MEETING IN PUBLIC - Western Sussex Hospitals

Transcription

Meeting of the Board of Directors
10.00am to 1.00 pm on Thursday 30 July 2015
Boardroom, Washington Suite, Worthing Hospital,
Lyndhurst Road, Worthing, BN11 2DH
AGENDA – MEETING IN PUBLIC
1 10.00
Welcome and Apologies for Absence
Chair
2 10.00
Declarations of Interests
All
3 10.00
Minutes of Board Meeting held on 2 July 2015
To approve
Enclosure
Chair
4 10.05
Matters Arising from the Minutes
To note
Enclosure
Chair
5 10.10
Chief Executive’s Report
To receive and agree any necessary action
Enclosure
MG
PATIENT SAFETY/EXPERIENCE ITEMS
6 10.25
Quality Report
Enclosure
AP/GF
7 10.40
Medical Staff Revalidation Report
Enclosure
GF/TT
8 10.55
CQC National Children’s Inpatient and Day Case Survey
Results 2014
To note
Enclosure
AP
9 11.05
Action Plan to address results from National Inpatient
Survey
Enclosure
AP
Patient First Report
Enclosure
MG
10 11.15
OPERATIONAL ITEMS
11 11.30
Performance Report
 Business Continuity Incident Dec/Jan 2014/15 –
Debrief Report
Enclosure
Enclosure
JF
JF
12 11.55
Organisational Development and Workforce Performance
Report
To receive and agree and necessary actions
Enclosure
DF
13 12.05
Financial Performance Report
To receive and agree any necessary actions
Enclosure
KG
14 12.20
Report on the use of the Trust Company Seal (Quarter 1
2015/16)
To note
Enclosure
AG
15 12.25
Operational Plan Objectives And Board Assurance
Framework 2015/16 Quarter 1 Review
Enclosure
AG/MJ
16 12.30
Monitor Self-Assessment Report (Quarter 1, 2015/16)
Enclosure
AG
Enclosure
AG
STRATEGIC ITEMS
17 12.35
Risk Management Strategy
To approve
OTHER ITEMS
18 12.40
Other Business
19 12.45
Resolution into Board Committee
To pass the following resolution:
“That the Board now meets in private due to the confidential
nature of the business to be transacted.”
20 12.45
Date of Next Meeting
The next meeting in public of the Board of Directors is scheduled
to take place at 10.00am on 1 October 2015 in the Boardroom,
Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing,
BN11 2DH
Chair
21 12.45
Close of Meeting
Chair
22 12.45
Questions from the Public
Following the close of the meeting there will be an opportunity for
members of the public to ask questions about the business
considered by the Board.
Chair
Andy Gray
Company Secretary
Tel: 01903 285288 / Mobile: 07785332416
Chair
Verbal
Chair
Minutes
Minutes of the Board of Directors meeting held in Public at 10.00am on Thursday 2
July 2015 in the Bateman Room, Chichester Medical Education Centre, St Richards
Hospital, Chichester.
Present:
Mike Viggers
Joanna Crane
Lizzie Peers
Martin Phillips
Marianne Griffiths
Denise Farmer
Dr George Findlay
Karen Geoghegan
Amanda Parker
Chairman
Non-Executive Director
Chief Executive
Director of Organisational Development &
Leadership
Medical Director
Director of Finance
Director of Nursing and Patient Safety
In
Attendance:
Adam Creeggan
Andy Gray
Barbara Mathieson
Director of Performance
Company Secretary
Assistant to Company Secretary
PB/6/15/01
Welcome and Apologies
Action
1.1 The Chairman welcomed all those present to the meeting.
1.2 Apologies for absence were received from Bill Brown, Jane Farrell, Jon
Furmston and Mike Rymer.
PB/6/15/02
Declarations of Interests
2.1 There were no declarations of interest.
PB/6/15/03
Minutes of Board Meeting held on 28 May 2015
3.1 The Board received the minutes of the meeting held on 28 May 2015.
3.2 The Board resolved that the minutes of the Board meeting held 28
May 2015, would be approved as an accurate record of the meeting
and signed by the Chairman.
3.3 Mike Viggers confirmed that the question from Hazel Thorpe on Local
Community Transport would be carried forward to the next meeting.
3.4 Mike also responded to John Todd’s question on the closures of various
Terraces at St Richards by confirming that the necessary safety work
would be completed during July.
PB/6/15/04
Matters arising from Minutes
4.1 The Board received and noted the report of matters arising from its
meeting held on 28 May 2015.
4.2 PB/5/15/11.9 Validate Outpatient Figures
It was confirmed that the variance was due to different diagnostic codes
being used and this would be resolved for future reports.
Chief Executive’s Report
PB/6/15/05
5.1
Marianne Griffiths, Chief Executive presented her report for May and
confirmed that she was pleased to announce that the Coastal West
Sussex Clinical Commissioning Group would be commissioning Western
Sussex Hospitals NHS Foundation Trust (WSHFT) as the Prime Provider
of Musculoskeletal Services (MSK) for the area. As such, detailed
contract negotiations were beginning and Marianne confirmed that the
Trust was committed to offering patients a more joined up, holistic and
improved service. It was also confirmed that there would be a MSK
patient group set up and that a GP would be invited to be a member.
Marianne asked that particularly thanks be noted to Mike Jennings and all
the staff across the Trust who had worked so hard to secure the contract.
5.2 Marianne then spoke about the Trusts Patient First Staff Achievement and
Recognition (STARS) Awards and confirmed that there had been a
fantastic response with 219 nominations received to date.
5.3 As part of the Patient First initiative and the goal of developing a culture of
continuous quality improvement across the Trust it was confirmed that a
partner had been secured to help develop tools and techniques to deliver
the expected outcomes. To aid this, Ward Information screens had been
installed as a pilot. They would deliver real time information to patients
and visitors and it was expected to roll these out across the Trusts wards
in the middle of August. The Trust was progressing with its Ward
Accreditation Programme and it was confirmed that most were expected
to start at the Bronze level. It was noted that there was a planned AP/AG
presentation on Ward Accreditation to the Trust Board in September.
5.4 Marianne confirmed that the Trust was marking two years of being a
Foundation Trust and that as a result some of the first Trust Governors
would be completing their terms of office. Marianne acknowledged the
support and work of the Council of Governors and confirmed that elections
to find new Governors were taking place.
5.5 Marianne encouraged members of the public to attend the Trust’s AGM
which was due to take place at St Richards on Monday 27 July 2015 and
the Stakeholder Forum which would take place at Worthing on the 20
August 2015.
5.6 Mike Viggers confirmed that the award of the MSK Contract to the Trust
was fantastic news and that the number of nominations which had been
received for Star awards underlined the enthusiasm that both staff and the
public had for the Trust.
PB/6/15/06
Quality Report
6.1 Dr George Findlay, Medical Director and Amanda Parker Director of
Nursing and Patient Safety presented the Quality Report for Month 2, May
2015/16.
6.2 George confirmed that as part of the refresh of the Quality Strategy
outlining key quality objectives for the next three years, the Quality Report
would be refreshed and redesigned. The Trust Quality Board had
reviewed and approved a new format with a view to making a
Minutes page 2
recommendation to the Trust Board. This would be covered under item 10
of the Agenda.
6.3 George confirmed that the crude non-elective mortality fell from 3.23% in
April to 2.82% in May which was lower than the equivalent month in May
2014. The 12 month rolling average also reduced to 3.28%. The most
recent data for the Hospital Standardised Mortality Ratio (HSMR) was
noted to be from February 2015 and was 92.1. Split by site this was 87.4
for St Richards and 95.7 for Worthing.
6.4 Regarding Stroke Care national data for January 2015 to March 2015 for
the Sentinel Stroke National Audit Programme had been published. The
overall score and banding for each site was confirmed. For St Richard’s
hospital the score had improved from 63 to 67 but remained as a Band C.
For Worthing Hospital the score improved from 66 to 78 moving from
Band C to Band B. For context the Board were reminded that of the 202
units included in the audit only 23% were branded as B. The Board
commended the improvement in both sites metrics for Stroke Care over
the last few months.
6.5 Amanda confirmed that there had been five Serious Incidents Requiring
Reporting (SIRI) during the period. Four were falls which resulted in the
need for surgery and one was related to a maternal unplanned admission
to ITU.
6.6 There were zero cases of Methicillin-resistant Staphylococcus Aureus
(MRSA) bacteraemia during May. It was also noted that there were five
cases of hospital attributable Clostridium Difficile during May; two on the
Worthing site and three at St Richards Hospital. Of these there were two
cases of C diff. in which a lapse of care was noted (both on the Worthing
site). In both cases this was due to environmental factors and dirty
commodes. These wards are being monitored and audited regularly to
ensure standards were maintained.
6.7 In May there were 33 falls resulting in harm against a benchmark of 43. Of
the 33 falls in May, in 7 instances the patient had previously fallen during
their inpatient stay. The 33 falls equated to 1.17 falls resulting in harm per
1000 occupied bed days compared to the national benchmark of 2.5
(Royal College of Physicians Report of the 2011 Inpatient Falls Pilot
Audit).
6.8 Amanda reported that during May the Trust reported seven cases of
hospital acquired pressure ulcers (Grade 2). There were no hospital
acquired grade 3 or 4 pressure ulcers in in the month. There were 88
patients admitted to the Trust from the Community with pressure damage.
6.9 To conclude the report, Amanda confirmed that the Safer Staffing
Scorecard showed that there was 97% coverage of nursing staff across
the wards for May. This was reflecting the closure of two escalation wards
within the Trust. Mike Viggers asked that a review of the metrics was
undertaken relating to staffing levels and the occurrence of C Diff over the
AP
past few months to confirm if there was a correlation .
6.10 Martin Phillips asked for clarification regarding the % Stroke thrombolysis
within 60 minutes of hospital arrival as the figures seemed low. George
reminded the Board that only a small number of patients were suitable to
receive the treatment and that national the figure was around 40%.
Minutes page 3
PB/6/15/07
Quarterly Complaints (Quarter 4 2014/15)
7.1 Amanda Parker, Director of Nursing and Patient Safety presented the
Quarterly Complaints report for Quarter 4, 2014/15. She noted that there
were 151 formal complaints received within the Trust for the period. This
was comparable to other periods and it was noted that there had not been
any step change in the number received during the busy period within the
Trust. For the same period it was confirmed that the number of PALs
enquires had increase but it was noted that this may be attributable to the
move of the PALS office at Worthing which was making it more
accessible. Amanda also confirmed that reporting on the time to respond
to formal complaints would be included within future reports. The number
of complaints regarding clinical treatment was particularly noted but it was
confirmed that they were not related to one specific area.
7.2 Unusually for the Trust three complaints referred to the Parliamentary
Health Service Ombudsman (PHSO) had been upheld. In two of the
cases this related specifically to documentation of lessons to learn. This
was felt to be an area to be very clear about when answering formal
complaints.
7.3 Amanda confirmed that the National Children’s and Day Case Survey had AP
now been issued and would be brought to a future meeting.
7.4 Complaints relating to Ophthalmology were discussed and the significant
actions being taken to reduce the number being received within the Trust
were noted. It was expected therefore that the number of formal
complaints for the specialty would reduce for the next reporting period.
7.5 Mike Viggers commended the Trust on the actions it was undertaking to
make improvements within Ophthalmology and particularly in dealing with
capacity issues.
PB/6/15/08
Quality Strategy
8.1 George Findlay presented the Quality Strategy and confirmed that it set
out the Trust’s ambition in relation to improvements in the quality of care
services provided and programmes of work that would be undertaken over
the next three years to achieve this.
8.2 The Board APPROVED the Western Sussex
Foundation Trust Quality Strategy for 2015-18.
Hospitals
NHS
8.3 It was noted that the Quality Strategy would be of particular benefit for all
staff as a reminder of the quality priorities for the forthcoming years for the
Trust and would help with the day to day delivery of patient care.
PB/6/15/09
Performance Report
9.1 Adam Creeggan, Director of Performance presented the Performance
Report for Month 2, May 2015. He confirmed that on provisional Month 2
positions the Monitor Risk Assessment Framework performance for
Quarter 1 was forecast as 3 penalty points. The Trust continued to report
a ‘managed failed’ in Referral to Treatment (RTT) as part of an agreed
recover planning process and this would generate 2 of the 3 penalty points
in Quarter 1. The remaining compliance failure point related to
underperformance against the 2 week cancer metric.
Minutes page 4
9.2
Adam outlined the key indicators of operational pressure for May as :• 11,599 A&E attendances compared to 12,111 in May 2014 (4.2%).
• 4,411 emergency admissions compared to 4,197 in May 2014
(+5.1%).
• Formally reportable delayed transfers of care totaled 3.75% for
May 2015.
• Occupancy of funded bed stock was 95.7% for May 2015.
9.3 During May the Trust was fully compliant with 96.82% of patients waiting
less than four hours from arrival at A&E to admission, transfer, or
discharge, against a national target of 95%. For context and comparison
Adam confirmed that national data for the period 4th May to 31st May
2015 relating to Type 1 (Major A&E) departments showed compliance of
91.45%. Compliance for Surrey and Sussex Area providers (excluding
WSHFT) for the same period showed 91.04% for Type 1 A&E
attendances, with Western Sussex Hospitals being the highest performer
within the sector.
9.4 The provisional position for May showed the Trust was compliant against
4 out of 7 cancer metrics in month. Board members were reminded that
compliance was determined by the aggregated quarterly position. May
showed non-compliance for urgent 2 week rule patients with performance
of 92.1% (compared to 85.3% in April) against a target of 93% patients
referred to be seen within 2 weeks, and 85.5% for breast symptomatic
patients (compared to 74.3% in April).
9.5 As a related consequence of delays in the 2 week element of the pathway,
compliance for the metric relating to treatment within 62 days of referral
under the two week rule was challenged. May was fully compliant;
however June was forecast to be non-compliant as an unavoidable but
essential consequence of recovery actions. Compliance continued to be
set against significant and sustained increases in demand via the GP 2
week referral route.
9.6 Adam confirmed that the Trust was non-compliant for 62 day referral to
treatment from screening in May with performance of 82.22% against the
target of 90% for this metric, relating to 4 non-compliant pathways of 22.5
in the Month. The Trust remained compliant on an aggregate basis for this
metric for the Quarter to date, and was forecast to be fully compliant in
June and in aggregation for Quarter 1. It was also noted that whilst the
recovery programme had delivered to plan, referrals under the Cancer 2
week rule in May remained above the planned recovery expectation,
+10.3% higher than May 2014, and +21.5% when compared to May 2013.
9.7 In May the Trust completed 10,333 Referral to Treatment (RTT/18 Weeks)
pathways, 3.0% higher than May 2014 in crude terms and 8.3% higher
once adjusted for the working days in May 2015.
9.8 There had been an increase in the total elective waiting list from 33,489 in
March to 34,372, and waiting list growth stood at 24.0% since May 2014.
The continued imbalance between demand and available capacity driving
waiting list growth continued to commit the Trust to recovery actions and
associated non-compliance in all 3 metrics relating to Referral to
Treatment (RTT).
9.9 Delivery of the recovery programme was tracked via incomplete waiting
Minutes page 5
list compliance, and the May position of 88.24% was consistent with the
planned improvement target of 88.38% despite the growth in waiting list
size observed in month. May represents a 0.51% improvement on the
April position of 87.87%.
9.10 The scale of recovery requirement and inherent risks relating to demand
generated a need for continuous monitoring and refinement of recovery
action and associated timeline for return to compliance. This assurance
process would continue through the recovery programme, with the next
System Summit with NHS England, Monitor and CWSCCG scheduled for
10th July 2015.
9.11 Adam confirmed that the Elective transformation programme was
progressing and that the diagnostic phase had been completed.
9.12 The Trust was non-compliant against the diagnostic waiting time metric in
May with 95 patients of 6,628 patients (1.43%) waiting over 6 weeks
against the requirement of no greater than 1%. 57 of the 95 breaches in
May were waiting between 6 and 7 weeks for non-obstetric ultrasound
tests. June was forecast to be a challenged month, but recovery of full
compliance is expected from July 2015.
9.13 Joanna Crane talked about the lack of compliance with the 62 day rule for
treatment for cancer patients and asked how well the Trust was able to
flex up to demand. Adam noted that cancer services were either running
at or exceeding capacity levels and that this had been because of recent
unusual demand spikes. Joanna also commented that the Trust was fairly
regularly non-compliant with the diagnostic waiting time metric. Adam
confirmed that there were recruitment issues with some of the specialties
and the Trust was trying to manage this against the increased referral
rates. He also confirmed that WSHFT compliance continued to better
than at most other Trusts.
9.14 Martin Philips commented on the “Did not arrive” rates for Outpatients
within the Trust and asked if there was anything further which could be
done to bring the rate down. Adam confirmed that improvement to
communication with patients was taking place including sending text
reminders and it was hoped that this would help.
9.15 To conclude the item Mike Viggers summarised the discussion which had
taken place on the Performance Report and the priority actions and key
issues. These included demand management and the ability of the Trust
and local health economy to deliver increased capacity in the form of
sustainable uplift. These requirements would be aided by the Bed
Reconfiguration plan, the elective uplift plan and the delivery of the RTT
sustainability recovery programme. Supporting areas such as protecting
core diagnostic delivery, reviewing Outpatients and pathway redesign with
Primary Care were also important. As such the Board confirmed that they
were assured that progress was taking place.
PB/6/15/10
Draft revised Quality and Operational Performance Scorecards
10.1 Adam Creeggan confirmed that as part of the Trust’s business planning
cycle it reviewed its reporting metrics annually. He noted that for the
2015/16 year this work had been challenged by a number of issues
including the timing of the revision Monitor Risk Assurance Framework
(RAF).
Minutes page 6
10.2 Adam confirmed that alongside the review of the Monitor scorecard, a
detailed review of the Operational Performance Scorecard had been
undertaken against a number of external and internal strategic
requirements. Metrics were reviewed on the following five criteria:
• The metric was nationally mandated to be reported to the Trust
Board.
• The metric was of significant importance for WSHFT as an
organisation.
• The metric described a wide-range of the services offered by
WSHFT.
• Data is made available on a regular basis (ideally monthly) even if
there is a time lag to allow reporting to the board.
• Target, thresholds, benchmarking or control limits are available or
can be generated to add value to the metric for the board to
consider action.
10.3 George Findlay confirmed that the Quality Scorecard had been considered
by the Quality Board and how it linked to the Quality Strategy. Previous
Quality Scorecards had included 90 metrics. For future reporting, it was
proposed, would be under five domains:•
•
•
•
•
Reducing mortality and improving outcomes
Safe care
Improved Patient Experience
Other Quality Metric
Workforce Metrics
10.4 It was also noted that there would be more graphical representation of the
information in the form of run charts which would more easily show
variation.
10.5 George confirmed that the other metrics would continue to be reviewed by
the Quality Board which met bi-monthly.
10.6 Lizzie Peers asked if a seminar could be held on the proposed changes as
she would like to understand more about how the metrics which would be
reported linked to both the Organisational Strategy and Quality Strategy.
She said that she would like to understand more of the detail of what it
was proposed would no longer be reported to the Trust Board. Another
area for consideration and understanding would be the setting of targets
and exception reporting from the Quality Board.
10.7 The Board confirmed that they felt it was appropriate to make changes to
the scorecards and that what had been received was a good start. The
flow of information needed to be considered further.
10.8 It was confirmed that a Board Seminar to discuss the proposed revised GF/JF/A
Quality and Operational Performance Scorecards be held as soon as G
possible
PB/6/15/11
11.1
Organisational Development and Workforce Performance Report
Denise Farmer presented the Organisational Development and Workforce
Performance Report for May 2015.
11.2 Denise confirmed that the new “Time to Hire” system was helping with
areas of recruitment. The recent domestic recruitment campaign had
resulted in offers to 50 nurses some of whom had already started work in
Minutes page 7
the Trust. A further event would take place in Worthing on the 22 July
2015. Denise also confirmed that an international recruitment campaign
was taking place in the Philippines where it was hope to recruit up to 150
nurses.
11.3 Denise reported that that adverts had recently been issued for the posts of
Surgical Care Practitioner which were new posts being created to support
Surgeons.
11.4 Denise outlined the proactive media work which the Trust had been
involved in over the previous month and confirmed that it gave positive
assurance to patients who used the Trusts services.
11.5 Joanna Crane asked if there was a timetable for the potential
improvement actions on staff turnover. Denise confirmed that she hoped
that these would be available for the next report.
11.6 Martin Phillips asked about the time it was taking to hire new staff and
whether measuring areas which were within the Trust Control e.g. the time
to issue offer letters, to ensure the most appropriate processes were in
place.
PB/6/15/12
12.1 Karen Geoghegan presented the Financial Performance Report for the
Trust for Month 2 – May 2015. She confirmed that during the period the
Trust accrued a deficit of £415k in month bringing the year to date position
to £1.2m deficit. It was confirmed that the Trust delivered a Continuity of
Service rating of “3” in the month.
12.2 Karen confirmed that the Trust reported an adverse variance of £390k in
month due to a shortfall in income from clinical activities and pay
pressures. Income from activities at the end of May was cumulatively
below plan by £674k. Although overall non-elective activity was above
plan the greater proportion of short-stay admissions which were paid at a
lower rate was leading to an overall under-performance in non-elective
income. It was also noted that there was slippage against the capital
programme of £165k in May. This was due to lower than expected
expenditure on IT schemes.
12.3 Karen outlined the risks associated with achieving the planned outcome at
year end of delivering a surplus of £992k. This included the management
of patient flow to ensure that activity was able to be delivered within
funded capacity and that any need to use escalation and premium rate
options was minimised. The delivery of the savings with the efficiency
programme and the required uplift in elective activity would also be key.
PB/6/15/13
Other Business
13.1 Mike Viggers confirmed that it was the last Board meeting that Martin
Phillips would be attending as he was shortly due to complete his turn of
office as a Non-Executive Director of the Trust. Mike said that Martin’s
contribution to work of the Trust over the past 7 ½ years should be
celebrated and that in particular his contribution to support the Hospital
Charity and various elements of patient support and safety should be
noted.
Minutes page 8
13.2 Martin thanked the Board for their warm wishes.
PB/6/15/14
Resolution in Board Committee
14.1 The Board resolved to meet in private due to the confidential nature of the
business transacted.
PB/6/16/15
Date of Next Meeting
15.1 It was noted that the next Board Meeting would take place on Thursday
30 July 2015, Boardroom , Washington Suite, Worthing
Barbara Mathieson
Assistant to Company Secretary
July 2015
Signed as an accurate record of the meeting
………………………………………………….
Chair
…………………………………………………
Date
Minutes page 9
WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST
BOARD MEETING HELD ON 2 July 2015
QUESTIONS ASKED/COMMENTS MADE BY MEMBERS OF THE PUBLIC ATTENDING THE
MEETING
No.
Question/Comment
Response
Member of the Public
Offered his congratulations to the Trust on
the positive outcome of the MSK
procurement exercise carried out by Costal
West Sussex Clinical Commissioning Group
Mike Viggers thanked the Public for their
support for the Trust in securing the
outcome for the Trust which was felt to be
very positive.
Margaret Bamford – Public Governor for
Arun
Margaret spoke about two patients who were
suffering from Breast Cancer and their
particular issues with having to travel to and
the treatment received at Brighton. She
asked if there was anywhere else that they
could receive treatment.
Marianne Griffiths shared the plans to build
three LINACS at St Richards and confirmed
that the lead in time would be 18 months
once agreement had been reached with the
partners. This was expected in the near
future.
Margaret spoke about the change over date
for junior doctors being the 5 August and
asked what measures the Trust was putting
in place to ensure quality standards were
maintained and that there were no
safeguarding concerns.
George Findlay confirmed that there was a
robust shadowing period planned and there
would be more senior staff on the wards.
George also noted that at the current time
there were still some vacancies which would
need to be filled by temporary staff. Looking
back at the metrics for previous years
change over periods for junior staff had
confirmed that there were no direct evidence
of any issues or an excess of patient safety
incidents.
Vicki King – Public Governor for Marianne Griffiths confirmed that the
Chichester
learning from the visits were forming the
Vicki asked how the Executive visits to both core part of the Trust’s Patient First
Seattle and Japan would support the Programme. She also noted that each
improvement of patient care within the Trust. project within the programme would have a
baseline metric or survey which success /
improvement would be measured against.
Outcomes would be regularly reported to the
Trust Board and Council of Governors.
Vicki also asked of the Trust consider
reporting other local acute providers
outcomes for areas such as A&E and FFT to
illustrate a comparison.
Adam
Creeggan
confirmed
that
benchmarking and comparison with other
local Trusts was regularly considered
internally within the Trust.
Minutes page 10
John Todd – Public Governor for Adur
John spoke about the improvements in the It was confirmed that the relevant staff would
Stroke Metrics for the Trust and suggested be congratulated on the results.
that the staff should be complimented.
John asked about the time it appeared to be Denise Farmer confirmed that she would be
taking for the Trust to issue appointment happy to follow up on any specific queries
but noted that at the recent nursing
letters.
recruitment events verbal offers were being
made on the day. She also confirmed that
the Trust was following up with various
people who were known to be trained nurses
but who were currently not working.
Minutes page 11
MATTERS ARISING FROM BOARD MEETINGS HELD IN PUBLIC
Matters Arising from Board Meeting held in Public 2 April 2015
Minute Ref
Description of Action
PB/3/15/9.10
With CCG partners undertake analysis of
referrals under Cancer 2-week rule
Responsible
Person
JF/GF
Deadline
Report
July
Analysis to be undertaken with CCG Partners through
Quarter 1 and reported to Trust Board via Performance
report..
Responsible
Person
DF
Deadline
Report
July
July
To be incorporated in July Organisational Development
and Workforce report
On Agenda for meeting on 30 July 2015
Deadline
Report
Matters Arising from Board Meeting held in Public 28 May 2015
Minute Ref
PB/5/15/7.4
Update Board on Development of the
Leadership Strategy
Bring action plan for addressing concerns AP
raised in the National Inpatient Survey to
a future Board meeting
PB/5/15/9.6
Matters Arising from Board Meeting held in Public 2 July 2015
Minute Ref
PB/6/15/5.3
PB/6/15/6.9
PB/6/15/ 7.3
Responsible
Person
Bring presentation to Trust Board on Ward AP/AG
Accreditation Programme.
Undertake analysis of C Diff occurrence
AP
against staffing levels
Circulate National Children’s and Day
AP
Sept
On draft September Agenda
July
Within Quality Report
July
On Agenda for meeting on 30 July 2015
PB/5/15/10.8
Case Surveys
Hold a Trust Board Seminar on the
revised Quality Scorecards
GF/AG
July
Held on 16 July 2015
To:
Trust Board
Date: 30 July 2015
From: Marianne Griffiths, Chief Executive
Agenda Item: 5
FOR INFORMATION
CHIEF EXECUTIVE’S BOARD PAPER
1. A vision for the NHS
I was very pleased to hear Health Secretary, Jeremy Hunt MP’s, announcement this month of a
new partnership between the NHS and Virginia Mason Institute, what he called “perhaps the
safest hospital in the world”. I believe this is a huge vote of confidence in the philosophy behind
our very own Patient First programme
Patient First was inspired by a visit to the VMI more than a year ago now and continues to be
underpinned by its example and practices. Many of the ambitions Mr Hunt outlined in his
speech are ones we are already working towards through our Patient First programme.
He talked about a healthcare system “powered by a culture of learning and continuous
improvement”, with a commitment to “eliminate waste and concentrate on the things that add
real value for patients and staff, leading to better, safer, more efficient care.” And the specifics
too reflect a lot of what is already happening inside our own clinics and on our wards: patient
safety alerts, electronic dashboards, freeing time to care through improved efficiency.
Patient First’s safety huddles, ward accreditation scheme and electronic information screens
are all new initiatives that will make a real difference to patient safety and quality of care.
The pathway the Secretary of State set out for the trusts that will be working with Virginia
Mason is a five-year one at minimum. We are already at least a year down that road and in a
great position to make further strides - the new practices we have put in place so far are only
the tip of the iceberg.
There is also a huge amount of educational and planning work also going on to enable us to roll
out the Lean principles behind Patient First right across the organisation.
It’s a hugely exciting time for this trust and the community we serve and remains a great
opportunity for us all to take control and ensure we become one of the best trusts in the country
providing the highest quality, safest care.
Patient First Staff Achievement and Recognition (STARS) Awards
I am truly delighted to report that we received more than 300 nominations for this year’s awards
before the closing date of July 12. That is more than double the figure for 2014 and thank you to
everyone who has already completed a form
It is heartening to think that so many members of staff and volunteers feel they work alongside
colleagues and teams who they believe deserve recognition and that patients and relatives
have been so touched by the quality of care received that they have taken the time to complete
and submit a nomination.
The members of the judging panel, made up of patient, staff and governor representatives now
have the difficult task of deciding on the winners of each of the ten categories, ahead of our
glittering ceremony in October.
Ward information screens
Screens are now in place on wards across the Trust and were due to be switched during the
week of our July board meeting. The screens provide a range of information to patients, visitors
and staff including staffing levels, patient safety, uniform guides, feedback and visiting guides.
Ward Accreditation Programme
This programme, which recognises excellent care and supports continuous improvement, also
continues, with wards being assessed against a range of criteria and includes interviews with
staff and patients as well as ward observations.
Welcome home packs
Older people returning home after a stay at Worthing Hospital will benefit from a new scheme
initiated by staff and supported by volunteers and local supermarkets. Welcome Home Packs,
containing essentials like milk, bread, cheese and fruit, will help frail and isolated patients to be
more comfortable on their first night back home. Some patients have told us how stressful it
was returning home to an empty house where there was nothing fresh to eat. Therefore we are
pleased our new Welcome Home Packs address that basic need, making sure they will have
food nearby. By providing a sandwich, cake and a drink to tide them over, we will take some of
the pressure out of that first day back home and aid their recovery.”
The idea of providing goody bags was raised at a Patient First meeting where staff discuss how
to further improve services for patients. The Trust’s Lead Governor Margaret Bamford was
present and felt inspired to make Welcome Home Packs a reality.
Morrison’s, Sainsbury’s, Tesco and Waitrose in Worthing are all backing the scheme, rallying
the wider community in support of the hospital’s Welcome Home Packs. The supermarkets will
donate the groceries to go in the bags, apart from Waitrose which is helping to fund the scheme
through its Community Matters charitable initiative.
Throughout July, shoppers at the town centre store can donate their green tokens from the
checkout to support Welcome Home Packs for older patients at Worthing Hospital. Welcome
Home Packs are being piloted at Worthing from September before the scheme is replicated at
St Richard’s.
2. Nursing recruitment drive
This recruitment campaign is designed to help us overcome a shortfall of more than 20,000
trained nurses available to work in the UK and I am delighted to report that we had a very
successful trip to the Philipines, offering more than 100 highly-trained nurses nurses roles here
at the trust. The new recruits undergo rigorous English-language tests set by the British Council
and follow the Nurcing and Midwifery Council’s registration process. It is hoped the first will
arrive by the end of the year, with the remainder joining the trust in 2016.
Page 2 of 4
It has been more than a decade since teams from Worthing and St Richard’s last visited the
country and many of the nurses recruited then, still live and work in West Sussex and refer to
the UK as ‘home’.
The overseas recruitment is in addition to the jobs offered to 50 nurses as a result of the
ongoing nursing recruitment drive locally. Open and Selection Days are being held throughout
the summer:
 Wednesday 22 July at Worthing Hospital
 Wednesday 2 September at St Richard’s Hospital
 Wednesday 14 October at St Richard’s Hospital
3. Care Quality Commission (CQC) date for standard inspection
The CQC has now confirmed the date for their standard inspection as December 8- 11 this
year. The inspection is an opportunity for teams to demonstrate the excellent care they provide.
4. End of Life Care
Some of the good work being championed by Trust Chairman Mike Viggers around end-of-life
care has been featured on national television. The Trust was part of a Channel 5 News series
on this important issue, aired between July 20 and 25. Debbie Peters, Matron for End of Life
and Palliative Care, and Dr Gordon Caldwell spoke to the cameras about some of the initiatives
the Trust has put in place to ensure patients’ wishes are prioritised and acted upon in their final
days and weeks. These include:






the introduction of an end of life care matron
working with Macmillan, our local hospices and community NHS partners to develop
consistent guidelines for end-of-life care, to make sure all patients receive the same
high standards of care and communication, wherever they are being looked after
the introduction of advanced care plans to offer all patients in the final weeks and
months of their lives the opportunity to express their personal and spiritual wishes for
what they would like to happen over the period ahead,
partnerships with local hospices St Barnabas House in Worthing and St Wilfrid’s in
Chichester, to provide specialist advice and support to staff and patients
rapid discharge processes to ensure people who wish to spend their final days in their
own home are provided with appropriate support to ensure that happens
all junior doctors attend training placements at t either St Barnabas or St Wilfrid’s to
learn not just the clinical skills but the inter-personal ones that are very often every bit as
important to the care of patients approaching their final days.
5. Employee of the month
I am delighted to reveal that June’s Employee of the Month is Abigail Crick. Abby, as she is
known to her colleagues, was nominated by Kelly Salter for the many and various
improvements she has made to the Trust’s sleep clinic.
Page 3 of 4
Abby is described as proactive, pragmatic and a valued member of the team. Abby noticed that
some patients were becoming confused about which appointments to attend and that the
department was fielding lots of calls as a result. In order to improve the experience for patients
attending the clinic, Abby has increased the information available for them and changed
appointment letters to make them clearer. The result is patients feel less anxious about their
appointments, and the number of calls to the department has reduced.
Abby has also begun mentoring and training a new member of the team, despite being in post
herself for less than a year.
Kelly adds: “Abby is a resilient member of staff who fully engages in her role and always adopts
a ‘can do’ attitude. She is extremely helpful and often goes above & beyond to accommodate
request from patients and colleagues.”
6. Welcome to new colleagues
I am pleased to announce the appointment of Dr Daniel Quemby (GMC: 6030455) to the
position of Fixed Term Consultant in Anaesthetics based at St Richard’s Hospital from 3rd
August 2015 as well as Dr Ankur Arora (GMC: 7176669) to the position of Fixed Term
Consultant in Radiology from 6th July 2015.
Page 4 of 4
To: Trust Board
Date of Meeting: 30th July 2015
Agenda Item: 6
Title
Month 03, 2015/16 Quality Report
Responsible Executive Director
Dr George Findlay (Medical Director) and Amanda Parker (Director of Nursing and Patient Safety)
Prepared by
Jamie Cochrane (Planning and Performance Manager).
Status
Disclosable
Summary of Proposal
Not applicable
Implications for Quality of Care
Describes performance against quality outcome KPIs, including safety, infection control, experience,
effectiveness and mortality.
Link to Strategic Objectives/Board Assurance Framework
This report pulls together key national, regional and local quality indicators relating to quality and safety
providing assurance for the board and (if necessary) highlighting issues.
Financial Implications
Describes KPIs that have potential financial impact (e.g. CQUIN)
Human Resource Implications
Describes KPIs linked to workforce
Recommendation
The Board is asked to: Note the contents of this report.
Communication and Consultation
Not applicable
Appendices
Appendix I: Quality Scorecard
Appendix II: Ward Staffing Scorecard
1
INTRODUCTION
1.1
This report brings together key national, regional and local quality indicators relating to quality and
safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within
Western Sussex Hospitals Foundation Trust (WSHFT).
1.2
The paper describes performance on an exceptional basis determined by RAG (red/amber/green)
ratings based on national, regional or local targets. Further quality items are shown as dashboards in the
appendices.
2
2015/16 RFRESH
2.1
As part of the refresh of the Quality Strategy outlining key quality objectives for the next three years, this
report will be refreshed and redesigned. The Trust Quality Board has reviewed and approved a new
format with a view to making a recommendation to the Trust Board. A discussion took place at the last
Trust Board and this will be progressed shortly.
2.2
As described in April, to provide assurance in the interim period, the format and metrics used for
2014/15 have been used. Targets for this interim period have been applied according to the following
hierarchy: 1. Where national targets are available these are applied, 2. Where specific local targets or
thresholds have been previously agreed these have been applied, 3. where the 2014/15 targets were
based on 2013/14 levels, these have been refreshed to use the 2014/15 levels as a benchmark. (Any
exceptions to this are noted below).
2
Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board
3
KEY QUALITY OBJECTIVES
3.1
Dashboard Definitions
3.1.1
The full Clinical Quality Dashboard is presented as Appendix I. Figures are in-month figures (e.g. the
number of falls reported in June) unless otherwise stated. The dashboard shows 13 months to allow
trends to be identified, although some data items are reported retrospectively. Year to date
actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios
are recorded as 12 month positions). A subset of the key measures from the report is presented at 3.3.
3.1.2
Exception reports are included under the relevant section of this report (i.e. under the broad headings
Effectiveness, Safety and Experience).
3.1.3
Only the current financial year and year to date values are RAG rated, with the exception of those
metrics reported in arrears with no data in the current financial year where the most recent data-point of
last year is RAG rated.
3.2
Domain scores
3.2.1
The domain score is an overall indication of the performance in relation to each of the three areas. The
score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1,
ambers score 2, greens score 3. These scores are then totalled and divided by the total number of
indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score
can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red
score for the domain as a whole. For example if a domain had two greens and a red the calculation
would be as follows:
3 (green) + 3 (green) + 1 (red) = 7
7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.
3.2.2
Year to date domain scores are calculated based on the year to date RAG ratings for each metric.
Previous months are retrospectively updated to take account of any measures reported in arrears.
3.2.3
As with any aggregate indicator, it remains essential that the board retains sight of the individual
elements as well as the domain score as a whole.
3
3.3
Overview of Key Quality Objectives
3.3.1
The following table shows performance against key, top level quality objectives.
Indicator
Apr
May 2015
Jun 2015
2015
2015/16
2015/16
to date
Target /
limit
Effectiveness Domain Score
2.33
2.47
2.64
2.38
2.5
Safety Domain Score
2.28
2.44
2.78
2.56
2.5
Experience Domain Score
2.67
2.60
2.60
2.60
2.5
3.23%
2.82%
2.99%
3.01%
3.27%
<92
E01 Trust crude mortality rate (non-elective)
E02 Hospital Standardised Mortality Ratio for top
91.2
91.2
56 diagnoses (Dr Foster, based on rolling 12
(data to
(data to
Mar)
Mar)
months)
S05 Number of Serious Incidents Requiring
7
7
3
17
60
S14 Numbers of hospital attributable MRSA
0
0
0
0
0
S28 Numbers of hospital C. diff where a lapse in
0
2
1
3
18 (national
Investigation (number reported in month) (note:
unlike previous years, this includes falls resulting
in fracture).
the quality of care was noted
target = 39)
X01 The Friends and Family Test: Percentage
94.0%
94.4%
95.3%
94.2%
91.7%
91.1%
91.1%
91.3%
0
0
0
0
0
43
48
44`
135
570
Recommending Inpatients
X02 The Friends and Family Test: Percentage
Recommending A&E
X15 Mixed Sex Accommodation breaches (for
clarity the number of breaches is reported here,
but in the scorecard, in line with the reporting of
this metrics in other Trust scorecards this is
expressed
as
a
proportion
of
Consultant
Episodes)
X20 Number of complaints
4
4
EFFECTIVENESS
4.1
Crude Trust Mortality
4.1.1
Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to
non-elective activity. The Trust will continue to use the previous year as a benchmark.
4.1.2
Crude non-elective mortality rose from 2.82% in May to 2.99% in June, but remained slightly lower than
the equivalent month in 2014 (June 2014 = 3.01%). As such the 12 month mortality remained 3.28%.
4.2
Hospital Standardised Mortality Ratio (HSMR)
4.2.1
There is a delay in data being available in Dr Foster tools to allow for coding and processing by the
Health and Social Care Information Centre and Dr Foster. As such, the most recent data available is
March 2015. WSHFT HSMR for the twelve months to March 2015 is 91.2 (where 100 is the level
predicted by the Dr Foster model).
4.2.2
The twelve month HSMR to March 2015 split by site is lower for St Richards (87.0) than for Worthing
(94.5), however both are lower than 100.
5
4.2.3
This data is rebased to take account of improvements in national performance during 2013/14. In
addition, Dr Foster now make available data using quarterly and monthly benchmarks (i.e. data
benchmarked against national performance up to September 2014). The 2013/14 benchmark is shown
in the scorecard. The WSHFT position, however, is below 100 using each of the available benchmarks.
From next month a more recent benchmark will be used. This will have the effect of increasing the
WSHFT HSMR to approximately 96, but will be more sensitive to detect potential alerts.
4.2.4
A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high
actual versus expected mortality and any mortality CuSum alerts.
4.3
Summary Hospital-Level Mortality Indicator (SHMI)
4.3.1
The latest data was published by the Health and Social Care Information Centre in April. For the period
October 2013 to September 2014 the Trust SHMI score was 1.02 (where 1.00 is the national average),
with the Trust banded as ‘as expected’.
4.4
Exception Reports Relating to Effectiveness
4.4.1
Exception report relating to E07 Crude Non-elective mortality relating to renal failure (acute kidney
injury): The percentage mortality for this disease group was higher than target. There actual number of
deaths for this disease group was only marginally higher than previous months. The high percentage
was the result of a smaller denominator that usual. This may change as further records are coded. The
year to date percentage remains within target.
6
5
SAFETY
5.1
Central Alert System (CAS) Safety Alerts
5.1.1
There are no outstanding alerts for the Trust relating to June 2015 or earlier.
5.2
Serious Incidents Requiring Investigation (SIRIs)
5.2.1
There were 3 incidents which occurred in June that have initially been graded as serious incidents
requiring investigation. A detailed SIRI report is provided to the Committee section of the Trust Board.
The Board should note there is a slight variation in the month by month numbers between the SIRI
report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas
the latter assigns them to the month in which the SIRI was raised. (The SIRI report records 18 SIRIs
reported in April to June, compared to 17 occurring in these months).
5.2.2
Recent actions undertaken/planned following SIRIs include ensuring that, where wards have changed
specialty, appropriate training and education equipment and relevant documentation is made available
(in relation to a delayed diagnosis), refresher training on falls prevention at the Surgical Sisters’ Meeting
and the rollout of the new standardised intentional rounding form across all wards which is much clearer
in relation to the use of equipment (in relation to falls) and changes to the process for radiological review
(in relation to a delayed diagnosis).
5.3
Infection control
5.3.1
There were zero cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia during June.
5.3.2
There were two cases of hospital attributable Clostridium difficile during June; both on the Worthing site.
7
5.3.3
The 2 cases in June equate to a rate of 7.7 cases of C diff per 100,000 bed days. This compares
favourably with the national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range
10.3 to 17.6) (source: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annualdata).
5.3.4
Of the two cases in June one was related to a lapse of care, where staff had failed to follow trust policy
on sampling. Within the ward staff have been reminded of the need to send timely samples in line with
the guidance available.
5.3.5
An analysis was undertaken of C diff cases that occurred between September 2014 and June 2015 to
identify if staffing vacancy would appear to contribute to cases that occurred during the winter months
when activity was higher.
5.3.6
The review looked at 26 cases of which 14 were considered to involve a lapse of care. The cases
occurred within 17 ward areas. Staffing vacancy and the ability to use temporary staffing to supplement
staffing were considered.
5.3.7
Following review the Director of Infection Prevention and Control concluded that all areas bar two had
covered their vacancy factor with temporary staffing during the month the C Diff case occurred.
5.3.8
Of the wards where the vacancy was not covered, one case was not deemed a lapse of care. In the
lapse of care instance the lapse was related to failure to clean equipment and commence
documentation. This may be related to staffing at the time and is the only case where there appears to
potentially have been an impact.
5.3.9
There appears to be no overall evidence to conclude that staffing impacted on the occurrence of C diff
cases during the winter period.
5.4
Falls
5.4.1
In June there were 27 falls resulting in harm against a benchmark of 43.
5.4.2
There were no falls resulting in severe harm or death in June.
5.4.3
Of the 27 falls in June, in 7 instances the patient had previously fallen during the inpatient stay.
8
5.4.4
The 27 falls equate to 1.04 falls resulting in harm per 1000 occupied bed days compared to the national
benchmark of 2.5 (Royal College of Physicians Report of the 2011 Inpatient Falls Pilot Audit). Other
sources, such as the South East Coast Quality Observatory showing NHS Safety Thermometer data
also
confirms
that
WHSFT
has
a
low
level
of
falls
resulting
in
harm
(source:
http://www.qualityobservatory.nhs.uk/index.php?option=com_cat&view=item&Itemid=&cat_id=588).
5.4.5
As part of the Trust’s membership of NHS QUEST (a network of Foundation Trusts who wish to focus
relentlessly on improving quality and safety), the Trust is engaged in the Breakthrough Series
Collaborative: Falls Programme.
5.5
Tissue Viability
5.5.1
The guidance on reporting and categorisation has been reviewed and as such trust reporting of pressure
ulcers has changed in the last year. These changes are as follows:
•
Patients who develop pressure ulcer after admission but within 72 hours are now treated as
hospital acquired harm.
•
Patients with grade 2 ulcers (community or hospital origin) that deteriorate to grade 3 during
admission must be reported as such.
•
Patients who sustain pressure injury due to a device (e.g. a surgical collar, Plaster of Paris) are
now reported as pressure ulcer (previously would not have be reported)
•
Patients with pressure ulcers where depth of wound is not possible to measure due to slough
are now classed as ungradeable but are treated as potentially at least 3 or 4 unless shown
otherwise (previously would be treated as category 2 unless shown otherwise)
5.5.2
A detailed review of the impact of these changes has been undertaken in relation to ulcers recorded
from April 2014 onwards. As a result the number of reported grade 3+ incidents for 2014/15 is now 11.
Data in the scorecard for April and May 2015 have been updated retrospectively to include the addition
ulcers identified. Data for last financial year have not been changed.
5.5.3
The target (based on last financial year) has been removed from the time being as it clearly does not
reflect the inclusion of the categories outlined above.
5.5.4
Based upon the new reporting arrangements, during June the Trust reported 10 cases of grade 2
hospital acquired pressure ulcers (including 2 patients where existing grade 1 ulcers deteriorated).
9
5.5.5
In addition to this there was a hospital acquired grade 3 pressure ulcers (a grade 2 which deteriorated).
There were no grade 4 pressure ulcers.
5.5.6
The incidence of pressure ulcers (including those developing within 72 hours after admission) per 1000
bed days in June was 0.35.
5.5.7
There were 67 patients admitted to the Trust from the Community with pressure damage.
5.6
NHS Patient Safety Thermometer
5.6.1
The NHS Patient Safety Thermometer is used across all relevant acute wards. This tool looks at point
prevalence of four key harms (falls, pressure ulcers, urinary tract infections and deep vein thrombosis
(DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard
showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score is
available to each ward.
5.6.2
The harm-free care score for the Trust in June was 97.3% (indicator S02), better than the target of
93.8% (target based on national average for 2014/15).
5.6.3
The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to
admission. The actual number of patients with no new harms during their inpatient stay at WSHFT
(indicator S03) was 98.97%. A new target of 99% of patients suffering no new harms following
admission for 2015/16 has been set within the Trust Quality Account. This will prove a stretching target
as it is considerably higher than the national average of 97.7%.
5.6.4
National data relating to the NHS safety thermometer is available here:
http://www.safetythermometer.nhs.uk/
5.6.5
As part of the Trust’s 2015/16 CQUIN programme, WSHFT are rolling out the use of the Medication
Safety Thermometer – a separate, but complementary data collection focused on appropriate
prescription and administration of medicines – across all key wards during 2015/16.
10
5.7
Exception Reports Relating to Safety:
5.7.1
Exception Report: Indicator S09 – Total Moderate or above medication incidents: There was one
moderate incident relating to medication or prescribing in June. This incident is still under review.
5.7.2
Exception Report: Indicator S10 – Anti-microbial prescribing audits: The quarter 1 audit has taken place.
These results are currently being compiled and will be included in next month’s scorecard.
11
6
PATIENT EXPERIENCE
6.1
PALS and Complaints
6.1.1
All complaints are responded to by the Trust Office. The process is administered by the Customer
Relations Team. The Quarterly Complaints Report provides an in-depth analysis of trends and lessons
learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the
Trust Board.
6.1.2
During June 2015 the Trust received 44 complaints (two of which were graded as high resulting in
further investigation).
6.1.3
Worthing
Southlands
Chichester
Total
All complaints
25
1
18
44
High grade complaints
1
0
1
2
The majority of complaints in June related to clinical treatment. These were not attributable to one
clinical site or area.
6.2
Friends and Family Test (FFT)
6.2.1
Patients who access hospital services are asked whether they would recommend WSHFT to their
friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case,
A&E and maternity are all offered the opportunity to respond to the question (plus a number of other
areas outside the scope of the official friends and family data collection).
6.2.2
Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can
address problems or get positive feedback as quickly as possible. In addition to this a dashboard is
available giving wards access to their individual scores and a poster printed with ward performance to
display to the public.
6.2.3
Friends and Family Test Response Rates: As described previously the criteria for inclusion in Friends
and Family changed significantly for 2015/16. Specifically the changes are as follows:
i)
The inclusion of paediatric patients in the A&E denominator.
ii)
The inclusion of elective day-cases in the inpatient denominator.
iii)
The inclusion of short stay non-elective patients in the inpatient denominator.
12
6.2.4
The table below shows the impact of the changes on the numerator and denominator:
Eligible patients
Average
Responses
Jun 2015
Average
2014/15
Jun 2015
2014/15
Inpatients
2791
5999
963
1138
A&E
6778
8973
1827
1647
6.2.5
As such the reduction in response rates actually reflects an increased denominator rather than fewer
responses.
6.2.6
Data collection has commenced in Paediatric A&E and further work is being undertaken to increase the
response rate in day case areas.
6.2.7
Friends and Family Test Recommend Rates: In line with national guidance the Friend and Family test is
now reported as a ‘percentage recommending’ score (calculated as the percentage of respondents
indicating they were either ‘highly likely’ or ‘likely’ to recommend the service divided by the total
respondents including ‘don’t knows’). National performance is published on the NHS England website:
http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/
6.2.8
Targets will be agreed in relation to the new scores for 2015/16. The table below shows the latest local
scores against national benchmarks:
Percentage
recommending
WSHFT in June (year to date in
National median (April 2014 to
March 2015)*
brackets)
Inpatient care
95.3% (94.5%)
94.1%
A&E
91.1% (91.3%)
86.8%
Maternity: Delivery care
96.5% (96.5%)
95.4%
Outpatient care
84.7% (88.3%)
No benchmark
* Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted
above.
6.3
Feedback from Hospital Experience Questionnaires
6.3.1
Detailed results from the Real-Time Patient Experience (RTPE) project are routinely fed back to
divisions and wards. 153 inpatients gave their views on the Trust using the RTPE system in June.
13
6.4
Exception Reports Relating to Experience
6.4.1
None to note.
7
CARE QUALITY COMMISSION (CQC)
7.1
CQC Compliance
7.1.1
The CQC have informed the Trust that they have been forced to postpone their inspection of the Trust
due for October 2015. Revised dates are expected shortly.
7.2
CQC Intelligent Monitoring Reports
7.2.1
The latest CQC Intelligent Monitoring Report was published in May 2015 and is available on the CQC
website via the following link:
http://www.cqc.org.uk/sites/default/files/RYR_105v3_WV.pdf
7.2.2
The Trust is now banded as 6 (where 6 is the lowest risk) for priority for inspection.
8
NATIONAL AND LOCAL REPORTS
8.1
Ward screens project: New information screens, funded by Love Your Hospital charity, are being piloted
in three areas across the Trust - AMU and Ford at St Richard’s and Durrington. Similar screens are due
to go live in all medical and surgical wards in the coming weeks. These screens display information to
patients, visitors and staff including staffing levels, patient safety metrics (safety thermometer, falls,
infection control and pressure ulcers), user experience (friends and family and realtime patient
experience), uniform guides, and visiting times. Staff are encouraged to ask questions about the
information so they can in turn help patients and visitors understand it. The content is individualised for
every ward and will also be available via the Trust’s public website. The screens also provide staff
members who do not have regular access to email another way of finding out about Trust meetings,
events, and key messages.
14
9
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
9.1
Since 2009/10 a proportion of the money the Trust receives has been payable on achievement of
agreed quality metrics.
9.2
Agreement has been reached in relation to 2015/16 CQUIN measures. National measures include care
for patients suffering acute kidney injury and sepsis, reducing urgent care admissions and continuation
of the national dementia screening measures. The local CQUIN programme for 2015/16 relates to seven
day services, care for patients with diagnosed dementia (in addition to the national screening project),
supporting patients during end of life care, increasing training in mental capacity assessment, and roll
out of the medication safety thermometer and ward accreditation.
10
RECOMMENDATION
10.1
The Board is asked to note the contents of this report.
15
Operational Planning and Performance: Quality
QUALITY SCORECARD
JUNE 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
YTD
Actual
2.33
2.47
2.64
2.38
YTD
Target
Target
Trend
EFFECTIVENESS
Effectiveness domain score
Trust-wide mortality
E01 Trust crude mortality rate (non-elective)
3.01%
2.90%
3.44%
2.82%
2.83%
2.74%
3.64%
4.24%
4.22%
3.44%
3.23%
2.82%
2.99%
3.01%
2.98%
3.27%
E02 Crude mortality rate (non-elective): 12 month rolling
3.14%
3.09%
3.16%
3.16%
3.16%
3.15%
3.17%
3.21%
3.25%
3.27%
3.30%
3.28%
3.28%
3.28%
3.27%
3.27%
E03 Trust Hospital Standardised Mortality Ratio (HSMR)
95.4
93.3
95.4
94.6
94.1
93.3
92.6
92.3
92.1
91.2
92
92
E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M)
0.99
1
1
19.9%
19.9%
1.02
Improve mortality in specific conditions
E07 Crude non-elective mortality for Renal failure
25.0%
15.0%
21.7%
12.5%
23.8%
30.8%
23.8%
17.4%
19.4%
34.8%
13.8%
13.3%
30.0%
17.7%
E09 SMR for hip fracture (all diagnoses/procedures)
112.4
110.2
108.9
105.1
99.2
93.4
90.0
96.7
89.5
75.8
100
100
E09a Worthing SMR for hip fracture (all diagnoses/procedures)
128.5
129.4
134.1
132.1
125.9
121.8
118.9
122.5
115.6
105.7
100
100
E09b St Richard's SMR for hip fracture (all diagnoses/procedures)
89.5
84.2
74.3
67.9
64.6
59.0
53.4
64.7
58.8
40.1
100
100
E10 30 day mortaliy rate following hip fracture
4.6%
11.1%
13.4%
9.7%
6.2%
7.5%
11.1%
10.8%
8.0%
2.9%
2.5%
2.5%
8.2%
8.2%
13.6%
13.2%
13.9%
12.3%
13.6%
12.9%
12.3%
12.9%
13.3%
12.3%
12.7%
13.7%
13.7%
13.5%
13%
13%
E13 C-Section Rate
25.9%
28.5%
26.0%
26.7%
28.7%
24.1%
29.9%
30.1%
26.3%
24.1%
29.4%
24.2%
27.6%
27.1%
26%
26%
E14 % Mothers requiring forceps for delivery
9.8%
12.6%
11.3%
9.2%
12.5%
12.6%
10.6%
10.4%
14.2%
13.4%
10.5%
11.1%
10.8%
10.8%
<15%
<15%
E15 % Deliveries complicated by post-partum haemorrhage
0.2%
1.0%
0.7%
1.3%
0.2%
0.5%
0.2%
0.5%
1.0%
0.9%
0.4%
0.2%
0.4%
0.3%
1%
1%
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0.9%
2.8%
3.1%
2.5%
2.9%
1.8%
2.0%
3.3%
2.4%
2.7%
1.8%
2.5%
3.1%
2.5%
<10%
<10%
E18 % Emergency admissions staying over 72h screened for dementia
92.1%
95.4%
92.5%
90.9%
92.6%
90.8%
89.6%
96.0%
90.3%
93.4%
93.4%
94.9%
97.6%
95.3%
90%
90%
% Patients identified as at risk of dementia for whom further
E19
investigations are carried out
94.2%
97.2%
90.1%
92.3%
91.3%
91.3%
90.8%
94.2%
90.9%
87.1%
85.7%
96.5%
95.3%
92.5%
90%
90%
E20 % Patients with identified dementia referred to specialist services
96.7%
100.0% 100.0% 96.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
90%
90%
tbc
tbc
Reduce mortality following hip fracture
Reduce the rate of readmission following discharge from the Trust
E11 Emergency readmissions within 30 days %
To improve maternity care by encouraging natural chilbirth
E16 Maternal deaths
E17 Admission of term babies to neonatal care
Caring for the elderly patient
100.0% 100.0% 96.6%
E25 Number of admissions for patients with dementia flag
163
147
146
149
E39 Ward moves for patients flagged with dementia
82
84
54
113
E42 Night-time ward moves for patients flagged with dementia
41
44
33
32
86.6%
69.6%
60.9%
70.1%
75.4%
E43
Documentation Audit: % patients with dementia with Knowing Me
document
6a Quality scorecard 1516_M03_v2.xlsm.Quality Scorecard
144
130
208
233
181
185
222
186
186
59
71
130
190
124
105
132
107
118
357
tbc
tbc
32
38
61
75
35
44
37
42
39
118
tbc
tbc
76.2%
72.8%
67.5%
74.8%
97.8%
95.4%
97.8%
99.4%
97.6%
75%
75%
Page 1 of 6
594
Printed 23/07/2015 15:04
QUALITY SCORECARD
JUNE 2015
JUN
YTD
Actual
YTD
Target
Target
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
E26 % CT scans undertaken within 12 hours
76.3%
81.6%
81.7%
81.2%
80.6%
80.3%
89.2%
91.1%
97.4%
93.3%
88.6%
93.5%
90.9%
95%
95%
E27 % Stroke thrombolysis within 60 minutes of hospital arrival
100.0% 61.1%
20.0%
56.3%
42.9%
83.3%
57.1%
77.8%
58.3%
77.8%
55.6%
83.3%
71.4%
95%
95%
E28 % Swallow screen for stroke patients within 4 hours of admission
77.4%
73.3%
79.6%
79.6%
72.1%
80.4%
79.7%
73.8%
81.3%
82.4%
80.0%
73.5%
76.8%
95%
95%
E29 % of stroke patients admitted to stroke unit within 4 hours of admission
74.6%
71.6%
80.4%
71.6%
72.6%
64.4%
63.4%
68.4%
76.3%
80.7%
83.8%
78.7%
81.4%
90%
90%
E30 % high risk TIA patients seen within 24 hours
63.6%
66.7%
90.0%
92.9%
84.0%
69.2%
87.5%
60.0%
81.3%
80.0%
50.0%
50.0%
60%
60%
E21 Patients recruited to interventional studies within CRN portfolio
25
12
29
13
8
6
12
24
15
9
15
7
17
39
n/a
n/a
E22 Patients recruited to observational studies within CRN portfolio
30
35
46
60
103
269
60
65
115
100
44
39
31
114
n/a
n/a
E23 Local Clinical Research Network (LCRN) Score
155
95
191
125
143
299
120
185
190
145
119
74
116
309
326
1305
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
99.9
96.1
96.1
81.0%
83.0%
83.0%
84.0%
85.0%
83.0%
83.0%
84.0%
85.0%
84.0%
85.1%
83.0%
84.7%
tbc
tbc
Trend
Stroke care
Ensure active engagement with research
Data Quality
E24 NHS IC Data validity summary (YTD)
E37 % inpatients with electronic discharge summaries produced
Page 2 of 6
85.0%
Printed 23/07/2015 15:04
QUALITY SCORECARD
JUNE 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
YTD
Actual
2.28
2.44
2.78
2.56
YTD
Target
Target
Trend
SAFETY
Safety domain score (Patient Aggregate Safety Score - PASS)
Safer staffing
S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts)
97.3%
97.6%
97.1%
96.8%
96.7%
97.1%
95.4%
95.5%
94.2%
95.5%
97.0%
96.8%
96.6%
96.8%
tbc
tbc
Safer Staffing: Average fill rate - registered nurses/ midwives (night
shifts)
98.1%
98.5%
97.6%
97.5%
97.5%
98.0%
95.8%
96.9%
96.3%
95.6%
97.5%
97.6%
97.3%
97.5%
tbc
tbc
S38 Safer Staffing: Average fill rate - care staff (day shifts)
95.9%
96.2%
96.3%
95.9%
94.4%
93.3%
91.3%
90.5%
89.5%
91.7%
93.8%
93.0%
93.9%
93.6%
tbc
tbc
S39 Safer Staffing: Average fill rate - care staff (night shifts)
98.1%
98.2%
97.1%
97.4%
97.2%
95.3%
91.1%
93.3%
92.0%
92.9%
94.7%
93.3%
95.0%
94.3%
tbc
tbc
S02 Safety Thermometer: % of patients harm-free
94.3%
94.7%
95.0%
93.7%
94.4%
94.1%
95.5%
93.8%
94.5%
96.6%
96.3%
95.3%
97.3%
96.3%
S03 Safety Thermometer: % of patients with no new harms
98.0%
98.0%
98.0%
98.3%
97.6%
97.6%
98.6%
98.1%
98.5%
99.0%
98.6%
98.0%
99.0%
98.5%
99%
99%
0.26%
0.12%
0.24%
0.23%
0.26%
0.21%
0.23%
0.11%
0.22%
0.44%
0.11%
0.00%
0.19%
0.2%
0.2%
S37
NHS safety thermometer
Safety Thermometer CQUIN: % of patients with catheters and UTIs where
S29
0.12%
best practice protocol was not followed.
Monitoring of clinical incidents
93.82% 93.82%
S04 Total incidents
768
969
803
768
810
709
839
789
726
755
725
760
733
2218
20312747
8122 10988
S05 Total moderate, severe or death incidents
10
16
6
15
16
8
15
11
16
8
15
13
12
40
38
153
S06 Total serious incidents (SIRIs)
2
10
2
6
4
2
9
6
7
2
7
7
3
17
15
60
S07 Number of outstanding CAS alerts
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
101
99
104
102
115
107
112
98
67
103
74
83
98
255
264-357
1056 1428
1
0
0
0
0
0
0
0
0
2
1
0
1
2
1
5
80%
80%
Improve safety of prescribing
S08 Total incidents involving drug/prescribing errors
S09 Moderate/severe incidents involving drug/prescribing errors
S10 Reduced errors on zero tolerance anti-microbial prescribing audits
59%
58%
53%
60%
Reduce incidence of healthcare acquired infections
S14 Number of hospital attributable MRSA cases
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
S15 Number of hospital C.diff cases
3
1
8
3
2
3
5
3
1
2
0
5
2
7
10
39
S28 Number of C. diff cases where a lapse in the quality of care was noted
2
1
4
2
0
2
3
3
0
1
0
2
1
3
5
18
S16 Number of reportable MSSA bacteraemia cases
6
5
5
4
6
8
9
8
6
6
4
6
8
18
n/a
n/a
S17 Number of reportable E.coli cases
22
23
37
18
19
25
29
27
25
37
21
23
25
69
n/a
n/a
Page 3 of 6
Printed 23/07/2015 15:04
QUALITY SCORECARD
JUNE 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
YTD
Actual
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
YTD
Target
Target
Trend
Improve theatre safety for patients
S18 Full compliance with WHO Surgical Safety Checklist
S19 NEVER events
S30 SSIs: Total hip replacement (YTD is rolling 12 months)
0.5%
1.0%
1.1%
tbc
tbc
S33 SSIs: Total knee replacement (YTD is rolling 12 months)
0.7%
1.6%
1.2%
tbc
tbc
S34 SSIs: Large bowel surgery (YTD is rolling 12 months)
14.6%
10.7%
15.6%
tbc
tbc
S35 SSIs: Breast surgery (YTD is rolling 12 months)
3.8%
5.1%
3.4%
tbc
tbc
Reduce number of falls in hospital
S21 Falls resulting in harm
35
53
47
47
44
38
46
42
32
45
42
34
27
103
128
513
S22 Falls resulting in severe harm or death
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
93.8%
90.5%
90.5%
92.0%
92.0%
87.5%
85.0%
92.5%
92.0%
90.5%
92.0%
96.5%
85.0%
91.2%
80%
80%
0.91%
1.15%
0.53%
1.35%
1.16%
0.77%
1.09%
0.55%
0.57%
0.74%
0.76%
0.76%
S23 Falls assessment within 24hrs of admission
S24 Avoidable falls identified on the Safety Thermometer
n/a April to September 2014
Pressure ulcers
S25 Grade 2 pressure ulcers
5
5
7
7
9
7
8
7
8
9
12
10
10
32
tbc
tbc
S26 Grade 3 & 4 pressure ulcers
0
0
0
0
1
0
1
2
0
0
0
0
1
1
tbc
tbc
96.4%
96.3%
96.1%
96.0%
95.6%
96.2%
95.0%
95.9%
96.0%
95.2%
94.6%
94.0%
94.4%
94.3%
95%
95%
Other safety metrics
S11 VTE Assessment Compliance
Page 4 of 6
Printed 23/07/2015 15:04
QUALITY SCORECARD
JUNE 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
YTD
Actual
2.67
2.60
2.60
2.60
YTD
Target
Target
Trend
EXPERIENCE
Experience domain score
Friends and Family Test
X38 Trust Friends and Family Recommend %: Inpatient
92.5%
92.7%
90.3%
90.3%
90.1%
95.0%
93.7%
94.3%
93.4%
94.6%
94.0%
94.4%
95.3%
94.5%
tbc
tbc
X39 Trust Friends and Family Recommend %: A&E
90.3%
88.5%
91.5%
91.4%
88.9%
91.1%
89.3%
93.0%
91.7%
93.3%
91.7%
91.1%
91.1%
91.3%
tbc
tbc
Maternity Friends and Family Recommend %: Antenatal care
X40
(36 weeks)
95.2%
89.5%
96.2%
89.5%
95.8%
100.0% 95.2%
95.3%
98.4%
96.6%
100.0% 94.1%
100.0%
97.5%
tbc
tbc
X41 Maternity Friends and Family Recommend %: Delivery care
98.2%
98.2%
94.5%
95.2%
96.5%
95.8%
94.6%
97.0%
97.3%
97.9%
98.2%
95.0%
96.5%
96.5%
tbc
tbc
X42 Maternity Friends and Family Recommend %: Postnatal ward
98.5%
94.8%
92.8%
88.2%
92.6%
95.7%
95.1%
92.7%
94.4%
95.4%
96.7%
95.0%
96.5%
96.1%
tbc
tbc
X43 Maternity Friends and Family Recommend %: Postnatal community care
91.1%
90.2%
84.0%
93.5%
75.9%
100.0% 100.0% 76.5%
98.1%
93.9%
100.0% 100.0% 100.0% 100.0%
tbc
tbc
91.2%
88.7%
84.7%
88.3%
tbc
tbc
X44 Trust Friends and Family Recommend %: Outpatient
Friends and Family Test response rates
X24 Trust Friends and Family Response Rate: Inpatient
29.6%
34.3%
28.4%
28.6%
33.0%
34.6%
28.5%
42.8%
39.8%
56.7%
47.3%
20.8%
19.0%
24.8%
30%
30%
X25 Trust Friends and Family Response Rate: A&E
23.0%
21.0%
25.0%
30.0%
34.0%
28.9%
24.7%
27.1%
25.4%
30.1%
26.1%
17.2%
18.4%
20.0%
25%
25%
X33 Maternity Friends and Family Response Rate: Delivery care
27.0%
33.0%
29.0%
27.0%
25.0%
33.3%
20.9%
30.0%
27.7%
36.3%
12.2%
13.8%
19.3%
15.1%
tbc
tbc
9.6%
9.7%
9.9%
8.3%
8.5%
7.6%
8.3%
7.7%
8.7%
9.4%
8.4%
7.8%
7.5%
7.9%
8.6%
8.6%
6
46
21
23
16
30
41
84
30
24
17
19
26
62
85
340
0.09%
0.10%
0.09%
0.09%
0.09%
0.10%
0.07%
0.09%
0.08%
0.09%
0.09%
0.08%
0.08%
0.08%
0.09%
0.09%
20
17
38
14
25
45
56
75
32
18
18
11
30
59
100
399
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0%
0%
X14 Compliance with MUST tool after 24 hours
86.8%
84.3%
86.3%
84.0%
82.0%
80.0%
73.0%
78.5%
75.5%
79.5%
81.3%
82.5%
72.5%
78.8%
80%
80%
X15 Compliance with MUST tool after 7 days
98.3%
96.5%
94.0%
96.0%
94.0%
95.3%
88.5%
94.0%
95.0%
94.0%
93.2%
97.8%
92.0%
94.3%
95%
95%
Reduction in patients suffering a bad experience dealing with the Trust
X08 Percentage of re-booked outpatient appointments
X09 Clinics cancelled with less than 6 weeks notice for annual/study leave
X11 PALS contacts relating to appointment problems (% of total appts)
X12 Reduce patients cancelled on the day of surgery for non-clinical reasons
X13 Breaches of mixed sex accommodation arrangements
Nutritional Assessment
Page 5 of 6
Printed 23/07/2015 15:04
QUALITY SCORECARD
JUNE 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
YTD
Actual
X16 Internal PLACE compliance : St Richard's Hospital
97%
98%
98%
99%
97%
98%
98%
98%
96%
99%
92%
98%
97%
96%
85%
85%
X17 Internal PLACE compliance : Worthing Hospital
91%
92%
92%
98%
98%
98%
92%
91%
97%
98%
98%
97%
94%
96%
85%
85%
X18 Number of complaints
45
42
51
56
45
57
51
51
41
54
43
48
44
135
143
570
X19 Complaints where staff attitude or behaviour is an issue
3
6
6
6
2
5
8
5
6
10
6
2
3
11
17
67
X20 Complaints where staff communication is an issue
2
2
6
4
4
6
4
8
3
2
7
2
3
12
12
49
X21 Complaints about nursing
5
2
4
3
5
7
5
1
5
4
4
4
2
10
12
46
YTD
Target
Target
Trend
Cleanliness / PLACE Survey
Improve our customer service and become a more caring organisation
Page 6 of 6
Printed 23/07/2015 15:04
SAFER STAFFING SCORECARD - Registered Nurses and Midwives
Shift
WSHFT
Acute Cardiac Unit
Acute Medical Unit(Chichester)
Ashling
Barrow
Beacon
Becket
Beeding
Birdham
Bluefin
Bosham
Botolphs
Boxgrove
Broadwater
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
97.6%
98.5%
97.1%
97.6%
96.8%
97.5%
96.7%
97.5%
97.1%
98.0%
95.4%
95.8%
95.5%
96.9%
94.2%
96.3%
95.5%
95.6%
97.0%
97.5%
96.8%
97.6%
96.6%
97.3%
96.8%
97.5%
Day
95.5%
96.5%
97.7%
98.4%
98.0%
95.5%
93.2%
92.1%
94.5%
95.7%
96.1%
97.0%
96.3%
Night
100.0%
99.2%
99.2%
99.2%
99.2%
93.5%
96.8%
95.5%
91.1%
97.5%
97.6%
96.7%
97.3%
Day
95.0%
94.0%
97.1%
95.7%
94.0%
94.1%
94.8%
93.2%
92.5%
95.7%
97.2%
95.9%
96.3%
Night
97.8%
95.2%
97.7%
97.4%
95.9%
96.1%
96.1%
97.1%
93.0%
96.8%
97.8%
94.6%
96.4%
Day
97.1%
98.2%
98.5%
98.9%
98.1%
96.8%
97.8%
94.8%
97.8%
97.8%
96.8%
98.5%
97.7%
Night
98.4%
100.0%
95.0%
98.4%
98.3%
95.2%
93.5%
94.6%
90.3%
98.3%
93.5%
98.3%
96.7%
Day
98.3%
100.0%
99.4%
96.1%
100.0%
92.7%
92.7%
95.6%
97.2%
97.7%
96.6%
96.5%
96.9%
Night
96.8%
100.0%
98.3%
93.5%
100.0%
96.8%
93.5%
100.0%
98.4%
100.0%
98.4%
96.7%
98.4%
Day
98.9%
100.0%
99.4%
97.8%
99.4%
97.2%
92.1%
89.4%
95.5%
97.1%
95.5%
100.0%
97.5%
Night
98.4%
98.4%
100.0%
96.8%
98.3%
93.5%
96.8%
96.4%
90.3%
98.3%
98.4%
100.0%
98.9%
Day
98.1%
93.2%
91.3%
91.9%
92.0%
96.8%
98.4%
94.6%
97.4%
98.0%
99.0%
97.3%
98.1%
Night
97.8%
95.7%
92.2%
95.7%
94.4%
96.8%
98.9%
96.4%
98.9%
100.0%
98.9%
97.8%
98.9%
Day
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
98.9%
98.9%
100.0%
99.2%
Night
98.9%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Day
98.6%
99.5%
99.5%
99.5%
100.0%
96.7%
99.0%
95.7%
98.6%
99.0%
96.6%
97.0%
97.5%
Night
100.0%
98.4%
100.0%
100.0%
100.0%
96.8%
98.4%
94.6%
96.8%
96.7%
95.2%
98.3%
96.7%
Day
100.0%
100.0%
100.0%
100.0%
98.3%
96.0%
95.9%
100.0%
97.6%
99.2%
96.0%
100.0%
98.2%
Night
100.0%
98.9%
100.0%
100.0%
96.2%
96.0%
100.0%
95.5%
99.2%
99.2%
99.2%
97.8%
98.8%
Day
100.0%
98.8%
100.0%
100.0%
99.6%
99.2%
89.5%
92.0%
95.6%
97.1%
97.2%
99.6%
97.9%
Night
100.0%
100.0%
100.0%
100.0%
100.0%
96.8%
90.3%
91.1%
91.9%
95.0%
98.4%
100.0%
97.8%
Day
94.8%
97.4%
87.8%
88.6%
90.4%
88.9%
94.4%
85.7%
90.7%
94.7%
94.8%
93.1%
94.2%
Night
92.5%
94.6%
90.0%
91.4%
93.3%
92.5%
94.6%
86.9%
87.1%
94.4%
94.6%
93.3%
94.1%
Day
98.0%
99.2%
99.2%
99.2%
99.2%
93.1%
97.6%
97.8%
98.4%
97.9%
98.0%
97.5%
97.8%
Night
100.0%
100.0%
96.7%
98.4%
100.0%
91.9%
100.0%
98.2%
100.0%
95.0%
96.8%
98.3%
96.7%
Day
98.7%
93.9%
90.6%
96.1%
96.8%
95.3%
95.7%
91.3%
93.0%
95.1%
93.4%
96.0%
94.8%
Night
98.4%
95.2%
96.7%
100.0%
98.3%
100.0%
98.4%
96.4%
96.8%
96.7%
98.4%
100.0%
98.4%
6b SaferStaffingScorecard_1516_M03_v1.xlsx SaferStaffingWardNurseScorecard
1 of 6
Trend
23/07/2015 15:04
Shift
WSHFT
Brooklands
Buckingham
Burlington
Castle
Chilgrove
Chiltington
Clapham
Coombes
Courtlands
Ditchling
Durrington
Eartham
Eastbrook
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
97.6%
98.5%
97.1%
97.6%
96.8%
97.5%
96.7%
97.5%
97.1%
98.0%
95.4%
95.8%
95.5%
96.9%
94.2%
96.3%
95.5%
95.6%
97.0%
97.5%
96.8%
97.6%
96.6%
97.3%
96.8%
97.5%
Day
96.2%
96.1%
93.6%
95.7%
96.0%
97.6%
94.2%
93.1%
94.2%
92.1%
93.7%
94.1%
93.3%
Night
96.8%
95.2%
96.7%
98.4%
98.3%
98.4%
95.2%
94.6%
95.2%
91.7%
96.8%
95.0%
94.5%
Day
99.5%
95.7%
96.5%
94.3%
99.5%
96.7%
99.0%
93.6%
96.6%
100.0%
99.0%
96.0%
98.4%
Night
100.0%
95.2%
98.3%
98.4%
98.3%
98.4%
96.8%
96.4%
95.2%
100.0%
98.4%
98.3%
98.9%
Day
98.3%
98.7%
98.7%
97.8%
96.8%
97.0%
94.8%
96.2%
96.5%
96.9%
99.6%
97.3%
97.9%
Night
98.7%
98.7%
100.0%
98.7%
98.6%
97.4%
97.4%
98.5%
97.3%
94.5%
100.0%
97.3%
97.3%
Day
98.5%
94.3%
94.1%
94.3%
95.9%
94.9%
95.5%
96.0%
99.7%
100.0%
100.0%
100.0%
100.0%
Night
99.2%
95.2%
93.3%
90.3%
95.0%
98.4%
97.6%
98.2%
99.2%
100.0%
100.0%
100.0%
100.0%
Day
99.1%
99.1%
98.5%
99.5%
99.0%
97.2%
99.5%
97.9%
96.7%
98.1%
99.1%
99.5%
98.9%
Night
100.0%
96.8%
100.0%
100.0%
100.0%
96.8%
100.0%
98.2%
95.2%
96.7%
100.0%
98.3%
98.4%
Day
97.6%
96.1%
97.5%
94.7%
100.0%
96.7%
98.1%
93.1%
99.0%
96.0%
99.0%
98.0%
97.7%
Night
98.4%
100.0%
100.0%
98.4%
98.3%
98.4%
98.4%
94.6%
100.0%
98.3%
98.4%
100.0%
98.9%
96.4%
Day
98.0%
98.0%
95.8%
93.1%
96.3%
98.8%
96.4%
93.3%
96.0%
96.7%
97.6%
95.0%
Night
100.0%
98.4%
98.3%
100.0%
100.0%
100.0%
98.4%
94.6%
95.2%
96.7%
98.4%
96.7%
97.3%
Day
98.4%
98.8%
97.1%
97.2%
98.3%
98.8%
96.8%
97.8%
98.8%
97.9%
98.8%
98.3%
98.4%
Night
98.4%
100.0%
93.3%
100.0%
98.3%
96.8%
100.0%
98.2%
100.0%
98.3%
98.4%
100.0%
98.9%
Day
98.4%
98.4%
96.7%
95.2%
96.7%
94.8%
96.0%
96.9%
94.0%
98.3%
94.0%
96.3%
96.2%
Night
98.4%
96.8%
95.8%
93.5%
96.7%
96.0%
93.5%
94.6%
93.5%
96.7%
97.6%
89.2%
94.5%
Day
98.6%
100.0%
100.0%
95.4%
96.7%
94.0%
96.8%
94.4%
94.5%
97.6%
97.7%
99.5%
98.3%
Night
98.4%
100.0%
100.0%
95.2%
95.0%
93.5%
96.8%
96.4%
95.2%
98.3%
98.4%
100.0%
98.9%
Day
95.9%
97.7%
97.1%
91.7%
97.6%
95.9%
95.4%
98.0%
96.3%
98.6%
99.5%
93.3%
97.2%
Night
98.4%
98.4%
96.7%
98.4%
100.0%
95.2%
96.8%
98.2%
95.2%
100.0%
100.0%
100.0%
100.0%
Day
94.5%
97.2%
93.3%
97.2%
95.2%
94.0%
96.8%
94.4%
95.4%
97.6%
96.8%
97.1%
97.2%
Night
95.2%
100.0%
95.0%
98.4%
96.7%
93.5%
100.0%
92.9%
96.8%
100.0%
98.4%
98.3%
98.9%
Day
97.6%
95.6%
95.4%
98.0%
96.3%
96.0%
94.8%
92.4%
95.2%
96.3%
96.4%
97.5%
96.7%
Night
96.8%
98.4%
98.3%
100.0%
100.0%
98.4%
98.4%
94.6%
96.8%
96.7%
98.4%
100.0%
98.4%
2 of 6
Trend
23/07/2015 15:04
Shift
WSHFT
Emergency Floor
Enhanced Surgical Care Unit
Erringham
Fishbourne
Ford
Graffham
Howard Children's Unit
Lavant
Middleton
Neonatal Unit
Petworth
Selsey
Wittering
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
97.6%
98.5%
97.1%
97.6%
96.8%
97.5%
96.7%
97.5%
97.1%
98.0%
95.4%
95.8%
95.5%
96.9%
94.2%
96.3%
95.5%
95.6%
97.0%
97.5%
96.8%
97.6%
96.6%
97.3%
96.8%
97.5%
Day
n/a
n/a
n/a
n/a
n/a
89.4%
90.9%
90.0%
92.1%
95.4%
94.0%
90.6%
93.3%
Night
n/a
n/a
n/a
n/a
n/a
90.0%
94.7%
95.1%
94.1%
97.0%
97.1%
94.2%
96.1%
Day
100.0%
100.0%
99.2%
100.0%
100.0%
99.2%
100.0%
100.0%
100.0%
99.2%
100.0%
99.2%
99.5%
Night
100.0%
100.0%
100.0%
100.0%
98.3%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
98.3%
99.5%
Day
98.2%
98.2%
97.1%
97.7%
99.0%
98.2%
97.2%
96.9%
94.5%
97.1%
98.6%
97.6%
97.8%
Night
95.2%
96.8%
98.3%
96.8%
96.7%
98.4%
100.0%
96.4%
98.4%
100.0%
100.0%
98.3%
99.5%
Day
98.4%
98.0%
98.3%
n/a
98.8%
95.6%
91.5%
94.6%
90.7%
97.9%
96.0%
95.8%
96.6%
Night
100.0%
100.0%
95.0%
n/a
100.0%
95.2%
91.9%
96.4%
85.5%
100.0%
93.5%
96.7%
96.7%
Day
95.2%
96.1%
97.7%
98.4%
95.7%
95.2%
93.5%
94.6%
92.9%
96.7%
92.6%
95.7%
94.9%
Night
98.9%
96.8%
96.7%
98.9%
95.6%
92.5%
96.8%
95.2%
88.2%
96.7%
87.1%
95.6%
93.0%
Day
97.4%
100.0%
99.3%
98.7%
100.0%
98.7%
100.0%
96.4%
100.0%
99.3%
98.7%
100.0%
99.3%
Night
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
96.4%
100.0%
100.0%
96.8%
100.0%
98.9%
Day
96.5%
99.1%
97.2%
100.0%
100.0%
98.4%
100.0%
96.5%
99.2%
99.2%
99.2%
100.0%
99.4%
Night
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
98.3%
100.0%
100.0%
99.4%
Day
98.9%
94.3%
96.3%
99.6%
98.1%
95.7%
94.3%
94.0%
97.1%
93.7%
91.0%
97.4%
94.0%
Night
100.0%
93.5%
96.7%
100.0%
100.0%
93.5%
90.3%
98.2%
96.8%
85.0%
91.9%
98.3%
91.8%
Day
99.2%
99.2%
100.0%
99.2%
98.8%
98.0%
98.0%
92.4%
96.0%
96.3%
98.8%
94.6%
96.6%
Night
98.4%
100.0%
100.0%
98.4%
100.0%
95.2%
95.2%
96.4%
100.0%
100.0%
100.0%
96.7%
98.9%
Day
98.9%
98.9%
100.0%
100.0%
100.0%
100.0%
100.0%
98.6%
100.0%
100.0%
100.0%
97.8%
99.2%
Night
100.0%
99.0%
98.9%
100.0%
100.0%
100.0%
100.0%
98.6%
100.0%
98.8%
100.0%
100.0%
99.6%
Day
98.4%
98.9%
97.8%
98.9%
98.3%
94.6%
94.6%
94.0%
97.3%
99.4%
99.5%
100.0%
99.6%
Night
100.0%
100.0%
98.3%
98.4%
100.0%
93.5%
96.8%
98.2%
100.0%
96.7%
100.0%
100.0%
98.9%
Day
97.5%
94.1%
97.4%
98.3%
98.3%
96.7%
95.8%
94.4%
93.3%
94.0%
97.1%
96.1%
95.7%
Night
95.7%
94.6%
98.9%
97.8%
100.0%
97.8%
96.8%
96.4%
96.8%
96.7%
96.8%
98.9%
97.4%
Day
96.4%
96.4%
97.9%
98.8%
96.7%
93.5%
97.2%
95.1%
94.8%
96.7%
96.0%
95.4%
96.0%
Night
100.0%
100.0%
100.0%
98.4%
98.3%
93.5%
96.8%
98.2%
90.3%
98.3%
95.2%
96.7%
96.7%
3 of 6
Trend
23/07/2015 15:04
SAFER STAFFING SCORECARD - Care Staff
Shift
WSHFT
Acute Cardiac Unit
Acute Medical Unit(Chichester)
Ashling
Barrow
Beacon
Becket
Beeding
Birdham
Bluefin
Bosham
Botolphs
Boxgrove
Broadwater
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
96.2%
98.2%
96.3%
97.1%
95.9%
97.4%
94.4%
97.2%
93.3%
95.3%
91.3%
91.1%
90.5%
93.3%
89.5%
92.0%
91.7%
92.9%
93.8%
94.7%
93.0%
93.3%
93.9%
95.0%
93.5%
94.3%
Day
96.8%
87.1%
92.0%
96.8%
93.3%
87.1%
86.5%
89.3%
82.6%
86.7%
92.3%
97.3%
92.1%
Night
100.0%
67.7%
96.7%
93.5%
96.7%
80.6%
90.3%
89.3%
67.7%
70.0%
77.4%
96.7%
81.3%
Day
97.3%
96.8%
97.8%
96.3%
93.6%
93.1%
93.3%
91.1%
89.8%
95.0%
92.5%
95.0%
94.2%
Night
98.6%
80.7%
97.2%
97.3%
91.4%
87.8%
91.8%
93.9%
86.3%
95.8%
83.4%
90.1%
89.7%
Day
98.2%
94.0%
98.1%
98.2%
95.2%
91.7%
89.9%
82.1%
91.2%
97.6%
95.2%
96.2%
96.3%
Night
100.0%
91.9%
100.0%
93.5%
96.7%
90.3%
88.7%
78.6%
85.5%
98.3%
90.3%
98.3%
95.6%
Day
98.7%
100.0%
93.2%
98.0%
95.2%
86.8%
87.4%
93.4%
91.3%
95.2%
98.0%
94.5%
95.9%
Night
100.0%
98.4%
95.0%
100.0%
100.0%
93.5%
96.8%
100.0%
96.8%
96.7%
98.4%
98.3%
97.8%
Day
94.7%
98.7%
91.8%
94.0%
93.1%
92.7%
84.1%
86.0%
80.7%
84.9%
91.3%
100.0%
92.1%
Night
98.4%
98.4%
95.0%
100.0%
100.0%
93.5%
91.9%
100.0%
95.2%
90.0%
98.4%
100.0%
96.2%
Day
89.9%
93.2%
92.4%
89.3%
92.4%
91.6%
86.4%
85.6%
81.9%
87.2%
93.8%
87.8%
89.6%
Night
95.2%
100.0%
96.7%
96.8%
98.3%
87.1%
88.7%
96.4%
88.7%
93.3%
96.8%
95.0%
95.1%
Day
90.3%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
97.0%
100.0%
98.9%
Night
96.4%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
96.7%
100.0%
100.0%
100.0%
100.0%
100.0%
Day
96.4%
99.0%
92.0%
91.8%
94.2%
87.1%
88.2%
89.2%
90.8%
90.4%
91.8%
89.4%
90.6%
Night
100.0%
98.4%
90.0%
88.7%
93.3%
85.5%
85.5%
83.9%
87.1%
93.3%
91.9%
91.7%
92.3%
Day
90.3%
96.8%
93.3%
100.0%
100.0%
93.5%
96.8%
82.1%
100.0%
100.0%
100.0%
100.0%
100.0%
Night
93.5%
95.0%
96.7%
100.0%
100.0%
100.0%
96.8%
89.3%
96.8%
88.9%
86.2%
100.0%
91.8%
Day
100.0%
100.0%
100.0%
100.0%
99.3%
96.1%
76.8%
84.3%
83.9%
82.0%
88.4%
99.3%
89.9%
Night
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
87.1%
82.1%
87.1%
90.0%
87.1%
98.3%
91.8%
Day
96.7%
97.4%
95.0%
94.8%
97.3%
86.7%
92.2%
87.7%
95.9%
95.0%
89.6%
88.2%
90.9%
Night
100.0%
98.4%
98.3%
93.5%
96.7%
79.0%
98.4%
87.5%
95.2%
88.3%
95.2%
91.7%
91.8%
Day
95.9%
95.4%
96.7%
98.6%
96.2%
92.6%
90.3%
83.2%
89.9%
98.6%
90.8%
89.0%
92.8%
Night
100.0%
98.4%
95.0%
98.4%
91.7%
88.7%
90.3%
76.8%
83.9%
98.3%
83.9%
88.3%
90.1%
Day
100.0%
100.0%
94.6%
93.6%
94.7%
96.5%
96.0%
91.7%
89.0%
91.6%
97.7%
94.0%
94.5%
Night
98.4%
100.0%
93.3%
96.8%
95.0%
95.2%
98.4%
98.2%
88.7%
95.0%
98.4%
98.3%
97.3%
6b SaferStaffingScorecard_1516_M03_v1.xlsx SaferStaffingWardCareScorecard
4 of 6
Trend
23/07/2015 15:04
Shift
WSHFT
Brooklands
Buckingham
Burlington
Castle
Chilgrove
Chiltington
Clapham
Coombes
Courtlands
Ditchling
Durrington
Eartham
Eastbrook
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
96.2%
98.2%
96.3%
97.1%
95.9%
97.4%
94.4%
97.2%
93.3%
95.3%
91.3%
91.1%
90.5%
93.3%
89.5%
92.0%
91.7%
92.9%
93.8%
94.7%
93.0%
93.3%
93.9%
95.0%
93.5%
94.3%
Day
93.9%
97.0%
94.3%
90.8%
88.8%
85.9%
82.3%
91.9%
86.6%
91.8%
89.7%
97.5%
92.9%
Night
96.8%
96.8%
98.3%
93.5%
90.0%
85.5%
95.2%
98.2%
88.7%
98.3%
96.8%
98.3%
97.8%
Day
94.2%
96.1%
96.0%
89.7%
93.3%
92.3%
88.4%
88.6%
90.3%
86.7%
85.2%
93.3%
88.4%
Night
96.8%
100.0%
100.0%
100.0%
96.7%
98.4%
98.4%
96.4%
98.4%
91.7%
88.7%
100.0%
93.4%
Day
98.0%
90.7%
97.9%
81.5%
94.5%
84.1%
93.4%
95.6%
92.7%
87.0%
93.3%
96.6%
92.3%
Night
98.4%
98.4%
100.0%
100.0%
96.7%
93.5%
98.4%
100.0%
98.4%
100.0%
100.0%
95.0%
98.4%
Day
95.2%
90.3%
92.5%
87.1%
87.5%
75.8%
70.2%
77.7%
96.0%
100.0%
100.0%
100.0%
100.0%
Night
96.8%
100.0%
100.0%
90.3%
83.3%
61.3%
77.4%
67.9%
100.0%
100.0%
100.0%
100.0%
100.0%
Day
99.2%
96.8%
97.5%
94.4%
96.7%
93.5%
95.2%
92.9%
95.2%
92.5%
95.2%
94.2%
94.0%
Night
100.0%
100.0%
100.0%
95.2%
98.3%
98.4%
95.2%
96.4%
96.8%
95.0%
93.5%
98.3%
95.6%
Day
93.8%
96.9%
95.2%
92.3%
94.2%
92.3%
90.3%
88.1%
94.9%
96.8%
90.3%
88.8%
92.0%
Night
96.8%
98.4%
96.7%
98.4%
93.3%
91.9%
96.8%
91.1%
96.8%
93.3%
95.2%
90.0%
92.9%
Day
97.4%
100.0%
92.7%
92.3%
79.3%
91.0%
93.5%
96.4%
92.3%
90.0%
83.2%
94.7%
89.2%
Night
96.8%
98.4%
96.7%
98.4%
85.0%
88.7%
100.0%
96.4%
96.8%
88.3%
91.9%
93.3%
91.2%
Day
94.8%
97.4%
96.7%
94.8%
84.0%
89.7%
91.6%
78.6%
92.9%
93.3%
88.4%
96.7%
92.7%
Night
95.2%
100.0%
98.3%
100.0%
86.7%
85.5%
95.2%
85.7%
98.4%
91.7%
88.7%
96.7%
92.3%
Day
91.1%
92.7%
94.2%
97.6%
92.5%
87.9%
89.5%
78.6%
87.9%
92.5%
97.6%
98.3%
96.2%
Night
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
Day
97.8%
100.0%
100.0%
95.7%
90.0%
91.4%
91.4%
91.7%
97.3%
93.3%
93.0%
87.2%
91.2%
Night
98.4%
100.0%
100.0%
100.0%
93.3%
93.5%
95.2%
100.0%
96.8%
90.0%
96.8%
91.7%
92.9%
Day
93.5%
96.2%
95.6%
88.2%
85.6%
84.9%
90.9%
81.0%
89.8%
88.3%
96.2%
91.1%
91.9%
Night
98.4%
100.0%
96.7%
98.4%
100.0%
87.1%
100.0%
91.1%
100.0%
93.3%
100.0%
98.3%
97.3%
Day
94.6%
100.0%
99.3%
95.9%
99.3%
96.6%
96.6%
89.4%
98.6%
97.9%
93.8%
91.5%
94.4%
Night
100.0%
98.4%
100.0%
98.4%
100.0%
96.8%
96.8%
100.0%
98.4%
95.0%
98.4%
95.0%
96.2%
Day
96.8%
96.1%
90.0%
91.0%
88.7%
89.7%
98.1%
89.3%
97.4%
99.3%
96.8%
97.3%
97.8%
Night
98.4%
98.4%
96.7%
93.5%
95.0%
95.2%
98.4%
92.9%
98.4%
100.0%
98.4%
96.7%
98.4%
5 of 6
Trend
23/07/2015 15:04
Shift
WSHFT
Emergency Floor
Enhanced Surgical Care Unit
Erringham
Fishbourne
Ford
Graffham
Howard Children's Unit
Lavant
Middleton
Neonatal Unit
Petworth
Selsey
Wittering
Day
Night
Jun 2015
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
YTD
Actual
96.2%
98.2%
96.3%
97.1%
95.9%
97.4%
94.4%
97.2%
93.3%
95.3%
91.3%
91.1%
90.5%
93.3%
89.5%
92.0%
91.7%
92.9%
93.8%
94.7%
93.0%
93.3%
93.9%
95.0%
93.5%
94.3%
Day
n/a
n/a
n/a
n/a
n/a
92.1%
95.6%
97.7%
94.0%
93.9%
94.7%
94.8%
94.5%
Night
n/a
n/a
n/a
n/a
n/a
90.3%
98.1%
96.4%
94.8%
96.0%
93.5%
94.0%
94.5%
Day
98.4%
100.0%
98.3%
96.8%
100.0%
100.0%
93.5%
98.2%
93.5%
100.0%
100.0%
100.0%
100.0%
Night
100.0%
100.0%
100.0%
87.5%
100.0%
100.0%
88.9%
87.5%
88.9%
100.0%
100.0%
87.5%
96.2%
Day
94.6%
97.3%
96.7%
91.9%
93.3%
93.5%
91.4%
91.1%
91.9%
93.3%
93.5%
89.4%
92.1%
Night
96.8%
98.4%
98.3%
100.0%
96.7%
95.2%
96.8%
94.6%
95.2%
96.7%
100.0%
98.3%
98.4%
Day
97.8%
86.0%
96.1%
n/a
97.8%
95.2%
88.2%
89.3%
91.9%
97.8%
87.1%
92.8%
92.5%
Night
100.0%
90.3%
93.3%
n/a
100.0%
90.3%
79.0%
83.9%
85.5%
100.0%
83.9%
91.7%
91.8%
Day
97.4%
97.4%
96.7%
96.1%
93.3%
94.2%
92.3%
90.7%
90.3%
98.0%
94.8%
97.3%
96.7%
Night
100.0%
98.4%
98.3%
95.2%
95.0%
93.5%
90.3%
96.4%
88.7%
95.0%
96.8%
98.3%
96.7%
Day
91.9%
96.8%
98.3%
96.8%
95.0%
91.9%
90.3%
89.3%
96.8%
98.3%
95.2%
93.3%
95.6%
Night
96.8%
100.0%
96.7%
100.0%
86.7%
87.1%
100.0%
85.7%
96.8%
100.0%
96.8%
96.7%
97.8%
Day
100.0%
97.4%
100.0%
100.0%
100.0%
100.0%
100.0%
96.3%
100.0%
100.0%
100.0%
100.0%
100.0%
Night
77.8%
100.0%
100.0%
85.7%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
86.7%
95.3%
Day
96.4%
96.0%
97.9%
98.8%
97.1%
93.5%
94.4%
88.4%
96.8%
94.6%
96.4%
94.6%
95.2%
Night
100.0%
95.2%
100.0%
100.0%
91.7%
87.1%
91.9%
92.9%
90.3%
90.0%
91.9%
90.0%
90.7%
Day
96.1%
97.4%
98.7%
99.4%
91.3%
92.3%
83.9%
97.1%
91.0%
92.7%
92.9%
90.0%
91.9%
Night
100.0%
100.0%
96.7%
100.0%
95.0%
91.9%
85.5%
94.6%
91.9%
93.3%
93.5%
90.0%
92.3%
Day
86.4%
92.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
93.3%
97.8%
Night
88.9%
100.0%
95.8%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
96.6%
97.0%
97.8%
Day
96.1%
95.5%
97.3%
98.1%
98.0%
97.4%
87.1%
89.3%
96.8%
100.0%
93.2%
99.3%
97.5%
Night
98.4%
98.4%
98.3%
98.4%
98.3%
98.4%
88.7%
87.5%
95.2%
100.0%
88.7%
98.3%
95.6%
Day
97.4%
99.5%
96.2%
97.4%
98.4%
94.2%
96.3%
93.0%
92.6%
96.7%
93.7%
94.6%
95.0%
Night
98.4%
98.4%
96.7%
98.4%
98.3%
90.3%
98.4%
87.5%
88.7%
96.7%
87.1%
95.0%
92.9%
Day
98.1%
97.4%
98.0%
96.8%
88.0%
85.2%
77.4%
82.1%
83.2%
98.7%
90.3%
88.7%
92.5%
Night
100.0%
98.4%
100.0%
96.8%
91.7%
85.5%
72.6%
82.1%
87.1%
96.7%
88.7%
90.0%
91.8%
6 of 6
Trend
23/07/2015 15:04
To: Trust Board
Agenda Item: 7
Annual Board Report for Appraisal & Revalidation
The purpose of this report is to update the Trust Board on revalidation and medical appraisal and give the
necessary assurance to allow a positive Statement of Compliance to be made to the higher-level responsible
officer.
George Findlay – Medical Director/Responsible Officer (RO)
Prepared by
Tim Taylor – Assistant Medical Director for Appraisal & Revalidation
Status
Disclosable
Summary of Proposal
This report represents the Trust’s revalidation and appraisal performance for 2014/15 It outlines the number
of medical appraisals undertaken, revalidation recommendations made and includes a report from NHS
England following an external verification visit in April.
Revalidation is the process for determining whether doctors are fit to practice. This further drives quality
improvement and patient safety through medical appraisal.
Links to Corporate Objectives on Quality Improvement, Leadership & Safety
The Trust has a statutory obligation to provide the resources required to support the successful
implementation of revalidation
The duties of the Responsible Officer have considerable overlap with HR processes. Areas where HR need
to support the RO include systems and processes, advice on employee relations and employment law,
resources for case management and case investigation and training and induction.
Recommendation
The Board is asked to note the contents of the Annual Report for Appraisal & Revalidation and approve
submission of the Statement of Compliance.
This report will be shared with the Trust’s medical appraisers
Appendices
Appendix 1 – NHS England Independent Verification Visit Report (June 2015)
Appendix 2 - Statement of Compliance (to be signed by CEO/Chairman)
[Type text]
This report can be made available in other formats and in other languages. To discuss your
requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903
285288.
To:
Trust Board
From: Tim Taylor
Date: 30 July 2015
Agenda Item: 7
Assistant Medical Director for Appraisal and Revalidation
FOR [DECISION & INFORMATION]
ANNUAL BOARD REPORT FOR APPRAISAL AND REVALIDATION
1.0
INTRODUCTION
1.01
Medical Appraisal and Revalidation have been devised to enable doctors to demonstrate they
are up to date and fit to practice, through a system of strengthened medical appraisal, patient
and colleague feedback, and improved clinical governance. The system provides a focus for
doctor’s efforts to maintain and improve their practice. Successful revalidation is required for a
doctor to continue to hold a License to Practice.
The purpose of revalidation is to assure patients and the public, employers and other
healthcare professionals that licensed doctors are up to date and fit to practise. Within the
model of revalidation a doctor is revalidated, and effectively re-licensed every five years. This
depends on satisfactory completion of five annual appraisals, patient and colleague feedback,
evidence of continuing professional development, reviews of complaints and relevant
information about clinical outcomes.
The Responsible Officer (RO) has a statutory duty to ensure the Trust has processes for
medical appraisal and revalidation. He has full accountability for making recommendations to
the GMC for revalidation of all those doctors with a prescribed connection to the Trust,
ensuring the cycle of appraisals are undertaken, reviewing and monitoring appraisals and
providing annual assurance to the Board that medical appraisal and revalidation is being
carried to a high standard by the Trust.
The purpose of this paper is to update the Trust Board on revalidation and medical appraisal
and give the necessary assurance to allow a positive statement of compliance to be made to
the higher-level responsible officer.
2.00
SUMMARY OF PROPOSAL
2.01
This paper updates the Trust Board on revalidation and medical appraisal for the 2014/15appraisal year and provides the supporting information to enable completion of the Statement
of Compliance required for the Higher Level Responsible Officer.
The Trust has a statutory responsibility to ensure that doctors keep up to date and are fit to
practice. Revalidation can play a strong part in driving improvements in professional practice
and is a critical tool for patient safety.
The Trust is subject to external scrutiny of revalidation and appraisal and in April 2015 an
NHS England Independent Verification visit took place. The report is discussed within this
paper. Revalidation also forms part of the CQC inspection regime.
Reviewing the Trust’s revalidation and appraisal performance for 2014/15 shows that at the
end of the appraisal year the Trust had a prescribed connection with 383 doctors including
permanent and fixed term consultants, staff and associate specialist grade (SASG), medical
bank and medical training initiative (MTI) doctors. Trainee doctors have a connection with the
Deanery rather than the Trust.
Of the 383 medical staff, 310 had a completed appraisal (81%) during the 2014/15-year and
160 revalidation recommendations were made. Positive recommendations were made for 125
doctors and a recommendation for a deferral was made for 34 doctors. One doctor was
declared non-engaged.
2.02
3.00
The Trust has a statutory duty to support the Responsible Officer in discharging their duties
under the Medical Professional (Responsible Officer) Regulations 1 and it is expected that
provider boards will oversee compliance by:
•
Monitoring the frequency and quality of medical appraisals in their organisations.
•
Checking there are effective systems in place for monitoring the conduct and performance
of their doctors.
•
Confirming that feedback from patients is sought periodically so that their views can inform
the appraisal and revalidation process for their doctors.
•
Ensuring that appropriate pre-employment background checks (including pre-engagement
for Locums) are carried out to ensure that medical practitioners have qualifications and
experience appropriate to the work performed.
RECOMMENDATIONS
(a) The Board is asked to accept this report as evidence of progress implementing
revalidation and medical appraisal. The annual report is to be shared with the higher-level
responsible officer accompanied by the relevant audits.
(b) The Board is asked to approve the ‘statement of compliance’ confirming that the
organisation, as a designated body, is in compliance with the regulations.
4.00
GOVERNANCE ARRANGEMENTS
4.01
Responsible Officer (RO)
Dr George Findlay
Assistant Medical Director for Revalidation and Appraisal (ARA)
Dr Tim Taylor
Senior Appraisers (SA)
Core: Dr Nick Ashford (Radiology) and Dr Jeremy Quiney (Pathology)
Medicine: Dr Mike Chard
Surgery: Mr David Beattie
Women and Children: Dr Rowena Remorino
Medical HR Lead
Ms Mandi Atkinson
Revalidation Project Manager
Ms Lynn Helyer
1
The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General
Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’
Page 2 of 20
Revalidation Administrator
Ms Rebecca Downer
The Medical Appraisal and Revalidation Group (MARG)
This group oversees the implementation of revalidation and appraisal and is chaired by the RO
and attended by the ARA, senior appraisers, SASG lead, medical HR lead, a representative of
the medical staff committee and the revalidation team. From summer 2015 a Patient and
Public Involvement (PPI) representative will join the group. Progress with appraisal and
revalidation is monitored on a quarterly basis. The committee works to terms of reference
defined within the appraisal policy and reports to the Board.
Maintaining the list of doctors with a prescribed connection to WSHT
The Revalidation Project Manager updates the list of doctors with a prescribed connection to
WSHT as their designated body, by adding or removing them from GMC Connect. The GMC
Connect list of doctors is validated against ESR data on a monthly basis.
Internal Assurance
Internal assurance follows the recommendations of the NHS England Framework for Quality
Assurance for Responsible Officers and Revalidation (2014).
4.02
Policy and Guidance
•
An annual data gathering exercise - the Annual Organisational Audit (AOA). This takes
the form of a pro-forma questionnaire and enables Trust performance to be
benchmarked. The results for 2014/15 are awaited.
•
The Trust appraisal policy has been updated this year to take account of developments in
local processes.
5.0
MEDICAL APPRAISAL
5.01
Appraisal Performance Data
The Trust medical appraisal rate for doctors with a prescribed connection for 2014/15 is 81%
as reported in the AOA
•
Number of doctors – 383
•
Number of completed appraisals – 310
•
Approved incomplete or missed appraisals - 30
•
Unapproved incomplete or missed appraisals - 43
Missed and incomplete appraisals
The 2014/15 missed and incomplete appraisal audit showed that a lack of time is the
commonest cause of a missed appraisal (22/30 doctors). Service pressures including
exceptional workload, cross-cover for absent colleagues and problematic job plans were
identified as underlying factors. Other causes included time pressures for appraisers,
prolonged leave e.g. sickness or bereavement, difficulties communicating with new starters
and delays instigated by an appraiser due to inadequacies in a doctor’s supporting information.
5.02
Appraiser Numbers
Page 3 of 20
This year medical appraiser numbers have reduced to 55. When additional appraisals
undertaken for the hospices are taken into account the overall appraiser/doctor ratio is 1:8.
There are proportionately less appraisers in surgery and medicine compared to other divisions
and efforts to recruit from these areas continue.
There is appraiser turnover due to retirements and individuals changing priorities although the
decision that all Clinical Directors should be trained appraisers will help compensate.
The Trust continues to provide facilities for appraisal and the Responsible Officer (Dr Tim
Taylor) for two small local Designated Bodies, namely St. Barnabas and. St. Wilfrid’s Hospices
under a Service Level Agreement. The 12 hospice doctors are appraised within the medical
division.
A very small number of additional appraisals are undertaken for doctors without a prescribed
connection to the Trust. These are for agency locum doctors on long-term contracts where
WSHT is their main place of work. These appraisals are undertaken for a fee.
5.03
Quality Assurance
The Trust’s quality assurance follows the NHS England Quality Assurance Framework.
The Independent Verification process
The NHS England Revalidation team undertook an Independent Verification visit in April 2015.
The team reviewed key-supporting information and during the site visit members of the
revalidation team were interviewed. There were well-attended drop in sessions for appraisers
and doctors. The Independent Verification visit report summary is shown below.
Designated Body Name: Western Sussex Hospitals NHS Foundation Trust
Core Standard Group
ICE development continuum
Initiation
1
Compliance
2
3
Excellence
4
5
6
Designated body & Responsible Officer
Appraisal
Monitoring performance and RtC
HR processes
Overall
Engagement / Enthusiasm / Effort
ICE Maturity Continuum
Initiation
Compliance
Excellence
Description
Action Options
1
Meets few core standards, little or no commitment to alter Revisit soon, escalate to MD, Regional Director
this
or Secretary of State
2
Meets a few core standards, plan in place to achieve
compliance
Obtain action plan update, revisit
3
Meets most core standards, some quality assurance
Suggest improvements and teleconference
review in 6 months
4
Meets most core standards, quality assured in all areas
Suggest improvements and invite a report
back in 1 year
5
Meets all core standards, quality assured with some quality
No action
improvement
6
Committed to continuous improvement. All core standards
Share good practice, win an award?
met and significant areas of good practice
Page 4 of 20
Comment on the outcomes of the Independent Verification visit
Top scores were achieved for engagement/enthusiasm/effort and excellence was identified for
the domains of Designated Body/Responsible Officer, Monitoring Performance, Responding to
Concerns and HR. The Appraisal domain was satisfactory but scored slightly lower. A
significant contributory factor is likely to be the Trusts difficulty achieving a 95% appraisal rate.
However the Trust’s high overall score provides strong assurance about the quality of
revalidation and medical appraisal within the organisation.
Quarterly Reporting
Data on the appraisal rate is reported quarterly to NHS England.
Annual Organisational Audit
The 2015 Annual Organisational Audit (AOA) has been submitted to NHS England but at the
time of writing the results are awaited. When available they will provide a means of
benchmarking appraisal performance.
AOA reporting now identifies appraisals as type 1a or type 1b. Type 1a meet tight standards for
scheduling and sign off. Type 1b appraisals have taken place to a satisfactory standard but
have not met these criteria. All WSHT appraisals have been identified as type 1b due to issues
with the CRMS dashboard facility.
Complaints and Serious Incidents
There have been no complaints or serious incidents arising from appraisal or revalidation.
Quality assurance of appraisers
Recruitment
Appraisers are recruited using a job description and person specification (revised 2014). New
appraisers attend an approved 1-day training course and are interviewed by their divisional
senior appraiser. Mentorship has been introduced and an experienced appraiser sits in for new
appraisers first two appraisals offering feedback and support. This process has been
commended in the NHS England Independent Verification report.
Appraiser development
Two very well attended appraiser development sessions have taken place over the year.
Topics included reflective learning, benchmarking the quality of appraisals and the links
between the Patient First program and appraisal. Feedback on the sessions has been
excellent.
The senior appraisers held a further development session focussing on quality assurance of
appraisal.
Appraisal for appraisers
The appraiser role is considered during appraiser’s annual appraisal and forms part of these
doctors scope of practice.
Quality assurance of appraisals
Final sign off
Each appraisal is reviewed against an agreed set of standards by the senior appraiser
ensuring that the full scope of practice is addressed, appropriate supporting information
Page 5 of 20
provided and a comprehensive summary written. Direct feedback on CRMS provides a
quality improvement tool.
Audit of Supporting Information.
An audit of 40 appraisals has taken place to ascertain the appropriateness of supporting
information. Overall the standard of supporting information was high but three appraisals were
found to have insufficient supporting information. Inappropriate content included clinic lists (2)
and meeting agendas (6).
Doctor’s feedback on the quality their appraisals
Mandatory feedback forms are completed for each appraisal. The scores indicate high levels of
satisfaction with the organisation of appraisal, the appraisers and the appraisal process.
Feedback on appraisal obtained from the Medical Engagement Scale (MES) survey
The MES (2014) was used to triangulate information on doctor’s experience of appraisal.
Responses indicated that up to a third of doctors considered appraisal a ‘box ticking exercise’
and a third did not value their appraisals for their professional development. A third of doctors
surveyed provided positive and a third provided neutral response to these questions.
5.04
Access, security and confidentiality
Information is held securely in CRMS web-based appraisal folders and only accessible to
appraisers, the relevant senior appraiser, assistant medical director for revalidation and
appraisal, responsible officer and CRMS administrator.
Patient identifiable information should not be visible in doctor’s appraisal portfolios. Any lapses
in doctor’s supporting information are detectible and addressed before final sign off.
5.05
Clinical Governance
The Trust provides data for doctors undergoing their appraisal. This year there has been a
significant development with the provision of consultant data packs by the Information
Department. The packs include activity and outcome data with information mandatory training
status. In the future the pack is planned to include complaints and incident data. This
innovation was recognised by NHS England during their Independent Verification visit as of
great benefit to doctors.
6.0
REVALIDATION RECOMMENDATIONS
6.01
Number of recommendations for the 14/15 appraisal year - 160
Recommendations completed on time - 159
Positive recommendations - 125
Deferral requests – 34
Non-engagement notifications – 1
Late recommendations – 1
Number of formal investigations carried out under MHPS – 4
This has been the busiest year for making revalidation recommendations so-far.
Recommendations were made for 42% of the doctors with a prescribed connection to WSHT.
2015/16 requires similar volumes of recommendations before a quieter period later in the
revalidation cycle.
Page 6 of 20
There were 34 deferred recommendations (21%). Almost all were on grounds of insufficient
supporting information. In the remaining cases deferrals were made as the doctors were under
GMC or local investigation.
7.0
RECRUITMENT AND ENGAGEMENT BACKGROUND CHECKS
7.01
The TRAC system has now been in place 5 months and provides the Trust with a robust and
auditable process for all recruitment including bank, fixed term and substantive posts
(excluding Agency locums) for pre-employment and ID checks including Revalidation and RO
references.
This system provides a RAG rating process of the effectiveness, therefore enabling a clear and
transparent overview, and where reports can be downloaded as required for audits and KPI’s.
As all the checks are managed through this system, there is now not a requirement to
copy/print the documents and place in personal files as hard copies, but to ensure that there is
always access and records kept of these documents, they are scanned and saved
electronically into the individuals personal file on the IT shared server within Medical HR.
We continue to have the pre-employment/ID checklist as a hard copy on the personal file.
7.02
Locum doctors
Locum doctors routinely arranged through the Temporary Staffing team are sourced via Crown
Commercial Solutions (CCS) Framework Agencies who have responsibility for ensuring
Locums are compliant with pre-employment requirements/checks.
If it is not possible to source a locum through a CCS Framework Agency, and the Division
authorises the use of a non-framework agency, the Temporary Staffing Team will ask the
Agency to complete a RO type reference and checklist to confirm that all the necessary
checks have been fulfilled.
8.0
MONITORING PERFORMANCE
8.01
Doctor’s performance is monitored at divisional and executive levels.
At divisional level, performance of individuals, teams and specialities are monitored through the
monthly divisional operational and governance meetings and at the quarterly divisional
governance reviews. These meetings incorporate service line management, complaints and
litigation, risk reporting and mortality and morbidity data.
At executive level the medical director monitors Clinical Outcome Benchmarking data from Dr
Foster including relevant alerts and handles any concerns that arise according to the raising
concerns policy.
Performance concerns can also be raised through the appraisal process and the process for
this is defined in the remediation and re-skilling policy. No serious concerns arose about
performance at appraisal in the 2014/15 appraisal year.
9.0
RESPONDING TO CONCERNS AND REMEDIATION
9.01
The Trust has ratified and valid ‘Responding to Concerns’ and ‘Remediation and Re-skilling’
policies in place.
For the period April 2014 to March 2015 there were 4 formal investigations carried out under
Maintaining High Professional Standards (MHPS). 2 of these proceeded to a formal conduct
Page 7 of 20
hearing under the Trust’s Disciplinary Policy, 1 led to informal action and 1 is due to proceed to
a formal capability hearing.
One member of staff was excluded from work during the course of the investigation and 2 had
restrictions on practice imposed during their investigation. These were all reviewed in line with
the timescales and procedure outlined in MHPS.
One member of staff had restrictions on practice put in place due to health concerns alongside
a referral to the GMC for investigation. This is in addition to a number of staff where health
concerns are managed informally in line with advice from Occupational Health and HR.
These numbers do not record the full extent of work being undertaken to address concerns.
There have been a significant number of informal recorded meetings undertaken to ensure
medical staff are made aware when and if their performance or behaviour has fallen below the
expected standard of the Trust. Dealing with issues informally in the first instance, wherever
possible, allows concerns to be discussed in an open and facilitative way, identifying any
support required for improvements to be made. This is in line with the approach for resolving
concerns with all other staff groups across the Trust. Where this approach does not result in an
improvement, formal processes are then utilised.
A Case Management update session was facilitated by the Employee Relations team for the
Chiefs of Service and Medical Director. This provided an update on relevant employment law
and also provided an opportunity for a review of cases undertaken within the Trust. An action
plan was developed as a result of the session which included the following:
•
•
•
•
Follow ups on specific organisational issues arising from investigations
An agreement to review MHPS policy
Additional standards to be implemented in case management e.g. a 10 working day
period to review an investigation report on receipt
All Clinical Directors to attend Case Investigation training
10.0
RISKS AND ISSUES
10.1
Medical Appraisal Rates
There is a clear expectation that medical appraisal rates will reach 95% and this requires a
significant improvement from the 81% achieved to date. The action plan incorporates close
performance management of the scheduling and completion of appraisals, a defined escalation
policy and targeting problem groups i.e. doctors on fixed term contracts and new starters.
10.2
Ensuring appraisal is a reflective process
The NHS England visit raised concerns about over-zealous requirements for doctor’s appraisal
supporting information at the Trust. An audit did not corroborate this concern but the need to
ensure appraisal is a reflective process that is not dominated by the collection of supporting
information is a priority for 2015/16.
10.3
Links between Doctor’s Personal Development Plans and Trust Quality and Job Planning
Objectives
The visit also raised the importance of ensuring individual’s development plans align with Trust
Quality and Job Planning objectives. Developing these links are priorities for 2015/16.
10.4
The Appraisal Software System
Page 8 of 20
The CRMS software has continued to develop but has so far not provided a usable RO
dashboard facility. This creates difficulties monitoring appraisal and revalidation performance
and with reporting to NHS England.
11.0
EXECUTIVE TEAM REFLECTIONS
11.01 It is important to recognise the strong commitment and contribution of the Trust’s appraisers
and senior appraisers who have worked hard to raise the standards of appraisal to their current
high level. The NHS England Independent Verification visit noted the highest levels of
engagement, effort and enthusiasm and commented that their drop in sessions for doctors and
appraisers had the highest attendance they had witnessed.
The visit provided strong assurance about the high standard of revalidation and appraisal at
WSHT but also highlighted areas for development and emphasised the importance of
achieving a 95% appraisal rate. Considerable progress has been made and further
improvement in the appraisal rate is expected with existing performance management
measures and escalation processes. Changes to the appraisal software need to be considered
to improve the monitoring of appraisal.
Additional achievements include the appointment of a Patient and Public Involvement
representative for Revalidation and Appraisal, the introduction of the quarterly consultant data
pack and mentoring processes for new appraisers. Case investigation processes have also
developed further with the introduction of an annual review meeting for case managers and HR
identifying themes and Trust learning from the last year’s investigations.
11.1
Corrective Actions, Improvement Plan and Next Steps
Priorities for the Trust in 2015/16 are shown below:
•
Raising appraisal rate to 95%
•
Through close performance management of the scheduling of sign off of appraisal
•
Rigorous use of the Trust and GMC escalation processes for any poorly engaged
medical staff
•
Targeting specific groups including new starters and doctors on fixed term contracts
•
Developing links between appraisal outputs i.e. PDP’s, Trust quality objectives and Job
planning
•
Increasing reflection within doctor’s appraisals through an on-going program of appraiser
development
•
To review systems for 360 peer and patient feedback to align with the principles of
Patient First
•
Provide appraiser and case investigator training for clinical directors
•
To develop a business plan for new appraisal software that includes appraisal, leave and
job planning modules
•
Continue internal revalidation and appraisal audit program
•
Further develop the consultant performance data pack to include information on
complaints and incidents
•
Provide statement of compliance for NHS England
Page 9 of 20
Appendix 1
Date of Visit: 23 April 2015
Designated Body:
Type/sector of DB
RO
Chief Executive
Head of Medical HR
Appraisal Lead and AMD Revalidation
Revalidation Project Manager
Complaints and Claims Manager
Head of Information Services
Revalidation Administrator
PA to the Medical Director and RO
Independent Verification Visit
Designated Body: Western Sussex NHS FT
Western Sussex NHS FT
Acute
Dr George Findlay
Marianne Griffiths
Mandi Atkinson
Dr Tim Taylor (also RO for 2 local hospices)
Lynn Helyer
Tracey Nevell
Mark Dennis
Rebecca Downer
Melissa Francis
Revalidation Team/Panel involved:
Vicky Banks, Associate Medical Director and
Appraisal Lead, Revalidation, NHS England
(South)
Anne Younger, Senior Revalidation Manager,
NHS England (South)
Martin Cooper, RO, Royal Devon and Exeter
NHS Foundation Trust
Andrew Foulkes, Medical Director, Surrey and
Sussex, NHS England (South)
Sol Mead, Lay Representative
Meeting Preparation
Summary
This medium sized, two site acute trust gained FT status in July 2013 and had 405 doctors with a prescribed connection as at end March 2014, with a
significant proportion being staff grade (91) and short term (76). Their appraisal rate for 2013/14 was 68% and as of Q3 this year stood at 40.8%
suggesting that many appraisals are scheduled for the last quarter. An escalation process and other measures are being implemented to improve this
rate. The trust declared good practice across all areas of revalidation as well as an external review in their Annual Organisational Audit for 2013/14.
GMC operational data published prior to the visit states WSHT have a 14% deferral rate and no failures to engage. There has been one late
recommendation out of 227, which was for less than 7 days.
WSHT have successfully made a case to retain musculoskeletal planned care services following a CCG tendering process which awarded a £235
million contract to a joint venture company formed by BUPA and Central Surrey Health.
Their CQC Intelligent monitoring of March 2014 gives the lowest priority for a CQC inspection, with just one risk identified out of 186. CQC inspections
in January (Worthing) and November (St Richards) 2014 were all green rated.
On the day of the visit meetings were held with:
•
•
•
•
•
•
•
•
•
•
•
•
Mike Viggers – Trust Chairman
Dr George Findlay – Responsible Officer and Medical Director
Mandi Atkinson – Head of Medical HR
Appraisers – 15
Appraisees – 11
Marianne Griffiths – Chief Executive
Dr Tim Taylor – AMD Revalidation
Delia Read, PALS Manager
Mark Dennis Head of Information Systems
Rebecca Downer Revalidation Administrator
Ashlee Metcalf Head of Patient Safety
Senior appraisers
Key Area Summary
The Designated Body and Responsible
Officer
Examples of good practice
Areas for development
As a relatively new foundation trust Western
Sussex Hospitals NHS FT has made several
recent changes to its Board which Mike Viggers,
as Chairman feels puts them in a stronger, more
inclusive place.
There has been recent investment to raise the
Worthing site standards including a £7m
endoscopy suite.
The Responsible Officer, Dr George Findlay, is
also the Medical Director which combines into a
full time role. He is supported by Dr Tim Taylor
as the Associate Medical Director and appraisal
lead with 2 sessions job planned as an additional
responsibility for this role. There are 5 senior
appraisers with 1 SPA and Lynn Helyer is the
Page 11 of 20
Key Area Summary
Revalidation Project Manager reporting to the
Medical Staffing Manager. Lynn also has a
revalidation administrator, Rebecca Downer
working with her; both work part time. The RO,
AMD, and senior appraisers meet quarterly to
review medical appraisal and revalidation
progress, the group being known as the Medical
Appraisal and Revalidation Group (MARG).
The trust is aware that its medical appraisal rates
are lower than they would like and are working
on a range of actions to address this. One of
these actions is to exclude applications for
clinical excellence awards from consideration
unless an appraisal has taken place. Another is
the appointment in 2013 of a SASG appraiser
and appraisal lead, Dr Adrian Richardson, in
recognition of the challenges in, for example,
gathering activity and outcome data for this
group of doctors to make appraisal meaningful.
A process of medical engagement with the
organisation’s direction and strategy is taking
place with consultants, including an evening
meeting with the MD and CE before the end of
April 2015 to which 85 consultants had signed up
by the date of the visit.
The trust is keen to develop a compact with
consultants with defined behavioural elements
which clearly states expectations of both the
trust and its doctors.
A behavioural compact with doctors has the
potential to be good practice and it is hoped that
when implemented the RO and trust will be
willing to share this and their learning from its
implementation across the Network
The trust has had the CRMS system for over 3
years, and now feels that a more sophisticated
dashboard could enable tighter management of
appraisal and revalidation.
Page 12 of 20
Key Area Summary
A recent initiative has been to develop and
supply all consultants with a quarterly data pack
including mandatory training, activity, income
and Dr Foster risk adjusted mortality information.
This information will also be supplied to
appraisers. Complaints and incident data is
sourced by individual doctors requesting their
own information. SEMA/HELIX information is
being sourced for non-consultant doctors
Quarterly Data packs are supplied to consultants;
open sessions have been provided to support
interpretation of them. The trust are seeking to
improve the quality of this data by gaining
feedback from consultants
The trusts’ recent launch of data packs is very
supportive for doctors. The inclusion of
qualitative data eg. Complaints and
compliments information is an ongoing
development.
Access to serious incident information is already
web based through Datix, and plans exist to
move to a web base for complaints as well.
Where the doctors’s name becomes know as
part of handling a complaint, this is now added to
the database.
Appraisal
There is a recruitment process, job description
and person specification for appraisers.
Appraisers are appointed for three years. Once
signed off by the appraiser, senior appraisers
read and check all appraisals against a checklist
then providing final sign off. The appraisal can
be rejected at this stage and returned to the
appraiser and appraisee for any issue to be put
right.
There is perceived to be different standard for an
appraisal immediately prior to revalidation to that
for the other 4 years. Feedback from appraisers
suggested this has resulted in some mixed
messages about thresholds of acceptability for
Senior Appraisers or other experienced
appraisers sit in the first 3 appraisals and a
reflective template is in use for appraisers
In 2015/16 whole scope of practice information
will be brought to appraisal by doctors using the
declaration of interest form, aligning trust
contractual requirements with those of
revalidation
The trust intend communicating that all
appraisals need to be of a high standard
suitable for revalidation.
Consider also communicating that the intention
is to continue working to improve the quality of
the whole process.
Page 13 of 20
Key Area Summary
appraisal. It could also result in reduced
engagement in appraisal in the first few years of
the 5 year cycle.
There has been an Audit using the Excellence
tool of about 30 appraisals followed by its use in
self-assessment by appraisers.
CPD is expected to be in line with college
requirements
Leaving confirmation of fitness to practice
entirely up to the doctor constitutes a risk which
could be remedied by periodic checks by the
revalidation team. Some organisations are
making annual checks. Consider seeking
independent fitness to practise confirmation
Every year each doctor is required to bring an
MPIT form confirming fitness to practice in each
of their roles, so covering their scope of practice,
to appraisal
Colleague feedback goes to appraisers who
have been trained, whereas patient feedback
goes to the doctor
Colleague and patient feedback is required twice
every 5 years
Consider arranging for all feedback to go to the
appraiser to feed back to the doctor.
There are plans to train appraisers to link
organisational objectives, to help them to phrase
PDP’s in a SMART manner, and to match them
to job plans
The appraiser drop in session was attended by
15 doctors who reflected that the quality of
appraisal has improved within the trust. They
advised that they knew who to go to with any
queries and were aware of the roles of senior
appraiser, appraisal lead and RO. They advised
that they have 0.5 SPAs for about 8 appraisals.
Some appraisers felt the link between appraisal
and the management structure could be more
explicit
The doctor drop in session was attended by 11
The trust review of job planning which was
mentioned as about the start could include how
to reinforce and clarify the purposes of and
complementary relationship between appraisal,
organisational objectives and job planning – so
that each plays a relevant part in improving
Page 14 of 20
Key Area Summary
doctors who felt the trust organises the process
of appraisal well, and they value the quality
support given by the revalidation team, the
appraisal lead and appraisers.
patient safety
Some doctors perceived that they had to include
clinic lists/attendance sheets in their appraisal
documentation and felt this did not help achieve
the objectives of appraisal, expressing frustration
that they had to take time to copy and scan
information already in the hands of the trust.
Note: a spot audit by the trust following the
review teams’ visit showed that clinic lists and
attendance sheets are hardly ever being
included at appraisal; the trust observe that the
perception above may be out of date.
More regular conversations about activity and
outcomes within division at individual doctor
level could add value, both in improving the
quality of the data and in aiding triangulation
between divisional and individual performance.
If outputs are then fed into appraisal this could
make appraisal conversations even more
meaningful
The doctors valued the development
conversations which take place, however they
echoed similar appraiser colleagues in observing
that routine conversations about activity and
outcomes at individual level do not take place in
their divisions, so a meaningful link into appraisal
is sometimes difficult.
Some doctors felt there was no way to challenge
data (such as Dr Foster) and staff grades
advised that the lack of activity data hampers
their ability to analyse and reflect on their
performance.
The RO aims to reach higher appraisal rates by
a series of means, including cleaning the data,
tightening processes for doctors joining the trust
so they are clear that appraisal is a necessity,
and with the use of a dashboard/ checklists to
monitor compliance.
Ensuring the Clinical Directors are all appraisers
will also send a message to the rest of the
medical workforce that appraisal skills are valued
and valuable for those who hope to progress in
medical management
There was felt to be an opportunity for the
chiefs of service to be “wise men” in helping all
doctors triangulate and reflect on individual
performance by feeding into appraisal and job
planning
Page 15 of 20
Key Area Summary
Monitoring Performance and Responding to
Concerns
The responsible officer has a monthly meeting
with the HR employee relations lead as part of
ensuring issues are identified and dealt with
earlier.
Whole scope of practice processes are being
tightened up by marrying the declaration of
interest process with appraisal.
The MD is ensuring that all Clinical Directors are
trained case investigators and is initiating a
review of the MHPS derived concerns policy. He
holds regular meetings with the Chiefs and HR
and sees all complaints and moderate/serious
harm incident data with a monthly triangulation
exercise to spot trends. The emphasis is firmly
on having honest difficult conversations early
rather than later when behavioural issues arise.
The initiative to introduce a compact, mentioned
above, is intended to support this.
In the drop in sessions both doctors and
appraisers felt they knew who would see
appraisals and also knew who they would go to
with any concerns
Recruitment and Engagement
Locums are mainly (90%) sourced from
framework agencies and the intention is for all to
be obtained through this channel in future. There
is an induction pack especially for locums and
this is one means by which they know who to
contact. Appraisals are conducted for some long
term locums.
The trust new starter checklist includes obtaining
a revalidation reference from the previous RO,
the MPIT form being used to obtain these
Include appraisal and revalidation information in
the induction package
Page 16 of 20
Key Area Summary
Following employment there is a 3 month review
and mini PDP put in place for all locums
The trust have been actively recruiting a patient
representative to be involved in revalidation,
unfortunately the person identified has become
ill. A staff Governor, Paul Benson, has now been
appointed as PPI representative.
There may be an opportunity to bring the
potential for revalidation to support the patient
safety goals into the refresh of the Quality
Strategy and raise knowledge of it with
Governors
A new language testing policy and process is
being piloted in the Surgery division which in
addition to mandatory face to face interviews for
all new doctors is intended to give language
competency assurance.
Public and Patient Involvement
Governors are involved in the refresh of the
Quality Strategy and there are patient reference
groups involved in improvement initiatives
Page 17 of 20
Designated Body Name: Western Sussex Hospitals NHS Foundation Trust
Core Standard Group
ICE development continuum
Compliance
Initiation
1
2
3
Excellence
4
5
6
Designated body & Responsible Officer
Appraisal
Monitoring performance and RtC
HR processes
Overall
Engagement / Enthusiasm / Effort
ICE Maturity Continuum
Initiation
Compliance
Excellence
Description
Action Options
1
Meets few core standards, little or no commitment to alter Revisit soon, escalate to MD, Regional Director
this
or Secretary of State
2
Meets a few core standards, plan in place to achieve
compliance
Obtain action plan update, revisit
3 Meets most core standards, some quality assurance
Suggest improvements and teleconference
review in 6 months
4 Meets most core standards, quality assured in all areas
Suggest improvements and invite a report
back in 1 year
5
Meets all core standards, quality assured with some quality
No action
improvement
6
Committed to continuous improvement. All core standards
Share good practice, win an award?
met and significant areas of good practice
Page 18 of 20
Appendix 2
Designated Body Statement of Compliance
The board of Western Sussex Hospitals NHS Foundation Trust has carried out and submitted an
annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible
Officers) Regulations 2010 (as amended in 2013) and can confirm that:
1. A licensed medical practitioner with appropriate training and suitable capacity has been
nominated or appointed as a responsible officer;
Requirement satisfied
2. An accurate record of all licensed medical practitioners with a prescribed connection to the
designated body is maintained;
3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all
licensed medical practitioners;
4. Medical appraisers participate in on-going performance review and training / development
activities, to include peer review and calibration of professional judgements (Quality Assurance
of Medical Appraisers or equivalent);
5. All licensed medical practitioners 2 either have an annual appraisal in keeping with GMC
requirements (MAG or equivalent) or, where this does not occur, there is full understanding of
the reasons why and suitable action taken;
6. There are effective systems in place for monitoring the conduct and performance of all licensed
medical practitioners1, which includes [but is not limited to] monitoring: in-house training,
clinical outcomes data, significant events, complaints, and feedback from patients and
colleagues, ensuring that information about these is provided for doctors to include at their
appraisal;
7. There is a process established for responding to concerns about any licensed medical
practitioners1 fitness to practise;
8. There is a process for obtaining and sharing information of note about any licensed medical
practitioners’ fitness to practise between this organisation’s responsible officer and other
responsible officers (or persons with appropriate governance responsibility) in other places
where licensed medical practitioners work;
2
Doctors with a prescribed connection to the designated body on the date of reporting.
9. The appropriate pre-employment background checks (including pre-engagement for Locums)
are carried out to ensure that all licenced medical practitioners 3 have qualifications and
experience appropriate to the work performed; and
10. A development plan is in place that addresses any identified weaknesses or gaps in
compliance to the regulations.
Signed on behalf of the designated body
Name: _ _ _ _ _ _ _ _ _ _ _
Signed: _ _ _ _ _ _ _ _ _ _
[Chief Executive or Chairman a board member (or Executive if no board exists)]
Date: _ _ _ _ _ _ _ _ _ _
3
Doctors with a prescribed connection to the designated body on the date of reporting.
Page 20 of 20
To: Trust Board
Agenda Item: 8
Title
National Children and Young Persons Inpatient and Day Case Survey Results
Amanda Parker, Director of Nursing and Patient Safety
Prepared by
Amanda Parker, Director of Nursing
Status
Disclosable
Summary of Proposal
a) The purpose of this report is to provide an update and analysis of the national inpatient survey
results.
1. These results provide an opportunity to improve a patient’s experience by utilising the feedback from other
patients.
Support of Board Assurance Framework number A1, B2, B3, B5
1. None.
1. Professional performance management issues for individuals.
2. Learning and development requirements.
3. Organisational, behavioural and cultural issues.
Recommendation
The Board is asked to note the contents of the report.
Communication
The action plan that identifies key strategies and actions to improve patients’ experience will be managed by
the Women’s and children’s division and be reviewed by the Patient Experience and Engagement
Committee who will inform the Patient Experience and Feedback Committee of progress.
Appendices
National CYP Inpatient and Day Case Survey Executive summary
National CYP Inpatient and Day Case Survey 2014
This report can be made available in other formats and in other languages. To discuss your requirements please
contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.
Care Quality Commission – Children and Young people’s inpatient and day case survey
2014
1. Background
1.1
This was the first national children’s survey conducted by the CQC. It represents the
experiences of nearly 19,000 children and young people who received inpatient or day
case care in 137 NHS acute trusts during August 2014.
The CQC rate children’s services independently for every NHS trust that provides care for
young people. Robust feedback also helps to ensure that the needs of children are not
‘drowned out’ by the views of adults and the wider workings of acute hospitals.
Listening to the voices of children, young people and their parents and carers about their
experiences of medical services is crucial in helping CQC to highlight good care and
identify potential risks to the quality of services.
1.2 The survey comprised of 56 separate questions, some of which were applicable to children
and young people over 8yrs old, and others to the parents of younger children. Over half
of the responses nationally were from children, who were on the urgent care pathway, with
the remainder on the scheduled care pathway.
1.3 Some of the questions were not applicable to the different pathways, or there were too few
responses (minimum of 30), to score specific areas, which further impacts on being able to
benchmark
2. Summary of the WSHT findings (Responses)
2.1 The national response rate was 27% from 157 Hospital Trusts. WSHT had a response
rate of 38%, which is significantly higher than average. Benchmarking nationally is not
necessarily thought to be helpful, as there are many different variables which will affect the
findings. For example the type of hospital trust, and the number of questions therefore
responded to, will impact. However, as this is the first survey, a comparison has been
anonymously made against similar Trusts in the Southern region. Table one below shows
the differences in the response rates, with WSHT being shown as no 11:
Table 1 (WSHT number 11)
2.2 It can be seen from this that 4 Trusts in the cohort had response rates above 35%, far
exceeding the national rate, and conversely four below the national average of 27%.
3. Summary of findings (Expected ranges)
3.1 The vast majority of the responses nationally fell within an expected range (amber), which
was statistically defined, for each individual question.
3.2 When the results statistically fell outside of the expected range, the result was defined as
better than expected (Green) or worse than expected (Red).
3.3 Table 2 below shows the same Trust’s responses, indicating the areas outside of the
expected range.
Table 2 (Number of questions falling outside of the expected range)
5
4
3
2
1
Worse than expected
0
-1
1
2
3
4
5
6
7
8
9
10 11
Better than expected
-2
-3
-4
-5
3.4 It can be seen from this, that parents and children at WSHT felt their experience was better
than other Trusts nationally in four defined areas. This compares favourably to other
Trusts in the South Coast area of similar size and type.
3.5
It can also be seen that WSHT did not have any areas, where the
considered worse than expected.
3.6
The four areas considered to be statistically better than the expected range for WSHT
were:
•
•
•
•
services
were
Parents/Carers of 0-7r olds feeling their child was safe: 9.8/10
8 -15 yr olds feeling they were being listened to: 9.6/10 (Highest national score)
Parents/Carers saying they thought staff did all they could to ease their child’s pain:
9.1/10
8-15 yr olds saying they were told how their operation/procedure had gone in a way
they could understand 9.3/10
4. High performing areas
4.1 Each question appeared to have significant variances in what was statistically considered
to be outside of the normal range. The percentage scoring above 9/10 are shown in
table 3 below:
Table 3
% over 9/10
60%
50%
40%
30%
% over 9/10
20%
10%
0%
1
4.2
5.
6.
2
3
4
5
6
7
8
9
10
11
It can be seen from this that WSHT responses have indicated a high level of satisfaction
for the 54/56 questions answered.
Overall
5.1
From the information gleaned above it would seem that WSHT had a high response rate
with most falling well within the expected range, and a significant number at the high end
of the expected range. Four fell outside of the expected range and graded as better
performing (Green).
5.2
Although WSHT did not receive any areas graded as worst performing, there are areas,
in which the score was slightly below average in the expected range, as outlined below.
These will form the basis for the development of an action plan, in which our clinical staff
will be fully involved.
Comments from children and families
6.1 As part of the survey parents, children and young people were invited to make comments
which were plentiful, with a small selection below:
6.2 Positive:
•
•
I would like to add that nurses looking after my child have been absolutely amazing. Always kind,
professional and very caring. Play room located on the ward is a wonderful idea and my child loved
spending his 'hospital time' there. Overall as a parent I am very pleased with the quality of care my
child received. Thank you.
I found it very comforting that my baby was always comforted and shown love when I could not be
there. As a mother this was very important to me. I also found it very comforting that the surgeons
came around each morning. Everyone made our tough experience as good as it could be and we are
eternally grateful.
•
•
•
•
•
This was our daughter's third visit to St. Richards' A&E and second on to a ward. The ward staff are
so kind, attentive and brilliant. On both occasions our daughter has come home with 'souvenirs', toys
given to her by staff plus, more importantly, a very positive experience and memory of hospital!
My son was treated with the most care and attention. They listened to my concerns and treated my
son accordingly. I was made at ease and left the hospital confident that my child was OK and on the
mend Bluefin Ward Staff do a great job, and as a mother of 2 young boys, its great to be filled with
confidence of the ability of our local hospital staff.
They were very good the way they treated myself, partner and little one. You should be proud of the
staff we have been dealt with - very professionally and very good staff. My advice keep staff like that
and you will have a brilliant hospital. Many thanks for your staff support.
I was in so much pain, I didn't want to sleep in hospital. But the staff sorted out my appendix so I
didn't die - that was good. They helped me to go to the toilet and wheeled my drip in with me. I'm
glad they helped me to survive - the pain was horrible. Nurse Lucy was very gentle and talked to me.
Hello doctors/nurses (in Howard Ward, Children's unit). I would just like to say thank you for looking
after me while I was in pain. You was very kind and helpful towards me. Sorry I screamed a lot while
having my blood tests, you still managed to do it though.
6.3 Negative
• Unfortunately I really saw the difficulties staff have with paperwork and passing on information. I
had to continue to explain the injury to new members of staff - if this was digital format it would
save so much time. The wait for surgery to remove fish bone was 17 hours. This was far too long for
my child to be in pain
• Food - no healthy choices or fresh fruit/veg. Parents room - cramped with anyone else in there. Had
runout of milk/sugar etc. so couldn't make drinks. Parents facilities - bed wheeled in - not shown
how to setup, had to ask for bedding. Put away early in morning and only had cot so difficult to sit
down etc. as no chairs. Noise levels in evening - nurses made no consideration to babies trying to get
to sleep/just fallen asleep. Nurses - one lovely lady, all others made not interaction with my baby.
Inconsiderate when administering medicine through drip and caused unnecessary distress through
sheer laziness. Discharge took 6hrs – Ridiculous
• I was told I wasn't allowed to stay overnight with my daughter because I was breastfeeding my baby
and the baby couldn't stay.
• The pharmacy was appalling - exceptionally long wait (even though only one other person waiting),
unfriendly and rude.
• The staff on Howard Ward were lovely when we got up there; very caring and polite. Our only down
point was the experience in A&E. We were left down there for about 7 or 8 hours and were basically
left to fend for ourselves when the Children's Nurses shift finished. I asked other staff floating about
what was happening as my son was getting worse and was pretty inconsolable. One member of staff
actually said that we could discharge ourselves if we wanted; lost all faith in A&E.
7 Conclusion
The action plan to be developed will identify key strategies and actions to improve patients’
experience. It will be managed by the Women’s and children’s division and be reviewed by
the Patient Experience and Engagement Committee who will inform the Patient Experience
and Feedback Committee of progress.
Patient survey report 2014
National children's inpatient and day case survey 2014
Western Sussex Hospitals NHS Foundation Trust
National NHS patient survey programme
The Care Quality Commission
The Care Quality Commission (CQC) is the independent regulator of health and adult social care in
England.
Our purpose is to make sure hospitals, care homes, dental and GP surgeries, and all other care
services in England provide people with safe, effective, compassionate and high-quality care, and
we encourage them to make improvements.
Our role is to monitor, inspect and regulate services to make sure they meet fundamental standards
of quality and safety, and to publish what we find, including performance ratings to help people
choose care.
To improve the quality of services that the NHS delivers, it is important to understand what people
think about their care and treatment. One way of doing this is by asking people who have recently
used local health services to tell us about their experiences.
This survey focused on young patients who were admitted to hospital as inpatients or for treatment
as day case patients. One hundred and thirty seven acute and specialist NHS trusts across England
participated. We received feedback about the care of nearly 19,000 young patients, which is a
response rate of 27%. Young patients were eligible to take part in the survey if they were:
• aged between 0-15 years
• not staying in hospital at the time patients were sampled
• not 'well babies' i.e. newborn babies where the mother is the primary patient
• were admitted to hospital in August 2014 (some trusts also sampled patients who were
admitted in July or September also)
Questionnaires and reminders were sent to patients between October 2014 and January 2014.
The children's survey is part of a wider programme of NHS patient surveys, which covers a range of
services including acute adult inpatients, A&E, maternity services and community mental health
services. To find out more about our programme and the results from previous surveys, please see
the links in the further information section.
The Care Quality Commission will use the results from this survey in our regulation, monitoring and
inspection of NHS acute trusts in England. We will use data from the survey in our system of
Intelligent Monitoring, which provides inspectors with an assessment of risk in areas of care within
an NHS trust that need to be followed up. The survey data will also be included in the data packs
that we produce for inspections.
NHS England will use the results to check progress and improvement against the objectives set out
in the NHS mandate, and the Department of Health will hold them to account for the outcomes they
achieve. The NHS Trust Development Authority will use the results to inform quality and governance
assessments as part of their Oversight Model for NHS Trusts.
Interpreting the report
This report shows how a trust scored for each evaluative question in the survey, compared with
other trusts. It uses an analysis technique called the 'expected range' to determine if your trust is
performing 'about the same', 'better' or 'worse' compared with other trusts. For more information,
please see the 'methodology' section below. This approach is designed to help understand the
performance of individual trusts, and to identify areas for improvement.
Throughout the report, results are presented for two main groups of respondents: children and
young people, and their parents or carers. Each of these groups used different questionnaires
although both focused on the care provided to the young patient. In this report, results are
2
presented using feedback from the following groups:
- children and young people aged 8-15 years
- parents and carers of patients aged 0-15 years
- parents and carers of patients aged 0-7 years (where questions were only asked of this group)
Responses from parents and carers are divided into these two groups because children under 8
years of age were not asked any questions. Parents and carers of these children were therefore
asked more questions than the parents and carers of older children.
This report shows the same data as published on the CQC website available at the following link:
www.cqc.org.uk/childrenssurvey
Standardisation
Trusts have differing profiles of people who use their services. For example, one trust may have
more younger patients than another trust. This can potentially affect the results because carers or
parents may answer questions in different ways, depending on certain characteristics of their
children. For example, the parents of older children may report more positive experiences than
those of younger respondents. This could potentially lead to a trust's results appearing better or
worse than if they had a slightly different profile of people.
To account for this, we 'standardise' the data. Results have been standardised in different ways for
the different groups that took part in this survey. The data provided by children aged 8-15 has been
standardised by route of admission (whether a patient was admitted as an emergency or their
admission was planned) and the type of stay (day case or inpatient). The data provided by parents
or carers of children aged 0-15 has been standardised by the same two variables plus survey age
group (whether the child was aged 0-7 or 8-15). This helps to ensure that each trust's profile reflects
the national distribution (based on all of the respondents to the survey). It therefore enables a more
accurate comparison of results from trusts with different population profiles. In most cases this will
not have a large impact on trust results; it does, however, make comparisons between trusts as fair
as possible.
Scoring
For each question in the survey, the individual (standardised) responses are converted into scores
on a scale from 0 to 10. A score of 10 represents the best possible response and a score of zero the
worst. The higher the score for each question, the better the trust is performing.
It is not appropriate to score all questions in the questionnaire as not all of the questions assess the
trusts in any way, for example, they may be may be 'routing questions' designed to filter out
respondents to whom following questions do not apply.
For full details of the scoring please see the technical document (see further information section).
Graphs
The graphs in this report show how the score for the trust compares to the range of scores achieved
by all trusts taking part in the survey. The black diamond shows the score for your trust. The graph
is divided into three sections:
• If your trust's score lies in the orange section of the graph, its result is 'about the same' as most
other trusts in the survey.
• If your trust's score lies in the red section of the graph, its result is 'worse' compared with most
other trusts in the survey.
• If your trust's score lies in the green section of the graph, its result is 'better' compared with
most other trusts in the survey.
The text to the right of the graph clearly states whether the score for your trust is 'better' or 'worse'
compared with most other trusts in the survey. If there is no text the score is 'about the same'.
These groupings are based on a rigorous statistical analysis of the data, as described in the
following 'methodology' section.
Graphs are presented based upon themes, under each theme will be both the data from adults and
from children/young patients.
3
Methodology
The 'about the same,' 'better' and 'worse' categories are based on an analysis technique called the
'expected range' which determines the range within which the trust's score could fall without
differing significantly from the average, taking into account the number of respondents for each trust
and the scores for all other trusts. If the trust's performance is outside of this range, it means that it
performs significantly above/below what would be expected. If it is within this range, we say that its
performance is 'about the same'. This means that where a trust is performing 'better' or 'worse' than
the majority of other trusts, it is very unlikely to have occurred by chance.
In some cases there will be no red and/or no green area in the graph. This happens when the
expected range for your trust is so broad it encompasses either the highest possible score for all
trusts (no green section) or the lowest possible for all trusts score (no red section). This could be
because there were few respondents and / or a lot of variation in their answers.
Please note that if fewer than 30 respondents have answered a question, no score will be displayed
for this question (or the corresponding section). This is because the uncertainty around the result is
too great.
A technical document providing more detail about the methodology and the scoring applied to each
question is available on the CQC website (see further information section).
Tables
At the end of the report you will find tables containing the data used to create the graphs, the
response rate for your trust and background information about the young people and their parents
and carers that responded.
Further information
The full national results are on the CQC website, together with an A to Z list to view the results for
each trust (alongside the technical document outlining the methodology and the scoring applied to
each question):
www.cqc.org.uk/childrenssurvey
Full details of the methodology of the survey can be found at:
http://www.nhssurveys.org/surveys/769
More information on the programme of NHS patient surveys is available at:
www.cqc.org.uk/public/reports-surveys-and-reviews/surveys
More information on CQC's hospital intelligent monitoring system is available on the CQC website:
http://www.cqc.org.uk/public/hospital-intelligent-monitoring
4
Going to hospital
Children and young people said:
When arriving at the hospital, they were told
what would happen to them whilst there
All parents and carers said:
Hospital staff told them what would happen to
their child in hospital
Parents and carers of 0 to 7 year olds said:
The hospital gave them a choice of admission
dates
The hospital did not change the admission date
Best performing trusts
About the same
Worst performing trusts
'Better/Worse' Only displayed when this trust is better/worse than
most other trusts
This trust's score (NB: Not shown where there are
fewer than 30 respondents)
5
The hospital ward
They felt safe on the hospital ward
They liked the hospital food
They were given enough privacy when receiving
care and treatment
The ward had appropriate equipment or
adaptations for their child
The hospital room or ward their child stayed on
was clean
Their child did not stay on an adult ward
They felt their child was safe on the hospital
ward
Better
Their child was given enough privacy when
receiving care and treatment
There were appropriate things for their child to
play with on the ward
Their child liked the hospital food
About the same
most other trusts
6
Hospital staff
A member of staff agreed a plan with them for
the child's care
They had confidence and trust in the members
of staff treating their child
They were encouraged to be involved in
decisions about the child's care and treatment
Members of staff were aware of the child's
medical history
Staff knew how to care for the child's individual
or special needs
Staff were available when their child needed
attention
Members of staff caring for their child worked
well together
The hospital staff played with their child while
they were in hospital
Their child was well looked after by hospital staff
About the same
most other trusts
7
Speaking with patients and providing information
Staff talked to them in a way they could
understand
Someone at the hospital talked to them about
any worries they had
The people looking after them listened to them
Better
The people looking after them were friendly
Staff gave them information about the child's
condition and treatment in a way they could
understand
Hospital staff kept them informed about what
was happening whilst the child was in hospital
Staff asked if they had any questions about their
child's care
New members of staff treating the child
introduced themselves
Members of staff communicated with the child in
a way they could understand
They were not told different things by different
people, which left them feeling confused
The people looking after their child listened to
them
The people looking after their child were friendly
Staff treated them with respect and dignity
About the same
most other trusts
8
Facilities for parents and carers
They had access to hot drinks facilities at the
hospital
The facilities for staying overnight for parents
and carers were good
Pain
Hospital staff did everything they could to help
their pain
Hospital staff did everything they could to ease
the child's pain
Better
Operations and procedures
Someone told them what would be done, before
the operation or procedure
Someone from the hospital explained how the
operation or procedure went, in a way they
could understand
Better
Staff explained to parents and carers what
would be done during the operation or
procedure
Staff answered their questions about the
operation or procedure, in a way they could
understand
Someone from the hospital explained how the
operation or procedure had gone, in a way they
could understand
About the same
most other trusts
9
Being prepared to leave hospital
Hospital staff told them what to do or who to talk
to if worried about anything when home
They were given enough information on how
their child should use and take any new
medicine
They were given advice on how to care for the
child when home
They were told what would happen next after
the child left hospital
They were given written information about the
child's condition or treatment to take home
They were told what to do or who to talk to, if
worried about their child when home
Overall experience
Very poor experience
Very good experience
Very poor experience
Very good experience
They had a good overall experience of care in
the hospital
They felt their child had a good experience of
care in the hospital, overall
About the same
most other trusts
10
Going to hospital
When arriving at the hospital, they were told what would happen to them whilst
there
8.9
7.3
9.7
54
8.6
7.1
9.9
153
The hospital gave them a choice of admission dates
-
1.6
7.1
The hospital did not change the admission date
-
7.6
9.9
They felt safe on the hospital ward
9.5
8.7
9.9
57
They liked the hospital food
6.7
4.9
9.3
39
They were given enough privacy when receiving care and treatment
9.0
7.7
9.8
57
The ward had appropriate equipment or adaptations for their child
9.1
7.7
9.9
140
The hospital room or ward their child stayed on was clean
9.2
7.5
9.9
152
Their child did not stay on an adult ward
10.0 8.6 10.0 152
Hospital staff told them what would happen to their child in hospital
The hospital ward
They felt their child was safe on the hospital ward
9.8
8.0 10.0
96
Their child was given enough privacy when receiving care and treatment
9.5
8.1
9.9
96
There were appropriate things for their child to play with on the ward
8.9
6.3
9.7
87
Their child liked the hospital food
5.4
3.9
7.7
49
11
Hospital staff
A member of staff agreed a plan with them for the child's care
9.2
7.1 10.0 144
They had confidence and trust in the members of staff treating their child
9.0
7.5
9.9
153
They were encouraged to be involved in decisions about the child's care and
treatment
7.7
6.7
9.0
152
Members of staff were aware of the child's medical history
7.2
6.6
9.2
135
Staff knew how to care for the child's individual or special needs
8.6
7.5
9.9
150
Staff were available when their child needed attention
8.5
7.1
9.7
153
Members of staff caring for their child worked well together
8.8
7.4
9.8
147
The hospital staff played with their child while they were in hospital
7.9
4.2
9.8
43
Their child was well looked after by hospital staff
9.2
7.9 10.0
95
Staff talked to them in a way they could understand
9.1
7.3
9.9
56
Someone at the hospital talked to them about any worries they had
8.9
6.3
9.7
46
The people looking after them listened to them
9.6
7.3
9.6
58
The people looking after them were friendly
9.6
8.3 10.0
58
9.2
8.1 10.0 154
Speaking with patients and providing information
Staff gave them information about the child's condition and treatment in a way they
could understand
Hospital staff kept them informed about what was happening whilst the child was in 8.5
hospital
7.1
9.4
154
Staff asked if they had any questions about their child's care
8.2
6.6
9.7
141
New members of staff treating the child introduced themselves
8.9
7.4
9.5
97
Members of staff communicated with the child in a way they could understand
8.4
6.5
9.3
91
They were not told different things by different people, which left them feeling
confused
8.0
6.7 10.0
96
The people looking after their child listened to them
8.7
7.2
9.8
97
The people looking after their child were friendly
8.9
7.7
9.8
97
Staff treated them with respect and dignity
9.3
8.1 10.0
95
12
Facilities for parents and carers
They had access to hot drinks facilities at the hospital
9.4
6.7
9.9
149
The facilities for staying overnight for parents and carers were good
7.5
5.2
8.7
87
9.0
7.3
9.6
41
9.1
7.4
9.8
86
Someone told them what would be done, before the operation or procedure
9.2
8.1
9.9
37
Someone from the hospital explained how the operation or procedure went, in a
way they could understand
9.3
6.6
9.5
36
Staff explained to parents and carers what would be done during the operation or
procedure
9.3
8.3 10.0
79
Staff answered their questions about the operation or procedure, in a way they
could understand
9.7
8.4
9.8
77
Someone from the hospital explained how the operation or procedure had gone, in
a way they could understand
9.0
7.6
9.8
80
8.1
6.5
9.3
56
They were given enough information on how their child should use and take any
new medicine
9.1
8.8 10.0
50
They were given advice on how to care for the child when home
8.4
7.5
9.8
141
They were told what would happen next after the child left hospital
8.7
6.8
9.9
135
They were given written information about the child's condition or treatment to take
home
7.8
4.5
9.7
81
8.8
7.1
9.9
90
Pain
Hospital staff did everything they could to help their pain
Hospital staff did everything they could to ease the child's pain
Operations and procedures
Being prepared to leave hospital
Hospital staff told them what to do or who to talk to if worried about anything when
home
They were told what to do or who to talk to, if worried about their child when home
13
Overall experience
They had a good overall experience of care in the hospital
8.5
7.2
9.4
58
8.7
7.3
9.4
152
They felt their child had a good experience of care in the hospital, overall
14
Background information
The sample
This trust
All trusts
155
18736
38
27
This trust
All trusts
(%)
(%)
Male
52
56
Female
48
44
(%)
(%)
95
79
Multiple ethnic group
3
5
Asian or Asian British
1
8
Black or Black British
0
3
Arab or other ethnic group
0
1
Not known
1
4
Number of respondents
Response Rate (percentage)
Demographic characteristics
Gender (percentage)
Ethnic group (percentage)
White
15
To: Trust Board
Agenda Item: 9
Title
National Adult Inpatient Survey Action Plan
Amanda Parker, Director of Nursing and Patient Safety
Prepared by
Amanda Parker, Director of Nursing
Status
Disclosable
Summary of Proposal
a) The purpose of this report is to provide an update on actions identified following the national adult
inpatient survey results and demonstrate their linkage to ongoing trust activity. The action plan is for
review at the patients experience and engagement committee on July 22nd.
1. The results provide an opportunity to improve a patient’s experience by utilising the feedback from other
patients and the actions identify areas where work will improve the experience for patients.
Support of Board Assurance Framework number A1, B2, B3, B5
1. None.
1. Professional performance management issues for individuals.
2. Learning and development requirements.
3. Organisational, behavioural and cultural issues.
Recommendation
The Board is asked to note the contents of the report.
Communication
The action plan identifies actions to improve patients’ experience it will be managed and reviewed by the
Patient Experience and Engagement Committee who will inform the Patient Experience and Feedback
Committee of progress.
Appendices
Patient experience priorities action plan
Patient Experience Priorities 2015/16
Issue
Owner
Providing clear,
written
information
about medicines
Saffron
Mawby
Actions
Results from national inpatient (IP) survey presented to
Medicines Optimisation Committee
Due
Monitor
Q1
Medicines
optimisati
on group
Develop RTPE feedback questionnaire to mirror the questions in
the IP survey and undertake at the point of discharge once per
quarter
Q1
Complete roll out of POD(patient own drugs) lockers to aid POD
usage and transfer
Q2
Develop a business case for ‘Medicines a Patient Profile’ system
to improve the information given to all patients, at discharge,
about their current medication.
Q2
Promote the pharmacy ‘Patient Info’ helpline at discharge
Q2
Run a series of additional training sessions on consultation skills
for pharmacy staff and possibly nursing staff
Q3
Implement a pilot of self-administration for a targeted patient
group
Q3
Develop a process for improved referral to community medicines
use review services
Q3
Investigate the role of expert patients in establishing initiatives
for improved patient information
Q4
Investigate the benefits of patient adherence focus in-line with
current work in Sussex Partnership Trust
Q4
PEEC
Target*
(monitor
monthly
using
RTPE)
97%
satisfaction
RTPE
Medicines
information
pt. survey
to be
repeated
and
reported
each
quarter
Update June 2015
Action complete
Survey designed - to
commence in July
following completion
of Healthwatch
discharge review
Existing Work streams
• Medication Discharge Pathway – led by Marianne Griffiths
Noise at Night
Lisa
Ekinsmyth
Review of night time staffing numbers led by DN
Q1
Purchase of additional soft closure bins to ensure cross trust
coverage.
Q1
Complete night time Sit and See observations both sites
Q2
Director of Nursing ‘night review’
Q2
Repeat bedside conversations project with night time focus
Q2
Ensure cross trust use of night time care packs – monitor using
ward accreditation
Develop Top Tip cards to promote a good night sleep
Q2
Review night time care study day
.
Q3
7 day
working
group
89%
satisfaction
Reported to board
May2015
Bins ordered and
awaiting distribution
PEEC
Full out of
hours
plan has
been
shared
with CCG
Q2
Existing Workstreams
• CQUINS in place for reducing night time ward moves and delirium training needs analysis led by dementia team with progress to be reviewed by dementia
strategy group
• Falls Quest Workstream to promote effective and consistent approach to night time settling, progress to be reviewed by falls collaborative group.
Involvement in
discussions
about discharge
Trust lead
tbc
•
Review with stakeholder forum members the key things
would improve discharge experience
Q1
•
Nesta young people’s volunteer project includes key
outcome to improve the support to patients on the day of
discharge and to include a final check on key discharge
information. (including patient information leaflet).
Q3
• Discharge planning workshops for ward staff are in place and led by discharge team
• Discharge checklist within existing nursing assessment documentation;
• Discharge patient information leaflet in place. To make sure all wards are using appropriately.
PEEC
92%
satisfaction
involvement
in decisions
about care
87%
satisfaction
discharge
conversation
Action complete;
feedback shared to
Quest project lead
•
•
•
The Trust has signed up to KSS safe discharge and transfer collaborative led by discharge team; with outcomes to be confirmed
Quest Discharge Pilot. (Lavant Ward) commenced in May with milestones to be reviewed each quarter. Led by Katrina O’Shea
Healthwatch discharge survey to be conducted through discharge lounges in June with report expected in September.
Quality of Food
and Mealtime
Support
Christina
Connolly /
Lisa
Ekinsmyth
•
Review of visiting times by DN to encourage increased carer
support
Q2
•
Stakeholder forum in June included breakout group to
gather ideas to improve mealtime support
Nesta young people volunteering project has mealtime
support as key element with aim to expand to areas in a
staged manner and to include suppertime support. This is
also a key element for review by the falls collaborative
Q1
Food
Strategy
Group
PEEC
•
Q3
94%
satisfaction
with
assistance
with food
and drink
Action Complete
Falls
Collaborat
ive
• Mealtime PLACE reviews ongoing
• Review of catering structure and housekeeping role; facilities and estates to develop case for single coordination of team
• Protected mealtimes, red tray and cups in place; on-going review by food strategy group
• Finger food pilot complete for full roll out across the Trust; progress to be reviewed by food strategy group
• ‘Lets do Lunch’ dining companions pilots have started with plans to expand by increasing staff and patient volunteer numbers
Privacy during
conversations
Lisa
Ekinsmyth
Privacy Pegs distributed across Trust in quarter 1
Q1
Sit and see programme in place which includes review of privacy
Q1
EoL
board
PEEC
94%
satisfaction
Action Complete
• Full review of curtains across the Trust led by David Jones
• Full action plan for end of life care includes key actions to improve privacy. Including requirement for wards to identify a place for breaking bad news and
private conversations; weekly walkabouts by senior staff from palliative care team, target for improving staff uptake of communication training. This action
plan is reviewed by the end of life operational group.
• PLACE visits include assessment of privacy and dignity
Information
about waiting
times A/E and
Emergency
Floor
Gary
Wright/
Catherine
Keegan
Sue
Shepherd
Patient information leaflet in place in A/Es; adapted for use for
Emergency Floor
Q1
Sit and see visits to feedback to staff
Q2
PEEC
FFT
Action Complete
• Use of TV screens with Free WiFi containing Trust patient info; project underway led by Donna Steeles, Simon Sturgeon and communications team.
Welcome and
Information
about Waiting
Times OPD
Fiona
Keeling
/Emma
Plummer
•
Implement “Always Events” to support consistent staff
behaviour regarding communication to waiting patients Pilot
in eye clinics and then roll out through clinics in staged
approach
Sit and See rolling programme to provide regular staff feedback
about behaviours
PEEC
Q2
Q1
FFT
Aim RPTE
score>75%
for
information
about
waiting
times
Aim >95%
for
welcome.
Visits to clinics on all 3
sites during quarter 1
• KPMG review of outpatients underway
• White boards in place for staff to highlight key information including any delays
• Customer Care Programme working with reception teams to embed the ‘Western Sussex Way’
• Implementation of TV screens and free WiFi, containing trust patient info(as described above)
Communication
Lisa
Review with stakeholder forum members the key things would
Q1
PEEC
FFT theme
including
Ekinsmyth
improve preoperative experience.
monitoring
preoperative
care and
Embed the use of the end of bed folder which contains
Q2
consistency of
supportive information about a wide range of subject areas.
information
across all areas.
Review of preoperative service underway led within surgical division
Programme in place (PMO) to standardise ward boards and handover
Bed reconfiguration programme to deliver ‘right patient, right place, right time’ and ensure consistent communication across teams
*Target based on being a top scoring Trust
Action Complete
To: Trust Board
Agenda Item: 10
Title
Patient First – Progress Report
Marianne Griffiths, Chief Executive
Prepared by
Jenny Procter – Programme Director PMO
Denise Farmer – Director of OD and Leadership
Status
Discloseable
Summary of Proposal
The purpose of this paper is to provide the Trust Board with an update on the implementation of the
Trust’s Patient First Programme, our trust-wide approach to improving the experience and quality of care
we offer patients. The Patient First Programme Board will oversee and assure delivery of all
improvement and transformation work in the Trust.
The Patient First programme’s key aim is to improve the quality of care for patients and improve patient
experience.
Links across all of the Trust’s Strategic Objectives
A number of workstreams within the Patient First Programme have resource implications and will
contribute to our sustainability through achievement of savings.
A Workforce Transformation Workstream and an Organisational Development Workstream are now in
place. The workforce impact, and workforce development opportunities will be assessed and delivered
as art of the Our People strategic theme.
Recommendation
The Board is asked to NOTE progress on the development of the Patient First Programme
Communication Strategy has been approved by the Patient First Programme Board.
Appendices
N/A
Patient First Programme – Update Report
July 2015
1. Introduction
The Patient First Programme has entered a period of intense activity as Ward
Accreditation is implemented, the rapid improvement process for elective and nonelective care concludes and the detailed preparation for the launch of the Patient
First Improvement Programme is undertaken in partnership with KPMG and
ThedaCare.
The programme continues to be supported by a range of communication and
engagement activities including roadshows for staff through July and August.
Patient First was also the theme of this year’s Annual General Meeting, held on July
27.
This report provides a summary update of progress against key objectives and
outlines the priorities for August.
2. Context
Introduced in November 2014, Patient First is the Trust’s approach to ensuring
patients receive safe, high quality care, now and in the future. The philosophy behind
the programme is centred on:
•
•
•
•
The patient being at the heart of every decision
Empowering staff to build on existing high standards
Continuous improvement of services through small steps of change
Standardising practices to ensure consistency of service
Patient First has a strong focus on safety and we have prioritised changes that
directly support that focus. For example the introduction of daily Safety Huddles,
where everyone working on a ward comes together at the same time each day to
discuss how they will provide a safe service that day, including ensuring they have
the right staff and resources.
3. Patient First Themes
a. Sustainability. The main focus of this strand of work is the development of
the workforce transformation programme and specifically identification of
schemes to improve our substantive staffing levels. We know that investing in
staff who have been recruited to the organisation and developed and
managed in line with our values will have a beneficial impact on care for our
patients and enable us to reduce the premia we currently pay for agency staff.
International and Domestic Recruitment campaigns are progressing well,
although changes in immigration arrangements are causing a delay in the
arrival of international recruits. To mitigate this delay, a ward level programme
of improved resource management is now in place. Divisional Medical
Workforce plans are also progressing and the process has revealed a number
of opportunities that will be worked up by the Divisional management teams.
A specification for external support to develop an improvement programme
for administration and clerical services is being developed and work is
ongoing with the Divisions to identify tactical saving opportunities in 2015/16.
b. Our People. We have entered an exciting stage in planning the
implementation of the Patient First Improvement Programme with our
partners (KPMG/ThedaCare ) . A roadmapping exercise with the Executive
will be completed in the next two weeks and will set the key milestones for the
development programme as well as enhance the Executive’s understanding
of organisational readiness.
An all staff survey was issued to inform the road mapping exercise. Nearly
2,000 of our staff responded to the Patient First survey and the information
reviewed through five ‘lenses’. These lenses characterise the attributes of a
high performing lean organisation. Table 1 outlines the lenses, what good
looks like and the Trust’s current position in relation to this. The results reflect
the maturity of the organisation’s lean development and correlate to
responses received in the National Staff survey and the Medical Engagement
scale survey, and give us helpful information to enable us to focus our
priorities, and use as a baseline against which we can measure progress.
A response to the survey will be agreed and issued to staff in August.
Five lenses
What good looks like
Survey findings
Strategy
Deployment
We know what we are
focussed on and what is
expected of us
There is variability across the Trust in
how goals are communicated and
cascaded down to the frontline,
including how a specific department
contributes to the trust vision and
goals.
Visual
Management
We can transparently
track how we are
performing against
goal(s)
Some performance measures are
displayed, with many accessible
electronically; however limited
discussion of displayed measures
occurs, with much of the discussion on
performance occurring only in formal
meetings.
Performance
Review
Methods
We have a process to
review results, align on
what is required to
improve and are able to
root cause problem solve
The safety huddle has been a good
start for engaging frontline; there is an
opportunity to build on the safety
huddles to look at how performance is
reviewed, how issues are raised and
how improvement is made and
supported.
Standard Work
We have the discipline to
remain focused on what
is important over time
Variability in process, communication
and management is recognised across
and within sites; there is a real desire
for meaningful interaction with senior
management.
Change
Readiness
We have the
organisational
capabilities and culture
to support change
There is a motivation for all levels of
the Trust to be involved in
improvement and change; however the
opportunities to do so are not clear,
especially for those at the frontline.
Other activity to support the Our People theme includes the development of
the Leadership Framework and in particular Leadership Compacts and the
continued engagement with staff through the Patient First Roadshows. We
have developed a draft leadership Behaviours framework with cross
organisational staff engagement, and work on developing a compact for
matrons and ward sisters has started. A draft will be available for the
Programme Board in September/October
The Executive Team has approved a pilot that will test the quality impact of
Band 4 Associate Practitioner roles. If successful, these roles will reduce
reliance on hard to recruit Band 5 nurses and provide a significant
development opportunity for staff with the ambition to nurse who may not
want to pursue the degree led route for nurse training. The outcome of the
pilot will be considered in November.
Finally the Trust’s Patient First staff recognition awards closed on 12th July
with more than 300 nominations received. The awards are designed to honour
all those staff who demonstrate exemplary behaviours and go above and
beyond their job role for the benefit of those around them.
For 2015 the event has been renamed the Patient First Awards with new
categories available and nominations were encouraged from both staff and
members of the public.
c. Quality . The Trust is undertaking a comprehensive review of Clinical Nurse
Specialist roles to understand the contribution they make to patient care and
identify opportunities to enhance that further
A review of Consultant led activity data is also underway which has revealed
a significant opportunity to improve the quality of recording of outpatient
activity by Consultant. Consideration will be given to the minimum standards
for data capture that may be reflected in a Medical Leadership Compact.
A ward accreditation programme designed to ensure consistent high
standards are met on all wards has also been introduced. Wards are
inspected against an accreditation framework, designed around 14 standards
with each one divided into three elements; Environment, Care and
Leadership. The aim is for all wards to have, after their initial review, a
development plan that will lead to them all achieving Gold accreditation by
2017.
As part of our membership of Quest, Lavant ward is pioneering the
application of improvement methodologies and will be presenting PDSA
cycles in July’s system wide WebEx. We appear to be progressing well
compared to other Trusts, data collection and testing of change has
commenced and we will present our progress in December when WSHFT
host a Quest peer review day
One of our priorities for improvement is Outpatient services. The diagnostic
phase is progressing well. Meetings have been held with key stakeholders
and data is being collected and analysed in support of the work on capacity
analysis and benchmarking.
Led by our Lead Governor, we have developed relationships with local
supermarkets in Worthing to put in place a scheme for providing ‘welcome
home’ packs of some food staples for patients who may need them. The idea
was hatched following feedback from patients and staff about how we could
better support discharge from hospital. Once we have the scheme up and
running we intend to launch it at SRH too.
d. Systems and Partnerships. Significant work has been undertaken in the
Divisions to complete a process of rapid improvement to confirm the
improvement objectives for elective and non-elective services. Sessions led
by the Chief Operating Officer were held in July to review and support the
work: the outputs will now form the basis of Transformation Programmes for
Non-Elective and Elective care. The first objective for both Programmes is to
right size capacity to deliver the Trust’s activity plan and the principal outputs
will be a new bed reconfiguration (already approved) and new schedules for
theatres and outpatients. Both programmes will be enabled by a number of
improvement workstreams including the roll out of ambulatory care, senior
daily review to expedite discharge, theatre efficiency and a new model for
pre-assessment.
4. Planned activity in August
Work will continue to support delivery of all improvement work within the Programme.
Specific actions include:
•
Completion of Patient First Improvement Programme Roadmapping Exercise
and publication of the Programme Development Roadmap
•
Executive response to the Patient First survey issued to all staff and
identification of any actions in addition to the Development Roadmap
•
Establishment of Non Elective and Elective Transformation Steering Groups
•
Establishment of Non Elective and Elective Transformation Programmes and
completion of PIDs
•
Patient First Engagement Roadshows
To: Trust Board
Agenda Item: 11
Title
Month 3, 2015-16 Performance Report
Jane Farrell, Chief Operating Officer/Deputy Chief Executive
Prepared by
Adam Creeggan, Director of Performance
Giles Frost, Head of Operational Planning and Performance
Status
Disclosable
Summary of Proposal
The paper sets out organisational compliance against national and local key performance metrics. The report
summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as
detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the
Monitor Risk Assessment Framework and, when relevant, other efficiency indicators. This paper describes performance
on an exceptional basis determined by RAG rating, national significance, or in year trend analysis.
Describes Quality Outcome KPIs
Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing
on a range of measures to improve clinical effectiveness.
Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial
performance and investing in appropriate infrastructure and capacity.
Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures
through the introduction and spread of best practice throughout the organisation.
Describes KPIs linked to financial performance
Describes KPIs linked to workforce
Recommendation
The Board is asked to: NOTE
Not applicable
Appendices
Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Monitor Risk Assessment Framework
Scorecard.
1
To:
Trust Board
Date: 30th July 2015
From: Jane Farrell, Chief Operating Officer/Deputy Chief Executive
Agenda Item: 11
FOR INFORMATION
WSHFT PERFORMANCE REPORT: MONTH 3, 2015/16
1.
INTRODUCTION
1.1
This report summarises both in year and projected year end performance for Western Sussex
Hospitals NHS Foundation Trust, detailed in dedicated performance scorecards relating to:
1.2
•
The Monitor Risk Assessment Framework
•
Other efficiency indicators, where relevant.
This paper describes performance on an exceptional basis determined by RAG rating, national
significance, or in year trend analysis.
1.3
In addition to the performance exception narrative, each exception is examined in detail in the
Key Performance Deliverables section of this report. Each metric under review examines detailed
trending, prevailing cause and effect, and summarises recovery programme actions.
2.
SUMMARY PERFORMANCE
2.1
Based on provisional Month 3 positions, the Monitor Risk Assessment Framework performance
for Quarter 1 is notionally three points, based on application of the scoring mechanism in the
current iteration of the Risk Assessment Framework. This relates to continued ‘managed fail’ in
Referral to Treatment (RTT) as part of an agreed recovery planning process generating 2 of the 3
penalty points in Quarter 1. The remaining compliance failure point relates to underperformance
against 2 week cancer metrics for the quarter.
2.2
At the time of writing Monitor have yet to conclude the consultation outcomes relating to the Risk
Assessment Framework (RAF) and the implications of the move to monthly reporting for RTT,
A&E and Cancer metrics outlined in June by the Secretary of State for Health. However,
2
monitoring return templates supplied by Monitor to assess Quarter 1 do not apply any penalty
score to completed RTT pathway metrics, indicating that these metrics will not form part of
assessment following publication of the revised RAF. Board Members are therefore asked to note
the inferred outcome of consultation would be expected to reduce the Quarter 1 assessment from
3 points (Amber/Red) to 2 points (Amber).
2.3
The Trust had 2 cases of C.difficile in June. This generates an aggregate volume of 7 cases in
Quarter 1 against a target of no greater than 10 cases.
2.4
Key indicators of operational pressure during June include:
•
11,508 A&E attendances compared to 11,986 in June 2014 (-4.0%). When
scrutinised by age group there was a -6.9% decrease in 65-84 years and -3.3%
decrease >=85 years June 2015 compared to June 2014.
•
4,140 emergency admissions compared to 4,116 in June 2014 (+0.6%). When
scrutinised by age group there was a -2.2% decrease in 65-84 years and a 3.7%
increase in >=85 years June 2015 compared to June 2014.
•
Formally reportable delayed transfers of care totalled 3.43% for June 2015. This
excludes patients who are medically fit for discharge but have not been classified as
delayed transfers under national guidance as a multi-disciplinary case review had
not taken place.
•
2.5
Occupancy of funded bed stock was 91.9% for June 2015.
Graphical trending of key activity types over time is appended to the Operational Performance
Scorecard.
3.
PERFORMANCE EXCEPTIONS
3.1
A&E Compliance
3.1.1
The Trust was fully compliant in June with 97.4% of patients waiting less than four hours from
arrival at A&E to admission, transfer, or discharge, against a national target of 95%.
3.1.2
st
th
For context and comparison, national data for the period 1 – 28 June relating to Type 1 (Major
A&E) departments shows compliance of 92.3%. Compliance for Surrey and Sussex Area
providers (excluding WSHFT) for the same period shows 92.0% for Type 1 A&E attendances,
with Western Sussex Hospitals being the highest performer within the sector.
3.2
Cancer
3
3.2.1
The provisional position for June shows the Trust was compliant against 6 out of 7 cancer metrics
in month. Board members are reminded that compliance is determined by the aggregated
quarterly position.
3.2.2
June shows a return to compliance for urgent GP referred two week rule patients, with 94.2% of
patients seen within 2 weeks against a target of 93%. As described in the May board paper, as
the Trust was non-compliant for April and May, the provisional performance for the quarter in
aggregate is 90.5%.
3.2.3
June shows non-compliance for breast symptomatic patients in June with 92.3% of patients seen
within 2 weeks against a target of 93%. This relates to 15 breaches in month of 194 patients
seen. This aligns to the forecast recovery profile relayed to Trust Board in the Month 1
Performance Report, and the Trust remains on course for restoration of compliance from Quarter
2.
3.2.4
The two week rule referral pathway is only available to GPs, and under national guidance the
receiving provider organisation cannot refuse or downgrade any referral received. Consistent with
the message in preceding Performance Reports to Trust Board, compliance is set against
significant and sustained increases in demand via this referral route. The operational response to
demand has been significant, with 17.9% more attendances for 2 week rule referrals in June
2015 compared to June 2014, and 50.9% more than seen in June 2013.
3.2.5
Whilst the recovery programme has delivered to plan, referrals under the Cancer 2 week rule in
June remained above the planned recovery expectation, +22% higher than June 2014, and
+47.6% when compared to June 2013. In addition to the crude increase in referral volumes, June
also continues to generate a notably higher post diagnostic conversion to a cancer pathway, with
the level fluctuating between c9.5% of attendances to c11.5% from a baseline of c8% June 2014
(an increase of approximately 20%).
3.2.6
The Trust continues to work actively with Coastal West Sussex CCG to identify and respond to
increased demand profiles based on GP practice level referral trending and conversion to
treatment pathways.
3.2.7
National Quarter 1 cancer compliance data is not available at the point of writing to provide
context on cancer compliance, however, the most recent published data (Quarter 4 2014/15)
shows aggregate compliance for cancer treatment within 62 days is 80.3.% for Surrey and
Sussex Providers (excluding WSHFT), with 5 of 8 Trusts failing to meet the target requirement of
85%.
3.2.8
Outside of the known changes to national reporting requirements, all Providers were instructed in
July to submit weekly reporting on the size and distribution of cancer waiting lists with immediate
effect. This process does not align directly with the national metric set as the latter considers wait
time at the point of treatment for patients with a confirmed diagnosis of cancer, whereas the
waiting list contains patients waiting for treatment and/or definitive diagnosis. In addition, a
4
specific request that Trust Boards receive compliance reporting based on specific tumour site has
been received, and this increased reporting detail will be included as a standing monthly item of
this report with effect from the Month 4.
3.3
Referral to Treatment (RTT/18 Weeks)
3.3.1
As relayed in preceding Performance Reports to Trust Board in conjunction with Coastal West
Sussex CCG, WSHFT has generated a detailed recovery programme to restore sustainable RTT
compliance in West Sussex.
3.3.2
Summary highlights of delivery are:
•
In June the Trust completed 12,350 RTT pathways; exceeding plan by 850 cases
(7.4%). This volume represents an increase of 6.5% on the previous highest in-month
pathway completion volume for WSHFT, and is 14.3% higher than June 2014.
•
The additional pathway volume has supported a reduction in PTL size from 34,372 to
33,862, however this position is 454 cases larger than planned. This is a reflection of
referral pressure in May which exceeded planned levels by 1,196 cases, and drove a
commensurate increase in PTL size. June has also seen referrals exceed plan (+607
cases), hence the over-performance in complete pathways in aggregation has been
required to restore the PTL to planned levels.
•
Increased activity levels belie a number of anaesthetic and senior medical manpower
pressures. Operational teams have reacted rapidly to ensure throughput has been
extended to cope with increased demand levels and compensated for the casemix
specific constraints. This requirement has generated some variation from plan e.g. an
increased need to undertake patients requiring local anaesthetic rather than general
anaesthetic.
•
The increased referral volume have had significantly increased urgency, with the
predominance being either referrals for suspected cancer or graded as urgent. Both
categories generate a need for patients to be treated in a maximum of 4 weeks, with a
consequent reduction in the ability to treat patients exceeding 18 weeks. As a result,
despite increased throughput and a reduction in PTL size, the forecast incomplete
position of 88.6% within 18 weeks was not met, with actual compliance being 87.7%
3.3.3
Above planned levels of referral demand (particularly in Urgent/Cancer) continue to generate
system risk, and the Trust continues to undertake System Summits with Monitor, NHS England
(South), Coastal West Sussex CCG and the 18 week Intensive Support Team/IMAS to ensure
th
project oversight and mitigation, the most recent meeting taking place on 10 July 2015.
3.3.4
Alongside WSHFT, eight provider Trusts in the South Region have formal recovery programmes
in place with the common theme for proceeding compliance failure being an inability to flex
capacity to meet unplanned demand growth.
5
3.4
Fractured Neck of Femur (#NOF) operation within 36 hours of admission
3.4.1
During June, 93.65% of medically fit Fractured Neck of Femur (NoF) patients were operated on
within 36 hours of admission against a target of 90%.
3.5
Diagnostic Test Waiting Times
3.5.1
The Trust was non-compliant against the diagnostic waiting time metric in June with 104 patients
of 7,234 patients (1.44%) waiting over 6 weeks against the requirement of no greater than 1%.
3.5.2
63 of the 104 breaches in June were waiting for non-obstetric ultrasound tests. As detailed in the
Month 2 Performance Report, increased obstetric ultrasound requirement and the associated
need to reallocate available Sonographers to this priority clinical pathway has put significant
pressure on non-obstetric ultrasound compliance. Consultant Radiologist resource has been
diverted to ultrasound, alongside increased Radiologist and Sonographer out of hours sessions.
As reported in the May report, June was forecast to be a challenged month, but recovery of full
compliance is expected from July 2015.
3.5.3
The most recently published data for NHS South shows that of the 15 providers in the Region,
only WSHFT has achieved in-month compliance in April and May of 2015/16. WSHFT had the
best regional compliance level in April 2015, and the second best in May 2015. Aggregate
compliance for Providers in the South Region in May 2014 was 4.2% in May compared to the
1.38% at WSHFT.
3.5.4
Activity levels continue to exceed planned levels in key modalities:•
Magnetic Resonance Imaging (MRI): 1,965 tests June 2015 compared to 1,627
June 2014 (+20.8%)
•
Computed Tomography (CT): 3,329 tests undertaken June 2015 compared to
2,872 tests in June 14 (+15.9%).
•
Non-obstetric ultrasound: 5,359 tests June 2015 compared to 4,365 June 2014
(+22.8%)
4
RECOMMENDATION
4.1
The Board is asked to receive the Month 3 positions, and note the provisional Quarter 1
compliance score of 3 points (Amber/Red) against the Monitor Risk Assessment Framework.
Board Members are also asked to note the probable amendment to the Risk Assessment
Framework, and the inferred reduction Quarter 1 assessment to 2 points (Amber).
Adam Creeggan, Director of Performance
Giles Frost, Head of Operational Planning and Performance
st
21 July 2015
6
Mark Dennis, Head of Information Services
t: 01903 285273 (ext 5273)
JUNE 2015
Key Performance Deliverables Report
A&E 4-hour waiting time target
Description / Comments / Actions
Target
Month
YTD
Projected O/T
95%
97.39%
97.46%
>95%
Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in
A&E
Significant increase in underlying acuity observed from early 2013/14
100%
95%
90%
Actions:
1. Enhanced discharge planning arrangements
2. Augmented patient flow arrangements in conjunction with external partners
3. Dedicated operational delivery plan in place under the leadership of the Chief
Operating Officer
85%
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
75%
Jun
80%
Cancer - Two weeks from urgent GP referral to first appointment
Month
YTD
Projected O/T
93.0%
94.15%
90.52%
>93%
Patients can expect to be seen within 2 weeks following an urgent GP referral for
suspected cancer.
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Significant increases in demand level observed from Q1 2013/14.
Jun
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Target
Actions:
1. Dedicated weekly action focused delivery meeting under the leadership of the Chief
Operating Officer
2. Mitigation actions agreed with health partners including enhanced advice and
guidance for GP's from WSHT consultant staff prior to referral, improved feedback
mechanism for GP on appropriateness of referral, and real time access to referral data
by GP practice, conversion to a cancer pathways and volumes receiving definitive
treatment for malignancy.
Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms
Month
YTD
Projected O/T
93%
92.27%
84.08%
>93%
Patients with breast symptoms can expect to be seen within 2 weeks following an
urgent GP referral.
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Significant increases in demand level observed from Q1 2013/14.
Jun
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Target
Cancer - 62 days from referral to treatment following screening contact
Target
Month
YTD
Projected O/T
90%
97.78%
93.43%
>90%
Actions:
Operating Officer
2. Mitigation actions agreed with health partners including enhanced advice and
guidance for GP's from WSHT consultant staff prior to referral, improved feedback
mechanism for GP on appropriateness of referral, and real time access to referral data
by GP practice, conversion to a cancer pathways and volumes receiving definitive
treatment for malignancy.
Patients with cancer can expect to commence treatment within 62 days following
referral after a positive screening test.
Delays in receipt of onward referral from screening which reduces the time to secure
capacity to treat patients.
100%
95%
90%
85%
80%
Actual
11ia Key deliverables report M03.1.xlsx.Exception Report
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
70%
Jun
75%
Actions:
1. Transitional leadership for MDT/tracking supported by GM - Access.
2. Augmented pathway management/tracking with enhanced oversight through DCS
led Cancer Delivery Group
3. Close working with the screening service to maximise the time available to the Trust
to secure capacity
Operating Officer
Target
Page 1 of 2
Printed 23/07/2015 16:27
t: 01903 285273 (ext 5273)
JUNE 2015
Key Performance Deliverables Report
Cancer - 62 days from referral to treatment following urgent referral by a GP.
Month
YTD
Projected O/T
85%
85.16%
87.03%
>85%
Patients with cancer can expect to commence treatment within 62 days following
urgent referral by a GP.
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity
to treat patients.
Jun
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Target
Actions:
1. Transitional leadership for MDT/tracking supported by GM - Access.
2. Augmented pathway management/tracking with enhanced oversight through DCS
led Cancer Delivery Group
3. Close working with the screening service to maximise the time available to the Trust
to secure capacity
Operating Officer
Referral to treatment - Admitted patients
Target
Month
YTD
Projected O/T
90.0%
85.26%
85.58%
< 90%
All patients can expect to commence treatment within 18 weeks of a referral to
consultant.
Non-compliance an expected outcome of planned RTT recovery programme.
100%
95%
90%
Actions:
1. Short term increase in internal capacity
Operating Office
85%
80%
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
70%
Jun
75%
Referral to treatment - Non Admitted patients
Target
Month
YTD
Projected O/T
95.00%
86.60%
86.12%
< 95%
All patients can expect to commence treatment within 18 weeks of a referral to
consultant.
Non-compliance an expected outcome of planned RTT recovery programme.
100%
95%
90%
Actions:
1. Short term increase in internal capacity
Operating Office
85%
80%
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
70%
Jun
75%
% Medically fit hip fracture patients going to theatre within 36 hours
Target
Month
YTD
Projected O/T
90%
93.65%
95.11%
>90%
100%
To ensure the best possible outcomes, hip fracture patients who are medically fit
should be operated on within 36 hours of admission. This standard is part of the 'Best
Practice Tariff' payment process under PbR.
Increased levels of demand have impacted sustained compliance. Mitigating actions
implemented by the Surgical Division have significantly improved performance.
95%
90%
Actions:
1. Improved tracking and escalation processes in place to manage fluctuations in
demand on daily basis
85%
11ia Key deliverables report M03.1.xlsx.Exception Report
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
75%
Jun
80%
Page 2 of 2
Printed 23/07/2015 16:27
t: 01903 285273 (ext 5273)
JUNE 2015
OPERATIONAL PERFORMANCE
SCORECARD
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
2015/16
YTD
96.71%
95.03%
97.10%
95.96%
95.39%
94.47%
85.99%
94.09%
95.73%
97.73%
98.22%
96.82%
97.39%
97.46%
95%
97.67%
98.14%
97.20%
96.04%
95.35%
95.06%
95.12%
94.15%
93.09%
89.63%
85.30%
92.13%
94.15%
90.52%
93%
98.18%
96.00%
96.34%
96.82%
97.27%
93.41%
92.41%
92.41%
97.02%
84.88%
74.32%
85.51%
92.27%
84.08%
93%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.00%
94%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
98%
98.83%
100.0%
99.56%
98.21%
99.57%
100.0%
99.50%
98.85%
100.0%
98.93%
99.18%
99.57%
98.85%
99.2%
96%
86.84%
98.85%
96.83%
88.10%
85.71%
86.84%
100.0%
93.75%
89.47%
91.94%
100.0%
81.82%
97.78%
93.4%
90%
80.95%
73.68%
78.38%
91.30%
85.71%
80.00%
82.35%
100.0%
81.82%
93.75%
100.0%
85.3%
80.0%
85.19%
N/A
88.26%
85.45%
86.64%
89.70%
85.27%
86.77%
87.61%
87.24%
91.23%
84.80%
89.10%
86.94%
85.16%
87.03%
85%
Jun
2015/16
Target
Trend
NATIONAL AND OPERATIONAL PERFORMANCE TARGETS
O01
O02
O03
A&E : Four-hour maximum wait from arrival to admission, transfer
or discharge
Cancer: 2 week GP referral to 1st outpatient
Cancer: 2 week GP referral to 1st outpatient - breast symptoms
O04
Cancer: 31 day second or subsequent treatment - surgery
O05
Cancer: 31 day second or subsequent treatment - drug
O06
O07
O08
Cancer: 31 day diagnosis to treatment for all cancers
Cancer: 62 day referral to treatment from screening
Cancer: 62 day referral to treatment from hospital specialist
1
1
1
1
1
1
1
1
O09
Cancer: 62 days urgent GP referral to treatment of all cancers
O12
RTT - Admitted - 90% in 18 weeks
86.12%
89.90%
89.54%
88.18%
88.80%
87.22%
88.57%
88.45%
85.30%
85.88%
85.49%
86.05%
85.26%
85.58%
90%
O13
RTT - Non-admitted - 95% in 18 weeks
86.23%
88.78%
91.09%
88.37%
88.13%
86.30%
86.83%
86.06%
86.04%
84.50%
85.28%
86.45%
86.60%
86.12%
95%
O14
RTT - Incomplete - 92% in 18 weeks
93.41%
92.72%
92.51%
92.48%
90.27%
90.05%
89.64%
88.18%
87.71%
87.79%
87.87%
88.24%
87.66%
87.93%
92%
O15
RTT delivery in all specialties
22
23
19
20
24
25
26
29
30
27
32
29
31
31
0
O16
Diagnostic Test Waiting Times
3.62%
2.63%
1.98%
0.93%
0.92%
1.66%
3.07%
1.46%
0.99%
1.17%
0.86%
1.43%
1.44%
1.26%
<1%
O17
Cancelled operations not re-booked within 28 days
0
3
0
1
1
2
3
10
2
0
1
1
0
0
-
O18
Urgent operations cancelled for the second time
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
O19
Clinics cancelled with less than 6 weeks notice for annual/study
leave
6
46
21
23
16
30
41
84
30
24
24
24
24
24
-
O20
Mixed Sex Accommodation breaches
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
3.60%
2.87%
3.01%
3.22%
2.97%
2.45%
3.40%
3.55%
3.69%
3.69%
3.77%
3.08%
3.43%
3.4%
3.5%
100.0%
90.6%
90.2%
98.1%
84.0%
86.3%
90.3%
100.0%
98.5%
90.6%
98.5%
92.7%
93.7%
95.1%
90%
94.9%
#N/A
0.0%
0.0%
80%
O33
Delayed transfers of care
2
IMPROVING CLINICAL PROCESSES
O23
O24
% hip fracture repair within 36 hours
Patients that have spent more than 90% of their stay in hospital on
a stroke unit
+
11ib Operational performance scorecard M03.1.xlsx.SCORECARD
1
89.8%
91.3%
89.2%
Page 1 of 3
88.3%
Printed 23/07/2015 16:27
t: 01903 285273 (ext 5273)
JUNE 2015
OPERATIONAL PERFORMANCE
SCORECARD
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
JUN
2015/16
YTD
2015/16
Target
Trend
OPERATIONAL EFFICIENCY
O36
Average length of stay - Elective
2.96
2.92
2.92
2.96
2.97
2.96
3.12
3.00
3.48
3.36
3.28
3.09
3.10
3.15
3.72
O37
Average length of stay - Non-elective Surgery
5.40
5.56
5.29
5.95
5.77
6.52
5.58
5.65
5.28
5.84
5.84
5.41
5.06
5.41
6.07
O38
Average length of stay - Non-elective Medicine
7.69
7.51
7.08
7.50
7.30
7.42
7.31
7.92
8.24
7.60
7.83
7.25
7.59
7.56
7.80
O39
Day case rate (CQC basket of procedures source: Dr Foster)
88.44%
89.63%
85.95%
87.77%
87.96%
86.98%
88.73%
85.93%
86.47%
#N/A
#N/A
#N/A
0.00%
0.00%
75.0%
O40
Elective day of surgery rate (DOSR)
96.9%
96.6%
97.0%
97.6%
97.9%
97.2%
97.7%
98.1%
97.9%
98.5%
99.0%
97.5%
98.0%
98.2%
90.0%
O41
Did not attend rate (outpatients)
6.64%
6.67%
6.79%
6.72%
6.65%
6.47%
6.45%
6.62%
6.61%
6.60%
6.50%
6.54%
6.59%
6.52%
7.65%
SUSTAINABILITY
O43
Bank staff - % of all staff pay
6.44%
4.95%
5.45%
6.47%
6.08%
5.63%
6.59%
6.99%
6.44%
6.73%
6.57%
6.33%
0.00%
0.00%
7%
O44
Agency staff - % of all staff pay
6.30%
5.61%
6.50%
5.65%
6.27%
4.87%
5.76%
6.45%
5.99%
5.82%
6.62%
5.61%
0.00%
0.00%
2%
O45
Nurse : occupied bed ratio
1.998
2.010
2.092
2.062
2.047
2.026
1.913
1.791
1.785
1.866
1.846
1.846
0.000
1.231
-
O46
% nurses who are registered
72.55%
72.44%
72.63%
72.71%
72.70%
72.62%
72.50%
72.40%
72.18%
71.87%
71.64%
71.56%
0.00%
0.00%
-
O47
% Staff appraised
83.04%
81.07%
81.49%
78.80%
78.97%
78.98%
77.75%
77.09%
77.54%
76.58%
77.61%
77.33%
76.69%
76.69%
90%
3.47%
4.06%
4.03%
4.18%
4.61%
4.33%
4.51%
4.91%
4.34%
3.85%
3.56%
3.82%
#N/A
4.12%
3.3%
7.16%
7.15%
7.28%
7.03%
7.32%
7.74%
7.83%
8.00%
8.12%
8.39%
8.57%
8.73%
8.87%
8.87%
11%
4,759
4,835
4,164
4,773
4,811
4,576
4,543
4,911
4,571
5,168
4,879
4,561
5,367
14,807
13,916
792
791
714
733
760
811
688
661
722
686
659
660
805
2,124
2,127
O48
Sickness Absence: % Sickness (reported one month in arrears)
O49
Staff Turnover: Turnover rate (YTD position)
3
ACTIVITY
A01
Day Cases
A02
Elective Inpatients
A03
Non-elective inpatients
4,998
5,268
5,065
5,012
5,182
4,867
5,334
5,267
5,012
5,290
5,246
5,370
5,186
15,802
14,881
A04
Outpatient First attendances
15,020
15,438
12,669
16,089
15,715
14,907
14,564
15,704
14,240
16,425
16,443
15,300
18,281
50,024
16,653
A05
Outpatient Follow-up attendances
23,277
25,510
21,090
25,587
27,325
25,386
24,503
26,826
25,386
27,718
27,341
26,084
30,603
84,028
106,036
A06
Outpatients with procedure
4,425
4,583
4,061
4,853
5,020
4,787
4,581
5,146
4,527
4,707
5,046
4,933
4,912
14,891
18,186
A07
A&E Attendances
11,987
12,565
11,792
11,383
11,162
10,786
11,101
9,885
9,459
11,059
11,010
11,599
11,508
34,117
36,129
Notes
1
National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification.
2
Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course.
3
Staff sickness is reported one month in arrears.
11ib Operational performance scorecard M03.1.xlsx.SCORECARD
Page 2 of 3
Printed 23/07/2015 16:27
Activity Trending1
Activity
Day cases
Non-elective Inpatients
Elective Inpatients
2015/16
2014/15
2013/14
2014/15
950
900
850
800
750
700
650
600
550
500
4,000
3,500
First Outpatients
2014/15
2015/16
2015/16
2014/15
2015/16
2013/14
2015/16
1,600
950
2,200
1,500
900
1,400
850
1,300
800
1,600
1,200
1,100
1,000
1,000
M12 (Mar)
M10 (Jan)
M09 (Dec)
M11 (Feb)
M11
(Feb)
M10
(Jan)
M09
(Dec)
M12 (Mar)
M11 (Feb)
M10 (Jan)
M09 (Dec)
2014/15
700
M12 (Mar)
M11 (Feb)
M10 (Jan)
M09 (Dec)
M08 (Nov)
M07 (Oct)
M06 (Sep)
M05 (Aug)
M04 (Jul)
M03 (Jun)
M01 (Apr)
600
M02 (May)
M12
(Mar)
M11 (Feb)
M09
(Dec)
M10 (Jan)
M08
(Nov)
M06
(Sep)
M07 (Oct)
M05
(Aug)
M04 (Jul)
M03 (Jun)
M02
(May)
M01 (Apr)
M12
(Mar)
M11 (Feb)
M10 (Jan)
M09
(Dec)
M08
(Nov)
M07 (Oct)
M06
(Sep)
M05
(Aug)
M04 (Jul)
M03 (Jun)
M02
(May)
650
M01 (Apr)
Notes
2013/14
750
1,200
1,400
M08 (Nov)
Emergency Admissions (age >85)
2014/15
2,400
1,800
M03 (Jun)
M12 (Mar)
M11 (Feb)
M10 (Jan)
M09 (Dec)
M08 (Nov)
M07 (Oct)
M06 (Sep)
M04 (Jul)
M05 (Aug)
600
2014/15
2,000
M08
(Nov)
700
Emergency Admissions (age 65-84)
2013/14
M07 (Oct)
800
Emergency Admissions (age 0-64)
2015/16
2014/15
900
M01 (Apr)
M11 (Feb)
M12 (Mar)
M10 (Jan)
M09 (Dec)
M08 (Nov)
M07 (Oct)
M06 (Sep)
M05 (Aug)
M04 (Jul)
M03 (Jun)
M02 (May)
M01 (Apr)
4,000
2013/14
1,000
M03 (Jun)
5,000
2015/16
1,200
1,100
M02 (May)
6,000
M07
(Oct)
A&E Attendances (age >85)
2013/14
2,600
2,500
2,400
2,300
2,200
2,100
2,000
1,900
1,800
1,700
1,600
7,000
M06
(Sep)
M12
(Mar)
M11
(Feb)
M10
(Jan)
M09
(Dec)
M08
(Nov)
M07
(Oct)
M06
(Sep)
M05
(Aug)
M04
(Jul)
M03
(Jun)
M02
(May)
M01
(Apr)
M12
(Mar)
M11
(Feb)
M09
(Dec)
M10 (Jan)
M08
(Nov)
M06
(Sep)
M07 (Oct)
M05
(Aug)
M04 (Jul)
M03 (Jun)
M02
(May)
M01 (Apr)
2,500
A&E Attendances (age 65-84)
2014/15
8,000
M08 (Nov)
2,700
15,000
A&E Attendances (age 0-64)
9,000
M06 (Sep)
2,900
10,000
2013/14
M04 (Jul)
3,100
17,000
10,000
M05 (Aug)
3,300
M07 (Oct)
11,000
Notes
M03 (Jun)
3,500
19,000
M05
(Aug)
12,000
3,700
M06 (Sep)
21,000
M04
(Jul)
13,000
3,900
M05 (Aug)
23,000
2014/15
4,100
M03
(Jun)
14,000
2013/14
4,300
M04 (Jul)
25,000
2015/16
2014/15
M02
(May)
27,000
15,000
Outpatients with procedure
2013/14
M01
(Apr)
16,000
2015/16
M01 (Apr)
M11 (Feb)
M12 (Mar)
M10 (Jan)
M09 (Dec)
M07 (Oct)
M08 (Nov)
M04 (Jul)
Follow-up Outpatients
2013/14
M01 (Apr)
2015/16
M06 (Sep)
3,000
M05 (Aug)
M11 (Feb)
M12 (Mar)
M10 (Jan)
M09 (Dec)
M07 (Oct)
M08 (Nov)
M06 (Sep)
M04 (Jul)
M05 (Aug)
M03 (Jun)
M02
(May)
M01 (Apr)
3,500
2014/15
4,500
M03 (Jun)
4,000
2013/14
5,000
M01 (Apr)
4,500
5,500
M02 (May)
5,000
2015/16
M02 (May)
2013/14
M02 (May)
2015/16
5,500
Please Note: Outpatient currencies have excluded physiotherapy and clinical physiology from trend information as these currencies distort numbers due to changes to counting for these areas.
Page 3 of 3
23/07/201511ib Operational performance scorecard M03.1.xlsx
t: 01903 285273 (ext 5273)
JUNE 2015
Monitor Risk Assessment Framework
Threshold
Apr
May
Jun
Q1
90%
85.49%
86.05%
85.26%
85.26%
95%
85.28%
86.45%
86.60%
85.28%
92%
87.87%
88.24%
87.66%
87.66%
95%
98.22%
96.82%
97.39%
97.46%
85%
89.10%
86.94%
85.16%
87.03%
90%
100.00% 81.82%
97.78%
93.43%
94%
100.00% 100.00% 100.00% 100.00%
98%
100.00% 100.00% 100.00% 100.00%
Weighted
Score
Jul
Aug
Sep
Q2
Weighted
Score
Oct
Nov
Dec
Q3
Weighted
Score
Jan
Feb
Mar
Q4
Weighted
Score
(Forecast)
ACCESS
M1
M2
M3
M5
M6a
M6b
M7a
M7b
Maximum time of 18 weeks from point of referral to treatment in
aggregate – admitted
aggregate – non-admitted
aggregate – patients on an incomplete pathway
A&E: maximum waiting time of four hours from arrival to
admission/transfer/discharge
All cancers : 62-day wait for first treatment following urgent GP
Referral
All cancers : 62-day wait for first treatment following consultant
screening service referral
All cancers : 31-day wait for second or subsequent treatment - surgery
treatments
All cancers : 31-day wait for second or subsequent treatment - drug
treatments
M8
All cancers : 31-day wait from diagnosis to first treatment
96%
99.18%
99.57%
98.85%
99.19%
M9a
Cancer : two week wait from referral to date first seen - All patients
93%
85.30%
92.13%
94.15%
90.52%
M9b
Cancer : two week wait from referral to date first seen - Symptomatic
breast patients
93%
74.32%
85.51%
92.27%
84.08%
2.0
0.0
0.0
0.0
0.0
1.0
OUTCOMES
M17
Clostridium Difficile – meeting the Clostridium Difficile objective
39
0
5
2
7
0.0
M27
Certification against compliance with requirements re access to
healthcare for people with a learning disability
YES
YES
YES
YES
YES
0.0
Monitor Compliance Framework Score
3.0
Green : 0
Amber/Green : 1
Amber : 2
Amber/Red : 3
Red : 4 or more
Notes
i From 1 October 2013 MRSA was removed from the Monitor Risk Assessment Framework
11ic Monitor scorecard M03.1.xlsx.SCORECARD
Page 1 of 1
Printed 23/07/2015 16:27
To:
Trust Board
Date: 30 July 2015
From: Jane McGovern. Emergency Panning and Business
Continuity Manager
Agenda Item: 11.2
FOR Jane Farrell, Chief Operating Officer
Business Continuity Incident Declared – January 2015
Debrief report
1. INTRODUCTION
1.1. Winter 2014/2015 saw an unprecedented demand on services across the Health Economy.
Demand far outstripped capacity which resulted in a number of Trusts, nationally and locally,
declaring Major Incident/Business Continuity Incident/Significant Incident which resulted in
substantial media coverage.
1.2. Western Sussex Hospital NHS Foundation Trust (WSHFT) declared a local Business
Continuity Incident – due to Capacity and Demand in the early hours of Monday 5th January
2015. All local health partners and West Sussex County Council were advised. Brighton and
Sussex Universities NHS Trust (BSUH), East Sussex Healthcare Trust, (ESHT) and Surrey
and Sussex Hospitals NHS Trust (SASH) were all in a similar position all having declared a
similar incident as a result of the local health economy pressures.
1.3. Locally the incident was understood to be an ‘internal incident’ which was being managed
effectively across all local health partners. There was some exposure by local media through
reporting and interviews which were aimed particularly at the local population.
1.4. There was a significant impact on in-patient services at both Worthing Hospital and St
Richards Hospital over the next 10 -14 days due to the increase in the use of escalation beds,
the resultant staff shortages and a substantial rise in delayed discharges/transfers.
1.5. During the first week of the incident being declared there was a noticeable decrease in A&E
attendances and admissions following the initial surge. This was possibly due to the extensive
media coverage and due to the support of some local GP practices which opened over the
following weekend.
1.6. There was a gradual improvement, over time, as services returned to a new ‘normal’. New
working practices were put in place both internally and within the local health economy with
processes put in place to address delayed discharges and patient flow which have been
adopted on a permanent basis.
1.7. On Friday 16th January 2015 the incident was downgraded to a Business Continuity Standby
which resulted in normal timetables being reinstated, training/meetings etc. with a final stand
down on Friday 23rd February 2015 when pay enhancements were suspended and ‘normal’
business resumed.
1.8. It must be recognised that although the incident was ‘stood down’ in February the increased
demand on services continues with similar pressures being experienced as we move into April
2015.
2. RECOMMENDATIONS
2.1. The Committee is asked to note the findings of this report.
3. CONTEXT
The incident impacted on all areas of Health and Social Care. This report will summarise the
impact on Western Sussex Hospitals NHS Foundation Trust bringing together the feedback
responses from management and staff and the comments captured in the formal debrief
sessions. Any actions identified will be monitored through the Coastal West Sussex
Resilience Group and the WSHFT Emergency Planning and Business Continuity Integrated
Performance Group.
This report will summarise:The Winter Planning
 The Winter Resilience process and the plans put in place
 Specific issues considered/addressed
The metrics/volumes experienced in Winter 2014/2015 compared with Winter 2013/2014
 A&E Attendances
 A&E Admissions
 Occupied Beds
 Escalation Beds and Outliers
 Delayed Transfers of Care
 December – February Heat Map
The Declaration of the Business Continuity Incident
 Triggers
 Process followed – command and control
 Communication
 Escalation Measures
 De –escalation/Stand down
Working with partner organisation
 Leadership/Command and Control
 Constraints
Actions taken
 Opening escalation areas
 Cessation of elective surgery
 Enhanced staff bank rates to support staffing shortages
 Actions to increase Medical staffing capacity
 Re-allocation of non-clinical staff
 Postponement of training and meetings
Conclusion
 Next Steps
 Preparations for Winter 2015/2016
4. MAIN REPORT
4.1. Winter Planning

The Winter Resilience process and the plans put in place
Western Sussex Hospitals NHS Foundation Trust (WSHFT) works closely with local
Health and Social Care partners in their preparations for winter. The Coastal West
Sussex (CWS) Resilience Group is responsible for ensuring lessons are learnt from
previous years, integrated plans are in place to manage the increase in demand across
the system and any allocated funding is distributed effectively. There is director level
representation from the following partners: Coastal West Sussex Commissioning Group
 West Sussex County Council
 Sussex Community NHS Trust
 Sussex Partnership NHS Foundation Trust
 South East Coast Ambulance NHS Foundation Trust (SECAmb)
Page 2 of 10
The group works together to provide assurance to the NHS England, Surrey and Sussex
Area Team that any increase in demand is, as far as is possible, catered for.

Specific issues considered/addressed
Each organisation will commit to an approved plan to ensure the safety of the patient over
times of increased demand. The following identified pressures are considered and
addressed accordingly: Increased bed capacity across the system - Hospitals and other NHS health
providers across West Sussex. (escalation)
 Capacity provided by WSCC to assess, transfer and care for patients ready for
discharge
 Staffing requirements to manage the increase in demand and patient flow
 Planning for patient discharge/transfer
 Transport services
 GP ‘Out of Hours’ arrangements
 Hospital admissions avoidance.
 Patient flow/discharge delays
4.2. The metrics/volumes experienced in Winter 2014/2015 compared with Winter 2013/2014
2015 proved to be particularly challenging due to the configuration of the holiday periods.
Christmas weekend resulted in 4 consecutive ‘closed’ days with New Year having a similar
impact with just one ‘open’ day within the first four days of January. The closure of primary
care facilities (GP’s, dentists, pharmacies etc) the reduction in the provision of support
services (social and community) and the traditional holiday demands internally and externally,
all impacted on the hospital’s services to a level which was unprecedented.
Although it was a mild winter there was still the expected increase in the acuity of the patients
which attributed to the increased demand on in-patient and support services.
Delays in the discharge process compounded the issue. Community and social services were
compromised due to delayed access to assessments and placements, staffing shortages and
the loss of nursing homes and home care services (due to the closure) were also contributory
factors.
With GP access limited (IC24) and the 111 system overwhelmed there was an increase in 999
calls and self-presenters to A&E.
For further statistical information see Appendix1






A&E Attendances
A&E Admissions
Occupied Beds
Escalation Beds and Outliers
Delayed Transfers of Care
December – February Heat Map
4.3 The declaration of the Business Continuity Incident

Triggers
There are standard triggers for escalation across Sussex which indicate the overall bed
capacity and patient flow position of the acute and community hospitals. (See appendix
2). The status of each hospital/service is rated green/amber/red/black – black indicating
the highest risk. Regular bed meetings are run throughout each day and the status
updated accordingly. The current ‘status’ is circulated to management teams but not
widely available. It is proposed that the bed status be more widely available, perhaps
using the PC Desktops. The Emergency Planning Team will be taking this forward.
Page 3 of 10

Process followed – command and control
WSHFT had been running on ‘black’ for a number of weeks before the incident was
declared. The decision to declare Business Continuity was taken when all avenues for
internal escalation had been exhausted and external support was required to ease the
situation. There were identified pressures identified at both ends of the system, increased
demand at the front door (in A&E both from SECAmb and self-presenters) and delays at
the back door (patient assessments and discharge). A Hospital Emergency Control
Centre was set up in the Chief Executive’s Office at the Worthing site. Regular meetings
via a teleconference link were made with St Richard’s Hospital and our partner agencies.
These meetings were attended by members of the Executive Teams, Directors of
Operations, Communications, Operational Managers and a member of the Emergency
Planning Team.
From feedback it was suggested that a Hospital Emergency Centre set up at the St
Richard’s site would have placed a more formal footing at the site and eased
communication. Actions will be taken to ensure this is considered in future.

Communication
Once declared calls were made to all our local and neighbourhood health and social care
partners to inform them of the incident with a request to open communication channels
for multi-agency support.
Throughout the incident the regular multi-agency teleconferences at director level, helped
to ensure there was integrated working and support in managing the patient flow.
Regular Internal communications were issued to inform staff of the situation.
The Communications Team were in regular contact with the local media regarding the
incident arranging local coverage and interviews aimed at the local catchment area.
From the feedback there were several remarks relating to communication – both positive
and negative. Considering the scale of the incident this is to be expected as
communication is very important and very difficult to get right. In some areas the
pressures were such that they impacted on relations – both internally and with our
partner agencies at all levels. Comments have indicated that more training in ‘dealing
with difficult people’ would be beneficial and more specific training on dealing with stress
in a crisis. The Emergency Planning Team will take this forward.

Escalation Measures
The declaration of the Business Continuity Incident enabled extraordinary measures to
be put into place. It opened communication channels; ensured multi-agency support,
increased staff awareness, prompted the cancellation of elective surgery and authorised
enhanced pay for bank staff. There was the additional support of staff working extra
hours, inter departmental cover and the cancellation of all training and meetings. All
these actions were implemented through the Hospital Emergency Control Centre (HECC)
which was the centre of command and control.
At both Worthing and St Richard’s Hospitals a ‘Live List’ of patients identified for potential
discharge was produced to identify delays. The numbers of patients on the lists were in
the region of cc120 and cc90 respectively. This issue was exacerbated by the increase in
admissions. At the peak of the incident there were up to 15 ambulances waiting outside
to admit patients with no capacity to accept them. A multi-agency operational group was
established on both sites to monitor the lists, highlighting any avoidable delays to ensure
patient flow. The meetings were held daily during the incident and have proved to be
successful. The meetings continue twice a week on Tuesdays and Thursdays.
Page 4 of 10
Bed escalation areas were opened as a result of the pressures. A set process needs to
be developed, in advance, for the emergency opening of additional beds. Several
comments from the feedback referred to this issue and highlighted the importance of
having nursing, medical and support services staff available. Equipment, beds, linen,
storage and facilities/housekeeping support also need to be ready and available. This will
be picked up as an action from the debrief.

De-escalation/Stand down
The national media coverage encouraged the public to stay away from acute hospitals
and A&E and to seek alternative health services. Three days into the incident,
attendances in A&E and admissions reduced and discharges were actioned as
availability increased. As a result the full Hospital Emergency Control Centre was
stepped down but support was available from the Emergency Planning Team.
The communications team issued regular messages informing staff of the situation
advising of different ways of working to increase patient flow. Enhanced pay for bank
staff was extended until 23rd February 2015 as an incentive to ease staff shortages.
After two weeks the incident was downgraded to a Business Continuity standby which
resulted in normal timetables being reinstated, training/meetings etc. with a final stand
down on Friday 23rd February 2015 when all enhancements were suspended and
‘normal’ business resumed.
The ‘new’ normal has continued to show pressures in the system as, in April 2015,
escalation areas are still fully utilised and delays with discharges continue.
4.4 Working with partner organisation

Leadership/Command and Control
WSHFT took the lead in the response to the incident by declaring Business Continuity in
order to mobilise staff and resources. Once the enormity of the situation was realised
support was forthcoming from: Coastal West Sussex Commissioning Group
 West Sussex County Council
 Sussex Community NHS Trust
 South East Coast Ambulance NHS Foundation Trust (SECAmb)
The Surrey and Sussex Escalation Framework does give guidance on incident response.
If the incident impacts on each element of the local health economy, leadership would be
best provided by a central body which would be in a position to co-ordinate the response
for and from each service. WSHFT will work with the Coastal West Sussex CCG and the
NHS England Surrey and Sussex Area Team to consider what lessons can be learnt for
future escalation events.

Constraints
There were a number of constraints which impacted on the services of all partners.
1. For the South East Coast Ambulance Services the main issue was the inability for
WSHFT to offload patients from ambulance which resulted in long waits. Statistics
show that during the week ending 04/01/2015 23 ambulance were waiting for over 60
minutes to transfer patients in through A&E. During the week ending 11/01/2015
there were 5 which highlights the success of the actions put in place to improve the
situation. (See Appendix 1 Figure 6)
2. For West Sussex County Council there were issues with staffing and the provision of
social service assessments, placements, packages of care and domiciliary care
which resulted in a number of delayed discharges. This contributed towards the
increased bed occupancy and the number of required escalation beds. (See
Appendix 1 Figures 3, 4and 5)
Page 5 of 10
3. The Sussex Community Trust experienced similar difficulties as WSHFT in that there
was an increase in the acuity of patients, and delayed discharges together with a
staffing shortage which, even though great steps had been taken to recruit, did not
reach the required levels. It is worthy of note that a number of community beds were
closed due to lack of staffing prior to the onset of winter which did impact on the
overall capacity.
4. Constraints within WSHFT have been recognised but again, worthy of note is the
number of staff vacancies, reduced community capacity with the Sussex Community
Trust and social services together with the level of bed stock did affect the overall
response.
5. Patient Choice also impacts on patient flow. A West Sussex multi-agency agreed
policy has been put in place to address the issue. Patients will be advised, upon
admission, that it is not acceptable for them to remain in a hospital bed when they
have been assessed as ‘fit for discharge’. The discharge may be for rehabilitation in
specialist hospitals or for continued health care in the community whether it be
temporary or permanent. Although the number of patient discharge delays due to
issues around patient choice is relatively small, bed capacity is such that the
concerns needs to be formally recognised and officially followed through.
4.5 WSHFT Actions taken
 Declaration of the Business Continuity Incident
 Establishing Command and Control
 Regular meetings and teleconferences with partners
 Opening escalation areas
 Cessation of elective surgery
 Enhanced staff bank rates to support staffing shortages
 Actions put in place to increase Medical staffing capacity
 Actions to identify patients eligible for discharge, actions required and delayed
discharges (Live List)
 Re-allocation of non-clinical staff
 Postponement of training and meetings
5.6 Conclusion

Next Steps
Unprecedented steps had to be taken over winter 2014/2015 to address the increase in
admissions and lack of capacity. The incident was nationwide with mass media
coverage. West Sussex Services were put under severe strain resulting in a different way
of working for all parties. There times of stress and times where patient safety was
inevitably put at risk Incidents were kept to a minimum and teams worked together in
very difficult circumstances.
There are projects planned for 2015 which will look at staff recruitment, bed configuration
and improving establishments which will ultimately improve services.
Pressures right across the healthcare system are being address however the provision of
care within the community is very much affected by Nursing Home closures and the lack
of domiciliary care provision. The problems are identified but very difficult to resolve.
There were a number of examples of ‘What went well’ some of which have been adopted
permanently and some which relate the pulling together of resources.
Throughout the feedback there were common themes relating to staff. The following
phrases were used throughout: Good Team work
 Willingness to help
 Staff working above and beyond
Page 6 of 10


Good support for each other
Skilled management
Departments providing support services (with no contact with patients) were very busy
over the period the staff worked hard and were dedicated to providing a good service.
Sometimes these support services go unrecognized but they certainly understood their
contribution and the managers praised their commitment and hard work.
Making reference to the feedback and the comments raised at the debrief sessions an
action list for ‘areas for improvement’ has been prepared and circulated. Some of the
generic actions have been highlighted within this report.
Progress and completion of the actions will be monitored through the CWS Resilience
Group and the Emergency Planning and Business Continuity Integrated Performance
Group.

Preparations for Winter 2015/2016
The CWS Resilience Group continues to meet and planning for Winter 2015/2016 has
already commenced and the lessons learnt will be very much taken into account.
Page 7 of 10
Appendix 1
Figure 1
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Dec 14 to Feb 15 Heatmap
Week ending
07/12/14 14/12/14 21/12/14 28/12/14 04/01/15 11/01/15 18/01/15 25/01/15 01/02/15 08/02/15 15/02/15 22/02/15 01/03/15
A&E Attendances
A&E Admissions
Ambulance Delays over
60mins
G&A Occupied beds
Escalation beds in use
Outliers
Delayed Transfers of Care
This year
2,558
2,486
2,646
2,444
2,500
2,134
2,094
2,222
2,252
2,264
2,503
2,305
2,407
Previous year
2,450
2,412
2,291
2,294
2,342
2,228
2,272
2,410
2,412
2,442
2,386
2,408
2,553
This year
734
710
741
803
768
672
664
721
711
707
808
706
695
Previous year
696
744
656
737
709
678
688
672
706
705
675
675
753
This year
7
6
19
5
23
5
0
0
1
3
3
4
8
Previous year
1
1
1
3
4
3
0
1
0
0
7
8
7
This year
795
838
859
806
914
890
882
876
893
909
881
859
842
Previous year
805
812
786
722
824
812
820
822
849
850
866
844
836
This year
53
67
65
40
85
94
89
79
90
95
87
66
44
Previous year
55
64
60
47
72
71
78
80
88
86
94
89
86
This year
30
51
60
27
29
31
28
53
54
71
67
68
62
Previous year
31
35
29
16
54
58
52
45
37
50
42
27
29
This year
22
26
30
29
32
29
27
37
33
33
34
29
30
Previous year
21
20
19
15
22
30
26
20
18
21
23
33
23
Page 9 of 10
Appendix 2
CAPACITY ESCALATION PLAN: WORTHING [Version 2.7/24Jan14/CK]
Total Trust
Capacity
Score
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
E
Accident & Emergency
D
a. ED is experiencing normal
levels of activity with normal
levels of staffing
b. ED have available space in
Majors and Resus [or 34 or
less patients within the
department]. Patients for
admission allocated beds
within 45 mins of referral.
c. Ambulance handovers are
predominantly occurring within
15 mins but not longer than 30
mins.
d. A&E 4 hour performance
being maintained at 98%
compliance within the midnight
to midnight period.
e. Available space in CDU
a. A&E is experiencing a peak of
demand of 15-17 patients per hour
for 2 consecutive hours
b. Between 35-40 patients within
the department. 1-3 patients for
admission not allocated beds within
60 mins of referral.
c. The number of patients waiting to
be seen by an A&E doctor for
greater than 60 mins is 10-15.
d. Anticipated pressure or less than
2 breaches on receiving patients
from the ambulance crews within
30 minutes.
e. Between 3 to 6 breaches of the 4
hour Performance standard during
the midnight to midnight period.
a. A&E is experiencing a peak of
demand of 18-20 patients per hour for
2 consecutive hours
b. Between 41-49 patients in A&E. 4-6
patients not allocated beds with 90
mins of referral.
c. The number of patients waiting to be
seen by an A&E doctor for greater than
60 mins is 16-20.
d. Unable to receive 3 or more patients
from the ambulance crews within 30
minutes.
e. 7 to 14 breaches of the 4 hour
Performance standard during the
midnight to midnight period.
Assessment Areas
C
3
Actions at AMBER have been
insufficient to resolve and pressure
increasing. Other areas of LHE are also
experiencing pressures. Patient flow is
severely compromised. Actions needed
by all to mitigate.
a. Acute Medical Unit [AMU]: 6
or more beds of available
capacity with appropriate
turnover of patients to other
medical beds. ACA
experiencing normal levels of
demand.
b. Becket Elderly Assessment
Unit: 4 or more beds of
available capacity with
appropriate turnover of
patients into DOME Beds.
c. Castle [SAU]: 3 or more
beds of available capacity with
appropriate turnover of
patients.
a. Acute Medical Unit [AMU]: with 4
or 5 beds of available capacity with
delayed turnover of patients to
other medical beds. ACA
experiencing increased levels of
demand.
b. Becket Elderly Assessment Unit:
With 2 or 3 beds of available
capacity with some delayed
turnover of patients to other DOME
beds.
c. Castle [SAU]: With 2 beds of
available capacity with some
delayed turnover of patients to
other surgical beds.
a. Acute Medical Unit [AMU]: Between
1 and 3 beds of available capacity with
significantly reduced turnover of
patients to other medical beds. ACA
experiencing high levels of demand.
With less than 1 bed of available
capacity with significantly reduced
turnover of patients to other DOME
beds.
c. Castle [SAU]: With less than 1 bed of
available capacity with significantly
reduced turnover of patients to other
surgical beds.
a. Acute Medical Unit [AMU]: Negative to
0 beds of available capacity with limited
prospect of discharges or turnover.
Negative to 0 beds of available capacity
with limited prospect of discharges or
turnover.
c. Castle [SAU]: Negative to 0 beds of
available capacity with limited prospect of
discharges or turnover.
a. Capacity in line with
planning assumptions listed in
enclosed tab, varied to time of
day. Capacity available to
meet expected demand.
b. Discharge predictions are
good.
c. Escalation: All escalation
areas closed
d. Outliers: Less than 5
outliers [except Orthopaedics
in Surgery] but only for specific
patient reasons.
a. Capacity planning lower than
needed in ONE main area
[Medicine, Surgery or DOME]
according to planning assumptions
detailed.
b. Discharge predictions below
expected normal levels.
c. Escalation: Level 2 Escalation
Areas open.
d. Outliers: Between 6 and 12
outliers [except Orthopaedics in
Surgery] some for specific patient
reasons.
a. Capacity planning lower than needed
in TWO main areas [Medicine, Surgery
or DOME] according to planning
assumptions detailed.
b. Discharge predictions below
predicted admissions.
d. Escalation: Level 3 Escalation Areas
open.
e. Outliers: Between 13 and 20 outliers
[except Orthopaedics in Surgery]
a. Capacity planning lower than needed
in ALL main areas [Medicine, Surgery or
DOME] according to planning
assumptions detailed.
B. Discharge predictions below predicted
admissions and actions taken with
community teams will not resolve.
d. Escalation: Level 4 Escalation Areas
open.
e. Outliers: More than 21 outliers [except
Orthopaedics in Surgery]
All Electives allocated an
appropriate bed and proceed
as scheduled
Elective patients are experiencing
delays but they are all expected to
be admitted by the end of the day
Elective non-urgent or cancer patients
are all under consideration for being
cancelled due to inpatient bed capacity
reasons and some patients have been
cancelled as a result.
All Elective non-urgent or cancer patients
are being cancelled due to inpatient bed
capacity reasons. Only clinically urgent
cases are being electively admitted.
a. Available capacity in ICU,
HDU or ESCU as listed in the
planning guidance.
No Ward Fit patients waiting to
move. Capacity for Stroke,
FNOF, CCU and Paeds
b. Available theatre for CEPOD
a. One of either ICU or HDU is full
but with capacity in the other.
b.1 or 2 ward fit patients unable to
move within target times [Page 18
Inpt Policy]. Capacity short in TWO
of alternate areas [Stroke, FNOF,
CCU and Paeds]
a. ICU and HDU are full but have
capacity if ward fit patients are moved
B. 3 ward fit patients unable to move
within target times. Capacity short in
THREE alternate areas [Stroke FNOF,
CCU and Paeds]
a. ICU, HDU and ESCU are all full with
no 'ward fit' patients. Requiring cover
from St Richards or other hospitals.
b. More than 4 'ward fit' patients who are
unable to move within the target times.
c. All other alternate areas with no current
capacity. Paediatrics requiring cover from
network.
Critical Care incl
ICU, HDU, ESCU,
CCU, Theatres,
Paeds & Stroke,
FNOF
B
2
Showing signs of pressure in
certain areas. Focussed action
required to mitigate further
escalation. Enhanced co-ordination
needed to return to GREEN.
Elective
Care
Score
Definition
A
1
Able to maintain patient flow
and meet anticipated demand
within available resources
Inpatient Beds Please refer to
Inpatient Placement Policy
Trust Score = A + B + C + D + E
4
Pressures continue to escalate.
Emergency patients care is being
severely compromised. SIRI to be
reported by affected organisation. Trust
wide co-ordination required to manage
incident to recover capacity and restore
patient safety.
a. A&E is experiencing a peak of demand
of more than 20 patients per hour for 2
consecutive hours
b. 50 patients or more within the
department. 7 or more patients not
allocated beds within 2hrs of referral.
c. The numbers waiting to be seen by an
A&E doctor for greater than 60 mins
exceed 21.
c. Unable to receive a patient from the
ambulance crews within 60 minutes
d. 15 or more breaches of the 4 hour
Performance standard during the
midnight to midnight period.
Page 10 of 10
To: Board
Agenda Item: 12
Title:
Report on Organisational Development and Workforce performance
Denise Farmer, Director of OD and Leadership
Prepared by:
Jennie Shore, Deputy Director of Human Resources
Status:
Disclosable
Summary of Proposal:
This report details the Trust’s performance in relation to the supply, development and engagement of its
workforce and the organisations culture.
Implications for Quality of Care:
Provision of high quality, engaged staff has a direct impact on the quality of care.
Financial Implications:
Supports good financial performance
Human Resource Implications:
As described
Recommendation
The Board is asked to NOTE the report
Consultation:
n/a
Appendices:
Appendix 1: Registered Nurses and Midwives Revalidation Readiness Report – July 2015
Appendix 2: Workforce Data report
Date: 30 July 2015
To:
Trust Board
From: Denise Farmer, Director of Organisational Development
and Leadership
Agenda Item: 12
FOR INFORMATION
ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT
1.00
INTRODUCTION
1.01
This sets out the key performance indicators relating to the Trust’s workforce at 30 June 2015.
2.00
SUMMARY OF PROPOSAL
2.01
Workforce Capacity
With the exception of the Medicine Division, workforce capacity was within budgeted
establishment, with substantive staff accounting for 86% of total capacity used. This gap
continues to drive a high use of temporary staffing within the Trust. At 7.9% the use of bank
staff during June was at similar levels to those experienced in the winter months. Whilst the
use of agency remains at a similar level to last month there were increases in medical agency
and associated spend in the Medicine, Surgery and Women and Children Divisions:
predominately to cover vacancies and maternity leave.
2.02
Recruitment activity
Nursing
Following the recent international recruitment campaign to the Philippines, 149 nurses have
been made offers of employment with the Trust. This follows a two centre tour last month
where 226 nurses were tested, interviewed and assessed. Recent changes to national
immigration requirements and the high volumes of applications being dealt with by the NMC
have resulted in the expectation of, hitherto unanticipated, delays in the nurses joining the
Trust.
Robust project management support is in place from both TTM Healthcare and the Programme
Management Office. The progress of each nurse at every stage of the process is being
tracked weekly. The predicted timescale for completion of all stages (International English
Language Testing System (IELTS) examination and Competency Based Testing (CBT);
application to and decision from NMC; Certificate of Sponsorship and application of Visa and
final travel arrangements) is 8 months. It is expected that the earliest date the first nurses will
arrive in the UK will be January 2016 and this will be followed by preparation for the Objective
Structured Clinical Examination (OSCE).
In the meantime TTM Healthcare has set up a programme of webinars to deliver IELTS
training and recruited a trainer to coach the nurses prior to taking the English examination.
TTM is also providing a loan to the nurses so they can pay for the IELTS and CBT. Further
assistance is being provided to ensure that the nurses are uploading all documents required by
the NMC so that timescales are reduced as much as possible.
In order to mitigate the risk from this delay, we have engaged TTM, as part of the LLP
Framework, to block book a temporary supply of band 5 general and theatre nurses until
March 2016. To date 12 nurses have been booked across Medicine and Surgery and we will
continue to source additional supply.
Domestic recruitment campaigns continue to take place every 6 weeks and a “keeping in
touch” letter has been posted to those newly qualified nurses due to join the Trust at the end of
September. A number of HCA bank contracts are being converted to permanent roles
following a recent offer to do so.
Expanding our nursing workforce
In addition to recruiting more staff we are also looking at other alternatives ways to support the
delivery of patient care. One strategy currently being pursued as a pilot project is to introduce
the role of Associate Practitioner.
The introduction of Band 4 Associate Practitioner roles (HCAs with additional responsibilities
and qualifications) will support the skill mix on wards and release time for Band 5 nursing roles
on wards to focus on other tasks e.g. supervision, dispensing medication. Job Descriptions
have been written for each division (Medicine, Surgery and Theatre) and competency
frameworks will be put in place prior to appointment.
As this is a new concept within Western Sussex Hospitals it will piloted for 3 months on three
wards where there are currently vacancies, in order to be able to measure the impact of these
roles and to ensure potential risks are identified and mitigated. The pilot will be reviewed
monthly and evaluated at the end of the 3 month pilot. After this a decision as to whether we
continue, and indeed extend, the scheme will be made.
Surgical Care Practitioners
Recruitment to six Surgical Care Practitioners within Urology, Colorectal, Trauma and
Orthopaedics has commenced with interviews scheduled for the end of July. Appointees will
attend a 2 year postgraduate, masters level diploma accredited by the Royal College of
Surgeon with blocks of University study placements. It is likely that the training will be run by
Plymouth University and this will be confirmed at a later date.
Discussions with Health
Education Kent, Surrey and Sussex (HEKSS) are ongoing with regards to funding and support.
Junior Doctors Changeover
The Board is reminded of the junior doctors changeover that will take place on Wednesday
5 August, with Foundation Year 1 doctors shadowing between 29 July – 4 August.
Arrangements have been put in place to ensure there is no adverse impact on patient safety.
This includes strengthened consultant cover and visibility, restrictions on leave and limiting
activity where appropriate.
2.03
Workforce Efficiency
Sickness absence during May increased in month from 3.6% last month to 4.1%. There were
in month increases in short term absence within Core, Medicine and Women and Children.
Early reporting for June indicates a small reduction in sickness absence within the Clinical
Divisions, but a significant rise within the corporate areas. Outliers are the Performance and
Access, Informatics and Finance Directorates.
Noting the seasonality of sickness absence, Divisions have been directed to refocus their
efforts on the management of sickness in line with the Trust’s revised Health and Wellbeing
policy. Support continues to be available through the employee relations team.
2.04
Changes to Immigration
The Immigration Act 2014, which comes into force from 1 April 2016, introduces an income
threshold of £35k per annum for skilled migrants wishing to stay in the UK permanently
(indefinite leave to remain) after five years of employment. Those who do not meet the new
minimum income threshold will need to find some other way in which to stay in the UK or
extend their Tier 2 visa by another year and then leave after a total of six years in the UK.
The Trust currently employs 55 staff (11 Registered Nurses; 22 HCAs; 9 Housekeepers,
4 AHPs, 3 Scientists, 1 Pharmacist and 5 other) on a Tier 2 or Dependent’s visa issued after
Page 2 of 11
1 April 2011, who may be affected after 1 April 2016. Staff have been contacted and asked to
urgently provide updated evidence of their visa status in order that the full impact can be
assessed. This piece of work will be completed by the end of August.
2.05
Staff Appraisals
With the exception of Women and Children Division, the number of appraisals undertaken in
the last 12 months has deteriorated further to 76.7%. Divisions have been asked to establish
and implement improvement plans that will be monitored through the Trust’s Management
Board.
2.06
Staff Family and Friends Test
During June 158 staff participated in the Staff Family and Friends Test. Of concern is the
continuing deterioration of staff recommending the Trust as a place to work. Common themes
emerging from those staff who have provided comments are ‘insufficient staff to cope with the
ongoing level of demand’, lack of support from managers and working in a stressful and
pressured environment. These themes are echoed in the findings of the Staff Survey.
The Trust Quality and Risk Committee received an update this month on the progress of the
Staff Survey and actions being taken across the Trust and Divisions.
2.07
Facilities and Estates Management Restructuring
The senior management restructuring across Facilities and Estates has been completed with
the new arrangements anticipated to be implemented by 31 August. A number of individuals
have been displaced and we are now seeking alternative roles for them.
2.08
NMC Revalidation
Registered nurses and midwives will be requireed to be revalidated with the NMC from 1 April
2016 as part of a 3 year process. A Revalidation Readiness Report, prepared by the Director
of Nursing and Patient Safety, is appended.
2.09
Senior Nurse Appointment
I am pleased to confirm that Kimberley O’Hara, Head of Nursing for Surgery joined the Trust at
the beginning of July. This follows the retirement of Janie Whittaker.
2.10
National Pay Reform
At the heart of the Health Secretary’s recent speech to the Kings Fund in mid-July, were plans
to reform medical contracts to improve 7-day services across the NHS. These reforms were
based on the reports from the NHS Pay Review Body and the Doctors’ and Dentists’ Review
body.
In summary the findings of the reports are:
•
•
•
•
•
•
Changes are required to the approach for time-served, mainly annual incremental
progression in both contracts, strengthening the link between pay and performance
The ‘night’ window for out of hours work should start at 2200 hrs with a common definition
applied across all staff groups
A revision of the pay package for junior doctors that is cost-neutral
Contractual safeguards are in place to ensure that medical staff are not expected to work
excessive hours and can maintain a reasonable work-life balance
Removal of the opt-out clause in the Consultant contract for weekend working
Local Clinical Excellence Awards (CEA’s) to be reformed as performance pay or payments
for excellence with reconsideration of the value of the national CEA’s
The government has asked the British Medical Association (BMA) to engage with them over
the summer and if agreement to introduce modernised professional contracts cannot be
reached, it has been announced that change will be enforced. The government is seeking the
immediate removal of the consultant opt-out and early implementation of new terms for
Page 3 of 11
consultants from April 2016, with the introduction of a new juniors’ contract from the August
2016 intake.
Other health trade unions have been invited to enter formal negotiations, with NHS Employers,
to agree a balanced package of affordable proposals in line with the earlier pay deal
agreement, for implementation from April 2016.
The announcements highlight the scale of workforce reform across the NHS and set out a
clear timescale for implementing those reforms. We will now be discussing these with our
Staff Side colleagues on the Employee Partnership Forum (EPF) and the Local Negotiating
Committee (LNC).
The Board will be updated as the situation develops.
2.11
Developing our Leadership framework and compact
A significant enabler for our Patient First Programme will be leadership. Through the
engagement events we have held, and a series of development sessions with groups of
leaders and other staff, we are making progress in developing our Leadership Behaviours
Framework and in translating that into how we will describe success and develop, reward and
recruit people in a way that reinforces and strengthens that.
An important element will be providing clarity to all staff (initially those with leadership and
management responsibilities) about our expectations in the form of a compact i.e. what do we
expect from you e.g. in terms of management responsibilities, delivery, behaviours; and what
can you expect from this organisation that enables you to succeed e.g. support, resources,
respect.
In essence, the behavioural framework is about how we will embed our values and our vision
for leadership in the organisation, the compact will be the translation of that into a commitment
between individuals and the Trust.
Leadership Behaviours framework
The model below describes the significant Leadership traits that staff have articulated as
necessary to support the Patient First Programme.
Page 4 of 11
We have started to develop examples of what each of these mean, here in WSHT. Whilst
there is more work to do to engage staff, there is sufficient recognition and agreement on the
framework to plan implementation e.g. through appraisal and recruitment processes. This
work will take place over the next few months with a draft framework and implementation plan
available for Board review by October.
Developing and introducing a compact
Whilst some elements of the compact between staff and the organisation will be common, we
feel that to ensure real impact on individuals i.e. on their performance, their behaviours and
commitment, we need to develop compacts for specific roles. The Patient First Programme
Board agreed that, in particular to support the Ward Accreditation process, we should start with
Matron and Ward Sister roles. The initial work has started on this with a group of senior
nursing staff. A draft compact and implementation plan will be available to the Patient First
Programme Board in September.
2.12
Workforce Skills and Development
Statutory and Mandatory Training
For the first time, attendance on all six statutory and mandatory modules is now at, or above,
the Trust target of 90%. The number of staff who have completed all modules of their
mandatory training has increased from 81.1%- 82.9%, which means that there is still a small
number of staff, mainly Medical, who have not completed all of the e-learning modules on their
mandatory training. This is being monitored and chased up via the weekly Workforce reports.
DNAs
The DNA rate for training is currently 8.9% (an increase of 1% since last month.)
Progress re staff who have never attended any mandatory training
The number of staff who have never attended any mandatory training, or have not attended
any mandatory training for more than a year has decreased and is currently as follows:
Not attended any training for more than 12 months
0 (figure for last month was 2)
Never attended any Mandatory training (and started in the Trust more than 3
months ago)
9 (figure for last month was 14)
Six of the staff who were on the “never attended” list last month have now completed their
training. There is now only one member of staff who has been in the Trust longer than six
months and not attended any mandatory training (figure for May was three). However, there is
also a further eight staff who have now been in the Trust for three months or longer and have
not yet completed any mandatory training. This will again be escalated to the Chiefs and we
are working with Workforce Managers to ensure that all of their staff are booked on training as
a priority.
Widening Participation
Apprenticeships
During the first quarter of this financial year the Trust recruited a new apprentice in medical
imaging at St Richard’s. This is the fourth year that the department has recruited an
apprentice, the previous three all gained substantive contracts on completion and two are still
in the department.
Page 5 of 11
Five existing staff enrolled onto programmes including the new level 3 procurement apprentice
qualification. A further five new apprentices are waiting to start pending HR clearance, these
include posts in the bereavement office, theatres and the safeguarding department: all areas
that have not had a previous apprentice.
Since 2011 the Trust has recruited 69 individuals into apprentice posts. Plans are in place to
celebrate the 100th new apprentice.
Pre –employment programme
The pre -employment programme for students who are interested in a career in the NHS,
including medicine, nursing and midwifery, has started in the Trust. Twelve students have
spent week 1 in class, covering subjects such as infection control, manual handling, and
safeguarding. They are now on placements across site including clinical and non-clinical areas.
During their final week they will complete an Employability skills certificate and on the last day
there will be a celebration of achievement lunch.
This is a joint programme run by Health Education Kent, Surrey and Sussex and Sussex
Education Business partnership. It is the first time that it has run in West Sussex and is the
most successful of the 3 programmes that have run so far.
At the end of the programme we will encourage students to apply for apprenticeships in the
Trust.
Supported Internships
We have recently been approached by Northbrook and Chichester Colleges to provide
placements for Supported Internships. The Supported Internship is specifically aimed at young
people aged 16 to 25 who have special educational needs, a learning difficulty or an education
health and care plan. These interns want to enjoy the benefits of employment, but need extra
support to do so.
All these students will have the work skills to carry out everyday tasks but this programme is
designed to develop these skills.
This is a great opportunity to help the students who believe they are unable to work due to their
disability. Hopefully, this will boost their confidence helping them improve skills such as
communication and decision making. It will also give them a sense of independence that they
may never had.
The facilities and estates teams across the Trust are keen to support this initiative and are
planning on taking students both at St Richard’s and Worthing.
The students are not paid, it is hoped that at the end of the placement if a vacancy came up we
would support the student to apply.
2.13
Communications and Engagement
Recruitment campaign
The communications team has continued to provide support for the Trust’s nursing recruitment
campaign and specifically the Open and Selection Days held throughout the summer:
•
•
•
Wednesday 22 July at Worthing Hospital
Wednesday 2 September at St Richard’s Hospital
Wednesday 14 October at St Richard’s Hospital
This has included promotion of the event both on and offline as well as the creation of
resources promoting the organisation as an employer.
Page 6 of 11
Details can be found at www.westernsussexhospitals.nhs.uk
AGM
The Trust’s Annual Members meeting, incorporating our Annual General meeting is due to take
place on 27July at Chichester Medical Education Centre, St Richard’s hospital, starting at
9.30am.
Organised by the communications team, the annual event is an opportunity to hear a review of
the year both in terms of successes and challenges. The clinical presentation for this year’s
event focusses on the Trust’s Patient First programme and how it is supporting staff to further
improve services.
Patient First Programme
A series of other activities designed to promote the Trust’s Patient First programme are being
promoted by the communications team, including the Trust’s annual staff recognition awards
and Patient First information sessions, hosted by Chief Executive Marianne Griffiths.
More than 300 nominations have now been received for the awards, designed to honour all
those staff who demonstrate exemplary behaviours and go above and beyond their job role for
the benefit of those around them. The nominations will now be assessed by a judging panel
made up of staff and patient representatives and members of the Trust Board. The winners will
be revealed at the awards ceremony in October.
Welcome Home Packs
Other stories featured in the local media include news that older people returning home after a
stay in hospital will benefit from a new scheme initiated by staff and supported by volunteers
and local supermarkets.
Welcome Home Packs, containing essentials like milk, bread, cheese and fruit, will help frail
and isolated patients to be more comfortable on their first night back home.
The idea of providing goody bags was raised at a regular meeting held at Western Sussex
Hospitals NHS Foundation Trust where staff discuss how to further improve services for
patients.
The Trust’s Lead Governor Margaret Bamford was present and felt inspired to make Welcome
Home Packs a reality. Morrison’s, Sainsbury’s, Tesco and Waitrose in Worthing are all
backing the scheme, rallying the wider community in support of the hospital’s Welcome Home
Packs.
3.0
RECOMMENDATION
The Board is asked to NOTE the report.
Page 7 of 11
APPENDIX 1
Registered Nurses and Midwives Revalidation Readiness Report – July 2015
1. Summary
The purpose of this report is to assure the Board that appropriate arrangements are in place to
enable registered nurses and midwives to meet the Nursing and Midwifery Council’s Revalidation
expectations. This report provides a brief overview of revalidation requirements, details the
numbers of staff who are required to revalidate with the Nursing and Midwifery Council (NMC), the
processes in place and the on-going action plan to assure readiness for Revalidation which is due
to commence in April 2016.
2. Overview of Revaluation Expectations
A registered nurse or midwife will be required to declare from April 2016 onwards, as part of a
triennial process, they have:
• Practised for 450 hours during the last three years (as an example 450 hours equates to 12
weeks work at 37.5hrs per week in 3 years).
• Followed requirements on continuing professional development undertaking a minimum of 40
hours over 3 years related to the role they are in; 20 hours should be participatory learning
(learning with others).
• Obtained confirmation from a third party about the reliability of their declaration and meet the
expectations set out in the NMC Code.
• Demonstrated that they are using practice related feedback to reflect on their practice.
• A portfolio of evidence maintained electronically to assure their declaration.
Please refer to appendix 1 for further information.
3. Nursing and Midwifery Staff Impacted by Revalidation Requirements
The Learning and Development Department has established internal processes in association
with the Human Resources team to identify nursing and midwifery staff required to revalidate. A
process for alerting individual staff members and their managers is already a part of the existing
on-going reregistration processes. At the time of reporting the Trust have 2,251 registered nurses
and midwives who are required to meet revalidation expectations triennially in order to remain on
the NMC register. Revalidation is planned to commence in April 2016 and currently there are 124
registered nurses and midwives who need to revalidate between April and June 2016. These staff
are identified and will form a pilot group for WSHT. All will receive written information, their
managers notified, and invited to preparation sessions run by the Practice Development team.
It is noted that this period has a small number of staff who require to revalidate and that from
reregistration data outlined in figure 1 the Trust will have a substantial peak of staff who will need
to revalidate in September each year due to the annual University out turn for student
qualification. The pilot group will enable requisite processes to be tested and learning from the
national pilot sites and internal application can be streamlined to manage the September peak.
Figure 1
Page 8 of 11
4. Processes in Place to Assure Readiness.
Revalidation activity is currently being led by the Head of Practice Development Nursing and
Midwifery Education with updates provided to the Director and Deputy Directors of Nursing.
Nursing and midwifery staff are updated through a variety of communication methods. Activity
taken to date includes the following:
a. Awareness and culture
We are ensuring that a session on revalidation is included in all our Registered Nurse
Development Programmes (Bands 5/6/7) and also the Cornerstone Preceptorship
Programme. Revalidation has been discussed by the Educational Link Nurse network and
will be supported by them. We have a webpage on StaffNet with current information on
Revalidation. Information is also provided on Registered Nurse Induction and Trust
Induction on the Professional Development Marketplace stand.
Future plans include workshops initially to inform about the revalidation process and
introduce the requirements for reflective work. It is thought that these workshops will
become a feature of the Practice Development Calendar to discuss and practice reflective
writing. We are in the process of designating a project lead for revalidation within the
practice development team who will undertake a full stakeholder assessment and identify
action as a result of this.
b. Resources and Capacity
The NMC revalidation documentation has been added to the appraisal process for RNs
and that will be the forum for discussion. There will be a need to ensure Ward
Managers/Appraisers are aware of the revalidation process and requirements and it will be
for the project-lead to identify the best way to facilitate this. Initial thoughts are that this
could be provided through the Mentorship updates and perhaps some drop-in sessions, as
well as the current Band 6/7 Development Programme. The PD department is currently
looking into facilitating a monthly line managers ‘coffee and chat’ session which would be
based around a ‘hot topic’ and this could cover revalidation.
c. Systems and Processes
A workforce report will give us the numbers of nurses who will be revalidating in April
2016. Revalidation documentation has been added to the current appraisal
documentation. The project lead will be looking into all the various forms of data
(feedback) already collected to facilitate access for RNs to this information but also to
inform the current educational programme curricula. Furthermore the project lead will be
reviewing online access to the NMC and also to portfolios.
d. Guidance tools and support
The project lead will be working on an advertising campaign which will include signposting
to appropriate in-house and external resources for revalidation. S/he will also be
consulting with the Practice Development team to identify a range of reflective tools and
written examples that can be accessed by our RNs. There is also further work to be done
regarding what information we provide regarding the people involved within the
organisation e.g. confirmers, and also we will work on some departmental guidelines about
revalidation at WSHFT.
We will also be exploring the introduction of an electronic system as current proposals are
document based, this would bring nursing revalidation in line with medical staff revalidation
processes.
Page 9 of 11
5. On-going actions
It is noted that current plans need to be dynamic as the NMC final guidance is still awaited with
national pilot sites due to report and final guidance not anticipated until October 2016.The key
actions to be implemented are:
• Additions to be made to the trust policy on Professional Registration to include
revalidation.
• Education process for Trust staff who will act as confirmers (currently acting as
appraisers).
• Pilot group support programme based on NMC resources.
• Guidance on creating an electronic portfolio of evidence.
• Joint working with our partners e.g. Nursing agencies to ensure staff working for the Trust
are supported to achieve revalidation requirements processes such as education and
confirmers who are conversant with their practice.
6. Conclusion
There is a comprehensive process in place to implement arrangements to enable registered
nurses and midwives to complete the revalidation process. The arrangements implemented to
date and planned are designed to enable NMC registrants to provide evidence to their relevant
professional body; demonstrating that they continue to meet the professional standards which are
a condition of their ability to practise.
The action taken to date supports meeting the requirements of the Care Quality Commission
Outcome 14 demonstrating the Trust currently has appropriate arrangements in place to enable
staff to receive required training, professional development, supervision and appraisal; and be
enabled to obtain further qualifications appropriate to the work they perform. These arrangements
provide the basis for revalidation.
7. Recommendation
The board are asked to note the contents of this report.
Page 10 of 11
Appendix 1A
NMC Guidance on Revalidation requirements
Page 11 of 11
WSHFT WORKFORCE SCORECARD
JUN 2015
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
2015/16
YTD
Target/
Ceiling
Amber Limit
Budgeted FTE
6203.8
6215.2
6123.2
6174.6
6179.0
6274.2
6286.8
6287.2
6287.2
6287.2
6431.3
6437.3
6437.3
6435.3
N/A
N/A
Total FTE Used
6334.7
6252.9
6497.9
6381.7
6298.8
6227.1
6349.7
6329.4
6357.1
6393.3
6356.1
6249.6
6339.3
6315.0
N/A
N/A
Total FTE Used Variance from Budget
131.0
37.7
374.7
207.1
119.8
-47.0
62.9
42.2
69.8
106.1
-75.2
-229.7
-98.1
N/A
N/A
N/A
Total FTE Used Vacancy Factor
-2.1%
-0.6%
-6.1%
-3.4%
-1.9%
0.7%
-1.0%
-0.7%
-1.1%
-1.7%
1.2%
3.6%
1.5%
1.9%
N/A
N/A
Substantive Contracted FTE
5670.6
5670.8
5831.4
5677.0
5700.1
5644.9
5668.6
5687.6
5693.5
5701.8
5665.0
5664.3
5646.9
5658.7
N/A
N/A
Substantive FTE Worked
5568.7
5617.0
5560.0
5553.7
5606.3
5515.1
5582.8
5592.1
5586.6
5599.8
5612.7
5571.4
5540.3
5574.8
N/A
N/A
Substantive FTE Used Vacancy Factor
8.6%
8.8%
4.8%
8.1%
7.8%
10.0%
9.8%
9.5%
9.4%
9.3%
11.9%
12.0%
12.3%
12.1%
N/A
N/A
Bank Usage As % Of Total FTE Used
7.3%
7.0%
7.6%
8.8%
6.9%
7.3%
8.2%
7.2%
7.8%
7.8%
7.8%
6.4%
7.9%
7.4%
N/A
N/A
3.2%
2.3%
2.7%
2.2%
2.6%
2.1%
2.5%
3.0%
2.6%
3.0%
3.1%
3.0%
3.0%
3.1%
N/A
N/A
Key performance Indicators
1) WORKFORCE CAPACITY
NB
Agency Usage As % Of Total FTE Used
2) WORKFORCE EFFICIENCY
NB
1
3.7%
3.8%
3.8%
3.8%
3.9%
3.9%
4.0%
4.0%
4.1%
4.1%
4.1%
4.1%
N/A
3.3%
3.3%
In Month Sickness Absence %
3.5%
4.1%
3.9%
4.1%
4.6%
4.3%
4.5%
4.9%
4.3%
3.8%
3.6%
3.8%
0.0
3.3%
3.3%
In Month Maternity Leave %
2.7%
2.6%
2.5%
2.5%
2.6%
2.7%
2.8%
2.8%
2.6%
2.5%
2.6%
2.6%
0.0
N/A
N/A
In Month Other Absence %
1.1%
1.1%
0.8%
1.3%
1.5%
1.5%
1.2%
1.2%
1.2%
1.3%
1.4%
1.3%
0.0
N/A
N/A
In Month Total Absence %
7.3%
7.8%
7.2%
7.8%
8.7%
8.5%
8.5%
8.9%
8.2%
7.6%
7.5%
7.7%
0.1
N/A
N/A
Sickness Episodes
1055
1174
1103
1243
1489
1232
1652
1568
1295
1324
1134
1214
N/A
N/A
Rolling 12 Month Sickness Absence
Maternity Heads
201
187
190
175
186
185
193
203
191
184
187
197
N/A
N/A
In Month Long Term Sickness Absence % (28 Days Or More)
1.7%
2.2%
2.3%
2.2%
2.3%
2.4%
2.1%
2.1%
1.9%
1.8%
1.8%
1.8%
0.0
N/A
N/A
In Month Short Term Sickness Absence % (<28 days)
1.7%
1.9%
1.6%
1.9%
2.3%
1.9%
2.4%
2.8%
2.4%
2.0%
1.8%
2.0%
0.0
N/A
N/A
In Month Stress Related Sickness Absence %
0.4%
0.6%
0.7%
0.7%
0.8%
0.7%
0.7%
0.7%
0.7%
0.7%
0.6%
0.7%
0.0
N/A
N/A
In Month Musculo Skeletal Sickness Absence %
0.8%
1.0%
0.9%
0.8%
0.9%
0.8%
0.8%
0.8%
0.8%
0.7%
0.7%
0.9%
0.0
N/A
N/A
Number of Staff breaching Management Triggers for sickness absence
962
973
990
974
976
1002
999
1032
1034
1024
990
994
N/A
% of Staff (headcount)
14.4%
14.6%
14.8%
14.5%
14.6%
15.0%
15.0%
15.4%
15.4%
15.3%
14.8%
14.9%
Rolling 12 Month Turnover
7.2%
7.1%
7.3%
7.0%
7.3%
7.7%
7.8%
8.0%
8.1%
8.4%
8.6%
8.7%
11.0%
11.0%
3) TRAINING & PERSONAL DEVELOPMENT
N/A
8.9%
N/A
NB
83.0%
81.1%
81.5%
78.8%
78.1%
79.0%
77.7%
77.1%
77.5%
76.6%
77.6%
77.3%
76.7%
N/A
90.0%
80.0%
85.3%
82.2%
82.0%
80.3%
79.4%
79.3%
76.9%
77.6%
78.5%
78.0%
80.0%
81.1%
82.9%
N/A
90.0%
80.0%
% In Date - Fire
90.7%
89.3%
89.4%
87.6%
87.4%
87.4%
86.4%
86.6%
88.4%
87.6%
89.3%
90.5%
90.9%
N/A
90.0%
80.0%
% In Date - Infection Control (Role Specific)
91.3%
88.9%
89.6%
87.8%
87.5%
87.2%
86.4%
86.7%
88.2%
87.5%
89.2%
90.0%
91.3%
N/A
90.0%
80.0%
% In Date - Back Training (Role Specific)
93.7%
91.4%
92.5%
91.4%
90.8%
90.5%
90.4%
90.7%
90.7%
90.3%
90.8%
90.4%
92.0%
N/A
90.0%
80.0%
% In Date - Child Protection (Role Specific)
97.7%
95.9%
97.0%
96.9%
96.9%
97.0%
96.9%
96.9%
97.0%
96.8%
96.6%
97.5%
97.5%
N/A
90.0%
80.0%
% In Date - Information Governance
90.4%
88.9%
89.1%
87.6%
87.5%
87.2%
86.0%
86.6%
88.3%
87.5%
89.1%
90.1%
90.7%
N/A
90.0%
80.0%
% In Date - Adult Protection
72.2%
70.5%
71.0%
69.8%
69.1%
69.0%
75.5%
77.1%
80.3%
81.8%
85.3%
87.6%
90.2%
N/A
90.0%
80.0%
24
21
14
16
14
11
11
19
20
19
12
14
9
N/A
1
1
1
1
1
0
0
1
1
0
0
2
0
N/A
% Appraisals Up To Date
% In Date - All Mandatory Training
2
Number of Staff with no mandatory training
Number of Staff > 12 months since any mandatory training
4) REAL-TIME STAFF FEEDBACK
NB
321
114
106
123
109
95
108
76
122
382
109
99
158
366
N/A
N/A
% Respondents who would recommend this trust as a place to work
3
63.6%
70.2%
77.4%
77.2%
76.1%
73.7%
73.1%
65.8%
76.2%
61.0%
62.4%
76.8%
69.8%
69.5%
N/A
N/A
% Respondents happy with standard of care if a friend/relative needed treatment
3
81.6%
81.6%
86.8%
87.0%
86.2%
85.3%
88.0%
78.9%
82.0%
78.0%
87.2%
92.9%
83.0%
86.9%
N/A
N/A
Total Respondents To Survey
Notes:
1 Absence data is available one month in arrears
2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection amd Information Governance training is up to date.
3 Change in method June 2014. Pre Jun 14: % of staff who responded "Agree" or "Strongly Agree" to the question. From Jun 14: % of staff (including Bank) who responded "Likely" or "Extremely likely" (also note increased total respondents).
Trend
To: Finance and Investment Committee
Agenda Item: 13
Title
Financial Performance - June 2015
Presented by
Karen Geoghegan, Director of Finance
Prepared by
Alison Ingoe, Deputy Director of Finance; David Lowe, Assistant Director of Finance
Status
Confidential
Summary of Proposal
In June the Trust accrued a surplus of £277k in the month bringing the year to date position to £967k deficit,
in line with the plan for Q1. This delivers a Continuity of Service rating of '3' in the month. The forecast for
2015/16 is to deliver a surplus of £992k and a continuity of service rating of '3' in line with the plan approved
by the Trust Board in April.
The attached report provides further commentary and analysis of the financial position.
Financial planning principles have been established to ensure that expenditure budgets reflect anticipated
activity levels and that agreed staffing levels are maintained.
Support for/integration with Corporate Objectives and Strategies
G1. Maintain an acceptable financial risk rating
These are noted within the Financial Performance Report
N/A
Recommendation
The Finance and Investment Committee is asked to NOTE the Financial Performance Report for June
2015
Consultation
N/A
Appendices
Finance Report Month 3 2015-16
Summary
In June the Trust accrued a surplus of £277k in the month bringing the year to date position to £967k deficit, in line with the plan for Q1. This delivers a Continuity of Service rating of '3' in the month. The forecast for 2015/16 is to deliver a surplus of
£992k and a continuity of service rating of '3' in line with the plan approved by the Trust Board in April.
G
Continuity of Service Rating
Plan
3
3
Year to Date
Year End Forecast
Actual / Forecast
3
3
The Trust is reporting a Continuity of Service Rating (CoSR) of '3'. Both component
metrics have improved in month due to the in month surplus
G
Sustainability & Financial Performance Rating
Plan
3
3
Year to Date
Year End Forecast
Actual / Forecast
3
3
Subject to the outcome of consultation, the shadow Sustainability and Financial
Performance rating for June would be a '3'. The Income and Expenditure margin
metric is currently on the threshold between a '1' and a '2' and this rating is therefore
sensitive to fluctuations in financial performance.
R
Agency Expenditure
Expenditure as % of Total
Paybill (YTD)
Medical
Nursing
Other Staff Groups
All Agency
2013/14
5.0%
3.4%
2.4%
3.5%
2014/15
11.6%
6.5%
3.1%
6.1%
2015/16
9.9%
6.4%
3.0%
6.2%
A
Surplus £k
Year to Date £k
Year End Forecast £k
Plan
(998)
992
Actual / Forecast
(967)
992
A
Cash £k
Year to Date £k
Plan
16,769
11,729
Actual
7,923
11,729
The Trust reported a surplus of £227k against a planned deficit position of £260k in The adverse cash position is being caused by higher than planned levels of
June. This improved the year to date financial position to £967k deficit, which is in trade receivables and accrued income. This reflects the timing of agreements
line with the plan for the same period.
with the CCG for activity levels and payments in respect of these. A payment
has been agreed with the CCG for July which will improve this position.
A
Income £k
Year to Date £k
Year End Forecast
Plan
99,788
397,592
Actual / Forecast
99,013
397,592
Income from activities at the end of June is cumulatively below plan by £674k.
Overall non-elective income is below plan due to case mix changes towards more
short-stay admissions which are paid at a lower rate. PbR excluded items are
significantly above plan but equally offset by direct costs. Elective income
increased in month. Commercial income is also below plan.
A
Capital £k
Year to Date £k
Plan
2,502
15,070
Actual / Forecast
2,043
15,070
Overall spend on agency at Q1 is above 14/15 levels. Rates as prportion ov the
There was slippage against the capital programme of £459k as at the end of June
paybill are rising and are significantly above 2013/14 levles. Focus on reducing
due mainly to timing of equipment purchases within the Endoscopy programme.
agency expenditure continues through recruitment and retnetion programmes as well
as managing sickness.
G
Operating Costs £k
Year to Date £k
Plan
(95,219)
(374,456)
Actual / Forecast
(94,367)
(374,456)
The combined pay & non pay position year to date is £852k favourable to plan.
Vacancies continue within Nursing and Medical areas, however high levels of
sickness within senior Medical grades are driving higher agency usage than in
May. Although cumulatively underspent, non pay showed an adverse variance
on high cost drugs and devices in June, a large proportion of which is offset by
income.
Efficiency and Transformation Programme £k
Year to Date £k
Plan
2,941
19,467
A
Actual / Forecast
2,906
19,242
At the end of June, the Efficiency Programme delivered cumulative savings of
£2.91m against a plan of £2.94m (98.8%). The forecast out-turn variance will be
mitigated by pipeline schemes that are currently being validated.
Key Risks:
1. Management of patient flow to ensure that activity is able to be delivered within funded capacity and recourse to escalation and premium rate options are minimised. In partnership with the CCG, the Trust has re-based the non-elective threshold,
this allows the Trust to plan with a greater degree of certainty for expected levels of non-elective activity. A review of bed capacity is concluding and will ensure that this is aligned with expected acute activity levels. The Trust is working closely with
health economy partners to ensure that the levels of fit for discharge patients and community bed capacity is managed.
2. Delivery of savings within the efficiency programmme. As in 2014/15 the Trust has a signficant efficiency requirement in order to deliver its planned surplus. The savings profile increases in Q2 and again in Q3 in order to deliver the total
programme. The Programme Management Office is now fully established and governance around the programme has been strengthened. Pipeline schemes are continuining to be developed to provide head-room within the programme.
3. Ability to manage agency spend across nursing and medical workforce. Appointment to key posts witihn the medical establishment and recruitment and retention programmes for nursing are key components of the Trust's Workforce Transformation
programme.
G
Financial Risk Rating
The Trust is reporting a Continuity of Service Rating (CoSR) of '3'. There has been an improvement in the liquidity metric to (2.2) days ((3.0) days in May) due to the in-month surplus and the profile of capital expenditure. The capital service metric
has increased to 1.71 (1.25 in May) due to the phasing of capital and interest payments on loans and leases. The Trust is shadow monitoring itself against Monitor's Sustainability and Financial Performance ratings which, subject to consultation, are
due to be in place for all foundation trusts from Quarter 2. Under these new ratings the Trust would achieve a rating of '3'.
YTD
Liquidity Ratio
Capital Servicing Capacity Ratio
Plan
Metric
(0.2)
Plan
Rating
3
Actual
Metric
(2.2)
Actual
Rating
3
2.2
3
1.71
2
3
3
Sustainability & Financial Performance
YTD
Liquidity Ratio
Plan
Metric
(0.2)
Plan
Rating
3
Actual
Metric
(2.2)
Actual
Rating
3
2.2
3
1.71
2
Income and Expenditure Margin
(0.7%)
2
(1.0%)
2
Income and Expenditure margin as a % of income
1.2%
4
1.1%
4
Capital Expenditure Variance
0.0%
2
18.4%
3
Sustainability and Financial Performance Rating
Financial Criteria
Liquidity Ratio
CoS Weight %
50%
SFP Weight
25%
Metric to be scored
Liquidity ratio (days)
Definition
3
Rating categories
4
3
3
2
1
0.0
-7.0
-14.0
<-14
Annual debt service
2.5x
1.75x
1.25x
<1.25x
Surplus/(Deficit) before exceptional items
1%
0%
(1.0%)
<(1.0%)
0%
(1.0%)
(2.0%)
<(2.0%)
10%
20%
25%
≥25%
Working capital balance x 360
Annual operating expenses
Revenue available for capital service
50%
25%
Capital servicing capacity (times)
Income and Expenditure Margin
N/A
25%
I&E Margin (%)
I&E Plan Variance
N/A
15%
Operating I&E Margin (%)
Capital (Variance from Plan)
N/A
10%
Absolute Variance from Plan (%)
Total Operating and Non Op Income
Operating Surplus/(Deficit)
Operating Income
Absolute Variance from Plan
Planned Expenditure
A
Surplus
The Trust reported a surplus of £227k against a planned deficit position of £260k in June. This improved the year to date financial position to £968k deficit, which was in line with the plan for the same period.
Year To Date
Actual
£k
(967)
Plan
£k
(998)
(Surplus) Deficit
Variance
£k
31
Plan
£k
(Surplus) Deficit
992
Year Forecast
Forecast
£k
992
Variance
£k
-
Income from activities was above plan during June recovering some of the previous under-performance, however small decreases in private patient income and other operating income were also reported. Pay costs were underspent against plan with reductions
being seen in Medical waiting list initiative payments and Nursing bank pay in some of the Divisions offsetting higher expenditure within Women & Children and Facilities & Estates. Non pay expenditure was overspent in the month, higher levels of activity in
Rheumatology, Chemotherapy and Cancer Drugs fund have resulted in increased expenditure on PbR excluded drugs. Clinical Supplies and Services are above plan in Medicine predominantly with higher levels of ICD's being used. The increased ICD usage is
also offset by additional income for PbR excluded items. A richer case mix of activity in Surgery also accounted for higher levels of consumables being used in month within Orthopaedics and General Surgery .
Year to Date
Prev Yr Actual
£k
96,134
(64,643)
(27,966)
3,525
99,788
(66,454)
(28,765)
4,569
Actual
£k
99,013
(65,709)
(28,658)
4,646
3.7
4.6
4.7
(279)
11
(3,630)
(1,732)
(2,106)
(274)
254
(2,126)
(228)
8
(3,603)
(1,743)
(998)
(208)
208
(998)
1
(221)
12
(3,542)
(1,879)
(983)
(195)
212
(967)
Surplus %
(2.2)
* EBITDA Earnings before Interest Taxation Depreciation and Amortisation
(1.0)
(1.0)
Income
Pay
Non-Pay
EBITDA *
EBITDA %
Profit / Loss on Disposal of Fixed Assets
Interest Payable
Interest Receivable
Depreciation
Impairments
Public Dividend Capital Dividend
Net Surplus / (Deficit)
Reverse Impairment
Donated Assets
Donated Asset Depreciation and Amortisation
Performance against Control Total
Plan
£k
Variance
£k
(775)
745
107
77
Income
Pay
Non-Pay
EBITDA *
1
8
4
62
(136)
15
13
3
31
Profit / Loss on Disposal of Fixed Assets
Interest Payable
Interest Receivable
Depreciation
Impairments
Public Dividend Capital Dividend
Net Surplus / (Deficit)
Reverse Impairment
Donated Assets
Donated Asset Depreciation and Amortisation
Performance against Control Total
1,500
1,000
1,000
500
Budget
Actual
0
Aug
Sep
Oct
Nov
Dec
Jan
Feb
£000s
£000s
1,500
Jul
(914)
32
(14,288)
(6,974)
992
(762)
762
992
(914)
32
(14,288)
(6,974)
992
(762)
762
992
0.2
0.2
Variance
£k
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Cumulative Surplus by Month
2,000
Jun
5.8
Surplus %
Surplus by Month
May
5.8
EBITDA %
2,000
Apr
397,592
(262,131)
(112,325)
23,136
Full Year
Forecast
£k
397,592
(262,131)
(112,325)
23,136
Plan
£k
500
Budget
Actual
0
Mar
Apr
(500)
(500)
(1,000)
(1,000)
(1,500)
(1,500)
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
A
Income
At the end of June, income has underperformed against plan, however in month the Trust saw increased levels of activity due to the increased number of working days. This has lead to recovery of some of the prior month's under
performance.
Year To Date
Year End Forecast
Total Income
Prev Yr. Actual
£k
96,134
Plan
£k
99,788
Actual
£k
99,013
Variance
£k
(775)
Plan
£k
397,592
Total Income
Forecast
£k
397,592
Variance
£k
0
At the end of June income from activities is 434k below the Trust operational plan. Overall non-elective activity is below plan which, alongside a greater proportion of short-stay admissions which are paid at a lower rate, is causing an
overall under-performance in non-elective income.
Daycase admissions are above plan, but income is below plan. The Trust is performing less complex surgery, and more lower-paid work in Endoscopy and Clinical Haematology. Elective admissions are below plan - work is being
undertaken to recover this position. High Outpatient activity levels exceed the income and the activity plan. PbR excluded drugs cumulatively exceed plan by approximately 1,392k - the largest variances are for cancer drugs fund and CCG
funded Home Delivery drugs. The reported income position includes seasonal resilience monies to reflect the costs of continued provision of community beds.
In June Private Patient activity continues to be below plan, causing an adverse variance both in month and year to date. Plans are being put in place to increase income back to plan levels in future quarters. Education and Training income
is broadly on plan. Other operating income was slightly below plan as a result of decreased pharmacy sales, which are offset by decreased drug expenditure costs.
Prev Yr Actual
£k
Income
Clinical Commissioning Groups
Specialist LAT
WSCC - Sexual Health
NCA
Other Trust Income
Income From Activities
Private Patients
Education, Training and Research
Donated Asset Income
Other Income
Other Operating Income
Total Income
Year to Date
Actual
£k
Plan
£k
68,158
12,884
1,230
843
3,011
86,126
1,523
2,579
274
5,633
10,009
96,134
Variance
£k
Income
84,542
3,841
636
656
0
89,675
1,575
2,567
208
5,762
10,113
99,788
83,980
3,795
621
595
250
89,241
1,516
2,560
195
5,500
9,772
99,013
(562)
(47)
(14)
(61)
250
(434)
(60)
(7)
(13)
(262)
(341)
(775)
3,795
4,723
928
of which : PbR Drugs/Devices
Clinical Commissioning Groups
Specialist LAT
WSCC - Sexual Health
NCA
Other Trust Income
Income From Activities
Private Patients
Education, Training and Research
Donated Asset Income
Other Income
Other Operating Income
Total Income
Monthly Income
36,000
Full Year
Forecast
£k
Plan
£k
291,291
46,719
7,734
7,984
3,000
356,727
6,757
10,269
1,916
21,923
40,865
397,592
Variance
£k
291,291
46,719
7,734
7,984
3,000
356,727
6,757
10,269
1,916
21,923
40,865
397,592
0
0
0
0
0
0
0
0
0
0
0
0
Monthly Income Yearly Comparison
36,000
35,000
35,000
34,000
£'000
32,000
33,000
2014-15
32,000
2015-16
31,000
31,000
30,000
30,000
Feb
Mar
29,000
Mar
Jan
Feb
Dec
Jan
Actual
Nov
Dec
Oct
Nov
Budget
Sep
Oct
Aug
Sep
Jul
Aug
Jun
Jul
May
Jun
Apr
May
29,000
Apr
£'000
34,000
33,000
A
Contract Performance
The Trust reports income based on the contract monitoring position for prior months and estimate of income for the current month, based on priced and coded activity in the month as available. An estimate is made for the value of uncoded spells and missing days and included within the reported income
position.
1) Context
Contract negotiations are concluding and contracts have been signed by Coastal West Sussex, and NHSE. Signature for associate CCGs is expected shortly.
Baselines reflect out-turn position 14/15 plus growth. The contract with the CCG reflects the commissioner's expectation of QIPP. Similarly, the specialised services contract reflects NHSE's view of QIPP schemes. The Trust and NHSE have agreed to review the QIPP schemes and associated plans at the
end of the first quarter and to vary the contract if required following this review. An uplift to elective activty levels totalling £5.6m has been agreed with the CCG and is reflected in the Trust's income plan. Mechanisms to ensure close monitoring of activity levels and financial position are being established with
CCG and NHSE in line with contractual agreements.
A Deed of Variation has been signed with WSCC to extend contractual agreements for WSHFT delivery on Integrated Sexual Health Services for 2015/16 - 2019/20. ISHS with WSCC moves to cost per case at national tariff with risk share in 2015/16.
2) YTD Report
Trust internal monitoring information shows underperformance agains the CCG and NHS England contract with reduced Elective ativity, and with Non-Elective and Daycase activity performed at lower-than-plan casemix as outlined in the income report. PbR excluded drugs and devices exceed plan.
It is important to note that the performance indicated is compared to the Trust's plan and does not reflect the over-performance against commissioner contracts. The Trust is over-performing against the Coastal West Sussex CCG contract, although the recently signed contract variation for Elective uplift
activity will reduce this. The affordability of this level of performance to the CCG will need to be closely monitored. The NHSE contract is performing marginally below plan.
Table 1. Total Financial Values by Contract
Table 2. Activity and Income by Point of Delivery
Activity Volumes
Estimated Values for YTD June 2015
£'000
Coastal West Sussex (and associate CCGs)
NHS England
Integrated Sexual Health Services
Non Contract Activity
Reciprocal Overseas
Total
Point of Delivery
FYE Plan
295,671
46,719
7,734
YTD Plan
73,874
11,718
1,948
YTD Actual
73,989
10,918
1,462
YTD Var
115
(800)
(486)
8,336
358
358,817
2,045
90
89,675
2,167
71
88,606
122
(19)
(1,069)
Daycases
Elective Spells
Elective Excess Bed days
Non Elective Spells
Non Elective short-stay
Non Elective Excess Bed days
Outpatients
A&E
Other
YTD Plan
YTD Actual
£'000
YTD Var
YTD Plan
14,147
2,239
245
13,847
14,807
2,124
508
12,873
660
(115)
263
1,757
4,953
2,929
5,736
140,442
148,943
8,501
36,129
34,117
(2,012)
(974)
1,172
783
CQUIN
Total
NB: Variances are reported against Western Sussex Hospitals Planned Income Levels
Table 3. - Reconciliation to Income Reporting
YTD Actual
YTD Var
9,616
7,201
54
25,736
9,595
6,436
113
23,307
(21)
(765)
59
(2,429)
1,367
1,210
14,472
2,632
1,416
15,435
1,265
206
963
3,841
24,157
3,692
23,896
(150)
(261)
2,021
89,676
2,085
88,606
64
(1,070)
Table 4. Contract Income by CCG and NHS England
£000s
Contract Monitoring Performance -(unadjusted )
CQUIN 2.4%
Total Contracted Income
86,525
88,606
Income Recharged non-contract
Winter pressure funding
Cystic Fibrosis
NCA credit notes
Total Income from Activities
SUSSEX CCGs and NHS ENGLAND
2,081
665
53
(82)
89,241
NHS COASTAL WEST SUSSEX CCG
NHS HORSHAM AND MID SUSSEX CCG
NHS BRIGHTON AND HOVE CCG
NHS HIGH WEALD LEWES HAVENS CCG
NHS CRAWLEY CCG
NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG
NHS HASTINGS AND ROTHER CCG
NHS SOUTH EASTERN HAMPSHIRE CCG
NHS PORTSMOUTH CCG
NHS GUILDFORD AND WAVERLEY CCG
NHS FAREHAM AND GOSPORT CCG
NHS EAST SURREY CCG
Subtotal CCG Acute Contracts
NHS England
Total
Page 5
£'000
YTD Plan
69,922
1,155
952
58
103
37
16
1,440
52
109
YTD Actual
69,762
999
1,217
44
160
49
27
1,366
179
70
YTD Var
(159)
(157)
265
(14)
57
12
11
(73)
127
(39)
32
73,875
11,718
85,593
114
3
73,989
10,918
84,907
82
3
114
(800)
(686)
This table represents the Trusts
assessment of the performance
against commissioners only with
whom a Contract SLA has been agreed.
There are some differences between
the Trust's income plan and the agreed
contract values due to QIPP
assumptions
G
Operating Costs
The combined pay & non pay position year to date is £852k favourable to plan. Vacancies continue within Nursing and Medical areas, however high levels of sickness within senior Medical grades are driving higher agency usage than in May. Although cumulatively underspent, non pay
showed an adverse variance on high cost drugs and devices in June, a large proportion of which is offset by income.
Prev Yr Actual
Pay
Non Pay
Operational Costs
Plan
£k
(66,454)
(28,765)
(95,219)
(64,643)
(27,966)
(92,609)
Year To Date
Actual
£k
(65,709)
(28,658)
(94,367)
Variance
£k
745
107
852
Year Forecast
Forecast
£k
(262,131)
(112,325)
(374,456)
Plan
£k
(262,131)
(112,325)
(374,456)
Pay
Non Pay
Operational Costs
Variance
£k
-
Pay: Expenditure remained at a similar level to May, with vacancies in Admin & Managerial areas offsetting pressures within Medical agency. In month there has been a reduction in waiting list initiative payments, however activity has increased which could indicate productivity gains are
being made. Medical agency expenditure has increased in month largely driven by sickness. Vacancies remain in Core Services, Medicine & Surgery, whilst long-term sickness absence continues to drive premium pay expenditure in the Women & Children Division. Nursing expenditure
has decreased in bank as anticipated with the continued closure of escalation beds.
Non Pay: High activity within Chemotherapy and Rheumatology was reflected in increased volumes of high cost drugs, which are offset by increases in income. ICD expenditure was also above plan which again was reflected in increased income levels. Between May and June there was
an increase in clinical consumable costs linked to increased activity.
Prev Yr Actual
£k
Pay
Management & Admin
Medical and Dental Staff
Nursing & Midwifery
Other Healthcare
Estates
Other Staff
Plan
£k
(8,592)
(18,549)
(24,610)
(8,807)
(4,085)
(64,643)
Total Pay
Non-Pay
Services from Other NHS Bodies
Purchase of Healthcare from Non NHS Bodies
Drugs & Medical Gases - tariff
Drugs & Medical Gases - PbR excluded
Supplies and Services - Clinical
Supplies and Services - Clinical PbR Excluded
Supplies and Services - General
Establishment Expenses
Premises
Education and Training
Clinical Negligence Premium
Other Non-Pay
(9,311)
(18,647)
(24,707)
(9,506)
(4,074)
(209)
(66,454)
(882)
(911)
(8,230)
(9,105)
(1,081)
(1,824)
(3,798)
(236)
(1,339)
(561)
(27,966)
(92,609)
Total Non-Pay
Total Expenditure
Year to Date
Actual
£k
Variance
£k
(9,056)
(18,578)
(24,914)
(9,077)
(4,084)
(65,709)
(949)
(1,003)
(3,877)
(5,062)
(8,571)
(556)
(1,240)
(1,762)
(3,981)
(107)
(432)
(1,227)
(28,765)
(95,219)
(871)
(923)
(2,704)
(6,454)
(8,360)
(939)
(1,056)
(1,722)
(3,846)
(75)
(432)
(1,275)
(28,658)
(94,367)
255
69
(207)
429
(11)
209
745
78
80
1,172
(1,392)
211
(383)
183
40
135
32
(0)
(48)
107
852
Pay
Management & Admin
Nursing & Midwifery
Other Healthcare
Estates
Other Staff
Total Pay
(38,231)
(73,399)
(99,926)
(38,727)
(16,582)
4,734
(262,131)
0
0
0
0
0
0
0
Total Non-Pay
Total Expenditure
(3,726)
(2,556)
(15,860)
(19,078)
(33,598)
(2,078)
(5,615)
(8,491)
(15,410)
(161)
(5,214)
(537)
(112,325)
(374,456)
(3,726)
(2,556)
(13,106)
(21,832)
(33,379)
(2,297)
(5,615)
(8,491)
(15,410)
(161)
(5,214)
(537)
(112,325)
(374,456)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Monthly Pay
Monthly Non Pay
£000s
£000s
22,000
21,000
20,000
May
Jun
Jul
Aug
Sep
Budget
Oct
Nov
Dec
Jan
Feb
10,500
10,000
9,500
9,000
8,500
8,000
Mar
Apr
May
Jun
Jul
Aug
Actual
Sep
Budget
Oct
Nov
Dec
Jan
Feb
Mar
Dec
Jan
Feb
Mar
Actual
Monthly Pay Yearly Comparison
Monthly Operating Costs
22,500
32500
32000
22,000
31500
£000s
£000s
Variance
£k
(38,231)
(73,399)
(99,926)
(38,727)
(16,582)
4,734
(262,131)
Non-Pay
Services from Other NHS Bodies
Purchase of Healthcare from Non NHS Bodies
Drugs & Medical Gases
Drugs & Medical Gases - PbR excluded
Supplies and Services - Clinical
Supplies and Services - Clinical Pbr Excluded
Supplies and Services - General
Establishment Expenses
Premises
Education and Training
Clinical Negligence Premium
Other Non-Pay
23,000
Apr
Full Year
Forecast
£k
Plan
£k
31000
30500
21,500
21,000
30000
20,500
29500
Apr
May
Jun
Jul
Aug
Sep
Budget
Oct
Actual
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
2014-15
Sep
Oct
2015-16
Nov
R
Payroll & Agency Costs
Agency
Year To Date
Agency by Division
Year to Date
2013/14
2014/15
Plan
Actual
Variance
Plan
Actual
£k
£k
£k
£k
£k
£k
£k
Variance
£k
(862)
(2,143)
(1,496)
(1,840)
(344)
Surgery
(516)
(672)
(156)
Nursing & Midwifery
(778)
(1,135)
(704)
(1,600)
(896)
Medicine
(1,075)
(2,264)
(1,189)
Other Healthcare
Management & Admin
Estates
Other Staff
(386)
(65)
(47)
-
(414)
(86)
(165)
-
(850)
(3)
(87)
-
(467)
(89)
(105)
-
384
(86)
(18)
-
Core
Women & Children
Corporate
(1,442)
(88)
(19)
(769)
(237)
(159)
674
(149)
(140)
(2,138)
(3,943)
(3,140)
(4,101)
(961)
(3,140)
(4,101)
(961)
Total
Agency Expenditure Comparison
Agency Type Comparison
1,600
2,500
1,400
2,000
1,000
800
£000s
£000s
1,200
600
400
200
1,500
2014-15
1,000
2015-16
2014-15
Prev Yr Actual
£k
(16,406)
(23,475)
(8,393)
(8,506)
(3,920)
(60,700)
Mar
Feb
Jan
Dec
0
Medical and
Dental Staff
2015-16
Payroll
Nursing & Midwifery
Other Healthcare
Management & Admin
Estates
Other Staff
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
500
Year To Date
Plan
Actual
£k
£k
(17,152)
(16,738)
(24,003)
(23,314)
(8,656)
(8,610)
(9,308)
(8,967)
(3,987)
(3,979)
(209)
(63,314)
(61,608)
Nursing &
Midwifery
Other
Healthcare
Management
& Admin
Variance
£k
413
689
45
341
7
209
Staff in post incl Bank
Prev Yr Actual
WTE
685
2,615
907
1,156
661
-
Plan
WTE
752
2,658
1,038
1,256
734
(1)
Year To Date
Actual
WTE
688
2,528
913
1,226
684
-
1,706
6,024
6,437
6,040
Estates
Variance
WTE
(63)
(130)
(125)
(31)
(50)
1
(398)
Surgery: In June the division has delivered increases in all activity and income specialties compared to
last month due to the increased number of working days in month. Prior months' underperformance to
plan needs to be recovered in future months and plans are being developed. Nursing vacancies remain
an issue, substantive and bank pay costs have remained lower than last month, without a rise in Agency
expenditure contributing to the continued favourable pay variance. Waiting list initiatives within Medical
staff also have reduced in month. Non Pay expenditure remains above plan year to date, with a richer
orthopaedic casemix driving costs within clinical supplies and services.
£k
26,892
619
27,510
(15,890)
(5,577)
(21,467)
Year To Date
Plan
£k
28,210
537
28,747
(15,891)
(5,149)
(21,040)
6,044
7,707
PY Actual
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
EBITDA Surplus/(Deficit)
Actual
Variance
£k
26,385
548
26,933
(15,571)
(5,410)
(20,982)
£k
(1,825)
11
(1,813)
320
(261)
58
5,952
(1,755)
PY Actual
£k
12,377
263
12,640
(7,519)
(2,451)
(9,970)
Plan
£k
15,621
266
15,886
(7,545)
(2,503)
(10,048)
Year To Date
Actual
£k
14,958
234
15,192
(7,727)
(2,417)
(10,144)
Variance
£k
(663)
(31)
(694)
(182)
86
(96)
2,670
5,838
5,048
(790)
Medicine: Activity has increased significantly in June compared to May in both outpatients and
elective/daycases due to more working days and the undertaking of additional work to reduce a backlog
of Gastroenterology surveillance patients. Cardiology outpatient activity has also increased as planned
due to the appointments of a locum Cardiologist and a Specialty Doctor. Vacancy pressures, coupled
with an activity rise has led to an increased use of agency staff, causing an adverse variance to plan on
pay in the Division. The continued reduction in bed capacity resulted in lower agency nursing costs and
the requirement for bank cover partially offsetting the Medical pay pressures.
Non-Pay costs remained above plan for Drugs and Clinical Supplies with increased income relating to
PbR excluded drugs and devices offsetting this expenditure.
RAG
R
G
R
G
R
G
R
Women & Children: Outpatient and elective activity has increased during June, although there is still an
adverse impact on year to date activity against plan as a result of high levels of consultant sickness
within the division. This adverse activity variance to plan is partially offset within Non-Pay where high
cost drugs expenditure is below budget. Clinical Supplies are above plan both in month and year to
date, due to start-up costs within quarter 1 resulting from the transfer of Gynaecology from the Day
Surgery unit to an outpatients setting. Expenditure pressure within Pay remains high due to the
premium cost of covering medical staff vacancies with agency doctors along with a requirement to cover
on-calls as a result of senior medical staff sickness.
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
A
Divisional Performance
£k
39,477
1,049
40,526
(19,631)
(7,505)
(27,136)
Year To Date
Plan
£k
37,721
718
38,439
(19,591)
(6,766)
(26,357)
13,390
12,082
PY Actual
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
Actual
Variance
£k
40,442
778
41,220
(19,899)
(8,044)
(27,943)
£k
2,720
61
2,781
(308)
(1,278)
(1,586)
13,277
1,195
RAG
G
G
G
R
R
R
G
Facilities & Estates: The division’s year to date position remains adverse to plan. Higher activity levels
experienced in the Trust in month have resulted in increased catering receipts, recovering the shortfall
on income in prior months.
Pay expenditure increased compared to the previous month, and remains above plan, with rises in
housekeeping and portering, driven by the increased Saturday lists being undertaken within Surgery and
Medicine. Non-pay expenditure includes establishment expenses for phones and bleeps, a telecoms
strategy is being developed to put mitigating actions in place. There was also a non-recurrent increase in
postage due to mailings for staff governors. Premises costs are also above plan with ad hoc
maintenance expenditure arising in month.
R
R
R
R
G
R
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
1,313
1,313
(3,956)
(3,659)
(7,615)
1,351
1,351
(3,954)
(3,639)
(7,593)
Year To Date
Actual
£k
1,357
1,357
(4,170)
(3,842)
(8,012)
R
(6,302)
(6,242)
(6,655)
RAG
PY Actual
£k
Plan
£k
Variance
£k
Core: Year to date the Division continues to report a favourable position, however non-recurrent
expenditure has produced an adverse position in month. Pay continues to be underspent against plan as
a result of reductions in agency expenditure as substantive posts are implemented earlier than planned.
The delivery of the Surgical activity uplift is impacting on the level of waiting list sessions being worked
and Saturday working is increasing in frequency above the initial plan as operational plans are
implemented. Haematology and cancer drug fund expenditure are high in month however they come
with accompanying higher levels of income. This drug expenditure is masking a favourable variance in
pharmacy drugs sales which are lower than plan in month driving the adverse variance to plan on the
other income line. Mobile scanner hire is increasing as imaging requests rise, permanent solutions to
reduce these costs are being explored. Send away test activity within Pathology rose in month, however
the new contractual arrangements are being implemented in quarter 2. Efficiency Schemes for the
Division remain on plan in month and are forecast to deliver plan for the remainder of the year.
£k
6,564
2,984
9,548
(11,434)
(4,717)
(16,151)
Year To Date
Plan
£k
6,916
2,993
9,908
(12,399)
(5,596)
(17,995)
(6,603)
(8,087)
PY Actual
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
Actual
Variance
RAG
£k
6,994
2,765
9,759
(11,933)
(5,664)
(17,597)
£k
79
(228)
(149)
466
(67)
398
G
R
R
G
R
(7,838)
249
G
G
Corporate: Expenditure in the Corporate departments remains favourable to plan in aggregate. Income
remains below plan due to Private Patients activity delivering below plan, work is in progress to recover
the position in future quarters. Admin and Managerial vacancies across all departments have continued
to produce a favourable variance although this has been partially offset by the use of bank staff and
administrative agency for hard to recruit to posts.
Non Pay expenditure remains favourable to plan with controls on non-essential spend remaining in
place.
RAG
PY Actual
£k
Plan
£k
6
6
(216)
(203)
(419)
G
G
R
R
R
Contract Income
Other Income
Total Income
Pay
Non Pay
Total Expenditure
5
2,914
2,919
(6,112)
(3,833)
(9,945)
3,730
3,730
(6,450)
(3,665)
(10,115)
(413)
R
(7,026)
(6,385)
Year To Date
Actual
Variance
£k
£k
3,619
(111)
3,619
(111)
(6,385)
66
(3,475)
190
(9,859)
256
(6,240)
145
RAG
G
R
R
G
G
G
G
Statement of Financial Position
The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values, as well as movement in liabilities.
Year to Date
Property, Plant and Equipment
Full Year
Plan
Actual
Variance
£k
£k
£k
Notes
269,858
270,710
852
389
347
(42)
-
-
-
270,247
271,057
810
Non Current Assets
5,711
6,180
469
Inventories
Trade and Other Receivables
20,212
25,394
5,182
Cash and Cash Equivalents
16,769
7,923
(8,846)
-
-
-
42,693
(34,755)
39,496
(33,076)
(3,196)
1,680
(1,658)
(2,175)
(517)
-
-
-
(806)
(411)
395
-
-
-
Current Liabilities
(37,220)
(35,663)
1,557
Borrowings
(27,205)
(26,636)
569
-
-
-
(2,932)
(3,007)
(75)
Intangible Assets
Other Assets
Non Current Assets
Inventories
Non Current Assets Held for Sale
Current Assets
Trade and Other Payables
Borrowings
Other Financial Liabilities
Provisions
Other Liabilities
Provisions
1
Variance
£k
£k
Notes
272,958
-
389
389
-
-
-
-
273,347
273,347
-
6,052
6,052
-
Trade and Other Receivables
20,248
20,248
-
Cash and Cash Equivalents
11,729
11,729
-
-
-
-
38,029
38,029
-
(31,977)
(31,977)
-
(2,122)
(2,122)
-
-
-
-
(1,034)
(1,034)
-
-
-
-
Current Liabilities
(35,132)
(35,132)
-
Borrowings
(25,047)
(25,047)
-
-
-
-
(2,704)
(2,704)
-
248,493
248,493
-
Other Assets
Non Current Assets Held for Sale
Current Assets
Borrowings
Other Financial Liabilities
3
Forecast
£k
272,958
Property, Plant and Equipment
Intangible Assets
2
Plan
Provisions
Other Liabilities
Provisions
TOTAL ASSETS EMPLOYED
TOTAL ASSETS EMPLOYED
245,583
245,248
(335)
Financed by:
Financed by:
Public Dividend Capital
239,091
239,090
(1)
Retained Earnings
(40,275)
(36,608)
3,668
-
-
-
46,767
42,765
(4,002)
Surplus/(Deficit) for Year
Revaluation Reserve
TOTAL TAXPAYERS EQUITY
Public Dividend Capital
239,091
239,091
-
Retained Earnings
(37,365)
(37,365)
-
-
-
-
46,767
46,767
-
248,493
248,493
-
(Surplus)/Deficit for Year
Revaluation Reserve
TOTAL TAXPAYERS EQUITY
245,583
245,248
(335)
1. The variance on Property, Plant and Equipment is due to the over-programming of the capital plan
and the phasing of the expenditure, which the Trust expects to come back on plan during the year
2. Within trade and other receivables, accrued income (£5.2m) is higher than the planned amount due
to the timing of payments from the Trust's main commissioner in relation to seasonal resilience,
elective uplift programme invoicing and contractual overperformance
3. The provisions for liabilities and charges includes employer’s liability claims and redundancy
provisions and is lower than plan due to the reclassification of a redundancy provision after the plan
had been submited to Monitor. The Trust therefore anticipates that the provisions will continue to be
lower than plan for the financial year.
The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values,
as well as movement in liabilities. The plan is the Monitor plan submitted in May.
A
Cash
The income and expenditure position has contributed £0.3m to the adverse variance against plan. The movement in working capital includes an increase above planned levels in trade receivables and accrued income of £5.1m,
this relates predominantly to accrued income representing seasonal resilience (£0.7m), elective uplift programme (£1.5m) and the balance relates to contractual overperformance and CQUIN payments which are invoiced and
paid in arrears. This position will improve in July as the contract variation for the the elective uplift programme has been agreed and the CCG will make a year to date payment.
Cash Balance
EBITDA
Non Cash I&E Items
Movement in Working Capital
Provisions
Cashflow from Operations
Capital Expenditure
Cash receipt from asset sales
Cashflow before financing
PDC Received
PDC Repaid
Dividends Paid
Interest on Loans and leases
Interest received
Donations received in cash
Drawdown on debt
Repayment of debt
Cashflow from financing
Net Cash Inflow / (Outflow)
Opening Cash Balance
Closing Cash Balance
Plan
£k
16,769
Year To Date
Actual
£k
7,923
Variance
£k
(8,846)
Plan
£k
11,729
Full Year
Forecast
£k
11,729
Variance
£k
-
Plan
£k
Year to Date
Actual
£k
Variance
£k
Plan
£k
Full Year
Forecast
£k
Variance
£k
4,915
4,644
(271)
24,402
24,402
-
-
(195)
(195)
-
-
-
(9,204)
(17,008)
(7,804)
(10,401)
(10,401)
-
(76)
(108)
(32)
(304)
(304)
-
(4,365)
(12,667)
(8,302)
13,697
13,697
-
(1,285)
(2,040)
(754)
(15,070)
(15,070)
-
-
-
-
-
-
-
(5,651)
(14,707)
(9,056)
(1,373)
(1,373)
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
(6,974)
(6,974)
-
(236)
(209)
28
(991)
(991)
-
8
12
4
77
77
-
-
195
195
-
-
-
-
-
-
-
-
-
(500)
(516)
(16)
(2,158)
(2,158)
-
(728)
(518)
211
(10,046)
(10,046)
-
(6,379)
(15,225)
(8,846)
(11,419)
(11,419)
-
23,148
23,148
-
23,148
23,148
-
16,769
7,923
(8,847)
11,729
11,729
-
EBITDA
Non Cash I&E Items
Movement in Working Capital
Provisions
Cashflow from Operations
Capital Expenditure
Cash receipt from asset sales
Cashflow before financing
PDC Received
PDC Repaid
Dividends Paid
Interest on Loans and leases
Interest received
Donations received in cash
Drawdown on debt
Repayment of debt
Cashflow from financing
Net Cash Inflow / (Outflow)
Opening Cash Balance
Closing Cash Balance
Aged Debtors
The Trust debtors is a mixture of invoiced debtors, accrued income and prepayments as set out in the table below. It shows that the Trust has outstanding debtors of 31 days or more of £3,318k. The
most significant component of outstanding debtors greater than 90 days relates to commissioning income of £0.6m, NHS debt has remained static, whilst Non NHS debt over 30 days has reduced by
£0.5m in the same period, due to payments from Surrey County Council and Qinetiq.
Invoiced Debtors
Overdue
Within
Terms
1-30 days
£k
CCG's
NHS England
Trusts
Foundation Trusts
Other NHS
Non-NHS
Total
233
333
56
56
7
80
766
13%
Debtors
Total
£k
244
470
441
352
16
124
1,647
29%
Provision for Bad Debts (including RTA Provision)
Accrued Income (including Work in Progress)
Prepayments
Other Debtors
Total Trade & Other Receivables
31-60
days
£k
129
12
441
97
13
77
769
13%
61-90
> 90 days
days
£k
£k
(1)
587
57
19
90
690
57
321
2
49
(1)
680
204
2,345
4%
41%
(973)
11,763
4,288
4,584
25,394
£k
1,193
890
1,719
883
86
961
5,731
1,647k
1-30 days
2,345k
31-60 days
61-90 days
> 90 days
769k
204k
Other debtors consists of £2.0m of RTA debtors, £1.6m of Private Patients, £0.8m relates to Love Your Hospital after a £0.3m payment was made in June (the remaining payments will be made in July).
The balance is made up of VAT and other miscellaneous debtors
Accrued income consists of £7.4m of commissioner income, £0.8m of provider to provider income, non-contracted activity £0.5m, drugs/pharmacy £0.4m, private patients £0.2m, work-in-progress £2.4m
and £0.1m of other miscellaneous including radiology, catering and clinical excellence awards.
A
Capital
There was slippage against the capital programme of £459k in the year to date to June. This was due to underpsends in Endoscopy work of £0.2m, EPMA £0.2m and Paperlight £0.1m strategic capital schemes. This is offset by underpsends in the operational capital area in medical
equipment £0.3m, backlog maintenance of £0.1m offset by underspend in PC's/Laptops of £0.1m
Year To Date
Year End Forecast
Plan
£k
2,056
446
2,502
Strategic Capital
Operational Capital
Total
Actual
£k
1,502
541
2,043
Variance
£k
554
(95)
459
Plan
£k
9,241
5,829
15,070
Strategic Capital
Operational Capital
Total
Forecast
£k
9,241
5,829
15,070
Variance
£k
-
Strategic Capital spend - The main areas of overspend are in Endoscopy equipment which has had equipment purchases that have been
purchased ahead of plan due to clinical operational timings, this has been offset by the estates work within Endoscopy and EPMA.
Operational Capital spend - The reported variances against medical equipment and backlog maintenance represent timing differences in schemes.
The forecast out-turn is not affected by these differences.
Strategic Capital
Operational Capital
Year to Date
Actual
Plan
Source of Funds
£k
Strategic Funds C/F
External Funding
Capital Investment Loan New
Capital Investment Loan C/F
Transfer from Operational Capital
Donated Capital
£k
Variance
Plan
Forecast
Forecast
Variance
£k
£k
£k
£k
Risk
Rating
-
-
-
-
-
-
G
798
798
798
798
-
9,241
9,241
9,241
9,241
-
G
G
G
G
G
166
95
141
19
(95)
(141)
147
255
343
1,184
250
255
343
1,184
250
-
A
G
A
G
Source of Funds
Depreciation (net of IFRIC 12)
Technology Fund 2 for Inpatient
Documentation
Transfer to Strategic Capital
Loan Repayments
Health Education England Funding
Donated Funds
Total Funding
Full Year
Plan
Plan
Year to Date
Actual
Variance
£k
13,920
110
£k
1,131
-
£k
1,112
-
(9,241)
(1,158)
170
2,028
(798)
178
-
5,829
Forecast
Actual
Plan
£k
Variance
Risk
Rating
19
-
£k
13,920
110
£k
13,920
110
£k
(798)
178
-
-
(9,241)
(1,158)
170
2,028
(9,241)
(1,158)
170
2,028
511
492
19
5,829
5,829
8
21
566
405
8
41
269
(0)
8
(269)
41
8
21
566
405
8
21
566
405
-
2,350
360
380
100
265
130
380
265
127
120
-
131
65
0
21
-
(131)
62
120
(21)
-
2,350
360
380
100
265
130
380
265
2,350
360
380
100
265
130
380
265
-
600
5,829
150
446
13
2
39
541
137
(2)
(39)
(95)
600
5,829
600
5,829
-
-
G
G
G
G
G
G
-
Application of Funds
Strategic Capital Schemes
Endoscopy Equipment Worthing
Endoscopy Equipment SRH
Endoscopy equipment (scopes)
Paperlight
Interventional Radiology Room
Application of Funds
BabyPac 2
Exercise Treadmill test system - CIU
General medical equipment
Contingency
-
-
-
1,814
1,814
-
G
RTT - Pre Assessment
Recommssion Theatre 4
Laparoscopes
Cardiology & Respiratory Service Development
A&E Door
Infection Control
Haemotology
IT Support - Ante Natal Care
-
-
-
33
180
69
40
50
450
200
33
180
69
40
50
450
200
-
G
G
G
G
G
G
G
-
-
-
118
118
-
G
Estates Strategy
Health & Safety
Legally Committed
Non Medical Equip
Statutory Compliance
Sustainability
Bed Capacity
DS Fluoroscan
Sonisite
Operating Trolleys
-
-
-
874
55
40
60
874
55
40
60
-
G
G
G
G
PC's/Laptops
Pathology redesign IT kit
Miscellaneous
Total Expenditure
Manometry
Equipment Replacement Programme
Southlands Ophthalmology
Endoscopy Work
1,250
WiFi
31
Infrastructure
84
Clinical Portal/EDM
39
EPMA (Year 2)
486
Video Conferencing MDT and Corporate
Video Conferencing for Education (HEE Funded)
Critical Care Information System
-
-
-
170
170
-
1,032
4
209
1
1,502
218
31
80
39
277
(1)
554
20
1,000
2,000
2,529
250
250
775
771
150
170
(4,859)
9,241
20
1,000
2,000
2,529
250
250
775
771
150
170
(4,859)
9,241
-
G
G
G
G
A
G
G
G
A
G
G
G
Camera System
Overprogramming
2,056
-
Backlog Maintenance
Business Continuity
G
G
A
G
A
G
G
G
G
G
G
G
G
G
G
A
Efficiency and Transformation Programme
At the end of June, the Efficiency Programme delivered cumulative savings of £2.91m against a plan of £2.94m (98.8%). The in-month variance continued to be driven by slippage against commercial income schemes, which is expected to be recovered
in year and by a shortfall against IM&T schemes offset by over-performance against Procurement savings. The forecast out-turn variance against Core Services represents updated timelines for delivering savings within Pathology. This scheme will be
carried forward to 2016/17 and the in year reduction in savings will be mitigated by pipeline schemes.
Workstream
Plan
£k
Back Office & Corporate Support
Business Case Benefits Realisation
Commercial Opportunities
Core
Facilities & Estates
IM&T
Medical Workforce
Medicines Management
Nursing Workforce
Operational Productivity
Terms & Conditions
Women & Childrens
Transformation
Efficiency Plan Total
Month 3 YTD
Actual
Variance
£k
£k
890.0
405.3
272.0
215.3
67.4
340.7
96.8
78.4
314.9
154.7
105.5
2,941.0
973.8
344.1
272.0
202.1
1.7
337.7
117.6
80.4
314.9
140.2
80.1
41.1
2,905.7
83.7
(61.2)
(0.0)
(13.2)
(65.7)
(3.0)
20.8
2.1
(14.4)
(25.4)
41.1
(35.3)
Forecast Out-turn
Plan
Forecast Variance
£k
£k
£k
3,672.1
250.0
2,547.6
1,444.6
899.2
291.7
1,644.8
426.7
403.7
609.8
274.4
502.4
6,500.0
19,467.1
3,665.9
250.0
2,547.6
1,241.1
884.6
291.7
1,641.8
426.7
405.7
609.8
274.4
502.4
6,500.0
19,241.9
(6.3)
(0.0)
(203.5)
(14.6)
(0.0)
(3.0)
(0.0)
2.1
(0.0)
(0.0)
0.0
(225.3)
Month 3 (June) Plan vs Actual
1,200
1,000
£000s
800
600
Plan
Actual
400
200
0
Back Office &
Corporate Support
Business Case Benefits
Realisation
Commercial
Opportunities
Core
Facilities & Estates
IM&T
Medical Workforce
Medicines
Management
Nursing Workforce
Operational
Productivity
Terms & Conditions
Women & Childrens
Transformation
MONITOR FINANCIAL RISK INDICATORS
MONITOR FINANCIAL RISK INDICATORS
YTD RAG
Forecast Qtr
RAG
Unplanned decrease in EBITDA margin in two consecutive quarters
Financial risk rating (FRR) may be less than 3 in the next 12 months
FRR 2 for any one quarter
G
G
G
G
G
G
G
G
R
R
R
R
G
G
G
G
Working capital facility (WCF) used in previous quarter.
Debtors > 90 days past due account for more than 5% of total debtor
balances
Creditors > 90 days past due account for more than 5% of total
creditor balances
Two or more changes in Finance Director in a 12 month period
Interim Finance Director in place over more than one quarter-end
Quarter end cash balance <10 days of operating expenses
R
R
Capital expenditure < 75% of plan for the year to date
Any particular occurrences that could have an impact on the
operation of the business of the Trust
Trust financial performance is adverse to plan and operational
performance is currently highlighting underlying cost pressures.
Slippage against efficiency and transformation programme. The Trust
must identify and deliver 'pipeline' schemes to ensure sufficienct
headroom so potential slippage on schemes is recovered in full
The anticipated level of income from commissioners may be in
excess of local health economy available funds.
A
Indicators of Forward Financial Risk
The indicators below have previously been identified by Monitor as indicators of forward financial risk against financial performance.
Although the new Monitor Risk Assessment Framework is now in place the indicators below still provide a helpful indication of
operational financial performance. The Trust will monitor performance against these as a helpful indicator of emerging risks in
addition to the Continuity of Service Rating and delivery against the control total surplus.
G
G
G
G
YTD RAG
Forecast Qtr
RAG
A
A
A
A
A
A
Number of Indicators Breached
Position
YTD
3
Explanation if Risk
Forecast Q4
3
Action if Risk
EBITDA in the quarter is on The Trust is meeting the planned EBITDA for the
plan
quarter, and is forecasting to meet its financial
forecast in the year
The Trust has planned for a deficit in Q1, with a
plan to make a c£1m surplus during Q2 in order
to be at a breakeven position by the end of that
quarter, which the Trust will continue to monitor
FRR in 3 for the YTD
FRR has remained a 3
The Trust must deliver its planned savings as
part of the efficiency programme and control the
costs of over-performance in order to achieve its
forecast financial position
No working capital facility.
Not applicable
Not applicable
Over 5%. Debtors over 90
days account for 40.9% of
the total invoiced debts.
Performance due to some slow NHS payments.
This is under constant review.
Comprehensive formal review of debtors and in
particular NHS partner organisations
Over 5%. Creditors over 90 NHS creditors account for 4.4% of the 90 day
days account for 8.9% of
balances, the remaining material balances relate
the total invoiced creditors. to specific non NHS creditors.
Work is ongoing to clear NHS balances and the
major non NHS creditors are being targeted.
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Cash balance at end of
month is equivalent to 8
days operating expenses
Increase in cash position against plan is
summarised on cash sheet
Review of accrued income and conversion to
debtors to enable cash to be collected. Work
continues on agreeing over-performance with the
Trusts Main Commissioners
Capital Expenditure is
81.6% of plan year to date
due to the phasing of the
overprogramming
Capital expenditure reviewed by the Finance &
Investment committee.
The Capital Investment Group, chaired by the
Director of Finance, continues to meet monthly to
oversee the 2015/16 plan and out turn.
No plans to undertake a major acquisition,
investment or divestment. No plans for a major
change in capital structure.
IMPACT
Adverse financial
performance will impact on
the EBITDA margin and
CoS rating.
Non-delivery of efficiency
programmes will adversely
affect EBITDA and CoS
rating.
MITIGATION
NEXT STEPS
Performance across operational budgets will need
to improve and agency spend reduce. This will be
managed by exception through the director-led
deep dive reviews
Enhanced infrastructure to support programmes
and enable delivery. Identification of new pipeline
schemes to enable headroom. Delivery of each
workstream is formally reviewed weekly by the
Programme Steering Group
Non-recovery of income will Regular discussions with the CCG Finance
adversely affect will
Directors over system finances and affordability.
adversely affect EBITDA
and CoS rating.
Formal risk assessment of plans supported
through external review. Additional support for
'high risk' work streams in place for 10 weeks to
mobilise delivery. Substantive PMO team
recruited in order to facilitate delivery
Work through the local Contract Management
Group to validate and agree current levels of
activity and secure income
To: Trust Board
Agenda Item: 14
Title
Notification of Sealed Documents
Prepared by
Andy Gray, Company Secretary
Status
Disclosable
Summary of Proposal
It is a requirement of the Trust Standing Orders (Part C : Section 17 and 18) that a register of sealing is
maintained and use of the Common Seal is reported to the Trust Board Quarterly.
This report covers the period 1st April 2015 to 30th June 2015. Appendix 1 details use of the Common Seal
during this period.
None Identified
Links to good governance requirements, Trust standing Orders state reporting requirement to Trust Board.
Financial implications in relation to possible sales receipts and associated costs.
None Identified
Recommendation
The Board is asked to: Note the contents of this report.
Not applicable
Appendices
Appendix I: Register of Use of Common Seal
Appendix 1
REGISTER OF SEALING
It is a requirement of the Trust Standing Orders (Part C: Section 17 and 18) that a register of sealing is maintained and use of the
Common Seal is reported to the Trust Board Quarterly.
For the period 1st April 2015 to 30th June 2015
No.
Date of
Seal
27th May
2015
Title of Sealed Document,
34
26th June
2015
35
26th June
2015
33
Signed in Presence Of
(1)
Marianne Griffiths
(Chief Executive)
Signed in Presence of
(2)
nd
2 Signatory not
required for Contract
variation.
Lease to South Eastern Power in relation to Electrical
supply substation to new Breast Screening unit at
Worthing Hospital
Karen Geoghegan
(Director of Finance)
Amanda Parker
(Director of Nursing and
Patient Safety)
Title No. WSX 331100. Transfer of land registration title
only. Land adjacent to 59 Bostock Road, Chichester,
from BDW Trading Limited to Western Sussex Hospitals
NHS Foundation Trust.
Karen Geoghegan
(Director of Finance)
Amanda Parker
(Director of Nursing and
Patient Safety)
Deed Variation in relation to a Contract for the Provision
of Integrated Sexual Health Services to West Sussex
County Council
To: Trust Board
Agenda Item: 15
Title:
OPERATIONAL PLAN OBJECTIVES AND BOARD ASSURANCE FRAMEWORK2015/16 QUARTER 1
Responsible Executive Director:
Mike Jennings, Commercial Director and Andy Gray, Company Secretary
Prepared by:
Mike Jennings, Commercial Director and Andy Gray, Company Secretary
Status:
Discloseable
Summary of Proposal:
This paper presents an update to the Board on:
a) Quarter 1 RAG rated progress of programmes supporting the delivery of the Trust’s
Corporate Objectives
b) The Board Assurance Framework Quarter 1 2015/16
c) The BAF Quarterly Tracker Quarter 1 2015/16 supporting visibility in movement in
mitigated risk scores on a quarterly basis.
Implications for Quality of Care:
Quality is a key element of the Trust’s Corporate Objectives.
Link to Strategic Objectives/Board Assurance Framework:
The Trust’s Corporate Objectives cover the full range of the Trust’s strategic objectives.
Financial Implications:
Human Resource Implications:
Recommendation:
The Board is asked to:
a) REVIEW and NOTE progress against the delivery programmes contained within the
Operational Plan as at Quarter 1 2015/16
b) REVIEW and NOTE the Board Assurance Framework and quarterly tracker
Communication and Consultation:
Appendices:
Appendix 1: Corporate Objectives programmes update to Quarter 1 2015/16
Appendix 2 : Board Assurance Framework to Quarter 1 2015/16
Appendix 3 : Board Assurance Framework Quarterly Tracker
WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST
To:
Date: 30th July 2015
Board
From: Mike Jennings, Commercial Director
Agenda Item: 15
FOR INFORMATION
OPERATIONAL PLAN AND BOARD ASSURANCE FRAMEWORK 2015/16 QUARTER 1 REVIEW
1. INTRODUCTION
1.1. At the Board March 2015 meeting the Board approved the Trust’s Operational Plan for 2015/16
detailing how the Trust will achieve the corporate objectives it had set itself for the year, delivered
through a range of programmes, each with key aims, work-streams, milestones and measures of
success identified.
1.2. The Board also approved a Board Assurance Framework (BAF) for the financial year. The BAF
sets out and rates the principal risks to the achievement of the Trust’s corporate objectives for the
year, together with the controls and sources of assurance through which the risks are managed.
The BAF states that it will be subject to review following the end of each quarter and that in-depth
risk reviews will be undertaken through a schedule approved by the Board.
1.3. This paper presents:
a) Quarter 1 RAG rated progress of programmes supporting the delivery of the Trust’s
Corporate Objectives
b) The Board Assurance Framework Quarter 1
c) The BAF Quarterly Tracker
2. RECOMMENDATIONS
a) REVIEW and NOTE progress against the delivery programmes contained within the
Operational Plan for quarter 1 of 2015/16
b) REVIEW and NOTE the Board Assurance Framework and quarterly tracker
3. PROGRESS ON DELIVERING THE OPERATIONAL PLAN
3.1. For 2015/16 the Trust has published an Operational Plan that outlines how the Trust will achieve
its corporate objectives for the year. The corporate objectives are linked back to the Trust’s key
strategic themes outlined in the Patient First Programme.
3.2. Delivery programmes have been put in place to ensure that these corporate objectives are
delivered. Each of these programmes are set out in the Operational Plan, highlighting the aims of
the programme, the key work streams, the measures of success to be used and the corporate
objectives supported.
3.3. Appendix 1 looks specifically at progress against each of these programmes in quarter 1, and
incorporates comments on progress.
3.4. Significant progress has been made across the range of objectives. Under objective D4, the
achievement o access targets, elective access targets have not been achieved in Quarter 1. A
recovery plan has been enacted for cancer services, and compliance to waiting times has been
achieved in June, continued compliance is expected in quarter 2. The 18 week waiting target for
elective referrals remains the focus of a local health economy recovery plan, incorporating actions
by WSHFT and Coastal West Sussex CCG. If current health economy wide actions are completed
to plan, recovery is expected within 2016/17.
3.5. The quarterly progress report will continue be provided to the Board for the rest of the financial
year.
4. BOARD ASSURANCE FRAMEWORK QUARTER 1
4.1. Executive Directors have reviewed the risks assigned to them, assessing the validity of the risks,
their gross and net ratings, and the effectiveness of the controls and sources of assurance used to
manage the risks.
4.2. The Quarter 1 review has identified a number of additional controls, areas of assurance and
additional controls that are in place to mitigate risks of achieving the Trust Objectives. These are
highlighted in red and in bold at Appendix 2: Board Assurance Framework to Quarter 1 2015/16.
4.3. The Board should note the following:
•
•
•
Objective B3(a) : Failure to deliver improvements in stroke services. Due to improvements made in
relation to Stroke Care the current risk mitigated score is now below the target risk score set for
this Risk.
Objectives C1, C2 and C4, The risk mitigated score is now in line with the target risk score.
Objective D1(a) : this risk relates to Workforce Capacity and has been rated as a Risk 16 at the
end of Quarter 1 reflecting current concerns.
Page 2 of 2
Corporate Objectives 2015/16
Our People
Ref Corporate Objective
Exec
Primary Delivery Programmes/ Purpose
A1 (a) Improve the overall experience patients receive from our DNPS Develop and deliver the Trust’s 'Customer Care'
Trust
training programme
The Trust is introducing a major change to the way it
improves customer care by introducing ‘The Western
Sussex Way’ - an innovative approach to training,
recruitment, induction and appraisal, which seeks to
transform the way Trust staff interact with patients and their
carers.
A1 b
A2 a
Continue to develop and deliver staff engagement and
leadership development programmes in order to
improve patient experience
To deliver coordinated and standardised service
improvement methodologies across the Trust in priority
areas
DODL
DODL Develop the leadership strategy for the Patient First
Programme
The Trust has continued to support staff through its
Leadership Development plans, and is extending the
programme to cover Nurses and Managers as well as
Clinicians. The aim is to equip a cadre of staff to have the
skills to manage the Trust through the challenging future it
faces.
DODL
CEO
Sub Sections
Staff Engagement Programme
To ensure constant improvement and value is added
through enabling staff to identify and lead service
improvement.
DoDL
Develop and implement service improvement learning
programmes for the Patient First Transformation
Programme (including Lean training) To encourage all
staff to adopt and use evidence-based service change and
improvement tools, to improve the quality of service they
deliver.
CEO
1
Milestones
Q1 milestones progress
Q1. Establish operational group which will meet quarterly to Q1 PEEC now reviews the recommendations from
develop annual work plan in response to triangulating patient the Patient experience manager and oversees the
experience data.
action plan to improve patient experience
Q2. Respond to national inpatient survey
Q3/Q4 : monitor progress against work plan
DNPS &
DODL
Patient, public and member engagement programme
To ensure constant improvement and value is added
through identifying issues and areas for improvement that
matter to our patients.
A2 b
A3
Programme
Exec Lead(s)
Governors
Medical Engagement
Staff Survey
Q1 - scope and align current engagement processes to
Membership Strategy agreed and work of
ensure robust and efficient Support Membership Committee Membership committee progressing.
in development and implementation of membership strategy
Increase opportunities for patient voice in planning services
and training staff
Q1 - Draft Leadership 'compact' and strategy and agree
implementation process
Q2 - Agree Leadership
development priorities and process to inc priorities such as
Lean, coaching etc
Leadership framework drafted - to go to Board
30/7/15.
Q1 - Agree action plans inc staff side engagement and
methodologies for measuring progress
Agree action plan for Freedom to Speak up review
MES action plan drafted. PF Improvement
Programme in place. Freedom to speak up review,
Action plan agreed by Board Patient First
Engagement events + road shows delivered.
Q1 - Select Partner to deliver service improvement training
programme
Procurement process held - service improvement
partner selected. Programme design phase is
underway.
Quality Improvement
Corporate Objective
B1 a
Reducing Mortality and Improving Outcomes
Exec
MD
Primary Delivery Programmes/ Purpose
Reducing Mortality and Improving Outcomes 1.
Implementation of care bundles for sepsis, AKI and cardiac
arrest.
B1 b
Reducing Mortality and Improving Outcomes 2.
Implementation of 'Better Births@ Programme.
B1 c
Reducing Mortality and Improving Outcomes 3 (yr 1)
Introduction of a structured programme to review each
death in hospital and learn from each event.
B2 a
Delivering Safe, Harm Free Care
DNPS Delivering Safe, Harm Free Care 1
Reducing Hospital Acquired Infections, we will better our
targets for C Diff, and maintain zero MRSA infections for
2015 16.
Programme Comments
Exec Lead(s)
Milestones
Q1 milestones progress
Q1 - Agree Care bundles to be implemented
Q2 - Design mechanisms to monitor compliance
Q3 - Set targets and monitor progress
care bundles agreed and piloting in some clinical
areas. Monitoring mechanisms partly agreed
Q1. Plan to be developed with new Head of Midwifery
Q2. monitor progress against work plan
Stakeholder event held re better Births with key
themes looking at; person centred care, enhancing
experience, engaging and involving service users
and staff, quality and effectiveness and access &
support with the goal to identify end points not
solutions. Learning points will inform the
programme going forward.
Q1,Q2 - Scope methodology to identify structure review
process
Q3 - Implement review process
Initial structured review process agreed. Currently
testing the process against 50 patient notes before
final sign off
DNPS
Q1. Develop 2015/16 work plan
MSSA bacteraemia: reduce no. of avoidable post
48 hour cases by 20% (i.e. to 4 for year)
All C Difff and MRSA have an RCA review meeting
to identify any lapses of care
C. difficile: limit 39 post 72 hr cases for year.
Stretch target: No more than 18 with significant
lapse of clinical care.
DNPS
Q1. Develop work plan based on output from QUEST Falls
Collaborative
Q2. monitor progress against workplan
Falls collaborative meeting regularly, work plan in
place and pilot wards identified and testing
recommendations
MD
DNPS
MD
B2 b
Programme to reduce Falls within the Hospital
We will reduce the number of falls within the hospital.
B2 c
Implementation of Electronic Prescribing and
Medicines Administration
To deliver significant patient safety benefits, enabled
through deployment of an IT system, by reinforcing best
practice in medicines prescribing and administration, and
providing clinical decision support for users, thereby
significantly reducing prescribing and medications
administration errors.
MD
Q1: Rollout to Medical wards Chichester & DOME wards
Worthing (14 wards)
Q2: Rollout to Emergency Floor & Medical Wards Worthing
(7 wards); EPMA Paediatrics rollout; EPMA Surgical Pilot
Q3: Surgical rollout (13 wards); rollout to remaining areas,
i.e. OPD, Maternity, A&E, etc.
On track as per Q1 milestone and roll out.
Improve our stroke services
To deliver improvements in quality of care as outlined by
Sentinel Stroke National Audit programme (SSNAP).
MD
Q1 - Additional stroke consultant in place, setting of
trajectory for improvement plan
Q2 - Monitor Improvements
Staffing in place. Significant improvement in SNNAP
grading across SRH and WH. Model of care for
stroke within Trust complete and ready to be
shared with CCG
B3 a
Delivering Reliable Care
MD
To review models of care including HASU provision within
the Trust. To work with the Sussex wide stroke review in
developing a Sussex wide service model for Stroke
Q1 - Submit Trust solution for configuration to CCG
Q2 - Engagement with the Sussex wide Review
Q3 - Agree plan in line with Sussex Wide Review
2
B3 b
DNPS Improve the care we provide to dementia patients
To continue to progress improvements in care to patients
with dementia, implementing our dementia strategy
DNPS
Q1. Objectives identified. To be developed into workplan.
Appoint Dementia Matron
Dementia strategy group meets monthly and
reviews work plan set at beginning of 2015/16.
Matron post appointed to an candidate withdrew
shortly before start date - to be reviewed and
reappointed to
B4
Deliver quality improvements internally and as agreed in
partnership with our local Clinical Commissioning group Deliver CQUIN
CD
Deliver the programme of quality improvements
specified through CQUIN's sought by the Trust’s
Commissioners through the CQUIN programme, both for
the CCG and NHS England.
CD
Q1 Sign off of CQUINS for 1516 contract
1516 CQUINS signed off and in contract for CCG
Allocation of resources to achieve CQUINs 1516
and NHS England contracts.
Establishment of new project tracker and delivery board
Q1 milestones all met.
meetings to programme manage achievement of milestones
within each project
Q1 - Q4 tracking and delivery of milestones as per each
individual CQUIN
B5
Improving the Patient Experience
MD
Out Patients
Transformation programme to review, redesign and
implement the end to end pathway in outpatients, in order
to improve the patient experience whilst delivering internal
efficiency and productivity improvements.
MD
Q1 - Select external support to conduct diagnostic exercise
prior to service improvement
Q2 - Diagnostic work and delivery plan
Q3 and Q4 - as per delivery plan milestones
3
External Partner selected. Diagnostic phase
underway.
Systems and Partnerships
C1 In partnership with our local Clinical Commissioning
Group develop our lead role in the local health economy
for unscheduled care
COO Develop System-Wide Urgent Care
COO/CD
Q1 - Agree Lead provider scope and contractual
arrangements
Q3 - New lead provider arrangement in place
Q1-Q2 - Define scope and responsibilities for lead of urgent
care integrated system
Vision for system wide urgent care set out by
Coastal Cabinet and within Coastal West Sussex
urgent and emergency care vanguard application.
Contractual format and organisational form is
under discussion within Coastal Cabinet.
Q1 - Agreement by CCG to appoint WSHFT as prime
provider
Q2 - Set up of project management governance structures
and resourcing of design and delivery groups
Q3 - Submission of final "bid" to CWS CCG and signing of
contract
Q4 - Implementation phase with "Go Live" at end of Q4
Q1 - CCG agreement to have WSHFT as preferred
bidder for MSk services. Governance structure with
steering board and key partners involved
developed. This will now be expended to include
primary care and commissioner representation.
1) Accountable Lead Provider role within 'One Call
One Team'
2) Play a lead role in LHE Urgent Care Review
(overseen by coastal cabinet)
C2
Develop and redesign our MSK pathways in response to
CCG specification
CD
To design an integrated MSK service, linking from primary
to acute care. To implement the service in the second half
of the year.
CD
C3
Deliver improved cancer pathways for our population
through working with our tertiary partners
MD
Improve and reshape our cancer services
The Trust intends to reshape its cancer services, to provide
an improved accessible and equitable service across the
Trust. The provision of all cancer services, including
individual tumour groups chemotherapy. To work with
partners to design and deliver a new radiotherapy
treatment facility at St Richards Hospital.
MD/CD
Q1 - Finalise Heads of Terms and agree Implementation
plan with partners, confirm contract for Linaccs and
commence works
Q2 - Agree cancer pathways as priority areas
Q3, Q4 - Increase local provision of chemotherapy
Q4 - implement new cancer pathways
Agreement reached with strategic partners.
Working on finer detail at present to allow plans
for radiotherapy facility to be signed off by end
August. New pathway for urological cancer agreed
by Board in July.
C4
Implement Seven Day Working
COO
Q1 - Establish Governance Arrangements
Q2 - Agree Local Health Economy Plans and deliverables
Q3 - Monitor achievement of milestones in plan
7 Day system-wide development re-established as
15/16 priority for Coastal Executive (via Better Care
Fund)
COO Implement the seven-day working programme
Plan and Initiate the introduction of seven day working
across the Trust, in conjunction with partner organisations
in the Local Health Economy
4
Delivery and Sustainability
D1
To Deliver service Transformation Programmes in
priority areas such as Outpatients, Non Elective
Pathways, Elective Pathways, Workforce Redesign
CEO
Formation of Patient First Programme Board
Implement a new governance and delivery structure for the
main Trust transformation Programmes.
CEO
Maximise workforce capacity through a dedicated
programme management approach
To transform the trust workforce through a transformation
programme
D1 a
Q1 - Agreement of formation of PF Transformation Board
and new governance structures
Q1 - Formation of workforce transformation Board
Q1 - Identify and resource key programmes of change
Q2 onwards - delivery against identified milestones within
each project
Programme management arrangements in
place + programme agreed.
Some slippage on PIDs and on delivery.
Q1 - Hold planning event with key stakeholders to form the
key elects of the strategy
Q1 - Agree quick wins elective strategy and surgical
reconfiguration
Q1 - Rapid Improvement diagnostic events held,
utilising internal resources and supported by
KPMG, to both identify quick wins, and to inform
the on-going development of a longer term
strategy.
Quick win PIDs under development ready for
implementation during Q2.
DoLD
D1 b
Elective Care Strategy
Transformation programme to review the end to end
pathway in elective care to align capacity to demand and
ensure the Trust meets its 18 weeks and Cancer waiting
targets.
COO/CD
Q1 - Engage appropriate external resource to facilitate
development of the strategy
Q2 - implement quick wins identified
Q2 - Agree Elective strategy
Q3 and Q4 - Implementation stage according to strategy
timeline
D1 c
D1 d
D1 e
Complete: PF Transformation Board is in place.
Each transformation work stream also has its own
governance structure in place to oversee the work
of each individual programme.
Non Elective End to End Pathways
Deliver benefits realisation from new Emergency Floor at
Worthing Hospital. Review of the pathway at St Richards
Hospital to introduce the emergency floor model of care.
CD
COO
Develop Southlands Hospital including the relocation
of Ophthalmology services
Invest in Southlands Hospital to develop it as a thriving
ambulatory care centre, with Ophthalmology at the heart of
the development.
CD
Implement improvements in our Endoscopy services
Invest in Endoscopy to enhance patient experience,
improve patient flow and efficiency. Reduce operational
risk through an equipment replacement programme. To
maintain accreditation from the Joint Advisory Group at St.
Richard’s and re-achieve accreditation at Worthing – a ‘kite
mark’ of a well-run Endoscopy service.
COO
5
Q1 - Embedding of emergency floor systems and processes
Worthing
Q1 - emergency admission review
Q2 - scoping of SRH emergency floor options
Q3 - SRH emergency business case approved
Q4 - Implementation of SRH emergency floor
Q1 - Rapid Improvement diagnostic events held,
utilising internal resources and supported by
KPMG, to both identify quick wins, and to inform
the on-going development of a longer term
strategy.
Quick win PIDs under development ready for
implementation during Q2.
Emergency Floor service and workforce review
completed.
Q1 - OBC approved
Q1 - Appoint principle design contractor and work up full
design
Q2 - Approve Full Business Case
Q3 - Appoint building contractors
Q4 - begin construction
OBC Approved in Q1. Principle supply chain
manger appointed through procure 21 process.
Design programme underway. Resultant detailed
design timeline for project means that FBC not
expected until Q3.
Q1 - hand over of facility - equipping unit
Q3 - unit fully operational
WH Endoscopy Capital development on track.
D2a
To refresh the clinical services strategy
MD
D2b
CD
work begun within the health economy, exploring
urgent care models with partner organisations in
line with the 5 yr fwd view. Further work has been
undertaken on the cancer strategy as referenced in
C3
Q1 - initial future model of care outlined in the
Coastal West Sussex urgent and emergency care
vanguard application. Also outlined some key
concepts for the future strategic direction for the
LHE - these concepts have been discussed set out
in conjunction with Coastal Cabinet.
Review the Trust’s Clinical Services Strategy
MD
Q1 - Review of current clinical services strategy in line with
national vision
Q2 - refresh Clinical strategy
Review Trust organisational form in line with 5 year
forward view and the Dalton Review, and emerging
risks in the local and national context
CD
Q1- Document Trust Outline vision of future models of care
Q2 - Agree with LHE partners strategic direction for LHE
Develop and expand Private Patient Services, including
a new business case for development of a new unit in
Worthing.
CD
Q1 - review funding approach and assess possible partners
Q1 - development of further opportunities not dependant on
bed base as per efficiency scheme
Q2 - Engage partner - finalise OBC
Q3 - OBC approved -develop FBC
Q4 - approval of FBC
Q1 - Approach has been made to both an
intermediary to assess options in the equity
funding market, and to the local LIFT co. to assess
the market appetite to fund development through
that route.
On-going investigation and development of
opportunities in ophthalmic, and Women's
services.
COO
Q1 to Q4 - tracking delivery of and compliance against
targets
Revised RTT Recovery and Sustainability
Programme agreed in partnership with CCG and
submitted to Monitor and NHSE.
All
other access targets on track to deliver.
Dof
Q1 to Q4 - tracking delivery of and compliance against
financial plan
D3
To exploit the Trust's commercial opportunities,
including Any Qualified Provider tenders and Private
Patient activity, to support our core NHS business
D4
Maintain an acceptable Monitor governance rating
throughout the period
COO Achieve primary Quality Measures of RTT, cancer and
A&E waiting times
D5
To Maintain a minimum Monitor Continuity of Service
Rating of 3
DoF
To Maintain a minimum Monitor Continuity of Service
Rating of 3
As at end of Q1, Trust performance is in line with
financial plan and Trust is reporting delivery of a
Continuity of Service rating of 3
6
D5a
Delivery of the Efficiency Programme
DoF
Embed sustainable Programme Management
arrangements to support the delivery of the efficiency
programme
Dof
Q1 - Confirm transition arrangements to in house team
Q1 onwards - Tracking delivery of efficiency programmes
Q2 onwards - Continued tracking of 1516 and on going
rolling programme of pipeline schemes
Q4 - Finalise 1617 programme
In house team in place and aligned with workstreams. As at end of Q1, Trust is reporting minor
slippage of £35k against a plan of £2.9m (delivery
of 98.8% of target)
D6
D7
Delivery of capital programme
To Refresh the Trust Estates Strategy
DoF
DoF
Delivery of capital programme within resources available
and on time to maintain Trust assets and deliver service
improvements
Dof
DoF
*
7
Q1 - Embed new governance arrangements for capital
programme through the Capital Investment Group
Q2 - on-going tracking of delivery
Q1 : Milestone : Completion of Seven Facet Survey
Q2 : Milestone : Refreshed Estate Strategy to Board
Q3 : Milestone : Develop implementation and compliance
plan against Estate Strategy
Q4 : Milestone : Monitor on-going implementation and
compliance plan
Capital Investment Group established and in
operation.
Executive Team discussed Premises Assurance
Model in June 2015. Director of Estates and
Facilities developing action plan and timeline for
implementation.
DRAFT
BOARD ASSURANCE FRAMEWORK 2015/16 QUARTER 1 Report
Gross Risk Rating
Existing Controls
Risk Exec Lead
Corporate
Objective Ref :
Risk Description
ie. Actions already fully implemented to
manage risk
Sources of Assurance
Control / Assurance Gap
Action Plan
Net Risk Rating
Board Oversight Arrangements
In depth Risk Review assigned to the
Action Plan Summary (actions Committee indicated (at the interval
with timescales planned to
indicated) or covered through reporting
TARGET RISK
close identified gaps)
arrangements indicated.
SCORE
ie. Evidence relating to the specific measures what additional actions need to be
under 'Existing Controls'. Can be positive (+) taken to manage this risk OR what
or negative (-) : State whether assurances are additional assurance do we need
(+) or (-) and the Date received / Frequency
to seek
Likelihood
Impact
Total
Patient First Strategic Theme : Our People
Strategic Objective : (A1) : Improve the overall experience that patients receive from the Trust
DNPS We incur adverse feedback regarding patient
4
4
16
A1 (a,b)
experience from our patients and the public
and media.
Provision of patient monthly safety metrics to National in-patient and out-patient surveys,
provide public assurance.
and monitoring of action plans at Board
and/or Quality & Risk Committee (+)
Monthly Quality report and Board, including
Review of RTPE feedback to ensure that
public concerns are identified and resolved in RTPE data & Friends & Family Test (+)
Routine quarterly & exceptional reports to
a timely fashion.
Management Board and Quality & Risk
Committee regarding CQC (+)
Monthly Divisional Integrated Performance
Review Panel meetings
Healthwatch - monthly meetings established
Reporting required only if post mitigated
Risk Score Band is greater than Target
Risk Score Band
Likelihood
Impact
Total
3
4
12
3
3
9
3 x3 =9
Produce Leadership Strategy and Through Board as part of monthly
Development Plan by 30/3/15
Workforce report
2
4
8
3 x3 =9
Service Improvement
infrastructure recruitment
completed. In post during next
quarter. Recruitment well
developed, majority in place.
3
4
12
3 x 4 = 12
3
4
12
2 x4 =8
3x3=9
Q1 develop Operational group to Quality and Risk Committee Q1 and Q3 if
oversea patient experience
required
feedback and develop annual
action plan
Stakeholder engagement and feedback :
Patients’ stories to the Trust Board
Peer reviews of Care & Compassion : Review Increased referrals into the organisation
through the choose and book process or
of the Safety Thermometer.
other routes
Partnership working with the Patients
Partnership working with the Patients
Association.
Association.
The Communications Team work closely with
Friend & Family test results
the local press in the handling of media
relating to the Trust.
RTPE and real time staff survey responses.
National Staff survey results
Sit & See review
Governor Chair of Patient Stakeholder group
CQC Insight report : Friends & Family Test
Routine meeting with CCG Lead of Quality
Healthwatch Involvement
Strategic Objective : (A2) : Continue to develop and deliver leadership development programmes in order to improve patient experience
DODL Compromised delivery of performance,
3
3
9
Ongoing delivery of accredited programmes
A2 (a,b)
change management and staff engagement
Working with partners to develop further
due to inadequate leadership
appropriate programmes to support our
priorities
Evaluation of programmes Staff survey
results
Leadership Strategy and
Development Plan to support Patient
First Programme
Strategic Objective : (A3) : Continue to develop and deliver standardised service improvement methodologies programmes across the Trust in priority areas
CEO Inappropriate or insufficient focus and
4
4
16
Service improvement priorities and resources Quarterly annual plan progress report to
A3
resourcing causes us to fail to deliver the
agreed by Executive Team and supported
Board
appropriate pace and scale of improvements
through new Efficiency and Transformation
to underpin the Patient First Transformation
Programme delivery arrangements.
CIP delivery reports to F&I Committee and
programme.
Board
Resources to be flexed as necessary to
deliver priorities
Patient survey results (re priority relating to
customer care)
Through Board as part of Patient First
Reporting.
Monthly performance reports to Board
Patient First Strategic Theme : Quality Improvement
Strategic Objective : (B1) : Reducing Mortality and Improving Outcomes
We fail to implement care pathways
adequately in order to improve mortality
B1 (a,b,c)
3
4
12
Care bundle progress monitored at monthly
Divisional Integrated Performance Review
Panel meetings.
Feedback data from Enhancing Quality (EQ)
programme to Board
Through Board as part of monthly quality
report.
Reporting of site specific care pathway data
Development of site-specific metrics to
to Board
demonstrate processes in place and working
Monthly diagnosis group-specific mortality
Reporting of care bundle process metrics to reporting to Board
Board.
Quality Board to monitor Quality Strategy
MD
Strategic Objective : (B2) : Delivering Safe, Harm Free Care
B2 (a,b,c)
DNPS Patients receive below standard care resulting
in avoidable harm
4
4
16
Regular reporting.
Inquests (+/-)
Root cause analysis findings (=/-)
M monthly reporting of harms ie falls /
pressure in juries/MRSA/C Diff (+)
Triangulation of vacancy rates v
harm events by ward
Strategic Objective : (B3) : Delivering Reliable Care
Page 1 of 3
Through Board as part of monthly quality
Q1. Review and enhance existing report.
monitoring arrangements and
develop 2015/16 Work plan
B3 (a)
MD
Failure to deliver improvements in stroke
services
B3 (b)
DNPS Failure to implement our Dementia Strategy
4
5
20
Trust participating in Sussex wide
engagement group
3
4
12
Dementia Group meets monthly(+)
Work Plan in place for 2015/16 which
includes achievement of metrics(+)
update reporting to Trust Board
Recruitment to dementia matron
position - actions currently being
overseen by Matron for Medicine
3
2
6
3 x 4 = 12
2
4
8
2 x4 =8
Q1 Monitoring arrangements in Through Quality and Risk Committee Q3 if
place via SSNAP
required
Q1 Operational performance
improvement delivered via
Stroke Operational Group
Q1 To review models of care
including HASU provision
within the Trust
Q1. Review and enhance existing
monitoring arrangements
Through Quality and Risk Committee Q3 if
required
Strategic Objective : (B4) : Deliver quality Improvements internally and as agreed in partnership with our local Clinical Commissioning group - Deliver CQUIN
B4
MD
We fail to programme manage the quality
improvements relating to CQUIN
3
4
12
Programme management approach to EQ / Monthly board report on CQUIN and EQ to
CQUIN and enhanced recovery programmes show timeliness of data
through an Executive led CQUIN Delivery
programme
2
4
8
3x3=9
Strengthen capacity within Information Team
Strategic Objective : B5 : Improving the Patient Experience
Failure to improve the patient experience in
B5
MD
Outpatients through transformational change
programme
4
5
20
Through Monthly Finance reports Finance
and Investment Committee
Q1. sign off of CQUINS for
2015/16 contract
Governance structure under auspices of
Patient First transformation Board defined.
Tracking of patient experience and
complaints via Board sub-committees
3
4
12
3x3=9
Reporting.
Q1. Confirm external support to
support diagnostic
Patient First Strategic Theme : Partnerships
Strategic Objective : (C1) : In partnership with our local Clinical Commissioning Group develop our lead role in the local health economy for unscheduled and planned care pathways
C1
COO
Failure to reach consensus on system wide
service model with partners.
4
4
16
Ongoing engagement with our
commissioners through Coastal Cabinet to
ensure success of integrated work streams
including the Lead Provider development.
Manage Divisional unscheduled care
programmes to improve access and
discharge arrangements.
Coastal Cabinet and Single Performance
Conversation (SPC) meeting papers.
3
4
12
3x4=8
Through Quality and Risk Committee Q1
and Q4 if required.
1. Principals of NEL Model
agreed and Vanguard Bid
cemented
2. Elective strategy agreed with
Commissioners and joint
working strengthened
3. Elective and Non Elective
Transformation Programmes
established
3
4
12
3 x 4 = 12
Named as Most Capable
Provider. Contract to be
formally signed Q3.
2
4
8
2x4=8
Q1. Finalise Heads of Terms and To Board Q2 and Q4 if required
agree implementation with
partners.
3
4
12
2x4=8
Review of Annual Plan progress at Divisional
Integrated Performance Review Panel and
Board meetings.
Demand and acuity remains high risk.
Strategic Objective : (C2) Develop and redesign our MSK pathways in response to CCG specification
C2
CD
Failure to be named as Lead Provider for
MSK services and/or failure to deliver service
redesign in a sustainable way.
5
4
20
On going engagement with partners to
redesign pathways
Internal engagement with clinical leads to
ensure care pathway design is robust and
successfully integrated with WSHT services.
Ensuring channels of communication remain
open with Stakeholders nd Partners
Reporting to Executive Team on progress
and developments in the bid as it is
developed. (+)
To Board as required Q1, Q2, Q3, Q4.
Reporting to Finance and Investment
Committee. (+)
Legal Advice Taken.
Strategic Objective : (C3) : Deliver improved Cancer pathways for our population through working with our tertiary partners
C3
MD
Failure to deliver a new radiotherapy
treatment facility at St Richards Hospital
4
4
16
4
4
16
Regular Board updates on progress in
partnership arrangements
negotiations on-going and being
reported via Board
Strategic Objective : (C4) : Implementing Seven Day Working
C4
COO
Failure of Partners to support system wide
delivery arrangements
Internal working group established
and Q4 if required.
7 Day whole system
development agreed as priority
for Coastal Executive
Q1. Establish wider governance
arrangements
Patient First Strategic Theme : Delivery and Sustainability
Strategic Objective : D1 Formation of Patient First Board
D1
CEO Failure to implement an appropriate
Governance and Delivery Structure for the
Patient First Programme Board
3
4
12 Interim Structures agreed
Strategic Objective : D1 (a) Maximise Workforce Capacity through a dedicated programme management approach
4
4
16
Structured reporting to Board on workforce
D1a
DOLD Failure to deliver on programmes of work
reduces affordable capacity and impacts on
issues
patient care and sustainability
Strategic Objective : D1 (b)
Develop Elective Care Strategy
4
4
16
D1b
COO Failure to agree Elective care Strategy
impacts on patient care and efficiency of the
Hospitals
Preparation for planning event underway
Page 2 of 3
3
3
9
3 x3 =9
Q1 : formation of workforce
transformation Board.
Transformation Board
established. Additional PMO
support sourced and regular
reporting to F&I established
Reporting.
4
4
16
3 x3 =9
Q1 : formation of workforce
transformation Board
Reporting.
3
4
12
3 x 4 = 12
Q1 : planning event with key
stakeholders
All on track
Q2 Agree Elective Strategy
Reporting.
Strategic Objective : D1 (c) Review of Non Elective pathways (patient flow)
3
D1c
COO Failure to deliver benefits of new Emergency
floor and implement similar at SRH
4
12
Develop Southlands Hospital including relocation of Ophthalmology services
Clinical model fails to deliver patient benefits
4
D1d
CD
and required efficiency
4
16
Emergency Floor operational on-time
Business case well developed
Detailed work on-going as part of
FBC development.
Strategic Objective : D1 (e): Implement improvements in Endoscopy services
3
4
12
D1e
COO Failure to implement improvements impacts
Work on programme to deliver new service
on patient experience, patient flow and
efficiency.
Strategic Objective : D2 To refresh the clinical services strategy
MD
Insufficient clinical engagement and/or
4
4
16
Executive led delivery meetings in place and Reports to Executive Team on progress and
D2 (a,b)
management focus compromises scale and
regular reporting on progress.
developments (+)
pace of delivery.
Strategic Objective : D3 Exploit the Trust's commercial opportunities, including Any Qualified provider tenders and Private Patient activity, to support our core NHS business
CD
Inappropriate or insufficient focus and
4
4
16
Commercial Director appointed to manage
Efficiency programme monitoring of both
D3
resourcing causes us to fail to deliver growth
commercial agenda.
private patient and commercial opportunity
agenda. (+)
in market share in private patient, and in other
areas of opportunity. Market share may also
Resources approved to support private
reduce as a result of lack of focus, leading to
patient strategy.
Joint Private Practice Committee minutes. (+)
reduced levels of financial contribution.
Creation of Joint Private Practice Committee. Reports to Executive Team. (+)
Provide regular reporting on Private
Patient Activity to F and I Committee.
9 3 x3 =9
3
3
3
4
3
3
3
4
12
3 x 4 = 12
3
4
12
3 x3 =9
12
3 x3 =9
WH model and impact
assessment informing SRH
development
Reporting.
Q1 : final OBC approval. OBC
Approved by Trust Board.
Through Finance and Investment
Committee Q2 and Q4 if required.
9 3 x3 =9
and Q4 if required.
and Q4 if required.
local LIFT company engaged to Through Finance and Investment
explore investment appetite.
Specialist advice sought.
Lack of Market Share Analysis.
Recruitment completed.
Capacity Issues
Improved process to perform competitor and Reports to Finance and Investment
Committee. (+)
market analysis in place.
Strategic Objective : D4 Maintain an acceptable Monitor Governance Rating throughout the period
COO A mismatch between demand and capacity
4
4
D4(a)
16
leads to access targets not being met
D4(b)
CoSec Corporate Governance processes not
systematically embedded in organisation
leading to gaps in implementation and
development.
3
Strategic Objective : D5 : Maintain a minimum Continuity of Service Rating of 3
DoF
Ability to manage financial pressures
4
D5 (a)
generated from additional demand and deliver
productivity improvements required. Local
Health Economy Sustainability and ability of
commissioners to afford any increases in
activity above contracted levels.
Ongoing engagement with our
commissioners through Coastal Cabinet to
ensure success of integrated work streams
including the Lead Provider development.
Coastal Cabinet and Service Delivery Board
meeting papers.
Reporting to Coastal Cabinet monthly and
Clinical Commissioning Group to monitor the
delivery and effectiveness of planned and
unscheduled care demand management
schemes.
Daily heat map reporting.
Progress against work plan developments
reported via Audit Committee. (+)
Work embedded in routine practice. (-)
3
4
12
2x4=8
Daily Senior System Resilience
calls established across Local
Health Economy, on-going.
Ongoing resource
requirements agreed (Q1 and
Q2)
1. Resilience plans in development
2
4
8
2x4=8
Plan completion by March 2015. Through Quality and Risk Committee Q2
Resilience planning completed, and Q4 if required.
recruitment to Board
Administrator and Governance
Assistant completed. Annual
plan to be developed when in
post.
New Income / Activity reporting
developed and presented to
Finance and Investment
Committee
4
4
16
3 x 4 = 12
2015/16 Contract agreed
reflecting realistic activity
levels.
Daily and weekly reporting of high-risk areas.
Through Board as part of monthly
reporting on performance
Monthly reports to the Board.
Exception reports from Directors of Clinical
Services to Chief Operating Officer.
3
9
(i) Development of Annual Company
Secretary Work plan
(ii) Additional Resilience Development
4
16
Financial Plan reviewed at F&I and approved Monthly financial performance report to
at Board Service
Board and F&I Committee
Contract with commissioners reflects activity
plans and is transparent about collective risk
Anticipating further operational
challenges as the Trust maintains
seasonal escalation into Q4.
Efficiency programme reports to F&I
Committee
Through Board and Finance and
Investment Committee as part of monthly
Finance reports
CoS3 deleivered Q1
Cash and Liquidity report monthly to F&I
committee
Efficiency Programme Steering group meets
weekly and reviews delivery of plans and
development of pipeline schemes to mitigate
risk
D5 (b)
DoF
Failure to deliver efficiency programme
4
4
16
Programme Management Office recruited to.
Strategic Objective : D6 : Delivery of Capital Programme within resources available and on time to maintain Assets and Service Improvements.
DoF
Slippage against agreed Capital Programme
4
4
Embedding of new Governance
D6
16
and/or in-year investment requirements
arrangements for Capital Investment Group
exceed available resources.
Strategic Objective : D7 : Refresh of Estate Strategy
DoF
Lack of identification of key Estate issues that
D7
may impact implementation of clinical strategy
3
4
development of on-going monitoring and
reporting mechanisms
12 Enhanced arrangements through Capital
Investment group
Plan approved
3
4
3
4
2
3
12
3 x 4 = 12
12 3 x3 =9
6
3 x3 =9
Q1: Finalise 2015/16
programme
2015/16 Plan Approved by
Trust Board.
Transformation Programme
documents in development
Through Board and Finance and
Investment Committee as part of monthly
Finance reports
2015/16 Plan Approved
Refreshed estates strategy to
Board (Q2 2015/16)
Completion of Six Facet Survey
Routine reporting via Finance and
Investment Committee
Page 3 of 3
Quarterly BAF Monitoring 2015-16 to Quarter 1
Appendix 2
Ref
Lead
Mitigated Risk Values
Target
Risk
Score
Score
at 1st
Apr 15
Q1
Q2
Patient First Strategic theme : Our People
Strategic Objective
Principle Risk
A1 (a,b)
DNPS
Improve the overall experience that patients
receive from the Trust
A2(a,b)
DODL
Continue to develop and deliver leadership
development programmes in order to
improve patient experience
We incur adverse feedback regarding patient
experience from our patients and the public
and media.
Ongoing delivery of accredited programmes
Working with partners to develop further
appropriate programmes to support our
priorities
resourcing causes us to fail to deliver the
appropriate pace and scale of improvements to
underpin the Patient First Transformation
programme.
A3
CEO
Continue to develop and deliver
standardised service improvement
methodologies programmes across the
Trust in priority areas
9
12
12
9
9
9
9
8
8
12
12
8
12
12
12
12
6
8
8
8
9
8
8
Patient First Strategic theme : Quality Improvement
Strategic Objective
Principle Risk
B1
(a,b,c)
MD
Reducing Mortality and Improving
Outcomes
We fail to implement care pathways adequately
in order to improve mortality
B2
(a,b,c)
B3 (a)
DNPS
Delivering Safe, Harm Free Care
MD
B3 (b)
DNPS
Patients receive below standard care resulting
in avoidable harm
Failure to deliver improvements in stroke
services
Failure to implement our Dementia Strategy
B4
MD
Deliver quality Improvements internally
and as agreed in partnership with our local
Clinical Commissioning group - Deliver
CQUIN
We fail to programme manage the quality
improvements relating to CQUIN
12
Q3
Q4
B5
MD
Target
Risk
Score
Improving the Patient Experience
Failure to improve the patient experience in
Outpatients through transformational change
programme
Score
at 1st
Apr 15
Q1
Q2
9
12
12
12
16
12
12
16
12
8
8
8
12
16
12
9
9
9
9
12
16
12
12
12
9
9
9
9
12
12
Patient First Strategic theme : Partnerships
C1
COO
C2
CD
C3
MD
C4
COO
Strategic Objective
Principle Risk
In partnership with our local Clinical
Commissioning Group develop our lead
role in the local health economy for
unscheduled and planned care pathways
Develop and redesign our MSK pathways in
response to CCG specification
Failure to reach consensus on system wide
service model with partners.
Deliver improved Cancer pathways for our
population through working with our
tertiary partners
Implementing Seven Day Working
Failure to be named as Lead Provider for MSK
services and/or failure to deliver service
redesign in a sustainable way.
Failure to deliver a new radiotherapy treatment
facility at St Richards Hospital
Failure of Partners to support system wide
delivery arrangements
Patient First Strategic theme : Delivery and Sustainability
Strategic Objective
Principle Risk
D1
CEO
Formation of Patient First Board
D1a
DOLD
D1b
COO
Maximise Workforce Capacity through a
dedicated programme management
approach
Develop Elective Care Strategy
D1c
COO
D1d
CD
Failure to implement an appropriate
Governance and Delivery Structure for the
Patient First Programme Board
Failure to deliver on programmes of work
reduces affordable capacity and impacts on
patient care and sustainability
Failure to agree Elective care Strategy impacts
on patient care and efficiency of the Hospitals
Failure to deliver benefits of new Emergency
floor and implement similar at SRH
Clinical model fails to deliver patient benefits
and required efficiency
Review of Non Elective pathways (patient
flow)
Develop Southlands Hospital including
relocation of Ophthalmology services
Q3
Q4
D1e
COO
D2
(a,b)
MD
D3
CD
D4 (a)
COO
D4 (b)
CoSec
D5 (a)
DoF
D5 (b)
DoF
D6 (a)
DoF
D7
DoF
Strategic Objective
Principle Risk
Implement improvements in Endoscopy
services
To refresh the clinical services strategy
Failure to implement improvements impacts on
patient experience, patient flow and efficiency.
Insufficient clinical engagement and/or
management focus compromises scale and
pace of delivery.
resourcing causes us to fail to deliver growth in
market share in private patient, and in other
areas of opportunity. Market share may also
reduce as a result of lack of focus, leading to
reduced levels of financial contribution.
A mismatch between demand and capacity
leads to access targets not being met
Corporate Governance processes not
systematically embedded in organisation
leading to gaps in implementation and
development.
Ability to manage financial pressures generated
from additional demand and deliver
productivity improvements required. Local
Health Economy Sustainability and ability of
commissioners to afford any increases in
activity above contracted levels.
Failure to deliver efficiency programme
Exploit the Trust's commercial
opportunities, including Any Qualified
provider tenders and Private Patient
activity, to support our core NHS business
Maintain an acceptable Monitor
Governance Rating throughout the period
Maintain an acceptable Monitor
Governance Rating throughout the period
Maintain a minimum Continuity of Service
Rating of 3
Maintain a minimum Continuity of Service
Rating of 3
Delivery of Capital Programme within
resources available and on time to
maintain Assets and Service
Improvements.
Refresh of Estate Strategy
Slippage against agreed Capital Programme
and/or in-year investment requirements
exceed available resources.
Lack of identification of key Estate issues that
may impact implementation of clinical strategy
Target
Risk
Score
Score
at 1st
Apr 15
Q1
Q2
9
9
9
12
12
12
9
12
12
8
12
12
8
8
8
12
16
12
12
16
16
9
12
12
9
6
6
Q3
Q4
To: Trust Board
Date of Meeting: 30 July 2015
Agenda Item: 16
Title
Quarterly Submission to Monitor – Quarter 1 2015/16
Prepared by
Status
Disclosable
Summary of Proposal
The Board is required to approve the Quarterly Self-Assessment prior to submitting to Monitor. Monitor will
assess the trust’s performance for the last quarter and will discuss any issues in a review meeting the date
of which is to be confirmed.
No direct implications – the report seeks assurance that quality of care standards are maintained
Links to key objectives of (i) Maintain an acceptable financial risk rating; (ii) Maintain a Monitor Governance
rating of no worse than Amber Green throughout the year
No direct implications – the report seeks assurance that the financial plan is maintained going forward
None
Recommendation
The Board is asked to APPROVE the submission
To public Board meeting.
Appendices
1 Internal checklist
2 Governance submission
contact the Company Secretary on 01903 285288.
To:
Board of Directors
From: Andy Gray, Company Secretary
Date: 30 July 2015
Agenda Item: 16
FOR DECISION
QUARTER 1 2015/16: MONITOR QUARTERLY SELF ASSESSMENT
1. INTRODUCTION
1.1 The Board of Directors is asked to review the Trust’s performance as presented
and the attached self-certification checklist attached at Appendix 1. The Board is
asked to note the statement at Appendix 2 which is required to be signed by the
Chair and Chief Executive.
1.2 The Board should note that following the Quarter 3 submission Monitor rated the
Trust as having (i) a Continuity of Services Rating of 3 and (ii) A Governance
Risk Rating of ‘Under Review’ ; Monitor is requesting further information following
multiple breaches of the referral to treatment targets, before deciding next steps.
1.3 It should also be noted that the Trust has placed on Monthly Financial monitoring
and is therefore required to submit a high level financial template, as provided by
Monitor, on a monthly basis.
2
SUMMARY OF SUBMISSION
2.1 The return covers the period01 April 2015 to 30 June 2015. In making this return,
the Board of Directors is considering performance against the Annual Plan for
2015-16, derived from the Operational Plan submitted to Monitor.
2.2 In signing the Financial declaration the Board is confirming that it anticipates that
the trust will continue to maintain a Continuity of Service risk rating of at least 3
over the next 12 months.
3
RECOMMENDATION
3.1 The Board is asked to APPROVE the submission to Monitor.
Appendix 1
Monitor Quarterly Reporting Exception Checklist
The following checklist is taken from the Compliance Framework (note that this has
not been updated into the 2013 Risk Assessment framework which supersedes the
Compliance Framework) FOR THE PERIOD 1 April 2015 to 30 June 2015
Lead
Finance / KG
•
Finance / KG
•
Finance / KG
•
Finance / KG
•
Finance / KG
•
Governance/AG
•
Finance / KG
Governance/AP
•
•
Governance
/AP/AG
•
Governance/AP
Governance/AP
•
Governance/No
•
Finance / KG
All
•
•
Unplanned significant reductions in income
or significant increases in costs
Requirement for additional working capital
facilities
Failure to comply with the NHS Foundation
Trust Annual Reporting Manual
Discussions with external auditors which
may lead to a qualified audit report
Transactions potentially affecting the
financial risk rating and/or resulting in an
‘investment adjustment’
Removal of director(s) for significant
contractual or non-contractual dispute with
another NHS body
Adverse report from internal auditors
Risk of failure to maintain registration with
the Care Quality Commission
Significant third party investigations that
suggest material issues with governance
e.g. fraud or Care Quality Commission
reports of ‘significant failings’
Care Quality Commission responsive or
planned reviews
Outcomes or findings of Care Quality
Commission responsive or planned
reviews
Other patient safety issues which reflect
quality governance issues (e.g. serious
incidents)
Performance penalties to commissioners
Enforcement notices from other bodies
implying potential or actual breach of any
other requirement of the licence, e.g.:
o Health and Safety Executive or fire
authority notices
o Material issues impacting on the
trust’s reputation
o Adverse reports from overview
and scrutiny committees
o Patient group and Healthwatch
concerns
Quarter 1 2015/16
No
No
No
No
No
Chair re-appointment
approved by Council of
Governors at April meeting,
period of 3-years.
No
No
No
No
No
None identified. All SIRS’s
investigated and submitted
within timeframes
No
No
No
No
No
Appendix 2
Worksheet "Governance Statement"
Click to go to index
In Year Governance Statement from the Board of Western Sussex Hospitals
The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)
For finance, that:
4
Board Response
The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.
Confirmed
For governance, that:
11
The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of
thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going
forwards.
Not Confirmed
Otherwise:
The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk
Assessment Framework page 22, Diagram 6) which have not already been reported.
Consolidated subsidiaries:
Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable
funds.
Signed on behalf of the board of directors
Signature
Signature
Name M. Viggers
Capacity Chairman
Date
Name K Geoghegan
Capacity Director of Finance
Date
Confirmed
The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:
RTT: compliance was compromised in 2014/15 by significant and sustained rises in demand above planned levels. In order to ensure sustainable
delivery, the Trust has submitted detailed recovery plans to restore aggregate compliance by the end of Q1 2016/17. Compliance failure in Q1 2015/16 is
consistent with the planned milestone outcome of that recovery programme, and RTT completed pathways exceed the planned volume. Above planned
levels of referral demand (particularly in Urgent/Cancer) continue to generate system risk, and the Trust continues to work closely with Monitor, Surrey
and Sussex Local Area Team, Coastal West Sussex CCG and the 18 week Intensive Support Team/IMAS to ensure project oversight and mitigation of
system risk.
Cancer 2 week rule metrics: an unprecedented 25% spike in referrals in March 2015 generated a scale of variation that overwhelmed WSHFT capacity,
creating an unavoidable backlog and necessary recourse to recovery and mitigation. An extensive recovery programme was implemented through which
the Trust has undertaken 13.5% more cancer attendances than Q1 2014/15 through which compliance has improved in each month of Quarter 1 2015/16
This essential action to restore the waiting list size, distribution, and eliminate backlog generated a large volume of patients breaching the two week
standard in April 2015 an essential enabler to recovery of compliance. While this enforced non-compliance in Q1, these recovery actions restored
compliance in 2 week rule in June 2015, and full compliance in both 2wk metrics is forecast for Q 2015/16.
Appendix 3
Worksheet "Capex Declaration"
Click to go to index
Capital Expenditure Declaration for Western Sussex Hospitals
Where year-to-date capital expenditure is less than 85% or greater than 115% of levels in the latest annual plan (or any later capital expenditure
reforecast) an NHS foundation trust must submit a capital expenditure reforecast for the remainder of the year. This is set out at the bottom of page
22 of the Risk Assessment Framework issued by Monitor April 2014.
If you have triggered one of these criteria (see work sheet “Capex Reforecast Trigger”) then you must complete the work sheet “Capex Reforecast” and
sign one and only one of the declarations below. If you have not triggered one of these criteria then please do not input into this work sheet and the
work sheet “Capex Reforecast” at all.
Declaration 1
The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the attached
reforecast plan.
Signed:
On behalf of the Board of Directors
Acting in Capacity as: [job title here]
Declaration 2
The Board cannot make Declaration 1 and has provided relevant details on documents accompanying this return.
Signed:
On behalf of the Board of Directors
Acting in Capacity as: [job title here]
To: Trust Board
Agenda Item: 17
Title
Joanna Crane, Chair on behalf of the Quality and Risk Committee
Prepared by
Status
Disclosable
Summary of Proposal
The purpose of this paper is to present the updated Risk Management Strategy to the Trust Board for
Approval as recommended by the Quality and Risk Committee at its meeting 14th July 2015.
The Risk Management Strategy sets the strategic framework for managing risk within the Trust and therefore
supports patient safety and safe, effective care.
Links to Objectives of Quality and safety.
N/A
N/A
Recommendation
The Trust Board is asked to APPROVE the Risk Management Strategy
Director of Nursing & Patient Safety
Deputy Director of Nursing
Medical Director
Director of Organisational Development & Leadership
Members of the Quality & Risk Committee
Head of Clinical Governance
Risk & Patient Safety Manager
Risk Manager (Non-clinical)
Appendices
Appendix 1 – Main paper
Appendix 2 – Risk Management Strategy – updated July 2015
contact, Company Secretary, on [email protected] or 01903 285288.
To:
Quality & Risk Committee
From: Andy Gray, Company Secretary
Date: 30 July 2015
Agenda Item: 17
FOR APPROVAL
REVIEW OF RISK MANAGEMENT STRATEGY
1.00
INTRODUCTION
1.01
The Trust is required to have a Board approved Risk Management Strategy (RMS)
which ensures that there are processes in place to identify significant risks to the
corporate objectives.
1.02
The current RMS was due for review in May 2014. This review was paused pending
completion of work being undertaken under the auspices of the Audit Committee
relating to Risk Appetite.
1.03
The Trust Board approved an organisational Risk Appetite Statement in January
2015 and this has helped to form the context for the review of the RMS.
1.04
The updated RMS was reviewed by the Quality and Risk Committee at its July
meeting and recommended to Trust Board for Approval.
2.00
UPDATED RISK MANAGEMENT STRATEGY
2.01
The RMS has been updated to reflect the change of status to a Foundation Trust
and the particular requirements of the Trust Provider Licence and the Foundation
Code of Governance.
2.02
The revised RMS seeks to be a simplified , more accessible document than the
original version.
2.03
The strategy has been reviewed by a range of colleagues with responsibility for risk
management across the organisation, both clinical and non-clinical. It has also been
reviewed alongside the Risk Management Policy, which sets out operational
processes for risk management to support the strategy.
3.00
MONITORING OF IMPLEMENTATION
3.01
The Company Secretary will retain responsibility for the RMS while the Risk
Management Policy remains the responsibility of the Director of Nursing and Patient
Safety.
3.02
The Trusts Risk management processes will be the subject of annual Internal Audit
reviews.
3.03
An annual workplan for the further development of risk management practice
throughout the Trust will be developed by the Director of Nursing and Patient Safety
and it is proposed that the Quality and Risk Committee receive a quarterly report on
progress against the plan.
4.00
RECOMMENDATIONS
The Trust Board is asked to APPROVE the reviewed Risk Management Strategy.
contact, Company Secretary, on [email protected] or 01903 285288.
RISK MANAGEMENT STRATEGY
Summary statement: How does the document
support patient care?
The Risk Management Strategy sets out the strategic goals
towards which the Trust is working with regard to Risk
Management
Staff/stakeholders involved in development:
Job titles only
Director of Nursing & Patient Safety
Deputy Director of Nursing
Medical Director
Director of Organisational Development & Leadership
Members of the Quality & Risk Committee
Head of Clinical Governance
Risk & Patient Safety Manager
Risk Manager (Non-clinical)
Division:
Corporate
Department:
Chief Executive
Responsible Person:
Company Secretary
Author:
Company Secretary
For use by:
All staff
Purpose:
This document summarises the structures and processes
through which the Trust manages risk, linked to strategic
risk management where appropriate.
This document supports:
Standards and legislation
This document supports compliance with:
Key related documents:
Risk Management Policy
Statutory and Regulatory guidance, in particular meeting the
requirement of the Annual Governance Statement and the
Foundation Trust Code of Governance
Board Assurance Framework
Maternity Risk Management Strategy
Event, Investigation Management and Analysis
Learning and Development Policy
Health& Safety Policy
Monitor Risk Assessment Framework (updated March 2015)
Approved by:
Trust Board
Approval date:
TBC
Ratified by Board of Directors/ Committee of
the Board of Directors
Trust Board through the Quality and Risk Committee
Ratification Date:
tbc
Expiry Date:
May 2014
Review date:
April 2018
If you require this document in another format such as Braille, large print, audio or another language
please contact the Trusts Communications Team
Reference Number:
S1
Page 1 of 14
Contents
Page No:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
INTRODUCTION ................................................................................................................... 3
STRATEGIC OBJECTIVES
4
DEFINITION OF RISK MANAGEMENT
5
APPROACH TO RISK MANAGEMENT
5
STRATEGIC AIMS
6
RISK MANAGEMENT STRUCTURES AND RESPONSIBILITIES
6
RISK MANAGEMENT TRAINING
7
COMMUNICATIONS
7
FURTHER DEVELOPMENT OF RISK MANAGEMENT
7
MONITORING AND REVIEW OF THIS STRATEGY
7
FURTHER INFORMATION/REFERENCES
8
APPENDIX A1 : BOARD GOVERNANCE STRUCTURES
9
APPENDIX A2 : BOARD AND COMMITTEES WITH RESPONSIBILITY FOR
QUALITY GOVERNANCE
10
1.00
INTRODUCTION
Page 2 of 14
1.01
The Trust Board is responsible for ensuring that the organisation consistently follows the
principles of good governance applicable to Foundation Trusts and specifically the
Foundation Trust Code of Governance.
1.02
Western Sussex Hospitals NHS Foundation Trust is committed to putting the Patient First
and to achieving excellent patient care. It places great emphasis upon encouraging
communication and developing high quality services, which are flexible and innovative in
their approach to meet the needs of patients and staff alike. The Trust’s organisational
values support this commitment and are embedded through our Patient First Programme.
1.03
This Risk Management Strategy supports these objectives. The ongoing development of
risk management will ensure that the objectives are realised in an environment that is safe
and secure for patients, visitors and staff.
1.04
The systematic identification, analysis and control of risk are afforded a high priority within
the Trust. Training and education, supported by an open and learning culture encourages
all staff to report potential or actual risks and incidents as a basis for organisational learning
and improvement.
1.05
As an NHS Foundation Trust the Board is responsible for meeting the requirements set out
in the Trust licence regarding continuity of services and governance. The Compliance
Framework (2013/14) and Monitor Risk Assessment Framework (updated March 2015)
state that this includes:
•
•
•
•
•
•
•
•
•
•
•
The board providing effective leadership through appropriate board structures and
committees, clear responsibilities and lines of accountability;
Planning and other strategic decision-making processes are rigorous and robust
Systems are in place to ensure the provision of accurate and timely information
Effective systems of performance management and risk assurance in place
Issues and risks can be identified and appropriately escalated
Internal processes and structures are sufficient to ensure ongoing compliance with the
licence, healthcare standards and legal requirements.
Systems of financial oversight and controls are sufficient to ensure the licensee can
remain an ongoing concern
The licensee’s governance systems ensure effective oversight of the quality of care it
provides
The licensee has sufficient quality expertise at board level, and ensures it incorporates
quality considerations appropriately in its plans
The licensee should be able to monitor quality of care effectively, taking timely and
appropriate action to address issues arising and having regard to stakeholder views
where necessary
The licensee should have systems in place to ensure there is sufficient capability at all
levels to secure compliance with its licence.
1.06
The Trust must ensure that it delivers its objectives effectively. To achieve this the Trust is
required to have a Board approved Risk Management Strategy which ensures that there
are processes in place to identify significant risks to the corporate objectives, that an
understanding of the nature of the risk is sought and that remedial measures are rapidly put
into action.
1.07
In setting out its approach to risk management the Trust Board has agreed the following
Risk Appetite Statement.
Page 3 of 14
‘We aim to put the Patient First in all that we do and safety and quality should not be
compromised. We must deliver against the strategic objectives we have set ourselves
working in partnership with patients, our membership, our Governors and Strategic
Partners.
In working to achieve long term sustainability we will not accept risks that impact on patient
safety in any material way. However, we have a greater appetite to take considered risks on
issues that may impact on organisational or reputational issues. We have a varying appetite
on reputational issues; for example we have a low appetite for patient safety reputational
issues but may have greater risk tolerance to some business decisions that have a
reputational impact. We have greatest appetite to accept risk, where benefits are
anticipated, by pursuing innovation and challenging current working practices.’
This provides an overarching organisational context for risk management as well as
supporting on-going risk management development.
1.08
The strategy is therefore to identify hazards and risks that exist within the Trust and control,
eliminate or reduce to an acceptable level all risks which have any adverse effect on:
•
•
•
•
1.09
the quality of care
the health, safety and welfare of patients, staff and visitors
the ability of the Trust to meet its contractual commitments
the Trust to meet its statutory and obligatory duties.
In order to deliver the strategy the Trust has:
•
•
•
•
•
•
•
established the frequency with which risks are likely to occur
established the severity and the potential consequences of risks
established a system for prioritising the risks, in order that some objectivity can be
applied to any decisions regarding necessary control measures
has in place checks and balances to protect the services, reputation and finances of
the Trust
established a process of identification, assessment, control, elimination and mitigation
of risk
created an environment that is conducive to raising awareness and understanding
thus minimising risks by involving every member of staff in the risk management
process
reduced risks to patients, employees and others by managing and controlling them
where acceptable
2.
STRATEGIC CONTEXT OBJECTIVES
2.01
The overall objective of the Risk Management Strategy is to ensure robust risk
management is in place, sufficient to assure the Trust Board that the Trust remains within
its licensing authorisation as defined by Monitor, and which highlights to the Executive
Team and Trust Board, or its Committee’s, any risks which may prevent the Trust from
complying with its provider licence.
2.02
The Risk Management Strategy sets out the strategic goals towards which the Trust is
working with regard to Risk Management, and provides a framework that sets out clear
expectations about the roles, responsibilities and requirements of all Trust staff.
2.03
The Strategy promotes continued development of the Board Assurance Framework as the
vehicle for informing the Annual Governance Statement.
Page 4 of 14
3.00
DEFINITION OF RISK MANAGEMENT
3.01
The Trust is committed to the effective management of risks. Such risks can arise
externally or internally within any part of the Trust’s activities or services, both clinical and
non-clinical.
3.02
The Trust regards risk management as:
“The activity and process by which the organisation identifies, assesses, mitigates and
manages any actual or potential event or issue which could threaten the achievement of the
organisations objectives and plans, its ability to provide services of the required quality, or
its compliance with legal, regulatory and policy requirements.”
4.00
APPROACH TO RISK MANAGEMENT
4.01
The Trust approaches risk management in three ways:
•
•
•
proactively identifying risks to the achievement of its strategic objectives set at
corporate, divisional and departmental level.
identifying risks (principally operational) arising at any time.
areas for risk reduction will be identified and captured in an annual work plan
overseen by the Director of Nursing and Patient Safety
4.02
In respect of corporate objectives, the associated risks, and the means of mitigating and
managing them, are set out in the Trust’s Board Assurance Framework (BAF) which is
approved by the Board alongside the Annual Plan each year, and reviewed quarterly.
4.03
The Trust promotes a culture of pro-active reporting and management of Risks within all
areas of the organisation. It is acknowledged thatrisks are endemic in the majority of Trust
activities. . It is within this scenario that this strategy has been developed. There are a
number of different risks that can impact on the health, safety and welfare of patients,
visitors and staff and on the effective running of the Trust.
4.04
By approaching the control risk in a strategic and structured manner, overall risk is
reduced. This results in better quality care for patients, a safer environment and, by
minimising likelihood and impact, maximises the available resources for patient services
and care.
4.05 To ensure that the structure and process for managing risk across the organisation is
reviewed annually by the Trust Internal Auditors and reported to the Audit Committee.
5.00
STRATEGIC AIMS
5.01
The Trust’s Risk Management Strategy and Risk Management Policy represent its
philosophy towards risk and the mitigation of risk.
5.02
The Trust Board recognises that risk management is an integral part of normal
management. This strategy provides the framework for risk management, which:
•
Is based on best practice, national guidance and compliance with the standards Care
Quality Commission Requirements for registration and the fundamental standards of
care.
•
Integrates risk management across the Trust and supports convergence of all aspects
of Governance.
Page 5 of 14
•
Supports the Trust Board, in agreeing the Annual Governance Statement and
realising the significant quality, financial and organisational benefits from minimising
risk.
•
Embeds risk management practices into the day-to-day function of the Trust and
within the role of every staff member.
This strategy defines the:
5.03
•
Roles, responsibilities and structure for risk management.
•
Arrangements for integrating the approach to risk management which includes,
patient experience, complaints, legal claims and health and safety.
•
Approach to training and education to make the risk management process effective
and ensure a safety culture.
•
Risk management monitoring, auditing and review process.
The Trust actively supports risk management to improve the quality of patient care and the
safety of its staff and visitors to the Trust, as well as reduce the likelihood of claims and
costs arising from mistakes and possible negligence.
5.04 The Trust will ensure that the Risk Management policy is implemented ensuring:
•
•
•
all risks are being identified through a comprehensive and informed Risk Register
and risk assessment process.
the open reporting of adverse events is encouraged and learning is shared
throughout the organisation
that both divisional and corporate governance is place to review existing risks and
holistically consider the potential for new
5.05
To ensure that all individuals within the organisation are aware of their role, responsibilities
and accountability with regard to Risk Management.
6.00
RISK MANAGEMENT STRUCTURES AND RESPONSIBILITIES
6.01
The Trust approach to risk management promotes the management of risk as inherent to
the management of services.
6.02
There are key Boards and Committees which have clearly designed responsibilities in
respect of risk management. These include the Trust Board which reviews and appraises
the BAF. The Trust Board receives on a quarterly basis all risks rated 15 and above via
the Risk Register. The Quality and Risk Committee reports to the Trust Board and
receives and reviews on a quarterly basis all risks greater than 12 and above via the Risk
Register. The particular responsibility for these Boards and Committees is set out in their
Terms of Reference (TOR). An overview of these arrangements is provided at Appendix
B1 and B2.
6.03
Reporting structures from the Risk Register is set out in the Trust Risk Management Policy.
6.04
The schedule of reviews for the BAF is defined within that document, this schedule is
approved by the Board each year. At more operational level the clinical and principal
corporate Divisions within the Trust review relevant risks, both clinical and non-clinical, at
Management Board, Health & Safety Committee and/or Governance Review meetings.
Page 6 of 14
The detailed processes by which this takes place are set out in the Risk Management
Policy and in policies and procedures relating to health and safety management, which
supplement this strategy.
6.05
Whilst all staff have responsibility for risk management, staff in certain roles have particular
duties in respect of managing risk and these are defined in Trust Risk Management Policy.
7.00
RISK MANAGEMENT TRAINING
7.01
The Board recognises that for risk management to be effective it is essential for all staff to
understand their responsibilities and be trained to use the systems and processes which
the Trust has in place to identify, record, manage and report risks.
7.02
Staff training begins at the point of induction and continues thereafter with training at
defined points. This is defined through the Learning and Development Policy which
includes induction, mandatory training and on-going risk management training, both clinical
and non-clinical. The Policy makes clear the responsibilities of managers and all staff in
meeting the requirements of key training programmes. Attendance for staff training is
coordinated by the Trust’s Learning and Development Unit. The Company Secretary
arranges, co-ordinates and records attendance at training for Board members.
7.03
The Risk and Patient Safety Manager and the Risk Manager (Non-clinical) work with the
Head of Learning and Development on risk management education and training, which
supports specific service needs and the sharing of lessons learned from the risk
management process.
7.04
As identified in section 6.01 an annual work plan for the further development of risk
management practice throughout the Trust will be developed by the Director of Nursing and
Patient Safety.
8.00
COMMUNICATIONS
8.01
This strategy and the Risk Management Policy will be placed on the Trust’s intranet for
access by all staff.
9.00
FURTHER DEVELOPMENT OF RISK MANAGEMENT
9.01
Having set out its Risk Appetite the Trusts intention is to use this as a framework from
which to set target risk scores for each of the risks to its Corporate Objectives. These will
be presented to the Executive, the Quality & Risk Committee and the Board quarterly. This
will be supported by a new quarterly ‘tracker’.
9.02
Further development will be determined through additional requirements or Board
initiatives.
9.03
Focussed risk reduction initiatives will be overseen by the Director of Nursing and Patient
Safety through an annual work plan.
10.00 MONITORING AND REVIEW OF THIS STRATEGY
10.01 This strategy reflects existing practice within the organisation and will be updated should
significant overriding changes in context or regulation require this to be done.
10.02 The Trust Risk Management Policy sets out the detailed risk reporting and review
arrangements
Page 7 of 14
11.0
FURTHER INFORMATION/REFERENCES
11.1
For further information, refer to the following documents:
•
•
•
•
•
•
•
•
•
•
Event, Investigation Management and Analysis Policy
Complaints Policy
Learning and Development Policy
Health & Safety Policy
Raising Concerns Policy
Claims Policy
Being Open Policy
Risk Management Policy
Maternity Risk Management Strategy
Board Assurance Framework
Page 8 of 14
APPENDIX A1: BOARD-LEVEL GOVERNANCE STRUCTURE
Page 9 of 14
Page 10 of 14
APPENDIX A2: BOARD AND COMMITTEES WITH RESPONSIBILITY FOR QUALITY GOVERNANCE
Page 11 of 14
APPENDIX B: EQUALITY IMPACT ASSESSMENT
EQUALITY IMPACT ASSESSMENT
Name of Policy, Service, Function, Project or Proposal
Department
Corporate
Lead Officer for Assessment
What is the main Purpose of the
Policy/Service/Function/Project/Proposal?
List the main activities of the policy or service redesign (e.g. Manual Handling would relate to health and
safety of patients; health and safety of staff;
compliance with NHS and Government legislation or
standards etc.)
Is the policy or service relevant to:
To comply with requirements of Monitor
Compliance Framework
Compliance with legislation
Promoting Good Relations between different people?
Yes
Eliminating discrimination?
Yes
Promoting Equality of Opportunity?
Yes
Which groups of the population do you think may be
affected by this proposal?
Minority Ethnic People
Women and Men
People in religious/faith groups
Disabled people
Older people
Children and young people
Lesbian, gay, bisexual and transgender people
People of low income
People with mental health problems
Homeless people
Staff
Any other group (please detail)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Do you have any information that tells you of the current use of this service? Yes/No (if yes please
detail)
Yes – details of numbers of requests are reported to the Information Governance Committee
Is it broken down by ethnicity, gender, disability, age, religion and sexual orientation?
(please detail)
Does this information reflect the proportions from the 2001 Census?
Yes/No (If no, can you explain why)
Page 12 of 14
No
No detail known
If there is no information available or if this is patchy, specify the arrangements that will make this
available
Using the information above, please complete the grids below:
How will the Policy etc. affect Men and Women in different ways?
Gender
Positive
Impact
Negative
Impact
Neutral
Women
Men
Reason/Evidence
Don’t
know
X
X
How will the Policy etc. affect Black and Minority ethnic people?
Race
Positive
Impact
Negative
Impact
White
Mixed
Other Ethnic
Group
Black/Black
British
Asian/Asian
British
Neutral
Reason/Evidence
Don’t
know
Reason/Evidence
Don’t
know
Reason/Evidence
Don’t
know
X
X
X
X
X
How will the policy affect people with disabilities?
Disability
Positive
Impact
Negative
Impact
Visually
Impaired
Hearing
Impaired
Physically
Disabled
Learning
Disability
Mental Health
Related
Neutral
X
X
X
X
X
How will the policy affect people of different ages?
Varying ages
Positive
Impact
Negative
Impact
Neutral
X
How will the policy affect people of different sexual orientation?
Sexual
Orientation
Positive
Impact
Negative
Impact
Neutral
Reason/Evidence
Don’t
know
X
Page 13 of 14
How will the policy affect Transgender or transsexual people?
Positive
Impact
Negative
Impact
Neutral
Transgender
X
Transsexual
X
Reason/Evidence
Don’t
know
How will the policy affect people of varying religious beliefs?
Varying
beliefs
Positive
Impact
Negative
Impact
Neutral
Reason/Evidence
Don’t
know
X
How will the policy affect those with carer responsibilities or impact on basic human
rights?
Carers /
Human
Rights
Positive
Impact
Negative
Impact
Neutral
Reason/Evidence
Don’t
know
X
Considering your responses above, what are the areas that are have a positive and / or
negative impact?
Positive + /
Negative Gender
Race
Disability
Age
Sexual Orientation
Religious Belief
Reason Given for Impact
The Strategy will ensure that all Groups are treated
equally.
Page 14 of 14

MEETING IN PUBLIC - Western Sussex Hospitals

Transcription

Similar documents

Information for Emergency Weekend Appointments Dental Access

Hexter-Fair FirstAmerican Title~

2012-DM No. 1206-Regional Technolympics Participants

The Anchor

Appraisal Districts San Antonio Area

The Eastern Eye

request to correct name or address on a real property account

Pope John Paul II`s Teaching on Sexuality and Marriage: An Appraisal