Board of Directors - Basildon and Thurrock University Hospitals

Transcription

Board of Directors
agenda
Date
24 November 2010
Time
1:00pm
Place
Training Rooms B2/3
Postgraduate Education
Centre
Basildon University Hospital
Contact
Angus Wyatt
Basildon and Thurrock
University Hospitals NHS
Foundation Trust
Nethermayne
Basildon
Essex
SS16 5NL
Tel: 0845 155 3111
Extension
3874
Email:
[email protected]
1
Members of the Board of Directors
Chairman
Mr M Large
Non Executive Directors
Mrs J Gibson
Mr R Holmes
Mr J Kent
Mr T Parks
Mr P Sheldrake
Ms H Sturgess
Mr P Wardle
Executive Directors
Mr A R Whittle
Mrs J Galpin
Mr M Magrath
Dr S Morgan
Mr A Ray
Mrs D Sarkar
Mr A Sewell-Jones
Mr N Taylor
Chief Executive
Director of Estates and Facilities
Director of Operations and Service Development
Medical Director
Acting Director of Finance (non voting member)
Director of Nursing
Programme Director and Director of Continuous
Improvement
Director of Personnel and Organisational Development
Quorum
No business shall be transacted at a meeting of the Board of Directors unless at least
five Directors including not less than two executive and not less than two nonexecutive Directors are present.
2
PART ONE – PUBLIC MEETING
AGENDA
Item No
Page No
The meeting will be preceded by a Clinical Presentation on Organ
Donation – Dr Amin Darwish
5
SECTION 1 – Administration
(1) 1
(1) 2
(1) 3
(1) 4
Chairman’s Welcome and Note of Apologies for Absence
Minutes of the Meeting held on 27 October 2010
Matters Arising from the Minutes of the Meeting held on 27 October
2010
Evaluation of the Meeting held on 27 October 2010
7
15
SECTION 2 - Operational Performance
(2) 5
(2) 6
(2) 7
Performance Report for October 2010
Report from the Programme Management Office and KPI Schedule
Items considered by the Board of Clinical Directors
17
66
77
SECTION 3 – Contemporary Reports from Executive Directors
(3) 8
Chief Executive
Verbal report
(3) 9
Chairman
Verbal report
(3) 10
Joint Report of the Director of Nursing and Medical Director
Quality innovation and Patient Safety Strategy (Presentation)
(3) 11
Director of Personnel and Organisational Development
Health and Safety Improvement Notices – Verbal report
(3) 12
Corporate Secretary
CQC Provider Compliance Review Notification
79
SECTION 4 – Reports on Committee meetings since 28 July 2010
(4) 13
Clinical Governance Committee (15 November 2010 - verbal)
SECTION 5 – Reports for Information
None
3
SECTION 6 – Regulatory Matters – Report from Corporate
Secretary
(6) 14
Compliance with CQC Conditions
81
SECTION 7 –
(7) 15
Questions from Governors - to respond to written questions from
Governors
(7) 16
Public Questions - to respond to written questions from members of the
public
(7) 17
Use of the Corporate Seal - to note the occasions on which the
Corporate Seal has been used since the last meeting
(7) 18
Date, Time and Venue of next Meeting
The next meeting is scheduled for Wednesday 22 December, at 1:00pm,
in Rooms B2/B3, Education Centre, Basildon Hospital
(7) 19
Any Other Business
Exclusion of the Press and Public: To Resolve
“That representatives of the Press and other Members of the Public be
excluded from the remainder of this meeting, having regard to the confidential
nature of the business to be transacted, publicity on which would be prejudicial
to the Public Interest” (Section 1(2) Public Bodies (Admission to Meetings) Act
1960)
4
BOARD OF DIRECTORS
MEETING: 24th NOVEMBER 2010
REPORT RE WORK OF THE ORGAN DONATION COMMITTEE
BACKGROUND
¾ The main findings of the Organ Donation Taskforce were around the widening gap
between the need for organs and their supply, and how the UK rates of donation
are seen to be amongst the lowest of any developed nation.
¾ August 2008 - the then Secretary of State determined that Chief Executives and
Medical Directors are to be accountable to their Boards for “donation performance”.
Progress has to be reported periodically to Executive Boards.
¾ National roll out programme with the formation of Donation Committees and the
prescribed aim of “making donation usual, NOT unusual”; linked to a
countrywide target to increase the level of donations by 50% within a 5 year period.
¾ Programme required the appointment of Hospital-based Clinical Leads (“CLODs”);
working in association with local Lay Chairmen (“DCCs”)
¾ Programme is resourced via NHS Blood and Transplant (“NHSBT”) with additional
funds paid to Hospitals, including money for Committee expenses and financial
“rewards” for providing organs for donation.
¾ Programme provides for the appointment of additional Donor Transplant
Coordinators (“DTCs” / ”SNODs”) and an expansion of their role, including the
support of more retrieval teams.
¾ National Launch Event was followed by a programme of personal development for
CLODs and DCCs.
¾ Some Hospitals yet to form Committees or to identify a suitable Lay Chairman.
¾ The ”Six Big Wins” to focus on are:
o increased rates of consent/ authorisation,
o increased diagnosis of brain-stem death,
o increased donation after cardiac death,
o increased rates of donation in Emergency Medicine,
o increased rates of referral,
o increased quality & quantity of organs through improved donor management.
BTUH
¾ Appointments
o Summer 2009 - Dr Amin Darwish appointed as CLOD
o February 2010 - Neville A. Brown JP nominated as DCC
o By late Spring 2011 - our DTC Hannah Perry will have been trained by NHS BT
and will be resident in the hospital
¾ BTUH OD Committee met in March, May and September 2010
¾ The presentation by Dr Darwish will :
o help explain aspects of the “Six Big Wins”
o outline the main local challenges connected with this programme
o report progress with “engagement” of a range of colleagues across BTUH
o provide some relevant statistics
o outline what may feature in the BTUH Organ Donor Annual Plan
(to be discussed at our next Committee meeting in December 2010; date tbc)
NAB/AD 101117
5
This page is left blank intentionally
6
BOARD OF DIRECTORS
MINUTES OF THE MEETING
HELD ON WEDNESDAY 27th OCTOBER 2010
PART 1
Present:Non Executive
Directors:
Executive
Directors:
Mr M Large
Mrs J Gibson
Mr R Holmes
Mr J Kent
Mr T Parks
Mr P Sheldrake
Ms H Sturgess
Chairman
Mr A Whittle
Mrs J Galpin
Mr M Magrath
Dr S Morgan
Mrs D Sarkar
Mr A Ray
Chief Executive
Director of Estates and Facilities
Director of Operations and Service Development
Medical Director
Director of Nursing
Acting Director of Finance (non-voting member)
Mrs S Lawton
Ms A Saville
Mrs R Taylor
Mrs P Trinnaman
Mr A Wyatt
Mr G Mummery
Sharna
Mrs N Laver
Mr J Austin
(for Mr N Taylor)
Corporate Secretary
(for Mr A Sewell-Jones)
Associate Director – Communications
Board Secretary
Staff
Staff
Communications
Evening Echo
In Attendance:
Governors in
Attendance:
Neville J Brown JP
Ms B Hallows
Mr D Sydney
Mr T Hubbard
116/10 APOLOGIES
Apologies for absence were received from Mr A Sewell-Jones (Programme Director
and Director of Continuous Improvement), Mr N Taylor (Director of Personnel and
Organisational Development) and Mr P Wardle (Non Executive Director).
117/10 MINUTES
The minutes of the Part 1 meeting held on 29th September 2010 were approved as a
correct record and signed by the Chairman subject to the amendment of Minute
106/10 to amend the title to read: “Report of the Acting Director of Finance”.
118/10 MATTERS ARISING
7
The Board satisfied itself that all necessary action had been taken in relation to the
action log appended to the minutes.
119/10 EVALUATION OF THE MEETING HELD ON 29th SEPTEMBER 2010
The Board noted the detail of the evaluation of the Board of Directors Meeting held
on 29th September 2010.
120/10 PERFORMANCE REPORT FOR SEPTEMBER 2010
The Board considered the performance report for September 2010 against the key
themes of Patient Safety, Patient Experience, Efficiency and Effectiveness and Look
and Feel. During discussion the following points were noted:•
The Trust’s rebased 12 month rolling average HSMR had been recorded at
98.3. The Trust’s performance for the first quarter was recorded at 88.
•
The Board was advised by the Director of Nursing that the Trust had now
established a group whose main focus was to consider further, the Trust’s
patient fall performance with a view to improving it going forward and a robust
action plan had been developed
•
The Trust had now introduced measures to improve compliance with achieving
the MRSA Emergency Admissions Screening performance.
•
All waiting time standards had been achieved within the month with the
exception of the 62 day cancer screening to treatment target where the Trust
had recorded 2.5 breaches against a total volume of 9 patients during Q2. The
pathways of the 3 patients that breached 62 days had been reported to the
Finance and Performance Committee and related to patient initiated delays in
diagnoses and complex care pathways.
•
The Trust’s performance in relation to the access standard for A&E had seen
the Trust recorded as 4th best performer in the Country.
•
Feedback from the Patient Tracker system and the continued high performance
against the question “would you recommend this hospital?”, recording 96%
satisfaction against this question.
•
The Board was advised of the Trust’s performance in relation to DSSA breaches
and noted that the Trust supplied monthly reports to the Primary Care Trust. It
was considered useful for this detail to be included in the Performance Report
going forward.
Action 1: Directorof Operations and Service Development
•
The Trust recorded a net Income and Expenditure position of a £0.2m deficit in
September with a £0.6m deficit for the year to date. The full year forecast had
deteriorated to reflect a £1m deficit at year end.
•
The Trust delivered £5.9m of cost improvements, against a plan of £7.1m. A
financial recovery plan has been instigated and discussed in detail at both the
Finance and Performance Committee and Board of Clinical Directors. The
Board noted the success in the control of pay budgets related to a decrease in
the use of Agency staff, with a subsequent increase in the use of Bank staff.
8
•
The Finance and Performance Committee had received a presentation from the
Management team of the Essex Cardiothoracic Centre in relation to its
proposals to return to planned activity levels for the remainder of the financial
year.
121/10 REPORT OF THE PROGRAMME MANAGEMENT OFFICE AND KPI SCHEDULE
The Board considered the report of the Programme Director and Director of
Continuous Improvement which presented an update on the progress and
achievements of the projects overseen by the Programme Management Office since
the last meeting. The Board noted the summary key issues which included:
•
The PMO was currently overseeing 30 projects.
•
There were 2 projects in the pipeline.
•
Of the 1,165 milestones (or actions) that were due for completion since the start
of the programme, 26 were outstanding (2%).
•
At the current time there were 42 key performance indicators (KPIs) being
monitored by the Programme Board and of these, 18 or 43% were not being
fully met.
•
One project (A&E Improvement) was currently temporarily suspended from the
programme pending major revision to the projects and was therefore not
currently being measured.
122/10 ITEMS CONSIDERED BY THE BOARD OF CLINICAL DIRECTORS
The Board noted the report of the Chief Executive which presented the list of items
considered by the Board of Clinical Directors since the last Board of Directors
meeting. The Chief Executive advised the Board that the Trust’s A&E performance
reflected the success of the Trust in managing its bed capacity. The Board of
Clinical Directors had also recently considered the financial recovery plan.
123/10 REPORT OF THE CHIEF EXECUTIVE
The Board received a verbal report from the Chief Executive which advised on the
following matters:
Primary Care Trust Turnaround Plan
NHS South West Essex Board was due to consider version two of the Primary Care
Trust turnaround plan at its meeting today. The Primary Care Trust plan was, so far,
broadly on target and it was recognised that the plan would reduce this
organisation’s income. Whilst it was noted that the programmes of work proposed
by the Primary Care Trust had received a degree of support from this Trust, the pace
of change within the plan remained a challenge for all those involved.
The Trust continued to meet with the Primary Care Trust. Following a question from
Mr T Parks, the Board was advised that the Trust had responded robustly to Primary
Care Trust proposals to delay the treatment of patients. It was however recognised
that the focus of the Primary Care Trust’s delay in treatment did not relate to patients
requiring urgent treatment but related to a planned slow down in elective activity.
The Trust had however, reminded the Primary Care Trust that contractual terms
were in place covering activity and waiting times.
9
Hospital Open Day
The Chief Executive advised the Board of the recent successful Open Day, where
the Trust had welcomed approximately 800 members of the public. There had been
good media coverage of the day.
HSMR
The Board was advised that Dr Foster was due to publish its Good Hospital Guide,
although the Trust had not received early sight of the detail to be published in the
guide.
Healthcare Financial Management Association
The Board was pleased to note the Trust had two short listed entries for awards from
the Healthcare Financial Management Association. Mr A Ray had been nominated
for Deputy Director of Finance of the year and his team’s work in improving efficiency
and establishing ward based metrics had seen their nomination for an award also.
124/10 REPORT OF THE CHAIRMAN
The Board received a verbal report from the Trust Chairman which advised on the
following matters:
Trust Open Day
The Chairman echoed the sentiments of the Chief Executive in that the recent Trust
Open Day had been a tremendous success. The turnout had been good with a
number of visitors remarking that they had been impressed with the quality of the
facilities and services provided by the Trust.
Appointments
The Chairman advised the Board of the recent appointment of Hannah Coffey as
Director of Operations, who was due to start her employment with the Trust in the
New Year. The Board was also pleased to note the appointment of Mrs Diane
Sarkar to the substantive position of Director of Nursing. The Board of Governors
was in the process of considering appointments to the positions of Trust Chairman
and 3 Non Executive Directors.
East of England Innovations Council
The Chairman advised the Board of the Trust’s intention to pursue and maintain its
good performance in relation to awards for innovation from the East of England
Innovations Council.
125/10 REPORTS ON COMMITTEE MEETINGS SINCE 29th SEPTEMBER 2010
Clinical Governance Committee
The Board received a verbal update from the Chair of the Clinical Governance
Committee advising of the matters which had been considered at the Clinical
Governance Committee Meeting held on 11th October 2010. The Committee
continued to monitor the Trust’s ongoing performance in the lead up to the NHSLA
Risk Management Standard assessments which were scheduled for General and
Maternity Services.
10
The Committee had also considered in detail, revisions to Trust processes in relation
to the management of complaints and the investigation process related to serious
incidents. The Committee had discussed in detail the new quality strategy which
was due to be published imminently. The Committee had also trialled patient stories.
The Committee had also received a quarterly report on Corporate Clinical Audit.
Finance and Performance Committee
The Board received a verbal report from the Chair of the Finance and Performance
Committee in relation to those matters considered at the Finance and Performance
Committee Meeting held on 25th October 2010. The Committee had considered in
detail the six monthly results for financial performance and had discussed and
agreed the Monitor Q2 return on behalf of the Board. The recent Care Quality
Commission visit had also been discussed.
The Committee had also received reports from the management teams of the Essex
Cardiothoracic Centre and Obstetrics and Gynaecology Directorate in relation to
their service line reporting performance for the year to date and going forward. The
Board was reminded that the maternity direct initiative had been extremely popular
following its introduction earlier in the year with over 1000 contacts for the year to
date.
126/10 REGULATORY MATTERS
The Board noted the report of the Corporate Secretary which informed the Board on
progress with the action plans developed to ensure compliance with the conditions to
the Trust’s registration with the Care Quality Commission.
Contact with Regulators
The Board noted the report of the Corporate Secretary which provided a summary of
contacts with Regulators and external agencies between 29th September 2010 and
20th October 2010.
127/10 QUESTIONS FROM GOVERNORS
There were no questions from Governors.
128/10 PUBLIC QUESTIONS
There were no public questions.
129/10 USE OF THE CORPORATE SEAL
It was noted that the Corporate Seal had not been used since the last
meeting.
130/10 DATE, TIME AND VENUE OF NEXT MEETING
The Board was advised that the next Part 1 meeting was scheduled for
Wednesday 24th November at the earlier time of 1:30 pm in Rooms B2/3,
Education Centre, Basildon Hospital.
131/10 ANY OTHER BUSINESS
There were no other items of business.
11
Signed …………………………………………………
(Chairman)
Date………………………..……………………………
12
BOARD OF DIRECTORS (PART 1) MEETING 2010
ACTION LOG - PUBLIC
Minute Ref
and subject
Action
No
Action required
Action
Owner
Date
raised
Date Due and
Report to
Action Status/ Progress
Outcome/ Impact for patients
(date action
Agreed)
120/10
Performance
Report
1
Include DSSA breach information in
monthly performance report to the Board
27
Director of
October
Operations
2010
and Service
Development
24 November
2010 BoD
13
14
Evaluation of Board of Directors’ meeting held on 27 October 2010
27-Oct-10
ORGANISATION
The meeting agenda was
effectively organised.
4.6
You had sufficient time in advance
of the meeting to review Board
materials.
4.6
Background material provided
was adequate to make informed
decisions.
4.4
The source of data was known
and was complete and accurate.
4.5
AGENDA
The meeting discussions were
valuable and focused.
AVERAGE SCORE
The meeting agenda included
relevant topics and focused on
key priorities.
The impact on quality was given
appropriate consideration in the
making of decisions.
4.3
4.5
4.6
PARTICIPATION
Robust discussion and debate of
proposals took place prior to
decisions being made.
Board members are encouraged
to and feel free to participate in
the meeting.
4.4
4.7
Your time was well spent
participating in this meeting.
4.7
Board members clearly
understand the aims of the Trust
and role of the Board.
4.6
CHAIRMANSHIP
The chairman ensured that
actions were assigned and
executive directors were held to
account for delivery.
The extent of the chairman’s own
contribution allowed executive
directors were held to account for
their own areas of responsibility.
4.8
4.8
15
Evaluation of Board of Directors’ meeting held on 27 October 2010
Much better time management, especially on Performance
Report. Good Agenda, which benefitted from being lighter
than more recent meetings. Excellent input and challenge
from the deputy directors
Good succinct
Well paced. Good debate
High use of abbreviations/ acronyms which are not explained
Presentation of the Performance report was improved
It was a relatively light agenda. I don’t know whether this
contributed to the relatively low attendance from Governors.
Comments Overall evaluation of
the meeting
Focused discussion and debate. Short agenda this month
I thought that the Performance Report seemed to have been
developed so it was clearer and discussion focused on key
changes –good or bad with explanation/clarification if
required. I have felt in the past that it was a bit like an account
and this ‘exception reporting‘ with questions is so much
better. I did not get a handle on the verbal report for clinical
governance-possibly it was me? Verbal reports still need to
be clear and factual. The Chairman usually makes a short
statement/point after these so that helps but not on that one. I
tend to watch and listen as there is not time to read all the
papers and left with most of my questions answered and an
overall confident and positive feel good factor-thanks.
The venue was changed and no ‘alert’ was sent to inform
governors
Comments Suggestions for future
meetings
Other Comments
Agree that timing changes are sensible. We still need to look
at acoustics / PA system
Large and important documents requiring a decision should
not be tabled
Discussion on Quality Strategy and Serious Incidents would
have been better with papers in advance of the meeting
16
Performance Report
October 2010
Board of Directors
November 2010
17
Section A: Performance Dashboard – October 2010
Patient Safety
Previous
month
RAG
Hospital Standardised Mortality Ratio (HSMR)
Hospital Acquired MRSA bacteraemia Hospital Acquired Clostridium difficile episodes Hospital acquired pressure ulcers
Patient falls
98.3
2
23
6
832
12 mth
YTD
YTD
In mth
YTD
Efficiency and Effectiveness
RAG
Monitor Financial Risk Rating
Cost Improvement Plan surplus/(deficit)
% of relevant staff with documented appraisals
Vacancy factor
Sickness absence
YTD
YTD
12 mth
In mth %
In mth %
99.9
2
20
11
683
Previous
month
3
3
(£1,589k) (£1,040k)
73
71 8.2
9.25 3.06
2.98 Patient Experience
Previous
month
RAG
< 18 wks referral to treatment (admitted)
< 18 wks referral to treatment (non‐admitted) A&E 4hr to admission or discharge All cancer targets being met
Overall satisfaction score (Patient Tracker) In mth %
In mth %
In mth %
In mth
In mth %
91.4
96.5
99.1
5 of 7
88
90.5 96.5 98.0 6 of 7 89 Would you recommend this hospital? (Patient Tracker)
In mth %
96
97 Look and Feel
Previous
month
RAG
Cleaning scores ‐ Very High Risk Areas
Cleaning scores ‐ High Risk Areas
Statutory maintenance completed
Water systems maintenance completed
Planned preventative maintenance completed
In mth %
In mth %
In mth %
In mth %
In mth %
98
96
90
95
93
18
98 97 89
96 80 Section B: Executive Summary
Patient Safety
Measures to improve Patient Safety in 2010/11 will continue to include the effectiveness of actions to reduce Inpatient Falls, Medication Incidents and Pressure Ulcers. An observational audit to assess compliance with the World Health Organisation (WHO) Surgical Checklist has been planned for the fourth quarter of the year.
National Patient Safety Week occurs from 15‐21 November 2010. The Trust has registered to participate in this event, many of the arrangements will be similar to last year, along with accompanied Executive walkabouts, the Patient Safety Team will man a patient safety awareness stand within the hospital main reception featuring changing topic throughout the week. This report has provided an update on Serious Incidents (SIs).
Only 53% of emergency patients were screened for MRSA in September, which is down from September (60%) and August (69%). The Director of Nursing has requested action plans from all Directorates. A verbal update will be provided at the Board.
Patient Experience
The number of complaints has increased slightly with 41 received in October (39 in September). There are no identifiable trends developing, however “every aspect of medical care/treatment” continues to be the primary theme, with a high number this month (9) being received in the Accident and Emergency Department (the same number was received last month).
Directorates are looking at strategies to provide local analysis of these figures.
The overall Patient Tracker satisfaction score was 88%. The number of responses again exceeded the monthly target (3,500) with 3,721 in October, a slight decrease on September (3,886).
The number of formal plaudits (acknowledged by the Chief Executive) significantly increased with 32 received in October (17 in September). The collated number of plaudits, which includes those received via the “Get It Right” comment cards, PALS contacts, NHS Choices and written expressions of appreciation directly to the wards, increased to 152 (145 reported in September). The A&E and 18 week targets were achieved in October. However, the 62 day cancer screening to treatment target and 2 week wait target were not achieved in the month – Section D provides a full explanation. Achievement of the 18 week admitted target in future months remains at risk due to a high backlog of patients waiting over 18 weeks for admission, as also explained in Section D.
19
Section B: Executive Summary
Efficiency and Effectiveness
The Trust has a £0.7m cumulative net deficit for the seven months to the end of October, with October being break‐
even in the month. The year‐end forecast is maintained at a £1m deficit, but the internal target is still a £1m surplus. The current FRR is 3, as assessed by Monitor. The forecast for the year‐end is a FRR of 3. There is an increased risk to the forecast due to the PCT Turnaround plan, which potentially could increase the deficit. The net deficit would have to be greater than £4.3m to not achieve a FRR of 3.
The Trust has delivered a £6.8m CIP to date against a plan of £8.4m. New schemes have been added to meet the shortfall.
Pay Expenditure continues to be lower than last year, this is a result of successful management action to reduce agency and increase bank usage. October saw a reduction in the use of Medical Agency staffing.
The CTC Directorate activity recovery plan has seen an improvement in income of £0.2m in October.
A Financial Recovery Plan has been instigated to ensure achievement of the financial targets. This plan was presented to and agreed by the Board of Clinical Directors in October. Compliance with appraisals within the Trust has already exceeded target, with 77% of staff being recorded as having had an appraisal as at October.
Sickness absence continues to be at a relatively low rate (3.68% for the 12 months including October). Vacancies have reduced to 8.35% with nursing and midwifery vacancies now being below the Trust‐wide figure."
Look and Feel
Delivery of the capital programme is progressing. During October the first phase of the Accident and Emergency Department and Fracture Clinic project was handed over to the Trust and became operational. The new offices have been occupied by the Orthopaedic Consultants, their secretaries and the A&E management team. The new minors department was opened in October in line with the project programme. A temporary children’s A&E was also opened in space that will eventually become part of the extended minors department. The permanent children’s department will not be completed until towards the end of the project in 2012.
Cleaning scores have been maintained at or above the target level. During October there was one occasion when the cleaning score was reported to be below the Trust trigger point of 96% for very high risk areas and 93% for high risk areas. The Trust achieved its stretch targets of average scores
of 98% and 95% respectively in the month.
Work commenced in October on the refurbishment of the restaurant to support the introduction of a steam cuisine style food service for patients. This work will take place on a phased basis to allow the Trust to continue to serve food in 20
the restaurant during the period of the works. Section C: Patient safety ‐ Mortality
•
The 12 month rolling average for the period September 2009– August 2010 is 97.3
•
The combined HSMR for the period April – August 2010 is 87. •
The in month HSMR for August is 88.7.
•
The HSMR for the original top 5 HRGs are all within expected limits and the Trust HSMR value has been within expected limits for the last 5 quarters (data source: EoE Quality Observatory) 21
Source of data: Dr Foster Intelligence
Section C: Patient safety – Mortality Comparison data
Chart A
•
In April 2010, Dr Foster added additional functionality to the mortality system which enables trusts to “re‐base” their HSMR data. Whilst this is not wholly accurate, it does show estimated performance in relation to other trusts. •
Chart A shows the HSMR trend over recent years up to August 2010 as of 1 November 2010. •
Chart B shows the relative position of the Trust following re‐basing for the first 5 months of the year (blue dot) The grey dots in the funnel represent all other acute trusts.
•
The current HSMR for the period April – August 2010 is 87.
Chart B
22
Data source: Dr Foster Intelligence HSMR Comparison Report as of 01/11/2010
Month
Trust Total Absolute No.
of Deaths
Discharges
% of Trust Absolute Rolling 12 months HSMR 09/10 Trajectory Rolling
Deaths
(Basket of 56)
HSMR (Basket of 56)
Jul-07
110
5500
2.0%
137.2
Aug-07
111
5412
2.1%
136.6
Sep-07
138
5252
2.6%
137.7
Oct-07
131
5723
2.3%
137.1
Nov-07
138
5689
2.4%
135.6
Dec-07
167
5197
3.2%
137.5
Jan-08
168
5605
3.0%
136.4
Feb-08
155
5353
2.9%
136.4
Mar-08
182
5408
3.4%
136.3
Apr-08
142
5881
2.4%
136.8
May-08
163
5717
2.9%
139.1
Jun-08
139
5732
2.4%
141.4
Jul-08
121
6071
2.0%
140.4
Aug-08
110
5525
2.0%
140.1
Sep-08
106
5622
1.9%
139.0
Oct-08
142
5781
2.5%
139.2
Nov-08
139
5568
2.5%
139.3
Dec-08
155
5484
2.8%
136.6
Jan-09
192
5809
3.3%
136.5
Feb-09
145
5563
2.6%
135.0
Mar-09
143
6218
2.3%
133.0
Apr-09
126
5687
2.2%
129.3
May-09
114
5599
2.0%
124.3
Jun-09
140
5885
2.4%
122.5
119
119
The number of actual deaths in hospital continues to decrease. Whilst this could be concluded to coincide with seasonal variation, it should be noted that the period April – September 2010 saw a 4.5% reduction in the number of deaths in hospital when compared to same period in 2009. 119
116
Jul-09
100
6151
1.6%
120.1
Aug-09
100
5338
1.9%
118.6
108
113
Sep-09
142
6006
2.4%
117.5
Oct-09
131
6358
2.1%
114.3
116
120
Nov-09
138
6043
2.3%
110.9
Dec-09
119
5791
2.1%
107.8
115
117
Jan-10
173
5466
3.2%
105.6
Feb-10
136
5400
2.5%
102.5
Mar-10
Apr-10
134
139
6411
5780
2.1%
2.4%
115
Source of Data:
100
Dr Foster
106
HSMR monthly trend (August 2009 – August 2010)
97.7
104.3
103
May-10
108
6026
1.8%
103.4
Jun-10
103
6157
1.7%
99.9
99
105
Jul-10
101
6176
1.6%
98.3
Aug-10
113
5927
1.9%
97.4
101
98
Sep-10
125
6065
2.1%
Trust Actual Deaths*:
AQUIP/MD_DEATHS_1
Discharges: Ardentia/md_spells_drfoster
23
Section C: Patient safety ‐ Infection control
In October there were 6 cases of hospital acquired C. Diff. Year to date, the Trust has had 29 cases against a ceiling of 42. Cumulative C‐Diff
Performance
Trajectory
2009/10 Cumulative
C‐Diff
A p r ‐1 0
M a y ‐1 0
Ju n ‐1 0
J u l‐ 1 0
A u g ‐1 0
S ep ‐1 0
O c t‐ 1 0
N o v ‐1 0
D ec ‐1 0
Ja n ‐1 1
F eb ‐1 1
M a r ‐1 1
Incentive trajectory
MRSA Bacteraemia
5
4
Cumulative MRSA
Bacteraemia
3
2
Performance
Trajectory
1
A p r ‐1 0
M ay ‐1 0
J u n ‐1 0
J u l ‐1 0
A u g ‐1 0
S e p ‐1 0
O c t ‐1 0
N o v ‐1 0
D e c ‐1 0
J a n ‐1 1
F e b ‐1 1
M a r ‐1 1
‐
Data source for HCAI: Laboratory results.
2009/10 Cumulative
MRSA Bacteraemia
The performance ceiling trajectory for MRSA bacteraemia for 2010/11 is 4 hospital acquired cases per year, equating to one per quarter. In October there were no new cases, the total for the year to date therefore remains at 2. Hand Hygiene scores , as observed by patients, achieved 90%. The ambition is to achieve the levels of compliance realised at the end of the 2009/10. The Trust also monitors compliance with hand hygiene standards through the Saving Lives audits, which for September, indicates an overall compliance of 98%. MRSA screening of emergency patients continues within A&E and the admission units. Only 53% of emergency patients were screened for MRSA in October, which is down from September (60%) and August (69%). The Director of Nursing has requested action plans from all Directorates by 24 November 2010.
100%
95%
2009/10
90%
2010/11
Standard
85%
80%
75%
Apr
M ay
Ju n
Ju l
Aug
Sep
O ct
Nov
D ec
Ja n
Feb
M ar
90
80
70
60
50
40
30
20
10
‐
Hand Hygiene
(data source: Dr Foster Intelligence PET 3.0)
MRSA Emergency Admission Screening
100%
90%
80%
70%
60%
50%
M RSA Emergency
Admission Screening
Performance
Improvement Trajectory
A p r ‐1 0
M a y ‐1 0
Ju n ‐1 0
Ju l‐1 0
A u g ‐1 0
S e p ‐1 0
O c t‐1 0
N o v ‐1 0
D e c ‐1 0
Clostridium Difficile
24
MRSA screening for elective admissions has been a national requirement since April 2009 with the aim of reducing the burden of MRSA in the community. Whilst this Trust has been compliant with this requirement, the system for screening has recently changed to ensure full capture of all day case patients. The information is Source of data: Laboratory results
reported monthly to the PCT and is monitored through the quality contract monitoring meetings.
Section C: Patient safety – Patient Falls
Inpatient Falls
(data source: Incident Reporting on Ulysses Safeguard System)
1,800
1,600
1,400
1,200
1,000
800
600
400
200
‐
Cummulative Inpatient Falls
Performance Improvement
Trajectory
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
2009/10 Cumulative Patient falls
The Falls Group categorise falls into three areas:
•
Mobility
•
Clinical
•
Slips and Trips
There was a reduction in the number of falls with 139 inpatient falls reported in October, affecting 110 patients. (149 falls in September affecting 114 patients). There was a small rise in the number of “mobility” falls (41 in October, 37 in September and 37 in August). Clinical falls were slightly reduced with 7 in October (8 in September). Slips and Trips have fallen significantly with 91 in October (104 in September). Many of the falls were not witnessed by staff..
The number of falls for the year to date (April‐October) was 971 which is 9.4% above the trajectory of 880. The majority of incidents relate to patients who experience a first fall and then no other. Even with robust assessment, it is not always possible to predict these events. The Lead of the Falls Group has developed an action plan and this will be discussed during the November meeting. Some of
the actions include identifying the cause of the unwitnessed falls. Monitoring the detail of patient falls (see chart below) will help focus on the appropriate actions to reduce 2nd and 3rd falls. There was no RIDDOR reportable falls in October. Patient Falls
No. of Patients reported to have 1, 2 and 3+ falls
100
120
80
100
1 Fall
80
Clinical
60
Mobility
40
Slips & Trips
20
60
2 Falls
40
3+ Falls
20
Oct‐1 0
Se p‐1 0
Aug‐1 0
Jul‐1 0
Jun‐1 0
May‐1 0
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
‐
Apr‐1 0
0
25
Section C: Patient safety – Medication Incidents
Medication Incidents
(data source: Ulysses Safeguard @ 12/11/10)
30
Administration
25
20
Dispensing
15
10
Prescribing
5
0
Apr‐10 May‐
10
Jun‐10 Jul ‐10
Aug‐
10
Sep‐10 Oct‐10
Medication Incidents
(data source: Incident Reporting on Ullysses Safeguard System)
60
50
40
30
20
10
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
Oct‐09
Sep‐09
Aug‐09
Jul‐09
Jun‐09
May‐09
2010/11
Apr‐09
‐
•The use of an adapted medication matrix is being considered for medical staff. Nursing and Midwifery staff continue to follow the medication matrix should a medication incident occur.
• Current performance indicates a 35% reduction in medication incidents compared to the same period (April – October) in 2009/10. September
October
Clinical Sciences
0
0
CTC
1
2
Medicine and Emergency Care
7
12
Outpatients
0
0
Surgical Services
5
4
Women & Children’s
5
6
The Safe Handling of Medicines Policy will be reviewed and lessons learnt from previous incidents will be reflected in changes in practice within the updated policy.
The frequency of checking Controlled Drug stock levels will be reviewed and new guidance issues.
Due to be completed by end of October 2010
The NRLS report for the period October 2009 to March 2010. Presented at the Clinical Governance Management Group (CGMG) in October and an overview provided to the Quality Contract Meeting with NHS South West Essex. The Directorates continue to produce action plans to reduce incidents and improve learning.
Ongoing and reported monthly to the CGMG
2009/10
There was an increase in the number of medication incidents reported during October (24) compared to September (18). Whilst there was a downward trend in the number of dispensing incidents with 6 in October (3 in September), the data shows an upward trend in administration incidents. The breakdown of medication incidents by directorate for October, compared to 26
September, is shown in the table to the left. Medicine and Emergency Care reported 12 incidents in October compared to 7 in September.
Section C: Patient Safety ‐ Serious Incidents (SIs)
There are currently 4 SIs still under investigation. 4 of the incidents reported are now also being reviewed by the Coroner and Legal Department relating to potential claims.
T OT AL R E P OR T E D S E R IOU S IN C ID E N T S
(Jan u ary to Octo b er 2010)
REPORTED SERIOUS INCIDENTS BY CATEGORY
January - October 2010
12
withdrawn
3
10
2
8
1
Feb-10
M ar-10
A pr-10
M ay -10
M onthly Total
Jun-10
Jul-10
A ug-10
S ep-10
O c t-10
Cum m ulative Total
LD
PACS Failure
Power Outage
Theatre Flood
Retinal Screening
Jan-10
Student Nurse Allegation
0
Maternity
Legionella
2
Gynae
0
4
Never Event
6
THEMES AND TRENDS
REPORTED SERIOUS INCIDENTS BY DIRECTORATE
7
5
6
4
5
4
3
3
2
2
1
1
0
0
Women & Childrens
Clinical Sciences
Surgical Specialties
Medicine and
Emergency Care
Cardiothoracic
Centre
Estates and
Facilities
Clinical Care Delivery
Issues
Impacts on Service
Delivery
Never Events
27
Trust Reputation
Section C: Patient safety – Principles of Care (data source: Audit data compiled by the Clinical Effectiveness Unit)
Principles of Care Audit
(6 Essential Standards ‐ CQC Conditions) 100%
95%
90%
85%
Principles of Care Audit - Trust Totals
O c t ‐1 0
S e p ‐1 0
A u g ‐1 0
J u l ‐1 0
J u n ‐1 0
M a y ‐1 0
A p r ‐1 0
M a r ‐1 0
F e b ‐1 0
J a n ‐1 0
D e c ‐0 9
80%
• A random sample of 10 healthcare records were audited during October 2010.
• To ensure that questions are relevant to appropriate areas, the audit tool was reviewed and refined in relation to the Medical Admissions Unit (MAU) resulting in 9 of the standards assessed as not appropriate to the clinical area. Since the establishment of monthly auditing, the target for each of the standards has been reviewed and 6 standards have been identified as being essential to meet the needs of all patients and to ensure the welfare and safety of the patient. The target will remain at 90%. For the remaining standards, a trajectory has been set in order to achieve the 90% target across all standards by November 2010.
• In October the overall average (of all standards) was 92% (93% in August). The improvement trajectory target of 89% was exceeded, with 14 individual standards achieving against their target (between 92%‐99%). For the 6 essential standards, the average performance for October was 96% against the 90% trajectory
• There are 14 standards where performance has reduced this month but the majority by only 1 or 2 percent and there are a further 13 standards showing an improvement or are maintaining a consistent performance.
Performance Improvement Trajectory
Principles of Care Audit
Principles of Care Audit (All Standards)
(Monthly Result by Directorate)
(Total average for all standards) 100%
100%
95%
95%
90%
90%
O c t ‐1 0
S e p ‐1 0
A u g ‐1 0
J u l ‐1 0
80%
J u n ‐1 0
80%
M a y ‐1 0
85%
A p r ‐1 0
85%
Cardiothoracic Centre Medicine & Emergency
Care
Oct-10
Total average for all standards
Surgical Specialties
Women & Children's
28
Source of data: Internal Systems
Section C: Patient safety – Pressure Ulcers Pressure Ulcer Incidents per 1000 Occupied Bed Days
Pressure Ulcers
(data source: Tissue Viability Team & Incident Reports)
Grade 2
1.6
1.4
Grade 3
70
1.2
60
Grade 4
50
1
Incidence
0.8
40
Total
30
20
Target
0.6
0.4
10
Patients
0.2
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
M ar-10
0
Feb-10
Community
Acquired
Jan-10
O c t‐1 0
S ep ‐1 0
A u g‐1 0
Ju l‐1 0
Ju n ‐1 0
M ay ‐1 0
A p r ‐1 0
M ar ‐1 0
F eb ‐1 0
Jan ‐1 0
D ec ‐0 9
‐
The graph (above left) shows the pressure ulcer rates from December 2009. There were 6 hospital acquired pressure ulcers reported in October 2010 (6 in September). The number of patients affected was 6. Performance continues to surpass trajectory.
There were 51 community acquired pressure ulcers reported in October, affecting 43 patients.
The incidence of pressure ulcers (as shown above right) is calculated as the rate of ulcers per 1000 occupied bed days. As can be seen, there has been a significant reduction from 1.4 per 1000 bed days in January 2010 to 0.31 in October 2010.
The Tissue Viability Group is implementing robust systems to ensure shared learning from Root Cause Analysis (RCAs).
29
Section C: Patient safety – Other
Vulnerable Patients
Safeguarding
The Named Nurse for Safeguarding Adults has commenced her review of the arrangements for the management and investigation of safeguarding adult concerns and learning from the outcome of cases. There is a necessity to revise Trust processes to ensure that Clinical Directorates are able to take full ownership of issues that arise through investigations and serious case reviews. Governance arrangements for responding to and learning from incidents is being reviewed and strengthened through more robust monitoring of progress against action plans. This will be via Clinical Directorate reporting mechanisms to the Clinical Governance Management Group and through the Vulnerable People Working Group.
Learning Disabilities A regional event was held on 15 November 2011 to launch the strategy ‘Learning Disabilities Vision for the East of England 2011‐2021’. The Trust’s Nurse Advisor for Learning Disabilities has been invited to present the Trust’s Resource File as an exemplar of ‘Innovation and good practice in Acute Hospitals” at this event.
A Review of the Trust policy on Caring for people with a Learning Disability, the Specialist Assessment Form (SAF) and the care pathway for people accessing day surgery and dental services. This is was following direct feedback from family carers, Community Learning Disability Teams and following the occurrence of an incident in day surgery. This incident is being managed through the Trust’s Serious Incident Policy. Changes are being made to the policy, SAF form and to the planned care pathway to ensure that sufficient consideration is given to pre‐operative assessment and planning. This will include, where necessary, the option of individual case review by the multidisciplinary team. 2 case reviews have already been carried out, with a third being arranged, at which the team, in discussion with family carers, can plan reasonable adjustments to the care pathway, in particular, those with challenging behaviour. The Trust’s Communication team is working with the Nurse Advisor for LD to develop web based information for patients, carers, staff and the public. It is anticipated that the Learning Disabilities web pages will be launched in the first quarter of 2011. Dementia
A Project initiation Document (PiD) has been completed and submitted to the Project Management Office Board for consideration at the meeting being held on the 18 November 2010, highlighting the standards against which the Trust should be able to evidence compliance. The proposed project brings the national dementia strategy, together with the ‘Who Cares’ carers’ project which remains in pilot form on the Trust’s older people’s wards. The Department of Health Strategy for dementia includes direct reference to 30
supporting family carers and the pilot will require Trust wide roll out once formally evaluated by Leeds University later this year.
Section C: Patient safety – Emergency preparedness
Ensure clear plans are in place to deal with a Flu Pandemic and for business continuity in the event of an unexpected incident or event. Evidenced by successful completion of 2 communication tests and 1 tabletop exercise (or incident) by March 2011.
Hospital Incident Control Room.
As part of the Trust’s new refurbishment of A&E and the fracture clinic, a dedicated Hospital Incident Control Room has been established. The control room is equipped with up to date technology and can be set up within a short period of time following notification of an incident. The control room will go live early in November. A number of training exercises and scenarios are planned to allow staff and managers to become familiar with the control room environment. Major Incident Plan
To coincide with the launch of the new control room a review of the Trust’s major incident plan and staff action cards is being undertaken. Influenza Pandemic Plan
The Department of Health has recommended that Health Trusts review their influenza pandemic plans ahead of the publication of the National Framework. The Framework was due out in September but has been delayed. Influenza pandemic plans will now be more generic and expanded to include infectious diseases, surge management, increasing capacity in ITU and dealing with paediatric critical care. Planning for the Unexpected
The Trust’s Open Day on Saturday 16th October included details of ‘Planning for the Unexpected’. It provided information to members of the public on how the Trust prepares for an emergency or major incident, but also provided information on how to prepare themselves and their family in case an emergency occurred within the community. Advice included:
•
Preparing an Emergency Supply Kit
•
Preparing your home
•
What to do in an Emergency 31
Section D: Patient experience – Background and context
•
•
•
•
Measuring patient experience is challenging in that there is no single metric which will provide robust information on all aspects of patient experience.
As can be seen from the reports in the following pages, this Trust measures a suite of metrics designed to provide assurance in a number of areas which patients have indicated are important to them. The metrics chosen are centred on a number of themes:
– Access to services, including waiting times for cancer and performance against the NHS Constitutional right not to wait longer than 18 weeks to treatment. – Performance against the A&E standard of discharge, transfer or admission within 4 hours of arrival
– Privacy and Dignity through compliance with Delivering Single Sex Accommodation standards. – Results of National Patient Surveys with their associated actions. – Content and volume of complaints. – Content and volume of PALS contacts.
– Patient Feedback from comments cards, NHS Choices website postings, plaudits and the results from the Dr Foster Patient Experience Tracker. To provide evidence of the aspiration to improve the patient experience score year on year, the Trust strives to achieve the following:
No avoidable breaches of the cancer waiting time standards. No avoidable breaches of the 18 week referral to treatment standard. 98% of patients seen and discharged from A&E within 4 hours of arrival. No non clinically justified breaches of the single sex accommodation standard.
70% of complaints responded to within the timeframe agreed with the complainant
Over 90% of PALS contacts resolved within 5 working days
Over 90% overall satisfaction with the care provided in hospital, with 95% or more of patients stating that they would recommend this hospital to others. 32
Section D: Patient experience ‐ Cancer •
October results are provisional and awaiting ratification.
•
5 of 7 cancer targets were met in the month (there is no threshold for the 8th).
•
The 62 day screening was not achieved in October (0.5 breach from 1.5 treatments). The patient that breached 62 days waited 20 days for his first appointment due to a holiday. The patient was referred to a tertiary centre on day 37 of the 62 day pathway and treated at the tertiary centre on day 75.
•
The 2 week referral target was not achieved in October, but is expected to be achieved in Q3. There were 414 patients seen in October following a 2 week referral, and of these 32 chose to wait longer than the offered appointment within 2 weeks. 11 of the 32 were offered appointments that were not at their local hospital and this contributed to patients’
decisions to wait longer than necessary. From the end of October, all patients have been offered appointments at their local hospital.
•
Source of all data: National Cancer Waiting Times Database.
33
Section D: Patient experience ‐ 18 week access
The October admitted position for the Trust is provisionally
91.4%, which is above the 90% threshold. The non admitted
position is provisionally 96.5%, above the 95% threshold.
Following the cancellation of operations in August and
September due to electrical problems, the backlog of patients
waiting over 18 weeks increased and has now plateued at
about 230. Future deliver of the 18 week admitted target is
therefore at risk, as the backlog of patients waiting over 18
weeks has increased from the typical position of 120.
Source of all data: Patient Administration System
Patients awaiting admission for treatment
Waiting time from referral (weeks)
>18
17‐18
16‐17
08/08/2010
115
22
23
15/08/2010
115
26
27
22/08/2010
135
29
34
29/08/2010
149
30
37
05/09/2010
152
26
32
12/09/2010
162
35
43
19/09/2010
188
41
52
26/09/2010
197
48
28
03/10/2010
217
28
36
10/10/2010
221
41
36
17/10/2010
223
31
32
24/10/2010
224
29
41
31/10/2010
233
40
28
14‐16
70
78
98
111
126
112
113
107
80
103
103
90
71
34
Section D: Patient experience – A&E
•
Performance in October increased to 99.15% within 4 hours. Use of escalation beds increased slightly in October to 5.4, compared to 3.7 per day in September.
•
The revision to the NHS Operating Framework reduced the threshold for this target to 95%. Monitor’s Compliance Framework has been amended to require performance below 95% to be reported. The contract with PCTs still requires 98% performance.
–
Source of data: Ascribe Symphony A&E System
35
Section D: Patient experience – CQUIN indicators
Annual Target
90
Q2 Target
90%
50%
TBA
TBA
Not yet available
Not yet available
Reduction in Length of Stay as measured by Dr Foster
95
100
Increase in same day admission for elective surgery
95%
N/A
Measure at M12
94.75%
Increase % of smokers at pre‐operative assessment offered to stop smoking services
Increase % of women provided with 1:1 care during labour
75%
50%
98%
85%
Measure at M12
Reported at Q2
Reported at Q2
98%
Increase home birth rates
2.00
1.80
1.75
1.34%
Reduce transfer rate from midwife led unit to obstetric ward
30%
37%
40%
22.80%
Implement direct access midwifery care
TBA
TBA
Implemented
Increase % of low risk patients receiving brain imaging to include MRI or carotid scans within 7 days of referral
95%
50%
Not reported
44%
12%
7%
6%
22
24
Reported at Q2
23
Reduction in Hospital Standardised Mortality Ratio
% of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool
Inpatient survey results ‐ Improvement in responsiveness to personal needs. The indicator will be a composite, calculated from 5 survey questions.
90
Financial impact
PCT audit
98%
£32,000
88%
£42,500
Increase % patients receiving thrombolysis within 3 hours of onset
Reduce average length of stay in Stroke Unit
Q1 Q2 performance performance
88
Not yet available
29%
62.40%
24
The VTE target for Q2 of 50% was achieved with 62.4% of adult inpatients being VTE risk assessed on admission.
Validation is currently taking place regarding the % of deliveries recorded as home birth rates. Although performance will increase it is likely to remain under the target for Q2. Lead midwives have been designated to support women in choosing a home birth.
There was a significant reduction in the transfer rate from the midwife led unit to the obstetric ward, with Q2 performance lower than the target for the year.
There was a significant improvement in the % of low risk patients receiving brain imaging within 7 days of referral as a result of implementing a 5 day dedicated imaging clinic for stroke patients.
36
Section D: Patient experience – Privacy and Dignity
Delivering Single Sex Accommodation (DSSA)
The national standards in relation to DSSA are that: Patients should not share sleeping, toileting or washing facilities with members of the opposite sex. Patients of one sex should not have to walk through accommodation used by the other sex when not fully clothed. In order to test compliance with this, from 1 August 2010 the PCT require (through the contract) the Trust to undertake a Root Cause Analysis for any breach. The following breaches have been reported with a total loss of income YTD to the Trust of £7,334:
Aug‐10
Sep‐10
Oct‐10
Total
No of breaches reported Lost income
5
£6,115
1
£1,220
1
Awaiting coding
7
£7,334
37
Section D: Patient experience – Complaints
Complaints Received Monthly Comparison
2008/09, 2009/10 & 2010/11
60
50
40
30
20
10
-
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2008/09
27
18
19
26
21
19
19
24
17
25
19
34
2009/10
26
36
40
23
15
29
31
32
35
33
53
49
2010/11
38
33
35
44
43
39
41
The downward trend experienced during July and August 2009/10 was in contrast to a significant rise during the same months in 2010/11. This has now consolidated to a consistent increase at up to 20% on the previous year. There were no red rated complaints in October. There were 6 amber rated complaints, of which 3 related to medical care/treatment, 2 to medical judgement/diagnosis and 1 to nursing care/treatment. In each case, collaboration with the Patient Safety Team identified whether the investigation should be managed via the complaints or the Trust’s incident procedures, in line with Trust policy. These complaints are currently under investigation and will be RAG rated on completion.
• There were 41 complaints received in October 2010 (39 in September). The primary themes were:‐
– Every aspect of medical care/treatment 20 (48.78%). The three contributing themes being:‐
• Medical care & treatment 10 (24.39%)
• Medical judgement & diagnosis 8 (19.51%)
• All aspects of clinical treatment 2 (4.87%)
– Appointment delay/cancellation 4 (9.75%)
– Waiting Times 4 (9.75%)
– Discharge/Follow‐up 3 (7.31%)
– Others (including Attitude, Communication, Nursing care/treatment, Missing Medical Records, Hotel Services) 10 (24.39%)
• General Surgery has experienced a substantial increase in complaints with 9 in October (2 in September). 8 of these related to “Every aspect of medical care/treatment”. This will be brought to the Patient Experience and Complaints Leads (PECL), and Directorate actions will be reported to the Clinical Governance Management Group (CGMG). • General Medicine has experienced an increase with 7 complaints in October (2 in September). A&E remains high at 9 in October (10 in September).
• Complaints relating to Nursing Care/Treatment continue to decrease with 3 in October (6 in August, 4 in September).
38
Section D: Patient experience – Complaints Activity
The charts below represent the number of complaint responses that have been sent out from the Trust in October 2010. 53 complaint responses were sent and of these 20 (38%) were in target. 33 responses (52%) were sent out of target as follows:‐
•
•
•
•
20 due to the final signing process
7 to quality or timing of reports from Directorates
5 due to delays in Patient Experience Team (PET)
1 due to unavailable medical records.
There are actions in place to:‐
• Improve the quality of the response and ownership from the Directorates
• Improve administration processes in PET
• Streamline the process for final sign off
Each of the above elements is reported and monitored monthly at PECL meetings.
11 contacts have been received in October relating to previously investigated complaints where further information or a meeting has been requested.
Reasons for Responses sent out of target
October 2010
Responses sent during October 2010
3%
15%
20
38%
Final signing process
Quality or timing of
report from Directorate
In Target
33
62%
Out of Target
21%
61%
Delays in Patient
Expereince Team
Unavailable Medical
39
Records
Section D: Patient experience – Patient Advice & Liaison Service (PALS)
•
PALS received 210 contacts in October 2010 of which 92.9% were responded to in target. The main categories were:‐
Advice
48 (22.85%)
Appointment Delay/cancellation OPD
31 (14.76%)
Clinical Treatment
20 (9/52%)
Staffing
16 (7.61%)
Communication
14(6.66%)
Others including Diagnostic Tests, Waiting times, Environment, etc 88 (41.9%)
It is important to note that PALS contacts also include requests for information relating to any of the above categories, as well as concerns or complaints. Non‐
specific advice continues to be the highest ranked category.
PALS continue to deal with enquiries and concerns which benefit from an earlier response, and where the circumstances are deemed not to require a more rigorous investigation.
Patient Advice & Liaison Service (PALS)
(data source: Ullysses Safeguard System)
250
200
150
2010/11
100
2009/10
•
•
50
Contacts with PALS remains consistent with the primary reason being Advice. •
‐
Apr
May
Jun
Jul
Aug
Sep
Oct
There has been an overall decrease in the number of contacts received in October (209) compared to September (234). PALS Contacts by Directorate
2010/11
90
80
70
60
50
40
30
20
10
0
Cardiothoracic
Services
Clinical Sciences
Estates &
Facilities
Medicine &
Emergency Care
Nursing
Outpatients
Services
Surgical
Specialties
Women's And
Children's
Other
August
16
8
10
31
12
21
72
15
9
September
14
13
3
52
6
25
83
25
13
October
14
15
4
44
10
12
83
17
11
The Directorate of Surgery continues to be the area involved in the greatest number of issues, with 83 contacts in October (83 in September). Of the 83 contacts in October, 27 were related to either the Fracture Clinic (Environment) or the Pain Management Clinic 40
(Waiting times due to clinical staffing issues).
Section D: Patient experience – Comment Cards / NHS Choices
•
•
•
There has been a decrease in the number of comment cards received with 12 in October (compared to 26 in September, 22 in August, 40 in July, 39 in June). A recent review of wards/departments (21/10/10) has shown that “Get It Right” leaflets and comment cards are not on display in many areas. It is a requirement for the Trust (CNST Risk Management Standards and CQC Registration) that users of health services are able to easily assess processes via which comments or complaints can be made. This will be brought to the PECL meeting and members will be reminded of their responsibility to ensure areas within their directorates are in compliance with this. A similar review will take place before the end of the year.
The highest number of cards received in the past have been primarily plaudits, however for October 2010, an equal number of cards were received regarding Waiting Times/Appointment Delays (4). The categories for October are broken down as follows:‐
Plaudits 4
Waiting Times/ Appointment Delays
4
Communication
2
Estates
2
Unfortunately not all comment cards provide details of specific areas within the hospital, nor contact details for a response to be sent. Of the 12 received in October, the directorates identified were:‐
Surgery
3
Medicine
2
Estates
2
"Get It Right" Comment Cards by Category
April - October 2010
Compliments
•
Waiting times
Air Conditioning
Staff Attitude
Hearing aid moulds
Car Park
Medical treatment
Security
Communication
Estates
Other
•
All comment cards are entered onto a central database for collation with existing Patient Experience reports.
All cards have been responded to where it is requested, all concerns and comments are responded to and in every case, brought to the attention of the clinical directorates. Any action taken and the outcome is monitored by the Directorate of Nursing Quality Facilitator. Any significant trends or 41
issues are discussed at the PECL Group.
Section D: Patient experience – Plaudits
It is recognised that plaudits from patients/relatives/carers are a good indicator that the service provided by the Trust is meeting service user needs and expectations.
The common themes in the formal plaudits to date are related to thanking staff for the care and attention received.
The number of formal plaudits significantly with 37 received in October (17 in September).
•
Formal Plaudits
(Data source: PET Office)
40
35
•
30
25
2009/ 10
20
2010/ 11
15
•
10
5
Apr
May
Jun
Jul
Aug
Sep
Oct
All plaudits recorded Formal plaudits received in PET (acknowledged by Chief Executive)
Plaudits via Comment Cards
No. of plaudits compliments received in PALS
No of plaudits received on wards/depts
No of positive comments posted on NHS Choices
Totals
October 2010
37
4
8
101*
2
152
*This figure is reliant on the wards sending totals to the Nursing Directorate Quality Facilitator and does not indicate a downward or upward trend.
•
•
It was reported in the March Performance Report that from April 2010, all plaudits would be reported including those received via the Patient Experience Team (PET) Office, “Get It Right” Comment Cards, PALS contacts and also plaudits received on the wards. Wards have been asked via their PECL representatives to submit the number of plaudits received on wards so that these can be added to the total plaudits received and also shown on the monthly ward metrics. It was reported in the April report that positive comments posted on the NHS Choices website would be included in this section.
In order to monitor the comparison of formal plaudits received at the Trust, the chart below will be continued to track the year on year increase: Formal Plaudits
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2010/11
32
33
21
33
35
17
37
2009/10
17
9
15
20
19
26
22
12
27
25
11
16
2008/09
12
8
2
20
17
7
27
23
38
18
26
14
Total
208
219
42
212
Section D: Patient experience – Patient Experience Tracker •
Patient Experience Tracker Overall Number of Responses (data source: Dr Foster Intelligence PET 3.0)
4500
4000
2009/10
3500
3000
2500
2010/11
•
•
2000
Performance
Improvement
Trajectory
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
1500
Patient Tracker Satisfaction Scores (all questions)
•
•
2009/10
92%
90%
88%
86%
84%
82%
80%
78%
76%
The response volume continues to exceed the Target of 3,500 per month, but with a slight decrease with 3,721 responses in October (3,886 in September). Wards and departments have been complimented for this achievement, however reminded of the need to offer the Patient Tracker to patients.
For October, the overall patient satisfaction score was 87% (88% in September) against a target of 90%.
The positive score to the question, “Would you recommend this Hospital?” in October was 95%.
The Trust’s overall satisfaction score for the hand washing question achieved the target of 90% in October. However there were a number of areas where scores for this question, and others , fell below the target. These areas have been asked to provide action plans to PECL to address poor performance.
The question “Overall, how you would rate the waiting time”, for Outpatient areas, scored a low satisfaction score with 64% in October. This will be reported to the November PECL meeting. Are you bothered by noise at night by hospital staff?
2010/11
25%
20%
Apr May Jun
Jul
Aug
Sep
Oct Nov Dec
Jan
Performance
Improvement
Trajectory
Feb Mar
15%
10%
5%
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
Would you recommend this Hospital?
May‐
10
Apr‐10
0%
During October, 21% of patients reported that they were disturbed by noise at night, this an increase on last month (18%).
Were you satisfied with the food?
•81% of patients in October responded they were satisfied with the food provided. (data source: Dr Foster Intelligence PET 3.0)
100%
100%
90%
90%
80%
80%
70%
43
70%
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
60%
Apr‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Mar‐10
Feb‐10
Jan‐10
Dec‐09
Nov‐09
60%
Section E: Efficiency & Effectiveness – Finance Overview
Annual Plan:
Year to date:
FY Forecast:
3
3
3
3
= Regulatory concerns in one or more components.
Significant breach of Terms of Authorisation is unlikely.
For more detail see Appendix
Key Points
• Net I&E position break even in October, with £0.7m deficit year to date
• Full year forecast held at £1.0m deficit at year end, with a risk of a further deterioration to £2.9m deficit
• £6.8m CIP delivered against plan of £8.4m
• The Financial Recovery Plan has to deliver £2.0m of further cost reductions
• CTC income increased £0.2m in October versus previous months
Financial Summary
Year to Date
Budget
Var.
Forecast
Budget
Var.
£m
£m
£m
£m
£m
£m
152.8
153.5
(0.7)
264.9
261.6
3.3
(143.4)
(141.5)
(1.9)
(248.3)
(242.7)
(5.6)
9.4
12.0
(2.6)
16.6
18.9
(2.3)
(0.7)
1.7
(2.4)
(1.0)
1.0
(2.0)
6.8
8.4
(1.6)
14.0
15.2
(1.3)
Net Cash Inflow/(Outflow)
13.3
5.1
8.2
0.1
(4.9)
5.1
Cash at End of Period
34.4
26.0
8.4
21.0
15.9
5.1
(11.7)
(15.8)
4.1
(22.2)
(30.3)
Total Operating Income
Total Operating Expenditure
EBITDA
Net Surplus/(Deficit)
CIP Achieved
Forecast Q3 Monitor Return
• Net I&E position £1.3m deficit YTD
• Financial Risk Rating: 3
Full Year Forecast
Actual
Capital Spending
44
8.1
Section E: Efficiency & Effectiveness – Full Year Financial Forecast
Total Trust – Full Year Forecast
Full Year Forecast by Directorate
At Month 7 the full year forecast remains at a £1.0m deficit, £2.0m Forecast
Full Year
Actual
£m
worse than plan. However, there is a risk that the forecast will
deteriorate to a £2.9m deficit if the financial recovery plan is not achieved, or if the PCT withhold further funding for work carried out.
Directorate Commentary – Full Year Forecast
• Protected Income forecast increased by £0.6m versus prior month, largely due to the anticipated release of reserves into the position. However, there remain significant risks on clinical income due to SWE PCT’s large deficit, and their proposed actions to reduce payments to the Trust.
• Medicine’s forecast overspend has increased by £0.5m following a 3rd consecutive month of rising nursing expenditure, and ongoing higher expenditure on drugs.
Year End Cash Forecast – The forecast of £21.0m cash at bank remains unchanged from prior month.
Forecast
Forecast FY Actual
Full Year Change vs
Variance Prior Month
£m
£m
Protected and Other Income
235.0
1.9
0.6
Accident and Emergency
Outpatient Services
Women and Children Services
Medicine
Surgery
Trauma and Orthopaedics
Clinical Sciences
Critical Care
Cardiothoracic Centre
Corporate Directorates
Reserves
(6.9)
(8.2)
(23.6)
(36.6)
(25.5)
(8.9)
(28.7)
(9.1)
(27.6)
(43.9)
0.8
(0.9)
(0.8)
(1.9)
(2.6)
(1.1)
(0.7)
(2.0)
(0.5)
0.8
(1.5)
7.0
(0.2)
0.2
0.3
(0.5)
(0.2)
(0.2)
0.1
(0.2)
0.2
(0.1)
0.0
16.6
(2.3)
0.0
Non Operating Items
(17.5)
0.3
0.0
Net Surplus/(Deficit)
(1.0)
(2.0)
0.0
EBITDA
45
Section E: Efficiency & Effectiveness – Activity and Income (1)
Detailed clinical income by point of delivery, and by directorate, is shown in the appendices.
Elective Inpatients – October elective activity was 22 spells (3%) behind plan, with income £361k (15%) behind. The Point of Delivery - Activity
Full Year
Activity
Plan
YTD
Actual
YTD
YTD
Variance Variance
to Budget to Profiled
on 12ths
Budget
shortfall was largely driven by lower activity in Surgery, with 30 less spells (15%) than planned, resulting in a £222k shortfall in income. YTD Surgery remains 14% (196 spells) behind its activity plan, although the resultant income shortfalls are offset by higher daycase activity. CTC elective activity levels caught up a YTD shortfall in 7,326
23,716
41,062
297,744
24,629
93,487
Elective Inpatient (Spells)
Day Case (Spells)
Non-Elective (Spells)
Outpatients (Atts)
Outpatient Procedures
Accident & Emergency (Atts)
4,151
14,959
23,125
179,347
16,191
44,722
(123)
1,125
(828)
5,663
1,824
(9,812)
(279)
879
(828)
4,810
1,753
(9,812)
October, but doing a less complex casemix than plan, and therefore giving a YTD income shortfall of £870k.
Day cases – Activity was up again against plan 2% (51 spells) in October. However, within this activity, and across specialties, the casemix was less complex than plan, with significant activity and income underperformance in the CTC (worth £270k) only partially offset by higher activity in Clinical Sciences and T&O. YTD the CTC’s shortfall on daycase income amounts to £896k, which is only offset by higher activity in other directorates.
Non‐Elective Inpatients – Across the Trust although activity was down 2%, income was a net £291k (4%) better than plan, largely due to higher activity in the CTC worth £271k. Although Obstetrics had a better month in October, with YTD activity lower than plan, and a lower casemix
46
Section E: Efficiency & Effectiveness – Activity and Income (2)
(significant reduction in caesareans), income is Point of Delivery - Income
£1,075k behind plan YTD for the specialty. This income is not subject to the 30% threshold, but is being offset elsewhere in the Trust by activity Current
Month
Actual
£'000
Full Year
Budget
£'000
Month
Var. to
Budget
£'000
YTD
Actual
£'000
YTD
Var. to
Budget
£'000
that is. Given these activity changes, the cost base of the unit needs to be reduced to offset the loss of income.
The table right now splits out the income lost due to activity above 2008/09 levels. For any emergency activity above 2008/09 levels, the Trust only gets paid 30% of normal tariff, and in October the Trust lost £292k due to excess activity. YTD the Trust has now lost £1,119k, and this rate of loss is expected to accelerate going into winter unless the Trust takes action to reduce admissions. Since it is likely to be loss 26,271
21,780
82,696
(1,233)
32,013
10,070
984
172,580
12,224
20,308
34,388
Elective
Day Case
Non Elective
Emergency Threshold Adj.*
Outpatients
Accident & Emergency
Partially Completed Spells
CTC Transitional Funding
Total Mandatory
Outpatients (incl. procedures)
Critical Care
Other Non- Mandatory
1,977
1,805
7,373
(292)
2,818
814
(92)
82
14,486
(361)
(111)
481
(189)
(5)
(25)
(92)
(302)
14,822
13,140
48,355
(1,119)
19,052
5,847
(40)
574
100,631
(1,064)
210
116
(400)
286
(27)
(40)
(919)
1,391
1,449
2,855
312
(243)
(47)
7,605
10,396
20,135
439
(1,450)
389
239,501
Total Protected Income
20,181
(280)
138,768
(1,541)
1,740
20,382
261,623
Non-Protected
Other Income
Total Income
236
1,858
22,276
91
26
(162)
1,455
12,625
152,848
440
434
(667)
making, the Trust is having to subsidise this activity, and furthermore it reduces capacity for elective work. Outpatients – Both first attendances and follow * All emergency activity above 2008/09 levels is only paid at 30% of tariff
ups were behind plan by 6% and 4% respectively in the month, largely due to a significant drop in Critical Care – Income was £243k lower than plan in October due to underperformance in the CTC and NICU. CTC Critical activity during the school half term week at the Care is £883k behind plan YTD, and NICU £509k behind. However, due to the ongoing forecasted lower activity in NICU, end of October. Nevertheless, income was on the contract has been fixed with commissioners to avoid risk to both parties.
plan for mandatory outpatients, and due to a YTD Other Non‐Mandatory – This includes £2,017k YTD for C‐QUIN assuming that all targets are achieved. A small provision is adjustment to Medicine, non‐mandatory held for non‐achievement of known elements, but the remainder has to be delivered for the Trust to receive this outpatients had higher income in the month.
income.
Non‐Protected – Income was £91k better than budget in the month due to higher RTA income in A&E. 47
Section E: Efficiency & Effectiveness – Expenditure
Total pay expenditure was £351k (3%) overspent in October before the release of reserves, worth £380k. Medical staffing expenditure was overspent in October by £177k, although total spending is reducing (see graph right). The majority of this overspend is within A&E (see comment below in Directorate Key Issues) and Critical Care. Critical care spending is high due to long term sickness and extra lists due to the theatre power outage in September.
Where agency staff are used for vacant posts, only programmed activities should be covered so that the agency premium is absorbed by SPA costs included within budgets.
Nursing expenditure increased in the month to £504k over budget, with increases in all areas and particularly in Obstetrics. While agency costs across the Trust are reducing, this was largely due to higher recruitment, and the Trust now has more substantive nurses than ever before. Therefore, costs of using temporary staff have to be kept down to avoid the Trust failing to achieve the full year forecast.
Drugs expenditure was £142k above budget in October, with high spending in General Medicine.
Clinical Supplies expenditure was £210k (9%), with Clinical Sciences in particular overspent.
48
Section E: Efficiency & Effectiveness – CIP
Year to date the Trust has achieved £6.8m CIP savings, compared to a target of £8.4m, resulting in a YTD variance of £1.6m. This variance has deteriorated in month 7 by £0.5m due to under performance in a number of clinical directorates, as well as Estates and Facilities. Key elements driving this under performance include slippage in recruiting A&E doctors substantively, lower CTC clinical income, failure to close escalation areas, failure to realise savings from the theatre closure, and slippage on achieving non‐pay savings through standardisation of consumables. Non‐achievement in Estates is largely linked to the delay in implementing Steam Cuisine.
At month 7 the risk‐weighted full year forecast position will be unaffected. Several central non‐recurrent items are held to offset these slippage gaps.
CIP delivery is £13.2m against a target of £15.2m, £0.1m less than forecast in September (see appendix for risk weighted forecast). The forecast still includes £1.0m of schemes rated as amber risk, but negligible schemes still rated as a red risk. The forecast full year CIP before risk adjustment is £14.0m, £1.3m short of target.
Shortfalls in CIP achievement are largely explained by slippage in the implementation timing of savings, and therefore the recurrent
Quality assessment of all CIP schemes is shown on the dashboard, and 21 schemes will deliver improved quality. • Of the five schemes awaiting quality assessment three of these relate to generalised non‐pay savings. Each non‐pay saving suggested will have a quality assessment undertaken on an individual basis. All clinical directorates have Resource Efficiency Groups set up to bring together staff at all levels, from clinician to ward hostess, with the procurement team to identify smarter purchasing options, more efficient ways of working and ensure quality is maintained/improved in all changes.
• The CTC is implementing a change in clinical practice that is subject to clinical audit before quality sign‐off can be given, and the final decision on this is awaited shortly.
49
• Surgical Services have successfully transferred a ward to the Medical Directorate, and this should facilitate improved patient care and financial control, as medical patients will be treated within speciality rather than as outliers.
Section E: Efficiency & Effectiveness – Cash Management
The overall cash variance this month was £8,389k higher than plan and the larger variances in specific items are commented below.
Debtors
£1.4m prepayment accruals due to timing differences on various accounts.
£1.1m over performance not included in annual plan.
Creditors
£1.6m difference in plan and actual due to accruals for SWE PCT therapy services. £3.6m increase in accruals against planned movement.
£0.6m re agency doctor invoices delayed payments due to Cash Balance Variances
YTD queries being raised.
£’000
£2.4m in advance from Specialist Commissioning in advance of November contract payment.
£0.8m other timing differences. Capital
£’000
Cash balance per Budget
EBITDA
Stock
25,963
(2,606)
409
Capital spending is £4.1m behind plan YTD. For further Debtors
details on the capital programme, see the Look and Feel Creditors
9,051
Net Operating Cash flow variance
4,401
Capital Expenditure
4,100
Other
(112)
section.
The Balance Sheet and Cash Flow Statement are shown in (2,453)
the appendices.
Net cash inflow/(outflow) variance
Actual cash balances
50
8,389
34,352
Section E: Efficiency & Effectiveness – Financial Risk
The key risks to achieving the financial plan in 2010/11 are:
• PCT Turnaround programme.
• Non‐delivery of the Financial Recovery Plan. • Failure of PCT to pay for activity due to cash flow problems;
• Medical non‐elective patient outliers reducing capacity for elective work;
• The PCT decommissioning significant elements of activity, in year, and into 2011/12;
• Directorates failing to implement their cost improvement plans resulting in significant over spends;
• The Trust reducing activity but not reducing costs to offset the loss of income;
• Failure to achieve the internal activity plan within the bed capacity constraints;
• Failure to deliver the requirements of CQUIN and thus not receiving the 1.5% payment;
• Not meeting the new contract requirements and receiving penalties;
• Failure to record all clinical activity accurately;
• Meeting the quality and accuracy of coding required by the new contract and PCT commissioning team;
Mitigation and Recovery Plan
• Slippage of capital programme to mitigate PCT cash flow problems;
• Weekly metrics review of pay and activity, with Chief Executive, Acting Director of Finance, Clinical General Managers and Director of Operations and Service Development;
• Monthly performance review meetings with each directorate;
• Fortnightly CIP review meetings;
• CIP dashboard with workbook and milestones for all schemes;
• Weekly Vacancy Control Group reviewing all posts for recruitment;
• Overseas recruitment plan for medical staff vacancies;
• Increased sign‐off control for expenditure;
• Management of unauthorised and authorised absence;
• Controls over bank and agency usage;
• Utilisation of outpatient clinic space;
• Utilisation of theatre sessions;
• CTC activity recovery plan agreed from September 2010;
• Increased directorate KPI’s to monitor performance;
• Action plan to reduce directorate/corporate overheads.
51
Section E: Efficiency & Effectiveness – I&E Statement
Full Year
Month
Plan
Budget
Actual
£'000
£'000
£'000
£'000
Year to Date
Budget Variance
£'000
Actual
Budget Variance
£'000
£'000
£'000
INCOME
240,320
239,501
20,181
20,461
138,768
140,309
1,740
1,740
Protected activities
Non-protected activities
236
145
(280)
91
1,455
1,015
(1,541)
440
19,672
20,382
Other operating income
1,858
1,832
26
12,625
12,191
434
261,733
261,623
22,276
22,438
(162)
152,848
153,515
(667)
(165,301)
(164,506)
(13,297)
(13,804)
507
(90,668)
(95,971)
(109)
(401)
(516)
(38)
(478)
(6,543)
(351)
(6,191)
(165,410)
(164,907)
(13,813)
(13,842)
29
(97,211)
(96,322)
(889)
(12,823)
(13,160)
Drugs
(1,334)
(1,191)
(142)
(8,467)
(7,989)
(478)
(30,061)
(28,787)
Clinical Services (excl. drugs)
(2,572)
(2,362)
(210)
(16,980)
(16,157)
(823)
(34,522)
(35,866)
Other Non-Pay (excl. depreciation)
(3,129)
(3,009)
(120)
(20,759)
(21,010)
252
(46,205)
(45,156)
(1,050)
(143,417) (141,478)
(1,939)
PAY
NHS
Non-NHS
5,303
NON-PAY
(77,406)
(77,813)
(242,816)
(242,720)
18,917
18,903
(11,057)
(11,057)
(850)
450
(850)
464
(6,440)
(6,440)
1,020
1,020
(402)
(402)
618
618
Total Expenditure
EBITDA
Depreciation
(7,034)
(6,562)
(472)
(20,847)
(20,404)
(443)
1,429
2,035
(606)
9,431
12,037
29
(6,270)
(6,334)
(894)
Profit/(loss) on disposal
(15)
Interest Payable
(70)
Interest Receivable
Capital dividends payable
Net surplus/(deficit)
Asset Impairment
Retained surplus/(deficit)
(923)
-
(15)
(15)
(71)
1
(372)
29
39
(10)
(514)
(537)
23
(35)
543
(578)
(35)
543
(578)
165
(3,596)
(657)
(657)
-
(2,606)
64
(15)
(496)
124
270
(105)
(3,757)
1,721
1,721
161
(2,377)
-
52
(2,377)
Section E: Efficiency & Effectiveness – I&E Run Rate
09/10
Q1 Ave Q2 Ave Q3 Ave
Actual Actual Actual
INCOME
Protected activities
Non-protected activities
Other operating income
PAY
NHS
Non-NHS
NON-PAY
Drugs
Clinical Services (excl. drugs)
Other Non-Pay (excl. depreciation)
Total Expenditure
EBITDA
Depreciation
Profit/(loss) on disposal
Interest Payable
Interest Receivable
Capital dividends payable
Net surplus/(deficit)
09/10
10/11
Jan
Actual
Feb
Actual
Mar
Actual
FY
Actual
Apr
Actual
May
Actual
Jun
Actual
Jul
Actual
Aug
Actual
Sep
Actual
Oct
Actual
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
19,262
154
1,915
21,331
19,539
193
1,865
21,597
19,599
173
1,994
21,766
20,103
112
2,044
22,258
20,493
197
2,164
22,855
21,619
218
2,246
24,084
257,015
2,256
25,771
285,042
19,778
124
1,696
21,598
19,797
173
1,758
21,728
19,673
227
1,798
21,698
19,494
196
1,873
21,563
19,807
250
1,761
21,818
20,038
248
1,882
22,168
20,181
236
1,858
22,276
(12,080) (12,252) (12,559) (12,889) (12,557) (12,897)
(1,088) (1,027) (1,267) (1,361) (1,290) (1,491)
(13,169) (13,280) (13,826) (14,250) (13,847) (14,388)
(161,578)
(15,554)
(177,132)
(12,783) (12,853) (12,783) (12,802) (13,078) (13,072) (13,297)
(1,112) (1,149) (1,152)
(972)
(814)
(828)
(516)
(13,895) (14,002) (13,935) (13,774) (13,892) (13,900) (13,813)
(1,020) (1,051) (1,193) (1,312) (1,161) (1,511)
(2,338) (2,436) (2,582) (2,203) (2,336) (2,755)
(2,902) (2,939) (3,383) (3,584) (3,696) (3,858)
(6,260) (6,426) (7,158) (7,098) (7,193) (8,124)
(19,428) (19,705) (20,984) (21,348) (21,039) (22,512)
(14,969)
(31,945)
(42,191)
(89,104)
(266,236)
(1,312) (1,066) (1,365)
(862) (1,208) (1,320) (1,334)
(2,335) (2,541) (2,586) (2,124) (2,220) (2,602) (2,572)
(2,955) (3,038) (2,374) (3,098) (3,013) (3,152) (3,129)
(6,602) (6,645) (6,325) (6,083) (6,442) (7,074) (7,034)
(20,497) (20,647) (20,261) (19,857) (20,333) (20,974) (20,847)
1,902
1,891
782
910
1,816
1,572
18,805
1,101
1,081
1,437
1,706
1,484
1,193
1,429
(931)
(39)
16
(539)
(942)
(0)
(51)
20
(539)
(953)
(39)
21
(539)
(992)
(37)
24
(149)
(767)
(37)
1
(500)
(979)
78
(38)
13
(448)
(12,170)
78
(534)
231
(6,487)
(898)
(37)
3
(537)
(898)
(38)
45
(537)
(899)
(37)
16
(537)
(894)
(37)
28
(537)
(894)
(38)
22
(537)
(894)
(115)
23
(397)
(894)
(15)
(70)
29
(514)
411
380
(728)
(244)
513
197
(77)
(368)
(348)
(20)
266
38
(190)
(35)
53
Section E: Efficiency & Effectiveness – Clinical Income by POD
Full Year
Current Period
Budget
£'000
Actual
£'000
Year to Date
Budget Variance
£'000
£'000
Actual
£'000
Budget Variance
£'000
£'000
26,271
21,780
81,463
Elective
Day Case
Non Elective
1,977
1,805
7,080
2,338
1,917
6,789
(361)
(111)
292
14,822
13,140
47,237
15,886
12,931
47,520
(1,064)
210
(284)
16,313
15,699
32,013
Outpatients - 1st
Outpatients - Follow Up
Total Outpatients
1,440
1,378
2,818
1,439
1,385
2,823
1
(7)
(5)
9,439
9,613
19,052
9,563
9,203
18,766
(124)
410
286
10,070
984
172,580
Accident & Emergency
Partially Completed Spells
CTC Transitional Funding
Total Mandatory
814
(92)
82
14,486
839
82
14,788
(25)
(92)
(302)
5,847
(40)
574
100,631
5,874
574
101,551
(27)
(40)
(919)
6,931
20,308
5,395
6,362
8,023
4,201
3,955
5,125
6,885
3,587
(3,851)
66,921
GP Direct Access
Critical Care
Excluded Drugs
Excluded Devices
Outpatients - Attendances
Outpatients - Procedures
Community Midwifery
Renal
Other Non-Mandatory
C-Quin Income
Reserves
Total Non-Mandatory
676
1,449
601
376
945
446
330
326
601
288
(342)
5,696
578
1,692
556
459
708
370
330
284
575
299
(178)
5,674
98
(243)
45
(83)
237
75
42
26
(11)
(164)
22
4,457
10,396
3,440
2,988
4,900
2,705
2,307
3,195
4,140
2,017
(2,410)
38,137
4,043
11,847
3,399
3,141
4,703
2,462
2,307
2,990
4,021
2,092
(2,246)
38,759
414
(1,450)
42
(152)
196
243
205
119
(75)
(164)
(622)
239,501
Total Protected Income
20,181
20,461
(280)
138,768
140,309
(1,541)
54
Section E: Efficiency & Effectiveness – Balance Sheet
March 2011
Plan
Current Period
Budget
£'000
£'000
210,250
210,250
15,889
15,889
12,975
12,975
28,864
28,864
22,040
22,040
6,824
6,824
217,074
217,074
22,431
22,431
194,643
194,643
114,176
114,176
53,153
53,153
1,153
1,153
26,161
26,161
194,643
194,643
194,643
194,643
Actual
Mar 10
Budget Variance
£'000
£'000
195,314
201,780
(6,466)
191,896
34,352
25,963
8,389
20,924
Other current assets
13,395
11,857
1,538
19,000
CURRENT ASSETS
47,747
37,821
9,926
39,924
CURRENT LIABILITIES, due within one year
29,304
23,550
5,754
27,079
Net current assets/(liabilities)
18,443
14,271
4,172
12,845
Total assets less current liabilities
213,758
216,051
(2,293)
204,741
20,192
20,215
(23)
10,499
193,566
195,836
(2,270)
194,242
114,176
114,176
0
114,176
53,153
53,153
-
53,153
1,350
1,243
107
1,370
24,886
27,263
(2,377)
25,543
193,566
195,836
(2,270)
194,242
193,566
195,836
(2,270)
194,242
-
-
-
-
16,000
16,000
-
16,000
16,000
16,000
-
16,000
NON-CURRENT ASSETS
Cash NON-CURRENT LIABILITIES, due after one year
Total assets employed
Public dividend capital
Revaluation reserve
Donated asset reserve
Income & expenditure reserve
TAXPAYER'S EQUITY
Total funds employed
£'000
Actual
£'000
FINANCING FACILITIES
-
-
16,000
16,000
16,000
16,000
NHS
Non-NHS
Total committed and unused financing facilities
55
Section E: Efficiency & Effectiveness – Cash Flow Statement
Full Year
Month
Plan
Budget
Actual
£'000
£'000
£'000
18,917
18,903
(217)
(53)
(217)
(53)
EBITDA
Year to Date
Budget Variance
£'000
1,429
Transfers from reserves
(18)
£'000
2,035
(18)
Actual
Budget Variance
£'000
(606)
(1)
9,431
(129)
£'000
£'000
12,037
(2,606)
(128)
Stocks
163
(0)
163
355
6,445
6,445
Debtors
314
(737)
1,051
5,096
7,549
(2,453)
(5,519)
(5,519)
Creditors
1,790
(100)
1,890
3,844
(5,093)
8,937
(1)
(1)
Provisions
Net operating cash flow
(27)
-
19,572
19,558
(30,298)
(30,298)
(167)
(154)
(10,894)
(10,894)
(6,440)
(6,440)
Capital dividends paid
52
138
(0)
PDC received/(repaid)
-
-
12,386
12,386
(4,948)
(4,948)
Capital expenditure
Net interest received/(paid)
Net cash flow before financing
Net Loans received/(repaid)
Net movement in cash
3,651
1,180
(1,967)
(2,902)
(4)
1,680
(32)
1,700
45
(1,677)
(1,539)
(27)
2,471
936
(49)
3,357
(86)
(32)
3,239
(42)
(53)
(1)
(1)
409
(41)
18,555
14,310
4,245
(11,673)
(15,773)
4,100
(171)
(7)
(164)
6,711
(1,470)
8,181
(3,168)
(3,220)
52
(0)
0
9,793
9,793
0
13,336
5,103
8,233
56
Section E: Efficiency & Effectiveness – Monitor Financial Risk Rating
Based on financial performance metrics, Monitor allocate foundation trusts a finance risk rating between 1 and 5, where 1 is highest financial risk and 5
is lowest. The finance risk rating is made up of five components, with the Trust’s YTD and forecast position as follows:
Financial Risk Rating
Metric
EBITDA Margin
EBITDA, % Achieved
ROA
I&E Surplus Margin
Liquid Ratio
Weighted Average
Criteria
Underlying Performance
Achievement of Plan
Financial Efficiency
Liquidity
YTD
Actual
Rating
6.2%
3
82.0%
3
2.4%
2
-0.4%
2
43.3
4
2.9
Forecast Full Year
Actual
Rating
6.3%
3
87.7%
4
2.5%
2
-0.4%
2
47.2
4
3.0
Current Risk Ratings:
Weight
5
4
25%
11%
9%
10%
100%
85%
20%
6%
5%
20%
3%
2%
25%
60
25
100%
3
5%
70%
3%
1%
15
2
1%
50%
-2%
-2%
10
1
<1%
<50%
< -2%
< -2%
<10
Weighted Average Risk Rating Definitions
Rating 5 - Low est risk - no regulatory concerns
Rating 4 - No regulatory concerns
Rating 3 - Regulatory concerns in one or more components. Significant breach of Terms of Authorisation is unlikely
Rating 2 - Risk of significant breach in Terms of Authorisation in the medium term, e.g. 9 to 18 months in the absence of remedial action
Rating 1 - Highest risk - high probability of significant breach of Terms of Authorisation in the short-term, e.g. less than 9 months, unless remedial action is taken
Over-riding Monitor Metric Rules
The overall risk rating is a w eighted average of the five metrics, but there are four rules that overide this average:
1. If any one metric is ranked at 1 or 2 than the maximum Trust rating is 3
2. If any 2 metrics are ranked at 1 or 2 then the maximum Trust rating is 2
3. If any 2 metrics are ranked at 1 then the maximum Trust rating is 1
4. If any metric is ranked at 1 then the maximum Trust rating is 2
NB For the pupose of these over-riding rules, the ROA and I&E Surplus metrics are averaged together, leaving a total of 4 metrics against w hich these rules are tested
Glossary of term s
EBITDA
EBITDA
EBITDA Margin
EBITDA % Achieved
ROA
I&E Surplus Margin
Liquidity
Liquid Ratio
EBITDA is earnings before deducting interest, taxes, depreciation and amortisation. It also excludes exceptional items and dividends. It is a measure of
the performance of the "underlying business" i.e. the surplus/deficit from day to day operations and is similar to the directorate financial statements.
This is EBITDA as a percentage of total income.
This is designed to measure the ability of the Trust to achieve its financial plans. The target is therefore 100% or more.
Return on assets measures how efficiently the Trust uses its assets. It is defined as the Net Surplus before dividends as a percentage of the total assets
of the Trust.
This is the Net Surplus as a percentage of total income.
This ratio measures the Trust's ability to pay its bills from liquid assets (assets that are easily realisable), and is intended to show w hether the Trust can
continue to pay its bills in the short term. The metric show s for how many days the Trust could continue to pay its bills just using its net w orking capital.
Net w orking capital (i.e. liquid assets) consists of cash in bank and debtors due in less than one year, less creditors due in less than one year.
57
Section E: Efficiency & Effectiveness – CIP Board Dashboard
58
Section E: Efficiency & Effectiveness – CIP Directorate Dashboard
59
Section E: Efficiency and Effectiveness – Workforce
Vacancies
10.0%
8.0%
Frozen Vacancies
6.0%
Active Vacancies
4.0%
Target Vacancies
2.0%
A pr‐1 0
M ay‐1 0
Jun‐1 0
Jul‐1 0
A ug‐1 0
Sep‐1 0
O ct‐1 0
Nov‐1 0
Dec‐1 0
Jan‐1 1
Feb‐1 1
M ar‐1 1
0.0%
The vacancy rate for the month of October 2010 is 8.35% and the annual rate (in the 12 months to October 2010) is 8.82%. The vacancy position within nursing and midwifery has reduced further to 7.79% in October. The vacancy control group continues to meet to review the workforce position. Membership has been expanded to include representation from the service planning to ensure activity projections and any planned PCT changes on activity are included in discussions prior to recruitment decisions taking place. A review of the overall vacancy position will also be discussed on a weekly basis. The Trust are following the recent published guidance on the EOE Employment Framework whereby all positions are now advertised on the NHS Jobs Restricted Website for a period of 7 days prior to national advertising. This provides an opportunity for employees placed at risk to apply for positions locally. Data Source – Electronic Staff Record
The annual rate of turnover (i.e., the number of staff retiring or resigning) in the 12 months to October 2010 is 10.83 %, and the monthly rate is 0.69%. It is predicted that turnover will stabilise at around 10‐11% by year end. Staff Turnover
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
0.0%
Data Source: Electronic Staff Record
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
O ct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Staff Turnover
60
Section E: Efficiency and Effectiveness – Workforce
Appraisal compliance is monitored on a monthly basis. In October
performance increased to 77% with a further 2% of the workforce with appraisal dates confirmed. Weekly discussions are taking place with senior managers to ensure that those employees without a scheduled appraisal date are followed up and dates are confirmed. Performance will continue to be monitored on a fortnightly basis to ensure improvements continue to be made. Directorates have set milestones Staff Appraisals
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Appraisals
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Data source: Electronic Staff Record Sickness Absence
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Sickness Absence
The Trust’s sickness figure for the month of October 2010 is 3.38% and the
annual figure (based on a 12‐month rolling average) is 3.68 %. The annual Chartered Institute of Personnel and Development Absence Management Survey 2010 states that the average level of absence within the Health Sector is 4.7%. The Trust position is considerably lower than this. Detailed weekly reviews of all employees absent the previous week is undertaken between the personnel team and the appropriate directorate manager. This will continue to ensure we are consistently addressing all episodes of non attendance. Data source: Electronic Staff Record 61
Section F: Look and Feel – Estates
Number of Job Requests
Statutory Maintenance Completed
3,400
100%
3,200
95%
3,000
2,800
20010/11
2,600
2009/10
2,400
90%
In M onth
Target
85%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Jun‐10
Apr‐10
2,000
May‐10
80%
2,200
The number of job requests in October reduced sharply compared to September and was 8% lower than October last year. The reduction in jobs may be related to the additional cost control measures introduced whereby only H&S related maintenance requests are actioned. Overall, maintenance performance in October, 7 of the 8 KPI measures improved compared to September. All 3 planned preventative maintenance targets were fully met in October. For the first time this year, the Estates team fully met their urgent response stretch target and overdue work reduced markedly.
Planned Preventative Maintenance (PPM) Completed
Water Systems Maintenance Completed
100%
100%
95%
90%
90%
In M onth
80%
In M onth
85%
Target
70%
Target
M ar‐1 1
Feb‐11
Jan‐1 1
Dec‐10
Nov‐10
O ct‐10
Sep‐10
A ug‐1 0
Jul‐1 0
Jun‐10
May‐1 0
M ar‐1 1
Feb‐11
Jan‐1 1
Dec‐10
Nov‐10
O ct‐10
Sep‐10
A ug‐1 0
Jul‐1 0
Jun‐10
M ay‐1 0
A pr‐1 0
Data given is provided from the Estates ‘Shire’ work management system
A pr‐1 0
60%
80%
62
Section F: Look and Feel – Cleaning
Cleaning Scores ‐ High Risk Areas
Cleaning Scores ‐ Very High Risk Areas
98%
96%
Very High Risk Actual
98%
Target
96%
94%
High Risk Actual
Target
94%
92%
92%
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
Apr‐10
May‐10
90%
Mar‐11
Jan‐11
Feb‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
90%
The cleaning service is monitored according to a risk assessment undertaken in accordance with the National Standards for Cleanliness in the NHS.
The Trust has a stretch target to achieve 98% for Very High risk areas and 95% for High Risk areas but to have only a limited number of areas below
the standard of 96% and 93% respectively.
In Octber 2010 there was one occasion when the weekly monitoring of a High Risk area showed a score of less than 93%. This related to Horndon
Ward with a score of 87%. Action was taken immediately to address the issues found and the ward did not fall below the trigger point again during the
month. There were no Very High Risk areas that scored less than 96% in the month.
Cleaning Scores ‐ Low Risk Areas
Cleaning Scores ‐ Significant Risk Areas
95%
96%
94%
92%
90%
88%
86%
84%
82%
80%
90%
Significant Risk Actual
Target
Low Risk Actual
85%
Target
80%
75%
Data given on the graphs above comes from the Innovise cleaning monitoring system.
Mar‐11
Jan‐11
Feb‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
May‐10
Apr‐10
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
Apr‐10
May‐10
70%
63
Section F: Look and Feel – Capital Investment
YTD
YTD
Spend Oct Budget
2010
Oct 2010
Annual
Allocation
£000
10,020
2,068
499
600
5,359
£000
£000
Forecast
Year End
Spend
£000
A&E/Fracture Clinic Redevelopment
Catering Services Review
Windows
Ward Refurbishment
Other estates projects
3,368
607
387
649
2,392
5,845
1,477
241
600
2,844
6,060
1,763
387
649
4,177
3,373 Electronic Medical Records
2,264 IT Strategy - Infrastructure/Systems
1,534
993
1,777
1,122
3,373
1,864
875
2,189
2,307
589
120
16,685
20,700
4,249 Clinical Equipment - Replacement/New
1,746 General Contingency
30,178
‐
10,805
Work is progressing with the capital programme including: Security Team Office/CCTV Monitoring
The new Security Office in the main reception project completed in October. The remodelled facility provides a fully integrated CCTV monitoring suite to ensure the Trust has an effective & compliant system utilising enhanced digital technology to improve image quality.
Ward Refurbishment
The former Fleming Ward refurbishment completed on 5th
November and re‐opened as James McKenzie Ward with patients moved from the Frank Ahrens cardiac ward. The refurbished ward incorporates features to prevent infections such as curved surfaces, air‐tight light fittings and easy‐clean fixtures. The Former Frank Ahrens will be renamed Acute Medical Ward (West) and integrated with the adjacent MAU ward renamed Acute Medical Unit (East). Catering Project The Restaurant refurbishment work started on 16th October and will complete by the end of the year. A temporary restaurant facility will be provided whilst the works progress. 4 Bed Bay of the Refurbished James McKenzie Ward November 2010
The first 4 wards all located in the Jubilee Wing went live with
the new ‘Steam Cuisine’ service on 10th November. The wards will be rolled‐out progressively over the next 2 months. The service is being provided temporarily from a mobile cold‐store facility on level A re‐using the link corridor originally built for the decant theatres. The replacement level B Kitchen facility will be tendered shortly. 64
65
BOARD OF DIRECTORS
PART 1
MEETING DATE: 24 NOVEMBER 2010
AGENDA ITEM: (2) 6
PROGRAMME MANAGEMENT OFFICE UPDATE
REPORT OF THE PROGRAMME DIRECTOR AND DIRECTOR OF CONTINUOUS
IMPROVEMENT
Purpose
This report is intended to update the Board of Directors on the progress and
achievements of the projects overseen by the Programme Management Office
(PMO).
Composition of the Report
No. of pages: 5
No. of appendices: 2
Summary - Key Issues
•
•
•
•
•
The PMO is currently overseeing 32 projects.
At present, there are 2 projects in the pipeline.
Of the 1,289 milestones (or actions) that were due for completion since the
start of the programme, 54 are outstanding (4%).
At the current time, there are 74 key performance indicators (KPIs) being
monitored by the Programme Board. Of these, 17 or 23% are not being fully
met.
The A&E project has been reinstated on the dashboard and improvements
are continuing.
Anticipated Outcome (complete this if appropriate)
Recommendation(s)/ Decision Required
The Board of Directors is asked to note the progress made in relation to the work of
the PMO and the progress against the milestones of the projects.
Key Risks and Board Assurance
• Failure to deliver the programme will lead to the potential of additional
intervention by Monitor.
Regular reporting to Monitor to provide confidence of continuous
improvement
• The increasing challenging financial context will require sustained
performance improvement to deliver the financial plan.
Cost improvement plans to be monitored using the principles of the PMO and
66
•
key projects to be overseen by the PMO.
Failure to deliver the QIPP initiatives proposed by NHS South West Essex
may lead to additional financial pressure, in addition to those internally
generated.
Major QIPP projects will be managed through the PMO to ensure visibility of
service and financial impact and timely delivery.
Implications
Projects will impact across the 4 key themes of the organisation’s strategy together
with compliance with requirements of the regulators such as the Care Quality
Commission (CQC) and Monitor and the commissioners, NHS South West Essex.
Implications of not accepting recommendation(s):
None
Acronyms / Abbreviations used in the Report (where not stated):
Monitor – The independent regulator of NHS foundation trusts
PwC – PricewaterhouseCooper
HSMR – Hospital Standardised Mortality Ratio
TIA – Transient Ischaemic Attack
A&E – Accident and Emergency Department
QIPP – Quality, Innovation, Productivity and Prevention
Author: Adam Sewell-Jones
Status: Programme Director
Date: 15 November 2010
67
PROGRAMME MANAGEMENT OFFICE
UPDATE REPORT AS OF 12 NOVEMBER 2010.
1. Introduction
Following the intervention by Monitor in November 2009, the Trust, in partnership
with PricewaterhouseCoopers(PwC), set up a Programme Management Office
(PMO). The role of this office is to co-ordinate the delivery of a set of projects such
that the anticipated benefits can be realised within the timescales of the programme
and in the future. Projects will be managed through this process where they are seen
to be critical to the strategic work of the Trust, are considered to be a core business
function or outcome, or where they are indicated by regulatory or contractual
concerns.
The PMO consists of:
Adam Sewell-Jones
Ruth Taylor
Andrea Saville
Iris Smith
Katy John
Annemarie Halls
Programme Director and Director of Continuous Improvement
Deputy Programme Director
Programme Manager (part time)
Programme Manager (part time)
Programme Assistant
Programme Administrator
2. The Current Programme
The PMO is currently overseeing 31 projects, many of which were originally included
in the Quality Improvement Plan: Patient Experience and Safety agreed with the
Commissioners and NHS East of England in the summer of 2009. Others have been
added following concerns expressed by either Monitor or the Care Quality
Commission (CQC) or following additional alerts raised by the Dr Foster Intelligence
System. In addition, some projects remain under the monitoring of the PMO.
The key themes for these projects are:
• Capacity management and discharge
• Reducing HSMR
• Care Quality Commission Registration Conditions
• Risk management standards
• Health and Safety Executive requirements
• The Department of Health Productive series
• Management and Prevention of Pressure ulcers
• Response and management of the deteriorating patient.
• Quality, Innovation, Productivity and Prevention (QIPP) programme
Each project has a Project Manager, Clinical Lead and Executive Sponsor. The
Project Manager (with the support of the Clinical Lead) meets with the PMO weekly,
or less frequently where appropriate, to review progress against actions and
performance against the agreed key performance indicators (KPIs). The Programme
Board, consisting of the executive directors, the PMO team and a non-executive
director meets fortnightly to review the progress of all projects and to discuss any
areas of concern or high risk. Action is taken to address all areas of concern
following this meeting.
2.1
Closed Projects October
During October 2010, no projects were closed.
2.2
New Projects October
68
There were 8 new projects established in November, all of which are related to the
QIPP initiative to reduce the new to follow up ratios to the national median or upper
quartile performance.
2.3
Suspended Projects October
1 previously suspended project has been reactivated:
A&E Improvement Project.
This project had been suspended to facilitate the work required to commission the
new A&E build and was reactivated when the move into the new area was
successfully completed.
3. The Pipeline
In addition to the projects mentioned above, the PMO supports a “pipeline” of
projects which may or may not be translated into projects to be overseen by the
office. At the current time, there are two projects in the pipeline, one related to end of
life care and one relating to the national dementia strategy.
4 Performance to date
As of Friday 12 November 2010, there were:
1
22
9
red;
amber; and
green rated projects.
Of the 1,289 milestones (or actions) in the current projects that were due for
completion since the start of the programme, 54 are outstanding (4%). Reasons for
the variance are challenged by the PMO and remedial action identified to reduce the
slippage. As failure to deliver against milestones can be seen as poor performance
on behalf of the Project Lead, the PMO has been working closely to reduce this
number to zero.
The dashboard, which is prepared weekly, is attached for information at Appendix 1
and reflects the progress of all projects as of close of play on Friday 15 October
2010.
At the current time, there are 74 key performance indicators being monitored by the
Programme Board. Of these, 17 or 23% are not being met. RAG rating is based on
the following performance tolerance levels: less than 3% from target is green,
between 3-6% variance is amber and over 6% is red. This is deterioration on
previous weeks and reflects the number of amber projects at the time of the report. It
also reflects the HSMR position following the national re-basing as a number of the
projects have this as a KPI.
It should be noted that this position (and that of the milestones) is affected by the
removal of the closed projects from the monitoring and reporting position.
5 Key Achievements to Date
There have been a number of achievements since the introduction of the PMO. Most
notable are:
•
HSMR for the top 5 HRG chapters originally identified in the Quality Improvement
Programme in 2009 have significantly improved, with none now being indicated
69
as red or significantly worse than average over the 12 month rolling average as
can be seen below:
Sep
2009
Oct
2009
Nov
2009
Dec
2009
Jan
2010
Feb
2010.
Mar
2010
Apr
2010
COPD
133.9 129.4 127.2 119.9 112.3 104.8 103.6 102.1
Pneumonia 117.1 111.1 112.1 108.9 102.8 103.2 98.3
98.1
Stroke
105.1 101.7 98.2
90.7
86.6
83
80.4
77.2
AMI
128.6 129.8 123.6 126.3 131.2 126
119.5 119.2
Heart
133.7 130
129
124.5 122.5 119.7 112.2 104.6
Failure
Trust
117.5 114.3 110.9 107.9 105.6 102.5 96 3
94.9
Overall
(data source: Dr Foster Intelligence System as of 1 November 2010)
•
•
•
•
•
•
•
•
•
•
•
May
2010
Jun
2010 1
Jul
2010 2
Aug
2010
101.8
99.3
80.1
110.1
94.3
118.8
101.3
89.5
119.2
110.1
115.3
99.7
89.5
108.6
107
109.7
99.7
88.6
116.7
112.3
93.1
99.9
98.3
97.4
Sustained achievement of increased cleaning monitoring scores for high and very
high risk areas
Approx 70% of all children arriving in the A&E department are seen in the
Children’s Area.
In excess of 90% of those attending the Children’s A&E currently express
satisfaction with the service.
Weekend discharges within the Directorate of Medicine and Emergency Care
have increased to 16% of the total weekly discharge.
Nurse facilitated discharge protocol has been successfully implemented in both
the medical and surgical directorates.
98% target for A&E patients to be admitted or discharged within 4 hours has
been achieved consistently since March 2010 with average journey time through
the department of 196 minutes (weel commencing 8 November).
Length of stay for patients with a stroke is below 20 days and HSMR is currently
89.5 (after re-basing).
A one stop clinic has been introduced for low risk TIA patients to be seen within 7
days of the onset of symptoms.
The Principles of Care Audit results for October indicate that:
o 98% of patients had their baseline observations recorded within 2 hours of
admission
o 99% of patients had an accurate PARS score calculated with 90%
appropriately escalated to the relevant team.
o 85% of patients had their pressure areas assessed within 2 hours of
admission
o 97% of patients had a care plan
In October 96% of patients who were admitted with Heart Failure were seen
within 48hrs by the Nurse Specialist in Heart Failure and 97% received an ECHO
within 48 hours of admission.
Reporting times for radiological examinations have improved: over 90% of urgent
requests are being reported within 24 hours and over 60% are reported within 7
days. In addition, 94% of reports are completed using digital dictation.
1
Dr Foster re-based HSMR based on 2009/10 national averages. The overall result is that all
HSMR values are likely to increase. The figures for June 2010 reflect the effect of this rebasing.
2
None of the HSMR values for this period are denoted as significantly worse than expected
(i.e. they are not showing as red on the system)
3
Measurement changed for Trust position to reflect standalone position rather than Peer SHA
as previously.
70
6 Forward Planning
For the future, meetings have been held with the directorates in order to determine
their priorities and to provide an indication of the need for any of these priorities to be
managed through this process.
In order to provide high visibility of decision making, all projects that directorates
would like to be taken forward by the PMO will be presented to the Programme
Board and the decision made whether this is appropriate. Where there is agreement
for the PMO approach to be used, this decision will be clearly recorded and
communicated to the directorate. Likewise, any project that is ready to be closed will
be approved and recorded by the Programme Board. In this way, there is a clear
evidence trail of the rationale for opening and closing projects.
7 Project Risks
Each project has a risk register to track the key risks to the delivery of the project.
The Programme Board reviews the red risks on a monthly basis, using the PMO risk
register. As of 12 November 2010, the highest risks were:
•
•
Impact of the failure to achieve Risk Management Standards for maternity or
general.
Potential Impact of the PCT and Social Services economic constraints on the
ability to facilitate complex discharges.
Mitigating action is being taken to reduce these risks and the risk register is reviewed
monthly by the Programme Board.
8
Monitor KPIs
Performance against the KPIs agreed with Monitor for October is attached at
Appendix 2.
9
Conclusion
The discipline of the PMO approach to performance management continues to show
tangible improvements in the quality of services provided by the Trust, with evidence
to support this. The PMO has been operational for nearly one year and consideration
is now being given to the future of the Office. As the discipline of the PMO is
increasingly being embedded at directorate level, with many projects being delivered
locally using this methodology, it is time to review the role and function of the PMO
as it is currently configured and this will form the basis of a further report to the Board
in December.
71
Appendix 1
MILESTONES
Programme Management Office report on project progress
Dashboard date: 15 November 2010
PMO
reference
Overall Risk
(RAG)
Previous Week
A
A
Karen Fashanu
Beth Smyth
G
G
Karen Bates
Develop and implement local guidelines for
pneumonia (Monitoring)
A
A
1.01.02 Capacity management and discharge
Discharge project: Surgery
A
Discharge project: Medicine
A
Priority area
1.04 Top 5 HSMR: Stroke
Project Name
Stroke Improvement Programme (Monitoring)
Reduction in the incidence of Hospital Acquired PU,
2.13 of grade 2 and above
Pressure Ulcer Management (Monitoring)
1.06 Top 5 HSMR: Pneumonia
1.05 Top 5 HSMR: COPD
1.07.01 Top 5 HSMR: Heart failure
1.08.1 Top 5 HSMR: AMI
Discharges: Paediatrics
A
Project manager
Deputy project
manager
RISKS - criteria and classification TBC
in line with Trust process
KEY PERFORMANCE INDICATORS
This Week
Cumulative YTD
Planned
no. of
Actual Missed % Behind
milestones
Planned no.
Actual Missed % Behind
of milestones
Performance against KPIs
Last week
No. of KPIs
not met
Previous %
behind
Planned no.
of KPIs
% Behind
Rating (top)
Mitigation
actions set
out
ISSUES FOR PROGRAMME BOARD
Risk RAG
Exception Reporting
Finance manager
Information analyst
Clinical lead
Executive lead
Duncan Stockwell Farhad Huwez
Stephen Morgan
0
0
0%
88
0
0%
3
1
33%
33%
Moderate risk
Yes
G
KPIs regarding 90% of time on the stroke unit is 75% in September against a target of 90% Quarterly data. HSMR for July - 89.5 - HSMR update due 1.11.10. LOS is recorded as 24.9 against
a target of 25 for September. (Monitoring)
Linda Smart/Kirstie
Metcalf/Cathy
Plumley
N/A
N/A
Diane Sarkar
0
0
0%
106
0
0%
3
0
0%
0%
Moderate risk
Yes
G
Workbook not been updated. LS advised that the project lead has been on annual leave and will
feed in the data this week. (Monitoring)
Andrea Holloway
Sarah Lincoln
Duncan Stockwell Johnson Samuel
Stephen Morgan
0
0
0%
17
0
0%
2
1
50%
100%
Moderate risk
Yes
G
A
Pam Charlesworth
Deborah McCarthy
/ Nicki Abbott
Jenny Davis
Wendy English
Mr Carew (Orth) &
Mr Lafferty (Surg.)
Mark Magrath
1
1
100%
17
1
6%
2
0
0%
N/A
High risk
Yes
R
A
Dawn Patience
Sam Neville
Wendy English
Dr I Gupta
Mark Magrath
1
1
100%
43
1
2%
2
0
0%
0%
High risk
Yes
R
. HSMR for August remains at 99.7. LOS being achieved with 13.9 against a target of 13 for
September 2010. (Monitoring)
Milestone due this week regarding stakeholder meeting to relaunch enhanced recovery programme.
KPI regarding 95% of patients with EDD recorded on PAS is 98.2% w/c 1.11.10 and 80% of those
with an EDD discharged on or before EDD is 93.2 w/c 1.11.10. Red risks within this workbook
include financial constraints within the PCT, noro virus and flu outbreak and seasonal trauma.
WORKBOOK NOT UPDATED
One milestone not met re: continuing HC checklist training for 5 pilot wards . Average LOS by
ward/directorate recorded as 8.66 for September. Number of discharges per week recorded as 260
for 11.10.10. Red risks within this workbook include financial constraints within the PCT, noro virus
and flu outbreak and seasonal trauma.WORKBOOK NOT UPDATED
G
No Milestones due this week. DC has agreed to review the milestones in relation to what has been
completed prior to her taking over the project. DC will also consider new actions for the workbook.
DC hoping to engage Nursing staff prior to Consultant engagement in order to push this project
forward. KPIs have been agreed, but trajectories are to be set regarding LOS for Wagtail and Puffin
wards. LOS for Wagtail recorded as 1.7 for September and Puffin recorded as 3, trajectories to be
added to the workbook. Project has been RAG rated as amber due to lack of visibility. WORKBOOK
NOT UPDATED
A
Debbie Crisp
Jane Thomas
Sarah Lincoln
Karen Stewart
Karen Stewart
Karen Stewart
Karen Stewart
Linda Smart
Maureen Duncan Dr Sharief
Mark Magrath
0
0
0%
28
0
0%
2
0
0%
N/A
Moderate risk
Yes
Embed COPD pathway
G
G
Andrea Holloway
Karen Stewart
Duncan Stockwell Deepak Mukherjee
Stephen Morgan
0
0
0%
60
0
0%
2
0
0%
0%
Moderate risk
Yes
G
Heart failure
A
A
Danny McCormack Tina Faulkner
Jenny Davis
Anita Sutton
Pat Phen
Stephen Morgan
0
0
0%
12
0
0%
2
1
50%
50%
Moderate risk
Yes
G
AMI
A
A
Tina Faulkner
N/A
Anita Sutton
Pat Phen
Stephen Morgan
0
0
0%
16
0
0%
2
1
50%
50%
Moderate risk
Yes
G
Jacqueline Smith
No Milestones due this week. Achieving KPI regarding HSMR with 109.7 (against 110) recorded for
August 2010. LOS has dropped for September with 6.8 against a target of 8. Compliance audit has
now been completed which shows 60% compliance with the pathways. Dr Mukherjee will be
circulating feedback at various Consultants meeting over the coming weeks.
One KPI not being met regarding HSMR with 112.3 for August 2010 against a target of 100. No
milestones due this week.
Milestones on track. HSMR for August is recorded as 116.7 against a trajectory of 108. LOS is 7.1
for October 2010 against a target of 8.95. JS continues to audit all cases coded as AMI.
Milestones outstanding with regards to the Named Paediatrician, HB has agreed to formalise a
protocol for under 16 year olds, which will go to CD Board. HB to update KPI data re: number of
Consultant Anaesthetists received advanced paediatric life support and number of A&E nursing staff
trained in advanced paediatric life support or equivalent. WORKBOOK NOT UPDATED
1.10 Children's Services Review
Children's Services Review
Response and management of deteriorating
2.02 Response and management of deteriorating patient patient
Ensuring compliance with Trusts standards for
2.05 DNAR
Resuscitation
3.04 Top 5 HSMR: Other perinatal conditions.
Perinatal Mortality
A
A
Helen Boswell
Tracey Glester
Karen Stewart
Maureen Duncan Ruth Taylor
Diane Sarkar
2
2
100%
40
2
5%
2
2
100%
0%
Moderate Risk
Yes
G
Novi Ukpemo
N/A
Chris Welch
Diane Sarkar
2
2
100%
81
3
4%
1
0
0%
0%
Moderate risk
Yes
G
N/A
Mike Imana
Stephen Morgan
2
0
0%
56
0
0%
2
0
0%
0%
Moderate
Yes
G
Milestone outstanding re: Publishing the patient safety strategy, fortnightly review of health records,
contact Wendy English with regards to PAMS information. KPI being achieved with 100%
recognition of the deteriorating patient against a target of 89%. WORKBOOK NOT UPDATED
Milestones are on track. KPIs for October shows 81% of compliance with DNAR forms against a
target of 90%, and 94% signed by a consultant against a target of 80%.
Mr Ikomi
Chris Welch
0
0
0%
38
0
0%
1
1
100%
100%
Moderate
Yes
G
Milestones on track. HSMR has increased again to 177.4 for August 2010 against a target of 100.
Again this data continues to include the exceptionally high HSMR for September 2009 data.
However CEMACH data does not currently show Perinatal Mortality as a significant outlier.
G
G
Linda Smart
Marie
Nicholson/Cathy
Plumley
R
G
Rachel Johnson
Rachel Crisp
Jenny Davis
G
G
Debbie Crisp
Helen Boswell
N/A
PMO met with both HB and AF this week and had a very successful meeting. One milestones
remains outstanding regarding extending Paediatric centre hours until midnight. However AF and
HB have agreed to write a paper setting out that the original report around the extension to opening
hours was completed very shortly after the unit opened and what is now required.
It was also agreed that the Paediatric A&E unit does not need to be staffed by Paediatric Nurses
alone. Agenda items in place for the next Paediatric Emergency care pathway meeting (Paeds and
A&E) to include:
- Registrar on shift supervising FY2s.
- For the 1st month, no children are discharged without the FY2 checking with the Registrar. Flashcards for adult nurses supported by regular training programmes.
- Resus Training to be arranged.
3.05 Children's Services Review
3.07.5 CQC
Paediatric emergency care pathway
NMC action plan
A
G
A
G
Helen Boswell
Lyn Cook
Sally Brown
Avril Archibald
N/A
TBC
N/A
Stephen Morgan
Diane Sarkar
0
0
0
0
0%
0%
56
52
1
1
2%
0%
2
2
1
0
0%
0%
50%
0%
Moderate
Moderate risk
Yes
Yes
G
KPI not being achieved with regards to % of children being seen in the A&E/Paediatric unit with
71.6% against an increased trajectory of 80% (October). WORKBOOK NOT UPDATED
G
Milestones delay is regarding costings for the Midwifery lead unit which LC has still not received
despite involvement of Jenny Galpin and Diane Sarkar. With regards to the Operational policy; the
policy steering group was cancelled in October, so the next meeting will not take place until the end
of November. LC will attempt to get this approved electronically. KPIs are being achieved.
One milestone outstanding regarding agreeing reporting standards and trajectory. Both KPIs are
being achieved. Last data update 4.10.10. Reports typed within one week not achieving with 70% No trajectory set. Trajectory not yet been agreed.
RAG rating to be debated - Milestone remaining outstanding. KPI regarding reports typed
within one week also has no trajectory, but target is set at 90.
3.09 Capacity management
2.14.01 CNST
Radiology
A
G
Risk Management Standards - General LEVEL 1
G
G
A
A
G
G
Michael Catling
Paul Osborne
N/A
Dr Hails
Mark Magrath
0
0
0%
23
1
4%
2
1
50%
0%
0
0
0%
53
0
0%
2
0
0%
100%
Risk Managements Standards - Maternity
0
G
G
Yes
High risk
Yes
G
G
Marie Nicholson
Linda Smart.
N/A
N/A
Andrea Saville
0
0
20
0
0%
1
0
0%
N/A
High risk
Yes
R
Diane Sarkar
0
2.14.02 CNST
Moderate risk
0
0
0
0
0
0
0
0%
N/A
Moderate
Yes
G
Lynn Cook
Helen Boswell
N/A
4.02 Core business projects
Productive theatres
A
A
Marcie Tunbridge
James Leek
Jenny Davis
5.01 H&SE
Manual Handling
G
G
Stephanie Lawton
Meera Nair
N/A
N/A
Julie Plane
Andrea Saville
Diane Sarkar
5
0
0%
72
0
0%
2
0
0%
0%
Moderate
Yes
G
G
Kevin Lafferty &
Lyndsey Rylah &
Bryony Lovett &
Robert Carew
Chris Welch
17
17
100%
298
20
7%
2
0
0%
100%
Moderate
Yes
N/A
Nigel Taylor
0
0
0%
12
0
0%
0
0
0%
0%
Moderate
Yes
G
Milestones and KPIs are complete for level 1 including all policies received. compliant and
bookmarked.
No milestones due this week for level 2. KPIs recorded as 51/51documents received for compliance
checking. External auditor is completing a systematic review of information required for level 2.
Bookmarking and hyperlinking will take place once this has been completed. Red risk still remains
around Insufficient evidence of embedding at level 2
Milestones and KPIs for level 3 not being measured.
Milestones are on track. Both KPIs are being achieved with 84% of health records compliant
against a target of 75% in October 2010, and 100% of deadlines met with regards to CNST action
plan on 1.11.10.
Milestones outstanding regarding monthly news letter, review success of measures for each of the
3 components and new session start-up process to be agreed with Clinicians.
KPI regarding the amount of operating time undertaken during a list is being achieved with 73.9%
against a revised trajectory of 70% in w/c 1.11.10. Marcie has commenced population of utilisation
of the number of lists which has been reported as 108 against a target of 118.75 for w/c 25.10.10
with 9 lists that were planned not to go ahead and 1 cancelled at short notice. WORKBOOK NOT
UPDATED
No milestones outstanding. No KPIs to be measured. All link co-ordinators have either already
completed their training or are scheduled to complete by end of December 2010.
Two milestones remain outstanding regarding finalising core shifts and determine annual leave
entitlement. JM is awaiting OPD to finalise their core shifts and continues to chase them. TOIL
balance for the Trust recorded as +835 w/c 1.11.10. Red risk remains regarding Bradford scoring
and the absence interface.
4.01 Core business projects
E-rostering
A
A
Anthony Fitzgerald Jenny Mullin
TBC
Nigel Taylor
0
0
0%
19
2
11%
2
0
0%
0%
High risk
Yes
R
72
Appendix 1
Milestones outstanding regarding discussion at capacity board and agreeing action plan to address
system wide capacity problems. KPI regarding patients with a LOS over 44 days have increased
with 21 w/c 8.11.10 against a trajectory of 40. This may often be the case as patients with a LOS
over 30 days are not being looked. KPIs regarding Patients with a LOS over 100 days has reduced
to w/c 8.11.10 against a target of 5. Targets have been amended in relation to the best of last years
performance.
Red risk remains relating to PCT and social services financial situation.
1.02 Capacity management and discharge
Complex discharges
A
A
A
A
Wendy Hurrell-SmithAndy Graham
6.01.1 QIPP
New to follow up OPD project - Urology
6.01.2 QIPP
New to follow up OPD project - General
Surgery
A
A
Lisa Want
6.01.3 QIPP
New to follow up OPD project - Cardiology
A
A
Yvonne Brierley
6.01.4 QIPP
New to follow up OPD project - Maternity
G
A
Lynn Cook
N/A
Lisa Want
Mr Ravi/Mr Vohra
Mark Magrath
Mark Magrath
2
0
0
0
0%
0%
10
8
0
2
0%
25%
2
3
0
1
0%
33%
0%
0%
Extreme Risk
Moderate
Yes
Yes
R
R
Two milestones have slipped this week re: complete milestones to reflect agreed actions (internal)
and highlight to Emma Timpson actions required by Primary Care. KPI data is being populated but
a trajectory needs to be agreed. Follow up ratio stands at 1:3.7 recorded w/c 8.11.10 (Aim to get to
1:2).
Milestones being missed regarding external actions required to be discussed with Emma Timpson,
reviewing the proceedure for outpatient appointments, review meetings with service managers to
share findings and review of follow-up appointments 6 weeks in advance. KPIS being populated with
the follow-up ratio currently recorded as 1:1.2 w/c 8.11.10 (Aim to get to 1:1)
Mr Menon
Mark Magrath
4
4
100%
11
6
55%
3
1
33%
0%
Moderate
Yes
G
Tina Faulkner
Dr Phen
Mark Magrath
2
1
100%
8
1
13%
3
1
33%
0%
Extreme Risk
Yes
R
Sue Grace
Mr Ikomi
Mark Magrath
1
1
100%
4
1
25%
3
0
0%
0%
Moderate
No
G
Milestones outstanding regarding implementing agreement of actions to be taken. KPI data is being
populated. New to follow-up ratio recorded as 1:3.4 w/c 11.10.10. (aim to get to 1:1.45). Red risk
regarding PCT support.
Milestone slipped regarding determining actions to reduce F/up ratio. KPI data has been populated
and the follow-up ratio recorded at 1:1.1 w/c 8.11.10 (Target of 1:2.2)
7 milestones outstanding this week re: Audit the cause of follow ups to determine clinical
applicability, Identify if the care pathway is being followed by Consultants and Registrars and
Identify the actions required to reduce to required levels and complete workbook with actions.
Undertaking spot audits of 10 sets of notes (fortnightly) has also not been completed.
KPI data is being populated and the follow up ration was recorded as 1:1.5 w/c 8.11.10 (Aim to get
to 1:1.14)
Red risks have been reviewied in light of the new BAF Risk Register and also down graded.
6.01.5 QIPP
New to follow up OPD project - Gynaecology
A
A
Jane Thomas
6.01.6 QIPP
New to follow up OPD project - Oral Surgery
A
A
Jo McCollum
6.01.7 QIPP
New to follow up OPD project - Pain
Management
A
A
Carol Banks
Mr Thakkur
Mark Magrath
4
4
100%
15
7
47%
3
1
33%
0%
Moderate
Yes
G
Dawn Bramham
Mark Magrath
2
1
50%
4
1
25%
3
1
33%
N/A
High risk
To be added
R
Dawn Bramham
Mark Magrath
2
2
100%
10
3
30%
3
0
0%
N/A
Moderate risk
Yes
R
Two milestone slipped this week re: Complete workbook with additional actions and agreeing
changes to clinic template and implement changes. KPIs data is being populated with a follow up
ratio of 1:1.4 w/c 8.11.10 (Aim to get to 1:2.4) . Trajectory to be agreed.
One milestone slipped this week re:to review appointments to determine reasons for follow-up. KPI
data is being populated with follow up ratio recorded as 1:2.1 w/c 8.11.10 (Aim 1:1)
6.01.8 QIPP
3.03 Releasing Time to Care
1.11.03 A&E
New to follow up OPD project - T&O
A
A
Kim Saunders
Nikki Abbott
Releasing Time to Care
A
A
Alison Griffiths
Ganine Byford
A &E working towards 2012
LD - Person centered pathways for better health
outcomes
7.01.1 Quality Improvement
3.10
N/A
N/A
Julie Hickman
Lokesh
Narayanaswamy
A
A
Lesley Roberts
Anthony Fitgerald
Karen Stewart
Hayley Peters
A
A
Shoenagh McKay
Julie Hickman
N/A
N/A
N/A
N/A
Karen Fashanu and
Diane Baker
TBC
N/A
Simple discharges: CTC (CLOSED)
N/A
N/A
Tina Faulkner
N/A
N/A
Andy Graham
Anita Sutton
Wendy HurrellSmith
Jenny Davis
Direct admissions (CLOSED)
N/A
End of Life
Mark Magrath
1
1
100%
5
1
20%
3
1
33%
N/A
Extreme Risk
Yes
R
One milestone slipped re agreeing protocols for follow-ups of non complex hip replacements.. KPI
data is being populated with a follow up ratio of 1:1.6 for fracture clinic w/c 25.10.10 (Aim to get to
1:1.2) and T&O recorded as 1:1.6 w/c 8.11.10 (Aim to get to 1:1.2). Red risk remains regarding
insufficient management capacity to deliver this project. To be reviewed once detail of workbook
completed with actions. Clinical Lead is yet to be confirmed.
Diane Sarkar
0
0
0%
0
0
0%
0
0
0%
N/A
Moderate
Yes
G
PMO met with AG and discussed the best monitoring format for this project. It was agreed that the
PMO approach is not flexible enough for this project and a steering group arrangement was
considered. PMO debated this at the Programme Board on 5.11.10.
Stephen Morgan
Diane Sarkar
3
0
0%
7
0
0%
7
2
29%
0%
Moderate
Yes
G
0
51
0
37
0%
73%
0
1289
0
54
0%
4%
0
74
0
17
0%
23%
0%
TBC
TBC
TBC
Milestones on track. KPI regarding average journey time through Majors in minutes (Median) is not
being achieved with 221 minutes recorded w/c 1.11.10 against a target of 210. Also KPI with
regards to average journey time through Minors in minutes (Median) is not being achieved with 187
minutes against 180 w/c 1.11.10.
Workbook to be revised following SM meeting with the Project Manager for the EoE Project team.
PMO agreed to meet again w/c 22.11.10.
0%
0%
TBC
TBC
TBC
PMO meetings to start shortly, following discussion with Dr Morgan.
TBC
TBC
Anita Sutton
Paul Kelly
Mark Magrath
0
0
0%
17
0
0%
3
0
0%
0%
Low Risk
Yes
G
CLOSED
N/A
David Gertner
Mark Magrath
0
0
0%
3
0
0%
1
0
0%
0%
Moderate risk
Yes
G
CLOSED
CLOSED PROJECTS
1.09.02 A&E and MAU
Nursing establishment on MAU (CLOSED)
N/A
N/A
Kim Perry
Lesley Roberts
Karen Stewart
Steven Lewis
Elsir Osman
Maggie Rogers
0
0
0%
27
0
0%
0
0
0%
0%
Low risk
Yes
G
CLOSED
1.09.01 A&E and MAU
3.02 A&E and MAU
MAU education workstream (CLOSED)
MAU medical leadership (CLOSED)
N/A
N/A
N/A
N/A
Kim Perry
Lesley Roberts
Anthony Fitzgerald
Karen Stewart
Steven Lewis
Maggie Rogers
Stephen Morgan
0
0
0
0
0%
0%
12
46
0
0
0%
0%
2
3
0
0
0%
0%
100%
0%
Low risk
High risk
Yes
Yes
G
G
CLOSED
CLOSED
1.11.02 A&E and MAU
A&E: RIE (CLOSED)
Clinical data capture: generic clerking form
(CLOSED)
Primary Percutaneous Coronary Intervention
(PPCI) (CLOSED)
CQC Condition 4 - Assessment and Care
Planning (CLOSED)
N/A
N/A
Sarah Noon
Lesley Roberts
Karen Stewart
Hayley Peters
Elsir Osman
Elsir Osman
Lokesh
Narayanaswamy
Stephen Morgan
0
0
0%
70
0
0%
1
0
0%
100%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Kim Perry
Anthony Fitzgerald Karen Stewart
Duncan Stockwell Indi Gupta
Stephen Morgan
0
0
0%
29
0
0%
2
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Tina Faulkner
Anita Sutton
Jenny Davis
Anita Sutton
Stephen Morgan
0
0
0%
21
0
0%
4
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Julie Hickman
Linda Smart
N/A
Maggie Rogers
0
0
0%
13
0
0%
5
0
0%
0%
High Risk
Yes
G
CLOSED
N/A
N/A
Pam Charlesworth
Amanda Fife
N/A
Maggie Rogers
0
0
0%
21
0
0%
0
0
0%
0%
High risk
Yes
G
CLOSED
N/A
N/A
Sarah Noon
Lesley Roberts
Karen Stewart
TBC
Lokesh
Narayanaswamy
Stephen Morgan
0
0
0%
11
0
0%
1
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Linda Smart
N/A
Mark Magrath
Nigel Taylor
0
0
0
0
0%
0%
75
14
0
0
0%
0%
2
0
0
0
0%
0%
0%
0%
Moderate
Moderate
Yes
Yes
G
G
CLOSED
CLOSED
Novi Ukpemo
N/A
Linda Johnson
Maggie Rogers
0
0
0%
27
0
0%
0
0
0%
0%
Moderate risk
Yes
G
CLOSED
N/A
N/A
Adam SewellJones.
Alan Whittle
0
0
0%
27
0
0%
0
0
0%
0%
Moderate
Yes
G
CLOSED
Novi Ukpemo
N/A
N/A
Chris Welch
N/A
Mark Magrath
Nigel Taylor
0
0
0
0
0%
0%
79
3
0
0
0%
0%
1
0
0
0
0%
0%
0%
0%
Moderate
TBC
Yes
TBC
G
TBC
CLOSED
CLOSED
N/A
Duncan Stockwell Dr Yung
Stephen Morgan
0
0
0%
14
0
0%
1
1
100%
100%
Moderate
Yes
G
CLOSED
Novi Ukpemo
N/A
Diane Sarkar
0
0
0%
98
0
0%
2
0
0%
0%
Moderate risk
Yes
G
CLOSED
Diane Sarkar
Nigel Taylor
0
0
0
0
0%
0%
16
9
0
0
0%
0%
3
1
0
0
0%
0%
0%
0%
Moderate risk
Moderate risk
Yes
Yes
G
G
CLOSED
CLOSED
Jenny Galpin
Mark Magrath
0
0
0
0
0%
0%
23
23
0
0
0%
0%
3
1
0
0
0%
0%
0%
0%
High risk
Moderate risk
Yes
Yes
G
TBC
CLOSED
CLOSED
1.13 Clinical data capture and coding
1.08 Top 5 HSMR: AMI
3.07.4 CQC
2.07 Response and management of deteriorating patient PARS Service Review (CLOSED)
Improved medical workforce for A&E
1.11.01 A&E and MAU
(CLOSED)
3.01 Delivering Single Sex Accommodation
5.02 H&SE
Delivering Single Sex Accommodation
(CLOSED)
Health & Safety Training (CLOSED)
N/A
N/A
N/A
N/A
Marie Nicholson
Stephanie Lawton
Linda Smart &
Cathy Plumley
Meera Nair
Nursing documentation project (CLOSED)
N/A
N/A
Julie Hickman
Alison Griffiths
CQC Non-compliance (CLOSED)
N/A
N/A
Andrea Saville
5.03 H&SE
Coding
Violence and Aggression (A&E)
N/A
N/A
N/A
N/A
Ruth Taylor
Eghosa Bazuaye
Emma Timpson
(Baz)
Anthony Fitzgerald Sarah Noon
2.06 Reduce HSMR for Lung Cancer
Lung Cancer
N/A
N/A
Andrea Holloway
1.17 Learning disabilities
Learning disabilities
N/A
N/A
3.07.1 CQC
3.07.2 CQC
CQC Condition 1 - Training for acutely ill
patients
CQC Condition 2 - Staff Appraisals
N/A
N/A
N/A
N/A
Shoenagh MacKay Julie Hickman
Pam
Charlesworth/Julie
Hickman
Linda Smart
Stephanie Lawton Meera Nair
3.07.3 CQC
CQC Condition 3 - Legionella
Enabling capacity in MEC
N/A
N/A
N/A
N/A
Rob Speight
Simon Myles
Anthony Fitzgerald
3.07.6 CQC
Sarah Lincoln
Hayley Peters
Paul Kelly
Julie Hickman
N/A
N/A
N/A
Dr Gertner
KEY
Closed projects
Monitoring
Pipeline or suspended
73
Appendix 2
Proposed Key Performance Indicators (KPIs) for Basildon & Thurrock University Hospitals NHS Foundation Trust
Date:
Metric Area of ToA ref no. breach
1
HSMR/Pathway Improvement
18‐Oct‐10
Objective
Achieve an annual rebased HSMR index of less than 100.
Objective Leads (Exec/Operational)
Medical Director/Associate Medical Director
Risk rating
8
Key Performance Indicator
Dr Foster 12 month rolling average (basket of 56 HRGs) against index in place at the time of reporting
Apr‐10
Actual
2
Hygiene Code
Maintain average environmental cleanliness scores Director of Estates and at or above 95% in clinical areas identified as high and Facilities/ Facilities 98% in clinical areas identified as very high risk in the Manager
NPSA national specifications for cleanliness with individual scores only falling below 93% for high and 96% for very high on a limited number of occasions in accordance with the agreed trajectory. This includes each theatre, ward & critical care area as well as A&E, maternity and pharmacy. Any area scoring less than 93% and 96% respectively to have an action plan to address areas of concern. 10
Provide evidence to the CQC of successful delivery Chief Executive/ against agreed action plans to allow for the removal Corporate Secretary
of all conditions of registration.
5
Trajectory
Number of occasions where high(H) or very high(VH) risk areas score below 93% and 96% respectively against the cleaning services elements in the national specifications for cleanliness . This is measured by regular ward/dept level monitoring reports.
Actual
Trajectory
3
CQC Registration
5
6
7
Children’s Services 75% of children attending A&E are treated in the designated Paediatric A&E unit Children’s Services Maintain high level (90% satisfaction) of Patient Experience in Children's A&E from Jan 2010
Governance
8
Director of Operations and Service Development/ GM, Medicine and Emergency care
9
Director of Nursing/ GM, Medicine and Emergency care
6
To achieve and maintain a governance risk rating of Chief Executive/ green, as set out within the Compliance Framework Associate Director of Operations
(2010/11). 8
Deliver all actions agreed following the PwC Corporate governance review in line with timescales contained Secretary/Chief in the action plan
Executive
4
Sep‐10
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
97.7
Mar 2010 data
104.4
Apr 2010 data
98.3
103.4 May 99.9 Jun Jul 2010 data
2010 data
2010 data
97.4
Aug 2010 data
Sep 2010 data
Oct 2010 data
Nov 2010 data
106
103
99
105
101
98
97
96
95
94
93
H ‐ 0
VH ‐ 2
H ‐ 0
VH ‐ 2
H ‐ 1
VH ‐ 3
H ‐ 0
VH ‐ 0
H ‐ 0
VH ‐ 0
H ‐ 0
VH ‐ 0
H ‐ 1
VH ‐ 0
H ‐ 2
VH ‐ 13
H ‐ 2
VH ‐ 13
H ‐ 2
VH ‐ 12
H ‐ 2
VH ‐ 11
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
H ‐ 2
VH ‐ 10
Agreement with CQC to Completed Completed extend to for condition for condition 15th September
1
2
Submitted
Completed
Condition 4 and 5 applications to vary condition submitted. Relevant staff Application to Application to Training vary vary trained to needs condition 1 condition 3 recognise analysis completed for deteriorating submitted. submitted. detriorating patient.
Application to patient
vary condition 2 submitted. Mar‐11 Comments
The changes in the 12 month rolling average trajectory is driven by the net impact of each new months performance and the removal of month 13. Other measures of mortality continue to be reviewed including crude death rate and deaths as percentage of discharges. Work is continuing Dec 2010 to focus on both clinical quality and coding improvements. The impact of coding improvements data
can be applied retrospectively and therefore previously reported figures can still be improved upon. Detailed work has been undertaken with Dr Foster and notes are constantly reviewed. Note: The trajectory increase has changed for data from Apr 2010 as the Dr Foster rebase has now taken place (previously anticipated in Oct 2010)
92
Regular inspections undertaken to ensure contract standard is being delivered. The NPSA states that "there are no national targets within these specifications, however, good practice would suggest that individual hospitals/trusts set their own aims. These should be realistic, achievable, challenging and regularly reviewed to ensure they contribute to an ethos of continuing improvement. Weekly monitoring of scores for all areas is undertaken by the executive team. This is considered at executive team meetings and through weekly ward/dept level scores being shared with the team. Exception reports and actions to address areas below this will be monitored by the Board. The requirement for an action plan where performance falls below 93% will ensure any areas of concern are addressed promptly if not already done so locally. Whilst the aim for these areas is 100% compliance, the threshold reflects the range of measures scored in each area and the practical challenge of delivering a perfect environment 100% of the time e.g. if the inspection takes place in a bathroom as a patient leaves it following use.
H ‐ 2
VH ‐ 10
Registration achieved with 5 conditions from April 1 2010. 4 conditions now removed. Confirmation received that final condition being removed following unannounced visit.
Completed for condition 3
NMC action plan complete. Actual
11
12
12
14
14
14
14
Internal training courses only provided twice per year, due to the need to use a faculty including external instructors . All staff will be trained within deadline; trajectory and targets have been set to deliver the standards included with the National Service Framework for Children. The qualification lasts for 3 years and any new staff will be picked up as part of the ongoing programme. Training of all consultants will now be achieved by Jan 2011 due to timing of training course. The Resuscitation Training Team actively seek vacant places on other organisation's training programmes. These are being utilised if available to achieve the objective earlier in 2010. Trajectory
9
12
12
13
13
13
13
13
16
16
16
16
% of children attending A&E using the Paediatric A&E unit Actual
69%
67%
67%
66%
67%
70%
68%
Trajectory
65%
65%
65%
70%
70%
70%
75%
75%
75%
75%
75%
75%
Actual
94%
91%
90%
90%
92%
98%
92%
Trajectory
90%
90%
90%
90%
90%
90%
90%
The increased opening hours of the unit planned for July will now happen in September due to the inability to recruit appropriate staff to ensure a robust rota, therefore performance will be behind trajectory but is still expected to deliver the target. As highlighted in July, it has been agreed with the A&E department to amend the metric to increase from 0‐15 years to 0‐16 years. This supports the operating arrangements of the department but reduces the target to 75%. Parallel data for this year supports the 5% reduction to target. The 25% not attending will include those children not deemed appropriate (e.g. due to seriousness of injuries and other factors) as well as those attending during the night and these categories increase when including 16 year olds.
Unit opened end of Nov 2009. Satisfaction data captured from Jan 2010. Questionnaires based on a "yes/no" response to reflect positive and negative experience. An overall score of 90% indicates that 90% of answers to a standard 5 questions were positive. The target of 90% is in line with the stretch target the Board has agreed for satisfaction levels across the organisation. 5 questions for children and 5 for accompanying adults have been set and are being piloted. Responses will be asked of all children (where appropriate) and accompanying adults attending the paediatric unit. Additional qualititive data is also being collected and improvements have been made as a result.
Percentage positive response score against 5 yes/no patient experience questions.
90%
90%
90%
90%
90%
It is acknowledged that the Trust will be rated red for governance until Monitor deem otherwise and so the metrics are based on the points system within the compliance framework. The points from June are against the updated Compliance Framework.
Monitor validated self‐certified service performance score
2.3 forecast 1.5 forecast 1
2.3 (Amber‐Red)
Trajectory
Governance
Aug‐10
Staff undertaking training identified in needs assessment (cumulative)
Actual
8
Jul‐10
100.2
Feb 2010 data
Trajectory
Medical Children’s Services All 16 Consultant Anaesthetists who work with children to receive Advanced Paediatric Life Support Director/Associate Medical Director
training by Dec 2010 (and maintain certification through re‐training every 3 years) as agreed with the Healthcare Commission, 12 of whom will be trained by May 2010.
Jun‐10
102.9
Jan 2010 data
Achievement against milestones identified in detailed plan.
Actual
4
May‐10
1 forecast
1 forecast
1 forecast
0 forecast
<1.9 (Amber‐Green)
The review carried out by PwC in Q4 2009/10 provided 35 recommendations for improvement. Against these recommendations the Trust agreed 67 actions, with completion dates, which were agreed with PwC. Following the follow‐up review in July 2010, additional actions have been developed but the KPI here rermains against the original plan.
Number of actions delivered
Actual
31
44
60
Trajectory
33
43
60
61 and review completed
PwC to conduct review of progress
61
62
63
64
61
64
64
74
64
66
66
66
67
18/11/2010
Appendix 2
Metric Area of ToA ref no. breach
9
A&E Leadership
10
11
Capacity Management
Learning Disabilities (LD)
Objective
75% Percentage of patients referred to specialty doctor in 2 hours or less where appropriate
Eliminate the use of escalation beds (day‐care facilities used by inpatients due to inpatient bed unavailability) by Apr 2010.
Objective Leads Risk (Exec/Operational)
rating
12
Director of Operations and Service Development/ GM, Medicine and Emergency care
Director of Operations and Service Development/ Associate Director of Operations
LD specialist nurse/ Ensure all patients with LD admitted as inpatients Director of Nursing
have an LD assessment completed (as part of healthcare record) within 24 hours of admission and care plans are in place where appropriate
16
Key Performance Indicator
% of appropriate patients referred to specialty doctors within 2 hours
Apr‐10
Jun‐10
Jul‐10
Aug‐10
Sep‐10
Oct‐10
Actual
40%
40%
42%
39%
42%
36%
37%
Trajectory
40%
40%
45%
50%
60%
65%
75%
Nov‐10
75%
Dec‐10
75%
Jan‐11
75%
Feb‐11
75%
Mar‐11 Comments
The Trust is delivering the 4 hour A&E target, however continued improvement in this domain will further improve performance and reduce overall time spent within the department. A change in process has been agreed and will be implemented an arrival of new middle grade doctors to improve performance in this area. An improvement event has been undertaken and a new process was piloted in Sep with the target expected to be achieved in Oct. Unfortunately the commencement of middle grades has not happened in line with the plan when the trajectory was first agreed owing to visa / certification issues. However the recruitment to establishment is now almost complete with staff scheduled for commencement Oct/Nov. 75%
Average number of escalation beds used per day
Actual
5
May‐10
Trajectory
% of inpatients with LD having an full LD assessment completed (as part of healthcare record) and care plans in place as appropriate within Actual
24 hours of admission as reviewed by the LD specialist nurse.
Trajectory
8
4.5
2.5
0.8
1.1
3.7
5.2
8
4
0
0
0
0
0
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
One ward currently closed for refurbishment has now re‐opened and the decant ward is available from 15th Nov 2010. NHS SW Essex closed 17 community beds during September. Financial pressure on both the PCT and Social Services increases the risk around this metric. Additional improvements to internal discharge processes are being implemented to mitigate this.
0
0
0
0
0
The LD specialist assessment was introduced during 2009. The LD specialist nurse reviews all new admissions to the hospital and the assessment carried out by the clinicians includes all issues included within the rule 43a letter issued by the coroner to the Trust in Jul 2009.
Full assessment includes: All risk assessments completed within 6 hours, admission assessment of condition within one hour, consultation of preferences and special requirements with carers within 24 hours. Delivery against any specific care plans is part of the Principles of Care monthly audit programme and is reported to the Board monthly.
100%
100%
100%
100%
100%
75
18/11/2010
76
BOARD OF DIRECTORS
PART 1
MEETING 24 NOVEMBER 2010
AGENDA ITEM: (2) 7
ITEMS CONSIDERED BY THE BOARD OF CLINICAL DIRECTORS
SINCE THE LAST BOARD OF DIRECTORS MEETING
REPORT OF THE CHIEF EXECUTIVE
Performance Report*
The Board considered the Performance Report for September 2010.
Financial Recovery Plan
The Board considered the report which proposed a number of actions to return the Trust’s
financial position to a forecast surplus.
Payment by Results Briefing Paper 2011/12
The Board noted the report which provided detail of the proposed changes to the payment
by results regime for the 2011/12 financial year.
Guidelines for the Prevention and Management of Venous Thromboembolism
The Board considered the report which presented the new Trust Guideline for the
prevention and management of Venous Thromboembolism, which had been formulated to
ensure compliance with NHSLA risk management standards.
Infection Control
The Board received an update from the Director of Infection Prevention and Control who
advised the Board of the requirements to have in place a documented process for infection
control to satisfy the requirements of NHSLA, level 2. Risk Management Standards.
The Delivery of Adult Physiotherapy and Occupational Therapy Services
The Board noted that Physiotherapy and Occupational Therapy Services staff who worked
within the hospital had transferred to Trust employment from 1st November 2010.
Dates of Meetings 2011
The Board considered and agreed proposed dates for Board of Clinical Directors meeting
for 2011.
1
77
Management Core Brief
The Board agreed the Management Core Brief for cascade to all staff.
Clinical Tutor Update
The Board received an update in relation to Medical Education at the Trust
Service Restriction Policy
The Board received a presentation from Dr Andrea Atherton, Director of Public Health,
NHS South West Essex, advising of the changes to the Service Restriction Policy, arising
from the NHS South West Essex Turnaround Plan
Summary Care Record Programme
The Board received a presentation in relation to the benefits of introducing the Summary
Care record at the Trust
Care Quality Commission Mortality Outlier Alert
The Board received the reports which provided information and the associated required
actions relating to the mortality outlier alerts received from the Care Quality Commission
(CQC) in respect of the HRG diagnosis groups:- Intestinal Obstruction without Hernia
- Chronic Ulcer of Skin
Updated Assessment of NHS South West Essex Turnaround Plan *
The report advised on the Trust’s assessment and impact of the NHS South West Essex
revised turnaround programme for 2010/11
Clinical Site Management Reconfiguration
The Board agreed proposals to strengthen current arrangements for clinical site
management, and improvements to the overall utilisation of inpatient capacity.
Policies and Guidelines
The Board approved the following reviewed and updated policies
• External Visits
Serious Incidents (SIs)
The Board received a verbal update in relation to recent Serious Incidents, and agreed
that Serious Incidents would feature as a standing item on Board Agenda.
2
78
PART 1
BOARD OF DIRECTORS
AGENDA ITEM (3) 12
NOTIFICATION OF A PLANNED PROVIDER COMPLIANCE REVIEW BY THE CARE QUALITY
COMMISSION
REPORT OF THE CORPORATE SECRETARY
Purpose
On Tuesday 9 November 2010, the Trust received notification from the Care Quality Commission
(CQC) of its intention to undertake a planned Provider Compliance Review in response to information
received about the Trust. The purpose of this report is to inform the Board of Directors of the
immediate actions taken and the process followed to provide the information requested by the CQC in
the timeframes given.
Composition of the
Report
No. of pages:
No. of appendices:
2
0
Summary– key issues
To support this review, the CQC has requested additional information on the 16 outcomes of the
“Essential Standards of Quality and Safety” most directly related to the quality and safety of care. The
Trust was required to return the information to the CQC by Wednesday 17 November 2010. This
deadline was met.
The outcomes to be reviewed are detailed in the attached letter from the CQC.
Key points:
1 A strategic response team consisting of Executive Directors and members of the Programme
Management Office and Compliance Unit was convened to determine the actions needed to
confirm compliance with the essential standards.
2 Daily meetings were held to review progress and ensure that all actions agreed were taken.
These meetings were noted using a trained loggist.
3 An initial review of Performance Accelerator was completed in order to determine the level of
evidence currently available (the Directorates have been updating this information since
September, for the 6 month report to the Board). For consistency, the Executive team members
reviewed the same outcomes that they had initially reviewed at the time of registration.
4 A gap analysis was undertaken and meetings were scheduled on 12 and 13 November with the
outcome leads in order to test the evidence and agree additional evidence requirements.
5 Additional evidence was requested and submitted both corporately and at Directorate level in
the period 10 – 16 November 2010.
6 The reporting format (accessed directly from Performance Accelerator) lists every item of
evidence on the system which enables the CQC to review the level of detail considered when
determining compliance.
The Trust can expect a full site visit as a result of this notification, although the timescale for this is not
yet known.
79
Recommendation(s)/ Decision required
The Board of Directors is requested to note the report.
The Trust must maintain full compliance with the Essential Standards of Quality and Safety and ensure
up to date evidence of compliance is available at any time. In order to provide on-going assurance to
the Board of Directors, a quarterly review of compliance will be undertaken and the results presented
to the Board of Directors.
Implications
Patient Safety and Patient Experience: the Trust is required to maintain compliance with the Essential
Standards of Quality and Safety in order to provide health services. The focus of compliance is on the
outcome of care for patients.
Financial (efficiency, economy, effectiveness): The CQC is able to impose financial penalties for noncompliance.
Equality and Diversity: To maintain registration the Trust is required to explain how it promotes
equality, diversity and human rights.
Legal: Registration is a legal requirement in order to provide health and social care in England.
Communications/Reputation: Registration without conditions will significantly improve the Trust’s
reputation.
NHS Constitution: The Essential Standards of Quality and Safety support the pledges and rights in the
NHS Constitution.
Acronyms/ abbreviations used in the report (where not stated):
None
Author: Ruth Taylor
Status: Deputy Programme Director
80
PART 1
BOARD OF DIRECTORS
AGENDA ITEM (6)15
CQC REGISTRATION – PROGRESS WITH ACTION PLAN
REPORT OF THE CORPORATE SECRETARY
Purpose
The purpose of this report is to inform the Board of Directors of progress with the action plans
developed to ensure compliance with the conditions to the Trust’s registration.
Composition of the
Report
No. of pages:
No. of appendices:
2
0
Summary– key issues
1. On 1 April 2010, the Care Quality Commission (CQC) granted the Trust Registration subject to
5 conditions. Four of these have been removed subsequently by the CQC.
2. The final condition linked to compliance with the Health and Safety Executive Improvement
Notice relating to control of legionella in the water systems was reviewed by the Health and
Safety Executive on 14 September. The CQC conducted an unannounced visit on 28
September 2010 and the final report confirms that the Trust is complaint with Outcome 10
(Regulation 15) Safe and Suitable premises indicating that the condition has been removed.
Recommendation(s)/ Decision required
The Board of Directors is requested to note the report.
The Trust must now maintain full compliance with the Essential Standards of Quality and Safety and
ensure up to date evidence of compliance is available.
Implications
Patient Safety and Patient Experience: the Trust is required to maintain compliance with the Essential
Standards of Quality and Safety in order to provide health services. The focus of compliance is on the
outcome of care for patients.
Financial (efficiency, economy, effectiveness): The CQC is able to impose financial penalties for noncompliance.
Equality and Diversity: To maintain registration the Trust is required to explain how it promotes
equality, diversity and human rights.
Legal: Registration is a legal requirement in order to provide health and social care in England.
Communications/Reputation: Registration without conditions will significantly improve the Trust’s
81
reputation and build confidence.
NHS Constitution: The Essential Standards of Quality and Safety support the pledges and rights in the
NHS Constitution.
Acronyms/ abbreviations used in the report (where not stated):
None
Author: Andrea Saville
Status: Corporate Secretary
82

Board of Directors - Basildon and Thurrock University Hospitals

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