TRUST BOARD MEETING IN PUBLIC AGENDA - West Herts College · HWE STP Hertfordshire & West Essex...
Transcript of TRUST BOARD MEETING IN PUBLIC AGENDA - West Herts College · HWE STP Hertfordshire & West Essex...
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TRUST BOARD MEETING IN PUBLIC
AGENDA
06 February 2020 at 9.30am – 12.30pm Lecture Hall, Postgraduate Centre, St Albans Hospital
Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283
Time Item
ref Title Objective Accountable
officer Paper or verbal
Link to
BAF
9.30 01/79 Opening and welcome
Information Chair Verbal
02/79 Maternity safeguarding patient story
Information Chief Nurse Present-ation
INTRODUCTION
9.50 03/79 Apologies for absence
Information Chair Verbal
04/79 Declarations of interest
Information Chair Paper
05/79 Minutes of the meeting held on 09 January 2020
Approval Chair Paper
06/79 Board action log from 09 January 2020 and previous meetings and decision log
Information Chair Paper
07/79 Chair’s report
Information Chair Paper
08/79 Chief Executive’s report Information Chief Executive
Paper
09/79 Board assurance framework Approval Chief Executive
Paper
PERFORMANCE
10.00 10/79 Performance report on access standards
Information and
assurance
Chief Operating Officer
Paper 4a&b
11/79 Integrated performance report (month 8) Key messages from:
Chief Operating Officer
Chief Nurse
Chief Medical Officer
Chief People Officer
Chief Finance Officer
Information and
assurance
Chief Operating Officer
Paper 4a&b
STRATEGY
10.45 12/79 Five year strategy (2020 – 25)
Approval Chief Executive Paper
Agenda
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AIM 2: GREAT TEAM (OBJECTIVE 5 – 8)
11.10 13/79 2020- 25 People Strategy Approval Chief People Officer
Paper
AIM 4: GREAT PLACE (OBJECTIVE 10 – 12)
11.20 14/79 Strategy update Information and
assurance
Deputy Chief Executive
Paper
RISK AND GOVERNANCE
11.30 15/79 Corporate risk register report Information and
assurance
Chief Medical Officer
Paper
ASSURANCE FROM COMMITTEES
11.40 16/79 Assurance report from Trust Management Committee
Information
and
assurance
Chief Executive Paper
17/79 Assurance report from Finance and Performance Committee
Information
and
assurance
Chair of Committee/Chief Financial Officer
Paper
18/79 Assurance reports from Quality Committee
Information
and
assurance
Chair of Committee/ Chief Nurse
Paper
ADMINISTRATION
19/79 Any other business previously notified to the chair
N/A Chair Verbal
QUESTIONS FROM THE PUBLIC
11.50 20/79 Questions from Hertfordshire Healthwatch
N/A
Chair Verbal
21/79 Questions from our patients and members of the public
N/A Chair Verbal
CLOSING
12.00 22/79 Draft agenda for next meeting Approval Chair Paper
23/79 Date of the next board meeting: 05 March 2020, Executive Meeting Room, Watford
Information Chair Verbal
Agenda
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Acronyms and abbreviations
Acronyms and abbreviations
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A AAA Abdominal Aortic Aneurysm ACS Accountable Care System AAU Acute Admissions Unit A&E Accident and Emergency ABPI Association of the British Pharmaceutical Industry AC Audit Commission ACS Adult Care Services ADM Assistant Divisional Manger AGM Annual General Meeting AGS Annual Governance Statement AHP Allied Health Professional ANP Advanced Nurse Practitioner
B BAF Board Assurance Framework BAMM British Association of Medical Managers BAU Business as usual BBE Bare Below Elbow BC Business Continuity BCP Business Continuity Plan B&H Bullying and Harassment BISE Business Integrated Standards Executive BMA British Medical Association BME Black and ethnic minorities BSI Bloodstream infection
C CAB/C&B Choose and Book Caldicott Guardian The named officer responsible for delivering and implementing the
Confidentiality and patient information systems CAMHS Child and adolescent mental health services CAS Central Alert System CCG Clinical Commissioning Groups
CCIO Chief Clinical Information Officer CCORT Clinical Care Outreach Team CCU Critical Care Unit CDI Clostridium Difficile Infection C.Diff Clostridium Difficile CEO Chief Executive Officer CfH/CFH Connecting for Health CFO Chief Financial Officer CHC Continuing Health Care CHD Coronary heart disease CIO Chief Information Officer CIP Cost improvement programme CIS Care Information Systems CMO Chief Medical Officer CNS Clinical Nurse Specialist CNST Clinical Negligence Scheme for Trusts COI Central Office of Information COO Chief Operating Officer
Acronyms and abbreviations
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COPD Chronic Obstructive Pulmonary Disease COSHH Control of Substances Hazardous to Health CPA Clinical Pathology Accreditation CPD Continuing Professional Development CPOP Clinical Policy and Operations CFPG Capital Finance Planning Group CPR Cardiopulmonary resuscitation CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation CRS Care Records Service CSE Child sexual exploitation CSSD Central Sterile Service Department CSU Commissioning Support Unit CT Computerised Tomography
D DBS Disclosure Barring Service DCC Direct Clinical Care DD Divisional Director DGH District General Hospital DGM Divisional General Manager DM Divisional Manager DIPC Director of Infection Prevention and Control DHSC Department of Health and Social Care DNA Did Not Attend DNR Do Not Resuscitate DO Developing our Organisation DoC Duty of Candor DoLS Deprivation of Liberty Safeguards DPH Director of Public Health DQ Data Quality DTA Decision to admit DTOC Delayed Transfers of Care DQ Data Quality
E EA Executive Assistant EADU Emergency Assessment and Discharge Unit ECG Echocardiogram ECIP Emergency Care Improvement Programme ED Emergency Department ED Executive Director EDD Expected Date of Discharge EDS Equality Delivery System EHR Electronic Health Record EHRC Equality and Human Rights Commission EIA Equality Impact Assessment ENHT East & North Herts NHS Trust ENT ear, nose and throat EoE East of England EoL End of Life EPAU Early Pregnancy Assessment Unit EPRR Emergency Preparedness, Resilience and Response ERAS Enhanced Recovery Programme after Surgery ESR Electronic Staff Record EWTD European Working-Time Directive
Acronyms and abbreviations
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F FBC Full Blood Count FBC Full Business Case FCE Finished Consultant Episode FFT Friends and Family Test FD Finance Director FGM Female genital mutilation FOI Freedom of Information FRR Financial Risk Rating FSA Food Standards Agency FT Foundation Trust FTE Full Time Equivalent FYE Full Year End G GDC General Dental Council GGI Good Governance Institute GMC General Medical Council GP General Practitioner GUM Genito-urinary medicine
H H&S Health and Safety HAI Hospital Acquired Infection HAPU Hospital Acquired Pressure Ulcer HCA Health Care Assistant HCAI Healthcare-Associated Infections HCC Hertfordshire County Council HCT Hertfordshire Community NHS Trust HDA Health Development Agency HDD Historical Due Diligence HDU High Dependency Unit HEE Health Education England HHH Hemel Hempstead Hospital HES Hospital Episode Statistics HIA Health Impact Assessment HITP Hertfordshire Integrated Transport Partnership HON Head of Nursing HPA Health Protection Agency HPFT Hertfordshire Partnership NHS Foundation Trust HR Human Resources HRG Health Related Group HSC Health Service Circular; (House of Commons) Health Select Committee HSC Health Scrutiny Committee, sub-committee of Overview and Scrutiny
Committee, Hertfordshire County Council HSE Health and Safety Executive HSMR Hospital Standardised Mortality Ratio (Rates) HSO Health Service Ombudsman HTM 00 Health Technical Memorandum HUC Herts Urgent Care HVCCG Herts Valley Clinical Commissioning Group HWE STP Hertfordshire & West Essex Sustainability and Transformation Parternship
Acronyms and abbreviations
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I IBP Integrated Business Plan IC Information Commissioner ICAS Independent Complaints Advocacy Service ICNs Infection Control Nurses ICO Information Commissioners Office ICS Integrated Care System ICT Information, Communications and Technology IDT Integrated Discharge Team IVF In Vitro Fertilisation ICU Intensive Care Unit IDVA Independent domestic violence advisors IG Information Governance IMAS Interim Management Service IM&T Information Management and Technology IP Inpatient IPR Integrated Performance Report ISE Integrated Standards Executive IST Intensive Support Team IT Information Technology ITFF Independent trust financial facility ITU Intensive Treatment Unit
J JSNA Joint Strategic Needs Assessment
K KLOE Key Line of Enquiry KPI Key Performance Indicator
L LAs Local authorities LABV Local Asset Backed Vehicle LAT Local Area Team (of NHS England) LCFS Local Counter Fraud Service LD Learning Disability L&D Learning and Development LDB Local delivery board LGBT Lesbian Gay Bisexual and Transgender LHCAI Local Health Care Associated Infections LHRP Local Health Resilience Partnerships LMC Local Medical Committee LSMS Local Security Management Specialist LSP Local Service Provider LTFM Long Term Financial Model
Acronyms and abbreviations
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M MAU Medical Assessment Unit MCA Mental Capacity Act MD Medical Director MDA Medical Device Agency MDT Multi-Disciplinary Team MEWS Modified Early Warning Score MH Mental Health MHRA Medicines and Healthcare Products Regulatory Agency MIU Minor Injuries Unit MMR Measles, mumps, rubella MRET Marginal rate emergency tariff MRI Magnetic resonance imaging MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus
N NBOCAP National Bowel Cancer Audit Programme NE Never Event NED Non Executive Director NHS National Health Service NHS CFH NHS Connecting for Health NHSE NHS England NHSLA NHS Litigation Authority NHSTDA NHS Trust Development Agency NHSP NHS Professionals NHSP Newborn Hearing Screening Programme NICE National Institute for Health and Clinical Excellence NICU Neonatal Intensive Care Unit NIHR National Institute for Health Research NMC Nursing and Midwifery Council #NoF Fractured Neck of Femur NPSA National Patient Safety Agency NSF National Service Framework NTDA NHS Trust Development Agency
O OBC Outline Business Case OD Organisational Development OJEU Official Journal of the European Union OLM Oracle Learning Management OMG Operational Management Group ONS Office for National Statistics OOH Out of Hours Service OP Outpatient OSC (local authority) Overview and Scrutiny Committee OT Occupational Therapist/Therapy
Acronyms and abbreviations
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P PA Programmed Activities PAC Public Accounts Committee PACS Picture Archiving and Communications System PALS Patient Advice and Liaison Service PAM Premises Assurance Model PAS Patient Administration System PAS 5748 Publicly Available Specification 5748 - provides a framework for the
planning, application and measurement of cleanliness in hospitals PbR Payment by Results PCC Primary Care Centre PCT Primary Care trust PEG Patient Experience Group PFI Private Finance Initiative PHO Public Health Observatory PID Project Initiation Document PLACE Patient Led Assessment of the Care Environment PMO Programme Management Office PMR Provider Management Regime PPI Proton Pump Inhibitors PPI Patient and Public Involvement PR Public Relations PSED Public Sector Equality Duty PSQR Patient Safety, Quality and Risk Committee PTL Patient Tracker List
Q QA Quality Assurance Q&A Questions and Answers QG Quality Governance QGAF Quality Governance Assurance Framework QIA Quality Impact Assessment QIP Quality Improvement Plan QIPP Quality, Improvement, Prevention and Promotion QRP Quality Risk Profile QSG Quality and Safety Group
R R&D Research and Development RA Registration Authority RAG Risk and Governance/Red Amber Green RCA Root Cause Analysis RCN Royal College of Nursing RCP Royal College of Physicians RCS Royal College of Surgeons RES Race Equality Scheme RFH Royal Free Hospitals NHS Foundation Trust RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RSRC Risk Summit Response Committee RTT Referral to Treatment RTTC Releasing Time to Care
Acronyms and abbreviations
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S SACH St Albans City Hospital SCBU Special Care Baby Unit SES Single Equality Scheme SFI Standing Financial Instructions SHMI Standardised Hospital Mortality Index SHO Senior House Officer SI Serious Incident SIC Statement of Internal Control SIRG Serious Incident Review Group SIRI Serious Incident Requiring Investigation SIRO Serious Incident Risk Officer SLA Service Level Agreement SLR Service Line Reporting SLM Service Line Management SMG Strategic Management Group SMS Security Management Service SOC Strategic Outline Case SOP Standard Operating Procedure SQ Safety and Quality SPA Supporting Professional Activity SRG System Resilience Group STEIS Strategic Executive Information System ST & M Statutory and Mandatory STF Sustainability and Transformation Funding STP Sustainability and Transformation Partnership SUI Serious Untoward Incident (same as Serious Incident, more commonly
used).
T T&D Training and Development TDA Trust Development Authority (also known as NTDA) TEC Trust Executive Committee TLEC Trust Leadership Executive Committee TNA Training Needs Analysis T&O Trauma and Orthopaedic TOP Termination of Pregnancy TOR Terms of Reference TPC Transformation Programme Committee TSSU Theatre Sterile Service Unit TUPE Transfer of Undertakings (Protection of Employment) Regulations TVT Tissue Viability Team
U UCC Urgent Care Centre UTI Urinary Tract Infection
V
Acronyms and abbreviations
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VFM Value For Money VSM Very Senior Manager VTE Venous Thromboembolism
W WACS Women’s and Children’s Services WBC Watford Borough Council WFC Workforce Committee WGH Watford General Hospital WHHT West Hertfordshire Hospitals NHS Trust WHO World Health Organisation WRVS Women’s Royal Voluntary Service WTD Working-time directive WTE Whole Time Equivalent (staffing)
Y YTD Year to date YCYF Your care, your future
Acronyms and abbreviations
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Last updated : August 2019
Declaration of board members and attendees interests
06 February 2020
Agenda item: 04/79
Name Role Description of interest Relevant dates
From To
Phil Townsend Chairman Son works for ATOS Sintel a separate legal entity wholly on work associated with the BBC
Jan 2019
Christine Allen Chief Executive None
Paul Bannister Chief Information Officer None January 2019 Present
Dr Andy Barlow Divisional Director, Medicine Barlow Medical Services Ltd
Director, London & Hertfordshire Respiratory Diagnostics Ltd
April 2011 Sept 2018
Present Present
John Brougham Non-Executive Director Non-Executive Director and Chair of the Audit Committee of Technetix Ltd
2010
Present
Helen Brown Deputy Chief Executive None
Tracey Carter Chief Nurse and Director of Infection
Prevention and Control None
Paul Cartwright Non-Executive Director Charitable Funds for West Hertfordshire Hospitals NHS Trust
Member of the Council for Kings College London.
Nov 2015 August 2019
Present Present
Paul da Gama
Chief People Officer None
Ginny Edwards Non-Executive Director (Vice-Chair) Trustee Peace Hospice Care
Director of Edwards Consulting Ltd
Charity Committee for West Hertfordshire
2011 2011 2014
Present Present Present
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Tab 4 D
eclarations of interest
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Last updated : August 2019
Name Role Description of interest Relevant dates
From To
Hospitals NHS Trust
Volunteer organisation 'Help Force' advisor
In Touch networks - coaching consultant
Husband is CEO of The Nuffield Trust
Husband is Director of Edwards Consulting Ltd
Husband is a non-remunerated member of the Strategy Committee of Guy's and St Thomas's Charitable Trust
2019 2019 2011 2011 2011
Present Present Present Present Present
Natalie Edwards Associate Non-Executive Director None
Mr Jeremy Livingstone Divisional Director of Surgery , Anaesthetics
and Cancer
Jeremy Livingstone Ltd – Private practice Present
Jonathan Rennison Non-Executive Director Trustee of Rising Tides Ltd
Change Management and strategy support with Kings College London
Director of Yellow Chair Ltd
Edgecumbe Consulting - Associate
Association of NHS Charities
The Teapot Trust - Coaching
London Plus - Business Planning
In Touch networks - coaching consultant
Charity Committee for West Hertfordshire Hospitals NHS Trust
Governance, strategy and business planning support to London North West University Healthcare NHS Trust - work is focused on their NHS Charity.
Organisational development, change management, leadership development with Quo Vadis Trust - mental health residential care and supported housing service.
May 2015 March 2017 Aug 2012 April 2015 Sept 2016 June 2016 Oct 2016 Feb 2019 Jan 2019 August 2019 August 2019
Present Present Present Present Present Present Apr 2019 Present Present Present Present
Don Richards Chief Financial Officer None
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Tab 4 D
eclarations of interest
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Last updated : August 2019
Name Role Description of interest Relevant dates
From To
Sally Tucker Chief Operating Officer None
Dr Mike van der Watt Chief Medical Officer Owner and Director Heart Consultants Ltd 2010 Present
Dr Anna Wood Deputy Medical Director/Director of Clinical
Standards and Audit None
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eclarations of interest
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TRUST BOARD MEETING IN PUBLIC
09 January 2020
Executive Meeting Room, Watford Hospital
Chair Title Attendance
Phil Townsend Chairman Yes
Voting members
Christine Allen Chief Executive Yes
John Brougham Non-Executive Director Yes
Helen Brown Deputy Chief Executive Yes
Tracey Carter Chief Nurse and Director of Infection Prevention and Control
Yes
Paul Cartwright Non-Executive Director Yes
Ginny Edwards Non-Executive Director (Vice-Chair) Yes
Jonathan Rennison Non-Executive Director (Senior Independent Director)
Yes
Don Richards Chief Financial Officer Yes
Dr Mike van der Watt Chief Medical Officer and Director of Patient Safety Yes
Non voting members
Dr Andy Barlow Divisional Director, Medicine Yes
Paul da Gama Chief People Officer Yes
Natalie Edwards Associate Non-Executive Director Yes
Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer
No
Dr Anna Wood Deputy Medical Director/Associate Medical Director for Clinical Standards and Audit
Yes
Sally Tucker Chief Operating Officer Yes
In attendance
Meg Carter Representative of Hertfordshire Healthwatch Yes
Louise Halfpenny Director of Communications Yes
Jean Hickman Trust Secretary (notes) Yes
Dr Renton L’Heureux Consultant Paediatrician Yes (item 2)
7 members of the public
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MEETING NOTES
Agenda item
Discussion Lead Dead-line
01/78 Opening and welcome
01.01 The chairman opened the meeting and welcomed the Board and members of the public. He noted that it was a light agenda due to the long bank holiday period and reported that discussions were ongoing as to whether the Board meeting in December should be moved to later in the month in 2020 and the January 2021 meeting cancelled. The chairman assured the Board that no changes would be made until the next Care Quality Commission (CQC) inspection report had been received. The chairman noted that it was evident from conversations at visits undertaken by the Board prior to the meeting that the Trust was preparing well for the next CQC inspection. He reminded the Board that feedback on the visits would be received in the private session of the Board meeting. Finally, the chairman reported that the inaugural meeting of the chairs of provider organisations in the integrated care partnership (ICP) had recently been held.
02/78 Paediatric community service
02.01 Dr L’Heureux joined the meeting to update the Board on paediatric integrated care clinics. He advised that the Trust had worked in partnership with Herts Valleys Clinical Commissioning Group (HVCCG) to establish the clinics which had resulted in a significant reduction in the number of referrals to the hospital with over 60% of patients being assured and discharged.
02.02 The divisional director for medicine recognised that it was the first local integrated paediatric care clinic and noted that the approach followed the model used to set up tele-dermatology, respiratory and gynaecology community clinics. It was acknowledged that HVCCG was supportive of establishing community clinics, which had been a long process but was gradually getting easier. The deputy chief executive reported that the director of integrated care was working closely with a number of specialties that were keen to establish integrated care clinics and acknowledged that more support was required to allow this to be taken forward.
02.03 Ginny Edwards enquired whether changes to health visiting had impacted on the paediatric community clinic. The Board was informed that a paediatric taskforce had been established; this would consider all aspects of the community clinics and consider establishing multi-disciplinary team clinics.
02.04 The chairman thanked Dr L’Heureux for the presentation and noted that the Board would like to see evidence at future meetings of work around integrated care.
OPENING
03/78 Apologies for absence
03.01 Apologies were received from the divisional director of surgery, anaesthetics and cancer.
04/78 Declarations of interests
04.01 No further declarations of interest were received from those circulated prior to the meeting.
05/78 Minutes of the meeting held on 05 December 2019
05.01 Minute 10.03. It was reported that the urology services was developing an electronic system and it was not already in operation.
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Agenda item
Discussion Lead Dead-line
05.02 Subject to the amendments recorded above, the minutes were agreed to be a true record of the meeting.
06/78 Board action log from 05 December 2019 and previous meetings and decision log
06.01 All actions had been completed. The decision log was noted.
07/78 Chair’s report
07.01 The chairman presented his report and highlighted the excellent work done by the volunteer coordinator and volunteers to collect and deliver around 800 Christmas presents to inpatients as part of an initiative led by the Trust’s charity, Raise. The Board was reminded that an excellent television programme had been broadcast over Christmas which involved 60 members of staff in a choir created by Gareth Malone. A visit by a selection of staff to 10 Downing Street to meet the prime minster was also highlighted by the chairman.
08/78 Chief Executive’s report
08.01 The Board received a report from the chief executive. She advised that the Trust was under significant pressure and a business continuity exercise was into operation. She provided assurance that the situation was being carefully managed and advised that the Trust was able to handle the level of pressure due to the planning and processes which had been put in place, including increasing the ambulatory care capacity. The chief executive informed the Board that new medical assessment unit and orthopaedic outpatient facilities were expected to be open in the spring. She thanked staff for their continued hard work in very difficult circumstances which ensured that patients received the care they deserved. The chief executive also thanked the cytology team who were being transferred as part of national changes to the NHS cervical screening programme. Ginny Edwards asked how the Board could be assured on the quality and performance of the new cervical screening service and was informed that the national driver for the change had been to improve the service.
08.02 The Board was informed on additional investment for a new CT scanner and MRI unit and was pleased to be advised that the Trust had met its target to vaccinate 80% of frontline staff against flu. The chief executive reported that a redecoration programme to improve the current buildings was well underway and noted that a new electronic patient record programme was being rolled out which would provide a real time bed state. The chief executive concluded her report by welcoming the new charity director to the Trust.
PERFORMANCE
09/78 Board assurance framework.
09.01 The chief executive presented a report on the latest board assurance framework and reminded the Board on the importance of the framework in supporting the monitoring of risks to achieving the strategic objectives. An extreme risk on the BAF relating to the replacement of the existing local area network (LAN) was highlighted and the Board was reminded that it had approved a business case in December 2019 to mitigate against this. The chief executive advised that the trust management committee would closely monitor the delivery of the LAN and the Board would receive an update in February 2020. It was noted that two risks rated at amber were being monitored by the finance and performance committee and the Board would be updated on these risks
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Agenda item
Discussion Lead Dead-line
through the access standards report and the integrated performance report. The Board noted that the risk appetite statement had been updated following discussion at the last Board meeting and would be considered when there was conflict or concern around the management of a risk.
10.02 Resolution: The Board approved the latest board assurance framework
10/78 Performance report on access standards
10.01 The chief operating officer presented a paper which provided assurance on the monitoring of compliance against national access standards, outlining areas that were performing well and those that needed improvement. In particular, the chief operating officer reported that the Christmas and New Year period had been challenging, however she assured the Board that the Trust’s refreshed surge plan had worked effectively. She noted that there had not been a downward trend in demand for emergency care over the bank holiday and patients had reported that this was due to being unable to book a GP appointment over that period of time. The Board was informed that winter systemwide meetings had been reconvened at which performance would be discussed and actions would be captured which could be used to improve future performance. The actions being taken to improve referral to treatment (RTT) performance were also reviewed.
10.02 The chairman reported that he had seen the new hospital ambulance liaison officer (HALO) service in action on a recent walkabout and the chief operating office confirmed that this was working well. She reminded the Board that the 2020 Christmas and New Year would present greater challenges due to the way the bank holidays fell and she provided assurance that executive level discussions were underway to agree the required resources which would ensure business as usual, including reviewing the staff leave policy. In response to a question from Natalie Edward, the chief operating officer advised that the HALO service was funded to 31 March 2020.
10.03 Paul Cartwright asked for an update on a pilot relating to the medical ‘take’ in the emergency department. The divisional director of medicine advised that as the pilot continued to demonstrate significant improvements the trust management committee had agreed to move to a business as usual position. Following discussions with the local negotiating committee, planning had commenced which was being supported by the workforce team. The chief medical officer brought the Board’s attention to benchmarking which indicated that A&E performance had moved from being placed 76th in the country to 29th, which was described as a phenomenal achievement. The deputy chief executive advised that the trust management committee had approved a business case which covered additional A&E staffing until June 2020 whilst a complex medical staffing analysis was undertaken to establish the permanent establishment.
10.04 Ginny Edwards acknowledged the significant work undertaken to manage the increased demand and reminded the Board on previous concerns raised by staff which related to the use of the cardiac cath lab as a surge area. The chief operating officer confirmed that following direct engagement with staff the escalation process had been improved to allow the cath lab to continue to function alongside being used as a surge area.
10.04 Jonathan Rennison asked for clarity on the impact that the increase in
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Agenda item
Discussion Lead Dead-line
emergency demand over Christmas and New Year had on the RTT position. The chief operating officer advised that as there had only been low levels of elective work planned over the bank holiday period and assured the Board that the Trust was in close control regarding the implications and recovery.
11/78 Integrated performance report
11.01 The Board received a summary from the chief operating officer on operational performance in November 2019. In particular, she reported that IT network failures in November 2019 had significantly impacted on performance and further IT issues had been experienced in December following a black start generator testing exercise which had resulted in manual and paper based systems being used across a number services for up to a week. The Board was informed that the clinical prep service had moved into a new area and further work to improve the emergency footprint was continuing.
11.02 The chief nurse gave a summary of her report in the IPR, which advised the Board on a review of category three and four pressure ulcers and an assessment of clostrioides cases. The chief nurse reported on the results of a table top exercise with HVCCG which focused on antimicrobials and advised that a report on an above position for third and fourth degree tears and maternity haemorrhage had been received by the quality committee. The quality committee had also reviewed an update on the end of life care strategy. The Board was informed on the development of a system to record compliments across the Trust and the completion of works to improve the children’s waiting area in the minor injuries unit (MIU) at St Albans and the urgent treatment centre (UTC) in Hemel Hempstead. The chief nurse advised the Board on a successful bid to fund a volunteer project coordinator to support a better experience for patients and staff in the emergency department and the patients’ lounge, with the aim of expanding the service to the MIU and UTC in the future.
11.03 The chief medical officer presented an update on a pilot (operation SMART) which provided early consultant assessment in the ED department, as well as the latest position with regard to patients presenting with flu and on plans to roll out job planning.
11.04 The Board received a report from the chief people officer on performance against the workforce metrics, including vacancy, sickness absence, turnover, mandatory and essential training, appraisal rates. The Board was assured that all metrics remained green. The chief people officer also advised that the flu vaccination target of 80% had been met, the initial national staff survey results had been received and would be shared with the Board in February 2020 and initiatives to help mitigate against the impact of changes to pension tax arrangements had been launched. He reminded the Board that the people, education and research committee would continue to monitor the workforce metrics.
11.05 The chief financial officer presented a report on the latest financial position which had been discussed in detail by the finance and performance committee. He advised that despite a constant rise in emergency pressures, the Trust continued to manage income and expenditure in line with the financial plan. The chief financial officer reminded the Board that it would discuss the financial position in detail in the private session of the meeting and provided a summary update on the positive progress being made to the efficiency programme, as
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Agenda item
Discussion Lead Dead-line
well as the challenges being experienced to pay costs and the latest position with regard to capital expenditure. The chief financial officer concluded his report by advising that the Trust expected to meet the control total budget set by NHS Improvement at the end the financial year.
11.06 The chairman asked the chief information officer to update the Board on the latest position with regard to the IT system. He reported that the system was beginning to demonstrate signs of improvement despite challenges in December from significant issues following a black start generator test. He advised that the IT team had reacted well and considerable work had taken place over the Christmas and New Year period to stabilise the system.
11.07 The chief operating officer advised that it had been possible to anticipate the level of flu cases due to the previous outbreak in Australia and explained that the peak of flu cases in the Trust had been seen in December 2019 when a co-hosted escalation plan had been enacted. The chief nurse added that point of care testing had been launched earlier than the previous year, supported by the isolation suite, which had helped to manage the situation.
11.08 Ginny Edwards assured the Board that the quality committee would discuss the rise in pressure ulcers and in the caesarean section rate and would consider whether appropriate action was being taken. The chief nurse confirmed that work was ongoing with the chief medical officer with regard to the caesarean section rate and reminded the Board that pressure ulcer management was monitored as part of the quality priorities within the quality account.
11.09 Paul Cartwright queried an increase in divisional income due to overseas visitors. The chief financial officer advised that despite a robust system of control being put in place, there was always a high risk of non-payment from overseas visitor. He noted that this was managed by only recording the cash received rather than the value of the invoices.
12/78 2018/19 annual report on end of life care
12.01 The chief nurse presented a 2018/19 annual report on end of life care, which included a full review of the Gosport independent panel report. She assured the Board that the report had been fully discussed by the quality committee and highlighted a reduction in the number of complaints and identified the key themes and learning which had been shared with divisions to improve practices. In particular, the chief nurse brought the Board’s attention to improvements made as a result of complaints from patients with learning difficulties and to the end of life care key achievements and future priorities.
12.02 The deputy chief executive noted that it was often due to complex issues if a patient’s preferred place of death was not achieve. She reported that staff had advised on Board visits that end of life care discussions often happened too late due to deep rooted cultural issues. The deputy chief executive advised that work was planned through the five year strategy to achieve cultural changes. The deputy medical director commented that this was a national challenge and reminded the Board on the importance of working with general practitioners to begin conversations regarding end of life care.
12.03 The chairman noted the excellent report and thanked the end of life care team for their hard work.
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Agenda item
Discussion Lead Dead-line
13/78 2020-23 research and development strategy
13.01 The Board received a research and development strategy from the chief people officer for the period of 2020 to 2023. It was noted that the strategy had been fully discussed by the people, education and research committee. The chief people officer provided a summary of the five key objectives of the strategy and pointed out that a good IT system and adequate time for clinicians and support staff to facilitate research activities would be required in order to achieve the objectives. The chief information officer advised that he believed an upgrade onto a Windows 10 operating system was required and although this was not available to the entire Trust at the current time, it may be possible to upgrade the research department.
13.02 John Brougham agreed in principle with the strategy and asked for clarity on the position with regard to achieving the recruitment target. The chief medical officer reported that the Trust was exceeding targets and the main focus was now on commercial projects from pharmaceutical companies.
13.03 The chief financial officer suggested that the strategy may not be ambitious enough to encourage innovation. The chief medical officer responded that it would only be possible to pursue innovation when clinician’s job plans included dedicated time for research and there was a dedicated research lead in each department.
13.04 Jonathan Rennison welcomed the strategy and pointed out that it did not cover how the Trust planned to focus on smaller scale research. It was acknowledged that this was an ambition; however at the current time as the Trust was not a tertiary centre it was limited on which research projects it could offer.
13.05 Ginny Edwards recognised the purpose and outcomes in the strategy, and suggested that the recruitment and education aspects needed to be mapped across into the people strategy and the strategic outline case (SOC) for the redevelopment of services. The deputy chief executive confirmed that the core assumption in the SOC was that non-clinical support space would need to be developed, however it was not included in the funding allocation and therefore it was anticipated that this would be achieved through a leasing arrangement. She further advised that the Trust was actively working on a project to relocate back office staff which would free up space on the hospital sites.
13.03 The chief executive also welcomed the strategy and asked for it to be reformatted into the corporate house style.
13.04 Resolution: The Board approved the 2020-23 research and development strategy.
14/78 2020-23 people strategy
14.01 The chief people officer presented a 2020-23 people strategy, which was a refresh of the previous successful 2016-19 workforce and development strategy. He noted that the people strategy focused on the emerging concept of ‘TeamwestHerts’ and on partnership working at ICP/integrated care system level, as well as other sharing opportunities. The Board was informed that the strategy had a proactive thread on diversity and inclusion throughout.
14.02 Ginny Edwards suggested that the strategy should be expanded to acknowledge and recognise the invaluable part that volunteers played in the people force.
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14.03 John Brougham recognised that the strategy would not have been possible a few years ago when the Trust was in a much different place. He stated that the strategy needed to emphasise on the importance of networking and on working on a sustainability and transformation partnership basis.
14.04 The Board reviewed the metric which underpinned the strategy and it was agreed that the strategy would be updated to align with the overall strategy and be re-presented for final approval in February 2020.
PDG
02/20
15/78 Draft five year strategy
15.01 The Board received the draft five year strategy from the deputy chief executive which set out a framework, vision and a communication tool for patients and staff. She reminded the Board that the Trust was now able to be less internally focused and advised that the strategy was very much a long term plan which would reflect and adapt over time to changes in commissioning and the partnership environment. It was noted that not all elements of the strategy were new and that the Trust had been working on a number over the last five years. The deputy chief executive advised that the strategy was aligned to the corporate objectives and confirmed that it outlined the core priorities to deliver as a provider and by which route this would be achieved. The Board was informed that the next stage would be to asses whether the strategic measures had been set correctly and for the strategy to be fully aligned with supporting strategies. Following engagement with clinicians, the deputy chief executive reported that the clinical strategy would be updated to explain how it would deliver the overarching strategy and how it related to the redevelopment plan, the digitalisation transformation plan and to the ICP. The Board was informed on delivery and engagement plans and, in particular, on a broadly positive engagement event which had taken place on 08 January 2020. Comments from this event would be reflected in the final draft of the strategy which would be presented to the Board for approval in February 2020.
15.02 Paul Cartwright commented on the excellent approach and requested for the Board to be updated on individual projects as they were progressed. In particular, he requested for the Board to receive the IT strategy. The chief information officer verbalised a high level summary of the IT projects currently underway and those which were planned for the future. He advised that the Board would receive the strategy outline case for the electronic patient record in February 2020 and the outline business case in April 2020.
15.03 John Brougham recognised that the five year strategy would underpin all the Trust’s plans and was at the core of the future. He commented on the importance of being paperless by 2025 and noted that this would be a significant investment which would need specific delivery commitments on an annual basis.
15.04 The Board discussed the metrics set out in the draft strategy and the deputy chief executive responded that the Trust was keen to set a reasonable level of ambition on which to benchmark itself. She advised that the Board would have an opportunity to discuss the metric before it came back to the Board for final approval in March 2020.
15.05 The deputy chief executive pointed out that following staff engagement the ‘sunny tree’ pictorial image of the Trust’s aims and objectives had been updated. Ginny Edwards commented that she would prefer the word ‘valued’ to replace ‘happy’ as this could be subjective. Jonathan
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Rennison suggested that words should be added to the birds in the tree to portrait the Trust’s values, such as kindness and speak-up,.
15.06 The chief executive praised the work done by the deputy chief executive and team to bring the strategy to its current position and suggested that some narrative could be included to explain the metric and to signal the Trust’s plans to become paperless. The deputy chief executive noted that the suggested changes would be made and the final document would be presented to the Board in February 2020.
16/78 Corporate objective review
16.01 The deputy chief executive presented a report which provided an update on the progress of the twelve 2018-20 strategic objectives. She pointed out that a large number of the areas had either made good progress or had been delivered, however some had not achieved as much as hoped which in some cases had been due to unfeasible targets. The deputy chief executive reported that a new set of high level objectives with clearly defined metrics to allow them to be appropriately tracked would be presented to the Board as part of the five year strategy in February 2020 and more detailed objectives would be received by the Board in March/April 2020.
17/78 Corporate risk register report
17.01 The chief medical officer provided a summary of a report on the corporate risk register. He advised that the register currently had 26 open risks with an additional risk relating to a no deal EU exit to be added following discussion by the risk review group in January 2020.
18/78 Assurance report from Trust Management Committee
18.01 The chief executive presented an assurance report from the trust management committee and pointed out areas of focus over the past month.
19/78 Assurance report from People, Education and Research Committee
19.01 The Board received an assurance report from Natalie Edwards on the work of the people, education and research committee. She noted that a number of the items discussed by the committee had already been covered under other parts of the agenda. The Board was informed that the committee had reviewed a consolidation of its work plan, had received assurance on progress towards achieving hospital teaching status and had introduced a divisional assurance programme on a rolling basis.
20/78 Assurance report from Finance and Performance Committee
20.01 John Brougham presented an assurance report from the finance and performance committee and noted that many of the items would be discussed on the Board meeting agenda, either in the public or private section of the meeting. On behalf of the committee, John Brougham recommended that the Board ratify an NHS revenue support loan of £1.4m to cover funding requirements for December 2019.
20.05 Resolution: The report was received for information and assurance and a loan of £1.4m was ratified.
21/78 Assurance report from Quality Committee
21.01 Jonathan Rennison presented an assurance report on the work of the quality committee. He informed the Board that the committee had received strong evidence from the surgical anaesthetic and cancer division on key performance, governance processes and learning. The
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committee had also received assurance from an annual report relating to litigation and claims and on medical devices, which had a clear action plan in place which had yet to be delivered. An action plan to address concerns around food hygiene had been reviewed, some actions had been completed and some were in progress. The committee had also reviewed the corporate and BAF risks associated to quality.
CORPORATE TRUSTEE
22/78 Report from the Charity Committee
22.01 The Corporate Trustee received a report on the work of the charity committee from Jonathan Rennison. It was noted that the committee had reviewed a report on investments and had been assured that these were performing well and were aligned with the charity’s agreed profile and risk appetite. Jonathan Rennison informed the Corporate Trustee that a new charity website had been developed and a successful Christmas appeal had been held which had provided presents for every inpatient in the hospital on Christmas day. He reported that the launch of a new Trust lottery had been delayed whilst a preferred provider was confirmed and advised that a new charity director had joined the Trust with a further recruitment campaign underway to appoint a fundraising officer. Jonathan Rennison concluded his report by advising the Corporate Trustee that discussions were underway around the possible relaunch of the hospital radio as ‘Raise’ and he confirmed that this would be discussed at the next committee meeting.
23/78 Any other business
23.01 No other business was raised.
24/78 Questions from Hertfordshire Healthwatch
24.01 Meg Carter, representative for Hertfordshire Healthwatch provided feedback that an engagement event on 08 January 2020 to discuss the Trust’s five year strategy had been constructive and represented stakeholders from across a wide area.
24.02 The Board was asked whether a pay on exit system could be installed when the new multi-storey car park was built as the current pay on entry system was difficult for patients to know exactly how long they would need to park. The chief financial officer advised that an entry system had previously been considered and would be discussed again at the appropriate time.
25/78 Questions from patients and members of the public
25.01 No questions were raised by the public.
26/78 Draft agenda for next meeting
26.01 The agenda was approved subject to changes to reflect the meeting conversation.
27/78 Date of the next meeting
27.01 The next meeting will be held on 06 February 2020 in the Lecture Hall, St Albans City Hospital
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Agenda item: 06/79Action log Part 1 – 06 February 2020
Ref No.
Action from agenda item
Action Lead for completing the action
Date to be completed
Update
1 14.04/78 To update the People Strategy to align with the overall five year strategy and represent to the Board.
Chief People Officer
02/20 Strategy updated and on Board meeting agenda in February 2020.
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Board meeting/decision date
Decision reference (from minutes)
Item presented to Board for action Comments/outcome
1/9/2020 20.05/78 Assurance report from Finance and Performance Committee The Board ratified an NHS revenue support loan of £1.4m for December 2019.
1/9/2020 09.02/78 Board assurance frameworkThe Board approved the latest version of the BAF.
1/9/2020 13.04/78 2020-23 Research and Development Strategy The Board approved the 2020-23 research and development strategy
12/5/2019 22.02/77 Charity update The Corporate Trustee approved Grant Thornton as the preferred bidder for external auditor services.
12/5/2019 20.02/77 Assurance report from Finance and Performance Committee The Board ratified an NHS revenue support loan of £3.4m for November 2019.
12/5/2019 09.01/77 Board assurance frameworkThe Board approved the laterst version of the BAD and risk appetite statement and the threshold matrix, subject to an amendment to the finance/value for money category.
11/7/2019 26.02/76 Assurance report from Charity CommitteeThe Corporate Trustee approved the use of PayPal.
11/7/2019 19.02/76 Corporate risk register reportThe Board endorsed the changes to the corporate risk register.
11/7/2019 18.02/76 Full business case for urgent and emergency care The Board approved the award of the contract to Greenbrook Healthcare, acknowledging that this would be subject to finalisation and signing of the contract.
11/7/2019 16.02/76 Assurance report from Finance and Performance CommitteeThe Board ratified the financial trajectory for 2020/21 (deficit no greater than £3.242m); 2021/22 (deficit no greater than £1.934m) and a break even state thereafter.
11/7/2019 13.02/76 Annual freedom to speak-up report and update The Board approved a recommendation for Ginny Edwards to be the nominated non-executive freedom to speak up lead.
11/7/2019 12.02/76 Seven day board assurance framework report The Board approved the seven day board assurance framework self-assessment for submission to NHS Improvement.
11/7/2019 09.04/76 Board assurance frameworkThe Board approved the recommended changes to the BAF
10/3/2019 22.03/75 Assurance report from Charity CommitteeThe Corporate Trusteee approved the 2019/20 terms of reference and work plan.
10/3/2019 19.01/75 Assurance report from Finance and Performance CommitteeThe Board ratified an NHS revenue support loan of £3.7m for September 2019.
10/3/2019 17.02/75 2019/20 committee terms of reference and work plansThe terms of reference and work plans for the finance and performance committee and the terms of reference for the auditor panel and remuneration committee were approved.
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10/3/2019 16.02/75 Corporate risk register report The Board endorsed the changes to the corporate risk register.
10/3/2019 15.02/75 Development of integrated care partnershipThe Board confirmed its support for the proposed development of an integrated care partnership for west Hertfordshire and agreed the key future steps.
9/5/2019 22.02/74 Assurance report from Finance and Performance CommitteeThe Board ratified an NHS revenue support loans of £2.7m for July 2019 and £3.9m for August 2019.
9/5/2019 19.02/74 2019/20 terms of reference and work plansThe terms of reference and work plans for the Board, audit committee, quality committee and people, research and education committee were approved.
9/5/2019 16.03/74 Workforce race equality standard report 2018/19 The report was approved for publication.
9/5/2019 15.03/74 Workforce disability equality standard report 2018/19 The report was approved for publication.
9/5/2019 14.03/74 Proposal to change the Trust’s name to West Hertfordshire Teaching Hospital NHS Trust The application was approved for submission.
9/5/2019 13.03/74 Annual medical appraisal report and statement of complianceThe Board approved the submission to NHS England/Improvement
9/5/2019 12.03/74 Emergency planning and business continuity reportThe Board approved the self-asessment against the emergency planning and resilience standards
7/4/2019 11.02/72 Clinical negligence scheme for Trusts – Maternity incentive scheme submissionThe Board delegated authority to Jonathan Rennison to sign-off the submission.
7/4/2019 14.03/72 Proposal to move oesophagogastric cancer surgery to Hammersmith HospitalThe Board approved the proposal
7/4/2019 15.02/72 Outline business case for urgent care servicesThe Board approved the outline business case and commencement of procurement
7/4/2019 16.02/72 Joint corporate risk register and board assurance framework reportThe Board reviewed and endorsed changes to the corporate risk register
7/4/2019 18.02/72 Assurance report from Finance and Investment CommitteeThe Board ratified an NHS revenue support loan of £4.5m for June 2019 to cover funding requirements
7/4/2019 22.02/72 Assurance report from Charity Committee
The Corporate Trustee received the report for information and assurance. It approved the recruitment of a new charity director and delegated authority to the committee to approve the charity’s annual report and accounts
5/2/2019 20.02/70 Assurance report from Finance and Investment Committee Approved the NHS revenue support loan for £6.3m
5/2/2019 17.02/70 Annual statement of modern slavery and human trafficking Approved for publication on website
5/2/2019 15.05/70 Future services in west HertfordshireThe Board confirmed the decision made on 07 March 2019 to move forward with options one to four and exclude new build emergency care hospital options.
5/2/2019 13.01/70 Gender pay gap report 2017/18 Approved for publication on website
5/2/2019 12.05/70 Public sector equality duty report 2017/18 Approved for publication on website
4/4/2019 12.03/69 Busines case for overseas nursing recruitement Approved the business case for overseas nursing recruitment and investment of £1.55m
4/4/2019 13.03/69 Corporate risk register and board assurance framework Approved the board assurance framework
4/4/2019 15.02/69 Assurance report from Finance and Investment Committee Approved the NHS revenue support loan for £0.5m
04/04.2019 18.02/69 Assurance report from the Charity Committee The Corporate Trustee approved in principle the use of designated haematology special purpose funds towards the redevelopment of the Helen Donald unit.
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Trust Board Meeting 06 February 2020
Title of the paper Chairman’s report
Agenda Item 07/79
Presenter Phil Townsend, Chairman
Author(s) Jean Hickman, Trust Secretary
Purpose
For approval For discussion For information
Executive Summary
The aim of this paper is to provide an update to the Board on items of national and local interest/relevance.
Trust strategic aims (please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to
work Objectives 6-8
Aim 3 Improve our
finances
Objective 9
Aim 4 Strategy for the
future
Objective 10-12
Links to well-led key lines of enquiry
Is there the leadership capacity and capability to deliver high quality, sustainable care? Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver? Is there a culture of high quality, sustainable care? Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there clear and effective processes for managing risks, issues and performance? Is appropriate and accurate information being effectively processed, challenged and acted on? Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services? Are there robust systems and processes for learning, continuous improvement and innovation? How well is the trust using its resources?
Previously considered by
Committee/Group Date
N/A
Action required The Board is asked to receive the report for information.
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Agenda Item: 07/79 Trust Board Meeting – 06 February 2020 Chairman’s report Presented by: Phil Townsend, Chairman 1. PURPOSE 1.1. The aim of this paper is to provide an update on items of national and local
interest/relevance to the Board.
2. NATIONAL NEWS AND DEVELOPMENTS
National People Plan 2.1. The National People Plan, which sets a vision for how people working in the NHS will be
supported to deliver care and identifies the actions needed to be taken to help them, is expected to be published shortly.
2.2. The Board will be discussing the Trust’s People Strategy at this meeting (agenda item 13) which is a refresh of the previous Workforce and Development Strategy 2016-2019. The strategy, which is aligned with the National Interim People Plan and the NHS Long Term Plan, places great emphasis on partnership working, quality improvement, diversity and inclusion and living the Trust’s values.
2.3. There is a national focus on workforce and promoting the NHS as a career choice as part
of the government strategy to address the 100,000 shortfall in NHS personnel, which will help to support some of the Trust’s own initiatives.
International Year of the Nurse and Midwife
2.4. 2020 is the International Year of the Nurse and Midwife and the Trust will use the
opportunity to promote awareness and career choices related to the profession. Planning has already started for the Trust’s celebrations, including different activities each month throughout the year and the opportunity for some nurses and midwives to attend a regional conference in May will 2020.
National Financial Update
2.5. Following the formation of a new government in December 2019, overall NHS spending
plans for the next five years are set to remain in line with existing plans – an average real terms increase of about 3.4% per year until 2024. In addition, the Conservatives pledged extra money in their manifesto for plans to increase the number of nurses in the NHS by 50,000 by 2024/25. This will be achieved through further training, international recruitment and better retention of existing staff.
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3. LOCAL NEWS AND DEVELOPMENTS
Five year strategy
3.1. Following an extensive engagement schedule, reaching both internal and external stakeholders, the Board will discuss the Trust’s five year strategy for approval at this meeting (agenda item 12). The strategy sets out the Trust’s vision to provide ‘the very best care for every patient, every day’ and includes further work in collaboration with partner organisations to create a local health and care system that is fit for the future. Integrated Care Partnership
3.2. During the autumn, all boards within the west Hertfordshire system received and discussed case for change documents relating to the development of the local integrated care partnership (ICP). The case for change highlighted a number of questions that need to be addressed as the ICP is developed, these fall into four categories: vision, aims, objectives and principles; scope and pace; service design; and form and enablers. A programme of work was presented to chief executives and chairs on 31 January 2020 for discussion with a view to beginning the next steps of the design work. Integrated Care System
3.3. As the local integrated care partnership is developed, it is also important to ensure a strong and effective integrated care system (ICS). As a system, all partners have signed up to becoming an integrated care system by April 2021 and are currently part of the NHS England accelerator programme. There are four areas of focus: leading partnerships, system architecture, system payment mechanisms and population health management.
Mount Vernon Cancer Centre
3.4. Following the evaluation of bids to run the Mount Vernon Cancer Centre, NHS England’s
regional leadership team has agreed with a recommendation that University College London Hospitals NHS Foundation Trust (UCLH), subject to a period of due diligence, should be awarded the contract to run the centre from April 2021. It has also been agreed that UCLH should be appointed to provide leadership support to Mount Vernon Cancer Centre from April 2020.
3.5. There will be no immediate changes to where patients receive treatment whilst clinicians and patients consider the best way to meet the needs of the Mount Vernon Cancer Centre population in the long-term. The Trust was be engaging in the review process and will update the Board as it progresses.
Local leadership changes
3.6. David Evans, previously director of commissioning at Herts Valley Clinical Commissioning Group (HVCCG). He has been appointed as the interim chief executive and will remain in post as the joint accountable officer across all three CCGs in this area (Herts Valleys, East and North Herts and West Essex) until a substantive appointment is secured. Celebrating staff
3.7. Congratulations and well done to Dr Radhika for receiving a UCL MBBS Top Teacher award. UCL students nominated Dr Radhika following their year five obstetrics and gynaecology placement.
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Supporting national healthcare campaigns 3.8. Thank you to staff who organised the following events in January 2020 in support of
national healthcare campaigns:
Staff across the organisation marked Holocaust Memorial Day by telling the story of the hundreds of Jewish women who won their freedom from the Nazis by working as NHS nurses.
The maternity team who celebrated an alternative to ‘Blue Monday’ with ‘Brew Monday’ by touring the women’s and children’s unit with a trolley to offer tea and cake to staff
The Trust’s charity raised £205 through an online auction of a keyboard which had been signed by Gareth Malone, the famous choirmaster. Gareth worked with the Trust on a TV documentary which was broadcast over Christmas 2019.
4. BOARD NEWS
Director of Governance appointed 4.1. Dr Anna Wood has been appointed to the newly created role of director of governance. Dr
Wood, previously deputy medical director/associate medical director of clinical standards and audit, will have responsibility for a number of key areas of integrated clinical governance and compliance and will work very closely with the chief medical officer and the chief nurse to ensure complete join up in terms clinical governance and compliance. The chief nurse will remain the overall executive lead for trust governance and the chief medical officer will continue to be the executive lead for patient safety and risk.
Board visit programme
4.2. As part of the monthly Board visit programme, the Board visited four areas at Watford
hospital in January 2020, namely the patient lounge, katherine ward, occupational health, starfish/safari ward and the palliative care team. Verbal feedback from the visits was received by the Board in the private session of the Board meeting in January 2020 and will be included in a bi-annual engagement Board report. Board development programme
4.3. The Board met for a development session on 22 January 2020 at which the Board discussed a forthcoming CQC inspection and the actions needed to be taken to achieve a ‘good’ rating.
5. KEY MEETINGS
5.1. Since the last Board meeting, I have undertaken the following business:
Attended a stakeholder event for a new joint accountable officer appointment
Had a meeting with Dean Russell, MP for Watford
Presented a number of staff awards
Introduced the new chair of Herts Community Trust to the Trust
Attended several meetings with leaders from HVCCG
Toured St Albans hospital with the head of nursing for surgery, anaesthetics and cancer
Chaired the inaugural West Herts ICP chairs’ event
Attended a number of assurance committee meetings
Met with Daisy Cooper, MP for St Albans
Attended a West Herts strategy and integrated day
Chaired a number of consultant interview panels
Attended an East of England chairs’ event
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6. RECOMMENDATION
6.1. The Board is asked to receive the report for information. Phil Townsend Chairman February 2020
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Trust Board Meeting 06 February 2020
Title of the paper Chief Executive’s report
Agenda Item 08/79
Presenter Christine Allen, Chief Executive
Author(s) Jean Hickman, Trust Secretary
Purpose
For approval
For discussion For information
Executive Summary
The aim of this paper is to provide an update to the Board on items of national and local interest/relevance.
Trust strategic aims
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to
work Objectives 6-8
Aim 3 Improve our
finances
Objective 9
Aim 4 Strategy for the
future
Objective 10-12
Links to well-led key lines of enquiry
Is there the leadership capacity and capability to deliver high quality, sustainable care? Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver? Is there a culture of high quality, sustainable care? Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there clear and effective processes for managing risks, issues and performance? Is appropriate and accurate information being effectively processed, challenged and acted on? Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services? Are there robust systems and processes for learning, continuous improvement and innovation? How well is the trust using its resources?
Previously considered by
Committee/Group Date
N/A
Action required The Board is asked to receive the report for information.
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Agenda Item: 08/79
Trust Board meeting – 06 February 2020 Chief Executive’s report Presented by: Christine Allen, Chief Executive Officer 1. PURPOSE
1.1. The aim of this paper is to provide an overview of the work of the executive team since the
previous Board meeting. 2. AIM ONE: BEST CARE
Winter pressures
2.1. Like many trusts across the country, the New Year has seen little let-up in demand for
emergency care and the Trust has continued to see increased levels of demand. Patient safety has remained the Trust’s key priority and staff have been doing all they can to enable more flow within the hospitals.
2.2. The level of teamwork demonstrated over this very challenging time has been
commendable and when everyone is so busy, it is easy to forget the impact that behaviour has on others, but it is clear that our patients and their families do notice. They not only comment on the kindness, compassion and standard of care they have received, they also note that this has taken place in a pressurised environment and, despite all that is going on, staff have remained calm and caring, providing much-valued and needed support and reassurance to patents and their families.
2.3. As a small gesture of thanks for their hard work and dedication over the Christmas and New
Year period, all staff have been given a voucher to exchange for a coffee and cake in the Trust’s restaurant over the next few weeks.
Care Quality Commission inspection
2.4. The Trust is due to be inspected by the Care Quality Commission (CQC) over the next two
months. On 26 February 2020, NHS Improvement’s use of resources assessment will take place. This is aimed at understanding how effectively the Trust is using its resources to provide high quality, efficient and sustainable care in line with the recommendations of Lord Carter’s review of operational productivity and performance.
2.5. In addition, on 10 March 2020, a three day well-led inspection will be undertaken by the CQC. This will assess whether the Trust has strong integrated governance and leadership in place across quality, finance and operations, whether it is in line with the changing operating environment and has an appropriate emphasis on organisational culture,
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improvement and system working.
2.6. The third and final element of the regime will be an unplanned inspection of a number of clinical areas. The Trust will have 30 minutes advance notice of this assessment.
Wuhan novel coronavirus
2.7. The Trust is following guidance published by Public Health England to an international alert
recently raised by the World Health Organisation regarding Wuhan novel coronavirus. The guidance outlines the patient pathway in the event of a suspected or confirmed case and outlines clinical management guidance for these patients, including the correct personal protective equipment for staff and visitors to wear.
2.8. Staff from across infection prevention and control, emergency planning and operations are working closely together to ensure the management of suspected cases is clear within the areas identified as points of admissions. A Trust policy has been developed, based on the available guidance which was discussed by the quality committee in January 2020.
Urgent Treatment Centre
2.9. An urgent treatment centre at the front door of the emergency department at Watford
hospital will open on 01 April 2020. Greenbrook HealthCare has been appointed as the provider of this service and the opening hours will be 8am to 2pm. Palliative care services
2.10. Patients, families and health and care professionals are now able to access advice on palliative and end of life care from a West Herts Advice Line, hosted by Peace Hospice Care and The Hospice of St Francis. The service operates from 5pm to 9am everyday including weekends and bank holidays and calls are handled by an experienced nursing team who liaise with on-call doctors and consultants.
Respiratory referral management system
2.11. The respiratory department has developed a referral management system hub in collaboration with Herts Valleys Clinical Commissioning Group and the Central London Community Healthcare Trust. The hub aims to provide a single point of access for all outpatient respiratory referrals enabling earlier accurate diagnosis and screening of patients with respiratory conditions.
3. AIM TWO: GREAT TEAM Supporting staff
3.1. Ensuring that staff are supported to allow them to continue to provide the best possible care
is vitally important. It is particularly important to be mindful of the impact that is created by the challenges faced by the rising demand, patient expectation and being able to discharge patients safely and effectively in order to create capacity.
3.2. With this in mind, staff are encouraged and supported to maintain and improve their
physical and mental health through the Trust’s health and wellbeing programme. In particular, February is national heart month when staff will be encouraged to take care of their heart and understand what they can do to help themselves.
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Flu vaccination campaign
3.3. The Trust has met its target of vaccinating 80% of frontline patient facing staff, however
with an increase in the number of patients with flu in our hospitals, staff are being reminded of how important it is for them to get their flu jab. NHS Electronic Staff Record
3.4. Staff are now able to view their payslips and P60s through an NHS electronic staff record system. The system also allows staff to update their personal information and provides links to useful sites such as training and current job vacancies.
4. AIM FOUR: GREAT PLACE
Improving the environment 4.1. It’s been a few months since the Trust heard the great news that it is one of the six NHS
trusts sharing the £2.7bn pledged by the government. The Trust’s redevelopment plan is part of the national HIP 1 (health infrastructure programme) and final allocations are dependent on the submission of more detailed business cases.
4.2. In the meantime, a refresh and redevelopment programme is continuing across all three
hospital sites, including painting, new flooring, improved lighting and widening doors. In addition, in January there has been a real focus on de-cluttering and tidying clinical and non-clinical areas.
Updating NHSmail email addresses
4.3. When the Trust moved onto NHS mail in 2019, it was assigned the prefix ‘wherts-tr’. This has now been personalised to ‘westherts’ to make it more meaningful and easily identifiable for external organisations or members of the public.
5. RECOMMENDATION
5.1. The Board is asked to receive this report for information. Christine Allen Chief Executive February 2020
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1
Trust Board Meeting06 February 2020
Title of the paper Board assurance framework report
Agenda Item 09/79
Presenter Christine Allen, Chief Executive
Author(s) Jean Hickman, Trust Secretary
Purpose For approval For discussion For information
¸
Executive Summary This report is to provide the Board with assurance that risks to achieving the
Trust’s strategic objectives are being appropriately mitigated, to consider those elements that report direct to Board and any recommendations of changesfrom assurance committees.
Elements of the BAF were reviewed on 30 January 2019 by the Quality Committee and the Finance and Performance Committee and no changes were recommended to the Board.
Trust strategic aims
Aim 1Best quality care
Objectives 1-5
Aim 2Great place to
workObjectives 6-8
Aim 3Improve our
finances
Objective 9
Aim 4Strategy for the
future
Objective 10-12¸ ¸ ¸ ¸
Links to well-led key lines of enquiry
☒Is there the leadership capacity and capability to deliver high quality, sustainable care?☒Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver?☒Is there a culture of high quality, sustainable care?☒Are there clear responsibilities, roles and systems of accountability to support good governance and management?☒Are there clear and effective processes for managing risks, issues and performance?☒Is appropriate and accurate information being effectively processed, challenged and acted on?☒Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services?☒Are there robust systems and processes for learning, continuous improvement and innovation?☒How well is the trust using its resources?
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Previously considered by
∑ Finance and Performance Committee – 30 January 2020∑ Quality Committee – 30 January 2020
Action requiredThe Board is asked to consider and approve the latest version of the BAF.
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Agenda Item: 09/79
Trust Board meeting – 06 February 2020
Board Assurance Framework report
Presented by: Christine Allen, Chief Executive
1. Purpose
1.1 This report aims to provide the Board with assurance that risks to achieving the Trust’sobjectives are being appropriately mitigated, to consider those elements that report direct to Board and any recommended changes from the committees.
2. Background
2.1 All NHS Trusts are required to use a Board Assurance Framework (BAF), not least because it’s been proven good practice for many years in both healthcare and a whole range of complicated high-risk organisations. The BAF is a “live” document that changes over time, and in particular it picks up all the controls that the Trust has in place to manage, minimise and/or remove the identified risks and points towards concise and comprehensive evidence that the controls are working.
2.2 The BAF forms part of the Trust’s overall board assurance and integrated risk management arrangements. It brings together three things:
∑ The Trust’s four aims and twelve underpinning strategic objectives∑ A headline summary of all the issues (risks) that might get in the way of achieving those
objectives∑ A headline summary of what the Trust is doing about those issues, along with a concise
description of how the Board can be assured that what is being doing is working.
2.3 Where appropriate the BAF is cross-referenced against operational risks on the corporate risk register. It should be noted that the BAF and corporate risk register are complementary but not the same thing.
2.4 The difference between “assurance” and “reassurance” is vital to make the BAF work. Reassurance is when someone tells you all’s well; Assurance is when they tell you what’s happening, show you the evidence and you can judge for yourself if all’s well. The diagram below demonstrates this in more detail.
Reassurance Assurance
∑ It is OK because management say it is
∑ Strong management personalities may dominate
∑ Track record of success∑ Professional background or
expertise∑ No contradictory evidence
∑ It is OK because how management have responded to questions from the Board has given me confidence by:
- Clear and logical explanations from Board members
- What has happened; why it has happened and what is the response
- Management explanations are consistent
It is OK because I have reviewed various reliable sources of information, such as:- Independent information
source- Evidence of historical
progress, outcomes- Triangulation with other
information
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2.5 The approved risk appetite statement and threshold matrix is attached for Board reference (appendix 1). These are both dynamic documents and are used by the Board and assurance committees to influence decision making at an individual risk level.
3. Monthly review
3.1 The current BAF can be found in appendix 2. The description, controls, assurances and actions to address gaps in controls and assurances were reviewed and updated by executive leads in January 2020.
3.2 Elements of the BAF were reviewed on 30 January 2020 by the Quality Committee and the Finance and Performance Committee. No changes are recommended to the Board at the current time.
3.3 There is one area of extreme risk (assessed as red) where only limited assurance can be gained by the Board as detailed below. The rating of this risk will be reviewed once the work described below comes to fruition.
Risk no. Risk description Board assurance10e Failure to deliver upgrade to local
area network (LAN), telephonyservices
The Board will receive an update on the plan and implementation of the LAN in the private session of the Board meeting on 06 February 2020.
The first element of works to move to a digital telephony platform is scheduled for early March 2020.
3.4 The following risks are assessed as high (amber) and only limited assurance can be gained by the Board:
Risk no. Risk description Board assurance4a Non-delivery of the Trust’s
improvement plan for emergency care
The performance report on access targets and the integrated performance report under item 10 and 11.
10b Failure to secure improved service from new IT provider due to ineffective relationship and management of ITO provider and failure to address capacity/capability gaps within the Trust in-house IT team
A number of mitigating actions are underway within the IT department to manage this risk. A report outlining the improved quality of service from the new provider will be received by the Board at the end of quarter one 2020/21.
4. Next steps
4.1 The BAF will be refreshed to align with updated strategic objectives, which will be discussed for approved by the Board in February 2020 as part of the Trust’s five year strategy.
4.2 The committee chairs and executive leads are currently undertaking an exercise to cross reference the BAF risks against the work plans to ensure that all risks are being appropriately monitored.
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5. Risks
5.1 There is a risk that failure to keep effective oversight of the Trust’s key risks may lead to the Trust not achieving its organisational strategic aims and objectives.
6. Recommendation
6.1 The Board is asked to consider the latest version of the BAF.
Christine AllenChief Executive
January 2019
Appendix 1. Risk appetite statement and threshold matrixAppendix 2. Board Assurance Framework
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Exec leadLead
Committee
Link to
Corporate
Risk Register
Link to
Stand-
ards
Rating of risk
to delivering
objective
Control Gaps Identified assuranceAssurance
Gaps
1a Failure to sustain expected or better than expected
performance on key mortality indicators (SHMI and
HSMR)
Chief Medical
Officer
Quality Committee CQC Low 1. Morbidity and mortality meetings
1. Structured judgement review process fully embedded
1. Divisional Governance meetings
1. Consultant coders and medical examiners fully established
2. Quality, Mortality review group
2. Quality Committee reports
3. Dr Foster
None known
1b Failure to deliver quality priorities set out in the
Quality Account with a focus on harm free care and
Patient Safety.
Chief Nurse Quality Committee CQC,
NHSLA,
HSE
Medium Practice development gap to
support skill mix and ward
leaders to develop practice.
1. Quality Account.
1. Monitoring of patient safety and effectiveness through quality safety group and patient experience
metrics at patient experience group.
1. Ward leaders supervisory and supporting delivery of harm free care with specialist nursing teams.
1. Matrons part of QI forum reviewing overall ward dashboard metrics and harm free care.
1. Senior NMAHP staff going 'Back to the Floor' .
1. Divisional quality summits held by heads of nursing
2. Quarterly monitoring of progress with quality priorities by Quality Committee
2. Each priority is assigned an executive lead.
3. Quality assurance visits by HVCCG.
None known Development of practice development nursing team.
Using 'Back to the floor' to test what we are hearing and seeing, and
using themes to support development.
QI Forum to develop and review actions.
Discharge phone back system and utilising to ascertain themes and
actions for patient experience.
To undertake patient engagement and experience events.
Development of co-production
GIRFT governance strengthened
Chief Nurse
2a Failure to implement standardised ‘in hospital’
pathways, with improvement in consistency of care
and improved outcomes (working with the Royal
Free Partnership group)
Chief Medical
Officer
Quality Committee Medium Funding and recruitment for
additional clinical leadership
sessions.
1. CPG progress dashboard
1. Quality team meetings.
1. Leadership and supervision from Royal Free Associate Director
2. Trust management committee updates
2. Quality committee reports
3. Royal Free Partnership Board Strategy update papers to Trust Board
Proposal for additional resource for manual data collection.
Standardisation of clinical time to provide leadership for the pathway.
Director of
Integrated
Care/CPG
Lead
Action completed. Proposal was
reviewed by the Trust Management
Committee in November 2019.
Divisions are reviewing clinical job
plans to support time commitment
required. The proposal will be a
considered for approval at the
corporte finance review meeting.
2b Failure to deliver integrated pathway
developments agreed with HVCCG as set out within
the service delivery implementation plan (SDIP)
Deputy Chief
Executive
Quality Committee Medium 2. Trust management committee
3. QIPP Board (HVCCG)
2c Failure to develop patient centred planned and
ambulatory care pathways including maximising
planned surgery on the St Albans City Hospital site,
medical specialties at Hemel Hempstead General
Hospital and women's and children's services
Deputy Chief
Executive/
Chief
Operating
Officer
Quality Committee Medium 1. Divisional performance reviews
1. Acute redevelopment programme executive
3. QIPP Board (HVCCG)
Review St Albans pilot Deputy
Chief
Executive/
Chief
Operating
Officer
AIM 1:
Risk
no.
What could prevent
us from meeting this objective?
CQC,
NHSLA,
HSE, etc
1. First line of assurance (divisional)
2. Second line of assurance (committee)
3. Third line of assurance (external)
OBJECTIVE 1.
TO DELIVER EXCELLENT CLINICAL
OUTCOMES FOR OUR PATIENTS
-MORTALITY
- HARM FREE CARE
OBJECTIVE 2.
TO IMPLEMENT BEST PRACTICE,
INTEGRATED CARE PATHWAYS AND
REDUCE UNWARRANTED CLINICAL
VARIATION IN CARE AND OUTCOMES
Low/Medium/
High/
Extreme
The sub-committee
responsible for
monitoring the risk
BOARD ASSURANCE FRAMEWORK 2019/20
Mar-20
Strategic Objective 2019/20 Risks Identified
Exec lead
(to deliver
specific
action)
What the organisation aims to deliver (outcome
required)
Are the identified actions being
achieved?
Where we are
not gaining
effective
evidence?
Actions to address control and assurance gaps. Time
scale /review
date
Board level
lead
responsible for
achieving the
objective
Risks scored
15 and
above
Mar-20
BEST CARE
Update
Actions to Address gaps (controls and assurance)
Nov-19
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Exec leadLead
Committee
Link to
Corporate
Risk Register
Link to
Stand-
ards
Rating of risk
to delivering
objective
Control Gaps Identified assuranceAssurance
Gaps
Risk
no.
What could prevent
us from meeting this objective?
CQC,
NHSLA,
HSE, etc
1. First line of assurance (divisional)
2. Second line of assurance (committee)
3. Third line of assurance (external)
Low/Medium/
High/
Extreme
The sub-committee
responsible for
monitoring the risk
Strategic Objective 2019/20 Risks Identified
Exec lead
(to deliver
specific
action)
What the organisation aims to deliver (outcome
required)
Are the identified actions being
achieved?
Where we are
not gaining
effective
evidence?
Actions to address control and assurance gaps. Time
scale /review
date
Board level
lead
responsible for
achieving the
objective
Risks scored
15 and
above
Update
Actions to Address gaps (controls and assurance)
3a Failure to roll out recognised quality improvement
(QI) methodology - developing internal capacity to
support QI and suite of training for clinical staff.
Chief Nurse/
Deputy Chief
Executive
Quality Committee CQC Low 1. Quality account agreed
1. Proactive quality improvement culture within the Trust
2. Monitoring of progress with quality priorities by quality committee
2. The following actions agreed as next steps: Source and connect current staff who have a Quality
Improvement (QI) title/aspect within their existing role.
3. CQC report
Awareness of
QI
methodology
being
embedded.
Widespread
training of staff
in QI.
Awareness campaign to commence.
Dosing programme being developed.
QI projects linked to quality priorities and application process.
Chief Nurse Action completed. Campaign
started. Paper received by Quality
Committee
Action completed. Programme
developed. Part Funding identified
in 19/20 from CPD monies.
4a Non-delivery of the Trust's improvement plan for
emergency care
Chief
Operating
Officer
Finance & Performance
Committee
3995 NHS High
Performance measures are
adverse to plan although a
number of metrics have seen
improvement in relation to
patient flow overall.
Lack of senior decision makers
on presentation to ED.
1. ED escalation, improvement and transition plans
1. Discharge Working Group
1. Patient Flow Transformation Board
1. ED team check ins with CEO
2. Trust Management Committee
2. Finance and Performance Committee
3. Joint Urgent Care Programme Board (with HVCCG)
3. System resilience group
3. Local Delivery Board
3. NHSI Progress Review Meeting
3. HVCCG Contract & Quality Review meeting
None known SMART Medical take redesign pilot has been embedded with steps to
transition as 'Business as usual' which enables
cardiology/respiratory/frailty and Gen med in ED.
Increase utilisation of Ambulatory Care and focus upon ambulance
handover.
Chief
Medical
Officer
Action completed. The pilot
continues to deliver improved
patient flow and efficiency. Each
department’s team job plans for
2020/21 are developed to make
SMART “business as usual”, where
appropriate
4b Non-delivery of the Trust's improvement plan for
planned care
- referral to treatment waiting time standard
- cancer waiting time
Chief
Operating
Officer
Finance & Performance
Committee
3828 NHS Medium Some performance measures
are better than planned, with a
number of other measures
showing steady improvement
against plan
1. RTT Improvement Plan
1. Cancer Improvement Plan
1. Weekly Access meetings
1. Divisional Performance reviews
1. Elective Care Programme Board
2. Trust Management Committee
2. Finance & Performance Committee
3. NHSI Progress Review Meeting
3. HVCCG Contract & Quality Review meeting
None known
4c Failure to deliver patient experience improvement
actions as set out in the quality account.
Chief Nurse Quality Committee CQC Medium None known1. Developing opportunities for increased patient involvement in service improvement/ redesign
1. Developed Trust Carer Lead role
1. To develop bespoke local patient surveys
1. Follow up calls on discharge for communication
2. Patient experience metrics.
2. Evidence of assurance for actions from national surveys
2. Divisional reports including learning from complaints, incidents and claims
2. Patient Experience & Carers Strategy progress updates
3. CQC National patient survey reports
3. CCG quality assurance visits
3. PHSO reports
4. GIRFT reviews
None known Develop and implement communication bundle.
Discharge phone back system and utilising to ascertain themes and
actions for patient experience.
Map patient engagement and develop PPI events twice a year a
steering group.
Commission Healthwatch review of patient engagement and use to
develop strategy and action.
Develop the governance and dashboard for MH patients in partnership.
Implement LD patient end of life care pathway.
Chief Nurse LD EOLC pathway developed and
reviewed at panel.
Evaluation of discharge phone call
service undertaken.
Healthwatch review completed and
co-production being developed.
Mar-20
OBJECTIVE 4.
TO IMPROVE THE PATIENT EXPERIENCE
AND THE RESPONSIVENESS OF OUR
SERVICES
OBJECTIVE 3.
TO IMPLEMENT AND EMBED OUR
'QUALITY COMMITMENT' AND 'WEST
HERTS WAY' QUALITY IMPROVEMENT
METHODOLOGY
Oct-19
Sept-19 Jan-
20
Nov-19
Jan 20
Mar-20
Jan-20
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Executive Lead
Lead Committee
Link to Corporate
Risk Register
Link to Stand-
ards
Rating of risk to delivering the
objectiveControl gaps Identified assurance Assurance Gaps
5a Failure to meet Clinical Research Network recruitment targets
Chief Medical Officer
People, Education and Research
Medium For the current year. This has to be reviewed on a yearly basis
1. Continual presence at each clinical divisional level to reinforce good practice and encourage research recruitment. 2. Research and Development steering group2. Quarterly report to People, Education and Research Committee3. North Thames Clinical Research Network
Director Research and Development, or deputy to continue presence at divisional clinical governance meetings to highlight research needs in the trust. To have an open door policy to discuss any new research interests.
Chief Medical Officer
5b Failure to secure a higher level of support from the National Institute for Health Research (NIHR) for commercial studies
Chief Medical Officer
People, Education and Research
Medium For the current year. This has to be reviewed on a yearly basis
1. To apply lean strategies of working. 1. To look for opportunities to apply for additional funding2. Continual review by People, Education and Research Committee to look at additional funding streams2. Quarterly report to People, Education and Research
Committee
The research funding is not under Trust control and is centrally driven and changes on a yearly basis
5c Failure to identify clinical capacity within job plans to support enhanced research capability
Chief Medical Officer
People, Education and Research
Medium To be trialled as an initiative in one or two clinical areas
1. Consider adding funded PA's to new consultant contracts in a bid to secure accountable research time2. Quarterly report to People, Education and Research Committee
Time taken to get funded PA's into practice
To trial funded PA time for research in one or two clinical departments
Chief Medical Officer
6a Failure to achieve improved results in the national staff survey through implementation of corporate and divisional staff engagement improvement plans
Chief People Officer
People, Education and Research
Low Staff survey is annual. Mixed results in quarterly F&FT in whether staff would recommend the Trust as a place to work
1. Developed Big 5 programme1. Used various communication channels to promote Big 51.Regular updates to TMC1. Implemented onboarding questionnaires for new starters2. Report performance to PERC3. Benchmark against other organisations
Some signifcant culture issues within organisation that are being addressed, but may impact on results
OD interventions to address hot spots in organisation where concerns exist in terms of staff engagement
Chief People Officer
6b Failure to improve performance against the workforce race equality standard indicators to improve the experience of staff from BME and other under represented groups
Chief People Officer
People, Education and Research
Medium Annual staff survey still shows that BAME staff report less positive experience and engagement
1. Developed and published workforce race equality scheme (WRES) with a set of actions to deliver race equality indicators1. Established BAME staff network1. Communicated Trust commitment through the focus on race equality as part of the BIG 5 programme1. Executive directors have a equality objective2. Provide regular updates to trust management committee and provide assurance to PERC3. Publish results which enables benchmarking
Creation of organisational weide pisitive action programme to demonstrate commitment
To further promote development opportunities for BAME staffTo establish programme of reverse mentoring
Chief People Officer
Mar-20
BOARD ASSURANCE FRAMEWORK 2019/20
Mar-20
Exec lead (to deliver
specific action)
Strategic Objective 2019/20 Risks Identified Actions to Address gaps (controls and assurance)
Update1. First line of assurance (divisional)2. Second line of assurance (committee)3. Third line of assurance (external)
AIM 2:
OBJECTIVE 6.
TO HAVE HAPPY,
HEALTHY, WELL
SUPPORTED STAFF WHO
FEEL ABLE TO DELIVER
GREAT CARE AND 'MAKE
A DIFFERENCE' IN AN
INCLUSIVE
ENVIRONMENT AND TO
BE A CLINICALLY LED
ORGANISATION
Where we are not gaining effective
evidence?
Actions to address control and assurance gaps.
Are the identified actions being
achieved?
OBJECTIVE 5.
TO FURTHER DEVELOP
THE TRUST'S
PARTICIPATION IN
RESEARCH AND
DEVELOPMENT
Board level lead
responsible for achieving
the risk to the objective
The sub-
committee
responsible for
monitoring the
risk
Risks scored 15 and above
Low/Medium/High/Extreme
What the organisation aims to deliver (outcome required)
Risk no.
What could preventus from meeting this objective?
CQC, NHSLA,
HSE, etc
Time-scale/review
date
Mar-20
Feb-20
GREAT TEAM
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7a Failure to achieve and maintain a positive vacancy rate
Chief People Officer
People, Education and Research
3995 Medium National vacancies in particular professional groups including nursing and doctors.
Impact of Brexit difficult to predict.
1. Approved business case for o/s nursing and established recruitment campaigns with good supply currently. 1. Workforce information shared with TMC and PERC in
monthly workforce report. 1. Divisional action plans focused on recruitment strategies monitored through Divisional Performance Reviews
Need more work on strategy for recruitment to medical vacancies
and difficult to recruitment positions such within Paeds/ theatreas
Currently recruiting to Head of Medical Resourcing and seeking to strengthen team with better skill mix.
Production of overall plan to recuit internationally for doctors.Recruitment for nurses from Australia
Chief People Officer
7b Failure to achieve and maintain a positive turnover rate
Chief People Officer
People, Education and Research
Medium 1. Good staff engagement programme with Big 5. 1. Established onboarding questionnaires as well as exit questionnaires to pick up staff at risk of leaving. 1. Divisional action plans monitored through Divisional Performance Reviews.1. Established career development support under 'Developing You' to improve retention. 2. Report to TMC and PERC via workforce performance reports.
Need abetter staff benefits package to help retain our staff
Production of business case to offer staff discounted food.Proudction of new package of staff benenfits
Chief People Officer
8a Failure to demonstrate Trust meets criteria for Teaching Hospital Status
Chief People Officer
People, Education and Research
Low A formal senior workforce group has been established where progress can be tracked and will report to TMC and PERC on progress.
1. Project plan developed to track progress. 1. Existing team resourced to undertake work required. 2. Report on progress to People, Education and Research Committee
Further work to establish governance around this and monitoring progress.
Written support from Medical SchoolNHS Comms. to check our proposed name is OKKet stakeholder engagementCollate our ‘Significant Teaching [and learning] Commitment’*Submit to DoH to amend our Establishment Order
Chief People Officer
8b Failure to maintain high levels of compliance in core and essential training
Chief People Officer
People, Education and Research
Low Core mandatory training above target of 90%. Essential training on improving trajectory towards target.
1. Acorn 2 established with elearning and reminders to staff when training due. 2. Reported to TMC2. People, Education and Research Committee workforce performance report. 3. Benchmark against organisations in STP quarterly.
ABLS and Fire Training which are face to face have lower levels of comliance
Plans in place to bring in additional support for both these elements to ensure 90% compliance
Chief People Officer
8c Failure to provide clear development options in place for every banding of role within the Trust
Chief People Officer
People, Education and Research
Medium Work on portal at STP level still at early stage and being fully scoped. Leads for all areas to be identified.
1. Developed apprenticeships approach locally for clinical staff and non clinical staff in junior roles. 1. Developed First Line Leadership Programme, Senior Leader Programme and Clinical Leadership Programmes. 1. Mapping career development options for all staff. 2. People Education and Research Committee3. Linking with STP to develop portal for development activity across region.
Need to agree upon prefered approach to management of apprenticeships, likely to be lead provider model for whole of ICP
Work being undertaken to devised our strategic apprenticeship approach. Launch of lead provider model
Chief People Officer
OBJECTIVE 8.
TO BECOME AN
EXCELLENT
ORGANISATION FOR
EMPLOYEE
DEVELOPMENT
OBJECTIVE 7.
TO REDUCE VACANCY
RATES AND REDUCE
OUR RELIANCE ON
AGENCY WORKERS
Jul-20
Jun-20
Apr-20
Mar-20
Apr-20
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Executive LeadLead
Committee
Link to Corporate
Risk Register
Link to Stand-
ards
Rating of risk to delivering the
objectiveControl Gaps Identified assurance Assurance Gaps
9a Failure to deliver the in-year financial plan.
Chief Finance Officer
Finance and Performance
42044205
Low Clarity is not yet secured regarding actions required to secure Financial Recovery Fund beyond simple achievement of annual control total
Ability to manage reduction in costs to match reduced funding
Prevention or identification of spending outside required control processes
1. Documented budget meetings, analysing variances and taking corrective actions1. Accurate forecasting and development of recovery plans. 2. Trust Management Committee2. Finance & Performance Committee3. Financial Assurance Meeting - NHSI/E3. Oversight and Support Meeting - NHSI/E
Formal written communications from NHSI/E explicitly stating the terms and conditions required to secure FRF payments
Guarantee that all service changes have not adversely affected the financial position
Assurance that changes in medical staff capacity are fully controlled
Complete medical workforce control project and implementation of medirota software.
Chief Financial Officer
The control project and rollout of medirota software is ongoing. Divisions have been asked to deliver on their respective actions
9b Failure to achieve year on year improvement in the underlying financial position
Chief Finance Officer
Finance and Performance
Medium Capital availability for schemes which require it, irrespective of governance compliance.
Limited CIP plan beyond the current year.
Division / directorate capacity for identification, compliance & delivery.
Limited SLR and benchmarking take-up reduces opportunity to identify potential new CIPs.
1. Detailed reporting of delivery against plan and variance in context of overall financial performance.
1. CIP forecast reviewed on at least a monthly / twice monthly basis within divisions
1. Monthly Trust Management Committee2. Monthly Finance & Performance Committee3. Detailed deep-dives by NHSI, other external bodies, and internal audits as validation of scheme management and underlying controls.
Project management software capacity not fully utilised, including integration with programme management processes
Complete drivers of deficit analysis.
Further develop 5 year rolling cost improvement programme. (See regular Board Part 2 FRP paper)
Complete roll out of project management software.
Chief Financial Officer
Completed.
9C Failure to achieve performance targets against key value for money metrics. ( e.g. model hospital, Carter metrics)
Chief Finance Officer
Finance and Performance
Medium More frequent reporting and action planning to improve performance against Model Hospital metrics.
1. Outcome of a comprehensive assessment against Model Hospital metrics undertaken in 2018/19.
1. Outcome of financial benchmarking exercise undertaken at department/ cost centre level in 2017/18
Report demonstrating improvements against last set of assessment.
Introduce reporting framework to assess improvements against model hospital metrics.
Chief Financial Officer
Jan-20
Mar-20
Mar-20
Mar-20
Jan 20
Mar-20
BOARD ASSURANCE FRAMEWORK 2019/20
OBJECTIVE 9.
TO DELIVER BEST VALUE CARE
Where we are not gaining effective evidence?
Actions to address control and assurance gaps.
Exec lead (to deliver
specific action)
What the organisation aims to deliver (outcome required)
Risk no.
What could preventus from meeting this objective?
CQC, NHSLA, HSE, etc
Are the identified actions being achieved?
Strategic Objective 2019/20 Risks Identified Actions to Address gaps (controls and assurance)
UpdateTime-scale /review date
AIM 3: BEST VALUE
Risks scored 15 and above
Low/Medium/High/Extreme 1. First line of assurance (divisional)
2. Second line of assurance (committee)3. Third line of assurance (external)
Board level lead
responsible for achieving the
risk to the objective
The sub-committee
responsible for
monitoring the risk
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Exec leadLead
Committee
Link to Corporate
Risk Register
Link to Stand-
ards
Rating of risk to
delivering
Control Gaps Identified assurance Assurance Gaps
10a Failure to achieve a successful and safe transition to a new IT provider
Chief Information Officer
Board 4114 High A lack of documentation around infrastructure and routing and technical processes from CGI
1. ICT and Business continuity incident control rooms during transition 1. ICT resource engaged to manage a controlled and documented programme course
The Board approved for this risk to be removed as the Trust had transitioned onto a new IT provider.
10b Failure to secure improved service from new IT provider due to ineffective relationship and management of ITO provider & failure to address capacity / capability gaps within the Trust in-house IT team.
Chief Information Officer
Board High Insufficient non technical skills to deploy the new governance and contractual processes
1. A divisional restructuring that will help us obtain the right seniority and balance of skills across technical and non technical resources appropriate to working in a hybrid ITO model.
Any restructure will not be complete during 2019
Personal involvement and leadership of key commercial relationship and meetings by the CIO
Chief Information Officer
10c Failure to meet the compliance requirements of the general data protection regulations and data security toolkits and associated audits
Chief Information Officer
Board 38974197
Medium A cultural and educational programme needs to be wrapped around the re-formed information group that is monitoring the DSPT action plan
2. Trust management committee Promotion of the importance of information governance and security and a structured training programme
Chief Information Officer
10d Failure to implement remote access to radiology and other specialty images
Chief Information Officer
Board Low None - specialist technical advice being sought to complete the pilot - no other reason the actions will not be achieved
1. Directorate team meetings
10e Failure to deliver upgrade to local area network (LAN), telephone and services. (Subject to approval of business cases for capital funding).
Chief Information Officer
Board 3896 Extreme At present actions are on target - there are no obvious control gaps
1. Directorate team meeting.2. Trust management committee3. Trust Board
N/A In December the Board approved the Full Business Case for the redesign and replacement of the existing LAN. This business case represents a £1.7m investment by the Trust. The contract variation is in the process of being signed. It is expected that the design work will be complete by the end of January 2020 with the implementation commencing in February 2020, with the aim of seeing improvement by the summer.
A telephony business case for £400k has been approved, which is the first part of a two year plan to move to a digital (rather than analogue) platform. The first element of this is to replace the zip trunks which is scheduled for early March 2020.
10f Failure to improve 'paper' medical records and groundwork to support future implementation of electronic health records. (progress may be limited subject to approval of business case for capital funding).
Chief Information Officer
Board 3120 Medium We are behind schedule due to the lack of a clear plan, ownership of delivery and dedicated resource
1. Production of a clear plan -signed off by TMC 1. Resource to deliver the plan
Resource not yet funded
Request to get capital resource to enable us to award the tender to develop the plan and manage delivery
Chief Information Officer
Action completed. Funding identified. Consultants, Prederi have been commissioned and are currently writing the business case with the expectation that it will be completed by the end of January 2020.
10g Failure to develop outline business case for electronic health record implementation
Chief Information Officer
Board Medium Lack of experienced resource
1. Directorate team meeting.2. Trust management committee3. Trust Board
Resource to support the development of the Strategic and Outline business case has been commissioned
Chief Information Officer
Action completed. Funding secured from HVCCG. Procurement process completed and Deloitte have been commissioned to write the business case. It is expected that the strategic outline case wil be completed by mid-January 2020 and the outline business case by mid-March 2020.
The sub-committee
responsible for monitoring the
risk
Risks scored 15 and above
Mar-20
Where we are not gaining
effective evidence?
Actions to address control and assurance gaps.
Exec lead (to deliver specific action)
Time-scale/revie
w date
BOARD ASSURANCE FRAMEWORK 2019/20
Board level lead responsible for
achieving the risk to the objective
Nov-19
Nov-19
What the organisation aims to deliver (outcome
required)
Risk no.
Strategic Objective 2019/20
Risks Identified Actions to Address gaps (controls and assurance)
Update
Mar-20
AIM 4: GREAT PLACE
What could preventus from meeting this objective?
CQC, NHSLA, HSE, etc
Low/Medium/High/Extreme
1. First line of assurance (divisional)2. Second line of assurance (committee)3. Third line of assurance (external)
Are the identified actions being achieved?
OBJECTIVE 10.
TO IMPROVE OUR IT AND MOVE
TOWARDS FULL
DIGITALISATION
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11a Failure to proactively communicate and engage with local communities and stakeholders in the development and delivery of our services
Deputy Chief Executive
Board Medium Stakeholder strategy/plan to be reviewed and updated
1. Executive team meeting.2. Trust management committee3. Healthwatch review of trust engagement strategy
Stakeholder strategy / plan to be developed
Deputy Chief Executive
11b Failure to actively engage in the development of an integrated care partnership for West Hertfordshire
Deputy Chief Executive
Board Low 2. Trust management committee3. Sustainability and transformation partnership and HVCCG local delivery board
Joint work & OD programme with HVCCG and system partners to develop an ICP in development. Agree and implement internal governance to oversee transition to ICP
Deputy Chief Executive/HVCCG Programme Director (TBC)
All boards within the west Hertfordshire system have received and discussed case for change documents relating to the development of the integrated care partnership (ICP). A programme of work was presented to chief executives and chairs on 31 January 2020 for discussion with a view to beginning the next steps of the design work.
11c Failure to work with Herts Valleys Clinical Commissioning Group to test new contractual forms that share risk and support innovation.
Deputy Chief Executive
Board Low 2. Trust management committee2. Finance and Performance Committee
Agree minimum income guarantee
Agree full business case for UEC
Chief Financial Officer
Deputy Chief Executive
Completed.Board report - Nov-19
Completed.Full business case Nov-19
11d Failure to demonstrate active engagement in the West Herts and Essex Sustainability and Transformation Partnership
Deputy Chief Executive
Board Low 3. Sustainability and transformation partnership governance3. Sustainability and transformation partnership chair's meetings
12a Failure to deliver agreed capital programme within agreed capital allocation.
Deputy Chief Executive/ Chief Financial Officer
Finance and Performance Committee
Low 1. Capital Finance Planning Group2. Trust Management Committee
Bring forward annual prioritisation process & develop multi-year view.
Continue regular calls with (new) Regional team to ensure joint understanding of opportunities and expectations and problem solve.
Deputy Chief Executive/ Chief Financial Officer
Projects that are currently approved are not forecast to cause an overspend against the approved capital resource limit. This forecast is assured by the Capital Finance Planning Group and TMC. There has been some movement against the plan set at the beginning of the year as previously reported to the board – some schemes have not progressed or timescales have slipped meaning that expenditure will cross over into next year (e.g. cardiac cath lab replacement, medical records revolumisation). Conversely some new / ‘emergency’ schemes have been included (e.g. uninterrupted power supply (UPS) replacement programme) and ambulatory care expansion. The Board received a detailed update in part 2 of the January 2020 Board and supported continuation of the current programme of spend which would lead to full utilisation of the capital allocation.
12b Failure to develop and achieve approval of development control plans and business cases to deliver the strategic priorities set out within the interim estate strategy
Deputy Chief Executive
Board Medium 2. Acute redevelopment executive2. Trust Management Committee2. Capital Programme Finance Group2. Finance and Performance Committee
New terms of reference for delivery executive agreed - to be enacted
Terms of reference for delivery executive to be enacted
Deputy Chief Executive
Delivery Executive in place and well attended, providing additional oversight of strategic capital projects. Good progress made with business cases - capital prioritisation for 20/21 to be confirmed by February 2020. Availability of capital expected to be a constraint in 2020. DCPs under development via acute redevelopment programme.
12c Failure to develop and achieve approval of outline business case/s for the long term redevelopment of our hospitals
Deputy Chief Executive
Board Medium 1. Redevelopment team weekly catch-ups2. Programme executive2. Trust Management Committee2. Finance and Performance Committee
Internal governance arrangements only partially effective and require review
Complete development Control plans for SACH and Hemel.Business case for priority schemes
Secure approval for strategic outline case for the redevelopment of services and agree next steps
Deputy Chief Executive
Mobilising additional capacity and expert advisory support for the redevelopment programme. Liaison with DH & NHSE/I re next steps for HIP 1 programme & funding release to support OBC development.
12d Failure to maximise capital funding via the full range of funding options (emergency capital applications, STP capital bids, other sources e.g. Salix)
Deputy Chief Executive/Chief Financial Officer
Finance and Performance Committee
Low 2. Capital Programme Finance Group2. Finance and Performance Committee
Confirm emergency capital (external)Opportunistic bids (e.g. winter, diagnostics)
Prepare for wave 5 bids
Deputy Chief Executive
Emergency Capital allocation for 19/20 confirmed. Successful bid for winter funding for ambulatory assessment expansion (0.5m). Approval for Salix funds granted, however scheme not ready for progression until 2020/21. The Trust has received additional funding to replace 1 x MRI and 1 x CT scanners via the national programme to replace medical equipment > 10 years old. This funding will be available in 2020/2021. The Trust will need to fund any associated building works.
Jan-20
Mar-20
OBJECTIVE 11.
TO WORK WITH LOCAL
STAKEHOLDERS AND PARTNER
ORGANISATIONS TO IDENTIFY WHERE, BY WORKING
TOGETHER, WE CAN IMPROVE CARE FOR OUR
PATIENTS
Dec 19
Mar-20
Mar-20
OBJECTIVE 12.
TO IMPROVE THE QUALITY OF OUR
ESTATE AND IMPLEMENT OUR SERVICE DRIVEN
ESTATES STRATEGY
Mar-20
Oct-19
Nov-19
Apr-20
Mar-20
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Trust Board 06 February 2020
Title of the paper Performance report on access standards
Agenda Item 10/79
Presenter
Sally Tucker, Chief Operating Officer
Author(s)
Jane Shentall, Director of Performance
Purpose
Please tick the appropriate box
For approval
For discussion For information
Executive Summary
This paper provides assurance on the monitoring of compliance with national Access standards in December 2019, identifying factors affecting performance and the actions to ensure a return to compliance.
Consistent compliance with the diagnostic waiting times standard has been maintained for many months, and this continues with 99.7% achieved this month. ED performance is lower at 79.4% (November 82.2%) and the position remains adverse to plan (88.2%). However December’s attendances at WGH ED were the highest recorded for 2019/20 at 9812, with a ytd increase of 8.7%. Ambulance arrivals were 9.4% higher than the previous month. Performance against the RTT 92% standard remained the same as the previous month, at 87.4% and is just below the trajectory plan (88.4%) for the month. There were no 52 week breaches at month end. Performance remains compliant with the 2 week wait and 2 week wait breast symptomatic and all 31 day standards. There has been an improvement in 62
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day screening, with the target achieved this month (100%, target 90%). Performance against the 62 day referral to treatment standard at 83.2%, has not reached target (85%) but is better than the previous month (77.1%) and is in line with plan (83.1%). NB: Performance data accurate at time of reporting (31/1/20), but subject to change prior to external submission deadlines
Trust strategic aims (please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to work
Objectives 6-8
Aim 3 Improve our finances
Objective 9
Aim 4 Strategy for the future
Objective 10-12
Links to well-led key lines of enquiry
☒Is there the leadership capacity and capability to deliver high quality, sustainable
care? ☒Is there a clear vision and credible strategy to deliver high quality, sustainable care
to people, and robust plans to deliver? ☒Is there a culture of high quality, sustainable care?
☒Are there clear responsibilities, roles and systems of accountability to support good
governance and management?
☒Are there clear and effective processes for managing risks, issues and
performance?
☒Is appropriate and accurate information being effectively processed, challenged and
acted on?
☒Are the people who use services, the public, staff and external partners engaged
and involved to support high quality sustainable services?
☐Are there robust systems and processes for learning, continuous improvement and
innovation?
☒How well is the trust using its resources?
Previously considered by
Committee/Group Date
Trust Management Committee 29 January 2020
Finance & Performance Committee 30 January 2020
Action required
The Board is asked to receive this report for information and for assurance of ongoing monitoring of performance against nationally mandated waiting times.
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Agenda Item: 10/79 Trust Board meeting – 06 February 2020 Performance report on access standards
Presented by: Sally Tucker, Chief Operating Officer
1. Purpose The purpose of this report is to provide clarity and context for performance against access targets, to identify the relevant factors where standards have not been achieved, and to describe the actions in place to improve waiting times and achieve compliance.
1.2 The relevant standards and guidance are included in appendix 1. 2. Indicators not achieved in the reporting period 2.1 At the time of reporting the following standards and indicators were not achieved in
December 2019.
3 A&E 95% target 3.1 Performance in December fell to 79.4% (from 82.2%). Compliance with the standard was
maintained at MIU (100%) and UTC (99.8%). Minors performance has fallen (from 94.3%) to 92.4%, with a decrease in Majors (from 58.9%) at 53.9%. CED has continued to experience significant pressure, achieving only 85.9% (previous month 87.7%).
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3.2 In keeping with the overall position, performance against the 4 hour standard for non-admitted pathways was lower at 78.1% (vs 80.6% in November) as was admitted pathway performance (from 63.2%) at 56.8%, but still better than the start of the year (April 50.2%).
3.3 Benchmarking using Model Hospital shows WHHT in a better position than most peers for
November. WHHT is placed 29th of 94 providers (last month 76th) in terms of A&E performance. The trust position compares favourably with a regional peer median of 79% and a national median of 79.19%.
The chart below benchmarks WHHT with the Nightingale Group1 – other acute providers
with more than one site (shown in grey) where the median is 75.8%.
Despite the downturn in performance in December, when comparing trends across a 12
month period from November 2018, WHHT is improving while the regional and national position is deteriorating.
3.4 Increasing demand (activity above plan) continues as shown in the table and chart below.
Year to date the 11% overall growth rate has been consistent since August, and at WGH, the year to date growth has been above 8% since September.
December saw the highest recorded attendances at WGH (9812) year to date.
1 East Kent University NHS Foundation Trust Gloucestershire Hospitals NHS Foundation Trust
Mid-Yorkshire Hospitals NHS Trust North Cumbria University Hospitals NHS Trust Royal Cornwall Hospitals NHS Trust United Lincolnshire Hospitals NHS Trust University Hospitals of Morecambe Bay NHS Foundation Trust Worcestershire Acute Hospitals NHS Trust
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3.5 Despite the ongoing growth in demand for urgent emergency care, the SMART (senior
clinicians from a range of medical specialties, working in ED) pilot has continued to impact ongoing flow as demonstrated in the chart below which shows type 1 (WGH) ED attendances and AAU admissions for 2019/20 in comparison with the previous year.
Looking at April to September 2018 7907 patients were admitted to AAU. In the same
period in 2019 this had risen by 6% to 8377. Between October and December 2018 there were 4147 admissions to AAU. SMART was implemented in October 2019 and
%
Increase
on
2018/19
YTD
Total atts
2019/20
Total atts
2018/19
%
Increase
on 18/19
YTD
WGH atts
2019/20
WGH atts
2018/19
April 15.3% 13127 11383 10.3% 8586 7787
May 12.3% 26833 23896 6.8% 17404 16303
June 10.3% 40355 36578 5.8% 26054 24619
July 10.3% 54895 49760 6.6% 35370 33197
August 11.3% 68058 61173 7.7% 43907 40776
September 11.6% 81895 73353 8.3% 52902 48851
October 11.6% 95779 85784 8.2% 62087 57374
November 11.1% 109734 98748 8.2% 71447 66057
December 11.3% 124105 111504 8.7% 81259 74747
2019/20
Month
Cummulative attendances Cummulative attendances
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admissions (3529) from then through to December 2019 were 15% lower than the same period the previous year.
In October 2018 there were 14.3% more admissions in comparison to the previous month
but in October 2019 there were 17.6% fewer admissions than in September 2019. 4 Ambulance Handover Delays 4.1 There was a 9.4% increase in the number of ED arrivals by ambulance in December 2019
compared to the previous month (3085 vs 2821). The average daily ambulance arrivals rate increased from 94 in November to just over 99 in December and year to date the increase is 7.3%. The chart below shows the distribution of delays in the context of all ambulance arrivals.
4.2 There has been an increase in delays, over 60 minutes (192 vs 84) and 30-60 minutes (455 vs 383) and when comparing with previous years, this is a very similar picture to that of December 2017 (60+ - 192, 30-60 – 435).
4.3 The handover improvement trajectory plan factored in an increase in ambulance arrivals in
December, but the actual number was higher than anticipated.
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4.4 In response to the worsening picture, the January joint ambulance handover improvement meeting with EEAST has been brought forward and the outcome of discussions is awaited.
5 Progress against the ED improvement plan 5.1 Actual performance remains adverse to the trajectory plan. Demand above the
planned/expected level of activity is remains the most significant factor in the adverse variance to plan. Although demand management initiatives are in place in the system, the impact is limited. The implementation of an Urgent Treatment Centre at Watford, acting as the single point of entry and streaming patients to the appropriate area for onward care, is expected to have a significant impact on performance improvement.
6 RTT Incomplete pathways 6.1 December’s performance against the 92% RTT standard was the same as the previous
month, ie 87.4%. In previous years, there was a drop in performance between November and December, by 2% in 2017 and 1.3% in 2018, so maintaining the same level performance is a positive indicator, given the potential risks to elective activity at that time of year.
6.2 Benchmarking using Model Hospital indicates that WHHT is placed 41st (previously 72nd) of 114 providers in terms of RTT incomplete pathway performance (86.8%) in October 2019, the national sector median being 84.2% and the regional median 81.4%.
The following chart benchmarks WHHT with the Nightingale Group (see p4) where the median is 81.9%.
Trajectory plan - ED
Trust
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
be
r
Oct
ob
er
No
vem
be
r
De
cem
be
r
Jan
uar
y
Feb
ruar
y
Mar
ch
National standard 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%
Plan 81.1% 88.0% 88.5% 89.3% 90.2% 88.4% 87.8% 89.8% 88.2% 88.8% 90.6% 93.0%
Actual performance 81.2% 79.9% 82.1% 81.3% 80.5% 83.0% 83.4% 82.2% 79.4%
70%
75%
80%
85%
90%
95%
100%
April May June July August September October November December January February March
% p
ati
ents
wit
hin
targ
et
WHHT ED Improvement Trajectory
Actual performance Plan National standard
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Although December’s position was unchanged from the previous month, when comparing trends across a 12 month period from November 2018, WHHT is improving while the regional and national position is deteriorating.
6.3 The total PTL size is slightly lower than the previous month (December 23011 vs November 23017) and remains lower than that of March 2019 (24178) and the reduction in the backlog over 18 weeks continues, when compared with the previous month (2896 vs 2948) and April 2019 (4653).
6.4 Six breaches of the 28 day rebooking rule occurred in December, 2 Ophthalmology, 1
Urology, 1 ENT, 1 Orthopaedic and 1 Gynaecology. Most of the breaches were the result of not offering a new date within 28 days, with reasonable (3 weeks) notice. Patients are not always able or willing to accept a date within 28 days but there is more to do to ensure this is recorded appropriately.
7 52 week waits 7.1 At the end of December there were no patients whose waiting time exceeded 52 weeks.
7.2 Harm reviews for patients whose wait exceeds 48 weeks continue. As long waits reduce,
so does the number of harm reviews. The table below shows the latest position.
ENT 1 38 0
Ophthalmology 1 34 0
Oral Surgery 1 1 0
General
surgery
All with consultants being completed in administrative time.
3 low harm are from prolonged urinary catheterisation and
psychological distress.
3 new moderate harms identified in October under SI. Chasing
clinicians to complete outstanding reviews
Orthopaedics 1 280 12 No further Harm been identified
6Urology 4 225
Comments / update
1 305 0All re-escalated with teams, to date we are not aware of any harm.
Speciality
Review in
progress -
awaiting
treatment
Reviews
completed
Harm
identified
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8 Progress against the RTT improvement programme 8.1 The improvement plan target for December was 88.4%, with an actual performance of
87.4%. While modelling indicated fewer clock stops would be made this month as a result of the Christmas/New Year break and less working days, the actual number was lower still and this is the main factor for variance to plan.
Outsourcing is ongoing and recent discussions with commissioners have resulted in agreement to work more collaboratively in terms of identifying additional capacity in the private sector and other NHS organisations with a view to increasing activity further. Some weekend and in week additional theatre lists are being undertaken but the impact of the NHS Pensions tax issue continues to affect take up of ad hoc sessions.
9 Cancer Waiting Times Performance
9.1 Two week wait and two week wait breast symptomatic performance improvements have been maintained, with compliance in both standards.
9.2 All 31 day pathway standards have been achieved this month. 9.4 Performance against the 62 day referral to first treatment standard is currently at 83.2%, an
improvement on November’s position of 79.2%. There are 15.5 breaches across the tumour sites, from a total of 91.5 pathways, in Urology, Lung and Breast. This is a provisional position which is expected to change up to national submission (3 February 2020).
A rolling 12 month summary of performance is included in appendix 3.
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9.5 Model Hospital benchmarking of October’s performance shows WHHT ranked 72nd of 116
providers in terms of the 62 day urgent referral to first definitive treatment, the national sector median being 78.5% and the regional median 77.5%.
The chart below benchmarks WHHT with the Nightingale Group (see p4) where the median is 72.9%.
While WHHT’s performance is better than both the regional and national median, the deteriorating trend can be seen in all 3 below. However, this is less significant for WHHT than for the regional position.
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9.6 Harm reviews have traditionally always been undertaken for patients whose waiting time exceeded 104 days and the RTT harm review process was built on the cancer model. The trigger for a cancer RCA and harm review has been lowered to include patients treated beyond 62 days as described in the regional inter-trust referral policy, with the responsibility for completion of the RCA with the treating hospital.
9.7 Given that a number of WHHT cancer pathways are closed with treatment at tertiary
centres, RCAs should be led by the treating hospital. However, following discussion with HVCCG, it was agreed that WHHT would implement a local RCA and review process, obtaining details from treating hospitals where possible.
9.8 The chart below shows the total number of breaches for 2019/20 and progress to date. No
harms have been identified to date.
10 Progress against the cancer improvement plan
10.1 At 83.2%, performance is in line with plan (83.1%).
10.2 The focused work with Lung and Urology is ongoing. The action groups for both tumour
sites are in place, both working on pathway redesign. Several changes in Urology have been agreed – a straight to test pathway (MP MRI), referral triage assessment (to direct
Trajectory plan - 62 day
Current month is provisional
Trust
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
be
r
Oct
ob
er
No
vem
be
r
De
cem
be
r
Jan
uar
y
Feb
ruar
y
Mar
chNational standard 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%
Plan 77.2% 77.4% 79.5% 81.3% 81.3% 80.8% 82.2% 84.3% 83.1% 85.6% 85.3% 86.4%
Actual performance 78.8% 85.2% 82.4% 74.5% 83.1% 85.7% 80.2% 77.1% 83.2%
68%
70%
72%
74%
76%
78%
80%
82%
84%
86%
88%
April May June July August September October November December January February March
% p
ati
ents
wit
hin
targ
et
WHHT 62 Day GP Improvement Trajectory
Actual performance Plan National standard
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and stream referrals through the correct pathway) and “micro” tracking of patients on the PTL to support a reduction in delays. These are to be implemented in January/February.
11 Risks
11.1 There is one risk on the corporate risk register (3828) which describes the principal focus of patient safety and the risk of harm associated with long waits. Although there has been a sustained reduction in the number of long waits and clinical harm reviews are well established, it is still relevant. The current score is 15 but this will reduce as waiting times decrease.
Risks to achievement of the Access standards include:
Failure of system wide demand management schemes resulting in
Increases in demand, above plan
Insufficient capacity to meet demand
A reduction in the uptake of vacated theatre sessions (surgeon and/or anaesthetist) both in week and at weekends, as a result of the pensions issue.
Reduced flow of inpatients from the hospital in to community capacity
Failure to deliver the core ED improvements required to improve flow in the department.
Estate (theatre) infrastructure.
Urgent care admissions to the elective care bed base at WGH.
Prioritisation of cancer and urgent treatment resulting in cancellation of routine surgery.
Patient choice / patient initiated treatment delays.
12 Recommendation
12.1 The Board is asked to receive this report for information and for assurance of ongoing monitoring of performance against nationally mandated waiting times.
Sally Tucker Chief Operating Officer 30 January 2020
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Appendix 1 The Access standards
95% of patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department
Less than 1% of patients should wait 6 weeks or more for a diagnostic test, measured against 15 key diagnostic tests (see below).
More than 92% of patients on incomplete (open) pathways should have been waiting no more than 18 weeks from referral.
A maximum of 2 weeks - from urgent GP referral for suspected cancer to first outpatient appointment – 93%
operational standard - from referral or any patient with breast symptoms (where cancer is not suspected) to first
hospital assessment – 93% operational standard
Maximum one month (31 days) - from decision to treat to first definitive treatment – operational standard of 96% - decision to treat/earliest clinically appropriate date to start second/subsequent treatment
where the treatment is surgery (operational standard 94%), drug treatment (operational standard 98%), radiotherapy (operational standard 94%)
Maximum two months (62 days) from - urgent GP referral for suspected cancer to first treatment – 85% operational standard - urgent referral from NHS Cancer Screening Programme (breast, cervical, bowel) for
suspected cancer to first treatment – 90% operational standard The 15 key diagnostic tests 1. Imaging - Magnetic Resonance Imaging 2. Imaging - Computed Tomography 3. Imaging - Non-obstetric ultrasound 4. Imaging - Barium Enema 5. Imaging - DEXA Scan 6. Physiological Measurement - Audiology – Audiology Assessments 7. Physiological Measurement - Cardiology - echocardiography 8. Physiological Measurement - Cardiology - electrophysiology 9. Physiological Measurement - Neurophysiology - peripheral neurophysiology 10. Physiological Measurement - Respiratory physiology - sleep studies 11. Physiological Measurement - Urodynamics - pressures & flows 12. Endoscopy - Colonoscopy 13. Endoscopy - Flexi sigmoidoscopy 14. Endoscopy - Cystoscopy 15. Endoscopy – Gastroscopy https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/DM01-guidance-v-5.32.pdf
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Appendix 2 Specialty level RTT performance against 92% open pathway standard – December 2019
Service Total PTL
< 18 weeks
18 Weeks Plus
% Under 18 Weeks
VASCULAR SURGERY 137 93 44 67.88%
PAIN MANAGEMENT 600 411 189 68.50%
ORAL SURGERY 1369 970 399 70.85%
ORTHODONTICS 96 69 27 71.88%
UROLOGY 1758 1361 397 77.42%
ENT 1924 1519 405 78.95%
TRAUMA & ORTHOPAEDICS 2255 1832 423 81.24%
GENERAL SURGERY 1434 1199 235 83.61%
OPHTHALMOLOGY 1715 1444 271 84.20%
PAED UROLOGY 141 121 20 85.82%
NEUROLOGY 1202 1093 109 90.93%
PAED EPILEPSY 12 11 1 91.67%
RHEUMATOLOGY 428 394 34 92.06%
COLORECTAL SURGERY 480 445 35 92.71%
ENDOCRINOLOGY 375 350 25 93.33%
DIABETIC MEDICINE 91 85 6 93.41%
GASTROENTEROLOGY 1704 1603 101 94.07%
PAED OPHTHALMOLOGY 172 164 8 95.35%
UPPER GI SURGERY 69 66 3 95.65%
PAED GASTROENTEROLOGY 100 96 4 96.00%
DERMATOLOGY 1767 1701 66 96.26%
HEPATOLOGY 86 83 3 96.51%
RESPIRATORY MEDICINE 543 528 15 97.24%
NEPHROLOGY 41 40 1 97.56%
CARDIOLOGY 1920 1878 42 97.81%
GERIATRIC MEDICINE 98 96 2 97.96%
CLINICAL HAEMATOLOGY 244 240 4 98.36%
GYNAECOLOGY 928 913 15 98.38%
BREAST SURGERY 247 243 4 98.38%
PAEDS 693 685 8 98.85%
GENERAL MEDICINE 11 11 0 100.00%
PAED ENDOCRINOLOGY 27 27 0 100.00%
PAED CLINICAL HAEMATOLOGY 23 23 0 100.00%
PAED DERMATOLOGY 69 69 0 100.00%
PAED CYSTIC FIBROSIS 1 1 0 100.00%
PAED CARDIOLOGY 101 101 0 100.00%
STROKE MEDICINE 5 5 0 100.00%
MEDICAL ONCOLOGY 12 12 0 100.00%
GYNAECOLOGICAL ONCOLOGY 23 23 0 100.00%
ORTHOTICS 77 77 0 100.00%
CLINICAL ONCOLOGY 33 33 0 100.00%
Total 23011 20115 2896 87.41%
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Tab 10 Performance Report on Access Standards
14 of 236 Trust Board Meeting in Public-06/02/20
Appendix 3
Cancer waiting times performance – update (at 30/1/20)
NB:
Performance is provisional at the time of writing
There has been a national change in the reporting of 31 day subsequent pathways. Although WHHT still submits data for all subsequent treatments (drug, surgery, palliative, radiotherapy and other) only subsequent treatments for drugs, surgery and radiotherapy are now available in the cancer waiting times preview for national reporting. On that basis subsequent treatments for palliative and other will be removed from reporting going forward, but radiotherapy (94% target) will be added.
Standard Target Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 YTD
2ww 93.0% 94.1% 94.8% 93.2% 93.0% 91.3% 93.0% 92.3% 91.1% 92.5% 93.2% 94.1% 96.3% 96.9% 93.5%
2ww breast 93.0% 90.8% 91.1% 90.7% 88.0% 87.4% 94.1% 90.8% 97.0% 98.4% 100.0% 100.0% 96.3% 98.4% 95.2%
31 day 1st 96.0% 97.9% 97.5% 97.7% 97.7% 99.4% 96.8% 98.2% 98.9% 96.5% 95.0% 94.3% 98.0% 99.4% 97.2%
31 day surgery 94.0% 100.0% 92.6% 96.3% 100.0% 100.0% 95.0% 93.8% 100.0% 100.0% 100.0% 78.9% 100.0% 100.0% 95.6%
31 day drug 98.0% 100.0% 97.1% 95.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.4% 90.0% 100.0% 100.0% 98.7%
31 day palliative 94.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
31 day other 94.0% 100.0% 93.3% 100.0% 100.0% 100.0% N/A 100.0% N/A N/A N/A N/A N/A N/A 100.0%
62 day 85.0% 78.7% 77.5% 74.3% 84.2% 78.6% 86.8% 83.0% 75.0% 83.9% 88.0% 80.2% 77.1% 83.2% 81.9%
62 day screening 90% 86.7% 90.0% 80.0% 75.0% 100.0% 100.0% 73.3% 93.1% 83.3% 64.0% 72.7% 100.0% 100.0% 84.8%
10
Tab 10 P
erformance R
eport on Access S
tandards
15 of 236T
rust Board M
eeting in Public-06/02/20
Trust Board 06 February 2020
Title of the paper Integrated Performance Report
(January 2020 reporting period – December 2019 data)
Agenda Item 11/79
Presenter
Sally Tucker, Chief Operating Officer
Author(s)
Jane Shentall , Director of Performance
Purpose
For approval
For discussion For information
Executive Summary
Safe Care & Improving Outcomes
Mortality indicators remain stable, and within the as expected range – HSMR 96.9, SHMI 100.3 (slides 4, 22)
There was 1 hospital and healthcare apportioned clostridium difficile case (previous month 3) with a year to date total of 37 (slides 4, 23-24)
The overall C-section rate has reduced, but remains above target (28%); choice is reflected in the elective rate at 16.4% which is above the local target (11%), but the emergency rate is better than target (15%) at 13.8% and benchmarking (October) is comparable with peers. The year to date rate for all c-sections is 32% (slides 4, 26).
The indicator for safe care, nursing shift fill, at 102.4%, is consistently better than target (95%), as is the year to date position at 102% (slides 4, 27)
There has been a rise in the percentage of patient safety incidents that are harmful, at 10.4% (previous month at 9.1%, year to date 8.9%) (slides 4, 31)
Safety thermometer new harms, at 98.9% (year to date 98.6%), remain better than the national picture, with no category 3 (ytd 12) or category 4 (ytd 0) pressure ulcers (slide 4, 32-35)
VTE risk assessment is below target (95%) at 92.7% but year to date the rate is 95% (slides 4, 36)
Stroke indicator performance has fallen - 66.7% (ytd 66.4%) of patients were admitted to the Stroke unit within 4 hours (target 90%, national average 56.3%), but more patients, 96.8% (was 95.6%) spent 90% of their admission on the unit (target 80%, ytd 94.3%, national average 83.6%) (slides 4, 37)
Caring & Responsive Services
Ambulance turnaround delays increased, with 455 (was 383) between 30 and 60 minutes and 192 over 60 minutes (previously 84) (slides 5, 36)
ED 4 hour performance is lower than last month at 79.4% (was 82.2%) with a year to date position of 81.4% (slides 5, 38)
Reporting requirements for delayed transfers of care (DToCs) have changed, now only bed days and beds used are reported - 804 bed days (previously 725) and 26 beds (was 24) were used (slides 5, 40)
Inpatient and Day Case Friends & Family positive scores are stable and above the 95% target. A&E scores at 94.8% and Maternity at 93.3% are below target (slides 5, 41-42)
Complaints response times are compliant with the target (80%) at 80% (ytd 81.4%), with 3 reactivated complaints received in the month (slides 5, 43)
RTT (incomplete) performance is unchanged, at 87.4% (ytd 85%). There were no 52 week breaches for the third consecutive month (slides 5, 45)
2 week wait (96.9%, ytd 93.3%) and 2 week wait breast symptomatic (98.4%, ytd 95.5%) are consistently compliant with waiting time standards (93%) (slides 5, 46)
All cancer 31 day targets have been achieved (slides 5, 47)
62 day urgent referral to first treatment is below target (85%) but has improved at 83.2% (was 79.2%), and is at 81.9% year to date (slide 5, 48)
62 day screening standard was achieved at 100% (90%, ytd 85.6%) (slides 5, 48)
11
Tab 11 Integrated Performance Report
1 of 236 Trust Board Meeting in Public-06/02/20
Short notice appointment cancellations have risen slightly to 4.3% (from 3.7%) and are better than the local target, year to date 4.4% (target 5%) (slides 5, 49)
Outpatient DNA rates have improved to 9.2% (from 9.1%, ytd 8.7%) and the latest available benchmarking (Q2 2019/20) shows the trust position is slightly above the national and regional medians (slides 5, 49)
Workforce & Finance
12 month turnover rates are lower than November (15.1%) at 14.3% but remain above target (13%), year to date the rate is 14.9%; the vacancy rate is stable at 10.2% (ytd 10.4%) and close to target (10%) (slides 5, 50)
Sickness absence rates are similar to the previous month at 3.8% but above target (3.5%) - year to date the rate is 3.5% (slides 6, 50)
All staff appraisal rates are better than the target (90%) at 91.9% (including medical staff) (slides 5, 51)
Mandatory training rates remain consistently better than target (90%) at 93.9%; Essential training compliance is 91.1% and better than target (90%) (slides 5, 51)
Bank pay is better (lower) than the target (12%) at 11.2% (ytd 11.6%), but agency pay at 4.9% is above (worse than) target (4.4%) and is 5.1% ytd (slides 6, 17)
Actual I&E expenditure was better than plan and the forecast remains unchanged (slides 6, 11)
Capital expenditure is worse than plan at month end and year to date (slides 6, 20)
CIP delivery is behind plan in month (£1.903m delivered against a plan of £1.922m) but the year to date actual is better than the year to date target. (slides 6, 19).
A range of activity counts are now included for information (slide 6): - GP referrals are lower than the previous month - A&E attendances are significantly higher than expected - Elective overnight spells are in line with plan - Total elective spells are higher than expected - Outpatient attendances are lower than planned - Outpatient attendances are higher than the target total - Births are lower than planned Activity RAG ratings are shown in the context of the minimum income contract where the primary objective is to match capacity to demand. Therefore, non-elective activity above plan/expectations would be rated red. Births are classified as non-elective activity and so activity below plan is rated green. Elective spell underperformance against expectations is rated red in the context of waiting list management.
NB: Data correct at the time of reporting – 31/01/2020
Trust strategic aims
(please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to work
Objectives 6-8
Aim 3 Improve our finances
Objective 9
Aim 4 Strategy for the future
Objective 10-12
Links to well-led key lines of enquiry
☒Is there the leadership capacity and capability to deliver high quality, sustainable
care? ☒Is there a clear vision and credible strategy to deliver high quality, sustainable care
to people, and robust plans to deliver? ☐Is there a culture of high quality, sustainable care?
☒Are there clear responsibilities, roles and systems of accountability to support good
governance and management?
☒Are there clear and effective processes for managing risks, issues and
performance?
☒Is appropriate and accurate information being effectively processed, challenged and
acted on?
☐Are the people who use services, the public, staff and external partners engaged
and involved to support high quality sustainable services?
☒Are there robust systems and processes for learning, continuous improvement and
innovation?
☒How well is the trust using its resources?
11
Tab 11 Integrated Performance Report
2 of 236Trust Board Meeting in Public-06/02/20
Previously considered by
Committee/Group Date
Trust Management Committee 29 January 2020
Finance & Performance Committee 30 January 2020
Action required
The Board is asked to receive this report for information and assurance.
11
Tab 11 Integrated Performance Report
3 of 236 Trust Board Meeting in Public-06/02/20
Integrated Performance Report
January 2020
Reporting Period: December 2019
1
Trust Board: 6 February 2020 11
Tab 11 Integrated P
erformance R
eport
4 of 236T
rust Board M
eeting in Public-06/02/20
Patient Experience
The very best care for every patient, every day
How Are we Doing?
2
Safety Thermometer
New Harm Free Care
Target 95%
Inpatient Friends & Family
positive scores
Target 95%
CWT: 62 day referral
to first treatment
Target 85%
Complaints
response times
Target 80%
I&E I&E
forecast actual
(Full year) (YTD actual & YTD plan)
Target
Mandatory
Training
Appraisal
Rates
Target 90%
VTE
assessment
Target 95%
Clostrioides
Difficile
cases
ED 4 hour
standard
Target 95%
RTT open
pathways
Target 92%
Agency
pay
Target 4.4%
Vacancy
rate
Target 10%
Safe Care &
Improving Outcomes
Caring &
Responsive Services
Workforce
& Finance
98.9%
92.7%
95.8%
80.0%
79.4% 87.4%
Target 2
93.9% 91.9%
4.9% 10.2%
83.2%-£22,741 -£20,729
1
20,810-£
11
Tab 11 Integrated P
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eport
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Essential Measures – Executive Summary
Quality & Safety Patient Experience
Workforce & Finance
Patient Experience
The very best care for every patient, every day
Reporting Sub-Committees
3
All staff appraisal Improved, and better than target
Reporting Sub-Committee
Quality Committee People, Education & Research Committee
Finance & Performance Committee
Reporting Sub-Committees Reporting Sub-Committees
People, Education & Research Committee
Finance & Performance Committee
Mortality SHMI has increased this month but
Remains within as expected range
Infection Control – clostrioides
Difficile Hospital & healthcare associated
cases – some improvement
Serious incidents & Never
Events (NE) Variable
Patient safety incidents
which are harmful Worse than previous month
Combined Caesarean Section Standard not achieved – variable but
lower than previous month
VTE assessments Deteriorated and target not
achieved
Stroke Indicators Admission to the Stroke Unit
within 4 hrs – target not achieved
90% admission spent in the Stroke
Unit – variable, consistently achieved
Complaints response times Target not achieved
Inpatient Friends & Family Test Positive scores mainly compliant
although variable, ED just below target
Mixed sex accommodation Variable but none reported this month
Outpatient DNA rates Increase on previous month and
worse than target
ED waiting times Performance deteriorated. Below
target and adverse to plan
RTT waiting times Improving although below target and
just below plan
Cancer waiting times 2ww achieved and improving
62 day not achieved but improving,
better than previous month and in line
with plan
Mandatory training Consistently achieved and stable
Turnover at 12 months Worse than target but better than
recent months
Income & Expenditure
Capital Spend
Other Finance Indicators Financial risk rating
Activity vs plan
Elective activity
Non-elective activity
CIP Efficiency Full year savings of
£15.15m identified (target £15m)
Safe Care &
Improving Outcomes
Caring &
Responsive Services
Workforce
& Finance
SHMI 100.3
HSMR 96.9
1 (Cat1: 1 +
Cat 2:0) YTD 37
SI 3 YTD 23
NE 1 YTD 2
10.4%
YTD 8.9%
30.2%
YTD 32.0%
92.7%
YTD 95.0%
4 hr 66.7%
YTD 66.4%
Adm 96.8%
YTD 94.3%
80.0%
YTD 81.4%
0
YTD 24
79.4%
YTD 81.4%
87.4%
YTD 85.0%
Resp 17.6%
+ ve 95.8%
9.2%
YTD 8.7%
2ww 96.9%
YTD 93.3%
62 day 83.2%
YTD 81.7%
91.9%
YTD 88.1%
93.9%
YTD 92.4%
14.3%
YTD 14.9%
(£1.99)m
YTD (£20.73)m
(£0.96)m
YTD (£6.19)m
£1.90m
YTD £11.05m
FRR 3Elec 3523 vs 3156
Non-Elec 4617 vs 3974
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Indicator Summary
The very best care for every patient, every day
4
Key Description
Performance better than
target/threshold
Performance better
than target/threshold
Performance worse than
target/threshold
Performance worse
than target/threshold
Performance improved - statistically significant change
compared to previous 12 months (2
standard deviations SPC)
Performance
deteriorated - statistically
significant change compared to
previous 12 months (2 standard
deviations SPC)
Performance stable - no
statistically significant change
compared to previous 12 months (2
standard deviations SPC)
Theme Page Target Trend Oct-19 Nov-19 Dec-19 YTD actualYTD
target
Data
period
National /
Local /
Trust
Bench-
marking
Bench-
marking
period
SHMI (Rolling 12 months) 22 100Performance deteriorated and
worse than target95.4 99.0 100.3 Jul-19 National 100 Jul-19
HSMR - Total (Rolling three months) 22 100Performance improved and
better than target99.5 99.5 96.9 Sep-19 National 100 Sep-19
Clostridioides Difficile - Hospital associated (Cat 1) 23 n/aPerformance stable and better
than target2 1 1 24 Dec-19 National
Clostridioides Difficile - Healthcare associated (Cat 2) 23 n/a Performance stable and better
than target1 2 0 13 Dec-19 National
Clostridioides Difficile - Hospital and Healthcare associated Total 23 2Performance stable and better
than target3 3 1 37 28 Dec-19 National
Hand Hygiene Compliance 24 95%Performance stable and better
than target96.5% 95.2% 96.2% 97.1% 95% Dec-19 Local n/a
30 Day Emergency Readmissions - Elective * 25 4.3% Performance stable and better
than target4.0% 3.2% 3.4% 3.5% 4.3% Jun-19 National 4.3% Jun-19
30 Day Emergency Readmissions - Emerg * 25 13.6% Performance deteriorated but
better than target12.3% 13.0% 13.5% 12.9% 13.6% Jun-19 National 13.6% Jun-19
Caesarean Section rate - Combined* 26 28.0% Performance stable but worse
than target31.5% 34.3% 30.2% 32.0% 28.0% Dec-19 Local 28.0% 2017/18
Caesarean Section rate - Emergency* 26 15.0% Performance stable and better
than target16.0% 18.9% 13.8% 16.3% 15.0% Dec-19 Local 16.0% 2017/18
Caesarean Section rate - Elective* 26 11.0% Performance stable but worse
than target15.5% 15.3% 16.4% 15.7% 11.0% Dec-19 Local 12.0% 2017/18
% nursing hours (shift fill rate) 27 95.0% Performance stable and better
than target101.9% 102.5% 102.4% 102.0% 95.0% Dec-19 National n/a
Serious incidents - number* 31 0Performance stable but worse
than target4 1 3 23 0 Dec-19 National n/a
Serious incidents - % that are harmful* 31 0.0% Performance stable but worse
than target100.0% 100.0% 100.0% 100.0% 0% Dec-19 National n/a
% of patients safety incidents which are harmful* 31 0.0% Performance stable but worse
than target7.9% 9.1% 10.4% 8.9% 0% Dec-19 National n/a
Never events 31 0 Performance deteriorated and
worse than target0 0 1 2 0 Dec-19 National n/a
Safety Thermometer Harm Free Care (acquired within and outside of Trust) 33 95.0%Performance stable but worse
than target92.2% 88.7% 91.9% 91.1% 95.0% Dec-19 National 94.0% Dec-19
Safety Thermometer % New Harm Free Care (acquired within Trust) 33 95.0% Performance stable and better
than target98.2% 98.5% 98.9% 98.6% 95.0% Dec-19 National 97.8% Dec-19
Category 4 pressure ulcers - New (Hospital acquired) 35 0 Performance stable and better
than target0 0 0 0 0 Dec-19 Local
Category 3 pressure ulcers - New (Hospital acquired) 35 0Performance stable and better
than target1 0 0 12 0 Dec-19 Local
VTE risk assessment* 36 95.0%Performance deteriorated and
worse than target94.8% 95.1% 92.7% 95.0% 95.0% Dec-19 National 95.5% Q2 19/20
Patients admitted to stroke unit within 4 hours of hospital arrival 37 90.0%Performance stable but worse
than target71.0% 81.1% 66.7% 66.4% 90.0% Dec-19 National 56.8% Sep-19
Stroke patients spending 90% of their time on stroke unit 37 80.0%Performance stable and better
than target92.6% 95.6% 96.8% 94.3% 80.0% Dec-19 National 83.8% Sep-19
Quality of Care: Mortality Indicators
Patient Safety
Domain
Safe care &
Improving
Outcomes
Quality of Care: Infection Control
Quality of Care: Emergency Readmissions
Quality of Care: Caesarean Section rates
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Tab 11 Integrated P
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Indicator Summary The very best care for every patient, every day
5
Theme Page Target Trend Oct-19 Nov-19 Dec-19 YTD actualYTD
target
Data
period
National /
Local /
Trust
Bench-
marking
Bench-
marking
period
Ambulance turnaround time between 30 and 60 mins 0Performance deteriorated and
worse than target402 383 455 3174 0 Dec-19 National n/a
Ambulance turnaround time > 60 mins 0Performance stable but worse
than target116 84 192 1259 0 Dec-19 National n/a
% Patients admitted through A&E - 0 day LOSPerformance improved but
worse than target38.3% 38.7% 37.2% 34.3% Dec-19 National
Discharges between 8am and 12pm (main adult wards excl AAU) 33.0%Performance deteriorated and
worse than target18.5% 21.2% 16.4% 19.4% 33.0% Dec-19 National
Mixed sex accommodation breaches 39 0Performance stable and better
than target0 1 0 24 0 Dec-19 National
58 Trusts
breachingNov-19
LOS > 21 days 40 71Performance stable but worse
than target92 80 100 100 71 Dec-19 National n/a
Delayed Tranfers of Care (DToC) beddays used in month 40 n/aPerformance stable and better
than target1088 725 804 7239 n/a Dec-19 National n/a
Delayed Tranfers of Care (DToC) beds used in month 40 n/a Performance stable and better
than target35 24 26 30 n/a Dec-19 National n/a
A&E FFT % positive 41 95% Performance stable but worse
than target90.6% 94.2% 94.8% 91.8% 95% Dec-19 National 84.0% Nov-19
Inpatient Scores FFT % positive 41 95% Performance stable and better
than target95.6% 95.2% 95.8% 94.8% 95% Dec-19 National 85.8% Nov-19
Daycase FFT % positive 42 95% Performance stable and better
than target98.9% 98.8% 99.3% 98.1% 95% Dec-19 National n/a
Maternity FFT % positive 42 95%Performance stable but worse
than target96.5% 96.9% 93.3% 96.0% 95% Dec-19 National 96.4% Nov-19
Complaints responded to within target/agreed timescale 43 80% Performance stable and better
than target78.6% 81.3% 80.0% 81.4% 80% Dec-19 National n/a
Reactivated complaints 43 0 Performance stable but worse
than target3 0 3 36 0 Dec-19 National n/a
New indicators to be included in Q4
New indicators to be included in Q4
ED 4hr waits (Type 1, 2 & 3) 38 95.0% Performance stable but worse
than target83.4% 82.2% 79.4% 81.4% 95.0% Dec-19 National 79.8% Dec-19
Referral to Treatment - Incomplete* 45 92.0% Performance improved but
worse than target86.9% 87.4% 87.4% 85.0% 92.0% Dec-19 National 84.4% Nov-19
Referral to Treatment - 52 week waits - Incompletes 45 0 Performance stable and better
than target0 0 0 17 0 Dec-19 National 1398 (all Trusts) Nov-19
Diagnostic (DM01) <6 weeks 99.0% Performance stable and better
than target99.9% 99.5% 99.7% 99.8% 99.0% Dec-19 National 97.1% Nov-19
Cancer - Two week wait * 46 93.0% Performance improved and
better than target94.1% 96.2% 96.9% 93.3% 93.0% Dec-19 National 90.2% Q2 19/20
Cancer - Breast Symptomatic two week wait * 46 93.0%Performance stable and better
than target100.0% 96.3% 98.4% 95.5% 93.0% Dec-19 National 85.3% Q2 19/20
Cancer - 31 day * 47 96.0% Performance stable and better
than target94.3% 98.1% 98.8% 97.3% 96.0% Dec-19 National 96.0% Q2 19/20
Cancer - 31 day subsequent drug * 47 98.0% Performance stable and better
than target90.0% 100.0% 100.0% 99.4% 98.0% Dec-19 National 99.2% Q2 19/20
Cancer - 31 day subsequent surgery * 47 94.0% Performance stable and better
than target78.9% 100.0% 100.0% 95.5% 94.0% Dec-19 National 91.3% Q2 19/20
Cancer - 31 day subsequent radiology * 47 94.0% Performance improved and
better than target- - - - 94.0% Dec-19 National 91.3% Q2 19/20
Cancer - 62 day * 48 85.0% Performance stable but worse
than target80.4% 79.2% 83.2% 81.7% 85.0% Dec-19 National 77.7% Q2 19/20
Cancer - 62 day screening * 48 90.0% Performance stable and better
than target72.7% 96.0% 100.0% 85.6% 90.0% Dec-19 National 86.7% Q2 19/20
Outpatient cancellation rate within 6 weeks^ 49 5.0% Performance stable and better
than target5.4% 3.6% 4.3% 4.4% 5.0% Dec-19 Local n/a
DNA rate 49 8.0%Performance stable but worse
than target9.0% 8.8% 9.2% 8.7% 8.0% Dec-19 National n/a
Patient Experience: Complaints
Patient Experience: End of life care
Access to Services
Access to Services: Outpatients
Cancer
Patient Flow: Emergency Department
Patient Flow: In hospital flow
Patient Experience: Friends & Family Test
Domain
Caring &
Responsive
Services
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Tab 11 Integrated P
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Indicator Summary
The very best care for every patient, every day
6
* No official cash target ** Straight line target
Theme Page Target Trend Oct-19 Nov-19 Dec-19 YTD actualYTD
target
Data
period
National /
Local /
Trust
Bench-
marking
Bench-
marking
period
Staff turnover rate (rolling 12 months) 50 13.0%Performance improved but
worse than target14.7% 15.1% 14.3% 14.9% 13.0% Dec-19 National
15.0% (Beds and
Herts orgs)Q1 19/20
% staff leaving within first year (excluding medics and fixed term contracts) 50 n/a Performance stable and better
than target16.7% 17.1% 17.0% 18.6% n/a Dec-19 National n/a
Vacancy rate 50 10.0%Performance stable but worse
than target10.7% 10.1% 10.2% 10.4% 10.0% Dec-19 National
11.1% (local
survey)Q1 19/20
Sickness rate 50 3.5%Performance improved but
worse than target3.9% 3.9% 3.8% 3.5% 3.5% Dec-19 National 3.7% (EoE orgs) Q1 19/20
Appraisal rate (Total) 51 90.0% Performance improved and
better than target90.8% 89.9% 91.9% 88.1% 90.0% Dec-19 National
Mandatory Training 51 90.0% Performance deteriorated but
better than target92.7% 93.9% 93.9% 92.4% 90.0% Dec-19 Local 91.0% (local
survey)Q1 19/20
Essential Training 51 90.0%Performance improved and
better than target90.3% 91.1% 91.1% 87.6% 90.0% Dec-19 Local
Financial Risk Rating 10-20 3 Performance improved and
better than target3.00 3.00 3.00 Dec-19 Local
Income & Expenditure Actual 10-20 -£2,003Performance stable and better
than target£119 -£1,054 -£1,987 -£20,729 -£20,810 Dec-19 Local
Income & Expenditure forecast 10-20 -£22,741Performance improved and
better than target-£22,741 -£22,741 -£22,741 -£22,741 -£22,741 Dec-19 Local
Cash balance at the end of the month 10-20 £1,765Performance improved and
better than target£3,693 £7,077 £7,827 £7,827 £1,765 Dec-19 Local
Capital expenditure 10-20 -£2,482Performance stable but worse
than target-£900 -£723 -£960 -£6,185 -£18,045 Dec-19 Local
CIP delivery against plan 10-20 £1,922Performance stable but worse
than target£1,388 £1,539 £1,903 £11,045 £9,164 Dec-19 Local
% Bank Pay** 10-20 12.0%Performance stable and better
than target11.4% 12.6% 11.2% 11.6% 12.0% Dec-19 Local n/a
% Agency Pay** 10-20 4.4%Performance stable but worse
than target5.1% 4.6% 4.9% 5.1% 4.4% Dec-19 Local
7.3% (local
survey)Q1 19/20
GP referrals 6,839 Performance stable and better
than target9,204 7,916 7,173 71,456 71,042 Dec-19 National
A&E attendances 12,777 Performance deteriorated and
worse than target13,869 13,937 14,269 110,611 103,097 Dec-19 National
Elective spells (overnight) 465 Performance stable and better
than target549 494 468 4,544 5,092 Dec-19 National
Elective daycase 2,691 Performance stable and better
than target3,332 3,186 3,055 29,284 29,605 Dec-19 National
Total elective spells 3,156 Performance stable and better
than target3,881 3,680 3,523 33,828 34,697 Dec-19 National
Non-elective spells 3,974 Performance stable but worse
than target4,788 4,642 4,617 39,030 35,745 Dec-19 National
Births 406 Performance stable and better
than target390 357 350 3,235 3,635 Dec-19 National
Outpatient attendances 16,946 Performance stable and better
than target21,755 21,368 17,876 179,910 180,124 Dec-19 National
Recruitment & Retention
Activity (chargeable)
Workforce and
finance
Domain
Developing Staff
Finance overview
Activity RAG ratings are shown in the context of the minimum income contract where the primary objective is to match capacity to demand. Therefore, non-elective activity above plan/expectations would be rated red. Births are classified as non-elective activity and so activity below plan is rated green. Elective spell underperformance against expectations is rated red in the context of waiting list management.
11
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eport
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eeting in Public-06/02/20
Key messages for the Board
Chief Medical Officer
Chief Nurse
The very best care for every patient, every day
7
Safe Care &
Improving Outcomes
The Wuhan novel coronavirus (WN-CoV) was raised as an international alert from the World Health Organisation (WHO) in January. Public Health England
(PHE) guidance has been issued which the Trust has followed. The infection prevention control team (IPC), emergency planning and operations have worked
in partnership to ensure the management of suspected cases is clear within the areas identified as points of admissions such as the emergency department
(ED). A policy has been developed based on the guidance issued and has been approved by the Director of Infection & Prevention Control (DIPC), trust
preparedness has been discussed at the Quality Committee and will be reported in the committee assurance report to Trust Board.
The Trust has tested the policy and it has been amended after a review at the end of January including any further emerging guidance from PHE.
The ward accreditation programme has been reviewed and the programme is underway, all wards will have been accredited by August 2020.
I’m very pleased to confirm that Dr Howard Borkett-Jones has been appointed as the Associate Medical Director for Appraisal and Revalidation, and Dr
Ashleigh Reece has been appointed as the Director (and AMD) for medical education. They will commence in their posts in April 2020.
The SMART medical take pilot has continued to deliver improved patient flow and efficiency, and the trust’s ED performance is nearly at upper quartile, having
previously been in the lowest quartile of all reporting acute trusts in England. We remain above the region’s reported ED performance, and this has now been
maintained for the duration of the pilot. We have therefore requested that each department’s team job plans for 2020/21 are developed to make SMART
“business as usual”, where appropriate.
All staff are obviously focused on the imminent CQC inspection, and multiple teams have been proudly submitting their achievements since the last inspection,
and ensuring they are fully prepared to demonstrate their commitment to the trust’s values of the very best care for every patient, every day!
11
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Key messages for the Board
Patient Experience Workforce & Finance Chief Nurse
Chief Operating Officer
The very best care for every patient, every day
8
Caring &
Responsive Services
Maternity have had an initial assessment for UNICEF ‘baby friendly’ stage 2 with very good preliminary results, we now await the final report by April 2020.
The Safeguarding team have developed Makaton (a programme using speech with signs and symbols to help communication) lanyards and card packs
which they have piloted and are now rolling out to all paediatric areas – to be completed by February 2020.
We will also be launching a campaign across the Trust using useful signs and shared across the intranet each month in 2020
We have continued to see a sustained position in our response to complaints and will be continuing work to build on this, developing the complaints team to
support investigating and learning. The learning from complaints has been built into our ward accreditation programme. This will also form part of our shared
governance model supporting leadership and encouraging personal and professional development whilst focusing on improving pat ient safety, patient
experience and staff experience. A paper will be presented at Trust Management Committee in March 2020.
The Trust continued to experience high levels of demand during December. Record attendances were reported on Monday 23rd December with 366
attendances at Watford alone. Whilst we saw reduced demand on Christmas Day, Boxing day saw in excess of 300 attendances at Watford. Christmas &
New Year proved to be a busy period with the Trust’s surge plan being fully executed and culminating in a Business Continuity Incident being declared on 30th
December 2019 and not stood down until 9th January 2020.
Point of Care Flu Testing was operationalised prior to Christmas, speeding up the process of diagnosis and any subsequent isolation actions necessary. The
Trusts cohorting plan was enabled with Red Suite being used as a Flu ward, the use of PPE and Deep Clean programmes was enacted.
Good progress was made with a number of the Winter enabling schemes including the relocation of Medical Records Clinic prep staff, the expansion of rooms
within ambulatory care and the relocation and provision of new accommodation for IDT, Emergency Planning and Operational Management.
In terms of patterns of demand during December, Respiratory and Stroke saw increases, placing pressure into the specialist bed areas.
11
Tab 11 Integrated P
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eeting in Public-06/02/20
Key Messages for the Board
Patient Experience Workforce & Finance
Chief People Officer
Chief Finance Officer
Chief People Officer
Chief Finance Officer
The very best care for every patient, every day
9
Workforce
& Finance
Despite vacancy rates being marginally above target, we have seen an increase of 112wte in post over the last 12 months, with 516wte current vacancies. For Band
5 nurses the vacancy rate is currently 4.6%, a small increase from 2.5% last month, the main cause being a reduction of staff joining during the festive period. We
also have our first cohort of internal OET students due to take their exams in March / April. We predict circa eight to ten candidates will be in a good position to pass
their exam. Turnover is 14.3%, a small decrease from last month and from 12 months ago when it was 15.4%. The percentage of staff who leave their post before
serving one year is currently 17%. The 3 monthly turnover rates which help identify more immediate changes is currently 14%. Sickness absence is 3.8%, which is
high by normal trust standards, but still compares well against peer groups with the Trust being ranked 6 / 16 in terms of the lowest sickness scores for local NHS
benchmarking. Appraisal rates stand at 91.9%, mandatory training rate remains above target at 94%. Essential training compliance is now 91%, the same as
the last three months. The overall BAF workforce assessment rating remains green.
The Trust confirmed allocation of its Continued Professional Development (CPD) funding for 2020-21 with £596k being allocated for CPD against a funding
requirement of £820k. A robust process is in place to decide upon priority requirements and to mitigate against risks with non-funding. The Trust has also
commenced on a major new organisational development programme aimed at its obstetrics and midwifery staff. The Trust has also launched its reverse mentoring
scheme of its Executive team by BAME staff. Finally two key appointment into the HR function have also been made this month with the appointment of a new
Deputy Director of HR and Freedom to Speak Up Guardian.
After the important third quarter results, we continue to report success in managing revenue income and expenditure in line with the plan. For the month of
December (Month 9) we planned to spend £2.0m more than income received, and this was achieved. The results take the year to date deficit to £20.73m which is
also in line with our plan.
As reported last month innovative changes in clinical practice are mitigating the demand for hospital beds, and consequently the demand for extra temporary staff.
Admitted care income, for the year to date, continues to be behind plan mainly due to more efficient emergency patient treatment pathways. However, due to
prudent estimates for elective care activity, based on previous year’s experience, we earned more elective income than planned. Good elective activity performance
helps to minimise waiting for routine operations. The efficiency programme continues to generate savings. After nine months we’ve developed efficiencies worth
£11m, having planned to achieve £8.7m at this stage. We expect savings to rise to £15.3m by the end of the year. Throughout the year keeping pay costs within
budget has been a challenge. The overspending was £0.3m again this month. 1:1 nursing care pressures continue although agency spend is lower than previous
years for the fourth consecutive year.
Overall we expect to end the year meeting the Control Total budget set by NHSI. Our forecast to spend c£21m on new and replacement assets remains, although
after 9 months only £6m of this forecast has been spent. Additional reviews of projects confirm that the forecast remains intact, as much of the work was planned for
the winter period. The expectations for building refurbishment and replacement IT and equipment (ahead of the Trust‘s major redevelopment) are especially high for
the 2020/21 year. 11
Tab 11 Integrated P
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eeting in Public-06/02/20
Key Messages for the Board
Patient Experience Workforce & Finance
Chief People Officer
Chief Finance Officer
Chief Information Officer
The very best care for every patient, every day
10
Corporate - ICT
The Chief Information Officer’s portfolio covers ICT, Business Intelligence and Outpatient administration. These key messages will likely focus on ICT to avoid
potential duplication elsewhere in the IPR.
During December we formally closed the ICT transition programme, with WHHT and Atos signing off a programme closure report that included lessons learnt, and
the 24 December 2019 marked the end of a 3 month (post cut over) stabilisation period with Atos. We are therefore, now, operating in business as usual, with
contractual terms and conditions applying, formal performance being reported and monitored and governance meetings held as appropriate.
From a service perspective, December painted a mixed picture. On the whole, service began to stabilise, with calls to the service desk reducing from 5,404 in
November to 3,839 in December and high priority incidents reducing from 64 in November to 20 in December. Additionally, the total incident backlog (i.e. those that
have breached the SLA standard) reduced from 782 in November to 567 in December and call answering statistics (87% answered within 20 seconds) were
positive, but we need to improve the end user experience during an incident and ensure we have enough physical presence on the floor and we are working hard
with Atos to improve this.
Unfortunately, 10 December 2019 saw a serious incident. At 8am, the Trust performed a Black start generator test. This caused the UPS in the main computer room
to fail which in turn caused a number of distribution switches to fail. The power interruption also caused network traffic to re-route through two core switches which
caused disruption across a range of applications, including PAS, printing, PACS, Infoflex. It took 16 hours for impacted IT services to return to normal service. A full
incident investigation has been undertaken and UPS provision across the Trust has been reviewed.
11
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August 2019– Income and Expenditure
Summary
11
A – The trust reported a favourable position in month by delivering an over performance of £16k in December. The YTD position is also on plan with an actual £20.73m deficit, which is £81k better than plan (J). B- The in month income position showed an over performance of £763k against plan. Bii – Divisional income showed an over performance of £572k against plan in month. This was largely driven by an increase in receipt of Education Funding received from the deanery. The YTD divisional income position is now better than plan by £708k (Fii). Bi- NHS Revenue over performed in month by £275k. An improvement against plan within surgical elective activity was the main driver behind the over performance. The YTD position on NHS revenue shows under performance of £1,186k of which £2,345k relates to other SLA which includes pass through items (Fi). C – The overall pay bill for the month was £21,782k which was £263k overspent. Medical and Nursing pay positions represent the key areas of concern. Premium cover for high levels of vacancies and sickness across divisions represent the main problems within medical staff. The cost of 1:1 nursing care sits within other clinical pay. This is explained further on the pay slides. The YTD pay position is £2,557k overspent (G). D – The non pay position reported an underspend of £491k in month. A £184k was overspend within Clinical supplies was driven by the increase in high cost devices within Cardiology. Although the majority of the drugs overspend (£289k) was pass-through, a general increase in spend was seen across drugs , including home care. E – Financing charges underspent by £7k . The YTD £143k underspend (I) is linked to the timing of interest payable on revenue loans.
Workforce & Finance: Income and Expenditure December 2019
The very best care for every patient, every day
Trust Definition Expense Type Annual Budget Budget Actual Variance Budget Actual Variance
Income Divisional Income 56,423 5,429 6,001 572 Bii 40,231 40,940 708 Fii
NHS Revenue 324,083 25,296 25,571 275 Bi 244,045 242,859 (1,186) Fi
Income Unallocated CIPs 620 85 (85) 315 (315)
Income Total 381,126 30,809 31,571 763 B 284,591 283,799 (792) FPay Medical Pay (78,717) (6,508) (6,633) (125) (58,904) (60,227) (1,323)
Non-Clinical Pay (50,340) (4,082) (4,097) (15) (37,640) (36,734) 906
Nursing Pay (77,172) (6,834) (6,429) 404 (57,356) (58,388) (1,032)
Other Clinical Pay (28,626) (2,413) (2,394) 19 (21,391) (21,370) 21
Scientific, Technical & Profes (25,779) (2,131) (2,229) (98) (19,341) (20,086) (745)
Pay Unallocated CIPs 2,711 448 (448) 425 42 (383)
Pay Total (257,922) (21,519) (21,782) (263) C (194,207) (196,764) (2,557) GNon Pay Clin Supp Serv (31,012) (2,265) (2,449) (184) (23,144) (22,949) 195
Drugs (22,557) (1,694) (1,983) (289) (16,975) (16,262) 713
OTHER (NON CLIN) (80,187) (5,727) (5,830) (103) (61,123) (58,792) 2,330
Non Pay Unallocated CIPS 819 (86) 86 (49) 49
Non Pay Total (132,937) (9,772) (10,263) (491) D (101,290) (98,003) 3,287 HRecharges Recharges () ()
Recharges Total () ()
Financing Charges Depreciation (8,999) (759) (759) () (6,722) (6,671) 51
Trust Debt Redemption (3,952) (757) (753) 3 (3,140) (3,082) 58
Unwinding Discount (57) (5) (1) 4 (43) (9) 34
Financing Charges Total (13,008) (1,520) (1,514) 7 E (9,904) (9,761) 143 I
Total (22,741) (2,003) (1,987) 16 A (20,810) (20,729) 81 J
In Month (£000's) YTD
11
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12
Overview Dashboard
Commentary See earlier pages for I&E detail. A financial risk rating of 3. Five divisions: Medicine, Surgery , Corporate, CSS and Environment are adverse to budget year to date. The Better Practice Payment statistics show 80% on number and 57% on value. This represents an improvement compared to November. The cash balance at the end of December was £7.8m. Savings were £1.9m in December.
Workforce & Finance: Finance overview dashboard
The very best care for every patient, every day
11
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eeting in Public-06/02/20
August 2019– Trust Income Performance
In Month Performance (£s)
In Month Performance (spells)
Divisional income showed an over performance of £572k against plan in month. The majority of this is driven by a YTD adjustment in relation to the Trust’s education budget.
Divisional Income
NHS Revenue: Performance by Month (£s)
13
NHS Revenue in December over performed by £275k by delivering £25.6m against a plan of £25.3m. This can be explained at a point of delivery level: • A&E over performed by £131k which was linked to both an increase in
volume and complexity of attendances. • Critical care showed a small over performance of £27k. Occupancy levels
continue to remain consistent. • Elective performance was £545k above plan. At a high level activity
numbers dropped but this was mitigated against by a substantial increase in orthopedic case mix.
• For Non Elective the in month position broadly in line with plan. A £71k under performance was delivered in month.
• Outpatient performance was £666k better than plan. All clinical divisions saw an over performance in month against plan. The most notable over performances were within Women's’ & Children's’, £232k, and Medicine, £238k. .
Finally other SLA income underperformed by performed by £1,081k. This was driven by an underperformance against pass-through drugs and an adjustment associated with the minimum income contract.
Workforce & Finance: Trust Income - December 2019
The very best care for every patient, every day
Expense Type POD Annual Budget Budget Actual Variance
NHS Revenue A&E 20,052 1,729 1,860 131
Critical Care 13,147 1,134 1,161 27
Elective 55,082 3,774 4,318 545
Non elective 117,497 10,134 10,057 (77)
Other SLA 43,180 3,329 2,311 (1,018)
Outpatient 75,125 5,197 5,863 666
NHS Rev Unallocated CIPs
NHS Revenue TotalTotal 324,083 25,296 25,571 275
In Month (£000's)
Expense Type POD Annual Budget Budget Actual Variance
NHS Revenue A&E 124,013 10,533 11,827 1,294
Critical Care 21,831 1,855 1,211 -644
Elective 46,421 3,132 3,686 554
Non elective 51,550 4,379 5,070 691
Other SLA 3,731,065 252,217 263,013 10,796
Outpatient 453,623 30,630 36,470 5,840
NHS Revenue Total Total 4,428,503 302,745 321,277 18,532
In Month (Activity)
1,650
1,700
1,750
1,800
1,850
1,900
Budget Actual
£000
s
Plan vs Actual
A&E
A&E
1,115
1,120
1,125
1,130
1,135
1,140
1,145
1,150
1,155
1,160
1,165
Budget Actual
£000
s
Plan vs Actual
Critical Care
Critical Care
3,500
3,600
3,700
3,800
3,900
4,000
4,100
4,200
4,300
4,400
Budget Actual
£000
s
Plan vs Actual
Elective
Elective
10,000
10,020
10,040
10,060
10,080
10,100
10,120
10,140
Budget Actual
£000
sPlan vs Actual
Non elective
Non elective
500
1,000
1,500
2,000
2,500
3,000
3,500
Budget Actual
£000
s
Plan vs Actual
Other SLA
Other SLA
4,800
5,000
5,200
5,400
5,600
5,800
6,000
Budget Actual
£000
s
Plan vs Actual
Outpatient
Outpatient
11
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Year To Date (YTD)– Trust Income Performance
YTD Performance (£s)
YTD Performance (spells)
YTD divisional income is £708k above plan. This is driven by an increase in overseas patients ,car parking income and education funding
Divisional Income
NHS Revenue: Performance by Month (£s)
• Month 9 YTD Shows Income under recovery of £1.19m. £242.86m has been generated against plan.
• A&E has a YTD over performance of £915k which is linked to a price and volume variance.
• Critical care is £175k better than plan and has seen an average occupancy rate of 73%.
• Elective performance is £1,485k away from the YTD plan. This is mostly driven by underperformances across the Surgery division linked to reduced uptake of consultant additional sessions.
• Non Elective activity continues to be the feature of the YTD over performance with a surplus against plan of £659k. However, a consistent lower birth rate within maternity is masked within the performance. In addition to this, a declining case mix over the last 3 months has seen the level of over performance begin to decline.
• YTD Outpatient performance shows £894k over performance. Under performances within Surgery (£889k) and WACS (113k) is offset by over performances within Medicine (£1,120k), Emergency medicine (£129k) and Clinical support (£647k).
• Other SLA income was £2,344k away from plan. This is mostly driven by lower pass-through drugs and devices which are mostly offset within the non pay position.
The very best care for every patient, every day
Workforce & Finance: Trust Income - Year to date
14
POD
A&E
Critical Care
Elective
Non elective
Other SLA
Outpatient
NHS Rev Unallocated CIPs
Total
POD
A&E
Critical Care
Elective
Non elective
Other SLA
Outpatient
Total
14,600
14,800
15,000
15,200
15,400
15,600
15,800
16,000
16,200
Budget Actual
£0
00
s
Plan vs Actual
A&E
A&E
9,800
9,850
9,900
9,950
10,000
10,050
10,100
10,150
Budget Actual
£0
00
s
Plan vs Actual
Critical Care
Critical Care
38,500
39,000
39,500
40,000
40,500
41,000
41,500
Budget Actual
£0
00
s
Plan vs Actual
Elective
Elective
89,400
89,600
89,800
90,000
90,200
90,400
90,600
90,800
Budget Actual
£0
00
s
Plan vs Actual
Non elective
Non elective
28,500
29,000
29,500
30,000
30,500
31,000
31,500
32,000
32,500
Budget Actual
£0
00
s
Plan vs Actual
Other SLA
Other SLA
55,400
55,600
55,800
56,000
56,200
56,400
56,600
56,800
57,000
Budget Actual
£0
00
s
Plan vs Actual
Outpatient
Outpatient
11
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eeting in Public-06/02/20
August 2019– Trust Pay Performance
The Trust reported an in month overspend of £263k. The key areas of spend are; • Medical pay overspent by £125k. Within this it should be noted: - There was a £145k overspend within Emergency Medicine. This is linked to temporary staffing premiums for medical cover within A&E. - A £46k overspend within Women's & Children's associated with Locum Consultant spend within Gynaecology and temporary staffing premiums to cover rota gaps within Paediatrics. - This was partially offset by underspends within Surgery and Medicine of £6k and £45k respectively. • Nursing pay showed an underspend against plan of £404k. This was driven by the receipt of winter pressure money allocated
to the winter surge budget which offset monies spent earlier in the financial year. After taking this into consideration, it should be noted that nursing pay remained consistent with the average monthly trend. Further to this, the following points should be noted:
• The division of Medicine was over spent by £73k. This is attributed to both temporary staffing cover and additional costs
relating to outpatient attendances. - The cost for enhanced care nursing was £143k in month which generated a £60k overspend. • Agency premium to cover scientific and professional vacancies across clinical support, theatres and cardiology generates a
combined overspend of £98k in month. • The phasing of the CIP target created a negative variance within the pay lines of £448k.
Trust Pay Performance
15
Workforce & Finance: Trust Pay December 2019
The very best care for every patient, every day
Expense Type Annual Budget Budget Actual Variance Budget Actual Variance
Medical Pay (78,717) (6,508) (6,633) (125) 681.78 698.18 -16.40
Non-Clinical Pay (50,340) (4,082) (4,097) (15) 1,252.67 1,247.93 4.74
Nursing Pay (77,172) (6,834) (6,429) 404 1,620.97 1,671.63 -50.66
Other Clinical Pay (28,626) (2,413) (2,394) 19 1,017.83 1,078.80 -60.97
Scientific, Technical & Profes (25,779) (2,131) (2,229) (98) 507.41 519.97 -12.56
Pay Unidentified CIPs 2,711 448 (448) 0.00 0.00 0.00
Total (257,922) (21,519) (21,782) (263) 5,080.66 5,216.51 -135.85
In Month (£000's) WTE
(6,660)
(6,640)
(6,620)
(6,600)
(6,580)
(6,560)
(6,540)
(6,520)
(6,500)
(6,480)
(6,460)
(6,440)
Budget Actual
Medical Pay
Medical Pay
(4,100)
(4,095)
(4,090)
(4,085)
(4,080)
(4,075)
(4,070)
Budget Actual
Non-Clinical Pay
Non-Clinical Pay
(9,300)
(9,200)
(9,100)
(9,000)
(8,900)
(8,800)
(8,700)
(8,600)
Budget Actual
Nursing & Other Clinical Pay
Nursing & Other Clinical Pay
(2,240)
(2,220)
(2,200)
(2,180)
(2,160)
(2,140)
(2,120)
(2,100)
(2,080)
Budget Actual
Scientific, Technical & Profes
Scientific, Technical & Profes11
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Year to Date – Trust Pay Performance
The year to date reported position shows an
overspend of £2,294k.
Key year to date themes to note are:
1. Medical pay is showing an overspend of
£1,323k. This represents agency
premium to cover vacancies and
pockets of sickness across all divisions.
2. Nursing and Other clinical pay
combined overspent by £1,011k. The
majority of this overspend relates to
double running costs associated with
qualified nursing. In addition to this, 1:1
nursing care continues to be a key
driver for spend. The YTD overspend
on 1:1 nursing care is £371k.
3. Scientific & therapeutic vacancies
across clinical support, theatres and
cardiology are causing a £745k YTD
overspend.
4. The above overspends are buffered by
unutilised growth monies sitting on the
non clinical pay line.
YTD Pay Performance
16
Workforce & Finance: Trust Pay year to date
The very best care for every patient, every day
Expense Type Annual Budget Budget Actual Variance
Medical Pay (78,717) (58,904) (60,227) (1,323)
Non-Clinical Pay (50,340) (37,640) (36,734) 906
Nursing Pay (77,172) (57,356) (58,388) (1,032)
Other Clinical Pay (28,626) (21,391) (21,370) 21
Scientific, Technical & Profes (25,779) (19,341) (20,086) (745)
Pay Unallocated CIPs 2,711 425 42 (383)
(257,922) (194,207) (196,764) (2,557)
YTD
(23,000)
(22,500)
(22,000)
(21,500)
(21,000)
(20,500)
(20,000)
(19,500)
(19,000)
(18,500)
1 2 3 4 5 6 7 8 9 10 11 12
Pay Spend
Plan Actual 18-19 Actual
(60,500)
(60,000)
(59,500)
(59,000)
(58,500)
(58,000)
Budget Actual
Medical Pay
Medical Pay
(37,800)
(37,600)
(37,400)
(37,200)
(37,000)
(36,800)
(36,600)
(36,400)
(36,200)
Budget Actual
Non-Clinical Pay
Non-Clinical Pay
(80,000)
(79,800)
(79,600)
(79,400)
(79,200)
(79,000)
(78,800)
(78,600)
(78,400)
(78,200)
Budget Actual
Nursing & Other Clinical Pay
Nursing & Other Clinical Pay
(20,200)
(20,000)
(19,800)
(19,600)
(19,400)
(19,200)
(19,000)
(18,800)
Budget Actual
Scientific, Technical & Profes
Scientific, Technical & Profes
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August 2019- Trust Bank & Agency Spend
17
Workforce & Finance: Bank & Agency Spend December 2019
The very best care for every patient, every day
Agency The Trust has set an internal target of
£13m for 2019-20.
This is £1m lower than the internal target
set last year and total spend for 18-19
amounted to £14.9m.
Agency expenditure in the month totaled
£1.06m. This was slightly higher than the
in month target of £1.03m
YTD the Trust is £0.07m adrift of its
internal agency target but well within the
ceiling set by NHSI.
Bank Bank spend for December was £2.43m.
There continues to be a shift from agency
to bank as shown by the graphs.
However the Trust has spent £0.24m
more on bank & agency when compared
to December last year. Cumulatively,
2019-20 spend for temporary staffing is
£2m higher than the same period last
year.
11
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August 2019– Trust Non Pay Performance
Non Pay Performance YTD Performance
18
Workforce & Finance: Non Pay December 2019
The very best care for every patient, every day
Expense Type Annual Budget Budget Actual Variance Budget Actual Variance
Clin Supp Serv (31,012) (2,265) (2,449) (184) (23,144) (22,949) 195
Drugs (22,557) (1,694) (1,983) (289) (16,975) (16,262) 713
OTHER (NON CLIN) (80,187) (5,727) (5,830) (103) (61,123) (58,792) 2,330
Non Pay Unallocated CIPS 819 (86) 86 (49) 49
Total (132,937) (9,772) (10,263) (491) (101,290) (98,003) 3,287
In Month (£000's) YTD
(23,200)
(23,150)
(23,100)
(23,050)
(23,000)
(22,950)
(22,900)
(22,850)
Budget Actual
Clin Supp Serv
Clin Supp Serv
(17,200)
(17,000)
(16,800)
(16,600)
(16,400)
(16,200)
(16,000)
(15,800)
Budget Actual
Drugs
Drugs
(61,500)
(61,000)
(60,500)
(60,000)
(59,500)
(59,000)
(58,500)
(58,000)
(57,500)
Budget Actual
OTHER (NON CLIN)
OTHER (NON CLIN)
The in month non pay position reported an overspend of £491k. Actual Spend was £10.26m against a budget of £9.77m. The main drivers of the position include: 1. An overspend against Clinical Supplies of £184k. At a high level, this was driven by an increase in purchases of high
cost devices within cardiology.
2. A £289k overspend against Drugs. £200k of this relates to pass-through items and is offset by income. A £103k underspend spend on Other Non Clinical. A retrospective bill for water and sewerage and an increase in the level of bad debt provision have driven the adverse position against budget.
3. The YTD non pay position shows an underspend of £3.28m. This is driven by lower pass through expenditure on drugs and unutilised growth monies. In addition to this, the prior month release of a central provision, VAT rebates and revenue to capital corrections mask specific non pay challenges that divisions are facing. These are covered by the divisional slides later on in this pack.
11
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Efficiency Programme - Planning Workforce & Finance: Efficiency Programme
The very best care for every patient, every day
19 11
Tab 11 Integrated P
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20
Workforce & Finance: Capital Expenditure December 2019
YTD Capital spend by Scheme
The Annual Plan for 2019/20 has reverted to £25.9m a with revised capital forecast
of £21.1m.
The very best care for every patient, every day
Month Scheme Spend (£m)
1 Bought Forward schemes 0.15
Month 1 Total Spend 0.15
2 Your Care Your Future 0.2
2 Winter Pressure 0.2
2 Tactical Servers & NHSMail2 0.1
2 Fire Safety 0.1
2 OCT Scanner and Server 0.1
Month 2 Total Spend 0.7
3 Acute Redevelopment 0.2
3 IT infrastructure 0.8
3 Fire Safety 0.2
Month 3 Total Spend 1.2
4 Your Care Your Future 0.1
4 NHS mail2 0.1
4 Isolation Rooms 0.2
4 Fire Safety 0.2
4 Estates projects 0.1
Month 4 Total Spend 0.7
5Your Care Your Future & Strategic Estate
development0.05
5 NHS mail2 & Tactical Servers 0.1
5 Isolation Rooms 0.05
5 Fire Safety 0.05
5 UPS Cardiac Cath Lab batteries 0.07
5 Estates projects 0.06
Month 5 Total Spend 0.38
6Your Care Your Future & Strategic Estate
development 0.12
6 IT Cyber Resilience 0.07
6 Fire Safety 0.2
6 Hotwell project 0.05
6 Estates projects 0.03
Month 6 Total Spend 0.47
7 Power Tools for Theatres 0.2
7 Lift 5&6 0.1
7 Fire Safety 0.2
7 Estates projects 0.4
Month 7 Total Spend 0.90
8 Holywell Orthopaedics Outpatients 0.1
8 Theatres 0.04
8 Shrodells Garden Prep for Portakabin 0.07
8 Fire Safety 0.26
8 Hotwell Boiler 0.05
8 Refurbishment of Clinical Areas – CQC related 0.12
8 IT projects 0.07
8 Other sundry 0.01
Month 8 Total Spend 0.72
9 Holywell Orthopaedics Outpatients 0.2
9 Shrodells Garden Prep for Portakabin 0.2
9 Lift 5&6 0.1
9 Fire Safety 0.1
9 IT Related projects 0.1
9 Medical Equipment 0.2
9 Other sundry 0.1
Month 9 Total Spend 1.00
YTD Spend 6.22
11
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Detailed reports
21 11
Tab 11 Integrated P
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The very best care for every patient, every day
Safe Care & Improving Outcomes: Mortality Indicators
In this reporting period:
The latest available (August 2018 to July 2019) Summary Hospital Mortality Indicator (SHMI) was 100.56 and within the ‘as
expected’ range (band 2). SHMI data had a new baseline calculated in May and the Trust has been informed by Dr Foster
that this increased all trusts’ SHMI by approximately 3%. For the 12 month period (October 2018 to September 2019), the
Trust’s overall HSMR of 99.2 was within the ‘as expected’ range.
Factors / Themes:
A case note deep dive review is undertaken for each ‘outlying’ primary diagnostic SMR group with a speciality or senior trust
consultant and the coding manager.
Next steps:
Monthly specialty/departmental Mortality Review meetings continue, cases from which are then referred for Structured
Judgement Review in accordance with criteria described in the Trust’s ‘Learning From Deaths’ policy.
A large percentage of cases are now being referred by the Medical Examiners in a timely way and the backlog of SJRs is
being worked through.
22
Benchmarking: MODEL HOSPITAL
Summary Hospital Mortality
Indicator (SHMI)
Period: 31/04/19
WHHT 0.99 Sector: 1.00
Performance stable Better than target/threshold
HSMR – rolling 3 months SHMI – rolling 12 months
0
30
60
90
120
150
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb
2016/17 2017/18 2018/19 2019/20
HSMR (overall) HSMR (weekend) Threshold (HSMR overall)
60
90
120
SHMI (Rolling 12 months) Actual SHMI (Rolling 12 months) 100
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Objective Ref
Safe Care & Improving Outcomes: Safe Chief Medical Officer Quality Committee 1a / 1b / 2a / 3a / 4a
11
Tab 11 Integrated P
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eeting in Public-06/02/20
The very best care for every patient, every day
Safe care & Improving Outcomes: Infection Control (1 of 2)
In this reporting period:
Clostrioides difficile Infection (CDI) objectives for 2019/20 are based on a new criteria for apportioning of cases; this system commenced on
1 April 2019:
• Hospital onset healthcare associated – cases detected 2 days or more after admission (cat 1).
• Community onset healthcare associated – cases that occur in the community that have had a hospital admission/inpatient in the
previous 4 weeks (cat 2).
• Community onset indeterminate association – cases detected in the community when a patient has had an admission or been an
inpatient in the previous 12 weeks but not the most recent 4 weeks (cat 3).
• Community onset community associated – cases that occur in the community when the patient has not had an admission or been an
inpatient in the previous 12 weeks (cat 4).
Objectives for acute providers are based on the first 2 categories and the Trust has a trajectory of no more than 34 cases with identified
lapses in care for the full year. The IPC Team is continuing to embed the implementation of the CDI action plan, which includes data review
and visits to clinical areas to support to raise awareness regarding learning for CID reviews.
In December 1 x cat 1 case and 0 x cat 2 case. Monthly RCA meetings with community/CCG colleagues continues, where appeals for
lapses in care are determined. The next appeal meeting will be in February where the additional CDI cases will be reviewed. Our total
successful appeals remains at 25 cases, where no lapses in care identified.
MRSA bacteraemia (MRSAb): There is no formal target set for MRSAb, a zero tolerance approach is in place. No cases of MRSAb were
identified in December.
Factors / Themes:
All CDI cases have an individual review meeting, in addition to the monthly appeals meeting with the CCG. Learning from all CDI cases is
included in action plans and fed back to the IPC panel. CDI management and awareness continues, including weekly CDI power training to
embed compliance with the learning from the RCA reviews. Divisional governance meetings are attended to give feedback and support the
divisions to deliver local actions to improve CDI management. Matron’s meeting is attended to provide support with RCA and action plans
from IPC. The recent CCG CDI deep dive is being implemented progressively, in order to reduce our CDI numbers and improve patient care
and experience.
23
Benchmarking: MODEL HOSPITAL
Rolling 12 month trust apportioned
Cdiff infections / 12 month avg
occupied bed days
Period: to March 2019
WHHT 6.42 Peer 13.68
National 11.11
(Peers = Nightingale Group – acute
multi-site trusts)
Clostrioides Difficile Infection (CDI) MRSA MSSA
0
5
10
15
20
25
30
35
40
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019/20
Clostridioides Difficile Actual Clostridioides Difficile Target
Clostridioides Difficile Actual YTD Clostridioides Difficile Target YTD
Actual YTD (Excl. cases with no lapses in care)
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
MRSA bacteraemias Actual 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
MRSA bacteraemias Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
E. Coli Bacteraemia 1 1 3 8 3 2 4 4 2 2 8 3 2 2 2 3 5 2 3 3 1 6 6 5 6 4 4 5 3 6 3 3 3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
MSSA Actual MSSA Trajectory MSSA Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Objective Ref
Safe Care & Improving Outcomes: Safe Chief Nurse & DIPC Quality Committee 1b / 2a / 2b / 2c / 3a
Performance stable Better than target/threshold
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The very best care for every patient, every day
In this reporting period:
E. Coli bacteraemia (E colib)
There were 3 post-48hr (trust apportioned) cases and 26 pre-48 hour cases (non-trust) reported in December. There is no externally set target for the trust but the national
target is to deliver a 25% reduction by 2021 and 50% by 2024; this is reflected in the quality indicator which is monitored by the CCG. Thematic data is gathered for post-
48 hour cases and reviewed alongside microbiology review of the pre-48 hour cases. Broader work with partner organisations regarding AMR, ‘To Dip and Not To Dip’
and trust-wide implementation of the hydration QI project for the prevention of UTIs, to improve hydration in patients. Our new antimicrobial pharmacist is supporting this
programme to contribute to improving antimicrobial stewardship, which aims to reduce gram-negative resistance.
Methicillin-sensitive Staphylococcus aureus (MSSAb)
There were 3 post-48 hour (trust apportioned) case and five pre-48 hour (non-trust) cases of MSSAb reported in December. Each case is reviewed by a microbiologist
using an RCA tool to identify and share learning. Our new antimicrobial pharmacist will contribute to this work.
Infection Prevention Control (IPC) Progress Update
The IPC Code of Practice (CoP) audits continues. The IPCT provide ward-based support for areas that have not met the required audit standards. Scores below 80% are
escalated to departmental leads, divisional senior teams and the DIPC. During December work on the use of PPE, hand hygiene practices, ANTT, Sharps, Chlorclean and
environmental reviews took place.
Next steps:
Extensive work is underway through conducting weekly environmental walkabouts with IPC, Facilities, Estates, Mitie and the divisional team. The aim is to ensure we
work together ensuring IPC and cleanliness is seen as everyone's business, ensuring we have a clean and safe environment. All walkabouts are documented and
distributed to the relevant leads to ensure that the findings are followed up and actioned.
Compliance with hand hygiene and CPE screening continues to remain good. Flu and norovirus are closely monitored to reduce the risks of outbreaks and maintain good
patient safety, quality and experience.
24
Safe care & Improving Outcomes: Infection Control (2 of 2)
Carbapenemase-producing Enterobacteriaceae (CPE) Hand hygiene compliance
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
JulAug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
CPE Actual 2 1 4 0 2 2 0 3 2 5 1 4 3 2 8 4 8 4 8 0 1 1 3 5 5 2 3 3 2 1 0 6 2
CPE Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
1
2
3
4
5
6
7
8
9
70%
75%
80%
85%
90%
95%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Hand hygiene Actual Hand hygiene Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Objective Ref
Safe Care & Improving Outcomes: Safe Chief Nurse & DIPC Quality Committee 1b / 2a / 2b / 2c / 3a
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The very best care for every patient, every day
Safe care & Improving Outcomes: Emergency Readmissions
In this reporting period:
The readmission rate, benchmarked against the most up to date national position (June 2019) was in line with the national
average overall, and for readmissions following an elective and emergency (original) admission.
Factors / Themes:
Combined readmission rates (emergency and elective admissions), includes all patients with more than one admission to
the hospital within a period of 30 days, regardless of whether the second admission was related.
25
Benchmarking: MODEL HOSPITAL
Emergency Readmission 30 days
Period: Q2 2019/20
WHHT 7.90% Peer 7.27%
National 7.85%
(Peers = Nightingale Group – acute
multi-site trusts)
Performance stable Better than target/threshold
Emergency Readmissions
0%
2%
4%
6%
8%
10%
12%
14%
16%
Apr
May
Jun Jul Aug
Sep
Oct
Nov
Dec
Jan Feb
Mar
Apr
May
Jun Jul Aug
Sep
Oct
Nov
Dec
Jan Feb
Mar
Apr
May
Jun Jul Aug
Sep
Oct
Nov
Dec
Jan Feb
Mar
2017/18 2018/19 2019/20
Overall - National Elective - NationalEmergency - National Emergency - WHHTOverall - WHHT Elective - WHHT
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Objective Ref
Safe Care & Improving Outcomes: Safe Chief Medical Officer Quality Committee 2a / 2b / 2c / 3a / 4c
11
Tab 11 Integrated P
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eeting in Public-06/02/20
The very best care for every patient, every day
Safe care & Improving Outcomes: Caesarean Section rates
C-section rate
The elective LSCS rate of 14.2% was just above the national target of 14% keeping the total LSCS rate in the amber alert
range at 30%. This is an improvement on November’s figure of 34.3%.
The c section audit was presented at the Women's and Children’s Divisional governance meetings and a number of actions
agreed
1. It appeared that there was variation in the use of Syntocinon, a drug which augments labour. There will now be focused
work on the use of this drug particularly training and education in order to provide confidence and consistency of its
use.
2. A focus will be given to instrumental deliveries. From February there will be a yearly compulsory training day for all
levels of medical staff. This will ensure the doctors have up to date skills ,knowledge and competencies in the use of
forceps and ventouse for those working on the labour ward.
3. This will be re audited again in 3 months.
4. A second stage of labour audit has also been completed during he last few months. This will be presented at the next
governance meeting. There will be a comparison of the two audits presented at the Divisional Performance Meeting in
January, this will include the findings, outcomes and an action plan.
26
Benchmarking: MODEL HOSPITAL
Emergency Caesarean section rate
Period: October 2019
WHHT 15.8% Peer: 15.9%
National: 16.3%
(Peers = Nightingale Group – acute
multi-site trusts)
Caesarean section rates
13%
12%
11%
10% 11%
11% 14
%12
%10
%11
%11
% 13%
12% 15
%14
%13
%12
%12
% 14%
14%
13%
13%
14%
10% 16
%16
%13
% 16%
14% 18
%15
%15
%16
%
17%
18%
13%
17%
13% 17% 19
%17
%18
%15
% 16% 16
%17
% 17% 24
%19
%16
% 19% 24
%12
%15
% 19%
18%
20%
17%
16%
15%
19%
15%
16%
16% 19%
14%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
Caesarean Section rate - Elective Actual Caesarean Section rate - Emergency Actual
Caesarean Section rate - Combined Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Medical Officer Quality Committee 2a / 2c / 3a / 4c
Performance stable Better than target/threshold
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Benchmarking: MODEL HOSPITAL
Care hours per patient day – total
nursing & midwifery staff
Period: October 2019
WHHT: 7.8 Peer: 7.9
National: 8.0
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Safe care & Improving Outcomes: Workforce and CHPPD
In this reporting period:
Overall fill rate was 102.4% (national threshold of 95%). Within the total fill rates, 98.7% were registered nurses and 98.8% were
unregistered. 71.2% shifts were RAG rated green, 28.6% shifts were rated amber and 0.1% rated red.
Current nursing band 5 vacancy rate on adult inpatient areas has risen to 4.6%, with significant vacancies within paediatrics and theatre
services; on going recruitment initiatives continue. The current turn over for band 5s this month is 17%, the trust target is16%.
There were no NICE red flags relating to shifts with less than 2 RNs identified, but three were reported with a short fall in RN time. When a
NICE red flag relating to staffing is recorded on safecare the ward manager and matron are alerted and mitigations recorded on both safecare
and Datix. In addition Red flags and mitigations taken are also discussed at the monthly workforce meetings.
Ward leaders supervisory time was 74.6%, indicating the majority of their time was focused on promoting patient safety, developing and
supporting junior staff and managing the ward. The other 25.4%, is when they are deployed to clinical time supporting safe staffing or due to
leave (11.37 and 14.05 respectively). Safe Care % utilisation – of the 32 inpatient areas, 3 in maternity and 1 in children services had fill rates
below 95% (range 90.8%-93.9%), and one maternity area had fill rates below 90%. Although fill rates are low in maternity no red flags were
reported. Senior staff attend the daily operational meeting and provide assurance around safe staffing and mitigations taken, including staff
redeployment. Staff also report on any quality or patient safety issues incurred from staffing decisions made the previous day for inpatient and
surge areas.
Bank and agency requested hours was 64,636 hours with a fill rate of 85.4%; (76.3% bank and 9.1% agency). A number of escalation beds
were open - the highest utilisation being 30 December when there were an additional 57 beds open across ten areas. Simpson ward opened
an additional 3 beds on the 31st December increasing its capacity to 24 patients. In the week commencing 29 December, due to flu, Red
suite was not able to utilise 5 beds. All additional shifts requested within hours are authorised by Heads of Nursing and out of hours by the
senior nurse in discussion with on call manager. Enhanced care team usage in December was 7795.21 hours. CHPPD is currently 7.95.
27
Factors/ Themes:
For N&M staffing continues to positively benchmark for CHPPD against our peers in Model Hospital.
October data on Model Hospitals shows WHHT at 7.8, peers 7.8 and National 8.0.
There was a positive visit by NHSI on the Trust on 4th December to discuss our Level of Attainment
for nursing and midwifery.
ESRGo Project –Interface ESR and E-roster went live on10th December - no major issues reported.
Paediatric establishment review final sign off December 2019.
UTC and MIU establishment review sign off December 2019.
ED establishment scheduled sign off January
Paediatric and Theatre recruitment drive to Australia scheduled in January 2020
Paper to TMC by Chief of People to review current OSCE pipeline
DHSC has committed to £7million of capital funding. Bidding is now open to accelerate NHS
Providers’ utilisation of workforce deployment systems , WHHT submitted a bid in September for
Nursing, Midwifery and AHP – outcome of bids due December 2019, still waiting to hear.
Performance stable Better than target/threshold
104.4%103.8%
102.6%102.6%103.3%
102.5%102.4%
102.8%103.2%
100.6%101.4%
103.0%
100.2%
101.9% 102.5%102.4%
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
90%
92%
94%
96%
98%
100%
102%
104%
106%
Care
Hour
s Per
Patie
nt D
ay
Perce
ntag
e ove
rall p
lanne
d vs.
actua
l nur
sing h
ours
Workforce and CHPPD: Percentage overall planned vs. actual nursing
Care Hours Per Patient Day (CHPPD) % Fill Rate Threshold - fill rate
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1b / 4c / 7a / 7b / 8c
11
Tab 11 Integrated P
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eeting in Public-06/02/20
Ward scorecard: themes from adult IP scorecard & Safety Thermometer
28
The very best care for every patient, every day
Analysis
Safety Alerts
In December there were 46 safety alerts- this is similar to November (46). Falls with harm and pressure ulcers continue to be the main cause of the safety alerts.
Process Alerts
In December there were 60 process alerts compared with 53 in November
The alerts have similar figures to November. Supervisory time scored (22/30 process errors), FFT responses (18/33 process errors) The FFT process errors are higher than in
November (11/33)r. The improvement in the commode audit has been sustained 2/28 process errors compared with 13/27 in October.
Divisional Nurse Summit meetings continue within medicine, surgery and emergency medicine. Quality Improvement Forum continues to identify, support and guide quality
initiatives; all matrons now attend.
Next Steps
1. Increased ward based teaching on assessments with clinical staff
2. National Pressure ulcer collaborative on-going on Croxley and Tudor ward
3. Swarming on phased implementation to the Trust using a QI approach. Two ‘swarm meetings have taken place on Heronsgate ward. Swarming is due to be rolled out to
Tudor Ward in February 2020
4. VTE section added to the discharge checklist.
5. Through the new E Coli steering group – work streams have been instigated to analyse the high use of urinary catheters, use of catheter passports, education and training.
6. MUST training e-learning module developed. Dieticians leading on MUST training and have sessions planned for the next 6 months.
7. Harm Free Study Day to be delivered in December 2019. Ward based awareness campaigns on harm free care planned monthly
8. 9 Divisional Nurse Summit to explore the supervisory time scores.
All data is taken to the Quality Improvement Forum (QIF) to drive learning, innovation and improvement. At this forum the wards needing support are identified. Currently
supporting AAU Level 3 Blue/ Yellow and plans to develop a support programme for Letchmore in January 2020.
Evaluation
• The safety thermometer data for Falls is the same as the National average for December (it was below National average in November. For HAPU the Trust is below the
National average- an improvement on November 2019
• Tissue viability and falls remain a focus within Divisions
11
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29
Ward Scorecard
The very best care for every patient, every day
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30
Ward Scorecard (Other/ Non Adult Inpatient)
The very best care for every patient, every day
11
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The very best care for every patient, every day
Safe Care & Improving Outcomes: Patient Safety
31
Benchmarking: MODEL HOSPITAL
Serious Incidents closed within 60
days
Period: 2018/19
WHHT 95% Peer: 72%
National: 61%
In this reporting period:
Never events
There was 1 (one) Never Events reported in December 2019 which met the criteria for “wrong site block.” Immediate actions
have been taken by the division and the investigation is underway.
Serious Incidents
There were 3 serious incidents declared in December 2019; 2 in WACS and 1 Medicine
At the end of December 2019 the Trust had 17 open SIs. Of these, 5 investigations were complete and with commissioners
pending formal closure on StEIS. There were 12 ongoing open SI investigations, 2 of which were overdue.
Learning from SIs
There were 2 completed reports submitted to the commissioners during December 2019 -
Learning:
DW122277 - Registered nurse to complete first set of baseline observations on patients returning from theatre to enable
recognition of any deterioration.
DW121123 - Anaethetists must review patients with head injuries who are being transferred to a specialist unit.
% of patient safety incidents which are harmful
10.4% of incidents reported in December 2019 were recorded as having caused harm to the patient, compared to 9.1% in
November 2019. This increase in incidents causing harm to patients will be closely monitored by the patient safety team, but
may be due to natural variation.
There were 20 incidents reported in December 2019 with a moderate or above level of harm. There were zero (0) incidents
reported in December 2019 with a harm level of Death/Catastrophic.
Benchmarking: MODEL HOSPITAL
% medication incidents reported
as causing harm or death/all
medication errors
Period: 31/03/2019
WHHT 10.0% Peer: 17.1%
National: 10.7%
(Peers = Nightingale Group – acute
multi-site trusts)
Safety incidents (% harmful) Medication incidents causing serious harm Serious Incidents
-2
-1
0
1
2
3
4
5
6
7
8
9
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
De
c
Ja
n
Feb
Ma
r
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
De
c
Ja
n
Feb
Ma
r
Ap
r
Ma
y
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
De
c
Ja
n
Feb
Ma
r
2017/18 2018/19 2019/20
Actual Target to follow UPL will be used Upper control limit (3 sd)
Lower control limit (3 sd) Mean
0%
5%
10%
15%
20%
25%
30%
35%
40%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Actual Target
0
1
2
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Actual Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1a / 1b / 2a / 3a / 4a / 4b / 4c
Performance deteriorated Worse than target/threshold
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The very best care for every patient, every day
Safe Care & Improving Outcomes: Falls & Falls with harm
32
In this reporting period:
In December there were 106 falls in total. 29 Falls with harm. 4 patients sustained moderate harm. Analysis shows that 23
(79.3%) falls were not witnessed, 6 (20.7%) falls were witnessed , 17 incidents occurred during the day shift and 12 during the
night shift, 17 (58.6%) incidents involved patients with cognitive impairment. Of these 10 patients were reported as having
dementia. The majority of falls (22/75.9%) occurred around the bed area.
Falls with harm remain low in comparison to the number of falls reported locally and nationally. Of the 106 falls reported in
December, 12 recurrent fallers accounted for (33%) 35 incidents. In December three clinical areas reported significant number
of falls; Heronsgate/Gade – 10, Tudor/Castle – 9 and Bluebells – 9.
Next steps:
• To further improve learning for SI’s and Divisional Learning Reviews they are presented at the bi-monthly Patient Falls
Review group where there is a focus around disseminating learning and what can be done differently – this has been
reinforced through the QIF meeting
• Swarming will now be piloted on two clinical areas Heronsgate/Gade and Tudor/Castle – SOP to be revised.
• Matrons have conducted a full survey and are evaluating the results regarding night lights within the wards following findings
from a night walk by senior staff . Ongoing trial of nightlights- To be reviewed in January 2020 at quality improvement
forum.
• NHSI falls collaborative – pilot on Ridge and Croxley ward to commence
• Focusing on the CQUIN three high impact interventions to reduce falls and improve patient safety and outcomes. Q3 data
shows 57% compliance which is an increase when compared to Q2 results of 26%
Benchmarking: MODEL HOSPITAL
Proportion of patients with harm
from a fall in care
Period: April 2019
WHHT 0.2% Peer: 0.8%
National: 0.3%
(Peers = Nightingale Group – acute
multi-site trusts)
Performance stable Better than target/threshold
Number of falls (total and with harm)
0
20
40
60
80
100
120
140
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
Num
ber o
f fal
ls
Number of falls Number of falls with harm
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1b / 2a / 3a / 4c
11
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The very best care for every patient, every day
33
Safe Care & Improving Outcomes: Harm free care
In this reporting period:
The Adult Safety Thermometer focuses on four commonly occurring harms in healthcare: pressure ulcers, falls, UTI in
patients with a catheter and VTEs. This is a point prevalence survey with a national target of 95%. New Harm Free Care
acquired in the Trust during December 98.9% compared to national average of 97.8%
December comparison with national data:
• New Pressure Ulcers 0.5% (decrease from 1.2% in
November) compared with a national average of 0.9%
• Falls with harm 0.5% ( an increase from 0.2% in November)
vs national figure 0.5%
• New VTE 0.2% (a decrease on November 0.3%) vs national
figure 0.5%
• Patients with a urinary catheter 16.6% (a decrease on
November 19.6% ) vs national figure 13.9% Patient with
catheter and UTI 0.3% (an increase from 0.2%) in November
vs national figure 0.7% .
Benchmarking: MODEL HOSPITAL
Proportion of patients with harm
free care (including harm acquired
outside the trust
Period: April 2019
WHHT 90.1% Peer 93.2%
National 94%
(Peers = Nightingale Group – acute
multi-site trusts)
Adult safety thermometer: Harm free care
Adult safety thermometer : Pressure ulcers (new harms)
Performance stable Worse than target/threshold
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Ap
r
Ma
y
Jun
Jul
Aug Sep Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Aug Sep Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
Harm Free Care (acquired within and outside of Trust)
Harm Free Care (acquired within and outside of Trust) Target
New Harm Free Care (acquired within Trust)
New Harm Free Care (acquired within Trust) national average
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1a / 1b / 2a / 3a / 4a / 4b / 4c
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019/20
Pressure Ulcers New Harms Pressure Ulcers New Harms - national average
Adult safety thermometer : New VTE Adult safety thermometer : Falls with harm Adult safety thermometer : Catheter & UTI
0
0.2
0.4
0.6
0.8
1
1.2
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019/20
New VTEs New VTEs - national average
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019/20
Falls with harm Falls with harm - national average
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2019/20
Catheter and New UTIs Catheter and New UTIs - national average
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The very best care for every patient, every day
34
Safe Care & Improving Outcomes: Harm free care
In this reporting period
Children and Young People's Services Safety Thermometer:
The Children and Young People’s Service Safety Thermometer focuses on patient observations (PEWS completed) that are
triggered but not escalated, extravasation (leakage of a fluid out of its container), patients in pain at the time of survey and
any pressure ulcer or any moisture lesion. Harm free care was 73.7% in December 2019, lower than the national average of
86.2%. We believe this was a reporting error, the audit was completed by a new auditor and the questions were interpreted
incorrectly. The questions have now been reviewed and necessary training for undertaking the audit has been completed.
This should be reflected in the next month’s results.
Maternity Safety Thermometer:
The Maternity Safety Thermometer captures data representative of a particular day and does not capture a proportionate
number representative across the month. On the day of review, 0.0% of women experienced a 3rd/4th degree tear in this
audit, which is below the national average of 2.1%. The proportion of term babies born with an APGAR of 7 or less at 5
minutes was 0.0%, well below the national average of 3.1%. The proportion of woman with a maternal infection from onset of
labour to 10 days postnatal was 0.0% lower than the national average being 6.2%. These figures are not representative of the
month’s total figures, but represent a ‘snapshot’ of the cases on the day. PPH rates were, however, 13.8%, above the national
average of 9.9%, which although is not consistent with the monthly data, is representative of the trend of maternal
haemorrhages within the maternity department. A programme is in place to monitor cases of maternal haemorrhages. These
indicators are monitored through the maternity dashboard at quality committee.
The combined harm free care point prevalence audit score is above the national average of 70.0.% (86.2%).
Children safety thermometer: Harm free care Maternity Safety thermometer: Harm free care
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Aug Sep Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
Children's Harm Free Care Actual Children's Harm Free Care national average
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1a / 1b / 2a / 3a / 4a / 4b / 4c
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Aug Sep Oct
No
v
De
c
Jan
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep
Oct
No
v
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Aug Sep Oct
Nov
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Maternity Harm Free care Maternity Harm Free care National Average
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Benchmarking: MODEL HOSPITAL
Proportion of patients with new
pressure ulcers (grade 2-4)
Period: April 2019
WHHT 1.0% Peer 0.7%
National 0.7%
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Safe Care & Improving Outcomes: Pressure ulcers (HAPUs)
35
Stable In this reporting period
In December there were 27 reportable HAPU’s affecting 24 patients. In addition there were 12 category 1 pressure ulcers
affecting 8 patients and 13 cases of SDTI affecting 10 patients.
0 x Category 4 / 2 x Unstageable / 0 x Category 3 / 25 x Category 2 / 12 x Category 1 / 13 x SDTI
The pressure ulcer incidence data for December is almost identical to November although there was a slight increase in the
overall number of patients affected. The majority of pressure damage remains in the medical division (9 wards), compared to 5
surgical areas. Both of the unstageable pressure ulcers occurred on surgical wards. The unstageable HAPU on ITU had no
lapses of care identified.
The 9 medical device related pressure ulcers (MDRPUs) occurred across clinical wards in both Medicine & Surgery. A third of
the MDRPU were related to the use of NIV therapy, although preventative measures had been put in place. The remaining
MDRPU occrred as a result of AES stocking, catheter and nasogastric tubing. Of the 13 SDTI’s, 7 were on patients were
discharged with the SDTI remaining uncategorisable, the remaining injuries were identified on patients who subsequently died.
Next steps:
• Continued focus within the safety huddles patients with medical devices and heel offloading.
• Effective repositioning being highlighted to clinical areas in ward wards. TVN team undertaking check and challenge
exercise across clinical areas, and supporting wards experiencing repositioning challenges.
• Target work from the TVN team member working alongside HCA and clinical support workers to enable role modelling good
patient care in relation to skin management. Focus was on Ridge ward and AAU 3 Blue/Yellow in December, and
commenced in Elizabeth in January.
• Implementation programme for NHSI recommendations for defining and measuring pressure ulcers, published in June 2018
• Continued support to the matrons who validate Category 2 pressure ulcers for the clinical areas.
• The Trust is progressing through the National collaborative ‘Stop the Pressure’ on Croxley and Tudor ward.
Pressure Ulcers (HAPUs)
AprMay Jun Jul Aug Sep Oct NovDec Jan FebMar AprMay Jun Jul Aug Sep Oct NovDec Jan FebMar AprMay Jun Jul Aug Sep Oct NovDec Jan FebMar
2017/18 2018/19 2019/20
Unstageable Pressure Ulcers 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 2 2 3 8 1 5 1 2 0 5 0 1 2
Category 4 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0
Category 3 1 0 1 4 2 3 2 2 4 9 3 3 8 4 4 1 3 10 0 0 0 2 1 1 3 4 0 1 1 2 1 0 0
Category 2 19 13 15 13 13 16 19 8 14 22 17 16 21 11 11 21 12 24 21 20 22 31 23 31 16 17 15 12 14 28 20 25 25
Deep TissueInjuries 13 8 4 7 18 11 16 18 11 14 14 9 9 13
0
5
10
15
20
25
30
35
40
45
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Nurse Quality Committee 1b / 2a / 2c / 3a
Pressure Ulcers SPC Grade 2 Pressure Ulcers SPC Grades 3 & 4
0
5
10
15
20
25
30
35
40
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2018/19 2019/20
Category 2 Mean Upper control limit (3 sd) Lower control limit (3 sd)
-4
-2
0
2
4
6
8
10
12
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2018/19 2019/20
Category 2 Mean Upper control limit (3 sd) Lower control limit (3 sd)
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Benchmarking: MODEL HOSPITAL
VTE assessment
Period: Q2 2019/20
WHHT 94.73% Peer: 94.78%
National 96.06%
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Safe care & Improving Outcomes: VTE risk assessment
36
In this reporting period:
The current reported position is worse than target, however compliance is expected to improve as inpatient episodes are
completed and then coded.
Factors / Themes:
Gaps in risk assessments in admitting areas.
Next steps:
• Regular reporting is being provided to all wards where VTE risk assessments are below threshold
• Focused awareness and training sessions in AAU Level 1.
• VTE prevention specialist nurse to target these areas and to visit Safety Huddles as well as liaise with senior sisters.
• VTE learning is part of Doctors’ and nurses’ mandatory training
Performance deteriorated Worse than target/threshold
VTE risk assessment
80%
85%
90%
95%
100%
Ap
r
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
VTE risk assessment Actual VTE risk assessment Target Mean
Upper control limit (3 sd) Lower control limit (3 sd)
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Medical Officer Quality Committee 1a / 1b / 2a / 2c / 4c
11
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The very best care for every patient, every day
Safe Care & Improving Outcomes: Stroke
In this reporting period:
Stroke
Performance against the 4 hour target for admission to the stroke unit was 68.1%.
Maintaining ring fenced beds on the stroke unit is challenging when the Trust experiences capacity constraints affecting “right
bed” availability. However patients continue to receive stroke specialist care and input while they await transfer to the stroke
unit.
90% stay on the Stroke Unit
96.9% of stroke patients in this reporting month spent 90% of their stay on the stroke unit, better than the 96.9% target.
Thrombolysis within one hour
45.5% of patients were thrombolysed within 1 hour (target is 50%)
37
Benchmarking: SSNAP
Period: July to September 2019
Admission within 4 hours: 56.8%
90% admission on Stroke
Unit: 83.8%
Stroke: Admission within 4 hours Stroke: 90% of admission on Stroke Unit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Safe Care & Improving Outcomes: Safe Chief Medical Officer Quality Committee 1a / 1b / 2a / 2b / 2c / 3a / 4a / 4c
Performance stable Better than target/threshold
11
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Benchmarking: MODEL HOSPITAL
% of patients admitted or
discharged within 4 hours of
arrival
Period: November 2019
WHHT: 82.2% Peer: 75.8%
National: 79.2%
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Caring & Responsive Services: Emergency Department
In this reporting period:
Overall performance against the 95% 4 hour standard is lower than the previous month at 79.4%. Increasing acuity has been
a major factor impacting the position and Minors performance has reduced from 93.8% to 92.3% and CED performance was
85.9% (from 87.8%). Compliance above the standard was maintained at HHGH UTC and MIU, both over 99%.
Next Steps:
• The regular check in meetings between the service team and Executive colleagues continue, together with the weekly
access meetings. There is a robust framework for monitoring the improvement plan.
• The ambulatory care service returned to full capacity mid December. This will support an increase in patients being
streamed away from the ED.
• Work with system partners is ongoing to develop the urgent care strategy which includes the development of Urgent
Treatment Centres (UTCs) across all 3 trust sites.
• Ambulance handover delays spiked in December but work with EEAST continues. The monthly programme board meetings
oversee this work stream with a joint action plan between EEAST and the Trust is in place. The focus will be on improving
the 15 minute off load times and initially a reduction in 60 minute delays, by ensuring a robust STARRing SOP and
escalation policy. Validation of activity is underway between EEAST and WHHT.
• A recruitment plan for medical staffing is in place, 4 Middle Grades have been recruited but await their visas, Consultant
recruitment has not been as successful. The department is reviewing the possibility of joint posts and being supported by
recruitment agencies.
• The new medical take model pilot is underway with regular review meetings being held. This has shown a reduction in LOS
and conversion to admission.
38
AE&: Attendances within 4 hours
70%
75%
80%
85%
90%
95%
100%
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Responsive Chief Operating Officer Finance & Performance Committee 1a / 1b / / 2b / 2c / 4a / 4c / 12b / 12c / 12d
Performance deteriorated Worse than target/threshold
11
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The very best care for every patient, every day
Caring & Responsive Services: Mixed sex accommodation breaches
In this reporting period:
There were no breaches in December 2019.
Factors / Themes:
All historical breaches occurred in ITU and were due to pressures on the emergency care pathway.
Next steps:
The monitoring and management of patients requiring step down from ITU is reviewed daily as part of the regular
operational management meetings. Privacy and dignity is maintained at all times. Full length curtains are used and patients
are offered the use of the toilet/shower if they are able.
39
Benchmarking:
Not currently available
Mixed sex accommodation breaches
0
20
40
60
80
100
120
140
160
180
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
MSA breaches Actual MSA breaches Target
Performance stable Better than target/threshold
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Effective Chief Nurse Quality Committee 4a / 4c / 12b / 12c
11
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The very best care for every patient, every day
Caring & Responsive Services: Delayed Transfers of Care
In this reporting period: 804 bed days, the equivalent of 26 beds were used, compared to 725 bed days/24 beds used by
DToC patients in November. The national reporting of the snapshot position on one day only of the number of patients
waiting each month, expressed as a percentage of beds, has ceased. As a result, only the bed days and total beds consumed
will be included. This is a more robust measure to illustrate the impact because it includes all patients waiting in the month
rather than the number of patients waiting on one day. The position is better (33%) than the challenging position seen in
October 2019. The split of delays were fairly even: Health 34.8%, Social Care 35.3%, Joint 29.9%, although there is weekly
variance in the % split, the greatest in delays attributable to social care, which may be accounted for by the volume of
referrals and the new winter care capacity being brought online.
Health: 25% of patients were delayed awaiting rehab beds or other health funded beds, it maybe suggested that these were
delays awaiting either CHC bed resource and / or Holywell beds, given the excellent flow and bed availability observed in
CLCH beds over the festive period. Referrals for rehab were at less than 20% of the total IDT workload. 61.9% of the health
delays were attributed to people funding their own care either sourcing the support independently, through CHS or the Local
Authority. There was a relatively even split between people requiring residential and home care. 8% of people were recorded
as delayed due to choice which suggests an improved awareness and use of the policy.
Social: The most challenging area of performance is delay awaiting care homes at 46% of social care’s reportable delays.
This may mask some of the demand for home care and people being recorded as delayed awaiting care homes whilst
awaiting for home care. The alternate decision making is often a response to hospital pressures and lack of care capacity.
34.2% of people delayed are accountable to home care, which like last month, is well documented and probably accounting
for at least 30% of all IDT delays, possibly more. The other area of note is that approximately 6% of people were delayed due
to assessment which is an area for development although it may represent the high level of referrals over the festive period
and unlike last year, there was no break in activity levels , placing increased pressure on holiday period staffing levels.
40
Benchmarking: MODEL HOSPITAL
Total number of bed days lost due
to patients not being transferred to
a more appropriate care setting
Period: March 2019
WHHT: 579 Peer: 928
National: 579
(Peers = Nightingale Group – acute
multi-site trusts) Delayed Transfers of Care
0
10
20
30
40
50
60
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Beds used by DToC patients in month
Performance deteriorated Worse than target/threshold
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Effective Chief Operating Officer Finance & Performance Committee 1b / 2b / 2c / 4a / 4c / 11a
11
Tab 11 Integrated P
erformance R
eport
43 of 236T
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eeting in Public-06/02/20
Benchmarking: MODEL HOSPITAL
Inpatient FFT scores % positive
WHHT: 95.5% Peer: 95.3%
National: 96.2%
A&E scores - % positive
Period: November 2019
WHHT 94.2% Region 86.7%
National 85.6%
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Caring & Responsive Services: Friends & Family Test (1 of 2)
In this reporting period:
Inpatients 17 adult inpatient wards achieved the trust’s response rate target of 30%;12 achieved the CCG’s 35% target
Overall there were 3 lower scoring inpatient wards at 10% , 9.4% and 8.4% (Bluebell, Sarratt & Starfish). The areas with low
scores were Ambulatory Care, Cath Lab, Helen Donald, Endoscopy, Fraility, ESAU, DSU, and Safari .
A total of 1039 comments were received from inpatients of which only 5 were negative. 95.8% positive response with 843
indicating extremely likely to recommend the organisation , 196 likely and 33 neither likely or unlikely
A positive comment from Aldenham ward ‘All the staff and doctors work non stop making sure everyone is comfortable,
Nurses are so warming and friendly. Thank you so much ’
There has been a decrease in the response rate due to the delayed Christmas postal service
NB: Changes to FFT commence in April when the question will change to ‘how was your experience of our service?
A&E
The positive recommendation rate improved to 94.8% with an increased overall response of 2.0%
5 responses were not recommending due to the length of time spent waiting to be seen. One of the 202 positive comments
was ‘They treat you with dignity and respect. They see you as soon as they can even when busy and very professional ’
NHSEI have reiterated that the FFT is not designed to make comparisons between organisations. It should be used for
continuous improvement, opportunity for feedback, anonymous, quick and easy for users, can be shared with staff in near real
time, collectively can identify themes.
Next steps:
Following a presentation from NHSI/E on the FFT changes being implemented in April 2020, a paper will be presented to PAC
& TMC
41
Performance stable Better than target/threshold
Inpatient FFT: responses and % positive A&E FFT: responses and % positive
0%
20%
40%
60%
80%
100%
120%
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
Dec Ja
n
Feb
Ma
r
Ap
r
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Mar
2017/18 2018/19 2019/20
Inpatient Scores FFT % positive performance Inpatient FFT response rate
Inpatient FFT response rate Target Inpatient FFT response rate trajectory
0%
20%
40%
60%
80%
100%
120%
Ap
r
May Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
A&E FFT response rate performance A&E FFT % positive Performance
A&E FFT response rate Target A&E FFT response rate Trajectory
New targets for response rate agreed with HVCCG in July 18
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Caring Chief Nurse Quality Committee 2a / 2c / 3a / 4c / 11a / 12c
11
Tab 11 Integrated P
erformance R
eport
44 of 236T
rust Board M
eeting in Public-06/02/20
Benchmarking: MODEL HOSPITAL
Maternity scores from FFT – Q2
Birth % positive
Period: November 2019
WHHT: 96.9% Peer: 98.2%
National: 97.9% (Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Caring & Responsive Services: Friends & Family Test (2 of 2)
Day Case
The average response rate within day surgery has remained the same at 23.6%; St Albans is 26.8% and Watford is 1.3%.;
the recommendation rate remains at 99%. A positive comment from Day surgery from St Albans is ‘you are all very kind
and professional also very understanding, specially with people with language difficulties. a big thank you for talking care of
my mum,
Outpatients
The recommendation rate remains above 94% at 94.1% with a negative response of 1.3% of patients not recommending
the service. There were a total 2269 responses which has decreased significantly due to the Christmas period.
Of the 1570 positive comments for outpatients one at Gastro outpatients at St Albans said ‘friendly receptionist and clinic
receptionist great atmosphere fantastic service for elderly patients’
Themes continue to be regarding length of time waiting to be seen and some communication issues with cancelled
appointments.
Maternity
The response rate has decreased to 29.7%. There were 98 positive comments with only 2 negative.
One of the positive comments was ‘such a scary and vulnerable time and every member of staff even the housekeeper
were so respectful and kind.’
Next steps:
Following a presentation from NHSEI on the changes due in April 2020, a paper will be presented to PAC & TMC with
recommendations for alternative feedback mechanisms for capturing patient experience.
42
Performance stable Better than target/threshold
Daycase FFT: responses and % positive Outpatient FFT: responses and % positive Maternity FFT: responses and % positive
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Daycase FFT % positive Performance Daycases FFT response rate Performance
Daycases FFT response rate Trajectory Daycases FFT response rate Target
New targets for response rate agreed with HVCCG in July 18
88%
89%
90%
91%
92%
93%
94%
95%
96%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Outpatient FFT % positive Performance Outpatient FFT response rate Performance
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Caring Chief Nurse Quality Committee 2a / 2c / 3a / 4c / 11a / 12c
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Maternity FFT % positive PerformanceMaternity FFT response rate PerformanceMaternity FFT response rate Target
New targets for response rate agreed with HVCCG in July 18
11
Tab 11 Integrated P
erformance R
eport
45 of 236T
rust Board M
eeting in Public-06/02/20
Benchmarking: MODEL HOSPITAL
Number of written complaints
received per 1000 staff (wte)
Period: Q2 2019/20
WHHT 19.18 Peer 29.99
National 23.66
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Caring & Responsive Services: Complaints
In this reporting period:
The Trust’s monthly target of 80% was achieved. 16 new complaints were received in December 2019.
• 12.5% (2) relate to Surgery, Anaesthetics and Cancer (SAC)
• 50% (8) Medicine
• 12.5% (2) Emergency Medicine/USC
• 25% (4) Women’s & Children’s (WACs)
At month end there were a total of 55 live complaints. 26 complaints were closed in the month. 3 complaints were
reopened during December.
Improvement plan: During December SAC performance improved with 28 open complaints (down from 38 previous
month) which was aided by a lower level of complaints being received. The complaints team continue to work with SAC to
address the backlog and improve performance (January having seen a further decrease in open complaints). Weekly
meetings are held with the SAC Divisional Manager and senior staff to review all complaints and progress going forward to
improve the response rate.
Factors/Themes: Trust wide, most common themes remain all aspects of clinical care (including clinical care and
treatment) 69% (11); attitude of staff and communication at 13% (2), 18% (3) around admission and delays in appointments.
No specific themes or trends have been identified although communication remains a consistent factor in complaints
received.
43
% Complaints responded to within one month/ agreed time Reactivated complaints
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
Complaints timely response Target Mean
Upper control limit (3 sd) Lower control limit (3 sd) Trajectory
-4
-2
0
2
4
6
8
10
12
14
Apr
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar Ap
r
May Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2017/18 2018/19 2019/20
Reactivated complaints Threshold Mean
Upper control limit (3 sd) Lower control limit (3 sd)
Performance improved Better than target/threshold
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Caring Chief Nurse Quality Committee 1b / 2a / 2c / 3a / 4a / 4b / 4c / 10e / 10f / 11a / 12c
11
Tab 11 Integrated P
erformance R
eport
46 of 236T
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eeting in Public-06/02/20
The very best care for every patient, every day
Caring & Responsive Services: End of life care
In this reporting period:
The NHS End of Life Care Strategy (2008) emphasised that improved end of life care provision in acute hospitals was
crucial; this is where more than half of all deaths take place.
Referrals to Specialist Palliative Care
The strategy identified that people weren’t supported to die in their place of choice; and although progress has been made,
this has been evidenced in many other reports. There continues to be a national focus on reducing the numbers of patients
dying in hospital and offering everyone who is approaching the end of their life the opportunity to express and share their
preference for where they want to die as well as any goals that are important to them (National Palliative and End of Life
Care Partnership, 2015).
In December, 85 referrals were made to the Trust Specialist Palliative Care Team. Of the patients with capacity to make
decisions about PPD, 100% had an identified PPD.
Patients who died at WGH where their identified preferred place of death (PPD) was not achieved
Two patients died in a setting that was not their preferred place of death. In both cases the reason was due to the patients’
physical symptoms not permitting their transfer.
Patients on an Individualised Plan of Care for the Dying Person (IPCD)
Of the 10 patients whose death was reviewed in December, six patients did not have an IPCD and it was deemed that for
two it would not have been appropriate. Learning from the audit will be fed back to ward areas to support the identification of
patients appropriate for an IPCD.
Treatment Escalation Plans (TEP)
TEPs ensure that every patient’s care is reviewed, individualised and their levels of care are considered in line with Trust
guidelines. In December 2019, of the 10 deceased patients reviewed, 7 had a TEP in place. In 5 the TEP had been
reviewed as needed and was appropriate. There were 3 patients without a TEP.
44
Benchmarking:
Not currently available
Stable
Referrals to Trust Specialist Palliative Care Team Patients on Individualised Plan of Care for the Dying Person Patients with a Treatment Escalation Plan
0
20
40
60
80
100
120
140
Jan-17 Mar-17May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18May-18 Jul-18 Sep-18 Nov-18 Jan-19 Mar-19May-19 Jul-19 Sep-19 Nov-19
Nu
mb
er
of r
efe
rral
s p
er
qu
arte
r
Jan-17
Feb-17
Mar-17
Apr-17
May-
17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Apr-18
May-
18
Jun-18
Jul-18
Aug-18
Sep-18
Oct-18
Nov-18
Dec-18
Jan-19
Feb-19
Mar-19
Apr-19
May-
19
Jun-19
Jul-19
Aug-19
Sep-19
Oct-19
Nov-19
Dec-19
Total referrals 98 111 120 103 96 108 84 72 90 120 112 93 94 94 68 78 79 74 69 82 70 89 89 83 102 83 76 81 89 68 95 86 85 98 101 85
Upper control limit 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110 110
Lower control limit 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68
Referrals to Trust Specialist Palliative Care Team
0
2
4
6
8
10
12
Patients on Individualised Plan of Care for the Dying Person
Number of patients on IPCD
Number where IPCD would have been appropriate
Number of patient deaths
Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 0ct-19 Nov-19 Dec-19
Notes reviewed 11 10 6 5 9 7 4 11 9 10
Patients with a TEP 11 9 5 5 8 6 4 9 7 7
Patients without a TEP 0 1 1 0 1 1 0 2 2 3
TEP reviewed appropriately 7 8 3 2 5 4 1 9 3 5
0
2
4
6
8
10
12Patients with a Treatment Escalation Plan
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Caring Chief Nurse Quality Committee 2a / 2b / 2c / 3a / 4c / 11a
11
Tab 11 Integrated P
erformance R
eport
47 of 236T
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eeting in Public-06/02/20
Benchmarking: MODEL HOSPITAL
RTT – 18 weeks incomplete wait
Period: October 2019
WHHT: 86.86% Peer: 81.88%
National: 84.2%
(Peers = Nightingale Group – acute
multi-site trusts)
The very best care for every patient, every day
Caring & Responsive Services: RTT Open pathways
In this reporting period:
At 87.4% performance against the 92% open pathway standard is unchanged from the previous month. The position is
favourable when compared with the most recent national data available (November 2019) which shows that WHHT
performance that month was better than the national average (84.4%).
The median waiting time at WHHT (ie the weeks half the patients on an RTT pathway were waiting) was better than the
national position (6.8 vs 7.7 weeks) and the 92nd percentile wait time (22.5 vs 23.9 weeks). The overall PTL size remains
lower than the March 2019 position and is on track to meet national expectations. The 18 week plus backlog continues to
decrease.
At the end of the month there were no patients whose waiting time exceeded 52 weeks.
Next steps:
Good progress is being made against, although actual performance is lower than the improvement plan target. However,
waiting list initiatives, outsourcing and focused validation continue as the primary actions driving change.
45
RTT - % within 18 weeks Number of 52 week waits
Performance improved Worse than target/threshold
74%
76%
78%
80%
82%
84%
86%
88%
90%
92%
94%
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Mar
2017/18 2018/19 2019/20
Performance Mean Upper control limit (3 sd)
Lower control limit (3 sd) Target Series3
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2017/18 2018/19 2019/20
52+ actual 0 0 0 0 0 0 0 1 0 20 41 52 63 70 114 124 123 111 87 83 51 35 23 4 2 3 4 4 1 3 0 0 0
52+ week trajectory 101 76 59 35 11 0 0 0 0 0 0 0 0 0 0
0
20
40
60
80
100
120
140
Nu
mb
er
of
pat
ien
ts
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Responsive Chief Operating Officer Finance & Performance Committee 2c / 4b / 4c / 12c
11
Tab 11 Integrated P
erformance R
eport
48 of 236T
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The very best care for every patient, every day
Caring & Responsive Services – Cancer: Two week wait
In this reporting period: The provisional position for December is compliant at 96.9% with 1405 referrals of which 43 were seen beyond 14 days. The referral numbers are slightly below average. (Average since April 2019 is 1594 referrals/month) The areas with the highest number of breaches were: • LGI with 18 - this is a month on month improvement • Breast with 8 • Gynae with 6 • Skin with 5 - this is a month on month improvement The LGI improvement is expected to continue as colonoscopy scheduling changes are happening in January 2020 to increase flexibility. Breast symptomatic The provisional position for December is compliant at 98.4%. There were 128 referrals and 2 patients were seen beyond 14 days. Next steps: Monitor the affect of the change in scheduling for the colonoscopies
46
Benchmarking: NHSI ANALYTICS HUB
Cancer Waiting time dashboard
Period: November 2019
WHHT: 96.2% Peer: 88.8%
National: 91.3%
(Peers = East of England region
Two week waits: % within target time Breast symptomatic patients: % within target time
86%
88%
90%
92%
94%
96%
98%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
Two week wait performance Two week wait target
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr
May Jun
Jul
Aug Sep
Oct
No
v
De
c
Jan
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep Oct
Nov
De
c
Jan
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep Oct
Nov
De
c
Jan
Feb
Mar
2017/18 2018/19 2019/20
Breast Symptomatic performance Breast Symptomatic target
Performance improved Better than target/threshold
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Responsive Chief Operating Officer Quality Committee 2c / 4b / 4c / 12c
11
Tab 11 Integrated P
erformance R
eport
49 of 236T
rust Board M
eeting in Public-06/02/20
The very best care for every patient, every day
Caring & Responsive Services: Cancer 31 day
In this reporting period: 31 day first The position for December is provisionally compliant at 98.8% with 167 pathways with 2 breaches. There were 1 x breast and 1 x urology breach. 31 day subsequent Surgery The provisional position for December is provisionally compliant at 100%, with 9 pathways 31 day subsequent Drug, The position for December is provisionally compliant with 100% . There were 16 pathways all in target 31 day subsequent palliative The provisional position for December is compliant at 100 % Next steps: Escalation processes continue to be an area of focus, particularly within urology. Actions within POA to ensure that the process is timely, including anaesthetic review.
47
Benchmarking: NHSI Analytics Hub
Period: November 2019
31 day first:
WHHT: 98.0% Region: 96.6%
National: 95.9%
31 day surgery:
WHHT: 100% Region: 88.9%
National: 91.7%
31 day first: % within target time 31 day subsequent drug: % within target time 31 day subsequent surgery: % within target time
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb
2017/18 2018/19 2019/20
Cancer - 31 day Performance Cancer - 31 day Target
70%
75%
80%
85%
90%
95%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Cancer - 31 day subsequent drug Performance Cancer - 31 day subsequent drug Target
0%
20%
40%
60%
80%
100%
120%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Cancer - 31 day subsequent surgery Performance Cancer - 31 day subsequent surgery Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services : Responsive Chief Operating Officer Quality Committee 2c / 4b / 4c / 12c
Performance improved Better than target/threshold
11
Tab 11 Integrated P
erformance R
eport
50 of 236T
rust Board M
eeting in Public-06/02/20
Benchmarking: MODEL HOSPITAL
62 day wait from urgent GP referral
Period: October 2019
WHHT: 77.55% Peer: 74.69%
National: 78.54%
Peers = Nightingale Group – acute multi-
site trusts
Benchmarking: NHS Analytics Hub
Period: November 2019
WHHT: 78.3% Peer: 75%
National: 77.4%
Peers = East of England Region
The very best care for every patient, every day
Caring & Responsive Services: Cancer 62 day urgent GP referral
In this reporting period:
62 day GP – urgent
The provisional position for December is non- compliant at 83.2% although this is an improvement on the previous month.
Provisionally there are 92 treatments with 15.5 breaches (21 patients).
12 x urology 2 x H&N 2 x gynae 1 x derm 1 x breast 3 x lung
Breaches
A review of the breaches indicate an increase in administrative errors, these include clinicians not ordering tests,
escalations which are ineffective, booking tests as routine patients rather than 2ww, booking outside target despite
escalations. The usual issues of not having sufficient capacity quickly is still a problem when patients cancel at short notice
and re-booking quickly is very difficult.
104 day breaches
Open pathways: In December’s submission there were 11 patients on an open pathway longer than 104 days. A
review of the breaches indicated some complex pathways requiring discussion at >1 MDT, waiting for clinical review after
investigations, particularly those appearing benign, some late referrals (x2), some patient choice with holiday and wanting
specific hospital sites and time of day.
Closed – Provisionally the Trust has closed 4 pathways over 104 days (including consultant upgrades and screening) :
3 x urology, 1 x lung.
Next Steps:
Continue working with services to implement the Cancer Improvement Plan and monitor progress in each area.
48
62 day GP: % within target time 62 day GP: Tumour Site 62 day screening: % within target time
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
2017/18 2018/19 2019/20
Cancer - 62 day Performance Cancer - 62 day Trajectory Cancer - 62 day Target
0%
20%
40%
60%
80%
100%
120%
Apr
May Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep
Oct
Nov
Dec Ja
n
Feb
Mar
2017/18 2018/19 2019/20
Cancer - 62 day screening Performance Cancer - 62 day screening Target
Performance improved Better than target/threshold
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Caring Chief Operating Officer Finance & Performance Committee 2c / 4b / 4c / 12c
Tumour type October November December Q3 (provisional)
Breast 95.7 93.8 91.3 94.1
Gynaecological 100 100 100 100
Haematological 33.3 50 100 64.3
Head and Neck 100 50 100 85.7
Lower Gastrointestinal 60.9 100 100 81.6
Lung 25 0 25 21.4
Skin 100 100 100 100
Upper Gastrointestinal 60 100 100 78.9
Urological 61 54.1 60 58.6
Testicular 100 0 100 75
Acute leukaemia 100 0 0 100
Other 0 100 0 66.7
Total 80.4 79.2 83.2 81.0
11
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The very best care for every patient, every day
Caring & Responsive Services: Outpatients
In this reporting period:
Short notice, hospital initiated cancellation rates remain within tolerance levels (target 5%) this month (excluding valid
cancellations and patient initiated cancellations).
It should be noted that the total cancellation rate does not equate to unfilled capacity as vacated appointment slots are often
re-filled.
The DNA rate has also increased slightly at 9.2% and specialties with high DNA rates continue to include ENT, Oral
Surgery, Gastroenterology, Thoracic (Respiratory) Medicine, Cardiology and Neurology.
Next steps:
The Elective Care Programme Board will task the Outpatient Users Group, overseen by the Outpatient Transformation
Board works with services to give assurance that there are appropriate actions in place to address these and other issues
relating to outpatients.
49
Benchmarking: MODEL HOSPITAL
Did not attend rate
Period: Q2 2019/20
WHHT 7.63% Peer: 6.72%
National: 7.14%
(Peers = Nightingale Group – acute
multi-site trusts
All cancellations Under 6 weeks All cancellations Under 6 weeks
12.3% 4.3% 10.2% 9.6%
Total cancellations: 25.2%
Hospital initiated Patient initiated
Performance stable Better than target/threshold
Outpatient cancellation rate DNA rate
0%
2%
4%
6%
8%
10%
12%
14%
16%
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb
2017/18 2018/19 2019/20
Outpatient cancellation rate Actual
Outpatient cancellation rateTarget
Mean
Upper control limit (3 sd)
Lower control limit (3 sd)
Outpatient cancellation rate within 6 weeks
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
11.0%
12.0%
Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb
2017/18 2018/19 2019/20
DNA rate Actual Mean
Upper control limit (3 sd) Lower control limit (3 sd)
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Caring & Responsive Services: Responsive Chief Operating Officer Finance & Performance Committee 3a / 4b / 4c / 10e / 10g / 11a
11
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Model Hospital benchmarking:
Proportion of staff leaving each
month
Period: October 2019
WHHT: 1.54% Peer: 0.83%
National: 0.98%
Peers = Nightingale Group – acute multi-
site trusts)
The very best care for every patient, every day
Workforce & Finance: Recruitment & Retention
50
In this reporting period:
Staff in Post and Vacancies
The number of staff in post increased to 4,550wte, an increase of 112wte over the last 12 months. This includes the TUPE transfer of staff
for Simpson Ward. The funded establishment has increased by 67wte over the same period. The Trust’s workforce establishment is now
5066wte (excl external staff working on rotation).
The number of vacancies is currently 516wte (10.2%) (568wte in Dec 2018). For Band 5 nurses the vacancy rate is currently 4.6%, a small
increase from 2.5% last month, but a significant change when compared with 123wte or 17.2% in March 2018 and 32% in 2015. The
figure includes approx. 22 overseas transitional nurses who are currently working towards their NMC registration. There are plans to
recruit both in the UK and abroad to reduce these vacancies to maintain the vacancy rate at under 5%. Current projections show that
recruitment plans will meet this aim.
Sickness Rate :
Sickness absence is currently 3.8%, above the 3.5% target. The Trust is ranked 6 / 16 in terms of the lowest sickness scores as at Q2 for
local NHS benchmarking organisations.
Labour Turnover and Number of staff leaving within first year
Turnover based on a rolling 12 months is currently 14.3%, a decrease from last month and from 12 months ago when it was 15.4%. The 3
monthly turnover rate is 14% and this helps identify more immediate changes in trends. 17% of staff leave their post before serving 1
year. However, this is better than 22.6% a year ago. Nursing Band 5 turnover has increased slightly to 17.0% or just under for the last 3
months.
Next steps:
Adverts have been increased and interviews are held bi-weekly. Regular review of overseas nurse pipeline and with a plan to increase to
approx. 10 per month to March 2021. The first cohort of internal OET students are due to take their exam in March / April. Early mock
results show that around half are on their way to pass, on the lead up to their exam focus will be given to the areas where they need most
support. A CPD funding bid has been submitted to fund a further 10 HCA’s to undertake their OET this year (subject to approval).
Accommodation is being addressed, the Trust is looking at a contract to manage a new build of 30 apartments within 10 mins walk from
WGH (pending business case and approval).
Performance stable Worse than target/threshold
Staff turnover and vacancy performance Sickness absence performance Number of staff leaving within first year
To be updated 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Apr
May Jun
Jul
Au
g
Sep
Oct
No
v
De
c
Jan
Feb
Ma
r
Apr
May Jun
Jul
Au
g
Sep Oct
No
v
Dec Ja
n
Feb
Mar
Apr
May Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Staff turnover Performance Staff turnover Trajectory Staff turnover target
Vacancy rate Performance Vacancy rate Trajectory Vacancy rate Target
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Sickness rate performance Sickness rate target Sickness rate Trajectory
Mean Upper control limit (3 sd) Lower control limit (3 sd)
0%
5%
10%
15%
20%
25%
0
50
100
150
200
250
Apr
May Jun
Jul
Aug Sep
Oct
Nov
De
c
Jan
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep Oct
Nov
De
c
Jan
Feb
Mar
Apr
Ma
y
Jun
Jul
Aug Sep Oct
Nov
De
c
Jan
Feb
Mar
2017/18 2018/19 2019/20
Number of staff % of new staff
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Workforce & Finance: Well Led Chief People Officer People, Education & Research Committee 3a / 6a / 6b / 7a / 7b / 12c
11
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The very best care for every patient, every day
Workforce & Finance – Developing Staff
51
In this reporting period:
Appraisals
• Current compliance is at 91.9% (target 90%) for December. This figure includes medical staff. It should be noted that
the Trust’s appraisal rate was compliant for most of November, but fell marginally below target when measured at the
end of the month. Performance improved to a compliant position again in the first week of December.
Mandatory training
• The all Trust mandatory training rate remains above target at 93.9%, an increase compared to last month. Compliance
in the low 90’s has now been consistently maintained since November of 2018.
• Essential training compliance is now also at 90% or above since October 2019. It is currently at 91.1%, the same as the
last three months.
Benchmarking: Model Hospital
Trust staff with appraisal completed
by the required date
Period: 2017/18
WHHT: 76% Peer: 83%
National: 93%
Performance stable Better than target/threshold
Benchmarking: Model Hospital
Statutory & Mandatory training
compliance rate
Period: 2017/18
WHHT 86% Region 87%
National 89% Peers = Nightingale Group – acute multi-
site trusts)
Appraisal performance Essential training and mandatory training performance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Jan
Fe
b
Ma
r
2017/18 2018/19 2019/20
Appraisal rate Performance Appraisal rate Target Appraisal rate Trajectory
Mean Upper control limit (3 sd) Lower control limit (3 sd)
60%
65%
70%
75%
80%
85%
90%
95%
100%
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep Oct
No
v
De
c
Jan
Feb
Ma
r
2017/18 2018/19 2019/20
Essential training Mandatory Training Performance Mandatory Training Target
DOMAIN EXECUTIVE LEAD SUB-COMMITTEE BAF Ref
Workforce & Finance: Well Led Chief People Officer People, Education & Research Committee 3a / 5c / 6a / 6b / 8b / 8c
Performance improved Better than target/threshold
11
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Workforce & Finance: Workforce BAF scorecard
The very best care for every patient, every day
52
The Board Assurance Framework shows key workforce indicators in the context of current performance, performance 12 and 3 months ago, Trust workforce targets, the distance to these targets and a RAG rating based on 5 scales. It also has benchmarking data taken from NHS healthcare providers in the Hertfordshire and West Essex and Bedford, Luton and Milton Keynes STPs. The RAG rating is based on distance to targets – if current performance is within 0% to 20% (or exceeds) its target then the RAG rating is green. If performance is within 60% – 80% of target then the rating is yellow. This is repeated at 20% intervals for amber and brown until performance is over 80% from the target when the RAG rating is red. If 2 indicators are rated red, then the overall rating is red. If all indicators are rated green, or one is amber then the overall rating is green. Any other combination is amber. The BAF performance indicators reflect core areas of the workforce that we are monitoring. These include B5 nurse vacancies and turnover, reflecting the focus on recruitment and retention of these staff in conjunction with NHSI. These areas are identified as the Trust’s highest workforce risk factors.. The turnover of our band 5 nurses is currently at 16.9% vs 13.4% overall for all registered midwives/nurses. This represents a small increase from when we have hit our target of under 16% two months ago, and this is a reduction from nearly 30% turnover in May 17 to approx. 15%, an overall reduction of almost a half). For Band 5 nurse vacancy rates, these are currently 4.6%, a small increase from 2.5% last month, and 0% over the previous few months. This in turn though is a significant decrease from 123wte or 17.2% in March 2018 and 32% in 2015. NB – the Band 5 Nurse vacancy wte figure includes approx. 22 overseas transitional nurses who are currently working towards their NMC registration. There are plans to recruit both in the UK and abroad to reduce these vacancies over 19/20 to maintain the vacancy rate at under 5%. Current projections and action being taken show that recruitment plans will meet this aim. When measured at month end, combined appraisals rates are compliant against the 90% target (91.9% overall). The overall rate for medical staff (97%) includes all medics apart from training posts. Mandatory training compliance is 94%, and is now consistently above the 90% target. It should be noted that results are now taken from the Acorn system to ensure improved reporting accuracy. The November monthly Trust sickness rate is 3.8% against a 3.5% target, and so is above target. The 12 month sickness figure is 3.38%, below the target. It is anticipated that sickness will rise over Winter months. The current agency pay bill percentage is 4.9%. The overall target rate for 2019/20 is 5%, reflecting the reduced agency cost target envelope. The 12 month turnover rate is 14.3%, amongst the lowest rates we have recorded. The Trust is ranked 7 / 13 nearby NHS organisations. The Trust has received data in relation to the 2019 staff survey however the detail of this is embargoed until 18th February 2020. We can confirm that we continue to compare favourably with our NHS comparator organisations. In 58% of questions we have improved or remained the same as compared to last year. In 42% we have unfortunately performed worse than we did last year (but only typically by only 1%). In 68% of questions we have continued to do better than our comparators. 11
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Data sources
53
Theme Source Executive lead Lead Board IPR Quality IPRPatient
Experience IPRDivisional IPRs
SHMI (Rolling 12 months) Dr Foster MD 1 1 -1 1
HSMR - Total (Rolling three months) Dr Foster MD 1 1 -1 1
Clostridioides Difficile - Hospital associated (Cat 1) WHHT CN 1 1 -1 1
Clostridioides Difficile - Healthcare associated (Cat 2) WHHT CN 1 1 -1 1
Clostridioides Difficile - Hospital and Healthcare associated Total WHHT CN 1 1 -1 1
Hand Hygiene Compliance CN 1 1 -1 1
30 Day Emergency Readmissions - Elective * Dr Foster MD 1 -1 -1 1
30 Day Emergency Readmissions - Emerg * Dr Foster MD 1 -1 -1 1
Caesarean Section rate - Combined* WHHT MD 1 1 -1 1
Caesarean Section rate - Emergency* WHHT MD 1 1 -1 1
Caesarean Section rate - Elective* WHHT MD 1 1 -1 1
% nursing hours (shift fill rate) WHHT CN 1 1 -1 1
Serious incidents - number* WHHT MD 1 1 -1 1
Serious incidents - % that are harmful* WHHT MD 1 1 -1 1
% of patients safety incidents which are harmful* WHHT MD 1 1 -1 1
Never events WHHT MD 1 1 -1 1
Safety Thermometer Harm Free Care (acquired within and outside of Trust) WHHT CN 1 1 -1 1
Safety Thermometer % New Harm Free Care (acquired within Trust) WHHT CN 1 1 -1 1
Category 4 pressure ulcers - New (Hospital acquired) WHHT CN 1 1 -1 1
Category 3 pressure ulcers - New (Hospital acquired) WHHT CN 1 1 -1 1
VTE risk assessment* WHHT MD 1 1 -1 1
Patients admitted to stroke unit within 4 hours of hospital arrival SSNAP MD 1 1 -1 1
Stroke patients spending 90% of their time on stroke unit SSNAP MD 1 1 -1 1
Domain
Safe care
&
Improvin
g
Outcome
s
Safe
Quality of Care: Mortality Indicators
Quality of Care: Infection Control
Quality of Care: Emergency Readmissions
Quality of Care: Caesarean Section rates
Patient Safety
11
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Data sources
54
Theme Source Executive lead Lead Board IPR Quality IPRPatient
Experience IPRDivisional IPRs
Ambulance turnaround time between 30 and 60 mins East of England Ambulance Service COO 1 -1 -1 1
Ambulance turnaround time > 60 mins East of England Ambulance Service COO 1 -1 -1 1
% Patients admitted through A&E - 0 day LOS WHHT COO 1 -1 -1 1
Discharges between 8am and 12pm (main adult wards excl AAU) WHHT COO 1 -1 -1 1
Mixed sex accommodation breaches WHHT COO 1 -1 -1 1
LOS > 21 days WHHT COO 1 -1 -1 1
Delayed Tranfers of Care (DToC) beddays used in month Integrated Discharge Team COO 1 -1 -1 1
Delayed Tranfers of Care (DToC) beds used in month Integrated Discharge Team COO 1 -1 -1 1
A&E FFT % positive Meridian CPO 1 1 1 1
Inpatient Scores FFT % positive Meridian CPO 1 1 1 1
Daycase FFT % positive Meridian CPO 1 1 1 1
Maternity FFT % positive Meridian CPO 1 1 1 1
Complaints responded to within target/agreed timescale WHHT CN 1 1 1 1
Reactivated complaints WHHT CN 1 1 1 1
New indicators to be included in Q3 WHHT CN 1 1 1 1
New indicators to be included in Q3 WHHT CN 1 1 1 1
ED 4hr waits (Type 1, 2 & 3) WHHT COO 1 -1 -1 1
Referral to Treatment - Incomplete* WHHT COO 1 -1 -1 1
Referral to Treatment - 52 week waits - Incompletes WHHT COO 1 -1 -1 1
Diagnostic (DM01) <6 weeks WHHT COO 1 -1 -1 1
Cancer - Two week wait * WHHT COO 1 -1 -1 1
Cancer - Breast Symptomatic two week wait * WHHT COO 1 -1 -1 1
Cancer - 31 day * WHHT COO 1 -1 -1 1
Cancer - 31 day subsequent drug * WHHT COO 1 -1 -1 1
Cancer - 31 day subsequent surgery * WHHT COO 1 -1 -1 1
Cancer - 31 day subsequent radiology * WHHT COO 1 -1 -1 1
Cancer - 62 day * WHHT COO 1 -1 -1 1
Cancer - 62 day screening * WHHT COO 1 -1 -1 1
Outpatient cancellation rate within 6 weeks^ WHHT COO 1 -1 -1 1
DNA rate WHHT COO 1 -1 -1 1
Patient Experience: End of life care
Access to Services
Cancer
Access to Services: Outpatients
Patient Flow: Emergency Department
Patient Flow: In hospital flow
Domain
Caring &
Responsi
ve
Services
Effective
Caring
Responsi
ve
Patient Experience: Friends & Family Test
Patient Experience: Complaints
11
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Data sources
55
Theme Source Executive lead Lead Board IPR Quality IPRPatient
Experience IPRDivisional IPRs
Staff turnover rate (rolling 12 months) WHHT CPO 1 -1 -1 1
% staff leaving within first year (excluding medics and fixed term contracts) WHHT CPO 1 -1 -1 1
Vacancy rate WHHT CPO 1 -1 -1 1
Sickness rate WHHT CPO 1 -1 -1 1
Appraisal rate (Total) WHHT CPO 1 -1 -1 1
Mandatory Training WHHT CPO 1 -1 -1 1
Essential Training WHHT CPO 1 -1 -1 1
Financial Risk Rating WHHT CFO 1 -1 -1 1
Income & Expenditure Actual WHHT CFO 1 -1 -1 1
Income & Expenditure forecast WHHT CFO 1 -1 -1 1
Cash balance at the end of the month WHHT CFO 1 -1 -1 1
Capital expenditure WHHT CFO 1 -1 -1 1
CIP delivery against plan WHHT CFO 1 -1 -1 1
% Bank Pay** WHHT CFO 1 -1 -1 1
% Agency Pay** WHHT CFO 1 -1 -1 1
GP referrals WHHT CFO 1 -1 -1 1
A&E attendances WHHT CFO 1 -1 -1 1
Elective spells (overnight) WHHT CFO 1 -1 -1 1
Elective daycase WHHT CFO 1 -1 -1 1
Total elective spells WHHT CFO 1 -1 -1 1
Non-elective spells WHHT CFO 1 -1 -1 1
Births WHHT CFO 1 -1 -1 1
Outpatient attendances WHHT CFO 1 -1 -1 1
Workforc
e and
finance
Well led
Domain
Recruitment & Retention
Developing Staff
Finance overview
Activity (chargeable)
11
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1
Trust Board Meeting06 February 2020
Title of the paper Five Year Trust Strategy
Agenda Item 12/79
Presenter Helen Brown, Deputy Chief Executive
Author(s) Helen Brown, Deputy Chief Executive
Purpose Please tick the appropriate box For approval For discussion For information
¸
Executive Summary
This Trust Strategy sets out our priorities for the next five years and has been developed with input from a wide range of staff, stakeholders and patients, following an extensive engagement schedule, reaching both internal and external stakeholders.
The Trust has engaged extensively in the development of the strategy. A paper summarising who has been involved in the engagement programme, the key feedback received and how this has been reflected in the strategy is attached for information. Overall engagement was very positive. The 4 key aims were widely supported. The engagement process has influenced the development of the strategy in a wide range of ways – including ensuring the strategy uses accessible language that reflects the values of our staff, the emphasis given to key aspects of the strategy (e.g. the importance of involving patients in their care, improving communication, improving health and joining-up care, and the urgency and importance of improving our estate and digital infrastructure).
Some stakeholders would like to see more detail on how the ambitions set out in the strategy will be delivered.
Further detail on actions to deliver the strategy are / will be included within a range of supporting strategies as set out in the strategy document. Annual delivery programmes will be developed as set out in the final section of the strategy and progress will be monitored via Board committees. Progress updates will be reported via the relevant Board sub-committees with updates on progress across the whole programme provided to the Board via regular reporting cycle.
Final drafts of the 5 year strategy – full and summary versions are attached for Board approval.
Key changes since the draft presented to the February Board include:
∑ Finalised high level measures of success for each aim
12
Tab 12 Five year strategy
1 of 236 Trust Board Meeting in Public-06/02/20
2
∑ Current baseline performance against each measure of success is included within annexe one to the strategy.
∑ Placeholders for ‘pop out’ case studies have been included within the draft – these are being finalised.
A fully designed version with photographs and completed case studies will be made available to the Board in advance on the meeting.
A supporting ‘case studies’ brochure has been developed to provide greater depth and an opportunity for the Trust to showcase how we have been developing services in line with our strategy over recent years.
The following documents are attached for Board review and approval:
∑ 5 year Trust Strategy – summary version∑ 5 year Trust Strategy – full version∑ Engagement summary report
Trust strategic aims
(please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1Best quality care
Objectives 1-5
Aim 2Great place to
workObjectives 6-8
Aim 3Improve our
finances
Objective 9
Aim 4Strategy for the
future
Objective 10-12¸
Links to well-led key lines of enquiry
☐Is there the leadership capacity and capability to deliver high quality, sustainable care?☒Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver?☐Is there a culture of high quality, sustainable care?☐Are there clear responsibilities, roles and systems of accountability to support good governance and management?☐Are there clear and effective processes for managing risks, issues and performance?☐Is appropriate and accurate information being effectively processed, challenged and acted on?☒Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services?☐Are there robust systems and processes for learning, continuous improvement and innovation?☐How well is the trust using its resources?
Previously considered by
In addition to the engagement programme highlighted above, the strategy hasbeen reviewed by the trust management committee, CAG and at the January Trust Board.
Action required The Board is asked to receive the final draft of the five year Trust strategy for approval.
12
Tab 12 Five year strategy
2 of 236Trust Board Meeting in Public-06/02/20
5 year strategy – summary version 30/12/19 v. 0.1
Five Year Strategy2020-2025
Summary Version
12
Tab 12 Five year strategy
3 of 236 Trust Board Meeting in Public-06/02/20
5 year strategy – summary version 30/12/19 v. 0.1
Introduction
Our vision is to provide ‘the very best care for every patient, every day’. Over recent years #teamwestHerts has made tremendous progress in improving services for our patients; we have moved out of ‘special measures’ and have won a range of national awards, reduced our vacancies and have seen our staff morale continue to rise.
This strategy sets out our priorities for the next five years and has been developed with input from a wide range of staff, stakeholders and patients. Its delivery will require similar collaboration; we are absolutely committed to working in partnership to create a local health and care system that is fit for the future and will deliver the very best care for every patient, every day.
Christine Phil
Phil TownsendChairman
Christine AllenChief executive
12
Tab 12 Five year strategy
4 of 236Trust Board Meeting in Public-06/02/20
5 year strategy – summary version 30/12/19 v. 0.1
About us
We provide services to approximately 500,000 people living in Hertfordshire and north London.
We run services from our hospitals at Watford, St Albans and Hemel Hempstead. We also provide services from a range of community settings across west Hertfordshire.
• Watford General Hospital (WGH) provides emergency care, with accident and emergency, inpatient services, an acute admissions unit, women’s and children’s services and a range of outpatient and diagnostic services.
∑ St Albans City Hospital (SACH) is a dedicated centre for planned surgery. It has a minor injury unit, two surgical wards, an outpatients department and cancer and diagnostic services.
∑ Hemel Hempstead Hospital (HHH) provides urgent care, endoscopy, diagnostics, outpatient clinics and an inpatient ward.
National and Local Context
The NHS Long Term Plan published in 2019 and the NHS Five Year Forward View (2014) set the direction for health and care services over the next 10 years. The Hertfordshire and West Essex (HWE) Health and Care Strategy (2019) and ‘Your Care, Your Future’ (2014) set out our health system’s local strategies and plans for implementing the national vision.
West Hertfordshire Integrated Care Partnership
One of the key elements of both national and local plans is the development of ‘Integrated Care Partnerships’ which bring health and care organisations together to collectively meet the needs of local people. Work is underway to develop the vision, aims, principles and priorities for a West Hertfordshire Integrated Care Partnership. The Trust is playing a key leadership role in this work. 12
Tab 12 Five year strategy
5 of 236 Trust Board Meeting in Public-06/02/20
5 year strategy – summary version 30/12/19 v. 0.1
Our Four Key Aims
We have developed four key aims to support delivery of our vision ~ ‘the very best care for every patient, every day’:
BEST CAREensure our patients and their carer’s have a
great experience of care
BEST VALUEdeliver efficient care to make the best use of
every NHS £
GREAT TEAMgreat people & a great place to work and
learn
GREAT PLACEmodern, fit for purpose estate and digital
technology
This strategy summarises our key aims and priorities for the next five years. Working in partnership to deliver the new integrated care model is a key strand, reflected within each of the aims.
Best Care: our priorities
Promote a quality improvement culture which supports all staff to reduce harm, learn from mistakes and improve care. Use data to improve care.
Ensure consistent high quality across everything we do – reduce variation through implementing 7 day working and rolling out clinical practice group (CPG) programme (in partnership with the Royal Free London), implementing 40 best practice standardised care pathways for common conditions over the next 5 years.
Improve access and reduce waiting times.
Provide patients and carers with choice, valuing them as active partners in decisions about their health and wellbeing.
Work with partners to improve the health of our population (not just manage ill health) and to redesign care to make it more responsive, person centred and more joined up. Enhance quality of life for people with complex needs or long term conditions – plan ahead more and support people to manage their own health conditions.
Improve outpatient care – ‘make every contact count’. Reduce the need to travel to hospitals to receive care that could be delivered closer to home or via digital technology.
Identify opportunities to develop our more specialist services, reducing the need for local people to travel out of area for care. Work with neighbouring hospitals to ensure local people with more specialist needs can access the best care and treatment available.
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5 year strategy – summary version 30/12/19 v. 0.1
Involve local people and patients in our quality improvement and redesign work.
How will we measure success?
We want to be one of the best hospital trusts in England for:
• Mortality: HSMR and SHMI are the key national indicators for mortality.
• Harm free care: new pressure ulcers, falls with harm, new venous thromboembolism, urinary tract infections (in patients with a catheter) and e-coli bacteraemia
• Access to care (national waiting time standards): emergency department 4 hour waits, 18 week referral to treatment and diagnostic waiting times, cancer two week wait, cancer 62 day treatment and the new faster diagnosis standard (maximum 28 days to communication of definitive cancer / not cancer diagnosis).
We want to significantly improve our patients’ experience of care
• Patient Experience: Friends and Family Test scores and national patient survey results
(Our full strategy document sets out further detail on our baseline performance and future measures of success).
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5 year strategy – summary version 30/12/19 v. 0.1
Best Value: our priorities
We spend more than £1m every single day of the year delivering our services. We need make the best possible use of this money for the benefit of local people and ensure financial strength and stability for our hospitals.
To achieve best value, we will work with partners to:
∑ Identify opportunities to become more efficient – focusing on how to bring costs down together whilst continuing to deliver the best possible care
∑ Develop new contract arrangements that move away from ‘cost per case’ and instead focus on best value for the whole system.
Within the trust we will:
∑ Build on our successful track record in delivering savings, aiming for cost efficiency savings of£50m over the next five years. We will continue to use our clinically led quality impact assessment process to ensure that cost improvement plans do not adversely impact delivery of safe patient care.
∑ Improve how we use our capacity (maximising theatre and outpatient slots and making the best use of clinical time).
∑ Identify new opportunities for research & development and education & training funding. ∑ Grow our specialist services and reduce the need for patients to travel out of area for care
(and improve value by delivering growth at marginal cost). ∑ Make better use of our existing charitable funds and raise more to support improvements to
care for patients.∑ Deliver our annual control totals and reach breakeven by 2023.
How will we measure success?
We regularly make financial information available through our board papers and our savings programme and progress against the control total can be tracked.
We aim to achieve a ‘cost per weighted activity unit’ that places us in the top 50% of acute hospital trusts for efficiency (using the NHS Improvement Model Hospital metrics).
Measuring ‘value’ is more difficult than measuring ‘efficiency’. For example, we could deliver a surgical procedure, such as a foot amputation in a diabetic patient, in a very cost efficient way. However, it would be much better value if, through improved diabetic medical management, we can prevent the amputation altogether.
We will work with partners through the new integrated care partnership to identify metrics that help us measure value as well as efficiency.
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Great team: our priorities
We want to be known for having happy, engaged and well supported staff with a great team working culture and a real sense of pride to be part of teamwestHerts.
And we are aiming to be an organisation that attracts talented people who want to deliver outstanding care.
To achieve this we will:
∑ Continue to develop our clinical leadership– supporting, developing and empoweringour clinical leaders.
∑ Deliver excellence in training, education & development for our staff and learners, achieving Teaching trust status by 2021.
∑ Work hard to create a truly inclusive culture and actively value the diversity of all staff, all the time.
∑ Design new roles that support care delivery, fill workforce gaps and provide development and career and role opportunities for our staff, including apprentices and volunteers.
∑ Expand our research and development activity so that more staff have the opportunity to be involved in research and more patients can benefit.
∑ Support the health and wellbeing of our staff and give real recognition to our people for great work, including a review of the benefits we provide to our people.
∑ Support our volunteers to help our patients through offering valuable and fulfilling opportunities – doubling the number of volunteer hours over the next 5 years.
How will we measure success?
We want to in the top 20% of acute hospital trusts in England for staff engagement in the annual staff survey.
(Our full strategy document sets out further detail on our baseline performance and future measures of success).
Winner of the Nursing Times Workforce Award for
‘Best UK Employer of the year, 2019’
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Great Place: our priorities
Whilst we aim to provide the best care, the age of our buildings makes it hard to always deliver the best experience for our patients and staff. We are delighted that funding has been announced to improve our estate and we are committed to making modernising our information technology at the same time.
To deliver our ‘great place’ aim, we will:
∑ Finalise our plans for a major investment in our hospitals and aim to start building by 2022 at the latest.
∑ Continue to improve the safety and appropriateness of our estate in the short to medium term – including investment in fire safety, theatres improvement (WGH), diagnostics and urgent and emergency care.
∑ Complete our planned telephony upgrades to improve patient and staff experience. ∑ Upgrade our IT infrastructure to improve speed and reliability and significantly improve staff
experience, increasing efficiency and freeing up time to care. (Our programme includes: installing a new local area network, rolling out windows 10 across our hospitals, upgrading our patient administration system and implementing a patient portal.
∑ Develop plans and secure funding to implement an electronic patient record. ∑ Work with partners to make sure our IT systems talk to each other – so that, with the
consent of patients, we can share data and support more effective, better co-ordinated care across different health and care providers.
∑ Identify opportunities to use digital technology to improve patient experience, reduce unnecessary travel and make care easier to access and more efficient.
∑ Take immediate steps to improve how we store and manage our current paper medical records.
How will we measure success?
We hope that our progress against ‘great place’ will be hard to miss as so much of this work is about our buildings.
Our aim is that by 2025 we will have
∑ improved facilities delivered by 2025∑ Become paperless as part of our digital transformation
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5 year strategy – summary version 30/12/19 v. 0.1
A Well Led Organisation
Delivering our four strategic aims; best care, best value, great team and great place will require strong leadership, successful partnership working and good governance.
Over the past three years we have being working hard to build a culture of continuous improvement, to improve staff engagement, to develop clinical leadership and make sure we have strong governance to provide assurance from ‘ward to board’ that we are providing high quality, good value care and meeting our statutory duties.
Over the next five years we will continue to keep our leadership and governance arrangements under review to make sure they are working effectively and adapting appropriately to the new ‘integrated care partnership’ way of working.
Delivering our Strategy
Our improvement programme will be organised under our four aims with the following key programmes of work monitored via Board committees, with regular progress updates to the Trust Board:
Best Care Best Value Great Team Great Place
Quality Improvement programme (Quality Account).
Quality committee.
Long term financial recovery plan
Finance and Performance Committee.
People Programme
People, Education and Research Committee
Digital transformation programme
Finance and Performance Committee.
Integrated care Partnership / service development improvement Programme
Quality Committee.
Annual cost improvement plan
Finance and Performance Committee.
Research & Development Programme
People, Education and Research Committee
Estate Transformation Programme
Finance and Performance Committee.
Access Improvement Programme
Finance and Performance Committee
Raise – Charity strategy.
Charity Committee
Communications and Engagement Strategy
Trust Management Committee
This is a summary version of our 5 year Strategy – the Full version can be found here <<insert weblink>> or by contacting [email protected]
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Our Vision
the very best care, for every patient, every
day
Five Year Strategy2020-2025
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Introduction
We have really brought our vision - ‘the very best care for every patient, every day’ - to life overrecent years through the efforts and commitment of #teamwestHerts. Huge progress has been made to improve services for our patients; we moved out of ‘special measures’, won a range of national awards, reduced our vacancies and have seen our staff morale continue to rise.
We want to build on this. Our five year strategy sets out how we will continue our successful improvement journey and deliver national and local priorities for the NHS.
The strategy has been developed to help us steer a course at a time when the NHS is facing many challenges. Our local population is living longer and the number of patients with multiple conditions and complex health needs in increasing; the incidence of mental ill health in our community is rising and demand for emergency care continues to grow.
Whilst we get lots of positive feedback about our care, we know there is much still to do. Patients and their families tell us that care and support sometimes comes too late and can feel disjointed. In common with many other hospital trusts across the country, we have a financial deficit despite a good track record in making savings and efficiencies.
Pressure on the NHS and care services will continue and so we need to make changes – in collaboration with our partners – to the way we work to develop a local healthcare system which meets the future needs of our population and makes the best use of available resources. For example, we must build closer links with GPs, community healthcare providers and our other partners to improve our patients’ experience, providing earlier care and support, not just when a crisis point has been reached.
This strategy sets out our priorities for the next five years and has been developed with input from a wide range of staff, stakeholders and patients. Its delivery will require similar collaboration; we are absolutely committed to working in partnership to create a local health and care system that is fit for the future and will deliver the very best care for every patient, every day.
Christine Phil
Phil TownsendChairman
Christine AllenChief executive
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About us
We provide services to a population of approximately 500,000 people living in Hertfordshire and north London.
We run services from our hospitals at Watford, St Albans and Hemel Hempstead. We also provide services from a range of community settings across west Hertfordshire.
• Watford General Hospital (WGH) provides emergency care, with accident and emergency, inpatient services, an acute admissions unit, women’s and children’s services and a range of outpatient and diagnostic services.
∑ St Albans City Hospital (SACH) is a dedicated centre for planned surgery. It has a minor injury unit, two surgical wards, an outpatients department and cancer and diagnostic services.
∑ Hemel Hempstead Hospital (HHH) provides urgent care, endoscopy, diagnostics, outpatient clinics and an inpatient ward.
National and Local Context
The NHS Long Term Plan published in 2019 and the NHS Five Year Forward View (2014) set the direction for health and care services over the next 10 years. The Hertfordshire and West Essex (HWE) Health and Care Strategy (2019) and ‘Your Care, Your Future’ (2014) set out our health system’s local strategies and plans for implementing the national vision.
Hertfordshire and West Essex Integrated Care System
Across the country, NHS organisations, together with local authorities, are developing new ways of working to meet the challenges facing health and care services and deliver the ambitions in the NHSlong term plan.
The Hertfordshire and West Essex Sustainability and Transformation Partnership (HWE STP) will become a more formal ‘Integrated Care System’ to support organisations to work together to achieve improved health outcomes, provide more joined up care for local residents and ensure that services are managed in the most cost effective way possible to meet the needs of the population.
At a local level, four integrated care partnerships (ICPs) are being developed; three that are geographical; West Hertfordshire, East & North Hertfordshire and West Essex and one specialist Hertfordshire-wide integrated care partnership for people with complex mental health needs.
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West Hertfordshire Integrated Care Partnership
Work is underway to develop the vision, aims, principles and priorities for the West Hertfordshire Integrated Care Partnership. The Trust is playing a key leadership role in this work.
Currently, acute hospitals are, in the main, responsible for meeting the health needs of people who are already ill and need specialist care and treatment. Hospitals have historically been paid for on a case-by-case basis. In the new ICP model we will share responsibility with partners for preventing ill health, enabling earlier diagnosis and treatment and ensuring that care is joined-up. The way we are funded is changing to reflect this, with a move towards ‘fixed’ or ‘population’ budgets.
We will continue to be driven by wanting to provide the very best care for every patient in our careevery day; but we will also need to think differently about how, where and when care is provided -continuously striving to improve health outcomes, reduce health inequalities and meet the health and care needs of local residents.
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Our Four Key Aims
We have developed four key aims to support delivery of our vision ~ the very best care for every patient, every day:
BEST CAREthe very best care for every patient, every
day
BEST VALUEdeliver efficient care to make the best use of
every NHS £
GREAT TEAMgreat people & a great place to work and
learn
GREAT PLACEmodern, fit for purpose estate and digital
technology
This strategy summarises our key aims and priorities for the next five years. Working in partnership to deliver the new integrated care model is a key strand, reflected within each of the aims.
The strategy is underpinned by a series of more detailed Trust strategies and improvement plans. A number of these ‘underpinning’ strategies are currently being updated or are due to be updated within the next year and several are updated on an annual basis as part of our annual business planning cycle.
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Key National Strategies
Best Care Best Value Great Team Great Place
Five Year Forward View (2014) and NHS Long Term Plan (2019)
NHS Outcomes Framework (2019)
National Patient Safety Strategy (2019)
Health and social care strategy – due 2020
Finance annexe to the long term plan (2019)
Interim NHS People Plan (2019)
Final People Plan - due 2020
Personalised health and care 2020 (2014)
Health Infrastructure Plan (2019)
Key local strategies
Best Care Best Value Great Team Great Place
A Healthier Future – Improving health and care in Herts and west Essex
NHS Long Term Plan – Herts and west Essex delivery plan (2019)
Your Care Your Future – HVCCG (2015)
HWE STP Medium Term Financial Plan (2018)
HWE STP WorkforceStrategy (2019)
HWE STP Estates and Capital workbook (2018 & 2019 update)
Key WHHT supporting strategies and plans
Best Care Best Value Great Team Great Place
Quality Commitment (2017)
Patient Experience & Carer’s Strategy (2016 -19)
Clinical Strategy (2016)
Access Improvement Plan (2019 / continuously updated)
Quality Account (annual)
Service Delivery Improvement Plan (SDIP) (annual)
Long Term Financial Recovery Plan (2019 / continuously updated)
Drivers of the deficit report (2019)
Cost Improvement Plan (annual)
People Strategy (2020)
Research Strategy (2020)
Nursing, Midwifery and Allied Health Professions strategy (2017 - 20)
Workforce Race Equality Standard (WRES) Report (annual)
Strategic Outline Case (SOC) – redevelopment of our hospitals. (2019)
Interim estates Strategy (2017)
Digital Vision (2018)
Communications and engagement strategy (2020)
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Best Care
Our vision is to provide ‘the very best care for every patient every day’. This means ensuring that our services are safe, effective, caring and responsive. Our quality ambition is to match the highest performing NHS hospitals. In some areas, our performance is comparable – for example, on mortality and harm free care indicators. But there are others where we can improve, such as performance against waiting time standards. We want to ensure consistent high quality across everything we do, ensuring that our patients and their carers have a great experience of care.
The best performing hospitals in the country have developed really strong safety and quality improvement cultures which support and enable all staff to reduce harm, learn from mistakes and improve care. We have started this work and have many areas of good practice and pockets of excellence. Continuing to strengthen our quality improvement culture across all our services and improving how we use data to improve care is an essential element in delivering our ‘best care’ aimover the next five years.
We will also continue to work with the Royal Free London and partners on the ‘clinical pathway group’ (CPG) programme. This brings clinicians together to design and systematically implement best practice ‘care pathways’ for common clinical conditions, continuously testing and improving design using in-depth monitoring and analysis. In 2019, we began work on eight standardised best practice pathways and over the next five years we expect to implement another 40.
Ensuring senior doctors, therapists and nurses are available every single day through implementing ‘7 day working’ also remains a priority, as does continuing to improve access in line with national waiting time standards for emergency care, planned care, cancer treatment and diagnostics.
Other priorities include providing patients and their carers with choice, valuing them as active partners in decisions about their health and wellbeing, supporting patients with additional needs (e.g. mental health, learning disabilities and vulnerable children) and continuing to improve end of life care.
Importantly, providing the very best care for every patient every day doesn’t just mean providing great care for local people when they are ill and receiving treatment in one of our hospitals. We need to work to improve the health of our population, not just manage ill health.
We also need to join up care and constantly ask ourselves whether we can redesign care with local health and care partners, including voluntary sector providers, to make it more responsive, person-centred and better co-ordinated.
For people with complex needs or long term conditions we need to plan ahead more and actively support people to manage their own health conditions at home or in primary and community care settings, and by doing this, prevent - as far as possible - the need for hospital care.
Pop out with integrated diabetes service / diabetic foot
Pop out with details of Dr Narayan’s award for clinical audit practitioner of the year and / or a QI case study e.g mat neo
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There are also real opportunities to improve outpatient care by ‘making every contact count’. We want to make outpatient care more convenient for patients and make the best use of the skills and time of our specialist clinicians by working more closely with local GPs and community providers and harnessing the potential of new digital technologies to transform how care is provided.
Pop out with case study from one of our integrated care redesign programmes – joint paediatric clinics – Renton.
We also need to join up care between hospitals when more specialist interventions are needed or where neighbouring hospitals have clinical expertise or facilities that could benefit local residents. There are many examples of this already which work well but there are more opportunities to develop specialist care pathways that would benefit local people.
Pop out re UGI centre at Hammersmith?
Equally we will continue to identify opportunities to develop our more specialist services, reducing the need for local people to travel out of area (e.g. into London) for care.
Pop out re cardiac MRI
Finally, we will do more to engage local people and our patients in improving services. People who have experience of the care we provide can make a real contribution by helping us to design new service models that better meet the needs of local people. We want to move from ‘communication’ and ‘engagement’ towards ‘co-production’. A patient’s ‘pathway’ or programme of care is often provided by a number of organisations and so we are working with local partners to embed this approach into our new integrated care partnership, sharing skills and resources and developing a joint approach to help us do this really well.
What do we plan to do:
• Promote a quality improvement culture, providing training and support to our staff so that they have the skills to turn great ideas into real improvements in care for our patients.
• Work with the RFL CPG programme to design and implement a minimum of 40 standardised best practice clinical pathways, improving outcomes and reducing variation in care.
• Develop a new clinical strategy that sets out
• future service models across our hospital sites
• how we plan to develop our services to reduce the need for local residents to travel elsewhere for care that we could provide locally
• how we can work with neighbouring hospitals to improve care for local residentswhere they have specialist skills and expertise that can benefit our patients
Our updated clinical strategy will inform our hospital redevelopment plans (see Aim Four –‘Great Place’)
∑ Work with partners to jointly agree priorities for the west Hertfordshire Integrated Care Partnership and reflect these into our clinical strategy and improvement plans.
• Maternity, Children and Young People • Planned care and outpatient transformation
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• Urgent and Emergency care • Mental Health • Frailty and end of life care
• Work with partners to strengthen how we engage with patients and the public in our quality improvement and service transformation work, developing and embedding a culture of ‘co-production’.
• Work with partners to ensure that, together, we are using data in the most effective way to support new care models and meet the needs of the population.
• Annually update our ‘Quality Account’ publishing a report on progress and setting out in detail our quality and safety priorities and actions for the year ahead.
How will we measure success?
We want to be one of the best acute hospital Trusts in England for:
• Mortality (SHMI & HSMR): ‘as expected’ or ‘better than expected’ for HSMR and above national median for SHMI.
• Avoidable Harm (harm free care): continuous improvement and better than national average for new pressure ulcers, falls with harm, new venous thromboembolism, urinary tract infections (in patients with a catheter) and e-coli (detailed measure to be confirmed following NHS E updated guidance)
• Access to care (national waiting time standards): continuous improvement and top 25% of hospitals for emergency department 4 hour waits, 18 week referral to treatment and diagnostic waiting time and above national median for cancer two week wait, 62 day treatment and the new faster diagnosis standard (maximum 28 days to communication of definitive cancer / not cancer diagnosis).
We want to significantly improve our patient’s experience of care:
• Patient Experience: improve our scores on the Friends and Family Test and national patient survey result to above the national median.
A baseline of current performance is set out in annexe one.
OUR ANNUAL QUALITY ACCOUNT, SERVICE DELIVERY IMPROVEMENT PLAN / INTEGRATED CARE PARTNERSHIP PLAN AND UPDATED CLINICAL STRATEGY WILL SET OUT IN MORE DETAIL ACTIONS TO DELIVER OUR ‘BEST CARE AIM’.
Best Value
Every day, 365 days per year, we spend more than £1m delivering our services. We need to be confident that we are making the best possible use of this money for the benefit of local people and ensure financial strength and stability for our hospitals.
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In common with many hospital trusts up and down the country, our costs significantly exceed our income, despite a good track record in meeting our annual cost improvement targets and delivering more than £50m savings over the past four years.
Pop out – best example we have of a cost efficiency improvement?
Benchmarking data indicates that our costs are comparable to similar sized hospital trusts. However, our poor estate and IT and three site configuration make it more difficult for us to be as efficient as hospitals with more modern infrastructure.
Our plans to modernise our hospitals through investment in improving our buildings and digital technology are part of the solution and are set out in more detail under our ‘Great Place’ strategic aim.
We know there is much more that can be done to make our services more efficient and in turn make the best use of every NHS £, even before investment in our estate and IT.
We carried out an in-depth assessment to understand what drives our deficit. A combination of operational, structural (poor estates and digital infrastructure) and strategic (system wide) issues were identified. We will use the findings to devise the longer term solutions required to get us to a financially balanced position. We will continuously update this plan over the coming years as weidentify further opportunities to improve efficiency and value.
Historically, acute hospitals have been paid under an arrangement called ‘payment by results’ –receiving a payment for every outpatient attendance, surgical procedure and emergency attendance or admission. In 2019 we agreed a new ‘guaranteed income contract’ contract with our main commissioner, Herts Valleys CCG, which fixes our income for the year. This is a big change and is intended to help both organisations plan with more certainty and focus on reducing the total cost of delivering care across all local organisations. We plan to build on this approach for future years; this is an important step towards the new ways of working that the proposed west Hertfordshire Integrated Care Partnership will bring.
Raise – the charity that supports the Trust – will play a bigger part in helping to deliver ‘best value’by encouraging fund holders to be more active in their stewardship of their funds to ensure that money already donated and any new income is used to good effect, maximising the positive impact of all charitable donations. Additionally, Raise will establish a capital appeal for a new interventional radiology suite, thereby making best value from local goodwill and support by turning this into tangible benefit for our patients.
What do we plan to do?
• Achieve ‘break-even’ by 2023
• Develop a multi-year strategy to eliminate our deficit and meet our agreed annual control totals (our agreed deficit figure set by regulators).
• Work with partners to identify opportunities to deliver the best overall value for every NHS £ for local people. This will be driven clinically but ensuring best value will be a key factor in decisions about changes to care models. New contract and payment arrangements will support this.
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• Work smarter across the organisation to deliver costs efficiency savings of more than £50mover the next five years. (We will continue to use our clinically led quality impact assessment process to ensure that cost improvement plans do not adversely impact delivery of safe patient care).
• Improve how we plan and use our capacity as effectively as possible (maximising use of theatre and outpatient slots and making the best use of clinical staff time).
• Grow our specialist services and reduce the need for patients to travel out of area for care and improving value by delivering growth at marginal cost.
• Identify new opportunities for research and development and education and training funding.
• Raise – make best use of our existing charitable funds and raise more to support improvements to patient experience.
How will we measure success?
∑ Deliver our annual control totals and reach breakeven by 2023 (and publish this in our publically available board papers).
∑ Achieve a ‘cost per weighted activity unit’ that places us in the top 50% of acute trusts for efficiency (using the NHS Improvement Model Hospital metrics)
Measuring ‘value’ is more difficult than measuring ‘efficiency’ – for example we could deliver a surgical procedure, such as a foot amputation in a diabetic patient, in a very cost efficient way. However, it would be much better value if, through improved diabetic medical management, we canprevent the amputation altogether. We will work with partners through the new integrated care partnership to identify metrics that help us measure value as well as efficiency.
OUR ‘DRIVERS OF THE DEFICIT’ REPORT, LONG TERM FINANCIAL RECOVERY PLAN, ANNUAL COST IMPROVEMENT PLANS AND JOINT ‘ SERVICE DEVELOPMENT AND IMPROVEMENT PLAN’ WILL SET OUT IN MORE DETAIL ACTIONS TO DELIVER OUR ‘BEST VALUE AIM’.
GREAT TEAM
Evidence shows that happy, engaged and well supported staff are more likely to deliver outstanding care. . We want all our staff to feel a real sense of pride in being part of teamwestHerts and to bean organisation that attracts and retains talented people who want to deliver outstanding care and have a growing reputation for being a great place to work
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Over the past five years we have worked hard to engage our staff and improve their satisfaction at work. We have significantly reduced vacancy rates, particularly in more junior nursing roles and have provided a range of support and development opportunities to encourage our staff to stay with us and ensure they have the skills and support to enable them to deliver great care.
Pop out – workforce redesign example – e.g. nursing associates & ANPs
We have also focused our efforts on promoting a positive, supportive, clinically led ‘team-working’ culture. Our new ‘People Strategy’ sets out in detail our plans for the next five years. Team working and clinical leadership continue to be at the heart of our strategy.
We want to be known as an organisation that provides excellent education, training and professional development and to offer opportunities for more of our staff to be involved in research and development.
Pop out simulation centre?
As models of care change, with a focus on more joined-up, preventative care we need to work in partnership, through the Hertfordshire and West Essex ‘One Workforce’ programme and with organisations in neighbouring areas, to ensure our collective health and care workforce is able to meet future needs and adapt to the new ways of working.
Pop out – example from STP of joint work – e.g. rotations
What do we plan to do?
Put clinical leadership at the forefront – support, develop and empower our clinicians, freeing up time for them to lead, not just internally but in helping to shape and deliver new integrated care models in partnership with colleagues across the health and care system.
Use the expertise of our disability and diversity staff to help us create a truly inclusive culture and actively value the ‘diversability’ of all staff, all the time. Deliver excellence in training, education & development for our staff and learners, achieving Teaching trust status by 2021.
Design new roles that support care delivery, fill workforce gaps and provide development and career opportunities for our staff, including making best use of the apprenticeship levy.
Expand our research and development activity so that more staff have the opportunity to be involved in research and more patients can benefit.
Support the health and wellbeing of our staff, giving real recognition to our people for great work(including a review of the benefits we provide to our people).
Winner of the Nursing Times Workforce Award for
‘Best UK Employer of the year, 2019’
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Collaborate with health and care partners to get the best outcomes and experience of care for local residents through the Hertfordshire and West Essex ‘One Workforce’ programme and our partnership with the Royal Free London.
Support our volunteers to help our patients through offering valuable and fulfilling volunteering opportunities. Our ambition is to double the number of volunteer hours donated for the benefit of patients over the next five years.
How will we measure success?
We want to be one of the best hospitals in England for staff engagement
∑ To be in the top 20% acute hospital Trusts in the country for NHS national staff survey results.
A baseline of current performance is set out in annexe one.
OUR UPDATED PEOPLE STRATEGY, ANNUAL WORKFORCE RACE EQUALITY STANDARD REPORT AND RESEARCH AND DEVELOPMENT STRATEGY SET OUT IN MORE DETAIL ACTIONS TO DELIVER OUR ‘GREAT TEAM’ AIM.
Great Place
We want to be a great place to receive care and to work, and have already described our strategic priorities to improve the quality of our clinical care and to recruit, retain, engage and support our staff.
Our estate and digital infrastructure impedes us –our patients and our staff are impacted by the current poor state of our hospital buildings and digital technology. Our Great Place aim therefore focuses on addressing this ‘twin challenge’ – upgrading our hospital estate and IT so that both patients and staff can benefit from modern, fit for purpose care facilities.
We are very pleased that the need for investment has been recognised by the Government and that we are one of six hospital trusts in the first wave of the new national ‘health infrastructure programme’ (HIP). Our strategic outline case (SOC) published in July 2019 sets out our plans for a major rebuild and refurbishment of emergency care and specialist services at Watford General Hospital, and investment in planned surgical and cancer services at St Albans City Hospital and in planned medical services at Hemel Hempstead Hospital. Making rapid progress with our plans so that construction can start as soon as possible is a key priority; we aim to commence building workby 2023 at the latest.
Our IT is also a source of frustration for staff and patients and does not enable us to take advantage of modern digital technology that can support more effective and efficient ways of delivering care.
In 2019 we moved to a new outsourced IT support provider and are working with them to make improvements to our IT infrastructure and improve how the support service responds to organisational needs.
We are committed to implementing a full, modern electronic patient record (EPR) as soon aspossible – this will support improvements in our care, information sharing with partners to support joined up care and release time to care by reducing the administrative burden on our clinical staff.
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Over the life time of this strategy we will develop a detailed business case for an EPR, work to secure the required funding and complete the necessary streamlining of our processes, ready for implementation. The Royal Free London (RFL) - who have recently upgraded their EPR and opened the new Chase Farm Hospital as a fully paperless hospital - are supporting us in this project. We will learn from their experience and identify opportunities to fast track our improvement programme where possible.
We also plan to take immediate steps to improve how we store and manage our current paper medical records, a key step on the way to an EPR.
Investment in estate and digital technology needs to go hand in hand – we want our buildings and digital technology to support best practice, efficient care and not inhibit it. Our estate and digital transformation programme will be clinically-led and we are committed to involving local residents and patients in developing our plans. We will also work with other HIP hospitals to make sure we are learning from each other and from national and international best practice in estate and digitally enabled transformation.
In the meantime, we continue our work to ensure our buildings are maintained safely and to make improvements when urgently required to enable us to continue to deliver safe care. Our transitional estates plan sets out key priorities while we progress our long-term major redevelopment plans.
We will also continue to invest in improving our core IT infrastructure and will look for opportunities to use modern digital technology to improve care delivery. Priorities for the next five years include further improvements to our IT and telephony infrastructure and upgrades to key clinical systems.
Pop out – upgrading telephony to support outpatient booking processes?
The NHS Long Term Plan identifies significant opportunities to transform outpatient care models by using modern digital technologies.
We want to improve patient experience by making our appointment systems easier to access and more responsive – we know that our current appointment systems are frustrating for patients.
We also want to reduce the need for costly and time consuming (for patients and staff) face to face outpatient appointments where possible. We will do this through implementing IT-enabled patient tracking and information management systems that help us to deliver new care models and by making use of new clinical apps and other communication tools.
Pop out teledermatology
We will work with our partners to ensure that our IT system ‘talk to’ each other so that, with the consent of patients, we can share data and support more effective care for patients across the whole health and care system.
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What do we plan to do?
• Finalise our plans for a major investment in our hospitals – aim to start building by 2023 at the latest.
• Continue to improve the safety and appropriateness of our estate in the short to medium term – including investment in fire safety, theatres improvement (WGH), diagnostics and urgent and emergency care.
• Complete our planned telephony upgrade to improve patient and staff experience.
• Upgrade our IT infrastructure to improve speed and reliability and significantly improve patient and staff experience, increasing efficiency and freeing up time to care. The programme includes: installing a new local area network, rolling out windows 10 across our hospitals, upgrading our patient administration system (PAS) and implementing a patient portal.
• Develop plans and secure funding to implement an electronic patient record.
• Take immediate steps to improve how we store and manage our current paper medical records.
• Improve patient experience by making our appointment systems easier to access and more responsive.
• Work with partners to make sure our IT systems talk to each other so that we can share data and support more effective care for patients.
• Identify opportunities to use digital technology to improve patient experience, reduce unnecessary travel and make care easier to access and more efficient.
How will we measure success?
We will track the progress of our redevelopment programme against the timeline we have set – for –building work to commence no later than 2023 - and will share information publically.
We will become paperless by 2025.
OUR ANNUAL CAPITAL PROGRAMME WILL SET OUT IN MORE DETAIL OUR PLANS TO IMPROVE ESTATE AND DIGITAL TECHNOLOGY IN THE SHORT TO MEDIUM TERM.
OUTLINE AND FULL BUSINESS CASES FOR ESTATE REDEVELOPMENT AND DIGITAL TRANSFORMATION / ELECTRONIC PATIENT RECORD IMPLEMENTATION WILL BE DEVELOPED TO ENABLE US TO SECURE SUBSTANTIAL LONG TERM INVESTMENT IN OUR INFRASTRUCTURE AND SET OUT DETAILED DELIVERY PLANS.
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A Well Led Organisation
Delivering our four strategic aims; best care, best value, great team and great place will require strong leadership, successful partnership working and good governance.
Over the past three years we have being working hard to build a culture of continuous improvement, to improve staff engagement, to develop clinical leadership and make sure we have strong governance to provide assurance from ‘ward to board’ that we are providing high quality, good value care and meeting our statutory duties.
Over the next five years we will continue to keep our leadership and governance arrangements under review to make sure they are working effectively and adapting appropriately to the new ‘integrated care partnership’ way of working.
Delivering our Strategy
Our improvement programme will be organised under our four aims with the following key programmes of work monitored via Board committees, with regular progress updates to the Trust Board:
Best Care Best Value Great Team Great Place
Quality Improvement programme (Quality Account).
Quality committee.
Long term financial recovery plan
Finance and Performance Committee.
People Programme
People, Education and Research Committee
Digital transformation programme
Finance and Performance Committee.
Integrated care Partnership / service development improvement Programme
Quality Committee.
Annual cost improvement plan
Finance and Performance Committee.
Research & Development Programme
People, Education and Research Committee
Estate Transformation Programme
Finance and Performance Committee.
Access Improvement Programme
Finance and Performance Committee.
Raise – Charity strategy.
Charity Committee
Communications and Engagement Strategy
Trust Management Committee
For more information please contact: [email protected]
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Annexe One – Baseline data for key measures of success (note: final version with latest data to be included in publication draft of strategy).
Proposed top line objective Measure BaselineWHHT will be one of the best hospitals in the country for safe, harm free care.
Q1 Lowest Q2 Q3 Q4 TopNew harms Continuous improvement from our current baseline and better than national average for each of the 4 key Safety Thermometer metrics (New Pressure Ulcers, Falls with harm, New Venous Thromboembolism of any type, urinary tract infections (in patients with a catheter). Reduction in e-coli bacteraemia - detailed measure TBC following NHS E guidance for 2020.
NHSI Safety Thermometer• new harm free care• New Pressure Ulcers (category II, III, IV) • Falls with harm within previous 72 hours • New Venous Thromboembolism of any type• Patient with catheter and UTI • E-Coli
• 98.5% vs 95.0% YTD to Nov• 1% vs national figure 1% • 0.2% vs national figure 0.5%• 0.3 % vs national figure 0.5%• 0.2%vs national figure 0.7% (measure TBC)
Top 50% of hospitals in the country for mortality using SHMI
Consistently achieving ‘as expected’ or ‘better than expected’ HSMR.
NHSI New Model Hospital SHMI
HSMR
Trust value: 1.01 @ Aug 18 - July 19.
Current performance 'as expected'.
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WHHT will be one of the best hospitals in the country for access to care (waiting time standards)
Continuous improvement in performance and top25% of hospitals for Emergency care, Referral totreatment and diagnostic waiting times
Continuous improvement and above nationalmedian for three key cancer standards (urgent 2week wait, 62 day wait from urgent GP referral,faster diagnosis standard (28 days forcommunication of definitive cancer / not cancerdiagnosis).
NHSI New Model Hospital
•ED - Trust value: 82.21% Position: 28/ 94 = 70.2% Median 79.19% Benchmark 95.00% Nov 19•RTT - Trust value: 86.86% Position: 40/ 114 = 64.9% Median 84.2% Benchmark92.0% Oct 19Diagnostic waiting times - 99.5% Nov 19
•Cancer 2WW - 96.2%.(nov 19), YTD @ nov 19 = 92.6%. Banchmark 93%. Ju•Cancer 62 day wait from GP referral-Trust value: 77.55% Position: 63/ 116 = 45.7% Peer 78.54% National 85.00% Oct 19Data on 28 day standard not yet available (new standard)
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WHHT will significantly improve our patients’experience of careHigher than national average scores across usingnew model hospital Friends and Family Test (FFT)and Patient Experience national patient surveyresults.
NHSI Friends and Family Test
•FFT - Inpatient % patient rate. Trust value: 95.5% Peer 96.1% Quartile 2 lowest 50%. Nov 19•FFT Maternity - Trust value: 96.9% Peer value 97.9% Quartile 2 – lowest 50% Nov 19•A&E % positive. Trust value: 94.2% Peer Value 85.4% Quartile 4 –highest 25% Nov 19•Out Pt % positive - Distribution chart not available. Trust value: 93.2% Quartile 2- assume lowest 50% Nov 19
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WHHT will deliver efficient, best value care &ensure our hospitals are financially sustainable.
Achieve a ‘cost per weighted activity unit’ thatplaces WHHT in the top 50% of acute trusts forefficiency.
NHSI New Model Hospital 16-17 Trust £3442 National £3,48717-18 Trust £3546 National £3,48618-19 Trust £3,650 (not yet validated)
◊
WHHT will be one of the best hospitals in thecountry for staff engagementTop 20% of acute hospitals in England for staffengagement. (NHS Staff Survey)
NHS Staff Survey
Scores ranked 0-10. The national average score is 7. WHHT scored 7.02 in 2018. Highest national score was 7.6. 2017 6.9 (highest 7.4)
◊
National Distribution
Note - A national distribution for new harms or individual indicators is not currently readily available via Safety Thermometer.
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Strategy Engagement Programme – January 2020
Developing the Trust Strategy and setting out the priorities for the next five years has required the collective effort of a wide group of staff, stakeholders and patients.
Over the past six months the strategy has been on something of a road show, with opinions being canvassed from as wide an audience as has been possible to reach.
Over 250 people from over 44 organisations have taken part in the engagement programme and contributed their thoughts and views on what good care means to them, our shared values and priorities and how we might go about achieving them.
Our thanks are extended to the following for taking part.
Herts Valley CCG Patient Panel
Three Rivers District Council
Dacorum Council
Hertfordshire County Council
Watford and Three Rivers Trust
Carers in Hertfordshire
Central London Community Healthcare Trust
Rothschild House PPG
Hertfordshire Partnership Trust
East and North Herts CCG
Three Rivers District Council
Age UK
Peace Hospice
Macmillan
Herts Valley CCG.
Hertfordshire County Council
Healthwatch Hertfordshire
Central London Community Healthcare Trust
Herts and West Essex STP
Carers in Herts
Herts Community NHS Trust
Headway
MIND
Moorfield’s Eye Hospital
Marie Curie
Herts Hearing Advisory Service
Beds and Herts Local Medical Committee
Royal Free London NHS Trust
Community Action Dacorum
Rennie Grove Hospice Care
Thanks also to our staff and volunteers, including the WHHT Patient’s Panel, for their input into the development of the strategy.
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A final draft was presented at a Strategy Engagement Stakeholder Event held in January 2020. Close to one hundred people attended the event.
The agenda on the day included:
∑ Overview of WHHT and highlights from recent years - (Tracey Carter, Chief Nurse)∑ Introduction to the five year strategy - (Clare Parker, Director of Integrated Care Partnership
Development and Helen Brown, Deputy Chief Executive)∑ Developing our approach to engaging local people and partners - (Louise Halfpenny, Director
of Communications and David Thorpe, Deputy Chief Nurs
From the earliest draft of this strategy, through to the engagement event in January, the feedback has generally been positive.
Language was important to get right and testing this out helped shape the four strategic aims of Best Care, Best Value, Great Team and Great Place. Healthy debates around a hierarchy of each of those balanced in the end with a shared understanding that our primary aim is to provide the best care for every patient and that best value is also important, both of which are enabled by having a great team working in a great place. There is no great care without a great team after all – so all agreed that valuing, supporting and developing our staff is an absolutely key priority.
All stakeholders, both internal and external also recognised and welcomed the emphasis on ‘joined up’ care and the need for WHHT to play a very active role in new models of integrated care, with a greater focus on health and well-being and a shared responsibility for system sustainability and value.
The key themes of feedback included:
∑ Improved communication – both with individual patients and their carer’s, as well as between different health and care professionals and organisations
∑ greater involvement of patients, their carer’s and local people in the design and delivery of care– requiring a shift in culture for NHS staff and supporting cultural change with appropriate training and development or OD interventions.
∑ the importance of investing in our staff and ensuring that ‘teamwestHerts’ is a great team to be part of and our hospitals great places to work
∑ the urgent need for an improved estate and digital infrastructure& the significant opportunities this would present to transform care, particularly through adopting digital technology
Each of these is directly addressed in the strategy.
Best Care
Improved communications between teams, patients and their families and other services was a strong theme within the Best Care aim. Some examples of comments received include:
∑ Care planning for the patient must be shared with the whole family so that choice is fully understood, personalised care is delivered and so that the service understands the individual needs of the patient.
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∑ Tailor communication styles around the patient’s needs, i.e., autism, LD, sensory disorders and dementia.
∑ Support carers∑ Need more psychological support for cancer patients∑ Use volunteers more on wards for patient support e.g. end of life
This feedback is valuable to us and reflects itself in our priority to provide patients and their carers with choice, valuing them as active partners in decisions about their health and wellbeing. It is also a priority to continue to find better ways to support patients with additional needs (e.g. mental health, learning disabilities and vulnerable children) and continuing to improve end of life care. The Trust has a number of improvement projects in place designed to improve communication with our patients and their carers and will further develop our approach and focus on improvement in this area over the life of the strategy.
The Trust is also working with Healthwatch to develop co-production plans to strengthen how weengage local people and our patients to improve our services.
We want to significantly improve our patient’s experience of care and will measure our success in this area through improvement in our scores on the Friends and Family Test and national patient survey result to above the national median.
Best Value
All stakeholders involved in the development of the strategy agreed that delivering ‘Best Value’ care should be a priority, although it is important that financial savings and efficiencies should not compromise the delivery of ‘Best Care’. Discussion on this aspect of the strategy cross referenced to the other 3 aims – can’t have good value without good care and effective use of our workforce, estate and IT are all essential to delivering best value care. There was also a discussion about the relationship between an ‘efficient’ hospital and ‘good value’ healthcare more broadly.
Some examples of comments received include:
∑ Maximise opportunities to develop the skills of our staff, develop new roles / skill mix teams and invest in education, training and development.
∑ A lot of face to face outpatient’s appointments are unnecessary for the patient. To journey in, pay to park and have a long wait, to be told you are fine feels pointless. The ‘you are fine and can be discharged’ patients could be communicated with by phone and that could be best care and best value for all.
∑ More one stop clinical ‘shops’ are needed.∑ Invest in ‘pre-habilitation’ before surgery for conditions such as cancer.∑ Use IT to maximise efficiencies in stock control, warehousing, supply chain and
procurement. ∑ Equipment loans and returns, linked to and a shared service with the community. ∑ The Trust is limited by its facilities and an estate that requires significant investment.
A confirmed measurement of success will be to achieve a ‘cost per weighted activity unit’ that places us in the top 50% of acute trusts for efficiency (using the NHS Improvement Model Hospital metrics.)
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We will work with partners to develop a set of ‘value measures’ as part of the developing integrated care partnership.
Great Team
Staff was the highest focus of feedback across the engagement process overall, with a majority of comments around investing in our staff. Some examples of those comments are:
∑ Promote flexible working.∑ Better car parking at lowest cost for staff ∑ Promote key worker housing schemes or offer accommodation.∑ Health and wellbeing of staff is vital.∑ Promote healthy lifestyles with changing facilities and showers. ∑ Use senior staff to talk about their career journey in inductions. ∑ Inclusion and diversity allowing staff to bring their whole selves to their workplace.
(See also comments in previous sections re staff development, new roles and team working culture).
We want to be known as an organisation that provides excellent education, training and professional development and to offer opportunities for more of our staff to be involved in research and development.
Our People Strategy sets out in more detail our approach to ensuring we continue to build a ‘great team’ and meet our ambition to be a top 20% acute provider for staff engagement.
Great Place.
There was consensus amongst all participants that the estate improvements are a long over-due necessity. Equal weight was given to the vital need for a modern digital infrastructure. Additionally the following comments were made:
∑ Transport links need to improve∑ Transport for those with disabilities needs to improve.∑ Improve signage and way-finders around the estate. Follow a patient’s journey to see where
improvements are needed. ∑ Consider using technology for estate wayfinding and traffic/transport updates.
The engagement event proved to be a valuable opportunity to describe the planned improvement programme to upgrade of our IT infrastructure that will improve speed, reliability and improvepatient and staff experience, freeing up time to care.
Further work is required on outline and full business cases for estate redevelopment and digital transformation. Substantial investment is required.
We acknowledge the importance of the feedback around transport and access to our hospitals.
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Specific areas of feedback on the strategy
In addition to the feedback summarised above, specific points in relation to the draft strategy included the following:
The strategy is quite internally focused / more detail requested on local integrated care plans.
The strategy is explicitly focused on WHHT’s role as a provider of acute health care services, but recognises our responsibility to actively contribute to the broader integrated care agenda. As the local Integrated Care Partnership develops more detail will be shared with stakeholders about how organisations will work together differently and set out the key aims and priorities for the partnership.
The strategy is quite ‘aspirational’ and doesn’t provide very much detail on exactly what the Trust is planning to do to deliver the ambitions set out.
The strategy is a high level document that sets out the key areas of focus for the Trust over the next 5 years. Supporting strategies and plans will set out in more detail the specific actions that the Trust is planning to take. Some of these strategies are being updated currently or are due to be updated in 2020 – for example our Clinical Strategy. Our annual quality account provides more detail on our quality improvement work.
Baseline data should be provided for any measures of success included within the strategy.
Baseline data for proposed measures of success has been included as an annexe to the strategy.
Case studies should be used to ‘bring the strategy to life’.
The final designed version of the strategy will include short ‘pop outs’ that illustrate some of the key priorities within the strategy. These focus on improvements we have already made but bring to life the types of changes and improvements we will continue to make over the coming years.
A separate ‘case studies’ brochure is being developed as a supporting document to the strategy that provides lots of examples of how we are developing our services in line with our strategy.
Travel and access to our sites, including car parking can be very difficult, especially for people with disabilities, young children or frail older people.
We plan to set up a ‘travel and access working group’ to review opportunities to make improvements to access to our 3 hospitals, working in partnership with district councils and transport providers and with support and advice from expert advisors. We will also be producing a ‘green travel plan’.
Thank you to everyone in Team West Herts and to our partners, who have helped shape and develop this five year strategy.
Helen Brown – Deputy CEONatalie Miles-Kemp – Head of Strategy Delivery.
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Trust Board06 February 2020
Title of the paper 2020-2025 People Strategy
Agenda Item 13/79
Presenter Paul Da Gama Chief People Officer
Author(s) Jayne Taylor, Head of ODPaul Mendes, Head of Education, Learning and DevelopmentTania Marcus, Head of HR Business Partnering & ODLaura Bevan, Deputy Director of HRPaul Da Gama, Chief People Officer
Purpose Please tick the appropriate box For approval For discussion For information
√
Executive Summary
This strategy refreshes our previous Workforce and Development Strategy 2016-2019.
As a Trust we are in a much, much stronger place now and whilst we must continue to ensure that the foundations we have laid over the duration of the last strategy remain strong, in this new People Strategy we have placed much greater emphasis on partnership working, quality improvement, diversity and inclusion, and living our values.
We have cross referenced the strategy again the Herts and West Essex Workforce Strategy (HW STP, 2019), the NHS Long Term Plan and the Interim People Plan (NHSE, 2019) among other key policy drivers including the Topol Review(HEE, 2019). We have tried to ground the strategy in the reality of what we know will happen over the next few years whilst also striving to instill a sense of excitement going forwards.
The new People Strategy follows a similar structure to the previous version with four phases that mimic the career pathway of a typical team member, andthe four cross cutting themes mentioned above. The four phases are Building our team; supporting and engaging our team; developing our team; and moving forwards.
Each of the phases is comprised three parts. For example, Building our team covers attracting the best people; a great first few months and beyond; and a flexible and inclusive workforce. At the end of the discussion about each phase we have added a tangible set of commitments and included examples of how we would measure success.
The final structure outlines governance, monitoring and evaluation, and a summary of what we aim to achieve.
The senior HR team is currently attending a number of meetings to gain feedback on the draft. The questions the team are asking are:
• Does what’s being proposed sound right? • Is there anything missing? What else?• Does the strategy align sufficiently to other related strategies e.g. the
NHS Interim People Plan, our STP workforce plan, our nursing and
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midwifery strategy?
It is important that we have a strategy that guides our work and provides a mechanism to coordinate an enormous amount of work, and to have a framework in place to review it and evaluate progress. Soon after approval a detailed implementation plan will be developed which will be the blueprint for this work.
Trust strategic aims
(please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1Best quality care
Objectives 1-5
Aim 2Great place to
workObjectives 6-8
Aim 3Improve our
finances
Objective 9
Aim 4Strategy for the
future
Objective 10-12√ √
Links to well-led key lines of enquiry
☒Is there the leadership capacity and capability to deliver high quality, sustainable care?☒Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver?☒Is there a culture of high quality, sustainable care?☒Are there clear responsibilities, roles and systems of accountability to support good governance and management?☒Are there clear and effective processes for managing risks, issues and performance?☒Is appropriate and accurate information being effectively processed, challenged and acted on?☐Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services?☒Are there robust systems and processes for learning, continuous improvement and innovation?☒How well is the trust using its resources?
Previously considered by Committee/Group Date
Professional advisory committee 18.11.19Joint consultative committee 05.11.19Trust management committee 11.12.19People, education and research committee 12.12.19Board - draft 09.01.20
Action requiredThe Board is asked to receive this strategy for approval.
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People Strategy
2020-2025
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Contents
Page
Section 1 Introduction 3
Section 2 Vision, Values and Aims 5
Section 3 Overview of our People Strategy 6
Section 4 Creating the Right Conditions for Success 6
Section 5 The Phases of the Strategy - Building our team - Supporting and engaging our team - Developing our team - Moving forward
9 9
14 18 23
Section 6 Governance, monitoring and evaluation 28
Section 7 Summary of What we will Achieve and introduction to the implementation plan
29
References 30
Appendix I 31
Appendix II 34
Version control (remove from approved version)
Version Date Distribution Outcome
7.7 30.10.19 Direct reports
7.8 05.11.19 Direct reports LB to edit + AB changes
7.9 25.11.19 Direct reports Case studies included. Changes suggested by TM made
7.10 28.11.19 Direct reports Changes made by team on 02.12.19
7.11 02.12.19 Direct reports, PERC, TMC
Changes made to graphic, from clinical leaders feedback and TMC
Final 18.12.19 Direct reports, JH, PDG
Changes suggested by Deputy CEO
Final v1.2
15.01.20 PDG, Board Changes made following Board review
Final 28.01.20
28.01.20 Board
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Section 1: Introduction
This strategy builds upon the work developed through our original Workforce and
Development Strategy 2016-2019. It has as its main aim to help us to move from
being a good place to work and learn, to a great one.
The position in which we find ourselves as we embark upon the next five-year phase
of our journey to becoming ‘Outstanding’ could not be more different to the one from
which we started in 2016. Some of the biggest changes include:
Our staff survey results have gone overall from bottom quartile to top 20% in
the country.
A massive improvement in filling our vacancies – we’ve gone from a 32%
vacancy rate for our nursing workforce to 0% for band 5 nurses within our
adult in patient wards.
A sea change in agency spend - at the start of the last strategy we were
spending £37m on agency workers, today that figure is less than £13m.
All of our key workforce metrics have vastly improved e.g. appraisal
compliance rates were less than 50%, today they stand at over 90%.
These changes haven’t gone unnoticed and I was delighted that this culminated in
our Trust winning the prestigious Nursing Times Employer of the Year Award for
2019. There is little doubt that these improvements have been fundamental in
helping us to deliver on our Trust’s vision of providing the very best care for every
patient, every day.
One of the concepts which emerged most powerfully during the life-time of our
previous strategy has been that of teamwestHerts. Originally intended as a branding
exercise for a range of Human Resources initiatives, it has become a powerful
descriptor for one of our greatest strengths, namely the way in which our people
come together each and every day to do the most remarkable of things. Whatever
the challenge, when teamwestHerts come together, brilliant things happen!
That is why we have moved our focus from ‘people’ to ‘team’ within this strategy.
Working together as a team is good for our people, our stakeholders and most
importantly our patients. Strong engagement is seen as fundamental to the
successful delivery of our strategy.
Our teamwestHerts approach is underpinned by a genuine commitment to promote
inclusion and diversity, on-going quality improvement and working in collaboration
with all our partners. Our values and ensuring that we live by them, are key to
ensuring that we achieve the goals set out in this strategy.
The refresh of our strategy coincides with an exciting time nationally and locally.
In January 2019 we saw the publication by NHS England of the 10-year NHS Long
Term Plan followed by the Interim People Plan in June 2019. Nationally we know
there is a drive to put the people who provide care as well as those who receive care
at the heart of the NHS.
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The Interim People Plan 2019 is clear that the future workforce will look very different
from how it looks today. There will be more staff, working in very different ways and
in different settings. There is a real push to make better use of modern technology,
and grasping the opportunities to be had by it offers to transform care for the better.
The plan also emphasizes the need for a strong, distributed leadership culture which
has a strong focus on quality improvement.
Locally, there has never been a more exciting time to work in west Hertfordshire. The
NHS Long Term Plan is clear that integrated care systems (ICSs) should be the
main organising unit for local health systems. In Hertfordshire and West Essex which
is our ICS footprint we have a strong commitment to working together. The system-
wide Health and Social Care Workforce Strategy 2019 and the Workforce Strategy
2019 have shaped and influenced our own People Strategy 2020-2025 and we are
working together to ensure that as a health and social care system we have the right
numbers of staff, with the right skills, delivering excellent patient-centered care. We
have strong and evolving working relationships with our STP partners, but also with
the Royal Free London NHS Foundation Trust which we will continue to develop and
we will work together on specific pieces of work where it is to our mutual benefit to
do so.
In west Hertfordshire we are also at the cusp of seeing the start of an exciting
journey to transform our hospital buildings and estate. During the lifetime of our
People Strategy we will start to see major improvements to existing estate and
technology and by the end of the period covered by the strategy we should be
seeing significant work starting on new buildings, creating sites that are inclusive,
accessible and which support the delivery of best care for best value for our patient
population and is a great place for our great team to work in. This, and our other key
aims and priorities are set out in the Trust’s Five-Year Strategy 2020-2025 .
As Chief People Officer it has been my pleasure and privilege to be part of the
transformation that has taken place over the lifetime of our previous strategy. Roll on
2020-25 and the next stage of our exciting journey!
Paul da Gama, Chief People Officer
February 2020
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Section 2: Vision, values and aims
The vision of the Trust is to provide:
“the very best care for every patient, every day”
We have three values underpinned by a set of behaviour standards. Our three values are:
Commitment, Care, Quality1
Our four key aims are:
BEST CARE
the very best care for every patient every day
BEST VALUE
deliver efficient care to make the best use of every NHS £
£
GREAT TEAM
great people & a great place to work and learn
GREAT PLACE
modern, fit for purpose estate and digital technology
Although our People Strategy aligns with all four aims, clearly it most closely informs
the Great Team aim. Evidence shows that happy, engaged and well supported staff
are more likely to deliver outstanding care. We want West Herts Hospitals to be a top
20% trust for staff engagement, a great place to work and to be an organisation that
attracts and retains talented people who want to deliver outstanding care. We want
our staff to feel a real sense of pride in being part of teamwestHerts.
1 To note that it is the intention to revisit the values as one of our first pieces of work attached to this strategy
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Section 3: Overview of our people strategy
The graphic wheel below shows our overall strategy and how the four different
phases all fit together with the four threads that run through and join up our strategy.
Section 4: Creating the right conditions for success
In this section we provide the context of the four phases of our People Strategy and
the four threads that run through it.
Building our team is about ensuring we
have the best people in the right roles, with the right skills, doing the right things, in the right way. This involves making sure that our recruitment practices are first class and that we give people the best experience we can when they join us and beyond. It means working with our partners to embrace the Herts and West Essex ‘One Workforce’ programme, ensuring we attract talented people who are comfortable with our values, making sure our systems and processes are inclusive and celebrate diversity, and that we consistently strive to improve and learn as individuals, across teams and as an organisation.
Supporting and engaging our team is
about making sure we look after our most valuable asset – our staff. Their health and wellbeing are of fundamental importance to us and we want staff to know this. We want to be an organisation that celebrates the great things our staff do, that add up to make our patient care the best it can be. We want to make sure that every single member of staff and all our volunteers are listened to and feel engaged. We are particularly keen to strengthen the voices of those less well heard through a range of safe space channels, such as staff networks and employee groups, and via Speak Up Champions.
Developing our team is about making sure
we develop our staff and volunteers so that our teams feel they have every opportunity to
Moving forwards is all about embracing
change. We are hugely excited about emerging plans for the development of our
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contribute their full potential, develop their careers and gain great job satisfaction. We want our hospitals to be great places to learn for our students as well as for our staff. We want to be known as an organisation that provides excellent education, training and professional development. We want to make sure that we embrace the concept of distributed leadership – recognizing that we are all leaders, and we want to make sure there are opportunities to develop leadership skills appropriate to each role. We particularly want to promote a supportive, clinically-led ‘team working’ culture and we want to develop people who can lead across our teams, our hospital and the wider system.
sites and need to make sure that we support change. We are hearing about and experiencing the power of new technologies and need to make sure we embrace the opportunities these bring. We also want to embrace new roles and new ways of work made possible by regulation and new flexibilities. We will be doing this with our system partners to ensure our collective health and care workforce is able to meet future demands and adapt to new ways of working. We need to ensure that we build a truly inclusive culture so everyone can benefit. We particularly want to offer more opportunities for staff to become involved in research and development.
There are four key threads running through and joining up all the elements of our strategy
Partnership Working Diversity and Inclusion Working closely with our staff and volunteers, promoting our teamwestHerts brand and further developing our communication processes Working closely with our patients, their carers and families, our local communities including HealthWatch, the voluntary sector and the education sector Internally we want to build our relationship with our staff side colleagues Continuing to strengthen links with the Herts and West Essex Sustainable Transformation Partnership and the ‘One Workforce’ programme, and the Royal Free London NHS Foundation Trust and understanding how the changing landscape impacts on us.
Creating a truly inclusive culture and actively valuing the diversity of all staff, all the time
Making sure we hear the voices and perspectives of our diverse teams, to help us to be a great place to work and learn
Including the voices of all our teams, and empowering our teams to ensure that no-one has a less positive experience of working within the Trust because of a protected characteristic
Making sure that across all our services and functions that we always consider the impact of change on all members of our teams.
More closely reflecting the demographic of our local community at all levels of the organisation.
Quality Improvement (QI) Living the Values Building a community of QI practitioners and embedding quality improvement across all areas of the organisation, making sure it is at the forefront of our thinking Ensuring that there is absolute cohesion between the People Strategy and the quality improvement agenda.
Co-creating a new set of values, refreshing our behaviours and making sure our values drive all we do Promoting strong leadership and great, high performing teams and promoting a positive, supportive and clinically led ‘team working’ culture
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Using research and innovation to drive future improvement and maximize evidence based clinical practice, and making sure our People Strategy aligns with the Research and Development Strategy 2020-2023.
Empowering members of teamwestHerts, our partners and others to challenge bad practice, to act where we do not live up to our values, to encourage good practice and the best care of our patients
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Section 5: The phases of the strategy
In this section we expand the four different phases of our strategy: - Building our team - Supporting and engaging our team - Developing our team - Moving forwards.
Each phase is made up of three inter-related areas. Each area is described and we have also included some examples of our commitments to bring about change, and provided examples of how we will measure success. We have also included a few short cases studies highlighting some of the great work that has taken place over the life-time of our previous strategy. A full implementation plan will accompany this strategy which will contain all commitments and related measures – although we have included a snapshot of some of these here. Clearly there are some parts of our strategy that will be easier to measure than others. In our implementation plan we have included much more detail about how we will utilize a range of qualitative and quantitative measurement so that we can effectively measure and monitor the progress of our actions. Whilst the strategy is designed to cover the next five-year period (2020-2025), its implementation requires this to be a dynamic and constantly changing document that will reflect in real time our progress towards meeting our commitments.
5.1 Building our team
This is the first phase of our strategy and encompasses three inter-related areas:
Attracting the best people
A great first few months and beyond
A flexible and inclusive workforce.
Attracting the best people The first phase of our strategy is all about finding the right people. This means recruiting and retaining a stable, competent, cost effective workforce. It means working with our local communities to reach out to a wide range of people with different skills as well as reaching out nationally and internationally to attract and retain talented people who want to deliver outstanding care to come and work with us including students who have trained with us. We will be building on the tremendous success of our overseas nurse recruitment campaign and looking at how this approach can be used among other hard-to-recruit-to posts. As models of care change, with a focus on more joined-up, preventative care we will work with our partners across the system where it makes sense to do so and seek to make employee movement between the organisations in our Integrated Care System as straight-forward as possible, through the ‘One Workforce’ programme. We need to make sure that wherever our new staff come from and whatever their role in the Trust we have recruitment processes that are fair and transparent, professional, inclusive, flexible and slick. We will for example be exploring robotic
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solutions to increase efficiency in how we bring new staff into the organisation. We will also look at the best way of organizing our recruitment services so that they are efficient and cost effective and that is likely to see us partnering up with other NHS providers across many recruitment activities. We will endeavor to attract people from our diverse local community and we are introducing reverse mentoring which will help to ensure our leaders recognize and value the talents of people from a diverse range of backgrounds. Whilst we seek wherever possible to employ staff on a permanent contractual basis,
we recognize that across the NHS and locally, temporary staff are a vital and valued
part of our workforce. During the period of this strategy we will continue to work with
our bank services partner, NHSP, and will make sure that our temporary staffing
processes are robust and that we look after our temporary team.
We will be building on our ‘One Workforce’ approach to managing temporary staffing
(see below) within our Integrated Care System and will be collaborating with other
local NHS trusts to procure the most effective quality temporary staffing solution that
also offers value for money. We will continue to work across the Integrated Care
System to maximize opportunities offered by the shared bank.
Across the NHS and locally we are also fortunate to be supported by an army of
volunteers who support us in countless different ways. We could not run our
hospitals without our volunteers and we will develop our volunteer function, attracting
new volunteers and doubling our volunteer hours over the course of this strategy,
making sure that they feel supported, engaged and valued. We are particularly keen
Focus on success: Case studies from our 2016-19 strategy
Case Study 1: Managing our Temporary Workforce
In 2015 with our agency spend out of control, we came together with a number of
other local trusts to form The Herts and Beds Agency Consortium. The key goals
being to collaborate to procure best value and consistent agency rates and to move
away from ‘agency’ to ‘bank’ as our main source of temporary workers. We began
by having a clear procurement strategy and use only those agencies offering better
rates, offering them longer lead in times in return. In addition, we did substantial
work to align internal processes with all partner organisations so we were not
inadvertently competing with each other.
Working collectively has delivered major benefits including consistent agency and
staff bank rates across trusts. There is no longer any benefit from workers ‘rate
chasing’ between trusts, which has led to a more stable workforce and better
consistency of care.
It has also led to the formation of one of the first truly shared banks within the UK
with five core members - some with different bank systems, coming together to
facilitate their workers to be able to work within each other’s organisations.
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to ensure our volunteering opportunities are available to members of local
communities who may be interested in developing a future career with us or as part
of the wider NHS family. We will actively encourage and support any of our
volunteers who want to join our team as employees.
When we have our teams in place, we must make sure we use them in the best
possible ways to provide high quality services for patients. This means making sure
we have excellent processes to allocate our staff to the work that needs to be
undertaken, and that staff are working appropriately and effectively.
That is why at WHHT we are committing to:
Exploring technological solutions (including robotics) across the recruitment and on-boarding functions including medical resourcing
Exploring the use of apps to make it easier and more cost effective for temporary and locum staff to work shifts in our hospitals where we need them
Rebranding our recruitment and on boarding materials and changing the focus from a reactive to a proactive approach to how we attract and recruit staff
Revisiting our search approaches for different staff groups (including overseas staff and hard to recruit to posts) and ensuring we appeal to a diverse market
Looking for ways of ensuring the student workforce chooses our hospitals as their employer of choice
Working with our local communities to offer valuable and fulfilling volunteering opportunities and supporting those volunteers looking for a career in the NHS
Ensuring an effective temporary staffing provision through collaborative procurement and management of the outsourced provider.
Some of the ways we will measure success include:
An increase in the ratio of appropriate candidates to posts particularly for hard to fill roles
Reduced time to hire by 10%
Candidates reporting increasingly improved satisfaction with recruitment and onboarding functions as measured by the onboarding survey. At least 90% of candidates will rate their recruitment experience positively.
Clearer published career pathways in place for every staff group
Increasing conversion of students to employees by 20%
Doubling the number of volunteer hours donated for the benefit of patients by 2025
Increased temporary staffing fill in areas where this is needed so that on average our unfilled shifts are no higher than 10% and agency staffing spend consistently under target.
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Case Study 2: Recruitment of Band 5 nurses
In 2016 the Trust had a worrying high level of Band 5 Nurse vacancies – approximately 30% of these posts were vacant and therefore we were running with staff shortages and lots of agency staff. We therefore embarked on a real recruitment drive both locally and overseas, mainly to India and the Philippines. We have welcomed so many new nurses to the Trust over the past three years and amazingly in August 2019 we hit a 0% vacancy rate for Band 5 nurses on our adult ward nurses. The nurses who have joined us have fed back that their recruitment experience has been really positive. They have been well supported to complete their English language test and their Objective Structured Clinical Examination (OSCE) which they require to obtain their NMC pin. Perhaps more importantly however they have been able to join in small groups and so have built lasting friendships with other nurses joining the Trust who share similar backgrounds. Our overseas nurses have quickly settled in to become highly valued colleagues that help make teamwestHerts the thriving diverse community we are so proud of! On average an amazing 96% of our Indian and Pilipino nurses are still with us after three years.
A great first few months and beyond Attracting great and talented staff to join our organisation and work in our Integrated Care System is a great start but we also need to make sure that we keep these staff and so retention is vital. We will make sure that people who join us are fully supported during the first few weeks and months by, for example, expanding the remit of on-boarding support, ensuring people have a positive, robust and meaningful induction with continuing development opportunities, enhancing the skills of our managers and expanding coaching opportunities. We will create a sense of belonging by engaging effectively with new staff and seeking to meet their expectations in respect of the Trust being a great place to work and learn. The Trust already offers staff a comprehensive corporate and local induction so new starters are brought up to speed from the outset with what they need to know to settle quickly into their new roles and teams but we want to make this even better. New starters will be supported through their initial few months with regular input from their line managers to ensure they understand and can meet their objectives and perform well in their roles. Having an effective appraisal helps to motivate and engage staff and we have made great strides in improving appraisal. We want to continue to improve this and make sure all staff receive an annual appraisal with a clear focus on their performance in respect of their objectives and behaviours, their wellbeing and on the support that they may benefit from to enhance performance further and help them in their career aspirations.
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New employees will benefit from excellent preceptorship and build long and effective relationships with their preceptor or mentor to ensure they can develop the skills and approaches required to perform well in their new roles. There are new career development pathways which take our clinical staff from registration to senior positions. That is why at WHHT we are committing to:
Measuring the employee’s onboarding experience through the on-boarding survey and taking steps to improve this based on feedback
Providing a positive, robust and meaningful induction with on-going continuing development opportunities
Providing excellent preceptorship to new clinical and non-clinical staff and on-going professional development and clinical supervision for clinical staff
All staff having a comprehensive annual appraisal with a focus on wellbeing, behaviours, objectives and their career aspirations so these can be planned for and met wherever possible.
Some of the ways we will measure success include:
Improved retention rates for new starters. On average our turnover rates for new starters leaving within a year has been circa 22%, our goal is to bring this down to 17%
Consistently excellent feedback from new starters about their onboarding experience as measured by the onboarding survey
Consistently achieving the 90% target for appraisals. The effectiveness of appraisals will be measured by the following staff survey question: Did your appraisal help you improve the way in which you did your job? We want to achieve a 90% positive response to this question
Positive evaluation of satisfaction with preceptor programmes. A flexible and inclusive workforce To recruit and retain the very best staff we need to create a flexible and inclusive workforce where all staff feel valued and able to contribute and give their best at work no matter what their role or their background. The Trust will be ensuring that it uses best practice approaches to create a truly inclusive culture and actively value the diversity of all staff, all the time. We will carefully monitor any differences in staff experience based on employees’ race, gender, sexual orientation and disability and seek to ensure all staff can benefit from working in a culture whereby diversity is celebrated and innovation through difference is maximized. The Trust will also create tailored and targeted interventions through clear action plans based on data, metrics and indicators from the Workforce Race Equality Standards as well as the Workforce Disability Equality Standards. This will include maximizing the employee support groups and networks particularly for staff and volunteers with a protected characteristic under the Equality Act (2010). It is recognized that our staff can bring their best selves to work when they are also being supported in their home lives and wherever possible the Trust will support
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employees in meeting their other responsibilities, for example as carers of young children or elderly parents. In becoming a more flexible employer the Trust is genuinely committed to exploring opportunities for agile working, aided by technological advancements. We have already been able to make some progress with this for some of our corporate teams but want to give all staff greater control and input about when and how they work through, for example, effective rostering. We are also working with our Bank provider to build work pattern opportunities that better match the preferences of our Bank staff with a view to increasing satisfaction with work/life balance for the temporary and permanent workforce. We also aspire to being more inclusive – bringing the equality, diversity and inclusion agenda to every part of the organisation and to everything we do. This includes ensuring that we support all people with a protected characteristic under the 2010 Equality Act, including people with a disability or long-term health condition by embedding the use of Equality Impact Assessments and each Director being accountable for a diversity and inclusion-related objective. We are committed to progressing to Disability Confident Leader status. That is why at WHHT we are committing to:
Ensuring employees contribute to rostering where possible to ensure their home life needs are also met
Building an inclusive culture that values the diversity of all staff at all times and facilitating opportunities for staff and volunteers with particular protected characteristics to meet together for mutual support and development
Supporting our staff who have caring responsibilities and personalising our approach to how we manage and care for our team.
Some of the ways we will measure success include:
Improved staff survey results relating to equality, diversity and inclusion so that we are at least above average for our benchmark group in all questions.
WRES and WDES indicator improvements year on year
We will have reduced our gender pay gap from 33% to 28%
Better representation of a diverse workforce at all levels of the organisation, including in the most senior roles
Staff reporting effective rostering including medical staff
Greater take up of agile working and use of technology to support staff to work remotely where possible.
5.2 Supporting and engaging our team
The second phase of this strategy encompasses three inter-related areas:
Looking after your health and wellbeing
Recognising your efforts
Listening to you
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Looking after your health and wellbeing We recognize the importance of having a happy and healthy workforce who feel a part of a team and who look forward to coming to work. We want to look after the physical, mental, spiritual and emotional health of our staff. Intrinsically we know this the right thing to do and there is a growing body of evidence that happy, healthy staff correlates to better clinical outcomes. As part of this area we are implementing the NHS Workforce Health and Wellbeing Framework, which looks at all aspects of staff health and wellbeing as well as continuing to promote our award-winning Schwartz rounds, Freedom to Speak Up and Safe Space initiatives and our pastoral and spiritual care services. We will continue to offer structured and formal debrief sessions when required as well as localized counselling services. A particular priority over the course of this strategy is to strengthen our support for the mental health and wellbeing of staff and to build upon the many initiatives and resources already introduced. The Trust will also be introducing the Thrive at Work initiative - a standard of good practice and a quality mark for health and wellbeing at work. We are working in partnership with colleagues from the Royal Free to develop an Occupational Health offer across both organisations that will bring benefits in terms of efficiencies and impact. Together we will introduce a range of practical resources and gain support from the wider community. Looking after thehealth and wellbeing of staff is something we will do throughout their time with us, from when they first start with us, if something happens whilst they work here that means they require additional support and workplace adjustment, if they take a break and return to work, and when they are thinking of perhaps retiring from work. We also understand that it can be difficult and stressful for staff to find local and affordable accommodation. This can be especially challenging for staff joining us from overseas. We will therefore look at our accommodation offering with a view to expanding this and thereby supporting our staff. That is why at WHHT we are committing to:
Ensuring our health and wellbeing services are known about and support is accessible for all staff
Maximising opportunities for peer support and clinical supervision
Developing a support package for staff who are off sick with stress and muscular skeletal ailments from the first day of absence
Provision of a range of new affordable and accessible staff accommodation options
Tackling violence and bullying so that all staff can come to work knowing that all actions have been taken to mitigate risks for a safe working environment
Having a toolkit of interventions to provide excellent support for the mental health and wellbeing of staff and ensuring managers are competent in its use.
Some of the ways we will measure success include:
An improvement in our health and wellbeing staff survey questions so that we are at least average for our sector in all questions.
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Achievement of the standards within the Health and Wellbeing Framework developed by NHS Employers, NHS England and NHS Improvement
Long, and short-term sickness rates that are consistently below 3.5%
Gaining Disability Confident Leader status.
Case study 3: Improvements in engagement - The Big 5
In 2017 West Hertfordshire Hospitals NHS Trust was in the bottom quarter for results
for the NHS Staff Survey with a response rate of 41 per cent. Staff did not believe
that the Trust was listening to their feedback. In light of this, the trust set about
addressing the lack of engagement by developing a campaign called the Big 5. The
Big 5 focussed on five key themes from staff survey results with each theme being
promoted for a whole month and a series of activities under each theme. The Big 5
was branded, widely promoted across the Trust and visibly linked to the staff survey
to ensure staff recognised they were being listened to.
The various initiatives have improved morale and culture at the Trust as well as
enabling us to recognise and value our staff and teams. The Big 5 is now in its
second year and has helped move the trust from the bottom third to the top 20 per
cent of organisations in NHS Staff Survey ratings.
Recognising your efforts One of the key factors affecting whether we feel engaged at work is the degree to which we feel valued and recognised by the organisation we work for and the people we work with. Recognising staff for their work can take many forms from a personal thank you from more senior staff, to an item in the staff newsletter, right through to a formal awards ceremony. We are always looking for new ways to make sure that we are making and taking time to recognise the enormous efforts that people make to do demanding jobs and ‘go the extra mile’. We look at what the best organisations do including those that are successful in winning some of the prestigious national awards to see what good practice we can bring to our organisation and teams. When we do something outstanding, we will also enter national awards as a way of sharing our good work with others, and more importantly, as a way of celebrating success with our teams - letting them know how proud we are of them. We also want to make sure that we remunerate our staff fairly for the work they do
and that we enhance the potential for staff to take advantage of opportunities to
maximise their own income and make their money go further. As a Trust we work to
Agenda for Change terms and conditions and already have a number of salary
sacrifice schemes but will be looking to extend our staff benefits by introducing a
WHHT staff discount scheme to complement the NHS staff discount scheme so that
we are amongst the best Trusts in the country in terms of staff benefit packages.
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That is why at WHHT we are committing to: • Supporting the health and wellbeing of our staff, giving real recognition to
our people for great work • Developing a fully branded, cohesive staff benefit/reward/discount
package that incorporates all the Trust’s reward initiatives • Exploring increased discounts on staff food over and above what we
already have • Looking at other useful facilities we can bring to our hospitals such as
hairdressing, opticians etc. • Celebrating and sharing staff awards and achievements via a dedicated
page on the internet and intranet and through e update • Continuing with the Big 5 and expanding staff recognition activities • Building our webpages / microsite and facilitating a one-stop
teamwestHerts portal
Some of the ways we will measure success include:
Year-on-year improvement in questions relating to staff feeling valued in our Staff Survey results. Our goal is to achieve the following positive response rates for these questions:
o 75% of our colleagues say that they look forward to going to work o 85% of our colleagues say that their manager values their work.
Increase in nominations for staff awards
Uptake of staff signing up to salary sacrifice and staff discount schemes. Listening to you We want our staff, without exception, to have strong voices and for them to tell us what we get right and what we need to do to improve when things go wrong. We already engage in the national staff survey and the staff Friends and Family Test which are formal ways of gathering in staff feedback. We will continue to develop forums for all groups of staff to have strong voices, to provide feedback and ensure that we respond to this feedback. Two ideas we are looking at, for example, include implementing an “only a coffee away” initiative and a big conversation tent because we want all teams to genuinely feel empowered to change things that need changing. We will build on the Big 5, our response to the staff survey. The Big 5 takes the five
‘big ticket’ areas of feedback each year and looks at ways of making things better or
introducing new and innovative initiatives to the Trust. We aim to develop this
successful initiative and incorporate clinical engagement plans to ensure we are
responsive to staff feedback.
We will continue to build upon the work to strengthen our partnership working with our staff side colleagues. We will ensure they are represented at key meetings / panels where staff experience is on the agenda. We will be maximizing the use of IT such as the staff engagement app to ensure
there are proactive ways of enabling staff to feedback to the organisation about how
we are doing.
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Our recognition initiatives are about rewarding individuals and teams who are doing
outstanding things but we also recognise that not everyone works in high functioning
teams or has brilliant experiences of the workplace. When things go wrong, we want
to make sure that we address concerns quickly and consistently. We will continue to
strengthen and promote our Freedom to Speak Up opportunities and address reports
of bullying and/or harassment. We will move to a resolution approach with an
absolute focus on mediation to achieve better communications and team work and
address concerns. We will also react quickly when teams are experiencing difficulties
with relationships and will provide structured support from our HR and Organisational
Development professionals.
That is why at WHHT we are committing to:
Continuing with the Big 5 which focuses on areas that staff tell us are of most concern
Developing new forums for staff feedback and conversation and strengthen existing staff networks, recognising the contributions that staff make to these networks
Introducing an improved staff engagement app and maximising use of other technology to enhance engagement
Developing a resolution approach to achieve better communication, team work and address concerns.
Refreshing our comprehensive clinical engagement plan. Some of the ways we will measure success include:
Incremental increase in overall staff engagement score in the annual Staff Survey and questions relating to motivation, involvement and advocacy.
Incremental reduction in the numbers of staff reporting abuse, bullying and/or harassment via the Staff Survey
Incremental increase in numbers engaging in quarterly staff Friends and Family test.
Staff networks optimised and impacting the Trust; ensuring inclusion is wired into all decision making measured through numbers participating and evidence of impact.
5.3 Developing our team The third phase of our strategy encompasses three inter-related areas:
Developing your career
Everyone as a leader
A great place to learn Developing your career From the moment people join the Trust we want them to be supported and enthused to develop their full potential. This includes students who are on placements with us as we want them to choose us as their employer of choice when they qualify. Supporting and enthusing development is achieved through the Trust actively offering our staff learning opportunities, and through our managers and leaders having a great understanding of how they can best support their staff at all levels to
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develop and help staff achieve fulfilling careers. Staff will be supported both in their learning and in making evidence-based decisions in their role by a professionally staffed library and knowledge service and the Research Office We know that people will have diverse aspirations and at times staff will be striving to achieve promotional opportunities and at other times they may be looking to simply gain more expertise within their existing role or looking to diversify in terms of their skills and experience. Through regular discussion, we need to understand the development aspirations of our staff and seek to match these wherever possible. In this respect we will continue to provide the “Careers Matters” service, expanding it to be a one stop shop for expert careers advice and, where appropriate, coaching. It will be a hub where people can seek advice and guidance on developing their career in any direction and they will be offered:
Coaching to help them decide for themselves their direction.
Expert advice so that they will know the steps required.
Networking with those already in the desired roles so that they may get a deeper understanding of what the roles involve.
Mentoring to help them achieve their desired outcome. For those starting out in their careers, those looking for career change, and those looking to enhance their careers along specific clinical and professional pathways, the Trust is committed to continuing to use its Apprenticeship Levy to provide as many Traineeship and Apprenticeship opportunities as possible whether this involves training brand new staff as healthcare support workers or administrative staff, developing our people to become nursing associates (or therapies assistants, clinic coordinators, trainee healthcare scientists etc.) or then converting those assistants and associates into fully qualified nurses, allied health professionals, managers, accountants or scientists. Now that graduate professional apprenticeships are becoming available, we will actively look to start using these, in particular the direct nursing apprenticeship. The Trust will also continue to provide and expand its well-received nurse development programmes ranging from the preceptorship programme through to the implementation of the clinical nurse specialist and matrons’ frameworks. These opportunities are now open to our allied health professional staff and biomedical scientists as well as nurses. For those aspiring to be future leaders whether clinically or managerially we will link them into expert advice and where appropriate support people to engage in regional and national development programmes. We will be developing our Talent Management Strategy over the next few months, working to firm up our framework of support and take an active role in the regional Talent Management Community of Practice to ensure we have access to resources and intelligence to inform this area of work. Ensuring diversity and inclusion is embedded into this will be crucial. That is why at WHHT we are committing to:
Maximising use of the Reducing Pre-registration Attrition and Improving Retention (REPAIR) initiative to help students make the transition to becoming qualified staff and promoting on-going clinical supervision
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Expanding the scope of the Careers Matters service to create a one-stop resource for all those who wish to develop, change or explore new careers
Expanding the scope of our apprenticeship offerings, in particular introducing direct graduate apprenticeships in nursing and other professions and reaching out to our local community
Further enhancing and expanding the excellent development programmes for nurses and other clinical staff to incorporate action learning, coaching and clinical supervision
Recognising and managing our talent pool, and developing our Talent Management Strategy
Some of the ways we will measure success include:
The number of staff accessing careers matters and the number of those who report they found it helpful with their career development
In the staff survey the percentage of our staff believing their manager supports them to receive training, learning or development should be at least 95%
In the staff survey less than 15% of our staff should say they will be looking for a job in a new organisation within 12 months
An increase in our apprenticeship metrics and levy spend and the number of new professionals either directly or incrementally created through these programmes
The numbers attending and numbers benefitting from the development programmes for nurses and other clinical staff
Having a board-approved Talent Management Strategy which is fully implemented.
Everyone as a leader, supported by the very best managers The Trust recognises that every one of its people has the potential and ability to act as a leader within the organisation. Through effective leadership we can drive the Trust forward to become the best that it can be for its patients and service users. All staff should feel confident to express their ideas and suggest and implement innovations to help us to continually improve the services we provide. We also aim to ensure that research activity is integrated into clinical care. We will therefore offer a suite of leadership and management programmes to develop our staff at all levels, building on the success of the Trust’s own long-established Leadership Academy which has been running for the past 12 years. The Trust has already introduced an International Coach Federation accredited coaching skills course relevant for all staff. This is in addition to the new coaching courses for all levels of managers. The new “Evolve” First Line Leadership and Management programme started in 2019 and in 2020 it will be joined by “Rise,” a refreshed programme to develop first line managers into senior managers.
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Case study 4: MSc in Healthcare Leadership & Management
The WHHT Trust Leadership Academy started to deliver credit bearing short courses from 2008. There are six short courses delivered by the Trust and accredited by the University of Hertfordshire. The beauty of the courses is that they are delivered locally by our own teaching staff and the content is totally grounded in the work of the Trust. The assessment for each short course focuses on the student’s own area of work and enables the students to engage in quality and service improvement. Students who wish to do so can bolt these courses together to form an MSc in Healthcare Leadership & Management. Many students take up to five years to complete the whole programme which is a big challenge for people who are working in demanding jobs. To date we have had 32 members of teamwestHerts who have been awarded the MSc and we have a further 36 people who (all being well) will get their awards in 2020.
The Trust is a clinically led organisation so our Clinical and Divisional Directors need to be accomplished leaders and require highly targeted leadership and management support. The “Transform” programme for clinical leaders, established in October 2019, will provide them with all the skills, knowledge and support they need to be great clinical leaders. The Trust puts clinical leadership at the forefront and is part of an excellent community of practice in the East of England and a core member of the Hertfordshire and West Essex STP team focused on the leadership agenda through its Health and Care Academy. The Trust therefore will both drive and benefit from excellent leadership, in both its practice and specific programmes, across the STP. We will
support, develop and empower our clinicians, freeing up time for them to lead, not just internally to the Trust but in helping to shape and deliver new integrated care models in partnership with colleagues across the health and care system.
As a system the aspiration is for member organisations to take lead responsibility on appropriate interventions which will foster a greater level of collaborative working and maximise the use of resources, whilst preventing duplication of effort. As part of the Health and Care Academy website a ‘virtual hub’ will be created for leadership and development opportunities across health and social care, enabling easier sharing of best practice and access to the development programmes available in member organisations as well those organised at STP level.
Our reverse mentoring programme will also help create distributed leadership – the concept of everyone as a leader - by turning traditional mentorship on its head as senior leaders/board members become the mentees and colleagues from our staff become the mentors. There will be a focus upon colleagues with protected characteristics to become mentees. That is why at WHHT we are committing to:
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Putting clinical leadership at the forefront and supporting clinicians to maximise leadership opportunities
Developing the “Rise” Leadership and Management Programme for senior managers
Delivering a complete cycle of the first “Evolve” (First Line), “Rise” (Senior) and “Transform” (Clinical) Leadership and Management Programmes, evaluating them, and then delivering a new cycle every year thereafter
Providing coaching support to all leaders and managers in the Trust who would benefit from it
Providing coaching skills to all leaders and managers in the Trust so as to improve both their emotional intelligence and leadership and management skills
Continuing to support the STP level iteration of the Mary Seacole Programme
Actively contributing to the development of the leadership agenda and the development of leadership programmes at STP level, sharing our knowledge accordingly
Rolling out reverse mentoring Some of the ways we will measure success include:
Numbers attending leadership and management programmes and the quality of the evaluations
Incremental increase in staff survey questions relating to leadership and management development
STP level programmes accessed by our staff and staff from across the STP accessing our programmes
Numbers accessing coaching and subsequent improvements in morale in those areas
Positive evaluation of the reverse mentoring scheme by mentors and mentees A great place to learn To make the Trust a great place to learn we need a conducive learning environment, whether staff are learning with state of art equipment in the new simulation centre or simply using a seminar room for a follow up coaching session. We also need to support all learning, whether that is through our programmes, clinical research or simply the individual search for knowledge. We need to support the implementation of our Research Strategy 2020. Through our educational support services of the libraries, simulation, learning management systems and the investment the Trust provides for individual and departmental Continuing Professional Development (CPD), we will support all learning, truly making this Trust a great place to learn. With Acorn we have a learning management system that ensures that all mandatory training is properly counted and reported, reminding staff when their compliance is due. Our Simulation Centre has state of the art equipment and a dedicated team that generates valuable income. Going forward we are looking to achieve Teaching Hospital status by 2021 to give the Trust the recognition it deserves for great learning. We will be using Acorn to
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support developmental training in addition to mandatory training, starting with the leadership programmes to provide high class e-learning, both to back up our classroom offerings, and act as a standalone resource. That is why at WHHT we are committing to:
Deliver excellence in training, education and development for our staff and learners achieving Teaching Hospital Status for the Trust by 2021
Broadening out the e-learning offering to cover all non-mandatory training, starting with support for the leadership programmes and standalone resources in these areas increasing the activity and revenue of the Simulation Centre.
Auditing the décor and equipment of our classrooms and learning centers, making improvements where necessary and affordable
Upgrading the MEC Lecture theatres
Increasing research activity and supporting the implementation of our Research Strategy 2020.
Some of the ways we will measure success include:
Teaching hospital status being obtained by 2021
Classrooms and lecture theatres judged by user satisfaction surveys as being positive learning environments
Numbers of new e-learning programmes becoming available, and the metrics of those accessing them
Simulation Centre revenue and activity increasing incrementally.
5.4 Moving Forwards
The fourth phase of our strategy encompasses three inter-related areas:
Innovation & Technology
Working differently
Supporting change
Innovation & Technology Whilst we recognise that our IT infrastructure is currently in a poor condition it is an exciting time for us, with the promise of better hospitals and major investment in our buildings and IT. This is so important because we want to be able to introduce innovation which is not only about creating new things but is also about structured adoption of best practice. Best practice learning might come from government or other publications such as the Topol Review, from networking with colleagues from the Royal Free or across the STP or from systems and processes that people have observed from outside the sector. There is a clear need to ensure that staff are enabled to use new technology so they can make full use of what is available including decision support, artificial intelligence, robotics and genomics and adopt digital solutions. We recognize therefore that whilst many of the issues around access to IT infrastructure sit within the accountability of other parts of the
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organisation, it is fundamentally our role to make certain our people have the competences to maximize its power. That there is a link between innovation and technology is without question. Over the course of our People Strategy we expect to see massive strides made in digitalisation, technology to allow us to go ‘paperless’ and become more mobile, a plethora of ‘Apps’, robotic solutions, patient safety devices and probably things we have not even imagined. As a Trust we are embarking on a massive ‘catch up’ programme to address the poor state of our Information Technology and as this happens we need to be ready to adopt digital solutions such as the use of robotics in recruitment, agile and mobile working within a secure framework, better electronic learning to include the regular use of skype, webinars and other technologies across all our hospital sites. We also plan to continue our journey to make sure that our staff have crucial information at their fingertips. The full roll out of the electronic staff record (ESR) so that our staff can have better information on a self-serve basis to information about pay and pensions is a priority and will also give staff access to information about total rewards and benefits. As a workforce it is vital that staff, wherever they are based, are up-to-date in their practices and can access the best and newest evidence. This means having good access to information and our library and information services play a significant part in this process as mentioned above. We must ensure that we are using technology to deliver training and education where possible. We want, over the duration of this strategy, to support the objectives set out in the Research and Development Strategy as research and development are so fundamentally important to enabling our teams to provide the best care, for every patient, every day. Finally, we need to make sure that as a function responsible for looking after teamwestHerts we are exemplars of good practice in terms of our own parts of the website. We want people to be able to relate to our clear workforce brand and be able to promote our services with the minimum effort of the part of users. We need informatics leadership across the organisation. That is why at WHHT we are committing to:
Supporting all staff to be competent to fully embrace the power of technology appropriate to their roles and to adopt new technologies in their practice
Expanding our research and development activity so that more staff have the opportunity to be involved in research and more patients can benefit
Rolling out ESR self-service and supporting all staff to use it
Streamlining and modernising our library and information services and maximising elearning
Revising our parts of the website
Supporting a move towards agile and digitally enabled working as soon as the IT systems allow
Some of the ways we will measure success include:
Staff trained and competent to use and adopt digital solutions/technology
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Complete coverage of ESR, including increased data on the demographic and diversity of our people
Staff use and satisfaction with library and information services
Hits and positive feedback on our webpages
Agile working fully implemented. Working differently Over the past few years in the NHS we have seen the introduction of many new roles and advancement of existing roles. The Five Year Forward View introduced new ways of working and the NHS Long Term Plan and Interim People Plan have built upon these and added to them. New roles and new ways of working do bring challenges as well as multiple benefits. Making sure we have the right staff, with the right skills, working safely and effectively in the right services is no simple task and as an employer we must ensure that the governance structures we have in place enable staff to work differently. Developing the support workforce (clinical and non-clinical) including assistant practitioner roles, social prescribing roles, and the use of volunteers is highlighted in the NHS Long Term Plan. We expect to see an expansion of the Nursing Associate which we have been involved with from the outset and Physicians Associate roles. We need to make sure we are making best use of the Apprenticeship Levy in developing our staff at all levels but particularly for these staff. Advanced roles such as expanding advanced practitioners in A&E and theatres will be crucial to enable us to maintain services and we need to ensure robust medical and non-medical credentialing is in place to support the governance framework around these extended roles. We need to make sure we apply these principles to our valued clinical nurse specialist roles as well and enable them to work in an increasingly autonomous way, with access to excellent evidence and support. We also recognise the aspiration of the STP to move to a more integrated workforce and as we move to more Integrated Care Provider contracts and to an Integrated Care System we will be working together to look at how this can become a reality. The vision is to have ‘One workforce across Hertfordshire and West Essex; delivering high quality, seamless, and person centred care’. The STP workforce strategy is built upon five key themes:
1. Attraction, recruitment and retention
2. Education and development
3. Innovation and technology
4. Leadership and organisational development
5. Enabling a one workforce approach
Finally, we need to make sure we use benchmarking data being produced as part of the national Model Hospital work to reduce unwarranted variation in our workforce and to learn from and adopt, where relevant, best practice from those that are achieving the best results.
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Fundamental to delivering change is the role of the Organisational Development teams who can support our people to think differently and work in different ways. This may challenge some in a variety of ways and we need to ensure that people can be equipped to manage and cope with change. That is why at WHHT we are committing to:
Designing new roles that support care delivery, fill workforce gaps and provide development and career opportunities for our staff, including making best use of the apprenticeship levy
Adopting new roles and new ways of working in a proactive way with appropriate development and appropriate governance structures in place
Embracing the concept of credentialing as set out in the NHS Long Term Plan
Working with STP partners to deliver the STPs workforce strategy
Strengthening our Organisational Development (OD) offer to support key organizational and system priorities.
Some of the ways we will measure success include:
Number of staff working in new (defined) roles including the number of nursing associates, physician’s associates, advanced practitioners and the impact on overall performance
Spending of the Apprenticeship Levy
Numbers of staff actively engaged in OD work
Level of joint working with the STP measured through numbers of shared initiatives, numbers participating.
Supporting change There has never been a more exciting time to work at WHHT with a massive
redevelopment programme on the horizon, digital transformation opportunities,
integrated care which will change the shape of services and shared decision-making.
We are closer than ever before to being able to significantly invest in our three
hospital sites. The development of the sites will bring great opportunities to work
differently and we recognize that the shape of our teams might need to change.
When this becomes evident, we will be working with staff and service users who
have the requisite knowledge and experience to harness their ideas about how best
to do things differently. Co-production and co-design are genuine aspirations and we
must make sure our leaders, our staff and our patients are enabled to understand
what this means and how to do it well.
We will also be looking to adopt Agile Working and there may be opportunities to
streamline or outsource some services across the STP or wider system. Advances in
medicine may also mean that some services can safely be managed out of hospital
and we expect to see more and more use of remote telemedicine.
As we plan for our site development and new ways of working, we will require
support with good people management practices and we expect that our HR
Business Partner (HRBP) roles will be significant in ensuring any required changes
are handled sensitively and effectively and with the full consultation of our teams. As
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new teams emerge, they may also need support from our HR and Organisational
Development (OD) practitioners, and others to work in new environments, with new
technology and in new teams.
The Herts & West Essex Health and Workforce Strategy sets out the clear aspiration
for one workforce and we need to be prepared and ready for this. We will also work
collaboratively with our colleagues at the Royal Free who have recent experience of
moving from old buildings to new premises on a large scale.
That is why at WHHT we are committing to:
Further developing our existing HRBPs
Refining our OD capability and capacity to support organizational and system priorities
Ensuring that the needs of our staff (as well as our patients) are considered in the new hospital development
Some of the ways we will measure success include:
Smooth transitions when services change measured through levels of challenge
A stable and skilled HRBP and OD resource able to meet the demands of the organization
Evaluation of success for key OD programmes e.g. Electronic Health Record (EHR) implementation
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Section 6: Governance, monitoring and evaluation
Having an approved People Strategy is clearly an important first step in our
continued improvement journey but if the strategy is not implemented, and the
actions we propose are not put into practice then our progress towards excellence
will falter.
Governance The team responsible for developing the strategy wants to be held to account for its delivery. The group that will oversee the implementation of the strategy is the newly established ‘Great Place to Work Implementation Group’. This groups reports to the Trust Management Committee and feeds into the ‘People, Research and Education Committee’ which is a committee of the Trust Board. Monitoring Each of the four phases of the People Strategy has a lead with responsibility for ensuring that the activities within the phase are monitored and reported on. The lead role is one of co-ordination – leads are not necessarily responsible for the actions within the phase although in some cases roles will be coterminous. All four leads have a shared responsibility for ensuring the threads of the strategy are given due cognizance. Evaluation Dedicated agenda time at the monthly Senior People Leadership Management Group will be used to continuously update the detailed implementation plan. Each lead will be expected to provide a short, written highlight report for their phase and report any exceptions to progress, with an associated rectification plan. There will be four scheduled formal reviews – one at the end of the each of the first four years of the strategy. The strategy will then be renewed mid-way through the fifth year.
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Section 7: Introduction to the implementation plan
A full implementation plan will accompany this strategy which will contain all
commitments and related measures. We have included the basis of the plan in
Appendix I, which is derived from the measures of success set out in the previous
sections of our strategy.
In Appendix II we have included further detail of our staff survey metrics – this will be
one of the significant ways that we will measure the progress of our People Strategy.
We have included the 2018-2019 staff survey results for the Trust in questions
relevant to our People Strategy and our stretch targets where appropriate.
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References
Carter, Lord Carter of Coles 2016 Productivity in NHS Hospitals. DHSC. London.
Department of Health and Social Care 2019 Kark review of the fit and proper
persons requirement. DHSC. London.
Health Education England 2019 Preparing the healthcare workforce to deliver the
digital future – The Topol Review. Available from https://topol.hee.nhs.uk
Herts and West Essex STP 2019 Health and Social Care Workforce Strategy.
Unpublished.
NHS Employers 2018 NHS Health and Wellbeing Framework. Available from
www.nhs.employers.org
NHS England 2019 NHS Long Term Plan. Available from www.longtermplan.nhs.uk
NHS England 2019 Interim People Plan. Available from www.England..nhs.uk
NHS England 2015 Five-year forward view. Available from www.England.nhs.uk/wp-
content/uploads/2014/10/5yfv-web.pdf
West M. and Dawson J. F. 2012 Employee engagement and NHS performance The
Kings Fund. London.
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Appendix 1: Summary of what we will achieve
1. An increase in the ratio of appropriate candidates to posts particularly for hard to fill roles
2. Reduced time to hire by 10% 3. Candidates reporting increasingly improved satisfaction with recruitment and
onboarding functions as measured by the onboarding survey. At least 90% of candidates will rate their recruitment experience positively.
4. Clearer published career pathways in place for every staff group 5. Increasing conversion of students to employees by 20% 6. Doubling the number of volunteer hours donated for the benefit of patients by
2025 7. Increased temporary staffing fill in areas where this is needed so that on
average our unfilled shifts are no higher than 10% and agency staffing spend consistently under target
8. Improved retention rates for new starters. On average our turnover rates for new starters leaving within a year has been circa 22%, our goal is to bring this down to 17%
9. Consistently excellent feedback from new starters about their onboarding experience as measured by the onboarding survey
10. Consistently achieving the 90% target for appraisals. The effectiveness of appraisals will be measured by the following staff survey question: Did your appraisal help you improve the way in which you did your job? We want to achieve a 90% positive response to this question
11. Positive evaluation of satisfaction with preceptor programmes. 12. Improved staff survey results relating to equality, diversity and inclusion so
that we are at least above average for our benchmark group in all questions. 13. WRES and WDES indicator improvements year on year 14. We will have reduced our gender pay gap from 33% to 28% 15. Better representation of a diverse workforce at all levels of the organisation,
including in the most senior roles 16. Staff reporting effective rostering including medical staff 17. Greater take up of agile working and use of technology to support staff to
work remotely where possible. 18. An improvement in our health and wellbeing staff survey questions so that we
are at least average for our sector in all questions. 19. Achievement of the standards within the Health and Wellbeing Framework
developed by NHS Employers, NHS England and NHS Improvement 20. Long, and short-term sickness rates that are consistently below 3.5% 21. Gaining Disability Confident Leader status 22. Year-on-year improvement in questions relating to staff feeling valued in our
Staff Survey results. Our goal is to achieve the following positive response rates for these questions:
a. 75% of our colleagues say that they look forward to going to work b. 85% of our colleagues say that their manager values their work.
23. Increase in nominations for staff awards 24. Uptake of staff signing up to salary sacrifice and staff discount schemes.
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25. Incremental increase in overall staff engagement score in the annual Staff Survey and questions relating to motivation, involvement and advocacy.
26. Incremental reduction in the numbers of staff reporting abuse, bullying and/or harassment via the Staff Survey
27. Incremental increase in numbers engaging in quarterly staff Friends and Family test.
28. Staff networks optimised and impacting the Trust; ensuring inclusion is wired into all decision making measured through numbers participating and evidence of impact.
29. The number of staff accessing careers matters and the number of those who report they found it helpful with their career development
30. In the staff survey the percentage of our staff believing their manager supports them to receive training, learning or development should be at least 95%
31. In the staff survey less than 15% of our staff should say they will be looking for a job in a new organisation within 12 months
32. An increase in our apprenticeship metrics and levy spend and the number of new professionals either directly or incrementally created through these programmes
33. The numbers attending and numbers benefitting from the development programmes for nurses and other clinical staff
34. Having a board-approved Talent Management Strategy which is fully implemented.
35. Numbers attending leadership and management programmes and the quality of the evaluations
36. Incremental increase in staff survey questions relating to leadership and management development
37. STP level programmes accessed by our staff and staff from across the STP accessing our programmes
38. Numbers accessing coaching and subsequent improvements in morale in those areas
39. Positive evaluation of the reverse mentoring scheme by mentors and mentees 40. Teaching hospital status being obtained by 2021 41. Classrooms and lecture theatres judged by user satisfaction surveys as being
positive learning environments 42. Numbers of new e-learning programmes becoming available, and the metrics
of those accessing them 43. Simulation Centre revenue and activity increasing incrementally. 44. Staff trained and competent to use and adopt digital solutions/technology 45. Complete coverage of ESR, including increased data on the demographic and
diversity of our people 46. Staff use and satisfaction with library and information services 47. Hits and positive feedback on our webpages 48. Agile working fully implemented. 49. Number of staff working in new (defined) roles including the number of
nursing associates, physician’s associates, advanced practitioners and the impact on overall performance
50. Spending of the Apprenticeship Levy 51. Numbers of staff actively engaged in OD work
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52. Level of joint working with the STP measured through numbers of shared initiatives, numbers participating.
53. Smooth transitions when services change measured through levels of challenge
54. A stable and skilled HRBP and OD resource able to meet the demands of the organization
55. Evaluation of success for key OD programmes e.g. Electronic Health Record (EHR) implementation.
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Appendix II: Key staff survey metrics and how they will change
over the course of the strategy
The table below details the key staff survey related metrics set out in this document
and their current position in terms of how many of our staff either agree or strongly
agree with the statement, how this benchmarks against other NHS providers and our
target goal for this metric. There are ten grouped themes within the staff survey. A
significant number are relevant but we have tried to pick out those that relate most
specifically to our People Strategy.
Question Current Performance
Benchmark Performance
Target goal
I look forward to going to work
65% 58% 75%
I am enthusiastic about my job.
78% 74% 80%
I would recommend my organisation as a place to work.
59% 60% 65%
If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation.
59% 68% 70%
The organisation acts fairly with regard to career progression/promotion regardless of ethnic background, gender, religion, sexual orientation, disability of age
82% 84% 85%
I have experienced musculoskeletal problems as a result of work activities
31% 29% 27%
I have felt unwell as a result of work-related stress
36% 39% 34%
I have come to work despite not feeling well enough to perform duties
52% 57% 50%
I have experienced discrimination at work from patient/service users, their relatives or other members of the public
9% 6% 5%
I have experienced discrimination at work from a manager/team leader or other colleagues
9% 8% 5%
I have experienced bullying and harassment from patients/public
28% 29% 20%
Experienced harassment, bullying or abuse at work from managers in the last 12 months.
12% 14% 10%
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I have experienced bullying and harassment from colleagues
20% 20% 13%
Has your employer made adequate adjustment(s) to enable you to carry out your work?
74% 73% 85%
How satisfied are you with the opportunities for flexible working
54% 51% 60%
Does the organisation take positive action on health and well being
91% 89% 92%
My immediate manager values my work
76% 71% 85%
I am satisfied with the support I get from my immediate manager
73% 68% 75%
My immediate manager gives me clear feedback on my work
67% 59% 70%
My manager asks for my opinion before making changes which affect my work
60% 53% 70%
My immediate manager takes a positive interest in my health and well-being
71% 67% 75%
I am able to make suggestions to improve my working environment
75% 73% 85%
My manager supports me to receive training, learning or development
93% 92% 95%
I am involved in deciding on changes introduced that affect my work area/team/department
54% 51% 55%
I receive the respect I deserve from my colleagues at work
75% 71% 80%
I have unrealistic time pressures.
31% 33% 25%
Relationships at work are strained
16% 17% 10%
My immediate manager encourages me at work.
73% 67% 75%
I often think about leaving this organisation
27% 30% 20%
I will probably look for a job in a new organisation within the next 12 months
21% 21% 15%
As soon as I can find another job, I will 16% 15% 12%
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leave this organisation.
Did it (the appraisal, annual review, development review or KSF review) help you to improve how you do your job?
78% 70% 80%
Did it (the appraisal, annual review, development review or KSF review) help you agree clear objectives for your work?
89% 84% 90%
Did it (the appraisal, annual review, development review or KSF review) leave you feeling that your work is valued by your organisation?
81% 76% 90%
Were the values of your organisation discussed as part of the appraisal process?
85% 79% 90%
Experienced physical violence at work from patients / service users, their relatives or other members of the public in the last 12 months.
15% 15% 10%
Experienced physical violence at work from managers in the last 12 months.
1% 1% 0%
Experienced physical violence at work from other colleagues in the last 12 months.
2% 2% 0%
My organisation treats staff who are involved in an error, near miss or incident fairly.
61% 57% 65%
I would feel secure raising concerns about unsafe clinical practice.
69% 68% 80%
I am confident that my organisation would address my concern.
59% 54% 80%
There are enough staff at this organisation for me to do my job properly.
37% 29% 50%
[How satisfied are you with] The recognition I get for good work.
60% 55% 70%
[How satisfied are you with] The 81% 81% 85%
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support I get from my work colleagues.
[How satisfied are you with] The extent to which my organisation values my work.
52% 44% 60%
[How satisfied are you with] My level of pay.
31% 34% 35%
Senior managers here try to involve staff in important decisions.
39% 32% 45%
Senior managers act on staff feedback.
40% 30% 45%
Have you felt pressure from your manager to come to work?
26% 26% 20%
Have you felt pressure from colleagues to come to work?
21% 22% 20%
The last time you experienced harassment, bullying or abuse at work, did you or a colleague report it?
46% 46% 75%
In the last 12 months, have you had an appraisal, annual review, development review, or Knowledge and Skills Framework (KSF) development review?
87% 87% 90%
Were any training, learning or development needs identified?
72% 67% 90%
Have you had any training, learning or development in the last 12 months?
71% 70% 80%
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Trust Board Meeting
06 February 2020
Title of the paper Strategy Update
Agenda Item 14/79
Presenter
Helen Brown, Deputy Chief Executive
Author(s)
Helen Brown, Deputy Chief Executive
Purpose
Please tick the appropriate box
For approval
For discussion For information
Executive Summary
This paper provides an update to the Committee on the progress of the key strategic work programmes for 2019-2020.
Trust strategic aims (please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to
work Objectives 6-8
Aim 3 Improve our
finances
Objective 9
Aim 4 Strategy for the
future
Objective 10-12
Links to well-led key lines of enquiry
☐Is there the leadership capacity and capability to deliver high quality,
sustainable care?
☒Is there a clear vision and credible strategy to deliver high quality,
sustainable care to people, and robust plans to deliver?
☐Is there a culture of high quality, sustainable care?
☒Are there clear responsibilities, roles and systems of accountability to
support good governance and management?
☒Are there clear and effective processes for managing risks, issues and
performance?
☒Is appropriate and accurate information being effectively processed,
challenged and acted on?
☐Are the people who use services, the public, staff and external partners
engaged and involved to support high quality sustainable services?
☐Are there robust systems and processes for learning, continuous
improvement and innovation?
☒How well is the trust using its resources?
Previously considered by
Trust Management Committee – 29 January 2020
Action required
The Board is asked to receive the report as assurance on the progress of the key strategic work programme in delivery for year 2019-2020.
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Agenda Item: 14/79 Trust Board meeting – 06 February 2020 Strategy Update. Presented by: Helen Brown, Deputy Chief Executive
1. Purpose 1.1 This paper provides an update to the Committee on the progress of the key strategic work
programmes for 2019-2020.
1.2 In line with the new bi-monthly reporting schedule, the following work programmes are included this month and are reporting on the January (M10) position (with the exception of the Access programme which is reporting a December, M9 position): 1. Workforce 2. Getting to Good 3. Clinical 4. Integrated Care 5. Access 6. Research
1.3 The Committee is asked to note the attached paper and the position on the 13 projects
reported.
1.4 Table 1 (Year 1 – 2019-2020 Strategic Priorities) lists projects which are within a variety of project life cycle stages, ranging from ‘development of business case’ to ‘in delivery’ and for which project leads provide RAG rated updates.
1.5 RAG ratings are based on delivery against the Trust’s improvement plans and are reported and tracked through their associated committees.
1.6 Emergency Care Transformation remains Red rated, as performance continues to be adverse to plan. This month’s performance report highlights an unprecedented demand and activity in December 2019.
1.7 There were two movements on RAG rating in month; the first relates to the Urgent Treatment Centre on the Watford site, which has moved from an Amber rating to a Green rating to reflect the programme of work being back on track and the second relates to the RTT & Cancer Access Programme, which has moved from a Green rating to an Amber rating, due to both standards not currently being met, details of which are set out in the January TMC Access Performance update paper.
1.8 The project to transfer oesophago-gastric (OG) services to the new Specialist OG Cancer Unit at Hammersmith has now completed.
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1.9 Of the remaining schemes, five projects remain Amber rated and four projects remains Green rated.
2. The priorities are listed below and known RAGs are as follows.
Table 1: Year 1 – 2019-2020 Strategic Priorities.
3. Discussion.
Great People
3.1 Following further work to ensure strategic alignment to the new Five Year Strategy, the ‘PeopleStrategy’ is being presented to Trust Board in February 2020 for approval.
G A R C TBC
Green / on trackAmber / some
risks or delays.
Red / significant
risks or delays.
Complete /
closed.
New to list or
update yet to be
received
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Best Care - Getting to Good
3.2 CPG Programme. All pathways have been process mapped against existing pathways. Seven out of eight pathways have cohorts identified, annual activity reviewed and a measurement plan agreed. A Data Collection Officer came into post in January 2020 (3 days a week) to support the manual data collection process. The next step is to present the data analysis for all pathways at divisional level to understand any unwarranted variation and to begin redesigning pathways.
3.3 Quality Hub Development and QI Roll Out. A QI coaching course with representation from the Divisions commenced in November 2019 and is due to complete in April 2020. Funding has been secured to run a further two cohorts of QI coaching course in 2020/2021. A Quality Improvement Awareness Campaign (bitesize sessions) is underway with an emphasis on the QI PDSA methodology, to support the dosing strategy until the end of March 2020. A second QI Lead is now in post.
3.4 The ‘Getting it Right First Time’ (GIRFT) programme has recently been extended to now cover a series of forty surgical and medical workstreams.
3.5 Recent workstreams launched include the Lung Cancer workstream; the Trust is awaiting dates for the deep dive visit which is expected in be in Q1 2020/21. The Paediatric T&O workstream has also recently launched and a Trust data collection exercise is underway, with a visit expected to be scheduled from May onwards. An Adult Spinal Services review is also underway at the Trust. This review has been developed to support assurance on delivery of adult spine services in England and helps supplement the ongoing work being led by GIRFT on adult spine delivery and transformation. GIRFT visits continue to be well attended by the clinical leads and wider clinical team, with divisional support, alongside key members of the Executive team. Recent deep dive visits held at the Trust include Radiology (12th December) and Emergency Medicine (15th January). Follow up meetings will be scheduled to review the GIRFT recommendations from these visits and to agree implementation plans. Progress will be monitored both at divisional level and through the Trust's Quality Committee.
Best Care - Clinical Strategy/Service Redesign
3.6 The number of patients being identified for Enhanced Care at SACH is now increasing and uptake from General Surgery and Urology has been good. It is worth noting that the service was originally anticipated to be running 5 days per week; however this is not the case due to a lack of outreach nursing cover on Friday nights & weekends meaning that the service is only available 4 days per week. The division is considering whether it would be appropriate to amend activity targets to reflect this. 109 procedures took place during 2019 (February 2019 to December 2019) and work is ongoing to continue to improve performance with an action plan being developed to support this. Data for January 2020 is positive with 24 cases completed.
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3.7 Plans to launch a Vascular Network across Hertfordshire and West Essex continue to be progressed. East and North Herts NHS Trust (E&NH) have been chosen as the hub, with Princess Alexandra Hospital (PAH) and WHHT being specified as the spoke services.
The next steps for this project are to assess the impact of proposed changes on local
services. The draft pathways, appropriate for wider clinical sharing, have been drafted and
shared at CAG and at divisional management groups, with the key concerns being out of
hours cover, under the proposed staffing model, ways of mitigating these issues are being
developed with the hub.
Further impact on the financial and staffing impact of the network is dependent on
information being generated by the hub team, this has been delayed, though is now
expected by mid February 2020, with an impact assessment over the following months, to
integrate into the business case before it goes through Board approval processes in all
relevant NHS organisations.
The outline business case is being developed and is currently expected to come to WHHT
Trust Board in May, with a full business case proposed to be presented later in the year.
3.8 Medical Take Pilot. TMC have now approved an extension to the pilot until June 2020, which also extends the pilots to weekends. The project team are engaging with HR representatives to ensure oversight on job plans for the transition to BAU and progress any related management of change processes.
3.9 The process of completing the transfer of both WHHT surgeons & registrars and WHHT patients to the new Hammersmith Oesophago-gastric cancer unit has now been completed. The focus is now on backfilling WGH Theatres with benign activity and measuring the performance and associated financial benefit of the move of OG activity to Hammersmith. A benefits realisation paper will be presented to TMC in April 2020, six months post the new service go-live in September 2019.
Best Care - Integrated Care
3.10 There are no areas for escalation on the 2019-20 SDIP. Progress on pathways include:
Development of an Integrated Dermatology Pathway: The community pilot launched in February 2019. The first six months audit of the pilot has been developed and discussed with Herts Valleys CCG (HVCCG). HVCCG has asked WHHT to provide a pilot community service for St Albans and Hertsmere localities up until the end of July 2020. The proposed model was presented at TMC on 29th January and approval to proceed was given. Development of the Cardiology Pathway: The service specification for the Cardiology Referral Support Service (CRSS) along with associated activity and financial modelling has been agreed between WHHT & HVCCG. The proposal for the new service model was presented to TMC 29th January 2020 and approved. Next steps are the CRSS will be rolled out from April 2020.
3.11 The Urgent Treatment Centre at WGH has a confirmed go live date of 1st April 2020 (subject to a final ‘go / no-go readiness assurance process in March 2020) with Greenbrook Healthcare as the service provider. Good progess is being made with all aspects of the
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implementation plan and a positive relationship has been established between Greenbrook, the WHHT Emergency Care leadership team and the Programme team. Stakeholder engagement is underway and a successful open evening was held for all stakeholders on the Watford site.
4. Recommendation
4.1 The Board is asked to receive the report as assurance on the progress towards delivery status of strategic priorities.
Helen Brown Deputy Chief Executive January 2020
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Appendix A WHHT Strategy Delivery Master Programme 2019-2020
Vis
ion
AIM
S
Best Care Best Value Great People Great Place
Getting to Good CIP Workforce Digital Programme
Mike Van der Watt / Tracey Carter Rodney Pindai Paul Da Gama Paul Bannister / Sean Gilchrist
Clinical Pathway redesign / Royal Free
CPG programme ( 7 x clinical pathways)Private Patients programme
Develop the Trust’s refreshed People Strategy
(and supporting Implementation Plan)Electronic Patient Record (Outline Business Case)
Quality Hub development and QI roll out Health Records Standardisation (Business Case)
Practice Development to support R&R of
new workforce and skill mix Telephony Replacement (Business Case)
GIRFT (Getting it Right First Time) Transition to ATOs
New Local Area Network
Financial recovery plan Research StrategyStabilising the IT infrastructure (Migration & Service
Improvement)
Don Richards Mike Van der WattCancer Information System (CIS) - full implementation
and benefits realisation
Interim Estate
Esther Moors
Consolidation of Orthopaedic Outpatients at SACH
(Holywell)
Urology Centre (Business Case) - in scope
Develop Interventional Radiology service (OBC)
Medical Take Redesign (4 week pilot)Neonatal FBC - to improve the environment on
Woodlands Neonatal Unit
ED Development (Wave 4 capital - FBC) Capital from
NHSI
Watford Theatre Reconfiguration (FBC)
WGH Multi-Storey Car Park FBC & approvals
To improve Pathology service to the Trust and HVCCG
(STP Pathology outsourcing)
Back office relocation (to release space at WGH for
key estate and IT priorities)
Hemel Planned Care -in scope
2019-20 Winter Plans (to provide additional
assessment space for Winter)
Acute Redevelopment
Esther Moors
Refresh Strategic Outline Case (SOC) Yr 1
Strategic Programme 2019-20 v8.0 20191107
2019-2020 Integrated Care (incl SDIP & Urgent and Emergency Care Redesign)
Access
Sally Tucker / Jane Shentall
Emergency Care Transformation (ED Access)
Patient Flow Transformation (Inpatients)
RTT & Cancer Programme Yr 1 (Elective)
WHHT Strategy Delivery Master Programme 2019-2020
OUR VISION IS TO PROVIDE THE BEST CARE TO EVERY PATIENT EVERY DAY.
Str
ate
gic
Pri
ori
tie
s 1
9-2
0 Clinical Strategy/Service Redesign
Helen Brown
SACH Expansion of Enhanced Surgical Activity for Enhanced Care Patients
Vascular Hub
To merge WHHT Oesophago-gastric cancer unit with Imperial
Integrated Care
Fran Gertler / Helen Brown
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Trust Board Meeting 06 February 2020
Title of the paper
Corporate risk register report
Agenda Item
15/79
Presenter
Mike van der Watt, Chief Medical Officer
Author(s)
Dorothy Otite, Interim Risk Manager
Purpose Please tick the appropriate box
For approval For discussion For information
Executive
Summary
The purpose of this report is to provide an update on the status of the Corporate Risk Register (CRR) including current risk scores, new, escalated, de-escalated and closed risks.
Trust strategic
aims
(please indicate which of the 4 aims is relevant to the subject of the report)
Aim 1 Best quality care
Objectives 1-5
Aim 2 Great place to
work Objectives 6-8
Aim 3 Improve our
finances
Objective 9
Aim 4 Strategy for the
future
Objective 10-12
Links to well-led key lines of enquiry
☒Is there the leadership capacity and capability to deliver high quality,
sustainable care?
☒Is there a clear vision and credible strategy to deliver high quality,
sustainable care to people, and robust plans to deliver?
☒Is there a culture of high quality, sustainable care?
☒Are there clear responsibilities, roles and systems of accountability to
support good governance and management?
☒Are there clear and effective processes for managing risks, issues and
performance?
☒Is appropriate and accurate information being effectively processed,
challenged and acted on?
☒Are the people who use services, the public, staff and external partners
engaged and involved to support high quality sustainable services?
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☒Are there robust systems and processes for learning, continuous
improvement and innovation?
☒How well is the trust using its resources?
Previously
considered by
Since the last Board meeting, the CRR has been reviewed by the Risk Review Group once (on 20 January 2020). Specific elements of the CRR have been reviewed through the committee structure during this period.
Action required
The Board is asked to review the corporate risk register and endorse the
changes to the CRR.
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Agenda Item: 15/79 Trust Board meeting – 06 February 2020 Corporate Risk Register Report Presented by: Mike van der Watt, Chief Medical Officer
1. Purpose
1.1 The purpose of this report is to provide the Board with an update on the status of the CRR including current risk scores, new, escalated, de-escalated and closed risks.
1.2 To provide the Board with assurance that the risks to achieving the strategic aims and objectives are being appropriately mitigated against and that progress is being made against fulfilling the actions as commissioned by each respective committee.
2. Background
2.1 The CRR forms part of the Trust’s overall board assurance and integrated risk management arrangements.
2.2 The CRR contains all risks rated 15 and above from each of the operational & divisional
risk registers. The risk register is a ‘live’ document recorded on Datix; each lead for risk regularly reviews and updates the entries.
2.3 The Chief Medical Officer is the Trust’s delegated lead executive for risk management. 2.4 The Quality Committee is a subcommittee of the Board which oversees assurance for risk
management arrangements within the Trust.
3. Corporate Risk Register (CRR)
3.1 This report captures the decisions made by the Risk Review Group (RRG) on 20 January 2020. Data for this report was extracted from the CRR on 13 January 2020, a total of 25 open risks were registered.
3.2 Appendix 1 provides a full summary of all corporate risks as presented to the RRG on 20 January 2020.
3.3 Table 1 below presents the movement of risks by division, against each month since
August 2018 to date as registered on the CRR.
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3.4 Risk activity
The following provides an overview of risk activity as discussed at the Risk Review Group on 20 January 2020.
New risk (1) Risk 4241 was discussed at the RRG meeting on 20 January 2020; there was discussion related to the risk and it was highlighted that an order had been placed in December which would resolve this risk and that delivery was imminent. The risk was not accepted onto the Corporate Risk Register and the group agreed that this risk would be reviewed at the next RRG meeting in February.
ID Division Current Risk Rating
Risk title Rationale Exec Lead
4241 Medicine 16 L4 X C4
McKesson storage/ archiving capacity deficit
There are concerns that McKesson (a Picture Archiving Communication System (PACS)) may reach full capacity due to an increase in demand for inpatient echocardiography investigations and the introduction of a 7 day echocardiography service. Once capacity has been reached the system’s ability to store and archive images will immediately cease leading to Cardiology’s inability to provide an in/outpatient echocardiography service or undertake some CCL procedures in the interest of patient safety. This has a potential negative impact on patient safety, putting the Trust at risk of prosecution or a major incident. Including potential impact on the Trust’s reputation and regulatory concerns.
Chief Medical Officer
Mitigated risk approved for closure/Closed risk (1) Risk 4114 was reviewed by the RRG and agreed for closure and removal from the risk register.
ID Division Current Risk Rating
Risk title Rationale Exec Lead
4114 Clinical Informatics
15 L5 X C3
Delivery of the ICT Service Transition Programme
The final Programme Board took place on 10th December 2019 to close down the programme of work. As such this risk has been fully mitigated and should be closed.
Chief Information Officer
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De-escalated risks (2) Two risks were presented to the RRG for de-escalation. Risk 3710 – Further work has been undertaken to mitigate this risk and there is a QI project which is addressing the documentation compliance element. The group agreed the de-escalation of this risk. Risk 4065 – The RRG discussed this risk and requested further information is obtained from the Director of Environment to clarify the rationale behind the scoring of the risk and the actions which are being taken to mitigate it. The risk will be reviewed by the group in February 2020.
ID Division Risk Rating
Risk title Exec Lead Rationale
3710 Corporate 15 ↓12 Incomplete / Non- compliance with Do Not Attempt Cardiopulmonary Resuscitation process
Chief Medical Officer
Safeguarding panel continues to monitor compliance with MCA and DNACPR using a Dip audit tool. This risk has been de-escalated to the Corporate Services Divisional Risk Register due to completion of the actions and strengthening of the controls in place to mitigate the risk.
4065 Environment 15 ↓12 Non-compliant Georgian Wired (GW) Glazing in Non-compliant Georgian Wired (GW) Glazing in areas of the Trust
Director of Environment
This risk was not approved for addition to the CRR at the last RRG meeting as the group requested that the score is reviewed.
Revised current risk scores (0) During the reporting period, there has been no movement in risk scores other than the de-escalated risk reported above. The remaining risks on the CRR have remained static. Emerging risk (0) During the reporting period, no emerging risk has been identified or reported.
4. Risks 4.1 A failure to keep effective oversight of the Trust’s key risks may lead to the Trust not
achieving its organisational strategic aims and objectives.
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5. Recommendation
5.1 The Board is asked to review the CRR and agree the changes made to the CRR during this reporting period.
Dr Mike van der Watt Chief Medical Officer January 2020
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Appendix 1 – Corporate risk register summary (by Division)
ID
OP
EN
ED
DA
TE
DIVISION
RISK TITLE
INIT
IAL
R
ISK
RA
TIN
G S
CO
RE
PROGRESS NOTE
RA
TIN
G (
CU
RR
EN
T)
EX
EC
UT
IVE
LE
AD
New Risk (1)
4241
10/1
2/2
019
Medicine McKesson storage/archiving capacity deficit 2
0 This risk was not accepted onto the Corporate Risk
Register by the RRG on 20 January 2020; to be reviewed by the group in February 2020.
16
Mike van der Watt
Closed risk (1)
4114
20/1
1/2
018
Clinical Informatics Delivery of the ICT Service Transition Programme 1
2 The final Programme Board met on 10th December
to close down this programme of work. As such this risk is fully mitigated.
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Paul Bannister
Risks by Division
Clinical Informatics (6)
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3894
12/0
6/2
017
Clinical Informatics ICT Applications reduced availability, poor reliability & performance
20
Both e-handover and iReporter have been moved onto the new SQL environment. This leaves Infoflex remaining; this is being scheduled with the supplier.
20
Paul Bannister
3899
12/0
6/2
017
Clinical Informatics ICT Trust Bleep System
20
Now that the Business Case has been approved, the team are working with procurement to produce the requirements specification. This will then go to procurement to go out to tender.
20
Paul Bannister
3897
12/0
6/2
017
Clinical Informatics Cyber Risk
16
Maintenance windows being negotiated and agreed with Emergency Planning and Operational teams. This is key to allow the patching work to take place. A new patching policy has been created and the patching schedule features in this. Once schedule agreed, plans will be updated to align.
16
Paul Bannister
4116
23/1
1/2
018
Clinical Informatics Delivery of the Trust's Digital transformation programme
16
Tender process to develop user requirements, strategic outline case and outline business case has completed and a business case discussed at Trust Management Committee on 9th Oct for consultancy resources. Detail requirements gathering exercise will be further clinical engagement. Benefits review has completed and a report will be used to reflect back findings of initial engagement.
16
Paul Bannister
3896
12/0
6/2
07
Clinical Informatics ICT Data Networks reduced availability, poor reliability & performance
16
The business case was approved by the Trust Board on 5th December. A work order with Atos signed to ensure that the HLD can be started straight away. Hardware will be ordered and installation plans being created now all governance is approved.
16
Paul Bannister
4197
16/0
8/2
019
Clinical Informatics Missing Patches - ICT Server Estate 1
6 Maintenance windows being negotiated and agreed
with Emergency Planning and Operational teams. This is key to allow the patching work to take place. A new patching policy has been created and the patching schedule features in this. Once schedule agreed, plans will be updated to align.
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Clinical Support Services (3)
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4082
01/1
0/2
018
Clinical Support Potential shortage of spare parts to repair AAU CT scanner impacting on patient care
16
Work has commenced on building new fluid store relocation and waiting area for CT Expected go live date 03/20
20
Sally Tucker 3965
11/1
2/2
017
Clinical Support Delays in imaging of patients requiring interventional radiology procedures
16
Discussions with RFH on-going Business case for new IR suite and development. Discussions with RFL re: potential OOH cover underway. Target to go live in April
16
Patrick Hennessey
2755
28/0
7/2
011
Clinical Support Risk of failure of the MRI scanner at HHGH and deterioration in image quality
16
In 2020 -Business case to determine location and development costs to install in March 2020. Contingency plan for HHGH developed hard standing from mobile MRI to be installed by March 2020. Standby contract for mobile scanner in negotiation. HHGH MRI scanner end of supported life 31/12/19
16
Sally Tucker
Corporate Services (6)
3120
09/0
7/2
014
Corporate Lack of Storage facility for Patient Medical Notes leading to missing, poor condition and delayed location
20
Business case currently being written for Clinic Prep at SACH to move into area occupied by Orthopaedics who are due to move into new area. Multi volume tracking on Patient centre still being tested, last test 30/08/2019 failed. 20 Patients who have multi or fat volumes have been sent for trial sanitizing pilot (re-volumisation) on 02/09/2019, these are due to be returned w/c 16/09/2019 and will be shown to clinicians for feedback. Hemel Library racking has completely broken, NHSP staff injured themselves DW124344, Estates have been asked to repair or replace.
20
Paul Bannister
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3949
24/1
0/2
017
Corporate Patient experience and patient safety is compromised due to ongoing challenges with current non-emergency transport provider
15
The CCG continues to negotiate a contract for 2019/20. Current gaps whereby the Trust does not have a commissioned service to use: - Mental Health informal transfers - Mental Health formal transfer requiring mobility assistance - Out of Area Transfers/Discharges - London outpatient appointments - Transfers to providers within NHSE London area
15
Sally Tucker 3828
09/1
1/2
016
Corporate Patients may come harm and have a poor experience due to long waits for elective care
20
RTT performance continues to improve, although it is slightly below plan. 1
5 Sally Tucker
4190
10/0
7/2
019
Corporate Senior medical staff may alter working arrangements resulting in the Trust being unable to maintain consultant led services
20
This risk remains static as Trust is awaiting national guidance following consultation on this issue. Once further update provided on possible amendments to pension scheme, Trust will plan actions accordingly and communicate widely with staff. Currently we continue to monitor any impact on availability of senior clinicians to undertake additional sessions and on 18th November: a further imminent development was discussed in media reports that for this year only where doctors face large tax bills which can be paid from an individual’s pension fund under something called scheme pays with a co sequence reduction in pension when it is drawn, the government will make good the difference significant adverse impact has been identified.
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Paul Da Gama
4191
10/0
7/2
019
Corporate Risk of a financial liability to Trust following outcome of legal case 'Flowers'
20
Awaiting National Directive further to outcome of the legal case. The Trust has calculated potential liability of circa £1.2million.
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4207
12/0
9/2
019
Corporate Inadequate post in-patient discharge appointment booking processes
20
Wider workstream looking at the role of ward managers underway in reducing the variation in the way they work
16
Sally Tucker
Emergency Medicine (1)
3995
06/0
3/2
018
Emergency Medicine Challenges in Recruitment of Emergency Medicine Medical Workforce
20
We are currently working with the Procurement Team to try and find an agency that we can work with to recruit 4 further ED consultants. We will be taking the results of these discussions to our regular meetings with the Exec to work with them to find a way forward We have recruited several MG into our CESR programme which will (in the long term) help to improve our consultant numbers In the short term, we are reliant on a small group of locum ED consultants who work here regularly; this helps to decrease some of the risk in using many locums, as they are more aware of our policies and procedures We have also had 2 of our substantive ED consultants return to work (after sick leave and maternity leave, albeit not full time) which has eased some of the burden
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Michael Van der Watt
Environment (4)
4135
15/0
2/2
019
Environment Lack of A E & CP's across Safety Groups in accordance with HSE and DoH Managing safely guidance and accepted Codes of Practice
20
AE post-potential strong candidate identified, interviews scheduled end of November 2019.
16
Patrick Hennessey
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Finance (2)
4154
08/0
4/2
019
Environment Non-compliance with HTM00 (safe systems of work) 1
6 ATR being presented to vacancy panel to recruit to
Health and Safety Manager role - Review January 2020 New Head of Compliance recruited October 2019 (Fixed Term Contract). Substantive role to start in Jan 2020
16
Patrick Hennessey
2795
15/1
2/2
011
Environment Management and control of - Asbestos Containing Materials (ACMs)
20
Capital team governance procedures implemented Summer 2019 - to be reviewed Jan 2020 Permit to work system and contractor induction to be reviewed by Jan 2020 All lift shafts have now been surveyed awaiting reports - Project Team to advice on dates for reports - Review End of Jan 2020.
16
Patrick Hennessey
4155
09/0
4/2
019
Environment Potential lack of Assurance across the Trust for Fire Safety 1
2 Agreed at RRG (16/12/19) to review all fire related
risks with a view to amalgamate them into 1 or 2 risks. This will be done in conjunction with Head of Compliance during a governance review in Jan 2020
15
Patrick Hennessy
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4205
05/0
9/2
019
Finance Risk of not receiving Financial Recovery Fund as a result of failure to meet base criteria
20
Drivers of the deficit are in its closing stages. The Trust achieved its year to date deficit target as at month 6 (September) and it is expected that a payment of some sort is payable. Ongoing uncertainty around the precise criteria against which the Trust is being measured means this cannot be confirmed at the time of writing. The risk remains at corporate levels for this reason, and also because the margin by which this achievement occurred was narrow, and later parts of the financial year are more challenging as efficiency expectations in particular increase. The agreement of a Minimum Income Guarantee (MIG) between the Trust and HVCCG will not necessarily improve the chances of the Trust satisfying the FRF criteria. It will, however, effectively fix a significant part of the Trust's financial position and enable a greater focus on cost improvement / recovery actions.
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4204
05/0
9/2
019
Finance Risk of not receiving Provider Sustainability Fund income as a result of failure to achieve financial plans
20
The Trust achieved its year to date deficit target as at month 6 (September) and therefore expects to receive the relevant portion of PSF income. The risk remains at corporate levels as the margin by which this achievement occurred was narrow, and later parts of the financial year are more challenging as efficiency expectations in particular increase. The agreement of a Minimum Income Guarantee (MIG) between the Trust and HVCCG will not necessarily improve the chances of the Trust meeting its financial plans. It will, however, effectively fix a significant part of the Trust's financial position and enable a greater focus on cost improvement.
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Don Richards
Medicine (1)
4129
25/0
1/2
019
Medicine Unreliable functioning of central cardiac monitor 1
5 On placement of order, the equipment came out as
being much more expensive than originally budgeted for and agreed. Now going back through finance for approval of additional funding.
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Agenda Item: 16/79
Report to: Trust Board
Title of Report: Assurance report from Trust Management Committee
Date of Board meeting:
06 February 2020
Recommendation:
For assurance
Chairperson: Christine Allen, Chief Executive
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Trust Management Committee at its meetings on 08 January 2020 and a development session on 22 January 2020.
Background
The Committee meets monthly and its areas of responsibility are:-
Delivery of the clinical strategy
Revenue investment up to £1m
Operational performance
Operational risk
Safety and business continuity
Information technology
Internal and external communication strategy
Clinical quality
Business planning
Environment
Business undertaken
Topics covered at the meeting on 22 January, included:
The committee received information on the arrangements for a forthcoming CQC inspection. In preparation for the visit, the Committee considered a self-assessment of outpatient services across the Trust which were not located within the main department. The review included cardiology, diabetes and endocrinology, dermatology, respiratory, clinical haematology, surgery and ophthalmology.
An update on the acute redevelopment programme was received and the programme plan was discussed.
A summary report which set out the progress being made against the two year corporate objectives was received. This report was discussed by the Board in January 2020.
The Committee received feedback from the clinical advisory group and the professional advisory group.
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In addition to the regular meeting in January, a development session was held on 22 January 2020 at which the Committee considered the actions needed to be taken to achieve a ‘good’ rating by the Care Quality Commission, as well as reviewing the embargoed results of the national staff survey and discussing the draft five year strategy. The Committee agreed that the frequency of meetings would reduce from twice to once a month and a Good Place Programme Board would be held in place of the second meeting. It was agreed that any urgent Committee business would be discussed at the end of the Good Place Programme Board meetings as required. This new arrangement would be effective as from 01 February 2020.
Risks to refer to the risk register
None
Items to escalate to the Board
None
Attendance
Christine Allen Chief Executive
Freddie Banks Associate Medical Director, Clinical Strategy
Paul Bannister Chief Information Officer
Andy Barlow Divisional Director, Medicine
Mary Bhatti Divisional Manager, Women and Children’s
Howard Borkett-Jones Associate Medical Director for Education
Helen Brown Deputy Chief Executive
Tracey Carter Chief Nurse
Paul da Gama Chief People Officer
Fran Gertler Director of Integrated Care
Sean Gilchrist Director of Digital Transformation
Louise Halfpenny Director of Communications
Patrick Hennessey Director of Environment
Jean Hickman Trust Secretary
Stephanie Johnson Divisional Manager, Medicine
Martin Keble Divisional Director, Clinical Support
Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer
Jason McKee Divisional Manager, Surgery, Anaesthetics and Cancer
Natalie Miles-Kemp Head of Programme Delivery Support
Esther Moors Acute Redevelopment Programme Director
Elaine Odlum Divisional Manager, Medicine
Rodney Pindai Director of Contracts, Efficiency & Commercial Development
Sally Tucker Chief Operating Officer
Karen Walker Head of Nursing, Children’s
Angela Wellman Head of Nursing, Medicine and Emergency Medicine
Karen Walker Head of Nursing, Children’s
Anna Wood Deputy Medical Director
In attendance Julia Alderman Business Coordinator for CEO and Chairman
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Report to: Trust Board
Title of Report: Assurance report from Finance and Performance Committee
Date of meeting: 06 February 2020
Recommendation: For information and assurance
Chairperson: John Brougham, Non-Executive Director
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Finance and Performance Committee at its meeting on 30 January 2020.
Background The Committee meets monthly and provides assurance on scheduled reports from all Trust operational committees with finance, investment and access performance brief according to established work programmes.
Access Performance
The Committee reviewed the waiting time performances in November, for ED, ambulance handovers, cancer treatment, elective care referral to treatment (RTT) and diagnostic tests.
RTT
The RTT 18 week wait performance was unchanged from November at 87.4%. Whilst this is below the national standard of 92%, and the recovery plan for December of 88.4%, it is better than the latest reported national median of 84.2%. The Committee was assured that actions to improve performance are in place, including ongoing outsourcing and, following recent discussions with commissioners, agreement to work more collaboratively to identify additional capacity in the private sector and other NHS organisations with the aim of increasing capacity further. The Committee was assured that these actions were primarily targeted to improve waiting times in the most challenged specialities. There were no patients at the end of December with waiting times in excess of 52 weeks, and the Committee was again assured that an appropriate harm review process is in place for all patients exceeding the national wait times.
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A&E December is traditionally a very difficult month for A&E across the NHS, and attendances at the Trust were up by 11.3% compared to last year, and by 13.1% from November, with the highest attendances this year at Watford. Performance against the 95% 4 hour waiting standard fell from 82.2% in November, (which ranked the Trust 29th of 94 providers, with a national median of 79.2%), to 79.4%. National comparators for December will not be known until February, but the national median is expected to be lower than in November. In December both the MIU at St Albans and the UTC at Hemel Hempstead matched performance in November at more 99%, whilst at Watford, Majors was down from 58.9% to 53.9%, CED was down from 87.7% to 83.9%, and Minors was down from 94.3% to 92.4%. The Committee was assured that the SMART pilot, implemented in October, with senior clinicians from a range of medical specialities working in ED, has made a significant improvement in flow of patients, and consequently reduced waiting times. Ambulance Turnarounds There was a significant increase in ambulance waiting times in December. Ambulance arrivals increased by more than 9% in December, but waiting times in excess of 30 minutes increased by 38%. A major factor in the increased delays was the arrival of ambulances in clusters, and the outcome of the imminent joint handover improvement meeting with EESAT is awaited. Cancer December performance matched November with 7 of the 8 national waiting time targets met. There were month on month improvements against 5 of the standards, with the other 3 maintaining the 100% performance achieved in November. The maximum 62 day waiting time performance from GP referral for suspected cancer to first treatment is still provisional, at 83.1%, up from 77.1% in November, in line with the recovery plan for December, ahead of the latest national median of 78.5%, and behind the standard of 85%. Performance against this standard, and the recovery plans, to improve to achieve it on an ongoing basis, remains a key focus for the Committee. The Committee also noted that harm reviews will now take place for all cancer patients exceeding 62 days waiting compared to 104 days previously. Diagnostic Tests The Committee noted the strong performance in achieving the National Standard of 99% of patients waiting no more than 6 weeks for diagnostic tests recording 99.7% in December.
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Integrated Performance Report The Committee reviewed the effectiveness of the IPR and concluded that it provides a very good overview of the Trust’s performance, and improvement actions, covering safe care and Improving outcomes, caring and responsive services, workforce and finances. The Committee also commended the recent addition of key messages from each of the chief officers.
Financial Performance (i) I&E The Committee reviewed the December results and the latest forecast for the year to seek assurance that the full year budget would be met. The deficit of £2.0m in December was in line with budget, and £0.2m better than forecast, resulting in a year to date deficit of £20.7m, which is £0.1m better than budget. Compared to budget year to date, revenues of £283.8, are £0.8m lower, mainly due to lower pass through high cost drugs which are offset by lower other costs, pay costs are £2.6m higher, primarily in medical and nursing, and other costs in total are lower by £3.3m, with lower high cost drugs the main contributor. Over the past six months the Trust has taken actions to reduce the rate of medical and nursing pay, without impacting patient care, including reducing high cost agency consultants and improved management and controls over medical and nursing rotas. The Committee continues to review the outcomes and was assured that many of the actions are now embedded, which is essential to the delivery of not just this year’s deficit target but also next year’s plan. The Committee noted the continued strong performance in achieving CIPs, with a further £1.9m in December bringing year to date to £11.0m, £2.4m ahead of budget. The forecast for the year is now £15.3m, compared to the budget of £15.0m, with more than 85% recurrent savings, which is well ahead of previous years and the national average. The latest forecast for the year still requires delivery of defined, but not yet underpinned, actions but the Committee was assured that this challenge has now reduced from £1.4m last month to £1.0m. Following the review of risks, opportunities and actions, the Committee was assured that, although achievement of the full year budget is not guaranteed, the Trust remains on track to deliver the £22.7m deficit target. The Committee recommends that a paper on the forecast deficit for the year, including recovery plans and risks, is presented to the February Board. (ii) Capital Spend
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The Committee reviewed capital spend to date and the programme of spend for the year. Capital spend of £1.0m in the month brought year to date spend to £6.2m, leaving a significant challenge to deliver the full year authorised spend in the year of £20.9m. The Committee was concerned that the full year spend, all on much needed facilities at the Trust, would not be achieved, and was assured that plans are in place to deliver the £20.9m. The Committee supported initiating essential work to upgrade the Trust’s underlying operating software from Windows 7 to Windows10 as a key project in the fourth quarter, and taking the opportunity to apply to NHS to fund it. The Committee recommends that a paper on capital spend in the fourth quarter is presented to the February Board. (iii) Revenue Funding Funding of revenue spend is subject to monthly approval by the NHS and
following review the committee recommends ratification by the February
Board of an NHS Revenue Support Loan of £2.6 million to meet the
funding requirements in January.
(iv) Divisional Finance Review The Committee reviewed a presentation by the Director of the Clinical Support Services Division. The Division has an annual budget spend of £28m, and year date is £0.7m overspent on a budget of £21.5m. Revenues are on budget, and forecast to be on budget for the year. The majority of the spend variance is due to agency premium covering scientific and technical vacancies in pharmacy, radiology, pathology and therapies, and outsourcing. The Committee reviewed the plans to reduce the rate of costs in the final quarter, including accelerating CIPs from £0.8m year to date to hit the budget of £1.4m for the year. The Committee was assured by the glowing endorsements, from its Executive members, of the excellent quality of service provided by the Division to the Trust’s clinical divisions. (iv) 2020/21 Budget and 5 year plan The Committee was updated on progress of finalising the budget and plan. National planning guidance is expected to be received shortly, with initial submission of the plan to NHS by March 5, and final submission by end April.
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The plan will be reviewed by the February Committee, and March Board, prior to the initial submission, and by the March Committee and April Board prior to the final submission. The presentation covered the work underway to draft all elements of the plan, both within the Trust, and together with HVCCG, including, activity levels, minimum income contract, quality and performance plans, people resources, levels of costs and efficiencies, capex and funding. Areas of risk and opportunity were reviewed on the Trusts ability to deliver the agreed I&E control total for 2020/21, and planned break even by 2022/23. The Committee recommends that an update on the status of the budget and plan, including risks and opportunities, Is presented to Part 2 of the February Board. (v) Business Cases The Committee reviewed the Strategic Outline Business Case ( SOC) to deploy an Electronic Patient Record( EPR) solution for the Trust. This is an underpinning platform in delivering digital transformation throughout the NHS to achieve its strategic direction for new care models. The Committee agreed the urgent need to enhance the Trusts digital capabilities and fully supports the need to move towards paper free care, and introduce an EPR solution. This would enable benefits in patient care and experience, through optimising clinical pathways, reducing unwarranted variations in care and outcomes, and also improving waiting times. An EPR solution also provides significant cost saving opportunities in the Trust. The Committee reviewed the options to deliver an EPR solution and agreed with the preferred route, at this stage, of an enterprise wide solution which involves selecting one fully integrated software solution supplier from the NHS list of accredited suppliers. The Committee reviewed the financial case, recognising that at this is based on top down assumptions and asked for additions to the supporting narrative to give greater clarity. The Committee recommends that, with the changes noted above, the SOC is presented to the February Board for approval to proceed to an Outline Business Case (OBC), which will assess the case in greater depth in all areas, including clinical, operational, procurement, and financial. Watford Theatres Reconfiguration Project The Committee received an update on the project, which is now on course for review of the Full Business Case (FBC) by the June Committee, and for review and approval by the July Board.
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Watford Multi Story Car Park (MSPC) Business Case The Committee was given a verbal update on progress in finalising the FBC for the MSCP at Watford, and recommends an update is given to the February Board Corporate Risk Register (CRR) and Board Assurance Framework (BAF) The Committee reviewed the latest status of the rating and mitigating actions, of the three risks under its remit on the CRR and the seven on the BAF. The Committee was assured that all the risk ratings should remain unchanged, that actions to mitigate the risks were up to date and appropriate and recommends that the risks as reviewed should be incorporated in the Trust wide CRR and BAF at the February Board.
Risks to refer to risk register
See above
Issues to escalate
The Committee recommends the following:
To part 1 of the February Board
For Ratification
NHS revenue support loan of £2.6m to meet the funding requirements in January
To part 2 of the Board
For approval
The Electronic Patient Record SOC
For discussion and comment
Forecast and deficit for the year, recovery and risk
Capital spend 4th quarter
Update on status 20/21 budget and 5 year plan
Update on multi storey car park FBC
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Attendance record
Present
John Brougham, Non-Executive Director (Committee Chair)
Christine Allen, Chief Executive
Don Richards, Chief Financial Officer
Phil Townsend, Trust Chair
Mike van der Watt, Chief Medical Officer
Sally Tucker, Chief Operating Officer
Tracey Carter, Chief Nurse
In attendance
Stephen Dunham, Associate Director of Efficiency, Costing and Financial Risk
Rodney Pindai, Director of Contracting, Efficiency & Commercial Development
Soheb Rafiq, Associate Director, Financial Management
Jane Shentall, Director of Performance
Minutes
Laura Abel, Assistant Trust Secretary
Attended for specific items:
Martin Keble, Chief Pharmacist and Sue Daniels, Radiology Services Manager – Divisional Update, Clinical Support Services, Phyllis Dasilva, Management Accountant, Clinical Support Services.
Tim Duggleby – Head of Strategy and Redevelopment – Update on Business Case for Car Park
Paddy Hennessy – Director of Environment – Update on Business Case for Reconfiguration of Theatres
Sean Gilchrist, Director of Digital Transformation, Paul Bannister, Chief Information Officer, Mark Richards, Deloitte
Apologies
Tom Drabble, Patient Panel
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Report to: Trust Board
Title of Report: Assurance report from Quality Committee
Date of Board meeting:
06 February 2020
Recommendation: For information and assurance
Chairperson: Jonathan Rennison, Non-Executive Director
Purpose
The report summarises the assurances received, approvals, recommendations and decisions made by the Quality Committee at its meeting on 19 December 2019.
Background The purpose of the Quality Committee is to provide the Board with assurance that high standards of safety and compliance, harm free, high quality, safe and effective services/clinical outcomes that are provided by the Trust and in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the Trust.
Assurances
received / areas of
challenge
Quality Assurance Report from Surgery and Anaesthetics:
The committee received a quality assurance report from surgery and
anaesthetics. The presentation and report were both clear, and evidence-
based in their approach, providing high degrees of assurance on key
areas of performance, as well as highlighting areas of concern and
providing assurance of actions and activities to address concerns and
mitigate risks. Key areas reported include:
Well Led:
Appraisal rate at 89.9% with a clear plan to improve performance to above 90%.
Core training compliance at 94% and essential training at 89%
The divisional strategy is being refreshed and strong leadership in place that meets weekly to discuss performance, risk and issues to ensure all are sighted on good practice and are aware of key concerns and how they are being addressed.
Robust governance with well-attended governance meetings and clarity on assurance and risk management – issues, complaints and risks discussed and addressed through governance meetings to ensure learning is shared and disseminated.
Responsive:
The complaints response rate is lower than the Trust target at just 75%. This is due to vacancies within the department. A revised process has been agreed with a clear recovery trajectory.
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Vacancies should be filled from February 2020, with new arrangements in place to ensure recovery until that time.
Issues arising from the urology issue which was previously reported are being proactively addressed. Harm reviews of patients have been undertaken, with three patients identified with harm. This is being investigated further. A review group is overseeing changes to the pathway as a result of this issue. A locum consultant has been recruited to help clear the backlog of patients.
RTT is improving and currently is at 80.55% with an ongoing focus on further improvement and recovery to achieve targets.
High rate of band-5 nursing vacancies in theatres across WGH and SACH – currently 23% vacancy rate. A proactive recruitment and development plan is in place to address this, and safe staffing protocols are followed daily with clear escalations to ensure safe staffing at all times.
Effective:
CIP Plan – the division has identified saving schemes to achieve its target of £4.64 million – they are performing well against the plan and on track to deliver in line with monthly and YTD forecasts.
The division highlighted their non-compliance with the majority of RTT pathways and highlighted the robust harm review process that is in place for all patients waiting longer than 48 weeks. Assurance was received on the process to ensure patients do not come to harm, and that ensures that there is a clear focus on improving performance in a timely manner.
Assurance was received on their active audit programme, the sharing and dissemination of learning from audits and how their audit programme is an integrated part of divisional governance and performance improvement.
Follow-up calls – the division have been having follow-up calls with patients since July, and this is proving successful at identifying and addressing issues and concerns from patients in real-time. The issues being raised in the follow-up calls are being reviewed, and themes identified. Any themes will be reviewed and where appropriate actions put in place to address these and implement learning.
Safe/Caring:
The division has successfully developed and implemented a learning disability surgical pathway. This involves close working with the safeguarding team, patients and families to ensure that admission and treatment are well managed, safe and as easy as possible for the individual and families concerned. Several areas within the division have achieved Purple Star Accreditation to support patients with learning disabilities.
The governance team have a proactive approach to reviewing all Datix reported incidents, completing an investigation, ensuring learning is captured and shared, as well as following clear lines of
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escalation when relevant.
Safe staffing – the division proactively monitors staff daily through the Trust’s approach to safe staffing and ensure that they have a clear plan to provide safe staffing across all parts of the division daily. In addition to this, the division takes part in the Trust's biannual establishment reviews. This contributes to its ongoing approach to providing a safe and caring environment for patients.
The division has a proactive approach to learning and ensures that learning is shared through well attended governance meetings, using governance boards on each ward, and highlight learnings, risks and issues for staff to be aware of. These are discussed daily in safety huddles as well as being shared through relevant newsletters within the division. The aim is to ensure that all staff are aware of key issues and risks, and any learning from these.
Challenges & Concerns:
Ongoing non-compliance with RTT targets and standards – clear action plan in place to support recovery, though it is acknowledged that recovery will not be possible in all specialties. A proactive approach is taken to identifying patients at risk of breaching 52 weeks and ensuring that they are offered treatment dates to prevent breaches occurring.
Theatre productivity – the Trust is not achieving the recommended 85% target for theatre productivity. Current performance stands at 70%. A review has been undertaken, and a clear process and action plan are being developed to improve theatre productivity and work towards an 85% utilisation rate. Feedback from a visit from NHSI who provided a review of the elective site at SACH and a review of the Watford sites is now being incorporated into an action plan to support improvement in theatre productivity performance.
Anaesthetics staffing – high number vacancies at consultant and middle grades. This is reflective of local and national shortages for these posts. There has been a successful recruitment programme with one new starter in November 2019 and another in Jan 2020. A proactive and continuous recruitment programme is in place to address this issue. Robust mitigations are in place using locums, and increased agency spend is mitigated through the use of long-term locums wherever possible.
SACH Enhanced Care Programme – this pilot programme has been successful, but they have not been able to treat the expected number of patients. The team are reviewing this and are working closely with stakeholders to improve the identification of patients suitable for treatment at SACH. They expect to see improvements in performance in 2020.
Annual report on litigations claims:
The Committee received a report on annual litigations and claims for the
Trust during 2018/19. In that period the Trust received 50 new clinical
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claims, which was an increase of 4 cases when compared to the previous
year. Forty-three claims were closed, with payments being made to 70%
of claimants (total 30 claimants). The divisions with the highest payments
to claimants were:
WACS - £11,484,251
Surgery - £1,987,198
The Trust’s total contribution to all NHSR indemnity schemes was £16.9
million, which was a decrease of £754,010 from the previous year. The
trust received 65 letters before action, with Surgery and WACs receiving
the most LBAs. The Trust did not receive any Prevention of Future
Death's (PFD) notifications. In cases where the coroner was likely to
consider a PFD, the Trust was able to demonstrate that incidents had
been the subject of serious incident reviews or investigations, and that
action had already been taken.
The Committee was assured that we have robust processes in place to
track and monitor litigations and claims, with a transparent and open
approach to acknowledging failings where appropriate. We were also
assured that learning from cases is captured, shared and embedded to
help improve the quality of our care and prevent similar incidents from
happening again. The report asked that we take assured of compliance
with the legal processes – a question was raised as to what legal
processes we are required to be compliant with is in this instance. It was
requested that future reports list the relevant processes so that the
committee can take an informed view as to our compliance with those
processes.
Quality Assurance Framework - Getting to Good and Beyond:
The Committee received a report on moving to good and beyond which
provided an overview of activities of our quality improvement programme,
as well as our response to previous CQC inspection findings and our
preparations for our next CQC visit. We were informed of a number of
deep dives that have taken place to demonstrate progress against their
respective programmes of work. The areas reviewed were:
Human Resources – appraisals and training
DNACPR
MIU & UTC.
Assurance was received on the work delivered to date to address areas
of concern and ongoing work which is continuing to ensure high-quality,
safe care. The committee was informed that we are now moving from a
proactive monitoring programme to a proactive engagement programme
to ensure that staff, patients, service users and key stakeholders are
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aware of and understand the changes that we have made. The program
will support staff to reflect on their own successes and achievements in
their teams and divisions so that they can articulate what they have
changed and achieved, and what they are proud of. The team wish to
support staff to link their achievements to some of the key areas of
improvement at a Trust-wide level.
Internal Audit Report on Maintenance of Medical Devices:
The committee received a report from RSM, the Trust’s internal auditors
on the Maintenance of Medical Devices. The report presented a position
of partial assurance and highlighted concerns in
maintaining accurate records of medical devices within the Trust
ensuring an appropriate maintenance programme to ensure safety
having an appropriate renewal plan for medical devices (including decommissioning end of life devices).
Several actions are highlighted, with deadlines and a clear responsible
individual. However, at this point, the Committee was not assured that we
have an appropriate grip and control in our management of medical
devices. The Committee has requested that a further report comes back
to the committee once actions have been completed and additional work
delivered to improve our performance and to demonstrate more robust
management of medical devices within the Trust.
Report on a visit from the Local Authority Environmental Health
Officer:
We received a report on a visit from our Local Authority Environmental
Health Officer (EHO), which identified a series of failing in the Trust in
several areas, resulting in a score of 1 out of 5 (on a five-point scale, with
5 being a high or 'good' score). We were presented with a clear action
plan that has been developed to address the issues raised by the EHO.
Some actions have been completed, and others are in progress with
completion dates in early 2020. The Committee noted that several of the
issues could have been avoided through appropriate forward planning
and more structured management of our soft services. The Committee
has requested that progress on the action plan is reported to the
Committee to provide assurance that we have improved our food hygiene
and catering services management.
Corporate Risk Register and BAF:
We received a report on the Corporate Risk Register and were notified of
two escalated risks, both within the environment division:
Risk No 4155: Potential lack of assurance across the trust for fire safety.
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Risk No 4065: Non-complaint Georgian wired glazing in areas of the Trust.
The Risk Review Group approved one new risk for Clinical Informatics:
Risk No 4197: Missing patches – ICT server estate, a high number of security patches are missing from the WHHT server estate (cybersecurity risk).
One risk was de-escalated within the Environment Division:
Risk No 3958: Risk of condensate tank failing. The risk was de-escalated due to major works being completed to address the issue of the condensate tank failing.
The Committee received some assurance that the escalated and new
risks are being appropriately managed and that actions are in place to
address gaps in assurance and controls. These risks will continue to be
monitored and further assurance received on measures to effectively
manage them and to address any gaps in controls and assurance.
Quality Integrated Performance Report:
The Committee received the Quality Integrated Performance Report,
which provides a detailed presentation of our quality performance data
and performance metrics. Key areas of good performance include:
Prevent compliance training exceeds the 85% trajectory set by NHSE at 88%.
There were zero cases of category four pressure ulcers and a slight decrease in the overall number of HAPUs during October.
There were no cases of MRSAb.
While we are above our trajectory for C-diff, we received positive feedback from C-diff peer review undertaken by the CCG.
We continued to sustain improved performance in the number of falls with harm.
We continued to see an improvement in the overall attrition rate of women delivering within the Trust and have seen an increase in the number of women delivering in the birth centre.
Areas of poor performance highlighted in the report include:
A drop in our complaints response rate, dropping to 79% in October.
Our combined c-section rate is at 31.5%, which is above the Trust target of 28% and above the national average of 26.7%.
Harm Free Care as measured by the Safety Thermometer fell below the 95% national target; however, the new harm-free care within the Trust was above the national average at 98.2% against a national average of 97.7%.
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The home birth rate is below the trust target of 2%.
There was a good discussion, with questioning and challenge in several
areas within the report and good assurance received on actions to
address poor performance, including triangulating information from other
reports received at the Committee. Overall the Committee was assured
on areas of good performance as well as receiving assurance of clear
understanding of issues affecting poor performance and clear action
plans to address poor performance.
Bi-annual Quality Account:
The committee received a bi-annual report on progress against our
Quality Commitment. The committee reviewed the report and the
presentation of information and data to support progress. We were
assured that clear progress had been made, in areas of under-
performance, this was clearly understood, learning captured and clear
plans in place to improve our performance.
Committee Discussion:
At the end of each agenda item, the committee discussed the level of
assurance that it had for that item and agreed a high, medium or low
assurance view. At the end of the meeting, we discussed this approach.
Committee members found it to be a useful committee discussion where
we acknowledged our level of assurance and were able to provide a
reason for our position using evidence from the committee papers and
presentations. We discussed if our assurance level should be recorded
as part of the minutes for the meeting, and the committee was not in
agreement on this issue. Some felt it is appropriate to record the
Committee's position in the minutes. In contrast, others thought it should
not be recorded until further work is done to understand this approach
and how it might best be used to strengthen our governance. The
committee is recommending to the board that we discuss this issue and
agree on a standard approach to discussions on assurance and the
recording of committee assurance positions for our governance structure.
Risks to refer to risk register
There are no new risks to escalate to the Board.
Recommendations to the Board
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Attendance record
Attended
Jonathan Rennison, Non-Executive Director (co-chair)
Ginny Edwards (co-chair)
John Brougham, Non-Executive Director
Christine Allen, Chief Executive
Tracey Carter, Chief Nurse and Director of Infection Prevention and Control
Marsha Jones, Associate Chief Nurse, Quality Governance
David Thorpe, Deputy Chief Nurse
Sally Tucker, Chief Operating Officer
Mike van der Watt, Chief Medical Officer
Anna Wood, Deputy Medical Director
Attendees
Jean Hickman, Trust Secretary
Laura Abel, Assistant Trust Secretary (notes)
Attendees for specific items
Paula King, Head of Nursing, Surgery, Anaesthetics and Cancer
Jason McKee, Divisional Manager, Surgery, Anaesthetics and Cancer
Trisha McSkeane, Head of Legal and Clinical Effectiveness
Alison Fuller, Interim Associate Chief Nurse
Sam Abbas Manager, RSM Risk Assurance Services LLP
Liam Commins, Deputy Director of Environment
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TRUST BOARD MEETING IN PUBLIC
AGENDA
05 March 2020 at 9.30am – 12.30pm Executive Meeting Room, Watford Hospital
Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283
Time Item
ref Title Objective Accountable
officer Paper or verbal
Link to
BAF
01/80 Opening and welcome
Information Chair Verbal
02/80 Patient story Information Chief Nurse Present-ation
INTRODUCTION TO THE MEETING
03/80 Apologies for absence
Information Chair Verbal
04/80 Declarations of interest
Information Chair Paper
05/80 Minutes of the meeting held on 06 February 2020
Approval Chair Paper
06/80 Board action log from 06 February 2020 and previous meetings and decision log
Information Chair Paper
07/80 Chair’s report
Information Chair Paper
08/80 Chief Executive’s report Information Chief Executive
Paper
09/80 Board assurance framework Approval Chief Executive
Paper
PERFORMANCE
10/80 Performance report on access standards
Information and
assurance
Chief Operating Officer
Paper 4a&b
11/80 Integrated performance report (month 9) Key messages from:
Chief Operating Officer
Chief Nurse
Chief Medical Officer
Chief People Officer
Chief Finance Officer
Information and
assurance
Chief Operating Officer
Paper 4a&b
AIM ONE: BEST CARE (OBJECTIVE 1 – 4)
12/80 Bi-annual establishment review of adult inpatient wards
Information and
assurance
Chief Nurse Paper
22
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AIM TWO: GREAT TEAM
13/80 Business case for overseas nurse recruitment
Approval Chief People Officer
Paper
14/80 Bi-annual freedom to speak up/whistle blowing report
Information and
assurance
Chief People Officer
Paper
AIM FOUR: GREAT PLACE
15/80 Strategy update Information and
assurance
Deputy Chief Executive
Paper
16/80 Communications and engagement strategy
Approval Deputy Chief Executive
Paper
RISK AND GOVERNANCE
17/80 Detailed corporate objectives Approval Deputy Chief Executive
Paper
18/80 Corporate risk register report Approval Chief Medical Officer
Paper
19/80 Annual review of corporate governance structure
Information and
assurance
Trust Secretary Paper
20/80 Annual self-assessment of Board effectiveness
Approval Chair/ Trust Secretary
Paper
ASSURANCE FROM COMMITTEES
21/80 Assurance report from Trust Management Committee
Information
and
assurance
Chief Executive Paper
22/80 Assurance report from People, Education and Research Committee
Information
and
assurance
Chair of Committee/Chief People Officer
Paper
23/80 Assurance report from Finance and Performance Committee
Information
and
assurance
Chair of Committee/Chief Financial Officer
Paper
24/80 Assurance reports from Quality Committee
Information
and
assurance
Chair of Committee/ Chief Nurse
Paper
CORPORATE TRUSTEE
25/80 Report from the Charity Committee
Information
and
assurance
Chair of Committee/
Deputy Chief Executive
Paper
ADMINISTRATION
26/80 Any other business previously notified to the chair
N/A Chair Verbal
QUESTIONS FROM THE PUBLIC
27/80 Questions from Hertfordshire Healthwatch
N/A
Chair Verbal
28/80 Questions from our patients and members of the public
N/A Chair Verbal
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CLOSING
29/80 Draft agenda for next meeting Approval Chair Paper
30/80 Date of the next board meeting: 02 April 2020, Executive Meeting Room, Watford
Information Chair Verbal
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