’s Compliance Framework has been amended to require performance below 95% to be reported. The contract with PCTs still requires 98% performance.
–
Source of data: Ascribe Symphony A&E System
36
Section D: Patient experience – CQUIN indicators
Annual Target
90
Q2 Target
90
Q1 performance
88
90%
25%
29%
TBA
TBA
Not yet available
95
100
Increase in same day admission for elective surgery
95%
N/A
Increase % of smokers at pre‐operative assessment offered to stop smoking services
75%
50%
Increase % of women provided with 1:1 care during labour
Increase home birth rates
Reduce transfer rate from midwife led unit to obstetric ward
98%
2.00
30%
85%
1.80
37%
Measure at M12
Reported at Q2
Reported at Q2
98%
1.75
40%
Implement direct access midwifery care
TBA
TBA
Not reported
Increase % of low risk patients receiving brain imaging to include MRI or carotid scans within 7 days of referral
95%
50%
44%
Not yet available
12%
7%
22
24
Reported at Q2
23
Not yet available
Not yet available
Reduction in Hospital Standardised Mortality Ratio
% of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool
Inpatient survey results ‐ Improvement in responsiveness to personal needs. The indicator will be a composite, calculated from 5 survey questions.
Reduction in Length of Stay as measured by Dr Foster
Increase % patients receiving thrombolysis within 3 hours of onset
Reduce average length of stay in Stroke Unit
Q2 performance
Not yet available
Not yet available
Not yet available
Financial impact
Measure at M12
Not yet available
Not yet available
98%
2.68%
Not yet available
Implemented
£42,500
The CQUIN indicators for Q2 will be reported next month, once coding is completed.
We are waiting to agree with the PCT the audit methodology for reporting of % of smokers offered stop smoking services.
37
Section D: Patient experience – Privacy and Dignity
Delivering Single Sex Accommodation (DSSA)
The national standards in relation to DSSA are that: Patients should not share sleeping, toileting or washing facilities with members of the opposite sex. Patients of one sex should not have to walk through accommodation used by the other sex when not fully clothed. In order to test compliance with this, from 1 August 2010 the PCT require (through the contract) the Trust to undertake a Root Cause Analysis for any breach. For the week commencing 2 August there were no breaches reported. The PCT has recommended a change in the questions asked to reflect admissions to Basildon Hospital and these will be agreed in July 2010. 38
Section D: Patient experience – Complaints
•
–
60
50
‐
Oct
Nov
Dec
Jan
Feb
Mar
•
There were no red rated complaints in September. There were five amber rated complaints, of which four related to medical judgement/diagnosis and one to communication. These complaints are currently under investigation and will be RAG rated on completion in line with Trust policy.
The graph to the right represents the number of complaint responses that have been sent out from the Trust within the target date agreed with the complainant. This includes agreed extensions where additional investigation has been identified as being necessary during the process. This will be updated monthly as each month is completed. The figures for June 2010 show that:
• 85.71% complaints were responded to (30 of the 35 received).
• 37.14% of responses were sent within target. • 48.57% were sent outside of target as follows:
•
•
•
52.94% due to quality or timing of reports from Directorates
41.17% due to delays in Patient Experience Team (PET)
5.88% due to the final signing process.
•14.28% of responses are outstanding. Actions have been identified to:
•
Improve the quality of the response and ownership from the Directorates
•
•
Speed up the process in PET
Streamline the process for final sign off
Each of the above elements is reported and monitored monthly at Patient Experience an Complaints Leads (PECL) group. •
•
Complaint Responses within agreed target
(data source: Ulysses Safeguard)
120%
100%
Responses with agreed
target
80%
60%
Total responses
40%
20%
0%
Improvement Trajectory
Feb‐11
Sep
Mar‐11
Aug
Jan‐11
Jul
Dec‐10
Jun
Oct‐10
May
Nov‐10
Apr
Sep‐10
10
Aug‐10
2010/11
20
–
–
–
–
Jul‐10
2009/10
30
Jun‐10
40
Apr‐10
(data source: Ullysses Safeguard System)
There were 39 complaints received in September 2010 (43 in August). The main themes were:‐
Every aspect of medical care/treatment 18 (46.15%)
• Medical judgement & diagnosis 11 (28.20%)
• Medical care & treatment 6 (15.38%)
• All aspects of clinical treatment 1 (2.56%)
Communication 7 (17.94%)
Nursing Care & Treatment 4 (10.25%)
Attitude 4 (10.25%)
Others, including Environment, Appointment Delay, Waiting times) 6 (15.38%)
The number of complaints has reduced slightly. Every Aspect of Medical Care/Treatment continues to be the primary theme. The majority of these (9) relate to Accident and Emergency and this represents 23% of the total number of complaints received by the Trust in September. This is being taken to the Patient Experience and Complaints Leads (PECL). Directorate actions will be reported to the Clinical Governance Management Group (CGMG). There are no other trends to note.
Complaints relating to Nursing Care/Treatment have decreases to 4 (6 in August).
May‐10
Complaints
39
Section D: Patient experience – Patient Advice & Liaison Service (PALS)
•
PALS received 234 contacts in September 2010 of which 93.3% were responded to in target. The main categories were:‐
Advice
54 (23.07%)
Appointment Delay/cancellation OPD
34 (14.52%)
Clinical Treatment
27 (11.53%)
Communication
29 (14.52%)
Appointment Delay/cancellation IP
17 (7.26%)
Diagnostic Tests
16 (6.83%)
Others including Discharge, Staffing, Privacy & Dignity 57 (24.35%)
It is important to note that PALS contacts also include requests for information relating to any of the above categories, as well as concerns or complaints. Non‐
specific advice continues to be the highest ranked category.
PALS continue to deal with enquiries and concerns which benefit from an earlier response, and where the circumstances are deemed not to require a more rigorous investigation.
Patient Advice & Liaison Service (PALS)
(data s ource: Ullysses Safeguard System)
250
200
150
2010/11
100
2009/10
•
•
50
Contacts with PALS remains consistent with the primary reason being Advice. •
‐
Apr
May
Jun
Jul
Aug
Sep
PALS Contacts by Directorate
2010/11
100
50
0
Cardio tho racic
Services
Clinical
Sciences
Estates &
Facilities
M edicine &
Emergency
Care
Nursing
Outpatients
Services
Surgical
Specialties
Wo men's A nd
Children's
Other
A pril
5
16
4
48
7
14
62
26
9
M ay
10
13
4
58
11
12
78
24
10
June
6
13
4
73
9
19
70
20
13
July
13
11
4
36
11
16
65
11
18
A ugust
16
8
10
31
12
21
72
15
9
September
14
13
3
52
6
25
83
25
13
There has been a considerable increase in the number of contacts in September, 234, (184 in August), relating to the majority of directorates. The Directorate of Surgery continues to be the area involved in the greatest number of issues, with 83 contacts in September, with the Directorate of Medicine and Emergency Care also showing a marked increase with 52 contacts in September (31 in August).
40
Section D: Patient experience – Comment Cards / NHS Choices
"Get It Right" Comment Cards by Category
September 2010
•
•
•
3
1
Plaudits
2
Staff Attitude
Medical treatment
20
•
The number of comment cards received increased slightly with 26 in September (22 in August). The highest number of cards received were plaudits (76.92%). All comment cards are entered onto a central database for collation with existing Patient Experience reports.
All cards have been responded to where it is requested, all concerns and comments are responded to and in every case, brought to the attention of the clinical directorates. Any action taken and the outcome is monitored by the Directorate of Nursing Quality Facilitator. Any significant trends or issues are discussed at the PECL Group. Other
"Get It Right" Comment Cards
September 2010 (By Directorate)
NHS CHOICES During September, 4 comments were posted on the NHS Choices website, containing negative comments. 4%
CTC
0%
19%
Clinical Sciences
Medicine & Emergency Care
0%
Outpatients
Surgical Services
58%
15%
Women & Children's
4%
Comments relating to services provided on a Trust site by the PCT are forwarded to the PCT Patient Experience Team. Other/Unspecified
Comments continue to be logged by the Directorate of Nursing Quality Facilitator, however as it is not always possible to identify a particular service, ward or department, it has been agreed that all NHS Choices notifications will be forwarded to all Clinical General Managers. Details of any action taken should be forwarded to the Directorate of Nursing Quality Facilitator, and the Communications Team.
41
Section D: Patient experience – Plaudits
It is recognised that plaudits from patients/relatives/carers are a good indicator that the service provided by the Trust is meeting service user needs and expectations.
The common themes in the formal plaudits to date are related to thanking staff for the care and attention received.
The number of formal plaudits reduced with 17 received in September (35 in August), however the year to date figure is 38% higher than for the same period in 2009/10.
•
Formal Plaudits
(Data source: PET Office)
40
35
•
30
25
2009/10
20
2010/11
15
•
10
5
Apr
May
Jun
Jul
Aug
Sep
All plaudits recorded *Formal plaudits received in PET (acknowledged by Chief Executive)
Plaudits via Comment Cards
No. of plaudits compliments received in PALS
No of plaudits received on wards/depts
No of positive comments posted on NHS Choices
Totals
September 2010
17
19
3
106*
0
145
≠This figure is reliant on the wards sending totals to the Nursing Directorate Quality Facilitator and does not indicate a downward or upward trend.
•
•
It was reported in the March Performance Report that from April 2010, all plaudits would be reported including those received via the Patient Experience Team (PET) Office, “Get It Right” Comment Cards, PALS contacts and also plaudits received on the wards. Wards have been asked via their PECL representatives to submit the number of plaudits received on wards so that these can be added to the total plaudits received and also shown on the monthly ward metrics. It was reported in the April report that positive comments posted on the NHS Choices website would be included in this section.
In order to monitor the comparison of formal plaudits received at the Trust, the chart below will be continued to track the year on year increase: *Formal Plaudits
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2010/11
32
33
21
33
35
17
2009/10
17
9
15
20
19
26
22
12
27
25
11
16
2008/09
12
8
2
20
17
7
27
23
38
18
26
14
Total
171
219
42
212
Section D: Patient experience – Patient Experience Tracker The overall response rate during September was 3,878 which is above the target response rate of 3,500. This is the fourth consecutive month since the implementation of the Patient Tracker that responses have exceeded the target. Wards and departments have been complimented for this achievement.
For September, the overall patient satisfaction score was 88% against a target of 90%.
Responses to the question, “Would you recommend this Hospital?”, has been consistently high since it was introduced. The positive score for September was 96%.
During September, 19% of patients reported that they were disturbed by noise at night, this is slight increase on last month (18%). 78% of patients in September responded they were satisfied with the food provided. This question is being tracked in order to compare results when the Steam Cuisine catering arrangements are introduced later this year. •
Patient Tracker Satisfaction Scores (all questions)
(data source: Dr Foster Intelligence PET 3.0)
2009/10
92%
90%
88%
86%
84%
82%
80%
78%
76%
•
2010/11
•
Apr May Jun
Jul
Aug
Sep
Oct Nov Dec
Jan
Feb Mar
Performance
Improvement
Trajectory
•
•
Patient Tracker Satisfaction Scores (all questions)
(data source: Dr Foster Intelligence PET 3.0)
2009/10
92%
90%
88%
86%
84%
82%
80%
78%
76%
Are you bothered by noise at night by hospital staff?
(data source: Dr Foster Intelligence PET 3.0)
2010/11
25%
20%
10%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
0%
Oct‐10
5%
Sep‐10
Feb Mar
Aug‐10
Jan
Jul‐10
Oct Nov Dec
Jun‐10
Aug Sep
May‐10
Jul
15%
Apr‐10
Apr May Jun
Performance
Improvement
Trajectory
Would you recommend this Hospital?
(data source: Dr Foster Intelligence PET 3.0)
Were you satisfied with the food?
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
43
May‐10
100%
95%
90%
85%
80%
75%
70%
65%
60%
Apr‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
Apr‐10
(data source: Dr Foster Intelligence PET 3.0)
100%
95%
90%
85%
80%
75%
70%
65%
60%
Section E: Efficiency & Effectiveness – Finance Overview
Annual Plan:
Year to date:
FY Forecast:
3
3
3
3
= Regulatory concerns in one or more components.
Significant breach of Terms of Authorisation is unlikely.
For more detail see Appendix
Key Points
• Net I&E position £0.2m deficit in September, with £0.6m deficit year to date
• Full year forecast has deteriorated to reflect £1.0m deficit at year end
• £5.9m CIP delivered against plan of £7.1m
• A Financial Recovery Plan has been instigated.
Financial Summary
Year to Date
Total Operating Income
Total Operating Expenditure
EBITDA
Net Surplus/(Deficit)
CIP Achieved
Full Year Forecast
Actual
Budget
Var.
Forecast
Budget
Var.
£m
£m
£m
£m
£m
£m
130.6
131.1
(0.5)
263.8
261.4
2.4
(122.6)
(121.1)
(1.5)
(247.2)
(242.5)
(4.7)
8.0
10.0
(2.0)
16.5
18.9
(2.4)
(0.6)
1.2
(1.8)
(1.0)
1.0
(2.0)
5.9
7.1
(1.1)
14.5
15.2
(0.7)
Actual Q2 Monitor Return
Net Cash Inflow/(Outflow)
11.6
6.8
4.9
0.1
(4.9)
5.0
• Net I&E position £0.6m deficit YTD
• Financial Risk Rating: 3
Cash at End of Period
32.7
27.7
5.0
21.0
15.9
5.1
Capital Spending
(9.7)
(12.9)
3.2
(22.2)
(30.3)
44
8.1
Section E: Efficiency & Effectiveness – Full Year Financial Forecast
Total Trust ‐ Full Year Forecast
Full Year Forecast by Directorate
At Month 6 the full year forecast is for a £1.0m deficit, £2.0m worse Forecast
Full Year
Actual
£m
Full Year
Budget
£m
Forecast
Full Year
Variance
£m
Protected and Other Income
234.3
233.0
1.3
Accident and Emergency
Outpatient Services
Women and Children Services
Medicine
Surgery
Trauma and Orthopaedics
Clinical Sciences
Critical Care
Cardiothoracic Centre
Corporate Directorates
Reserves
(6.7)
(8.5)
(23.9)
(36.1)
(25.3)
(8.8)
(28.8)
(8.9)
(27.9)
(43.8)
0.8
(6.0)
(7.5)
(21.7)
(34.0)
(24.4)
(8.2)
(26.7)
(8.6)
(28.4)
(42.5)
(6.1)
(0.7)
(1.0)
(2.2)
(2.0)
(0.8)
(0.6)
(2.1)
(0.3)
0.6
(1.4)
6.9
16.6
18.9
(2.3)
Non Operating Items
(17.5)
(17.9)
0.3
Net Surplus/(Deficit)
(1.0)
1.0
(2.0)
than plan
The forecast has deteriorated since month 5 from breakeven to a £1.0m deficit. This is due to a significantly worse performance in September than planned.
Directorate Commentary ‐ Full Year Forecast
• Clinical Sciences are forecasting a £2.1m overspend driven by non pay pressures across all of the specialities.
• Medicine are forecasting an expenditure variance against budget, with a forecast £2m overspend, driven by medical staffing and nursing overspends. • Women & Children forecast overspend of £2.2m is due to agency medical and nursing usage.
• Corporate Directorates forecast overspend is driven by non pay costs, particularly anticipated in estates over the winter season
• Cash position year end forecast of £21.0m
EBITDA
45
Section E: Efficiency & Effectiveness – Activity and Income (1)
Detailed clinical income by point of delivery, and by directorate, is shown in the appendices.
Elective Inpatients – September elective activity was 19 spells (3%) behind plans, but due to a CTC elective over Point of Delivery - Activity
Full Year
Activity
Plan
YTD
Actual
YTD
YTD
Variance Variance
to Budget to Profiled
on 12ths
Budget
performance against plan in September,
income is above plan YTD by £181k. YTD CTC elective activity remains behind the activity plan by 32 cases, worth £735k, predominantly in cardiothoracic surgery, which largely explains the Trust wide elective income deficit of £722k. Key activity variance is in Surgery and 7,326
23,716
41,062
297,744
24,629
93,487
Elective Inpatient (Spells)
Day Case (Spells)
Non-Elective (Spells)
Outpatients (Atts)
Outpatient Procedures
Accident & Emergency (Atts)
3,525
12,817
19,761
152,162
13,427
37,513
(138)
959
(770)
3,290
1,113
(9,231)
(253)
824
(770)
3,898
1,163
(9,230)
T&O (58 cases), caused by the theatre power outage. YTD Surgery and T&O are both behind plan on activity by 231 cases, but income only behind plan by £5k.
Day cases – Activity was up again against plan 6% (127 spells) in September. Income broke even against plan in the month, suggesting that the high volume of procedures were a weaker case mix than planned. CTC continues to be behind plan for cardiology, 135 cases YTD resulting in a £627k income variance. YTD income remains ahead of budget and therefore makes up some of the shortfall in inpatient elective income.
46
Section E: Efficiency & Effectiveness – Activity and Income (2)
Non‐Elective Inpatients – The Trust has lost £826k Point of Delivery - Income
of income YTD due to the 30% threshold of payment on activity above the 08/09 threshold. This rate of loss will accelerate going into the Current
Month
Actual
£'000
Full Year
Budget
£'000
Month
Var. to
Budget
£'000
YTD
Actual
£'000
YTD
Var. to
Budget
£'000
winter unless the Trust takes action to reduce admissions. Non‐elective activity was 5% behind plan in the month, and 4% behind plan YTD. This predominantly driven by underperformance in obstetrics which is outside of the threshold, and makes up £499k of the £496k income under recovery in September. YTD Medicine has over 26,271
21,780
81,463
32,013
10,070
984
172,580
Elective
Day Case
Non Elective
Outpatients
Accident & Emergency
Partially Completed Spells
CTC Transitional Funding
Total Mandatory
2,380
1,863
6,292
2,826
815
(67)
82
14,193
181
(27)
(496)
38
(24)
(67)
(395)
12,845
11,335
40,156
16,234
5,032
52
492
86,145
(703)
321
(575)
291
(3)
52
(617)
1,055
1,483
3,307
(9)
(209)
454
6,215
8,947
17,280
127
(1,207)
437
performed on income by £403k, 86 cases ahead of plan, but management of this activity is a key priority, due to the 30% threshold. Medicine lost 12,224
20,308
34,416
Outpatients (incl. procedures)
Critical Care
Other Non- Mandatory
£503k of the £826k adjustment.
Outpatients – First attendances were behind plan in September by 7%, delivering income below 239,529
Total Protected Income
20,038
(159)
118,587
(1,261)
1,740
20,134
261,403
Non-Protected
Other Income
Total Income
248
1,882
22,168
103
131
74
1,218
10,767
130,572
348
408
(505)
plan of 4%. Follow up activity remained above plan by 2% trend, with income up by 5%. YTD higher follow up income is offsetting lower first attendance activity and income, which is not in line with commissioner requirements. Furthermore, moving the activity focus from follow ups to firsts would also be financially advantageous to the Trust.
Critical Care – Income was £209k lower than plan in September due to underperformance in the CTC. CTC Critical Care is £739k behind plan YTD, due to the lower than planned levels of cardiothoracic surgery.
Other Non‐Mandatory – Income was £454k above plan in the month largely driven by release of YTD provision. GO Direct Access, excluded drug and devices, and renal were all above plan in September
Non‐Protected – Income was £103k better than budget in the month due to higher RTA income in A&E. 47
Section E: Efficiency & Effectiveness – Expenditure
Total pay expenditure was £417k (3%) overspent in September before the release of reserves, worth £251k. Medical staffing expenditure was overspent in September by £230k with a £1,228k overspend YTD. Medical Staffing agency expenditure was £362k in September, and £2903k YTD. Medical Staffing key over spends in September:
Medicine
£83k
A&E
£75k
T&O
£31k
Anaesthetics
£50k
Outpatients
£60k
Where agency staff are used for vacant posts, only programmed activities should be covered so that the agency premium is absorbed by SPA costs included within budgets.
Nursing expenditure has remained at a lower level throughout September. Women & Children directorate had the largest nursing overspend in September (£100k), and this was caused by £97k expenditure on Agency, despite lower levels of activity/income. The key challenge remains maintaining or reducing this lower level of expenditure through the winter months.
Clinical Supplies expenditure was £2,602k in September, the highest month so far YTD, causing an overspend of £295k. This was due to increased expenditure on Medical and Surgical Equipment across the Trust. 48
Section E: Efficiency & Effectiveness – Directorate Performance
The table facing adjusts clinical income Indicative Directorate Performance
variances against budget to reflect the I&E
Variance
£'000
extent to which directorates can reasonably be expected to reduce cost when income is lower, or incur more cost when income and activity is higher – 50% of cost is assumed as fixed, and 50% variable on activity levels. The resultant Directorate Variance gives indicative performance versus the directorate budgets set for the Trust to meet its financial targets. Accident and Emergency
Outpatient Services
Women and Children Services
Medicine
Surgery
Trauma and Orthopaedics
Clinical Sciences
Critical Care
Cardiothoracic Centre
Key issues for Red rated directorates, or those with 3 consecutive months of falling performance, are detailed below.
Clinical
Income
Variance
(Adjusted)
£'000
(391)
(396)
(819)
(1,371)
(193)
(369)
(854)
(218)
812
(3,800)
Central Performance Variance Adjustment
Corporate Over/(Under) Performance
Other Income Over/(Under) Performance
Reserves
EBITDA Variance
50
102
(717)
502
(42)
230
391
159
(1,281)
(606)
Indicative
Directorate Performance
Variance
Rating
Jul Aug Sept
£'000
(341)
(294)
(1,536)
(870)
(235)
(139)
(462)
(59)
(469)
(4,406)
(671)
(581)
82
3,576
(2,000)
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ÐR
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ÐG
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ÏG
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ÎG
ÏG
ÎR
ÐR
ÎA
ÏG
ÏA
ÏG
ÏG
ÏG
Ï
Î
Ð
Î
Ï
Î
Ï
Ï
Ï
R
R
R
A
A
A
A
A
A
G
R
R
G
R
G
G
R
A
A
A ÎA ÎR Ð
KEY ISSUES
Women & Children – High use of agency doctors across W&C, and high levels of temporary agency nursing across obstetrics. Income/activity in obstetrics continues to be significantly behind plan, and cost reductions to mitigate this are required.
Outpatients – High usage of agency and locum Consultants, which are not fully offset by the over recovery of income.
Accident and Emergency – High use of Medical agency staffing is not fully offset by over‐recovery of income. Recruitment into substantive middle grade posts has slipped, but should be fully established by the beginning of December.
49
Section E: Efficiency & Effectiveness – CIP
Year to date the Trust has achieved £5.9m CIP savings, compared to a target of £7.1m. YTD £1.6m of the CIP is due to reduction in pay costs , however, there are still significant pay CIPs to be achieved around the usage of medical agency.
With the growth in non‐pay expenditure in September clinical supplies CIP is now forecasting a £0.4m deficit at year end. Income generation CIPs continue to be forecast at a £0.5m deficit at year end, largely due to the CTC under performance on income.
At month 6 the risk‐weighted full year forecast CIP delivery is £13.3m against a target of £15.2m (see appendix for risk weighted forecast). The forecast still includes £2.6m of schemes rated as amber risk, but with only £0.2m rated as a red risk. The forecast full year CIP before risk adjustment is £14.5m, £0.7m short of target.
Shortfalls in CIP achievement are largely explained by slippage in the implementation timing of savings, and therefore the recurrent A number of additional CIPs have been identified in September, involving 12 new schemes, with a forecast saving of £0.7m in this financial year.
Quality assessment of all CIP schemes is shown on the dashboard, and 21 schemes will deliver improved quality. • Of the five schemes awaiting quality assessment three of these relate to generalised non‐pay savings. Each non‐pay saving suggested will have a quality assessment undertaken on an individual basis.
• All clinical directorates have Resource Efficiency Groups set up to bring together staff at all levels, from clinician to ward hostess, with the procurement team to identify smarter purchasing options, more efficient ways of working and ensure quality is maintained/improved in all changes.
• The new CIP schemes have no impact on patient quality.
position will be unaffected. Several central non‐recurrent items are held to offset these slippage gaps.
50
Section E: Efficiency & Effectiveness – Cash Management
The overall cash variance this month was £4,996k higher than plan although there were some larger variances in specific items that are noted below.
Debtors
£2.8m not invoiced to Specialist Commissioning as the contract had not been agreed. Contract negotiations have finished and this will be addressed in October..
£0.7m other timing differences.
Creditors
£2.0m difference in plan and actual due to accruals for un invoiced costs
£1.6m re pharmacy GRNI due to issues with the new Cash Balance Variances
YTD pharmacy system leading to a delay in invoices being £’000
available to pay.
£2.0m increase in accruals against planned movement.
Cash balance per Budget
£0.7m re agency invoices delayed payments due to queries EBITDA
being raised.
Stock
£0.9m other timing differences. Debtors
Capital
Capital spending is £3.2m behind plan YTD. For further details on the capital programme, see the Look and Feel section.
The Balance Sheet and Cash Flow Statement are shown in the appendices.
£’000
27,663
(2,000)
246
(3,504)
Creditors
7,172
Net Operating Cash flow variance
1,914
Capital Expenditure
3,165
Other
Net cash inflow/(outflow) variance
Actual cash balances
(83)
51
4,996
32,659
Section E: Efficiency & Effectiveness – Financial Risk
The key risks to achieving the financial plan in 2010/11 are:
• PCT Turnaround programme.
• Non‐delivery of the Financial Recovery Plan. • Failure of PCT to pay for activity due to cash flow problems;
• Medical non‐elective patient outliers reducing capacity for elective work;
• The PCT decommissioning significant elements of activity, in year, and into 2011/12;
• Directorates failing to implement their cost improvement plans resulting in significant over spends;
• The Trust reducing activity but not reducing costs to offset the loss of income;
• Failure to achieve the internal activity plan within the bed capacity constraints;
• Failure to avoid financial risk imposed by the PCT in commissioning negotiations;
• Failure to deliver the requirements of CQUIN and thus not receiving the 1.5% payment;
• Not meeting the new contract requirements and receiving penalties;
• Failure to record all clinical activity accurately;
• Meeting the quality and accuracy of coding required by the new contract and PCT commissioning team;
• Double running costs on the recruitment of overseas nurses.
Mitigation and Recovery Plan
• Slippage of capital programme to mitigate PCT cash flow problems;
• Weekly metrics review of pay and activity, with Chief Executive, Acting Director of Finance, Clinical General Managers and Director of Operations and Service Development;
• Monthly performance review meetings with each directorate;
• Fortnightly CIP review meetings;
• CIP dashboard with workbook and milestones for all schemes;
• Weekly Vacancy Control Group reviewing all posts for recruitment;
• Overseas recruitment plan for medical staff vacancies;
• Increased sign‐off control for expenditure;
• Management of unauthorised and authorised absence;
• Controls over bank and agency usage;
• Utilisation of outpatient clinic space;
• Utilisation of theatre sessions;
• CTC activity recovery plan agreed from September 2010;
• Increased directorate KPI’s to monitor performance;
• Action plan to reduce directorate/corporate overheads.
52
Section E: Efficiency & Effectiveness – I&E Statement
Full Year
Month
Plan
Budget
Actual
£'000
£'000
£'000
£'000
Year to Date
Budget Variance
£'000
Actual
Budget Variance
£'000
£'000
£'000
INCOME
240,320
239,529
20,038
20,197
118,587
119,848
1,740
1,740
Protected activities
Non-protected activities
248
145
(159)
103
1,218
870
(1,261)
348
19,672
20,134
Other operating income
1,882
1,751
131
10,767
10,359
408
261,733
261,403
22,168
22,093
74
130,572
131,077
(505)
(165,301)
(164,366)
(13,072)
(13,692)
620
(77,371)
(82,167)
(109)
(373)
(828)
(42)
(786)
(6,027)
(314)
(5,713)
(165,410)
(164,739)
(13,900)
(13,734)
(166)
(83,398)
(82,481)
(918)
(12,823)
(13,003)
Drugs
(1,320)
(1,161)
(158)
(7,133)
(6,798)
(336)
(30,061)
(28,952)
Clinical Services (excl. drugs)
(2,602)
(2,307)
(295)
(14,408)
(13,795)
(613)
(34,522)
(35,807)
Other Non-Pay (excl. depreciation)
(3,152)
(3,037)
(115)
(17,630)
(18,001)
371
(39,171)
(38,594)
(578)
(122,570) (121,074)
(1,495)
PAY
NHS
Non-NHS
4,796
NON-PAY
(77,406)
(77,761)
(242,816)
(242,500)
18,917
18,903
(11,057)
(11,057)
(850)
450
(850)
464
(6,440)
(6,440)
1,020
1,020
(402)
(402)
618
618
Total Expenditure
EBITDA
Depreciation
(7,074)
(6,506)
(568)
(20,974)
(20,240)
(735)
1,193
1,853
(660)
8,002
10,002
11
(5,376)
(5,411)
(894)
Profit/(loss) on disposal
Interest Payable
Interest Receivable
Capital dividends payable
Net surplus/(deficit)
Asset Impairment
Retained surplus/(deficit)
(115)
(905)
(71)
(44)
23
39
(16)
(397)
(537)
140
(190)
380
(570)
(190)
380
(570)
(302)
136
(3,082)
(622)
(622)
(425)
232
(3,220)
1,178
1,178
(2,000)
35
123
(96)
138
(1,799)
-
53
(1,799)
Section E: Efficiency & Effectiveness – I&E Run Rate
09/10
INCOME
Protected activities
Non-protected activities
Other operating income
PAY
NHS
Non-NHS
NON-PAY
Drugs
Clinical Services (excl. drugs)
Other Non-Pay (excl. depreciation)
Total Expenditure
EBITDA
Depreciation
Profit/(loss) on disposal
Interest Payable
Interest Receivable
Capital dividends payable
Net surplus/(deficit)
10/11
Q1 Ave
Actual
Q2 Ave
Actual
Oct
Actual
Nov
Actual
Dec
Actual
Jan
Actual
Feb
Actual
Mar
Actual
FY
Actual
Apr
Actual
May
Actual
Jun
Actual
Jul
Actual
Aug
Actual
Sep
F'cast
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
19,262
154
1,915
21,331
19,539
193
1,865
21,597
19,676
165
1,934
21,774
19,178
197
1,988
21,362
19,942
157
2,062
22,160
20,103
112
2,044
22,258
20,493
197
2,164
22,855
21,619
218
2,246
24,084
237,416
2,084
23,776
263,276
19,778
124
1,696
21,598
19,797
173
1,758
21,728
19,673
227
1,798
21,698
19,494
196
1,873
21,563
19,807
250
1,761
21,818
20,038
248
1,882
22,168
(12,080) (12,252) (12,488) (12,640) (12,549) (12,889) (12,557) (12,897)
(1,088) (1,027) (1,130) (1,225) (1,445) (1,361) (1,290) (1,491)
(13,169) (13,280) (13,618) (13,865) (13,994) (14,250) (13,847) (14,388)
(149,018)
(14,287)
(163,306)
(12,783) (12,853) (12,783) (12,802) (13,078) (13,072)
(1,112) (1,149) (1,152)
(972)
(814)
(828)
(13,895) (14,002) (13,935) (13,774) (13,892) (13,900)
(1,020) (1,051) (1,184) (1,147) (1,249) (1,312) (1,161) (1,511)
(2,338) (2,436) (2,546) (2,661) (2,539) (2,203) (2,336) (2,755)
(2,902) (2,939) (3,378) (3,114) (3,657) (3,584) (3,696) (3,858)
(6,260) (6,426) (7,108) (6,922) (7,445) (7,098) (7,193) (8,124)
(19,428) (19,705) (20,726) (20,787) (21,439) (21,348) (21,039) (22,512)
(13,775)
(29,363)
(38,808)
(81,946)
(245,252)
(1,312) (1,066) (1,365)
(862) (1,208) (1,320)
(2,335) (2,541) (2,586) (2,124) (2,220) (2,602)
(2,955) (3,038) (2,374) (3,098) (3,013) (3,152)
(6,602) (6,645) (6,325) (6,083) (6,442) (7,074)
(20,497) (20,647) (20,261) (19,857) (20,333) (20,974)
1,902
1,891
1,048
575
722
910
1,816
1,572
18,024
1,101
1,081
1,437
1,706
1,484
1,193
(931)
(39)
16
(539)
(942)
(0)
(51)
20
(539)
(953)
(39)
16
(539)
(953)
(38)
19
(539)
(954)
(39)
28
(539)
(992)
(37)
24
(149)
(767)
(37)
1
(500)
(979)
78
(38)
13
(448)
(11,217)
78
(496)
210
(5,948)
(898)
(37)
3
(537)
(898)
(38)
45
(537)
(899)
(37)
16
(537)
(894)
(37)
28
(537)
(894)
(38)
22
(537)
(894)
(115)
23
(397)
411
380
(467)
(936)
(782)
(244)
513
197
651
(368)
(348)
(20)
266
38
(190)
54
Section E: Efficiency & Effectiveness – Directorate I&E
Full Year
Current Period
Budget
£'000
239,529
5,283
244,812
Actual
£'000
Central Income
Protected Activities
Unprotected Activities
Other Operating Income
Total Central Income
Budget
£'000
Year to Date
Variance
£'000
Actual
£'000
Budget
£'000
Variance
£'000
20,038
435
20,473
20,197
441
20,638
(159)
(6)
(165)
118,587
2,726
121,313
119,848
2,644
122,492
(1,261)
82
(1,179)
(571)
(883)
(1,972)
(3,204)
(2,059)
(765)
(2,583)
(918)
(2,912)
(15,867)
(490)
(806)
(1,820)
(2,953)
(2,018)
(699)
(2,447)
(811)
(2,689)
(14,731)
(82)
(77)
(152)
(252)
(42)
(67)
(137)
(107)
(223)
(1,137)
(3,498)
(5,144)
(11,764)
(18,849)
(12,817)
(4,401)
(15,338)
(5,085)
(15,407)
(92,304)
(3,106)
(4,749)
(10,945)
(17,478)
(12,624)
(4,032)
(14,485)
(4,867)
(16,219)
(88,504)
(391)
(396)
(819)
(1,371)
(193)
(369)
(854)
(218)
812
(3,800)
(361)
(933)
(94)
(594)
(1,499)
(271)
(111)
451
(3,412)
(391)
(842)
(76)
(590)
(1,299)
(257)
(146)
(453)
(4,053)
30
(91)
(18)
(4)
(201)
(14)
35
904
641
(1,976)
(5,434)
(487)
(3,451)
(7,988)
(1,775)
(811)
915
(21,007)
(1,959)
(5,056)
(458)
(3,519)
(7,756)
(1,716)
(876)
(2,645)
(23,985)
(16)
(378)
(29)
68
(231)
(59)
65
3,560
2,979
1,193
1,853
(660)
8,002
10,002
(2,000)
Directorate I&E
(6,044)
(9,364)
(21,864)
(35,112)
(24,731)
(8,223)
(28,706)
(9,731)
(33,612)
(177,386)
(3,874)
(10,109)
(914)
(7,018)
(16,018)
(2,774)
(1,750)
(6,065)
(48,523)
18,903
Accident and Emergency
Outpatient Services
Women and Children Services
Medicine
Surgery
Trauma and Orthopaedics
Clinical Sciences
Critical Care
Cardiothoracic Centre
Total Clinical
Directorate Of Finance
Operations & Service Development
Training & Education
Directorate Of Nursing
Estates & Facilities
Board
Personnel
Reserves
Total Corporate
EBITDA
55
Section E: Efficiency & Effectiveness – Clinical Income by Directorate
Full Year
Current Period
Budget
£'000
10,131
10,375
39,553
53,702
29,839
23,311
14,286
10,661
46,726
3,587
242,172
Actual
£'000
Accident and Emergency
Outpatient Services
Women and Children Services
Medicine
Surgery
Trauma and Orthopaedics
Clinical Sciences
Critical Care
Cardiothoracic Centre
C‐QUIN Income
Total Clinical
Year to Date
Budget Variance
£'000
£'000
Actual
£'000
Budget Variance
£'000
£'000
840
982
2,672
4,807
2,409
1,976
1,478
1,068
3,428
288
19,951
844
922
3,329
4,513
2,538
1,978
1,270
900
3,823
299
20,417
(4)
60
(657)
294
(129)
(2)
208
168
(395)
(11)
(467)
5,166
5,445
18,372
27,867
14,932
12,235
8,089
5,651
20,406
1,729
119,892
5,066
5,241
19,805
26,864
15,017
11,775
7,306
5,334
22,969
1,793
121,169
100
204
(1,433)
1,003
(85)
460
783
317
(2,562)
(64)
(1,277)
29
984
(3,656)
(2,643)
Personnel
CTC Transitional Funding
Reserves
Total Corporate
2
82
3
87
2
82
(305)
(220)
(0)
307
307
14
492
(1,812)
(1,306)
14
492
(1,828)
(1,322)
(0)
16
16
239,529
Total Protected Income
20,038
20,197
(159)
118,587
119,848
(1,261)
56
Section E: Efficiency & Effectiveness – Clinical Income by POD
Full Year
Current Period
Budget
£'000
Actual
£'000
Year to Date
Budget Variance
£'000
£'000
Actual
£'000
Budget Variance
£'000
£'000
26,271
21,780
81,463
Elective
Day Case
Non Elective
2,380
1,863
6,292
2,199
1,890
6,789
181
(27)
(496)
12,845
11,335
40,156
13,548
11,014
40,731
(703)
321
(575)
16,313
15,699
32,013
Outpatients - 1st
Outpatients - Follow Up
Total Outpatients
1,371
1,455
2,826
1,421
1,367
2,788
(49)
87
38
7,999
8,235
16,234
8,124
7,818
15,942
(125)
417
291
10,070
984
172,580
Accident & Emergency
Partially Completed Spells
CTC Transitional Funding
Total Mandatory
815
(67)
82
14,193
839
82
14,587
(24)
(67)
(395)
5,032
52
492
86,145
5,035
492
86,763
(3)
52
(617)
6,931
20,308
5,238
6,547
8,023
4,201
3,955
5,412
6,885
3,587
(4,137)
66,949
GP Direct Access
Critical Care
Excluded Drugs
Excluded Devices
Outpatients - Attendances
Outpatients - Procedures
Community Midwifery
Renal
Other Non-Mandatory
C-Quin Income
Reserves
Total Non-Mandatory
661
1,483
560
465
686
369
330
465
581
288
(42)
5,845
578
1,692
526
440
699
366
330
451
574
299
(345)
5,610
83
(209)
33
25
(13)
3
14
7
(11)
303
235
3,781
8,947
2,839
2,612
3,955
2,260
1,977
2,869
3,539
1,729
(2,068)
32,441
3,465
10,154
2,843
2,681
3,996
2,092
1,977
2,706
3,446
1,793
(2,069)
33,085
316
(1,207)
(3)
(69)
(41)
168
163
93
(64)
1
(644)
239,529
Total Protected Income
20,038
20,197
(159)
118,587
119,848
(1,261)
57
Section E: Efficiency & Effectiveness – Balance Sheet
March 2011
Plan
Current Period
Budget
£'000
£'000
210,250
210,250
15,889
15,889
12,975
12,975
28,864
28,864
22,040
22,040
6,824
6,824
217,074
217,074
22,431
22,431
194,643
194,643
114,176
114,176
53,153
53,153
1,153
1,153
26,161
26,161
194,643
194,643
194,643
194,643
Actual
Mar 10
Budget Variance
£'000
£'000
195,230
199,307
(4,076)
191,896
32,659
27,663
4,996
20,924
Other current assets
13,980
11,117
2,863
19,000
CURRENT ASSETS
46,640
38,780
7,860
39,924
CURRENT LIABILITIES, due within one year
28,028
22,538
5,491
27,079
Net current assets/(liabilities)
18,612
16,243
2,369
12,845
Total assets less current liabilities
213,842
215,549
(1,708)
204,741
20,259
20,238
193,582
195,311
114,176
114,176
0
114,176
53,153
53,153
-
53,153
1,332
1,261
71
1,370
24,921
26,720
(1,799)
25,543
193,582
195,311
(1,729)
194,242
193,582
195,311
(1,729)
194,242
-
-
NON-CURRENT ASSETS
Cash NON-CURRENT LIABILITIES, due after one year
Total assets employed
Public dividend capital
Revaluation reserve
Donated asset reserve
Income & expenditure reserve
TAXPAYER'S EQUITY
Total funds employed
£'000
Actual
£'000
21
(1,729)
10,499
194,242
FINANCING FACILITIES
-
-
16,000
16,000
16,000
16,000
NHS
Non-NHS
Total committed and unused financing facilities
-
-
16,000
16,000
-
16,000
16,000
16,000
-
16,000
58
Section E: Efficiency & Effectiveness – Cash Flow Statement
Full Year
Month
Plan
Budget
Actual
£'000
£'000
£'000
18,917
18,903
(217)
(53)
(217)
(53)
EBITDA
Budget Variance
£'000
1,193
Transfers from reserves
Stocks
Year to Date
(18)
£'000
1,853
(18)
Actual
Budget Variance
£'000
(660)
(0)
8,002
(111)
£'000
£'000
10,002
(2,000)
(111)
426
0
426
192
6,445
6,445
Debtors
2,916
68
2,848
4,782
8,286
(3,504)
(5,519)
(5,519)
Creditors
1,748
(119)
1,868
2,054
(4,993)
7,047
(1)
(1)
Provisions
Net operating cash flow
19,572
19,558
(30,298)
(30,298)
(167)
(154)
(10,894)
(10,894)
(6,440)
(6,440)
Capital dividends paid
(0)
PDC received/(repaid)
12,386
12,386
(4,948)
(4,948)
Capital expenditure
Net interest received/(paid)
Net cash flow before financing
Net Loans received/(repaid)
Net movement in cash
-
-
-
6,265
1,784
4,481
(2,083)
(2,881)
(89)
12
798
(101)
4,092
(1,085)
5,177
(3,220)
(3,222)
2
(15)
(53)
(0)
(1)
246
(14)
14,904
13,130
1,774
(9,706)
(12,871)
3,165
(167)
(52)
5,031
(3,220)
207
(115)
4,824
(3,220)
-
(0)
0
-
-
-
-
1,600
1,568
32
9,825
9,793
32
2,472
(2,739)
5,211
11,636
6,780
4,856
59
Section E: Efficiency & Effectiveness – Monitor Financial Risk Rating
Based on financial performance metrics, Monitor allocate foundation trusts a finance risk rating between 1 and 5, where 1 is highest financial risk and 5
is lowest. The finance risk rating is made up of five components, with the Trust’s YTD and forecast position as follows:
Financial Risk Rating
Metric
EBITDA Margin
EBITDA, % Achieved
ROA
I&E Surplus Margin
Liquid Ratio
Weighted Average
Criteria
Underlying Performance
Achievement of Plan
Financial Efficiency
Financial Efficiency
Liquidity
YTD
Actual
Rating
6.1%
3
78.9%
3
2.4%
2
-0.5%
2
43.4
4
2.9
Forecast Full Year
Actual
Rating
6.3%
3
87.5%
4
2.5%
2
-0.4%
2
47.4
4
3.0
Current Risk Ratings:
Weight
5
4
25%
11%
9%
10%
100%
85%
20%
6%
5%
20%
3%
2%
25%
60
25
100%
3
5%
70%
3%
1%
15
2
1%
50%
-2%
-2%
10
1
<1%
<50%
< -2%
< -2%
<10
Weighted Average Risk Rating Definitions
Rating 5 - Low est risk - no regulatory concerns
Rating 4 - No regulatory concerns
Rating 3 - Regulatory concerns in one or more components. Significant breach of Terms of Authorisation is unlikely
Rating 2 - Risk of significant breach in Terms of Authorisation in the medium term, e.g. 9 to 18 months in the absence of remedial action
Rating 1 - Highest risk - high probability of significant breach of Terms of Authorisation in the short-term, e.g. less than 9 months, unless remedial action is taken
Over-riding Monitor Metric Rules
The overall risk rating is a w eighted average of the five metrics, but there are four rules that overide this average:
1. If any one metric is ranked at 1 or 2 than the maximum Trust rating is 3
2. If any 2 metrics are ranked at 1 or 2 then the maximum Trust rating is 2
3. If any 2 metrics are ranked at 1 then the maximum Trust rating is 1
4. If any metric is ranked at 1 then the maximum Trust rating is 2
NB For the pupose of these over-riding rules, the ROA and I&E Surplus metrics are averaged together, leaving a total of 4 metrics against w hich these rules are tested
Glossary of term s
EBITDA
EBITDA
EBITDA Margin
EBITDA % Achieved
Financial Efficiency
ROA
I&E Surplus Margin
Liquidity
Liquid Ratio
EBITDA is earnings before deducting interest, taxes, depreciation and amortisation. It also excludes exceptional items and dividends. It is a measure of
the performance of the "underlying business" i.e. the surplus/deficit from day to day operations and is similar to the directorate financial statements.
This is EBITDA as a percentage of total income.
This is designed to measure the ability of the Trust to achieve its financial plans. The target is therefore 100% or more.
Return on assets measures how efficiently the Trust uses its assets. It is defined as the Net Surplus before dividends as a percentage of the total assets
of the Trust.
This is the Net Surplus as a percentage of total income.
This ratio measures the Trust's ability to pay its bills from liquid assets (assets that are easily realisable), and is intended to show w hether the Trust can
continue to pay its bills in the short term. The metric show s for how many days the Trust could continue to pay its bills just using its net w orking capital.
Net w orking capital (i.e. liquid assets) consists of cash in bank and debtors due in less than one year, less creditors due in less than one year.
60
Section E: Efficiency & Effectiveness – CIP Board Dashboard
Cost Improvement Programme
Board Summary - September 2010
Reporting Month
Orig.
Target
£000
By Month
Forecast Month
April 2010
May 2010
June 2010
July 2010
August 2010
September 2010
October 2010
November 2010
December 2010
January 2011
February 2011
March 2011
Total
Weighted Risk Rating
Apr 2010
£000
1,330
981
1,025
1,222
1,246
1,250
1,336
1,326
1,336
1,381
1,401
1,407
1,213
987
1,109
1,282
1,305
1,311
1,396
1,382
1,391
1,506
1,519
2,426
15,239
16,827
Gross
Schemes
£000
Weighted
CIP
£000
May 2010
£000
Ô
Ï
Ï
Ï
Ï
Ï
Ï
Ï
Ï
Ï
Ï
Ï
1,213
791
973
1,275
1,301
1,307
1,393
1,379
1,387
1,506
1,519
2,426
Jun 2010
£000
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ï
Ô
Ô
1,213
791
1,166
975
1,098
1,128
1,276
1,286
1,295
1,446
1,438
1,941
16,469
15,053
Jul 2010
£000
Ö
Ö
Ï
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ô
1,213
791
1,166
759
1,064
1,104
1,298
1,301
1,309
1,459
1,459
1,961
14,884
Aug 2010
£000
Ö
Ö
Ö
Ô
Ô
Ô
Ï
Ï
Ï
Ï
Ï
Ï
1,213
791
1,166
759
1,152
1,033
1,168
1,173
1,210
1,401
1,429
1,952
Oct
2010
£000
Sep 2010
£000
Ö
Ö
Ö
Ö
Ï
Ô
Ô
Ô
Ô
Ô
Ô
Ô
14,447
1,213
791
1,166
759
1,152
833
1,121
1,159
1,250
1,440
1,457
2,192
14,532
Nov
2010
£000
Dec
2010
£000
Jan
2011
£000
Feb
2011
£000
Mar
2011
£000
Ö
Ö
Ö
Ö
Ö
Ô
Ô
Ô
Ï
Ï
Ï
Ï
-
-
-
-
-
-
Monthly CIP Actuals / Forecast versus Target
Prior
Month
£000
1,500 Red
Amber
Green
Blue (Delivered)
219
2,581
4,778
6,954
33 %
67 %
95 %
100 %
72
1,729
4,539
6,954
75
2,090
4,759
6,090
Weighted CIP Total
13,295
13,015
Target
15,238
15,239
Variance
(1,943)
(2,224)
(4)%
(17)%
(5)%1,400 14 %
2%
1,300 Red
1,200 Scheme Value by Risk Rating
Amber
Green
Blue (Delivered)
Monthly CIP Target
1,100 Current Monthly Forecast
Prior Monthly Forecast
1%
1,000 18%
48%
33%
900 800 61
700 Section E: Efficiency & Effectiveness – CIP Directorate Dashboard
Cost Improvement Programme
Directorate Summary - September 2010
By Directorate
Full Year
F'cast
Var
£000
£000
Target
£000
Last Mth
Mvmt
£000
F'cast
£000
Year to Date
Actual
Var
£000
£000
Target
£000
Clinical Directorates
Accident and Emergency
Outpatient Services
Women and Children
Medicine
Surgical Services
Clinical Sciences
Cardiothoracic Centre
2,365
324
1,484
2,459
1,104
989
1,636
2,145
252
801
1,728
746
703
1,334
(220)
(72)
(683)
(730)
(358)
(286)
(302)
(9)%
(22)%
(46)%
(30)%
(32)%
(29)%
(18)%
2,091
281
832
1,752
855
746
1,089
54
(29)
(31)
(24)
(109)
(43)
245
3%
(10)%
(4)%
(1)%
(13)%
(6)%
22 %
1,049
195
672
1,010
482
368
769
878
135
344
600
227
255
410
Corporate Directorates
Directorate of Finance
Planning & Service Dvlpt
Training & Education
Directorate of Nursing
Estates & Facilities
Board
Personnel
188
415
88
92
1,244
71
124
185
322
188
92
876
71
114
(3)
(93)
99
0
(368)
(10)
(1)%
(22)%
112 %
0%
(30)%
-%
(8)%
185
304
98
92
1,114
71
120
(0)
18
90
(238)
(6)
(0)%
6%
91 %
-%
(21)%
-%
(5)%
176
297
42
92
504
71
62
171
253
51
92
498
71
59
Central Schemes
2,655
4,975
2,320 87 %
4,692
283
6%
1,265
-
-
-
-
-
-%
-
15,238
14,532
(706)
14,323
210
Pay
Drugs
Clinical Supplies
Non-Clinical Supplies
Misc. Other Operating Exp.
4,469
375
2,967
794
803
3,916
492
2,572
832
1,271
(553)
117
(395)
38
468
(12)%
31 %
(13)%
5%
58 %
3,887
513
2,781
771
1,225
29
(21)
(209)
61
46
Other CIP
Clinical Coding
Income Generation
Invest to Save
Other CIP
2,005
1,548
1,339
2,121
1,098
2,085
117
(451)
746
6%
(29)%
-%
56 %
1,898
974
2,273
223
123
(188)
Unallocated
938
145
(793) (85)%
-
Total Trust
15,239
14,532
Other / Unallocated
Total Trust
-%
Quality
Impro- No
To
vement Impact Assess
(171)
(60)
(328)
(410)
(254)
(113)
(359)
Risk Rating
Red
Milestones
Comp- Over- Futleted due
ure
Amber Green Blue
(16)%
(31)%
(49)%
(41)%
(53)%
(31)%
(47)%
3
3
2
-
4
6
3
1
12
13
1
1
2
1
1
1
3
3
3
6
7
4
9
4
11
6
1
24
11
63
17
42
32
21
2
11
32
2
1
5
1
6
27
5
8
2
(5) (3)%
(44) (15)%
10 23 %
0 0%
(6) (1)%
- -%
(3) (5)%
1
1
2
1
7
9
1
2
17
2
4
-
-
2
5
-
7
8
2
2
14
2
1
4
15
9
4
5
30
2
-
8
-
1
3
5
-
1,868
603
48 %
6
40
-
2
15
24
5
-
-
-
-
-
-%
2
5
-
-
-
-
-
-
-
-
7,054
5,914
(1,140)
21
126
5
3
38
101
10
275
62
57
1%
(4)%
(8)%
8%
4%
2,095
158
1,181
335
508
1,562
154
849
384
632
(533) (25)%
(4) (3)%
(332) (28)%
49 15 %
125 25 %
5
5
1
4
28
3
13
11
31
1
4
-
1
1
-
9
1
10
3
9
23
2
12
8
26
1
-
89
9
50
7
33
9
10
2
6
4
2
17
1
2
12 %
13 %
-%
(8)%
907
729
684
894
322
1,117
(13) (1)%
(407) (56)%
- -%
433 63 %
4
1
1
12
16
11
-
1
-
1
4
1
13
12
5
2
6
15
46
2
6
9
-
11
-
145 100 %
457
-
(457) (100)%
-
1
-
-
-
-
1
24
20
20
7,054
5,914
21
126
5
3
38
101
10
275
62
57
By CIP Monitor Category
(706)
14,323
210
(1,140)
62
Section E: Efficiency and Effectiveness – Workforce
Vacancies
10.0%
8.0%
Frozen Vacancies
6.0%
Active Vacancies
4.0%
Target Vacancies
2.0%
Apr‐10
May‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
O ct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
0.0%
Staff Turnover
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
0.0%
M ar ‐1 1
F eb ‐1 1
Jan ‐1 1
D ec ‐1 0
N o v ‐1 0
O c t‐1 0
S ep ‐1 0
A u g‐1 0
Ju l‐1 0
Ju n ‐1 0
M ay ‐1 0
A p r ‐1 0
Staff Turnover
The vacancy rate for the month of September 2010 is 8.20% and the annual rate (in the 12 months to September 2010) is 9.0%. This shows a marked reduction from the previous month. Following the establishment of the vacancy control group in February 2010, the number of vacancies actively being recruited to on a weekly basis has reduced significantly. Therefore the target Since April 2010, 324 posts have been submitted to the vacancy control group for consideration. The majority of positions advertised related to clinical posts. Out of the 324 requests, 242 posts were approved for recruitment. Where appropriate posts approved have been recruited to on fixed term contracts only. The remaining posts have been frozen and will not be recruited to. The vacancy control group will continue to review posts on a weekly basis. Data Source – Electronic Staff Record
The annual rate of turnover (i.e., the number of staff retiring or resigning) in the 12 months to September 2010 is 11.19 %, and the monthly rate is 1.16%. Turnover increased in September from the previous month with a greater number of leavers than starters. With a reduction in the number of posts actively being advertised, this is not unusual. In addition, though there were higher number of support workers who left the Trust in the month of September, over 50% moved on to commence nurse training.. They are expected to qualify in 2014. Figures from the Chartered Institute of Personnel and Development’s Recruitment, Retention and Turnover Survey 2009, indicate that the annual turnover rate in the UK for the economy as a whole is 15.7% which is noticeably lower than the previous year’s rate of 17.3%. Turnover within the NHS has decreased from 13.2% to 11.4%. It is predicted that turnover will stabilise between 10‐11% by year end. Data Source: Electronic Staff Record
63
Section E: Efficiency and Effectiveness – Workforce
Appraisal compliance is monitored on a monthly basis. In September performance increased to 73% with a further 3% of the workforce with appraisal dates confirmed. Weekly discussions are taking place with senior managers to ensure that those employees without a scheduled appraisal date are followed up and dates are confirmed. Performance will continue to be monitored on a fortnightly basis to ensure improvements continue to be made. Staff Appraisals
80%
70%
60%
50%
Appraisals
Data source: Electronic Staff Record 40%
30%
20%
10%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
0%
Sickness Absence
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
O ct‐10
Sep‐10
A ug‐10
Jul‐10
Jun‐10
May‐10
A pr‐10
Sickness Absence
The Trust’s sickness figure for the month of September 2010 is 3.06% and the annual figure (based on a 12‐month rolling average) is 3.69%. The in month sickness position has increased slightly from the previous month. Detailed weekly reviews of all employees absent the previous week is undertaken between the personnel team and the appropriate directorate manager. This will continue to ensure we are consistently addressing all episodes of non attendance. It is predicted that sickness should be no greater than 3‐3.5% by year end. Data source: Electronic Staff Record 64
Section F: Look and Feel – Estates
Number of Job Requests
Statutory Maintenance Completed
3,400
100%
3,200
95%
3,000
2,800
20010/11
2,600
2009/10
In M onth
90%
Target
85%
2,400
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Jun‐10
Apr‐10
2,000
May‐10
80%
2,200
The number of job requests in September increased sharply compared to August but was the same as September last year. One of the three planned maintenance targets were fully met in September. Planned Preventative Maintenance (PPM) Completed
Water Systems Maintenance Completed
Data given is provided from the Estates ‘Shire’ work management system
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
O ct‐10
Sep‐10
A ug‐10
M ar‐1 1
Feb‐1 1
Jan‐1 1
Dec ‐1 0
Nov‐1 0
O ct‐1 0
Sep‐1 0
A ug‐1 0
Jul‐1 0
Jun‐1 0
M ay‐1 0
A pr‐1 0
80%
Target
Jul‐10
Target
85%
In M onth
Jun‐10
In M onth
90%
May‐10
95%
95%
90%
85%
80%
75%
70%
65%
60%
Apr‐10
100%
65
Section F: Look and Feel – Cleaning
Cleaning Scores ‐ High Risk Areas
Cleaning Scores ‐ Very High Risk Areas
98%
96%
Very High Risk Actual
98%
Target
96%
94%
High Risk Actual
Target
94%
92%
92%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Feb‐11
90%
Mar‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
90%
The cleaning service is monitored according to a risk assessment undertaken in accordance with the National Standards for Cleanliness in the NHS. The Trust has a stretch target to achieve 98% for Very High risk areas and 95% for High Risk areas but to have only a limited number of areas below the standard of 96% and 93% respectively.
In September 2010 there were no occasions when the weekly monitoring of Very High Risk areas showed scores less than 96%. There were also no High Risk areas that scored less than 93% in the month.
Cleaning Scores ‐ Significant Risk Areas
96%
94%
92%
90%
88%
86%
84%
82%
80%
Cleaning Scores ‐ Low Risk Areas
95%
90%
Significant Risk Actual
Target
Low Risk Actual
85%
Target
80%
75%
Data given on the graphs above comes from the Innovise cleaning monitoring system.
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
Apr‐10
May‐10
70%
66
Section F: Look and Feel – Capital Investment
YTD
YTD
Forecast
Spend
Budget Year End
Sept 2010 Sept 2010 Spend
Annual
Allocation
£000
10,020
2,068
499
600
5,359
£000
£000
£000
A&E/Fracture Clinic Redevelopment
Catering Services Review
Windows
Ward Refurbishment
Other estates projects
2,250
249
335
240
2,144
5,010
1,182
200
400
2,164
6,060
1,910
335
473
4,353
3,373 Electronic Medical Records
2,264 IT Strategy - Infrastructure/Systems
1,429
893
1,458
934
3,373
1,864
752
1,542
3,705
398
120
13,287
22,193
4,215 Clinical Equipment - Replacement/New
1,746 General Contingency
30,178
‐
8,592
Work is progressing with the capital programme including: A&E and Fracture Clinic
The new build accommodation is complete and the first phase has been occupied by the Trust. The new A&E Minors area opened to patients on 7th October and the admin offices on the first floor also became operational. The Contractor reports that
the scheme is progressing to plan.
Security Team Office/CCTV Monitoring
The existing Security Office in the main reception is being remodelled to provide a fully integrated CCTV monitoring suite to ensure the Trust has an effective & compliant system. Work will be completed in October.
Ward Refurbishment
Works to completely refurbish Fleming Ward are progressing to programme and due to complete at the end of October. The refurbished ward will be renamed James McKenzie Ward and be occupied by the current Frank Ahrens cardiac ward. The Former Frank Ahrens will be renamed and integrated with the adjacent MAU ward. Minor works will be carried out to enable these moves.
< Artist’s Impression of the Coffee Bar element of the New Restaurant
Catering Project The first phase of the Ward Kitchen refurbishment to suit the requirements of the Steam Cuisine system has been completed. The first wards to be migrated onto the steam cuisine service are due in November. The main contractor has been appointed to undertake the Restaurant refurbishment phase. Work will start on 16th October and complete by the end of the year. 67
This page is left blank intentionally
68
BOARD OF DIRECTORS
PART 1
MEETING DATE: 27 OCTOBER 2010
AGENDA ITEM: (2) 6
PROGRAMME MANAGEMENT OFFICE UPDATE
REPORT OF THE PROGRAMME DIRECTOR AND DIRECTOR OF CONTINUOUS
IMPROVEMENT
Purpose
This report is intended to update the Board of Directors on the progress and
achievements of the projects overseen by the Programme Management Office
(PMO).
Composition of the Report
No. of pages: 5
No. of appendices: 2
Summary - Key Issues
•
•
•
•
•
The PMO is currently overseeing 30 projects.
At present, there are 2 projects in the pipeline.
Of the 1,165 milestones (or actions) that were due for completion since the
start of the programme, 26 are outstanding (2%).
At the current time, there are 42 key performance indicators (KPIs) being
monitored by the Programme Board. Of these, 18 or 43% are not being fully
met.
One project (A&E Improvement) is currently temporarily suspended from the
programme pending major revision to the projects and is therefore not
currently being measured.
Anticipated Outcome (complete this if appropriate)
Recommendation(s)/ Decision Required
The Board of Directors is asked to note the progress made in relation to the work of
the PMO and the progress against the milestones of the projects.
Key Risks and Board Assurance
• Failure to deliver the programme will lead to the potential of additional
intervention by Monitor.
Regular reporting to Monitor to provide confidence of continuous
improvement
• The increasing challenging financial context will require sustained
performance improvement to deliver the financial plan.
69
•
Cost improvement plans to be monitored using the principles of the PMO and
key projects to be overseen by the PMO.
Failure to deliver the QIPP initiatives proposed by NHS South West Essex
may lead to additional financial pressure, in addition to those internally
generated.
Major QIPP projects will be managed through the PMO to ensure visibility of
service and financial impact and timely delivery.
Implications
Projects will impact across the 4 key themes of the organisation’s strategy together
with compliance with requirements of the regulators such as the Care Quality
Commission (CQC) and Monitor and the commissioners, NHS South West Essex.
Implications of not accepting recommendation(s):
None
Acronyms / Abbreviations used in the Report (where not stated):
Monitor – The independent regulator of NHS foundation trusts
PwC – PricewaterhouseCooper
HSMR – Hospital Standardised Mortality Ratio
TIA – Transient Ischaemic Attack
A&E – Accident and Emergency Department
QIPP – Quality, Innovation, Productivity and Prevention
Author: Adam Sewell-Jones
Status: Programme Director
Date: 18 October 2010
70
PROGRAMME MANAGEMENT OFFICE
UPDATE REPORT AS OF 14 SEPTEMBER 2010.
1. Introduction
Following the intervention by Monitor in November 2009, the Trust, in partnership
with PricewaterhouseCoopers(PwC), set up a Programme Management Office
(PMO). The role of this office is to co-ordinate the delivery of a set of projects such
that the anticipated benefits can be realised within the timescales of the programme
and in the future. Projects will be managed through this process where they are seen
to be critical to the strategic work of the Trust, are considered to be a core business
function or outcome, or where they are indicated by regulatory or contractual
concerns.
The PMO consists of:
Adam Sewell-Jones
Ruth Taylor
Andrea Saville
Iris Smith
Katy John
Annemarie Halls
Programme Director and Director of Continuous Improvement
Deputy Programme Director
Programme Manager (part time)
Programme Manager (part time)
Programme Assistant
Programme Administrator
2. The Current Programme
The PMO is currently overseeing 30 projects, many of which were originally included
in the Quality Improvement Plan: Patient Experience and Safety agreed with the
Commissioners and NHS East of England in the summer of 2009. Others have been
added following concerns expressed by either Monitor or the Care Quality
Commission (CQC) or following additional alerts raised by the Dr Foster Intelligence
System. In addition, some projects remain under the monitoring of the PMO.
The key themes for these projects are:
• Capacity management and discharge
• Reducing HSMR
• Care Quality Commission Registration Conditions
• Risk management standards
• Health and Safety Executive requirements
• The Department of Health Productive series
• Management and Prevention of Pressure ulcers
• Response and management of the deteriorating patient.
• Quality, Innovation, Productivity and Prevention (QIPP) programme
Each project has a Project Manager, Clinical Lead and Executive Sponsor. The
Project Manager (with the support of the Clinical Lead) meets with the PMO weekly,
or less frequently where appropriate, to review progress against actions and
performance against the agreed key performance indicators (KPIs). The Programme
Board, consisting of the executive directors, the PMO team and a non-executive
director meets fortnightly to review the progress of all projects and to discuss any
areas of concern or high risk. Action is taken to address all areas of concern
following this meeting.
2.1
Closed Projects July and August
During September 2010, 3 projects were closed with the approval of the Programme
Board having consistently achieved both milestones and KPIs. These were:
71
•
•
•
CQC condition 1 – Training for acutely ill patients
CQC condition 2 – Staff appraisals
CQC condition 3 - Legionella
All KPIs will be monitored through business as usual methods and the PMO will
continue an informal oversight to ensure that performance is maintained and
standards do not deteriorate. The milestones and KPIs relating to these projects are
no longer included in the cumulative position detailed in this report.
2.2
New Projects September
8 new projects were developed during September. These all relate to the PCT
required reduction to follow-up appointments and are across a range of specialities.
2.3
Projects moved to monitoring only in September
There are a number of projects which have completed all milestones but for which
the Programme Board would like to maintain visibility of the KPI performance. In
order to do this, 1 further project has been moved to a monitoring review to ensure
performance does not slip. This is:
• Develop and implement local guidelines for pneumonia
The Programme Board is updated monthly on the progress with these projects and in
the event that the performance deteriorates, a review meeting is held to determine
what actions have been or need to be taken to bring the performance back on track.
2.4
Suspended Projects September
1 project remains suspended:
A&E Improvement Project.
This project has been suspended to facilitate the work required to commission the
new A&E build and will be reactivated when the move into the new area has been
successfully completed. This project will recommence week beginning 18 October
2010.
This Releasing Time to Care project has been redrafted and is no longer
suspended.
2.5
Re-opened Projects September
1 project previously closed has been re-opened:
•
Complex discharges
This is reflective of the increased challenge in facilitating complex discharges due to
both the time of year and the impact of financial pressures within both PCT and
Social Services budgets.
3. The Pipeline
In addition to the projects mentioned above, the PMO supports a “pipeline” of
projects which may or may not be translated into projects to be overseen by the
office. At the current time, there are two projects in the pipeline, one related to end of
life care and one relating to QIPP initiatives.
4 Performance to date
As of Friday 15 October 2010, there were:
72
0
19
11
red;
amber; and
green rated projects.
Of the 1,165 milestones (or actions) in the current projects that were due for
completion since the start of the programme, 26 are outstanding (2%). Reasons for
the variance are challenged by the PMO and remedial action identified to reduce the
slippage. As failure to deliver against milestones can be seen as poor performance
on behalf of the Project Lead, the PMO has been working closely to reduce this
number to zero.
The dashboard, which is prepared weekly, is attached for information at Appendix 1
and reflects the progress of all projects as of close of play on Friday 15 October
2010.
At the current time, there are 42 key performance indicators being monitored by the
Programme Board. Of these, 18 or 43% are not being met. RAG rating is based on
the following performance tolerance levels: less than 3% from target is green,
between 3-6% variance is amber and over 6% is red. This is deterioration on
previous weeks and reflects the number of amber projects at the time of the report. It
also reflects the HSMR position following the national re-basing as a number of the
projects have this as a KPI.
It should be noted that this position (and that of the milestones) is affected by the
removal of the closed projects from the monitoring and reporting position.
5 Key Achievements to Date
There have been a number of achievements since the introduction of the PMO. Most
notable are:
•
HSMR for the top 5 HRG chapters originally identified in the Quality Improvement
Programme in 2009 have significantly improved, with none now being indicated
as red or significantly worse than average over the 12 month rolling average as
can be seen below:
Sep
2009
Oct
2009
Nov
2009
Dec
2009
Jan
2010
Feb
2010.
Mar
2010
COPD
133.9 129.4 127.2 119.9 112.3 104.8 103.6
Pneumonia 117.1 111.1 112.1 108.9 102.8 103.2 98.3
Stroke
105.1 101.7 98.2
90.7
86.6
83
80.4
AMI
128.6 129.8 123.6 126.3 131.2 126
119.5
Heart
133.7 130
129
124.5 122.5 119.7 112.2
Failure
Trust
117.5 114.3 110.9 107.9 105.6 102.5 96 3
Overall
(data source: Dr Foster Intelligence System as of 1 October 2010)
Apr
2010
May
2010
Jun
2010 1
Jul
2010 2
102.1
98.1
77.2
119.2
104.6
101.8
99.3
80.1
110.1
94.3
118.8
101.3
89.5
119.2
110.1
115.3
99.7
89.5
108.6
107
94.9
93.1
99.9
98.3
1
Dr Foster re-based HSMR based on 2009/10 national averages. The overall result is that all
HSMR values are likely to increase. The figures for June 2010 reflect the effect of this rebasing.
2
None of the HSMR values for this period are denoted as significantly worse than expected
(i.e. they are not showing as red on the system)
3
Measurement changed for Trust position to reflect stand alone position rather than Peer
SHA as previously.
73
•
•
•
•
•
•
•
•
•
•
•
Sustained achievement of increased cleaning monitoring scores for high and very
high risk areas
Over 70% of all children arriving in the A&E department are seen in the
Children’s Area.
98% of those attending the Children’s A&E currently express satisfaction with the
service.
Weekend discharges within the Directorate of Medicine and Emergency Care
have increased to 16% of the total weekly discharge.
Nurse facilitated discharge protocol has been successfully implemented in both
the medical and surgical directorates.
98% target for A&E patients to be admitted or discharged within 4 hours has
been achieved consistently since March 2010.
Length of stay for patients with a stroke is below 20 days and HSMR is currently
89.5 (after re-basing).
A one stop clinic has been introduced for low risk TIA patients to be seen within 7
days of the onset of symptoms.
The Principles of Care Audit results for September indicate that:
o 98% of patients had their baseline observations recorded within 2 hours of
admission
o 99% of patients had an accurate PARS score calculated with 90%
appropriately escalated to the relevant team.
o 85% of patients had their pressure areas assessed within 2 hours of
admission
o 97% of patients had a care plan
In September 96% of patients who were admitted with Heart Failure were seen
within 48hrs by the Nurse Specialist in Heart Failure and 97% received an ECHO
within 48 hours of admission.
Reporting times for radiological examinations have improved: over 90% of urgent
requests are being reported within 24 hours and over 60% are reported within 7
days. In addition, 94% of reports are completed using digital dictation.
6 Forward Planning
For the future, meetings have been held with the directorates in order to determine
their priorities and to provide an indication of the need for any of these priorities to be
managed through this process.
In order to provide high visibility of decision making, all projects that directorates
would like to be taken forward by the PMO will be presented to the Programme
Board and the decision made whether this is appropriate. Where there is agreement
for the PMO approach to be used, this decision will be clearly recorded and
communicated to the directorate. Likewise, any project that is ready to be closed will
be approved and recorded by the Programme Board. In this way, there is a clear
evidence trail of the rationale for opening and closing projects.
7 Project Risks
Each project has a risk register to track the key risks to the delivery of the project.
The Programme Board reviews the red risks on a monthly basis, using the PMO risk
register. As of 18 October 2010, the highest risks were:
•
Impact of the failure to achieve Risk Management Standards for maternity or
general.
74
•
Potential Impact of the PCT and Social Services economic constraints on the
ability to facilitate complex discharges.
Mitigating action is being taken to reduce these risks and the risk register is reviewed
monthly by the Programme Board.
8
Monitor KPIs
Performance against the KPIs agreed with Monitor for September is attached at
Appendix 2.
9
Conclusion
The discipline of the PMO approach to performance management continues to show
tangible improvements in the quality of services provided by the Trust, with evidence
to support this. The PMO has been operational for nearly one year and consideration
is now being given to the future of the Office. As the discipline of the PMO is
increasingly being embedded at directorate level, with many projects being delivered
locally using this methodology, it is time to review the role and function of the PMO
as it is currently configured and this will form the basis of a further report to the Board
in December.
75
This page is left blank intentionally
76
Appendix 1
MILESTONES
Programme Management Office report on project progress
Dashboard date: 15 October 2010
PMO
reference
Priority area
1.04 Top 5 HSMR: Stroke
Project Name
Stroke Improvement Programme
(Monitoring)
Reduction in the incidence of Hospital Acquired PU,
2.13 of grade 2 and above
Pressure Ulcer Management (Monitoring)
Develop and implement local guidelines for
1.06 Top 5 HSMR: Pneumonia
pneumonia (Monitoring)
Deputy project
manager
This Week
Cumulative YTD
Planned
no. of
Actual Missed % Behind
milestones
Planned no.
Actual Missed % Behind
of milestones
Performance against KPIs
Last week
No. of KPIs
not met
Previous %
behind
Planned no.
of KPIs
% Behind
Rating (top)
Mitigation
actions set
out
ISSUES FOR PROGRAMME BOARD
Risk RAG
Exception Reporting
Overall Risk
(RAG)
Previous Week
A
A
Karen Fashanu
Beth Smyth
G
G
Karen Bates
Linda Smart/Kirstie
Metcalf/Cathy
Plumley
N/A
N/A
A
A
Andrea Holloway
Sarah Lincoln
Duncan Stockwell Johnson Samuel
Project manager
RISKS - criteria and classification TBC
in line with Trust process
KEY PERFORMANCE INDICATORS
Finance manager
Karen Stewart
Karen Stewart
Information analyst
Clinical lead
Duncan Stockwell Farhad Huwez
Linda Smart
Executive lead
Stephen Morgan
0
0
0%
88
0
0%
3
1
33%
33%
Moderate risk
Yes
G
Diane Sarkar
0
0
0%
106
0
0%
3
0
0%
0%
Moderate risk
Yes
G
Stephen Morgan
0
0
0%
17
0
0%
2
2
100%
100%
Moderate risk
Yes
G
All KPIs are being achieved.(Monitoring)
No outstanding milestones. HSMR for July 99.7. LOS not being achieved with 18.3 against 13.
(Monitoring) ?WORKBOOK NOT UPDATED WITH LOS
One milestone outstanding regarding maintaining database of planned weekend discharges. KPIs
have been agreed and due to be measured w/c 18.10.10
1.01.02 Capacity management and discharge
Discharge project: Surgery
A
A
Pam Charlesworth
Deborah McCarthy
/ Nicki Abbott
Jenny Davis
Wendy English
Mr Carew (Orth) &
Mr Lafferty (Surg.)
Mark Magrath
2
1
50%
2
0
0%
2
0
0%
0%
Moderate Risk
Yes
G
1.01.03 Capacity management and discharge
Discharge project: Medicine
A
A
Dawn Patience
Sam Neville
Karen Stewart
Wendy English
Dr I Gupta
Mark Magrath
1
0
0%
1
0
0%
2
0
0%
0%
Moderate risk
Yes
G
1.01.04 Capacity management and discharge
Discharges: Paediatrics
A
A
Helen Boswell
Jane Thomas
Karen Stewart
Maureen Duncan Dr Sharief
Mark Magrath
1
1
100%
25
0
0%
2
2
100%
100%
Moderate risk
Yes
G
Embed COPD pathway
A
A
Andrea Holloway
Sarah Lincoln
Karen Stewart
Duncan Stockwell Deepak Mukherjee
Stephen Morgan
0
0
0%
62
0
0%
2
1
50%
50%
Moderate risk
Yes
G
Heart failure
A
A
Danny McCormack Tina Faulkner
Jenny Davis
Anita Sutton
Pat Phen
Stephen Morgan
1
1
100%
11
1
9%
2
1
50%
50%
Moderate risk
Yes
G
AMI
G
G
Tina Faulkner
N/A
Anita Sutton
Pat Phen
Stephen Morgan
1
0
0%
16
0
0%
2
0
0%
50%
Moderate risk
Yes
G
1.05 Top 5 HSMR: COPD
1.07.01 Top 5 HSMR: Heart failure
1.08.1 Top 5 HSMR: AMI
1.10 Children's Services Review
Children's Services Review
Response and management of
2.02 Response and management of deteriorating patient deteriorating patient
Ensuring compliance with Trusts standards for
2.05 DNAR
Resuscitation
A
A
Helen Boswell
G
G
G
G
Jacqueline Smith
KPIs regarding 90% of time on the stroke unit is 81% in June against a target of 90% - Quarterly
data. HSMR for July - 89.5 (Monitoring). ?WORKBOOK NOT UPDATED
Karen Stewart
Maureen Duncan Ruth Taylor
Diane Sarkar
0
0
0%
42
4
10%
2
0
0%
0%
Moderate Risk
Yes
G
Linda Smart
Tracey Glester
Marie
Nicholson/Cathy
Plumley
Novi Ukpemo
N/A
Chris Welch
Diane Sarkar
0
0
0%
74
0
0%
1
0
0%
0%
Moderate risk
Yes
G
Rachel Johnson
Rachel Crisp
Jenny Davis
N/A
Mike Imana
Stephen Morgan
0
0
0%
52
0
0%
2
0
0%
0%
Moderate
Yes
G
Milestones on track this week. KPIS have been agreed and will be measured as of w/c18.10.10.
One milestone outstanding regarding 2nd week trial of Nurse Lead discharge. Dr Sharief is currently
reviewing the criteria for Nurse Lead Discharge. KPIs not being achieved for August regarding LOS
for Gynaecology Elective and Non Elective which has increased to 1.43 against 0.97 and Paediatric
elective and non elective which has increased to 2.37 against a target of 1.63. September data not
yet available. HB will be changing the project lead to Debbie Crisp w/c 18.10.10. ?WORKBOOK
NOT UPDATED.
AH has added 2nd stage milestones regarding undertake audits of compliance with the COPD
pathway (FNMB) and undertake audits of compliance with the COPD pathway (Other Medical
Wards) and also around appointing the 4th Consultant (Permanent). Not achieving KPI regarding
HSMR with 115.3 recorded for July 2010. LOS has dropped for September with 6.6 against a target
of 8.
One milestone outstanding regarding PCTs decision on cardiac rehab which is being delayed due to
financial constraints. One KPI not being met regarding HSMR with 107 for July 2010 against a
target of 100.
Milestones on track. HSMR for July is recorded as 108.6 against a trajectory of 111. LOS is 8.8
against a target of 8.95.
Milestones remain outstanding with regards to named Paediatric consultant draft guidelines
consultation and implementation and implementation of system to record EPLS APLS training
record. Named Consultant guidelines are due to go to the CD Board on 25.10.10. KPIs are on
track.
3.04 Top 5 HSMR: Other perinatal conditions.
Perinatal Mortality
G
A
Debbie Crisp
Helen Boswell
N/A
Mr Ikomi
Chris Welch
1
1
100%
36
1
1%
1
1
100%
100%
Moderate
Yes
G
Milestones and KPIs on track.
KPIs for September are being met with 91% of compliance with DNAR forms against a target of
90%, and 90% signed by a consultant against a target of 80%.
One milestone outstanding re: review the feasibility of reductions of clinics . HSMR has increased
slightly to 165.8 for July 2010 due to the inclusion of September 2010 data.
3.05 Children's Services Review
Paediatric emergency care pathway
G
A
Helen Boswell
Sally Brown
N/A
Dr Saravanan
Stephen Morgan
1
1
100%
58
1
2%
2
0
0%
50%
Moderate
Yes
G
One milestones remains outstanding regarding extending Paediatric centre hours until midnightt.
KPIs being achieved regarding % of children attending A&E using the Paediatric A&E unit with 73.2
%(0-15yr olds) in September against a target of 75% and 97.8% satisfaction score.
NMC action plan
G
G
Lyn Cook
Avril Archibald
N/A
Diane Sarkar
0
0
0%
52
0
0%
2
0
0%
0%
Moderate risk
Yes
G
Milestones on track and KPIs are both achieving target.
G
Two milestones outstanding regarding reporting standards and trajectory and agree implementation
of new system of work. One KPIs not being achieved regarding examinations typed within one day
for inpatients with 83% w/c 13.09.10 against a target of 90%.
?WORKBOOK NOT UPDATED
3.07.5 CQC
3.09 Capacity management
Radiology
Risk Management Standards - General LEVEL 1
2.14.01 CNST
Risk Management Standards - General LEVEL 2
G
G
A
G
Michael Catling
Paul Osborne
N/A
Dr Hails
Mark Magrath
0
0
0%
22
2
9%
2
1
50%
0%
Moderate risk
Yes
0
0
0%
58
1
2%
2
2
100%
100%
High risk
Yes
0
0
0
13
0
0%
1
0
0%
N/A
High risk
Yes
R
R
G
Marie Nicholson
Karen Bates
N/A
N/A
Andrea Saville
R
Diane Sarkar
Milestones on track for level 2. External auditor is completing a systematic review of information
required for level 2. Bookmarking and hyperlinking will take place once this has been completed.
0
Risk Management Standards - General LEVEL 3
2.14.02 CNST
Risk Managements Standards - Maternity
Milestones outstanding for level 1 regarding policies being checked and approved at Board meeting
for standard 4 - VTE and Infection control . KPIs for level 1 almost complete with 52/54 policies
compliant and 2 requiring final ratification.
0
0
0
0
0
0
0
0%
N/A
Moderate
Yes
Milestones and KPIs for level 3 not yet being measured.
G
A
G
A
G
Lynn Cook
Helen Boswell
N/A
4.02 Core business projects
Productive theatres
A
A
Marcie Tunbridge
James Leek
Jenny Davis
5.01 H&SE
Manual Handling
G
G
Stephanie Lawton
Meera Nair
N/A
N/A
Andrea Saville
Julie Plane
Kevin Lafferty &
Lyndsey Rylah &
Bryony Lovett &
Robert Carew
Diane Sarkar
1
0
0%
48
0
0%
2
0
0%
0%
Extreme Risk
Yes
Chris Welch
10
3
30%
246
3
1%
1
1
100%
100%
Moderate
Yes
N/A
Nigel Taylor
0
0
0%
12
0
0%
0
0
0%
0%
Moderate
Yes
R
G
G
Milestones are on track. Both KPIs are being achieved. Project remains amber due to red risks
regarding failure to provide evidence of compliance embedding clinical practice prior to assessment.
Risks were challenged again this week.
Milestones remain outstanding regarding Audit & review implemented changes for scheduling
theatre lists and implementing measures for session start up . KPI regarding the amount of
operating time undertaken during a list is not being achieved with 70.12% against a trajectory of
87% in w/c 27.09.10. ?WORKBOOK NOT UPDATED
No milestones outstanding. No KPIs to be measured. All link co-ordinators have either already
completed their training or are scheduled to complete by end of December 2010.
Two milestones remain outstanding regarding finalising core shifts and determine annual leave
entitlement. TOIL balance has increased slightly this month to -2190. A&E currently have over 30
members of staff with over 37.5 hours toil owing equating to 2694.34 hours. Trajectory and target to
be added shortly.
Milestones on track. KPIs being achieved with patients with a LOS over 44 days remaining steady
with 37 w/c 11.10.10. Patients with a LOS over 100 days reduced to 9 w/c 11.10.10 from 11 w/c
4.10.1.
4.01 Core business projects
E-rostering
G
G
Anthony Fitzgerald Jenny Mullin
TBC
Nigel Taylor
2
2
100%
18
2
11%
2
0
0%
0%
Moderate
Yes
G
1.02 Capacity management and discharge
Complex discharges
A
A
Wendy Hurrell-SmithAndy Graham
N/A
Mark Magrath
2
0
0%
5
0
0%
2
0
0%
N/A
Extreme Risk
Yes
R
Project has been rag rated as amber due to red risk relating to PCT and social services financial
situation.
R
Milestones and KPIs have been added to the workbook. Milestones due to commence from w/c
18.10.10. KPI data to be added to the workbook. Awaiting information from the information team.
Risks added to the workbook re:
Lack of clinical support to complete project
Lack of PCT support to manage GP referrals
6.01.1 QIP
New to follow up OPD project - Urology
A
N/A
Lisa Want
Mark Magrath
0
0
0%
0
0
0%
0
0
0%
N/A
Moderate
Yes
6.01.2 QIP
New to follow up OPD project - General
Surgery
A
N/A
Lisa Want
Mark Magrath
1
1
100%
1
1
100%
0
0
0%
N/A
Moderate
Yes
6.01.3 QIP
New to follow up OPD project - Cardiology
A
N/A
Yvonne Brierley
Mark Magrath
1
0
0%
1
0
0%
0
0
0%
N/A
Extreme Risk
Yes
R
6.01.4 QIP
New to follow up OPD project - Maternity
A
N/A
? Debbie Crisp
Mark Magrath
N/A
N/A
N/A
N/A
6.01.5 QIP
New to follow up OPD project Gynaecology
A
A
Jane Thomas
6.01.6 QIP
New to follow up OPD project - Oral
Surgery
A
N/A
Jo McCollum
Dawn Bramham
G
Mark Magrath
2
2
100%
6
2
33%
0
0
0%
N/A
High risk
Yes
R
Mark Magrath
0
0
0%
0
0
0%
0
0
0%
N/A
High risk
To be added
R
One milestone outstanding regarding meet with information lead to review cause of follow up
appointments. KPI data to be added to the workbook - awaiting information from the information
team. Risks added to the workbook re:
Lack of clinical engagement
Lack of PCT support to manage primary care
Milestones on track. KPI data to be added to the workbook. Risks added to the workbook re:
Lack of clinical engagement
Lack of support from GP referrers
Lack of support from GPs to accept patients management and for patients to remain safely
managed.
HB to confirm who will be leading on this project. Meetings to commence w/c 18.10.10
Two milestones outstanding this week re obtaining clinic information from the information team and
undertaking spot audits. KPIs have been agreed but data needs to be added to the workbook. Risks
have been added to the workbook re:
Lack of clinical engagement to secure achievement of reducition targets.
Lack of support from the GPs to re-patriating discharged patients
Junior doctor support from senior clinicians
Milestones due to commence w/c 18.10.10. KPIs have been agreed, data needs to be added to the
workbook. Risks have been added to the workbook re:
Lack of clinical engagement (BTUH)
Lack of support from centralised "hub" from MEHT
Lack of support from dentists to support discharged patients.
77
Appendix 1
New to follow up OPD project - Pain
Management
6.01.7 QIP
6.01.8 QIP
3.03 Releasing Time to Care
New to follow up OPD project - T&O
Releasing Time to Care
1.11.03 A&E
A
A
A
N/A
N/A
N/A
Carol Banks
Kim Saunders
Alison Griffiths
Dawn Bramham
TBC
Ganine Byford
N/A
Hayley Peter
Mark Magrath
Diane Sarkar
Lokesh
Narayanaswamy
Stephen Morgan
TBC
TBC
0
0%
0
0
0%
0
0
0%
0
2
0
0
0%
0%
0
2
0
0
0%
0%
0
0
0
0
0%
0%
21
7
33%
1165
26
2%
42
18
43%
2
100%
30
17
57%
2
1
N/A
N/A
50%
50%
0%
0%
N/A
Extreme Risk
Moderate
N/A
Yes
Yes
N/A
Milestones due to commence w/c 18.10.10. KPIs have been agreed, data needs to be added to the
workbook. Risks to be added to the workbook.
R
G
Milestones due to commence w/c 18.10.10. KPIs have been agreed, data needs to be added to the
workbook.
Risks have been added to the workbook re:
Lack of clinical engagement
PACS inability to pull down images and the increase in the repeat images will adversely effect
delivery of this project.
Waiting time for imaging and reports (over 4 weeks total) adversely impacts on the number of follow
up appointments needed.
Milestones are on track and KPIs have been added to the workbook.
PMO meetings to resume following Lesley Roberts return from A/L w/c 18.10.10. 17
milestones outstanding regarding: review reception process flow, review of cubical assignment,
investigate wrist band printer and implement team boards, two week audit on documentation, the
display of satisfaction results and review RAPT in majors process, all senior management staff to
undertake 'Silver' incident training and undertake review of minors flow and implement redesigned
process.
KPI regarding 75% of patients referred to specialty in 2 hours or less, where appropriate, is not
being achieved with 30.9% recorded w/c 13.09.10.
N/A
End of Life
LD - Person centered pathways for better
health outcomes
N/A
N/A
N/A
N/A
Simple discharges: CTC (CLOSED)
N/A
N/A
Tina Faulkner
Anita Sutton
Paul Kelly
Mark Magrath
0
0
0%
17
0
0%
3
0
0%
0%
Low Risk
Yes
G
CLOSED
N/A
N/A
Andy Graham
Anita Sutton
Wendy HurrellSmith
Jenny Davis
Direct admissions (CLOSED)
N/A
N/A
David Gertner
Mark Magrath
0
0
0%
3
0
0%
1
0
0%
0%
Moderate risk
Yes
G
CLOSED
1.09.02 A&E and MAU
Nursing establishment on MAU (CLOSED)
N/A
N/A
Kim Perry
Lesley Roberts
Karen Stewart
Steven Lewis
Elsir Osman
Maggie Rogers
0
0
0%
27
0
0%
0
0
0%
0%
Low risk
Yes
G
CLOSED
1.09.01 A&E and MAU
3.02 A&E and MAU
MAU education workstream (CLOSED)
MAU medical leadership (CLOSED)
N/A
N/A
N/A
N/A
Kim Perry
Lesley Roberts
Anthony Fitzgerald
Karen Stewart
Steven Lewis
Maggie Rogers
Stephen Morgan
0
0
0
0
0%
0%
12
46
0
0
0%
0%
2
3
0
0
0%
0%
100%
0%
Low risk
High risk
Yes
Yes
G
G
CLOSED
CLOSED
1.11.02 A&E and MAU
A&E: RIE (CLOSED)
Clinical data capture: generic clerking form
(CLOSED)
Primary Percutaneous Coronary
Intervention (PPCI) (CLOSED)
CQC Condition 4 - Assessment and Care
Planning (CLOSED)
N/A
N/A
Sarah Noon
Lesley Roberts
Karen Stewart
Hayley Peters
Elsir Osman
Elsir Osman
Lokesh
Narayanaswamy
Stephen Morgan
0
0
0%
70
0
0%
1
0
0%
100%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Kim Perry
Anthony Fitzgerald Karen Stewart
Duncan Stockwell Indi Gupta
Stephen Morgan
0
0
0%
29
0
0%
2
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Tina Faulkner
Anita Sutton
Jenny Davis
Anita Sutton
Stephen Morgan
0
0
0%
21
0
0%
4
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Julie Hickman
Linda Smart
N/A
Maggie Rogers
0
0
0%
13
0
0%
5
0
0%
0%
High Risk
Yes
G
CLOSED
N/A
N/A
Pam Charlesworth
Amanda Fife
N/A
Maggie Rogers
0
0
0%
21
0
0%
0
0
0%
0%
High risk
Yes
G
CLOSED
N/A
N/A
Sarah Noon
Lesley Roberts
Karen Stewart
TBC
Lokesh
Narayanaswamy
Stephen Morgan
0
0
0%
11
0
0%
1
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Linda Smart
N/A
Mark Magrath
Nigel Taylor
0
0
0
0
0%
0%
75
14
0
0
0%
0%
2
0
0
0
0%
0%
0%
0%
Moderate
Moderate
Yes
Yes
G
G
CLOSED
CLOSED
Novi Ukpemo
N/A
Linda Johnson
Maggie Rogers
0
0
0%
27
0
0%
0
0
0%
0%
Moderate risk
Yes
G
CLOSED
Adam SewellJones.
Alan Whittle
0
0
0%
27
0
0%
0
0
0%
0%
Moderate
Yes
G
CLOSED
Chris Welch
N/A
Mark Magrath
Nigel Taylor
0
0
0
0
0%
0%
79
3
0
0
0%
0%
1
0
0
0
0%
0%
0%
0%
Moderate
TBC
Yes
TBC
G
TBC
CLOSED
CLOSED
N/A
2
N/A
N/A
7.01.1 Quality Improvement
Karen Stewart
Julie Hickman
0
A &E Improvement
3.10
Sarah Noon
Lesley Roberts
Karen Fashanu and
Diane Baker
TBC
Mark Magrath
Moderate
Yes
G
TBC
TBC
TBC
PMO meetings to start shortly, following discussion with Dr Morgan.
PMO review meetings to be set w/c 11.10.10
CLOSED PROJECTS
1.01.01 Capacity management and discharge
1.03 Capacity management and discharge
1.13 Clinical data capture and coding
1.08 Top 5 HSMR: AMI
3.07.4 CQC
2.07 Response and management of deteriorating patient PARS Service Review (CLOSED)
Improved medical workforce for A&E
1.11.01 A&E and MAU
(CLOSED)
3.01 Delivering Single Sex Accommodation
5.02 H&SE
Delivering Single Sex Accommodation
(CLOSED)
Health & Safety Training (CLOSED)
N/A
N/A
N/A
N/A
Marie Nicholson
Stephanie Lawton
Linda Smart &
Cathy Plumley
Meera Nair
1.18 Clinical data capture and coding
Nursing documentation project (CLOSED)
N/A
N/A
Julie Hickman
Alison Griffiths
CQC Non-compliance (CLOSED)
N/A
N/A
Andrea Saville
1.12 Clinical data capture and coding
5.03 H&SE
Coding
Violence and Aggression (A&E)
N/A
N/A
2.06 Reduce HSMR for Lung Cancer
Lung Cancer
1.17 Learning disabilities
Learning disabilities
3.07.6 CQC
Hayley Peters
Paul Kelly
N/A
N/A
N/A
N/A
Ruth Taylor
Eghosa Bazuaye
Emma Timpson
(Baz)
Anthony Fitzgerald Sarah Noon
Novi Ukpemo
N/A
N/A
N/A
N/A
Andrea Holloway
N/A
Duncan Stockwell Dr Yung
Stephen Morgan
0
0
0%
14
0
0%
1
1
100%
100%
Moderate
Yes
G
CLOSED
N/A
N/A
Novi Ukpemo
N/A
Diane Sarkar
0
0
0%
98
0
0%
2
0
0%
0%
Moderate risk
Yes
G
CLOSED
3.07.1 CQC
3.07.2 CQC
CQC Condition 1 - Training for acutely ill
patients
CQC Condition 2 - Staff Appraisals
N/A
N/A
N/A
N/A
Shoenagh MacKay Julie Hickman
Pam
Charlesworth/Julie
Hickman
Linda Smart
Stephanie Lawton Meera Nair
Diane Sarkar
Nigel Taylor
0
0
0
0
0%
0%
16
9
0
0
0%
0%
3
1
0
0
0%
0%
0%
0%
Moderate risk
Moderate risk
Yes
Yes
G
G
CLOSED
CLOSED
3.07.3 CQC
3.06 Capacity management and discharge
CQC Condition 3 - Legionella
Enabling capacity in MEC
N/A
N/A
N/A
N/A
Rob Speight
Simon Myles
Anthony Fitzgerald
Jenny Galpin
Mark Magrath
0
0
0
0
0%
0%
23
23
0
0
0%
0%
3
1
0
0
0%
0%
0%
0%
High risk
Moderate risk
Yes
Yes
G
TBC
CLOSED
CLOSED
Sarah Lincoln
Julie Hickman
N/A
N/A
N/A
Dr Gertner
KEY
Closed projects
Monitoring
Pipeline or suspended
78
BOARD OF DIRECTORS
PART 1
MEETING 27 OCTOBER 2010
AGENDA ITEM: (2) 7
ITEMS CONSIDERED BY THE BOARD OF CLINICAL DIRECTORS
SINCE THE LAST BOARD OF DIRECTORS MEETING
REPORT OF THE CHIEF EXECUTIVE
Performance Report*
The Board considered the Performance Report for August 2010.
Managing Capacity 2010/11 – Avoiding Escalation / Escalation Procedure for Cancer
Patients
The Board agreed the actions to take where demand for hospital beds exceeds or is
predicted to exceed available supply.
Policies and Guidelines
The Board approved the following reviewed and updated policies
• Policy for Consent to Examination and Treatment
• Medical Devices Training Policy
And the following new policies:
• Clinical Effectiveness Policy
• Being Open Policy
Serious Incidents (SIs)
The Board noted the action plan developed as a result of the CQC Feedback at the end
the inspectors’ visit on 28 September 2010 and the amendments to the process for the
management of SIs.
Management Core Brief
The Board agreed the Management Core Brief for cascade to all staff.
1
79
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80
PART 1
BOARD OF DIRECTORS
MEETING DATE: 27 OCTOBER 2010
AGENDA ITEM (5)12
CQC REGISTRATION – PROGRESS WITH ACTION PLAN
REPORT OF THE CORPORATE SECRETARY
Purpose
The purpose of this report is to inform the Board of Directors of progress with the action plans
developed to ensure compliance with the conditions to the Trust’s registration.
Composition of the
Report
No. of pages:
No. of appendices:
2
0
Summary– key issues
1. On 1 April 2010, the Care Quality Commission (CQC) granted the Trust Registration subject to
5 conditions. Four of these have been removed subsequently by the CQC.
2. The final condition linked to compliance with the Health and Safety Executive Improvement
Notice relating to control of legionella in the water systems was reviewed by the Health and
Safety Executive on 14 September. The CQC conducted an unannounced visit on 28
September 2010 primarily to review the Trust’s management of Serious Incidents. The Trust is
awaiting confirmation of the outcome of the visit.
Recommendation(s)/ Decision required
The Board of Directors is requested to note the report.
Key Risks and Board Assurance
The Trust must now maintain full compliance with the Essential Standards of Quality and Safety and
ensure up to date evidence of compliance is available.
Implications
Patient Safety and Patient Experience: the Trust is required to maintain compliance with the Essential
Standards of Quality and Safety in order to provide health services. The focus of compliance is on the
outcome of care for patients.
Financial (efficiency, economy, effectiveness): The CQC is able to impose financial penalties for noncompliance.
Equality and Diversity: To maintain registration the Trust is required to explain how it promotes
equality, diversity and human rights.
Legal: Registration is a legal requirement in order to provide health and social care in England.
Communications/Reputation: Registration without conditions will significantly improve the Trust’s
reputation and build confidence.
NHS Constitution: The Essential Standards of Quality and Safety support the pledges and rights in the
NHS Constitution.
81
Acronyms/ abbreviations used in the report (where not stated):
None
Author: Andrea Saville
Status: Corporate Secretary
Date: 20 October 2010
82
BOARD OF DIRECTORS
MEETING DATE: 27 OCTOBER 2010
PART 1
AGENDA ITEM (5) 13
CONTACT WITH REGULATORS
REPORT OF THE CORPORATE SECRETARY
Purpose
The purpose of this report is to provide a summary to the Board of contacts with Regulators and
external agencies between 29 September 2010 (the date of the last report) and 20 October 2010
and an update of feedback from visits (where received).
Composition of the report
No. of pages: 2
Summary
The Trust has had 2 contacts with Regulators or external agencies since the last report to the
Board of Directors
Recommendation(s)/ Decision required
The Board of Directors is requested to note the report
Impact on Quality of Service
Contact with regulators and external assessment provides evidence of quality governance.
Implications for:
Patient Safety and Patient Experience: The issues highlighted at each visit need to be reported,
reviewed, acted upon and where appropriate, prompt changes in practice.
Financial (efficiency, economy, effectiveness): Registration and accreditation is required in order to
provide services
Legal: It is a legal requirement to be registered with the CQC from 1 April 2010.
Communications/Reputation: Registration and accreditation with external organisations provides
recognition of the Trust’s standards and assists the Trust’s reputation enhancement and builds
confidence.
Acronyms/ abbreviations used in the report (where not stated): None
Author: Andrea Saville
Status: Corporate Secretary
Date: 19 October 2010
83
Date
Organisation and Purpose
Result
Visits to/ Contact with the Trust since the Board of Directors’ meeting 29 September 2010
21 September
BSi pre-assessment visit for accreditation against Business Continuity
Report received – recommended for next stage on 21/22 December
2010
BS25999 2007
26 October 2010
Routine telephone call to Monitor
84