Surrey and Sussex Healthcare NHS Trust Board Papers
July 2015
Trust Board Meeting – IN PUBLIC Thursday 30th July 2015 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH
AGENDA 1
2
3
11:00
11:30
12:15
GENERAL BUSINESS 1.1
Welcome and apologies for absence
A McCarthy
Verbal
1.2
Declarations of Interests
A McCarthy
Verbal
1.3
Minutes of the last meeting held on 25th June 2015 - For approval
A McCarthy
Paper
1.4
Action tracker
A McCarthy
Paper
1.5
Chairman’s Report For assurance
A McCarthy
Verbal
1.6
Chief Executive’s Report For assurance
M Wilson
Paper
1.7
Board Assurance Framework & Significant Risk Register – For approval & assurance
G FrancisMusanu
Paper
SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1
Clinical Presentation For discussion & assurance
D Holden
Paper
2.2
Chief Nurse & Medical Director’s Report For assurance
D Holden/ F Allsop
Paper
2.3
15 Step Challenge - Update For assurance
F Allsop
Paper
2.4
Safety & Quality Committee Update For assurance
P Lambert
Paper
OPERATIONAL PERFORMANCE 3.1
3.2
Integrated Performance Report (M03) For assurance
A Stevenson
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
Finance & Workforce Committee Update For assurance
R Durban
Paper
Paper
3.3
4
5
12:55
13:25
Audit & Assurance Committee Update For assurance
P Biddle
Paper
RISK, REGULATORY AND STRATEGY ITEMS 4.1
Care Quality Commission Action Plan Update For assurance
S Jenkins
Paper
4.2
Staff Survey Action Plan Update For assurance
Y Parker
Paper
4.3
Annual Plan Update – Q1 For assurance
S Jenkins
Paper
OTHER ITEMS 5.1
Minutes from Board Committees to receive & note 5.1.1
Finance and Workforce Committee
5.1.2
Safety & Quality Committee
5.1.3
Audit & Assurance Committee
All
A McCarthy 5.2
ANY OTHER BUSINESS
5.3
QUESTIONS FROM THE PUBLIC
A McCarthy
Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to gillian.francismusanu@sash.nhs.uk 5.4
DATE OF NEXT MEETING 27th August 2015 at 11.00am
Minutes of Trust Board meeting held in Public Thursday 25th June 2015 from 10:00 to 12:30 Room AD77, PGEC East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (PBo) Paul Bostock (FA) Fiona Allsop (BB Barbara Bray (PBi) Paul Biddle (RD) Richard Durban (RS) Richard Shaw (PL) Pauline Lambert (AH) Alan Hall
Chairman Chief Executive Chief Finance Officer / Deputy Chief Executive Chief Operating Officer Chief Nurse Deputy Medical Director 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 Dr Des Holden (Medical Director).
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 – 28th May 2015 The minutes of the meeting held on 28th May 2015 were approved as a true and accurate record, with the following clarification noted; Item 4.1 CQC Improvement Action Plan When the Board challenged whether the CQC would now be satisfied on inspection of the recommendations made in May 2014, it was confirmed that they may not be fully satisfied however, it would be recognised that significant progress has been made and actions identified to address all areas of concern.
1.4
Action Tracker The outstanding actions were updated and closed. TBPU-01 : Review of reporting structure to avoid repetition of data reported within the IP board report and Chief Nurse board report Page 1 of 11
Workforce metrics and revised slides to be shared at the next Board meeting in July 2015. TBPU-02 : CIP QIA forms relating to schemes which have been rejected and subsequently approved to be circulated to the board. Post implementation review for Q1 to return to the Board. DH to present to the Board in July or August 2015. 1.5
Chairman’s Report for Assurance The Chairman announced the resignation of Paul Bostock, Chief Operating Officer and congratulated him on his new appointment as Chief Operating Officer for Royal Cornwall Hospitals Trust which he will commence at the end of October 2015. A new appointment process will be promptly established to ensure adequate handover. Along with the Chief Executive and Director of Strategy, the Chairman attended the NHS Confederation Conference in June where Jeremy Hunt (Secretary of State for Health) and Simon Stevens (Chief Executive – NHS England) promoted the Five Year Forward View’s ambition for the health sector to deliver a £22bn annual saving in five years’ time. The Carter Review was also on the Agenda – an interim report which outlines the work that has been carried out by Lord Carter of Coles to review the productivity of NHS hospitals, working with a group of 22 NHS providers. The report provides interim recommendations and next steps. A full report will be published in autumn 2015. It was also announced that Monitor and the NHS Trust Development Authority are to work much more closely together and under a single leader, with a new chief executive due to be appointed by the end of the summer. The rationale for this was expressed as an improvement in the operation and collaborative working of both organisations to better relate to the future NHS agenda. The Secretary of State, Jeremy Hunt has asked for a review of the pay of the most senior staff in the NHS. NHS Trusts and CCGs have been asked to undertake an urgent review of policies on Executive remuneration and to consider whether the amounts are necessary and publicly affordable. NHS Trust appointments made to Executive Boards with a salary which is above that of the Prime Minister’s will need to be approved by the Chief Secretary to the Treasury. Foundation Trusts will need to seek views of Ministers via Monitor and NHS England and provide justification to the Secretary of State. It was noted that SaSH was not currently on the VSM framework. The Board duly noted the report.
1.6
Chief Executives report for Assurance The board received and noted the Chief Executive’s report in advance of the meeting. MW presented the report and highlighted the following; Leaders of the NHS 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. The guidance is backed by the recently-announced £1.98 billion of additional funding, with specific financial allocations to healthcare commissioners. Page 2 of 11
It includes a new support package for GPs, plans for a radical upgrade in the prevention of illness, and new access and treatment standards for mental health services. The Trust will review and consider the impact of this report as a Board 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. Elections to the Council of Governors continues. The Trust has received an overwhelming number of nominations for the public, patient and staff constituencies. The voting process continues and the results will be announced on 3rd July 2015. AM clarified that the Council of Governors will operate in shadow form until FT authorisation. An induction programme and timetable for Governors will be developed in accordance to expectations for the FT application process. MW was pleased to report that the Trust had been shortlisted to participate in the Virginia Mason development programme which is being run by the Trust Development Authority. A small team from the Trust gave a presentation to the review panel on 9th June and are waiting to hear if they have been shortlisted to the final 7 who will receive a site visit at the beginning of July. Further, the Trust has been shortlisted for a “Trust of the Year” award by the Patient Safety Congress. The results will be announced on 6th July. Finally, the Trust has been listed in the “Top 100 places to work” by the HSJ and winners of each category will be announced on7th July. On behalf of the Board, the Chairman congratulated the Trust for these achievements and award recognitions. 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 BAF details 13 risks to the Trust’s strategic objectives (5 red-rated, 7 amber-rated, 1 green-rated). The Board was asked to discuss and agree the proposed changes to the narrative of risks 2.2 relating to delivery of planned efficiencies and 3.1 relating to the recruitment and retention of clinical staff. In relation to Risk 3.1; the Board felt that the current risk scoring should be increased to 15 and asked the Chief Nurse to consider this proposal in advance of the next Board report. Action: FA GFM highlighted that the Significant Risk Register currently presents 8 risks, each with mitigating actions to reduce the level of risk to an acceptable level. The Executive Committee reviewed and agreed the proposal to de-escalate one risk from the significant risk register to align with the BAF. Specifically the risk related to the current local availability of qualified nurses and pressures on temporary staffing cost. Page 3 of 11
The Board resolved to agree with the risk ratings and recorded controls and assurances, noting comments above. The Board resolved to approve the proposed changes to the BAF and updated SRR. The board duly approved the report. 2.
Safety, Quality and Patient Experience 2.1 Patient Story for discussion BB presented the Board with a patient story, providing assurance around some of the lessons learnt from the investigation and the actions taken by the Trust to manage patient expectations. BB summarised the investigation of a complaint on behalf of a patient who recently attended the Breast Outpatient Clinic following a mastectomy procedure in October 2014. The Patient’s expectation was to attend her appointment with the named female consultant as indicated on her appointment letter and at the time of consultation, refused to be seen by a male Registrar in their absence due to the sensitive nature of her medical condition. The Trust will work with divisions to look at how it can access better patient feedback to allow it to design services which are more individualised and meet more patient’s needs. Currently, all appointment letters state that the patient will be seen by the consultant or a member of their team. In this case, that did not meet the patient’s expectations. However, there is some action which the registrar could have taken to prepare the patient and to ease any anxieties, by taking the time to inform the patient of the Consultant’s availability upon arrival and in advance of her consultation. The proportion of female breast surgeons across the country is considerably low. However, we need to consider how patients are given the opportunity of choice and communicate alternative options to them in order to manage expectations. The Board recommended that appointment letters should clearly communicate that there may be a change in gender where the named consultant is not available to conduct the consultation. 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 May 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 staff within the Maternity service which has been appropriately managed by the Matrons. FA highlighted that NICE had suspended further work in relation to the current and planning nurse staffing guidance in order to review and develop a broader multidisciplinary approach to staffing models. However, existing guidance regarding adult inpatient wards and maternity remains in place. Page 4 of 11
The Department of Health has published a letter to Chief Executives outlining controls to manage agency spend across the health system, including a restriction on the use of agencies not on the national framework, the introduction of a shift/daily/hourly rate cap for agency staffing and NHSE/Monitor/TDA approval of consultancy contracts for professional services above £50,000. FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. PS added that an update on the Agency Contract variations will also be reported to the FWC in advance. Action FA BB continued to present the Medical Director’s report, highlighting that the Trust had awarded 30 consultants, out of a total of 42 applications for Clinical Excellence Awards. The Chief Executive has issued an internal communication to staff and personal congratulation to those consultants in receipt of an award. The board recognised that its commitment to reward clinical excellence amongst consultants was appropriate but challenged whether the budget was being spent in the best way. BB confirmed that the national formula dictates the financial limit for each reward and nursing staff receive financial increments through the Agenda for Change formula. The Board duly noted and took assurance from the report. 2.3
Safer Staffing Review Update for Assurance The board received and noted the report in advance of the meeting. FA presented a bi-annual review of nursing acuity and dependency on the acute inpatient adult wards in the Trust, in line with the recommendations of the National Quality Board report relating to Safe Staffing published in November 2013. FA reported that the review of nurse staffing was undertaken utilising the Safer Nursing Care Tool, current establishments and nurse sensitive indicators. The results concluded that the funded nursing establishment, including the agreed uplift in the ward budgets to meet night ratios were sufficient to provide safe, effective care in the Trust and meet the acuity and dependency needs of the patient. There is currently 3.5% positive variance to the safer staffing tools recommendations. The 22% uplift has increased from a finance view in order to benchmark against other Trusts. This is justified by guidance to apportion 18% to wards and 4% to divisions in order to manage sickness absence and annual leave. The board 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 the overseas recruitment programme. Acuity and dependency data will now be collected on a twice yearly basis to allow for seasonal variations. The Board duly noted and took assurance from the report. Page 5 of 11
2.4
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 4th June 2015. RS highlighted that the committee received a presentation on the principle results of the national in-patient survey and the action plan being developed in response. The committee was positively encouraged by the overall results but sought further assurance on the operational and quality concerns raised within the survey regarding discharge. A report describing actions to further develop discharge processes will be presented to the Board in September 2015. The committee received a report on the Clinical Audit Plan for 2015/16 which demonstrated a more focused programme with a reduced number of planned audits. The new emphasis on shared learning and completion within the financial year has received positive engagement. The board duly noted the report for assurance.
3.
Operational Performance 3.1
Integrated Performance Report (M2) for Assurance The board received the Integrated Performance report in advance of the meeting. PBo summarised the Trust’s operational performance during May 2015. The latest HSMR data shows overall the Trust mortality is lower than expected for our patient group when benchmarked against national comparators. AH challenged the trending adverse position in the previous four months and whether the Board should be aware of any concerns in respect of mortality. PBo assured the Board that there were no concerns when benchmarked against similar peers. The Clinical Effectiveness committee will continue to review mortality performance. In May, 96.0% 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 under significant pressure PBo was concerned that the Trust would not be able to deliver the ED standard during June due to significant increase in the volume of emergency attendances and admissions. ED attendance has increased from a planned 2% to 3.8%. Emergency admissions has also increased to 8.4%. Escalation remains open whilst the Trust continues to manage operational pressures and capacity. Ambulance handover data was not available at the time of reporting. However it was noted that emergency ambulance off-loading remained a challenge during high levels of capacity. All Cancer Access standards were achieved in April, with the exception of the 62 day Referral-to-Treatment-from-Screening standard. The standard reflects a very small number of patients, some of which chose to receive treatment elsewhere. There is great confidence that the standard will be delivered during June and for Page 6 of 11
the quarter. The recently formed Cancer Division are now focusing on developing and improving the fragile pathway. Incomplete pathways and Admitted RTT standards were achieved at aggregate level whilst a number of specialty failures of the admitted and the non-admitted standards as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. Non-achievement of the standard is part of the Trusts plans to reduce the 18-week backlog. The trust declared three Serious Incidents (SI’s) during May 2015. There were no reported cases of MRSA and three cases 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 15.9% in May. HR Business Partners within divisions continue to support actions to improve recruitment and retention with a significant focus on nursing. Sickness absence remained at 4.3% in May. PS reported the planned position is YTD deficit for the first quarter of the year, reflecting the profile cost of improvement plans. The Trust is marginally ahead of plan at month 2 with a £1.1m deficit due to the use of reserves earlier in the year than anticipated. However, there are clear pressures within the position particularly from spend to manage emergency capacity. Contract income is adverse to plan, predominantly due to a phasing issue 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. PS further reported that the underlying position at the end of May 2014/15 is £1.3m deficit, reflecting non-recurrent contingency savings. Risks to the 2015/16 financial plan are estimated at £6.8m. The cash balance at the end of May 2015 was £2.9m, above plan due to the delay in capital invoices. The capital spend forecast this year is £17.1m. It was noted that there has been an 8% growth in emergency activity, compared to a planned growth of 2%. Escalation remains open in order to meet capacity demands and this presents a cost pressure to the Trust. The use of agency staff during May and June was notably high and the Chief Executive has asked Directors to provide an update in relation to their CIP workstreams in order to identify further cost savings. PS confirmed that the Board will receive the Forecast report for discussion in the private meeting of the Board. The Board duly noted and took assurance from the report. 3.2
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 23rd June Page 7 of 11
2015. RD highlighted that the committee discussed the Month 2 finance, capital and IT reports. RD further highlighted that the committee discussed the 2015/16 Month 2 CIP report in detail. It was noted that some schemes had underachieved YTD however, the programme was on plan with £0.5m having been delivered at month 2. The committee received an update from the Chief Nurse on the temporary nursing staff project which described a significant delay in implementation. The committee also received a report on the 2016/17 CIPs which will be discussed by the Board in the private part of this meeting. The committee recommended grouping potential schemes under headings to provide clarity and allow the Board to see the balance between types of activity. RD described the use of the Quality Reserve budget for funding investments which provide a significant quality or clinical benefit but at a cost pressure. The committee noted the successful Data Flip which transferred Cerner Millennium from BT hosting to Cerner hosted environment. Dr Ben Upton presented the draft IT Implementation Road Map which proposed a roll out timetable for EPMA and a schedule of projects aimed at delivering ‘paperlight’ EPR within 2 years. The Executive Committee will be asked to consider whether the project has delivered the benefits expected and what learning has been achieved. The Board duly noted the report for assurance. 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 reviewed and adopted the 2014/15 accounts with 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 annual Counter Fraud report was presented and detailed expectation that the Trust’s NHS Protects “self review tool” would show no adverse issues. 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. Page 8 of 11
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. Since the CQC inspection, progress has been made to address the concerns raised in the report. However, the main concerns around patient waiting times and the large number of ad-hoc clinics remains a challenge. SJ presented a revised action plan to demonstrate progress against key recommendations and a new suite of KPIs to monitor the success of progress. The key areas which have delivered significant improvement and which the CQC would likely be satisfied by include; Environment Leadership Communication and internal systems and processes. Customer Care training has now been implemented and will continue to be developed throughout the Trust. Patient views are being collected from the Your Care Matters campaign and FFT process. The Board duly noted and took assurance from the report. 4.2
Quality Account 2014/15 for Approval The board received and noted the report in advance of the meeting. BB presented the report on behalf of the Medical Director. The Quality Account describes how the Trust has 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. RS added that the report had been well received by the Safety & Quality Committee, with minor comments made. PL suggested that for future iterations, the report should refer to safeguarding. The Board conveyed its congratulations to Laura Warren, Head of Communications for the production of the report. Non-Executive Directors will receive the report in hard format in July. The board resolved to approve the report.
4.3
Information Governance Annual Report for Assurance The board received and noted the report in advance of the meeting. IM presented the report which provides assurance to the Board that the Trust is addressing information governance (IG) obligations. In summary; the Trust achieved the highest overall rating of ‘Satisfactory’ following its final assessment. Page 9 of 11
 
96% of staff completed their annual information governance training during 2014/15. The Trust received 549 FOI requests during 2014/15 with 50 breaches of the FOI 20 Day Working Day response standard.
The Trust has an action plan to refresh and improve its compliance with the IG Toolkit standards and continue to promote the importance of Information Governance. The Board duly noted and took assurance from the report. 4.4
Security Annual Report 2014/15 For Assurance The board received and noted the report in advance of the meeting. IM presented the report which provides a summary of the security activities throughout the Trust during 2014/15. In summary, the hospital continues to be described as a safe and secure public environment for patients, staff and visitors. A number of actions have been implemented in response to concerns raised in the staff survey, including increased security presence within the Emergency Department. The Board would be keen to better understand the nature of concerns highlighted within the Staff Survey relating to bullying and harassment. Action GFM Throughout the year, there have been 245 reported incidents of physical and verbal abuse; an increase of 19% and 21 reported incidents of theft; relating to staff and patients. The Board should not be concerned by the increase in the number of reported incidents; often a single suspect can represent a number of individual complaints/incidents. Planned security improvements for the coming year include the development of a joint working agreement between local Trusts and the Police and continuing to encourage staff attendance onto the conflict resolution training courses. The Board duly noted and took assurance from the report.
4.5
Serious Incident Report For Assurance The board received and noted the report in advance of the meeting. FA presented the report which provides the Board with a summary of serious incidents declared by the Trust during May 2015 and an update on the overall position with regard to the management of incidents. In summary, the Trust reported three serious incidents during May 2015 and Falls and Clinical Diagnosis remain the two key categories of serious incident. The Trust has a total of 20 serious incidents currently open with the CCG, four of which are now overdue. Significant improvements have been made in the closure of incidents within divisions. All incidents are thoroughly reviewed and actions implemented Page 10 of 11
immediately upon recognition. The Board duly noted and took assurance from the report Other Items 5.1
Minutes of Board Committees to receive and note
5.1.1
Finance and Workforce 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 30th July 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 Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.
These minutes were approved as a true and accurate record. Alan McCarthy Chairman:
Date:
Page 11 of 11
TRUST BOARD ACTION TRACKER Action Ref
Forum
Subject
Action
RO
Date Open
Date Due
Date Closed
Status
ACTIONS FROM LAST BOARD MEETING
TBPU‐01
TB Public
BAF & SRR
TBPU‐02
TB Public
Chief Nurse report
TBPU‐03
TB Public
Security Annual Report
In relation to Risk 3.1; the Board felt that the current risk scoring should be increased to 15 and asked the Chief Nurse to consider this proposal in advance of the next Board report. FA FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. PS added that an update on the Agency Contract variations will also be reported to the FWC in advance. FA The Board would be keen to better understand the nature of concerns highlighted within the Staff Survey relating to bullying and harassment. GFM
25/06/2015
OPEN
25/06/2015
OPEN
25/06/2015
OPEN
TRUST BOARD IN PUBLIC
Date: 30th July 2015 Agenda Item: 1.6
REPORT TITLE:
CHIEF EXECUTIVE’S REPORT Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval ( )
Discussion (√)
Assurance (√)
Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National: • Secretary of State Key Announcements for the NHS • Lord Rose – NHS Leadership Review – “Better Leadership for Tomorrow” • Virginia Mason Institute Development Programme Local: • Completion of Governor Elections •
HSJ Shortlist of Top Organisations
Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact
Ensures the Board are aware of current and new requirements.
Financial impact
N/A
Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A
Highlights national requirements in place to improve patient experience. Identifies possible future strategic risks which the Board should consider Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation
TRUST BOARD REPORT – 30th July 2015 CHIEF EXECUTIVE’S REPORT 1.
National Issues
1.1
Secretary of State Key Announcements for the NHS
On 16th July, the Secretary of State Jeremy Hunt set out the government’s 25 year vision for a patient-led, transparent and safer NHS. There was a clear emphasis on transparency, choice, empowered patients and local decision making. It signalled a move away from a target driven culture to one of learning and improvement with an overall ambition for the NHS to become the world’s largest learning organisation. Changes to the regulation architecture and a renewed focus on improvement: • NHS Improvement was announced as the new operating name for a jointly led NHS Trust Development Authority and Monitor. • The new joint body will be chaired by Ed Smith, currently Vice-Chair of NHS England, supported by Ara Darzi as a new non-executive director. • The recruitment for a chief executive of NHS Improvement will commence immediately and is due to be completed by the end of September. • The safety function currently at NHS England and led by Dr Mike Durkin will transfer to NHS Improvement. • NHS Improvement will also host a new Independent Patient Safety Investigation Service. • Introduction of international buddying programme - Initially five NHS trusts will be buddied with Virginia Mason in Seattle, with an expectation to develop further international partnerships in the future. Changes to the consultant contract to enable a seven-day NHS: • The opt out clause for weekend working will be removed from the consultant contract for newly qualified hospital doctors. Doctors currently in service will still be able to exercise weekend opt-outs, but the off-contract payments for this activity will be reformed. • The British Medical Association (BMA) has been offered a six week window to discuss and agree the changes with the government, after which a new contract will be imposed. Leadership capacity in the NHS: •
The government accepted in principle, the 19 recommendations within the Rose report ‘Better leadership for tomorrow’. This included a proposal to merge Monitor and the NHS TDA, and a suggestion that the functions of the Leadership Academy come under the purview of Health Education England (HEE)
Proposals relating to patient safety, quality of care and patient choice: The government also published ‘Learning not blaming’, its response to Sir Robert Francis QC’s Freedom to Speak Up review, the Public Administration Select Committee report on investigating clinical incidents in the NHS, and Dr Bill Kirkup’s independent report on the Morecambe Bay investigation. •
Proposals include: improving incentives for staff to speak out against poor quality care in the NHS; the establishment of an independent agency to investigate patient
2
• •
safety incidents to be hosted by NHS Improvement; modernising the supervision of midwifery. GPs will be asked to inform patients of the Care Quality Commission rating and waiting time data at hospitals. NHS England will develop proposals for introducing meaningful patient choice and control over their care offered in services for maternity, end of life care and long term conditions.
Jeremy Hunt also acknowledged the need for a shift in culture from a top-down target driven system to one centred around transparency, learning and improvement. He spoke about a reduction in bureaucracy and top-down direction, allowing the space for ‘local ingenuity and innovation’. The Secretary of State referred to the roll out of ‘intelligent transparency’, ‘natural competitiveness’ and ‘self-directed improvement’ as key to this culture change. To underpin this approach he announced that from March 2016 England will be the first country in the world to publish avoidable deaths by trust, and that ratings on the overall quality of care provided to different patient groups by local health economy will also be made publicly available. Full details of the speech are available at: https://www.gov.uk/government/speeches/making-healthcare-more-human-centred-andnot-system-centred
1.2
Lord Rose – NHS Leadership Review – “Better Leadership for Tomorrow”
Early in 2014 the Secretary of State for Health asked Lord Rose to review what might be done to attract and develop talent from inside and outside the health sector into leading positions in the NHS; and to recommend how strong leadership in hospital Trusts might help transform the way things get done. Early in 2015 the Secretary of State requested that this report was extended to consider how best to equip Clinical Commissioning Groups to deliver the Five Year Forward View. The report “Better Leadership for Tomorrow” was published on 16th July. The key strengths that the Review found include: • the commitment of staff at all levels and in all parts of the NHS; • the profound goodwill of its stakeholders, and the strong support of its funder, the Department of Health. The quality of NHS clinical care, which is highly regarded, is not always matched by its ability to identify, assess, and manage its staff consistently. Some of the systems and procedures necessary for this do not exist, or where they do exist are only partially effective. The level and pace of change in the NHS remains unsustainably high: this places significant, often competing demands on all levels of its leadership and management. The administrative, bureaucratic and regulatory burden is fast becoming insupportable. The following three areas were identified of particular concern: • Vision: There is a lack of One NHS Vision and of a common ethos. • People: The NHS has committed to a vast range of changes however; there is insufficient management and leadership capability to deal effectively with the scale of challenges associated with these. • Performance: There is a need for proper overall direction of careers in management across the medical, administrative and nursing cadres.
3
Many of these problems are chronic and have been unaddressed over an extended period and by different Governments. Clearly, some of these recommendations are of a strategic nature; others tactical and operational. Several are interrelated and overlapping, as one would expect them to be in a complex organisation. There are seven general themes that emerged and the Review grouped the general themes under the following headings: 1. NHS vision & ethos (one vision of the NHS) 2. Leading constant change (one vision of the NHS, its People) 3. Training (one vision of the NHS, its People) 4. The management environment (its People) 5. Performance management (its Performance) 6. Bureaucracy (its Performance) 7. Trusts (its Performance) The report also identified a total of 19 recommendations under the following headings: • Training • Performance management • Bureaucracy • Management support The whole NHS will need to review and digest these and consider how and when they will be implemented. The full report is available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445738/Lor d_Rose_NHS_Report_acc.pdf
1.3
Virginia Mason Institute Development Programme
Surrey and Sussex Healthcare NHS Trust is one of just five NHS trusts in the country set to benefit from the influence of internationally acclaimed healthcare experts as part of a new initiative launched by Health Secretary Jeremy Hunt and the NHS Trust Development Authority (TDA) on 16th July 2015. The USA’s ‘Hospital of the Decade’ will mentor the Trust in an ambitious development programme – bringing their tried and tested system to East Surrey Hospital to help staff develop and deliver improvements in healthcare for local people. As part of a trailblazing move to make the NHS one of the world’s greatest learning organisations, clinicians and leaders from the Virginia Mason Institute will teach our doctors and nurses the principles and systems that have made it so successful. The initiative is led by the TDA and will mean patients in our area can benefit from the systems that have led to Virginia Mason receiving awards for excellent and safe care. As a Trust we are delighted to be chosen as part of this development programme which will help us continue our journey of transformation and become one of the country’s safest hospitals, delivering world class services to the people we care for.
4
Virginia Mason has demonstrated over the last decade that by getting the quality of care right for each patient this improves productivity and lowers cost through reducing waste. Through this partnership, five NHS Trusts will eliminate waste and concentrate on the things that add real value for patients and staff, leading to better, safer, more efficient care. They will lead the way in bringing some of the most innovative ways of working from one of the safest hospitals in the world into the NHS. Staff from the Virginia Mason Institute will spend time at the Trust over the course of the next five years helping the doctors, nurses and leaders work out how they can improve using the tools developed in Seattle. The programme will run over five years and set The Trust on the road to becoming a leading healthcare institution, at the same time sharing learning and benefitting the NHS as a whole.
2.
Local Issues
2.1
Completion of Governor Elections
Our Governor elections have now been completed and the Board will be pleased to note that each of the seats in our constituency areas have been filled. Our stakeholders are also now confirming the names of their nominated governors. We will hold an informal event with our new governors on 29th July and have put in place plans for their induction and training prior to being set up as a shadow Council of Governors. 2.2
HSJ Shortlist
The Trust has also been confirmed in the top 40 places to work by the Health Service Journal. This is very positive news for the Trust and the second year we have been acknowledged in this category.
3.
Recommendation
The Board is asked to note the report and consider any impacts on the trusts strategic direction.
Michael Wilson Chief Executive July 2015
5
TRUST BOARD IN PUBLIC
Date: 30th July 2015 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 22ndth July 2015 AAC 17th July 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, 6 of which are recorded as key strategic risks and red rated. There are 9 significant risks recorded on the Trust risk register, including a new risk related to the financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report (1697) 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 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: July 2015 BAF and the current SRR
2
An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT – 30th July 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 Red Amber Green (15-25) (8-12) (1-6) 1.Deliver safe services and be in the top 20% 0 2 0 against our peers 2.Deliver effective and sustainable clinical 1 0 1 services within the local health economy 3.Ensure patients are cared for and feel cared 1 0 0 about 4.Responsive - Become the secondary care provider and employer of choice for the 1 0 0 catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around 3 4 0 a clinical leadership model Total
6 3
6
1
An Associated University Hospital of Brighton and Sussex Medical School
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 have been minor amendments throughout regarding controls, actions and assurances the main point of note is following the discussion at the June public board meeting the increase in scoring of risk 3.1 (from 12 to 15) “The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.” 2.2 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services and be in the top 20% against our peers
Initial Risk Rating: Severity x Likelihood
1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties. 1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy 2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
S4 x L2 = 8
S4 x L1 = 4
S3 x L4 = 12
S3 x L4 = 12
S3 x L3 = 9
Initial Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood
Target Risk Score
S3 x L3 = 9
S3 x L2 = 6
S3 x L1 = 3
S5 x L3 = 15
S5 x L3 = 15
S5 x L2 = 10
S3 x L4 = 12
4
Target Risk Score
S4 x L3 = 12
Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.
Current Risk Rating: Severity x Likelihood
Current Risk Rating: Severity x Likelihood S3 x L5 = 15
Target Risk Score
S3 x L2 = 6
An Associated University Hospital of Brighton and Sussex Medical School
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 behaviour 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
2.3.
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
Key risks Strategic risks Identified
The BAF highlights the following 6 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. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage 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
5
Current rating
Target risk score
S5 x L3 = 15
S5 x L2 =10
S3 x L5 = 15
S3 x L2 = 6
S4 x L4 = 16
S4 x L2 = 8
S5 x L3 = 15 S5 x L3 = 15
S4 x L2 = 8 S3 x L2 = 6
S5 x L3 = 15
S4 x L3 =12
An Associated University Hospital of Brighton and Sussex Medical School
3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 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 include a new risk to the SRR relating to the financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report (1697). 5.1 SRR Breakdown ID
Title
Initial Rating 16
Current Rating 15
Residual Rating 9
Next Review 30/10/2015
1401
Risk of outbreak of viral gastroenteritis
1491
Failure to maintain Emergency Department performance
20
16
6
31/07/2015
1501
Patient admitted to the right bed first time
9
15
6
31/07/2015
1672
Increasing Sickness Absence Levels with impact on day to day management and expenditure Cancelled and / or delayed elective operations
15
15
9
31/07/2015
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 Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report
16
16
9
22/07/2015
15
15
9
26/08/2015
1678
1697
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
Gillian Francis-Musanu Director of Corporate Affairs July 2015
Colin Pink Corporate Governance Manager
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An Associated University Hospital of Brighton and Sussex Medical School
Risk Appetite – 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber 7
An Associated University Hospital of Brighton and Sussex Medical School
Page 1
Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A Consistently meet national patient safety standards in all specialties and across divisions 1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.
Director responsible
Chief Nurse
Initial Risk Current rating
S4 x L3 = 12 S4 x L2 = 8
Target risk score
S4 x L1 = 4
Linked to Risk
1009,1055
Controls in place (to manage the risk)
Gaps in Control
1. 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. 13. System developed to split Trust and Community acquired VTE events
1) Developing and embedding ward safety dashboards 2) Updating and planning RCA analysis training for new managers/leaders 3) Embedding DATIX incident review process within 14 day timeframe
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 14/15 (+) 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
Update by
Page 3
FA 16/07/15
1)
Date discussed at board
May 2015
To be discussed at July Board
Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care
Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). 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 – 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
Gaps in assurance Page 4
Assurance Level gained: RAG
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 16/07/15 Update by Date discussed at Board
Page 5
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 July Board
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
2.A Achieve the best possible clinical outcomes for our patients
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties
Director responsible
Medical Director
Initial Risk Current rating
S3 x L3 = 9 S3 x L2 = 6
Target risk score
S3 x L1 = 3
Linked to Risk
1460
Controls in place (to manage the risk) 1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads
Gaps in Control 1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released
Potential Sources of Assurance (documented evidence of controls effectiveness) 1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason development program
Actual Assurances: Positive (+) or Negative (-)
Gaps in assurance Ability to benchmark in real time National Safety Dashboard to be implemented when available Mitigating actions underway
Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report
(+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 198 Assurance Level gained: RAG
1) Development of ward based performance dashboards Update by Page 6
DH 16/07/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 01/04/2015 To be discussed at July Board
Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
2.B Deliver services differently to meet need of patients, the local health economy and the Trust 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.
Controls in place (to manage the risk) 1) 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 15/07/2015 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 July Board
Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference
3.B Deliver high quality care around the individual needs of each patient
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.
Controls in place (to manage the risk) 1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by 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 but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO 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 Page 8
Director responsible
Chief Nurse and Medical Director
Initial Risk Current rating
S3 x L4 = 12 S3 x L5 = 15
Target risk score Linked to Risk
S3 x L2 = 6 770, 1295, 1580, 1652
Gaps in Control 1. E-Roster system is not updated out of hours 2. Unfilled 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
organisation 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 Trust’s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload
Gaps in assurance Trust position known - no identified gaps in assurance
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 16/07/2015 and DH 16/07/2015
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 July Board
4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference
4.A.1 Deliver access standards
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage 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 (-)
Page 10
Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) 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 (-) ED standard not delivered June 2015 (-) 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)
Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway 1) 2) 3) 4)
Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance Refresh winter capacity plans based on assessment of Q1 activity Planned local health economy summit regarding emergency growth
Agreed breaking the cycle 2 encompassing internal and external bodies
Update by
Page 11
PB 15/07/15
Date discussed at Board
Assurance Level gained: RAG
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) July 2015 2) July 2015 3) Aug 2015 4) Sep 2015 To be discussed at July 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 and Surrey are not physically signed contracts cannot be signed until the national contract variation for the Trust’s agreed tariff (ETO) is issued which requires an Indicative Activity Plan). 3) Contract management process in place (this operated effectively in 2014/15). 4) Financial reporting, including periodic forecast scenarios, is in place and effective. 5) Chief Officer meeting (which includes coordination of has been in place since Nov 2014. Its structures are still embedding.
1) Signed Contracts not in place for Surrey and NHSE (Sussex is signed). 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 – meeting is proving more effective but streamlining of system resilience process is being discussed. 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 being applied to local 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 M03 (-) 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.
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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 – 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 for M03. 5) Specific action around dermatology, diabetes and cardiology where there is underdelivery PS 06/07/15 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 July 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 M03 cost improvement plans are largely included in Divisional budgets but there is adverse performance on agency and escalation. Red rated savings have been partially mitigated. 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;. (+) Contingency reserve of £1.9m established and, after taking account of “must dos”, 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 remain very high, with escalation still in use and significant. (-) At M03 there is significant overspending in Divisions and adverse delivery now on the medical agency and escalation CIPs, and anticipated adverse performance on nursing agency as the year progresses.
Gaps in assurance Assurance Level gained: RAG Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans and PMO meetings have become fortnightly for Medicine. 2) Controls are being exercised in divisions and centrally – vacancy restriction and non clinical procurement. 3) Only essential spend to be authorized from contingency and position reviewed at Q1. PS 06/07/15 To be discussed at July Board Update by Date discussed at Board
Page 14
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) Positive 1) Delivery of 2014/15 financial position and delivery of (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) 2015/16 financial plan (+) Technically the LTFM passes muster – issues are over planning assumptions. 2) Delivery of long term financial model and integrated (+) LTFM submitted describes viable position business plan documentation, and delivery against them
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, NHSE 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 red. Gaps in assurance Assurance Level gained: RAG Forecast is likely to be discussed with Board – at M02 risk to the forecast exceeded mitigation. Mitigating actions underway
Please see items above. Additional CIP contingency is identified, more is being sought . Update by
Page 15
PS 06/07/15
Date discussed at Board
Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable To be discussed at July 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 2015/16 – a loan application has been drafted and submitted, but has not been actioned.
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 06/07/15 To be discussed at July 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 organisation 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 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% (-) compliance rates for Achievement Review
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.
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 Establish process for annual performance review to identify and talent map for Medical Dental, 8a’s and above
Update by
Page 17
20/07/2015
Date discussed at Board
1) 31 March 2016 2) 30 October 2015 3) Complete and ongoing 4) February 2016
To be discussed at July 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 complete with all seats filled (+) 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 completed in July 2015 2) Monitor formal assessment in progress GFM 13/07/15 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 July Board
Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference
Key Action for 2015/16 objectives and description of any potential significant risk to this priority
5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems
Controls in place (to manage the risk) 1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2)IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change
Director responsible
Director of Information and Facilities
Initial Risk
S5 x L3 = 15
Current rating
S4 x L3 = 12
Target risk score
S3 x L3 = 9
Linked to Risk
1428, 999, 1483
Gaps in Control 1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits
Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Business Continuity System now in place (7/24)
Gaps in assurance Trust position known, no identified gaps in assurance
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 14/07/15
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 July Board
Due date
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
Risk of outbreak of viral gastroenteritis
Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures.
D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Surveillance of diarrhoea and vomiting Red aprons system
16 3
5
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
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
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.
Done date
Next Review
Treatment Plan
Residual Rating
Current Rating
Current Likelihood
Current Consequence
Existing controls
Initial Rating
Involvement of Risk Type Service Users
Description
Patient Safety Financial Manageme nt
Risk Owner Paul Bostock Des Holden Paul Simpson Paul Simpson
Financial Management Staffing - general
HR - Workforce
Yvonne Parker
Specialty Operations Medical Director's Office Finance Fin. Manageme nt Finance - Fin. Management
Directorate CORP CORP CORP CORP CORP
Open Date 29/08/2013 23/01/2013 11/06/2015 20/05/2015 01/02/2015
Responsiveness Monitoring Committee Safety Executive Committee Executive Committee Workforce
ID 1491 1401 1696 1688 1672
Title
6 31/07/2015
06/12/2013 26/07/2013 26/07/2013 02/09/2013 11/02/2014 06/12/2013
9 30/10/2015
22/09/2014 21/05/2014 26/07/2013 25/09/2013 26/07/2013
Risk from agency overspending
Risk of failure to achieve financial plan as a result CIP PMOs and nursing agency PMO to deliver outputs in respect of reduced of overspending on agency staff agency usage following recruitment. Position being reviewed (ongoing).
16 4
4
16 As described on the board assurance framework
9 22/07/2015
Risk of potential overspending from operational pressures
Risk of failure to meet the Trusts financial plan due to overspending.
i) Divisions to implement action plans and contingencies to control/or recover overspending. Specific action is required in all Divisions. ii) Divisions to take action to improve length of stay (being discussed at Execs in June) iii) Action on medically Ready for Discharge patients is being taken forward with health system partners.
16 4
4
16 As described on the board assurance framework
12 22/07/2015
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
15 Actions described in the Agency 31/03/2015 PMO 31/08/2015 Focused interventions to support the Trust's Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)
9 31/07/2015
Service Access Involvement of Service Users Financial Management
Natasha Hare Paul Bostock Paul Simpson
Admissions / Waiting List Operations Finance - Fin. Management
SURG CORP CORP
23/03/2015 19/09/2013 11/06/2015
Responsiveness Responsiveness Executive Committee
1678 1501 1697
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 avoid cancellations Improve Theatre Utilisation Ring-fencing of Tandridge and Woodland Wards
27/02/2015 20/06/2015 15/05/2015
09/02/2015
6 13/08/2015
Patient admitted to the right bed first time
If the Trust does not maintain and improve ability to allocate the right bed first time there is an increased risk of receiving poor quality of our care (effectiveness, experience and safety)
1) Operational meeting three times a day chaired by 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 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
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 31/07/2015
Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report
Risk of failure to meet the financial plan as a result of a) increased costs to deliver staffing ratios, 7 day costs and expectations detailed in national guidance and plans, and b) failure to deliver adequate adjusted treatment index (Carter).
a) Internal governance of costed proposals (Execs/Board approvals) b)Clear internal milestones to maintain control and avoid "creep" (eg: deliver agency reductions first) c) Programme plan for 7 day working overseen by Director of Strategy with reporting to Execs; d) Standard business case and business planning processes to support implementation (so we already have 7 day working in place in several key areas); e) Carter work is directly linked to CIP governance process and an ad hoc group has been established by Director of Service Development
15 3
5
15 Review and develop plans; to brief the Board on progress against risks of establishment targets not being met and any potential action to review the Board's decision on implementation.
30/09/2015
9 26/08/2015
National Children’s Inpatient and Day Case Survey 2014
Sara Cuming, Clinical Auditor Joanne Farrell, Matron Children’s Services June/July 2014
Background • To improve the quality of services that the NHS delivers • Asking people who have recently used local health services to tell us about their experiences. • This survey focused on young patients who were admitted to hospital as inpatients or for treatment as day case patients. • 137 acute and specialist NHS trusts across England participated. • Received feedback about the care of nearly 19,000 young patients - response rate of 27%. • SASH response rate 23%
Methodology • Total 300 children who were Inpatients/Daycases during July, August and September 2014 • Selected using the inclusion and exclusion criteria – aged between 0-15 years – not staying in hospital at the time patients were sampled – not 'well babies' i.e. newborn babies where the mother is the primary patient
• Split between the following categories – All Parents and Carers (0-15yrs) – Children and Young people (8-15yrs) – Parents and Carers (0-7yrs)
• Areas were responses <30 there are no scores available (11 questions)
National Areas of good Care National Score
SASH Score
8-15 year olds said that when they had an operation or procedure staff told them what to expect
91%
75%
8-15 year olds said that they felt safe on the ward all the time
89%
94%
8-15 year olds said that hospital staff talked to them about how they were going to care for them in a way that they could understand
82%
83%
8-15 year olds said that when they experienced pain, staff did everything they could to help control it
80%
86%
Most children said they had good overall experiences of care, with children scoring their overall experience as seven or above out of 10
87%
90%
Parents or carers agreed that their childâ&#x20AC;&#x2122;s experience had been this positive
88%
94%
National Areas of poor Care National Score Parents and carers felt staff were not always aware of their child’s medical history before treating them
41%
Parents and carers said they were definitely not encouraged to be involved in decisions about their child’s care and treatment
35%
Parents and carers said staff were not always available when their child needed attention
32%
One in eight children (8-15) were not told who to talk to or what to do if they were worried about anything when they got home.
24%
One in five parents or carers were not given any written information to take home about their child’s condition or treatment, but they would have liked some
20%
SASH Score 43% (7.7)
34% (8.4)
31% (8.6)
18%
4%
(9.7)
Variance -2%
1% 1% 6%
16%
SASH Highlights • Local headline data – 4 areas where we were rated better than most other trusts – Parents and carers of 0 to 7 year olds said: • Their child was well looked after by hospital staff • Staff treated them with respect and dignity
– All parents and carers said: • Staff asked if they had any questions about their child's care • They were given written information about the child's condition or treatment to take home
Overall Experience
National View of Parents view of child's overall experience (All)
National Picture of Overall experience (8-15)
KSS and Neighbouring Trusts When comparing outcome data against 14 KSS and neighbouring trusts • 48% of SASH’s scored questions were ranked top or equal top • Majority of the highest scored questions related to hospital staff • We achieved the highest score for overall experience
Overall Experience KSS and Neighbouring Trusts
Conclusions • What we have achieved – Overall experience was overwhelmingly positive when compared to the national data – Overall experience show us to be best performing Trust within our region and other neighbouring Trusts
• Barriers - Report difficult to analyse – – – – –
Not all questions had reportable responses Split between peer groups Only 23% response rate No free text comments available Can only identify trends
• Areas identified were improvements could be made – Improve Communication – More Engagement with families – Be Aware of the need for privacy especially in 8-15 year olds
CQC Key Inspection Questions SASH
QVH
High
9.2
9.9
9.9
8.8
9.9
9.9
9.3
10
10
-
-
9.8
8.9
9.9
9.9
9.2
9.8
9.8
7.7
9.2
9.2
Safe ‘Did the ward where your child stayed have 1. Keeping people appropriate equipment or adaptations for your safe child?’ ‘How clean do you think the hospital room or ward was that your child was in?’
Effective ‘Did a member of staff agree a plan for your child’s 1. Assessing patient's care with you?’ needs ‘Did you think the hospital staff did everything they could to help ease your child’s pain? ‘Did you feel that staff looking after your child 2. Staff knowledge knew how to care for their individual or special and experience needs?’ 3. Working well ‘Did the members of staff caring for your child together work well together?’ 4. Staff being ‘Were the different members of staff caring for and informed treating your child aware of their medical history?’
CQC Key Inspection Questions SASH
QVH
High
Caring 1. Dignity, respect ‘Were members of staff available when and compassion your child needed attention’ ‘Did hospital staff keep you informed about what was happening whilst your child was 2. Involvement in hospital?’ ‘Did you have confidence and trust in the members of staff treating your child?’
8.6 9.7 9.7 8.4 9.4 9.4 9.2 9.9 9.9
Responsive Meeting people’s ‘Did you have access to hot drinks facilities needs in the hospital?’ ‘How would you rate the facilities for parents or carers staying overnight?’
9.6 9.3 9.9 8.1
-
8.7
Other Areas Children with a physical and/or learning disability or mental health condition ‘All trusts must also do more to ensure that children with physical disabilities, a mental health condition or those with a learning disability are receiving care that meets their specific needs.’ • SASH Response – Recognise challenges – Working with stakeholders – Risk Register
Draft Action Plan Action
Responsibility
To be achieved
• Share the results with all members of staff /committees and prepare action plan
Present to Governance, Patient Experience, Paediatric team , other appropriate audiences
Joanne Farrell / Sara Cuming
July 2015
• Parents and carers felt staff were not always aware of their child’s medical history before treating them
Annual Record keeping audit will evidence compliance of clerking of recording medical history within the case notes
Paed Cons/ Sara Cuming
Aug 2015
Included in Education and training, induction etc
Joanne Farrell/ Paed Education Cons
Sept 2015
Work with surgical specialties with improving engagement and communication with children and parents and what they should expect during their stay
Joanne Farrell/Surgical Gov/Specialties
Sept 2015
• When arriving in hospital, Children were not always being told what would happen in hospital (8-15) (CQC) • Parents and carers said they were not definitely encouraged to be involved in decisions about their child’s care and treatment (All) • Told different things by different people (0-7) • When Children had an operation or procedure staff did not tell them what to expect (8-15) • Parents & carers were not always provided with information before an operation or procedure (All)
Draft Action Plan Action
Responsibility
To be achieved
Cascade to all members of the paediatric team (inc. Drs) the need to maintain child’s privacy at all times • RHD when results shared • Nursing team meetings
Joanne Farrell
Sept 2015
• Staff did not always help to ease pain (All) • Children said they were not always given privacy when being examined (8-15)
•
•
•
Parent and carers did not always think the hospital room or ward was that their child was in was clean (CQC)
TBA
Parents and carers reported that members of staff were not always available when their child needed attention (CQC)
TBA
Parents and carers felt that staff looking after your child did not know how to care for their individual or special needs (CQC)
Challenges identified Risk Register
Bill Kilvington
Ongoin g
TRUST BOARD IN PUBLIC
Date: 30 July 2015 Agenda Item: 2.2
REPORT TITLE:
Chief Nurse & Medical Director Report Fiona Allsop, Chief Nurse Des Holden, Medical Director Fiona Allsop, Chief Nurse Des Holden, Medical Director
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval ()
Discussion (√)
Assurance (√)
Purpose of Report: To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues Chief Nurse Report • The Safer Staffing report (June 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 further changes to NICE guidance to support the setting safer staffing levels for nursing and its impact within the Trust is outlined • There is information presented on a planned nursing recruitment day. Medical Director’s Report Inclusion of trust as part of the TDA Virginia Mason improvement project The Idea to innovation Factory Challenges around CDiff cases Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model
Corporate Impact Assessment: Legal and regulatory impact
Yes
Financial impact
Yes
Patient Experience/Engagement
Yes
Risk & Performance Management
Yes
NHS Constitution/Equality & Diversity/Communication
Yes
Attachment:
2 An Associated University Hospital of Brighton and Sussex Medical School
Chief Nurse/ Medical Director Report – 30 July 2015 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 – June 2015
Ward
Ward Specialty
Entries RN Day
RN Night NA Day
NA Night
Total Day
Total Night
Overall
Abinger Ward
430 - GERIATRIC MEDICINE
30
89.92%
100%
96.43%
98.78%
93.31%
99.3%
95.59%
Acute Medical Unit
300 - GENERAL MEDICINE
30
96.55%
96.67%
93.23%
96.67%
95.56%
96.67%
96.05%
Birthing Centre
501 - OBSTETRICS
30
100%
100%
N/A
N/A
100%
100%
100%
Bletchingley Ward
300 - GENERAL MEDICINE
30
94.16%
94%
99.11%
99.17%
96.5%
96.3%
96.43%
Brockham Ward
502 - GYNAECOLOGY
30
94.48%
96.72%
96.57%
91.53%
95.16%
94.17%
94.76%
Brook Ward
100 - GENERAL SURGERY
30
100%
96.67%
93.32%
100%
97.78%
97.18%
97.51%
Buckland Ward
101 - UROLOGY
30
94.69%
95%
92.84%
94.83%
94.05%
94.92%
94.37%
Burstow Ward
501 - OBSTETRICS
30
82.72%
73.33%
78.77%
88.33%
81.4%
79.33%
80.46%
Capel Annex l Ward
100 - GENERAL MEDICINE
30
98.33%
98.33%
95.17%
98.33%
96.98%
98.33%
97.47%
Capel Ward
430 - GERIATRIC MEDICINE
30
91.17%
97.78%
94.93%
100%
92.33%
98.67%
95.09%
Chaldon Ward
300 - GENERAL MEDICINE
30
91.51%
95.83%
96.47%
93.75%
93.71%
94.76%
94.11%
Charlwood Ward
301 - GASTROENTEROLOGY
30
91.13%
133.33%
96.89%
101.75%
93.18%
117.95%
102.92%
Copthorne Ward
301 - GASTROENTEROLOGY
30
88.2%
91.67%
110.5%
98.33%
95.98%
95%
95.59%
Coronary Care Unit
320 - CARDIOLOGY
30
86.21%
98.33%
100%
90.32%
86.52%
95.6%
91.11%
Delivery Suite
501 - OBSTETRICS
30
94.51%
89.94%
85.66%
81.67%
92.3%
87.87%
90.1%
Discharge Lounge
300 - GENERAL MEDICINE
30
85.85%
96.67%
88.46%
96.67%
87.09%
96.67%
90.47%
Godstone Ward (Haem)
303 - CLINICAL HAEMATOLOGY
30
101.09%
98.33%
N/A
N/A
101.09%
98.33%
99.71%
Godstone Ward (Med)
300 - GENERAL MEDICINE
30
90%
100%
87.75%
100%
89.1%
100%
94.01%
Holmwood Ward
320 - CARDIOLOGY
30
95.77%
98.28%
93.26%
100%
95.06%
99.12%
96.49%
TU/HDU
192 - CRITICAL CARE MEDICINE
30
97.58%
98.69%
64%
93.1%
93.15%
98.29%
95.63%
Leigh Ward
110 - TRAUMA & ORTHOPAEDICS
30
98.33%
98.33%
87.53%
98.33%
93.72%
98.33%
95.28%
Meadvale Ward
430 - GERIATRIC MEDICINE
30
91.4%
98.36%
96.67%
100%
94.23%
99.17%
95.96%
Neonatal Unit
420 - PAEDIATRICS
30
99.2%
102.48%
92.68%
81.48%
97.22%
96%
96.62%
Newdigate Ward
110 - TRAUMA & ORTHOPAEDICS
30
94.56%
96.67%
86.93%
85%
91.32%
90.83%
91.16%
3 An Associated University Hospital of Brighton and Sussex Medical School
Nutfield Ward
430 - GERIATRIC MEDICINE
30
95.34%
100%
95.61%
101.67%
95.44%
100.83%
97.24%
Outwood Ward
420 - PAEDIATRICS
30
96.53%
100.64%
100%
70%
97.01%
95.7%
96.47%
Rusper Ward
501 - OBSTETRICS
30
95.83%
100%
N/A
N/A
95.83%
100%
97.73%
Surgical Assessment Unit
100 - GENERAL SURGERY
30
96.67%
95%
86.67%
86.67%
94.67%
90.83%
92.96%
Tandridge Ward
300 - GENERAL SURGERY
30
86.49%
93.44%
83.31%
91.67%
85.11%
92.56%
87.61%
Tilgate Annex
100 - GENERAL MEDICINE
30
96%
86.67%
98.86%
101.67%
97.06%
92.67%
95.36%
Tilgate Ward
300 - GENERAL MEDICINE
30
96%
95.56%
97.7%
100%
96.62%
96.67%
96.64%
Woodland Ward
100 - GENERAL SURGERY
30
91.1%
100%
101.15%
96.55%
94.78%
98.28%
95.93%
94.1%
96.9%
93.51%
94.87%
93.9%
96.14%
94.8%
Total
Commentary The Trust has delivered planned versus actual staffing profile for June. The continued 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 continues to recruit new staff members. Tandridge Ward is showing as amber due to changes in activity related to day surgery patients and inconsistency in recording. The matron for the ward has provided additional clarification for the ward staff to mitigate this.
Changes to NICE safer staffing work Further to last monthâ&#x20AC;&#x2122;s report it has now been confirmed that NICE intend to publish the emergency department staffing guidance in the coming months for reference and consideration. Nursing Recruitment A recruitment day is scheduled for 25 July targeting local staff for permanent and bank posts. European recruitment has been undertaken with a further campaign planned in August. Non-European recruitment continues at a slower pace than originally anticipated. Medical Directors Report Virginia Mason Project After a competitive process we have been chosen to partner with Virginia Mason Institute, Americas hospital of the decade, for a five year programme of improvement. Other chosen organisations include Leeds, Shrewsbury, barking-Dagenham-Redbridge, Coventry. There are few details yet other than what is in the public domain, but first steps will be a visit to Seattle in September for two staff members tasked with improvement, followed by a meeting in January for up to 8 staff members. While we have an expectation of receiving visitors from VM, and also from Cambridge Massachusetts as yet we have received no details of this. The Idea to Innovation Factory Two years ago we received ÂŁ50k to implement the Induct system to allow front line staff to
4 An Associated University Hospital of Brighton and Sussex Medical School
flag their ideas of how things could be done better. These ideas would be reviewed for service development and even for commercial possibilities and then taken forward. The system is in use extensively in Scandinavia, and in a small number of CCG and community providers, but is not in any UK acute trust. We lost the money because we were not able to spend it in a tight time line at the end of the financial year. After on going discussions with the company they have put the system into sash for one year, at no cost. This allows them to develop a product and point to a demonstrator site and allows us to evaluate its suitability and value to us. CDiff diarrhoea At time of writing we have had 11 cases of CDI and root cause analyses have found a number of areas of improvement that we could make. We have taken a very visible, multistep approach but it revolves on a theme of doctors and nurses assessing and making plans together for patients with suspicious diarrhoea rather than either group planning in isolation. 3.
Recommendation
To note the report
Fiona Allsop Chief Nurse July 2015
Des Holden Medical Director July 2015
5 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 30th July 2015 Agenda Item: 2.3
REPORT TITLE:
15 Steps Challenge
EXECUTIVE SPONSOR:
Fiona Allsop Chief Nurse Lynn Sanders Corporate Matron
REPORT AUTHOR: REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval ( )
Discussion (√)
Assurance (√)
Summary of Key Issues Report outlining the15 steps challenge activity between April to June 2015 including completed improvement actions carried out as a result of recommendations from the 15 steps team. Themes around the recommended improvements from the 15 Steps activities include: Signage Storage of equipment Environmental improvements Information for patients and visitors about feedback Patient Flow improvements The 15 steps challenge has to date visited 13 areas and has bought about many improvements at ward level and department level. General awareness of first impressions of visitors to the ward has been raised and engagement in the activity is evident when verbal feedback is given to the ward teams on the day of the visit. 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: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory implications
yes
Financial implications
yes
Patient Experience/Engagement
yes
Risk & Performance Management
yes 1
NHS Constitution/Equality & yes Diversity/Communication Attachments: 15 Step Challenge Update Report
2
Fifteen Steps Programme The team is made up of a Non‐Executive lead, a clinical staff member, a non‐clinical staff member and a patient representative or volunteers, and the combination of this team has provided a selection of viewpoints on how the ward feels from a patient or visitors perspective. Through the visits from the 15 steps team a “fresh eyes” approach has enabled feedback to the ward teams and recommendations for improvements made. It has also provided an opportunity for a structured visit for the non‐executive directors to visit the clinical areas with clear objectives. In this period, two large departments were visited during peak times. The admissions unit management team responded by drafting an action plan, a summary of the actions to date are below. The Emergency Department was given verbal feedback on the day, and once actions and improvements have been agreed will be included in the next report. Ward/Depart ment Admissions unit
Date
Overall comments
April 2015
Main Recommendations/ areas for improvement
Team lack clarity if, how and when Outpatients Project will address Admissions area, but emphasise need for improvements now
Patient experience in Admission lounge not specifically captured on F & F/YCM
Feedback of Actions
Improve signage in main and side corridors; ensure terminology in letter consistent with signage terms Notice boards alongside reception area have no relevance to staff; relocate staffing notices and consultant room locations elsewhere No patient feedback / performance visible ‐ understood as Pre‐Admissions has no dedicated YCM feedback code; feedback gets lost or included in Day case surgery
Two additional signs to go up. Estates managing. Contact made with company to provide boards. Proofs provided. To order. Authorised by Cathy White, and additional comments box being added to YCM questionnaire. 3
• Hot, cramped, waiting environment needs improving for current volumes • Better communications / scheduling of patients to reduce waiting time and
Improve look and feel ‐ make tidy, repaint, brighten, some pictures, footstools for elderly/infirm, air con, soft close doors to create calm and comfort Poor/limited waiting area in corridor for assessments/instructions not ideal Potential risk for H & S incident with traffic in narrow corridor Review suitability for patients with Learning difficulties or Mental Health problems ‐ additional resources to manage/support Comfort and hydration for vulnerable / elderly patients with up to 6‐8 hours wait
All notices taken down except fasting guidelines, old furniture discarded. Existing furniture rearranged to create better feel. Estates visited area, to discuss with Ian Mackenzie redecoration, improved lighting, and improved air handling. LJ to chase. Plasticised seating necessary for Infection Control. 5 new recliners and four foot stools ordered for vulnerable patients, additional TV to be ordered so that all patients can view screen, and all wall mounted. RECEIVED, waiting for TV to be mounted. Risk assessment completed. Risk assessment completed
Communication with Admissions Lounge 4
anxiety of patients
(with risk of cancellation) Hydration, food and medication for those waiting long periods depend on access to and approval from anaesthetist doing surgery (often difficult to secure) Live screens of theatre lists to keep patients better informed, allowing autonomy to hydrate Bleep system to release patients from admissions lounge Need to increase privacy for gowned patients going to theatre Consider cultural needs of some female patients
Team to contact theatre coordinator for advice if in doubt. Communication to clinicians and lead anaesthetist regarding hydration timings. Notices regarding fasting to be displayed. Discussion with Waiting List Team to ensure correct timings are entered on admissions letters. Considered with Lead Anaesthetist later Admission time for pm lists or whether carbohydrate loading more suitable, awaiting feedback. Unable to comply due to confidentiality and Caldicott Principles. Decreases flexibility in theatre utilisation. Some better communication within departments will ensure patients are not starved for longer than necessary. Questionable transmission range, being checked. Business case to be resubmitted as previously declined. Only affects Princess Alexandra Theatres where if necessary patients can change in the Anaesthetic Rooms. No formal changing facilities available. 5
• Waiting list scheduling not working as too many patients are sitting around for long periods of time • Conflicts for space with pre‐ assessment staff waiting for pre‐ admissions staff to vacate their rooms in early morning • Poor staff morale makes recruitment and retention difficult
Emergency Department Paediatrics
June 2015
Calm, welcoming, bright, clean environment Welcoming play area, interactive toys/activities on display Don’t take your troubles home posters clearly displayed. Good, clean and welcoming environment
Reduce volumes of patients in admission lounge currently all patients told to turn up at 7 for some lists while for other lists, 7 and 11am (if scheduled for afternoon surgery). Other hospitals stagger admissions Staff recruitment and retention issues as staff recognise need for improving environment and patient experience Not a lot on information board Philosophy poster good but very small and yellow writing hard to read No information in different languages Does the exit for the young patients have to be via the waiting trolleys with distressed patients? Can it be via the main hospital corridor?
Patient flow addressed immediately which has made marked improvement, by procedure for not admitting family and friends being adhered to. Patient information under review. Patient’s currently admitted at 07.00 for morning lists and 11.00 currently for afternoon lists. Afternoon admission time under review as previously above. Covert storage room back into a clinical room, to ease congestion and share changing facilities with x‐ray for patients admitted to PAT. Actively in recruitment process. Newly appointed Ward Manager driving improvement. Actions/Improvements to be added at a later date
6
Emergency Department Majors
June 2015
Hand gels available. Good storage of equipment Information leaflets available Environment safe and clean Trolleys with drinks available Generally uncluttered Good interactions between nursing and medical staff Patients offered drinks and entertainment Environment is calm and welcoming
Very clean, spacious Good welcome from the Sister Bright Environment Bed space wall covering easy clean Felt like a professionally managed environment Staff professionalism gave confidence in care Full six step hand‐washing technique witnessed Caring interaction with patients with mental Health problems
Some equipment is out of date on checks Some equipment in corridors but in designated areas Unit appeared well staffed with only 1 patient. Not clear whether staff would help the rest of ED if busy
Toilets available although signage rather small and the one in the main area room area slightly blocked by linen trolley that would make it difficult for someone with mobility issues
Garden next to waiting area very overgrown
Signage distinction to areas; no themes or colour identification Confusion regarding clear identification of nurse in charge and the difference of” staff base” and reception. Mixed sex toilets to be reviewed Not every opportunity used with hand gels Not all doctors wearing name badges Dirty linen bags over full and full bags left on floor in main department
Actions/Improvements to be added at a later date
7
Emergency Department Waiting room
June 2015
Good curtain use and use of clips Patient flow calm and constant Calm environment Uncluttered and walls had few posters Patient information leaflets are good Calm 3 Hand gel dispensers located in front of the patient reception station Information available in waiting room E11 – overseas patients Tell us about your care 111 or 999 posters
Nursing staff from minors are welcoming. Very limited interaction with staff Posters and printer blocking view of staff – no eye contact possible. Reception staff not engaging with patients in waiting room Water in jugs and paper cups providing cold drinks on an unclean trolley located in the alcove adjacent to coffee machine Cleanliness poor – evidence of dust on protective barrier strip around waiting room walls. Used vomit bowl on floor. Nursing staff to be alerted when a patient requires attention. Remove supply of vomit bowls stored on top of coffee machine. Early warning detection in drinks area taped up and wiring dangling down. Ceiling void needs filling.
Actions/Improvements to be added at a later date
8
TV In totally the wrong location Friends and family cards are available but in the wrong place
9
Date: 25th June 2015
TRUST BOARD IN PUBLIC
Agenda Item: 2 REPORT TITLE:
SQC Richard Shaw, Chair Safety & Quality Committee Richard Shaw, Chair Safety & Quality Committee
EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
n/a
Action Required: Approval ()
Discussion ( )
Assurance ( )
Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in July 2015. Recommendation: N/A Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact
Compliance with CQC, MHRA and Audit Commission
Financial impact
Serious incidents often become claims
Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment:
Reporting, investigation and learning from serious incidents informs risk management
Trust Board Report Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 2nd July 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 explored a number of issues arising from the ECQRM meetings in June. Updates will be provided to the next meeting on actions to reduce noise at night is to be provided to the next Committee meeting as well as actions that arising from analysis of two Outstanding Trusts will help move the Trust towards an Outstanding rating. The Committee clarified that the elevated risk for stroke on the CQC Intelligent Monitoring Report relates to access to the stroke ward and that greater emphasis is being placed on ringfencing of beds. There was also discussion about progress in coding of deaths in low risk mortality groups which had the potential to become an elevated risk. The Committee questioned whether it would now be appropriate to replace the phrase “clinically led, managerially enabled” with wording such as: “patient focused, clinically led, managerially enabled”. It was thought that this might helpfully reinforce the importance of a patient-focused approach and asked the Executive Committee to might consider this. At the June CQRM meeting with partners, no items in respect of clinical performance by SASH were escalated. Quality Report and SQC Dashboard Discussion of the Quality Report explored management of concerns about a mismatch between demand and capacity in Urology. There was also interest in an audit or re-admissions, and the Committee asked for further information about the outcomes to be reflected in a future Quality Report, following consideration at the Clinical Effectiveness Sub-Committee. In response to a question about the new RTT targets and the risk of unintended consequences, a short report is to be provided to the next meeting of SQC. Caesarian Sections The Committee received a presentation from the Obstetric team on its work to ensure that the Caesarean section rate is appropriate for the Trust’s patients taking into account their clinical condition. It explored how the team manages complexities, such as maternal co-morbidities and the increasing maternal age profile. It also discussed how mothers respond to a caesarean section and what the long term implications are. It was impressed by the extensive work that the department and the Birth Choice Clinic have been doing to ensure that the clinical pathways for pregnant women are clinically appropriate and effective. The Committee took good assurance from the presentation and discussion, noting that the team takes a balanced and sensitive approach that considers the needs of the individual and agrees plans with the mother. It was concluded that Caesarian Section rates in the Trust did not give rise to concern.
Maternity Friends and Family Responses The Committee had previously expressed concern about low response rates to the Friends and Family survey. It was explained that there are three touch points for pregnant women giving feedback to the Trust, at 36 weeks, at post-natal discharge and at the point of transfer from a community midwife to a health visitor. By the time they reach the last touch point they have given feedback three times in six weeks. This is a national problem that has given rise to low response rates. The Trustâ&#x20AC;&#x2122;s response rates are somewhat below national levels, and on a par with neighbouring trusts. WACH have organized focus groups to gather more in-depth feedback, and comments have been positive. The Committee was assured that the service received sufficient feedback to enable improvements to be made to the service. National Surveys The Committee welcomed the news that the National Childrenâ&#x20AC;&#x2122;s and Young People Survey had recently been published and had ranked the Trust as one of the best performing in the country. The next meeting of the Committee is on 6th August at 2pm.
Integrated Performance Report M03 â&#x20AC;&#x201C; June 2015
Presented by: Angela Stevenson (Deputy 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 – June 2015 Patient Safety • There were no Never Events in June 2015 and five SIs. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and three Trust acquired C-Diff cases in June 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 June 2015, 94.8% 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 TWW Breast Symptomatic Standard. • In June 2015 the national bodies revised the performance management of RTT measures, focusing on the “Incompletes Standard”. The Trust continues to achieve this standard and is working to reduce long waiters. Patient Experience • Both the ED and Inpatient FFT reduced in June, ED FFT from 95.3% to 93.7% and Inpatient FFT from 95.1% to 94.7% 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
An Associated University Hospital of Brighton and Sussex Medical School 2
Performance – June 2015 Finance • The Trust is on plan at month 3 with a (£2)m deficit. 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
No of Never Events in month
0
1
0
0
0
0
0
0
0
1
1
0
0
No of medication errors causing Severe Harm or Death
1
0
0
0
0
0
0
0
0
0
0
0
0
Safety Thermometer - % of patients with harm free care (all harm)
92.3%
90.8%
92.5%
92.0%
95.0%
93.0%
93.0%
93.0%
92.0%
92.0%
91.3%
93.5%
92.0%
Safety Thermometer - % of patients with harm free care (new harm)
97.3%
95.3%
96.1%
94.5%
98.0%
96.0%
97.0%
96.0%
95.0%
96.0%
95.9%
97.3%
95.2%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
TBC
100%
100%
100%
100%
100%
98%
100%
96%
96%
100%
98%
100%
98%
1
11
3
3
3
2
2
5
6
5
3
3
5
Serious Incidents - No per 1000 Bed Days
0.06
0.63
0.17
0.17
0.17
0.12
0.11
0.26
0.35
0.26
0.16
0.16
0.27
Percentage of Patient Safety Incidents causing Severe harm or Death
0.4%
1.6%
0.6%
1.1%
0.7%
0.2%
0.2%
0.6%
0.7%
0.6%
0.2%
0.6%
0.5%
0
0
0
0
0
1
0
1
1
0
0
0
0
Percentage of patients who have a VTE risk assessment WHO Checklist Usage - % Compliance 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 June 2015 and no medication errors causing severe harm or death in June 2015. • Safety Thermometer – performance continued at expected levels in June 2015. • Five SIs were declared in June 2015. • Two patient falls sustaining a fractured neck of femur. • A delayed diagnosis of lung cancer. Earlier diagnosis may not have prolonged life but would have improved quality of life.
An Associated University Hospital of Brighton and Sussex Medical School 4
Patient Safety • Missed Torsion of testicle. A patient presented to ED with hemiscrotal pain. The presentation was unusual and was thought to be an infection. This was discussed with a senior Urology registrar before the patient was discharged to reutn for an USS the next day. The USS revealed a testicle with no vascularity and an orchidectomy was performed on that day. • Management of deteriorating patient - A patient was admitted with a presenting problem of faecal impaction. Initial treatment interventions were ineffective and despite fluid resuscitation, the medical review at 19:30 found the patient to be hypoxic and severely hypotensive. The patient’s condition was handed over to the night team but the patient was not medically reviewed again despite being assessed as unwell and with a documented EWS of 6 at 05:10 and again at 07:05, there is no evidence of this being escalated. The patient died at 08:40. • Delayed Diagnosis. A patient was discharged from ED without a documented review of chest x-ray. The patient was re-admitted several months later following a deterioration in her health and metastatic lung cancer was diagnosed. A review of the chest xray taken in November showed obvious shadowing. Infection Control Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
MRSA BSI (incidences in month)
0
0
0
0
0
0
0
0
1
0
0
0
0
CDiff Incidences (in month)
2
2
3
0
1
4
0
2
6
1
1
3
3
MSSA
2
2
2
3
0
1
1
0
2
1
1
0
1
E-Coli
23
18
17
22
18
15
16
14
18
12
11
23
20
Trend
• There were no cases of MRSA in June 2015, and threes case of trust acquired C.diff. • 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
HSMR (56 Monitored diagnoses - 12 Months)
93.4
93.7
93.2
92.7
91.6
93.0
94.4
93.5
93.0
93.5
Emergency readmissions within 30 days (PBR Rules)
6.6%
7.2%
6.7%
6.9%
7.3%
7.1%
6.9%
6.6%
6.6%
6.4%
Apr-15
May-15
7.1%
7.2%
Jun-15
Trend
• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators. HSMR is now stated using a quarterly national benchmark to allow alignment with CQC. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
C Section Rate - Emergency
14%
17%
14%
17%
12%
14%
17%
18%
16%
17%
13%
17%
18%
C Section Rate - Elective
11%
10%
13%
9%
12%
13%
11%
7%
11%
8%
11%
9%
10%
0
0
0
0
0
0
0
0
0
0
0
0
0
7.5%
8.5%
6.1%
8.0%
5.4%
3.8%
6.3%
6.0%
6.0%
6.0%
7.0%
6.2%
4.0%
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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
96.6%
97.6%
95.9%
95.4%
94.3%
95.7%
93.3%
92.0%
91.3%
95.0%
96.8%
96.0%
94.8%
0
0
0
0
0
0
0
0
0
0
0
0
0
Ambulance Turnaround - Number Over 30 mins
77
41
72
97
151
183
344
163
259
247
227
192
251
Ambulance Turnaround - Number Over 60 mins
0
0
3
2
6
4
10
26
51
31
21
48
49
ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA
Trend
• In June 2015, 94.8% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches. • 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. • Processes for external validation of Ambulance handover data is yet to be agreed. Internally validated data for Q1 is shown above and highlights the operational pressures being faced by the hospital. • 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Cancer - TWR
93.6%
93.1%
93.0%
93.2%
93.8%
93.1%
93.1%
93.1%
93.1%
93.1%
93.3%
94.2%
93.1%
Cancer - TWR Breast Symptomatic
93.7%
93.2%
94.4%
93.2%
93.3%
93.6%
93.5%
93.4%
96.3%
93.8%
93.8%
93.8%
90.6%
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
98.1%
99.2%
97.1%
99.2%
100.0%
99.1%
98.4%
97.1%
100.0%
100.0%
98.2%
97.0%
96.2%
Cancer - 62 Day Referral to Treatment Standard
86.9%
90.8%
87.9%
78.8%
87.1%
86.3%
86.1%
85.4%
88.0%
83.7%
86.4%
83.9%
86.5%
Cancer - 62 Day Referral to Treatment Screening
100.0%
50.0%
100.0%
83.3%
83.3%
100.0%
100.0%
92.3%
100.0%
92.3%
84.6%
92.3%
100.0%
Trend
• All Cancer Access Standards were achieved in June 2015 except for the TWR Breast Symptomatic Standard. • Cancer performance remains a national challenge and a national improvement programme is being put in place. The Trust has already begun some of the priorities within this programme to support improved cancer care. This includes • Demand and capacity review, several locum / substantive consultant appointments are in progress as a result
• Review of data and PTL processes • Pathway reviews to incorporate the new NICE guidance
An Associated University Hospital of Brighton and Sussex Medical School 8
Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
95.2%
94.9%
93.9%
93.8%
93.5%
93.3%
92.2%
92.1%
94.0%
93.7%
93.6%
93.5%
92.6%
0
0
0
0
0
0
0
0
0
0
0
0
0
RTT Admitted - 90% in 18 weeks
94.7%
92.8%
90.4%
90.7%
88.1%
81.4%
91.1%
90.2%
82.1%
88.4%
91.6%
90.1%
92.0%
RTT Non Admitted - 95% in 18 weeks
96.5%
95.2%
95.8%
93.2%
93.9%
92.8%
95.0%
91.7%
91.0%
93.5%
93.6%
95.3%
93.4%
Percentage of patients w aiting 6 weeks or more for diagnostic
0.0%
0.3%
0.1%
0.0%
0.0%
0.4%
0.1%
0.9%
0.7%
1.4%
1.0%
0.2%
0.8%
% of operations cancelled on the day not treated within 28 days
0.0%
0.0%
0.0%
1.0%
1.6%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
2.2%
RTT Incomplete Pathways - % under 18 weeks RTT Patients over 52 weeks on incomplete pathways
Trend
• In June 2015, the national oversight bodies of the NHS changed the focus of RTT measurement to be on the Incompletes standard (ie those currently waiting over 18 weeks for their treatment) • While the Trust is achieving this standard at aggregate level, due to the volume of elective referrals and the need to find more capacity to reduce outpatient waits, full speciality compliance is a challenge. The clinical divisions are currently working on trajectories and the additional capacity required in each speciality to deliver full compliance from end of October. • Within Diagnostics, the quality standard for waits over 6 weeks was achieved in June 2015. • One patient was treated in June who had previously been cancelled on the day but was unable to be treated within 28 days
An Associated University Hospital of Brighton and Sussex Medical School 9
Patient Experience Patient Voice Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-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%
94.7%
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%
93.7%
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%
83.3%
100.0%
98.0%
95.0%
95.0%
93.0%
100.0%
95.5%
97.2%
100.0%
94.7%
97.0%
94.9%
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%
86.5%
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%
100.0%
0
0
0
0
0
0
0
0
0
0
0
0
0
23
20
28
17
30
24
20
18
26
22
25
22
27
Maternity FFT - Delivery - % positive responses
Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)
Trend
• The June Friends and Family Test (FFT) score for inpatients remains similar to the last four months, at 94.7%. The inpatient response rate for June increased to 38%, the highest since March 2015. There has been a drop in the June ED FFT, down to 93.7% from 96.2% in May. The ED response rate for FFT remains at 11%, well below the 20% target. • FFT scores for the first three touchpoints for maternity have all dropped this month, whilst response rates for the three have remained similar. Most notable is the 36/40 touchpoint where the score has dropped to 83.3, the lowest score for many months. • National FFT data for May was released in early July. The combined adult and paediatric ED Friends and Family Test score for May was 96.1%. SaSH continues to perform well above the national average (88.3% in May) and was ranked 13 th best in the country. National ED results ranged from 98.2% to 66.3% positive. • Our May inpatient FFT score was 95.1%, just below the National average of 95.4%. National results ranged from 100% to 78% positive. The drop in response rate to 20% is because the national figures now include day case patients as well as inpatients.
An Associated University Hospital of Brighton and Sussex Medical School 10
Workforce Workforce Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Average fill rate – registered nurses/midwives (%) - Day
97.7%
97.5%
95.7%
95.4%
96.4%
97.1%
95.1%
94.8%
95.9%
96.5%
96.8%
95.7%
96.9%
Average fill rate – care staff (%) - Day
97.3%
95.1%
97.5%
96.4%
95.3%
95.0%
93.1%
92.6%
93.8%
94.5%
96.1%
93.8%
93.5%
Average fill rate – registered nurses/midwives (%) - Night
97.9%
98.2%
97.2%
98.1%
99.2%
99.4%
97.3%
97.2%
97.7%
96.7%
96.5%
97.1%
94.1%
Average fill rate – care staff (%) - Night
97.5%
97.2%
97.5%
96.7%
97.4%
95.3%
93.7%
93.3%
94.9%
94.9%
95.2%
95.9%
94.9%
Overall Sickness Rate
3.6%
3.8%
3.2%
4.0%
4.4%
4.0%
4.5%
4.3%
4.4%
4.2%
4.2%
4.3%
4.1%
%age of staff who have had appraisal in last 12 months
80%
80%
75%
74%
72%
69%
72%
67%
68%
73%
71%
68%
58%
15.0%
15.0%
15.8%
15.6%
15.3%
15.3%
15.6%
15.7%
15.7%
15.2%
15.5%
15.9%
15.6%
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 decreased to 15.6% in June 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 decreased to 4.1% in June 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-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
1.6
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
(2.5)
(2.4)
1.6
1.6
1.6
YTD £m Surplus / (Deficit) - Plan
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.4
1.0
1.9
1.4
2.3
(0.8)
(1.2)
(2.0)
YTD £m Surplus / (Deficit) - Actual
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.5
1.0
1.9
(2.9)
(2.4)
(0.8)
(1.1)
(2.0)
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
3.8
3.8
3.8
Outturn UNDERLYING £m Surplus / (Deficit) - Actual
3.4
3.4
3.4
1.0
1.0
(0.7)
(5.2)
(5.2)
(5.2)
(5.2)
3.8
3.3
3.3
YTD Savings £m - Actual
1.1
1.9
2.8
3.8
5.0
6.2
7.4
8.6
9.8
11.0
0.3
0.5
0.8
(8.0)
(8.5)
(8.5)
(8.5)
(8.5)
(6.3)
(6.3)
(5.5)
(0.7)
0.0
0.0
(1.0)
TBC
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
7.6
7.6
7.6
YTD Cash position £m Fav / (Adv) - Actual
2.4
2.7
3.1
3.0
3.8
2.8
4.8
3.8
3.8
2.6
3.2
2.9
2.6
(18.0)
(18.0)
(17.0)
(10.0)
(7.0)
(4.0)
(8.0)
(8.0)
(18.0)
(21.0)
(20.0)
(21.0)
(23.0)
YTD BPPC (overall) volume £m
94%
94%
94%
94%
90%
85%
88%
87%
86%
82%
62%
75%
78%
YTD BPPC (overall) value £m
90%
87%
88%
87%
92%
78%
84%
83%
83%
81%
65%
73%
75%
Outturn Capital spend Fav / (Adv) - forecast
19.3
19.3
19.4
19.4
19.4
19.4
19.3
19.3
19.3
19.3
17.1
17.1
17.1
OT Risk £m Surplus / (Deficit) - Assessment
YTD Liquid ratio - days
Trend
• The Trust is on plan at month 3 with a (£2)m deficit. • Contract income is adverse to plan at the end of quarter 1 due to phasing of additional capacity and the impact of emergency activity • The cost improvement schemes are on plan at month 3 with £0.8m delivered, including contingency from new schemes identified last month. • The underlying position at the end of June is £(2.2)m deficit, reflecting the non recurrent contingency savings. • The outturn forecast is a £1.6m surplus, however the Board will be reviewing the Q1 forecast and associated risks. Those risks are significant, as discussed in past reports.
An Associated University Hospital of Brighton and Sussex Medical School 12
Finance • Risks to the 2015/16 financial plan to be agreed. • The cash balance at the end of June 2015 was £2.6m and remains slightly above plan. The cash forecast will be reviewed with the forecast. • The capital forecast this year is spend of £17.1m.
An Associated University Hospital of Brighton and Sussex Medical School 13
Integrated Performance Report M03 â&#x20AC;&#x201C; June 2015
Presented by: Angela Stevenson (Deputy 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 – June 2015 Patient Safety • There were no Never Events in June 2015 and five SIs. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and three Trust acquired C-Diff cases in June 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 June 2015, 94.8% 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 TWW Breast Symptomatic Standard. • In June 2015 the national bodies revised the performance management of RTT measures, focusing on the “Incompletes Standard”. The Trust continues to achieve this standard and is working to reduce long waiters. Patient Experience • Both the ED and Inpatient FFT reduced in June, ED FFT from 95.3% to 93.7% and Inpatient FFT from 95.1% to 94.7% 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
An Associated University Hospital of Brighton and Sussex Medical School 2
Performance – June 2015 Finance • The Trust is on plan at month 3 with a (£2)m deficit. 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
No of Never Events in month
0
1
0
0
0
0
0
0
0
1
1
0
0
No of medication errors causing Severe Harm or Death
1
0
0
0
0
0
0
0
0
0
0
0
0
Safety Thermometer - % of patients with harm free care (all harm)
92.3%
90.8%
92.5%
92.0%
95.0%
93.0%
93.0%
93.0%
92.0%
92.0%
91.3%
93.5%
92.0%
Safety Thermometer - % of patients with harm free care (new harm)
97.3%
95.3%
96.1%
94.5%
98.0%
96.0%
97.0%
96.0%
95.0%
96.0%
95.9%
97.3%
95.2%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
TBC
100%
100%
100%
100%
100%
98%
100%
96%
96%
100%
98%
100%
98%
1
11
3
3
3
2
2
5
6
5
3
3
5
Serious Incidents - No per 1000 Bed Days
0.06
0.63
0.17
0.17
0.17
0.12
0.11
0.26
0.35
0.26
0.16
0.16
0.27
Percentage of Patient Safety Incidents causing Severe harm or Death
0.4%
1.6%
0.6%
1.1%
0.7%
0.2%
0.2%
0.6%
0.7%
0.6%
0.2%
0.6%
0.5%
0
0
0
0
0
1
0
1
1
0
0
0
0
Percentage of patients who have a VTE risk assessment WHO Checklist Usage - % Compliance 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 June 2015 and no medication errors causing severe harm or death in June 2015. • Safety Thermometer – performance continued at expected levels in June 2015. • Five SIs were declared in June 2015. • Two patient falls sustaining a fractured neck of femur. • A delayed diagnosis of lung cancer. Earlier diagnosis may not have prolonged life but would have improved quality of life.
An Associated University Hospital of Brighton and Sussex Medical School 4
Patient Safety • Missed Torsion of testicle. A patient presented to ED with hemiscrotal pain. The presentation was unusual and was thought to be an infection. This was discussed with a senior Urology registrar before the patient was discharged to reutn for an USS the next day. The USS revealed a testicle with no vascularity and an orchidectomy was performed on that day. • Management of deteriorating patient - A patient was admitted with a presenting problem of faecal impaction. Initial treatment interventions were ineffective and despite fluid resuscitation, the medical review at 19:30 found the patient to be hypoxic and severely hypotensive. The patient’s condition was handed over to the night team but the patient was not medically reviewed again despite being assessed as unwell and with a documented EWS of 6 at 05:10 and again at 07:05, there is no evidence of this being escalated. The patient died at 08:40. • Delayed Diagnosis. A patient was discharged from ED without a documented review of chest x-ray. The patient was re-admitted several months later following a deterioration in her health and metastatic lung cancer was diagnosed. A review of the chest xray taken in November showed obvious shadowing. Infection Control Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
MRSA BSI (incidences in month)
0
0
0
0
0
0
0
0
1
0
0
0
0
CDiff Incidences (in month)
2
2
3
0
1
4
0
2
6
1
1
3
3
MSSA
2
2
2
3
0
1
1
0
2
1
1
0
1
E-Coli
23
18
17
22
18
15
16
14
18
12
11
23
20
Trend
• There were no cases of MRSA in June 2015, and threes case of trust acquired C.diff. • 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
HSMR (56 Monitored diagnoses - 12 Months)
93.4
93.7
93.2
92.7
91.6
93.0
94.4
93.5
93.0
93.5
Emergency readmissions within 30 days (PBR Rules)
6.6%
7.2%
6.7%
6.9%
7.3%
7.1%
6.9%
6.6%
6.6%
6.4%
Apr-15
May-15
7.1%
7.2%
Jun-15
Trend
• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators. HSMR is now stated using a quarterly national benchmark to allow alignment with CQC. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
C Section Rate - Emergency
14%
17%
14%
17%
12%
14%
17%
18%
16%
17%
13%
17%
18%
C Section Rate - Elective
11%
10%
13%
9%
12%
13%
11%
7%
11%
8%
11%
9%
10%
0
0
0
0
0
0
0
0
0
0
0
0
0
7.5%
8.5%
6.1%
8.0%
5.4%
3.8%
6.3%
6.0%
6.0%
6.0%
7.0%
6.2%
4.0%
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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
96.6%
97.6%
95.9%
95.4%
94.3%
95.7%
93.3%
92.0%
91.3%
95.0%
96.8%
96.0%
94.8%
0
0
0
0
0
0
0
0
0
0
0
0
0
Ambulance Turnaround - Number Over 30 mins
77
41
72
97
151
183
344
163
259
247
227
192
251
Ambulance Turnaround - Number Over 60 mins
0
0
3
2
6
4
10
26
51
31
21
48
49
ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA
Trend
• In June 2015, 94.8% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches. • 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. • Processes for external validation of Ambulance handover data is yet to be agreed. Internally validated data for Q1 is shown above and highlights the operational pressures being faced by the hospital. • 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Cancer - TWR
93.6%
93.1%
93.0%
93.2%
93.8%
93.1%
93.1%
93.1%
93.1%
93.1%
93.3%
94.2%
93.1%
Cancer - TWR Breast Symptomatic
93.7%
93.2%
94.4%
93.2%
93.3%
93.6%
93.5%
93.4%
96.3%
93.8%
93.8%
93.8%
90.6%
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
98.1%
99.2%
97.1%
99.2%
100.0%
99.1%
98.4%
97.1%
100.0%
100.0%
98.2%
97.0%
96.2%
Cancer - 62 Day Referral to Treatment Standard
86.9%
90.8%
87.9%
78.8%
87.1%
86.3%
86.1%
85.4%
88.0%
83.7%
86.4%
83.9%
86.5%
Cancer - 62 Day Referral to Treatment Screening
100.0%
50.0%
100.0%
83.3%
83.3%
100.0%
100.0%
92.3%
100.0%
92.3%
84.6%
92.3%
100.0%
Trend
• All Cancer Access Standards were achieved in May 2015 except for the TWR Breast Symptomatic Standard. • Cancer performance remains a national challenge and a national improvement programme is being put in place. The Trust has already begun some of the priorities within this programme to support improved cancer care. This includes • Demand and capacity review, several locum / substantive consultant appointments are in progress as a result • Review of data and PTL processes • Pathway reviews to incorporate the new NICE guidance
An Associated University Hospital of Brighton and Sussex Medical School 8
Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
95.2%
94.9%
93.9%
93.8%
93.5%
93.3%
92.2%
92.1%
94.0%
93.7%
93.6%
93.5%
92.6%
0
0
0
0
0
0
0
0
0
0
0
0
0
RTT Admitted - 90% in 18 weeks
94.7%
92.8%
90.4%
90.7%
88.1%
81.4%
91.1%
90.2%
82.1%
88.4%
91.6%
90.1%
92.0%
RTT Non Admitted - 95% in 18 weeks
96.5%
95.2%
95.8%
93.2%
93.9%
92.8%
95.0%
91.7%
91.0%
93.5%
93.6%
95.3%
93.4%
Percentage of patients w aiting 6 weeks or more for diagnostic
0.0%
0.3%
0.1%
0.0%
0.0%
0.4%
0.1%
0.9%
0.7%
1.4%
1.0%
0.2%
0.8%
% of operations cancelled on the day not treated within 28 days
0.0%
0.0%
0.0%
1.0%
1.6%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
2.2%
RTT Incomplete Pathways - % under 18 weeks RTT Patients over 52 weeks on incomplete pathways
Trend
• In June 2015, the national oversight bodies of the NHS changed the focus of RTT measurement to be on the Incompletes standard (ie those currently waiting over 18 weeks for their treatment) • While the Trust is achieving this standard at aggregate level, due to the volume of elective referrals and the need to find more capacity to reduce outpatient waits, full speciality compliance is a challenge. The clinical divisions are currently working on trajectories and the additional capacity required in each speciality to deliver full compliance from end of October. • Within Diagnostics, the quality standard for waits over 6 weeks was achieved in June 2015. • One patient was treated in June who had previously been cancelled on the day but was unable to be treated within 28 days
An Associated University Hospital of Brighton and Sussex Medical School 9
Patient Experience Patient Voice Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-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%
94.7%
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%
93.7%
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%
83.3%
100.0%
98.0%
95.0%
95.0%
93.0%
100.0%
95.5%
97.2%
100.0%
94.7%
97.0%
94.9%
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%
86.5%
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%
100.0%
0
0
0
0
0
0
0
0
0
0
0
0
0
23
20
28
17
30
24
20
18
26
22
25
22
27
Maternity FFT - Delivery - % positive responses
Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)
Trend
• The June Friends and Family Test (FFT) score for inpatients remains similar to the last four months, at 94.7%. The inpatient response rate for June increased to 38%, the highest since March 2015. There has been a drop in the June ED FFT, down to 93.7% from 96.2% in May. The ED response rate for FFT remains at 11%, well below the 20% target. • FFT scores for the first three touchpoints for maternity have all dropped this month, whilst response rates for the three have remained similar. Most notable is the 36/40 touchpoint where the score has dropped to 83.3, the lowest score for many months. • National FFT data for May was released in early July. The combined adult and paediatric ED Friends and Family Test score for May was 96.1%. SaSH continues to perform well above the national average (88.3% in May) and was ranked 13th best in the country. National ED results ranged from 98.2% to 66.3% positive. • Our May inpatient FFT score was 95.1%, just below the National average of 95.4%. National results ranged from 100% to 78% positive. The drop in response rate to 20% is because the national figures now include day case patients as well as inpatients.
An Associated University Hospital of Brighton and Sussex Medical School 10
Workforce Workforce Indicator Description
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Average fill rate – registered nurses/midwives (%) - Day
97.7%
97.5%
95.7%
95.4%
96.4%
97.1%
95.1%
94.8%
95.9%
96.5%
96.8%
95.7%
96.9%
Average fill rate – care staff (%) - Day
97.3%
95.1%
97.5%
96.4%
95.3%
95.0%
93.1%
92.6%
93.8%
94.5%
96.1%
93.8%
93.5%
Average fill rate – registered nurses/midwives (%) - Night
97.9%
98.2%
97.2%
98.1%
99.2%
99.4%
97.3%
97.2%
97.7%
96.7%
96.5%
97.1%
94.1%
Average fill rate – care staff (%) - Night
97.5%
97.2%
97.5%
96.7%
97.4%
95.3%
93.7%
93.3%
94.9%
94.9%
95.2%
95.9%
94.9%
Overall Sickness Rate
3.6%
3.8%
3.2%
4.0%
4.4%
4.0%
4.5%
4.3%
4.4%
4.2%
4.2%
4.3%
4.1%
%age of staff who have had appraisal in last 12 months
80%
80%
75%
74%
72%
69%
72%
67%
68%
73%
71%
68%
58%
15.0%
15.0%
15.8%
15.6%
15.3%
15.3%
15.6%
15.7%
15.7%
15.2%
15.5%
15.9%
15.6%
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 decreased to 15.6% in June 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 decreased to 4.1% in June 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
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-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
1.6
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
(2.5)
(2.4)
1.6
1.6
1.6
YTD £m Surplus / (Deficit) - Plan
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.4
1.0
1.9
1.4
2.3
(0.8)
(1.2)
(2.0)
YTD £m Surplus / (Deficit) - Actual
(2.8)
(2.1)
(1.5)
(1.3)
0.1
0.5
1.0
1.9
(2.9)
(2.4)
(0.8)
(1.1)
(2.0)
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
3.8
3.8
3.8
Outturn UNDERLYING £m Surplus / (Deficit) - Actual
3.4
3.4
3.4
1.0
1.0
(0.7)
(5.2)
(5.2)
(5.2)
(5.2)
3.8
3.3
3.3
YTD Savings £m - Actual
1.1
1.9
2.8
3.8
5.0
6.2
7.4
8.6
9.8
11.0
0.3
0.5
0.8
(8.0)
(8.5)
(8.5)
(8.5)
(8.5)
(6.3)
(6.3)
(5.5)
(0.7)
0.0
0.0
(1.0)
TBC
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
7.6
7.6
7.6
YTD Cash position £m Fav / (Adv) - Actual
2.4
2.7
3.1
3.0
3.8
2.8
4.8
3.8
3.8
2.6
3.2
2.9
2.6
(18.0)
(18.0)
(17.0)
(10.0)
(7.0)
(4.0)
(8.0)
(8.0)
(18.0)
(21.0)
(20.0)
(21.0)
(23.0)
YTD BPPC (overall) volume £m
94%
94%
94%
94%
90%
85%
88%
87%
86%
82%
62%
75%
78%
YTD BPPC (overall) value £m
90%
87%
88%
87%
92%
78%
84%
83%
83%
81%
65%
73%
75%
Outturn Capital spend Fav / (Adv) - forecast
19.3
19.3
19.4
19.4
19.4
19.4
19.3
19.3
19.3
19.3
17.1
17.1
17.1
OT Risk £m Surplus / (Deficit) - Assessment
YTD Liquid ratio - days
Trend
• The Trust is on plan at month 3 with a (£2)m deficit. • Contract income is adverse to plan at the end of quarter 1 due to phasing of additional capacity and the impact of emergency activity • The cost improvement schemes are on plan at month 3 with £0.8m delivered, including contingency from new schemes identified last month. • The underlying position at the end of June is £(2.2)m deficit, reflecting the non recurrent contingency savings. • The outturn forecast is a £1.6m surplus, however the Board will be reviewing the Q1 forecast and associated risks. Those risks are significant, as discussed in past reports.
An Associated University Hospital of Brighton and Sussex Medical School 12
Finance • Risks to the 2015/16 financial plan to be agreed. • The cash balance at the end of June 2015 was £2.6m and remains slightly above plan. The cash forecast will be reviewed with the forecast. • 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: 30 July 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 28th July 2015. The key points from the meeting were as follows: Financial, Workforce, Capital and IT M03 performance reports
M03 reports were received for Finance, Workforce and Organisational Development, Capital and IT.
The Trust has reported a £2m deficit at month 3 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 the Workforce & Organisational Development monthly report, feedback on vacancy reporting and the Workforce Internal Control framework.
The Committee received reports on Capital and IT.
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 – 30 July 2015
Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 28 July 2015 and it was quorate. points from Part 1 were as follows:
The key
Financial, Workforce, Capital and IT M03 performance reports The month 3 Finance, Capital and IT reports were presented to the Committee: -
The Trust is on plan for month 3 with a £2m deficit. Contract income is adverse to plan at the end of quarter 1 due to phasing of additional capacity and the impact of emergency activity. NEL 2 day admissions have increases in the first quarter above the planned level and the 70% marginal rate tariff is not covering the full cost of these admissions. The Trust is continuing to outsourcing elective activity to meet the 18 week target.
-
Temporary staffing costs continue to be high, especially in the Medical division, due to the cost of agency premiums to cover the nursing vacancies. Non pay and drugs are also overspent due to the increased emergency activity.
-
The cost improvement schemes are on plan at month 3 with £0.8m delivered, including contingency from new schemes identified last month. From next month the 2016/17 CIP paper with include gateway criteria alongside the risk rating to monitor the achievement of the plans.
-
The cash balance at the end of June 2015 was £2.6m and remains slightly above plan.
-
The Workforce and Organisational Development paper was presented to the Committee and it was highlighted that the achievement review process is not yet completed but the target is for all staff to have had their achievement review by winter. The Committee will receive a more in depth report next month on sickness, its drivers and resolutions. A paper on Nurse Staffing showed a funded establishment of 1601 and a vacancy level of 267 (17.3 %).
-
The Capital and IT reports were presented and noted by the Committee. The Committee have requested more detail in the IT report on the benefits already gained and those expected with the IT roadmap rollout.
[END]
An Associated University Hospital of Brighton and Sussex Medical School
3
TRUST BOARD IN PUBLIC
Date: 30th July 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 â&#x20AC;&#x201C; 17/07/15
Action Required: Approval ()
Discussion ()
Assurance (â&#x2C6;&#x161;)
Purpose of Report: This report provides the Board with an executive summary of the July Audit and Assurance Committee. Summary of key issues The committee noted the review of the Board Assurance Framework and proposals to strengthen the committees review. Noting requests to update on due actions where possible. Management discussed actions and assurances taken following the Internal Audit of Temporary Staffing. The committee took assurance from the progress to date and considering outsourcing elements of the TSB process to improve our resourcing capability. The committee took significant assurance from External Audits review of Trust accounts, value for money and quality accounts. 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:
Legal and regulatory impact
The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the
“breakeven duty”. The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources. The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services. Financial impact
Committee review of Trust financial position
Patient Experience/Engagement
No relevant aspects
Risk & Performance Management
The committee provides assurance about internal control and risk management. This report discusses BAF reporting
NHS Constitution/Equality & Diversity/Communication
No relevant aspects
Attachment: Internal Audit Strategy, External Audit Letter
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT – 30/07/2014 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 17/07/2015; it was quorate. The key points from this meeting were as follows: 1) Board Assurance Framework The committee discussed the board assurance framework, focussing on individual controls and assurances recorded in finance and quality related risks specifically asking for updates relating to due actions. The committee noted that BAF risks relating to finance and foundation Trust journey would need to be updated throughout July and August. The committee discussed proposals to develop assurance processes to support its work reviewing the BAF. 2) Internal Controls Management presented its review of internal controls relating to legal requirements (Health and Safety, Fire Safety, Sustainability etc.). The committee took assurance from both the review and comments from Internal Audit. 3) Internal Audit Temporary Staffing The Committee discussed the recent internal audit of temporary staffing and management’s response to its findings. The committee took assurance from the actions management had taken to date to mitigate against the issues raised by the audit but noted continuing concerns over the effectiveness of the TSB (temporary staffing bureau). The committee asked that the Finance and Workforce Committee continued to seek assurances over effectiveness of controls, effect on agency spend and forecasting. The committee noted that the Trusts was considering options for the management of TSB including potential outsourcing. 4) Internal Audit Strategy The Head of Internal Audit presented its strategy and plan for audit activity for 2015/16 (attached for information). The committee noted the robust process that had been taken to develop the plans and the focus on significant risks, key controls and strategic intention. The committee agreed the plan. 5) External Audit Letter External Audit presented its annual audit letter which summarised its findings for the three key audits it had carried out as follows; a) Accounts, unqualified opinion on the Trust’s annual accounts (income and expenditure for the year). b) Value for money, a qualified conclusion linked to the Trust end of year deficit of £2.4 million in 2014/15. c) Quality accounts, an unqualified opinion on the Trust's Quality Account. The committee noted the strong assurances that this provided and agreed that the £2.4 million deficit was recognised and that financial controls had been sound. Paul Biddle Non-Executive Director & Chair of Audit & Assurance Committee July 2015
3 An Associated University Hospital of Brighton and Sussex Medical School
Surrey and Sussex Healthcare NHS Trust Internal audit strategy 2014/2015 - 2016/2017 Presented at the Audit Committee meeting of: 17 July 2015
www.bakertilly.co.uk
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 1
Contents 1 Introduction ................................................................................................................................................................... 2 2 Developing the internal audit strategy .......................................................................................................................... 4 3 Internal audit resources ................................................................................................................................................ 8 4 Audit committee requirements ..................................................................................................................................... 9 Appendix A: Internal audit plan 2015/2016 ..................................................................................................................... 10 Appendix B: Internal audit strategy ................................................................................................................................. 16 Appendix C: Factors influencing the internal audit strategy ............................................................................................ 23 Appendix D: Internal audit charter ................................................................................................................................... 24 Appendix E: Our internal audit approach to an assignment ............................................................................................ 29 Appendix F: Overview of internal audit assignment opinions ......................................................................................... 30 For further information contact ........................................................................................................................................ 31
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 2
1 Introduction Our approach to developing your internal audit plan is based on analysing your corporate objectives, risk profile and assurance framework as well as other, factors affecting Surrey and Sussex Healthcare NHS Trust in the year ahead including changes within the sector. 1.1 Background Surrey and Sussex Healthcare NHS Trust continues to improve and is proud to be one of the best performing Trusts in England. In the past year, 2014-15, the Trust has succeeded in meeting clinical standards and delivering high quality care and a positive experience for its patients through a number of elements. The application to become a Foundation Trust has successfully completed a number of key milestones: November 2014: Formal Board-to-Board with the Trust Development Authority (TDA) March 2015: The TDA Board gives approval for us to move to the final Monitor assessment stage April 2015: Monitor assessment begins At the end of March 2015 the Trust had recruited over 10,000 members.
1.2 Vision The Trust’s vision is “Safe, high quality healthcare that puts our community first.” The Trust’s values are Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour 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 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 Safety and quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 3
1.3 Objectives This year, as part of its ongoing development of the Trust, the Trust has reviewed its strategic objectives to align them with the five domains of Care Quality Commission (CQC) inspection standards and to focus its priorities as: 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: Become the secondary care provider of choice for our catchment population. 5. Well-led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 4
2 Developing the internal audit strategy We use your objectives as the starting point in the development of your internal audit plan. 2.1 Risk management processes We have evaluated your risk management processes and consider that we can place reliance on your risk registers / assurance framework to inform the internal audit strategy. We have used various sources of information (see Figure A below) and discussed priorities for internal audit coverage with the following people:
Chief Finance Officer Director of Corporate Affairs Audit Committee Chair Executive Committee Audit Committee (to be discussed in July 2015)
The plan is based on their comments and our assessment of your needs based on prior working, issues elsewhere in the Sector and our Strategic Internal Audit plan. Based on our understanding of the organisation, and the information provided to us by the stakeholders above, we have developed an annual internal plan for the coming year, and a high level strategic plan. This was also supplemented by linking our work to the Trust’s own Internal Control System Map which has been aligned to Board Committees.
Figure A: Sources considered when developing the Internal Audit Strategy.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 5
2.2 How the plan links to your strategic objectives Each of the reviews that we propose to undertake is detailed in the internal audit plan and strategy within Appendices A and B. In the table below we bring to your attention particular key audit areas and discuss the rationale for their inclusion or exclusion within the strategy. As well as assignments designed to provide assurance or advisory input around specific risks, the strategy also includes: time for tracking the implementation of actions and an audit management allocation. Full details of these can be found in Appendices A and B.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 6
Area
Reason for inclusion or exclusion in the audit plan/strategy
Link to strategic objective
Right Bed First Time
The Trust needs to find patients the right bed, the first time they are admitted through the Emergency Department (ED) which should lead to improvements in health outcomes and patient experience, and reduce overall length of stay. The Trust needs the ability to make fast, informed decisions about patient placement from ED admission to the subsequent placement of the patient onto an appropriate ward and is seeking to have an effective real time bed tracker as part of this process.
1. Safe: Deliver safe services and be in the top 20% against our peers. 3. Caring: Ensure patients are cared for and feel cared about.
Supervision For Temporary Staff
Despite pressures on capacity and demands on time it is important that supervision of temporary staff remains a priority as ineffective processes could have a detrimental effect on patient safety and quality of clinical care. We will review processes to record supervision of temporary staff to demonstrate that it is taking place and effective actions are being taken where extra support and/or training is required. We will consider the accuracy, completeness and timeliness of reporting of compliance.
1. Safe: Deliver safe services and be in the top 20% against our peers.
Capital Schemes
As the Trust has limited availability of revenue funding and the focus is on service delivery and patient care it becomes difficult to reduce funds to maintain and improve environment where services are provided. We will consider the overarching setting of the Capital Programme, Business Case processes and the management and reporting against the programme. Additionally for a sample of projects we will undertake testing in regards to value for money around the capital procurement. In addition, we will focus on how the backlog maintenance is prioritised and delivered. We will also incorporate some review of former IT Capital Projects to determine whether the intended benefits have been realised.
5. Well-led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model.
Agency
Recent letters have been issued from the Secretary of State 5. Well-led: Become an regarding the use of Agency, the need to control expenditure employer of choice and and additional assurance required deliver financial and clinical sustainability In addition, annually the challenge is becoming harder to around a clinical drive through financial efficiencies and Agency cost in 14/15 leadership model. was still one of the Trust main areas of overspend/ standardisation and compliance issues. This area will link in with the Trust CIP and also Workforce planning We will the review the new arrangements for managing Agency across the Trust in particularly at ward/unit level. This will build on work already undertaken in 14/15.
Cost Improvement Plans
We will focus the review on assumptions made, timing of development of CIP schemes and also inclusion of quality assessments. We will also assess longer term CIP planning and review how projects are delivering against plan.
5. Well-led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 7
2.3 Working with other assurance providers The Audit Committee is reminded that internal audit is only one source of assurance and through the delivery of our plan we will not, and do not, seek to cover all risks and processes within the organisation. We will however continue to work closely with other assurance providers, such as External Audit and Local Counter Fraud to ensure that duplication is minimised and a suitable breadth of assurance obtained.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 8
3 Internal audit resources Your internal audit service is provided by Baker Tilly Risk Advisory Services LLP. The team will be led by Nick Atkinson - Partner, supported by David May as your Client Manager. 3.1 Fees Our fee to deliver the plan of 250 days is £84,435 (excluding VAT). There are additionally ten days carried forwards from 2014/15 to create an overall 260 day plan.
3.2 Conformance with internal auditing standards Baker Tilly affirms that our internal audit services are designed to conform to the Public Sector Internal Audit Standards (PSIAS). Further details of our responsibilities are set out in our internal audit charter within Appendix D. Under PSIAS, internal audit services are required to have an external quality assessment every five years. Our Risk Advisory service line commissioned an external independent review of our internal audit services in 2011 to provide assurance whether our approach meets the requirements of the International Professional Practices Framework (IPPF) published by the Global Institute of Internal Auditors (IIA) on which PSIAS is based. The external review concluded that “the design and implementation of systems for the delivery of internal audit provides substantial assurance that the standards established by the IIA in the IPPF will be delivered in an adequate and effective manner”.
3.3 Conflicts of Interest We are not aware of any relationships that may affect the independence and objectivity of the team, and which are required to be disclosed under internal auditing standards.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 9
4 Audit committee requirements In approving the internal audit strategy, the committee is asked to consider the following: • Is the Audit Committee satisfied that sufficient assurances are being received within our annual plan (as set out at Appendix A) to monitor the organisation’s risk profile effectively? • Does the strategy for internal audit (as set out at Appendix B) cover the organisation’s key risks as they are recognised by the Audit Committee? • Are the areas selected for coverage this coming year appropriate? • Is the Audit Committee content that the standards within the charter in Appendix D are appropriate to monitor the performance of internal audit? It may be necessary to update our plan in year, should your risk profile change and different risks emerge that could benefit from internal audit input. We will ensure that management and the audit committee approve such any amendments to this plan.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 10
Appendix A: Internal audit plan 2015/2016 Audit area
Scope for 2015/16
Audit days
Proposed timing
Estimated audit committee date
We will focus on the controls in place regarding stock ordering and management of Pharmacy with particular focus on the CIP aspect of Drug wastage.
10
July 2015
September 2015
We will review processes to record supervision of temporary staff to demonstrate that it is taking place and effective actions are being taken where 10 extra support and/or training is required. We will consider the accuracy, completeness and timeliness of compliance.
January 2016
March 2016
For a sample of key performance figures reported to the Board we will review the underlying data quality to provide assurance that the information reported is accurate. In addition we will review the indicator as determined by either the Trust or Monitor & the Governors for Quality Accounts depending on its FT Status. The review includes tracing data from source through collection, validation to report to ensure processes are robust.
13
April 2016
July 2016
To consider the approach to development of CIPs including assumptions and Quality Impact assessments. We will review progress to deliver to date and how longer term (16/17) CIP plans are being developed and planned for development. We will undertake some deep dive reviews into progress on delivery on specific projects.
12
September 2015
November 2015
We will consider the overarching setting of the Capital Programme, Business Case processes and the management and reporting against the programme. Additionally for a sample of projects we will undertake testing in regards to value for money around the capital procurement. In addition, we will focus how the backlog maintenance is priortised and delivered.
10
November 2015
January 2016
Risk based assurance Pharmacy Stock
Supervision For Temporary Staff
Data Quality
Cost Improvement Plans
Backlog Maintenance & Capital Schemes
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 11
Audit area
Scope for 2015/16
Temporary Staffing
We will the review the new arrangements for managing Agency usage across the Trust in particularly at ward/unit level. This will build on work already undertaken in 14/15. It will also provide assurance around use of appropriate agencies and consultants following the letter from the Secretary of State requiring additional assurances.
Mortality Reporting
Infection Control
To ensure a consistent and coordinated approach for the review of adult deaths in hospital. The need to consider mortality rates and national mortality indicators, available at diagnosis and individual patient level, to ensure that deaths are reviewed and patients are safe. Ensure that there are clear reporting mechanisms in place, to escalate any areas of concern identified, so that the Trust is aware and can take appropriate action We will assess Trust arrangements and ensure that there is robust evidence of compliance in all criteria with the Health and Social Care Act (2008) Code of Practice for the Prevention and Control of Health Care Associated Infections. Our review will focus on how well the Trustâ&#x20AC;&#x2122;s departments are equipped to prevent and deal with infectious disease, particularly HCAI. We will review action plans in place to address identified weakness as well as review lessons learnt and how best practice can be disseminated across the Trust to ensure that the Trust maintains a top decile performance.
Audit days
Proposed timing
Estimated audit committee date
14
January 2016
March 2016
October 2015
January 2016
November 2015
January 2016
10
10
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 12
Audit area
Scope for 2015/16
Duty of Candour
We will consider the adequacy of the Duty of Candour arrangements in the Trust This will, include;
Overseas Patient Income
Right Bed First Time
the adequacy of the revised Duty of Candour Policy ; Assess its understanding amongst staff and whether staff are confident to use it within the Trust and have had appropriate training. For a sample of complaints and near misses we will track through to see how the Duty of Candour is evidenced. How the outcomes are measured in light of the duty of candour. Lessons Learned feedback into improving Patient Experience & Patient Care
Our review will have a specific focus on the new guidelines coming into place for overseas visitors and whether the Trust can demonstrate through its systems that it is doing everything to ensure it qualifies for any payments. This will also take into account the new funding arrangements on income due from CCGs.
To ensure the Trust is finding patients the right bed, the first time they are admitted through the Emergency Department (ED) which leads to improvements in health outcomes and patient experience, and reduces overall length of stay. To evaluate the Trust’s ability to make fast, informed decisions about patient placement from ED admission to the subsequent placement of the patient onto an appropriate ward, using effective real time bed management functionality. To consider adding some specialist support in this area around the current plans.
Audit days
Proposed timing
Estimated audit committee date
10
January 2016
March 2016
10
November 2015
January 2016
12
August 2015
September 2015
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 13
Audit days
Proposed timing
Estimated audit committee date
15
October 2015 & June 2016
November 2015 & July 2016
Audit area
Scope for 2015/16
RTT Data (Performance Management)
RTT is a key quality and performance indicator and the audit would support the Trustâ&#x20AC;&#x2122;s return (which meets expected target) and provide some assurance that this data is sound and accurate. . This will be performed twice during the year
Workforce Reporting (Data Quality)
For a sample of key performance figures reported to the Finance & Workforce Committee we will review the underlying data quality to provide assurance that the information reported is accurate. In particular we will focus on the appropriateness of the establishment levels information and the links between HR and Finance and ESR.
10
October 2015
January 2016
We will review the arrangements to ensure that all activity is captured, billed accurately and completely and supported by a Provider to Provider agreement. Also to ensure there is adequate engagement with the other providers and an understanding of future risks and opportunities for income generation and shared/joint working.
10
September 2015
November 2015
We will review Trust arrangements for managing these risks associated with mobile devices and arrangements for ensuring that appropriate safeguards are in place for handling and processing patient data on mobile devices.
10
April 2016
July 2016
March 2016
July 2016
Provider to Provider Services
Mobile Devices
Core assurance Information Governance Toolkit
The purpose of the review is to examine the attainment levels submitted for a number of requirements within the toolkit, with a view to providing an opinion on the appropriateness of the information submitted and the adequacy of the documentation held to support these scores. This also ensures that if investigated the Trust can demonstrate actual compliance.
10
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 14
Audit area
Proposed timing
Estimated audit committee date
We will conduct a risk assessment on the function and test the higher risk elements to give assurance over the adequacy of the financial controls. This will include elements of the payroll system. As part of this process we will also undertake a review of cash handling, controls and security arrangements of cash collected at Surrey and Sussex Healthcare. This work is done on a rotation basis and in consultation with management.
9
February 2016
March 2016
The Audit Committee would like assurance over the effectiveness of the cash forecasting processes, recognising the challenges around cash management.
6
September 2015
November 2015
10
March 2016
July 2016
Scope for 2015/16
Financial Feeder Systems
Cash Forecasting
Payments to staff
Audit days
Our review will look at the payments that are made to staff in the course of their employment, including expenses, be it travel or petty cash expenditure.
Assurance Framework
Failure to assess and manage clinical and non-clinical risks effectively, resulting in harm
9
Throughout the Year
Each Meeting
Capital Projects Benefits Realisation
We will support the Trusts with a specialist review to consider how benefits are realised from Capital Projects with a specific focus on large scale IT Projects to determine whether they have achieved what they set out to achieve and how the establishment of such projects might lead to greater value moving forwards.
10
October 2015
January 2016
10
Throughout the Year
Each Meeting
Other internal audit input Follow Up
To meet internal auditing standards and to provide management with on-going assurance regarding implementation of recommendations
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 15
Audit area
Advisory Audit
Scope for 2015/16
TOTAL
Proposed timing
Estimated audit committee date
10
To be determined
To be confirmed
20
Throughout the Year
Each Meeting
To allow for additional advisory audits to be undertaken at the request of the Audit Committee or management based on the demand to reduce costs: This could include some of the following areas:
Audit Management
Audit days
Assistance in technical issues around VAT, Salary Sacrifice, PAYE etc. Cash Release from Improvement in Quality Contract Management (Procurement)
This will include: Annual planning Preparation for, and attendance at, Audit Committee meetings Regular liaison and progress updates Liaison with external audit Preparation of the annual internal audit opinion
260
Please note the 260 days includes 10 days bought forward from the 14/15 plan which are to be utilised in 15/16 in particular around the advisory audits and the focus on the demand to reduce costs.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 16
Appendix B: Internal audit strategy Proposed area for coverage
Scope and Associated risk Area
2014/15
2015/16
2016/17
Risk based assurance Safeguarding Children
Management Concern for the Internal Control System Map - Failure to safeguard children from exploitation and/or abuse
Clinical Governance
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.
Safeguarding Adults
Management Concern for the Internal Control System Map - Failure to safeguard vulnerable Adults from exploitation and/or abuse
Data Quality (including Quality Accounts)
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.
Mortality
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.
Duty of Candour
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.
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Proposed area for coverage
Scope and Associated risk Area
2014/15
Consent
1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.A.1 Consistently meet national patient safety standards in all specialties and across divisions Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care 1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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. 2.A Achieve the best possible clinical outcomes for our patients. 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
Infection Control
NICE Guidance
Incident Management
Right Bed, First Time
Complaints
Clinical Audit
2.A Achieve the best possible clinical outcomes for our patients. There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties 2.A Achieve the best possible clinical outcomes for our patients. There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties 2.A Achieve the best possible clinical outcomes for our patients. 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
2015/16
2016/17
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 18
Proposed area for coverage
Scope and Associated risk Area
2014/15
Lessons Learned
2.A Achieve the best possible clinical outcomes for our patients 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 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients.
3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients Ineffective staff development means that the Trust does not have the skilled workforce to deliver current and future services. Ineffective staff development means that the Trust does not have the skilled workforce to deliver current and future services. Ineffective staff development means that the Trust does not have the skilled workforce to deliver current and future services. If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients. 1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 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.
Temporary Staffing
Workforce Strategy & Recruitment
Workforce Reporting
E-Rostering
Absence Management
Statutory and Mandatory Training
Nursing Revalidation
Medical Revalidation
Appraisals
Supervision
2015/16
2016/17
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 19
Proposed area for coverage
Scope and Associated risk Area
Patient Experience
2.A Achieve the best possible clinical outcomes for our patients 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
RTT Data (Performance Management)
5.A Live within our means to remain financially sustainable. As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective.
Procurement
5.A Live within our means to remain financially sustainable. Failure to stop divisional overspending against budget
Disciplinary Procedures
5.G.2 We are a well governed organisation. Failure to have a streamlined disciplinary process in place to enable the Trust to deal with these matters in a timely and effective manner 5.G.2 We are a well governed organisation. There is a risk that Clinical leadership efforts will not embed if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates 5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication Linked to all Risks under Objective 4. (BAF)
Whistleblowing
Business Continuity Planning / Disaster Recovery Business planning
IT Project Management & Implementation
Mobile Devices
IT Security
Information Governance Toolkit
5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication
2014/15
2015/16
2016/17
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 20
Proposed area for coverage
Scope and Associated risk Area
Patients’ Property and Monies
Risk of reputational damage as a result of poor management of patient property and monies. Sector Risk Management Concern - There is a risk that the Trust isn’t able to deliver service in an effective timely manner due to the estate not fully supporting the clinical strategy Failure to maintain transparency and accountability across the organisation. Audit Committee Work plan
EME Services
Register of Interests & Gifts and Hospitality
2014/15
2015/16
2016/17
Stock Control
5.A Live within our means to remain financially sustainable. Failure to stop divisional overspending against budget
Income Contract Management
5.A Live within our means to remain financially sustainable. Failure to stop divisional overspending against budget
Budgetary Control & Financial Reporting
5.A Live within our means to remain financially sustainable. Failure to deliver income plan
Cost Improvement Planning
5.A Live within our means to remain financially sustainable. Failure to stop divisional overspending against budget
Backlog Maintenance & Capital Schemes
5.A Live within our means to remain financially sustainable. Unable to deliver medium term financial plan.
Monitor Licence
The Health and Social Care Act 2012 makes changes to the way NHS service providers will be regulated. These changes include the introduction of a licence for providers of NHS services. Regulatory Requirement new for 14/15 for all provider non-Foundation Trusts. We will review Trust arrangements for ensuring that the Trust meets and complies with the conditions for holding a Monitor Licence and will review compliance on a sample basis annually.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 21
Proposed area for coverage
Scope and Associated risk Area
2014/15
2015/16
2016/17
Core assurance Financial Feeder Systems
We will provide assurance as to the robustness of the core financial systems feeding into the overall financial ledger and financial reporting systems
Cash and Treasury Management
We will undertake a review of cash handling, controls and security arrangements of cash collected at Surrey and Sussex Healthcare . This work is done on a rotation basis and in consultation with management.
Payment to staff
We will provide assurance as to the robustness of the core payroll systems operated locally at the Trust
Fixed Asset Register
We will provide assurance as to the robustness of the core Fixed Asset System.
Private & Overseas Patient Income
Failure to deliver income plan
Other Internal Audit input Assurance Framework
We will continue to provide a rolling programme of reviews to give assurance to the Audit Committee concerning the various sections and risks with associated controls and assurances from within the Board Assurance Framework.
Follow Up
To meet internal auditing standards and to provide management with on-going assurance regarding implementation of recommendations
Contingency
To allow for additional audits to be undertaken at the request of the Audit Committee or management based on changes in assurance needs as they may arise during the year.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 22
Proposed area for coverage
Scope and Associated risk Area
Audit Management
This will include: Annual planning Preparation for, and attendance at, Audit Committee meetings Regular liaison and progress updates Liaison with external audit Preparation of the annual internal audit opinion
2014/15
2015/16
2016/17
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 23
Appendix C: Factors influencing the internal audit strategy The diagram below highlights the planned internal audit coverage against the changing risk environment. This analysis allows us to ensure that the type and level of coverage proposed meets the organisationâ&#x20AC;&#x2122;s assurance needs for the forthcoming and future years.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 24
Appendix D: Internal audit charter 1.0 Need for the charter 1.1 This charter establishes the purpose, authority and responsibilities for the internal audit service for Surrey & Sussex NHS Healthcare Trust. The establishment of a charter is a requirement of the Public Sector Internal Audit Standards (PSIAS) and approval of the charter is the responsibility of the audit committee. 1.2 The internal audit service is provided by Baker Tilly Risk Advisory Services LLP (“Baker Tilly”). Your key internal audit contacts are:
Partner
Client manager
Name
Nick Atkinson
David May
Telephone
07730 300 307
07972 004 131
Email address
Nick.atkinson@bakertilly. David.may@bakertilly.co. co.uk uk
1.3 We plan and perform our internal audit work with a view to reviewing and evaluating the risk management, control and governance arrangements that the organisation has in place, focusing in particular on how these arrangements help you to achieve its objectives. 1.4 An overview of the individual internal audit assignment approach and our client care standards are included at Appendix E and F of the audit plan issued for 2015/16. 2.0 Role and definition of internal auditing “Internal Audit is an independent, objective assurance and consulting activity designed to add value and improve an organisation’s operations. It helps an organisation accomplish its objectives by introducing a systematic, disciplined approach in order to evaluate and improve the effectiveness of risk management, control, and governance processes”. Definition of Internal Auditing, Institute of Internal Auditors and the Public Sector Internal Audit Standards
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 25
2.1 Internal audit is a key part of the assurance cycle for your organisation and, if used appropriately, can assist in informing and updating the risk profile of the organisation. 3.0 Independence and ethics 3.1 To provide for the independence of Internal Audit, its personnel report directly to the Nick Atkinson (acting as your head of internal audit). The independence of Baker Tilly is assured by the internal audit service reporting to the Chief Executive, with further reporting lines to the Director of Finance and Director of Corporate Affairs. 3.2 The head of internal audit has unrestricted access to the Chair of Audit Committee to whom all significant concerns relating to the adequacy and effectiveness of risk management activities, internal control and governance are reported. Conflicts of Interest 3.3 Conflicts of interest may arise where Baker Tilly provides services other than internal audit to Surrey & Sussex NHS Healthcare Trust. Steps will be taken to avoid or manage transparently and openly such conflicts of interest so that there is no real or perceived threat or impairment to independence in providing the internal audit service. If a potential conflict arises through the provision of other services, disclosure will be reported to the audit committee. 3.4 The nature of the disclosure will depend upon the potential impairment and it is important that our role does not appear to be compromised in reporting the matter to the audit committee. Equally we do not want the organisation to be deprived of wider Baker Tilly expertise and will therefore raise awareness without compromising our independence. 4.0 Responsibilities 4.1 In providing your outsourced internal audit service, Baker Tilly has a responsibility to: ď&#x201A;ˇ
Develop a flexible and risk based internal audit strategy with more detailed annual audit plans which align to the corporate objectives. The plan will be submitted to the audit committee for review and approval each year before work commences on delivery of that plan.
ď&#x201A;ˇ
Implement the audit plan as approved, including any additional reviews requested by management and the audit committee.
ď&#x201A;ˇ
Ensure the internal audit team consists of professional internal audit staff with sufficient knowledge, skills, and experience.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 26
Establish a quality assurance and improvement program to ensure the quality and effective operation of internal audit activities.
Perform advisory activities where appropriate, beyond internal audit’s assurance services, to assist management in meeting its objectives.
Bring a systematic disciplined approach to evaluate and report on the effectiveness of risk management, internal control and governance processes.
Highlight control weaknesses and required associated improvements and agree corrective action with management based on an acceptable and practicable timeframe.
Undertake action tracking reviews to ensure management has implemented agreed internal control improvements within specified and agreed timeframes.
Provide a list of significant performance indicators and results to the audit committee to demonstrate the performance of the internal audit service.
Liaise with the external auditor and other relevant assurance providers for the purpose of providing optimal assurance to the organisation.
5.0 Authority 5.1 The internal audit team is authorised to:
Have unrestricted access to all functions, records, property and personnel which it considers necessary to fulfil its function.
Have full and free access to the audit committee.
Allocate resources, set timeframes, define review areas, develop scopes of work and apply techniques to accomplish the overall internal audit objectives.
Obtain the required assistance from personnel within the organisation where audits will be performed, including other specialised services from within or outside the organisation.
5.2 The head of internal audit and internal audit staff are not authorised to:
Perform any operational duties associated with the organisation.
Initiate or approve accounting transactions on behalf of the organisation.
Direct the activities of any employee not employed by Baker Tilly unless specifically seconded to internal audit.
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 27
6.0 Key Performance Indicators (KPIs) 6.1 In delivering our services we require full cooperation from key stakeholders and relevant business areas to ensure a smooth delivery of the plan. We proposed the following KPIs for monitoring the delivery of the internal audit service:
Delivery
Quality
Audits commenced in line with original timescales agreed Conformance with the Public Sector Internal in the internal audit plan. Audit Standards. Draft reports issued within 10 working days of debrief meeting.
Liaison with external audit to allow, where appropriate and required, the external auditor to place reliance on the work of internal audit.
Management responses received from client management within 10 working days of draft report.
Response time for all general enquiries for assistance is completed within 2 working days.
Final report issued within 3 days from receipt of management responses.
Response to emergencies such as concerns of potential fraud with 1 working day.
Completion of internal audit plan by the end of the financial year.
Consideration of the feedback and scores from client satisfaction questionnaires.
7.0 Reporting 7.1 An assignment report will be issued following each internal audit assignment. The report will be issued in draft for comment by management, and then issued as a final report to management, with the executive summary being provided to the audit committee. The final report will contain an action plan agreed with management to address any weaknesses identified by internal audit. 7.2 The Head of Internal Audit will issue progress reports to the Audit Committee and management summarising outcomes of audit activities, including follow up reviews. 7.3 As your internal audit provider, the assignment opinions that Baker Tilly provides the organisation during the year are part of the framework of assurances that assist the board in taking decisions and managing its risks.
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7.4 As the provider of the internal audit service we are required to provide an annual opinion on the adequacy and effectiveness of the organisationâ&#x20AC;&#x2122;s governance, risk management and control arrangements. In giving our opinion it should be noted that assurance can never be absolute. The most that the internal audit service can provide to the board is a reasonable assurance that there are no major weaknesses in risk management, governance and control processes. The annual opinion will be provided to the organisation by Baker Tilly Risk Advisory Services LLP at the financial year end. The results of internal audit reviews, and the annual opinion, should be used by management and the Board to inform the organisationâ&#x20AC;&#x2122;s annual governance statement. 8.0 Data Protection 8.1 Internal audit files need to include sufficient, reliable, relevant and useful evidence in order to support our findings and conclusions. Personal data is not shared with unauthorised persons unless there is a valid and lawful requirement to do so. We are authorised as providers of internal audit services to our clients (through the firmâ&#x20AC;&#x2122;s Terms of Business and our engagement letter) to have access to all necessary documentation from our clients needed to carry out our duties. 8.2 Personal data is not shared outside of Baker Tilly. The only exception would be where there is information on an internal audit file that external auditors have access to as part of their review of internal audit work or where the firm has a legal or ethical obligation to do so (such as providing information to support a fraud investigation based on internal audit findings). 8.3 Baker Tilly has a Data Protection Policy in place that requires compliance by all of our employees. Non-compliance will be treated as gross misconduct. 9.0 Fraud 9.1 The audit committee recognises that management is responsible for controls to reasonably prevent and detect fraud. Furthermore, the audit committee recognises that internal audit is not responsible for identifying fraud; however internal audit will assess the risk of fraud and be aware of the risk of fraud when planning and undertaking any internal audit work. 10.0 Approval of the internal audit charter 10.1 By approving this document, the annual plan, the audit committee is also approving the internal audit charter.
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Appendix E: Our internal audit approach to an assignment
Surrey & Sussex Healthcare NHS Trust Internal Audit Strategy 2015/2016 | 30
Appendix F: Overview of internal audit assignment opinions
ď&#x192;&#x; Increasing level of assurance
For internal audits classed as â&#x20AC;&#x153;risk based assuranceâ&#x20AC;? reviews (compared with advisory input), we use four opinion levels as shown below. Each assignment report will explain the scope of the review, and therefore the context and scope of the opinion.
Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Urgent action is needed to strengthen the control framework to manage the identified risk(s).
Taking account of the issues identified, the Board can take partial assurance that the controls to manage this risk are suitably designed and consistently applied. Action is needed to strengthen the control framework to manage the identified risk(s). Taking account of the issues identified, the Board can take reasonable assurance that the controls in place to manage this risk are suitably designed and consistently applied. However, we have identified issues that need to be addressed in order to ensure that the control framework is effective in managing the identified risk(s).
Taking account of the issues identified, the Board can take substantial assurance that the controls upon which the organisation relies to manage the identified risk(s) are suitably designed, consistently applied and operating effectively.
For further information contact Name Nick Atkinson – Partner - Baker Tilly Risk Advisory Services LLP nick.atkinson@bakertilly.co.uk Direct Line: +44 (0)20 3201 8028 Mobile: +44 (0)7730 300307 Name David May – Audit Manager – Baker Tilly Risk Advisory Services LLP david.may@bakertilly.co.uk Phone: +44 (0)1293 843121 Mobile: +44 (0)7972004131
This report, together with any attachments, is provided pursuant to the terms of our engagement. The use of the report is solely for internal purposes by the management and Board of our client and, pursuant to the terms of our engagement, should not be copied or disclosed to any third party without our written consent. No responsibility is accepted as the plan has not been prepared, and is not intended for, any other purpose. Baker Tilly Corporate Finance LLP, Baker Tilly Restructuring and Recovery LLP, Baker Tilly Risk Advisory Services LLP, Baker Tilly Tax and Advisory Services LLP, Baker Tilly UK Audit LLP, and Baker Tilly Tax and Accounting Limited are not authorised under the Financial Services and Markets Act 2000 but we are able in certain circumstances to offer a limited range of investment services because we are members of the Institute of Chartered Accountants in England and Wales. We can provide these investment services if they are an incidental part of the professional services we have been engaged to provide. Baker Tilly & Co Limited is authorised and regulated by the Financial Conduct Authority to conduct a range of investment business activities. Baker Tilly Creditor Services LLP is authorised and regulated by the Financial Conduct Authority for credit-related regulated activities. Before accepting an engagement, contact with the existing accountant will be made to request information on any matters of which, in the existing accountant's opinion, the firm needs to be aware before deciding whether to accept the engagement. © 2014 Baker Tilly UK Group LLP, all rights reserved.
The Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust Year ended 31 March 2015 July 2015
Darren Wells Director T 01293 554 120 E darren.j.wells@uk.gt.com Jamie Bewick Senior Manager T 07880 456 144 E jamie.n.bewick@uk.gt.com
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
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Contents Section
Page
1. Executive summary
3
2. Audit of the accounts
5
3. Value for Money
8
4. Audit related services
10
Appendices A Reports issued and fees
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
2
Section 1:
Executive summary
01. Executive summary 02. Audit of the accounts 03. Value for Money
04. Audit related services
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
Executive summary Purpose of this Letter Our Annual Audit Letter (Letter) summarises the key findings arising from the following work that we have carried out at Surrey and Sussex Healthcare NHS Trust (the Trust) for the year ended 31 March 2015: • auditing the accounts (Section two) • assessing the Trust's arrangements for securing economy, efficiency and effectiveness in its use of resources (Section three) • other audit related services carried out for the Trust during the years reviewing the Trust's Quality Account (Section four). The Letter is intended to communicate key messages to the Trust and external stakeholders, including members of the public. We reported the detailed findings from our audit work on the accounts and the Trust's arrangements for securing economy, efficiency and effectiveness in its use of resources to the Audit and Assurance Committee (those charged with governance) in the Audit Findings Report on 27 May. We reported the detailed findings from our work on the Trust's Quality Account in our separate Quality Account Report on 30 June. Responsibilities of the external auditors and the Trust This Letter has been prepared in the context of the Statement of Responsibilities of Auditors and Audited Bodies issued by the Audit Commission (www.auditcommission.gov.uk). The Trust is responsible for preparing and publishing its financial statements, accompanied by an Annual Governance Statement. It is also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources (Value for Money). © 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
Our annual work programme, which includes nationally prescribed and locally determined work, has been undertaken in accordance with our Audit Plan issued in March 2015 and was conducted in accordance with the Audit Commission's Code of Audit Practice (the Code), International Standards on Auditing (UK and Ireland) and other guidance issued by the Audit Commission. Audit conclusions The audit conclusions we provided in relation to 2014/15 are as follows: • an unqualified opinion on the accounts which give a true and fair view of the Trust's financial position as at 31 March 2015 and the Trust's income and expenditure for the year • a qualified "except for" conclusion in respect of the Trust's arrangements for securing economy, efficiency and effectiveness in its use of resources as a result of the Trust incurring a deficit of £2.4 million in 2014/15. We issued an unqualified limited assurance report in respect of the Trust's Quality Account in relation to this separate engagement. Acknowledgements This Letter has been agreed with the Chief Finance Officer. We would like to record our appreciation for the assistance and co-operation provided to us during our audit by the Trust's staff. Grant Thornton UK LLP July 2015
4
Section 2: Audit of the accounts
01. Executive summary 02. Audit of the accounts 03. Value for Money 04. Audit related services
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
Audit of the accounts
Audit of the accounts
Conclusion
The key findings of our audit of the accounts are summarised below:
Prior to giving our opinion on the accounts, we are required to report significant matters arising from the audit to 'those charged with governance' (defined as the Audit and Assurance Committee at the Trust). We presented our report to the Committee on 27 May 2015 and summarise only the key messages in this Letter.
Preparation of the accounts The Trust presented us with draft accounts in accordance with the national NHS timetable. Good quality working papers were provided at the outset of the audit and Trust finance staff were prompt and helpful in responding to our queries. As a consequence we were able to complete our audit efficiently, to meet the Trust's reporting timetable.
We issued an unqualified opinion on the Trust's 2014/15 accounts on 3 June 2015, meeting the deadline set by the Department of Health (DH). Our opinion confirms the accounts give a true and fair view of the Trust's financial affairs and of the income and expenditure recorded by the Trust.
Issues arising from the audit of the accounts There were no significant matters arising from the audit of the Trust's accounts. The financial statements were prepared to a high standard of quality and we did not identify any significant misstatements. Annual Governance Statement and Annual Report The Trust produced an annual governance statement and a draft annual report which were compliant with the Department of Health's requirements. The final version of the annual report had not yet been published at the time of completing our audit. We have discussed the publication requirements with the Trust.
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Financial performance 2014/15
Looking forward
The Trust's Performance against its financial targets is set out in the table below:
In 2015/16 the Trust has signed up to an enhanced national tariff of 70 per cent for emergency activity. This should address the issue of the marginal tariff which was the main driver behind the 2014/15 overspend.
Target
Actual
Met?
Breakeven
(£2.4 million deficit)
No
3.5%
3.5%
Yes
Capital resource limit
Not to exceed £19,614k
£19,330k
Yes
External finance limit
Not to exceed £9,595k
£9,595k
Yes
Surplus/ (deficit) Capital cost absorption rate
The Trust incurred a deficit of £2.4 million in 2014/15. The primary reason was the increased level of non elective activity for which the Trust was only paid at 30 per cent of the national tariff.
© 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
The Trust is also working more closely with its partners in the local health economy towards establishing a health campus, with clearer care pathways and risk sharing arrangements. In March 2015 the Trust submitted an integrated business plan to Monitor, as part of its application to become a Foundation Trust. The plan sets out how the Trust plans to maintain financial stability over the next five years and achieve a surplus in each of those five years. The plan assumes the Trust will achieve cost improvement savings over the next five years. While the targets for these savings are challenging, the Trust has a strong track record of achieving its cost improvement programmes. Planned savings are also less than the Trust has achieved over the last five years. The plan has been subject to significant external scrutiny. In March 2015 the Trust Development Authority referred the Trust to Monitor in support of its application to become a Foundation Trust.
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Section 3: Value for Money
01. Executive summary 02. Audit of the accounts 03. Value for Money
04. Audit related services
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
Value for Money Value for Money conclusion The Code describes the Trust's responsibilities to put in place proper arrangements to: • secure economy, efficiency and effectiveness in its use of resources • ensure proper stewardship and governance • review regularly the adequacy and effectiveness of these arrangements. We are required to give our VfM conclusion based on the following two criteria specified by the Audit Commission which support our reporting responsibilities under the Code: The Trust has proper arrangements in place for securing financial resilience. The Trust has robust systems and processes to manage effectively financial risks and opportunities, and to secure a stable financial position that enables it to continue to operate for the foreseeable future. The Trust has proper arrangements for challenging how it secures economy, efficiency and effectiveness. The Trust is prioritising its resources within tighter budgets, for example by achieving cost reductions and by improving efficiency and productivity. Key findings Securing financial resilience We have undertaken a review which considered the Trust's arrangements against the three expected characteristics of proper arrangements as defined by the Audit Commission:
© 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
• Financial governance • Financial planning • Financial control. The Trust has continued to progress its long term plan to become a financially sustainable organisation and to achieve Foundation Trust (FT) status. The Trust Development Authority referred the Trust for FT assessment in March 2015. Challenging economy, efficiency and effectiveness We have reviewed whether the Trust has prioritised its resources to take account of the tighter constraints it is required to operate within and whether it has achieved cost reductions and improved productivity and efficiencies. The Trust has continued its good track record of achieving its Cost Improvement Programmes. The Trust has well established arrangements, which include quality impact assessments for all proposed schemes. The Trust's most recent reference cost index (2013/14) is 92, indicating that the overall cost base is lower than other comparable trusts. Overall VfM conclusion The Trust made a deficit of £2.4 million in 2014/15 and continues to be in breach of the statutory break even duty, because of historic deficits incurred over the last decade. Except for this matter and on the basis of our work, and having regard to the guidance on the specified criteria published by the Audit Commission, we are satisfied that in all significant respects the Trust put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2015.
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Section 4: Audit related services
01. Executive summary 02. Audit of the accounts 03. Value for Money 04. Audit related services
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
Audit related services Quality Accounts For 2014/15 the Trust is required to obtain external audit assurance on its Quality Account. To provide this assurance we have undertaken limited assurance procedures in accordance with guidance issued by the Audit Commission to assess whether:
Conclusions
We provided an unqualified limited assurance opinion on the Trust's Quality Account, in accordance with requirements, on 29 June 2015.
• the Quality Account is prepared in all material respects in line with the criteria set out in the Regulations • the Quality Account is consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance 2014/15 issued by the Audit Commission ('the Guidance') • the indicators in the Quality Account identified as having been the subject of limited assurance, are reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.
Key findings We provided the Trust with a report setting out the detailed findings of our work on 29 June 2015. We highlighted a number of presentational issues in the way the Trust had reported its key indicators of quality, which the Trust corrected in the final version of the Quality Account.
© 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
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Appendices
Appendices
Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
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Appendix A: Reports issued and fees We confirm below our final fees charged for the audit and non-audit services.
Fees for other services
Fees for audit services
Trust audit Charitable fund audit Total audit fees
Per Audit plan £
Actual fees £
80,370
80,370
1,800
1,800
82,170
82,170
Service
Fees £
Audit related services •
Quality Accounts
10,000
Reports issued Report
Date issued
Audit Plan
March 2015
Audit Findings Report
May 2015
Quality Account Report
June 2015
Annual Audit Letter
July 2015
© 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
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Š 2015 Grant Thornton UK LLP | Annual Audit Letter for Surrey and Sussex Healthcare NHS Trust
TRUST BOARD IN PUBLIC
Date: 30 July 2015 Agenda Item: 4.1
REPORT TITLE:
CQC Improvement Action Plan
EXECUTIVE SPONSOR:
Sue Jenkins Director of Strategy Sue Jenkins Director of Strategy
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Executive Committee
Action Required: Approval ()
Discussion ()
Assurance (√)
Purpose of Report: This report provides the Board with assurance that the 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; July 2015
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT –30 July 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 continues with main OPD sites (East Surrey, Crawley, Horsham) currently being uploaded to system by “Bookwise”. Staff training scheduled for late August with full go live by end of September 2015. Further development at Earlswood not progressed further but still an option that is being explored. Timescale will be subject to planning permission and agreement with landlord and anticipated at 12 – 18 months
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
Plans to develop East Entrance as 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 were undertaken groups to ensure views and during June 2015. Feedback to staff feedback from staff are is being given through staff meetings considered and actioned – June and email updates. Action plan is being developed and implemented. 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. Internal processes for handling are being developed. Once in place CCGs will be offered the ability to submit referrals by email. East Surrey CCG have appointed a project manager to work with GPs and providers to deliver a higher percentage of referrals via e-referrals (formerly Choose and Book). Initial meeting has taken place. The Trust is exploring other external systems to support the move to a fully electronic 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
G
G G
G
B
G G
A G
A
4 An Associated University Hospital of Brighton and Sussex Medical School
4.3
4.4
Discuss proposed e-referral system to all GPs via CCGs – June 2015 Offer amnesty to return all referrals to OBO – June 2015
4.5
Share details of revised process with consultants – June 2015
4.6
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 Complete validation of waiting lists – June 2015
4.7
4.8
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
required and completion will take approximately 3 months and will link with work undertaken at 4.1 Linked to update at 4.1
Planned as part of summer workstream. This will be part of the work to pause bookings in key specialties where first appointment waits are beyond 6 – 8 weeks. Meetings have taken place with lead clinicians, some clinician groups, divisional boards and medical secretary leads to share details of revised booking processes to support better management of changes to clinics and appointments. Further meetings with targeted groups will take place over the summer. Ongoing discussion at weekly Elective Care Board.
G A
G
G
Presentation given to lead clinician meeting on 22 June 2015.
B
This is an on-going process which 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 between 8 and 13 weeks by end of Q4 (specialty dependent). 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 standing item at weekly Elective Care Board. Recruitment underway with 50% of required temporary staffing in place and being trained. Recruitment processes continuing. On-going and part of the “Bookwise” work now planned for September. Better use of satellite locations being encouraged through job planning of
A
G
A A
G
A
5 An Associated University Hospital of Brighton and Sussex Medical School
new clinicians. 5.0 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. 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
Total number of clinics cancelled per month
Total number of clinics cancelled <6 weeks
7 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 June 2015
% referrals received electronically 8% 8% 6%*
* Reduction in June percentage due to issues encountered with HSCIC migration from Choose and Book platform to e-Referrals. System was only intermittently available for two weeks. Referrals logged on Cerner < 24 hours Month April 2015 May 2015 June 2015
Referrals logged on Cerner <24 hours 25% 30% 20% **
** Challenges encountered due to staff sickness and annual leave. Referrals graded by clinician and returned to OBO <48 hours (2 working days)
8 An Associated University Hospital of Brighton and Sussex Medical School
Month April 2015 May 2015 June 2015
% referrals graded < 48 hours 25% 25% 25%
Total number of patients waiting >18 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q2
Total number of patients waiting >13 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q4
6.0 Recommendation
9 An Associated University Hospital of Brighton and Sussex Medical School
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 July 2015
An Associated University Hospital10 of Brighton and Sussex Medical School
TRUST BOARD IN PUBLIC
Date: 30th July 2015 Agenda Item:
REPORT TITLE:
2014 Staff Survey - Update
EXECUTIVE SPONSOR:
Yvonne Parker, Director of HR
REPORT AUTHOR (s):
Janet Miller, Deputy Director of HR
REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
N/A
Action Required: Approval (√)
Discussion (√)
Assurance (√)
Purpose of Report: The report provides and update on actions being taken within the Services following the 2014 results as requested at May Board. • The Trust has a well established process in place which views the Staff Survey as a continuous process rather than a ‘one off annual event’. • Staff within the service are engaged in determining the actions that will be worked on as a result of the survey outcomes for their work area. • This approach reinforces the strategic impact of the Staff Survey as a key component of building our ‘open and transparent’ culture of staff engagement. Summary of key issues Results of 2014 survey have been shared with services with the following headlines noted. • The 56% response rate ensured reliability of data • Year on year improvement in Staff Engagement score (2012 = 3.71; 2013 = 3.83; 2014 = 3.86 ) which put us in top 20% of Acute Trusts nationally. • Included in HSJ Top 100 Employers (top 40 NHS Acute Trusts) • Trust responses were either in the top 20% or ‘statistically significant’ improvements for all responses apart from 2 areas. • 2 areas where the Trust were worse than other acute Trusts were • Number of appraisals (NB quality of appraisals however was in best 20%) • Violence and aggressions experienced by staff from patients Trust priority is to continue with its strategic approach to staff engagement with actions to promote through behaviours and values work. Improve compliance for Appraisal – now incorporated into Achievement Review work Work with those areas of the Trust where violence and aggression is being reported. Recommendation: The Board are asked to note the contents of 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
NHS Standard contract with CCG’s requires evidence of compliance with WRES and EDS which the Staff Survey provides evidence for.
Financial impact Patient Experience/Engagement
High levels of staff engagement correlate with higher levels of patient satisfaction.
Risk & Performance Management NHS Constitution/Equality & Diversity/Communication
Specific questions in the Staff Survey provide evidence for Public Sector equalities duties and NHS Standard Contract.
Attachment: Update report and action plan.
2 An Associated University Hospital of Brighton and Sussex Medical School
TRUST BOARD REPORT â&#x20AC;&#x201C; 30th July 2015 2014 STAFF SURVEY UPDATE 1.
Introduction
The Board received a summary of the Trustâ&#x20AC;&#x2122;s 2014 Staff Survey responses at its meeting on 26th March which showed significant improvement in the reported staff engagement and satisfaction in the workplace when benchmarked against other Trusts nationally. This is the fourth year of our strategic approach to Staff Engagement and Organisational development (OD) which focuses on long term priorities, with staff engagement as a key process informed and measured by the staff survey data and the Board approved continuation of this approach. 2.
Main Content of the Report
For the past 4 years the Trust has undertaken a census (rather than sample) survey of every employee which has given us rich and comprehensive data by which services can develop actions based on the staff survey which are meaningful to the staff teams. Each year Trust wide actions (based on the strategic approach outlined above) are developed which have been summarised below. In addition anonomised data is provided by our survey provider at departmental level (provided responses are received from at least 10 staff to preserve anonymity). These are provided to Divisions and Corporate areas and HR Business Partners facilitate discussions within the services so that teams can determine the areas that they wish to work on This local action plan approach reinforces the staff involvement in the survey and ensures that staff can see that actions result from their responses. 3.
Recommendation
The Board are asked to note the contents of the report
Yvonne Parker Director of Human Resources July 2015
3 An Associated University Hospital of Brighton and Sussex Medical School
Improvement Issue
Actions
Progress
Communication All, staff and senior staff meetings, of Staff Survey Directorate / Team meetings via HR BPs, results E-bulletin. Local analysis and action planning
Map staff survey questions to wards and Departments to identify high and low performing areas.
Departmental responses (above 10 responders) circulated.
3rd party violence against staff
Map staff survey data for with datix incident reporting data to continue to understand the staff work experience and prioritise activity.
Report from Datix shows an increase in staff who report physical and verbal abuse, targeted work with areas identified (Emergency Department, Facilities) Conflict resolution training has poor uptake â&#x20AC;&#x201C; review of offering with view to establishing specific bespoke training package which will include de-escalation techniques and managing expectations within a customer service model. Deputy Chief Operating Officer has been meeting with police â&#x20AC;&#x201C; good relationship established communication and understanding of their role to be disseminated.
Lead
Completion Target Date
Yvonne Parker
Completed
HR Business Partners
Completed
Report completed September 2015 Nathaniel Johnson/ Richard Bridgeman/ Service Managers
Tie in with training package
Improvement Issue
Actions
Progress
Lead
Appraisal
New Achievements Review replaces appraisal process. 3 year improvement programme which sets timetable of completion by July each year.
Achievements Review launched and all managers briefed on the new process.
Director of HR, Divisional & Divisional/Directorate Management Teams
Staff survey is completed in September – December so majority of staff will have had AR (Appraisal) by this date. Communication for Staff Survey 2015 to include AR = appraisal.
Incident Management – feedback and learning
Training has been rolled out and managers are responding positively to this.
Compliance reports show slippage – (50% at end of June). Reinforced message and action plans required by services to get back on track. Capacity in the hospital is impacting.
Develop a method of ensuring that shared learning and key information concerning incident management is cascaded to services.
Newsletters have been developed and delivered in Medicine, Pharmacy, Pathology. Elsewhere Divisional governance meetings share ‘lessons learnt’.
An Associated University Hospital of Brighton and Sussex Medical School
July 2017
March 2016
Divisional reporting to reinforce Trust 1st year expectation of objectives set by end of July.
Revised training (3 modules) rolled out to staff during 2015/16 to minimise risk that ‘quality of appraisals’ question will deteriorate.
Completion Target Date
Completed
September 2015
Service Managers
May 2015
5
Improvement Issue
Actions
Progress
Lead
Sharing of good Work in partnership with high performing NHS Trusts to develop new approaches practice to tackling common issues. E.g. Solutions to improve appraisal rates and approaches to reducing the incidence of violence against staff.
Work on Achievement Review drew heavily on success of neighbouring Trusts
AR Task & Finish Group
Wellbeing Stress
Toolkit on HRBP and Health and Safety intranet pages. Compliance with this element of H&S audit improving.
Undertake the Management Standards exercise across all teams and develop / implement actions accordingly (Work related Stress). Increase publicity for CIC (Trust’s Employee Assistance Programme provider) – non work related stress.
Ensure that there are robust recruitment plans in place to address the vacancy gap in Nursing.
Membership of network of London Trusts
Deputy Director of HR
Managers / Health and Safety
Deputy Director of HR/ Now referenced in Firstcare calls for OH Manager absence attributed to ‘stress’. OH report increasing awareness of the service. CIC reports on activity to be shared at Workforce Committee (next report due December) Candidates recruited in Philippines delayed. A contingency plans has now been established.
Divisional Chief Nurses
Completion Target Date On going
On going On-going
Completed December 2015 Ongoing
Establish Wellbeing Group and revise Wellbeing Strategy based around building a resilient workforce
An Associated University Hospital of Brighton and Sussex Medical School
6
TRUST BOARD IN PUBLIC
Date: 30 July 2015 Agenda Item: 4.3
REPORT TITLE:
Annual plan 2015/16 Q1 update
EXECUTIVE SPONSOR:
Sue Jenkins Director of Strategy Sue Jenkins Director of Strategy
REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)
Executive Committee 22.7.15
Action Required: Approval
Discussion
Assurance (√)
Purpose of Report: The purpose of this report is to provide assurance to the Board that the annual operating plan for 2015/16 has been delivered Summary of key issues The annual plan for 2015/16 was approved by the Board in April 2015. Since then the Quality Account has been produced and the annual plan has subsequently been updated (see highlighted yellow entries) with the final version entries. This report provides progress against each of the 107 actions for Quarter 1, April to June 2015. Of the 107 actions the status for the quarter is reported as follows:Status Q1 – April to June 2014 Red 1 <1% Amber 27 25% Green 75 70% Blue 4 4%
4% of the actions have already been completed and 74% are being delivered according to plan or have been completed. There is only one red status which relates to 2.2 – Manage non elective demand. Non elective demand, particularly for those patients that stay >1 day is currently 8.6% growth against a 2% forecast. This has caused significant operational pressures for the Trust. Winter plans are currently being reviewed to ensure that capacity is available and the quality and safety of care is not compromised going forward.
Recommendation:
The Board are asked to confirm that this report provides assurance that the annual plan 2015/16 is being delivered Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about SO4: Responsive â&#x20AC;&#x201C; Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication
The annual plan demonstrates delivery of key actions to support the strategic objectives Business cases will be developed for any significant resource developments. The annual plan includes a number of objectives linking to patient experience and engagement Delivery of the annual plan is monitored by the executive Committee and reported to the Trust Board The annual plan demonstrates delivery of the organisations strategic objectives
Attachment: Annual plan 2015/16 Q1 update
2 An Associated University Hospital of Brighton and Sussex Medical School
Annual plan 2015/16 v1.3 Work stream off track and unlikely to deliver as described
RR
A
Work stream off-track but plans in place to recover
SO1 - Safe - Deliver safe services and be in the top 20% against peers New Action Ref Source or bf
G
Work stream on track and to plan
Lead director
Lead manager/clinician
1.1 NEW Strategic objectives delivery plan
Complete deep dive process for all relevant specialties
Sue Jenkins
-
1.2 NEW Strategic objectives delivery plan
Maintain a CQC inspection rating of good or outstanding
Fiona Allsop
-
1.3 NEW Strategic objectives delivery plan
Demonstrate improved learning from incidents across the Trust
Fiona Allsop/ Des Holden
Katharine Horner
1.4 NEW Strategic objectives delivery plan
Actively participate in national Patient Safety Collaborative in Kent, Surrey and Sussex area
Des Holden
Julian Webb
1.5 NEW Strategic objectives delivery plan
Implement achievement review and include safety goals for all staff
Yvonne Parker
Janet Miller
1.6 NEW Quality account
Evidence compliance with Sign up to Safety
Fiona Allsop
Kim Rayment
1.7
BF
Clinical strategy Divisional plans
Maintain the low incidence of surgical site infections
Des Holden
Barbara Bray
1.8
BF
Clinical strategy Divisional plans
Meet all access targets including ED, 2 weeks referral, 31 days and 62 days
Paul Bostock
Ben Emly
Deliver CQUIN plans for 2015/16:Local - Discharge to Assess (Sue Jenkins) Local - Improving Discharge (Paul Bostock) Local - Enhanced Quality (Jonathan Parr) Local - Ward accreditation (Fiona Allsop) National - Acute Kidney Injury (Phil Williams) National - Sepsis (Julian Webb) National - Dementia and delirium (Steve Adams) National - Avoid emergency admissions (Paul Bostock) National - Improving diagnosis of mental health patients in ED (Julian Webb)
Des Holden
Jonathan Parr
Monitor compliance with national midwifery staffing guidance
Fiona Allsop
Michelle Cudjoe
Explore opportunities of improving the safety journey by learning from international best practice i.e. Virginia Mason
Des Holden
Sue Jenkins
1.9 NEW Quality account
1.10
BF
Clinical strategy Divisional plans
1.11 NEW Quality Account
B
Q1 Update Deep dive process complete for this year but re arrangement of Digestive Diseases still to be confirmed. Reports being developed and shared with ECQR Good rating still in place Paper prepared for SQC to demonstrate learning from incidents across the trust. It triangulates the CQC and NRLS and staff survey data. This will be presented in August 2015 Fully signed up. Leads for emergency laporotomy and sepsis identified. Attended all relevant events Compliance with new process for all staff to have SMART objectives set by end of July 15 is running at 50%. This is the first year of the revised process so priority is for all 8a and above to enable the 9 blocker to be used in February 2016. Spreadsheets showing compliance have been sent to HRBPs outstanding areas are being monitored by Director of HR. Quarterly strategic project meetings set up for year 1 of the 3 year project. Q1 update report completed and sent for Patient Safety Committee meeting on 15th July 2015 and Executive Committee for Quality and Risk meeting on 12th August 2015. SSIs are discussed monthly at Divisional Board. Every orthopaedic infection has an RCA that is reported to Divisional Board. Woodland elective beds are not consistently ring-fenced. ED - achieved for Q1 RTT - achieved incomplete standard at aggregate level, some specialty failures. Plans in development. Cancer - all achieved except breast symptomatic Clinical leads identified and baseline data now being collected where appropriate.
Complete
RAG status A G G
G
A
G
G
A
G
Run birth rate plus tool for April 2015. Awaiting results and will develop plan in response Applied for national development programme with TDA and acceptance onto the programme has been confirmed
G G
1.12
BF
Quality Account Quality strategy
Avoidable falls/ falls resulting in Demonstrate further improvement harm in number of falls
1.13
BF
Quality Account Quality strategy
Pressure damage
1.14
1.15
BF
BF
Quality Account Quality Strategy
Quality Account Quality Strategy
Dementia
Develop community facing approach to dementia care
Healthcare acquired infection
Meet the DH central infection control targets of <15 Cdiff cases and no preventable MRSA blood stream infections Continue to screen patients for MRSA and administer MRSA suppression treatment in a timely way
NEW Quality Account Quality Strategy
1.16
Venous thromboembolism (VTE)
BF
1.17
1.18
BF
BF
Quality Account Quality strategy
Quality Account Quality strategy Clinical strategy Divisional plans
Maintain achievement of no hospital acquired major pressure damage and aim to reduce hospital acquired minor damage
World Health Organisation (WHO) safer surgery checklist
Fiona Allsop
Francis Fernando
Fiona Allsop
Louise Evans
Fiona Allsop
Steve Adams
Des Holden
Ashley Flores
-
Continue risk assessment on > 95% of patients on admission
Des Holden
-
Continue to audit quality of safer surgery processes
Des Holden
Barbara Bray
Des Holden
Barbara Bray
Maintain and further improve timely admission and operative intervention Improve length of stay for #NOF
Improve follow up data collection and reporting
Currently working with East Surrey CCG to ensure that SASH participates actively in wider dementia care initiatives and are an active visible participants in local community developments. Also Working with services in West Sussex to develop an integrated community care focused model of dementia care. In terms of feedback from carers, we are currently working with the patient experience team to plan a series of focus groups to measure carers experiences and help develop plans to continually improve the way in which we support carers of people with dementia. 7 Cdiff cases reported for Q1. Plan being reviewed to bring back on trajectory
Improve completion of assessment Des Holden on discharge
Fractured neck of femur (hip)
Annual Objectives: to reduce harmful falls from 26% to 20% and reduce the total number of falls by 10%. For the 1st Quarter of 2015/16: total number of falls: 344, a 29% increase from 267 last year, No harms: a 30.5% increase from 200 to 261, Minor harms: a 39.6% increase from 58 to 81, Moderate harms: a massive 700% decrease from 7 to 0, Major harms remain the same: 2 and there were no catastrophic harms due to falls for the last 2 years. The increase in the number of falls can be attributed to the robust reporting system (Datix) and enhanced staff awareness. Target for the year is 40 incidents of major pressure damage. For Q1 there have been 10 incidents therefore we are on track to deliver this years target
0 cases reported to date. Compliance with MRSA sreening documentation is 100%. Audit of MRSA suppression is on the IPCAS annual programme for 2015-2016. VTE group established. VTE nurse appointment increased from temporary part time to substantive full time Monitored via VTE group. Focus is shifting to assessment at discharge as well as on admissio. Currently not being measured but plan being developed 100% compliance with use of the checklist. On-going qualitative audit to provide Divisional Board additional reassurance such as observation by other staff and feedback to team leaders; video recording and feedback and improvement of the data collection. Time to theatre remains good with the exception of one week in Q1 where the trauma load was extremely high. Patients not having surgery within 36 hours have comorbidity that needs addressing. FIB for analgesia is expected but not always achieved early - anaesthetic dept are setting out strategy to improve. Resource for follow-up data is now in place. Time to ward still a challenge pathway has been adjusted to allow to go to theatre on the way to the ward for FIB or for surgery and for this to count as time to ward.
G
G
G
A
G
G
A
G
A
1.19
BF
Quality Account Quality strategy
Patients admitted with stroke
To improve SSNAP audit performance to at least a B rating
Des Holden
Ben Mearns
Further improve scanning time
Des Holden
Ben Mearns
Improve use of safety information at divisional meetings 1.20
BF
Quality Account Quality Strategy
Incident reporting
Increase number of audits that impact on patient safety
Fiona Allsop
Katharine Horner Jonathan Parr DCNs
Make patient safety data more transparent for staff and patients
Sue Jenkins
Natasha Hare Linda Judge
Deliver medical records improvement plan
Ian Mackenzie
Phil Stone
Deliver Dictate IT improvement plan
Jim Davey
Angela Stevenson
Improve communications and information around medication on discharge
Paul Bostock
David Heller
1.21
BF
CQC improvement plan
Deliver outpatients improvement plan
1.22
BF
CQC improvement plan
1.23
BF
CQC improvement plan
1.24
BF
Quality Account
Maintain compliance of 95% and increase average compliance to 97% from January to March 2016
1.25 NEW Quality Account
Safety thermometer
Fiona Allsop
Vicky Daley
1.26 NEW Quality Account
Continue to maintain high standards of cleanliness and to ensure patients are not disturbed unnecessarily
Fiona Allsop
Vicky Daley
Lead Director
Lead Manager/clinician
Develop second cardiac angiography suite
Paul Bostock
Angela Stevenson
SO2 - Effective: Deliver effective and sustainable clinical services within the local health economy New Action Source or bf
Ref
IBP service development Estate strategy
2.1
BF
2.2
BF
IBP service development Strategic objectives delivery plan
Manage non elective care
Paul Bostock
Angela Stevenson
2.3
BF
Strategic objectives delivery plan
Continue participation in wider health system transformation forums to influence development of new models of care
Sue Jenkins
-
Currently at Band D. Plans in place to address which will be monitored via effectiveness committee. Analysis of pathway underway with Clinical Chief leading work stream Dashboard to demonstrate compliance with safety measures has been developed at service level and will be reviewed in divisional governance meetings Audit programmes were signed off in June and Divisions included a greater number of audits in their programmes relating to patient safety. Patient safety dashboard show compliance with metrics at service level for staff. Outpatient staff focus groups completed and action plan being developed. 15 steps quality walk planned for next quarter. Monthly updated provided to the Board. 68% of actions are currently rated Green 32% are rated Amber Apart from new build which is scheduled for planning permission late July 2015 all items are complete Plan delivered and savings realised Patient Medicines Information Help Line for patients has been converted to a freephone number. Planning of further changes in progress. Move to using Cerner for discharge letters and ePMA will help to improve information on changes to medicines late in 2015/16 95% compliant for Q1 Compliance with the safety thermometer is monitored and discussed as part of the scorecared item at the Patient Safety and Clinical Risk Sub-committee Infection control is a standing item at the Patient Safety and Clinical Risk Committee and the Nursing and Midwifery Professionals Committee. Any specific areas of concern relating to standards of cleanliness are discussed within these forums and actions agreed. Noise at night has been identified as an outcome from the most recent national Inpatient Survey. The action plan out of this survey is being monitored via the Patient Experience Sub-committee. Have reviewed cleaning schedules and day to day reporting lines for cleaning staff in ward areas
Q1 Update Building on track for autumn opening. Two consultant cardiologists appointed and due to commence November 2015 Growth in non elective activity with length of stay > 1 day is 8.6% against 2% forecast. Meetings planned with Commissioners to ensure recognition and accetance of activity figures. Strategic Resilience Groups considering application for ORCP funding to support in part Joint bid prepared for Urgent and Emergency Care Vanguard. Bid was unsuccessful but local work stream being developed to progress thinking
A A G
B G
A
G B
G
G
G
RAG status G
R
G
2.4 NEW Strategic objectives delivery plan Clinical strategy 2.5 BF Divisional plans
Develop plans to support re-procurement of EPR and EPMA Redesign the stroke pathway to create a seamless in and out of hospital patient centred pathway across all providers
Ian Mackenzie
-
Des Holden
Ben Mearns
2.6
BF
Clinical strategy Divisional plans
Redesign the pathways in elderly medicine to create seamless Des Holden patient care across all providers including early supported discharge
Ben Mearns
2.7
BF
Clinical strategy Divisional plans
Redesign service to create HDU respiratory beds
Virach Phongsathorn
2.8
BF
Clinical strategy Divisional plans
2.9
BF
Clinical strategy Divisional plans
2.10
BF
2.11
BF
2.12
BF
Clinical strategy Divisional plans Estate strategy Clinical strategy Divisional plans
Quality Account Quality strategy
Des Holden
Redesign of service to ensure that the birthing unit provides intrapartum and postnatal care for 20% of women booked for maternity Des Holden services at East Surrey hospital To consider recommendations from the strategic review of radiology services undertaken in autumn 2013 and agree and implement Des Holden action plan Redesign of service to support the installation of a digital mammography machine on the ESH site Implement a managed equipment service which is supported by a rolling equipment replacement schedule Focus on categories of death rather than individual and make recommendations via clinical effectiveness committee to make improvements Mortality Roll out enhanced review of all patient deaths
Debbie Pullen Michelle Cudjoe Ed Cetti Mo Luqman
Paul Bostock
Ed Cetti Mo Luqman
Des Holden
Ed Cetti Mo Luqman
Quality Account Quality strategy
2.14
Quality Account Quality strategy
2.15
BF
BF
Quality Account Quality strategy
Readmissions
Undertake review of one monthâ&#x20AC;&#x2122;s clinical readmission data and implement any lessons learned
(NICE) technology appraisals
Increase statement compliance. Audit against NICE technology appraisals and post on audit intranet
Des Holden
Jonathan Parr
Jim Davey
Des Holden
BF
7 day working SDIP
Maintain core hospital at home beds all year
Paula Tooms
Enhanced recovery
2.18 NEW Quality account
Enhanced quality
Commence enhanced recovery pathways for breast and Csections Commence new enhanced quality pathways for COPD, fractured neck of femur and emergency laparotomy
G A B G
Strategic review, reveiwed at Division. Five year plan formulated to address actions
G
Business case approved at Executive Board July 2015 Breast service have plan for redesign of their clinic
G
OBC approved at Execs awaiting TDA approval which will be due in September 2015 at the earliest Mortality Group not yet met to discuss process of categorisation. Planned for Q2
Divisions now reporting M&M discussions at governance meetings, although the Mortality Group has not yet met to review roll out. Latest data reports the Trust remains 'Better than Expected (April 14 - Mar 15) Trust still has one of lowest readmission rates and therefore agreed with CCGs to replace planned audit with joint review of common patient pathways which is underway Audits identified and underway. One reported, stating the Trust was fully compliant.
Length of stay report at individual consultant level in place to review and understand variation. At capacity with 29 SaSH at Home patients being cared for
Sue Jenkins
-
Des Holden
Jonathan Parr
Rapsid group established and reviews pathways including reductions in ED attendances, hospital admissions and expediting discharges. Liaised with SECAmb to implement IBIS and facilitate access from community and hospital clinicians. Have reviewed ED top 20 attendances Work being led and overseen by clinical chiefs. Business case for individual spacialties in development Trust represented at C-Section meetings. Planning work not yet commenced for Breast pathway by AHSN
Des Holden
Jonathan Parr
COPD data collection underway. Trust represented at #NoF meetings. Emergency Laparotomy planning work not yet commenced by AHSN
Paul Bostock
Implement 7 day working for all relevant specialties
2.17 NEW Quality account
Jonathan Parr
Angela Stevenson
Review pathways to develop alternatives to admission
2.16
-
Reduce LOS
Reducing need for admission
High dependency respiratory bay developed on Tilgate Annexe and now operational 20% of patients used birthing unit for Q1
B
G
A
Maintain â&#x20AC;&#x153;better than expectedâ&#x20AC;? rating for mortality by Dr Foster 2.13
Procurement was completed in October 2014 Continuing to work with Surrey and Stroke networks to develop whole system pathway for stroke Daily review of all patients being developed for implementation in Q2
Jim Davey
A G
G
G
A G
G
G A
A
SO3 - Caring - Ensure patients feel cared for and cared about New Action Ref Source or bf
Lead Director
Lead Manager/clinician
3.1
BF
Strategic objectives delivery plan
Demonstrate that audit plans include issues raised by YCM, FFT and inpatient survey
Des Holden
Jonathan Parr
3.2
BF
Strategic objectives delivery plan Nursing & Midwifery strategy
Demonstrate delivery of â&#x20AC;&#x153;Provide safe and effective care in all that we doâ&#x20AC;? objective from nursing and midwifery strategy at safety and quality committee
Fiona Allsop
Vicky Daley DCNs
Establish and undertake a programme of patient listening events
Fiona Allsop
Cathy White
Fiona Allsop
DCNs
Paul Bostock
Angela Stevenson Jane Penny
Paul Bostock
Angela Stevenson
3.3 NEW Strategic objectives delivery plan
3.4 NEW
Strategic objectives delivery plan Nursing & Midwifery strategy
3.5
BF
Clinical strategy Divisional plans
3.6
BF
Quality Account Quality strategy
Demonstrate that nursing review and assessment reflects individual needs of patients Work with Olive Tree, Friends of east Surrey and Macmillan Cancer Support to develop and implement a Cancer Information and Support Centre at East Surrey Hospital Continue to ensure there are no mixed sex breaches Right bed, right time Share and implement learning from Breaking the Cycle
Paul Bostock
Angela Stevenson
Participate in 5th National Audit of Care of the Dying patient
3.7 NEW
Quality Account Quality strategy
End of life care
Complete internal audit of end of life care documentation
Fiona Allsop
Jane Penny
Develop and introduce second version of SaSH end of life care plan
3.8 NEW Estates strategy
3.9 NEW Quality Account
Review and develop scheme to modernise East Entrance environment and facilities including additional retail outlets.
Implement oral healthcare initiative and demonstrate improvement of patient and clinical care
Ian Mackenzie
Des Holden
Q1 Update Audit plan for this year is smaller and more focussed. It includes areas that have been highlighted by incidents, complaints and patient feedback Providing safe and effective care is integral to the work of the organisation and the various workstreams are being delivered through a variety of means and forums. This includes the learning from incidents, themes and trends identified and discussed via the Patient Safety and Clinical Risk Sub-Committee, Tissue Viability committee and Falls Operational committees. The Nursing and Midwifery Strategy was discussed at length at the Nursing and Midwifery Professinal Committee on the 21st July. It was agreed that the divisions will undertake a review of the 3 key objectives including "Providing safe and effective care in all that we do", and will feedback divisional priority areas of focus, to the next NMPC Planned strategy review for July 2015. Focus groups have been undertaken among endoscopy patients and are planned to take place in July for maternity patients. Carers discussions are being planned for October 2015 Part of nursing and midwifery strategy due to be reviewed July 2015 Building work commenced due to complete end 2015. Cancer Manager appointed to start end August 2015, development of cancer information centre to plan No mixed sex breaches for Q1 Action plan developed and in place. Further breaking the cycle weeks planned. Next one due at beginning of August when junior doctors rotate Registered to take part. Data entry underway and this closes in August 2015. In addition clinical audit case note review of patients who died in May 2015 is also underway. Data entry for this audit will be completed in August and September 2015. Completed for 26 patients on end of life care plan during October 2014. Results being collated and audit currently being written up. In progress and reviewed by end of life steering group. Palliative care team considering comments and feedback and will update care plan in response. Will be presented to cancer divisional meeting and clinical effectiveness group in August 2015. Aim to roll out September 2015
RAG status G
G
G
G G G G
G
G
G
Shaun Cunningham
Work to modernise East Entrance will take place September/October 2015
G
Mili Doshi
Three people for the mouth care matters team recruited ( advert out for the fourth) and due to start September 2015. Training for all Hospital Staff on-going. Mouth Care matters official launch Tuesday 22nd September 2015 Over 90% of staff attending a training session say the training should be mandatory for all nursing staff
G
3.10
BF
Quality Account
3.11 NEW Quality Account
Nutrition
Continue to make improvements to protected meal times
Fiona Allsop
Vicky Daley
Seek ways to broaden how we get Fiona Allsop feedback from wider community
Vicky Daley Cathy White
Patient feedback
Continue to promote FFT and YCM and make changes on basis of feedback SO4 - Responsive - Become the secondary care provider of choice for our catchment population New Action Ref Source or bf Develop programme of engagement activities with patients and 4.1 NEW Strategic objectives delivery plan members
Fiona Allsop
Vicky Daley Cathy White
Lead director
Lead manager/clinician
Gillian FrancisMusanu
Laura Warren
4.2
BF
IBP service development
Chemotherapy service development
Paul Bostock
Angela Stevenson Jane Penny
4.3
BF
Strategic objectives delivery plan Membership strategy
Establish CoG and demonstrate meaningful engagement which shapes our services
Gillian FrancisMusanu
Laura Warren Colin Pink
4.4
BF
Clinical strategy Divisional plans Estate strategy
Complete refurbishment of and open theatres
Paul Bostock
Bill Kilvington Barbara Bray
4.5
BF
Market Development strategy
To maintain market share through excellent service provision and securing AQP contracts where CCGs have given notice on the service that was previously part of the acute contract
Paul Simpson
Larisa Wallis
4.6
BF
Market Development strategy
To expand market share for elective activity targeted market that have traditionally referred patients to other providers
Paul Simpson
Larisa Wallis
4.7
BF
Market Development strategy
To expand market share for elective activity by working with CCGs and other providers to repatriate elective activity from distant tertiary Paul Simpson providers where this is clinically appropriate
Larisa Wallis
Paul Simpson
Being reviewed via nutrition steering group. The Deputy Chief Nurse is a member of the Nutritional Steering Group. Going forward, the DCN will ensure that there is a focus of the group on ensuring that improvements are being made to protected meal times The Patient Experience Sub-Committee meets on a monthly basis, and there are standing items on the agenda on FFT and YCM. The Deputy Chief Nurse and Patient Experience manager are meeting on the 23rd July to discuss identifying ways of broadening feedback from the wider community. Q1 Update Engagement plan and activities in draft. For review by CoG in Sept 2015. Plan to relocate Chemotherapy services Business Case to Executive Committee in Q2 Election of shadow council of governors underway, results of election complete and published with all seated allocated. Selection of nominated governors by key stakeholders due for completion by end of July 2015.
G
G
RAG status A G
G
All ten operating theatres are now fully operational. The remaining section of recovery will become operational mid August, along with the new changing rooms, staff rest room and anaesthetic department offices. The reception and children's preoperative waiting area will commence once these works are complete. Reports from Dr Foster being re developed to monitor changes in market share on quarterly basis. Anaesthetics hot topic event held for all stakeholders and well attended. No live AQPs or ITT being progressed Working paper re additional elective activity developed and shared with Board and Executive team. Detailed plans at specialty level being worked up but compromised due to levels of non elective activity Mechanism for shift of activity to be facilitated by CCGs and in place by Q2. Monitored via regular contracting meeting
G
High level plan supporting repatriation of outsourced activity in place. Ability to deliver is compromised by pressures from non elective activity.
A
G
A
Larisa Wallis
BSUH/SaSH joint venture for pathology services progressing. New name agreed as Frontier. Final business case to be considered by both Boards later this year
G
Private patients policy and processes currently under review
G
4.8
BF
Market Development strategy
To explore opportunities for further joint ventures/partnership arrangements to continue to develop the East Surrey Hospital campus so that local patients can receive an increasing range of specialist services at ESH whether provided by SASH or a partner organisation
4.9
BF
Market Development strategy
To move to new markets, such as private practice, where this is clinically and financially viable and supports the long term strategic intentions of the Trust
Paul Simpson
Larisa Wallis
4.10
BF
QGAF
Deliver QGAF action plan
Des Holden/ Fiona Allsop
Colin Pink
Initial work to complete QGAF actions finished and submitted to Monitor (as per timetable). Feedback due Q2 any specific issues will be included going forward.
A
SO5 – Well led – Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model New Action Source Lead director or bf
Ref
Lead manager/clinician
5.1
BF
Strategic objectives delivery plan
Demonstrate increase in market share due to repatriation of services
Paul Simpson
Larisa Wallis
5.2
BF
Strategic objectives delivery plan
Develop nurse recruitment plan, monitor delivery and report to workforce committee
Fiona Allsop
Sue Carr DCNs
5.3 NEW Strategic objectives delivery plan
5.4 NEW
Strategic objectives delivery plan IBP service development
Develop and implement SLM model with clinical leads
Paul Simpson
Catriona Tait
Develop plans for new outpatient facilities
Sue Jenkins
Natasha Hare
5.5 NEW Strategic objectives delivery plan
Establish multisource feedback system for all staff
Yvonne Parker
-
5.6
BF
Strategic objectives delivery plan
Complete delivery of SaSH plus GE clinical leadership programme
Des Holden
Colin Pink
5.7
BF
Strategic objectives delivery plan
Complete delivery of Foresight board development programme
Gillian FrancisMusanu
-
5.8 NEW Strategic objectives delivery plan
5.9 NEW Membership strategy
5.10 NEW
Membership strategy IBP
Governance processes adapted to support clinical leadership model Gillian Francis and remain effective Musanu Establish and deliver engagement and communications strategy for members following FT authorisation Hold election for Council of Governors Council of Governors (CoG)
Complete induction for CoG Establish CoG meetings and effective engagement and communications strategy
Colin Pink
Gillian Francis Musanu Gillian Francis Musanu Gillian Francis Musanu
Laura Warren
Gillian Francis Musanu
Laura Warren
Laura Warren
-
5.11
BF
IT strategy
Upgrade of end-of-life Trust operating systems
Ian Mackenzie
Peter Hodgetts
5.12
BF
IT strategy
Provide upgraded email solution
Ian Mackenzie
Peter Hodgetts
5.13
BF
IT strategy
Complete Network Upgrade
Ian Mackenzie
Peter Hodgetts
Q1 Update Revising Dr Foster reports to demonstrate shifts in activity Recruitment plan in place. Reporting and monitoring via PMO and FWC. Have had 3 successful workshops, led by GE, that were well attended. These workshops looked at what we would want to have as part of SLM and what we need to do to move to SLM. The next step is a handover meeting with CEO and Medical Director. Business case due in Winter 2015 Established multi source feedback system for staff. Capita staff FFT now well established. Looking to extending the questions to include more efeedback. HRBPs meeting following staff survey to develop action plans. Wellbeing group recently established. Staff leaver procedures have been written to include more questions and earlier on line completion whilst staff are in post. Culture champion network in place with supporting events and work streams. Achievement review process developed and launched for all non medical and dental staff. Initial plans for development of performance framework in consideration. On-going scoping events for service line reporting model underway. Board development on-going. Main programme with Foresight completed Initial review of ECQR completed and changes to standing agenda items made to deliver greater clinical content. Review of divisional reporting methods to ECQR under review. Effectiveness of ECQR subcommittees to commence Q2 Revised membership strategy being drafted and will be reviewed and signed of by shadow council of Governors Election of shadow council of governors complete. Nominated governors due for completion by end of July. Induction for shadow council of governors planned, supporting materials in final draft Meeting & communication plan in draft for sign-off at first shadow CoG meeting due in Sept 2015. This project is 99.4% complete. Mopping up of 12 devices is currently being worked on. NHS Mail doesn’t become available until early 2016 and Trust has stated objective to move when ready. National NHS Mail team have confirmed we are on their work list and will schedule date when available. A PM is currently being recruited to support the project. Network SOC being developed. A proposal from Cerner is currently being considered, with a paper going to the Exec Board this Summer
RAG status A A
G
G
G
A
G
A
A G A A G
G
G
Deliver estates capital programme
Ian Mackenzie
Shaun Cunningham
This is on-going and by definition will continue indefinitely
G
5.15 NEW Quality Account
Continue to embed the setting of personal goals that effect the quality of service for all staff in annual achievement reviews
Des Holden Yvonne Parker
Adam Stacey-Clear Janet Miller
Annual achievement reviews launched which include quality goals
G
5.16
BF
Workforce and OD strategy
Launch the Leadership Framework and an effective assurance process for the organisation to assess how each line manager is performing against the key people performance requirements
Yvonne Parker
Nathaniel Johnston
5.17
BF
Workforce and OD strategy
Develop integrated workforce plans (demand and supply) at divisional/ business unit level - identifying workforce changes required for 24/7 working in appropriate areas
Yvonne Parker
Janet Miller
5.14
5.18
BF
BF
Estate strategy
Workforce and OD strategy
Focus on increasing workforce productivity realise the benefits of technological business processes across the Trust
Yvonne Parker
-
Meeting with Dr Jean Arokiasamy ( trust leadership tutor) in July 2015 and Amanda Grindall, Director of Leadership at Health Education Kent, Surrey and Sussex to understand how we can utilise national and local leadership programmes at SaSH, leading to the development of our local offer in Autumn 2015 Trust level WP which aligns to Trusts LTFM completed and submitted 6 June 2015. Business cases for consultant posts to support Service Developments (including 24/7 working) are being considered at Executive Committee Upgrade of e-rostering system completed in Q1. Line management of temporary staffing bureau moved from HR to nursing team
G
G
G
harness productivity gains identified in service developments advances in medical/surgical innovations e.g. telemedicine,
5.19
BF
Workforce and OD strategy
Refocus of induction to support OD intervention around behaviours and values.
Yvonne Parker
Nathaniel Johnston
5.20
BF
Workforce and OD strategy
Have in place a range of interventions to reduce the top reasons for absence such as workplace stress musculoskeletal disorders (MSD), flu.
Yvonne Parker
Janet Miller
Create the SaSH identity and brand so that we are recognised as the ‘Employer of Choice’
Yvonne Parker
Nathaniel Johnston
5.22 NEW Workforce and OD strategy
Ensure access to a range of leadership programmes, to cover the range of levels and focused on leading our values and behaviours.
Yvonne Parker
Nathaniel Johnston
5.23 NEW Workforce and OD strategy
Develop a Talent Management framework and succession planning tool to help identify potential leaders to fill key positions within the organisation.
Yvonne Parker
Nathaniel Johnston
5.24 NEW Workforce and OD strategy
Develop knowledge and skills vital for innovative thinking and service improvement
Yvonne Parker
Nathaniel Johnston
5.21
BF
Workforce and OD strategy
The induction programme is being reviewed currently. The standards of behaviour focus group is meeting twice a week and an output of this group will be materials that describe our values and behaviours for our new starters to be shared as part of the on boarding process, ready for new year 2016 Return to Work risk assessment for all stress absences included in FirstCare script. Wellbeing Strategy being revised and Wellbeing Group relaunched to identify further interventions. Support for managers to utilise HSE Management Standards, CIC services and occupational health support, accelerated access to physiotherapy and dermatology, flu immunisation campaign Work is currently underway to develop a recruitment campaign for nursing that promotes us as an employer of choice. Monthly recruitment events will be held during summer/autumn. Winter 2015. We are updating our recruitment material so that it has the latest information about the Trust including our recent inclusion in the HSJ Top Employers list and our Virginia Mason work NJ is meeting with Dr Jean Arokiasamy ( trust leadership tutor) in July 2015 with Amanda Grindall, Director of Leadership at Health Education Kent, Surrey and Sussex to understand how we can utilise national and local leadership programmes at SaSH, leading to the development of our local offer in Autumn 2015 Developing a proposal for a new learning and talent management system that will enable us to successful record against an organisation talent grid and develop online succession plans. Currently reviewing the service improvement module on the essentials of management programme to ensure it is up to date with the latest thinking in the NHS around innovation and improvement
G
G
G
G
G
G
5.25 NEW Workforce and OD strategy
Ensure effective processes are in place for the prevention and management of violence and aggression against staff.
Yvonne Parker
5.26 NEW Workforce and OD strategy
Promoting schemes to recruit local people into the NHS careers Yvonne Parker and posts.
5.27 NEW Workforce and OD strategy
Positively engaging parents, young people, careers advisors, university advisors, through individual contact and Trust initiatives.
5.28 NEW
IBP service development IT strategy
Yvonne Parker
Joint venture for pathology - As part of the proposed pathology development with BSUH procure laboratory system that meets Paul Simpson long-term Trust requirements.
Nathaniel Johnston
Nathaniel Johnston
Nathaniel Johnston
Bruce Stewart
Currently undertaking a review into our offer for conflict resolution, to explore what the need is to support staff in difficult situations. Will be exploring this during summer 2015 to introduce a new approach in autumn 2015 HR and the corporate nursing teams are working closely with Health Education Kent, Surrey and Sussex to connect with schools and colleges in out local area to promote health careers to young people. We have just concluded our annual work experience programme and we are preparing for an apprenticeship launch in October 2015 HR and the corporate nursing teams are working closely with Health Education Kent, Surrey and Sussex to connect with schools and colleges in our local area to promote health careers to young people. Just concluded our annual work experience programme and we are preparing for an apprenticeship launch in October 2015 New LIMS procurement part of main new build procurement, with current anticipated go-live of March 2017. Four suppliers expected to express an interest Currently arranging site visits. One particular LIMS, if chosen to be the preferred solution could be aquired without procurement.
G
G
G
A
Minutes of the Finance and Workforce Committee Held on 23 June 2015 at 8.30am In AD77, East Surrey Hospital, Redhill PART 1 Present Richard Durban Alan Hall Paul Biddle Paul Bostock Fiona Allsop (part meeting) Paul Simpson Gillian Francis-Musanu (part meeting) Ian Mackenzie
Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Operating Officer Chief Nurse Chief Finance Officer Director of Corporate Affairs Director of Information and Facilities
Lorraine Clegg Ben Upton Sue Jenkins Natasha Hare (part meeting) Catriona Tait
Deputy Chief Finance Officer Clinical Lead for Health Informatics Director of Strategy Assistant Director of Operations - Surgery 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 26th May 2015 were approved. Review of Actions The action tracker was presented and noted that the items would be discussed within the presented papers apart from the workforce issues as no workforce reports had been received.
3
BUSINESS PLANNING Post Implementation Review Timetable Paul Simpson presented the Post Implementation Review timetable (PIR) with a list of suggested dates that the reports will come to the Committee. Richard Durban commented that the PIRs are to identify if the business case benefits have been delivered and any organisational learning. Ian Mackenzie asked that that the Power Supply PIR be moved to September 2015. Richard Durban requested that implementation date of projects be added to the document, that the PIRs should be 3 to 6 months after the implementation date and that the PIR for Digital Dictation should be presented in October 2015. The Committee approved the PIR timetable.
MES OBC Addendum Richard Durban advised the Committee that the MES addendum had been circulated by email for approval prior to submission to the Trust development Authority (TDA). Alan Hall commented and the FWC Chair had approved the submission. Managed Printing Service Update on Procurement Paul Simpson gave a verbal update to the Committee on the Managed Printing Service (MPS) business case. He advised the Committee that the tendering process had been completed and that Ricco were the preferred bidders. Ricco would now audit Trust print equipment and then the full business case (FBC) would come to the Committee. Ben Upton stated that it had been a good process with clinical engagement. Richard Durban asked when the business case would come to the Committee and what the financial benefits had been in the outline business case (OBC). Paul Simpson advised that it is planned that the FBC would come to the Committee in 2 months’ time and that the OBC had a £100k benefit which was mainly VAT. 4
FINANCE Financial Performance M02 Richard Durban asked the Committee to consider whether there should be any changes in how it operated given the Monitor feedback to our FT application. Paul Simpson presented the M02 finance report and highlighted the following: - 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 underlying position at the end of May is £(1.3)m deficit, reflecting the non recurrent contingency savings. Paul Simpson advised the Committee that overspending in Medicine is impacting escalation but we are delivering other CIPs. There have been peaks in the length of stay in the month and schemes have been identified in Medicine via the PMO to improve the position. Surgery has improved from M01 to M02. If the Trust continues to spend at the current rate we will spend the reserve in the first half of the year. Paul Biddle asked if we were gaining on the non-elective tariff. Paul Simpson replied that we are making a small profit on non-elective activity. Paul Simpson added that there had been a high level of spend from March to May 2015 and the Trust has a high length of stay. Richard Durban asked if it was an increase of 8%. Paul Simpson replied that the increase of 8% was in emergency activity with one plus days and that in terms of income and activity we are 1% ahead. Paul Bostock added that the patients staying longer is the 2
activity that has the greatest impact on patient flow. Richard Durban asked what the consequence was of the 8% increase in emergency plus one day activity against the 2% increase in emergency activity in the plan. Paul Bostock replied that the impact was on escalation, where 30 beds were open This situation has continued into June and this has an impact on elective surgery. Paul Simpson advised that it is the emergency admissions that are driving the additional cost. Richard Durban asked what actions the Trust is taking to improve the situation. Paul Bostock advised that there was a summit being held that afternoon to look at reducing emergency admissions. Ben Upton added that in Emergency Medical forums there was no evidence that the numbers are going to fall and the Trust needs to work on improving the discharge of patients to improve capacity. Paul Biddle asked what it was that is driving the increases length of stay. Paul Bostock replied that when we compare ourselves to other Trusts we are not any worse. The problem is that when we spread patients around the hospital it takes us longer to clear them if the patients are not in the right place. Ben Upton added that it is the flow through the hospital and that the emergency department is admitting fewer patients that the average. Paul Simpson added that Michael Wilson is looking at systems resilience groups and the contract between Sussex CCG and Sussex Community to evaluate actions outside the hospital. Paul Biddle asked what the year-end forecast is likely to be and Richard Durban commented that it was import that the Q1 forecast is presented at the next meeting. Paul Simpson said that the Q1 forecast is being worked on at the moment and it will tie into the elective and outpatient plan. Alan Hall asked what the phasing will be. Paul Simpson replied that the phasing may have been ambitious in our original plan and will be reworked. Alan Hall commented while the Trust is not showing an overspend 10% of the budget is held in reserves and asked if that should be allocated to the divisions. Paul Simpson confirmed that the Trust will do a quarterly reconciliation of activity against plan and then additional budgets will be given from reserves. Lorraine Clegg added that the reserves were to fund the additional theatre activity when it opens and the is a concern that we may not be able fund these costs as the reserves will have already been allocated. Paul Biddle stated that he was expecting an increase to inpatients but activity is down by 1%, outpatients is down by 12% and income is down 4% against plan. Paul Simpson replied that the income and activity is based on day 5 so some of this will not yet be coded, there are some outpatient issues in Dermatology. Natasha Hare commented that the Trust had a real push on outpatient activity in M11 that we would not be able to sustain. Paul Bostock added that this year was about capacity and building up activity. Paul Biddle said that he was concerned that this would lead to a big gap in activity and income. Alan Hall asked about the Monitor process and the £18m cash injection. Paul Simpson advised that the Board would discuss revised timings - probably be in September or October 2015 - and that he had not had a recent conversation with the TDA in respect of the £18m. Alan Hall commented that the cash flow on page 26 of the Finance report was stilling showing that the Trust would receive the £18m in September. Lorraine Clegg advised that the Trust was applying for a $4.4m capital loan and the £18m was to pay off creditors. Paul Biddle requested that the finance report and the Q1 Forecast include a realistic reflection of cash forecast. 3
2015/16 CIP update Paul Simpson presented the 15/16 CIP update paper highlighting the RAG rating and that the Trust is not using mitigations but contingencies to manage the CIP position. He told the Committee that the red CIPs related to capacity issues and that the Nursing and Private Patient schemes had problems and a revised savings position would be presented for M03 reporting. Michael Wilson had tasked the directors to report on their savings schemes. Paul Simpson advised the Committee that the contingency schemes were reversals of accruals, the annual leave accrual and £100k of CQUIN. Paul Biddle suggested that the forecast is likely to confirm risks plus the lead time in CIPs schemes meant we should already be looking at additional CIPs. Paul Simpson advised that it is a standing item on the Executive Committee agenda but nothing has yet been identified. Richard Durban asked if we are looking at the list of mitigations that the Board approved. Paul Simpson replied that these are being reviewed and then we will show a clear view on what we need to use. Richard Durban added that he had spoken to Alan McCarthy about the process for using and agreeing the mitigations. Fiona Allsop advised the Committee that the International nursing recruitment is going to take longer and the situation is changing rapidly. The Trust needs a short and medium term strategy to fill the gaps as we had planned for the international nurses to be in place by July 2015 but it will now be September 2015 with phasing until February 2015. Richard Durban asked if it was correct than only 1 in 7 was passing the English language test. Fiona Allsop said that the recruiting agency had put in increase support and a development programme giving nurses three chances to pass the test. She added that the tests have changed but 30 have passed English and another 99 are looking to pass. They then have a competency test and then apply to the NMC, which takes 56 days. Overall there is a 22 week delay. Alan Hall asked if the time delay adds any additional risk in terms of people dropping out. Fiona Allsop responded that two had dropped out so far and there would likely be more so there is a alternative plan to fill the gaps. Richard Durban noted that language skills were essential and it was not just a matter of cramming to pass a test. He then asked that once the nurses arrive how long is it until they get their PIN. Fiona Allsop advised that it would take 3 months and in this time we would have double running. Alan Hall commented that against the approved business case this would be an impact of £500k to £750k. Richard Durban asked if there would be any impact on the Trust from the proposed £35k minimum salary for staff on visas. Fiona Allsop advised that there is an allocation of numbers each month but lobbying is going as it may impact on our ability to recruit nurses. The £35k minimum is equivalent to a Band 7 nurse and it will not be earned by all the staff recruited. As yet the Trust does not know if the £35k is basic salary or total earnings. Action: Report to August meeting with an update on the project, including visas.
FA
Natasha Hare presented the Medical Agency CIP paper and asked for questions. Alan Hall asked about the issues relating to junior medical staff. Natasha Hare replied that there were gaps in junior medical staff rotas in the Medical Division and there would be a net saving of £150k by replacing agency staff with permanent staff. Surgery is delivering the CIP but we need to see some movement in Medicine. Ben Upton added the agency costs and rates are high but hopefully the government cap on agency will bring staff back into NHS contracts and we need to ensure we get the good staff. Alan Hall commented that this has worked in the past and we should look at 4
what Radiology is doing. Lorraine Clegg added that we would get charged a joining fee form agencies if staff became permanent. 2016/17 CIP update Paul Simpson presented the 16/17 CIP update paper. He advised that the structure for the CIP schemes is going to the Board on Thursday and that the Trust is looking to change focus from top slicing schemes to productivity schemes. Paul Biddle asked what overstaffing meant. Paul Simpson replied that using the Virginia Mason model, increasing staff to improve quality then leads to a reduction in cost. The Committee asked that the schemes were grouped by type eg income/contribution, cost improvement, productivity in order that the Board could see the overall shape and focus of our plans.. Paul Biddle added that the full year effect of 2015/16 CIPs should be included in the table. 6
WORKFORCE AND ORGANISATIONAL DEVELOPMENT Safer Staffing Richard Durban noted that our establishment exceeded the safer staffing level by 3.5% or 22 heads and while at first sight this appeared an opportunity for saving it was within a tolerance margin. Fiona Allsop added that is it an Acuity tool for that month only and we need to see the October output as well. She advised there are quite a few things it does not include that affect the number of nurses. Alan Hall asked where the safer staffing level was in relation to our mapped out journey to our target nursing establishment. Fiona Allsop said that the Trust target is to achieve 1:7 during the day and 1:10 at night in September 2015 and that is the end of the journey. DH temp staffing pilot Fiona Allsop updated the Committee on the DH temp staffing pilot, advising that it is a toolkit we have to work through but as yet it has not identified anything of which we were not already aware. As yet we do not know what the 16 days of DH support will be but nothing that has been done so far indicates it will deliver anything of substance.
6
CAPITAL AND ESTATES Capital & Estates Report M02 Ian Mackenzie presented the Capital & Estates M02 report. Richard Durban queried the projects over £1m – Resus, CT and Maple Annex- and whether relevant business cases have come or should come to the FWC. Ian Mackenzie replied that Maple Annex is another name for the Medical Records business case which is currently out to tender and planning and the FBC will be presented to the August FWC. The other business cases would come to the FWC in due course.
Paul Biddle asked if we were confident on getting the £4.4m capital loan despite a tightening within the Treasury. Lorraine Clegg replied that we had good paperwork for our loan applications and had never been refused in the past and Paul Simpson added that it was a tightening across the board. Alan Hall asked that of the £17m we were planning to spend only £8m was funded from depreciation and were we in danger of spending capital funds that we do not have. Paul Simpson 5
replied that the capital is not spent until approved to commence by the Capital Investment Group and that the TDA have not yet agreed the Capital Resource Limit (CRL) for 2015/16. Action: Clarity on capital funding to be reported to July Committee 7
PS
IT IT Report M02 Ian Mackenzie and Ben Upton presented the M02 IT Report. Richard Durban asked how the data centre flip went. Ian Mackenzie advised that it went very well after 9 months of planning. Ben Upton added that there had been a noticeable improvement in the display quality which was not expected. He advised that the downtime had been difficult and a few issues had been noted in the 24/7 business continuity which will be picked up in the PIR. IT implementation Roadmap Ben Upton presented the IT Roadmap, showing the planned development of the Electronic Patient Record (EPR). He advised that the project would be renamed SaSH EPR to get people thinking about the patient record rather than just Radiology and Pathology ordering and reporting. The system will have more functionality that we need to exploit and we have gone out to advert for a nurse computing lead. The aim of the project was to go “paper light” and increase computer use with access from anywhere and vital signs and built in alerts. Richard Durban asked for was leading the work on this project. Ben Upton replied that he has overall oversight and we have an EPR project manager, we have learnt from other Trust and spent 2 years looking at what we need from the system. Richard Durban then asked if there was assurance in terms of resources. Ben Upton replied that that he could give assurance as we are using our resources more efficiently and training was likely to be the main cost. The Committee noted that the Executive was reviewing the IT Roadmap and looked forward to a further update in due course.
8
GENERAL Date of next meeting Tuesday 28th July 2015 8.30am – 11.00am – AD77
6
Safety & Quality Committee Thursday 4th June 2015 14.00 - 16.00 AD77 Trust Headquarters, East Surrey Hospital Minutes of Meeting
Present: Richard Shaw Pauline Lambert Paul Simpson Des Holden Fiona Allsop Debbie Pullen Victoria Daley Barbara Bray Nandu Gandhi (deputising for VP) Katharine Horner Ben Emly Jonathan Parr
RS PL PS DH FA DP VD BB NG KH BE JP
Non-Executive Director (Chair) Non-Executive Director Chief Financial Officer Medical Director Chief Nurse Chief of WACH Deputy Chief Nurse Chief of Surgery Clinical Lead for Cardiology Patient Safety & Risk Lead Head of Information Clinical Governance Compliance Manager Risk Manager for Medicine
Stephanie Biden SB Presenting papers: Cathy White CW Patient Experience Lead Ashley Flores AF Infection Control Laura Warren LW Communications Apologies Virach Phongsathorn, Paul Bostock, Colin Pink, Julian Webb
Action 1
GENERAL BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were noted. 1.2. Minutes of the previous meeting The May meeting minutes where agreed as an accurate record. 1.3.
Actions from previous meeting were discussed as follows
C/F 5th March 2015 â&#x20AC;˘ Assessment of peri-natal mental health service gaps based on NICE guidance. PS reported that this issue was being managed through the CQRM because it was important to get the view of the CCG. This will be removed from the action plan.
COMMITTEE BUSINESS 1.4. Highlights from Executive Committee for Quality & Risk RS asked for an update on the review of ECQR. PS explained that the th
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intention is to reduce the bureaucracy of the meeting and building on the experience of the last year, refine the format. There are two ECQR meetings each month. The second meeting in the month will include the presentation of the sub-committee reports and the Divisional Governance Meeting minutes. The other meeting will be split into four thirty minute slots, at which current topics will be discussed in more depth. RS asked that a future ECQR report include the topics identified to be discussed. PL asked about the 15 steps programme. BB explained that surgery have been working on the issues raised following the 15 steps review of admissions and will now use the same process to review outpatients. PL asked whether there was any further feedback on the actions put in place to address the never event in paediatrics (misplaced NG tube). FA reported that the team have focused on the implementation of the competency assessment tool. This work is being extended to adult services where it is expected that the priority will be the clinical services where placement of an NG tube is most likely and that the nursing staff in these services will become the clinical experts for the Trust. PL asked about the sickness levels among senior staff in maternity. FA reported that there are 25 staff members on sick leave from a pool of 100 midwives. They have long term, complex medical conditions; DP confirmed that they were all being managed appropriately. FA gave assurance that the other members of staff have been identified to â&#x20AC;&#x153;act upâ&#x20AC;?. DP explained that the labour ward is always prioritised in terms of staffing, taking staff from the community and Burstow Ward if necessary. Five midwives are expected to join the service in the next few weeks. PL asked for further information about the preventable CDiff case. DH reported that this was related to the choice of anti-biotics. PL asked whether there was a problem with nurses working without a PIN (NMC number demonstrating fitness to practice). FA reported that there was one case of a midwife working without a PIN. FA gave assurance that there is a system in place to monitor the expiry dates of PINs. RS extended the discussion to include overseas nurses citing the issue at Stepping Hill Hospital. FA explained that the nurse involved in the Stepping Hill case had been recruited in 2003; there were very different systems in place then. The assurance that the Trust has is that all potential recruits go through a two step process in the Phillipines; a language test and a competency based assessment. They then apply for a visa and start the process with the NMC. On arrival in the UK they work for twelve weeks in a Band 3 capacity, which gives them the chance to work within the UK healthcare system th
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and receive SASH training and support. They will then go to Northampton to undertake OSCIs; six practical based assessments which have to be passed on the day to be then put forward for registration with the NMC. The OSCI process is new, introduced in January 2015. If the candidate fails they are given one more chance. 1.5.
Highlights from CQRM
PS reported that there were no material issues raised about performance. The CCG raised some issues around CQUINs which JP has since resolved. PS confirmed that the Trust has been paid for the CQUINs. There were two areas where the Trust was partially achieving; stroke (access to beds) and discharges. PS reported that there was a Single Performance Conversation meeting. FA attended the meeting and reported that there had been a discussion about the discharge process. East Surrey CCG undertook to set up a separate working group to pull together an integrated pathway and identify the gaps particularly in relation to access to assessments for packages of care and patients who require access to rehabilitation. 2
QUALITY PERFORMANCE 2.1 Quality Report RS requested that the Committee Reports be consolidated next month. Clinical Effectiveness: RS asked about deaths in low risk diagnosis groups. DH explained that BB has done a lot of work to reassess the coding of patients who have died coded to a low risk diagnosis group. This work needs to filter through the system and there is a risk that in the meantime the original data will be used to calculate the intelligent monitoring score. In the longer term the score will self correct. Patient experience: PL asked about the standards of behaviour work being undertaken in the Trust. CW explained that the group was in its early stages and was formed to raise awareness of, and set standards of acceptable behaviour within the Trust. PS made the point that the number of complaints has been broadly the same 13/14 to 14/15, he asked whether there was more that should be done. BE suggested that in real terms the number had gone down given that there has been an increase in beds. FA agreed that there is always more that can be done. PL asked about the post-natal community response to FFT which is showing as only 1%. FA explained that the post-natal ward are giving a card to the women as they are discharged and the community midwives will follow this up when they review the women at home. th
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Patient safety and workforce reports have both previously been reviewed at Board. 2.2 SQC Dashboard RS asked about low level of admissions to the fractured neck of femur ward within 4 hours. BB explained that the issue is the availability of beds and uneven patient flow. Most patients are seen by orthopaedics within 2 hours. Some patients go direct to theatre and have been being counted as a late admission to the ward. BE reported that there will be a review of the measures around fractured neck of femur. FA added that the standard is that the patient is in the right place to receive appropriate treatment within 4 hours and that may be theatres as opposed to the ward. JP stated that the Trust is in the â&#x20AC;&#x153;better than expectedâ&#x20AC;? category for fractured neck of femur. 3
PATIENT EXPERIENCE 3.1 Annual Complaints Report FA drew the committeeâ&#x20AC;&#x2122;s attention to the fact that the complaints backlog is being addressed and the timeliness of responses is improving as a result. In addition a complaints review group has been established to track the progress of responses, problem solve any issues and share learning. A key area for improvement in 2015/16 will be the quality and timeliness of responses and sharing the learning. RS observed that there are two main issues the process of responding to the complaints and the culture around improvement. RS asked for confirmation that the committee will receive quarterly updates of the metrics. KH confirmed that this would be the case. RS asked whether it is possible to benchmark Trust performance. KH explained that at the end of Q2 the Health and Social Care Information Centre will produce their analysis of the KO41 data and an analysis of the Trust performance will be undertaken. RS asked for this report to be brought to SQC. JP added that CQC have a measure within the Intelligent monitoring framework and that the Trust is not an outlier. FA confirmed that complaints that highlight a failure in care will also be logged as an incident and investigated. PL asked about the acknowledgement rates. FA explained that the dips in performance were related to sickness and the introduction of the new system. KH added that this will be monitored and reported in the quarterly report. RS asked how the committee will be assured that there has been an improvement in values and behaviours. It was agreed that this would th
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be given some thought. 3.2 National in-patient survey CW presented a summary of the results of the national inpatient survey, highlighting the main issues and the resulting action plan. RS remarked that the discharge process is a key issue that appears in a number of report, which reinforces its importance. RS asked whether discharge is being reviewed in enough depth to address the issue. BE replied that discharge and length of stay was discussed at Execs for 2 hours the previous week. The intention is to redesign the process with a clear focus on the needs of the patient. In this way patient flow and experience will be solved at the same time. The patient management and discharge issues will be managed through Execs. DH suggested that a high level summary of the Quality Discharge work could be brought to Trust Board in three months. PL asked about the issues relating to food. CW replied that in some cases the issues related to the physical management of food and patients who need support to eat and then there are issues about the food being cold and unappealing. NG commented that the report reflected his experience on the ward and that getting all the steps right for a smooth discharge is important. DP pointed that the number of respondents in each survey is small. CW reinforced the point that the overall clinical care is valued by patients; the negative comments related to the “hotel” aspects of admission for example food, quality of sleep etc. The “noise at night” comments are related to patients who are confused and disorientated which is difficult to address. VD observed that managing patient’s expectations might be a way forward. RS summarised that the Quality Discharge work would be brought to Trust board in three months time and will focus on the operational and quality aspects of discharge. The Inpatient Survey action plan will be monitored by the Patient Experience Committee, updates will be included in the Quality Report. 4
SAFETY 4.1 Q4 incident report FA presented the report. RS asked for more clarification on the chart showing the position of the Trust in relation to a sub-set of hospitals, judged to be peers. The Trust is showing an average of 28.3 incidents per 1,000 bed-days (April to September 2014). FA explained that it is very difficult to have a clear view of where the Trust wants to be in relation to incidents. As an example, Frimley Park is the next Trust on the chart to SASH th
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reporting 28.8 incidents per 1,000 bed-days, Frimley is judged as outstanding. RS concluded that the report is a detailed analysis of the position and demonstrates an understanding of the situation. 5
QUALITY 5.1 Draft Quality Account DH explained that the Quality Account is brought to the committee to give an opportunity to ask questions and highlight any potential errors or omissions. The report will be signed off by the Trust Board. The Trust Board takes assurance from the fact that the Quality Account has been reviewed by the committee. LW highlighted to the committee that the report illustrates the successes of the Trust. The Quality Account has gone to external stakeholders for comment. The comments have been positive about the progress and achievements of the Trust. There are a number of statutory requirements to the report which makes it more difficult to make it a “soft read” for lay people. The content has been streamlined. The report will go to design next. There was a short discussion about the falls section of the report which it was agreed would be reviewed. RS commented that it is a detailed account of the last year for the Trust. DH confirmed that when the report goes to Board it will have an introduction from the Chief Executive and the artwork will be in place. 5.2 MRSA screening AF reported that the Department of Health screening guidelines have changed. Previously the Trust was required to screen all emergency admissions and all elective admissions, apart from some Day Surgery exceptions. The guidance now states that patients going into high risk areas (ITU, orthopeadics and cardiothoracics) or patients who have been previously positive for MRSA should be screened. It is therefore proposed that screening in some areas should be stopped: • •
Elective c-section patients Day case surgery and minor procedures (except angio)
The Trust will continue to screen: • •
All major surgery electives Admission screening of emergency patients (highest risk area for the Trust is Care for the Elderly).
DH confirmed that the policy change has been brought to the meeting in view of the MRSA discussions at recent meetings. AF confirmed that patients who are at risk because of their immune th
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status and those who are at risk because of the volume of healthcare interventions that they are having, will continue to be screened. RS thanked AF for the assurance provided around the changes in policy. 5.3 2015/16 Audit Plan JP reported that the process for finalizing the audit plan for 2015/16 has been a smoother and more positive process than last year. The plans are more focused, they have reduced in volume but the proposed audits are of a higher quality. Surgery has focused their audits on issues raised by serious incidents and Medicineâ&#x20AC;&#x2122;s plan is dominated by the national programmes. WaCH have a successful core programme, they are tightening up their process around action plans. The focus for the audit team is to make sure that these audits are now completed within the financial year. Divisions will be asked to update the Clinical Effectiveness sub-committee. The team will ensure the audit registration process is followed, and certificated issued on completion which will be important for revalidation. DP felt that the reduction in volume will lead to better quality audits because the audit facilitator will have more time to guide clinicians. JP reported that a quarterly report will be taken at Clinical Effectiveness which will be reported through the sub-committee report. The Divisions have been asked to highlight exceptions within their quarterly reports and examples of where learning can be shared or practice has changed. 6
ANY OTHER BUSINESS DH reported that the Trust is through to the final ten in the selection process for the Virginia Mason project, five Trusts will be chosen. REVIEW OF THE MEETING PL asked committee whether the NEDs are asking the right questions. BB commented that the meeting brings issues together. BE suggested that some of the operational issues (18 weeks) could be included in future agendas as an indicator of a safe service. DATE OF NEXT MEETING 2nd July 2015 14.00 â&#x20AC;&#x201C; 16.00 AD77
th
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AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 27th May 2015, 15:00 â&#x20AC;&#x201C; 17:00 Venue: Room AD77, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Shaw
PB RS
Committee Chair / Non-Executive Director Non Executive Director
In attendance: Paul Simpson Gillian Francis-Musanu Lorraine Clegg Djafer Erdogan Darren Wells Jamie Bewick David May Sarah Pratley Colin Pink
PS GFM LG DE DW MW NA SP CP
Chief Finance Officer Director of Corporate Affairs (from 11.00am) Deputy Finance Director Head of Financial Accounts Grant Thornton (External Audit) Grant Thornton (External Audit) Baker Tilly (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 Durbanâ&#x20AC;&#x2122;s apologies for absence where noted.
1.1
Minutes of last meeting The minutes of the meetings of the March and April meetings were reviewed and agreed 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. The committee agreed to close action reference 1.3, 2.2 and 2.3 noting that the final action was due to be discussed at the July meeting.
2
Review of Annual Accounts
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2.1
2014/15 Accounts Analysis PS presented the accounts analysis for the 2014/15 financial year. Highlighting that the Trust delivered a £2.4m NHS deficit due to the significant MRET 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. PB asked for the detail surrounding the £14 million gain that occurred following the valuation of the Trust’s estates. DE highlighted that the valuation had been higher than expected and that this would impact positively on future capital spending. PS thanked LE and DJ for the work that had gone into supporting the valuation project. PB asked external audit if they had any concerns over the figures. DW confirmed that they recognised the figures and had no concerns. PB asked how assured the Trust was that the liquidity figures for the Trusts where accurate and being managed. PS stated that a loan application had been made but had been deferred.
2.2
Final Audited Accounts LC introduced the final audited accounts indicating the minor changes that had been made since the draft accounts in April. The main change was an update on sickness absence figures DW confirmed that the changes to drafted accounts were visible and caused no concerns. PS indicated that it was good set of accounts and all relevant income settlements are in place. PB asked if the External audited recognised the figures included. DW confirmed that this had been sampled and that they are happy that there are no issues.
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PB asked for assurances that money indicted as overseas provision was accounted for. DE stated that this was well managed, in plan and actively chased to recover. MW agreed with DE on this matter.
2.3
Review of Annual Report GFM presented the final draft annual report. The Committee discussed the commentary included and noted some minor changes to make before final submission. RS queried the information relating to non-elective emergency activity. LC indicated that this was a data presentation issue and that emergency activity had not decreased by 7.2%. The committee agreed to include extra comparison data to highlight the actual changes. PB queried the inclusion of detailed financial plans in the annual report. PS indicated that the information was available and had historically been included in the annual report. The committee resolved to keep the information in the annual report as t would be available under freedom of information. The committee signed off the annual report noting necessary non material changes before submission. Action GFM to make minor amends to reflect AAC conversations.
2.4
GFM
Review of Annual Governance Statement GFM presented the final draft of the annual governance statement noting that there had been no significant changes since the April meeting. RS highlighted that the board attendance table had drifted down the report. The committee discussed whether the description of the control issues reflected the known position, specifically elective cancellations, right bed first time and emergency pressures. The committee agreed that the document reflected board conversations. The committee signed off the annual governance statement noting necessary non material changes before submission Action CP to make final amends to AGS.
2.5
CP
External Audit Findings DW presented external audits findings, stating that the draft financial
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statements and supporting working papers were of a very good quality. Confirming 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. PB thanked DW for the report and his teams work DW discussed the value for money opinion highlighting the Trust has arrangements in place to secure economy, efficiency and effectiveness This is taking into account the deficit of ÂŁ2.4 million in 2014/15 and breach of the statutory break even duty. PB asked whether cash flow was taken into account. LC confirmed that this was regularly updated and included in the long term financial model. DW indicated that external audit would make a qualified value for money conclusion based on the performance management of the cumulative deficit. PB asked whether this position would change if the Trust achieved its aspiration of becoming a foundation trust. DW confirmed that since the debt issue would be resolved the Trust would likely revive an unqualified value for money opinion.
2.6
Representation letter PS stated that the letter was attached for review and would require signing before submission. The committee agreed with the content of the letter and stated that it could be submitted.
2.7
Head of Internal Audit Opinion DM introduced the Head of internal audit opinion which indicated that significant assurance can be given that there is a generally sound system of internal control in place. Going on to highlight the three main issues identified in year Temporary Staffing, Nice Guidance Compliance and Project Management, all of which had been discussed previously. PB thanked DM for the opinion.
2.8
Compliance with accounting standards PS stated that this paper was for information and reflected work carried out in year. This supports the function of final sign off of accounts.
2.9
Formal Adoption of accounts:
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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. Action DJ to ensure accounts are signed and uploaded by close of play Monday
3
3.1
Board Assurance Framework GFM introduced the draft 2015/16 Board Assurance Framework, highlighting this was based on the board seminar review and included draft changes to the Boards risk appetite. The committee discussed financial risks, the long term financial model and CIPs, noting the board opinion on CIPs and the sign off from the Medical Director and Chief Nurse. The committee noted that the HR and productivity related risks did not reflect recent board discussions as issues had merged on the BAF that should be separate. The committee noted that this would need to be agreed by board before adoption. GFM asked whether the committee was happy with the process of drafting the latest BAF. The committee confirmed that they were happy with the process that had supported the development of the latest iteration of BAF and risk appetite.
4
4.1
Update on Board Memorandum PS stated that there was little update to the AAC and that due diligence was the next key step.
5
5.1
Counter Fraud Annual report SP 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. SP went on to highlight recent confiscation orders following successful fraud investigations, recommendations that had been made on the overtime policy and the staff fraud survey.
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DJ
RS asked if there was any evidence that locum or agency fraud was more prevalent in the trust. SP Pratley confirmed that there was no evidence. RS asked if there were any more recommendations that could be made to reduce the fraud related to free treatment. SP reflected that this was linked to individual abuse of situation rather than premeditated fraud. However this is being actively monitored and there are attempts to proactively reduce new cases. The committee raised no further questions.
6
6.1
AOB PB brought the meeting to a close, thanking everyone for the work that had been undertaken to sign off the accounts and the breadth of the conversations throughout. There was no other business.
6.2
Date of Next Meeting: 17Th July 2015, 09:30 pre-meet, 10:00 meeting start.
Audit & Assurance Committee th Minutes 27 May 2015
An Associated University Hospital of Brighton and Sussex Medical School
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