Board of Directors
agenda Date 29 June 2011 Time 1:30pm Place Training Rooms B2/3 Postgraduate Education Centre Basildon Hospital
Contact Angus Wyatt Basildon and Thurrock University Hospitals NHS Foundation Trust Nethermayne Basildon Essex SS16 5NL Tel: 0845 155 3111 Extension 3874 Email:
[email protected]
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Members of the Board of Directors Chairman Sir P Dixon Non Executive Directors Vacancy Mr R Holmes Mr J Kent Mr T Parks Mr P Sheldrake Ms H Sturgess Mr P Wardle Executive Directors Mr A R Whittle Ms H Coffey Mrs J Galpin Mr M Magrath Dr S Morgan Mrs D Sarkar Mr A Sewell-Jones Mr N Taylor
Chief Executive Director of Operations Director of Estates and Facilities Director of Strategic Development Medical Director Director of Nursing Director of Finance Director of Personnel and Organisational Development
Quorum No business shall be transacted at a meeting of the Board of Directors unless at least five Directors including not less than two executive and not less than two nonexecutive Directors are present.
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PART ONE – PUBLIC MEETING AGENDA Item No
Page No SECTION 1 – Administration
(1) 1
Chairman’s Welcome and Note of Apologies for Absence
(1) 2
Minutes of the Meeting held on 25 May 2011
(1) 3
Matters Arising from the Minutes of the Meeting held on 25 May 2011 and review of progress on Action Log
5
SECTION 2 - Reports (2) 4
Chairman’s Report (attached)
17
(2) 5
Chief Executive’s Report (attached)
19
SECTION 3 – Reports from Committees of the Board (3) 6
Report from the Board of Clinical Directors (attached)
55
(3) 7
Audit Committee Report (attached)
59
(3) 8
Clinical Governance Committee Report (attached)
61
(3) 9
Health and Safety Committee Report (attached)
65
(3) 10
Joint Negotiating Committee Report (attached)
69
(3) 11
Report from the Board of Governors Strategic Planning Event (attached)
71
SECTION 4 – Decisions reserved for the Board (4) 12
Risk Management Strategy and Policy (attached)
79
3
SECTION 5 – (5) 13
Use of the Corporate Seal - to note the occasions on which the Corporate Seal has been used since the last meeting
(5) 14
Public Questions - to respond to written questions from members of the public
(5) 15
Questions from Governors
(5) 16
Date, Time and Venue of next Meeting The next meeting is scheduled for Wednesday 27 July 2011, at 1:30pm, in Committee Rooms 1 and 2, Level G, Tower Block, Basildon Hospital
(5) 17
Any Other Business Exclusion of the Press and Public: To Resolve “That representatives of the Press and other Members of the Public be excluded from the remainder of this meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the Public Interest” (Section 1(2) Public Bodies (Admission to Meetings) Act 1960)
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BOARD OF DIRECTORS MINUTES OF THE MEETING HELD ON WEDNESDAY 25th MAY 2011 PART 1 Present:Non Executive Directors:
Executive Directors:
Sir Peter Dixon Mr R Holmes Mr J Kent Mr T Parks Mr P Sheldrake Ms H Sturgess
Chairman
Mr A Whittle Ms H Coffey Mrs J Galpin Mr M Magrath Dr S Morgan Mrs D Sarkar Mr A Sewell-Jones Mr N Taylor
Chief Executive Director of Operations Director of Estates and Facilities Director of Strategic Development Medical Director Director of Nursing Director of Finance Director of Personnel and Organisational Development
Mrs P Trinnaman Ms A Saville Mr A Wyatt
Associate Director – Communications Corporate Secretary Board Secretary
In Attendance:
Governors in Attendance: Ms B Hallows Mr M Medlock Mr J Sibley Mr R Sweeting Mr D Sydney Mr B Wellman Mr K Wright
BD77/11
APOLOGIES Apologies for absence were received from Mr P Wardle.
BD78/11
MINUTES The minutes of the meeting held on 27th April 2011 were approved as a correct record subject to the amendment of the Action Log appended to the minutes to reflect the actions outlined in the minutes.
BD79/11
MATTERS ARISING The Board satisfied itself that all necessary action had been taken in relation to the Action Log appended to the minutes. The Board reviewed the Action Log and agreed the following: 1
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Action 4 The Director of Estates and Facilities advised the Board that the actions in relation to improving patient satisfaction with food were contained within the performance report. In summary the Board noted that in May and June work was scheduled to provide additional staff training for those wards recording poor scores on the Patient Experience Tracker in relation to food. Work would also commence to improve the product range and change the lunchtime service on two wards as a trial, to support the protected mealtime. Subject to the approval of tenders, new permanent cold storage would be installed by late summer which would allow further expansion of the product range held by the Trust. Nursing Care Planning and Documentation KPIs The Board was advised that the Key Performance Indicators relating to the nursing care and documentation exercise had been considered and agreed by the Clinical Governance Committee and would be presented to a future meeting of the Board as part of the new Key Performance Indicators for review and management within the Performance report for the current financial year. Action 6: Director of Nursing
BD80/11
EVALUATION OF THE MEETING HELD ON 27th APRIl 2011 The Board noted the detail of the evaluation of the Board of Director’s Meeting held on 27th April 2011. Board members were reminded that the mechanism for evaluating Board Meetings was subject to review and that proposals for the ongoing evaluation of Board Meetings and its Committees was due to be presented to the next meeting of the Board for further discussion. Action 7: Corporate Secretary
BD81/11
CHAIRMAN’S REPORT The Board noted the Chairman’s intention to have a clearer focus with written reports from Committees and from the Chairman, the Chief Executive and the Board of Clinical Directors at all meetings. The Board was also advised of the recent meeting with Monitor, where Monitor had noted positively the Trust’s progress in addressing its concerns. It was recognised that de-escalation of the Trust’s significant breach of its terms of authorisation related in part to satisfying the Care Quality Commission that all aspects of the essential standards were being met and maintained going forward.
BD82/11
CHIEF EXECUTIVE’S REPORT The Board considered the report of the Chief Executive as follows: CQC Essential Standards Compliance Review – Basildon Hospital The Board was advised that the Care Quality Commission had undertaken an unannounced inspection at Basildon Hospital on 10th and 11th May 2011. The primary purpose of the assessment was to review evidence of improvement against the outcomes where moderate concerns were reported from the 2
6
December 2010 review. The Board noted that initial verbal feedback at the end of the visit had been very positive although concern had been raised in relation to the completion of DNAR (do not attempt resuscitation) forms by Medical Staff within the appropriate timeframe. The Board was advised that immediate action had been taken to address the concerns raised by the CQC, in relation to this matter and also the security of medicine storage on the Acute Medical Unit. Following a question regarding the Trust’s awareness of issues in relation to the completion of DNAR forms, it was noted that the completion of forms had been audited previously and had been raised at the Board of Clinical Directors for action. It was questioned whether the completion of DNAR forms was an issue for the Acute Medical Unit or whether it was an issue for the whole Trust and the Board was advised that the counter signature of the DNAR form on AMU remained an issue, due to patients being transferred to other ward areas within the first 48 hours of their admission to the Hospital. The Board however noted that completion of the DNAR forms across the rest of the Trust required attention. The Medical Director advised the Board that the Trust’s Resuscitation Policy had been considered and agreed at the Board of Clinical Directors earlier in the week and that compliance with completion of the DNAR form would be reaudited to provide further assurance that the Trust was progressing in this area. The Board was reminded that the Trust’s Policy in relation to Do Not Attempt Resuscitation had been subject to a presentation at an earlier meeting of the Board and it was recognised that the Board had received limited assurance at that time in relation to the signature and completion of DNAR forms, which was consistent with the findings of the Care Quality Commission at its inspection visit. Nursing and Midwifery Council Follow Up Visit The Board was advised that the Nursing and Midwifery Council (NMC) had undertaken a comprehensive review of Nursing and Midwifery training provision on 19th and 20th May 2011. The NMC inspectors had undertaken an assessment of the effectiveness of implementation of the Trust’s action plans developed following the 2009 review, as well as an assessment of the Anglia Ruskin University and University of Essex academic contribution to Nursing and Midwifery training, at the Trust. The Board noted that the verbal feedback following the review had been extremely positive, with the NMC Inspectors having been very impressed with the engagement of the Trust’s Heads of Nursing and the standards and delivery of nursing care on wards which had been evidenced during their visit. The Board was advised that the action plan arising from the 2009 review had been achieved; however, a number of minor issues had been raised in relation to the University’s contribution to Nursing and Midwifery training. The Board was advised that the NMC report was due to be published on 29th July 2011. As a direct consequence of the positive inspection visit, the NMC had requested THAT the Trust co-author a report in relation to the changes which had been introduced following the review visit in 2009.
Foundation Trust Network The Board noted that in a recent ballot, FTN members had recently voted in favour of the Foundation Trust Network becoming independent of the NHS Confederation. The Board noted that plans for the achievement of 3
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independence were in place, with an operative date of 1st June 2011. The Board noted the intention for Sue Slipman to become the first Chief Executive of the newly independent Foundation Trust Network, however, that Ms Slipman would be retiring from her position with effect from 1st April 2012. NHS East of England Strategic Health Authority Transitional Assurance Visit 20th May 2011 The Board was advised that the Department of Health Team of Director Generals, led by Sir David Nicholson, was visiting each Strategic Health Authority over the next two months to assess progress in relation to delivering QIPP plans and system transitional arrangements for the next year. The Trust had participated in the NHS East of England review on 20 May 2011
BD83/11
PERFORMANCE REPORT The Board considered the Performance Report for the period to April 2011 under the headings “Patient Safety, Efficiency and Effectiveness, Patient Experience and Look and Feel”. The Board focused its discussion on the performance dashboard and during discussion the following points were noted. •
The management of pressure ulcers and falls was now monitored through Key Performance Indicators and it was noted that for both standards, the Trust’s performance had fallen in April.
•
Six Serious Incidents had been declared in April. Three related to Grade 3 or 4 pressure ulcers. One related to a patient whose initial death certificate had highlighted Clostridium Difficile as the cause of death but a subsequent review had highlighted that this had not been the case. The Trust had requested withdrawal of this Serious Incident with its commissioners. The remaining Serious Incidents related to safeguarding of children and the failure of the telephone systems at Orsett Hospital. Considering further the reporting of pressure ulcers, the Board discussed whether it was realistic to achieve zero pressure ulcers. The Board noted that the Trust aimed to record zero in relation to avoidable pressure ulcers, however, it was recognised that a small proportion of pressure ulcers were not avoidable.
•
The Board was advised of the Trust’s performance in relation to the 18 week referral to treatment standards. It was noted that the Trust had recorded failure against the standard for April and that achievement of the standard in quarter 1 remained at risk. The Board recognised that the Primary Care Trust’s management of the referral gateway process had resulted in 4,500 patients waiting for a first appointment. Of these, the PCT had advised the Trust that 1,000 would breach the 18 week referral to treatment standard. The Trust had introduced a database to track any adverse incidents or outcomes associated with the delay introduced by the Primary Care Trust’s Referral Gateway. Following a question from Ms H Sturgess, the Board recognised the ongoing risk of the Primary Care Trust identifying significant financial challenges towards the latter part of the current financial year. As a consequence of this, there remained a risk of the Primary Care Trust further delaying or stopping referrals to the Trust as had been the case in the last financial year. 4
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Whilst this was not an unlikely scenario, the contract which would soon be signed for the provision of services in the current financial year was affordable to the PCT. The 4,500 backlog of patients equated to a typical month’s GP referral volume to this Trust and the Board noted that in order to clear the backlog, the Trust could be required to complete 13 months of clinical activity in 12 months, recognising that the Trust planned to reduce its overall capacity in the current financial year, to meet the Primary Care Trust’s commissioning requirements. Whilst failure to achieve the 18 week referral to treatment standard was likely in Quarter 1, it was agreed that by Quarter 3 the Trust should be recording achievement of the standard and avoid failure of this target in three consecutive quarters, within its concomitant regulatory implication. •
5 of 7 cancer waiting time standards had been achieved in April. The 62 day screening to treatment and the breast symptomatic standards were not achieved within the month. In relation to the 62 day screening to treatment standard, the Board was advised that all patients who had breached the standard had chosen to wait longer for their treatment. The Director of Operations advised of the introduction of a communication strategy with patients, which sought to review and follow up those patients who had not responded to the invitation to book an urgent appointment. The Director of Operations was also meeting with the Director of Operations at Southend Hospital to discuss the treatment of Basildon patients at Southend Hospital, in particular, the need to pro-actively manage patients to avoid breaches of waiting time standards. It was recognised that the failure of this standard within the month related to a patient treated at Southend and basildon Hospital where this Trust recorded half a breach point. Given the low volume of patients treated against this standard, this was sufficient to fail the standard.
•
The Trust had recorded 92.6% performance against the target of 93% for the breast symptomatic standard. The Board noted that this was a direct consequence of the referral gateway where General Practitioners were now referring more patients through the two week wait route which had exceeded the Trust’s capacity. Analysis of GP referrals had highlighted that more patients were being referred through the two week wait route, with a declining number of patients being referred through the breast symptomatic route. Analysis had identified which GP practices had changed referral behaviour, the detail of which had been shared with NHS South West Essex and it was hoped that this change in referral pattern would change following PCT intervention. Given the multi faceted impact of the referral gateway, the Board supported the Medical Director in challenging the Governance arrangements of the gateway with the Medical Director of NHS South West Essex at the next Medical Directors’ Meeting. Action 8: Medical Director
•
The A&E performance standard had changed for 2011/12, with Q1 being measured on total time in the department for the 95th percentile 5
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of patients. The Trust was well within the standard, recording performance at 180 minutes against the standard of 240 minutes. Referencing previous discussion in relation to the new A&E standards, the Director of Operations advised that no Trust was achieving all standards at the present time, however, it was noted that this Trust’s performance was moving in the right direction. Achievement of the 60 minutes senior clinical review standard remained a challenge.
BD84/11
•
The Trust recorded a £1.1 million cumulative net deficit as at 30th April 2011 which was a slightly improved performance compared to plan. This had resulted in an in month Monitor financial risk rating of 2. The quarter end and year end forecast remained for a financial risk rating of 3.
•
The Trust delivered a £1.5 million cost improvement programme for the month in line with plan.
•
The project for the refurbishment of the A&E and Fracture Clinic remained ahead of plan. The Trust was now undertaking “on load” generator testing to ensure the Trust was well prepared to deal with the risk of power failures.
REPORT FROM THE BOARD OF CLINICAL DIRECTORS The Board noted the report of the Chief Executive which presented detail of matters which had been considered at the Board of Clinical Directors since the last meeting. Following a question from the Chairman, the Board was advised of the engagement of Tribal Consulting in relation to a proposed review of patient flows and capacity planning. It was anticipated that the report following on from the review would be completed by Tribal in July 2011.
BD85/11
IMPROVING THE QUALITY OF STROKE CARE The Board considered the report of the Director of Operations which presented a briefing on the current performance and priorities for stroke services at the Trust. The matter of stroke performance had been considered in detail at the Clinical Governance Committee. The Board was disappointed to note the Trust’s failure to achieve the majority of stroke care standards as set out in table 3 of the report with only one area being RAG rated as ‘Green’. Following discussion at the Clinical Governance Committee, the Trust had set an aim for upper quartile performance against key indicators and it was agreed that the Clinical Governance Committee should identify a small number of metrics to be monitored for improved performance. The Clinical Governance Committee would then report back to the Board, identifying the metrics for improvement, with an update on progress being presented within 6 months. Action 9: Director of Operations
BD86/11
ANNUAL ENERGY REPORT The Board noted the report of the Director of Estates and Facilities which presented an update on the use of energy and progress with implementation of the sustainable development strategy. 6
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The Board discussed the reporting arrangements for sustainability issues and considered them to be of sufficient importance to warrant annual reporting to the Board. It was noted that matters of significance could be reported to the Finance and Performance Committee for detailed review on an exception basis.
BD87/11
FINANCE AND PERFORMANCE COMMITTEE REPORT The Board noted the report of the Chair of the Finance and Performance Committee which presented an overview of issues considered at the Finance and Performance Committee Meeting held on 6th May 2011 under the following headings: • • • • • •
The Committee self assessment check list. F&P Committee Report 2010/11. F&P Committee Annual Plan 2011/12. Managing Operating Cash Policy and Procedure. Update on strategic direction. Review Annual Plan – 3 year plan from 2011/12.
The Board received the detail of the Finance and Performance Committee effectiveness for 2010/11, the revised Terms of Reference, achievements against the Committee Work Plan for 2010/11, as well as the agreed Work Plan for 2011/12.
BD88/11
CLINICAL GOVERNANCE COMMITTEE The Board noted the report of the Chair of the Clinical Governance Committee which presented an overview of issues considered at the Clinical Governance Committee held on 9th May 2011 under the following headings: • • • • • •
Quarter 4 Annual Clinical Audit Report. Audit of Medical Record Keeping. Quality Strategy Key Performance Indicators. Sentinel Stroke Audit Results 2010. Head of Midwifery Report, Quarter 3. NHSLA Risk Management Standards – Maternity Progress Report.
The Board was advised that matters which had required escalation to the Board had been dealt with and that it was the intention to present the Annual Report of the Committee as well as the Annual Plan to the next meeting of the Board for sign off. Action 10: Chair of the Clinical Governance Committee
BD89/11
USE OF THE CORPORATE SEAL The Corporate Seal had not been used since the last meeting.
BD90/11
PUBLIC QUESTIONS There were no public questions.
BD91/11
QUESTIONS FROMR GOVERNORS The Board received a written question from John Langridge, Public Governor, Thurrock, as follows: 11 7
“Q The hospital being financially challenged, the services that have been stopped, can you tell me what has become of the staff. 1 How many have been redeployed? 2 How many have been made redundant, positions?
and
what
was
their
Under the national pay agreement for the N H S called ‘Agenda for Change’, staff who worked on the 29th April 2011 are entitled to an enhancement in their pay ranging from double time to time plus 60%, but a large number of trusts across England are refusing to pay, Scotland, Wales and Northern Ireland are paying the enhancements. Q Is Basildon hospital paying the enhancement to staff that worked on the 29th April, if so where was the saving made to keep us within the financial budget? The British Medical Association ( B M A ) in England has agreed that all hospital doctors working on the 29th April should be given time off in lieu for the hours worked. Q How would this affect the hospital if the doctors took time off, as cover would have to be made at a cost, where would this extra cost come from?
Response from the Director of Personnel and Organisational Development We are making progress with implementing the reductions to the workforce. The vast majority of changes have been successfully achieved through removing vacancies (and not using bank/agency), with individuals affected being redeployed. This is still on-going and is not completed yet. So far only three members of staff have been made redundant. Although I cannot rule out further redundancies, the likelihood is low at present. This may change later in the year depending on how successful the PCT is in reducing referrals to the Hospital. I don’t have a figure for redeployments as much of this is still on-going but it will be 20+ already, not counting those redeployed from the usual round of ward changes. We have always paid the national terms and conditions of service and did so on 29 April. It was a bank holiday and we paid it as such. Staff can take time off in lieu if they work a bank holiday or be paid, they have the choice. There was no additional funding for this, it was “all in the tariff”.
The Board also received a number of questions from Governors attending the meeting, as follows:
from Don Sydney, Appointed Governor Basildon CVS in relation to the avoidability of Pressure Ulcers, particularly in relation to elderly emaciated patients. In response, the Director of Nursing advised that the Trust risk assessed patients against standards relating to nutrition, hydration and moving and handling, and had introduced a plan of care model, for the care of all patients. A full assessment had to be made on each individual patient and 8
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the management and avoidance of pressure ulcers was a complex and challenging process.
from Ms B Hallows in relation to levels of obesity and emaciation recorded at the Trust. Levels of obesity had increased both in patients and maternity attendances. There was a need for the Trust to have sufficient equipment for the management of bariatric patients and it was recognised that nutritional assessments were carried out to ensure that all patients received sufficient nutrition to get better but for obese patients, this required a balance with a need to reduce their weight. In relation to maternity patients, the Board noted that obesity presented a significant challenge, particularly for midwives supporting mothers in the delivery of their babies.
from Mr Ken Wright in relation to changes at Brentwood Community Hospital. In response the Director of Strategic Development advised that management of Community Services provided by NHS Southwest Essex had now transferred to North East London Foundation Trust as an interim measure whilst Community Services were subject to tender. As part of that tender exercise, the Trust was bidding to provide intermediate care bed facilities.
from Mr Ken Wright in relation to Anticoagulation Clinics. The Anticoagulation Service at Brentwood Community Hospital was now commissioned from a Consultant Haematologist who had previously worked at Queen’s Hospital. It was recognised that the services were not provided by Queen’s Hospital.
from Mr J Sibley in relation to the Trust’s reduction in oil usage as compared to the 2009/10 financial year. Oil is used to provide emergency backup in the event of other power systems failing. It is used to run emergency generators and as a backup fuel for the boilers at Basildon. Oil is consumed in the event of an interruption of either the gas or electricity supplies or routine testing of the standby arrangements. Therefore, the information provided in the Energy Report related to less oil being used in 2010/11, rather than a planned reduction in the use of this fuel. The suggestion that the sustainability impact be taken into account when considering service developments was supported and it was noted that the Trust’s Capital Investment Group and Sustainability Development Group actively manage the Trust’s plans to reduce its carbon footprint.
Signed ………………………………………………… (Chairman)
Date………………………..……………………………
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BOARD OF DIRECTORS (PART 1) MEETING 2011 ACTION LOG - PUBLIC Minute Ref and subject
Action No
Action required
Action Owner
Date raised
Date Due and Report to
Action Status/ Progress Outcome/ Impact for patients
25 May 2011 BoD
Included in Performance Report of the Chief Executive
(date action Agreed)
BD64/11 Performance report
4
BD68/11 Information Governance Toolkit Annual Compliance Report 2010/11
5
BD79/11Matters Arising
6
BD80/11 Evaluation of the Meeting held on 27th April 2011
7
BD83/11 Performance Report
8
BD85/11 Improving The Quality Of Stroke Care
9
Present KPI’s arising from nursing care planning and documentation exercise to the next meeting of the Board for information Prioritise delivery of level 2 for the non key information governance standards
Director of Nursing
27 April 2011
27 April Director of 2011 Strategic Development
July 2011 CGC
On agenda for CGC July 2011
Present new Key Performance Indicators for review and management within the current financial year Present proposals for the evaluation of Board Meetings and its Sub Committees.
Director of Nursing
25 May 2011
29 June 2011
Completed agreed 1 June 2011 in Quality Report
Corporate Secretary
25 May 2011
29 June 2011
It is proposed to undertake an evaluation of the papers prior to evaluating Board and Committee meetings.
Challenge the Governance arrangements of the referral gateway with the Medical Director of NHS South West Essex at their next Medical Directors Meeting The Clinical Governance Committee to identify a small number of metrics to be monitored for improved Stroke performance. The Clinical Governance Committee would then
Medical Director
25 May 2011
27 April 2011
Completed. Evidence of process requested from PCT
Director of Operations
25 May 2011
29 June 2011 BoD
Agenda for CGC July meeting
Progress to December 2011 10
14
BD88/11 Clinical Governance Committee
10
report back to the Board, identifying the metrics for improvement, with an update on progress being presented within 6 months. Present the Annual Report of the Clinical Governance Committee, as well as the Annual Plan to the next meeting of the Board for sign off.
BoD
Chair of the Clinical Governance Committee
11
25 May 2011
29 June 2011 BoD
On agenda
15
BD88/11 Clinical Governance Committee
10
report back to the Board, identifying the metrics for improvement, with an update on progress being presented within 6 months. Present the Annual Report of the Clinical Governance Committee, as well as the Annual Plan to the next meeting of the Board for sign off.
BoD
Chair of the Clinical Governance Committee
12
25 May 2011
29 June 2011 BoD
On agenda
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BOARD OF DIRECTORS MEETING 29 JUNE 2011
AGENDA ITEM: (2) 4
REPORT OF THE CHAIRMAN
1.
Meetings with MPs
I have now had 1:1 meetings with all of the local MPs with the exception of Eric Pickles. We are still trying to arrange a meeting with him as soon as possible. They inevitably have concerns about the hospital given the issues of the last 18 months, and I stressed determination to deal with these issues and ensure that the hospital continues to deliver the highest possible standards of care for the community. Many of their concerns were centred around the treatment of older patients, which is an area that everyone in the NHS is currently grappling with. I have explained that we are working collaboratively with the commissioners to ensure that we deal with the ever increasing national problem of frail elderly patients, and that we are insisting upon high standards in every aspects of care from our staff. I have discussed with the Chief Executive the need for a better programme of engagement with MPs and with other community leaders, and this is something we shall be working on over the coming weeks.
2.
Anglia Ruskin University Postgraduate Medical Institute
The Chief Executive and I attended a dinner at the Postgraduate Medical Institute along with representatives from the University and from most of the Trusts in Essex. The purpose of the meeting was not just the promotion of the Institute, but also to discuss the question of how we might work towards developing a system of partnership working within the area, modelled on the more formal Academic Health Science Systems, 5 of which were authorised by the Government across the whole of England some years ago. The purpose of these systems is to ensure that that we obtain the best possible outcomes from research and education, and that good practice is shared on a collaborative basis. There is also the opportunity for joint working between Trusts in areas of common interest to ensure that we learn from each other and use resources effectively.
3.
Governing Body Review
The Governors are intending to establish a time limited group to look at the ways in which the governing body works, and I have suggested that it would be helpful to have representation from Non-Executives on that group. The intention is to look at the way in which meetings are used, and try to ensure that we get the best out of the very considerable energy that Governors demonstrate. As Board members will know, I wish to put Governors on to the Clinical Governance Committee. My view is that the direct involvement of patients and the public in this way can only enhance our performance.
Page 1 of 2
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4.
Health Bill
I am sure that everybody will have read the voluminous comment that is appearing around the proposed changes to the Health Bill. At this stage, one of the most significant things appears to me to be the fact that there is to be a re-emphasising of national targets including of course the 18 week target. I happen to believe that this is good news in general since waiting around for things to be done is a miserable business for patients, and one of the key achievements of the last few years has been bringing down waiting lists. It is of course particularly relevant to some of our current issues and we do need to ensure we have a continuing productive dialogue with our commissioners to make sure that we are able to see patients within reasonable timescales and to do all we can for them within the frameworks we have to operate with.
SIR PETER DIXON CHAIRMAN
Page 2 of 2
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BOARD OF DIRECTORS MEETING
PART 1
29 JUNE 2011
AGENDA ITEM: (2) 5
CHIEF EXECUTIVE’S REPORT
1.
Monitor Review of Annual Plan – First Stage
On 16 June 2011 as part of Monitor’s annual plan review, telephone conversations took place between Alex Bartholomew, Compliance Manager at Monitor, Dr Stephen Morgan, Medical Director, and Adam Sewell-Jones, Director of Finance, to discuss the recent submission of the Annual Plan covering 2011 to 2014. The conversation with the Medical Director was limited to a discussion around the process for assurance over the quality impact of the Trust’s cost improvement programmes. During this conversation, Dr Morgan was able to share the process being followed by the Trust including examples of schemes that had been supported and rejected based on potential quality impact. The results of the quality impact assessment process, due for completion by the end of June, will be reported to the Board at the July meeting, in accordance with Monitor guidance. The conversation with the Finance Director was more wide ranging and covered the following:
Key Risks to the Financial Assumptions This discussion focussed largely on the ability of the PCT to demand manage activity in line with its commissioning intentions. Explanation was provided as to system wide working being undertaken, particularly in the area of unplanned care. Failure to limit activity to the plan would result in a potential over performance of income and a failure to realise cost improvements associated with reducing capacity.
Contract Status Monitor was informed that the specialist commissioning contract was now signed, and that agreement had been reached with NHS South West Essex over the acute contract and this would be signed subject to the PCT being successful in its bid to the SHA for transitional funding support. It was confirmed that the Trust had agreed PBR contracts and, whilst marginal rates had been agreed for significant over performance, income would be due at full tariff for activity delivered against plan.
Scale and Achievability of CIPs including Income Generation CIPs An overview of the 420 schemes currently being taken forward was provided by the Finance Director and again, the process for ensuring the impact on quality has been assessed was explained to the Compliance Manager. Key points highlighted were the split between schemes reflecting the efficiency requirement within tariff, and those relating to decommissioning of activity. Page 1 of 4
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Flow of information to the Board Whilst not relating directly to the Annual Plan submission, this picked up on a conversation held at the last meeting of Board members with Monitor. The Finance Director provided an overview of discussions taking place around the role of the Board and its committees, and the increased focus on committees seeking detailed assurance, with Board meetings receiving reports from these committees as well as from the Chief Executive.
Review of Clinical and Corporate Management Structure An overview was provided of the reasons for the review, together with intended outcomes and a broad indication of likely structure.
Serious Incidents The compliance manager questioned why the Trust was predicting an increase in serious incidents for 2011/12 above those reported in 2011. Explanation was provided about both the change in definitions requiring pressure ulcers to be recorded as serious incidents, together with the increased awareness of the importance of serious incident reporting. The discussion highlighted the fact that a high reporting organisation is generally seen as a safer one and that, whilst the focus is to reduce incidents occurring, the Trust was committed to continue being open with its reporting in order to ensure lessons are learnt and best practice shared.
Governance Declaration It was noted that the Trust had declared risks to achieving a number of measures within the governance assessment of the Annual Plan, including waiting time targets, A&E performance standards, 62 day cancer waits and CQC concerns. The Compliance Manager said he fully understood the reason for this declaration based on on-going conversations between Monitor and the Trust and asked for an indication when the Trust felt it would return to compliance. The Finance Director explained that much was dependent on the release of routine patient referrals held by the PCT referral gateway over recent months, but hoped that the impact would have been dealt with by the second half of the year. With regard to the CQC, the Finance Director informed the Compliance Manager that a draft report of the most recent inspection was expected within the next week. No other questions were raised and this concludes the first phase of Monitor’s Annual Plan review process.
2.
CQC Compliance Report – Responsive Visit to Basildon Hospital 10/11 May 2011
The draft compliance report was received on 21 June, and the Trust has 10 working days in which to submit comments on factual accuracy. The final report is therefore likely to be published by the CQC in mid-July.
Page 2 of 4
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3.
Visit to University College London Hospital (UCLH) NHS Foundation Trust
The Director of Operations and Chief Executive recently spent a morning at UCLH to review its approach to a number of operational issues which are topical for this Trust. This included: •
The role and function of an Investment Committee to oversee major capital investments and evaluation of service development opportunities
•
Use of Trust intranet as a prime source of internal staff communications
•
Governor reporting arrangements
•
Board reporting arrangements
•
Staff development programmes and facilities
The visit was very fruitful, and on-going informal 2-way communications with UCLH will continue in areas of mutual interest.
4.
Delivery of South Essex Quality, Innovation, Productivity and Prevention Programme (QIPP) 2011/12
A number of meetings have been held over the last month involving all health provider organisations and PCT Directors to agree South Essex wide arrangements for oversight of the QIPP programme delivery with specific emphasis on emergency care pathways. It is vital for future system financial stability and to improve patient experience. A QIPP Reform Plan progress meeting, convened by NHS East of England, will be held on 28 June, and feedback from the meeting will be provided at the Board.
5.
Performance Report for May 2011
The Performance Report for May is attached. This report will be considered by the Board of Clinical Directors on 27 June, and any actions or matters for report to the Board will be fed back at the meeting. Performance in May was strong in most areas, with the notable exception of compliance against waiting time standards. These will continue to be at risk as a consequence of the late booking of appointments for GP referrals held by the PCT Referral Management Centre. Although this should be a time limited problem, it will affect this Trust’s performance until the second half of the financial year and this in turn heightens the risk of regulatory action by Monitor, as reflected in the red risk rating shown for governance compliance. The highlights for the month, drawn from the KPIs shown on the summary dashboard are: •
HSMR – The final figure for financial year 2010/11 was recently released via the Dr. Foster Intelligence system, indicating a rating of 88.8 for the Trust. This is likely to rise to approximately 99 following re-basing, which would signal successful delivery of the improvement planned.
Page 3 of 4
21
•
VTE Risk Assessments – Performance at 71.2% is below trajectory, although, until June figures are available from the new real time data collection system, the results are subject to refresh, as patient episodes which have not been clinically coded are excluded. Improvement in performance is a high priority because there will be a corresponding patient safety benefit and financial incentive to the Trust.
•
Falls – There was a substantial improvement in the falls rate in May, however it will be important to see this sustained over the year.
•
Finance – The three main measures of financial performance including the Monitor Financial Risk Rating area all on track.
ALAN WHITTLE CHIEF EXECUTIVE
Page 4 of 4
22
Performance Report May 2011 Board of Directors 29 June 2011
23
To deliver high quality healthcare, ensuring the best experience for patients using our services, strengthening our reputation with stakeholders as a provider of clinical services and an employer of choice, whilst remaining viable financially and operationally
Deliver high quality healthcare
1. Continually improve performance against all key measures of safety
Falls
2. When things do not go well, ensure learning is shared to prevent reoccurrence
SI reporting
Optimise the experience of patients using our services
3. Listen to patients, carers and other stakeholders and ensure the Trust’s services meet their needs and expectations in a timely manner and in the most appropriate setting.
Cancer experience TBC
Pressure ulcers
Complaint responses sent
HSMR
CQUINS TBC
VTE MRSA C-Diff
4. Optimise outcomes through effective care delivery
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice
5. Achieve and maintain full compliance with CQC essential standards and with the Trust’s Terms of Authorisation as set by Monitor
6. Strengthen relationships with commissioners, other partners and the local community ensuring full compliance with contracts entered into
Remain a viable organisation financially and operationally
7. Scale the organisation to meet commissioner needs
8. Drive down cost base and attract new income sources (e.g. vertical integration, tertiary care) by understanding cost and income relationships for all core services and ensuring investment/disinvestment decisions are made based on contribution to strategic plans.
Care planning and documentation
Cleaning scores - Very High Risk
Cancer Waiting
Vacancies
Financial Risk Rating
Appraisals
Cleaning scores - High Risk
A&E
Absence
Tertiary income
Estate Statutory maintenance
Waiting times admitted
Estate Water systems Estate Planned Preventative Maintenance
Waiting times non-admitted
Cost Improvement Programme
Compliance Framework
24
Executive Summary ‐ Deliver high quality healthcare Current Previous Falls per 1,000 bed days
YTD
5.1%
6.0%
Incidence rate of grade 3 and 4 pressure ulcers per 1,000 bed days
YTD
0.7%
0.5%
HSMR – 12 month rolling average
YTD
89
90.4
VTE risk assessment
In mth
71.2%
75%
MRSA bacteraemia
YTD
0
0
C‐Diff
YTD
5
4
Compliance with 45 day SI reporting requirement
In mth
100%
Comments Following the receipt of the Rapid Response Report on Essential Care after Inpatient Falls, the Falls Group has now met and actions are being developed to comply with this alert. Additional reviews of RIDDOR reportable falls has been undertaken and the preliminary findings are included in this report. The supporting work streams between the Trust and the Primary Care Trust (PCT) continue to review the incidence of pressure ulcers across South West Essex. The roll out of the SKIN Care Bundle started during March and new trajectories for pressure ulcers have been agreed for 2011/12. The 12 month rolling average HSMR for the period April 2010 –March 2011 is 88.8 and continues to be indicated as “green” or significantly better than peer on the Dr Foster Intelligence system. 90.4 for March 2010 – February 2011. At the time of data submission to UNIFY, 71.2% of admissions in April had been risk assessed for VTE, below the likely CQUIN target for April of 90%. Once April activity coding is complete performance will increase to the level of the previous month. On 19 May 2011, the Patient Administration System was upgraded to allow ward based VTE risk assessment data entry. From this point, daily information is available on admissions that have not had a risk assessment recorded, allowing for corrective action. May data is not yet available.
100% Three Serious Incidents (SIs) were declared during May.
25
Executive Summary ‐ Optimise the experience of patients using our services Current Previous
Comments
Cancer patient experience Mth end score Complaints responses sent
In mth
CQUINS
In mth
Compliance with BTUH record keeping policy and observation of care audits
71%
89%
The results show that there has been an improvement in all standards where a comparison was possible. In particular the completion use of care plans has greatly improved and there was only 1 case out of 74 (1.3%) where the care plan was incomplete. There was only 1 standard that fell below the 90% target which was documentary evidence of patient / carer involvement in the care plan
In mth
Staff (as appropriate) receiving a performance appraisal which includes an Mth end assessment of their competence within last 12 months
There were 37 complaints received in May (40 in April). During May, 48 complaint responses were sent. Of these, 34 (70.8%) were within the target date.
89%
89%
The Appraisal position in May remained at 89% compliance. Directorates have been reminded of the importance of ensuring robust plans are in place to ensure appraisals are undertaken in a timely manner.
26
Executive Summary ‐ Enhance reputation with stakeholders as a provider of clinical services and an employer of choice Current Previous Cancer Waiting times achieved against 7 targets In mth A&E median wait in minutes
In mth
3
5
181
180
Waiting times (weeks) ‐ admitted
In mth 23.10
23.24
Waiting times (weeks) ‐ non‐admitted
In mth 17.50
18.24
Compliance Framework breach points
In mth
3.0
3.0
Cleaning scores ‐ Very High Risk. Number of In mth occasions where the score was less than 96%
0
0
Cleaning scores ‐ High Risk. Number of occasions In mth where the score was less than 93%
0
0
Estates Statutory maintenance Target
In mth
95%
94%
Estate Water systems Target
In mth
99%
96%
Estate Planned Preventative Maintenance Target
In mth
87%
95%
Comments 3 of 7 cancer standards were met in the month. For the quarter we are projecting non achievement of 2 standards although the margins are tight for a further 2.
Relates to risks of achieving 62 day cancer targets, Admitted waiting time target and Non‐admitted waiting time target. Monitoring of the standard of cleaning achieved during May showed that there were no occasions when the weekly monitoring of Very High Risk areas fell below 96% or where High Risk areas fell below 93%.
Estates maintenance performance for the month was very good. The number of job requests in May increased compared to April and was 7% higher than the total in May last year. All Estates maintenance KPI targets were fully met and all measures improved on the performance recorded for the same month last year.
27
Executive Summary – Remain a viable organisation financially and operationally Current Previous Monitor Financial Risk Rating (FRR)
YTD
3
Vacancy levels as % of funded establishment
Mth end
10.21%
Time lost through absence Tertiary income via the CTC
In mth YTD
2.84% £5,110
Comments Year to date I&E position £0.3m deficit. Expenditure remains within budget. Pay 2 costs remain well controlled Vacancies reduced to 10.21% with a reduction to the establishment resulting from the consultation process. It is expected that the establishment will shrink further as 10.81% some changes will only be effective July 2011. Vacancies in the Trust continue to be reviewed weekly and use of the internal bank covers nursing vacancies pending substantive appointments. 2.63% £2,462
Cost Improvement Programme
YTD
£2,591
£1,513 £2.6m CIP delivered, as planned
28
Deliver high quality healthcare – Patient Falls There was a reduction in the total number of falls with 104 in May affecting 83 patients, compared to 117 falls affecting 84 patients in April. There were 17 “mobility” falls reported in April (22 in March). Two “clinical” falls were reported in May (2 in April). In May, 96 Slips and Trips were reported compared to 98 in April. The Directorates have been asked to ensure that all relevant information is included on incident forms to ensure the data is robust. The Falls Group and Directorates are undertaking additional work to drill down into the detail of these incidents relating to times of day, activity, staffing. This work continues and updates are included in the Directorate reports to CGMG. A new trajectory has been established of 5.6 falls per 1000 bed days to be achieved by end March 2012. This is in line with national guidance and will offer a more robust monitoring of falls against activity. In May there were 5.1 falls per 1000 bed days.. There were two RIDDOR reportable falls in May. One related to a fractured neck of femur and the other to a head injury. The Falls Team has started to identify root causes and contributory factors associated with injurious falls.
Patient Falls
There has been a sustained reduction in falls since November 2010.
(data source: Incident Reporting on Ulysses Safeguard System)
140 120 100 80
Clinical
60
Mobilit y
40
Slips & Trips
20 A p r ‐1 1
M ar ‐1 1
F eb ‐1 1
Jan ‐1 1
D ec ‐1 0
N o v ‐1 0
O c t‐1 0
S ep ‐1 0
A u g ‐1 0
Ju l‐1 0
Ju n ‐1 0
M ay ‐1 0
‐
29
Deliver high quality healthcare – Pressure Ulcers
Pressure Ulcers (12‐month rolling programme)
Grade 2
(data source: Tissue Viability Team & Incident Reports)
•There was an increase in Incidence in May 2011 with 14 hospital acquired pressure ulcers affecting 7 patients •In addition, there were 44 patients admitted with a total of 56 community acquired pressure ulcers. In accordance with the East of England SHA, all Grade 3 and 4 Pressure Ulcers, whether community or hospital acquired, are reported by the Trust to the PCT. The community acquired pressure ulcer Serious Incident declarations are now being investigated by the Community Services. • The roll out of the SKIN Care Bundle to the Tissue Viability Link Nurses commenced in March with additional support being given to 3 wards where there has been an increased incidence of pressure ulcers. •The incidence of pressure ulcers is calculated as the rate of ulcers per 1000 occupied bed days. The Trust target in 2010/11 was set at 1 per 1000 bed days. A new trajectory of 0.3 per 1000 bed days has been set to be achieved by March 2012. The National Target is between 0.3‐0.5 per 1000 bed days. •The trajectory starts at 0.6 per 1000 bed days as this was the average achieved during 2010/11 and is the starting point for 2011/12. • The rate/1000 bed days for May was 0.7
Grade 3
120 100 Grade 4
80 60 40
Patients
20 May‐11
Apr‐11
Mar‐11
Feb‐11
Jan‐11
Dec‐10
Nov‐10
Oct‐10
Sep‐10
Aug‐10
Jul‐10
Jun‐10
‐
Community Acquired
30
Deliver high quality healthcare ‐ HSMR
The 12 month rolling average for the period April 2010 ‐ March 2011 is 88.8. It should be noted that this value continues to be indicated as “green” or significantly better than peer on the Dr Foster Intelligence system. This value is estimated to increase to 99 following the annual re‐basing of the data which usually occurs in August each year. The graph (above left) shows the Trust position currently (blue dot) and the estimated position following re‐basing (black dot). The grey dots represent the relative positions of all other Trusts following re‐basing. There are no HRG chapters with a high HSMR in March 2011 and no new alerts have been received from Imperial College, Dr Foster Unit or the Care Quality Commission.
31
Source of data: Dr Foster Intelligence
Deliver high quality healthcare – VTE and Serious Incident Reporting within 45 day VTE At the time of data submission to UNIFY, 71.2% of admissions in April had been risk assessed for VTE, below the likely CQUIN target for April of 90%. Once April activity coding is complete performance will increase to the level of the previous month which was 76%. The current method of data capture relies on the coding of notes and hence the delay in reporting by a month. A real time system based on entering patients’ VTE assessments onto PAS on admission was implemented during May. Work is underway to ensure data completeness and accuracy of reporting. The two systems will run in parallel for two months until assurance can be placed on the real time system. Data for May is not yet available. Serious Incidents All declared Serious Incidents have to have the final report with the PCT by day 45, unless an extension has been agreed by the PCT. The report will include the incident details, the findings, conclusions, recommendations, root cause analysis and lessons learnt. An action plan will also be presented with the report. Internally a 100 day review meeting is held to provide assurance that all the actions have been completed. NB: Please note on the graph that where there is not a value eg: for April and August 2010/2011, this denotes there were no reports due for returning in the indicated month
Compliance with 45 day reporting requirement Compliance with requirement 2011/12
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Performance Trajectory
Feb
Mar
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
2010/11
32
Deliver high quality healthcare ‐ Infection control
In May there was 1 case of hospital acquired C. Diff. The full year ceiling is 45 cases (down from 72 in 2010/11). The performance ceiling trajectory for MRSA bacteraemia for 2011/12 is 3 hospital acquired cases. In May there were 0 new cases (pre 48 hours), the total for 2010/11 was 3. Hand Hygiene scores, as observed by patients, achieved 86%. MRSA screening compliance continues to be a challenge in terms of reliability of data. MSSA – 3 cases in May. E‐coli – 3 cases in May.
33 Data source for HCAI: Laboratory results.
Optimise the experience of patients using our services ‐ Cancer experience Following the publication of the National Patient Experience Survey in December 2010, the Trust undertook a review of cancer management with a view to improving accountability and performance of cancer services. A number of actions were agreed ranging from the establishment of a Trust Cancer Board, to the formation of tumour group level action plans that incorporated actions to deliver improved performance in the patient experience survey, peer review and cancer waiting times
•Establishment of a Trust wide Cancer Board – this has met twice and is chaired by the Medical Director. The main focus is to ensure that the Tumour Group leads are delivering their locally developed action plans, as well as ensuring a trust wide implementation of national and network guidance and a focus on cancer strategy •Improvement pathway management with Southend ‐ A monthly meeting has been set up with Southend Hospital to ensure that patient pathways are managed as efficiently as possible. These meetings will include both Trust’s Director of Operations, Cancer lead clinicians and Cancer Managers to review waiting time performance, patient pathways and more strategic cancer issues •Information Prescriptions ‐ The Trust is currently one of 15 national Beacon sites for the roll out of Information Prescriptions which are designed to assist healthcare professionals guide patients and relatives to relevant and reliable sources of information about their condition, treatment options, care services and issues such as emotional aspects, diet and lifestyle, getting back to work as well as information to support carers. This is designed to help patients feel more in control, better able to manage their condition and maintain their independence. This work is key to improving our communication with cancer patients and their relatives which was an area that we scored consistently poorly on in the patient experience survey • Macmillan ‘Info‐Space’ ‐ A dedicated space has been created in the main outpatient department (funded by Macmillan), which will be staffed by a range of cancer healthcare professionals and provide information and advice to patients, carers and relatives, including the provision of information prescriptions. This will be operational at the beginning of July • Acute Oncology Service – a multi‐disciplinary working group has been set up to deliver the business case for acute oncology services, which will vastly improve the pathways for cancer patients that present at A&E. This service concentrates on rapid response to emergency attendances and admissions for cancer patients, as well as increasing the availability of oncology support on site, at ward rounds and with rapid assessment clinic capacity. We are aiming to have a service starting in September, subject to funding approval • Peer Review – the Trust had its Peer Review visit on the 15th June which covered POSCU (Paediatric) and Colorectal multi‐disciplinary teams. Verbal feedback from the review team stated that the Trust had improved services considerably since the last visit and there were a number of good practice areas that were highlighted. An ‘immediate risk ‘was highlighted for Colorectal surgery relating to a surgeon’s attendance at the core mdt meeting, 34 which will need to be rectified within 7 days of formal notice from the Peer Review team. The Trust will receive the formal reports in late July/early August
Optimise the experience of patients using our services – Patient Experience including Complaints Complaint Responses Sent During May 2011, 48 complaint responses were sent. Of these, 34 (70.8%) were in target. 14 (29.2%) responses were out of target due to quality* of reports from Directorates, as follows:‐ •Medicine and Emergency Care – 9 •Surgical Specialties – 4 •Women & Children’s – 1 * Where reports have not fully addressed the issues raised or have failed to provide supporting evidence of the investigation or lessons learned. Each of the above elements is reported and monitored monthly at PECL meetings and via weekly meetings with the Directorates. The target by year end 2010/11 was to attain a minimum of 70% responses sent out within target date. This was achieved. Re‐Opened Complaints There were 10 re‐opened complaints received in May. Parliamentary Health Service Ombudsman (PHSO) Requests During May the Trust received 4 first stage requests (copies of complaint file and healthcare records) and advice of 2 second stage reviews of existing cases. The PHSO advised the Trust of 3 cases where they have declined to investigate on behalf of complainants.
35
Optimise the experience of patients using our services – Patient Experience including Complaints Complaints Received 37 new complaints were managed by the Patient Experience Team (PET) in May compared to 40 in April. There were no red rated complaints in May. The primary categories were as follows::‐ Every Aspect of Medical Care/Treatment = 21 Nursing/Midwifery Care/Treatment = 7 Attitude = 3 Communication = 2 All Others = 4
PALS Contacts 183 PALS contacts were received in May (176 in April). 95.1% of PALS contacts were dealt with in target (5 days). PALS deal with enquiries and concerns which benefit from an earlier response, and where circumstances are deemed not to require a more rigorous investigation via the complaints process. PALS referred 2 issues to the Patient Experience Team requiring a more robust investigation.
36
Optimise the experience of patients using our services – CQUINS The Trust has agreed CQUIN values for 2011/12 with the two main commissioners of: • •
£2,411,351 for South West Essex PCT £664,736 for Specialist Commissioning
The individual CQUIN schemes have yet to be agreed but will include those nationally mandated: • • •
VTE Assessment VTE Appropriate Prophylaxis Patient Experience
The locally proposed schemes from South West Essex PCT cover: • • • • • •
Enhanced Recovery Programme Normal Birth Deliveries Newly Acquired Pressure Ulcers Breastfeeding Inpatient Diabetes Productive Theatres
The locally proposed schemes from Specialist Commissioning cover: • • • •
Home Dialysis Surgical Site Infection Rates Renal Transplant Ongoing Care of Babies discharged from Neonatal Services
37
Optimise the experience of patients using our services – Care planning and documentation In January 2011, following feedback from the unannounced inspection in December 2010, the CQC raised concerns with the Trust regarding inconsistencies of nursing documentation and the lack of evidence of formal care planning. Clinical visits undertaken by senior corporate nurses identified a number of factors that influenced the quality of nursing practice, including poor documentation, patient assessment and care planning. A project was commenced to address short fall in the framework for nursing documentation with the express purpose of improving nursing and midwifery practice. This project is near completion and the CQC action plan in relation to their concerns is now complete. Informal and formal evaluation of the outcome of the project has indicated that there have been significant improvements to the quality of nursing documentation in the terms of compliance with standards, the application of the nursing process and in the handover of information between staff. The framework for patient assessment and care planning will ensure that personalised and patient‐centred care is the priority for all nursing and midwifery staff and will lead to better patient care, safety and experience. The results show that there has been an improvement in all standards where a comparison was possible. In particular the completion use of care plans has greatly improved and there was only 1 case out of 74 (1.3%) where the care plan was incomplete. There was only 1 standard that fell below the 90% target which was documentary evidence of patient / carer involvement in the care plan. Record keeping and Care
Apr
May
Risk assessments completed
97%
100%
Care plans based on the risk assessments
70%
97%
Care plans completed correctly
74%
98%
Care plans reflect care being given
NA 92%
Evaluation of care for previous 24 hours Patient/carer involvement in care
100%
NA
99% 86%
38
Optimise the experience of patients using our services – Appraisals The target for Performance Appraisal in 2011/12 is to ensure that all staff (for whom it is relevant) have a documented annual appraisal, confirming their competence for their job and that they have clear objectives based on those of the Trust as a whole. The Trust achieved its highest level of appraisal performance in 2010/11 with 90% of staff having completed an annual appraisal. Taking into account, annual turnover, maternity and career break leave together with long term sickness absence, the target in 2011/12 is to achieve a target of 90%. The appraisal position at the end of May 2011 remained at 89%. Personnel staff are working closely with directorate managers to ensure robust plans are in place for all staff appraisals to be undertaken.
Data source: Electronic Staff Record
39
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice– Estates Maintenance
The number of job requests in May increased compared to April and was 7% greater than the total in May last year. This is the time that the year‐on‐year comparison has shown an increase in job requests since July last year. An increase in job requests can lead to cost pressures. Overall, maintenance performance in May was excellent. All 8 of the Estates KPI measures were fully met including the 3 planned (shown in the graphs here) and 3 breakdown maintenance KPIs. In addition, all 8 KPIs are better than the same month 12 months ago. Overdue work performance is significantly improved over the past year with both 4 week and 3 month KPI measures being fully met. Monthly on‐load standby generator tests have been introduced successfully and will be carried out between 8‐9am on the first 40 Tuesday of every month. Data given is provided from the Estates ‘Shire’ work management system, performance data improves over time as job tasks are completed and processed
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice – Cleaning
The cleaning service is monitored according to a risk assessment undertaken in accordance with the National Standards for Cleanliness in the NHS. The Trust has a stretch target to achieve 98% for Very High risk areas and 95% for High Risk areas but to have only a limited number of areas below the standard of 96% and 93% respectively. In May 2011 there were no occasions when the weekly monitoring of Very High Risk areas fell below 96% or where High Risk areas fell below 93%.
Data given on the graphs comes from the Innovise cleaning monitoring system.
41
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice ‐ Cancer Target Cancer 31 day wait for second or subsequent treatment ‐ surgery Cancer 31 day wait for second or subsequent treatment ‐ drug treatments Cancer 31 day wait for second or subsequent treatment ‐ radiotherapy Cancer 62 Day Waits for first treatment (from urgent GP referral) Cancer 62 Day Waits for first treatment (from Consultant led screening service referral) Cancer 31 day wait from diagnosis to first treatment Cancer 2 week (all cancers) Cancer 2 week (breast symptoms)
• • •
•
•
•
Threshold Q1 >94% 100% >98% 100% >94% N/A >85% 82.6% >90% 59.1% >96% 100% >93% 93.5% >93% 93.6%
Q2
Q3
Q4
May results are provisional and awaiting ratification. 3 of 7 cancer standards were met in the month (radiotherapy is not applicable as we do not provide this service). For the quarter we are projecting non achievement of 2 standards although the margins are tight for a further 2. The 62 day wait to first treatment (from urgent GP referral) is currently falling short of the target (82.6% (to date) against a 85% target).. Clear escalation processes are in place in order to ensure there are no avoidable delays in the pathway, ensuring where possible patients treatment is planned before 30th June. The impact on this target is due to the referral gateway, seeing an increase of referrals by 100%, adding additional pressure to all services within the trust. Predicted figures for Q1: best 85.8% worse 79.5%. This target remains at high risk. The 62 day screening to treatment standard was not achieved in May. This target remains at high risk. Although low patient numbers and patient choice are impacting on this target, bowel screening ‘colonoscopy’ capacity is also having a direct impact. Bowel screening department have clear plans in place to improve capacity but improvements to the target are unlikely to be seen in quarter 1. The 2 week breast symptomatic standard was not met for May. (89.5% against a 93% target). This remains a direct impact of the referral gateway and that GPs have significantly increased their referral rate to breast cancer 2WW clinics, reducing volumes of breast symptomatic patients to offset the usual impact of patient choice. The cumulative figures for the quarter are now 93.6% against a 93.%. This target remains high risk. The 2WW (all cancers) standard was not met for May. (91.8% against a 93% target). All breaches in the month are patient choice over the bank holiday period. The increased referral rate remains consistent. Although the target has not been achieved for May we are predicted to achieve Quarter 1.
42
Source of all data: National Cancer Waiting Times Database.
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice– A&E
• • •
•
For Q1 the Trust is only being measured against the 95th percentile of the total time in A&E for all patients against a threshold of 240 minutes (4 hours). May performance was well within this standard at 181 minutes. As reported to the Board, the Trust will be expected to achieve against a further 4 standards from Q2. Consistent performance against 3 out of the 4 indictors was demonstrated in April and May The outlying indicator is defined as the time from arrival to treatment decision, which should be within 60 minutes. May performance was 102 minutes and there are key work streams in place to reduce this which are being monitored on a bi‐ weekly basis. A new rota has been designed to increase consultant and middle grade cover in the department in line with the activity flows. There is also a plan to implement a larger Extended Nurse Practitioner (ENP) service This 4th indicator will not be delivered from July (the beginning of Q2) as the current rota and recruitment plans will start delivering at the latter end of Q2. However, no Trust has yet indicated that it is able to deliver 60 minutes. This will potentially mean a 0.5 point breach against the Monitor Compliance Framework
43
–
Source of data: Ascribe Symphony A&E System
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice – Waiting times
• Waiting time standards have changed for admitted and non‐admitted pathways. From April we are required to meet average waiting times for the 95th Percentile of patients ; 23.0 weeks or less for admitted patients and 18.3 weeks or less for non‐admitted patients. Additionally, we are still required to treat 90% of admitted and 95% of non‐admitted patients within 18 weeks as part of the PCT contract • May performance improved in comparison to April. Performance was better than target for non‐admitted (17.5 weeks) and slightly worse than target for admitted patients (23.1 weeks). 89.48% of admitted and 95.77% of non‐admitted patients were treated within 18 weeks, therefore the 95% non‐admitted target was achieved, but the 90% admitted target was not. • The Trust has worked with the PCT to review average polling ranges for first appointments. In specialties where the patient has a high probability of requiring admission (such as most of the Surgical specialties) a polling range of 8 weeks has been agreed. In other specialties, polling ranges are set at either 10 or 12 weeks. All have been calculated to provide the greatest opportunity for patients to be treated within the required maximum times and have been implemented from early June. • Delivery of these standards during Q1 and Q2 remain at significant risk while those patients currently in the backlog are being booked for their first appointments. This risk has been flagged to the Strategic Health Authority (SHA) and Monitor. Current forecasts are that neither target for admitted patients will be achieved in Q1 and that performance against both targets for non‐admitted patients is very close. Source of all data: Patient Administration System
44
Enhance reputation with stakeholders as a provider of clinical services and an employer of choice – Compliance Framework
Current Actual/Forecast Target or Indicator (per 2011-12 Compliance Framework) Threshold Weighting Q1 Clostridium Difficile -meeting the C.Diff objective 45 1.0 MRSA - meeting the MRSA objective 3 1.0 Cancer 31 day wait for second or subsequent treatment - surgery >94% 1.0 Cancer 31 day wait for second or subsequent treatment - drug >98% treatments Cancer 62 Day Waits for first treatment (from urgent GP referral) >85% 1.0 Cancer 62 Day Waits for first treatment (from Consultant led screening >90% service referral) Referral to treatment time, 95th percentile, admitted patients 93% 0.5 Cancer 2 week (breast symptoms) A&E Clinical Quality- Total Time in A&E (95th percentile)
