AGENDA - Poole Hospital Pack July Part 1.pdf · 24 July 2013 - 09:00 Board Room, Poole Hospital...

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Poole�Hospital�NHS�Foundation�Trust

Board�of�Directors

Board�of�Directors�Public�Meeting�July

24�July�2013�-�09:00

Board�Room,�Poole�Hospital�BH15�2JB

AGENDA

1 Apologies�for�Absence

2 Declaration�of�Interests

3 Part�1�Minutes�of�the�Board�Meeting�held�on�26�June�2013BoD�Jul�13�1�Minutes�Part�1�-�26�Jun�2013�Draft 8

4 Matters�Arising�–�Action�ListBoD�Jul�13�2�Part�1�Board�of�Directors�Actions 14

5 Chairman’s�ReportOwner:�Chairman

6 Chief�Executive’s�ReportOwner:�Chief�Executive

BoD�Jul�13�3a�Chief�Executive�July�Board�report�13 16BoD�Jul�13�3b�Press�release�on�provisional�finding 20

7 FOR�APPROVAL

8 Annual�Care�Quality�Commission�(CQC)�ReportOwner:�Director�of�Nursing�&�Patient�Services

BoD�Jul�13�4a�cover�sheet�CQC�Annual�Report�July�2 21BoD�Jul�13�4b�CQC�annual�report�July�2013 22

http://www.eshareuk.com

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9 Annual�Policy�Review�for�ClaimsOwner:�Medical�Director

BoD�Jul�13�5a�APRR�Cover�Sheet�Claims�July�13 26BoD�Jul�13�5b�APRR�-�Claims�13 27

10 Annual�Policy�Review�for�ComplaintsOwner:�Medical�Director

BoD�Jul�13�6a�APRR�Cover�Sheet�Complaints�July�13 39BoD�Jul�13�6b�APRR�-�Complaints�13 40

11 Annual�Complaints�Summary�ReportOwner:�Medical�Director

BoD�Jul�13�7a�Annual�Report�Cover�Sheet�13 53BoD�Jul�13�7b�Annual�Report�13 54

12 QUALITY�&�SAFETY

13 Chairman’s�Report�of�the�Quality,�Safety�&�Performance�Committee�held�on22�July�2013Owner:�QSPC�Chair

For�scrutiny

14 Francis�Report�–�Trust�Response�(Early�Stage)Owner:�Director�of�Nursing�&�Patient�Services

For�information

BOD�Jul�13�8�cover�sheet�Francis�Update��July�2013 61

15 Position�Report�on�Clostridium�DifficileOwner:�Director�of�Nursing�&�Patient�Services

For�information

BOD�Jul�13�9a�cover�sheet�C�Diff�July�2013 62BoD�Jul�13�9b�Clostridium�difficile�infections 63

16 PERFORMANCE

17 Chairman’s�Report�of�the�Finance�&�Investment�Committee�held�on�22�July2013Owner:�FIC�Chair

For�information


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18 Integrated�Trust�Performance�Report�Owner:�Director�of�Finance/Chief�Operating�Officer/�Director�of�Nursing�&�Patient�Services/Director�of�Human�Resources

For�information

BoD�Jul�13�10�INTEGRATED�PERFORMANCE�REPORT�JUNE�2 65

19 STRATEGY�&�PLANNING

20 Merger�UpdateOwner:�Chief�Executive/Prog�Director

For�information

BoD�Jul�13�11a�July�Cover�Sheet��-�Part�1�-�Merger 116BoD�Jul�13�11b�Part�1�Board�of�Directors�Merger�Pr 117

21 Wau�Board�Report�June�2013Owner:�Vice�Chairman

BoD�Jul�13�12�Wau�Board�Report�July�2013 119

22 Today’s�Board�SeminarOwner:�Chairman

23 Questions�from�the�Council�of�GovernorsOwner:�Chairman

24 Any�Other�Business

25 Date�and�Time�of�Next�Public�Meeting�–�Wednesday�25�September��in�theBoard�Rooms,�Poole�Hospital

26 Withdrawal�of�Press�and�Public�giving�opportunity�for�Governors�to�speakwith�individual�directors.

27 2013�Meeting�dates:30�October�27�November�

28 A�glossary�of�abbreviations�that�may�be�used�in�Board�of�Directors�paperswill�be�found�at�the�back�of�the�Part�1�papers.

29 AGENDA�–�PRIVATE�MEETING

30 Part�2�Minutes�of�the�Board�meeting�held�on�26�June�2013


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31 Matters�Arising�–�Action�List

32 Chairman’s�Report�to�Part�2

33 Chief�Executive’s�Report�to�Part�2

34 FOR�APPROVAL

35 Monitor�Quarterly�Certifications�(Quarter�1)Owner:�Chief�Executive

36 Merger�Position�Regarding�Competition�CommissionOwner:�Chief�Executive

37 Emergency�Care�ReportOwner:�Chief�Operating�Officer

38 Outline�Business�Case�for�Scanned�Medical�RecordsOwner:�Director�of�Informatics

39 Business�Case�for�the�Network�UpgradeOwner:�Director�of�Informatics

40 Business�Case�on�Cardiology�DevelopmentOwner:�Director�of�Finance

41 QUALITY�&�SAFETY

42 Risk�Register:�New�Red�Risks�SummaryOwner:�Director�of�Nursing�&�Patient�Services

For�information

43 Serious�Untoward�Incident�Summary�ReportOwner:�Medical�Director

For�information

44 Summary�of�Claims�&�Litigation�ReportOwner:�Medical�Director

For�information


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45 Strategic�Risks�ReportOwner:�Director�of�Nursing�&�Patient�Services

To�receive

46 PERFORMANCE

47 Finance�Report�Month�3Owner:�Director�of�Finance

For�scrutiny

48 Back�Log�Maintenance�Report�on�Poole�Hospital�-�Initial�AssessmentOwner:�Director�of�Finance

For�information

49 Back�Log�Maintenance�Report�on�Poole�Hospital�–�Action�PlanOwner:�Director�of�Finance

For�information

50 STRATEGY�&�PLANNING

51 Merger�UpdateOwner:�Chief�Executive

For�information

52 Position�Statement�on�Finances�and�CIPs�for�the�Proposed�OrganisationOwner:�Chief�Executive/�Director�of�Finance

For�information

53 HR�Horizon�Scanning�ReportOwner:�Director�of�Human�Resources

For�information

54 GOVERNANCE�&�AUDIT

55 Board�Development�Sessions�Programme�and�Action�Report�2013/14Owner:�Company�Secretary

For�information


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56 MINUTES�FOR�SCRUTINY

57 Minutes�of�the�Workforce�Committee�held�on�24�June�2013

58 Minutes�of�the�Finance�&�Investment�Committee�held�on��24�June�2013

59 Any�Other�Business

60 Date�and�Time�of�Next�Private�MeetingWednesday�25�September�at�12.00�noon�in�the�Board�Room,�Poole�Hospital

Attendees


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IndexBoD�Jul�13�1�Minutes�Part�1�-�26�Jun�2013�Draft.doc...............................................................8

BoD�Jul�13�2�Part�1�Board�of�Directors�Actions.doc............................................................... 14

BoD�Jul�13�3a�Chief�Executive�July�Board�report�13.doc....................................................... 16

BoD�Jul�13�3b�Press�release�on�provisional�findings�on�propo...............................................20

BoD�Jul�13�4a�cover�sheet�CQC�Annual�Report�July�2013.doc..............................................21

BoD�Jul�13�4b�CQC�annual�report�July�2013.doc...................................................................22

BoD�Jul�13�5a�APRR�Cover�Sheet�Claims�July�13.docx........................................................ 26

BoD�Jul�13�5b�APRR�-�Claims�13.docx...................................................................................27

BoD�Jul�13�6a�APRR�Cover�Sheet�Complaints�July�13.docx................................................. 39

BoD�Jul�13�6b�APRR�-�Complaints�13.docx............................................................................40

BoD�Jul�13�7a�Annual�Report�Cover�Sheet�13.docx...............................................................53

BoD�Jul�13�7b�Annual�Report�13.docx....................................................................................54

BOD�Jul�13�8�cover�sheet�Francis�Update��July�2013.doc..................................................... 61

BOD�Jul�13�9a�cover�sheet�C�Diff�July�2013.docx..................................................................62

BoD�Jul�13�9b�Clostridium�difficile�infections.docx..................................................................63

BoD�Jul�13�10�INTEGRATED�PERFORMANCE�REPORT�JUNE�2013.docx........................ 65

BoD�Jul�13�11a�July�Cover�Sheet��-�Part�1�-�Merger�Update.do...........................................116

BoD�Jul�13�11b�Part�1�Board�of�Directors�Merger�Programme�Up.......................................117

BoD�Jul�13�12�Wau�Board�Report�July�2013.doc................................................................. 119

Board�Governance�Governance�Cycle�May�2013.docx........................................................123

Glosssary�of�abbreviations�Feb�13.doc.................................................................................127


POOLE HOSPITAL NHS FOUNDATION TRUST

BOARD OF DIRECTORS

Part 1 Minutes of the meeting of the Board of Directors of Poole Hospital NHS Foundation Trust held at 10.00 am on Wednesday 26 June 2013 in the Board Room, Poole Hospital Present: Mrs Angela Schofield Chairman

Mr Chris Bown Chief Executive Mr Peter Gill Director of Informatics Mrs Jean Lang Non-Executive Director Mr Ian Marshall Non-Executive Director Mr Michael Mitchell Non-Executive Director Dame Yvonne Moores Non-Executive Director (Vice Chair) Mrs Mary Sherry Chief Operating Officer Mr Martin Smits Director of Nursing & Patient Services Mr Robert Talbot Medical Director Mrs Sarah-Jane Taylor Director of HR and Organisational

Development Mr Paul Turner Director of Finance Mr Nick Ziebland Non-Executive Director

In Attendance: Mr Michael Beswick Company Secretary

Miss Jill Retigan Secretary The Chairman welcomed the governors present to the meeting. PHFT 219/13 Apologies for Absence

Apologies for absence were received from Mr Guy Spencer, Non-Executive Director.

PHFT 220/13 Declarations of Interest It was noted that the Board of Directors could potentially have an interest in

any item related to merger. PHFT 221/13 Part 1 Minutes of the Board Meeting held on 29 May 2013 (Paper 1) The minutes were AGREED as a correct record of the meeting. PHFT 222/13 Matters Arising – Action List (Paper 2) 357/12: Mr Beswick would present a 2013 Board Development Sessions

Programme and Action Report to the private meeting of the Board of Directors in July. ACTION: MB

174/13: Mr Smits confirmed that work to formulate the Trust’s response to the

Francis Report continued. It was noted that this would also be the subject of the August Board Development Session. It was agreed that an update report would be provided at the July Board Meeting and this would include: an update on the Trust’s Response, the Gap Analysis and the action plan from the Draft National Patient Survey, which would be treated separately to the

BoD�Jul�13�1�Minutes�Part�1�-�

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Overall�Page�8�of�130Page�1�of�6


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overall Trust Response. ACTION: MSm

174/13: It was noted that Directors had visited areas prior to Board Sub-

Committee meetings. These were detailed and future plans discussed. 180/13: The Chairman asked about the position with Clostridium Difficile and

it was noted that the Annual Infection Control Report would be submitted to the July Quality, Safety & Performance Committee in July. Dame Yvonne Moores noted that she would provide an update to the Board as part of her Chairman’s Briefing in July. It was further agreed that a report on the position with Clostridium Difficile would be submitted to the July Board meeting.

ACTION: YM/MSm It was noted and was agreed all other matters arising unless the subject

of this or future Board of Directors agendas have been executed. PHFT 223/13 Chairman’s Report The Chairman reported on the following items:

Mrs Sandra Yeoman, Governor, and her husband had both received the MBE in the Queen’s Birthday Honours.

The Trust had been rated as a red governance risk by Monitor following submission of the Annual Plan. The change was due to the anticipated financial deficit in 2014/15 and 2015.16. A meeting with Monitor was planned for Friday, 28 June 2013.

A Parliamentary Question from Fiona McTaggart, MP for Slough, had been received. The question related to the legal costs for merger and a response had been issued.

The Oncology Department had acquired one of the TrueBeam Systems made available under the NHS Supply Chain Initiative to roll out the most modern cancer treatments for patients in the UK.

The Clinical Commissioning Group had held a Care and Compassion Day during June, this had been an excellent event which had provided the opportunity to share learning and improve networks.

The Mayor and Mayoress of Poole had visited the hospital on 5 June. They enjoyed a tour of clinical areas and attended the Volunteers Tea.

The May private meeting of the Board of Directors approved the 2012/13 Annual Report/Accounts/Quality Accounts and the 2013/14 Annual Plan and Certification. Also reports had been scrutinised, including the Annual Staff Survey Report and Action Plan and the Board received an update on Carbon Reduction within in the Trust.

Upcoming Fundraising events were detailed, including the Dragon Boat Race on 14 July and the Renaissance Club Golf Day on 26 July.

A Board Development Session had taken place on the 19 June when the Board had considered Monitor’s New Licensing Regime.

The Chairman offered congratulations on behalf of the Board to Mrs Sherry, who had been appointed as the Chief Operating Officer at Moorefield’s Eye Hospital and would be leaving the Trust in early October.

The report was NOTED.

PHFT 224/13 Chief Executive’s Report (Paper 3)


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3

Mr Bown presented his report and noted the following key points:

The work relating to the potential merger continued to be a demand on the work of Executive Directors.

The Health Overview & Scrutiny Committee of Poole Borough Council had visited the hospital and the feedback received was that they had been impressed with everything they had seen.

The June Monitor FT Bulletin had been received the previous day and would be circulated to the Executive Team who would take any appropriate actions.

The recent Recruitment Day had been a very well attended and positive event. The Chairman noted her thanks to everyone involved.

The report was NOTED. PHFT 225/13 Patient Safety Culture Survey (Paper 4)

Mr Smits presented the report and noted that the Patient Safety Culture Survey had been undertaken at both Poole and Bournemouth Hospitals to provide a benchmark to support the Monitor Quality Governance Framework processes and identify areas for future development. The report was discussed and it was noted that the resulting actions would be managed by the Risk and Governance Group and overseen by the Quality, Safety and Performance Committee. ACTION: YM The Board of Directors NOTED the report and AGREED the areas for action.

PHFT 226/13 Chairman’s Report of the Finance & Investment Committee held on 24 June 2013

Mr Mitchell referred to his tabled report and noted the following:

The committee received the finance report for month 2 which was broadly in line with expectations. He noted that issues would arise in the future in absence of the proposed merger.

A new approval method for Capital Expenditure Projects submitted to the committee had been agreed.

The committee had received a detailed report on agency costs from HR and had agreed that these costs would be considered further with Divisional Directors.


PHFT 227/13 Chairman’s Report of the Workforce Committee held on 28 May 2013 Mr Ziebland referred to his tabled report and noted the following:

The committee had progressed from urgent actions and was now acting as a strategic enabler for the Trust, with the first area of focus being the poor level of appraisals, despite the best efforts of HR. This was discussed in detail. It was noted that the recording of completed appraisals was problematic, although a new system had been introduced. The Board noted the importance of regular appraisals and it was agreed that Mrs Taylor would meet with Mrs Sherry to look at the detail. ACTION: SJT/MShy


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4

It was also agreed that the HR Recovery Plan for appraisals would be presented at the September or October Board meeting. ACTION: SJT

The position with turnover and recruitment of staff was being monitored and the Committee were pleased to note the substantial number of new joiners coming through.

The Trust had been shortlisted for a national Chartered Institute of Personnel and Development award for the work the Trust has undertaken in regards to health and wellbeing. The panel would meet in July and the results would be published in September.


PHFT 228/13 Report on HR KPIs for the Integrated Trust Performance Report (Paper 6)

Mrs Taylor presented the report and detailed the HR KPIs currently reported

to the Workforce Committee and these were discussed alongside the KPIs currently reported in the Integrated Trust Performance Report (IPR).

The options were considered by the Board and it was agreed that a mock up

of the agreed HR KPIs with trend exception reporting by department would be included in the July IPR. ACTION: SJT

Discussion regarding early warning indicators took place and it was agreed

that a HR Horizon Scanning Report, which had been considered by the Workforce Committee, would be presented to the part 2 July Board meeting. ACTION: SJT

The report was NOTED. PHFT 229/13 Integrated Trust Performance Report (Paper 6)

Mr Turner, Mrs Sherry and Mr Smits presented the report and highlighted key areas. It was noted that the report had been subject to review and would now be based on exception reporting.

Detailed discussion took place particularly in regard to: The financial position for the first two months of the year. The Trust

was broadly at break even and the cash balance was reasonable at just under fourteen million pounds.

The Financial Risk Rating (FRR) for the Trust had been reduced to 2. Mr Turner reported that at their May meeting the Board had delegated authority for the final decision on whether to renew the Working Capital Facility to the Chief Executive, Chairman and Director of Finance. Following deliberation they had decided not to renew the facility as it was expensive and served no useful purpose during 2013/14. This, alongside the predicted financial position for 2014/15 and 2015/16 as detailed in the Annual Plan, had caused the reduction in the FRR from 3 to 2. It was noted that the financial challenge to the Trust was not due to current performance but the ongoing 5% year on year required cost improvement for an already efficient organisation.

Operational performance had improved in May.

An excellent recovery to the Four Hour Emergency Department target had been evidenced although the quarterly target remained fragile and high levels of breach management continued.


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5

Attendance had steadied during this traditionally quiet period although it was anticipated that this would increase during the summer in line with previous years.

There had been an increase in referrals to Trauma.

Delayed Transfers of care and the waiting times for access to Community Hospitals.

Although improvements had been seen the bed occupancy rates and number of outlying patients remained above target.

No cases of MRSA and Clostridium Difficile had been reported during the month.

An increase in people using the Patients Advice and Liaison Service had been noted. It was noted that some advice services previously funded by the PCT had been reduced or closed.

Mr Talbot provided an update on Mortality and it was agreed that the latest Mortality Report would be submitted to the Quality, Safety & Performance Committee for scrutiny. ACTION: RT Dame Yvonne Moores reported that she had attended the Critical Care and Resuscitation meeting. She noted that an audit of 39 cardiac arrests in one month had been scrutinised and no areas of significant concern had been identified. The report was NOTED.

PHFT 230/13 Merger Update (Paper 8)

Mr Bown presented the report and detailed the meeting held with the Competitions Commission (CC) in June. He reported that the early findings of the CC were expected at the beginning of July and the final report in mid August. Work with the Royal Bournemouth & Christchurch Hospitals (RBCH) relating to communications was underway. Mr Bown reported that the volume of questions from the CC had reduced and planning work continued. Mr Bown detailed the joint Governor event planned for 1 July. Mr Ziebland asked about the timings and required agreements from both boards should the CC issue their findings with remedies required. This was discussed in detail and it was agreed that Mr Bown would discuss the process with the Merger Programme Director. ACTION: CB The report was NOTED.

PHFT 231/13 Today’s Board Seminar The Chairman reported that no Board Seminar would be held due to the

convening of a Remuneration Committee. PHFT 232/13 Questions from the Council of Governors

No questions from the Council of Governors had been received.

PHFT 233/13 Any Other Business There was no other business.


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6

PHFT 234/13 Date and Time of Next Meeting

Board meeting to take place at 9.00 am on Wednesday 24 July in the Board Rooms, Poole Hospital.

PHFT 235/13 Withdrawal of Press and Public

The Chairman moved that any members of the public and representatives of the press should withdraw from the meeting.


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2


Report to the Board of Directors – 24 July 2013

BOARD OF DIRECTORS ACTION LIST

Minute No Action Deadline Lead Directors Update

174/13 Francis Report: August Seminar on the Trust's Response to the

Francis Report, Board and Sub Committee evaluation and the

PWC Governance Review alongside the Monitor Quality Care

Framework.

August Chris Bown/

Angela Schofield/

Michael Beswick

Subject to August

Seminar

174/13 Francis Report: Feedback forms to collect data for a quarterly

board report, including front door services, i.e. Phlebotomy, to

be considered as part of the Francis Review

When

appropriate

Martin Smits Subject to August

Seminar

174/13 Francis Report: Francis Report Gap Analysis to form action

plan. To be brought to the Board.

When

appropriate

Martin Smits Subject to August

Seminar

174/13 Francis Report: Quarterly Complaints Report to include

information from the PALS report

When

appropriate

Robert Talbot/

Martin Smits

Subject to future Report

222/13 2013 Board Development Sessions Programme and Action

Report to the private meeting of the Board of Directors in July.

July Michael Beswick Subject to July part 2

agenda

222/13 FRANCIS: Update report to the July Board Meeting. To would

include an update on the Trust’s Response, the Gap Analysis

and the action plan from the Draft National Patient Survey,

which would be treated separately to the overall Trust

Response.

July Martin Smits Subject to July agenda

222/13 YM to update the Board on the Annual Infection Control Report

as part of her QSPC briefing

July Dame Yvonne

Moores

Subject to July meeting

BoD�Jul�13�2�Part�1�Board�of�D

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Minute No Action Deadline Lead Directors Update

225/13 Patient Safety Culture Report: resulting actions to be managed

by the Risk and Governance Group and overseen by the

Quality, Safety and Performance Committee.

Dame Yvonne

Moores

Subject to July matters

arising

227/13 SJT and MShy to meet and discuss the detail regarding

appraisals.

When

appropriate

Sarah Jane

Taylor/ Mary

Sherry

Subject to July matters

arising

227/13 HR Recovery Plan for appraisals to the September or October

Board meeting

September/

October

Sarah Jane

Taylor

Subject to Sept or Oct

agenda

228/13 Mock up of the agreed HR KPIs with trend exception reporting

by department to be included in the July IPR.

July Sarah Jane

Taylor

Subject to July IPR

228/13 HR Horizon Scanning Report that had been submitted to the

Workforce Committee to part 2 July Board meeting

July Sarah Jane

Taylor

Subject to July part 2

agenda

229/13 Mortality Report to be submitted to the Quality, Safety &

Performance Committee for scrutiny

July Robert Talbot On July QSPC agenda

230/13 Discuss process and timings for Boards if required following CC

response

When

appropriate

Chris Bown Subject to July matters

arising

BoD�Jul�13�2�Part�1�Board�of�D

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3 Chief Executive’s Report

24 July 2013 Part 1

Board of Directors Meeting Merger Update Since our last Board meeting, the Competition Commission has published its provisional findings which put forward the likelihood of a prohibition of the merger. Clearly both trusts are bitterly disappointed with this outcome and I attach the press statement made in response. Both trusts will now be responding to the Competition Commission as we strongly believe that the clinical and financial benefits of the merger outweigh any loss of competition. The interests of competition must not be put before the interests of patients, their care, welfare and safety. The merger will be covered in the Merger Programme Director’s report. Monitor Investigation of PHFT Financial Sustainability A meeting with Monitor to discuss the next steps was scheduled for 28 June 2013. This meet was postponed pending the outcome of the Competition Commission’s findings. It is expected that this meeting will now be rearranged. Health Promoting Hospital Launch We are delighted to announce that we have become a member of the International Network of Health Promoting Hospitals and Health Services, which was initiated by the World Health Organization, to put into action the World Health Organisations principles of health promotion, and health education. The Health Promoting Hospitals model focusses on the idea that health promotion activities in hospitals need to become an integral part of the health care process in order to improve the quality of care for patients with chronic diseases and long-term conditions. The International Network of Health Promoting Hospitals & Health Services is a "network of networks". In total, it consists of more than 40 National / Regional HPH Networks, collaborating to reorient health care towards active promotion of health. Each of the National / Regional HPH Networks consists of a minimum of 3 hospital and health service members. Furthermore, more than 60 hospitals and health services are individual HPH members of the International Network, since they are positioned in places yet without a National / Regional Network. In total, the International HPH Network is made up of more than 900 hospital and health service members in more than 40 countries.

BoD�Jul�13�3a�Chief�Executive�

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http://www.hphnet.org/members/nr-networks

http://www.hphnet.org/members/nr-networks

http://www.hphnet.org/members/hhs-members

http://www.hphnet.org/members/hhs-members


At Poole we are extremely proud of the services we provide to our patients. However

we recognise the ever changing landscape. Hospitals need to adapt and expand their

efforts to focus on health promotion activities, in collaboration with the ever-widening

community networks of health and social care agencies. This requires the commitment

of all health care professionals.

To maintain a quality of life, patients and relatives have to be educated and more

intensively prepared for discharge from hospital. A high number of hospital

readmissions and health complications could be prevented if patients are empowered

to self-manage their conditions and if subsequent providers of health and social care

are fully involved in this process.

In doing so the services we offer our patients could be further enhanced through our

membership of the Health Promoting Hospitals Network. This will enable us to achieve

a better health gain by improving the quality of health care, the relationship between

hospitals/health services, the community and the environment, as well as the

conditions for and satisfaction of patients, relatives and staff.

Some of the benefits as listed below

A strong international network with effective membership of collaborators

and builds on existing knowledge and experience

A broad framework with technical support, tools, education, teaching, staff

exchange and training

Helping health service providers go from good practice to best practice

based on EVIDENCE

Bridges public health and health care and helps improve health in

Healthcare (and other settings)

Combined international & national joint efforts

A focus on developing partnerships

Welcomes further synergy and collaboration

Monitor Bulletin Each month, Monitor sends a bulletin to NHS foundation trust chief executives, chairs, finance, medical and nursing directors. Others can subscribe via the Monitor website to receive the bulletin. The FT Bulletin presents in five categories:

1. For information


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2. For action

3. Publications, Consultations/Engagement

4. Events and development programmes

5. External news/updates

Since the last board meetings the Executive Directors of the Trust confirm that they

received the June 2013 Monitor FT Bulletin and are cognisant of the information and

the requirements contained therein. The content of this Monitor Bulletin can be found in

the attached annex. At the time of producing this report the publication of the July 2013

Monitor Bulletin is awaited.

MONITOR BULLETIN JUNE 2013

For Information

Secretary of State to appoint Chair of Monitor

David Bennett gives evidence to the Health Select Committee

Our additional powers from the Care Bill – what they could mean for your

trust

Answers to your frequently asked questions on integrated care

Monitor investigates four foundation trusts

Peterborough and Stamford – outcome of independent report

Our first investigation under NHS purchasing rules

New Panel for Advising Governors launched

Report into commissioning of learning disability services in Cornwall

Delay in assessment assumptions – to align with work on the Tariff

147th foundation trust authorised

Coventry and Warwickshire Partnership FT application deferred

Monitor’s partnership agreement with NHS England

NHS Confederation Conference – working in partnership

Monitor – out and about

For Action

We need your views on our proposals for the 2014/15 National Tariff

Are you meeting this legal requirement for you Board meetings?

Tell us your views on the closure of NHS walk in centres?

Consultation & Engagement

Draft FT Annual Reporting Manual 2013/14 for consultation


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Enforcement guidance on the Procurement, Patient Choice and

Competition Regulations: consultation document

Substantive guidance on the Procurement, Patient Choice and

Competition Regulations: consultation document

Publications

Updated Approved Costing Guidance

Guidance on the application of merger control rules for pathology services

Performance of the foundation trust sector for 2012/13

Events

Chair/CEO induction day

Webinar: Local Payment Variations

Procurement, Patient Choice and Competition Regulations events –

Pricing and incentives workshops

Strategic Financial Leadership Programme

NHS mental health pricing and incentives workshop

Chris Bown Chief Executive July 2013


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Competition Commission issues provisional findings on Foundation Trust merger

The Competition Commission (CC) has published its provisional findings on the proposed merger between Poole Hospital NHS Foundation Trust (PHFT) and The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (RBCHFT).

In a joint statement, Tony Spotswood, Chief Executive at RBCHFT, and Chris Bown, Chief Executive at PHFT, said:

“The Trusts are bitterly disappointed that the interests of competition are being put before the interests of patients, their care, welfare and safety. The Competition Commission has a duty which is to assess whether the proposed merger will result in a significant lessening of competition. The two Trusts have emphasised that they provide complementary services, work together collaboratively, do not compete and wish to come together to protect and enhance services for patients and the residents of Poole and Bournemouth.

“The Competition Commission asserts that the merger (with the number of management organisations reducing from two to one) will reduce patient choice. We refute this. We plan to maintain two viable hospitals.

“The likely prohibition of the merger will now create uncertainty about the future of services for the residents of east Dorset. The merger would have provided a basis to increase consultant delivered care, improve the quality of care and provided local people with new facilities for obstetric care, emergency care and treatment of cancer.

“The Trusts consider that the process is not fit for purpose and will be raising this at the highest level.”

The Trusts will now consider fully the contents of the CC’s provisional findings before responding.

The CC’s final decision is currently expected by 26 August 2013.

Details of the CC announcement can be found at http://www.competition-commission.org.uk/our-work/directory-of-all-inquiries/royal-bournemouth-and-christchurch-poole/news-releases

BoD�Jul�13�3b�Press�release�on

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http://www.competition-commission.org.uk/our-work/directory-of-all-inquiries/royal-bournemouth-and-christchurch-poole/news-releases




BOARD OF DIRECTORS

Meeting Date: 24 July 2013

Agenda Item: 7 Paper No: 4

Title:

Annual Care Quality Commission Report 2012-2013

Purpose:

For information

Summary:

This annual report reviews the Trust’s overall compliance against the Care Quality Commission (CQC) essential standards of Quality and Safety for 2012/13. The report includes details of the CQC unannounced visits for 2012. This report provides the Board of Directors and other key committees/groups with positive assurance that the Trust continues to achieve a high level of compliance against the CQC Essential Standards of Safety and Quality.

Recommendation:

The Board is asked to note this report.

Prepared by:

MANDY BAKER, Assistant Director Of Nursing(Governance)

Presented by:

MARTIN SMITS Director Of Nursing & Patient Services

Assurance Framework:

YES / No Risk Register I/D No:

Healthcare Standards:

Please specify which standard/ standards that apply;

CQC Standard (Please provide details): Outcome 16 - Quality monitoring

Other; i.e /NHSLA/HSE etc NHSLA Standard level 3 - various

Monitor compliance: YES

Human Resources implications NO Financial implications YES

Legal implications YES

Please ensure all boxes are completed in order to comply with national requirements

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4 POOLE HOSPITAL NHS FOUNDATION TRUST

Board of Directors – 24 July 2013

CQC Essential Standards of Quality and Safety Compliance Report April 2012 – March 2013

1. INTRODUCTION

1.1 This annual report reviews the Trust’s overall compliance against the Care Quality Commission (CQC) essential standards of Quality and Safety for 2012/13. The report includes details of the CQC unannounced visits for 2012.

2. INTERNAL ASSESSMENT PROCESS

2.1 The essential standards are monitored against a series of excel documents which are RAG rated and provide a visual overview of the Trust’s compliance status. A detailed trust wide review of the excel documents against the 16 outcomes and update of the trust’s initial self-assessment had been completed during the year 2011/12. A further full review is planned every 3 years – next due for the 2014/15 reporting period.

2.2 A review of the NHSLA standards against the CQC outcomes was planned to form part of the NHSLA Level 3 Review in 2013. The review has been put on hold following the announcement by the NHSLA that they will be undertaking a major review of their standards during 2013/14 and therefore all planned NHSLA assessment visits had been suspended.

2.4 The format and programme of self-assessment for the management of announced CQC inspections continues. This process is also being used as a framework for self assessment of other external reviews in the Trust such as the HSE.

2.5 Internal audit has conducted a number of audits related to the CQC outcomes within the year:

P/01/12 Central Alert System

P/02/12 Risk Management & Incident Reporting System

P/03/12 Medical Devices

P/07/11 CQC Involvement & Information

P/19/11 Patient Nutrition

P/14/12 Drug Fridge Management Actions identified are addressed via the internal audit process and monitored by the Audit and Governance Committee.

2.6 The Trust has supported it’s compliance review process against the CQC by also reviewing risk prioritisation in conjunction with other external monitoring/requirements for example

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NHSLA/NPSA/CAS/HSE.

2.7 Primarily the internal focussed review process against the CQC standards for the year involved more specific assessment at ward and departmental level and a number of new initiatives that relate to the CQC standards have also been introduced. For example;

Further roll out of the internal unannounced visits to wards to look at safety and storage of Drugs commenced in June 2012 is underway.

The Patient Safety Thermometer process has been fully implemented and ward audit scorecards are being introduced. It is planned that key results will be fed back to wards via matrons with effect from 1 April 2013.

The Golden Rules have been refreshed and launched publicly. Formal monitoring is being introduced as part of the ward audit programme.

2.8 A detailed report of the gap analysis against the CQCs Quality Risk Profile and details of actions taken to address the gaps has been presented to the July meeting of the Quality, Safety and Performance Committee.

3. CQC INSPECTIONS 2012/13

3.1 The trust was subject to an unannounced visit by the CQC in July 2012. During the 3 day inspection the CQC visited a number of wards and departments and reviewed 5 of the 16 Essential standards of quality and safety Outcomes;

1 - Respecting and involving patients

4 - Care and welfare of patients

7 - Safeguarding patients (adults and children)

14 - Supporting staff

17 – Complaints

The trust was found to be non-complaint against only 1 aspect of Outcome 1 (Respecting and Involving Patients) in relation to compliance with the Trusts DNAR policy. An action plan was instigated, subsequently completed and reported to the Quality, Safety and Performance Committee. During the follow up visit in December 2012 and the most recent unannounced visit (2013) the CQC again reviewed progress in relation to DNAR and found a high level of on-going compliance in all areas visited.

The CQC is currently reviewing the 16 essential standards and is likely to announce significant changes in the summer of 2013. The trust has been subject to the on-going annual unannounced inspection in May 2013. The CQC were broadly complimentary about what they saw. The final report is expected early July.

4. SUMMARY

4.1 This report provides the Board of Directors and other key committees/groups with positive assurance that the Trust continues to achieve a high level of compliance against the CQC Essential Standards of Safety and Quality. Where shortfalls have been identified action plans have been implemented and all issues have been addressed to date.


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4.2 The Board of Directors is asked to note this report.

Mandy Baker

Assistant Director of Nursing - (Governance)

July 2013


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BOARD OF DIRECTORS – COVER SHEET

Meeting Date: 24 July 2013 Agenda Item: 9 Paper No: 5

Title:

Annual Policy Review Report - Claims

Purpose:

To brief the Board on the Trust’s compliance with the Policy and Procedure for the Management of Clinical Negligence Claims, Employer/Public Liability Claims and Property Expense Scheme Claims

Summary:

The Trust has a policy that describes the process governing the management of claims and compliance against the NHSLA criteria. This paper sets out the outcome of the monitoring and audit and provides assurance to the Trust that claims are being managed in accordance with the policy and the NHSLA requirements.

Recommendation:

For approval

Prepared by:

CARRIE STONE Legal Services Manager

Presented by:

ROBERT TALBOT Medical Director

This report is relevant to: (Please tick relevant box)

Assurance Framework

Yes Risk Register I/D No.

Healthcare Standards: Please specify which standard

Financial implications NO

Monitor compliance

Human Resources implications NO

Internal monitoring

Yes Legal implications NO

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ANNUAL POLICY REVIEW REPORT

POLICY AND PROCEDURE FOR THE MANAGEMENT OF

CLINICAL NEGLIGENCE CLAIMS EMPLOYER/PUBLIC LIABILITY CLAIMS

AND PROPERTY EXPENSE SCHEME CLAIMS

Date: July 2013 Presented to: Board of Directors Action Plan: Yes Date of Next Annual Report: July 2014 Author: Legal Services Manager

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CONTENT

1. INTRODUCTION 3 2. MONITORING AND AUDIT 3 2.1. AIMS AND OBJECTIVES 3 3 METHODOLOGY 3 4 RESULTS 4 5 CONCLUSIONS 6 6 GOOD PRACTICE 7 7 RECOMMENDATIONS 7 8. APPENDICES 8-12


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1. INTRODUCTION 1.1 This is the sixth annual report relating to the Policy and Procedure for the Management of Clinical Negligence Claims, Employers/Public Liability Claims and Property Expense Scheme Claims. The fifth annual policy review report was submitted and approved by the Board of Directors in July 2012. Six monthly reports on claims are provided to the Board of Directors and the Patient Safety and Quality Committee. Aggregated data is reported to the Complaints, Claims, Incidents and PALS Review Group (CCIP) on a quarterly basis.

1.2 The policy was revised and ratified by the Board of Directors in August 2006, and amended following revised CNST reporting guidelines in July 2007, September 2008 and November 2009. These minor amendments were approved by the Medical Director. The current version of the policy is Version 5. The next review date is November 2015. 1.3 There were no recommendations arising from the 5th APRR. 2. RESULTS OF MONITORING AND AUDIT

2.1 Aims and Objectives 2.1.1This review is intended to provide the Board of Directors with assurance that the Policy and Procedure for the Management of Clinical Negligence Claims, Employers/Public Liability Claims and Property Expense Scheme Claims continues to be delivered and managed effectively. Where gaps in compliance are identified confirmation that actions have been taken or clear action plans to remedy gaps are in place, thus ensuring that the Trust:

Complies with the NHSLA Reporting Guidelines

Communicates with relevant stakeholders

Aggregated analysis is undertaken

Organisational learning is identified and implemented 3 METHODOLOGY 3.1 The audit and monitoring criteria for the policy are listed below. Review of NHSLA Reporting Guidelines. The NHSLA guidance sets out reporting timescales for claims. These include

for disclosure of information, preliminary analysis, reporting of cases to the NHSLA, Letters of Claim, Part 36 Offers, reporting of Court Proceedings and acknowledgement of employer’s and public liability cases. Each case is managed against these time-scales. The timescales are:-

Clinical negligence cases

Requests for disclosure of healthcare records to be processed within 40 days.

Preliminary analysis for each claim to be completed within 40 days of the disclosure request being received. Some complex cases will take longer

Report relevant cases to the NHSLA within 2 months of request for records or sooner if the event is serious


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All Letters of Claim and Part 36 offers to be notified to the NHSLA within 24 hours.

Acknowledge Letters of Claim within 14 days.

All Court Proceedings to be notified within 24 hours. Liabilities to third parties (employers liability and public liability cases)

Acknowledge Letters of Claim within 21 days.

Report cases with standard disclosure list completed, to the NHSLA within 21 days.

All cases were reviewed for the period April 2012 to March 2013 by reviewing data held on DATIX and each individual case file. Communication with relevant stakeholders Each case is reviewed for reporting requirements to relevant stakeholders, which includes consideration of reporting to the NHSLA on the basis of the information obtained and sharing information with key members of staff. Aggregated Analysis On a six monthly basis claims themes are included in the Claims Review Report to the Board of Directors, the Patient Safety and Quality Committee and in the quarterly reports to the CCIP Review Group Organisational Learning Any risk management issues are identified during the preliminary analysis performed for each clinical negligence claim. All red and amber graded claims are discussed with the Medical Director and risk management issues identified through that review are shared at the CCIP Review Group, with relevant Clinical Leads and Consultant staff. The appropriateness of grading is also reviewed with the Medical Director. Since the previous APRR, “Solicitors Risk Management Reports” are sent to the relevant Consultant by the Legal Services Manager in order that the actions identified can be considered and implemented. These issues identified and the lessons learned are discussed at the CCIP Review Group to monitor compliance and evidence of actions taken. 4 RESULTS The specific results for each are given below. 4.1Review of NHSLA Reporting Guidelines There have been no Property Expense claims in the period April 2012 to March 2013. Clinical Negligence cases – Appendix 1

68 cases were notified to the Trust: of these: of these 64 requests for disclosure of healthcare records were received. All of these were processed within the 40 day timescale.

Of the 68 cases, 52 have had a preliminary analysis performed. In 4 cases an analysis was not required as it became apparent the claim was not against the Trust. In 3 cases no allegations were received. In 3 cases the notes were not available. 6 cases remain outstanding. It is not possible to identify from the DATIX system whether a preliminary analysis has been completed within 40 days. However, a review of the files has


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identified that 52 cases out of the 61 claims requiring a preliminary analysis had one completed within 40 days. This represents 85% of claims had a preliminary analysis undertaken within the time-scale. 94% were completed in the previous APRR. The causes of delay were a combination of notes not being available and the availability of the Legal Services Manager. 6 cases were identified as high probability and all were notified to the NHSLA, with completed preliminary analyses.

The Trust received 33 Letters of Claim and 4 Court Proceedings and these were notified to the NHSLA within 24 hours.

Liabilities to third parties (employer’s liability and public liability cases)

7 new employer’s liability and public liability cases were opened. All were acknowledged and within the 21 day time-scale.

All 7 cases were notified to the NHSLA with standard disclosure lists completed: 6 were reported within 21 days. This represents 85% of claims reported within the time-scale. For the previous year there was 75% compliance. 4.2 Communication with relevant stakeholders For the 68 open clinical negligence claims, the relevant consultants have been given details of the claim and asked to provide reports on the standard of clinical care received, an opinion as to whether the care represents a reasonable standard and comments on causation. Comment has also been requested on any allegations received at the time disclosure of healthcare records is requested, on receipt of Letters of Claim, independent expert reports and Particulars of Claim. Following preliminary analyses, 22 claims were graded as amber. All of these have been discussed with the Medical Director, in line with the Trust’s policy. These reviews considered the facts, comments from clinicians, the appropriateness of grading, probability of settlement, quantum and actions arising from the analyses. 6 of the 68 new clinical negligence cases were reported to the NHSLA as they carried a high probability of settlement, following preliminary analysis. 4.3 Aggregated analysis Claims themes were provided in the six monthly reports to the Board of Directors and the Patient Safety and Quality Committee. Aggregated analysis was provided on a quarterly basis to the CCIP Review Group, which also considered key themes and correlation between complaints, claims and adverse events. 4.4 Organisational Learning On closure of claims or in circumstances where it is clear there has been a breach of duty early on in the investigation of a claim, the Trust’s policy on the management of clinical negligence claims requires the completion of an analysis and conclusion. The relevant consultant is asked to review the conclusions, identify, where appropriate, areas where a change in practice is required, additional training/education is needed and how the lessons arising from the case can be disseminated through the specialty. A claims management root cause analysis form is sent with a request for information, to ensure consistency of approach across the Trust. 54 claims were closed


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for the period April 2012 to March 2013. Of these, 30 have been through the process to date. (Appendix 2). Organisational learning is reported on a six monthly basis to the Board of Directors and Patient Safety and Quality Committee. Learning arising from claims is also reported at the CCIP Review group, on a quarterly basis and disseminated to all Divisions. Following the introduction of the “NHSLA – Solicitors’ Risk Management Reports”, the Trust received 10 reports for the period April 2012 to March 2013. Each of these reports has been followed up with the relevant clinician and responses received in all instances with evidence of implementation of action points. These are routinely reported in the aggregated report to the CCIP Review Group on a quarterly basis and lessons disseminated to the Divisions. 5 CONCLUSIONS 5.1 The monitoring and audit of this policy in respect of:

NHSLA Reporting Guidelines

Communication with relevant stakeholders

Aggregated analysis

Organisational learning confirms that

Preaction Protocol disclosure within 40 days was achieved in all clinical claims where requests had been received by the Trust

52 clinical claims had preliminary analyses completed and of these 85% were completed within 40 days. The previous APRR reported 94% completion.

All letters of claim and Particulars of Claim were notified to the Trust within 24 hours

All 7 LTPS claims were acknowledged within 21 days and all cases were notified to the NHSLA with standard disclosure lists completed. There was, an improvement in percentage terms of claims notified to the NHSLA within the 21 day time-scale (85% as opposed to 75%)

For all clinical claims, the relevant consultant(s) were contacted and asked to provide reports on the clinical care received

22 amber claims were discussed with the Medical Director in line with Trust policy

6 of the 68 clinical claims were reported to the NHSLA as they carried a high probability following preliminary analysis

Aggregated analysis was provided on a quarterly basis to the Complaints, Claims, Incidents and PALS Review Group (CCIP) and the Clinical Governance Committee (CCG) and to the Board of Directors and Patient Safety and Quality Committee on a six monthly basis

Evidence of organisational learning was demonstrated through the six monthly Claims Report to the Board of Directors, and Patient Safety and Quality Committee, completed Analyses and Conclusions in 30 out of the 54 closed clinical claims and via the quarterly Aggregated Reports for the CCIP and CCG. The “NHSLA’s Solicitors’ risk Management Reports” were sent to relevant consultant staff in all 10 instances, the actions and learning being disseminated through the CCIP Review Group.


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The overall view therefore is that the monitoring and audit of this policy has provided assurance to the Trust that claims are largely being managed in accordance with the policy and the NHSLA reporting requirements for claims received by the Trust. 6 GOOD PRACTICE

6.1 The regular review of Amber claims with the Medical Director. 7 RECOMMENDATIONS 7.1 None 8 APPENDICES Appendix 1: Claims Compliance – Open Appendix 2: Claims Compliance – Closed Carrie Stone Legal Services Manager July 2013


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Appendix 1


LEGAL SERVICES DEPARTMENT

CLAIMS COMPLIANCE

1st HALF 2012/2013

Claim Number

Claimant – details not included

Disclosure/Acknowledgement

Preliminary Analysis

L13/2012 Completed Completed

L14/2012 Completed No – no allegations rec’d





L19/2012 Completed Not required – RBH case

L20/2012 Not applicable Completed



L23/2012 Completed No notes available







L30/2012 Completed

EL31/2012 Not applicable NHSLA


L33/2012 Completed Not required – RBH case



EL36/2012 Acknowledged 14 days

NHSLA 21 days

L37/2012 Completed Not our case – no need


L39/2012 Completed NHSLA - High






L45/2012 Not applicable Completed

L46/2012 Completed Completed - NHSLA





1. LD L78/2011 LOC April 2012


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2. NB L28/2010 LOC May 2012 3. LH L13/2012 High June 2012 4. GW L69/2011 LOC May 2012 5. LH Medium June 2012 6. JJ L12/2009 POC June 2012 7. AP L27/2010 POC July 2012 8. LBJ L60/2011 LOC August 2012 9. JM LOC August 2012 10. CM L65/2011 LOC August 2012 11. OH LOC August 2012 12. JC L46/2012 LOC September 2012 13. ET L45/2012 NHSLA September 201 14. JH L1/2012 High August 2012 15. KK L47/2011 LOC August 2012 16. JJu L20/2011 LOC July 2012 17. CG L50/2010 LOC September 2012

CLAIMS COMPLIANCE 2nd HALF 2012/2013

Claim Number

Claimant – details removed

Disclosure/acknowldgement

Preliminary analysis



NHSLA – 29 days


NHSLA – 18 days



NHSLA – same day

L56/2012 Completed Completed – See L8/2012

L57/2012 Not requested Not applicable






NHSLA – 8 days

L63/2012 Completed



L66/2012 Completed

L1/2013 Completed

L2/2013 Completed






NHSLA – 12 days


L9/2013 Completed

L10/2013 Completed Notes not available

L11/2013 Completed

L12/2013 Completed NHSLA - high

L13/2013 L14/2013

Completed Not applicable

Completed No allegations received


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L15/2013 L16/2013 L22/2013 L18/2013 L19/2013 L20/2013 L21/2013

Completed Completed Completed Completed Completed Completed Completed

Completed Completed Completed Completed Completed Completed

1. CG L50/2010 LOC October 2012 2. JF L16/2012 LOC October 2012 3. TJ L40/2011 LOC November 2012 4. PW L73/2011 LOC October 2012 5. KC L8/2010 POC November 2012 6. SR L17/2012 LOC October 2012 7. DT L39/2009 POC December 2012 8. KLC LOC January 2013 9. GJ L48/2012 LOC February 2013 10. TW L8/2012 LOC January 2013 11. GB L24/2010 LOC February 2013


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Appendix 2

LEGAL SERVICES DEPARTMENT CLOSED CLAIMS COMPLIANCE

2012/2013

Litigation Type Claimant details removed

Analysis & Conclusion

Response

1st half

Clinical Not applicable – RBH case

Clinical Completed Not required




Clinical Completed

Clinical Completed

Clinical Completed

Non clinical Not applicable

Clinical Completed

Non clinical Not applicable


Non Clinical Completed




Clinical

Clinical SUI

Non Clinical Not applicable

Clinical

Clinical Not applicable

Clinical SUI

Clinical SUI

Non Clinical Not applicable

Clinical NHSLA report Received report


Clinical Completed

Clinical Letter Not required

Clinical No – SUI Not required



Clinical Completed

Clinical




Clinical Completed Completed


Clinical Completed





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Nonclinical Completed

Non clinical

Clinical

Clinical



Nonclinical

Clinical

Clinical

Clinical

Clinical

Clinical Completed

Clinical

Clinical

Non clinical

Clinical


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Title:

Annual Policy Review Report - Complaints

Purpose:

To brief the Board on the Trust’s compliance with the Policy and Procedure for the Management of Complaints

Summary:

The Trust has a policy that describes the process governing the management of complaints and compliance against the NHSLA criteria. This paper sets out the outcome of the monitoring and audit and provides assurance to the Trust that complaints are being managed in accordance with NHSLA requirements.

Recommendation:

For approval

Prepared by:


Presented by:



Assurance Framework

Yes Risk Register I/D No.


Financial implications NO

Monitor compliance

Human Resources implications NO

Internal monitoring

Yes Legal implications NO

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POLICY AND PROCEDURE FOR THE MANAGEMENT OF COMPLAINTS

ANNUAL POLICY REVIEW REPORT 2013

Date: July 2013 Presented to: Board of Directors Action Plan: Yes Date of Next Annual Report: July 2014 Author: Legal Services Manager

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1 INTRODUCTION 3 2 RESULTS OF MONITORING AND AUDIT 3 3 METHODOLOGY 4 4 RESULTS 4 5 CONCLUSIONS 7 6 NEW STANDARDS/LEGISLATION 7 7 RECOMMENDATIONS 7 8 ACTION PLAN 7 9 APPENDICES 8-13


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1 INTRODUCTION 1.1 This is the sixth annual monitoring report relating to the Policy and Procedure for the Management of Complaints. Quarterly reports detailing trends and actions in relation to formal complaints are provided to the Board of Directors, the Risk Management and Safety Group and the Patient Safety and Quality Committee. An annual report is also provided to the Board of Directors. Aggregated data arising from complaints, claims, incidents and PALS issues are presented to the Complaints, Claims, Incidents and PALS Review Group and the Clinical Governance Committee on a quarterly basis. 1.2 The Policy and Procedure for the Management of Complaints was

approved by the Trust Board and subsequent amendments approved by the Medical Director and recorded in the policy document. The policy underwent significant amendment in May 2009, following the publication of SI 2009 No 309 “NHS England, Social Care England The Local Authority Social Services and NHS Complaints (England) Regulations 2009 and was approved by the Board of Directors in May 2009. Minor amendments were made in October 2009, March 2010 and April 2013, to reflect minor changes in terms of organisation changes and job titles. (Version 6).

1.3 An update from the previous year’s action plan was presented to the Board of Directors in February 2013. The action point completed is as follows:

Response times continued to be monitored through the quarterly complaints reports - quarterly reports confirmed adherence to timescales and reflected that 85% of responses were written within 25 days.

(The detailed 2011/2012 APRR updated action plan can be found in Appendix 1)

2 RESULTS OF MONITORING AND AUDIT

2.1 Aims and Objectives 2.1.1 This review is intended to provide the Board of Directors with assurance that the Policy and Procedure for the Management of Complaints continues to be delivered and managed effectively. Where gaps in compliance are identified confirmation that actions have been taken or clear action plans to remedy gaps are in place, ensuring that the Trust:

Complies with SI 2009 No 309 and ensures there is a process in place for listening and responding to complaints of patients, relatives and their carers

Ensures there is a procedure of non discrimination – patients, relatives and their carers are not treated differently as a result of raising a complaint

Complies with the process for the handling of joint complaints


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Achieves the relevant key quality target laid down by the Primary Care Trust (Clinical Commissioning Group since April 2013).

3 METHODOLOGY 3.1 The audit and monitoring criteria for the policy is listed below.

Management of the complaints process: The process for listening to complaints of patients, relatives and their carers. The acknowledgement times and response times for complaints are provided on a quarterly basis in the reports to the Board of Directors, CCIP Review Group and the Patient Safety and Quality Committee. This information is obtained using data held on the Datix complaints system. Accessibility of the complaints procedure to patients, relatives and carers is reported in a similar manner. The contractual target is that 85% of all complainants receive a response to their complaint within 25 working days. The Statutory Instrument only sets down one timescale with regard to acknowledgements within 3 working days.

Internal and external communication and collaboration with other organisations when necessary – the process for the handling of joint complaints. The number of complaints that cross multi-agencies is obtained by the review of individual complaints files. The revised policy includes a flow chart describing the process for multi-agency/external agency complaints. There are no percentage targets as this process is entirely dependent on how many cross organisation complaints are received.

The procedure to ensure that patients, relatives and their carers are not treated differently as a result of a complaint. Paragraphs 11.17 and 11.18 of the Policy states that complainants must not be discriminated against and that correspondence pertaining to the complaint will not be filed in the patient’s healthcare records. A random selection of healthcare records pertaining to clinical care complaints were reviewed by the Legal Services Manager.

Process by which the organisation aims to improve as a result of complaints being raised. The number, nature and trends of complaints together with the identification of remedial actions are provided on a quarterly basis to the Board of Directors and the CCIP Review Group. The report is developed using data held on the Datix system for complaints. Action Plans arising from the aggregated data presented to the CCIP Review Group are sent to the Divisions for implementation.

4 RESULTS 4.1 The specific results for each are given below. 4.1.2 Management of the Complaints Process.

472 formal complaints were received by the Trust. The response times for the acknowledgement of complaints for the financial year 2012/2013 was 99%, an improvement of 1% on the previous year. Whilst the NHS Complaints Procedure no longer stipulates a time-scale within which the organisation must provide a substantive response, the Trust aims to respond to 85% of complaints within 25 days, in line with a contractual obligation with the PCT. The response to complaints was 86% within the 25 day time-scale, which is the same as for the previous financial year. 63 complaints were responded to outside the timescale.


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The following table demonstrates the reasons for this. The figures in brackets are the figures from the previous APRR:

Reason outside timescale Total

Delay due to Consultant 31

Delay due to Division/Department 18

Delay due to further investigation/complex complaint 10

Delay due to Legal Services Department 4

Totals: 63

The amended Regulations, in place in 2008/2009, governing the NHS Complaints procedure, allowed for extensions beyond the recommended 25 working days, following discussion with the complainant. Data on requests for extensions has been included in the Quarterly Complaints Reports to the Board of Directors since approval of the first APRR in July 2008. When it became apparent that the response was likely/probable to overrun the agreed response timescale by more than five working days, 29 requests for extensions were made. (Appendix 3) Response times within Divisions are monitored through the Quarterly Performance Reviews and discussed at the Complaints, Claims, Incidents and PALS Review Group.

The table below illustrates the methods by which patients and/or their relatives complain. There has been an increase in email contact from the previous year, from 22% to 27% and a decrease in complaints received by letter, from 59% to 49%.

All complaints are graded according to severity by the Legal Services

Manager according to consequence and likelihood utilising the “grading of complaints” tool (Appendix A of the policy) and a summary of all red and amber complaints is provided in the quarterly complaints report. The Complaints, Claims, Incidents and PALS Review Group receive summaries of red and amber complaints as does the Patient Safety and Quality Committee. Since the 2nd APRR, new red and amber complaints are reviewed by the Medical Director as is the case with red and amber claims.

Received via E-mail 27%

Received via Letter

49%

Received in Person

3%

Received via the

telephone 21%

Method


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All complaints have been categorised by subject and the numbers, trend analysis and outcomes provided in the quarterly reports to the Board of Directors, Patient Safety and Quality Committee, Risk Management and Safety Committee and the CCIP Review Group.

All Parliamentary and Health Service Ombudsman requests and their

outcomes and recommendations were reported in the quarterly reports and the annual report to the Board of Directors, Patient Safety and Quality Committee and the CCIP Review Group. 4.1.3 Internal and external communication and collaboration with other organisations when necessary.

A Protocol for Dealing with Joint Complaints is in place between Dorset Healthcare Providers, PCT and Social Services. Collaboration with and/or referral to other agencies eg. Primary Care Trusts, Foundation Trusts and Social Services have taken place in 8 instances. Where appropriate, complainants have been offered the opportunity of a joint response, but these offers have not always been taken up. Of the 8 cases involving more than one organisation, 4 complaints were coordinated by the Trust: the remainder were coordinated either by the Primary Care Trust, Dorset Healthcare NHS Foundation Trust or the Royal Bournemouth Hospital. Appendix 3.

The Trust’s Annual Complaints Report 2012/2013 will be shared with the Clinical Commissioning Group following approval by the Board of Directors. A summary of the report is available in the Trust’s annual report.

4.1.4 The procedure to ensure that patients, relatives and their carers are not treated differently as a result of a complaint

The policy states that correspondence pertaining to the complaint will not be filed in the patient’s healthcare records. 344 sets of records were reviewed and 9 sets of case notes/EPR contained complaints correspondence. Following the fourth APRR, the Legal Services Manager wrote to all Divisional Directors reminding them that complaints correspondence should not be filed in patients’ notes. This reflects a stable trend. Appendix 4.

4.1.5 Process by which the organisation aims to make improvements as a result of formal complaints received The number, nature and trends of complaints together with the identification of remedial actions were provided on a quarterly basis to the Board of Directors and the Patient Safety and Quality Committee. The Complaints, Claims, Incidents and PALS Review Group and the Clinical Governance Committee receive quarterly reports identifying organisational and departmental learning and key themes from the aggregated analysis. Action plans from this analysis are sent out to Divisions, Clinical Directors, Matrons and the Director of Medical Education requesting evidence of implementation of the learning. The Legal Services Department’s publication “Snapshots” also highlights learning from complaints. This is published widely across the Trust. The reports are developed using data held on the Datix system for incidents, complaints, claims and PALS issues.


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Organisational learning and recommendations arising from Serious Untoward Incidents were reported to the Board of Directors, the Clinical Governance Committee, Risk Management and Safety Group, the Patient Safety and Quality Committee and the Complaints, Claims, Incidents and PALS Review Group with subsequent outcome reports to ensure that recommendations and remedial actions are completed. 5 CONCLUSIONS

The monitoring and audit of this policy in respect of:

The process for listening to patients, relatives and their carers

The process for the handling of joint complaints

The procedure to ensure non discrimination

The process by which the organisation aims to improve as a result of complaints raised

confirms that:

99% of complaints were acknowledged within 3 days – an improvement on the previous year

86% of complaints were responded to within the Trust target – the improvement from 2011 being maintained

29 requests for extensions were made –Complainants use a variety of different media to raise complaints

All Ombudsman’s requests and outcomes have been reported

Joint working on complaints resulted in joint responses at the complainant’s request

The non discrimination measure is largely being followed and the percentage of complaints correspondence found in patients’ healthcare records remains stable

There is a clear process ensuring that organisational improvements arise as a result of complaints raised. Evidence of organisational learning was demonstrated through the quarterly complaints reports to the Board of Directors and via the aggregated analysis reports for the Complaints, Claims, Incidents and PALS Review Group.

The overall view therefore is that the monitoring and audit of this policy has provided assurance to the Trust that complaints are largely being managed in accordance with the policy.

6 NEW STANDARDS/LEGISLATION 6.1. None. 7 RECOMMENDATIONS

7.1 As in previous APRR’s whilst the “complaints regulations” do not stipulate a time scale for responding to complaints. The Trust will continue to monitor the target of 85% compliance with the 25 day time-scale through the quarterly complaints reports to the Board of Directors, Patient Safety and Quality Committee and the Complaints, Claims, Incidents and PALS Review Group.


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6

8

8 ACTION PLAN 8.1 The recommendations detailed above are included in the action plan at Appendix 2. The action plan will be reviewed by the Board of Directors in six months’ time to track progress. 9 APPENDICES 9.1 Appendix 1: Action Plan 2011/2012 9.2 Appendix 2: Action Plan 2012/2013 9.3 Appendix 3: Complaints Extension requests and Joint Working 9.4 Appendix 4: Record Review 2012/2013 Carrie Stone Legal Services Manager


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6

9

Appendix 1 Poole Hospital NHS Foundation Trust 9.1 Appendix 1: Action Plan Annual Policy Review Report Action Plan for:

Policy and Procedure for the Management of Complaints

Lead for Action Plan: Legal Services Manager

Reviewing Committee: Board of Directors

Date Action Plan Initiated: July 2012 Update January 2013

Code: Red Amber Green

Issue Identified Action Lead Target Date

Progress Review Date

Green Importance of maintaining 85% compliance with local resolution responses within 25 working days.

To monitor target of 85% compliance through the Board of Directors, Patient Safety and Quality Committee and the CCIP Review Group

Legal Services Manager

On going Achieved and update confirmed to Board of Directors – January 2013

January 2013


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6

10

Appendix 2 Poole Hospital NHS Foundation Trust 9.1 Appendix 1: Action Plan Annual Policy Review Report Action Plan for:

Policy and Procedure for the Management of Complaints

Lead for Action Plan: Legal Services Manager

Reviewing Committee: Board of Directors

Date Action Plan Initiated: July 2013

Code: Red Amber Green

Issue Identified Action Lead Target Date

Progress Review Date

Green Importance of maintaining 85% compliance with local resolution responses within 25 working days.

To monitor target of 85% compliance through the Board of Directors, Patient Safety and Quality Committee and the CCIP Review Group

Legal Services Manager

On going January 2014


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6

11

Appendix 3

COMPLAINTS COMPLIANCE 2012/2013

Name Extension Requested Response

1st QUARTER

No < 1 week

No , 1 week

No < 1 week

No < I week

Requested

Requested agreed

Requested

Requested agreed

Requested

Requested agreed

Requested Requested

Agreed Agreed

2ND QUARTER

Requested Agreed

Requested Agreed

Requested Agreed

Requested

No 1 week

Not requested

Requested Agreed

Requested Agreed

Requested Agreed

3rd quarter

Requested Agreed

Requested Agreed

Requested Not agreed

Requested Agreed

Requested Agreed

No < 1 week

No

No

No

No < 1 week

No < 1 week

Requested Agreed

No< 1 week

4th quarter

Requested Agreed

Requested Agreed

Requested Agreed

Requested

Requested

No < 1 week


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6

12

Requested

Requested

Requested

Requested

JOINT RESPONSES

1st Quarter

PCT and PHT PCT led response

DHFT and PHT DHFT led response

PHT and RBH PHT led response

2nd quarter

DUHFT and PHT DUHFT led response

PHT and RBH PHT led response

3rd quarter

RBH and PHT RBH led response

PHT and SS PHT led response

PHT and SS PHT led response


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6

13

Appendix 4

RECORD REVIEW

2012/2013

MONTH NUMBER OF RECORDS REVIEWED

COMPLAINTS CORRESPONDENCE PRESENT

COMPLAINTS CORRESPONDENCE NOT PRESENT

April 37 0

May 31 1, 1 EPR,1 physio

June 39 1, 1 obs

July 28 1

August 19 0

September 17 1

October 26 0

November 33 2 EPR

December 23

January 27

February 22

March 42


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Title:

Complaints Annual Report 2012/2013

Purpose:

The Statutory Instrument 2009 No 309 £NHS England, Social Care, England, the Local Authority Social Services and NHS Complaints (England) Regulations 2009” requires an annual report which must cover a number of key areas and is available to any person on request.

Summary:

The report covers the number of complaints, how many complaints have been referred to the Parliamentary and Health Service Ombudsman and the actions taken to improve matters as a consequence of complaints made as per the Statutory Instrument Para 18 (1).

Recommendation:

For Approval

Prepared by:


Presented by:



Assurance Framework

Risk Register I/D No.


Financial implications YES / NO

Monitor compliance

Human Resources implications YES / NO

Internal monitoring

Yes Legal implications YES

BoD�Jul�13�7a�Annual�Report�Co

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7 POOLE HOSPITAL NHS FOUNDATION TRUST

COMPLAINTS ANNUAL REPORT

1st April 2012 to 31st March 2013

Briefing Paper for the Quality and Safety Committee

To be held on Monday, 22nd July 2013

1 INTRODUCTION 1.1 The Statutory Instrument 2009 No 309 “NHS England, Social Care, England – the Local Authority Social Services and NHS Complaints (England) Regulations 2009” requires that Trust Boards must receive quarterly reports on complaints in order to monitor arrangements under the Regulations and use the information collected to identify trends and consider any lessons that feed into service improvement. The key areas to be covered in the annual report include the number of complaints received in total, the outcome, an analysis of the nature of the complaints, how many complaints have been referred to the Parliamentary and Health Service Ombudsman and the action taken to improve matters as a consequence of complaints being made. Reports must avoid any possible breach of patient confidentiality. 2 THE MANAGEMENT OF COMPLAINTS

2.1 The Trust’s Complaints Policy was amended and approved by the Trust Board in May 2009 following the publication of the revised complaints arrangements as set out in the 2009 Regulations. Guidance for the Investigation of Complaints, Claims and Incidents is available to staff and a guide “How to handle a complaint/concern” assists staff in dealing with patients’ complaints and concerns at ward and departmental level. Training is provided to all newly appointed registered nurses and Foundation Years 1 and 2 medical staff on the complaints policy and how to deal with difficult situations. The Trust employs a senior manager charged with managing the complaints procedure. The Medical Director is the Executive Director with responsibility for leading and overseeing the Complaints Policy, ensuring that processes are robust, lessons are learned and the impact for patients and the Trust mitigated. The Local Resolution stage of all investigations is scrutinised by the Chief Executive and letters of response are signed by the Chief Executive, in line with the requirements of the Statutory Regulations and the Trust’s Complaints Policy. The Trust’s Chairman receives copies of all complaints and responses. A leaflet entitled “How to make complaints, comments and suggestions – a guide for patients”, is available on all wards and departments and the Trust’s web-site provides information on how to access the complaints procedure. 3 NUMBER OF COMPLAINTS RECEIVED 3.1 The number of formal complaints received by the Trust for the year ending 31st March 2013 was 472. For the same period last year the total number received was 430. This equates to one complaint in every 737 admissions, Emergency Department attendances and Outpatient appointments. For the previous year, 1:791 patients/carers complained about an aspect of their hospital experience.

BoD�Jul�13�7b�Annual�Report�13

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7 3.2 The following graph illustrates the trend over the past eleven years, by

financial year:

3.3 When reviewing the trend in terms of the number of complaints received by

the Trust over the last eleven years, the average number received annually is 400. For the previous year, the average was 392.

3.4 The NHSLA standards highlight the importance of ensuring that patients, relatives and carers have clear access to register formal complaints. The Trust’s “complaints leaflet” was redistributed to all wards and departments earlier in the year, together with the “Being Open” leaflet. The Trust accepts complaints in a variety of different formats, although letters remain the most common form of contact. The table below illustrates the methods by which patients and/or their relatives complain: there has been an increase in email contact from the previous year, from 22% to 27% and decrease in complaints received by letter, from 59% to 49%.

4 NATURE OF COMPLAINTS RECEIVED 4.1 Complaints relating to professional and clinical care, staff attitude,

communication problems and discharge and transfer arrangements are the most common cause of complaint. There has been a slight rise in complaints relating to clinical care from 38% to 41%. Looking at the trend over the

0

100

200

300

400

500

02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13

Complaints received April 02 - March 13

Received via E-mail 27%

Received via Letter

49%

Received in Person

3%

Received via the

telephone 21%

Method


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7 previous 11 years for those complaints involving clinical care, this year falls within the range. In terms of outcome, 36% were not upheld, 31% were upheld partially, 24% were upheld in their entirety, 6% of complainants received reimbursement for lost or damaged property, 3% of complainants withdrew their complaints and 1% resulted in disciplinary action being taken. The common themes arising from complaints are described in the quarterly reports to the Board of Directors and the Patient Safety and Quality Committee.

4.2 The following table illustrates the nature of complaints received across the

Trust. The incidence of the top 3 categories has changed since the previous year, with admission, discharge and transfer arrangements appearing in the “top 3” for the first time. Complaints concerning the attitude of staff are more prevalent in terms of numbers:

Category of Complaint Total

All aspects of clinical treatment 195

Attitude of staff 83

Admissions, discharge and transfer arrangements 48

Communication/information to patients (written and oral) 48

Patients' property and expenses 42

Appointments, delay/cancellation (out-patient) 26

Appointments, delay/cancellation (in-patient) 8

Hotel services (including food) 5

Patients' privacy and dignity 4

HA/PCG commissioning (including waiting lists) 4

Others 4

Aids and appliances, equipment, premises (including access) 2

Patients' status, discrimination (eg racial, gender, age) 1

Policy and commercial decisions of trusts 1

PCT commissioning (including waiting lists) 1

Totals: 472 4.3 This table illustrates where, by Division, complaints about clinical care have been received. Comparison with the previous year indicates a change in the profile with a greater number involving the Medical and Surgical Divisions:

Division Total

Medical Division 87

Surgical Division 68

MCD Division 39

Operations 1

Totals: 195 5 STAFF ATTITUDE


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7 5.1 Turning to complaints about staff attitude towards patients and their relatives,

18% of all complaints received raised concerns about this issue. This reflects a small increase of 3% in complaints of this nature from the previous financial year. Complaints of this nature are raised in the quarterly reports to the Board of Directors and the Patient Safety and Quality Committee. Action points are directed to all the Divisions and relevant Directorates. Customer care and communication training has been provided for individual members of staff. The Complaints, Claims, Incidents and PALS Review Group monitors complaints of this nature to review emerging trends and to monitor the impact of action plans and the highlighting of attitude in the Legal Services Department’s publication “Snapshots”. In terms of outcome, 44% were not upheld, 32% were upheld partially, 19% were upheld in their entirety, 3% were withdrawn by the complainant and 2% were referred for disciplinary investigation. A higher percentage was not upheld than has been seen in the previous two financial years.

5.2 The following tables illustrate where, by division/directorate and staff type, complaints of this nature have arisen:

Staff Type Total

Consultant 18

Staff Nurse 16

Registrar 13

Administrative/Trust Staff 7

Radiographer 6

Health Care Assistant 5

Associate Specialist 3

Physiotherapist 3

Midwife 2

Nurse Practitioner 2

Clinical Assistant 1

F1 1

Medical Laboratory Assistant 1

Other 1

F2 1

Sister 1

Technical Staff 1

Totals: 82

6 ACTIONS ARISING FROM COMPLAINTS AND LESSONS LEARNED 6.1 Summaries of a selection of complaints where action has been taken or

lessons learned following investigation are reported on a quarterly basis to the Board of Directors, Patient Safety and Quality Committee, Complaints,Claims, PALS and Incident Review Group and the Risk Management and Safety Group. Divisions are expected to provide updates on actions taken. The use of the checklist for all formal complaints, which is completed by the lead investigator(s) identifies the root cause(s) of the complaint and also confirms what action has been taken and to whom the

Division/Directorate Total

Medical Division 34

Surgical Division 24

MCD Division 22

Finance, IT and Estates 1

Operations 1

Totals: 82


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7 information is disseminated and discussed. Where appropriate, lessons learned in one division are notified to all divisions through the Complaints, Claims, PALS and Incident Review Group.

6.2 The following table illustrates outcomes at the conclusion of complaints investigations:

Outcomes at conclusion of complaint investigation

Total

Advice/warnings given to staff 223

No change recommended/necessary 210

Organisational change or review 19

Procedural/guideline alteration/production 11

Training/educational requirement identified 5

Remedial work, alteration to building/grounds 3

Human Resource Issues 1

Totals: 472

6.3 With regard to the 210 complaints where no changes were recommended or

necessary, 169 of these complaints were not upheld: of the remainder 12 were withdrawn and 28 received reimbursement or personal apologies.

6.4 Evidence of learning from complaints include:

Clinical Director reminded radiology of correct protocolling for particular type of CT scan.

Manufacturer of sweat test equipment provided additional training and support to nursing staff.

Matrons for Medicine and Children’s Services liaising to ensure that adults with autism in transition period are managed appropriately.

Review of clinic resulting in information now being forwarded to reception staff and radiotherapy nurse now checking waiting area to keep patients informed.

Leaflet written to accompany Anticoagulation Yellow book clarifying communication and referral process and consultant ensuring that doctors have a clear understanding of process of referral.

Detailed flow chart developed to assist staff when caring for patients following a TVT procedure.

Process now in place whereby appropriately trained staff in Outpatients can undertake FNA’s to reduce patient delays

Staff reminded of the importance of establishing GP details are accurate when patients attend physiotherapy appointments

Eligibility criteria for TBSI patients redefined by PCT

Staff reminded of importance of checking patients prior to discharge for cannulae in situ

Complainant’s views on disabled facilities to be taken into account during survey.

Review of discharge criteria when breastfeeding not established

Guidelines for bowel management and education session commenced on Lulworth Ward


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7 Importance of medicines reconciliation on the patient’s arrival to the ward or as

soon as possible thereafter reinforced to junior medical staff.

System implemented in Children’s Unit to ensure that test results are checked and communicated to parents in a timely manner.

Review of discharge process in care of the elderly to ensure improvements in communication with relatives and carers.

Ward staff reminded of correct fitting of Jura walkers and the provision of advice to patients regarding their use.

Email sent by Infection Prevention and Control with regard to the disposal of soiled clothing

Staff reminded of the uniform policy and the use of mobile phones

Junior medical staff reminded that must check EPR before contacting patients

Antibiotic guidance in Dermatology Department reviewed and amended

Review of threshold for lockdown on Portland Ward initiated in view of patient who absconded from the ward

Practice with regard to transporting soup across the dome entrance area changed

Pathway for back pain reviewed and reinforced

EPU information leaflet amended and sent to patient for comment 7 REQUESTS TO THE HEALTH SERVICE OMBUDSMAN 7.1 The Statutory Instrument 2009 No 309 “NHS England, Social Care, England -

the Local Authority Social Services and NHS Complaints (England) Regulations 2009”, requires that the number of complaints referred to the Health Service Ombudsman is specified. In 2012/2013, 5 complainants referred their complaints, which equates to 1:94 complaints received. For the previous year the ratio was 1:53. Until April 2009, requests were made to the Health Care Commission for independent review, the Ombudsman being the third stage. The amendments to the regulations changed this process, streamlining it to a two stage process of Local Resolution and then the Ombudsman. The 5 requests have been reported in more detail in the quarterly complaints reports to the Board. In all 5 cases the Ombudsman decided not to investigate the complaints.

8 RESPONSE TIMES 8.1 The guidance on response times at the Local Resolution stage allows three

working days to acknowledge complaints. Letters of acknowledgement were sent to all complainants, 99% of which were within 3 days, which is an improvement of 1% over the previous year. The NHS Complaints Procedure no longer stipulates a time-scale within which the organisation must provide a substantive response. However, the Trust continues to aim for 85% responses within 25 days. For this financial year, 86% of all complaints received were replied to within that time-scale.

9 OUTCOMES 9.1 In terms of outcome, the vast majority of complainants want an acknowledgement of their concerns, to know why it happened, to receive a meaningful apology where shortcomings are identified, to be made aware of changes in practice arising from the investigation and for someone to be held accountable for what went wrong. Very few complainants start out wanting financial recompense. The Trust follows a policy of “Being Open” and


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7 apologises in those instances where complaints are upheld or partially upheld. 9.2 The table below illustrates the outcome of investigations:

Outcome Total

Complaint not upheld 169

Complaint upheld partially 146

Complaint upheld 114

Ex-gratia/reimbursement payments made 28

Complaint withdrawn 12

Referral to disciplinary procedure 3

Totals: 472

9.3 28 patients were offered reimbursement for loss of or damage to property or

out of pocket expenses. To date, 22 patients have received payments, totalling £4,378.

9.4 14 patients who sought explanations regarding the outcome of treatment

subsequently instructed solicitors to investigate the potential for a successful claim.

9.5 Since the second quarter of 2011/2012, the Legal Services Manager has also reported to the Board of Directors and the Patient Safety and Quality Committee the number of complainants who have contacted the Trust after the Local Resolution letter has been sent. The following table illustrates the nature of the contact made:

Nature of response Total

Seeking legal advice 3

Further questions 8

Clarification 2

Disputes investigation findings 8

Thank you to Legal Services Manager 21

The BOARD is asked to APPROVE this report. Carrie Stone Robert Talbot Legal Services Manager Medical Director May 2013


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BOARD OF DIRECTORS-PART 2



Title:

Francis Report-Update

Purpose:

For Information

Summary:

The Board considered the response to the Francis Report at its May meeting. A verbal update will be given to the Board at this July meeting and there will be a review of the progress across the Trust at the August Board seminar. The meeting update will cover:-

1) Handling the gap analysis against the recommendations of the Francis report.

2) A new approach to patient questionnaires. 3) Trust action plan. 4) National developments.

Board members will be sent separately relevant documents.

Recommendation:

The Board is asked to receive this update

Prepared by:


Presented by:












BOD�Jul�13�8�cover�sheet�Franc

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BOARD OF DIRECTORS-PART 2



Title:

Position Report on Clostridium Difficile

Purpose:

For Information

Summary:

This report highlights the performance against the Clostridium Difficile targets for 2012-2013 and actions being taken to achieve the challenging target for 2013-2014.

Recommendation:

The Board is asked to note this report.

Prepared by:


Presented by:












BOD�Jul�13�9a�cover�sheet�C�Di

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9

Clostridium difficile infection (CDI)

- The target for hospital attributable Clostridium difficile was reduced to

25 for 2012/13 (2011/12 target was 35 with a final total of 24 reported).

- The final number reported for 2012/13 was 27, exceeding the target by

2. This number did include patients who did not respond to first line

treatment or were relapses of the infection and therefore were tested

again – such cases are discussed with the Clinical Commissioning

Groups (previously with the PCT) with a view to counting them as non-

trajectory cases. For 2013/14 this will continue with cases discussed

at the monthly RCA meeting held with the CCG along with other Trusts

in Dorset.

- Acute Trust apportioned CDI 2013

- Quarter 1 6

- Quarter 2 7

- Quarter 3 6

- Quarter 4 8

- Total 27

- The CDI objective for acute Trust apportioned cases for 2013/14 has

been further reduced by 30.0% on the baseline.

- The average number of cases per 100,000 bed days by quarters for

2012/13 for acute Trusts in England was 17.25, 16.32, 17.37, 17.01.

- The baseline figure for Poole Hospital is 16.1 per 100,000 bed days

with a final objective number of 19 cases. (27% decrease on base

line).

- The provisional numbers of trust-apportioned cases for April-Jun was

around 15.0, Jul-Sept 18.0 and Oct-Dec 15.0 per 100,000 bed days.

- There were no outbreaks of CDI in the Trust for 2012/13 with the

majority of cases being single cases on individual wards.

- There were periods of increased incidence (PII) noted during 2012/13

each on different wards. A PII is defined as 2 or more cases on a ward

within a 28 day period.

- These PIIs were:

1. May 2012 - 2 cases – the C. difficile strains were typed and

found to be different and therefore cross infection excluded.

2. Nov 2012 – 2 cases – strains found to be different types and

therefore not cross infection.

3. Jan 2013 – 3 cases found to be type 014. Cross infection is

possible but this is also one of the commonest types found.

- The response to a PII is enhanced audit of compliance with cleaning

standards, hand hygiene, audits of antibiotic use and staff awareness.

2013/14 target:

- Recognising the target of 19 will be a challenge to meet, the CDI

control strategy has been reviewed and formalised with a number of

new measures taken.

BoD�Jul�13�9b�Clostridium�diff

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9

- Weekly ward round of all patients in the Trust with a CDI by a

microbiologist and ICN with a specific form stuck into the patients

notes documenting current clinical stage of the infection and

recommendations. This is in addition to the daily ICN visit to ensure

fluid balance charts are completed appropriately and patient is being

isolated correctly.

- Ensuring C. difficile tests are carried out as soon as possible in the

day so a consultant microbiologist can be informed of the result and

immediately assess the patient and advise treatment if necessary.

- Weekly antibiotic ward rounds on a rolling basis by a consultant

microbiologist and antibiotic pharmacist, but concentrating on wards

with high antibiotic use: results to be discussed at the monthly

Infection Control Group meetings.

- More formal recording of compliance/non-compliance audits with the

antibiotic policy carried out by the Microbiology FY2 SHO daily on

Ansty and the RACE unit.

- Issue of laminated credit-card size alert cards to patients with CDI to

show to GPs and on future admissions to alert clinicians about

patients who will be more vulnerable to infection if prescribed

antibiotics.

- This data should assist in reassuring the Clinical Commissioning

Group that appropriate controls are in place in the Trust to prevent

CDI.

- Note about laboratory testing:

Dept. of Health guidelines state a screening test should be used to

detect possible C. difficile infection such as GDH detection, and then

any positives confirmed with a toxin test. Only toxin positive cases are

reported under the mandatory scheme as infections.

The laboratory at Poole, in common with many other hospitals, use an

additional test (PCR detection of the toxin gene) if the screening test is

positive but the toxin test is negative. We believe genuine cases may

be missed otherwise and we advise such PCR positive cases are

treated

BoD�Jul�13�9b�Clostridium�diff

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1

INTEGRATED PERFORMANCE REPORT – COVER SHEET Meeting Date: 28th November 2012


Title: Integrated Performance Report

Purpose:

To report on performance against key indicators for the Trust in June 2013.

Summary:

Financial Performance

The Trust has achieved a surplus of £76k in June bringing the cumulative surplus for the 3

months to £155k compared to plan of £61k. The forecast for the year to March 2014

remains in line with the planned surplus of £0.2m.

The Financial Risk Rating (‘FRR’) has fallen to 2 as a result of the liquidity rating falling to 1

and because of the deficits forecast for 2014/15 and 2015/16.

The new, draft ‘Continuity of Service Rating’ remains at 4, providing a far better

assessment of the Trust’s real liquidity position

Clinical Performance & Quality The Monitor A&E metric (95% within 4 hours) was achieved in June (97.14%), and Quarter

one (95.38%).

There was one further C-Diff case identified in June, the year to date total of three is

currently within the planned level for the year of 19.

The MRSA year to date total for 2013-14 is zero.

All the monitor cancer standards, were achieved in May, the most recent period available.

RTT standards for admitted and non-admitted clock stops were met for June at aggregate

and Unify specialty level.

The 48 hour operating target (95%) was achieved in June for both general trauma patients

and all fractured Neck of Femur (NoF) targets. The PCT 36 hour NoF target was also

achieved in June.

There were no Endoscopy patients waiting in excess of the six week diagnostic target at

the end of June.

Stroke performance was achieved in June. The monthly delayed discharges snapshot for June was 3.23%. There were no Mixed Sex Accommodation (MSA) breaches in June.

Recommendation:

For discussion and noting.

BoD�Jul�13�10�INTEGRATED�PERFO

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2

Prepared by:

PAUL TURNER Director of Finance / KATE THOMAS Performance Manager /SOPHIE JORDAN Operations & Performance Manager

Presented by:

PAUL TURNER Director of Finance MARY SHERRY Chief Operation Officer MARTIN SMITS Director of Nursing SARAH-JANE TAYLOR HR Director


Assurance Framework

Risk Register I/D No.


Financial implications YES

Monitor compliance

Human Resources implications YES

Internal monitoring

Legal implications NO


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3

Year End

Target /

LimitMar-12 Mar-13 Apr-13 May-13 Jun-13

YTD/

current

Actual

YTD

Target /

LimitForecast

Jan-00

PATIENT EXPERIENCE

meeting the C-Diff objective (ytd) 19 24 27 2 2 3 ↑ 3 19 1.0

meeting the MRSA objective (ytd) =<1 1 4 0 0 0 ↑ 0 =<1 1.0

MSA occurances 0 0 1 0 0 0 ↔ 0 0

MSA patients 0 0 5 0 0 0 ↔ 0 1

VTE (target 90% to Mar 2013, 95% from Apr 1203) 95% 93.00% 94.10% 95.40% 95.50% ↑ 95.40% 95%

CLINICAL QUALITY

Dr Foster Mortality relative risk rating (3 month rolling) 100% 78.0 101.0 96.2 ↑ 96.2 100%

All deaths - actual as % of expected (Dr Foster) 100% 88.8% 98.9% 93.8% ↑ 93.8% 100%

HSMR deaths - actual as % of expected (Dr Foster) 100% 94.3% 97.4% 93.2% ↑ 93.2% 100%

Number of SUIs reported within appropriate timeframe all 1 1 1 3 3 ↔ 3 all

Number of Serious Untoward Incidents (SUIs) 0 1 1 1 3 3 ↔ 3 0

ACCESS AND TARGETS

Referral to waiting time (weeks) for admitted (95th centile) 23.0 21.3 17.1 17.7 17.0 17.1 ↓ 17.1 -

Referral to waiting time (weeks) for non-admitted (95th centile) 18.3 17.0 16.7 15.3 15.1 15.0 ↑ 15.0 -

Referral to treatment (18 weeks) for admitted 90% 92.5% 98.0% 96.8% 97.9% 97.7% ↓ 97.7% 90% 1.0

Referral to treatment (18 weeks) for non-admitted 95% 96.6% 97.2% 97.3% 98.4% 98.2% ↓ 98.2% 95% 1.0

Referral to waiting time (18 weeks) for incomplete pathways 92% 93.5% 97.5% 98.4% 98.7% 98.2% ↓ 98.2% 92% 1.0

Maximum 62 day wait from referral to treatment for all cancers 85%

90.1%

qtr 92.2%

87.4%

qtr 89.3%92.1% 85.7% ↓

85.7% 85%

62 day wait for 1st treatment - consultant screening service 90%

100%

qtr 98.2%

100%

qtr 100%94.4% 95.7% ↑ 95.7% 90%

31 day wait for 2nd or sub treatment : Anti cancer drug treat 98%

100%

qtr 100%

100%

qtr 100%100.0% 100.0% ↔

100.0% 98%

31 day wait for 2nd or sub treatment : Surgery 94%

97.9%

qtr 98.8%

100.0%

qtr 98.9%96.8% 96.0% ↓

96.0% 94%

31 day wait for 2nd or sub treatment : Radiotherapy 94%

99.3%

qtr 99.6%

100.0%

qtr 98.2%99.2% 97.2% ↓ 97.2% 94%

31 days wait diagnosis to start of 1st treatment: All cancers 96%

100%

qtr 98.8%

99.2%

qtr 99.3%100.0% 100.0% ↔ 100.0% 96% 0.5

2 week wait from urgent GP referral to 1st appt (susp cancer) 93%

95.8%

qtr 96.3%

97.3%

qtr 99.3%94.8% 97.4% ↑

97.4% 93%

2 week wait for Symptomatic Breast Patients 93%

100%

qtr 96.1%

88.7%

qtr 93.5%91.9% 98.0% ↑ 98.0% 93%

percentage of patients within the 4 hour target 95% 96.11%

93.28%

qtr 94.85% 92.51% 96.40%

97.14%

qtr 95.38%↑ 97.14%

qtr 95.38% 95%1.0

Total time in A+E (95th centile) =< 4 hours 3hrs 59 4hrs 29 5hrs 07 3hrs 59 3hrs 58 ↑ 3hrs 58 =< 4 hours

Time to initial asessement (95th centile) =< 15 mins 12 21 22 19 17 ↓ 17 =< 15 mins

Time to treatment decision (median) =< 60 mins 67 62 61 55 68 ↓ 68 =< 60 mins

Unplanned reattendance rate =< 5% 2.83% 2.50% 2.90% 2.62% 2.20% ↑ 2.20% =< 5%

Left without being seen =< 5% 3.35% 3.10% 3.30% 3.00% 3.40% ↓ 3.40% =< 5%

TRUST PERFORMANCE SUMMARY

Year To Date

June 2013

Dire

ctio

n #

Monitor

targets &

weightings

0.5

A&

E

2011-12

RT

T

2012-13 2013-14

1.0

cancer

1.0


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4

Year End

Target /

Limit

Mar-12 Mar-13 Apr-13 May-13 Jun-13

YTD/

current

Actual

YTD

Target /

Limit

Forecast

No waits more than 6 weeks for diagnostic investigations 0 27 0 0 0 0 ↔ 0 0

Elective Access - rebooking 0 1 1 5 0 0 ↔ 0 0

Patients who spend at least 90% of their time on a stroke unit 80% 68% 82% 81% 81% 81% ↔ 81% 80%

Higher risk TIA cases who are treated within 24 hours 60% 70.6% 43% 49% 60% 46% ↓ 46% 60%

Outpatient Access : ASIs at =< 4% 4% 8% 27% 16% 12% 22% ↓ 22% 4%

Screening to normal results within 14 days 90% 96.8% 90.0% 89.0% 97.0% 93.0% ↓ 93.0% 90%

Screening to assessment in 21 days - screening to 1st appt offer 90% 94.8% 97.0% 84.0% 94.0% 92.0% ↓ 92.0% 90%

Screening to assessment in 21 days - screening to attended appt 90% 92.2% 92.0% 78.0% 82.0% 87.0% ↑ 87.0% 90%

90% of eligible woman screened within 36 months 90% 99.2% 99.0% 99.2% 98.6% 98.6% ↔ 98.6% 90%

Delayed transfers of care to be maintained at a minimal level 3.5% 6.18% 2.44% 1.10% 3.24% 3.23% ↑ 3.23% 3.5%

Trauma inpatients (fit for surgery) receive treatment within 48 hrs 95% 96% 98% 97% 95% 96% ↑ 96% 95%

Hip fractures (fit for surgery) receive treatment within 48 hrs 95% 96% 99% 99% 100% 99% ↓ 99% 95%

OPERATIONAL EFFICIENCY

Theatre Utilisation - Main 85% 87.0% 87.0% 87.0% 85.0% 88.0% ↑ 88.0% 85%

Theatre Utilisation - Day (target 85% to Mar 2013, 80% from Apr 2013) 80% 74.0% 74.0% 77.0% 78.0% 76.0% ↓ 76.0% 80%

Day Case Rates (basket of 25) 75% 83.5% 78.7% 79.0% ↑ 79.0% 75%

Bed Occupancy 95% 96% 98% 98% 96% 95% ↑ 95% 95%

WORKFORCE INDICATORS

Staff Turnover (Overall) <=11% 0.92% 1.05% 0.64% 1.00% 0.41% ↑ 2.05% <=11%

Staff Turnover (Auxiliaries and HCAs) <= 13.5% 1.54% 0.62% 1.24% 1.86% 0.40% ↑ 3.50% <= 13.5%

Absence <=3.5% 3.85% 3.57% 3.80% 3.42% 3.33% ↑ 3.45% <=3.5%

FINANCE & ACTIVITY

Cash balance 15.4 15.0 19.8 13.7 13.3 ↔ 13.3 13.3 11.3

Income 195.10 19.00 16.90 17.00 17.30 ↔ 51.28 51.06 203.40

Operating Expenditure -182.20 -18.00 -16.00 -16.10 -16.17 ↔ -48.18 -47.99 -191.20

EBITDA 12.30 0.80 0.80 0.80 0.95 ↑ 2.57 2.55 10.10

EBITDA % 6.3% 4.4% 4.3% 4.8% 5.5% ↑ 5.1% 5.0% 5.0%

Surplus/Deficit 1.00 -0.10 0.00 0.03 0.08 ↑ 0.15 0.06 0.20

SLA over / (under) performance 0.8 0.3 0.28 0.28 -4.70 ↑ 0.09 0.00 0.0

CIP 0.20 0.30 0.3 ↔ 1.00 0.88 3.90

Financial Risk rating - current 3 3 3 2 2 ↔ 2 2 2

Financial Risk rating - revised 3 4 4 4 4 ↔ 4 4 3

2013-14

# : Arrow direction indicates improvement ↑, deterioration ↓, or no change ↔ in performance since the previous month

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INTEGRATED FINANCE AND PERFORMANCE REPORT

Month Three - June 2013

Key Issue

Executive Summary RAG Sch

Monitor Targets

Monitor standards were met in Month 2 and 3.

RTT

The Trust achieved the targets for admitted clock stops (97.7% against

90% target) and non-admitted (98.2% against 95% target) clock stops, at

aggregate level in June. The incomplete pathways target was achieved,

(98.2% against 92% target).

Cancer

All the cancer standards, were achieved in May, the most recent period

available,

ED

The Monitor A&E metric (95% within 4 hours) was achieved in June

(97.14%), and Quarter one (95.38%). There has been a trend of

improvement during the quarter, and work is on-going to achieve July and

quarter 2.

MRSA

The MRSA year to date total for 2013-14 is zero. The 2013/14 target is zero, and the Monitor de minimis limit is 6 cases.

CDiff

There was one further C-Diff case identified in June, the year to date total

of three is currently within the planned level for the year of 19.

Mo

nito

r sco

rec

ard

Clinical Quality

The Clinical Quality scorecard is comprised of five key indicators, none of which are part of the Monitor scorecard. For the most recent year to date position (April/ June 2013) there are red rated indicators relating to SUIs only.

Mortality

During the three month period ended April 2013, (the latest information available from the Dr Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 96.2, now within the target of 100.

Mortality performance for April 2013 has been green rated as the overall number of deaths was less than the expected level calculated by Dr Foster.

The HSMR subset for April 2013 has been green rated as the overall number of deaths was less than the expected level calculated by Dr Foster.

An audit has now been undertaken the Mortality group will continue to ensure

o cases with a zero or very low co-morbidity rating are reviewed ;

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o deaths are reviewed by clinicians; o Pneumonia remains under scrutiny.

Serious Untoward Incidents

o There were 2 SUI identified in June, all of which were reported within the prescribed timescale.

Key Issue

Executive Summary RAG Sch

Patient Experience

The Patient Experience scorecard is comprised of six key indicators; three of these are part of the Monitor scorecard. For the most recent year to date position (June 2013) C-diff has been red rated:

C-Diff

There was one C-Diff case identified in June, the year to date total of

three is currently within the planned level for the year of 19. Action: DoN

to review

MRSA

The MRSA year to date total for 2013-14 is zero. The 2013/14 target is zero, and the Monitor de minimis limit is 6 cases.

Action: Infection Control issues remain under continued scrutiny DoN/Infection Control.

Mixed Sex Accommodation (MSA)

There have been no occurrences of mixed sex accommodation (MSA) breaches in June. Venous Thromboembolism (VTE)

VTE performance for June was 95.5%, continuing to achieve the increased target of 95% for 2013/14.

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Key Issue Executive Summary RAG Sch

Access and Targets

The Access and Targets scorecard is comprised of 22 key indicators, of which, five areas are red rated.

RTT (Performance Report appended)

The Trust achieved the targets for admitted clock stops (97.7% against

90% target) and non-admitted (98.2% against 95% target) clock stops, at

aggregate level in June. The incomplete pathways target was achieved,

(98.2% against 92% target).

At Unify specialty level, all specialities achieved the admitted and the non-

admitted targets for June.

Operationally the Trust continues to pursue the achievement of RTT

targets at specialty level for each and every specialty.

Cancer

All the Monitor cancer standards were achieved in May, the most recent

period available.

Emergency Department: 4 hour target (Performance Report appended)

The Monitor A&E metric (95% within 4 hours) was achieved in June

(97.14%), and Quarter one (95.38%). There has been a trend of

improvement during the quarter, and work is on-going to achieve July and

quarter 2.

Diagnostic Access

There were no Endoscopy patients waiting in excess of the six week

diagnostic target at the end of June.

The percentage of all 15 key diagnostic tests waiting 6+ weeks is within

the 1% PCT contract target, although numbers are still to be finalised due

to the implementation of a new system.

The department has been running additional lists in order to keep pace

with demand.

Breast Screening (Performance Report appended)

Three of the four reported breast screening targets were achieved in June.

Screening to assessment within 21 days was not achieved despite 92% of

women being offered an assessment appointment within that period. This

was due to both patient choice and issues with PACs downtime.

Delayed Transfers of Care (Operations Summary appended)

The percentage of patients formally delayed on the last Thursday of June

(DH reporting methodology) was 3.23 %.

An increased focus is now being put on the reduction of informal delays

and all other internal delays in order to further improvements in patient

pathways.

48 hours standard for #NoF and Trauma (Performance Report appended)

The 48 hour operating target (95%) was achieved in June for general trauma patients (97%) and for fractured NoF patients (99%). The 36 hours local target was also achieved.

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Stroke (Performance Report Appended)

Stroke performance was achieved in June, with 81% of patients spending

90% of their stay on a stroke ward, against a target of 80%.

ASI (Appointment Slot Issues)

ASIs continued to exceed the 10% local target during June (22%), the deterioration in performance has been due to both demand and capacity, exacerbated by technical issues.

Actions continue to reduce the level of ASI, targeted at specialty level in the coming months.

Efficiency The Efficiency scorecard is comprised of four key indicators; none of these are part of the Monitor scorecard. For the most recent year to date position (April/ June 2013) there is one red rated indicator:

Theatre Utilisation (Performance Report Appended)

Main theatre utilisation (88%) attained the 85% target in June.

Day theatre utilisation did not achieve 80% target (79%).

Both metrics have improved since last month. Bed Occupancy

Average bed occupancy in June was 95%, against the internal target of 95%, an improvement on previous months. Daycase Rate

The day case rate for April was 79%, (the most recent period available from Dr Foster), achieving the 75% target.

Effic

ien

cy S

co

reca

rd

Workforce Indicators

The Workforce Indicator Scorecard (Appended) comprises of eight key measures of HR performance, three of which are RAG rated.

Staff Turnover (overall) at 0.5%, rated green

Staff Turnover (Auxillaries and HCA) at 1.86%, amber rated

Staff sickness at 3.33%, the lowest recorded for May since 2007

Finance & Activity

The Trust has achieved a surplus of £76k in June bringing the cumulative surplus for the 3 months to £155k compared to plan of £61k. The forecast for the year to March 2014 remains in line with the planned surplus of £0.2m. The financial performance in Q1 represents a realistic ‘normalised’ position as the non-recurring costs and benefits included are largely off-setting:

£0.5m charitable income compared to sustainable level of 0.25m

£0.3m merger costs However contract income in 2013/14 does include £3.3m ‘transitional’ funding

which, although recurring, isn’t at present supported by activity / services.

The Financial Risk Rating (‘FRR’) has fallen to 2 as a result of the liquidity

rating falling to 1 following the non-renewal of the Barclays Working Capital

Facility. Even if the facility has been renewed, the FRR would have reduced

to 2 because of the deficits forecast for 2014/15 and 2015/16.

The new draft ‘Continuity of Service Rating’ remains at 4, providing a far

better assessment of the Trust’s real liquidity position.

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The Trust has delivered savings of £1m in Q1, slightly ahead of plan and expects to achieve approximately 90% the annual CIP target of £4.3m. However it is likely that around 20% of the CIP target will be delivered non-recurrently.

The Trust has spent £1.3m (10%) of its annual capital expenditure and committed a further £2.1m bringing the total to £3.3m, 27% of the total programme. It is likely that The Trust will need to commit additional capital funds in year to address key priorities. Recommendations will be made via the Finance and Investment Committee in September

The Trust’s cash balance remains broadly in line with plan: £13.3m against

plan of £13.1m.

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Operations Summary June 2013

(For the period of 1st to 30th June 2013)

Note: This report summarises various operational aspects year to date. The performance

information relates to actual activity rather than a comparison against contract.

SUMMARY

1 ACTIVITY 1.1 There is no significant in month variance to the non-elective admissions year to date.

1.2 Attendances at the Emergency Department have marginally increased by 0.7% in June

2013 compared to the same period last year, this is a reduction on the previous month.

1.3 Elective activity have steadily increased year to date, with 9.3% more elective admissions

and the day case rate increasing by 2.1%.

1.4 The number of Maternity Ante Natal Day Assessment (ANDA) admissions year to date has

decreased by 3.9% compared to the same period last year. This is an improvement on last

month. Community ANDA activity has now been fully repatriated back to PHFT. The

overall maternity activity has reduced and is continually being monitored by the Division.

The new maternity tariff has been introduced for 13/14. It is believed that local trusts have

reduced the number of ANDA referrals by diverting activity to community midwives. This

inter trust activity is being captured and reviewed monthly due to the nature of the national

service change. The impact will not be fully understood until Quarter 2.

1.5 Paediatric non-elective admissions have decreased by 3.9% YTD.

1.6 The variance in Trust activity (YTD) is summarised below

Activity Year to Date

Year to

date

13/14

Previous year to

date 12/13

Variance

Adult Non Elective Admissions (Spells)

(Inc emergency & transfers excl maternity)

5,899 5,941 -0.7%

Child Non Elective Admissions (Spells)

(Excl maternity and Incl. children under 16)

1,841 1,912 -3.9%

Maternity Admissions (Spells) 2,799 2,895 -3.4%

Emergency Dept Attendances 15,167 15,064 +0.7%

Elective Inpatient Spells (all ages) 1,033 948 + 9.3%

Day Cases (all ages), including regular day attenders 7,115 6,969 +2.1%


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11

1.7 The table below shows a comparison of non-elective admission figures by specialty from

April 2012 to date.

Data Source: Kate Thomas

1.8 The graph below shows an increase in new outpatient activity in June by 5.1% compared to

the previous year, this also corresponds with an overall increase in outpatient activity by

6.1% YTD compared to 12/13

Data source: Operations Monthly Report

Specialty

Apr 2012

to June

2012

Apr 2013

to June

2013

%

variance

100 General Surgery 690 636 -7.8%

110 Trauma & Orthopaedics 865 824 -4.7%

120 ENT 207 207 0.0%

140 Oral Surgery 11 4 -63.6%

144 Maxillo-Facial Surgery 76 65 -14.5%

180 Accident & Emergency 207 152 -26.6%

190 Pain 0 0 -

300 General Medicine 1,028 1,040 1.2%

301 Gastroenterology 0 0 -

303 Clinical Haematology 59 63 6.8%

307 Diabetic Medicine 0 2 -

314 Rehabilitation 3 5 66.7%

315 Palliative Medicine 36 42 16.7%

320 Cardiology 38 27 -28.9%

326 Acute Medicine 937 994 6.1%

330 Dermatology 2 1 -50.0%

370 Medical Oncology 49 117 138.8%

400 Neurology 7 3 -57.1%

410 Rheumatology 1 3 200.0%

420 Paediatrics 15 12 -20.0%

430 Elderly 1,274 1,295 1.6%

502 Gynaecology 289 240 -17.0%

800 Clinical Oncology 143 135 -5.6%

GRAND TOTAL 5,937 5,867 -1.2%

4000

4500

5000

5500

6000

6500

7000

7500

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

New Outpatient Attendances

New Outpatient Attend13/14




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2 LENGTH OF STAY

2.1 Adult Non Elective average Length of Stay (LOS) for June 2013 was 5.3 days. This is a

reduction on the previous month of 0.5 days.

2.2 The graph below shows the average adult non elective LOS from April 11 to date


2.3 The table below shows LoS by Directorate from January 2012 to date. The majority of

areas have seen a reduction in LoS, however there are still a number of outlying services.

(The Medical and Elderly medicine statistics include assessment unit activity).

Data Source: Information Team – C Stewart

5.00

6.00

7.00


Non-Elective: Adult

Non-Elective - Adult13/14



2012 2013

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Grand

Total

ACCIDENT AND EMERGENCY 0.6 1.2 1.0 1.2 0.9 0.6 0.7 1.2 0.7 0.8 1.0 0.6 0.8 0.7 1.0 0.5 0.7 1.4 0.6

ACUTE INTERNAL MEDICINE 0.8 1.1 1.0 1.3 0.7 0.9 1.0 1.1 1.0 1.1 0.9 1.0 0.8 0.8 1.0 0.8 0.8 0.8 0.9

CARDIOLOGY 5.1 6.5 5.3 4.7 4.1 4.2 4.1 3.6 7.8 5.9 5.8 3.5 3.6 5.3 3.9 5.5 3.8 5.7 4.8

CLINICAL ONCOLOGY 4.3 3.6 4.4 4.9 5.5 4.4 5.2 5.1 3.7 3.9 3.9 5.1 5.1 4.1 5.0 4.6 3.3 3.6 4.6

DERMATOLOGY 2.8 4.0 11.0 10.4 15.5 13.0 12.0 23.3 14.5 1.0 13.8 6.7 8.4 11.0 5.0 5.5 6.0

EAR, NOSE AND THROAT 1.9 1.8 1.7 2.1 2.4 2.2 1.8 2.6 2.2 2.4 1.9 2.5 2.3 1.8 1.7 2.2 2.4 1.8 2.1

GASTROENTEROLOGY 1.8 30.5 18.5 2.0 1.5 6.5 3.5 4.0 10.5 10.3 2.5 4.8 4.3 16.5 4.3 5.5

GENERAL MEDICINE 4.7 4.5 4.4 4.6 4.3 4.5 4.8 4.6 4.4 4.8 4.9 4.4 5.6 4.8 4.0 5.0 4.9 4.8 4.3

GENERAL SURGERY 2.7 2.9 2.7 2.9 3.0 2.9 2.5 2.8 2.7 2.8 3.6 3.1 2.8 3.1 3.3 2.9 2.8 2.8 2.9

GERIATRIC MEDICINE 7.2 7.6 7.8 7.0 7.0 7.3 7.6 7.4 7.5 7.3 7.7 7.1 8.0 7.8 7.3 7.3 8.0 7.4 7.8

GYNAECOLOGY 1.6 1.9 1.9 1.6 1.9 1.9 1.8 1.7 1.6 1.9 1.7 2.2 2.1 1.4 1.5 1.4 1.7 2.1 1.8

HAEMATOLOGY (CLINICAL) 5.1 8.8 6.5 8.8 12.4 8.9 10.6 10.9 5.6 6.5 6.8 7.7 7.1 8.3 8.5 6.8 7.2 7.5 8.0

MAXILLO-FACIAL SURGERY 1.0 1.2 1.2 2.0 1.4 1.9 2.2 1.9 1.1 1.2 1.8 2.5 1.6 2.2 2.0 1.9 1.3 1.9 1.6

MEDICAL ONCOLOGY 4.7 3.6 3.5 5.5 3.3 2.8 5.2 3.5 1.9 3.0 4.9 3.3 3.6 5.7 3.8 3.1 4.2 5.2 4.0

NEONATOLOGY 11.4 17.4 19.8 24.4 16.0 17.7 15.5 15.9 19.1 17.7 9.7 10.1 14.1 16.8 11.4 8.2 12.2 15.0 15.9

NEUROLOGY 19.0 11.9 18.9 11.9 18.0 3.4 15.1 6.8 8.3 6.7 11.0 14.0 14.2 14.2 4.8 23.5 30.9 4.6 12.7

OBSTETRICS 1.0 1.2 1.1 1.0 1.1 1.1 1.1 1.2 1.3 1.2 1.1 1.2 1.2 1.3 1.1 1.1 1.1 1.3 1.1

ORAL SURGERY 2.5 2.1 2.2 2.5 1.9 2.4 1.9 1.9 2.5 2.1 1.5 2.9 2.0 2.8 2.6 2.6 2.8 2.3 2.4

PAEDIATRICS 1.4 1.2 1.1 1.2 1.1 1.0 1.2 1.2 1.0 1.1 1.1 0.9 1.1 0.9 1.1 0.9 0.9 1.0 1.1

PALLIATIVE MEDICINE 12.4 10.5 10.3 12.4 10.0 12.0 8.2 16.1 10.3 8.5 9.2 12.3 12.0 10.3 8.2 7.5 9.8 8.0 10.9

REHABILITATION 39.5 25.0 16.0 58.8 30.0 31.0 24.0 25.3 45.7 75.0 52.7 81.3 29.5 16.0 81.0 8.0 50.3 27.0 35.0

RHEUMATOLOGY 6.0 6.0 8.5 1.0 2.5 4.0 3.8 2.3 1.2 9.0 5.0 0.0 4.5 1.0 6.0 13.0 6.7

TRAUMA AND ORTHOPAEDICS 7.0 6.1 6.3 6.6 5.5 5.9 6.1 6.1 6.2 7.2 7.0 7.0 8.0 7.9 7.3 7.3 6.5 6.2 6.5

WELL BABIES 1.3 1.3 1.4 1.3 1.6 1.6 1.4 1.8 1.5 1.5 1.4 1.8 1.5 1.6 1.5 1.6 1.7 1.7 1.5

Grand Total 3.1 3.1 3.0 3.2 3.0 3.0 3.0 3.3 3.0 3.2 3.2 3.1 3.4 3.2 3.1 3.2 3.3 3.1 3.1


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13

2.4 The percentage of time the Trust is in a red bed state is a clear indication of how

pressurised the whole system is. The Hospital was in a red bed state for 50% of the time

during June 2013.

3 DELAYED TRANSFERS OF CARE

3.1 The percentage of patients formally delayed on the last Thursday of June 2013 (DH

reporting methodology) was 3.25% reporting 0.25% under Trust target. There is no

movement from the recorded May performance. The total number of bed days lost in month (453) a decrease on last month, April (342) and May (569).

3.2 Delays during May were due to: Angiography/Angioplasty at RBCHFT (44%), Community

Hospitals (25%), Social Services (8%), Intermediate Care (8%), Self-Funding patients (7%),

and the CHC assessment process (8%). Actions continue to be progressed on a

continuous basis to improve delays overall and tackle the main causes of delays

3.3 The total number of bed days lost during June (493) showed an improvement in delays performance from partner agencies compared to May (569).


0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%


% Delayed Transfers of Care From Acute Beds including Paediatrics

Yr13/14

Yr12/13

Yr11/12

0

250

500

750

1000

1250

1500


Total Bed Days Lost

TOTAL Delays13/14

TOTAL Delays12/13

TOTAL Delays11/12


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3.4 The number of bed days lost due to self-funding patients in June was 30 bed days

compared to 28 in April and 38 May. The number remains low, however the hospital is

experiencing a rise in the number of people delayed on daily basis, is attributed to the loss

of the Help and Care service, who assisted in the early identification of self-funding patient

via an externally funded pilot.


3.5 The number of patients delayed waiting for a community hospital increased in month with

an average of 5 patients per day, compared to 7 recorded in May. The Discharge Team

continue to validate of delays with the Community Hospital Matron weekly and daily

communications with hospital leads to ensure speedier transfer of patients. There have

been significant challenges transferring patients to the community setting due to a lack of

capacity in specific community hospitals over the month.


0

50

100

150

200

250

300

350


Number of Bed Days lost due to awaiting Self-Funding (data started Aug-09)

Self-Funding13/14

Self-Funding12/13

Self-Funding11/12

0

250

500

750

1000

1250


Number of Bed Days lost due to awaiting transfer to Community Hospitals

Community Hospitals13/14




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15

3.6 The number of patients delayed as a result of the Continuing Health Care (CHC)

assessment process has risen with 67 bed days lost in June, however the average number

of delays remains at two per day. The ward teams continue to find the administration

element of CHC process a challenge to manage in a busy ward environment. The data

below also includes the Funding out of Hospital (FoH) statistics.


3.7 Delays for intermediate care were 41 in June, compared to with 43 bed days lost in May.

There are concerns that capacity may be challenging for the Intermediate Care teams in

future months, this is monitored on a daily basis by the Operations Team.


0

50

100

150

200

250


Number of Bed Days lost due to awaiting CHC (data started Aug-09)

CHC: Bed Days 13/14

CHC: Bed Days 12/13

CHC: Bed Days 11/12

0

50

100

150

200

250

300

350


Number of Bed Days lost due to awaiting Intermediate Care (data started Mar-11)

Intermediate Care13/14




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3.8 34 beds days were lost to patients formally delayed due to social services during the

snapshot period in June, which is an improvement from the May performance.


3.9 Delays for patients awaiting transfer for cardiac intervention/imaging (Angio wait) remains

high with Angios attributed to 44% of all delays. Negotiations are in progress to reduce the

5 working day transfer agreement with Royal Bournemouth Hospital, but this remains an

issue due to bed state challenges within the trust.


0

100

200

300

400


Number of Bed Days lost due to awaiting Social Services (Section5)

Social Services 13/14



0

100

200

300


Number of Bed Days lost due to awaiting Angio

Angio Waits: Bed Days13/14




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17

3.10 The table below demonstrates variance in the total number of bed days lost due to formal

delays compared to the same period in the last financial year. There is an obvious

improvement on the position reported in 12/13

Bed Days Lost

Previous YTD 12/13 YTD 13/14 Variance

Overall Bed Days Lost 1947 1364 -30%

Community Hospitals 487 339 -30%

Social Services 217 105 -51%

Continuing Healthcare 332 111 -67%

Housing 45 0 -100%

Self-Funding 352 96 -72%

Intermediate Care 43 110 +56%

Angios 471 603 +28%


3.11 The Discharge Support Team record all patient delays, which includes reimbursable

(Formal) delays and informal where partners may be provided with time to assess a patient

before it becomes a formal issue. The graph below shows that on any given day there are

a large number of patients informally delayed within the Trust who could be supported by

social and health care teams outside of an acute setting, The main focus for the operations

team in 2013/2014 is to work with partner agencies and in house teams to reduce the

number of informal delays, a trust wide project ‘Improving Delays’ has been initiated to

support this work.

0

10

20

30

40

50

60

Formal Delays Informal Delays


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4 CANCELLATIONS

4.1 All waiting list cancellations

4.1.1 The number of Elective admissions cancelled has slightly risen in month but is consistent

with the same period in 2012/13.

4.1.2 The graph below shows the % of elective admissions cancelled as a % of all elective

admissions.

Data source: Operations Report

4.2 Waiting list cancellations within 1 day of the TCI (To Come In) date

4.2.1 Elective admissions cancelled within a day of their TCI date (subset of the total in the

previous paragraph) has decreased in month.

4.2.2 The graph below shows the % of elective admissions cancelled within a day of their TCI

date by the Hospital as a % of all elective admissions. The performance has declined in

June by 1%, however it is in line 12/13 performance.

Data Source: Information Team – Operations Report

0

20

40

60

80

100

120

140

160

180


%

month

Elective Admissions cancelled within 1 day of TCI

Electivecancellations(above) <= 1 day13/14



0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%


%

month

Elective Admissions cancelled within 1 day of TCI as % of all Elective Admissions

% Electivecancellations <= 1 day13/14




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19

4.3 Cancelled operations

4.3.1 The graph below shows the cumulative position for cancelled operations on the day of

admission or operation. The trend is following previous years data.

Data Source: Information Team – K Thomas

4.3.2 The graph below shows monthly numbers of cancelled operations on the day of admission

or operation, split by cause.

Data Source: Information Team – K Thomas

0

50

100

150

200

250

300

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Monthly cumulative position for cancelled operations

cancelled ops 2010/11




0

5

10

15

20

25

30

35

40

Ap

r-1

0M

ay-1

0Ju

n-1

0Ju

l-1

0A

ug-

10

Sep

-10

Oct

-10

No

v-1

0D

ec-

10

Jan

-11

Feb

-11

Mar

-11

Ap

r-1

1M

ay-1

1Ju

n-1

1Ju

l-1

1A

ug-

11

Sep

-11

Oct

-11

No

v-1

1D

ec-

11

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2M

ay-1

2Ju

n-1

2Ju

l-1

2A

ug-

12

Sep

-12

Oct

-12

No

v-1

2D

ec-

12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3M

ay-1

3Ju

n-1

3

Cancelled operations per month split by cause

other

no bed

staff sickness

no theatre time

list cancelled


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20

5 READMISSIONS

5.1 The readmission rate is calculated by dividing the number of discharges that were followed

by an emergency readmission within 30 days by total number of discharges (excluding

deaths).

5.2 The table below shows the readmission rates by specialty from April 2012 to date.

5.3 There are significant readmission rates in May (>10%) within, Acute Internal Medicine

(12%), Geriatric Medicine (14.7%) and Palliative Medicine (14.3%). This is being monitored

closely by the Directorate teams to ensure safe discharging is in place.

Prepared by:

Sophie Jordan

Operations and Performance Manager

July 2013

Discharging specialty of original

admission Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13

ACCIDENT AND EMERGENCY 10.4% 2.6% 5.6% 11.7% 8.3% 6.8% 5.4% 3.3% 5.1% 5.8% 9.7% 8.6% 4.7% 8.6%

ACUTE INTERNAL MEDICINE 13.8% 9.6% 9.1% 8.2% 8.4% 7.1% 11.6% 9.3% 9.5% 8.1% 8.8% 11.2% 10.9% 12.0%

CARDIOLOGY 6.8% 6.1% 7.5% 14.7% 7.7% 13.1% 7.7% 9.5% 4.9% 8.8% 8.0% 6.6% 7.6% 5.4%

CLINICAL ONCOLOGY 0.3% 0.3% 0.0% 1.4% 0.3% 1.5% 0.0% 0.8% 0.8% 0.0% 0.0% 0.6% 1.2% 0.6%

DERMATOLOGY 1.0% 0.6% 0.5% 0.0% 0.9% 0.9% 1.0% 0.0% 0.5% 0.7% 1.2% 0.4% 0.3% 1.5%

EAR, NOSE AND THROAT 4.7% 6.5% 3.0% 3.5% 1.2% 1.8% 3.4% 3.0% 2.1% 6.9% 5.4% 3.3% 2.0% 2.8%

GASTROENTEROLOGY 0.0% 2.1% 1.3% 3.0% 1.5% 2.1% 3.8% 3.5% 0.0% 1.1% 3.6% 4.4% 2.4% 7.1%

GENERAL MEDICINE 8.2% 8.7% 9.9% 9.9% 9.9% 6.7% 7.8% 7.5% 9.8% 10.5% 7.8% 8.8% 6.9% 7.7%

GENERAL SURGERY 7.3% 6.5% 5.1% 7.4% 5.0% 7.3% 5.8% 5.0% 5.5% 4.9% 5.5% 5.3% 4.6% 6.6%

GERIATRIC MEDICINE 14.2% 17.0% 15.5% 14.7% 13.8% 14.4% 13.6% 15.2% 15.5% 15.1% 13.0% 14.5% 15.1% 14.7%

GYNAECOLOGY 5.7% 5.2% 4.3% 9.0% 4.1% 3.3% 5.8% 5.4% 6.4% 3.1% 4.7% 3.9% 6.7% 2.7%

HAEMATOLOGY (CLINICAL) 2.0% 0.0% 0.9% 0.8% 0.5% 1.3% 1.6% 0.8% 1.0% 2.0% 0.8% 1.5% 0.4% 0.7%

Max Fax & Oral Surgery 5.4% 0.6% 0.6% 0.5% 0.6% 3.4% 1.0% 1.6% 2.2% 2.4% 1.9% 1.7% 2.5% 0.5%

MEDICAL ONCOLOGY 0.0% 0.0% 0.5% 0.0% 0.0% 0.0% 0.0% 0.6% 2.7% 0.6% 1.2% 0.5% 1.1% 1.6%

NEUROLOGY 0.0% 3.2% 2.2% 4.0% 0.0% 0.0% 0.0% 5.4% 2.0% 2.3% 3.9% 4.4% 2.2% 0.0%

OBSTETRICS 0.0% 0.1% 0.0% 0.0% 0.0% 0.0% 0.1% 0.0% 0.1% 0.1% 0.1% 0.1% 0.0% 0.4%

PAEDIATRICS 5.2% 5.9% 5.5% 3.2% 3.4% 3.7% 3.6% 3.6% 4.0% 3.5% 3.8% 4.3% 5.5% 6.9%

PALLIATIVE MEDICINE 0.0% 14.3%

RHEUMATOLOGY 0.0% 3.5% 2.0% 0.8% 1.6% 2.3% 2.0% 1.2% 0.7% 1.3% 2.2% 1.8% 2.2% 0.7%

TRAUMA AND ORTHOPAEDICS 6.1% 3.4% 5.9% 5.3% 6.5% 4.1% 6.4% 5.9% 5.8% 5.8% 5.6% 6.0% 6.2% 4.6%

Grand Total 4.8% 4.5% 4.3% 4.6% 4.1% 4.0% 4.2% 4.1% 4.5% 4.3% 4.1% 4.4% 4.3% 4.5%

Month of Discharge of Original Admiss ion


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21

Quality Indicator Dashboard

JUNE 2013

All target/thresholds are marked as a dotted black line.

0

500

1000

1500

2000

2500

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Activity

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Delayed Transfers of Care

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Re-admissions

65%

70%

75%

80%

85%

90%

95%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Stroke

3

3.5

4

4.5

5

5.5

6

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Length of Stay

92%

93%

94%

95%

96%

97%

98%

99%

100%

101%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Bed Occupancy


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22

0%

20%

40%

60%

80%

100%

120%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Mortality

0

10

20

30

40

50

60

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Complaints

0

50

100

150

200

250

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

PALS

0

100

200

300

400

500

600

700

800

900

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

AIRS (Clinical)

0

5

10

15

20

25

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Pressure Ulcers (Acquired Grade II or Above)

0

1

2

3

4

5

6

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

SUI

0

0.5

1

1.5

2

2.5

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

MRSA Bacteraemia


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23

Prepared by:

Sophie Jordan/Matt Braithwaite

Operations and Performance Manager/Information Analyst

July 2013

0

1

2

3

4

5

6

7

8

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

C. Diff

0

20

40

60

80

100

120

140

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Patient Falls

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Staff Sickness

0

2

4

6

8

10

12

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Norovirus

0

5

10

15

20

25

30

35

40

45

Ap

r 1

2

May

12

Jun

12

Jul 1

2

Au

g 1

2

Sep

12

Oct

12

No

v 1

2

De

c 1

2

Jan

13

Feb

13

Mar

13

Ap

r 1

3

May

13

Jun

13

Outliers (Per Day)


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24

Cancer Waiting Times MAY 2013: Poole Hospital NHS Foundation Trust – Summary report

The following convention is used for indicating compliance with the performance standards:

Indicates that the target was not achieved in the month

Data are taken from the Open Exeter national database for Cancer Waiting Times.

14 days: Urgent GP referral to Date First Seen

Measure

Maximum 2 week wait from urgent GP referral for suspected cancer to first hospital assessment by 2000

Everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they

need to be seen urgently and requesting an appointment by 2000

Target 93% or more

Source National Cancer Waiting Times Database (Open Exeter)

Time Period MAY 2013

May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13

Cancer Access urgent referral to 1st OPA - 14 days 96.2 94.1 95.8 95.2 93.3 94.5 95.8 97 97.3 97.2 97.3 94.8 97.4

Symptomatic breast referral to 1st OPA - 14 days 96.4 95.7 97.6 87.1 97.7 98.7 94.2 97.8 97.8 94.4 88.7 91.9 98

Cancer Access first txs - 31 days 99.4 100 100 99.3 98.5 99.3 100 99.3 98.8 100 99.2 100 100

Cancer Access subsequent txs(anti cancer) - 31 days 100 100 100 100 100 100 100 100 100 100 100 100 100

Cancer Access subsequent txs(surgery) - 31 days 100 100 96.6 100 100 100 100 96 96.6 100 100 96.8 96

Cancer Access subsequent txs(radiotherapy) - 31

days 98.8 100 99.3 98.1 97.7 100 86.2 98.5 95.5 100 100 99.2 97.2

Cancer Access urgent referrals - 62 days 86 87.3 89.2 91.5 81.7 86.6 91.2 86.8 90.8 89.6 87.4 92.1 85.7

Cancer Access screening patients - 62 days 93.9 100 100 98.1 94.4 100 100 100 100 100 100 94.4 95.7

Cancer Access consultant upgrade - 62 days 100 100 100 87 100 100 100 100 100 100 100 100 86.7

Tumour Type Total

referrals

seen

during the

period

% meeting

standard

in Poole

Median

wait

National

%

meeting

standard

Suspected brain/central nervous system tumours 4 100 14 97

Suspected breast cancer 123 99.2 5 97.4

Suspected children's cancer 2 100 9 97.8

Suspected gynaecological cancer 55 90.9 8 96.1

Suspected haematological malignancies (excluding acute leukaemia) 3 66.7 8 98

Suspected head & neck cancer 74 100 9 95.8

Suspected lower gastrointestinal cancer 47 97.9 9 95

Suspected lung cancer 22 100 9 97.6

Suspected other cancer 1 100 2 94.8

Suspected sarcoma 3 100 10 94.9

Suspected skin cancer 128 97.7 10 95.4

Suspected upper gastrointestinal cancer 37 94.6 8 93.8

Totals 499 97.4 95.8


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25

Breach reasons

No. of patients Breach reasons

13 Patient cancelled/declined 1st. OPA/investigation within target

14 days: All breast symptom referrals

Measure Maximum 2 week wait from referral of any patient with breast symptoms to first hospital assessment by

DECEMBER 2010

Target 93% or more



Breach reasons

No. of patients Breach reasons

1 Patient cancelled/declined 1st. OPA/investigation within target

31 days: Decision to Treat to First Treatment

Measure Maximum 31 day wait from decision to treat to first treatment for all cancers by 2005

Target 96% or more



a) By tumour site

Total referrals

seen during the

period

% meeting

standard at

Poole

Median

wait

National

% meeting

standard

Totals 51 98 7 95.8

Tumour Type Patients

treated

following an

urgent

referral for

suspected

cancer

Total

treated

Treated on

or within

31 days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Brain/Central Nervous System 0 1 1 0 100 1 98.4

Breast 7 17 17 0 100 19 99.5

Gynaecological 7 12 12 0 100 9 98.2

Haematological 1 8 8 0 100 3 99.8

Head & Neck 4 6 6 0 100 23 96.2

Lower Gastrointestinal 6 17 17 0 100 8 98.8

Lung 3 15 15 0 100 0 98.9

Other 1 1 1 0 100 1 99.7

Sarcoma 1 2 2 0 100 3 97.3

Skin 22 38 38 0 100 7 98.7

Upper Gastrointestinal 2 7 7 0 100 5 99.3

Urological 2 7 7 0 100 0 96.8

All Cancers 56 131 131 0 100 98.5


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26

b) By treatment type

No breaches

31 days: Second and Subsequent Treatments

Measure Maximum 1 month wait from ready to treat to treatment for all second and subsequent treatments

(chemotherapy and surgery by December 2008, all other treatments DECEMBER 2010)

Target 98% - Anti Cancer drug treatments ; 94% - Surgery treatments ; 94% - Radiotherapy treatments



a) By tumour site

Treatment Group Patients

treated

following an

urgent

referral for

suspected

cancer

Patients

treated

following

an urgent

referral for

breast

symptoms

Patients

treated

following

an urgent

referral

from an

NHS

Cancer

Screening

Service

Patients

treated

following

a referral

from

another

source or

urgency

Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Drug Treatments 10 2 1 8 21 21 0 100 4 99.9

Palliative Treatments 1 0 0 15 16 16 0 100 0 100

Radiotherapy Treatments 7 0 1 13 21 21 0 100 9 97.6

Surgery 38 0 9 26 73 73 0 100 9 97.7

All Treatments 56 2 11 62 131 131 0 100 98.5

Tumour Type Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Brain/Central Nervous System 6 6 0 100 1 98.7

Breast 93 89 4 95.7 8 98.7

Gynaecological 16 16 0 100 11 99.2

Haematological 10 10 0 100 6 99

Head & Neck 10 10 0 100 22 97.5

Lower Gastrointestinal 23 23 0 100 4 98.9

Lung 21 21 0 100 6 99.4

Other 3 3 0 100 9 99.3

Sarcoma 1 1 0 100 0 98.1

Skin 16 15 1 93.8 6 98.7

Upper Gastrointestinal 7 7 0 100 6 99

Urological 69 69 0 100 0 98.5

All Cancers 275 270 5 98.2 98.8


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27


Breach reasons

Treatment Group Wait

Days

Report

Surgery 43 Surgical theatre lists short over Easter Period

Radiotherapy

Treatments

44 Patient chose to delay treatment

Radiotherapy

Treatments

44 Patient on holiday 09/04/2013 - 07/05/2013. Treatment started after

patients return.

Radiotherapy

Treatments


Radiotherapy

Treatments


62 days: Urgent GP referral to First Treatment

Measure Maximum 62 day wait from urgent GP referral to first treatment for all cancers by 2005

Target 85% or more



Treatment Group Total

treated

Treated

on or

within 31

days

Treated

after 31

days

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

Drug Treatments 76 76 0 100 4 99.7

Other Treatments 2 2 0 100 11 95.4

Palliative Treatments 31 31 0 100 0 99.9

Radiotherapy Treatments 141 137 4 97.2 7 98.2

Surgery 25 24 1 96 16 98.1

All Treatments 275 270 5 98.2 98.8


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28

a) By tumour site


Breach reasons

Tumour Type First

Seen

Trust

First

Treatment

Trust

Wait

Days

Report

Gynaecological RBD RD3 117 Referral from other trust not received until day 103

Haematological

(Excluding Acute

Leukaemia)

RD3 RD3 71 Thought by clinician to be low risk (dog bite lump

thought to be reactive) so core biopsy not

expedited. Histology confirms lymphoma

Haematological

(Excluding Acute

Leukaemia)

RD3 RDZ 107 complex pathway

Head & Neck RD3 RD3 69 Unable to schedule within target due to complex

procedure that needed to be attended by specific

clinicians

Sarcoma RD3 RPY 91 Treatment delayed while investigations were

Actual no.

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Breast 7 7 0 100 96.5

Gynaecological 7 5 0.5 90 84.3

Haematological 2 1.5 1.5 0 81.2

Head & Neck 4 3 1 66.7 73.4

Lower GI 6 5.5 1 81.8 76.8

Lung 3 3 0 100 79.1

Other 1 0.5 0 100 80

Sarcoma 2 1.5 0.5 66.7 74.5

Skin 22 21.5 1 95.3 97.1

Upper Gastrointestinal 2 2 0 100 79.8

Urology 4 2 2 0 81.7

Total 60 52.5 7.5 85.7 85.7

Treatment Group Actual no.

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Drug Treatments 12 10 3.5 65 83.4

Palliative Treatments 1 1 0 100 90.1

Radiotherapy Treatments 7 4 0.5 87.5 59.7

Surgery 40 37.5 3.5 90.7 88.7

Totals 60 52.5 7.5 85.7 85.7


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29

performed on a pelvic mass.

Skin RD3 RD3 110 Patient given a TCI date of 4/3/13 but was then

admitted as an emergency with cardiac problems.

Urological (Excluding

Testicular)



Testicular)



Testicular)

RDZ RD3 206 CARP received day 84 of pathway.

Lower Gastrointestinal RD3 RD3 113 Complex pathway with numerous diagnostic

investigations scan and biopsy


Testicular)

RNZ RD3 71 CaRP not received from referring trust until after

treatment had commenced.

62 days: Suspected cancer patients detected through national screening programmes

Measure Maximum 2 month wait from referral from NHS Cancer Screening Programme to treatment by December

2008

Target 90% or more



a) Breast

b) Gynaecological

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

RD3 RBD 11 5.5 0 100 36 97

RD3 RD3 7 7 0 100 35 97

RD3 RDZ 14 7 0 100 37 97

32 19.5 0 100 97Total

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

RD3 RD3 1 1 0 100 62 89.5

Total 1 1 0 100 89.5


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30

c) Gastrointestinal

ALL SCREENING PROGRAMMES

Breach reasons

Tumour Type First

Seen

Trust

First

Treatment

Trust

Wait

Days

Report

Lower

Gastrointestinal

RD3 RD3 65 Patient was seen 02/05/13 and booked to start chemo

15/05/13 (4 days before target) on a trial but was found

not to fulfil criteria on blood test. Booked to start chemo

17/05/13 not on trial but not able to start due to PICC line

being not in right position.

62 days: Suspected cancer patients not referred urgently and upgraded by Consultants

Measure Maximum 2 month wait from consultant upgrade of urgency of a referral to first treatment by December 2008

Target PCT target - 90%



First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

Median

Waiting

Time

National

%

meeting

standard

RD3 RD3 3 3 1 66.7 56 81.4

Total 3 3 1 66.7 81.4

First

Seen

Provider

First

Treatment

Provider

Actual

Total

treated

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

RD3 RBD 11 5.5 0 100 94.7

RD3 RD3 11 11 1 90.9 94.7

RD3 RDZ 14 7 0 100 94.7

36 23.5 1 95.7 94.7Total

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National

%

meeting

standard

Gynaecological 1 1 0 93.1

Lower GI 4 0 100 93.3

Lung 1.5 0 100 91.4

Sarcoma 1 0 100 100

Totals 7.5 1 86.7 92.3


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31

Breach reasons

Tumour Type Consultant

Upgrade

Trust

First

Treatment

Trust

Wait

Days

Report

Gynaecological RD3 RD3 84 Patient too unwell to consent to chemotherapy with

further imaging being requested ? brain Mets.

62 days: Breast symptomatic referral (non cancer) to first treatment

Measure Maximum 2 month wait from breast symptomatic referral (non cancer) to first treatment

Target No standard set



No breaches

Key of Trust Codes:

RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST

RAN ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

RBA TAUNTON AND SOMERSET NHS FOUNDATION TRUST

RBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST

RD3 POOLE HOSPITAL NHS FOUNDATION TRUST

RDZ THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST

RHM SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

RJZ KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST

RM1 NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

RNZ SALISBURY NHS FOUNDATION TRUST

RPY THE ROYAL MARSDEN NHS FOUNDATION TRUST

RVL BARNET & CHASE FARM HOSPITALS NHS TRUST

RWA HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

Symptomatic

breast referral

Accountable

total treated

Accountable

total over

target

Poole %

meeting

standard

National %

meeting

standard

Totals 2 0 100 93.1


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32

CWT Trends in performance

Prepared by: Anne Foulkes Business and Performance Manager (Medicine Division) July 2013


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33

PERFORMANCE EXCEPTION REPORT JUNE 2013

Emergency Department Professional Standards

The Risk: The 4-hour target for June was met (97.14%), which allowed a Quarter One performance of 95.38%.

The remaining professional standards are monitored on a weekly basis and reported to the Trust’s performance meeting. Whilst the standards do not carry Monitor weighting, they are a key gauge for quality within the department.

The performance for June and Quarter 1 to date is outlined below:-

Performance has been mixed during June across the range of performance standards and July to date remains mixed. There remains key pressure points during the 24-hour period and on particular days; the warm weather particularly is having an effect on the numbers of attendances (increasing them). All staff are aware of the need to progress the care of every patient and escalate any difficulties early in the pathway in order to avoid breaches.

Current Position and Actions:

Staffing levels remain a significant risk to performance. The proposals to increase nurse staffing

and skill mix, along with additional resource for medical staffing are currently being discussed with

the Urgent Care Board for Dorset. It is anticipated that some additional funding will be available to

support the on-going delivery of the performance standards and will be in place by the end of July

2013.

The chart below demonstrates the weekly performance trend against the 95% target for 4 hours:-

Standard TargetPerformance for

April

Performance for

May

Performance for

June

Comparision with

previous month

Performance for

Q1 13/14

% of patients seen within 4

hours≤ 95% 92.83% 96.40% 97.14% ↑improved by 0.7% 95.38%

Total time in the department ≤ 240 minutes 287 239 238↓improved by 1

minute240

Clinician seen time ≤ 60 minutes 61 55 68↓improved by 6

minutes61

Left without being seen <5% 3.30% 3.0% 3.39%↑increased by

0.39%3.2%

Time to nurse assessment ≤ 15 minutes 22 19 17↓improved by 2

minutes19

Re-attendance rate (all) Between 1% & 5% 6.10% 5.66% 5.30%↓improved by

0.36%5.70%


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34

Action:

• Extra doctors being booked to cover gaps in rotas and weak points of the day based on recent

presenting patterns (dependent on availability)

• Additional nurses recruited (vacancies filled)

• Consultant of the day agreed and in place to ensure overseeing of department and proactive

management of patients throughout the day

• Reinforcement of high levels of escalation through to senior management if any patient reaches 3

hours with no clear plan of action (either for admission or discharge)

• Newly expanded discharge facility – extended use of the discharge lounge and agreement that

patients can go there without their discharge summary (Doctors to complete in the lounge if not

done before moving)

• Use of Red Cross service to support discharge for appropriate patients needing extra support to

return home

In progress:-

Review of consultant job plans and rotas to provide maximum cover across the 24-hour period

Further review of a number of clinical pathways to improve onward movement to assessment

wards or admission where necessary

Working with commissioners and partners to identify “quick win” solutions to support admission

avoidance, flow and timely discharge.

Bids with potential to be supported through Urgent Care Board funding priorities to develop

sustainable measures:

Increase numbers of ENP nurses in the emergency department to mitigate the risk of

shortages of middle-grade doctors

Consider options for MAT/RAT assessment by consultants at ambulance handover

Appoint additional Acute physicians to provide 7-day cover and senior review within 12 hours

for acute medicine admissions

Review Emergency department consultant job plans and recruit to 6th post to provide cover up

to 8pm Monday to Friday and for extended periods at the weekend

Boost staffing to Clinical Site Management team to support flow, safety and quality across the

hospital

Additional evening sessions to be provided by DME consultants to support flow, reduce length

of stay and increase senior decision making across the 24 hour period

Prepared by: Sarah Knight Directorate Manager, Emergency Services July 2013


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35

PERFORMANCE REPORT – JUNE 2013

Referral to Treatment (RTT)

Summary of Risk: The NHS Operating Framework 2012-13 RTT operational standards are:

- Non-admitted target: 95% of RTT periods where patients received their first definitive treatment in an outpatient (non-admitted) setting must be completed within 18 weeks of referral.

- Admitted target: 90% of RTT periods where the patient needs to be admitted (as an inpatient or day case) for their first definitive treatment must be completed within 18 weeks of referral.

- Incomplete target: 92% of patients who have not yet started treatment should have been waiting no more than 18 weeks (patients who have had a clock start but have not had a clock stop).

Within the PHFT contract with the PCT, it is expected that each of the main specialties achieves all three targets at specialty level. All remaining ‘sub-specialties’ are grouped together into a category ‘X01’; this category must be achieved at aggregated level.

Current position: The Trust RTT position at the end of June 2013:

- Non-admitted target: 98.2% (Target: 95.0%) - Admitted target: 97.7% (Target: 90.0%) - Incomplete target: 98.2% (Target: 92.0%)

At Unify specialty level, all specialties (except cardiology) passed both the Admitted and Non-admitted targets for June 2013. The ‘X01’ aggregate level was also passed for both Admitted and Non Admitted.

Cardiology breached the Admitted target (one breach out of nine patients) with a performance of 88.9%. This is an in-month non-reportable specialty as it is below the de-minimis limit of 20 clock stops.

Within the ‘X01’ category for Admitted, whilst this passed the aggregate target at 93.1%, within the category - Clinical Oncology breached the Admitted target (one breach out of four patients) with a performance of 75.0%. This is an in-month non-reportable specialty as it is below the de-minimis limit of 20 clock stops.

Within the ‘X01’ category for Non-admitted, whilst this passed the aggregate target at 97.0%, within the category: - Pain Management breached the Non-admitted target with a performance of 71.4%. This is based on 20 out of 28 patients being treated within target. This is an in-month non-reportable specialty. - Restorative Dentistry breached the Non-admitted target with a performance of 90.0%. This is based on one breach out of ten patients. This is an in-month non-reportable specialty as it is below the de-minimis limit of 20 clock stops.

At the Trust Weekly Performance meeting, monitoring at patient level continues of all patients waiting over 26 weeks for treatment, and the reasons for the pathway delays.


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36

Actions for July 2013: A number of specialties require significant pro-active monitoring and management to ensure the achievement of the targets at specialty level.

At time of writing this report, the Trust is performing well at aggregate and specialty level, however it is still very early in the month to make definitive predictions regarding the month end position.

The Performance Team has identified the following specialties as having challenges to meeting the non-admitted targets during June 2013.

Surgical Division: Pain Management: The service continues to be very closely managed. As a specialty within ‘X01’ category, as long as the aggregate X01 target is achieved, this specialty can tolerate higher numbers of breaches whilst the pain management service undergoes transition to DHUFT. The number of potential breaches is being closely monitored to ensure that the XO1 target isn’t put at risk in the coming months. The X01 category is not at risk during July.

Paper-based referrals continue to be received from GPs and secondary services, primarily rheumatology. These are being triaged by Consultants within the pain service and returned where clinically appropriate.

Medical Division: Neurology: All patients are continuously reviewed to ensure that their pathway is completed in the best possible timeframe. The new Consultant Neurologist (7.5PA/week) 22 commences in post on 22.07.2013 and it is intended that this appointment will alleviate the pressures within the department. Pressures regarding waiting times for CT scans and the time taken to receive the CT scan report are proving challenging and this is being managed in conjunction with the radiology department. Rheumatology: The impact of reduced Specialist Registrar capacity within the specialty remains a challenge, as this has resulted in reduced outpatient clinic capacity. This impact is being closely managed by the Directorate Manager to ensure the RTT Non-admitted is achieved. General Medicine: Work has been undertaken with the medical secretaries within the General Medicine specialty to ensure that all RTT clocks are being stopped correctly. Whilst challenging, it is not envisaged that there is a risk of not achieving the Non-admitted RTT target in July. MCD Division: Gynaecology: The Directorate continues to deliver a good performance against Admitted and Non-admitted targets however due to a recent number of cancelled theatre sessions (due to lack of anaesthetic cover) and loss of Consultant activity due to annual/study leave, it is expected that the performance will be challenging to deliver over the next few months. The Directorate will continue to work hard to ensuring the delivery of all RTT targets. The review of the urodynamic diagnostic pathway has proved challenging and has highlighted the need for a more streamlined patient pathway, in particular the need for patients to be fit and able to receive the relevant urodynamic diagnostic investigations, Work is underway to streamline the patient diagnostic pathway, however until this is imbedded there will be risks surrounding the delivery of the six week diagnostic target in this speciality.

Prepared by: Suzie Scaddan Trust RTT Lead July 2013


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37

PERFORMANCE REPORT

Theatre services- Critical Care Directorate – JUNE 2013

The Risk: Day Theatres is not reaching the 80% target

Current Position: Previous calculations have shown that best achievement for Day Theatres ranges between 80 and 82%. This is based on the number of patients that is reasonable to put on each session which range from 2 patients to 6 patients. Based on these levels of activity it is impossible for every list to achieve 85% as any list with three patients or more is already unable to achieve the target. Day Theatre reached 76% utilisation for May 2013 which is 2% less utilisation than May 2013

Graph 1 shows the total utilisation in Day Theatres. Utilisation in ENT (76%) decreased utilisation by 2% and OMF (71%) decreased utilisation by 5% on last month. Both of these specialities had losses on their list as the result patients cancelled on the day being unfit and DNAs which totalled 3.3%

74 75

71

77

82

78

76 76

74

77 78

76

64

66

68

70

72

74

76

78

80

82

84

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

% o

f o

pe

rati

ng

tim

e

Day Theatre Utilisation rolling annual activity

Target utilisation Utilisation


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38

Graph 2 shows the number of patients that were booked for total sessions and the number of completed patient episodes. The patient cancellations for this month were 1.6% which is within the agreed acceptable level of 2%.

Graph 3 shows the percentage of time lost across total sessions in Day Theatres as indicated by the reasons on the chart. Time lost on day of surgey equated to 4.8% (14 hours) of time allocated although 1.6% (5 hours) of activety was transferred into underutilised capacity preventing overruns or cancellations where required

52

9

43

4

43

5

50

2

48

2

25

7

46

5

42

1

41

7

43

9

45

8

37

3

51

3

41

3

40

5

49

6

46

8

24

4

37

8 4

18

45

9

43

2 4

71

35

9

0

100

200

300

400

500

600


Nu

mb

er

of

pat

ien

ts

Day Theatres patient activity

2012/13 2011/12

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%


Time lost on day of surgery

Patient unfit Cancellations/DNAs

Procedure - less time Trauma - no patients waiting

Patient declined surgery Operation no longer required

session under booked Bed not available

Clinical/staff shortages kit availability


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39

Graph 4 shows perform against the Basket of 25. This information comes from the Dr Foster intelligence and therefore is always presented two months behind the month being reviewed. At the Day Surgery Management meeting (June 2013) it was identified that if four more patients had surgery before 3pm, therefore allowing them to be discharged without an overnight stay, then the 80% target would have been reached. In the same time period last year 82% was being achieved. The impact of bed pressures has had an impact on efficiency.

Actions:

A new working group which is solely looking at Day Theatre Efficiency has its first meeting in July

and an example of the following issues will be reviewed

a – review Day Theatre schedule, some sessions have already been moved in the last month to

ease pressure on busy days, further work needs to take place

b – matching ‘bed spaces’ to activity and managing gender balance on busy days i.e. Wednesday

is heavy for female beds with the number of Gynae lists undertaken

c – improving starts times which have started to slip

Meet with Clinical Lead OMF/ENT to discuss utilisation.

Meet with pre-assessment regarding cancellations on the day of patients unfit for surgery

Prepared by:

Vivian Stevens

Head of Theatres Services

July 2013

80% 80%

78.7%

79%

Mar-13 Apr-13

Basket of 25 2013-2014

Target Actual


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40

PERFORMANCE REPORT – TRAUMA – JUNE 2013

Trauma Directorate- Waiting Times for Surgery: Fractured Neck of Femur within 36 hours of being clinically appropriate for surgery (PCT target 95%) Fractured Neck of Femur within 36 hours of admission (Best Practice Tariff Criteria – internal target 90%) Trauma Patients within 48 hours of being deemed fit for surgery (PCT target 95%)

The Risk: Fractured neck of femur patients June 2013 95% operated on within 36 hours of being deemed clinically appropriate for surgery. 86% operated on within 36 hours of admission. All trauma patients June 2013 96% within 48 hours of being fit for surgery. Due to the fluctuation in daily admission numbers, the complexity of the case mix and the management of competing access targets in theatres across all specialties the MDT members involved continue to face challenges in maintaining the patient flow to theatre. The previously reported increase in capacity and improved management of the NOF pathway has made these fluctuations easier to cope with during May and June this year, although the current level of capacity available is being tested to the full some days as we move into summer.

Current Position: A busy month with a total of 432 trauma admissions overall, of which 348 were operated on. Within this 82 fractured neck of femur patients were admitted. Due to the pattern of admissions the department had several periods of Stage 1 escalation, each lasting between one and nine days. Overall, a challenging month again but compared to June last year when the number of admissions, neck of femurs and operations were very similar the compliance with the quality access targets was much improved. During the month there were six revision total hip replacement procedures performed and six primary total hip replacements for fractured neck of femur. Of the six primary procedures four were within 36 hours of admission, one was unfit but operated on within 36 hours of being fit and one had to wait due to surgeon availability. Of the eleven fractured neck of femur patients that breached the target of 36 hours from admission, seven were unfit upon admission (but did attend theatre within 36 hours of being fit), two breached because of other trauma cases taking priority after the hip patients had been listed, one breached because of the need for an experienced total hip replacement surgeon and one because of insufficient theatre capacity during one period of escalation where there was a large emergency take that included several neck of femur patients.

Patients not fit pre-op &

needed optimising

Other trauma

cases taking

priority/ran out

of time

Insufficient

theatre capacity

Awaited

specialist

surgeon for

THR

Patient

awaited a pre-

op CT scan

7 2 1 1 0


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41

Actions:

To continue with all the current practices around prioritising fractured neck of femur patients, breach

avoidance/breach management for individual patients and highlighting crucial patients and their

breach times to surgeons and to theatres.

To continue to undertake review of each breach in detail and highlight any changes required as a

result.

To continue with the Middle Grade training programme for total hip replacement surgery, in order to

improve surgeon availability to undertake this procedure. Whilst waiting times have reduced

undertaking THR’s within 36 hours remains a challenge at busy times.

Further to MDT discussions held regarding THR surgery and THR revision surgery at weekends and

on twilight lists and agreement reached that THR surgery can be undertaken as routine in the

majority of cases. Complex hips require a higher level of experience, more equipment and have the

potential for greater risk. If the Directorate requests scheduling of a hip revision at weekends/bank

holidays or in the evening a check list will be completed in conjunction with Anaesthetics and

Theatres to confirm whether all required resources and experience are in place before the

procedure is agreed.

To continue the on-going review of trauma demand vs theatre capacity during the busy summer

months.

77 81 73 73 67 7790

56 62 70 8067

82

0

50

100

150

200

250

300

350

400

450

500

0%

20%

40%

60%

80%

100%

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

% o

pera

ted

wit

hin

36h

rs o

f ad

mis

sio

n

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

% Patients Operated on within 36hrs 68% 52% 58% 75% 93% 88% 84% 88% 90% 74% 86% 90% 86%

Number of NOF's admitted 77 81 73 73 67 77 90 56 62 70 80 67 82

Number of Trauma Admissions 439 450 488 407 427 403 378 355 316 363 388 425 432

% Patients Operated on within 36hrs Number of NOF's admitted Number of Trauma Admissions


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42

Prepared by:

Yvonne Hunter

Directorate Manager –Trauma & Orthopaedics

July 2013

0

10

20

30

40

50

60

70

Jun-11

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Nu

mb

er

of

Bre

ach

es

Month

Total Breaches June 2011 - June 2013

NOFs

Non NOFs

Combined

0

2

4

6

8

10

12

14

Jun-11

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Nu

mb

er

of

Pa

tie

nts

Bre

ach

ed

Month

Non NOFs: Treament times for Patients Breaching the 48 Hour Target: June 2011 - June 2013

2-3 days 3-4 days 4-5 days >5 days

0

10

20

30

40

50

60

70

80

90

100

Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13

Pe

rce

nta

ge o

f p

atie

nt

to t

he

atre

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Trauma 48 hrs from adm 97 91 91 91 91 97 91 95 98 96 93 98 96 94 95 93 96 97 95 97 96 98 97 96 96

NOF 36 hrs from adm 77 58 51 46 55 77 72 77 76 73 69 80 68 52 58 75 93 88 84 93 90 74 86 90 86

NOF 36 hrs from fit 85 70 66 62 66 93 79 92 86 79 77 92 68 70 63 81 99 97 96 95 97 96 96 97 95

Percentage of Patients to Theatre June 2011 - June 2013

Trauma 48 hrs from adm NOF 36 hrs from adm NOF 36 hrs from fit

0

5

10

15

20

25

30

Jun-11

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Nu

mb

er

of

pa

tie

nts

Bre

ach

ing

Month

NOFs - Treatment Times for Patients Breaching the 36 hour Target: June 2011 - June 2013

36-48 hours 2-3 days 3-4 days > 4 days


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43

PERFORMANCE EXCEPTION REPORT – JUNE 2013

Stroke: Target: ≥80% of patients should spend > 90% of their LOS on the Stroke Unit

The Risk: The Trust has achieved this target month by month in year.

Current Position:

In June there were 32 Stroke patients discharged during the month, with 81% (26) of patients spending

> 90% of their LOS on the Stroke Unit (target ≥ 80%).

The following table indicates the number of live Stroke discharges and the % that achieved the target in the previous months.

June

The Trust has managed to maintain this target for the last 8 months.

June outturn was below the same period 2012, with actual Stroke numbers reduced considerably from all previous months.

The Stroke pathway only left fragile by staff vacancy and sickness issues.

The team still has the support of ESD and the Red Cross, which have enabled safe, successful discharges for a number of clients. The number of patients discharged during May with ESD increased to 36%, June figures not yet available.

Direct access increased to 84% (27 patients), an increase on May in % but not on actual patient numbers. We remain aware that clinical care elsewhere is appropriate prior to patients joining the Stroke pathway. These will continue to affect figures though these cases are reviewed upon validation, managed onwards and appropriately actioned. There were 3 cases of non-direct access where we believe Stroke beds were available. This will; be followed up with CMT.

The service continues to escalate delays due to the arrangement of care packages, these issues are raised weekly with ward discharge coordinators meetings with our secondary and Local Authority colleagues.

0

10

20

30

40

50

60

70

80

90

100

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3Stroke Discharges Patient spending 90% LoS on Stroke Unit


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44

CT scan access <24 hours for June was 93% (30 patients). The general increase and maintenance of this target remains a result of greater communication between teams and input from colleagues in imaging and their continued ability to remain flexible in our requests for imaging during the patient pathway. Any delays/potential delays are discussed and raised at the earliest opportunity.

7 day TIA clinic provision commenced at the beginning of March. There is now a new referral process for GP’s to follow which is managed by Southwest Ambulance Service (SWAST) and marries up with the CaptureTIA IT system we have at PHT. Further work is underway to encourage GP’s to use the live referral option whilst the patient is in the surgery. SWAST are able to provide us with data for referrals made after 6 hours into the system so that we are able to liaise directly with surgeries.

PHT have had successful weekends on take, processes for ongoing evaluation and governance are in place along with colleagues from Royal Bournemouth and Salisbury General Hospitals.

May saw a further decrease in TIA referrals, in pattern with Stroke admissions and discharges (31 in June compared to 57 in May). The number classified as high risk also decreased in proportion (15 in June compared to 30 in May), with a drop in those able to be seen within 24 hours at PHT (46% in June compared to 60% in May).

Actions:

1. Continued refinement of Stroke/TIA IT system and SWAST information provision for future

reporting and liaison with GP practices.

2. Ward & CMT processes reviewed to maintain direct access targets.

3. Recruitment action plan continues to be updated and managed to support staffing on

ASU/Rockley and DME services.

4. Stroke Consultant post out to advert W/B 15th July.

5. LoS and capacity monitored at monthly Capacity Meetings and Monthly Stroke meetings.

0

10

20

30

40

50

60

70

80

90

Total High Risk Seen <24 %

Prepared by: Barry Duell Directorate Manager (DME, Diabetes, Rheumatology, Neurology & Gastroenterology)

July 2013


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45

PERFORMANCE EXCEPTION REPORT – June 2013

Appointment Slot Issue (ASI): Trust performance for June was 22%

Summary: Provider to ensure that ‘sufficient appointment slots’ are made available on the Choose and Book system. Standard: <4% slot availability issues. The Trust risks fines for every week >10%.

Current Position: At end of June 2013, the Trust position was 22%.

Rheumatology: Polling range at 12 weeks. 118 ASI.

Dermatology: Polling range at 10 weeks. 80 ASI.

Orthopaedic All: Polling range at 6 weeks. 51 ASI.

Respiratory: Polling range at 9 weeks. 28 ASI.

Urology: Polling range 10 weeks. 16 ASI.

Ophthalmology: Polling range at 8 weeks. 13 ASI.

Rheumatology

Department continues with ESP cover for SpR post, sessions remain on choose and book.

Locum Consultant Dr Asim Kurshid starts in post on October 7th. Corporate induction booked, clinics are being opened from October 7th. Discussions will now commence regarding substantive post in department.

SpR appointed as joint post between PHT and RBCH meaning that ESP cover will need to continue to retain current clinical capacity. SpR should commence in post in September/October 2013/

Dr’s Richards, Thompson & Rahmeh are providing a number of sessions and ward cover in Dr Westlake’s absence.

Demand continues, capacity and demand modelling is underway for speciality.

Agreement to return routine pain referrals to their GP to be managed in the community. Rheumatology pathways and capacity may continue to be adversely affected by Pain Clinic referrals until the community service commences later this year.

Dermatology:

We do not have a SpR for clinics until mid-August which has impacted on clinic slots (70), once they are in post pressure caused by bank holidays / annual leave will be reduced.

Due to an increase in fast track referrals pressure has been felt in the department, Consultants have assisted greatly in over booking and adding extra clinics. The main causes of the increase in referrals are the Dermatoscopes that the CCG purchased for GP practices. Referrals are being received for lesions that do not present as a skin cancer (it’s usually the suspected SCC referrals) and are presumably sent by GP’s that lack experience and training in the management of skin cancer - often locums. We are getting high numbers of benign seborrheoic warts sent in as suspected melanoma, and it is the dermoscopy that is to blame here: seb warts are usually quite straight forward to diagnose clinically - just by looking at them. The issue arises when they are looked at with a dermatoscope - many of the features that suggest an atypical growth are present - i.e. abnormal blood vessels, irregular pigmentation etc. GPs haven't been trained to look beyond these features to see that it is a

Actions for June/July 2013:


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46

benign growth - and as the CCG don't appear to have plans to remedy this we cannot foresee how this is going to change. It takes months of sitting in clinic alongside somebody trained in dermscopy to become competent. Photos/teledermatology is not helpful as an atypical mole needs to be compared with all the patient's other naevi to see what is normal/abnormal for that individual. We will continue to monitor the situation.

We don't get to see 2 week referrals before clinic - the referral letter is often not that helpful as the description of the lesion as a malignancy often has little bearing on what is actually present.

Slots issues resolving and no concerns identified going forwards.

Orthopaedic All:

Paediatric Orthopaedics:

24 ASI’s in the last week of June due to a combination of the referral pattern in month and reduced capacity in August because of consultant leave.

Due to nature of the specialty all new patients are seen by the consultant or by a Middle Grade under supervision.

Additional Middle Grade cover is under consideration for all consultant leave periods going forward to see follow ups, thereby leaving additional new slots available within some of the consultant’s clinics. However, there will be a cost attached to this as backfill for leave is not included in the budget for this sub-specialty of orthopaedics.

Adult Orthopaedics

Reducing ASI’s in the adult elective service is proving to be a challenge and work is on-going to provide additional capacity where possible.

Backfill for leave is not currently built into the service provision and currently all additional resources/funding are being channelled to support the pressure on the fracture clinics which in May and June saw 400 additional attendances.

An updated review of demand and capacity in all aspects of elective and acute T&O is currently underway.

Respiratory:

Pressure from reduced capacity (higher polling range) at RBCH has added to the workload for PFT, a locum is now in post there and the service should soon be able to resume as normal. This will see a reduction in RBCH area patients choosing PFT on Choose and Book as polling ranges will be more aligned.

Consultant leave (there are only 3 in department) has also impacted over the summer months.

Urology:

There has been no loss of capacity as all leave is covered and the increase in ASI’s in this specialty to 16 in June appears to be due to an increased number of referrals in month.

This is being looked at in more detail and the situation monitored during early July.

RBH will be asked if they can supply clinician cover for an additional clinic if deemed necessary.

Ophthalmology:

The number of ASI’s for the adult service increased in this specialty due to a combination of leave and a change in the pattern of clinics which has affected the capacity sufficiently enough to take the ASI’s into double figures.

Situation to be monitored over early July and RBH to be approached for an additional Middle Grade clinic if deemed necessary.

Barry Duell/Yvonne Hunter Directorate Managers - Medical & Surgical Divisions (July 2013)


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47

PERFORMANCE EXCEPTION REPORT: May 2013

Cancer Waiting Times target: 62 day target from consultant upgrade of urgency of a referral to first treatment – operational standard ≥ 90%

The Risk: The target ‘62 day target from consultant upgrade of urgency of a referral to first treatment’ was not achieved in May. 86.7% of patients started treatment within 62-days – the CCG target is ≥ 90% (assessed quarterly).

Current Position:

One out of 7.5 accountable patients first treated in the month breached the target - the patient was

too unwell to start chemotherapy as planned. This target is not a MONITOR target, but a target of ≥

90% has been set by the CCG – measured on a quarterly basis. The number of patients treated in

this target category each month is very small, typically less than 10 patients. As a result, in order to

achieve the CCG target of ≥ 90%, the Trust cannot, on average, have any more than 0.5 of

accountable patient breach in a month.

The target was, however, achieved for the quarter with 95.5% of patients meeting the target.

(Note: patients are allocated as 0.5 to the Trust where the patient was first seen and 0.5 to the Trust

where the patient was first treated. So a patient first seen and first treated at PHFT would count as 1

and a patient first seen at another Trust and then first treated at PHFT would count as 0.5)

Action:

- The pathways for individual patients who are at risk of breaching the target continue to be

discussed at the Weekly Performance meeting with the Chief Operating Officer, Divisional Directors,

Directorate Managers and service leads. Actions are identified to try to avoid patients breaching the

target with appointments, admissions, diagnostic reporting expedited by the relevant senior

managers in conjunction with the Cancer MDT facilitators.

- However, no waiting times adjustments are permissible in cases of patients with co-morbidities

which result in the patient being unable to be seen or treated within the standard time.

Anne Foulkes Business Manager, Medical Division July 2013


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48

PERFORMANCE EXCEPTION REPORT: June 2013

Dorset Breast Screening Unit Targets

Issue:

The DBSU failed to meet one target in June 2013 relating to the date of attended appointment.

The unit achieved 87% screening to date of first attended appointment (Target 90%)

The DBSU failed to meet one target in June 2013 relating to the date of attended appointment. The unit

achieved 87% screening to date of first attended appointment (Target 90%)

Current Position:

Despite 92% of women being offered an assessment appointment within 21 days 8 women

attended their assessment appointment between 3-4 weeks. Of these 3 chose to change their

appointment due to holidays / work commitment, and 5 were delayed due to films going to

arbitration. This was exacerbated by the reduction in film reading due to PACs downtime of

approximately 20 hours in DBSU during June

The remaining 13 were assessed after 5 weeks , 4 due to patient choice , 4 due to problems associated

with the retrieval of films 3 for women who had TR appointments and 2 women who initially chose not to

attend their assessment appointments

Actions:

To review radiologist timetabling at the planning meeting so that the correct film readers are

available for film arbitration in DBSU

Progressing IT intervention to stabilise PACs system

Produced by:

Shirley Langdon - Breast Screening Superintendent

July 2013


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Staff Experience – Appendix 1

Reporting for Month of June 2013

Standard Description TargetMonitoring

periodJul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Comment

Staff

Turnover

(Overall)

Overall avoidable

staff turnover under

11% (average rate

of 0.91% per

month)

<=11% Monthly 0.71% 0.90% 0.72% 0.62% 0.59% 0.79% 0.53% 0.80% 1.05% 0.64%

1.00%

(1.64%

Cumulative

)

9.84%

projected

0.41%

(2.05%

cumulative)

8.20%

projected

Avoidable' staff turnover in M3 was 0.41% (14 leavers) compared with 0.63% in the same month last year. This

is a considerable slowdown compared to the two previous months. The quarter 1 rate of 2.05% projects to a year

end rate of 8.20% , well within the target of <=11%

Staff

Turnover

(Auxiliaries

and HCAs)

Overall avoidable

staff turnover in

Auxiliaries/ HCAs

under 13.5%

(average rate of

1.12% per month).<=

13.5%Monthly 1.73% 1.95% 2.37% 1.50% 0.85% 1.46% 1.25% 1.04% 0.62% 1.24%

1.86%

(3.10%

Cumulative

)

18.60%

projected

0.40%

(3.50%

cumulative)

14.00%

projected

Auxiliary turnover rate in M3 was 0.40% (2 leavers), a significant slowdown compared to the first two months of

the financial year, and the cumulative rate for quarter 1 is only slightly higher than at the same stage last year

(3.05%). The year end projection is currently 14%, marginally higher than the 13.5% target. Quarter 2 usually

sees the highest number of Auxiliary leavers as many start professional training courses in September and October.

So it is likely that this rate will rise.

Auxiliary/HCA turnover is a significant problem nationally and much has been done in the Trust to support this

staff group in terms of recruitment, training and development, with the support of senior nursing staff and

management. A meeting has been held with the Associate Director of Education and the HR Director and the

HRD has asked Education to devise and roll out a HCA development programme to support the HCA work group

and aid with retention, this has been agreed and is a feature of the 13-14 committments in the Trusts Annual Plan.

Sickness

Absence

Sickness absence

rate <= 3.5%. (By

31st March 2013).

First figure is rate

for the month,

second is

cumulative rate for

year to date.

<=3.5% Monthly 3.49%

3.30%

3.51%

3.34%

3.67%

3.40%

3.45%

3.41%

3.42%

(3.41%)

3.68%

(3.44%

)

4.13%

(3.50

%)

4.07%

(3.56%)

3.71%

(3.57%)

3.86%

(3.86%

cumulati

ve ytd)

3.17%

(3.51%

cumulative

ytd)

3.33%

(3.45%

cumulative

ytd)

Following the extremely good performance on sickness in 2012-13 - the year end sickness rate being the best

achieved by the Trust in the last decade (3.57%) - the current year has started at a higher level. This was largely

due to the norovirus outbreak in the spring which added some 300 days additional absence, mostly in April,

compared to the previous two month period. The refreshed April rate was 3.86%, high for the period. The

refreshed May rate was 3.17% the best May rate recorded since ESR records began in 2007, and this is a very

positive result. June has seen a slight increase to 3.33% which is still below the Trust target of 3.5%.

Sickness related staff salary costs in the year at M3 were £732k compared with £698k at the same stage last year.

In the inter-organisation comparator group of 50Trusts in the south and south west (data from the NHS Information

Centre). Poole was 17th in the latest 12 month data comparison (April 2012 - March 2013) with a rate of 3.58%.

The average sickness rate for the whole group remained 4.15%, whilst a more local benchmark shows an average

rate of 3.71%. Nine of the top 10 performing organisations were PCTs and successor organisations.


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Standard Description TargetMonitoring

periodJul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Comment

Appraisal Appraisal Records

On ESR

25% 29% 43%

The recently launched project to get appraisals recorded on ESR has continued with much progress being made

since last month. Managers have been reminded of the importance to record appraisals on ESR and have been

given until the end of August 2013 to complete the entry of current live appraisal records. There has been a

marked improvement in the last 2 months with recorded appraisal rates rising from 25% in April to 43% in June.

Establishmen

t compared

with

Substantive

Staff in Post

WTE establisment

and staff in post on

the final day of the

month.Monthly

3224

estab

3048 in

post

Varianc

e =

-176 wte

3224 estab

3046 in

post

Variance =

-178 wte

3224 estab

3049 in

post

Variance =

-175 wte

The variance between wte establishment staffing and wte staff in post on the last day of the month has remained

constant durin g the financial year to date. This figure is consistent with the number of activities going through the

various stages of the recruitment process.

NB the change from month to month is not simply the result of staff in post, plus starter, minus leavers, due to the

fact that the most common day for staff to leave the Trust is the final day of the month. Therefore these leavers

are included both in the leaver figures and in staff in post.

Substantive

Starters

Headcount and

WTE

57

(48.86

wte)

22

(18.48 wte)

58

(50.57 wte)

The 58 substantive starters in June reflects the on-going high level of recruitment in the Trust. The dip in

substantive staff recruited in May was more than made up for by the number of Bank staff recruited in that month,

with some 80 people attending the May induction sessions.

Substantive

Leavers

Headcount and

WTE

29

(24.46

wte)

42

(34.59 wte)

57

(52.98 wte)

June leaver numbers include 37 (33.20 wte) IT/Information Governance staff transferred to RBH. These are not

included in the turnover statistic. The number of staff leaving the Trust in June for other reasons slowed

considerably compared torecent months.

Nursing Bank

and Agency

Requests

Number of

individual requests

for temporary

nursing cover.Monthly

2685

shift

request

s

2803 shift

requests

2960 shift

requests

Demand for temporary nurse staffing remains high. In order to meet the high level of demand continuing

significant effort has been put into the recruitment of bank nursing staff, in particular HCAs, during 2012-13. Since

March 2013 90 Bank HCAs and a small number of new bank Registered Nurses and Midwives have been

appointed to help cope with the high deamnd levels on to reduce relaince on agency staff. The number of active

bank nursing staff has increased significantly in the past 12 months and stands at the highest level recorded by the

Trust.

Nursing Bank

and Agency

fill rate

Percentage of

requested shifts

filled by the Nurses

Bank (excl

cancelled requests).

Monthly 85.32% 90.95% 87.64%

The fill rate for temporary nursing staff in June was 87.64%, slighly down on May's rate, but still higher than the

period February - April. Of the filled shifts in June,13.80% were from agencies, a increase compared to May,

10.58% and higher than the average of 12.29% for 2012-13.


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51

Appendix 2 – Quality Scorecard

Safety Target April May June July Aug Sept Oct Nov Dec Jan Feb Mar YTD

A Infection Control - MRSA Bacteraemias (Cumulative) 1 0 0 0 0

B Infection Control - MRSA Screening 95%

C Infection Control - Norovirus Outbreaks N/A 11 0 0 11

D Infection Control - C.Diff (Cumulative) 19 2 0 1 3

E MSSA (Cumulative) N/A 1 3 0 4

F E.Coli (Cumulative) N/A 0 1 1 2

G Infection Control - Handwashing audit compliance 98% 98% 99%

H National Reporting and Learning System (% of low/no harm incidents) N/A 98%

I National Reporting and Learning System (% of severe harm incidents) 0.70% 0.2%

J NPSA Safety Alerts - Number outstanding 0 0 0 0

K Number of Serious Incidents Requiring Investigation (declared) N/A 1 3 2 6

L No of Serious Incidents Requiring Investigation open outside of timescale 0 0 0 0 0

M Percentage of staff trained in safeguarding adults 74% ** 73%

N Staff trained in safeguarding children to level 1 (all staff as % of workforce) 76% ** 75%

O Staff trained in safeguarding children to level 2 (clinical staff as % of workforce) 44% ** 45%

Oi Staff trained in safeguarding children to level 3 (clinical staff as % of workforce) 37% ** 36%

P Number of confirmed Never Events 0 1 0 0 1

Q Emergency Department Ambulance Handover delays

R Hospital Standardise Mortality Indicator (HSMR) <100

S Summary-Level Hospital Mortality Indicator (SHMI) N/A

T Compliance with WHO surgical site Checklist 66% N/A N/A

Effectiveness

U Patient falls resulting in a fracture or significant injury 0 2 3 1 6

V Stage 3 or 4 pressure Ulcer occurrence (acquired in care) 0 1 0 0 1

W Percentage of patients who fell more than once (as a % of falls) 11% 20% 12%

X VTE % of risk assessments 95% 94% 95.40% 95.90%

Y PROMS response rate 83% 83% 81%

Patient Experience

Z Total number of Complaints N/A 44 42 **

Aa Total number of Complaints acknowledged within 3 working days N/A 97% 100% **

Ba Percentage of cancelled Operations N/A 2.24% 0.70% 1.60%

Ca Breaches in same sex accomodation 0 0 0 0

DaPatient satisfaction - Were you involved as much as you wanted to be in decisions

about your care and treatment?7.25

EaPatient satisfaction - Did you find someone on the hospital staff to talk about your

worries and fears?6.10

FaPatient satisfaction - Were you given enough privacy when discussing your condition

or treatment?8.30

GaPatient satisfaction - Before you left hospital, were you given any written or printed

information about what you should or should not do after leaving hospital?7.05

HaPatient satisfaction -Did a member of staff tell you about medication side effects to

watch for when you went home?5.50

Workforce

Ia Sickness absence rate % <3.5 3.80% 3.42% 3.33% 3.67%

Ja Staff turnover rate % <11 0.64% 1% 0.41% 1.64%

Ka Mandatory Training % 74% ** 74%

La Appraisal % 29% 38% 43%

CQUIN

1 . VTE Target April May June July Aug Sept Oct Nov Dec Jan Feb Mar YTD

Ma % of all appropriate adult inpateints who have had a VTE risk assessments on

admission94.1% 95.40% 95.90%

Na % adults at risk of VTE commenced on appropriate prophylaxis 99.5% 99.9% 100%

2. PATEINT EXPERIENCE

Oa Composite score from Annual adult inpatient survey

3. DEMENTIA

Pa Dementia screening - % all patients over 75 screened following admission

Qa Dementia risk assesment - % of those at risk have assessment within 72 hours of

admission

Ra Referral for specialist diagnosis - % of patients identified referred

4. NHS SAFETY THERMOMETER

Sa Monthly survey using Safety Thermometer 100.00% 100.00% 100%

5. HIGH IMPACT INNOVATIONS

Ta Demonstration of full implimentation of 6 high impact interventions (will require narrative )

5.1 Use of assistive technologies

5.2 Full implementation of oesophageal doppler monitoring (ODM)

5.3 Implementation of 'child in a chair in a day'

5.4 Exploring opportunities to increase national and international healthcare activity

5.5 Reduction of inappropriate face to face contacts

5.6 Supporting carers of people with dementia

6. END OF LIFE CARE

Ua Implementation of end of live care enablers at ward level ( will require narrative report

in quarterly quality report)

7. LEARNING FROM UNEXPECTED DEATHS

Va Quarter 1 overall report on current mechanisms in place to ensure standardised

approach across all trust in future

Wa Updates on action plan/implementation of new structure and identified leadrning from

analysis

8. IMPROVING FRONT LINE CARE

Xa The role of leadership

SPECIALIST COMMISSIONING CQUIN

Ya NICU Therapeutic hypothermia 1 1 **

Za NICU retinopathy screeing 6 2 **

Ab NICE Breastfeeding 82% 76% 78% 83%

Key

* see exception report ** to follow **** see CQUIN action plan

Poole Hospital NHS Foundation Trust 2013-14


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BOARD OF DIRECTORS PAPER PART 1 – COVER SHEET



Title: Merger Update

Purpose: To provide the Board of Directors with an ongoing briefing on the merger programme and an update on progress

Summary:

Introduction The purpose of this paper is to provide the Board of Directors with an update on the merger programme. In particular, the Board of Directors is asked to note progress in the following areas:

the Competition Commission (CC) provisional findings, published on 11 July 2013

key communication and engagement activities

Deborah Matthews Programme Director

Recommendation:

The Board of Directors is asked to note progress to date regarding the proposed merger project.

Prepared

by:

DEBORAH MATTHEWS Programme Director

Presented

by:

CHRIS BOWN Chief Executive DEBORAH MATTHEWS Programme Director

Assurance

Framework:

YES / No Risk

Register I/D

No:


Please specify which standard/

standards that apply;

CQC Standard (Please provide details:

Other; i.e /NHSLA/HSE etc Monitor compliance: YES NO

Human Resources implications YES NO Financial implications YES NO

Legal implications YES NO


BoD�Jul�13�11a�July�Cover�Shee

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MERGER PROGRAMME

Briefing Paper for the Board of Directors

24 July 2013

Introduction

The purpose of this paper is to provide the Board of Directors with a monthly update on the

merger programme.

The Competition Commission

The Competition Commission (CC) published its provisional findings on the proposed merger between Poole Hospital NHS Foundation Trust (PH) and The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (RBCH) on Thursday 11 July 2013. The CC has provisionally concluded that the proposed merger would result in a significant lessening of competition (SLC) and therefore create a loss of choice for patients in the wider Dorset area in the supply of the following services:

20 elective inpatient services

36 outpatient services:

1 non-elective inpatient service: maternity (comprising obstetrics and gynaecology)

1 private service: cardiology The CC is concerned that if the merger went ahead, not only would patients lose this choice, but the trusts would lose an important incentive to maintain or improve quality in order to attract patients. The initial findings are extremely disappointing and both parties disagree with this initial assessment, as summarised below:

we have emphasised throughout the process that we provide complementary services, work together collaboratively, do not compete and wish to come together to protect and enhance services for patients;

we disagree that the merger will reduce patient choice, as we plan to maintain two viable hospitals;

we also have concerns about the process that we have had to follow, which is not fit for purpose, and we will be raising these concerns at a higher level;

we believe that the benefits of merger (submitted to the CC) outweigh the loss of any competition;

the merger would also deliver merger-specific savings of £13.7 million, which could be achieved over and above those the trusts could deliver on a stand-alone basis during the financial years 2014/15 and 2015/16.

The CC has also published:

a notice of possible ‘remedies’. These are prohibition of merger or any remedies that the trusts would like to propose;

details of potential service reconfiguration which the trusts were required to develop as hypothetical clinical scenarios at the start of the competition process.

BoD�Jul�13�11b�Part�1�Board�of

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It is important to stress that any changes to the configuration of services would be subject to full public consultation and must receive the support of commissioners and GPs before any decisions can be made. The final deadline for all parties’ responses is early August 2013. Both trusts will now consider fully the contents of the CC’s provisional findings before responding to them. It is important that we continue to reinforce the benefits of the merger until the final decision has been made as the CC will consider the evidence relating to relevant customer benefits (RCBs) before making its final decision. The target deadline for completion of the investigation remains on track for 26 August 2013.

Merger reference made 08 January

Gathering of information, questionnaires issued January – February 2013

Publish statement of issues 28 January 2013

Site Visit 18 February 2013

Main party hearing (1) 23 April 2013

Deadline for all parties’ responses / submissions in advance of provisional findings

18 June 2013

Main party hearing (2)

11 June 2013

Notify provisional findings and if required consider possible remedies

Early July 2013

Hold response hearing(s) (if required) Late July 2013

Final deadline for all parties’ responses / submissions

Early August 2013

Publish final report Mid-August 2013

Statutory deadline 26 August 2013

Programme Governance and Controls

Following completion of the CC investigation both parties will review plans for the formal

submission to Monitor. As a result of the CC provisional findings, the current target date for

submission to Monitor (30 September 2013) is now significantly at risk.

Communications and Stakeholder Engagement

Local and national media statements were proactively issued by both parties on Thursday 11

July to all regular TV, radio and print media.

Staff briefings at RBCH and PH were held on Friday 12 July 2013 to present the CC findings

and next steps. These were well attended.

Arrangements are being finalised to convene an urgent joint CoG, to brief both sets of

Governors on the latest developments with the CC. A Joint Governor briefing to update

members on the benefits of merger and the CC investigation was held on Monday 01 July

2013 (1600 – 1800) at The Salterns Hotel, Lilliput.

Work has continued on a) the listening exercise and b) the series of advertorials published in

local press across Dorset and west Hampshire.

Deborah Matthews

Programme Director

BoD�Jul�13�11b�Part�1�Board�of

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1

BOARD OF DIRECTORS – PART 1

Meeting Date: 24 July


Title:

Report on Visit to Wau Teaching Hospital April 2013

Purpose:

To present progress to date and ask for the Boards support for future visits.

Summary:

We have recently secured outside funding to support further developments in Wau, South Sudan. Our achievements to date are many improvements in basic care. We now plan to develop a high care ward to further enhance patient care. Our work supports the millennium goals of reducing maternal mortality and improving paediatric care.

Recommendation:

The Board of Directors are asked to note this report.

Prepared by:

DR FRANKIE DORMON Presented by:

DAME YVONNE MOORES


YES / NO Risk Register I/D No:



Other; i.e /NHSLA/HSE etc

Monitor compliance: YES / NO

Human Resources implications YES / NO Staff use their annual leave.

Financial implications YES / NO None, funded by charity.

Legal implications YES /NO None apparent.


BoD�Jul�13�12�Wau�Board�Report

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2


POOLE AFRICA LINK

Report to the Board of Directors – 26 July 2013

ANNUAL UPDATE ON THE CHARITY FUNDED LINK BETWEEN POOLE HOSPITAL AND WAU TEACHING HOSPITAL IN SOUTH SUDAN

1. INTRODUCTION AND OVERVIEW

1.1. On July 9th 2011, South Sudan became a country in its own right. This independence has resulted in a renewed energy to improve health services and the Link is ideally placed to take a lead role in this transformation. Conflict remains however, and currently the financial situation remains uncertain and austerity measures remain in place, although it is said that the issues between the North and South over the flow of oil are being resolved slowly.

1.2. The link between Poole Hospital NHS Foundation Trust and Wau Teaching Hospital (WTH) has been in place since April 2009 and continues to build on previous work to assist South Sudan healthcare professionals to develop their own skills and self-sufficiency. After 8 multidisciplinary team visits, improvements are very evident to see. The strength of our link lies in the relationships we have developed with medical staff, and the nurse training schools run by local nuns.

2. ENVIRONMENT

General Condition of the Hospital Wards and Grounds 2.1. Since our first visit there has been a tremendous improvement in the state of the hospital buildings.

Many areas had completed refurbishment by the Ministry of Health and staff are developing a feeling of pride in their surroundings.

2.2. The theatre suite has been renovated, a huge improvement. There is still very limited provision of anaesthesia beyond the use of ketamine. A Consultant Surgeon funded by the Intergovernmental authority on development (IGAD) made huge changes during his secondment in Wau.

2.3. The Paediatric wards have been partly renovated with Ward A being the best. The ward was clean,

light and each bed had sheets and mosquito nets were available. A recent fundraising event by the Wau UN base staff, with whom we have close relationships, will result in solar power to ensure light during the night for paediatric and gynaecology wards.

2.4. The outpatient emergency department has been totally renovated and many of these improvements

are as a direct result of our appeals to the Ministry of Health in Juba.

High Dependency Unit (HDU): 2.5. This project is part of our 5 year plan, supported by recent additional two year funding secured from

the Pharo Foundation. During the February visit the project was agreed by hospital management and local Minister of Health and area identified for the HDU. The April team set up the clinical area, identified the nursing team and began their training especially on the importance of observations and how they could improve patient care through the philosophy of HDU. We have provided and installed a solar panel to provide a vital source of light for the HDU. The unit is there in a skeletal form; hopefully we now can build on these foundations and start to formally admit patients.

2.6. Water remains a challenge, having to be delivered by donkey cart or lorry. There are working wells used by relatives staying in the hospital grounds. Running water is now available in theatre. Food is now provided for patients and staff have a canteen.


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3

2.7. The state of the electricity sockets and lighting remains poor. Power is supplied by a generator

which is expensive to run. Frequent power surges necessitated power surge protectors for most electrical items. The generator is officially functional from 9 – 3pm. Solar power is the way forward and needs more investment to ensure drugs and blood can be kept at the correct temperature and light is available at night. Staff

2.8. There is a new Director General of the hospital, Dr Alex Bakiet, who was the first Wau doctor to

benefit from a 6 week visit to Poole Hospital NHS Trust, a programme which we have since continued for others. Following training by our teams and a recent management course in Nairobi, Dr Bakiet will be in a good position to take WTH thro the challenges that face it. Two other doctors, one dentist and a clinical assistant have now come from South Sudan to Poole for development. Documentation and Administration

2.9. Documentation remains poor although now the Ministry of Health have recently provided the

hospital with charts and there has been some improvement in recording of observations. Administration is slowly improving under the direction of Dr Bakiet. The lack of internet connection, which is too expense to run, continues to stifle development and block communication and development for staff, also making communication for our teams very challenging.

3. OTHER PROGRESS

Equipment

3.1. We have now purchased 4 oxygen concentrators and this year commissioned a container delivery

for all the equipment we have purchased. We also took out unwanted resuscitation and other disposable equipment and set up emergency trolleys on several wards, providing the appropriate teaching to accompany the equipment. Patients in theatre now receive oxygen via a mask and their saturations are being measured. We have secured several pulse oximeters from the Lifebox charity. Other equipment sent this year includes a monitor, ECG machine, many sets of surgical instruments and books for which we have fundraised or obtained gifts and grants. In addition a team member raised money for a new operating microscope for Juba teaching hospital and Wau Teaching Hospital has benefitted from the old Juba one. Teaching

3.2. Teaching remains the main objective of our visits; as well as informal and formal teaching at WTH to

doctors, nurses, student nurses and midwives during our visit, we teach daily to the student nurses at both of the schools of nursing in Wau. Wau trains two thirds of nurses in South Sudan so our influence and involvement here is not to be underestimated. The first batch of nurses we taught have now graduated which is very encouraging.

4. PLANNING FOR THE FUTURE

1 Year Plan

4.1. The foundation for the HDU has now been created. The basic training has started and on the next visit, there are plans to identify medical and nursing leads and start admitting patients.

4.2. The blood bank should be up and running again by our next visit. 4.3. Nurse training is on-going on all other wards. Documentation is improving and we plan to improve

data collection where possible.


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4

5 Year Plan 4.4. With the development of a functioning recovery/HDU, further developments on medical and surgical

wards and theatres will be possible. As the student nurses finish their training there will be opportunities to further develop their skills. Areas which require further development at a multidisciplinary level include;

Surgical services supported by more advanced forms of anaesthesia,

Pathology services, including more routine measurement of haemoglobin and improved availability of blood for transfusion.

Structured training courses in Acute Illness Management, diabetes, eclampsia, and Acute Trauma Management.

Team working and communication.

Roll out of nursing skills developed on HDU/Recovery to other wards.

In addition we are working on plans to secure permanent safe and secure accommodation to enable longer visits for some team members.

5. ACKNOWLEDGEMENTS 5.1. We remain very grateful to all our friends in Wau and Juba, the Church, the Nurse Training Schools,

our UN contacts and the MOH in Juba. As always we learn as much from our visits as we teach and Poole staff have a great personal developmental opportunity.

5.2. We hope that the Board of Poole Hospital FT recognise the huge benefits of this link and will continue to give us their valuable support for the future.

5.3. More information can be found on our website: www.pooleafricalink.org.uk 6. CONCLUSION 6.1. The Board of Directors are asked to note this report.

DR FRANKIE DORMON HILARY FENTON-HARRIS Medical Lead for Poole Africa Link PAL co-ordinator


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http://www.pooleafricalink.org.uk/



BOARD OF DIRECTORS (Part 1 or Part 2)

GOVERNANCE CYCLE MARCH 2013

REGULAR REPORTS

Audit and Governance Committee Report (Receive) Chairman A&G

Finance and Investment Committee Report (Receive) Chairman FIC

Quality and Safety Committee Report (Receive) Chairman QSC

Workforce Committee Report (Receive) Chairman WC

Council of Governor Report (Receive) Chairman CoG

Risk Matrix (Receive) DoNPS/CEO

Exception Report on Governance Issues (For Information – When required) DoS

EXCEPTION REPORTS (e.g.)

Appointment Committee and Remuneration Committee Report (or brief) (Receive)

Chairman RC

Monitor Concerns CEO

CQC Key Submissions/Concerns DNPS

NHSLA Submission levels DNPS

NICE Compliance MD

Risk Issues DoN

Working Capital Utilisation Report (Receive) DoF

Commissioner Contract Variations (Approve) DoF

Cash Investments (Approve) DoF

Amendments to Directors’ Interests (Receive) CS

Board Governance Cycle (Approve) CS

Serious Untoward Incidents (New) Summary Part 2 MD

MONTHLY REPORTS

Chairman’s Report (Receive) Chairman

CEO Report (Receive) CEO

Merger Updates (Part 1) DoS

Any Red Risks added to the Risk Register DoNPS

Integrated Performance (Scrutinise) - Summary of Summary Paper Part 1 (£/ Contract /MPE/HR Activity/Compliance/Quality ) (Including FRP and if needed also to Part 2 of BoD

(Note detail to FIC, QSC & HEG)

Lead DoF

Support COO/DHR/DNPS

Integrated Performance (Scrutinise ) - Summary Paper Part 2 (£/ Contract /MPE/HR Activity/Compliance/Quality ) (Including FRP and if needed also to

Lead DoF

Support

Board�Governance�Governance�Cy

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Part 2 of BoD

(Note detail to FIC, QSC & HEG)

COO/DHR/DNPS

CIP – for 2012/13 monthly updates PT part 2 as part of Finance Report DoF

Board Development Action Plan six monthly review (from Feb 12) CS October/April

QUARTERLY REPORTS

Monitor Quarterly Certifications - Submissions (Approve) (Q3 – January; Q4 - April; Q1 - July; Q2 - October)

CEO

Summary of Complaints Report (Part 1) (Q3 – February; Q4 - May; Q1 - August; Q2 - November)

MD

Progress on Delivery of the Annual Plan (Part 1) (Part of CE Briefing) (Q3 – January; Q4 - April; Q1 - July; Q2 - October)

CEO

½ YEARLY & ANNUAL REPORTS

BOARD BUSINESS

Trust Assurance Framework

Annual Framework (Approve)

½ Year Review (Scrutinise)

½ Year Review of Annual Plan Objectives

(Also subject to A&GC Scrutiny Nov)

DNPS

DNPS

DoS

October

November

April/May

Risk Register Report DNPS October April (Annual Report)

Annual CQC Report DNPS July (Annual Report)

Review Strategic Risks DNPS September (Annual Report)

Summary of Claims & Litigation Report Part 2

MD January July

(April – Sept) (Oct – March)

Annual membership report (Covered by Annual Report and Annual Plan)

CoS April April - March

Information Governance SIRO (Summary)

DoF October March

Annual Policy Review for Complaints MD July

Annual Policy Review for Claims MD July

Complaints Summary Report MD (see also quarterly reporting)

July (Annual Report)

NHS Constitution Gap Analysis ? March September

ANNUAL GOVERNANCE REVIEW REPORTS

REVIEW REPORTS Lead ½ Yearly Annual Reports

Code of Conduct (5 yearly due 2013) CoS/ Chairman - November/December

Constitution (3 yearly due 2012) (Note CoG Approval)

CoS/ Chairman - November/December

Scheme of Reservation & Delegation (Approve 3 yearly)

BBM/ CEO - November/December


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Standing Financial Instructions (Approve 2 yearly)

DoF - November/December

Audit & Governance Committee Terms of Reference (Approve 5 Yearly)

Chair A&G/ DoF

- November 2013

Finance & Information Committee Terms of Reference (Approve 3 yearly)

Chair F&I/ DoF - December 2013

Quality and Safety Committee Terms of Reference (Approve 3 yearly)

Chair QSC/ DNPS

- January 2014

Seal of Documents Register CoS - April

Gifts & Hospitality Register CoS - April

POLICY

General Policies inc Research Governance – via Strategic Intent

HEG or its sub-committees

ANNUAL BOARD BUSINESS & OPERATIONAL REPORTS

BOARD ANNUAL BUSINESS Lead ½ Yearly Annual

Strategic Plan (Approve) Supporting Functional Strategies & Policy Intent (Approve)

CEO

Execs

(5 Year) TBA

5 Year) TBA

Annual Plan & Certification inc;

Clinical Quality

Mandatory services

Service Performance

Risk Management

Compliance with ToA

Board Roles, Structure and Capacity

(Scrutinise Draft at March Seminar)

Receive Draft (BoD Pt 2) Approve Final (BoD Pt 2) -

CEO CEO

-

March April/May

Draft Sources of Assurance (Board Certifications 2013/14)

CEO March

Annual Governance Statement (previously Statement of Internal Control (Approve)

CEO/DoF/DNPS - April/May

Annual Report/Accounts/Quality Accs (Approve)

DoF/ DCM/DNPS

- May/June

Audit Letter to Auditor (Agree) Chairman May/June

Board Reporting Governance Cycle (Approve)

Co Sec - March

Register of Interests (Receive) CoS/ Chairman - November/December

BOARD ANNUAL OPERATIONAL

Commissioner Contract(s) (Approve) (Scrutinise at March Seminar)

DoF/COO - March/April

Annual Budget/Capital Programmes DoF - March

Annual Staff Survey Report and Action Plan (Receive)

DoHR - May

Annual Emergency Preparedness Report (Receive)

COO TBA


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Annual Clinical Excellence Awards (Confirm Process)

DHR - March

MJB Mar 13


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COMMONLY USED ABBREVIATIONS

ABBREVIATION EXPLANATION

18-week target Delivery of a maximum 18-week wait from GP referral to start of treatment (RTT)

A & E Accident and Emergency

A&GC Audit & Governance Committee

AfC Agenda for Change is the pay system for NHS staff implemented in 2004. A summary of the system is available on the Department of Health website

AHPs Allied Health Professionals – physiotherapists, occupational therapists, speech therapists and orthotists. Previously known as PAMs (Professions Allied to Medicine)

AIRS Adverse Incident Recording System – the Trust’s no-blame system for reporting all clinical and non-clinical adverse incidents and near misses

AQP Any Qualified Provider – this scheme means that, for some conditions, patients will be able to choose from a range of approved providers, such as hospitals or high street service providers.

ASI Appointment Slot Issues

c.difficile Clostridium difficile - the major cause of antibiotic-associated diarrhoea and colitis, an intestinal infection that mostly affects elderly patients with other underlying diseases.

CEA Clinical Excellence Awards - given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care

CHKS CHKS is a national independent provider of comparative performance and benchmarking healthcare data

CEPOD CEPOD (Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

CIP Cost Improvement Plan

CoG The Council of Governors comprises:

14 public governors who are elected by members of their own constituency – Poole (8); Purbeck, East Dorset & Christchurch (3); Bournemouth (2); North Dorset, West Dorset , Weymouth & Portland (1);

4 staff governors who are elected by members of Trust staff – clinical (3); non-clinical (1);

6 appointed governors nominated by the Trust’s partner organisations – Bournemouth & Poole PCT (1); Dorset PCT (1); Dorset County Council (1); Poole Borough Council (1) Bournemouth Borough Council (1); Bournemouth University (1).

CQC The Care Quality Commission is the independent regulator of health and social care in England. The CQC regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations, and protects the rights of people detained under the Mental Health Act

CQUIN Commissioning for Quality and Innovation - tThe CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation. Its aim is to support the vision set out in High Quality Care for All of an NHS where quality is the organising principle. The framework was launched in April 2009 and helps ensure quality is part of the commissioner-provider discussion everywhere.

CRES Cost Releasing Efficiency Saving

CRT Clinical Record Tracking – a bar-code based system for recording the location of patients’ medical records.

DATIX National software programme for Risk Management

Dr Foster Dr Foster Intelligence, a joint venture between the Department of Health’s

Glosssary�of�abbreviations�Feb

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Information Centre and a private sector company Dr Foster LLP. Dr Foster provides a range of health information to the public (online and via supplements in the national media) and makes NHS performance data available under licence to health sector organisations

EBITDA Earnings Before Interest, Taxation, Depreciation and Amortisation

EBME Electrical, Biomedical Equipment

ENT Ear, Nose and Throat

ESR Electronic Staff Record - the national, integrated Human Resources (HR) and Payroll system used by all NHS organisations throughout England and Wales. The ESR has a bi-directional interface with NHS Pensions. Personal data for all staff will be transferred to a data warehouse. This will include contact details, salary information, HR records, trainings, qualification, occupational health and other records. It will also include sensitive information such as sickness record absence, disabilities, ethnic origin

EWTD European Working Time Directive - lays down minimum requirements in relation to working hours/rest periods/annual leave for all workers and working arrangements for night workers. The current limit is an average of 48 hours work per week.

FCE Finished Consultant Episode is a measurement which assigns a patient’s episode of care to a consultant

FFCE First Finished Consultant Episode identifies the first consultant episode of care during a patients hospital stay

FIC Finance & Investment Committee

Foundation Trust/FT

NHS foundation trusts are autonomous organisations, free from central Government control. They decide how to improve their services and can retain any surpluses they generate, or borrow money, to support these investments. They establish strong connections with their local communities; local people can become members and governors. These freedoms mean NHS foundation trusts can better shape their healthcare services around local needs and priorities. NHS foundation trusts remain providers of healthcare according to core NHS principles: free care, based on need and not ability to pay. Poole Hospital NHS Foundation Trust was authorised on 1 November 2007

FRP Financial Recovery Plan.

H@N Hospital at Night - the provision of multi disciplinary teams working in hospital Out of Hours who between them have the full range of skills and competencies to meet patients’ immediate needs

HDU High Dependency Unit, for patients requiring close monitoring and high levels of care but not life support

HR Human Resources

HRG Healthcare Resource Group – groupings of treatment episodes which are similar in resource use and in clinical response

HSE Health & Safety Executive

ICU or ITU Intensive Care Unit or Intensive Therapy Unit

I&E Income and Expenditure

IG Information Governance

IT or IM&T Information Technology or Information Management & Technology

KSF Knowledge & Skills Framework - identifies the knowledge and skills that individuals need to apply in their post. Used to provide a fair and objective framework on which to base review and development for all staff

LNC Local Negotiating Committee – the main management/medical staff forum

LoS Length of Stay

LTFM Long Term Financial Model


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MDT Multi-Disciplinary Team

Monitor The independent regulator of NHS Foundation Trusts. Monitor rigorously assesses applicants for NHS foundation trust status and subsequently monitors their activities to ensure that they comply with the requirements of their terms of authorisation. Monitor has powers to intervene in the running of a foundation trust in the event of failings in its healthcare standards or other aspects of its activities, which amount to a significant breach in the terms of its authorisation

Mortality rate The ratio of total deaths to total population in a specified community or area over a specified period of time. The death rate is often expressed as the number of deaths per 1,000 of the population per year.

MRSA Methicillin Resistant Staphylococcus Aureus – an antibiotic resistant infection commonly found on the skin and/or in the noses of healthy people. Although usually harmless at these sites, it may occasionally get into the body (eg through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or indwelling catheters) and cause infections. These infections may be mild (eg pimples or boils) or serious (eg infection of the bloodstream, bones or joints). An infection of the bloodstream is called a bacteraemia

MSC Medical Staff Committee

NCEPOD NCEPOD (National Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

NHSLA National Health Service Litigation Authority – the NHS clinical “insurance” scheme

NICE National Institute for Health & Clinical Excellence

NICU Neonatal Intensive Care Unit

NPfIT National Programme for Information Technology

NPSA National Patient Safety Agency

NSF National Service Framework - sets national standards and identifies key interventions for a defined service or care group. Also sets measurable goals within specified time frames.

NREC Nominations, Remuneration & Evaluations Committee - a sub-committee of the CoG responsible for the making recommendations to the CoG regarding the appointment, remuneration and performance review of the Chairman and non-executive directors

NVQ

National Vocational Qualification

OMF Oral Maxillo Facial

OFT Office of Fair Trading

PA/SPA Programmed Activities and Supporting Professional Activities. PAs identify medical staff clinical sessional commitments. SPAs are defined as “activities that underpin direct clinical care. This may include participation in training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities.”

PACS Picture Archiving and Communications System – the digital storage of x-rays

PALS Patient Advice and Liaison Service - provide information, advice and support to help patients, families and their carers

PBC Practice Based Commissioning – an initiative which enables clinicians and other front line staff to redesign services that better meet the needs of their patients

PCT Primary Care Trust. The two local PCTs are now known as NHS Bournemouth & Poole and NHS Dorset.

PEAT Patient Environment Action Team - PEAT team Inspections are a national initiative coordinated by the Department of Health

PFI Private Finance Initiative

PEWS Poole Early Warning System – a system to identify and alert staff of the deteriorating patient based on scoring patient observations against a number of


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criteria. Patients causing ‘alarm’ are reviewed by the nurse in charge of the ward and an emergency call made to switchboard requesting attendance of a member of the patients medical team or on call team

DToC Delayed Transfer of Care

PbR Payment by Results - the funding system for the NHS in England. This pays a standard tariff for the treatment of different conditions. Not all hospital activity is funded by PbR and hospitals still have to negotiate “block funding” to cover these areas – eg. diagnostic and screening tests.

PHFT Poole Hospital NHS Foundation Trust

PID Project Initiation Document

PMETB Postgraduate Medical Education and Training Board

PMO Project Management Office

PROM Patient Recorded Outcomes Measures

PTIP Post Transaction Implementation Plan

PYLL Potential Years of Life Lost

QIPP The Quality, Innovation, Productivity and Prevention Programme. This is about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients.

QSC Quality & Safety Committee

RBH Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

RCI/Reference costs

Reference Cost Index – reference costs are the average cost to the NHS of providing a defined service within a given financial year. The RCI compares the actual cost of activity with the same activity at national average costs - organisations with costs equal to the national average score 100 whilst an organisations with a score of 80 or 115 has costs 20% below/ or 15% above the national average. The RCI is used for benchmarking and as the basis of PbR

RTT Referral to Treatment. The current RTT Target is 18 weeks.

SHA Strategic Health Authority – NHS South West is one of the ten Strategic Health Authorities in England formed on 1 July 2006

SIRO Senior Information Risk Owner

SLA Service Level Agreement - a SLA is an agreement that sets out formally the relationship between service providers and customers for the supply of a service by one or another.

SLM Service Line Management

SLR Service Line Report

SMR Standardised Mortality rate – see Mortality Rate

SpR Specialist Registrar – medical staff grade below consultant

SPF Staff partnership Forum – t the main management/ staff forum, previously known as the JCNC (Joint Negotiating & Consultation Committee)

TAL

NHS Direct provides The Appointments Line service as part of the Choose & Book system. Choose and Book is the electronic hospital appointments booking system. It allows people to make their first outpatient appointment online, at their GP practice, or by calling the Appointments Line (TAL). Patients can choose the place, date and time of the appointment to suit them.

WTE Whole Time Equivalent

February 2013


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AGENDA - Poole Hospital Pack July Part 1.pdf · 24 July 2013 - 09:00 Board Room, Poole Hospital...

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