delivering our vision - east surrey hospital · delivering our vision – how are we doing? october...
TRANSCRIPT
Delivering our Vision How are we doing?
October 2017
“We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first”
2
Through integration and partnership we aim to become both a provider and employer of choice
Annual priorities
Reduce avoidable
harm
Improve discharge planning
Staff health, well being and working lives
Create best environment for patients
Improve efficiency of elective care
Values
Safety & quality
One team
Dignity & respect Compassion
Vision We will pursue perfection in the
delivery of safe, high quality healthcare which puts the people of
our community first
Patient
Strategic objectives
Safe Effective Well-led Caring Responsive
3
• There were 8 SIs declared in October 2017.
• Patient safety indicators continue to show expected levels of
performance.
• There were no MRSA bloodstream infections and 3 Trust-apportioned
Clostridium Difficile cases in October 2017.
• Mortality is lower than expected for our patient group when benchmarked
against national comparators.
• Readmission indicators continue to see the Trust perform well.
SAFE - People are protected from abuse and avoidable harm
EFFECTIVE - People’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best
available evidence.
• Friends & Family Test continues to show good patient feedback for the
Emergency department during a time of both high demand and refurbishment
while Inpatient FFT dropped slightly to 94.5% in October maintaining Amber
performance on the Trust RAG rating.
CARING - service involves and treats people with compassion,
kindness, dignity and respect.
Delivering our vision – How are we doing?
October 2017 summary
Serious
Incidents
8
%
Emergency
readmissions
within 7 days
3.8%
%
HSMR
(July-17)
91.7
%
ED FFT
96.7%
Inpatient FFT
94.5%
Safety Thermometer
99.3%
4
• The 4hr ED standard was not achieved in October 2017 with
performance of 93.2%. National performance for ‘Type 1
Departments’ in October was 87.8%.
• October saw improvements in both the Cancer TWW standards with
both returning to achieving the 93% standard.
• 62 Day GP performance continued to exceed the national standard
with over 90% of patients starting treatment within 62 days.
• 18 Weeks RTT - The Trust did not achieve the RTT Incomplete
pathways standard with performance of 86.8%. Recovery actions
and trajectory are in place.
• The SASH Star Awards were held on 9th November with awards presented to staff in
ten categories. We also recognised staff with long service ranging from 20 to 45 years.
• The 2017 National Staff Survey was launched on 5th October. Response rates are
currently at 53% against a national average of 28%. The survey closes on 1st
December.
• The work to support mental health awareness, (with South London & the Maudsley NHS
Trust), is on-going with positive feedback received for these interventions to date.
• ‘Staff Health’ has been chosen as one of three key priorities for the Trust across the
next twelve months.
• The Trust’s Inclusion Strategy has been developed and is now with stakeholder groups
(i.e. Black, Asian, and minority ethnic network (BAME), Local Negotiating Committee
(LNC), Joint Negotiating Consultative Committee (JNCC)), for review and comment.
RESPONSIVE - services meet people’s needs.
WELL LED - leadership, management and governance of the
organisation assures the delivery of high-quality person-centred care,
supports learning and innovation, and promotes an open and fair culture
Delivering our vision – How are we doing?
October 2017 summary
ED 95% seen
in 4 hours
93.2%
%
Vacancy Rate
10.9%
%
Staff
turnover
16.2%
%
RTT
Incomplete
86.8%
62 Day GP
90.4%
5
FINANCE AND USE OF RESOURCES
Delivering our vision – How are we doing?
October 2017 summary
• The Trusts Income & Expenditure 2017/18 Control Total is a £21.3m adjusted surplus.
Current forecasts show a £16m risk against delivery of this control total.
• The Trust achieved a £5.3m [adjusted] surplus at the end of October 2017, which was
£1.8m worse than plan for the YTD position. This is driven by a £0.9m shortfall in
clinical income and a £0.9m shortfall in Sustainability & Transformation Funding (STF).
• The position includes £3.1m STF for successfully delivering the Q1 & Q2 financial plans.
• £2.8m of savings have been achieved YTD.
YTD £m
Adjusted
Surplus
£5.3m
Action: The Board are asked to note and accept this report
Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance
on safe high quality care (Including mortality).
Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and
therefore license care services under the Health and Social Care Act 2009 and associated regulations.
Patient experience/
engagement: This paper includes significant detail on both patient experience and access to services.
Risk & performance
management
This is the main Board assurance report for performance against quality and financial measures and is
linked to risk management through the SRR.
NHS constitution; equality
& diversity;
communication.
This report covers performance against access standards with the NHS Constitution.
YTD £m
Savings
£2.8m
Are we safe?
Section 2
6
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
7
• Positive Safety Thermometer performance continued for the “New Harm” measure with performance of
99.3% in October.
• The Trust declared eight serious incidents in October 2017.
• 2017/24286 - Falls – There was an unwitnessed patient fall resulting in a fractured neck of femur.
• 2017/24554 – Clinical Diagnosis - Delay in recognition of degree of trauma leading to delay in
transfer to trauma centre .
• 2017/24874 - Falls - There was a witnessed patient fall resulting in a fractured neck of femur.
• 2017/24941 – Falls - There was a witnessed patient fall resulting in the patient suffering a
haemorrhagic stroke and they sadly died.
• 2017/25142 – Falls - There was an unwitnessed patient fall resulting in a fractured neck of femur
• 2017/26053 – Infection Control - Patient was positive for Group A streptococcus from a blood culture
taken on 06/10/17. There is a possibility that this is cross infection. Typing and investigation
underway.
• 2017/26488 - Maternity/Neonatal – The incident is the discovery at a routine growth scan of the
intra-uterine death of a baby at 32 weeks gestation. The investigation will review all care given.
• 2017/26722 – Maternity/Neonatal – The incident is the intra-uterine death of a baby during labour.
The investigation will focus on the triage process and admission to unit to determine whether there
was a missed opportunity to manage care.
Serious
Incidents
8
Safety
Thermometer
99.3%
Safety
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
8
• Daily staffing - The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is
assured that adequate staffing is in place. The Trust has delivered the planned vs actual staffing profile for
October at organisational level. The overall compliance is similar to previous months.
• Nurse recruitment - Continues both locally and from overseas.
• Retention - The Trust continues to imbed the various work streams outlined in the retention strategy. As part
of the support programme offered to the Trust from NHS Improvement, the Deputy Chief Nurse and the
Deputy Director of Workforce will be attending the next retention masterclass on the 23rd November, where it
is hoped that feedback will be given on the Trust’s retention improvement plan.
• The Trust has now received a copy of the recommendations document following the Health Education
England Kent, Surrey and Sussex commissioned crowdsourcing work on staff retention. This is being
reviewed with a view to incorporating the findings into the organisations’ retention plans.
Ward staffing
RN Fill Rate
Day
95.4%
RN Fill Rate
Night
95.8%
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
9
• There were no cases of MRSA blood stream infection in October 2017 and 3 cases of Trust-apportioned
Clostridium difficile.
• Twenty cases of Clostridium difficile for 2017/18 have been reviewed by the CCG and 4 cases have
been viewed as a ‘lapse in care.’
• The topic of the most recent RPIW for the SASH+ work stream for diarrhoea was stool sampling.
• ARK study – Brighton has seen an immense reduction in antimicrobial consumption on Q1 of their
CQUIN this year. Aim for SASH to participate in the ARK study in Jan 2018.
• Explore Point of Care testing – Pro-calcitonin (inflammatory marker for acute infection) in ICU/admissions
with the aim to reduce initiation of antibiotics.
• A band 7 pharmacist has started a microbiology rotation.
• The Retention Pathway is under review and a Urology Nurse Specialist ward round pilot has commenced,
the pilot will focus on the management of retention and urinary catheter reviews.
Infection control
MRSA
0
C-Diff
3
Delivering our vision – How are we improving?
Safe – Reduce avoidable harm
10
• In October 2017, Inpatient falls were 5.23 per 1000 bed stay days which remains
below the national average.
• Focused work continues on the 8 falls pilot wards where we have seen a collective
reduction in falls of 26%.
• In October we had 4 Serious Incidents relating to falls which are currently being
investigated, any learning will be shared.
• The Monthly Falls Focus Group has implemented several falls initiatives and have
recently taken delivery of beds that incorporate an alarm to alert staff that a patient
at risk of falls is moving. The Deputy Chief Nurse for Innovation and Improvement
and the Clinical Matrons continue to monitor progress with these interventions.
Reduce falls
• In October, we reported four Grade 2 and two Grade 3 wounds.
• The pressure damage investigation process has been revised and the Root
Cause Analysis (RCA) are being presented to the bi-monthly Serious Incident
Review Group with effect from November 2017.
• The monthly Pressure Damage Board will re-focus as a working group and
disseminate the shared learning, action plans and changes in practise.
• Pressure Damage continues to be discussed daily at ward safety huddles.
• Pressure Damage prevention/management has been re-instated onto the
mandatory training agenda for clinical staff.
• Thursday 16th November is World Pressure Ulcer Prevention Day, we will be
holding education events throughout the Trust to enhance staff and patient
knowledge.
Reduce pressure damage
Total Falls
102
Falls / ‘000
Bed days
5.23
Total
Pressure
Damage
15
Pressure
Damage / ‘000
Bed days
0.77
Delivering our vision – How are we doing?
Safe – Scorecard
11
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
No of Never Events in month 0 0 0 0 0 0 0 0 0 0 0 0 0
Serious Incidents - No declared in month 4 0 1 4 2 2 1 4 4 6 3 4 8
Serious Incidents - No per 1000 Bed Days 0.21 0.00 0.05 0.21 0.11 0.10 0.05 0.21 0.21 0.31 0.16 0.21 0.41
Patient Safety Incidents causing Severe harm or Death - Number in Month 4 0 3 1 0 0 2 1 3 5 1 4 2
Patient Safety Incidents causing Severe harm or Death - Percentage of all patient safety
incidents0.5% 0.0% 0.5% 0.2% 0.0% 0.0% 0.3% 0.1% 0.6% 0.8% 0.2% 0.7% 0.5%
Safety Thermometer - % of patients with harm free care (new harm) 94.8% 94.4% 96.8% 94.2% 97.9% 98.7% 99.0% 99.3% 98.0% 99.0% 98.8% 98.8% 99.3%
Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 97% 97% 97%
MRSA BSI (incidences in month) 0 0 0 1 0 1 0 0 0 0 0 0 0
CDiff Incidences (in month) 0 1 2 1 5 5 3 4 2 4 6 4 3
MSSA Trust Incidence 1 1 6 3 2 6 8 4 1 1 1 0 1
E-Coli Trust Incidence 3 6 4 5 4 5 7
Average fi l l rate – registered nurses/midwives (%) - Day 97.6% 98.7% 96.9% 97.5% 96.7% 95.6% 95.4% 96.9% 95.9% 94.4% 93.4% 93.5% 95.4%
Average fi l l rate – care staff (%) - Day 91.1% 88.7% 92.4% 91.9% 96.4% 93.0% 96.5% 96.6% 94.7% 94.9% 92.3% 96.3% 94.4%
Average fi l l rate – registered nurses/midwives (%) - Night 98.3% 97.7% 97.0% 97.3% 97.9% 97.4% 96.7% 97.9% 97.0% 97.5% 96.7% 96.0% 95.8%
Average fi l l rate – care staff (%) - Night 93.9% 92.8% 92.3% 95.4% 95.0% 94.9% 96.1% 95.3% 96.6% 96.5% 95.4% 95.1% 94.3%
Falls - Total in month 116 93 131 116 92 101 97 84 96 115 101 76 102
Falls per '000 Bed days 6.06 5.07 6.86 6.00 5.16 5.20 5.15 4.31 5.06 5.91 5.25 4.07 5.23
Pressure Damage (Hospital Aquired) - Total in Month 9 15 13 14 14 17 8 14 17 8 15 20 15
Pressure Damage per '000 Bed days 0.47 0.82 0.68 0.72 0.78 0.87 0.43 0.72 0.90 0.41 0.78 1.07 0.77
Safety
Ward Staffing
Infection Control (Trust Aquired)
Reduce Avoidable Harm
Are we effective?
Section 3
12
Delivering our vision – How are we doing?
Effective – People’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence
13
• Latest HSMR data for the Trust continues to show improvements in relative risk and
remains rated ‘better than expected’ for our patient group when benchmarked against
national comparators.
• July in-month Hospital Standardised Mortality Rate for #NoF was a relative risk of
87.3.
• Latest SHMI data also shows positive performance.
Mortality and readmissions
• Readmission indicators continue to see the Trust perform well.
• Divisional audit programmes remain on track.
• The Trust reported significant progress in meeting NICE guidance around Acutely Ill
Patient.
Other effectiveness
HSMR
(July-17)
91.7
SHMI
(Mar-17)
0.95
7 day
Readmission
3.8%
28 day
Readmission (Sept-17)
8.0%
Delivering our vision – How are we improving?
Effective – Improve discharge planning
14
• Daily calls with Senior Leaders from partner organisations to discuss ‘Delayed Transfer of Care’
(DTOC) patients continue with additional twice weekly calls with Chief Executive Officers.
• Improvements to the Discharge Tracker have been made and it is now automated and accessible by all
ward staff and community teams.
• CCGs have committed to 100k resilience monies to deliver required improvements and to strengthen
the Integrated Discharge Team over the winter period. The Team is working with external experts to fill
vacant posts.
• A post that has been funded to support delivery of the CQUIN ‘Supporting proactive and safe
discharge’ has been appointed to with a start date being agreed.
Discharge Planning
• The Trust continues to embed SAFER flow and a project is underway to move towards using
real-time data in the management of inpatient beds and associated resources.
SAFER Flow
Delivering our vision – How are we doing?
Effective – Scorecard
15
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
HSMR (56 Monitored diagnoses - 12 Months) 93.4 93.9 95.8 95.9 94.7 94.8 94.4 93.0 93.4 91.7
SHMI 0.96 0.95
Emergency readmissions within 7 days 3.6% 3.4% 4.2% 3.6% 3.5% 3.7% 3.7% 3.8% 3.9% 3.5% 3.6% 3.7% 3.8%
Emergency readmissions within 28 days 7.4% 7.3% 8.4% 7.5% 7.2% 7.7% 7.5% 8.0% 8.0% 7.4% 7.6% 8.0%
Maternity - C Section Rate - Emergency 15.1% 15.9% 16.5% 12.8% 17.9% 17.1% 20.0% 20.0% 19.4% 16.5% 18.5% 15.3% 16.0%
Research - Overall Recruitment % Vs Expected 77% 88% 86% 100% 96% 98% 90% 79% 98% 110%
YCM - Were you kept informed of your estimated data of discharge from hospital? 71 68 67 70 64 68 67
YCM - When you were ready to be discharged, were you satisfied with the plan that was put in
place?84 79 79 82 79 77 83
Average No of Adults Over 7 Days 272 253 280 296 292 277 293 280 290 294 285 279 282
Average No of Adults Over 14 Days 163 152 163 184 178 171 182 171 185 188 180 173 177
Average No of MRD 102 98 96 110 105 108 115 97 95 123 117 109 116
Discharge Planning
Mortality and Readmissions
Other Effectiveness
Are we caring?
Section 4
16
Delivering our vision – How are we doing?
Caring – service involves and treats people with compassion, kindness, dignity and respect
17
Outpatient
FFT
88.8%
• Inpatient FFT – Inpatient FFT dropped slightly to 94.5% in October from 95.7% in September
but maintains Amber performance on the Trust RAG rating. The response rate average for all
inpatient areas is 33%.
• Emergency Department FFT - The FFT score has increased to 96.7% in October from 95.5%
in September. The response rate for October was unusually low at 8.89%. This was due to the
building works in the Emergency Department and an interruption to the usual patient feedback
methods which has now been rectified.
• Maternity FFT – The FFT score for the postnatal ward has decreased significantly to 89.6% in
October from 95.7% in September. The Delivery/birthing centre score for September also
dropped to 80% however this was based on only 5 responses. Work is underway with the
maternity teams to understand the latest patient feedback score with a focus on improving
response rates at the same time as reviewing patient feedback.
• Outpatients FFT - The FFT score for Outpatients has decreased slightly to 88.8% from 89%
in September. The number of responses however has increased to 1335 in October compared
to 1200 received in September.
Friends and family test
ED FFT
96.7%
Inpatient FFT
94.5%
Raising awareness and supporting carers – Continuous opportunities are being used to promote the carers
passport and raise carer awareness among staff. An event is being organised in the restaurant to welcome carers
of patients for ‘tea and a chat’ hosted by our two carer support organisations. On the same day, and in recognition
of ‘carers rights day’, a staff even has also been arranged to reach out to staff who are carers to offer support and
listen to what these staff members need would appreciate in the way of support.
The carers steering group continues to meet regularly and the two carer support organisations visit wards
throughout the week to identify and provide assistance to carers of patients
Carers
Delivering our vision – How are we doing?
Caring – service involves and treats people with compassion, kindness, dignity and respect
18
• Mixed Sex Breaches – The Trust continues to report zero mixed sex breaches in October. The organisation is
currently awaiting feedback from NHS England/NHS Improvement following the week long mixed sex accommodation
audit undertaken at the end of September.
• Complaints – In October complaints received increased to 52 in comparison to 36 the previous month. 100% of
complaints have been acknowledged within 3 working days, as per statutory requirements, consistently for the last 7
months and 100% of complaints were closed within the agreed timeframe in October.
• Accessible Information Standard – The testing phase for producing patient letters in alternate formats is currently
underway.
• Way Finding – Executive approval for the budget has been provided and the project is now being mobilised. Final
artwork is being prepared by the contractor for review and sign off. Following this, samples of proposed signs will be
installed in one area for final agreement and the signage within the scope of the project will then be installed in January
as well as a de-cluttering of old signage. Areas within the project scope are; main corridors, cardiology, therapies and
the two entrances.
Other Patient Experience
Complaints
per 10,000 pt.
contacts
11
Mixed Sex
Breaches
0
• Responsiveness to feedback – Automated actions generated by the Meridian system require key staff to make
appropriate and continuing improvements in their areas. Areas with a low FFT score are monitored and work streams
arise from this feedback. For example work continues in outpatients with oversight from the SASH+ team with Patient
experience involvement.
• Focusing on priorities for improvement at ward/departmental level – Priorities are consistently being raised to key
staff through the alerts system on the reporting platform and by the monthly batch reports provided to the clinical areas
by Meridian. The monthly ‘Patient Experience Committee analyses data from meridian to assess overall performance.
However it is agreed that a better approach to identifying top trends through the system should be provided and this is
going to be implemented in the coming months.
Patient experience platform
Delivering our vision – How are we improving?
Caring – Create best environment for patients
19
• The new GP streaming area opens on the 9th November. The new ambulance bay continues to work well with excellent
compliance from all vehicles.
• The new Kingsfold Ambulatory Care Unit opened in October 2017.
• Work has commenced on design work for the different elements of the Neonatal project. These will be used to inform the tenders
which will be issued in early 2018.
Estate / Building Developments – Major Schemes
A variety of improvement works have been undertaken across the hospital wards and the following table summarises the main
activities:
Ward Improvement Works
Ward Works Status
Tandridge General refurbishment Preparing tender for revised scheme
Delivery Suite Bathrooms Underway
Delivery Suite Sluice and SANDs room In plan
Leigh & Newdigate Sluice Complete
Leigh & Newdigate Over-bed lighting and power Underway
Various Yellow toilet and shower doors Underway
Meadvale MDT room Complete
Outwood Bathrooms November
Outwood External windows Underway
Buckland Over-bed lighting Complete
Abinger MDT Room In plan
Capel Bathrooms In plan
Chaldon Flooring In plan
Abinger & Meadvale Rear Entrance In plan
Holmwood General Refurbishment Complete
Delivering our vision – How are we improving?
Caring – Create best environment for patients
20
In addition to work in ward areas a number of other smaller projects have taken place or are planned, these are shown below:
Estate / Building Developments – Other Improvement Works
Outpatients General refurbishment Complete
Chapel Multi-faith facilities and refurbishment In plan
Diagnostic Imaging Various works Complete
Phlebotomy and Haematology Minor works including new back-door Complete
ED New flooring Underway
PGEC New reception and seating for lecture theatre In plan
Lung Function Refurbishment Complete
Bereavement New office Complete
Security New office Complete
Modular 1 Refurbishment and office moves Underway
Chamomile Courtyard New dementia garden by Pendleton Unit Tender being prepared
Mortuary Visitors’ Room Refurbishment Complete
Chipstead New OPD consulting room, ECG room and assessment
space
Underway
Main Kitchen Ventilation Upgrade Complete
Trust HQ
Toilet Upgrade Complete
Delivering Our Vision – How are we doing?
Caring – Scorecard
21
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
Emergency Department FFT - % positive responses 96.1% 96.8% 96.0% 96.3% 96.6% 96.9% 96.3% 95.7% 93.8% 95.7% 93.7% 95.5% 96.7%
Inpatient FFT - % positive responses 95.4% 94.8% 95.5% 96.7% 96.2% 95.8% 96.6% 95.6% 95.2% 96.2% 95.2% 95.7% 94.5%
Day Case FFT - % positive responses 95.4% 94.8% 95.5% 96.7% 96.2% 95.8% 96.6% 96.9% 94.4% 94.7% 93.9% 96.1% 95.5%
Outpatient FFT - % positive responses 91.1% 91.2% 88.0% 89.7% 90.7% 90.6% 88.0% 88.7% 88.6% 88.0% 90.5% 89.0% 88.8%
Maternity FFT - Antenatal - % positive responses 98.6% 95.6% 93.9% 98.5% 95.2% 95.9% 100.0% 94.7% 90.6% 87.5% 96.8% 100.0% 100.0%
Maternity FFT - Delivery - % positive responses 97.1% 96.9% 98.7% 97.8% 97.3% 98.8% 96.7% 100.0% 100.0% 83.3% 100.0% 100.0% 80.0%
Maternity FFT - Postnatal Ward - % positive responses 92.8% 86.6% 96.2% 92.3% 89.0% 92.1% 95.8% 91.0% 94.9% 95.2% 97.3% 95.6% 89.6%
Maternity FFT - Postnatal Community Care - % positive responses 96.4% 98.3% 92.5% 100.0% 92.0% 100.0% 97.7% 96.2% 100.0% 96.6% 97.2% 100.0% 100.0%
Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0
Complaints - Number received in month 48 36 36 56 43 57 41 50 55 37 42 36 52
Complaints - Rate per 10,000 patient contacts 10 7 8 12 10 11 10 10 11 8 9 8 11
Friends and Family Test
Other Caring
Are we responsive?
Section 5
22
Delivering our vision – How are we doing?
Responsive – services meet people’s needs
23
ED 4hr
93.2%
Amb
Handover
over 60min
38
• October continued to be a busy month for emergency care. The ED 4hr standard was not
achieved in October 2017 with performance of 93.2%, however SASH system AEDB
performance was 95.9%.
• Ambulance turnaround performance remains a challenge in October 2017 with 38 breaches of
the 1hr standard. The re-development of the Emergency Department “Front Door” including
physical re-configuration and revised streaming will support improvements in ambulance
handover. From December, all 1hr breaches will be investigated as moderate incidents with an
RCA and reported through the Serious Incident Review Group.
Emergency department
• October saw improvements in both the Cancer TWW standards with both returning to achieving
the 93% standard.
• 62 Day GP performance continued to exceed the national standard with over 90% of patients
starting treatment within 62 days.
• Performance on the screening standard was 75.0% as a result of two breaches on the breast
screening pathway with delay due to patient deferrals.
Cancer treatment
Two Week
Wait
94.0%
62 Day GP
90.4%
Delivering our vision – How are we doing?
Responsive – services meet people’s needs
24
• The Trust did not achieve the 92% RTT Incomplete pathway standard with performance
of 86.8% in September 2017.
• RTT remains a challenge with the impact of emergency pressures, cancer referrals,
tracking system change over as well as specialty specific capacity issues being the root
causes of the under performance.
• At the end of October 2017, 22 patients were waiting over 52 weeks for treatment. Of
these 22 patients, 9 have since either received treatment or been discharged back to
the care of their GP. Treatment plans are in place for the remaining 13 patients.
• No patient harm has been identified from RTT 52 week breaches and root cause
analysis of the pathway is undertaken by clinical divisions.
• The 6 week diagnostic standard was not achieved in October 2017 with performance of
1.19% with capacity issues in Cardiac CT being the key driver. Recovery is expected in
November 2017.
RTT and diagnostics
RTT
Incompletes
86.8%
6 Week
Diagnostic
1.19%
Delivering our vision – How are we improving?
Responsive – Improve efficiency of elective care
25
• Outpatients has seen positive performance with £579k of savings YTD. The DNA rate
reduced in October to 7.7%. The un-booked rate remained static in October, driven by a
variety of factors including staffing levels. Recruitment plans are in place which will
support further improvement in this indicator in the coming months. Review of capacity in
specialties with short waiting times are also underway.
• Theatres saw improved performance in October 2017, although remains behind trajectory
and significantly impacted YTD by Q1 performance.
• Theatre cases per session increased to 3.03 with some specialties continuing to show
improvements compared to prior year. Cancellation rates were 7.2% which is behind
trajectory but an improvement on September – there were zero on-the-day bed
cancellations.
• Endoscopy productivity was adverse to trajectory in October and a number of measures
are being put in place to support improvement and these are yielding benefit in November.
• Across all booking teams there has been an impact on plans from delays in EPR upgrades
and office moves as well as from staff sickness.
Overview of October 2017
OPD (OBO)
DNA Rate
7.7%
OPD (OBO
Un-booked
Rate
10.4%
THR - Cases
Per Session
3.03
THR
Cancellation
Rate
7.2%
Endo -
Patients Per
Session
5.51
Endo - Points
Per Session
7.54
Delivering our vision – How are we doing?
Responsive – Scorecard
26
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
ED 95% in 4 hours 95.4% 95.1% 89.8% 87.0% 90.9% 95.1% 92.9% 92.6% 92.8% 93.6% 94.4% 94.1% 93.2%
Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0
Ambulance Turnaround - Number Over 30 mins 189 224 336 253 194 249 188 253 199 246 306 225 299
Ambulance Turnaround - Number Over 60 mins 11 22 80 66 34 19 27 46 50 33 47 40 38
Cancer - TWR 94.8% 94.3% 94.5% 94.7% 94.4% 95.0% 92.2% 93.0% 93.7% 90.6% 91.1% 91.6% 94.0%
Cancer - TWR Breast Symptomatic 99.0% 95.8% 94.7% 95.4% 93.0% 95.7% 93.0% 93.5% 93.5% 95.7% 90.5% 85.7% 94.1%
Cancer - 62 Day Referral to Treatment Standard 89.8% 89.7% 86.6% 87.9% 86.0% 86.4% 87.9% 86.0% 85.2% 86.9% 85.7% 86.3% 90.4%
Cancer - 62 Day Referral to Treatment Screening 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 71.4% 100.0% 81.8% 75.0% 80.0% 87.5% 75.0%
Cancer - 31 Day Diagnosis to Treatment 96.0% 95.6% 100.0% 97.7% 99.0% 98.7% 100.0% 99.2% 98.6% 99.2% 95.5% 95.2% 97.3%
Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0%
Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
RTT Incomplete Pathways - % waiting less than 18 weeks 92.1% 92.5% 90.9% 90.5% 90.0% 90.1% 88.7% 87.3% 87.3% 86.9% 86.4% 86.1% 86.6%
RTT Patients over 52 weeks on incomplete pathways 3 4 5 13 15 19 19 53 51 33 23 20 22
Percentage of patients waiting 6 weeks or more for diagnostic 9.5% 8.3% 4.7% 0.4% 0.3% 0.2% 0.4% 0.7% 1.0% 0.9% 0.7% 0.8% 1.19%
No of operations cancelled on the day not treated within 28 days 9 5 2 7 3 9 7 18 21 15 5 11 12
Cancer Access
RTT
Emergency Department
Are we well led
Section 6
27
Delivering our vision – How are we doing?
Well led – leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture
28
Vacancy Rate
10.9%
• Vacancy rates across all staff groups has decreased by 0.7% to 10.9%. For Nursing, vacancy rates
have remained at 19%.
• Turnover has reduced by 0.3% to 16.2% for all staff groups, but increased by 0.5% for nursing to
19%.
• We are reviewing our approach to recruiting nursing and midwifery staff and are undertaking an
assessment of different options for this (e.g. direct sourcing, etc.).
• Our Retention Plan has been submitted to NHSi and we are awaiting feedback. Our objective is to
reduce turnover by 1% across all staff groups in the 12 months from October 2017 to November
2018.
• We have submitted a bid to Health Education England Kent, Surrey and Sussex for funding to
support our succession planning and talent management programmes.
• We have started to design the management training component (‘How to Get Thing’s Done’), of our
overall ‘SASH Leaders’ programme.
Establishment
Turnover
Rate
16.2%
• MAST figures have remained fairly static at 76%.
• All clinical Divisions have a compliance rate of at least 77%, with Cancer & Diagnostics currently at
80%, (against a green RAG rating KPI of 80%).
• We are reviewing areas with low compliance rates (i.e. Estates & Facilities), to consider bespoke
solutions to increase their overall rate.
• Achievement Review completion rates increased to 84%, by the end of October against a target of
90%. We have however subsequently achieved the 90% target.
• The Trust’s HR Business Partners are working with Divisions to ensure all relevant staff have a
completed achievement review for 2017.
Training and Achievement Review
MAST
Compliance
76.1%
Achievement
Review
84%
Delivering our vision – How are we improving?
Well Led – Staff health, well being and working lives
29
• Sickness has increased by 0.3% to 4.1%.
• There has been a reduction in absences for planned surgery and MSK related issues.
• There has been a significant increase in absences for ‘colds, coughs, and flu’, as well as
increases for GI and mental health related conditions.
• Long term sickness is at 1.8%
• Short term sickness is at 2.3%
• The new in-house Employee Relations Team are proactively managing sickness cases
with line managers to ensure these are concluded in a timely manner
Sickness
• The Trust’s Flu vaccination campaign commenced on 9th October and over 2,200 vaccinations have
been administered so far. Our target is that 70% of all frontline staff are vaccinated by 31st
December.
• The collaborative work with South London & the Maudsley, (SLaM), which is to support staff with
managing their mental health is on-going. The mental health impact assessments are now complete
and analysis of the outcomes of these are being reviewed to support ‘next steps’ in this programme.
• SLaM are also delivering Mental Health Awareness sessions for staff and managers which have
been well received.
• We continue to promote ‘Active SASH’ activities across the Trust – we are currently promoting on-
site circuit training for staff (which commences on 5th December).
• We are developing our ‘Step Ahead’ campaign which encourages staff to walk more frequently and
sets out a number of walks they can take in lunch breaks, etc.
Health and Well being strategy
Sickness %
4.1%
Delivering our vision – How are we doing?
Well Led – Scorecard
30
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
Total Establishment (WTE) 3891 3937 3944 3952 3925 3932 3929 3944 3950 3961 4006 4006 4027
Vacancy Rate (All Staff) 11.2% 11.5% 11.8% 11.0% 9.8% 9.4% 9.5% 9.5% 9.6% 10.4% 11.1% 11.6% 10.9%
Staff Turnover rate 15.6% 15.5% 16.4% 16.4% 16.1% 15.8% 16.0% 15.7% 15.8% 15.9% 16.1% 16.5% 16.2%
% of Staff who have had an Achievement Review YTD 86.4% 95.2% 96.4% 97.0% 97.2% 97.6% 1.3% 11.5% 19.5% 39.7% 53.0% 65.0% 84.0%
%age of staff who have completed MAST training in the last 12 months 80.3% 79.9% 80.0% 80.3% 76.8% 78.0% 77.2% 76.0% 77.0% 75.0% 77.0% 76.6% 76.1%
Overall Sickness Rate 3.9% 4.2% 4.3% 4.1% 3.7% 3.5% 2.8% 3.5% 3.6% 3.8% 4.1% 3.8% 4.1%
Establishment and Training
Staff health, well being and working lives
Do we use resources effectively
Section 7
31
Delivering our vision – How are we doing?
Effective use of resources
32
• The Trust’s Income & Expenditure 2017/18 Control Total is a £21.3m adjusted surplus. Current
forecasts show a £16m risk against delivery of this control total.
• The Trust achieved a £5.3m [adjusted] surplus at the end of October 2017, which was £1.8m worse
than plan for the YTD position. This is driven by a £0.9m shortfall in clinical income and a £0.9m
shortfall in Sustainability & Transformation Funding (STF).
• The position includes £3.1m STF for successfully delivering the Q1 & Q2 financial plans.
• £2.8m of savings have been achieved YTD.
• The 2017/18 savings programme totals £6.2m.
• The Programme includes:
• £2m saving in agency premium,
• £2.4m productivity savings,
• £1.8m non pay savings,
• YTD achievement is £2.8m (including £1.2m use of contingency reserves) against a plan of £2.8m.
Savings Plan
YTD Savings
£m - Actual
£2.8m
YTD £m
Adjusted
Surplus
£5.3m
Income and Expenditure
Delivering our vision – How are we doing?
Effective use of resources
33
• The planned Capital Resource Limit (CRL) for 2017/18 is £18.8m including £1.1m CRL deferred from
2016/17.
• The capital programme will be funded by £9.8m from depreciation, £7m capital investment loans, £0.9
Public Dividend Capital for ED Primary Care Screening and other internally generated funds; the Trust will
repay £1.3m of existing capital investment loans.
• Major projects in the 2017/18 capital programme include, Ambulatory Care Unit £2.9m, Pathology Joint
Venture £2.7m, EPR Digitise £2.0m, Day Surgery Unit £1.7m and Estates Fixed Allocation £1.5m.
• The cash balance at the end of August 2017 was £5.4m.
• The Trust repaid £3.5m revolving working capital in April 2017 and borrowed a further
£1.3m in July leaving an outstanding balance of £13.8m.
• This cash has supported the Trust’s Better Payment Practice Code performance
which is 87% by volume, 86% by value in the first four months of 2017/18.
Capital Plan
Cash Management
Delivering our vision – How are we doing?
Resources – Scorecard
34
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Trend
Outturn £m Surplus / (Deficit) - Plan 15.2 15.2 15.2 15.2 15.2 15.2 21.3 21.3 21.3 21.3 21.3 21.3 21.3
Outturn £m Surplus / (Deficit) - Forecast 15.2 15.2 0.3 5.0 5.0 5.0 21.3 21.3 21.3 21.3 21.3 21.3 21.3
YTD £m Surplus / (Deficit) - Plan 1.8 6.2 5.0 6.8 10.1 15.2 (1.6) (0.3) 1.1 2.7 3.0 4.3 7.1
YTD £m Surplus / (Deficit) - Actual 0.1 2.8 2.0 3.6 2.0 3.5 (1.0) 0.1 1.2 2.7 3.1 4.4 5.3
Annual Outturn UNDERLYING £m Surplus / (Deficit) - Plan 7.5 7.5 7.5 7.5 7.5 7.5 12.5 12.5 12.5 12.5 12.0 12.5 12.5
Annual Outturn UNDERLYING £m Surplus / (Deficit) - Actual 7.5 7.5 (4.6) (2.8) (2.8) (4.3) 12.5 12.5 12.5 12.5 12.0 12.0 12.0
YTD Savings £m - Actual 3.1 4.4 5.6 6.8 8.0 9.2 0.3 0.7 1.0 1.4 1.8 2.2 2.8
OT Risk £m Surplus / (Deficit) - Assessment (14.9) (14.9) (4.0) (2.5) (2.5) 0.0 (8.0) (8.0) (8.0) (16.3) (16.3) (16.0) (16.0)
Outturn Cash position £m Fav / (Adv) - Forecast 2.1 6.3 2.5 2.5 2.5 5.6 2.7 2.7 2.7 2.7 2.7 2.7 2.7
YTD Cash position £m Fav / (Adv) - Actual 4.8 7.2 5.3 4.4 2.9 5.6 3.8 5.9 2.6 3.9 5.4 5.1 6.0
YTD Liquid ratio - days (16.0) (10.0) (9.0) (7.0) (11.0) (12.0) (14.0) (13.0) (12.0) (11.0) (10.0) (9.0) (8.0)
YTD BPPC (overall) volume £m 77% 79% 80% 82% 83% 83% 94% 93% 92% 88% 86% 82% 74%
YTD BPPC (overall) value £m 77% 79% 80% 80% 82% 82% 97% 94% 91% 87% 87% 83% 78%
Outturn Capital spend Fav / (Adv) - forecast 15.9 12.6 12.4 11.3 11.4 11.4 18.8 18.8 18.8 18.8 18.8 18.8 18.8