Surrey and Sussex Healthcare NHS Trust Board Papers
June 2015
Trust Board Meeting – IN PUBLIC Thursday 25th June 2015 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH
AGENDA 1
11:00
GENERAL BUSINESS 1.1
Welcome and apologies for absence
A McCarthy
Verbal
1.2
Declarations of Interests
A McCarthy
Verbal
1.3
Minutes of the last meeting held on 28th May 2015 - For approval
A McCarthy
1.4
Action tracker
A McCarthy
1.5
Chairman’s Report For assurance
A McCarthy
1.4_ACTION TRACKER - TB.pdf
1.6
Chief Executive’s Report For assurance
P Simpson
Verbal
1.7
Board Assurance Framework & Significant Risk Register – For approval & assurance
G FrancisMusanu
1.6_CEO Report.pdf
1.3_Minutes in Public 28.5.15.pdf
1.7_BAF and SRR Report - Cover Sheet
1.7a_BAF Report.pdf
1.7b_SRR Report.pdf
2
11:30
SAFETY, QUALITY AND PATIENT EXPERIENCE Patient Story For discussion & assurance
F Allsop
2.2
Chief Nurse & Medical Director’s Report For assurance
D Holden/ F Allsop
2.3
Safer Staffing Review Update For assurance
F Allsop
2.4
Safety & Quality Committee Update For assurance
R Shaw
2.1
2.1_A Patient Story.pdf
2.2_CN MD Report.pdf
2.2a_CNO Safer Staffing Letter 11.6.1
2.3_Safer Staffing Review.pdf
2.4_SQC Update.pdf
3
12:15
OPERATIONAL PERFORMANCE 3.1
Integrated Performance Report (M02) For assurance
P Bostock
3.2.1
Operational & Quality Key Performance Indicators
D Holden/ F Allsop
3.2.2
Workforce Key Performance Indicators
F Allsop
3.2.3
Finance Key Performance Indicators
P Simpson
3.1_Integrated Performance Report -
3.2_FWC Chair Update - Part 1.pdf
3.3_AAC Update.pdf
4
12:55
3.2
Finance & Workforce Committee Update For assurance
R Durban
3.3
Audit & Assurance Committee Update For assurance
P Biddle
RISK, REGULATORY AND STRATEGY ITEMS 4.1
Care Quality Commission Action Plan Update For assurance
S Jenkins
4.2
2014/15 Quality Account For approval
D Holden
4.3
2014/15 Information Governance Annual Report For approval
I Mackenzie
4.4
Security Annual Report For approval
I Mackenzie
4.5 Serious Incidents Report For assurance
F Allsop
4.1_CQC Action Plan Update.pdf
4 2_Quality Account 2014-15 cover sheet
4.2a_SASH Quality Account June 2015 v3
4.3_IG Annual Report 2014-15.pdf
4.4_Security Annual Report 14-15.pdf
4.5_SI Report (May data).pdf
5
13:25
OTHER ITEMS 5.1
Minutes from Board Committees to receive & note 5.1.1
Finance and Workforce Committee
All
Minutes of the Finance and Workforc
5.1.2
Safety & Quality Committee
5.1.3
Audit & Assurance Committee
Minutes of the Finance and Workforc
A McCarthy 5.2
ANY OTHER BUSINESS
5.1.2_SQC Minutes May 2015 final.pdf
A McCarthy 5.3
QUESTIONS FROM THE PUBLIC Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to gillian.francismusanu@sash.nhs.uk
5.4
DATE OF NEXT MEETING 30th July 2015 at 11.00am
5.1.3a_ACC Minutes March 2015 - Final.pd
5.1.3b_ACC Minutes April 2015 - Final.pdf
Minutes of Trust Board meeting held in Public Thursday 28th May 2015 from 10:00 to 12:30 Room 7/8, PGEC East Surrey Hospital Present (AM) Alan McCarthy (PS) Paul Simpson (PBo) Paul Bostock (DH) Des Holden (FA) Fiona Allsop (PBi) Paul Biddle (RD) Richard Durban (RS) Richard Shaw (PL) Pauline Lambert (AH) Alan Hall
Chairman Chief Finance Officer / Deputy Chief Executive Chief Operating Officer Medical Director Chief Nurse Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director/Designate
In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (SMB) Sacha Beeby 1.
Director of Corporate Affairs Director of Strategy (item 4) Notes
General Business 1.1
Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, staff and members of the public. Apologies for absence were noted from Michael Wilson (Chief Executive).
1.2
Declarations of Interest The Chairman asked whether any of the Board members had any additional declarations of interest; none were recorded.
1.3
Minutes of the last meeting – 30th April 2015 The minutes of the meeting held on 30th April 2015 were approved as a true and accurate record, with the following minor amendment made; Item 2.4 Safety & Quality Committee update The committee will continue to receive quarterly reporting on the delivery of the Strategy.
1.4
Action Tracker The outstanding actions were updated and closed. TBPU-01 : Timetable for implementation of electronic patient records � share with the board in May Clinical Health Informatics Group (CHIG) will make its recommendations to the Executive Committee. August 2015 initial roll-out in ED, followed by the remaining specialties. FWC to receive the implementation map in June 2015. Page 1 of 14
Update on electronic prescribing due at Trust Board in June 2015. TBPU-02 : Letter to family of Patient Story‐ acknowledging discussion by Board MW to follow up this action. TBPU-03 : PROMS roll‐out ‐ progress reported through Integrated Performance Framework PROMS reported through IPQR with a 6 month update and progress report. TBPU-04 : Develop an indicator within the Quality Dashboard to demonstrate progress against mitigating actions to reduce the number of cancelled and delayed elective operations ‐ progress to be monitored and reported by SQC Due in next report to Safety & Quality Committee TBPU-05 : Board Seminar discussion to better understand the management of MRSA and Cdiff infections, to enable to board to challenge strategically in relation to Infection Control Seminar meeting in June 2015 scheduled. TBPU-06 : Breaking‐the‐Cycle ‐ Progress against the action plan to be shared with the Board, particularly in relation to divisional plans to increase senior medical and nursing cover on ward‐rounds. On the agenda for May 2015. TBPU-07 : The Board welcomed an Audit report and triangulation of data measuring the number of patients getting to the right bed or specialty on admission against operational pressures and expanding capacity (the recent opening of two new wards). Recommendations to SQC in June 2015.
1.5
Chairman’s Report for Assurance The Chairman announced the resignation of Yvette Robbins from the Trust Board as Deputy Chair and Non-Executive Director on 8th May 2015. The Chairman acknowledged Yvette’s 10 years of service with the Trust and the board paid thanks to her dedication and commitment to the organisation during that time. The Board duly noted the report.
1.6
Chief Executives report for Assurance The board received and noted the Chief Executive’s report in advance of the meeting. PS presented the report on behalf of the Chief Executive and highlighted the following; The Prime Minister has announced plans for 7-day working in the NHS to improve the provision of care at weekends. Clinical Chiefs will continue to support and oversee the development of 7-day working throughout the Trust, with the support of Clinical Commissioning Groups (CCGs). The Board agreed to discuss the Trust’s plans for 7-day working in more detail during a Board Seminar session, to better understand progress against delivery of the 10 clinical standards which have been developed nationally to measure the success of 7-day working. This will then be reported to the Public Board. Page 2 of 14
DH acknowledged that 7-day working will have a significant impact on the Trust and on operational and HR pressures. Divisions are presenting plans to increase consultant cover on wards to ensure patient review by consultant, 7 days a week. The Trust is in discussions with its community partners to agree the support needed to implement this and has strategically chosen to focus on those clinical standards which are most achievable. Elections to the Council of Governors have now commenced with announcement of the results expected on 3rd July 2015. Stakeholders are being approached for nominations of the 9 governors who will be appointed by key stakeholders. Once established, the Council of Governors will operate in shadow form until the Trust has achieved authorisation as an NHS Foundation Trust. In May 2015, the Trust welcomed Sir Bruce Keogh (National Medical Director for NHS England) to East Surrey Hospital. After an informal meeting with a number of clinicians and clinical leads, he invited questions and responded with empathy and real understanding for some of the queries raised. Sir Bruce then toured the hospital and met with members of staff from the Emergency Department, Acute Medical Unit and Theatres and was complimentary of the Trust’s achievements during the last few years. PS further highlighted some of the key events held by the Trust since the last meeting, including; Hot Topic event on Anaesthetics and Critical Care. The event was very well attended and the audience engaged well with the clinicians. The powerful story of a patient who spent 4 weeks in critical care at East Surrey Hospital was very well received. Non-Executive Directors were also very pleased to report a successful event. East Surrey Macmillan Cancer Centre A ceremony celebrated the start of the building of the new East Surrey Macmillan Cancer Centre which is due to open later this year and complements the Trust’s strategy for Cancer service provision. Marie Curie Partnership celebration The Trust celebrated the start of a new End of Life discharge liaison partnership with Marie Curie, supported by St Catherine’s Hospice. This partnership aims to support patients being discharged from hospital to their preferred place of care. Patient Safety Awards The Trust has been shortlisted in the Trust of the Year category of the national Patient Safety Awards 2015. The winners will be announced on 6th July at the annual Patient Safety Congress in Birmingham and the Board wished the team well in the process. The Board duly noted and took assurance from the report. 1.7
Board Assurance Framework and Significant Risk Register for Approval and Assurance GFM introduced the BAF and SRR for discussion and approval by the Board. The report described the proposed risk appetite for 2015/16 and details the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in pursuit of its objectives. The Board raised no objections. Page 3 of 14
A summary review of the 2014/15 BAF and strategic priorities to support the process for developing the 2015/16 BAF was undertaken by the Chief Nurse and Corporate Affairs Director. From this, new risks were proposed and changes identified to ensure the existing document was focussed on key issues. Following review by the Audit & Assurance Committee and the Executive Team, the draft 2015/16 BAF is presented to the Trust Board for approval. The BAF details 13 risks to the Trust’s strategic objectives (5 red-rated, 7 amber-rated, 1 green-rated). 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care In relation to the above BAF risk, PL challenged whether this was more relative to patient flow through the hospital. DH clarified that the Trusts business was primarily to provide good patient care. 3.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and failure to assess and monitor nursing staffing levels may impact negatively on the quality of care provided to Trust patients. In relation to the above BAF risk, RS identified that this reflected two separate risks for the organisation, relating to both recruitment & retention and nurse staffing levels. FA clarified that the Trust was expected to measure delivery of the standard for nurse staffing levels and agreed to review the risk and how they are better integrated with the wider staffing population. 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. The board noted the importance of managing the risk and mitigating actions. Productivity metrics are described in the detail. 5. 3 Unable to provide realistic medium term financial plan PS confirmed that the detail has been updated to clarify and reflect the risk of provision and the risk of delivery. GFM highlighted that the Significant Risk Register currently presents 9 risks, each with mitigating actions to reduce the level of risk to an acceptable level. The Executive Committee reviewed and agreed the proposal to include two escalated risks to the significant risk register, specifically related to divisional overspend and contract income. The Board resolved to agree with the current risk ratings and recorded controls and assurances, as reported. The proposed Risk Appetite was also agreed. The Board resolved to approve the new BAF and updated SRR and noted comments in relation to the addition of two new strategic risks; #1688 - Risk from Divisional Overspending #1689 - Risk of Contract income below plan PS agreed to review and reconsider the above red-rated risks which do not demonstrate confidence in the ability to deliver the budget. The board duly approved the report. Page 4 of 14
2.
Safety, Quality and Patient Experience 2.1 Patient Story for discussion FA introduced Francis Fernando (Falls & Patient Safety Nurse Consultant) who presented the Board with a patient story, providing assurance around some of the lessons learnt from the SI investigation of a patient fall and demonstrating the actions taken by the Trust to mitigate risk of repetition. Francis summarised some of the contributory factors relating to the patient’s fall, which include clinical condition and environment. Recommendations have been made for future falls work to support the development of the Falls pathway within ED, AMU and SAU and expansion of the Falls Prevention Team. Integration and partnership links continue to be explored for increased learning and exploration. Some of the key lessons learnt from the investigation include; Trust Policy in relation to patient falls had been followed by nursing and clinical teams. Next of Kin were informed and assessments and referrals completed in a timely manner Incident was recorded on Datix Timely discussions with the patient’s family before and after surgery and when the patient became very unwell. Falls Care Bundle to be completed accurately, with actions identified and implemented as soon as possible. This includes accurate documentation of post-fall care. Neuro-observations should have been undertaken despite no apparent head injury, as per NICE and NPSA Guidelines (Following a CT scan on admission, the patient was identified as having a mass on the left frontal lobe) Appropriate escalation when Early Warning Scores (EWS’) are triggered. In summary, the number of falls reported has increased due to increased capacity and continued focus on awareness. However, falls resulting in harm have only slightly increased when compared to the previous year, with a further 29% reduction in the number of reported falls resulting in major harm since 2014/15. The Trust continues to share learning from SI investigations throughout the Trust and demonstrate increased awareness of patients presenting as high risk of falling. Staff training and engagement continues through the MAST programme and visits to ward areas. E-learning provides remote access to training and has been completed by Falls Champions identified throughout the Trust. RS acknowledged some of the positive feedback on the increased profile of Falls Prevention and the Safety & Quality Committee is due to receive a presentation from the team to discuss some of the developments underway and improvements made so far. It was noted that a spectrum of interventions were needed to target falls resulting in harm and to support those patients at high risk. AH challenged the need to ensure compliance with some of the Falls Prevention initiatives amongst staff and allow sufficient time to embed new practices. Falls Prevention Champions will encourage staff engagement and this will be further supported by Matrons who will continue to manage their teams and expectations in changes to practice. Roles and responsibilities must be defined and clearly understood. Page 5 of 14
The board accepted that the after-care was entirely appropriate in this case and the focus of the investigation was around fall prevention. The Board took assurance from the presentation. 2.2
Chief Nurse and Medical Director’s Report for Assurance The board received and noted the report in advance of the meeting. FA presented the first half of the joint report focusing on the Safer Staffing report for April 2015 which indicated that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against the existing template. The Board noted some variation in the availability of nursing assistants during the day which has been appropriately managed by the Matrons. FA summarised progress against the planned safer staffing uplift of one registered nurse to seven patients (1:7) during the day and one registered nurse to ten patients (1:10) at night on adult wards, to be achieved by September 2015. There are no concerns in relation to progress against this trajectory, as the International Recruitment programme progresses to plan. FA announced the appointment of Victoria Daley who commenced in post as Deputy Chief Nurse on 18th May 2015. The NMC introduced a revised Code of Conduct in April 2015 which sets out the professional standards that nurses and midwives must uphold in order to be registered to practice in the UK. The revised Code of Conduct is a reflection of some of the recommendations made following the Sir Robert Francis review and will be a key tool used as part of the proposed nurse revalidation process which comes into effect from April 2016 and will also apply to overseas nurses. The Board will be obligated to approve the proposal for the nurse revalidation process which will be presented later in the year. DH continued to present the Medical Director’s report, highlighting that the Trust had made an application to the TDA for support to develop a quality improvement plan with Virginia Mason Hospital. The programme will focus on reducing needless variations in care as perceived by patients and will be awarded to up to 5 Trusts. DH further highlighted the national focus on Medicines Optimisation and multimorbidity. A national project on Medicines Optimisation, led by NHS England has become the focus of a number of regional events. The recently attended South East England event identified three key themes; Polypharmacy, atrial fibrillation and the challenge of reducing stroke, and chronic obstructive pulmonary disease. The event was attended by our Pharmacy and medical teams and was highly relevant to SASH. The Brighton and Sussex Medical School held an enabling event with Professor Sube Banerjee who gave an interesting speech on single chronic disease instances in the elderly. He described the observation that most such patients have each of their diseases managed with drugs as though they were single pathologies, and that the effect of drugs used in this way is much less than when single diseases are treated in isolation. The Chairman was pleased to note the CQC’s Outstanding accreditation of the Page 6 of 14
Trust’s End of Life Care and to receive a copy of a recent internal communication to all staff which described the story of a patient who spent the last weeks of her life in our care. The Medical Director took the opportunity to share some of the concerns raised by the patient’s family and some of the lessons learnt from the complaint. The Board duly noted and took assurance from the report. 2.3
Safety & Quality Committee Update for Assurance The board received and noted the report in advance of the meeting. The report summarised some of the key discussion points of the last committee meeting held on 7th May 2015. RS highlighted that the committee looks forward to receiving the outcome of a presentation to the Executive Committee on the top ten issues identified by Your Care Matters. The board expressed an interest in the outcome of those discussions and will receive an update through the Safety & Quality Committee report to the Trust Board. The committee were assured by the report on the CQRM meeting with no concerns being raised in relation to the Trust’s performance. The committee also welcomed the decision by East Surrey CCG not to close community stroke rehabilitation beds. RS further highlighted that the committee received a presentation on Mouth Care Matters which described the work of the dental team in improving the oral health of hospital patients. The team have received external funding for additional members of staff to provide training for nursing teams through interactive teaching on the wards. The committee also received a presentation on the Early Warning Scores project which is leading to earlier interventions and improved outcomes for patients. The committee welcomed the project and took assurance from the evidence of improved patient outcomes. The committee considered a quarterly report on complaints and challenged failure in processes and how lessons were learnt where poor attitude and communication was a factor. The board duly noted the report for assurance.
3.
Operational Performance 3.1
Integrated Performance Report (M1) for Assurance The board received the Integrated Performance report in advance of the meeting. PBo summarised the Trust’s operational performance during April and May 2015. In April, 96.8% of patients were admitted or discharged within 4 hours, with no 12 hour trolley wait breaches. Delivery of the 4 hour ED standard remains a challenge across the country and SaSH remains one of the best performing Trusts in the country. Page 7 of 14
Ambulance handover data was not available at the time of reporting and AH sought further assurance that patients were not kept in Ambulance vehicles in order to meet the 4 hour standard. PBo assured the Board that this is not the case. The Trust continues to work with SECAmb to manage ambulance waiting times during peaks in emergency activity. The 4 hour standard also applies to those patients presented by Ambulance and this commences from the time of arrival. The number of cancelled or delayed elective operations significantly reduced during April, with a total of 4 patients cancelled within Cardiology. RS welcomed a more detailed update at the Safety & Quality Committee. The trust continued to step up efforts to close escalation areas during April and May. Despite emergency activity pressures, the trusts ability to manage patient flow improved during these months. All Cancer Access standards were achieved in April, with the exception of the 62 day Referral-to-Treatment-from-Screening standard. This relates to one accountable breach due to two colorectal patients; one patient was referred to the Trust at day 50 and could not be progressed in the remaining 12 days of the standard. The other breach resulted from the Trust not being able to offer a patient who wanted to re-schedule an alternative date within the standard. Incomplete pathways and Admitted RTT standards were achieved at aggregate level whilst the non-admitted standard was not achieved. Non-achievement of the standard is part of the Trusts plans to reduce the 18-week backlog. The trust declared one Never Event and three Serious Incidents (SI’s) during April 2015. There were no reported cases of MRSA and one case of trust acquired C.difficile. The trust continues to monitor ward nursing on a daily basis and is assured that adequate staffing is in place. It also continues to monitor temporary staffing usage on a weekly basis. Staff turnover increased marginally to 15.5% in April. HR Business Partners within divisions continue to support actions to improve recruitment and retention with a significant focus on nursing. Sickness absence remained at 4.2% in April. The Executive Team will review actions to improve performance against the statutory and mandatory training programme – noting the target was missed during April. The Executive Committee will also review establishment and vacancy reporting and levels of sickness absence to better understand the data and agree actions to address performance in these areas. The board welcomed the addition of a performance indicator to measure agency spend and the risk to the organisation as identified within the BAF and SRR. The board noted that the commentary within the report relating to Workforce remained unchanged from previous months and the reporting structure would need further consideration and improvement to avoid repetition of data reported within the Integrated Performance report and the Chief Nurse report. A taskforce group will now be established to ensure that the existing suite of performance metrics is appropriate and relevant for the board. Page 8 of 14
PS reported that the planned position is a YTD deficit for the first quarter of the year, reflecting the profile cost of improvement plans. The Trust is on plan at month 1 with a £0.8m deficit (a surplus is expected later in year) and as reported in quarter 4 2014/15, emergency activity remains high and elective performance continues to improve. The continuation of overspending from additional duty hours and agency spend is driving costs within divisions. Divisions need to agree the allocation of reserved. The cost improvement plan for the year is £8.2m and in April, the trust is on plan with £0.3m delivered. PS further reported that the underlying position at the end of March 2014/15 is £0.8m deficit and risks to the 2015/16 financial plan are estimated at £0.6m but are fully mitigated. The cash balance at the end of April 2015 was £3.2m, above plan due to the delay in capital invoices. The capital spend forecast this year is £17.1m. Non-elective activity was assumed to increase by 2% however, at month 1 this has increased beyond expected levels and is estimated at 8% year-on-year. Nonelective income activity is 3% above plan and despite the increase in activity and additional capacity, the trust continued to perform well with elective work. During February and March, the ratio for the treatment of day-case patients and inpatients was estimated at 80:20 respectively. However, during April this ratio was reversed and demonstrates an increase in the number of inpatients treated by the Trust. The Board duly noted and took assurance from the report. 3.2
Breaking the Cycle Initiative for Assurance PBo presented the key outputs of the national Breaking the Cycle initiative which the Trust commenced on week commencing 7th April 2015. The objective during that week was to micromanage each inpatient journey with the aim of improving patient care and improving patient flow. The key operational changes made during this time included;
Increased consultant presence on the wards. All patients were reviewed at least once daily by a consultant The Nurse in Charge was supernumerary and attended the Ward-round Set a standard which was to discharge within 2 hours once a discharge was known to be definite Made the divisions responsible for delivering on the standard. Divisions reported to the site team times for discharge Medical division had Liaison Officers on every ward, surgery had a central bleep which the site team used to escalate issues and to confirm discharge times.
The commitment of staff and clinical teams was outstanding. Discharges increased by around 20% and outweighed the number of patients admitted every day of the week. 30% of patients were discharged by 1300hrs, with the remaining 70% discharged by 1600hrs. By the end of the week, the team had successfully closed Transfer Bay, Angio Page 9 of 14
and Medical escalation and considerably reduced the number of medical outliers in surgery. Woodland and Tandridge wards were ring-fenced and performance against the 4hr ED standard of 98% was achieved with only 1 breach over the weekend. This initiative will continue to run as follows; • The day after a Bank Holiday • The week after Easter Bank Holiday • The week after New Year • Junior Doctor handover week Emergency triggers to deploy the initiative will also include • Sustained dip in performance • High number of outliers • Ongoing use of escalation Divisions are currently scoping plans to take forward some of the developments and investments needed, as identified by the post-project review and the Executive Team will need to consider the longer-term strategy to get the organisation into a position which allows it to financially invest and implement such improvement plans. The Board duly noted and took assurance from the report. 3.3
Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting RD summarised some of the key discussions of the meeting held on 26th May 2015. RD highlighted that the committee had received an updated 5 year Communications Strategy and plan. The committee discussed some of the key priority areas identified within the plan, including links to other trust initiatives. The strategy/plan will return to the Committee in 6 months following input of the Head of Communications. The 2015/16 CIP programme was discussed and the intention to have a rolling 12 month review of schemes rather than a fixed April to March plan was welcomed. The committee requested a deep dive into the Clinical Supplies CIP covering 2015/16 and 2016/17. The savings were based on volume discount and loyalty payments. Strong clinical support was evidenced and the committee agreed that other large value schemes should be presented to provide additional assurance. The committee approved the funding of additional costs relating to asbestos removal and stoppages for noise during the Theatres Phase 2 project. Finally, RD reported that the committee received an update on the progress of the Dictate IT project which highlighted the quality improvements that the project has brought to the Trust at cost neutral. A formal post implementation review will be returned to the committee in due course. The Board duly noted the report for assurance. Page 10 of 14
3.4
Audit & Assurance Committee Update for Assurance PBi summarised some of the key discussions of the meeting held on 27th May 2015. The committee approved the annual accounts with an unqualified report by Grant Thornton. The trust was complimented on the high standard of accounts and timely completion. The annual governance statement and annual report were received and gave significant assurance to the committee. The Board duly noted the report for assurance.
4.
Risk, Regulatory and Strategy Items
4.1
CQC Improvement Action Plan for Assurance The Board received and noted the report and action plan in advance of the meeting. Sue Jenkins, Director of Strategy presented the CQC Action Plan which was developed following a visit by the Chief Inspector of Hospitals in May 2014 and in response to their findings in relation to service improvement. The board receives a monthly update on progress against the action plan. Progress against the detailed action plan confirms that three of the four main workstreams are rated as Green or Blue. The systems and processes workstream has been reviewed and a more detailed plan has now been developed. SJ reported that national benchmarking demonstrates that the Trust is in the bottom quartile for RTT compliance and has missed delivery of the standard for the last three quarters in 2014/15. The longest waits are in Paediatric ophthalmology and this is mainly due to capacity. However, a new Paediatric Ophthalmologist has been appointed and will see waiting times improve significantly. There are a number of challenges which need to be addressed over the coming weeks to improve the process of how outpatient referrals are processed and reduce the number of access points to clinic templates - ensuring appointments are booked appropriately and by clinical priority. Compliance with the access policy has been patchy which means that there is a lack of consistency across the specialties. SJ described the proposal to move forward with a hybrid model of full booking supported by e-referrals and Choose and Book. SJ further summarised the key principles and benefits of the proposed system as described within the report as follows; The principles of the proposed way forward will ensure that  Patients will be at the centre of the process in terms of choosing appointments and effective and timely communication  There will be as many electronic referrals as possible to ensure tracking Page 11 of 14
of referrals is transparent Variation will be reduced to support the improvement of quality across the pathway All patients will receive a consistent service regardless of the specialty that they are referred to or point of contact that they choose The system will support patients being offered appointments in clinical and then date priority
The benefits of these principles and the proposed system are that; Communications are traceable as majority will be electronic and where they aren’t a scanning facility of paper referrals will be used to make them electronic This process will work currently and with improving wait times All patients will be booked in order of referral Patients will be notified of an appointment < 72hours Reduced variation will improve quality of the process Can be worked alongside CaB for those GPs that wish to move to this system The board challenged the lengthy delay in the completion and closure of the action plan following the CQC’s appraisal of Outpatient Services at the Trust and AH questioned whether the CQC would be suitably assured by the improvements made to address the recommendations made. PBo responded and reminded the board that at the time of the CQC’s visit, there were no plans in place to address the issues identified. The Trust now recognises what needs to be done and plans are in place to address those areas of concern. SJ added that the Trust was unsighted on the level of growth in referrals and did not anticipate some of the complexities of demand and capacity. Linda Judge, recently appointed to manage the Outpatients department has already made significant contributions to the improvement of services and support for staff. The Chief Executive recently met with members of the Outpatient Department to better understand their concerns and pressures. Outpatient Staff Focus Groups have been established and provide an additional forum for staff to raise any concerns they may have. The team have been invited to host a Hot Topic event and showcase some of the improvements made within the department. A new suite of KPIs will be delivered to monitor the success of progress and reports will be circulated to consultants, service managers and ADOs. Reports will be at both specialty and consultant level and will include; Number of incoming calls to the Outpatient Booking Office 50% of referrals received electronically by end of December 2015 95% of referrals logged on Cerner within 24hours 95% of referrals graded by clinician and returned to Outpatient Booking Office within 48hours Milestones agreed by specialty for first appointment by end of June 2015 Number of patients breaching milestone by consultant Total wait list size by specialty and consultant Cancellation within 6 weeks by consultant Capacity gap in next 12 weeks by specialty. The Board duly noted and took assurance from the report. Page 12 of 14
4.2
Annual Plan 2015/16 for Approval The board received and noted the report in advance of the meeting. SJ presented the Annual Plan for 2015/16 which brings together all of the actions and objectives from a number of strategies and plans that have been developed. The detailed plan confirms the 95 actions that will be taken, the lead director and manager and the timescale for updates which will be done on a quarterly basis. Each of the actions have been aligned to one of the strategic objectives of the Trust. Actions which were not complete or are still on-going from the 2014/15 plan have been included along with new actions for 2015/16. Quarterly updates will be reported to the Executive Team and Finance & Workforce committee prior to Trust Board in order to provide assurance at Board-level. AM added that the Chief Executive’s personal objectives make specific reference to the Annual Plan, as described. The board resolved to approve the report.
4.3
2015/16 Cost Improvement Plan (CIP) QIA update for Approval The board received and noted the report in advance of the meeting. DH presented the 2015/16 Cost Improvement Plan (CIP) QIA update and highlighted that the 2015/16 Cost Improvement Plans have now had Quality Improvement Assessments signed off by the Chief Nurse and Medical Director. Those that have been signed off have a total CIP value above the total CIP total of £8.2m to take account of contingency schemes, noting that £1.2m of schemes are red-rated in terms of delivery. One QIA has been rejected and is covered by the contingency saving. Contingency schemes totaling £0.5m have been identified and the CIP profile sees an increasing value as we reach month 4. There are no CIPs in progress without a QIA in place. The board commented that rejected schemes were clearly identifiable. A six monthly review of the quality impact against each of the schemes would be welcomed by the board, with a three monthly review of those schemes where a risk has been identified. DH confirmed that the risks associated to commencing a scheme before the QIA is officially signed off are relatively low and do not impact on quality. There are currently no schemes in progress which have not been signed off by the Medical Director or Chief Nurse. The board welcomed future reports to clearly identify the schemes which have been rejected and those which have been re-submitted and subsequently approved or rejected. The forms should clearly highlight the date of first and subsequent submissions. DH agreed to circulate the latest forms relating to schemes which have Page 13 of 14
been rejected and subsequently approved. Post implementation review for Quarter 1 of the schemes approved to return to the Board in July 2015. The board should be able to articulate whether the schemes have delivered the quality expectation. The board resolved to approve the report, noting the above comments. Other Items 5.1
Minutes of Board Committees to receive and note
5.1.1
Finance and Workforce The minutes of the committee were noted with no questions raised.
5.1.2
Safety & Quality Committees to receive and note The minutes of the committee were noted with no questions raised.
5.1.3
Audit & Assurance Committees to receive and note The minutes of the committee were noted with no questions raised
5.2
Any Other Business No further business was discussed by the Board.
5.3
Questions from the Public There were no questions raised from members of the public.
5.4
Date of the next meeting Thursday 25th June 2015 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital
Note: This is a public document and therefore will be placed into the public domain via the Trustâ&#x20AC;&#x2122;s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.
These minutes were approved as a true and accurate record. Alan McCarthy Chairman:
Date:
Page 14 of 14
TRUST BOARD ACTION TRACKER Action Ref
Forum
Subject
Action
RO
Date Open
Date Due
Date Closed
Status
ACTIONS FROM LAST BOARD MEETING
TBPU‐01
TBPU‐02
TB Public
TB Public
Integrated Performance Report
Review reporting structure to avoid repetition of data reported within the Integrated Performance report and the Chief Nurse report. A taskforce group is to be established to ensure that the existing suite of performance metrics is appropriate and relevant PBo for the board.
28/05/2015
OPEN
2015/16 Cost Improvement Plan (CIP) QIA update
DH agreed to circulate the latest CIP QIA forms relating to schemes which have been rejected and subsequently approved. Post implementation review for Quarter 1 of the schemes approved to return to the Board in July 2015. DH
28/05/2015
OPEN
TRUST BOARD IN PUBLIC
Date: 25th June 2015 Agenda Item: 1.6
REPORT TITLE:
CHIEF EXECUTIVE’S REPORT
EXECUTIVE SPONSOR:
Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs
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: Forward View Into Action Local: Governor Election Process Virginia Mason Development Programme Patient Safety Awards Shortlist HSJ Shortlist Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact
Ensures the Board are aware of current and new requirements.
Financial impact
N/A
Patient Experience/Engagement
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
Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A
TRUST BOARD REPORT – 25th June 2015 CHIEF EXECUTIVE’S REPORT 1.
National Issues
1.1
The Forward View Into Action: Planning for 2015/16
Leaders of the NHS in England have published planning guidance for the NHS, setting out the steps to be taken during 2015/16 to start delivering the NHS Five Year Forward View. NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Public Health England and Health Education England have come together to issue the joint guidance called The Forward View into action: planning for 2015/16, coordinating and establishing a firm foundation for longer term transformation of the NHS. The guidance is backed by the recently-announced £1.98 billion of additional funding, with specific financial allocations for healthcare commissioners. The coordinated guidance includes a new support package for GPs, plans for a radical upgrade in prevention of illness, and new access and treatment standards for mental health services. The planning guidance requires leaders of local and national health and care services to take action on five fronts. It:
sets outs seven approaches to a radical upgrade in prevention of illness with England becoming the first country to implement a national evidence-based diabetes prevention programme
explains how £480 million of the £1.98 billion additional investment will be used to support transformation in primary care, mental health and local health economies;
makes clear the local NHS must work together to ensure patients receive the standards guaranteed by the NHS Constitution;
underlines the NHS’s commitment to giving doctors, nurses and carers access to all the data, information and knowledge they need to deliver the best possible care;
details how the NHS will accelerate innovation to become a world-leader in genomic and genetic testing, medicine optimization and testing and evaluating new ideas and techniques.
In addition to The Forward View into action: planning for 2015/16, NHS England has published a technical annex and range of supporting materials. Monitor and the NHS Trust Development Authority have also published respective technical guidance documents and supporting materials for commissioners and providers. As a provider organisation we will review and consider this report as a Board and impact and the transformation required to start to deliver the Five Year Forward View both as an individual organisation and with our partners across the local health economy. The full document is available at: http://www.england.nhs.uk/ourwork/forward-view/
2
2.
Local Issues
2.1
Governor Election Process
Elections to the Council of Governors continues. The Trust received at total 84 nominations for the public, patient and staff constituencies which is an overwhelming response. The voting process is currently in progress with an expected declaration of results by 3rd July 2015 once established, the Council of Governors will operate in shadow form until the Trust has achieved authorisation as an NHS Foundation Trust.
2.2
Virginia Mason Development Programme Application
Following more than 63 applications the Trust has been long listed to the last 10 to participate in the Virginia Mason development programme which is being run by the Trust Development Authority. A team including the Chair, CEO, Medical Director, Chief Nurse, a junior doctor and a nurse from the emergency department gave a presentation to a review panel last week and the Trust are currently waiting to hear if they have been shortlisted to the final 7 who will receive a site visit at the beginning of next month. Five Trusts are expected to progress to take part in the programme which will commence in the summer.
2.3
Patient Safety Awards - Shortlist
The Trust has been shortlisted for a â&#x20AC;&#x153;Trust of the Yearâ&#x20AC;? award by the Patient Safety Congress. Six finalists have been identified and site visits have been undertaken by a panel of judges during June. A final presentation by a small team headed by the CEO will take place on 22 June and results will be announced on 6 July. 2.4
HSJ Shortlist
The Trust has also been listed in the top 100 places to work by the health Service Journal and winners of each category i.e. best acute trust, community trust, mental health trust etc. will be announced on 7 July 3.
Recommendation
The Board is asked to note the report and consider any impacts on the trusts strategic direction.
Michael Wilson Chief Executive June 2015
3
Date: 25th June 2015
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 Corporate Governance Manager Executive Team week off the 15th June 2015
Action Required: Approval (√)
Discussion (√)
Assurance (√)
Purpose of Report: The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions, and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework. Summary of key issues The BAF details 13 risks to the trusts strategic objectives, 5 of which are recorded as key strategic risks and red rated. The main focus of this report is the need to agree the proposed changes to risks relating to delivery of planned efficiencies 2.2 in and staffing 3.1. There are 8 significant risks recorded on the Trust risk register. Recommendation: The Board is asked to discuss and approve the report and consider the following: Review the BAF and its alignment to strategic objectives Does the Board agree with the recorded controls and assurances Discuss and approve the changes to risks 2.2 and 3.1 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
1
An Associated University Hospital of Brighton and Sussex Medical School
Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement
The report is a requirement for all NHS organisations. As discussed in sections 5 (Income generation linked to activity referred to throughout the document) Patient experience and engagement is one of the Trusts strategic objectives. .
Risk & Performance Management
These are highlighted throughout the report.
NHS Constitution/Equality & Diversity/Communication
Discussed throughout the report but with the greatest detail in objective 3.
Attachment: June 2015 BAF and the current SRR
2
An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT – 25th June 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.
Board Assurance Framework
The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2015/16: 1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy 3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2.
Current status
The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows: Objective 1.Deliver safe services and be in the top 20% against our peers 2.Deliver effective and sustainable clinical services within the local health economy 3.Ensure patients are cared for and feel cared about 4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around
3
Red (15-25)
Amber (8-12)
Green (1-6)
0
2
0
1
0
1
0
1
0
1
0
0
3
4
0
An Associated University Hospital of Brighton and Sussex Medical School
a clinical leadership model Total
5
7
1
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). 2.1 Updates since last Board Review Since the last board meeting the Executive has reviewed and updated the BAF to reflect current as detailed in descriptions. There are two significant proposed changes to reflect the discussion at the May Board meeting detailed below, these are for review, discussion and agreement. Original
Proposed Change
2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. 3.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and failure to assess and monitor nursing staffing levels may impact negatively on the quality of care provided to Trust patients.
2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits.
The detail on both risk pages have been modified to better suit the new description to facilitate the discussion and approval processes. 2.2 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services and be in the top 20% against our peers
Initial Risk Rating: Severity x Likelihood
1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties. 1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care
4
Current Risk Rating: Severity x Likelihood
Target Risk Score
S4 x L3 = 12
S4 x L2 = 8
S4 x L1 = 4
S3 x L4 = 12
S3 x L4 = 12
S3 x L3 = 9
An Associated University Hospital of Brighton and Sussex Medical School
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy
Initial Risk Rating: Severity x Likelihood
2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties Proposed 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
S3 x L2 = 6
S3 x L1 = 3
S5 x L3 = 15
S5 x L3 = 15
S5 x L2 = 10
S3 x L4 = 12
Objective 4 – Responsiveness – Become the secondary care provider for the catchment population 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care
Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to provide realistic medium term financial plan 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position 5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behavior and performance. 5.6 If the Trust does not achieve authorisation as a Foundation Trust this would leave the Trust without local autonomy and an alternative organisational would be imposed leading to reduction in choice and focus on local health provision 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems
5
Target Risk Score
S3 x L3 = 9
Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood Proposed 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.
Current Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood S3 x L4 = 12
Target Risk Score
S3 x L2 = 6
Initial Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood
Target Risk Score
S4 x L4 = 16
S4 x L4 = 16
S4 x L2 = 8
Initial Risk Rating: Severity x Likelihood S5 x L3 = 15
Current Risk Rating: Severity x Likelihood S5 x L3 = 15
Target Risk Score
S5 x L3 = 15
S5 x L3 = 15
S3 x L2 = 6
S5 x L3 = 15
S4 x L3 = 12
S4 x L2 = 8
S5 x L3 = 15
S5 x L3 = 15
S4 x L3 = 12
S3 x L3 = 9
S3 x L3 = 9
S3 x L2 = 6
S4 x L2 = 8
S4 x L2 = 8
S4 x L1 = 4
S5 x L3 = 15
S4 x L3 = 12
S3 x L3 = 9
S4 x L2 = 8
An Associated University Hospital of Brighton and Sussex Medical School
2.3.
Key risks Strategic risks Identified
The BAF highlights the following 5 key red risks (including proposed increase) to the Trust objectives that have been identified at time of updating the framework. These are: Risk description 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position
Current rating
Target risk score
S5 x L3 = 15
S5 x L2 =10
S4 x L4 = 16
S4 x L2 = 8
S5 x L3 = 15 S5 x L3 = 15
S4 x L2 = 8 S3 x L2 = 6
S5 x L3 = 15
S4 x L3 =12
3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are now 8 risks on the Trust significant risk register. Each is in date and has mitigating actions to reduce the level of risk to an acceptable level. The Executive Committee reviewed and agreed the proposal to two de-escalate one risk from the significant risk register to align with the board assurance framework. Specifically the risk related to the current local availability of qualified nurses and pressures on temporary staffing cost. 5.1 SRR Breakdown ID
Title
Initial Rating
Current Rating
Residual Rating
Next Review
1401
Risk of outbreak of viral gastroenteritis
16
15
9
30/06/2015
1491
Failure to maintain Emergency Department performance
20
16
6
30/06/2015
1501
Patient admitted to the right bed first time
9
15
6
30/06/2015
15
15
12
30/06/2015
15
15
9
30/06/2015
1604
1672
Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position Increasing Sickness Absence Levels with impact on day to day management and expenditure
6
An Associated University Hospital of Brighton and Sussex Medical School
ID
Title
Initial Rating
Current Rating
Residual Rating
Next Review
1678
Cancelled and / or delayed elective operations
15
15
6
13/08/2015
1688
Risk of potential overspending from operational pressures
16
16
12
22/07/2015
1696
Risk from agency overspending
16
16
9
22/07/2015
6. 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: Review the BAF and its alignment to strategic objectives Does the Board agree with the recorded controls and assurances Discuss and approve the changes to risks 2.2 and 3.1
Gillian Francis-Musanu Director of Corporate Affairs June 2015
Colin Pink Corporate Governance Manager
7
An Associated University Hospital of Brighton and Sussex Medical School
Risk Appetite â&#x20AC;&#x201C; 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber 8
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
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A Consistently meet national patient safety standards in all specialties and across divisions 1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.
Director responsible
Chief Nurse
Initial Risk Current rating
S4 x L3 = 12 S4 x L2 = 8
Target risk score
S4 x L1 = 4
Linked to Risk
1009,1055
Controls in place (to manage the risk)
Gaps in Control
1. Clinical teams 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. Matron on site 7 days a week 6. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7. Nursing staffing levels with daily real-time escalation 8. Incident reporting policy to be reviewed to include recent structural changes 9. Ward safety boards 10. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 11. Training undertaken for clinical staff in the assessment and management of patients at risk of falls 12. Patient falls strategic group meet monthly and report KPIs to the patient safety and clinical risk committee.
1) Lack of system to differentiate between Trust and community acquired cases of VTE
Potential Sources of Assurance (documented evidence of controls effectiveness)
Actual Assurances: Positive (+) or Negative (-)
1) 2)
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 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends (+) 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 (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 13/14 (+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year
External reports and visits both scheduled and unscheduled Patient tracking and analysis (Whiteboard project)
Page 2
(+) Resource focus on patient safety and falls (+) Evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Established links with falls team within community Negative (-) Never events incidence low (3 in last 12 Months ??, low harm) (-) NRLS reporting
Gaps in assurance
Assurance Level gained: RAG
Ability to benchmark in real time
Mitigating actions underway
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.
1) Develop Emergency Department falls pathway 2) Develop system to differentiate between Trust and community acquired cases of VTE
Update by
Page 3
FA 12/06/15
Date discussed at board
1) 2)
May 2015 July 2015
To be discussed at June Board
Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care
Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). This presentation is done in departmental meetings with IC doctor and Nurse attendance. This increases learning in the clinical team when compared to consultant attendance at IC meeting. 7) Discussion group being setup to discuss any lapses of care in C. diff cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place â&#x20AC;&#x201C; ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci. Potential Sources of Assurance (documented evidence of controls effectiveness) 1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff cases
Director responsible
Medical Director
Initial Risk
S3 x L4 = 12
Current rating
S3 x L4 = 12
S3 x L3 = 9 Target risk score 1049, 1050, 1401, 1514 Linked to Risk Gaps in Control 1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)
Actual Assurances: Positive (+) or Negative (-) Positive (+)Incidence of CDI 2014/15 (-)0 MRSA BSI 2014/15 (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated April 2015) (+) Recent CQC inspection highlighted improvements in MRSA screening (+)TDA visit inspecting controls and procedures (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance
Negative (-)Period of increased incidence of CDI Godstone ward, typing suggests cross infection (-)Period of increased incidence of CDI Meadvale ward, typing suggests cross infection Page 4
Gaps in assurance Extensive auditing and monitoring in place. Trust position known
Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C.diff Antibiotics (Sidoxamicin and Chloramphenicol IV) DH 11/06/15 Update by Date discussed at Board
Page 5
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2015/16 3) Ongoing 4) Under review To be discussed at June Board
Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
2.A Achieve the best possible clinical outcomes for our patients
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties
Director responsible
Medical Director
Initial Risk Current rating
S3 x L3 = 9 S3 x L2 = 6
Target risk score
S3 x L1 = 3
Linked to Risk
1460
Controls in place (to manage the risk) 1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads
Gaps in Control 1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released
Potential Sources of Assurance (documented evidence of controls effectiveness) 1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic code
Actual Assurances: Positive (+) or Negative (-) Positive (+) CQC Chief Inspector of Hospitals Report
(+) CQC risk rating, lowest possible (+)The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 198
Gaps in assurance Ability to benchmark in real time National Safety Dashboard to be implemented when available Mitigating actions underway 1) Development of ward based performance dashboards Update by Page 6
DH 11/06/15
Date discussed at Board
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 01/04/2015 To be discussed at June Board
Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.B Deliver services differently to meet need of patients, the local health economy and the Trust 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards 5) Establish Frailty Service in community staffed with HCE Consultants to reduce need for readmission 6) White board project facilitates agreement and work towards agreed date of discharge. Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle
Director responsible
Chief Operating Officer
Initial Risk
S5 x L3 = 15
Current rating
S5 x L3 = 15
Target risk score
S5 x L2 = 10
Linked to Risk
1221, 1480, 1601, 1405, 1547
Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Still to agree 15/16 contract with BICS 3) Repatriation of tertiary services effected and influenced by external factors 4) Medical Division plans to reduce length of stay (business case in early stages of preparation)
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 (+) Initial work on repatriating Cardiology Lab (8 wk pause to support winter pressures) (+) Extended theatre working days Crawley (20% increase capacity)
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 (8% vs 2% plan) Gaps in assurance Assurance Level gained: RAG Agreed activity modelling across SECNational policy decisions and effective of general election Mitigating actions underway 1) CQC Action plan (Outpatient Action Plan) 2) Theatre efficiency action plan 3) Breaking the cycle and reducing LOS action plan 4) Implement transformation team PB 12/06/2015 Update by Page 7
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Ongoing 2)End of quarter 1 3)End of quarter 2 4)End of quarter 2 To be discussed at June Board
Objective 3 - Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Priority ID and reference
3.B Deliver high quality care around the individual needs of each patient
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits.
Controls in place (to manage the risk) 1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Workforce subcommittee, Exec Committee and the Board 2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level 3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken 4. PMO in place to monitor agency use and progress of the five related work streams a. E-roster- migration to v10 approved b. Nursing recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored through Agency PMO, Workforce subcommittee and divisional team meetings c. Recruitment process reviewed, KPIs under development to provide assurance d. Bank recruitment in progress to reduce use of agency nursing staff e. International recruitment undertaken and nurses planned to commence July 15 f. Nursing temporary staffing utilization (hours/costs) monitoring using Base Usage Value reports monthly 5. SNCT/Birthrate Plus tool utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand 6. Pilot site for Department of health project analyzing agency spend across all clinical staff groups 7. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles 8. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 9. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients. 10. Strong relationship with HEKSS who place junior doctors in the organisation Page 8
Director responsible
Chief Nurse and Medical Director
Initial Risk Current rating
S3 x L4 = 12 S3 x L4 = 12
Target risk score Linked to Risk
S3 x L2 = 6 770, 1295, 1580, 1652
Gaps in Control 1. E-Roster system is not updated out of hours 2. Unfilled agency shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically within theatres 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision
Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Staff absence reports 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilistation and spend at PMO
Actual Assurances: Positive (+) or Negative (-) Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure 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. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3.
Implement e-roster upgrade and utilize core functionality (bank and messaging)
4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016 Update by
Page 9
FA 12/06/2015 and DH 11/06/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016 To be discussed at June Board
4 - Responsive to peopleâ&#x20AC;&#x2122;s needs â&#x20AC;&#x201C; Become the secondary care provider of choice for the catchment population Priority ID and reference
4.A.1 Deliver access standards
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care
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
Controls in place (to manage the risk) 1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity 10) 10th Theatre opened (May 15)
Gaps in Control 1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge
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.
Actual Assurances: Positive (+) or Negative (-)
Gaps in assurance Winter plans and local health economy position going into winter months Page 10
Positive (+) ED Standard delivered March, April and May 2015 (+) Maintaining top 20% performance (+) 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 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care (-)Unplanned increase in >1 LOS emergency admission patients (8% vs 2% plan) Assurance Level gained: RAG
Mitigating actions underway 1) 2)
Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance Refresh winter capacity plans based on assessment of Q1 activity
Update by
Page 11
PB 12/06/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) July 2015 2) June 2015 To be discussed at June Board
Objective 5 – Well Led Priority ID and reference
5.A Live within our means to remain financially sustainable
Key Action for 2014/15 objectives and description of any potential significant risk to this priority
5.1 Failure to deliver income plan
Director responsible
Chief Finance Officer
Initial Risk Current rating
S5 x L3 = 15 S5 x L3 = 15
Target risk score Linked to Risk
S4 x L2 = 8 1479,1480,1601,1648,1649
Controls in place (to manage the risk)
Gaps in Control
1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – at time of writing NHSE is not agreed and CCG contracts cannot be signed until the national contract variation for the Trust’s agreed tariff (ETO) is issued). 3) Contract management process in place (this operated effectively in 2014/15). 4) Financial reporting, including forecast scenarios presented to Board 5) Chief Officer meeting (which includes coordination of has been in place since Nov 2014. Its structures are still embedding, but reporting lines from System Resilience Groups (SRGs) are now established.
1) Signed Contracts not yet in place – NHSE is not agreed. 2) Risk share agreement (for emergency activity) with Sussex CCGs and Sussex Community Trust not yet agreed (due to be in place by Q1) 3) Chief Officer meeting – confirmation needed of the extent of embedding of structures and reporting. 4) CCG plans make assumptions on activity reductions that are only partly adjusted in Contract plans – to be reviewed at Q1; 5) Activity growth above CCG assumptions, including market share, is referred to as an assumption in Activity Planning schedule – activity plans to be reviewed and amended at Q1; 6) Some actions long stopped to Q1 to resolve – this includes payment for safer staffing, ambulatory attendance pricing and payment for hospital @ home services. 7) NHS England instruction for CCGs to increase volume of activity in plans not yet communicated by CCGs
Potential Sources of Assurance (documented evidence of controls effectiveness)
Actual Assurances: Positive (+) or Negative (-)
1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN 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 and reporting from health system management (e.g.: System Resilience Groups and Chief Officer Meetings) 5) Output of Contract Management Process .
Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions Negative (-) Risk over income growth assumptions. (-) Adverse income variance at M02 (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16.
Gaps in assurance Red at start of year because of level of risk and ongoing process to complete contractual commitments.
Page 12
Assurance Level gained: RAG
Mitigating actions underway 1) Complete negotiation with NHS England over specialist commissioning contract 2) Receive ETO Contract Variation and sign contracts (Sussex is now done â&#x20AC;&#x201C; a separate issue prevents signing) â&#x20AC;&#x201C; Surrey is in progress) 3) Complete all contractual commitments by long-stop dates (end date - Q1 reconciliation in July); 4) Revised elective income plan being prepared, with revised cost schedule before M03. 5) Specific action around dermatology, diabetes and cardiology where there is underdelivery PS 18/06/15 Update by Date discussed at Board
Page 13
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable.
To be discussed at June Board
Objective 5 – Well Led Priority ID and reference
5.A Live within our means to remain financially sustainable
Key Action for 2014/15 objectives and description of any potential significant risk to this priority
5. 2 Failure to stop divisional overspending against budget
Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board
Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.
Director responsible
Chief Finance Officer
Initial Risk Current rating
S5 x L3 = 15 S5 x L3 = 15
S3 x L2 = 6 Target risk score 1602, 1663 Linked to Risk Gaps in Control 1) Management of increased levels of emergency activity subject to review; 2) Investment in incremental changes to meet additional activity demand subject to review. 3) At April 2015 not all cost improvement plans are included in Divisional budgets and red rated savings have not been mitigated. 4) Slippage on medical agency CIP Actual Assurances: Positive (+) or Negative (-) Positive (+) 2015/16 budgets were set based on the M06 2015/16 FOT and there will be a quarterly adjustment for activity changes;. (+) Overspending in 2014/15 ended the year within overall forecast tolerance (noting as below that some Divisions carry risk) (+) Contingency reserve of £1.9m established and no commitments for investment to be made until Q1 is complete (+) red rated CIPs mitigated to £0.7m Negative (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency cost remains high (-) At M02 there is overspending (reducing in surgery, but not reducing in Medicine) and adverse delivery on the medical agency CIP
Gaps in assurance Red at start of year because of level of risk. Mitigating actions underway 1) PMO/Performance structure continues - Medical Division required to produce a recovery plan by 29 June – single actions with other Divisions 2) Controls are being exercised in divisions and centrally – vacancy restriction nad non clinical procurement. 3) Only essential spend to be authorized from contingency and position reviewed at Q1. PS 18/06/15 Update by Date discussed at Board
Page 14
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable
To be discussed at June Board
Objective 5 – Well Led Priority ID and reference
5.A Live within our means to remain financially sustainable
Key Action for 2014/15 objectives and description of any potential significant risk to this priority
5. 3 Unable to deliver medium term financial plan
Director responsible
Chief Finance Officer
Initial Risk Current rating
S5 x L3 = 15 S4 x L3 = 12
S4 x L2 = 8 Target risk score 1603 Linked to Risk Gaps in Control 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Lack of alignment between CCG activity plans and actual performance. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider NHS finance regime. 4) Risk over capacity from other operational pressures 5) Process being initiated (M02) with health system partners to provide overall health system financial view (Chief Officer’s Finance Sub-Group)
Controls in place (to manage the risk) 1) Items referred to in 5.A.1 and 5.A.2 above 2) V7.0 long term financial model and integrated business plan completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015 4) Board to Board held with the TDA in November 2014, Monitor assessment now in train culminating in Monitor Board to Board in June 2015. 5) Cost improvement plan process in place (including PMO structure) 6) Elective/outpatient activity growth and income plan in place – capacity created 7) Contracts with CCGs allow for payment for “over performance” Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Delivery of 2014/15 financial position and delivery of Positive 2015/16 financial plan (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) 2) Delivery of long term financial model and integrated (+) Technically the LTFM passes muster – issues are over planning assumptions. business plan documentation, and delivery against them (+) LTFM submitted describes viable position (+) Monitor “pre-assessment” review has proceeded to full assessment and downside completed (+) Downside mitigations are outlined, and this includes uncomplicated items (like applying contingency and reserves) Negative (-) alignment with CCG plans is not complete (Sussex indicative activity plan is complete but includes QIPP and financial balancing items, Surrey not yet validated, NHS E not received). There are already differences between actual performance on activity and CCG plans. Overall, on basis of current assumptions and delivery of LTFM, RAG remains amber as mitigations are sufficient to cover risk (hence impact has been reduced to 4). Assurance RAG amber. Gaps in assurance Assurance Level gained: RAG Final review of LTFM by Monitor and extent of downside scenario Mitigating actions underway
Please see items above. Additional CIP contingency is identified, more is being sought . Update by Page 15
PS 18/06/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable To be discussed at June Board
Objective 5 – Well Led Priority ID and reference
5.A Live within our means to remain financially sustainable
Key Action for 2014/15 objectives and description of any potential significant risk to this priority
5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position
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
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)
Gaps in Control 1) No agreement on medium term solution to liquidity – being pursued during April 2015.
Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance 2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board 3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)
Actual Assurances: Positive (+) or Negative (-) Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations Negative (-) no confirmed additional cash to resolve underlying liquidity problem – likely to be resolved in FT application process – potentially through a working capital loan (-) 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. Assurance RAG "amber" - 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. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action currently, coupled with actions to maintain service income and Actions proceeding to timetable manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses. PS 18/06/15 To be discussed at June Board Update by Date discussed at Board
Page 16
Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5.E We are an organization that is clinically led and managerially enabled. Key Action for 2015/16 objectives 5.5 There is a risk we will fail to realize the strategic benefits of and description of any potential having an Achievement Review significant risk to this priority Process that effectively monitors and influences behavior and performance. Controls in place (to manage the risk) Priority ID and reference
1) 2)
3) 4) 5) 6)
New Achievement Review Policy with implementation /communication and training plan. Personal objectives are being linked to Trust/Divisional and team objectives and the SMART methodology is being used to assess performance New AR process includes assessment of Behaviours against Trust value Personal Development Plans as part of AR identify development needs 2) Training Need’s Analysis at Divisional level extrapolated to Trust level inform strategic planning of development priorities. AR Task and Finish group continues to embed new process and implement for medical staff during 2015/16
Director responsible
Director of Human Resources
Initial Risk Current rating
S3 x L3 = 9 S3 x L3 = 9
Target risk score
S3 x L2 = 6
Linked to Risk
910, 1674
Gaps in Control 1) 2) 3) 4)
new system yet to reap full benefits activity levels in the Trust affecting capacity for compliance change to annual timetable with delivery in first part of financial year yet to embed an agreed model for medical and dental Achievement Review yet to be agreed.
Potential Sources of Assurance (documented evidence of controls effectiveness)
Actual Assurances: Positive (+) or Negative (-)
1) AR review audits focusing on objective setting and linked to quality of services 2) staff survey results 3) Feedback from junior doctors 4) Monthly reporting against AR completion timetable at Divisional and Trust level at ECQR&CC – Workforce Committee and Finance Investment and Workforce Committee through 5) Development of behavior based recruitment systems will support the long term strategic implementation of achievement reviews.
Positive (+) Task and Finish group successful launch of new policy and process slides and comms plan for launch at ESH and Crawley (+) development of toolkit and intranet resources (+)TNA update to August 2015 Finance Investment and Workforce Committee (+) recent audit personal quality objectives in appraisals (+) 2014 staff survey results for quality of appraisals puts us in the top 20% of Trusts Negative (-) 2014 staff survey Q on appraisal in last 12 months is in bottom 20% (-) previous compliance rates for Appraisal
Gaps in assurance
Assurance Level gained: RAG
New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s
Mitigating actions underway 1) 2) 3) 4)
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.
continue with T&F weekly meetings to review compliance and active feedback on toolkit and resources series of training courses to support implementation commenced and will run throughout 2015/16 T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the same across all staff groups Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors
Update by
Page 17
YP 22/05/15
Date discussed at Board
1) Ongoing 2) 31 March 2016 3) 30 October 2015 4)Complete and ongoing
To be discussed at June Board
Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference
5.G.2 We are a well governed organisation
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
5.6 If the Trust does not achieve authorisation as a Foundation Trust this would leave the Trust without local autonomy and an alternative organisational would be imposed leading to reduction in choice and focus on local health provision.
Controls in place (to manage the risk) 1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer Potential Sources of Assurance (documented evidence of controls effectiveness) 1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of Monitor information requests
Director responsible
Director of Corporate Affairs
Initial Risk Current rating
S4 x L2 = 8 S4 x L2 = 8
Target risk score
S4 x L1 = 4
Linked to Risk
1531
Gaps in Control No significant gaps in control identified
Actual Assurances: Positive (+) or Negative (-) Positive (+) Completion of Monitor pre-assessment phase (+) Monitor formal assessment underway (+) Election to the Council of Governors underway with 83 nominations (+) FT membership over 10,000 (+) Monitor Exe to Exe Challenge took place on 1st June 2015 (+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor confirmed further timescale for Board to Board in Nov 2015
Gaps in assurance Completion of Historical Due Diligence Mitigating actions underway 1) Elections to the Council of Governors started in May 2015 2) Monitor formal assessment in progress GFM 18/06/15 Update by Date discussed at Board
Page 18
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at June Board
Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems
Controls in place (to manage the risk) 1) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 2) Clinical Informatics Group 3) Clinical IT leads 4) EPR User Group now well established 5) Various project group (EPMA etc.) 6) Internal Audit 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) EPR Contract now signed and implementation underway with datacenter transfer scheduled for Mid-June 2015 10) Cerner Optimisation Group no win place 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
Director responsible
Director of Information and Facilities
Initial Risk
S5 x L3 = 15
Current rating
S4 x L3 = 12
Target risk score
S3 x L3 = 9
Linked to Risk
1428, 999, 1483
Gaps in Control 1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits
Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA) (+) EPR Contract signed and implementation commenced (+) Business Continuity System now in place (7/24) Negative (-) Major IT transition approaching – 2015 Assurance Level gained: RAG
Mitigating actions underway 1. Procurement of replacement EPR as national contract ending November 2015 - contract signed and implementation commenced 2. Establishment of Chief clinical Information Officer role 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
Update by
Page 19
IM 11/06/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. EPR Contract awarded October 2014 – preferred supplier now selected. 724 Go-live November 2014. PC Upgrade plan in-place, funded and business continuity almost complete Network review first draft now complete and action plan being prepared. To be discussed at June Board
5
Stat and mandatory training Policy Communications messages to staff, visitors and patients Norovirus leaflets Hand hygiene facilities Restricted visiting Use of signs at entrance to wards and bays, and red aprons to facilitate communication that an outbreak is taking place.
Failure to maintain Emergency Department performance
Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care
1) EDD Patient Pathway 2) Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt
20 4
4
16 As described on the board assurance framework
31/03/2014
Done date 06/12/2013 26/07/2013 26/07/2013 02/09/2013 11/02/2014 06/12/2013
Next Review
Due date 31/03/2013 30/06/2013 01/04/2013 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2015 22/09/2014 31/03/2014 30/03/2013 25/09/2013 31/01/2013
Residual Rating
Current Rating
Treatment Plan
15 Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&V Meeting with stakeholders regarding norovirus preparedness Audit of post-outbreak cleaning Pilot Patient Hand Hygiene Champions in Elderly Care Stakeholders meeting to discuss health system norovius planning Monitor use of ED risk assessment for patients admitted with diarrhoea and/or vomiting Monitor ward refurbishment programme Stakeholder norovirus study day Prepare options appraisal for emptying bays to facilitate terminal cleaning following outbreak
9
22/09/2014 21/05/2014 26/07/2013 25/09/2013 26/07/2013
30/06/2015
16 3
Current Likelihood
Current Consequence
Existing controls D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Surveillance of diarrhoea and vomiting Red aprons system
6
30/06/2015
Patient Safety Involvement of Service Users
Des Holden Paul Bostock
Medical Director's Office Operations
CORP CORP
23/01/2013 29/08/2013
Safety Responsiveness
1401 1491
Description Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures
Initial Rating
Risk Type
Risk Owner
Specialty
Directorate
Open Date
Monitoring Committee
ID
Title Risk of outbreak of viral gastroenteritis
1) Operational meeting three times a day chaired by Chief / Deputy Chief Operating Officer with clinical involvement from Matrons, Nurse Specialists and therapists 2) Daily Board rounds by clinical site team. Focusing on #NOF, Stoke and Medical outliers
93
5
15 As described on BAF Reviewing compliance to establish a key baseline target
27/06/2014 31/08/2015
31/03/2014
6
30/06/2015
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)
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 walk round 5) Additional screens arriving to reduce chance of mixed sex accommodation breaches during winter pressures 6) Matron on site 7 days a week
Risk of not being able to pay 1) Bi weekly review of forward cash flow by suppliers from in sufficient finance team and CFO cash due to poor liquidity 2) Cash and working capital policy and strategy problem 3) Annual cash plan linked to business plan and capital plan
15 5
3
12 As described on the BAF
01/09/2014
12
Increasing Sickness Absence Levels with impact on day to day management and expenditure
Continuing risk to the delivery of effective services and Trust Strategic Objectives caused by the resources required to actively manage the Trusts rising Sickness Absence rate and ensure safe services. This is also having a significant effect on the ability to control the Trusts temporary staffing costs.
Firstcare real time sickness absence monitoring reports and daily updates to managers inbox. Daily sit reps at ward level used to ensure shift by shift safe levels of service. eRostering software to manage rota's prospectively. Agency PMO.
15 3
5
31/03/2015 15 Actions described in the Agency PMO Focused interventions to support the Trust's 31/08/2015 Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)
9
Cancelled and / or delayed elective operations
Due to on-going operational pressures and increasing demand for emergency inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints.
1. Access Policy revised 2014 2. Weekly PTL / performance meetings to monitor progress. 3. Plans to increase elective surgery from May, with an additional theatre and ward approved and on track.
15 3
5
15 Manage the number of IPs booked on lists to 27/02/2015 20/06/2015 avoid cancellations 15/05/2015 Improve Theatre Utilisation Ring-fencing of Tandridge and Woodland Wards
30/06/2015
30/06/2015
Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position
09/02/2015
6
13/08/2015
Involvement of Service Users Financial Management Staffing - general
Yvonne Parker Natasha Hare
HR - Workforce Admissions / Waiting List
Service Access
Paul Bostock
Operations
CORP
CORP Finance - Fin. Management Paul Simpson CORP SURG
19/09/2013 18/06/2014 01/02/2015 23/03/2015
Responsiveness Executive Committee Workforce Responsiveness
1678
1672
1604
1501
Patient admitted to the right bed first time
1) Divisions to implement action plans and contingencies to control/or recover overspending. Specific action is required in all Divisions. 2) Divisions to take action to improve length of stay (being discussed at Execs in June) 3) Action on medically Ready for Discharge patients is being taken forward with health system partners.
16 4
4
16 As described on BAF
12
Risk from agency overspending
Risk of failure to achieve financial plan as a result of overspending on agency staff
CIP PMOs and nursing agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing).
16 4
4
16 As described on BAF
9
22/07/2015
Risk of failure to meet the Trusts financial plan due to overspending.
22/07/2015
Financial Management Financial Management
Paul Simpson
Finance - Fin. Management
CORP
CORP Finance - Fin. Management Paul Simpson
20/05/2015 11/06/2015
Executive Committee Executive Committee
1688 1696
Risk of potential overspending from operational pressures
TRUST BOARD IN PUBLIC
Date: 30.4.15 Agenda Item: 2.1
A Patient Story
REPORT TITLE:
Failure to anticipate or meet the expectations of a patient and her partner seen in out-patients Dr Des Holden (MD) and Fiona Allsop (Chief Nurse)
EXECUTIVE SPONSOR: REPORT AUTHOR (s):
Des Holden and Fiona Allsop
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Discussion (√) Purpose of Report: To inform the Board of a complaint in relation to out-patient (and in-patient) care and allow discussion of the factors the story highlights. In particular to discuss patient expectations, and how processes designed to promote a high standard of care can fail when adhered to too blindly. Summary of key issues Issues to be discussed fall under two main headings 1. Most of our out-patient clinics will feature both consultant and trainee medical staff. We inform patients they will be seen by the consultant or one of the team in their outpatient booking letter, but this does not always address or meet expectations. 2. Meeting with patients and their families can allow an opportunity to discuss other concerns that didn’t result in a complaint at the time. In this case the hand over between ward and hospital at home was inadequate, leading to worry and loss of confidence. Actions taken 1. We have acknowledged and apologised that for this patient our normal way of arranging an out-patient clinic appointment did not adequately meet her needs. 2. Further work with Linda Judge, and with the divisions will look at how we can get better patient feedback to allow us to design services which are more individualised and meet more patient’s needs. 3. The hospital at home team, held a team meeting for training purposes on the inpatient day in question and there was inadequate allowance for this or discussion and assurance provided by the ward staff. This is being fed back to both teams and a new pathway for lack of hospital at home coming to the ward will be developed. We have no evidence that this has happened since October 2014.
Recommendation: The Trust Board should discuss the patient story in terms both of the clinical care and of the handling of the complaint, having seen the external reviews and the PHSO report, to ensure it is satisfied that lessons have been learned since this patient’s episodes of care ended.
Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact
Relevant to regulation
Financial impact
nil
Patient Experience/Engagement
Poor experience for patient and family
Risk & Performance Management
Small risk if repeated (in patient element)
NHS Constitution/Equality & Diversity/Communication Attachment:
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT â&#x20AC;&#x201C; (25.6.15) Patient Story A woman attended the breast out-patient department in march having had a mastectomy in October 2014. She had received a letter to confirm appointment which said she would be seen by Miss Waheed (consultant) or a member of her team. Having sat in a crowded waiting area for a period of time her name was called and she was invited to go into a consulting room by a member of staff who held the door open for her. Through the door she could see a young male doctor who she did not recognise and had not met and she found that she could not go in to the room for her consultation. She asked to see the consultant and was told that the consultant list was full and her case had been assigned to the registrar. The patient refused to see the registrar. She was subsequently seen by Miss Waheed. Her husband subsequently came up to trust HQ and discussed the failings in care of our system with the trust Chair, who was in his office at the time. I met with the patient and her husband to talk through their experience. This was several weeks later. In the interim she had been contacted as part of a patient survey. When we met she described not just her out-patient experience but also an event in relation to her in-patient surgery in October. At her pre-operative assessment she had been told that after her operation, while on the ward, she would be reviewed by the hospital at home team who would provide her with a dressings pack and analgesia. She would then be discharged and would be seen by the team the following morning. After her surgery no one from the team came to see her. She described that the nursing staff did not know why that was but continued with the plan and discharged her to be seen the following day. She did not take the pack or the analgesia. The following day the patient and her husband needed to make several phone calls to the hospital at home team in order to get a late morning review. From the point of the review onwards they were very happy with care. Investigation suggested that a team day had happened on the day of the patientâ&#x20AC;&#x2122;s surgery and she and two other patients were not visited prior to discharge. It appears the ward did not know of the training day, no provision of a different pathway of care was implemented for the day and no deviation from the pathway of supported discharge appears to have been considered. The patient gave a very powerful description of her out-patient experience and said that her in-patient and discharge experience had never risen high enough on her concern list to prompt complaint. She described her inability on the day to enter a room with a young male member of staff who she did not know, having been mutilated. She said she would have been perfectly happy to see him if she had had a problem with another part of her body. The experience of the in-patient discharge has been fed back to the ward and the hospital at home service. We need to make more effort and do more work on what patients expect when they come to clinic. While it is often said that there is value in managing or even setting expectations early in a clinical pathway, we should set ourselves the challenge of relooking at our services from the viewpoint of our users to see what else we can do to understand anxiety and dissatisfaction and address these as much as possible. Dr. Des Holden Medical Director 19.6.2015
3 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 25 June 2015 Agenda Item: 2.2
REPORT TITLE:
Chief Nurse & Medical Director Report
EXECUTIVE SPONSOR:
Fiona Allsop, Chief Nurse Des Holden, Medical Director Fiona Allsop, Chief Nurse Des Holden, Medical Director
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval ()
Discussion (√)
Assurance (√)
Purpose of Report: To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues
The Safer Staffing report (May 2015 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. The recent suspension of the work NICE has undertaken to produce guidance to support the setting safer staffing levels for nursing and its impact within the Trust is outlined The recent advice received on Agency Spend is also outlined. Local Clinical Excellence Awards Update on Virginia Mason Programme Application
Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact
Yes
Financial impact
Yes
Patient Experience/Engagement
Yes
Risk & Performance Management
Yes
NHS Constitution/Equality & Diversity/Communication
Yes
Attachment: Chief Nursing Officerâ&#x20AC;&#x2122;s Safer Staffing Letter
2 An Associated University Hospital of Brighton and Sussex Medical School
Trust Board Report - – 25 June 2015 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, a summary of recent changes to National Institute for Clinical Excellence (NICE) guidance in relation to safer staffing for nursing and the impact of DH advice regarding agency staffing spend. 2.
Staffing Planned versus Actual – May 2015
Ward
Ward Specialty
Entries
RN Day
Abinger Ward
430 ‐ GERIATRIC MEDICINE
31
93.28% 98.33% 95.43% 100%
Acute Medical Unit
300 ‐ GENERAL MEDICINE
31
94.37% 99.54% 89.1%
91.94% 92.82% 96.77% 94.58%
Birthing Centre
501 ‐ OBSTETRICS
31
100%
N/A
Bletchingle y Ward
300 ‐ GENERAL MEDICINE
31
98.63% 99.35% 95.36% 97.58% 97.05% 98.57% 97.58%
Brockham Ward
502 ‐ GYNAECOLOGY
31
97.63% 96.77% 91.21% 86.89% 95.47% 91.87% 94.06%
100 ‐ GENERAL SURGERY
31
100%
98.39% 90.42% 75%
Buckland Ward
101 ‐ UROLOGY
31
95.6%
96.77% 91.3%
Burstow Ward
501 ‐ OBSTETRICS
31
83.08% 77.42% 82.12% 86.89% 82.76% 81.17% 82.04%
Capel Annex l Ward
100 ‐ GENERAL MEDICINE
31
98.91% 100%
430 ‐ GERIATRIC MEDICINE
31
97.16% 98.92% 98.39% 100%
Chaldon Ward
300 ‐ GENERAL MEDICINE
31
95.61% 94.83% 96.11% 98.45% 95.82% 96.73% 96.17%
Charlwood Ward
301 ‐ GASTROENTEROLOG Y
31
90.57% 96.77% 91.49% 98.39% 90.89% 97.58% 93.6%
Copthorne Ward
301 ‐ GASTROENTEROLOG Y
31
96.72% 95.16% 103.1% 100%
RN Night
NA Day
NA Night
Total Day
Total Night
Overall
94.41% 99.3%
96.26%
100%
N/A
100%
100%
100%
Brook Ward
96.8%
95.71% 96.33%
91.94% 94.26% 94.35% 94.29%
94.58% 100%
97.05% 100%
98.13%
Capel Ward
97.54% 99.35% 98.33%
98.93% 97.58% 98.39%
3 An Associated University Hospital of Brighton and Sussex Medical School
Coronary Care Unit
320 ‐ CARDIOLOGY
31
90.11% 100%
Delivery Suite
501 ‐ OBSTETRICS
31
93.17% 90.32% 94.04% 90.32% 93.39% 90.32% 91.86%
Discharge Lounge
300 ‐ GENERAL MEDICINE
31
87.95% 96.77% 94.86% 100%
91.23% 98.39% 93.83%
Godstone Ward (Haem)
303 ‐ CLINICAL HAEMATOLOGY
31
99.44% 100%
N/A
99.44% 100%
99.72%
Godstone 300 ‐ GENERAL Ward (Med) MEDICINE
31
95.76% 100%
81.52% 100%
89.86% 100%
94.28%
Holmwood Ward
320 ‐ CARDIOLOGY
31
96.59% 100%
93.55% 100%
95.72% 100%
97.28%
ITU/HDU
192 ‐ CRITICAL CARE MEDICINE
31
97.75% 98.5%
75.92% 93.33% 94.69% 98.14% 96.35%
110 ‐ TRAUMA & ORTHOPAEDICS
31
96.93% 100%
97.59% 98.39% 97.22% 99.19% 97.88%
Meadvale Ward
430 ‐ GERIATRIC MEDICINE
31
95.4%
97.55% 100%
Neonatal Unit
420 ‐ PAEDIATRICS
31
96.06% 97.56% 100%
Newdigate Ward
110 ‐ TRAUMA & ORTHOPAEDICS
31
98.74% 90.32% 90.96% 95.24% 95.43% 92.8%
Nutfield Ward
430 ‐ GERIATRIC MEDICINE
31
97.11% 98.39% 94.37% 100%
96.09% 99.19% 97.11%
Outwood Ward
420 ‐ PAEDIATRICS
31
97.03% 100%
88.84% 90%
96.07% 98.48% 97.13%
Rusper Ward
501 ‐ OBSTETRICS
31
100%
N/A
100%
Surgical 100 ‐ GENERAL Assessment SURGERY Unit
31
95.97% 95.16% 74.19% 85.48% 91.61% 90.32% 91.04%
Tandridge Ward
300 ‐ GENERAL SURGERY
31
95.6%
Tilgate Annex
100 ‐ GENERAL MEDICINE
31
95.17% 95.7%
100%
Tilgate Ward
300 ‐ GENERAL MEDICINE
31
97.42% 100%
98.92% 100%
Woodland Ward
100 ‐ GENERAL SURGERY
31
92.26% 98.28% 95.65% 96.55% 93.52% 97.41% 94.77%
400%
100%
96.77% 100%
98.39%
N/A
Leigh Ward
100%
96.55% 100%
97.76%
93.75% 97.37% 96.26% 96.82%
94.53%
100%
N/A
100%
100%
Total
96.77% 90.36% 93.44% 93.34% 95.12% 93.98% 98.41% 96.97% 96.79% 96.9% 97.98% 100%
98.66%
95.75% 97.13% 93.77% 95.88% 95.07% 96.66% 95.72%
4 An Associated University Hospital of Brighton and Sussex Medical School
Commentary The Trust has delivered planned versus actual staffing profile for May. The variance on Burstow Ward is due to staffing shortfalls in the maternity service and has been actively managed by the matrons with no adverse outcomes in relation to clinical care. The maternity service has recruited five new staff members and will continue to recruit into July. Progress against planned safer staffing uplift
Changes to NICE safer staffing work It has been announced that, with immediate effect, the current and planned nursing staffing guidance work being undertaken by NICE has been suspended. This is to allow the work to be reviewed to develop a broader multidisciplinary approach to staffing models and to reflect other factors in determining staffing. The existing guidance regarding acute adult inpatient wards and maternity is unaffected by these changes and remains in place. These changes are not expected to have a significant impact on staffing decisions already agreed within the Trust. A copy of the letter from Jane Cummings, Chief Nursing Officer for England is embedded for information.
CNO safe staffing letter 11 June 2015 s
Agency Staffing Spend On 2 June the Department of Health published a letter to Chief Executives outlining controls to manage agency spend. These controls include; A restriction on the use of ‘off framework’ agencies Use of a ceiling on the level of agency spend for organisations in receipt of financial support or in breach of their licence Introduction of a shift/day/hourly rate cap for agency staffing NHSE/Monitor/TDA sign off on consultancy contracts for professional services above £50,000 Expectations on the remuneration of Very Senior managers The Trust has undertaken significant work in relation to nursing agency spend over the last 12 months of which the Board is aware. Further advice and guidance is expected over the coming weeks and the Board will be kept appraised of any significant information and potential implications. Medical Director’s Report: 3.
Local Clinical Excellence awards
42 consultants applied for clinical excellence awards this year and the committee awarded 28 consultants one point, and four applicants two points. The monetary value of each point is approximately £2900 for individuals with 6 points or less and doubles for those with 7-9 points. Not all budget was awarded as the committee wished to award excellence rather than application per se.
5 An Associated University Hospital of Brighton and Sussex Medical School
4.
TDA Virginia Mason Development Programme.
The TDA received just under 70 applications from providers to take part in a development programme along the lines of the Virginia Mason Hospital in Seattle USA, known for its quality and safety of service through reduction in variation. We presented our application to the TDA as one of 10 finalists (see May trust board CN MD report) and at time of writing we are waiting to see whether we will receive a site visit (likely to be 6-8th July) by staff from TDA and from VMH as part of the process to select 5 winners. 5.
Recommendation
To note the report
Fiona Allsop Chief Nurse June 2015
Dr. Des Holden Medical Director
6 An Associated University Hospital of Brighton and Sussex Medical School
Gateway reference: 03587
Jane Cummings’ Office NHS England Skipton House, 6B7 80 London Road London SE1 6LH 11 June 2015 Dear Colleague, Ensuring the NHS is safely staffed I am writing to update you on the next steps on our shared work programme to improve the safety and quality of NHS staffing. But let me first tackle head on three misconceptions. First, nothing we are doing changes the NICE guidance that has already been issued. ‘Safe staffing for nursing in adult inpatient wards in acute hospitals’ (July 2014) and ‘Safe Midwife Staffing in Maternity Settings’ (January 2015) are important parts of our approach to ensuring safe and high quality care. The next phase of the NHS’ role in this area is focusing on new care areas and will not involve going back on the guidance already published. Second, nothing in this work programme in any way challenges or contradicts the CQC’s important role to inspect and rate hospitals and indeed providers across health and adult social care. They make their own judgements on what is or is not safe, and are free to form their own independent judgements about safety and safe staffing. Finally, this is not about saving money; more about using the money we have as efficiently and effectively as possible. I would not suggest anything that would compromise patient safety. It would be against all I have repeatedly highlighted since I became CNO and is fundamental to our profession. It would also be a false economy – compromising safety just causes distress to patients, adds to the cost of care and a growing litigation bill. But to see NICE’s work as the totality of our focus on safe staffing is to miss the point. The ultimate outcome of good quality care is influenced by a far greater range of issues than how many nurses are on any particular shift, even though that is important. As we continue to develop our approach to safe staffing for those working in mental health, urgent and emergency care, learning disability and community services there are six things that will help to guide us. These are six reasons why we now need to take a different approach. First, we must take into account all the staff involved, not just nurses. In urgent and emergency care, as in other care settings, we need to look at doctors, paramedics
Gateway reference: 03587
and other Allied Health Professionals (AHPs) as well as nurses. As the NHS Five Year Forward View acknowledges, healthcare is increasingly delivered by a multiprofessional workforce â&#x20AC;&#x201C; for example, nurses, care assistants, psychiatrists, psychologists, activity leaders and AHPs are all crucial to a well-run mental health service. Getting the right mix of staff in these multi-disciplinary teams is vital. Second, many care settings are not in a hospital and span organisational boundaries. It would therefore be inappropriate to develop a staffing structure for one type of organisation and then expect it to span multiple institutions and roles. Third, we must remember that this is not just about filling rotas or looking only at numbers or input measures. It is also about how much time nurses spend with or supporting patients, their families and carers and what the outcomes for those people are. Fourth, as you know we are working to develop new ways of providing care. Just as there is no one-size fits all approach for these new models of care, there will be no identikit approach to the mix of staff we need. The number of staff caring for patients on an orthopaedic ward in Cornwall or Doncaster is a good guide to how safe those wards are â&#x20AC;&#x201C; we are not changing the current NICE guidance in acute hospitals for this reason. But the different settings for other types of care mean there is no one right answer. Fifth, underpinning these will be the work outlined in my letter of 4 June, which sets out the need for career progression for non-registered staff, nurse retention and flexible working. Sixth, we must recognise that, unlike in acute wards, there is as yet little research or evidence into what safe staffing looks like for other care settings. We need to find a new approach to testing what is right, which includes looking at what evidence exists, commissioning new research and national and international best practice. I believe if we use these principles it will guide us in our planned next steps. We will continue to use NICE for commissioning evidence reviews where appropriate and also bring in other independent professionals and experts to guide us. This will include professional organisations such as the RCN, RCM, QNI, AHP organisations and medical Royal Colleges. The Mental Health Taskforce has agreed to lead the work on establishing what is the right balance of staff in the many settings treating those with mental illness. They will report back by the end of the year and take into account the mental health staffing guidance that has recently been developed with colleagues from the Mental Health Directors of Nursing Network and commissioned through the Compassion in Practice Strategy. NICE has already done some excellent work on nurse staffing in urgent and emergency care. We will ask the new Urgent and Emergency Care Vanguards to build on this guidance, developing it to take into account other professionals from clinical pharmacists to care assistants, junior doctors to GPs, paramedics to other AHPs whom we should include. This work will help to inform us about the
Gateway reference: 03587
appropriate balance of staff for the Emergency Department as well as alternative urgent care services of the future. For the areas of work such as learning disability and community care, we will establish work programmes to support the development of guidance by working with the new learning disability fast-track sites and the Five Year Forward View vanguards. We also recognise the importance of safe staffing in nursing homes, which collectively have more than two hundred thousand beds (more than in acute hospitals) and a high turnover of nursing staff. The National Quality Board and its members will help oversee this programme, working closely with the NHS TDA, Monitor, Health Education England, the Care Quality Commission and the Department of Health. At the Provider Directors of Nursing meeting we held on 9 June, it was clear that those present agreed with our approach and offered to support the work. I will confirm the governance and organisational arrangements in the next few weeks, ensuring that key stakeholders are involved. I look forward to working with you on this, and will ensure there is regular communication about our ongoing work as it progresses, together with opportunities for you to support and contribute. Many thanks.
Yours sincerely,
Jane Cummings Chief Nursing Officer England
TRUST BOARD IN PUBLIC
Date: 25 June 2015 Agenda Item: 2.3
REPORT TITLE:
Safer Staffing Review Paper
EXECUTIVE SPONSOR:
Fiona Allsop, Chief Nurse
REPORT AUTHOR:
Lynn Sanders, Corporate Matron
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Finance and Workforce Committee 23 June 2015 Nursing & Midwifery Professional Committee – 16 June 2015
Action Required: Approval (√)
Discussion (√)
Assurance (√)
Summary of Key Issues This report is a biannual review of nursing acuity and dependency on the acute inpatient adult wards in the Trust in line with the recommendation of the National Quality Board Paper relating to Safe Staffing published in November 2013. Key points to note are: The review of nurse staffing was undertaken utilising the Safer Nursing Care Tool, current establishments and nurse sensitive indicators Data was collected using an electronic tool to reduce variation and improve accuracy The results concluded that the nursing establishments were sufficient to provide safe effective care in the Trust.
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 SO5: Well - led
Corporate Impact Assessment: Legal and regulatory implications Financial implications Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication
Yes – failure to demonstrate appropriate level and skill mix of nursing staff will result in adverse regulatory and legal judgements Yes – impact on productivity, efficiency and safety resulting in increased costs Yes – potential impact resulting in poor patient experience and reputational risk for the Trust Yes – impact on productivity, efficiency and safety resulting in increased risk and poor performance Yes – potential failure to meet NHS Constitution
Attachments: Safer Nursing Care Tool
1
th
Trust Board Report – 25 June 2015 Safer Staffing Review - Update Executive Summary This report is a biannual review of nursing acuity and dependency on the acute inpatient adult wards in the Trust in line with the recommendation of the National Quality Board Paper relating to Safe Staffing published in November 2013. The Safer Nursing Care Tool (SNCT) was first used in November 2014 to determine a baseline of nursing staffing requirements of the Trust using an acuity and dependency tool. Professional judgement, minimum nurse to patient ratios and an approach to monitoring risk and incidents were also used for the staffing review alongside with the initial staffing tool (Hurst) calculations previously used in the Trust. Each ward area completed a daily submission into the database for a period of 28 days throughout April 2015. An electronic form was used to reduce the impact of subjectivity or ambiguity in the level of acuity or dependency the nurses allocated to their patients. The SNCT nurse staffing multipliers were applied and daily recommended ward establishment were produced. These figures were averaged over the whole collection period to produce total ward establishment recommendations. These figures were then compared with the funded establishment to determine the variation between staffing funded and staffing recommended by the SNCT. Key points to note are:
Data was collected using an electronic tool to reduce variation and improve accuracy There is currently 3.5% positive variance to the safer staffing tools recommendations. Current establishment figures are based on the September 2015 profile which includes the agreed additional staffing to meet minimum ratios. Compliance of daily submission varied between areas but total compliance across whole site was 88% with a minimum data entry of 20 out of a possible 28 days The nurse staffing review carried out in the Trust over the last year has demonstrated that the funded nursing establishment, including the agreed uplift in the ward budgets in September 2015 to meet night ratios, for the Trust as a whole is sufficient to meet the acuity and dependency needs of the patients. The Trust is currently managing a significant amount of nursing vacancies covered by bank and agency staff, this could also affect the nurse sensitive indicators and the team dynamics within any ward environment
2
Introduction The Safer Nursing Care Tool (SNCT) was first used in November 2014 to determine a baseline of nursing staffing requirements of the Trust using an acuity and dependency tool. Professional judgement, minimum nurse to patient ratios and an approach to monitoring risk and incidents were also used for the staffing review alongside with the initial staffing tool (Hurst) calculations previously used in the Trust. It was recognised that the method and quality of the data obtained was not consistent and therefore no definitive recommendations about staffing needs based on this study followed. Method Following a review of the staffing acuity paper in 2014 an alternative method to capture patient details was designed in order to improve validity of the data and to ensure uniformity of assessments. An electronic form was developed to allow entry of basic patient information, which would then have the patient acuity and dependency categories applied depending on the parameters entered. This reduced the impact of subjectivity or ambiguity in the level of acuity or dependency the nurses allocated to their patients. Each ward area completed a daily submission into the database for a period of 28 days throughout April 2015. The SNCT nurse staffing multipliers were applied to the data entry details on the database, and daily recommended ward establishment were produced. These figures were averaged over the whole collection period to produce total ward establishment recommendations. These figures when compared with the funded establishment gives a comparison between staffing funded and staffing recommended The SNCT recommended figures are based on a 22% uplift being included. Currently the ward budgets have an 18% allowance included in the establishment, and the remaining 4% held centrally in the divisions. In order for a true comparison to be made, the current ward establishment has been elevated to incorporate 22% uplift. Table 1. Critical Care Patient Classification (Comprehensive Critical Care, DH 2000). Level 0 Level 1a Level 1b Level 2
Level 3
Patient requires hospitalisation Needs met by provision of normal ward care Acutely ill patients requiring intervention or those who are UNSTABLE with a GREATER POTENTIAL to deteriorate. Patients who are in a STABLE condition but are dependent on nursing care to meet most or all of the activities of daily living. May be managed within clearly identified, designated beds, resources with the required expertise and staffing level OR may require transfer to a dedicated Level 2 facility /unit Patients needing advanced respiratory support and/or therapeutic support of multiple organs.
3
Table 2. Results summary showing indicators, current and recommended establishments (including 22% uplift).
Apr‐15 Abinger Bletchingley
Indicators Complaints FFT (Target 90% of a 30% (number in 12 months) response rate – shown in green) Beds 23 75 8 40 95.1 6
Establishments inc 22% Current WTE Acuity Study Indicative WTE Balance WTE
Safety Therm (%)
RN Ratio (% Target 65)
86.6
59
31.89
31.08
‐0.81
97.1
63
63.79
54.55
‐9.24
Medicine
Brockham
20
92.5
5
98.4
61
25.84
22.95
‐2.89
Surgery
Brook
11
100
2
98.6
80
12.8
12.11
‐0.69
WACH
Buckland
21
97.7
4
97.4
67
28.27
27.11
‐1.16
Cancer
Capel Annex
21
94.7
0
95.2
55
28.8
27.87
‐0.93
Capel
20
96.9
4
95.4
65
29.78
26.10
‐3.68
Chaldon
28
100
1
98.6
57
37.67
38.68
1.01
Charlwood
20
70
7
96.5
72
26.19
26.08
‐0.11
Copthorne
20
92.9
8
97.5
72
26.19
21.92
‐4.27
Godstone (Stroke& Med)
28
90.5
0
97.1
71
34.51
39.32
4.81
Godstone (Haem)
5
100
0
93.3
76
11
8.17
‐2.83
Holmwood &CCU
28+8
95
8
95
68
50.94
44.92
‐6.02
Leigh
28
100
7
96.9
62
34.54
34.40
‐0.14
Meadvale
23
92.9
7
91.5
59
32.01
31.88
‐0.13
Newdigate
28
93.3
6
96
62
34.54
39.71
5.17
Nutfield
28
100
4
89.6
58
31.42
39.59
8.17
Tilgate Annex
21
94.1
0
95.2
58
31.42
30.78
‐0.64
Tilgate
26
100
6
93.8
70
34.51
31.61
‐2.90
Woodland
24
98.1
11
99.4
64
33.49
28.76
‐4.73
65
639.6
617.59
‐22.01
Totals
4
Notes: There is currently 3.5% positive variance to the safer staffing tools recommendations.
Current establishment figures are based on the September 2015 profile which includes the agreed additional staffing to meet minimum ratios.
Compliance of daily submission varied between areas but total compliance across whole site was 88% with a minimum data entry of 20 out of a possible 28 days
Brockham and Buckland current staffing excludes nursing cover for GAU and Urology clinic based on the ward. The acuity study includes activity with ward attenders out of hours. . Godstone Haematology ward uplift is funded at 20% instead of 22% across other areas.
Godstone Medical beds and Stroke beds are combined in all elements
Chaldon staffing excludes the stroke bleep holder establishment
Family and Friends score, safety thermometer are based on a year’s average and complaints are based on a year’s total. Bletchingly, Tilgate annex and Capel Annex have been open for a part year and therefore the scores are based on the months available.
An error occurred with the data submitted from Holmwood ward which resulted in no acuity figures retrieved from the database. Following discussion with the Divisional Chief Nurse and Matron, the possibility of a smaller collection sample obtained after the end of the original collection period was not recommended as this may not produce a representative picture of patient acuity over a longer period. The professional judgement of the staffing requirements is entered in place of acuity study results. Tandridge ward’s activity was variable during the data collection period. The tool is designed to measure inpatient activity only, and during the transition period of the ward from medicine to surgery, the volume of patients admitted for day surgery procedures varied from 6-12 at a given time. It is predominantly staffed using temporary nurses and the staff ratio changed to reflect the need on a daily basis. For this reason the unit was excluded from the study at this time as no accurate average activity was possible. Table 3. Categories of patients across Trust during April 2015 Patient Acuity and Dependancy Category
level 0
3% 48%
44%
level 1a level 1b
5%
level 2
5
Table 4. Comparison between recommended tool establishment, funded establishment and actual shifts covered. (Establishment data from Sept 2015 predicted Finance Budget Statements) Whole site Tool Recommendations Funded Establishment Tool Recommendations Funded Establishment
618 WTE 645 WTE 506 WTE 528 WTE
Including 22% uplift Baseline‐ no uplift
Medicine Tool Recommendations Funded Establishment Tool Recommendations Funded Establishment Surgery
396 WTE 407 WTE 325 WTE 333 WTE
Tool Recommendations Funded Establishment Tool Recommendations Funded Establishment WACH
190 WTE 196WTE 156 WTE 160 WTE
Tool Recommendations Funded Establishment Tool Recommendations Funded Establishment Cancer
22.9 WTE 25.8 WTE 18.6WTE 21.2 WTE
Tool Recommendations Funded Establishment Tool Recommendations Funded Establishment
8.2 WTE 11 WTE 6.7 WTE 9.1 WTE
Including 22% uplift Baseline‐ no uplift
Including 22% uplift Baseline‐ no uplift
Including 22% uplift Baseline‐ no uplift
Including 22% uplift Baseline‐ no uplift
6
Table 5. Results graph showing staffing compliance within existing establishments of all grades of nursing staff as recorded daily on the staffing portal
Total Staffing Compliance April 2015 102.00% 100.00% 98.00% 96.00% 94.00%
Commentary Level 2 and 3 patients The safer staffing tool is designed for the ward nurses to self-assess the patients’ level of acuity and dependency using the categories described in Appendix 1, however a degree of experience and judgement is required when a patients level of care fluctuates and when the ward is supported for short periods of deterioration by the outreach team and MET team. In total 109 patients were categorised as reaching level 2 for a period of time during their inpatient stay. This list was validated by cross referencing patient details with the outreach team using the Ward Watcher database to confirm that a level 2 acuity had been reached, a number of patients levels were adjusted to level 1a as a result of reassessment. In addition assumptions were applied for the respiratory specialist areas, if any patient was receiving non-invasive ventilatory support from NIVVY or CPAP then although Critical Care Outreach were not involved due to the advanced skills of the qualified nursing team. There were no patients recorded as level 3 in the study areas. Patients reaching this level of care would require critical care support in a dedicated facility with advanced skills. Level 1a This category is used to describe patients who are acutely ill and unstable. There is a significant reduction in patients within this category using this method of data collection from the previous review. This tool captures the highest scoring category from the parameters entered by the ward nurses. It is likely that if a patient is acutely ill, then the dependency of nursing care is also higher, therefore this has triggered a 1b category. The effect on the multiplier results is not significant and this allows for additional time spent providing the nursing care required for all the needs. 7
Additional ward activity On Buckland (Urology) and Brockham (Gynaecology) ward activity includes short stay ward attenders. In part this workload is covered by additional staff allocated outside of the clinical ward establishment. At periods out of hours and additional excess activity is included within the nursing workload within the shift. The multipliers allow for a normal level of activity. Where the ward activity exceeds this, professional judgement needs to be applied. A simple way of calculating this would be - if there were 12 patients attending the ward each day and the intervention takes 1 hour of nursing time to complete this would require the following equation (assuming that the patient is Level 0) No. of patients x 1 hour ÷ 24 (to calculate the number per day) x 0.99 = Therefore 12 x 1 ÷ 24 = 0.5 x 0.99 = 0.49 WTE Buckland average additional ward activity in minutes = 74 minutes per day This calculates to an additional 0.04 WTE without uplift, 0.05 WTE with 22% uplift. Brockham additional ward activity=122 minutes per day This calculates to an additional 0.22 WTE without uplift, 0.27 WTE with 22% uplift. This additional workload has been included within the tool figures in the chart 1 Limitations/Issues
Environmental factors when planning safe staffing levels are essential in order to provide sufficient supervision and monitoring of patients especially out of hours. Although the tool has not reflected a high need within some areas, the layout or visibility of the patient areas result in a higher number of staffing requirements. For example Capel ward has proportionately more side rooms than most wards, and therefore will need additional staffing at night in order to ensure there is always a nurse present in the vicinity.
Where the bed number of the ward is below average, the minimum staffing number will not be lower than two trained nurses to ensure safe cover during patient care activities and rest breaks. This results in an apparent additional staff on duty when the data is reviewed.
The tool does not recognise wards with a high number of admissions and discharges where the nursing workload is increased due to tasks associated with these processes as there is a heavy burden on completion of assessment’s and paperwork when turnover of patients is increased. In addition, it is well recognised that when the clinical areas run with average bed occupancy over 85%, the ward area becomes less efficient.
Monitoring of Nurse Sensitive Indicators (NSI) such as infection rates, complaints, pressure ulcers and falls is recommended to ensure that staffing levels deliver the patient outcomes that are aimed to achieve. This study has not recorded these indicators alongside the data collected, but has cross referenced against ward performance information relating to Friends and Family Test, complaints and the safety thermometer.
8
Whilst the establishment of the nursing numbers required to deliver safe patient care is essential, it is also important to recognise the other roles needed to ensure that the workforce are well managed and developed. The management (non- clinical) hours within the Senior Sisters/Charge Nurses working pattern are not included in this data. They are rostered for 50% of their contracted hours to work in a clinical capacity, and the remainder is for administration and management tasks. Audits and workplace assessments are often carried out during clinical shifts, for example the safety thermometer and hand hygiene audits are performed regularly during the shifts by the nursing team on duty.
Professional Judgement The results of any staffing tool should be aligned with the professional judgement of the senior nursing team to ensure that the outcome results match the operational demands of the area. The factors considered include the experience and skills of the staffing team, geography of the ward layout, nurse sensitive indicators and acuity and dependency of the patient case mix within the clinical area. Following the publication of “Right Staffing” paper from the National Quality Board November 2013 and with the agreement of the Trust Board in March 2014, the qualified staffing ratio that this Trust is working towards is a 1:10 ratio at night and a 1:7 during the day, with long term objectives of achieving 1:7 on a 24 hour basis. In order for the initial ratios to be achieved, a number of posts have already been agreed for the divisions. These agreed posts are included in the ward establishments in table 2, although the staff to fill these posts are due to commence employment later in the year following the recent overseas recruitment. On a daily basis, the staffing for each area is assessed by the Matron, Divisional Chief Nurses, and overseen by the Deputy Chief Nurse to ensure that the skill mix and competencies meet the needs of the patient group. Next Steps Acuity and dependency data will be collected on a twice yearly basis in March and September going forward, to allow for seasonal variations. Data validation is now more robust, with the additional support of the critical care outreach team regarding the identification of level 2 patients within the ward area. This information will then form part of a staffing assessment paper which will be presented to the Board. Currently the data input is collected using the Trust intranet portal. This will not be supported in the future due to the redesign of the information service and therefore an alternative solution will need to be agreed. The future development of electronic clinical records will enable the utilisation of live acuity information which is based on vital signs, nursing assessments, clinical diagnosis and problems. This could be compared to staffing deployment on a shift basis and enable the operational team to manage staffing allocation to patient need on a day to day basis. Models are in development for the purpose of a staffing review in Acute Admissions and Emergency department settings, further discussion to be undertaken following their publication.
9
Conclusion The nurse staffing review carried out in the Trust over the last year has demonstrated that the funded nursing establishment, including the agreed uplift to be included in the ward budgets in September 2015 to meet night patient ratios, for the Trust as a whole is sufficient to meet the acuity and dependency needs of the patients. In addition it should be noted that the Trust is currently managing a significant amount of nursing vacancies covered by bank and agency staff, this could also affect the nurse sensitive indicators and the team dynamics within any ward environment. This is expected to improve following overseas recruitment. Fiona Allsop Chief Nurse June 2015
10
Appendix 1
11
12
Date: 25th June 2015
TRUST BOARD IN PUBLIC
Agenda Item: 2.4 Safety & Quality Committee Update
REPORT TITLE: 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 (ď&#x192;ź)
Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in June 2015. Recommendation: To note the report and gain assurance. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact
Compliance with CQC, MHRA and Audit Commission
Financial impact
Serious incidents often become claims
Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A
Reporting, investigation and learning from serious incidents informs risk management
Trust Board Report â&#x20AC;&#x201C; 25th June 2015 Safety and Quality Committee Chairâ&#x20AC;&#x2122;s Report The Safety and Quality Committee met on 4th June 2015. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Dashboard and Quality Report. ECQRM and CQRM The Committee noted the outcome of a review of ECQRM. The first of the two meetings each month will focus on in-depth discussion of four current topics. The second will consider reports from the five sub-committees and the minutes of divisional governance meetings. The Committee will be kept informed of issues identified for future discussion as well as the conclusions. The Committee sought assurance on a number of issues raised at the April meetings of ECQRM, including: the recent Never Event in Paediatrics; the management of sickness rates in Maternity; the recent preventable C-Diff case; and the robustness of the PIN system, which demonstrates fitness to practice of nursing staff. Quality Report and SQC Dashboard There was discussion of coding errors that suggested increased numbers of deaths in low risk diagnosis groups. Actions are underway to correct these, but there is a risk in the meantime that the original data may impact on the SCQ Intelligent Monitoring report. There was also discussion of the actions being taken to improve FFT response rates in Maternity, especially among community post-natal patients. Complaints The Committee discussed the Annual Complaints Report, and was assured that the Trust is not an outlier for complaints in the CQC Intelligent Monitoring report. The Health and Social Care Information Centre will produce an analysis at the end of Quarter 2 which should provide benchmarking data, and this will be reported to the Committee. There was discussion of areas for improvement in the handling of complaints. A complaints group has been established to improve the timeliness of responses, including acknowledgement rates, and this performance data will be reported quarterly to the Committee. In future a complaint about a failure in care will also be logged as an incident and investigated as such. The Committee gave its support to the work of a recently established group that aims to raise awareness of expected standards of behavior.
National In-Patient Survey The Committee received a presentation on the principal results of the national in-patient survey and the action plan being developed in response. Noting that the overall results were encouraging, the Committee focused its discussion on the operational and quality concerns about discharge raised in the survey. It was assured that a work to re-design discharge processes is being overseen by ECQRM, and the Committee recommended that there should be a report on this work to the Board in three monthsâ&#x20AC;&#x2122; time. The wider action plan relation to the survey will be overseen by the Patient Experience Committee, with updates included in the Quality Report.
.Draft Quality Account The Committee made comments and suggested amendments in the draft Quality Account and endorsed it for submission to the Board. This provides a thorough and positive report on the Trustâ&#x20AC;&#x2122;s performance over 2014/15 and includes a number of supportive comments from partners and stakeholders.
MRSA Screening Department of Health Screening Guidelines have been recently amended, and in light of this screening will now not normally take place for elective C-section patients and day case surgery and minor procedures. The Committee was assured that risks had been thoroughly evaluated and that patients at risk because of their immune status or the volume of their health care interventions would continue to be screened.
Clinical Audit The Committee welcomed a report on the Clinical Audit Plan for 2015/16, which showed a more focused programme with a much reduced number of planned audits, and a revised balance between national audits and those responding to the local incidents. The process has been tightened up and there is now a clear expectation that all audits will be registered and completed within the financial year. There is also an improved emphasis on shared learning. The programme will be overseen by the Clinical Effectiveness Committee. Virginia Mason Project The Committee was pleased to hear that the Trust had been placed on a shortlist of ten Trusts, of which five will be finally selected, to take part in the Virginia Mason project on safety. The next meeting of the Committee is on 2nd July at 2pm.
Richard Shaw Non-Executive Director Safety & Quality Committee Chair June 2015
Integrated Performance Report M02 â&#x20AC;&#x201C; May 2015
Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Fiona Alsop (Chief Nurse) Paul Simpson (Chief Financial Officer)
An University HospitalHospital of AnAssociated Associated University of Brighton andand Sussex Medical School School Brighton Sussex Medical
1
Performance – May 2015 Care Quality Commission • The Trust is not subject to any CQC enforcement action and continues to progress the improvement plans which followed the CQC Inspection in May 2014. Patient Safety • There were no Never Events in May 2015 and three SIs. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and three Trust acquired C-Diff case in May 2015. Clinical Effectiveness • The latest HSMR data shows overall Trust mortality is lower than expected for our patient group. • Maternity indicators continue to show expected performance. Access and Responsiveness • In May 2015, 96.0% of patients were admitted or discharged within the ED standard of 4 hours with no 12 hour trolley wait breaches. • All Cancer Access Standards were achieved except the 62 Day Referral to Treatment Standard. • In May 2015, all RTT standards were achieved at aggregate level. Patient Experience • The May adult ED FFT score of 95.3% is very similar to the April figure. The inpatient score has risen slightly to 95.1% (from 94.4% in April).
An Associated University Hospital of Brighton and Sussex Medical School 2
Performance – May 2015 Workforce • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Ward staffing levels are now published on the Trust’s external website at ward level. The Trust is also continuing to monitor temporary staffing usage on a weekly basis Finance • The Trust is marginally ahead of plan (£0.1m after rounding) at month 2 with a (£1.1)m deficit. However, there are clear pressures within the position, particularly from spend to manage emergency capacity.
Key Risks • The Significant Risk Register for the Trust includes six quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Increasing sickness absence levels and Cancelled and / or delayed elective operations.
Action: The Board are asked to note and accept this report Legal:
What are the legal considerations & implications linked to this item? Please name relevant Act
Regulation:
What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body.
Patient safety: Legal actions from unintentional harm to patients would normally be covered by negligence, an area of English tort (civil) law, providing the remedy of compensation. Case law is extensive. Criminal action could be pursued if investigation judged intentional harm and remedies will vary according to severity. Staff safety: The Health and Safety at Work Act etc 1974 may apply in respect of employee health and safety or non clinical risk to patients (usually reported under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995) 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. The health and safety executive regulates compliance with health and safety law. A raft of other regulators deal with safety of medicines, medical devices and other aspects.
An Associated University Hospital of Brighton and Sussex Medical School 3
Patient Safety Patient Safety Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
No of Never Events in month
0
0
1
0
0
0
0
0
0
0
1
1
0
No of medication errors causing Severe Harm or Death
0
1
0
0
0
0
0
0
0
0
0
0
0
Safety Thermometer - % of patients with harm free care (all harm)
92.8%
92.3%
90.8%
92.5%
92.0%
95.0%
93.0%
93.0%
93.0%
92.0%
92.0%
91.3%
93.5%
Safety Thermometer - % of patients with harm free care (new harm)
97.0%
97.3%
95.3%
96.1%
94.5%
98.0%
96.0%
97.0%
96.0%
95.0%
96.0%
95.9%
97.3%
Percentage of patients who have a VTE risk assessment
96%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
WHO Checklist Usage - % Compliance
100%
100%
100%
100%
100%
100%
98%
100%
96%
96%
100%
98%
100%
7
1
11
3
3
3
2
2
5
6
5
3
3
Serious Incidents - No per 1000 Bed Days
0.40
0.06
0.63
0.17
0.17
0.17
0.12
0.11
0.26
0.35
0.26
0.16
0.16
Percentage of Patient Safety Incidents causing Severe harm or Death
0.6%
0.4%
1.6%
0.6%
1.1%
0.7%
0.2%
0.2%
0.6%
0.7%
0.6%
0.2%
0.6%
0
0
0
0
0
0
1
0
1
1
0
0
0
Number of Sis
Number of overdue CAS and NPSA alerts
Trend
• Patient safety indicators continue to show expected levels of performance. • There were no Never Events in May 2015 and no medication errors causing severe harm or death in May 2015. • Safety Thermometer – performance returned to expected levels in May 2015. • Three SIs were declared in May 2015.
• A patient was assessed as requiring intravitreal ozurdex for central retinal vein occlusion. The TCI card for booking treatment was filed in the notes instead of being sent to the booking office. The delay in treatment has resulted in a deterioration of vision which is likely to be permanent.
An Associated University Hospital of Brighton and Sussex Medical School 4
Patient Safety • A patient presented in June 2014 with a history of green sticky mucus from her right lower lid since September 2013. She reported having had a lump excised at ESH in 2009. She was told it was a "fluid filled cyst". There were no old notes available at the time of the consultation. On examination, she had a large diverticulum in the lower fornix, which was assumed a complication from her previous surgery. At surgery in October 2014, a biopsy was performed, which was reported as a basal cell carcinoma. There was a note at the bottom of the histology report stating that she had previously had a BCC incompletely excised from the same lid in 2009. There is no evidence of follow up following this result. The patient required an exenteration (removal of eye and socket). • A patient was admitted to DSU for a diagnostic hysteroscopy with curettage and Mirena insertion. The patient was readmitted to ITU the following day with an unrecognised vaginal perforation. The patient had a perforated bowel which required laparotomy and bowel resection. Infection Control Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
MRSA BSI (incidences in month)
0
0
0
0
0
0
0
0
0
1
0
0
0
CDiff Incidences (in month)
0
2
2
3
0
1
4
0
2
6
1
1
3
MSSA
0
2
2
2
3
0
1
1
0
2
1
1
0
E-Coli
25
23
18
17
22
18
15
16
14
18
12
11
23
Trend
• There were no cases of MRSA in May 2015, and threes case of trust acquired C.diff. • The trust continues to enforce good antimicrobial practice with on-going audit and reporting of results to clinical teams. • In light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register: • Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3)
An Associated University Hospital of Brighton and Sussex Medical School 5
Clinical Effectiveness Mortality and Readmissions Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
HSMR (56 Monitored diagnoses - 12 Months)
94.0
90.1
89.0
90.1
92.5
90.1
88.9
89.6
90.8
92.7
Emergency readmissions within 30 days (PBR Rules)
6.6%
6.6%
7.2%
6.7%
6.9%
7.3%
7.1%
6.9%
6.6%
6.6%
Mar-15
Apr-15
6.4%
7.1%
May-15
Trend
• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
C Section Rate - Emergency
15%
14%
17%
14%
17%
12%
14%
17%
18%
16%
17%
13%
17%
C Section Rate - Elective
10%
11%
10%
13%
9%
12%
13%
11%
7%
11%
8%
11%
9%
0
0
0
0
0
0
0
0
0
0
0
0
0
6.7%
7.5%
8.5%
6.1%
8.0%
5.4%
3.8%
6.3%
6.0%
6.0%
6.0%
7.0%
6.2%
Maternal Deaths Admissions of full term babies to neo-natal care
Trend
• Maternity continues to show positive performance overall and quality measures remain under monitoring at the Clinical Effectiveness committee.
An Associated University Hospital of Brighton and Sussex Medical School 6
Access and Responsiveness Emergency Department Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
96.1%
96.6%
97.6%
95.9%
95.4%
94.3%
95.7%
93.3%
92.0%
91.3%
95.0%
96.8%
96.0%
0
0
0
0
0
0
0
0
0
0
0
0
0
Ambulance Turnaround - Number Over 30 mins
105
77
41
72
97
151
183
344
163
259
247
Ambulance Turnaround - Number Over 60 mins
19
0
0
3
2
6
4
10
26
51
31
ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA
Trend
• In May 2015, 96.0% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches. • Ambulance Handover data is awaiting validation with SECAmb. • While the Trust has delivered the ED Standard, the Trust remains under significant operational pressure, partly driven by a 9% increase in the number of Overnight Non Elective admissions when compared to last year. • In light of the on-going operational pressures in the Trust, the following three 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 to manage winter pressures – 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) • Cancelled and / or delayed elective operations - Due to on-going operational pressures and increasing demand for emergency inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)
An Associated University Hospital of Brighton and Sussex Medical School 7
Access and Responsiveness Cancer Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Cancer - TWR
93.1%
93.6%
93.1%
93.0%
93.2%
93.8%
93.1%
93.1%
93.1%
93.1%
93.1%
93.3%
94.2%
Cancer - TWR Breast Symptomatic
93.5%
93.7%
93.2%
94.4%
93.2%
93.3%
93.6%
93.5%
93.4%
96.3%
93.8%
93.8%
93.8%
Cancer - 31 Day Second or Subsequent Treatment (SURGERY)
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Cancer - 31 Day Second or Subsequent Treatment (DRUG)
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Cancer - 31 Day Diagnosis to Treatment
100.0%
98.1%
99.2%
97.1%
99.2%
100.0%
99.1%
98.4%
97.1%
100.0%
100.0%
98.2%
97.0%
Cancer - 62 Day Referral to Treatment Standard
87.0%
86.9%
90.8%
87.9%
78.8%
87.1%
86.3%
86.1%
85.4%
88.0%
83.7%
86.4%
TBC
Cancer - 62 Day Referral to Treatment Screening
100.0%
100.0%
50.0%
100.0%
83.3%
83.3%
100.0%
100.0%
92.3%
100.0%
92.3%
84.6%
92.3%
Trend
• All Cancer Access Standards were achieved in May 2015 except for the 62 Day referral to treatment standard. • The final performance on the 62 Day referral to treatment standard is to be confirmed (tertiary treatment data is not yet fully available). • While the confirmed breaches are across several pathways, a high proportion are on the Urology pathway. The Deputy COO and Chief of Cancer are undertaking a review of the pathway across the health system to try and remove any delays and reduce variation for patients.
An Associated University Hospital of Brighton and Sussex Medical School 8
Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
RTT Admitted - 90% in 18 weeks
94.4%
94.7%
92.8%
90.4%
90.7%
88.1%
81.4%
91.1%
90.2%
82.1%
88.4%
91.6%
90.1%
RTT Non Admitted - 95% in 18 weeks
97.2%
96.5%
95.2%
95.8%
93.2%
93.9%
92.8%
95.0%
91.7%
91.0%
93.5%
93.6%
95.3%
RTT Incomplete Pathways - % under 18 weeks
96.0%
95.2%
94.9%
93.9%
93.8%
93.5%
93.3%
92.2%
92.1%
94.0%
93.7%
93.6%
93.5%
0
0
0
0
0
0
0
0
0
0
0
0
0
Percentage of patients w aiting 6 weeks or more for diagnostic
0.0%
0.0%
0.3%
0.1%
0.0%
0.0%
0.4%
0.1%
0.9%
0.7%
1.4%
1.0%
0.2%
% of operations cancelled on the day not treated within 28 days
0.0%
0.0%
0.0%
0.0%
1.0%
1.6%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
RTT Patients over 52 weeks on incomplete pathways
Trend
• In May 2015, all three RTT standards were achieved at aggregate level • There were a number of speciality failures of the admitted and non-admitted standards as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. Several specialities also failed the incompletes standard. • Within Diagnostics, the quality standard for waits over 6 weeks was achieved in May 2015, for the second month following the underperformance in March 2015.
An Associated University Hospital of Brighton and Sussex Medical School 9
Patient Experience Patient Voice Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Inpatient FFT - % positive responses
98.0%
98.0%
96.0%
97.0%
97.0%
95.0%
95.7%
96.9%
94.2%
94.4%
95.1%
Emergency Department FFT - % positive responses
99.0%
98.0%
98.0%
95.0%
96.0%
93.0%
95.8%
97.1%
94.7%
95.4%
95.3%
Maternity FFT - Antenatal - % positive responses
97.0%
99.0%
96.0%
97.0%
95.0%
90.0%
97.6%
97.1%
97.0%
96.3%
100.0%
100.0%
98.0%
95.0%
95.0%
93.0%
100.0%
95.5%
97.2%
100.0%
94.7%
97.0%
Maternity FFT - Postnatal Ward - % positive responses
92.0%
93.0%
93.0%
90.0%
92.0%
96.0%
85.9%
91.0%
97.3%
86.7%
91.0%
Maternity FFT - Postnatal Community Care - % positive responses
93.0%
100.0%
100.0%
94.0%
100.0%
85.0%
100.0%
100.0%
100.0%
100.0%
77.8%
Maternity FFT - Delivery - % positive responses
Mixed Sex Breaches
0
0
0
0
0
0
0
0
0
0
0
0
0
Complaints (rate per 10,000 occupied bed days)
23
23
20
28
17
30
24
20
18
26
22
25
22
Trend
• The May adult ED FFT score of 95.3% is very similar to the April figure. The inpatient score has risen slightly to 95.1% (from 94.4% in April). • The FFT score for three of the maternity touchpoints has improved since April. The antenatal 36/40 touchpoint is 100% (up from 96.3%); delivery is 97.0% (up from 94.7%; and postnatal ward is 91.0% (up from 86.7%). • National FFT data for April was released in early June. The combined adult and paediatric ED Friends and Family Test score for April was 95.6%. SaSH continues to perform well above the national average (87.5% in April) and was ranked 14 th best in the country. National ED results ranged from 98.2% to 65.6% positive. • The April Inpatient FFT score was 94.6%, just below the National average of 95.2%. National results ranged from 100% to 85% positive. • There were no Mixed Sex Breaches in May 2015.
An Associated University Hospital of Brighton and Sussex Medical School 10
Workforce Workforce Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Average fill rate – registered nurses/midwives (%) - Day
97.3%
97.7%
97.5%
95.7%
95.4%
96.4%
97.1%
95.1%
94.8%
95.9%
96.5%
96.8%
95.7%
Average fill rate – care staff (%) - Day
95.6%
97.3%
95.1%
97.5%
96.4%
95.3%
95.0%
93.1%
92.6%
93.8%
94.5%
96.1%
93.8%
Average fill rate – registered nurses/midwives (%) - Night
97.5%
97.9%
98.2%
97.2%
98.1%
99.2%
99.4%
97.3%
97.2%
97.7%
96.7%
96.5%
97.1%
Average fill rate – care staff (%) - Night
96.7%
97.5%
97.2%
97.5%
96.7%
97.4%
95.3%
93.7%
93.3%
94.9%
94.9%
95.2%
95.9%
Overall Sickness Rate
3.3%
3.6%
3.8%
3.2%
4.0%
4.4%
4.0%
4.5%
4.3%
4.4%
4.2%
4.2%
4.3%
%age of staff who have had appraisal in last 12 months
82%
80%
80%
75%
74%
72%
69%
72%
67%
68%
73%
71%
68%
14.5%
15.0%
15.0%
15.8%
15.6%
15.3%
15.3%
15.6%
15.7%
15.7%
15.2%
15.5%
15.9%
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.
• Staff Turnover increased to 15.9% in May 2015. There remains a significant focus on Nursing recruitment and a new “Leavers Pathway” was rolled out in May 2015. This includes an online questionnaire with a link given to all leavers when they resign. • Sickness absence increased to 4.3% in May 2015. • The following workforce related risks sit on the Trust’s significant risk register: • Increasing Sickness Absence Levels with impact on day to day management and expenditure – Risk score 15 (Likelihood of 5 and consequence of 3)
An Associated University Hospital of Brighton and Sussex Medical School 11
Finance Indicator Description
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Outturn £m Surplus / (Deficit) - Plan
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
1.6
1.6
Outturn £m Surplus / (Deficit) - Forecast
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
(2.5)
(2.4)
1.6
1.6
YTD £m Surplus / (Deficit) - Plan
(1.7)
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.4
1.0
1.9
1.4
2.3
(0.8)
(1.2)
YTD £m Surplus / (Deficit) - Actual
(1.7)
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.5
1.0
1.9
(2.9)
(2.4)
(0.8)
(1.1)
Outturn UNDERLYING £m Surplus / (Deficit) - Plan
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.8
3.8
Outturn UNDERLYING £m Surplus / (Deficit) - Actual
3.4
3.4
3.4
3.4
1.0
1.0
(0.7)
(5.2)
(5.2)
(5.2)
(5.2)
3.8
3.3
YTD Savings £m - Actual
0.6
1.1
1.9
2.8
3.8
5.0
6.2
7.4
8.6
9.8
11.0
0.3
0.5
(8.0)
(8.0)
(8.5)
(8.5)
(8.5)
(8.5)
(6.3)
(6.3)
(5.5)
(0.7)
0.0
0.0
(1.0)
Outturn Cash position £m Fav / (Adv) - Forecast
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
7.6
7.6
YTD Cash position £m Fav / (Adv) - Actual
2.6
2.4
2.7
3.1
3.0
3.8
2.8
4.8
3.8
3.8
2.6
3.2
2.9
(15.0)
(18.0)
(18.0)
(17.0)
(10.0)
(7.0)
(4.0)
(8.0)
(8.0)
(18.0)
(21.0)
(20.0)
(21.0)
YTD BPPC (overall) volume £m
94%
94%
94%
94%
94%
90%
85%
88%
87%
86%
82%
62%
75%
YTD BPPC (overall) value £m
89%
90%
87%
88%
87%
92%
78%
84%
83%
83%
81%
65%
73%
Outturn Capital spend Fav / (Adv) - forecast
19.3
19.3
19.3
19.4
19.4
19.4
19.4
19.3
19.3
19.3
19.3
17.1
17.1
OT Risk £m Surplus / (Deficit) - Assessment
YTD Liquid ratio - days
Trend
• The planned position is a YTD deficit for the first quarter of the year, reflecting the profile of cost improvement plans. • The Trust is marginally ahead of plan (£0.1m after rounding) at month 2 with a (£1.1)m deficit. However, there are clear pressures within the position, particularly from spend to manage emergency capacity. • Contract income is adverse to plan with most of that due to a phasing issue (which match cost profiling on elective work) and reaction to capacity issues from emergency activity. • The cost improvement plan for the year is £8.2m and in May the Trust is on plan with £0.5m delivered. Further schemes have been identified since last month to reduce the level of red rated risks.
An Associated University Hospital of Brighton and Sussex Medical School 12
Finance • The underlying position at the end of May is £(1.3)m deficit, reflecting the non recurrent contingency savings. • Risks to the 2015/16 financial plan are estimated at £6.8m of which £5.8m are mitigated. This reflects the spend pressure. • The cash balance at the end of May 2015 was £2.9m, above plan due to the continued delay in capital invoices. • The capital forecast this year is spend of £17.1m
An Associated University Hospital of Brighton and Sussex Medical School 13
TRUST BOARD IN PUBLIC
Date: 25 June 2015 Agenda Item: 3.2
REPORT TITLE:
Finance & Workforce Committee Chair Update – Part 1
EXECUTIVE SPONSOR:
Paul Simpson (Chief Financial Officer)
REPORT AUTHOR (s):
Richard Durban (Non-Executive Director and FWC Chair)
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
No – Board Update
Action Required: Approval ( )
Discussion ( )
Assurance (√)
Purpose of Report: To update the Board on the discussions and actions from the Finance and Workforce Committee. Summary of key issues
The Finance and Workforce Committee met on the 23rd June 2015. The key points from the meeting were as follows: Business Planning
The Committee received and agreed the Post Implementation Review timetable for Business Cases approved by the Committee.
Financial, Workforce, Capital and IT M02 performance reports
M02 reports were received for Finance, Capital and IT. Workforce and Organisational Development Reports were not received.
The Trust has reported a £1.1m deficit at month 2 which is in line with its annual financial plan.
Updates were received by the Committee on the progress of 2015/16 and 2016/17 Cost Improvement Plans.
The Committee received a safer staffing report and an update on the DH temporary staffing pilot.
The Committee received a presentation of the draft IT Road Map covering the implementation of the EPR and EPMA enabled changes.
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: 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.
Legal and regulatory impact
Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”. Legal aspects related to capital works will depend on the nature of the works. The main regulators, are as follows: -
Financial impact
External audit (the Grant Thornton for this Trust) gives an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.
The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services The report provides assurance about savings, capital spend and the structure of the business planning process.
Patient Experience/Engagement
Indirect impact through Trust planning and workforce.
Risk & Performance Management
The committee, and this report, provides assurance about workforce and capital management.
NHS Constitution/Equality & Diversity/Communication Attachment: Report Paper
An Associated University Hospital of Brighton and Sussex Medical School
2
TRUST BOARD REPORT – 25 June 2015
Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 23 June 2015 and it was quorate. points from Part 1 were as follows:
The key
Post Implementation Review Timetable The Committee received and agreed a timetable for Post Implementation Reviews (PIRs) for business cases that it had approved. These would answer two broad questions – had the benefits been delivered and what were the organisational learnings from the implementation? It was agreed that in general PIRs should be completed and reported to the Committee between 3 to 6 months after the implementation date. Financial, Workforce, Capital and IT M02 performance reports The month 2 Finance, Capital and IT reports were presented to the Committee. The Workforce and Organisational Development Reports (M02 KPIs, a report on sickness, establishment/vacancy reporting and the Workforce Internal Control Framework) were not available to the Committee: -
The Trust is marginally ahead of the financial plan (£0.1m after rounding) at month 2 with a (£1.1m) deficit. However there are clear pressures within this position, particularly from cost and capacity issues resulting from higher than planned emergency activity. Contract income is adverse to plan mostly due to a phasing issue (which match cost profiling on elective work) but in part due to capacity issues resulting from the high emergency activity. The Committee discussed the position in depth including the allocation of central reserves, the work on improving our Length of Stay performance and divisional actions.
-
The Committee noted that a Q1 forecast would be produced for discussion at the next meeting and subsequently at the Board. This should also include a cash forecast.
-
The 2015/16 Month 2 CIP report was discussed in detail. It is on plan with £0.5m having been delivered at M02, although £ 130,000 of this was through contingency schemes. It was noted that some schemes had underachieved ytd eg postage/legal fees, premises(energy). The Chief Nurse provided an update on the Nursing Temporary staff project which described a significant delay in implementation and resulting mitigating actions (nb a report is being presented to the Private Board on the 25th June). This was being in the process of being costed. The Committee also discussed the visa and foreign language testing position.
-
The Committee received a paper on the 2016/17 CIPs and these will also be discussed at the Private Board meeting on 25th June. The Committee suggested grouping the potential schemes under headings eg cost saving, contribution from additional income, IT enabled to provide clarity and allow the Board to see the balance between types of activity.
-
The Chief Nurse presented an update on the Safer Staffing levels that showed that in April 2015 the Trust’s establishment exceeded the September safer staffing level target by 3.5% or 22 heads. This was seen as being within tolerance and did not afford an opportunity to reduce the establishment. An update was also received on the DH temporary staffing pilot.
An Associated University Hospital of Brighton and Sussex Medical School
3
-
The Capital and IT reports were presented and noted by the Committee. The Committee was advised that the TDA had not yet approved the Trust Capital Resource Limit for 2015/16 but that expenditure would not exceed the available funding levels and is managed within the Capital Investment Group. This would be made overt in future monthly reports to the FWC.
-
The Committee noted the successful “data flip” which transferred Cerner Millennium from BT hosting to a Cerner hosted environment over the weekend of 20/21 June. It congratulated all involved.
-
The Committee received a presentation on the draft IT implementation road map from Dr Ben Upton. This contained a proposed roll out timetable for EPMA and a schedule of projects aimed at delivering a “paper light” EPR within 2 years. It would be discussed at the Executive Committee on 24th June.
[END]
An Associated University Hospital of Brighton and Sussex Medical School
4
TRUST BOARD IN PUBLIC
Date: 25th June 2015 Agenda Item: 3.3
REPORT TITLE:
Audit & Assurance Committee Chair Update
NON EXECUTIVE SPONSOR:
Paul Biddle (Non-Executive Director and AAC Chair) Colin Pink Corporate Governance Manager
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Audit & Assurance Committee – 27/05/15
Action Required: Approval ()
Discussion ()
Assurance (√)
Purpose of Report: This report provides the Board with an executive summary of the May Audit and Assurance Committee. Summary of key issues The committee reviewed and adopted the 2014/15 accounts noting; the final deficit position, the successful management of cash and overall liquidity position. This was supported by financial papers and strong assurances from External Audit. The committee reviewed and accepted the final drafts of the annual report and annual governance statements with strong assurances from both Internal and External Audit. The committee reviewed the annual counter fraud report which detailed expectation that the Trust’s NHS Protects “Self Review Tool” would show no adverse issues. Recommendation: The Board is asked to note this report. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: 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. Legal and regulatory impact Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”.
The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trustâ&#x20AC;&#x2122;s compliance with International Financial Reporting Standards and with NHS accounting conventions â&#x20AC;&#x201C; this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trustâ&#x20AC;&#x2122;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: N/A
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT – 25/06/2014 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 27/05/2015; it was quorate. The key points from this meeting were as follows: 1) Accounts Analysis: Management presented its accounts analysis for the 2014/15 financial year. Highlighting that the Trust delivered a £2.4m NHS deficit due to the significant NMET income reduction, but delivered its £11.0m savings plan. The Trust did not receive any income support in 2014/15 although £3.1m winter resilience money was received, and the underlying deficit was £5.2m. Managing cash throughout the year was challenging, but the plan for the year was met. A temporary borrowing loan (TBL) was needed whilst contract income was agreed with CCG’s (this TBL was repaid as planned in March). The Trust received £6.2m of Public Dividend Capital (PDC) in 14/15 to fund capital spend (theatres refurbishment & maternity settings), while a £4.4m capital investment loan was received (Cardiology). Working capital remains very weak and the liquid ratio will continue to fluctuate to minus 21 days. To correct this problem an estimated £18.0m of cash would need to be injected into the statement of financial position to achieve the foundation trust liquid ratio benchmark. 2) External Audit Findings: External Audit presented its findings stating that the draft financial statements and supporting working papers were of a very good quality. They confirmed that they had not identified any adjustments affecting the Trust's retained surplus position and anticipated providing an unqualified audit opinion in respect of the financial statements. With regards to value for money the Trust has arrangements in place to secure economy, efficiency and effectiveness (Taking into account the deficit of £2.4 million in 2014/15 and breach of the statutory break even duty). 3) Final Audited Accounts and Formal Adoption of accounts: The Committee discussed the final accounts in detail noting; the quality of the accounts, that cash balance had been maintained as planned, income settlements in place and assurances from External Audit. The Committee resolved to formally adopt the accounts. 4) Annual Report and Annual Governance Statement: Management presented the draft reports. The Committee discussed the commentary included and noted some minor changes to make before final submission. The Committee queried the inclusion of detailed financial plans in the annual report, but resolved to keep the information in the annual report. The committee signed off the final reports noting necessary non material changes before submission.
3 An Associated University Hospital of Brighton and Sussex Medical School
5) Counter Fraud Annual report The Trusts LCFS specialist service presented the counter fraud annual report. This highlighted the expectation that the Trustâ&#x20AC;&#x2122;s NHS Protectâ&#x20AC;&#x2122;s self-review tool would be good with no significant issues, issues identified by proactive and reactive investigations, actions taken by the Trust and initiatives to raise fraud awareness.
Paul Biddle Non-Executive Director AAC Chair June 2015
4 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 25 June 2015 Agenda Item: 4.1
REPORT TITLE:
CQC Improvement Action Plan
EXECUTIVE SPONSOR:
Sue Jenkins
REPORT AUTHOR (s):
Sue Jenkins
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Executive Committee
Action Required: Approval ()
Discussion ()
Assurance (√)
Purpose of Report: This report provides the Board with assurance that the recommendations made following the CQC visit in May 2014 are being addressed Summary of key issues The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. Since the CQC inspection work has been ongoing to address the concerns raised in the report. However the main concern around patient waiting times and the large number of ad-hoc clinics remains a challenge. This report details the actions being taken over the summer of 2015 to address this challenging area and demonstrates progress against existing and revised KPIs that have been previously shared with the Board Recommendation: The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. 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 Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication
Compliance with CQC recommendations and delivery of action plan to address areas highlighted is essential Capital and revenue implications will be addressed through separate business cases Feedback from patients regarding their experience in outpatients is a key part of this action plan A monthly steering group is in place to ensure delivery of the plan N/A
Attachment: CQC Improvement action plan â&#x20AC;&#x201C; June 2015
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT –25 June 2015 CQC Improvement Plan Update - Outpatients 1. Introduction The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. A revised action plan is now presented which demonstrates progress against key recommendations. Revised and new KPIs are also reported. 2. Outpatient review update There are four key work streams that the outpatient action plan covers. They are Environment Workforce and leadership skills Communications Systems and processes The table below details the key actions that are being undertaken for each of the four areas and a RAG status is included:RAG B G A R
Definition Action complete Action being delivered to plan Action delayed or outside of budget but plans in place to bring back on track Action unlikely to be delivered to plan
Ref 1.0 1.1
Details Environment Identify and implement IT solution to support more efficient room allocation – Go live due late July 2015
1.2
Accommodation for additional clinics and re-provision of priority areas including ophthalmology, clinical haematology and gynae
Progress “Bookwise” identified as preferred solution Business case approved by CHIG Implementation underway but go live has slipped to early September due to staffing pressures. Further development at Earlswood still in negotiation with specialty teams including rheumatology and dental with a view to moving off site. This will potentially release space for priority areas to be relocated to. Timescale will be subject to planning permission and agreement with landlord and anticipated at 12 – 18 months Plans to develop East Entrance as
RAG G A
G
3 An Associated University Hospital of Brighton and Sussex Medical School
1.3
2.0 2.1
2.2
2.4
3.0
4.0 4.1
4.2
4.3
4.4
4.5
additional outpatient space are being drawn up. Timescale ties in with medical records annexe re-provision. Clinical haematology plans paused whilst clinical team reviews space options within budget. Timescale for completion before 31.03.16 Consider development of Included in capital plan for 16/17 and business case for re-provision of 17/18. outpatients’ facilities Plans to be developed and OBC due by end of 15/16 Workforce Review skill mix of nursing staff - Skill mix is being reviewed as part of registered to un-registered an overall strategy to address the CQC concern of a ‘flat structure’ being in place. This will be incorporated in the consultation mentioned in point 2.2. Develop consultation to support A consultation is planned for late extended day and 6 day service summer to extending clinic hours to a provision 12 hour day. Evening and weekend clinics are already taking place on an ad-hoc basis. Develop outpatient staff focus Staff focus groups have been groups to ensure views and undertaken during June 2015. Action will be developed and feedback from staff are plan considered and actioned – June implemented on the basis of feedback 2015 Communications Ensure on-going and effective Meetings and improved communications with:communications in place with all stakeholders on both formal and CCGs informal basis. Led by lead clinician GPs for outpatients and supported by SaSH clinicians management team. Systems and processes Set up e-referral email address – An NHS.net email address is in June 2015 place. Next steps are to communicate this to CCGs. There is a real drive by two Surrey CCGs to use e-Res (the new Choose and Book system). Develop standard template for e- This work has commenced and is onreferrals – June 2015 going. Detailed input and support from each of the specialties is required and completion will take approximately 3 months. Discuss proposed e-referral Linked to update at 4.1 system to all GPs via CCGs – June 2015 Offer amnesty to return all Planned as part of summer referrals to OBO – June 2015 workstream where bookings will This will be part of the work to ‘pause’ bookings. Share details of revised process To meet with lead clinicians and
G
G G
G
G
G G
A G
A
G A
G
4 An Associated University Hospital of Brighton and Sussex Medical School
with consultants – June 2015
4.6
4.7
Share and discuss details of revised process with service managers and ADs – June 2015 Share and discuss details of revised process with lead clinicians – June 2015
4.8
Complete validation of waiting lists – June 2015
4.9
Agree new realistic consistent milestones across all specialties – June 2015
4.10 Agree KPIs to measure success and compliance – June 2015 4.11 Develop reports to share compliance with KPIs – June 2015 4.12 Agree demand and capacity plans for all specialties – June 2015
4.13 Recruit temporary team to support OBO for 10 weeks to facilitate change in practice and training of team – June 2015 4.14 Ensure rooms are available to support revised clinic templates – July 2015
consultants and provide overview of processes to be implemented. Meeting scheduled for late June 2015. Ongoing discussion at weekly Elective Care Board.
G
To meet with lead clinicians and consultants and provide overview of processes to be implemented. Meeting scheduled for late June 2015. This is an on-going process which has started in June and will take an estimated three months to complete. Review of milestones currently underway. Aim is to have all new first appointments <18 weeks by end of Q2 and all new first appointments < 13 weeks by end of Q4 New KPIs being discussed and actioned to provide realistic reporting. Will be in place by end of July 2015 Will be in place by end of July 2015
G
Working on going with Information team to identify up and coming demands and requirements for additional resources. Also discussed at weekly Elective Care Board. Draft business case considered by executive team and approval to be gained at next meeting on 24.6.15
A
Ongoing and part of the Room Allocation Software (Bookwise) work now planned for August.
G G
A A
G
A
6.0 Measuring success A new suite of KPIs has been developed to monitor the successful delivery of the action plan and the following demonstrate progress so far.
5 An Associated University Hospital of Brighton and Sussex Medical School
Total ad hoc clinics per month
Medicine division ad hoc clinics
Surgery division ad hoc clinics
6 An Associated University Hospital of Brighton and Sussex Medical School
WACH division ad hoc clinics
Number of patients affected by clinics cancelled in medicine division
Number of patients affected by clinics cancelled in surgical division
7 An Associated University Hospital of Brighton and Sussex Medical School
Number of patients affected by clinics cancelled in WACH division
Total number of clinics cancelled per month
Total number of clinics cancelled <6 weeks
8 An Associated University Hospital of Brighton and Sussex Medical School
Calls in and out of central booking office
Referrals received electronically â&#x20AC;&#x201C; target 50% by December 2015 Month April 2015 May 2015
% referrals received electronically 8% 8%
Referrals logged on Cerner < 24 hours Month April 2015 May 2015
Referrals logged on Cerner <24 hours 25% 30%
Referrals graded by clinician and returned to OBO <48 hours (2 working days) Month % referrals graded < 48 hours April 2015 25% May 2015 25% Total number of patients waiting >18 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q2
9 An Associated University Hospital of Brighton and Sussex Medical School
Total number of patients waiting >13 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q4
7.0 Recommendation The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Sue Jenkins Director of Strategy June 2015
An Associated University Hospital10 of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 25th June 2015 Agenda Item: 4.2
REPORT TITLE:
Quality Account 2014/15
EXECUTIVE SPONSOR:
Dr Des Holden Medical Director Laura Warren Head of Communications Executive Committee for Quality & Risk – March & April 2015 and Safety and Quality Committee - May 2015
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Action Required: Approval (√ )
Discussion (√)
Assurance (√)
Purpose of Report: The publication of an annual Quality Account is mandatory, as is some of the prescribed content and consultation with the local health and social care economy. The account will be uploaded to Department of Health NHS Choices website by 30th June. Summary of key issues This account builds on that of 12 months earlier and describes how we have performed against the quality targets we set ourselves at that time. The opinion of some of our partners and of the executive is that we continue to make progress towards the Trust’s objectives of delivering care which is safe, effective, responsive to patients needs and is well led by clinicians and managers working together. Recommendation: The Board is asked to review and approve the 2014/15 Quality Account. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact
Mandatory requirement
Financial impact
Enabling
Patient Experience/Engagement
As the account describes the quality of patient care, and experience it is relevant to this.
Risk & Performance Management
Included in the report
NHS Constitution/Equality &
The report will be made available on the NHS
Diversity/Communication
Choices Website and the Trust Website.
Attachment: 2014/15 Quality Account
2
Quality Account 2014-2015
2
Contents
Quality Account 2014-2015
Contents Introduction............................................................ x
Statutory declarations
Vision and values............................................. x
• Review of services....................................................... x • Participation in clinical audit................................... x • Participation in clinical research............................ x • Goals agreed with commissioners...................... x • Care Quality Commission registration and inspection............................................................... x • Data quality.................................................................... x • NHS Number and GP practice Code Validity..... x • Information governance........................................... x • Clinical coding............................................................... x • Summary of hospital-led mortality indicator (SHMI) and the percentage of deaths with palliative care coding.................................................. x • Patient reported outcome measures (PROMS)..................................................... x • Responsiveness to inpatients’ personal needs............................................................... x • P ercentage of patients admitted who were at risk of VTE........................................................................ x • Patient safety indicators............................................ x • C.difficile infections.................................................... x • Staff recommendation of the Trust as a place to be treated.................................................................. x • Patients’ recommendation of the Trust as a place to be treated.................................................. x
What we do............................................................. x Culture champions.......................................... x How we look at the safety and quality of our services............................... x Our safety and quality priorities.. x Patient experience • Eliminate clinically inappropriate mixed sex accommodation................................................... x • Cleanliness...................................................................... x • End of life care.............................................................. x • Nutrition........................................................................... x • Patient feedback.......................................................... x Safety • Falls..................................................................................... x • Skin care........................................................................... x • Safety thermometer................................................... x • Dementia......................................................................... x • Healthcare acquired infection................................ x • Venous thromboembolism (VTE)......................... x • World Health Organisation (WHO) safer surgery checklist........................................................... x • Fractured neck of femur (hip)................................ x • Patients admitted with stroke................................ x • Access to services........................................................ x • Incident reporting........................................................ x Clinical effectiveness • Mortality.......................................................................... x • Readmission to hospital............................................ x • Reducing need for admission................................ x • Enhanced recovery...................................................... x • National Institute for Health and Clinical Excellence (NICE) technology appraisals (TAs)............................................................. x • Amber Care Bundle.................................................... x • Safe and appropriate discharge arrangements • Mental health................................................................ x • COPD Bundle................................................................. x
Staff awards and recognition.......... x Our priorities for 2014-15....................... x Glossary........................................................................ x Appendices............................................................... x • Statement of our directors’ responsibilities.......... x • What our partners say.............................................. x
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4
Introduction
Quality Account 2014-2015
Introduction
Quality Accounts are an important way for local NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders. The quality of the services is measured by looking at patient safety, the effectiveness of treatments that patients receive and patient feedback about the care provided.
NHS Choices
Thank you for taking an interest in our quality account, which is designed to give you information about how we assure our patients and their carers, our partners and commissioners and ourselves on the quality, safety and effectiveness of the services we offer. It has been another year where we are proud to have maintained standards set nationally for access to services in the emergency department and to in-patient and operative care despite the challenges of more people than ever needing unplanned care. It has been another year where we have met the standards set for us on patients suffering from healthcare acquired infection and the first year in our history where, although we reported a single MRSA contaminant at blood culture, we did not have a single MRSA blood stream infection. Every patient who contracts an infection related to hospital treatment has a story that is used to drive learning and improvement and this year the challenge is to reduce infections where there is a failing of care to an absolute minimum, a challenge we very much want to meet. I reported in our last quality account that we had received a very useful and reassuring ‘mock’ CQC inspection provided by colleagues from many departments at Frimley Park NHS Foundation Trust. This was followed in June 2014 by a three day inspection of all our services by the Care Quality Commission themselves. This was a planned inspection and as well as reviewing much of the data related to our clinical performance and outcomes, it also met with patients, carers
5
6
What we do
Quality Account 2014-2015
and members of staff to gainan overall picture of the care we provide. I was delighted that as a direct result of our strong clinical leadership and the commitment of staff across the Trust we were rated as ’good’ across all five inspection domains: • safety • effectiveness • patient experience • access and responsiveness • well led In addition, our end of life services were awarded ‘outstanding’. This rating was a tremendous achievement and one we are very proud of - nonetheless we were told we could do more for patients attending our out-patient services, improve the availability of our medical notes and in relation to our medical secretary and PA workforce. In all of these areas we are advanced in delivering the improvements we are grateful to the CQC for raising. We have had our best ever year for recruiting patients into clinical trials. The ability for patients to participate in research studies is a less widely publicised marker of quality of service - with many of the studies receiving national and local attention. Studies suggest that as many as nine out of ten patients would be willing to take part and the challenge we face is identifying studies which are appropriate for us to take part in and asking patients whether they are willing to take part. Both of these aspects require an effective and hardworking research and development team and a willing and informed clinical workforce. We plan to build on last year’s success by working ever more closely with the Local Clinical Research network, which covers Kent Surrey and Sussex, so that we are thought of early when trials are looking for recruitment centres. We will also ensure that we support our research active staff to enable them to have time to spend with patients explaining studies.
We continue to be an associated university hospital of Brighton and Sussex Medical School and, in addition, this year we have become a member of Surrey Health partners. This initiative links clinicians and academics around central clinical themes (clinical academic groups) promoting research ideas, design and delivery to ensure the best care is available to patients. We have continued to be a member of the Kent Surrey and Sussex Academic Health Science Network (AHSN) and, as reported in this account, we have continued to perform well within their Enhancing Quality and Enhancing Recovery programmes. These programmes look at the frequency with which patients with certain clinical diagnoses receive specific quality interventions and drive safety and effectiveness of care. Looking forward, this year we will work with the AHSN to further strengthen our capacity to define quality for patient pathways and design and evaluate even more effectively the care we give. Our journey towards Foundation Trust status continues. At the time of writing this introduction we have been referred by the NHS Trust Development Authority to Monitor, the Foundation Trust assessor and regulator. We are part of a final assessment undertaken by Monitor and we are pleased that at this stage we have recruited more than 10,000 members who have chosen to be involved and in the future plans of our organisation. In many ways, the most important advantage of being a Foundation Trust is having this proactive membership of people who have signed up as interested in how we deliver our services for them and the communities we serve. I am very grateful that so many people have taken this step and look forward to working with them this year to further improve the care we give.
Michael Wilson Chief Executive
What we do Surrey and Sussex Healthcare NHS Trust provides extensive acute and complex services at East Surrey Hospital in Redhill alongside a range of outpatient, diagnostic, day case and planned care at Caterham Dene Hospital and Oxted Health Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex. Serving a population of over 535,000 we care for people living, working and visiting east Surrey, north-east West Sussex, and south Croydon, including the towns of Crawley; Horsham; Reigate and Redhill. East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit,
which cares for seriously injured patients in partnership with the major trauma centres at St George’s University Hospitals NHS Foundation Trust and Royal Sussex County Hospital Brighton. East Surrey Hospital has 666 beds and ten operating theatres – along with four more theatres at Crawley Hospital in our day surgery unit. We are a major local employer, with a diverse workforce of around 3,600 providing healthcare services to the community we serve. The Trust is an associated university hospital of Brighton and Sussex Medical School. In 2014-15 we had an income of £244m and we have delivered an increase in activity across the services we provide and in the number of people we have cared for:
In 2014-15 we saw more than
87,000
patients at our emergency department There were
We also saw
32,172 35,300
4,463 320,000
patients
elective patients
births
required emergency admission
were admitted
patients at our outpatient clinics
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8
Our vision, Our values
Quality Account 2014-2015
I couldn't have had better treatment. All the staff were courteous and helpful. Really impressed with East Surrey Hospital.
Our vision, Our values
1 mile
CSH Surrey
• Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour
Safe, high quality healthcare that puts our community first.
GREATER LONDON
CROYDON
SURREY
• One team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth
KENT
Caterham Dene Hospital
REIGATE & BANSTEAD
First Community Health & Care MOLE VALLEY
• Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care
East Surrey Hospital TANDRIDGE
Crawley Hospital
• Safety and quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care
Horsham Hospital
CRAWLEY MID SUSSEX
WEST SUSSEX
HORSHAM
EAST SUSSEX
Sussex Community Trust
9
11
10 Quality Account 2014-2015
Our culture champions Colin Pink, corporate governance manager, updates us on the role of culture champions at Surrey and Sussex Healthcare NHS Trust…
Putting our patients first and at the centre of what we do is key to enabling us to achieve our goal of moving from a ‘good’ organisation to an ‘outstanding’ one - making sure that everyone has quality, safety, productivity and patient experience as the cornerstones of their decision making. In partnership with our staff, we have outlined the behaviours and expectations that explain what our organisational values look like in everyday practice and now we must strive to make sure they become part of the way we work, day in and day out. To that end we have set up a network of culture champions who will help give us focus and visibility and help the organisation embed our culture in everything we do. Chosen by the executive team and clinical chiefs our core group of culture champions are a mix of people - all bands, all divisions, all occupations - who are already role models for our values and behaviours. Their role is to help us to embed our values and behaviours by supporting our teams and staff: • At an individual level to help colleagues understand our values and what it means for them, for our Trust and, most importantly, for our patients
Culture champions - living the values
• At a team level working with leaders to propose different ways in which our values can be communicated and integrated • At a Trust level to create awareness and focus and support initiatives to integrate values and behaviours in our systems and processes - recruitment; induction, recognition In collaboration with members of staff from across the organisation, we have developed a framework of ‘behavioural anchors’ that support our four key values: • Dignity • One Team • Compassion • Safety and Quality
The anchors provide all staff with a fair and transparent interpretation of what our values mean in day-to-day situations and will be become a powerful tool in challenging behaviours and setting appropriate expectations.
Our new achievement review process is different; it signifies a change in how contribution is reviewed by considering the extent to which people achieve their objectives in a way that reflects our values and behaviours.
Changing the way we assess individual achievement and contributions to our organisation is one of the ways that we are creating focus to accelerate our journey to ‘outstanding’. A new style achievement review was developed during 2014/15, which replaces our existing appraisal system, has been designed to help us feedback and reflect each person’s contribution to our success.
To date this is making very positive changes to the Trust which, for example in our theatre team, can be seen in their development of team goals and beliefs and the use of behavioural questions in interviews for new staff.
How we look at the safety and quality of our services
12 Quality Account 2014-2015
How we look at the safety and quality of our services Katharine Horner, patient safety and risk lead, explains the background to how we look at the safety and quality of our services…
The hospital was clean and tidy and the staff have all been wonderful, extremely kind and caring.
As we continue to grow and expand services we remain committed to improving and providing high quality safe and effective care to our patients and their families. On a daily basis, teams across all wards and departments come together to discuss patient safety issues such as the number of patients who have a high risk of falling, the dependency of patients on the ward and any staffing issues. Each clinical division holds a monthly governance meeting to which safety concerns and risks are escalated. The information contained within the scorecard covers a wide range of performance indicators for safety, clinical effectiveness, patient experience, performance and productivity and covers all services provided. This means that the sub-committees of our Board can focus on the right quality and safety priorities for patients. The patient safety sub-committee provides an important interchange of information and experience for the teams responsible for ensuring that patients are safe. We recognise that incident reporting is only effective if the organisation learns lessons from the incidents that have occurred. We have continued to see incident reporting rates at a level that is consistent with a healthy incident and reporting awareness culture. We were pleased to see an improvement in the 2014 National Staff Survey indicators: • ‘percentage of staff reporting errors, near misses or incidents witnessed in the last month’ (KF13) • ‘percentage of staff agreeing that they would feel secure raising concerns about unsafe clinical practice’ (KF15) Both indicators are better than the national average. In addition for indicator, ‘Fairness and effectiveness of incident reporting procedures’ (KF14) the improved picture for 2014 placed us in the best 20% of Trusts in the country.
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14
Our safety and quality priorities
Quality Account 2014-2015
Our safety and quality priorities Patient experience Eliminate clinically inappropriate mixed sex accommodation Improvement sought for 2014-15: We said we would continue to ensure there are no mixed sex breaches and enhance the privacy and dignity experience for all our patients. • 2014-15 Performance rating ➜ Met In 2014-15 we had no mixed sex breaches. Improvements sought for 2015-16: To continue to ensure there are no mixed sex breaches and enhance the privacy and dignity experience for all our patients.
Cleanliness Improvements sought for 2014-15: Investment in new equipment to assist in a more streamlined cleaning regime and cleaning during the day rather than during the night to alleviate unnecessary noise for our patients. • 2014-15 Performance rating ➜ Met New equipment has allowed us to provide a more streamlined cleaning routine. Our scheduled regular cleaning programme takes place during the daytime - we do not routinely clean during the night to ensure that our patients are not disturbed unnecessarily. Improvements sought for 2015-16:To continue to maintain high standards of cleanliness and to ensure patients are not disturbed unnecessarily.
End of life care
Nutrition
Improvements sought for 2014-15: The Trust’s End of Life Care Strategy (20112014) is due for renewal this year. This work will be taken forward via the End of Life Care Steering Group. We will continue to promote the use of, and audit, the newly introduced End of Life Care Plan. We will introduce a palliative care weekend service by expanding the nursing team by two whole time equivalent clinical nurse specialists.
Improvements sought for 2014-15: We said we would continue to focus on implementing protected mealtimes and have an on-going audit to monitor progress and adherence to this initiative. We also said that we will introduce a new two week menu cycle and the dieticians and catering department have been working very closely to ensure this menu offers variety and continues to meet the nutritional standards for hospital catering. The new breakfast menu will include prunes and yoghurts at breakfast time following feedback from patients.
• 2014-15 Performance rating ➜ Met Our end of life care strategy has been renewed for 2014-2017. The strategy has been reviewed and agreed by the end of life care steering group and at board level by the clinical effectiveness group and implementation is monitored via an action plan. We have expanded the service provision from five days a week to include Saturdays and Bank Holidays since September 2014 and are working towards expanding this to a seven day service. A two year pilot discharge liaison project has been launched by SASH and Marie Curie to aid hospital discharge for patients at the end of life to their preferred place of care. Improvements sought for 2015-16: We will continue to audit end of life care via participation in the 5th National Audit of Care of the Dying Patient and internal audit of end of life care documentation. We will develop, introduce and embed the second version of SASH end of life care plan.
• 2014-15 Performance rating ➜ Met Our audits confirm good progress and that the two week menu cycle is proving popular with patients. Improvements sought for 2015-16: We will continue to make improvements to protected mealtimes and our recent audits confirm good progress. The nutrition and hydration steering and the oral nutrition and hydration group will continue to monitor progress and we will continue to monitor feedback and make adjustments as necessary.
Patient experience Improvement sought for 2014-15: We said we would encourage more senior frontline staff to respond directly to comments on Patient Opinion and that we would roll out the Your Care Matters programme to cover all patient pathways, build upon using it as a way to track performance and consistently respond to the comments we receive and strive to make improvements. We also said that we would
communicate the changes that we make to staff and our patients and their families and improve both admission and discharge patient literature. • 2014-15 Performance rating ➜ Met Your Care Matters: Our bespoke patient feedback programme now covers the full range of different patient pathways and includes the Friends and Family Test as the first question. Patients are asked to take part in a short survey once they have experienced an episode of care. The programme is widely promoted across the Trust to both patients and staff and text reminders are also used to encourage participation. The survey gives patients the opportunity to commend staff for a job well done and also asks for any comments or suggestions on how the service might be improved. These staff commendations and additional comments are automatically emailed to key staff within the service. They are able to share positive comments and review additional comments alongside other sources of patient feedback such as PALS contacts, Patient Opinion and face to face interactions and make improvements where possible. Changes that are made as a consequence of listening to our patients’ views are widely communicated using ward boards and digital screens across the hospital. Improvements sought for 2015-16: We will continue to promote both staff and patient engagement with the Friends and Family Test and Your Care Matters and will make changes based on the feedback we receive. We will further broaden the way we seek feedback from the wider community through increased use of focus groups and wider consultation with stakeholder groups. We will continue to train our staff in customer care skills.
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Our safety and quality priorities
Quality Account 2014-2015
Safety
Also, in 2014-15:
Falls Improvement sought for 2014-15: We said we would improve data collection. The falls prevention team would start monthly falls clinics and develop routine monthly falls ward rounds to continue to reduce the overall number of falls and promoting good reporting and management processes. There is a goal to reduce the total number of falls by 25%.A 25% reduction is pragmatic for an organisation that is not an outlier for falls and considered by majority of staff as a stretch target. If delivered, this will result in a meaningful improvement in the safety of our patients.
T he total number of patients who suffered no harm due to a fall has increased by
5.2%
We have also, working with our colleagues at the Kent, Surrey and Sussex Falls Collaborative and also with NHS England at a national level, assessed our current falls prevention practices/ strategies per NICE guidance and participated in the first national in-patient falls audit by the Royal College of Physicians and the Falls and Fragility Fractures Audit Programme (FFFAP). We will also be participating in the largest research of its kind in the UK with regards to preventing injuries to older people through the provision of shock-absorbing flooring led by the University of Portsmouth. Total falls Falls with harm
2013/14
2014-15
1049
1049
315
314
Improvements sought for 2015-16: Maintain our achievement of no hospital acquired major pressure damage and continue to strive to reduce hospital acquired minor damage.
T he number of patients who suffered major harms has decreased by
21% 50% There was a
reduction in the number of patients who suffered an extreme harm T he total number of serious incidents due to a fall has also decreased by
29%
Improvements sought for 2015-16: We will continue to seek to achieve a 25% reduction in total falls and in harms caused.
Pressure damage Improvement sought for 2014-15: The number of patients affected by pressure damage is reported to the Trust Board at every meeting. We will reduce hospital acquired minor damage by 25% and have no hospital acquired major pressure damage. • 2014-15 Performance rating ➜ Met
Improvements sought for 2015-16: To maintain 95% average compliance with safety thermometer new harm metrics and increase average compliance to 97% throughout January to March 2016.
Dementia
compared to 2013-14
• 2014-15 Performance rating ➜ Partially Met We have started the monthly falls clinics and the weekly falls ward rounds. In addition, we also reconvened our falls prevention group in March 2014 to monitor trends and themes on falls. Patients are referred to our specialist falls nurse consultant, who joined us in year, and we have started ward staff teaching on falls prevention; conducted an audit on the use of falls care bundles for high risk areas;updated our Trust falls strategy and appointed falls champions.
We have continued to reduce hospital acquired minor damage by over 50% and we had no hospital acquired major pressure damage.
Safety thermometer Improvement sought for 2014-15: We said that a specific maternity safety thermometer that was being piloted would be introduced and that the Trust would continue to engage with community services and clinical commissioning group chief nurses to ensure a joined up approach. The ‘new harms’ score is between 94.19% - 96.5% - the Trust has interrogated this data to allow it to identify areas for improvement. • 2014-15 Performance rating ➜ Met The maternity safety thermometer has not yet been publishes and so we have been unable to introduce and implement. Harm free (all harms) %
Harm free (new harm) %
April 2014
90.5
95.4
May 2014
92.8
97
June 2014
93.4
97.6
July 2014
90.8
95.3
August 2014
92.5
96.1
September 2014
92
94.5
October 2014
95
98
November 2014
93
96
December 2014
93
97
January 2015
93
96
February 2015
92
95
March 2015
92
96
Improvement sought for 2014-15: We said that in order to ensure the most effective and significant engagement with local commissioning and care quality improvement initiatives, we would engage and commit to local commissioning intentions and care quality improvements. We also said that we would demonstrate a community facing mind-set and approach to dementia care, ensuring that the organisation is involved at the heart of efforts to minimise avoidable admissions, whilst maintaining a commitment to providing the highest standards of care for those who require inpatient admission and that we would actively seek feedback from carers of people with dementia about the care each individual receives and how well as an organisation we support the carer. We also said that we will disseminate and utilise this feedback in developing care delivery and where appropriate provide feedback and evidence to the carer demonstrating how their input has been successfully employed to make alterations and improve service provision. • 2014-15 Performance rating ➜ Met We have been successful in ensuring that we have adopted a strong community facing approach to dementia care and are a key partner in local commissioning efforts to develop high quality dementia care. We have been central in efforts to develop high quality services which support a reduction in avoidable admissions and we continue to support the development of these services. We have also sought to solicit the views and opinions of carers of people with dementia to improve how we support them and this will continue to be a key feature of our aims going into 2015-16.
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Our safety and quality priorities
Quality Account 2014-2015
Improvements sought for 2015-16: We will continue to develop and build new pathways for both dementia and delirium which will be linked to the East Surrey Integrated Dementia Action Plan (ESIDAP) and to primary care and community pathways. Close involvement and support of the implementation of the ESIDAP will help in continuing to develop a community facing mind set, collaborative approaches to care and the avoidance of unnecessary admissions. We are committed to holding a number of carers’ focus groups to benchmark how well we support carers currently and at how we can improve. In-line with our commitment to the national Sign up for Safety pledge we will audit and benchmark our performance in the assessment and management of pain in dementia and undertaking an assessment of the knowledge and skills of staff to identify any training needs that can be met.
Healthcare acquired infection Improvements sought for 2014-2015: We said that we will meet the Department of Health targets of no more than 29 patients who are affected by Cdiff, and will have no preventable MRSA blood stream infections. We also said that we would continue to analyse all cases and disseminate learning and that thefocus in the coming year would be to ensure that we identify patients with MRSA promptly with our screening programme and that we would prescribe and administer the MRSA suppression treatment in a timely way. • 2014-15 Performance rating ➜ Met • Clostridium difficile* - 24 cases** • MRSA blood stream infections - 0 (with 1 contaminant) *The national maximum for all Trusts reporting cases of patients aged two years old or over during the reporting period was 121 minimum was 0 **This equates to 11.3 cases per 100,000 bed days
For the prevention of Clostridium difficile, there has been a continuing emphasis on antibiotic prescribing and improved timely risk assessment of all patients with symptoms of diarrhoea. There has been a continued focus on prompt isolation of affected patients. All cases of Clostridium difficile had full root cause analysis performed and the clinical teams fed these investigations findings back at divisional governance and taskforce meetings, so that learning could be spread throughout the organisation. MRSA infections are more likely if a patient has intravenous lines, a urinary catheter, wounds, or if it is not known that they are a carrier. Over recent years there has been an overall reduction in MRSA blood stream infection, due to an enhanced focus on screening and the care of patients with intravenous lines and urinary catheters. Learning: Each Clostridium difficile case was subject to a comprehensive investigation undertaken by clinical team in conjunction with the infection prevention and control team. In 2014-15 there were 24 Trust apportioned episodes of Clostridium difficile - 16 cases arose within the medical division and 8 in the surgical division; 19 patients had received an antibiotic post admission, all prescriptions being clinically justified. In four of these cases, although antibiotics were required, prescribing was not in line with Trust antibiotic policy (for choice, dose or duration). There were three episodes of probable cross-infection and there were no deaths directly attributed to Clostridium difficile infection. Tackling Norovirus: Keeping the virus that causes vomiting and diarrhoea away from the hospital is a challenge every year. The virus spreads easily and causes huge disruption in all hospitals and schools, particularly over the winter. The whole health economy is working more effectively on Norovirus control, with planning meetings occurring in September of each year. In October 2014, we organised a conference on Norovirus and invited our community partners
to join us to decide the best way to prevent and control the spread of the virus. Representatives from nursing and care homes, the ambulance service, Public Health England and other local NHS trusts all attended to discuss working together with us in seeking a common goal. We looked at ways of avoiding admitting people with Norovirus symptoms, patient transport and the control of the illness in care and nursing homes. The Trust has seen a slightly higher level of activity compared to last year, in common with community settings. There were seven episodes of ward closures due to confirmed Norovirus throughout winter and spring. The focus of the coming year will be on cleaning standards, hand hygiene and the continued presence in wards by infection prevention and control nurses, to support the clinical assessment of patients with diarrhoea. Improvements sought for 2015-16: We will meet the Department of Health objectives of no more than 15 patients who are affected by Clostridium difficile and will have zero preventable MRSA blood stream infections. We will continue to analyse all cases and disseminate learning. For MRSA, the focus in the coming year will be to ensure that we continue excellent practice in the care of intravenous lines and urinary catheters. For the prevention of Clostridium difficile we will continue the high focus on antibiotic prescribing and ensure that hand hygiene and glove use is high on the agenda. There will also be a continued presence in wards by infection prevention and control nurses to support the clinical assessment of patients with diarrhoea.
Venous thromboembolism (VTE) Improvement sought for 2014-15: We said that the risk assessment will continue to be carried out on more than 95% of patients on admission and that the reassessment of risk will be highlighted through staff education, in line with NICE guidance. Also, that patient
information leaflets will be available to all admitted patients within the Trust, highlighting the risk of VTE and on-going preventative advice on discharge. We also said that a multi-disciplinary team would review any cases where a patient develops a venous thrombosis either whilst an inpatient, or within 90 days of discharge and that the numbers of such cases and whether care was substandard will be published within our Board performance papers. • 2014-15 Performance rating ➜ Met Over the last year, 95% of patients looked after by us had a formal VTE assessment carried out on admission and recorded in the notes. Improvements sought for 2015-16: To continue to develop the improvements achieved by the multi-disciplinary review of venous thrombosis.
World Health Organisation (WHO) safer surgery checklist Improvement sought for 2014-15: We said that we would continue to audit the quality of our safer surgery processes. • 2014-15 Performance rating ➜ Met Improvements sought for 2015-16: We will continue to audit the quality of our safer surgery processes.
Fractured neck of femur (hip) Improvement sought for 2014-15: We said that we will maintain and further improve our best practice performance for hip fracture care and that we will aim to improve performance for time of admission to the hip fracture unit. We also said that we will look to improve our length of stay through collaborative multi-disciplinary working across the Trust and the community and that we hope to be able improve our follow-up data collection and reporting to achieve greater
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Our safety and quality priorities
Quality Account 2014-2015
understanding of longer term outcomes for our hip fracture patients.
The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence based standards, and national and local benchmarks. SSNAP audit has five metrics:
• 2014-15 Performance rating ➜ Partially Met We have maintained very good access to theatres and to pre-op local anaesthetic blocks for pain relief. Tracking longer term outcomes beyond discharge was not routinely performed this year. Fractured neck of femur: average length of stay 2010-11
2011-12
2012-13
2013-14
2014-15
19.2
19.7
21.3
20.5
19.6
Fractured neck of femur: % to ward within four hours 2010-11
2011-12
19.2
19.7
Improvements sought for 2015-16: Further improvements in pre-operative pain management and improved follow up for treated patients, in addition to an increased number of patients admitted to the ward within four hours; in-line with best practice standards.
Patients admitted with stroke Improvement sought for 2014-15: We said that we will continue to ensure quality by improving the performance in general and further improvement on scanning time although the target was met and to review stroke coding and mortalities for 2013-14. And that we would focus particularly on reinforcing ring-fencing to admit acute stroke patients to the Acute Stroke unit within four hours from presentation to hospital. We also said that we would focus on improving clinical outcomes for patients who have had a stroke within 72 hours, follow-up assessment between four and eight months after initial admission and discharged with a joint health and social care plan. • 2014-15 Performance rating ➜ Met/Partially Met
• Metric 1: Stroke patients scanned within one hour of hospital arrival ➜ Met • Metric 2: Stroke patients scanned within 24 hours of hospital arrival ➜ Met • Metric 3: Percentage of patients admitted directly to an acute stroke unit within four hours of arrival to hospital ➜ Not Met • Metric 4: Stroke - 90% or more time spent on stroke unit ➜ Partially Met • Metric 5: Adjusted mortality for 2014-2015 ➜ Met 1: Stroke Patients scanned within one hour of hospital arrival Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14 51.9% 53.1% 57.8% 41.7% 2: Stroke patients scanned within 12 hours of hospital arrival Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14 91.4% 92.7% 96.3% 96.4%
Access to services Improvement sought for 2014-15: We said that we wanted to deliver the national standards for the emergency department (ED), referral to treatment (RTT) and cancer and, where possible, reduce waiting times for as many patients as possible.
Incident reporting
• 2014-15 Performance rating ➜ Met Last year we saw an increase in the numbers of people treated by our emergency department (ED) from 82,000 to around 87,000 and against the national four hour access standard for the emergency department, 95.1% were admitted or discharged within four hours. For the 18 week admitted pathway we treated 20,667 patients – 18,513 (89.6%) were treated within 18 weeks against the NHS constitution standard of 90%. There were 468 patients waiting more than 18 weeks for admitted treatment at the end of the year compared to 165, 12 months earlier. Cancer access standards were achieved:
3: Percentage of patients admitted directly to an acute stroke unit within four hours of arrival to hospital Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14 60.8% 52.1% 51.9% 33.3% Two week wait
Improvements sought for 2015-16: Our objective is to deliver the national standards for the emergency department (ED), referral to treatment (RTT) and cancer; being above the medial for national performance in all measurers and moving towards upper quartile for as many as possible.
Surrey and Sussex Healthcare NHS Trust
Nationally set standard
93.15%
93%
Improvement sought for 2014-15: We said we would continue to improve the use of safety information at divisional governance level by increasing incident reporting rates whilst maintaining the percentage of harm, increasing the numbers of audits recorded that impact on patient safety and ensure that patient safety data is made more transparent for our patients and staff. • 2014-15 Performance rating ➜ Partially Met There is a steady increase in the numbers being reported on a monthly basis (with some fluctuations). The percentage of harm has remained broadly static over the year. We have robust processes in place to capture incidents. We have provided training to staff and there are various policies in place relating to incident reporting. We have identified that there scope for improvement in our incident report culture as we want to capture and learn from every incident.
4: Stroke-90% or more time spent on stroke unit Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14 84.9% 91.5% 90.1% 74.2%
Two week wait: breast symptomatic
93.7%
93%
62 day*
86.5%
85%
5: Adjusted mortality for 2013-2014 2013-14 2014-15 (Apr – Dec) 108.46 88.23
62 day screening
94.3%
90%
99.3%
96%
Severe harm or death
100%
98%
100%
94%
Improvements sought for 2015-16: To improve SSNAP audit performance to at least a ‘B’ rating. To work with commissioners on the community rehabilitation and reenablement pathway.
31 day first treatment 31 day subsequent treatment: surgery 31 day subsequent treatment: drugs
*Nationally this figure was not achieved
Level of harm None to moderate
2012-13 2013-14 2014-15 3775
4717
5737
55
37
39
Total
3830
4754
5776
Percentage of severe harm or death incidents
1.5%
0.8%
0.7%
22
Our safety and quality priorities
Quality Account 2014-2015
Improvements sought for 2015-16: A key objective for the coming year is to improve trust-wide communication on safety issues to ensure that we improve dissemination of learning from incidents. We will further strengthen our incident investigation and processes for addressing safety issues throughout the organisation. We will continue to improve the safety culture within the Trust by encouraging the reporting of low and no harm incidents. During 2015/16 we will be working with services to continue to support the development of service specific trigger lists. This will assist areas in accurately reporting incidents.
Amber Care Bundle We reviewed this priority following the trial at Guy’s and St Thomas’ Hospital and believed it was not appropriate to take forward at this time. However, we have reviewed our end of life care bundle internally and Surrey and Sussex Healthcare NHS Trust received an assessment of ‘Outstanding’ for End of Life Care as part of the Chief Inspector of Hospitals inspection in 2014.
Safe and appropriate discharge arrangements We continue to focus on arrangements for safe and appropriate discharge to: • To understand the effectiveness of the current integrated discharge processes/service Assess compliance with National Standards for Effective Discharge • To determine any correlational links between compliance, non-compliance with standards and identify delayed discharge challenges attributed to a) SaSH b) the wider economy • Stretch on 14/15 Safe and Timely Discharge CQUIN • To determine opportunities for the development of a wider system integrated discharge processes
Mental health
COPD Bundle
Dementia training: The training which is currently provided has been established based on and to comply with Health Education England requirements for Tier 1 Foundation Level Dementia Awareness training: (http://southwest. hee.nhs.uk/ourwork/dementia/tier1outcomes/) for acute providers.
We continue to implement the British Thoracic Society chronic obstructive pulmonary disease discharge bundle:
In addition, Health Education Kent Surrey and Sussex (HEKSS) have agreed a local requirement for Tier 1 Training which is also met by the programme provided as mandatory for all Surrey & Sussex Healthcare NHS Trust staff.
• Referral for pulmonary rehabilitation and point of contact for patient on discharge
The training programme is a 45 minute awareness raising session focussed at all patient facing clinical and non-clinical staff. It is currently provided exclusively as classroom based, face to face teaching, however a key objective for 2015/16 is to develop an e-learning module which can support greater numbers of non-clinical staff to undertake the training. The current taught module covers the following key areas: • The prevalence and consequences of dementia • The nature of dementia as a condition • Key signs and symptoms • The difficulties faced by sufferers • Subtypes and differences in sub types and distinction from other conditions • Signposting to services • Key clinical skills – such as empathy and communication skills Staff feedback has been collected as part of the routine evaluation of all mandatory training.
• Patient reviewed by respiratory consultant before discharge • Personalised self-management plan received before discharge
• Advice on smoking cessation • Assessment of depression by health and wellbeing, assessed using the Hospital Anxiety and Depression (HAD) Scale
My visit was an eye-opener. The patience, kindness and compassionate treatment of the bed-bound elderly patients both day and night staff, was truly exceptional. A shining example of the NHS from start to finish.
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Our safety and quality priorities
Quality Account 2014-2015
Clinical effectiveness Mortality Improvement sought for 2014-15: We said that we would continue to roll out our enhanced review of all patient deaths to ensure all divisions are using the electronic system for reporting deaths. Themes will then be identified by the mortality review group, which will provide assurance that learning happens to the Clinical Effectiveness Committee. We also said that we would seek to ensure that our mortality rate, as reported through Dr Foster Intelligence remains, ‘better than expected’ - investigating any mortality outlier alerts. • 2014-15 Performance rating ➜ Partially Met This year, the work of the mortality group has focussed on standardising reporting from speciality morbidity and mortality meetings and ensuring that discussions were taking place and divisional level around the findings at these meeting. A template was rolled out at the end of last year and divisions now have regular updates on specialty morbidity and mortality meetings and The Trust Mortality Review will now begin to have divisional reports fed into it through 2015/16 where it will be able to look for any emerging themes and trends and instigate further reviews where applicable. The Group will also act as a forum for cascading learning from the divisional reports as well.. The mortality rates for the Trust have continued to improve this year with Dr Foster Intelligence reporting that as of the beginning of this year the Trust continued to have a ‘better than expected’ mortality rate when compared with the national average. The mortality rate, which includes any death within 30 days of discharge (Standardised Hospital Mortality Indicator) for the Trust is improved and remains slightly better than the national average and was classed as ‘as expected’.
No alerts on specific procedures or conditions were identified by the Care Quality Commission in their data on mortality as defined in the Intelligent Monitoring Report.
of pathways to reduce A&E attendances and provide alternatives to hospital admissions.
Improvements sought for 2015-16: The mortality group will increasingly look at categories of death, rather than just individual deaths and make recommendations through the clinical effectiveness committee to improve care.
Improvements sought for 2015-16: We will continue to develop additional ambulatory care pathways. We will work with commissioners to further reduce acute length of stay and continue with discharge to assess and introduce discharge to assess in the emergency department.
Enhancing Quality Performance Report Period: Jan 2014 - Oct 2015
• 2014-15 Performance rating ➜ Met
Appropriate Care Score (ACS) Composite Quality Score (CQS)
Graph 1 - Heart Failure South East Coast (ACS) South East Coast (CQS) Trust J
Trust H
Readmission to hospital Improvement sought for 2014-15: We said that we will continue to improve on the changes made during 2013/14. There will be a clinical review of one month’s clinical readmission data and any lessons learnt will be implemented. Readmission performance is one of the main Key Performance Indicators reported to the Trust Board, Executive Board and Divisional Boards on a monthly basis.
Enhancing Quality (EQ) Improvements sought for 2014-15: We said that we will continue to further improve on our performance in the two pathways of heart failure and pneumonia whilst working with the Academic Health Science Network in new clinical areas of focus, including chronic obstructive pulmonary disease and acute kidney injury.
Trust A
Trust B
Trust E
Trust F
Trust K
Trust G
• 2014-15 Performance rating ➜ Met
• 2014-15 Performance rating ➜ Met
The Trust formally reported a readmission rate of 7% which is less than half of the national average and indicates excellent performance.
For heart failure and community acquired pneumonia, the teams have worked collaboratively across the network to make further improvements to the care of patients with these conditions. The Trust also began benchmarking data for acute kidney injury patients working on improving the identification and treatment of the condition.
Readmission data for one month was clinically validated jointly between hospital consultants and GPs to evaluate any alternatives to admission.
Trust D
Trust I
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Graph 2 - Pneumonia With CURB South East Coast (ACS) South East Coast (CQS) Trust D
Improvements sought for 2015-16: Working jointly with the Clinical Commissioning Group’s (CCG) clinical teams we will audit readmissions for one month in Quarter 1 and act promptly on any agreed actions.
Reducing need for admission Improvement sought for 2014/15: We said that we would work with our health partners to ensure 40 community and 20 virtual hospitalat-home places are commissioned for the whole year. The newly established Urgent Care Pathway Board are reviewing a number
Throughout 2014/15 the Trust has consistently remained as the best performer in the region for Heart Failure with over 90% getting all the required interventions when being treated at the Trust: (Graph 1) For the pneumonia pathway, the whole region has seen their results improve over the year and there has been a significant reduction in the variation of care across Kent, Surrey and Sussex. The table shows the Trust around the average for the region although the variation between the top performing and bottom performing Trusts is just 10%. (Graph 2)
Trust K
Trust F
Trust A
Trust G
Trust B
Trust J
Trust I
Trust H
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
(Data period: January – December 2014. SASH = Trust J)
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Our safety and quality priorities
Quality Account 2014-2015
For acute kidney Injury, the Trust is one of only five Trusts contributing to the benchmarking data and there remains significant variation between all Trusts. But coupled with the increased focus through this year’s commissioning for quality and innovation (CQUIN) standard, the Trust is refining its clinical pathways to improve on 2014-15 results through collaborative working with the network. Improvements sought for 2014-15: The enhancing quality project remains within the CQUIN for the coming year; the Trust will continue to focus on further improvement for the coming year as well as looking to work with the Academic Health Science Network to establish new pathways for chronic obstructive pulmonary disease (COPD), fractured neck of femur and emergency laparotomy.
Enhanced recovery Improvement sought for 2014-15: Having addressed our data collection methodology, we said that we would now seek to further increase the use of enhanced recovery whilst maintaining high levels of data completeness to demonstrate statistically significant improvements by improving our data collection methodology but also deliver a genuine increase in ER use within the division of surgery. • 2014-15 Performance rating ➜ Partially Met The enhanced recovery project team continued its focus on increasing the numbers of patients going through each of the pathways. The group was able to review the monthly reports on progress and focus effort on the parts of the pathway which were underachieving.
Enhanced recovery – orthopaedics Clinical Area Measures Patient information on ERP VTE_ Prophylaxis Antibiotics Prior Epidural, Regional or Spinal Anaes Early Mobilisation Discharge advice
Numer- Denomiator nator
2014 2015
2013 2014
222
225 98.67% 90.98%
215
225 95.56% 94.27%
195
225 86.67% 97.94%
190
225 84.44% 92.97%
197
225 87.56% 61.86%
205
225
91.11% 93.56%
CQS
1,224
1,350 90.67% 88.16%
ACS
141
225 62.67% 51.80%
Enhanced recovery – gynaecology Clinical Area Measures Patient information on ERP Antibiotics Prior Hypothemia Prevention Nausea and Vomatting control Discharge advice
Numer- Denomiator nator
2014 2015
2013 2014
74
91 81.32%
73.11%
86
91 94.51% 97.48%
88
91 96.70% 74.79%
85
91 93.41% 99.16%
83
91 91.21% 94.96%
CQS
416
455 91.43% 87.90%
ACS
61
91 67.03% 52.94%
Enhanced recovery – colorectal Clinical Area Measures Patient information on ERP Carbothydrates Given
Numer- Denomiator nator
2014 2015
2013 2014
57
67 85.07% 81.98%
66
67 98.51% 89.19%
50
67 74.63% 83.78%
47
67 70.15% 78.38%
58
67 86.57% 72.07%
CQS
276
335 82.99% 81.08%
ACS
26
67 38.81% 36.94%
IOFM Usage Post Op Nutrition Discharge advice
For the three benchmarked pathways, we improved its performance in delivering the key parts of each of the pathways with significant improvements in the orthopaedic and gynaecological enhanced recovery pathways. The Trust also ensured it met the minimum data completeness requirements. Improvements sought for 2015-16: We will maintain and improve performance and commence pathways for breast surgery and caesarean section.
National Institute for Health and Clinical Excellence (NICE) technology appraisals (TAs) Improvement sought for 2014-15: We said that we would continue to ensure that we remain compliant with all published NICE Technology Appraisals that are applicable to the Trust. We also said that in order to gain further assurance where we require audit evidence to support Level 2 and 3 compliance, the pharmacy team will priorities a number of appraisals to be audited by the division this year. • 2014-15 Performance rating ➜ Met We remain compliant for all TAs and this year we identified five appraisals which we wanted to focus our audits on, identified by the Chief Pharmacist. The following were chosen based on the following criteria: TA 294: Aflibercept solution for injection for treating wet age related macular degeneration now a choice of medicines, choice of locations, and is a growing activity so the Trust needs to ensure it is being used appropriately TA 290: Mirabegron for treating symptoms of overactive bladder - a new drug, where the trust needs to ensure that the choice is appropriate within NICE guidance TA 261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism. Since it’s introduction there has been
a need for discussion on benefit and risks of treatment options with the patients. The audit is required to ensure this is properly recorded. TA 265: Denosumab for the prevention of skeletalrelated events in adults with bone metastases from solid tumours. A new high cost treatment, so the trust need to review the choice of patients. TA 243: Rituximab for the first-line treatment of stage III-IV follicular lymphoma. Audit required to ensure doctors are using and documenting treatment criteria. These were then added to the audit programmes of the relevant specialities a number were still ongoing at the time of writing the report. For TA 243, (Rituximab) the completed audit was used to assess whether all haematology patients treated with rituximab screened for hepatitis B surface antigen and anti-hepatitis B core antibody. Through the use of the audit tool, compliance was zimproved from 66% to 100% in the re-audit which completed in March 2015. Improvements sought for 2015-16: Audits against NICE TA will be undertaken and be posted on audit intranet.
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Statutory declarations This section details the information that every NHS Trust must include in their Quality Account. We have highlighted an explanation of the key terms at the start of each topic.
29
Statutory declarations
Quality Account 2014-2015
Cases submitted
% of cases submitted
Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)
133
72%
Bowel cancer (NBOCAP)
271
100%
During 2014/15, Surrey and Sussex Healthcare NHS Trust provided 38 different acute services and eight specialised services to NHS patients (these numbers are based on the service specifications included in the contracts with Clinical Commissioning Groups and NHS England). We have reviewed all the data available to us on the quality of care in all of these services. The income generated by the NHS services reviewed in 2014/15 represents 100 per cent of the total income generated from the provision of NHS services by Surrey and Sussex Healthcare NHS Trust for 2014/15.
Cardiac Rhythm Management (CRM)
577
100%
Case Mix Programme (CMP) - ICNARC
417
98%
We have repeated the ‘Deep Dive’ programme which takes a detailed look at services at speciality level, seeking assurance and evidence that we are compliant with the five quality domains defined by the Care Quality Commission (CQC). The outcomes of these are reported to the safety and quality committee.
Falls and Fragility Fractures Audit Programme (FFFAP)
Review of services
We continue to develop the quality programme to ensure inclusion of all services within this review. Divisions receive information on a monthly basis on patient safety, clinical effectiveness and patient experience for their areas. They report on their services at monthly governance meetings and to the executive committee for quality and risk and at performance reviews.
Participation in clinical audit Clinical audit involves improving the quality of patient care by looking at current practice and modifying it where necessary. We take part in regional and national clinical audits. Sometimes there are also national confidential enquiries that investigate an area of healthcare and recommend ways to improve that area of healthcare. During 2014-15, 30 national clinical audits and four national confidential enquiries covered NHS services that Surrey and Sussex Healthcare NHS Trust provides. During that period Surrey and Sussex Healthcare NHS Trust participated in 100% national clinical audits and 98% national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate. The national clinical audits and national confidential enquiries that Surrey and Sussex Healthcare NHS Trust was eligible to participate during 2014-15 were:
Coronary Angioplasty/National Audit of PCI
100%
Diabetes (Adult)
100%
Diabetes (Paediatric) (NPDA) Epilepsy 12 audit (Childhood Epilepsy)
Head and neck oncology (DAHNO) Inflammatory Bowel Disease (IBD) programme
N/A Just commenced
Just commenced
N/A 26 168
98.20%
Lung cancer (NLCA)
74.9%
Major Trauma: The Trauma Audit & Research Network (TARN)
100%
Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) National Cardiac Arrest Audit (NCAA) National Chronic Obstructive Pulmona
Began data collection March 2015 32
100%
National Comparative Audit of Blood Transfusion programme National Emergency Laparotomy Audit (NELA)
191
National Heart Failure Audit
181
National Joint Registry (NJR)
409
National Prostate Cancer Audit
N/A
National Vascular Registry
Oesophago-gastric cancer (NAOGC)
100%
100%
All data submitted via network 100%
Neonatal Intensive and Special Care (NNAP) Non-Invasive Ventilation - adults
100%
-
-
89
90%
Paediatric Intensive Care Audit Network (PICANet) Renal replacement therapy (Renal Registry) Pulmonary Hypertension (Pulmonary Hypertension Audit)
N/A -
Rheumatoid and Early Inflammatory Arthritis
308
Sentinel Stroke National Audit Programme (SSNAP) (Organisational)
395
-
99%
30
Statutory declarations
Quality Account 2014-2015
The national clinical audits and national confidential enquiries that Surrey and Sussex Healthcare NHS Trust participated in, and for which data collection was completed during 2013/14, are listed above alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Examples of improvements to care delivered by the clinical audit programme: Audit of elective caesarean section bookings: womenâ&#x20AC;&#x2122;s and childrenâ&#x20AC;&#x2122;s division. In response to higher than average caesarean section rates an audit of reasons for caesarean sections showed that best practice was not being followed when booking women for an elective procedure. The Trust set up a specialist birth choices clinic (BCC) to counsel women who have had one previous caesarean section and any other reason which did not indicate a caesarean section as best practice for the delivery.
The hospital was clean and tidy and the staff have all been wonderful, extremely kind and caring.
The birth choices clinic started in October 2012 and the audit showed a significant impact with a fall of the elective caesarean section rates from 17.8% in October 2012 to 6.9% in January 2013 and an average of 9.8% during 2013/14. The audit demonstrated that the change in service and the implementation of the vaginal birth after caesarean (VBAC) pathway reduced the elective caesarean section rates in the largest group of women opting for a caesarean section. This audit is now a rolling audit, which monitors the elective caesarean section requests against the clinical outcomes to ensure compliance with the birth choices clinic pathway and maintain the elective caesarean section rate under the national rate of 10%.
Sepsis audit: medicine division. The introduction of the sepsis six bundle has been shown to reduce the relative risk of death by 46.6%, so the audit looked at compliance between April and June 2013. To help build on the levels of compliance a drive to improve awareness including simulation training was implemented and a re-audit followed in May - July 2014. Overall compliance with the Sepsis Six improved between 2013 and 2014 - demonstrated by an increase in all domains. Average mortality at 30 days decreased between the two data sets from 38% to 18.9% with similar improvements for the length of stay for patients. A poster presentation of this audit at the recent Kent Surrey Sussex Academic Health Science (KSS AHSN) Awards ceremony saw this audit awarded best poster prize in a competition judged by Sir Bruce Keogh. Mouth Care Matters audit: surgery division. An original audit focussed on whether patients who are hospitalised for more than 24 hours had a mouth care assessment carried out and if a mouth care assessment was carried out and daily mouth care and mouth care supportive measures were in place. The topic was picked up from a complaint and also during the recent Care Quality Commission (CQC) inspection and was conducted in February, both looking at case notes, and a survey of staff. With poor compliance, training has been rolled out across the organisation including awareness campaigns around the importance of maintaining mouth hygiene for patients. The training package has now been successfully introduced in the Trust and significantly has now received regional funding by KSS to roll out across the south-east. It was also a recent topic at the Patient Safety Executive.
31
Statutory declarations
32 Quality Account 2014-2015
Participation in clinical research Clinical Research involves gathering information to help us understand the best treatments, medication or procedures for patients. It also enables new treatments and medications to be developed. Research must be approved by an ethics committee. The key reason for our commitment to research is to improve clinical treatments, care and outcomes for our patients. We want to offer our patients the opportunity to be involved in research activities in order to improve patient experience and enable them to benefit from improved health outcomes.
Our performance in delivering research as measured against the National Institute for Health Research (NIHR) national performance metrics is strong with increases in both the number of different research studies for patients to engage with and numbers of patients recruited to studies. Our strengthening relationship with the pharmaceutical industry is enabling us to offer our patients access to the newest treatments within clinical trials. The Trust supported the recruitment of patients to 45 different high quality studies – ten of these studies were pharmaceutical industry sponsored studies. In 2014-15, we recruited 760 patients to participate in research approved by a research ethics committee.
Our key priorities are to: • Increase number of patients participating in research studies • Increase number of high quality National Institute for Health Research (NIHR) Portfolio research studies open at our Trust. • Maintain our high quality research management processes and enhance performance in project delivery • Develop our infrastructure, staff and facilities, to support research • Become a preferred partner for the pharmaceutical research industry and increase our research income from commercial contracts We have highlighted research activity in four different areas of the organisation: • Anaesthetics • Urology • Dermatology • Paediatrics
Anaesthetics
2012-13 2013-14
2014-15
Number of studies open to recruitment
Number of pharmaceutical industry studies*
Number of research participants
38 40 45
5 5 11
616 506 771
*Included within total number of studies open figure
Our clinicians are able to develop their own research ideas into research protocols bringing new ideas and solutions into clinical practice for the benefit of patients. Designing research protocols which enhance personal knowledge and education in our clinical teams allows us to provide higher quality clinical care. Dr Matthew Mackenzie, consultant anaesthetist, successfully secured funding from the Association of Anaesthetists of Great Britain and Ireland (NIAA) for his study: ‘Simulation Aided Assessment of a Clinical Algorithm’ within the anaesthetics department.
The study utilised the Newman Simulation Suite, at East Surrey Hospital, and sought to examine the use of emergency protocols of relevance to anaesthetic practice by inviting members of the anaesthetic department to manage a simulated emergency situation on a high-fidelity mannequin. The benefit to staff participants was that they were provided with personal updates in the emergency management of anaesthetic related complications listed as core continuing professional development (CPD) topics by the Royal College of Anaesthetists, which meant that the research provided relevant clinician training. The research will also provide an overall contribution to the development of national emergency protocols in the future.
Urology Opening a new national trial has allowed the urology team to offer some of our intermediate risk bladder cancer patients access to a potentially advanced treatment. The new study is exploring the benefits of giving hyperthermic (heated) mitomycin compared to current standard treatment, mitomycin at room temperature. It is thought that hyperthemic mitomycin will prove to be a superior treatment due to increased absorption by any remaining cancer cells at a higher temperature and therefore improve disease free survival. Since the trial started, the urology team have recruited nine patients to date and remain the second highest recruiter nationally, the highest being the lead site. Of these nine patients, four have received hyperthermic mitomycin.
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Statutory declarations
34 Quality Account 2014-2015
Paediatrics Participation in clinical trials can provide increased support for families and young children at the early stages of managing newly diagnosed medical conditions. A study for newly diagnosed diabetic children aged 7 months to 15 years began at Surrey and Sussex Healthcare NHS Trust in September 2012. Families recruited to the study are randomised to receive either insulin by continuous infusion via a pump or standard intermittent injections, to see which is more effective in the management of diabetes in babies, children and young people.
Dermatology research The randomised treatment must be started within 14 days of diagnosis and all patient education, which ordinarily may normally take up to three months to deliver must be completed within that 14 day timeframe. Families recruited to the study are then supported during an intense 12 month follow up which tracks the course of their normal diabetes management and logs all interventions and clinical episodes. Quality of life, control of blood glucose and costs are all documented. Whilst the treatment itself does not actually change at all the study provides an opportunity to acquire a pump very early from diagnosis which can be a big asset. Initially, families can find the thought of the randomisation quite daunting but getting so much educational input early on helps them to understand the condition and to quickly develop skills to support their child.
One of the key ways of offering new treatments to our patients is through participation in clinical trials. Incorporating clinical trial research activities into clinical practice can also encourage new ways of working which lead to improved models of patient care. In 2011, the dermatology department introduced a new way of working to help accommodate a small Clinical Research Network psoriasis study. This change has had a significant, long-term impact on research engagement and patient care. Dedicated psoriasis clinics are run on a monthly basis where patients can be reviewed in a 'one stop shop'. In addition to promoting research activity, the changes have promoted more individualised, holistic care for patients and streamlined the review process for patients. Research participation has been integrated into the clinical pathway for patients with psoriasis which has maximised recruitment potential for studies and allowed the team to take on more complex, clinical trials. Running clinical trials allows us to offer opportunities to have new treatments and the reassurance of additional follow up visits with a consultant dermatologist, specialist nurse and research nurse which promotes a positive patient experience. One of our research participants, Jack Champ, 73, from West Sussex, pictured with Nwando Onugha, lead dermatology nurse, describes his experience:
At all times I have been treated with respect, great care and fully informed. I am pleased that I was asked to take part in the research. Jack Champ Dermatology patient
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Statutory declarations
Quality Account 2014-2015
Goals agreed with commissioners
Care Quality Commission report
Clinical Commissioning Groups (CCG) hold the NHS budget for their area and decide how it is spent on hospitals and other health services. This is known as commissioning East Surrey, Surrey Downs, Crawley and Horsham & mid Sussex CCGs are the four main commissioners of our services. They set us targets based on quality and innovation.
Everyone at Surrey and Sussex Healthcare NHS Trust has a huge commitment to safety, quality and providing care and compassion and this focus on excellence was endorsed in 2014-15 by the Care Quality Commission (CQC) team of doctors, nurses and senior NHS managers who completed an inspection in May 2014.
A proportion of our income in 2014-15 was conditional on achieving quality improvement and innovation goals agreed between Surrey and Sussex Healthcare NHS Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework.
Their report, published in August, by the Chief Inspector of Hospitals focused on five key questions about the healthcare services we provide, are they:
Further details of the agreed goals for 2014-15 and for the following 12 month period are available on request from: clinical.audit@sash.nhs.uk
• Well-led.
Care Quality Commission registration and inspection Last rrat ated ed 6 August 2014
Surr Surrey ey and Sussex Healthcar Healthcare NHS The Care Quality Commission (CQC)eregulates and inspects health organisations across Trust England. Surrey and Sussex Healthcare NHS Trust to register with the Care Overall is required Inadequate Requires Good Outstanding rating Quality Commissionimprovement and its current registration status is ‘registered without conditions’. The Care Quality Commission did not Ar Aree ser servic vices es taken enforcement action against the Trust Good Safe? during 2014-15. Effective?
Good
Well led?
Good
Surrey and Sussex Healthcare NHS Trust has not Good or investigations Caring? participated in any special reviews by the CQC during the reporting period. Good Responsive?
• Safe • Effective • Caring • Responsive to people’s needs Thanks to the hard work of our staff, we achieved a ‘Good’ rating across the board in all five areas - to put this context nationally at the time of the most recent (31) inspections only four other Trusts achieved an overall ‘Good’ rating and only two of these were green in all domains. This puts us amongst the best in the country for the quality of services and the CQC said that our staff should be extremely proud of what they have achieved. The report highlighted several areas of outstanding and good practise, including: • End of life Care achieved an ‘Outstanding’ in the responsiveness category • The excellent care and facilities on the midwife-led birthing unit and the neonatal intensive care unit • The pre-assessment clinic at Crawley Hospital, which has been extended in the evening in response to feedback and local demand
• Staff focus groups: best attended – more staff than they had seen in any other Trust • Clear ambition across the Trust to be the best – from catering staff through to the Chair • Staff willingness to go the extra mile and work together to meet individual pastoral needs • Strong desire to be clinically-led • Large number of specialist nurses with a strong focus on learning and development The report recommended some areas where improvements could be made – the majority of which were in our out-patients areas. These included a need to ensure adequate capacity to meet demand and improvements to the quality of service including waiting times and cancellations. We have made significant progress in addressing these points - the refurbishment of the out-patients department at East Surrey Hospital and improvements to seating and signage; the opening of the Earlswood Community Diabetes and Endocrine Centre and the involvement of our patients in focus groups to help us to gather feedback and to co-design and shape the service as we plan for the future, are just some of the ways we have moved forward and focused on putting people first. We know that this will help us to improve the experience we provide for our patients and also for the teams involved. The inspectors said our staff were the most engaged out of all of the Trusts they had visited and we know this makes a real difference to patient experience and care. They also said they would be very proud to work here and would want their family and friends to be cared for here which is a great endorsement of everyone’s efforts and commitment.
Last rrat ated ed 6 August 2014
Surr Surrey ey and Sussex Healthcar Healthcaree NHS Trust Overall rating
Inadequate
Requires improvement
Good
Outstanding
Ar Aree ser servic vices es Safe?
Good
Effective?
Good
Caring?
Good
Responsive?
Good
Well led?
Good
The Care Quality Commission is the independent regulator of health and social care in England. You can read our inspection report at www.cqc.org.uk/provider/RTP We would like to hear about your experience of the care you have received, whether good or bad. Call us on 03000 61 61 61, e-mail enquiries@cqc.org.uk, or go to www.cqc.org.uk/share-your-experience-finder
I am very proud of our staff – this is their story and I am glad their talent, hard work and dedication has been recognised. The report also makes for reassuring reading for the community we serve and shows our commitment to safety and quality. Michael Wilson Chief executive
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Statutory declarations
Quality Account 2014-2015
Data quality Data quality measures whether we record patients’ NHS and GP numbers in their notes as well as ethnicity and other equality data. The chief operating officer has overall accountability for the quality of data provided to the Trust Board and executive committee. The Trust has a data quality strategy which describes the agreed strategic actions to improve data quality. The information team meets regularly to discuss data quality and provides regular updates to the information governance steering group on the completeness and validity of data available to the Trust. We have a data quality team that is responsible for the day to day management of data quality. The team undertakes national data quality checks, reviews the challenges from the Clinical Commissioning Groups (CCGs) and checks clinical coding daily. The data is also checked externally by Indigo 4 Services Limited, who provide services to a range of NHS organisations. The internal audit plan for 2014/15 – 2015/16 includes review of data quality and Information governance. Internal audit also carries out audits of systems that provide narrative on elements of data quality, such as Board assurance framework reviews and financial feeder system audits. Internal Audit will make recommendations to improve systems where potential is identified, these recommendations are developed into actions which are managed locally and ultimately monitored by the audit and assurance committee.
Clinical coding
NHS Number and GP Practice Code validity Surrey and Sussex Healthcare NHS Trust submitted records during 2014-15 to the Secondary Users Service for inclusion in Hospital Episode Statistics, which are included in the latest published data. The percentages of records in the published data are: NHS Number compliance
Valid All %
Emergency In-patient Out-patient department (ED) 105,337 445,64 85,969 105,848 99.5%
446,476 99.8%
87,276 98.5%
Total 636,954 639,600 99.6%
GP Practice Code
Valid All %
Emergency In-patient Out-patient department (ED) 105,537 444,297 86,385 105,848 99.7%
446,476 99.5%
87,276 99.0%
Total 636,219 639,600 99.5%
Information governance Information governance means keeping information about patients and staff safe. Surrey and Sussex Healthcare NHS Trust’s Information Governance Assessment Report score for 2014-15 was 72% and was graded ‘satisfactory’. The report was finalised and submitted on 31 March 2015. Of the 45 requirements within the assessment, 37 were scored at level two; and eight at level three. Action plans will be updated in order to sustain and improve upon these scores during 201516. Our aim is to improve our compliance year on year and a key element in achieving this is ensuring that all staff receive annual training and regular updates relating to information governance. All information governance risks are added to the Trust risk register and reported in-line with the Trust risk management policy. During 2014-15 no serious untoward incidents were reported to the Information Commission’s Office.
Clinical coding is the translation of medical terminology as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internally recognised. The process is bound by National Standards issued by the Health and Social Care Information Centre (HSCIC). The mechanism for receiving payment is called Payment by Results (PbR). The Information Governance clinical coding Audit (IG Audit) in 2014-15 looked at 200 finished consultant episodes (FCEs) for accuracy of both diagnosis and treatment: IG clinical coding audit 2014-15 Primary diagnosis correct
91.50%
Secondary diagnoses correct Primary procedure correct Secondary procedures correct
94.80% 95.72% 96.24%
These accuracy levels mean the Trust achieved Level 2 in the Information Governance Assessment Requirement 11-505 for 2014-15. Improvement aims for 2015-16: We will continue to train two new trainee coders using the clinical coding Standards Course and help our experienced coders work towards accreditation by supporting them to sit the National clinical coding Qualification (NCCQ). Our aim is to continue to deliver 100% coded activity at post-inclusion ensuring no loss of income to the Trust due to uncoded or miscoded episodes. The depth of coding is steadily increasing - 5.8 diagnosis codes per FCE and we will continue to work with clinicians to ensure coding accurately reflects clinical diagnosis. On-going training programmes for clinical coders are planned for continuous professional development.
We are keen to have on-going clinical engagement in all aspects of coding more so in mortality coding as the data impacts the trusts performance figures. The long-term plan is to set up divisional coding leads to liaise with the clinical leads of those particular divisions which in turn will improve both mortality and morbidity coding.
Summary of hospital-led motality indicator (SHMI) and the percentage of deaths with palliative care coding SHMI is a hospital-level indicator, which provides a summary reporting of mortality (deaths) at trust level across the NHS for England. The SHMI is the ratio between the actual number of patients who die following treatment at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated here. It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge. SHMI values for each trust are made available along with bandings indicating whether a trust’s SHMI value is ‘as expected’ or otherwise. The bandings are: 1 – where the Trust’s mortality rate is ‘higher than expected’ 2 – where the Trust’s mortality rate is ‘as expected’ 3 – where the Trust’s mortality rate is ‘lower than expected’
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Statutory declarations
Quality Account 2014-2015
Our SHMI compares favourably to the national average of 100% as it is lower at 93.07% (6.93% less than average) which was an improvement on our position from the previous year. Improvement aims for 2015-16: We will seek to continue to improve our mortality through full participation in the Dr Foster process of actions in response to alerts and by working with external partners to ensure seamless care between primary and community and secondary care. Summary of hospital-led mortality indicator 2014-15 Trust value
0.9307
Trust banding Lowest (national) Highest (national)
2 0.5966 1.1982
Percentage of deaths with palliative (end of life) care coding
Trust Lowest (national) Highest (national) Average (national)
As reported in last year’s Quality Account 0.9307
October 2013 – September 2014
2 0.5966 1.1982
0 49.4 25.44
34.3
The percentage of elective admissions resulting in a death occurring either in hospital or within thirty days (inclusive) of discharge for the period Oct 13 – Sept 14 was 0.2% (Range 0.2-7.8) The percentage of non-elective admissions resulting in a death occurring either in hospital or within thirty days (inclusive) of discharge for the period Oct 13 – Sept 14 was 3.7% (Range 1.2-5.9) Some patients are admitted to our care and die while with us, or within a short period of time after discharge. For some of these patients their nearness to death is recognised, either because of the terminal nature of their illness or because all curative and life prolonging treatment options have
been exhausted. In this case, end of life care or palliative care can provide symptom control. We recorded 34.3% of our deaths as palliative, or end of life care, which is just above the national average. This represents an increase from last year which came from the introduction of a palliative care weekend service allowing us to more accurately record patients requiring palliative care and reflects a trend nationally for more accurate identification of patients. The large range in the table above also reflects the differing patient populations of different hospitals in England.
Patient reported outcome measures (PROMS) Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using preand post-operative surveys. PROMs measure a patient's health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected from patients through PROMs questionnaires before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients. The most recent data available shows:
Groin hernia
2012/13
Eligible episodes
*
432
Trust average health gain *
National average 0.087 0.085 Hip replacements 0.440 249 0.434 National average 0.416 0.436 Knee replacements 0.255 242 0.321 National average 0.302 0.323 Varicose veins * 102 * National average 0.095 0.093 * Data suppressed due to small numbers. No data = no figures to report.
Single index measure which ranges from 0 to 1, where 1 is the best possible state of health.
Responsiveness to inpatients’ personal needs This indicator is calculated as the average of five survey questions from the national inpatient survey which is carried out each year. Each question describes a different element of the overarching theme - responsiveness to patients’ personal needs. The questions are:
Percentage of patients readmitted within 28 days of discharge
• Were you involved as much as you wanted to be in decisions about your care and treatment?
There is a national expectation that patients who are admitted for episodes of care should not need to be readmitted soon after they are discharged. The Trust uses the Dr Foster quality monitoring tool as part of its reviews of readmissions - this tool shows a 28 day readmission rate based on latest data published on the Health and Social Care Information Centre: Compendium of Population Health Indicators.
• Were you given enough privacy when discussing your condition or treatment?
• Did you find someone on the hospital staff to talk to about your worries and fears?
2010/11
2011/12
Under 16s
10.39
11.31
Average (national) Adults and over 16s Average (national)
N/A 9.83 11.04
N/A 11.47 11.08
• Did a member of staff tell you about medication side effects to watch for when you went home? • Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? Responsiveness to inpatients' personal needs
2012/13 Inpatient survey
2013/14 Inpatient survey
Trust value
74.2
74.3
Lowest (National) Highest (National)
68 88.2
66.8 88.2
For the 2014 inpatient survey we were ranked as 123rd among trusts in England in these categories - we will continue to work to improve our patients’ experience.
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Statutory declarations
Quality Account 2014-2015
Percentage of patients admitted who were at risk of VTE In 2014-15, we said that the risk assessment will continue to be carried out on more than 95% of patients on admission and that the reassessment of risk will be highlighted through staff education, in line with NICE guidance. Also, that patient information leaflets will be available to all admitted patients within the Trust, highlighting the risk of VTE and on-going preventative advice on discharge. We also said that a multi-disciplinary team would review any cases where a patient develops a venous thrombosis either whilst an inpatient, or within 90 days of discharge and that the numbers of such cases and whether care was sub-standard will be published within SASH Board performance papers. • 2014-15 Performance rating ➜ Met Over the last year, 95% of patients looked after by us had a formal VTE assessment carried out on admission and recorded in the notes. Improvement aims for 2015-16: We will move to 95 of patients having their ongoing VTE risk assessed at discharge
Patient safety incidents These are incidents reported to the National Reporting and Learning System (NRLS) where the Trust has failed to provide ‘harm free care’. The Trust incident reporting system is webbased and available on every Trust computer at each hospital site - this has increased our ability to report and respond to safety incidents at pace. It has also facilitated the ability to track trends in safety incidents within the organisation more readily so that we can target our improvement work. Risk management training is included in the mandatory training programme. The risk management team provide ad hoc bespoke training to clinical teams on risk management which includes the reporting of incidents.
C.difficile infections
Emergency department
We said we would have no avoidable Trust acquired MRSA blood stream infections (zero tolerance), and no more than 29 patients affected by Clostridium difficile diarrhoea. 2014-15 Performance rating: Clostridium difficile - 24 cases • 2014-15 Performance rating ➜ Met 2014-15 Performance rating: MRSA blood stream infections- 0 (with 1 contaminant) • 2014-15 Performance rating ➜ Met
Patients’recommendation of the Trust as a place to be treated The Friends and Family Test in our inpatient wards and emergency department is well established. The most recent figures show the percentage of respondents who are ‘extremely likely’ or ‘likely’ to recommend Surrey and Sussex Healthcare NHS Trust as: Inpatient wards Date
April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2014 February 2014 March 2014
Surrey and Sussex Healthcare NHS Trust 97.4%
National average
97.1% 98.0% 98.1% 98.2% 86.7% 96.7% 97.0% 94.7% 95.7% 96.9% 94.2%
94.2% 94.1% 94.2% 93.8% 93.5% 93.7% 94.7% 94.5% 94.2% 94.5% 94.7%
93.9%
Date
April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014 January 2014 February 2014 March 2014
Surrey and Sussex Healthcare NHS Trust 97.9%
National average
97.7% 98.0% 98.7% 97.9% 97.5% 95.3% 96.4% 92.7% 95.8% 97.1% 94.7%
86.0% 86.1% 86.3% 87.5% 86.4% 86.8% 87.4% 86.2% 88.1% 87.9% 86.9%
86.5%
Our Emergency Department was in the top 10% of all Trusts for Q4 and we exceeded the Commissioning for Quality and Innovation (CQUIN) target response rate in both inpatients and ED patients for Q4.
Staff recommendation of the Trust as a place to be treated The Staff Friends and Family Test is conducted in Q1, Q2 and Q4 - the National NHS Staff Survey takes place in Q3. Figures show the percentage of respondents who are ‘extremely likely’ or ‘likely’ to recommend Surrey and Sussex Healthcare NHS Trust as:
Surrey and Sussex Healthcare NHS Trust Q1 – As a place to work Q2 – As a place to work Q4 – As a place to work Q1 – As a place to receive care Q2 – As a place to receive care Q4 – As a place to receive care
National Surrey average and Sussex Healthcare NHS Trust rank order
78%
62%
20th
76%
61%
27th
74%
62%
33rd
89%
76%
42nd
90%
77%
36th
88%
77%
41st
Response rates: • Q1 response rate for Surrey and Sussex Healthcare NHS Trust was 22% against a national average of 14% • Q2 response rate for Surrey and Sussex Healthcare NHS Trust was 10% against a national average of 12% • Q4 response rate for Surrey and Sussex Healthcare NHS Trust was 14% against national average of 13%
Treated with total dignity and professionalism.
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Staff awards and recognition
Quality Account 2014-2015
Staff awards and recognition
I have to say that I was overwhelmed by the care provided by the NHS at East Surrey hospital. They were so helpful, kind, loving, compassionate and professional. They saved my wife's life and I can't thank them enough. Comment posted on Patient Opinion
Providing high quality patient care and sustaining high levels of service provisions would not be possible without the professionalism, dedication and commitment of our staff. Our patients and their relatives and friends regularly let us know just what a difference our staff have made to them through a range of feedback options designed to meet the needs of the people we care for.
Your Care Matters We receive around 1,000 responses a month to our Your Care Matters patient feedback survey. Patients are encouraged to take part and can do so on-line, by using a Freephone number or, for some services, completing a paper copy.
Patient Opinion Patient Opinion is an an independent website that provides an online option for patients to tell their story about their experiences and about the level of care they have received. In the past 12 months 346 patients have told their story and their comments were viewed more than 67,100 times.
The nursing staff were helpful and kind and at each stage introduced themselves and explained the tests and procedures. Comment posted on Patient Opinion
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Staff awards and recognition
Quality Account 2014-2015
Annual staff awards Every
day of the year our staff are responsible for delivering high quality care to the communities we serve and we know just how much the people they care for appreciate their compassion and commitment through the feedback we receive. Each year we make sure that we celebrate this hard work and dedication at our annual Staff Awards of Excellence. Over 100 staff were nominated in 11 categories for our 2014 awards along with those recognised for long service – the winners in each category were: Innovation and Service Improvement: Samantha Shale, senior occupational therapist
As a result of her investigation in to the sensory needs of patients with dementia Samantha introduced a number of sensory items on to her ward. Showing colleagues how these could be used to distract or stimulate patients resulting in a ward that has a calmer, dementia friendly feel. Frontline Employee of the Year Sandhya (Sandy) Blakey, ward manager Sandy was recognized for her dedication and commitment to putting patients first and improving patient care and also for looking after relatives and staff. One of her collegaues wrote: "She's always ready to listen to each and every one of us. The reason we work so well as a team is due to her excellence in leadership." This was also recognised in our recent CQC inspection.
Behind the Scenes Employee of the Year Nalani Ruberoe, medical records clerk Nalanie was recognised for being hard working, kind and helpful and for always going the extra mile to ensure that the patient is always having a positive experience. Compassion (individual ward) Dr Jane Preston, dental officer
Frontline One Team Michelle Cudjoe; Denise Newman; Adaline Smith; Janice Blythman, maternity matron team This team was nominated for making a truly inspirational difference in delivering a safe service and developing our maternity services into something that the Trust is really proud of. They have worked exceptionally well as a team and achieved many notable successes:
Jane was nominated for the level of compassion she shows patients and her colleagues – making everyone feel valued and special as she not only listens to their concerns but goes out of her way to help them. Compassion (team award) Angela Main; Julie Anthony; Lisanne Eagle; Caroline North; Sue Munn; Dr Naomi Collins and Christina Probert, palliative care team The team was recognised as promoting excellent patient care, dignity and compassion to all in, sometimes very difficult circumstances and for providing support for healthcare professionals at the trust, offering not just education and advice but importantly emotional support for those who need it. They inspire others to care for those at the end of their life, with dignity and respect.
Behind the Scenes One Team Diane Mintrim; Hilda Williams; Lesley Harmer, medicalstaffing team The team were recognised for their sustained commitment, dedication and organisation in the smooth running of clinical staffing particularly the new intake of junior doctors joining the Trust. This attention to detail was noted by many of the junior doctors, who said it was one of the most organised inductions they had ever had.
feedback from patients. One patient wrote: "She was always so positive and friendly. Always so patient with everyone in our bay - she showed an interest in each and every one of us and was reassuring, calm and confident in her care." Dignity and Respect Chatardharry Bissonauth (Krit), nursing assistant Krit was praised for his exceptional manner in nursing patients and for going out of his way to ensure each and every one of his patients is looking their very best every day. Most of his patients know him by name and ask for him to attend to their needs - a real testament to how they value the care that he offers. Safety and Quality Debbie Cawston, senior radiographer Debbie works remotely and she was recognised for bringing consistency to the X-ray department at Horsham and her ability to meet the challenges of remote working and her expert delivery of both clinical and non-clinical aspects of her role means that there are frequent health and safety audits, exceptionally infrequent incidents, zero serious incidents and low waiting times. Volunteer of the Year Gordon Thomson, volunteer
Your Care Matters – improving the patient experience Lynne McDowell, staff nurse Lynne has received a number of SenSASHional commendations through Your Care Matters
A veteran of the trust, Gordon has volunteered with us for 22 years – he is loyal, supportive, generous, diplomatic and kind and greatly respected and appreciated and was recognised for his reliability, dedication, commitment and hard work.
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Our priorities for 2015-16
Quality Account 2014-2015
Our priorities for 2015-16
National Patient Safety Collaborative Likely to be based on five scoping events
In this account we have detailed our areas of focus within the topics of patient experience, safety and experience and outlined what we intend to achieve in 2015-16. To enable us to define our priorities for the coming year we have shared our account with our: • Board • Clinical chiefs of service
SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider for the catchment population SO5: Well led – Become an employer of choice and deliver financial and clinicalsustainability around a clinical leadership model
Priorities for 2015-16
• Lead clinicians
Our priorities for 2015-16 will include:
• Assistant directors of operations
Sign Up to Safety
• Senior nursing staff • Divisional teams • Members We have also shared this account with: • Healthwatch (West Sussex & Surrey) • Clinical Commissioning Groups • West Sussex Health & Adult Social Care Select Committee (HASC) • Surrey Health Scrutiny Committee & Surrey County Council Quality Account Reference Group
Emerging priority areas: All our quality improvement work will be based on benchmarked quality performance through locally generated metrics and those provided through accepted agencies (Dr Foster, national and regional data sets) based on the Trust’s five strategic objectives: SO1: S afe – 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
Five pledges in the sign up to safety plan; put safety first, continually learn, honesty, collaboration and support. 1. Identify, evaluate and implement patient safety systems that look to enhance the quality of our care by increasing the chances of the initial signs of a deteriorating patient being acted on appropriately. 2. Seek to improve the Trust’s systems for identifying and managing pain specifically with patients who have a diagnosis of dementia. 3. E nsure that the Trust is compliant with the statutory responsibility regarding Duty of Candor. 4. Learn from COPD EQ pilot and seek to identify and share learning across South East Coast over the 3 year period of the pilot. 5. Help people understand why things go wrong and how to put them right.
1. Pressure ulcer 2. Safe discharge and transfer 3. Culture and leadership 4. Medication errors 5. Sepsis
Commissioning for quality and innovation (CQUINS) • All National projects – Sepsis, Acute Kidney Injury, Dementia, Urgent Emergency Care: ‘Reducing the proportion of avoidable emergency admissions to hospital’ and ‘Improving diagnoses and re attendance rates of patients with mental health needs at A&E’ • All NHS England projects – not yet released • Local CQUIN for Ward Accreditation • Local CQUIN for discharge pathways • Local CQUIN for participation in the Academic Health Science Network Enhancing Quality and Recovery programme
Mouth care for frail elderly • Mouth Care Matters initiative, funded by Health Education England, led by the Surrey and Sussex Healthcare NHS Trust dental team • four additional four dental nurse practitioners who will work across the hospital to support and provide extra training for our nursing and ward teams as they care for our patients • improving the oral health of the people we care for, especially older patients will also have a positive impact on their general health and well-being too
Waiting times • Reduce our waiting times for elective care to achieve and maintain a position that is higher than the National average • Improve the process and timeliness of patient discharge from ITU beds to wards
Outpatient services Patient experience improvements defined in the Care Quality Commission (CQC) action plan.
Virginia Mason Programme and safety • Review the possibility of starting the Trust on a safety journey guided by the principals established by the Virginia Mason Hospital (or similar depending on position) • Establish our Patient Safety Executive • Establish a series of anaesthetic standards to be adopted by all anaesthetists
Nutrition Review training on Malnutrition Universal Screening Tool (MUST) with a focus on improvement. Improve compliance for protected meal times; provide more support for patients who need help with eating and further develop menus and food choices for patients with specific needs.
Quality Goals linked to achievement reviews Continue to embed the setting of personal goals that effect quality of service for all staff.
2014-15 priorities to be retained We will retain key priorities from the 14/15 Quality Account and continue to improve all priorities.
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Glossary
Quality Account 2014-2015
Glossary
Community services
National patient surveys
Health services provided in the community, for example health visiting and podiatry (footcare).
The National Patient Survey Programme, coordinated by the Care Quality Commission, gathers feedback from patients on different aspects of their experience of recently received care, across a variety of services/settings. Visit: www.cqc.org.uk
Acute Trust
Clinical audit
Department of Health
A Trust is an NHS organisation responsible for providing a group of healthcare services. An acute Trust provides hospital services, for example, Surrey and Sussex Healthcare NHS Trust. But not mental health hospital services, which are provided by a mental health Trust.
Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary.
The Department of Health is a department of the UK government but with responsibility for government policy for England alone on health, social care and the NHS.
Audit Commission The Audit Commission regulates the proper control of public finances by local authorities and the NHS in England. The Commission audits NHS trusts to review the quality of their financial systems. It also publishes independent reports that highlight risks and good practice to improve the quality of financial management in the health service, and, working with the Care Quality Commission, undertakes national valuefor-money studies. Visit: www.auditcommission.gov.uk
Board (of Trust) The role of the Trust’s Board is to take corporate responsibility for the organisation’s strategies and actions. The chair and nonexecutive directors are lay people drawn from the local community. The chief executive is responsible for ensuring that the Board is empowered to govern the organisation and to deliver its objectives.
Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and social care in England. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. Visit: www.cqc.org.uk
Clinical Commissioning Group Clinical commissioning groups are predominantly GP-led groups of local healthcare professionals that commission the local health services for their catchment population, based on the needs of the patient population.
Commissioners Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. Clinical Commissioning Groups are the key organisations responsible for commissioning healthcare services for their area. They commission services, including acute care, primary care and mental healthcare, for the whole of their population with a view to improving the health of their population.
Commissioning for Quality and Innovation High Quality Care for All included a commitment to make a proportion of providers’ income conditional on quality and innovation, through the Commissioning for Quality and Innovation(CQUIN) payment framework.
Foundation Trust A type of NHS Trust in England that has been created to devolve decision-making from central government control to local organisations and communities so they are more responsive to the needs and wishes of their local people. NHS Foundation Trusts provide and develop healthcare according to core NHS principles – free care, based on need and not on ability to pay. NHS Foundation Trusts have members drawn from patients, the public and staff and are governed by a board of governors comprising people elected from and by the membership base.
Hospital Episode Statistics Hospital Episode Statistics is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere.
National Institute for Health and Clinical Excellence The National Institute for Health and Clinical Excellence is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Visit: www.nice.org.uk
NHS Choices The first port of call for the public for all information on the NHS. NHS Information Centre The NHS Information Centre is England’s central, authoritative source of health and social care information. Acting as a ‘hub’ for high quality, national, comparative data for all secondary uses, they deliver information for local decision makers to improve the quality and efficiency of frontline care. Visit: www.ic.nhs.uk
Providers Providers are the organisations that provide NHS services, for example Surrey and Sussex Healthcare NHS Trust.
Registration From April 2009, every NHS Trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC).
Research Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. It might involve either patients or people in good health, or both.
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Appendices
Quality Account 2014-2015
Appendices Appendix A: Statement of our directors’ responsibilities Commissioners The content of this report was agreed with the Trust’s Executive Team, Senior Clinical Staff (Executive Committee for Quality & Risk), the Safety and Quality Committee and the Trust Board. Our priorities for quality improvement in 2014/15 are based on our Quality Strategy and follow consultation through our clinical divisions with staff, and with our other stakeholders, including patients and their carers. The report has been reviewed by: • Crawley, Horsham, Mid Sussex Clinical Commissioning Group • East Surrey Clinical Commissioning Group • Surrey Downs Clinical Commissioning Group • Surrey Health Scrutiny Committee • West Sussex Health and Adult Social Care Select Committee • Healthwatch Surrey • Healthwatch West Sussex They have been invited to review the report and their comments are included.
Statement of directors’ responsibilities in respect of the Quality Account 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 National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011).
Appendix B: What our partners say In preparing the Quality Account, directors are required to take steps to satisfy themselves that: • the Quality Account present 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 • the Quality Account has been prepared in accordance with Department of Health guidance The directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Account. By order of the Board 25 June 2015 Chair
25 June 2015 Chief Executive
Crawley, Horsham and Mid-Sussex, East Surrey and Surrey Downs Clinical Commissioning Groups Thank you for giving Crawley, Horsham and Mid-Sussex, East Surrey and Surrey Downs Clinical Commissioning Groups the opportunity to comment on your Quality Account for 2014/15. The CCGs have reviewed the Surrey and Sussex Healthcare NHS Trust Quality Account and can confirm that the quality account complies with the guidelines and demonstrates progress against its priorities identified for 2014/15. The Quality. Account provides information across the three areas of quality: patient safety, patient experience and clinical effectiveness and highlights an on-going commitment to the improvement of the quality of care.
Performance against 2014/15 priorities The CCGs agree that the report is comprehensive and although mainly reflecting the good work that the Trust has done, it is in fact balanced with areas where improvements are required. With regards to patient safety we are pleased to note that the organisation has done well to maintain reductions in Falls, Major hospital acquire pressure damage and Healthcare Acquired Infections. In particular, the section on Healthcare Acquired Infections clearly highlights how the processes put in place have enabled the Trust to successfully reduce the number of hospital acquired infections.
We have also considered that there were areas of strength within the accounts, namely that the accounts clearly show how the organisation has set its future priorities for quality. We note specific improvements made on environmental cleanliness and nutrition. The investments in the new cleaning equipment as well as the introduction of the 2 week menu cycle and dieticians show a real commitment to improved patient experience. Also noteworthy, is the Trusts performance in the Friends & Family Test as evidenced by high rating on a national level. We particularly welcomed the inclusion of patient’s feedback and staff recognition within the accounts. The Trusts performance in reducing readmission rates is also to be noted.
Priorities for 2015/16 Rather than selecting new priorities, the organisation has sought improvements on existing priorities from 2014/15. The CCGs support the priorities for 2015/16 which appear appropriate in this context, and it is encouraging to note that the organisation acknowledges the areas where further improvements are required. However, a full evaluation of the priorities for 2015/16 was limited as draft version was incomplete and we have not been able to evaluate the ones not included. The document could be strengthened by consistently including the improvements for all areas.
Conclusion The Trust continues to make sustained progress with its improvement priorities within the context of continued whole system challenges, in particular around demand and workforce issues. We believe that the Quality Account captures the good work that the Trust is doing and outlines the quality aspirations for 2015/16. The CCGs consider the priorities outlined for 2015/16 appropriate and look forward to reviewing progress at the regular Quality conversations throughout the year.
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54
Appendices
Quality Account 2014-2015
Healthwatch West Sussex Introduction
and Horsham hospitals • Staffing – poor attitude, inconsistency of consultant and general staffing levels
As the independent champion for health and social care for patients across West Sussex Healthwatch (HWWSx) are pleased to be invited to comment on Surrey and Sussex Healthcare NHS Trust (SaSH) draft Quality Account (QA) for 2014-15.
Further anonymised details can be supplied if required.
We note that the Care Quality Commission (CQC) has awarded a “Good” rating to the Trust with some areas reported as “Outstanding”. The CQC did identify a need to improve outpatient services and communication with patients, therefore, we are delighted to see a clear focus on patient engagement embedded in the proposed priorities for 2015/16. We await with interest the report on Responsiveness to Patient Personal Needs.
• HWWSx welcome the reduction in hospital acquired infections and pressure damage. An improvement in access to services addresses a number of issues reported to us. The use of the WHO Safer Surgery checklist can only lead to improvement in surgical practice.
The Trust is commended for using a variety of tools to elicit patients’ views and experience. However evidence of actions taken as a result are not included in the QA for 2014-15. Our commentary not only reflects the content of the Trust’s draft QA but is also drawn from patient experience as recorded in our Client Relationship Management (CRM) system. HWWSx received both positive and negative comments from patients. In summary: Positive • Staff - A number of patients praised the nursing and midwifery staff at Horsham, Crawley and East Surrey Hospitals Negative • Delays in treatment - including not hearing back about treatment/repeated cancellation and postponement of appointments/ information lost or incorrect. • Discharge - inadequate arrangement and lack of follow up care. • Treatment - condition not taken seriously or condition not resolved • Safety and hygiene - particularly in East Surrey
Safety
Priorities for 2015/16 Data quality and accuracy of coding are a major issues for all healthcare providers. We are pleased to note that the Trust is reviewing these areas. We welcome the priority of a seamless care pathway between primary/secondary care as it will address some of the issues reported to us.
Reported improvement 2014/15
Priorities for 2015/16 The Trust is to be commended in recruiting a falls champion and working towards timely treatment for fractured neck of femur using the research based FNF care pathway. Maternity services at the Trust are recognised as offering high quality care which is supported by the Maternity Safety Thermometer now rolled out across Kent, Surrey and Sussex. We have been made aware of national concern around stroke, therefore, HWWSx is pleased to see the Trust is introducing SSNAP standards. Serious incidents and near misses are a source of learning and we welcome the Trust’s renewed focus on disseminating this to staff. We would wish to see evidence of this included in the Quality Account.
Effectiveness Reported improvement 2014/15 HWWSx congratulate the Trust in reducing the readmission rate and the need for admission through partnership working with community providers. We would expect all Trusts to be compliant with NICE guidance, to take part in the National Clinical Audit Programme and Confidential Enquires and hope to see evidence of improved outcomes over time.
Patient experience Reported improvement 2014/15 As the independent patient’s voice we commend the Trust in its efforts to hear directly from patients and carers and offer more information on their services. We would wish to see continued evidence of improvements made as a result of patient feedback in the 2015-16 QA. Priorities for 2015/16 HWWSx very much welcome the inclusion in the QA of increased patient feedback through focus groups and a Customer Care programme to support the philosophy of patients at the heart of care. The development of Cultural Champions will assist staff and ensure that individuals with protected characteristics receive equal access and an improved experience of care from the Trust.
Conclusions from the service user perspective As an organisation representing patient interests, viewing evidence of service improvement is of primary importance to us. HWWSx commends the Trust for their stated aim of putting the patient at the heart of their care. A commitment to high quality, safe care with a view to continuous improvement is welcomed. We congratulate the Trust on the improvements achieved as identified in the QA 2014-15 report but would wish to see a more outcomes focused approach in the future with clear evidence of actions taken as a result of meaningful patient engagement.
A significant number of West Sussex residents’ access healthcare at various Trust sites. We now welcome the recently introduced formal opportunity for engaging with the Trust’s Quality Nurse Lead and hope this continues throughout 2015-16 and to work together on the development of the Quality Account. HWWSx looks forward to building an open, transparent and mutually respectful relationship with the Trust to support continuous improvement in the delivery of healthcare for all patients.
Surrey Health Scrutiny Committee The Committee is grateful for the opportunity to comment on the Surrey & Sussex Healthcare NHS Trust (SASH) Quality Account following regular meetings with both the Medical Director and Director of Quality & Nursing throughout the last year. • Two Members of the Committee are responsible for oversight of the Trust’s quality and have scrutinised this year’s account and wish to put on record the following comments: • The Committee noted the high quality of care provided by SASH and that it achieved a good inspection outcome from the Care Quality Commission. • The Committee welcomed the fact that SASH had met 70% of their targets, with the remainder being partly met. • The Committee welcomed the action that the Trust was taking in relation to working with partners to increase dementia and stroke awareness and welcomed the fact that the trust had a lead champion for the target areas. However, the full data was not available for stroke care – a partially met performance which meant the committee could not fully scrutinise performance in this area. • The Committee welcomed the actions being
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Appendices
Quality Account 2014-2015
taken to improve quality to an even greater level to achieve a better result at its next CQC inspection. • The Committee welcomed the further focus on screening and IV line/catheter hygiene to achieve zero attributable cases of MRSA and the emphasis on root cause analysis of all incidents of C. difficile which, together with appropriate antibiotic prescribing and hygiene practices, has kept incidences below the targeted maximum. • The Committee welcomed the introduction of mouth care assessments for in patients • The Committee regrets that amongst the items where the data was unavailable for the draft were two important areas: firstly safe and appropriate discharge and secondly mental health as problems with provision in both areas have occurred across Surrey. The Committee notes that SASH had committed to a planned discharge programme and would expect to assess progress in implementation and analysis of factors hindering progress such as difficulties with patient transport services. • The Committee noted that other NHS trusts tend to include references to complaints and, whilst noting that the SASH would be limited by the regulator, advised that they would welcome a section on complaints in the quality account. • The Committee noted this year’s objective for improvement to encourage more senior frontline staff to respond directly to comments on Patient Opinion and roll out the Your Care Matters programme to cover all patient pathways, building upon existing performance measurements and to consistently respond to the comments they receive and strive to make improvements. • The Committee will continue to work closely with the Trust and looks forward to continued improvements in 2015/16.
West Sussex Health & Adult Social Care Select Committee (HASC) Thank you for offering the Health & Adult Social Care Select Committee (HASC) the opportunity to comment on Surrey and Sussex Healthcare NHS Trust’s Quality Account for 2014-15. HASC is pleased that clinicians are now key in managerial decision-making and that external benchmarking is used to measure all aspects of safety, clinical effectiveness and patient experience. The ‘Your Care Matters’ programme and the Patient Opinion website are important and have provided ways for patients to give vital feedback to the Trust. HASC welcomes the move towards more transparency as a result of recommendations in the Francis Report and also the reconfiguration of staff ward ratios. Finally, we look forward to hearing whether or not the Trust achieves Foundation status.
How to contact us Surrey and Sussex Healthcare NHS Trust Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at: East Surrey Hospital Redhill Surrey RH1 5RH Telephone: 01737 768511 Surrey and Sussex Healthcare NHS Trust provides non-emergency services at Crawley Hospital which is managed by NHS Property Company. Crawley Hospital Crawley West Sussex RH11 7DH Telephone: 01293 600300 We also provide a number of services at four community sites: Caterham Dene Hospital Church Road Caterham Surrey CR3 5RA Telephone: 01883 837500 Horsham Hospital Hurst Road Horsham West Sussex RH12 2DR Telephone: 01403 227000
Oxted Health Centre 10 Gresham Road Oxted RH8 0BQ Telephone: 01883 734000 Surrey and Sussex Healthcare NHS Trust Trust Headquarters Canada Avenue Redhill Surrey RH1 5RH Telephone: 01737 768511 Email: enquiries@sash.nhs.uk www.surreyandsussex.nhs.uk twitter: @sashnhs
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Need help or advice? The Patient Advice and Liaison Service (PALS) focuses on improving services for NHS patients. It aims to:
You can contact PALS by:
• advise and support patients, their families and carers
• telephone: 01737 768511 x 6922 or 6831 (for all sites)
• provide information on NHS services
• e-mail: pals@sash.nhs.uk
• listen to your concerns, suggestions or queries
• writing to: PALS, c/o East Surrey Hospital, Redhill, Surrey RH1 5RH
• help sort out problems quickly on your behalf
This information is available in other languages and formats including audio tape, large print and Braille. For further information please contact PALS (Patient Advisory Liaison Service) on 01737 231958 or email: enquiries@sash.nhs.uk
TRUST BOARD IN PUBLIC
Date: 25th June 2015 Agenda Item: 4.3
REPORT TITLE:
Information Governance Annual report
EXECUTIVE SPONSOR:
Ian Mackenzie, Director of Information and Facilities
REPORT AUTHOR:
Dipa Bhella, Information Governance Manager
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
IGSG members: June 2015
Action Required: Approval ( )
Discussion ( )
Assurance (√)
Summary of Key Issues
IG Toolkit Assessment 2014/15 Assurance Framework Compliance with Legal and Regulatory Framework Information Security Incidents Risk Management and Assurance Development Plans for Next Year
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 for the catchment populations of Surrey & Sussex SO5: Well - led Corporate Impact Assessment: Legal and regulatory implications
Ensures the Board is aware of the Trust’s compliance with key legislation and broader information governance compliance
Financial implications
N/A
Patient Experience/Engagement
N/A
Risk & Performance Management
Informs the Board of the Information Governance Risk and Assurance Framework
NHS Constitution/Equality & Diversity/Communication
N/A
Attachments:
TRUST BOARD REPORT – 25th June 2015 Information Governance Annual Report to the Board – Senior Information Risk Owner
1. Introduction 1.1. The purpose of this report is to provide assurance to the Board that the Trust is addressing information governance (IG) obligations. This report comments on: 1.1.1. compliance with the Information Governance toolkit and improvements in relation to managing risks to information 1.1.2. organisational compliance with legislative and regulatory requirements relating to the handling of information, including compliance with the Data Protection Act (1998) and Freedom of Information Act (2000); 1.1.3. any Serious Untoward Incidents within the preceding twelve months, relating to any losses of personal data or breaches of confidentiality. 1.1.4. the direction of information governance work during 2015/16 and how it aligns with the strategic objectives of Surrey and Sussex Healthcare NHS Trust. 2. Information Governance Toolkit Assessment 2.1. The Information Governance Toolkit is the mechanism through which NHS and related organisations demonstrate their compliance with a number of information governance requirements – of which there are 45 for the acute hospital sector. 2.2. The Trust is required to upload evidence to support its assessment of its compliance against criteria set within the toolkit. This then determines the scores for each requirement which range from level zero to three. To achieve an overall organisational rating of ‘Satisfactory’ (the highest level possible), each requirement must be scored at level 2 or above. 2.3. Prior to submitting its final assessment, the Trust’s internal auditors, Baker Tilly, audited a random sample of 7 requirements based on the interim scores submitted by the Trust in October 2014. Based on the evidence available at the time of the audit, agreed the scores of all seven of the requirements.
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An Associated University Hospital of Brighton and Sussex Medical School
2.4. In the year ending 31st March 2015, the Trust achieved an overall rating of ‘Satisfactory’. The breakdown of the scores are shown in the table below: Table 1: SASH IG Toolkit Final Assessment (2014/2015) Assessment Information Governance Management Confidentiality and Data Protection Assurance Information Security Assurance Clinical Information Assurance Secondary Use Assurance Corporate Information Assurance Overall
Level 0
Level 1
Level 2
Level Total 3 Req'ts
Overall Score
Grade
0
0
2
3
5
86%
Satisfactory
0
0
7
2
9
74%
Satisfactory
0
0
14
1
15
68%
Satisfactory
0
0
5
0
5
66%
Satisfactory
0
0
6
2
8
75%
Satisfactory
0
0
3
0
3
66%
Satisfactory
0
0
37
8
45
72% Satisfactory
2.5. The Trusts results are comparable with other Acute Trusts within Surrey and Sussex as shown below: Table 2: Overall IG Toolkit Scores: Acute Hospitals in Surrey & Sussex Level 0 0 0
Level 1 0 0
Level 2 19 44
Level 3 26 0
0
0
39
6
Frimley Park
0
3
30
12
RSCH SASH Western Sussex Hospitals
0 0
0 0
44 37
1 8
0
0
33
12
Assessment ASPH BSUH E. Sussex Healthcare
Total Req'ts 45 45
Overall Score 85% 66%
Satisfactory Satisfactory
45
71%
Satisfactory
45
73%
45 45
67% 72%
Not Satisfactory Satisfactory Satisfactory
45
75%
Satisfactory
N/R* 1
Grade
*Not relevant 2.5.1. Frimley Park Hospital were deemed ‘not satisfactory’ because they have requirements at level 1. 2.6. Information Governance Training: 96% of staff completed their annual information governance training during 2014/2015 this now needs to be refreshed for 2015/16. 95% of staff must complete their training each financial year, for the Trust to achieve level 2 in this requirement of the IG Toolkit assessment.
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An Associated University Hospital of Brighton and Sussex Medical School
3. Assurance framework 3.1. The Trust’s Information Governance Management Framework was reviewed in June 2014. It identifies the roles and responsibilities of key staff within the Trust and the reporting structures. 3.2. The Information Governance Steering Group (IGSG) is chaired by the Trust’s Senior Information Risk Owner (SIRO), who is the Director of Information and Facilities. Membership includes the Caldicott Guardian (the Medical Director) and representatives from Human Resources, Finance, Information Technology, Information Management and Data Quality, Health Records, Communications and Information Governance. 3.3. The reporting framework is as follows:
4. Trust Compliance with Legal and Regulatory Framework 4.1. Compliance with key legislation, such as the Data Protection Act 1998 (DPA) and Freedom of Information Act 2000 (FOIA) is regulated by the Information Commissioner’s Office (ICO). Internally, the IGSG monitors compliance with the FOIA and DPA at each of its meetings. 4.2. The Information Commissioner’s Office (ICO) conducted a follow-up audit in November 2014 the review demonstrated that a number of steps have been taken against many of the recommendations.
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An Associated University Hospital of Brighton and Sussex Medical School
4.3. Freedom of Information Requests: The Trust received 549 FOI requests during 2014/15. There were 50 breaches of the FOI 20 working day response standard in the year to date. These have largely been due to the complexity of the request and delays in sourcing or collating the data. Compared to previous year the Trust has steadily improved its compliance, achieving an overall compliance rate of 91%. 4.4. Table 3: FOIA Compliance 2014/2015 Received Compliant Breach % Compliance
Q1 128 118 10
Q2 142 133 9
Q3 120 102 18
Q4 159 146 13
Grand Total 549 499 50
92%
94%
85%
92%
91%
4.5. Subject Access Requests: In the year 2014/15 the Trust received 1749 enquiries relating to accessing health records (148 monthly average). 4.6. Table 4: SAR Compliance
2013/2014 Received Compliant Breach % Compliance
Q1 382 382 0
Q2 438 437 1
Q3 411 405 6
Q4 518 499 19
Grand Total 1749 1723 26
100%
99%
98%
96%
99%
There have been a small number of SAR breaches throughout the year mainly due to notes not being located within the time frame alongside staff shortage. The Trust did receive one complaint via the regulator, the Information Commissioner, over the Trust’s handling of subject access requests. The complaint related to a patient’s request for access to their health records, the Trust’s investigation identified problems locating the notes and actions taken to locate them. The regulator were informed that the Trust has a case note tracking system and an updated version had recently been installed to improve the detection and tracking of notes. Further to the upgrade the patient’s notes were located and a copy sent. The Information Commissioner was satisfied with the response and refrained from taking regulatory action.
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An Associated University Hospital of Brighton and Sussex Medical School
Since March 2014, SARâ&#x20AC;&#x2122;s have been recorded onto Datix the process has helped improved compliance, improved governance arrangements; enabled potential issues to be identified earlier; and improved visibility and performance monitoring. The SAR policy has been revised and information on the SAR process, including the application form has been published on the website.
5. Information Security Incidents 5.1. Staff are encouraged to report information governance risks and incidents. All 1 incidents were classified as level zero in accordance with DH guidance . As table 4 below shows the majority of incidents reported, relate to medical records; in particular the delay in obtaining notes for clinics and appointments due to an increase in ad-hoc clinics and clinics reinstated due to clinician changes. The introduction of the new radio frequency identification tagging system that has been applied to the medical records has shown a reduction in incidents reported compared to previous year figures.
5.2. Table 4: Information Security Incidents 2014/15 Email Found/disclosed records in a public place Medical records / notes Post Inappropriate disposal Inappropriate disclosure Failure to secure records Verbal breach Total
Q1 2
Q2 0
Q3 0
Q4 1
Total 3
9 32 8 1 6 4 0 39
15 33 5 0 5 1 1 51
9 26 4 0 1 1 1 35
4 31 8 0 6 4 0 41
37 126 25 1 18 10 2 220
1
Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward Incidents Requiring Investigation: Version 2.0_June 2013
Â
6
An Associated University Hospital of Brighton and Sussex Medical School
6. Risk Management & Assurance 6.1. As well as line management responsibility for information governance staff, the SIRO is responsible for overseeing the development and implementation of the Trust’s information risk strategy. 6.2. The SIRO is supported in this by the information governance team and by Information Asset Owners (IAOs) within each business area. The IAOs are responsible for managing information risks to the assets within their control. This involves developing system security policies and business continuity plans as well as documenting their personal data information flows, updating asset registers, conducting regular information risk assessments, and ensuring staff have completed their annual information governance training. 6.3. The IAOs reviewed the system security policies and risk assessments for their information assets. Overall no information assets have been highlighted as ‘red risks’, and show that robust controls are in place to reduce the impact of risks that may occur. 6.4. During 2014/2015 all IAO’s completed their annual training in Information Risk Management via the e-learning tool. 6.5. Whilst progress was made, the Trust recognises that further work is required to embed further assets to these processes. 7. Development plans for next year 7.1. The Trust has a dynamic action plan to refresh and improve its compliance with the IG Toolkit standards. This will be formally reviewed once the toolkit is published for the year ahead. 7.2. Evidence for many of the toolkit requirements is readily refreshed as part of established daily business or monitoring activities. However, some objectives are harder to achieve and for this reason they are being targeted early on. 7.3. Key areas identified for 2015/16 are to: 7.3.1. Review evidence and maintain the scores of the IG toolkit at level 2 and above 7.3.2. Identify the evidence required to achieve level 3 on the requirements 7.3.3. Promote and monitor the uptake of IG training which requires 95% of staff to undertake or refresh their training annually 7.3.3.1.
Identify IG champions in key areas to promote training and increase compliance.
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An Associated University Hospital of Brighton and Sussex Medical School
7.3.3.2.
Promote IG refresher packs to clinical areas
7.3.4. Improve compliance with Subject Access Requests and Freedom of Information requests.
8. Summary and recommendations 8.1. In summary, much has been achieved in the last year, which is supported by the ‘Satisfactory’ rating in the IG Toolkit assessment and internal audit opinion. 8.2. The Board is asked to receive and note this report.
Ian Mackenzie Director of Information & Facilities June 2015
8
An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 25th June 2015 Agenda Item: 4.4
REPORT TITLE:
Security Annual Report 2014/15
EXECUTIVE SPONSOR:
Ian Mackenzie Director of Information and Facilities Richard Bridgman Security Manager
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Executive Committee – 10 June 2015
Action Required: Approval (X)
Discussion ()
Assurance (√)
Purpose of Report: To approve the Annual Report Summary of key issues Summary of the security activities for the year 2014/2015 Recommendation: The Board is asked to approve the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact
Annual requirement to provide a report
Financial impact
Included in the report
1
Patient Experience/Engagement
Included in the report
Risk & Performance Management
Included in the report
NHS Constitution/Equality & Diversity/Communication
Included in the report
Attachment: Security Annual Report for 2014/15
2
Security Annual Report 2014/2015
April 2015
3
Executive Summary
The hospital continues to be described as a safe and secure public environment for patients, staff and visitors. There have been actions in year that have improved the experience of patients, visitors and our staff. In response to the staff survey, a security lectern has been placed in ED reception where the security guard will man to demonstrate the Trustâ&#x20AC;&#x2122;s security presence. Attendance on Conflict Resolution Training courses has improved significantly on previous years. One new policy, (Safer Holding) and four, reviewed, existing policies, (Security Management, Missing Persons, Violence and Aggression, Lone Workers) have been ratified and are being implemented Throughout the reporting year there has been 245 reported incidents of physical and verbal abuse, an increase of 19%. One patient created 21 reported incidents and the need to report incidents has been subject of the security managersâ&#x20AC;&#x2122; presentation on MAST training courses. Only fourteen crime incidents were reported to the police, one resulted in a police caution and one is still in the judiciary process, twelve were filed. There have been 21 reported incidents of theft, 15 relating to patient and staff property. Planned security improvements for the coming year include development of a joint working agreement between local Trusts and the Police, initiating a newly designed security inspection checklist auditing the security arrangements around the hospital and continuing to build on the success of increased attendance at conflict resolution training by focusing on filling available spaces.
4
Security Manager’s Annual Report 2014/2015 This report provides the Trust Board with a summary of the security activities for the year 2014/2015 This document has been prepared to report to The Board of Surrey and Sussex NHS Trust and the NHS Counter Fraud and Security Management service the progress of The Trust in the provision of Local Security Management over the past year; it is also intended to inform The Trust’s Board and Security Management service of the work planned for the forthcoming year 2015/2016. The Security Manager, Richard BRIDGMAN, is an accredited Local Security Management Specialist (LSMS) and has been in post for 4 years. The hospital enjoys a safe environment, being set in a rural location away from main towns. There are two residential estates close by and these are relatively quiet without any identified crime trends, which could impact on the hospital. Incidents which occur on site are mainly isolated, not forming a crime trend, and are of a relatively minor nature. In line with the NHS Security Management Service strategy document “Protecting your NHS: A Professional Approach to Managing Security in the NHS” this report will refer to the seven generic actions for managing security:
Creating a pro-security culture Deterring those who may be minded to breach security Preventing security breaches from occurring Detecting security incidents and breaches and ensuring these are reported Investigating security incidents and breaches Applying sanctions against those who breach security Seeking redress through the criminal and civil justice systems
And the four priority actions for the protection of the following:
Patients and staff NHS Property and assets Maternity and paediatric units Drugs, prescription forms and hazardous material
Overview of 2014/15 statistics – (as recorded on Datix):
5
Incident
2013/14
2014/15
Physical Assaults
89
140
Verbal Abuses
74
68
Theft of NHS property
3
6
Theft of staff and patient property
9
22
(A physical assault is the intentional application of force to a person or another without lawful justification resulting in physical injury or personal discomfort) The reporting year shows an increase, in physical assaults and theft of staff/patient property, on the last reporting year. In November 2014 one patient in Godstone Ward was particularly violent resulting in 21 incidents of physical assault being reported. Generally, crime trends remain as they were which are individual, unrelated incidents. As a new venture, security has a presentation on the MAST training programme which may account for improved reporting and increased numbers. CREATING A PRO-SECURITY CULTURE
The Trust currently has in place a security policy intended to give direction to staff members in order to promote a security culture. It is intended to provide assurance to employees and others that The Trust will ensure, so far as is reasonably practicable, that the personal safety of service users and employees are addressed, maintained, improved and monitored. The policy intends to protect property against theft and damage and is designed to; ď&#x201A;ˇ ď&#x201A;ˇ ď&#x201A;ˇ
Minimise the security problems that occur and closely monitor the implementation and effectiveness of this policy. Highlight and improve security awareness. Set in place a mechanism for identifying actual or potential security risks
Annual Security Report All NHS bodies are required to ensure that their Security Management Specialist produces an Annual Security Report which covers the work carried out in the seven generic and four specific areas of action. Annual Reports for the Trust have been produced since the appointment of Security Management Specialists.
6
Trust Policies One new policy was ratified: Safer Holding Policy - 26 November 2014 Four policies have been reviewed and ratified in the reporting year: Missing Persons Policy - 19 August 2014 Security Management Policy – 27 March 2015 Violence and Aggression Policy – 27 March 2015 Lone Worker Policy – 27 March 2015
Police Support/Surgeries Throughout the reporting period the Police have performed a number of support functions with the aim of raising crime awareness amongst staff and members of the public visiting the hospital. In cooperation with the Surrey Police Safer Neighbourhood Team; PC 3009 Rowe and PCSO 11835 Martin, crime prevention initiatives were undertaken, such as prevention of theft of and from vehicles in the car parks. In addition to the specific events, on a monthly basis, the Neighbourhood Policing team has run ‘drop in’ surgeries whereby staff, patients and visitors have the opportunity to meet the officers and discuss any police related concerns. This arrangement has worked extremely well. The Safer Neighbourhood Team manned a Police stand during the ‘Wellbeing Day’, in March 2015, engaging with staff offering advice, answering police related queries and property marking Throughout the year the Safer Neighbourhood Team monitored and responded appropriately to incidents and crimes in and around East Surrey Hospital liaising with the Security Manager, security guards and staff. They have taken on investigations, particularly those which the Trust has been able to give supportive evidence from the CCTV system. Routine patrols are carried out on a weekly basis offering reassurance and a high visibility presence to staff, patience and visitors. The main hospital site is located in the Earlswood, Salfords and Whitebushes patrol area of Surrey Police, and is in an average crime rated area. Police Officers attending the Trust Security Management Committee report that there have not been any significant crime trends in the surrounding area for the reporting year. In September 14, Pc Becky Rowe left the role and Pc Kinza Dunn (nee Labassi) returned having been on extended leave.
7
Security Presentations Throughout the reporting year the security manager has presented to new and existing staff, on the Mandatory and Statutory Training programme, giving an opportunity to inform staff about security issues. The security presentation gives a general overview of security trends/ manned guarding / CCTV and incident reporting Website A security page on the Trust Intranet website has been designed and is in the process of being placed on the website. The page introduces the security manager, gives an overview of the hospital site and some generic security advice. Necessary forms and related policies will be attached. DETERRING SECURITY INCIDENTS OR BREACHES
Physical security measures have been developed within the hospital and continue to do so. Door access control requests have been reviewed and approved as appropriate. CCTV and access control systems have been identified for security purposes within the new builds. There has been liaison with Capital Project managers, over new builds to ensure new buildings are secure and viewed by CCTV as necessary. CCTV signage has been designed and produced and signs have been placed around the hospital site to ensure the Trust complies with the Data Protection Act and serve as a deterrent to potential offenders. PREVENTING SECURITY BREACHES FROM OCCURRING
Sharing best practice The Trust Security Manager and Security Managers from other health bodies in the area meet quarterly to share best practice and, where appropriate, share intelligence on security breaches.
NHS Protect Alerts Crime alerts received from NHS Protect are assessed by the security manager. Six, which were relevant to the Trust, were disseminated to appropriate staff for their information and necessary action. Conflict Resolution Training
8
Under Secretary of State Directions, a key preventative measure to support the development of a pro-security culture is the introduction of a national syllabus for Conflict Resolution Training (CRT) in the NHS. The NHS CFSMS has developed the syllabus in association with the British Medical Association, the Royal College of Nursing and UNISON. Conflict Resolution Training relies on the ability of the member of staff and the aggressor to be able to communicate with each other effectively and for both parties to wish for the situation to deescalate. However most of the physical assaults occur in clinical settings where patients who assault staff may be confused and/or have limited capacity to communicate owing to medication or clinical condition. It is the employer’s responsibility to ensure that staff are trained to assess rapidly changing situations, evaluate the risks to themselves and others and act in an appropriate manner. Measures have been put in place with an out-sourced training provider ‘MAYBO’ to deliver the training as an ongoing programme and funding will be identified so the programme can continue June 2015 to May 2016. Some wards have a higher incidence of more challenging patients and it was recommended there is a need to train staff in assault avoidance and clinical holding techniques. As a result, in June 2014 Maybo commenced this training. A CRT programme, provided by Maybo (Conflict Management Training Company) has been in place throughout the reporting period, and a total of 796 members of staff have been trained. This is a significant improvement on the reporting year 13/14 which totalled 285 staff trained.
Conflict Management Training - 01 Apr 2014 - 31 Mar 2015 Staff Group
Classroom online eLearning Completed
Add Prof Scientific and Technic Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists
26 151 96 61 13 5
+ Trust % Trained Headcount
78 699 719 168 320 90
33.33 21.60 13.35 36.31 4.06 5.56
9
Medical and Dental Nursing and Registered Students Total Completed
80 Midwifery 309
536 1154
14.93 26.78
0 741
4 3768
0.00
Conflict Management Training for Trainee Doctors - 01 Apr 2014 - 31 Mar 2015 Staff Group
Classroom online elearning Completed
Medical and Dental (Trainee) Total Completed
55 55
+ Trust % Trained Headcount
242 242
22.73
(Conflict Management Training is for all staff who have direct contact with patients and/or visitors) Some wards/departments have more of a need for conflict training than others but difficulty with attendance has meant preference has been relaxed. CCTV The CCTV cameras have been maintained over the reporting year. As new builds have been developed the number of cameras feeding back to the East Entrance has increased. There are now 105 cameras. The most recent to be added come from the Theatres extension and the Radiotherapy building. Cameras which are located on the existing hospital building and have been obstructed by new builds, for example; cameras viewing the east car park obstructed by the newly built Tilgate Annexe, have been relocated on the new build and afford an unobstructed view of the east carpark. Security Guarding CORPS Security remain contracted to supply one guard 24/7 based at the Trust. Security are called by either direct land line, bleep or via the porter radio. The table below shows incidents responded to in one month.
10
CORPS Security performance A one month example of the recorded responses that Corps Security guards respond to: – March 2015 Incident Physical assault Verbal assault Staff assistance Criminal damage Theft Missing patient Intruder alarm Totals
Week 1 0 0 3 0 0 1 1
Week 2 0 0 5 0 2 3 0
Week 3 0 0 3 0 0 6 0
Week 4 2 0 10 1 1 3 0
5
8
9
15
The March returns of 37 are average for a month. It would be fair to estimate that over a year, 500 incidents are responded to by the Corps Security guards. DETECTING SECURITY INCIDENTS AND BREACHES AND ENSURING THESE ARE REPORTED The reporting of incidents and breaches are encouraged as it allows the Trust to identify areas of weakness and take measures, where appropriate, to reduce or eliminate risk. All security related incidents (recorded on-line) are automatically sent to the security manager for information and any necessary action. It is important that staff report any untoward, violent or potentially violent incident to the switchboard via the 2222 line or bleeping the security officer. The security officer will then attend as appropriate and/or call for police assistance for the most serious cases. Staff are encouraged to call Security sooner rather than later. It is particularly important that thefts are reported as soon as they are discovered; this allows the security guard to start investigating immediately and increases the chances of identifying and/or apprehending offenders. By reviewing reported crime incidents two offenders have been identified which have resulted in police action; May 14 – Porter – Cautioned by police and dismissed for stealing food from service corridor. Dec 14 – Member of the public – Charged - Indecent exposure/ breach of ASBO – At this time trial deferred for psychiatric reports INVESTIGATING SECURITY INCIDENTS AND BREACHES
11
Priority is given to investigating the most serious incidents and those involving assaults on staff. Internal investigations or reports to police are carried out. Reported security incidents recorded on Datix are assessed by the security manager. Where it is appropriate, there will be an investigation or a reassurance visit to the ‘victim In the reporting year there have been 14 incidents reported to the police which have been recorded as crimes. Of these: One offender was arrested and cautioned One offender was charged pending court appearance One person was interviewed for an offence but there was no further action Eleven were filed by police as ‘no line of investigation’. SEEKING TO APPLY SANCTIONS
Currently, when suspected offenders are identified or apprehended by staff, the police are called. If appropriate the police will arrest the individual. The Trust’s stance is that wherever appropriate, i.e. there is sufficient evidence and it is in the public interest, individuals should be charged and prosecuted for alleged offences. SUPPLYING INFORMATION SO THAT REDRESS CAN BE SOUGHT Security incidents and breaches have a direct impact on the resources allocated to the NHS to deliver high quality patient care. Time and money spent on replacing stolen NHS equipment, repairing and replacing damaged NHS equipment or dealing with the consequences of violence is time and money diverted from the delivery of health care. Where losses are incurred the Trust should and does seek redress through the criminal courts from those responsible for causing them. PROTECTION OF PEOPLE Assaults The Trust continues to regard violence and aggression towards staff as its primary priority area for action. Amongst the actions taken to provide a safe and secure environment the Trust reviews its Policy and Procedures for violence and aggression within given timescales These policies and procedures are available to all members of staff on the Trust’s intranet site. The Security Manager reviews every reported incident of violence or 12
aggression against staff and where appropriate carries out an investigation to establish the cause. The Trust maintains and continues to develop close links with relevant organisations such as the police. Under the various assault categories there have been 245 recorded incidents in the reporting period 2014/15 as opposed to a recorded figure of 199 for 2013/14. There is, according to these statistics, a 19% increase in assaults against staff for this reporting period. (It is worth noting that 21 of the reporting years 245 incidents were as a result of one patient. Also staff are more proficient in incident recording as a result of MAST training). Assault Figures â&#x20AC;&#x201C; Totals and Variance
Abuse of Staff by Patient Physical abuse, assault or violence Verbal abuse Disruptive, aggressive behaviour - other Racial Sexual Threatening/Abusive Phone call Abuse of Staff by other Staff Verbal abuse Disruptive, aggressive behaviour - other Phone call - threatening or abusive Abuse of Staff by Visitor Physical Abuse Verbal abuse Threatening/Abusive Phone call Disruptive, aggressive behaviour - other Totals:
13/14 Total
14/15 Total
Variance
134 89 22 16 4 2 1
201 136 36 22 3 1 3
+47 +14 +6 -1 -1 +2
28 23 4 1
18 11 4 3
-12 = +2
37 0 29 4 4
26 2 17 3 4
+2 -12 -1 =
199
245
+46
Abuse incidents by Division â&#x20AC;&#x201C; 2013/14 90 80 70 60
Abuse of Staff by Patient
50 40
Abuse of Staff by other Staff
30
13
20
Abuse of Staff by Visitor / member of public
10 0 Cancer
Clinical Estates & Support Facilities Services
Medical
Surgical Women & Children's
Abuse incidents by Division â&#x20AC;&#x201C; 2014/15
Missing Persons The number of responses by security and clinical staff to persons who go missing from the wards/departments is not accurately reflected by the information held on the Datix system. The activity log held by the security guard shows that responses to missing persons around the hospital is more likely to be an average of 5 per week, 260 per year. These will range from a missing person found within the hospital within minutes to a high risk missing person who has left the hospital and involves a police search. Recorded missing person incidents year 2013/14 Total Acute Medical Unit Bletchingley Ward Charlwood Ward Discharge Lounge Hazelwood Ward Surgical Assessment Unit (SAU) Tilgate Ward Godstone Ward
4 1 2 1 3 1 1 5 14
Woodland Ward Totals:
1 19
Recorded missing person incidents year 2014/15 Abinger Ward AMU (Acute Medical Unit) Angio suite Buckland Ward Capel Ward Discharge Unit Emergency Department (ED) Godstone - Medicine Ward Godstone Haematology Ward Hazelwood Ward (no longer existing) High Dependency Unit (HDU) Holmwood Ward Nutfield Ward Maternity - Rusper Ward Surgical Assessment Unit (SAU) Tandridge Ward Tilgate Ward
1 2 1 1 2 3 3 2 1 2 2 2 2 1 1 2 2
Totals:
30
PROTECTION OF PROPERTY AND ASSETS Trust property The Trust has in place asset registers held with Finance and IT. All incidents of theft, damage and burglary are reported as a matter of course on the Trustâ&#x20AC;&#x2122;s on-line Datix incident reporting system. If appropriate they will be reported to the police. Despite the physical security measures in place throughout the Trust the emphasis must still be placed on the human element, i.e. personal responsibility, to ensure that property and belongings are secured Patients property
15
The vast majority of thefts are committed by perpetrators who did not need to break and enter the premises. Invariably, the thefts tended to be of an opportunist nature. The handling and management of patients’ property at ward level is a set procedure which includes documentation of the transfer of property between wards/departments, and timely removal of patients’ property to cashiers. The management of patients’ property should be regarded as an integral part of the patient experience. It is to be expected that patients would want to have and use mobile personal devices such phones, palmtops etc. The existing procedure caters for this and patients must take responsibility for such devices, if they elect to bring them into the hospital, and sign to retain them. Photo I.D. badge/access control Staff I.D. badges are issued and activated with standard access areas. Authorised areas are added on the authority of the ‘authorised area’ manager. Once an employee leaves the trust the security card administrator is notified by HR from the ‘leavers list’ and the employee’s card is then de-activated. The number of Trust buildings and departments having an access control system installed is increasing and will continue to increase. Theft and Vandalism During the period 2014/15 there has been 21 incidents of theft and vandalism recorded by the Trust as opposed to 17 incidents during the corresponding period from 2013 to 2014. The comparison shows crime incidents have remained at a low level. Crime Figures 2013/2014
Total
17 6 3 3 5
Crime Figures Theft - patient property Theft - staff property Theft - Trust property Vandalism Crime Figures 2014/2015
Total Crime Figures Theft - patient property Theft - staff property
21 8 7
16
Theft - Trust property Vandalism
4 2
PROTECTION OF MATERNITY AND PEDIATRIC UNITS
The Maternity Department is a secure area with swipe access given only to authorised staff. The Child/Baby Identification/Abduction Policy has been reviewed by Maternity staff and has been ratified. DRUGS, PRESCRIPTION FORMS AND HAZARDOUS MATERIALS
Incidents which expose vulnerabilities to the security of medicines and drugs are reviewed and further measures put in place.
Risks and Managing risks Risks relevant to security have been dealt with in the reporting period and at this time there are no security risks on the register Staffing Security staffing currently comprises of the Trust Security Manager, Richard Bridgman and a contracted security guard who is on site 24/7. Security Improvements in 2014/15 Lone Worker Alarms To date 61 alarms have been issued, which includes risk assessed areas within the hospital, such as Ophthalmology and Clinical Site Managers. CCTV CCTV cameras continue to be installed, mainly from within the capital project new builds. To date 105 cameras are in place. Regular maintenance has ensured the cameras are serviceable. Security lectern The proposal to site a security lectern in ED reception, after consultation, was approved. Its purpose is to provide a security presence and reassurance to staff, 17
patients and visitors. The guard will sit at the lectern, when available, on Thursday/Friday and Saturday evenings and at any other time as he wishes. When the guard is not sat at the lectern then the word security boldly written on the front panel will remind potential wrong doers there is a security presence on site Corps Security, the contracted security company, has kindly contributed £200 to the cost of the lectern and will have their logo displayed on the front panel Property marking A number of property UV property marking pens have been obtained and a bulletin item circulated to staff informing them of this facility – Property has been marked in Dental Services and within Capital Projects Assault Avoidance and Clinical Holding Technique training Training courses were offered to staff, commencing June 2014. Two sessions; one day per month. Poor attendance has been an issue and some courses have been cancelled or postponed due to poor attendance. Planned Security Improvements for 2015/16 Joint Working Agreement A police lead agreement addressing working practices between Surrey Police and Surrey NHS bodies, to work closer to reduce the problem of crime, violence and anti-social behaviour affecting the NHS and reduce the demands placed on each organisation during the reporting and investigation of any incident. This agreement is currently in the consultation process Security Inspection Checklist Develop and maintain a bi-annual checklist, inspected by the LSMS, auditing the integrity of the physical security arrangements around the Trust. Key Objectives 2015/16 To work towards compliance with Secretary of State’s directions regarding security management in accordance with the following: Secretary of State’s directions to tackle violence against staff; a professional approach to managing security in the NHS; Secretary of State’s directions on NHS Security Management measures
18
To continue investigating all physical assaults on staff in accordance with Secretary of States Directions. To continue to monitoring risk assessments and security policies for each ward and department with respect to security, managing violence and lone working. CONCLUSION The security focus will be to continue developing work in the seven generic areas for improving security. The Trust has identified the funding to continue providing conflict resolution training for the 2015/16 financial year. It is essential that there is continued investment in training of staff in conflict resolution and development of further training for preventing assaults in in-patient areas. Throughout the reporting year improvements have been made to the placing and maintenance of the CCTV cameras around the hospital. This has resulted in valuable assistance with internal and police investigations. The CCTV system has benefited from the capital projects and has expanded as the new builds have been developed. The use of the Risk Assessment Tool for Violence, Aggression and Self Harm should give confidence to department managers to reduce the risk to their wards/dept. The Security Manager will provide advice and assistance to departments on security issues, and the organisation as a whole will continue to use the risk assessment model to reduce risk and focus on prevention. From a security point of view, the hospital can continue to be described as being a safe and secure environment for patients, staff and visitors. Richard Bridgman Security Manager April 2015
19
REPORT TITLE:
Date: 28/5/15 Agenda Item: 4.5 Serious Incident Report for May 2015
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 May 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 three serious incidents in May 2015, two of which occurred in May the other occurred in September 2014, with a date of knowledge of 5th May 2015. • Falls and clinical diagnosis remain the two key categories of serious incident. • As at 10th June 2015 the Trust has 20 serious incidents open with the CCG, of which 4 are overdue. • Since 1st January 2015 all RCA investigation reports have been submitted to the CCG on time. Recommendation: The Board is asked to note the contents of this report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about
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:
Page 1 of 4
TRUST BOARD REPORT Serious Incident Report – period: May 2015 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.
2.
Patient Safety Incidents in May 2015
2.1
There were a total of 633 incidents reported on Datixweb in May 2015 of which 517 (82%) were clinical/patient safety incidents. These incidents breakdown as follows:
2.2 500
None Low Moderate Severe Total
Mar 409 99 12 2 522
Apr 376 84 11 1 472
May 392 108 7 3 511
400
392
300 200 108 100
None
2.3
7
3
Moderate
Severe
0 Low
The incident categories are shown for those incidents categorised as moderate or severe harm. There were no incidents in May that caused the death of a patient. The incidents reported as SIs are shown in brackets. May-15 Care implementation Clinical diagnosis Maternity / Delivery Surgery - management of operations Total
Moderate 2 1 2 2 7
Severe 0 2 (2*) 0 1 (1) 4
*1 SI declared in June 2015
3.
Serious Incidents declared in May 2015
3.1
The Trust declared three serious incidents in May 2015. • 2015/16307 The patient was assessed as requiring intravitreal ozurdex for central retinal vein occlusion. The TCI card for booking treatment was filed in the notes instead of being sent to the booking office. The delay in treatment has resulted in a deterioration of vision which is likely to be permanent. (Incident date September 2014) • 2015/16765 The patient presented in June 2014 with a history of green sticky mucus from her right lower lid since September 2013. She reported having had a lump excised at ESH in 2009. She was told it was a "fluid filled cyst". There were no old notes available at the time of the consultation. On examination, she had a large diverticulum in the lower fornix, which was assumed a complication from her previous surgery. At surgery in October 2014, a biopsy was performed, which was reported as a basal cell carcinoma. There was a note at the bottom of the histology report stating that she had previously had a BCC incompletely excised from the same lid in 2009. There is no evidence of follow up following this result. The patient required an exenteration (removal of eye and socket). • 2015/17304 Patient was admitted to DSU for a diagnostic hysteroscopy with curettage and Mirena insertion. The patient was readmitted to ITU the following day with an unrecognised vaginal perforation. The patient had a perforated bowel which required laparotomy and bowel resection.
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. Patient falls and clinical diagnosis are the two main themes of serious incidents over the last twelve months.
Page 3 of 4
4. 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. All RCAs for Serious Incidents declared since 1/1/15 have been submitted to the CCG on time. The backlog of overdue SIs from 2014 continues to diminish. 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 10th June 2015.
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 June 2015
Page 4 of 4
Minutes of the Finance and Workforce Committee Held on 26 May 2015 at 9.00am In AD77, East Surrey Hospital, Redhill PART 1 Present Richard Durban Alan Hall (via telephone) Paul Biddle Paul Bostock Fiona Allsop Paul Simpson Gillian Francis-Musanu
Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Operating Officer Chief Nurse Chief Finance Officer Director of Corporate Affairs
Lorraine Clegg Jim Davey (part meeting) Sue Jenkins Janet Miller (part meeting) Shaun Cunningham (part meeting) Catriona Tait
Deputy Chief Finance Officer Director of Service Development Director of Strategy Deputy Director of Human Resources Head of Capital Projects Head of Costing & SLR (Minute Taker)
In attendance
1
WELCOME AND APOLOGIES FOR ABSENCE Apologies: Apologies were received from Yvonne Parker (Director of Human Resources) and Ian Mackenzie (Director of Information and Facilities). Declarations of Interest: There were no declarations of interest.
2
MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 28th April 2015 were discussed and are to be amended to include the discussion around MES OBC business case efficiencies and will come to the next meeting. Review of Actions The action tracker was presented and noted that the items would be discussed within the presented papers apart from the IT Roadmap action which is for the June meeting.
3
BUSINESS PLANNING Communication Strategy and Annual Plan Gillian Francis-Musanu presented the 5 year communications plan highlighting that it focused on actions for this year and would be refreshed in the next few months. Paul Biddle queried why a plan to cover any possible delay in FT authorisation was not included. Gillian Francis-Musanu replied that we did not yet know how long the delay will be but we are working on plans. Richard Durban commented that the document needed a clearer sense of priorities and asked how the strategy linked to the market development plan and the nursing recruitment strategy, both of which relied on excellent communications. Gillian Francis-Musanu responded that communications with members, raising the Trust profile internally and digital communications
were the priorities and that the Head of Communication is a member of the market development group. Paul Simpson added that this group also includes the Director of Strategy. Fiona Allsop advised that the international recruitment was now done but we need to do some work on the SaSH brand and what we are offering staff. Alan Hall commented that the strategy needed some key outcomes or metrics. Gillian Francis-Musanu thanked the Committee for their comments and advised she would include them in the next iteration of the strategy. Action: Updated Communication strategy and action plan to be presented to the Committee in November 2015 GFM Annual Plan Sue Jenkins presented the Trust Annual Plan, advising that it brought forward objectives from 2014/15 and added new objectives for 2015/16, it was on the agenda for the 28/5 Board and that there would be quarterly reporting to the Board. Paul Biddle commented that there were no numeric objectives. Richard Durban noted that some elements were action points i.e. to do something and some were outputs i.e. KPIs which were also part of our integrated performance reporting. Gillian Francis-Musanu commented that this was the high level document and each action has several elements. Sue Jenkins added that this was the overarching plan and that specific figures for surgical site infections, falls etc. will be included in the quarterly updates. Paul Biddle asked that under 4a Market development as we have included a figure in the IBP, should we have included it in the action plan document and also whether we should include access targets and the financial plan. Sue Jenkins replied that the access targets are included but the financial plan and reporting are in a separate document. Paul Simpson added that the Trust needs to ensure it does not duplicate its reporting. Alan Hall asked if there were any actions that have been brought forward that are of concern. Sue Jenkins replied that some were brought forward due to the timescales of the actions but there were a few red actions. The Committee supported the Action Plan before presentation to the Board for approval 4
FINANCE Financial Performance M01 Paul Simpson presented the M01 finance report and highlighted the following: - The planned position is YTD deficit for the first quarter of the year, reflecting the profile of cost improvement plans. - The Trust is on plan at month 1 with a ÂŁ0.8m deficit. - As in Q4 of 2014/15 emergency activity remains high with improved elective performance. This still carries a cost and there is also a continuation of overspending in the divisions particularly from additional duty hours. - Cash is on plan Paul Simpson advised the Committee that the risk page (p 23) has been updated to reflect the mitigations and assessor case received from Monitor. Income and activity on page 21 shows that 2
outpatient and day case activity is going up and elective activity is satisfactory in M01. Emergency activity with a length of stay of more than 2 days is higher than in April in previous years. Paul Bostock commented that the income was slightly below plan and asked if the plan included the ÂŁ14m growth. Lorraine Clegg replied that the ÂŁ14m was phased in as agreed with the Services. Jim Davey asked what contractual coverage we have with the CCGs to deal with increased emergency activity. Lorraine Clegg advised that we have agreed with the CCGs that it will be reviewed at the end of quarter 1. Paul Simpson then stated that Pricing Enforcement was not going to look at the Surrey MRET spending and then he took the Committee through the risk table on page 23. Alan Hall asked if the contract income was net of cost and Lorraine Clegg confirmed that it was the contribution. Paul Simpson advised that the discussion with Monitor regarding the risk assessment was that Monitor were being prudent. Alan Hall asked about the Keogh cost and that we would not proceed with it if the CCGs will not contribute. Paul Simpson replied that the Board conversation was that we would go ahead with it if the CCGs did not contribute but that we would include it as downside mitigation. Paul Biddle asked about the ÂŁ3.8m underlying surplus on page 11 of the report and Lorraine Clegg advised that this was how Monitor advised that the underlying position should be calculated. Richard Durban asked why the divisional spend was so far off the recently agreed budget and when will we see the overall shape of our financial performance e.g. staff costs down, elective income up match our plans Lorraine Clegg advised that there was still work to be done aligning the budgets to the extra activity i.e. allocating centrally held monies. Paul Bostock stated that in April we had done more day cases and less outsourcing with an increase in emergency activity which gives us confidence in our ability to deliver the activity plans. Paul Simpson added that the Trust was also looking at the length of stay for Emergencies but that we still have unresolved difficulties with the CCGs on emergencies with we will review after quarter 1 along with the impact of the income price reduction through the deflator model. Paul Biddle highlighted that we need to get the responsibility out to the divisions. 2015/16 CIPs and update on Clinical Supplies CIP Paul Simpson presented the CIP paper. Paul Simpson said that he and Lorraine Clegg had reviewed the CIP plan with the TDA and for the Monitor downside. Paul Simpson advised the Committee that the TDA understands Monitors perception of the risk but think that our plans are as robust as other Trusts. Alan Hall asked why we had lost visibility of the QIA status in the report and that previously there had been more detail. Lorraine Clegg said that the table in the back shows the values of the QIAs and Paul Simpson advised that there was a paper at Thursdays Board meeting about the QIAs. Paul Biddle said that the Trust needs to get the mind-set that schemes do not run just from 1st April to 31st March. Paul Simpson agreed saying that the Trust is looking to do that and that the design of the CIP schemes has improved and it is intended that the work streams will be a continuous process. Paul Simpson advised that the Trust is also starting a transformation piece that will feed into the 2016/17 CIP programme. Richard Durban asked that the FWC has an update next month on the transformation process. 3
Action: Update to June FWC on the CIP transformation process
PS
Jim Davey then presented the Clinical Supplies CIP paper which rested on achieving better prices for guaranteed volume and longer term commitment to suppliers. Richard Durban asked if the clinicians were fully supportive and Jim Davey replied that there was a high level of clinical engagement. Paul Biddle asked how the Orthopaedic saving was split. Jim Davey replied that it is 80% guaranteed with one supplier for 2 years and that the projects are focused on buying items cheaper. For mesh suppliers the scheme had asked 6 companies in to present products with the aim to get the clinicians to agree on the day and that if clinicians trust that items are not going to be imposed on them then they will engage. He advised that the project team meet weekly. Richard Durban asked what percentage the CIP represented of the total clinical supplies cost. Paul Simpson advised it was 6% of clinical supplies costs. Richard Durban then asked if £1.24m saving (6%) was seen as the maximum that the scheme would achieve. Jim Davey replied that it was the target but we would try to exceed it. Richard Durban commented that this had been a useful review and requested that details of the next 3 biggest schemes be brought to the Committee. Action: Details of the next 3 biggest CIP schemes to the Committee 6
PS
WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce & Organisational Development Report M01 Janet Miller presented the Workforce & Organisational M01 Report. Richard Durban asked about the definition of Mandatory and Statutory training (MaST) and how we review and change it. Janet Miller replied that the Statutory element is what we have to do by law but organisations interpret it differently. Only a small part is actual statutory – safeguarding and fire – the others are Mandatory as defined by the Department of Health or Trust policies. The Trust has a matrix that came to the Executive team 4 years ago and is currently being reviewed. Fiona Allsop added that this was coming to the Executive team in the next couple of months. Richard Durban asked if there was an explanation for the discrepancies in Establishment and Vacancy reporting. Janet Miller replied that the definition of establishment is those staff that you need to permanently recruit to deliver activity, but you might want to flex your workforce to meet changes in demand. Fiona Allsop said it was a local decision on what level to recruit to ie base or with some uplift, but that all external reporting includes the uplift. Paul Bostock added that he cannot reconcile the Medical level of nursing vacancies with the recruitment requirements. Fiona Allsop replied that the medical data is not as clean as the surgical data. Richard Durban requested as a matter of urgency the Executive team a) resolves the definition and reporting of Trust establishment and vacancy levels and b) ensures accurate and appropriate analysis, insights and resulting actions are reported to the FWC Action: Executive to resolve the definition and reporting of establishment and vacancy levels YP/JM 4
Alan Hall asked about sickness absence and the analysis that had been requested at the last meeting. Janet Miller advised that these analytics will be looked at the next workforce subcommittee meeting and reported to the next FWC. Action: Report on sickness levels to be presented to the June FWC YP/JM Draft Internal Control Framework Richard Durban introduced the draft internal control framework which is to be reviewed by the Executive team before the final version comes to the Committee next month. In general the Committee felt that in light of current KPIs the draft presented an overly optimistic view. 6
CAPITAL AND ESTATES Capital & Estates Report M01 Shaun Cunningham presented the Capital & Estates M01 report. He requested that the Committee approve an additional £100k for the £8.3m Theatre phase 2 development due to an issue with asbestos and delays due to noise. Richard Durban advised it will have to come from the £17.06m capital funds for the year and Lorraine Clegg replied that it will but approval is required from the FWC. Paul Simpson asked whether as the project was nearing completion there would be no more requests for additional funding. Shaun Cunningham replied that the Quantity Surveyor is advising that we are within budget but the contractor has not yet been able agree a final price. The committee gave approval for the additional £100k to be allocated to the Theatre project
7
IT IT Report M01 Paul Simpson advised that the EPR data centre flip is at the end of June and that EPMA project came to the Executive Committee and the team were considering the next steps. Dictate IT Jim Davey presented the Dictate IT update and took the Committee through the paper. Alan Hall asked if the original business case was cost neutral and Richard Durban advised that the original case was a £300k saving through staff reduction. Jim Davey advised that the savings made through additional activities not requiring additional costs have not been calculated. Richard Durban advised that as this was a Board approved business case it needed to have a formal Post Implementation Review (PIR) that covered whether agreed benefits have been achieved or not and any organisational learning from the project. Alan Hall asked if we should be happy with the outcome of 107 Medical Secretaries and will it be reduced to the correct level. Jim Davey advised that it will be reduced to the correct level as we have broken the cycle of 1:1 Consultants to Medical Secretaries, done a time and workflow 5
resource study and that any leavers are being replaced at a lower level. Richard Durban asked about the trade union input and Jim Davey confirmed that the fortnightly board includes 2 trade union reps who are a senior secretary and a Consultant. Paul Simpson advised that the PIR will come towards the end of the year. Richard Durban asked for a PIR timetable for Board/FWC approved business cases. Action: PIR timetable to the June FWC meeting 8
PS
GENERAL Date of next meeting Tuesday 23rd June 2015 8.30am â&#x20AC;&#x201C; 11.00am â&#x20AC;&#x201C; AD77
6
Minutes of the Finance and Workforce Committee Held on 28 April 2015 at 9.00am In AD77, East Surrey Hospital, Redhill PART 1 Present Richard Durban Alan Hall Paul Biddle Paul Bostock Fiona Allsop (part meeting) Paul Simpson Ian Mackenzie Gillian Francis-Musanu
Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Operating Officer Chief Nurse Chief Finance Officer Director of Information and Facilities Director of Corporate Affairs
Michael Wilson (part meeting) Alan McCarthy Coral Jackson Janet Miller (part meeting) Garry East (part meeting) Mohammad Luqman (part Meeting) Catriona Tait
Chief Executive Trust Chair Head of Financial Reporting Deputy Director of Human Resources ADO Clinical Services Radiology Manager Head of Costing & SLR (Minute Taker)
In attendance
1
WELCOME AND APOLOGIES FOR ABSENCE Apologies: Apologies were received from Yvonne Parker (Director of Human Resources). Declarations of Interest: There were no declarations of interest.
2
MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 24th March 2015 meeting were approved. Review of Actions The action tracker was presented and noted that the items would be discussed within the presented papers. The IT Roadmap action was moved to the June meeting.
3
BUSINESS CASE INVESTMENT Managed Equipment Service (MES) Outline Business Case Garry East presented the MES Outline Business Case and requested Committee approval to proceed to TDA approval and then Full Business Case. Garry East advised the Committee that the proposed MES was a 12 year Equipment Replacement Programme provided by an external provider and that Option 3 was the preferred option even though it had a financial challenge. Garry East confirmed that the CIPs in the MES are not double counted in any other Trust CIPs and that the project is around improving services and patient experience. The Committee discussed the 3 options in the paper. Do nothing is not sustainable with the â&#x20AC;&#x153;inhouseâ&#x20AC;? and managed equipment service options being the choices. The latter includes a VAT
benefit (making it affordable) and the risk of that was discussed (and the FBC will include an opinion on HMRC treatment). Other aspects of discussion concerned the balance between capital and revenue in the different options and noted the robust clinical buy-in approach. The committee noted the opportunity under opt 3 for higher throughput of patients and non pay savings from reduced maintenance commitments. It also noted the opportunity that newer technologies will enable realisation of more efficient working practices e.g. replacement of analogue plain film equipment in radiology with digital equipment. It looked forward to seeing these included in the FBC to ensure a full a proper recognition of the opportunity arising from the investment decision. The Committee approved the outline business case to proceed to the TDA approval process and (subject to TDA approval) to full business case on the preferred option, option 3 which is an external managed equipment service and brings us flexibility within the funding and expertise. 4
BUSINESS PLANNING Communication Strategy and Annual Plan Richard Durban advised that as the paper was late it would be moved to the next meeting. Gillian Francis-Musanu confirmed that a shorter paper would come to the May FWC meeting.
5
FINANCE Financial Performance M12 and CIP Update Paul Simpson presented the M12 Financial Performance report to the Committee. The main highlights included the Trust reporting a £2.5 million deficit at the end of the 2014/15 financial year. The TDA had offered financial support to the Trust of £1.4m in mid-April if the Trust could improve its position by £1m which would have been a break-even position but the Trust did not accept this proposal. The total MRET (Marginal Rate Emergency Tariff) deduction for 2014/15 was £7.2m. The 2014/15 savings target was achieved with the use of mitigations. The Trust’s Capital spend was within its Capital Resource Limit. Divisions continued to overspend in M12 due to the increased emergency activity and the Committee noted continued focus on control to support Divisions managing within budgets for 2015/16. Paul Biddle raised concern over the £13.9m negative working capital and Alan Hall asked what had caused the movement in working capital in M12. Paul Simpson replied that the Trust had spent capital cash in March in order to stay within the agreed External Financing Limit (EFL) and that the Trust does have significant aged creditors which it has been managing. 2014/15 & 2015/16 CIPs Richard Durban commented that some of the CIPs that did not deliver in 2014/15 are in the 2015/16 plans such as agency savings. Paul Simpson replied that 158 job offers have been made to Filipino nurses so there is a better chance of the CIP being delivered in 2015/16 due to improved planning. Paul Biddle asked if the £854k saving is just the premium on the agency nurses. Paul Simpson responded that the premium we currently pay ranges up to 50% and that we have added in costs and been prudent when calculating the saving. Richard Durban asked what the feedback had been from Monitor following their review of the CIP 2
schemes. Paul Simpson said that Monitor picked 5 schemes to review and have some questions about the level of red rated and the development of our programme at this time of the year. The level of red rated has reduced and we are now mitigating the organisational redevelopment against the restructuring scheme. Paul Biddle asked if Monitor classify ÂŁ8m of CIP schemes as too low or appropriate to which Paul Simpson responded that it is reasonable for the size and strategy of the Trust. Alan hall queried why the QIA table had a different level of green risks. Paul Simpson said this was a timing issue. All the QIAs have been done but not all have been signed off for QGAF. Richard Durban asked if any of the QIAs had been sent back. Paul Simpson replied that the Trust had chosen scheme that did not impact on quality and whilst some had been amended none had been sent back. 2014/15 Reference Cost Submission Paul Simpson presented the paper outlining the Trusts approach and resources for the 2014/15 Reference Cost submission, confirming it was the same process as last year. The Committee approved the paper. 6
WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce & Organisational Development Report M12 Janet Miller presented the M12 Workforce and Organisational Development Report. Richard Durban asked why the MaST (Mandatory and Statutory Training) levels were low, should the Committee be concerned and what is being done to increase the rates. Janet Miller replied that the organisation was changing the way the 10 elements were being recorded so the rates cannot be compared to previous statistics and that the updated statistics would be finalised this week. Richard Durban said that MaST rate had been 55% throughout the year and that this needs to be reviewed at year end and the reporting agreed by the Executive team. Action: An update on MaST training to come to the May meeting
YP
Update on Surgery Workforce Issues Paul Bostock spoke on the Surgery workforce issue reporting that the figures reported include the vacancy rate so are incorrectly reported. The Surgical vacancy gap is still 100 as new areas have been opened, 2 x theatres and a new ward, and the division is making good progress to recruit to them. Paul Simpson advised that Medicine recruit to their vacancy rate so Richard Durban asked how we provide clarity on the vacancy rate. Paul Simpson stated that we need to produce a clear report and notes about the recruitment strategies of the division which needs to include the permanent establishment that the Trust is reporting to. Action: A report clarifying establishment and vacancy reporting to come to the May meeting YP Sickness Absences risk and mitigations Alan Hall commented that Surgery shows as an outlier on almost all of the people KPIs and the Committee is looking for some assurance that there are no issues in the Surgical Division. Paul Simpson stated that through the Surgical PMO process there have been no concerns raised and 3
Paul Bostock said that surgery is not seen as an outlier against the other division, it has been set a high recruitment target but has a strong management team especially the divisional chief nurse. Janet Miller presented the sickness report and advised the Committee that although the trend is rising we are in line with the national rate of 4.9% and with comparable organisations and that the risk is in the staff time taken up in managing the sickness absence. Alan Hall stated that he did not agree with this and that the risk is to the patient experience. Janet Miller replied that permanent staff recruitment is the solution to running at capacity. Alan Hall asked if the Trust produced statistics that shows sickness rates compared to vacancy rates. Paul Simpson replied that we do not produce them. Richard Durban asked that if our sickness is line with other Trusts do we see it as a problem and we should be focusing on recruitment and retention rather than sickness. Fiona Allsop agreed saying that permanent staff and settled teams should have a positive impact on sickness. Alan Hall commented that there is something happening but there is no analysis that can indicate the 4 or 5 causes and Paul Bostock agreed that there needed to be more management effort in looking at sickness. Paul Simpson stated that we do not currently have all the statistics so it needs discussion at workforce committee and executives. Alan McCarthy added that is we want to be the best then we need to aspirational and compare ourselves to the best performing Trusts rather than the national average. Action : The workforce sub Committee to investigate sickness rates and reporting and a report subsequently to come to the FWC YP 7
CAPITAL AND ESTATES Capital & Estates Report M12 Ian Mackenzie presented the Capital & Estates M12 report. He highlighted the following from the report: - The programme has been delivered on time and in budget. - Work on the Macmillan Centre started on 27th April 2015. - The temporary Angio lab has been delivered - All the theatres on the East Surrey site are now open. Alan Hall asked about the Earlswood site and the development intentions. Ian Mackenzie replied that it was only small capital works that were required at the Earlswood site but there was the possibility of another site close by.
8
IT IT Report M12 I Mackenzie presented the IT report and noted the appointment of Ben Upton to the post of Chief Clinical Information Officer (CCIO) and that the PIR for E-prescribing was being presented to the Executive team meeting on 29th April 2015.
9
GENERAL Fiona Allsop presented a paper for Committee approval to undertake and participate in a pilot 4
using a recently developed toolkit to reduce agency spend across the organisation. Fiona Allsop would be the Board Sponsor and Susan Carr will be the project lead. The Committee approved the Trust submits an expression of interest to the TDA and Monitor in respect of this pilot. Date of next meeting Tuesday 26th May 2015 9.00am â&#x20AC;&#x201C; 11.30am â&#x20AC;&#x201C; AD77
5
Safety & Quality Committee Thursday 7th May 2015 14.00 - 16.00 AD77 Trust Headquarters, East Surrey Hospital Minutes of Meeting
Present: Richard Shaw Yvette Robbins Pauline Lambert Alan McCarthy Michael Wilson Paul Bostock Des Holden Debbie Pullen Nicola Shopland Colin Pink Katharine Horner Ben Emly Jonathan Parr Lorraine Clegg Csaba Dioszeghy Nandoo Ghandi Suzanne Robinson
RS YR PL AM MW PB DH DP NS CP KH BE JP LC CD NG SR
Non-Executive Director (Chair) Deputy Chair, Non-Executive Director Non-Executive Director Chairman Chief Executive Chief Operating Officer Medical Director Chief of WACH Divisional Chief Nurse Corporate Governance Manager Patient Safety & Risk Lead Head of Information Clinical Governance Compliance Manager Deputy Chief Finance Officer Consultant Emergency Medicine Clinical Lead, Cardiology Surgical Division Risk Manager
Presenting papers: Mili Doshi MD Dental Consultant Claire Rowley CR Lead Nurse, Critical Care Outreach Team Observing: Linzi Emerson Monitor Ruth Liley Monitor Apologies Paul Simpson, Julian Webb, Fiona Allsop, MIchelle Cudjoe, Victoria Daley
1
GENERAL BUSINESS Chair welcomed everyone to the meeting and apologies were noted. 1.2.
Action
Minutes of the previous meeting
PB noted that there was question annotated on the minutes. For the record he confirmed that in the region of 80 patients are discharged each day and that the Trust aims to discharge 10 of these patients before 10am. The question will be removed from the final version. KH YR commented that there are a number of typos which she will highlight outside of the meeting. RS highlighted an action for PB that had not been added to the action log. PB confirmed that he would be circulating a pro-forma showing which teams would be responsible for each ward further to the ward configurations. Otherwise the April meeting minutes where agreed as an accurate record. 1.3. Actions from previous meeting were discussed as follows th
SQC Minutes 7 May 2015 Page 1 of 7
All actions are on the agenda C/F 4th December 2014 The draft Clinical Coding Strategy was present by LC. She explained that it formalised the current position within the Trust, she acknowledged that it is draft and some of the wording will be amended. PL asked whether there are enough clinical coders in the organisation. LC confirmed that there are sufficient for the current level of activity. The organisation has 21 coders which is in line with the national benchmark of 1 coder for 4,000 fce. Training and developing the coders is not a problem, but recruitment is. As income is grown then more coders will be needed. YR commented that the quality of the coding is a reflection on the quality of the notes, YR asked how the organisation knows that the records are fit for purpose. DH explained that the Trust has embarked on a programme of education to ensure that clinicians update patient records in a style which is sympathetic to the coding process. DH observed that it would be helpful for the coders to be based closer to the clinical teams. RS asked whether recruitment of coders is an issue. LC explained that recruiting trained coders is a problem and the Trust strategy is to recruit coders at a more junior level and then train them which puts some pressure on the existing team. Access to training is not an issue, but it takes time. AM asked about the issue of specificity. BE explained that there are different categories of condition, for example stroke, that carry with it different profiles for mortality. In addition there a range of co-morbidities which also need to be coded.
2
RS asked that a paper come back to SQC in May 2016 to update on the PS progress made over the coming year. QUALITY PERFORMANCE Mouth Care Matters MD gave a presentation to the meeting explaining the work of the dental team in improving the oral health of hospitalised patients. DH asked MD to clarify the funding position for the team going forward. MD explained that funding has been agreed for 4 members of staff, dental nurses or hygienists for a year to work on the wards improving the oral health of patients. AM asked about the issues of 2 way link between oral hygiene and disease progression. It was confirmed that there is a strong link. YR asked whether hydration and nutritional intake for patients is monitored and tracked. NS explained that a food chart and/or fluid chart will be commenced if indicated by the MUST screening tool. PL asked how non-compliant patients are managed. MD explained that this is a question of common sense and judgement to ensure that effective care is given but that patient choice is respected. MD explained that her team is experienced in negotiating care with patients; they have equipment to make the process quick yet effective. DH asked about the provision of paediatric toothbrushes on the ward. NS confirmed that information has been circulated to all wards and that they th
SQC Minutes 7 May 2015 Page 2 of 7
should appear on their stock lists. RS noted that the team are offering 3 hours of interactive teaching sessions on the ward, he asked how MDâ&#x20AC;&#x2122;s team are able to cope with the commitment. MD confirmed that this level of training would not be possible without the additional 4 members of staff. The team will move through the hospital ward by ward. RS asked whether MD will be doing audit work to demonstrate the impact of the initiative. MD confirmed that they will re-audit the oral assessments following the launch of the mouth care bundle. The team have audited how patients feel about their oral health since being in hospital and this has been quite negative, so this will be re-audited in the coming year. MW confirmed that he has agreed with Health Education England to fund the posts after the first year. He also informed the meeting that he has agreed with the Dean that there will be a formal academic evaluation of the initiative, with a view to rolling it out across Kent, Surrey and Sussex.
3
RS thanked MD for her presentation and for bringing this valuable initiative to the attention of the meeting. SAFETY Progress and impact of the Early Warning Scores Project CR gave a presentation to the meeting explaining the impact of the relaunch of EWS on the care of patients within the Trust and the future plans of the team. BE asked how the implementation of Groundvision might make a difference to nursing time or safety. CR explained that the evidence suggests that patients would be triggered earlier in their deterioration which would significantly increase the work of the CCOT. She confirmed that electronic monitoring of patients is being adopted by an increasing number of Trusts. NS added that any electronic system would have to be compatible with Cerner (which Groundvision is not). YR observed that the workload for the team is going up as earlier interventions are improving outcomes for patients. She asked whether the team is sufficiently resourced to manage the workload. CR replied that at this point in time they are managing the workload. The pressure is the amount of teaching and training that they are delivering to clinical teams. However in time, this investment will be reflected in the appropriate management of patients, resulting in fewer patients being referred to the team. DP asked whether CR had been involved in the paediatric team and the development of PEWS, one of the issues is whether to wake sleeping children to check their GCS. CR replied that they have found the same issue in adult inpatients, that it is not necessary to hold a conversation with the patient, simply get recognition that they are alert and aware of their environment. MW informed the meeting that he had asked FA to consider what aspects of the practice development training could be delivered corporately. RS asked whether the training was mandatory or voluntary. CR replied that the sepsis and AKI training is voluntary but that she is booked up until November th
SQC Minutes 7 May 2015 Page 3 of 7
because Trust staff are keen to develop their skills in these areas. YR asked about the visibility of the individual EWS in order to ensure appropriate individual patient monitoring. CR replied that an important part of the teamâ&#x20AC;&#x2122;s current work is the training of nursing assistants. This includes scenario training and role play. It has been recognised that they are pivotal in the escalation process.
4
RS thanked CR for the presentation. The Committee was assured that the signs of improvement a a result of early intervention are very encouraging. YR added that the non-execs are seeing fewer serious incidents where deterioration was a key factor. PATIENT EXPERIENCE 4.1 Quarterly Complaints Report NS presented the quarterly complaints report. There were 126 complaints in Q4, which represents a slight decrease on Q3. There has been a drive to resolve complaints at the bedside. The main reasons for complaints are care implementation, clinical diagnosis and attitude of staff. The number of reopened complaints has decreased by 45% to 11 in Q4 which may be indicative of an improvement in the appropriateness and quality of responses. The Trust sits just under the national benchmark of 6.6 complaints per 1,000 discharge episodes. It was noted that performance relating to the acknowledgement of complaints deteriorated in Q4 to only 50%. This is being pro-actively monitored and managed. NS noted that a Complaints operational group has been set up in the last month to provide scrutiny of complaints and the process. RS asked whether the indicator on reopened complaints could be set out as a succession of quarters to demonstrate any trends, rather than a snapshot. YR was concerned that this picked up just the patients who remained unhappy with their response and were motivated to respond. YR asked whether there was a process for measuring overall satisfaction with the complaints service. KH replied that the Complaints Department undertake an audit of complainant satisfaction and the output of this will be published in the Annual Complaint Report. RS commented that a concern had been raised about SIs being declared as the result of a complaint, rather than the Trust incident process. KH replied that in 2014/15 5 SIs were logged on Datixweb as having been opened as the result of a complaint: 1 & 2 - the Trust was aware of the issues, having been raised in person with the Medical Director, rather than through the Datix system. 3. Staff within the Trust were not aware of the whole patient journey, therefore they would not have raised the presenting situation as an incident. The complaint forced a more holistic look at the care pathway at which point it was recognised to be a serious incident. 4. An RCA was completed and submitted to the CCG but did not identify evidence of an incident within the Trust, the complaint could not be upheld. 5. This was a significant failure of process and is currently under investigation. th
SQC Minutes 7 May 2015 Page 4 of 7
DH stated that the gold standard is that Trust staff raise all concerns at the time that they are aware of it. The attribution of the source of the knowledge to the complaint is incorrect in two cases and another did not meet the definition of a serious incident, or even an incident, once the investigation was complete. AM asked how lessons are being learnt about poor attitude as this does not feature in the report. KH said that in many cases complaints are anonymised and made available to staff on notice boards to read in their breaks. In the past year customer care training has reached 250 patient facing non-clinical staff and is part of the Patient Experience team work. In addition if members of staff are named in complaints work is done on an individual basis using self-reflection techniques. RS asked about the figure for acknowledgements. KH explained that a member of staff has now been recruited into post full time which will allow for a more immediate response to patients. In addition the implementation of Datixweb (1st April) is making the process more efficient.
5
DP gave the example of the serious incident in gynaecology which was identified as a result of the complaint (see 5 above), what training would be put in place for staff. NS confirmed that the incident had been discussed at the Serious Incident Review Group and that the failure of the team to report the incident would be addressed by the action plan. QUALITY PERFORMANCE 5.1 Quality Report RS asked whether there was sufficient information coming through in the Quality Report and the scorecards to enable the non-executive directors to assess whether strategic risks are being successfully mitigated. There are 4 clinical risks on the current Strategic Risk Register: viral gastroenteritis, ED performance, cancellation of operations and right bed first time. • ED performance is well monitored and documented. • Norovirus: there is a daily operational dashboard disseminated across the Trust showing the number of patients affected. PB will take this forward and distill this information into a couple of lines on the performance report showing how many patients/beds have been affected. • Cancellations are not formally recorded on the performance report. Hospital initiated cancelations and non-clinical cancellations will be recorded. These will be brought back to the next Board meeting. • Right bed, first time. Need to be clear on what should be measured and how it is monitored. PB suggested that some time is taken to define the pathways. MW suggested that we need to be clear on what the risk is. Less clinical safety, more patient experience and operational efficiency. PB will report back to SQC to clarify the way forward. YR asked about the percentage of patients waiting 6 weeks or more for diagnostics. PB explained that this was due, in part, to the fact that endoscopy was used as an escalation area over the winter. This was stopped in mid-February; however there is a legacy of patients who have been delayed, the backlog is being cleared. The position for April is under 1%. MW added that 2 new wards are now open which will prevent a th
SQC Minutes 7 May 2015 Page 5 of 7
reoccurrence of a similar situation. DH informed the meeting that the Trust has been approached by BSUH for support in clearing their diagnostic backlog. PB added that last year there was a 22% increase in gastro referrals last year from within the Trust catchment areas, in April ‘15 the figure was 17% higher than April ‘14. This will be monitored with a view to investing additional resources to maintain the service. YR observed that 25% of sickness is related to work related reasons. DH clarified that this is where staff have categorised their sickness as stress, and that 25% of this is work related. RS asked for clarification on the comment: “readmissions - no concerns presented on scorecard, however rating to be reviewed in light of benchmarked reports highlighting the Trust as a possible outlier”. JP explained that the RAG rating will be reviewed in light of the benchmarking reports and the scorecard updated if necessary. MW noted that there is a readmission audit. Last year this showed 7%, the year before 6%. 5.2 SQC Dashboard YR asked for more information about the emergency section rate. DP confirmed that each section is audited and that more detail can be provided. DH confirmed that this has been discussed three times at the Clinical Effectiveness Committee. The team have identified that they are outliers for breach and as a result they will actively promote the turning of babies. DH suggested that this work could be brought back to SQC for discussion, and DP this was supported. DP added that the acuity of women presenting is higher and therefore more likely to require intervention.
6
PB confirmed that there is additional work to do with SECAM to improve the number of ambulance hours list. This will be monitored through the Access and Responsiveness Committee. COMMITTEE BUSINESS 6.1 Highlights from Executive Committee for Quality and Risk The inpatient survey was presented; the feedback is being cross referenced with other sources of patient feedback. The Patient Experience Manager will be formulating an action plan which will be monitored through the Patient Experience sub-committee. The National Report, with full detail, has been delayed until after the general election. RS noted that the top 10 issues as identified by Your Care Matters will be presented to ECQR; the expectation is that this will be reflected in the subcommittee report so that the information is shared at a higher level. AM commented that he would be interested to see this information come to Trust Board. 6.2 Highlights from CQRM BE informed that the meeting that February performance was discussed, no concerns were raised. The Governance processes around the “Hospital at Home” service were discussed which gave the meeting full assurance. The Chief Nurse for Surrey is going to spend a day with the team. East Surrey has rescinded their threat of closing stroke beds. They have th
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included a clause within the contract promising a joint review before any community services are closed.
7
MW added that at the Regional Stroke Meeting Surry have confirmed that SASH, Frimley Park and Ashford and St Peters have been confirmed as hyper acute stroke units. It was noted that community stroke rehabilitation beds and early supported discharge are vital to this. ANY OTHER BUSINESS None. DATE OF NEXT MEETING 4th June 2015 14.00 â&#x20AC;&#x201C; 16.00 AD77
th
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AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 17th March 2015, 09:30 â&#x20AC;&#x201C; 12:00pm Venue: Room AD77, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Durban Yvette Robbins
PB RS YR
Committee Chair / Non-Executive Director Non Executive Director Non-Executive Director
In attendance: Alan McCarthy
AM
Chairman
Paul Simpson Gillian Francis-Musanu Darren Wells Marcus Ward Nick Atkinson Stuart Doyle Colin Pink
PS GFM DW MW NA SD CP
Chief Finance Officer Director of Corporate Affairs (from 11.00am) Grant Thornton (External Audit) Grant Thornton (External Audit) Baker Tilly (Head of Internal Audit) Local Counter Fraud Specialist Corporate Governance Manager
Action by 1
1.0
Welcome and Apologies for absence PB welcomed members to the meeting. Richard Shawâ&#x20AC;&#x2122;s apologies for absence where noted.
1.1
Minutes of last meeting The minutes of 13th January 2015 meeting were reviewed. The committee noted changes relating to whistleblowing and agreed the minutes as a true record.
1.2
Actions from previous meetings: PB introduced the action log and requested updates from the action owners present noting that all but one action had been closed or was on the agenda for discussion. RD suggested that the responsibility for the remaining action be passed onto the FWC committee to manage until completion, the committee agreed.
Audit & Assurance Committee Minutes 13th January 2015
An Associated University Hospital of Brighton and Sussex Medical School
Page 1 of 7
1.3
Review of Draft Annual Governance Statement GFM presented a working draft of the Annual Governance Statement for early review. PB and PS noted the initial commentary and requested greater detail to be included in the elements of the statement that detailed governance arrangements. RD agreed highlighting that the governance framework should reflect the assurance provided by the finance and workforce committee. GFM highlighted inclusions in the report that reflected the changes in national guidance. PS highlighted that there may well be changes to the financial commentary at the end of the report. PB asked whether the Trustâ&#x20AC;&#x2122;s deficit would affect the commentary. DW stated that it would not affect annual account position but would be included in commentary on value for money. The committee thanked management for the early site of the draft AGS and requested that updates be made before review at the April committee. Action CP
2
2.1
CP
Review of BAF GFM presented the draft board assurance framework highlighting the work that had occurred at the board seminar to prepare the next iteration of the BAF for 2015/16. The committee discussed the BAF in preparation for public board on 26th March. PB requested specific updates to financial risks to reflect the end of year position. RD requested that workforce related risks reflected the risks recorded on the significant risk register. The committee then went on to discuss emerging risks that should be considered for addition to the updated (15/16) BAF focussing on specific risks; to describe the impact of the high usage of agency, issues relating to the agreement of contracts/income plans and the possible impact of current negotiations. PB asked for assurance that the gap in funding to meet expected end of year financial position would be resolved. PS stated that this was a significant issue and agreed that the issue needed to be resolved by the 27th March. As such current negotiations to receive expected payments are critical. ACTION: CP to ensure the BAF was updated
Audit & Assurance Committee Minutes 13th January 2015
An Associated University Hospital of Brighton and Sussex Medical School
Page 2 of 7
CP
The Committee accepted the report.
2.2
Review of SRR GFM presented the latest revision of the SRR to the committee, ahead of its submission to the board. YR highlighted the gastroenteritis outbreak risk and asked whether it still represented a significant operational risk. Action CP to discuss the significant outbreak risk with the Medical Director.
CP
The committee asked that the Chief Nurse and Director of HR updated their BAF entries to include details included in workforce issues highlighted in the SRR. Action CP
CP
The committee noted the remaining elements of the SRR and the conversations linked to BAF risks with no further comment. 2.3
Review of risk management KLOE CP presented an updated review of the Trustâ&#x20AC;&#x2122;s risk management systems for assurance. The committee agreed that this provided positive assurance of the controls in place and continuing progress in improving the system and compliance with the policy. PS went on to highlight improvements in the process of managing risks at executive committee level. RD and GFM discussed how this report supported the committees review of corporate governance controls which would be reviewed later on the agenda. This opinion was validated by NA who confirmed that there where visible improvements in risk management systems over the last two years.
3
3.1
The committee noted the report with no further actions. Internal Control systems; Corporate Governance GFM presented its review of corporate governance controls which had been updated and reviewed by the Executive team.
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An Associated University Hospital of Brighton and Sussex Medical School
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This provided assurance that systems are in place to manage elements of corporate governance. The Committee noted the positive steps taken to tighten controls relating to Emergency Planning and Business Continuity and accepted the review of current situation. PB stated that, should the Trust achieve its aspiration to attain foundation trust status, the controls map would need to be updated to include elements of how the board would function and the role of the council of governors. The committee agreed stating that a section relating to licence and contracts would be a key control. The committee accepted the assessment corporate governance control systems. 3.3
Losses Comps and Waivers PS introduced the paper describing the recent management of losses comps and waivers, highlighting that the number of waivers had reduced in year. AM asked for confirmation of the total oversea debt. LC indicated that the Trustâ&#x20AC;&#x2122;s oversea debt is ÂŁ724, 000 over the last 4 years and that overseas debt agency are attempting to recover. YR asked for assurance over the management of overpayment of salaries. PS assured the committee that appropriate processes are in place and this issue was inflated by 10 specific cases. NA stated that the Trust benchmarked well for this particular issue.
4
4.1
Draft Head of Internal Audit Opinion NA discussed his draft end of year opinion that is based on the work undertaken in 2014/15, significant assurance can be given that there is a generally sound system of internal control, highlighting the main issues that had been identified throughout the year. NA confirmed that issues related to NICE Guidance Compliance (One remaining item being clarified) and project management reviews that had now been addressed.
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An Associated University Hospital of Brighton and Sussex Medical School
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As the temporary staffing audit had just been completed the committee requested a review of the initial deadlines on the action plan. 4.2
Internal Audit Progress Report NA presented the internal audit update report, highlighting good assurance for safeguarding children systems, management of consent and lessons learned (Amber/Green). The committee took assurance that SQC was reviewing the management of serious incidents and the activity of the new serious incident management review group (SIRI). The report into temporary staffing systems had identified multiple issues and had been graded as (Amber/Red). The committee accepted that it was a difficult and complex situation to manage but there was an expectation that the process that supports the issue would be sound. The committee requested that the Executive team look to review the findings of the audit, monitor the actions identified and that an update report be taken to the committee. Action To ask FA and YP to review the auditâ&#x20AC;&#x2122;s implications and bring an update report on the management of temporary staffing the committee to include summary of actions and due dates as above. Finally the committee discussed the regular BAF audit which provided strong assurance (Green) that the assurances relied on are independent, timely and relevant to the risks and controls (Risk 2.A.1 and 3.B.2). The Committee noted and took assurance from the report.
4.3
External Audit DW introduced the committee update and Trust audit plan, including value for money and quality account review. RD asked when final opinions on the 14/15 financial year would be ready. DW confirmed that the final opinion would be ready no earlier than the end of June. DW highlighted that there are significant and known risk associated
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An Associated University Hospital of Brighton and Sussex Medical School
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YP/FA
to income and expenditure, that the Trust’s value for money position bench marked well and highlighted IT risks. PS noted the IT process risks raised which would need to be discussed with IM. Action PS to discuss with IM PB asked the committee’s opinion on the national better care fund issues raised by the document. The committee agreed that the crux of the matter would be alignment of CCG and provider plans and the reduction in health economy system emergency activity. PB thanked External Audit for their report. 4.4
LCFS Progress report SD introduced the update report, providing good assurance that the Trust’s counter fraud efforts continued to learn and improve. In particularly highlighting lessons learnt and systems improvements from the recent review of issues raised in the Trust’s radiology review. RD asked for further information on the radiology issue, PS highlighted the good practice that had been identified and the 5 key issues that needed to be resolved. PB stated that the Trust needs to remain ever mindful of the need to ensure proactive and reactive fraud systems remain high priority to reduce the fraud risk profile. The committee discussed specific cases highlighted in the report with no further comment.
5
5.1
AOB and summary of meeting No AOB was raised. PB summarised the meeting reflecting on the usefulness of corporate governance and annual governance statement. The committee agreed that the temporary staffing issues raised by audit would need to be reviewed until controls had been embedded.
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PB brought the meeting to a close. 6
6.1
Date of Next Meeting: 27th May 2015, 09:30 pre-meet, 10:00 meeting start.
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AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 23rd April 2015, 10:00am â&#x20AC;&#x201C; 11:00am Venue: Room AD77, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Durban Richard Shaw In attendance: Paul Simpson Gillian Francis-Musanu Laura Warren Jamie Bewick Nick Atkinson Djafer Erdogan
PB RS YR
PS GFM LW JB NA DE
Committee Chair / Non-Executive Director Non Executive Director Non-Executive Director
Chief Finance Officer Director of Corporate Affairs Head of Communications Grant Thornton (External Audit) Baker Tilly (Head of Internal Audit) Head of Financial Accounts
Action by 1
1.0
Welcome and Apologies for absence PB welcomed members to the meeting. Yvette Robbins apologies for absence where noted.
2
2.1
Review of Draft Accounts Paper for AAC PS presented the draft accounts paper to the committee with an overview of the financial statements. The committee discussed the unaudited I & E position of ÂŁ2.382m deficit, failure of the Trust to meet the statutory breakeven duty and the balance sheet; issue of section 19 letter regarding failure to break even was debated and JB confirmed that external audit did not intend to issue one for 2014-15. PB noted and stressed the importance of the weak liquidity of the Trust and that the issue should be viewed in line with that of a public limited company; PS reiterated that liquidity problem had been historic and would be resolved by injection of FT liquidity cash. The valuation of the estate was discussed and DE & PS assured the committee that the DV carried out the 5 yearly valuation and that there would be no issues with auditors as had happened previously when the Trust experienced significant impairments.
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The committee requested clarification of the number of years outstanding on the outstanding capital investment loans and the working capital loan. The provision for impairment of receivables (bad debt provision) was analysed and the committee had confirmation that the provision was made for all Non NHS debt over 90 days old, however the committee was assured that every effort was made to collect the debt nonetheless. The average no of persons employed was challenged and PS assured the committee that this would be updated on the final submission paper.
2.2
Draft Annual Accounts The committee was presented the draft annual accounts for approval for submission to Department of Health (DH) on 23rd April 2015 noon.
The committee reflected on the draft accounts seeking clarifications on clinical negligence premium, accounting policies, cash flow and whether the Trust had joint ventures.; it was confirmed that the clinical negligence in the accounts represented the annual charge of insurance, DE confirmed that no new accounting standards affected the Trust accounting policies for 2014-15 (confirmed by external audit) and that the Royal Surrey on ESH site was not a joint venture. PB queried whether any monies were outstanding from the CCGâ&#x20AC;&#x2122;s, PS / DE confirmed that agreements were settled. PB also raised whether Charitable Funds were to be consolidated and PS and DE confirmed that there would not be consolidation as per previous year on the basis of materiality. The committee approved the draft accounts for submission to DH. 3
3.1
Draft Annual Report GFM and LW presented the draft annual report to the committee and the committee approved the report with some minor changes to be completed for final approval in May 2015.
4
4.1
Draft Annual Governance Statement GFM presented the draft statement to the committee and the
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committee approved the statement with some minor changes to be completed for final approval in May 2015. 4
4.1
Date of Next Meeting: 27th May 2015, 09:30 pre-meet, 10:00 meeting start.
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