Board papers August 2016 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

August 2016

Trust Board Meeting – IN PUBLIC Thursday 25th August 2016 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

11:00

11.30

12.15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 28th July 2016 - For approval

A McCarthy

Paper

1.4

Action tracker

A McCarthy

Paper

1.5

Chairman’s Report For assurance

A McCarthy

Verbal

1.6

Chief Executive’s Report For assurance

P Simpson

Paper

1.7

Board Assurance Frame Work & Significant Risk Register – For approval

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient Story For assurance

D Holden

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

F Allsop/ D Holden

Paper

2.3

Safety & Quality Committee Update For assurance

R Shaw

Paper

OPERATIONAL PERFORMANCE Paper 3.1

3.2

Integrated Performance Report (M04) For assurance 3.1.1

Safety & Quality Performance Indicators

F Allsop/ D Holden

3.1.2

Operational & Access Performance Indicators

A Stevenson

3.1.3

Patient Experience Performance Indicators

F Allsop

3.1.4

Workforce Performance Indicators

F Allsop

3.1.3

Finance Performance Indicators

P Simpson

Finance & Workforce Committee Update

R Durban

Paper

For assurance 3.3

13.00

13:25

Audit & Assurance Committee Updated Terms of Reference â&#x20AC;&#x201C; For approval

P Biddle

Paper

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Consultant Re-Validation Statement of Compliance For approval

D Holden

4.2

Shadow Council of Governors Update For assurance

G FrancisMusanu

Presentation

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note

A McCarthy

5.1.1

Finance and Workforce Committee

Paper

5.1.2

Safety & Quality Committee

Paper

5.2

ANY OTHER BUSINESS

A McCarthy

5.3

QUESTIONS FROM THE PUBLIC

A McCarthy

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to: gillian.francis-musanu@sash.nhs.uk 5.4

Review of Meeting

5.5

DATE OF NEXT MEETING 29th September 2016 at 11.00am Annual General Meeting 29th September 2016 at 6.00pm

A McCarthy

Verbal

Minutes of Trust Board meeting held in Public Thursday 28th July 2016 from 11:30 to 13:30 Room AD77, Trust Headquarters, East Surrey Hospital Present (AM) Alan McCarthy (RD) Richard Durban (MW) Michael Wilson (PS) Paul Simpson (DH) Des Holden (FA) Fiona Allsop (AS) Angela Stevenson (PL) Pauline Lambert (PB) Paul Biddle (RS) Richard Shaw

Chairman Non-Executive Director and Deputy Chairman Chief Executive Chief Finance Officer Medical Director Chief Nurse Chief Operating Officer Non-Executive Director Non-Executive Director Non-Executive Director

In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (NS) Nicola Shopland (SB) Stephanie Biden (CP) Colin Pink 1.

Director of Corporate Affairs Director of Strategy (items 4.2 & 4.3) Divisional Chief Nurse (item 2.1) Divisional Risk and Governance Manager (Item 2.1) Head of Corporate Governance

General Business 1.1

Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, members of the public, shadow governors and staff. Apologies for absence were noted from Alan Hall and Mark Preston

1.2

Declarations of Interest â&#x20AC;&#x201C; For approval The Chairman asked whether any of the Board members had any additional declarations of interest; none were raised.

1.3

Minutes of the last meeting held on 30th June 2016 The minutes of the meeting held on 30th June were discussed and approved as a true and accurate record.

1.4

Action Tracker

1.4.1

GFM updated the Board on the following actions which were due: TBPU-01: GFM confirmed that this Action is now closed. TBPU-03: AS confirmed that this Action is now closed. TBPU-04: GFM confirmed that this Action is now closed.

The remaining two actions are due in August and September 2016. Page 1 of 11

There were no other matters arising. 1.5

Chairman’s Report for Assurance AM reported that the Board had won the ‘Board Leadership’ category at the Health Service Journal, annual patient safety congress awards. Winning this award is fantastic recognition of the efforts and achievements of everyone across the whole organisation and the difference the care they provide makes to patients. The Trust was also shortlisted for ”Organisation of the Year”. This award was won by Frimley Health Foundation Trust. AM congratulated the Trust and the Board for its hard work and conviction to the cause of continuous improvements in patient safety. The Board noted the report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW echoed AM comments on the Board’s and Trust’s success. MW introduced his paper and reflected on NHS Improvements (NHSI) consultation on its proposals for the development of a single oversight framework. This would seek to align NHSI and Care Quality Commissions (CQC) standards into one system. MW highlighted that framework would be underpinned by ensuring that Trust’s meet their constitutional requirements, deliver standards and work within their respective budgets. This had been discussed at the Board Seminar and a response to the consultation would be submitted by the Trust. MW went on to talk about the overall national picture sighting examples where NHS Trust’s had gone into special measures. The delivery of performance, constitutional requirements and budgetary controls targets is key. This is becoming steadily more challenging across the country. The threshold to enter special measures is changing as is the response that is triggered centrally when enacted. MW highlighted that the Trust’s ‘Star Awards’ had now opened and that nominations for staff and teams were open to the public. AM asked what thought had been put into to developing system wide metrics to support organisation specific intelligence. MW commented that Sustainability and Transformation Plan (STP) level metrics are being developed and that a robust national conversation about aggregate performance had commenced in earnest. There are areas within the local STP with significant financial and performance issues and it will be a significant challenge to meet the targets set for 2020. There were no further questions were raised. The Board duly noted and took assurance from the report.

1.7

Board Assurance Frame Work & Significant Risk Register for Approval Page 2 of 11

The Board received and noted the report in advance of the meeting. GFM introduced the BAF which had previously been discussed Private Board and by the Executive Committee. The only significant change to the document agreed at Private Board in June is the amalgamation of the three access risks into two risks. This was because the one of the narrative of risks, controls, assurances and actions was closely aligned and blurred the detail of the risk. The BAF details thirteen risks against the five objectives. The SRR has ten risks detailed on it, all of which have been reviewed by the Executive team. The Board discussed the 2016/17 BAF noting that it aligned with conversations at recent Board Seminars and Private Board. RD commented on the new risk relating to the aspirations of the Trust and the impact of the development of the STP, noting that this could be a very fluid risk and that it was good to record on the BAF. RS asked for an update on the Trust’s management of gastroenteritis that remains on the SRR. DH reflected that this had become less of a winter or seasonal issue, the Trust and local health economy continue to see issues into summer. There is still an impact on occupancy and flow although in recent years this has not been as significant. The Executive Team continue to review and the management of diarrhoea is one of the first three SASH+ areas of focus because of the impact on patients and their experience. There were no further questions. The Board duly noted and approved the BAF. 2.

Safety, Quality and Patient Experience 2.1 Patient Story for Assurance FA introduced the Nicola Shopland and Stephanie Biden who would present this month’s patient story. FA commented how she had attended a local resolution meeting with the daughter of a patient who had passed away whilst under the Trust’s care and that the emotion expressed during the meeting had left a lasting impression on all those involved. NS told the story of a 93 year old lady who had been admitted via the emergency department following a stroke. Her daughter had raised a complaint which covered the patient’s experience in the Emergency Department; concerns around being excluded from the resuscitation room and communication about her mother’s immediate condition. This was investigated and responded to by staff from the Medical Division. The complaint was reopened as the patient’s daughter wished to gain further clarity over several issues surrounding her mother’s admission and final days before her death. A local resolution meeting (LRM) was attended by the Chief Nurse, the Chief of Medicine and the Divisional Chief Nurse for Medicine. During the meeting the extent to which the original response had not dealt with the daughter’s complaints and the impact that the episode had on the patient’s daughter became apparent. It was agreed as part of a number of actions that this patient story would be shared at the Patient Safety Executive and with the Board. The daughter described that her mother had dementia and how very distressing it had been not be allowed into the resuscitation room as she knew that she would Page 3 of 11

be able to help settle her mother and how isolated she felt as a result. She spoke of how little information she received of the severity of the stroke whilst in ED and that when the information was shared it was in a manner that she considered was not confidential or private. The patient was then admitted to Chaldon Stroke Unit and there were on-going issues with communication, particularly around the ‘do not attempt resuscitation’ discussion, identifying to the family who the responsible consultant was and ensuring the family are aware of the treatment plan. NS reflected that a review of the notes indicated a very clear and structured medical record with evidence of communication between the consultant and the daughter; however the consultant had not been implicit to the daughter that he was the consultant in charge of her mother’s care. She went on to speak of how staff had referred to her mother as ‘Bed F’ and rarely used her name. NS stated that the team had put in a range of actions following this LRM, relating to communication, the review of DNAR forms the suitability of the visitors room on Chaldon, allowing people into the resuscitation room were appropriate and personal feedback to the ward manager and consultant in charge of the patient’s care. NS reflected that the clinical care was good and that the Team had thought that they had delivered good care and the original response to the complaint had not triggered the local resolution meeting process. RD asked if the patient had just been unlucky. NS stated that the care provided by the stoke team was good but conceded that there is room for improvement and that in this particular case the unresolved communication issues had not been addressed throughout the episode. DH reflected that we in the NHS do not challenge ourselves enough as to whether we are doing the right thing for each patient. It’s alright to consider each case and ‘break rules’ to get it right for the patient. It would be naive to assume that our rules fit each case and each individual. The future state will need to be driven by the need to think outside the box and deliver the right care. This is a journey and we have agreed to start to think differently. The Board went on to talk about the business rules that govern patient experience and the development of increased visiting hours and inclusion of relatives at ward rounds. DH reflected that our language puts us into a superior mind set; referring to patients as citizens is a good step forward as it avoids the quasi power difference between clinician and patient. MW agreed stating the need to ensure that people can make informed choices about their care. MW asked NS for the timelines for changes to be made. NS confirmed that actions had already been taken in particular the issues highlighted in resuscitation, she had observed a change but this had not been audited. There were no further questions were raised. Action GFM and NS to write to the daughter to confirm that her case had been heard and express the condolences of the Board for her loss. Action RS was asked to look into the matters that this patient story had raised at Page 4 of 11

the Safety and Quality Committee. The Board duly noted the patient story and the agreed actions and next steps. 2.2

Chief Nurse and Medical Directorâ&#x20AC;&#x2122;s Report for Assurance The Board received and noted the report in advance of the meeting. FA introduced the report highlighting the new patient metrics relating to care hours per patient day (CHPPD) and that guidance on interpretation and use is still in development. The Safer Staffing report indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity throughout June. In July 2016 the National Quality Board published revised guidance on safe, sustainable and productive staffing. The new guidance contains a set of expectations for nursing and midwifery staffing to help Boards make local decisions to deliver high quality care for patients within the available staffing resource. It includes elements of the Carter report including the implementation of CHPPD as the principal measure of nursing, midwifery and healthcare support worker deployment. The guidance is presented in three sections which was detailed in the report. RD asked what extra value this new guidance added. FA commented that the guidance was useful and provided the Board with a new tool to monitor benchmark and facilitate decision making process. PS noted the change in national monitoring of staff usage and indicated that NHSI will seek to act on variance from the normal bell curve distribution. The Board agreed to review guidance and form an opinion on staffing levels. FA stated that this could be done once a year preferably in November to support business planning and should include nursing and medical staff. This was agreed. Action: FA/DH DH commented on the change in language which moved towards 7 day services and the timeframes for seeing patients. MW and FA agreed the need to discuss the possibility of changing the ratios of 1 to 8 to 1 to 7 which would be exceptionally challenging both in relation to funding and the available workforce. However there was an indication that acuity and skill mix would come into play as guidance is developed. There were no further questions for FA. DH introduced the medical directors report noting that nationally Junior Doctors had rejected the new deal prepared by the BMA. As such contract implementation is still scheduled for October and negotiations continue. DH had spoken to the BMA and the possibility of more industrial action is not known. DH reported that there had been two MRSA blood stream infections on one of the Trustâ&#x20AC;&#x2122;s wards. There was evidence that these were linked as there are patients on the ward who are colonized with the same type of MRSA, this could be patient to patient or environmental issues. PL asked for assurance that the Trustâ&#x20AC;&#x2122;s response had been robust. DH confirmed that he considered that it was, highlighting twice weekly meetings to review lessons learnt and ensure delivery of actions. Page 5 of 11

There were no further questions. The Board duly noted and took assurance from the report. 2.3

Safety & Quality Committee Update (SQC) for assurance The Board received and noted the report in advance of the meeting. RS presented the report highlighting the activity of the July meeting, focusing on Commissioning for Quality and Innovation (CQUIN) for flu, venous thromboembolism (VTE) risk assessment recording, the emergency department section of the diagnostic deep dive and a paper on the impact of the business of winter on quality of care. The Medicine Division had provided a very good presentation on its governance and plans, which had highlighted the work to support delivery of 7 day services. The diagnostic deep dive for ED was well received and provided good assurance. Similarly the paper on the impact of winter on the Trust had provided assurance indicating that there had not been a significant impact on safety but there had been impact on patient experience and staff. The Board discussed improvements in VTE risk assessment recording and the implications of how best to use complaints data and trend analysis. The Board duly noted and took assurance from the report.

2.4

Safety & Quality Committee (SQC) Annual Report for assurance The Board received and noted the report in advance of the meeting. RS presented the report highlighting the role of the Committee, the assurances it had received over the year deep dives, quality monitoring, ECQR activity and external reports. RS went on to highlight the main challenges identified for the coming 12 months, these included; delivery of strategy, key themes, considering the impact of the STP and sharing learning to drive safety and quality improvements. RD asked if clinical attendance was an issue for the Committee. RS agreed that clinical attendance was key and stated he was happy with the quoracy of the Committee and that divisional clinical attendance at SQC had improved in year. AM thanked RS for the report stating that the SQC continues to be a significant part of the Boardâ&#x20AC;&#x2122;s form and function. For the record AM highlighted that he had become a member of the Committee in February 2016, which was not made clear by the attendance section on page three of the report. The Board duly noted and took assurance from the report.

Operational Performance 3. 3.1

Integrated Performance Report (M01) for Assurance The Board received and noted the report in advance of the meeting. Page 6 of 11

3.1.1

Safety & Quality Performance Indicators FA introduced the safety and quality elements of the report highlighting the never event recorded in July, VTE assessment compliance and improvements in safety thermometer compliance. DH highlighted the mortality indicators for the Trust, stating that HSMR was currently recorded as significantly better than average. AM asked for more information on the Never event. DH confirmed that surgery had been performed on a spinal disc which was bulging on both sides. The patient had been consented to have surgery on the left side whilst attempting to correct the right hand side. There was significant scaring and the surgeon operated on the right hand side. This was identified before the patient left the theatre. The surgical team decided to carry out the initially consented procedure and the patient is reportedly delighted with the outcome. This meets the definition of a never event despite the outcome for the patient.

3.1.2

Operational & Access Performance Indicators AS spoke to the access elements of the report, highlighting the new page showing NHSI trajectories and Trust performance. There was good assurance for delivery but AS indicated that there is risk of delivery in Q4. This will be discussed at Board Seminar. AS highlighted ED performance against standards indicating that emergency growth had now reached 6% which equates to 133 ambulance attendances compared to 90 last year. Two week rule for cancer had not been achieved but the teams were anticipating good performance in July. RTT performance is good but risk increase as referrals from the south continue to increase. ED pressures are impacting on summer plans to deliver elective. MW reflected that GPs have a key role in delivering two week standards as patients report that they do not understand how critical the referral is. The Board discussed the number of potential discharges flow through the local system and the significant challenges that the Trustâ&#x20AC;&#x2122;s local partners and GP practices are facing. Specifically focusing on issues being reviewed by NHS England relating to SEC Ambulance and local 111 telephone service. PL stated that efforts and plans felt robust and that the direction of travel was good.

3.1.3

Patient Experience Performance Indicators FA discussed the trends that were emerging in patient experience data, highlighting â&#x20AC;&#x2DC;Friends and Family Testâ&#x20AC;&#x2122; for ED maternity and outpatients. There were no questions.

3.1.4

Workforce Performance Indicators FA presented the workforce review of metrics, focusing on sickness absence which has risen but is still in a good position. The Trust has reviewed guidelines for mandatory training and will update the KPI accordingly. Achievement reviews are being reviewed and there is expectation that performance will increase in coming months. Bank and agency spend is higher than trajectory, however the position is well Page 7 of 11

known and supported by strong governance. RD confirmed that he had nothing to add from the Finance and Workforce Committee (FWC). 3.1.5

Finance Key Performance Indicators PS introduced the financial elements of the report noting that the capital resource limit should read as £13.1 million rather than £15.9 million and the RAG indicator should be green. Capital spend is on track and under review. The Trust is on track to deliver its financial plan and is currently reporting a position that is better than expected for month three, reporting a deficit of £2.5 million. This has allowed the Trust to review and update the interim budget for discussion later in the agenda. There continues to be risk to delivery of the budget, this is reviewed regularly at FWC and currently stands at £6.8 million. PS confirmed that the ‘sustainability and transformation funding’ trigger has been achieved at Q1, based on financial performance. The Trust has also achieved its agency spend plan for the quarter. The payment is due and not accrued for in the deficit reported at month three. RD confirmed that this had been reviewed by the FWC. PS went on to describe the output of the NHSi Lord Carter efficiency engagement visit. The Trust outlined how it is meeting the challenge and taking this work forward. There is specific focus on pathology services, medicines management, e-Rostering, procurement and agency spend. The Trust’s CIPs cover all these areas. The Trust has reviewed the bench marking data for ‘Getting it right first time’ for orthopedics and bench marks well overall. There will be a national procurement database tool which it is hoped will ensure that the best deals are available to all, which the Trust will make good use of. The national model hospital data portal has gone live, based on 14/15 reference costs, this indicates that the Trust has the second lowest cost per activity unit in the country and will in future include clinical hours per patient day and data on the costs of emergency activity. The Board duly noted and took assurance from the report.

3.2

2016/17 Financial Budget for Approval PS introduced the final revenue budget for approval; this had been discussed in detail earlier in the week at FWC. The main changes from the interim budget relate to the clarity achieved from agreement of contracts, forecasting based on the month 3 reported position and the allocation of reserves which is detailed in the appendix. RD reflected on the conversations at FWC highlighting the associated risk of delivery, mitigations and the level of confidence of delivery of quarter 2. Delivery of the budget will be harder as the year progresses, there is no capacity to Page 8 of 11

reduce focus. Marginal rate (MRET) conversations and readmission fines are not agreed with CCGs and contribute to the control total surplus. The Board noted the risk and that both were flagged to NHSi formally in a letter prior to the start of the year. The FWC have recommended that the budget is adopted. The Board noted that it was a very challenging budget and that the Trustâ&#x20AC;&#x2122;s core assumptions highlighted to NHSi had not been advised as formally. The Board duly noted and approved the budget as final. 3.3

Finance & Workforce Committee (FWC) Chair Update â&#x20AC;&#x201C; for Assurance The Board received and noted the report in advance of the meeting. RD introduced the report highlighting that a great deal of the meetings output had already been discussed. The FWC had took assurance on continuing improvements in payment of suppliers and debtors. The committee received a paper that highlighted the improvements in Medical Records provision since the movement of the offsite storage to Salfords. RD reminded the Board that the in year ÂŁ6 million working capital facility would now need to be repaid by the end of the financial year. There were no questions raised. The Board duly noted and took assurance from the report.

3.3

Audit & Assurance Committee Update, Annual Audit Letter & Quality Account Audit - for Assurance PB introduced the paper which detailed the July AAC. There had been good assurance from External Audit detailed in both the annual audit and quality account letters. The Committee had agreed Internal Audits annual plan for 2016/17 which includes areas of Board interest such as the management of temporary staffing and the delivery of the clinical audit plan. PB reported that a tendering process to appoint External audit for 2017 had commenced and that PS had agreed to join the members of the AAC on the selection panel. The Board duly noted and took assurance from the report.

3.5

Charitable Funds Committee Update for Assurance PS introduced the paper in AH absence. Reporting that the Trust had filled the vacant fundraiser post who is settling into post. The Committee had discussed the ongoing issue relating to the failure of fund holders to spend their balances as per Trust policy. The Committee is now seeking follow up of plans from division that detail how funds will be spent during 2016/17. There were no questions raised. The Board duly noted and took assurance from the report. Page 9 of 11

Risk, Regulatory and Strategy Items 4.1

Serious Incidents Quarterly Report for Assurance The Board received and noted the report in advance of the meeting. FA introduced the report which details current cases and learning from investigations. The Trust reported 12 serious incidents during the first quarter of 2016/17. All incidents were reviewed and escalated appropriately as part of the process. There were no questions raised. The Board duly noted and took assurance from the report.

4.2

2016/17 Annual Plan, Q1 Update â&#x20AC;&#x201C; for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the paper highlighting the number of actions which have been amalgamated and streamlined for ease of monitoring. There is also an update to the spreadsheet that allows monitoring of direction of travel. There are four complete actions two actions recorded as red, off track, which related to the never event and the MRSA blood stream infection. Overall 32% of actions are on plan or better. Delivery of the annual plan is on track. The Board discussed the paper commenting on the useful changes to format and positive assurance on delivery at end of Q1. The Board duly noted and took assurance from the report.

4.3

SASH+ Update - for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the report highlighting the work to date and the positive impact that it was having, highlighting a recent case where a staff member had â&#x20AC;&#x2DC;stopped the lineâ&#x20AC;&#x2122; and raised an issue that was impacting on flow and experience. SJ highlighted that RPIWs were now planned for the next 18 months and that members of the Board were welcome to be involved. The Cardiology value stream remains a challenge and is the focus of the Trust Guiding Team. The Board discussed the issues surrounding the delivery of improvement targets set by the Guiding Team. Noting that in some cases metrics had increased to a level higher than the benchmark, this is linked to clinician engagement, use of escalation and unexpected growth in referrals from Trust clinicians managing inpatients. DH agreed stating that the clinicians involved wanted to resolve the other medical patients within their specialty footprint. The Board challenged as to when the expected output of the work would be delivered. MW reminded the Board that the plan is learned through the process and that Cardiology was chosen because it was a challenge. Dr Ben Mearns, Chief of Medicine is reviewing the case and will report back at the next Guiding team meeting. Page 10 of 11

The Board duly noted and took assurance from the report. Other Items 5.1

Minutes of Board Committees to receive and note

5.1.1

Finance and Workforce to receive and note The minutes of the Committee were noted with no questions raised.

5.1.2

Safety and Quality Committee to receive and note The minutes of the Committee were noted with no questions raised.

5.1.3

Audit & Assurance Committee to receive and note The minutes of the Committee were noted with no questions raised.

5.2

Any Other Business PL asked for the Trust’s perspective on the day’s news story relating to consultants overtime. DH commented that the story was based on a national freedom of information request made by the BBC. These costs will be linked to waiting list initiatives and the overtime rates built into the doctor’s contract agreed by the government. The Trust does use additional sessions to cover issues such as endoscopy lists. MW noted that in some specialist cases there isn’t another option other than to use ‘overtime’ and that the significant overtime expenditure is the symptom rather than the cause. There was no other business.

5.3

Questions from the Public There were no questions raised.

5.4

Date of the next meeting Thursday 29th September 2016 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman:

Date:

Page 11 of 11

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING - August 2016 Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015 TBPU-02

TB Public

To devlop and bring plans for fraility unit to public 2016/17 Operational Plan board

TBPU-05

TB Public

Quality Governance Assurance Framework

TBPU-06

TB Public

Patient story

TBPU-07

TB Public

Patient story

TBU-08

TB Public

Chief Nurse & Medical Director Report

The Board asked for the implementation of kite marks to be considered before the next review of the QGAF AS Write to the daughter to confirm that her case had been heard and express the condolences of the Board for her loss. GFM Look into the matters that this patient story had raised at the Safety and Quality Committee.

RS The Board agreed to review guidance and form an opinion on staffing levels. FA stated that this could be done once a year preferably in November to support business planning and should include nursing and medical staff. FA/DH

31/03/2016

30/09/2016 OPEN

30/06/2016

30/09/2016 OPEN

28/07/2016

31/08/2016 CLOSED

28/07/2016

31/10/2016 OPEN

28/07/2016

30/11/2016 OPEN

Status

TRUST BOARD IN PUBLIC

Date: 25th August 2016 Agenda Item: 1.6

REPORT TITLE:

CHIEF EXECUTIVE’S REPORT Paul Simpson Deputy Chief Executive & Chief Finance Officer Gillian Francis-Musanu Director of Corporate Affairs

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval ( )

Discussion (√)

Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National/Regional: • National tariff proposals for 2017/18 and 2018/19 • Single Oversight Framework Consultation – Next Steps Local: • Launch of the Kent Surrey and Sussex School of Physicians Associates Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A

Highlights national requirements in place to improve patient experience. Identifies possible future strategic risks which the Board should consider Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

TRUST BOARD REPORT –25th August 2016 CHIEF EXECUTIVE’S REPORT 1. 1.1

National/Regional Issues National tariff proposals for 2017/18 and 2018/19

On 3rd August NHS England and NHS Improvement jointly published proposals for the national tariff as part of a consultation. Summary of proposals include two major changes: •

To set a national tariff for two years which would include two price lists, one for 2017/18 and the second for 2018/19

•

To move from using HRG4 currency design to using phase 3 of HRG4+. HRG4+ is more detailed than HRG4, and better accounts for different levels of complexity. It also better reflects current clinical practice because the design is based on more recent cost and activity data. They propose to retain the same currency design for the second year.

NHSE/NHSI is also proposing a number of other changes to complement the move to HRG4+ currency design. These include an update to top-up payments for specialised services, removing the interventional radiology best practice tariff (BPT), and adding four new national prices. Proposals include model prices for 2017/18 (based on HRG4+) by using the same method adopted by the Department of Health for the 2013/14 Payment by Results (PbR) tariff, with updated inputs and further adjustments. For the second year of the proposed two year tariff (2018/19) the proposal is to roll these prices over with some adjustments. The consultation advises that options are being considered to limit financial volatility for providers and commissioners that may arise from a change of currency, or from inadequacies in costing data, particularly for orthopaedic services. However, the extent of the impact described in the consultation has a very wide range of variation with big winners and big losers for Providers. The prices published alongside the consultation document are the prices for 2017/18 scaled to 2016/17 levels. This means the intention to equalise the funds that would be paid for the same group of patients under both years’ prices prior to overall adjustments (for example, for inflation or efficiency). This should allow providers and commissioners to develop a clear understanding of how the proposals in the consultation document would affect them when benchmarked against 2016/17 levels. Other proposals for currency design include updating the maternity pathway,(which is implied as not currently covering costs) updating the high cost drugs and devices lists, and introducing, changing and removing certain BPTs. The proposals include simplifying the method for calculating BPTs. Again, the proposal is that these aspects of currency would remain the same in the second year of the tariff (2018/19).

Proposals to reintroduce the “gain/share” on specialised commissioning were removed at the last minute but the marginal rate 70% payment for emergency activity remains. For locally determined prices, the proposal will require commissioners and providers to link a proportion of payment for mental health services to locally agreed quality and outcome measures or agree an alternative payment approach consistent with the rules for local pricing. Prior to the statutory consultation, they will work with the service through their enhanced impact assessment to identify unplanned or undesirable effects from the proposals in this document. NHSE/NHSI will also continue to work with a range of stakeholders to develop final policies and resolve known issues with their proposals. Responses to the consultation are due by 12 noon on 26th August 2016. A full copy of the consultation document is available at: https://improvement.nhs.uk/uploads/documents/TED_final_1.pdf

1.2

Single Oversight Framework Consultation – Next Steps

NHS Improvement noted that over 170 responses were received in relation to the consultation on the single oversight framework. The plan is to shortly publish the final framework and their responses to the comments received. The Framework will take effect soon after publication.

Local Issues

2.1

Launch of the Kent Surrey and Sussex School of Physicians Associates

We celebrated the launch of the Kent Surrey and Sussex School of Physicians Associates (PAs). SASH is the largest employer of PAs in the region and we are recognised, by Health Education England Kent Surrey Sussex as being a centre of excellence for PAs. It is this recognition that has led to the development and launch of the School of PAs which is the first of its kind. On behalf of the Board I would like to say well done to everyone involved in this fantastic initiative and we look forward to seeing the school grow.

Recommendation

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Paul Simpson Deputy Chief Executive & Chief Finance Officer July 2016 3

Date: 25th August 2016

TRUST BOARD IN PUBLIC

Agenda Item: 1.7 Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance

REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Committee 24/08/2016

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: The 2016/17 Board Assurance Framework (BAF) highlights potential risks to the Trust’s strategic objectives, mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details risks on the Trust risk register system that are recorded as significant which have been considered by the Executive Team and the links to the Board Assurance Framework. Summary of key issues The BAF details 13 risks to the trusts strategic objectives, 7 of which are recorded as key strategic risks and red rated. There are 10 significant risks recorded on the Trust risk register. The BAF and the SRR have been reviewed by the Executive Committee as part of the regular monthly review. Recommendation: The Board is asked to discuss and approve the report and consider the following: • Does the Board agree with the recorded controls and assurances listed in the BAF The Board is asked to note the risks as recorded on the SRR. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population SO5: Well led - Become an employer of choice and deliver financial and clinical 1

An Associated University Hospital of Brighton and Sussex Medical School

sustainability around a patient focused clinical model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement

The report is a requirement for all NHS organisations. As discussed in sections 5 (Income generation linked to activity referred to throughout the document) Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

Discussed throughout the report but with the greatest detail in objective 3.

Attachment: Aug 2016 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 25Th August 2016 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.

Board Assurance Framework

The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The strategic objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2.

Current status

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows: Objective

Red (15-25)

Amber (8-12)

Green (1-6)

1. Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers 2. Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy 3. Caring – Working in partnership with staff, families and carers 4. Responsive – Become the secondary care provider of choice for our catchment population 5. Well led – Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model

Total

An Associated University Hospital of Brighton and Sussex Medical School

2.2 Headline information by objective (BAF) Objective 1 - Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

1.1 There is a risk that the Trust will not meet its objective to be within the top 20% benchmark for safety standards if opportunities to innovate and learn from benchmarked outcome data/peer review are not adopted and implemented.

S4 x L3 = 12

Objective 2 – Effective - As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy

Initial Risk Rating: Severity x Likelihood

2.1 There is a risk that the Trust will not meet its objective of delivering effective and sustainable care if it does not embed relevant research and education programmes that support the development of local services with the best outcomes.

S4 x L3 = 12

Objective 3 – Caring – Working in partnership with staff, families and carers

Initial Risk Rating: Severity x Likelihood

3.1 The Trust will not meet its priority of delivering high quality care which is wrapped around the individual needs of each patient if the organisation does not seek to shape patient centered clinical services and learn from all sources of patient feedback.

S3 x L3 = 9

Objective 4 – Responsive – Become the secondary care provider of choice for our catchment population 4.1 There is a risk that the Trust will not meet its objective of becoming the secondary provider of choice for our catchment area if it does not deliver all national standards including seven day working. 4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on income, expenditure and ultimately quality objectives.

Current Risk Rating: Severity x Likelihood

S4 x L2 = 8

Current Risk Rating: Severity x Likelihood

S3 x L3 = 9

Current Risk Rating: Severity x Likelihood S3 x L3 = 9

Target Risk Score

S4 x L1 = 4

Target Risk Score

S3 x L2 = 6

Target Risk Score

S3 x L2 = 6

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S5 x L2 = 10

An Associated University Hospital of Brighton and Sussex Medical School

5. Well led – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5. There is a chance that the Trust may not meet its priority to benefit from the opportunities of strengthening partnerships, collaboration and developing high quality safe and sustainable systems that emerge from the solutions within the STP. 5.1 Failure to deliver income plan. 5. 2 Failure to stop divisional overspending against budget. 5. 3 Unable to deliver medium term financial plan.

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position. 5.5 There is a risk that the Trust will not meet its objective of becoming an ‘employer of choice’ if it does not deliver a workforce strategy that drives the recruitment and retention of talent and ensures a positive staff experience for all groups of staff through on-going education, development, engagement, inclusion and well-being. 5.6 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits. 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems.

2.3.

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L3 = 12

S3 x L3 = 9

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S3 x L2 = 6

S3 x L4 = 12

S3 x L5 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

Key risks Strategic risks Identified

The BAF highlights the following 7 key red risks to the Trust objectives that have been identified at time of updating the framework (not including the proposed reduction). As follows: Risk description Target risk Current rating score 4.1 There is a risk that the Trust will not meet its objective of becoming the secondary provider of choice for our catchment area if it does not deliver all national standards including seven day working. 4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on income, expenditure and ultimately quality objectives. 5.1 Failure to deliver income plan. 5. 2 Failure to stop divisional overspending against budget. 5. 3 Unable to deliver medium term financial plan. 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position. 5.6 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S5 x L2 = 10

S5 x L3 = 15 S5 x L3 = 15 S5 x L3 = 15

S4 x L2 = 8 S3 x L2 = 6 S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L5 = 15

S3 x L2 = 6

An Associated University Hospital of Brighton and Sussex Medical School

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. 3.1 SRR Breakdown ID 1401 1491 1501 1603 1604

1663 1678 1688 1689 1779

Title

Initial Rating

Current Rating

Residual Rating

Next Review

Risk of outbreak of viral gastroenteritis Failure to maintain Emergency Department performance Patient admitted to the right bed first time Unable to deliver realistic medium term financial plan Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position Risk of not achieving Cost Improvement Plan RTT Access Standards Risk of potential overspending from operational pressures Risk of Contract income below plan Failure to delivery productivity gain from income growth

31/08/2016

20/09/2016

15 16

6 6

31/08/2016 20/09/2016

15/09/2016

20/09/2016

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following: â&#x20AC;˘ Does the Board agree with the recorded controls and assurances

The Board is asked to note the risks recorded on the Significant Risk Register.

Gillian Francis-Musanu Director of Corporate Affairs August 2016

Colin Pink Head of Corporate Governance

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite â&#x20AC;&#x201C; 2016/17 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. The Board acknowledges that financial challenges throughout 2016/17 will be significant and there will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 2: SASH risk quantification matrix

An Associated University Hospital of Brighton and Sussex Medical School

Abridged consequence chart Risk Type Patient Safety

Insignificant • No obvious injury / harm

Minor

Moderate

• Non-permanent avoidable injury / harm requiring only first aid / minor treatment

• Short-term avoidable injury / harm with recovery / treatment up to 1 month

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience • Upheld complaints regarding death in the related to poor treatment / care Trust

• Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / • National media coverage / political action local media involvement against the Trust

• Care pathway problems resulting in short- • Care pathway problems resulting in term treatment / care delay <3 hours short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in • Care pathway problems resulting in medium term delays (up to 1 month) or 5medium term delays (1-6 months) or 1010 patients affected 20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

• No harm injury

• Short term / non-permanent injury / ill health. • Injury / ill health resulting in 0-7 days absence from work.

• Medical treatment required

• Permanent or extensive injury / ill health / permanent disability or loss of limb • Injury / ill health resulting in >7 days (RIDDOR reportable) absence from work or restricted duties for >7 days (RIDDOR reportable)

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

• Suspension of services provided due to • Permanent removal of services and / or a failure to provide “well led” services as prosecution due to a failure to provide described by the CQC “well led” services as described by the CQC • Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has • Permanent loss of core service or facility serious impact on patient care resulting in major contingency plans being involved

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following:  Infant abduction  Infant discharged to wrong family  Rape or serious assault

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

Patient 'Experience' & • No significant impact on patient Care Pathways and experience Involvement of • No complaints / concerns raised Service Users

Major

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

• Short term disruption to service(s) with minor impact on patient care

An Associated University Hospital of Brighton and Sussex Medical School

Trust Board in Public â&#x20AC;&#x201C; 25th August 2016

Board Assurance Framework August 2016

Executive Lead: Gillian Francis-Musanu, Director of Corporate Affairs Author: Colin Pink, Head of Corporate Governance

Page 1

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference Director responsible 1.A Consistently meet national patient safety standards in all specialties and across divisions Initial Risk Key Action for 2015/16 objectives 1.1 There is a risk that the Trust will Current rating and description of any potential not meet its objective to be within significant risk to this priority the top 20% benchmark for safety Target risk score standards if opportunities to innovate and learn from Linked to Risk benchmarked outcome data/peer review are not adopted and implemented

Chief Nurse S4 x L3 = 12 S4 x L2 = 8 S4 x L1 = 4 1009,1055

Controls in place (to manage the risk) 1. Clinical teams in place to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance 4. Work undertaken to deliver â&#x20AC;&#x2DC;5 sign up to safety pledgesâ&#x20AC;&#x2122; (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) 5. Matron on site 7 days a week to monitor nursing patient care and staffing 6. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7. Nursing staffing levels monitored daily and issues managed 8. Ward safety boards updated regularly and ward performance discussed at divisional level 9. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 12. Patient falls strategic group meet monthly and report KPIs to the patient safety committee. 13. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR. 14. IPCAS Team and Group in place, Weekly taskforce in place 15. Infection control manual in place and information resources available 16. Antibiotic policy and guidelines in place 17. Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues.

Gaps in Control 1) Developing ward safety dashboards 2) Ward accreditation system under development 3) Updating and 4) Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 5) High bed occupancy can cause infection control risk to increase (e.g. side room availability)

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. opportunity walks) 2) Ward Dashboards

Actual Assurances: Positive (+) or Negative (-)

Page 2

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible

3) Divisional and Trust Level Dashboards 4) VMI/SASH Plus Program

(+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST audit (+) QGAF assessment and action plan (+) EWS audit (+) Datix incident reporting and analysis including increase in reporting (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Strong evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Initiation of ‘Stop, Access, Send’ initiative for the management of loose stool (+) Management of diarrhoea ‘SASH+ Value Streams’ (+) Antimicrobial prescribing audit compliance Negative (-) Never events incidence (-) NRLS reporting (benchmarked position) (-) Incidence of CDI 2015/16 (-) MRSA 2 x BSI

Gaps in assurance Ability to benchmark in real time

Assurance Level gained: RAG

Mitigating actions underway 1) VMI/SASH plus development program 2) 5 work streams identified in Trusts sign up to Safety Pledges (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) 3) Actions described in the IPCAS strategy 4) Develop actions from the strategic falls group Update by

Page 3

FA 05/08/16

Date discussed at board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Ongoing action plan 3) Ongoing 4) October 16

August 2016

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference Director responsible 2.A Achieve the best possible clinical outcomes for our patients Initial Risk Key Action for 2015/16 objectives 2.1 There is a risk that the Trust will Current rating and description of any potential not meet its objective of delivering significant risk to this priority effective and sustainable care if it Target risk score does not embed relevant research and education programmes that Linked to Risk support the development of local services with the best outcomes.

Medical Director S4 x L3 = 12 S3 x L3 = 9 S3 x L2 = 6 TBC

Controls in place (to manage the risk) 1) Oversight training by GMC/RCN/ other professional bodies for AHPs 2) Local Academic Board in place 3) CRN oversight of the research portfolio

Gaps in Control 1) Educational bodies not yet forward looking enough to provide new staffing models. Therefore Education models not aligned with future needs 2) KSS CRN worst performing nationally measured by cost each patient recruited to studies and patient recruitment per 1000 population

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) GMC Survey trainees 2) Staff surveys (Qs relating to training/ doing job / appraisal) 3) Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 4) NHSE 7 day service returns 5) Reporting on patient recruitment to studies / % achieved recruitment st targets and % studies meeting recruitment of 1 patient from study initiation deadlines

Actual Assurances: Positive (+) or Negative (-) Positive (+) GMC survey improving (for instance gateway 2 dark green flags and reducing red flags in pediatrics) (+) funding received from KSS CRN continues (based on formula that rewards recruitment) (+) HEKSS funding of school of Physicians Associates and Mouth Care Matters programs Negative Narrative: Most of what is currently available relates to/supports traditional structure and expectations that needs to be challenged and changed (see 5YFV, STPs). Challenge needs to focus on smarter strategy and intelligence.

Gaps in assurance Position is known, future state needs to be developed

Assurance Level gained: RAG

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. TBC

1) Strategic actions being developed

Update by

Page 4

DH 08/08/2016

Date discussed at Board

August 2016

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3. Ensure patients are cared for and Director responsible feel cared about Initial Risk Key Action for 2015/16 objectives 3.1 The Trust will not meet its Current rating and description of any potential priority of delivering high quality care Target risk score significant risk to this priority which is wrapped around the individual needs of each patient if Linked to Risk the organisation does not seek to shape patient centered clinical services and learn from all sources of patient feedback. Controls in place (to manage the risk) Gaps in Control 1. Patient experience committee reviews performance and escalates Hard to reach groups of patients areas of work and concerns to Executive Committee for Quality & Risk Patient listening events (ECQR) and Board Engagement with the voluntary sector 2. ECQR receives reports and provides feedback 3. Quarterly meetings with Surrey and Sussex Healthwatch Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Your Care Matters (YCM) results (including free text comments) 2. FFT scores and free text responses 3. Staff survey 4. National patient surveys 5. Complaints 6. PALS concerns 7. Duty of Candour 8. Engagement with representatives from shadow Council of Governors 9. Patient feedback with SASH plus improvement work

Gaps in assurance Trust position known - no identified gaps in assurance

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6 TBC

Actual Assurances: Positive (+) or Negative (-) Positive (+) Carers passport (+) Opening visiting (going live in September) (+) Standards of behavior and feedback from staff (+) Recent cancer survey results (+) National cancer survey (+) National pediatric survey Negative (-) No clear improvement in YCM or national results relating to discharge or communication around medication and danger signals (-) Outpatient YCM comments (-) National patient survey, not in top 50% (-) Compliance with Accessible Information Standard (-) Outpatient and Pediatric feedback via YCM Assurance Level gained: RAG

Mitigating actions underway 1. Focus groups among recently discharged inpatients 2. Open visiting 3. Re-procuring the YCM service 4. Developing IT solution for Accessible Information Standard Update by Date discussed at Board FA 05/08/2016

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Work at early stage – December 2016 2. Underway – September 2016 3. Underway – September 2016 4. TBC August 2016

4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Page 5

Chief Nurse

Priority ID and reference

4.A.1 Deliver access standards

Key Action for 2015/16 objectives and description of any potential significant risk to this priority

4.1 There is a risk that the Trust will not meet its objective of becoming the secondary provider of choice for our catchment area if it does not deliver all national standards including seven day working.

Controls in place (to manage the risk) 1) EDD Patient Pathway under review 2) Acute and Ambulatory Pathways under review 3) Clinical Site Team 4) Review of Integrated Discharge Team and complex discharge process 5) Plans for escalation areas agreed and management tools in place 6) Review of breaches and winter last year to identify areas for improvement. 7) Review of 7 day working 8) Implementation of SAFER and Urgent and Emergency Care Improvement Plan 9)Whiteboard implementation Project 10) Reviewing SaSH@Home pathways 11) IRU admission criteria under review 12) Reviewing booking process in TWR and RTT 13) Fortnightly Elective Care Board 14) Weekly divisional patient tracking list meetings 15) Top 20 weekly MRD meeting with community partners 16) Daily focus on Top 50 Longest stay patients *Owned by SASH System Potential Sources of Assurance (documented evidence of controls effectiveness) 1)NHSE and NHSI aware through formal monthly IDM 2) Combined weekly Quality and Performance Dashboard reporting on a combination of quality and safety standards, including the ED national indicators, reported to exec meeting weekly 3) Performance Management Framework reporting to Trust Board 4) Monthly Access and Responsiveness reporting to Trust board 4) External stakeholder and peer review inspections 5) Daily sit rep reporting to NHSI 6) SRG changed to monthly A&E Delivery Group 7) Whole system operational resilience plans signed off for 14/15 9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions. 10) External company (Deloittes) appointed by C&HCCG to undertake whole system Demand and Capacity Review *Owned by SASH System

Page 6

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

Gaps in Control 1) Ambulatory pathways yet to imbed (New Consultant undertaking review) 2) Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge* 3) Demand and capacity alignment â&#x20AC;&#x201C; Beds* 4) Delivery of internal actions relating to Urgent and Emergency care implementation plan* 5) Demand and Capacity alignment outpatients and theatres *Owned by SASH system

Actual Assurances: Positive (+) or Negative (-) Positive (+)External company (Deloittes) appointed by C&HCCG to undertake whole system Demand and Capacity Review including MRD (+) ED trajectory delivered for Q1 and July (+) Cancer 62 day delivered since Feb 16 (+) RTT incompletes delivered consistently (+) Top 20 patient delay weekly meetings (+) Monitoring and managing compliance #NOF, Stroke and medical outliers (+) Bed modelling refreshed including emergency demand increases Negative (-) ED standard not delivered Jan to April 16 (-) Cancer 2 week wait Access standard not delivered April to June 16 (-) Adult Bed occupancy remains higher than plan due to increased activity (-) Circa 110 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care*

(-) Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan) *Owned by local health economy Gaps in assurance Winter plans and local system position going into winter months Mitigating actions underway 1) 2) 3) 4) 5) 6) 7)

Refresh winter capacity plans based on assessment of Q1 activity A&E Delivery Group winter planning Review of pathways and winter plans Delivery of internal actions relating to Urgent and Emergency care implementation plan Ambulatory care unit delivery Frailty unit Developing SASH system escalation plan

Update by

Page 7

AS 11/08/2016

Date discussed at Board

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Aug 16 2) Ongoing 3) Ongoing 4) Ongoing 5) Ongoing 6) September 16 7) October 16 August 2016

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference Director responsible 4. Responsive to people’s needs – Chief Operating Officer Become the secondary care Initial Risk S5 x L3 = 15 provider of choice for the catchment population Key Action for 2015/16 objectives 4.2 There is a risk that if the Trust Current rating S5 x L3 = 15 and description of any potential does not deliver the planned significant risk to this priority efficiencies it will be unable to create Target risk score S5 x L2 = 10 the necessary capacity, which will have an adverse impact on income, Linked to Risk 1221, 1480, 1601, 1405, 1547 expenditure and ultimately quality objectives. Controls in place (to manage the risk) 1) Transformation Team in place 2) SASH System A&E Delivery Group* 3) CEO strategic meetings 4) Partnership boards 5) Trust part of national SASH+ transformation programme 6) Integrated Reablment Unit build complete 7) Operational and Acute capacity 8) Systems developed to support winter 9) Safer Care Bundles and Toolkits 10) Transformational boards 12) Executive lead Internal Productivity Work streams 13) Carter actions and reviews *Owned by SASH System Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Review of Business Continuity Plan 6) Divisional Performance Reviews 7) Productivity reporting 8) Benchmark reporting

Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Repatriation of tertiary services affected and influenced by external factors 3) Clear action plans linked to root causes of efficiency issues and using service improvement methodologies not yet fully embedded 4) Delivery of internal actions relating to Urgent and Emergency care implementation plan* *Owned by local health economy

Actual Assurances: Positive (+) or Negative (-) Positive (+) Internal audit of readmission figures provides positive assurance (+) Joint working with Royal Surrey County ( Chemo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Extended theatre working days Crawley (20% increase capacity) (+) Second Cath Laboratory in place (+) VMI Guiding Team established, initial Value Streams agreed Negative (-) Medically ready for discharge (100 pts. vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)

Gaps in assurance Demand and Capacity Plans for SEC Mitigating actions underway Page 8

Assurance Level gained: RAG

Progress against mitigation (including dates, notes

1) Full action plan development for productivity programme (theatres, outpatients, VMI Value streams, LOS) 2) Delivery of internal actions relating to Urgent and Emergency Care Implementation Plan

Update by

Page 9

BE 11/08/2016

Date discussed at Board

on slippage or controls/ assurance failing. 1) Ongoing 2) Ongoing

August 2016

Objective 5 â&#x20AC;&#x201C; Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5. Well Led - become an employer Chief Executive of choice and deliver financial and clinical sustainability around a Initial Risk S4 x L3 = 12 clinical leadership model Key Action for 2014/15 objectives 5. There is a chance that the Trust Current rating S4 x L3 = 12 and description of any potential may not meet its priority to benefit significant risk to this priority Target risk score S3 x L3 = 9 from the opportunities of strengthening partnerships, Linked to Risk N/A collaboration and developing high quality safe and sustainable systems that emerge from the solutions within the STP. Controls in place (to manage the risk) Gaps in Control 1) Development of a robust sustainability and transformation plan which is fully owned across the Sussex & East Surrey Foot Print Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Establishment of STP Board 2) Agreed leadership of STP Board 3) Meeting the deadlines for submission of plans to NHSE 4) SaSH involvement in STP work streams 5) Board understanding and input into STP solutions 6) Place base plans 7) Agreed implementation plans across the STP footprint 8) Engagement of relevant stakeholders

Actual Assurances: Positive (+) or Negative (-) Positive: (+) STP Board actively engaged (+) SaSH CEO confirmed leader of STP in Sussex & East Surrey (+) All current submission milestones met (+) New models of care for population-based catchments being explored (+) 4 Executive Directors actively engaged in STP work streams (+) Board engagement and input into emerging solutions (+) All checkpoint submissions completed to time Negative: (-) Financial gap across the STP footprint (-) Vacancies in senior posts across the footprint (-) National workforce issues in key disciplines (-) Growing and ageing population leading to real underlying growth in demand

Gaps in assurance Development of next phase plans

Assurance Level gained: RAG

Mitigating actions underway Development of next phase plans due for submission 30/09/16

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to plan.

Update by

August 2016

Page 10

GFM 08/08/2016

Date discussed at Board

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.A Live within our means to remain financially sustainable

Director responsible

Chief Finance Officer

Initial Risk

S5 x L3 = 15

5.1 Failure to deliver income plan

Current rating

S5 x L3 = 15

Target risk score Linked to Risk

S4 x L2 = 8 1689, 1785,1778,1779

Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity/ financial) savings & productivity plans. 1) There are issues with Sussex over MRET and the provision of services to 2) Agreed contracts in place with main sets of commissioners (NHSE and manage urgent care (hence separate transformation meeting). 2) Winter demand has been a significant issue, and activity continues to CCGs) – all Contracts were finally signed in May. 3) Contract management process in place (this operated effectively in 2015/16). describe growth. This is an SRG issue. 3) The strategic management of activity is not currently effective, but the Trust is 4) Financial reporting, including periodic forecast scenarios, is in place and doing all it can to support making it so. effective – the first detail forecast went to Board in July. 5) SRG and Transformation meetings in place and operating – specific joint 4) Action at East Surrey CCG (reviewing approach and investments) may have working with ESCCG and Surrey County Council. an impact on income and/or plans to manage emergency activity. Potential Sources of Assurance (documented evidence Actual Assurances: Positive (+) or Negative (-) of controls effectiveness) Positive 1) Financial performance and contractual reporting to Exec (+) STF milestones for first quarter STF payment achieved – STF paid. Committee, Finance & Workforce Committee and Trust (+) At M04 income is above plan (noting the profile) Board (including CQUIN reporting process). (+) East Surrey CCG have agreed MRET threshold increase and IRU is open…[nb: there is risk from 2) Performance Review (PMO) and Exec Quality and Risk new directions provided by NHS England that could see changes to previous agreements] process with Divisions, monthly contract cycle with CCGs. Negative Service line reporting process (-) Risk over income growth assumptions, primarily because of capacity and the unplanned increase 3) Outputs and reporting from contract and information in elective referrals (and happening earlier than anticipated) teams (-) Dispute with Sussex over MRET changes [although potentially drawing to an agreed conclusion] 4) Output and reporting from health system management (-) Too much non elective activity, not enough elective – risk over emergency demand (e.g.: System Resilience Groups and Chief Officer Meetings) (-) disputes over 2015/16 income not yet resolved (reconciliation process complete allowing 5) Output of Contract Management Process . negotiation to begin) Gaps in assurance

Assurance Level gained: RAG

Red because of level of risk, issues with strategic health system management of urgent care activity and transactional processes with CCGs.

Mitigating actions underway 1) Complete all contractual commitments according to timetable; 2) Revise forecast for elective activity; 3) Embed the integrated reablement unit and open the frailty unit (both joint working with ESCCG). 4) Robust contractual processes being operated. Update by Date discussed at Board PS 12/08/2016

Page 11

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable.

August 2016

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5. 2 Failure to stop divisional overspending against budget

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / productivity plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – first at Q1 in July and internal PMOs are based on that forecast. 5) Structure of roster and agency PMOs in place and NHSi agency reduction plan submitted, with weekly NHSi reporting on compliance Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency and roster PMOs.

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S3 x L2 = 6 Linked to Risk 1663,1688 Gaps in Control 1) Cost improvement plan forecasts (CIPs delivering at M04) suggest adverse delivery on agency (medical and nursing). 2) There is overspending in specific areas – notably WaCH (less so in Radiology, Medicine and E&F – improvements in these areas at M04).

Actual Assurances: Positive (+) or Negative (-)

Positive (+) STF milestones for first quarter STF payment achieved – STF paid. (+) Budget changes made to match activity – overall spend is within tolerance (noting overspending areas and budget profile) at M04 (+) Internal audit (IA) advises CIP process sound (but notes non-delivery, see below) Negative (-) IA advises effectiveness of savings delivery rated red/amber – risk to forecast. (-) Nurse agency CIP reported to FWC shows use of contingency, but still means a c£1.0m shortfall without further action (-) Emergency activity pressures have continued and unplanned increase in elective referrals (-) Overall agency costs remain very high, with escalation still in use and significant costs across Divisions. However, spend appears flat rather than rising. Gaps in assurance Assurance Level gained: RAG Overspending and agency savings delivery are the main areas of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans Actions proceeding to timetable 2) Additional PMOs in place for agency control 3) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement. The latter tightened again in February (and maintained since then) 4) Decisions on business cases taken in light of affordability and contribution. Update by Date discussed at Board PS 12/08/2016 August 2016

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical Page 12

leadership model Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5. 3 Unable to deliver medium term financial plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S4 x L2 = 8 Linked to Risk 1603 Controls in place (to manage the risk) Gaps in Control 1) Items referred to in 5.A.1 and 5.A.2 above 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) V8.0 long term financial model and integrated business plan 2) Reliance on centrally determined rules for tariff and the wider NHS finance completed (submitted to NHSi in June 2016) and supports 2016/17 regime. budget 3) Risk over capacity from other operational pressures 3) TDA Plan submitted in April 2015, 2016/17, resubmitted (minor 4) Overall health system financial view describes significant loss of resource to BCF cash changes) July 2016 funding and recovery of non recurrent actions in CCGs in 2015/16- reduces 4) Cost improvement plan process in place (including PMO structure) resource available for health and social care overall. 5) Demand and capacity planning for 2016/17 is now largely complete 5) Central actions over NHS overspend may have an adverse impact on Trust 6) Contracts agreed with commissioners because of manner of application (e.g. withholding capital and cash). 6) STP process identifies significant “do nothing” deficit [noting impact of actions reduces that considerably] Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Production of 2016/7 budget, revised long term Positive financial model and integrated business plan (+) STF milestones for first quarter STF payment achieved – STF paid. documentation, and delivery against them 2) Agreed contracts with commissioners describing Negative realistic demand and acceptable financial values (-) overall health system loss of resource in 2015/16 (to BCF and from CCG non recurrent recovery) 3) Sign off of sustainability & transformation funding and likely continuation of seepage in 2016/17 with NHS Improvement (-) Health system STP footprint in overall deficit.

Gaps in assurance Significant risk and unknown impact of central actions to manage NHS overspending. Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable

Please see items above. Update by

Assurance Level gained: RAG

PS 12/08/2016

Date discussed at Board

August 2016

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical Page 13

leadership model Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

Controls in place (to manage the risk) 1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital management processes 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score

S4 x L3 = 12

Linked to Risk

1604

Gaps in Control 1) No agreement on medium term solution to liquidity – being pursued during 2016/17 (as it was last year) 2) Threat of central cash controls in line with control totals.

NOTE: This risk was reviewed at FWC 22 September 2015 and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £12.5m working capital facility has now been agreed and cash drawn down, with a further draw down of £7.0m cash. Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) 1) Twice monthly reporting to CFO by finance team, Positive SBS reporting on bank balance (+) Cash targets met in 2015/16 2) Monthly finance reporting to Executive Committee, (+) Liquid ratio has followed expectations Finance and Workforce Committee and Trust (+) Cash has been managed well in 2015/16 and to date, Green internal audit report on cash Board management 3) Confirmation of working capital injection (either (+) Adequate working capital facility sufficient to cover cash needs into 2016/17 has been agreed. through a loan, working capital facility or, if Negative available, PDC) (-) no additional cash to resolve underlying liquidity problem – restrictions being applied by NHSi as described in “gaps in control”. (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. Overall rating “red” noting risk to forecast I&E. No current cash problem but underlying problem unresolved. Gaps in assurance Assurance Level gained: RAG In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Assurance level “red” noting unresolved underlying cash issue. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action, but coupled to action to maintain income and manage spend Actions proceeding to timetable 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model Update by

Page 14

PS 12/08/2016

Date discussed at Board

August 2016

Objective 5 - Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.E We are an organisation that is Director of Organisational clinically led and managerially Development & People enabled. Initial Risk S3 x L3 = 9 Key Action for 2015/16 objectives 5.5 There is a risk that the Trust will Current rating S3 x L3 = 9 and description of any potential not meet its objective of becoming significant risk to this priority an ‘employer of choice’ if it does not Target risk score S3 x L2 = 6 deliver a workforce strategy that drives the recruitment and retention Linked to Risk 1740 of talent and ensures a positive staff experience for all groups of staff through on-going education, development, engagement, inclusion and well-being. Controls in place (to manage the risk) Gaps in Control 1) Reviewed and ‘refreshed’ the Trust’s Workforce Strategy ensuring 1) Operational activity levels in the Trust stated as reason by line managers for nonrelevant objectives in place compliance with Corporate targets 2) Trust-wide and Divisional resourcing plans being devised to ensure the Trust is able to identify and recruit ‘talent’ that compliments the current staff 3) Retention Strategy being developed collaboratively between Workforce and Nursing Directorates 4) Multi-disciplinary education and training strategy in development 5) New Achievement Review (ARs) process launched in April 2016 which will support the development of all staff and as well provide structure to Talent Management 6) Inclusion strategy being developed in conjunction with BRAP, (an independent equalities charity), which will link to national inclusion initiatives and regulatory requirements (e.g. EDS2, WRES, Public Sector Equality Duties) 7) SaSH Health & Well-being Strategy being developed as well as a programme to deliver the 2016/17 Healthy Workforce CQUIN Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Progress towards Trust’s Workforce Strategy objectives is reported monthly to the Finance & Workforce Committee. The quarterly Annual Plan report to the Board also includes Workforce Strategy updates 2) Key Workforce Indicators (e.g. recruitment, establishment, sickness, turnover, AR compliance, etc.), reported on a monthly basis to the Trust Board 3) Key Inclusion objectives are reported on a national basis (e.g. annual WRES report, National Staff Survey, etc.) 3) For 2016/17, Health & Well-being initiatives will be reviewed by CCGs as part of the national CQUIN Page 15

Actual Assurances: Positive (+) or Negative (-) Positive (+) Accurate Workforce data being published on a monthly basis (+) Close collaborative working between key internal and external stakeholders (i.e. Workforce, Finance, Nursing, HR Business Partners, BRAP, etc.) (+) National frameworks in place to support local delivery (e.g. Health CQUIN, WRES, etc.) (+) Quality of appraisals in top 20% nationally in 2015 Staff Survey Negative (-) 2015 Staff Survey on appraisal completion in last 12 months is in lowest 20% nationally (-) 2015 Staff Survey on bullying and harassment in lowest 20% nationally (-) 2016/17 compliance rates for Achievement Review remains adverse to plan (-) Nursing recruitment challenging with negative effect on Bank and Agency usage

Gaps in assurance Some of the individual strategies / work-plans (i.e. Inclusion, Well-Being, Education & Training), which support the overarching Trust Workforce Strategy are still being developed Mitigating actions underway 1) Individual strategies with objectives and action plans being drafted for approval 2) ‘It’s Not Okay’ campaign being developed to address issues of bullying and harassment 3) Promotion of 2016 AR cascade process on-going Trust-wide to support delivery of 90% compliance rate 4) Pro-active Recruitment planning in place including international campaigns 5) 2016/17 Q1 Actions for the Health CQUIN being delivered Update by Date discussed at Board MP 17/08/2016

Page 16

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

August 2016

Objective 5 - Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.B Deliver high quality care around Chief Nurse and Medical Director the individual needs of each patient Initial Risk S3 x L4 = 12 Key Action for 2015/16 objectives 5.6 The continuing challenge to Current rating S3 x L5 = 15 and description of any potential recruit and retain clinical staff is Target risk score S3 x L2 = 6 significant risk to this priority impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality Linked to Risk 770, 1295, 1580, 1652 benefits. Controls in place (to manage the risk) Gaps in Control 1. Workforce KPIs including vacancy rates, turnover and temporary 1. E-Roster system is not updated out of hours staffing monitored by Nursing agency PMO, Workforce subcommittee, 2. Unfilled shifts both nursing/midwifery and medical Exec Committee and the Board 3. The Trust still carries a volume of vacancies specifically in clinical areas and 2. Monitoring of Safety Thermometer, patient experience and staff turnover in some areas is above Trust target turnover, sickness at ward level and at associated subcommittee, Exec 4. Imperfect induction for short notice, short term medical locums and the Board 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 3. Planned versus actual staffing levels monitored on a shift by shift basis, 6. Medical trainees select a preference that affects the decision reported daily by Matrons and issues escalated to DCNs with evidence actions taken. CHPPD reported monthly to NHSI. 4. PMO in place to monitor agency use and progress of work streams a. E-roster- migration to v10 implemented b. Nursing recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored by Agency PMO, Workforce subcommittee and divisional team meetings c. Recruitment process reviewed, KPIs in place to provide assurance d. Bank recruitment in progress to reduce use of agency nursing staff e. International recruitment in place, monitored and via divisional agency PMO f. Weekly reporting in place to NHSI in place on all agency use g. Monthly reporting of total agency spend against NHSI agreed trajectory 5. SNCT/Birthrate Plus tool/NICE guidelines utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand. Triangulated with safety and workforce metrics. 6. SASH recruitment brand and retention strategy in place including the development of new nursing roles 7. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 8. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients. 9. Strong relationship with HEKSS who place junior doctors in the organisation 10. Practice development nurses recruited to support ward nursing teams improve retention. 11. Care certificate implemented Page 17

Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Staff absence reports monitored in divisions 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation GMC and NMC 5. Monitoring agency utilisation and spend at PMO 6. Weekly & monthly reporting of agency use to NHSI

Actual Assurances: Positive (+) or Negative (-) Positive (+)SNCT/CHPPD data (+) Recruitment plans developed by ward and reported fortnightly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure (+) European recruitment undertaken (+) Initial feedback from nursing revalidation. Negative (-)Benchmarked high proportion of agency staff usage against other Trustâ&#x20AC;&#x2122;s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload

Gaps in assurance Trust position known - no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway 1. 2. 3. 4.

Continue to monitor effectiveness of recruitment plans 7 day working plans for medical staff under development across the Trust Implement plans to manage staffing issues in Theatres Increasing direct entry nursing students by 100% (40 to 80) from February 2016

Update by

Page 18

FA 05/08/2016 and DH 20/07/2016

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Ongoing 2. Being implemented 3. Being implemented 4. Being implemented August 2016

Objective 5 â&#x20AC;&#x201C; Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.F. Ensure IT support/optimise Director of Information and Facilities patient experience by improving patient interface, sharing and Initial Risk S5 x L3 = 15 capture of patient information and patient communication Key Action for 2015/16 objectives 5.7. There is a risk that the Trust will Current rating S4 x L3 = 12 and description of any potential not fully realise the benefits Target risk score S3 x L3 = 9 significant risk to this priority available from well embedded IT systems Linked to Risk 1428, 999, 1483 Controls in place (to manage the risk) 1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2) IT Strategy aligned with Clinical Strategy and IBP and reviewed Feb 16 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented â&#x20AC;&#x201C; greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive 11) EPR Roadmap signed-off by Executive November 2015 and Trust working on implementation plan and business case with EPR Provider 12) EPR OBC Agreed by FWC and Executive Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change

Gaps in assurance Trust position known, no identified gaps in assurance Mitigating actions underway

Gaps in Control 1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits

Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Trust moved to latest version of EPR software (+) Business Continuity System now in place (7/24) Assurance Level gained: RAG

1. Procurement and implementation of replacement EPR - complete 2. Establishment of Chief clinical Information Officer role - complete 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years 5. EPR Roadmap now approved by Executive and approval to proceed agreed 6. EPR Digitise Business Case now approved 7. Move to latest version of Cerner software now taken place Update by Date discussed at Board IM 17/08/2016 Page 19

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan now complete 4. Network review first draft now complete and approval to proceed approved

August 2016

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

Minor • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

Moderate • Short-term avoidable injury / harm with recovery / treatment up to 1 month

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience • Upheld complaints regarding death in the related to poor treatment / care Trust

• Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / • National media coverage / political action local media involvement against the Trust

• Care pathway problems resulting in short- • Care pathway problems resulting in term treatment / care delay <3 hours short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in • Care pathway problems resulting in medium term delays (up to 1 month) or 5medium term delays (1-6 months) or 1010 patients affected 20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

• No harm injury

• Short term / non-permanent injury / ill health. • Injury / ill health resulting in 0-7 days absence from work.

• Medical treatment required

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has • Permanent loss of core service or facility serious impact on patient care resulting in major contingency plans being involved

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following:  Infant abduction  Infant discharged to wrong family  Rape or serious assault

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

Patient 'Experience' & • No significant impact on patient Care Pathways and experience Involvement of • No complaints / concerns raised Service Users

Major

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

Page 21

• Short term disruption to service(s) with minor impact on patient care

Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures. This has a significant impact on the Trust's ability to deliver high quality care.

D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Surveillance of diarrhoea and vomiting Red aprons system

Stat and mandatory training Policy Communications messages to staff, visitors and patients Norovirus leaflets Hand hygiene facilities Restricted visiting Use of signs at entrance to wards and bays, and red aprons to facilitate communication that an outbreak is taking place.

1) EDD Patient Pathway 2) Discharge management 3) Plans for escalation areas agreed 20 and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt

Done date

Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Trial and review of decontamination products in use in the Trust Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&V Meeting with stakeholders regarding norovirus preparedness Audit of post-outbreak cleaning Pilot Patient Hand Hygiene Champions in Elderly 5 15 Care Stakeholders meeting to discuss health system norovirus planning Monitor use of ED risk assessment for patients admitted with diarrhoea and/or vomiting Monitor ward refurbishment programme Review of cleaning resource for enhanced cleaning during outbreak Stakeholder norovirus study day Prepare options appraisal for emptying bays to facilitate terminal cleaning following outbreak

31/03/2013 30/06/2013 01/04/2013 30/06/2016 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2015 22/09/2014 31/03/2014 30/03/2013 31/03/2016 25/09/2013 31/01/2013

06/12/2013 26/07/2013 26/07/2013 25/07/2016 02/09/2013 11/02/2014 06/12/2013 22/02/2016 05/05/2016 22/09/2014 21/05/2014 26/07/2013 29/04/2016 25/09/2013 26/07/2013

As described on the board assurance framework Implementation of divisional escalation plan following key triggers. Escalation bed plan agreed implementation plans in place for each area. Ambulance handover escalation plan agreed and in place with new process for managing handovers agreed to maintain flow. Escalation 4 16 to division with clear triggers in place. Weekly ED review meeting to review previous weeks performance and implement lessons learnt Plans in place to manage with reduced capacity during January through March 2016 whilst building works are underway.

31/03/2014 01/09/2016 30/09/2015 01/09/2016 01/09/2016 31/12/2015

22/02/2016

30/09/2015

23/05/2016

Next Review

Due date

Residual Rating

Current Rating

Current Likelihood

Current Consequence 3

Treatment Plan

31/08/2016

Failure to maintain Emergency Department performance

Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures.

Existing controls

31/08/2016

Risk of outbreak of viral gastroenteritis

Description

Initial Rating

Risk Owner

Risk Type Patient Safety

Holden, Des Stevenson, Angela

Involvement of Service Users

Specialty

Open Date 23/01/2013

Medical Director's Office Operations

29/08/2013

Committee Safety

1401 1491

Responsiveness

Title

Risk of not achieving Risk of not achieving Cost financial plan as a result of Improvement Plan non-delivery of Cost Improvement Plans

1) Items referred to in 5.A.1 and 5.A.2 above 2) V8.0 long term financial model (submitted to NHSi June 2016)and 15 integrated business plan completed (submitted to TDA in February 2014) 3) NHSi Plan submitted 2016.

3 15

1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy 3) Annual cash plan linked to business plan and capital plan

3 15

i) Delivery of savings managed through PMO (on-going) ii) Agency management is subject to broader focus.

31/03/2014 23/11/2015 14/06/2016

As described on the BAF

23/09/2016

As described on the BAF

01/09/2016

Treatment plan will vary according to CIP. i) Action plans to reduce shortfall. ii) Contingency 4 16 within each area.

31/03/2017

Next Review

27/06/2014 31/08/2015 18/01/2016

31/08/2016

20/09/2016

Done date

Residual Rating

Current Rating

Current Consequence

Current Likelihood

As described on BAF Reviewing compliance to establish a key baseline target 5 15 Build an integrated discharge unit to increase community capacity

Due date

20/09/2016

Paul Financial Managemen

1663 Executive Committee 09/12/2014 Finance Fin Simpson,

Risk of not being able to pay suppliers from in sufficient cash due to poor liquidity problem

Treatment Plan

20/09/2016

1) Operational meeting three times a day chaired by AD Site Services with clinical involvement from Matrons, Nurse Specialists and therapists If the Trust does not 2) Daily Board rounds by clinical site maintain and improve ability team. Focusing on #NOF, Stroke to allocate the right bed first and Medical outliers time there is an increased 3) Live 'To come In' lists available to risk of receiving poor quality view in all specialty wards to of our care (effectiveness, encourage active pull of patients experience and safety) from AMU to the correct specialty bed 4) Matrons review ward areas on a daily basis 5) Matron on site 7 days a week

Unable to deliver realistic As described on the BAF medium term financial plan

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

Existing controls

Initial Rating

Risk Type

Risk Owner Stevenson, Angela

Involvement of Service Users

Open Date

Specialty Operations

19/09/2013

Description

18/06/2014 Finance - Fin. Management Simpson, Paul Financial Management

Committee

ID 1501

Responsiveness

1603

Patient admitted to the right bed first time

1604 Executive Committee 18/06/2014 Finance - Fin. Management Simpson, Paul Financial Management

Executive Committee

Title

1779 Executive Committee 21/06/2016 Finance - Fin. Management Simpson, Paul Financial Management

Risk of Contract income below plan

Failure to delivery productivity gain from income growth

i) Continuation of 2015/16 actions around internal management and external management; the health system response will need to improve in 2016/17 and the basis of that is currently being navigated through SRG. i) Budgeted income/activity and Risk to Trust overall financial budget agreed, plus financial plan as a result business plans from Divisions. capacity issues reducing ii) Monitored through financial and income and of not achieving activity reporting. productivity gain from iii) PMO management and CEO income growth. Productivity Group.

Risk the Trust does not achieve its financial plan as a result of lower than planned contract income from capacity issues.

4 16

As described on the BAF.

i) Output from productivity/LoS work. ii) Discussion with CCGs on resourcing a shared 4 16 problem. iii) Contingency actions.

31/03/2017

i) Action plans agreed through Productivity Group for various initiatives. ii) Additional budget 31/03/2017 4 16 allocated for additional posts (to allow productivity benefit).

Next Review

09/02/2015 05/08/2015 18/09/2015

31/08/2016

Manage the number of IPs booked on lists to 27/02/2015 avoid cancellations 20/06/2015 5 15 Improve Theatre Utilisation 15/05/2015 Ring-fencing of Tandridge and Woodland Wards

20/09/2016

Risk of potential overspending from operational pressures

i) Divisions to implement action plans and contingencies to control/or recover overspending. Specific Risk of failure to meet the action is required in all Divisions. Trusts financial plan due to 12 ii) Agency PMO to deliver outputs in overspending. respect of reduced agency usage following recruitment. Position being reviewed (ongoing).

Done date

15/09/2016

Due date

20/09/2016

Treatment Plan

Residual Rating

1. Access Policy revised 2014 2. Weekly PTL / performance meetings to monitor progress. 3. Service Level plans to increase capacity where required. 4. Operational plan for winter 2015/16 to support inpatient elective care

Current Rating

RTT Access Standards

Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints

Current Likelihood

Current Consequence

Initial Rating

Risk Type

Risk Owner Emly, Ben

Service Access Financial Management

Open Date

Specialty Operations

23/03/2015

20/05/2015 Finance - Fin. Management Simpson, Paul

Committee

ID 1678

Responsiveness

1688

Existing controls

1689 Executive Committee 01/04/2015 Finance - Fin. Management Simpson, Paul Financial Management

Executive Committee

Description

Title

TRUST BOARD IN PUBLIC

Date: 25th August 2016 Agenda Item: 2.1

REPORT TITLE:

Patient Story Dr Des Holden Medical Director Dr Des Holden Medical Director

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Patient Safety Executive

Action Required: Approval ()

Discussion (√)

Assurance (√)

Purpose of Report: Patient story to share with the Board. Summary of key issues A 65 year old woman presented to ED with shortness of breath with a significant past history of medical illnesses and admission to hospital. A diagnosis of community acquired pneumonia was made and the patient agreed to be admitted. While waiting for a bed she left ED with her husband and collapsed at the toilets near to Boots. A MET call was activated and the patient was transferred back to ED. there was then a period of confusion resulting in a lack of recorded physiological observations for approximately three hours after which, while she was being reviewed by the medical team, she collapsed and died. A post mortem examination showed pulmonary embolus. An SI was declared on basis of unexpected severe outcome. The investigation concluded that departmental busyness contributed to an environment in which a failure in communication between senior nurse, agency and junior nurse. As a consequence there was a lack of clarity over who was responsible for documenting and reacting to changes in condition. Recommendation: For information and discussion Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population Corporate Impact Assessment: Legal and regulatory impact

Potential impact to CQC rating if we do not listen and learn from patient feedback

Financial impact

Nil

Patient Experience/Engagement

It is important that the organisation can demonstrate that it listens to and learns from patient feedback

Risk & Performance Management

NHS Constitution/Equality & Diversity/Communication

It is important that the organisation can demonstrate that it listens to and learns from patient feedback

Attachment: N/A

2 An Associated University Hospital of Brighton and Sussex Medical School

Trust Board Report â&#x20AC;&#x201C; 25th August 2016 Patient Story Details of case A 65 year old woman was seen in ED with shortness of breath. She had a past history of valvular heart disease, chronic obstructive pulmonary disease, ear nose and throat and musculoskeletal problems. An initial diagnosis of an infective complication on top of her lung disease was made and she was seen in the ED by senior medical staff who commenced antibiotics. There was discussion about the need for admission (the patient did not want this) but as a plan of care this was agreed. While waiting in ED for a bed to become available the patient was accompanied out of the department to toilets near Boots as the ED toilet could not accommodate her wheelchair. In this location she became acutely unwell and collapsed. A medical emergency team call was placed and the team arrived quickly and brought the patient back to the department. At the time of this incident there were 77 patients in the department. The senior nurse transferred the patient to the high dependency area where there was an experienced agency nurse where she made some recovery. Normal practice in this area, which can accommodate four patients, is for the nurse in the area to look after all 4 patients. However a junior nurse (who had her own case load of patients in the main department was asked to settle the patient into the bay and perform initial observations. A misunderstanding arose at this point with the agency nurse believing the junior nurse was to provide on-going care. This was not what the junior nurse understood and she returned to looking after her other patients. This was not apparent to the agency nurse who needed to leave the high dependency area to accompany another patient. The result was that whilst automated readings of pulse and blood pressure and oxygen saturation so were being performed, no one was documenting or acting on these. When the agency nurse returned to the bay the patient was being re-reviewed by the physician team and during this review the patient became acutely unwell, reported they couldn't breathe and suffered a cardiac arrest. A resus call was put out and CPR commenced at which point the patient's partner confirmed to the team that the patient had an active DNAR decision in place. The team stopped CPR and the patient was pronounced dead. Post mortem examination confirmed the cause of death as pulmonary embolus. This diagnosis had been considered by the medical team and a plan had been made that if further signs of this presented appropriate imaging should be requested. Investigation revealed the miscommunication and misunderstandings that led to observations not being recorded or acted on. It is unlikely that these failings caused the outcome, which was likely to have occurred even if this documentation had been excellent. The investigation concluded that whilst extreme busyness did not cause the miscommunication it was an environmental factor that contributed. The Board is asked to note and discuss this case. Dr Des Holden Medical Director August 2016

3 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 25th August 2016 Agenda Item: 2.3

Chief Nurse & Medical Director Report

REPORT TITLE:

Fiona Allsop, Chief Nurse Des Holden, Medical Director Fiona Allsop, Chief Nurse Des Holden, Medical Director

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report:

To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues

Chief Nurse Report • The Safer Staffing report (July 2016 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. • Care Hours Per Patient Day (CHPPD) reported for July data • Nurse Associate pilot update • Recruitment to Deputy Chief Nurse for Innovation & Improvement Medical Director Report • Meeting with SECAMB • Launch of KSS School of Physicians Associates Recommendation:

To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model Corporate Impact Assessment: Legal and regulatory impact

Yes

Financial impact

Yes

Patient Experience/Engagement

Yes

Risk & Performance Management

Yes

NHS Constitution/Equality & Diversity/Communication

Yes

Attachment: NA

Page 1

TRUST BOARD REPORT – 25th August 2016 Chief Nurse & Medical Director Report Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring and on recruitment activity. 2.

Staffing Planned versus Actual – July 2016

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

99.42%

100%

93.04%

100%

96.08%

100%

97.55%

Acute Medical Unit

300 - GENERAL MEDICINE

95.73%

98.62%

85.73%

91.94%

92.79%

96.19%

94.31%

Birthing Centre

501 - OBSTETRICS

94.6%

95.16%

N/A

94.6%

95.16%

94.88%

Bletchingley Ward

300 - GENERAL MEDICINE

95.66%

100%

94.88%

100%

95.32%

100%

97.05%

Brockham Ward

502 - GYNAECOLOGY

97.3%

98.92%

87.97%

100%

94.14%

99.19%

96.15%

Brook Ward

100 - GENERAL SURGERY

98.42%

95.24%

100%

98.96%

95.52%

97.55%

Buckland Ward

101 - UROLOGY

98.39%

100%

95.62%

98.39%

97.28%

99.19%

98%

Burstow Ward

501 - OBSTETRICS

95.13%

82.8%

81.56%

91.94%

90.6%

86.45%

88.72%

Capel Annex l Ward

100 - GENERAL MEDICINE

97.07%

100%

89.32%

100%

93.75%

100%

96.01%

Capel Ward

430 - GERIATRIC MEDICINE

93.4%

100%

96.14%

96.77%

94.27%

98.71%

96.22%

Chaldon Ward

300 - GENERAL MEDICINE

97.26%

100%

95.8%

95.65%

96.63%

97.4%

96.9%

Charlwood Ward

301 - GASTROENTEROLOGY

99.18%

100%

94.3%

100%

97.4%

100%

98.41%

Copthorne Ward

301 - GASTROENTEROLOGY

97.56%

100%

95.74%

94%

96.95%

97%

96.97%

Coronary Care Unit

320 - CARDIOLOGY

97.85%

100%

N/A

93.55%

97.85%

Delivery Suite

501 - OBSTETRICS

96.19%

97.31%

97.27%

91.94%

96.46%

95.97%

96.21%

Discharge Lounge

300 - GENERAL MEDICINE

95.33%

100%

94.67%

93.55%

95%

96.77%

95.63%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

100%

N/A

100%

Godstone Ward (Med)

300 - GENERAL MEDICINE

99.36%

98.92%

91.02%

97.85%

96.24%

98.39%

97.16%

Hazelwood

300 - GENERAL MEDICINE

96.77%

100%

95.32%

100%

96.05%

100%

97.63%

Holmwood Ward

320 - CARDIOLOGY

96.59%

100%

91.38%

100%

95.18%

100%

96.94%

TU/HDU

192 - CRITICAL CARE MEDICINE

99.3%

98.9%

86.81%

83.33%

97.27%

97.72%

97.48%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

95.64%

100%

95.7%

97.66%

97.42%

97.57%

Meadvale Ward

430 - GERIATRIC MEDICINE

94.21%

100%

98.39%

96.4%

99.19%

97.36%

Neonatal Unit

420 - PAEDIATRICS

96.98%

98.39%

100%

93.33%

97.94%

96.74%

97.36%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

98.04%

100%

95.1%

95.7%

96.8%

97.42%

97.04%

Nutfield Ward

430 - GERIATRIC MEDICINE

98.71%

100%

97.85%

100%

98.39%

100%

98.92%

Outwood Ward

420 - PAEDIATRICS

98.08%

99.36%

64.85%

63.33%

93.87%

93.58%

93.75%

Rusper Ward

501 - OBSTETRICS

96.46%

95.16%

N/A

96.46%

95.16%

96.03%

Page 2

Surgical Assessment Unit

100 - GENERAL SURGERY

95.97%

100%

93.55%

95.48%

96.77%

96.06%

Tandridge Ward

300 - GENERAL SURGERY

97.59%

100%

89.23%

90.32%

93.87%

95.16%

94.26%

Tilgate Annex

100 - GENERAL MEDICINE

99.35%

90.91%

94.2%

100%

97.42%

95.24%

96.69%

Tilgate Ward

300 - GENERAL MEDICINE

98.06%

100%

91.4%

96.77%

95.56%

99.19%

96.77%

Woodland Ward

100 - GENERAL SURGERY

97.62%

100%

97.58%

100%

97.6%

100%

98.38%

97.29%

98.35%

93.38%

95.78%

95.95%

97.37%

96.51%

Total

Planned versus actual commentary The Trust has delivered planned versus actual staffing profile for July. The report shows a stable picture in relation to overall compliance. The red shifts on Outwood were managed by the clinical team with no concerns regarding patient safety.

Care hours per patient day (CHPPD) July RTP04

EAST SURREY HOSPITAL - RTP04

Abinger Ward

430 - GERIATRIC MEDICINE

1302

1167

1466.5

1405.5

690

678.5

805

782

89.6%

95.8%

98.3%

97.1%

RTP04

EAST SURREY HOSPITAL - RTP04

Acute Medical Unit

300 - GENERAL MEDICINE

3473

3222.5

1414.5

1229

2495.5

2438

1426

1403

92.8%

86.9%

97.7%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

Birthing Centre

501 - OBSTETRICS

713

678.5

713

632.5

95.2%

88.7%

RTP04

EAST SURREY HOSPITAL - RTP04

Bletchingley Ward

300 - GENERAL MEDICINE

3023

2817.5

2821.5

2745.5

1782.5

1748

1426

1403

93.2%

97.3%

98.1%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

Brockham Ward

502 - GYNAECOLOGY

1448

1333.5

697

632

908.5

885.5

471.5

460

92.1%

90.7%

97.5%

97.6%

RTP04

EAST SURREY HOSPITAL - RTP04

Brook Ward

100 - GENERAL SURGERY

716.5

352

344.5

713

100.0%

97.9%

100.0%

RTP04

EAST SURREY HOSPITAL - RTP04

Buckland Ward

101 - UROLOGY

1628

1563

747.5

736

667

632.5

667

598

96.0%

98.5%

94.8%

89.7%

RTP04

EAST SURREY HOSPITAL - RTP04

Burstow Ward

501 - OBSTETRICS

1426

1183.5

713

597

1069.5

724.5

713

667

83.0%

83.7%

67.7%

93.5%

RTP04

EAST SURREY HOSPITAL - RTP04

Capel Annex l Ward

300 - GENERAL MEDICINE

1433.5

1399

1069.5

713

667

713

690

97.6%

100.0%

93.5%

96.8%

RTP04

EAST SURREY HOSPITAL - RTP04

Capel Ward

430 - GERIATRIC MEDICINE

1633

1408.5

713

696.5

1069.5

977.5

713

678.5

86.3%

97.7%

91.4%

95.2%

RTP04

EAST SURREY HOSPITAL - RTP04

Chaldon Ward

300 - GENERAL MEDICINE

2668

2405.5

2139

2047

1426

1334

1391.5

1345.5

90.2%

95.7%

93.5%

96.7%

RTP04

EAST SURREY HOSPITAL - RTP04

Charlwood Ward

301 - GASTROENTEROLOGY

1398

1176.5

773.5

628

552

563.5

517.5

84.2%

81.2%

100.0%

91.8%

RTP04

EAST SURREY HOSPITAL - RTP04

Copthorne Ward

301 - GASTROENTEROLOGY

1426

1372

707.5

692.5

713

678.5

713

701.5

96.2%

97.9%

95.2%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

Coronary Care Unit

320 - CARDIOLOGY

1046.5

977.5

690

678.5

333.5

276

93.4%

200.0%

98.3%

82.8%

RTP04

EAST SURREY HOSPITAL - RTP04

Delivery Suite

501 - OBSTETRICS

2139

1932

713

582.5

2139

1966.5

713

632.5

90.3%

81.7%

91.9%

88.7%

RTP04

EAST SURREY HOSPITAL - RTP04

Discharge Lounge

300 - GENERAL MEDICINE

666.5

610

628

586

345

356.5

91.5%

93.3%

100.0%

RTP04

EAST SURREY HOSPITAL - RTP04

Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY

713

100.0%

RTP04

EAST SURREY HOSPITAL - RTP04

Godstone Ward (Med)

1077

1019.5

713

655.5

713

701.5

94.7%

91.9%

100.0%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

Holmwood Ward

320 - CARDIOLOGY

1793

1709

690

644

713

701.5

95.3%

93.3%

100.0%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

ITU/HDU

192 - CRITICAL CARE MEDICINE

4599.5

4512

752

699

4508

4393

356.5

345

98.1%

93.0%

97.4%

96.8%

Leigh Ward

RTP04

300 - GENERAL MEDICINE

302 - ENDOCRINOLOGY

410 - RHEUMATOLOGY

110 - TRAUMA & ORTHOPAEDICS

1590.5

1495.5

1181.5

1071.5

713

644

713

644

94.0%

90.7%

90.3%

RTP04

EAST SURREY HOSPITAL - RTP04

Meadvale Ward

430 - GERIATRIC MEDICINE

1257

1159

1426

1403

713

701.5

92.2%

98.4%

100.0%

98.4%

RTP04

EAST SURREY HOSPITAL - RTP04

Neonatal Unit

420 - PAEDIATRICS

1506

1425.5

651.5

598

1414.5

1391.5

678.5

609.5

94.7%

91.8%

98.4%

89.8%

110 - TRAUMA & ORTHOPAEDICS

1628.5

1495

1190

1149

713

736

713

563.5

91.8%

96.6%

103.2%

79.0%

RTP04

EAST SURREY HOSPITAL - RTP04

Newdigate Ward

RTP04

EAST SURREY HOSPITAL - RTP04

Nutfield Ward

430 - GERIATRIC MEDICINE

1786

1663.5

1030

1022.5

713

93.1%

99.3%

100.0%

RTP04

EAST SURREY HOSPITAL - RTP04

Outwood Ward

420 - PAEDIATRICS

2636.5

2528.5

401.5

359.5

2104.5

1989.5

402.5

299

95.9%

89.5%

94.5%

74.3%

RTP04

EAST SURREY HOSPITAL - RTP04

Rusper Ward

501 - OBSTETRICS

1150

1058

11.5

690

621

92.0%

100.0%

90.0%

RTP04

EAST SURREY HOSPITAL - RTP04 Surgical Assessment Unit 100 - GENERAL SURGERY

1426

1357

356.5

345

713

609.5

713

667

95.2%

96.8%

85.5%

93.5%

RTP04 RTP04 RTP04 RTP04

EAST SURREY HOSPITAL - RTP04 EAST SURREY HOSPITAL - RTP04 EAST SURREY HOSPITAL - RTP04 EAST SURREY HOSPITAL - RTP04

Tandridge Ward

300 - GENERAL MEDICINE

1426

1314

1069.5

951.5

713

701.5

713

644

92.1%

89.0%

98.4%

90.3%

Tilgate Annex

300 - GENERAL MEDICINE

340 - RESPIRATORY MEDICINE

1782.5

1686.5

1069.5

1023.5

1058

966

713

690

94.6%

95.7%

91.3%

96.8%

Tilgate Ward

300 - GENERAL MEDICINE

340 - RESPIRATORY MEDICINE 1782.5

1702

1069.5

1007.5

966

954.5

322

310.5

95.5%

94.2%

98.8%

96.4%

Woodland Ward

100 - GENERAL SURGERY

1782.5

1644

966

996.5

690

667

690

655.5

92.2%

103.2%

96.7%

95.0%

706 2.6 1025 5.5 59 22.2 645 7.1 563 3.9 312 4.6 620 3.5 591 3.2 639 3.2 608 3.9 879 4.3 606 2.9 587 3.5 232 7.1 184 21.2 200 4.8 183 7.8 795 2.2 845 2.9 464 19.2

3.1

5.7

2.6

8.1

0.0

22.2

6.4

13.5

1.9

5.9

1.4

6.0

2.2

5.7

2.1

5.4

2.8

6.0

2.3

6.2

3.9

8.1

1.9

4.7

2.4

5.9

1.4

8.5

6.6

27.8

4.7

9.5

0.0

7.8

1.7

3.9

1.6

4.5

2.3

21.4

834 711 506

2.6

2.1

4.6

2.6

3.0

5.6

2.4

8.0

817 850 510 252 249

2.7

2.1

4.8

2.8

2.0

4.8

8.9

1.3

10.2

6.7

0.0

6.7

7.9

4.1

12.0

712 650

2.8

2.2

5.1

4.1

2.6

6.7

787 694

3.4

1.7

5.1

3.3

2.4

5.7

CHPPD commentary The report for July is shown above. The data comparison with June shows that the CHPPD are broadly similar for June and July across the acute inpatient wards. Care hours per patient day are calculated by dividing the total numbers of nursing hours on a ward or unit by the number of patients in beds at the midnight census. This calculation provides the average number of care hours available for each patient on the ward or unit. Currently the hours reported for nursing only in acute inpatient wards which are shown the white. The orange areas are excluded. This tool links with planned versus actual reporting and other data such as safety thermometer, incident reporting, sickness rates, vacancy rates and professional Judgement to determine the appropriate staffing levels for a ward or unit.

Page 3

Agency Cap reporting to NHS Improvement Since November 2015, the Trust has been required to report to NHSI shifts that are above the rate cap, off of a framework or both. The Trust use Mayday nursing agency as the main tier 1 provider. At the current time, the majority of these shifts are above the agency capped rate. All shifts above the rate cap are subject to use only in â&#x20AC;&#x2DC;break glassâ&#x20AC;&#x2122; circumstances. The justification of use for each shift is recorded on the Healthroster system. The total number of break glass shifts for all staff groups in July 2016 were 3448 compared with 2,655 shifts for June. Nurse Associate pilot submission The Trust has submitted an application to be a pilot site for the proposed nursing associate role. This has been submitted in partnership with Farnham College and the Hallmark Group who provide nursing home care in Surrey. If successful the Trust will provide placement support for approximately 10 nurse associate students commencing in January 2017. Deputy Chief Nurse, Innovation and Improvement Paula Tucker has been appointed to this role and will commence in November 2016. Medical Director Report SECAMB Summit Chief operating officer and medical director attended a summit with SECAMB, other acute providers, commissioners and both NHSi and NHSE on 17th August discussing the regional problem of delays in offloading patients at emergency departments to return crews to readiness for further calls. A useful discussion occurred with agreement that metrics other than time to offload should be developed (for instance time to attend a 999 call) and that a well consulted and agreed escalation plan appropriate system wide was needed and should be developed. There was very little appetite for a policy of immediate unloading where no nursing team could accept, which has been muted as a national response. Launch of KSS School of Physicians Associates On the evening of 24th August the launch of the KSS school of Physicians Associates will happen in the atrium. This will be attended by established PAs, faculty from sash, and representatives from the 4universities hosting courses. 3.

Recommendation

The Board is asked to note the report.

Fiona Allsop Chief Nurse August 2016

Dr Des Holden Medical Director

Page 4

Care Hours Per Patient Day Care hours per patient day have been developed to quantify the nursing time available to each patient by the available registered nursing staff and nursing assistants. Only complete sites your organisation is accountable for

Day

Main 2 Specialties on each ward

Ward name Specialty 1

Specialty 2

Registered midwives/nurses

Night Registered midwives/nurses

Care Staff

Day

Night

Care Hours Per Patient Day (CHPPD)

Care Staff

Cumulativ e count Average fill rate Average fill rate over the Registered Average fill rate Average fill rate - registered - registered Total Total Total Total Total Total Total Total month of midwives/ Care Staff monthly monthly monthly monthly monthly monthly monthly monthly nurses/midwives - care staff (%) nurses/midwives - care staff (%) patients at nurses (%) (%) planned actual planned actual planned actual planned actual 23:59 each staff hours staff hours staff hours staff hours staff hours staff hours staff hours staff hours day

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

1,302

1,287

1,422

1,361

713

1,070

98.8%

95.7%

100.0%

711

2.8

3.4

Acute Medical Unit

300 - GENERAL MEDICINE

3,462

3,435

1,426

1,376

2,496

1,426

1,380

99.2%

96.5%

100.0%

96.8%

991

6.0

2.8

8.8

713

667

100.0%

93.5%

33.7

0.0

33.7 6.0

Birthing Centre Bletchingley Ward

501 - OBSTETRICS

1,426

1,422

1,155

1,178

1,070

1,058

713

736

99.7%

102.0%

98.9%

103.2%

731

3.4

2.6

1,426

1,403

713

679

1,070

357

334

98.4%

95.2%

100.0%

93.5%

556

4.4

1.8

6.3

713

345

333

713

100.0%

96.7%

100.0%

308

4.6

1.1

5.7

101 - UROLOGY

1,445

1,403

932

928

713

702

713

702

97.1%

99.6%

98.4%

624

3.4

2.6

6.0

501 - OBSTETRICS

1,426

1,403

713

659

1,070

955

713

679

98.4%

92.4%

89.2%

95.2%

531

4.4

2.5

7.0

Capel Annex l Ward

300 - GENERAL MEDICINE

1,426

1,403

1,070

1,024

713

702

98.4%

95.7%

100.0%

98.4%

665

3.2

2.6

5.8

Capel Ward

430 - GERIATRIC MEDICINE

1,539

713

740

1,070

1,047

713

100.0%

103.7%

97.8%

100.0%

614

4.2

2.4

6.6

Chaldon Ward

300 - GENERAL MEDICINE

1,955

1,853

1,426

1,380

713

1,070

1,058

94.8%

96.8%

100.0%

98.9%

821

3.1

3.0

6.1

Charlwood Ward

301 - GASTROENTEROLOGY

1,375

1,409

838

830

713

102.5%

99.1%

100.0%

604

3.5

2.6

6.1

Copthorne Ward

301 - GASTROENTEROLOGY

1,426

1,415

730

707

713

690

713

99.2%

96.8%

100.0%

588

3.6

2.4

6.0

320 - CARDIOLOGY

1,070

1,047

725

713

345

357

97.8%

98.4%

103.3%

227

7.8

1.6

9.3

501 - OBSTETRICS

Brockham Ward Brook Ward Buckland Ward Burstow Ward

Coronary Care Unit Delivery Suite Discharge Lounge Godstone Ward (Haem) Godstone Ward (Med) Holmwood Ward ITU/HDU Leigh Ward Meadvale Ward Neonatal Unit Newdigate Ward Nutfield Ward

300 - GENERAL MEDICINE

302 - ENDOCRINOLOGY

6.2

502 - GYNAECOLOGY 100 - GENERAL SURGERY

2,139

2,066

713

671

2,139

2,105

667

644

96.6%

94.0%

98.4%

96.6%

134

31.1

9.8

40.9

300 - GENERAL MEDICINE

611

596

602

590

357

97.5%

98.1%

100.0%

12.9

12.8

25.7

303 - CLINICAL HAEMATOLOGY

713

702

311

306

713

98.4%

98.6%

100.0%

182

7.8

1.7

9.5

1,783

1,737

1,070

1,104

1,070

1,058

97.4%

103.2%

100.0%

98.9%

788

3.6

2.7

6.3

320 - CARDIOLOGY

1,783

1,771

713

690

713

702

99.4%

96.8%

100.0%

98.4%

841

3.0

1.7

4.6

192 - CRITICAL CARE MEDICINE

4,536

4,387

745

650

4,451

4,405

357

345

96.7%

87.2%

99.0%

96.8%

468

18.8

2.1

20.9

300 - GENERAL MEDICINE

410 - RHEUMATOLOGY

110 - TRAUMA & ORTHOPAEDICS

1,591

1,568

1,201

1,254

713

702

1,070

98.6%

104.4%

98.4%

100.0%

852

2.7

5.4

430 - GERIATRIC MEDICINE

1,280

1,208

1,426

1,380

713

94.4%

96.8%

100.0%

709

2.7

3.0

5.7

420 - PAEDIATRICS

1,598

1,502

701

724

1,449

1,380

690

633

94.0%

103.3%

95.2%

91.7%

560

5.1

2.4

7.6

110 - TRAUMA & ORTHOPAEDICS

1,599

1,604

1,160

1,264

713

1,058

100.3%

109.0%

100.0%

826

2.8

5.6

430 - GERIATRIC MEDICINE

1,783

1,756

1,081

1,069

713

702

98.5%

98.9%

100.0%

98.4%

857

2.9

2.1

4.9

1,783

1,760

357

299

96.8%

71.4%

98.7%

83.9%

571

7.2

0.9

8.1

713

97.6%

100.0%

248

8.5

0.0

8.5

Outwood Ward

420 - PAEDIATRICS

2,421

2,344

322

230

Rusper Ward

501 - OBSTETRICS

1,426

1,392

Surgical Assessment Unit

100 - GENERAL SURGERY

Tandridge Ward

300 - GENERAL MEDICINE

Tilgate Annex

300 - GENERAL MEDICINE

Tilgate Ward

300 - GENERAL MEDICINE

Woodland Ward

100 - GENERAL SURGERY

340 - RESPIRATORY MEDICINE 340 - RESPIRATORY MEDICINE

1,426

1,403

357

713

98.4%

100.0%

254

8.3

4.2

12.5

1,820

1,793

1,414

1,380

713

702

713

656

98.5%

97.6%

98.4%

91.9%

684

3.6

3.0

6.6

1,783

1,070

1,058

736

713

702

100.0%

98.9%

96.9%

98.4%

642

3.9

2.7

6.6

1,786

1,752

1,070

1,035

1,081

357

98.1%

96.8%

100.0%

797

3.6

1.7

5.3

1,783

1,047

1,024

713

100.0%

97.8%

100.0%

666

3.7

2.6

6.4

Date: 25th August 2016

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 REPORT TITLE:

Safety & Quality Committee Update

NON-EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Richard Shaw Chair Safety & Quality Committee Richard Shaw Chair Safety & Quality Committee n/a

Action Required: Approval ()

Discussion ( )

Assurance ()

Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in July 2016. In addition to standing items, these included quarterly assurance reports on Children and Adult Safeguarding, Complaints and PALS, and Incidents. Recommendation: N/A Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers Corporate Impact Assessment: Legal and regulatory impact

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

Patient Experience/Engagement

n/a

Risk & Performance Management

Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication

N/A

Attachment: None

Trust Board Report – 25th August 2016 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 4th August 2016. The Committee considered its standing items and sought assurance on a number of issues discussed at July meetings of the Executive Committee for Quality and Risk and CQRM. These included: •

•

Trauma Peer Review: The Committee asked for further information about the recent Peer Review, which found incomplete TARN data. It was assured that clinical care was found to be robust, and that actions are being taken to address data accuracy and will be considered at Clinical Effectiveness Committee. SQC will receive a report on progress in December. CQC: The Committee sought information about changes being considered in the CQC regime for assessment of Trusts, notably the potential inclusion of local information from sources such as local media and Healthwatch. The Chief Executive was asked to report on this to the Trust Board when it was clear what changes would be made. CQRM: Discussion had focused on first quarter activity growth in ED, with increase in patients brought by ambulance. Although not all patients were admitted some escalation areas had been opened with a consequential impact on elective surgery. There was some discussion about steps being taken to improve the effectiveness of CQRM as a multi-agency forum.

We took good assurance from the handling of these issues. Quality Report Discussion of the Quality Report focused on three topics: • A very recent MRSA bloodstream infection: a report will be made to the Committee at its next meeting on the methodology employed to manage, limit and investigate an MRSA outbreak. • Top 20% Safety: The Trust has an objective to be within the top 20% of Trusts national for patient safety. The committee requested a report setting out how this should be measured and what metrics were available. • Timeliness of Data: Safety and Quality data is presented monthly to SQC in the Quality Report but is about 4-5 weeks old by the time it reached the committee. It was agreed that it was not practical for the SQC to receive this data sooner but that: SQC’s focus would be on identifying and seeking assurance on longer term challenges; SQC would nevertheless ask for a verbal update at each meeting on any significant more recent developments; the Trust Board would continue to refer matters to SQC where it wanted further assurance. Complaints and PALS SQC received two quarterly reports – one on Complaints and the other on Compliments, Comments and PALS. The number of complaints received in the quarter was broadly similar to the same quarter last year but PALs contacts were 34% higher. The Committee was well assured about the process for handling complaints which involves early contact with the complainant and has led to a reduction in re-opened complaints. The main themes in both PALS contacts and complaints were the same: appointments, poor communication and staff attitude. SQC was assured by the commitment to actions at a local level, and recognized that the number of complaints is small in relation to the volume of activity in the Trust. Nevertheless a small number of complaints may be indicative of a wider problem. We noted the actions being taken to address the handling of appointments and asked for further assurance about the effect of actions taken at divisional level.

Incidents In the quarterly report on Incidents at the Trust, SQC probed an increase in Maternity incidents and received good assurance that this was a means of ensuring investigation. Falls continue to be by far the largest reason for incidents declared and the committee’s next meeting will discuss a report on a new approach to the management of falls. A new role of Deputy Chief Nurse will be an important component in this. Children and Adults Safeguarding SQC received quarterly reports on both Children’s and Adults’ Safeguarding which provided good assurance. In both cases one of the biggest challenges is to ensure staff training requirements are met. Extra provision is being made and key staff are being targeted. Priority areas in Children’s Safeguarding are FGM, domestic abuse, child sexual exploitation and Prevent training for staff; and in Adults’ FGM, domestic abuse, honour based violence and modern slavery. Because of the overlap of some of these issues, and the fact that they are often family-based, there is increasingly close joint working between the two services. The Committee has struggled to obtain assurance about the effectiveness of multi-agency working and how concerns raised by the Trust about the community are dealt with. There are practical difficulties about this but the next quarter’s reports will include an explanation of internal and external governance arrangements. Next Meeting The next SQC meeting is at 2pm on 1st September.

Richard Shaw Non-Executive Director Chair of Safety & Quality Committee August 2016

Integrated Performance Report M04 â&#x20AC;&#x201C; July 2016

Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer)

An University HospitalHospital of AnAssociated Associated University of Brighton andand Sussex Medical School School Brighton Sussex Medical

Performance – July 2016 Patient Safety • There were 6 SIs declared in July 2016 . • Other patient safety indicators continue to show expected levels of performance. • The Trust had 1 MRSA bloodstream infection and 1 Trust acquired C-Diff case in July 2016. Clinical Effectiveness • Mortality is lower than expected for our patient group when benchmarked against national comparators. • Maternity indicators continue to show expected performance. Access and Responsiveness • The 4hr ED standard was achieved with performance of 95.3% in July 2016 • All cancer targets were achieved during July 2016. • 18 Weeks RTT - The Trust continues to deliver against incomplete pathways, which measures % of patients still waiting at the end of each month, but referral growth from the south presents a significant risk. Patient Experience • Nationally ED was ranked 7th in June 2016 (FFT score of 95.9% compared to a national average of 86.2%), based on an above average response rate (17% compared to 13%). Trusts with less than a 5% response rate have not been included in the rankings. Workforce • On-going local and overseas recruitment continues in order to reduce agency usage across the Trust • The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is assured that adequate staffing is in place.

An Associated University Hospital of Brighton and Sussex Medical School 2

Performance – July 2016 Finance • The Trusts YTD deficit at the end of month 4 was £(3.0)m, £1.9m better than the planned £(4.9)m deficit position. Although still ahead of plan, there remains overspending within Divisions (except Surgery & Clinical Services). YTD we are £(0.15)m adverse against the planned agency reduction target. Key Risks • The Significant Risk Register for the Trust includes four quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis and RTT Access Standards. Action: The Board are asked to note and accept this report

Legal:

All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality care (Including mortality).

Regulation:

The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/ engagement:

This paper includes significant detail on both patient experience and access to services.

Risk & performance management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management through the SRR.

NHS constitution; equality & diversity; communication.

This report covers performance against access standards with the NHS Constitution.

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

No of Never Events in month

No of medication errors causing Severe Harm or Death

Safety Thermometer - % of patients with harm free care (all harm)

92.2%

93.2%

95.4%

90.3%

92.6%

91.2%

89.1%

90.2%

91.5%

94.7%

93.8%

92.3%

Safety Thermometer - % of patients with harm free care (new harm)

94.8%

96.7%

97.6%

95.0%

96.2%

95.1%

93.8%

94.5%

95.0%

96.5%

97.6%

96.2%

95%

96%

95%

100%

98%

Serious Incidents - No per 1000 Bed Days

0.05

0.23

0.32

0.11

0.38

0.16

0.33

0.51

0.38

0.16

0.10

0.26

Percentage of Patient Safety Incidents causing Severe harm or Death

0.6%

0.8%

0.6%

0.8%

0.5%

1.4%

0.7%

0.2%

Percentage of patients who have a VTE risk assessment WHO Checklist Usage - % Compliance Number of Sis

Number of overdue CAS and NPSA alerts

Trend

• There were 6 Serious Incidents declared in July 2016, detail is provided overleaf. • VTE – the standard for initial assessment continues to be achieved in July, the assessment process was deployed into Cerner, the Trust’s electronic patient record, which will support further improvement in this standard. • Safety Thermometer – both the “All harm” and the “New Harm” indicators continue to achieved expected performance. The main type of harm was community acquired pressure damage. • The percentage of patient safety incidents causing severe harm or death remained at baseline levels - 0.2% in July 2016.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety • 6 Sis were declared in July 2016 (in all cases full investigations have been started) and details are provided below: • 2016/17703 (Missed diagnosis) • The patient presented with non-specific abdominal symptoms in January 2013, an ultrasound scan was carried out which concluded that the patient had a simple gallstone. In September 2013 the patient represented with worsening symptoms, a CT scan revealed a large left kidney tumour extending into the renal vein with paraaortic lymph node involvement. A review of care has identified an error of image interpretation. The delay in diagnosis did, as a minimum, reduce the patient's life expectancy.

• 2016/17926 (Fall) • Patient was on her way to the toilet when she lost her balance. The patient was usually independent; she did not call for assistance. The fall resulted in a right hip fracture.

• 2016/18875 (Fall) • The incident occurred at 01:35. The patient was standing in his bed space using a urine bottle when he fell. This was his usual practice for night time toileting. Although a member of staff was in the bay he was helping another patient, the fall was unwitnessed. The patient reported that he had lost his balance. The patient sustained a fractured neck of femur.

An Associated University Hospital of Brighton and Sussex Medical School 5

Patient Safety • Continued…

• 2016/19041 (MRSA) • There have been five new acquisitions of MRSA attributed to one ward since May 2016 (including a blood stream infection). Strain relatedness has not yet been confirmed. This incident is being declared as a precautionary measure.

• 2016/20015 (Maternity Incident) • The incident concerns a baby born in poor condition (water birth) that required active resuscitation and then transfer to a tertiary unit for cooling and ongoing treatment. The investigation will review the following issues: • •

Vigilance of foetal heart rate during active second stage of labour

• •

Delay of 7 minutes between delivery of head and birth of baby

• •

Timeliness of activation of emergency bell and neonatal emergency call

• 2016/20384 (Fall) • On 27th July 2016 the patient was assessed, having complained of pain, and a fractured neck of femur was identified. The patient reported to the orthopaedic surgeon that he had "had a big fall". There is no record of a fall. There is a recorded incident where the patient was found crawling on the bathroom floor; this is a known habit of the patient. This occurred on 23rd July, four days before the identification of the fracture. At this stage it is unclear when the fracture was sustained, however it is known to be a new fracture as there was no evidence of callus formation at surgery.

An Associated University Hospital of Brighton and Sussex Medical School 6

Patient Safety Infection Control Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

• There was one case of MRSA in July 2016 and one case of Trust acquired C.diff. • In light of the on-going risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register: • Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

An Associated University Hospital of Brighton and Sussex Medical School 7

Clinical Effectiveness Mortality and Readmissions Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

HSMR (56 Monitored diagnoses - 12 Months)

97.2

99.3

99.5

98.3

97.4

97.6

96.2

94.0

Emergency readmissions within 30 days (PBR Rules)

7.4%

7.3%

6.3%

7.1%

6.8%

Apr-16

May-16

Jun-16

6.5%

8.1%

6.8%

Jul-16

Trend

â&#x20AC;˘ Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national comparators. Maternity Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

C Section Rate - Emergency

17%

14%

15%

16%

17%

14%

18%

C Section Rate - Elective

13%

10%

12%

11%

10%

11%

Admissions of full term babies to neo-natal care

5.1%

5.8%

7.1%

6.6%

5.9%

3.8%

6.1%

5.0%

3.9%

7.0%

2.7%

4.7%

Trend

â&#x20AC;˘ Maternity indicators continue to be monitored and reviewed by the Divisional Governance process as well as the Clinical Effectiveness Committee.

An Associated University Hospital of Brighton and Sussex Medical School 8

Access and Responsiveness STP Trajectories Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Trajectory

90.0%

93.0%

94.0%

95.0%

94.4%

95.0%

Actual

91.3%

95.5%

96.4%

95.3%

Trajectory

85.0%

Actual

86.3%

86.0%

90.0%

85.2%

Trajectory

92.0%

92.2%

92.4%

92.6%

92.8%

93.0%

92.8%

92.4%

92.2%

92.0%

Actual

92.6%

92.5%

92.7%

92.6%

Trajectory

0.6%

Actual

0.1%

0.5%

0.3%

0.4%

ED 95% in 4 hours

Cancer - 62 Day Referral to Treatment Standard

RTT Incomplete Pathways - % waiting less than 18 weeks

Percentage of patients waiting 6 weeks or more for diagnostic

â&#x20AC;˘ The table above shows the agreed STP Trajectories and YTD performance. â&#x20AC;˘ In all cases, the Trust is achieving the trajectories but there remains risk around the ED 4hr Standard, where the Trajectory is reliant on a reduction in MRD patients during the later part of the year, and the RTT trajectory, where there has been significant increase in referrals in from the South Coast which was not reflected in the contract plans.

An Associated University Hospital of Brighton and Sussex Medical School 9

Access and Responsiveness Emergency Department Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

96.1%

97.1%

95.5%

92.9%

95.5%

92.8%

91.4%

88.6%

91.3%

95.5%

96.4%

95.3%

Ambulance Turnaround - Number Over 30 mins

220

225

231

191

227

255

296

231

172

168

191

Ambulance Turnaround - Number Over 60 mins

ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA

Trend

• The ED 4hr standard was achieved in July 2016 with performance of 95.3%. • Volumes / Acuity of emergency attendances / admissions continue to be an issue and discharge delays are also a significant driver of performance with an average of 110 beds occupied by patients who are medically ready for discharge. This is an increase from 101 in June 2016, it continues to present a challenge for managing acute bed stock. • Ambulance turnaround performance has deteriorated in July 2016 with an increase in both 30 minute and 60 minute delays. • In light of the on-going operational pressures in the Trust, the following risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 10

Access and Responsiveness Cancer Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Cancer - TWR

93.0%

89.6%

90.0%

93.2%

94.3%

93.0%

93.3%

93.7%

91.0%

90.3%

91.7%

95.3%

Cancer - TWR Breast Symptomatic

93.3%

94.2%

93.8%

93.4%

96.2%

90.7%

84.1%

89.8%

87.1%

91.1%

82.0%

93.9%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

100.0%

95.2%

100.0%

95.3%

95.8%

96.2%

95.7%

100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

100.0%

Cancer - 31 Day Diagnosis to Treatment

99.2%

99.3%

98.2%

96.6%

96.1%

96.2%

96.0%

96.7%

98.5%

97.1%

96.0%

Cancer - 62 Day Referral to Treatment Standard

84.2%

86.2%

85.6%

88.3%

86.0%

81.1%

87.5%

87.9%

86.3%

86.0%

88.4%

85.2%

Cancer - 62 Day Referral to Treatment Screening

88.9%

100.0%

87.5%

90.9%

100.0%

90.9%

100.0%

87.0%

100.0%

80.0%

100.0%

Trend

â&#x20AC;˘ All key cancer standards were achieved in July 2016. â&#x20AC;˘ The TWR action plan has been progressed throughout June and July and performance on the TWR is now 93.9% in July as a result. Improvement has also been seen in the TWR Breast Symptomatic standard, however patient deferral remains a challenge despite clinical conversations with patients in relation to the urgency of appointment.

An Associated University Hospital of Brighton and Sussex Medical School 11

Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

92.0%

92.1%

92.2%

92.5%

92.1%

92.0%

92.2%

92.6%

92.5%

92.7%

92.6%

RTT Admitted

82%

78%

79%

81%

78%

77%

76%

78%

79%

RTT Non Admitted

89%

88%

85%

86%

87%

84%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.1%

0.5%

0.2%

0.1%

0.0%

0.1%

0.5%

0.3%

0.4%

133

112

133

119

RTT Incomplete Pathways - % waiting less than 18 weeks RTT Patients over 52 weeks on incomplete pathways

Last Minute Elective Cancellations for non clinical reasons No of operations cancelled on the day not treated within 28 days

Trend

• At aggregate level, the trust continues to deliver against the Incomplete pathways standard. Capacity challenges remain in General Surgery, Trauma and Orthopaedics, Ophthalmology, Cardiology, Rheumatology and Neurology –recruitment is underway to support resolution • Despite planned increases in capacity, referral growth is exceeding the system plan with significant changes in referral patterns south of the Trust. • At the end of July 2016, two patients were waiting over 52 weeks on an incomplete pathway. Both are booked for treatment in Aug. • 66 patients were cancelled at the “last minute” for non clinical reasons and 2 patients breached the 28 day standard day for treatment following a last minute cancellation • The following risk remains on the significant risk register: • RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints – Risk score 15 (Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 12

Patient Experience Patient Voice Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Emergency Department FFT - % positive responses

95.8%

96.9%

95.3%

97.3%

97.5%

95.8%

96.3%

95.0%

95.4%

94.9%

95.9%

94.9%

Inpatient FFT - % positive responses

95.3%

96.1%

95.0%

95.1%

97.4%

95.0%

96.5%

95.6%

96.0%

94.7%

Maternity FFT - Antenatal - % positive responses

98.8%

94.3%

96.5%

96.1%

96.0%

97.5%

98.5%

95.3%

98.9%

95.4%

93.2%

100.0%

Maternity FFT - Delivery - % positive responses

87.9%

95.4%

95.1%

97.6%

91.7%

95.5%

97.1%

94.7%

100.0%

98.8%

99.0%

97.7%

Maternity FFT - Postnatal Ward - % positive responses

87.7%

87.9%

88.9%

88.8%

88.9%

88.4%

92.0%

93.3%

95.3%

97.6%

94.0%

97.7%

96.1%

97.1%

98.9%

Maternity FFT - Postnatal Community Care - % positive responses Outpatient FFT - % positive responses

83.3%

88.3%

87.3%

89.3%

92.8%

90.0%

89.5%

89.0%

89.6%

86.7%

89.1%

88.9%

Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)

Trend

• The FFT scores for both ED and inpatient wards have dropped slightly in July. • Both areas show an increase in the response rate (45% for inpatients and 21% in ED). • In maternity the 36/40 touchpoint has achieved the highest FFT score for over a year, based on an improved response rate (17%). The score for the postnatal community touchpoint has also improved and is the highest it has been since January 2016. The FFT score for the postnatal ward is stable, and with the exception of April and May, where scores were higher, it is higher than it has been in previous months. The score for the delivery touchpoint has dropped compared to the previous three months. • The number of responses to the FFT question on the Your Care Matters survey in outpatients has increased in July and is now that highest it has been in the last year. The issue was discussed at the recent audit day and nurses now refer to it when greeting patients at the new kiosks.

An Associated University Hospital of Brighton and Sussex Medical School 13

Patient Experience • The document ‘Supporting our patients: visiting guidelines’ has been finalised following consultation with clinical staff and open visiting will be launched on 12th September. • Members for the Carers’ Steering group have been identified and the first meeting will take place at the end of September. • The phone etiquette task & finish group is working on promoting how to optimise use of the telephone system and disseminating this information. • Progress is being made on the inpatient action plan which will be discussed at the next patient experience committee meeting. • Two shadow governors have agreed to be part of the patient experience committee and will attend their first meeting in September.

National comparisons for June • Nationally ED was ranked 7th in June 2016 (FFT score of 95.9% compared to a national average of 86.2%), based on an above average response rate (17% compared to 13%). Trusts with less than a 5% response rate have not been included in the rankings. • The average combined national FFT score for inpatients and daycases for June 2016 was 95.4%. The combines SASH score was 95.9%. The combined SASH response rate was 24.3% compared to 25.5% nationally.

An Associated University Hospital of Brighton and Sussex Medical School 14

Workforce Workforce Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Average fill rate – registered nurses/midwives (%) - Day

92.5%

95.0%

95.1%

95.4%

95.1%

96.3%

95.6%

94.5%

97.3%

98.1%

97.6%

97.4%

Average fill rate – care staff (%) - Day

94.5%

95.1%

97.2%

98.7%

97.1%

97.0%

97.3%

99.5%

98.2%

98.1%

98.2%

93.5%

Average fill rate – registered nurses/midwives (%) - Night

94.3%

96.4%

96.9%

97.2%

97.9%

98.0%

97.6%

98.8%

98.6%

98.9%

98.3%

Average fill rate – care staff (%) - Night

93.8%

96.4%

96.9%

97.8%

98.2%

97.6%

97.4%

97.3%

97.2%

98.2%

98.0%

95.7%

Overall Sickness Rate

3.7%

4.4%

4.0%

3.8%

4.3%

4.0%

3.6%

3.2%

3.5%

3.4%

%age of staff who have had appraisal

57%

64%

72%

74%

72%

70%

66%

0.4%

14.7%

23.8%

41.6%

15.2%

15.0%

14.4%

13.8%

14.1%

14.4%

14.5%

15.3%

Staff Turnover rate

Trend

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place.

An Associated University Hospital of Brighton and Sussex Medical School 15

Finance Indicator Description

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Outturn £m Surplus / (Deficit) - Plan

1.6

15.2

Outturn £m Surplus / (Deficit) - Forecast

1.6

(3.0)

(4.2)

(6.6)

(6.5)

15.2

YTD £m Surplus / (Deficit) - Plan

(0.7)

(0.6)

(2.0)

(1.3)

(0.6)

0.0

1.6

(2.3)

(4.0)

(4.9)

YTD £m Surplus / (Deficit) - Actual

(2.6)

(3.3)

(3.6)

(4.2)

(5.3)

(3.9)

(4.8)

(6.5)

(1.3)

(2.5)

(3.0)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

3.8

7.5

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

3.3

(6.3)

(7.6)

(7.2)

7.5

YTD Savings £m - Actual

1.9

2.1

2.5

2.8

3.2

3.6

4.1

5.4

0.2

0.5

1.0

1.6

OT Risk £m Surplus / (Deficit) - Assessment

0.0

(6.8)

(7.2)

Outturn Cash position £m Fav / (Adv) - Forecast

1.2

2.4

2.5

2.3

2.1

YTD Cash position £m Fav / (Adv) - Actual

3.0

3.9

4.8

5.0

5.7

4.5

6.8

2.5

2.7

3.0

3.7

4.9

(25.0)

(19.0)

(13.0)

(16.0)

(15.0)

(18.0)

(16.0)

(13.0)

(18.0)

(17.0)

YTD BPPC (overall) volume £m

76%

69%

59%

60%

53%

52%

47%

28%

32%

53%

62%

YTD BPPC (overall) value £m

74%

68%

61%

63%

60%

59%

55%

41%

51%

58%

64%

Outturn Capital spend Fav / (Adv) - forecast

17.1

14.1

9.0

13.1

15.9

YTD Liquid ratio - days



The Trust’s 2016/17 plan has been profiled as below, reflecting the phasing of the £9.7m sustainability funding, clinical activity and cost improvements.

 

Mth 1

Mth 2

Mth 3

Mth 4

Mth 5

Mth 6

Mth 7

Mth 8

Mth 9

Mth 10

Mth 11

Mth 12

£000's

In Month I&E Plan

(2,299)

(1,641)

(902)

(63)

2,820

231

3,675

4,374

(1,172)

1,804

3,240

5,133

Cuumulative I&E Plan

(2,299)

(3,940)

(4,842)

(4,905)

(2,085)

(1,854)

1,821

6,195

5,023

6,827

10,067

15,200

2,425

STP Funding (incl above) in mth



Trend

The Trusts YTD deficit at the end of month 4 was £(3.0)m, £1.9m better than the planned £(4.9)m deficit position. Although still ahead of plan, there remains overspending within Divisions (except Surgery & Clinical Services). YTD we are £(0.15)m adverse against the planned agency reduction target.

An Associated University Hospital of Brighton and Sussex Medical School 16

Finance 

 

The hospital has remained busy through summer with the capacity restrictions that brings. M04 sees income reduce for day cases and outpatients, with inpatient electives continuing to track below plan. As a result the risk to the forecast has been increased and is now £7.2m (from £6.2m). The cash balance at the end of July 2016 was £4.9m. The Trust has drawn down £7.3m of its 2016/17 revolving working capital facility. This has supported on-going improvement in BPPC performance which is now 62% by volume, 64% by value year to date. The Trust has applied for a £15.9m Capital Resource Limit (CRL) in the 2016-17 plan resubmission (which includes potential schemes for EPR Digitise, clinical capacity investment and pathology). The capital programme funding assumes the agreement of £3m PDC for the 2015/16 transfer from capital to revenue and a £3.5m capital investment loan.

An Associated University Hospital of Brighton and Sussex Medical School 17

TRUST BOARD IN PUBLIC

Date: 25 August 2016 Agenda Item: 3.3

REPORT TITLE:

Finance & Workforce Committee Chair Update – Public

EXECUTIVE SPONSOR:

Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s):

Richard Durban (Non-Executive Director and FWC Chair)

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

No – Board Update

Action Required: Approval ( )

Discussion ( )

Assurance (√)

Purpose of Report: To update the Board on the discussions and actions from the Finance and Workforce Committee. Summary of key issues

The Finance and Workforce Committee met on the 23rd August 2016 and was quorate. 

Post Implementation Reviews (PIR) for the MacMillian Centre and the Cardiology units were presented with learnings from the relationships with external organisations and the use of Private patient income in future Business cases



M04 reports were received for Finance & the 16/17 CIP, Workforce and Organisational Development, Capital and IT.



The Trusts YTD deficit at the end of month 4 was £(3.0)m, £1.9m better than the planned £(4.9)m deficit position. Sustainability and Transformation funding has been paid for Q1. The Trust is £150K adverse to plan YTD against the NHSi agency spend target.

Recommendation:

Relationship to Trust Strategic Objectives & Assurance Framework: SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact

The FWC reviews assurance in respect of workforce, capital and investment projects, business planning (which includes financial planning) and cash aspects. Employment law: laws governing the rights of individuals and terms and conditions

terms include: National Minimum Wage Act 1998; the Working Time Regulations 1998; Employment Rights Act 1996; Equality Act 2010; Employment Rights Act 1996, and; the Transfer of Undertakings (Protection of Employment) Regulations 2006. Other key laws affecting employees include the Pensions Act 2004 and the Trade Union and Labour Relations (Consolidation) Act 1992. Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”. Legal aspects related to capital works will depend on the nature of the works. The main regulators, are as follows: -

Financial impact

External audit (the Grant Thornton for this Trust) gives an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services The report provides assurance about savings, capital spend and the structure of the business planning process.

Patient Experience/Engagement

Indirect impact through Trust planning and workforce.

Risk & Performance Management

The committee, and this report, provides assurance about workforce and capital management.

NHS Constitution/Equality & Diversity/Communication Attachment: Report Paper

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT AUGUST 2016

Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 23rd August 2016 and it was quorate. The key points from Public meeting were: Post Implementation Reviews The Committee were presented with the Post Implementation Review (PIR) for the MacMillian Centre and the Cardiology Unit. The MacMillian Centre opened to the public on 27 January 2016. The project came in below its Capital budget (£448K SASH budget to £410K SASH actual) and is currently running below its revenue budget which is in part due to the volunteer base which has been building as demand has required. Lessons around the relationship with external organisations were acquired from this well run project as well as the positive impact that user involvement during the planning process can have. The Cardiology Unit was opened in November 2015 with the initial aims to increase NHS activity going through the laboratories, reduce waiting time, increase the number of procedures and to start a private patient service. The unit has enabled the reduction of waiting times with urgent patients now being seen in 2 weeks and routine patients waiting down to 6-8 weeks. Inpatients have also seen reductions in waits to just a few hours. Private patient activity has yet to be developed due to, inter alia, capacity constraints in the hospital requiring the day ward to be used as an escalation area. The Committee was told that demand was increasing, activity from the likes of Angiography and pacemaker procedures has increased and that outpatient waiting list is the biggest challenge for the team along with developing an electrophysiology service. The Committee discussed the use of Private patients in future business cases as a generator of extra income sources given Cardiology’s income being year to date greater than planned on NHS work. A paper on the future income plan would be produced and shared with the FWC . The Committee discussed the SASH + work in Cardiology and also noted the patient benefits delivered by the project.

Finance Performance & CIP M04 Reports The Trusts YTD deficit at the end of month 4 was £(3.0)m, £1.9m better than the planned £(4.9)m deficit position. Sustainability and Transformation funding for Q1 has been paid. This payment has enabled the Trust to improve its better payment practises. We are seeing the highest number of attendances to the Emergency Department ever seen but that the conversion rate is good with admissions similar to those seen in 2015/16. M04 has seen income reductions in Day cases and outpatients with inpatient elective activity continuing to track below plan. The income risk was increased by £1m giving a total risk to the plan of £7.2m. An Associated University Hospital of Brighton and Sussex Medical School

Agency spend has remained flat resulting in a £150K year to date (YTD) adverse spend. Although still ahead of plan, there was overspending within all Divisions (except Surgery and Clinical Services). Radiology has improved, WACH remains of significant concern. The cash balance at the end of July 2016 was £4.9m. The Trust has drawn down £7.3m of its 2016/17 revolving working capital facility. The CIP report showed that the end of July the Trust achieved savings of £1.6m and is ahead of the NHSI plan by £0.2m. Month 04 Workforce and Organisational Development The papers were received by the Committee and noted. Considerable work has been undertaken by the team to improve MAST compliance and completion rates through logistical and technical improvements. The review of the establishment changes in the previous months has been completed in all areas other than for Junior Doctors and Estates. The M04 Capital report The Capital report was received and noted. The Trust is yet to receive written confirmation of the return of the Capital to Revenue transfer for 2015/16. This however has not been included in the budgets. The M04 IT report was received and noted.

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 25th August 2016 Agenda Item: 3.3

REPORT TITLE:

Audit & Assurance Committee Chair Update

NON EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Paul Biddle (Non-Executive Director and AAC Chair) Colin Pink Head of Corporate Governance Audit & Assurance Committee – 26/05/16 & 12/07/16

Action Required: Approval (√)

Discussion ()

Assurance ()

Purpose of Report: This report provides the Board with an update of the Audit & Assurance Committee’s Terms of Reference which requires formal Board approval. Summary of key issues The Audit Committee updated its Terms of Reference in May 2016 to include responsibilities of acting as the Audit Panel which will review and make a recommendation to the Trust Board on selection of external audit provision.

The Chief Finance Officer or the Director of Corporate Affairs should also sit as a member of the Audit Panel and provide advice and support. The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and management’s responses to their work. This will be achieved by: •

Carrying out ongoing review of External Audit service provision.

Recommendation: The Board is asked to approve the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model Corporate Impact Assessment:

Legal and regulatory impact

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust.

Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”. The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources. The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services. Financial impact

Committee review of Trust financial position

Patient Experience/Engagement

No relevant aspects

Risk & Performance Management

The committee provides assurance about internal control and risk management. This report discusses BAF reporting

NHS Constitution/Equality & Diversity/Communication

No relevant aspects

Attachment: Updated Terms of Reference for the Audit & Assurance Committee

2 An Associated University Hospital of Brighton and Sussex Medical School

Audit and Assurance Committee: Terms of Reference 1.

Introduction

1.1

The AACs role is to develop, monitor and ensure development of integrated governance arrangements, providing assurance that bodies are well managed across the whole range of their activities. The AAC shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), which supports the achievement of the organisation’s objectives. These terms of reference build on the work of the Cadbury Committee, Greenbury Reports and the reports by Smith, Higgs and Turnbull (reference “Combined Code – Principles of Good Governance and Code of Best Practice”) and subsequent guidance and best practice in the private and public sector.

Constitution

2.1 The Board hereby resolves to establish a committee of the Board to be known as the Audit and Assurance Committee (The Committee). 2.2 The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these terms of reference.

Membership

3.1 3.2 3.3 3.4

The Committee shall be appointed by the Board from the non-executive directors of the Trust and shall consist of not less than three members. A quorum shall be two members. The Board will appoint one of the members to be Chair of the Committee. The Chairman of the organisation shall not be a member of the Committee.

Attendance

4.1

4.2

4.3 4.4

The Chief Finance Officer, Director of Corporate Affairs and appropriate internal and external Audit representatives shall normally attend meetings. However, at least once a year the Committee should meet privately with the external and internal auditors. The Committee shall request the attendance of the Executive Directors when discussing risk or requiring assurance in relation to their areas of responsibilities. As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee The Head of Corporate Governance shall be the secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the Chairman and committee members.

Frequency

5.1

Meetings shall be held not less than five times a year and normally will take place every two months.

5.2

The External Auditor or Head of Internal Audit or Counter Fraud representatives may request a meeting is held if they consider that one is necessary. This is to be agreed by the Chair of the Committee.

Authority

6.1

The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary.

7.1

Duties The duties of the Committee can be categorised as follows:

Governance, Risk Management and Internal Control 7.1 7.1.1 The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisationâ&#x20AC;&#x2122;s activities (both clinical and non-clinical), which supports the achievement of the organisationâ&#x20AC;&#x2122;s objectives. In particular, the Committee will review the adequacy of: -

all risk and control related disclosure statements (in particular the Annual Governance Statement,, together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board

the underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements

the policies for ensuring compliance with relevant national regulatory frameworks, legal and code of conduct requirements

the policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions

the Trustâ&#x20AC;&#x2122;s internal control framework, supported by the other subcommittees of the Board.

7.1.2 In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions to ensure review is external, but will not be limited to these. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

7.1.3 In relation to the Board Assurance Framework the committee will use this to guide its work and will provide assurance that the controls and actions taken to address any gaps are robust and support the delivery of corporate objectives.

7.2 Internal Audit The Committee shall ensure there is an effective internal audit function established by management, which provides appropriate independent assurance to the Audit Committee, Chief Executive and Board and meets mandatory Public sector Internal Audit Standards. This will be achieved by: -

consideration of the provision of the internal audit service and the cost of audit

review and approval of the internal audit strategy, operational plan and the more detailed programme of work, ensuring this is consistent with the audit needs of the organisation as identified in its approved assurance framework

consideration of the major findings of internal audit work (and managementâ&#x20AC;&#x2122;s response), and ensure co-ordination between the internal and external auditors to optimise audit resources

ensuring the internal audit function is adequately resourced

annual review of the effectiveness of internal audit (through external audit and performance against its work plan and performance indicators).

7.3 External Audit The Board has appointed the Audit Committee as its Audit Panel which will review and make a recommendation to the Trust Board on selection of external audit provision. The Chief Finance Officer or the Director of Corporate Affairs should also sit as a member of the Audit Panel and provide advice and support. The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and managementâ&#x20AC;&#x2122;s responses to their work. This will be achieved by: -

As the Audit Panel the Committee shall carry out ongoing review of External Audit service provision.

discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the annual plan, and ensure coordination, as appropriate, with other external auditors in the local health economy

discussion with the External Auditors of their evaluation of local audit risks and assessment of the Trust and its associated impact on the audit fee

review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses

7.4 Other Assurance Functions 7.4.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arms Length Bodies or Regulators/Inspectors (e.g. CQC, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.), reports by the Trustâ&#x20AC;&#x2122;s local counter fraud specialist. 7.4.2 In addition, the Committee will review the work and function of other committees, working groups and senior responsible officers within the organisation, whose work can provide relevant assurance to the Committeeâ&#x20AC;&#x2122;s own scope of work. 7.4.3 In reviewing work of around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function and outcome measures from the Trusts clinical benchmarking systems.

Management

The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control. They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as appropriate.

Financial Reporting

9.1 The Committee shall review the annual report and financial statements before submission to the Board, focusing particularly on: -

the wording in the Annual Governance Statement and other disclosures relevant to the terms of reference of the Committee

changes in, and compliance with, accounting policies and practices

unadjusted mis-statements in the financial statements

major judgmental areas

- significant adjustments resulting from the audit 9.2 The Committee should also ensure (through management reporting, internal and external audit reporting) the systems for financial reporting to the Board, including those of budgetary control, are effective and that reporting provides complete and accurate information about the Trustâ&#x20AC;&#x2122;s financial position.

10. Reporting

10.1 The minutes of the Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action. 10.2 The Committee will report to the Board annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the assurance framework, the completeness and embedding of risk management in the organisation, the integration of governance arrangements.

11. Other Matters The Secretary to the Committee shall be the Head of Corporate Governance whose duties in this respect will include the following, shall support the Committee administratively: -

Agreement of agenda with Chairman and attendees and collation of papers

Organising the attendance of appropriate persons to meetings (other than those who would usually attend)

Taking the minutes and keeping a record of matters arising and issues/ actions to be carried forward

Advising the Committee on pertinent matters

Audit and Assurance Committee: Standing Agenda 1

General Business Apologies Declaration of interests Minutes of previous meeting Agreed actions tracker

Risk Management Board Assurance Framework Risk Management Systems

Internal Control Systems Review annual governance statement Review internal controls Note business of other committees

Specific Duties Review annual accounts Reviews losses waivers and special payments

Independent Assurance Receive and approve annual internal audit plan and updates Receive and approve annual external audit plan and updates Receive and approve other sources of external assurance such as Counter Fraud)

Specific Duties Review of other reports and policies as appropriate (e.g. changes to standing orders) Review of audited annual accounts and financial statements Review changes to standing financial instructions and

changes to accounting policies

Audit and Assurance Committee: Meeting Timetable The meetings shall occur at regular intervals throughout the year and shall receive reports in a sequence that allows the Committee to review annual reports with foresight of other relevant assurance reports. The expected timetable of the Committee is set out below: Audit and Assurance Committee Timetable

March 1.

Plan how to discharge Audit Committee duties

Self-assess Committee’s effectiveness

Review Committee’s terms of reference

Produce annual Audit Committee report

Private discussions with internal and external audit

May

July

Sept

Nov

Jan 

   



Risk Management 6.

Review the Board Assurance Framework in Full



7. 8.

Review the risk management system in full

Receive the Significant Risk Register

 



Internal Control Systems 10. Note business of other committees and review interrelationships 11. Review draft Annual Governance Statement

 

12. Review Internal Controls and work plan 13. Review specific elements of internal control

 



Specific Duties 14. Review of other reports and policies as appropriate – for example, changes to standing orders

15. Review of audited annual accounts and ﬁnancial statements



16. Review changes to standing ﬁnancial instructions and changes to accounting policies



17. Review of losses and special payments



Independent Assurance 18. Receive sources of assurance of external assurance



19. Review and approve annual internal audit plan



20. Review and approve internal audit terms of reference



21. Review the effectiveness of internal audit 22. Review internal audit progress reports



 



23. Receive annual internal audit report and associated opinions



24. Agree external audit plans and fees 25. Review the effectiveness of external audit 26. Review external audit progress reports

 

27. Receive the External Auditor’s report to those charged with governance

 

28. Receive the External Auditor’s annual audit letter



29. Review and approve annual counter fraud plan 30. Review counter fraud progress reports

 



31. Review the organisation’s assessment against CFSMS qualitative assessments



32. Review the effectiveness of the Local Counter Fraud Specialist



33. Receive counter fraud annual report to AAC



Presentation Title Annual Board Report 36pt Arial Bold

A Framework of Quality Assurance for Sub heading 24pt Officers Arial Responsible and Revalidation 25th August 2016 Dr Adam Stacey-Clear – Responsible Officer Dr Des Holden – Medical Director

Executive Summary •

This report Follows the NHS England template as outlined in the Framework for Quality Assurance and is an annual requirement for all designated bodies.

•

The annual Organisation Audit findings for Surrey and Sussex Healthcare NHS Trust will be presented

•

296 doctors with a GMC connection to The Trust were included in the audit, April 1st 2015-March 31st 2016

•

A statement of compliance confirming compliance with The Medical Profession (Responsible Officers) regulations 2010 needs to be signed by either the CEO or Chairman following this report.

Appraisals – Why? •

Revalidation demonstrates that a Doctor is up to date and fit to practice through Appraisal and Clinical Governance

•

This leads to improved Safety and Quality in Healthcare

•

Fit for Practice – minimum standards as per GMC guidelines

•

Fit for Purpose – above and beyond requirement for GMC – able to undertake the roles for which they are employed

Governance Arrangements •

Surrey and Sussex Healthcare NHS Trust (SASH) has a Medical Appraisal Policy on the Trust website which is available for all doctors to read

•

The Responsible Officer is Adam Stacey-Clear who regularly attends network RO meetings on a regular basis throughout the year. The RO and Medical director Des Holden also attend quarterly meetings with the GMC Liaison Officer, Michael Cotton.

•

The human resources dept. maintains a list of employed doctors at the Trust.

•

All completed appraisal forms are read by AS-C.

Access, Security and Confidentiality

•

All appraisals are stored in a secure folder on the G drive

•

No patient identifiable data is stored in any appraisal folders

•

No information management breaches.

•

The GMC have provided ASC with a secure link which lists all doctors with a prescribed connection to the Trust (designated body).

•

The list is regularly updated.

•

Transfer of information between designated bodies.

Slide 5

Appraisers •

44 trained appraisers in faculty of appraisers.

•

Rather unequal distribution of appraisals from those who responded to request for number of appraisals carried out.

•

Appraisal year runs from April 1st to March 31st.

•

Recent guidelines from NHS England recommend new appraisal categories:

Slide 6

Quality assurance

Conducted an external review of appraisers using an NHS England toolkit concentrating on the appraisal outputs and PDP. •

External verification visit from NHS England South, Dec 2015

•

Appraisee feedback working well, reliant on appraisal sign off certificate.

•

Six month PDP review working well

•

Appraiser support group meeting carried out in May 2016 with presentation by Dr Lisa Argent on appraisal outputs.

•

PDP includes a Trust quality improvement activity

Slide 7

NHS England visit Dec 2015 Designated Body classification following Independent Verification Designated Body Name: Surrey and Sussex Healthcare NHS Trust Core Standard Group

ICE development continuum Initiation 1

Compliance 2

Excellence 4

Designated body & Responsible Officer Appraisal Monitoring performance and RtC HR processes Overall Engagement / Enthusiasm / Effort

ICE Maturity Continuum

Description

Initiation

Meets few core standards, little or no commitment to alter Revisit soon, escalate to MD, Regional Director this or Secretary of State

Meets a few core standards, plan in place to achieve compliance

Obtain action plan update, revisit

Meets most core standards, some quality assurance

Suggest improvements and teleconference review in 6 months

Meets most core standards, quality assured in all areas

Suggest improvements and invite a report back in 1 year

Meets all core standards, quality assured with some quality No action improvement

Committed to continuous improvement. All core standards Share good practice, win an award? met and significant areas of good practice

Compliance

Excellence

Action Options

Analysis of scores-key areas for development overall •

Covering total scope of practice in terms of evidence seen

•

Documenting review of last year's personal development plans & recording origin of newly identified PDP items

•

Objective exploration of quality improvement activity

•

Recording that reflection has occurred & learning shared

•

Stage of revalidation and any outstanding requirement

•

Speciality guidance followed & mandatory training recorded

Slide 9

Key areas for organisational development around the process of appraisal and its quality assurance 1.Share the summary outputs with the appraiser faculty 2. To work in appraiser learning sets to establish what good looks like 3. Adapt the QA tool to better capture what the trust requires particularly in terms of quality improvement. 4. To consider establishing formal 1:1 appraiser performance reviews which includes this QA exercise but also has feedback from appraisees and the appraisal team incorporated. This is an ideal opportunity to explore key issues and understanding of the requirements. 5. Consider repeating the external review in 1-2 years to document improvement.

Slide 10

Medical Appraisal

•

279 doctors were included in this audit, 188 consultants and 108 associate specialists/Trust doctors/staff grade/fixed term locums

•

176 consultants completed an annual appraisal between 1/4/2015 and 31/3/2016.

•

8 late consultant appraisals were approved, 4 were not

•

103 associate specialists/Trust doctors completed an appraisal.

•

3 late SAS appraisals were approved, 2 were not.

•

Audit sheet for late appraisals is maintained.

•

Late appraisals default to the original due date the next year

Slide 11

NHS England appraisal guidelines

2015/16 AOA indicator SECTION 2: Appraisal

2.1

Number of doctors with whom the designated body has a prescribed connection as at 31 March 2016

Your organisationâ&#x20AC;&#x2122;s response

No. of doctors (in organisation)

Same sector:

All sectors:

DBs in sector: 55

Total DBs: 769

Total no. of doctors (in SAME sector)

Total no. of doctors (across ALL sectors)

2.1.1 Consultants

188

14853

49289

2.1.2 Staff grade, associate specialist, specialty doctor

108

3810

11593

Slide 13

2015/16 AOA indicator SECTION 2 (cont): Appraisal

Your organisation’s response

Same sector:

All sectors:

DBs in sector: 55

Total DBs: 769

Completed appraisals (1a & 1b)

2.1

Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had a completed annual appraisal between 1 April 2015 – 31 March 2016

Your organisation’s response and (%) calculated appraisal rate Same sector appraisal rate

ALL sectors appraisal rate

2.1.1

Consultants

176 (93.6%)

91.2%

89.7%

2.1.2

Staff grade, associate specialist, specialty doctor

103 (95.4%)

82.9%

83.8%

Slide 14

2015/16 AOA indicator SECTION 2 (cont): Appraisal

Your organisation’s response

Same sector:

All sectors:

DBs in sector: 55

Total DBs: 769

Approved incomplete or missed appraisal (2)

2.1

Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had an Approved incomplete or missed appraisal between 1 April 2015 – 31 March 2016

Your organisation’s response and (%) Same sector appraisal rate ALL sectors appraisal rate calculated appraisal rate

2.1.1

Consultants

8 (4.3%)

4.2%

5.5%

2.1.2

Staff grade, associate specialist, specialty doctor

3 (2.8%)

8.1%

9.2%

Slide 15

2015/16 AOA indicator SECTION 2 (cont): Appraisal

Your organisation’s response

Same sector:

All sectors:

DBs in sector: 55

Total DBs: 769

Unapproved incomplete or missed appraisal (3)

2.1

Number of doctors with whom the designated body has a prescribed connection on 31 March 2016 who had an Unapproved incomplete or missed annual appraisal between 1 April 2015 – 31 March 2016

Your organisation’s response and (%) calculated appraisal Same sector appraisal rate rate

ALL sectors appraisal rate

2.1.1

Consultants

4 (2.1%)

4.5%

4.8%

2.1.2

Staff grade, associate specialist, specialty doctor

2 (1.9%)

9.1%

7.0%

Slide 16

Late appraisals without prior permission

Dr Ria Kubaisi Dr Azhar Ansari Dr Mathew Cowan Dr Benjamin Field Dr Jonathan Stenner Mr Roger Wilson Dr Patrick Morgan

(completed 27/5/2016) (completed 27/5/2016) (completed 17/5/2016) (completed 18/5/2016) (completed 18/5/2016)

Slide 17

Recommendations submitted to the GMC

•

84 revalidation recommendations made.

•

11 deferrals

•

73 positive recommendations

•

Deferrals mainly due to lack of supporting information

•

16 doctors had left the Trust but not informed the GMC

•

9 doctors had told the GMC they were here but medical staffing had no record of them being here.

•

6 doctors were in training posts (and therefore not AS-C’s responsibility) but had told the GMC that we were their DB.

Slide 18

Conduct and Performance •

All Trust doctors are subject to the organizational policies e.g. capability and disciplinary in line with Maintaining High Professional Standards best practice. The Trust recognizes the BMA code of conduct.

•

The Trust reviews doctors performance in the yearly job plan, supported by the annual appraisal process for all medical and dental staff. Linking job planning with appraisal is currently being developed as part of a new Trust strategy.

•

The clinical effectiveness strategy supports Medical and Dental staff in their practice by ensuring evidence is practice based and clinically effective.

•

The complaints procedure is Trust policy. This is part of doctor’s feedback and concerns are raised at job planning stage to enable improvement in doctor’s practice and patient care.

Slide 19

Responding to Concerns

•

The Trust responds to concerns in respect of a doctor’s practice by supporting them with regular and ongoing development opportunities.

•

Fitness to practice concerns from The GMC about a doctor are dealt with following the GMC guidelines.

•

The Trust has an active whistleblowing (raising concerns) policy

Slide 20

Pre-employment background checks •

Medical staffing check qualifications against persons specifications for the post. DBS (formerly a CRB)

•

Photographic ID

•

Visa or Biometric card as proof of the right to work in the UK

•

2 proofs of address

•

GMC registration check

•

Must be on specialist register- substantive consultants

•

2 references

•

Occupational health check Locums employed through medacs

Slide 21

Areas for development • • • • • • • • • •

Embed behaviours and values achievement work into appraisals which would contribute to the achievement of Trust goals Clarify how PDP items link into job planning to further align PDP’s with Trust objectives Incorporate achievement reviews into appraisal to integrate organisational development into revalidation process for doctors Greater engagement of Trust and staff grade doctors-appoint Staff grade lead Better support for doctors to gain patient feedback and recognition that this is for personal development not for comparison between individuals Appraisers would welcome identifying ‘softer’ options for PDP inclusion An appraisal which meets GMC Good Medical Practice would be expected to take >30 minutes Hospice appraisers could be available to Trust staff and vice versa Support all doctors to learn from complaints Opportunity to use patient involvement to inform action on issues raised by complaints-being considered by the Trust

Risks and Issues

•

Information transfer for visiting doctors whose designated body is not SASH.

•

Appraisals in March- cohort of doctors have now been moved to earlier in the year to offset the March crush.

•

Appraisal policy changes to incorporate sanctions imposed for late appraisals.

•

All doctors will be sent a link to the new appraisal policy when reminders are sent out

Slide 23

Board Reflections

•

Working party to explore patient and public involvement in revalidation

•

PDP six month check

•

Verification visit

•

Appraiser quality assurance audit

•

Transfer of Information Form between SASH and other organisations used to update ROs of any concerns

•

Improved appraisee feedback

Slide 24

Date: 25th August 2016

TRUST BOARD IN PUBLIC

Agenda Item: 4.4 REPORT TITLE:

Update from the Shadow Council of Governors Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Shadow Council of Governors Meeting 19.8.16

Action Required: Approval ( )

Discussion ( )

Assurance (√)

Purpose of Report: To provide an update to the Board on the work of the Shadow Council of Governors. Summary of key issues The fourth Shadow Council of Governors took place on 12th July 2016. The meeting was quorate and well attended by both elected, nominated governors and Executive and NonExecutive Directors. Key area of Focus for this meeting: • Trust Update from the Chief Executive • Presentation on the development of the East Surrey & Sussex Sustainability and Transformation Plan • Update from the Governors • Update from Membership Development Sub-Group • Report from the Finance and Workforce Committee The Shadow Council noted the resignation of the nominated governor from East Surrey Clinical Commissioning Group due to current work pressures. Recommendation: The Board is asked to note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model. Corporate Impact Assessment: Legal and regulatory impact

A Council of Governors is a statutory requirement for an NHS Foundation Trust and forms part of the governance structure

Financial impact

N/A

Patient Experience/Engagement

A significant and important part of the role of the Council of Governors

Risk & Performance Management

Relevant aspects included in the report

NHS Constitution/Equality & Diversity/Communication

Important to the role and function of the Council of Governors

Attachment: N/A

TRUST BOARD REPORT â&#x20AC;&#x201C; 25th August 2016 UPDATE FROM THE SHADOW COUNCIL OF GOVERNORS 1.

Introduction

The Shadow Council of Governors (SCoG) held its fourth meeting on 12th July 2016. The meeting was well attended by elected, staff and nominated Governors. 1.2

Main Agenda Items

The following items were discussed: Trust Update: The Chief Executive gave an overview on developments within the Trust including current performance and quality in relation to the NHS constitutional standards, increased levels of activity, bed occupancy levels and challenges ahead particular in terms of winter. An overview was given on financial performance and the financial plan for 2016/17. Questions from the governors included the impact of the junior doctorâ&#x20AC;&#x2122;s industrial action, Trusts financial savings targets and the current position in relation to the Trusts Foundation Trust application and progress with nursing recruitment. The Shadow Council commended the Trust on the recent achievement of the National Patient Safety Board Leadership Award and also pleased to note that governors could nominate staff for the Annual SaSH Awards. Following discussion on EU staff all governors expressed their support for overseas and EU clinical staff within the Trust and asked that their support should be included in the next CEO weekly message. Development of the Sustainability and Transformation Plan (STP): The Chief Executive gave an overview of the requirement within the Five Year Forward View to develop STPs and current progress with the East Surrey and Sussex STP; including the main priorities, place based models of care and the emerging themes. The Shadow Council asked a number of questions and indicated the need to be kept up to date with current and future developments. Feedback from individual governors: Governors fed back on current involvement opportunities in a range of areas including, Organ Transplant and End of Life Committees. One governor thanked the Trust for proactive communication to governors regarding the recent incident relating to the ambulances which caught fire and asked that governors continue to be kept informed by the Trust. Feedback from the Membership Development Sub-Group: The governor chair of the membership development sub-group fed back on the recent meeting. There were mixed views on the low response to the recent communication from governors to FT members however the majority felt that this should be seen as positive particularly as there was no negative feedback. Preparation would continue around membership recruitment so that when the Trust had confirmation from NHS Improvement plans would be ready to be rolled-out. Work of the Finance and Workforce Committee (FWC): The Non-Executive Chair of the FWC provided an update on the role of the FWC within the Trust. An overview of the key themes from the year was shared and the Shadow Council showed particular interest in gaining better understand of productivity and benchmarking. Governor Resignation: The Shadow Council noted the recent resignation of Dr Anthony Clarke from the role of nominated governor from East Surrey Clinical Commissioning Group (ESCCG) due to pressure of work. The Council noted thanks for his contribution

thus far and wished him well. In due course the Trust would be in contact with ESCCG to request a new nomination. An update on the work and activities of the Shadow Council of Governors will continue to be provided to the Board on a quarterly basis. 2. Recommendation The Board is asked to note the report from the Shadow Council of Governors.

Gillian Francis-Musanu Director of Corporate Affairs August 2016

Minutes of the Finance and Workforce Committee Held on 26 July 2016 at 8.00am In AD65, East Surrey Hospital, Redhill PUBLIC Present Richard Durban Paul Biddle Paul Simpson Fiona Allsop Angela Stevenson Ian Mackenzie (part meeting) Gillian Francis-Musanu Mark Preston

Non-Executive Director (Chair) Non-Executive Director Chief Finance Officer Chief Nurse Chief Operating Officer Director of Information & Facilities Director of Corporate Affairs Director of Organisational Development and People

Peter Burnett Catriona Tait

Deputy Chief Finance Officer Head of Costing & Service Line Reporting (Committee Secretary)

In attendance

WELCOME AND APOLOGIES FOR ABSENCE Apologies: There were apologies from Alan Hall (Non-Executive Director). Declarations of Interest: There were no declarations of interest.

MINUTES OF THE PREVIOUS MEETING The minutes of the 28 June 2016 meeting were approved. Action Tracker It was noted that all the due actions from the action tracker were on the agenda. Medical Records Ian Mackenzie presented a report that highlighted the improvements in Medical Records provision since the movement of the offsite storage to Salfords and the introduction on a 24/7 service. Lead times were improved and costs had been reduced. The team was congratulated on a successful project. Paul Biddle asked that the criteria are for destroying records. Ian Mackenzie replied that there is a maximum and a minimum length of time that records can be kept for.

Ian Mackenzie advised that the new Medical Records building was due to complete in October and an update on the resulting freed up clinical space and opportunities for more efficient working would be reported to the August FWC meeting. 3

FINANCE Financial Performance M03 Paul Simpson presented the M03 Finance performance report. The Trusts YTD deficit at the end of month 3 was £(2.5)m, £2.3m better than the planned £(4.8)m deficit position. The Sustainability and Transformation funding trigger has been achieved at Q1 (based on financial performance). The Trust has achieved its agency spend plan for the quarter. Although the Trust is still ahead of plan, there was overspending within all Divisions (except Surgery). Paul Biddle commented that there was a slight underspend on pay. Paul Simpson replied that the Trust has phased the budget differently rather than using reserves but that although agency is showing a slight decline it is not reducing by as much as is needed. The cash balance at the end of June 2016 was £3.7m. The Trust has drawn down £7.2m of its 2016/17 revolving working capital facility. The Committee noted that the in year £6m working capital facility would now need to be repaid by 31/3/17 and that payment to suppliers was improving. 2016/17 CIP Update Paul Simpson presented the 2016/17 CIP paper and highlighted that it showed that at the end of June the Trust achieved savings of £1.0m and is ahead of the NHSI plan.. The Trust remains confident the full £9.2m savings can be successfully delivered in 2016/17. 2016/17 Budget Paper Paul Simpson presented the 2016/17 final budget and highlighted that the Trust was staying with the previous surplus of £15.2m which includes: a) the receipt of £9.7m sustainability and transformation funding; b) A cost improvement/savings plan of £9.2m (3.1% of turnover, after excluding set offs for pass through costs and taking account of income included in Divisional budgets); c) A £2.7m productivity gain from additional activity valued at £3.6m – this item describes the main stretch for the Trust and increases the overall efficiency gain to 4% of turnover). Paul Simpson advised the Committee that the achievement of this surplus has the following caveats: a. Contracts are signed (bar Sussex MSK) without material adverse impact on the budget;

b. The readmission penalty will not be levied; c. MRET threshold change has been agreed with East Surrey CCG, but not with Sussex CCGs (subject to a dispute process); The Committee then reviewed the risks and mitigations against them in detail and noted that the control total would reduce (to £11m) if the caveats were not achieved. Paul Biddle asked when the Trust would receive the £2.4m STP Q1 funding. Peter Burnett replied that we were already chasing NHSi for payment. The Committee recommended that the Board approves the final budget. 4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M03 and M03 KPIs Mark Preston presented the Workforce & Organisational Report to the Committee advising the Committee that an exercise was being undertaken within workforce to review the establishment changes that have been processed in the previous months to ensure the procedures are being correctly followed. Mark Preston then presented the National Staff Surveys report to the Committee. It was noted but there was no discussion.

CAPITAL AND ESTATES Capital & Estates Report M03 Ian Mackenzie presented the M03 Capital & Estates report. Paul Simpson reminded the Committee that that the Trust has set a capital budget of £9m but advised that the planning returns we have submitted to NHSi are for a £15.9m Capital Resource Limit (CRL) in the 2016-17 plan resubmission (which includes potential schemes for EPR Digitise, clinical capacity investment and pathology). The capital programme funding assumes the agreement of £3m PDC for the 2015/16 transfer from capital to revenue and a £3.5m capital investment loan. Richard Durban asked if that meant the capital was guaranteed and Paul Simpson replied that we had been given conflicting advice from NHSi.

IT IT Report M03 The IT report was presented by Ian Mackenzie and noted by the Committee.

GENERAL Date of next meeting Tuesday 23rd August 2016 8.30am â&#x20AC;&#x201C; AD77

Safety & Quality Committee Thursday 7th July 2016, 14.00-16.00 AD65 Trust Headquarters, East Surrey Hospital Minutes of Meeting

Present: Richard Shaw Alan Hall Fiona Allsop Paul Simpson Ben Mearns Zara Nadim Vicky Daley Katharine Horner Jonathon Parr

RS AH FA PS BM ZN VD KH JP

Colin Pink Ben Emly Sue Moody

CP BE SM

Csaba Dioszeghy Suzanne Robinson

CD SR

Jamie Moore Natalie Blundell

JM NB

Non-Executive Director (Chair) Non-Executive Director Chief Nurse Finance Director Chief, Medical Division Chief, WaCH Deputy Chief Nurse Patient Safety & Risk Lead Clinical Governance Compliance Manager Corporate Governance Manager Head of Information Clinical Quality Manager Horsham and Mid Sussex CCG ED Consultant Surgical Risk and Governance Manager Surgical Chief Nurse Surgical F1

Apologies: Pauline Lambert, Des Holden, Angela Stevenson, Alan McCarthy, Barbara Bray, Ed Cetti Action 1 COMMITTEE BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were noted. All attendees introduced themselves. Minutes of the previous meeting The minutes of the last meeting were accepted as an accurate record. 1.2.

1.3.

Actions Log and matters arising

C/F 4th February 2016 Data Quality Audit - on the agenda (1.3.1)

C/F 3rd March 2016 Both items on the action log will be taken to the Board. To be removed from the action log. th

SQC Minutes 7 July 2016 Page 1 of 8

C/F 5th April 2016 Explanation of the RTT targets to be included as a 20 minute item in the Quality section of the agenda in September.

C/F 5th May 2016 Paper on the potential link between activity and patient safety issues – on the agenda (3.1) Has there been a change in the criteria applied to upheld or not upheld in PALS? FA reported that there has not been a change in criteria applied to cases to determine whether they are upheld or not. There has been a steady increasing trend in activity. Paper to update the committee on the 2015/16 audit position – on the agenda (1.3.2) KH reported an update from Ashley Flores, Lead Infection Control Nurse. The Infection Control Bio Hazard alert on Cerner now appears as a pop up to alert staff and details the nature of the alert. This had been discussed at a previous meeting. 1.3.1. Update on the Data Quality (Date of death) audit BE explained that the accuracy of date of death recording is routinely audited. He presented data that showed that the accuracy is static; 24% were recorded wrong, principally the day after the date of death when compared to the mortuary records. The data is corrected and resubmitted to SUS on a regular basis so that the HMSR is accurate. Work continues with the Divisions to reinforce the importance of a live bed state. A number of the wards now have patient focus boards which will hopefully drive some improvement. Following a short discussion BE undertook to revisit the possibility with IT of importing the data held in the mortuary system into Cerner. It was noted that the issues and solutions identified remain the same. 1.3.2. Update on the 2015/16 audit position JP reported that the Clinical Effectiveness Committee did not meet in June because it could not be quorate. The Chiefs have been asked to supply the reasons and evidence why proposed audits for 15/16 did not go ahead. The report will be taken at Clinical Effectiveness in July and can be included on the agenda for the August meeting of SQC, along with the Q1 16/17 report. 1.4. Highlights from Executive Committee for Quality & Risk CP presented a short summary of the ECQR meeting in June. RS asked why there was only one meeting in June. CP explained that DH has been chairing a series of meeting around how ED works, the ECQR time slot was used to allow further discussion with the Divisions. AH asked for clarification on the progress on VTE compliance. BM explained that VTE assessment has been transitioning from the Patient Tracking System (PTS) into Powerchart, part of Cerner. The systems have been working in parallel to allow the junior doctor’s time to assess and develop the form to an acceptable point that it can be made mandatory. PTS has now been disabled and all VTE assessment is being done in Powerchart. A mandatory screen pops up on Cerner four

SQC Minutes 7 July 2016 Page 2 of 8

hours after admission. BM warned that VTE performance may dip but performance is expected to improve from week commencing 11th July. AH expressed concern about the CQUIN for flu vaccinations. BM explained that the target is that 75% of staff must have had the vaccination or choose not to have it. The Trust remains committed to ensuring that as many staff as possible have the vaccine for the protection of patients and colleagues. RS requested an update on the progress of discussions with Guildford about the management of the 62 day target.

1.5. Highlights from Clinical Quality Review Meeting PS presented his report. The main issues discussed were: â&#x20AC;˘ Emergency activity which continues to increase. â&#x20AC;˘ significant increases from the south of the region in terms of elective work, the issue being that it is not planned AH requested that the report include the names of those invited to the meeting and those who attended. AH would like to assess how well the meeting is utilised.

BE/PS

2 QUALITY PERFORMANCE 2.1 Quality Report Due to pressure of time, RS suggested that the report was noted. The committee agreed.

2.2 SQC Annual report to the Board RS introduced the report and asked the committee to review section six and indicate whether it accurately reflected the challenge for the committee. AH asked that the challenge for the Trust in the revised healthcare system (STP) be reflected in the report. RS agreed that if the STP is going to work then there are implications for the healthcare system and the way that the Trust operates. This may result in new priorities for the Trust or SASH may be asked to play a new role which may impact quality or safety. It was agreed that this should be reflected as a forward challenge for 2016/17 FA asked that safeguarding, stroke and fractured NOF be added to the list as a key area of focus. With those changes the committee agreed that the report should be submitted to the Board.

3 SAFETY 3.1 March review of activity and safety CP presented a report prepared by the Virtual Team which looked at the activity in March and whether it had impacted on the safety of patients. The team reviewed the available data and tested a number of hypotheses one being that when the Trust gets busy it might be expected that patient experience would be compromised and following that, it might impact on patient safety. CP explained to the committee th

SQC Minutes 7 July 2016 Page 3 of 8

that it became apparent early in the process that there was no single indicator for “busyness”, BE’s team devised a pressure index which is a composite of a number of indicators. It showed that although March was busy, activity peaked in February. The reported incidents in February and March could not be attributed solely to increased activity. Mortality data released for March was very encouraging. It became apparent that complaints were not a useful indicator due to the potential time lag between an adverse event and the complaints being made. The Your Care Matters score demonstrated a drop in satisfaction during this period. Workforce data showed high sickness in February. In summary the data showed that the patient and staff experience in February and March dipped, but that patient safety was not compromised. There is still more analysis to be undertaken. RS asked for some additional issues to be considered:

• Is any evidence that patient’s whose operations are cancelled come to harm?

• MRFD - is there any evidence that the patients come to harm Virtual team because they have not had a timely discharge?

• Is there any national research on this subject? • Is there any evidence that high usage of locums in periods of high activity impact patient safety?

FA confirmed that patients will decompensate the longer they stay in hospital. KH confirmed that this data is available for falls.

3.2 Deep dive diagnostics – Emergency Department Report CD presented a summary of the issues faced by the Emergency Department when managing diagnostics for patients. RS commented that the rapid flow of patients through the department enhances the challenges for the ED team. ED is a one stop shop, the aim of the team is to make a decision regarding on-going care, not necessarily a diagnosis. Although diagnostics are ordered they are not always incorporated by ED clinicians in their decision making. The range of diagnostic tests is limited by the maximum stay in the department for most patients of four hours: ECG, blood tests, x-ray, CT or ultrasound. The tests need to be ordered, completed and evaluated within 4 hours. CD explained that for efficiency purposes ECGs are ordered early in the patient’s pathway. Bloods are requested as soon as possible, x-ray and CT are requested following clinical review. Triage and Rapid Assessment and Treatment (RATS) (both nurse led) will request bloods and perform ECGs. Strict guidelines govern which blood tests are requested for different presenting symptoms, the decision to do an ECG is based on the experience of the triaging nurse. The ED doctors will ask for further diagnostics, ultrasounds/CT scans after discussion with their senior colleagues. Specialist teams providing reviews in ED will also request diagnostics. th

SQC Minutes 7 July 2016 Page 4 of 8

ECG based on presenting complaint and history of the patient, this is not governed by a guideline. Far too many ECGs are undertaken. Audit shows that the accuracy of ECG interpretation is good. Bloods are requested at triage according to guidelines and they are normally available when the doctor undertakes his assessment. Blood test reviews are normally prompt. SM asked how much point of care testing is done. CD replied that this is work in progress. Arterial blood gas, lactate and urine tests are done at the point of care. Blood ketones and blood glucose will be available soon but the rest is done in the lab. Issues:

• The type of test is governed by the perceived complaint, which can

provide clinicians with red-herring results, which then need to be acted upon. CD gave the example of troponin levels being assessed for a patient who mentions chest pain.

• Over processing. • It is estimated that 10-15% of blood results are handed over to the admitting team. There is no system to ensure that the admitting team have either seen or acted upon the results. BM added that as part of the admitting process all outstanding blood tests should be checked.

• A small minority of blood results will not be available by the time the patient is discharged (for example thyroid function) the GP is asked to check the results on the discharge summary.

• If pathology finds a worrying or potentially life threatening result they

will call the doctor’s office. CD described a serious incident caused by a delay in actioning this advice.

• Collecting and transferring the sample to the lab can be unpredictable using the tube system.

• Approximately 15% of blood samples are haemolysed (spoiled) in

the lab which necessitates new bloods to be taken, incurring a delay in the patient pathway. FA asked where the problem with the tube system has been escalated and discussed.

Microbiology There is no failsafe system for microbiology results. This cohort of patients is likely to be admitted, but if they are discharged from ED a request to follow up the results is included on the discharge summary. If the microbiology team identify a significant result then the ED doctor is informed and the results are actioned. This is infrequent; three times in six months. BM added that the microbiologists will take ownership of a significant or unusual infection, but a MSU with an e-coli, a routine finding is more vulnerable to the system. CD described an incident where there was a delay in actioning a finding of hybridkaelemia. (1:11) As a consequence it was requested that results are phoned through to the nurse in charge’s desk (always staffed, computer available for identification of patient and clinician, tannoy to summon the doctor). The success of this approach has been variable. th

SQC Minutes 7 July 2016 Page 5 of 8

CD acknowledged that GPs have expressed concern about having to review results at the request of ED. CD gave assurance that this is kept to a minimum, but that sometimes it cannot be avoided. BM confirmed that this an unresolved question which needs to be agreed with the CCG. The BMA stipulate that the doctor who requests the tests should review the results however, in an integrated healthcare system where the GP is part of the patientâ&#x20AC;&#x2122;s pathway this is less clear. X-rays - There are a small number of guidelines which indicate that an x-ray can be requested at triage, for example suspected fractured neck of femur, but most are questions after clinical assessment. They are hot reported by the ED doctor for decision making, all will then be reported within a few days by a Radiologist. The radiology report will be sent to the consultant who is on-call that day, so the consultant who receives the report may not have seen the patient. The report is checked is in line with the clinical outcome for the patient, if not the consultant will take action. CT scans - Are always requested by a doctor, according to guidelines following a discussion with the senior clinician. Renal stones CT have a streamlined system, which are again hot reported with a radiology report following. All other CT scans are reported within an hour by radiology. CD acknowledged that there may be too many head and neck CTs because the guideline is cautious following some incidents in which neck fractures were missed. This will be the subject of a forthcoming audit. Some CTs need to be agreed with a radiologist first because there is no Trust guideline in place. Out of hours CTs are agreed with and reported by Medica, this can be time consuming. Ultrasounds - These are infrequent because of the availability of slots. The team is moving towards bedside ultrasounds performed by the ED team. CD informed the committee that national figures indicate that 2% of the fractures presenting to ED will be missed. They are usually not clinically significant, but all incidents are reviewed. CD also highlighted instances where reviewing specialties order tests under the ED consultantâ&#x20AC;&#x2122;s name, sometimes without his/her knowledge. This can present challenges when the results come back. BM assured the committee that the incidents highlighted by CD have all been investigated and actions put in place to reduce the likelihood of repeat incidents. He reiterated that results are only phoned through for abnormal results, this is in addition to the normal process of reporting results which all clinicians should be checking. RS thanked CD for his presentation and for highlighting a number of instances where the process can be improved. The plan is for the issues to be addressed through ECQR. PS suggested that the Division review the issue of the pneumatic tube failure and the phoning through of results within their Divisional Governance meeting.

4 SAFETY th

SQC Minutes 7 July 2016 Page 6 of 8

4.1 Medicine Division Annual Report to SQC BM gave a short presentation on the highlights of the past year and the upcoming challenges. He explained that the Division has created business cases for service improvements prioritising issues identified through risk assessment and complaints. RS asked about Outpatients BM explained that as a structure and process it sits within Surgery, however the activity is incorporated within Medicine plans which have all been reviewed as part of the business planning process. Endocrinology and rheumatology are developing their services as a consequent. Cardiology has encountered problems meeting demand, so Care for Elderly consultants are now taking a number of the referrals for patients over 85 years old to improve access. BM provided assurance that complaints relating to outpatients are resolved by working with surgery. The Trust has identified outpatients as an area which will benefit from the VMI work. However, BM confirmed that the Division has struggled to meet demand, but that the Division is aware and planning. PS confirmed that the business planning process has been changed and that the next step will be to bring it forward to before Christmas. This will allow plans to be in place before the beginning of the financial year. PS confirmed that in the performance review process, Medicine was able to give significant assurance which is underpinned by the performance indicators. RS asked what kept BM awake at night, BM denied sleepless nights, however indicated that he would like to have the stroke strategy confirmed. He also reported that he was looking forward to the challenge of meeting a seven day service. RS asked whether length of stay was under control. BM explained that by addressing some of the smaller issues for example, continuing health care and rapid acute care, length of stay will benefit from the system redesign. RS thanked BM for an interesting and thorough presentation.

4.2 Audit outcome: Obtaining consent NB presented an audit undertaken in Surgery with Barbara Bray while she was working as an F1 at the Trust. It was undertaken in July 2015. The audit found:

• Around 10% of consent forms are not fully legible • 16% emergency/CEPOD and 13% elective procedure forms have abbreviations

• Emergency/CEPOD forms are filled in worse than elective procedure forms

• Over half of the patients having elective procedures have not had the opportunity to reflect on the information on their consent form

ZN noted that patients are often given information on their procedures as part of the outpatient preparation process. th

SQC Minutes 7 July 2016 Page 7 of 8

As a consequence of the audit BB has completed mandatory training for all medical staff. Staff in POPPA no longer accept patients with incomplete forms. They complete an incident form for each. This work will be continued as an element of the compulsory notes audit. The use of KH asked how many patients are returned to the ward where there is insufficient paperwork. SR informed the committee that it is about three per month. FA noted that it would be interesting to undertake a piece of work around patient understanding of the risks and benefits of surgery.

5.1 Any other business No items raised.

5.2 Proposed agenda for next meeting JP noted that CQC intelligence monitoring has now stopped; therefore it will be removed from the agenda. A new system is being piloted, the output of which is not expected for all Trusts until Q3.

DATE OF NEXT MEETING Thursday 4th August 2016 14.00 â&#x20AC;&#x201C; 16.00 AD65

SQC Minutes 7 July 2016 Page 8 of 8