Board papers July 2016 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

July 2016

Trust Board Meeting – IN PUBLIC Thursday 28th July 2016 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

11:00

11.30

12.15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 30th June 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 Frame Work & Significant Risk Register – For approval

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient Story For assurance

F Allsop

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

F Allsop/ D Holden

Paper

2.3

Safety & Quality Committee Update For assurance

R Shaw

Paper

2.4

Safety & Quality Committee Annual Report For assurance

R Shaw

Paper

OPERATIONAL PERFORMANCE Paper 3.1

Integrated Performance Report (M03) For assurance 3.1.1

Safety & Quality Performance Indicators

F Allsop/ D Holden

3.1.2

Operational & Access Performance Indicators

A Stevenson

3.1.3

Patient Experience Performance Indicators

F Allsop

3.1.4

Workforce Performance Indicators

M Preston

3.1.3

Finance Performance Indicators

P Simpson

13.00

13:25

3.2

2016/17 Financial Budget For approval

P Simpson

Paper

3.3

Finance & Workforce Committee Update For assurance

R Durban

Paper

3.4

Audit & Assurance Committee Update, Annual Audit Letter & Quality Account Audit For assurance

P Biddle

Paper

A Hall

Paper

3.5

Charitable Funds Committee Update For assurance

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Serious Incidents Quarterly Report For assurance

F Allsop

Paper

4.2

2016/17 Annual Plan â&#x20AC;&#x201C; Q1 Update For assurance

S Jenkins

Paper

4.3

SaSH Plus Update For assurance

S Jenkins

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note

A McCarthy

5.1.1

Finance and Workforce Committee

Paper

5.1.2

Safety & Quality Committee

Paper

5.1.3

Audit & Assurance Committee

Paper

5.2

ANY OTHER BUSINESS

A McCarthy

5.3

QUESTIONS FROM THE PUBLIC

A McCarthy

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

DATE OF NEXT MEETING 26th August 2016 at 11.00am

TRUST BOARD IN PUBLIC

Date: 28th July 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/Regional: •

NHS Improvement Consultation on Single Oversight Framework

Local: • Trust Wins Board Leadership Award • Nominations open for SASH Star Awards 2016 Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

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

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

TRUST BOARD REPORT –28th July 2016 CHIEF EXECUTIVE’S REPORT 1.

National/Regional Issues

1.1

NHS Improvement Consultation on Single Oversight Framework

NHS Improvement has set out the approach they propose to take in overseeing providers using a Single Oversight Framework for both NHS trusts and foundation trusts shaping the support they provide. It describes the proposed approach to: •

the main areas of focus of oversight

•

how they collect the information required from providers

•

how they identify potential concerns with a provider’s performance

•

how they segment the provider sector according to the level of challenge each provider faces. Alignment with CQC

•

NHS Improvement will use the new oversight framework to identify where providers need support in any of five areas (themes): •

Quality of care: use CQC’s most recent assessments of whether a provider’s care is Safe, Caring, Effective and Responsive, in combination with in-year information where available. This will also include delivery of the four priority standards for 7 day hospital services.

•

Finance and use of resources: oversee a provider’s financial efficiency and progress in meeting its financial control total. They are co-developing this approach with CQC.

•

Operational performance: support providers in improving and sustaining performance against NHS Constitution and other standards. These will include A&E waiting times, referral to treatment times, cancer treatment times, ambulance response times, and access to mental health services.

•

Strategic change: working with system partners they will consider how well providers are delivering the strategic changes set out in the 5YFV, with a particular focus on their contribution to Sustainability and Transformation Plans (STPs), new care models, and, where relevant, implementation of devolution.

•

Leadership and improvement capability: building on the joint CQC and NHSI well-led framework, they will develop a shared system view with CQC on what good governance and leadership looks like, including organisations’ ability to learn and improve.

•

Segmentation: Propose to segment the provider sector according to the scale of issues faced by individual providers. This will be informed by data monitoring and, importantly, judgement based on an understanding of providers’ circumstances. The segment a provider is in will determine the nature of the support provided. While this will be tailored to the circumstances of providers, they have identified three broad categories of support for providers – universal offers, targeted offers and mandated.

Segmentation does not in itself constitute an assessment of provider performance. NHS Improvement teams will work with providers to determine the appropriate, tailored, support package for each, including directly provided support and support facilitated by, for example, other parts of the sector. All interested parties and stakeholders to respond to the consultation by 5pm on 4 August 2016. The Trust is reviewing the consultation document and will respond to the consultation. Full consultation document is available: https://improvement.nhs.uk/resources/have-your-say-single-oversight-frameworkconsultation/

Local Issues

2.1

Trust Wins Board Leadership Award

I am pleased to confirm that the Trust won the Board Leadership Award in the national Patient Safety Awards which was announced on 5th July 2016. This is great national recognition for SASH and for our Trust Board.

2.2

SASH Star Awards 2016

Our SASH Star Awards publicly acknowledge and celebrate an individual or team’s exceptional contribution to the Trust’s ongoing success. We have aligned our awards to reflect our core values: Dignity and Respect; Compassion; Safety and Quality and One Team. Awards are offered in 9 categories, and will be presented to individuals and teams who work ‘above and beyond’ to provide the best service at all times. The nine categories are: • • • • • • • •

One Team: Frontline Team of the Year One Team: Behind the Scenes Team of the Year Innovation and Service Improvement Frontline Employee of the Year Behind the Scenes Employee of the Year Improving Patient Experience Volunteer of the Year Supporting Diversity in the Workplace

Nominations can be made by any member of Trust staff, service users, carers, patients, external agencies or voluntary organisations using our online forms at http://www.surreyandsussex.nhs.uk/working-for-us/benefits-for-staff/annual-staffawards/#categories Closing date is Friday 9 September 2016.

Recommendation

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

Michael Wilson Chief Executive July 2016

Date: 28Th July 2016

TRUST BOARD IN PUBLIC

Agenda Item: 1.7 REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance Executive Team throughout June & July 2016 Private Board in July

Action Required: Approval (√)

Discussion (√)

Assurance (√)

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

An Associated University Hospital of Brighton and Sussex Medical School

Legal and regulatory impact Financial impact Patient Experience/Engagement

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

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

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

Attachment: July 2016 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 28Th July 2016 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.

Board Assurance Framework

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

Current status

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). The draft BAF was agreed at the June Private Board. Since this review the risks have been reviewed. The only amendment to the risks agreed in July is to remove the 2nd of the 3 access risks; ‘There is a risk to the Trust’s priority to optimise the use of its bed base if it does not seek to mitigate against the impact of overcrowding in ED and high bed utilisation across its services’. When updating the supporting narrative, the content significantly mirrored the other two access risks. The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows:

Objective 1. Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers 2. Effective – As a teaching hospital deliver effective, improving and sustainable clinical 3

Red (15-25)

Amber (8-12)

Green (1-6)

An Associated University Hospital of Brighton and Sussex Medical School

Objective

Red (15-25)

Amber (8-12)

Green (1-6)

services within the local health economy 3. Caring – Working in partnership with staff, families and carers 4. Responsive – Become the secondary care provider of choice for our catchment population 5. Well led – Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model

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

Initial Risk Rating: Severity x Likelihood

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

S4 x L3 = 12

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

Initial Risk Rating: Severity x Likelihood

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

S4 x L3 = 12

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

Initial Risk Rating: Severity x Likelihood

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

S3 x L3 = 9

Current Risk Rating: Severity x Likelihood

S4 x L2 = 8

Current Risk Rating: Severity x Likelihood

S3 x L3 = 9

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

Target Risk Score

S4 x L1 = 4

Target Risk Score

S3 x L2 = 6

Target Risk Score

S3 x L2 = 6

An Associated University Hospital of Brighton and Sussex Medical School

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

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

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

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S5 x L2 = 10

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

S4 x L3 = 12

S3 x L3 = 9

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S3 x L2 = 6

S3 x L4 = 12

S3 x L5 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

Target Risk Score

An Associated University Hospital of Brighton and Sussex Medical School

2.3.

Key risks Strategic risks Identified

The BAF highlights the following 7 key red risks to the Trust objectives that have been identified at time of updating the framework (not including the proposed reduction). As follows: Risk description

Target risk Current rating score

4.1 There is a risk that the Trust will not meet its objective of becoming the secondary provider of choice for our catchment area if it does not deliver all national standards including seven day working. 4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on income, expenditure and ultimately quality objectives. 5.1 Failure to deliver income plan. 5. 2 Failure to stop divisional overspending against budget. 5. 3 Unable to deliver medium term financial plan.

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position. 5.6 The continuing challenge to recruit and retain clinical staff is impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits.

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S5 x L2 = 10

S5 x L3 = 15 S5 x L3 = 15

S4 x L2 = 8 S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L5 = 15

S3 x L2 = 6

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. The controls and supporting mitigation systems relating to unplanned use of the recovery unit have been reviewed and the Executive team have agreed to downgrade this risk from the SRR. 3.1 SRR Breakdown ID 1401 1491 1501 1603

Title Risk of outbreak of viral gastroenteritis Failure to maintain Emergency Department performance Patient admitted to the right bed first time Unable to deliver realistic

Initial Rating 16

Current Rating 15

Residual Next Rating Review 9 29/07/2016

29/07/2016

31/07/2016

An Associated University Hospital of Brighton and Sussex Medical School

1604

1663 1678 1688 1689 1779

medium term financial plan Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position Risk of not achieving Cost Improvement Plan RTT Access Standards Risk of potential overspending from operational pressures Risk of Contract income below plan Failure to delivery productivity gain from income growth

31/07/2016

19/08/2016

15 16

6 6

29/07/2016 19/08/2016

15/09/2016

19/08/2016

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: ď&#x201A;ˇ Does the Board agree with the recorded controls and assurances ď&#x201A;ˇ Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Director of Corporate Affairs July 2016

Colin Pink Head of Corporate Governance

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. The Board acknowledges that financial challenges throughout 2016/17 will be significant and there will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 2: SASH risk quantification matrix

An Associated University Hospital of Brighton and Sussex Medical School

Abridged consequence chart Risk Type Patient Safety

Insignificant  No obvious injury / harm

Minor

Moderate

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

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

Health & Safety

 Avoidable death

 Minor harm event involving >5 patients

 Moderate harm event involving >5 patients

 Major harm incident involving >5 patients

 Minor unsatisfactory patient experience related to treatment / care given

 Unacceptable patient experience related to poor treatment / care

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

 Informal complaints raised / PALS contacted

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

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

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

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

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

 No harm injury

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

 Medical treatment required

 Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

 Death (RIDDOR reportable)

 Minor loss £2K to £100k

 Moderate loss, £100k - £1M

 Major loss, £1M-£10M

 Loss > £10M

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

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

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

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

 Adverse Monitor continuity of service rating <1 month

 Adverse Monitor continuity of service rating > 1 month

 A breach of Monitor Terms of authorisation

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

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

Financial Management  Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

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

 Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

An Associated University Hospital of Brighton and Sussex Medical School

Page 1

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference Director responsible 1.A Consistently meet national patient safety standards in all specialties and across divisions Initial Risk Key Action for 2015/16 objectives 1.1 There is a risk that the Trust will Current rating and description of any potential not meet its objective to be within significant risk to this priority the top 20% benchmark for safety Target risk score standards if opportunities to innovate and learn from Linked to Risk benchmarked outcome data/peer review are not adopted and implemented Controls in place (to manage the risk) 1. Clinical teams in place to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance 4. Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5. Work undertaken to deliver â&#x20AC;&#x2DC;5 sign up to safety pledgesâ&#x20AC;&#x2122; (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) 6. Matron on site 7 days a week to monitor nursing patient care and staffing 7. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 8. Nursing staffing levels monitored daily and issues managed 9. Incident reporting policy in place and monitored 10. Ward safety boards updated regularly and ward performance discussed at divisional level 11. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 12. Training undertaken for clinical staff in the assessment and management of patients at risk of falls 13. Patient falls strategic group meet monthly and report KPIs to the patient safety committee. 14. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR. 15. RCA analysis training delivered for new managers/leaders 16. IPCAS Team and Group in place, Weekly taskforce in place 17. Infection control manual in place and information resources available 18. Antibiotic policy and guidelines in place 19. Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues.

Page 2

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

Gaps in Control 1) Developing ward safety dashboards 2) Ward accreditation system under development 3) Updating and 4) Embedding DATIX incident review process within 14 day timeframe 5) Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 6) High bed occupancy can cause infection control risk to increase (e.g. side room availability)

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. opportunity walks) 2) Ward Dashboards 3) Divisional and Trust Level Dashboards 4) VMI/SASH Plus Program

Actual Assurances: Positive (+) or Negative (-) 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 audit (+) 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 reduction in falls with harm in year (+) Strong evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+)Initiation of ‘Stop, Access, Send’ initiative for the management of loose stool (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Antimicrobial prescribing audit compliance Negative (-) Never events incidence (-) NRLS reporting (-) Incidence of CDI 2015/16

Gaps in assurance Ability to benchmark in real time

Assurance Level gained: RAG

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

Page 3

FA 15/07/16

Date discussed at board

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

July 2016

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

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

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

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

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

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

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

Assurance Level gained: RAG

Mitigating actions underway

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

1) Strategic actions being developed

Update by

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DH 20/07/2016

Date discussed at Board

July 2016

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

S3 x L2 = 6 TBC

Positive Carers passport Opening visiting (going live in September) Standards of behavior and feedback from staff Recent cancer survey results Negative No clear improvement in YCM or national results relating to discharge or communication around medication and danger signals Outpatient YCM comments Assurance Level gained: RAG

Mitigating actions underway

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S3 x L3 = 9 S3 x L3 = 9

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

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

1. Focus groups among recently discharged inpatients 2. Open visiting 3. Re-procuring the YCM service Update by FA 15/07/2016

Chief Nurse

Date discussed at Board

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

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

Controls in place (to manage the risk) 1) EDD Patient Pathway 2) Pathways under review and being implemented 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) 7 day medical consultant ward rounds established 7) Additional community beds* 8) Increasing hospital at home capacity 9) Integrated Reablement Unit built* 10) Safer Care Bundle 11) SRG plans and agreements* 12) Urgent and Emergency care implementation plan 13) Daily Cancer access meeting 14) Fortnightly Elective Care Board 15) Weekly divisional patient tracking list meetings *Owned by local health economy 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. *Owned by local health economy Page 6

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

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

Actual Assurances: Positive (+) or Negative (-) Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex* (+) ED Standard delivered May June 16 (+) Cancer 62 day delivered since Feb 16 (+) RTT incompletes delivered consistently (+) 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 Jan to April 16 (-) Cancer 2 week wait Access standard not delivered April to June 16 (-) 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) *Owned by local health economy Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway 1) 2) 3) 4) 5) 6)

Refresh winter capacity plans based on assessment of Q1 activity SRG Winter planning Review of pathways Delivery of internal actions relating to Urgent and Emergency care implementation plan Ambulatory care unit delivery Frailty unit

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BE 22/07/2016

Date discussed at Board

Assurance Level gained: RAG

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

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference Director responsible 4. Responsive to people’s needs – Chief Operating Officer Become the secondary care Initial Risk S5 x L3 = 15 provider of choice for the catchment population Key Action for 2015/16 objectives 4.3 There is a risk that if the Trust Current rating S5 x L3 = 15 and description of any potential does not deliver the planned significant risk to this priority efficiencies it will be unable to create Target risk score S5 x L2 = 10 the necessary capacity, which will have an adverse impact on income, Linked to Risk 1221, 1480, 1601, 1405, 1547 expenditure and ultimately quality objectives. Controls in place (to manage the risk) 1) Transformation Team in place 2) System Resilience Group 3) CEO strategic meetings 4) Partnership boards 5) Trust part of national Virginia Mason transformation programme 6) Integrated Reablment Unit build complete 7) Operational and Acute capacity 8) Systems developed to support winter 9) Safer Care Bundles and Toolkits 10) Transformational boards 11) SRG actions and commitments* 12) Exec Internal Productivity Work streams 13) Carter actions and reviews *Owned by local health economy Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting

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 4) Delivery of internal actions relating to Urgent and Emergency care implementation plan* *Owned by local health economy

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 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)

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Gaps in assurance 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, LOS) 2) Delivery of internal actions relating to Urgent and Emergency care implementation plan

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BE 22/07/2016

Date discussed at Board

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Ongoing

July 2016

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

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

Gaps in assurance Development of next phase plans

Assurance Level gained: RAG

Mitigating actions underway Development of next phase plans due for submission 30.09.16

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

Update by

July 2016

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GFM 14/07/2016

Date discussed at Board

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

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

5.A Live within our means to remain financially sustainable

Director responsible

Chief Finance Officer

Initial Risk

S5 x L3 = 15

5.1 Failure to deliver income plan

Current rating

S5 x L3 = 15

Target risk score Linked to Risk

S4 x L2 = 8 1689

Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity/ financial) savings & productivity plans. 1) There are issues with Sussex over MRET and the provision of services to 2) Agreed contracts in place with main sets of commissioners (NHSE and manage urgent care (hence separate transformation meeting). 2) Winter demand has been a significant issue, and activity continues to CCGs) – all Contracts were finally signed in May. 3) Contract management process in place (this operated effectively in 2015/16). describe growth. This is an SRG issue. 3) The strategic management of activity is not currently effective, but the Trust is 4) Financial reporting, including periodic forecast scenarios, is in place and doing all it can to support making it so. effective – the first detail forecast to Board in July. 5) SRG and Transformation meetings in place and operating – specific joint working with ESCCG and Surrey County Council. Potential Sources of Assurance (documented evidence Actual Assurances: Positive (+) or Negative (-) of controls effectiveness) Positive 1) Financial performance and contractual reporting to Exec (+) The reconciliation process is seeing payment for over performance against CCG contract plans Committee, Finance & Workforce Committee and Trust [although the process has seen delay in payments in 15/16, which should be corrected by contract Board (including CQUIN reporting process). clauses in 16/17] 2) Performance Review (PMO) and Exec Quality and Risk (+) At M03 income is above plan (noting the profile) process with Divisions, monthly contract cycle with CCGs. (+) East Surrey CCG have agreed MRET threshold increase. Service line reporting process 3) Outputs and reporting from contract and information Negative teams (-) Risk over income growth assumptions, primarily because of capacity and the unplanned increase 4) Output and reporting from health system management in elective referrals (and happening earlier than anticipated) (e.g.: System Resilience Groups and Chief Officer Meetings) (-) Dispute with Sussex over MRET changes 5) Output of Contract Management Process . (-) Too much non elective activity, not enough elective – risk over emergency demand (-) disputes over 2015/16 income not yet resolved (reconciliation process is now in train) Gaps in assurance Assurance Level gained: RAG Red because of level of risk, issues with strategic health system management of urgent care activity and transactional processes with CCGs.

Mitigating actions underway 1) Complete all contractual commitments according to timetable; 2) Revise forecast for elective activity for M04; 3) Embed the integrated reablement unit and open the frailty unit (both joint working with ESCCG). 4) Robust contractual processes being operated. Update by Date discussed at Board PS 18/07/2016

Page 11

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

July 2016

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

5.A Live within our means to remain financially sustainable

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

5. 2 Failure to stop divisional overspending against budget

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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S3 x L2 = 6 Linked to Risk 1663,1688 Gaps in Control 1) Cost improvement plan forecasts (CIPs delivering at M03) suggest adverse delivery on agency (medical and nursing). 2) There is overspending in specific areas – notably Radiology and WaCH (less so in Medicine and E&F).

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

Positive (+) Budget changes made to match activity – overall spend is within tolerance (noting overspending areas and budget profile) at M03 (+) Internal audit advises CIP process is sound (but notes non-delivery, see below) Negative (-) Internal audit advises effectiveness of savings delivery rated red/amber – risk to forecast. (-) Nurse agency CIP reported to FWC shows use of contingency, but still means a £0.6m shortfall without further action (-) Emergency activity pressures have continued and unplanned increase in elective referrals (-) Overall agency costs remain very high, with escalation still in use and significant costs across Divisions. Gaps in assurance Assurance Level gained: RAG Overspending and agency savings delivery are the main areas of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans Actions proceeding to timetable 2) Additional PMOs in place for agency control 3) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement. The latter tightened again in February (and maintained since then) 4) Decisions on business cases taken in light of affordability and contribution. Update by Date discussed at Board PS 18/07/2016 July 2016

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Objective 5 â&#x20AC;&#x201C; Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

5.A Live within our means to remain financially sustainable

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

5. 3 Unable to deliver medium term financial plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S4 x L2 = 8 Linked to Risk 1603 Controls in place (to manage the risk) Gaps in Control 1) Items referred to in 5.A.1 and 5.A.2 above 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) V8.0 long term financial model and integrated business plan 2) Reliance on centrally determined rules for PbR, Better Care Fund and the wider completed (submitted to Monitor in June 2016) and supports NHS finance regime. 2016/17 budget 3) Risk over capacity from other operational pressures 3) TDA Plan submitted in April 2015, 2016/17, resubmitted (minor 4) Overall health system financial view describes significant loss of resource to BCF cash changes) July 2016 funding and recovery of non recurrent actions in CCGs in 2015/16- reduces 4) Cost improvement plan process in place (including PMO structure) resource available for health and social care overall. 5) Demand and capacity planning for 2016/17 is ongoing but his 5) Central actions over NHS overspend may have an adverse impact on Trust hitting milestones because of manner of application (e.g. withholding capital and cash). 6) Contracts agreed with commissioners 6) STP process identifies significant â&#x20AC;&#x153;do nothingâ&#x20AC;? deficit [noting impact of actions reduces that considerably] Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Production of 2016/7 budget, revised long term Positive financial model and integrated business plan (+) Expect to hit STF milestones for first quarter STF payment documentation, and delivery against them 2) Agreed contracts with commissioners describing Negative realistic demand and acceptable financial values (-) overall health system loss of resource in 2015/16 (to BCF and from CCG non recurrent recovery) 3) Sign off of sustainability & transformation funding (-) Health system STP footprint in overall deficit. with NHS Improvement Gaps in assurance Significant risk and unknown impact of central actions to manage NHS overspending. Mitigating actions underway

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

Please see items above. Update by

Page 13

Assurance Level gained: RAG

PS 18/07/2016

Date discussed at Board

July 2016

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

5.A Live within our means to remain financially sustainable

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

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

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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score

S4 x L3 = 12

Linked to Risk

1604

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

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

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PS 18/07/2016

Date discussed at Board

July 2016

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

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

Gaps in assurance Some of the individual strategies / work-plans (i.e. Inclusion, Well-Being, Education & Training), which support the overarching Trust Workforce Strategy are still being developed Mitigating actions underway 1) Individual strategies with objectives and action plans being drafted for approval 2) ‘It’s Not Okay’ campaign being developed to address issues of bullying and harassment 3) Promotion of 2016 AR cascade process on-going Trust-wide to support delivery of 90% compliance rate 4) Pro-active Recruitment planning in place including international campaigns 5) 2016/17 Q1 Actions for the Health CQUIN being delivered Update by Date discussed at Board MP 14/07/2016

Page 16

Assurance Level gained: RAG

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

July 2016

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

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 NHSI

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

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

Assurance Level gained: RAG

Mitigating actions underway 1. 2. 3. 4.

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

Update by

Page 18

FA 15/07/2016 and DH 20/07/2016

Date discussed at Board

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

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

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

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

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

1. Procurement and implementation of replacement EPR - complete 2. Establishment of Chief clinical Information Officer role - complete 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years 5. EPR Roadmap now approved by Executive and approval to proceed agreed 6. EPR Digitise Business Case now approved 7. Move to latest version of Cerner software now taken place Update by Date discussed at Board IM 11/07/2016

Page 19

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

July 2016

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

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

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

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

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

Page 21

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

D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Risk of outbreak of viral Surveillance of diarrhoea and gastroenteritis (outbreak of vomiting diarrhoea and vomiting). Red aprons system Impact on patient safety 16 and trust reputation. Has Stat and mandatory training operational impact due to Policy bed closures. 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.

Due date

Done date

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

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

Next Review

Treatment Plan

Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Trial and review of decontamination products in use in the Trust Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&V Meeting with stakeholders regarding norovirus preparedness 5 15 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 Review of cleaning resource for enhanced cleaning

Residual Rating

Current Rating

Current Likelihood

Current Consequence

Existing controls

29/07/2016

Risk of outbreak of viral gastroenteritis

Description

Initial Rating

Risk Owner

Specialty

Open Date

Committee

Risk Type Patient Safety

Holden, Des

Medical Director's Office

23/01/2013

Safety

1401

Title

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

31/03/2014 22/02/2016 01/09/2016 30/09/2015 30/09/2015 01/09/2016 01/09/2016 31/12/2015 23/05/2016

29/07/2016

Involvement of Service Users

Operations

Stevenson, Angela

29/08/2013

Responsiveness

1491

Failure to maintain Emergency Department performance

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

As described on the board assurance framework Implementation of divisional escalation plan following key triggers. Escalation bed plan agreed implementation plans in place for each area. Ambulance handover escalation plan agreed and in place with new process for managing handovers 4 16 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.

Risk of not achieving Cost Improvement Plan

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

i) Delivery of savings managed through PMO (ongoing) ii) Agency management is subject to broader focus and structure of PMOs for this is in place. iii) Reporting internally and to FWC.

As described on the BAF

01/09/2016

Treatment plan will vary according to CIP. i) Action plans to reduce shortfall. ii) 31/03/2017 4 16 Contingency within each area.

29/07/2016

3 15

23/09/2016

31/07/2016

As described on the BAF

31/07/2016

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

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

27/06/2014 31/03/2014 31/08/2015 23/11/2015 18/01/2016 14/06/2016

19/08/2016

Involvement of Service Users

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

Financial Management

3 15

Financial Management

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

Financial Management

Operations

Stevenson, Angela

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

Simpson, Paul

Finance - Fin. Management

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

Simpson, Paul

Finance - Fin. Management Finance - Fin. Management

19/09/2013

Responsiveness

18/06/2014

Executive Committee

18/06/2014

Executive Committee

09/12/2014

Executive Committee

1501 1603 1604 1663

Patient admitted to the right bed first time

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

Risk of Contract income below plan

Failure to delivery productivity gain from income growth

i) Divisions to implement action plans and contingencies to control/or recover overspending. Risk of failure to meet the Specific action is required in all Trusts financial plan due to Divisions. 16 overspending. ii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing). i) Continuation of 2015/16 actions Risk the Trust does not around internal management and achieve its financial plan as external management; the health a result of lower than system response will need to 16 planned contract income improve in 2016/17 and the basis of from capacity issues. that is currently being navigated through SRG.

Risk to Trust overall financial plan as a result of not achieving productivity gain from income growth.

i) Budgeted income/activity and financial budget agreed, plus business plans from Divisions. ii) Monitored through financial and activity reporting. iii) PMO management and CEO Productivity Group.

4 16

As described on the BAF.

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

31/03/2017

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

29/07/2016

19/08/2016

Manage the number of IPs booked on lists to avoid 27/02/2015 09/02/2015 cancellations 20/06/2015 05/08/2015 5 15 Improve Theatre Utilisation 15/05/2015 18/09/2015 Ring-fencing of Tandridge and Woodland Wards

15/09/2016

Risk of potential overspending from operational pressures

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

19/08/2016

Service Access Financial Management Financial Management Financial Management

Operations

Emly, Ben Simpson, Paul

Finance - Fin. Management

Simpson, Paul

Finance - Fin. Management

Simpson, Paul

Finance - Fin. Management

Responsiveness

23/03/2015 20/05/2015

Executive Committee

01/04/2015

Executive Committee

21/06/2016

Executive Committee

1678 1688 1689 1779

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

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item: 2.1

REPORT TITLE:

Patient Story

EXECUTIVE SPONSOR:

Fiona Allsop, Chief Nurse Nicola Shopland Divisional Chief Nurse Medicine

REPORT AUTHOR (s): Stephanie Biden - Divisional Risk and Governance Manager, Medicine & Cancer REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Patient Safety Executive

Action Required: Approval ()

Discussion (√)

Assurance (√)

Purpose of Report: Patient story to share with the Board. Summary of key issues Complaint raised and responded to by medical division, the complaint was reopened as the patient’s daughter wished to gain further clarity over several issues surrounding her mother’s admission and final days before her death. A local resolution meeting was held attended by Chief Nurse, Chief of Medicine and the Divisional Chief Nurse for Medicine. The complaint covered the patient’s experience in the Emergency Department; concerns around her daughter being excluded from the resuscitation room and communication about her mother’s immediate condition. The patient was then admitted to Chaldon Stroke Unit and there were on-going issues with communication, particularly around the DNAR discussion, identifying to the family who the responsible consultant was and ensuring the family were aware of the treatment plan. Recommendation: For information and assurance Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population Corporate Impact Assessment:

Legal and regulatory impact

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

Financial impact

Nil

Patient Experience/Engagement

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

Risk & Performance Management

NHS Constitution/Equality & Diversity/Communication

See above

Attachment: N/A

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item:

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 focused patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues Chief Nurse Report  The Safer Staffing report (June 2016 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template.  Care Hours Per Patient Day (CHPPD) reported for June data  Provides an update on the National Quality Board guidance published in July titled ‘Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time’. Medical Director Report  HSJ patient safety awards  BMA ballot of junior doctors on new contract deal  MRSA colonisation of a cohort of patients in Capel Annex ward Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model Corporate Impact Assessment: Legal and regulatory impact

Yes

Financial impact

Yes

Patient Experience/Engagement

Yes

Risk & Performance Management

Yes

NHS Constitution/Equality & Diversity/Communication

Yes

Attachment:

nqb-guidance July 2016.pdf

Page 1

REPORT TO TRUST BOARD IN PUBLIC – 28TH July 2016 Chief Nurse & Medical Director Report

Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring, a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2.

Staffing Planned versus Actual – June 2016

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

98.82%

100%

96.96%

100%

97.85%

100%

98.69%

Acute Medical Unit

300 - GENERAL MEDICINE

98.85%

99.53%

88.9%

98.33%

95.95%

99.1%

97.35%

Birthing Centre

501 - OBSTETRICS

96.67%

98.33%

N/A

96.67%

98.33%

97.5%

Bletchingley Ward

300 - GENERAL MEDICINE

99.74%

100%

99.86%

100%

99.91%

Brockham Ward

502 - GYNAECOLOGY

98.35%

98.89%

95.08%

100%

97.25%

99.17%

98.01%

Brook Ward

100 - GENERAL SURGERY

100%

Buckland Ward

101 - UROLOGY

98.64%

100%

95.06%

98.33%

97.21%

99.17%

97.94%

Burstow Ward

501 - OBSTETRICS

98.88%

77.78%

79.35%

90%

92.37%

82.67%

87.96%

Capel Annex l Ward

100 - GENERAL MEDICINE

97.21%

100%

96.28%

98.33%

96.81%

99.17%

97.67%

Capel Ward

430 - GERIATRIC MEDICINE

96.78%

97.78%

96.69%

105%

96.75%

100.67%

98.45%

Chaldon Ward

300 - GENERAL MEDICINE

96.26%

100%

95.11%

98.88%

95.77%

99.33%

96.98%

Charlwood Ward

301 - GASTROENTEROLOGY

95.73%

103.33%

100.99%

100%

97.63%

101.67%

99.23%

Copthorne Ward

301 - GASTROENTEROLOGY

100%

98.94%

100%

99.64%

100%

99.78%

Coronary Care Unit

320 - CARDIOLOGY

98.17%

100%

N/A

96.67%

98.17%

98.89%

98.53%

Delivery Suite

501 - OBSTETRICS

93.7%

96.67%

93.84%

95%

93.73%

96.25%

94.99%

Discharge Lounge

300 - GENERAL MEDICINE

98.13%

100%

98.09%

100%

98.11%

100%

98.79%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

98.33%

100%

92.59%

100%

96.55%

100%

97.97%

Godstone Ward (Med)

300 - GENERAL MEDICINE

99.33%

100%

95.56%

99.58%

97.78%

98.81%

Hazelwood

300 - GENERAL MEDICINE

97.78%

100%

93.1%

100%

95.48%

100%

97.31%

Holmwood Ward

320 - CARDIOLOGY

100%

96.67%

98.31%

99.05%

99.16%

99.09%

ITU/HDU

192 - CRITICAL CARE MEDICINE

98.91%

100%

87.77%

89.66%

97.29%

99.24%

98.22%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

99.26%

100%

98.11%

98.89%

98.76%

99.33%

98.98%

Meadvale Ward

430 - GERIATRIC MEDICINE

98.19%

100%

98.28%

98.33%

98.24%

99.17%

98.56%

Neonatal Unit

420 - PAEDIATRICS

96.49%

104.2%

104.64%

98.11%

99.15%

102.33%

100.62%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

98.62%

100%

102.79%

97.78%

100.37%

98.67%

99.71%

Nutfield Ward

430 - GERIATRIC MEDICINE

94.75%

100%

98.19%

96.67%

96.04%

98.33%

96.8%

Outwood Ward

420 - PAEDIATRICS

94.72%

98.67%

81.53%

90%

93.08%

97.22%

94.89%

Page 2

Rusper Ward

501 - OBSTETRICS

89.71%

98.33%

N/A

90.25%

98.33%

92.95%

Surgical Assessment Unit

100 - GENERAL SURGERY

94.17%

95%

100%

98.33%

95.33%

96.67%

95.93%

Tandridge Ward

300 - GENERAL SURGERY

98.17%

100%

127.44%

96.67%

111.2%

98.33%

107.24%

Tilgate Annex

100 - GENERAL MEDICINE

100%

98.39%

98.8%

103.33%

99.56%

100.82%

99.99%

Tilgate Ward

300 - GENERAL MEDICINE

98%

98.89%

96.67%

97.5%

98.33%

97.78%

Woodland Ward

100 - GENERAL SURGERY

98.67%

100%

98.89%

96.67%

98.75%

98.33%

98.61%

97.61%

98.88%

98%

98.08%

97.74%

98.58%

98.08%

Total

Planned versus actual commentary The Trust has delivered planned versus actual staffing profile for June. The report shows a stable picture in relation to overall compliance with no red shifts at unit level in month. Care hours per patient day (CHPPD) Only complete sites your organisation is accountable for

Day Main 2 Specialties on each ward

Ward name

Specialty 1

Abinger Ward

430 - GERIATRIC MEDICINE

Acute Medical Unit

300 - GENERAL MEDICINE

Birthing Centre Bletchingley Ward Brockham Ward

501 - OBSTETRICS 300 - GENERAL MEDICINE

Day

Night

Care Hours Per Patient Day (CHPPD)

3344.5

3229

1417

1321

2415

2334.5

1380

1334

96.5%

93.2%

96.7%

690

100.0%

3314.5

3121

2962.5

2936

1725

1621.5

1380

1368.5

94.2%

99.1%

94.0%

99.2%

1387

1310.5

670.5

647.5

701.5

678.5

621

94.5%

96.6%

96.7%

91.5%

690

344.5

321.5

690

667

126.5

100.0%

93.3%

96.7%

100.0%

1505.5

1425.5

796.5

739.5

690

655.5

667

632.5

94.7%

92.8%

95.0%

94.8%

501 - OBSTETRICS

1380

1141.5

690

543.5

1035

759

690

609.5

82.7%

78.8%

73.3%

88.3%

Capel Annex l Ward

300 - GENERAL MEDICINE

1380

1357

1035

985

690

678.5

690

678.5

98.3%

95.2%

98.3%

Capel Ward

430 - GERIATRIC MEDICINE

1545

1408.5

690

655

1035

1012

690

91.2%

94.9%

97.8%

100.0%

Chaldon Ward

300 - GENERAL MEDICINE

2602

2381

2070

1997

1380

1322.5

1472

1380

91.5%

96.5%

95.8%

93.8%

Charlwood Ward

301 - GASTROENTEROLOGY

1336

1217.5

739.5

716.5

690

920

655.5

667

91.1%

96.9%

133.3%

101.8%

Copthorne Ward

301 - GASTROENTEROLOGY

1368.5

1207

733.5

810.5

690

632.5

690

678.5

88.2%

110.5%

91.7%

98.3%

Coronary Care Unit

320 - CARDIOLOGY

1000.5

862.5

690

678.5

356.5

322

86.2%

100.0%

98.3%

90.3%

Delivery Suite

501 - OBSTETRICS

2096

1981

697.5

597.5

2058.5

1851.5

690

563.5

94.5%

85.7%

89.9%

81.7%

300 - GENERAL MEDICINE

664.5

570.5

598

529

345

333.5

345

333.5

85.9%

88.5%

96.7%

Brook Ward Buckland Ward Burstow Ward

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

502 - GYNAECOLOGY

Night

Registered Registered Cumulativ Care Staff Care Staff midwives/nurses midwives/nurses e count Average fill rate Average fill rate over the Registered Total Total Total Total Total Total Total Total - registered Average fill rate - registered Average fill rate month of midwives/ Care Staff monthly monthly monthly monthly monthly monthly monthly monthly nurses/midwives - care staff (%) nurses/midwives - care staff (%) nurses patients at planned actual planned actual planned actual planned actual (%) (%) 23:59 each staff hours staff hours staff hours staff hours staff hours staff hours staff hours staff hours day 1279.5 1150.5 1387 1337.5 701.5 701.5 943 931.5 89.9% 96.4% 100.0% 98.8% 2.6 3.2 700

100 - GENERAL SURGERY 101 - UROLOGY

303 - CLINICAL HAEMATOLOGY

690

697.5

690

678.5

101.1%

98.3%

300 - GENERAL MEDICINE

1035

931.5

690

605.5

690

724.5

90.0%

87.8%

100.0%

320 - CARDIOLOGY

1725

1652

682

636

667

655.5

644

95.8%

93.3%

98.3%

100.0%

192 - CRITICAL CARE MEDICINE

4406

4299.5

669.5

428.5

4381.5

4324

333.5

310.5

97.6%

64.0%

98.7%

93.1%

110 - TRAUMA & ORTHOPAEDICS

1552.5

1526.5

1155

1011

690

678.5

690

678.5

98.3%

87.5%

98.3%

430 - GERIATRIC MEDICINE

1192.5

1090

1380

1334

701.5

690

91.4%

96.7%

98.4%

100.0%

420 - PAEDIATRICS

1437.5

1426

628.5

582.5

1391.5

1426

621

506

99.2%

92.7%

102.5%

81.5%

110 - TRAUMA & ORTHOPAEDICS

1545

1461

1140

991

690

667

690

586.5

94.6%

86.9%

96.7%

85.0%

430 - GERIATRIC MEDICINE

1716

1636

1037.5

992

690

701.5

95.3%

95.6%

100.0%

101.7%

Outwood Ward

420 - PAEDIATRICS

2652

2560

424

1794

1805.5

345

241.5

96.5%

100.0%

100.6%

70.0%

Rusper Ward

501 - OBSTETRICS

828

793.5

690

95.8%

100.0%

Surgical Assessment Unit

100 - GENERAL SURGERY

1380

1334

345

299

690

655.5

690

598

96.7%

86.7%

95.0%

86.7%

Tandridge Ward

300 - GENERAL MEDICINE

1565.5

1354

1198.5

998.5

701.5

655.5

690

632.5

86.5%

83.3%

93.4%

91.7%

Tilgate Annex

300 - GENERAL MEDICINE

1725

1656

1011.5

1000

1035

897

690

701.5

96.0%

98.9%

86.7%

101.7%

Tilgate Ward

300 - GENERAL MEDICINE

1725

1656

1000.5

977.5

1035

989

345

96.0%

97.7%

95.6%

100.0%

Woodland Ward

100 - GENERAL SURGERY

1725

1571.5

996

1007.5

667

644

91.1%

101.2%

100.0%

96.6%

1085 55 775 566 359 631 590 710 631 905 605 629 253 157 132 207 866 877 447

Overall

5.9

5.1

2.4

7.6

25.1

0.0

25.1

6.1

5.6

11.7

3.5

2.2

5.8

3.8

1.2

5.0

3.3

2.2

5.5

3.2

2.0

5.2

2.9

2.3

5.2

3.8

2.1

6.0

4.1

3.7

7.8

3.5

2.3

5.8

2.9

2.4

6.1

1.4

7.5

24.4

7.4

31.8

6.8

6.5

13.4

6.6

0.0

6.6

1.9

1.5

2.6

1.5

4.1

19.3

1.7

20.9

823 794 522

2.7

2.1

4.7

2.2

2.5

4.8

5.5

2.1

7.5

863 907 566 241 257 718 735 878 677

2.5

1.8

4.3

2.6

1.9

4.4

7.7

1.2

6.2

0.0

6.2

7.7

3.5

11.2

2.8

2.3

5.1

3.5

2.3

5.8

3.0

1.5

4.5

3.3

2.4

5.7

5.3

3.4

8.9

CHPPD commentary The report for June is shown above. The data comparison with May shows that broadly there were less CHPPD used across the acute inpatient wards in the month. Care hours per patient day are calculated by dividing the total numbers of nursing hours on a ward or unit by the number of patients in beds at the midnight census. This calculation provides the average number of care hours available for each patient on the ward or unit. Currently the hours reported for nursing only in acute inpatient wards which are shown the white. The orange areas are excluded. This tool links with planned versus actual reporting and other data such as safety thermometer, incident reporting, sickness rates, vacancy rates and professional judgement to determine the appropriate staffing levels for a ward or unit. Agency Cap reporting to NHS Improvement Since November 2015, the Trust has been required to report to NHSI shifts that are above the rate cap, off of a framework or both. The Trust use Mayday nursing agency as the main tier 1 provider. At the current time, the majority of these shifts are above the agency capped rate. All shifts above the rate cap are subject to use only in ‘break glass’ circumstances. The justification of use for each shift is recorded on the Healthroster system. The total number of break glass shifts for all staff groups in June 2016 were 2,655.

Page 3

National Quality Board guidance In July 2016 the National Quality Board (NQB) published revised guidance on safe, sustainable and productive staffing. This guidance entitled ‘supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time’ replaces the guidance published in November 2013. The new guidance contains a set of expectations for nursing and midwifery staffing to help NHS provider boards make local decisions that will deliver high quality care for patients within the available staffing resource. It encompasses elements of the Carter report including the implementation of CHPPD as the principal measure of nursing, midwifery and healthcare support worker deployment. The guidance is presented in three sections; Section 1 – Safe, sustainable and productive staffing: measurement & improvement 1a) patient outcomes, people productivity and financial sustainability There is an expectation that NHS provider boards will review workforce metrics, quality indicators and outcomes and productivity measures on a monthly basis as a whole and that there is evidence of improvements across all of these areas. In addition there is an expectation that provider boards implement in full the Carter recommendations and the findings from the model hospital work (due in September 2016). This includes     

Using local quality and outcomes dashboards that are published locally and discussed at public board meetings Developing metrics that measure patient outcomes, staff experience, people productivity and financial sustainability Comparing performance against internal plans, peer benchmarks and the views of NHS experts, taking into account any underlying differences Reducing wasted time by supporting and engaging staff in using their time in the best way possible to provide direct or relevant care or care support Using national good practice checklists to guide improvement action and taking into account the knowledge shared by top performers

Commissioners will monitor providers quality and outcomes and provide support through the quality surveillance groups. NHS provider boards hold individual and collective responsibility for making judgements about staffing and the delivery of safe, effective, compassionate and responsive care within available resources. 1b) reporting, investigating and acting on incidents NHS providers should follow best practice guidance in the investigation of all patient safety incidents. In addition they should actively encourage all staff to report any occasion where a less than optimal level of suitably trained or experienced staff harmed or seems likely to harm a patient. Staff in all care settings should be aware that they have a professional duty to put the interests of the people in their care first, and to act to protect them if they consider that they may be at risk. All NHS providers should have an identified Freedom to Speak Up guardian and should be able to demonstrate commitment to the principles in the Freedom to Speak Up Review of February Boards should ensure that they support and enable their executive team to take decisive action when necessary. 1c) Patient, carer and staff feedback NHS providers need a co-ordinated approach and the right leadership skills in place to drive continuous improvements in patient outcomes and productivity. They should do this by Page 4

developing the appropriate culture and behaviours, where staff and teams are engaged in developing their organisations and they are supported, respected and valued. Boards must ensure that their organisations foster a culture of professionalism and responsiveness in healthcare professionals, so that staff feel able to use their professional judgement to raise concerns and make suggestions for change that improves care. NHS providers should have a strong staff engagement plan, which routinely monitors the impact of their policies, demonstrates an understanding of the links between staff experience, patient experience and outcomes, and which supports staff retention. When an establishment review has taken place within an organisation, the board should ensure it considers feedback from frontline staff as part of its assurance activities. Section 2 - Care hours per patient day (CHPPD) The introduction of CHPPD for nurse and healthcare support staffing in the inpatient/acute setting is the first step in developing the methodology as a tool that can contribute to a review of staff deployment. Work has begun to consider appropriate application of this metric in other care settings and to include other healthcare professionals such as allied health professionals (AHPs). As with other indicators, CHPPD should never be viewed in isolation but as part of a local quality dashboard that includes patient outcome measures alongside workforce and finance indicators. The aim is to help ward sisters/charge nurses, clinical matrons and hospital managers make safe, efficient and effective decisions about staff deployment: Section 3 - Updated NQB expectations Expectation 1: Right staff Boards should ensure there is sufficient and sustainable staffing capacity and capability to provide safe and effective care to patients at all times, across all care settings in NHS provider organisations. Boards should ensure there is an annual strategic staffing review, with evidence that this is developed using a triangulated approach (ie the use of evidence-based tools, professional judgement and comparison with peers), which takes account of all healthcare professional groups and is in line with financial plans. This should be followed with a comprehensive staffing report to the board after six months to ensure workforce plans are still appropriate. There should also be a review following any service change or where quality or workforce concerns are identified. Safe staffing is a fundamental part of good quality care, and CQC will therefore always include a focus on staffing in the inspection frameworks for NHS provider organisations. Commissioners should actively seek to assure themselves that providers have sufficient care staffing capacity and capability, and to monitor outcomes and quality standards, using information that providers supply under the NHS Standard Contract. The key elements are; ď&#x201A;ˇ

Evidence-based workforce planning

ď&#x201A;ˇ

Professional judgement

ď&#x201A;ˇ

Compare staffing with peers

Page 5

Clinical leaders should use the competencies of the existing workforce to the full, further developing and introducing new roles as appropriate to their skills and expertise, where there is an identified need or skills gap. The key elements are; 

Mandatory training, development and education



Working as a multiprofessional team



Recruitment and retention

Expectation 3: Right place and time Boards should ensure staff are deployed in ways that ensure patients receive the right care, first time, in the right setting. This will include effective management and rostering of staff with clear escalation policies, from local service delivery to reporting at board, if concerns arise. Directors of nursing, medical directors, directors of finance and directors of workforce should take a collective leadership role in ensuring clinical workforce planning forecasts reflect the organisation’s service vision and plan, while supporting the development of a flexible workforce able to respond effectively to future patient care needs and expectations The key elements are; 

Productive working and elimination waste



Efficient deployment and flexibility



Efficient employment, minimizing agency

Medical Director Report 3.

HSJ patient safety awards

As previously reported Sash was a finalist in these annual awards in two categories, organisation of the year and trust Board of the year. As many will by now know we were successful and won the latter award, with Frimley Hospitals winning the former category. 4.

BMA ballot of junior doctors on new contract deal

The result of this ballot was announced in early July where a majority of those who were ballotted voted to reject the proposed contract. The DoH is now implementing the new contract and instructing trusts to introduce from October and at SaSH we are working with HR and with junior doctor representatives to design and implement new Rita's in line with the new contract expectations. 5.

MRSA colonisation of a cohort of patients in Capel Annex ward

Patients within a single bay on Capel annex ward have been found to be colonised with an MRSA of similar antibiotic sensitivity profile. This implies that they have become colonised in our care. Infection control are leading work on risk profiling and education of staff and the relevant bay has been closed to new admissions. No patient has had an MRSA bacteraemia and therefore this infection control issue would not show in our score card which records this as a trigger.

Page 6

Recommendation

To note the report. Fiona Allsop Chief Nurse July 2016

Dr Des Holden Medical Director

Page 7

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

Day

Main 2 Specialties on each ward

Ward name Specialty 1

Specialty 2

Registered midwives/nurses

Night Registered midwives/nurses

Care Staff

Day

Night

Care Hours Per Patient Day (CHPPD)

Care Staff

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

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

1,302

1,287

1,422

1,361

713

1,070

98.8%

95.7%

100.0%

711

2.8

3.4

Acute Medical Unit

300 - GENERAL MEDICINE

3,462

3,435

1,426

1,376

2,496

1,426

1,380

99.2%

96.5%

100.0%

96.8%

991

6.0

2.8

8.8

713

667

100.0%

93.5%

33.7

0.0

33.7

1,426

1,422

1,155

1,178

1,070

1,058

713

736

99.7%

102.0%

98.9%

103.2%

731

3.4

2.6

6.0

1,426

1,403

713

679

1,070

357

334

98.4%

95.2%

100.0%

93.5%

556

4.4

1.8

6.3

713

345

333

713

100.0%

96.7%

100.0%

308

4.6

1.1

5.7

101 - UROLOGY

1,445

1,403

932

928

713

702

713

702

97.1%

99.6%

98.4%

624

3.4

2.6

6.0

501 - OBSTETRICS

1,426

1,403

713

659

1,070

955

713

679

98.4%

92.4%

89.2%

95.2%

531

4.4

2.5

7.0

Capel Annex l Ward

300 - GENERAL MEDICINE

1,426

1,403

1,070

1,024

713

702

98.4%

95.7%

100.0%

98.4%

665

3.2

2.6

5.8

Capel Ward

430 - GERIATRIC MEDICINE

1,539

713

740

1,070

1,047

713

100.0%

103.7%

97.8%

100.0%

614

4.2

2.4

6.6

Chaldon Ward

300 - GENERAL MEDICINE

1,955

1,853

1,426

1,380

713

1,070

1,058

94.8%

96.8%

100.0%

98.9%

821

3.1

3.0

6.1

Charlwood Ward

301 - GASTROENTEROLOGY

1,375

1,409

838

830

713

102.5%

99.1%

100.0%

604

3.5

2.6

6.1

Copthorne Ward

301 - GASTROENTEROLOGY

1,426

1,415

730

707

713

690

713

99.2%

96.8%

100.0%

588

3.6

2.4

6.0

Coronary Care Unit

320 - CARDIOLOGY

1,070

1,047

725

713

345

357

97.8%

98.4%

103.3%

227

7.8

1.6

9.3

Delivery Suite

501 - OBSTETRICS

2,139

2,066

713

671

2,139

2,105

667

644

96.6%

94.0%

98.4%

96.6%

134

31.1

9.8

40.9

300 - GENERAL MEDICINE

611

596

602

590

357

97.5%

98.1%

100.0%

12.9

12.8

25.7

303 - CLINICAL HAEMATOLOGY

713

702

311

306

713

98.4%

98.6%

100.0%

182

7.8

1.7

9.5

1,783

1,737

1,070

1,104

1,070

1,058

97.4%

103.2%

100.0%

98.9%

788

3.6

2.7

6.3

320 - CARDIOLOGY

1,783

1,771

713

690

713

702

99.4%

96.8%

100.0%

98.4%

841

3.0

1.7

4.6

192 - CRITICAL CARE MEDICINE

4,536

4,387

745

650

4,451

4,405

357

345

96.7%

87.2%

99.0%

96.8%

468

18.8

2.1

20.9

110 - TRAUMA & ORTHOPAEDICS

1,591

1,568

1,201

1,254

713

702

1,070

98.6%

104.4%

98.4%

100.0%

852

2.7

5.4

430 - GERIATRIC MEDICINE

1,280

1,208

1,426

1,380

713

94.4%

96.8%

100.0%

709

2.7

3.0

5.7

420 - PAEDIATRICS

1,598

1,502

701

724

1,449

1,380

690

633

94.0%

103.3%

95.2%

91.7%

560

5.1

2.4

7.6

110 - TRAUMA & ORTHOPAEDICS

1,599

1,604

1,160

1,264

713

1,058

100.3%

109.0%

100.0%

826

2.8

5.6

430 - GERIATRIC MEDICINE

1,783

1,756

1,081

1,069

713

702

98.5%

98.9%

100.0%

98.4%

857

2.9

2.1

4.9

Outwood Ward

420 - PAEDIATRICS

2,421

2,344

322

230

1,783

1,760

357

299

96.8%

71.4%

98.7%

83.9%

571

7.2

0.9

8.1

Rusper Ward

501 - OBSTETRICS

1,426

1,392

713

97.6%

100.0%

248

8.5

0.0

8.5

Surgical Assessment Unit

100 - GENERAL SURGERY

1,426

1,403

357

713

98.4%

100.0%

254

8.3

4.2

12.5

Tandridge Ward

300 - GENERAL MEDICINE

1,820

1,793

1,414

1,380

713

702

713

656

98.5%

97.6%

98.4%

91.9%

684

3.6

3.0

6.6

Tilgate Annex

300 - GENERAL MEDICINE

1,783

1,070

1,058

736

713

702

100.0%

98.9%

96.9%

98.4%

642

3.9

2.7

6.6

Tilgate Ward

300 - GENERAL MEDICINE

1,786

1,752

1,070

1,035

1,081

357

98.1%

96.8%

100.0%

797

3.6

1.7

5.3

Woodland Ward

100 - GENERAL SURGERY

1,783

1,047

1,024

713

100.0%

97.8%

100.0%

666

3.7

2.6

6.4

Birthing Centre Bletchingley Ward Brockham Ward Brook Ward Buckland Ward Burstow Ward

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

501 - OBSTETRICS 300 - GENERAL MEDICINE

302 - ENDOCRINOLOGY

502 - GYNAECOLOGY 100 - GENERAL SURGERY

300 - GENERAL MEDICINE

410 - RHEUMATOLOGY

340 - RESPIRATORY MEDICINE 340 - RESPIRATORY MEDICINE

6.2

National Quality Board July 2016

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Safe sustainable and productive staffing

This document has been developed by the National Quality Board (NQB), which comprises:

Care Quality Commission

NHS England

NHS Improvement

National Institute for Health and Care Excellence

Health Education England

Public Health England

Department of Health

Contents Foreward

Policy Context

About this document

Section 1: Safe, sustainable and productive staffing: measurement and improvement 9 Patient outcomes, people productivity and financial sustainability

Reporting, investigating and acting on incidents

Patient, carer and staff feedback

Section 2: Care hours per patient day (CHPPD) CHPPD for nurse staffing in acute inpatient settings Section 3: Updated NQB expectations

12 12 14

Triangulated approach to staffing decisions

Expectation 1 Right staff

Expectation 2 Right skills

Expectation 3 Right place and time

21 25 27 28 29

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Foreword In 2013, the National Quality Board (NQB) set out 10 expectations and a framework within which organisations and staff should make decisions about staffing that put patients first.1 Putting people first remains our collective and individual responsibility and is central to the delivery of high quality care that is safe, effective, caring and responsive.This NQB document builds on our 2013 guidance to provide an updated safe staffing improvement resource. Key to high quality care for all is our ability to deliver services that are sustainable and well-led. In the past, quality and financial objectives have too often been regarded as being at odds with each other and therefore pursued in isolation. As set out in the Five Year Forward View,2 it is vital that we have a single, shared goal to maintain and improve quality, to improve health outcomes, and to do this within the financial resources entrusted to the health service. This means a relentless focus on planning and delivering services in ways that both improve quality and reduce avoidable costs, underpinned by the following three principles:

•

ight care: Doing the right thing, first time, in the right setting will ensure patients get the care R that is right for them, avoiding unnecessary complications and longer stays in hospital and helping them recover as soon as possible.

•

inimising avoidable harm: A relentless focus on quality, based on understanding the drivers M and human factors involved in delivering high quality care, will reduce avoidable harm, prevent the unnecessary cost of treating that harm, and reduce costs associated with litigation.

•

Maximising the value of available resources: Providing high quality care to everyone who uses health and care services requires organisations and health economies to use their resources in the most efficient way for the benefit of their community – any waste has an opportunity cost in terms of care that could otherwise be provided.

As the Carter productivity and efficiency report3 makes clear, improving workforce efficiency can benefit patient care through better recruitment and retention of permanent staff, better rostering, reduced sickness absence, matching work patterns to patient need, and reduced dependency on agency staff. The development of new service models means building teams across traditional boundaries and ensuring they have the full range of skills and expertise to respond to patient need across different settings. As provider and commissioner organisations work together to develop Sustainability and Transformation Plans,4 staffing decisions must support these new models of care. All this represents a significant people challenge. Now more than ever we need to help staff improve and innovate, enabling new ways of working in an environment of growing demand and rapid change. This safe staffing improvement resource can only set the context and offer support to local decision making. It is local clinical teams – and local providers and commissioners – who will ensure we continue to provide high-quality and financially sustainable services. The challenges we face are steep – but our teams have a track record of delivery when we work together and focus on putting patients first.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Policy Context In February 2013, Sir Robert Francis QC published his final report of the inquiry into failings at Mid Staffordshire NHS Foundation Trust.5 The report told a story of appalling suffering of many patients within a culture of secrecy and defensiveness, and highlighted a whole system failure. Compassion in practice,6 the strategy for nurses, midwives and care staff (2012), the Francis report and the government response, Hard truths: the journey to putting patients first,7 led to fundamental changes in how NHS provider boards are expected to assure they are making safe staffing decisions. The National Quality Board8 in November 2013 set out these expectations in relation to getting nursing, midwifery and care staffing right. It provided a clear governance and oversight framework alongside recommended evidence-based tools, resources and examples of good practice, to support NHS providers in delivering safe patient care and the best possible outcomes for their patients. The National Institute for Health and Care Excellence (NICE) undertook work to produce guidelines on safe staffing for specific care settings, which led to the publication of Safe staffing for nursing in adult inpatient wards in acute hospitals9 and Safe midwifery staffing for maternity settings.10 The Carter report11 and the NHS Five Year Forward View planning guidance12 make it clear that workforce and financial plans must be consistent to optimise clinical quality and the use of resources. The Carter report highlighted variation in how acute trusts currently manage staff, from annual leave, shift patterns and flexible working through to using technology and e-rostering. It underlined that, in addition to good governance and oversight, NHS providers need a framework to evaluate information and data, measure impact, and enable them to improve the productive use of staff resources, care quality, and financial control. Lord Carterâ&#x20AC;&#x2122;s report recommended a new metric, care hours per patient day (CHPPD), as the first step in developing a single consistent way of recording and reporting staff deployments. Jim Mackey, Chief Executive of NHS Improvement, and Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, stated in a letter to trusts13 that provider leaders have to deliver the right quality outcomes within available resources. They reiterated their joint commitment to working together on a single national regulatory framework for this purpose. Nursing and midwifery leaders have built on Compassion in practice to create a national nursing, midwifery and care staff framework, Leading change, adding value14. This framework is aligned to the Five Year Forward View, with a central focus on reducing unwarranted variation and meeting the â&#x20AC;&#x2DC;Triple Aimâ&#x20AC;&#x2122; measure of better health outcomes, better patient experience of care and better use of resources. The 2015 Shape of caring report15 recommended changes to education, training and career structures for registered nurses and care staff. We need to continue this work and identify both nationally and locally how we maximise the capabilities and contribution of healthcare assistants/ support workers/nursing associates16 to meet patient needs and provide fulfilling job roles and career pathways.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

As an integral part of developing their Sustainability and Transformation Plans, local health and care systems need to develop local plans for how they will develop, support and retain a workforce with the rights skills, values and behaviours in sufficient numbers and in the right locations. This updated NQB safe staffing improvement resource provides advice and support to help NHS providers and commissioners as they go about this vital task.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

About this document The National Quality Board’s 2013 guidance, How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability17 focused on supporting NHS provider boards to achieve safe nursing and midwifery care staffing. If we are to achieve the Five Year Forward View’s ambitions,18 19 the principles contained in this guidance now need to apply to nursing and midwifery staff and the broader multiprofessional workforce in a range of care settings, and do so in a way that optimises productivity and efficiency while maintaining the focus on improving quality. This document includes an updated set of NQB expectations for nursing and midwifery staffing to help NHS provider boards make local decisions that will deliver high quality care for patients within the available staffing resource. In preparing this document we spent time talking with and listening to directors of nursing and chief nurses (in both provider and commissioner organisations) and to other key stakeholders, at local meetings, national events and via correspondence, to understand the impact of the previous safe staffing improvement resource, and to share ideas and early drafts of this document. This engagement and the feedback received were important for testing and ensuring that this updated document continues to provide a helpful framework for NHS provider boards when they are reviewing staffing and making decisions. The Carter report20 identified that one of the obstacles to eliminating unwarranted variation in the deployment of nursing and healthcare support workers has been the absence of a single means of recording and reporting how staff are deployed. From May 2016, CHPPD is the principal measure of nursing, midwifery and healthcare support worker deployment. This data collection is an important first step in the journey to providing a single, consistent metric for NHS providers to record and report all staffing deployment. Another Carter recommendation was to develop a model hospital so trusts can learn what ‘good’ looks like from other trusts and adopt their best practice. Through the work on the model hospital, NHS Improvement is developing tools including a live model hospital dashboard that collects and presents patient outcome measures and staffing information in a standardised way. In Sections 1, 2 and 3, we have updated the 2013 NQB guidance by bringing it together with the Carter report’s findings, to set out the key principles and tools that provider boards should use to measure and improve their use of staffing resources to ensure safe, sustainable and productive services. In Section 3, we identify three updated NQB expectations that form a ‘triangulated’ approach (‘Right Staff, Right Skills, Right Place and Time’) to staffing decisions. An approach to deciding staffing levels based on patients’ needs, acuity and risks, which is monitored from ‘ward to board’, will enable NHS provider boards to make appropriate judgements about delivering safe, sustainable and productive staffing. CQC supports this triangulated approach to staffing decisions, rather than making judgements based solely on numbers or ratios of staff to patients.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

NHS provider boards are accountable for ensuring their organisation has the right culture, leadership and skills in place for safe, sustainable and productive staffing. They are also responsible for ensuring proactive, robust and consistent approaches to measurement and continuous improvement, including the use of a local quality framework for staffing that will support safe, effective, caring, responsive and well-led care. Appendix 1 shows measures that can be used alongside CHPPD to demonstrate and understand the impact of staffing decisions on the quality of care that people are receiving in acute inpatient wards.

Safe, Effective, Caring, Responsive and Well-Led Care Measure and Improve - patient outcomes, people productivity and financial sustainability - report investigate and act on incidents (including red flags) - patient, carer and staff feedback - Implementation Care Hours per Patient Day (CHPPD) - develop local quality dashboard for safe sustainable staffing Expectation 1

Expectation 2

Expectation 3

Right Staff 1.1 evidence-based workforce planning 1.2 professional judgement 1.3 compare staffing with peers

Right Skills 2.1 mandatory training, development and education 2.2 working as a multiprofessional team 2.3 recruitment and retention

Right Place and Time 3.1 productive working and eliminating waste 3.2 efficient deployment and flexibility 3.3 efficient employment and minimising agency

Publishing this updated NQB safe staffing improvement resource is the first step in a journey to developing other resources that will support NHS provider trusts with making staffing decisions that will deliver safe, effective, caring, responsive and well-led care. NHS Improvement is also coordinating work to develop safe staffing improvement resources for a range of care settings including: mental health, learning disability, acute adult inpatients, urgent and emergency care, childrenâ&#x20AC;&#x2122;s services, maternity services, and community services. The core principles underpinning this work are: to identify and review the best available evidence on safe, sustainable staffing; to be multi-disciplinary in approach to staffing; to be outcomes focused; to complete an economic impact assessment on any proposed safe staffing improvement resource; and to develop these staffing resources with the appropriate experts, focus groups and other key stakeholder groups, including patients, families and carers. NHS Improvement will begin to release these improvement resources later in 2016/17, with approval from the NQB. As this safe staffing improvement resource is implemented and used by NHS provider boards, clinicians and frontline managers, through their feedback and engagement, we will review and evaluate the impact of this resource over the next year to 18 months, to inform plans for future publications.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Section 1: Safe, sustainable and productive staffing: measurement and improvement Patient outcomes, people productivity and financial sustainability Providing high quality care to all patients means that NHS organisations and health economies must use their available resources in the most efficient way possible for the benefit of their community. There should be individual and collective responsibility as an NHS provider board for deploying staff in ways that ensure safe, sustainable and productive services. There should be clear lines of accountability for all professional staff groups. There should be collaborative decisionmaking between clinical and managerial staff, reporting to boards. NHS provider boards should have a proactive approach to reporting, investigating and acting on incidents and to driving continuous improvement. NHS provider boards will need to collaborate across their local health and care system, with commissioners and other providers, to ensure delivery of the best possible care and value for patients and the public. This may require NHS provider boards to make difficult decisions about resourcing as local Sustainability and Transformation Plans are developed and agreed. In this context, it is critical that boards review workforce metrics, indicators of quality and outcomes, and measures of productivity on a monthly basis – as a whole and not in isolation from each other – and that there is evidence of continuous improvements across all of these areas. To help optimise allocation of workforce resources and improve outcomes, NHS provider boards should implement in full the Carter recommendations, together with the findings from the model hospital and its equivalents for other care settings. This includes:

•

using local quality and outcomes dashboards that are published locally and discussed in public board meetings, including the use of nationally agreed quality metrics that will be published at provider level

•

developing metrics that measure patient outcomes, staff experience, people productivity and financial sustainability

•

comparing performance against internal plans, peer benchmarks and the views of NHS experts, taking account of any underlying differences

•

reducing wasted time by supporting and engaging staff in using their time in the best way possible to provide direct or relevant care or care support

•

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

using national good practice checklists to guide improvement action, as well as taking account of knowledge shared by top performers.

Commissioners monitor providers’ quality and outcomes closely, and where problems with staff capacity and capability create risks for quality, commissioners work in partnership with providers and consider how best to bring about improvements. Quality Surveillance Groups provide an opportunity for commissioners and local partners to work together to identify any risks to quality and safe staffing and coordinate actions to drive improvement. NHS provider boards hold individual and collective responsibility for making judgements about staffing and the delivery of safe, effective, compassionate and responsive care within available resources. While boards will use published national metrics to support the discharge of those responsibilities, more timely and more detailed local sources of data and information are typically available for local monitoring and improvement. Boards should use this local quality monitoring to support their judgements and decisions about safe staffing. While staffing capacity and capability are vital to all aspects of quality, they are particularly likely to affect specific quality indicators or measures. The NQB has developed recommendations for local providers to consider when monitoring the impact of staffing on quality: see Appendix 1.

Reporting, investigating and acting on incidents High quality care produces excellent outcomes for patients, and is safe, effective, caring, responsive and well led. NHS providers should follow best practice guidance in the investigation of all patient safety incidents, including root cause analysis21 for serious incidents.22 As part of this systematic approach to investigating incidents, providers should consider staff capacity and capability, and act on any issues and contributing factors identified. NHS providers should consider reports of the ‘red flag’ issues suggested in the NICE guidance,23 24 and any other incident where a patient was or could have been harmed,25 as part of the risk management of patient safety incidents. Incidents must be reviewed alongside other data sources, including local quality improvement data (eg for omitted medication)26 clinical audits27 or locally agreed monitoring information, such as delays or omissions of planned care. NHS providers should actively encourage all staff to report any occasion where a less than optimal level of suitably trained or experienced staff harmed or seems likely to harm a patient. These locally reported incidents should be considered patient safety incidents rather than solely staff safety incidents, and they should be routinely uploaded to the National Reporting and Learning System. Staff in all care settings should be aware that they have a professional duty to put the interests of the people in their care first, and to act to protect them if they consider that they may be at risk.28 Policies29 should be in place supporting staff who raise concerns as and when they arise. All NHS providers should have an identified Freedom to Speak Up guardian and should be able to demonstrate commitment to the principles in the Freedom to Speak Up Review of February 201530. NHS providers should adhere to Duty of Candour requirements,31 which require them to publish an annual declaration of their commitment to telling patients if something has gone wrong with their care and have support staff to deliver this commitment. Boards should ensure that they support and enable their executive team to take decisive action when necessary. Commissioners, regulators and other stakeholders should be involved in

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

considering any decision to close a care environment, or suspend services due to concerns about safe staffing, and identifying alternative arrangements for patients should be a priority.

Patient, staff and carer feedback NHS providers need a co-ordinated approach and the right leadership skills in place to drive continuous improvements in patient outcomes and productivity. They should do this by developing the appropriate culture and behaviours, where staff and teams are engaged in developing their organisations and they are supported, respected and valued.32 Boards must ensure that their organisations foster a culture of professionalism and responsiveness in healthcare professionals,33 so that staff feel able to use their professional judgement to raise concerns and make suggestions for change that improves care. This includes ensuring the organisation has policies to support clinical staff to uphold professional codes of practice. NHS providers should proactively seek the views of patients, carers and staff and the board should routinely consider any feedback relevant to staffing capacity, capability and morale, such as national and local surveys, stories, complaints and compliments. As the Carter report says, good staff engagement and robust local policies and procedures should be in place to tackle bullying and harassment, and to address variation in sickness absence and staff turnover. NHS providers should have a strong staff engagement plan, which routinely monitors the impact of their policies, demonstrates an understanding of the links between staff experience, patient experience and outcomes, and which supports staff retention, as documented by available research.34 35 Staff should work in well-structured teams. They should be engaged, enabled to practice effectively and able to make changes to delivery of care to improve quality and productivity.36 When an establishment review has taken place within an organisation, the board should ensure it considers feedback from frontline staff as part of its assurance activities.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Section 2: Care hours per patient day (CHPPD) CHPPD for nurse staffing in acute inpatients From May 2016, all acute trusts with inpatient wards/units began reporting monthly CHPPD data to NHS Improvement. Over time, this will allow trusts to review the deployment of staff within a specialty and by comparable ward. When looking at this information locally alongside other patient outcome measures, trusts will be able to identify how they can change and flex their staffing establishment to improve outcomes for patients and improve productivity. The introduction of CHPPD for nurse and healthcare support staffing in the inpatient/acute setting is the first step in developing the methodology as a tool that can contribute to a review of staff deployment. Work has begun to consider appropriate application of this metric in other care settings and to include other healthcare professionals such as allied health professionals (AHPs). As with other indicators, CHPPD should never be viewed in isolation but as part of a local quality dashboard that includes patient outcome measures alongside workforce and finance indicators. The aim is to help ward sisters/charge nurses, clinical matrons and hospital managers make safe, efficient and effective decisions about staff deployment: see Appendix 1. CHPPD is calculated by adding the hours of registered nurses and the hours of healthcare support workers and dividing the total by every 24 hours of inpatient admissions (or approximating 24 patient hours by counts of patients at midnight). CHPPD is reported as a total and split by registered nurses and healthcare support workers to provide a complete picture of care and skill mix.

Care hours per patient day =

Hours of registered nurses and midwives alongside Hours of healthcare support workers Total number of inpatients

During the pilot, data sets were used from 25 acute trusts, representing a variety of acute trust types from across England, testing a variety of local data collection methods to collate actual hours worked by registered nurses and support staff. The pilot supported the future use of CHPPD at a national level by:

•

developing consistent ‘rules’ for capturing data (eg whether or not to include senior supervisory sisters/charge nurses)

•

considering how in future to capture important contextual factors that affect nurse workload (eg whether a ward has high or low levels of housekeeping and ward clerk support, percentage single rooms)

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

• •

undertaking in-depth reviews to understand the impact of acuity and dependency

•

reviewing international best practice where nursing hours per patient day (NHPPD) are used, including Western Australia, New Zealand and South Africa.37

exploring the challenges of collecting accurate data on patient hours/days for the CHPPD metric denominator

In testing the CHPPD data collection with 27 trusts before implementation in May 2016, it was found that, although collecting patient count at midnight did not capture all the activity on ward areas, it was the least burdensome on trusts and ensures consistency in the data for comparison. As NHS Improvement develops the CHPPD metric further with NHS providers, it will continue to review and refine ways of reflecting activity throughout the day. NHS Improvement will be working with NHS providers to develop and inform the 2016/17 implementation plan for CHPPD. The programme’s initial focus will be to assess and evaluate the acute inpatient data collection for nurse staffing by October 2016 to inform the next phase of implementation. In parallel, NHS Improvement will engage with providers to scope the development of the CHPPD metric for other care settings and consider application for other healthcare professionals, such as AHPs. A robust process for review and evaluation will underpin NHS Improvement’s programme to assure the validity of CHPPD and its impact in supporting frontline decisions about staff deployment, as well as to inform future plans.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Section 3: Updated NQB expectations Triangulated approach to staffing decisions Expectation 1

Expectation 2

Expectation 3

Right Staff 1.1 evidence-based workforce planning 1.2 professional judgement 1.3 compare staffing with peers

Right Skills 2.1 mandatory training development and education 2.2 working as a multiprofessional team 2.3 recruitment and retention

Right Place and Time 3.1 productive working and eliminating waste 3.2 efficient deployment and flexibility 3.3 efficient employment and minimising agency

Implement Care Hours per Patient Day Develop local quality dashboard for safe sustainable staffing

Measure and Improve - Patient outcomes, people productivity and financial sustainability - Report investigate and act on incidents (including red flags) - Patient, carer and staff feedback -

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Expectation 1: Right staff Boards should ensure there is sufficient and sustainable staffing capacity and capability to provide safe and effective care to patients at all times, across all care settings in NHS provider organisations. Boards should ensure there is an annual strategic staffing review, with evidence that this is developed using a triangulated approach (ie the use of evidence-based tools, professional judgement and comparison with peers), which takes account of all healthcare professional groups and is in line with financial plans. This should be followed with a comprehensive staffing report to the board after six months to ensure workforce plans are still appropriate. There should also be a review following any service change or where quality or workforce concerns are identified. Safe staffing is a fundamental part of good quality care, and CQC will therefore always include a focus on staffing in the inspection frameworks for NHS provider organisations. Commissioners should actively seek to assure themselves that providers have sufficient care staffing capacity and capability, and to monitor outcomes and quality standards, using information that providers supply under the NHS Standard Contract.

Boards should ensure: 1.1 Evidence-based workforce planning • The organisation uses evidence-based guidance such as that produced by NICE, Royal Colleges and other national bodies to inform workforce planning, within the wider triangulated approach in this NQB resource (see Appendix 4 for list of evidence-based guidance for nursing and midwifery care staffing).

•

he organisation uses workforce tools in accordance with their guidance and does not permit T local modifications, to maintain the reliability and validity of the tool and allow benchmarking with peers.

•

orkforce plans contain sufficient provision for planned and unplanned leave, eg sickness, W parental leave, annual leave, training and supervision requirements.

1.2 Professional judgement • Clinical and managerial professional judgement and scrutiny are a crucial element of workforce planning and are used to interpret the results from evidence-based tools, taking account of the local context and patient needs. This element of a triangulated approach is key to bringing together the outcomes from evidence-based tools alongside comparisons with peers in a meaningful way.

•

rofessional judgement and knowledge are used to inform the skill mix of staff. They are also P used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

1.3 Compare staffing with peers • The organisation compares local staffing with staffing provided by peers, where appropriate peer groups exist, taking account of any underlying differences.

•

The organisation reviews comparative data on actual staffing alongside data that provides context for differences in staffing requirements, such as case mix (eg length of stay, occupancy rates, caseload), patient movement (admissions, discharges and transfers), ward design, and patient acuity and dependency.

•

The organisation has an agreed local quality dashboard that triangulates comparative data on staffing and skill mix with other efficiency and quality metrics: eg for acute inpatients, the model hospital dashboard will include CHPPD.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Expectation 2: Right skills Boards should ensure clinical leaders and managers are appropriately developed and supported to deliver high quality, efficient services, and there is a staffing resource that reflects a multiprofessional team approach. Decisions about staffing should be based on delivering safe, sustainable and productive services. Clinical leaders should use the competencies of the existing workforce to the full, further developing and introducing new roles as appropriate to their skills and expertise, where there is an identified need or skills gap.

Boards should ensure: 2.1 Mandatory training, development and education • Frontline clinical leaders and managers are empowered and have the necessary skills to make judgements about staffing and assess their impact, using the triangulated approach outlined in this document.38

•

Staffing establishments take account of the need to allow clinical staff the time to undertake mandatory training and continuous professional development, meet revalidation requirements, and fulfil teaching, mentorship and supervision roles, including the support of preregistration and undergraduate students.39

•

Those with line management responsibilities ensure that staff are managed effectively, with clear objectives, constructive appraisals, and support to revalidate and maintain professional registration.

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The organisation analyses training needs and uses this analysis to help identify, build and maximise the skills of staff. This forms part of the organisation’s training and development strategy, which also aligns with Health Education England’s quality framework.40

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he organisation develops its staff’s skills, underpinned by knowledge and understanding of T public health and prevention, and supports behavioural change work with patients, including self-care, wellbeing and an ethos of patients as partners in their care.

•

The workforce has the right competencies to support new models of care. Staff receive appropriate education and training to enable them to work more effectively in different care settings and in different ways. The organisation makes realistic assessments of the time commitment required to undertake the necessary education and training to support changes in models of care.

•

The organisation recognises that delivery of high quality care depends upon strong and clear clinical leadership and well-led and motivated staff. The organisation allocates significant time for team leaders, professional leads and lead sisters/charge nurses/ward managers to discharge their supervisory responsibilities and have sufficient time to coordinate activity in the care environment, manage and support staff, and ensure standards are maintained.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

2.2 Working as a multiprofessional team • The organisation demonstrates a commitment to investing in new roles and skill mix that will enable nursing and midwifery staff to spend more time using their specialist training to focus on clinical duties and decisions about patient care.

•

The organisation recognises the unique contribution of nurses, midwives and all care professionals in the wider workforce. Professional judgement is used to ensure that the team has the skills and knowledge required to provide high-quality care to patients. This stronger multiprofessional approach avoids placing demands solely on any one profession and supports improvements in quality and productivity, as shown in the literature.41

•

The organisation works collaboratively with others in the local health and care system. It supports the development of future care models by developing an adaptable and flexible workforce (including AHPs and others), which is responsive to changing demand and able to work across care settings, care teams and care boundaries.

2.3 Recruitment and retention • The organisation has clear plans to promote equality and diversity and has leadership that closely resembles the communities it serves. The research outlined in the NHS provider roadmap42 demonstrates the scale and persistence of discrimination at a time when the evidence demonstrates the links between staff satisfaction and patient outcomes.

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The organisation has effective strategies to recruit, retain and develop their staff, as well as managing and planning for predicted loss of staff to avoid over-reliance on temporary staff.

•

In planning the future workforce, the organisation is mindful of the differing generational needs of the workforce. Clinical leaders ensure workforce plans address how to support staff from a range of generations, through developing flexible approaches to recruitment, retention and career development43

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Boards should ensure: 3.1 Productive working and eliminating waste • The organisation uses ‘lean’ working principles, such as the productive ward,44 as a way of eliminating waste.

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The organisation designs pathways to optimise patient flow and improve outcomes and efficiency eg by reducing queueing.

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Systems are in place for managing and deploying staff across a range of care settings, ensuring flexible working to meet patient needs and making best use of available resources.

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The organisation focuses on improving productivity, providing the appropriate care to patients, safely, effectively and with compassion, using the most appropriate staff.

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The organisation supports staff to use their time to care in a meaningful way, providing direct or relevant care or care support. Reducing time wasted is a key priority.45

•

Systems for managing staff use responsive risk management processes, from frontline services through to board level, which clearly demonstrate how staffing risks are identified and managed.

3.2 Efficient deployment and flexibility • Organisational processes ensure that local clinical leaders have a clear role in determining flexible approaches to staffing with a line of professional oversight, that staffing decisions are supported and understood by the wider organisation, and that they are implemented with fairness and equity for staff.

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Clinical capacity and skill mix are aligned to the needs of patients as they progress on individual pathways and to patterns of demand, thus making the best use of staffing resource and facilitating effective patient flow.

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Throughout the day, clinical and managerial leaders compare the actual staff available with planned and required staffing levels, and take appropriate action to ensure staff are available to meet patients’ needs.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

•

Escalation policies and contingency plans are in place for when staffing capacity and capability fall short of what is needed for safe, effective and compassionate care, and staff are aware of the steps to take where capacity problems cannot be resolved.

•

Meaningful application of effective e-rostering policies is evident, and the organisation uses available best practice from NHS Employers46 and the Carter Review Rostering Good Practice Guidance (2016).

3.3 Efficient employment, minimising agency use • The annual strategic staffing assessment gives boards a clear medium-term view of the likely temporary staffing requirements. It also ensures discussions take place with service leaders and temporary workforce suppliers to give best value for money in deploying this option. This includes an assessment to maximise flexibility of the existing workforce and use of bank staff (rather than agency), as reflected by NHS Improvement guidance.47

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The organisation is actively working to reduce significantly and, in time, eradicate the use of agency staff in line with NHS Improvement’s nursing agency rules, supplementary guidance and timescales.48

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The organisation’s workforce plan is based on the local Sustainability and Transformation Plan (STP)49, the place-based, multi-year plan built around the needs of the local population.

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The organisation works closely with commissioners and with Health Education England, and submits the workforce plans they develop as part of the STP, using the defined process, to inform supply and demand modelling.

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The organisation supports Health Education England by ensuring that high quality clinical placements are available within the organisation and across patient pathways, and actively seeks and acts on feedback from trainees/students, involving them wherever possible in developing safe, sustainable and productive services.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Appendix 1 NQB recommendations for wider measures to monitor the impact of staffing on quality The definitive judgement of a provider’s quality is its CQC inspection rating. Alongside this, a range of metrics relevant to aspects of patient safety, clinical effectiveness and patient experience are suitable for both regulatory and public use, either to compare aspects of a provider’s quality with other providers, or to measure changes in aspects of quality over time. All NQB partners are committed to ensuring metrics used for regulation and performance management are increasingly aligned into a ‘single version of the truth’ to reduce burden and ensure effective commissioning and provider oversight. Here we offer guidance for local providers on using other measures of quality, alongside care hours per patient day (CHPPD), to understand how staff capacity may affect the quality of care. It is important to remember that CHPPD should not be viewed in isolation and, even alongside this suggested suite of measures, does not give a complete view of quality. The suggested measures draw on data sources in most or all providers without additional collection, are likely to be already in use locally, and provide up-to-date information. The suggested indicators in this Appendix are best considered as ‘balancing measures’ where the impact of any changes in workforce capacity may become visible. They are not intended to include all aspects of quality; other quality indicators will be needed to provide a rounded view of the overall quality in a care setting and the wider systems and structures that support the delivery of care. Given that the initial rollout of CHPPD is in acute inpatient settings, the examples and suggestions for other measures of how staffing capacity affects quality have been selected as particularly relevant to acute hospitals, but have been organised in a framework that could be applied to any setting. Even within acute hospitals these suggestions can and should be locally adapted: for example, specialist areas such as maternity units will need tailored metrics; providers with sophisticated data systems will have more options available to them; and specialist providers may have to develop monitoring more relevant to their specialties. Although initial collection of CHPPD relates to nursing staff, healthcare requires a multidisciplinary team approach, and the suggested list of quality indicators to use alongside CHPPD relates to a range of staff groups. It is vital that boards read and hear staff and patient voices and the findings of incident and serious incident investigations alongside the suggested list of quality indicators so that the nature and causes of any issues can be rapidly identified and acted on.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

NQB recommendations for monitoring the impact of staffing on quality in acute hospital inpatient settings Rationale for using as a quality indicator alongside CHPPD Patient and carer feedback

Staff feedback

Example indicators Italics = published indicator

Patient and carer feedback provides insight into the quality of their own care, and often extends into observations of the wider care environment and staff capacity

Friends and Family Test (inpatient and maternity)

Staff feedback provides insight into their own and their colleagues’ capacity, capability and morale, and of their perception of the quality of care

Staff Friends and Family Test (place to be treated/place to work)

Local staff FFT data52 submitted to UNIFY (published monthly but earlier data available to providers)

National staff surveys (place to be treated/ place to work and questions related to workload)

National staff surveys53

National patient surveys overall rating of care and questions related to staff capacity

Completion of key clinical processes

Local patient FFT data50 submitted to UNIFY (published monthly but earlier data available to providers) National patient surveys51 Local complaints and compliments data

GMC trainee survey (questions related to workload) Access to care

Existing local sources

Annual GMC trainee survey54 Local staff ‘barometers’ or feedback routes Local incident reports of lack of sufficient staff numbers, capacity or skills55

While staffing capacity will never be the sole factor, lack of staff capacity will affect access to care; for example, operations will be cancelled if any key staff in theatre or ward are unavailable

Cancelled elective operations – proportion of last minute cancellations

Clinical process measures provide a very early indication of changes in the quality of care delivery, so action can be taken before outcomes are affected

Medication omitted for non-clinical reasons (registered nursing staff)

Electronic prescribing systems Electronic observation systems

Processes are often the responsibility of a specific staff group, and so can help pinpoint staffing capacity issues for that group

Observations/Early Warning Scores not taken/calculated as planned (nursing staff) MRSA screening/decolonisation completion rates

UNIFY submissions (published quarterly but earlier data available to providers)

Those not treated within 28 days of a last minute cancellation

Electronic patient records Pathology databases National Clinical Audits with continuous local data submission (eg Stroke Sentinel Audit)

VTE risk assessment completion (medical UNIFY submissions (published quarterly but earlier staff) data available to providers) Mobilisation within 24 hours of surgery Local audits, CQuINS, process measures collected (AHPs) for local QI projects (eg Medication Safety National Clinical Audits (range of staff) Thermometer for omitted medication56)

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

NQB recommendations for monitoring the impact of staffing on quality in acute hospital inpatient settings Rationale for using as a quality indicator alongside CHPPD Harm during healthcare

While a wide range of measures need to ensure the system of care supports staff to do the right thing, some types of harm are particularly likely to be affected by staff capacity Pressure ulcer prevention typically requires constant nursing intervention in terms of skin care and position changes, and therefore monitoring of pressure ulcers can help pinpoint staffing capacity issues for that staff group

Example indicators Italics = published indicator Pressure ulcer prevalence Pressure ulcer incidence Prevalence of inpatient falls Incidence of inpatient falls

Existing local sources Safety Thermometer data (published monthly but earlier data available to providers) alongside local assessments of data completeness57 Local incident data on falls and pressure ulcers and subsequent investigations alongside local assessments of data completeness58 â&#x20AC;&#x2DC;Occurred in this trustâ&#x20AC;&#x2122; field in National Hip Fracture Database Local data on post-admission transfers to orthopaedics as potential indicator of serious injury from falls

Effective inpatient falls prevention relies on identifying underlying medical causes, medication review, early mobilisation, and nursing observation. Therefore monitoring falls can help pinpoint staffing capacity issues across medical, pharmacy, AHP and nursing staff

Notes on indicator presentation This guidance cannot encompass detailed advice on how local quality monitoring is presented, but it is important local presentations help leaders and boards see where changes are significant rather than likely to be due to chance or anticipated seasonal patterns, including the use of appropriate denominators. In the best trusts, wards, leaders and the board use statistical process control techniques both to understand change and identify sustained improvement, rather than just looking at the month-to-month change.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Additional areas important for monitoring Investigation and learning from patient safety incident and serious incident data As set out in Section 1 of this document, “Best practice guidance should be followed in the investigation of all patient safety incidents, including root cause analysis for serious incidents. As part of this systematic approach to investigating incidents, providers should consider staff capacity and capability, and act on any issues and contributing factors identified”. Summarising these findings is a vital part of contextualising any quantitative data used for quality monitoring. Workforce metrics that provide a window on staff capacity While this Appendix on quality monitoring does not encompass wider workforce metrics (these will be developed as part of the NHS Improvement work on the model hospital) provider boards may wish to consider the wider quality implications of some workforce metrics. For example, staff turnover and staff sickness rates, particularly stress-related absences, can be an indicator of workload pressures. An additional example is completion of mandatory training; this is a direct measure of training completion, but as staff capacity issues can lead to cancellations of mandatory training, it can also act as a proxy indicator for workload pressures. Workload metrics that provide context to CHPPD As set out in Section 3, Expectation 1.3 “the organisation reviews comparative data on actual staffing alongside data that provides context for differences in staffing requirements, such as case mix (eg length of stay, occupancy rates, caseload), patient movement (admissions, discharges and transfers), ward design, and patient acuity and dependency.”

Selection criteria for wider measures to help monitor the impact of staffing on quality Healthcare is delivered by people; there is arguably no aspect of healthcare quality that staff capacity and capability will not affect. But in suggesting metrics to accompany CHPPD, selections have to be based on those areas of quality where changes in staff capacity are most likely to have a visible impact. This means any suggested areas:

• • • • •

need to have very recent data available to providers or act as a periodic more robust source to compare with more frequently collected local data need to have a rationale where it is plausible or is shown that staff capacity is the major, or one of the major, factors affecting the metric (including a rationale for whether capacity of all staff groups or specific staff groups would be expected to have an impact) need adequate numbers (statistical power) if any true improvement or deterioration is to be distinguishable from random variation within a reasonable period in a typically sized provider if used to compare providers, have to be confirmed as appropriate for that purpose (ie not affected more by patient characteristics, differences in data collection, etc than by differences in actual quality) if used for a provider to compare against its own baselines, need to have stable data collection and completeness, and may need adjustment for seasonal factors (eg comparing against equivalent seasonal period, not past quarter, etc.)

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Appendix 2 Units of staffing measurement Type of measure Staff to patient rates/ ratios

Examples Care hours per patient day (CHPPD) reported as total and split by registered nurses and healthcare support workers to provide a complete picture of care and skill mix

How these can be used CHPPD is a unit of measurement that can be applied to any aspect of staffing, registered staff and/or whole care team. The Carter Report defines CHPPD as registered nurse hours plus healthcare support staff hours in a 24-hour period, divided by number patients at midnight (as a proxy for 24 hours of a patient stay). The concept of CHPPD can be adapted to all other staff groups with time allocated to wards or units: for example, physiotherapy hours per patient day, occupational therapy hours per patient day, etc.

Patient to staff rates/ ratios

Nursing hours per patient day (NHPPD)

NHPPD is a unit of measurement used in inpatient settings internationally. It is able to summarise variations in numbers of staff and numbers of patients over the course of a 24hour period. It typically refers to the number of registered nursing hours available per patient.

x patients per registered nurse

Typically used as a â&#x20AC;&#x2DC;snapshotâ&#x20AC;&#x2122; of current responsibilities or as an average of responsibilities over a longer period. Actual numbers of staff and of patients/women/ service users will tend to vary over the course of a day in inpatient settings and over days/ weeks in community settings.

x service users on caseload x women per midwife per year one-to-one observation

Registered to unregistered staff rates/ ratios

xx% of team are registered nurses xx% of team are midwives x:y ratio of registered nurses/ healthcare assistants

Difficult to interpret in isolation from other units of measurement, as a higher percentage/ ratio can be achieved by reducing healthcare assistants or by increasing registered nursing staff, but does give an indication of staff that will require supervision by registered nurses/midwives, in addition to their direct responsibilities.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Units of staffing measurement Type of measure

Examples

Whole-time equivalents (WTE)

Ward/unit/team has xx WTE in post

Head count

Ward/unit/team headcount is xx registered nurses

Ward/unit/team is funded for xx WTE

xx healthcare assistants x physiotherapists

How these can be used Provides a unit of measurement that overcomes local differences in the proportion of staff who work part-time, converting all parttime contracts into their whole-time equivalent, eg two staff working 30 hours per week plus one staff member working 15 hours is the equivalent of two staff working 37.5 hours per week, therefore 2.0 WTE Provides a unit of measurement that is important when counting activity every employed staff member has to undertake, regardless of how many hours they work, eg mandatory training.

x occupational therapists Fill rates

The ward/unit/team had xx% of planned staff overall The ward/unit/team had xx% of planned registered nurse/ midwifery staffing The ward/unit/team had xx% of required staff overall The ward/unit/team had xx% of required registered nurse/ midwifery staffing

Headroom/ uplift

xx% uplift xx% headroom

This was previously calculated by dividing actual staff by planned or required staff and multiplying by 100 to convert to a percentage. Difficult to interpret in isolation from other units of measurement, as previous plans may not reflect patient acuity/dependency on the day, and the percentage total cannot distinguish between ‘aiming high but delivering less’ and ‘aiming low and delivering even lower.’ Where registered nursing/midwifery staffing gaps are covered by a higher number of healthcare assistants, or where fluctuating numbers of staff are required for special observation, overall fill rates become even more difficult to interpret. Building in capacity to deal with planned and unplanned but predictable variations in staff available, such as annual leave, maternity and paternity leave, compassionate leave, jury service, sickness and study leave. If the headroom/uplift allowance is lower than actual requirements this can lead to greater use of temporary/agency staff.

Note: for all units of staffing measurement, creating averages over days, weeks or months can potentially be misleading: a ward/unit/team that fluctuates markedly between too few or too many staff to meet patients’ needs on different days of the week, or from week to week, will not be able to deliver the same quality of care as a ward/unit/team where staffing is more consistent.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Appendix 3 Methods of workforce planning Type of workforce tool Acuity/ dependency models

Summary

Examples

Using a decision matrix, patients are categorised according to their requirements into levels of care with associated evidence-based staffing multipliers derived from wards delivering good quality care. In this way, it discriminates between patients with differing needs. Some models also factor in additional workload demands such as patient turnover.

Safer nursing care tool for adults, inpatient wards, acute admissions units, children and young people wards:

The professional judgment model

Based on clinical staff views of the number of staff required for the usual patient casemix and usual activity on a particular ward/unit/ team (or in high dependency environments, the number of staff required for a typical patient)

Telford method

Activity Monitoring tools

Uses care plans/care pathways and related nursing time. Data are collected based on the tasks undertaken/assigned to nurses, providing insights into the needs of and intelligence to inform decisions about staffing numbers, staff deployment, models of care, and skill mix.

Birthrate plus

http://shelfordgroup.org/library/documents/ Shelford_Group_Safety_Care_Nursing_Tool. pdf Mental health and learning disability tools: https://hee.nhs.uk/hee-your-area/westmidlands/about-us/our-governance/our-letcs/ mental-health-institute-letc/safe-staffing-toolsmental-health-learning-disability http://www.who.int/hrh/documents/hurst_ mainreport.pdf

http://www.birthrateplus.co.uk/

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Appendix 4 Key existing evidence-based guidance for nursing and midwifery staffing Title

Summary

Link

Year

Strengthening the commitment; the Report of the UK Learning Disabilities Nursing Review

A UK-wide review of learning disabilities nursing supported by the four Chief Nursing Officers in the UK, published in 2012, made recommendations related to workforce planning

http://www.scotland.gov.uk/ Resource/0039/00391946.pdf

2012

Safe staffing for nursing in adult inpatient wards in acute hospitals

NICE inpatient guidelines

www.nice.org.uk/guidance/sg1

2014

Safe midwifery staffing for maternity settings

NICE maternity guidelines

www.nice.org.uk/guidance/ng4

2015

Mental health staffing framework: a practical approach

Mental health toolkit

https://www.england.nhs.uk/6cs/wpcontent/uploads/sites/25/2015/06/mhstaffing-v4.pdf

2015

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

References 1

https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf How to ensure the right people, with the right skills, are in the right place at the right time

https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_ productivity_A.pdf

https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

http://webarchive.nationalarchives.gov.uk/content/20150407084003/http:/www.midstaffspublicinquiry.com

https://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/270368/34658_Cm_8777_ Vol_1_accessible.pdf

https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf

https://www.nice.org.uk/guidance/sg1

https://www.nice.org.uk/guidance/ng4

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_ productivity_A.pdf

https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

15 January 2016. Available at: http://www.cqc.org.uk/sites/default/files/20160115_letter_nhstrusts_ quality_and_finances.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf

https://hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL.pdf

h ttp://www.healthwatchcambridgeshire.co.uk/sites/default/files/hee_nursing_associate_consultation_ document.pdf

https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf

https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499663/Provider_ roadmap_11feb.pdf

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_ productivity_A.pdf

https://www.england.nhs.uk/patientsafety/root-cause

https://www.england.nhs.uk/patientsafety/serious-incident

http://www.nice.org.uk/guidance/SG1

https://www.nice.org.uk/guidance/ng4

https://www.england.nhs.uk/patientsafety/report-patient-safety

https://www.safetythermometer.nhs.uk/index.php?option=com_content&view=article&id=3&Itemid=10

http://www.hqip.org.uk/national-programmes

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

http://www.nmc.org.uk/standards/guidance/raising-concerns-guidance-for-nurses-and-midwives http:// www.gmc-uk.org/guidance/ethical_guidance/raising_concerns.asp; http://www.hpc-uk.org/registrants/raisingconcerns/howto

h ttp://www.nhsemployers.org/your-workforce/retain-and-improve/raising-concerns-at-work-andwhistleblowing

https://www.gov.uk/government/publications/sir-robert-francis-freedom-to-speak-up-review http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawsonleadership-review2012-paper.pdf

http://www.cqc.org.uk/sites/default/files/20150327_duty_of_candour_guidance_final.pdf

https://www.rcplondon.ac.uk/guidelines-policy/work-and-wellbeing-nhs-why-staff-health-matters-patientcare

http://www.hpc-uk.org/assets/documents/10003771Professionalisminhealthcareprofessionals.pdf

http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawsonleadership-review2012-paper.pdf

http://qualitysafety.bmj.com/content/early/2013/07/08/bmjqs-2012-001767

ttp://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawsonh leadership-review2012-paper.pdf

http://ro.ecu.edu.au/cgi/viewcontent.cgi?article=7278&context=ecuworks

Health Education England is developing a set of e-learning modules on safe staffing for sisters, charge nurses and team leaders that will be published in 2016.

https://hee.nhs.uk/sites/default/files/documents/HEE_J000584_QualityFramework_FINAL_WEB.pdf

h ttp://www.nhsbenchmarking.nhs.uk/CubeCore/.uploads/NAIC/Reports/ NAICReport2015FINALA4printableversion.pdf http://www.ncbi.nlm.nih.gov/books/NBK269522

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499663/Provider_ roadmap_11feb.pdf

http://www.nhsemployers.org/~/media/Employers/Documents/Plan/Mind%20the%20Gap%20Smaller.pdf

http://www.institute.nhs.uk/quality_and_value/productivity_series/the_productive_series.html

Further support and guidance will be issued at a future date.

http://www.nhsemployers.org/your-workforce/plan/agency-workers/reducing-agency-spend/e-rostering

h ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/478691/Agency_letter_to_ trusts_post_consultation_final.pdf

https://www.gov.uk/guidance/rules-for-all-agency-staff-working-in-the-nhs

https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/stp

Local patient FFT can be used to measure change over time where providers have local insight into any changes in data collection and completeness, but cannot be used to compare providers with each other, as data collection will vary.

ational patient surveys can be used to compare providers with each other, so even though they are only N published annually, they provide important context for local FFT data. National patient surveys include questions on patientsâ&#x20AC;&#x2122; perceptions of sufficient staffing and questions that act as indicators of staff capacity.

Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time

Local staff FFT can be used to measure change over time where providers have local insight into any changes in data collection and completeness but cannot be used to compare providers with each other, as data collection will vary.

National staff surveys can be used to compare providers with each other, so though they are only published annually, they provide important context for local staff FFT data. National staff surveys include questions directly asking about staff perception of sufficient staffing, or that act as indicators of staff capacity.

The annual GMC national training survey collects medical trainee feedback on a wide range of topics and pivotal issues, such as intensity of work (by day and night), work beyond rostered hours, an expectation to cope with clinical problems beyond the traineeâ&#x20AC;&#x2122;s competence or experience and the ability to attend regular specialty-specific training.

Data collected through incident reporting systems or as serious incidents should never be presented as though they represented actual incidents or actual harm; this is important not because they will inevitably have missing data (as this is true for many other data sources too) but because to do so is counterproductive to the purpose of incident reporting. To support this, NQB partners have committed to using metrics drawn from National Reporting and Learning System and serious incident data only to identify implausibly low levels or patterns of reporting that may indicate issues with providersâ&#x20AC;&#x2122; safety culture or reporting processes. In the context of quality metrics for local consideration alongside CHPPD there is another important reason not to present local incident rates as simple dashboard metrics; overstretched staff may be less likely to find time to report incidents and provider boards could take false reassurance from this. Methods for assessing levels of under-reporting include annual skin surveys for pressure ulcers (http://www.sciencedirect.com/science/article/pii/S0965206X15000935) and case note review and the FallSafe under-reporting survey (see https://www.rcplondon.ac.uk/guidelines-policy/ fallsafe-resources-original) for inpatient falls.

hese local sources can be used to measure change over time where providers have local insight into T any changes in data collection and completeness but cannot be used to compare providers with each other, as data collection will vary and there are a range of factors other than quality of care that will affect outcomes.

Safety Thermometer data can be used to measure change over time where providers have local insight into any changes in data collection and completeness (eg annual skin surveys http://www.sciencedirect. com/science/article/pii/S0965206X15000935 but cannot be used to compare providers with each other, as data collection will vary and there are a range of factors other than quality of care that will affect outcomes (eg age-related risk of falling).

Data collected through incident reporting systems or as serious incidents should never be presented as though they represented actual incidents or actual harm; this is important not because they will inevitably have missing data (as this is true for many other data sources too) but because to do so is counterproductive to the purpose of incident reporting. To support this, NQB partners have committed to using metrics drawn from National Reporting and Learning System and Serious Incident data only to identify implausibly low levels or patterns of reporting that may indicate issues with providersâ&#x20AC;&#x2122; safety culture or reporting processes. In the context of quality metrics for local consideration alongside CHPPD there is another important reason not to present local incident rates as simple dashboard metrics; overstretched staff may be less likely to find time to report incidents and provider boards could take false reassurance from this. Methods for assessing levels of under-reporting include annual skin surveys for pressure ulcers (see above), case note review and the FallSafe under-reporting survey (see https://www. rcplondon.ac.uk/guidelines-policy/fallsafe-resources-original) for inpatient falls.

Date: 28th July 2016

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 REPORT TITLE:

Safety & Quality Committee Update

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

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

Action Required: Approval ()

Discussion ( )

Assurance ()

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

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

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

Reporting, investigation and learning from serious incidents informs risk management

Trust Board Report – 28th July 2016 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 7th July 2016. The Committee considered its standing items and sought assurance on a number of issues discussed at earlier meetings of the Committee and at the Executive Committee for Quality and Risk. These included: 



Data Quality: The accuracy of records of the date of death of patients is regularly audited, but these continue to show discrepancies with mortuary records. The Committee discussed ways of improving accuracy, including the potential for an IT, as distinct from a training, solution. Clinical Audit 2015/16: SQC will receive a report on the outcome of the 2015/16 programme, following discussion at Clinical Effectiveness Committee. This is expected to show improved completion rates and a rationale for decisions not to proceed with some audits. CQUIN: SQC noted Executive discussion of the CQUIN programme for 2016/17 and in particular discussed the target for 75% of staff to receive the flu vaccine (or choose not to do so). We endorsed the priority given to this as a way of helping protect patients and colleagues in winter months when the Trust is under high pressure and staff sickness rates tend to be high. VTE: The Committee welcomed the progress in moving the recording of VTE assessments from the Patient Tracking System (PTS) onto Powerchart in Cerner. After a transitional period of working in parallel, PTS has now been disabled. Performance is expected to improve from the w/c 11 July.

We took good assurance from the handling of these concerns. SQC Annual Report to the Board SQC discussed a draft annual report to the Board on the committee’s work during 2015/16 and its principal challenges for the current year. Some additions were made to the section on future challenges and the amended report was commended to the Board. Diagnostics Deep Dive: Following last month’s deep dive review of diagnostics, when a series of presentations were made covering different parts of the Trust, we received a final presentation on the Emergency Department. It was clear that ED faces particular pressures in diagnostics because patients are expected to be diagnosed and treated, referred or discharged within four hours. Some tests, such as ECG and blood, are therefore requested early in the patient pathway, while CT and Xray generally follow initial assessment. A number of issues were raised, for example potential over-processing, the checking of blood tests and the system of phoning through abnormal results. SQC has requested that Executives review the points raised in all the presentations and report back to the Committee on their conclusions. Review of Activity and Safety SQC discussed an initial report that looked at whether high levels of activity in the Trust, especially over winter months, could potentially have adverse impacts on patient safety. A pressure index has been developed, drawing on several different indicators of busy-ness. This showed that pressure peaked in February this year. There was no clear correlation with any adverse safety impact, although the peak in activity did coincide with increased staff sickness levels and lower patient satisfaction scores in Your Care Matters. Following discussion it was agreed that the next iteration of the report should investigate other potential impacts on safety, including any harm resulting from: cancelled operations; delays in discharge of patients medically ready for discharge; and increased use of agency staff.

Medicine Division: Annual Report The Committee received a presentation on the work of the Medicine Division, and on its principal achievements and challenges. We took good assurance from the Serviceâ&#x20AC;&#x2122;s track record of using risk assessments and patient complaints to identify priorities for improvement. Key challenges for the coming year included: providing a seven day week service; confirming the stroke strategy; and meeting the growing demand in Outpatients while improving performance. Audit on Obtaining Consent SQC received a presentation on a recent audit on Obtaining Consent in Surgery. This identified scope for improvement in areas such as legibility, avoidance of abbreviations and ensuring proper completion of forms. Actions have been taken through training and a more rigorous insistence on completion of consent forms prior to surgery. We took good assurance from this and also suggested that a further audit might look into patient understanding of the risks and benefits of surgery.

Next Meeting The next SQC meeting is at 2pm on 4th August.

Richard Shaw Non-Executive Director Chair â&#x20AC;&#x201C; Safety & Quality Committee July 2016

TRUST BOARD IN PUBLIC

Date: 28th July 2016 Agenda Item: 2.4

REPORT TITLE:

SQC annual report to the Board

EXECUTIVE SPONSOR:

Richard Shaw

REPORT AUTHOR (s):

Richard Shaw / Katharine Horner

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

n/a

Action Required: Approval ( )

Discussion ( )

Assurance ()

Purpose of Report: The purpose of this paper is to provide assurance to the Board that the Terms of Reference of the Safety and Quality Committee (SQC) are being met. Summary of key issues The report provides a summary of key issues addressed by the committee over the last 12 months. Recommendation: The Trust is asked to take assurance from this report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers

Corporate Impact Assessment: Legal and regulatory impact

Compliance with best practice, CQC and Audit Commission

Financial impact

Appropriate use of resources

Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Page 1 of 12

TRUST BOARD REPORT – July 2016 SAFETY AND QUALITY COMMITTEE ANNUAL REPORT 1.

Purpose The purpose of this paper is to provide assurance to the Board that the Terms of Reference of the Safety and Quality Committee (SQC) are being met, to highlight significant issues that have been raised, resolved or challenged and to describe improvements in the way the SQC works.

Context The SQC is a formal committee of the Board of Directors. The purpose of SQC is to provide the Board with a means of independent and objective review for the governance (oversight and scrutiny) of all aspects of quality and safety relating to the provision of care and services in support of getting the best clinical outcomes and experience for the patients of Surrey and Sussex Healthcare (SASH) and all other recipients of our services. The committee ensures its work remains focused on the quality and safety of patient care and the patient experience. The SQC is scheduled to meet every month, with one meeting each quarter dedicated to assurance. In the 12 month period to 30th June 2016 the committee met 10 times and reported progress on its work to the Board via the Chair of the Committee. The Agendas are split into 5 parts looking at quality performance, safety, patient experience and quality and general business.

Sources of assurance The SQC reviews the maintenance of effective system of governance and risk management across the whole of the organisation’s activities throughout the year. In order to gain a balanced insight and gain assurance the SQC: • is presented with a paper each month which gives highlights of the work of the Executive Committee for Quality and Risk (ECQR). • reviews the Trust Quality Report which proves an integrated overview of quality and safety across the Trust. This includes reporting key themes and trends across patient safety (incidents and complaints), alerts, infection control, clinical effectiveness, clinical audit, patient experience. The report includes narrative from each of the sub-committees. • reviews external assurance received by the Trust for example HMSR, FFT, external audit reports, national patient experience surveys, peer reviews. • receives a series of assurance papers each quarter covering key areas of safety, quality and patient experience compliance. • undertakes deep dive reviews of key areas of concern as agreed by the SQC which require more in-depth analysis.

Ways of Working The SQC has relied on a healthy balance of challenge and discussion led by the membership and supported by executive leads. Throughout the year the SQC has requested attendance from executive and management leads to provide support and allow challenge of any issues that have been identified as a significant issue. The Membership is outlined at section 3 of Appendix 1. The Committee’s terms of reference states that there shall not be less than three non-executive directors on the

Page 2 of 12

Jun 16

May 16

Apr 16

Mar 16

Feb 16

Alan Hall (from Nov_15) Alan McCarthy

No meeting held Jan 16

Dec 15

Pauline Lambert

Nov 15

Oct 15

Richard Shaw (Chair)

No meeting held Sept 15

Member

July 15

membership, one of whom shall be appointed as Chairman of the SQC; the quorum necessary for the transaction of business shall be three. Attendance throughout the year is has been as follows:

A = apologies received

Two meetings were cancelled over the past 12 months; September due high level of annual leave and January due to “breaking the cycle” week. 5.

Committee activity during 2015/6 The committee is presented with a paper each month which gives highlights of the work of the Executive Committee for Quality and Risk (ECQR). The committee has asked for further information and assurance on the following issues: • Actions arising out of the analysis of two outstanding Trusts which will help the Trust move towards an outstanding rating. • The committee has probed the actions being taken to reduce mortality in low risk conditions an issue which had the potential to become an elevated risk in the CQC intelligent monitoring rating. • It has been noted by the committee that most of the quality risks for the Trust are well documented and discussed. Many of the risks relate to the pressure on the hospital of increasing patient numbers, especially in ED, admission to the appropriate ward and timely discharge to the community. • Actions being taken to reduce noise at night to improve the inpatient experience. Each month the committee reviews the Quality Report which includes data from the Trust scorecard. Discussion has included the following issues over the last year: • the committee has requested short paper on the unintended consequences of the RTT target. • a review of a sample of cases was requested to assess the risk emanating from readmissions within 28 days following non-elective admission. • the committee requested an update on the work undertaken within the ED to improve ambulance turnaround times. • the committee has requested a presentation from the Obstetric team on the work being undertaken to implement the National GROW strategy. This was triggered by an unusual number of still births in March. • The committee noted the failure to meet the breast symptomatic two week wait target and requested specific feedback from the Cancer Division on the work being done to improve the pathway.

Page 3 of 12

Deep dives included: • The committee received a presentation from the Obstetric team on their work to ensure that the caesarean section is appropriate for the Trust’s patients taking into account their clinical condition. The committee took good assurance from the presentation and concluded that the caesarean section rates do not give rise for concern. • The committee reviewed the progress made on the Dementia Strategy over the previous 12 months and future challenges. • The committee received a presentation on venous thrombo-embolism which has been highlighted as a risk in the quality report. The presentation gave assurance that the Trust’s performance on VTE is being closely monitored and reviewed. • A clear analysis of the value and implications of the Safety Thermometer metric was presented by the Deputy Chief nurse. It was agreed that there were inconsistencies in the data and actions including staff training were agreed to address this. • Each Division has been asked to present a summary of work, achievements and challenges. The Cancer Division has presented and the Division took good assurance from the management of the service and the improvements that have been achieved. The significant pressure on the service by the sustained increase in referrals for suspected cancer (12-14% p.a. for three years) was noted. • A review of diagnostics which has appeared as a theme in Incidents in the Trust. The aim was to explore the processes involved in different aspects of diagnosis and see if areas for improvement could be identified. The Committee received five short presentations and discussed the implications for safety. The committee regularly receives the following assurance papers: • Quarterly incident report • Quarterly complaints report • Quarterly PALS report • Quarterly Safeguarding report (adults and children) • Quarterly CQUINS progress report • Quarterly Clinical Audit report • Divisional Annual report • Falls Annual report • National Patient Experience Surveys 6.

Challenges for 2016 The SQC has identified the following as main challenges for 2016/7: 1) Continuing to seek and provide assurance of the Trust’s quality and safety strategy by reviewing the Quality report each month and challenging the data where appropriate. 2) Ensure the committee retains focus on and receives updates on the progress of the following key areas; a. clinical audit b. falls prevention c. VTE compliance d. the safety implications of pressure on bed numbers e. right bed first time f. achieving and sustaining the symptomatic breast 2ww target Page 4 of 12

3) 4) 5) 6) 7.

g. safeguarding h. fractured neck of femur pathway i. stroke management Monitor the implications of the new Sustainability and Transformation Plan (STP) for the Trust and its potential impact on quality and safety. Continue to develop effective relationships with services and directorates to share learning and to drive safety and quality improvements. Improve working linkages with the Board and other sub-committees to provide focused assurance aligned to the Boardâ&#x20AC;&#x2122;s needs. Develop ways of working with the Shadow Council of Governors.

Conclusion The Committee has been successful in maintaining and improving robust assurance mechanisms. The Trust scorecard (included in the Quality Report) was revised during the year and provides better data and information about quality and safety across the organisation. This has allowed the committee to better understand the strengths and weaknesses of quality and safety performance and is therefore well positioned to support the targeting of improvement actions. The Board can be assured that the Safety and Quality Committee is meeting its terms of reference.

Richard Shaw, Non-Executive Director, Chair of Safety and Quality Committee June 2016

Page 5 of 12

Appendices Appendix 1:

Safety and Quality Committee: Terms of Reference 1. Background The Safety and Quality Committee (â&#x20AC;&#x153;the Committeeâ&#x20AC;?) is constituted as a standing committee of the Board of Directors. These terms of reference can only be amended by the Board of Directors. The purpose of the Committee is to assist the Board of Directors in executing their responsibility for seeking and monitoring assurance around safety, quality and patient experience. .

2. Authority The Board of Directors has delegated to the Committee the authority to deal with the matters set out in paragraph 6 below. The Committee is authorised by the Board of Directors to seek any information it requires from any employee of the Trust in order to perform its duties.

3. Membership and Attendance The members of the Committee shall be: (i) (ii) (iii) (iv) (v) (vi)

The Chairman and three non-executive directors appointed by the Board of Directors; Medical Director or Deputy; Chief Nurse or Deputy; Chief Operating Officer or Deputy Chief Financial Officer or Deputy. Clinical Chiefs of Service (6 including, Chief of Education and Chief Clinical Informatics Officer )

Members of the Board of Directors not specified in paragraph 3.1 above shall have the right of attendance. The Secretary shall circulate minutes of meetings of the Safety and Quality Committee to all members of the Board of Directors with Board papers. The Chairman of the Committee shall be a non-executive director appointed by the Board of Directors. As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee. The following individuals are required to attend part or all of the meetings as required by the Chairman of the Committee but shall have no voting rights: (i) (ii)

Divisional Chief Nurses Risk and Patient Safety Lead ;

Page 6 of 12

(iv)

Director of Informatics, Estates and Facilities â&#x20AC;&#x201C; by invitation only when required; Director of Corporate Affairs - by invitation only when required;

(v) (vi)

Clinical Governance Compliance Manager Corporate Governance Manager

(iii)

(vii)

Any other clinicians, nursing and midwifery staff and allied health professionals as appropriate to the business of the meeting concerned; and (viii) Accountable Officer for Controlled Drugs (by invitation only when required);

4. Quorum The quorum necessary for the transaction of business shall be five members, which shall include two non-executive directors, the Medical Director (or deputy) or Chief Nurse (or deputy), two Chiefs of Service or their deputies. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. In the absence of the Committee Chairman and/or an appointed Deputy, the remaining non-executive members present shall elect one of themselves to chair the meeting. Where a Committee meeting: i.

is not quorate under paragraph 4.1 within one half hour from the time appointed for the meeting; or

ii.

becomes inquorate during the course of the meeting,

The Committee members present may determine to adjourn the meeting to such time, place and date as may be determined by the members present.

5. Meetings The Committee shall meet monthly for two hours and at such other times as the Chairman of the Committee shall require. Risk and Patient Safety Lead â&#x20AC;&#x201C; or their nominee shall act as the Secretary of the Committee. Meetings of the Committee shall be summoned by the Secretary of the Committee at the request of the Committee Chairman. Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee no later than seven days before the date of the meeting. Supporting papers shall be sent to Committee members and to other attendees, as appropriate five days ahead of the date of the meeting.

6. Duties Page 7 of 12

The Committee shall support the Board of Directors with: 6.1.

STRATEGY The Committee will review and approve the Safety and Quality Strategy and the Quality Account following its development through EC and prior to presentation to the Board for approval.

6.2

CLINICAL GOVERNANCE CONTROL SYSTEMS The Committee will seek assurances that the following clinical governance controls are reviewed to provide assurance of the Trust’s statutory duties are executed and the control system’s design, function and performance is satisfactory, meets best practice and is benchmarked with leading Trust’s wherever possible. • • • • • • • • • • •

6.3

Clinical Audit CQC Compliance Incident management Mortality Infection, prevention and control NICE Compliance Complaints Patient Opinion Clinical Claims handling Safeguarding Clinical Data Quality

SAFETY The Committee will seek assurances that the safety of patients and any risk to their safety is managed effectively through EC. The Committee will specifically ask for evidence, via the minutes of EC meetings, that incident management metrics are reviewed and acted on, that timely root cause analyses are instigated for SUIs and HCAIs and lessons learnt, and that patients are safeguarded in patient areas and all transfers within the hospital and to the community. The Committee will review recurring themes and key trends of incidents to see that lessons are learnt are shared trust-wide to prevent recurrence of incidents. The Mortality group will report directly to the Committee on its findings and learnings. The Committee will look at the incidence of claims for compensation through the NHSLA scheme and how these are managed.

6.4

PATIENT EXPERIENCE The Committee will seek assurances that improving the Patient Experience is part of the trust’s everyday business. The trust’s Patient Experience Committee has been re-formed and will report to the Safety & Quality Committee, to provide additional assurance that the lessons are learnt from patient experiences, surveys, patient

Page 8 of 12

opinion sites, complaints, claims, patient constitution issues and stakeholder feedback and are shared across the whole organisation. The Committee should have confidence in the way the trust source patient feedback and involvement, utilising various methods of collecting and responding to patient information in order to widen participation that is representative of all patient groups. The Committee will expect the Patient Experience group to report on its oversight of complaints - both the management of the process as well as substance and response to complaints and lessons learnt. The Committee will ask for periodic reviews of complaints in the trust direct from the Complaints team to triangulate its source of assurance with reporting from the Patients Experience group. The Committee will assure itself that different patient groups (selected by demographics or condition) have the optimal patient experience, safety and the quality of services by triangulating different data sources, hard and soft intelligence with commentary from clinicians. 6.5

QUALITY OF SERVICE The Committeeâ&#x20AC;&#x2122;s programme of work will include a review of the improving quality of services by looking for evidence of clinical improvements in the trust arising from mortality reviews and in response to other drivers e.g. Francis Report, SUI action plans, to assure the trust is implementing the best clinical practices. It will review the rationale for the design of the clinical audit programme, conduct progress reviews and seek assurance from the clinical audit results. Compliance with NICE directives is also an important benchmark of best practice where applicable to the Trust and the Committee will seek assurance that the trust responds and adopts NICE directives in a timely way with assurance of implementation via clinical audit. The Committee will seek assurance that clinical data is collated and reported accurately, timely and using the correct methodology. The Committee will seek assurance that the trust's responsibility to manage and safeguard patient information thought its adherence to the Information Governance policy and maintenance of minimum standards

6.6

COMPLIANCE The Safety and Quality Committee will receive assurance of compliance with CQC and other regulators by exception reporting of potential risks to compliance with CQC and other regulators from EC, which is responsible for evidencing compliance.

7. Reporting arrangements 7.1

The Committee Chairman shall report formally to the Board of Directors on its proceedings after each meeting on all matters within its duties and responsibilities. Page 9 of 12

7.2

The Committee shall make whatever recommendations to the Board of Directors and/or Executive Committee that it deems appropriate on any area within its remit where action or improvement is needed. In particular, the Committee shall refer any substantive issues or concerns on delivery of the Safety and Quality Strategy to the Audit and Assurance Committee, the Executive Committee for Quality and Risk and or to the Board of Directors for wider consideration in light of its overall responsibility for ensuring the safety and quality of services provided by the Trust.

8. Review 8.1

The Committee shall, at least once a year, review its own performance, membership and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Board of Directors for approval.

Page 10 of 12

Appendix 2:

Safety and Quality Committee: Standing Agenda 1

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

Strategic & Regulatory

Safety

Patient Experience

Quality

General AOB Issues to report to Board Date of next meeting

Page 11 of 12

Appendix 3:

Safety and Quality Committee: Meeting Timetable The Committee shall meet monthly based on the indicative programme below: Subject

Quarterly

Biannually

Annually

Strategic & Regulatory

Approve Trust’s Safety and Quality Strategy

✓

Approve Trust's Quality Account

✓

Francis implementation

✓

CQC Compliance/ regulatory updates

✓

Safety

✓

Incident management

Infection, prevention and control

Mortality

Claim handling

✓

Safeguarding

✓

✓ ✓

Patient Experience

Patient Opinion

✓

Complaints

✓

Patient groups (by demographics or condition)

✓

Quality of Care

Clinical audit programme and audit results

Progress of clinical audit programme

Evidence at point of care

NICE Compliance

Information governance

Data Quality

✓ ✓ ✓ ✓ ✓ ✓

Page 12 of 12

Integrated Performance Report M03 â&#x20AC;&#x201C; June 2016

Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer) Mark Preston (Director of Organisational Development & People)

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

Performance – June 2016 Patient Safety • There were two SIs declared in June 2016 including one Never Event. • Other patient safety indicators continue to show expected levels of performance. • The Trust had one MRSA bloodstream infections and three Trust acquired C-Diff case in June 2016. Clinical Effectiveness • Mortality is lower than expected for our patient group when benchmarked against national comparators. • Maternity indicators continue to show expected performance. Access and Responsiveness • The 4hr ED standard was achieved with performance of 96.4% in May 2016 • While the key 62 Day GP Referral Cancer standard continues to be achieved, the TWR and TWR Breast Symptomatic standards remain a challenge and were not achieved in June 2016. Actions put in place are supporting improved performance in July 2016. • 18 Weeks RTT - The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month but referral growth from south of the Trust presents a risk. Patient Experience • In June 2016 the Inpatient FFT increased to 96.0%. The ED FFT also increased from 94.9% to 95.9%. Outpatient FFT remains an area for improvement with an FFT score of 89.1% Workforce • On-going local and overseas recruitment continues in order to reduce agency usage across the Trust • The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is assured that adequate staffing is in place.

An Associated University Hospital of Brighton and Sussex Medical School 2

Performance – June 2016 Finance • The Trusts YTD deficit at the end of month 3 was £(2.5)m, £2.3m better than the planned £(4.8)m deficit position. The Sustainability and Transformation funding trigger has been achieved at Q1 (based on financial performance). The Trust has achieved its agency spend plan for the quarter. Key Risks • The Significant Risk Register for the Trust includes four quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis and RTT Access Standards. Action: The Board are asked to note and accept this report

Legal:

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

Regulation:

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

Patient experience/ engagement:

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

Risk & performance management

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

NHS constitution; equality & diversity; communication.

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

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

No of Never Events in month

No of medication errors causing Severe Harm or Death

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

95.0%

92.2%

93.2%

95.4%

90.3%

92.6%

91.2%

89.1%

90.2%

91.5%

94.7%

93.8%

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

97.7%

94.8%

96.7%

97.6%

95.0%

96.2%

95.1%

93.8%

94.5%

95.0%

96.5%

97.6%

Percentage of patients who have a VTE risk assessment

95%

96%

WHO Checklist Usage - % Compliance

96%

100%

Serious Incidents - No per 1000 Bed Days

0.05

0.23

0.32

0.11

0.38

0.16

0.33

0.51

0.38

0.16

0.10

Percentage of Patient Safety Incidents causing Severe harm or Death

0.0%

0.6%

0.8%

0.6%

0.8%

0.5%

1.4%

0.7%

0.2%

Number of Sis

Number of overdue CAS and NPSA alerts

Trend

• There was one Never Event reported in June 2016, detail is provided overleaf. • VTE – the standard for initial assessment continues to be achieved in in early July, the assessment process was deployed into Cerner, the Trust’s electronic patient record, which will support further improvement in this standard. • Safety Thermometer – both the “All harm” and the “New Harm” indicators continue to achieved expected performance. The main type of harm was community acquired pressure damage. • The percentage of patient safety incidents causing severe harm or death remained at baseline levels - 0.2% in June 2016.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety • Two Sis, including the Never Event, were declared in June 2016 (in all cases full investigations have been started) and details are provided below: • 2016/16688 (Wrong site surgery – declared as a never event) - The patient was consented for a Left L5, S1 microdisectomy. The Consultant surgeon marked the level of decompression using x-ray. The WHO safety surgical checklist was completed with the surgeon, the anaesthetist and the surgical team present. It was known prior to surgery that the affected disc had a large left side bulge which was symptomatic and a smaller right side bulge. It was anticipated that both bulges would be resolved during surgery. It is the consultant’s usual practice to make a mid-line incision and then correct the most symptomatic side first, in this case the left side. Surgery was undertaken. When writing his notes the surgeon noted that the right L5, S1 disc only had been decompressed. As the patient was still in theatre the surgeon rescrubbed and completed the procedure on the left side. • 2016/17419 (accident) - Patient was mobilising with the aid of an HCA (1:1). The patient indicated that she was in pain on her right side. The HCA saw blood and that the ankle was disfigured. She assisted the patient to the ground and called for help. Patient found to have an open fracture of her tibia and fibula.

An Associated University Hospital of Brighton and Sussex Medical School 5

Patient Safety Infection Control Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

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

An Associated University Hospital of Brighton and Sussex Medical School 6

Clinical Effectiveness Mortality and Readmissions Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

HSMR (56 Monitored diagnoses - 12 Months)

96.1

97.2

99.3

99.5

98.3

97.4

97.6

96.2

94.0

Emergency readmissions within 30 days (PBR Rules)

7.6%

7.4%

7.3%

6.3%

7.1%

6.8%

Apr-16

May-16

6.5%

8.1%

Jun-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

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

C Section Rate - Emergency

14%

17%

14%

15%

16%

17%

14%

18%

C Section Rate - Elective

11%

13%

10%

12%

11%

10%

Admissions of full term babies to neo-natal care

5.0%

5.1%

5.8%

7.1%

6.6%

5.9%

3.8%

6.1%

5.0%

3.9%

7.0%

2.7%

Trend

â&#x20AC;˘ Maternity indicators continue to be monitored and reviewed by the Divisional Governance process as well as the Clinical Effectiveness Committee. Admission of full term babies to neo-natal care has returned to its baseline range.

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness STP Trajectories Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Trajectory

90.0%

93.0%

94.0%

95.0%

94.4%

95.0%

Actual

91.3%

95.5%

96.4%

Trajectory

85.0%

Actual

86.3%

86.0%

88.4%

Trajectory

92.0%

92.2%

92.4%

92.6%

92.8%

93.0%

92.8%

92.4%

92.2%

92.0%

Actual

92.6%

92.5%

92.7%

Trajectory

0.6%

Actual

0.1%

0.5%

0.3%

ED 95% in 4 hours

Cancer - 62 Day Referral to Treatment Standard

RTT Incomplete Pathways - % waiting less than 18 weeks

Percentage of patients waiting 6 weeks or more for diagnostic

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

An Associated University Hospital of Brighton and Sussex Medical School 8

Access and Responsiveness Emergency Department Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

94.3%

96.1%

97.1%

95.5%

92.9%

95.5%

92.8%

91.4%

88.6%

91.3%

95.5%

96.4%

Ambulance Turnaround - Number Over 30 mins

238

220

225

231

191

227

255

296

231

172

168

Ambulance Turnaround - Number Over 60 mins

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

Trend

• The ED 4hr standard was achieved in June 2016 with performance of 96.4%. • Volumes / Acuity of emergency attendances / admissions continue to be an issue. Comparing Q1 1617 with the same period in 1516, ED Attendances are 6% higher (Ambulances 5%), with significant differences across the key CCGs – East Surrey 3%, Crawley 13% and Horsham and Mid Sussex 12%. Overnight Non elective admissions are up 3%, with particular pressure in Paeds (8% increase) and 75+ year olds (6%) with similar disparities across the CCGs. • Discharge delays are also a significant driver of performance with an average of 101 beds occupied by patients who are medically ready for discharge. While this is a decrease from 128 in May 2016, it continues to present a challenge for managing acute bed stock. • Ambulance turnaround performance has improved in June 2016 with a reduction in both 30 minute and 60 minute delays. • In light of the on-going operational pressures in the Trust, the following risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 9

Access and Responsiveness Cancer Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Cancer - TWR

93.1%

93.0%

89.6%

90.0%

93.2%

94.3%

93.0%

93.3%

93.7%

91.0%

90.3%

91.7%

Cancer - TWR Breast Symptomatic

93.2%

93.3%

94.2%

93.8%

93.4%

96.2%

90.7%

84.1%

89.8%

87.1%

91.1%

82.0%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

100.0%

95.2%

100.0%

95.3%

95.8%

96.2%

95.7%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

100.0%

Cancer - 31 Day Diagnosis to Treatment

98.3%

99.2%

99.3%

98.2%

96.6%

96.1%

96.2%

96.0%

96.7%

98.5%

97.1%

Cancer - 62 Day Referral to Treatment Standard

80.7%

84.2%

86.2%

85.6%

88.3%

86.0%

81.1%

87.5%

87.9%

86.3%

86.0%

88.4%

Cancer - 62 Day Referral to Treatment Screening

87.5%

88.9%

100.0%

87.5%

90.9%

100.0%

90.9%

100.0%

87.0%

100.0%

80.0%

Trend

• While the key 62 Day GP Referral Cancer standard continues to be achieved, the TWR and TWR Breast Symptomatic standards remain a challenge and were not achieved in June 2016. • The Trust held a summit in relation to TWR in May 2016 and is progressing a number of actions to support improved delivery. The overall theme is moving towards treating the pathway as a “one week rule” with changes focussing on both process and capacity. • The resulting action plan has been progressed throughout June and July and Performance on the TWR is expected to exceed 94% in July as a result. Improvement has also been seen in the TWR Breast Symptomatic standard, however patient deferral remains a challenge despite clinical conversations with patients in relation to the urgency of appointment.

An Associated University Hospital of Brighton and Sussex Medical School 10

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

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

92.2%

92.0%

92.1%

92.2%

92.5%

92.1%

92.0%

92.2%

92.6%

92.5%

92.7%

RTT Admitted

84%

82%

78%

79%

81%

78%

77%

76%

78%

79%

RTT Non Admitted

89%

88%

85%

86%

87%

Percentage of patients w aiting 6 weeks or more for diagnostic

1.0%

0.1%

0.5%

0.2%

0.1%

0.0%

0.1%

0.5%

0.3%

133

112

133

119

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

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

Trend

• At aggregate level, the trust continues to deliver against the Incomplete pathways standard. Capacity challenges remain in General Surgery, Trauma and Orthopaedics, Ophthalmology, Cardiology, Rheumatology and Neurology – productivity and recruitment is underway to support resolution • Despite planned increases in capacity, referral growth is exceeding the system plan with significant changes in referral patterns to the south of the Trust. • At the end of June 2016, four patients were waiting over 52 weeks on an incomplete pathway. All have appointment / surgery dates in July 2016. • 28 patients were cancelled at the “last minute” for non clinical reasons and 12 patients breached the 28 day standard day for treatment following a last minute cancellation • The following risk remains on the significant risk register: • RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints – Risk score 15 (Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 11

Patient Experience Patient Voice Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Emergency Department FFT - % positive responses

91.4%

95.8%

96.9%

95.3%

97.3%

97.5%

95.8%

96.3%

95.0%

95.4%

94.9%

95.9%

Inpatient FFT - % positive responses

95.1%

95.3%

96.1%

95.0%

95.1%

97.4%

95.0%

96.5%

95.6%

96.0%

Maternity FFT - Antenatal - % positive responses

94.1%

98.8%

94.3%

96.5%

96.1%

96.0%

97.5%

98.5%

95.3%

98.9%

95.4%

93.2%

Maternity FFT - Delivery - % positive responses

93.8%

87.9%

95.4%

95.1%

97.6%

91.7%

95.5%

97.1%

94.7%

100.0%

98.8%

99.0%

Maternity FFT - Postnatal Ward - % positive responses

90.0%

87.7%

87.9%

88.9%

88.8%

88.9%

88.4%

92.0%

93.3%

95.3%

97.6%

94.0%

97.7%

96.1%

97.1%

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

91.9%

83.3%

88.3%

87.3%

89.3%

92.8%

90.0%

89.5%

89.0%

89.6%

86.7%

89.1%

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

Trend

• There has been a slight increase in the Friends and Family (FFT) score for inpatients, based on a 39% response rate • In the Emergency Department the FFT score is the highest it has been since February, although the response rate has dropped for the third month in a row and is now at 17%. The department has been made aware of this drop. • In maternity the FFT score and response rate for touchpoint 1 (36/40) have both dropped and are the lowest they have been for a year (93% score and 12% response rate). For the remaining three touchpoints the response rate is 26%. Both the delivery and postnatal community touchpoints have improved slightly since May, however the FFT score for the postnatal ward is the lowest it has been since March. • The number of response to the FFT question on the Your Care Matters survey in outpatients remains a challenge, however the score has recovered from the low in May and is back to 89%, a result similar to January-April. The YCM process and the role of staff has been discussed at the nurses audit day.

An Associated University Hospital of Brighton and Sussex Medical School 12

Patient Experience • Awareness and use of the carer’s passport across wards remains varied. A Carer’s Steering group is being planned to develop a Carers’ Strategy, oversee its implementation and introduce developments that will improve the support SASH provides to carers. • A roll-out plan has been agreed to introduce open visiting to wards. The expectation is that it will go live in early September, the proposal is currently out to consultation with staff. • The phone etiquette task & finish group has developed draft guidance for managing difficult phone conversations and a protocol for managing abusive callers. This will dovetail with work being undertaken by HR following the results of the staff survey. • The next meeting will address how to improve the efficiency of how inbound calls are managed and making the most of the system we have to improve how calls are directed to the right place first time. • An action plan following the results of the 2015 national inpatient survey is being formulated. National comparisons for May • Nationally the ED was ranked 13th in May 2016 (FFT score of 94.9% compared to a national average of 85.4%), based on an above average response rate (19% compared to 13%). Trusts with a response rate of less than 5% have not been included in the rankings. • The average combined national FFT score for inpatients and daycases for May 2016 was 95.5%. The combined SASH score for May was 95.8%. The SASH combined response rate was 25%, which was the national average.

An Associated University Hospital of Brighton and Sussex Medical School 13

Workforce Workforce Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

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

93.3%

92.5%

95.0%

95.1%

95.4%

95.1%

96.3%

95.6%

94.5%

97.3%

98.1%

97.6%

Average fill rate – care staff (%) - Day

94.3%

94.5%

95.1%

97.2%

98.7%

97.1%

97.0%

97.3%

99.5%

98.2%

98.1%

98.2%

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

95.2%

94.3%

96.4%

96.9%

97.2%

97.9%

98.0%

97.6%

98.8%

98.6%

98.9%

Average fill rate – care staff (%) - Night

94.4%

93.8%

96.4%

96.9%

97.8%

98.2%

97.6%

97.4%

97.3%

97.2%

98.2%

98.0%

Overall Sickness Rate

3.9%

3.7%

4.4%

4.0%

3.8%

4.3%

4.0%

3.6%

3.2%

3.5%

%age of staff who have had appraisal

56%

57%

64%

72%

74%

72%

70%

66%

0.4%

14.7%

23.8%

15.6%

15.2%

15.0%

14.4%

13.8%

14.1%

14.4%

14.5%

Staff Turnover rate

Trend

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. • Sickness absence increased slightly to 3.5% in June 2016.

An Associated University Hospital of Brighton and Sussex Medical School 14

Finance Indicator Description

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Outturn £m Surplus / (Deficit) - Plan

1.6

15.2

Outturn £m Surplus / (Deficit) - Forecast

1.6

(3.0)

(4.2)

(6.6)

(6.5)

15.2

YTD £m Surplus / (Deficit) - Plan

(1.1)

(0.7)

(0.6)

(2.0)

(1.3)

(0.6)

0.0

1.6

(2.3)

(4.0)

(4.9)

YTD £m Surplus / (Deficit) - Actual

(1.3)

(2.6)

(3.3)

(3.6)

(4.2)

(5.3)

(3.9)

(4.8)

(6.5)

(1.3)

(2.5)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

3.8

7.5

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

3.3

(6.3)

(7.6)

(7.2)

7.5

YTD Savings £m - Actual

1.3

1.9

2.1

2.5

2.8

3.2

3.6

4.1

5.4

0.2

0.5

1.0

OT Risk £m Surplus / (Deficit) - Assessment

0.0

(6.8)

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

2.6

1.2

2.4

2.5

2.3

2.1

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

2.5

3.0

3.9

4.8

5.0

5.7

4.5

6.8

2.5

2.7

3.0

3.7

YTD Liquid ratio - days

(22.0)

(25.0)

(19.0)

(13.0)

(16.0)

(15.0)

(18.0)

(16.0)

(13.0)

(18.0)

YTD BPPC (overall) volume £m

78%

76%

69%

59%

60%

53%

52%

47%

28%

32%

53%

YTD BPPC (overall) value £m

75%

74%

68%

61%

63%

60%

59%

55%

41%

51%

58%

Outturn Capital spend Fav / (Adv) - forecast

17.1

14.1

9.0

13.1

Trend

• The Trust’s 2016/17 plan has been profiled as below, reflecting the phasing of the £9.7m sustainability funding, clinical activity and cost improvements. Mth 1

Mth 2

Mth 3

Mth 4

Mth 5

Mth 6

Mth 7

Mth 8

Mth 9

Mth 10

Mth 11

Mth 12

£000's

In Month I&E Plan

(2,304)

(1,646)

(906)

(67)

2,816

227

3,671

4,380

(1,166)

1,810

3,246

5,139

Cuumulative I&E Plan

(2,304)

(3,950)

(4,856)

(4,923)

(2,107)

(1,880)

1,791

6,171

5,005

6,815

10,061

15,200

2,425

STP Funding (incl above)

• The Trusts YTD deficit at the end of month 3 was £(2.5)m, £2.3m better than the planned £(4.8)m deficit position. The Sustainability and Transformation funding trigger has been achieved at Q1 (based on financial performance). The Trust has achieved its agency spend plan for the quarter. • Although still ahead of plan, there remains overspending within all Divisions (except Surgery).

An Associated University Hospital of Brighton and Sussex Medical School 15

Finance • The cash balance at the end of June 2016 was £3.7m. The Trust has drawn down £7.2m of its 2016/17 revolving working capital facility. • The Trust has applied for a £15.9m Capital Resource Limit (CRL) in the 2016-17 plan resubmission (which includes potential schemes for EPR Digitise, clinical capacity investment and pathology). The capital programme funding assumes the agreement of £3m PDC for the 2015/16 transfer from capital to revenue and a £3.5m capital investment loan.

An Associated University Hospital of Brighton and Sussex Medical School 16

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item: 3.2

2016/17 Revenue Budget

REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s):

Paul Simpson Chief Finance Officer Peter Burnett Deputy Chief Finance Officer

Action Required: Approval



Discussion



Assurance ()

Purpose of Report:

Approval of the 2016/17 final revenue budget. Summary of key issues

The Board approved an interim 2016/17 budget in March 2016, noting unsigned contracts with commissioners and lack of clarity over the status of control totals. The budget is now presented as final, for Board approval. The key things that have changed to allow this are: 1) Of the four caveats listed by the Trust in its 3 March letter accepting the control total: a. Contracts are signed (bar Sussex MSK) without material adverse impact on the budget; b. The readmission penalty will not be levied; c. MRET threshold change has been agreed with East Surrey CCG, but not with Sussex CCGs (subject to a dispute process); d. The agency spend profile has been accepted (see below); 2) The Trust has resubmitted it’s I&E plan (with cash and capital amendments) to NHSi in July. NHSi did not ask for any changes to the control total, and have accepted the Plan, which includes the agency spend trajectory. However, they have not written to confirm that. The Trust maintains its stance on the caveats (so if the dispute with Sussex over MRET is found against the Trust the budget will be reduced). To restate key points: the budget provides a surplus of £15.2m (the “control total” notified by NHS Improvement).

The revenue budget includes: a) the receipt of £9.7m sustainability and transformation funding; b) A cost improvement/savings plan of £9.2m (3.1% of turnover, after excluding set offs for pass through costs and taking account of income included in Divisional budgets); c) A £2.7m productivity gain from additional activity valued at £3.6m – this item describes the main stretch for the Trust and increases the overall efficiency gain to 4% of turnover); The budget has also been “tidied”, with the allocation of reserves. Details of the budget, and an analysis of remaining reserves are attached as annexes A and B. Recommendation:

The Board is asked to approve the 2016/17 revenue budget. Relationship to Trust Strategic Objectives & Assurance Framework: Objectives S01 (Safe Services) S02 (Effective) and S05 (Well led) 4 apply. Corporate Impact Assessment: No legal breach is reported, or forecast. NHS Trust financial performance is subject to Schedule 5 of the NHS Act 2006 (the “breakeven duty”). This was breached in 2007/08 and the Auditor has notified the Secretary of State in several letters as required by Section 19 of the Audit Commission Act. The main regulators, are as follows: 

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



The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services

Legal and regulatory impact

Financial impact Patient Experience/Engagement

Direct – sets the interim revenue budget for 2016/17 and capital budget for 2016/17. No adverse impact – indeed the budget describes increased productivity and specific investment in

quality. CIPs are subject to quality impact assessment.

Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

No compliance issues. Risk and financial performance are a core part of the monthly internal performance management process and risk is described within the report. No compliance issues.

Attachment: Paper with Appendix A & B

Appendix A 2016/17 revenue budget (final column) 16/17 Annual Budget* ÂŁ'000 Income (excl Divisional income) NHS Clinical Income Chemo Profit Share High Cost Drugs Excluded devices Sustainability & Transformation Funding Other Income Total income

265,420 (105) (12,287) (1,058) 9,700 8,678 270,348

Divisions (inc Divisional income) Cancer and Diagnostic Services: Radiology Pathology Site Services Cancer

9,705 11,873 1,281 4,662 27,521

Surgical Medical WaCH Clinical Services (Escalation) E&F HR CEO Restructuring and PMO Finance Nursing IMT Corporate Affairs Overheads CQUINS costs Reserves & Centrally Held Savings Total Divisional I&E EBITDA

74,155 63,990 25,593 4,201 14,090 2,675 1,511 250 3,420 3,955 5,513 794 8,984 150 4,240 241,042 29,306

Total post EBITDA

14,107

Net Surplus / (Deficit)

15,200

* including forecast allocations

Appendix B 2016/17 revenue budget: reserves analysis

General & Inflation Reserves: Notes

Reserves*

ÂŁ'000 Agency Premium Nursing Rota Pathology Joint Venture Medical Equipment Service Provision Payawards, ER NI & Pay Pressures Drugs Inflation (PBR Included) Non Pay Inflation/Provisions Frailty Unit Funding Contingency

Offset against agency nursing savings target Offset against agency nursing savings target

Revenue funding for capital project

1,000 500 300 437 427 836 370 2,000 5,870

Quality Reserve: ÂŁ'000 216 200 126 110 71 27 250 1,000

Medical Records Business Case. Clinical Excellence Awards 11th ED Consultant Maternity Management Investment CQC Increase in Fees Mattresses (above contract levels) Other Quality Priorities

Reserve For Additional Activity

(326)

Total Reserves (Excluding Unallocated Savings)

6,544

Savings Awaiting Allocation

(2,303)

Total Reserves (Including Unallocated Savings) * including forecast allocations

[END]

4,240

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item: 3.3

REPORT TITLE:

Finance & Workforce Committee Chair Update – Public

EXECUTIVE SPONSOR:

Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s):

Richard Durban (Non-Executive Director and FWC Chair)

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

No – Board Update

Action Required: Approval ( )

Discussion ( )

Assurance (√)

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

The Finance and Workforce Committee met on the 26th July 2016 and was quorate. 

M03 reports were received for Finance & the 16/17 CIP, Workforce and Organisational Development, Capital and IT.



The Trusts YTD deficit at the end of month 3 was £(2.5)m, £2.3m better than the planned £(4.8)m deficit position. The Sustainability and Transformation funding trigger has been achieved at Q1 (based on financial performance). The Trust has achieved its agency spend plan for the quarter.



The Committee received the 2016/17 Final Budget Paper, an updated on the Medical Records Business Case and a report on the National Staff Survey.

Recommendation:

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

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

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

Financial impact

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

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

Patient Experience/Engagement

Indirect impact through Trust planning and workforce.

Risk & Performance Management

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

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

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT JUNE 2016

Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 26th July 2016 and it was quorate. The key points from Public meeting were: Finance Performance & CIP M03 Reports The Trusts YTD deficit at the end of month 3 was £(2.5)m, £2.3m better than the planned £(4.8)m deficit position. The Sustainability and Transformation funding trigger has been achieved at Q1 (based on financial performance). The Trust has achieved its agency spend plan for the quarter. Although still ahead of plan, there was overspending within all Divisions (except Surgery). The cash balance at the end of June 2016 was £3.7m. The Trust has drawn down £7.2m of its 2016/17 revolving working capital facility. The CIP report showed that the end of June the Trust achieved savings of £1.0m and is ahead of the NHSI plan.. The Trust remains confident the full £9.2m savings can be successfully delivered in 2016/17. The Committee noted that the in year £6m working capital facility would now need to be repaid by 31/3/17 and that payment to suppliers was improving..

2016/17 Budget Paper The Committee was presented with the final budget. The budget provides a surplus of £15.2m (the “control total” notified by NHS Improvement) and includes: a) the receipt of £9.7m sustainability and transformation funding; b) A cost improvement/savings plan of £9.2m (3.1% of turnover, after excluding set offs for pass through costs and taking account of income included in Divisional budgets); c) A £2.7m productivity gain from additional activity valued at £3.6m – this item describes the main stretch for the Trust and increases the overall efficiency gain to 4% of turnover); and has the following caveats: a. Contracts are signed (bar Sussex MSK) without material adverse impact on the budget; b. The readmission penalty will not be levied; c. MRET threshold change has been agreed with East Surrey CCG, but not with Sussex CCGs (subject to a dispute process); The Committee went through the risks and mitgations against them in detail and noted that the control total would reduce (to £11m) if the caveats were not achieved. The Committee recommends that the Board approves the final budget.

An Associated University Hospital of Brighton and Sussex Medical School

Month 03 Workforce and Organisational Development The papers were received by the Committee and noted. It was highlighted that an exercise was being undertaken within workforce to review the establishment changes that have been processed in the previous months to ensure the procedures are being correctly followed. The M03 Capital report The Trust has applied for a ÂŁ15.9m Capital Resource Limit (CRL) in the 2016-17 plan resubmission (which includes potential schemes for EPR Digitise, clinical capacity investment and pathology). The capital programme funding assumes the agreement of ÂŁ3m PDC for the 2015/16 transfer from capital to revenue and a ÂŁ3.5m capital investment loan. The M03 IT report was received and noted. Medical Records The Committee received a report that highlighted the improvements in Medical Records provision since the movement of the offsite storage to Salfords and the introduction on a 24/7 service. Lead times were improved and costs had been reduced. The team was congratulated on a successful project. The new Medical Records building was due to complete in October. The resulting freed up clinical space and opportunities for more efficient working would be reported to the August FWC meeting

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 28th July 2016 Agenda Item: 3.4

REPORT TITLE:

Audit & Assurance Committee Chair Update

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

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

Action Required: Approval (√)

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with an executive summary of the July Audit and Assurance Committee.. Summary of key issues The Committee noted: • Strong assurance from External Audit on the quality of end of year accounts and development of the Quality Account • The Trust’s Counter Fraud, Self Review Tool (SRT) review of had been scored green and the Trust is compliant with the requirements of NHS Protect. The Committee agreed Internal Audits plan of work for the next 12 months, including reviews of temporary staffing and workforce; consultant job planning; incident management and clinical audit. Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model

Corporate Impact Assessment: The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”.

Legal and regulatory impact

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

Financial impact

Committee review of Trust financial position

Patient Experience/Engagement

No relevant aspects

Risk & Performance Management

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

NHS Constitution/Equality & Diversity/Communication

No relevant aspects

Attachment: Annual Audit Letter, External audit review of Quality Account

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29/07/16 Audit & Assurance Committee (AAC) Chair Update The Audit and Assurance committee met on the 12/07/2016; it was quorate. 1) Review of Internal Audit Plan for 2016/17 Internal Audit presented its plan for the coming 12 months. The amount of activity had been reduced following the tendering process and overall improvement of audit findings. This had been reviewed by the Executive and aligned with strategic objectives. The four main areas of focus will be; temporary staffing and workforce; consultant job planning; incident management and clinical audit. There will also be elements of audit of divisional governance systems, theatre management and implementation of seven day working. The Committee agreed the plan. 2) External Audit, Annual Audit letter and Review of Quality Account External Audit presented the Annual Audit letter for the Trust (attached). This summarises the key findings from the audit of the Trust’s 2015/16 annual accounts. This gave an unqualified opinion on the Trusts financial statements from which the Committee took strong assurance. It also gave a qualified opinion on the Trust’s ‘value for money’ conclusion stating that they were satisfied that the Trust put in place proper arrangements to ensure economy, efficiency and effectiveness in its use of resources except for the fact that the Trust made a deficit of £6.5 million in 2015/15, having previously planned to make a surplus of £1.6 million. The development of the Quality Account provided strong assurance (attached) that the account was compliant with guidance. Noting that the language used in the report is balanced by the key messages recorded on page 4 of the report. 3) Internal Control systems Management presented its plan for review of internal control systems over the next two years highlighting plans to review data quality and clinical governance systems including clinical audit. The Financial Controller presented a paper on losses and waivers detailing the end of year position. The Committee took assurance that the system systems supporting losses and waivers are sound. 4) Other Business Counter Fraud presented its regular update highlighting that the Trust’s Self Review Tool (SRT) was completed and returned to NHS Protect. All areas of review were green and the Trust is compliant with NHS Protect guidance. The Committee discussed the tender of an External Audit provider, and decided to add Paul Simpson the Chief Finance Officer to the Audit Panel, which is now constituted of the 3 NEDs on the Audit Committee and the Chief Finance Officer. -End-

3 An Associated University Hospital of Brighton and Sussex Medical School

The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust Year ended 31 March 2016 July 2016

Iain Murray Engagement Lead T 020 7728 3328 E iain.g.murray@uk.gt.com Jamie Bewick Senior Manager T 07880 456 144 E jamie.n.bewick@uk.gt.com Crystal Braganza Executive E crystal.c.braganze@uk.gt.com ÂŠ 2016 Grant Thornton UK LLP | The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust | July 2016

Contents Section

Page

1. Executive summary

2. Audit of the accounts

3. Value for Money conclusion

4. Quality Accounts

Appendices A Reports issued and fees

ÂŠ 2016 Grant Thornton UK LLP | The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust | July 2016

Executive summary Purpose of this letter Our Annual Audit Letter (Letter) summarises the key findings arising from the work that we have carried out at Surrey and Sussex Healthcare NHS Trust NHS Trust (the Trust) for the year ended 31 March 2016.

Our work Financial statements opinion We gave an unqualified opinion on the Trust's financial statements on 2 June 2016.

This Letter is intended to provide a commentary on the results of our work to the Trust and its external stakeholders, and to highlight issues that we wish to draw to the attention of the public. In preparing this letter, we have followed the National Audit Office (NAO)'s Code of Audit Practice and Auditor Guidance Note (AGN) 07 – 'Auditor Reporting'.

Value for money conclusion We were satisfied that the Trust put in place proper arrangements to ensure economy, efficiency and effectiveness in its use of resources except for the fact that the Trust made a deficit of £6.5 million in 2015/15, having previously planned to make a surplus of £1.6 million. We therefore qualified our value for money conclusion in our report on the financial statements on 2 June 2016.

We reported the detailed findings from our audit work to your Audit and Assurance Committee as those charged with governance in our Audit Findings Report on 26 May 2016. Our responsibilities We have carried out our audit in accordance with the NAO's Code of Audit Practice, which reflects the requirements of the Local Audit and Accountability Act 2014 (the Act). Our key responsibilities are to: • give an opinion on your financial statements (section two) • assess your arrangements for securing economy, efficiency and effectiveness in its use of resources (the value for money conclusion) (section three). In our audit of your financial statements, we comply with International Standards on Auditing (UK and Ireland) (ISAs) and other guidance issued by the NAO.

Consolidation template We also reported on the consistency of the consolidation schedules submitted to the Department of Health with the audited financial statements. We concluded that these were consistent. Use of statutory powers In 2013/14 we issued a referral to the Secretary of State to inform him that the Trust was in breach of the statutory break even duty. The Trust remains in breach of the break even duty because of its cumulative deficit. However we are not required to issue another referral in 2015/16 because the Secretary of State is already aware of the issue, and the position has not materially changed since the last referral. Certificate We certify that we have completed the audit of the accounts of Surrey and Sussex Healthcare NHS Trust in accordance with the requirements of the Code of Audit Practice.

Working with the Trust During the year we have delivered a number of successful outcomes with you: • An efficient audit – we delivered an efficient audit with you, delivering the accounts within the challenging NHS deadline. • Improving your annual reporting – we benchmarked your annual report against good practice and made a number of recommendations for improvement. • Providing assurance over data quality – we provided assurance over the data quality of two key indicators, incident reporting and rates of c-diff infections. • Sharing our insight – we provided regular audit committee updates covering best practice. We also shared our thought leadership reports with you. • Networking events - your Non Executive Directors attended networking events for the local health economy at our Sussex office. We provided a forum for NEDs across the local health economy to discuss issues of common interest. We would like to record our appreciation for the assistance and co-operation provided to us during our audit by your staff. Grant Thornton UK LLP July 2016

Quality Accounts We completed a review of your Quality Account and issued our report on this on 29 June 2016. We concluded that the Quality Account and the indicators we reviewed were prepared in line with the Regulations and guidance.

Audit of the accounts Our audit approach Materiality In our audit of your financial statements, we use the concept of materiality to determine the nature, timing and extent of our work, and in evaluating the results of our work. We define materiality as the size of the misstatement in the financial statements that would lead a reasonably knowledgeable person to change or influence their economic decisions. We determined materiality for our audit of your accounts to be £5.1 million, which is 1.9% of your gross revenue expenditure. We used this benchmark as in our view, users of your financial statements are most interested in where it has spent the income it made in the year. We set a lower threshold of £250,000, above which we reported errors to the Audit and Assurance Committee in our Audit Findings Report.

The scope of our audit Our audit involves obtaining enough evidence about the amounts and disclosures in the financial statements to give reasonable assurance that they are free from material misstatement, whether caused by fraud or error. This includes assessing whether: • your accounting policies are appropriate, have been consistently applied and adequately disclosed; • significant accounting estimates made by management are reasonable; and • the overall presentation of the financial statements gives a true and fair view. We also read the annual report to check it is consistent with our understanding of the Trust and with the accounts on which we give our opinion. We carry out our audit in line with ISAs (UK and Ireland) and the NAO Code of Audit Practice. We believe the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion. Our audit approach was based on a thorough understanding of your business and is risk based. We identified key risks and set out overleaf the work we performed in response to some of the key risks. We also discuss our work in response to the going concern assumption and the results of this work.

Audit of the accounts These are the risks and significant issues which had the greatest impact on our overall strategy and where we focused more of our work.

Risks identified in our audit plan

How we responded to the risk

Going concern The Trust made a deficit of £6.5 million in 2015/16 and remains in breach of the statutory break even duty. The Trust also required working capital support of £12.5 million in year to shore up its cash position. The Trust's weak cash position is evidenced by its poor and deteriorating performance against the better payments practice code.

There was no clear disclosure of going concern in the draft financial statement. We requested that an appropriate disclosure should be added to the revised statements.

Revenue recognition Under ISA (UK&I) 240 there is a presumed risk that revenue may be misstated due to the improper recognition of revenue.

You did not agree signed memoranda of understanding with your main commissioners in 2015/16.

Valuation of property plant and equipment You revalue your land and buildings to ensure that carrying value is not materially different from fair value. This represents a significant estimate by management in the financial statements.

As part of our audit work we:

We asked you for evidence that the Trust's cash position would continue to be supported for the foreseeable future. You subsequently obtained a letter from NHS Improvement confirming that the working capital facility is on-going. We are therefore satisfied with management's assessment that the going concern basis is appropriate for the 2015/16 financial statements.

In the agreement of balances exercise your receivables exceed the counterparty payables by over £2 million. You were able to provide evidence to support your reported financial position. In our audit findings report we highlighted the fact that if these differences are not resolved in the your favour, this will increase the size of the deficit.



reviewed management's processes and assumptions for the calculation of the estimate;



reviewed the competence, expertise and objectivity of any management experts used;



reviewed the instructions issued to valuation experts and the scope of their work;



discussed the basis on which the valuation is carried out and the key assumptions with the valuer;



reviewed and challenged the information used by the valuer to ensure it is robust and consistent with our understanding;



tested revaluations made during the year to ensure they are input correctly into your asset register;



evaluated the assumptions made by management for those assets not revalued during the year and how management have satisfied themselves that these are not materially different to fair value.

We did not identify any significant issues with the valuation of property, plant and equipment.

Audit of the accounts Audit opinion We gave an unqualified opinion on your financial statements on 2 June 2016. You made the accounts available for audit in line with the national timetable for submission, and provided a good set of working papers to support them. The finance team responded promptly and efficiently to our queries during the course of the audit. Issues arising from the audit of the accounts We reported the key issues from our audit to your Audit and Assurance Committee on 26 May 2016.

Annual Governance Statement and Annual Report We are also required to review your Annual Governance Statement and Annual Report. You provided these on a timely basis alongside the draft accounts, with supporting evidence.

Other statutory duties We are also required to refer certain matters to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014. In 2013/14, we reported to the Secretary of State that the Trust was in breach of its statutory breakeven duty, which is the requirement to achieve a balanced financial position over a three year period. The Trust remains in breach of the breakeven duty, however we have not issued another referral because the position has not materially changed.

ÂŠ 2016 Grant Thornton UK LLP | The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust | July 2016

Value for Money conclusion Background We carried out our review in accordance with the NAO Code of Audit Practice, following the guidance issued by the NAO in November 2015 which specified the criterion for auditors to evaluate: In all significant respects, the audited body takes properly informed decisions and deploys resources to achieve planned and sustainable outcomes for taxpayers and local people. Key findings Our first step in carrying out our work was to perform a risk assessment and identify the key risks where we concentrated our work. The key risks we identified and the work we performed are set out in the table below. Risk identified Financial outturn You have a history of good budget setting, monitoring and forecasting. You have reported a deficit position and continue to be in breach of the statutory break even duty, because of historic deficits incurred over the last decade.

Work carried out We reviewed your reported financial performance and key financial indicators for the year We reviewed how savings are identified and monitored and how you performed against your financial plan. We reviewed your processes for medium term financial planning.

Overall VfM conclusion In 2015/16 the Trust made a deficit of £6.5 million, having previously planned to make a surplus of £1.6 million. We are satisfied that, in all significant respects, except for the matter we identified above, the Trust had proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2016.

Findings and conclusions The Trust made a retained deficit of £6.5 million in 2015/16, having originally planned to make a surplus of £1.6 million. The Trust also made a small deficit in 2014/15 and continues to be in breach of the statutory break even duty, because of historic deficits. The main factor behind the on-going deficit position was higher than planned emergency activity. You have a good track record of making cost improvements. However in 2015/16 you delivered only £5.4m (66%) of its planned £8.2m savings. The shortfall was due mainly to the non-achievement of agency reductions as a result of external influences and activity pressures. The budget for 2016/17 was presented to the March 2016 Board. The projection is for a £15.2 million surplus which is the control total notified by NHS Improvement. A qualified 'except for' conclusion is appropriate because for the last two years the Trust has not been able to achieve its forecast position and in 2015/16 did not achieve all of its cost improvement plans.

Value for Money Table 2: Value for money risks continued Risk identified

Work carried out

Findings and conclusions

Cash flow Liquidity is highlighted as a significant risk in your Board Assurance Framework. You have taken out a working capital loan in year. You continue to perform poorly against the better payment practice code.

We reviewed the credibility of your cash planning and forecasting. We also reviewed terms of the Trust's loans and support and the intentions of the TDA to carry on supporting the Trust.

The Trust has a significant issue with cash flow, which is signposted clearly in finance reports to the Board. This is reflected in very poor and deteriorating performance against the better payment practice code. The cash shortfall arises because of the historic deficit position and is exacerbated by the deficit in year. In 2015/16 you took out a working capital loan of ÂŁ12.5 million to shore up the cash position. NHS Improvement has provided you with a letter confirming they will continue to provide cash support for the foreseeable future.

Partnership working We reviewed how you are developing the health You are working with partner organisations campus and care pathways with partners in primary and community care towards a health campus model of greater partnership working and risk sharing

Your organisation is leading on innovative approaches towards greater partnership working with other Trusts, commissioners and local councils. These include collaborations with partners including Royal Surrey County, MacMilllan cancer and Guys and St Thomas. You are also establishing a joint venture for pathology services with Brighton and Sussex University Hospitals NHS Trust. The overall vision is for a health campus approach, where the local population's health needs can be met on a single site with extensive collaboration between the different parties involved.

Business process re-engineering You are looking to Lean Management and working with the Virginia Mason team to transform care for patients.

We reviewed the steps being taken to redesign services under the Virginia Mason initiative

SaSH is also one of only five Trusts in the country to be selected to take part in a pilot scheme with the Virginia Mason Institute, which is regarded as one of the highest -performing and safest hospitals in the world. You have begun reviewing the cardiology work stream and will also look at the processes for flow of outpatients and management of diarrhoea.

Relationships with commissioners You face financial challenges around the contractual position with your main commissioners.

We discussed with management the current state of relationships with commissioners and considered the impact of issues and disputes raised by the agreement of balances exercise.

Despite some difficult contract negotiations you have good relationships with your commissioners, as evidenced by the successful collaboration with East Surrey CCG and Surrey County Council in building an integrated re-ablement unit. You are in dialogue with all your commissioners around creating more efficient care pathways to reduce admissions and attendances in hospital. Contractual differences have been driven by the financial pressures of the local health economy. However you have made progress on these and have agreed contracts with all your commissioners for 2016/17.

ÂŠ 2016 Grant Thornton UK LLP | The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust | July 2016

Value for Money Table 2: Value for money risks continued Risk identified

Work carried out

Recruitment and retention We reviewed steps you are taking to improve You have a high level of expenditure on recruitment and retention and to minimise spending temporary staffing (around 1/6 of staff on agency. spend) which has remained high in spite of initiatives to improve permanent recruitment and retention

Findings and conclusions Despite initiatives to improve recruitment and retention your spending on temporary and agency staff continues to increase. This was a key factor behind the non-achievement of your 2015/16 cost improvement programme. Recruitment and retention are challenging both because of a shortage in the local labour market and because of your proximity to London, where pay is generally higher. An additional factor is that you are continuing to expand because of increasing demand. In 2015/16 you added additional ward and theatre capacity and 200 more staff. Therefore even as you have increased recruitment the demand for more staff has outstripped the additional supply. You have a keen focus on improvement in this area, which is the single biggest element of the 2016/17 cost improvement programme. There is a fortnightly meeting on rostering and there will also be a regular meeting on agency staffing. You have been actively recruiting more nursing staff from the Philippines, the EU and India.

You are also adopting a more rigorous approach to nursing staff planning and rostering. You have acquired health roster v5.1 and you have a programme of embedding the system in the wards, through intensive training and follow up. This should help ensure that agency staff are only employed when needed. You also work closely with the respective agencies to negotiate the best prices.

ÂŠ 2016 Grant Thornton UK LLP | The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust | July 2016

Quality Accounts The Quality Account The Quality Account is an annual report to the public from NHS Trusts about the quality of services they deliver. It allows Trust Boards and staff to show their commitment to continuous improvement of service quality, and to explain progress to the public.

• We confirmed that the commentary on indicators in the Quality Account was consistent with the reported outcomes • Our testing of two indicators included in the Quality Account found that these were materially reasonably stated in accordance with the Regulations and six dimensions of data quality .

Scope of work

Quality Account Indicator testing

We carry out an independent assurance engagement on your Quality Account, following Department of Health (DH) guidance. We give an opinion as to whether we have found anything from our work which leads us to believe that:

We tested the following indicators:

• the Quality Account is not prepared in line with the DH criteria;

We reviewed the process used to collect data for the indicator. We checked that the indicator presented in the Quality Report reconciled to the underlying data. We then tested a sample of cases to check the accuracy, completeness, timeliness, validity, relevance and reliability of the data, and whether the calculation is in accordance with the definition.

• the Quality Account is not consistent with other documents specified in the DH guidance; and • the two indicators in the Quality Account where we carry out detailed work are not compiled in line with the DH regulations and meet expected dimensions of data quality. Key messages • We confirmed that the Quality Account had been prepared in line with the requirements of the Regulations. • We confirmed that the Quality Account was consistent with the sources specified in the Guidance.

• Percentage of Patient Safety Incidents resulting in severe harm or death; • Rate of clostridium difficile infections.

Based on the results of our procedures, nothing came to our attention that caused us to believe that the indicators we tested were not reasonably stated in all material respects. Conclusion As a result of this we issued an unqualified conclusion on your Quality Account.

Appendix A: Reports issued and fees We confirm below our final fees charged for the audit and fees for the provision of non audit services.

Fees for other services

Fees

Statutory audit Charitable fund Total fees

Planned £

Actual fees £

2014/15 fees £

60,278

1,800

62,078

Service

Fees £

Quality accounts

10,000

Reports issued Report

Date issued

Audit Plan

March 2016

Audit Findings Report

May 2016

Annual Audit Letter

July 2016

Quality accounts report

July 2016

Report on the Quality Account 2015/16 Surrey and Sussex NHS Trust Year ended 31 March 2016 21/06/2016

Iain Murray Associate Director T 020 7728 3328 E iain.g.murray@uk.gt.com

Jamie Bewick Senior Manager T 01293 554 138 E jamie.n.bewick@uk.gt.com

Crystal Braganza Executive T 020 7728 2039 E crystal.c.braganza@uk.gt.com ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

The contents of this report relate only to the matters which have come to our attention, which we believe need to be reported to you as part of our audit process. It is not a comprehensive record of all the relevant matters, which may be subject to change, and in particular we cannot be held responsible to you for reporting all of the risks which may affect the Council or any weaknesses in your internal controls. This report has been prepared solely for your benefit and should not be quoted in whole or in part without our prior written consent. We do not accept any responsibility for any loss occasioned to any third party acting, or refraining from acting on the basis of the content of this report, as this report was not prepared for, nor intended for, any other purpose.

Contents Section

Introduction to our review Our conclusion

3 15

Compliance with regulations Consistency of information

5-6

Data quality of reported performance indicators

7-9

Fees

Appendix

Action plan

ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

Executive summary The Quality Account

• the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance

The Quality Account is an annual report to the public from providers of NHS healthcare about the quality of services they deliver. The primary purpose of the Quality Account is to encourage boards and leaders of healthcare organisations to assess quality across all the healthcare services they offer. It allows leaders, clinicians, governors and staff to show their commitment to continuous, evidence-based quality improvement, and to explain progress to the public.

Conclusion

Our work on your Quality Account is substantially complete although we are finalising our procedures in respect of: • Reviewing the final version of the quality account

Purpose of this report

• Reviewing feedback from stakeholders

This report to the Board summarises the results of our independent assurance engagement on your Quality Account. This report is provided in conjunction with our signed limited assurance report, which is published with the Trust's Quality Account and enables the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report.

Subject to this, we are proposing to issue an unqualified conclusion on your Quality Account.

In performing this work, we followed the Department of Health 'NHS Quality Accounts Auditor Guidance 2014-15', which is still extant for 2015/16.

The output from our work is a limited assurance opinion on whether anything has come to our attention which leads us to believe that: • your Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; • your Quality Account is not consistent in all material respects with the sources specified in the Guidance; and

The text of our proposed limited assurance report can be found at Appendix B.

Executive summary Key messages

• We confirmed that the Quality Account had been prepared in line with the requirements of the Regulations. • We confirmed that the Quality Account was consistent with the sources specified in the Guidance . • We confirmed that the commentary on indicators in the Quality Account was consistent with the reported outcomes. • Our testing of two indicators included in the Quality Account found that these were materially reasonably stated in accordance with the Regulations and six dimensions of data quality. Acknowledgements

We would like to thank the Trust staff for their co-operation in completing this review.

Compliance with regulations We checked that the Quality Account had been prepared in line with the requirements set out in the Regulations.

Requirement

Work performed

Conclusion

Compliance with regulations

We reviewed the content of the Quality Account against the requirements of 'the Regulations’ set by the Secretary of State, as described in:

Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016, the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;

•

the National Health Service (Quality Accounts) Regulations 2010

•

the National Health Service (Quality Accounts) Amendment Regulations 2011

•

the National Health Service (Quality Accounts) Amendment Regulations 2012.

Consistency of information We checked that the Quality Account is consistent in all material respects with the sources specified in the Department of Health "NHS Quality Accounts Auditor guidance 2014/15", which continues to be applicable for 2015/16.

Requirement

Work performed

Conclusion

Consistency with other sources of information

We reviewed the content of the Quality Account for consistency with the documentation specified in the Auditor guidance referred to above. This includes the board minutes and papers for the year, feedback from commissioners, survey results from staff and patients, the Head of Internal Audit opinion and annual governance statement.

Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016, the Quality Account is not consistent in all material respects with the sources specified in the Guidance.

Other checks

We also reviewed the Quality Account: • to check the consistency of indicator commentary with the reported outcomes • to check that Directors' Assertions on controls are consistent with disclosures in the Annual Governance Statement.

Overall, we concluded that: • the indicator commentary was consistent with the reported outcomes • Directors' Assertions on controls are consistent with disclosures in the Annual Governance Statement.

Data quality of reported performance indicators We undertook substantive testing on two indicators in the Quality Account to determine whether they have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the auditor guidance. Selecting performance indicators for review The Trust is required to obtain assurance from its auditors over two indicators. We selected two indicators from the four identified by the auditor guidance as being suitable for substantive testing and agreed the scope of our work with the Trust's management team. In line with the auditor guidance, we have reviewed the following indicators: â&#x20AC;˘ Percentage of Patient Safety Incidents resulting in severe harm or death, selected from the subset of mandated indicators because incident reporting has historically been a risk area for this Trust. â&#x20AC;˘ Rate of clostridium difficile infections, selected from the subset of mandated indicators as a more relevant indicator for this Trust.

ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

Data quality of reported performance indicators (continued) Indicator & Definition

Indicator outcome

Work performed

Conclusion

Rate of Clostridium Difficile Infections

Correct

We reviewed the process used to collect data for the indicator. We checked that the indicator presented in the Quality Account reconciled to the underlying data.

Based on the results of our procedures with the exception of the matters reported below nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016, the indicator has not been reasonably stated in all material respects.

The scope of the indicator includes all cases where the patient shows clinical symptoms of clostridium difficile infection, and has a positive laboratory test result for CDI recognised as a case according to the trust's diagnostic algorithm. A CDI episode lasts for 28 days, with day one being the date the first positive specimen was collected. The following cases are excluded from the indicator: â&#x20AC;˘ People under the age of two at the date of the sample taken; and â&#x20AC;˘ Where the sample was taken before the fourth day of an admission to the trust (where the day of admission is day one)

We then tested a sample of 12 items in order to ascertain the accuracy, completeness, timeliness, validity, relevance and reliability of the data, and whether the calculation is in accordance with the definition. 7 of these 12 sampled were classed as Trust apportioned. Additionally 5 cases were randomly selected from community apportioned cases to ensure the classification was correct. The testing looked at the date of admissions and first testing positive and ensuring the apportionment was correct and that the patient had indeed tested positive.

ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

In the first version of the quality account the Trust had only reported the actual number of cases, and had not included a narrative stating the number of cases per 100,000 bed days, which is a requirement. Following discussion with the Trust this was raised and subsequently amended to include a narrative in line with the guidance.

Data quality of reported performance indicators (continued) Indicator & Definition

Indicator outcome

Work performed

Conclusion

Patient Safety Incidents resulting in severe harm or death.

Correct

We reviewed the process used to collect data for the indicator. We checked that the indicator presented in the Quality Account reconciled to the underlying data.

Based on the results of our procedures, with the exception of the matters reported below, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016, the indicator has not been reasonably stated in all material respects.

The scope of the indicator includes all patient safety incidents reported through the National Reporting and Learning Service (NRLS). This includes reports made by the trust, staff, patients and the public.

We then tested a sample of cases in order to ascertain the accuracy, completeness, timeliness, validity, relevance and reliability of the data, and whether the calculation is in accordance with the definition. We placed reliance on work performed by the Internal Audit function, RSM. They had tested 20 cases in a similar manner on 18/06/2016, We retested 5 of these to be able to place reliance on their work. We then sampled an additional 5 cases from the remaining population. We tested by ensuring the information provided agreed to the system and for example was recorded in a timely manner and was included in the correct reporting period.

ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

The only issue found in respect of this indicator was that the figures reported in the first draft of the quality accounts were incorrect as they included all incidents instead of just patient safety related ones. This was raised with the client and subsequently amended.

Fees Fees for the work on the Quality Account Service

Fees (£)

For the limited assurance review of the Trust's Quality Account 2015/16

10,000

Our fee assumptions include:

 our fees are exclusive of VAT .

Appendix A â&#x20AC;&#x201C; Action plan There was no deficiencies identified in respect our out work performed on the Quality accounts, therefore we have no recommendation to note on this action plan.

ÂŠ 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

Appendix B – Form of limited assurance report Independent Auditor's Limited Assurance Report to the Directors of Surrey and Sussex NHS Trust on the Annual Quality Account We are required to perform an independent assurance engagement in respect of Surrey and Sussex NHS Trust’s Quality Account for the year ended 31 March 2016 (“the Quality Account”) and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 (“the Regulations”). Scope and subject matter The indicators for the year ended 31 March 2016 subject to limited assurance consist of the following indicators: 

Percentage of patient safety incidents resulting in severe harm or death



Rate of clostridium difficile infections

We refer to these two indicators collectively as “the indicators”. Respective responsibilities of directors and auditors The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations). In preparing the Quality Account, the directors are required to take steps to satisfy themselves that: 

the Quality Account presents a balanced picture of the Trust’s performance over the period covered;



the performance information reported in the Quality Account is reliable and accurate;



there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;



the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and



the Quality Account has been prepared in accordance with Department of Health guidance.

The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account. © 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

Appendix B – Form of limited assurance report Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:  the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;  the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the Guidance”); and  the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions.

We read the other information contained in the Quality Account and consider whether it is materially inconsistent with:  Board minutes for the period April 2015 to June 2016;  papers relating to quality reported to the Board over the period April 2015 to June 2016;  feedback from the Commissioners.  feedback from Local Healthwatch.  the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009.  feedback from other named stakeholder(s) involved in the sign off of the Quality Account;  the latest national patient survey.;  the latest national staff survey dated.;  the Head of Internal Audit’s annual opinion over the trust’s control environment.  the annual governance statement dated 31/05/2016.  the Care Quality Commission’s Intelligent Monitoring Report dated May 2015.  the results of the Payment by Results coding review.

Appendix B – Form of limited assurance report We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to any other information. This report, including the conclusion, is made solely to the Board of Directors of Surrey and Sussex NHS Trust.

We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Surrey and Sussex NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed

We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance procedures included:  evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;  making enquiries of management;  testing key management controls;  analytical procedures;  limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;  comparing the content of the Quality Account to the requirements of the Regulations; and  reading the documents. A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations

Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations. The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations. In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Surrey and Sussex NHS Trust. © 2016 Grant Thornton UK LLP | Report on the Quality Account | Surrey and Sussex Healthcare NHS Trust

Appendix B – Form of limited assurance report Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016  the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;  the Quality Account is not consistent in all material respects with the sources specified in the Guidance; and  the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.

Grant Thornton UK LLP

22 Melton St, London, NW1 2EP

ÂŠ 2016 Grant Thornton UK LLP. All rights reserved. 'Grant Thornton' means Grant Thornton UK LLP, a limited liability partnership. Grant Thornton is a member firm of Grant Thornton International Ltd (Grant Thornton International). References to 'Grant Thornton' are to the brand under which the Grant Thornton member firms operate and refer to one or more member firms, as the context requires. Grant Thornton International and the member firms are not a worldwide partnership. Services are delivered independently by member firms, which are not responsible for the services or activities of one another. Grant Thornton International does not provide services to clients.

grant-thornton.co.uk

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item: 3.5

REPORT TITLE:

Charitable Funds Committee Chair Update

EXECUTIVE SPONSOR:

Paul Simpson (Chief Finance Officer)

REPORT AUTHOR:

Paul Simpson

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

No – Board Update

Action Required: Approval ()

Discussion ()

Assurance (√)

Summary of Key Issues This report briefs the Board on the key issues discussed at the meeting of the committee on 7 July 2016.Key points were: •

A fund raiser has now been appointed which should increase activity on fund raising

•

The Committee continues to be exercised by the failure of many fund holders to spend their balances. Therefore, the Committee will be inviting representatives from Divisions to the next meeting to provide any mitigation on behalf of fundholders prior to unspent funds being transferred to the General Fund

Relationship to Trust Strategic Objectives & Assurance Framework: SO3: Caring – Working in partnership with staff, families and carers Corporate Impact Assessment: The Charity is registered with the Charity Commission in accordance with the Charities Act 1993, registered number 1054072.

Legal and regulatory implications

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

Charitable funds received by the Charity are accepted, held and administered as funds and property held on trust for purposes relating to the health service in accordance with the National Health Service Act 1977, the National Health Service and Community Care Act 1990, the National Health Service Act 2009. These funds are held on trust by the corporate body. The fund is audited by the Trust’s External Auditor (Grant Thornton UK LLP) The report provides assurance about the financial management of the charitable fund. A deliberate positive impact from the use of the fund to support patient experience. The committee, and this report, provides assurance about risk management relevant to the fund. No compliance issue

Charitable Funds Committee Chair Update The Charitable Funds Committee met on 7 July 2016. Fundraising Update The Committee emphasised the need to identify fund-raising objectives and the Trust needs to identify what the prime fund raising projects for Charitable Funds should be; the Executives to discuss, provide guidance and input in respect of long term projects that the Charity is to engage with the public. Fundraiser Recruitment Update New Fund Raising manager has been recruited (Paul Skelly) who will commence with the Trust 25th July 2016. Benevolent Fund & Give As You Earn Option for staff The Committee discussed opportunities around staff participation into a benevolent fund and Give As Your Earn (GAYE) to run alongside charity. SaSH currently do not have either of these in place; the new fund raiser to review opportunities and submit a report to the Committee advising pros and cons. Renaming Charity to SaSH Charity An application to the Charity Commission has been made for a copy of the Charity’s governing document to ascertain any restrictions regarding name change and what particular procedures need to be followed. Finance The new Charity accounting standard FRS102 was adopted noting that the standard will increase transparency however the accounts will not be impacted. The draft Annual Report and Accounts 2015-16 will be submitted to AH and PS for approval before independent examination in October 2016. Fund balances remain high in total £537k at May 2016 with income £14k and expenditure £19k year to date, despite the submission of expenditure plans in 2015/16 advising that the bulk of the fund would be spent. The Committee agreed that further work should be undertaken in respect of expenditure plans and the consolidation of smaller funds to encourage spending; liaison with Divisions at performance reviews to prompt the spending of donations and the Committee resolved to identify and challenge inactive funds. A representative of each Division (on behalf of the fund holders within the Division) would be invited to the next Charitable Funds meeting to provide any mitigation prior to consideration for transferring funds into the General Fund. Paul Simpson Member of the Charitable Funds Committee 28 July 2016 [END]

2 An Associated University Hospital of Brighton and Sussex Medical School

REPORT TITLE:

Date: July 28th 2016 Agenda Item: 4.1 Serious Incident Report for Q1 2016/7

EXECUTIVE SPONSOR:

Fiona Allsop

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

Katharine Horner

TRUST BOARD IN PUBLIC

n/a

Action Required: Approval ( )

Discussion ( )

Assurance ( )

Purpose of Report: This paper provides the Board of Directors with a report on the serious incidents declared in Q1 and an update on the overall position with regard to the management of serious incidents within the Trust. Summary of key issues • The Trust reported twelve serious incidents in Q1 2016/17. All incidents were reviewed and escalated appropriately. • As at 29th June 2016 the Trust has 21 serious incidents open with the CCG, of which thirteen have been submitted for closure. • There are two overdue SI reports that have breached the 60 working day deadline set by NHS England in their 2015 Serious Incident Framework. Recommendation: The Board is asked to note the contents of this report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers

Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management

Compliance with CQC, MHRA and Audit Commission Serious incidents often become claims Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication Attachment:

Serious Incident Report – Public Board

Page 1 of 5

TRUST BOARD REPORT Serious Incident Report – period: Q1 2016/17 1.

Introduction

1.1

A report on Serious Incidents (SI) is produced each month to provide assurance that they are being managed, investigated and acted upon appropriately and that action plans are developed from the Root Cause Analysis investigations.

1.2

This paper looks specifically at those incidents that are considered as SIs following the guidance from the NHS England’s ‘Serious Incident Framework” published March 2015.

1.3

A summary of open SIs is published weekly and circulated to Execs.

1.4

SI reports are reviewed by the Sussex Scrutiny Group. The Patient Safety and Risk Lead presents the reports to the panel and provides feedback to the Trust Serious Incident Review Group.

Patient Safety Incidents in 2016/17 Q1

2.1

There were a total of 2,068 incidents reported on Datixweb in Q1 2016/17 of which 1,732 (83%) were clinical/patient safety incidents. These incidents breakdown as follows:

The last five quarters are as follows:

2.2

The incident categories are shown for those patient safety incidents reported in Q1 2016/17 as moderate harm, severe harm or death.

Serious Incidents declared in Q1 2016/17

3.1

The Trust declared twelve serious incidents in Q1 2016/17; seven in April, three in May and two in June. 2016/8909 (adverse media interest) The patient had been reviewed at 06:15 when she was found to be tachycardic. She was waiting for a medical review. At 07:10 the patient was seen to be covered in blood but was responsive. The staff nurse and nursing assistant went to help. The nursing assistance witnessed the patient stab herself in the neck. The patient had sustained major blood loss, a MET call was initially made, which was changed to a cardiac arrest call. The patient was stabilised and has been transferred to St Georges. She was found to have a number of cuts to her neck, abdomen and wrists. She was in possession of a kitchen knife which had been brought in to hospital from home. The patient had not expressed suicidal thoughts. 2016/8916 (fall) Patient sustained an open fracture of the left tibia and fibula following an unwitnessed fall. When last checked, shortly before the incident, the patient had been sleeping. She is a known cancer patient with bone metastasis. She has been transferred to St Georges for further treatment. 2016/9140 (failure to act on test results) The patient had routine bloods on 1/4/16. The results showed raised potassium (6.5) and CRP (55). Records indicate that these results were phoned through to an ED consultant. There is no evidence in the patient's notes that these results were acted upon. Patient suffered a cardiac arrest and died on Sunday (03/04/2016). 2016/9145 (treatment delay) The baby had been correctly identified as high risk (Hep B mother) and was to have Hep B immunoglobulin and Hep B Vaccine within 24 hours of birth. The baby was born on 1/12/15. On 1/4/16, during a routine check, the immunoglobulin was found in the delivery suite fridge. The baby's notes show that the Hep B vaccine was given within one hour of birth, but there is no evidence that the immunoglobulin was given. 2016/9411 (treatment delay) Patient died 12/8/14, PM showed small bowel obstruction but no obvious case of sudden death. At Inquest it was identified that the patient had extremely low blood sugar, he had been given regular twice daily insulin despite being nil by mouth, no blood sugar measurements are recorded after admission. The inquest was adjourned for further investigation. 2016/9986 (maternity incident) Client arrived for induction of labour; the midwife was unable to detect a foetal heart. An intrauterine death was confirmed by ultrasound. A multidisciplinary review of the case identified concerns with management in the antenatal period. It is recorded in the notes that the baby was small for gestational age and the client reported reduced foetal movements. There is no evidence that this was escalated to a member of the obstetric team. 2016/10668 (fall) The patient, a 78 year old female, had an unwitnessed fall in the toilet. An x-ray has confirmed a fractured neck of femur. 2016/12433 (treatment delay) Serious Incident Report â&#x20AC;&#x201C; Public Board

Page 3 of 5

The incident is the cancellation and subsequent rebooking of an ophthalmology outpatient appointment four months later than the original clinical review period (4m). The patient was using steroid eye drops which have a known side effect of causing raised intraocular pressure. At the delayed appointment pressure was found to be raised and the optic nerve damaged with vision of hand movements. The raised pressure was treated with eye drops and reviewed 4/5/16 where the pressure was found to be controlled but there was no recovery of vision. 2016/12980 (treatment delay) A patient requiring interventional radiology was cancelled due to bed pressures. While awaiting a new (delayed) date for admission the patient died. 2016/14135 (fall) The patient was sitting on an armchair eating some grapes. As one fell to the floor, the patient tried to catch it and fell in the process. A right fractured neck of femur was confirmed. 2016/16688 (Wrong site surgery â&#x20AC;&#x201C; declared as a never event) The patient was consented for a Left L5, S1 microdisectomy. The Consultant surgeon marked the level of decompression using x-ray. The WHO safety surgical checklist was completed with the surgeon, the anaesthetist and the surgical team present. It was known prior to surgery that the affected disc had a large left side bulge which was symptomatic and a smaller right side bulge. It was anticipated that both bulges would be resolved during surgery. It is the consultantâ&#x20AC;&#x2122;s usual practice to make a mid-line incision and then correct the most symptomatic side first, in this case the left side. Surgery was undertaken. When writing his notes the surgeon noted that the right L5, S1 disc only had been decompressed. As the patient was still in theatre the surgeon rescrubbed and completed the procedure on the left side. 2016/17419 (Fall) Patient was mobilising with the aid of an HCA (1:1). The patient indicated that she was in pain on her right side. The HCA saw blood and that the ankle was disfigured. She assisted the patient to the ground and called for help. Patient found to have an open fracture of her tibia and fibula. 3.2

SI themes over the last 12 months The serious incidents are shown by the month in which they occurred, not the month in which they were declared. The date of knowledge and therefore declaration may be different. 57% (24) of the serious incidents that occurred in the last twelve months relate to patient falls.

Serious Incident Report â&#x20AC;&#x201C; Public Board

Page 4 of 5

Weekly overview A weekly open SIs overview summary is sent to the Patient Safety and Risk Lead and the Chief Nurse which indicates overall Trust and Divisional performance in completing SI investigations within the National timeframe. The Serious Incident Review Group closely monitors the investigation and submission process. The Divisions are asked to include an update on RCA reports to the Patient Safety and Clinical Risk Sub-Committee. This is the latest reported Trust position at 29th June 2016.

At the end of June there are two investigations which had breached the maximum 60 working days specified by the NHS England 2015 Serious Incident Framework. Both investigations are being closely monitored by SIRG and the CCG is being updated on progress. 5.

Recommendation The Trust Board are asked to discuss the report and take assurance regarding the management of SIs and the on-going work to improve performance on completing SI investigations within the National timeframe.

Name of Director Fiona Allsop Title of Director Chief Nurse July 2016

Serious Incident Report â&#x20AC;&#x201C; Public Board

Page 5 of 5

TRUST BOARD

Date: 28 July 2016 Agenda Item: 4.2

REPORT TITLE:

Annual plan 2016/17 Q1 Update Sue Jenkins Director of Strategy & KPO Lead Sue Jenkins Director of Strategy & KPO Lead

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

Executive Committee

Action Required: Approval

Assurance (√)

Discussion

Purpose of Report: The purpose of this report is to provide assurance to the Board that the annual operating plan for 2016/17 has been delivered Summary of key issues The annual plan for 2016/17 was approved by the Board in June 2016. This report provides progress against each of the 72 actions for Quarter 1, April to June 2016. Of the 72 actions the status for the quarter is reported as follows:Status Red Amber Green Blue

Q1 – April to June 2016 2 3% 47 65% 19 26% 4 6%

6% of the actions have already been completed and 32% are being delivered according to plan or have been completed which is line with where we should be at this point in the year. There are two red status actions which relates to 1.2 and 1.11 • 1.2 refers to the never event that was reported in June 2016. This event is currently under investigation and will be reported to the safety and quality committee and highlight the cause of the event as well as what steps will be taken to prevent a reoccurrence • 1.11 relates to a case of MRSA blood stream infection that was reported on Capel Annexe in June 2016. This is also being investigated and will be reported to the safety and quality committee once complete

Recommendation: The Board are asked to confirm that this report provides assurance that the annual plan 2015/16 is being delivered 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 SO4: Responsive â&#x20AC;&#x201C; 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

The annual plan demonstrates delivery of key actions to support the strategic objectives Business cases will be developed for any significant resource developments. The annual plan includes a number of objectives linking to patient experience and engagement Delivery of the annual plan is monitored by the executive Committee and reported to the Trust Board The annual plan demonstrates delivery of the organisations strategic objectives

Attachment: Annual plan 2016/17 Q1 update

2 An Associated University Hospital of Brighton and Sussex Medical School

Annual plan 2016/17 v1.2 - Q1 update April - June 2016 RAG status key

Trend key

Work stream off track and unlikely to deliver as described

Got worse since last report

Work stream offtrack but plans in place to recover

Same as last report

SO1 - Safe - Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers New Action Ref Source Lead director or bf Strategic objectives delivery plan Quality account 1.1 NEW Clinical strategy Divisional plans

Consistently meet national patient safety standards and benchmark in Angela Stevenson top 20% against peers

Strategic objectives delivery plan 1.2 NEW Quality account

Demonstrate 95% compliance with the safety thermometer and have Fiona Allsop as few never events as possible

Complete

RAG

Trend

Improved since last report

Lead manager/clinician

Q1 update

Ben Emly

Q4 benchmark report for 2015/16 available in Q1 demonstrates that safety thermometer for harm free care and VTE assessment are in bottom quartile. Improvements anticipated for 16/17 as plans are delivered for both areas

Safety thermometer compliance on track and delivered for Q1 One never event reported in June 2016. Currently under investigation and learning to be shared with SQC

Three value streams now under way which include cardiology inpatient flow, outpatients and management of diarrhoea. Two advanced lean trainers have been certified by VMI and 1 on track to complete in July Lean for leaders has been with 40 candidates participating

1.3 NEW

Strategic objectives delivery plan Quality account

Work in partnership with Virginia Mason Institute and develop a culture of continuous improvement

Sue Jenkins

1.4 BF

Strategic objectives delivery plan

Actively participate in national Patient Safety Collaborative in Kent, Surrey and Sussex area

Des Holden

1.5 BF

Strategic objectives delivery plan

Include quality goals in all clinical staff appraisals

Des Holden

1.6 NEW Quality account

Work stream on track and to plan

Fully engaged and participating in Collaborative. Have attended all relevant events and many of our clinicians are leading clinical workstreams Quality goals included in all medical appraisals and where absent they are returned for completion

G G

Develop and implement plans to ensure 100% of staff have received Fiona Allsop appropriate levels of PREVENT training by July 2018

Fiona Crimmins

WRAP training for PREVENT continues on the Nurse Preceptorship Programme and the Doctors Induction. WRAP has been added to the MAST programme - this is due to commence in September 2016. Additional sessions will also take place in the lecture theatre in February 2017.On review of this, further sessions will be booked. There are currently 5 further WRAP facilitators being trained to assist with training.

Barbara Bray

Tim Briggs national report demonstrates that orthopaedic SSIs are some of lowest in country

1.7

Clinical strategy Divisional plans

Maintain the low incidence of surgical site infections

1.8

Clinical strategy Divisional plans

Monitor and work towards compliance with national midwifery staffing Fiona Allsop guidance

Michelle Cudjoe

Additional midwifery posts included in business plan for WACH in 2016/17. Final activity and financial plans agreement for WACH still outstanding

1.9

Quality Account Quality strategy

Implement falls strategy and demonstrate a reduction in the number of falls that cause harm to our patients to less than 1.5 per 1,000 bed Fiona Allsop days

Vicky Daley

Falls group established including representation from CCG

Quality Account Quality strategy

Maintain achievement of no hospital acquired major pressure damage and aim to reduce hospital Fiona Allsop acquired minor damage to below 159 for the year

Louise Evans

No major pressure damage reported in Q1 and on track to deliver reduced minor damage

1.10

Pressure damage

Des Holden

1.11

Quality Account Quality Strategy

1.12

Quality Account Quality strategy

1.13 NEW Quality Account

Healthcare acquired infection

Meet the DH central infection control targets of <15 Cdiff cases and no preventable MRSA blood stream infections

Des Holden

Ashley Flores

1 MRSA blood stream infection in June 2016 - Capel Annexe. cases of Trust apportioned Clostridium difficile in Q1

World Health Organisation (WHO) safer surgery checklist

Continue to audit quality of safer surgery processes and achieve 100% compliance

Des Holden

Barbara Bray

Compliant at 100% for Q1

Carol Dixon

Feedback from patients with regard to cleanliness is reviewed regularly and in the first quarter there have been no formal or informal adverse comments relating to cleanliness from patients or visitors

Lead Manager/clinician

Q1 update

RAG

Trend

Continue to maintain high standards of cleanliness and to listen and respond to feedback from patients and visitors

Ian Mackenzie

SO2 - Effective: As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy New Action Source Lead Director Ref or bf 2.1 NEW Strategic objectives delivery plan

2.2 NEW

Strategic objectives delivery plan Quality account

Achieve top 20% performance in benchmarked clinical outcomes

Des Holden

Jonathan Parr

the Trust will be looking at a list of outcomes which can be translated into a league table approach and develop those over the course of the year.

Year on year recruit more research participants and ensure learning is published

Des Holden

Anne Shears

1st quarter recruitment figures strong. On track to reach target of 650 research participants this year.

Jane Griffiths

Internal and external integrated discharge Team review group set up and meet fortnightly. Aim to restructure Integrated Discharge team with management provided under umbrella of one provider and use of honorary contracts. This group also reviewing processes to enable assessment of patients outside of the acute hospital and capacity required to do this. Target set to achieve 90 % Discharge to assess by October.

Continue and embed discharge to assess

2.3

NEW Strategic objectives delivery plan

Angela Stevenson

Deliver services differently to meet the changing needs of patients, the local health economy and the Trust

2.4

Support and develop Integrated Reablement Unit

Angela Stevenson

Jane Griffiths

21 bedded Unit established in partnership with Commissioners. Key performance Indicators agreed and being monitored. Currently being managed by SASH whilst long term provider sourced. Currently undertaking three month review and agreeing long term staffing model.

2.5

Develop and implement frailty unit

Des Holden

Alison James

Business case approved and building works underway. Aim for frailty unit to open on 1st September 2016

Progress academic appointments with Surrey University and HEKSS Des Holden

Job description being developed for Medical post and will be submitted to college for approval. Process for recruitment agreed as medical posts first, followed by nurse and support posts

2.6 NEW Strategic objectives delivery plan

2.7

Clinical strategy Divisional plans

Redesign the stroke pathway to create a seamless in and out of hospital patient centred pathway across all providers

Des Holden

Ben Mearns

Stroke bid currently with commissioners. Stroke Project manager in post

2.8

Clinical strategy Divisional plans Estate strategy

Redesign of service to support the installation of a digital mammography machine on the ESH site

Angela Stevenson

Ed Cetti Mo Luqman

Complete

2.9

Clinical strategy Divisional plans

Implement a managed equipment service which is supported by a rolling equipment replacement schedule

Des Holden

Ed Cetti Mo Luqman

Work stream off-track but plans in place to recover

Progress appointment of hart failure Fiona Allsop specialist nurse

Nicola Shopland

Business case rejected. Currently under review for resubmission

Develop and implement policy for the management of patients with AF

Ben Mearns

AF guidance in development. All patients treated as per NICE guidance

Jonathan Parr

Achieved for Q1

2.10 NEW Quality account 2.11

2.12 BF

Quality Account Quality strategy

Demonstrate full compliance with NICE guidance for heart failure and atrial fibrillation

Des Holden

Maintain “better than national average” mortality rating for both HSMR Des Holden and SHMI

2.13 NEW Quality account

Maintain positive position for all three enhanced recovery pathways

Des Holden

Jonathan Parr

Improved over the last year and delivered for Q1

2.14 NEW Quality account

Continue reporting of #NOF enhanced quality data to AHSN and demonstrate improvement in patient pathway

Des Holden

Jonathan Parr

Achieved for Q1

Lead Director

Lead Manager/clinician

Q1 update

RAG

Trend

Fiona Allsop

Cathy White

FFT, patient opinion and YCM feedback reviewed on an ongoing basis. National surveys ongoing

Fiona Allsop

Vicky Daley DCNs (Jamie Moore)

"Patient Experience Improvement Plan" distributed to all ward managers and matrons on a monthly basis to gain feedback on issues identified and the work undertaken to address. Outputs are displayed on the digital screens around the organisation. Returns from the wards are minimal at the this stage. Actions to improve compliance to be explored through the Patient Experience Committee. Two wards in medicine in particular are considered best practice across the Trust

Mark Preston

Nathaniel Johnston

Customer Care Training package developed and pilot being held in August Full Trust-wide roll out due in September

Fiona Allsop

Cathy White

No patient focus groups held in Q1. Plan to conduct inpatient focus groups in Q2

SO3 - Caring - Working in partnership with staff, families and carers New Action Ref Source or bf 3.1

3.2

Strategic objectives delivery plan

Audit how patients feel cared about and respond to issues raised by YCM, FFT and inpatient survey

Show evidence of "you said we did" in all areas

Continue to develop and deliver customer care training

3.3

3.4

NEW Strategic objectives delivery plan

Treat patients, carers and their Demonstrate how patient listening families with dignity, respect and events influence service compassion development and improvement

3.5

Continue with values based recruitment

Mark Preston

Janet Miller

Values Based recruitment continues to be embedded into Trust recruitment processes

3.6

Work with patients and carers as part of the patient experience strategy

Fiona Allsop

Cathy White

Planning to establish a carers steering group in Q3

3.7

Demonstrate how patients are involved in the planning of care

Fiona Allsop

Cathy White

Patient representatives involved in a number of working groups and committees

Actively seek feedback from patients, carers and their families

Fiona Allsop

Cathy White

Patient opinion, YCM and FFT all in place and reviewed regularly

Engage with the voluntary sector

Gillian Francis Musanu

Colin Pink

Involvement opportunities for members and governors have been completed. Voluntary sector stakeholder list database being developed and scoped

Vicky Daley ADs (Jane Griffiths) DCNs (Jane Penny)

Ongoing review of cancer information as a result of NCPES. First meeting with patients to be held on 12.7.16 to influence this progress

No mixed breaches in Q1

Jane Penny

EOL care team participated in national EOL care audit results in April 2016, the team plan to re audit internally Summer 2016 7/7 service currently on hold due to staffing shortages, waiting for staff recruitment to post.

Vicky Daley

On track via nutrition steering group

Lead manager/clinician

Q1 update

3.8 NEW

Strategic objectives delivery plan

Listen to patients and their families and ensure their views shape clinical services that reflect their feedback and care needs

3.9

Develop information to cover areas and in a format that patients have Fiona Allsop influenced

3.10

3.11

Quality account Clinical strategy

Continue to ensure there are no mixed sex breaches

3.12

Audit EoLC plan BF

Quality Account Quality strategy

End of life care

3.13 3.14

Angela Stevenson

Fiona Allsop Implement 7 day service

Quality Account

Nutrition

Continue to make improvements to Fiona Allsop protected meal times

SO4 - Responsive - Become the secondary care provider of choice for our catchment population New Action Source Ref or bf

Lead director

RAG

Trend

4.1 NEW Strategic objectives delivery plan

Develop performance and benchmarking reports to track progress against delivery of national standards

Angela Stevenson

Ben Emly

Quarterly benchmark reports in place and reported to Executive Committee and Trust Board

4.2 BF

Develop plans to define and deliver 7 day services

Des Holden

Chiefs (Ben Mearns)

Plan in development to be presented at Execs 27th July 2016

4.3 NEW Strategic objectives delivery plan

Using patient feedback further develop the Macmillan Cancer Information Centre

Fiona Allsop

Jane Penny

Patients representative on cancer information steering group and participate in focus groups to help guide service objectives

4.4 NEW Strategic objectives delivery plan

Continue series of hot topic events with patient involvement

Des Holden

Laura Warren

A plan for hot topic events in 2016/17 has been drafted

4.5 NEW Strategic objectives delivery plan

Involve patients in SASH+ work in partnership with the Virginia Mason Institute

Sue Jenkins

Two rapid process improvement workshops have been held in Q1 and each have had a patient representative as part of the event

Strategic objectives delivery plan

4.6 NEW Strategic objectives delivery plan

Review and increase use of SaSH@home beds

Angela Stevenson

Weekly meeting with SASH@home in place as p[art of top 50 review. Undertaking audit to improve community interface and ensure that this service is more focussed around elective care

4.7 NEW Strategic objectives delivery plan

Complete Frontier pathology services joint venture implementation and delivery

Bruce Stewart

Michael Rayment

FBC addendum approved by both Trust boards in Jan and March 2016. Frontier Pathology fully live and implementing the plan as described.

Angela Stevenson

Ben Emly

Currently aiming to achieve 85% which is national standard. Average of 91.3% over Q1 and includes approximately 16 escalation beds in use.

Angela Stevenson

Ben Emly

Average of 91.3% over Q1 and includes approximately 16 escalation beds in use. Therefore in bottom 20%

Angela Stevenson

Natasha Hare

RTT on track with STP trajectory At the end of Q1 the elective activity is £150k adverse against plan. This is mainly a surgery issue where activity has been cancelled due to higher than forecast non elective activity

Work towards achieving 80% bed utilisation

4.8

4.9 NEW

Strategic objectives delivery plan

4.10

Work towards LOS being in top Ensure patients receive the right 20% care, in the right bed, at the right time, every time Deliver all elective plans

4.11

Market Development strategy

To maintain and expand market share for elective activity

Paul Simpson

Larisa Wallis

Overall outpatient referrals have increased by 16% in Q1 with huge increases (500%) from Brighton and Hove areas

4.12

Market Development strategy

To explore opportunities for new services, joint ventures, partnerships Paul Simpson and new markets

Larisa Wallis

Still progressing with Frailty unit development and delivery of integrated reablement unit and pathology joint venture. Currently awaiting outcome on two AQPs

Lead manager/clinician

Q1 update

SO5 – Well led – Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model New Action Ref Source Lead director or bf

RAG

Trend

5.1 NEW Strategic objectives delivery plan

Deliver financial plan and develop and implement a viable long term financial model

Paul Simpson

Peter Burnett

LTFM submitted to NHSI in June Q3 financial position ahead of plan

5.2 NEW Strategic objectives delivery plan

Ensure that key service development decisions are underpinned by clinical evidence

Des Holden

Chiefs (Barbara Bray)

Current development of frailty unit is evidence based

ADs (Natasha Hare)

A number of initiatives / projects underway that include consultation and active participation form a wide cross section of staff, including: Pendleton Frailty Unit Neonatal Unit redevelopment plans SaSH+ RPIWs underway in Cardiology (emergency referrals), Outpatient Bookings (ophthalmology) and the Management of Diarrhoea

5.3 NEW Strategic objectives delivery plan

Ensure staff are involved in key service developments

Angela Stevenson

5.4 NEW Strategic objectives delivery plan

Improve staff to patient ratios

Fiona Allsop

Vicky Daley DCNs (Nicola Shopland)

Plan in process to address nurse:patient ratios for Nutfield; Orthopaedic wards have an interim plan in place. Area left to address of high priority is Holmwood night shift and other recommendations from safer staffing. Currently reviewing the ratios on Godstone in light of activity levels. Monitoring staffing ratios on an ongoing basis. Developing reporting of care hours per patient day following further guidance from the National Quality Board

5.5 NEW Strategic objectives delivery plan

Deliver ongoing staff development programmes including talent management

Mark Preston

Nathaniel Johnston

The Workforce Development Team are reviewing the outcomes of Achievement Reviews to identify where training and development interventions are required SaSH Talent management tool is being used as part of the Achievement Review process and feedback to date has been positive

5.6 NEW Strategic objectives delivery plan

Accelerate delivery of EPR and increased use of technology

Ian Mackenzie

Anna Wickenden

EPR Digitise OBC Approved by FWC and Exec

5.7 NEW Strategic objectives delivery plan

Develop effective partnerships to design integrated services

Jim Davey

ADs (Alison James)

Frailty pathway/unit undertaken as joint project with local CCGs.

5.8 NEW Strategic objectives delivery plan

Lead development of STP and influence effective delivery

Michael Wilson

STP submitted on 30 June. Content shared with all Boards of relevant organisation

5.9 NEW Strategic objectives delivery plan

Develop and implement a health and well-being plan

Mark Preston

Bev Cornish

Trust Health & Well-being Strategy being developed National healthy workplace CQUIN targets set for 2016/17 and Trust plan has been devised to meet these

5.10

Membership strategy

Establish and deliver engagement and communications strategy for members following FT authorisation

Gillian Francis Musanu

Laura Warren

Membership development group active and meeting bimonthly. Action Plan on track

5.11

IT strategy

Provide upgraded email solution

Ian Mackenzie

Peter Hodgetts

Move to NHS Mail planed for 2016 - waiting for HSCIC to confirm date

5.12

IT strategy

Complete Network Upgrade

Ian Mackenzie

Peter Hodgetts

OBC to be presented to Exec in September 2016

5.13

Estate strategy

Deliver estates capital programme

Ian Mackenzie

On-going and on track

Workforce and OD strategy

Develop integrated workforce plans (demand and supply) at divisional/ business unit level - identifying workforce changes required Mark Preston for 24/7 working in appropriate areas

Janet Miller

HRBPs working with Divisions to identify key workforce issues (e.g. Recruitment, Retention, Temporary Staffing Usage, etc.), and developing local annual Workforce Plans to address these

Nathaniel Johnston

Values incorporated into template job descriptions; session on Induction on Trust values and standards of behaviour. Values based recruitment principles adopted as standard for Trust recruitment, training on recruitment using these now being provided. Standards of behaviour developed into OD intervention on "One Team - One Way". Timetable for workforce related policy revision agreed with union colleagues. Reviews are being carried out with union involvement

5.14

5.15 NEW Workforce and OD strategy

Incorporate the vision and strategy into all recruitment, induction, appraisal, working life and people related policy and activities within the Trust

Mark Preston

5.16 NEW Workforce and OD strategy

5.17 NEW Workforce and OD strategy

Develop and incorporate the associated values and behaviours into job specifications and descriptions and selection processes

Ensure robust arrangements are in place for effective performance management and good quality appraisal of individuals

Mark Preston

5.18 NEW Workforce and OD strategy

Develop clarity on how to be an effective leader and manager in the Trust and what staff should expect from their managers and leaders

5.19 NEW Workforce and OD strategy

Integrate our vision and values into our learning programmes as core Mark Preston to the way we do business

Mark Preston

David Vincent

HRBPs work with managers when developing job descriptions and person specifications documents for new roles. The Trust has started to introduce values based questions in particular for nursing and nursing leadership positions and a toolkit has been shared with divisions to support the development of such questions. Personality and emotional intelligence testing has been used for senior appointments (including Deputy Chief Nurse) and the results are mapped against the UK Chief Nurses Offices 6 Cs of compassionate care and transformational leadership traits

Nathaniel Johnston

2016 Achievement Review cycle commenced in April 2016 and is being managed on a cascade basis Compliance target is for 90% of staff with 12 months continuous service to have a completed AR by 31st October

Nathaniel Johnston

'Human Factors' training devised and developed by the Workforce Development Team for delivery from September 2016 On-going external and internal leadership training available to relevant staff including a refreshed essentials of management programme and a newly developed coaching skills for managers programme Training provided on operational HR policies and procedures as part of 'Effective Management' training delivered by the HR Business Partners

Nathaniel Johnston

As and when new programmes are developed, they are aligned to the SASH Vision and Values either in their ethos or in education delivery. There is now a section on the SASH vision and values within the Trust induction.

TRUST BOARD IN PUBLIC

Date: 28 July 2016 Agenda Item: 4.3

REPORT TITLE:

SASH+ (in partnership with the Virginia Mason Institute) update

EXECUTIVE SPONSOR:

Michael Wilson Chief Executive Sue Jenkins Director of Strategy & KPO Lead

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

Executive Committee & Trust Guiding Team

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 May 2016 including details about:• each of the value streams • training and development • the communications plans • the compacts

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 Department of Health. The programme is expected to achieve improvements in quality, performance and efficiency over the next five years

Patient Experience/Engagement

Patients will be involved in value stream work wherever possible

Risk & Performance Management

A Trust Guiding Team has been established to oversee this work. This group reports to a national Trust Guiding Board

NHS Constitution/Equality & Diversity/Communication

A national communications plan is being delivered to support the work and internally communications is being rolled out across the organisation

Attachment: SaSH + update

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT –28 July 2016 SASH+ update – working in partnership with the Virginia Mason Institute 1. Introduction 1.1 The Board receives regular updates relating to the Trust’s SASH+ work. 1.2 This paper provides the Trust Board with an update on progress since May 2016 including details about:• each of the value streams • training and development • the communications plan • the compact work 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 diarrhea

2.3 Each value stream has a suite of high level metrics that have been signed off by the Trust Guiding team. These confirm whether progress is being made to move from the current state high level value stream maps to the future state high level value stream map. Progress against the high level metrics will be reported to the Board for each of the value streams 2.4 Update on cardiology value stream 2.4.1 The first quarter results for the high level cardiology metrics are detailed below. The second quarter data is currently being colated:Baseline (October 2015— February 2016) Quality Metric 1: Number of bed H’woodchanges on 12.5% Holmwood & CCU CCU - 37.5% Quality Metric 2: Number of outliers n=3 on other wards 8%

Target

1st Quarter April 2016

Comments

Increase from 3.4/28 to 6/28 H'wood – Increase from 3/8 to 3.4/8 21% CCU 44% n=1 1/36 = 2.7%

3 An Associated University Hospital of Brighton and Sussex Medical School

Quality Metric 3: Non elective emergency readmission <7 days Quality metric 4: Non elective emergency readmission < 30 days Quality metric 5: Number of procedures cancelled

Quality metric 6: Day care conversion

Oct 15 – 7.4% 7.0%

Apr 16 – 7.5%

Sep 15 – 16.1%

14%

Mar 16 – 11.5%

Not plan/capacity 7.5% Not done/plan 13.5% Not done/capacity 20%

0% 0% 0%

63/120 = 52% 8/57 = 14% 71/120 = 59%

Oct 16 (32/114) 28.1%

18%

Apr 16 – (33/108) 30.6%

100% 35%

Apr 16 – 100% from 36.4% response rate

Oct 15 – 100% 100% 67.9% 35% response rate

Apr 16 – 96% 50% response rate

Service Metric 1: FFT for Holmwood Oct 15 – 93% 35.8% response rate

Service Metric 2: FFT for CCU

Delivery metric 1: LOS –non elective Oct 15 – 7.7 days Delivery metric 2: LOS—elective

Oct 15 – 1.4 days

Delivery metric 3: Time from referral 15 hours and to first seen by 30 minutes cardiologist

5.8 days Apr 16 – 6.9 days 0.96 Apr 16 – days 1.5 days 23 hours 2 hours

For in hours using new process 50 mins

n = 9 patients out of 13 who presented during week For OOH patients 9 hrs 38 mins For in hours not using process 13 hrs 05mins

4 An Associated University Hospital of Brighton and Sussex Medical School

Delivery metric 4: Time from referral 25 hours and to arriving in 36 minutes cardiology bed

90 mins For in hours using new process 33 mins

Morale Metric 1: Number of inliers on Holmwood, CCU and angio

Angio 36% H’wood 14% CCU 0%

0% 0% 0%

Angio (0/14) 0% H’wood (1/28) 3.5% CCU (0/8) 0%

Morale metric 2: Abbreviated Staff Survey

Net score 256.5

>300

N/A

Cost Metric 1: Excess agency costs

Cost Metric 2: ADHs paid

n = 9 patients out of 13 who presented during week For OOH patients 6 hrs 5 mins For in hours not using process 4 hrs 20mins

To be reported at 120 days

M1 -M7 £21,600 Apr 16 Angio £32k per Angio Med month £19k £11k(excluding Med £0k locum) ECG £1k ECG £22k Hwood Hwood/CCU £40k £238k (£60,200 (£43,300 per per month) month) M1 – M7 £21,600 (£3,100 per month)

£1,500 per month

Apr £13,200 per month

2.4.2

Our first rapid process improvement workshop (RPIW) for cardiology was held back in February 2016. It focused on improving the referral process for cardiology patients and reducing the lead time for a patient arriving at the hospital and being seen by a cardiologist and the patient arriving at the hospital and getting to a cardiology bed.

2.4.3

The challenge in embedding the new referral process for the cardiology team has continued. The value stream sponsorship team have continued to meet and at 90 days when the reporting out would normally be ceased it was recognised that the process was neither embedded nor sustainable.

2.4.4

The monitoring has continued and this RPIW is continuing to report out to at least 150 days at 30 day intervals. Key staff working in the cardiology team have been involved in addressing the issues around embedding the new process and the chief of medicine has been invited to join the sponsorship team and been actively involved in developing the solutions.

5 An Associated University Hospital of Brighton and Sussex Medical School

2.4.5

In April 2016 the Trust held its second RPIW for cardiology. This time the RPIW focused on the discharge process which was measured from the time the decision to discharge was made to when the patient left the cardiology bed.

2.4.6

The 60 day report out for this RPIW demonstrates that the work is in the main embedded and all metrics are either the same or better than the baseline or meeting the target. The data for the 90 day report out is currently being collated.

2.5 Outpatients value stream update 2.5.1 The high level metrics for outpatients have now been agreed and are detailed below: Baseline (April â&#x20AC;&#x201C; end June 2016)

Target

Quality Metric 1: Number of referrals in backlog, not admitted

984

Quality Metric 2: Number of cancellations by hospital: New appointments

1351

Follow ups

4331

Clinics cancelled <6/52

Service Metric 2: Friends and family results % r recommended

89.3%

100%

Delivery Metric 1: Time from receipt of referral to date of first appointment. (Lead time) for (a) Urgents and for (b) Routines

2.5 weeks (u) 9 weeks (r)

0 weeks

6.9% 6.8%

0% 0%

Service Metric 1: Number of patient complaints and concerns formally recorded about outpatient appointments. Count complaints

Delivery metric 2: % of DNAs A. for news B. For follow ups

6 An Associated University Hospital of Brighton and Sussex Medical School

Morale Metric 1: Staff survey results, taken from Management Standards for Outpatient Booking Office Domains: · Demand · Control · Managers support · Peer support · Relationships · Role · Change

2.87 3.24 3.00 3.50 4.17 3.60 3.11

3.08 3.50 3.95 4.15 4.27 4.29 3.77

Morale Metric 2: Staff vacancy rate outpatient booking office

Morale Metric 3: 18 week RTT Breach fines per month

£52600

£0

Finance identifying

£0

Cost Metric 2: Cost of ad hoc clinics for outpatient appts

2.5.2

The first RPIW for this value stream took place at the end of May 2016. The focus of this week was on the booking of new appointments for adult ophthalmology patients. There were 6 weeks of data collection, including timed observations of each operator in the process, as preparation for the RPIW.

2.5.3

Baseline metrics showed a lead time of: • Urgent Referrals Time from the receipt of the referral by outpatient booking office (OBO) to the date of the first appointment = 28 days 2 hrs 59mins During the RPIW week this lead time was reduced to 19 days and on the 30 day report out this reduced again to 18 days. The team are still aiming to achieve a target of 10 days • Sub-lead Time Time from receipt of referral by OBO to the date the booking is made for first appointment = 14 days 2hrs 59 mins During the RPIW week this lead time reduced to 5 days and at the 30 day report out increased slightly to 7 days. The target for this lead time is 5 days. • Routine Referrals Time from the receipt of the referral by OBO to the date of the first appointment = 107 days 18hrs 24mins During the RPIW week this lead time reduced to 33 days and at the 30 day report out this improved further to 25 days. This exceeded the target that was set for this lead time of 89 days.

7 An Associated University Hospital of Brighton and Sussex Medical School

• Sub-lead Time Time from receipt of the referral by OBO to the date the booking is made for the first appointment = 79 days 18hrs 24mins During the RPIW week this lead time reduced to 5 days and at the 30 day report out increased slightly to 7 days. This exceeded the target that was set for this lead time of 61 days. 2.5.4

Some of the other key successes, actions and learning from the RPIW are detailed below:• Our baseline data collection identified 1331 referrals that were in various offices awaiting grading and an appointment. In the first 30 days of improvement this work in progress has been reduced to 361 • A fax machine has been moved from the first floor to the ground floor where outpatient booking office staff sit and reduced the number of steps taken each day to retrieve the referral faxes from 726 to 0 for each person. The outpatient booking office staff describe this work as having “transformed their working day” • A number of duplicate and incomplete referrals were identified during the data collection process and these have been removed which has reduced the demand that was originally required for ophthalmology patients • There has been set up reduction implemented where medical secretaries are preparing the referrals for grading by the consultants. This process now happens on a daily basis • The booking process has been moved from partial booking to “live” booking and fire break clinics have been implemented to accommodate any rescheduling due to leave or sickness of clinicians • At our 30 day report out two key actions that were still outstanding included liaising with the post room to ensure that only ophthalmology referrals go to the ophthalmology team and that the switchboard passed calls relating to outpatients to the correct team.

2.5.5

The report out that was made to the Trust by the staff involved in the RPIW at the end of their week is available on the Trust intranet for all staff to access.

2.6 Management of diarrhoea value stream update 2.6.1 The high level metrics for outpatients have now been agreed and are detailed below:

Quality Metric 1: Percentage of all patients without a stool chart present

Baseline (April – end June 2016)

Target

57% N= 59/104

8 An Associated University Hospital of Brighton and Sussex Medical School

Quality Metric 2: Percentage of samples received by the lab which are un-testable

23% N=14/60 Enteric pathogens

2% N= 1/59 C.diff Quality Metric 3: Number of lead consultant or ward changes per patient per admission (transfer of clinical care)

2.3 (mean) 2 (median) N=16

2 (mean)

Quality metric 4: The percentage of patients 100% without an assessment of their baseline bowel function documented during initial clerking (ED/Medical) Service Metric 1: Time between identification of symptoms to return to normal bowel habit (last documented type 5-7 if normal bowel habit not documented) Service Metric 2: Length of time (duration) of isolation (for diarrhoea)

73 hours (median)

72 hours 100% of patients with normal stools documented

N=9/16

5.5 days (mean) N = 11/16 (Number of patients isolated)

1 day

Service Metric 3: Patient experience of care relating to management of diarrhoea

100% of patients agree/strongly agree (for bundled questions)

Delivery Metric 1: 15 hours 11 minutes Time between printing of stool (median) sample label to receipt by lab N= 66 samples

1 hour

Delivery metric 2: Time between identification of symptoms and isolation in side room.

53 hours (mode)

2 hours to transfer to side room

Delivery metric 3: Time between identification of symptoms and stool sample collection

15 hours (median)

N=10/16 0 hours

N= 12/16

9 An Associated University Hospital of Brighton and Sussex Medical School

Delivery metric 4: Time between identification of symptoms and documented differential diagnosis

57.5hours (Median)

14 hours

N=5/10

100% of patients with documentation

Morale Metric 1: Staff survey (staff experience caring for patients with diarrhoea) Cost Metric 1: Cost of closed beds

Cost Metric 2: Cost of untestable samples being sent to the lab

100% agree/strongly agree (bundled question responses) 252 bed days x £256 (mean cost of 1 bed per day) £64,512 15 X £19.11= £286.65 (M,C&S + C.diff)

2.6.2

The first RPIW for this value stream is planned for the week commencing the 18 July 2016 and will focus on ‘Identification of symptoms and initial care’. Examples of kaizen bursts that the teams will be looking to improve in the RPIW are: - ‘First mention of diarrhoea differs between nursing and medical notes (inconsistency)’ - ‘Patients often embarrassed and reluctant to inform others of symptoms, resulting in delays to identifying symptoms’ - ‘There is variability in responding to patients with diarrhoea, depending on level of professional experience’ - ‘Patients with communication difficulties, cognitive deficiency are unable to use call bell for help’

2.6.3

The baseline data collection work necessary to prepare for the RPIW is complete. This involved identifying patients with diarrhoea when presenting with symptoms in AMU and following their care in real time (where possible). The RPIW process owner and sponsor meet weekly in the lead up to the RPIW to ensure the appropriate preparation and planning is carried out before the event.

2.6.4

Some of the key initial baseline metrics for the RPIW include:• • • •

The lead time from identification of symptoms to a documented differential diagnosis is 2 days 9 hrs and 36 minutes. The target that has been set to improve to is 24 hours. The number of steps staff take to collect additional linen supplies from main stores is 348 steps. The target that has been set to improve to is 0 steps The percentage of patients without a stool chart is 89% and the target that has been set to improve to is 0% The time spent gathering supplies to attend to patients personal care needs is 10 minutes and 6 seconds. The target that has been set to improve to is 5 minutes.

An Associated University Hospital10 of Brighton and Sussex Medical School

3 Training and development 3.1 Local SASH+ training and development in accordance with the plan previously circulated to the Board continues. 3.2 The taster sessions continue on a monthly basis. This is a 2.5 hour session giving an overview of the Virginia Mason story and how the SASH+ work has come about. It covers a couple of lean tools and techniques including understanding what waste is and what it looks like and 5S – sort, simplify, sweep, standardise and sustain or selfdiscipline. These tools are simple and quick to learn and can be taken away by participants to use in their own work areas and with their teams. 3.3 In June the Trust launched the first module of its Lean for Leaders programme. This is an eight month development programme which consists of: • Six taught days delivered in partnership by colleagues from the Virginia Mason Institute and our own Kaizen Promotion Office team • On-site coaching and mentoring for all candidates • An opportunity to apply the learning from the taught days to undertake marked improvement assignments in your own work areas • Compulsory pre-reading of various books and articles 3.4 It is aimed at staff in key leadership roles and 42 candidates attended the first module. In between each module the candidates apply the tools and techniques that they have learnt and start undertaking improvement in their own areas of work. 3.5 Lean for leaders is a key tipping point for building both capacity and capability of the tools, techniques and culture of improvement across the organisation. 3.6 VMI are co-teaching our first lean for leaders course and certifying our KPO lead to be able to deliver this course in the future 3.7 The national team have also offered the opportunity for newly recruited Trust Guiding Team members to undertake the executive leadership development session in Seattle later this year. Three leaders including our Chief Operating Officer, our director of OD and people and our Head of Communications will be taking up this opportunity in early September. 4 Communication 4.1 The KPO and communications teams meet on a regular basis and have developed a communications plan 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 is aligned to the national NHSI VMI Communications Strategy. The Head of Communications and the KPO lead 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 has developed a communications plan which includes:• 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

An Associated University Hospital11 of Brighton and Sussex Medical School

• • • • • • • •

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 Our local draft compact is being shared and considered across the organisation for feedback. A further development and refining session with clinical leads, divisional chief nurses, chiefs, associate directors, the executive team and heads of department took place on 23 June to take this work forward. 5.5 A small sub group of the TGT including the medical director, chief of clinical education, director of OD and people and the KPO lead will be set up to oversee this work. 5.6 As part of the contract with VMI NHSI have identified up to 5 days that can be used by the Trust with Amicus providing support and expertise for this work during 2016/17. 6 Recommendation 6.1 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 July 2016

An Associated University Hospital12 of Brighton and Sussex Medical School

Minutes of the Finance and Workforce Committee Held on 28 June 2016 at 8.30am In AD77, East Surrey Hospital, Redhill PUBLIC Present Richard Durban Alan Hall Paul Simpson Fiona Allsop (part meeting) Angela Stevenson Ian Mackenzie Mark Preston

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

Alan McCarthy Peter Burnett Colin Pink (part meeting) Ben Emly Anna Wickenden (part meeting) Catriona Tait

Trust Chair Deputy Chief Finance Officer Head of Corporate Governance Head of Informatics EPR Programme Manager Head of Costing & Service Line Reporting (Committee Secretary)

In attendance

WELCOME AND APOLOGIES FOR ABSENCE Apologies: There were apologies from Paul Biddle (Non-Executive Director) and Gillian Francis-Musanu (Director of Corporate Affairs â&#x20AC;&#x201C; Colin Pink Deputised for part of the meeting). Declarations of Interest: There were no declarations of interest.

MINUTES OF THE PREVIOUS MEETING The minutes of the 24 May 2016 meeting were approved. Action Tracker Richard Durban went through the items on the Action Tracker that were due for this meeting but were not elsewhere on the agenda. Ian Mackenzie advised that a decision on who will be on the top floor of the Medical Records building is due next Tuesday. Angela Stevenson advised that there had been financial and operational issues with the Royal Surrey partnership and this will be

included within the partnership paper for July. Paul Simpson confirmed we had details of BBPC performance across our patch and this will be emailed round after the meeting. Paul Simpson advised that the Trust had received verbal confirmation from NHSi that the ÂŁ3m capital to revenue transfer will come back into the capital programme but this has not been received in writing. Paul Simpson advised that we had optionality in the capital programme for 2016/17 and we would not submit EPR digitise if the capital funding was not available. 3

BUSINESS PLANNING IT Roadmap phases 4 & 5 OBC Anna Wickenden presented the EPR Digitise OBC to the Committee outlining the benefits and risks of the scheme. Ian Mackenzie advised that the EPMA trial had been a success but had not been rolled out due to the resources required and that this will be one of the biggest change items that the organisation has ever had. Fiona Allsop added that it is a project we need to do but the concerns are in using it and the cultural and social change that is required rather than the system itself and that we need to use our learnings from other project rollouts such as Health roster and digital dictate. The Committee then discussed the OBC in detail with a focus on the following: - Implementation, including timing and risks - Benefits, both time and cash releasing - Capital, noting ÂŁ4.0m was required in the current f/y - Procurement of both hardware and software - Buy-in to the proposal by staff and GPs - Options around balancing functionality and complexity. It was agree that the outcome of the discussion would be reflected in the FBC. The Committee approved the EPR Digitise phase OBC which would now go to NHSI before the FBC was written. Radiology ERP Update Paul Simpson gave an oral update on the Radiology ERP business case, advising the Committee that the Trust had received notification from HMRC that VAT would not be reclaimable on the Medipass contract. The Trust has agreed with Medipass to go back to HMRC to challenge the decision and is also looking at other options. Richard Durban asked about the timelines and urgency of the project as the outline business case indicated there was equipment that needed replacement. Paul Simpson replied that we had replaced some equipment outside this project and there is a new lead clinician for Radiology who is reviewing the departments equipment

needs. Action: A written paper with option and the health of the radiology equipment to come to the July meeting PS 4

FINANCE Financial Performance M02 Paul Simpson presented the M02 Finance performance report. The Trusts YTD deficit at the end of month 2 was £(2.5)m, £1.5m better than the planned £(4.0)m deficit position. This improvement is attributable to achieving more income than planned in April and underspends on staffing costs. A new risk was noted - a week on week increase in elective referrals from the South which is increasing the numbers on our incomplete pathway. There continues to be overspending in all Divisions, bar Surgery. These overspends are being reviewed within the refreshed performance management framework in the Trust and a forecast will be completed at M03. We have now signed contracts with all commissions bar Sussex MSK. Surrey have agreed to increase the MRET threshold to outturn 2015/16 and planned growth. Sussex has not yet agreed and we are awaiting a response and are ready to go to dispute if needed. Paul Simpson also advised that we have received a letter from Paul Baumann and Bob Alexander regarding readmissions and are confirming with the CCGs our interpretation of the letter. Richard Durban noted that we have a forecast at the end of Quarter 1 when the Committee can take a view on the £15.2m control total. Paul Simpson replied that we have not had a formal response to our letter to NHSi so we are resubmitting our plan and maintaining the same control total. There is a £2m income risk from 2015/16 and we are now starting the final reconciliation process for 2015/16 with the CCGs. Alan Hall said the report did not allow the Committee to track the financial and operational trajectories we need to achieve if we are to receive the STP funding. Paul Simpson replied that we will include this in the monthly report. Action: Monthly report to include performance against the trajectories needed to secure STP funding PS Alan Hall commented that we were still holding £8m reserves in the centre and we had previously agreed that this would be split out to divisions as appropriate to ensure the divisional overspend positions are correct.

Action: £8m reserves to be split out and moved to divisional budgets where appropriate

The cash balance at the end of May 2016 was £3m. The trust has drawn down £4.2m of revolving working capital in May 16 and a further £1.8m in June 16. A capital budget of £9.0m has been agreed for 2016/17, which is £3.8m lower than the Trust’s Capital Resource Limit (CRL) application at £12.8m (which include potential schemes for EPR Digitise and Pathology). 2016/17 CIP Update Paul Simpson presented the 2016/17 CIP paper and highlighted that at the end of May the Trust achieved savings of £488k and is (almost) on plan. The Trust remains confident the full £9.2m savings can be successfully delivered in 2016/17. Richard Durban queried that as we are approaching the end of Quarter 1 should everything not be in gateway 4. Paul Simpson agreed and added that we need to move the report into risk of delivery rather than the risk of identifying the saving. Current Loans and Working Capital Agreements Paul Simpson distributed a paper of the on the current loan and working capital agreements, and the options available to the Trust in respect of repayment of the revolving working capital (RWC). This will be discussed further at the next meeting as cash will be reported as part of the Quarter 1 forecast. Nursing agency CIP Report Fiona Allsop presented a report of the Nursing Temporary Staffing Spend Cost improvement Plan (CIP), which represents £3.9 million (40%) of the 16/17 Trust CIP valued of £9.2 million. The CIP aims to reduce expenditure on nursing agency as a % of pay costs by providing a fully recruited nursing structure with an effective bank. There are unallocated savings against local recruitment and temporary bank staffing. In addition there are limited savings against agency procurement and it is anticipated that this this may yield further savings once the agency procurement process concludes in November 2016. The Trust is also in early discussions with other organisations within our STP footprint on a shared bank. The Committee welcomed the report and noted the use of the £1m contingency fund and the £600k risk to the full delivery of the target. Alan Hall asked if we knew the names of the staff that are due to join us in the next quarter. Fiona Allsop replied that we will know on Monday but there is a delay in the Filipino visas and we have had to up our offer to attract them. Alan McCarthy queried that the report showed a risk rating against safety and did this mean that we were unsafe? Fiona Allsop replied that we were not

unsafe and that this was highlighting the gaps in the rota from vacancies that are filled by bank or agency staff. 5

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M02 Mark Preston presented the Workforce & Organisational Report to the Committee. The following areas were highlighted: - Partial implementation of the new Junior Doctor’s Contract is on-going, including the recruitment of the ‘Safer Working Guardian’, following extended discussion between the DoH and the BMA. Full implementation is dependent on the outcome of the BMA referendum on the proposed terms and conditions – the results of which are due on 6th July - Current Achievement Review compliance below required target for May. It is planned that 90% of all staff with 12 months or more continuous service to be appraised by end of October 2016. The Committee noted the variance in compliance between divisions and directorates. - Bank and Agency Usage remains high although week-by-week usage across May showed wide variances - The Trust’s ‘Freedom To Speak Up Guardian’ post is being recruited to - The Trust is running the first two cohorts of ‘Lean for Leaders’ training on 16 th and 17th June. - Total Trust Establishment has increased but staff in post has decreased - Agency usage still remains high within the Trust – PMOs are being held to review this - Sickness rate has reduced - Number of ‘open’ Capsticks cases on a downward trend for the past two months Richard Durban stated that we seem to be doing a lot of staff surveys and asked if we were overdoing it. Mark Preston replied that he would look at it but it is useful to have the feedback, even if it is generally the same. Workforce and Organisational Development M02 KPIs Mark Preston presented the monthly W&OD KPIs highlighting that sickness is reducing and that suspensions and exclusions have been added to the report. Annual Workforce (Headcount) Plan Mark Preston presented the Annual Workforce (Headcount) Plan. This identified that the Trust’s established posts are within overall budget, the number of post holders are below the number of

established posts and that there are significant vacancy levels in certain staff group (e.g. Nursing & Midwifery). Richard Durban queried why the establishment is going up. Paul Simpson replied that there is now a headcount validation process between HR and finance. Business cases are coming in stream, some departments have downgraded posts to increase their establishment and there is always a fluctuation in the number of junior doctors. Richard Durban asked if the establishment will increase this year. Angela Stevenson advised that there are additional posts for this year through the business planning process. The Committee noted that business cases which drove productivity could reduce headcount. MAST Report Mark Preston presented a report on MAST training, describing the outcomes of a robust review of the definition and delivery of MAST training and the resulting proposed changes. Mark Preston advised that the proposed changes would be discussed at the Executive team shortly. 6

CAPITAL AND ESTATES Capital & Estates Report M02 The M02 Capital and Estates report was received and noted. Alan Hall asked if we were planning to spend anything on the Pathology Joint Venture this year. Paul Simpson replied that we had agreed ÂŁ300k to write the business case plus fees. Richard Durban asked about the Pathology joint venture build in the context of the STP. Paul Simpson advised that any build would have room for an expanded service to allow East and West Sussex joining the Joint Venture if required.

GENERAL Date of next meeting Tuesday 26th July 2016 8.30am â&#x20AC;&#x201C; AD65

Safety & Quality Committee Thursday 2nd June 2016, 14.00-16.00 AD65 Trust Headquarters, East Surrey Hospital Minutes of Meeting

Present: Richard Shaw Alan McCarthy Pauline Lambert Des Holden Fiona Allsop Paul Simpson (first hour) Barbara Bray Ben Mearns Zara Nadim Katharine Horner Jonathon Parr

RS AM PL DH FA PS BB BM ZN KH JP

Colin Pink (first hour) Vicky Daley

CP VD

Presenting papers: Bruce Stewart Tony Newman-Sanders Mohamed Luqman

Non-Executive Director (Chair) Chairman Non-Executive Director Medical Director Chief Nurse Finance Director Chief, Surgical Division Chief, Medical Division Chief, WaCH Patient Safety & Risk Lead Clinical Governance Compliance Manager Corporate Governance Manager Deputy Chief Nurse

BS TN-S ML

Apologies: Alan Hall, Ed Cetti, Angela Stevenson, Ben Emly, Sue Moody Action 1

COMMITTEE BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were noted. All attendees introduced themselves. Minutes of the previous meeting The minutes of the last meeting were accepted as an accurate record. 1.2.

1.3. Actions from previous meeting were discussed as follows RS informed the committee that actions for both June and July will deal with at the July meeting where the main focus of discussion will be winter pressures and opening up the discussion around growth of activity and safety. It was confirmed that DH will present an ppdate on Clinical Audit next month, DH is waiting for the final audit position from the Divisions. â&#x20AC;˘ RS noted the two updates attached to the agenda under action plan. The analysis of incidents currently overdue for review is for action by the Divisions. An update will be incorporated in the quarterly incidents report due for review at the August meeting. â&#x20AC;˘ Complaints by bed days will also be reviewed as part of the Quarterly nd

SQC Minutes 2 June 2016 Page 1 of 8

Complaints Report, again due at the August meeting.

1.4 Highlights from Executive Committee for Quality & Risk 1.5 Highlights from Clinical Quality Review Meeting 2.1 Quality Report The EQCR and Quality Report were noted. RS explained that these would not be discussed in detail given the key focus of the meeting. He asked whether there were any questions from the committee. PL asked for clarification on an incident highlighted within the Quality report. BM explained that a member of the public had approached a child in paediatric ED, it was identified very quickly that he was not a member of staff. It is a no harm incident but it raise some concerns with regard to security. A full investigation is underway in medicine.

DEEP DIVE DIAGNOSTICS DH introduced the main focus of the meeting which was a deep dive into issues relating to diagnostics. Each of the diagnostic areas had been asked to present a short report to address the key issues of quality, service delivery and safety.

3.1 Histopathology report â&#x20AC;&#x201C; presented by Bruce Stewart Turnaround times: BS highlighted a significant increase in the volume of requests received by the labs linked to changes in clinical practice for example bowel screening and urology testing. BS also explained that changes in the complexity of tests also resulted in operational pressure for example template biopsies are now used for prostate cancer which can result in 17 tissue samples for examination. BS demonstrated that the SASH key assurance indicators are mostly green apart from the turnaround times, but that these are reported to the Joint Management Board on a monthly basis for discussion. PS noted that an extract of this report should be presented to the SASH Board. BS added that meeting the Royal College of Pathology reporting standards are a key priority for the Pathology Joint Venture. BS explained that the cancer pathways have been reviewed in detail to ensure that diagnostics are able to support the Trust meet the 62 day targets. However the effect of this is that the less clinically urgent tests take longer. AM asked whether it was possible that the collective performance could be improved at the expense of performance within the Trust. It was agreed that this could be an outcome. PS noted that it was the expectation of the Joint Management Board that performance for SASH patients would be improved. Serious Incidents: BS explained that there had been six over the previous two years. The key issue is the diagnosis of malignant melanoma, which accounted for four of the six incidents. The diagnosis of malignant melanoma is known to be a complex area. The spread of incidents is over several years. Audit: BS reported that the team has an audit programme in action. The nd

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team has re-audited the correlation of local reporting against the local cancer network reporting by the skin cancer network. There has been a re-audit of the use of immuno histochemistry against poorly differentiated squamous cell carcinomas. There is a regular ongoing audit of benign pigmented lesions which assesses whether further cases have been missed. These audits are due to be presented to the Clinical Effectiveness Committee. BS explained that it was the teamâ&#x20AC;&#x2122;s intention to undertake a prospective, double reported, blind audit of pigmented lessons following two incidents raised by Dermatology where biopsies had been reported as malignant but had subsequently proved not to be. BS noted that there had been concern regarding discrepancies between a single network expert and the SASH team. The purpose of this audit is to provide assurance about the competency of the SASH team, and the external reporter. BS reported to the committee that the traffic light system has been abandoned. The intention of the system was to provide clinico-pathological correlation, to convey a high degree of clinical suspicion from the requestor to the path lab. BS reported that in fact it became a tool for double reporting and quicker turnaround time. A joint review (pathology and dermatology) concluded that the best way forward was to ensure accurate clinical details on the request form. A dataset has been included in the pigmented lesion audit form to enable a review of this. BS summarised published error rates from across the world, it was noted that the error rates within SASH are lower. BM asked whether it is possible to re-examine the original slides, BS confirmed that it was and is routinely done in serious incident reviews. If a sample is found to be malignant it will be blind double reported internally, however this does not happen if the slide is assessed as benign. This is why the prospective audit is being undertaken. The team now has a local designated skin lead who undertakes the second report on suspected malignant melanomas, undertakes the audits and has the link with the MDTs. However the team has not yet moved to true subspecialist reporting because there are not enough consultants within the team. BS noted that this is one of the advantages of the joint venture, that in time this might be achieved. Periodic audits are undertaken, 2-4 audits per year randomly chosen by the lab manager consisting of 20 cases per audit, across all reporting consultants, blinded and examined by the sub-specialty lead. They are scored for discrepancy. 234 audited no missed diagnosis. BS outlined an audit which examines local reporting against the skin MDT reporting where there has been a diagnostic disagreement which is clinically significant. The finding was 15-20% of samples, which is a concern. However, it should be noted that there have been some reversal of concern. 500 cases will be reviewed in the prospective audit. Each case will be reported simultaneously by the skin expert and the SASH team and double reported, reports audited for discrepancies will then be further reviewed. BS summarised by noting the extended timeframe of the incidents and the work that the team has undertaken, there is still work to do on confidence nd

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and assurance in the system. A possible outcome of the audit work may be that is reassured by the competence of the in-house team and ceases to work with the network expert. The committee had no further questions. BS was thanked for his contribution.

3.2 Specimen Group Report â&#x20AC;&#x201C; presented by Zara Nadim ZN started this section by summarising a serious incident in which a sample taken from a patient with a suspicious lesion was not sent to the lab for review. This prompted a review of the robustness of the system whereby samples are sent from outpatient areas to be lab. A pathology specimens group was set up to establish how the system can be improved. The revised process is based on the process undertaken in theatres. Once the sample has been taken by the clinician it is given to the nurse, both sign to confirm the name, and details of the patient. The sample is then placed in a bag to be sent to Pathology. ZN would like to make all samples trackable across the Trust. The aspiration would be to barcode the bag which could then be scanned at key points in the pathway providing an audit trail. This proposal will be incorporated into the work being undertaken on LocSSIPs. DH explained that the theatres have reasonable processes in place due to the number of samples taken on a daily basis. The concern was raised about the robustness of the processes employed in areas where samples are taken less often; ad hoc specimens on the wards, outpatient and radiology. DH asked how new or temporary staff are made aware of the signing process. The process is nurse led. In order for funding to be agreed for a tracking system DH asked ZN to produce an options paper which can be taken to Execs for approval. ML reported that for all samples taken in radiology, a request for the required test is generated on Cerner, a label produced and attached to the sample. The lab then confirm receipt of the sample on Cerner. The lab are therefore expecting the sample, TN-S undertook to establish whether an audit is undertaken of samples allegedly taken that then fail to arrive in the lab. BM noted that the SASH+ will be reviewing the diarrhoea pathway which will include the transit of samples.

3.3 Radiology Report â&#x20AC;&#x201C; presented by Mo Luqman and Tony Newman-Sanders The committee had asked for clarification on radiology reporting responsibilities within the Trust. ML noted that the Trustwide policy is currently under review. However, the current position is that the Radiology team are responsible for reporting all images except inpatient plain films and both fracture clinic and orthopaedic outpatient referrals. There has been some discussion about whether this is appropriate, particularly inpatient plain film. There has been at least one incident where pathology on a chest x-ray has been missed and not documented in the clinical notes nd

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appropriately. Radiology undertook a brief audit within ED to assess whether the x-ray report had been done within 48 hours of the patient leaving the ED. In 50% of cases there was no documentation in the clinical notes to show that a doctor has reviewed the X-ray before discharging or referring the patient. It is suspected that the position for inpatient reporting may be worse. Therefore the Radiology team intends to propose that they take responsibility for inpatient plain film reporting. The radiology department uses a company called Medica for additional support. Medical have undertaken routine reporting and undertake overnight emergency work. This will continue for the foreseeable future. If consultant work plans change it may be possible to take this back in-house. Some MRI scans are being outsourced to Gatwick Park, both the scanning and reporting. There are plans to bring this back in-house. DH asked how the Trust can be assured of the governance processes within the outsourced organisations. TN-S replied that the outsourcing companies have passed ISA accreditation process overseen by the Royal College of Radiologists this includes a 5% audit which is a more robust assurance process than most NHS organisations. TN-S added that it is the intention of the SASH Radiology department to undertake this audit. ML meets with Medica each month to review the contract and raise any issues (this includes diagnostic misses). ML explained that radiology use a Z5 code to flag images where there is a high suspicion of cancer. This code is understood by clinicians and picked up by the Cancer team to ensure that the code results in appropriate action. TN-S noted that in the past it has been the responsibility of the requesting clinical to ensure that he is aware of the results of tests that he/she had ordered and follows up the patient. However, case law (particularly in the US) is placing more responsibility on the reporting radiologist to get confirmation that the results have been received by the requestor and acted upon. TN-S noted that within the Trust this can be managed by the message centre inbox; however he acknowledged that there are some gaps in this process. AM asked where accountability lies. TN-S explained that the referring consultant has the right to rely on the expertise of the reporting radiologist. Therefore if there is a reporting error, accountability lies with the radiologist. If the report is correct and available on the system, but is not actioned accountability would traditionally have sat with the requestor, however this is now changing. TN-S highlighted two difficulties faced by Radiology. The college guidance is that critical and report results should be reported within an hour. Most organisations are finding this an impossible target to reach. This is further complicated by the report going into an electronic in-box; there needs to be assurance that the report has been read and understood. T-NS clarified that the ionising regulations state that for all x-rays a formal report by a fellow of the Royal College of Radiologists must be made on the patientâ&#x20AC;&#x2122;s record. In view of operational pressures SASH, like many other Trusts, put in place a number of non-reporting agreements which delegate nd

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the reporting requirement to the inpatient clinicians on the assumption that they are clinically competent to assess the x-rays that they order. The problem occurs when a junior doctor reviews the x-ray and misses something. More often however, no record of the outcome is made which places the Trust in breach of the regulations. This is a key driver in the proposal to repatriate inpatient reporting back to radiology. BM described the following mitigations in place:

• Admission pro-forma has a box in which the results of any x-rays should be entered.

• • • •

Post-take ward round asks for the same detail. Ward round standards require for radiology to be reviewed. Message centre is updated to show which images have been reviewed.

Point of discharge the juniors are asked to note the radiology BM would like the option for ward based clinicians to request a second opinion from a radiologist. The committee discussed whether there was assurance that Z5 codes are acted upon. JP reported that there is an audit due to be presented to the Clinical Effectiveness Committee In July which addresses this issue.

3.4 Emergency Department Report – to be presented in July by Casba Dioszeghy 3.5 Consultant view – presented by Ben Mearns BM gave a short overview of the process: the millennium system assumes that there is a consultant responsible for each patient. When a test is ordered for the patient it is stamped with the name of the consultant allocated, at that time, to the patient. Results will be directed back to that consultant and the pool (inpatient team) of the clinician responsible for the patient’s care at the point at which the result is generated. In some cases responsibility for the care of the patient has transferred from one consultant to another while the test is being processed. This ensures that both teams see the result. The results go into a system called “message centre” which looks and behaves like Outlook. There are a number of views, one being “30 day”, which carries the risk that results over that time may be missed. When a result is opened the options are to review, endorse or refuse. If a clinician refuses a result because the patient is not under your care, the system prompts the user to reassign the result to a new clinician, along with notes. Reassigning results can be time consuming for clinicians. The problem is where a result is assigned to a clinician because the patient was briefly under their care but has been passed on. It is common practice that if the result is normal then the receiving clinical will endorse the result and not pass it on. Abnormal results would be passed on. BM highlighted the problems as follows: nd

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• message centre is batched. • it does not highlight abnormal results to the clinician (bleep/page) this needs to be a manual process from the lab or radiology

• message centre allows results to be pooled, a consultant can ask junior doctors to authorise results on behalf of the consultant. This is not routinely used.

• blood results are in the notes, there is no audit trail in millennium. • nothing urgent is sent to message centre for immediate action. DH explained that if a patient is moved around the organisation the results can become increasingly historic in their attribution which is a risk. BM felt that clinicians do recognise patients who are in this situation and will look back at their results in millennium. He confirmed to the committee that there is an absolute expectation that results will be reviewed and endorsed. ZN made the point that it is possible to reject a patient without reassigning a new clinician. TN-S confirmed that this has been raised by ED too. KH noted that auditing the number of patients affected by this was an action out of a recent SI. BM summarised and welcomed the opportunity to work with TN-S to improve the technology available to clinicians.

3.6 Cerner – presented by Tony Newman-Sanders TN-S summarised the current technology available within the Trust and the planned system implementations. TN-S highlighted the risk of standalone systems within the Trust, for example maternity. Gaps in functionality:

• logging in and out of systems could be made more user friendly • data capture would be facilitated by voice recognition system • analytics and business intelligence - to support pulling data back out of the system

TN-S outlined a number of patient focussed systems which in time could be employed to help inform the patient about their healthcare. AM noted that the number of available systems demonstrates the need for a consistent NHS strategy. BM noted that it would be relatively easy to move PTS functionality across to millennium.

Conclusions DH concluded the meeting. ED will be invited to SQC next month to contribute their perspective to the discussion. The presentations have demonstrated that where benchmark data exists there is reasonable assurance that the Trust is not an outlier. In addition the Trust has put in place reasonable processes and is thoughtful about the audits undertaken to close off risks. DH highlighted the pigmented lesion audit as being important in restoring confidence in pathology team. The Trust needs to be maximising nd

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the value of health informatics by providing training and education to staff. However the Trust needs to get the processes right to ensure that patients are not subject to valueless moves which complicate the technology.

6.1 Any other business No items raised.

DATE OF NEXT MEETING Thursday 7th July 2016 14.00 â&#x20AC;&#x201C; 16.00 AD77

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AUDIT & ASSURANCE COMMITTEE Meeting held on 26th May 2016, 14:00am â&#x20AC;&#x201C; 17:00pm Venue: Room AD65, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Durban Richard Shaw In attendance: Peter Burnett Gillian Francis-Musanu Djafer Erdogan Ian Murray Jamie Bewick David May Michael Harling Colin Pink

PB RD RS

PBu GFM DE IM JB DM MH CP

Committee Chair / Non Executive Director Non Executive Director Non Executive Director

Deputy Chief Finance Officer Director of Corporate Affairs Financial Controller External Audit External Audit Internal Audit Local Counter Fraud Specialist Head of Corporate Governance Action by

1.1

Welcome and Apologies for absence The Chair welcomed members and attendees to the meeting. Apologies were received in advance of the meeting from Paul Simpson and Nick Atkinson.

1.2

Minutes of last meeting The Committee reviewed and agreed the minutes of the March and April meeting were a true record.

1.3

Actions from previous meetings: The action tracker was reviewed and the Committee noted the actions that had been closed prior to the meeting. External Audit commented that for the action relating to bad debt management (3.1) would be based on comparisons of level of debt provisions on balance sheets.

2.1

2014/15 accounts â&#x20AC;&#x201C; financial analysis

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PB introduced the report. Thanking the finance team for their efforts and the quality of the paper. The Committee noted and discussed two issues, achievement of CIPs in year and payment practice each of which is anticipated to improve throughout 2016/17. RS raised the impact of agency spend on CIP deliver which was discussed in detail, noting the effect on income and expenditure and the work that had been done to improve the position going into the new financial year. The Committee noted managementâ&#x20AC;&#x2122;s intent to improve the payment delays, noting that recent access to cash was allowing the Trust to improve its position. The accounts analysis was well received and it was agreed to share PBu/PS this document with the Board and Governors. Action PBu/PS RD commented that the report was useful and facilitated conversations relating to forecasted income growth, decisions on the delivery of CIPs and the ability to test the Trustâ&#x20AC;&#x2122;s decisions going into the new financial year. The Committee noted the report. 2.2

Final audited accounts The paper had been received in advance of the meeting and had been considered, in draft, at the April meeting. PB asked if there had been any material changes in the document. PBu stated that there had been some technical amendments in the classification of lines relating to purchasing of equipment for the new Angio Lab. There had been no material changes to the income and expenditure position. The Committee approved the accounts.

2.3

Review of Annual Report GFM presented the draft annual report for agreement. Similarly this had been received in April for review. The Committee considered the report and asked that the narrative be considered with the possibility of including more detail of the

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Trust’s position, greater emphasis on the challenges that are faced and growth within the system. The Committee raised minor technical issues throughout the report. GFM agreed to take forward these recommendations for inclusion in the final public version. The Committee agreed the annual report. 2.4

Annual Governance Statement CP introduced the annual governance statement which forms parts of the annual report and the submission of accounts. The statement is based on national guidance and elements highlighted by external audits recent benchmarking paper. The Committee noted final amendments and agreed the annual governance statement.

2.5

External Auditors Audit Findings Report JB introduced the report stating that the Trust’s accounts were of good quality, supported by clear working papers, with very few issues. The Committee discussed the end of year position noting the variance of £2 million of payment by commissioning and ongoing conversations with NHS England that would have an impact on 2016/17 income. JB highlighted that there was commentary on the Trust’s going concern and there was room for improvement in the narrative. There will be a going concern for the next 12 months. The Committee noted that the management of cash was being discussed at the FWC. There is expectation that the Trust’s going concern position will be in a better state by the end of this financial year if standards are achieved. JB highlighted areas of asset register that could be improved to provide clearer narrative, particularly it includes credit transactions and reversing journals. DE agreed with the comments and indicated that the Trust was moving to do reviewing record fortnightly. A qualified Value for Money conclusion had been given as the Trust

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reported a deficit of ÂŁ6.5 million. JB highlighted known areas of risk such as the Trustâ&#x20AC;&#x2122;s liquidity position, management of income from commissioners and agency and temporary staff spend. The Committee asked External Audit to consider the value for money commentary decision to align with known income and expenditure position. The Trust has a history of good budget setting, monitoring and forecasting, has reported a deficit position and continues to be in breach of the statutory break even duty, because of historic deficits incurred over the last decade. JB highlighted that because of the overall financial position, the Trust's relationships with its commissioners can be challenging and that demand management initiatives have not achieved a reduction in non-elective activity. There is however good evidence of working relationships and communication that mitigates against these issues. This leads to a cash flow position that impacts on payment of debtors. RD highlighted the Trustâ&#x20AC;&#x2122;s productivity plans that have impacted on 2015/16 expenditure and will continue to have positive impact going forward. JB indicated that the Trust continues to be in breach of the statutory break even duty. This was last referred to the Secretary of State in 2014. A referral is not required in 2016 as the position has not materially changed. JB and DE confirmed that the audit action plan had been discussed and agreed. JB confirmed that at this point in time External Audit would issues an unqualified audit report. PB thanked external audit for their work and the assurances provided. The Committee noted the report. 2.6

Representation Letter The representation letter was noted. No concerns or issues were raised.

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2.7

Head of Internal Audit opinion DM reported that 4 audits had been completed since the draft opinion had been presented in April. There was no change in overall opinion. DM confirmed that the organisation has an adequate and effective framework for risk management, governance and internal control. However Internal Auditâ&#x20AC;&#x2122;s work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective. The Committee noted the Head of Internal Audit opinion

2.8

Compliance with accounting standards â&#x20AC;&#x201C; letters from CFO and AAC Chair (Management Representations) The letter was presented for information. There were no comments or concerns raised.

2.9

FORMAL ADOPTION OF 2014/15 ACCOUNTS PB confirmed that the Board had delegated responsibility to the AAC to adopt the accounts. The Committee agreed to formally adopt the 2015/16 accounts and thanked the teams involved for their work.

3.1

Review of Workforce Internal Controls RD introduced the review of the updated workforce controls. The review was requested due to concerns over weaknesses within the control framework. This provided good overall assurance of actions taken and improvements made over the last 6 months. In particular improvements in process to control use of temporary staffing, improving governance of workforce issues and development of workforce strategy. The Committee discussed the positive movement in overall assurance and visibility of accountability that had come into place over the financial year. In particularly the focus of efforts has become

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very visible and there is assurance of good direction of travel. Erostering had improved the Trust’s ability to manage and there are plans to open temporary staffing bureau at the weekend. The Committee asked whether Internal Audit was reviewing the use of temporary medical staff. DM confirmed that this was underway. The Committee noted the report.

3.2

Review of Internal Controls Map CP introduced a review of the Trust’s internal controls map and draft plan for 2016/17. The Committee discussed the reviews to date and asked that controls relating to productivity, joint ventures and partnership working are included going forward. In particular the Committee asked that the clinical governance element of the controls map, including clinical audit which was prioritised for review. Action CP to update plan and commence internal controls review

3.3

2014/15 Reference Cost Audit The final reference cost audit report was presented and discussed. The Trust is compliant on Reference Costs and has an action plan that has been green rated by PWC. The audit provided assurance that reference costs have been prepared in accordance with the Costing Guidance issued by Monitor for 2014/15. The Committee noted the report.

4.1

Internal Audit Progress Report DM presented the update highlighting strong assurance for the systems that support the Trust’s Provider to Provider activities. The Internal audit of mortality and payroll systems had identified potential improvements in the Trust’s controls but had provided good overall assurance. In particular elements of the Trust’s policies supporting the management of mortality could be strengthened. In terms of payroll systems, the Trust could strengthen its management and mitigation of overpayments and would benefit from focused work

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relating to signing of time sheets. The Committee noted that the Trustâ&#x20AC;&#x2122;s performance on managing and closing agreed actions remains good. 4.2

External Audit Report External Audit confirmed that there was nothing further to report at present.

4.3

LCFS Report MH presented Counter Fraud provided a summary of work carried out throughout 2015/16 and plans for the coming year. A Trust wide fraud risk assessment is underway, which to date has not identified any significant new concerns. The Risk Assessment will be presented as soon as complete. The Committee noted the report.

5.1

Proposal for appointment of External Audit The Committee as the audit panel, discussed initial plans to support tendering process for External Audit. The initial plans were discussed and agreed. Procurement was asked to draft tender agreements for review by the Committee.

6.1

AOB No further AOB was raised.

6.2

Date of Next Meeting: 12th July 2016, 09:30am

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