Surrey and Sussex Healthcare NHS Trust Board papers
February 2016
Trust Board Meeting – IN PUBLIC Thursday 25th February 2016 - 11:30 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH
AGENDA 1
2
3
11:30
11.50
12:20
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 January 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
M Wilson
Paper
1.7
Board Assurance Framework & Significant Risk Register – For approval & assurance
G FrancisMusanu
Paper
SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1
Patients Story For assurance
F Allsop
Paper
2.2
Chief Nurse & Medical Director’s Report For assurance
D Holden/ F Allsop
Paper
2.3
Safety & Quality Committee Update For assurance
R Shaw
Paper
OPERATIONAL PERFORMANCE 3.1
3.2
Integrated Performance Report (M10) For assurance
A Stevenson
3.1.1
Operational & Quality Key Performance Indicators
D Holden/ F Allsop
3.1.2
Workforce Key Performance Indicators
F Allsop
3.1.3
Finance Key Performance Indicators
P Simpson
Finance & Workforce Committee Update For assurance
R Durban
Paper
Paper
4
5
13:05
13:25
RISK, REGULATORY AND STRATEGY ITEMS 4.1
Standards of Business Conduct Policy For approval
G FrancisMusanu
Paper
4.2
Update from the Shadow Council of Governors For assurance
G FrancisMusanu
Paper
4.3
Sash Plus Update For assurance
M Wilson
Paper
OTHER ITEMS 5.1
Minutes from Board Committees to receive & note 5.1.1
Finance and Workforce Committee
5.1.2
Safety & Quality Committee
5.2
ANY OTHER BUSINESS
5.3
QUESTIONS FROM THE PUBLIC 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
DATE OF NEXT MEETING 31st March 2016 at 11.00am
All
A McCarthy
A McCarthy
Minutes of Trust Board meeting held in Public Thursday 28th January 2016 from 11:00 to 13:30 Room AD77, Trust Headquarters, East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (DH) Des Holden (FA) Fiona Allsop (AS) Angela Stevenson (PB) Paul Biddle (RD) Richard Durban (AH) Alan Hall (RS) Richard Shaw
Chairman Chief Executive Chief Finance Officer / Deputy Chief Executive Medical Director Chief Nurse Chief Operating Officer Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director
In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (AA) Azhar Ansari (CP) Colin Pink 1.
Director of Corporate Affairs Director of Strategy (agenda item 4.4) Consultant Gastroenterologist (agenda item 2.1) Head of Corporate Governance (Notes)
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. The Chairman also extended a special welcome to Mark Preston, the new Director of Organisational Development and People. Apologies for absence were noted from Pauline Lambert.
1.2
Declarations of Interest No declarations of interest where declared.
1.3
Minutes of the last meeting – 17th December 2015 The minutes of the meeting held on 17th December where discussed and approved as a true and accurate record.
1.4
Action Tracker
1.4.1
GFM updated the Board on the following actions: TBU-01 is not due until 31.03.16 TBU-02 is not due until 31.03.16 TBU-03 Update annual plan is complete on the agenda for discussion TBU-04 Update finance BAF risks is complete on the agenda for discussion TBU-05 FA provided a verbal update. The SASH+ guiding team had considered the possibility of adopting and transitioning the 15 Step Challenge. There was agreement that this would be an effective use of time and there is value in both Page 1 of 8
observing the working environment before and after changes have been made. TBU-06 is not due until 31.03.16 TBU-07 is not due until 28.02.16 There were no other matters arising. 1.5
Chairman’s Report for Assurance The Chairman thanked all those involved in the opening of the new East Surrey Macmillan Cancer Support Centre on the 27 January. It is a fabulous facility for our patients and growing development of the Trust’s network of partner organisations. It is also good to see that in such challenging times that the project was delivered on time and on budget. The Chairman went on to discuss the completion of the Integrated Reablement Unit (IRU) which had been opened to patients earlier in the week. The Unit has not yet been opened formally but the Trust has kindly been allowed to use the bed capacity and some 19 patients are already under our care within the unit. This short term extra bed capacity will be of significant benefit to the Trust. The Board duly 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 introduced the report highlighting some key issues including Lord Priors visit to the Trust, he had met clinical teams and visited frontline services including the Emergency Department. The visit had been very positive. The Trust has been in period of black escalation and had initiated its internal business continuity processes. It is important to note this this reflects the whole system; GP, community providers and social care. MW commented on the IRU stating that it was an exciting development for Surrey and would see improvements in pathways for patients who are medically ready for discharge transitioning into primary care. It’s important to remember that this unit is not an enlarged discharge unit and that other discharge pathways will remain. The criteria for transfer to the unit will be key to its success. The junior doctor strike is still planned for the 10th February. It is expected that this strike will go ahead and the Trust has learnt from recent cancellation of industrial action and will put in mitigation to reduce the impact. The Board duly noted and took assurance from the report.
1.7
Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance GFM introduced the board assurance framework and significant risk register. The BAF detailed 13 risks to the trusts strategic objectives which had been updated by the Executive team through January. It was proposed that the BAF risk ‘5.2 Failure to stop divisional overspending Page 2 of 8
against budget’ is reduced to reflect revised forecast as expenditure is on track. The Board discussed the proposal and agreed to keep the risk at 15. The significant risk register lists 10 operational risks which were duly noted. The Board duly approved and took assurance from the report. 2.
Safety, Quality and Patient Experience 2.1 Clinical Presentation – for Assurance DH introduced Dr Ansari (AA), Consultant Gastroenterologist who gave a presentation on the innovative chronic bowel disease service that he had been piloting. This is an exciting pilot and may well be adopted by other chronic illnesses such as diabetes. AA introduced his supporting team including Mr Campbell-Smith and the senior nursing team including Branita Mills. Chronic bowel disease effects a significant proportion of the Trust’s patient demographic as such AA has developed a new patient centred pathway with East Surrey CCG. The service improves access to specialist advice, empowers patients to self-manage, reduces flare ups, complication rates and outpatient appointments. There has been significant impact on numbers of appointments and reduced the need for surgical intervention. The pathway enables direct patient contact with consultant physicians and their teams and allows for greater speed of assessing symptoms and monitoring condition, by reducing the need for face to face consultations. The model has been developing over 6 years during which time the number of patients has increased with minimal impact on the service and there is significant patient demand for the model. Recently the team had started to pilot an App developed by Johnson and Johnson. This provides more information and opportunities for contact between consultant and patient. DH stated that the local Academic Health Science Network (AHSN) had agreed to buy time to explore how this could impact on other long term chronic conditions. AM asked why it was only Surrey patients, AA confirmed that although the lead for development had been Surrey CCG the service was offered to all appropriate patients. MW highlighted that it was a very promising model but reminded the Board that we need to ensure its appropriately funded. PS and AA confirmed that the tariff for phone consultations was been applied but this is not a true alignment of the level of care been provided. Mr Tim Campbell-Smith confirmed that there had been a reduction in complications of surgery particularly colitis. AM thanked AA and the MDT for the presentation stating that the potential improvements for outcomes for patients was very welcome. The Board noted and took assurance from the report.
Page 3 of 8
2.2
Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the Chief Nurse’s report highlighting that the first 11 nurses form the Philippines had commenced work, the Trust had developed its methodology for reporting establishment and would commence new agency reporting regime in April. Revalidation would commence in April and the corporate team had good assurance over systems to support the Trust’s first 90 nurses. The ward accreditation CQUIN pilot is very positive and it is expected that the process will develop and strengthen throughout. AH asked for assurance on the Trust’s ‘glide path’ to meet the new agency cap. FA state that there was risk to delivery of the 12% agency target at the end of March; the Trust is currently running at 20% and moving in the right direction. Going on to highlight that recruitment drives often have double running cost as new staff need to be supported. RS asked what the impact of revalidation could be for the Trust. FA confirmed the process and evidence requirement, highlighting that this was a formalisation of elements of continuous professional development which are already in place. FA went on to highlight that should a nurse fail to meet the expectation of revalidation they would only be able to work at Band 2 level until requirements had been met. DH presented the Medical Directors report commenting on the appointment of a new clinical lead for imaging who has links with the AHSN and a strong informatics background. This is a very positive appointment for the Trust. The Trust had been in negotiation with the University of Surrey and had agreed the funding for 6 academic posts (2 Professors, 2 Lectures and 2 Students) which is a very exciting development for the Trust and will look at new models of care in alignment with the 5 year forward view. The AHSN is negotiating with the Trust to develop models for testing industry innovation across Kent, Surrey and Sussex. MW has been appointed as chair of the steering group which will look to run industry pilots across the local health economy. The Board duly noted and took assurance from the report.
Operational Performance 3. 3.1
Integrated Performance Report (M09) for Assurance The Board received and noted the report in advance of the meeting.
3.1.1
Operational & Quality Key Performance Indicators AS spoke to the access elements of the report, highlighting ED performance, continuing challenges with ambulance handover which is improving and efforts to reduce outliers and get patients in to the right bed first time. The Trust had achieved 62 week and 2 week cancer access targets but not met the 31 day diagnosis target, related to a short-term issue in dermatology. RTT remains very challenging with increased patient cancellation rates before Christmas impacting on surgical lists. Page 4 of 8
RS asked for assurance on actions to mitigate against ambulance handover issues. AS stated that following review the capacity to open 4 extra assessment areas had been developed. This is to be used at times of peak demand and is proving successful it does however require that nursing staff move swiftly between models of assessment and is embedding. The Board discussed increases in non-elective admissions noting specific increases in emergency attendances form Crawley and Horsham. MW stated that the Trust was in regular conversation with the local CCGs noting that there had been an observed reduction in use of out of hours 111 calls, and foot fall at minor injuries units which correlated with non-elective attendances. MW went on to reflect that with the recent announcement that a proportion of NHS pharmacies could be closing indicated that the situation would only become more challenging. DH highlighted that the Trust’s mortality indicators continued to provide good assurance, going on to note that in the last published data the Trust had been not seen the reduction in mortality indicators which had been achieved by a handful of similar organisations. The Trust declared 6 cases of C. difficile in December and the number of Trust apportioned cases is higher than last year’s overall numbers. The Board noted that of the cases reviewed by the CCG only 2 had identified lapses of care against a ceiling target of 15 cases. The Trust had also not identified any cases of cross infection, based on results of laboratory tests. FA discussed the recent cluster of serious incidents linked to falls with harm. The Trust was providing support and education to the teams involved. Overall patient experience remains positive but there are ongoing issues in elements of Friends and Family Test. 3.1.2
Workforce Key Performance Indicators FA presented the workforce elements of the report highlighting improvements in sickness absence, achievement review and staff turnover rates. The Board noted that 60 international nurses had joined the Trust since August and that the overall picture was improving. The Finance and Workforce Committee had reviewed theses KPI in detailed and noted wide variation in completion of achievement reviews, the Medicine Division had achieved circa 90% compliance.
3.1.3
Finance Key Performance Indicators PS introduced the financial elements of the report. The Trust is £5.3 million pounds in deficit at the end of Month 9 which is £4.0 million adverse to the revised TDA plan. This is assuming an accrual of £0.4 million relating to reimbursement from the TDA following the Junior Doctors industrial action in December. Agency costs reduced in month but are still high. The Women and Children’s division and Estates are adverse to their financial plan. The Trust base forecast is now a £3.0 million deficit which has been acknowledged by the TDA. This includes £3.0 million non-recurrent funding from a capital to revenue transfer and assumed funding in respect of the lost income from the junior doctors strike. The TDA have been advised that lack of funding will mean the forecast deficit will worsen to £4.2 million to reflect the impact of 3 days cancelled activity from the Junior Doctor’s dispute. Page 5 of 8
There remains risk to income, mainly emergency activity, activity impact of junior doctor’s industrial action and end of year penalties from the CCG. The Board noted that the TDA had reduced the delegated limit for capital schemes from £5.0 million to £1.0 million. PS noted that the metrics from Lord Carter’s review of efficiency indicated that the Trust was the 2nd most efficient hospital in England. The Board duly noted and took assurance from the report. 3.2
Finance & Workforce Committee Chair Update – for Assurance The Board received and noted the report in advance of the meeting. RD presented the report. The FWC had reviewed and agreed with the financial report received as part of the IPR 3.1.3. It had considered the draft 2016/17 revenue budget and agreed the addendum and final payments of the power network capital project. RD went on to highlight review of workforce issues seeking assurance on delivery of achievement reviews and training provision. The FWC took assurance from the successful upgrade of Cerner. The Board noted that the Trust had delivered £3.2 million of its savings. The Board duly noted and took assurance from the report.
3.3
Audit & Assurance Committee Update– for Assurance The Board received and noted the report in advance of the meeting. PB introduced the report. The Committee had discussed financial risk and issues in detail and considered plans to apply for a £9.6 million loan. The Trust’s Standards of Business Conduct had been reviewed and agreed in principal for Board ratification in February. Management confirmed that RSM had successfully been appointed following tendering to provide internal audit and counter fraud services. It is anticipated that closer working will be beneficial for the Trust. PB highlighted that the Committee had adopted the three lines of defense model of assurance as best practice and will start to seek and identify all levels of assurance. The Board duly took assurance and approved the report.
4.
Risk, Regulatory and Strategy Items 4.1
Review of Quality Impact Assessments for 2015/16 - for Assurance The Board received and noted the report in advance of the meeting. DH introduced the paper which looked to review the quality impact of Trust’s CIP Page 6 of 8
program. Each CIP had been reviewed to form a judgment of degree of delivery versus impact. DH stated that no adverse impact on quality had been identified and went on to highlight that in the case of the high risk drug CIP the delivery had been faultless which had delivered a saving and increased quality benefits to patients. The Trust continues to learn from its implementation of CIPs, clinical engagement was proving to be the key to success of plans. RD asked for assurance that all lessons are being learnt and there is greater assurance on feasibility of 2016/17 plans. PS assured the Board that the Trust had learnt valuable lessons throughout 2015/16. The Board duly took assurance from the report. 4.2
Emergency Preparedness Resilience Plan – for Approval The Board received and noted the report in advance of the meeting. AS provided the annual assurance report to the Board. Governance processes had strengthened and known issues are being resolves this includes elements of training and strengthening telecoms resistance. The Board discussed and approved the report and took assurance that appropriate systems are in place and mitigating actions are achievable and realistic.
4.2.a
NHS England Major Incident Assurance Return – for Approval The Board received and noted the report in advance of the meeting. AS introduced the assurance return, which detailed the Trust’s assessment of its preparedness to a specific set of questions for a major incident. The assessment detailed issues that the Trust was still resolving with local partners. The main issues of note are the development of plans to support reduction of public transport services and provide specialist training/briefing for the management of ballistic injuries. The Board duly approved and took assurance from the report.
4.3
NHS Planning Guidance 2016/17 – 2020/21 - for Assurance The Board received and noted the report in advance of the meeting. MW introduced the which details the requirements for the Trust prepare plans to support a local health and care system ‘Sustainability and Transformation Plan’, and reflect the national plan. In order to start to flesh out the details the Trust needs to first review detail of national contract and tariff plans. The report details all national and local health economy priorities that need to be considered and the Trust’s initial issues to address. The Board duly noted the report. Page 7 of 8
4.4
Annual Plan Update – Q3 - for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the quarterly update highlighting that actions relating to enhanced recovery programs for C-section had been achieved. In total 78 actions had been completed and there was expectation that the majority of actions would be delivered by the end of March 2016. The Board noted that there were 2 actions recorded as red, reduction in non elective demand and HCAI. Both issues are well known to the Board as are actions to militate against impact of growing non elective demand. DH indicated that once all necessary reviews are complete the HCAI action plan delivery may well be moved to amber. The Board duly 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
Audit and Assurance The minutes of the Committee were noted with no questions raised.
5.2
Any Other Business No AOB was raised.
5.3
Questions from the Public There were no questions raised.
5.4
Date of the next meeting Thursday 25th February 2016 at 11.30am 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 8 of 8
TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING Action Ref
Forum
Subject
Action
RO
Date Open
Date Due
Date Closed
Status
ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015
TBPU-01
TB Public
Patient story
The Board requested that Dr J Webb update the Board on findings and actions of the sample group. Dr ZN/DH Zara Nadim will now be undertaking this work.
TBPU-02
TB Public
Patient story
TBPU-03
TB Public
Cost Improvement Programme
The Board asked for feedback on the outcome of the retrospective audit to ensure that patients have received the correct follow up. SI action to be considered by the Effectiveness Committee. FA Provide a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC. FA
TBPU-04
TB Public
SaSH + (VMI Update)
The Board agreed that they would like to have early sight of the Trust’s Clinical Compact with its staff.
SJ
28/08/2015
31/03/2016
Not Due
26/10/2015
31/03/2016
Not Due
17/12/2015
31/03/2016
Not Due
17/12/2015
29/02/2016
On the agneda to close
TRUST BOARD IN PUBLIC
Date: 25th February 2016 Agenda Item: 1.6
REPORT TITLE:
CHIEF EXECUTIVE’S REPORT Michael Wilson Chief Executive 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: • Implementing the Forward View: Supporting Providers to Deliver • 2015 National Staff Survey Results Local: • Visit of local MP • Health Education England Film Crew 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 clinical leadership 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 February 2016 CHIEF EXECUTIVE’S REPORT 1.
National Issues
1.1
Implementing the Forward View: Supporting Providers to Deliver
On 11th February 2016, NHS Improvement launched a report setting out the task and clear expectations of what needs to be delivered by NHS provider organisations. It brings together all the key requirements of the Forward View into one document, for the first time, while providing links to the detail. It also shows how NHS Improvement and arm’s length bodies will provide support. The report also highlights the key priorities for NHS provider organisations in delivering high quality health and care this year and beyond. The report is part of a series of planned roadmaps that draw on messages from the NHS shared planning guidance, and set out the key priorities for the organisations responsible for delivering high quality health and care this year and beyond. Each roadmap reflects a shared vision for the health and care sector as set out in the Five Year Forward View about the challenges ahead, and the choices faced about the kind of health and care service we want and need in 2020. The report: • outlines the challenges and changes ahead • describes a coherent set of activities for NHS providers in the coming years • shows how providers across the country are beginning to deliver these • outlines the support providers can expect from NHS Improvement In summary report notes the challenge facing providers to 2020 is to deliver patient care of outstanding quality, regain NHS Constitution access standards, return to financial balance and eliminate unwarranted variation across all these areas, while at the same time making the transformation needed to ensure long-term sustainability. Getting the ‘quality, access, finance’ triangle right while transforming care adds up to an ambitious and stretching task. Provider boards will need clear strategies for achieving it, using the local Sustainability and Transformation Planning process to plan elements needing action across local health systems. Providers will also need to develop a new partnership with patients and their families. Quality: The vision for 2020 is that the vast majority of NHS providers will have an ‘Outstanding’ or ‘Good’ CQC rating and no trusts will be in special measures. At the same time, all providers will have to make improvements specified by national taskforces in the priority areas of cancer, mental health, maternity, dementia, and urgent and emergency care. They will also have made significant progress in eliminating unwarranted variation in clinical performance. Patient safety will have to consistently improve and all providers will be required to deliver seven-day services in line with the priority clinical standards. Access: The vision is that by 2020 all NHS providers will be delivering the agreed NHS Constitution access standards for urgent and emergency care, elective care and cancer care, and be meeting the new access standards for mental health services. Providers’ recovery plans will need to include measures such as better demand and capacity planning, better use of better quality data, better operational management within providers and across local systems, and improved referral management, responding to patient choice.
2
Finance: The vision for 2020 is that all NHS providers will have balanced their books and released significant efficiency savings, maximising value for patients and improving the quality of care. Fortunately, quality and efficiency are two sides of the same coin in healthcare. To start with, providers will need to achieve the best possible outturn position in 2015/16 and develop a plan for 2016/17 based on agreed control totals. Providers are expected to become less reliant on temporary staff by sticking to recent guidance on agency staff controls. Acute trusts will need to plan to achieve the savings of up to 10% of their expenditure identified in Lord Carter’s recent report. All providers may need to take action to release the value in surplus NHS estate: for example, by co-locating primary and secondary care where possible. Transformation for sustainability: The vision for 2020 is of providers joining up with other organisations to transform services in ways that best meet the needs of their local population. Providers will drive a shift of emphasis in NHS financial, regulatory and performance management processes from individual organisation performance to the performance of whole local health and care systems, recognising that the success of individual organisations remains important. NHS Improvement and NHS England will support this shift by increasingly engaging jointly with local health and care economies, encouraging joint planning and collaboration across boundaries. All local health and care systems will need clear plans to move to new care models – such as the five the sector is currently testing – and to reconfigure services where required. Providers will play a big part in developing these plans, and a more prominent role in prevention, early intervention and improving life expectancy. As a Trust we will review the key requirements and ensure these are incorporated into our plans and strategic direction. A full copy of the report is available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4996 64/Summary_provider_roadmap_11feb.pdf
1.2
2015 National Staff Survey Results
We have received the headline results from the 2015 National Staff Survey. Our response rate this year was 62% which is an improvement on the previous year (56 %). We have continued to increase our staff engagement score year on year for the past five years and both our response rate and staff engagement scores are in the top 20% nationally for 2015. The Survey is based on 32 Key Findings – of these we are placed in the top 20% nationally for 17. This is a positive and fantastic achievement and shows how we continue to develop as an organisation. Among our top scores staff told us that they: • would recommend the Trust as a place to work and or receive treatment; • are satisfied with the quality of work and patient care that we deliver; • are motivated at work; • are recognised and valued by colleagues and managers; • recognise good team working • are satisfied with the resourcing and support they receive • feel confident in reporting unsafe clinical practice
3
• •
recognise the effective use of patient and user feedback. feel that management were interested in their health and well-being
The results also show that issues of work related stress at SaSH were lower than the national average. These are all indicators we are proud of, however we recognise there are other areas we need to focus on to ensure a positive experience for all staff. These include managing violent or abusive interactions with patients, parents and visitors and staff confidence in reporting such issues. Whilst the quality of appraisals scored in the top 20% nationally, the quantity was in the lowest quartile and we need to ensure that all staff have undertaken an appraisal in line with the Achievement Review schedule which is commencing in April. We will now undertake more detailed analysis of the results and develop action plans to deal with issues you have raised and present a more detailed report to the Board in the next couple of months.
2.
Local Issues
2.1
Visit of Local MP
On Friday 5th February East Surrey MP Sam Gyimah came to see our new expanded and improved Surrey and Sussex Heart Centre and our cancer support centre. Sam was impressed to see our growing health campus and the increasing number of facilities and support we can offer to people closer to home. 2.2
Health Education England Film Crew
We recently had a film crew from Health Education England at the Trust who interviewed one of our physician associates, Moni Choudhury. HEE are producing a series of short films to highlight the variety of health roles across the country and SASH is great example of a trust using physician associates (PAs). Our 12 PAs are invaluable in helping us to support clinical staff and enhance patient care. More details will be available once the videos are published.
3.
Recommendation
The Board is asked to note the report and consider any impacts on the trusts strategic direction.
Michael Wilson Chief Executive 25th February 2016
4
Page 1
Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A Consistently meet national patient safety standards in all specialties and across divisions 1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.
Director responsible
Chief Nurse
Initial Risk Current rating
S4 x L3 = 12 S4 x L2 = 8
Target risk score
S4 x L1 = 4
Linked to Risk
1009,1055
Controls in place (to manage the risk)
Gaps in Control
1.
1) 2) 3) 4)
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
14.
Clinical teams in place to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance Policies, procedures and guidelines provide the framework by which risks and incidents are managed. Work undertaken to deliver ‘5 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) Matron on site 7 days a week to monitor nursing patient care and staffing Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) Nursing staffing levels monitored daily and issues managed Incident reporting policy in place and monitored Ward safety boards updated regularly and ward performance discussed at divisional level Serious incident review group established to monitor and evaluate investigation progress and progress against actions Training undertaken for clinical staff in the assessment and management of patients at risk of falls Patient falls strategic group meet monthly and report KPIs to the patient safety committee. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR.
Developing ward safety dashboards Ward accreditation system under development as part of 15/16 CQUIN Updating and planning RCA analysis training for new managers/leaders Embedding DATIX incident review process within 14 day timeframe
Potential Sources of Assurance (documented evidence of controls effectiveness)
Actual Assurances: Positive (+) or Negative (-)
1)
Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST audit (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis including increase in reporting (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15
2) 3) 4)
External reports and visits to clinical areas both scheduled and unscheduled (e.g. 15 step challenge) Ward Dashboards Divisional and Trust Level Dashboards VMI/SASH Plus Program
Page 2
(+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) 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 (+) Established links with falls team within community Negative (-) Never events incidence (-) NRLS reporting
Gaps in assurance
Assurance Level gained: RAG
Ability to benchmark in real time
Mitigating actions underway
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.
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)
Update by
Page 3
FA 10/02/16
Date discussed at board
1) 2)
Ongoing Ongoing action plan
To be discussed at February Board
Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care
Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). All cases C. diff joint review by CCGs and Trust. 7) Discussion group being setup to discuss any lapses of care in C. diff cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place – ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci. Potential Sources of Assurance (documented evidence of controls effectiveness) 1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff cases
Director responsible
Medical Director
Initial Risk
S3 x L4 = 12
Current rating
S3 x L4 = 12
Target risk score S3 x L3 = 9 Linked to Risk 1049, 1050, 1401, 1514 Gaps in Control 1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)
Actual Assurances: Positive (+) or Negative (-) Positive (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated July 2015) st (+)1 TDA visit inspecting controls and procedures nd (+)2 TDA visit comparison with other Trusts and brokered meeting with CCGs (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Initiation of ‘Stop, Access, Send’ initiative for the management of Negative (-)Incidence of CDI 2015/16
Gaps in assurance Extensive auditing and monitoring in place. Trust position known
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Assurance Level gained: RAG
Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C. diff Antibiotics (Fidaxomicin and Chloramphenicol IV) Update by Date discussed at Board DH 22/01/16
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Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2015/16 3) Ongoing 4) Under review To be discussed at February Board
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
2.A Achieve the best possible clinical outcomes for our patients
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties
Director responsible
Medical Director
Initial Risk Current rating
S3 x L3 = 9 S3 x L2 = 6
Target risk score
S3 x L1 = 3
Linked to Risk
1460
Controls in place (to manage the risk) 1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads
Gaps in Control 1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released
Potential Sources of Assurance (documented evidence of controls effectiveness) 1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason development program
Actual Assurances: Positive (+) or Negative (-)
Gaps in assurance Ability to benchmark in real time National Safety Dashboard to be implemented when available Mitigating actions underway
Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report
(+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 116 Assurance Level gained: RAG
1) Development of ward based performance dashboards Update by Page 6
DH 22/01/16
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 01/04/2015 To be discussed at February Board
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.B Deliver services differently to meet need of patients, the local health economy and the Trust 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
Controls in place (to manage the risk) 1) Transformation Team in place 2) System Resilience Group 3) 3x3 meetings 4) CEO strategic meetings 5) Partnership boards 6) Trust part of national Virginia Mason transformation programme 7) Integrated Reablment Unit build complete Potential Sources of Assurance (documented evidence of controls effectiveness)
Director responsible
Chief Operating Officer
Initial Risk
S5 x L3 = 15
Current rating
S5 x L3 = 15
Target risk score
S5 x L2 = 10
Linked to Risk
1221, 1480, 1601, 1405, 1547
Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Repatriation of tertiary services effected 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
Actual Assurances: Positive (+) or Negative (-) Positive (+) Contract 14/15 signed with BICS (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) 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
1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting
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 Assurance Level gained: RAG Agreed activity modelling across SEC National policy decisions and effective of general election Mitigating actions underway 1) Full action plan development for productivity programme (theatres, outpatients, VMI Value streams) 2) Breaking the cycle and reducing LOS action plan
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) End of quarter 4 2) Ongoing
Update by
To be discussed at February Board
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BE 19/02/2016
Date discussed at Board
Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference
3.B Deliver high quality care around the individual needs of each patient
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits. Controls in place (to manage the risk) 1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Nursing agency PMO, Workforce subcommittee, Exec Committee and the Board 2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level and at associated subcommittee, Exec and the Board 3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken 4. PMO in place to monitor agency use and progress of the five related work streams a. E-roster- migration to v10 approved and project commenced 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 undertaken but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO f. Weekly reporting in place to TDA/Monitor in place on all agency use above cap or outside framework g. Monthly reporting of total agency spend against TDA/monitor 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 6. Work underway to develop SASH recruitment brand and retention strategy 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. Page 8
Director responsible
Chief Nurse and Medical Director
Initial Risk Current rating
S3 x L4 = 12 S3 x L5 = 15
Target risk score Linked to Risk
S3 x L2 = 6 770, 1295, 1580, 1652
Gaps in Control 1. E-Roster system is not updated out of hours 2. Unfilled shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically in clinical areas and turnover in some areas is above Trust target 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision
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 and monitored in divisions 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilisation and spend at PMO 6. Weekly & monthly reporting of agency use to TDA/Monitor
Actual Assurances: Positive (+) or Negative (-) Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) 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 Negative (-)Benchmarked high proportion of agency staff usage against other Trust’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 Mitigating actions underway 1. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3.
Implement e-roster upgrade and utilize core functionality (bank and messaging)
4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016 Update by Date discussed at Board FA 10/02/2016 and DH 22/01/2016
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Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016 To be discussed at February Board
4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population 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 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care
Controls in place (to manage the risk) 1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity th 10) 10 Theatre opened (May 15) 11) Increasing hospital at home capacity 12) Integrated Reablement Unit built Potential Sources of Assurance (documented evidence of controls effectiveness) 1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations 9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.
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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)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed (New Consultant undertaking review) 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge
Actual Assurances: Positive (+) or Negative (-) Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered April, May, Aug, Sept, Oct, Dec 2015 (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) 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 June, July, Nov 2015 and Jan 2016 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 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)
Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway 1) 2) 3) 4) 5) 6)
Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance Refresh winter capacity plans based on assessment of Q1 activity Planned local health economy summit regarding emergency growth
Agreed breaking the cycle 2 encompassing internal and external bodies Planned breaking the cycle throughout weeks throughout winter Demand and Capacity plans for 16/17
Update by
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BE 19/02/16
Date discussed at Board
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Complete 2) Complete 3) Complete 4) Complete 5) March 2016 6) March 2016 To be discussed at February Board
Objective 5 – Well Led 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
Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity and financial) savings / transformation 1) There are issues with Sussex over the under commissioning of activity and plans. contractual action has started in respect of this. 2) Agreed contracts in place with main sets of commissioners (NHSE and 2) Winter demand has been a significant issue with the Health System declaring CCGs) – all Contracts were finally signed in August. “black” status in January on two occasions. This has triggered a risk summit and 3) Contract management process in place (this operated effectively in 2014/15). the completion of a serious incident review (nb: focus isn’t income, but planning) 4) Financial reporting, including periodic forecast scenarios, is in place and 3) The strategic management of activity is not currently effective, but the Trust is effective – a detail forecast was provided to Board in July and internal PMOs are doing all it can to support making it so. based on that forecast. 5) Chief Officer meeting (which includes coordination of has been in place since Note: other gaps in previous reports mitigated by actions currently in train with Nov 2014. Its structures are still embedding. CCGs. Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) Positive 1) Financial performance and contractual reporting to Exec Committee, (+) The reconciliation process is seeing payment for over performance against CCG Finance & Workforce Committee and Trust Board (including CQUIN contract plans {although the process has seen delay in payments] reporting process). (+) Internal action on income delivery in specific specialties has, generally, been effective 2) Performance Review (PMO) and Exec Quality and Risk process – part year shortfall, but underlying issues have now been corrected with Divisions, monthly contract cycle with CCGs. Service line reporting (+) Agreement now reached with Sussex over MRET and handover fines – surrey not process expected to be far behind [but not yet agreed] 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Negative Resilience Groups and Chief Officer Meetings) (-) Risk over income growth assumptions, now materialized – risk in last 3 months is from 5) Output of Contract Management Process . balance of emergency activity and capacity. This is the single biggest issue in the Trust’s financial performance in the last 6 months of the year - adverse income variance at M10 (-) Monitor response to MRET complaint provided no useful application in 2015/16 (although a deal done with Sussex over the original increase in the threshold) (-) Too much non elective activity, not enough elective – risk over emergency demand (-) disputes now received from Surrey – only one from Sussex – escalation status not confirmed by CCGs – 9 February letter to CCGs to clarify position (-) Tripartite letter on 19 January provides conflicting advice to that from the TDA about levying of fines in Q4. Gaps in assurance Assurance Level gained: RAG Red because of level of risk, activity planning differences, issues with strategic health system management of urgent care activity and transactional processes with CCGs.
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Mitigating actions underway 1) Complete all contractual commitments according to timetable (we are about to start end-year discussions over the FOT for income for each CCG); 2) Revised forecast for elective activity completed, now being monitored – performance is not on plan; 3) The integrated reablement unit opened on 21 January. 4) Robust contractual processes being operated. Update by Date discussed at Board PS 15/02/16
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Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable.
To be discussed at February Board
Objective 5 – Well Led 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 / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) TDA agency reduction plan now submitted
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 PMO.
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) Management of increased levels of emergency activity subject to review; 2) Cost improvement plans are not fully delivering with adverse performance on agency and escalation in particular. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery. 3) There is overspending in 2 specific areas against agreed forecast control totals at M09, and again at M10. The overspending risk has been revised to correct lower risk score in line with the January Board discussion. Actual Assurances: Positive (+) or Negative (-) Positive (+) Budget changes made to match activity and main Divisions within forecast tolerance (bar 2 specific areas) (+) Internal audit advises CIP process is sound (but notes non-delivery, see below) Negative (-) Internal audit advises effectiveness of savings delivery rated red/amber. (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant costs (albeit within forecast) across Divisions. (-) The forecast provides an adverse variance to plan.
Gaps in assurance Assurance Level gained: RAG Overspending is the main area 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 and PMO meetings have become more frequent for all Divisions. Nursing agency PMO and fortnightly agency steering group. 2) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement. The latter tightened again in February (spend to be put off even if urgent) 3) Decisions on business cases are now taken in light of affordability against forecast. Update by Date discussed at Board PS 15/02/16 To be discussed at February Board
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Objective 5 – Well Led 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) V7.0 long term financial model and integrated business plan 2) Lack of alignment between CCG activity plans and actual performance. completed (submitted to Monitor in April 2015) 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider NHS finance regime. 3) TDA Plan submitted in April 2015 4) Board to Board held with the TDA in November 2014, Monitor 4) Risk over capacity from other operational pressures assessment now in train culminating in Monitor Board to Board in 5) Overall health system financial view (Chief Officer’s Finance Sub-Group) June 2015. describes significant loss of resource to BCF funding – this reduces resource 5) Cost improvement plan process in place (including PMO structure) available for health and social care overall. 6) Elective/outpatient activity growth and income plan in place – 6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium term capacity created planning [some information now available – consultation published 11 February] 7) Contracts with CCGs allow for payment for “over performance” 7) Central actions over NHS overspend may have an adverse impact on Trust because of manner of application (e.g. withholding capital and cash). Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Delivery of 2014/15 financial position and delivery of Positive 2015/16 financial plan (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) 2) Production of 2016/7 budget, revised long term financial Negative model and integrated business plan documentation, and (-) alignment with CCG plans is not complete with significant variances between actual performance on delivery against them activity and CCG plans [CCGs are, in the main, paying over performance] (-) overall health system loss of resource Overall, on basis of current assumptions, RAG has turned red with the impact of urgent care activity and the level of risk to the forecast. Assurance RAG red. (-) 2016/17 sustainability and transformation funding and the applicable control total are not yet agreed with NHSi. Gaps in assurance Assurance Level gained: RAG Central actions to manage costs across the NHS are not yet clearly described and the tariff is not yet defined, plus cumulative impact of other finance risks here. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Please see items above. Tariff information is now available (11 February) but potentially subject to Progress is on timetable change. The 2016/17 budget has been reported to Board and the 8 February plan submission made. The Board is aware of action in relation to control totals and S&T funding. Update by Date discussed at Board PS 15/02/16 To be discussed at February Board
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Objective 5 – Well Led 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) NOTE: This risk was reviewed at FWC 22 September and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £9.6m working capital loan has now been submitted
Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance 2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board 3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)
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 2015/16 – a loan application has been drafted and submitted – awaiting confirmation of agreement 2) Delay in receiving cash payments to match accrued income from CCGs, although main CCGs are providing cash advances 3) Threat of central cash controls in line with control totals (nb: which the Trust has not agreed). Confirmation has been received verbally of an increased working capital facility but this has yet to be formalized, along with its operation (i.e.: NHSi may restrict access to the level of S&T funding proposed for the Trust). Rating maintained after past discussion at Board – position monitored. Actual Assurances: Positive (+) or Negative (-)
Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, Green internal audit report on cash management Negative (-) 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 3) Discussion will continue with NHSi over the cash facility they are making available. Update by Date discussed at Board PS 15/02/16 To be discussed at February Board Page 16
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.E We are an organisation that is clinically led and managerially enabled. Key Action for 2015/16 objectives 5.5 There is a risk we will fail to and description of any potential realize the strategic benefits of significant risk to this priority having an Achievement Review Process that effectively monitors and influences behavior and performance. Controls in place (to manage the risk) 1) 2) 3) 4) 5) 6)
New Achievement Review Policy with implementation /communication and training plan. Personal objectives are being linked to Trust/Divisional and team objectives and the SMART methodology is being used to assess performance New AR process includes assessment of Behaviours against Trust values Personal Development Plans as part of AR identify development needs Training Need’s Analysis at Divisional level extrapolated to Trust level to inform strategic planning of development priorities AR Task and Finish group continues to embed new process and implement for medical staff during 2015/16
Director responsible Initial Risk Current rating
Director of Organisational Development & People S3 x L3 = 9 S3 x L3 = 9
Target risk score
S3 x L2 = 6
Linked to Risk
1740
Gaps in Control 1) New system yet to reap full benefits 2) Operational activity levels in the Trust stated as reason by line managers for noncompliance with expected appraisal completion rates 3) Change to annual timetable with delivery in first part of financial year yet to embed 4) An agreed model for medical and dental Achievement Review yet to be agreed
Potential Sources of Assurance (documented evidence of controls effectiveness)
Actual Assurances: Positive (+) or Negative (-)
1) AR review audits focusing on objective setting and linked to quality of services 2) National Staff Survey results (2015 results - Level of appraisal completion is in the lowest 20% nationally, but quality of appraisals is in highest 20% nationally) 3) Feedback from junior doctors 4) Monthly reporting against AR completion timetable at Divisional and Trust level at ECQR&CC, Workforce Committee, and Finance Investment &Workforce Committee 5) Development of behavior based recruitment systems will support the long term strategic implementation of achievement reviews.
Positive (+) Task and Finish group successful launch of new policy and process slides and comms plan for launch at ESH and Crawley (+) development of toolkit and intranet resources (+)TNA update to August 2015 Finance Investment & Workforce Committee (+) recent audit personal quality objectives in appraisals (+) 2015 staff survey results for quality of appraisals puts us in the top 20% of Trusts nationally (+) Culture champion led initiative on standards of behavior (+) 64% compliance achieved following significant focused effort Negative (-) 2015 staff survey Q on appraisal in last 12 months is in bottom 20% (-) compliance rates for Achievement Review remains adverse to plan
Gaps in assurance
Assurance Level gained: RAG
New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s
Mitigating actions underway 1) 2) 3) 4) 5)
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.
Recovery plan for 2015/15 compliance in place Series of training courses to support implementation commenced and will run throughout 2015/16 and up to end of June 2016/17 T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the same across all staff groups Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors Establish process for annual performance review to identify and talent map for Medical & Dental, 8a’s and above (Talent Management grid to be included in AR paperwork from 2016)
Update by Page 17
MP 15/02/2016
Date discussed at Board
1) 31 March 2016 2) 30 June 2016 3) Piloting in Medicine Division in June 2016 4) Complete and ongoing 5) March 2016
To be discussed at February 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
5.G.2 We are a well governed organisation
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model. Controls in place (to manage the risk) 1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer Potential Sources of Assurance (documented evidence of controls effectiveness) 1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection – “Good” 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of all current Monitor information requests
Gaps in assurance Completion of Historical Due Diligence Mitigating actions underway 1) Shadow Council of Governors in place 2) Monitor formal assessment currently paused Update by GFM 05/02/16 Page 18
Update by
Director responsible
Director of Corporate Affairs
Initial Risk Current rating
S4 x L2 = 8 S4 x L2 = 8
Target risk score
S4 x L1 = 4
Linked to Risk
1531
Gaps in Control No significant gaps in control identified
Actual Assurances: Positive (+) or Negative (-) Positive (+) Completion of Monitor pre-assessment phase (+) Election to the Council of Governors complete (+) FT membership over 10,000 st (+) Monitor Exe to Exe Challenge took place on 1 June 2015 (+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor confirmed QGAF score as 3.5 – Further actions being implemented (+) Successful elections - Shadow Council of Governors in place (+) Discussion with Monitor on final timescales & remainder milestones to re-start the process (+/-) Awaiting national guidance on future FT model (NHS Improvement) Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at February 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 2015/16 objectives and description of any potential significant risk to this priority
5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems
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 Oct 14 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 – 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 Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change
Director responsible
Director of Information and Facilities
Initial Risk
S5 x L3 = 15
Current rating
S4 x L3 = 12
Target risk score
S3 x L3 = 9
Linked to Risk
1428, 999, 1483
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)
Gaps in assurance Trust position known, no identified gaps in assurance Mitigating actions underway 1. 2. 3. 4. 5.
Procurement and implementation of replacement EPR - complete Establishment of Chief clinical Information Officer role - complete Clinical Cerner Optimisation Group now in place with strong leadership Greater focus on IT in Capital Plan for 2015/16 and future years EPR Roadmap now approved by Executive and approval to proceed agreed 6. Move to latest version of Cerner software now taken place Update by Date discussed at Board IM 19/02/16 Page 19
Assurance Level gained: RAG
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 To be discussed at February Board
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
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
• 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
• 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
• 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)
Financial Management • Small loss <£1K
• Minor loss £2K to £100k
• Moderate loss, £100k - £1M
• Major loss, £1M-£10M
• Loss > £10M
Governance Arrangements
• 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
Health & Safety
Quality of Service
• 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
TRUST BOARD IN PUBLIC
Date: 25th February 2016 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 Team throughout February 2016
Action Required: Approval (√)
Discussion (√)
Assurance (√)
Purpose of Report: The 2015/16 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 11 significant risks recorded on the Trust risk register. 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 Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about 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 Financial impact
The report is a requirement for all NHS organisations. As discussed in sections 5 (Income generation linked to activity referred to throughout the document) 1
An Associated University Hospital of Brighton and Sussex Medical School
Patient Experience/Engagement
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: February 2016 BAF and the current SRR
2
An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT – 25th February 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 Trust has identified five main strategic objectives for 2015/16: 1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy 3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model These 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). There have been minor amendments throughout regarding controls, actions and assurances. The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows: Objective 1.Deliver safe services and be in the top 20% against our peers 2.Deliver effective and sustainable clinical services within the local health economy 3.Ensure patients are cared for and feel cared about 3
Red (15-25)
Amber (8-12)
Green (1-6)
0
2
0
1
0
1
1
0
0
An Associated University Hospital of Brighton and Sussex Medical School
4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Total
1
0
0
4
3
0
7
5
1
2.2 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services 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 deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties. 1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy 2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
S4 x L2 = 8
S4 x L1 = 4
S3 x L4 = 12
S3 x L4 = 12
S3 x L3 = 9
Initial Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood
4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care
4
Target Risk Score
S3 x L3 = 9
S3 x L2 = 6
S3 x L1 = 3
S5 x L3 = 15
S5 x L3 = 15
S5 x L2 = 10
S3 x L4 = 12
Objective 4 – Responsiveness – Become the secondary care provider for the catchment population
Target Risk Score
S4 x L3 = 12
Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.
Current Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood S3 x L5 = 15
Initial Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood
S4 x L4 = 16
S4 x L4 = 16
Target Risk Score
S3 x L2 = 6
Target Risk Score
S4 x L2 = 8
An Associated University Hospital of Brighton and Sussex Medical School
Objective 5 â&#x20AC;&#x201C; Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to deliver realistic 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 we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance. 5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model. 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 S5 x L3 = 15
Current Risk Rating: Severity x Likelihood S5 x L3 = 15
Target Risk Score
S5 x L3 = 15
S5 x L3 = 15
S3 x L2 = 6
S5 x L3 = 15
S5 x L3 = 15
S4 x L2 = 8
S5 x L3 = 15
S5 x L3 = 15
S4 x L3 = 12
S3 x L3 = 9
S3 x L3 = 9
S3 x L2 = 6
S4 x L2 = 8
S4 x L2 = 8
S4 x L1 = 4
S5 x L3 = 15
S4 x L3 = 12
S3 x L3 = 9
S4 x L2 = 8
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). These are: Risk description 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care 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
Current rating
Target risk score
S5 x L3 = 15
S5 x L2 =10
S3 x L5 = 15
S3 x L2 = 6
S4 x L4 = 16
S4 x L2 = 8
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
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 11 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 1672 1678 1688 1689
1697
Title
Initial Current Residual Next Rating Rating Rating 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 Sickness Absence Levels with impact on day to day management and expenditure RTT Access Standards Risk of potential overspending from operational pressures Risk of Contract income below plan Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report
16
15
9
31/03/2016
20
16
6
31/03/2016
9
15
6
31/03/2016
15
15
8
31/03/2016
15
15
12
31/03/2016
9
15
6
31/03/2016
15
15
9
31/03/2016
15
15
6
31/03/2016
16
15
9
31/03/2016
15
15
12
31/03/2016
15
15
9
31/03/2016
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 â&#x20AC;˘ Note the updated risks included in the Significant Risk Register
Gillian Francis-Musanu Director of Corporate Affairs February 2016
Colin Pink Head of Corporate Governance
6
An Associated University Hospital of Brighton and Sussex Medical School
Appendix 1: Risk Appetite â&#x20AC;&#x201C; 2015/16 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. 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 7
An Associated University Hospital of Brighton and Sussex Medical School
Appendix 2: SASH risk quantification matrix
8
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
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
• 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
• 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
• 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)
Financial Management • Small loss <£1K
• Minor loss £2K to £100k
• Moderate loss, £100k - £1M
• Major loss, £1M-£10M
• Loss > £10M
Governance Arrangements
• 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
Health & Safety
Quality of Service
• 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
9
An Associated University Hospital of Brighton and Sussex Medical School
Risk of Contract income below plan
Risk the Trust does not achieve its financial plan as a result of lower than planned contract income.
15
5
5 15
15
5
Treatment Plan Review and develop plans; to brief the Board on progress against risks of establishment targets not being met and any potential action to review the Board's decision on implementation.
Due date 31/03/2016
As described on the BAF
31/03/2016
31/03/2016
As described on the BAF
31/03/2016
31/03/2016
As described on the BAF
31/03/2016
31/03/2016
As described on the BAF
31/03/2016
31/03/2016
As described on the BAF
31/03/2016
31/03/2016
31/03/2016
3 15
i) Quarterly reconciliation with CCGs will inform variations to the monthly contract values (over performance at Q1 is likely to reduce the risk). ii) Manage emergency activity within capacity through structural changes to ward configuration, improving length of stay (notably in cardiology to release beds) and other actions to improve efficiency.
Done date
Next Review
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
Current Rating
Risk of not being able to pay suppliers from in sufficient cash due to poor liquidity problem
Current Likelihood
Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position
15
Current Consequence
Existing controls The Trust has set aside reserve budget for the cost of proposals to increase nurse/midwifery staffing, but this is funded partly by income from CCGs, which is not secure. 7 day working is already in place partially (part of the forecast). Additional nursing staff to deliver agreed ratios have been agreed, with implementation spread over 2 years and recruitment starting when agency is at acceptable levels.
Initial Rating
Risk Type Financial Management Financial Management
Description (Policies) Risk of failure to meet the financial plan as a result of a) increased costs to deliver staffing ratios, 7 day costs and expectations detailed in national guidance and plans, and b) failure to deliver adequate adjusted treatment index (Carter).
Financial Management Financial Management Financial Management Financial Management
Simpson, Paul Simpson, Paul
Specialty
Risk Owner Simpson, Paul Simpson, Paul
Simpson, Paul Simpson, Paul
Open Date 11/06/2015
CORP CORP
18/06/2014 01/04/2015
CORP CORP
09/12/2014 20/05/2015
CORP CORP
18/06/2014
Committee Executive Committee Executive Committee Executive Committee Executive Committee Executive Committee Executive Committee
ID 1697 1604 1689 1663 1688 1603
Title (Policies) Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report
3 15
Iii) Ring fence elective beds after new capacity has opened and monitor delivery. Risk of not achieving Cost Improvement Plan
Risk of not achieving financial plan as a result of non- i) Delivery of savings managed through PMO delivery of Cost Improvement Plans (ongoing)
9 Risk of potential overspending from operational pressures
Risk of failure to meet the Trusts financial plan due to overspending.
Unable to deliver realistic As described on the BAF medium term financial plan
i) Divisions to implement action plans and contingencies to control/or recover overspending. Specific action is required in all Divisions. ii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing). 1)Items referred to in 5.A.1 and 5.A.2 above 2)V3.0 long term financial model and integrated business plan completed (submitted to TDA in February 2014) V4.0 now approaching completion 3)TDA Plan submitted January 2014 4) Timetable for refreshed IBP and LTFM going forward is part of national planning guidance (next iteration due 20 June)
16
15
5
5
5
3 15
3 15
3 15
RTT Access Standards
Patient Safety
Holden, Des
CORP
23/01/2013
Safety
1) EDD Patient Pathway 2) Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt
Involvement of Service Users Involvement of Service Users
Patient admitted to the right bed first time
Risk of outbreak of viral gastroenteritis
1401
Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care.
20
Service Access
Stevenson, Angela Stevenson, Angela Stevenson, Angela
CORP
29/08/2013 19/09/2013
CORP CORP
23/03/2015
Responsiveness Responsiveness Responsiveness
1678
1501
1491
Failure to maintain Emergency Department performance
If the Trust does not maintain and improve ability to allocate the right bed first time there is an increased risk of receiving poor quality of our care (effectiveness, experience and safety)
1) Operational meeting three times a day chaired by AD Site Services with clinical involvement from Matrons, Nurse Specialists and therapists 2) Daily Board rounds by clinical site team. Focusing on #NOF, Stroke and Medical outliers 3) Live 'To come In' lists available to view in all specialty wards to encourage active pull of patients from AMU to the correct specialty bed 4) Matrons review ward areas on a daily basis 5) Matron on site 7 days a week
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
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
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.
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.
9
15
16
4
3
3
3
4 16
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 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.
31/03/2016 30/09/2015 14/12/2015 31/01/2016 31/12/2015
31/03/2016 30/09/2015 14/12/2015 Ongoing 31/12/2015
As described on BAF 27/06/2014 Reviewing compliance to establish a 31/08/2015 key baseline target 18/01/2016 Build an integrated discharge unit to increase community capacity
31/03/2014 23/11/2015
31/03/2016
Manage the number of IPs booked on lists to avoid cancellations Improve Theatre Utilisation Ring-fencing of Tandridge and Woodland Wards
27/02/2015 20/06/2015 15/05/2015
09/02/2015 05/08/2015 18/09/2015
31/03/2016
Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing 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 Care Stakeholders meeting to discuss health system norovius planning Monitor use of ED risk assessment for patients admitted with diarrhoea and/or vomiting Monitor ward refurbishment programme 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 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2015 22/09/2014 31/03/2014 30/03/2013 25/09/2013 31/01/2013
06/12/2013 26/07/2013 26/07/2013 02/09/2013 11/02/2014 06/12/2013 20/03/2015
31/03/2016
5 15
5 15
5 15
22/09/2014 21/05/2014 26/07/2013 25/09/2013 26/07/2013
Staffing - general
Parker, Yvonne
CORP
01/02/2015
Workforce
1672
Sickness Absence Levels with impact on day to day management and expenditure
Continuing risk to the delivery of effective services and Trust Strategic Objectives caused by the resources required to actively manage the Trusts rising Sickness Absence rate and ensure safe services. This is also having a significant effect on the ability to control the Trusts temporary staffing costs.
Firstcare real time sickness absence monitoring reports and daily updates to managers inbox. Daily sit reps at ward level used to ensure shift by shift safe levels of service. eRostering software to manage rota's prospectively. Agency PMO.
15
3
5 15
Actions described in the Agency 29/02/2016 PMO 29/02/2016 Focused interventions to support the Trust's Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)
31/03/2016
TRUST BOARD IN PUBLIC
Date: 25 February 2016 Agenda Item: 2.1
REPORT TITLE:
Patient Story
EXECUTIVE SPONSOR:
Fiona Allsop, Chief Nurse
REPORT AUTHOR (s):
Debbie Mayne – Matron Theatres
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval ()
Discussion (√)
Assurance ()
Purpose of Report: To provide an update on actions undertaken relating to WHO Safety Surgical Checklist following a Never Event in Theatres in 2015. Summary of key issues The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of care. Part of this initiative was to introduce a surgical safety checklist for use in perioperative environments. The checklist highlights generic core safety standards that may be applied to all perioperative settings and forms part of the 5 steps to safer surgery (NPSA, 2010). The investigation following the Never Event highlighted that: • Using the WHO Surgical Safety Checklist did not prevent the occurrence of a Never Event • Monthly audit of the WHO Checklist, suggested that 100% of patients have a completed checklist and questioned the validity of this audit Actions taken as a result included • Dedicated governance education • Review of WHO Surgical Safety Checklist Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about 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
Yes
Financial impact
Yes
Patient Experience/Engagement
Yes
Risk & Performance Management
Yes
NHS Constitution/Equality & Diversity/Communication
Yes
Attachment: Patient Story Presentation
2 An Associated University Hospital of Brighton and Sussex Medical School
Theatre Patient Story Review of the WHO Surgical Safety Checklist
An Associated University Hospital of Brighton and Sussex Medical School
Background •
A patient was scheduled for and had consented to ‘Total laparoscopic hysterectomy and left salpingooopherectomy, plus excision of endometriosis’
•
A Never Event occurred: The patient also had her right ovary and fallopian tube removed during the procedure
•
The event was not reported at the time. Trust managers only became aware, when the patient made a complaint a week after the procedure
•
The patient expressed her concern to theatre matron and the lead investigator that this could happen again
After event review â&#x20AC;˘
The after event review meeting reviewed the various steps that contributed to the incident taking place
â&#x20AC;˘
This included but was not limited to the use of the WHO Surgical Safety Checklist
The WHO Surgical Safety Checklist
The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of care
The launch saw the introduction of a new surgical safety checklist for surgical teams to use in perioperative environments as part of a major drive to make surgery safer worldwide (DH, 2008)
The NPSA (2009) has adapted this checklist for use in England and Wales and it is intended for use with all patients undergoing surgical procedures.
The checklist highlights generic core safety standards that may be applied to all perioperative settings and forms part of the 5 steps to safer surgery (NPSA, 2010)
The 5 Steps to Safer Surgery 1. The pre-operative briefing 2. The sign-in phase 3. The timeout 4. The sign-out phase 5. The de-brief
The AAR found that: the pre-operative briefing took place the sign-in took place in the anaesthetic room; patient identity and the correct, consented procedure were accurately confirmed
the time-out step was completed the sign-out was completed but largely unremarkable there was no debrief at the end of the list
Concerns •
Using the WHO Surgical Safety Checklist did not prevent the occurrence of a Never Event
•
Monthly audit of the WHO Checklist, suggests that 100% of patients have a completed checklist, so: • Is the checklist completed as a tick box exercise rather than a tool to ensure safety? • The theatre team are not giving safety a high enough priority
Actions Development of the theatre vision to foster team building Identification of team objectives to develop ownership by theatre team Identification of team behaviours These activities led to the identification of safety as a priority among theatre teams Dedicated governance afternoon sessions to raise awareness of:
Never events What is an incident? How to report incidents Responsibility for reporting
Actions Review of WHO Surgical Safety Checklist by matron and lead for practice development First draft shared with theatre team leaders Subsequent drafts shared at ‘WHO Clinics’ on governance afternoons - feedback given by theatre teams Feedback invited via clinical leads, divisional meetings and two week pilot
The current WHO Surgical Safety Checklist
Surgical Safety Checklist
The differences Key steps highlighted with colour Lead for each step is described Questions simplified Change in staff between step 1 and 2 recorded Specific record of incidents and responsibility for reporting
Next steps New checklist in use in operating theatres at ESH and CSSU by 1 April 2016
two week audit of theatre team engagement with use of current and new checklist
Review brief and debrief forms Develop specialism specific safety checklists
TRUST BOARD IN PUBLIC
Date: 25 February 2016 Agenda Item: 2.2
REPORT TITLE:
Chief Nurse & Medical Director Report 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 • • •
The Safer Staffing report (January 2016 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. The current progress on nursing recruitment is outlined. Information is provided outlining the proposal for an intermediate care role which sits between the role of a Care Assistant with a Care Certificate and a graduate Registered Nurse.
Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about 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
Yes
Financial impact
Yes
Patient Experience/Engagement
Yes
Risk & Performance Management
Yes
NHS Constitution/Equality & Diversity/Communication
Yes
Attachment:
2 An Associated University Hospital of Brighton and Sussex Medical School
Chief Nurse/ Medical Director Report – 25 February 2016 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, a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2.
Staffing Planned versus Actual – January 2016
Ward
Ward Specialty
Entries RN Day
RN Night NA Day
NA Night
Total Day
Total Night
Overall
Abinger Ward
430 - GERIATRIC MEDICINE
31
94%
100%
89.98%
100%
91.86%
100%
94.83%
Acute Medical Unit
300 - GENERAL MEDICINE
31
96.76%
98.16%
90.57%
95.16%
94.94%
97.07%
95.89%
Birthing Centre
501 - OBSTETRICS
31
100%
82.26%
N/A
N/A
100%
82.26%
91.13%
Bletchingley Ward
300 - GENERAL MEDICINE
31
97.83%
100%
95.6%
100%
96.77%
100%
98.05%
Brockham Ward
502 - GYNAECOLOGY
31
95.27%
91.4%
93.44%
109.68%
94.67%
95.97%
95.19%
Brook Ward
100 - GENERAL SURGERY
31
100%
98.39%
89.85%
N/A
96.51%
98.39%
97.25%
Buckland Ward
101 - UROLOGY
31
95.32%
100%
92.77%
98.36%
94.41%
99.19%
96.18%
Burstow Ward
501 - OBSTETRICS
31
96.46%
81.72%
98.88%
98.39%
97.27%
88.39%
93.23%
Capel Annex l Ward
100 - GENERAL MEDICINE
31
99.19%
100%
97.48%
98.39%
98.46%
99.19%
98.72%
Capel Ward
430 - GERIATRIC MEDICINE
31
96.94%
98.91%
104.14%
96.83%
99.61%
98.06%
98.93%
Chaldon Ward
300 - GENERAL MEDICINE
31
93.12%
96.77%
98.4%
95.7%
95.37%
96.13%
95.63%
Charlwood Ward
301 - GASTROENTEROLOGY
31
91.66%
96.43%
100%
94.64%
94.63%
95.54%
94.97%
Copthorne Ward
301 - GASTROENTEROLOGY
31
100%
100%
100%
98.39%
100%
99.19%
99.68%
Coronary Care Unit
320 - CARDIOLOGY
31
89.2%
98.36%
N/A
100%
90.28%
98.9%
94.54%
Delivery Suite
501 - OBSTETRICS
31
98.36%
96.77%
96.7%
98.39%
97.95%
97.18%
97.56%
Discharge Lounge
300 - GENERAL MEDICINE
31
90.38%
96.77%
96.49%
93.55%
93.39%
95.16%
94.01%
Godstone Ward (Haem)
303 - CLINICAL HAEMATOLOGY
31
100%
100%
N/A
N/A
100%
100%
100%
Godstone Ward (Med)
300 - GENERAL MEDICINE
31
94.84%
100%
102.15%
101.08%
97.58%
100.54%
98.85%
Hazelwood
300 - GENERAL MEDICINE
31
100.7%
98.39%
97.78%
98.39%
99.26%
98.39%
98.91%
Holmwood Ward
320 - CARDIOLOGY
31
97.84%
100%
95%
101.61%
97.05%
100.81%
98.42%
TU/HDU
192 - CRITICAL CARE MEDICINE
31
98.88%
99.47%
84.91%
93.33%
96.84%
99.01%
97.87%
Leigh Ward
110 - TRAUMA & ORTHOPAEDICS
31
101.17%
101.61%
94.68%
94.44%
98.27%
97.37%
97.93%
Meadvale Ward
430 - GERIATRIC MEDICINE
31
88.06%
100%
98.39%
100%
93.46%
100%
95.65%
Neonatal Unit
420 - PAEDIATRICS
31
96.15%
100.79%
98.56%
90.32%
96.89%
97.34%
97.1%
3 An Associated University Hospital of Brighton and Sussex Medical School
Newdigate Ward
110 - TRAUMA & ORTHOPAEDICS
31
93.94%
98.39%
106.2%
95.65%
99.03%
96.75%
98.16%
Nutfield Ward
430 - GERIATRIC MEDICINE
31
94.69%
100%
100%
100%
96.62%
100%
97.73%
Outwood Ward
420 - PAEDIATRICS
31
95.08%
96.24%
83.18%
80.65%
93.73%
94.01%
93.85%
Rusper Ward
501 - OBSTETRICS
31
100%
100%
N/A
N/A
100%
100%
100%
Surgical Assessment Unit
100 - GENERAL SURGERY
31
97.58%
98.39%
96.77%
100%
97.42%
99.19%
98.21%
Tandridge Ward
300 - GENERAL SURGERY
31
94.09%
100%
94.09%
98.39%
94.09%
99.19%
95.72%
Tilgate Annex
100 - GENERAL MEDICINE
31
96.77%
100%
99.67%
98.39%
97.84%
99.2%
98.3%
Tilgate Ward
300 - GENERAL MEDICINE
31
102.75%
110.71%
101.14%
110.71%
102.16%
110.71%
104.96%
Woodland Ward
100 - GENERAL SURGERY
31
92.16%
93.33%
105.38%
95%
97.15%
94.17%
96.17%
96.42%
98%
97.05%
97.6%
96.63%
97.85%
97.12%
Total
Commentary The Trust has delivered planned versus actual staffing profile for January. The report in January shows an improving picture in relation to overall compliance which is up 0.6% and also in individual areas with no red shifts at unit level in month. Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing and the first cohort of staff of 10 staff have commenced in the Trust. In addition 6 trained nurses have also commenced from the EU bringing the total number of international nurses to commence in the organisation to approximately 60 since July 2015. Nurse Associate Role Consultation Health Education England (HEE) released a consultation document on 29 January which outlines proposals to develop the role of Nursing Associate. HEE is seeking views on the new role intended to sit between a Care Assistant with a care Certificate and a graduate Registered Nurse. In particular views are sought to; • • • • •
Identify the principles for the proposed new care role. Consider the learning outcomes that will need to be assessed to assure quality, safety and public confidence in the proposed role. Identify what academic achievement would be required, alongside the practical skills and how this learning should be best delivered and assessed. Consider whether or not the proposed role should be regulated – and if so, how and by whom Agree the title of this new role.
The proposed new role is intended to enable flexibility across the nursing and care workforce to ensure safe, high quality care and the principles of the proposed new role that it is: • Firmly grounded in direct care provision working with patients, families and carers within communities • Able to deliver care in a range of settings • Able to work across a range of population groups and conditions to a defined level of competence with a greater emphasis on community and public health perspectives • Aware of their boundaries of competence and expertise
4 An Associated University Hospital of Brighton and Sussex Medical School
•
Able to work within multidisciplinary teams.
The anticipated benefits to the wider nursing and care workforce are seen as: • Freeing up Registered Nurse capacity to concentrate on expert patient care, with time for high quality preparation, interaction, communications, planning and assessment, raising their status and enhancing the patient experience. • Recognising the importance of career progression for Care Assistants (working with the professional regulators to develop a career progression pathway for the current workforce into an undergraduate nursing programme which, if approved, would allow for recognition of accreditation of prior learning thereby enabling an accelerated route from a Nursing Associate to Registered Nurse). • Widening of the nursing career framework enabling progression from apprenticeship to senior nurse level, with opportunities to step “off and on”. • A flexible and portable skillset that enables care provision across health and care settings. Parameters of the role The proposed scope of practice is focused on the delivery of the fundamental aspects of direct care. Its purpose is to improve standards of care, offer a new route into nursing and provide a higher skilled worker to enhance the current workforce. The Nursing Associate will work under the leadership of the Registered Nurse. HEE has stated that the role will be piloted across 30 sites in 2016 and SASH has expressed an interest to be one of the pilot sites. Responses are due by 11 March. 3. Recommendation To note the report
Fiona Allsop Chief Nurse 25 February 2016
5 An Associated University Hospital of Brighton and Sussex Medical School
Date: 25th February 2016
TRUST BOARD IN PUBLIC
Agenda Item: 2.3 REPORT TITLE:
SQC Chair Update Richard Shaw, Chair Safety & Quality Committee Richard Shaw, Chair Safety & Quality Committee
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
n/a
Action Required: Approval ()
Discussion ( )
Assurance (ď&#x192;ź)
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 February 2016. Recommendation: N/A Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact
Compliance with CQC, MHRA and Audit Commission
Financial impact
Serious incidents often become claims
Patient Experience/Engagement
Included in the report
Risk & Performance Management
Reporting, investigation and learning from serious incidents informs risk management
NHS Constitution/Equality & Diversity/Communication
Included in the report
Attachment: N/A
Trust Board Report â&#x20AC;&#x201C; 25th February 2016 Safety and Quality Committee Chairâ&#x20AC;&#x2122;s Report The Safety and Quality Committee met on 4th February 2016. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Quality Report. Once a quarter the Committee focuses on quarterly reports covering priority areas for assurance, including Infection Control, Adult and Children Safeguarding, Incidents and Complaints, and all of these items were considered at the February meeting. ECQRM and Quality Report The Committee noted that most of the quality risks for the Trust are well documented and discussed, and primarily relate to the pressure on the hospital of increasing patient numbers, especially in A&E, in admission to an appropriate ward, and in timely discharge to the community. An exception to this pattern is VTE. The Committee noted that the VTE target was met in December and asked for a report at a future meeting on the progress that has been made and the outstanding challenges. The Committee also noted the recent discussion about Falls at ECQRM. This is a topic that has received a lot of attention during the last year or so, but while the incidence of Falls initially decreased, there have been more recent signs of this trend plateauing. The Falls Lead is also changing so it is a good moment to review the approach within the Trust. SQC asked for a report at the March meeting. The Committee was pleased to note that all Cancer metrics were met in December after a challenging autumn. An invitation to attend SQC was re-issued to the CCG, with the comment that attendance could provide a useful additional source of assurance about SASH services. Complaints The Trust is piloting a new process for managing complaints which is designed to ensure there is clear accountability for addressing each point in the complaint and that a clear record of learning and improvements in patient experience is drawn out. Each complainant will be telephoned within three days of the complaint being received. The Committee welcomed this approach. It also expressed concern at the drop off in reports from PALS and was assured that a review of the future direction of PALS is taking place. Incidents The Committee probed the reasons for the length of time it takes to open and close some investigations into incidents. It was assured that the most severe incidents are flagged up to senior management and that incident management will now be added to the Dashboard as an indicator of safety culture in the Trust. Safeguarding The Trust is an outlier locally in the reporting to Surrey Police of missing persons: we report a higher number than other acute trusts. Work is taking place with Surrey Police to understand whether this reflects differences in risk or reporting. The Committee takes good assurance from the handling of adult safeguarding concerns raised about the Trust. But it remains unsighted on how the much larger number of concerns raised about community care are dealt with. Information about this will be included in future reports. The Committee also probed compliance with training in adult safeguarding, and a report on this will be taken to Finance and Workforce Committee.
In Children’s Safeguarding, the Committee welcomed the new multi-agency hub now in place for Surrey and Sussex and hoped that this would provide effective support for collaborative working. It also noted the challenging volume of work in the action plan and will monitor progress in delivering it. Mental Health Ahead of the recent national report on mental health services, the Committee welcomed the decision to nominate a Board-level lead in Mental Health and will take regular reports on the Trust’s work in this area. Infection Control The Committee received a half-year report on Infection Control. There have been two cases of MRSA blood stream infection in the last year, against a target of zero, and the Committee took time to understand the particular circumstances of each case. Of 24 cases of CDiff that have been reviewed, two were judged to have involved lapses of care on behalf of the Trust; although in neither case did this cause the infection. Nine other cases are yet to be reviewed. The Trust will face financial penalties if it exceeds 15 lapses of care in this financial year, and the Committee therefore took reasonable assurance from this. The Committee has previously probed the effectiveness of alerts on Cerner. Infection Control nurses put alerts on Cerner where patients are at risk of MRSA or CDiff. Clinical l staff are expected to check this as it may affect treatment options and bed allocation. A snapshot audit found that not all clinical staff were aware of the alerts and some wards, with high turnover, were not using the white boards effectively in relation to alerts. . The Committee asked for this to be discussed at the next meeting of the Infection Control meeting and the outcome of the discussion to be reported to ECQRM. Next Meeting The next SQC meeting is at 2pm on 3rd March.
Richard Shaw Non-Executive Director Chair – Safety & Quality Committee February 2016
Integrated Performance Report M10 â&#x20AC;&#x201C; January 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
1
Performance – January 2016 Patient Safety • There were three SIs declared in January 2016 and no Never Events. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and two Trust acquired C-Diff cases in January 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 not achieved with performance of 92.8% in January 2016 (YTD Performance is 95%)
• All Cancer Access Standards except the TWR Breast Symptomatic and the 62 Data Referral to treatment standards were achieved in January 2016 • 18 Weeks RTT - The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month. Patient Experience • In December 2016 the Inpatient FFT increased to 97.4%. The ED FFT decreased to 95.8% Workforce • The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local and overseas recruitment. • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Agency usage reduced in January, but the Trust is adverse to its agency trajectory.
An Associated University Hospital of Brighton and Sussex Medical School 2
Performance – January 2016 Finance • The Trust forecast has worsened to a £(4.2)m deficit (after donated asset technical adjustments), as the anticipated reimbursement from the TDA in respect of lost income resulting from the Junior Doctors industrial action has not materialised. This position also includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). The YTD variance to the forecast is £0.4m adverse. Key Risks • The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Increasing sickness absence levels 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
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
No of Never Events in month
0
0
1
1
0
0
0
0
0
0
0
0
0
No of medication errors causing Severe Harm or Death
0
0
0
0
0
0
0
0
0
0
0
0
0
Safety Thermometer - % of patients with harm free care (all harm)
93.0%
92.0%
92.0%
91.3%
93.5%
92.0%
95.0%
92.2%
93.2%
95.4%
90.3%
92.6%
91.2%
Safety Thermometer - % of patients with harm free care (new harm)
96.0%
95.0%
96.0%
95.9%
97.3%
95.2%
97.7%
94.8%
96.7%
97.6%
95.0%
96.2%
95.1%
Percentage of patients who have a VTE risk assessment
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
TBC
WHO Checklist Usage - % Compliance
96%
96%
100%
98%
100%
98%
96%
100%
100%
100%
100%
100%
100%
5
6
5
3
3
6
1
1
4
6
2
7
3
Serious Incidents - No per 1000 Bed Days
0.26
0.35
0.26
0.16
0.16
0.33
0.05
0.05
0.23
0.32
0.11
0.38
0.16
Percentage of Patient Safety Incidents causing Severe harm or Death
0.6%
0.7%
0.6%
0.2%
0.6%
0.5%
0.0%
0.2%
0.8%
0.6%
0.4%
0.8%
0.8%
1
1
0
0
0
0
0
0
0
0
0
0
0
Number of Sis
Number of overdue CAS and NPSA alerts
Trend
• Patient safety indicators continue to show expected levels of performance. • There were no Never Events reported in January 2016. • VTE risk assessment performance for January 2016 is undergoing validation - performance of 95% is expected. A dedicated session of the Executive Committee for Quality and Risk will focus on VTE including the systems for recording assessment completion • Safety Thermometer (all Harm) – performance decreased to 91.2% driven by an increase in patients with Catheters / UTIs (3.1% / 19 patients compared to 2% in December 2015)
An Associated University Hospital of Brighton and Sussex Medical School 4
Patient Safety Three SIs were declared in January 2016 (in all cases full investigations have been started): • 2016/559 Fall (Newdigate) Patient had an unwitnessed fall which resulted in a fractured neck of femur. • 2016/618 Diagnostic Incident – delay Patient with a diagnosis of bowel cancer was admitted for an elective laparoscopic right hemi colectomy on 26th March 2015; patient was transferred post operatively to ICU and died on 30th March 2015. Post mortem found cause of death to be sepsis. • 2016/1212 Fall (ED) The patient was found on the toilet floor having sustained an unwitnessed fall, the patient later reported that he had slipped. An x-ray confirmed fracture to the left hip, shoulder and hand. Infection Control Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
MRSA BSI (incidences in month)
0
1
0
0
0
0
0
0
0
0
1
0
0
CDiff Incidences (in month)
2
6
1
1
3
3
4
3
2
6
2
6
2
MSSA
0
2
1
1
0
1
0
0
0
3
0
0
0
E-Coli
14
18
12
11
23
20
18
34
27
29
18
23
22
Trend
• There were no cases of MRSA in January 2016 and two cases of Trust acquired C.diff. • There was no outbreak in January, but in light of the 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 5
Clinical Effectiveness Mortality and Readmissions Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
HSMR (56 Monitored diagnoses - 12 Months)
92.8
92.6
93.4
93.0
95.0
95.1
93.8
943.0
95.7
95.3
Emergency readmissions within 30 days (PBR Rules)
6.9%
6.7%
6.6%
6.4%
7.0%
7.2%
7.7%
7.4%
7.3%
6.3%
Nov-15
Dec-15
6.3%
6.9%
Jan-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
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
C Section Rate - Emergency
18%
16%
17%
13%
17%
18%
14%
17%
17%
14%
15%
16%
17%
C Section Rate - Elective
7%
11%
8%
11%
9%
10%
11%
13%
8%
13%
10%
9%
9%
6.0%
6.0%
6.0%
7.0%
6.2%
4.0%
5.0%
5.1%
5.8%
7.1%
6.6%
5.9%
3.8%
Admissions of full term babies to neo-natal care
Trend
â&#x20AC;˘ Maternity indicators continue to show expected performance.
An Associated University Hospital of Brighton and Sussex Medical School 6
Access and Responsiveness Emergency Department Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
92.0%
91.3%
95.0%
96.8%
96.0%
94.8%
94.3%
96.1%
97.1%
95.5%
92.9%
95.5%
92.8%
0
0
0
0
0
0
0
0
0
0
0
0
0
Ambulance Turnaround - Number Over 30 mins
163
259
247
199
170
206
238
220
225
225
231
191
227
Ambulance Turnaround - Number Over 60 mins
26
51
31
19
34
38
32
30
29
31
30
10
21
ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA
Trend
• The ED 4hr standard was not achieved in January 2016 with performance of 92.8%. • Volumes /Acuity of emergency attendances / admissions continue to be an issue and with overnight non-elective admissions up 7% (3% for East Surrey CCG and 16% for Crawley CCG) compared to last year. • Discharge delays are also a significant driver of performance with an average of 114 beds occupied by patients who are medically ready for discharge • Despite the positive work taken on the Ambulance handover process, Ambulance turnaround performance showed an adverse movement in January 2016 driven by volumes of Ambulance attendances. • 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 7
Access and Responsiveness Cancer Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Cancer - TWR
93.1%
93.1%
93.1%
93.3%
94.2%
93.1%
93.1%
93.0%
89.6%
89.9%
93.2%
94.3%
93.0%
Cancer - TWR Breast Symptomatic
93.4%
96.3%
93.8%
93.8%
93.8%
90.6%
93.2%
93.3%
94.2%
93.8%
93.4%
96.2%
90.7%
Cancer - 31 Day Second or Subsequent Treatment (SURGERY)
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
95.0%
Cancer - 31 Day Second or Subsequent Treatment (DRUG)
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Cancer - 31 Day Diagnosis to Treatment
97.1%
100.0%
100.0%
98.2%
97.0%
96.2%
98.3%
99.2%
99.3%
98.2%
96.6%
92.4%
97.6%
Cancer - 62 Day Referral to Treatment Standard
85.4%
88.0%
83.7%
86.4%
83.9%
86.5%
80.7%
84.2%
86.2%
85.6%
88.3%
85.8%
80.4%
Cancer - 62 Day Referral to Treatment Screening
92.3%
100.0%
92.3%
84.6%
92.3%
100.0%
87.5%
88.9%
100.0%
87.5%
90.9%
100.0%
100.0%
Trend
• In January 2016, all Cancer Access Standard except the TWR Breast Symptomatic and the 62 Data Referral to treatment standards. • On the Breast Symptomatic pathway, 10 patients breached the standard. This was driven by patient deferrals in December resulting in attendance over two weeks in January. • 18 patients (14.5 breaches) breached the 62 Day Referral to Treatment Standard across a range of pathways (Urology – 4 breaches, Skin – 3 breaches). Root cause analysis is being undertaken of all breaches to ensure pathway improvements are made and any capacity issues / internal delays are resolved.
An Associated University Hospital of Brighton and Sussex Medical School 8
Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
92.1%
94.0%
93.7%
93.6%
93.5%
92.6%
92.2%
92.0%
92.1%
92.2%
92.5%
92.1%
92.0%
0
0
0
0
0
0
0
0
0
0
0
0
0
RTT Admitted - 90% treated within 18 weeks
90.2%
82.1%
88.4%
91.6%
90.1%
92.0%
84.0%
81.5%
77.9%
78.5%
80.7%
81.1%
78.1%
RTT Non Admitted - 95% treated within 18 weeks
91.7%
91.0%
93.5%
93.6%
95.3%
93.4%
89.4%
89.1%
88.7%
87.9%
85.2%
85.4%
85.2%
Percentage of patients w aiting 6 weeks or more for diagnostic
0.9%
0.7%
1.4%
1.0%
0.2%
0.8%
1.0%
0.1%
0.5%
0.2%
0.2%
0.1%
0.0%
18
26
45
11
37
45
24
25
44
41
133
54
90
0.0%
0.0%
0.0%
0.0%
0.0%
2.2%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
RTT Incomplete Pathways - % waithing less than 18 weeks RTT Patients over 52 weeks on incomplete pathways
Last Minute Elective Cancellations for non clinical reasons % 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 which measures % of patients waiting less than 18 weeks at the end of each month. • Challenges remain in General Surgery, Trauma and Orthopaedics and Cardiology. A number of newly recruited consultants will increase capacity and support reduction in patients over 18 weeks with performance expected to improve over the coming months. • The diagnostic standard continues to be achieved • 90 patients were cancelled at the “last minute” for non clinical reasons, the increase on December being due to bed pressures • The following risk is 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. (effectiveness, experience and safety) – Risk score 15 (Likelihood of 5 and consequence of 3)
An Associated University Hospital of Brighton and Sussex Medical School 9
Patient Experience Patient Voice Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Inpatient FFT - % positive responses
95.7%
96.9%
94.2%
94.4%
95.1%
94.7%
95.1%
95.3%
96.1%
95.0%
95.1%
95.1%
97.4%
Emergency Department FFT - % positive responses
95.8%
97.1%
94.7%
95.4%
95.3%
93.7%
91.4%
95.8%
96.9%
95.3%
97.3%
97.5%
95.8%
Maternity FFT - Antenatal - % positive responses
97.6%
97.1%
97.0%
96.3%
100.0%
83.3%
94.1%
98.8%
94.3%
96.5%
96.1%
96.0%
97.5%
Maternity FFT - Delivery - % positive responses
95.5%
97.2%
100.0%
94.7%
97.0%
94.9%
93.8%
87.9%
95.4%
95.1%
97.6%
91.7%
95.5%
Maternity FFT - Postnatal Ward - % positive responses
85.9%
91.0%
97.3%
86.7%
91.0%
86.5%
90.0%
87.7%
87.9%
88.9%
88.8%
88.9%
88.4%
0
0
0
0
0
0
0
0
0
0
0
0
0
18
26
22
25
22
27
29
33
27
24
19
17
27
Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)
Trend
• Inpatients – The January Friends and Family Test (FFT) score for inpatient wards has increased slightly to 97.4%, based on a slightly increased response rate of 34% (compared to 30% in December). • Emergency Department – The January FFT score has dropped slightly to 95.8%. The response rate remains stable at 20%. • Maternity – FFT scores for both the antenatal and birth touchpoints have increased to 97.5% and 95.5% respectively. The antenatal score is based on a marked improvement in the response rate, up to 23% compared to 13% in December. This brings the response rate in line with that achieved for touchpoints two and three. The FFT score for the touchpoint three has remained very similar for the last four months National comparisons for December • Inpatients/daycases – The Trust was ranked average (95.4% against a national average of 95.3%). The combined response rate was below average (18.0% compared to 22.6%). • Emergency Department – Of those trusts with a response rate of greater than 2% SASH is ranked second, based on an above average response rate (19% compared to a national average of 13%). • Maternity – The Trust score for touchpoint one is in line with the national average. For touchpoints two and three the Trust’s score is below average
An Associated University Hospital of Brighton and Sussex Medical School
10
Workforce Workforce Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Average fill rate – registered nurses/midwives (%) - Day
94.8%
95.9%
96.5%
96.8%
95.7%
96.9%
93.3%
92.5%
95.0%
95.1%
95.4%
95.1%
96.3%
Average fill rate – care staff (%) - Day
92.6%
93.8%
94.5%
96.1%
93.8%
93.5%
94.3%
94.5%
95.1%
97.2%
98.7%
97.1%
97.0%
Average fill rate – registered nurses/midwives (%) - Night
97.2%
97.7%
96.7%
96.5%
97.1%
94.1%
95.2%
94.3%
96.4%
96.9%
97.2%
97.9%
98.0%
Average fill rate – care staff (%) - Night
93.3%
94.9%
94.9%
95.2%
95.9%
94.9%
94.4%
93.8%
96.4%
96.9%
97.8%
98.2%
97.6%
Overall Sickness Rate
4.3%
4.4%
4.2%
4.2%
4.3%
4.1%
3.9%
3.7%
4.4%
4.4%
4.0%
3.8%
3.8%
%age of staff who have had appraisal in last 12 months
67%
68%
73%
71%
68%
58%
56%
57%
64%
72%
74%
74%
72%
15.7%
15.7%
15.2%
15.5%
15.9%
15.6%
15.6%
15.2%
15.2%
15.0%
14.4%
13.8%
13.8%
Staff Turnover rate
Trend
• Sickness absence remained at 3.8% in January 2016, 0.5% less than the prior year. • The increasing trend on sickness absence levels which impacts on day to day management and expenditure remains on the Trust’s significant risk register – Risk score 15 (Likelihood of 5 and consequence of 3) • Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and is discussed on a weekly basis. Activity around international recruitment continues. • Agency usage reduced in January, with a favourable impact from new bank arrangements in theatres, but the Trust is adverse to its agency trajectory. • Staff Turnover fell remained at 13.8% in January 2016 as initiatives to improve retention and staff experience take effect. • 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 11
Finance Indicator Description
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Outturn £m Surplus / (Deficit) - Plan
2.3
2.3
2.3
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
Outturn £m Surplus / (Deficit) - Forecast
2.3
(2.5)
(2.4)
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6
(3.0)
(4.2)
YTD £m Surplus / (Deficit) - Plan
1.9
1.4
2.3
(0.8)
(1.2)
(2.0)
(1.1)
(0.7)
(0.6)
(2.0)
(2.0)
(1.3)
(0.6)
YTD £m Surplus / (Deficit) - Actual
1.9
(2.9)
(2.4)
(0.8)
(1.1)
(2.0)
(1.3)
(2.6)
(3.3)
(3.6)
(4.2)
(5.3)
(3.9)
Outturn UNDERLYING £m Surplus / (Deficit) - Plan Outturn UNDERLYING £m Surplus / (Deficit) - Actual YTD Savings £m - Actual OT Risk £m Surplus / (Deficit) - Assessment Outturn Cash position £m Fav / (Adv) - Forecast YTD Cash position £m Fav / (Adv) - Actual
3.4
3.4
3.4
3.8
3.8
3.8
3.8
3.8
3.8
3.8
3.8
3.8
3.8
(5.2)
(5.2)
(5.2)
3.8
3.3
3.3
3.3
3.3
3.3
3.3
3.3
(6.3)
(6.3)
8.6
9.8
11.0
0.3
0.5
0.8
1.3
1.9
2.1
2.5
2.8
3.2
3.6
(5.5)
(0.7)
0.0
0.0
(1.0)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
2.6
2.6
2.6
7.6
7.6
7.6
2.6
1.2
2.4
2.4
2.4
2.5
2.5
3.8
3.8
2.6
3.2
2.9
2.6
2.5
3.0
3.9
4.8
5.0
5.7
4.5
YTD Liquid ratio - days
(8.0)
(18.0)
(21.0)
(20.0)
(21.0)
(23.0)
(22.0)
(25.0)
(19.0)
(13.0)
(16.0)
(16.0)
(15.0)
YTD BPPC (overall) volume £m
87%
86%
82%
62%
75%
78%
78%
76%
69%
59%
60%
60%
53%
YTD BPPC (overall) value £m
83%
83%
81%
65%
73%
75%
75%
74%
68%
61%
63%
63%
60%
Outturn Capital spend Fav / (Adv) - forecast
19.3
19.3
19.3
17.1
17.1
17.1
17.1
17.1
17.1
17.1
17.1
14.1
14.1
Trend
• The Trust is reporting against the revised plan submitted to the TDA in September 2015 and the forecast notified to the TDA in December. • The Trust forecast has worsened to a £(4.2)m deficit (after donated asset technical adjustments), as the anticipated reimbursement from the TDA in respect of lost income resulting from the Junior Doctors industrial action has not materialised. This position also includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). The YTD variance to the forecast is £0.4m adverse. • At the end of month 10 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(3.9)m which is £(3.3)m adverse to the revised TDA plan. A £1.5m improvement from last month due to the inclusion of £3m TDA healthcare support income, partially offset by a reduction in elective income due to industrial action. Elective activity has been impacted by emergency activity (as in past months). • The underlying position at the end of January is a £(4.5)m deficit.
An Associated University Hospital of Brighton and Sussex Medical School 12
Finance • The Trust has achieved £3.6m of savings to date (a £2.6m shortfall measured against the TDA plan). The forecast CIP position is £3.5m adverse to the full year plan and this has been factored into the overall Trust forecast.
• The Trust’s cash balance at the end of January was £4.5m, with a forecast year end cash balance of £2.5m. Backlog creditors decreased by £2.0m to £11.3m. The TDA have advised that the Trust’s loan/PDC application will be replaced to an increase to our existing working capital facility. • The capital spend forecast this year has reduced by £3.0m, from £17.1m to £14.1m following an application to TDA for Capital to Revenue transfer which has been approved. • Further risk to the I&E position has been provided by the interpretation applied by CCG’s to a letter issued nationally on 19th January which discusses the suspension of fines. CCG’s appear to wish to continue to levy the fines to improve the CCG position.
An Associated University Hospital of Brighton and Sussex Medical School 13
TRUST BOARD IN PUBLIC
Date: 25 February 2016 Agenda Item: 3.2
REPORT TITLE:
Finance & Workforce Committee Chair Update – Part 1
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 February 2016 and was quorate. •
M10 reports were received for Finance & the 15/16 CIP, Workforce and Organisational Development, Capital and IT.
•
The Trust has year to date I&E deficit of £(3.9m) which is £(3.3m) adverse to the revised TDA plan.
•
The Trust’s cash balance at the end of January was £4.5m, with a forecast year end cash balance of £2.5m
•
The Trust has delivered £3.6m of savings and is behind both the TDA plan and also the internal plan
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
2
TRUST BOARD REPORT –23 February 2016
Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 23rd February 2016 and it was quorate. The key points from Public meeting were:
Finance Performance M10 Report M10 Finance performance report was received by the Committee. The Trust has year to date I&E deficit of £(3.9m) which is £(3.3m) adverse to the revised TDA plan. The Trust’s cash balance at the end of January was £4.5m, with a forecast year end cash balance of £2.5m. The Trust has been granted an extension to its working capital facility which will cover the Trust cash requirements until the end of the financial year. Month 10 CIP report The savings target YTD in the submitted TDA plan for 2015/16 is £6.2m and at month 10 the Trust has delivered £3.6m of savings and is behind both the TDA plan and also the internal plan. Contingency savings of £0.6m have been used to achieve this position. Month 10 Workforce and Organisational Development The paper was received by the Committee. The reported highlighted the results of the staff survey where the Trust scored in the top 20% in the country for 17 of the findings. The Committee discussed the 3 where the Trust was in the bottom 20% and the actions that are being taken to identify the reasons for the scores. The achievement review timetable was shared. Achievement review appraisals will be cascaded down from the executive team with 90% of staff who have been employed at the Trust for more than a year having had their appraisal by the end October. The Committee noted the improvement in the recruitment shown in the report. Month 10 Capital report The Committee noted the completion of the Theatres refurbishment project and the Cardiology Unit. Draft 2016/17 Capital plan The Committee receive the draft Capital Plan. This reflected the reduced scale of funding £9.0m v £17.1 (plan) and £14.1m (forecast) in 15/16. The Committee noted the need to ensure benefits are realised and the greater emphasis on productivity gains to increase capacity. -
The IT report was noted and the Committee.
[END]
An Associated University Hospital of Brighton and Sussex Medical School
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TRUST BOARD IN PUBLIC
Date: 25TH February 2016 Agenda Item: 4.1
REPORT TITLE:
Standards of Business Conduct Policy
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs Joint Consultative Committee 12.1.16 Executive Committee 13.1.16 Audit & Assurance Committee 15.1.16
Action Required: Approval (√)
Discussion (√)
Assurance (√)
Purpose of Report: This policy has been updated to reflect new regulation and overall strengthening processes for the Trust. Summary of key issues This policy is due for review and has been updated with the following requirements (red text): • Updating the Summary short guide for staff – Pg 5 • Inclusion of the Fraud Act 2006 – Pg 7 • Inclusion of the Fit & Proper Person Regulations – Pg 9 • Reference to the Policy for Commercial Representatives – Pg 13 • Reference to the Council of Governors – Pg 13 • Reference to the Drugs & Therapeutic Committee & Medical Devices Group – Pg 14 • Results of failing to making a declaration and the requirement for annual declarations – Pg 14 • Requirements on awarding contracts – Pg 15 • Re-wording of requirements under intellectual property, confidential and sensitive information – Pg 16 • Trust Board responsibility for ratifying the Policy. Recommendation: The Board is asked to Ratify this policy. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about 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 Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication
There are a number of legal and regulatory requirements included in the policy Non-adherence to the policy may have financial impacts on the Trust N/A Adherence to the policy reduces risks to individual members of staff and protects the reputation of the Trust This policy is disclosable under the Freedom of Information Act 2000.
Attachment: Revised Standards of Business Conduct Policy â&#x20AC;&#x201C; Final February 2016
2 An Associated University Hospital of Brighton and Sussex Medical School
Surrey & Sussex Healthcare NHS Trust AN ORGANISATION WIDE POLICY ON STANDARDS OF BUSINESS CONDUCT Draft/revision Key words: Openness, integrity, public funds, gifts, sponsorship, declaration, interests, business, conduct, transparent, hospitality, commercial, accountability
Version:
2.0
Status:
Final Version for Ratification
Date ratified:
12/12/2012
Name of Owner
Director of Corporate Affairs & Director of Human Resources
Name of Sponsor Group
Audit & Assurance Committee
Name of Ratifying Group
Trust Board
Type of Procedural document
Policy
Policy Reference:
To be completed by Policy Coordinator
Date issued:
12/12/2012
Review date:
December 2015
Updated:
February 2016
Review date:
February 2019
Target audience:
All Trust Staff, Volunteers and Agency/Contract workers.
Human Rights Statement
The Trust incorporates and supports the human rights of the individual, as set out by the European Convention on Human Rights and the Human Rights Act 1988
EIA Status Completed (Appendix 7) This policy will be made available in different languages and formats upon request. Requests of this nature should be made to the Patient Advice Liaison Service (PALS) at East Surrey Hospital, whose contact details are provided below: Telephone: 01737 768511 extensions 6922 or 6831 E-Mail: pals@sash.nhs.uk Correspondence: PALS at East Surrey Hospital, Canada Avenue, REDHILL, Surrey, RH1 5RH
The latest approved version of this document supersedes all other versions. Upon receipt of the latest approved versions all other version should be destroyed, unless specifically stated that the previous version(s) are to remain extant. If in any doubt please contact the document owner or Policy Coordinator.
Version Control
Date//Lead
1.1
January 2016 G Francis-Musanu
Comment Updating to include new regulations (FPPT) Revising requirement to submit annual declarations forms Including the Shadow Council of Governors Inclusion of Fraud Act 2006 Reference to the NHS Fraud and Corruption Reporting Line Overall strengthening of the policy
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Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Page No.
Summary Introduction Purpose Public Service Values Scope of Policy Organisational Responsibilities Fit & Proper Persons Test Conflict of Interests Employment external to the Trust Contracts Private Practice Intellectual Property Confidentiality – Sensitive Information Consultation and Communication with Stakeholders Approval and Ratification Review and Revision Dissemination and Implementation Archiving Monitoring and Compliance References Associated Documents
Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7
Brief Overview of Bribery Act 2010 Short Guide to Standards of Business Conduct for NHS Staff HSG (93)5 Form – Declaration of Interests Form – Declaration of Gifts/Hospitality/sponsorship Form – Declaration of Relationship with Candidate Nolan Principles Equality Impact Assessment
5 7 7 8 8 8 9 11 14 15 15 16 16 16 16 17 17 17 18 17 18 19 20 22 23 24 25 26
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Equality statement This document demonstrates commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 to promote positive practice and value the diversity of all individuals and communities. This document is available in different languages and formats upon request to the Trust Procedural Documents Coordinator and the Equality and Diversity Lead.
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Summary - of the Standards of Business Conduct Policy To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s Director of Corporate Affairs holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Director of Corporate Affairs, Trust Headquarters, East Surrey Hospital. Short Guide for staff Do: •
Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) 5) referred to in your terms and conditions of employment and consult your line manager if you are not sure
•
Make sure you are not in a position where your private interests and NHS duties conflict.
•
Declare any relevant interests. If in doubt, ask yourself:
1. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made? 2. Do I have access to information which could influence the Trust’s purchasing or contracting decisions, or could it be perceived by others that I have such access? 3. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could other perceive them to be detrimental? 4. Do I have any other reason to think I may be risking a conflict of interest? IF IN DOUBT – DECLARE IT
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Always : •
Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.
•
Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties.
•
Obtain the Trust’s permission before accepting any commercial sponsorship.
Do Not •
Abuse your past or present official position to obtain preferential rates for private deals.
•
Unfairly advantage one competitor over another or show favoritism in awarding contracts.
•
Misuse or make available ‘commercial in confidence’ information.
•
Accept gifts, inducements or inappropriate hospitality.
Casual gifts offered by Contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to be committing an offence under the Bribery Act. Such gifts should nevertheless, be politely but firmly declined. Articles of low intrinsic value totaling £25 such as diaries or calendars, or small tokens of gratitude from patients or relatives, i.e. chocolates etc. need not be refused. In cases of doubt staff should either consult their line manager or politely decline acceptance. Modest hospitality provided it is normal and reasonable in the circumstances i.e. lunches in the course of working visits may be acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Receipt of such hospitality should be declared. Staff should decline all other offers of gifts, hospitality or entertainment. If in doubt they must seek advice from their line manager and/or declare it.
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1. Introduction Public service values must be at the heart of the National Health Service (NHS). High standards of corporate and personal conduct based on a recognition that patients come first, have been a requirement throughout the NHS since its inception. Moreover, since the NHS is publicly funded, it must be accountable to Parliament for the services it provides and for the effective and economical use of taxpayers’ money (NHS code of conduct: code of accountability in the NHS: Appointments Commission/DOH - 2nd Rev: 2004). The Trust is committed to the highest standards of openness, probity and accountability so that its employees remain beyond suspicion. In addition, under the Bribery Act 2010, it is an offence for any employee to corruptly accept any gifts or consideration as an inducement or reward for: • doing, or refraining from doing anything, in his or her official capacity, or • corruptly showing favor or disfavour, to any person in their official capacity. A brief description of the Bribery Act can be found at Appendix 1. All staff should be aware of the NHS Management Executive Health Service Guidelines on ’Standards of Business Conduct for NHS HSG (93)5 see Appendix 2. Guidance contained within this document referring to the ‘Prevention of Corruption Acts 1906 and 1916’ has been superseded by the Bribery Act 2010. However, much of the information contained within HSG (93) 5 is still relevant and until the document is either updated or replaced by the Department of Health it should still be issued to employees, alongside a ‘Code of Conduct for NHS Managers’ 2002 as it still contains useful guidance. This policy has been written to take account of latest legislation as well as guidance and recommendations received from the Trust’s Local Counter Fraud Specialist, with particular reference to the new provisions under the Bribery Act 2010, which received Royal Assent and is now part of UK Law. www.legislation.gov.uk/ukpga/2010/23/introduction 2. Purpose The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted. The Fraud Act 2006 came into force in 2007 and created three ways of committing an offence of fraud, by false representation, by failing to disclose information and abuse of position. This policy offers guidelines intended to assist employees in being aware they have a duty to demonstrate high ethical standards of both business and personal conduct. Specifically it deals with gifts and hospitality and conflicts of interest to minimise placing themselves in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. All suspected breaches of this policy will be reported to the Local Counter Fraud Specialist for investigation and may result in criminal proceedings being commenced and/or disciplinary action being taken. 7
3. Public Service Values The NHS code of conduct: code of accountability in the NHS (Appointments Commission/DOH - 2nd Rev: 2004) defines three crucial public service values which must underpin the work of the health service. i) Accountability – everything done by those who work in the Surrey and Sussex Healthcare NHS Trust must be able to stand the test of parliamentary scrutiny, public judgments on propriety and professional codes of conduct; ii) Probity – staff should have an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal and professional conduct in decisions affecting patients, colleagues and suppliers and in the use of information acquired in the course of NHS duties; iii) Openness – there should be sufficient transparency about Surrey and Sussex Healthcare NHS Trust’s activities to promote confidence between staff, patients and the public. These Public Service values are in accordance with the Seven Nolan Principles of Public Life. See Appendix 6 4. Scope of Policy This policy applies equitably to all employees of the Trust and includes all those who work for the Trust, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer. 5. Organisational Responsibilities 5.1. Trust Board – Executive and Non Executive Directors The Trust Board must ensure compliance with the NHS Code of Conduct: Code of Accountability (Appointments Commission/DOH – 2nd Rev: 2004), the principles of which are contained in this policy and the reference documents. The Trust Board are responsible for ensuring all Executives, Non Executives and Senior managers complete declaration of interest forms on appointment and that these are reviewed. The Register of Interests is presented to the Trust Board on an annual basis for monitoring purposes and corrective action if appropriate. Any changes to declaration of interests should be made immediately and the CEO must be informed if these changes relate to an Executive Director. The Chairman must be in informed if this relates to a NonExecutive Director. 5.2. Managers Managers must ensure compliance with the NHS Code of Conduct for Managers 2002, the principles of which are contained in this policy and the reference documents. They must ensure all staff under their direction are aware of this policy and the referenced documents. 8
5.3. Employees All employees of, and those who work for, Surrey and Sussex Healthcare NHS Trust have a duty to ensure they are aware of and comply with this policy and referenced documents. In so doing employees and those working for the Trust must: a) ensure the interest of patients remain paramount at all times, b) be impartial and honest in the conduct of their official business and c) use the public funds entrusted to them to the best advantage of the service, always ensuring value for money Employees and those working for the Trust must also ensure that they do not: a) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties - for example to benefit their family and friends, religious belief, professional affiliation or political alignment, personal assets, investments or debts or b) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties for personal gain - for example a business interest, or an opportunity to make a financial profit or avoid a loss. 5.4. Human Resources HR will provide advice and guidance on the interpretation of this policy to managers and staff. 5.5. Trade Unions and Professional Organisations Trade Unions and Professional Organisations are required to be aware of this policy and the referenced documents and to advise staff accordingly. 6. Fit & Proper Person’s Test The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) places a duty on NHS providers not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director (NED) under given circumstances. Providers must not appoint a person to an executive director level post (including associate directors) or to a non-executive director post unless they are: • Of good character; • Have the necessary qualifications, skills and experience; • Are able to perform the work that they are employed for after reasonable adjustments are made; • Can supply information as set out in Schedule 3 of the Regulations (see the Role of the CQC below). Paragraph 5 (4) of regulations states that in assessing whether a person is of good 9
character, the matters considered must include those listed in Part 2 of Schedule 4.’ Part 2 of Schedule 4 refers to: • Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence, and • Whether the person has been erased, removed or struck off a register of professionals maintained by a regulator of health care or social work professionals. The Care Quality Commission’s (CQC) definition of good character is not the objective test of having no criminal convictions but instead rests upon a judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards and councils in reaching a decision and allows for the fact that people can and do change over time. The regulations list categories of persons who are prevented from holding the office and for whom there is no discretion: • The person is an undischarged bankrupt or a person whose estate has had a sequestration awarded in respect of it and who has not been discharged; • The person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; • The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986(40); • The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it; • The person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; • The person is prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment; • The person has been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider. It will be the responsibility of the Chair of the provider to discharge the requirement placed on the provider, to ensure that all directors meet the fitness test and do not meet any of the ‘unfit’ criteria. The CQC expects senior leaders to set a tone and culture of the organisation that leads to staff adopting a caring and compassionate attitude. It is important therefore that in making appointments boards and councils take account of the values of the organisation and the extent to which candidates provide a good fit with those values. The regulations give the CQC powers to assess whether both executive and non-executive directors (but not foundation trust governors) are fit to carry out their role and whether providers have put in place adequate and appropriate to ensure that directors are fit and proper persons. The CQC has the right to require the provision of information set out in Schedule 3 of the Regulations and such other information as is kept by the organisation that is relevant to the individual as follows: •
Proof of identity including a recent photograph. 10
•
Where required for the purposes of an exempted question in accordance with section 113A(2)(b) of the Police Act 1997(38), a copy of a criminal record certificate issued under section 113A of that Act together with, after the appointed day and where applicable, the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on request)(39)
•
Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced criminal record certificate issued under section 113B of that Act together with, where applicable, suitability information relating to children or vulnerable adults.
•
Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to: (a) health or social care, or, (b) children or vulnerable adults
•
Where a person (P) has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why P’s employment in that position ended.
•
In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.
•
A full employment history, together with a satisfactory written explanation of any gaps in employment.
•
Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.
The guidance states the following: (a) ’the appointed day’ means the day on which section 30A of the Safeguarding Vulnerable Groups Act 2006 comes into force; (b) ’satisfactory’ means satisfactory in the opinion of the Commission; (c) ’suitability information relating to children or vulnerable adults’ means the information specified in sections 113BA and 113BB respectively of the Police Act 1997 The Trust has procedures in place to ensure that Directors and Non-Executive Directors are fit and proper persons. 7. Conflict of Interest A ‘conflict of interest’ involves a conflict between the public duty and the private interest of a public service individual, in which a public official’s private interest could improperly 11
influence the performance of their official duties or responsibilities. Situations can arise in which there appears to be a conflict of interest but this is not in fact the case, or may not be the case. This situation is regarded as an “apparent conflict of interest”. Having an “apparent conflict of interest” as a public official, however, can be as serious as having an actual conflict because of the potential for suspicion of the official’s integrity and that of the organisation. An employee may have private interests which may be such as to cause a conflict of interests to arise in the future this is called a “potential conflict of interest”. 7.1 Managing a Conflict of Interest Employees must notify any conflicts, apparent conflicts or potential conflicts, to their Line Manager as soon as they become aware of such conflict and complete a declaration of interest form at Appendix 3. This form will be retained on the Trust’s Register of Interests and a copy retained in the employee’s personal file. . Managers should consider how a conflict of interest be managed. In the first instance advice should be sought from the Chief Financial Officer or Director of Corporate Affairs, where one or more of the following options may be considered: • removal of the interest • removal of the employee from involvement in an affected decision-making process • restriction of access by the employee to particular information • transfer of the employee to duties in a non-conflicting function • re-arrangement of the employee’s duties and responsibilities • assignment of the conflicting interest in a genuinely ‘blind trust’ arrangement. 7.2 Benefits – Gifts, Hospitality and Sponsorship The Trust is required to keep a record of all gifts or hospitality offered and/or received, even when refused. All employees must complete the Declaration of Gifts and Hospitality Form (see Appendix 4) when offered any gift or hospitality, however small. This will be recorded on the Trust’s Gifts and Hospitality Register held by the Director of Corporate Affairs. Sight of the Trust’s Gifts and Hospitality Register is a frequent feature under the Freedom of Information Act and the Trust is obliged to produce this on request. The following guidelines should be followed when offered any gift or hospitality: •
One off casual gifts of low intrinsic value (£25) such as diaries, calendars, pens and such small tokens of gratitude are considered acceptable and do not need to be declared but if multiple gifts of such value (£25) are offered, either at one time or over a period of time, this would not be acceptable, if such offers are made they should be politely but firmly declined and a declaration form completed to confirm declining the 12
offer. •
Gifts above the value of £25 are not acceptable and should be politely but firmly declined and a declaration completed to confirm declining the offer.
•
Modest hospitality is normally considered reasonable e.g. working lunches may be acceptable in the right circumstances.
•
All other offers of hospitality or entertainment should be declined. In cases of doubt employees should either consult their manager, the Chief Financial Officer or else politely decline acceptance.
Employees should only accept commercial sponsorship to attend relevant conferences or courses after they have received advance permission from the Trust by referring the matter to their Line Manager and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. Employees should refer offers of drugs and/or clinical equipment/devices to their Line Manager or Chief Financial Officer and acceptance of the offer can only be made after they have received advance permission from the Trust and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. There are strict guidelines contained in the Policy for Commercial Representatives which should be followed. Employees should also refer to their Line Manager in the first instance and also the Chief Finance Officer when seeking, or being offered, sponsorship funding from an external source towards costs, or for the cost, of a specific event or work programme. 7.3 Declaration of relationship to candidates The Trust Board, Senior Officers, Medical Staff and any other staff involved in the recruitment and selection of candidates must declare the relationship (see Appendix 5). Candidates for any staff appointments must declare if they are related to any employee of the Trust. This includes partners and anyone whose affairs are so closely connected with the affairs of the candidate that a benefit derived by the other person, or a substantial part of it, could pass to the candidate, or could constitute a conflict of interest. A copy of such declaration must be retained on the Personal File (see Appendix 5). 7.4 Declaration of Interests If an employee has interests in any outside business they should declare this to the Trust as their employer. The following are examples of situations where a declaration must be made: •
The individual (or their family or friends) has a financial interest in a business which may compete for a contract to supply goods or services to the Trust
•
The individual has access to information that may influence where the Trust is to place a contract for goods or services
•
The individual has outside interests that may be in any way detrimental to the NHS or to 13
patients’ interest. •
A role or interest undertaken in a capacity which is paid or unpaid which a member of staff wishes to place on record but does not fall into the categories above.
A full list of examples is listed in the declaration of interest forms at Appendix 3. 7.5 Council of Governors As part of our journey to become an NHS Foundation Trust we have elected a shadow council of governors. The shadow council consists of elected and appointed governors. All governors are required to declaration any interest. Declarations are held in the Governors Declaration of Interests Register. 7.6 Pharmacy Staff who present applications for additions to the formulary are required to make a declaration of interest as part of that process. All members of the Drugs and Therapeutic Committee and Formulary committee are asked to make a declaration of interest each time an application is considered by the committee. All declarations are recorded in the minutes of the meeting even if no relevant interest is declared. 7.7 Medical Devices Staff who present applications to the medical devices group are required to make a declaration of interest as part of that process. All members of the Medical Devices Group should make a declaration of interest each time an application is considered. All declarations should be recorded in the minutes of the meeting even if no relevant interest is declared. 7.8 FAILURE TO MAKE A DECLARATION
Should it be suspected that a member of staff has failed to appropriately declare an interest, or failed to demonstrate compliance with the conduct outlined in this policy, it may be deemed appropriate to take action in line with the Trust’s Disciplinary Policy and/or make a referral to the Trust’s Local Counter Fraud specialist (LCFS). Staff can obtain details via the intranet should they have any concerns It is the responsibility of ALL staff to ensure that declarations must be updated on an annual basis using Appendix 3 and sent to the Director of Corporate Affairs. 8. Employment external to the Trust 8.1 Working Time Regulations To comply with the Working Time Regulations (1998), it is a requirement that employees notify the Trust of any outside employment, including private work or work for outside agencies, particularly where their total time worked is in excess of 48 hours a week and they will be required to sign an “opt-out” agreement. 14
An opt-out form can be accessed from the Trust Intranet. 8.2 Conflict of Interest with outside employment Employees should not engage in any activities outside the Trust which may impact on their ability to fulfill their duties and responsibilities without first obtaining consent, which will not be unreasonably withheld. The Trust retains the right to review this position, should it become aware of issues affecting the employee’s employment with the Trust. Employees are advised not to take on outside employment or become involved in another company that may conflict with their Trust employment or be detrimental to it. This includes any work in or on behalf of a business owned by the employee, a member of his/her family or friends, as well as work for outside agencies. 9. Contracts All Trust employees who are in contact with suppliers and contractors, in particular those who are authorised to sign purchase orders, or place contracts for goods or services, must ensure that they are familiar with the Trust’s Standing Orders and Standing Financial Instructions. 9.1 Favoritism in Awarding Contracts Fair and open competition between prospective contractors or suppliers for Trust contracts is a requirement of the Trust’s Standing Financial Instructions, NHS Standing Orders and the EU Directives on Purchasing. Employees involved in placing or awarding contracts must not unfairly advantage one contractor or competitor over another, or show any favoritism in awarding contracts. This means that: no private, public or voluntary organisation which may bid for NHS business should be given an advantage over its competitors. each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them. All invitations to potential contractors to tender for NHS business should include a notice warning with regard to the consequences of engaging in any corrupt activity involving employees of the Trust. All contractors should be made aware of the Trust’s Whistle Blowing policy (Public Interest Disclosure Act). NHS Fraud and Corruption Reporting Line is available on Freephone 0800 028 4060 or by completing an online form at www.reportnhsfraud.nhs.uk 10. Private Practice Consultants and Associate Specialists are permitted to carry out private practice subject to the provisions of their Trust contract of employment and clearly identified in their job plan. 15
Other grades of staff may undertake private work or work for outside agencies provided this work does not conflict with their Trust employment or take place during their contracted hours with the Trust and complies with the requirements in their Contract of Employment and clearly identified in their job plan. Any work should also be subject to the conditions outlined in the NHS Code of Conduct for Private Practice and the Trust’s Policy on Private Patients and should be declared to the Trust using the declaration of interests form Appendix 3. 11. Intellectual Property Managers should ensure that they are in a position to identify intellectual property rights (IPR) as and when they arise so that they can exploit them properly. This will ensure that the Trust receives any reward or benefit (such as royalties), both in respect of work carried out by third parties, or work carried out by employees of the Trust. To ensure this is achieved managers should build appropriate specifications and provisions into the contractual arrangements before work is commissioned or begins, and seek legal advice in relation to specific cases. This complex area relates to copyright, patents, new inventions and collaborative research projects. Before any work is undertaken in this area, legal advice, in liaison with the Chief Finance Officer on intellectual property should be sought and contractual arrangements drawn up with the Trust, as to how rewards or benefits in respect of this work may be allocated. 12. Confidentiality – Sensitive Information Staff should ensure they are aware of information relating to business conducted by the Trust which is “commercial in confidence”. All such information should be restricted with regard to disclosure particularly if its disclosure would prejudice the principle of a purchasing system based on fair competition. This refers to both private and public providers of services. The term “commercial in confidence” should not be taken to include information about service delivery and activity levels, which should be publicly available, under the Freedom of Information Act. The exchange of data for medical audit purposes is subject to the rules governing patient confidentiality and data protection. 13. Consultation and Communication with Stakeholders The policy has been drawn up in consultation with the trade unions, counter fraud, the Executive Committee and the Audit and Assurance Committee. 14. Approval and Ratification The following groups were responsible for the discussion, approval and ratification of this policy: 16
Joint Consultative Committee The Executive Committee The Audit & Assurance Committee The Trust Board 15. Review and Revision All policies will be monitored and data presented to the relevant committee on a quarterly basis to analyse trends, and act on any areas of concern. 16. Dissemination and implementation The Trust process for dissemination of policies will be followed as described in the Organisation-wide Policy for the Management and Development of Procedural Documents. It will be posted on the dedicated Policies and Procedures page of the intranet and a notification to all staff of the new policy placed on the next available E Bulletin. All forms which are attached (Appendices 2 â&#x20AC;&#x201C; 5) are available as individual forms on the Form section of the intranet. Standards of Business Conduct are also referred to in all Employee Statement of Main Terms and Conditions of Employment. 17. Archiving This policy will be held in the Trust database and archived in line with the arrangements in the Organisation-wide Policy for the Management and Development of Procedural Documents. . 18. Monitoring and Compliance The Department of Corporate Affairs will monitor the daily operation of this policy. Breaches of the policy will be monitored and reported on an annual basis. Registers will be maintained by the Department of Corporate Affairs to record declarations of gifts/hospitality/sponsorship received or refused and disclosures of interest. Registers will be presented for review at the Audit & Assurance Committee and the Trust Board on a bi-annual basis. Annual reports will be made to the Trust Consultative Committee. Periodic communications to maintain a level of awareness of responsibilities of staff will be undertaken through the SASH news, e Bulletin, counter fraud initiatives, any other appropriate medium as identified. Executive and Non Executive Directors and Senior Managers will be written to on an annual basis to ensure compliance with the policy.
17
19. References Trustâ&#x20AC;&#x2122;s Standing Orders Trustâ&#x20AC;&#x2122;s Standing Financial Instructions Trust Policy for Commercial Representatives Standards of Business Conduct HSG (93)5 Code of Conduct for NHS Managers 2002 Professional Codes of Conduct Contracts of Employment Bribery Act 2010 Nolan Principles Standards for Members of NHS Boards 2011 (Professional Standards Authority for Health & Social Care) Private Patients Policy Fit & Proper Persons Regulations Working Time Directive Policy Fraud Act 2006 20. Associated Documents Disciplinary Policy Code of Conduct for Confidentiality Counter Fraud Response and Bribery Plan Policy for Raising Serious Concerns (Whistleblowing) Intellectual Property Policy Private Patients Policy Working Time Directive Policy Contracts of Employment Professional Codes Conduct Medical Devices Policy Trust Policy for Commercial Representatives
18
APPENDIX 1 Bribery and Corruption The new Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts1889 â&#x20AC;&#x201C; 1916. The Act sets out four offences: 1. Offering, promising or giving a bribe to another person to perform improperly a relevant function or activity, or to reward a person for the improper performance of such a function or activity (the active offence). It does not matter whether the person to whom the bribe is offered or given is the same person who is to perform the function or activity concerned. This applies to both public and private functions. 2. Requesting, agreeing to receive or accepting a bribe to perform a function or activity improperly (the passive offence). It does not matter whether the recipient of the bribe requests or receives it directly or through a third party, or whether it is for the recipient's benefit or not. In some cases, it is not necessary for the recipient to know or believe that the performance of the function or activity is improper. This applies to both public and private functions. 3. Bribing a foreign public official â&#x20AC;&#x201C; where a person directly, or through a third party, offers, promises or gives any financial or other advantage to a foreign public official ("FPO") (or to a third party at the request or acquiescence of the FPO) in an attempt to influence them in their capacity as a FPO in order to obtain or retain business, or to obtain an advantage in the conduct of business. To constitute bribery under the Act the FPO must be neither permitted nor required by applicable law to be influenced by the offer, promise or gift. 4. Failure of a commercial organisation to prevent bribery (the "Corporate Offence"). A commercial organisation will commit an offence if a person associated with it bribes another (in the UK or overseas) intending to obtain or retain business or a business advantage for that commercial organisation. An associated person includes any person who performs services for the commercial organisation. So, for example, an associated person may include not only employees, agents and subsidiaries, but also entities over which the organisation has no ownership or control.
19
APPENDIX 2 Short Guide to Standards of Business Conduct for NHS Staff To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s HR Director holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Chief Financial Officer, Maple House. Short Guide for staff Do: •
Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) 5) referred to in your terms and conditions of employment and consult your line manager if you are not sure
•
Make sure you are not in a position where your private interests and NHS duties conflict.
•
Declare any relevant interests. If in doubt, ask yourself:
5. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made? 6. Do I have access to information which could influence the Trust’s purchasing or contracting decisions, or could it be perceived that I have such access? 7. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could others perceive them to be detrimential? 8. Do I have any other reason to think I may be risking a conflict of interest? IF IN DOUBT – DECLARE IT
20
Always : •
Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.
•
Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties.
•
Obtain the Trust’s permission before accepting any commercial sponsorship.
Do Not •
Abuse your past or present official position to obtain preferential rates for private deals.
•
Unfairly advantage one competitor over another or show favoritism in awarding contracts.
•
Misuse or make available ‘commercial in confidence’ information.
•
Accept gifts, inducements or inappropriate hospitality.
Casual gifts offered by Contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to be committing an offence under the Bribery Act. Such gifts should nevertheless, be politely but firmly declined. Articles of low intrinsic value such as diaries or calendars, or small tokens of gratitude from patients or relatives, i.e. chocolates etc need not be refused. In cases of doubt staff should either consult their line manager or politely decline acceptance. Modest hospitality provided it is normal and reasonable in the circumstances i.e. lunches in the course of working visits may be acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Receipt of such hospitality should be declared. Staff should decline all other offers of gifts, hospitality or entertainment. If in doubt they must seek advice from their line manager and/or declare it.
21
APPENDIX 3 DECLARATION OF INTERESTS Name …………………………………………………………………………………. Title ………………………………………………………………………………….. Under the Codes of Conduct and Accountability, the Trust’s Standing Orders and Standing Financial Instructions and the content of the Standards of Business Conduct Policy I declare my interests as follows: Category
Details (include start date of interest & all locations)
Category A Directorships, including non-executive directorships held in Private companies or PLCs (with the exception of those of Dormant companies ) i.e. being a Board Member of a Statutory Organisation Category B Undertaking of private practice at any facility. Category C Ownership or private companies, business or consultancies likely or possible to do business with the NHS or any other organisation. Category D Majority, controlling or large shareholdings in organisations likely to possibly seek to do business with the NHS Category F A position of authority in a charity or voluntary organization in the field of health and social care Category F Any connection with a voluntary or other organisation contracting for NHS services Category G Any additional role or other interest undertaken in a capacity is paid or unpaid which a member wishes to place on record but does not fall into categories A-E above If this situation changes during the next 12 months I will advise you accordingly Signed …………………………………………………………………………………………………………………………. Date ……………………………………………………………………………………………………………………………. Countersigned Director /Chief of Service/Assistant Director………………………………………………………………………………… Date……………………………………………………………………………………………………………………………… Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.
22
APPENDIX 4 Declaration of Gifts, Entertainment, Hospitality/ Sponsorship/Sample Medical Equipment or Drugs Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy Nature of Hospitality /gift given: …………………………………………………………………………………………..
Hospitality/gift offered to: ……………….………………………………………………………………………………… Name of organisation: ……………………………………………………………………………………………………. Date ………………………………………………………………………………………………………………………… Value (Approx.)……………………………………………………………………………………………………………… Description of hospitality/sponsorship/gift/entertainment/sample medical equipment or drugs: ……………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………….. Do you have any personal relationship with, or personal business connection with the person/organization from whom you received, or to whom you offered hospitality/gift/sponsorship/sample medical equipment /drugs declared above Yes
No
If yes, please describe
Declaration I declare that the above record represents a complete and accurate statement of the hospitality/gift/sponsorship/ sample medical equipment/drugs I have given/received Signed……………………………………………………. Date ………………………….. Name …………………………………………………………. Countersigned…………………………………………………………………. Director/Chief of Service/Assistant Director/ …………………………………………………Date………. …………. Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.
23
APPENDIX 5 Declaration of relationships with Candidates Guidance: •
Candidates will be required to disclose in writing whether to their knowledge they are related to the Chairman, Director, Consultant Medical staff or other staff with responsibilities for the recruitment process. Failure to do so shall disqualify from the recruitment and selection process. If an appointment is made, it shall render the appointee liable to dismissal.
•
Relationships to which these rules apply are those of husband, wife, where two persons live together as partners, sons, daughter, grandson, granddaughter, brother, sister, nephew, nieces of either partner.
•
Direct or indirect canvassing of the Chairman or Directors or of any committee of the Trust by or on behalf of any candidates shall disqualify the candidate from the appointment.
•
Employees of the Trust shall not solicit for any person or any appointment with the Trust or recommend any person for such an appointment. However, this does not preclude the member of staff from giving a written or verbal reference on request concerning a candidate’s ability or experience for submission to the Trust.
Name …………………………………………………………………………………… Job Title ……………………………………………………………………………….. Declaration of Relationship Name of Candidate ………………………………………………………………….. Post applied for ……………………………………………………………………… Nature of relationship………………………………………………………………… Signed…………………………………………………Date…………………………. Countersigned
Director of HR …………………………………………………………………………
Copy to be placed on employee’s file and original to be retained by the Human Resources Team.
24
APPENDIX 6 The Seven Principles of Public Life (Nolan) 1.
Selflessness
Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. 2.
Integrity
Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. 3.
Objectivity
In carrying out public business, including making public appointments, awarding contracts or recommending individuals for rewards and benefits, holders of public office should make choices on merit. 4.
Accountability
Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. 5.
Openness
Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. 6.
Honesty
Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. 7.
Leadership
Holders of public office should promote and support these principles by leadership and example. The Committee on Standards in Public Life has set out â&#x20AC;&#x153;Seven Principles of Public Lifeâ&#x20AC;? which it believes should apply to all in the public service. www.public-standards.gov.uk
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APPENDIX 7
Equality Impact Assessment Names of assessors carrying out the screening procedure (min of 2- author / manager and staff member / patient representative) • Gillian Francis-Musanu • Sally Knight 1. Name of the strategy / policy / proposal / service function POLICY ON STANDARDS OF BUSINESS CONDUCT
Name of lead author /manager & contact number Gillian FrancisMusanu Date last reviewed or created & version number. New, December 2012
2. Who is the strategy / policy / proposal / service function aimed at? All staff, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer 3. What are the main aims and objectives? The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted 4. Consider & list what data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? Workforce data, Employee relations data.
5. Is the strategy / policy / proposal / service function relevant to any of the protected characteristics or human rights below? If YES please indicate if the relevance is LOW, MEDIUM or HIGH Protected Characteristics
• • • •
Age Disability Gender Reassignment Race/ Ethnic Communities / groups
• Religion or belief • Sex (male female) • Sexual Orientation(Bisexual, Gay, heterosexual, Lesbian) • Marriage & Civil Partnership • Pregnancy & Maternity • Human Rights
Patient, their carer or family NO NO NO NO
Staff
NO NO NO
NO NO NO Yes. Low negative NO NO NO
NO NO NO
NO NO NO 26
6.
What aspects of the strategy / policy / proposal / service function are of particular relevance to the protected characteristics? Race and potential for disciplinary action
7.
Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? Allegations of fraud may result in disciplinary action. In the past the number of BME staff in disciplinary cases has been disproportionate to the overall number in the Trust.
8.
Please identify what evidence you have used / referred to in carrying out this assessment. See q 4 and authors knowledge
9.
If you identify LOW relevance only can you introduce any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage? If so please identify here. Annual monitoring of breaches of the policy by protected characteristics of the staff involved will help identify any potential discrimination. This can be reported on as a subset of the employee relations report.
10.
Please indicate if a Full Equality Impact NO Assessment is recommended. (required for all where there is MEDIUM & HIGH relevance) If you are not recommending a Full Equality Impact assessment please explain why. The policy follows national guidance, good practice and UK legislation. The policy is identified in all employment contracts. Monitoring and reporting of the breeches by protected characteristics annually will provide additional assurance.
11.
12.
Signature of author / manager
Date of completion and submission
27
Definitions of relevance Low • • •
The policy may not be relevant to the Equality General Duty* as stated by law Little or no evidence is available that different groups may be affected differently Little or no concern raised by the communities or the public about the policy etc when they are consulted – (recorded opinions, not lack of interest) Medium •
• • High
The policy may be relevant to parts of the Equality General Duty* in the policy etc regarding differential impact There may be some evidence suggesting different groups are affected differently There may be some concern by communities and the public about the policy
There will be relevance to all or a major part of the Equality General Duty* in the policy regarding differential impact. • There will be substantial evidence, data and information that there will be a significant impact on different groups There will be significant concern by the communities and relevant partners on the potential impact on implementation of the policy etc. •
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Human Rights the right to life the right not to be tortured or treated in an inhuman or degrading way the right to be free from slavery or forced labour the right to liberty the right to a fair trial the right to no punishment without law the right to respect for private and family life home and correspondence the right to freedom of thought, conscience and religion the right to freedom of expression the right to freedom of assembly and association the right to marry and found a family the right not to be discriminated against the right to peaceful enjoyment of possessions the right to an education the right to free elections
28
Date: 25th February 2016
TRUST BOARD IN PUBLIC
Agenda Item: 4.2 REPORT TITLE:
Update from the Shadow Council of Governors
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs Shadow Council of Governors Meeting 26.01.16
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 second Shadow Council of Governors took place on 26th January 2016. The meeting was quorate and very well attended by both elected, nominated governors and Trust Executive Directors. Key area of Focus for this meeting: • Trust Update from the Chief Executive • Review of Quality Account Priorities • Trusts Patient Experience Strategy • Patient Experience Forum Legacy Report • Update from the Membership Development Sub-Group It was noted that one elected Governor from the Crawley constituency had resigned due to personal reasons. 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 clinical leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement
A Council of Governors is a statutory requirement for an NHS Foundation Trust and forms part of the governance structure Limited – mainly relating to claiming of reasonable travel expenses 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
2
TRUST BOARD REPORT â&#x20AC;&#x201C; 25th February 2016 UPDATE FROM THE SHADOW COUNCIL OF GOVERNORS 1.
Introduction
The Shadow Council of Governors held its second meeting on 26th January 2016. The meeting was well attended by elected, staff and nominated Governors.
1.2
Main Agenda Items
The following items were discussed: Trust and FT Journey Update: The CEO presented the current developments taking place at the Trust including an update on quality, performance, finance and estates. Discussion also took place on the current status of the Trusts FT application and the possible next steps. The requirements for the Governors input to the 2016/17 NHS Planning Guidance were also noted. Review & Input into the 16/17 Quality Account Priorities: The Medical Director presented the progress being made on the development of next Quality Account and sought feedback from the Governors on the draft priorities for the coming year. The governors agreed that these were appropriate and looked forward to seeing the draft version of the 2015/16 Quality Account. Update on the Patient Experience Strategy: The Chief Nurse and Patient Experience Survey Manager presented the Trusts Patient Experience Strategy and detailed the variety of methods the Trust uses to obtain and use the experience of patients and their carers as an important way of improving the quality and experience of services provided by the Trust. Legacy Report from Patient Experience Forum: One of the Governors presented the legacy report from the Patient Experience Forum, which gave an overview of the range of groups and committees where patientsâ&#x20AC;&#x2122; representatives had been involved and had worked with the Trust over a number of years. The Council agreed to discuss ways in which Governors could become more involved in similar activities over the coming months. Update from the Membership Development Group: One of the Governors gave feedback on the first meeting of the membership development group (a sub-group of the council of governors) and shared a range of approaches being implemented proactively by governors to engage with and to gain feedback from foundation trust members as well as looking at ways of increasing membership from particular constituencies. The Council also received feedback from the Director of Strategy which included an update on how the Trust Board had given consideration to the feedback from governors on the Trusts Vision, Values and Strategic Objectives. 1.3
Governor Resignation
The Shadow Council was informed that Richard Miller one of the elected Governors for the Crawley Constituency had resigned due to personal reasons. This will warrant a bielection for the Crawley Constituency in due course.
3
2. Recommendation The Board is asked to note the report from the Shadow Council of Governors. A report on the work and activities of the Shadow Council of Governors will be provided to the Board on a quarterly basis.
Gillian Francis-Musanu Director of Corporate Affairs February 2016
4
TRUST BOARD IN PUBLIC
Date: 25 February 2016 Agenda Item: 4.3 SASH+ (in partnership with the Virginia Mason Institute) update Michael Wilson Chief Executive Sue Jenkins Director of Strategy
REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Executive Committee
Action Required: Approval ()
Discussion ()
Assurance (√)
Purpose of Report: This report provides the Board with assurance that the SaSH + work (in partnership with Virginia Mason) is progressing to plan. Summary of key issues This paper provides the Trust Board with an update on progress since December 2015 including details about:• each of the value streams • training and development • the communications plans • the compacts • the Kaizen Promotion Office (KPO) Recommendation: The Board is asked to consider this report and ensure that it provides assurance around delivery of the SaSH + work (in partnership with Virginia Mason). Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about 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 implications Financial implications
The Trust has a contractual commitment to participate fully in this programme for a five year period The programme is being centrally funded by the Trust Development Authority (TDA) and the
Patient Experience/Engagement Risk & Performance Management
NHS Constitution/Equality & Diversity/Communication
Department of Health. The programme is expected to achieve improvements in quality, performance and efficiency over the next five years Patients will be involved in value stream work wherever possible A Trust Guiding Team has been established to oversee this work. This group reports to a national Trust Guiding Board A national communications plan is being delivered to support the work and internally communications is being rolled out across the organisation
Attachment: SaSH + update Appendix A â&#x20AC;&#x201C; SASH+ compact
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT –25 February 2016 SASH+ update – working in partnership with the Virginia Mason Institute 1. Introduction 1.1 In December 2015 the Trust Board received its first update on the SASH+ work which is being progressed in partnership with the Virginia Mason Institute and NHS Improvement. It was agreed that regular reporting on continued progress should take place on a bi-monthly basis. 1.2 This paper provides the Trust Board with an update on progress since December 2015 including details about:• each of the value streams • training and development • the communications plans • the compacts • the Kaizen Promotion Office (KPO) 2. Value stream updates 2.1 The Trust has identified three value streams which will be the initial focus of improvement work. 2.2 They are:• Inpatient flow – cardiology •
Outpatients
•
Management of diarrhoea
2.3 The following table confirms the progress that has been made against each of the value streams so far. Value Stream 1 Scope Executive Sponsor KPO lead Sponsor development session
Value Stream Sponsorship Team
Inpatient flow - cardiology From: decision to refer to cardiology To: Discharge from cardiology ward Michael Wilson – CEO Sue Jenkins Held on 3 December 2015 Facilitated by VMI Included 15 staff from cardiology team Agreed high level current state value stream map Agreed high level future state value stream map Agreed 4 priorities and draft project plans for RPIWs • Right patient right bed • Discharges • Cancellations and amendments to lists • Ward rounds James Sneddon Nandu Gandhi Rachel Danvers Alison James Caroline Pinney
3 An Associated University Hospital of Brighton and Sussex Medical School
Victoria Bailey Keith Middleton Michael Wilson - chair Sue Jenkins Meet weekly High level metrics agreed
*RPIW#1 topic
Right patient right bed
*An RPIW is a 5 day workshop focused on a particular process in which people who do the work are empowered to eliminate waste and reduce the burden of work
RPIW#1 dates RPIW#1 sponsor RPIW#1 process owner
8 â&#x20AC;&#x201C; 12 February 2016 Alison James Diane Winchester
4 An Associated University Hospital of Brighton and Sussex Medical School
RPIW#1 workshop leader RPIW#1 team leader RPIW metrics agreed
Rhonda Stewart (VMI sensei) Sue Jenkins
These metrics will be monitored and reported at 30,60 and 90 day intervals post RPIW
Notable successes that were recorded when the new process was tested
30 day report 60 day report 90 day report Successes
Lessons learned
Due 14 March 2016 Due 12 April 2016 Due 11 May 2016 Great engagement from all involved in RPIW Excellent and active patient involvement all week Team talk was a great forum to use to do final report out of the week to the whole organisation. The report out has been videoed and will be available to view once final edits are complete. Timing and amount of information to the home team (those working in cardiology but not part of the RPIW) is critical Each area represented learned about each others areas and how they affect their work Sharing information empowers staff
5 An Associated University Hospital of Brighton and Sussex Medical School
RPIW#2 topic RPIW#2 dates RPIW#2 sponsor RPIW#2 process owner RPIW#2 workshop leader RPIW#2 team leader Metrics 30 day report 60 day report 90 day report Value Stream 2 Scope Executive Sponsor KPO lead Sponsor development session
Value Stream Sponsorship Team
High level metrics agreed RPIW#3 topic RPIW#3 dates RPIW#3 sponsor RPIW#3 process owner RPIW#3 workshop leader RPIW#3 team leader Metrics 30 day report 60 day report 90 day report
Five days were used to do something constructive. There was designated time, a helpful structure, ambitious targets, rapid change and time for reflection The process works Discharge 4 – 8 April 2016 Keith Middleton TBC Sue Jenkins Allana Hansell To be agreed Due 9 May 2016 Due 14 June 2016 Due 13 July 2016 Outpatients From: decision to refer To: attendance at first follow up appointment or discharge Des Holden – Medical Director Allana Hansell Planned for 2 March 2016 Agenda shared with participants To be facilitated by VMI Have invited 25 outpatient staff to the event Observations currently underway to prepare high level current state value stream map Metrics being discussed Des Holden (chair) Angela Stevenson Natasha hare Sian Griffith Pramit Patel Linda Judge Jamie Moore Ben Emly Allana Hansell First meeting due on 22 February 2016 Currently being agreed Priority topics to be agreed at Sponsorship development session on 2 March 23 – 27 May 2016 TBC TBC Sue Jenkins Allana Hansell To be agreed Due 27 June 2016 Due 27 July 2016 Due 2 September 2016
6 An Associated University Hospital of Brighton and Sussex Medical School
Value Stream 3 Scope Executive Sponsor KPO lead Sponsor development session
Value Stream Sponsorship Team High level metrics agreed RPIW#3 topic RPIW#3 dates RPIW#3 sponsor RPIW#3 process owner RPIW#3 workshop leader RPIW#3 team leader Metrics 30 day report 60 day report 90 day report
Management of Diarrhoea From: onset of symptoms To: resolution of symptoms Ben Mearns â&#x20AC;&#x201C; Chief of medicine Katy Morris Planned for 28 April 2016 Observations currently underway to prepare high level current state value stream map Metrics being discussed Ben Mearns (chair) First meeting due on 22 February 2016 Currently being agreed Priority topics to be agreed at Sponsorship development session on 28 April 2016 18 â&#x20AC;&#x201C; 22 July 2016 TBC TBC Allana Hansell Helen Gallon To be agreed Due 22 August 2016 Due 21 September 2016 Due 21 October 2016
3 Training and development 3.1 SaSH recognise the importance of having a cohesive training and education plan that supports the roll out, implementation and delivery of the SaSH+ work over the next five years. 3.2 The current plan includes a range of courses delivering varying levels of expertise and knowledge to a range of staff:-
Type Induction
Format Presentation
Frequency Duration Audience Monthly 5 all new minutes starters
Grand round Taster session
Presentation
Twice yearly Monthly
presentation and practical exercises
30 minutes 2 .5 hours
trainees and consultants All staff wanting to understand what SASH+ work is all about
7 An Associated University Hospital of Brighton and Sussex Medical School
One day presentation masterclass and practical (planned) exercises
Quarterly
1 day
Leadership orientation
presentation and practical exercises
One off
1 day
Lean for leaders
6 days taught, work based assignments, coaching and mentoring Presentation, sharing learning, visits to the genba and practical exercises 7 days taught 12 assignments over 6 weeks RPIW x 2 sign off
June 2016 â&#x20AC;&#x201C; January 2017
8 months 40 Staff in leadership roles
annual
1 day
September 2015 â&#x20AC;&#x201C; July 2016
8 months 4 KPO specialists
Learning conference (planned)
ALT
All staff interested in improvement Wider healthcare system staff 30 Staff in leadership roles
wider healthcare system internal staff
3.3 A draft training and education plan has been developed including cohort numbers, course content and target audiences over the coming five years. This plan seeks to ensure that there is an opportunity for every single member of staff in the organisation to experience some learning and development about the SaSH+ work over the coming years. 3.4 A gap analysis has also been undertaken which indicates that additional capacity may be required of the following courses o
Leadership orientation
o
Lean for Leaders
o
Advanced Lean Training certification
3.5 Discussion is underway with the national team to consider the feasibility of additional procurement of the above courses 4 Communication
8 An Associated University Hospital of Brighton and Sussex Medical School
4.1 Communication activity is already underway and a communications plan is being developed to ensure that internal and external communications and stakeholder management is focused and that staff, external audiences, stakeholders and the media are engaged throughout and their views are listened to. This will be aligned to the national TDA VMI Communications Strategy. The Head of Communications and the KPO lead will meet their counterparts from the participating Trusts on a monthly basis to ensure that there is alignment, consistency of messages and open communication at a national and local level. 4.2 At a local level the Trust is a developing a communications plan which will include:4.2.1.1.1.1.1 Stakeholder engagement – both locally and as part of the national programme of stakeholder engagement • Regular Kaizen bulletins sharing the improvement story as it unfolds • Regular updates at TeamTalk meetings • Tailored SASH+ TeamTalk meetings for RPIW report outs and updates on value streams • Specific reference to the work in the CEO’s weekly message • A KPO wall which will visually depict the value stream progress • A web page sharing information and the stories from the SASH+ work as it progresses • Updates in Staff News and Yammer • Updates shared through our social media platforms • Media engagement – in-line with national partnership timeframes • Regular board reports which provides updates of the work undertaken along with delivery against key metrics as this progresses • A series of videos displayed on the trust information screens and the web page sharing progress, updates successes and learning • A visual identity for SASH+ and branded templates for all materials and corporate communications messages 5 Compact development 5.1 Underpinning the improvement work at both a national and trust wide level is the development of a compact which details reciprocal commitments and an explicit set of responsibilities from all parties engaging in this development work. 5.2 At a national level a compact has been developed between the TDA and the five participating NHS Trusts. 5.3 In order to support the improvement work at a SASH level a draft compact has been developed between the organisation and clinicians. This work has been led by Amicus, who are specialist experts in compact development, working in partnership with VMI. 5.4 The draft compact which is being shared and considered across the organisation for feedback is attached at Appendix A 6 Kaizen Promotion Office 6.1 In order to lead the SaSH+ work across the organisation, a Kaizen Promotion Office (KPO) has been established. The KPO is responsible for:• providing specialist support and advice for SaSH+ across the organisation and wider health system • building improvement expertise capacity and capability across the organisation • leading the initial value stream work to support the launch of SASH+ • developing and rolling out an education and training plan to share improvement tools, techniques and skills 9 An Associated University Hospital of Brighton and Sussex Medical School
• providing ongoing coaching and mentoring to those leading improvements in the work place • acting as a repository for all Kaizen work including monitoring of metrics and collating stories of success and learning • sharing progress, learning and achievements both internally and externally • hold the organisation to account for maintaining rigor and compliance with the improvement process methodology 6.2 All four members of the KPO team have commenced their advanced lean training which is certified by VMI. Completion of this training in April 2016 for the first of the candidates. 7 Recommendation 7.1 The Board is asked to consider this report and ensure that it provides assurance around delivery of the SaSH + work
Sue Jenkins Director of Strategy & Kaizen Promotion Office (KPO) Lead February 2016
An Associated University Hospital10 of Brighton and Sussex Medical School
An Associated University Hospital11 of Brighton and Sussex Medical School
Safety & Quality Committee Thursday 8th December 2015, 12.00-14.00 AD77 Trust Headquarters, East Surrey Hospital Minutes of Meeting
Present: Richard Shaw Pauline Lambert Alan Hall Fiona Allsop Paul Simpson Barbara Bray Ben Mearns Katharine Horner Ben Emly Colin Pink Jonathan Parr
RS PL AH FA PS BB BM KH BE CP JP
Cathy White
CW
Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Nurse Finance Director Chief of Surgery Chief of Medicine Patient Safety & Risk Lead Head of Information Corporate Governance Manager Clinical Governance Compliance Manager Patient Experience Survey Manager
Apologies: Angela Stevenson, Des Holden 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 October and November meeting were formally approved. 1.2.
1.3.
Actions from previous meeting were discussed as follows
C/F 2nd April Look back paper This information will be combined with a report which will assess the impact of each Breaking the Cycle week. It was agreed that the audit of emergency readmissions would be discussed at the February 2016 meeting. C/F 1st October Review of gender bias in Trust BE presented a short summary. There are 174 consultants in the Trust of which 64 (37%) are female. Since October 2012 53 new consultants have been appointed 25 (47%) are female. 2/5 Chiefs and 6/19 clinical leads are female. th
SQC Minutes 8 December 2015 Page 1 of 6
AS is setting up a focus group which will meet in the new year to look at key issues affecting female consultants: clinical excellence awards, maternity leave, childcare access to mentoring, and promotion. BB noted that there are fewer female consultant surgeons 7 out of 40, and there are three departments in surgery with no women consultants (the fourth is ED). RS asked whether this is grounds for concern, BB responded that this position reflects the national picture. The Trust is currently recruiting for lower and upper GI consultants but there have been no women applicants. In addition BB noted that surgical training is not family friendly, it is much harder to be part-time. BM noted that AMU is 50% female consultants, but a number of women have opted to work part-time, so a straightforward review of hours might be misleading. FA suggested that the focus group report back to the workforce subcommittee, and update to SQC in six months. C/F 5th November Update on VTE compliance Taken as part of the Quality Report. 1.4 Highlights from Executive Committee for Quality & Risk CP presented his report which covered the meeting which took place on the 25th November 2015; he noted that ECQR met once in November due to Breaking the Cycle (BTC). AH asked what the SSNAP audit is. BM provided a short summary of the purpose of the audit and recent results which have been positive, but noted that there is continuing work to raise the score to an A or a B. AH asked how a D rating would impact a patient’s care. BM summarised the issues that have adversely affected the score which the team are working to improve: • Admission to the stroke unit in less than 4 hours • 90% of admission on stroke unit • Early supported discharge (working with CCG) • Seven day therapy and consultant service • SALT assessment (reflective of national shortage of staff) BM notes that the team score highly for the following: • Swallow assessment • Early clinical review of patient • Prompt and appropriate thrombolisation. • CT scan within an hour PS noted that at one stage the Trust scored a B and that the service has fallen back. BM explained that the results do fluctuate, but by addressing the access target and seven day service will ensure a more consistent result. RS asked whether the issue is bed availability, BM explained that experience had shown that this is not the case, more work is being done on timely transfer from ED. th
SQC Minutes 8 December 2015 Page 2 of 6
RS noted the discussion which had taken place at ECQR clarifying that the low VTE figures are a recording rather than a safety issue. CP explained that DH had discussed the national changes in safety data which are likely to happen in the next year. CP explained that more work would be needed to understand new metrics and how they can be monitored within the Trust. RS asked for an explanation of LOCSSIPs and NATSLIPs. CP explained that there is a national drive to ensure that any invasive procedure has a locally agreed procedure that the organisation is aware of them and is assured by them. The Steering Group is chaired by FA, only one meeting has taken place. JP noted a mistake in the report “parental mortality” should “perinatal mortality”. 1.5 Highlights from Clinical Quality Review Meeting This meeting was held on the 17th November 2015 to review September performance. PS presented a summary of the meeting. No concerns were escalated to the Single Performance Conversation. No issues were identified by the CCG. PS noted that nothing is being escalated however East Surrey CCG have mentioned in their own quality reporting that stroke and #NOF are of concern. FA noted that there had been a site visit to review the stroke service, so it is not clear what the concerns are. PS will follow this up. PS noted concern that the Single Performance Conversation is not happening; this is a meeting at Chief Executive level. MW has escalated concerns regarding the number of times this meeting has been cancelled. 2
QUALITY PERFORMANCE 2.1 Quality Report BE presented the highlights of the report. PL asked about the GAP Audit (Good antibiotic prescribing). BM explained that this is a review of antibiotic prescribing on every ward in the Trust. It reviews the management of the patient looking at six key factors including; whether the correct antibiotic has been prescribed (normally 100%), if there has been a review within 2 days and the duration of course. BM anticipates better control with the introduction of electronic prescribing. RS asked whether the Trust has similar rates of CDIFF to other Trusts within the region. BE explained that it has not been benchmarked but anecdotal evidence from IC team would suggest that this is true. Norovirus is less easy to monitor because it is not a notifiable condition. PS asked BE to ensure that the Cdiff figures are being accurately reported on the dashboard, BE intends to include a second indicator showing cases where a lapse in care has been identified and agreed. PL asked about the mandatory training figures. FA explained that the MAST will be re-launched in January which is expected to improve the training th
SQC Minutes 8 December 2015 Page 3 of 6
figures. Training has been reviewed to look at different methods of delivering the training for example what can be done prior to start date and virtual training. 3
PATIENT EXPERIENCE 3.1 Presentation: Update on the Dementia Strategy SA presented his report, which highlighted some of the key successes of the dementia strategy and work yet to achieve. He cited the successes as being strong nurse leadership and 1,300 staff trained on dementia awareness. The areas for improvement were highlighted as the establishment of what constitutes a dementia friendly template for a ward, training for non-clinical staff and medical staff. The establishment of a dementia strategy group and care pathways for patients with dementia and delirium. RS asked FA about some of the issues and challenges raised by SAâ&#x20AC;&#x2122;s report. FA formally noted her thanks for SAâ&#x20AC;&#x2122;s hard work and the significant progress that has been made for this cohort of patients. FA felt that the problem was that the pathways were very nursing orientated and need to incorporate some of the other professional groups within the Trust. FA welcomed that Dr Broomheadâ&#x20AC;&#x2122;s involvement in the pathways as an key interface with clinical colleagues. FA explained that the barriers to progress can be summarised as competing priorities, but stressed that it is not a lack of will or intention. PL asked about the personalised care plan. SA stated that this is connected to the Butterfly Scheme and the importance of working with family and carers to understand the person, their preferences and life experiences and to adapt care appropriately. The problem has been ensuring that staff recognise where and when applying the Butterfly Scheme would be appropriate. AH commented that he found the report very balanced. He asked for more understanding on the extent or prevalence of dementia. SA explained that recently only 44% of dementia patients ever received a formal diagnosis. BM explained approximately 30-40% of inpatients have a degree of dementia or cognitive impairment. BM highlighted that dementia patients often have a longer length of stay and are no longer confined to the elderly care ward, that they access the full range of Trust services. FA thanked SA for leaving a clear indication of future strategy. At this point RS noted that the meeting was no longer quorate as BB left the meeting. 3.2 Management of FFT and Patient Feedback CW presented her report, highlighting the problem of sentiment analysis when looking to identify themes, the strategies used to feedback compliments to wards and encourage feedback from patients. CW noted the th
SQC Minutes 8 December 2015 Page 4 of 6
engagement of the ED. RS asked for clarification on Your Care Matters (YCM) and Friends and Family Test (FFT). CW explained that YCM is the Trust bespoke survey across all pathways. The Friends and Family question is the first question on all YCM surveys, but to supplement that, FFT is done separately for inpatients, ED and maternity. AH asked how VMI manage feedback from their patients. BM explained that soliciting patient feedback is a new strategy for them. RS asked about the low response rates. CW commented that she felt it was leadership and process. BM added that he felt that it can be dependent on the environment, for example it is easier in a protocol driven environment like OP or ED. PL asked what sort of response rates are being aimed for. CW replied that ED the target is 20% and in-patients is 30%. OP remains a big challenge. Texts are sent to patients with a number of appropriate exclusions. FA noted that the Trust needs to develop a clear communication strategy with patients with a Corporate identity. RS asked whether it was time to review or refresh the strategy. CW commented that the current approach is initiative and well received. The contract for YCM is being renewed in March 2016 which might be a break point to relaunch the strategy. CP noted that the recent comments on Patient Opinion have been very positive. PS asked whether a simple metric should be developed to capture this data, for example the number of positive comments. CW agreed to look into whether this would be possible. FA noted that this is one of a number of feedback mechanisms. 3.3 Q2 PALS report FA presented the Q2 report. PL commented that she found the key themes very helpful. AH asked how sustainable the PALS service is. KH summarised a number of different models in place in other Trusts and that in 2016 NHS England intend review their own recommendations regarding PALS services within Trusts based on their observations that there is a danger that it can disenfranchise front line staff from problem solving. FA agreed that further work needs to be done to ensure that the PALS service is robust and can cope with the needs of patients. 4
SAFETY 4.1 Safer staffing FA presented the highlights of her paper. PL asked about the nursing hours per patient day which FA explained would be available from the Health Roster system currently being used by the Trust. th
SQC Minutes 8 December 2015 Page 5 of 6
AH asked for the clarification on the wording in paragraph two and the double negative. It was agreed that it should read “there are no clinical areas which fell below 90% 4.2 Adolescent Mental Health update Deferred to February’s meeting 4.3 Clinical Diagnosis report Deferred to February’s meeting 5
QUALITY See private section of the agenda
Proposed agenda for next meeting The agenda was agreed with the caveat that an extra half hour should be added. Any other business There were no items of any other business. DATE OF NEXT MEETING Thursday 4th February 2016 14.00 – 16.00 AD77
th
SQC Minutes 8 December 2015 Page 6 of 6
Minutes of the Finance and Workforce Committee Held on 25 January 2016 at 3.30pm In AD65, East Surrey Hospital, Redhill PUBLIC Present Richard Durban Paul Biddle Alan Hall Angela Stevenson Ian Mackenzie Gillian Francis-Musanu Mark Preston Fiona Alsop
Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Operating Officer (Part Meeting) Director of Information & Facilities Director of Corporate Affairs Director of Organisational Development and People Chief Nurse
In attendance Michael Wilson Janet Miller Peter Burnett Laura Warren David Knight
1
Chief Executive (part meeting) Deputy Director of Organisational Development and People Deputy Chief Finance Officer Head of Communications(part meeting) Senior Cost Accountant (Committee Secretary)
WELCOME AND APOLOGIES FOR ABSENCE Apologies: Apologies were received from Paul Simpson (Chief Finance Officer) (Peter Burnett deputised) Declarations of Interest: There were no declarations of interest.
2
MINUTES OF THE PREVIOUS MEETING The minutes of the 15th December 2015 meeting were approved. Action Tracker Bowl Screening update due to the February meeting. All other action on the agenda or due to future meetings.
3
BUSINESS CASE INVESTMENT UKPN Full Business Case (FBC) Addendum Ian Mackenzie updated the Committee on the current legal and financial situation between the Trust and UK Power Networks (UKPN) and following negotiations the extra claim has been reduced
to £61K plus VAT. The Committee sort and received assurance that no further costs should now arise. Alan Hall sort clarification on the financial year in which this cost would materialise. Ian Mackenzie confirmed it would be the current financial year. The Committee approved the addendum on a “full and final” basis. 4
BUSINESS PLANNING Communication Planning Laura Warren presented the Communication plan to the Committee. The Committee welcomed the plan which provides a set of actions for 16/17 across all platforms. The Committee noted the progress made to date. It asked for an update on outcomes and a view on achievement against the strategic objectives at an appropriate time.
3
FINANCE Financial Performance M09 The month 9 Financial Performance paper was presented to the Committee by Peter Burnett. At Month 9 the Trust is reporting an income and expenditure deficit (after donated asset technical adjustment) of £(5.3m) which is £(4.0m) adverse to the revised TDA plan. Month 9 includes a £0.4m income accrual in respect of anticipated reimbursement from the TDA in respect of lost income from the Junior Doctors industrial action. Subsequent to the preparation of the accounts the Trust has been informed that this money will not now be reimbursed nor any loss of income from future industrial action days. Peter Burnett highlighted that the Junior Doctor reimbursement risk amounted to £1.6million. Mark Preston informed the Committee that this week’s strike had been postponed with both sides working with ACAS. A further strike is planned for the 10 February. The Committee was informed that the Trust is applying for a £9.6m loan which comes with the condition that the earlier £6m working capital loan is paid back leaving a net position of £3.6m. The £9.6m loan will be treated as PDC. In addition a Capital to Revenue adjustment of £3m has been agreed with the TDA. Action: Accounting treatment of the Capital to Revenue transfer to be provided to the Committee. – PBurnett/PS. The Trust’s cash balance at the end of December was £5.7m, with a forecast year end cash balance of £2.5m. Backlog creditors increased by a further £2.2m in month. The Committee requested a breakdown of backlog creditors. Action: Breakdown of 60-90 day old creditors to be provided to the Committee – PBurnett/PS
2015/16 CIP Update Peter Burnett presented the CIP paper to the Committee highlighting that the savings target YTD in the submitted TDA plan for 2015/16 is £5.3m and at month 9 the Trust has delivered £3.2m of savings and is behind both the TDA plan and also the internal plan. Non recurrent contingency savings of £0.6m have been used to achieve this position. The Committee noted that achieving the year end forecast of £4.8m would require delivery of £1.6m in Q4 against a quarterly average of £1.1m.
2016/17 draft Budget update Peter Burnett presented the Budget Update to the Committee. The draft budget shows a deficit of £(4.1m). This position is predicated on achieving the 15/16 forecast of £(6.0m) set off by the capital to revenue transfer of £3m i.e. a net position of a deficit of £(3.0m) . There are four main actions required to firm up the budget: -
Complete a demand & capacity plan for emergency activity Surgical Division to provide a capacity plan for elective activity describing cost and income Complete a demand and capacity plan for outpatients Directors to complete actions on the CIP
The Committee noted that the CIP is set at £9.2m v a forecast outturn of £4.8m for 15/16 although it recognised the contingency in the budget of £3.5m of which £1.5m is specific to nurse costs. The Committee asked that a percentage of the saving be applied depending on which gateway had been achieved; that the CIP is phased to show the rate required by quarter and that a total in excess of £9.2m be scoped to allow for underachievement; the Carter analysis may be helpful. The Committee sought assurance around the agency cap and the hourly rate. Fiona Allsop commented that how effective the cap is going to be is still not clear. Paul Biddle sought clarification on whether the negotiations with agencies are local or being conducted on a national scale. Fiona Allsop confirmed that the negotiations are on a local basis. Richard Durban asked if the Carter work had been included in the budget with Peter Burnett confirming that Carter were not specifically included. Alan Hall highlighted that the phasing in the budget would result in the savings doubling and given the current run rate this would appear unrealistic. Saving would have to hit £1 million a month. Fiona Allsop commented that nursing saving that make up the bulk of savings would start to feed in from March. Gillian Francis-Musanu commented that savings planning had started earlier this year and many savings are ready to start from the beginning of the new financial year and hence are expected to deliver early. Actions: CIP: a percentage of confidence to be added to the budgets reflecting the likelihood of being achieved; savings to be phased by quarter – PS Carter : the M10 CIP update to discuss the integration of the Carter findings – PS
Nurse recruitment and Agency use ; an update report to the February FWC - FA The Committee then discussed the demand and capacity issues facing the Trust and the planning for this and noted that the status of the actions around Emergency, Elective and Outpatients would be reported to the February FWC as part of the 16/17CIP update. A discussion was had around the use of the restricted amount of Capital in the next financial year with Ian Mackenzie highlighting the more robust business case process that ensures better quality of capital spend. Action: Draft 16/17 Capital Plan to be presented to the February FWC 4
IM
WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M09 Mark Preston presented the Month 9 Workforce and Organisational Development paper. The Committee noted plans against each of the 6 strategic objectives would be refreshed, that a new set of KPIs would be in place for the new financial year, that work to deliver the Achievement review target would continue and that the definition and approach to delivering mandatory training was being reviewed.
5
CAPITAL AND ESTATES Capital & Estates Report M09 The Month 9 Capital report was presented. The Committee noted the openings of the IRU and the Macmillan Information Centre.
6
IT IT Report M09 The IT report was noted and the Committee extended their congratulations to the IT team in the successful upgrade to the new Cerner version.
8
GENERAL Date of next meeting Monday 23rd February 2016 8.30am â&#x20AC;&#x201C; AD65