Council of GovernorsInformation, Advice and Support Service (SENDIASS). Mar 2013 Mar 2013 Mar 2014...

Agenda

WelcomeDeclaration

ofInterest

Apologies MinutesMatters Arising

Chairman'sReport

Chief Executive's

Report

IntegratedQualityReport

Any Other

Business

Attendance Record

IntegratedImprovement

Plan

DementiaStrategy

Presentation

Governanceand

Governors'responsibili-

ties

Council ofGovernors

2 June 2015 4.00pm

Village Hotel,The Green Business Park, Dog Kennel Lane,

Shirley, Solihull

June 2015

Council of Governors

.2

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Notice is hereby given that a meeting of the Council of Governors

of Heart of England NHS Foundation Trust will be held at the Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Solihull B90 4GW

on 2 June 2015 4.00 – 6.00pm

A G E N D A

Indicative Timings

(minutes) Presenter

1. Welcome

2 Chair

2. Apologies

1 Kevin Smith

3. Declarations of Interest - Governors - Directors

2 Chair (Enclosure)

Strategy

4. Chief Executive’s Report

10 Andrew Foster

(Enclosure)

Quality & Performance

5. Integrated Quality & Performance Report, including Finance

20 Jonathan Brotherton/ Darren Cattell/ Andrew Catto/ Sam Foster

(Enclosure)

6. Integrated Improvement Plan

10 Andrew Catto (Enclosure)

Matters for Report

7. Dementia Strategy Presentation

20 Niall Fergusson/ Phil Hall (Oral)

Governance & Administration

8. Minutes of previous meetings – 14 April & 5 May 2015

5 Chair (Enclosure)

9. Matters Arising/ Recommendations Tracker

5 Kevin Smith (Enclosure)

10. Governance and Governors’ responsibilities

5 Kevin Smith (Enclosure)

11. Attendance Record

2 Chair (Enclosure)

For Information

12. Chair’s Report

5 Chair

(To follow)

13. Any Other Business Previously Advised to the Chair

14. Date of Next Meeting

8 July 2015 – Harry Hollier Lecture Theatre, Good Hope Hospital, Sutton Coldfield Refreshments will be available from 3.30pm Kevin Smith Company Secretary 26 May 2015

June 2015


.3

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Welcome

June 2015


.4

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Apologies

June 2015


.5

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Declarations ofInterests

Council of GovernorsJune 2015

.6

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Declaration of Interests - Governors

COUNCIL OF GOVERNORS

REGISTER OF INTERESTS NAME INTEREST DECLARED DATE

DECLARED DATECEASED

Cllr Mohammed Aikhlaq

Awaiting information

Arshad Begum Nothing to declare 21 Nov 2011

Kath Bell Company Secretary - Succeed Services Ltd 21 Nov 2011

Nicola Burgess Awaiting information

Elaine Coulthard Nothing to declare 21 Nov 2011

Dr Olivia Craig No declaration received

Carol Doyle Awaiting information

Helen Griffiths Awaiting information

Emma Hale Nothing to declare 27 May 2014

Ron Handsaker 1. Shareholder – Santander 2. Director – 24/7 Industrial Services UK Ltd

200020 Oct 2014

Albert Fletcher Director – Aquarius (unpaid). A charity that specialises in helping and treating those with drink and/or drug issues.

28 May 2013

Richard Hughes 1.Chairman – Homestart (Tamworth) 2.Chairman – Tamworth Credit Union Ltd 3.Director – The Pathway Project 4.Director – Tamworth Community Advice Network CIC 5.Chairman – Tamworth Talking Newspaper Ltd 6.TrusteeChairman – The Rawlett Trust

7.Vice Chairman – Standards Committee, Tamworth Borough Council 8.Divisional President – St John’s Ambulance 9.Member – Appeal Committee, St Giles Hospice 10.Retired CEO & President Secretary, Tamworth Cooperative Society 11.Mr Hughes’ son holds a very senior managerial position with Barclays Bank 12.Chairman – Tamworth Community Advice Network CIC 13. Independent Member – Tamworth Borough Council Nominations Committee 14. Member – Conservation Advisory Committee, Tamworth Borough Council 15. President – Tamworth Male Voice Choir 16. Treasurer – St Andrew’s Methodist Church, Tamworth 17. Shareholder – BP 18. Shareholder – Santander 19. Trustee – Spirit of Tamworth Trust

21 Nov 2011

Amended 1 Sep 2013

Amended 23 Oct 2012 16 Feb 2012

23 Oct 2012

23 Oct 2012

23 Oct 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012

23 Oct 2012 23 Oct 2012 May 2014

23 Oct 2012 4 Mar 2014 23 Oct 2012

23 Oct 2012

23 Oct 2012


.7

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Declaration of Interests - Governors

Michael Hutchby Nothing to declare 16 Aug 2013

Sue Hutchings Shareholder in Lloyds TSB 19 Sept 2013

Phillip Johnson Nothing to declare 21 Nov 2011

Michael Kelly Nothing to declare 21 Nov 2011

Attiqa Khan Nothing to declare 16 Aug 2013

Heidi Lane 1. Member of Church – Renewal Christian Centre 2. Husband is an Elder of the Church. 3. Trust uses Christian Renewal Centre for

conferences & meetings

21 Nov 2011

Andrew Lydon Nothing to declare 16 Aug 2013

Anne McGeever 1. Registered with Therapy Bank in Worcestershire to provide services to BMI Droitwich Spa Hospital. 2. Unite Professionals Limited (Occupational Therapists) – ad hoc employment.

12 Sep 2014

14 Apr 2015

Margaret Meixner Awaiting information

CatherineNeedham

Nothing to declare 13 May 2014

Barry Orriss Nothing to declare 21 Nov 2011

Mark Pearson Member of Green Party 21 Jan 2015

Cllr Jim Ryan Archway Academy Ltd – Owner/MD Archway Community College - Owner/MD Archway Brimstone Security – Owner/MD Archway Renaissance LLP – Owner/MD Robert Ryan Housing Investments - Owner /MD

15 July 2013

Liz Steventon Friends of Solihull Hospital 21 Nov 2011

David Treadwell 1. Shareholder - Lloyds TSB 2. Shareholder - STW 3. Shareholder - National Grid

21 Nov 2011

Matthew Trotter 1. HEFT Employee 2. Director - Specialist Health Partnership 3. Director - Specialist ENT Care Ltd

12 Sep 13

15 Dec 14


.8

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Declaration of Interests - Voting Directors

REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING DIRECTORS

NAME DATE OF APPOINTMENT INTEREST (if any) DATE OF

NOTIFICATION DATE OF

TERMINATION OF INTEREST

Mr Jonathan Brotherton

04.03.15 Nothing to declare

Dr Patrick Cadigan 01.07.13 1. Consultant cardiologist at Sandwell and West Birmingham Hospital Trust.

2. Registrar of the Royal College of Physicians of London.

3. Member of the clinical advisory group advising the Trust Special Administrators re the future of Mid Staffs NHS Trust.

4. Member of the clinical advisory group to NHS England on rare diseases.

5. Undertakes paid consultancy work for McKinsey & Co.

Mar 2014

04.07.14

31.12.13

Mar 2014

Mr Darren Cattell 19.01.15 Director & Shareholder - Mill Street Consultancy Limited.

Sept 2005

Dr Andrew Catto 01.03.14 (Interim CEO -

14.11.14 to 16.02.15)

Nothing to declare.

Mr Andrew Edwards

01.10.14 1. Couch Perry & Wilkes. In receipt of annuity following business sale until May 2019.

Mr Andrew Foster 16.02.15 Director of Wrightington Wigan & Leigh NHS Foundation Trust.

Mrs Sam Foster 01.09.13 Nothing to declare.

Ms Hazel Gunter 04.03.15

Nothing to declare.

Mrs Karen Kneller 01.10.14 1. CEO of Criminal Cases Review Commission

2. Part time judge Social Entitlement Chamber Fitness to Practise

3. Member for General Dental Council 4. Director (unremunerated) of BRAP, an

equalities think tank.


.9

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties





Mr Les Lawrence 01.04.12 (Chair –

01.06.14)

1. Trustee for the National Institute for Conductive Education.

2. Governor of City of Birmingham School.

3. Director of Lindridge Enterprises Limited.

4. Director (unremunerated) of Bordesley Birmingham Trust Limited (since 7 July 2011).

5. Chairman of the Birmingham Special Educational Needs & Disability Information, Advice and Support Service (SENDIASS).

Mar 2013

Mar 2013

Mar 2014

July 2014

Mar 2015

Mr David Lock 01.07.13 1. Practising barrister and a member of Landmark chambers. Providing legal advice and representation to a wide range of individuals, NHS organisations, local authorities, charities and commercial organisations mainly on public law issues. These frequently involve issues concerning the rights of patients to NHS treatment as well as structural and management issues involving NHS bodies.

2. Member of Amnesty International. 3. Member of the BMA Ethics Committee

(unremunerated). 4. Member of the Labour Party and

occasional legal advice to Labour Party and elected Members of Parliament on NHS policy issues.

5. Mr Lock’s wife, Dr Bernadette Gregory, is a medical doctor employed by Redditch and Bromsgrove Clinical Commissioning Group and is Clinical Lead for the Worcestershire Integrated Care Project.

6. Chairman of Innovation Birmingham Limited.

7. Representing NHS England in relation to specialised services.

8. Receives instructions from the CQC.

Updated Jan 14

05.11.13

06.01.14

04.07.14

Ms Alison Lord 01.05.13 1. CEO and Shareholder of Allegra Ltd. 2. Voluntary role as a business mentor

for the Prince's Trust. 3. In her professional capacity as a

'turnaround executive' Ms Lord has relationships from time to time with major accountancy firms, legal firms, banks and venture capital providers.

4. Company Secretary - Adente Limited (unremunerated).

22.01.14

13.05.14


.10

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties





Dr Jammi Rao 01.07.13 1. Sole director of Gorway Global Ltd. a private company and owning 50% of its share capital. A consulting company offering management support, training and bespoke public health analytical support to public sector organisations involved in health, well-being and health care.

2. Board Director of Welcome CIC - a Community Interest Company supporting minority and disadvantaged communities by working with statutory and other agencies.

3. Trustee of the Faculty of Public Health as an elected General Board Member. Term of office from 2010 to July 2013.

4. Visiting Professorship in Public Health in the School of Health, Staffordshire University.

Jul 2013

Prof Laura Serrant 01.04.12 1. Director of Research & Enterprise at University of Wolverhampton

2. Non-executive director National Skills Academy for Health (unremunerated).

01.04.12

23.01.14

Mr Adrian Stokes 01.07.08 1. Director of Heartlands Education Centre Ltd.

2. Pfizer Virtual Customer programme.

01.07.08

20.06.11


.11

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Chief Executive's Report


.12

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


1

Chief Executive’s Report Introduction I have now been in post for just over three months and it has been quite a journey. There have been several ups and downs but for the most part I think we can see signs of small improvements in performance and more significant advances in our systems of governance. Monitor tell us that they feel more assured that the Executive team is performing cohesively and, through the Integrated Improvement Plan, can demonstrate that we are tackling all of the major challenges we face. I hope that we can move from a position of being constantly on the back foot, responding to concerns from our Regulators and others, onto the front foot when we can agree a suite of strategies and plans in September. By the time today’s HEFT Board meeting takes place, the WWL Board should have formally approved the extension of my interim period by a further 3 months, taking me through to mid-November 2015. This enables me to offer a little more stability and consistency of message which is very important to each of my three main priorities of Clarity, Staff Engagement and Quality Improvement. Clarity The two key areas of work are about how the Trust is managed and what are its plans for the future? We have extended the structure charts to a third level (Appendix A) and published them internally. This means that everyone can see the main responsibilities and reporting lines for Executive Directors, each of their direct reports, and each next in line direct report. The plan is to continue this process until we have a full line of sight from Ward to Board. The EMB has also held three discussions about the thorny issue of whether we manage by Site or by Service where currently we have an unhelpful hybrid of the two. The emerging view is that we should manage by Division. Thus the five Divisions include Heartlands and Good Hope as Sites, Solihull as a combined Site and Community, and Clinical Support and Women’s and Children’s as Cross-Site Divisions. The main principles of this should be that:

We will operate a clinically–led, devolved system of management where the Trust Board sits above the Executive Management Board (EMB)

The EMB comprises the Executive Directors, Associate Medical Directors and Heads of key departments

AMDs will have direct line management of all staff in their Division through Clinical Directors

The Clinical Support Division - stressing its role is indeed to support other Divisions and for CSS to reflect on possible future models of operation for example the equivalent of a Service Line Agreement

In so far as possible, every member of staff should have a single line manager There will also be discussion with Clinical Directors (CD) on developing CDs with a

Cross-Divisional responsibility. Their duty will not be to line manage other sites but to lead on collaboration between sites, professional standards and long term planning. There will also be work on the role of the clinical lead.

We will now consult with CDs and others to come up with a clear statement of how this will work in practice and the respective duties of a Divisional CD and a Cross-Divisional CD.


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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

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Attendance Record


Plan

DementiaStrategy

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2

Matthew Cooke continues to make good progress on the suite of strategies. Two large Listening Events were well attended and produced enthusiastic initial feedback. The next major draft will be discussed in the second part of this meeting. Staff Engagement Hazel Gunter is reporting on progress in Part 2 of the meeting so I will not comment further here other than to thank the many hundreds of staff who have now actively participated in various events and Alex Covey’s team who are enthusiastically managing this complex and ambitious programme. Quality Improvement We held a Quality Summit on 27th April to celebrate four examples of excellence that are already happening in the Trust:

Phil Hall, senior dementia nurse, gave a presentation on dementia care and we heard that the Trust has been selected as the acute pilot site for the Midlands to test a new Learning Needs Analysis (LNA) tool. This is part of the Skills for Health dementia innovation programme of work and its aim is to develop a national competency framework for staff working with people with dementia across healthcare organisations, social care, GP practices, care homes and voluntary organisations.

Michelle Davies, resuscitation officer gave a presentation on the excellent work they are doing at Good Hope on anaphylaxis, making sure that the lifesaving adrenalin injection is administered correctly.

Mr Haney Youssef talked us through the latest developments with peritoneal surgery and I had not previously known that HEFT is one of just three centres in England conducting this complex surgery. Mr Youssef is pioneering a new procedure called the “sugarbaker” which has spectacularly improved survival rates.

Dr Das Pillay and Caroline Maries-Tillott gave a presentation about antibiotic initiatives in the Trust. They have helped electronic prescribing wards to increase antibiotic stop date performance which has gone up by 28% compared to the same period last year. IV antibiotic administration within one hour has improved in the past 2 years from 56% to 71%. A ‘live’ antibiotic dashboard (unique in the NHS) is available for wards to maintain vigilance to avert delays in STAT antibiotic dose administration. This involved the introduction of a medication dashboard which is part of a wider quality and safety improvement project to advance the Trust’s performance of indicating stop/review dates and administration of antibiotic doses

A different kind of Quality Summit was held on 20 May when the CQC presented its findings following the unannounced inspection in December 2014. The final version of the report is due to be published on 1st June so we will arrange to have a full item about the report and our response at a future Trust Board meeting. In the meantime here are the headlines:

The Trust will receive an overall rating of “Requires Improvement”. There are two higher ratings (Outstanding and Good ) and one lower (Inadequate)

One department, Heartlands Emergency Services, was rated as Inadequate; Solihull Outpatients was rated as Good; all other departments were rated as Requires Improvement.

The report cites five examples of outstanding practice: Heartlands AMU complaints resolution, leadership on five wards at Heartlands, the Practice Placement Team, Sexual Health Information and widespread observation of compassionate care across the Trust.


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3

It also cites numerous areas for improvement and 26 must-dos, many of which have already been done. The number one outstanding issue is safety in ED.

We fully accepted the CQC report and recommendations and agreed to build them all into our Integrated Improvement Plan

Other Matters As at the last Board, my contention is that we should accord most priority to the challenges described above but there is still a long list of other major issues that need attention:

A&E performance and the controversial issue of what trajectory we can “commit” to 18 week performance (especially gastroenterology) Financial trading deficit last year and this Building and maintaining Monitor’s confidence Developing and mainstreaming the Integrated Improvement Plan The Deloitte Governance and IT reports The Kennedy report The Silverman report and excess mortality and harm Relationships with commissioners and the 15-16 contracts Staff shortages, especially nursing Surgical reconfiguration Solihull Urgent Care Centre Solihull Integration Plan Quality and capacity of senior and middle management

Andrew Foster 21 May 2015


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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

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Any Other

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Attendance Record


Plan

DementiaStrategy

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ties


Dep

uty

Dire

ctor

and

Chi

ef o

f Sta

ff (M

edic

al D

irect

or’s

Offi

ce)

Head

of R

evie

w a

nd

Reca

ll

Caro

line

Will

iam

s (In

terim

)

Head

of

Com

mun

icat

ions

Ka

te E

ccle

s

Med

ical

Illu

stra

tion

and

Mul

ti M

edia

Man

ager

Gl

enn

Man

nion

Med

ical

Dire

ctor

’s O

ffice

Ad

min

istr

atio

n

Clin

ical

Rev

iew

–

Spec

ialis

t cas

es

Reca

ll pl

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ng a

nd

deliv

ery

Med

ical

Illu

stra

tion

Gr

aphi

cs

Desig

n

Inte

rnal

Co

mm

unic

atio

ns

Exte

rnal

Co

mm

unic

atio

ns

Intr

anet

M

edia


.16

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Dep

uty

Med

ical

Dire

ctor

(Str

ateg

y an

d Tr

ansf

orm

atio

n)

Mat

thew

Coo

ke

Head

of C

linic

al

Serv

ices

Str

ateg

y

Joan

na H

odgk

iss

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ctor

of R

esea

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n

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arch

M

IDRU

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ht

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stra

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y Pl

anni

ng- J

onat

han

Brot

hert

on

Med

Lea

ders

hip-

DM

D (E

lder

ly)



.17

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Dep

uty

Med

ical

Dire

ctor

– A

ppra

isal,

Perfo

rman

ce a

nd O

utco

mes

Cl

ive

Ryde

r

As

soci

ate

Med

ical

Di

rect

or R

eval

idat

ion

–Ad

edej

i Oku

bade

jo

Ope

ratio

ns M

anag

er

(TBC

)

Dire

ctor

of M

edic

al

Safe

ty /

Qua

lity

Impr

ovem

ent

Ann

Keog

h

Med

ical

Rev

alid

atio

n

Inve

stig

atio

ns

Cald

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t Gua

rdia

n

Qua

lity

Impr

ovem

ent

Mor

talit

y

Adm

inist

ratio

n Su

ppor

t Pr

ojec

t Sup

port



.18

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Ch

ief N

urse

Sa

m F

oste

r

Depu

ty C

hief

N

urse

Sue

Hyla

nd

Head

of P

MO

Nic

k Va

rney

(in

terim

unt

il en

d Ju

ne ‘1

5)

Head

N

urse

s Ch

ildre

n’s

Head

of

Mid

wife

ry

Depu

ty C

hief

N

urse

Julie

Tun

ney

De

puty

Dire

ctor

of

Pat

ient

Ex

perie

nce

Ri

char

d Br

own

Head

Nur

se

Safe

guar

ding

Mar

ia K

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ne

Head

of

Gov

erna

nce

TB

C

Head

Nur

se

Infe

ctio

n Pr

even

tion

&

Con

trol

Gill

Abb

ott



.19

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Depu

ty C

hief

N

urse

Sue

Hyla

nd

Depu

ty C

hief

N

urse

Sue

Hyla

nd

Head

Nur

ses

Ch

ildre

n’s

BH

H GH

H So

lihul

l

Head

of M

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Head

Nur

se –

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Exp

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Co

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Nur

sing

Tea

m

De

puty

Chi

ef N

urse

Sue

Hyla

nd

De

puty

Chi

ef N

urse

Julie

Tun

ney



.20

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

De

puty

Dire

ctor

of P

atie

nt

Expe

rienc

e

Rich

ard

Brow

n

Ja

mie

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ery

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ad o

f Pat

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vice

s &

Enga

gem

ent



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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

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Plan

DementiaStrategy

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ties

Head

Nur

se

Safe

guar

ding

Mar

ia K

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ne

M

atro

n Ad

ult

Safe

guar

ding

Lorr

aine

Lon

gsta

ff

Le

ad M

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ife

Safe

guar

ding

Ca

rol O

wen



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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

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Attendance Record


Plan

DementiaStrategy

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Governanceand


ties

De

puty

Dire

ctor

of

Gove

rnan

ce

TB

C

He

ad o

f Co

rpor

ate

Risk

&

Com

plia

nce

Ra

chae

l Bl

ackb

urn

He

ad o

f Hea

lth

& S

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vern

ance

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e Au

cott

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vern

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se R

udd

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f Leg

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stig

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ns

Sara

h C

arr-

Cave

Pa

tient

Saf

ety

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sor

Caro

line

Mar

ies-

Tillo

tt



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WelcomeDeclaration

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Chairman'sReport

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DementiaStrategy

Presentation

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ties

Head

Nur

se

Infe

ctio

n Pr

even

tion

&

Con

trol

Gill

Abbo

tt

Depu

ty H

ead

Nur

se

Infe

ctio

n Pr

even

tion

&

Cont

rol

Ja

ne C

odd



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WelcomeDeclaration

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DementiaStrategy

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ties

D

irect

or o

f Fin

ance

and

Per

form

ance

(Int

erim

) D

arre

n C

atte

ll

Fina

nce

& P

erfo

rman

ce

Dep

uty

Fi

nanc

e D

irect

or

A

idan

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nn

Hea

d of

P

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rman

ce

(Inte

rim)

D

iane

Pov

ey

Dire

ctor

o

f Ass

et

Man

agem

ent

Jo

hn S

ella

rs

Dire

ctor

of

ICT

(Int

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)

Jon

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Dire

ctor

of

Fina

nce

Ope

ratio

ns

Jo

nath

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201

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TB

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Chairman'sReport

Chief Executive's

Report


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Business

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Plan

DementiaStrategy

Presentation

Governanceand


ties

D

irect

or o

f Fin

ance

Ope

ratio

ns

Jona

than

Gou

ld

Fina

nce

Ope

ratio

ns

Chi

ef F

inan

cial

C

ontro

ller

A

ngel

ine

Jone

s

H

ead

of In

com

e &

C

ontra

ctin

g

M

ike

Arc

her

P

rocu

rem

ent

Dire

ctor

Dav

e C

oley

Proj

ect

Sup

port

Mon

a Ta

ylor

May

201

5



.26

Agenda

WelcomeDeclaration

ofInterest


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Report


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Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

H

ead

of P

erfo

rman

ce (I

nter

im)

Dia

ne P

ovey

Perf

orm

ance

Ope

ratio

nal

Per

form

ance

&

Del

iver

y M

anag

er

C

laire

Rym

er

Hea

d of

Ser

vice

Im

prov

emen

ts

Va

canc

y

Cor

pora

te

Per

form

ance

&

Del

iver

y M

anag

er

D

awn

Car

ty

Pro

ject

Man

ager

Fi

nanc

e S

taff

Dev

elop

men

t

Sue

Lyd

don

Hea

d of

Clin

ical

C

odin

g

Ste

phen

Cro

ss

May

201

5



.27

Agenda

WelcomeDeclaration

ofInterest


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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Faci

litie

s &

C

orpo

rate

Mal

colm

Cla

rk

D

eput

y Fi

nanc

e D

irect

or

Aida

n Q

uinn

Ope

ratio

nal B

usin

ess

Supp

ort

H

eartl

ands

H

ospi

tal

C

lair

Youn

g

Goo

d H

ope

Hos

pita

l

Ele

na E

dwar

ds

Sol

ihul

l Hos

pita

l

Ada

m W

inst

anle

y

Clin

ical

Sup

port

Ser

vice

s

Cla

ire P

ooni

Wom

en’s

&

Chi

ldre

n’s

Jo

-Ann

e Jo

hn

Ric

hard

Bar

ratt

Hea

d of

Pro

ject

s S

ue K

ing

May

201

5



.28

Agenda

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ofInterest


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Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

D

irect

or o

f IC

T (In

terim

) Jo

nath

an R

ex

D

eput

y D

irect

or o

f IC

T

Ann

e S

mal

lpag

e

Hea

d of

ICT

Bus

ines

s D

eliv

ery

Lee

Woo

tton

H

ead

of

Med

ical

R

ecor

ds

Ly

nn D

ugga

n

ICT

H

ead

of IC

T P

rogr

amm

e M

anag

emen

t an

d Tr

aini

ng

C

arol

ine

Sad

ler

H

ead

of IC

T

Sys

tem

s D

evel

opm

ent

D

ave

Hex

tell

H

ead

of IC

T Te

chni

cal

Ser

vice

s

D

idie

r Mee

rt M

ay 2

015



.29

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Plan

DementiaStrategy

Presentation

Governanceand


ties

D

irect

or o

f Ass

et M

anag

emen

t Jo

hn S

ella

rs

Ass

et M

anag

emen

t

H

ead

of E

stat

es

M

ike

Tayl

or

Hea

d of

Fac

ilitie

s

Chr

is D

avie

s

H

ead

of C

apita

l P

roje

cts

M

ark

Pig

gott

O

pera

tions

Lea

d fo

r Ass

et

Man

agem

ent

K

aren

Ton

gue

May

201

5



.30

Agenda

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DementiaStrategy

Presentation

Governanceand


ties

Rol

e

TBC

PMO

R

ole

Nam

e

Rol

e N

ame

Rol

e N

ame

Rol

e N

ame

May

201

5



.31

Agenda

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ofInterest


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Plan

DementiaStrategy

Presentation

Governanceand


ties


Carl

Holla

nd

Head

of O

pera

tions

BH

H

Emer

gen

cy C

are

Gro

up

Gen

eral

M

anag

er

Ben

Rich

ards

Em

erge

ncy

Care

G

roup

G

ener

al

Man

ager

Be

n Ri

char

ds

Surg

ery

Gro

up G

ener

al

Man

ager

C

hery

l Hud

son

Ad

mis

sion

s &

Disc

harg

e

Govi

ndan

Ra

ghur

aman

AM

D, B

HH

Sara

h Q

uint

on

Head

Nur

se, B

HH

Em

erge

ncy

Care

As

soci

ate

Head

Nur

se

Sa

rah

Brow

n

Med

icin

e

G

roup

G

ener

al

Man

ager

M

ark

Houg

hton

Med

icin

e

As

soci

ate

Head

Nur

se

Ly

nn F

ishe

r

Surg

ery

G

roup

Cl

inic

al

Dire

ctor

TB

C

Surg

ery

As

soci

ate

Head

N

urse

Lo

uise

Ev

eret

t

Med

icin

e

G

roup

Cl

inic

al

Dire

ctor

Ra

hul

Muk

herje

e

Surg

ery

G

roup

G

ener

al

Man

ager

Ch

eryl

Hu

dson

Emer

genc

y Ca

re

Gro

up

Clin

ical

Di

rect

or

TBC

BHH

Site

Emer

genc

y De

part

men

t AM

U

Elde

rly C

are

Stro

ke

Card

iolo

gy

Gen

eral

M

edic

ine

Capa

city

M

anag

emen

t SA

U

Gen

eral

Su

rger

y

Thor

acic

Gas

tro

Uro

logy

Vasc

ular

Trau

ma

Neu

rolo

gy

CH

ON

C

Resp

irato

ry

Re

nal


.32

Agenda

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Plan

DementiaStrategy

Presentation

Governanceand


ties


Dr A

lan

Jone

s As

soci

ate

Med

ical

Dire

ctor

Eric

a Lo

ftus

He

ad o

f Ope

ratio

ns

Lab

Med

ID

/Sex

ual

Heal

th

OPD

& A

BC

Criti

cal C

are

&

Anae

sthe

tics

Thea

tres

, DS

U, P

re o

p,

SAL

Radi

olog

y Ph

arm

acy

Cl

inic

al

Com

plia

nce

Clin

ical

Di

rect

or

Dr R

eyno

lds

Clin

ical

Dire

ctor

Dr

O’B

rien

(CC)

&

Dr S

eeth

aram

a (A

naes

)

Clin

ical

Di

rect

or

Mr S

uper

Clin

ical

Di

rect

or

Dr S

mith

Stua

rt D

ale

Gene

ral M

anag

er

Clin

ical

Di

rect

or

Dr Jo

nes

Ther

esa

Pric

e Ge

nera

l Man

ager

Clin

ical

Di

rect

or

T Ca

rrut

hers

Stev

e W

alle

r Ge

nera

l Man

ager

Mar

ie P

eplo

w

Radi

olog

y

Rach

el

Ferr

eday

Th

eatr

es

Mar

ie N

olan

An

aes &

Crit

Ca

re

Hele

n Ev

ans

OPD

& A

BC

Trac

y Pe

arso

n ID

/Sex

ual

Heal

th

Jane

t Fre

el

Med

ical

De

vice

s

Balji

t Atw

al

Phar

mac

y

CLIN

ICAL

SU

PPO

RT

SERV

ICES


.33

Agenda

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ofInterest


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Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Andr

ew C

lem

ents

He

ad o

f Ope

ratio

ns

Plan

ned

Care

Ge

nera

l M

anag

er

Su

zann

e N

icho

lls

Pl

anne

d Ac

ute

and

Com

mun

.

Unp

lann

ed

Acut

e an

d Co

mm

un.

Ther

apie

s acr

oss

all a

cute

and

SO

L Co

mm

unity

Ge

nera

l M

anag

er

Unp

lann

ed

Care

Sally

Car

en

Vario

us

Child

rens

Co

mm

unity

Se

rvic

es

Gene

ral

Man

ager

Tr

ansf

orm

atio

n

Emm

a Ta

lla

N

urse

Lead

Ch

ildre

ns

Com

mun

ity

Ka

ty C

oate

s

Pr

ogra

mm

e M

anag

emen

t/De

liver

y St

rate

gies

Ther

apie

s M

ary

Ross

An

d ot

her

Clin

ical

Di

rect

ors

Rich

ard

Stey

n AM

D Va

ness

a W

ort

Head

Nur

se

SOLI

HULL

DIV

ISIO

N

Asso

c.

Head

N

urse

An

n Ed

gar

Nur

sing

Supe

rvis.

Nur

sing

Pr

ofes

s.

Advi

ce

Supe

rvis

ion


.34

Agenda

WelcomeDeclaration

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Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Phill

Lydd

on

Head

of O

pera

tions

Emer

gen

cy C

are

Grou

p Ge

nera

l M

anag

er

Ben

Rich

ards

Obs

tetr

ics

Ge

nera

l M

anag

er

Katy

Hog

an

Surg

ery

Grou

p Ge

nera

l M

anag

er

Che

ryl H

udso

n

Ad

mis

sion

s &

Disc

harg

e

Vaca

ncy

AMD

Bhav

na G

okan

i He

ad N

urse

O

bste

tric

s

Ope

ratio

nal

Depu

ty to

Ho

M

Trac

ey N

ash

M

atro

n M

idw

ifes

GHH

Asse

ssm

ent

& W

ards

M

aggi

e Co

lem

an

Deliv

ery

suite

Jo

selle

W

right

BH

H Lo

rna

Fost

er

ass/

war

ds

Carla

Ch

arle

s-Jo

nes

Deliv

ery

suite

Gyna

ecol

ogy

Ge

nera

l M

anag

er

Katy

Hog

an

Gyna

ecol

ogy

Mat

ron

Tr

acey

Nas

h

Paed

iatr

ics

Cl

inic

al

Dire

ctor

Ro

opa

Mul

ik

GH

H Cl

inic

al

Lead

An

jum

Ga

ndhi

Paed

iatr

ics

M

atro

n Am

ee

Deny

er

Gyna

ecol

ogy

Cl

inic

al

Dire

ctor

Ka

ther

ine

Barb

er

Clin

ical

Lea

d Pr

atim

a Gu

pta

Paed

iatr

ics

Ge

nera

l M

anag

er

Lynn

e Bo

wye

r

Obs

tetr

ics

Cl

inic

al

Dire

ctor

Ka

ther

ine

Barb

er

GHH

Site

Le

ad

Liz

How

land

Wom

en &

Chi

ldre

n's D

ivis

ion

Joy

Payn

e He

ad o

f Mid

wife

ry

Obs

tetr

ics

Head

of

Safe

guar

ding

Ca

rol O

wen

Lead

Mid

wife

Go

vern

ance

&

Safe

ty

Jane

t Pol

lard

MLU

& C

omm

unity

Kare

n M

cGui

gan


.35

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Dire

ctor

of W

orkf

orce

Ha

zel G

unte

r

Head

of T

rans

actio

nal

HR

Ray

Reyn

olds

- Rec

ruitm

ent

- Ban

k - E

mpl

oyee

Ser

vice

s - W

orkf

orce

Info

rmat

ion

Depu

ty D

irect

or o

f W

orkf

orce

/

Head

of O

pera

tiona

l HR

(inte

rim K

yria

cos K

yria

cou

6 m

onth

s)

(And

rew

McM

enem

y fr

om 2

9.06

.15)

- Ope

ratio

nal H

R - P

olic

y De

velo

pmen

t - O

ccup

atio

nal H

ealth

- S

ervi

ce T

rans

form

atio

n - W

orkf

orce

Pla

nnin

g

Head

of F

acul

ty

(Inte

rim)

Clai

re W

hitt

le

- Edu

catio

n - T

rain

ing

Head

of O

D Al

ex C

ovey

- Cul

ture

- E

ngag

emen

t - L

eade

rshi

p


.36

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Depu

ty D

irect

or o

f W

orkf

orce

/ He

ad o

f Ope

ratio

nal H

R (in

terim

Kyr

iaco

s Kyr

iaco

u 6

mon

ths)

(A

ndre

w M

cMen

emy

from

29.

06.1

5)

Al

ison

M

oney

Seni

or H

R Bu

sines

s Pa

rtne

r •B

HH S

ite

Mar

k Ti

pton

HR

Bu

sines

s Pa

rtne

r •G

ood

Hope

Si

te

Je

an

Deve

nney

HR

Busin

ess

Part

ner

•Cor

pora

te

& F

acili

ties

Hele

n Ba

rlow

HR

Bu

sines

s Pa

rtne

r •P

olic

ies

&

Proj

ects

Sara

Woo

d •W

ork

&

Wel

lbei

ng

Ju

lie

Stew

ard

•Wor

kfor

ce

Plan

ning

Fr

ieza

M

ahm

ood

HR

Busin

ess

Part

ner

•Sol

ihul

l Site

Leea

nne

Stok

es

HR B

usin

ess

Cons

ulta

nt

BHH

Nat

alie

Coo

ke

HR B

usin

ess

Cons

ulta

nt

W&

C

Laur

a G

raha

m

HR B

usin

ess

Cons

ulta

nt

CSS

OPE

RAT

ION

AL H

R M

ANAG

EMEN

T ST

RU

CTU

RE


.37

Agenda

WelcomeDeclaration

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Business

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Plan

DementiaStrategy

Presentation

Governanceand


ties


OD

TEAM

PRO

POSE

D ST

RUCT

URE

Alex

Cov

ey

Head

of O

D

Amy

Pass

ey

OD

Man

ager

St

aff E

ngag

emen

t

•En

gage

men

t Pr

ogra

mm

es

•St

aff S

urve

ys

tbc

OD

Man

ager

Cu

lture

& V

alue

s

•Va

lues

dev

elop

men

t •

Beha

viou

ral

fram

ewor

ks

•Su

ppor

t im

plem

enta

tion

of

Valu

es &

Beh

avio

urs

into

oth

er w

orki

ng

prac

tices

tb

c O

D M

anag

er

Tale

nt M

anag

emen

t

•Pr

ogra

mm

e le

ader

ship

•

Appr

aisa

l •

Tale

nt M

anag

emen

t •

Succ

essio

n Pl

anni

ng

Bi

ll N

utta

ll Le

ader

ship

Spe

cial

ist

(int

erim

12

mth

s)

•

Lead

ersh

ip

Deve

lopm

ent

Plan

s •

Appr

aisa

l •

Succ

essio

n Pl

anni

ng

Da

niel

le G

odda

rd

Cultu

re &

En

gage

men

t Pro

ject

M

anag

er

(inte

rim 6

mon

ths)

•Pr

ogra

mm

e m

anag

e Cu

lture

&

Enga

gem

ent

Wor

kstr

eam

s


.38

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Actin

g De

puty

Hea

d of

Ed

ucat

ion

Clai

re W

hitt

le

Asso

ciat

e De

an

Wor

kfor

ce

Deve

lopm

ent

Sa

ra Ja

skie

wic

z

•He

alth

care

Ca

reer

s De

velo

pmen

t Uni

t (H

CDU

) •

Prof

essio

nal

Educ

atio

n fo

r N

urse

s, M

idw

ives

&

AHP

s

Asso

ciat

e De

an

Lear

ning

, In

nova

tion

&

Desi

gn

Tr

acey

St

arke

y-M

oore

•Cl

inic

al S

kills

&

Sim

ulat

ion

•M

oodl

e •

Libr

arie

s

Actin

g De

puty

He

ad o

f Ed

ucat

ion

Acad

emic

Affa

irs

& B

usin

ess

Deve

lopm

ent

Cl

aire

Whi

ttle

•Ac

adem

ic C

ours

es

•Fa

culty

Bus

ines

s U

nit (

FBU

) ad

min

istra

tion

team

Asso

ciat

e De

an

Qua

lity

Assu

ranc

e &

Co

re C

ompl

ianc

e Ka

ren

Shar

p •

Man

dato

ry T

rain

ing

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ucat

ion

Qua

lity

Assu

ranc

e •

Pre

Reg

Non

-M

edic

al E

duca

tion

•Ac

cess

, Sys

tem

s &

Ev

ents

(Ed

Cent

re

Man

agem

ent)

FACU

LTY

TEAM

STR

UCT

URE


.39

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties


Ray

Reyn

olds

He

ad o

f Tra

nsac

tiona

l W

orkf

orce

and

Wor

kfor

ce

Info

rmat

ion

Cl

aire

Whi

te

Divi

sion

al

Man

ager

•Rec

ruitm

ent

•Med

ical

Wor

kfor

ce

•Em

ploy

men

t Co

mpl

ianc

e •M

edic

al W

orkf

orce

Lo

cum

Ban

k Te

ams

John

Hoo

d Em

ploy

ee

Serv

ices

Man

ager

•Pay

roll

•Pen

sion

s •C

ontr

acts

•E

xpen

ses

Jean

ette

Bul

lock

W

orkf

orce

In

form

atio

n M

anag

er

•Wor

kfor

ce

Info

rmat

ion

•KPI

s

Sally

Law

son

•Ser

vice

Tr

ansf

orm

atio

n •S

peci

alis

t HR

TRAN

SAC

TIO

NA

L H

R A

ND

WO

RK

FOR

CE

MAN

AGEM

ENT

STR

UC

TUR

E


.40

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Integrated Quality and PerformanceReport, including Finance

Integrated Quality and PerformanceReport, includingFinance


.41

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Inte

grat

ed P

erfo

rman

ce R

epor

t

Mon

th 1

- Ap

ril 2

015

1



.42

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Qua

lity

and

Risk

12 14 15 16 17 18 19 21Ap

prai

sals

Man

dato

ry T

rain

ing

20In

fect

ion

Cont

rol

Sick

ness

Volu

ntar

y Tu

rnov

er a

nd R

ecru

itmen

t

22 23 24 25 26 27

Heat

Map

- A&

EAc

cide

nt a

nd E

mer

genc

yHe

at M

ap -

18 w

eeks

, Dia

gnos

tics,

Ope

ratio

ns18

Wee

ks R

TT a

nd O

pen

Cloc

ksDi

agno

stic

sO

pera

tions

Heat

Map

- Ca

ncer

sCa

ncer

s 2 W

eek

wai

t, 31

and

62

day

Sum

mar

yHe

at M

ap -

Nur

sing

Per

form

ance

Nur

sing

- In

jurio

us F

alls

Nur

sing

- Pr

essu

re U

lcer

s

Heat

map

- In

fect

ion

Cont

rol,

VTE,

Mor

talit

y

Nur

sing

Wor

kfor

ceN

ursi

ng V

acan

cies

Sect

ion

Page

Num

ber

Perf

orm

ance

Indi

cato

r

Heat

Map

- W

orkf

orce

Per

form

ance

Wor

kfor

ce a

nd W

ell-b

eing

Patie

nt E

xper

ienc

eM

etric

sCo

mpl

aint

s

Exec

utiv

e Su

mm

ary

3 4 5 6 7

Cont

ents

9 10 11

Emer

genc

y Ca

re

Plan

ned

Care

2



.43

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ofInterest


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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

rgra

ted

Perf

orm

ance

Rep

ort -

Apr

il

Inte

grat

ed P

erfo

rman

ce R

epor

t

Exec

utiv

e Su

mm

ary

Perf

orm

ance

Ana

lysi

s Th

e m

ain

area

s of c

once

rn fo

r the

Tru

st re

mai

n ur

gent

car

e, R

TT a

nd d

iagn

ostic

s in

part

icul

ar in

end

osco

py.

Perf

orm

ance

aga

inst

the

A&E

4 ho

ur ta

rget

for A

pril

was

86.

25%

. Des

pite

the

signi

fcan

t inc

reas

e in

att

enda

nces

at H

eart

land

s and

Goo

d Ho

pe H

ospi

tal f

rom

Apr

il 20

14 to

Apr

il 20

15, t

here

has

bee

n an

impr

ovem

ent i

n A&

E 4

hour

co

mpl

ianc

e. O

vera

ll em

erge

ncy

adm

issio

ns h

ave

redu

ced

over

the

sam

e tim

e pe

riod.

Th

e ur

gent

car

e pa

thw

ay c

ontin

ued

to e

xper

ienc

e fu

rthe

r inc

reas

e in

dem

and

durin

g Ap

ril. T

his p

lace

d bo

th th

e He

artla

nds a

nd G

ood

Hope

Hos

pita

ls un

der s

igni

fican

t str

ain

in te

rms o

f hig

h be

d oc

cupa

ncy,

ED

cong

estio

n an

d de

lays

for l

arge

num

bers

of p

atie

nts w

aitin

g fo

r a b

ed to

bec

ome

avai

labl

e.

All t

hree

of t

he ta

rget

s for

refe

rral

to tr

eatm

ent w

ere

not a

chie

ved

this

mon

th. H

owev

er, b

oth

the

adm

itted

and

non

-adm

itted

pat

hway

hav

e im

prov

ed fr

om M

arch

to A

pril

as sh

own

in th

e he

at m

ap.

Traj

ecto

ries f

or re

duci

ng th

e RT

T ad

mitt

ed b

ackl

ogs h

ave

been

revi

sed

for 2

015/

16 a

nd th

e ov

eral

l bac

klog

(1,2

71) i

s per

form

ing

wel

l aga

inst

the

in m

onth

targ

et (1

,322

). Fr

om th

e ca

paci

ty v

ersu

s dem

and

wor

k un

dert

aken

it w

as

foun

d th

at to

ach

ieve

the

RTT

targ

ets t

he T

rust

will

nee

d to

app

roxi

mat

ely

unde

rtak

e an

add

ition

al 5

100

case

s com

pare

d to

201

4/15

. The

incr

ease

in d

eman

d is

pred

omin

antly

due

to u

rgen

t ref

erra

ls, th

is is

unde

r disc

ussio

n w

ith

the

CCGs

. Ga

stro

ente

rolo

gy (a

nd m

ore

spec

ifica

lly th

e En

dosc

opy

Serv

ice)

con

tinue

s to

expe

rienc

e in

crea

sed

dem

and

whi

ch si

gnifi

cant

ly im

pact

s on

the

over

all a

dmitt

ed b

ackl

og a

nd d

iagn

ostic

s com

plia

nce.

Th

ere

has b

een

a sig

nific

ant r

educ

tion

in h

ospi

tal l

ed c

ance

llatio

ns o

f ele

ctiv

e su

rger

y fr

om th

e pe

ak in

Janu

ary

to M

arch

. Th

e va

lidat

ed c

ance

r per

form

ance

for t

wo

wee

k w

aits

and

for b

reas

t sym

ptom

atic

targ

ets h

ave

faile

d in

Mar

ch 2

015.

The

re c

ontin

ues t

o be

an

abov

e av

erag

e in

the

num

ber o

f ref

erra

ls to

two

wee

k w

ait c

linic

s (in

clud

ing

brea

st

sym

ptom

atic

). Pe

rfor

man

ce a

gain

st th

e 31

and

62

day

canc

er ta

rget

s wer

e m

et in

Mar

ch 2

015,

99.

41%

and

86.

24%

resp

ectiv

ely.

Th

ere

have

bee

n no

new

cas

es o

f pos

t 48

hour

MRS

A ba

cter

aem

ia in

Apr

il, th

ere

is a

zero

tole

ranc

e ta

rget

for M

RSA

Bact

erae

mia

s in

2015

/16.

Clo

strid

ium

diff

icile

(C.d

iff) t

arge

t was

met

in A

pril

with

onl

y 2

case

s aga

inst

a ta

rget

of

less

than

6. T

he n

ew C

.diff

traj

ecto

ry fo

r 201

5/16

is m

ore

chal

leng

ing

this

year

, the

yea

r end

targ

et is

less

than

64

case

s. T

he T

rust

con

tinue

s to

mai

ntai

n go

od p

erfo

rman

ce in

falls

and

pre

ssur

e ul

cers

des

pite

an

incr

ease

in fr

ail a

nd

elde

rly p

atie

nts.

Re

crui

tmen

t of s

taff

espe

cial

ly n

ursin

g an

d m

edic

al st

aff

cont

inue

s to

be c

halle

ngin

g w

ith tu

rnov

er c

ontin

uing

to b

e ab

ove

targ

et. S

taff

sickn

ess h

as im

prov

ed th

is m

onth

and

is b

elow

the

new

201

5/16

traj

ecto

ry. T

he 8

5% ta

rget

fo

r man

dato

ry tr

aini

ng w

as a

chie

ved

in M

arch

201

5 (d

ata

is on

e m

onth

in a

rrea

rs).

The

appr

aisa

ls ta

rget

was

not

met

this

mon

th, h

owev

er th

ere

is an

impr

oved

per

form

ance

on

2014

/15.

App

raisa

l com

plet

ion

from

Apr

il is

now

re

port

ed a

s a ro

lling

12

mon

th p

ositi

on a

gain

st a

con

stan

t tar

get o

f 85%

acr

oss t

he w

hole

Tru

st.

3



.44

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ofInterest


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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Per

cent

age

of A

mbu

lanc

e Se

rvic

es

Han

dove

r ≥

60

min

utes

0.00

%

0.00

%

5.95

%3.

96%

Emer

genc

y Ca

re

Heat

Map

- A&

E

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RK

TARGET

In month trajectory

Last

Mon

th

Trus

t (M

ar-1

5)H

eart

land

s H

ospi

tal

Goo

d H

ope

Hos

pita

lSo

lihul

l H

ospi

tal

Clin

ical

Su

ppor

t Se

rvic

es

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Apr

-15

Perf

orm

ance

Im

prov

emen

t

80.2

3%97

.82% 0

86.2

5% 1

AOS5

A&

E: m

axim

um w

aiti

ng

tim

e of

fou

r ho

urs

from

arr

ival

to

adm

issi

on/t

rans

fer/

disc

harg

e>

95%

83.6

1%86

.45%

4.88

%

0.24

%0.

25%

0.27

%0.

48%

0.28

%

ANQ

R9Tr

olle

y w

aits

in A

&E

long

er t

han

12

hou

rs

Per

cent

age

of A

mbu

lanc

e Se

rvic

es

Han

dove

r ≥

30

min

utes

20

10

7.31

%1.

45%

4



.45

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

ED A

tten

danc

e (B

HH &

GHH

)

Emer

genc

y Le

ngth

of S

pell

(BHH

& G

HH)*

86.4

5%-7

.95%

16,8

1317

,909

6.52

%

Emer

genc

y Ca

re

Acci

dent

& E

mer

genc

y

Key

Emer

genc

y In

dica

tors

YTD

com

paris

onAp

rilAp

r-14

Apr-

15%

Var

ianc

e

A&E

Atte

ndan

ces a

nd A

mbu

lanc

e Ar

rival

s at H

eart

land

s & G

ood

Hope

Hos

pita

ls

Ambu

lanc

e Ar

rival

s5,

726

5,87

12.

53%

* Ba

sed

on p

atie

nts d

isch

arge

d fr

om a

dult

acut

e w

ards

onl

y

ED 4

hou

r per

form

ance

by

site

, Apr

-14

vs A

pr-1

5 co

mpa

rison

Emer

genc

y Ad

mis

sion

s (BH

H &

GHH

)6,

531

5,79

5-1

1.27

%7.

008.

2217

.43%

4 Ho

ur P

erfo

rman

ce (H

EFT,

no

WIs

)94

.40%

Head

lines

Th

e pe

rfor

man

ce in

Apr

il 20

15 w

as 8

6.25

%.

The

indi

vidu

al si

te p

ositi

on in

Mar

ch:

•He

artla

nds E

D (B

HH) –

86.

45%

,

•Go

od H

ope

ED (G

HH) –

80.

23%

, •

Solih

ull E

D (n

ow M

IU) –

97.

82%

.

Perf

orm

ance

Ana

lysi

s 1)

Incr

ease

d De

man

d Th

ere

cont

inue

s to

be a

n in

crea

sing

dem

and

plac

ed o

n em

erge

ncy

depa

rtm

ents

(ED)

at H

eart

land

s and

Goo

d Ho

pe

Hosp

itals.

The

incr

ease

in a

tten

danc

es co

ntin

ued

in th

e fir

st w

eeks

of A

pril

2015

, rea

chin

g a

peak

of 4

,238

at

tend

ance

s dur

ing

wee

k en

ding

19/

04/2

015

(for B

HH a

nd G

HH).

Co

mpa

ring

April

201

4 to

Apr

il 20

15, B

HH a

nd G

HH h

ad 1

,096

mor

e at

tend

ance

s. T

his i

ncre

ase

equa

tes t

o an

ad

ditio

nal 2

0 an

d 17

att

enda

nces

per

day

to B

HH a

nd G

HH E

Ds re

spec

tivel

y.

2) B

reac

h &

Cap

acity

Th

e m

ajor

ity o

f bre

ache

s (52

.35%

) wer

e du

e to

aw

aitin

g a

bed

or n

o ro

om in

AM

U .

Capa

city

issu

es a

re a

lso im

pact

ed

by th

e in

crea

se in

the

aver

age

cycl

e tim

e of

pat

ient

s in

AMU

are

as w

ho a

re la

ter t

rans

ferr

ed to

bas

e w

ards

. Co

mpa

ring

April

-14

to A

pril-

15:

•BH

H AM

U -

incr

ease

from

14.

09 h

ours

in A

pril

2014

to 1

9.37

hou

rs in

Apr

il 20

15 (+

37.5

% v

aria

nce)

. •

GHH

AMU

- in

crea

se fr

om 1

0.05

hou

rs in

Apr

il 20

14 to

26.

97 h

ours

in A

pril

2015

(+16

8.4%

var

ianc

e).

Th

e m

edia

n tim

e fo

r pat

ient

s in

ED w

ho a

re la

ter a

dmitt

ed to

hos

pita

l has

also

rem

aine

d hi

gh. T

he in

crea

se h

as b

een

as fo

llow

s:

•W

hen

BHH

last

ach

ieve

d th

e 95

% 4

Hou

r tar

get (

Janu

ary

2014

) m

edia

n tim

e in

ED

was

190

min

utes

. In

cont

rast

, du

ring

April

201

5 th

e m

edia

n tim

e in

BHH

ED

is sig

nific

antly

incr

ease

d at

221

min

utes

. •

Med

ian

time

in G

HH E

D w

as 1

93 m

inut

es in

Janu

ary

2011

(the

last

tim

e GH

H ac

hiev

ed th

e 4

hour

targ

et).

Curr

ently

, m

edia

n tim

e in

GHH

ED

is 27

1 m

inut

es.

Apr-14, 94.40%

Apr-14, 93.46%

Apr-14, 93.40%

Apr-14, 98.63%

Apr-15, 86.25%

Apr-15, 86.45%

Apr-15, 80.23%

Apr-15, 97.82%

60.0

0%

65.0

0%

70.0

0%

75.0

0%

80.0

0%

85.0

0%

90.0

0%

95.0

0%

100.

00%

Trus

t (no

WIC

)H

eart

land

sG

ood

Hop

eSo

lihul

l

A&E

4 ho

urs P

erfo

rman

ce: A

pr-1

4 vs

Apr

-15

Actio

ns T

aken

•

Laun

ch o

f ‘Dr

ive

for D

ischa

rge’

. Thi

s is a

n in

itiat

ive

to e

nsur

e av

aila

bilit

y of

six

AMU

and

two

SAU

spac

es a

t key

po

ints

dur

ing

the

day

to im

prov

e flo

w to

the

asse

ssm

ent u

nits

. Thi

s has

bee

n im

plem

ente

d to

cre

ate

capa

city

and

ke

ep th

e ED

s saf

e by

redu

cing

the

num

ber o

f bre

ache

s due

to n

o sp

ace

in A

MU

. •

Plan

ned

esta

tes w

ork

to c

reat

e a

larg

er E

D m

ajor

s are

a ha

s beg

un. T

his w

ill se

e ED

min

ors t

akin

g ov

er fr

actu

re

clin

ic a

nd fr

actu

re cl

inic

mov

ing

into

the

ther

apie

s dep

artm

ent.

This

mea

ns E

D M

ajor

s to

doub

le in

size

allo

win

g be

tter

man

agem

ent o

f the

surg

es in

our

mos

t acu

tely

unw

ell p

atie

nts.

•11

hou

rs o

f priv

ate

ambu

lanc

es co

ver w

as p

rovi

ded

to b

oth

GHH

and

BHH

sites

Mon

day

to F

riday

to su

ppor

t pa

tient

disc

harg

e. T

wo

new

disc

harg

e lo

unge

s ope

ned

on e

ach

site

to c

reat

e ea

rly fl

ow in

the

hosp

ital.

5



.46

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

89.6

1%

92.3

1%91

.22%

88.1

8%

AOS1

Adm

itte

d P

atie

nts

Trea

ted

wit

hin

18

Wee

ks

of R

efer

ral (

mia

)

AOS2

Non

-Adm

itte

d P

atie

nts

Trea

ted

wit

hin

18

W

eeks

of

Ref

erra

l (m

ia)

> 9

5%89

.83%

82.0

9%

93.1

0%

Heat

Map

- 18

Wee

ks, D

iagn

ostic

s, O

pera

tions

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RK

TARGET

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Apr

-15

Perf

orm

ance

Im

prov

emen

tH

eart

land

s H

ospi

tal

Goo

d H

ope

Hos

pita

lSo

lihul

l H

ospi

tal

Clin

ical

Su

ppor

t Se

rvic

es

Plan

ned

Care

In month trajectory

Last

Mon

th

Trus

t (M

ar-1

5)

No

urge

nt o

pera

tion

can

celle

d fo

r th

e 2

nd

tim

e

90.6

3%

> 9

0%78

.92%

83.6

9%83

.72%

78.6

6%

92.1

0%D

iagn

osti

cs w

aiti

ng

tim

es le

ss t

han

6 w

eeks

> 9

9%

Can

celle

d op

erat

ions

not

off

ered

ano

ther

da

te w

ithi

n 2

8 d

ays

AOS3

18

wee

k in

com

plet

e pa

thw

ays

(mia

)>

92%

90.2

6%88

.89%

90.9

1%88

.99%

6



.47

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

18 W

eeks

- Re

ferr

al to

Tre

atm

ent (

RTT)

Plan

ned

Care

18 w

eeks

Bac

klog

Tabl

e: H

igh

risk

Spec

ialti

es a

gain

st th

e O

vera

ll RT

T Pe

rfor

man

ce (A

pril

2015

)

Lega

cy O

pen

Cloc

ks c

losu

re im

apct

on

path

way

s

Head

lines

•

April

Adm

itted

Per

form

ance

: 82

.09%

. •

April

Non

-Adm

itted

Per

form

ance

: 93

.10%

. •

April

Inco

mpl

ete

Perf

orm

ance

: 89.

61%

52

Wee

k Br

each

Pos

ition

: The

re a

re 8

pat

ient

s wai

ting

mor

e th

an 5

2 w

eeks

on

the

inco

mpl

ete

path

way

at t

he e

nd o

f Apr

il. T

here

wer

e 59

patie

nts b

reac

hed

the

52 w

eek

stan

dard

in A

pril,

all

of th

ese

patie

nts b

reac

hed

due

to c

losu

re o

f leg

acy

open

clo

ck

path

way

s.

Perf

orm

ance

Ana

lysi

s Ca

ncel

latio

n of

Sur

gery

(on

& b

efor

e th

e da

y of

adm

issi

on)

18 p

atie

nts w

ere

canc

elle

d in

Apr

il, a

ll w

ere

due

to n

o be

ds a

vaila

ble

(BHH

- 15

, SO

L - 2

, GHH

- 1)

. Rel

ativ

e to

pre

viou

s m

onth

s, th

is is

a sm

all i

ncre

ase

on M

arch

whe

n 11

pat

ient

s wer

e ca

ncel

led.

O

ne o

f the

se p

atie

nts w

as o

n th

e ca

ncer

pat

hway

requ

iring

a c

ritic

al c

are

bed,

the

RCA

has b

een

com

plet

ed a

nd a

n ac

tion

plan

is in

pla

ce.

Ba

cklo

g Th

e nu

mbe

r of p

atie

nts i

n th

e ba

cklo

g at

the

end

of A

pril

was

1,2

71 v

ersu

s an

expe

cted

bac

klog

traj

ecto

ry p

ositi

on o

f 1,

322.

All

spec

ialti

es w

ith th

e ex

cept

ion

of U

rolo

gy a

nd G

astr

oent

erol

ogy

ache

ived

thei

r pre

dict

ed tr

ajec

tory

with

O

rtho

pead

ics o

ver a

chei

ving

by

76 p

atie

nts.

Th

e m

ain

spec

ialti

es co

ntnu

ing

to c

ontr

ibut

ing

to th

e ba

cklo

g ar

e as

follo

ws :

•

Gast

roen

tero

logy

= 3

87, 3

0.4%

of t

otal

bac

klog

. •

Ort

hopa

edic

= 2

51, 1

9.7%

of t

otal

bac

klog

. •

Gene

ral S

urge

ry =

167

, 13.

1% o

f tot

al b

ackl

og.

•U

rolo

gy =

135

, 10.

6% o

f tot

al b

ackl

og.

The

over

all b

ackl

og p

ositi

on fo

r May

is o

n ta

rget

for d

eliv

ery.

1198

1180

1182

1501

1285

1284

1231

1314

1253

1271 1322

1286

1314

1350

1337

1207

1079

928

809

741

701

589

0

200

400

600

800

1000

1200

1400

1600

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Back

log

Traj

ecto

ry

143

145

113

177

174

188

204

166

169

146

157

175

228

255

240

238

193

176

170

186

188

188

203

212

225

247

299

320

337

350

337

050100

150

200

250

300

350

400

Back

log

Traj

ecto

ry

7



.48

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

0-17

1819

-25

26-3

738

-51

52+

Tota

l12

5159

231

209

3717

8710

0815

5135

81

1118

820

3297

107

1010

6660

434

130

105

303

906

548

1753

614

683

377

2158

6715

538

341

1572

718

507

274

626

4310

359

Ope

n Cl

ocks

- Pa

tient

s who

hav

e at

tend

ed b

ut h

ave

no fu

rthe

r app

oint

men

t boo

ked

18 W

eeks

- O

pen

Cloc

ks

Plan

ned

Care

Ope

n Cl

ocks

pro

file

@15

/05/

2015

Ope

n Cl

ocks

with

no

futu

re a

ppoi

ntm

ent b

ooke

d - T

op 8

Spe

cial

ties

% o

f tot

al o

pen

cloc

ks >

18

wks

Gra

nd T

otal

Wee

ks

5971

252

916

869

176

481

88

Spec

ialty

Gas

troe

nter

olog

yCa

rdio

logy

T&O

Uro

logy

Gyn

aeG

en S

urg

Derm

atol

ogy

Resp

Med

24.1

8%4.

96%

11.1

0%13

.62%

6.09

%7.

26%

7.49

%3.

83%

Perf

orm

ance

Ana

lysi

s Ei

ght p

atie

nts r

emai

n on

an

open

cloc

k pa

thw

ay w

aitin

g 52

wee

ks o

r mor

e. A

ll bu

t tw

o pa

tient

s are

exp

ecte

d to

ha

ve th

eir p

athw

ay c

lose

d in

May

. The

se tw

o pa

tient

s are

und

ergo

ing

furt

her d

iagn

ostic

inte

rven

tions

follo

win

g fa

ce to

face

con

sulta

tion.

Th

ere

is st

ill a

sign

ifica

nt p

eak

of p

atie

nts o

n an

ope

n cl

ock

path

way

bet

wee

n 19

and

25

wee

ks. T

he n

ew P

atie

nt-

targ

eted

list

(PTL

) pro

vide

s bet

ter v

isabl

ity fo

r tea

ms t

o m

anag

e th

eir p

atie

nts o

n an

ope

n cl

ock

path

way

. Ga

stro

entr

olog

y ac

coun

ts fo

r 24.

18%

of t

otal

pat

ient

s with

an

open

cloc

k of

mor

e th

an 1

8 w

eeks

and

no

plan

ned

futu

re a

ppoi

ntm

ent.

Oth

er sp

ecia

lties

that

acc

ount

for m

ore

than

10%

of t

his g

roup

are

: •

T&O

- 1

1.10

%

•U

rolo

gy -

13.6

2%

Furt

her A

ctio

ns

•RC

As w

ill b

e un

dert

aken

on

both

pat

ient

s wai

ting

long

er th

an 5

2wee

ks w

hen

thei

r tre

atm

ents

are

com

plet

ed,

this

will

incl

ude

a re

view

of h

arm

. •

PTL

wil

be m

onito

red

thro

ugh

the

18 w

eek

and

Canc

er m

eetin

g w

ith a

ll Di

visio

ns h

avin

g in

tern

al p

roce

dure

s in

plac

e to

ens

ure

impr

oved

pat

hway

s man

agem

ent o

f pat

ient

s.

59

15

32

34

17

21

15

6

231

51

97

130

53

58

72

26

209

35

107

105

61

67

71

43

37

8

10

30

4 15

8

10

0

100

200

300

400

500

600

Gas

tro

Card

iolo

gyT&

OU

rolo

gyG

ynae

Gen

Sur

gDe

rmat

olog

yRe

sp M

ed

1819

-25

26-3

738

-51

52+

8



.49

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

No.

> 6

W

eeks

% w

ithin

6

wee

ksN

o. >

6

Wee

ks%

with

in

6 w

eeks

199

.96%

299

.87%

010

0.00

%0

-0

100.

00%

584

.38%

199

.79%

0-

0-

691

.78%

1278

.18%

274

57.1

2%17

857

.72%

2784

.39%

363

62.6

9%86

992

.10%

Neu

roph

ysio

logy

- pe

riphe

ral n

euro

phys

iolo

gy

Diag

nost

ics S

umm

ary

Diag

nost

ics t

ests

seen

with

in 6

wee

ks

Diag

nost

ics t

ests

seen

with

in 6

wee

ks

Mag

netic

Res

onan

ce Im

agin

gCo

mpu

ted

Tom

ogra

phy

Non

-obs

tetr

ic u

ltras

ound

Bariu

m E

nem

aDE

XA S

can

Uro

dyna

mic

s - p

ress

ures

& fl

ows

Cyst

osco

py

Audi

olog

y - A

udio

logy

Ass

essm

ents

Card

iolo

gy -

echo

card

iogr

aphy

Plan

ned

Care

Imag

ing

Phys

iolo

gica

l M

easu

rem

ent

Endo

scop

y

Tota

lGa

stro

scop

y

Mar

-15

Apr-

15Te

st

Resp

irato

ry p

hysio

logy

- sle

ep st

udie

s

Colo

nosc

opy

Flex

i sig

moi

dosc

opy

Card

iolo

gy -

elec

trop

hysio

logy

Head

lines

En

dosc

opy

and

the

rela

ted

Gast

roen

tero

logy

serv

ice

is co

nsid

ered

to b

e th

e sp

ecia

lty o

f hig

hest

risk

in S

ched

uled

Ca

re.

Chan

ge in

NIC

E gu

idlin

es a

re d

ue to

be

in e

ffect

from

the

end

of Ju

ne. T

hese

chan

ges w

ill fu

rthe

r inc

reas

e th

e de

man

d on

the

serv

ices

and

retu

rn to

com

plia

nce

will

not

be

met

unt

il la

ter i

n th

e ye

ar.

Perf

orm

ance

Ana

lysi

s Th

e nu

mbe

r of p

atie

nts o

n th

e En

dosc

opy

adm

itted

wai

ting

list h

as in

crea

sed

signi

fican

tly fr

om 5

78 in

Oct

ober

201

4 to

2,4

43 p

atie

nts a

t the

end

of A

pril

with

360

wai

ting

18 w

eeks

or m

ore.

Th

e Tr

ust h

as fa

iled

its 6

wee

k 99

% d

iagn

ostic

targ

et si

nce

Sept

embe

r 201

4 du

e to

the

dete

riora

tion

of p

erfo

rman

ce

with

in e

ndos

copy

. Ac

tions

Tak

en

•A

rem

edia

l act

ion

plan

(RAP

) for

the

serv

ice

was

subm

itted

to th

e CC

G de

taili

ng a

traj

ecto

ry to

retu

rn to

6 w

eek

com

plia

nce.

Acc

ordi

ng to

the

revi

sied

traj

ecto

ry, d

iagn

ostic

com

plia

nce

is ex

pect

ed to

retu

rn to

the

99%

targ

et in

Se

ptem

ber 2

015.

(Thi

s is d

epen

dant

on

addi

tiona

l cap

acity

)

99.51%

99.89%

99.74%

99.29%

98.53%

99.91%

99.79%

99.29%

99.75%

99.46%

99.57%

99.66%

99.17%

99.32%

99.22%

99.02%

98.44%

95.15%

98.03%

94.90%

93.48%

93.81%

92.10%

90.63%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

% <

6wks

Targ

etM

ON

ITO

R tr

ajec

tory

Valid

ated

su

mm

ary

figur

es fo

r Ap

ril w

ill b

e up

date

d in

ne

xt m

onth

s re

port

9



.50

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Apr-

14M

ay-1

4Ju

n-14

Jul-1

4Au

g-14

Sep-

14O

ct-1

4N

ov-1

4De

c-14

Jan-

15Fe

b-15

Mar

-15

Apr-

151

03

11

34

34

32

30

21

21

11

00

11

0

Plan

ned

Care

Canc

elle

d O

pera

tions

Brea

ches

of 2

8 da

y el

ectiv

e gu

aran

tee

Urg

ent O

pera

tions

Can

celle

d fo

r 2nd

Tim

e

Perc

enta

ge o

f Can

celle

d O

pera

tions

on

the

day

Urg

ent o

pera

tions

can

celle

d fo

r a se

cond

tim

e

Hosp

ital l

ed O

pera

tions

can

celle

d on

the

day

Head

lines

Th

ere

wer

e 75

hos

pita

l led

can

celle

d op

erat

ions

on

the

day

durin

g Ap

ril-1

5, a

slig

ht in

crea

se w

hen

com

pare

d w

ith th

e pr

evio

us m

onth

(72)

. 38

(51%

) of t

he ca

ncel

led

oper

atio

ns w

ere

at G

ood

Hope

, 21

(28%

) at H

eart

land

s and

16

(21%

) at S

olih

ull.

1

pate

int w

ith c

ance

r was

can

celle

d on

the

day

of th

eir s

urge

ry d

ue to

no

Criti

cal C

are

bed

In a

dditi

on tw

o pa

tient

s had

thei

r ‘ur

gent

’ ope

ratio

n ca

ncel

led

for a

seco

nd ti

me

at d

urin

g Ap

ril.

Perf

orm

ance

Ana

lysi

s Th

e fo

llow

ing

reas

ons a

ccou

nt fo

r 85%

of t

he H

ospi

tal l

ed c

ance

lled

oper

atio

ns o

n th

e da

y du

ring

April

201

5; R

an o

ut

of ti

me

(28)

, Sta

ff un

avai

labl

e (1

7),

Equi

pmen

t fai

lure

(11)

and

No

bed

(8).

•Th

ere

wer

e 28

(37%

) can

celle

d op

erat

ions

due

to a

lack

of t

ime,

11

at G

ood

Hope

, 10

at S

olih

ull a

nd 7

at

Hear

tland

s. T

he o

pera

tions

wer

e ca

ncel

led

by O

rtho

paed

ics (

8), G

ynae

colo

gy (7

), Ge

nera

l Sur

gery

(5),

Oph

thal

mol

ogy

(3),

Uro

logy

(3) a

nd T

hora

cic

Surg

ery

(2).

•17

ope

ratio

ns (2

3%) w

ere

canc

elle

d du

e to

staf

f mem

bers

bei

ng u

nava

ilabl

e, 1

4 of

thes

e w

ere

at G

ood

Hope

Ho

spita

l and

3 a

t Hea

rtla

nds H

ospi

tal.

10 o

f the

can

celle

d op

erat

ions

at G

ood

Hope

was

due

to n

o an

aest

hetis

t be

ing

avai

labl

e, th

is le

ad to

Oph

thal

mol

ogy

(9) a

nd C

ardi

olog

y (1

) can

celli

ng o

pera

tions

. •

11 o

pera

tions

(15%

) wer

e ca

ncel

led

due

to e

quip

men

t fai

lure

, 8 a

t Goo

d Ho

pe H

ospi

tal a

nd 3

at S

olih

ull H

ospi

tal.

•8

(11%

) ope

ratio

ns w

ere

canc

elle

d du

e to

no

bed,

7 w

ere

at H

eart

land

s and

1 a

t Sol

ihul

l. Ac

tions

take

n •

RCA

unde

rtak

en to

iden

tify

unde

rlyin

g ca

use

for p

atie

nt ca

ncel

led

with

can

cer.

Esca

latio

n pr

oces

s has

bee

n re

view

ed, r

eite

rate

d an

d en

hanc

ed a

s a re

sult.

•

Wee

kly

thea

tre

sche

dulin

g m

eetin

gs in

pla

ce to

faci

litat

e a

two

wee

k fo

rwar

d. T

his w

ill id

entif

y po

tent

ial i

ssue

s w

ith li

sts a

nd im

prov

e ef

ficie

ncy.

The

se m

eetin

gs h

ave

star

ted

to im

prov

e se

ssio

n ut

ilisa

tion

from

84.

79%

in M

arch

to

86.

16%

in A

pril

•

The

Thea

tre

Util

isatio

n Pr

ojec

t com

men

ced

in A

pril,

the

two

core

wor

kstr

eam

s are

pre

-ope

rativ

e pr

oces

s and

th

eatr

e sc

hedu

ling.

0.95%

0.77%

1.19%

1.36%

1.83%

1.33%

1.26%

0.93%

1.94%

1.95%

1.47%

0.87%

0.80

%

0.00

%

0.50

%

1.00

%

1.50

%

2.00

%

2.50

%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

% C

ance

lled

Ops

201

4/15

% C

ance

lled

Ops

201

3/14

Targ

et

72

65

80

86

109

86

96

53

70

88

44

68

73

60

78

89

108

93

89

67

127

164

121

72

75

020406080100

120

140

160

180

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

10



.51

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Plan

ned

Care

Heat

Map

- Ca

ncer

s (m

ia)

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RKLa

st M

onth

Tr

ust

(Feb

-15)

Hea

rtla

nds

Hos

pita

lG

ood

Hop

e H

ospi

tal

Solih

ull

Hos

pita

l

Clin

ical

Su

ppor

t Se

rvic

es

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Mar

-15

Perf

orm

ance

Im

prov

emen

t

AOS6

Patie

nts

first

see

n by

a s

peci

alis

t w

ithin

tw

o w

eeks

w

hen

urge

ntly

ref

erre

d by

the

ir G

P or

den

tist

with

su

spec

ted

canc

er (

mia

)>

93%

89.6

2%(M

ar-1

5)

AOS1

2Pa

tient

s re

ceiv

ing

thei

r fir

st d

efin

itive

tre

atm

ent

for

canc

er w

ithin

tw

o m

onth

s (6

2 da

ys)

of G

P or

de

ntis

t ur

gent

ref

erra

l for

sus

pect

ed c

ance

r (m

ia)

> 8

5%

AOS9

Patie

nts

rece

ivin

g su

bseq

uent

tre

atm

ent

(sur

gery

an

d dr

ug t

reat

men

t on

ly)

with

in o

ne m

onth

(31

da

ys)

of a

dec

isio

n to

tre

at -

Sur

gery

Mod

ality

(m

ia)

> 9

4%

AOS1

0

Patie

nts

rece

ivin

g su

bseq

uent

tre

atm

ent

(sur

gery

an

d dr

ug t

reat

men

t on

ly)

with

in o

ne m

onth

(31

da

ys)

of a

dec

isio

n to

tre

at -

Ant

i Can

cer

Dru

g M

odal

ity (

mia

)

> 9

8%

AOS7

Patie

nts

first

see

n by

a s

peci

alis

t w

ithin

tw

o w

eeks

w

hen

urge

ntly

ref

erre

d by

the

ir G

P w

ith a

ny

brea

st s

ympt

om e

xcep

t su

spec

ted

canc

er (

mia

)>

93%

99.4

1%(M

ar-1

5)94

.29%

(Mar

-15)

96.3

3%(M

ar-1

5)93

.09%

(Mar

-15)

96.9

2%(M

ar-1

5)

100%

(Mar

-15)

100%

(Mar

-15)

AOS8

Patie

nts

rece

ivin

g th

eir

first

def

initi

ve t

reat

men

t w

ithin

one

mon

th (

31 d

ays)

of

a de

cisi

on t

o tr

eat

(as

a pr

oxy

for

diag

nosi

s) f

or c

ance

r (m

ia)

> 9

6%

N/A

94.7

2%(M

ar-1

5)

99.2

4%(M

ar-1

5)

82.9

5%(M

ar-1

5)

QS8

Patie

nts

rece

ivin

g th

eir

first

def

initi

ve t

reat

men

t fo

r ca

ncer

with

in 1

00 d

ays

of G

P or

den

tist

urge

nt

refe

rral

for

sus

pect

ed c

ance

r (m

ia)

100%

AOS1

3Pa

tient

s re

ceiv

ing

thei

r fir

st d

efin

itive

tre

atm

ent

for

canc

er w

ithin

tw

o m

onth

s (6

2 da

ys)

of u

rgen

t re

ferr

al f

rom

the

nat

iona

l scr

eeni

ng s

ervi

ce (

mia

)>

90%

71.4

3% (

Feb-

15)

100%

(Mar

-15)

83.3

3%(M

ar-1

5)

92.7

4%(F

eb-1

5

92.3

3% (

Feb-

15)

98.8

4% (

Feb-

15)

100%

(Feb

-15)

100%

(Feb

-15)

81.9

8% (

Feb-

15)

91.3

8%(M

ar-1

5)

89.3

8%(M

ar-1

5)

85.9

0%(M

ar-1

5)

66.6

7%(M

ar-1

5)

97.9

9%(M

ar-1

5)

TARGET

11



.52

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Apr-

14M

ay-1

4Ju

n-14

Jul-1

4Au

g-14

Sep-

14O

ct-1

4N

ov-1

4De

c-14

Jan-

15Fe

b-15

Mar

-15

81.0

4%77

.91%

70.0

4%80

.11%

79.1

2%78

.75%

89.3

8%90

.36%

88.9

5%91

.24%

92.7

4%91

.38%

--

--

--

-88

.90%

88.9

0%90

.50%

91.5

0%93

.00%

60.5

9%65

.38%

55.2

4%82

.69%

83.5

8%85

.23%

88.0

8%87

.50%

81.0

5%76

.61%

92.3

3%89

.38%

--

--

--

-88

.50%

89.5

0%90

.50%

92.6

0%93

.60%

SPC

of T

wo

wee

k w

ait r

efer

rals

Indi

cato

rTa

ble

1: T

wo

wee

k w

aits

/Bre

ast S

ympt

oms:

per

cent

age

of p

atie

nts s

een

in 2

wee

ks

2 W

eek

Wai

t (T

93%

)M

onito

r Pla

n2

Wee

k W

ait -

(T93

%) B

reas

t Sym

ptom

sM

onito

r Pla

n

Plan

ned

Care

Canc

ers -

Tw

o w

eek

wai

t Per

form

ance

Conv

ersi

on ra

te fo

r Dia

gnos

is o

f Can

cer a

fter

2-w

eek

wai

t clin

ics

Two

Wee

k W

ait B

reac

hes (

inc

Brea

st)

Head

lines

Tw

o w

eek

wai

t per

form

ance

(Tar

get 9

3%),

Mar

ch 9

1.4%

(bel

ow tr

ajec

tory

).

Brea

st S

ympt

omat

ic tw

o w

eek

wai

t per

form

ance

Mar

ch 8

9.38

% (s

light

dec

reas

e fr

om 9

2.33

% in

Feb

ruar

y).

Perf

orm

ance

Ana

lysi

s Th

e vo

lum

e of

two

wee

k w

aits

refe

rral

s con

tinue

s to

be a

bove

ave

rage

. Add

ition

al ca

paci

ty is

bei

ng p

ut in

to p

lace

bu

t the

rate

of g

row

th is

exc

eedi

ng w

hat h

as b

een

plan

ned.

Thi

s is l

ikel

y to

be

exac

erba

ted

by th

e N

ICE

guid

ance

pu

ttin

g ac

hiev

emen

t of t

wo

wee

k w

aits

per

form

ance

at r

isk.

The

num

ber o

f pat

ient

s pos

itive

ly d

iagn

osed

with

can

cer r

educ

ed b

y 40

pat

ient

s (20

01 in

13/

14 v

196

1 in

14/

15).

Derm

atol

ogy,

Gyn

aeco

logy

, Upp

er a

nd Lo

wer

GI s

aw th

e m

ost s

igni

fican

t inc

reas

e in

refe

rral

rate

and

redu

ctio

n in

co

nver

sion

rate

. Tw

o w

eek

wai

t bre

ache

s (in

clud

ing

Brea

st) h

ave

mos

tly b

een

due

to p

atie

nt ch

oice

. The

pro

port

ion

of b

reac

hes d

ue

to p

atie

nt ch

oice

has

bee

n sig

nific

antly

hig

her t

han

capa

city

sinc

e O

ctob

er 2

014.

Ac

tions

Tak

en

•HE

FT re

pres

enta

tives

met

San

dwel

l and

City

cou

terp

arts

in A

pril

to d

iscus

s how

they

impr

oved

thei

r per

form

ance

, sp

ecifi

cally

in su

spec

ted

and

exhi

bite

d tw

o w

eek

wai

t Bre

ast r

efer

rals.

A si

gnifi

cant

fact

or w

as tr

ansf

er o

f ser

vice

s to

one

site

. A m

ulti-

disc

iplin

ary

grou

p w

ill d

iscus

s bre

ast p

erfo

rman

ce a

nd a

gree

furt

her s

hort

and

long

term

ac

tions

that

will

pro

vide

an

impr

ovem

ent i

n th

e st

anda

rd.

•Th

e Tr

ust i

s con

tinui

ng to

wor

k w

ith C

CG o

n th

e ap

prop

riate

ness

of t

wo

wee

k w

ait r

efer

rals.

Thi

s inc

lude

s up

datin

g of

refe

rral

form

s in

Derm

atol

ogy

neop

lasm

s (in

Mar

ch) a

nd G

ynae

colo

gy n

eopl

asm

s (in

June

). Fu

rthe

r w

ork

to u

pdat

e re

ferr

als f

orm

s for

Lung

and

Uro

logy

is u

nder

way

. An

aud

it w

ill c

omm

ence

in Ju

ly 2

015

to a

sses

s th

e im

pact

of t

his c

hang

e.

•Da

ta a

nd p

atie

nt e

xper

ienc

es re

gard

ing

inap

prop

riate

refe

rral

s are

bei

ng sh

ared

with

CCG

s and

GPs

.

142

239

205

158

176

185

108

132

158

00.2

0.4

0.6

0.8

11.2

050100

150

200

250

300

350

400

450

Jul-1

4Au

g-14

Sep-

14O

ct-1

4N

ov-1

4De

c-14

Jan-

15Fe

b-15

Mar

-15

No. Breaches

Capa

city

Patie

nt C

hoic

e%

Due

to P

atie

nt C

hoic

e

12



.53

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Apr-

14M

ay-1

4Ju

n-14

Jul-1

4Au

g-14

Sep-

14O

ct-1

4N

ov-1

4De

c-14

Jan-

15Fe

b-15

Mar

-15

96.1

0%95

.20%

98.9

0%97

.09%

97.9

8%98

.51%

99.4

3%99

.03%

97.7

0%98

.12%

98.8

4%99

.41%

80.5

7%78

.75%

83.4

1%86

.85%

87.5

0%87

.01%

85.4

1%88

.75%

87.5

8%86

.22%

81.9

8%86

.24%

100.

00%

100.

00%

92.3

1%10

0.00

%10

0.00

%94

.29%

100.

00%

100.

00%

88.8

9%50

.00%

71.4

3%66

.67%

405

87.6

%

Tota

lW

ithin

62

Days

% 6

2 Da

ys48

539

280

.8%

Plan

ned

Care

925

875

94.6

%91

991

599

.6%

Uni

vers

ity H

ospi

tals

of L

eice

iste

r NHS

FT

Glo

uces

ters

hire

Hos

pita

ls N

HS F

T91

887

2

% 3

1 Da

ysW

ithin

31

Days

Tota

l

397

82.2

%

955

98.9

%94

791

696

.7%

1,06

7

354

74.9

%

1,30

21,

280

98.3

%1,

296

1,28

098

.8%

1,03

597

.0%

985

951

96.5

%

95.0

%69

,131

67,5

9997

.8%

27,5

8183

.9%

438

328

74.9

%43

034

881

.0%

Uni

ted

Linc

olns

hire

Hos

pita

ls N

HS F

TO

xfor

d U

nive

rsity

Hos

pita

ls N

HS F

T

449

363

80.9

%44

334

8

458

399

87.0

%

78.6

%N

ottin

gham

Uni

vers

ity H

ospi

tals

NHS

FT

Glo

uces

ters

hire

Hos

pita

ls N

HS F

T

Canc

ers -

31

and

62 D

ays

Tabl

e: H

EFT

31 D

ay P

erfo

rman

ce v

Pee

r Tru

sts –

Qua

rter

3 2

014/

15

Tabl

e: H

EFT

62 D

ay P

erfo

rman

ce v

Pee

r Tru

sts –

Qua

rter

3 2

014/

15

31 D

ay P

athw

aySh

effie

ld T

each

ing

Hosp

itals

NHS

FT

All E

nglis

h Pr

ovid

ers

Tabl

e 1

: Tw

o w

eek

wai

ts/B

reas

t Sym

ptom

s: p

erce

ntag

e of

pat

ient

s see

n in

2 w

eeks

Indi

cato

r31

Day

Tar

get (

96%

targ

et)

62 D

ay T

arge

t (85

% ta

rget

)62

Day

Nat

iona

l Scr

eeni

ng P

rogr

amm

e

Uni

vers

ity H

ospi

tals

of L

eice

ter N

HS F

TEa

st K

ent H

ospi

tals

Uni

vers

ity N

HS F

TLe

eds T

each

ing

Hosp

itals

NHS

FT

Hear

t of E

ngla

nd N

HS F

T

32,9

11

462

966

The

New

cast

le u

pon

Tyne

Hos

pita

ls N

HS F

TN

ottin

gham

Uni

vers

ity H

ospi

tals

NHS

FT

Nor

folk

and

Nor

wic

h U

nive

rsity

Hos

pita

ls N

HS F

THe

art o

f Eng

land

NHS

FT

Oxf

ord

Uni

vers

ity H

ospi

tals

NHS

FT

62 D

ay P

athw

ay

The

New

cast

le u

pon

Tyne

Hos

pita

ls N

HS F

T

483

Guy

's an

d St

Tho

mas

' NHS

FT

All E

nglis

h Pr

ovid

ers

473

Head

lines

Pe

rfor

man

ce in

62

day

stan

dard

in M

arch

201

5 (T

arge

t 85%

): 86

.24%

Pe

rfor

man

ce in

62

day

scre

enin

g in

Mar

ch 2

015

(Tar

get 9

0%):

66.6

7%

Perf

orm

ance

Ana

lysi

s Q

uart

erly

per

form

ance

of a

ll 31

and

62

day

stan

dard

s was

ach

eive

d w

ith th

e ex

cept

ion

of th

e 62

day

nat

iona

l sc

reen

ing

prog

ram

me.

The

num

ber o

f pat

ient

s on

a 62

day

scre

enin

g pa

thw

ay w

ere

low

er in

Q4

com

pare

d to

pr

evio

us q

uart

ers

due

to th

e re

lativ

e re

duct

ion

in p

atie

nts u

nder

goin

g br

east

scre

enin

g lo

cally

. Th

e nu

mbe

r of p

atie

nts w

ho h

ave

wai

ted

mor

e th

an 1

00 d

ays f

or th

eir c

are

to b

e co

mpl

eted

redu

ced

to 4

in A

pril,

th

e lo

wes

t for

ove

r 12

mon

ths

Actio

ns T

aken

•

Wor

ksho

ps to

furt

her i

mpr

ove

patie

nt p

athw

ays i

n Lu

ng a

nd U

rolo

gy w

ill ta

ke p

lace

in M

ay

•Fo

cus i

s bei

ng a

pplie

d at

the

wee

kly

canc

er P

atie

nt-t

arge

ted

List

(PTL

) mee

ting

to e

nsur

e al

l pat

ient

s are

dat

ed a

nd

issue

s esc

alat

ed

•M

eetin

g w

ith C

CG w

ill ta

ke p

lace

in M

ay re

gard

ing

'pan

-Birm

ingh

am' m

anag

emen

t of p

atie

nts r

efer

red

late

into

th

eir p

athw

ay a

nd th

e im

pact

this

has o

n ou

tcom

es a

nd p

erfo

rman

ce

13



.54

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

ALQ

R26

ALQ

R24c

ALQ

R24b

89.5

1%10

0.00

%10

0.00

%94

.19%

Har

m F

ree

Care

95%

94.8

9%94

.04%

93.7

3%

00

00

00

12

11

10

02

93

61

2

zero

tole

ranc

e

Pres

sure

Ulc

er R

educ

tion

for

avoi

dabl

e gr

ade

2 pr

essu

re u

lcer

s

Pres

sure

Ulc

er R

educ

tion

for

avoi

dabl

e gr

ade

3 pr

essu

re u

lcer

s

Pres

sure

Ulc

er R

educ

tion

for

avoi

dabl

e gr

ade

4 pr

essu

re u

lcer

sze

ro to

lera

nce

5.17

81

54

No.

of I

njur

ious

Fal

ls

Redu

ctio

n in

ove

rall

falls

rate

(per

100

,000

be

d da

ys)

N/A

7.71

6.70

8.62

N/A TB

C

Qua

lity

& R

isk

Heat

Map

- N

ursi

ng P

erfo

rman

ce

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RK

TARGET

In month trajectory

Last

Mon

th

Trus

t (M

ar-1

5)H

eart

land

s H

ospi

tal

Goo

d H

ope

Hos

pita

lSo

lihul

l H

ospi

tal

Clin

ical

Su

ppor

t Se

rvic

es

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Mar

-15

Perf

orm

ance

Im

prov

emen

t

6.5010

14



.55

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Gra

ph: I

njur

ious

Fal

ls

Gra

ph: F

alls

rate

per

1,0

00 o

ccup

ied

bed

days

(OBD

)

Qua

lity

& R

isk

Falls

Tabl

e: N

ursi

ng M

etric

s - F

alls

Ass

essm

ent

Head

lines

Th

e Fa

lls a

sses

smen

t ele

men

t of t

he n

ursin

g m

etric

s ach

ieve

d a

scor

e of

95%

for A

pr-1

5, th

e hi

ghes

t sco

re si

nce

the

Falls

Bun

dle

was

firs

t int

rodu

ced

in Ju

l-14.

The

re is

a y

ear e

nd ta

rget

ove

rall

for 2

015-

16 o

f 95%

, with

eac

h el

emen

t of

the

falls

bun

dle

to a

chie

ve 9

0% b

y ye

ar e

nd.

Ther

e w

ere

no in

dica

tors

scor

ing

less

than

90%

for A

pr-1

5.

The

Trus

t fal

ls ra

te p

er 1

,000

occ

upie

d be

d da

ys h

as fa

llen

to 6

.50

in A

pr-1

5, it

s low

est r

ate

since

Jun-

13. T

here

is n

o of

ficia

l tar

get f

or 2

015/

16 b

ut th

e in

tern

al ta

rget

is n

ot to

per

form

abo

ve th

e up

per c

ontr

ol li

mit

(i.e.

less

than

8.8

0).

Perf

orm

ance

Ana

lysi

s Th

ere

wer

e te

n in

jurio

us fa

lls in

Apr

-15:

•

One

on

the

Hear

tland

s site

(War

d 29

) •

Five

at G

ood

Hope

(War

ds 1

1, 1

7, 1

8, 2

3 an

d Ce

darw

ood)

•

Four

on

the

Solih

ull s

ite (W

ards

19,

20A

, 20B

and

AM

U S

hort

Sta

y).

The

them

es fr

om R

CAs w

ill b

e pu

blish

ed o

n a

quar

terly

bas

is.

The

falls

rate

per

1,0

00 o

ccup

ied

beds

day

s wer

e sp

lit a

cros

s the

site

s as f

ollo

ws:

•

Hear

tland

s, 2

014/

15 =

7.4

1, A

pril

2015

= 6

.70

•Go

od H

ope,

201

4/15

= 9

.34,

Apr

il 20

15 =

8.6

2 •

Solih

ull,

2014

/15

= 7.

26, A

pril

2015

= 5

.17

Ac

tions

take

n •

Nur

sing

Care

indi

cato

rs h

ave

been

revi

sed,

ther

efor

e w

orki

ng to

new

met

rics i

n 20

15/1

6 •

The

new

met

ric q

uest

ions

are

now

live

•

Peer

revi

ews/

aud

its to

be

carr

ied

out b

y w

ard

man

ager

s or s

enio

r sist

ers.

Thi

s may

hav

e an

initi

al n

egat

ive

impa

ct

on p

erfo

rman

ce d

ue to

inte

rpre

tatio

n of

the

new

que

stio

ns.

Actio

ns fo

r Inj

urio

us F

alls

•RC

As to

be

com

plet

ed fo

r rec

urre

nt fa

llers

in M

ar 2

015.

•

Them

es to

be

iden

tifie

d an

d m

onito

red

over

the

next

12

mon

ths.

Thi

s inf

orm

atio

n w

ill b

e us

ed w

hen

deve

lopi

ng

targ

ets i

n 20

16/1

7.

7

0

5 7

8

2

6 5

5

8

4

8 10

024681012

Num

ber o

f Inj

urio

us F

alls

HEFT

Ave

rage

Upp

er C

ontr

ol L

imit

Low

er C

ontr

ol L

imit

6.70

6.73

6.50

6.91

8.15

7.15

7.13

7.01

8.05

7.26

6.96

7.71

6.50

5.00

6.00

7.00

8.00

9.00

10.0

0

HEFT

Fal

ls Ra

te p

er 1

,000

OBD

HEFT

Ave

rage

Upp

er C

ontr

ol L

imit

Low

er C

ontr

ol L

imit

15



.56

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Qua

lity

& R

isk

Avoi

dabl

e Gr

ade

2Av

oida

ble

Grad

e 3

Apr-

1512

2

Pres

sure

Ulc

ers

Tabl

e: N

ursi

ng M

etric

s - T

issue

Via

bilit

y

Tabl

e: N

umbe

r of

avoi

dabl

e Ho

spita

l acq

uire

d Pr

essu

re U

lcer

s (in

Mon

th a

nd Y

TD)

Grap

h 2:

Saf

ety

Ther

mom

eter

Poi

nt p

reva

lenc

e of

all

pres

sure

ulc

ers

2014

/15

(YTD

)21

466

Head

lines

The

Tiss

ue V

iabi

lity

Asse

ssm

ent i

ndic

ator

of t

he n

ursin

g m

etric

s ach

ieve

d a

scor

e of

94%

for A

pr-1

5. A

95%

yea

r en

d ta

rget

has

bee

n ag

reed

for t

he th

ree

elem

ents

of t

he ti

ssue

via

bilit

y m

etric

s tha

t wer

e un

der-p

erfo

rmin

g du

ring

2014

-15

(dai

ly sk

in in

spec

tions

, rep

ositi

onin

g fr

eque

ncy

com

plet

ed, a

nd re

posit

ioni

ng fr

eque

ncy

adhe

red

to).

The

se th

ree

elem

ents

wer

e al

so th

e m

ost c

omm

only

occ

urrin

g th

emes

from

the

RCAs

resu

lting

in p

ress

ure

ulce

rs b

eing

clas

sed

as a

void

able

. Th

e Tr

ust p

ress

ure

ulce

r poi

nt p

reva

lenc

e ha

s rem

aine

d be

low

the

aver

age

line

for t

he p

ast 1

4 co

nsec

utiv

e m

onth

s de

spite

the

smal

l inc

reas

e in

mon

th (f

rom

3.5

1 to

3.7

7).

The

Trus

t also

con

tinue

s to

sit w

ell b

elow

the

Nat

iona

l av

erag

e fig

ure

of 4

.48%

. Th

e nu

mbe

r of a

void

able

pre

ssur

e ul

cers

con

firm

ed fo

r Apr

-15

wer

e tw

elve

gra

de 2

, on

e gr

ade

3, a

nd o

ne

necr

otic

. Ho

wev

er, t

here

are

still

48

pres

sure

ulc

ers f

or A

pr-1

5 st

ill a

wai

ting

an o

utco

me

follo

win

g RC

A. F

inal

fig

ures

for 2

014-

15 sh

ow th

e Tr

ust h

as re

cord

ed 2

14 g

rade

2 a

void

able

pre

ssur

e ul

cers

whi

ch is

a 2

1% re

duct

ion

on

2013

-14

(271

). Co

mm

issio

ners

hav

e se

t a fu

rthe

r 20%

redu

ctio

n fo

r 201

5-16

in a

void

able

gra

de 2

pre

ssur

e ul

cers

w

hich

wou

ld m

ean

no m

ore

than

171

inci

denc

es a

cros

s the

Tru

st.

Poin

t pre

vale

nce

is no

long

er a

CQ

UIN

or K

PI b

ut is

requ

ired

as a

n in

form

atio

n re

quire

men

t (w

ith n

o se

t tar

get)

. Fu

rthe

r Act

ions

•

Disc

ussio

ns w

ith C

CG re

gard

ing

avoi

dabl

e pr

essu

re u

lcer

s and

targ

ets c

ontin

ues.

A p

oten

tial T

rust

targ

et o

f 10%

re

duct

ion

is st

ill to

be

agre

ed.

•In

tern

al ta

rget

set a

t 20%

redu

ctio

n ac

ross

all

sites

(inc

CSS

) to

be p

rese

nted

in M

ay 2

015.

•

Site

bas

ed tr

ajec

torie

s set

inte

rnal

ly fo

r the

redu

ctio

n of

pre

ssur

e ul

cers

to co

me

into

effe

ct fr

om M

ay 2

015.

3.82

3.62

3.20

3.78

3.93

3.62

3.34

3.86

3.36

3.99

3.92

3.51

3.77

1.00

2.00

3.00

4.00

5.00

6.00

CQU

IN T

arge

tPr

essu

re U

lcer

Pre

vale

nce

Nat

iona

l Ave

rage

16



.57

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Divi

sion

BHH

GHH SO

LO

&G

HEFT

Qua

lifie

d Co

mpl

ianc

eHC

A Co

mpl

ianc

e97

%10

5%10

9%12

1%99

%10

8%

96%

105%

101%

99%

4.00

%

3.08

%

4.87

%

4.40

%

5.70

%

8.59

%

7.62

%

5.17

%

6.18

%

Qua

lity

& R

isk

Nur

sing

Wor

kfor

ce

Gra

ph: %

Sic

knes

s in

Nur

sing

at H

EFT

Tabl

e by

site

sick

ness

in A

pril

2015

UN

IFY

Staf

fing

Retu

rn

Divi

sion

BHH

GHH SO

L

CSS

W&

C

Qua

lifie

d N

ursi

ngN

on-q

ualif

ied

Nur

sing

4.87

%

Wor

kfor

ce H

eadl

ines

:

Ove

rall

ther

e ha

s bee

n a

redu

ctio

n in

Nur

sing

sickn

ess.

Th

ere

is a

signi

fican

t diff

eren

ce b

etw

een

sickn

ess i

n qu

alifi

ed n

ursin

g an

d no

n-qu

alifi

ed n

ursin

g. Q

ualif

ied

nurs

ing

sickn

ess a

lone

is b

elow

the

4.65

% ta

rget

in A

pril

2015

. Ac

tions

•

Raisi

ng h

igh

leve

l of s

ickn

ess o

f non

-qua

lifie

d nu

rsin

g at

site

mee

tings

, esp

ecia

lly G

HH a

nd S

OL

•Th

e sp

lit b

etw

een

qual

ified

and

non

-qua

lifie

d nu

rsin

g sic

knes

s in

2014

/15

to b

e de

taile

d in

May

201

5 re

port

. N

atio

nal S

taffi

ng R

etur

n:

The

UN

IFY

natio

nal s

taffi

ng re

turn

show

ed th

at a

ll sit

es a

nd W

omen

s ser

vice

s acr

oss A

pril

2015

wer

e co

mpl

iant

w

ith st

affin

g to

thei

r fun

ded

esta

blish

men

ts (9

5% o

r ove

r). T

his i

nclu

ded

the

flex

area

s on

each

site

. How

ever

ther

e ar

e a

num

ber o

f war

ds a

t BHH

that

hav

e sig

nific

ant n

umbe

rs o

f qua

lifie

d va

canc

ies (

War

ds 2

,3,8

,9 a

nd 2

4). T

hese

ar

eas a

re h

eavi

ly re

liant

on

tem

pora

ry st

affin

g w

hich

is a

ffect

ing

the

skill

mix

and

con

tinui

ty o

f car

e.

Actio

ns

•Sp

ecifi

c w

ork

is be

ing

unde

rtak

en to

mea

sure

qua

lity

of c

are

war

ds w

ith a

sign

ifica

nt n

umbe

r of q

ualif

ied

vaca

ncie

s.

•Di

ffere

ntia

ting

betw

een

bank

and

trus

t sta

ff in

term

s of H

CAs,

to b

e av

aila

ble

in M

ay 2

015.

Thi

s is t

o de

term

ine

whe

ther

th

ere

is an

y im

pact

on

war

d sa

fety

.

4.10%

5.23%

5.55%

5.69%

5.55%

5.80%

6.11%

6.15%

5.95%

5.81%

5.25%

4.86%

4.98%

3.00

%

3.50

%

4.00

%

4.50

%

5.00

%

5.50

%

6.00

%

6.50

%

% S

ickn

ess i

n N

ursin

g &

Mid

wife

ryTr

ust S

ickn

ess T

arge

t

17



.58

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Nur

sing

Vaca

ncie

s

Gra

ph: Q

ualif

ied

Nur

sing

Vac

ancy

Pos

ition

Apr

il 20

15

Gra

ph: Q

ualif

ied

Nur

sing

Vac

ancy

Pos

ition

Apr

il 20

15 (A

&E,

CSS

and

W&

C on

ly)

Qua

lity

& R

isk

Head

lines

Th

e ke

y iss

ue re

mai

ns th

e sh

orta

ge o

f reg

ister

ed n

urse

s ava

ilabl

e to

recr

uit a

nd a

lso th

e cu

rren

t tur

nove

r of s

taff.

Th

e in

trod

uctio

n of

new

serv

ices

and

the

prov

ision

al p

lan

to su

bsta

ntiv

ely

esta

blish

som

e of

the

flexi

ble

capa

city

be

ds is

like

ly to

hav

e ha

d a

nega

tive

impa

ct o

n th

e va

canc

y po

sitio

n.

Actio

ns ta

ken

•86

pos

ts h

ave

been

offe

red

over

the

last

thre

e m

onth

s to

nurs

es w

ho q

ualif

y in

Sep

tem

ber 2

015.

•

Loca

l rec

ruitm

ent e

vent

s hav

e be

en h

eld

to ta

rget

vac

anci

es in

spec

ialis

t are

as. T

his h

as b

een

very

succ

essf

ul in

th

e Ac

ute

Med

ical

Uni

ts o

n al

l thr

ee si

tes.

•

Busin

ess c

ase

bein

g pr

epar

ed fo

r the

recr

uitm

ent o

f nur

ses i

nter

natio

nally

as a

resu

lt of

the

Recr

uitm

ent a

nd

Rete

ntio

n pa

per p

rese

nted

to E

MB.

•

The

Trus

t has

inve

sted

in N

ursin

g Ti

mes

Gro

up A

cces

s for

eve

ry re

gist

ered

nur

se a

cros

s the

Tru

st. T

his i

s aim

ed

at sl

owin

g do

wn

attr

ition

and

enc

oura

ging

new

recr

uitm

ent i

nter

est p

artic

ular

ly fr

om n

urse

s with

pos

t re

gist

ratio

n ex

perie

nce.

Fu

rthe

r Act

ion

•HR

and

Nur

sing

are

wor

king

toge

ther

to p

rodu

ce p

erso

nal d

evel

opm

ent a

nd p

asto

ral c

are

ince

ntiv

es to

mak

e th

e Tr

ust a

n em

ploy

er o

f cho

ice

•Pr

ogra

mm

e of

loca

l and

nat

iona

l rec

ruitm

ent e

vent

s pla

nned

thro

ugho

ut 2

015.

Data

not

ava

ilabl

e at

this

tim

e, d

ue to

be

avai

labl

e fo

r May

201

5 Re

port

Data

not

ava

ilabl

e at

this

tim

e, d

ue to

be

avai

labl

e fo

r May

201

5 Re

port

18



.59

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

ANQ

R2<

646

ANQ

R3

ANQ

R1

QS6

QS7

ANQ

R11

95.0

0%

N/A

Mor

talit

y -

HSM

R

Mor

talit

y -

SHM

I

93.5

3%95

.82%

97.4

3%

N/A

N/A

N/A

N/A

N/A

10

00

8

N/A

2

N/A 0

N/A

1M

inim

ise

rate

s of

Clo

stri

dium

dif

fici

le

VTE

ris

k as

sess

men

t: a

ll in

pati

ent

Serv

ice

Use

rs u

nder

goin

g ri

sk

asse

ssm

ent

for

VTE

, as

defi

ned

in

Con

trac

t Te

chni

cal G

uida

nce

93.1

7%N

/A

0 0

> 9

0%

> 9

0%

00

0

92.7

1%81

.60%

82.9

8%78

.94%

86.5

5%77

.43%

> 9

5%

0

N/A

N/A

N/A

N/A

95.0

6%

The

num

ber

of a

void

able

Clo

stri

dium

D

iffi

cile

Qua

lity

& R

isk

Heat

Map

- In

fect

ion

Cont

rol,

VTE,

Mor

talit

y

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RK

TARGET

In month trajectory

Last

Mon

th

Trus

t (M

ar-1

5)H

eart

land

s H

ospi

tal

Goo

d H

ope

Hos

pita

lSo

lihul

l H

ospi

tal

Clin

ical

Su

ppor

t Se

rvic

es

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Apr

-15

Perf

orm

ance

Im

prov

emen

t

2 00

Zero

tol

eran

ce M

RSA

MR

SA E

lect

ive

Scre

enin

g R

ates

(%

pa

tien

ts s

cree

ned)

MR

SA E

mer

genc

y Sc

reen

ing

Rat

es

(% p

atie

nts

scre

ened

)

19



.60

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Emer

genc

y Sc

reen

ing

Apr

-15

81.6

%YT

D81

.6%

Qua

lity

& R

isk

Infe

ctio

n Co

ntro

l

Trus

t wid

e

Elec

tive

Scre

enin

gA

pr-1

5YT

D

Tabl

e: T

rust

Wid

e Av

oida

ble/

Una

void

able

Tox

in P

ositi

ve P

ost 4

8 hr

C.D

iff c

ases

Gra

ph: T

rust

Wid

e Av

oida

ble/

Una

void

able

Tox

in P

ositi

ve P

ost 4

8 hr

C.D

iff c

ases

Post

-48h

r Cas

esA

pr-1

50

YTD

0D

ays

Bet

wee

n M

RSA

Bac

tere

amia

Cas

es10

5

Pre-

48hr

Cas

esA

pr-1

50

YTD

0

Head

lines

Th

ere

wer

e no

cas

es o

f pos

t 48

hour

MRS

A ba

cter

aem

ia re

port

ed in

Apr

il. T

here

is st

ill a

zero

tole

ranc

e ta

rget

for

MRS

A po

st 4

8 ho

ur b

acte

raem

ias.

Th

ere

have

bee

n tw

o ca

ses o

f pos

t 48

hour

toxi

n po

sitiv

e Cl

ostr

idiu

m D

iffic

ile (C

.diff

) in

April

aga

inst

the

mon

th

targ

et o

f 6 o

r les

s. T

he 2

015/

16 y

ear t

arge

t is ≤

64

case

s (16

per

qua

rter

).

Ther

e w

as o

ne n

ew c

ase

of C

PE id

entif

ied

in A

pril.

Thi

s was

from

a c

linic

al sp

ecim

en (s

putu

m) f

rom

a c

hild

who

has

re

ceiv

ed h

ealth

care

in In

dia.

Th

ere

wer

e tw

o ca

ses o

f sus

pect

ed e

bola

in A

pril.

Bot

h pa

tient

s wer

e re

turn

ing

heal

thca

re w

orke

rs w

ho w

ere

low

ris

k an

d lo

w p

roba

bilit

y of

ebo

la. I

n ea

ch c

ase

the

patie

nt w

as n

egat

ive

for e

bola

and

was

disc

harg

ed w

ithin

24

hour

s.

Perf

orm

ance

Ana

lysi

s •

Four

war

ds w

ere

clos

ed d

urin

g Ap

ril d

ue to

out

brea

ks o

f dia

rrho

ea a

nd v

omiti

ng co

nfirm

ed a

s Nor

oviru

s. T

hese

w

ere

BHH

war

d 6,

GHH

war

d 14

, GHH

war

d 16

and

GHH

war

d 9.

•Th

ere

was

an

outb

reak

dec

lare

d of

CPE

on

BHH

war

d 12

in A

pril

(all

the

patie

nts w

ere

in h

ospi

tal d

urin

g M

arch

). Th

e in

dex

patie

nt h

ad th

e or

gans

im id

entif

ied

from

a c

linic

al sp

ecim

en o

f urin

e an

d tw

o pa

tient

cont

acts

wer

e fo

und

to b

e po

sitiv

e on

scre

enin

g. T

ypin

g of

the

spec

imen

s ide

ntifi

ed th

at th

ey w

ere

indi

stin

guish

able

. All

thre

e pa

tient

s had

bee

n di

scha

rged

and

scre

enin

g of

the

rem

aini

ng p

atie

nts o

n th

e w

ard

was

neg

ativ

e.

Actio

ns ta

ken

•De

ep cl

eani

ng w

as c

arrie

d ou

t on

all n

orov

irus o

utbr

eak

war

ds p

rior t

o re

-ope

ning

.

•An

RCA

was

car

ried

out f

or th

e CP

E ou

tbre

ak o

n BH

H w

ard

12 a

nd a

ctio

ns in

clud

ed d

eep

clea

ning

of t

he e

ntire

w

ard

, aud

it of

pra

ctic

e, h

and

hygi

ene

educ

atio

n an

d re

-ass

essm

ent o

f clin

ical

staf

f for

AN

TT (a

sept

ic n

on-t

ouch

te

chni

que)

.

•Th

e eb

ola

actio

n gr

oup

mee

ts m

onth

ly a

nd a

deb

rief i

s car

ried

out f

or a

ll su

spec

ted

case

s.

•

CPE

scre

enin

g ha

s bee

n im

plem

ente

d in

adu

lt in

patie

nt a

nd a

dmiss

ion

area

s w

ith th

e sc

reen

ing

ques

tion

bein

g as

ked

of a

ll pa

tient

s and

incl

uded

in e

lect

roni

c and

pap

er d

ocum

enta

tion.

2 6

11

16

22

27

32

38

43

48

54

59

64

4

13

21

28

32

39

45

46

56

64

67

75

01020304050607080

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Trus

t wid

e Av

oida

ble/

Una

void

able

Toxi

n Po

sitiv

e Po

st 4

8hr

C.Di

ff Ca

ses

Avoi

dabl

eUn

avoi

dabl

eAw

aitin

g Ty

ping

2015

/16

Targ

et20

14/1

5

20



.61

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

W5

W6

8.5%

by

Mar

-16

9.00

%

W7

4.25

%

by M

ar-

164.

65%

W12

W13

85.8

6%83

.62%

86.1

0%85

.50%

86.0

7%84

.77%

86.4

2%

3.93

%5.

85%

3.71

%4.

07%

4.18

%4.

32%

73.8

2%62

.72%

60.0

9%74

.71%

80.9

2%66

.05%

73.2

9%

Vaca

ncie

s

Staf

f FFT

N/A

14.4

11.4

15.5

14.7

Volu

ntar

y Tu

rnov

er

Sick

ness

- in

mon

th p

ositi

on (Y

TD fi

gure

=

MAA

) mia

Aver

age

Tim

e to

Rec

ruit

from

vac

ancy

ap

prov

al to

star

t dat

e - A

ll St

aff G

roup

s<

11 w

eeks

85%

rolli

ng y

ear

No

targ

et se

t

Num

ber o

f App

raisa

ls Co

mpl

eted

Trus

twid

e Ag

ency

Spe

nd

Man

dato

ry T

rain

ing

85%

rolli

ng y

ear

9.01

%10

.34%

11.9

5%8.

58%

4.33

%

14.6

14N

/A

8.90

%Wor

kfor

ce &

Wel

l-bei

ng

Heat

Map

CC

G /

H

EFT

Ref.

MO

NIT

OR

CO

MP

LIA

NC

E -

RISK

ASS

ESSM

ENT

FRAM

EWO

RK

TARGET

In month trajectory

Last

Mon

th

Trus

t (M

ar-1

5)H

eart

land

s H

ospi

tal

Goo

d H

ope

Hos

pita

lSo

lihul

l H

ospi

tal

Clin

ical

Su

ppor

t Se

rvic

es

Wom

ens

&

Chi

ldre

n

Trus

t P

erfo

rman

ce

Apr

-15

Perf

orm

ance

Im

prov

emen

t

8.30

%9.

01%

21



.62

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Wor

kfor

ce &

Wel

l-bei

ng

Appr

aisa

ls

Appr

aisa

ls tr

ajec

tory

% A

ppra

isal

s com

plet

ed b

y Di

visi

on

CSS

Divi

sion

BHH

GHH SO

L

WC

CORP

FAC

HEFT

Mar

-15

Apr-

15

0.00

%0.

00%

0.00

%0.

00%

2014

/15

61.1

7%61

.08%

73.0

9%82

.53%

0.00

%0.

00%

0.00

%0.

00%

62.7

2%60

.09%

74.7

1%80

.92%

67.3

6%

73.8

2%

90.1

7%92

.57%

73.2

9%

66.0

5%86

.67%

89.0

2%

73.29% 58.76%

0%10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

% A

ppra

isals

Com

plet

ed 2

015/

16%

App

raisa

ls Co

mpl

eted

201

4/15

Targ

et 2

015/

16

Head

lines

Th

ere

has b

een

a ch

ange

in th

e w

ay a

ppra

isal c

ompl

eted

dat

a is

publ

ished

in 2

015/

16. T

he 2

015/

16 ta

rget

is 8

5%

over

a ro

lling

12

mon

ths (

rath

er th

an th

e tr

ajec

tory

use

d in

201

4/15

). Th

e ro

lling

12

mon

ths i

n Ap

ril 2

015

is 73

.29%

. All

data

in th

is re

port

is b

ased

on

this

new

met

hod

of d

ata

colle

ctio

n.

HR A

naly

sis

Ther

e ha

s bee

n gr

adua

l im

prov

emen

t thr

ough

201

4/15

from

58.

76 %

at t

he st

art o

f 201

4/15

to 7

3.29

% b

y Ap

ril

2015

. Th

e Di

rect

orat

es w

ith st

aff n

umbe

rs m

ore

than

50

whi

ch a

re m

ost c

ontr

ibut

ing

to th

e pe

rfor

man

ce b

eing

bel

ow

targ

et

are:

Th

ere

wer

e no

maj

or is

sues

in C

orpo

rate

and

Fac

ilitie

s.

Actio

ns

•Th

ere

is fu

rthe

r tra

inin

g fo

r app

raise

rs b

eing

pro

vide

d ce

ntra

lly b

y HR

.

•Im

prov

ing

and

simpl

ifyin

g th

e ap

prai

sal p

roce

ss in

clud

ing

inve

stig

atin

g an

onl

ine

appr

aisa

l sys

tem

.

22



.63

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Wor

kfor

ce &

Wel

l-bei

ng

Man

dato

ry T

rain

ing

(MIA

)

Man

dato

ry T

rain

ing

(MIA

)

Divi

sion

per

form

ance

(MIA

)

83.8

3%

Divi

sion

FAC

HEFT

Feb-

15

CORP

WC

BHH

GHH SO

LCS

S0.

00%

86.1

0%85

.50%

86.0

7%0.

00%

0.00

%0.

00%

0.00

%

Mar

-15

83.6

2%

84.7

7%76

.40%

83.0

3%85

.03%

85.5

9%84

.84%

2015

/16

0.00

%0.

00%

0.00

%

76.8

7%76

.87%

85.8

6%79

.02%

86.4

2%

0

60%

65%

70%

75%

80%

85%

90%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Man

dato

ry T

rain

ing

% C

ompl

ianc

e 20

15/1

6M

anda

tory

Tra

inin

g %

Com

plia

nce

2014

/15

Targ

et 2

015/

16

Head

lines

Th

e to

tal f

igur

e fo

r the

yea

r to

Mar

ch 2

015

is 86

.42%

aga

inst

a ta

rget

of 8

5%.

HR A

naly

sis

Desp

ite a

chie

ving

the

over

all t

rain

ing

targ

et, t

here

are

still

are

as w

here

com

plia

nce

can

be im

prov

ed:

•Re

susc

itatio

n 61

.33%

•

Fire

Saf

ety

59.7

7%

•Bl

ood

Tran

sfus

ion

(adm

inist

erin

g) 5

9.7%

Th

e re

leas

e of

staf

f is s

till a

fact

or in

non

-del

iver

y in

the

abov

e ar

eas.

Thi

s is c

ompo

unde

d by

a n

umbe

r of

vaca

ncie

s in

the

resu

scita

tion

team

whi

ch im

pact

s on

thei

r abi

lity

to d

eliv

er th

e m

anda

tory

trai

ning

. Al

l div

ision

s hav

e se

en a

n in

crea

se fr

om la

st m

onth

with

the

exce

ptio

n of

Cor

pora

te D

ivisi

on (0

.47%

dec

reas

e).

The

Dire

ctor

ates

with

mor

e th

an 5

0 st

aff a

nd re

lativ

ely

low

com

plia

nce

incl

ude:

He

artla

nds

El

derly

Med

72

.26%

CS

S

Lab

Med

76

.16%

Ac

tions

Tak

en

•N

on re

leas

e of

staf

f has

bee

n es

cala

ted

to A

MDs

. •

Resu

scita

tion

staf

fing

leve

l rev

iew

is c

urre

ntly

in th

e pr

oces

s of b

eing

com

plet

ed. E

stim

ated

4 w

eeks

•

Addi

tiona

l adm

in su

ppor

t con

firm

ed fo

r LM

S.

•Th

e th

ree

area

s of c

once

rn w

erer

aise

d at

the

Risk

Com

mitt

ee in

Apr

il 20

15.

•DN

A an

d Ca

ncel

latio

n re

port

s hav

e be

en e

scal

ated

to d

ivisi

onal

leve

l. Fu

rthe

r Act

ions

•

New

Lea

rner

Man

agem

ent S

yste

m (L

MS)

bei

ng la

unch

ed 1

st Ju

ne, g

radu

ated

roll

out w

ill ta

ke 9

wee

ks.

Not

ava

ilabl

e at

this

time

23



.64

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Divi

sion

per

form

ance

HEFT

Wor

kfor

ce &

Wel

l-bei

ng

Sick

ness

Trus

t Sic

knes

s

Divi

sion

BHH

GHH SO

LCS

SW

CCO

RPFA

C

Mar

-15

Apr-

15M

ovin

g An

nual

Ave

rage

4.57

%3.

93%

4.56

%5.

19%

4.00

%4.

93%

5.21

%3.

63%

6.50

%4.

71%

4.96

%4.

06%

4.97

%5.

27%

3.58

%6.

38%

4.71

%

5.85

%3.

71%

4.07

%4.

18%

3.34

%8.

02%

4.32

%

Head

lines

Si

ckne

ss fo

r Apr

il w

as 4

.32%

acr

oss t

he T

rust

, a v

ery

sligh

t red

uctio

n ag

ains

t the

Mar

ch fi

gure

of 4

.33%

. The

mov

ing

annu

al a

vera

ge fi

gure

has

stay

ed u

ncha

nged

com

pare

d w

ith la

st m

onth

so w

e ar

e ab

ove

targ

et w

hich

is f

orec

ast a

s a

mon

th b

y m

onth

redu

ctio

n ov

er th

e ye

ar.

HR

Ana

lysi

s Ar

eas w

ith si

gnifi

cant

staf

f num

bers

and

the

high

est s

ickn

ess l

evel

s for

the

mon

th o

f Apr

il 15

wer

e:

The

area

s with

the

high

est s

ickn

ess l

evel

s ove

r a ro

lling

-12

mon

th p

erio

d w

ere:

Ac

tions

•

HR c

ontin

ues t

o as

sist m

anag

ers w

ith th

e m

anag

emen

t of s

taff

sickn

ess.

Furt

her A

ctio

ns

•Th

ere

is re

view

of s

ickn

ess p

olic

y un

der c

onsu

ltatio

n w

ith st

aff s

ide

whi

ch sh

ould

hel

p to

impr

ove

proc

esse

s for

m

anag

ing

sickn

ess.

Thi

s is d

ue to

take

pla

ce a

t the

end

of M

ay.

•Co

ntin

ued

deve

lopm

ent o

f sta

ff en

gage

men

t pla

n as

par

t of o

vera

ll tr

ust p

lan.

A w

orki

ng g

roup

will

mee

t in

May

to

con

sider

ince

ntiv

es fo

r sta

ff ac

hiev

ing

low

sick

ness

.

4.32%

3.50

%

3.70

%

3.90

%

4.10

%

4.30

%

4.50

%

4.70

%

4.90

%

5.10

%

5.30

%

5.50

%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Sick

ness

201

5/16

Sick

ness

201

4/15

Targ

et 2

015/

16

24



.65

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ofInterest


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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Wor

kfor

ce &

Wel

l-bei

ng

Volu

ntar

y Tu

rnov

er &

Rec

ruitm

ent

Divi

sion

HEFT

GHH SO

LCS

S

Volu

ntar

y tu

rnov

er

Aver

age

time

to re

crui

t in

wee

ks

Aver

age

time

to re

crui

t

BHH

CORP

FAC

WC

Mar

-15

9.3

8.4

8.4

9.2

10.7

11.1

8.7

8.3

Apr-

1514

.411

.415

.514

.714

.611

.213

.514

.0

2015

/16

14.4

11.4

15.5

14.7

14.6

11.2

13.5

14.0

9.01%

0%1%2%3%4%5%6%7%8%9%10%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Volu

ntar

y Tu

rnov

er 2

015/

16Vo

lunt

ary

Turn

over

201

4/15

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et 2

015/

16

14

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Apr

May

Jun

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Mar

weeks

Aver

age

Tim

e to

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ruit

2015

/16

Aver

age

Tim

e to

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ruit

2014

/15

Targ

et 2

015/

16

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. Tim

e to

recr

uit 2

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ata

only

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udes

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ratio

nal m

anga

gem

ent

activ

ity d

urin

g re

crui

ting.

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5/16

targ

et a

nd d

ata

incl

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bot

h op

erat

ion

man

agm

ent a

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l rec

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ctiv

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lines

Vo

lunt

ary

Turn

over

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rnov

er w

as v

ery

sligh

tly a

bove

the

9% ta

rget

in A

pril

2015

(9.0

1%).

This

has s

tabi

lised

ove

r the

last

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ths.

Turn

over

Ana

lysi

s De

spite

bei

ng a

bove

targ

et d

urin

g Ap

ril 2

015,

turn

over

is e

xpec

ted

to re

duce

to 8

.5%

by

the

year

end

. Di

rect

orat

es w

ith m

ore

than

50

staf

f and

the

high

est l

evel

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ver a

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Re

crui

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me

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ire

The

targ

et is

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ks c

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of 6

.25

wee

ks fo

r the

Ope

ratio

nal M

anag

emen

t par

t of t

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roce

ss a

nd 4

.75

wee

ks

for t

he ce

ntra

l rec

ruitm

ent s

ectio

n. T

he a

ctua

l pos

ition

for A

pril

2015

was

8.5

wee

ks a

nd 5

.5 w

eeks

resp

ectiv

ely,

gi

ving

a to

tal o

f 14

wee

ks.

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uitm

ent A

naly

sis

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mai

n re

ason

for d

elay

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me

take

n to

shor

tlist

cand

idat

es a

nd re

turn

a su

cces

sful

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dida

te fo

rm.

The

mai

n ar

eas w

ith lo

ng ti

mes

cale

s are

: Ac

tions

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en

•A

repo

rt is

now

sent

mon

thly

to e

ach

of th

e ar

eas p

erfo

rmin

g po

orly

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rthe

r Act

ion

•An

alys

is in

to a

pot

entia

l lin

k be

twee

n th

e nu

mbe

r of v

acan

cies

and

long

are

as w

ith lo

nger

recr

uitm

ent t

imes

is

bein

g un

dert

aken

.

25



.66

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Apr-

15M

ay-1

5Ju

n-15

Jul-1

5Au

g-15

Sep-

15O

ct-1

5N

ov-1

5De

c-15

Jan-

16Fe

b-16

Mar

-16

2014

/15

24.9

1%29

.09%

16.3

5%18

.19%

% R

espo

nses

Inpa

tient

sA&

E

YTD

24.9

1%16

.35%

Inpa

tient

s FFT

201

4/15

Per

form

ance

, Pos

itive

vs N

egat

ive

resp

onde

rs

A&E

FFT

2014

/15

Perf

orm

ance

, Pos

itive

vs N

egat

ive

resp

onde

rs

Tabl

e: T

rust

Inpa

tient

War

d Su

mm

ary

Mar

-15

Patie

nt E

xper

ienc

e

Met

rics

Frie

nds a

nd F

amily

Tes

t per

cent

age

of re

spon

ses

Head

lines

Fr

iend

s and

Fam

ily T

est (

FFT)

Th

is is

no lo

nger

a C

QU

IN re

quire

men

t but

it is

an

impo

rtan

t and

use

ful m

etric

. Cur

rent

ly, t

he ta

rget

s are

se

t at t

he Q

uart

er 4

201

4/15

pos

ition

. •

The

abso

lute

num

ber o

f res

pons

es to

the

FFT

cont

inue

s to

grow

. •

The

num

ber o

f pos

itive

resp

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s for

inpa

tient

s is b

elow

the

regi

onal

scor

e of

95%

how

ever

this

does

va

ry m

onth

on

mon

th.

In th

e A&

E da

ta th

e po

sitiv

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spon

se ra

te is

low

er th

an th

at o

f inp

atie

nts,

this

indi

cate

s a lo

wer

leve

l of

satis

fact

ion

with

our

A&

E se

rvic

e. T

here

is a

lso a

larg

er d

iffer

ence

bet

wee

n th

e A&

E sc

ore

for H

eart

of

Engl

and

and

the

regi

onal

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7% in

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ch, f

or B

irmin

gham

and

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ck C

ount

ry re

gion

). Th

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is no

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ben

chm

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r neg

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spon

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ther

efor

e w

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e un

able

to d

raw

any

co

mpa

rison

s. C

ompa

rison

dat

a fo

r pos

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s was

not

ava

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the

time

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ritin

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urbe

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se a

t Nig

ht

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noise

at n

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que

stio

ns co

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o be

the

poor

est p

erfo

rmin

g m

etric

. On

furt

her a

naly

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is

diffi

cult

to ta

rget

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d ar

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here

ther

e m

ight

be

a pa

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issu

e du

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a w

ide

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war

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her A

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reem

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o be

reac

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resh

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for F

FT fo

r 201

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•

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her w

ork

to im

prov

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lidity

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para

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noise

at n

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a is

ongo

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•Da

ta fr

om in

patie

nt q

uest

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s is b

eing

mad

e m

ore

read

ily a

vaila

ble

to n

ursin

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aff.

5060708090

Q1

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/15

Invo

lved

in T

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ision

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ll bu

zzer

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at n

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rall

721

769

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1784

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2145

89%

87

%

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94%

92

%

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88

%

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%

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93

%

6%

7%

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2%

1%

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0500

1000

1500

2000

2500

3000

0%20%

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Apr-

14M

ay-1

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n-14

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g-14

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ct-1

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ov-1

4De

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b-15

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-15

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l Res

pons

esPe

rcen

tage

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itive

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rcen

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2335

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19

%

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%

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%

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11

%

0500

1000

1500

2000

2500

3000

0.00

%

15.0

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0%

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14M

ay-1

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n-14

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g-14

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ct-1

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ov-1

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l Res

pons

esPe

rcen

tage

Pos

itive

resp

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sPe

rcen

tage

Neg

ativ

e re

spon

ses

26



.67

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Inte

grat

ed P

erfo

rman

ce R

epor

t - A

pril

Patie

nt E

xper

ienc

e

Com

plai

nts

New

Com

plai

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Re-o

pene

d Co

mpl

aint

s and

Com

plai

nts r

efer

red

to O

mbu

dsm

an

Gra

ph 2

: The

mes

of N

ew C

ompl

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s

230

218

179

119

151

123

92

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46

72

92

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rter

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er 2

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-15

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rter

320

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uart

er 4

2014

-15

Dela

ys /

Canc

ella

tions

Attit

ude

/ Beh

avio

urAp

prop

riate

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atm

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Poor

/ La

ck o

f Inf

orm

atio

nM

edic

atio

n

Head

lines

Th

e nu

mbe

r of n

ew c

ompl

aint

s in

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(93)

incr

ease

d sli

ghtly

com

pare

d to

Mar

ch (8

9).

Valid

atio

n of

201

4/15

has

bee

n un

derw

ay.

The

num

ber o

f com

plai

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lose

d in

yea

r has

impr

oved

from

the

prev

ious

yea

r as h

as th

e nu

mbe

r of

com

plai

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hich

hav

e be

en re

open

ded:

N

B: T

hese

yea

r end

figu

res n

eed

to b

e va

lidat

ed.

Them

es A

naly

sis

The

mai

n th

emes

for c

ompl

aint

s sho

w a

sim

ilar p

ictu

re a

cros

s the

qua

rter

s of 2

014/

15. C

ompl

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s are

of

ten

com

plex

and

cove

r mor

e th

an o

ne is

sue.

The

big

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y fa

r in

each

qua

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re

late

to d

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cella

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en

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rent

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dule

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27



.68

Agenda

WelcomeDeclaration

ofInterest


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Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Prepared for Finance and Performance Committee meeting on 24 April 2015.Author Darren Cattell

1

EXECUTIVE SUMMARY

We remain under Section 111 Monitor Enforcement.

Financially we ended the year as expected, key areas are illustrated below highlighting pressures, nurse bank rate and underlying pay control, as we enter the new financial year:

Performance remains our key area of concern with little improvement in the last month of the year. Improvement trajectories for A&E and RTT are currently being finalised prior to final submission to Monitor for the new year.

Finance

• Underlying pay bill showed a material movement, £0.4m, in month which Divisions need to address as a matter of urgency entering the new financial year.

• Divisions need to now implement exit strategies, outside of agreed new investment measures to deliver care, to mitigate financial risk in quarter 1.

• Divisons are required to close GAP on efficiency plans and implement early delivery 2015/16 to achieve 2015/16 plan.

• Divisions need to improve delivery and have consistent delivery against our finalised 2015/16 CQUIN’s.

• Cash balance at year end was £87.7m.

The Report is being provided for: Trust Board and Council of GovernorsWhich other Committees has this paper been to? Finance and Performance Committee, 24th April 2015

FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORS

Month 12 to 31st March 2015

Trust reforecast following additional measures

investment(£5.6m)

Year end income £0.6m

Nurse bank rate

impact (£0.8m)

BCCrates

impact (£1.0m)

Year end stock,

holiday accrual &

provisions £1.6m

Underlying March pay movement

(0.4m)

2014/15 Year end

(5.6m)

Finance Executive Summary and Key Performance Indicators


.69

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


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Plan

DementiaStrategy

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ties

Prepared for Finance and Performance Committee meeting on 24 April 2015.Author Darren Cattell

2

• Capital expenditure for the year was £20.5m., including accruals which is £21.2m behind approved budget and £6.8m behind Monitor forecast.

Standing Financial Instructions Update

A paper was presented to FPC that proposed the following changes to the SFIs to help provide clarity on responsibilities;

1. Amend the delegated authority levels to revised authority levels that reflected the Trust structure and set the operational managers as the dominant authoriser. For purchase orders and contracts the CEO can approve up to £250k.

2. Above the CEO level of £250k, purchase orders and contracts would be approved by Finance and Performance Committee. This had previously been noted in the SFIs as Trust Board, but this duty had been delegated to Finance and Performance Committee for a number of years. This change requires Trust Board approval as Finance and Performance Committee would now be performing a duty that was previously the responsibility of Trust Board.

3. For business cases where there is a request to spend new money, the case could be approved by EMB up to £500k, and above this would require Trust Board approval.

4. There were other several other procedural changes proposed including;

o Self-approval of orders prohibited except for noted exceptions.

o Exceptions to the authority levels for less usual transactions.

Recommendations

Agreed recommendations:

1. Division’s financial performance to be reported at Delivery Unit meetings.2. Additional action to manage medical pay.3. Executive led improvement in areas of poor performance.4. Implement additional measures to improve performance.5. Exit strategies to be in place for winter/additional measures above new investment

decisions.6. Close GAP on 2015/16 SIEP and begin early implementation.7. Further review the decision regarding enhanced bank rates.8. Conclude demand and capacity investment decisions when linked to 4, 5 and 7 above.9. Accept revised SFI’s.

Darren CattellInterim Director of Finance & Performance March 2015Heart of England NHS Foundation Trust



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MARCH POSITION

The Trust had an I&E surplus in March.

Appendix 1

The final outturn clinical income value for 2014/15 is £577.4m, £11.1m above plan for theyear. Clinical income was £0.6m higher than expected at the end of the year compared to the forecast due to a combination of JMRA upside relating to fines and penalties, additionalRTT funding and end of year specialised services challenges to drugs and devices expenditure.

The main areas of performance were Specialised Services £6.3m plus additional incomerecovered through Cancer Drugs Fund (CDF) of £4.7m.

The in month expenditure position showed a material movement in underlying pay bill ofc£0.4m. Analysis shows this to be due to the following;

Site

Headlines

£k

Good Hope

Backlog claim of Waiting List InitiativesAdditional Capacity – Ward 3

13334

Heartlands

Additional Locums (sickness / vacancy)

121

Solihull New Waiting List InitiativesIncreased Winter / Thornbury

1525

Trustwide

A&E Nursing (sickness / vacancy)

52

Total 380 The table below summarises our current Finance & Performance position:

Category

Mar

Headlines

Finance Pay control

Costs to delivery performanceEfficiency (SIEP) delivery

Performance

A&E 4 hour18 week admitted RTT / non admitted RTT/ incomplete pathwaysCancer 2 week wait / breast symptoms/ 62 day waitsDiagnostics

Contracting

All contract risk for the JMRA has been covered in theyear end contract settlement, including fines andCQUIN non delivery. Contract negotiations for 15/16are still ongoing for both financial and non financial elements of the contract.

Prepared for Finance and Performance Committee meeting on 24 April 2015.

Author Darren Cattell

1



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Plan

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1. FINANCE

The Trust’s income and expenditure position in March was a £2.8m surplus and a £5.6m lossat year end.

The table below shows the key issues influencing the financial position:

Category Mar

Headlines£m

MedicalStaffing

(0.4)

Expenditure remains unaffordableWaiting List Initiatives spend of £0.4mGreatest pressures in BHH, SOL and GHH

Nursing &Midwifery

(0.7)

Expenditure remains unaffordableEnhanced bank rates continueGreatest pressures in BHH and GHH

SIEP

(0.5)

Most significant shortfalls in BHH, SOL and W&C’s

Overall Position

1.1 SIEP – Actual delivery in month was £1.4m (75% of target). The year end delivery for2014/15 was £16.4m (68%) with the balance of plans being high risk. The focus now mustbe early implementation of 2015/16 plans.

1.4 Cash Deposits – The cash balance at the end of March 2015 was £87.7m. Barring

some insignificant balances held in commercial accounts, this was all held in the Trust’sGBS accounts at the year end. Funds remaining in the GBS current accounts earn 25bpinterest.

1.5 Monitor Targets – The Trust’s Continuity of Service Rating (COSR) at the end of March

was 4. The COSR scale is 1 to 4 with 4 being the highest rating.

1.6 Capital – The total capital expenditure in the year was £20.5m, including accruals which is £21.2m behind the approved budget and £6.8m behind the forecast submitted toMonitor. A carry forward of £20.4m is being requested with the majority of this being dueto slippage on cross site plans.



2



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2 CONTRACTING LDP meetings continue with HEFT service leads and the CCG. Key items for considerationcurrently are the underlying activity growth assumptions on both the Acute and Community contracts. Discussions are underway at FD level to agree these principles. Subgroup meetings to work up the detail of the KPI’s, CQUINs, SDIPs and other contractual content arecontinuing and an escalation document is currently being drawn up to identify the currentgaps. This will support any required escalation and identify the risks preventing sign off.

3 ESCALATION PROCESS

The current escalation process will be revised in line with organisation needs at the start ofthe new financial year.

4 CURRENT ACTIONS

The below are the updated actions:

1. Division’s financial performance to be reported at Delivery Unit meetings.2. Additional action to manage medical pay.3. Executive led improvement in areas of poor performance.4. Implement additional measures to improve performance.5. Exit strategies to be in place for winter/additional measures above new investment

decisions.6. Close GAP on 2015/16 SIEP and begin early implementation.7. Further review the decision regarding enhanced bank rates.8. Conclude demand and capacity investment decisions when linked to 4, 5 and 7 above.

5 CONCLUSION

With investment in ongoing capacity clear exit strategies from winter and additional measures coupled with early delivery of service improvement efficiency plans will be essential to mitigating financial risk at the start of the new financial year. Additional investment andongoing support needs to impact positively on performance, care and all standards in quarter1 of 2015/16.

6 RECOMMENDATIONS

It is recommended the above actions are implemented.

Darren CattellInterim Director of Finance & PerformanceMarch 2015Heart of England NHS Foundation Trust



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ACTIVITY / WAITING LIST PERFORMANCE

1. A&E Activity 2014/15

• There were 18,154 A&E attendances in Feb-15, 348

attendances, 2% above plan.• In February 85.65% of patients were seen within 4

hours including walk ins.• At Heartlands 81.95% (1,626 breaches) of patients

within 4 hours, 76.52% (1,437 breaches) at Good Hopesite and 97.32% (81 breaches) at Solihull site.

• A&E activity excludes A&E outpatient attendances.• Form TF2A

In-Month Performance

2. Emergency Activity 2014/15 excluding Paediatrics, Paediatric Surgery and Obstetrics

• The Emergency activity was above plan by 1% inFebruary, 56 Spells.

• Heartlands 113 Spells, 4% and Solihull, 14 Spells, were above plan.

• Good Hope 39 Spells, 4% and Women & Childrens, Spells, 15% were below plan in month.

• Following the implementation of PMS2 a potential patient classification issue has been identified. This iscurrently under a detailed review and any necessaryretrospective realignment will be actioned.

• Form TF2A


3. Emergency Activity 2014/15, Paediatrics, PaediatricSurgery and Obstetrics

• The activity is above plan by 6%, 55 Spells in Feb-15.• The activity YTD is above plan by 6%, 562.• Following the implementation of PMS2 a potential

patient classification issue has been identified. This is currently under review and any necessary retrospective realignment will be actioned.




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4. AMU, MAU & SAU Activity 2014/15

• There were 1,938 spells during Feb-15, 246 Spells,

15% above plan.• Good Hope 102 spells, 20%, Heartlands, 87, 15% an

Solihull, 58, 9% were above plan in month.• There were 4,813, 25% additional spells YTD.


5. Maternity Spells Activity 2014/15

• In February 2015, there were 816 Births Trustwide (5 at Heartlands, 294 at Good Hope, and 12 at Solihull) This compares to the plan of 852 (-4%). In Febru there were 3 planned homebirth (2 at Heartlands andat Good Hope).




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6. Elective & Day Case Activity 2014/15

• The Day case and Elective activity was above plan by

3%, 220 Spells during Feb-15.• Heartlands, 2%, 75 Spells and Women and

Childrens, 32%, 146 Spells were below plan in mont• Solihull Division, 25%, 318 Spells, Clinical Support, 5

Spells, 46% and Good Hope, 69 Spells, 11% were above plan in month.

• Following the implementation of PMS2 a potential patient classification issue has been identified. This is currently under a detailed review and any necessary retrospective realignment will be actioned.

• There were 186 patients treated by the private sector during February and 1,550 YTD. Ophthalmology (58General Surgery (56), ENT (32), Orthopaedics (26),Urology (7), Vascular Surgery (4) and Gynaecology (3)had patients treated by the private sector in month.

• 122 patients were treated in the Vanguard Theatre in February and 897 patients since it opened in September.

• There were 24 cancelled sessions during February,97.22% of the scheduled sessions were utilised. The following specialties cancelled sessions, General Surgery (8), Gynaecology (5), Orthopaedics (4), Thoracic Surgery (2), Urology (2), Vascular Surgery (2) and ENT (1).

• 75% (18) of the Theatre sessions were cancelled due to no surgeon in month.

• In addition 20 sessions were cancelled in the VanguarTheatre during February.

• 121 operations were cancelled on the day during February, 51 (42%) of the cancelled operations were at Good Hope, 44 (36%) at Heartlands and 26 (21%) at Solihull.


7. Outpatient Activity 2014/15

• There were 64,935 Outpatient attendances during Feb-15, 719 atts, 1% maottreendances than planned.

• Good Hope 309 atts, 4%, Clinical Support, 123 atts, and Solihull, 922 atts, 4% were above plan in m

• Heartlands (303 atts, 1%) and Women &Childrens (331 atts, 8%) were below plan in month.

Total DNA Rates (February-15):

• Good Hope 8.06% (2,166*)• Heartlands 11.95% (3,780*)• Solihull 7.45% (1,783*)

The DNA rate for first attendances was 14.16% (1,361*) at Heartlands site during Feb-15. Good Hope (8.30%) and Solihull (8.12%) achieved the target of less than 11%.*No. of DNAs.




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INCOME AND EXPENDITURE

8. Performance against Monitor Standards 2014/15

• The overall I&E deficit was £8.4m at the end of month11.

• This deficit was £9.4m adverse to the Monitor plan a£2.8m adverse to the recent reforecast.

• Income was £14.9m favourable to plan while operating expenses were £28.5m adverse to the Monitor plan.

• PDC dividend expenditure was £1.2m favourable to plan, depreciation £3.0m favourable to plan.

• Continuity of Service Rating (COSR) was 4 for mont11, the highest rating.

In-month Performance

9. Income 2014/15

NHS Contract Income (Category A)

There was a trustwide over performance of £0.8m in month,£10.2m YTD.

• Specialised Services income was above plan by £0.4m in February, driven by drugs and vascularexcluded devices.

• Income relating to the Cancer Drugs Fund was £0.4m in month.


10. Income and Expenditure against Operational Budgets

• The Trust is (£12.5m) over spent at Month 11 of2014/15.

• Pay is over spent by (£9.2m)• Non Pay is over spent by (£6m)• Other Operating Revenue £3.1m over recovered• Form TF1




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11. Operational Budgets 2014/15

Heartlands Hospital (BHH) is over spent by (£15.1m)

Income under recovery (£0m)

Pay over spend (£5.9m)

Non Pay over spend (£9.2m)

Clinical Support Services (CSS) is under spent by £0.2m

Income over recovery £0.3m

Pay under spend £1.5m


Good Hope Hospital (GHH) is over spent by (£7.2m)

Income over recovery £0m



Solihull Hospital (SOL) is over spent by (£5.4m)


Pay over spend (£1m)


Womens and Childrens (WC) is over spent by (£2.8m)





Corporate Directorates (CD) is under spent by £0.8m Income under recovery (£0.1m)


Non Pay under spend £0m

Corporate Trust Wide (CTW) is under spent by £16.7m



Non Pay under spend £16m

Facilities (FAC) is under spent by £0.4m




Bad Debt provision included within the above: £1m



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INCOME AND EXPENDITURE12. Pay Expenditure

Pay Expenditure is over spent by (£9.2m) at Month 112014/15.

Material variances to operational budget relates to:

• Medical Staffing, which is over spent by (£7.5m) ,• Nursing & Midwifery overspent by (£4.7m),• Off set by other support staff underspend totalling

£3.1m• Form TF3


13. Non pay Expenditure

Non Pay is over spent by (£6m) at Month 11 in 2014/15.

Material overspends against operational budgets are:

• 2014/15 SIEP shortfall (£7.1m)• Clinical Supplies overspent (£5.2m)• Drugs over performance benefit £2m• Depreciation, Amortisation benefit £2.3m• Miscellaneous Other Expenses £2m

Form TF4




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14. Service Improvement Efficiency Plan 2014/15

Feb - In Month Year To Date Forecast @ Month 11

GROUPS Target ActualRec

ActualNon Rec

Variance Target ActualRec

ActualNon Rec

Variance AnnualTarget

Actual(3,4,5)

Variance(0,1,2)

heartlands hospital 625.0 285.6 43.6 (295.9) 6,875.0 2,475.7 499.2 (3,900.2) 7,500.0 3,301.8 (4,198.2)

good hope hospital 183.3 101.6 2.0 (79.7) 2,016.7 837.4 269.1 (910.2) 2,200.0 1,219.5 (980.5)

solihull 291.7 189.3 7.8 (94.6) 3,208.3 1,554.3 123.8 (1,530.2) 3,500.0 1,894.3 (1,605.7)

clinical support services 433.3 242.6 73.2 (117.5) 4,766.7 2,909.5 622.1 (1,235.1) 5,200.0 4,031.3 (1,168.7)

womens & childrens 225.0 51.0 0.1 (173.9) 2,475.0 540.4 0.7 (1,933.8) 2,700.0 592.3 (2,107.7)

facilities 116.7 102.7 19.3 5.3 1,283.3 1,030.6 201.6 (51.2) 1,400.0 1,355.4 (44.6)

corporate directorates 125.0 136.0 6.8 17.7 1,375.0 1,079.3 117.2 (178.5) 1,500.0 1,353.1 (146.9)

corporate trustwide 0.0 166.7 0.0 166.7 0.0 2,633.3 0.0 2,633.3 0.0 2,800.0 2,800.0

TOTAL 2,000.0 1,275.5 152.6 (571.9) 22,000.0 13,060.5 1,833.6 (7,105.9) 24,000.0 16,547.8 (7,452.2)

• The Trust achieved £1.43m (71.4%) efficiency in Month 11.• These results show a (£0.6m) shortfall against target at Month 11.

Based on Month 11 results the forecast out turn is £16.5m delivery of savings (68.9%).

Analysis of forecast:

• £16m in risk category 5 Delivered• £0.2m in risk category 4 Planned with expected delivery• £0.3m in risk category 3 Suggested plans




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BALANCE SHEET

15. Combined Capital Expenditure YTD 2014/15 YTD Expenditure was £17.8m, 77.0% of the reforecast YTD Monitor Plan (MP) and 42.9% of total Approved Budget (AB)£41.5m. Orders raised were £25.0m, 108.1% of YTD MP &60.2% of AB.

• Operational was £6.6m, 73.9% of YTD MP, key spends

on LAN & other IT projects• Other was £6.6m, 78.7% of YTD MP; with spend on

replacement MRI Scanner, Energy Sustainability,Document Scanning, Negative Pressure rooms.

• Site Strategy Investment expenditure was £4.4m,79.3% of YTD MP, spend on Hybrid Theatres, Dermatology relocation, AMU refurb at GHH, the Chemotherapy and Rheumatology units

• HPA was £136k, 78.1% of YTD MP

YTD Performance

16. Capital Expenditure in Month 2014/15

M11 In-month expenditure was £2.4m:

• FAC / Site Strategy £2.1m- Hybrid Theatres,

Dermatology relocation SOL, AMU refurbishment at GHH, Energy Sustainability, Ward 3 refurbishment at GHH.

• CD £162k- Corporate Community PC Replacement and iPads, Windows 7 compliance, LAN

• CSS £86k- Negative Pressure Isolation Rooms Ward28 at BHH

• WC £36k- Obstetrics Capacity Risks project at BHH, Bladder Scanner at GHH, 2 Bipad Machines


• Payment performance in February is about 70%. The

volume of invoices paid in February is 13,535 in line with normal volumes.

• The continued poor payment performance is due to backlog clearing and processing delays following the Readsoft upgrades and will also impact on March performance and beyond.

Cumulative Performance

17. Creditors 2014/15



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BALANCE SHEET

18. Debtors 2014/15

• Total debt reduced by £2.423m during February t£19.611m.

• Health Education England paid a training & education invoice for £5.156m during the month

• There was a deterioration in the underpayment of th monthly SLA mandate invoices by £1.387m to acumulative underpayment of £2.885m, in anticipationexpected contract penalties. Thoseunderpaying include Birmingham Cross City CCG£1.664m and Solihull CCG £1.116m.

• Solihull CCG recalled a £2.000m advance on the February SLA mandate payment, but replaced it with a £0.550m in advance of the March SLA mandate payment.

• A resilience funding invoice for £3.472m to Birmingham Cross City Clinical Commissioning Group remains outstanding and disputed. The invoice will be credited shortly and a replacement invoice for £2.129m will issued.

• Ante natal maternity pathways activity debt for April2013 to December 2014 increased to £3.525m ,including £1.719m with Burton Hospitals, £0.860m with Sandwell & West Birmingham Hospitals, and £0.490m with Birmingham Womens Hospital.

• Burton Hospitals Foundation Trust have debts of£2.337m, (including £1.719m for ante natal maternity pathways activity), and have recently placed the account on hold until this Trust settle their debtfor £0.595m


CASHFLOW

19. Monthly Closing Cash Balance vs Plan 2014/15

• The cash balance at the end of February 2015 was£101.6m, £18.6m above plan.

• Operating cash flows were £17.0m below plan. This was offset by favourable working capital movements of£18.6m. Capital expenditure in cash terms was£14.9m less than plan.

• The half yearly PDC dividend payment was processed in September and this was £1.7m less than planned including a rebate for the last financial year.

• All Trust funds remain in the GBS umbrella as a change in the rules on calculating PDC dividend means that it is currently financially unviable to invest in other commercial banks.

• £75m of funds have been reinvested in the National Loan Fund (NLF) for 6 months at a rate of 49bp. Afurther £9.0m was on deposit with NLF at the month end on a short term basis attracting interest rates of around 40bp.

• Funds in GBS attract 25bp.




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MONITOR - RISK ASSESSMENT FRAMEWORK KPIs

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

12

M

ay-…

Jun-

12

Jul-1

2 Au

g-12

Sep-

12

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-…

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Jan-

14

Feb-

14

Mar

-14

Apr-

14

M

ay-…

Jun-

14

Ju

l-14

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

18 weeks: Reported 1 month in arrears

Admitted Non-admitted HEFT have now resumed reported against the Admitted patient pathway (clock stops), and achieved 79.34% against the 90% target for Jan15, with the aim to continue to see

longer waits in order to help clear the backlog

HEFT managed to see 85.91% of non-admitted patients within 18 weeks against

the 95% target for Jan15

100%

95%

Target

99% 97%

Target

90%

95% 93%

85%

91%

80%

75%

89% 87% 85%

Incomplete Pathways

No data reported in month

100%

99%

98%

97%

96%

95%

94%

93%

92%

91%

90%

Out-turn

Target

A&E


Total time in A&E

The 95% target for A&E around 4 hour was not met in February with performance at 85.65%

100%

95%

Target

90%

85%

80%

75%

70%

N.Atkins PM-P&I 20/03/2015 Z:\Data\PMU\Performance Monitoring\KPI 2014-15\2014-15 Trust KPI.xlsbFC 1



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MONITOR - RISK ASSESSMENT FRAMEWORK KPIs Cancers: Reported 1 month in arrears

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

2 weeks 31 day GP

The Trust failed the 93% target for the 2 week GP cancer indicator in January at 91.24%, and also failed the 2 week Breast symptom 93% target, achieving 76.61%

The Trust achieved the 96% target for 31 day cancers in January , out-turning at 98.12% in month

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50%

100%

99%

98%

97%

96%

95%

94%

93%

92%

91%

90%

Target

2 week GP 2 week Breast Target

31 day anti-cancer 31 day surgery

The Trust met the 31 day anti-cancer drug target of 98% in January, achieving

100%

100%

The Trust met the 31 day surgery modality cancer target of 94% in January,

achieving 96.72%

Target

99%

98%

97%

96%

95%

94%

93%

92%

91%

90%

Target 99% 97% 95% 93% 91% 89% 87% 85%

Cancers: (continued)


62 day cancers 62 day screening

The Trust achieved the 62 day cancer 85% target in January, achieving 86.22% The Trust missed the 62 day national screening cancer 90% target in January,

achieving 50% 100%

95%

Target

100%

90%

T arget

90%

85%

80%

80% 70% 60% 50%

75% 40%




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MONITOR - RISK ASSESSMENT FRAMEWORK KPIs Infection Control

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

c-diff

The target for incidents of c-diff is no more than 6 in February, and in month the

Trust reported 3 cases, with a total of 67 YTD

12

10

8

6

4

2

0




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516.839 527.059 10.220 NHS Clinical Revenue 563.913 577.912 13.999 560.801

0.715 0.539 (0.177) Clinical Revenue - Private Patients 0.780 0.693 (0.087) 0.628

0.165 0.148 (0.017) Clinical Revenue - Overseas Visitors 0.180 0.168 (0.012) 0.163

3.963 3.861 (0.102) Research and Development revenue 4.323 4.188 (0.135) 4.132

20.662 21.376 0.714 Education and Training revenue 22.540 23.088 0.548 22.885

0.446 0.411 (0.035) PFI Specific Revenue 0.487 0.448 (0.039) 0.448

0.468 0.411 (0.057) Donations and Grants received 0.510 0.313 (0.197) 0.711

4.376 4.370 (0.006) Parking Revenue 4.774 4.829 0.055 4.800

0.848 0.954 0.106 Catering Revenue 0.925 1.029 0.104 0.910

0.246 0.264 0.018 Accommodation Revenue 0.268 0.257 (0.011) 0.306

5.944 9.509 3.565 Revenue from non patient services to other bodies

6.485 10.349 3.864 13.922

21.398 22.100 0.701 Miscellaneous other operating revenue 23.399 24.403 1.004 25.715

576.070 591.002 14.932 Total Operating Revenue 628.584 647.677 19.093 635.422

(350.981) (352.767) (1.786) Employee expenses, permanent staff (382.254) (383.759) (1.505) (376.603)

(0.176) (22.504) (22.328) Employee expenses, agency and contract staff (0.192) (24.702) (24.510) (19.900)

(46.180) (53.434) (7.254) Drugs (50.217) (57.160) (6.943) (51.377)

(58.430) (57.375) 1.056 Clinical Supplies (63.551) (61.202) 2.349 (62.338)

(16.116) (15.365) 0.751 Non Clinical Supplies (17.520) (16.315) 1.205 (17.173)

(2.407) (2.451) (0.044) Research and Development Expense (2.626) (2.701) (0.075) (2.636)

(1.826) (2.007) (0.181) Education and Training Expense (1.992) (2.018) (0.026) (2.229)

(1.049) (1.629) (0.580) Consultancy Expense (1.144) (1.926) (0.782) (2.241)

(66.500) (67.404) (0.903) Miscellaneous other Operating expense (72.853) (75.771) (2.918) (75.593)

(3.749) (1.021) 2.727 (Increase)/decrease in impairment of receivables

(4.090) (1.620) 2.470 (2.291)

(0.096) (0.087) 0.009 PFI unitary payment (0.105) (0.095) 0.010 (0.095)

(547.510) (576.043) (28.532) Total Operating Expenses (596.543) (627.269) (30.726) (612.475)

28.560 14.959 (13.601) EBITDA 32.041 20.408 (11.633) 22.947

(0.110) (0.162) (0.052) Gain / loss on asset disposals (0.120) (0.252) (0.132) (0.031)

(20.900) (17.924) 2.976 Total Depreciation and amortisation (22.800) (20.000) 2.800 (18.039)

(6.545) (5.386) 1.159 PDC Dividend expense (7.145) (5.876) 1.269 (5.574)

0.333 0.404 0.071 Total interest receivable 0.364 0.412 0.048 0.385

0.000 0.000 0.000 Other finance costs 0.000 0.000 0.000 (0.003)

(0.275) (0.249) 0.026 Interest expense (0.301) (0.271) 0.030 (0.282)

1.063 (8.359) (9.422) Surplus/(deficit) before impairments 2.039 (5.579) (7.618) (0.597)

0.000 0.000 0.000 Impairment (Losses) / Reversals 0.000 0.000 0.000 (4.759)

1.063 (8.359) (9.422) Surplus/(deficit) after impairments 2.039 (5.579) (7.618) (5.356)

February 2015 Trust Wide Income and Expenditure Form TF1A

Year to Date Full Year

Annual Actual Variance Annual Forecast Variance 2013/14

Plan Actual to Plan Forecast toPlan Plan

£m £m £m £m £m £m £m

Key perfomance Indicators (KPIs)


Annual Actual Variance Annual Forecast Variance 2013/14Plan Actual to Plan Forecast to

Plan Plan

0.20% (1.39%) (1.59%) Net I&E Margin 0.34% (0.82%) (1.17%) (0.09%) 28.092 14.548 (13.544) EBITDA (£m) adjusted 31.531 20.095 (11.436) 22.236

100.00% 51.79% (48.21%) EBITDA achieved, % of projection 100.00% 63.69% (36.31%) 58.93%

4.88% 2.46% (2.42%) EBITDA margin (%) 5.10% 3.15% (1.95%) 3.50%

28.425 14.952 (13.473) Revenue available for debt service (£m) 31.895 20.507 (11.388) 22.621



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Last Month This Month Variance to Annual Plan Forecast Variance 31 March Actual

£m

Actual

£m

Plan

£m

£m

£m

from Plan

£m

2014

£m

February 2015

Year to Date

Trust Wide Balance Sheet Form TF1B Full Year

5.100 5.109 (3.486) Intangible Assets, Net 9.238 10.617 1.379 3.051 236.009 237.990 (4.397) Property, Plant and Equipment, Net 245.492 239.824 (5.668) 239.867

4.312 4.302 (0.059) On balance sheet PFI assets 4.350 4.250 (0.100) 4.374 245.421 247.401 (7.941) Fixed Assets, net 259.080 254.691 (4.389) 247.292

2.756 2.762 1.723 Trade Receivables, non current, gross 1.039 2.700 1.661 2.771

(1.711) (1.711) (1.711) Impairment of receivables for bad and doubtful debts, non current 0.000 (1.711) (1.711) (1.711)

1.046 1.052 0.013 Trade and other receivables, net, non current 1.039 0.989 (0.050) 1.060 246.467 248.452 (7.929) ASSETS, NON CURRENT 260.119 255.680 (4.439) 248.352

9.424 9.240 1.362 Inventories 7.878 8.500 0.622 7.996 36.691 26.778 (4.199) NHS Trade Receivables, current, gross 31.002 30.000 (1.002) 21.616 2.215 4.283 (1.387) Non NHS Trade Receivables, current, gross 5.675 4.100 (1.575) 6.270 0.000 0.000 0.000 Other Related Party Receivables 0.000 0.000 0.000 1.049 2.159 1.850 0.156 Other Receivables 1.696 1.500 (0.196) 2.775

(9.046) (9.045) 0.665 Impairment of receivables for bad and doubtful debts, current (10.051) (9.735) 0.316 (9.802)

2.884 2.676 (0.048) Accrued Income 2.726 2.000 (0.726) 1.995 10.046 8.164 0.029 Prepayments 8.142 6.000 (2.142) 6.174 99.671 101.568 18.624 Cash and Cash Equivalants 78.706 83.000 4.294 86.699

154.044 145.513 15.201 CURRENT ASSETS 125.774 125.365 (0.409) 124.771

400.511 393.966 7.273 TOTAL ASSETS 385.893 381.045 (4.848) 373.123

(3.874) (2.716) 0.692 Trade Payables (2.026) (3.000) (0.974) (3.868) (18.101) (17.582) (1.906) Other Payables (19.505) (16.000) 3.505 (2.024) (3.917) (5.472) 1.413 Capital Payables (4.558) (3.654) 0.904 (4.136)

(58.708) (56.344) 13.257 Accruals (42.757) (51.450) (8.693) (47.577) (0.480) (0.480) 0.000 Finance Leases / PFI Leases, Current (0.480) (0.480) 0.000 (0.480) (1.958) (2.448) (0.529) PDC Dividend Payable 0.000 0.000 0.000 0.000

(11.328) (11.154) 3.330 Provisions, current (8.594) (11.100) (2.506) (20.667) (13.004) (11.128) 2.130 Deferred Income (9.006) (6.000) 3.006 (6.605)

(111.370) (107.324) 18.387 CURRENT LIABILITIES (86.925) (91.684) (4.759) (85.356)

42.674 38.189 (3.186) NET CURRENT ASSETS (LIABILITIES) 38.849 33.681 (5.168) 39.415

(7.531) (7.531) 5.181 Provisions, non current (2.580) (7.500) (4.920) 0.000 (1.640) (1.629) (0.112) Finance Leases, non current (1.740) (1.620) 0.120 (1.746) (2.410) (2.393) (0.172) PFI Leases, non current (2.564) (2.375) 0.189 (2.574)

(11.580) (11.553) 4.897 LIABILITIES, NON CURRENT (6.884) (11.495) (4.611) (4.320)

277.560 275.088 (16.012) TOTAL ASSETS EMPLOYED 292.084 277.866 (14.218) 283.447

214.169 214.169 0.000 Public Dividend Capital 214.169 214.169 0.000 214.169 18.575 16.103 (15.018) Retained Earnings / (Accumulated Losses) 32.691 19.459 (13.232) 22.728 44.986 44.986 (0.994) Revaluation Reserve 45.393 44.407 (0.986) 46.719 (0.169) (0.169) 0.000 Miscellaneous Other Reserves (0.169) (0.169) 0.000 (0.169) 277.560 275.088 (16.012) TOTAL TAXPAYERS EQUITY 292.084 277.866 (14.218) 283.447

Last Month Actual

Year to Date

This Month Actual

Variance to

Plan


Full Year

Annual Plan Forecast Variance from Plan

31 March

2014

(2.57%) (3.31%) Net Return After Financing (0.16%) (3.00%) (2.84%) 0.20 %

19.050 16.584 Liquidity 18.690 14.452 (4.239) 18.467



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February 2015

Trust Wide Cash flow

Form TF1C


Actual Plan Variance to Plan Annual Plan Forecast Variance fromPlan 2013/14

(8.359)

1.053

(9.412)

Surplus / (Deficit) after tax 2.037

(5.579) (7.616)

(5.357)

- Non - cash flows in operating surplus / (deficit): - - (0.155) (0.059) (0.096) Finance income/charges (0.064) (0.141) (0.077) (0.100)(0.411) - (0.411) Donations and grants received of PPE and intangibles - (0.313) (0.313) (0.711)

- - Other operating non-cash movements - - -17.924 20.900 (2.976) Depreciation and amortisation, total 22.800 20.000 (2.800) 18.039

- - Impairment losses / (reversals) - - 4.7590.162 0.110 0.052 (Gain) / loss on disposal of non current assets 0.120 0.252 0.132 0.0315.386 6.550 (1.164) PDC Dividend Expense 7.145 5.876 (1.269) 5.5741.021 3.989 (2.968) Other 4.353 0.910 (3.443) -

15.568 32.543 (16.975) Operating Cash Flows before movements in WC 36.391 21.005 (15.386) 22.235

Increase / (decrease) in working capital: (1.244) - (1.244) (Increase)/decrease in inventories - (0.504) (0.504) (0.258)

- - (Increase)/decrease in tax receivable - - - -(5.162) (0.282) (4.880) (Increase)/decrease in NHS Trade Receivables (0.308) (8.384) (8.076) (9.193)0.232 (0.052) 0.284 (Increase)/decrease in Non NHS Trade Receivables (0.057) 2.170 2.227 3.913

- - (Increase)/decrease in other related party receivables - 1.049 1.049 -0.925 (0.016) 0.941 (Increase)/decrease in other receivables (0.017) 1.275 1.292 (0.716)

(0.681) (0.025) (0.656) (Increase)/decrease in accrued income (0.027) (0.005) 0.022 0.046

- - (Increase)/decrease in other financial assets - - - -(1.990) (0.074) (1.916) (Increase)/decrease in prepayments (0.081) 0.174 0.255 (1.208)

- - (Increase)/decrease in Other assets (non chartable assets) - - - -4.523 0.082 4.441 Increase/(decrease) in Deferred Income (excl. Govt Grants.) 0.090 (0.605) (0.695) (3.687)

- - Increase/(decrease) in Deferred Income (Govt. Grants) - - - -(9.513) (0.770) (8.743) Increase/(decrease) in Current provisions - (1.663) (1.663) 7.225

- - Increase/(decrease) in post-employment benefit obligations - - - -

- - Increase/(decrease) in tax payable - - - -(1.152) 0.018 (1.170) Increase/(decrease) in Trade Creditors 0.020 (0.868) (0.888) 0.44015.558 12.846 2.712 Increase/(decrease) in Other Creditors 12.862 13.975 1.113 0.084

8.767 (12.276) 21.043 Increase/(decrease) in accruals (12.606) 3.873 16.479 5.801

- - Increase/(decrease) in other Financial liabilities - - - -

- - Increase/(decrease) in Other liabilities (non charitable assets) - - - -10.263 (0.549) 10.812 Increase / (decrease) in working capital, Total (0.125) 10.487 10.612 2.447

7.531 (0.230) 7.761 Increase/(Decrease) in Non-current Provisions - (0.404) (0.404) 0.124

33.362 31.764 1.598 Net cash inflow/(outflow) from operating activities 36.266 31.088 (5.178) 24.806

(17.797)

(15.791)

(2.006) Net cash inflow/(outflow) from investing activities: Property - new land, buildings or dwellings

(18.918) (10.427)

8.491 (12.180)

(3.540) 3.540 Property - maintenance expenditure (3.925) (1.759) 2.166 (3.495)

(2.987) 2.987 Plant and equipment - Information Technology (3.465) (7.599) (4.134) (3.594)

(5.676) 5.676 Plant and equipment - Other (6.675) (6.000) 0.675 (4.149)

- - Property, plant and equipment - other expenditure - - - (2.955)

0.087 (0.087) Proceeds on disposal of property, plant and equipment 0.100 0.114 0.014 -

- - Purchase of investment property - - - -

- - Proceeds on disposal of investment property - - - -

(2.942) 2.942 Purchase of intangible assets (3.614) (1.667) 1.947 (1.527)

- - Proceeds on disposal of intangible assets - - - -

- - Expenditure on capitalised development - - - -1.336 (0.500) 1.836 Increase/(decrease) in Capital Creditors 0.000 (0.482) (0.482) (1.396)

- - Government grants received - - - -

- - Purchase of investments & deposits made - - - -

- - Proceeds on disposal of investments & withdrawals - - - -

- - Other cash flows from investing activities - - - -(16.461) (31.349) 14.888 Net cash inflow/(outflow() from investing activities, Total (36.497) (27.820) 8.677 (29.296)

16.901 0.415 16.486 Net cash inflow/(outflow) before financing (0.231) 3.268 3.499 (4.490)

Net cash inflow/(outflow) from financing activities: - - Public Dividend Capital received - - - 3.055

- - Public Dividend Capital repaid - - - -(1.889) (3.572) 1.683 PDC Dividends paid (7.144) (5.876) 1.268 (5.270)

- - Finance leases - - - -(0.128) (0.128) - Interest element of finance lease rental payments - other (0.139) (0.137) 0.002 (0.139)(0.138) (0.138) - Interest element of finance lease rental payments - On-balance sheet PFI (0.151) (0.150) 0.001 (0.151)(0.108) (0.108) - Capital element of finance lease rental payments - other (0.118) (0.120) (0.002) (0.118)(0.181) (0.181) - Capital element of finance lease rental payments - On-balance sheet PFI (0.197) (0.197) - (0.197)0.404 0.334 0.070 Interest received on cash and cash equivalents 0.364 0.412 0.048 0.385

- - Movement in Other grants/Capital received - - - -

- - Donations received in cash - - - -0.009 - 0.009 (Increase)/decrease in non-current receivables - 0.070 0.070 0.434

- - Increase/(decrease) in non-current payables - - - -

0.001 (0.001) Other cash flows from financing activities 0.001 (0.968) (0.969) (0.476)(2.031) (3.792) 1.761 Net cash inflow/(outflow) from financing activities, Total (7.384) (6.966) 0.418 (2.477)

14.870 (3.377) 18.247 Net increase / (decrease) in cash (7.615) (3.698) 3.917 (6.967)

86.698 86.321 0.377 Opening cash balance 86.321 86.698 0.377 93.66514.870 (3.377) 18.247 Net increase / (decrease) in cash (7.615) (3.698) 3.917 (6.967)

101.568 82.944 18.624 Closing cash balance 78.706 83.000 4.294 86.698



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February 2015 Monitor Continuity of Service Ratings (COSR) Form TF1D

Metric

Actual

Year to DateRating

Weight

4

COSR:3

2

1

Capital Service Cover

2.59

4

50.0%

2.50

1.75

1.25

<1.25Liquidity 16.6 4 50.0% 0 -7.0 -14.0 <-14.0

Weighted Average 4.00 100.0% Overriding rules

4

Metric

Actual

FY ReforecastRating

Weight

4

COSR:3

2

1


3.17

4

50.0%

2.50

1.75

1.25

<1.25Liquidity 14.5 4 50.0% 0 -7.0 -14.0 <-14.0


4

Metric

Actual

FY PlanRating

Weight

4

COSR:3

2

1


4.17

4

50.0%

2.50

1.75

1.25

<1.25Liquidity 18.7 4 50.0% 0 -7.0 -14.0 <-14.0


4



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Prepared for Finance and Performance Committee 24 April 2015Author Angeline Jones

1

Appendix 2 Standing Financial Instructions Update

1. Introduction

Due to various changes in the Trust over the last year it is necessary to amend the Trust Standing Financial Instructions (SFIs). This paper seeks approval from the Finance and Performance Committee to amend the SFIs in the following areas;

• Amend the delegated authority levels to revised values, new authority levels and to reflect the operational managers as the dominant authoriser.

• Confirm the reporting arrangements for orders and contracts above chief executive level.

• Make self-approval of orders prohibited except for noted exceptions.

• Detail the exceptions to the authority levels.

• Note the authorisation process for approval of business cases.

• Provide clarity on authority levels for contracts

This change will give clarity to the Trust on the relevant approval rights and will mean that controls can apply whilst decision making is speeded up.

2. Reason for change

The Trust is continually evolving and in March 2014 a change to SFIs was approved by Finance and Performance Committee to reflect the structure that was in place at that time. Since then a Delivery Unit structure has been established, new structures in the heartlands division have been set up and a number of corporate posts have been disestablished. Following the recent structure announcements it is now necessary to update the SFIs to make the authority limits workable with the new posts and to clarify responsibilities.

3. Authority Levels

In 2014 the values were updated to reflect the division/ site structure with site Managing Directors that was in place at the time. Separate headings were set up to reflect that the structures within clinical areas were different to those in corporate and estates / facilities areas. In most cases these levels were applied into the Oracle system. The table below shows these values.



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Table 1 Previous Authority Levels

Role/ Title Corporate Estates Clinical Limit £Ward Manager/ Community

Services Manager C 2,000

Corporate Department Manager, Executive

Assistants.A 2,000

Estates Directorate Managers, Executive

Assistants, .Administrative Assistant.

E 2,000

Health and Safety Officer, Estates Managers, ,Hotel

Services ManagersE 5,000

Corporate Head of Department A 5,000

Matron / Community Services Equivalent C 5,000

Operational Manager C 5,000Catering Manager E 9,999

Corporate Senior Manager/ Business Consultant/

Business PartnerA 9,999

General Manager C 9,999Deputy Head of Hotel

Services E 10,000

Clinical Director C 10,000Programme Office Manager E 64,999

Head of Hotel Services/ Head of Estates E 64,999

Site Head of Operations C 64,999Deputy ED A 64,999

Associate Medical Director C 65,000Site Managing Director C 100,000Trust Medical Director C 100,000

Director of Asset Management E 100,000

Corporate Executive Director A 100,000

Finance Director E 125,000Deputy CEO A C 125.000

CEO A E C 150,000CEO & Chair A E C 250,000

Board A E C Over 250,000

A number of changes are suggested to the authority levels;

a) Increase the authority levels

An increase in the authority levels, particularly at the higher levels is proposed to reflect the expenditure level that is deemed appropriate for these senior posts. This reflects the increased costs over the last few years, the tendency to consolidate more business s into



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fewer supplier s and the raising of purchase orders for the total service rather than on an invoice by invoice basis.

b) Finance Director Level the same as all other Executive Directors and disestablishing Deputy Chief Executive as an approval level.

Previously the Finance Director has had a greater authority level than the other executive directors (ED) which has meant that for large orders they were required to be reviewed by the FD before it reached the Chief Executive. This had worked well when the Finance Director and the Deputy Chief Executive post were held by the same person. It is proposed that to provide clarity the Finance Director level is the same as all other ED levels so all orders over the value of an ED go the Chief Executive, and if the Chief Executive requires additional clarification, the requisition can be sent to the FD for review.

c) Operational lead the dominant authoriser

Previously the ordering for each cost centre has been through an operational manager who has had an authority level £1 lower than the clinician. In practice this has meant a delay in getting orders agreed as it requires the input of 2 senior people. Now that the triumvirate arrangements exist for each division and directorate, the proposal is that the operational lead will hold responsibility for approving the orders and where there is a query relating to a particular order will ensure that clinical and nursing colleagues are involved. This should streamline the approval process.

There will be some circumstances where a clinical director will be required to approve orders, such as is the case in pathology, and in these situations, they will be slotted into the managerial position in the hierarchy for that area.

d) Include an additional level for group reporting arrangements

In Heartlands and Solihull divisions there is a need for an additional level to be set up to reflect their structure of Group boards below the division. AN additional level of £25k is proposed for these areas.

The table below shows the proposed revised authority levels. Appendix 1 shows a mapping for the current levels to the proposed levels.

Table 2 proposed Authority levels

Role/ Title Revised limit £

Originator level £2,000Manager £5,000Senior Manager £10,000Group Head (applicable in Heartlands and Solihull division only) £25,000Reporting to Executive Director £65,000Executive Director (non-voting) £100,000Executive Director (Voting) £125,000CEO £250,000Board Over £250,000



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4. Reporting above Chief Executive Level

Currently orders that are in excess of the level of Chief Executive are required to be reported to the Board according to SFIs. However, practice over a number of years has meant that these are reported to the monthly Finance and Performance Committee. It is proposed that the SFIs are amended so that approval of the purchase orders is the responsibility of Finance and Performance Committee. This will include all orders.

5. Prohibiting self-approval

A review by the Trust’s counter fraud team has have found that there have been instances where the person raising the requisition has also approved that order, known as self-approval. The SFIs will need to explicitly state that this is prohibited unless this has been agreed in advance for that service (e.g. renal), code or where exceptional circumstances that have been approved by the manager mean that this is absolutely necessary. This will mean that if an individual is found to be self-approving they can be advised that is not permitted by SFIs.

6. Exceptions to the authority levels

There are a number of exceptions where the authority levels set out for a role are insufficient on a particular cost line for a role that manager is doing. The exceptions that are current practice are set out in the table below and are required to be approved by the Committee. As any new exception requirements are identified they will be added to the exceptions list in the SFIs.

Table 3 Variations to approval levels

Reason Responsible Manager

Variation to normal levels

Trust wide leased car arrangements

Employee services manager

Normal authority level £10k, needs £25k for leased car lines across whole Trust.

NHS logistics invoices Financial Controller Normal authority level £5k, approves invoices of up to £100k (all items have been previously approved by the budget holder vi i-proc, this is the payment of the consolidated invoice) .

Pathology consumables ordering under the Abbots contract

Pathology Manager Normal approval level would be £25k, needs £65k for this contract)

Mobile telephones and travel consolidated invoices

Chief Financial Controller

No change in approval level required, but approving invoices on Trust wide cost lines. Consolidated invoice, expenditure is already approved via manager at the point of agreeing to have the phone or booking travel.



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Public Dividend Capital Finance Director PDC payments of c£3-4m required twice per year, approved by FD due to timing of requests.

7. Business Cases and Contracts

There are three elements to incurring spend in the Trust.

When a new area of expenditure is identified in the Trust a business case is required. A business case approval process has been set out and recently agreed at an executive directors meeting. This is included in appendix 2. This shows that the SFI levels for approving a business case follow the board meetings/committees at the same levels as the individual roles except at the executive management board (EMB) where the board approvallevel is £500k, whereas the Chief Executive level is £250k.

A contract is required once a business case has been approved or when a contract for existing services has expired. The levels set out in table 1 above apply to signing of contracts as well as for raising purchase orders. Therefore, if a contract is required for several years the total value of that contract needs to be calculated and the contract signed by the relevant approving manager. This may result in the contract being approved by a higher approval level then is required for the annual purchase order for that service. For example, a three year contract at £40k per year will require sign off by the ED at £120k, but the purchase order can be approved by the person reporting into that ED.

These rules around business cases and contracts will need to be made explicit in the SFIs.

8. Next Steps

Once these revisions have been agreed the next steps are as in the table below.

Task Responsibility Due Date

1 Communicate revised approval levels to managers Angeline Jones

End of May

2 Confirm structures OBS Finance team

End of Aril

3 Set up roles and responsibilities in Oracle system Adrian James, Systems Manager

Mid May

4 Update SFI document with these changes, ratify at FPC, put on website

Angeline Jones

June FPC

5 Run a communications programme to make all managers aware of the requirements in SFIs

Angeline Jones

August

Business Case

Contract Purchase Order



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9. Recommendation

The Finance and performance Committee is requested to approve the following changes to Standing Financial Instructions;

• Approve the proposed changes in authority levels

• Approve making self-approval of orders prohibited except for noted exceptions.

• Approve the exceptions to the authority levels.

Appendix 1 – Tracker from current levels to proposed levels

Role/ Title Previous Limit £

Change Revised limit £

Originator level 0 New level £2,000Ward Manager/ Community Services Manager

2,000Move to generic originator level 0

Corporate Department Manager, Executive Assistants.

2,000Move to generic originator level 0

Estates Directorate Managers, Executive Assistants, .Administrative Assistant.

2,000

Move to generic originator level 0

Manager 0 New level £5,000Health and Safety Officer, Estates Managers, ,Hotel Services Managers

5,000

Move to generic manger level 0

Corporate Head of Department 5,000 Move to generic manger level 0

Matron / Community Services Equivalent 5,000 Move to generic manger level 0

Operational Manager 5,000 Move to generic manger levelCatering Manager 9,999 Move to generic senior manager level 0Corporate Senior Manager/ Business Consultant/ Business Partner

9,999

Move to generic senior manager level 0

General Manager 9,999 Move to generic senior manager level 0Senior Manager 0 New level £10,000Deputy Head of Hotel Services 10,000 Move to generic senior manager level

Clinical Director 10,000 Move to generic senior manager levelGroup Head (applicable in heartlands and Solihull division only)

0New level £25,000

Reporting to Executive Director 0 New level £65,000

Programme Office Manager 64,999 Move to generic reporting to executive

director category0

Head of Hotel Services/ Head of Estates 64,999 Move to generic reporting to executive

director category0



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7

Site Head of Operations 64,999 Move to generic reporting to executive director category

0

Deputy ED 64,999 Move to generic reporting to executive director category

0

Associate Medical Director 65,000 Move to generic reporting to executive

director category0

Site Managing Director 100,000 Move to generic executive director (non-voting) category

0

Trust Medical Director 100,000 Move to executive director (voting) category

0

Director of Asset Management 100,000 Move to generic executive director

(non-voting) category0

Executive Director (non-voting) 0 New level £100,000

Corporate Executive Director 100,000 Split between executive director Noting

and non-voting categories)0

Finance Director 125,000 Remove additional level, same authority as all EDs

0

Executive Director (Voting) 0 New level £125,000

Deputy CEO 125.000 Remove level 0CEO 150,000 Increase level £250,000CEO & Chair 250,000 Remove level 0Board Over

250,000Over

£250,000

Angeline JonesChief Financial ControllerApril 2015



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Prepared for Finance and Performance Committee meeting on 29 May 2015.Author Darren Cattell

1

EXECUTIVE SUMMARY

We remain under Section 111 Monitor Enforcement.

APRIL POSITION

The Trust had a larger I&E loss in April than planned.

April delivered a £2.7m loss when compared to the planned figure of £2.5m.

All 2015/16 contracts are still currently in negotiation for both the financial and non financial elements. Income is therefore prudently estimated based on activity under JMRA principles.

1. FINANCE

The Trust’s income and expenditure position in April was a £2.7m loss versus a planned loss of £2.5m.

The table below shows the key issues influencing the financial position, in terms of actuals but also in terms of plan:

Category Plan Apr Variance Headlines£m £m £m

NHS Clinical Income 49.7 49.7 -

MedicalStaffing (9.6) (10.4) (0.8)

Expenditure remains unaffordableUnderlying pay controls

Waiting List Initiatives spend of £0.4m

Greatest pressures in BHH, SOL and GHH

Nursing &Midwifery (13.6) (14.1) (0.5)

Expenditure remains unaffordableUnderlying pay controls

Enhanced bank rates continueGreatest pressures in BHH and

GHH

SIEP 0.6 0.4 (0.2) Most significant shortfalls in BHH, CSS, W&C’s and SOL

Other (28.4) (27.5) 1.3 Recognition of investment reserves

Overall Position (2.5) (2.7) (0.2)

FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORS

Month 1 to 30th April 2015

Darren Cattell, Interim Director of Finance & Performance



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2

1.1 Medical Staffing – Total medical expenditure remains unaffordable at £10.4m in month compared to a budget of £9.6m. Divisions need to address this as part of their efficiency plans going forwards, where not resolved as part of rebasing capacity.

1.2 Nursing & Midwifery – Nursing expenditure remains unaffordable at £14.1m in month compared to a budget of £13.6m. Divisions need to address this as part of their efficiency plans going forwards, where not resolved as part of rebasing capacity.

1.3SIEP – Actual delivery in month was £0.4m. Further action is required to close the early gap and deliver early implementation to mitigate risk in 2015/16.

1.4 Cash Deposits – The cash balance at the end of April 2015 was £84.0m, slightly ahead of plan. £65m was held on short term deposits with the National Loans Fund at the end of the month attracting rates of around 40bp. Funds remaining in the main GBS current accounts earn 25bp interest.

1.5 Monitor Targets – The Trust’s Continuity of Service Rating (COSR) at the end of Aprilwas 3 in line with the quarter one plan. The COSR scale is 1 to 4 with 4 being the highest rating.

1.6 Capital – The total planned capital expenditure in the year is £50.4m, including carry forwards. Spend year to date was £1.0m against a plan of £2.2m but did not include any accruals as the year end positon was still being finalised.

2 CONTRACTING

Contract negotiations have not yet concluded, the main areas yet to be resolved are CQUINs and Finance. Subgroup meetings are continuing in order to support the delivery of the final contract package, FD meetings are also ongoing with a focus on the underlying activity assumptions. This is pivotal to supporting the choice of contract type (i.e. JMRA) that best supports the Trust strategy in 2015/16.

3 CONCLUSION

The previously highlighted risk with regards to efficiency planning has resulted in a low level of delivery in April, this coupled with underlying pay controls requires an immediate response to mitigate risk in quarter 1 of the new financial year.

ACTION



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3

4 RECOMMENDATIONS

The below actions are recommended:

1. Escalate level of risk in relation to efficiency delivery with Executive led response to reduce gap, improve delivery and current forecast.

2. Divisions to commence pay controls as part of controls focus of SIEP planning.3. Release reserves to fund Q1 Enhanced Bank Rate costs pending further review the

decision regarding enhanced nurse bank rates.4. Finalise demand and capacity decisions to release reserves into Operational Budgets.

Darren CattellInterim Director of Finance & PerformanceApril 2015Heart of England NHS Foundation Trust



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1. A&E Activity 2015/16


• There were 21,507 A&E attendances in Apr-15, 836 attendances, 4% above Apr-14.

• In April 86.25% of patients were seen within 4 hours excluding walk ins.

• At Heartlands 86.45% (1,438 breaches) of patients within 4 hours, 80.23% (1,443 breaches) at Good Hope site and 97.82% (79 breaches) at Solihull site.

• A&E activity excludes A&E outpatient attendances.• Form TF2A

2. Emergency Activity 2015/16 excluding Paediatrics, Paediatric Surgery and Obstetrics


• The Emergency activity was below April 2014 by 4%, 181 Spells.

• Heartlands 61, 2%, Good Hope, 112, 11% and Women & Children, 37, 11% were below Apr-14.

• Clinical Support 7, 15% and Solihull, 22, 4% were above Apr-14.

• Following the implementation of PMS2 a potential patient classification issue was identified. This remains under ongoing review and any necessary retrospective realignment will be actioned if applicable.

• Form TF2A

3. Emergency Activity 2015/16, Paediatrics, Paediatric Surgery and Obstetrics


• The activity is above Apr-14 by 3%, 24 Spells in Apr-15.




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4. AMU, MAU & SAU Activity 2015/16


• There were 2,225 spells during Apr-15, 28 Spells, 1% above Apr-14.

• Good Hope Hospital 38 spells, 6%, Heartlands Hospital, 57, 7% were above April-14 outturn.

• Solihull Hospital was below Apr-14 by 68 Spells, 9%.

5. Maternity Spells Activity 2015/16


• In April 2015, there were 842 Births Trustwide (532 at Heartlands, 295 at Good Hope, and 15 at Solihull). This compares to 854 in April 2014 (-1%). In April there were 8 planned homebirth (4 at Good Hope, 2 at Heartlands and 2 at Solihull).



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6. Elective & Day Case Activity 2015/16


• There were 6,458 Day case and Elective spells during Apr-15, this was 5%, 373 Spells below Apr-14 outturn.

• Heartlands, 9%, 354 Spells, Women and Childrens, 22%, 91 Spells were below Apr-14 in month.

• Solihull Division, 1%, 11 Spells, Clinical Support, 27 Spells, 18% and Good Hope, 34 Spells, 5% were above Apr-14 in month.


• There were 26 sessions cancelled during Apr-15, 96.96% of the scheduled sessions were utilised. The following specialties cancelled sessions, General Surgery (17), Gynaecology (4), Orthopaedics (2), Thoracic Surgery (2) and Urology (1).

• 92% (24) of the Theatre sessions were cancelled due to no surgeon in month.

• In addition to this, 22 sessions were cancelled in the Vanguard Theartre during April, 59% of the scheduled lists were utilisted.

• 90 patients were treated in the Vanguard Theatre during April.

• There were 202 patients treated by the private sector during April. Ophthalmology (54), General Surgery (48), Orthopaedics (25), ENT (22), Urology (19), Gastroenterology (18), Gynaecology (14), Vascular Surgery (2) had patients treated by the private sector in month.

• There were 75 hospital led cancelled operations on the day during April-15. 38 (51%) of the cancelled operations were at Good Hope, 21 (28%) at Heartlands and 16 (21%) at Solihull.

7. Outpatient Activity 2015/16


• There were 68,391 Outpatient attendances during Apr-15, 1,639 atts, 2% additional attendances than Apr-14.

• Clinical Support Services, 505 atts, 11%, Good Hope, 436 atts, 6%, Heartlands 119 atts and Solihull, 708 atts, 3% were above Apr-14 outturn.

• Women & Childrens, 129 atts were below Apr-14 outturn.

Total DNA Rates (Apr-15):

• Good Hope Hospital 8.17% (2,381*) • Heartlands Hospital 12.62% (4,379*) • Solihull Hospital 8.70% (2,038*)

The DNA rate for first attendances was 12.91% (1,438*) at Heartlands site during Apr-15. Good Hope (7.52%) and Solihull (7.90%) achieved the target of less than 11%.*No. of DNAs.



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• The overall I&E deficit was £2.7m at the end of month 1.

• The Monitor plan has not yet been set and we expect to be reporting against this in month 2.

• Continuity of Service Rating (COSR) is estimated at 3 (2.5 rounded up) at this early stage of the financial year. The Trust has the lowest score on the capital service cover measure due to recording a negative EBITDA in month 1.


8. Performance against Monitor Standards 2015/16

NHS Contract Income (Category A)

For the month of April there was trust wide clinical income of £49.7m.

There is no graph showing an analysis of over performance as LDPs have not yet been finalized with commissioners.


9. Income 2015/16

• The Trust is (£4.2m) over spent at Month 1 of 2015/16. • Pay is over spent by (£2.1m) • Non Pay is over spent by (£3.3m) • Other Operating Revenue £1.2m over recovered • Form TF1


10. Income and Expenditure against Operational Budgets



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11. Operational Budgets 2015/16

Corporate Directorates (CD) is under spent by £0m



Non Pay over spend (£0m)

Corporate Trust Wide (CTW) is under spent by £3.3m


Pay over spend (£0m)

Non Pay under spend £2.1m

Facilities (FAC) is over spent by (£0.1m)




Bad Debt provision included within the above: £0.1m

Heartlands Hospital (BHH) is over spent by (£3.8m)

Income under recovery (£0.1m)



Clinical Support Services (CSS) is over spent by (£0.5m)




Good Hope Hospital (GHH) is over spent by (£1.5m)




Solihull Hospital (SOL) is over spent by (£1.1m)




Womens and Childrens (WC) is over spent by (£0.6m)


Pay under spend £0m




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Pay Expenditure is over spent by (£2.1m) at Month 1 2015/16.

Material variances to operational budget relates to:

• Medical Staffing, which is over spent by (£1.1m) , • Nursing & Midwifery overspent by (£0.9m). • Professional Bank and Agency (£0.1m) • Agency other (£0.2m)

• Form TF3


12. Pay Expenditure


Non Pay is over spent by (£3.3m) at Month 1 of 2015/16.

Material overspends against operational budgets are:• Prior and current year SIEP (£3.2m) • Clinical Supplies (£0.8m)

Form TF4


13. Non pay Expenditure



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• The Trust achieved £0.4m (20.9%) efficiency in Month 1. • These results show a (£1.6m) shortfall against target at Month 1.

Based on Month 1 results the year end out turn is £12.7m delivery of savings (53%).

Analysis of Forecast:

• £1.4m in risk category 5 Delivered • £2.0m in risk category 4 Expected Delivery. • £9.3m in risk category 3 Suggested Plans.

Divisions have to date completed 68 Quality Impact Assessments for 2015/16. A further 209 are in progress.

Apr - In Month Year To Date Forecast @ Month 1

GROUPS Target ActualRec

ActualNon Rec

Variance Target ActualRec

ActualNon Rec

Variance AnnualTarget

Actual(3,4,5)

Variance(0,1,2)

heartlands hospital 623.8 93.4 11.0 (519.3) 623.8 93.4 11.0 (519.3) 7,485.0 2,917.3 (4,567.7)

good hope hospital 183.3 31.7 0.6 (151.1) 183.3 31.7 0.6 (151.1) 2,200.0 935.4 (1,264.6)

solihull 289.8 41.6 29.1 (219.1) 289.8 41.6 29.1 (219.1) 3,477.5 2,048.5 (1,429.0)

clinical support services 436.5 4.9 43.9 (387.6) 436.5 4.9 43.9 (387.6) 5,237.5 3,520.6 (1,716.9)

womens & childrens 225.0 3.1 0.0 (221.9) 225.0 3.1 0.0 (221.9) 2,700.0 672.6 (2,027.4)

facilities 116.7 94.3 0.0 (22.3) 116.7 94.3 0.0 (22.3) 1,400.0 1,200.8 (199.3)

corporate directorates 125.0 65.3 0.0 (59.7) 125.0 65.3 0.0 (59.7) 1,500.0 703.4 (796.6)

corporate trustwide 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 760.0 760.0

TOTAL 2,000.0 334.4 84.6 (1,581.0) 2,000.0 334.4 84.6 (1,581.0) 24,000.0 12,758.6 (11,241.5)


14. Service Improvement Efficiency Plan 2015/16



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BALANCE SHEET

Expenditure YTD to month 1 was £975k, 45.2% of the YTD Monitor Plan (MP) and 1.9% of total Approved Budget (AB) £50.6m. Orders raised were £9.1m, 422.6% of YTD MP & 18.0% of AB.

• Other was £442k, 45.3% of MP; with spend various estates projects

• Operational was £357k, 36.6% of MP, key spends on SAN, Windows 7 Compliance project, Ultrasound Machine, LAN

• Site Strategy Investment expenditure was £176k, 18.0% of MP, spend on Dermatology relocation, Endoscopy BHH

YTD Performance

15. Combined Capital Expenditure YTD 2015/16

M1 In-month expenditure was £975k:

• FAC / Site Strategy £509k- Various estates projects • CD £346k- SAN, Document Scanning, Windows 7

Compliance project, LAN • BHH £75k- Ultrasound Machine, Profiling Beds, ECG• SOL £36k- Day Room upgrade, 2 Flexible

Nasendoscope• WC £9k- Ambulatory Blood Pressure Monitors,

Capacity Risks project for Obstetrics at BHH• CSS £1k- Histopathology Archive Provision, BHH

Mortuary Fridge refurbishment


16. Capital Expenditure in Month 2015/16

• Payment performance in April is about 69%. The volume of invoices paid in April is 15,818. This is a little higher than normal volumes and around 5,400 invoices higher than April 2014.

• The continued poor payment performance is due to backlog clearing and processing delays following the Readsoft upgrades and will also impact on performance into month 2 and 3.

• A special project team is being set up to tackle the backlog of old year invoices and from next month we should be able to report project and business as usual performance separately.

Cumulative Performance

17. Creditors 2015/16



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BALANCE SHEET

• Total debt reduced by £2.043m during April to £22.360m.

• NHS England paid several large value invoices in the month, including £0.684m for public health, £0.393m for cancer drugs recharges and £0.361m for clinical excellence awards

• Health Education England paid a training & education invoice for £0.577m during April

• A high volume of smaller value invoices issued during March to both NHS and Non NHS customers were also paid during April

• There are still underpayments of £2.372m against the 2014-15 SLA mandate invoices, including £0.944m by Solihull Clinical Commissioning Group and £1.349m by Birmingham Cross City Clinical Commissioning Group, who have also underpaid the April 2015 SLA mandate invoice by £0.505m, although this was for an estimated value only.

• There are four April 2015 SLA mandate invoices totalling £0.966m still outstanding with NHS England. These were issued late in the month and are expected to be paid shortly

• Ante natal maternity pathways activity debt for April 2013 to March 2015 increased slightly to £3.724m , including £1.957m with Burton Hospitals, £0.617m with Sandwell & West Birmingham Hospitals, and £0.643m with Birmingham Womens Hospital.

• A specialised services over-performance invoice for £3.145m issued to NHS England in March remains outstanding, as does an RTT funding invoice for £1.100m to Solihull Commissioning Group


18. Debtors 2015/16

CASHFLOW

• The cash balance at the end of April 2015 was £84.0m. • The Monitor plan has not yet been set and we expect

to report against this in month 2. • All Trust funds remain in the GBS umbrella as a

change in the rules on calculating PDC dividend means that it is currently financially unviable to invest in other commercial banks.

• £65m was held on short term NLF deposits at the month end attracting rates of about 40bp.

• Funds in GBS attract 25bp.


19. Monthly Closing Cash Balance vs Plan 2015/16



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18 weeks: Reported 1 month in arrears



HEFT have now resumed reported against the Admitted patient pathway (clock stops), and achieved 82.09% against the 90% target for Apr15, with the aim to ontinue to see

longer waits in order to help clear the backlog

HEFT managed to see 91.02% of non-admitted patients within 18 weeks against the 95% target for Apr15

Admitted Non-admitted

75%

80%

85%

90%

95%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

85%

87%

89%

91%

93%

95%

97%

99%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

HEFT have now resumed reported against the Incomplete pathways, and achieved 89.61% against the 92% target for Apr15

Incomplete Pathways

85%

87%

89%

91%

93%

95%

97%

99%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

Total time in A&E

70%

75%

80%

85%

90%

95%

100%Target

The 95% target for A&E around 4 hour was not met in April with performance at 86.25%

A&E



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Cancers: Reported 1 month in arrears

Cancers: (continued)



50%55%60%65%70%75%80%85%90%95%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

2 week GP 2 week Breast Target

The Trust failed the 93% target for the 2 week GP cancer indicator in March at 90.96%, and also failed the 2 week Breast symptom 93% target, achieving 88.41%.

The Trust achieved the 96% target for 31 day cancers in March, out-turning at 98.48% in month. March data is unvalidated.

2 weeks 31 day GP

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

The Trust met the 31 day anti-cancer drug target of 98% in March, achieving 100%.

The Trust met the 31 day surgery modality cancer target of 94% in March, achieving 96.97%.

31 day anti-cancer 31 day surgery

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

85%

87%

89%

91%

93%

95%

97%

99%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

The Trust achieved the 62 day cancer 85% target in March, achieving 84.40%.

The Trust missed the 62 day national screening cancer 90% target in March, achieving 62.50%. March data is unvalidated.

62 day cancers 62 day screening

75%

80%

85%

90%

95%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target

40%

50%

60%

70%

80%

90%

100%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Target



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Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

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Infection Control


c-diff

In month the Trust reported 2 cases of C-diff, with a total of 2 YTD

0

2

4

6

8

10

12

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16



.111

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Plan

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Presentation

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ties

Year to Date

AnnualPlan

Actual

Full Year

VarianceActual to

Plan

AnnualPlan

Forecast

£m £m £m £m £m

VarianceForecast to

Plan

£m

2014/15

£m

0.000 49.677 49.677 NHS Clinical Revenue 0.000 0.000 0.000 577.495

0.000 0.046 0.046 Clinical Revenue - Private Patients 0.000 0.000 0.000 0.589

0.000 0.011 0.011 Clinical Revenue - Overseas Visitors 0.000 0.000 0.000 0.161

0.000 0.436 0.436 Research and Development revenue 0.000 0.000 0.000 4.190

0.000 1.969 1.969 Education and Training revenue 0.000 0.000 0.000 22.841

0.000 0.037 0.037 PFI Specific Revenue 0.000 0.000 0.000 0.448

0.000 0.000 0.000 Donations and Grants received 0.000 0.000 0.000 0.501

0.000 0.346 0.346 Parking Revenue 0.000 0.000 0.000 4.781

0.000 0.097 0.097 Catering Revenue 0.000 0.000 0.000 1.014

0.000 0.027 0.027 Accommodation Revenue 0.000 0.000 0.000 0.278

0.000 1.546 1.546 Revenue from non patient services to other bodies

0.000 0.000 0.000 10.480

0.000 1.613 1.613 Miscellaneous other operating revenue 0.000 0.000 0.000 24.080

0.000 55.804 55.804 Total Operating Revenue 0.000 0.000 0.000 646.860

0.000 (32.939) (32.939) Employee expenses, permanent staff 0.000 0.000 0.000 (386.163)

0.000 (3.004) (3.004) Employee expenses, agency and contract staff 0.000 0.000 0.000 (25.630)

0.000 (5.500) (5.500) Drugs 0.000 0.000 0.000 (58.544)

0.000 (5.534) (5.534) Clinical Supplies 0.000 0.000 0.000 (62.776)

0.000 (1.473) (1.473) Non Clinical Supplies 0.000 0.000 0.000 (16.608)

0.000 (0.302) (0.302) Research and Development Expense 0.000 0.000 0.000 (2.709)

0.000 (0.205) (0.205) Education and Training Expense 0.000 0.000 0.000 (2.411)

0.000 (2.489) (2.489) Premises 0.000 0.000 0.000 (29.218)

0.000 (1.279) (1.279) CNST 0.000 0.000 0.000 (12.795)

0.000 (1.061) (1.061) Purchase of healthcare services non NHS 0.000 0.000 0.000 (9.228)

0.000 (0.659) (0.659) Purchase of healthcare services NHS 0.000 0.000 0.000 (7.352)

0.000 (0.279) (0.279) Consultancy Expense 0.000 0.000 0.000 (1.833)

0.000 (1.714) (1.714) Miscellaneous other Operating expense 0.000 0.000 0.000 (13.103)

0.000 (0.067) (0.067) (Increase)/decrease in impairment of receivables

0.000 0.000 0.000 0.029

0.000 (0.008) (0.008) PFI unitary payment 0.000 0.000 0.000 (0.095)

0.000 (56.513) (56.513) Total Operating Expenses 0.000 0.000 0.000 (628.434)

0.000 (0.709) (0.709) EBITDA 0.000 0.000 0.000 18.427

0.000 0.000 0.000 Gain / loss on asset disposals 0.000 0.000 0.000 (0.195)

0.000 (1.425) (1.425) Total Depreciation and amortisation 0.000 0.000 0.000 (18.360)

0.000 (0.573) (0.573) PDC Dividend expense 0.000 0.000 0.000 (5.656)

0.000 0.019 0.019 Total interest receivable 0.000 0.000 0.000 0.441

0.000 0.000 0.000 Other finance costs 0.000 0.000 0.000 (0.003)

0.000 (0.020) (0.020) Interest expense 0.000 0.000 0.000 (0.262)

0.000 (2.708) (2.708) Surplus/(deficit) before impairments 0.000 0.000 0.000 (5.608)

0.000 0.000 0.000 Impairment (Losses) / Reversals 0.000 0.000 0.000 0.000

0.000 (2.708) (2.708) Surplus/(deficit) after impairments 0.000 0.000 0.000 (5.608)

Key perfomance Indicators (KPIs)Year to Date

AnnualPlan

Actual

Full Year

VarianceActual to

Plan

AnnualPlan

Forecast VarianceForecast to

Plan

2014/15

NaN (4.85%) NaN Net I&E Margin NaN NaN NaN (0.84%)

0.000 (0.709) (0.709) EBITDA (£m) adjusted 0.000 0.000 0.000 17.925

NaN -Infinity NaN EBITDA achieved, % of projection NaN NaN NaN 63.69%

NaN (1.27%) NaN EBITDA margin (%) NaN NaN NaN 2.77%

0.000 (0.689) (0.689) Revenue available for debt service (£m) 0.000 0.000 0.000 18.366

Trust Wide Income and Expenditure Form TF1AApril 2015



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Year to Date

Last Month Actual

This Month Actual

Full Year

Variance to Plan

Annual Plan Forecast

£m £m £m £m £m

Variance from Plan

£m

31 March 2015

£m

3.553 3.655 3.655 Intangible Assets, Net 0.000 0.000 0.000 3.553242.015 241.468 241.468 Property, Plant and Equipment, Net 0.000 0.000 0.000 242.015

4.206 4.196 4.196 On balance sheet PFI assets 0.000 0.000 0.000 4.206249.775 249.319 249.319 Fixed Assets, net 0.000 0.000 0.000 249.775

2.592 2.534 2.534 Trade Receivables, non current, gross 0.000 0.000 0.000 2.592

(1.461) (1.461) (1.461) Impairment of receivables for bad and doubtful debts, non current 0.000 0.000 0.000 (1.461)

1.131 1.072 1.072 Trade and other receivables, net, non current 0.000 0.000 0.000 1.131250.906 250.391 250.391 ASSETS, NON CURRENT 0.000 0.000 0.000 250.906

8.491 8.634 8.634 Inventories 0.000 0.000 0.000 8.49123.658 28.360 28.360 NHS Trade Receivables, current, gross 0.000 0.000 0.000 23.6585.627 4.582 4.582 Non NHS Trade Receivables, current, gross 0.000 0.000 0.000 5.6270.244 0.244 0.244 Other Related Party Receivables 0.000 0.000 0.000 0.2442.377 1.533 1.533 Other Receivables 0.000 0.000 0.000 2.377

(8.396) (8.456) (8.456) Impairment of receivables for bad and doubtful debts, current 0.000 0.000 0.000 (8.396)

2.465 2.539 2.539 Accrued Income 0.000 0.000 0.000 2.4656.075 10.841 10.841 Prepayments 0.000 0.000 0.000 6.075

87.671 84.019 84.019 Cash and Cash Equivalants 0.000 0.000 0.000 87.671128.212 132.295 132.295 CURRENT ASSETS 0.000 0.000 0.000 128.212

379.118 382.687 382.687 TOTAL ASSETS 0.000 0.000 0.000 379.118

(6.655) (8.272) 8.272 Trade Payables 0.000 0.000 0.000 (6.655)(14.700) (15.149) 15.149 Other Payables 0.000 0.000 0.000 (14.700)(5.684) (3.179) 3.179 Capital Payables 0.000 0.000 0.000 (5.684)

(46.638) (52.778) 52.778 Accruals 0.000 0.000 0.000 (46.638)(0.480) (0.480) 0.480 Finance Leases / PFI Leases, Current 0.000 0.000 0.000 (0.480)0.000 (0.573) 0.573 PDC Dividend Payable 0.000 0.000 0.000 0.000

(8.748) (8.066) 8.066 Provisions, current 0.000 0.000 0.000 (8.748)(6.501) (6.430) 6.430 Deferred Income 0.000 0.000 0.000 (6.501)

(89.405) (94.926) 94.926 CURRENT LIABILITIES 0.000 0.000 0.000 (89.405)

38.807 37.370 37.370 NET CURRENT ASSETS (LIABILITIES) 0.000 0.000 0.000 38.807

(6.747) (7.531) 7.531 Provisions, non current 0.000 0.000 0.000 (6.747)(1.609) (1.598) 1.598 Finance Leases, non current 0.000 0.000 0.000 (1.609)(2.377) (2.360) 2.360 PFI Leases, non current 0.000 0.000 0.000 (2.377)

(10.733) (11.489) 11.489 LIABILITIES, NON CURRENT 0.000 0.000 0.000 (10.733)

278.980 276.272 276.272 TOTAL ASSETS EMPLOYED 0.000 0.000 0.000 278.980

215.309 215.309 215.309 Public Dividend Capital 0.000 0.000 0.000 215.30919.432 16.724 16.724 Retained Earnings / (Accumulated Losses) 0.000 0.000 0.000 19.43244.408 44.408 44.408 Revaluation Reserve 0.000 0.000 0.000 44.408(0.169) (0.169) (0.169) Miscellaneous Other Reserves 0.000 0.000 0.000 (0.169)278.980 276.272 276.272 TOTAL TAXPAYERS EQUITY 0.000 0.000 0.000 278.980

Infinity 11.84% Net Return After Financing NaN NaN NaN -19.08 %

Year to Date

Last Month Actual

This Month Actual

Full Year

Variance to Plan

Annual Plan Forecast Variance from Plan

31 March 2015

0.000 16.896 Liquidity NaN NaN NaN 19.154


Form TF1BTrust Wide Balance SheetApril 2015



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Trust Wide Cash flow

Actual Plan Variance to Plan Annual Plan Forecast Variance from Plan 2014/15

(2.708) (2.708) Surplus / (Deficit) after tax - (5.608) Non - cash flows in operating surplus / (deficit): -

0.001 0.001 Finance income/charges - (0.176) - Donations and grants received of PPE and intangibles - (0.501) - Other operating non-cash movements -

1.425 1.425 Depreciation and amortisation, total - 18.360 - Impairment losses / (reversals) - - (Gain) / loss on disposal of non current assets - 0.195

0.573 0.573 PDC Dividend Expense - 5.656 0.067 0.067 Other - (0.029)

(0.642) - (0.642) Operating Cash Flows before movements in WC - - - 17.897 Increase / (decrease) in working capital:

(0.143) (0.143) (Increase)/decrease in inventories - (0.495) - (Increase)/decrease in tax receivable -

(4.702) (4.702) (Increase)/decrease in NHS Trade Receivables - (2.042) 1.045 1.045 (Increase)/decrease in Non NHS Trade Receivables - (0.733)

- - (Increase)/decrease in other related party receivables - (0.244) 0.844 0.844 (Increase)/decrease in other receivables - 0.398

(0.074) (0.074) (Increase)/decrease in accrued income - (0.470) - (Increase)/decrease in other financial assets -

(4.766) (4.766) (Increase)/decrease in prepayments - (0.942) - (Increase)/decrease in Other assets (non chartable assets) -

(0.071) (0.071) Increase/(decrease) in Deferred Income (excl. Govt Grants.) - (0.104) - Increase/(decrease) in Deferred Income (Govt. Grants) -

(0.682) (0.682) Increase/(decrease) in Current provisions - (5.173) - Increase/(decrease) in post-employment benefit obligations - - Increase/(decrease) in tax payable -

1.617 1.617 Increase/(decrease) in Trade Creditors - 4.156 0.449 0.449 Increase/(decrease) in Other Creditors - 12.645 6.140 6.140 Increase/(decrease) in accruals - (1.237)

- Increase/(decrease) in other Financial liabilities - - - Increase/(decrease) in Other liabilities (non charitable assets) - -

(0.343) - (0.343) Increase / (decrease) in working capital, Total - - - 5.759 0.784 - 0.784 Increase/(Decrease) in Non-current Provisions - -

(0.201) - (0.201) Net cash inflow/(outflow) from operating activities - - - 23.656 Net cash inflow/(outflow) from investing activities:

(0.915) (0.915) Property - new land, buildings or dwellings - (7.560) - Property - maintenance expenditure - (1.333) - Plant and equipment - Information Technology - (3.616) - Plant and equipment - Other - (5.857) - Property, plant and equipment - other expenditure - - Proceeds on disposal of property, plant and equipment - - Purchase of investment property - - Proceeds on disposal of investment property - - Purchase of intangible assets - (2.169) - Proceeds on disposal of intangible assets - - Expenditure on capitalised development -

(2.505) (2.505) Increase/(decrease) in Capital Creditors - 1.548 - Government grants received - - Purchase of investments & deposits made - - - Proceeds on disposal of investments & withdrawals - - - Other cash flows from investing activities - -

(3.420) - (3.420) Net cash inflow/(outflow() from investing activities, Total - - - (18.987)

(3.621) - (3.621) Net cash inflow/(outflow) before financing - - - 4.669 Net cash inflow/(outflow) from financing activities:

- Public Dividend Capital received - 1.140 - Public Dividend Capital repaid - - PDC Dividends paid - (4.851) - Finance leases -

(0.012) (0.012) Interest element of finance lease rental payments - other - (0.139) (0.013) (0.013) Interest element of finance lease rental payments - On-balance sheet PFI - (0.151) (0.010) (0.010) Capital element of finance lease rental payments - other - (0.118) (0.016) (0.016) Capital element of finance lease rental payments - On-balance sheet PFI - (0.197) 0.019 0.019 Interest received on cash and cash equivalents - 0.441

- Movement in Other grants/Capital received - - Donations received in cash - - (Increase)/decrease in non-current receivables - 0.179 - Increase/(decrease) in non-current payables - - Other cash flows from financing activities -

(0.031) - (0.031) Net cash inflow/(outflow) from financing activities, Total - - - (3.696)

(3.652) - (3.652) Net increase / (decrease) in cash - - - 0.973

87.671 86.321 0.377 Opening cash balance 87.671 87.671 - 86.698 (3.652) - (3.652) Net increase / (decrease) in cash - - - 0.973 84.019 86.321 (3.275) Closing cash balance 87.671 87.671 - 87.671

Form TF1C

Year to Date

April 2015

Full Year



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April 2015

Year to DateMetric Actual Rating Weight 4 3 2 1

Capital Service Cover -1.11 1 50.0% 2.50 1.75 1.25 <1.25Liquidity 16.90 4 50.0% 0 -7.0 -14.0 <-14.0

Weighted Average 2.50 100.0%

Monitor Continuity of Service Ratings (COSR) Form TF1D

COSR:



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Plan

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ties

Safe

ty S

itRep

– A

pril

2015

1

Safety Sitrep - April 2015


.116

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ofInterest


Chairman'sReport

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Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

April

201

5

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ituat

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IMR)



.117

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Report


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Plan

DementiaStrategy

Presentation

Governanceand


ties

Sum

mar

y ris

k pr

ofile

^Dat

e ris

k ra

ted

as re

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15) a

nd a

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Risk

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itiga

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in p

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pril

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me

will

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draw

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15

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lihul

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now

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locu

ms.

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sing -

wise

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ndin

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r for

an

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tiona

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essm

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in re

spon

se to

our

last

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ble

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ptio

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NPs

are

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of s

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both

for o

ther

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an

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term

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pete

ncie

s. T

his i

s com

poun

ded

if th

e nu

rsin

g st

aff /

EN

Ps w

orki

ng w

ith th

em a

re

bank

staf

f and

is se

t with

in a

hos

pita

l site

that

has

litt

le o

n -sit

e ba

ck u

p fo

r unw

ell c

ases

. It i

s bec

omin

g in

crea

singl

y di

fficu

lt to

ob

tain

ade

quat

e nu

mbe

rs o

f sta

ff in

all

grou

ps o

f an

appr

opria

te ca

libre

to p

rovi

de a

safe

qua

lity

serv

ice.

Impl

icat

ions

of S

olih

ull C

CG E

RG p

ropo

sals

Al

l SH

Fe

b 15

16

16

In Ju

ne 2

014

Solih

ull C

CG p

ublis

hed

plan

s dev

elop

ed th

roug

h th

eir E

ffect

iven

ess R

evie

w G

roup

(ERG

). H

EFT

serv

ices

affe

cted

by

the

ERG

prop

osal

s are

: (1)

Non

-ren

ewal

: Virt

ual W

ards

; Hea

rt F

ailu

re; H

ospi

tal L

iaiso

n N

ursin

g; N

utrit

ion

Serv

ice;

Cas

tle P

ract

ice

Diet

etic

s and

Pod

iatr

y; p

lus B

alsa

ll Co

mm

on P

ract

ice

ENT;

(2) A

ctiv

ity th

resh

old:

MSK

; Pod

iatr

y; (3

)Con

trac

t ren

egot

iatio

n:

Diab

etes

; SAL

T (C

hild

ren)

; OT

(Pae

diat

ric).I

t is i

mpo

rtan

t to

high

light

that

the

re a

re im

plic

atio

ns o

f ERG

on

wid

er ca

re p

athw

ays

utili

zed

by p

atie

nts c

ared

for b

y HE

FT.

HEFT

are

cur

rent

ly in

form

al n

egot

iatio

ns re

gard

ing

ERG

prop

osal

s. A

s par

t of t

hese

ne

gotia

tions

info

rmat

ion

rega

rdin

g th

e CC

G im

pact

ass

essm

ent o

f ERG

pro

posa

ls ha

s bee

n re

ques

ted.

Dela

y in

dia

gnos

tic E

ndos

copy

test

s Al

l BH

H O

ct 1

4 15

20

The

endo

scop

y se

rvic

e is

not m

eetin

g re

quire

d tim

esca

les f

or d

iagn

ostic

end

osco

py te

stin

g of

out

-pat

ient

(2 w

eek

wai

t en

dosc

opy

requ

ests

, urg

ent r

eque

sts)

and

in-p

atie

nt re

ques

ts (e

spec

ially

upp

er G

I ble

ed w

hich

shou

ld b

e co

mpl

eted

with

in 2

4 ho

urs)

. GP

two

wee

k w

ait c

ance

r pro

form

a re

ques

ts a

re b

eing

com

plet

ed w

ithin

tim

efra

mes

. Urg

ent e

ndos

copy

requ

ests

cu

rren

tly w

ithin

4 -6

wee

ks (s

houl

d be

2).

Upd

ate:

A fu

rthe

r 600

pat

ient

s hav

e be

en id

entif

ied

that

wer

e no

t on

the

wai

ting

list

syst

em w

hich

has

incr

ease

d th

e ov

eral

l wai

ting

list t

o 15

80 p

atie

nts.

The

add

ition

al b

ackl

og n

ow m

eans

that

the

num

ber o

f pa

tient

s wai

ting

mor

e th

an 1

8 w

eeks

stan

ds a

t 195

with

pro

ject

ed re

turn

to 5

wee

k di

agno

stic

tim

e no

t exp

ecte

d un

til Q

3 20

15/1

6. T

here

hav

e be

en a

n in

crea

sing

num

ber o

f clin

ical

ly si

gnifi

cant

cas

es w

ith d

elay

ed d

iagn

osis.

STRA

TEGI

C RI

SKS-

Mon

itorin

g by

EM

B,

QRC

& T

B (a

s at A

pril

15)

Sum

mar

y &

scor

e

Futu

re fi

nanc

ial r

isk

(↔ 1

6)

Patie

nt fl

ow

(↔ 1

6)

Abili

ty o

f the

Tru

st to

un

dert

ake

stra

tegi

c co

nfig

urat

ion

(↔

12)

Staf

f Mor

ale

(↔

16)

18 W

eeks

(↔

12)

Brea

st R

ecal

l (↔

12)

Mor

talit

y (↔

12)

Enfo

rcem

ent A

ctio

n

(↔ 1

6)

PMS2

(↔

20)



.118

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ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Rem

aini

ng R

ed R

isks

from

201

3/14

Impl

emen

tatio

n of

IT sy

stem

for S

exua

l Hea

lth –

Lill

ie

BHH

CSSD

M

ar14

16

16

Pote

ntia

l los

s of v

ascu

lar s

ervi

ce (i

f una

ble

to p

rovi

de h

ybrid

th

eatr

e an

d lo

ss o

f com

miss

ioni

ng o

f the

se se

rvic

es)

Hybr

id th

eatr

e bu

ild n

ow u

nder

way

– ri

sk re

mai

ns a

t 16.

BHH

BHH

Mar

14

16

16

Impa

ct o

f ext

ende

d st

ay in

ED.

Re

view

ed Ja

n 20

15 –

risk

upg

rade

d to

20

GHH

BHH

BHH

Jan1

4 15

20

Chem

othe

rapy

pre

scrib

ing

/ adm

inist

ratio

n in

abs

ence

of E

P BH

H BH

H O

ct13

15

15

4

RED

OPE

RATI

ON

AL R

ISKS

-Mon

itorin

g by

site

s / d

ivis

ion.

Risk

Sum

mar

y: R

ed

Site

Di

visi

on

Dat

e^

Initi

al^

Curr

ent *

Sexu

al H

ealth

IT sy

stem

una

ble

to m

eet s

tatu

tory

repo

rtin

g BH

H CS

S Ju

l14

6 16

The

Tele

care

syst

em cu

rren

tly u

sed

to re

cord

att

enda

nce

and

drug

trea

tmen

t is u

nabl

e to

mee

t man

dato

ry d

ata

requ

irem

ents

for P

ublic

Hea

lth E

ngla

nd,

HIV

and

AIDS

Rep

ortin

g Sy

stem

(HAR

S). A

s wel

l as t

he re

puta

tiona

l im

pact

this

may

hav

e on

com

miss

ioni

ng d

ecisi

ons,

orga

nisa

tiona

l non

com

plia

nce

may

re

sult

in a

10%

fine

(equ

ates

to a

ppro

xim

atel

y £4

00k

for 1

4/15

cont

ract

val

ue).

The

depa

rtm

ent o

pted

to

impl

emen

t a n

ew (H

ARS

com

plia

nt) I

T sy

stem

. Cl

imat

e–HI

V bu

t tec

hnic

al d

iffic

ultie

s in

the

IT sy

stem

s / in

terf

aces

with

oth

er T

rust

syst

ems m

eans

that

they

rem

ain

unab

le to

com

ply

with

thes

e st

atut

ory

repo

rtin

g re

quire

men

ts. U

pdat

e: P

redi

cted

“Go

live”

dat

e is

Mar

ch 2

015.

Risk

scor

e to

be

revi

ewed

.

Impa

ct o

f una

ccep

tabl

e de

lay

for b

ackl

og o

f cas

es re

quiri

ng

com

plex

end

ovas

cula

r ane

urys

m re

pair

(EVA

R)

BHH

BHH

July

14

15

16

The

deat

h of

a p

atie

nt fr

om a

rupt

ured

thor

acic

ane

urys

m w

hilst

wai

ting

for a

dat

e fo

r tre

atm

ent a

t HEF

T id

entif

ied

a p

oten

tial 9

2 pa

tient

s on

the

EVAR

pat

hway

with

out a

n op

erat

ion

date

who

wer

e no

t rec

orde

d as

par

t of t

he H

EFT

wai

ting

list.

Follo

win

g va

lidat

ion

the

back

log

is 41

pa

tient

s who

are

cur

rent

ly li

sted

for s

urge

ry (w

ith a

noth

er p

oten

tial 2

4 pa

tient

s who

may

filte

r int

o th

e sy

stem

as t

he d

ecis

ion

is ta

ken

to

trea

t). T

he o

ldes

t cas

e is

38 w

eeks

from

dec

ision

to a

dmit.

38

addi

tiona

l list

s are

requ

ired

to a

ddre

ss th

e ba

cklo

g. U

pdat

e: P

lan

to c

lear

ba

cklo

g by

end

of M

arch

15

is on

trac

k, so

me

dela

ys in

rece

ivin

g co

mpl

ex g

raft

s but

neg

otia

tion

is on

goin

g to

exp

edite

this.

Emer

genc

y Re

scue

from

Lift

s at B

HH a

nd R

SU

BHH/

GHH

Corp

Au

g 14

16

16

In th

e ev

ent o

f a li

ft fa

iling

and

pas

seng

ers b

eing

trap

ped,

est

ates

staf

f are

trai

ned

annu

ally

to h

and

win

d th

e lif

t to

the

next

floo

r. Th

is ye

ar th

e tr

aine

r de

emed

it u

nsaf

e to

und

erta

ke th

is ta

sk/p

rovi

de tr

aini

ng fo

r the

lift

s in

the

mai

n w

ard

bloc

k at

BHH

and

RSU

at G

HH (d

ue to

the

load

ing

and

effo

rt re

quire

d to

han

d w

ind

the

lift).

The

lift

s in

mai

n w

ard

bloc

k (B

HH) f

ail a

ppro

xim

atel

y 1/

mon

th a

nd th

e lif

ts in

RSU

app

roxi

mat

ely

2/m

onth

. The

refo

re e

stat

es st

aff

will

hav

e to

per

form

this

task

, des

pite

thei

r tra

inin

g ha

ving

exp

ired.

A sa

fe sy

stem

of w

ork

for t

he re

leas

e of

pas

seng

ers f

rom

thes

e lif

ts is

bei

ng d

evel

oped

as

an

inte

rim m

easu

re



.119

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ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Mor

talit

y | H

eadl

ines

•

The

con

firm

ed r

ebas

ed 2

013/

14 H

SM

R is

107

.9,

whi

ch is

an

outli

er fo

r th

at y

ear

•D

ue to

issu

es w

ith P

MS

2 an

d in

put e

rror

, HS

MR

dat

a fro

m J

uly

onw

ards

is

not

rel

iabl

e fo

r m

orta

lity

mea

sure

men

ts b

ut w

ill b

e pu

blis

hed

by D

r Fo

ster

The

late

st H

SM

R a

s pr

ovid

ed b

y D

r Fos

ter

for N

ovem

ber i

s 91

.3.

•C

rude

num

ber o

f dea

ths

of d

eath

s ar

e be

ing

mon

itore

d un

til th

e is

sue

is

reso

lved

. •

Ther

e w

as a

mar

ked

rise

in th

e w

eekl

y nu

mbe

r of d

eath

s ov

er D

ecem

ber

whi

ch p

eake

d at

the

end

of

Dec

embe

r/beg

inni

ng o

f Ja

nuar

y. T

his

was

as

soci

ated

with

incr

ease

d co

nges

tion

in p

atie

nt fl

ow a

nd a

lso

mirr

ors

the

Flu

A s

pike

– th

is is

in li

ne w

ith th

e fin

ding

s of

the

Publ

ic H

ealth

Eng

land

(P

HE

) re

port

into

sea

sona

l flu

. The

re w

as a

dec

line

in c

rude

num

bers

of

deat

hs t

hrou

ghou

t Ja

nuar

y w

hich

has

sta

bilis

ed a

t a

slig

htly

hig

her

num

ber t

han

the

pre-

win

ter l

evel

, pos

sibl

y as

soci

ated

with

a m

inor

rise

in

Flu

B p

ositi

ve c

ases

sin

ce th

e st

art o

f Feb

ruar

y •

The

late

st S

umm

ary

Hos

pita

l-lev

el M

orta

lity

Indi

cato

r (S

HM

I) sc

ore

for J

ul

13 to

Jun

14

is s

light

ly h

ighe

r tha

n la

st q

uarte

r at 1

09, t

his

is w

ithin

the

HS

CIC

‘as

expe

cted

’ ban

ding

.

Dr F

oste

r HSM

R, 2

010/

11 to

Apr

-Nov

201

4/15

Mor

talit

y He

adlin

es

5

Gra

ph :

Trus

t wee

kly

num

ber o

f de

aths

to

12th

Apr

il 20

15

HSM

R De

c 12

- Nov

14 re

base

d us

ing

13/1

4 be

nchm

ark

CQ

C m

orta

lity

outli

er a

lert

s •

No

new

or o

pen

CQ

C m

orta

lity

outli

er a

lerts

Gra

ph s

how

ing

thre

e w

eekl

y av

erag

e nu

mbe

r of d

eath

s an

d +v

e flu

test

s



.120

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ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Site

HSM

R Ap

ril 2

008-

Nov

embe

r 20

14

Dr F

oste

r pro

vide

d HS

MR

data

to b

e us

ed w

ith ca

utio

n fr

om Ju

ly o

nwar

ds d

ue to

PM

S2 in

put e

rror

s with

resp

ect t

o ty

pe o

f adm

issio

n



.121

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WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Su

mm

ary

SUI p

rofil

e Ap

ril 2

015

7

OPE

N S

UI I

NVE

STIG

ATIO

NS

(as a

t 09/

04/1

5)

Site

/ D

ivis

ion*

Di

rect

orat

e Da

te

(N =

Nev

er E

vent

; P =

Pre

vent

ed N

ever

Eve

nt)

Stat

us

BHH

BHH

Mul

tiple

M

ay14

Sa

lmon

ella

Out

brea

k (M

ay /J

une)

201

4/18

537

Draf

t rep

ort r

ecei

ved

and

QA

proc

ess c

omm

ence

d O

pen

BHH

BHH

Card

iolo

gy

Dec1

4 De

lay

in D

iagn

osis

of B

reas

t Can

cer 2

014/

4130

8 Pa

tient

dia

gnos

ed w

ith m

etas

tatic

bre

ast c

ance

r in

Dece

mbe

r 14

afte

r hav

ing

an a

bnor

mal

ity n

oted

on

CT s

can

in 2

011,

w

hilst

und

er t

he c

are

of t

he c

ardi

olog

y te

am (

coin

cide

ntal

fin

ding

). A

reco

mm

enda

tion

was

mad

e w

ithin

the

CT

scan

re

port

to re

fer t

o Br

east

Ser

vice

, w

hich

doe

s not

app

ear t

o ha

ve b

een

actio

ned.

Ope

n

BHH

BHH

Gast

ro

Jan

15

Dela

yed

diag

nosis

201

5/14

30

Patie

nt re

ferr

ed to

gas

troe

nter

olog

y in

June

201

4, fo

llow

ing

resu

lts o

f an

abno

rmal

abd

omin

al u

ltras

ound

sca

n an

d CT

sc

an. T

he re

ferr

al w

as m

arke

d as

urg

ent.

The

patie

nt’s

firs

t out

patie

nt a

ppoi

ntm

ent w

as in

Sep

t 201

4, a

del

ay o

f app

rox

3 m

onth

s fr

om p

oint

of

refe

rral

to

first

out

patie

nt a

tten

danc

e. B

etw

een

Sept

embe

r an

d De

cem

ber

2014

the

pat

ient

un

derw

ent

furt

her

diag

nost

ic in

vest

igat

ions

and

was

giv

en a

dia

gnos

is of

mul

tifoc

al h

epat

oma

on a

bac

kgro

und

of

cirr

hosis

at

the

begi

nnin

g of

Jan

uary

201

4. T

he p

atie

nt h

as b

een

give

n a

limite

d pr

ogno

sis a

nd is

rec

eivi

ng p

allia

tive

care

.

Ope

n

BHH

BHH

Gast

ro

Jan

15

Dela

yed

Diag

nosis

201

5/14

35

In O

ctob

er 2

013,

an

urge

nt G

P re

ferr

al w

as s

ent

to t

he T

rust

reg

ardi

ng a

pat

ient

with

a 6

mon

th h

istor

y of

upp

er

abdo

min

al p

ain

and

wei

ght l

oss.

Ref

erra

l was

rece

ived

ear

ly N

ovem

ber 2

013,

and

mar

ked

“for

pan

crea

tic c

linic

soo

n”.

The

patie

nt h

ad a

com

plex

hist

ory

of im

pact

ed c

omm

on b

ile d

uct

ston

e w

hich

req

uire

d tr

eatm

ent

in 2

009

(mul

tiple

ER

CP’s

and

unsu

cces

sful

sur

gery

). Th

is ur

gent

ref

erra

l is

reco

rded

as

bein

g re

ceiv

ed o

n IC

ARE

in Ja

n 20

14. T

he P

atie

nt

was

firs

t see

n in

out

patie

nts

in A

pril

2014

and

sub

sequ

ently

und

erw

ent d

iagn

ostic

inve

stig

atio

ns a

nd M

DT d

iscus

sions

. In

June

201

4 th

e pa

tient

was

giv

en a

dia

gnos

is of

met

asta

tic c

olon

can

cer a

nd w

as re

ferr

ed to

onc

olog

y te

am fo

r fur

ther

m

anag

emen

t. Th

e pa

tient

die

d in

Oct

ober

201

4.

Ope

n

BHH

BHH

Gast

ro

Jan

15

Serv

ice

Failu

re 2

015/

1438

Du

ring

late

Dec

embe

r 201

4, a

n in

crea

se in

the

back

log

of p

atie

nts

wai

ting

for d

iagn

ostic

inve

stig

atio

ns w

as id

entif

ied,

th

is po

sitio

n w

as re

view

ed a

nd c

larif

ied

early

Janu

ary

2015

, with

an

addi

tiona

l 600

pat

ient

s co

nfirm

ed a

s no

t bei

ng o

n th

e ga

stro

ente

rolo

gy d

iagn

ostic

wai

ting

list,

som

e da

ting

back

to

Sept

embe

r 20

14. I

n Ju

ne 2

014,

a c

orpo

rate

risk

was

ra

ised

rela

ting

to a

bac

klog

in g

astr

oent

erol

ogy

for d

iagn

ostic

inve

stig

atio

ns a

nd a

pla

n w

as a

gree

d an

d pu

t int

o pl

ace

to m

anag

e th

e ba

cklo

g.

Ope

n

GHH

GHH

Mor

tuar

y

Feb

15

Wro

ng b

ody

rele

ase

2015

/604

7 Pa

tient

A d

ied

at G

HH a

nd w

as t

rans

ferr

ed t

o an

offs

ite m

ortu

ary.

Dec

ease

d pa

tient

B w

ith a

sim

ilar

nam

e w

as a

lso

tran

sfer

red

from

a d

iffer

ent t

o th

e sa

me

offs

ite m

ortu

ary.

Due

to

a de

cisio

n ch

ange

for

patie

nt A

to b

e cr

emat

ed n

ot

burie

d, it

was

nec

essa

ry fo

r pat

ient

A to

be

tran

sfer

red

back

to G

HH fo

r am

endm

ents

of r

equi

red

pape

rwor

k. In

err

or

patie

nt B

was

tran

sfer

red

to G

HH in

stea

d of

pat

ient

A. P

atie

nt B

was

then

rele

ased

for c

rem

atio

n in

stea

d of

pat

ient

A.

The

erro

r w

as n

oted

whe

n th

e pa

thol

ogy

labo

rato

ry r

outin

ely

rang

the

off

site

mor

tuar

y to

see

if

they

had

any

ou

tsta

ndin

g de

ceas

ed p

atie

nts

for G

HH. P

atie

nt A

was

ide

ntifi

ed a

s stil

l bei

ng a

t the

offs

ite m

ortu

ary.

Ope

n

NB

. Lin

ked

to “D

elay

in d

iagn

ostic

End

osco

py

test

s” R

isk



.122

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Sum

mar

y SU

I pro

file

April

201

5

8

OPE

N S

UI I

NVE

STIG

ATIO

NS

(as a

t 09/

04/1

5)

Site

/ D

ivis

ion*

Di

rect

orat

e Da

te

(N =

Nev

er E

vent

; P =

Pre

vent

ed N

ever

Eve

nt)

BHH

BHH

ED

Fe

b 15

Su

bopt

imal

care

of d

eter

iora

ting

patie

nt 2

015/

6003

Pa

tient

adm

itted

with

a h

istor

y of

che

st p

ain.

Whi

lst b

eing

cle

rked

the

patie

nt su

ffere

d a

card

iac

arre

st. T

he p

atie

nt w

as

succ

essf

ully

res

usci

tate

d bu

t fo

und

to h

ave

a po

tass

ium

of 9

.1m

mol

s. A

ppro

pria

te t

reat

men

t w

as g

iven

to

low

er t

he

pota

ssiu

m h

owev

er: t

he p

atie

nt s

uffe

red

a fu

rthe

r tw

o ca

rdia

c ar

rest

s an

d de

spite

pro

long

ed re

susc

itatio

n th

e pa

tient

di

ed. T

he p

atie

nt’s

pot

assiu

m a

t thi

s po

int w

as 8

.4m

mol

s. I

t wou

ld a

ppea

r tha

t for

a p

erio

d of

six

hour

s the

pat

ient

did

no

t hav

e a

repe

at p

otas

sium

che

ck o

r rec

eive

any

trea

tmen

t for

hyp

erka

laem

ia.

Ope

n

SOL

SOL

Acut

e M

ed/A

MU

M

ar 1

5 M

issed

dia

gnos

is of

pne

umot

hora

x 201

5/10

303

Patie

nt r

efer

red

at t

he w

eeke

nd v

ia G

P w

ith a

hist

ory

of b

reat

hles

snes

s, c

hest

pai

n, a

sthm

a an

d re

duce

d ai

r en

try

on

left

sid

e of

the

ches

t. Af

ter e

xam

inat

ion

and

inve

stig

atio

ns th

e cl

inic

ians

rev

iew

ed t

he p

atie

nts’

CXR

whi

ch i

dent

ified

th

e pr

esen

ce o

f a

poss

ible

lun

g m

ass

or a

bsce

ss.

Afte

r se

vera

l ho

urs

the

patie

nts

sym

ptom

s ha

d se

ttle

d an

d th

e ob

serv

atio

ns w

ere

with

in n

orm

al p

aram

eter

s. T

he p

atie

nt w

as d

ischa

rged

hom

e w

ith a

man

agem

ent p

lan

for a

n ur

gent

CT

, bro

ncho

scop

y, a

nd fo

llow

up

with

the

resp

irato

ry te

am to

exc

lude

lung

mas

s or

abs

cess

whi

ch w

ere

arra

nged

. The

CX

R w

as r

outin

ely

revi

ewed

3 d

ays

late

r by

a r

adio

logi

st w

ho id

entif

ied

a la

rge

pneu

mot

hora

x w

ith c

olla

psed

lung

. Th

ere

wer

e se

vera

l att

empt

s b

y cl

inic

ians

to c

onta

ct th

e pa

tient

, ho

wev

er it

was

foun

d th

at th

ey h

ad fl

own

abro

ad o

n ho

liday

. Onc

e co

ntac

t was

mad

e th

ey w

ere

advi

sed

to a

tten

d ho

spita

l The

pat

ient

was

trea

ted

succ

essf

ully

abr

oad

and

retu

rned

to th

e U

K th

ree

wee

ks la

ter.

Oth

er a

spec

ts o

f clin

ical

man

agem

ent u

nder

revi

ew.

NEW



.123

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

Su

mm

ary

SUI p

rofil

e : R

ecen

tly cl

osed

9

Rece

ntly

Clo

sed

SUI I

NVE

STIG

ATIO

NS

(as a

t 09/

04/1

5)

Site

/ D

ivis

ion*

Sp

ecia

lty

Date

(N

= N

ever

Eve

nt; P

= P

reve

nted

Nev

er E

vent

St

atus

SH

SH

Oph

thal

mol

ogy

Dec1

4 In

sert

ion

of in

corr

ect l

ens (

Nev

er E

vent

) 201

4/41

293

Patie

nt u

nder

wen

t ca

tara

ct s

urge

ry in

her

left

eye

in J

anua

ry 2

014

with

suc

cess

ful o

utco

me.

Pat

ient

the

n un

derw

ent

surg

ery

on ri

ght e

ye in

July

201

4. B

oth

of th

e le

nses

cho

sen

for h

er su

rger

ies w

ere

base

d up

on b

iom

etry

she

unde

rwen

t in

Nov

embe

r 201

3. In

Dec

embe

r 201

4, it

was

iden

tifie

d th

an a

n in

corr

ect l

ens

had

been

inse

rted

into

her

righ

t eye

and

as

a re

sult

she

had

poor

refr

acto

ry o

utco

mes

and

requ

ired

furt

her s

urge

ry.

Initi

al in

vest

igat

ion

has

iden

tifie

d th

at th

e w

rong

bi

omet

ry w

as in

the

patie

nt’s

elec

tron

ic m

ed iS

OFT

reco

rd th

at w

as u

sed

to se

lect

the

lens

requ

ired.

Clos

ed

Oph

thal

mol

ogy

shou

ld d

evel

op a

stan

dard

ope

ratin

g pr

oced

ure

for t

he ti

mel

y es

cala

tion

of p

atie

nts

in th

e ev

ent o

f poo

r sur

gica

l out

com

es

Oph

thal

mol

ogy

shou

ld c

onsid

er p

urch

asin

g so

ftw

are

whi

ch a

llow

s the

stor

age

of th

e IO

L Mas

ter b

iom

etry

dat

a an

d pr

into

ut w

ithin

the

Med

iSO

FT sy

stem

, so

all b

iom

etry

is a

vaila

ble

elec

tron

ical

ly.

Lead

bio

met

rist s

houl

d ex

plor

e w

ith M

ed iS

OFT

if th

ey a

re a

ble

to fa

cilit

ate

a lo

ck d

own

of d

ata

with

in th

e sy

stem

with

any

furt

her i

nfor

mat

ion

bein

g ad

ded

as a

n ad

dend

um.

Oph

thal

mol

ogy

shou

ld re

view

the

com

pete

ncie

s of

all

clin

ical

nur

se sp

ecia

lists

and

offe

r fur

ther

trai

ning

rega

rdin

g re

frac

tive

outc

omes

and

lens

cho

ice

if re

quire

d.

Oph

thal

mol

ogy

shou

ld m

anda

te th

at a

ll th

e su

rgeo

ns a

nd sc

rub

nurs

es a

re a

war

e of

the

prev

ious

lens

cho

ice

whe

n th

ey a

re o

pera

ting

on a

seco

nd e

ye.

BHH

BHH

ED/A

MU

Fe

b 15

De

terio

ratin

g pa

tient

201

4/36

858

A pa

tient

was

disc

harg

ed h

ome

follo

win

g a

faile

d en

dosc

opy

proc

edur

e. T

he p

atie

nt p

rese

nted

in

ED 2

hou

rs p

ost

proc

edur

e w

ith d

iffic

ulty

in b

reat

hing

and

mar

ked

surg

ical

em

phys

ema

. A C

T sc

an c

onfir

med

a p

erfo

rate

d oe

soph

agus

an

d th

e pa

tient

was

tran

sfer

red

to A

MU

. The

follo

win

g m

orni

ng th

e pa

tient

suf

fere

d a

card

iore

spira

tory

arr

est a

nd d

ied.

Co

ncer

ns h

ave

been

raise

d re

gard

ing

the

man

agem

ent o

f the

pat

ient

’s c

are.

Clos

ed

Ther

e sh

ould

be

agre

emen

t am

ongs

t EN

T, th

orac

ic, U

pper

GI s

urge

ons a

nd G

astr

oent

erol

ogy

for “

Susp

ecte

d Pe

rfor

ated

Oes

opha

geal

Pat

hway

” in

term

s of c

lear

ow

ners

hip,

man

agem

ent

supp

orte

d by

the

Trus

t to

agre

e a

solu

tion,

esp

ecia

lly o

ut o

f hou

rs. T

o be

put

on

the

trus

t Upp

er G

I sur

gica

l risk

regi

ster

.

Ther

e sh

ould

be

care

ful c

onsid

erat

ion

of H

DU a

dmiss

ion

for a

ll pa

tient

s w

ith su

rgic

al e

mph

ysem

a se

cond

ary

to o

esop

hage

al p

erfo

ratio

n, d

iscus

sed

with

and

revi

ewed

in p

erso

n by

the

criti

cal c

are

team

.

All p

atie

nts w

ith a

susp

ecte

d pe

rfor

atio

n on

adm

issio

n in

wor

king

hou

rs sh

ould

be

revi

ewed

by

an a

ppro

pria

te sp

ecia

lity

regi

stra

r in

pers

on, m

ust b

e di

scus

sed

with

thei

r con

sulta

nt o

n ca

ll. E

NT

shou

ld b

e in

volv

ed fo

r cer

vica

l lev

el o

esop

hage

al p

erfo

ratio

n an

d U

pper

GI s

urge

ons

or th

orac

ic fo

r bel

ow c

ervi

cal l

evel

per

fora

tions

. St

aff s

houl

d be

rem

inde

d no

t to

rely

sole

ly o

n M

EWS

as th

e in

dica

tor o

f sev

erity

of i

llnes

s. If

an

over

all a

sses

smen

t of c

once

rn is

pre

sent

it sh

ould

be

esca

late

d to

med

ics a

s app

ropr

iate

. St

aff s

houl

d be

rem

inde

d of

the

crite

ria to

invo

ke th

e Se

psis

6 Pa

thw

ay a

nd th

e im

plem

enta

tion

of th

e bu

ndle

.



.124

Agenda

WelcomeDeclaration

ofInterest


Chairman'sReport

Chief Executive's

Report


Any Other

Business

Attendance Record


Plan

DementiaStrategy

Presentation

Governanceand


ties

SUI:

Aug

ust 2

013

GHH

Care

of E

lder

ly

Opi

ate

over

dose

in o

piod

nai

ve p

atie

nt –

Pr

even

ted

Nev

er E

vent

Th

emes

: Com

mun

icat

ion/

non

adhe

renc

e to

po

licy

SUI:

Sep

tem

ber 2

013

SHH

T&O

The

atre

s Re

tain

ed ri

bbon

gau

ze fo

llow

ing

THR

– N

ever

Eve

nt

Them

es:

Com

mun

icat

ion/

non

adh

eren

ce

to p

olic

y/po

or a

war

enes

s of d

uty

of

cand

our

Com

mun

icat

ion

Doc

umen

tatio

n

M

edic

atio

n

Saf

er

Surg

ery

Det

erio

ratin

g Pa

tient

Com

mun

icat

ion

•Vita

l and

iski

lls re

sour

ces

•Nur

sing

safe

ty m

anua

ls •S

afet

y w

alka

roun

ds a

nd re

spon

sive

safe

ty re

view

pro

cess

es

•Risk

y bu

sines

s fo

rum

for j

unio

r do

ctor

s

Docu

men

tatio

n •S

urgi

cal s

afet

y ch

eckl

ist /

audi

t •N

ursin

g M

etric

s •A

nnua

l Tru

st-w

ide

docu

men

tatio

n au

dit

•Saf

ety

ther

mom

eter

•N

G tu

be p

olic

y an

d gu

idel

ine

S

UI T

hem

es (R

oot c

ause

s and

con

trib

utor

y fa

ctor

s) a

nd S

ched

ule

5 le

tter

s rec

eive

d by

HEF

T Co

mm

on th

emes

from

SU

Is a

nd a

ssoc

iate

d w

ork-

stre

ams

Dete

riora

ting

Patie

nt

Re-e

stab

lishe

d De

terio

ratin

g Pa

tient

Rec

ogni

tion

Grou

p Vi

tal a

nd iS

kills

reso

urce

s M

ews a

udit

Nur

sing

met

rics

Less

ons o

f the

mon

th

SUI a

t a g

lanc

e re

port

Ac

tion

card

s bei

ng p

rodu

ced

for i

ssue

to su

rgic

al re

gist

rars

man

datin

g th

e ci

rcum

stan

ces w

here

they

mus

t con

tact

thei

r con

sulta

nt

SUI:

Sept

embe

r 201

3 G

astr

oent

erol

ogy

BHH

Inju

ry d

urin

g liv

er b

iops

y Th

emes

: Com

mun

icat

ion

SUI:

July

201

3 SH

H ED

U

nexp

ecte

d In

fant

Dea

th

Them

e: D

ocum

enta

tion/

Com

mun

icat

ion

SU

I: A

ugus

t 201

3 GH

H U

rolo

gy/E

D De

lay

in ti

mel

y in

terv

entio

n an

d es

cala

tion

of th

e de

terio

ratin

g pa

tient

Th

emes

: Com

mun

icat

ion/

Non

esc

alat

ion

of

clin

ical

con

cern

s.

Med

icat

ion

•Saf

e M

edic

atio

n Pr

actic

e Gr

oup

•Med

icat

ion

Mat

ters

new

slett

ers

•Impr

ovem

ent t

o EP

syst

em

•New

Med

icin

es G

roup

for r

evie

win

g al

l sev

ere

harm

inci

dent

s fr

om

med

icat

ion

inci

dent

s •N

ew R

CA fo

r all

seve

re h

arm

m

edic

atio

n in

cide

nts

•Pat

ient

Saf

ety

Team

dev

elop

ed to

ol

for l

ive

info

rmat

ion

rela

ting

to m

issed

do

se a

nti-b

iotic

s.

SUI:

July

201

3 SH

H O

phth

alm

olog

y W

rong

lens

inse

rtio

n– N

ever

Eve

nt

Them

es: T

heat

re c

heck

ing

proc

edur

es/c

omm

unic

atio

n

SUI:

Oct

ober

201

3 Va

scul

ar S

urge

ry B

HH

Une

xpec

ted

deat

h fo

llow

ing

surg

ery

Them

es: N

on a

dher

ence

to V

TE p

olic

y/

com

mun

icat

ion/

docu

men

tatio

n SU

I: O

ctob

er 2

013

Gene

ral S

urge

ry B

HH

Wro

ng S

ite S

urge

ry –

Nev

er E

vent

Th

emes

: Doc

umen

tatio

n/co

mm

unic

atio

n

Safe

r Sur

gery

•S

harin

g th

e le

arni

ng fr

om th

eatr

e re

late

d N

ever

Eve

nts

•Kno

win

g th

e ris

k. P

erio

pera

tive

risk

asse

ssm

ent /

com

mun

icat

ion

tool

•S

afet

y w

alk

abou

t in

all t

heat

res a

cros

s sit

es

SUI:

Sept

embe

r 201

3 Ga

stro

ente

rolo

gy

Surg

ery

BHH

Dela

y in

esc

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re M

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gs



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SUI:

May

201

4 –

ITU

BHH

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ssat

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of in

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pic

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. Th

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atie

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ilote

d in

AM

U B

HH



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Sche

dule

5 S

ectio

n 7

(form

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e 43

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oron

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conc

erns

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ques

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edul

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r 16th

Mar

ch 2

015

asso

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n in

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inve

stig

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th

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e Tr

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s “de

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look

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d in

ques

t upd

ate



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13

CQC

IMR

Dec

embe

r



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Integrated Improvement Plan

Integrated Improvement plan


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Integrated Improvement plan

Title: HEFT Integrated Improvement Plan (IIP)

Attachments: 1

From: Dr Andrew Catto, Deputy CEO & Executive Medical Director

To: Board of Directors and Council of Governors

The Report is being provided for: Decision Y/N Discussion Y/N Assurance Y/N Endorsement Y/N The BoD is being asked to:

Review the IIP and consider if the IIP reaches the standard of an effective recovery plan given the current operational and regulatory context of the Trust.

Key points/Summary: The IIP:

Describes the HEFT programme management methodology Describes the next 30 / 60 / 90 days and the action HEFT will take Provides a framework around the assurance process HEFT will use Describes the programme structure and the governance arrangements in

the six constituent IIP programmes Recognises certain risks and constraints to delivery Describes a range of programme metrics to inform progress against the

HEFT improvement journey Recommendation(s): That the IIP is implemented in full and that the Executive Management Board manages and monitors the implementation of the IIP using the IIP Programme Board. The BoD and External Stakeholder Engagement Group will be updated on progress with the IIP. Assurance Implications: Strategic Risk Register Y/N Performance KPIs year to date Y/N

Resource/Assurance Implications (e.g. Financial/HR) Y/N Information Exempt from

Disclosure Y/N

Which other Committees has this paper been to? (e.g. F&PC, QRC, etc.)

Executive Management Board and Board of Directors Forum in draft format.

Stakeholder Engagement Group 20th May 2015


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HEART OF ENGLAND NHS FOUNDATION TRUST

INTEGRATED IMPROVEMENT PLAN

RECOVERY PLAN


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D o c u m e n t C o n t r o lChange history

V e r s i o n R e a s o n / S u m m a r y o f C h a n g e s

D a t e A u t h o r

V0.6 6th Draft - comments from Execs and Board +Executive summary &

revised Comms plan

18/5/15 Stuart A Brown

Document approvals - this document requires the following approvals

N a m e T i t l e V e r s i o n a n d D a t e

Andrew Foster Interim Chief Executive May 2015 - V0.6Andrew Catto Deputy Chief Executive and

Medical Director & SROMay 2015 - V0.6

Darren Cattell Interim Director of Finance May 2015 - V0.6Sam Foster Chief Nurse May 2015 - V0.6

Jonathan Brotherton Director of Operations May 2015 - V0.6Hazel Gunter Director of Workforce May 2015 - V0.6

Monitor Regional representative May 2015 - V0.6

Distribution

N a m e T i t l e D a t e o f i s s u e

V e r s i o n

This document will remain in DRAFT Format until formal agreement and acceptance by Monitor and the Trust Board as the definitive description of the IIP, it’s constituent programmes and the methodology and approach that will be used to deliver the IIP

Safe Effective Caring Responsive Well led

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TABLE OF CONTENTS1. ...........................................................Executive Summary 62. ....................................................................Introduction 132.1. .................................................................Purpose of this Document 13

2.2. ..........................................................................................Context 14

2.3. ....................................................................................Background 21

2.4. ...........................Sponsorship of the Integrated Improvement Portfolio 23

2.5. ..............................................................Key Priorities and Timelines 23

2.6. ......................................The 30 day challenge - Getting back on Track 24

3. ......................................................Vision and Objectives 263.1. ............................................................................................Vision 26

3.2. ......................................................................................Objectives 26

4. .....................................Programme Management & PMO 284.1. .........................................................................Structure of the IIP 28

4.2. .......................................................................................Approach 30

4.3. ...................................................................................Methodology 30

4.4. ......................................................................................PMO Tools 31

4.5. ............................................................Managing Interdependencies 33

4.6. .................................................Benefits management and realisation 34

4.7. ................................................................What does good look like? 34

5. ............................................................................Metrics 366. .........................................................Programme Profiles 396.1. .....................................................Governance Recovery Programme 39

6.2. ...................................................................Urgent Care Programme 41

6.3. ............................................................................IM&T Programme 43

6.4. .................................................................Cultures and Engagement 44

6.5. ...............................................................................Scheduled Care 47


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6.6. ........................................................................................Mortality 49

7. .........................................................Programme Costing 537.1. .........................................................Programme Management Costs 53

8. ...................................................................Stakeholders 568.1. .......................................................................Stakeholders Profiles 56

8.2. .................................................Stakeholder mapping & Management 56

9. ....................................................Scheduling/Milestones 599.1. ..........................................................................Thirty Days (o+30) 59

9.2. ...........................................................................Sixty Days (0+60) 60

9.3. ....................................................................................Ninety Days 60

10. ..............................................................................Risks 6310.1. .................................................Managing Risks Within The Portfolio 63

10.2. ..................................................................Links To Strategic Risks 64

11. ....................................................................Constraints 6611.1. ......................................................................Types Of Constraints 66

11.2. ............................................................................Potential Impact 66

12. ............................................................Communications 6812.1. ..........................................................Tactical Approach For The IIP 68

12.2. ....................................................................................Objectives 68

12.3. ...................................................Supporting the IIP implementation 68

12.4. ...................................................................Clinical communication 69

12.5. ..................................................................................Governance 69

12.6. .................................................................Culture and Engagement 69

12.7. .....................................................................................Resources 70

12.8. .............................................................................Implementation 71

13. ..........................................................Gateway Reviews 7313.1. ......................................................................Schedule Of Reviews 74

13.2. ....................................................................Description Of Review 75

13.3. ......................................Governance And Resources For The Reviews 75

14. ....................................................................Appendices 7714.1. ..................................................Appendix I -CCG “Unit of Planning” 77

14.2. .............................................Appendix II - PMO SAMPLE TEMPLATES 78




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14.3. .......................Appendix III - Sample of an Outcome relationship map 82

14.4. ....................................................Appendix IV - Main IIP Dashboard 83

14.5. ..................................................Appendix V - Monitor Undertakings 84

14.6. .........................Appendix VI - Interim Governance On Boarding Form 86




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1.EXECUTIVE SUMMARY

Heart of England NHS Foundation Trust (HEFT) is a multi site acute and community services provider with locations at Heartlands Hospital, Good Hope Hospital and Solihull Hospital, employing approximately 11000 staff across the three sites.During the twelve months preceding the publication of this document HEFT have been the subject to a number of reviews, the subsequent reports have not cast HEFT in a positive light in a number of areas which includes both clinical and managerial disciplinesThis has had direct and indirect consequences for HEFT, including major leadership changes with the highly publicised resignation in November 2014 of Dr Mark Newbold as the Chief Executive Officer. This followed the relatively recent change in the Chair, Mr. Les Lawrence was appointed as the new Chairman succeeding Lord Hunt. in July 2014. Further changes in the executive leadership team followed which understandably created a certain amount of instability and concern amongst those remaining in the leadership team and HEFT staff alike.Running in parallel to some of these events was the enforcement action that Monitor accepted under section 106 of the Health and Social Care Act ("the Act") and was compelled to impose upon HEFT on 20 December 2013 in relation to the Licensee's governance arrangements for urgent care. Amendments were accepted to those undertakings on 21 October 2014, following breaches of additional access and outcome performance indicators. As a consequence of these collective actions Monitor appointed an Improvement Director to work with HEFT to support a number of improvement initiatives. Following the resignation of Dr Mark Newbold the Medical Director, Dr Andrew Catto was appointed as the Interim Chief Executive Officer to immediately fill the void and bring some stability to the Trust. Dr Catto set about constructing a number of plans and initiatives designed to improve clinical services, safeguard the reputation of HEFT, Improve the leadership team and fill the gaps left by departing Executives - appointing an Interim Director of Finance and Director of Information Management &Technology (IM&T). Dr Catto led the development of an integrated leadership support and resilience programme (LSRP) between December 2014 and February 2015. The key programmes in the LSRP, which was presented to Monitor, key stakeholders and national clinical leaders, comprised the 7 work streams of governance, mortality / congestion, culture / engagement, safe staffing, IM&T /PMS2, performance and executive leadership, which have latterly become known as the Integrated Improvement Plan (the IIP). Further refinement has seen the IIP change, evolve and expand to include a number of Trust wide improvement programmes such as Urgent Care and Scheduled care whilst other smaller programmes have merged with others to form larger programmes. The IIP now consists of six primary change programmes see Fig 1 below:




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Scheduled Care Governance Urgent Care IM&T Mortality Cultures & Engagement


Figure 1 - Integrated Improvement Plan

However whilst there was a common intention to run these programmes as an Integrated programme the reality was that the programme management arrangements needed to support this approach were not in place at the time of conception, not even in an embryonic form.HEFT established a Programme Management Office (PMO) in January 2015 and engaged a small number of Interim resources to support the delivery of the IIP. Following the appointment of Mr Andrew Foster on the 16th of February the LSRP evolved into the Pyramid of Priorities, developed by Mr Andrew Foster which is based on a six phases of the delivery model as described in Fig 21 below:

4"

Recovery

1. Clarity (Governance & Strategy)

2. Quality Improvement 3. Staff Engagement

Internal Communications Board Development

Management Capacity Stakeholder Relationship

Safe Staffing ICT Investment

Estates Investment Mortality Reduction

Deloitte Governance Plan Monitor Enforcement Undertakings

• A&E • RTT

• Scheduled Care • Cancer

CQC Recommendations Kennedy Report Silverman Report

The$Pyramid$of$Priori.es$$Feb to April 2015.Creation of The Plan - conceptually based on the original January 2015 Leadership and Resilience Plan. Limited PMO capacity initially arising from simultaneous focus on establishing the Programme Office and running several other improvement programmes synchronously.

Clear Executive Leadership. Deputy CEO manages and assure the Plan. Interim DoF manages the timeliness and quality of submission. Supported by very experienced Programme Manager, Stuart Brown. Focused one week piece of work commissioned from Deloitte to align the dashboard metrics with the IIP.

1 2 3

4 5 6

Creating the Narrative – From the Deloitte Governance Report to the Resilience Plan to the Pyramid of Priorities to the IIP and Dashboard.

IIP is perceived as centre stage in the organisation - with buy-in from the Board, CoG and external stakeholders.

Introducing a Layered Approach to presentation and implementation so that the IIP can be seen in a national context, at full Trust level, at site, at service and down to the individual member of staff.

The IIP and our suite of strategies merge and become the entire plan enabling us to shift from back foot to front foot in September 2015.

Figure 2- Pyramid of Priorities and the Six Phase plan

As the last quarter of 2014/15 passed and the year end approached the Executive Management Board (EMB) and subsequently Monitor started to voice concern about the lack of clarity and intent surrounding the IIP. concerns were also raised about the quality and format of the reporting. There was confusion about the metrics and how meaningful they were/are not and the ambiguity that some of the reporting formats seemed to indicate. In March 2015 the Interim Director of Finance (DoF) and the Chief Nurse moved to engage additional interim support to deliver a Governance recovery programme based on the findings and recommendations of the Deloitte report commissioned by Monitor, who decided to share the report with the EMB to help them understand the breadth and depth of the challenges facing HEFT.



1 This is explained in more detail in Item 2.2 of the main body of the document


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In April 2015, a new stakeholder group was established comprising the HEFT executive team, NHS England, Lead Clinical Commissioning Groups (CCG’s), Monitor and the Care Quality Commission (CQC). This innovative approach, supported by the Monitor Director of Improvement replaced the Quality Steering Group (QSG)The implementation of the Governance recovery programme and subsequent analysis by the Interim DoF and Chief Nurse, coupled with the outputs of the first stakeholder meeting in April, heightened awareness within the EMB that the IIP PMO was not functioning as efficiently as desired or at the level required. Immediate action was taken with the appointment of Dr Andrew Catto as the Senior Responsible Owner (SRO) for the whole of the IIP and the transfer from the Governance recovery programme of one of the interim resources to lead the IIP as Programme Director. To lead the reform and restructure of the PMO this task also included the development and publication of this IIP recovery document.The plans and processes described in this document are built around a tried and tested methodology with an identified recovery timeline based on a 30/60/90 day phasing which aligns perfectly with Mr Andrew Foster’s six delivery phrases.Note : One of the biggest challenges facing HEFT is the current structure of the divisions and the directorate structures which are diverse in both their management and governance processes; as well as their cultures which present a number of issues in their own right. This recovery plan does not seek to address the divisional structure as part of the IIP at this point in time. It is felt that evolution rather than revolution is all that we can really hope to achieve within the life cycle of the IIP. In the third week of April a decision was made to restructure the PMO see Fig 3 below, with administration and governance moving under the Interim DoF and Strategic direction and delivery moving to Dr Andrew Catto. Since this decision was made there have been a number of movements within the PMO itself with additional specialist resources being added to bolster the skills and expertise needed to ensure and assure delivery.

Head of PMO

Director of Finance and PerformanceDarren Cattell

Programme Director IIP

Project Manager - Support to Culture & Engagement

Programme Manager - Support to Governance

Project Manager - Mortality/Congestion

Seconded team from Deloitte

Project Manager - Support to Urgent Care

Band 2 Administrator - Vacant

Project Manager - Support to Planned Care

Project Manager IM&T

Figure 3 - PMO structure




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Essentially each programme within the IIP will have a dedicated programme/project manager to provide support around change management techniques and processes and to provide support and rigour around the reporting requirements. The majority of these positions have been filled with existing personnel but we have also recruited a small number of additional subject matter experts to provide the necessary PMO management and leadership that is required. An additional Programme manager has been engaged to support the Governance programme and provide additional support to the PMO. A new Head of PMO will join the Trust on Thursday 21st of May. The following table provides detail on the current and near future manning arrangements available to the PMO:

Name Title Area of responsibility

Stuart A Brown IIP Programme Director IIP Programme

James Weller - joins 21/5 Head of PMO IIP PMO

Phill Wilson Project manager IIP Programme & Governance programme

Paul Arford Programme manager Urgent Care Programme

Lara Williams - joining date tbc

Project manager Mortality and Congestion

Vacant Project manager IM&T

Danielle Goddard Project manager Culture and Engagement


Change

Nick Varney Head of PMO and IIP

IIP Programmes Moves to Surgical reconfiguration

Keith Hawley Project manager Governance programme support and ad-hoc support as directed by Head

of PMO

Will leave the Trust on 11th of June or sooner if mutually

agreeable

Work commenced on the development of the narrative that describes the IIP and the delivery methodology on the 24th of April, in the form of a document Mind Map setting out the structure and content of the document. This was approved by the Deputy CEO and Interim DoF on the same day. The first draft of the narrative document was received at EMB the following week and then presented for discussion at the Trust Board on the 5th of May.




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The recovery plan is based on a 30/60/90 day plan, the following graphic Figure 4 describes the current status against that plan:

Improving

30

60

90

10

20

40

50 70

80

100

110 Cruis

ing

Pace

atta

ined

WARNING

Figure 4 - Recovery plan status

The 30/60/90 phases are described in full detail in the main body of the document in section 9.The programme gateway process has already begun with the support of Deloitte undertaking a programme delivery status assessment during the week commencing 11th of May 2015. The outcome of the assessment was in line with the internal assessments made by the SRO’s for the individual programmes.HEFT faces a significant se of challenges which it must overcome if we are to deliver the IIP on-time and within an agreed financial window. However there are a number of factors that bode well for the Trust in it’s quest to deliver the IIP:

• The Executive Leadership Team are totally committed to the delivery of the IIP and the determination to embed quality at every level of the organisation and make it a natural part of the “day job”;

• Engaging our staff,patients, commissioners and the wider health economy is at the center of our delivery strategy;

• We have a willing staff body who want to see change that genuinely improves patient care and staff wellbeing and want to play their part in delivering it;

• We have tangible hands on support from our regulator - they have provided access to best practice examples of “the way to do it” they have worked with us to engage constructively and beneficially with Deloitte’s and they have provided us with an Improvement Director who makes a positive contribution to our endeavors ;




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• We believe that the recent changes we have made to the structure and operating model of the PMO will now give us the drive and rigor that we need to deliver the IIP;

In conclusion, this is our plan and this is the journey we are committed to, we know we have a long way to go but we know we will achieve the desired outcomes and we know that patient care will be significantly improved as a result of HEFT completing this journey.

Andrew Foster - Interim CEO! ! Dr Andrew Catto - Deputy CEO

.............................................. ...................................................





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At the Heart of it……


Plan

SECTION 2 - INTRODUCTION





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2.INTRODUCTION

HEFT has been striving to drive a number of improvement programmes across the Trust in the areas of: Unscheduled care, Planned care , Governance - including performance, Mortality, Culture and engagement and IM&T. The set of programmes is the Integrated Improvement Plan (IIP).Having established a Programme Management Office (PMO) in January 2015 the Trust has made progress but it has lacked pace . Monitor, the Trust CEO and Executive Management Board (EMB) have expressed concerns about the format and quality of IIP reporting. Following a recent performance review with Monitor the Trust was asked to provide a comprehensive plan to get the IIP back on track as quickly as possible. The finalised plan will be presented to Monitor prior to May 20th 2015.

2.1.PURPOSE OF THIS DOCUMENT

This document details the narrative, proposed IIP plans, governance arrangements and programme and high level project interdependencies for the recovery of the portfolio of programmes comprising HEFT’s Integrated Improvement Programme – the IIP. (see Figure 5 below). The IIP articulates six specific programmes of work that are required to ensure the programme(s) are on track and maintaining traction and pace at a time of significant pressure for HEFT. The ultimate aim of the IIP is to deliver sustained change, by an engaged workforce, committed to improving high quality embedded care delivery.

Scheduled Care Governance Urgent Care IM&T Mortality Cultures & Engagement

Integrated Improvement Portfolio

TRUST Board

The IIP Programme Boardis ultimately Accountable (via the Executive Management Board to Trust Board

Fig 5 - The Integrated Improvement Programme(IIP)

The purpose of this document is to provide the Board of Directors, Regulators and stakeholders with the assurance on delivery. Assurance by clearly articulating the detail of the HEFT improvement plans, improvement metrics and the timeline for delivery.





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This document:

• describes the corporate Programme and Project Management (PPM) function, its role, responsibilities and relationships. PPM will be used extensively to support operational and corporate teams with delivery and also serve as robust assurance function. It is important to acknowledge that operational teams are responsible for the delivery of the IIP, not the PMO;

• lays firm foundations for multi programme delivery, communication, assurance and future reviews; and

• provides the basis for developing more detailed plans, and for considering how other initiatives relate to corporate PPM, so that current and future activities across HEFT can be aligned to maximum effect to support the delivery of HEFT’s strategic objectives. Ultimately this plan will be aligned to the Trust’s suite of strategies in September 2015.

2.2.CONTEXT2.2.1.Heart of England NHS Foundation Trust (HEFT)

Heart of England NHS Foundation Trust (HEFT) regulatory and quality chronologyIn July 2013 the Care Quality Commission announced that HEFT would be one of the 18 first wave Trusts to be inspected by a more robust new style inspection. At that time, HEFT was considered neither low nor high risk but a ‘variety of risk points’[Ref: http://www.cqc.org.uk/content/cqc%E2%80%99s-new-hospital-inspection-programme-start-tomorrow]. However, HEFT had been subject to registration conditions by the CQC when in April 2010 the regulator registered HEFT on condition it made improvements to three essential standards of care when it introduced a new registration system for all health and adult social care services. Two conditions were removed in October 2010 and the final condition in February 2011. HEFT underwent a further unannounced 3 day inspection in December 2014, the findings from which have now been received from the CQC and published on the CQC website2.The current overall status of HEFT as assessed by the CQC is: Requires improvement. [ref: http://www.cqc.org.uk/provider/RR1]In December 2013 HEFT was one of thirteen hospital trusts named by Dr Foster Intelligence (DFI) as having higher than expected higher mortality indicator scores for the period April 2012 to March 2013 in their Hospital Guide 2013.[4] although based on the Health and Social Care Information Centre (HSCIC)[ref http://www.hscic.gov.uk/] HEFT mortality was at the upper limit of expected. The principle reason for the difference being the statistical methodology adopted by DFI and HSCIC.In June 2014 Mr. Les Lawrence was appointed as the new Chairman succeeding Lord Hunt. In July 2014, NHSE in discussion with key Trust stakeholders, held a risk summit that focussed on key quality risks and performance concerns. The resulting action plan



2 The resultant action plans do not form part of this narrative at this point in time but will do in future iterations



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was monitored by the unusual step of HEFT attending meetings of the NHSE quality summit. HEFT was represented by the Chief Nurse and Executive Medical Director, ensuring that a strong focus on quality was maintained.Dr Mark Newbold resigned as Chief Executive in November 2014 after HEFT had a condition placed on its license by Monitor on 21 October 2014 relating to performance , governance and mortality. Dr Andrew Catto was appointed interim Chief Executive until 16th February 2015 when he was succeeded by Mr Andrew Foster as Interim Chief Executive. Following Dr Newbold's resignation, a number of changes were made at Executive Director level with the appointment of external interim Directors of Finance and IM&T. The Director of Patient Experience and External Affairs left HEFT in March 2015. The then interim CEO Dr Catto, with the support of the Board of Directors, developed an integrated leadership support and resilience programme (LSRP) between December 2014 and February 2015. The key programmes in the LSRP, which was presented to Monitor, key stakeholders and national clinical leaders, comprised the 7 work streams of governance, mortality / congestion, culture / engagement, safe staffing, IM&T /PMS2, performance and executive leadership.The LSRP evolved into the current pyramid of priorities (see Fig 6 below) developed by Mr Andrew Foster.

4"

Recovery

1. Clarity (Governance & Strategy)

2. Quality Improvement 3. Staff Engagement

Internal Communications Board Development

Management Capacity Stakeholder Relationship

Safe Staffing ICT Investment

Estates Investment Mortality Reduction

Deloitte Governance Plan Monitor Enforcement Undertakings

• A&E • RTT

• Scheduled Care • Cancer

CQC Recommendations Kennedy Report Silverman Report

The$Pyramid$of$Priori.es$$





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Fig 6

The CEO Andrew Foster and executive team are focussed on 3 high level deliverables see Figure 7 below:

CLARITYCULTURE

&ENGAGEMENT

QUALITY

Fig 7 - High level deliverables

In April 2015, a new stakeholder group was established comprising the HEFT executive team, NHS England, Lead CCGs, Monitor and the CQC. This innovative approach, supported by the Monitor Director of Improvement replaced the QSG. 2.2.2.The IIP in the context of the National Picture

The healthcare system is facing very significant care delivery changes and enduring financial pressures. With an ageing population, people are living longer with more complex health needs and often multi-morbidity, therefore the need for services will continue to grow faster than funding, meaning that the NHS and social care must innovate and transform service delivery, within the resources available, ensuring that patients, and their needs, are always put first. The planning guidance establishes key criteria:• Strategic plans covering a five year period, with first two years at operating plan level• An outcomes focused approach, with stretching local ambitions expected of

commissioners, alongside credible and costed plans to deliver them• Citizen inclusion and empowerment to focus on what patients want and need• More integration between providers and commissioners• More integration with social care – cooperation with Local Authorities on Better Care

Fund planning • Plans must be explicit in dealing with the financial gap and risk and mitigation

strategies. - No change not an option

It should also be noted that Acute Service providers have been under significant operational pressures for sustained periods of time, in some case providers have not seen the expected seasonal drops in emergency activity since the Winter of 20113/14. This has resulted in adverse publicity for some Trusts and for the wider NHS as a whole.Also at the time of writing and publication of this document the General Election is fast approaching so focus and publicity around the NHS is at a heightened level.





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2.2.3.NHS Outcomes Framework

Clinical outcomes are of key importance to patients and the Department of Health published a refreshed iteration of its NHS outcomes framework for 2015/16 [ref https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385749/NHS_Outcomes_Framework.pdf]. The Outcomes Framework comprises 5 domains: • Preventing people from dying prematurely• Enhancing quality of life for people with long-term 2 conditions• Helping people to recover from episodes of ill health or following injury• Ensuring that people have a positive experience of care• Treating and caring for people in a safe environment and 5 protecting them from

avoidable harmThese 5 outcomes are aligned to the development of the HEFT clinical strategy. 2.2.4.The IIP in the context of the Local Health Economy

HEFT serves a diverse range of communities in Birmingham East and North, Solihull, Sutton Coldfield and South Staffordshire; with up to 1.2 million people visiting HEFT every year and a base commissioning population of over 1 million people. A number of these populations have significantly challenging health needs. All CCG’s are supported by and provided with extensive access to a number of tools to inform their planning and commissioning intentions - PHE CCG Outcomes benchmarking support packs http://www.england.nhs.uk/la-ccg-data/#ccg-info]. HEFT predominantly serves three Clinical Commissioning Groups (CCG’s) : Birmingham Cross City , Sandwell and West Birmingham CCG and Solihull CCG , with a combined population catchment area of circa 1 400 000. However all in all there are 10 commissioning bodies that purchase services from HEFT at the following levels:

• NHS Birmingham Cross City CCG £231.5M• NHS Birmingham South And Central CCG £14.7M• NHS Sandwell And West Birmingham CCG £8.0M• NHS Solihull CCG £134.6M• NHS South East Staffs And Seisdon Peninsular CCG £33.5M• NHS Walsall CCG £6.2M• NHS Warwickshire North CCG £6.3M• Birmingham and the Black Country Area Team £112.6M• Health Education England £23M• Birmingham City Council £7.0M





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Five year key priorities for each the lead CCGs are as follows:

Key Priorities Solihull CCG

Birmingham Cross City

CCG

Sandwell and West

Birmingham CCG

Preventing illness, Improving Health Programme X

High quality primary care X X X

Better community provision X X X

Whole system approach - i.e. Your Care Connected (Joint commissioning) X X X

Commissioning elective care based on achieving better outcomes from interventions

X X

Urgent Care X X

Hospital transformation/Outpatient transformation X X

Mental Health - high quality and responsive X X

Children's and maternity services X

Preventing readmissions X

Long term conditions X

Intermediate care X

Stroke services X

Pathway management X

Effectiveness review X

HEFT has developed an excellent working relationship with commissioners and local authority partners in the delivery of the Better Care Funds (BCF) in Birmingham and Solihull with senior executive representation on BCF Boards. Regular dialogue between HEFT and Solihull / Birmingham Cross City CCGs established as an action of the quality summit ensures close dialogue between the very senior leaders.





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2.2.5.The IIP in the context of The Divisional Landscape

the following points provide a high level summary of the Divisional position in relations to the IIP:• The clinical services are delivered through 5 clinical divisions ( 3 site based, 2 specialty

based ) supported by 27 directorates• The management teams at division and directorate level are formed by a triumvirate

model ( doctor, nurse and manager ) • A mixture of site specific and cross site specialties/directorates• The Trust is failing across a range of key performance indicators and is under scrutiny

by the regulators• Significant additional corporate management support recently introduced to improve

performance• An Executive view that HEFT needs to become a highly devolved clinical led,

organisationSo this poses the question - What should good look like in a clinically led, management supported devolved division?• They should have a written plan setting out service priorities, key objectives,

timescales and leads;• A clear structure supported with roles and responsibilities;• Clear decision making arrangements with responsibilities and authority set out. As a

minimum a formal divisional board with recorded agreements;• Performance management framework at team and individual level;• Intelligent use of KPI’s supported with improvement/change capabilities;• Staff comms and engagement processes;• High quality leadership distributed and every level ( ward to board);• Effective relationships with key stakeholders ( executives, other divisions and CCG’s );• A distinctive culture characterised by positive behaviors, clinical leadership, drive for

quality and a common purpose.Why would you need good clinical leadership?Good hospitals are run by good strong clinical leadership which empowers clinicians but also makes them accountable (See Fig 8 - Driving clinical leadership) and HEFT is no different in their aspiration to become a “beacon” for clinical leadership. However HEFT also recognises that we are have some way to go before we can be recognised as having that characteristic. The current divisional and directorate structure presents a number of complex challenges for the senior management team of HEFT which question the long term viability of the





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current model which is based on site primacy. Many of the directorates operate with different management models which increases the level of complexity.

Clinical decisions impact

on the use of resources

Clinicians know how to cut costs

effectively

Clinicians deliver the patient experience

Clinicians deliverclinically effective

interventionsClinicians deliver

patient safety

Clinicians know where the waste is (productivity)

Most clinicians want to do it

better

Clinical Traction

Fig 8 - Driving clinical leadership

The Executive team have recognised the need to make some tactical changes in order to bring about some improvements in the current operating model (COM), now is not the time for a radical restructure of the COM and it may be some time before the optimum conditions for radical restructuring exist. They have also recognised that the COM represents a not inconsiderable risk to the overall delivery of the IIP. Some of the characteristics of the COM are manifest in some of the things that have been observed during a recent piece of work that was commissioned by Andrew Foster Divisions believe they have lost the right to manage their own business ( eg interim support, PMO, improvement boards etc) :• There is a lack of clarity on roles responsibilities boundaries and accountability across

sites and specialities; • General/Senior Management -sufficient capacity was observed at appropriate grade

mix with varying capability;• Managers at all tiers were working at levels below what was required;• Varying degrees of clinical leadership is in place;• The divisions do not have meaningful engagement with each other; • There appears to be a lack of synergy between divisions in the pursuit of corporate

objectives ( strong silo working ); • There are significant differences in the way the divisions operate but there is a lot of

problem processing and blaming others and not enough drive for change and improvement;

• Bidding for resources to solve problems is the starting point;• Getting to the reality has been a challenge.





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As mentioned above there needs to be some tactical changes to the COM and as we said this means that the issues identified in this analysis are key to delivery and is underpinned by a combination of cultural, process and structural issues. The recent clarity that the Associate Medical Director (AMD) is the divisional accountable officer is an important starting point. In addition to the engagement events held with staff, the next key engagement opportunity is for EMB (attended by all AMDs) to receive the analysis and agree a shared way forwards. This will be held on 5th May 2015. 2.2.6.The IIP in the context of individual HEFT staff members - Staff Engagement

The staff at HEFT are our biggest and most valuable asset. Without a strong, committed and well -motivated workforce we will not, despite our best intentions, deliver the level of service that we aspire to or the patient experience and level of care that our patients deserve. Furthermore, it has long been recognised that engagement of employees with their work and organisation is a factor in their job performance, but the research evidence has been steadily increasing over recent years. West and colleagues have carefully studied the relationship between employee engagement and a variety of individual and organisational outcome measures, including staff absenteeism and turnover, patient satisfaction and mortality, and safety measures, including infection rates. [Ref West http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership-review2012-paper.pdf] Culture and Engagement is a crucial, pivotal IIP programme in the IIP Portfolio. For the Culture & Engagement programme, the objectives are to develop a working environment in which staff feel significantly more engaged, and to reap the benefits of the associated improvements in performance and patient outcomes. This will be achieved by introducing a more structured approach to staff engagement, including senior team led large scale listening events, strong governance around how feedback is turned into action, and the introduction of the more locally focused Engaging Teams Programme, to build sustainable skills and capability across our teams.A programme of Listening Events has commenced across the 3 main sites and ‘you said – we did’ feedback to staff is evident throughout the Trust. Focussed listening sessions have been held in high clinical risk areas such as the Emergency Department (ED) .

2.3.BACKGROUND

The need to develop and deliver a robust well managed IIP spans a period of least three years during which a number of reviews and interventions have highlighted a number of quality, performance, engagement and governance concerns about HEFT. The concerns are not specific to one site or HEFT department, as they sit across a broad range of clinical services, subject matter and impact on all sites. In addition, the Deloitte review of governance identified the absence of Programme Management methodology throughout HEFT as a major shortcoming. A PMO at HEFT was developed using interim staff in late January 2015 and additional expertise was identified in early April 2015 to





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facilitate the development of the PMO into supporting the delivery a robust IIP methodology. Expert subject reviews by the Emergency Care Intensive Support Team (ECIST), Mr Stan Silverman FRCS, Deloitte - CQC as part of their previous standard inspection regime and more latterly under the new CQC Enhanced inspection regime. This led, in part, to further Monitor intervention and the issuing of Monitor Undertakings. The Silverman report, commissioned by the Executive Medical Director (delivered 29th September 2014) reached the following important conclusions:The Board of the Heart of England FT receive only partial assurance in regard to mortality as reports are based largely on information derived from coding data. The Board is uninformed about the potential shortfalls in care that might be revealed through structured review of all deaths.There is potential to vastly increase knowledge about safety and risk through the incident reporting system which currently appears to be suboptimal.There is a lack of compliance with guidance on best clinical practice in HEFT.Clinical staff are under severe pressure, morale is poor, and engagement is poor.Multidisciplinary working and good team working are poorly developed. Silo working is widespread.Clinical congestion is likely to be the biggest factor in causing raised mortality indicators. This can be addressed to a large extent by transforming clinical practice. The HEFT executive has focused on clinical congestion as the greatest threat to the delivery of safe care in the Emergency Department and this IIP has a strong focus on this key quality risk. We have triangulated these outcomes with other expert reviews and reports such as IST/ECIST, and the Deloitte Governance Review. Whilst they carry specific recommendations on leadership, board assurance and risk management, there is a common narrative considering they have been conducted independently.2.3.1. Monitor Undertakings

As HEFT’s regulator Monitor have a duty to provide assurance to the Secretary of State (SoS) for Health about the safety and financial viability of HEFT. The following undertakings represent the action that Monitor have agreed to take in order to provide that assurance. What is obvious from the timelines against the specific actions and milestones is that HEFT have not been able to meet Monitors expectations and assurance given to the SoS. This is further evidence of the need for this recovery plan.BACKGROUND: PREVIOUS AND CURRENT REGULATORY ACTIONMonitor accepted enforcement undertakings under section 106 of the Health and Social Care Act ("the Act") from the Licensee on 20 December 2013 in relation to the Licensee's governance arrangements for urgent care. Monitor then accepted amendments to those undertakings on 21 October 2014, which were made following breaches of additional access and outcome performance indicators. These are referred to collectively as the





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"existing undertakings". The undertakings (detailed in the Appendices) relate to breaches of the additional licence condition imposed under section 111 of the Acton 21 October 2014 ("the additional condition") and the broader governance conditions of the licence, and are without prejudice to the existing undertakings. The additional condition requires the Licensee to ensure that it has in place sufficient and effective Board, management and clinical leadership capacity and capability, as well as appropriate governance systems and processes.Full details of the Monitor Undertakings are contained in the appendices in Appendix V.

2.4.SPONSORSHIP OF THE INTEGRATED IMPROVEMENT PORTFOLIOOwnership and strategic direction of the IIP sits with the Deputy Chief Executive, and the collective responsibility for the delivery and the sustainability of the changes arising from this programme resides with the Executive Management Board and the Board of Directors.Monitor and The Care Quality Commission (CQC) will receive assurance from HEFT on the progress of IIP via the monthly external stakeholder group and secure evidence that HEFT remains financially viable and delivering safe care throughout the period of change implementation and beyond.

2.5.KEY PRIORITIES AND TIMELINES

There are six stages to the development and delivery of the IIP, Fig 9 below describes the six stage maturity model. (also appears in the Exec Summary)

Feb to April 2015.Creation of The Plan - conceptually based on the original January 2015 Leadership and Resilience Plan. Limited PMO capacity initially arising from simultaneous focus on establishing the Programme Office and running several other improvement programmes synchronously.

Clear Executive Leadership. Deputy CEO manages and assure the Plan. Interim DoF manages the timeliness and quality of submission. Supported by very experienced Programme Manager, Stuart Brown. Focused one week piece of work commissioned from Deloitte to align the dashboard metrics with the IIP.

1 2 3

4 5 6

Creating the Narrative – From the Deloitte Governance Report to the Resilience Plan to the Pyramid of Priorities to the IIP and Dashboard.

IIP is perceived as centre stage in the organisation - with buy-in from the Board, CoG and external stakeholders.

Introducing a Layered Approach to presentation and implementation so that the IIP can be seen in a national context, at full Trust level, at site, at service and down to the individual member of staff.

The IIP and our suite of strategies merge and become the entire plan enabling us to shift from back foot to front foot in September 2015.

Fig 9- IIP Six Stage Maturity Model





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Monitor have formally expressed concerns regarding progress to date on the IIP. (Andrew Foster has received a formal letter from Monitor expressing their concern around the progress of the IIP and it’s reporting architecture). There is specific concern that the presentation and content of the IIP thus far requires further development. This is acknowledged by the executive team and this document,along with other decisive action, will add traction to the delivery of the IIP and support the implementation of stage 5 of this process namely that the IIP is perceived as centre stage.The first iteration of this document and the high level plan metrics were received at EMB on 29th April and the first meeting of the IIP programme board was held on 29th April 2015.The draft IIP and metrics will be received at the Board of Directors on 5th May 2015.It is stressed that the IIP is a live document that will continue to evolve up to the stakeholder meeting when the final definitive version 1.0 will be published.

2.6.THE 30 DAY CHALLENGE - GETTING BACK ON TRACKThe next 30 days are a critical period for HEFT, a period where we have to demonstrate to the BoD, Monitor and the commissioners that the IIP has the required traction and pace to provide the required level of assurance. During this period we will be implementing the following actions:Additional skilled resources will be added to the PMO to provide additional support to the programmes that sit on the critical path;All programmes will be scheduled to undergo a rigorous Gateway review to assess their capability to deliver against the current agreed timelines. If it is determined that the delivery schedule is at risk a recovery action plan will be developed and implemented;





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Plan

SECTION 3- VISION & OBJECTIVES





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3.VISION AND OBJECTIVES

3.1.VISION

The HEFT 2020 Vision consists of the clinical strategy, quality strategy, quality improvement strategy and corporate strategy, supported by strategies for IT, HR and business. Each of the divisions will subsequently produce a strategic portfolio adding local detail to the Vision and their strategic deployment plans.

3.2.OBJECTIVESOur key objectives are to:

• Improve the quality of care, including the outcomes, the safety and the experience for all ;

• Engage with patients, carers, staff, our community, stakeholders and partners to redesign our services to provide improved access to services at the right time in the right place;

• Innovate and research new treatments and new ways of delivering care.

In five years time

Heartlands will be the centre for complex and emergency care. Based in the heart of the East

Birmingham community it has facilities which mean we can provide leading edge clinical services, some

of which have a national reputation. By concentrating some specialist care we will provide

the best outcomes and care.

Good Hope will continue to provide a full acute and emergency medical service. The recent investment in the new A&E department means it has a strong and sustainable future to manage this workload to

high standards. Over time the hospital will undertake less emergency surgery but will be home to some

surgical specialties, many of which serve a regional population.

Solihull Hospital and Community Services will become the centre of an integrated care system. For patients this means that their health and social care services will be aligned and integrated around their

individual needs. This is important since many of the patients at Solihull are elderly and the hospital care is often only one part of an overall package of care

and support they are receiving.It is planned that Solihull will have an urgent care facility which will be closely linked to primary care. The Hospital will continue to provide acute care but closely linked to the specialist centre at Heartlands.

Heart of England run community services in Solihull providing a wide range of support to people of all

ages.In Solihull we are already developing plans to bring together a wide range of public sector services. This will include “one stop shops” where people can seek help relating not just to their health but also for their overall well being, including leisure services, local

safety, finance and council services.In the future we will deliver more care in peoples’

homes and in community facilities across all of our catchment area and will work more closely with

partners so that our patients and their carers see all their care needs are joined up with less handovers

between individuals and organisations

Fig 10 - 5 Year aspiration





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Plan

SECTION 4-PROGRAMME MANAGEMENT AND PMO





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4.PROGRAMME MANAGEMENT & PMO

HEFT made a conscious decision in the third quarter to adopt a programme management approach and establish a fully functioning effective programme management office (PMO). The effectiveness and influence of the PMO to date has been variable. Confidence in the delivery of the programmes that make up the IIP now needs to move to the next level in order to provide Monitor, The Board and Commissioners with the level of assurance that they require. Based on this analysis HEFT is recruiting additional resources with an enhanced level of capability to provide the necessary skill mix and capacity to provide the drive delivery and provide the assurance required.

4.1.STRUCTURE OF THE IIP

Programme DirectorScheduled Care - Amanda Markell

UC Work Streams

Scheduled Care Work Streams

IM&T Work Streams

Mortality Work Streams

GRP Work Streams

PMO Rigour“Light touch”


PMO RigourLight touch


Work StreamLeadsClinical

Champion

Project manager

Work StreamLead

Clinical Champion

Project manager

Work StreamLead

Clinical Champion

Project manager

Programme DirectorGovernance - Angela

Hopper

Programme BoardGovernance

SROProgramme BoardScheduled Care

SRO

Tight knit Teams that

“Hunt as a Pack”Work at Pace

& Deliver on time!

Tight knit Teams that

transfer skills andKnowledge

& Deliver on time!

IIP Programme Board

Executive Management Board

SRO

ProgrammeDirector

Programme Board - Urgent Care

SRO

Programme DirectorUC - Andrew Stenton

ProgrammeBoardIM&T

SRO

Programme DirectorIM&T - Caroline Sadler

Programme BoardMortality

SRO

Work StreamLead

Clinical Champion

Project manager

Work StreamLead

Clinical Champion

Project manager

Programme DirectorMortality - Ann Keogh



ProgrammeBoardCultures & Behaviors

SRO

Programme DirectorCultures &

Engagement - Alex Covey

Cultures & Engagement Work Streams

Work StreamLead

Clinical Champion

Project manager

PMO Support & Delivery Resources

Fig 11 - IIP Structure

4.1.1.Matrix working

Managing the interdependencies within a programme of this size and complexity is challenging, with plenty of opportunities for silo working and duplication of effort. Individual Programme Directors and Work Stream leads will need to work effectively to mitigate any risk of this happening.





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The programme directors for each of the constituent IIP programmes will meet regularly with the IIP Programme Director, weekly for the next 30 days and fortnightly thereafter to review progress and resolve any interdependency issues 4.1.2.Personnel

In the third week of April a decision was made to restructure the PMO see Fig 12 below, with administration and governance moving under the Interim DoF and Strategic direction and delivery moving to Dr Andrew Catto.

Head of PMO

Director of Finance and PerformanceDarren Cattell

Programme Director IIP

Project Manager - Support to Culture & Engagement

Programme Manager - Support to Governance

Project Manager - Mortality/Congestion

Seconded team from Deloitte

Project Manager - Support to Urgent Care

Band 2 Administrator - Vacant

Project Manager - Support to Planned Care

Project Manager IM&T

Figure 12 - PMO Structure

Since this decision was made there have been a number of movements within the PMO itself with additional specialist resources being added to bolster the skills and expertise needed to ensure and assure delivery. The following table describes the current manning levels of the PMO, this may be subject to change and additions as the requirements become clearer over the coming weeks.


Stuart A BRown IIP Programme Director IIP Programme

James Weller - joins 21/5 Head of PMO IIP PMO

Phill Wilson Project Manager IIP Programme & Governance programme

Paul Arford Programme Manager Urgent Care Programme

Lara Williams - joining date tbc

Project manager Mortality and Congestion

Vacant Project manager IM&T

Danielle Goddard Project manager Culture and Engagement

The following table details the movements out of the PMO:





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Change

Nick Varney Head of PMO and IIP

IIP Programmes Moves to Surgical reconfiguration

Keith Hawley Project manager Governance programme support and ad-hoc support as directed by Head

of PMO

Will leave the Trust on 11th of June or sooner if mutually

agreeable

4.1.3.Corporate Fit

The PMO is directly accountable to the Deputy Chief Executive for the full scope of the IIP and is also accountable to the Director of Finance for the performance and finance element of all programmes.

4.2.APPROACH4.2.1.Assurance role

A programme assurance role is a very different model to the delivery driver model and requires different skill mixes and styles. The assurance roles is to all intents and purposes a very light touch review and report type approach and is not designed to provide intense challenge or roll your sleeves up support. The skill mix for an assurance PMO is generally fulfilled by staff that do not necessarily have subject matter expertise but do have the necessary programme management process knowledge and capability. 4.2.2.Delivery Driver

This role is much more focussed on tangible support to the projects and work streams and is usually staffed by personnel with a mixture of programme management skills and subject matter knowledge and capability in order to provide hands on support to projects and where necessary to offer leadership expertise to help remove blockages if required.

4.3.METHODOLOGYThe PMO will follow the standard Managing Successful Programmes (MSP) framework and the Prince2 frameworks originally developed by the Office of Government Commerce (OGC). This will ensure that we are following a consistent approach to programmes and projects and that an assurance regime is naturally embedded in the process.

Define Develop DeliverAssure

Fig 13 - Managing Successful Programmes





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4.4.PMO TOOLS 4.4.1.New Programme and Project Development

Each time a new programme or project is required it will follow a clearly defined development process, that addresses the key stages of a project - a copy of these stages can be found in the appendices in Appendix II 4.4.2.Software

The PMO is currently using a combination of Microsoft office applications to track and manage the IIP and constituent programmes which is both clunky and does not provide the opportunity for “real time” management and update - it also makes version control somewhat more challenging.A number of web based products are available such as Share point, PM3, Smartsheet, Basecamp - at very competitive prices. Packages.A brief review process will be undertaken as part of the “The 30 day challenge” to select the most suitable and user friendly package to provide a constructive and un-intrusive PMO tool that is capable of delivering the appropriate level of reporting direct to the relevant recipients i.e members of the Executive Management Board (EMB), Programme Directors, etc,etc. 4.4.3.Lean/Kaizen

Lean and Kaizen are proven methodologies for designing, developing and implementing change.Where appropriate we will use Lean methodology to effect and deliver change and we will use Kaizen events to implement those changes.4.4.4. PMO Templates

The PMO will be introducing additional/replacement templates into the PMO suite of documents that are designed to streamline the processes and improve efficiency whilst at the same time reducing the level of complexity and time required to complete the various documents.The document suite will include the following standard templates3:Programme/Project/Work stream Unique Identification Number (UIN) Reference tableBecause of the number of different reviews and reports that inform the IIP we currently have a plethora of different cross references within the various programmes. From the 1st of May we will initiate a revised Programme UIN system - this will be a HEFT generated UIN system.



3 Samples of which can be found in the appendices



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So that we do not lose the various threads of the individual reviews and reports from Deloitte, Silverman, Monitor, CQC, etc we will produce a PMO document that cross references the links from the IIP UIN system and these reports/reviews. This will be known as the Book of Reference (BR) Project status report (PSR)

A one side of A4 that describes the progress against predetermined milestones and timelines, reports risk status, reports any issues and describes the activity for the next period;Highlight report -

A more detailed report that can be used to appraise EMB of progress and outcomes to date.Master Risk register & Programme risk registers

Records risks, issues, opportunities, actions, dependencies, decisions and lessons learned.The IIP Master Risk log will feed into the Trust Strategic Risk Register/LogException report ;

Describes a situation where the programme or project has deviated against time, cost, resource or quality tolerances. The exception report asks the Programme Board to:

• Approve or reject the situation; • Defer making a decision until later; • Request more information; • Make a concession for the project manager to proceed without the need for any

corrective action;• Instruct the project manager to resolve the problem; • Give advice and guidance to the project manager; • Request an exception plan based on one of the options (theirs or the project

manager’s); • Seek advice and guidance from corporate or programme management ;or • Instruct that the project be prematurely closed.Change control form

A change request is a formal proposal for an alteration to some product or system relating to the programme or individual project/work stream. The IIP Change Control Form is aligned to the process described in Fig 14 below.It is the work steam lead’s responsibility to raise a change form as soon as it becomes evident that a deviation from scope is required and/or inevitable. Scope changes must follow the agreed change process so programme directors must ensure that the work stream leads act in a timely manner.





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Work stream/Project identifies need to deviate from the work

plan

Change is determined as

Legitimate

Change requestrejected

NO

Change is determined as

Material

Programme Lead and Executive Lead determine whether the change is material:

Materiality defined as one or other of:Extends timeline and impacts critical path

Impacts other ProgrammesImpacts the final output?

Change request

approved

NO

ProgrammeBoard

ConsidersYES Change is

implementedAPPROVES

RISK REVIEW &

MITIGATION PLANNING

REJECTS

Change Control Process

Fig 14 - IIP Change control process

4.5.MANAGING INTERDEPENDENCIESManaging interdependencies is a critical success factor for both the individual programmes and projects and the overarching IIP itself. As part of the Gateway review process a thorough analysis of the interdependencies will be undertaken using a workshop environment. Once we have clarity on the links and the potential impacts they will be managed via the matrix working arrangements described in 4.1.1We will also consider using a technique called Outcome relationship mapping, Outcome Relationship Mapping is a simple but powerful technique for exploring complex changes by identifying and analysing the potential impacts in other areas that would be affected by the change(s) which any organisation is seeking to implement - both internal and external to the organisation. Outcome relationship mapping can also be used to help:• Clarify policy/strategy effects, gaps, overlaps & contradictions• Strategic scoping & prioritisation• Planning and the setting up of portfolios, programmes and projects• Look for strategic risks (barriers, problems of success and associated risks)• Evaluation, identification of measures and targets & learning lessons• Communicate the vision





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• Define organisation and programme structures and identify relationships between teams, programmes & projects

• Stocktaking existing initiatives • Benefits realisation planning• Business Case developmentAn example of an Outcome relationship map can be found in the appendices in Appendix III

4.6.BENEFITS MANAGEMENT AND REALISATIONEach work stream must develop a benefits map and a benefits management and realisation plan. A benefit profile must contain as a minimum:• Benefit owner;• Description of the benefit;• Related issues and risks to the full realisation of the benefit;• Financial profile of the benefit;• Any dependencies on other programmes or projects outside the boundary of the parent

programme that the benefit realisation relies on;• Details of the beneficiary i..e Patient, Staff, Infrastructure, Quality & Safety;• Evidence that demonstrates when the benefit has been realised;• Other benefits that this benefit contributes to.

4.7.WHAT DOES GOOD LOOK LIKE? This defines what a successful PMO and Programme management function looks like, so we will measure the success of the PMO and Programme Director on the following key criteria:• On time performance of all constituent programmes and projects;• Delivery of programmes and projects within the agreed budgets;• On time performance of reporting timescales;• BRAG ratings are performing as expected;• Programme temperature - EMB, Trust Board and Monitor have confidence in the PMO

and Programme Director that the IIP is maintaining the desired momentum or exceeding expectations.





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Plan

SECTION 5- METRICS





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5.METRICS

The Trust have commissioned Deloitte's to work with us to develop the metrics that will be used to track progress of the IIP and its constituent programmes and projects. Where possible and practical we will be using both a leading KPI and a Lagging KPI for all the metrics we have agreed with Deloitte's and the Programme Executive leads (SRO’s) and the individual Programme Directors.5.1.Metrics

Individual programmes have a newly developed, in collaboration with Deloitte’s, set of metrics that will measure their progress against their key milestones and objectives. The specific metrics which have been developed for each individual IIP programme are contained in a separate document - IIP Dashboard. An image of the dashboard is contained in the appendices of this document in Appendix IV. The PMO will also provide reports against standard PMO disciplines, 5.2.Reporting Timetable

Each work stream will be required to complete a weekly PSR4 for the PMO and a comprehensive monthly Highlight report.Programme level reports will be required in accordance with the table shown below in 4.3.1 5.3.Reporting To Who

5.3.1. Monitor

IIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - Monthly

Individual IIP programme updates to

be provided by 5th working day

Updates to be collated and circulated by 8th working

day

IIP-3rd Monday of month for assurance

EMB- 3rd Tuesday of

month for final sign off

Submit to Monitor - 3rd Thursday of the month

May 08 - May 15 - May 18 - May 19 - May 21 - May

June 05 - June 12 - June 16 - June 17 - June 18 - June

July 07 - July 14 - July 20 - July 21 - July 22 - July

Aug 07 - Aug 12 - Aug 17 - Aug 18 - Aug 20 - Aug

Sept 07 - Sept 10 - Sept 14 - Sept 15 - Sept 17 - Sept



4 the latest copy of each PSR will be made available for the fortnightly EMB meetings



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IIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - MonthlyIIP Reporting Timeline - Monthly

Oct 07 - Oct 12 - Oct 19 - Oct 20 - Oct 22 - Oct

Nov 06 - Oct 11 - Nov 16 - Nov 17 - Nov 19 - Nov

Dec 07 - Dec 10 - Dec 14 - Dec 15 - Dec 17 - Dec

5.3.2. NHSE, CCG’s and Local authorities

Should the CCG’s and Local Authorities require formal reporting of HEFT’s IIP then the reports will be provided in accordance with the Monitor reporting timeline as shown in 4.3.15.3.3.Internal

See 4. 2 and 4.3.1





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Plan

SECTION 6- PROGRAMME PROFILES





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6.PROGRAMME PROFILES

6.1.GOVERNANCE RECOVERY PROGRAMMEBackground:

In 2014 Deloitte were commissioned to undertake an independent review of Governance arrangements at Heart of England NHS Foundation Trust against Monitors’ well-led framework for governance reviews. The final report was published in October 2014. Throughout the review a number of significant governance concerns were noted:• Lack of plans to support the implementation of the trust wide strategy – such as a

quality strategy;• A need to significantly strengthen risk management arrangements within the trust

including oversight form board level;• Significant concerns around the culture of the trust;• A complex structure lacking in clarity in accountability;• A weak governance structure.Deloitte recognised that the governance arrangements in the trust did not meet the requirements of a Foundation Trust, and identified a number of material areas where progress improvements were required:• Organisational Development;• Strategic Focus;• Board Leadership and cohesion;• Board Oversight;• Risk management and Board Assurance Framework.The final report was grouped under the four themed areas outlined within the Monitor well led framework. • Strategy and Planning;• Capability and Culture;• Process and Structures;• Measurement;Mr#Andrew Foster was appointed to HEFT in February 2015 as interim CEO. He revised the executive portfolios to include Governance within the portfolio of the Chief Nurse. The Chief Nurse has worked with the executive team and the PMO to develop the Trust Governance Recovery programme (GRP) in response to the Deloitte 2014 Governance review. As Senior Responsible Officer (SRO) for the GRP, the Chief Nurse will:





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• Be accountable for ensuring that the GRP meets its objectives and delivers the projected benefits within the agreed IIP Programme framework;

• Ensure that the executive team is fully aware of their roles in delivery of the programme and that the programme is sufficiently resourced;

• Ensure that the change process maintains its business focus, has clear authority and that the overall context including risk is actively managed;!

• Be the visible owner of the programme reporting to the IIP Board and Trust Board.Resources:The Executive Team have appointed four senior experienced interims to support key internal staff to deliver the GRP; this is a critical component of the IIP.The programme will deliver the recommendations from the Deloitte Governance review, in addition to both the implementation of a revised performance management framework and a refreshed Trust Assurance Framework.The Trust are also engaged with Deloitte to scope support with the delivery of a training programme, and consultation with the site and divisional teams to enable the development of an integrated quality governance dashboard and supporting processes regarding assurance and performance across a range of indicators and data sources. The proposal will include the opportunity for Deloitte subject experts to take up short-term secondments in the trust. Deloitte are also engaged with the Trust to refresh the trusts’ BAF. The Executive Team will revise alignment of the internal audit programme in line with the integrated plan.The Executive Team will also quality assure the GRP with external stakeholders such as Monitor, CCGs, NHSE and the patients association for the elements relating to patient experience. Monitoring successful delivery of the GRP will be seen through the key metrics under the IIP as agreed with Monitor. The Governance Programme Board, and IIP Programme Board will oversee this delivery. The SRO/Exec lead - Sam Foster -Chief Nurse

My role as the Executive lead (SRO) for this programme is to ensure that we maintain grip, pace and focus and that the programme delivers on it’s objectives, that we provide the requisite level of assurance to the Trust Board and to Monitor that we can and will achieve a greatly improved approach and understanding of our strategic risks and how they relate to our operational performance and our public reputation.

Sam Foster - Chief Nurse





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6.2.URGENT CARE PROGRAMME

To deliver a consistent and efficient patient pathway for patients presenting into the Trust’s urgent care systems.Impact of the programme

As a result of reducing variability within our processes, flow through patient processes will be improved. Consequently, delays for patients at the beginning of their pathway will be reduced and clinical risk reduced. Improvements urgent care pathway will also reduce the interference that urgent care demand creates within the elective inpatient pathways due to competition for bed capacity. Accordingly there will be positive impact on patient quality, overall costs and Trust performance against both the 4 hour emergency and 18 week admitted standards.Elements of the Programme

The Programme addresses all stages in the care of a patient, from first attendance through to discharge from the Hospital’s Services. Each of the three sites have specific plans to address both local constraints to delivery and common threads across all sites.The main elements being addressed are:• Flow within the Emergency Departments (ED) themselves:• Physical and staffing capacity;• Coordination and balancing of operational capacity within the ED to match the needs of

patients;• Internal Professional Standards and escalation processes to ensure appropriate

responses within ED and to requests from ED for support;• Bringing specialist opinion and decision making to the ‘front door’;• Ambulatory Care - presenting an alternative route for advice and treatment for ambulant

patients;• Reducing demand on both ED and admission capacity;• Ensuring that capacity for Ambulatory Care patients is sufficient and is available to

times of peak demand 7 days per week;• Reviews of the type of patient which can be managed through this route;• Promotion of ‘pull’ model from the A&E;• Developing existing links with GPs for direct referral;• Short Stay – many medical patents do not require a traditional specialist bed and can

be managed within acute medicine on a reduced Length of Stay;• Sizing of acute medical short stay capacity to match presenting demand, 7 days per

week;





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• Reviewing and updating guidance to ensure that appropriate patients are managed with Short Stay;

• Promoting and investing in a Frailty Service such that these patients receive a rapid assessment and are signposted to an appropriate service. In many cases this can avoid the patient losing the capability to manage in their usual place of residence;

• Delivering a model of care focussed of regular senior review of patients to ensure a rapid turnaround;

Discharge and external capacity;• Redesigning clinical coordination within each ward’s daily routine such that each

patient’s Length of Stay is appropriate;• Identifying and removing blocks to rapid discharge once a patient becomes Medically

Suitable for Discharge, 7 days per week;• Redesigning how each Hospital Site coordinates internal flow to ensure delays and

variability are reduced or eliminated;• Planning for known period of increased demand to ensure the Trust responds in a

planned, predictable and effective manner.Trust and site capacity and demand matching

• Review of physical capacity to ensure appropriate use of existing, or commissioning of additional, based upon demand.

The SRO/Exec Lead - Jonathan Brotherton Director of Operations“The Urgent Care Improvement Programme is a key element of the overall Improvement Plan for the Trust; ensuring that all unplanned patients are quickly assessed and appropriately treated. This programme involves the vast majority of our clinical services and so it is appropriate that, as Director of Operations, I act as its Senior Responsible Owner. I have an engaged clinical and managerial team working with me to deliver the significant changes that are required. I believe that together we will lift our performance and reduce, to the lowest possible level, the clinical risk to our patients”

Jonathan Brotherton - Director of Operations





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6.3.IM&T PROGRAMME

Our focus is on the opportunities and innovation that Information Management & Technology (IM&T) can offer to the Trust and sets out how the Trust can deal with rapid changes both in respect of the internal and potentially external health economies.The IM&T (IIP) element is based on the outcomes of the audits undertaken by Deloitte and Ideal. These outcomes of collective observations and recommendations have been documented and form the benchmark for the readiness activities which are currently being actively monitored via the IIP. The planning is also expanded into three sub-level plans for:

• Quick Wins - Benchmark Project Closure Readiness

• Stabilisation - Benchmark Business as Usual Readiness • Exploitation - Improvement Planning to Realise Benefits

The detailed sub-level plans are monitored on a daily basis and for further assurance a detailed project plan is currently under development.Our planning identifies requirements to drive and support innovation, improved access to Trust, Community, GP and Patient Services via robust and resilient technology and infrastructure. We are working toward improved data quality and reporting as we must ensure that the use of Trust information improves our patients’ safety and experience.Moving forward, the IIP will ensure improve Trust communications, engagement, more effective and co-ordinated planning to assist with closing service gaps that will ultimately prepare us for any future challenges.SRO/Exec Lead - Jonathan Rex - Director of IM&T

Appointed in an interim capacity to initially stabilise the IT function as well as some key project recovery and then review, with some carefully selected 3rd party consultancy, the capability and capacity of the department. In parallel there was a need to re-engage the IT function with the clinical and corporate functions and bring all that together in to an IT Strategy which aligned and underpinned the emerging corporate strategy.

Jon - Director of IM&T





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6.4.CULTURES AND ENGAGEMENT

The aim of the Culture and Engagement work stream is to:

• Systematically improve LEADERSHIP capability across the Trust• Step change Staff ENGAGEMENT across all areas of the workforce• Strengthen VALUES led cultureWithin LEADERSHIP,

The objectives are to develop the Board and senior leadership team in order that the Trust is able to operate effectively, and to develop a strong pipeline of future leaders so that the Trust is able to implement its strategy effectively. The first steps within this are to provide a clear analysis of the current leadership position, as relates to both individuals and development provision, and to work with the Board and senior leaders to agree both the current and future need in terms of leadership and to develop a practical plan that supports the long term development whilst prioritising immediate need with pace. Systems will be put in place to effectively monitor, review and take appropriate actions at both individual and Trust level.Visible outcomes will be an agreed HEFT Leadership Development Framework, Succession Plans for senior roles and a bespoke Leadership Development Programme.Within staff ENGAGEMENT,

The objectives are to develop a working environment in which staff feel significantly more engaged, and to reap the benefits of the associated improvements in performance and patient outcomes. This will be achieved by introducing a more structure approach to staff engagement, including senior team led large scale listening events, strong governance around how feedback is turned into action, and the introduction of the more locally focused Engaging Teams Programme, to built sustainable skills and capability across our teams.Visible outcomes will be improved engagement within local teams; and across the Trust, as measured by the Staff Survey. Within VALUES,

The objectives are to develop and strengthen a Trust culture where Values are key, and how we are with each other and our patients is a defining factor. The first steps are to develop a set of staff-generated Trust Values and associated behavioural frameworks. To launch the Values in a way which engages and motivates staff to embed them into local working practices, and to build sustainability by incorporating the Values into infrastructure such as appraisals, recruitment, leadership development programmes and induction.





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Visible outcomes will be a set of Trusts Values, a behavioural framework, Values base to the bespoke leadership development programme and a Board and senior team appraisal process in place.The SRO - Hazel Gunter - Director of Workforce

“My personal role is to lead the development of this programme to ensure it delivers on the outcomes and assuring the Board on this project, whilst also supporting the senior executives in their part of the culture and engagement programme”

Hazel Gunter

6.4.1.Key Milestones

Engagement:• Preparation of new quarterly Pulse Staff Engagement Survey based on WWL model;• Implement Workforce Committee chaired by NED and a Staff Engagement Steering

Committee chaired by Chief Executive;• Implement senior led Staff Engagement Events reporting to the Staff Engagement

Steering Committee;• Roll out Pulse Staff Engagement Survey across 25% of the workforce per quarter;• Implement "Engaging Teams" programme for first cohort;• Undertake analysis of first quarterly Pulse Staff Engagement Survey results at Trust

level;• Agree baselines for all nine categories of the quarterly Pulse Staff Engagement Survey

and forecast targets for the 3 key enablers.Values:• Develop and agree Trust values through Trust wide consultation for Board approval

and sign off;• Develop a locally led Trust values implementation plan;• Identify and recruit appropriate resource accountable for delivery of the values

implementation plan and appraisal process;• Define and develop permanent culture metric once values are agreed;• Launch value based appraisal process for Board and complete full appraisal cycle.Leadership:• Provide clear analysis of current leadership development offering within the Trust;• Define current and future leadership needs;• Conduct a gap analysis between defined needs and current status;• Develop and implement a practical plan to improve leadership across the Trust;





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• Agree a bespoke Leadership Development Framework and then implement a bespoke Leadership Development Programme;

• Implement a system to monitor and track delivery of the Leadership Development Programme;

• Implement succession plan for all executive board members.





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6.5.SCHEDULED CARE

To ensure that patient waiting times are minimised at all stages of the scheduled care patient pathway based upon joint trust and CCG patient access standards.Impact of the programmeAs a result of implementing a programme of robust development and management of performance against trajectories, along with identification of underlying factors that influence our ability to consistently ensure patients are treated as quickly as possible within each milestone of their pathway, the scheduled care programme will deliver a return to the 18 week and cancer performance standards. The work streams identified therefore focus both on the “here and now” as well schemes that will transform the way in which services are delivered to ensure sustainable change and improvement. Joint working with our partners to achieve success is key and is reflected within the programme and supporting structures which ensure performance is monitored, scrutinised, root causes understood and associated actions developed.

Elements of the programmeThe programme addresses all elements of scheduled care and key milestones within the patient pathway, from referral through to follow up and including the diagnostic and therapeutic elements of the patient journey. Whilst there is 1 overall plan, this is supported by specialty level trajectories and where necessary, specific recovery plans for those specialties identified as a “red risk”. The main elements of the programme are Planned care/RTT:• Reduce the backlog of patients >18 weeks to a level where RTT targets are achieved

and maintained;• Monitor performance and manage any deviations against specialty specific trajectories;• Manage closely patients on open clock pathways to further reduce risk to patients

breaching the 52 week standard;• Improve data quality by applying a multi-faceted approach that includes input from

operational, IT, finance and performance teams;• Provide a single waiting list that is clean and through which teams have full visibility of

their patients and their pathway position and status;• Centralise waiting list management functions to reduce risk and ensure equity of patient

waiting times across all sites for the same procedure;• Publish and launch a Patient Access Policy that has been developed in conjunction with

the IST and CCG colleagues and supports teams in better managing patients in line with DoH and local RTT rules;

• Provide greater certainty to our most vulnerable patients by ensuring that no category 1 patient is cancelled due to “no bed” being available;





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• Ensure that all cancer target are achieved, most critically the 2ww target for cancer and breast symptomatic achievement of which is challenging due to multiple factors including increase in referrals, high median wait times, patients not being aware of their reason for referral and high numbers of patients choice breaches;

• Work with other Trusts and CCG’s to revise specialty specific referral forms for 2ww that provide greater guidance to GPs at the point of referral;

• Implement new best practice pathways in our specialties that have a higher proportion of 62 day breaches due to their complexity, most notably Lung and Urology;

• Forward look and plan for changes in demand as a result of revised guidance from NICE and publicity campaigns;

• Provide a workforce and resource capacity for the whole of scheduled care that enables delivery and creates further capacity;

• Provide a governance structure and clear roles and responsibilities for scheduled care that support service improvements as well as the ability to monitor and manage performance of the position.

SRO/Exec Lead - Jonathan Brotherton - Director of Operations“My role as the SRO for this programme is to drive improvements in patient flow right across the whole of HEFT, so identifying the links between this programme and the Urgent Care Programme and then managing those interdependencies is critical to the successful delivery of both programmes and the realisation of the full range of benefits for patients and staff alike”

Jonathan Brotherton





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6.6.MORTALITY

Key objectives of the programme:There should be a Trust wide policy that all deaths will be reviewed. This should be with the intent of looking for suboptimal clinical care rather than to determine whether or not the death was avoidable or inevitable.The outputs of these reviews should be fed to the Mortality and Morbidity Performance Group for triangulation across specialities and with the outcomes of reviews of incident reports, patient experience, complaints and other data sources such as Trainee survey reports.Messages about hospital mortality should regularly go out to staff so that they are aware of the situation and know what they can do to improve matters.There should be a review of the incident reporting system in order to encourage incident reporting and make best use of the reports including near misses to improve safetyImproving flow through the Trust should be a high priority. Rather than a “magic bullet “ approach, it would be best to focus on the impact of accumulation of marginal differences. These should include:

• Better working between the ED and the specialities to get specialists as close to the “front door” as possible;

• Considering using the recommendations of the Royal College of Physicians Future Hospital Programme;

• A system of specialities “pulling” patients from ED; • Increasing the range and scope of ambulatory emergency clinics and making their

operational policies explicit; • Use of ward round checklists and adhering to the Royal College of Physicians and

Royal College of Nursing guidance on ward rounds; • Reviewing the processes for prescribing and dispensing TTO drugs; • Daily (7 days a week) senior review of all patients including all outliers; • Reviewing compliance with the 10 standards for 7 day working by undertaking the self-

assessment exercise on the NHS IQ website and developing an action plan; • Aim to achieve the same numbers of discharges per day at weekends as on weekdays; • Reduce non-medically indicated ward transfers; consider a policy of requiring all such

transfers to be discussed with the responsible consultant first .All clinical directorates should agree pathways and standards for care of non-elective admissions and undertake regular audits of compliance with results reported back to clinicians.





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Consider the use of an electronic track and trigger system for detection of deteriorating patients and escalation of care. A programme to improve staff engagement, multidisciplinary team working and empowerment (such as Listening into Action) should be considered as a matter of urgency. This should be prioritised to those clinical teams where poor engagement and team working are well known Review the interactions between consultants and coders to help improve the quality of medical notes and the way diagnoses are recorded. Consider using appraisal as a lever to improve consultant recording of diagnoses and engagement with the coding process. When these outcomes are triangulated with other reviews and reports such as the IST reviews and the Deloitte Governance Review, which carries very specific recommendations on Leadership, Board Assurance and Risk management, they all tell as similar story and make similar recommendations, albeit the reviews are approaching things from different angles,based on different criteria and carried out independently of each other.Key milestones:

Mortality process:• Review current Mortality and Morbidity Performance Group, including ToR,

membership, roles and responsibilities and agree reporting governance;• Agree pro forma and screening method for mortality case review;• Identify resources to support pilots;• Pilot redefined Trust process with AMU and Cardiology;• Submit proposal to Trust Board outlining the governance and reporting arrangements

for MMPG within the Trust BAF;• Pilot analysis and full Trust roll out of compulsory process to all Clinical Groups or

Directorates;• Define mechanism to identify and approve Quality Improvement schemes and

governance to support improvement monitoring.Education:

• Draft and agree education materials;• Develop schedule and timetable of engagement events;• Delivered all engagement as a mixture of open event or targeted events by Directorate.Coding :• Scope and develop clinical coding work stream to improve clinical engagement in

coding; • Complete visits to each directorate to increase clinical engagement in coding.Future Information Requirements:





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• Undertake visits to exemplar organisations with regards to advance mortality / morbidity analytics;

• Draft Business Case for Trust Board approval for development of Trust advanced mortality / morbidity analytics capability.

“My role as the Director of Medical Safety (Clive Ryder is SRO for this programme ) is very clear to me, to ensure that the programme is properly managed and resourced. To ensure that the Trust develops and implements robust policies and processes that enable us to fully understand the reasons that underpin our mortality rates and provide opportunities to improve our survival rates”

Dr Ann Keogh - Director of Medical Safety





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Plan

SECTION 7- PROGRAMME COSTING





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7.PROGRAMME COSTING

7.1.PROGRAMME MANAGEMENT COSTS

The following tables describe the running costs for the PMO for the next twelve months and for IIP Programme resources that might work within the services themselves but are still deemed as supernumerary or interim.Each of the IIP Programmes is responsible for managing its own budget and recruitment of substantive and interim resources. The PMO has got a mixture of resources working out of the PMO itself although they don’t necessarily have reporting lines directly into the PMO. This will be reviewed over the coming weeks to ensure the most effective and efficient structure to support the delivery of the IIP programmes.An interim governance process (see Fig 15 below) is also being introduced to ensure that we have control over recruitment and the on boarding processes5

Project lead identifies

additional need to Programme

Director

Resource available internally

Arrange/Negotiate

secondment

YES

AATR1* approved?

Log risk and escalate to IIP

programme Director

NO

Recruit/ EngageYES - identifysource

Deploy resourceONBOARD

Interim Support Engagement process

NO

Signatures required from:Programme Exec Lead

Programme DirectorDirector of FinanceExec Director for IIP

Finance department reviews interim

consultancy contract and signs

* Appointment of Additional Temporary Resource Form

Fig 15 - Interim Governance process for Interim/temporary support to the IIP



5 Samples of PMO reporting and other process templates can be found in the Appendices



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Plan

SECTION 8- STAKEHOLDERS





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8.STAKEHOLDERS

8.1.STAKEHOLDERS PROFILES

Understanding our stakeholders will help us manage their expectations and their levels of influence and interest in the IIP. Although it is sometimes an uncomfortable analysis to share publicly it is an essential part of programme management, there are numerous examples of large scale change programmes and projects that have failed because organisation did not understand their stakeholders, their level of expectation and their power to derail the programme or project. Therefore we will undertake a detailed profiling exercise to ensure that we don’t fall into the same trap. So we will be asking ourselves some or all of the following questions and reviewing them on a quarterly basis:

• What financial or emotional interest do they have in the outcome of our work? Is it positive or negative?

• What motivates them most of all?• What information do they want from us?• How do they want to receive information from us? What is the best way of

communicating our message to them?• What is their current opinion of our work? Is it based on good information?• Who influences their opinions generally, and who influences their opinion of us? Do

some of these influencers therefore become important stakeholders in their own right?• If they are not likely to be positive, what will win them around to support our

programmes and projects?• If we don't think we will be able to win them around, how will we manage their

opposition?• Who else might be influenced by their opinions? Do these people become stakeholders

in their own right? The outcome of the profiling exercise (the profiles) will be shared with the SRO’s.

8.2.STAKEHOLDER MAPPING & MANAGEMENTHow and when we communicate with our various stakeholders is critical to the success of the programme, so coupled with the IPP Communications Strategy we will pro-actively manage our stakeholder communications to ensure that our stakeholders are kept informed about the progress of the IPP and its constituent programmes.The following diagram (Fig 16) representative of how we will map our stakeholders and define the type and level of communications with them. As the IPP progresses through the various stages of Definition, Development Delivery and Assurance individual stakeholders will move up and down the grid depending on their level of interest and influence in the programme at a given point in time.





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KEY:1. CEO HEFT 2. DoF HEFT3. Chair HEFT4. Dep CEO5. Monitor Impr Dir6. Chief Nurse

7.Director of Operations 8. Programme Director -IPP 9. Programme Director - Gov 10.Programme Director - UC 11.Programme Director - SC12.Programme Director - C&E

13.Programme Director - Mort 14. Programme Director - IM&T15. Monitor16. CCG’s17. NHSE18. Director of Clinical Gov19. Head of OD20. Clinical Direcors

KEEP INFORMED

MAINTAIN INTEREST

ACTIVE CONSULTATION

KEY PLAYERS - Critical partners

WRITTEN

MOREFACE TO FACE

LEVE

L O

F IN

TERE

ST

INFLUENCE

21. Andrew Windsor - Income 22. Consultants & Junior Docs23.Ward managers & clerks24.Estates & Facilities25. Staff26.Commissioning Support Unit.27.Health and Wellbeing Board28. Patients

1

2

3

4

56

7

89

1011

12

13

14

15

16

1718

19

20

21

22

23

24

25

26

27

EXAM

PLE

28

Fig 16 - Stakeholder map

We will centralise communications with our key stakeholders through the communication team. Developing a core database of our stakeholders and tracking our interaction with them will ensure we are communicating consistently and effectively. The trust stakeholder communications plan is currently being updated, and will then be further developed using the feedback from the stakeholder review, currently being carried out on behalf of the trust by Deloitte.





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Plan

SECTION 9- SCHEDULING & MILESTONES





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9.SCHEDULING/MILESTONES

9.1.THIRTY DAYS (O+30)The next 30 days will be focused on ensuring that we have stabilised the IIP and it’s constituent programmes, as stated in 13.1 - Gateway Schedule. The following schematic (Fig 17 ) describes other PMO focussed activities that will take place during the next 30 days.It is evident that the IIP has lost some of it’s earlier momentum and grip so it is vital that we reinvigorate the programme as quickly as we can whilst at the same time increasing staff awareness of the programme and it’s objectives. We will need to overcome what is often referred to as “change fatigue” and the perception in some areas that they are being “done to” and that HEFT is placing too much emphasis on interim support and programme boards.As we will be making some changes to processes and documentation the next thirty days are likely to be punctuated with periods of frenetic intensive activity so that we do not lose any further momentum.One of the key features of 0+30 will be the Programme gateway reviews.

All programmes to have Gateway review 0

Review of PMO

templates

W/C 27/4 W/C 4/5 W/C 11/5 W/C 18/5

Adjust &

Streamline

Implement & EmbedChanges

Implement and Embed newley developed IIP Metrics

PMO Resource review - to ensure sufficient capacity to support IIP

delivery

Embed new B/R/A/G reporting format and reporting timetable

HEFT/ Monitor

Stakeholder Meeting

20/5

W/C 25/5

Fig 17 - The next 30 days





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9.2.SIXTY DAYS (0+60)By the time we reach the end of the first thirty days of the recovery phase we will have a clear understanding of which of the IIP programmes are performing to the required standard and which require support and intervention.So during 0+60 (see Fig 18 below) we will be undertaking “deep dives” on the full range of constituent projects and work streams to carry out similar analysis. During this period we will also be reviewing the BRAG reporting format to ensure that we are meeting Monitors expectations and providing the desired level of assurance - should we conclude that we are not we will establish a small task and finish group to deliver a remedial action plan .We will also be initiating a series of “re-ignition” events for the IIP to ensure that we regain the early momentum and engagement. These will be based on a the “European Cafe” format where different groups of staff from all levels of the organisation come together for short sharp high intensity workshops/briefing events.

Stakeholder profiling and mapping

MonitorSubmission

18/6

W/C 1/6 W/C 8/6 W/C 15/6 W/C 22/6

GovernanceProgramme Board - 25/6

IIP “re-ignition”

Events

Embedding the new Communications plan

Commence project/work stream “deep dives”(Gateway 2*)

Review effective use of new B/R/A/G reporting format and reporting timetable to ensure

compliance ready for next reporting cycle

HEFT/ Monitor

Stakeholder Meeting

20/6

W/C 29/6* this is based on the assumption that projects and work streams have undergone a Gateway 1 - Business Case

ScheduledCare

ProgrammeBoard

3/6

Fig 18 - The next 60 days

9.3.NINETY DAYS We intend to gain momentum very quickly over the next 30 and 60 days so we fully expect that a number of challenging but nevertheless important milestones will need to be achieved during this period.The following diagram (Figure 19) describes the next 90 days in the life cycle of the rejuvenated IIP and PMO. This diagram identifies a selection of some of those milestones.





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Days 0+30 Days 0+60 Days 0+ 90

See 9.1 0+30 days

See 9.2 0+60 days

When the process for ongoing review and actioning of 2ww delay reasons are embedded

May

Plann

ed C

areUr

gent

Care

Morta

lityGo

verna

nce

Cultu

re an

d En

gage

met

June July August

When the 7day a week service in AEC is established

When a standard forward planning process for periods of increased demand is implemented

A selection of Milestones that are due to be delivered in the next 90+ days

When full SOP Protocol for board rounds is implemented

When rapid assessment and treatment process for majors is implemented.

When the Medical redesign for Consultants across BHH is complete

When a written policy for the management of outliers is implemented

When an effective recruitment strategy for senior staff is implemented

When AEC is the default for emergency medical referrals

When the single PTL / waiting list is launched

When the processes for management of patients on an Open Clock Pathway are embedded

When the Trust achieves avoidance of all breaches of the 52 week standard

When the Implementation Plan to be developed to deliver the Reconfiguration is complete

When the new Mortality Policy is implemented across Directorate

When the Engaging Leadership Programme starts

When the Senior Leaders have implemented a systematic and effective cascade process

When the Trust values and behaviours are introduced

When the patient metrics are in place

When the PMF Framework is implemented across Organisation

When the Governor engagement exercise is complete

When the Kennedy work stream is closed

When succession planning system is in place

When the Forward Training Programme is complete

Figure 19 - The next 90 days





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Plan

SECTION 10- RISK





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10.RISKS

10.1.MANAGING RISKS WITHIN THE PORTFOLIO

As the IPP is going to follow MSP methodology it makes sense to use a recognised Risk management methodology, Management of Risk (M_o_R) that aligns to MSP. We will be managing risk and issues not just recording them. We will use a standard 5x5 scoring matrix for likelihood and impact as depicted in Fig 20 below:

1 2 3 4 5

2

3

4

5

1

Risk = Likelihood x Impact

EG - Likelihood 3 x Impact 3= Risk score 9= Amber

1 2

2

3 4 5

3

4

5

4 6 8 10

6 9 12 15

8 12 16 20

25201510

Likelihood

IMPACT

Fig 20 - Risk Matix

Each programme within the IIP will be required to maintain it’s own Risk Register that feeds into the main IIP risk register. Each project/Work stream will be expected to feed into the programme risk register and to manage risk effectively, escalating risks to the Programme Director if particular risk(s) start to increase in likelihood and impact.Risk management must become a business as usual discipline within HEFT, and reform of the approach to risk management is a major work stream within the Governance programme. The IIP programme has the resources and expertise to provide wide ranging in-house training on risk management practices and methodologies.The PMO will support a number of risk awareness and management training events as part of the work around the implementation of the new BAF. Each programme and constituent project and work stream will undertake a risk workshop in May 2015, recognising that this is a retrospective exercise we believe that it is an essential step to confirm that we have captured all the risks, developed robust mitigation plans and made the links to other programmes and projects. The following diagram (Figure 21)describes the minimum information that will be required for the risk registers:





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UIN Risk description

Risk owner

Risk score

Risk actionee Mitigation planRisk

responseMitigated risk score Comments

Unique identification number- assigned by

the PMO and identifies the risk throughoutthe lifecycle of the

programme

Describes what the risk is and where it originates

from and how it will be manifest

The senior manager orDirector whose business area

is most effected by the risk

This is the result of multiplying the impact

score (1-5) by the Likelihood score (1-5) i.e. Riskscore = 3 x 5 = 15

The individual or departmentwho will be responsible for

managing and delivering the agreed response to the risk

This will describe the Trust's approach to risk management of

this particular type of risk - Transfer,Terminate, Treat/Mitigate,

Tolerate

Describes the actions that willbe taken to reduce the likelihood andimpact of a given risk or group of risks

The recalculated risk scoreafter the mitigation has been taken,

sometimes referred to as the residual risk

Date raised

The date the risk was first discussed and entered into

the Risk log

Fig 21- Risk register entry guide

10.2.LINKS TO STRATEGIC RISKSOne of the main work streams in the Governance programme is the redesign and implementation of a much more robust risk management framework for the Trust. This is due to be in place by early September 2015 - in the run up to that implementation the PMO will work collaboratively with the Governance programme to ensure that programme risks are fully analysed and mitigation plans fully developed and recorded in the strategic risk register if the risk is deemed to be of such magnitude that it constitutes a strategic risk to HEFT.





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Plan

SECTION 11- CONSTRAINTS





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11.CONSTRAINTS

11.1.TYPES OF CONSTRAINTS

11.2.External

At the time of writing of this plan the Country is officially in Purdah6 which places obvious constraints on HEFT and indeed Monitor from making announcements about major reconfigurations in public services. The General Election itself provides uncertainty and constraints for all public sector bodies, especially this general election due to the complete uncertainty of the outcome. Certain outcomes of the election may provide an endorsement of HEFT’s plans whilst other outcomes may not and may initiate other demands on HEFTS reconfiguration plans or even more radical intervention.11.3.Internal

The main internal constraints that are likely to impact the delivery of the IIP are related to resource, insufficient capacity may slow down the programme , insufficient capability could threaten delivery overall.

11.4.POTENTIAL IMPACTThe internal constraints are likely to slow down the delivery in the first instance, prolonged resource starvation will of course introduce change fatigue and resent across the front line staff body initially i.e “we have heard it all before” and then there is a risk that this will potentially spread upwards through the senior management ranks and possibly even to Executive level.The external constraints have to a degree receded at the point when this final draft has been published. The outcome of the General election is now known and to all intents and purposes we can say with some confidence that the direction of travel will likely remain the same as it was pre-election.



6 Purdah is the pre-election period in the United Kingdom , specifically the time between an announced election and the final election results.[1] The time period prevents central and local government from making announcements about any new or controversial government initiatives (such as modernisation initiatives or administrative and legislative changes) which could be seen to be advantageous to any candidates or parties in the forthcoming election. Where actual advantage to candidates is proven in law based on precedent cases to have been given this amounts to a breach of Section 2 of the Local Government Act 198



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Plan

SECTION 12- COMMUNICATIONS





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12.COMMUNICATIONS

12.1.TACTICAL APPROACH FOR THE IIPEffective, clear and engaging communication is critical to the success of any major programme of change; HEFT’s IIP is no different. It is our intention to pursue a proactive communications approach to ensure that our messages are focussed and unambiguous. Our approach will be proportionate, driven, not least by the need to safeguard the reputations of HEFT and our partner organisations whilst at the same time providing transparency around progress and processes. The delivery of the communications and engagement strategy will be the responsibility of the IIP PMO and Heart of England’s communication team.

12.2.OBJECTIVESTo ensure that staff and stakeholders understand the changes that are taking place, and feel engaged and supported throughout the process by keeping them updated, using effective channels of communications including sufficient opportunities for feedback. We will work across all IIP programme areas to support delivery of the key objectives: • Improving the quality of care, including the outcomes, the safety and the experience for

all;• Engaging with patients, carers, staff, our community, stakeholders and partners to

redesign our services to provide improved access to services at the right time in the right place; and

• Innovating and researching new treatments and new ways of delivering care.The key work streams for the communications team are broadly defined below.

12.3.SUPPORTING THE IIP IMPLEMENTATIONClearly set out the overall programme’s strategy that will be used to communicate with key stakeholders and partners over the life cycle of the programme.We will: • Ensure that we communicate programme information in a timely and accurate manner

which is open and transparent;• Establish tailored local and cross CCG Borders stakeholder engagement processes;• Ensure a process for strategic coordination across the participating organisations to

ensure consistent messages and timelines;• Help staff to understand the vision for the delivery of the IIP;• Build awareness and involvement in the transition process;• Build trust and confidence in the process;





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• Ensure staff can raise and share their concerns, thoughts and ideas;• Help staff to feel enthused and motivated to be part of the new arrangements;• Support the HR processes around the transformation processes; and• Ensure key external stakeholders are kept informed and involved – particularly EMB,

Trust Board, Monitor, Staff Forums & Patients and their friends and families..

12.4.CLINICAL COMMUNICATIONincreasing knowledge about safety and risk and improving patient flow, patient quality, and trust performance against all clinical targets.We will:• Work closely with clinicians to improve the way we communicate with our front line staff,

through face to face regular meetings;• Explore the tools that are most effective for engaging out internal audience through

research• Develop a handbook (hard copy and online) which all front line staff can access easily

and which can be readily updated, which contains information on our targets and current status;

• Produce a series of guides which clearly explains to all staff our processes and procedures;

• Develop specific communications packages around Mortality, Urgent Care and Scheduled Care improvement plans;

• Continue to work closely with the IT team to support implantation of all IM&T systems and help with communicating any planned changes to staff effectively.

12.5.GOVERNANCE

Sufficient and effective Board, management and clinical leadership capacity and capability, as well as appropriate governance systems and processes.We will:

• Support the organisation in the development and delivery of its strategic objectives; • Support the implementation of new systems and processes;• Communicate changes to any governance effectively;• Promote a trust wide understanding of the need for improving governance .

12.6.CULTURE AND ENGAGEMENTDevelop a working environment in which staff feel significantly more engaged, and to reap the benefits of the associated improvements in performance and patient outcomes. We will:





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• Improve communications with governors and stakeholders, working in consultation to streamline and target our message and delivery channels;

• Clearly define our stakeholders through mapping; • Have a clear plan which addresses the issues raised in the Deloitte stakeholder review;• Fully support the patient engagement work stream by developing a plan to support

effective communications with patients about how to give feedback to the trust; • Fully supporting the Staff Engagement programme with the introduction of the values,

quality champions.We will achieve this by clearly identifying our internal channels, facilitating engagement across teams and promoting synergy.We will provide structure and guidelines for clear communications within a vast organisation where responsibility is devolved in order to empower teams to communicate with their audience and we will offer support where necessary.Ultimately we will provide a strong sustainable framework for effectively communicating with our staff, stakeholders and the media, which is fit for purpose and enhances the reputation of the trust both regionally and nationally.

12.7.RESOURCES

Currently the trust’s communications resources are disparate and need to work more effectively together. Corporate services functions such as events, web design, intranet management, graphic design, multimedia, and GP communications are not controlled within the communications team.As a team of five the focus has historically been on reactive external communications so has needed some reorganisation. In order to fully support the implementation of the IIP we are in the process of reorganising the current communications team and are taking on 3 new members of staff. Of these three one will primarily support the overall IPP delivery, one will support the culture and staff engagement agenda. The existing internal communications officer will lead on clinical communications. The Head of Communications will support the team, attend relevant meetings and specifically support governance and stakeholder work alongside patient experience.The other team members will focus on external communication and have a strong focus on becoming a proactive rather than reactive public relations function. Our external communications strategy will be broadly aligned to the internal communications strategy with subtle changes in messaging as appropriate to the audience(s) being targeted.Managing the interdependencies of the communications requirements within a programme of this size and complexity is challenging, we have chosen to work on the communication as a close group within one team to try to minimise the risk of silo working and duplication of effort. There is currently no budget allocation for communication to support the implementation of the IIP other than funding for one post. This needs to be resolved.





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12.8.IMPLEMENTATIONOver the next 30 days we will have the resource in place to produce a clear strategy and timeline to support the IIP. This will outline deliverables for each key communications work stream within the IIP. Implementation of the IIP Communications Strategy will take place during the latter half of May 2015 and will be fully embedded by the end of June.Each IIP Programme will be expected to allocate sufficient resource to manage the communications plan for their programme. They will be expected to work closely with the HEFT communications team and the Organisational Development senior management team to ensure that outgoing messaging is well thought out and appropriately targeted.The plan will support a go live date of September 2015 (we will try to bring this forward). It will also include details on how this will be measured and evaluated and sustained in the future.





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Plan

SECTION 13-GATEWAY REVIEWS





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13.GATEWAY REVIEWS

Although the original OGC Gateway review process has now ceased to be a service offered by Central Government the process and logical review stages still have merit and still add valuable oversight and assurance to public sector programmes.

Programmes

Develop programme

mandate

Start Programme

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Manage Delivery

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Develop Business

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Gateway 5Operational

review

Close Project

Gateway 5Benefits

Realisation

Figure 22 - Gateway review process

We will compliment the Gateway process with the self assessment processes and challenges that P3M3 provides7 around :

• Management Control; • Benefits Management; • Financial Management ;• Stakeholder Engagement ;• Risk Management; • Organizational Governance; • Resource Management.Each programme will undergo a retrospective Gateway 0 review to assure the decision and/or identify any flaws or gaps in the strategic assessment that supported the decision to initiate the programme in the first instance.Individual projects and work streams will be subject to a set of reviews during the life cycle of the project as shown in Fig 22 above.



7 Further details of which can be found in the Appendices



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13.1.SCHEDULE OF REVIEWSThe formal review schedule, which commenced in May 2015 utilising Deloitte , Programmes will be further reviewed by the Gateway panel ( see 12.3) in the first instance in June 2015 and quarterly thereafter. Projects will be reviewed monthly and will be required to submit a monthly highlight report and weekly project status report (PSR).For the purposes of scheduling each project will be assigned a unique identification number (UIN) - for example a Governance project will could have the following UIN - IIP-GV-018. The following tables sets out the timetable for May, subsequent schedules are contained in the appendices.

Programme W/C 25/5 W/C 1/6 W/C 8/6 W/C 15/6

Urgent Care X - GW-0

Scheduled Care X- GW-0

Mortality X-GW-0

Governance X-GW-0

IM&T X - GW-0

Culture and Engagement X - GW -0

Table - Gateway 0 review schedule - Programmes

Programme Project W/C 22/6 W/C 29/6 W/C 6/7 W/C 13/7

Urgent Care

Scheduled Care

Mortality

Governance

IM&T



8 UIN used for the Gateway process will be aligned to the UIN numbering system being implemented for Programme workbooks and other reporting architecture.



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Programme Project W/C 22/6 W/C 29/6 W/C 6/7 W/C 13/7

Culture and Engagement

Table - Gateway 1 review schedule - projects/work streams

13.2.DESCRIPTION OF REVIEW

Each review will be a structured review with a set agenda circulated in advance and will centre on check and challenge around the key themes identified above from the P3M3 project assurance methodology.

13.3.GOVERNANCE AND RESOURCES FOR THE REVIEWSThe Gateway review process will be accountable to Trust EMB and will report monthly to them9.The review panel will work on a “Star Chamber” approach10 - (“a court or other group that meets privately and makes judgements that can be severe”) with standing panel members and individual SRO’s required to attend as necessary. The standing members of the panel will be:

• Deputy Chief Executive and Medical Director (or delegated Deputy);• IIP Programme Director;• Finance representative;• Head of PMO.



9 This may be by way of a verbal update or a written brief depending on the length of the Board agenda

10 This approach can also be adopted for the CIP Programme(s) if and when it comes into the IIP



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Plan

SECTION 14-APPENDICES





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14.APPENDICES

14.1.APPENDIX I -CCG “UNIT OF PLANNING”

Fig 23 - Unit of planning





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14.2.APPENDIX II - PMO SAMPLE TEMPLATES

Fig 24 - Project exception report

Fig 25 - Project exception report





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Fig 26 - Highlight report





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Fig 27 - Sample project closure and review report





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Define project brief

Define project scope

Define initial milestone plan

Define the business case

Project Startup and Initiation

Project Planning Project Delivery Project Closure andBenefits realisation

Prioritise and schedule project

Manage change and progress

Manage communications

Develop comms plan

Refine project plan

Document project plan (Gant format if preferred)

Develop risk and issues logs

Launch project

Manage project outputs/products

Manage project stages

Close project

Review project outcomes

Evaluate benefits realisation

Direct/Manage Project

Document and review lessons learned

Fig 28 - Project stages





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14.3.APPENDIX III - SAMPLE OF AN OUTCOME RELATIONSHIP MAP

Seamless integration between Community Mental Health Teams, Community Health

Services & Social Care Teams achieved

1

More working with voluntary and

community sector

2More care & support provided at home or

near to home

3

Better integrated services

4

Fewer handovers5

More effective & efficient care

provision

6Reduced need for

nursery & residential care

7

Better joint commissioning arrangements

8

More use of community-based

services

9

Reduced demand for emergency & planned

hospital care

10

Reduced costs11

Single commissioning process, services &

work

12

Better managed admissions &

discharge

13

Transfer delays eliminated

14Reduced pressure in

A&Es & wards

15

Reduced stress16

Better care17

Faster & better recovery

18

Figure 28 - Outcome relationship map





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14.4.APPENDIX IV - MAIN IIP DASHBOARD

Figure 29 - Screenshot of IIP Metrics Dashboard - Sample data





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14.5.APPENDIX V - MONITOR UNDERTAKINGSOn the basis of the grounds set out below, and having regard to its Enforcement Guidance, Monitor has decided to accept from the Licensee the enforcement undertakings specified below pursuant to its powers under section 106 of the Act.Monitor has agreed to accept and the Licensee has agreed to give the following undertakings, pursuant to section 106 of the Act:Improvement programme:

• The Licensee is developing an Integrated Leadership Support and Resilience Programme ('the improvement programme') in response to leadership, clinical and governance concerns including those identified in the mortality review and the governance review;

• The Licensee will provide Monitor with its improvement programme covering the period from 1 January 2015 to 31 March 2015 by 23 January 2015, or such day to be subsequently agree;

• The Licensee will provide Monitor with its improvement programme covering the period from 1 April 2015 to 31 July 2015 by 13 February 2015, or such day to be subsequently agreed;

• .The Licensee will agree with Monitor:• milestones for the delivery of each major element of the improvement programme

and;.• success measures to monitor the delivery of the programme

For the period between 1 January 2015 and 31 March 2015 by 31 January 2015, or such day to be subsequently agreed, and for the period between 1 April 2015 and 31 July 2015 by 27 February 2015, or such day to be subsequently agreed.• The Licensee will implement the improvement programme according to the milestones

agreed with Monitor;• The Licensee will monitor its performance against the improvement programme and will

send Monitor written monthly updates summarising its performance. The monthly updates will:

• include actual performance against the actions outlined in the improvement programme;

• include any failures to deliver or risks to the delivery of actions in line with the milestones agreed for the improvement programme;

• include details of any mitigations to the identified failures to deliver or risks to delivery;

• include actual performance against the success measures agreed with Monitor;• be sent to Monitor for the first time in respect of February 2015;





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• be sent to Monitor within fourteen working days of the end of the month to which the written update relates; and

• be sent to Monitor until such time as Monitor agrees that the improvement programme has been delivered in full or the monthly updates are no longer require;

• The Licensee will implement comprehensive and effective management and governance arrangements to enable the delivery of the improvement programme. Such arrangements will as a minimum enable the Licensee's Board to:

• Obtain clear oversight over the progress in delivering the improvement programme;• Obtain an understanding of any risks to the successful achievement of the

improvement programme; and• Hold individuals to account for the delivery of its actions.

Improvement Director• The Licensee must cooperate with an Improvement Director appointed by Monitor for

the purpose of monitoring the work of the Licensee's Board and overseeing the implementation of the Licensee's improvement programme. In particular the Licensee must;

• Invite the Improvement Director to attend meetings of the Board, and permit the Director's participation at such meetings;

• Allow the Improvement Director reasonable access to the Licensee's premises; and• Provide such information, and allow such access to documents or records, as the

Improvement Director may reasonably request.





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14.6.APPENDIX VI - INTERIM GOVERNANCE ON BOARDING FORM

Figure 30 - Temporary resource on- boarding form





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HEFT IIP Dashboards

DRAFT FOR DISCUSSION ONLY

Integrated Improvement Programme Dashboard Reporting Period: 21/05/2015

Culture and Engagement Mortality

What will we deliver? Current Month

DoT What will we deliver? Current Month

DoT

1.00 1.00

1.00 1.00

2.00 1.00

1.00

How will we measure success? 2014/15 Outturn

Current Month

DoT 2015/16 IIP Target

2015/16 YTD Actual 2015/16 FOT How will we measure success? 2014/15 Outturn

Latest data DoT 2015/16 IIP Target

2015/16 YTD Actual

2015/16 FOT

Permanent Culture Metric (TBD by 30/09/2015) Avoidable mortality (TBD by 01/01/2016)National Survey Overall Engagement Score 3.53 N/A 3.63 SHMI 109.20 104.70 100.00 Staff Engagement Survey (FFT) Staff Recommender Index % (Likely / Very Likely) 51% N/A 61% Deaths per Week 98.00 53.00 TBCStaff Engagement Survey (FFT) Staff Recommender Index Mean Score 3.26 N/A 3.40

Scheduled Care Urgent Care



DoT

1.00 1.00

1.00 1.00

1.00


Current Month



Current Month


2015/16 YTD Actual

2015/16 FOT

Reduction in admitted pathways backlog 1,309.00 N/A 589.00 Time to Treatment in Ed (Minutes) - Admitted (95th Percentile) 981.80 683.00 480.00 Percentage of patients waiting less than 42 days (First OP appointment) 64.28% 61.43% 80.00% Time to Treatment in ED (Minutes) - Non-admitted (95th Percentile) (TBD by 30/04/2015) 298.00 269.00 240.00 Median wait time for 2 week cancer wait 12.50 13.00 10.00 Patients length of stay of 14 days or more 340.00 343.00 250.00

Median Time to Treatment in ED (Minutes) 63.00 52.00 60.00

Governance Recovery IM&T



DoT

1.00 1.00

1.00 1.00

1.00 1.00

1.00 1.00

1.00

1.00


Current Month



Current Month


2015/16 YTD Actual

2015/16 FOT

Governor Engagement Questionnaire Metric (TBD post analysis by 1/08/2015) TBC Total number of open PMS2 system generated anomalies 50.00 50.00 0.00Formal Complaints Metric (TBD by June 2015) TBC Overall how satisfied are you with the service you received? 100.00% 92.31% 95.00%Percentage of Cost Improvement Plans with approved Quality Impact Assessment 18% 19% 100.00% Percentage of Service Desk calls resolved within SLA 97.30% 96.76% 97.00%Percentage of SUIs closed within 60 days 25% N/A 95.00%Number of patients falling twice or more during the same admission� 32.00 50.00 TBC Indicator to be developed by Programme Team

SOL Urgent Care Redesign

Engagement:A more engaged workforce through the definition and implementaion of a Trust-wide staff engagement programme

Mortality Governance Process:Refine and implement revised governance process and supporting mechanisms to capture and review mortality data with supporting processes

Values and Culture:Define a set of Trust values and embed within the culture of the organisation

Mortality Education:Develop and roll out education programme to improve Executive and Clinical understanding with regards to mortality information

Leadership:Define and implement a bespoke Trust Leadership Development Programme

Future Information Requirements:Research best practice and define Trust vision for mortality analytics

Coding:Improve clinical engagement and understanding of clinical coding

Planned Care / RTT:Implement series of initiatives to comply with nationally mandated scheduled care targets

BHH Urgent Care Redesign

Cancer:Implement series of initiatives to comply with nationally mandated cancer targets

GHH Urgent Care Redesign

Kennedy Review:Assess residual work and transfer to PMO; determine executive lead and map in to action plan

Strategy and Market Review:Develop a Trust IM&T strategy to support the Trust Corporate strategy

Strategy Development and Planning:Develop Trust strategy and establish a Data Quality Strategy and Stakeholder Engagement Survey

Improving Performance Management and Data Quality:Implement a Performance Management Framework, associated reporting data quality and governance strategies and processes

Patient Experience:A refreshed patient experience dashboard and systems to ensure learning and remediation are in place

PMS2 Recovery:Review of PMS2 to ensure fit for purpose and reliable and subsequent remediation of issues identified

Governor Engagement:To assess, refresh and implement governor engagement arrangements

Competence:Review of competence and capability of the ICT Function to support the Trusts needs and subsequent remediation of issues identified

Management of Risk and BAF:Implement revised Board Assurance Framework to strengthen the understanding of key strategic risks. Develop committee reporting structure to Trust Board.

IM&T Governance and IM&T Project Governance:Develop and implement a Trust IM&T governance structure and IM&T programme governance arrangements

HEFT IIP Dashboards 18 05 2015.xlsx - Summary 1


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HEFT IIP Dashboards


CULTURE AND ENGAGEMENTHAZEL GUNTERALEX COVEY

OVERVIEW OF MILESTONES

Project % Complete AssessmentEngagement 67% On targetValues/Culture 35% On targetLeadership 13% Behind Schedule

KEY METRICSENGAGEMENT

VALUES / CULTURE

LEADERSHIP

DETAILED MILESTONES

% Complete Date Due Assessment

100% 01/05/2015 Completed on time




70% 03/06/2015 On target

0% 01/07/2015 On target0% 31/07/2015 On target

70% 19/06/2015 On target

30% 19/06/2015 Behind schedule



70% 31/05/2015 Behind schedule5% 30/06/2015 Behind schedule0% 31/07/2015 Behind schedule


10% 31/07/2015 Behind schedule0% 31/12/2015 Behind schedule0% 01/04/2016 Behind schedule0% 30/06/2016 On target

Last Updated: 18th May 2015Heart of England NHS Foundation Trust Culture and Engagement Dashboard

Launch values based appraisal process for Board and complete full appraisal cycle.

Resource now in place to take forward

CommentaryKey OutputThe completeness of the engagement workstreamsThe completeness of the values and cultures workstreamsThe completeness of the leadership workstreams

Plan in place and on track, event scheduled and distribution of pre-surveys commenced

Key Output

Scheduled to go to Board for sign off 02.06.15

Resource requirement identified for OD Manager, interviews w/e 15.05.15

Survey in place

(NB: ED reports to Urgent Care Improvement Board.) 5 events held, 9 additional events scheduled

Agree baselines for all nine categories of the quarterly Pulse Staff Engagement Survey and forecast targets for the 3 key enablers.Values / Culture

Identify and recruit appropriate resource accountable for delivery of the values implementation plan and appraisal process.

Resource requirement identified for OD Manager, interviews w/e 15.05.15

Define and develop permanent culture metric once values are agreed.

PROGRAMME:SENIOR RESPONSIBLE OFFICER:

PROGRAMME DIRECTOR:

Undertake analysis of first quarterly Pulse Staff Engagement Survey results at Trust level.

Implement "Engaging Teams" programme for first cohort

Develop and agree Trust values through Trust wide consultation for Board approval and sign off.Develop a locally led Trust values implementation plan.

CommentaryEngagement

Committee dates planned, ToRs etc established

Preparation of new quarterly Pulse Staff Engagement Survey based on WWL model.

Implement Workforce Committee chaired by NED and a Staff Engagement Steering Committee chaired by Chief Executive.

Implement senior led Staff Engagement Events reporting to the Staff Engagement Steering Committee.

Roll out Pulse Staff Engagement Survey across 25% of the workforce per quarter.

Provide clear analysis of current leadership development programmes within the Trust.

Implement succession plan for all executive board members.

Leadership

Define current and future leadership needs. Initial stakeholder meetings underwayConduct a gap analysis between defined needs and current status

Develop a practical plan to improve leadership across the Trust.Agree a bespoke Leadership Development Framework and then implement a bespoke Leadership Development Programme.Implement a system to monitor and track delivery of the Leadership Development Programme.

Identify current leadership support active across the Trust within senior teams and, ensuring a cohesive approach, communicate the support available.

2.00

2.50

3.00

3.50

4.00

Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16

Scor

e

Temporary Culture Metric Staff Engagement Survey (Pulse)

Clarity Enabler

Actual Target

0%

20%

40%

60%

80%

100%

Q32014/15

Q42014/15

Q12015/16

Q22015/16

Q32015/16

Q42015/16

Permanent Culture Metric

Actual Target

2.00

2.50

3.00

3.50

4.00

Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16

Scor

e

Temporary Culture Metric Staff Engagement Survey (Pulse)

Trust Enabler

Actual Target

Board Succession Plan

Staggered delivery of 1+1 Succession Plans commencing from Q1 2016/17.

Metric provider: Alex Covey

Last provided: N/A Next expected date: July 2016

3.53

3.63 3.75 3.80

2.5

3

3.5

4

4.5

Scor

e

National Staff Survey Overall Engagement Score

Actual Target

45% 51% 54% 57% 59% 61%

35%

45%

55%

65%

75%Sc

ore

Staff Engagement Survey (FFT) Staff Recommender Index

% (Likely/Very Likely)

Actual Target

3.24 3.26

3.28 3.31 3.34 3.40

2.20

2.60

3.00

3.40

3.80

Scor

e


Mean Score

Actual Target

0%

50%

75% 100% 100%

0%

20%

40%

60%

80%

100%

Executive Board Members roles with an approved Succession Plan

Actual Target

Staff Engagement Survey (Pulse) Clarity and Trust Enablers

Enablers scored out of five. Range

typically 2.0-4.0.

Awaiting first actual measure following Pulse survey results for

Q1 2015. No target available until Q2 2015 Pulse survey results are

calculated and volatility understood.


Last provided: n/a

Permanent Culture Metric

Indicator to be developed by 30.09.2015


Last provided: n/a Next expected date: October 2015

NSS Overall Engagement Score.

Annual measure - scores out of five.

Typical range for a high score is 3.8 and low score is 3.6.


Last provided: 30th April 2015 Next expected date: April 2016


% and Mean Score

Answer to question: How likely to recommend Trust as a place to work?

% = proportion of positive recommendations (either a score of 4 (likely) or 5 (very likely)).

Mean = reflects average of all five scores from all responses.

Metric provider: Alex Covey Last provided: 30th April 2015 Next expected date: July 2015

TBC upon agreement of Values and delivery of Values implementation plan.

IIP PMO recommended

HEFT IIP Dashboards 18 05 2015.xlsxCULTURE AND ENGAGEMENT 2


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IM&TJONATHAN REXCAROLINE SADLER

OVERVIEW OF MILESTONES

Project Key Output % Complete AssessmentPMS2 Recovery

Review of PMS2 to ensure fit for purpose and reliable and subsequent remediation of issues identified. 100% On target

Competence Review of competence and capability of the ICT Function to support the Trusts needs and subsequent remediation of issues identified.

70% On target

IM&T Governance and IM&T Project GovernanceDevelop and implement a Trust IM&T governance structure and IM&T programme governance arrangements. 77% On target

Strategy and Market Review Develop a Trust IM&T strategy to support the Trust Corporate strategy. 20% On target

KEY METRICSPMS2 Recovery

Competence Indicators

DETAILED MILESTONES


100% 31/03/2015 Completed on time100% 01/02/2015 Completed on time100% 01/04/2016 Completed on time100% 28/04/2015 Completed on time100% 31/05/2015 Completed on time

100% 28/02/2015 Completed on time100% 31/01/2015 Completed on time100% 31/01/2015 Completed on time20% 30/09/2015 On target0% 30/06/2015 On target0% 30/09/2015 On target

100% 28/02/2015 Completed on time65% 30/09/2015 On target80% 01/06/2015 On target


40% 31/08/2015 On target

0% 31/05/2015 On target15% 31/05/2015 On target80% 01/06/2015 On target

0% 31/07/2015 On target

0% 11/09/2015 On target

Last Updated: 18th May 2015Heart of England NHS Foundation Trust Culture and Engagement Dashboard

Commission and perform a full technical review of PMS2.


PROGRAMME DIRECTOR:

Commentary

Note the competence and capability will be revisited once the ICT strategy is drafted and again once the ICT strategy is finalised.

Key Output CommentaryPMS2 Recovery

Identify and recruit an interim ICT Director.

Reinstate the PMS2 project board.Develop and deliver enhanced PMS2 training for end users. Ongoing - training commenced in April as planned.Project sign off by the Project Board.Review lessons learned from the PMS2 project and implement an associated action plan. PMS2 User Group established to exploit leassons learned and action plan as per Business As Usual.CompetenceIdentify and recruit a NED capable of providing challenge relating to IM&T.

Establish a clinical IM&T sub-group with an agreed terms of reference and membership to provide clinical input to IM&T projects.

Commission and perform an independent review of the ICT function and capability.Develop and implement an action plan following the independent review of the ICT function and capability.Revisit the competence requirements upon agreement of the draft ICT strategy.Revisit the competence requirements upon agreement of the final ICT strategy.IM&T Governance and IM&T Project GovernanceEstablish an IM&T Steering Committee with suitable executive sponsorship. IM&T Steering Committee established and operational. Chaired by the relevant NED.

Establish and pilot the CCIO position to lead the clinical IM&T sub-group. CCIO resource confirmed. Interim Director of ICT to advise confirmation to proceed.Review, refresh and implement IM&T governance process and arrangements and enforce for new projects.

Governance arrangements for all existing in-flight projects to be reviewed and refreshed as necessary. IM&T Steering Committee and Clinical IT Committee in place to review Governance. CCIO post to support Governance requirements.

Obtain feedback on the draft IM&T strategy.

Refine the IM&T strategy and submit for Board approval.

Strategy and Market ReviewCommission and perform an independent strategic and market review.Perform strategy workshops with the clinical sub-group and representatives from the directorates. Dates scheduled for 3 x workshops at BHH, GHH and Sol.Develop an initial draft of the IM&T strategy. Meetings commenced. Deloitte to develop ICT strategy.

01,0002,0003,0004,0005,0006,0007,0008,0009,000

No.

of A

nom

alie

s

Open PMS2 System Generated Anomalies

Actual

88%

90%

92%

94%

96%

98%

100%

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

Overall how satisfied are you with the service you received?

Satisfied Target

90%

92%

94%

96%

98%

100%

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

Service desk calls resolved in SLA

Actual Target

Overall ICT Satisfaction Score

This is based on a monthly survey requesting feedback and measuring overall satisfaction for the ICT team. The

percentage of respondents who were satisfied overall is measured each month by this means.

Metric provider: Jonathan Rex Last provided: 14th May 2015

Next expected date: 14th June 2015

Service desk calls resolved in SLA

The percentage of calls resolved within agreed Service Level Agreements by the ICT helpdesk.

Metric provider: Jonathan Rex Last provided: 14th May 2015


Clearance of PMS2 System generated anomalies

This metric represents the number of open issues with regards to PMS2 System generated anomalies. Note this does not

include anomalies generated by user error.

Metric provider: Jonathan Daniels Last provided: 28th April 2015

Next expected date: 28th May 2015

IIP PMO recommended

HEFT IIP Dashboards 18 05 2015.xlsxIM&T 3


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GOVERNANCE RECOVERYSAM FOSTERANGELA HOPPER

KEY MILESTONE TRACKER

Project Key Output % Complete Date Due Assessment

Board Leadership and Development

Develop a clear set of values and behaviours for the Trust and improve board cohesion N/A N/A N/A

Patient Experience A refreshed patient experience dashboard and systems to ensure learning and remediation are in place 29% 30/06/2015 On target

Culture and Values Development

Implement an Organisation Development Plan N/A N/A N/A

Governor Engagement To assess, refresh and implement governor engagement arrangements 62% 30/07/2015 On target

Management of Risk and BAFImplement revised Board Assurance Framework to strengthen the understanding of key strategic risks. Develop committee reporting structure to Trust Board.

9% 30/09/2015 On target

Kennedy Review Assess residual work and transfer to PMO; determine executive lead and map in to action plan 90% 29/06/2015 On target

Strategy Development and Planning

Develop Trust strategy , Annual planning process and Stakeholder Engagement process 29% 31/03/2016 On target

Improving Performance Management and Data Quality

Implement a Performance Management Framework, associated reporting data quality and governance strategies and processes 54% 30/06/2016 On target

KEY PERFORMANCE TRACKERPATIENT EXPERIENCE

GOVERNOR ENGAGEMENT

MANAGEMENT OF RISK AND BAF

Apr-13May-13Jun-13Jul-13

Aug-13Sep-13Oct-13Nov-13Dec-13Jan-14Feb-14Mar-14Apr-14

May-14Jun-14Jul-14

Aug-14Sep-14Oct-14Nov-14Dec-14Jan-15

Replaces "Communication and Information reporting" and "People Engagement"


PROGRAMME DIRECTOR:

Commentary

N/A: Transferred to Culture and Engagement workstream

N/A: Transferred to Culture and Engagement workstream

Replaces "Improving Risk Management" and "Improving structures and committee membership"

18% 19%

0%

20%

40%

60%

80%

100%

120%

28/0

4/20

15

05/0

5/20

15

12/0

5/20

15

19/0

5/20

15

26/0

5/20

15

02/0

6/20

15

09/0

6/20

15

16/0

6/20

15

23/0

6/20

15

30/0

6/20

15

07/0

7/20

15

14/0

7/20

15

% of CIP Plans with approved QIA

Trust Target Actual Planned Improvement

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Governor Engagement Metric


Governor Engagement Questionnaire

Governor questionnaire to be developed by 30.04.2015, analysis to

be carried out mid July

Metric provider: Kevin Smith Last provided:

Next expected date:

Issue 1

Complaints often have more than one issues raised therefore the primary number is not fully reflective of the

possible areas of concern.

The second figure represents where attitude and behaviour is a sub theme.

National Averages and Planned

Improvements TBC by SRO.

Metric provider: Richard Brown Workstream lead: Helen Shoker

Last provided: 28th April 2015 Next expected date: 13th May 2015

0

20

40

60

80

100

120

0%

5%

10%

15%

20%

25%

30%

2014/15 May Jul Sep Nov Jan Mar

Formal complaints closed within planned timescales

Trust Target Actual Planned Improvement Total Complaints

119 151

123

303 288

213

247

23 23 19 25 0

50

100

150

200

250

300

350

Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16

No.

of C

ompl

aint

s

Top three areas of formal complaints Issue 1 - Staff Attitude and Behaviour

National Average No. of complaints for Issue (All)

Planned Improvement (All) Total Complaints

No. of complaints for Issue (Primary) Planned Improvement (Primary)

Patient Complaints

Trust currently achieving 26.5% of complaints response within 25 working days.

The trust is developing complaints handling which is

alligned to national guidance and regulatory compliance, anticipated to implement July 2015.

This will provide robust complaint handling data, by which performance can be measured.


Last provided: n/a Next expected date: 13th May 2015

230 218

179

303 288

213

247

38 33 24 29

0

50

100

150

200

250

300

350

Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16

No.

of C

ompl

aint

s

Top three areas of formal complaints Issue 2 - Delays and Cancellations




92

120

88

303 288

213 247

0

50

100

150

200

250

300

350

Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16

No.

of C

ompl

aint

s Top three areas of formal complaints

Issue 3 - Query Appropriate Treatment




Issue 2




National Averages and Planned

Improvements TBC by SRO.



Issue 3




Awaiting primary reason data for this

issue.



To be defined once questionnaire rolled out

% of QIAs with conditions approved at Trust Board

Metric to be developed as part of Trust's new QIA approval process.

Metric provider: Aidan Quinn

Last provided: n/a Next expected date: n/a

0

5

10

15

20

25

30

35

May

-13

Jul-1

3

Sep-

13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

No.

of p

ress

ure

ulce

rs

Number of grade 2 hospital acquired pressure ulcers determined as avoidable

Actual - Grade 2

0

10

20

30

40

50

60

70

80

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Number of patients falling twice or more during the same admission (April 13 - March 15)

Target Actual Planned Improvement

0

20

40

60

80

100

120

140

160

180

Apr-

12

Jul-1

2

Oct

-12

Jan-

13

Apr-

13

Jul-1

3

Oct

-13

Jan-

14

Apr-

14

Jul-1

4

Oct

-14

Jan-

15

Apr-

15

Jul-1

5

Oct

-15

Jan-

16

IR1 Medication - Administration Errors


Number of patients falling twice or more during the same admission

Target TBC as part of contractual

negotiations by 31.05.2015

Metric provider: Diane Povey Last provided: 28th April 2015

Next expected date: 22nd May 2015

Medication IR1

The number of medicine administraton errors reported each

month.

Trust target to be developed as part of contractual negotiations by

31.05.2015

Metric provider: Tim Burroughes Last provided: 13th May 2015


0%

20%

40%

60%

80%

100%

120%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

% of QIAs with conditions approved at Trust Board


25%

3

0

1

2

3

4

5

0%

20%

40%

60%

80%

100%

Q4 2014/15 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16

% of SUI closed within 60 days

Actual Planned Improvement Total no of SUIs

To be developed

% of CIP Plans with approved QIA

All CIP plans will have undertaken a Quality Impact Assessment by Medical

Director and Director of Nursing as part of the new QIA process being

developed by Finance to review each new CIP plan as developed and

approved.

Metric provider: Adam Winstanley Last provided: 13th May 2015

Next expected date: 22nd May 2015

% of SUI closed within 60 days

To comply with new statutory national guidance

Metric provider: Sarah Carr-Cave

Last provided: 28th April 2015 Next expected date: July 2015

Number of grade 2 hospital acquired pressure ulcers determined as avoidable

Target TBC as part of contractual

negotiations by 31.05.2015

Metric provider: Diane Povey Last provided: 13th May 2015


IIP PMO recommended

IIP PMO recommended

Data from April 2015 may be

subject to change

Monthly Reporting to be developed

Monthly Reporting to be developed Monthly Reporting to be developed

Monthly Reporting to be developed

HEFT IIP Dashboards 18 05 2015.xlsxGOVERNANCE RECOVERY 4


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IMPROVING PERFORMANCE AND DATA QUALITY MANAGEMENT

DETAILED MILESTONES


60% 30/06/2015 On target

50% 30/06/2015 On target

50% 30/09/2015 On target

5% 30/09/2015 On target



10% 08/07/2015 On target0% 30/07/2015 Not started

100% Active from Jan 2015 Completed on time100% Active from Jan 2015 Completed on time

Improving Risk Management5% 05/06/2015 On target0% 18/08/2015 On target

10% 15/07/2015 On target

10% 31/08/2015 On target



10% 30/09/2015 On target

75% 31/03/2016 On target


0% 15/06/2015 On target

40% 08/09/2015 On target

100% 30/04/2015 Completed on time50% 24/05/2015 On target

0% 30/09/2015 On target

0% 30/11/2015 On target0% 31/03/2016 On target0% 01/08/2015 On target0% 01/08/2015 On target

100% 27/01/2015 Completed on time100% 31/03/2015 Completed on time

0% 30/06/2015 On target100% 30/04/2015 Completed on time98% 19/05/2015 On target0% 30/06/2015 On target


100% 19/12/2014 Completed on time80% 31/05/2015 On target50% 31/05/2015 On target0% 31/06/2015 On target0% 30/03/2016 On target

Last Updated: 18th May 2015Heart of England NHS Foundation Trust Governance Recovery Dashboard

Draft strategy developed. To be submitted to Board 26.5.15. External capacity provided to support this.

Data quality metrics agreedDQ Strategy implemented - Refresh Divisional and Board architecture for DQ

Core KPI’s across domains including divisionally specific KPIs approved by EMBCore KPIs approved by Board Agreed PMF architecture specifically for the FPC is in placeCommunication plan for PMF including launch eventPMF embeddedDraft Data Quality Strategy

Staff consultation completed. Analysis in progress.

Process developed for engaging external stakeholders in developing corporate strategy (Recovery and On-going) Not yet started

Dependent on Board approval

Going to June Board

DQ Strategy approved by IGC

Core KPI’s across domains including divisionally specific KPIs proposed to executives

Identify supporting strategies including Quality StrategySupporting strategies specified and developed and aligned to corporate strategy Planning processes and cycle which enable:-Definition of strategy owners and stakeholders; delivery schedules-Delivery of directorate, other clinical and supporting strategies which include outcomes-Stakeholder engagementAnnual planning process and cycle communicated to all key staffOrganisation operating according to planning process and cycleAgreed overall future role for the newly established Citizens Assembly as well as its role in strategy development

PMF approved by Board

Draft PMFPMF approved by EMB

New BAF Committee and divisonal board structure and report pathways launched

Divisional leaders trained (interdependent on Leadership programme within Culture and Engagement workstream)

Due to start 15.6.2015

Corporate strategy developed with evidence of stakeholder engagement and clear responsibilities and timelines for delivery of strategic goals

Documented shared expectations including programme for governor training and evaluation process Dependent on outcome of workshopBoard members presentations to governors on a rotational basis BAURoutine reports from Executive team highlighting key issues (ahead of meetings to enable time for review) BAU

Board Assurance Framework (to include committee structure improvement) drafted BAF work commenced with external support

Board trained on BAF (interdependent on Leadership programme within Culture and Engagement workstream) Workshop planned for 15/7/15

Working with IIP leadership to design launch events

Risk management strategy drafted First draft completePlanned for 17/7/15

Finance to issue or CIP scheme to GM's and CD's for QIA completion

Develop SEIP policy to include QIA approval and monitoring structures

Risk management strategy launched at Board Planned for 8/9/15

Establish weekly meeting report to review QIA at SIEP meetingsFinance provided summary status and next steps to chief nurse and chief medical officer

Facilitated workshop session on shared expectations Workshop booked

Refreshed patient experience metrics clearly visible across Trust and prominent within BAF and PMF; also visible to external stakeholders Collaborative action plan in place to deliver

New systems developed and documented which ensure learning from events, trends and best practice; remediation and evaluation of interventions to demonstrate impact / improvement

Linked to BAF & PMF workstreams

Sub Board leadership teams appropriately use systems to inform achievements, performance and delivery Linked to BAF & PMF workstreamsUpdated web site functionality for patient feedback and engagement Scoping commencedGovernor Engagement

Questionnaire to assist in understanding between Governors and Trust BoardQuestionnaire issued and responses starting to arrive. Reminder sent.

Board Assurance Framework agreed As above

Refreshed patient experience dashboard fed in to PMF work stream Dashboard progressing in line with strategy development

Key Output CommentaryPatient Experience

Patient experience metrics and feedback processes assessed against ‘what good looks like’ and remediation plan documented12/14 actions have commenced, 2 have risks associated with timescales

On track

New serious reporting framework (March 2015) and never events guidance implementedTarget date for policy refresh is 15/06/2015 (June EMB to approve)

DQ Strategy embedded and Board applying suite of metrics to assure on data quality

Risk management strategy approved by QRC

Citizens Assembly has informed Trust strategy development & review processImproving Performance Management and Data Quality Management

Initial metrics to go to Board in May

Strategy developed and agreedGoing to IGC in MayGoing to IGC in MayDependent on above

Shared with execs and approved by PMBAs aboveJune Board

Comms aligning with wider workstream

Discussed at exec meeting 13.5.15

Scheduled to reestablish working group for annual planning process development 09/09/2015

Strategy Development and Planning

Process developed for engaging internal stakeholders in developing corporate strategy (Recovery and On-going)


Placeholder: KPI to be defined upon definition of data quality metrics

HEFT IIP Dashboards 18 05 2015.xlsxGOVERNANCE RECOVERY 5


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SCHEDULED CAREJONATHAN BROTHERTONAMANDA MARKALL


Project Key Output % Complete Month Due AssessmentPlanned care/RTT Implement series of initiatives to comply with nationally mandated scheduled care targets 63% 31/03/2016 On targetCancer Implement series of initiatives to comply with nationally mandated cancer targets 41% 31/12/2015 On target

KEY METRICS

Mar-15Apr-15

May-15Jun-15Jul-15

Aug-15Sep-15Oct-15

Nov-15Dec-15Jan-16Feb-16Mar-16

DETAILED MILESTONES


50% 31/03/2016 On target


30% 31/12/2015 On target

60% 30/06/2015 On target

75% 31/03/2016 On target

65% 30/09/2015 On target

75% 31/05/2015 On target

10% 31/12/2015 On target

40% 30/09/2015 On target

40% 31/08/2015 On target

Last Updated: 18th May 2015Heart of England NHS Foundation Trust Scheduled Care Dashboard


PROGRAMME DIRECTOR:

Commentary

Key Output CommentaryPlanned Care/RTTMonitor and manage performance against trajectories Unvalidated position positive, with performance ahead of trajectory

The Trust will have no avoidable breaches to 52 week standard There were however 59 unavoidable breaches due to the closure of legacy open clock pathways and this will continue until all legacy open clock pathways are closed.

Centralise management of all surgical specialty IPWL Directorate meetings planned with remaining non-centralised specialties in June and July

Agree and embed processes to ensure appropriate management of patients on an Open Clock Pathway Processes have been agreed and are being closely monitored until they are fully embedded.

Transfer all waiting list management standalone systems to PMS2 Only 3 out of 100 systems still outstanidng to be transferred. Plans are in development to migrate and a manual data quality process is being developed for all 3 systems in theinterim to mitigate any risk.

Ensure that no "category 1" patient will have their surgery cancelled due to "no bed" There have been no cancellations of patients on BHH or Solihull sites with, or suspected of having cancer in April. There was 1 cancellation on the BHH site due to no Critical Care bed. RCA has been undertaken, escalation process has been reiterated and further actions have been put into place.

Cancer

Implement new best practice pathways in Urology and Lung to improve 31/62 day performance Whilst fundamental agreement has been reached for some elements of both pathways, consistent improvement in performance is yet to be seen. A refresh of both pathways is taking place in May with workshops with the MDT planned.

New trajectory to be agreed based on revised plans which illustrates an improvement in performance and achievement of 93% 2 week wait standard Individual specialties' plans to deliver a median wait time of 10 days or less to be in place by end of May.

Through delivery of revised plans reduce the median wait time to 10 days or less by cancer site. Only 1 cancer site out of 10, achieved a median wait of 10 days in April. 70% of cancer site median wait times were 12 or 13 days. No site had median wait times over 13 days.

Develop and embed processes with CCG to share information and find solutions to improve levels of patient choice breaches. Fundamental agreement and support from CCG address patient choice breaches. Gynaecology referral form will be launched in early June following cross organisatonal facilitation by CCG. Referring GP has to acknowledge on all new referral forms (skin has already been launched and urology and lung are in development), that the patient has been told they are on a cancer pathway. An electronic audit of all new referral forms will take place in Q2 and Q3 and the results of this will be discussed directly with GPs and at CCG forum. Regular communications regarding 2ww guidance is sent to all GPs. Further work in Q1 to identify conversion rates by GP practice to be undertaken and circulated. Conversion rates for some sites is as low at 4% Patient stories to be anonymised and circulated to GPs to highlight the importance of patients being made aware at referral that they are on a cancer pathway.

0

200

400

600

800

1,000

1,200

1,400

1,600

Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16

No

of P

atie

nts

Admitted Pathways Backlog Trajectory

National Target Actual Planned Backlog Clearance

Admitted Pathway Backlog

This indicator demonstrates the expected reduction in backlog of patients waiting more than 18 weeks for their care to be completed on an admitted pathway. The rise in backlog in Quarter 2 reflects the expected increase in

backlog in Gastroenterology which will begin to reduce in August .

Acheiving the expected reduction in backlog will enable the 90% Admitted RTT Standard to be acheived.

National submission of RTT data occurs on the 14th working day of each month. Performance for April is expected to be ahead of trajectory and will be available on the 22/5/15.

Metric provider: Robert Watkins

Last provided: 28th April 2015 Next expected date: 22nd May 2015

40%

50%

60%

70%

80%

90%

Apr-13 Aug-13 Dec-13 Apr-14 Aug-14 Dec-14 Apr-15 Aug-15 Dec-15

% of patients waiting less than 42 days for first OP appointment


0

2

4

6

8

10

12

14

16

Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15

Days

Median wait time for two week cancer waits


% of patients waiting less than 42 days for first OP appointment (surgical specialties and gastroenterology)

Data shows % of patients waiting less than 42 days for first OP appointment

for those patients who have had a first appointment. The data measures the time from their referral into the Trust, up until that date of first attendance.

This indicator demonstrates the expected increase in patients being seen withing 42 days of GP referral received in the organisation ,to patient being seen in an out patient clinic.

Acheiving the standard of 80% will provide greater certainty that patient pathways (both Admitted and Non -Admitted) will be completed within 18 weeks,as there will be adequate time to undertake necessary diagnostic

and theraputic procedures.

Metric provider: Robert Watkins Last provided: 13th May 2015


Median wait time for two week cancer waits

This indicator demonstrates the expected reduction in median wait time s for patients on a 2 week wait pathway, from GP referral to being seen in an out patient clinic ,or for Upper and Lower GI , to undergoing diagnostic

endoscopic proceure. Acheiving the standard of 10 days or less will significantly imrove performance of the 2 week wait standard and

, for those patients who are positibvely diagnosed , will give greater certainty that their treatment will be completed within 31 or 62 days.


Last provided: 13th May 2015 Next expected date: 13th June 2015

IIP PMO recommended

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URGENT CAREJONATHAN BROTHERTONANDREW STENTON


Project Key Output % Complete Month Due Assessment

BHH Urgent Care Implement series of initiatives to improve compliance with the national emergency care 4 hr standard. 27% 31/03/2016 On target

SOL Urgent care Implement series of initiatives to maintain compliance with the national emergency care 4 hr standard. 34% 31/03/2016 On target

GHH Urgent Care Implement series of initiatives to improve compliance with the national emergency care 4 hr standard. 18% 31/03/2016 On target

KEY METRICS

04/05/1405/05/1406/05/1407/05/1408/05/1409/05/1410/05/1411/05/1412/05/1413/05/1414/05/1415/05/1416/05/1417/05/14

DETAILED MILESTONES


29%30/03/2016 On target

20%30/03/2016 On target

33% 01/10/2015 On target33%

01/07/2015 On target

29% 30/03/2016 On target10%

01/10/2015 On target

35%08/01/2016 On target

47% 01/10/2015 On target

25%30/08/2015 On target

20% 13/10/2015 On target

27%08/01/2016 On target

50%30/09/2015 On target

11%30/11/2015 On target

14%30/10/2015 On target

40%30/09/2015 On target

20%31/10/2015 On target

15%30/09/2015 On target

10%31/07/2015 On target

Last Updated: 18th May 2015Heart of England NHS Foundation Trust Urgent Care Dashboard

Improving ED flow to improve patient experience and reduce 4 hr breaches GP in ED model agreed, first phase in place. Additional ED consultant cover in place.

Development of a site-wide bed reconfiguration plan Bed requirements assessed. Ward 3 opened - effectiveness to be assessed.

Develop and approach that sustains effective communications with all stakeholders Initial discussions with GPs gaining ground towards joint developments

AMU and short stay areas development Acute Medical cover in place 7 days per week Initial frailty model in place.

Development of the Ambulatory Emergency Care Process Revised opening hours in place with temporary solution.

Development of improved patient flow, discharge and Post Acute Care ie: Discharge to Assess Business Case developed. Drive 4 Discharge process in place

GHH

Key Output CommentaryBHH

Interim staffing structure in place, Real time bed information project progressing

Consolidated Plan to Improve Discharge Significant progress for targeted pilot wards

SOL

Development of Site Escalation and Site Office Structures and Systems Interim staffing solution in place Business Case nearing completion

Development of the Ambulatory Emergency Care Policies reviewed and agreed, model of care agreed

Improvement Programme for the AMU and Short Stay Areas Bed model and senior staffing model agreed

Consolidated Plan to Improve Discharge 'Improving Discharge' initiative continues to be driven until embedded.

Improvement programme for the ED Departments Interim solution in place for staffing model

Development of Site Escalation and Site Office Structures and Systems

Development of improved Post Acute Care Provision to support early discharge Discharge to assess discussions progressing

Develop and deliver supporting Comms and Engagement for the whole programme Successful roll-out of Drive 4 Discharge initiative with good understanding and engagement

Improvement programme for the ED Departments Clarification of roles and enhancement of senior clinician availability. Plan completed for Majors Area expansion

Development of the Ambulatory Emergency Care AEC established, agreements on additional opening hours for BHH

Improvement Programme for the AMU and Short Stay Areas Drive 4 Discharge process in place

Focus on improvements in ED following initial improvements in flow

Focus on maintaining performance


PROGRAMME DIRECTOR:

Commentary

Focus on creating flow in Acute pathways.

100

200

300

400

04/05/14 04/10/14 04/03/15 04/08/15 04/01/16

No.

of P

atie

nts

Patient length of stay of 14 days or more

National Target Actual Planned Improvement

300

400

500

600

700

800

900

1,000

1,100

Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug-15

Min

utes

Time in the Emergency Department - Admitted (95th percentile)

Admitted Target Admitted Actual Planned Improvement

0

10

20

30

40

50

60

70

Feb-

14

Mar

-14

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

Min

utes

Median Time to Treatment in ED

Target Actual

150

200

250

300

350

400

Feb-14 Jun-14 Oct-14 Feb-15 Jun-15 Oct-15 Feb-16

Min

utes

Time in the Emergency Department - Non-admitted (95th percentile)

Non-admitted Target Non-admitted Actual Planned Improvement

Patient length of stay of 14 days or more

This 14 day indicator demonstrates the

number of patients on site at midnight,whose Length of Stay exceeds 14 days. Achieving the Trust target of 250 would support the release of beds

which will improve flow on site and reduce front end pressure.

Metric provider: Mark Patel

Last provided: 13th May 2015 Next expected date: 20th May 2015

Median time to Treatment in ED

This ED indicator reflects the amount of initial delay experienced by a patient once they have arrived in ED. Any delays at this point can have a significant impact on 4hr

breach performance. This indicator is crucial and supports the Trust's intention to improve the current breach profile to

meet and exceed the national emergency care standard



Time in the Emergency Department - Admitted

(95th percentile)

This indicator demonstrates the average length of time patients will wait, who require admission to an acute bed. The target for the Trust being 4 hrs or less. Achieving and

maintaining this level of performance will be a result of the improvement

work around the ED, AMU and Hospital Flow projects.


Last provided: 14th May 2015

Time in the Emergency Department - Non-admitted

(95th percentile)

This indicator demonstrates the average length of time patients will wait, who are discharged from the Trust. Early decision making by a senior clinician within ED in

this respect will help will improve the 4 hr performance.



IIP PMO recommended

HEFT IIP Dashboards 18 05 2015.xlsxURGENT CARE 7


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MORTALITYCLIVE RYDERANN KEOGH


Project Key Output % Complete Date Due Assessment

Mortality Governance ProcessRefine and implement revised process and supporting mechanisms to capture and review mortality data with supporting governance process

60% 28/02/2016 On target

Mortality Education Develop and roll out education programme to improve Executive and Clinical understanding with regards to mortality information

5% 31/01/2016 On targetOn target

Future Information Requirements Research best practice and define Trust vision for mortality analytics 5% 31/12/2015 On targetCompleted on time

Coding Improve clinical engagement and understanding of clinical coding 30% 31/01/2016 On targetCompleted late

KEY METRICS

DR FOSTER, QUARTERLY SHMI

PeriodFY2014/15 Q1FY2013/14 Q4FY2013/14 Q3FY2013/14 Q2FY2013/14 Q1FY2012/13 Q4FY2012/13 Q3FY2012/13 Q2FY2012/13 Q1FY2011/12 Q4FY2011/12 Q3FY2011/12 Q2

Oct 11-Sept 12Jan 12-Dec12Apr 12-Mar13Jul 12-Jun 13Oct 12-Sept 13Jan13-Dec 13

DETAILED MILESTONES



30% 30/06/2015 On target

5% 31/08/2015 On target


10% 28/02/2016 On target


Coding30% 31/05/2015 On target20% 31/01/2016 On target


Last Updated: 18th May 2015Heart of England NHS Foundation Trust Mortality Dashboard

Review current Mortality and Morbidity Performance Group, including ToR, membership, roles and responsibilities and agree reporting governance


PROGRAMME DIRECTOR:

Commentary

Key Output CommentaryMortality Governance Process

Agree pro forma and screening method for mortality case review

Identify resources to support pilotsLead resource identified and discussions commenced on potential role. First round interviews for interim support were unsuccessful, further applications received and interviews to be scheduled.

Pilot redefined Trust process with AMU and CardiologyInitial scoping completed with AMU and completed in broad agreement. Initial scoping session with Cardiology to be scheduled.

Delivered all engagement as a mixture of open event or targeted events by Directorate

Submit proposal to Trust Board outlining the governance and reporting arrangements for MMPG within the Trust BAF.Pilot analysis and full Trust roll out of compulsory process to all Clinical Groups or Directorates

Define mechanism to identify and approve Quality Improvement schemes and governance to support improvement monitoring Mechanism defined conceptually. Documentation and consultation to be performed before piloting.

EducationDraft and agree education materialsDevelop schedule and timetable of engagement events

Draft Business Case for Trust Board approval for development of Trust advanced mortality / morbidity analytics capability

Scope and develop clinical coding work stream to improve clinical engagement in coding Plan developed for priority areasComplete visits to each directorate to increase clinical engagement in coding Visits have commencedFuture information requirementsUndertake visits to exemplar organisations with regards to advance mortality / morbidity analytics Two visits completed, remainder identified and to be scheduled.

Four box Screening and Review Metric This tool will allow us to identify avoidable mortality. SRO and

Programme Director to develop metric by 01.01.2016

Metric provider: Last provided:

SHMI The latest Summary Hospital-level Mortality Indicator (SHMI) score for Oct 13

to Sept 14 is 104.7, which is within the ‘as expected’ banding. An equivalent metric for HSMR is being considered for future iterations by the

SRO, Programme Directors and the PMO.

Metric provider: Dylan Gibbons Last provided: 13th May 2015 Next expected date: May 2016

0

20

40

60

80

100

120

140

2011-Q4 2012-Q2 2012-Q4 2013-Q2 2013-Q4 2014-Q2 2014-Q4

HSM

R Ra

tio

Seven Day Mortality (HSMR Ratio)

Trust Target Weekend Weekday

0.80

0.90

1.00

1.10

1.20

1.30

1.40

1.50

2011-Q4 2012-Q2 2012-Q4 2013-Q2 2013-Q4 2014-Q2

Four Box Screening and Review Metric


Avoidable Mortality placeholder. Pilot by July 15. Launch across Trust

December 15.

0.80

0.90

1.00

1.10

1.20

1.30

1.40

1.50

2011

-Q4

2012

-Q1

2012

-Q2

2012

-Q3

2012

-Q4

2013

-Q1

2013

-Q2

2013

-Q3

2013

-Q4

2014

-Q1

2014

-Q2

2014

-Q3

% of Cases Reviewed placeholder


Cases Reviewed placeholder - AMU and Cardiology by July 15. Launch across

Trust December 15.

Seven Day Mortality HSMR Further review to consider change in weekend/weekday picture over last 2 quarters

and impact of PMS2

Metric provider: Dylan Gibbons Last provided: 28th April 2015 Next expected date: June 2015

% of Cases reviewed

Metric provider: Last provided: n/a

Next expected date:

IIP PMO

% of Cases reviewed

Metric provider: Dylan Gibbons Last provided: 13th May 2015


0

20

40

60

80

100

120

14 28 42 56 70 84 98 112

126

140

154

168

182

196

210

224

238

252

266

280

294

308

322

336

350

364

378

392

406

420

434

Adult Emergency Deaths - 16 and over

2007 2008 2009 2010 2011

2012 2013 2014 2015

70.0

80.0

90.0

100.0

110.0

120.0

130.0

140.0

Apr-

07

Aug-

07

Dec-

07

Apr-

08

Aug-

08

Dec-

08

Apr-

09

Aug-

09

Dec-

09

Apr-

10

Aug-

10

Dec-

10

Apr-

11

Aug-

11

Dec-

11

Apr-

12

Aug-

12

Dec-

12

Apr-

13

Aug-

13

Dec-

13

Apr-

14

Aug-

14

Dec-

14

HMSR using Dr Fosters 95% Confidence levels

80.085.090.095.0

100.0105.0110.0115.0120.0125.0

Quarterly SHMI using Dr Fosters 95% Confidence levels

SHMI Trust Target80859095

100105110115120

SHM

I Rat

io

SHMI

Trust Target Actual

Deaths per Week This tool provides early warning of changes in death rates from the historical norm. This allows us to be aware of and consider these changes ahead of published risk adjusted data (HSMR/SHMI). There was a marked rise in the weekly number of deaths over Dec 14 which peaked at the end of Dec/ beginning of Jan 15. Associated with increased congestion in patient flow and mirrored the Flu A spike – this is in line with the findings of the Public Health England (PHE) report into seasonal flu. There was a decline throughout Jan, which has stabilised at a slightly higher number than the pre-winter level, possibly associated with a minor rise in Flu B positive cases since the start of Feb 15. Target to be developed by SRO and Programme Director.

Metric provider: Dylan Gibbons Last provided: 13th May 2015

Next expected date: 20th May 2015

75.0

85.0

95.0

105.0

115.0

125.0

135.0

Apr-

07

Aug-

07

Dec-

07

Apr-

08

Aug-

08

Dec-

08

Apr-

09

Aug-

09

Dec-

09

Apr-

10

Aug-

10

Dec-

10

Apr-

11

Aug-

11

Dec-

11

Apr-

12

Aug-

12

Dec-

12

Apr-

13

Aug-

13

Dec-

13

Apr-

14

Aug-

14

Dec-

14

Monthly Trust Summary HSMR

Sep 14 10 year Benchmark Trust mean Trust UCL Trust LCL

Potential alternative metrics to be agreed with SRO

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15

Deaths per day at the trust

Weekday Weekend




HEFT IIP Dashboards 18 05 2015.xlsxMORTALITY 8


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Minutes of Meetingheld on 14 Apr and 5 May 2015


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Minutes 14 April 2015


Minutes of a meeting of the Council of Governors

of Heart of England NHS Foundation Trust held in St Johns Hotel, Warwick Road, Solihull

on 14 April 2015

PRESENT: Mr Les Lawrence (Chairman)

Mrs A Begum Mrs K Bell Mrs E Coulthard Dr O Craig Mr R Handsaker Mr R Hughes Mr M Hutchby Mrs S Hutchings Mr P Johnson Mr M Kelly

Ms A Khan Mrs H Lane Mr A Lydon Mrs A McGeever Mrs M Meixner Mr O’Leary Dr M Pearson Mrs J Thomas Mr D Treadwell Dr M Trotter

In attendance: Mr D Cattell Dr A Catto Mr A Edwards Mrs A Hudson (Minutes)

Ms K Kneller Mrs S Foster Mr K Smith (Company Secretary)

15.031 APOLOGIES AND WELCOME

Mr Lawrence welcomed everyone to the meeting and apologised for the absence of the Chair’s Report, this had been due to IT issues; a full report would be submitted to the next meeting. The Chair welcomed Ms Natalie Shaw, of PwC, who was in attendance to present item 10. Mr O’Leary apologised for missing the last meeting as he had been in hospital at the time. Apologies for Governors had been received from Cllr Aikhlaq, Dr Burgess, Mr Fletcher, Mr Orriss, Dr Needham and Mrs Steventon. Apologies for Directors had been received from Mr Brotherton, Dr Cadigan, Mr Lock, Ms Lord and Dr Rao.

15.032 DECLARATION OF INTEREST – Governors

The Chair referred to the Register of Interests and asked that Governors notify the Company Secretary of any changes so that the Register could be updated accordingly.

15.033 DECLARATION OF INTEREST – Directors The Register of Interests for Voting Directors was noted.


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15.034 CHIEF EXECUTIVE’S REPORT

The pre-circulated report was taken as read; Mr Foster reiterated he was continuing to focus on the three main priorities of Clarity, Quality and Engagement and it was noted that: Clarity - work had commenced on reporting lines and developing the Strategy for the organisation. Quality - the main concern was around the Emergency Departments and safety issues that resulted when it became congested. Plans were in place to consider the short, medium and long term priorities. Mr Foster was working towards a more celebrated approach to quality that included encouraging staff to become Quality Champions, an initiative that had proved successful at Wrightington, Wigan and Leigh NHS Foundation Trust (WWL). Engagement - there had been 8 staff engagement events held to date with future events planned; feedback so far had been positive. The Trust had been on a difficult journey especially over the last year and Mr Foster believed the Board’s acceptance of the Deloitte Governance Report had been a critical point and catalyst to make improvements. Mr Foster formally thanked Dr Catto and the Board for supporting the changes required. Dr Pearson referred to the Deloitte Governance Report and was concerned to know whether Governors were at fault for the poor systems in governance it highlighted and questioned why Nursing was now responsible for Governance. Mr Foster responded that Mrs Foster had been appointed to lead on Governance as part of the realignment of roles in the executive team and added that in most foundation trusts Governance sat within the remit of Nursing. He went on to say that Mrs Foster was developing a document setting out the roles and responsibilities for everyone in the organisation and this would be circulated upon completion. Mrs Foster advised that she was pleased to be taking on the added responsibilities that included Governance and Patient Experience and advised that she had appointed a Governance Support Team to move work forward and agreed to prepare a briefing paper for the next meeting. Dr Trotter referred to recently circulated structures and questioned some of the changes, including that of Director of Medical Safety. Dr Catto advised that as a result of the realignment Clinical Effectiveness and Quality Improvement formed part of his portfolio and changes in structures and reporting were in transition, the role of the Director of Medical Strategy had changed and was now the responsibility of the Deputy Medical Director - Quality & Safety. Both Dr Catto and Mrs Foster emphasised that the structures in the organisation were in transition but it was clear that the Medical and Nursing teams needed to work closely together going forward. In response to a question from Mr Lydon, Mr Foster confirmed that many of the new structures of responsibility were based on those in place at WWL. Mr Lydon advised that he had resigned as a member of the CoG Quality and Risk Committee as it was his opinion that the committee was dysfunctional and seldom received minutes and reports in a timely fashion. He asked whether there was a similar issue with the Board Quality and Risk Committee in particularly citing the lack of information within the Safety Sitrep Report around the spike in mortality in 2012/13 and asked why this had not been highlighted to Governors. The Chair advised it had not been raised with Governors as the Board had been satisfied that there was no significant issue at that time.



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Mr Foster noted that as part of the work on clarity, each of his direct reports had been reviewed and each layer in turn would be doing the same. The Emergency Departments had a high impact on quality and safety and thus was the number one issue to be addressed. Dr Catto advised that heightened mortality had been raised as a risk in January 2015. The meeting discussed the earlier reference to Governance and the statutory duties of Governors. It was agreed that Mr Smith would produce a short paper setting out the distinctions between Governors’ responsibilities and Governance. (Action: KS)

15.035 INTEGRATED QUALITY & PERFORMANCE REPORT, INCLUDING FINANCE

Dr Catto presented an overview of the report. Mr Brotherton had sent apologies as he was attending the Systems Resilience Group meeting with the CCG. There were three areas of focus; 18 week RTT target, cancer targets and Emergency Departments (EDs). Work continued to address poor performance which including longstanding issues and the need to learn from shortcomings in previous strategies and a lack of modelling; rectification work included capacity modelling led by Mr Cattell and staff engagement being undertaken as part of Mr Foster’s work. The 18 week RTT target had not been achieved due to a series of issues that included, amongst other things, hidden waiting lists and IT issues. The hidden waiting lists mainly consisted of Gastroenterology patients that had come to light as a result of inefficient practices. Other factors had included higher cancellation rates for elective procedures due the number of acute patients occupying surgical beds. The Board had, that morning, discussed and agreed to extra investment to improve the situation. April had seen a return to full reporting off RTT performance; an enormous amount of work had been undertaken over the last 6 months to close open clocks, together with reviews to ensure no significant harm to patients. Cancer performance had improved despite a continued increase in demand. There had been a dip in the 62 day target in March but following improvements the Trust was back on trajectory. Urgent care continued to experience an increase in demand and flow was slow but work was underway to address this. There had been a surge in the number of 999 calls with the Trust seeing up to 10 ambulances arriving at EDs within 30 minute timeframes that resulted in unsafe EDs. Teams were demoralised as a result of the constant pressure and non-delivery of A&E standards over the last 10 quarters. The report set out a list of actions that had been put in place to help address the issues; however feedback from ED colleagues had been that they did not feel the benefit from those actions, as a result ad hoc ED listening events had taken place and steps had been taken to overhaul the escalation management system; some success had been seen including earlier ward discharges and patients movement from AMU to wards, however ED still remained the greatest operational and safety risk. Finance and Performance Mr Cattell advised that the Trust continued to spend money in a planned manner on patient care including ED and outplacement of surgical patients. The Trust had not previously planned for the right level of patient activity and this had resulted in unplanned flex which was inefficient and costly to run. It was also noted that: Capital spend was a little behind plan due to a pause whilst the Board

considered a Strategic Plan; The Trust was on track to deliver the forecasted year end position; COSR rating was 4;



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The Trust remained in a strong cash position; Contracting discussions continued in order to agree the right levels of activity for

2015/16. It was important that the Trust managed its risk in relation to excess planned activity.

Mrs Foster reported that the corporate nursing team continued to monitor staffing levels. Ward 3 at GHH had been re-commissioned. Following a visit to WWL Quality Champion work had begun. Dr Catto, Mrs Foster and the Governance Recovery Team had begun investigative work around SUIs and how the Trust could take learning forward. Staff sickness was at its lowest for six months. Fall rates had shown a downward trend over the last three months. The report on the Salmonella outbreak at the Trust been received and had been complimentary on how the Trust had handled the situation. Open visiting had commenced across all sites from the 1 April 2015 and had multiple benefits for patients and carers; the greatest benefits were for dementia and end of life patients. Following several questions from the Governors, including Messrs Hughes and Treadwell, on open visiting Mrs Foster agreed to circulate the Trust Visitor Code to Governors; it set out how the Trust would manage open visiting including night time visits. Mrs Foster added that ward sisters had the authority to manage visitors locally in order to keep the ward environment safe. Overall the benefits were expected to outweigh the burdens. (Action: SF/KS) Mr Hughes congratulated Mrs Foster and the team for initiating open visiting. He went on to ask about staff recruitment and noted that he had never seen any advertisements in the local papers for staff. Mrs Foster advised that the Trust successfully recruited regionally, nationally and worldwide. All trusts, including HEFT, used NHS Jobs to advertise for staff; HEFT also attended university open days, etc. Ms Gunter added that the Trust had just held a very successful recruitment event and several others were planned but it needed to keep in mind that recruitment and retention remained a constant challenge. Mrs McGeever noted the great work underway to improve patient flow and in response to several points Dr Catto advised that the Trust now had a long of list actions that needed to be taken to achieve effective discharges, including TTO planning. Discharge lounges had been reinstated on all sites and this had resulted in a positive impact. In response to a question from Dr Pearson about complaints analysis and in particular those related to cancelled operations, Dr Catto advised that urgent care did sometimes take precedence over elective surgery; he and Mrs Foster, who was now responsible for complaints, had arranged for the Complaints Manager from Airedale to review the Trust’s complaints processes. Mr Lydon referred to discharges and explained that he believed that Social Services had a responsibility to help get patients out of hospital and, from his own experience, knew how long this could take. He felt that the Trust needed to challenge Social Services to improve. Mr Lydon asked for an update on falls that included what type of patients experience falls. Mrs Foster advised that she would be attending the next Governors Breakfast



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Meeting, in May, to talk about falls and invited Governors to forward questions via Mr Smith prior to the meeting in order that she could provide answers to detailed questions. The Chair suggested that Mary Ross, Clinical Director for Therapies, should also attend a Breakfast Meeting to give an update on the SIDs work she had implemented to reduce the re-admittance of elderly patients. (Action: KS)

15.036 RECOMMENDATION FOR RE-APPOINTMENT OF PROF LAURA SERRANT

The Chair referred to the pre-circulated paper setting out the recommendation for re-appointment of Prof Laura Serrant to the role of Non-executive Director. The Council of Governors approved the proposal and re-appointed Prof Serrant for a second three year term with retrospective effect from 1 April 2015.

15.037 NED APPRAISALS

The Chair advised that he had carried out the annual appraisal of the longer serving Non-executive Directors (NEDs) that had included discussions around the output from the 360 degree reviews, their strengths and weaknesses and he had agreed objectives with each NED for the coming year. Although appraisals had not been undertaken for the most recently appointed NEDs, Mr Edwards and Ms Kneller, their objectives had been agreed for the coming year.

15.038 CHAIR’S APPRAISAL Mr Lawrence left the room and Mr Smith took the chair for this item of business. Mr Hughes advised that he and Mr Lock, Senior Independent Director, had undertaken the Chair’s appraisal in line with previous years, using the same process as the NED appraisals, including a 360 degree review, to which the responses had been exemplary. Some improvement was required around managing the Chair’s frustration with poor performance. Five objectives had been set: Working towards the removal of the Monitor enforcement undertakings by 1

January 2016; Taking reasonable steps to appoint a substantive Executive Team by 1 January

2016; Leading the Board to work in a cohesive manner; Engagement with key external stakeholders; Demonstrating culture change, including winning the trust of staff. Mr Lydon questioned how and when the range of responses had been gained; Mr Hughes advised the questionnaire had been completed in September and had included tick box answers and spaces for comments. Mr Lydon noted that Lord Hunt, the previous chair, had been appraised as ‘extremely satisfied’ and that the Trust had been in a difficult place ever since. He suggested that the questions asked were not critical enough and that narrative answers, rather than tick boxes, should be used. Mr Hughes agreed to take on board these comments, reiterating that no major weaknesses had been raised as part of Mr Lawrence’s appraisal process. Mr Lawrence returned to the room and resumed the chair.

15.039 Quality Account & Report Update



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Mrs Foster presented an overview of the progress made on the 2014/15 Quality Account and the setting of objectives for 2015/16. It was noted that the Quality Account was an annual report to the public from providers of NHS services. Its primary purpose was to encourage boards and leaders of NHS organisations to assess the quality of services provided. The HEFT 2014/15 Quality Account was subject to internal review, external consultation and assurance from PwC, the Auditors, and needed to be compliant with the Monitor Annual Reporting Manual requirements. The report had been submitted to the Overview and Scrutiny Committee for comment; feedback had included the need for more benchmarking data, narrative and less jargon. The draft report would be circulated to Governors as part of the consultation process. The priorities for 2015/16 were:

Reduction of grade 2 pressure sores; Improving clinical outcomes for stroke; Reduction of incidence of multiple falls; Friends and family test response rates in ED.

In response to question from Mr Lydon, Mrs Foster advised that the priorities were new and replaced those set out in the 2014/15 Quality Account, The next step was the assurance review by PwC. The Trust’s performance on 18 week RTT and cancer waiting targets would be considered as part of this review. Dr Pearson questioned whether the Trust would have the means to be able to spot another ‘Paterson’ type event. Dr Catto and Mrs Foster advised that discussions with Deloitte were ongoing regarding the development of a dashboard to track underperformance and, although it was absolute impossible to give absolute assurance, current systems were much better at picking up irregularities. In response to a question from Mr Hughes, Dr Catto advised that operations were not observed unless a specific concern had been raised but could be videoed with the relevant consent. In response to a question from Mr Lydon, Dr Catto explained he didn’t regard the number of SUI’s and never events as a problem for the organisation, given its size; he would be more concerned if he thought there was under-reporting. Dr Catto preferred a culture where all incidents were reported and then downgraded, if appropriate, as this built trust and confidence with stakeholders. Mr Foster added that ‘Paterson’ had been a shocking case and one where several people within the organisation had known of the practice but felt unable to do anything about it. Going forward it was about a changing that type of culture and empowering people to raise concerns.

15.040 EXTERNAL AUDITOR UPDATE Ms Shaw advised that the external audit of systems and controls was underway and would continue over the next 6-7 weeks at the end of which PwC would produce its opinion on the Annual Report and Accounts for 2014/15. To date no significant issues or material weakness on financial controls and systems had been identified. In respect of economy, efficiency and effectiveness, it was expected that a modified opinion would be issued as a result of the Monitor enforcements undertakings.



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15.041 MINUTES OF PREVIOUS MEETINGS

The minutes of the meetings held on 3 February 2015 and 4 March 2015 were approved as a true record.

15.042 MATTERS ARISING

14.080 Decision not to purchase Chest Clinic building – Mr Cattell advised that the Trust leased the building used by the Chest Clinic from Birmingham City Council at a very low rent and the cost to purchase and refurbish would be very high; therefore it had been agreed not to purchase but to continue to lease. Mr O’Leary questioned whether it might be appropriate for the Chest Clinic to move to more suitable premises; Mr Cattell indicated that this might also be more expensive than the current arrangement but that it would be kept under review. 14.080 Overseas patients – Mr Smith advised that this had been fully reported at the March 2014 meeting and undertook to circulate the report on this subject from that meeting. (Action: KS) In response to a question from Mr Treadwell on whether attendees at A&E should be asked for sight of their passports, Mr Cattell advised that a vast amount of work was underway nationally on managing overseas visitors accessing the NHS and a report on how these changes would affect the Trust would be presented when these were understood. 14.080 Progress of decked car park for Good Hope – the Chair explained that a report on capital prioritisation, which would address this subject, would be brought in due course. 14.082.2 Substantive chair for F&SP – discussions were ongoing. 14.082.3 Progress of hospital environment projects and attendance of Mr Sellars – The Chair had discussed this with Mr Sellars and he would routinely be attending future meetings when possible to report on such issues. 14.082.6 Consider the need to strengthen administrative support to CoG committees – the pre-circulated paper describing committee membership and support was noted. 14.084 Report on CIP/SIEP and pay bill overspend rectifications. Mr Cattell noted that this had been covered within the finance section of the Integrated Performance Report 15.017 Investigate heating issues in BHH Tower Block and report back. Mr Mike Taylor, Head of Estates, reported that an energy efficiency survey had been undertaken on the whole of the block and showed that the 40 year old heating coil system within the ceiling was outdated; however rectification work had already been undertaken to mitigate the issues, this included installation of more valves, additional insulation and installation of computerised systems to monitor temperature variances. Maintenance teams would be looking to carry-out further works including draft proofing windows in readiness for the coming winter. A full report on the planned works would be submitted to the Hospital Environment Committee.

15.043 ATTENDANCE RECORD - Governors The report was noted.



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The Chair advised that attendance records for CoG sub-committees were also being developed.

15.044 CHAIR’S REPORT

As advised at the beginning of the meeting a full report would be presented to the next ‘formal’ meeting.

15.045 ANY OTHER BUSINESS Mr Treadwell had submitted the following items:

Acronyms should be avoided in Board and CoG reports and where they are used a key should be provided – noted.

Implementation of an attendance register for members of the public to sign in

when attending Public Board and CoG meetings - noted. Mr Lydon noted that the Trust’s AGM did not see much public attendance compared to the UHB AGM and questioned whether the Trust would consider a central venue and increased publicity for the event. He also advised that UHB did not rotate its meetings between different venues. The Chair noted that UHB only had one site whereas the Trust had three main sites; therefore rotation was appropriate for the Trust. The Chair agreed to consider the suggestion of a central venue and increased publicity for the forthcoming AGM. (Action: Chair/KS)

15.046 DATE OF NEXT MEETING

5 May 2015 at the Harry Hollier Lecture Theatre, Good Hope Hospital, Sutton Coldfield. There being no further business the meeting closed.

…………………… Chairman



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Minutes of a meeting of the Council of Governors

of Heart of England NHS Foundation Trust held in the Partnership Learning Centre, Good Hope Hospital, Sutton Coldfield

on 5 May 2015

PRESENT: Mr L Lawrence (Chair)

Mrs K Bell Dr Burgess Mrs E Coulthard Dr O Craig Mr A Fletcher Prof H Griffiths Mr M Hutchby Mrs S Hutchings Mr P Johnson

Mr M Kelly Mr A Lydon Mr O’Leary Mr Orriss Dr M Pearson Ms L Steventon Mrs J Thomas Mr D Treadwell Dr M Trotter

In attendance: Mrs S Bradshaw (Minutes) Mr D Cattell Dr A Catto Prof M Cooke Mr A Foster Mrs S Foster Mrs H Gunter

Ms K Kneller Mr D Lock Ms A Lord Mr J Sellars Mr K Smith (Company Secretary) Mrs J Tunney

Members of the public 15.047 APOLOGIES AND WELCOME

Apologies for Governors had been received from Mrs Begum, Mr Hughes, Mrs Lane, Mrs McGeever, Mrs Meixner and Dr Needham. Apologies for Directors had been received from Mr Brotherton, Dr Cadigan, Dr Rao, Mr Edwards and Prof Serrant.

15.048 MONTH 12 PERFORMANCE REPORT

Dr Catto presented the on behalf of Mr Brotherton. The themes in the report were similar to the previous month’s report. The main areas of concern were urgent care, referral to treatment (RTT), 62 day cancer targets, diagnostic support (in particular endoscopy) and Gastroenterology. The increased demand in urgent care in March was noted resulting in high bed occupancy and congestion in Emergency Departments (EDs). The RTT targets had not been met in the month but RTT reporting had re-commenced and there was an improvement in the RTT admitted backlog. There had been a strong focus on Gastroenterology, where additional capacity had been agreed. There had been improvements in the 2 week wait and breast symptomatic targets. Performance against the 31 day cancer target had been good but there was a shortfall against the 62 day cancer targets. Mrs Foster presented on quality and safety issues. The biggest risks were around the emergency pathway and safe staffing. Recruitment within Europe had proved less and less successful and therefore other countries, outside Europe, were being looked at. The

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Philippines was being looked at for nurses and the University of Islamabad for doctors. The Trust’s vacancy rate remained static and there was an overreliance on agency staff. Harms continued below the national averages (pressure ulcers and falls). A review of complaints and SUI (Serious Untoward Incidents) processes was underway. The draft CQC report from the visit in December 2014 has been received to check for factual accuracy; it contained no surprises. The final report would follow. Mrs Bell asked about recruitment from Greece; Mrs Foster explained that the Trust had sent three nurses to Greece on a recruitment campaign but only managed to recruit two nurses. In response to a question from Mr Orriss regarding the lengthy delay of the CQC report, Dr Catto explained that there were two main reasons (1) a key member of CQC staff had been on lengthy sick leave, and (2) there had been much internal discussion at CQC about ratings. It was still not clear whether or not CQC would state an overall rating in the final report. Mrs Steventon asked whether the Trust came out better in this inspection than the last. Dr Catto explained that the Trust remained rated the same; mainly yellow (‘needs improvement’) with some green and some red. Dr Catto believed it was an accurate picture of how the Trust stood in December 2014. Mrs Thomas asked if the CQC would do an interim assessment before they published the final report, given the delay. Dr Catto stated that there would be no reassessment despite the delay and the fact that the Trust had made progress in some areas since the inspection. Mr Treadwell asked if the Foreign Office had been approached to assist with the overseas recruitment. Mrs Foster replied that the Home Office set the policy on the visa regime which dictated where the Trust could recruit from, also that neither the Home Office nor the Foreign Office would act as recruitment agency on the Trust’s behalf. Mrs Foster outlined a new practice that had been introduced to reduce congestion in Emergency Departments (ED). The new scheme was ‘safer placement on wards’ and placed a limited number of ED patients awaiting discharge and transfer on wards related to their condition. These patients were nursed beside the nurses’ station. In practice this had meant one extra patient on eight separate wards in Good Hope. This approach had good clinical engagement. Dr Catto explained that this was a measure that had been carefully thought through; he referred to research which indicated that patients preferred to be placed on a ward, pending discharge, rather than in ED. Mrs Coulthard asked whether the reinstated discharge lounge at Good Hope was helping. Mrs Foster replied that it had six beds and 19 chairs and was working well so far. Mrs Coulthard noted that there had been no beds on A&E majors available at Good Hope after 8.00pm the previous Saturday evening. Dr Catto explained that when patients arrive at A&E the Trust does whatever it can to provide appropriate treatment. Dr Pearson questioned the use of flawed mortality rates (such as HSMR) given the understanding that congestion drives mortality. Dr Catto explained that due to the problems with the introduction of the new patient administration system (PMS2), HSMR would be an unreliable mortality indicator for the Trust for a while; however the Trust was monitoring crude mortality and undertaking a review of each death to ensure that trends and spikes were understood. Dr Catto noted that mortality spikes and the flu did seem to correlate over the winter.

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Mr Kelly explained that he and the late Gerry Robinson campaigned against the closure of the discharge lounges and he was therefore pleased to see them reinstated. Mrs Foster explained that the original discharge lounge on the ground floor had not been large enough to take beds and a number of the patients awaiting discharge were bed bound, so this arrangement did not work. The new lounge could take both beds and chairs. Mr Orriss asked about parking at Good Hope in the context of discharging ED cases from wards which would require more pick up time for relatives and carers. Mr Sellars explained that the 30 minute free tariff applied across all sites. The Chair asked Mr Sellars to discuss this further at the next Hospital Environment Committee meeting. Mr Lydon asked about mortality spike in 2013/14. Dr Catto explained that mortality spikes in ED were usually a surrogate for the entire hospital and that being clinically unwell in ED was not good for patients who were exposed to greater risk in that environment. Mr Webster congratulated the Trust on moving people that were awaiting discharge or transfer from ED to wards. He went on to note that the general consensus was that the Trust was in trouble but that not enough was being done to publicise the good things that the Trust was doing. He was also concerned about the possible inappropriate use of hospitals for patients near the end of their lives. His experience with his wife, who was terminally ill, had been that she had been sent to A&E several times, against his wishes, by her nursing home. He felt that the nursing home didn’t want his wife to die in their care although her demise was expected. Dr Catto acknowledged the dilemma of care and nursing homes tending to transfer end of life patients to hospital when little or nothing could be done to prolong their lives.

15.049 REPORTS FROM COG COMMITTEE CHAIRS

Finance and Strategic Planning Mr Fletcher presented the minutes and reported that there had been problems over some dates being changed and that the meetings had been less well attended as a result. Mr Cattell apologised and confirmed that this was being looked into. Mr Fletcher reported that Mr Johnson has chaired the March meeting, which had been a good meeting, and that the committee was looking to appoint a new chair. Mrs Bell would chair the next meeting.

Hospital Environment Committee Mrs Coulthard presented the minutes and highlighted that Good Hope’s fete would take place on 18 July 2015. Mrs Coulthard reminded the meeting that the A&E canopy was being installed at Good Hope and that it was hoped that it would be finished by end month. The next meeting would be at the Chest Clinic and interested Governors were invited to attend. The new signage for Good Hope had arrived but had taken seven years to organise! The privacy domes and speakers for A&E had taken four years to organise! Mrs Coulthard also raised the issue of the Good Hope Multi-storey car park which was thought to have been ‘written off’ in the capital prioritisation programme. Mr Foster said that a multi-storey car park for Good Hope could be considered in the ten year capital strategy but it would be competing against other projects for prioritisation. Mr Treadwell reported he had raised the issue of a Doctor’s mess and was pleased to note that there now was one at Good Hope. Mrs Steventon asked about parking concessions for foster carers. Mr Sellars responded that the special rate of £10 for 20 visits was available for all patients and their carers at the relevant Ward Managers’ discretion.

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Mrs Coulthard raised the issue of there being nowhere for medical staff to eat after 3.00pm. Mr Cattell noted that F&SP was looking into this and would ask Mr Gould to prepare a report for the Hospital Environment Committee. (Action: D Cattell) Mr Orriss explained that the Good Hope car park had been approved three years previous by the Board and that he couldn’t understand why it hadn’t been built by now. Mr Fletcher noted that car parks for both Good Hope and Heartlands had been discussed for the last three or four years and he was disappointed that there had been little communication back to the Governors regarding any change of plan. Mrs Coulthard explained that Mr Sellars had described two options for the Good Hope car park to the Hospital Environment Committee a few months previous and that there had been no suggestion of the project being abandoned at that point. The Chair asked Mr Cattell and Mr Sellars to prepare a full paper on the car park history and situation for the next ‘formal’ meeting. (Action: D Cattell/ J Sellars) Membership and Community Engagement Mr Fletcher explained that the last meeting had been cancelled. Patient and Staff Experience Mr Kelly explained that DNAs had continued to decrease from 90,000 to 80,000 and the friends and family test response rate was sitting at Heartlands 44%, Solihull 45% and Good Hope 20%. Complaints were running at less than 1% of patients with the key areas being; delays and cancellations, attitudes and behaviour, appropriate treatments, poor information and medication issues. Thee PLACE inspections had showed some examples of poor conditions for staff. Dr Pearson suggested that benchmarking the complaints rate against other Trust to see how the Trust’s performance compared. Mr Orriss asked whether patients were being texted reminders as he had not been when recently attending appointments at Good Hope. Mrs Foster confirmed that patients were generally texted reminders and that this should be considered further by the Patient and staff Experience Committee.

Quality and Risk Mrs Steventon asked that the minutes from the 26 January meeting be taken as read and reported that the committee had changed its strategy to drilling down into the work of the Board Quality and Risk Committee. The issue of cross-over with the Patient and Staff Experience Committee was being considered again. Mrs Gunter had given an update on the work done by the Kennedy Task Force. Mrs Foster was coming to the next meeting on 12 May. Mr Lydon reported that he had resigned from the committee as he was not happy with the accuracy and lack of timeliness of the minutes. He felt that the executives supporting the committee were lacking grip and would have preferred more regular un-minuted meetings with quarterly formal meetings. Mrs Steventon reported that having reviewed the minutes the previous week with the minute taker, it was discovered that the draft minutes were being held up in the management chain. Mr Fletcher suggested that minutes should be sent to committee chairs within seven days. The Chair emphasised that it was important that there be no interference by Trust officers and that the draft committee minutes should go directly to the committee chairs for review. Mrs Foster said that she would resolve the issue of a suitable minute taker for committee.

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Kennedy Task Force Dr Pearson reported that he had no update on the Kennedy Task Force and that the continuing work arising from the Kennedy Report was expected to be completed through routine channels but that there might be an alternative scrutiny arrangement. It was agreed that Dr Pearson should continue to represent the CoG in relation to any new scrutiny arrangement.

15.050 REPORT ON THE WORK OF THE BOARD AUDIT COMMITTEE

Ms Lord introduced herself; she had been a Non-executive Director since May 2013 and chair of the Audit Committee since July 2013. Every foundation trust has to have an Audit Committee. The Board must put in place governance processes and systems of control. The Audit Committee reviews these and is an assurance committee - not an operational committee. Ms Lord explained that ‘reassurance’ is when someone asks if everything is okay and is told ‘yes’; by contrast ‘assurance’ is when someone asks to see that everything is okay and is shown an evidence base that demonstrates everything is okay. The Committee only Non-executive Directors as members, to ensure its independence from management, but is supported by Internal Audit, External Audit, finance and other subject experts. It should be chaired by a qualified accountant, which Ms Lord is. The Committee initiates reviews of systems and controls and looks at the outcome of those reviews, the recommendations made and the actions taken. Most of the reviews are done by Internal Audit. Internal Audit is outsourced, currently to Deloitte, in common with many large organisations. Since Ms Lord took the chair certain governance failings had been noted within the Trust, including the Board Assurance Framework. Ms Lord was a strong supporter of the Deloitte Governance Review and welcomed the huge amount of work currently being done on the improvement programme, especially that led by Mrs Foster. Under Ms Lord’s chairmanship, the Committee reviewed the work of the then current internal auditor (KPMG), went out to tender and appointed Deloitte. The new auditors provide more rigorous and advice. Each year Internal Audit undertake a series of core internal control reviews which generally give substantial assurance. This year Deloitte had carried out three reviews where moderate assurance was received (1) CQC compliance, (2) IT controls, and (3) Procurement, and a limited assurance review of the Board Assurance Framework and Strategic Risk Register. From the programme of reviews a series of recommendations are created. There were over 100 overdue responses when Ms Lord became chair; there were now only four. Ms Lord acknowledged the hard work of Mrs Angeline Jones, Chief Financial Controller, and her team in chasing responses. The results of the reviews in 2014/15 had led to the Head of Internal Audit’s Opinion being graded as one of ‘Limited Assurance’. Ms Lord also explained the work of the Local Counter Fraud Service (LCFS), conducted by Deloitte, which proactively works to deter and prosecute fraud against the Trust. This year there had been 23 referrals; as a result four dismissals and two potential prosecutions had been progressed. The Audit Committee also considers the external auditors’ reports (PwC) in relation to the Annual Report and Accounts, including the Quality Account. For the year 2014/15 it is likely that the Trust would receive a modified conclusion on economy, efficiency and effectiveness as a result of the Monitor enforcement action. PwC test three indicators in the Quality Account; one is the 18 week RTT performance, which the Trust would be unable to report on for 2015/16, so an alternative would be reviewed instead.

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Mr Lydon stated that an important issue for the coming year would be the tender for the external auditors’ service. He thought that PwC would have had to provide a modified opinion regarding economy, efficiency and effectiveness in relation to 2013/14. Ms Lord explained that they had taken expert technical advice at that time and concluded that this was not the case. Ms Lord clarified what the external audit function could and could not do. Mr Lydon asked whether the external auditors were responsible for flagging issues and whether they did. Ms Lord explained that there was an agreed process for this and confirmed that the external auditors view was absolutely objective. Mrs Steventon asked what the Head of Internal Audit’s Opinion was for 2014/15. Ms Lord replied that the outgoing auditors reported no concerns at that time. Mr Kelly asked about the performance of the previous internal auditors; Ms Lord compared it to the banking crisis in that the problems were not seen until after the event. Mr Kelly asked whether the Audit Committee dealt with debtors. Ms Lord explained that the Audit Committee looks at whether debtors are accurately recorded and the process for their management but not with specific reference to individual debtors. Mr Lydon asked whether Monitor could recommend good audit firms; Ms Lord explained that this was not something that Monitor did and explained that reputable audit firms had a checklist approach to audit and were all independent of their client organisations. Dr Pearson asked whether clinical audit was covered by the Audit Committee. Ms Lord outlined that Audit Committee sees the structure of clinical reviews but the reviews would be considered by the Quality and Risk Committee from a clinical perspective. Dr Pearson asked what Ms Lord would do if she felt that she did not have sufficient assurance. Ms Lord replied that she would raise it with the full Board; Dr Pearson suggested that such issues be raised with the Governors too.

15.051 2015/6 ANNUAL PLAN

Mr Cattell referred to the report included in the pack. The Annual Plan Return (APR) was due for submission to Monitor by 14 May and it will have its final sign off by Board Monitor Standing Committee but Mr Cattell would also take a summary of the final form plan to the F&SP. The Trust would be striving to improve its performance and governance over coming months and had developed an Integrated Improvement Plan to help to achieve this; it would also require the development of a suite of strategies. All of this would be referred to in the narrative of the APR. The plan recognised that the Trust expected to spend £10m more than it received in income to help fix the things that were broken, including performance against national targets such as 4-hour A&E, 18 week RTT and 2 week waits. Mrs Coulthard asked if the funds were in place for Surgery Reconfiguration. Mr Cattell confirmed that there was a general allowance for this but noted that the Trust wouldn’t know exactly what was required until the public consultation exercise being run by the CCGs was completed. Mr Lydon asked whether investment in sub-acute beds was a priority. Mr Cattell confirmed that this was still on the Trust’s agenda as it clearly related to flow but at this stage it was not clear what was required, or when.

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Mr Treadwell asked about emergency evacuation of patients. Mr Foster confirmed that the Trust has an emergency plan and that in the event of a full scale emergency it is normal to rely on neighbouring hospitals.

15.052 ANY OTHER BUSINESS

Mrs Steventon reminded the meeting that the Friends of Solihull Hospital would be running the Solihull fete on 30 May. Mr Treadwell asked if the trust was aware of the ‘Hug in a Hospital’ event; Mr Foster confirmed that the Trust was aware. In response to a question from Mrs Thomas, the Chair confirmed that the staff engagement events were going well and that the latest events had considered the outline strategy for the Trust.

15.053 DATE OF NEXT MEETING

2 June 2015 at The Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Solihull B90 4GW. There being no further business the meeting closed.

…………………… Chairman

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Matters Arising & Decisions/Recommendations Tracker

Dat

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Due Status

Com

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24 Nov 2014 14.080

Report to go to F&SP Cttee regarding decision not to purchase Chest Clinic building.

DC Feb2014 Oral update given to CoG. 14 Apr 15

14.080 Receive full briefing from AQ/AJ on overseas patient income.

Chair Feb2014

Report presented at March 2014 meeting to be circulated by e-mail - KS.

18 May 15

14.080 Report on progress of decked car park for Good Hope.

AC Feb2014

Report on capital prioritisation to be brought to the CoG in due course.

14 Apr 15

14.082.2

Consider arrangements for appointment of substantive chair for F&SP Cttee.

Chair Feb2014 Discussions continuing.

14.082.3

Consider issues raised by E Coulthard regarding lack of focus, grip and pace regarding hospital environment projects.

AC Feb2014

J Sellars to routinely attend future CoG meetings to report on such issues.

14 Apr 15

14.082.6 Consider the need to strengthen administrative support for CoG Cttees

Chair Feb2014

Report on resource given to CoG.

14 Apr 15

14.084

Report to CoG on CIP/SIEP and pay bill overspend/ rectification status

DC Feb2014 Report given to CoG. 14 Apr 15

14.087

Consider with Lead Governor and CoG Cttee chairs whether an oversight and scrutiny Cttee might be appropriate.

Chair Apr2014 Ongoing.

3 Feb 2015 15.012

Consider Governor attendance at CoG and Committees with Lead Governor

Chair May2015 Ongoing.

15.017 Investigate heating issues in BHH Tower Block and report back.

DC Apr2015 Oral report given to CoG. 14 Apr 15

14 Apr 2015 15.034

Produce paper setting out the distinctions between Governance and Governors’ responsibilities.

KS Jun2015

15.035 Circulate Trust Visitor Code to Governors. SF/KS Apr

2015 Completed. 14 Apr 15

15.035

Invite Mary Ross, Clinical Director for Therapies, to a Breakfast Meeting to give an update on SIDs work.

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15.045

Chair agreed to consider a central venue and increased publicity for the 2015 AGM.

LL/KS Jul 2015

5 May 2015 15.049

Ask J Gould to prepare report for HEC on solution for clinical staff not being able to get a hot meal after 3.00pm (based on F&SP deliberations).

DC Jun2015

15.049

Prepare a full paper on the car park history and situation (BHH and GHH) for the next ‘formal’ meeting.

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Governance and Governors’ responsibilities

Governance The Board has a duty to promote the success of the Trust so as to maximise the benefits for the members of the Trust as a whole and for the public who will be treated by the Trust.

Governance is the means by which the Board leads and directs the organisation so that decision-making is effective and the right outcomes are delivered.

Good governance incorporates, amongst other things, corporate governance and quality governance. Robust corporate and quality governance arrangements complement and reinforce one another. Other important aspects of governance include, for example, finance governance and research governance.

Governance arrangements delegate responsibility from the Board down to the operating levels in the organisation. In the case of quality, this means that although individuals and clinical teams are at the frontline and responsible for delivering quality care, it is the responsibility of the Board to create a culture within the organisation that enables clinicians and clinical teams to work at their best, and to have in place arrangements for measuring and monitoring quality and for escalating issues, including, where needed, to the Board. The same applies equally to other aspects of governance.

Some important features of good governance are strong leadership capability and capacity, clear strategies, robust structures (e.g. Board, clinical and operational committees which meet regularly and have appropriate terms of reference), clear lines of accountability, robust and timely flows of information, appropriate policies and procedures, etc.

Governors’ responsibilities Governors have an important role to play in making the Trust publicly accountable for the services it provides. They should do this by exercising their statutory powers and responsibilities; these come from the National Health Service Act 2006 and the Health and Social Care Act 2012 and can be summarised as:

Hold the Non-executive Directors, individually and collectively, to account for the performance of the Board.

Represent the interests of the members of the Trust as a whole and the interests of the public.

Approve “significant transactions”. Approve an application by the Trust to enter into a merger, acquisition,

separation or dissolution. Decide whether the Trust’s non-NHS work would significantly interfere with

its principal purpose, which is to provide goods and services for the health service in England, or performing its other functions.

Approve amendments to the Trust’s constitution. Appoint and, if appropriate, remove the Chair. Appoint and, if appropriate, remove the other Non-executive Directors. Decide the remuneration and allowances and other terms and conditions of

office of the Chair and the other Non-executive Directors. Approve (or not) any new appointment of a Chief Executive. Appoint and, if appropriate, remove the Trust’s auditor. Receive the Trust’s annual accounts, any report of the auditor on them, and

the annual report at a general meeting of the Council of Governors.


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Governors should be committed to encouraging improvements in governance on a continuing basis by exercising their powers and responsibilities, such as holding the Non-executive Directors to account for the performance of the Board, but ultimately the legal responsibility for good governance sits with the Board.

Kevin Smith Company Secretary 18 May 2015


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21.1.15 16.3.1505.01.15 04.03.15

Mohammed Aikhlaq Ap - 7 Ab Ab Ap - 7 3Arshad Begum Ap - 7 Ap - 2 Ap7 Ap-1 3Kath Bell Ap - 3 5Nicola Burgess Ab Ap -1 Ap - 4 Ab 3Barry Clewer Ap - 1 Ap - 2 Ab 3Elaine Coulthard Ap - 6 Ap - 2 5Olivia Craig Ap - 1 Ap - 7 Ap - 7 Ap - 7 3Carol Doyle Ap - 7 Ap - 7 Ap - 7 Ap - 7 3Albert Fletcher Ap - 3 6Helen Griffiths Ab Ap-7 Ap - 7 4Ron Handsaker Ap - 4 Ap- 4 Ap- 4 4Emma Hale Ap-4 6Richard Hughes Ap - 7 6Michael Hutchby 7Susan Hutchings 7Phillip Johnson Ap - 1 6Michael Kelly 7Attiqa Khan Ab Ab Ab Ap-1 Ap-1 2Heidi Lane Ap - 7 Ap -1 Ap - 7 Ap-4 3Andrew Lydon Ap - 6 6Anne McGeever Ap - 4 Ap - 4 Ap - 4 Ap - 4 3Margaret Meixner Ap-1 6Catherine Needham Ap - 2 6David O'Leary Ab Ap -1 Ap - 7 Ap-2 3Barry Orriss Ap - 3 6Mark Pearson Ap-1 6Jim Ryan Ab Ap-1 5Elizabeth Steventon Ap - 3 Ap - 3 Ap-2 4Joy Townsend Ap - 3 Ap - 7 0Jean Thomas Ab 4David Treadwell Ap - 6 6Matthew Trotter Ap - 6 6Total 18 20 21 24 20 22 18

Board 9 6 7 8 9 8 8Public 2 0 3 3 2 5N.B. J Ryan went to St Johns Hotel, Solihull for 23 July meeting (per front cover of pack) so claims attendance

Key: Ap 1 = No reason statedAp 2 = Sickness Ap 3 = Holiday Ap 4 = Care Cover Obligations (Child/Elderly/Relatives etc)Ap 5 = Bereavement Ap 6 = Unavailable due to change of meeting date Ap 7 = Other (prior engagement etc)Ab = Absent (no apology received)

2014/15

Total attended NAME

27.5.1423.7.14 15.9.14 24.11.14

03.02.15


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Mohammed Aikhlaq Ap- 7 AbArshad Begum Ap-1Kath Bell

Nicola Burgess Ap-1

Elaine Coulthard

Olivia Craig

Carol Doyle Ab Ap-1Albert Fletcher Ap - 3

Helen Griffiths Ap - 3

Ron Handsaker AbEmma Hale Ab AbRichard Hughes Ap-1Michael Hutchby

Susan Hutchings

Phillip Johnson

Michael Kelly

Attiqa Khan AbHeidi Lane Ap-1Andrew Lydon

Anne McGeever

Margaret Meixner Ap-1Catherine Needham Ap-1 Ap-4David O'Leary

Barry Orriss Ap- 2

Mark Pearson

Jim Ryan AbElizabeth Steventon Ap-1

Jean Thomas

David Treadwell

Matthew Trotter

Board 5 8Public 4 3

Key: Ap 1 = No reason statedAp 2 = Sickness Ap 3 = Holiday Ap 4 = Care Cover Obligations (Child/Elderly/Relatives etc)Ap 5 = Bereavement Ap 6 = Unavailable due to change of meeting date Ap 7 = Other (prior engagement etc)Ab = Absent (no apology received)

14.04.15 02.03.15 07.10.15 04.11.15 Jan-16

2015/16

NAME 05.05.15 02.06.15 08.07.15 Feb-16 Mar-16

June 2015


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Any Other Business

Dates of Future Meetings

8 July 2015

Harry Hollier Lecture Theatre, Good Hope Hospital, Sutton Coldfield

Refreshments will be available from 3.30pm

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