meeting of the board of directors - st richard's …...meeting of the board of directors...

Meeting of the Board of Directors

10.00am to 12.00pm on Thursday 1 May 2014

Bateman Room, Chichester Medical Education Centre, St Richard’s Hospital, Spitalfield Lane, Chichester, West Sussex PO19 6SE

AGENDA – MEETING IN PUBLIC

1 10.00 Welcome and Apologies for Absence Chair

2 10.00 Declarations of Interests All

3 10.00 Minutes of Board Meeting held on 27 March 2014 To approve

Enclosure Chair

4 10.05 Matters Arising from the Minutes

To note Enclosure Chair

5 10.10 Chief Executive’s Report

To receive and agree any necessary action Enclosure MG

PATIENT SAFETY/EXPERIENCE ITEMS

6 10.20 Quality Report To receive and agree any necessary action

Enclosure CS/GF

7 10.30 Bi-Annual Nursing Report

To receive and accept Enclosure CS

OPERATIONAL ITEMS

8 10.40 Performance Report

To receive and agree any necessary action Enclosure AC

9

10.55 Organisational Development and Workforce Performance (to include presentation on website development) To receive and agree any necessary action

Enclosure/ Presentation

DF

10

11.20 Financial Performance To receive and agree any necessary action

a) Month 12

Enclosure

KG

11

11.30

STRATEGIC ITEMS Annual Plan Progress – Review of Board Assurance Framework

Enclosure

DF

12 11.40 Operational Plan 2014/2016

Enclosure

DF

13 11.50 Financial Plan 2014/2015 OTHER ITEMS

Enclosure KG

14 12.00 Quarter 4 Monitor Self - Assessment

Enclosure AG

15 12.05 Board Declaration of Interests Enclosure AG

16 12.10 Other Business Chair

17 12.20 Resolution into Board Committee To pass the following resolution: “That the Board now meets in private due to the confidential nature of the business to be transacted.”

Verbal Chair

Date of Next Meeting

The next meeting in public of the Board of Directors is scheduled to take place at 10.00 on 29 MAY 2014 in Boardroom A , Washington Suite, Worthing Hospital

Chair

Close of Meeting Chair

Questions from the Public Following the close of the meeting there will be an opportunity for members of the public to ask questions about the business considered by the Board.

Chair

Andy Gray Company Secretary: 01903 285288 | m: 07785 332416 E: [email protected]

mailto:[email protected]

Minutes of the Board meeting held (in public) at 10.00am on 27 March 2014 in the Bateman Room, Chichester Medical Education Centre, St Richards Hospital, Spitafield Lane, Chichester, West Sussex, PO19 6SE.

Present: Mike Viggers

Bill Brown Chairman Non-Executive Director

Tony Clark Non-Executive Director Joanna Crane

Jon Furmston Martin Phillips

Non-Executive Director Non-Executive Director Non-Executive Director

Marianne Griffiths Denise Farmer Jane Farrell

Chief Executive Director of Organisational Development and Leadership Chief Operation Officer – Deputy CE

Dr George Findlay Medical Director Karen Geoghegan Director of Finance Cathy Stone Director of Nursing & Patient Safety In Attendance: Andy Gray

Barbara Mathieson Company Secretary Assistant to Company Secretary (Minutes)

TBP/03/14/1 WELCOME AND APOLOGIES FOR ABSENCE 1.1 1.2

The Chairman welcomed all those present to the meeting. There were no apologies for absence.

TBP/03/14/2 DECLARATIONS OF INTERESTS 2.1 There were no interests to declare. TBP/03/14/3 MINUTES OF THE BOARD MEETING HELD ON 27 February 2014 3.1 3.2 3.3 3.4 3.5 3.6

The Board received the minutes of the meeting held on 27 February 2014 and noted the following amendments: TBP/02/14/6.3 Second sentence amended to read:- A reduction in the rate of knee infections ……. TBP/02/14/6.7 Last sentence amended to read:- …… the Trust was in the process of responding to. TBP/02/14/6.8 – Action amended to CS TBP/02/14/8.10 Last sentence amended to read:- The Chief Operation Officer also explained the need (to) for forecasting to take place at a more sub speciality level. TBP/02/14/10.2 First sentence amended to read:- The financial position for January 2014 was a surplus of £373K and a year to date surplus of £522K.

3.7

The Board resolved that the minutes of the meeting held on would be approved subject to the amendments outlined above as an accurate record of the meeting and signed by the Chairman.

TBP/03/14/4 MATTERS ARISING FROM THE MINUTES

4.1

Questions from the Public – John Gooderham on Vascular Services The Chief Executive updated the Board on the provision of Vascular Services within the Trust and the arrangements with Brighton and Sussex University Hospitals NHS Trust (BSUH). The Clinical model had been agreed with BSUH and the Business and Care Models were near to being finalised. The remaining surgeon’s contracts had now been transferred to BSUH and it was confirmed that all services and on-call arrangements were now in place.

TBP/03/14/5 CHIEF EXECUTIVE’S REPORT 5.1 5.2 5.3 5.4 5.5 5.6

The Chief Executive presented the report, the main points of which were as follows: Recent plans launched by NHS England to tackle Dementia were highlighted to the Board and a paper would be brought to the next Board meeting giving details of the Trusts proposed Dementia Strategic Plan. The paper would outline the Trusts approach and new planned processes. It was also noted that a Medical Matron was taking a lead on the Dementia work and Trust volunteers would be encouraged to work in the areas offering support to patients suffering from Dementia. The first stage of the planned Emergency Floor at Worthing Hospital had been completed. Overall the aim was to improve the ability to manage the admissions of adult patients. The new services would greatly improve the environment for both patients and staff and the second stage would be completed later in 2014. The Chief Executive reported on of the Executive Teams’ recent visit to the Virginia Mason Hospital & Medical Centre which had been funded through the Leadership Foundation. Virginia Mason had successfully implemented significant to both care and culture. The findings of the visit had been shared at the recent Trust Board Away Day and learning would be developed into a programme of work going forward. Ongoing partnership with the Virginia Mason Network alongside the Royal Surrey County Hospital NHS Trust who had recently also visited were planned. The Chair requested that additional information be provided to the Governors on the experience of Virginia Mason and the operation of the Emergency Floor. The Chief Executive confirmed that plans would be put in place to recognise the contribution to raising awareness of Pancreatic Cancer and in memory of Kerry Harvey, a former St Richard’s member of staff who had died from the disease in February 2014 The Trust had 10 members of staff nominated for the Surrey and Sussex - Proud to Care Awards 2014 and it was noted that it was a significant accolade to have that number of nominations.

CS MG

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5.7 5.8

The sculptures “The Gift” which would celebrate and raise the profile of organ donation would be unveiled on the 8 and 10 April at St Richards and Worthing. Members of the Board were encouraged to attend these events To conclude the Chief Executive outlined the care given to an individual patient by the employee of the month Rosemary Campbell. The certificate would be presented to her on the ward that she worked on.

TBP/03/14/6 QUALITY REPORT 6.1 6.2 6.3 6.4 6.5 6.6

The Director of Nursing and Patient Safety and the Medical Director presented the report, the key issues of which to note were as follows: It was reported that there had been an increase in the number of falls with inpatients and that this was for the second month running. Although the number of falls within the Trust is still below the national average the view is that any fall was one to many. No concerns relating to falls had been found for any specific ward or relating to the use of agency staff and the “Slipper Library” provided with the support of the Friends Charities had been a positive move to help to reduce falls. . The Director of Nursing and Patient Safety reported that nationally there had been a reduction in the number of cases of Meticillin–resistant Staphylococcus Aureus (MRSA) and no cases had been detected in the Trust for the period. There had been three cases of Clostridium Difficile ( C. Diff) during February of which one was deemed avoidable. There had been no concerns with the clinical care but a delay in sending the specimen for testing. It was also noted that the C Diff trajectory figures for 2014/2015 had been announced. For the Trust the figure was a limit of 56 cases for the year and was based on previous reporting from Nov 2012 to Nov 2013. The Chief Executive confirmed that there had been a change of approach by the CCG to the monitoring of C. Diff so that the ownership of the issues was undertaken by the whole health community. The monetary penalties had been reduced to £10K per case over trajectory and if a case was deemed to be avoidable but that the correct package of care was in place then it would not be included in any penalties levied against the Trust. The Board asked for more information to be included on Surgical Site Infections The Medical Director noted that the non-elective mortality rate for the Trust had improved over the past year and for the year to date the figures reported were on trajectory. The Hospital Standardised Mortality Ratio (HSMR) was 92. 3 (where 100 was the national average). The Summary Hospital – Level Mortality Indicator (SMHI) was as expected and the Trust would be looking to improve that score. Also, within the exception reports, which gave information on specific conditions, three areas performance against trajectory was better than excepted. Acute Renal Failure figures remained higher than trajectory. A review of recent cases had been undertaken on this small number of cases and no systemic factors of concern had been identified. However, the medical teams were not satisfied with the progress within this area and as a result reducing avoidable morality from Acute Kidney Injury had been suggested as one of the priority areas for improvement within 2014/2015 as part of the Trusts Quality Report.

CS

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6.7 6.8 6.9 6.10 6.11 6.12

The Medical Director highlighted to the Board two areas which all NHS Trusts had been asked to consider by NHS England. The Trusts guidance on the disposal of fetal remains would be considered to ensure that an appropriate policy was in place and details would be brought to the Board for reassurance. The second area was that of moving patients at night. Again the Trust would re-visit its policy and report back to Board. It was also reported to the Board that the Women and Children Division of the Trust had recently undergone a formal Clinical Negligence Scheme for Trusts (CNST) assessment and the Chief Executive and Director of Patient Nursing and Patient Safety were delighted to confirm that they had achieved level three and a score of 49 out of 50. The team effort of achieving this was acknowledged and praised alongside recognising the quality of care given to patients within these areas. It was recommended that the team learning from achieving level 3 CNST should be shared via a Board Seminar at a future date. The Director of Nursing and Patient Safety gave an update to the Board following the CQC visit to the Trust on the area of care of patients with Dementia. This visit had taken place on the 23 January 2014 and had resulted in positive feedback on the care provided and the areas of good practice identified. One minor action regarding the levels of doctors available had been identified and this had been addressed. Jon Furmston, Non – Executive Director commented on the ongoing improvement in mortality figures and asked what the main drivers for the achievement had been and if there were any areas where there could be further improvements. The Medical Director confirmed that the Trust had been an outlier for Fractured Neck of Femur but this had now improved. The priority for the next year would be to maintain the improvements. A good base line of care was important and now only small changes in figures should be expected. Following discussion it was agreed that the Trust should set itself an internal and lower figure for the number of attributable C. Diff cases for forthcoming period.

GF

TBP/03/14/7 Monitor Quality Report and Quality Account 2013/2014 7.1 7.2 7.3

The Medical Director presented the draft Monitor Quality Report and Quality Account 2013/2014 and explained that under NHS Foundation Trust status the Trust must include a report on the quality of care provided within their annual report. The information to be included within the report is specified by Monitor and was slightly more extensive than the Quality Accounts that all NHS Trusts publish. It was noted that external stakeholders had early input into the report through a consultation workshop which took place in February 2014. A key part of the report was the section which set out proposed quality improvements priorities for 2014/2015. The Medical Director asked the Board to approve the priorities and to note that the final draft of the report Quality Report and Account would be made

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7.4 7.5 7.6

available to the Board, external stakeholders and external auditors at the end of April. The final report would be submitted to the Board for approval on the 29 May 2014. The Chairman asked about the inclusion of “End of Life Care” as a priority. The Medical Director confirmed that it would be a key focus within the third priority but that it was important that the local Clinical Commissioning Group (CCG) took a lead in the work. The Trust would work alongside the CCG on improving pathways. Bill Brown asked about improving the use of Electronic Discharge Summaries as detailed within the Data Quality section of the report. The Medical Director confirmed that the use of these summaries had risen to over 90% and that it was now a suitable time to remove the paper alternative. It was also confirmed that this information would be included within the report. The Board resolved to note the draft report and confirmed their approval of the Quality Improvement Priorities for 2014/2015. .

TBP/03/14/8 Quarter 3 Complaints and PALS Report 8.1 8.2 8.3 8.4 8.5

The Director of Nursing and Patient Safety presented the Quarter 3 Complaints and PALS report to the Board and explained that it had been scrutinised by the recent Patient Experience and Feedback Committee. It was noted that there had been a reduction in the overall number of complaints received by the Trust with the exception of the A & E Departments. The majority of the complaints received by the Trust involved issues with communication and difficulties with appointments. Within Ophthalmology new systems had been introduced to help reduce the number of complaints and PALS enquires. All issues were now being filtered through a single member of staff who would check care needs and urgency with a clinician. Jon Furmston raised concern about the number of complaints within A&E when they performed well within the Friends and Family Test. The Board expressed concern that some of the data could put undue pressure on the team within A&E and it was acknowledged that further work was needed to triangulate all data received for the area. Tony Clark confirmed that the Patient Experience and Feedback Committee had reviewed complaint files which had involved A&E cases and all had been responded to in an excellent manner with areas for learning acknowledged.

CS

8.6 8.7

Joanna Crane raised a concern about the number of complaints received on the Worthing Site relating to the Co-ordination of Medical Treatment. This appeared to go against the information received from the inpatient survey which had shown an improvement within this area. The Chief Executive confirmed that co-ordination of care / medical treatment was one of the focuses included within the Francis Report. The ideal

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8.8

scenario to help with the increasing aging patients who have many co-morbidities would be for them to have a named consultant responsible for the individuals overall care. “Co- ordination of Care” was acknowledged that the Trust needed to improve and would be undertaking it through its Francis Report work. The Board resolved to note the report

TBP/03/14/9 PERFORMANCE REPORT 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10

The Chief Operating Officer presented the Performance Report for February 2014 to the Board. Overall the month had been operationally challenging and the impact on services had been considerable. It was noted that the Trust generated a Monitor Risk Assessment of 3 points for Quarter 4, with C Diff, non-admitted Referral To Treatment (RTT) completions, and RTT incomplete pathways being non- compliant in Month. A&E 4 hour performance was 94.2% against a target of 95%, however performance was assessed quarterly and the Trust forecast compliance in March, and for the quarter. The national level for the month was 91 .83%. The operational pressures within February included :-

• A&E attendance increase of 9703 compared to 9625 in February 2013: with a 3.9% increase in the age group 65-84 years and a 0.9% increase in >=85 years.

• A 1% increase in emergency admissions from February 2013 –

including a 3.1% in admissions for patients over 65.

• Delayed transfers of care were 3.0% for February 2014. The A&E performance to date in March was noted to be 97%. The Chief Operating Officer reported that a request for additional funding for winter pressures had been made to the local CCG to cover April 2014 and this had been agreed in principal subject to confirming details. The Trust achieved compliance against all seven cancer metrics in February 2014. Whilst the Trust had maintained full compliance against admitted pathways in February it did not achieve compliance against the non - admitted aggregate compliance. To conclude the Chief Operating Officer thanked all staff in the Trust in the face of the operational difficulties and noted the continued high standard of care. Martin Phillips commented that the average length of stay of inpatients was now over 8 days and asked if there was any specific reason for the jump and what the associated costs were. The Chief Operating Officer confirmed that this tended to be because the Trust was treating more unwell, higher acuity patients and because of delays in discharge.

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9.11 9.12 9.13

The DNA rate of 6% was also noted and it was confirmed that work was planned within the efficiency programme through the access team to help tackle this issue. Joanna Crane asked about the clinicians support for the RTT recovery plans and the Chief Operating Officer confirmed that each scheme had been developed with the appropriate clinical leads and had clinical manpower allocated on a named clinician basis. Ongoing support from all staff would be vital to sustain and deliver each area. The Board resolved to note the report.

TBP/01/14/10 Organisational Development and Workforce Performance 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9

The Director of Organisational Development and Leadership presented the report. It was noted that there was an ongoing increase in substantive posts throughout the Trust and recent overseas recruitment had helped with filling many nursing vacancies. The new NHS recruitment website had been launched and this it was hoped would also assist with recruitment and reporting. Sickness Absence was discussed as this remains a key priority to support quality and cost.. Throughout the Trust work was underway to manage sickness alongside the use of temporary staff. Actions and outcomes from the recent staff survey were in the process of being developed and included: Health and Wellbeing, Promoting a Safety Culture and Improving Communications. In addition a national Staff Friends and Family Test was being developed which should be available from the end of July. Work was also being undertaken on membership engagement and a Governor Membership Committee had been formed. It was confirmed that Dr Findlay had recently completed the “Responsible Officer” Training. The Board approved Dr Findlay as the Trust’s Responsible Officer and thanked Dr Tim Taylor for undertaking the role in the interim. The contribution and work which Dr Taylor had undertaken on appraisal and revalidation was also recognise. Joanna Crane raised some concerns on navigation of the Trust website and asked if there were plans to update it? The Director of Organisational Development and Leadership confirmed that the platform for the website had been rebuilt and that the staff intranet was currently being worked on. It was also expected that the external site would be ready for re-launch in June/July. The Board requested an item be included within the next report giving a progress update on the Trust website and including an outline of the involvement of stakeholders within the work. Bill Brown asked about the rate of sickness absence and it’s cost to the Trust. He quoted a suggestion that a 1% reduction in sickness absence could lead to a saving of circa £2m.

DF

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10.10

The Director of Organisational Development and Leadership confirmed that Sickness Absence would be the subject of a future Board Seminar.

DF

TBP/03/14/11 11.1 11.2 11.3 11.4 11.5

FINANCIAL PERFORMANCE The Director of Finance presented the report, the main points to note being as follows: The financial position for February 2014 was a deficit of £97k and a year to date surplus of £ 426k. The Trust was still forecasting a £ 1,023k surplus at year end but delivery of this was predicated upon securing income in full from NHS England for specialist activity and minimising the expenditure run-rate in March. Details of the Trusts Capital Programme had been included within the report and the increase in spend within Quarter 4 of 2013/2014 was noted alongside the need for some expenditure being carried forward to Quarter 1 of 2014/2015. The total would still be within the limits set. The Financial Plan for 2014/2015 for the Trust had been discussed in detail at the Finance and Investment Committee the previous day. Further work was in the process of being undertaken with the Commissioners but it was expected that contracts would be signed shortly. The Chairman stated that the 6% cost savings required for the forthcoming year would be a hard challenge. The Finance and Investment Committee would continue to monitor any slippage within the Cost Improvement Programmes (CIPs) and would look to continuously bring on line any new programmes to counter act this.

TBP/03/14/12 OTHER BUSINESS 12.1 12.2

The Company Secretary reminded the Board that the next Quarterly Return for Monitor had to be completed and submitted prior to the next meeting of the Board. It was therefore agreed that authority to sign the Quarterly Return would be delegated to the Chairman and Chief Executive Officer. The completed return would be included within the next Board papers. Bill Brown commented that the meetings of the Trust Board were no longer advertised within the Press. It was agreed that this should again be investigated by the Company Secretary and Head Communications and Engagement

AG/MV/MG AG/JK

TBP/03/14/13 RESOLUTION INTO BOARD COMMITTEE The Board resolved to meet in private due to the confidential nature of

the business to be transacted.

TBP/03/14/14 DATE OF NEXT MEETING

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The next meeting in public of the Board of Directors would take place at 10.00am on 1 May 2014 in the Bateman Room, Chichester Medical Education Centre, St Richards Hospital, Spitafield Lane, Chichester, West Sussex, PO19 6SE.

Barbara Mathieson Assistant to Company Secretary March 2014

Signed as an accurate record of the meeting

…………………………………………………. Chair

………………………………………………… Date

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WESTERN SUSSEX HOSPITALS NHS TRUST BOARD MEETING HELD ON 27 MARCH 2014 QUESTIONS ASKED/COMMENTS MADE BY MEMBERS OF THE PUBLIC ATTENDING THE MEETING No. Question/Comment Response 1 Martin Harbour (Staff Governor) raised concern about the

number of complaints being recorded for the A&E’s and asked if there was any analysis undertaken as to whether they would be deemed to be genuine complaints or that they were more a reflection of the busy departments.

The Director of Nursing and Patient Safety confirmed that it was always better to try and raise issues immediately with the PALs teams in order to gain resolution. PALs could pass issues as appropriate.

2 Vicky King (Public Governor–Chichester) asked if the Governors would be involved in the Trusts work streams from the Francis Report. She also asked for further clarification for the figure of the limit of C Diff cases attributable to the Trust as the increase seemed counterintuitive.

Margaret Bamford the Lead Governor confirmed that she had had recently sent an email to the Governors asking for them to indicate which areas they would be interested in and would soon be submitting the responses received to the Executive Team. The Director of Nursing and Patient Safety said that the figures now reflected community factors and that Infection Control was a “whole system issue”. All cases would now undergo a full local economy Root Case Analysis. The local CCG were focusing on Infection Control as a priority and the links to the Trusts mechanisms were being strengthened.

3 Richard Farmer (Patient Governor) asked the Board of their degree of confidence in the systems and controls in place throughout the Trust to counteract fraud

The Director of Finance confirmed that the Trust used the Local NHS Counter Fraud Service and had theirown internal counter fraud team who reported through the Audit Committee. However dealing with fraud was an area which the Trust would always be looking to seek improvement. The Chairman stressed the need for continuous education around the subject of fraud and how it was dealt with within the Trust. Statements of internal control of fraud would be signed off by the Board. Jon Furmston, Non – Executive Director and Chair of the Audit Committee confirmed that the Local Counter Fraud Service do find fraud within the Trust but usually only small scale.

No. Question/Comment Response He also asked if the Board had responded to the Monitor Consultative Document on Governance Reviews which recommended a performance review every three years and was such a review on the Boards Agenda.

The Chairman confirmed that Deloitte’s had carried out a Board review as part of a planned schedule and suggested that the information was shared with the Governors

4 Margaret Bamford (Public Governor- Arun) congratulated the Trust on recent very successful Medicines for Members sessions held. The presentations were excellent and involving patients who described their own experiences / care was very powerful. There was however a feeling that there could be more publicity under taken for these meetings and membership forms should be available at the events. The Governor also commented that the Governors of the Trust were an enthusiastic group who were very willing to offer help and support to the Trust. Engagement with them was therefore important.

The Chairman offered thanks for the positive feedback and agreed that membership forms should be available. This would be taken up by the Communications Team. The Chairman agreed with the comments regarding the Governors and stressed need to continue to develop the working relationship with them.

5 Barbara Porter (Public Governor– Adur) asked if the Surgical Site Infection Rates related to planned Surgery or to Trauma. Barbara reported that she had taken part in Ward and Nutrition Assessments on Bluefin Ward at Worthing. She described how impressed she was the efforts put into meal times on the Children’s ward to make them a positive experience. Siblings were encouraged to eat together and a number of plaudits had been received from patients who said how impressed with the care and calmness at meal times. This did much to help them deal with their sick child.

The Medical Director confirmed that the rates quoted were specific to Hip and Knee replacements. It was recognised that this was an area for improvement within the Trust particularly because they could have a significant impact on the patient and their recovery. The Chairman and Chief Executive thanked Barbara for her kind and positive comments and said they would make sure that they were fed back to the ward.

5 John Gooderham – (Public Governor – Horsham) – Question submitted in writing prior to the meeting. Would the Board confirm that there will be opportunities for patients, the public and their Governor representatives to be engaged in :

The Chief Executive confirmed the Boards intention that patients, the public and the Governors would be involved in all the areas identified.

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No. Question/Comment Response • Developing the cancer services strategy generally • Planning the introduction of flexible sigmoidscopy to

the bowel cancer screening and programme locally; and

• Taking forward the proposal to build a satellite radiotherapy unit at St Richard’s Hospital

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MATTERS ARISING FROM BOARD MEETINGS HELD IN PUBLIC

Matters Arising From Board Meeting Held in Public 27 February 2014 Minute Ref Description of Actions Responsible

Person Deadline Report Status

TBP/02/14/6.15 Provide feedback on the review of the Dementia Strategy

CS June Agenda June Board Meeting

TBP/02/14/7.6 Provide Schedule of deliverables from the Francis Report

CS June Workstreams have been re-profiled following on from visit to Salford Royal NHS Foundation Trust. Further update in Quarterly report due to Board June 2014.

Matters Arising From Board Meetings Held in Public 27 March 2014 Minute Ref Description of Action Responsible

Person Deadline Report Status

PB/03/14/5.4 Chair requested additional information be provided to Governors on the experience of Virginia Mason and the operation of the new Emergency floor.

AG

April Virginia Mason on April Council Agenda. Visit to Emergency Floor date to be confirmed

Completed

PB/03/14/6.5 Include more information data on SSI’s within the Quality Report

CS April Completed Completed

PB/03/14/6.6 Update to Board on Policy and practice relating to Patients being moved at night. (NHS Gateway reference 01360)

GF June On June Board Draft Agenda

PB/03/14.6.6 Update to Board on management of the disposal of fetal remains. (NHSGateway reference 01360).

GF June On June Board Draft Agenda

Public Questions Set internal stretch C-Diff target as differentiator to new national target.

CS April Incorporated in April performance report and inform Council of Governors July meeting.

PB/03/14/8.4 Additional scrutiny and triangulation of data relating to Accident and Emergency to be incorporated in Quarter 4 Complaints and PALS report.

CS June Incorporated into Quarter 4 report.

PB/03/14/10.8 Update to Board in April on Internet Site development.

DF April Incorporated in April Organisational Development and Workforce performance report.

To: Trust Board

Date: 1 May 2014

From: Marianne Griffiths, Chief Executive Agenda Item: XXX

FOR INFORMATION

CHIEF EXECUTIVE’S BOARD PAPER

1. External factors

New Chief Executive of the NHS, Simon Stevens, spent his first morning in the job meeting staff and patients at Shotley Bridge Hospital in County Durham.

Mr Stevens started his career in the NHS as a trainee manager at the hospital over a quarter of a century ago. He visited the cancer unit and rehabilitation service where he spoke with doctors and nurses and asked patients about the quality of their care, and what their food was like. Mr Stevens said: “It has been wonderful to be able to start my time as NHS England’s Chief Executive at the hospital where I began my NHS career twenty six years ago and which taught me so much about healthcare. I’ve started today listening to patients and I give you my absolute commitment that I intend to carry on doing so every day I am in this job.”

In his first speech as NHS England’s chief executive, Mr Stevens added: “At a time when resources are tight, we’re going to have to find new ways of tapping into three incredible sources of ‘renewable energy’.” He explained these sources included:

•boosting the critical role that patients play in their own health and care.

•supporting the amazing commitment of carers and volunteers and communities to sustain their health and social care services.

•unleashing the passion and drive of the million plus frontline NHS staff who are devoting their professional lives to caring.”

He added, “I’m more and more convinced that these three energy sources are going to be central to our future.”

‘Putting Patients First’ – NHS England’s Business Plan 2014/15 – 2016/17

NHS England has published a refreshed business plan, describing its role in delivering high quality care for all, now and for future generations. Putting Patients First: the NHS England business plan for 2014/15 – 2016/17 describes everything NHS England does as an organisation, both as a direct commissioner and as a leader, partner and enabler of the NHS commissioning system. It describes a strong focus on maintaining and improving present NHS performance and looking to the future to secure a sustainable NHS.

This business plan builds on Everyone Counts: Planning for Patients 2014/15 to 2018/19, NHS England’s earlier planning guidance for the system, which was published in December 2013.

Within the business plan long-term ambitions are described, medium-term objectives and the specific deliverables NHS England expects to achieve over the next year.

The business plan outlines how NHS England will work as an organisation and how it will work with others; setting out the key intentions it will carry out as part of its role to improve outcomes for patients and how it will measure the impact of this. These are set out in ‘business areas’ – those pieces of work that must be focused on to have maximum benefit for patients, fulfil NHS England’s statutory obligations and help the NHS change for the future.

The business plan reaffirms NHS England’s commitment to improving quality of care, improving equality and reducing health inequalities and ensuring that patients and the public are continually involved in decisions about their care and about the future of the NHS.

Child Protection – Information sharing project

NHS England and the Health and Social Care Information Centre (HSCIC) have launched a series of short films to promote the benefits of the Child Protection – Information Sharing project (CP-IS). The CP-IS is designed to help the NHS give a higher level of protection to children who present in unscheduled care settings by enabling local authorities to share child protection information with the NHS for the first time, at a national level.

Using animations and interviews with NHS staff, social workers and the staff of the National Society for the Prevention of Cruelty to Children, the films aim to demonstrate the very real difference effective information sharing makes in the lives of children at risk of cruelty. The films are available to view on NHS England’s YouTube channel. Contact [email protected] to find out more.

2. Dr Foster Award

Trust staff have received national acclaim for delivering better, safer care at weekends. Our Trust is one of only 12 nationally to be “Highly Commended” by the influential Dr Foster Intelligence, for making progress to deliver better care, seven days a week. The award recognises the significant reduction in the number of patients needing to be readmitted to hospital within 28 days of discharge, having initially been admitted at a weekend.

In 2011/12, 12.6% of Trust patients admitted on Saturday or Sunday, were then readmitted within 28 days of discharge. In 2012/13 that figure had fallen to 11.7%, prompting the commendation from Dr Foster. And the progress has been maintained since – between April to September 2013, the figure was lower still, at 10.8%.

This improvement suggests good decision-making by staff, and good co-operation between clinical teams, and as a result fewer patients need an additional hospital visit.

The period since 2011/12 has been marked by the introduction of the ‘One Call One Team’ project which has transformed unplanned care, and resulted in fewer people being admitted into hospitals when there are better alternatives available.

The Chief Executive of Dr Foster, Tim Baker, presented the certificate during a team photograph in the Chichester Treatment Centre at St Richard’s. I was pleased to have the opportunity to explain how this reflects well on everyone working at the Trust, from the people keeping our hospitals clean, to our great housekeeping staff, to our doctors and nurses, and I congratulate them all for their achievement.

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3. Council of Governors meeting

The Council of Governors met this month and I was pleased to attend and give a general update on operational and strategic activities.

4. Dementia Champion

Getting dementia care right is one of the Trust’s overriding priorities for the year ahead – and matron Katrina O’Shea will spend the next six months doing nothing else.

Katrina’s job is to support staff with new ways of caring for patients with a dementia, ensuring that these vulnerable people get the best possible experience whilst in our hospitals.

She will start by asking patients and carers what they think, and then test out ways of improving care. That may involve dedicated dementia wards at St Richard’s and Worthing, trialling communal meal times on elderly care wards, or a bigger commitment to using trained volunteers to activities with patients during the day – anything to help the patient feel more cared for, and more engaged with. It may also involve new, tailored pathways for patients with a dementia.

The proportion of acute hospital inpatients with a dementia is already about one in four – and that is climbing all the time.

We need to move towards a position where all staff feel that caring for people with a dementia is part of what they do, not somebody else’s job – it must be everyone’s business – from nursing staff to porters, receptionists, and consultants.

The Trust already has specialist nursing and therapy staff who have transformed dementia care in recent years and which is demonstrated by our Employee of the Month award this month. However the Board now wants to set out a new strategy, setting the standards that patients and carers should expect, and how Trust staff throughout our hospitals can deliver those standards.

5. New appointments

We extend a warm welcome to colleagues who have, or who are about to join us: Dr John Laurie – Consultant - Haematology – (GMC: 4709994). Dr Laurie has been with the Trust as a Fixed Term Consultant since April 2013. Dr Celia Bygrave – Consultant – Anaesthetics (sub-specialty Simulation) – start date 1st May 2014 (GMC: 6026523). Dr Bygrave has been with the Trust as a Fixed Term Consultant since August 2013. Dr Susan Calderbank – Consultant – Anaesthetics (sub-specialty Pre-assessment – start date to be confirmed (GMC: 6027654). Dr Calderbank has been a Fixed Term Consultant with the Trust since July 2013. Dr Janetta Milea – Consultant – Community Paediatrics – start date to be confirmed (GMC: 7087335)

Page 3 of 5

6. Employee of the Month

Nikki Jones and Dylan Jones, our dementia CQUIN (Commissioning for Quality and Innovation) administrators at St Richard’s and Worthing respectively, are this month’s winners with another high scoring nomination. The system for CQUINs was introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care.

Nikki and Dylan were nominated by Katrina O’Shea, Matron, Medicine Division, now our Dementia Champion, for the April 2014 award. Katrina said that their determination has ultimately resulted in raising the profile of dementia and delirium and why it is important to our staff and, most importantly, that the quality of care provided to patients has improved as a result of this. She explained how their dedicated support and persistence in helping the clinical teams across the Trust has resulted in us achieving the national Dementia CQUIN target.

Katrina said that they have both been instrumental in promoting the change in practice to ensure that patients with memory problems are diagnosed as early as possible and referred onto community services. She added that they were both new to this type of project and referred to the “courage” they both showed when voicing what the barriers were when the CQUIN assessment process was first launched.

Katrina also said in her nomination: “Implementing change across the organisation takes negotiation skills, consistency and patience, all of which they both share. From the outset Nikki and Dylan have shown incredible commitment and flexibility, including working weekends at short notice, to ensure that our weekly performance did not dip when the emergency admissions rose. I honestly do not think we would be celebrating the CQUIN if it had not been for their consistent performance. I would also like to add that Sally Smith, Dr Haigh and Dr Hedges all support me in this nomination”.

7. Events

2014 Proud to Care awards

The best nursing care from across Sussex and Surrey was on show at the 2014 Proud to Care awards, and staff from the Trust took a starring role. Our staff took three awards, and seven runners-up spots at the high-profile awards ceremony, recognising their tremendous work for their patients. They were up against the very best staff from hospitals, community teams, GP practices and care homes from across the two counties. The winners were:

Michelle Harris, Sister, St Richard’s – Individual Courage Award. Michelle was nominated for her determination to see that frail patients were helped to get the nutrition they needed. She worked with colleagues to introduce use ice cream smoothies to help patients eat nutritional yoghurts, and to help spread the idea around the Trust.

Sarah Randall, lung cancer specialist nurse, Worthing – Individual Competence Award. Sarah was nominated for her dynamism and hard work, her skill in running clinics which meet patient needs, and the respect she earns from oncology specialists.

Botolphs Ward Nursing Team, Worthing – Team Commitment Award. The team was recognised for their work to implement national guidelines to support stroke patients to get the right treatment, and effective care. Their commitment to keeping relatives and carers informed was noted, as was their continual efforts to improve what they do.

Page 4 of 5

The Trust’s runners-up were:

• Fernhurst Haematology Unit Nursing Team at St Richard’s (Public Choice Award)

• Acute Oncology Team, Trust-wide (Communication Award)

• Tangmere Ward Team at St Richard’s (Communication Award)

• Janice White, Labour Ward Co-ordinator at St Richard’s (Compassion Award)

• Palliative Care Team, Trust-wide (Compassion Award)

• Kim Cheetham, Matron at Worthing (Competence Award)

• Midwifery Patient Safety Team, Trust-wide (Competence Award)

This was the second Proud to Care award ceremony. Last year’s inaugural event was limited only to staff working in Sussex, but for 2014 that was extended to include Surrey. The keynote speaker at the event was England’s Chief Nursing Officer Jane Cummings.

Well done to all our staff!

Scuplture unveilings Identical statues have been unveiled in the reception areas at Worthing and St Richard’s, to celebrate those who donate organs, and to encourage others to do so. “The Gift” was created by sculptor Rodney Munday, and commissioned by the Trust’s Organ Donation and Transplant Committee. It gave me enormous pleasure to praise committee chairwoman Angela Fisher and clinical lead Dr Ryck Albertyn and highlight their passion and total commitment. Their work means that many people have their lives significantly, and materially, improved – that is real, and remarkable. Mr Munday said in his speech: “If this work encourages anyone to join the organ donation register it will have been a success. To that extent, perhaps it already has, since I have now signed up to the register myself.” After the ceremonies, large baskets of fruit were delivered to A&E, ITU and theatres at each hospital as a thank you to the staff there. To join the Organ Donation Register call the donor line on 0300 123 23 23 or visit www.organdonation.nhs.uk Friends of Chichester Hospitals AGM and presentation The Friends’ AGM takes place on Monday 19 May in the Chichester Medical Education Centre (CMEC). Dr Amanda Wellesley, A&E Consultant and Clinical Director for Emergency Medicine will give a presentation entitled “The day in the life of an A&E trolley” which is a timely link to the impending delivery of 20 new trolleys, purchased by the Friends at a cost of £96,000, for the St Richard’s A&E department. Refreshments will be available from 4.30pm and the meeting will begin at 5pm. All welcome! For more information please call 01243-831843 or email [email protected]

Page 5 of 5


Title

Month 12, 2013/14 Quality Report

Responsible Executive Director

Dr George Findlay (Medical Director) and Cathy Stone (Director of Nursing and Patient Safety)

Prepared by

Jamie Cochrane (Planning and Performance Manager), Mark Dennis (Head of Information Services), Sandie Ellard (Deputy Director of Nursing).

Status

Disclosable

Summary of Proposal

Not applicable

Implications for Quality of Care

Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.

Link to Strategic Objectives/Board Assurance Framework

The WSHT Quality Strategy 2011-2013 set out the strategic objectives for the Trust in relation to quality. This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues.

Financial Implications

Describes KPIs that have potential financial impact (e.g. CQUIN)

Human Resource Implications

Describes KPIs linked to workforce

Recommendation The Board is asked to: Note the contents of this report.

Communication and Consultation

Not applicable

Appendices

Appendix I: Quality Scorecard Appendix II: Infection Control Dashboard Appendix III: Fracture Neck of Femur Dashboard

To: Trust Board

Date of Meeting: 1 May 2014 Agenda Item: 6

1 INTRODUCTION 1.1 This report brings together key national, regional and local quality indicators relating to quality and

safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within

Western Sussex Hospitals Foundation Trust (WSHFT).

1.2 The paper describes performance on an exceptional basis determined by RAG (red/amber/green)

ratings based on national, regional or local targets. Further quality items are shown as dashboards in the

appendices.

2. KEY QUALITY OBJECTIVES

2.1 Dashboard Definitions

2.1.1 The full Clinical Quality Dashboard is presented as Appendix II. This includes measures identified in the

Trust Quality Strategy. Figures are in month figures (e.g. the number of falls reported in March) unless

otherwise stated. The dashboard shows 13 months to allow trends to be identified, although some data

items are reported retrospectively. Year to date actuals/targets are based on financial years unless

otherwise stated (e.g. standardised mortality ratios are recorded as 12 month positions). A subset of the

key measures from the report is presented at 2.2.

2.1.2 Exception reports are included under the relevant section of this report (i.e. under the broad headings

Effectiveness, Safety and Experience).

2.1.3 Targets are based on national or regional benchmarks where available. In the absence of established

benchmarks, locally agreed targets or levels have been defined. Where there has been no specific

agreement on a target, an improvement on 2012/13 baseline has been used. The list of the targets and

whether benchmarks are national, regional or local is available on the Trust’s public website:

http://www.westernsussexhospitals.nhs.uk/about-us/trust-board/trust-board-meetings/board-

papers/quality-scorecard-targets/

2 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

http://www.westernsussexhospitals.nhs.uk/about-us/trust-board/trust-board-meetings/board-papers/quality-scorecard-targets/

http://www.westernsussexhospitals.nhs.uk/about-us/trust-board/trust-board-meetings/board-papers/quality-scorecard-targets/

2.2 Overview of Key Quality Objectives

2.2.1 The following table shows performance against key, top level quality objectives.

Indicator Jan 2014

Feb 2014 Mar 2014 2013/14 to date

2013/14 Target /

limit

E01 Trust crude mortality rate (non-elective) 3.79% 3.83% 3.17% 3.22% 3.24%

E02 Hospital Standardised Mortality Ratio for top

56 diagnoses (Dr Foster, based on rolling 12

months)

90.8 - <100

S01 Patient Aggregate Safety Score (PASS) 85.7 82.8 104.3 88.7 <100

S05 Number of Serious Incidents Requiring

Investigation (number reported in month)

2 2 5 29 26

S09 VTE: Compliance with the DoH risk

assessment tool

96.1% 95.7% 95.5% 96.1% 95%

S14 Numbers of hospital attributable MRSA 0 0 0 4 0

S15 Numbers of hospital attributable C. diff 7 3 3 57 46

X01 The Friends and Family Test Score:

Inpatients

74 69 76 75 TbC

X02 The Friends and Family Test Score: A&E 78 75 73 75 TbC

X15 Mixed Sex Accommodation breaches (for

clarity the number of breaches is reported here,

but in the scorecard, in line with the reporting of

this metrics in other Trust scorecards this is

expressed as a proportion of Consultant

Episodes)

0 0 0 0 0

X20 Number of complaints 53 49 40 522 562


3. EFFECTIVENESS

3.1 Crude Trust Mortality

3.1.1 Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to

non-elective activity. The Trust Quality Strategy set out an objective to reduce its mortality rate by 10%

(relative to the year 2010/11) by the end of 2012. The Trust achieved this objective and for 2012/13 non-

elective mortality was 3.24% compared to 3.30% in 2012/13. The trust continues to seek to demonstrate

an improvement against the 2012/13 level (see the graph below) and to reduce the 12 month rolling

average.

3.1.2 Crude non-elective mortality fell from 3.83% in February to 3.17% in March. This is lower than the level

for the same month last year (March 2013 = 4.10%).

3.1.3 The mortality for the year as a whole was 3.22% compared to 3.24% in 2013/14. As such the Trust

achieved its objective of continuing to reduce crude non-elective mortality albeit by a smaller reduction

than in previous years. The 12 month rolling average (i.e. 3.22%) fell to below 3.24% for the first time in

2013/14.

3.1.4 The 3.17% mortality in March related to 162 deaths out of a total of 5111 non-elective admissions.


3.2 Hospital Standardised Mortality Ratio (HSMR)

3.2.1 There is a two month delay with Dr Foster data (to allow for coding and processing of data). As such

January 2014 is the most recent data available. WSHFT HSMR for the twelve months to January 2014

was 90.8 (where 100 is the national average), i.e. the Trust performance is significantly better than

predicted by the Dr Foster model.

3.2.2 The twelve month HSMR to January 2014 split by site is lower for St Richards (88.7) than for Worthing /

Southlands Hospitals (92.3), however both are lower than 100.

3.2.3 Each year Dr Foster rebase their data to take account of improving mortality rates nationally. This

usually takes place in the autumn and has the effect of increasing all Trust’s ratios as the national

average is reset to 100. The current estimate for WSHFT HSMR for April 2013 to January 2014 (the

period effected by the next rebasing) following rebasing is 98. Dr Foster may decide to change how this

rebasing works in future.

3.2.4 A further report is available to the Trust Quality Board showing the clinical diagnostic areas with high

actual versus expected mortality and any mortality CuSum alerts.

3.3 Summary Hospital-Level Mortality Indicator (SMHI)

3.3.1 The Summary Hospital Level Mortality Indicator for October 2012 to September 2013 will be published

on 30th April. A verbal update will be provided to the Board.

3.4 Exception Reports Relating to Effectiveness

3.4.1 Exception Report - Indicators E05 to E08 Mortality in Specific Conditions: These measures reflect the

pledge set out in the 2011/12 Trust Quality Account to reduce mortality in four key areas amenable to

mortality by 10% against 2011/12 levels.

3.4.2 During 2013/14 the required level of reduction was shown for Heart Failure, Chronic Obstructive

Pulmonary Disease (COPD) and Pneumonia. In the fourth diagnosis group, acute renal failure, although

mortality was lower in 2013/14 than last year (2013/14 = 24.1%, 2012/13 = 24.3%) it remained above

the target level (target = 20.4%). This will remain a priority for the coming year.

3.4.3 Performance for the last three years is shown below.


2011/12 2012/13 2013/14

COPD mortality 7.4% 6.7% 4.7%

Pneumonia mortality 20.0% 19.4% 16.5%

Acute renal failure 22.7% 24.3% 24.1%

Heart failure mortality 20.9% 17.7% 14.9%

3.4.4 Exception Report – E13: Caesarean section rate: The Trust C-section rate for March was 27.1%.

Although a reduction against last month, this remains higher than the indicative target of 24.7%. This

was related to a higher than usual number of women requiring emergency caesarean section at

Worthing. A breakdown of the reasons for each caesarean is produced as part of the exception reporting

for the maternity dashboard. All caesareans are subject to multi-disciplinary review to ensure the most

appropriate course of care was followed for both mother and baby. For the year as a whole the Trust

had a caesarean section rate of 26.1% compared to 24.7% in 2012/13. A review to establish an

appropriate benchmark for 2014/15 taking into account changing NICE guidance is being undertaken by

Kent Surrey and Sussex Strategic Clinical Network. This will be reviewed by the division prior to be

adopted in 2014/15.


3.4.5 Exception Report – E15: % Deliveries complicated by post-partum haemorrhage: The rate of deliveries

complicated by blood loss of greater than 2500mls was 1.2% for March against a limit of 1.0%. This

related to 6 cases, 4 at Worthing, 2 at St Richards. These cases have been reviewed under the clinical

governance and safety arrangements to ensure any issues could be taken forward. The Trust remains

below the 1.0% limit for the year 2013/14 as a whole.

3.4.6 Exception Report – E18: % Emergency admissions staying over 72 hours screened for dementia:

Although the Trust has achieved its CQUIN target in relation to dementia screening for 2013/14 it is

disappointing that the figure for March dropped below the 90% threshold. Under CQUIN arrangements

for 2014/15, the Trust will be required to achieve this target throughout the year. Teams have been

reminded of the importance of undertaking this assessment and, at the time of writing, performance for

April to date has improved. Work is being undertaken to embed this assessment in 2014/15 to ensure

the Trust continues to achieve 90% or greater.

3.4.7 Exception Report – E21 to E23: Engagement in research: For the first time the monthly CLRN score has

fallen below 100. This score is calculated by the number of interventional studies (E21) multiplied by 5

plus the number of observational studies (E22). Although performance varies considerably, there has

been a gradual reduction in 2013/14. In particular, the number of patients recruited to interventional

studies since January 2014 has been lower than previous due to several studies being completed. There

are a number of new interventional studies currently in set-up, due to commence in early 2013/14, which

will increase this score. In addition to which the Trust has now recruited to the post of Director of

Research and Clinical Effectiveness (start date 1st June).


4. SAFETY

4.1 Patient Aggregate Safety Score (PASS): Background and Methodology

4.1.1 The PASS is an aggregate score comparing performance against a baseline for a total of 15 measures.

These vary in polarity (i.e. whether a high score indicates a safer environment or not). The methodology

was presented to the board in full with worked examples in August 2011:

Group Measure Polarity Weighting Baseline (2012/13)

VTE VTE Prophylaxis given (syringe packs prescribed) Positive 0.50 1943

VTE risk assessments done Positive 1.00 93%

HCIA MRSA Negative 1.00 0.1

C. diff Negative 1.00 6.0

SIRIs SIRIs Negative 2.00 2.2

Patient safety

incidents

Total incidents Positive 1.00 674

Moderate, severe and death Negative 1.00 7.1

Complaints Complaints about nursing care Negative 0.67 3.4

Complaints about communications Negative 0.67 6.3

Complaints about staff attitude Negative 0.67 4.7

Tissue viability Total grade 2 or higher pressure ulcer incidents Negative 1.50 10.3

Falls Falls resulting in harm Negative 1.50 40.1

Prescribing Total incidents involving prescribing and drug

errors

Positive 0.50 91.3

Moderate, severe and death errors involving

prescribing / drug errors

Negative 1.50 0.33

Nutrition Nutritional Assessments in 24 hours Positive 1.00 85.8%

4.1.1 The measures are unchanged for 2013/14, but all baselines have been updated to 2012/13 figures so

that the PASS score for 2013/14 is an indication of whether the Trust in the current month is more or

less safe (based on these measures) than 2012/13. All individual elements of the PASS score are also

reported in the Quality Scorecard.

4.1.2 Scores can range from 0 to 200, with a lower score indicating a safer Trust and 100 being the equivalent

of the Trust last year.


4.2 PASS Performance 2013/14 to Date

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

to

date

PASS 89.9 88.9 85.0 96.8 98.3 81.8 84.3 98.3 68.9 85.7 82.8 104.3 88.7

4.2.1 The PASS score for the year as a whole is calculated based on the averages of each of the individual

months.

4.2.2 The March PASS score is 104.3. This is the highest month throughout 2013/14. For March the following

PASS measures showed adverse performance compared to the average for 2012/13: moderate

incidents; moderate prescribing incidents and SIRIs. In particular the prescribing incident impacts on the

score as a result of the high weighting and small baseline figure.

4.2.3 The February PASS score is now considerably lower than the figure reported last month as a result of

changes in the incident numbers following investigation.

4.3 Central Alert System (CAS) Safety Alerts

4.3.1 There are no outstanding alerts for the Trust relating to March 2014 or earlier.

4.4 Infection control

4.4.1 The Trust reported zero cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia

during March.

4.4.2 The year-end position for MRSA was 4 cases in total. Following Local Health Economy (LHE) scrutiny 3

of the cases were deemed to be unavoidable due to the complex nature of each case. The one case

that was highlighted as avoidable was in July 2013 and it was related to a contaminated blood sample.

The case was previously reported to both the Trust Board and the Infection Control Committee.

4.4.3 The limit for MRSA 2014/15 remains as zero unavoidable cases.


4.4.4 The Trust reported 5 cases of Methicillin-Susceptible Staphylococcus Aureus (MSSA) bacteraemia

during March, 2 of which were post 48 hours. The Root Cause Analysis (RCA) did not highlight any

cause for concern.

4.4.5 The Trust reported 3 cases of Clostridium Difficile during March, 2 on the Worthing site and 1 on the St.

Richards site. 2 of the cases were identified as unavoidable. The third case was identified as avoidable

as there was a delay in sending a specimen. However all aspects relating to isolation, hygiene and

antibiotic management had been fully implemented.

4.4.6 The year-end total was 57 cases against a ceiling of 46 however this does represent a 21% reduction

against last year’s outturn of 72 cases. This reflects very positively against the national reduction for

Acute Trusts of 12%.

4.4.7 The limit for next year is 56 cases with each case being assessed by the Clinical Commissioning Group

(CCG) and only those cases in which a lapse of clinical care is noted will be assigned to the trajectory.

The Trust has therefore set itself an internal stretch target of 21 cases as this represents a 12%

reduction in those cases as last year defined as avoidable.

4.4.8 During March the Trust experienced episodes of Norovirus which impacted on both sites and led to the

closure of bays within ward areas. Due to the vigilance of ward teams the adherence to strict infection

control processes by the operational teams and the excellent standards of environmental cleaning the

episodes were contained with impact on patients, families and carers being minimised.


4.5 Falls

4.5.1 Following the completion of the SHA Safer Smarter Nursing Programme, the Trust has continued to aim

to reduce the number of falls resulting in harm. The target for 2013/14 sought a further improvement

against the 2012/13 level. As such the limits for 2013/14 were 481 or less falls resulting in harm and 2

falls resulting in severe harm or death.

• In March there were 37 falls resulting in harm. There were no falls resulting in serious harm or

death.

• For the year as a whole there were 461 falls resulting in harm, 20 fewer than the previous year.

There were, however, 5 falls resulting serious harm compared to only 2 in 2012/3.

4.5.2 The 37 falls equate to 1.32 falls resulting in harm per 1000 occupied bed days compared to the national

benchmark of 2.5 (Royal College of Physicians Report of the 2011 Inpatient Falls Pilot Audit).

4.5.3 As part of our CQUIN goal for 2013/14 the Trust is undertaking an analysis of all the patients who are

identified as fallers on the NHS Patient Safety Thermometer (see indicator S24). A trajectory for the

reduction in preventable falls was agreed with commissioners. Performance is shown on the graph

below:


4.5.4 For the period covered by the CQUIN (June 2013 to March 2014) the Trust achieved a level of 0.61% of

patients suffering a preventable fall compared to 1.66% for the baseline period.

4.6 Tissue Viability

4.6.1 The number of pressure ulcers in the Trust has fallen over recent years from 283 in 2010/11 to 226 in

2011/12 and further to 124 in 2012/13. The Trust set a stretch target for 2013/14 of a further 5%

reduction against the 2012/13 value. This gave a limit for grade 2 pressure ulcers of 114. The Trust also

tried to maintain or reduce the number of grade 3 or 4 ulcers (i.e. a limit of 4).

4.6.2 During March the Trust reported 7 cases of hospital acquired pressure sores (Grade 2). This was

against an in-month trajectory of 10.

4.6.3 There were no hospital acquired grade 3 or 4 pressure ulcers in March.

4.6.4 During 2013/14 there were a total of 105 pressure ulcers against a target of 114 or less and the Trust

had no new grade 3 or grade 4 pressure ulcers throughout the year. Thereby achieving both targets for

the year.

4.6.5 The incidence of pressure ulcers (developing 72 hours after admission) per 1000 bed days in March was

0.25.


4.6.6 There were 107 patients were admitted to the Trust from the Community with pressure damage during

March.

4.7 NHS Patient Safety Thermometer

4.7.1 The NHS Patient Safety Thermometer is used across all relevant wards. This tool looks at point

prevalence of four key harms (falls, pressure ulcers, urinary tract infections and deep vein thrombosis

(DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard

showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score is

available to each ward.

4.7.2 The harm-free care score for the Trust in March was 93.1% (indicator S02), compared to a national

average of 93.6% (national averages based on most recently available data: March 2014).

4.7.3 The Safety Thermometer includes harms suffered by the patient in health care settings prior to

admission. The actual number of patients with no new harms during their inpatient stay at WSHFT

(indicator S03) was 97.0% compared to a national average of 97.4%.


4.8 Exception Reports Relating to Safety:

4.8.1 Exception Report: Indicator S05: Total moderate, severe or death incidents: As reported last month the

Trust has seen a sustained increase in the number of incidents resulting in moderate or above harm

during 2013/14. This is believed to be the result of improved recording of degree of harm. There has

been a particular increase in the reported levels of hospital acquired thrombosis / pulmonary embolism.

These are being automatically classed as a moderate harm incident. The programme of work underway

undertaking root cause analysis of all hospital acquired thrombosis, led by the VTE Nurses has

improved reporting and scrutiny of the care received by patients suffering VTE. In addition, five of the

incidents were related to falls resulting in fractures, but these were unrelated incidents occurring at

different times, sites and circumstances (e.g. different limbs).

4.8.2 Exception Report: Indicator S06: Total serious incidents (SIRIs): There were five serious incidents

requiring investigation (SIRIs) reported in March 2014. These are the subject of a separate report

available to the Committee part of the Board. The incidents are unrelated and do not pertain to a

particular individual, site or theme. A change in reporting arrangements issued by the Clinical

Commissioning Group in relation to SIRIs is likely generate a larger number of reported SIRIs from April

2014.

4.8.3 Exception Report: Indicator S13: Incidence of VTE: The Trust continues to see a greater total number of

patients with deep vein thrombosis or pulmonary embolism than in 2012/13. As previously reported, this

indicator is based on the National Quality Dashboard indicator, which does not distinguish between

hospital acquired VTE community acquired VTE. As such, in many cases the VTE will therefore be the

cause of the admission, not a consequence of it. The Trust subjects all hospital acquired VTE to a root

cause analysis the results of which are reported to the Thrombosis Committee.


5. PATIENT EXPERIENCE

5.1 PALS and Complaints

5.1.1 All complaints are responded to by the Trust Office. The process is administered by the Customer

Relations Team. The Quarterly Complaints Report provides an in depth analysis of trends and lessons

learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the

Trust Board.

5.1.2 During March 2014 the Trust received 40 complaints (of which 1 was graded as high resulting in further

investigation).

5.1.3 The majority of complaints in March related to clinical treatment. These were not attributable to one

clinical site or area.

5.1.4 In March there were 3 complaints received where nursing care was the primary issue. There were not

attributed to one clinical area or site.

5.1.5 During the whole of 2013/14 there were a total 522 complaints compared to 565 in 2012/13: a reduction

of 8%. There were also reductions in all three of the areas measured individually in the Trust scorecard:

attitude / behaviour, communication and nursing (indicators X19, X20 and X21 respectively) against

2012/13 levels.

5.2 Friends and Family Test

5.2.1 Data collection for the Government’s Friends and Family test is currently underway in A&E, the inpatient

wards, and in maternity.

5.2.2 National guidance details how this question will be scored nationally as follows: The proportion of

respondents who would be extremely likely to recommend (response category: ‘extremely likely’) MINUS

the proportion of respondents who would not recommend (response categories: ‘neither likely nor

Worthing Southlands Chichester Total

All complaints 23 2 15 40

High grade complaints 0 0 1 1


unlikely’, ‘unlikely’ and ‘extremely unlikely’) (the response ‘likely’ is included in the percentage but does

not have a positive or negative impact). This results in scores with a possible range of -100 to 100.

5.2.3 Immediate feedback is provided to wards on a continuous basis to ensure staff can address problems or

get positive feedback as quickly as possible. In addition to this a dashboard has been launched giving

wards access to their individual scores. Since the introduction of the system over 23,000 patients have

given their views on WSHFT services.

5.2.4 March scores are as follows (national averages are based on averages for data published to date i.e. for

inpatients and A&E April 2013 to February 2014):

• The overall score for the Trust (IP and A&E) was 74 based on 2737 responses (national

average = 64).

• The inpatient score was 76 based on 732 responses (national average = 72).

• The A&E score was 73 based on 2005 responses (national average = 54).

5.2.5 The Friends and Family data collection for maternity services was launched in October 2013 using text

messaging as one potential option to allow women to feedback on the quality of their care. Women are

asked at four separate points whether they would recommend the Trust. (national averages are based

on averages for data published to date i.e. for Maternity December 2013 to February 2014, the response

rate is only published in relation to the second indicator):

• Antenatal care: The Trust score was 74 based on 35 responses (national average = 66).

• Delivery: Trust score: 89 based on 124 responses: 30% response rate (national average = 76,

20% response rate)

• Post-delivery ward: Trust score: 80 based on 123 responses (national average = 65)

• Discharge from community midwifery care: Trust score: 50 based on 18 responses (national

average = 75).

5.2.6 The maternity friends and family scores will be added to the Trust scorecard from next month.

5.3 Feedback from Hospital Experience Questionnaires

5.3.1 Detailed results from the Real-Time Patient Experience (RTPE) project are routinely fed back to

divisions and wards and aggregate scores are included in the Quality Scorecard within the Experience

section (indicators X03 to X07). Targets for these measures for 2013/14 are based on an improvement

against 2012/13.


5.3.2 All five of these measures (indicators X03 to X07) were above target in March and for 2013/14 as a

whole.

5.3.3 333 inpatients gave their views on the Trust using the RTPE system in March.

5.4 Exception Reports Relating to Experience

5.4.1 Exception Report: Indicator X11: PALS contact relating to appointment problems: There was an error in

the position reported to February last month. This has been corrected retrospectively.

6 CARE QUALITY COMMISSION (CQC)

6.1 CQC Compliance:

6.1.1 Nothing to report

6.2 CQC Intelligent Monitoring Reports

6.2.1 These reports are published quarterly. The latest available report was published in March and continues

to band Western Sussex NHS Foundation Trust as Band 6 – within the lowest risk band. The full report

is available on the CQC website:

http://www.cqc.org.uk/sites/default/files/media/reports/RYR_102v2_WV.pdf

7 NATIONAL AND LOCAL REPORTS

7.1 Department of Health Guidance following Cheshire West

7.1.1 The Department of Health has issued guidance for health and social care organisations following the

Supreme Court's judgment in the Cheshire West case. The guidance is intended to assist health and

social care organisations to continue to comply with the law following the revised test for what

constitutes a deprivation of liberty as set out in Lady Hale's judgment. The guidance seeks to remind

health and social care professionals of the existing procedures under the Mental Capacity Act 2005 for

identifying and authorising a Deprivation Of Liberties (DOLs) but also highlights key points arising from

the Supreme Court's decision and 'suggested actions' following the judgment.

7.1.2 There are no current plans for the government to amend the DOLS regime; however the Department of

Health has confirmed its response to the House of Lords Select Committee report into Mental Capacity

Act and DOLs can be expected by the summer.


http://www.cqc.org.uk/sites/default/files/media/reports/RYR_102v2_WV.pdf

7.1.3 The Trust has a contract in place with Sussex Partnerships NHS Foundation Trust whereby they provide

advice, guidance and focused support on the implementation of an appropriate governance framework

around the detention and treatment of patients under the MHA 1983, Mental Capacity Act and

Deprivation of Liberties (DOLS).

7.1.4 Following the planned publication of the Department of Health response in the summer Sussex

Partnerships NHS Foundation Trust will advise our Trust of any changes required to our current practice.

7.2 Building a Culture of Candour

7.2.1 Following the Mid Staffs Inquiry, the requirement for a statutory Duty of Candour was identified. In a

report commissioned by the government Building a Culture of candour, thresholds for candour were

proposed together with a new model for categorising levels of harm. In response, the Department of

Health has now launched a consultation document Introducing the Statutory Duty of Candour with a plan

to place '..an organisational duty of candour that can be clearly understood and applied by care

organisations [registered with the CQC].' The duty will be included in the final regulations in the

Autumn to be monitored and enforced by the CQC. A full briefing will go to the Management Board and

a Board seminar is planned.

8 COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)

8.1.1 Since 2009/10 a proportion of the money the Trust receives has been payable on achievement of

agreed quality metrics. A detailed agreement has been reached with commissioners for 2013/14.

8.1.2 Agreement has been reached in relation to 2014/15 CQUIN measures and relevant indicators will be

added to the scorecard from next month.

9 RECOMMENDATION

9.1.1 The Board is asked to note the contents of this report.


To: Trust Board

Date of Meeting: 01 May 2014 Agenda Item:

Title

The purpose of this report is to provide the Trust Board with details of the staffing and capability levels for adult inpatient wards, midwifery and children’s wards across Western Sussex Hospitals NHS Foundation Trust


Cathy Stone, Director of Nursing and Patient Safety

Prepared by

Cathy Stone, Director of Nursing and Patient Safety & Heads of Nursing

Status

Disclosable

Summary of Proposal

This report provides a 6 monthly report to the Trust Board regarding Nursing staffing across Western Sussex Hospitals NHS Foundation Trust in response to Hard Truths ‘The Journey to Putting Patients First’ Volume One of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry 2.


To consider areas of concern and provide assurance of safe nursing staff levels.


Patient Safety agenda – improving the patient experience/learning lessons


1. Financial penalties may be incurred. 2. Subsequent patient litigation claims may occur. 3. Loss of Commissioner confidence may result in loss of Trust business.


1. Professional performance management issues for individuals. 2. Learning and development requirements. 3. Organisational, behavioural and cultural issues.

Recommendation

The Committee is asked to note the report


Appendices

Appendix A – National requirements and timelines. Appendix B – Current ward template

1

Report to the Board of Directors

Nurse Staffing levels for Adult Inpatient wards, midwifery and children’s wards across Western Sussex Hospitals Foundation Trust

1.0 There is now a requirement post the publication of the recommendations of the Mid Staffordshire NHS Foundation Trust Public Inquiry and Hard Truths; “The Journey to putting the Patients First” (Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry’s Recommendations), that Trust Boards should receive a report every 6 months on staffing capacity and capability.

The report should include;

• The methodology used to determine staffing levels. • The allowance within the model for annual leave and statutory and

mandatory training. • The skill mix review. • The details for supernumery/supervisory allowance for ward sisters. • Evidence of triangulation of professional judgement and scrutiny. • Details of workforce metrics. • Information related to key quality and outcome measures.

The Board is required to receive a monthly summary position of the staffing shortfalls in the previous months (from June 2014). In addition there is a requirement that ward staffing information and staffing availability is visible on a daily basis at ward level. Hard Truths also requires the publication of this information on the NHS Choices website. An overview of the national requirements and time line is provided within

Appendix A. 2.0 The greater focus now remains to ensure that Trusts have the correct capacity

and capability for its nursing workforce in order to meet the needs and expectations of its patients. Evidence is now available that failings in care and poor staffing levels have a direct impact on mortality, patient care indicators and increased staff sickness which ultimately reduce staff availability further. The key message from all the recent documentation is that the solution is not totally focussed on numbers but other key factors underpin safe dignified care. • Strong empowered leaders (Hard Truths - recommendation 195). • Resources directed at supporting leaders.

1

• Values based recruitment (Hard Truths – recommendations 191 & 197). • The use and development of patient experience metrics (Hard Truths –

recommendation 143).

3.0 Western Sussex Hospitals NHS Foundation Trust Approach to staffing levels on Adult Inpatient wards.

In 2001 the Audit Commission recommended that establishment setting (regardless of method) must be simple, transparent, integrated, benchmarked and linked to clinical outcomes. Today there remains no one recommended or mandated method but the utilisation of a range of approaches from using acuity based tool which measures patient dependency to a ratio to bed model, supported by professional ward leaders and their seniors. This approach is supported by the National Quality Board Guidance (NQB) ‘How to Ensure the Right People with the Right Skills are in the Right Place at the Right Time’ (November 2013). In addition the establishments must have built within them uplifts which enable the establishment of staff to absorb annual leave, short term sickness and study leave without the need to use temporary staff.

3.1 National Benchmarking

Within Western Sussex Hospitals NHS Foundation Trust (WSHFT) methods are used to set ward establishment, all of which have been recognised as good practice within the NQB guidance. Historically at the point of Trust merger in 2009 a total inpatient nursing skill mix review was undertaken. In addition, both legacy Trusts were piloting within the acute sector, the Association of UK University Hospitals (AuKuH) nurse dependency tool, following merger in response to the review £3 million was invested into frontline nursing staff, in addition the principal of one whole time equivalent (wte) ward sister and one wte deputy ward sister to one clinical ward area was established across the 3 acute inpatient sites. In 2012 the National Audit Office undertook a review of Trust Nurse staffing levels. This review compared nationally ward sizes against staff skill mix ratio and for the first time, care outcomes. WSHFT was placed in the upper quartile for nurse staffing nationally. In July 2013 an independent review to examine nurse establishments and roles in relation to the key recommendations of the Mid Staffordshire NHS Foundation Trust Public Inquiry was held.

2

The outcome of the independent review reported that the funded nursing levels at WSHFT were adequate for patient care. The report highlighted areas for development initiatives;

1) The allocation of night nursing staff. 2) The review of staff shift times in response to levels of activity.

A paper was presented to the Trust Board Finance & Investment Committee which supported the enhancement of the staffing of key ward areas within the night shift. The designated wards have subsequently received uplift in ward staffing.

3.2 Current practice All ward templates are routinely reviewed annually, in line with the budget

setting process. This review takes place with the ward sister, Matron and Head of Nursing for the respective clinical Division. The final proposal is ratified by the Director of Nursing & Patient Safety.

In accordance with the NQB guidance key factors influence the determination

of the establishment;

• Acuity of patient caseload. • Ward layout – visibility of patient areas. • Specialisation within a clinical ward area. • Timing of patient flow. • Outcome of care metrics. • Patient feedback.

Ward templates will then be reviewed by the individual Clinical Divisions throughout the financial year. If, as a result of changes to the wards activity, acuity or relocation, a further formal review will take place during the year. The review takes the same format as the annual review. A recent in-year example is the reprofiling of the Medical Acute Unit (MAU) nurse staffing on the Worthing site as a result of the opening of the Emergency Floor later in 2014. Ward staffing models are then constructed in line with the ward staffing templates which takes account of staff shift patterns and handover times.

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The majority of the inpatient wards allow for a 30 minute handover. Work has been undertaken since the Trust merger to standardise the length of time required for handover. The Trust is considering a Trust wide rollout of a walking handover to improve patient interaction and improve both efficiency and effectiveness of the ward handover process. There are some clinical areas which provide a lengthier handover time, but these are in agreement with the Matrons and the Head of Nursing and are aligned to patient need in individual specialist areas. All ward establishments are enhanced by 21% to allow for annual leave and statutory and mandatory leave cover. Whilst there are no national recommendations on the number of patients per nurse, the Safe Staffing Alliance recommends a staffing ratio of greater than 1 registered nurse to 8 patients as this would have a direct impact on patient care and safety. All wards with WSHFT during the day average a ratio of 1:6, with the 24 hour average remaining below 1:8. Currently all ward sisters are provided with a minimum of 15 hours a week supernumery time, 0.4wte. As part of the Matron development programme a project has been established to review the time taken by ward sisters on non-care related duties and how, through the use of non-clinical staff, a case can be made to establish ward sisters in total supervisory roles. A proposal will be brought to the Finance & Investment Committee during Quarter 2, 2014.

3.3 Skill Mix review There are no set recommended standards for skill mix. The Royal College of Nurses (RCN) recommended a minimum 65:35 registered nurse to

non-registered nurse split during the daytime shifts. However in the interest of safety, with regard to the patient population, wards that receive and manage highly complex patients will appropriately roster a skill mix level greater than that i.e. the haemo-oncology wards across both sites and this is in line with the increasing complexity of care relating to intravenous medication and chemotherapy.

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A copy of the current ward template is enclosed at part of Appendix B. These templates have been agreed and ratified as part of the 2014/2015 budget setting process. 3.4 Maternity

The workforce requirements for the Trust maternity units have been calculated using a mix of 2 models. Birthrate Plus and the more traditional method of calculating staff numbers based on ward activity and numbers. Birthrate Plus is based upon the principle of providing one-to-one care during labour and delivery to all women. Birthrate Plus requires maternity units to record for a period of 4 months covering all aspects of midwifery care. In addition it also adds an additional 10% to the workforce requirements which cover senior and expert maternity roles. WSHFT currently provides a midwife to woman ratio of 1:28 within National and local guidance. The Maternity Unit recently achieved Clinical Negligence Scheme for Trusts (CNST) Level 3 status. As part of the review staffing levels and staff on duty were assessed and were in line with areas of good practice. There are further challenges within midwifery that relate to the number of safeguarding cases which often require extra support and the flexibility of the staff maintains safety at all times. A further challenge to this service is the average number of maternity staff on maternity leave. These posts are currently being backfilled and therefore this can place a cost pressure on the budget.

3.5 Children’s Services The workforce requirements for the children’s units Howard ward/Bluefin

Ward/Beeding ward and the Neonatal Unit are staffed using 2 tools, ‘Defining Staffing Levels for Children’s and Young Peoples Services’ and intentional rounding to determine changing staffing requirements to clinical areas in response to a changing Paediatric and Neonatal acuity. The service also provides internal flexibility to respond to the acknowledged seasonal variation in Paediatric acuity and activity.

4.0 Daily review of establishment process

All ward shifts are reviewed by the relevant Divisional Matrons 3 times per day in liaison with ward sisters or the designated senior nurse on duty.

5

The Matrons then meet formally to review any short falls i.e. relocate staffing across ward areas, release ward sisters from office duties. Any unresolved concerns are then escalated to the Head of Nursing. The Director of Nursing receives a daily verbal overview of the Trust wide staffing. An escalation matrix has been developed and necessitates urgent escalation to Head of Nursing and Director of Nursing, if an internal solution cannot be identified. i.e. Day Shift

> 25% registered nurse shortfall ˃ 50% of all the staff are temporary Night Shift > Any registered nurse shortfall > 50% of all staff are temporary Currently the Trust produces an acute site operation plan which is reported 4 times daily. This is cascaded to the Chief Executive, Chief Operating Officer, Director of Nursing and Executive Director on call together with key operational staff across the Trust. Within the body of the report staffing levels and shortfalls are reported and mitigation plans are updated. These levels will form part of the daily shift overview provided on the NHS Choices website and will be available for the June Trust Board.

5.0 Human Resource indicators

The Trust currently provides E-rostering across all the inpatient ward areas. The rostering system brings together shift patterns, annual leave, sickness absence, staff skill mix and movement of staff between wards. The system allows for monthly reconciliation of hours worked against hours rostered. The scrutiny of these processes is monitored on a ward by ward basis through Matrons and ward sisters on a monthly basis.

5.1 Leadership The Trust has reintroduced a new clinical leadership programme incorporating the Trust Values in response to the National implementation.

The Trust has implemented the second phase of the programme specifically dedicated to the Matron workforce. The Trust also takes part in the National Nursing Leadership programme.

6

5.2 Recruitment Throughout the South East Coast, recruitment of registered nursing staff has

remained a challenge. This has been as a result of the reduction by the Health Education Institute of commissioned pre-registration student nurses. WSHFT has an extremely positive record of retaining and recruiting newly registered nurses. In addition WSHFT provide Open University placements for existing Health Care Assistants. The Trust is also establishing a return to practice/overseas adaption course for staff. The Trust currently presents workforce information monthly as part of the routine Trust Board papers. The Trust has recently undertaken overseas recruitment and will shortly be receiving over 30 Spanish nurses. Once fully inducted into the organisation the shortfall of nursing staff will be approximately 1%. Over the past 6 months there has been focussed attention on the recruitment and retention of both established and temporary (bank) nursing staff. This has been supported by the secondment of a Matron, to work in partnership with the Human Resources recruitment team. Recruitment within Paediatrics and Maternity does not remain a problem.

5.3 Reducing the use of temporary staff

The Trust currently spends approximately 10% of workforce spend on temporary nursing staff 7% bank and 3% agency. The additional nursing recruitment should significantly decrease the use of agency nursing staff. However should there be an unprecedented increase in activity across inpatient areas that result in the need to open extra ward based areas, in addition to those escalation areas planned for seasonal increases in activities this may result in the capacity of the Trust temporary bank system being exceeded which will then require recourse to agency usage. A full breakdown of band/agency spends and reconciliation against extra capacity is provided to the Finance & Investment Committee as part of the monthly finance report.

7

Extra initiatives this year include a review of the specialist support to patients suffering from dementia in order to provide a more care centered, cost effective approach to ward staffing.

6.0 Quality Care Metrics

Since merger WSHFT has provided, within the Public domain, a suite of quality indicators (Quality report). The report provides nationally benchmarked information to support quality metrics. The information provided to the Board is at summary level, however this information is generated and visibly displayed at ward level. Individual scrutiny of results takes place within each Clinical Divisional Board governance meeting. Trust Non-Executive Directors provide scrutiny and gain assurance at the quarterly Clinical Governance reviews, where all clinical outcomes and quality indicators per Division are reviewed. The Trust has developed its own internal Patient Safety Assessment Score (PASS) which is reported within the public domain. The Trust was a pioneer for the implementation of the National Safety Thermometer ensuring harm-free care for all patients. The Quality Board report highlights that all the quality of care metrics relating to inpatient areas exceed best practice i.e. the Trust remains free of Grade 4 pressure sores for 4 years and over a year for Grade 3 pressure sores. The in-hospital harm element of the Safety Thermometer reflects that over ˃ 98% of inpatients received harm-free care during their hospital stay. This month also sees the publication of the National Inpatient Survey which has identified an increase in patient satisfaction across the greater majority of domains. In addition, the Trust recently published staff survey was also extremely positive.

8

7.0 Proposals for future reporting

• The role out of Trust wide implementation of the safer nursing care acuity tool.

• The development of electronic reporting for escalation issues. • The development of supervisory ward sisters.

8.0 Conclusion

Since merger the Trust has undertaken a series of nationally benchmarked nurse establishment reviews to ensure that wards are established for safety staffing. The Trust formally reviews all ward staffing establishments. This was formally completed in April. During 2013/2014 enhancements were made to the night staffing template in response to patient need. On a monthly basis the Trust Board also receives positive outcome of care metrics which support the level of staffing established within acute wards. The staffing and recruitment at times of additional activity remains a challenge, though the report highlights the focus on recruitment throughout the Trust which will enable this challenge to be addressed in a sustainable manner. The paper can therefore assure the Board that it has safe staffing established nursing levels. However there is no element of complacency and as such should bed numbers increase or an increase in acuity arise staffing levels are adjusted accordingly.

9.0 Recommendation

The Board is asked to note the content of the report and endorse the key action areas and the work undertaken to date.

Cathy Stone Director of Nursing and Patient Safety April 2014

9

Version 1: 31st March 2014 Page 1

Hard Truths Commitments Regarding the Publishing of Staffing Data

Timetable of Actions

Action Required by Trusts: By When:

Periodicity: National Quality Board

Expectation(s):

Further Guidance:

A

The Board receives a report every six months on staffing capacity and capability which has involved the use of an evidence-based tool (where available), includes the key points set out in NQB report page 12 and reflects a realistic expectation of the impact of staffing on a range of factors. This report:

• Draws on expert professional opinion and insight into local clinical need and context

• Makes recommendations to the Board which are considered and discussed

• Is presented to and discussed at the public Board meeting

• Prompts agreement of actions which are recorded and followed up on

• Is posted on the Trust’s public website along with all the other public Board papers

June 2014

Every Six Months

1, 3 and 7

NQB pages 12, 18-

22 and 42

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APPENDIX A

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B

The Trust clearly displays information about the nurses, midwives and care staff present and planned in each clinical setting on each shift. This should be visible, clear and accurate, and it should include the full range of patient care support staff (HCA and band 4 staff) available in the area during each shift. It may be helpful to outline additional information that is held locally, such as the significance of different uniforms and titles used. To summarise, the displays should:

• Be in an area within the clinical area that is accessible to patients, their families and carers

• Explain the planned and actual numbers of staff for each shift (registered and non-registered)

• Detail who is in charge of the shift

• Describe what each member of the team’s role is

• Be accurate

From April and by June 2014 at the latest

Each shift

8

NQB pages 48-51

C

The Board:

• Receives an update containing details and summary of planned and actual staffing on a shift-by-shift basis

• Is advised about those wards where staffing falls short of what is required to provide quality care, the reasons for the gap, the impact and the actions being taken to address the gap

• Evaluates risks associated with staffing issues

• Seeks assurances regarding contingency planning, mitigating actions and incident reporting

• Ensures that the Executive Team is supported to take

From April and by June 2014 at the latest

Monthly

1 and 7

NQB pages 12, 13

and 45


decisive action to protect patient safety and experience

• Publishes the report in a form accessible to patients and the public on their Trust website (which could be supplemented by a dedicated patient friendly ‘safe staffing’ area on a Trust website).

D

The Trust will ensure that the published monthly update report specified in Row C [i.e. the Board paper on expected and actual staffing] is available to the public via not only the Trust’s website but also the relevant hospital(s) profiles on NHS Choices. The latter can be achieved either by placing a link to the report that is hosted on the Trust website on the relevant hospital(s)’ newsfeed on their NHS Choices webpage or by uploading the relevant document to the relevant hospital(s)’ NHS Choices newsfeed. For Trusts with multiple hospital sites that have their own NHS Choices webpages, this will require the separate posting of the Trust Board report to each hospital newsfeed. However, this is likely to reach more patients given that patients tend to review hospital, not Trust, NHS Choices webpages. This approach will also allow you to highlight hospital-specific plans and achievements, which may be of particular interest to a public audience. Given these requirements, the update reports should be written in a form that is accessible and understandable to patients and the public. This is likely to include ensuring that the information on staffing is not embedded within hundreds

By June 2014

Monthly

1 and 7


of pages of other Board papers. Your own NHS Choices web editor(s), who already provide your Trust and hospital-specific content to NHS Choices, will be able to advise you further on their preferred mechanism for making these documents available on NHS Choices – either via a link or by uploading a .pdf of the Board paper. NHS Choices will also be liaising directly with each Trust’s web editors with further information.

E

The Trust:

• Reviews the actual versus planned staffing on a shift by shift basis

• Responds to address gaps or shortages where these are identified

• Uses systems and processes such as e-rostering and escalation and contingency plans to make the most of resources and optimise care

Immediate

Each Shift

2

NQB pages 16 and

17

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Title

Month 12, 2013/14 Performance Report


Jane Farrell, Chief Operating Officer/Deputy Chief Executive

Prepared by

Adam Creeggan, Director of Performance Giles Frost, Head of Operational Planning and Performance

Status

Public Domain

Summary of Proposal The purpose of this paper is to inform the Trust Board of organisational compliance against national and local key performance metrics. The report summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the Monitor Risk Assessment Framework, and when relevant, other efficiency indicators. This paper describes performance on an exceptional basis determined by RAG rating, national significance, or in year trend analysis. Implications for Quality of Care

Describes Quality Outcome KPIs


Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness. Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation.


Describes KPIs linked to financial performance


Describes KPIs linked to workforce

Recommendation

The Board is asked to: NOTE


Not applicable

Appendices

Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Monitor Risk Assessment Framework Scorecard.

To: Trust Board

Date of Meeting: 1st May 2014 Agenda Item: 8

1

To: Trust Board Date: 1st May 2014

From: Jane Farrell, Chief Operating Officer/Deputy Chief Executive

Agenda Item: 8

FOR INFORMATION

WSHFT PERFORMANCE REPORT: MONTH 12, 2013/14 1. INTRODUCTION

1.1 This report summarises both in year and projected year end performance for Western Sussex

Hospitals NHS Foundation Trust, detailed in dedicated performance scorecards relating to:

• The Monitor Risk Assessment Framework under which the Trust is performance

managed following authorisation as a Foundation Trust effective July 1st 2013.

• Other efficiency indicators, where relevant.

1.2 This paper describes performance on an exceptional basis determined by RAG rating, national

significance, or in year trend analysis.

1.3 In addition to the performance exception narrative, each exception is examined in detail in the

Key Performance Deliverables section of this report. Each metric under review examines detailed

trending, prevailing cause and effect, and summarises recovery programme actions.

2. SUMMARY PERFORMANCE

2.1 The Trust generated a Monitor Risk Assessment Framework forecast score of 3 points for

Quarter 4, with C.difficile, non-admitted Referral to Treatment (RTT) completetions, and RTT

incomplete pathways being non-compliant in Month.

2.2 The Trust had 3 cases of C.difficile in March generating a cumulative volume of 57 cases against

the cumulative target for the end of Quarter 4 of 46 cases.

2.3 Non-admitted RTT compliance was 89.32% against a target of 95%. RTT incomplete pathway

compliance was 89.99% against a target of 92%. Under the Monitor Risk Assessment Framework

2

a single month of non-compliance triggers a compliance failure for the entire Quarter; however

formal ‘exception reporting’ is not triggered in a specific metric unless three consecutive quarters

of non-compliance is reported in the same metric.

2.4 Key indicators of operational pressure during March include:

• 11,995 A&E attendances compared to 11,091 in March 2013 (+8.2%). When

scrutinised by age group: there was a 7.8% increase in 65-84 years and a -2.1%

decrease in >=85 years March 2014 compared to March 2013.

• 4,252 emergency admissions compared to 4,004 in March 2013 (+6.2%). When

scrutinised by age group: there was a 12.0% increase in 65-84 years and a 3.6%

decrease in >=85 years March 2014 compared to March 2013 (6.2% increase in

admissions for patients over 65).

• Delayed transfers of care were 3.0% for March 2014.

• Occupancy of funded bed stock was 98.2% for March 2014, and 99.3% in

aggregation for Quarter 4. This compares to 91.5% in Quarter 1, 90.2% in Quarter 2,

and 93.7% in Quarter 3 2013/14.

3. PERFORMANCE EXCEPTIONS 3.1 A&E Compliance

3.1.1 The Trust was compliant in March with 97.27% of patients waiting less than four hours from

arrival at A&E to admission, transfer, or discharge, against a national target of 95%.

3.1.2 For context and comparison, national data for the period 3rd – 30th March relating to Type 1

(Major A&E) departments shows compliance of 93.52%, therefore, WSHFT operated 3.75%

ahead of the national average during the month. Compliance for Surrey and Sussex Area

providers (excluding WSHFT) for the same period showed 94.21% for Type 1 A&E attendances,

with WSHFT reporting the third highest performance within the sector.

3.1.3 Performance is assessed for A&E on a quarterly basis by Monitor. Performance for Quarter 4 was

95.40% hence compliant for the Quarterly assessment.

3.2 Cancer

3.2.1 Based on provisional data, the Trust achieved compliance against all seven cancer metrics

relevant to WSHFT in March 2014. Data becomes finalised following upload to the Open Exeter

national database by all national providers, which must occur by the 25th working day following

completion of the reporting month.

3

3.2.2 As reported to the Board through 2013/14, compliance is set against sustained increases in

cancer demand. Referrals under the Cancer 2 week rule have increased by circa 30%, with a

significant element of this growth occurring in 2013/14. This referral pathway is only available to

GPs, and within national guidance the receiving provider organisation cannot refuse or

downgrade any referral received.

3.2.3 Comparing March 2014 with March 2013, the Trust saw 21.0% more patients following 2 week

(urgent cancer) referral, 26.2% more patients completed treatment within 62 days of referral, and

27.5% more patients were treated within 31 days of a decision to treat. This increase in referral

demand and conversion to treatment far outstrips planned increases in operational resources in

2013/14, and therefore presents an on-going critical risk to sustained compliance across all

cancer metrics.

3.3 Referral to Treatment (18 Weeks)

3.3.1 The Trust maintained full compliance against the admitted pathway target in March with 90.62%

(2,493 of 2,751 completed pathways). The Trust did not achieve compliance against the non-

admitted aggregate compliance target of 95%, reporting a value of 89.32% for the month (5,711

of 6,394 patients waiting). The Trust was also non-compliant for incomplete pathways with

performance of 89.99% against a target of 92% (25,925 of 28,809 waiters) as of the end of

March.

3.3.2 Compliance failure was a predicted outcome reflecting the health economy gap between referral

demand and available capacity. The 2013/14 contract embedded a GP referral plan aligned to

the capacity available at the Trust. This plan was not achieved, and has resulted in an observed

range of up to 23.8% above planned levels, in turn generating waiting list growth of 18.5% from

April 2013 to March 2014. Breakdown of key specialties shows:

• Total referrals from all sources are up by 2.9% on plan

• Total referrals from A&E are up by 3.4% on plan

• Total referrals from GPs and MSK are up by 1.9% on plan across all specialties,

although February was 10.72% higher than plan, and March 5.44%.

• GP/MSK referrals to Orthopaedics are up 6.7% on plan

• A&E referrals to Orthopaedics (trauma) are up 0.9% on plan

• GP referrals to Ophthalmology are up 17.4% on plan

• GP referrals to Respiratory Medicine are up 23.8% on plan

• GP referrals to Cardiology are up 11.8% on plan

• GP referrals to Dermatology are -15.5% below plan, contrary to the planned 60%

reduction in CWSCCG QIPP plans for 2013/14

4

3.3.3 Alongside the aggregate imbalance of supply versus available demand, two significant and

atypical factors have compounded the ability to accurately forecast and deliver compliance in

aggregation, namely:

• A significant increase in urgent referrals with an associated need for urgent

treatment. In broad terms, 2013/14 saw a 10% increase in elective referrals

requiring treatment in 0-4 weeks of referral, and a consequent 10% reduction in

patients waiting 0-4 weeks.

• A significant increase in demand for ophthalmic services linked to the licencing of

Lucentis injections as treatment for Acute Macular Degeneration, and revision to

the DVLA eyesight requirement and the consequent lowering of Coastal West

Sussex CCGs threshold for cataract surgery.

3.3.4 To both recover non-compliance, and ensure sustainable compliance thereafter, the Trust has

developed an extensive recovery programme targeting nine specialties that make the biggest

contribution to aggregate compliance, and this was shared with Trust Board in the Month 11

Performance Report. During Q1 this programme delivers an additional 2870 outpatients, and a

further 1082 inpatients/day cases above the 2013/14 run rate. This volume reduces the waiting

list size and distribution to a point that can deliver aggregate compliance from Q2 2014/15, but a

further 6568 outpatients and 2275 inpatients/day cases are identified in the plan above current

run rate in Quarters 2-4 in order to maintain compliance from that point.

3.3.5 In April to date (22nd), a total of 1123 additional outpatients have been delivered and 339

inpatients/day cases. This additional capacity has reduced the outpatient waiting list by 2.1% and

the inpatient/day case list by 3.9% across all specialties.

3.3.6 The single largest element of the recovery programme relates to ophthalmology, and in April the

specialty is on target to deliver an increase of 1071 additional outpatients (+26.1%) and 270

additional day cases (+59.6%). In turn this has driven a reduction in the outpatient waiting list of -

537 patients (-21.3%) and a reduction in the inpatients/day cases waiting list of -214 (-3.9%). The

more modest reduction in the latter is as per plan and is an effect of additional capacity

successfully removing the volume equivalent to those converting from the outpatient list to the

inpatient/day case list.

3.3.7 To ensure alignment of capacity to the specific patient level recovery cohort, capacity is being

micromanaged to ensure allocation to either urgent patients, or patients who will be waiting 18

weeks or more on 30 June 2014, and therefore require admission/attendance before that date.

Specifically, this generates a listing of 8247 patients that either (a) have no admission date or

outpatient planned event date, or (b) have an admission date or outpatient planned event date

after 30 June 2014.

5

3.3.8 This cohort is tracked daily and managed on an exception basis, with an expectation that all

patients are allocated a date prior to 30 June 2014 of by mid-May (subject to patient choice). This

daily monitoring is set against the weekly programme management arrangements outlined to

Trust Board in the Month 11 Performance Report, and both will be maintained throughout the

recovery programme lifecycle.

3.3.9 The early implementation results described above confirms delivery is on course to achieve

restoration of aggregate compliance for Quarter 2. Both the plan and forecast delivery are

predicated on unchanged referral rates, therefore the peak in referring observed in February and

March (detailed in 3.3.2 above) generate a delivery risk that will be closely monitored.

3.4 Fractured Neck of Femur (#NOF) operation within 36 hours of admission. 3.4.1 During March 97.4% of medically fit Fractured Neck of Femur patients were operated on within

36 hours of admission against a target of 90%.

4 RECOMMENDATION

4.1 The Board is asked to receive and note the score of 3 points for the Monitor Compliance

Framework Q4 2013/14.

Adam Creeggan, Director of Performance

Giles Frost, Head of Operational Planning and Performance

19th March 2014

6

Mark Dennis, Head of Information Servicest: 01903 285273 (ext 5273)

8a Copy of Quality scorecard M12_v2.Quality scorecard Page 1 of 4 Printed 25/04/2014 15:39

MARCH 2014Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MAR YTD

ActualYTD

TargetTarget Trend

EFFECTIVENESSE01 Trust crude mortality rate (non-elective) 4.10% 3.76% 3.18% 2.83% 3.51% 2.66% 2.80% 2.77% 2.81% 3.46% 3.79% 3.83% 3.17% 3.22% 3.24% 3.24%

E02 Crude mortality rate (non-elective): 12 month rolling 3.24% 3.26% 3.28% 3.29% 3.37% 3.35% 3.35% 3.33% 3.31% 3.31% 3.29% 3.30% 3.22% 3.22% 3.24% 3.24%

E03 Trust Hospital Standardised Mortality Ratio (HSMR) 100.5 99.2 99.0 97.9 98.3 96.5 95.8 94.8 93.9 92.3 90.8 #N/A #N/A 90.8 100 100

E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 1.02 1.00 1.00

Improve mortality in specific conditions

E05 Crude non-elective mortality for Pneumonia 18.1% 15.8% 13.8% 15.3% 17.1% 17.9% 18.6% 16.4% 17.3% 17.8% 12.9% 15.8% 20.8% 16.5% 18.0% 18.0%

E06 Crude non-elective mortality for COPD 6.3% 6.7% 3.4% 6.2% 11.3% 4.8% 4.4% 4.6% 1.5% 3.1% 3.7% 4.4% 4.1% 4.7% 6.7% 6.7%

E07 Crude non-elective mortality for Renal failure 40.0% 45.9% 20.0% 30.0% 14.8% 0.0% 17.4% 9.4% 21.4% 34.5% 14.6% 34.4% 22.6% 24.1% 20.4% 20.4%

E08 Crude non-elective mortality for Chronic heart failure 22.8% 26.5% 16.7% 12.2% 19.1% 19.6% 14.0% 5.8% 9.1% 14.5% 17.9% 15.5% 10.8% 14.9% 18.7% 18.7%

Reduce mortality following hip fracture

E09 SMR for hip fracture (all diagnoses/procedures) 125.2 127.3 125.4 121.5 119.1 115.5 113.1 117.0 114.7 109.9 110.4 #N/A #N/A 110.4 100 100

E09a Worthing SMR for hip fracture (all diagnoses/procedures) 113.6 111.0 114.6 113.7 113.1 109.0 108.3 117.2 115.9 113.6 115.3 #N/A #N/A 115.3 100 100

E09b St Richard's SMR for hip fracture (all diagnoses/procedures) 143.2 152.1 141.4 132.9 128.1 125.1 119.9 116.8 112.9 104.1 103.0 #N/A #N/A 103.0 100 100

E10 30 day mortaliy rate following hip fracture 5.5% 15.5% 8.0% 3.3% 6.9% 4.8% 11.1% 5.5% 7.1% 8.3% 8.8% #N/A #N/A 8.3% 8.3% 8.3%

Reduce the rate of readmission following discharge from the Trust

E11 Emergency readmissions within 30 days % 11.9% 11.7% 11.3% 12.4% 12.4% 12.5% 11.6% 12.0% 11.5% 12.2% 13.1% 12.6% 12.4% 12.4% 12.2% 12.2%

E12 Emergency admissions not usually requiring admission 453 402 372 353 364 374 387 410 423 519 466 452 4,522 4498 4,907

To improve maternity care by encouraging natural chilbirth

E13 C-Section Rate 26.9% 27.9% 24.3% 23.9% 28.6% 23.5% 26.9% 25.0% 25.0% 26.7% 24.7% 29.6% 27.1% 26.1% 24.7% 24.7%

E14 % Mothers requiring forceps for delivery 9.7% 10.5% 10.5% 12.5% 10.8% 13.0% 11.2% 9.3% 13.9% 14.4% 13.8% 12.3% 11.1% 11.9% <15% <15%

E15 % Deliveries complicated by post-partum haemorrhage 1.00% 0.70% 0.90% 0.90% 0.00% 0.20% 0.70% 0.80% 0.00% 1.20% 1.20% 1.10% 1.20% 0.80% 1% 1%

E16 Maternal deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E17 Admission of term babies to neonatal care - 2.50% 2.20% 3.30% 3.70% 4.20% 2.40% 2.20% 1.50% 3.80% 2.20% 4.70% 5.30% 3.20% <10% <10%

Caring for the elderly patient

E18 % Emergency admissions staying over 72h screened for dementia - 10.2% 20.4% 31.0% 37.9% 54.8% 68.7% 77.0% 87.3% 90.9% 92.2% 93.7% 87.4% 62.6% 90% 90%

E19% Patients identified as at risk of dementia for whom further investigations are carried out

- 61.5% 80.9% 72.7% 77.5% 77.9% 74.6% 76.7% 83.1% 91.5% 96.0% 97.6% 95.7% 82.1% 90% 90%

E20 % Patients with identified dementia referred to specialist services - 75.0% 95.5% 93.1% 93.8% 91.5% 95.2% 98.0% 100.0% 95.7% 96.6% 100.0% 100.0% 94.5% 90% 90%

Ensure active engagement with research

E21 Patients recruited to interventional studies within CRN portfolio 45 49 24 27 22 31 30 22 19 21 12 13 12 282 n/a n/a

E22 Patients recruited to observational studies within CRN portfolio 41 30 35 8 13 12 13 9 22 23 48 39 33 285 n/a n/a

E23 CLRN Score 266 275 155 143 123 167 163 119 117 128 108 104 93 1695 1305 1305

Data Quality

E24 NHS IC Data validity summary (YTD) 94.9 95.8 95.8 96.6 96.8 97.7 98.0 98.4 98.6 98.6 98.7 #N/A 98.7 96 96

1.02 1.02

QUALITY SCORECARD

#N/A




ActualYTD

TargetTarget Trend

QUALITY SCORECARDSAFETYS01 Patient Aggregate Safety Score (PASS) 89.9 88.9 85.0 96.8 98.3 81.8 84.3 98.3 68.9 85.7 82.8 104.3 88.7 <100 <100

General Safety

S02 Safety Thermometer: % of patients harm-free 92.0% 93.0% 92.5% 93.9% 93.0% 95.4% 95.2% 95.5% 94.0% 95.2% 93.3% 93.4% 93.1% 94.0%

S03 Safety Thermometer: % of patients with no new harms 97.8% 97.1% 98.1% 98.4% 97.3% 98.3% 98.8% 98.2% 98.0% 98.4% 97.7% 98.2% 97.0% 98.0%

S04 Total incidents 765 711 722 773 744 680 692 812 719 799 780 863 772 9067 6068-10114

6068 - 10,114

S05 Total moderate, severe or death incidents 8 6 8 9 12 6 10 9 9 7 9 9 11 105 85 85

S06 Total serious incidents (SIRI) 3 2 1 0 3 4 4 3 2 1 2 2 5 29 26 26

S07 Number of outstanding CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Improve safety of prescribing

S08 Total incidents involving drug/prescribing errors 92 79 80 87 78 79 78 74 91 121 119 90 101 1077 826-1376 826 -1376

S09 Moderate/severe incidents involving drug/prescribing errors 0 0 2 1 0 0 0 0 2 0 0 0 1 6 4 4

S10 Reduced errors on zero tolerance anti-microbial prescribing audits 68% 80% 80%

Reduce incidence of healthcare associated VTE

S11 95% compliance with the DoH risk assessment tool 94.0% 94.4% 95.2% 95.6% 97.0% 96.0% 96.5% 96.6% 96.4% 96.5% 96.1% 95.7% 95.5% 96.1% 95% 95%

S12 Prescriptions for VTE prophylaxis 2069 1998 2184 1778 1913 2113 2160 2288 2103 2295 2241 2156 2469 25698 23320 23320

S13 Incidence of VTE 23 33 34 24 31 28 29 29 31 29 30 39 39 376 334 334

Reduce incidence of healthcare acquired infections

S14 Number of hospital attributable MRSA cases 0 0 0 0 1 1 0 0 2 0 0 0 0 4 0 0

S15 Number of hospital attributable C.diff cases 9 13 5 7 2 7 3 3 2 2 7 3 3 57 42 46

S16 Number of reportable MSSA bacteraemia cases 10 6 4 6 7 7 4 3 4 8 6 6 7 68 tbc tbc

S17 Number of reportable E.coli cases 21 25 30 23 25 30 17 18 15 30 24 25 24 286 tbc tbc

Improve theatre safety for patients

S18 Full compliance with WHO Surgical Safety Checklist 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

S19 NEVER events 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0

S20 Theatre related SIRIs 0 0 0 0 1 0 1 0 0 1 0 0 0 3 0 0

Reduce number of falls in hospital

S21 Falls resulting in harm 45 46 29 36 37 26 40 45 31 41 44 49 37 461 481 481

S22 Falls resulting in severe harm or death 1 2 0 0 0 2 1 0 0 0 0 0 0 5 2 2

S23 Falls assessment within 24hrs of admission 91.5% 92.0% 93.5% 94.5% 93.7% 95.5% 90.0% 93.3% 93.6% 91.0% 90.0% 90.3% 95.5% 92.7% 80% 80%

S24 Avoidable falls identified on the Safety Thermometer 1.70% 1.46% 1.42% 0.89% 0.85% 0.64% 0.48% 0.71% 0.24% 0.67% 0.69% 0.33% 0.70% 0.62% 1.41% 1.41%

Pressure damage

S25 Grade 2 pressure sores 13 12 9 7 9 9 5 8 6 8 15 10 7 105 114 114

S26 Grade 3 & 4 pressure sores 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 4

64%76% 69%61%67%

100%




ActualYTD

TargetTarget Trend

QUALITY SCORECARD

EXPERIENCEFriends and family test

X01 Trust Friends and Family Score: Inpatient (reported from Q2) - - - 75 79 73 76 75 78 74 74 69 76 75 Base-line Base-line

X02 Trust Friends and Family Score: A&E (reported from Q2) - - - 79 77 74 74 76 76 75 78 75 73 75 Base-line Base-line

Use of feedback from the real time patient experience project

X03 Realtime feedback on the hospital environment 76 75 77 76 76 76 77 76 78 75 77 77 77 76 75 75

X04 Realtime feedback on assistance 88 91 90 90 90 92 91 91 93 91 91 87 91 91 87 87

X05 Realtime feedback on compassion 88 89 90 90 89 89 90 90 90 89 90 90 90 90 88 88

X06 Realtime feedback on communication 79 75 79 79 79 76 79 80 78 80 78 74 80 78 77 77

X07 Overall experience of the Trust 92 91 93 93 93 92 93 93 94 93 93 91 92 93 92 92

Reduction in patients suffering a bad experience dealing with the Trust

X08 Percentage of re-booked outpatient appointments 10.0% 9.9% 8.8% 9.8% 9.0% 8.2% 7.8% 8.3% 8.3% 8.2% 7.5% 7.8% 8.9% 8.6% 9.8% 9.8%

X09 Clinics cancelled with less than 6 weeks notice 18 19 26 41 16 25 20 25 26 10 26 16 16 266 376 376

X10 Average number of ward stays per non-elective admission 1.73 1.78 1.78 1.82 1.80 1.75 1.74 1.81 1.74 1.73 1.84 1.85 1.73 1.78 1.75 1.75

X11 PALS contacts relating to appointment problems (% of total appts) 0.11% 0.12% 0.14% 0.16% 0.16% 0.21% 0.19% 0.14% 0.10% 0.07% 0.07% 0.09% 0.09% 0.13% 0.10% 0.10%

X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 45 31 17 21 16 26 16 27 24 28 45 45 23 319 455 455

X13 Breaches of mixed sex accommodation arrangements 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0 0

Nutritional Assessment

X14 Compliance with MUST tool after 24 hours 83.0% 84.0% 85.9% 86.7% 86.7% 89.5% 88.4% 86.8% 82.0% 79.5% 85.5% 89.0% 90.0% 86.2% 80% 80%

X15 Compliance with MUST tool after 7 days 93.5% 97.5% 98.0% 98.4% 97.5% 96.5% 98.6% 95.8% 97.0% 96.5% 94.5% 98.3% 97.5% 97.2% 95% 95%

Cleanliness / PEAT Survey

X16 Internal PLACE compliance : St Richard's Hospital 96% 97% 94% 95% 96% 98% 99% 97% 97% 99% 98% 97% 99% 97% 85% 85%

X17 Internal PLACE compliance : Worthing Hospital 95% 95% 92% 97% 96% 92% 91% 92% 99% 98% 96% 98% 96% 95% 85% 85%

Improve our customer service and become a more caring organisation

X18 Number of complaints 40 39 47 55 37 36 30 58 40 38 53 49 40 522 562 562

X19 Complaints where staff attitude or behaviour is an issue 7 6 6 4 2 2 5 4 3 2 3 6 3 46 56 56

X20 Complaints where staff communication is an issue 5 3 5 2 4 4 2 7 4 6 4 7 1 49 75 75

X21 Complaints about nursing 6 3 1 4 3 3 0 3 0 3 3 3 3 29 41 41

X22 Positive care and compassion observations in general care 83% n/a n/a

X23 Positive care and compassion observations in patient / visitor interactions 83% n/a n/a84%

80%

79%

88%

92%

81%

87%

88%




ActualYTD

TargetTarget Trend

QUALITY SCORECARD

CQUIN SCHEMESNational CQUINS

E18 % Emergency admissions staying over 72h screened for dementia 10.2% 20.4% 31.0% 37.9% 54.8% 68.7% 77.0% 87.3% 90.9% 92.2% 93.7% 87.4% 62.6% 90% 90%

E19% Patients identified as at risk of dementia for whom further investigations are carried out

61.5% 80.9% 72.7% 77.5% 77.9% 74.6% 76.7% 83.1% 91.5% 96.0% 97.6% 95.7% 82.1% 90% 90%

E20 % Patients with identified dementia referred to specialist services 75.0% 95.5% 93.1% 93.8% 91.5% 95.2% 98.0% 100.0% 95.7% 96.6% 100.0% 100.0% 94.5% 90% 90%

S11 95% compliance with the DoH risk assessment tool 94.0% 94.4% 95.2% 95.6% 97.0% 96.0% 96.5% 96.6% 96.4% 96.5% 96.1% 95.7% 95.5% 96.1% 95% 95%

S24 Avoidable falls identified on the Safety Thermometer 1.70% 1.46% 1.42% 0.89% 0.85% 0.64% 0.48% 0.71% 0.24% 0.67% 0.69% 0.33% 0.70% 0.62% 1.41% 1.41%

X24 Trust Friends and Family Response Rate: Inpatient 6.6% 12.3% 13.6% 16.1% 26.0% 17.8% 16.5% 20.6% 22.7% 32.9% 24.0% 26.2% 24.8% 21.1% 20% 20%

X25 Trust Friends and Family Response Rate: A&E 0.7% 1.4% 1.9% 6.8% 12.0% 9.8% 15.3% 19.4% 30.2% 42.0% 35.0% 34.0% 28.0% 19.7% 20% 20%


8b Copy of Infection Control Scorecard M12.Infection Control Page 1 of 1 Printed 25/04/2014 15:40

MARCH 2014Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Actual YTD Target Target Trend

Compliance with high impact intervention care bundles (HII)

Renal 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95% 95%

Central line 100% 100% 96% 100% 100% 99% 100% 100% 99% 100% 100% 100% 99% 99% 95% 95%

Ventilation 100% 100% 100% 99% 83% 100% 100% 98% 97% 100% 98% 100% 100% 98% 95% 95%

Hand hygiene 97% 97% 98% 99% 98% 99% 98% 97% 98% 97% 96% 98% 97% 98% 95% 95%

Peripheral IV Line 97% 99% 96% 97% 97% 97% 97% 97% 97% 98% 96% 97% 98% 97% 95% 95%

Catheter care 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 100% 100% 100% 100% 95% 95%

Screening

Compliance with elective MRSA screening 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Compliance with non-elective MRSA screening 98% 98% 98% 99% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 100% 100%

Hospital cleanliness

Very high risk 99% 99% 99% 99% 99% 99% 99% 99% 99% 100% 100% 99% 99% 99% 98% 98%

High risk 97% 97% 97% 98% 98% 98% 98% 98% 98% 98% 98% 98% 97% 98% 95% 95%

Significant risk 97% 96% 96% 97% 96% 96% 95% 95% 96% 97% 97% 96% 96% 96% 85% 85%

Low risk 91% 93% 97% 94% 94% 97% 94% 90% 94% 95% 95% 95% 91% 94% 75% 75%

Decontamination of equipment

Decontamination of equipment 98% 98% 98% 99% 100% 97% 99% 98% 98% 99% 98% 100% 98% 99%

INFECTION CONTROL SCORECARD


8c Copy of Monitor scorecard M12_v1.SCORECARD Page 1 of 1 Printed 25/04/2014 15:40

MARCH 2014

Threshold Apr May Jun Q1Weighted

Score Jul Aug Sep Q2Weighted

Score Oct Nov Dec Q3Weighted

Score Jan Feb Mar Q4

WeightedScore

(Forecast)

ACCESSM1

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted

90% 90.11% 90.22% 90.11% 90.15% 0.0 90.16% 90.06% 90.88% 90.35% 0.0 90.85% 90.27% 90.07% 90.40% 0.0 90.29% 90.05% 90.62% 90.32% 0.0

M2Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted

95% 96.43% 96.56% 96.90% 96.63% 0.0 96.19% 96.28% 95.50% 95.99% 0.0 95.46% 95.58% 95.17% 95.40% 0.0 90.48% 91.10% 89.32% 90.30% 1.0

M3Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

92% 93.69% 94.34% 94.43% 94.16% 0.0 94.39% 93.14% 93.13% 93.55% 0.0 92.56% 92.31% 92.04% 92.30% 0.0 92.06% 90.42% 89.99% 90.82% 1.0

M5A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge

95% 95.99% 97.78% 97.24% 97.01% 0.0 97.44% 96.02% 95.54% 96.36% 0.0 95.36% 96.06% 94.89% 95.43% 0.0 95.49% 94.02% 97.27% 95.40% 0.0

M6aAll cancers : 62-day wait for first treatment following urgent GP Referral

85% 92.73% 87.13% 87.56% 88.96% 85.66% 87.66% 84.76% 85.19% 86.82% 87.50% 87.79% 87.08% 86.04% 87.50% 88.76% 86.17%

M6bAll cancers : 62-day wait for first treatment following consultant screening service referral

90% 97.62% 89.36% 92.86% 93.57% 97.67% 91.07% 89.66% 92.17% 94.34% 92.45% 92.31% 93.23% 90.24% 97.22% 94.29% 91.14%

M7aAll cancers : 31-day wait for second or subsequent treatment - surgery treatments

94% 100.00% 100.00% 97.06% 98.92% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

M7bAll cancers : 31-day wait for second or subsequent treatment - drug treatments

98% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

M8 All cancers : 31-day wait from diagnosis to first treatment 96% 99.48% 100.00% 100.00% 99.84% 0.0 99.59% 96.35% 98.26% 98.21% 0.0 99.63% 100.00% 100.00% 99.86% 0.0 100.00% 99.52% 100.00% 98.88% 0.0

M9a Cancer : two week wait from referral to date first seen - All patients 93% 96.89% 97.83% 97.34% 97.37% 98.84% 98.42% 98.05% 98.46% 99.17% 98.71% 98.12% 98.68% 97.04% 99.02% 99.02% 98.04%

M9bCancer : two week wait from referral to date first seen - Symptomatic breast patients

93% 98.77% 97.69% 94.89% 97.25% 98.88% 97.06% 100.00% 98.53% 99.44% 95.88% 99.27% 98.14% 97.31% 98.51% 97.52% 97.95%

OUTCOMESM17 Clostridium Difficile – meeting the Clostridium Difficile objective 46 13 5 7 25 1.0 2 7 3 12 1.0 3 2 2 7 1.0 7 3 3 13 1.0

M18 MRSA – meeting the MRSA objective 0 0 0 0 0 0.0 1 1 0 2 0.0 0 2 0 2 see note i 0 0 0 0 see note i

M27Certification against compliance with requirements re access to healthcare for people with a learning disability

YES YES YES YES YES 0.0 YES YES YES YES 0.0 YES YES YES YES 0.0 YES YES YES YES 0.0

1.0 1.0 1.0

Notes

i From 1 October 2013 MRSA was removed from the Monitor Risk Assessment Framework

0.0

0.0 0.0

0.0

Green : 0 Amber/Green : 1 Amber : 2 Amber/Red : 3 Red : 4 or more

0.0

Monitor Compliance Framework Score

0.0

0.0 0.0

3

Monitor Risk Assessment Framework

0.0 0.0

0.0

0.0


8d Copy of #NOFDashboard_1402_Feb_v1.Western Sussex Hospitals Page 1 of 1 Printed 25/04/2014 15:40

version 1.5FEBRUARY 2014

% Patients operated on within 36 hours of A&E attendance (source: NHFDb) Mortality in hospital and within 30 days of admission (source: NHFDb/Sema Helix)

% Patients who saw Consultant Physician Pre-op (source: NHFDb) % Patients mobilised within 24 hours post-op Total LOS and LOS on post-op ward (source: NHFDb)

FRACTURED NECK OF FEMUR DASHBOARD Site: Western Sussex Hospitals Data for period:

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8d Copy of #NOFDashboard_1402_Feb_v1.Month summary Page 1 of 1 Printed 25/04/2014 15:40

Summary Table - Data from NHFDbFEBRUARY 2014

St Richard's Worthing WSHTAdmissions 27 48 75Discharges 28 48 76Number of deaths in hospital 1 7 8Hospital mortality rate % 3.6% 14.6% 10.5%Number of deaths within 30 days of admission(for admissions in November 2013)

1 7 8

Mortality rate within 30 days of admission 3.0% 12.1% 8.8%Average LOS 13.3 19.7 16.8

Medically fit patients 25 44 69Number operated wtihin 24 hours 18 29 47% operated within 24 hours 72.0% 65.9% 68.1%Number operated wtihin 36 hours 22 42 64% operated within 36 hours 88.0% 95.5% 92.8%

All patients 26 46 72Number operated wtihin 24 hours 18 29 47% operated within 24 hours 69.2% 63.0% 65.3%Number operated wtihin 36 hours 22 42 64% operated within 36 hours 84.6% 91.3% 88.9%

WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST

To: Board

Date of Meeting: 1st May 2014 Agenda Item: [insert agenda item]

Title:

Report on Organisational Development and Workforce performance Responsible Executive Director

Denise Farmer, Director of OD and Leadership

Prepared by

Jennie Shore, Deputy Director of HR

Status

Disclosable

Summary of Proposal The paper describes performance against the key areas of delivery in our Workforce strategy and highlights for the Board key workforce development issues this month Implications for Quality of Care Supports delivery of all Trust objectives Financial Implications

Impact on Pay costs as described


As described

Recommendation The Board is asked to NOTE the report Consultation

n/a

Appendices

Workforce data report

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.


To: Trust Board Date: 1 May 2014 From: Denise Farmer, Director of Organisational Development

and Leadership

Agenda Item: XXX

FOR INFORMATION ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT

1.00 INTRODUCTION 1.01 This sets out the key performance indicators relating to the Trust’s workforce at 31 March 2014. 2.00 SUMMARY OF PROPOSAL 2.01 Workforce Capacity The total workforce capacity used during March continued to exceed 100% of budgeted

establishment. The amount of temporary staff used fell marginally but continues to represent circa 10% of overall capacity.

Within the Medicine Division, capacity exceeded the funded establishment by 170.3 wte, despite an increase of 96.70 wtes to its establishment since March 2013. Temporary staffing accounted for 15% of the total workforce capacity of the Division, leading to a continued dependency on agency staff. Whilst this will be partially abated when all the trained nurses recently recruited join the Trust, the need for escalation beds continues to drive the high level of demand for temporary staffing. The recent recruitment campaign to Spain has been very successful and induction and orientation arrangements have been put in place to ensure our new starters have a really warm welcome. The first group of 11 nurses commenced in post on 31 March with a further 15 joining us on 28 April. The remaining nurses will join the Trust during May and June. Following the success of recent recruitment events a further ‘Bank’ open day to attract both qualified nurses and HCAs will be held on 9 May. Another recruitment event to attract student nurses due to qualify in September is now being planned for early summer. A local audit, recently completed by the recruitment supervisor, has demonstrated that the time to hire for external applications from offer letter to start date has improved to an average of 6.6 weeks (ranging from 4 to 10 weeks). Obtaining sufficient and adequate references that cover a minimum of a three year period is the biggest cause for delays. For some candidates, this has required obtaining a reference from numerous referees. It is anticipated that the improved functionality now available with NHS Jobs 2 will enable performance indicators for recruitment to be reported in more detail. This will commence when the transitional phase of implementation is completed.

2.02 Workforce Efficiency

Sickness absence during February remained at 3.8%. This continues to be a significant concern within the Facilities and Estates Division where absence peaked at 7.3% compared, for example, to 2.5% in the Core Services Division. The proportion of staff on long term absence has decreased by

0.3% since March 2013. Detailed monthly sickness reports for those staff breaching the agreed Trust ‘triggers’ are sent to managers with resulting actions being followed up by the HR team. Delivery of a reduction in sickness absence of 0.5% is a key work stream for improving productivity in 2014/15 and will form part of the performance management dashboards across the organisation.

Turnover for 2013/14 was 7.3% and represented a reduction of 1.2% on 2012/13 outturn. Turnover within the Core and Corporate Divisions was higher at 9% and 10% respectively.

2.03 Real time Staff Feedback

The number of staff participating in the Family and Friends test at the health and safety days was low again during March. This is being followed up to ensure that staff are actively encouraged and given time during their training to provide feedback.

The Family and Friends test has now been extended to staff and will be reported nationally on a quarterly basis. This will require the Trust to invite all staff to participate. Staff will be given the opportunity to provide their feedback via the online Meridian system (currently used for patients), feedback cards/drop boxes in key strategic places in the Trust and at the health and safety days. The methodology and response rate will be reviewed after the first return, due at the end of July.

2.04 Service changes Divisional Operational Management Restructuring – Feedback on the divisional restructuring has been considered and a Final Decisions document issued. This is now proceeding to implementation. In the meantime there has been increased turnover amongst operational managers which will lead to some operational pressures until the recruitment process is completed. CLRN – 7 staff TUPE transferred to the Royal Surrey County Hospital on 1 April. Bowel Screening – 2 staff TUPE transferred from Brighton and Sussex University Hospitals and Portsmouth Hospitals as part of the development of the screening programme on 1 April.

2.05 Workforce Skills and Development

Statutory and Mandatory Training Attendance on all of the core statutory and mandatory training has achieved or exceeded the Trust target of 90% and continues to maintain or increase. The exception is Adult Protection training, the provision of which is under review. The numbers of staff who have no training record has reduced to 39 medical staff (down by 12 in last month) and 17 other staff (down by 24 in last month) Workforce Managers are continuing to work with Divisions to ensure that these individuals complete their training as soon as possible.

Page 2 of 4

Senior Leaders Development Programme A development programme for some of our senior leaders - Clinical Directors, Divisional Directors and Chiefs of Service, has been launched. This programme has been developed in partnership with the University of Chichester and will lead to a Post Graduate Diploma in Leadership and Management. Customer Care Pilot Two pilots of the new Customer Care programme, The Western Sussex Way have taken place within the Recruitment and Learning and Development teams. The initial feedback has been extremely positive and a number of more customer focused behaviours have already been observed. Additional pilots are planned within the Surgical Division and Out-Patients. The Management Board has agreed to some significant changes to the corporate induction programme aimed at developing the right attitudes and behaviours with staff from the very start of their careers with us.

2.06 Communications and Engagement The winners of the 2014 Proud to Care awards received coverage in the local media. Our staff took

three awards and seven runners-up spots at the high-profile awards ceremony, recognising their tremendous work for their patients. They were up against the very best staff from hospitals, community teams, GP practices and care homes from across the two counties.

There was also coverage in the local media of news that the trust had received national acclaim for

delivering better, safer care at weekends. Our Trust is one of only 12 nationally to be “Highly Commended” by the influential Dr Foster Intelligence, for making progress to deliver better care, seven days a week. The award recognises the significant reduction in the number of patients needing to be readmitted to hospital within 28 days of discharge, having initially been admitted at a weekend.

The communications team organised and promoted the unveiling of identical statues in the main entrances at St Richard’s and Worthing hospitals. The “Gift” was created by sculptor Rodney Munday, and commissioned by the Trust’s Organ Donation and Transplant Committee to celebrate those who give organs and encourage others to do so. Both unveilings were featured in the local print and broadcast media.

A survey of catering facilities at St Richard’s, Worthing and Southlands hospitals continued this month with face to face interviews conducted with patients and visitors. More than 800 staff have already taken part and shared their views on the services provided.

2.07 Extranet and Website development Our current extranet and public website were both built on the EIBS EasySite content management system (CMS) following the merger in 2009. The Trust’s Extranet, StaffNet, is designed to provide information for our workforce ranging from general news about the Trust to policies and guidelines and other clinical resources. Staff can also

Page 3 of 4

find information about training and career opportunities as well as contact details for colleagues and departments across the organisation. Naturally, almost all the visitors to StaffNet are returning to the site and spend, on average, six and a half minutes there. The most popular pages are the marketplace (staff noticeboards), contacts and clinical resources. The public website contains a variety of information about the Trust and the services we provide ranging from information for visitors and patients about car parking and visiting hours to more general background about the history of the organisation, board members and our plans and strategies. There is also information on ways to get involved with the Trust including job opportunities, appeals for new members and ways to volunteer. On average the trust website receives around 25k unique visitors per month and around 60% of these are new visitors. The average time spent on the site is two minutes and the most popular areas are contacts, About Us, Services and Treatments, Careers and Visiting.

There is also an area for GPs aims to give timely and relevant information about services and guidelines developed jointly by specialists and GPs since 1996 when the Local Referral and Management Guidelines Committee was formed. Although intended for the Primary Care Community, we hope that this resource will be useful for colleagues in secondary care and other organisations. The GP site receives around 1,500 visitors each month and almost 80% of these are return visitors. The most common pages visited are around the two-week rule and referral forms followed by guidelines for ENT and urology. Visitors spend two and a half minutes on the site on average for each visit. Last year, the decision was taken to redevelop both StaffNet and website to take advantage of developments in design and functionality and ultimately improve the experience of visitors. The development of StaffNet involved interviews with staff, an online survey, editors as well as visitor usage statistics. More information about this and the development of the website will be provided at the board meeting.

3.00 RECOMMENDATION[S] The Board/Committee is asked to:

a) NOTE the report

Page 4 of 4

WSHT WORKFORCE SCORECARD x 43 MARCH 2014Key performance Indicators Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2013/14 YTD

Target/ Ceiling Amber Limit Trend

1) WORKFORCE CAPACITY NB

Budgeted FTE 5988.8 6038.0 6038.8 6041.6 6134.2 6136.7 6134.6 6155.8 6159.5 6171.7 6173.4 6175.9 6176.6 6128.1 N/A N/A

Total FTE Used 1 6052.7 6002.2 5880.5 5928.0 6142.3 6016.5 6124.7 6181.8 6189.7 6192.5 6235.2 6298.4 6305.5 6124.8 N/A N/A

Total FTE Used Variance from Budget 1 63.9 -35.8 -158.3 -113.7 8.1 -120.1 -9.9 26.0 30.3 20.8 61.8 122.4 128.9 N/A N/A N/A

Total FTE Used Vacancy Factor 1 -1.1% 0.6% 2.6% 1.9% -0.1% 2.0% 0.2% -0.4% -0.5% -0.3% -1.0% -2.0% -2.1% 0.1% N/A N/A

Substantive Contracted FTE 5426.4 5434.2 5440.6 5442.0 5446.8 5461.3 5507.2 5548.7 5568.7 5593.7 5639.9 5663.2 5674.1 5535.0 N/A N/A

Substantive FTE Used Vacancy Factor 9.4% 10.0% 9.9% 9.9% 11.2% 11.0% 10.2% 9.9% 9.6% 9.4% 8.6% 8.3% 8.1% 9.7% N/A N/A

Bank Usage As % Of Total FTE Used 1 8.2% 8.3% 5.5% 6.0% 9.0% 6.4% 7.5% 7.4% 7.5% 7.4% 6.4% 7.4% 7.2% 7.2% N/A N/A

Agency Usage As % Of Total FTE Used 1 2.1% 1.2% 2.0% 2.2% 2.4% 2.9% 2.6% 2.8% 2.6% 2.3% 3.1% 2.7% 2.8% 2.5% N/A N/A

2) WORKFORCE EFFICIENCY NB

Rolling 12 Month Sickness Absence 3.6% 3.6% 3.6% 3.6% 3.7% 3.7% 3.8% 3.8% 3.8% 3.7% 3.8% 3.8% N/A 3.3% 3.3%

In Month Sickness Absence % 2 3.6% 3.8% 3.5% 3.4% 3.6% 3.7% 3.8% 3.9% 4.1% 3.8% 3.9% 3.8% 3.4% 3.3% 3.3%

In Month Maternity Leave % 2 2.5% 2.4% 2.4% 2.3% 2.4% 2.5% 2.5% 2.4% 2.5% 2.5% 2.3% 2.3% 2.2% N/A N/A

In Month Other Absence % 2 1.1% 1.1% 1.1% 1.1% 1.1% 0.8% 1.2% 1.4% 1.4% 0.9% 1.3% 1.3% 1.0% N/A N/A

In Month Total Absence % 2 7.2% 7.3% 6.9% 6.8% 7.1% 7.0% 7.5% 7.8% 8.1% 7.2% 7.6% 7.5% 6.7% N/A N/A

Maternity Heads 2 170 168 168 169 172 186 182 179 180 181 173 171 N/A N/A N/A

In Month Long Term Sickness Absence % (28 Days Or More) 2 1.8% 2.0% 1.8% 1.4% 1.7% 1.9% 1.9% 1.8% 1.8% 1.8% 1.6% 1.5% 1.6% N/A N/A

In Month Stress Related Sickness Absence % 2 0.6% 0.6% 0.6% 0.5% 0.7% 0.8% 0.6% 0.4% 0.5% 0.5% 0.6% 0.5% 0.5% N/A N/A

In Month Musculo Skeletal Sickness Absence % 2 0.7% 0.6% 0.7% 0.7% 0.7% 0.7% 0.8% 0.7% 0.8% 0.8% 0.8% 0.9% 0.7% N/A N/A

Rolling 12 Month Turnover 8.5% 8.6% 8.5% 8.1% 8.1% 7.7% 7.6% 7.7% 7.5% 7.2% 7.2% 7.3% 7.3% N/A 11.0% 11.0%

3) TRAINING & PERSONAL DEVELOPMENT NB

% Appraisals Up To Date 85.1% 84.9% 85.7% 85.0% 81.6% 79.4% 79.4% 80.5% 80.5% 81.9% 82.4% 82.5% 82.6% N/A 90.0% 80.0%

% In Date - All Mandatory Training 3 76.7% 79.8% 80.4% 82.2% 81.9% 81.3% 81.3% 81.9% 83.6% 84.5% 85.7% 85.3% 86.1% N/A 90.0% 80.0%

% In Date - Fire 86.0% 88.0% 87.8% 89.7% 88.8% 88.2% 87.5% 88.4% 89.2% 90.0% 90.9% 90.2% 91.3% N/A 90.0% 80.0%

% In Date - Infection Control (Role Specific) 84.3% 86.4% 86.7% 88.3% 87.3% 88.0% 87.9% 88.3% 89.2% 90.1% 90.7% 90.7% 91.0% N/A 90.0% 80.0%

% In Date - Back Training (Role Specific) 90.1% 91.7% 91.9% 92.9% 92.5% 92.5% 92.7% 92.2% 92.9% 93.2% 94.2% 93.7% 93.7% N/A 90.0% 80.0%

% In Date - Child Protection (Role Specific) 95.2% 95.6% 95.2% 96.1% 95.6% 95.7% 95.5% 96.0% 96.6% 96.9% 97.3% 97.1% 97.4% N/A 90.0% 80.0%

% In Date - Information Governance 85.7% 87.7% 87.5% 89.3% 88.4% 87.9% 87.4% 88.3% 89.1% 89.8% 90.6% 90.2% 90.9% N/A 90.0% 80.0%

% In Date - Adult Protection 3 75.8% 76.1% 75.0% 73.6% 73.8% 73.9% 74.4% 75.1% 75.5% 75.8% 74.8% 74.0% N/A 90.0% 80.0%

4) REAL-TIME STAFF FEEDBACK NB

Total Respondents To Survey 52 58 68 127 177 127 214 136 180 42 27 18 32 1206 N/A N/A

% Respondents who would recommend this trust as a place to work 4 82.7% 75.9% 76.5% 85.8% 77.4% 89.0% 80.4% 79.4% 78.3% 69.0% 74.1% 88.9% 75.0% 80.0% N/A N/A

% Respondents happy with standard of care if a friend/relative needed treatment 4 84.6% 75.9% 75.0% 81.1% 81.4% 83.5% 79.4% 82.4% 82.8% 81.0% 74.1% 88.9% 81.3% 80.8% N/A N/A

Notes:1 Bank FTE used figures are not available for April and May 2013 and been approximated as follows: Monthly Bank Spend / June Average Cost Per Bank FTE2 Absence data is available one month in arrears3 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection amd Information Governance training is up to date.4 % of staff who responded "Agree" or "Strongly Agree" to the question

To: Board


Title

Annual Plan and Board Assurance Framework 2013/14: Quarter 4 Review

Responsible Executive Directors

Marianne Griffiths, Chief Executive Denise Farmer, Director of Organisational Development & Leadership

Prepared by

Oliver Philips, Head of Strategic Planning Andy Gray, Company Secretary

Status

Disclosable

Summary of Paper

At its meeting in April 2013 the Board approved the Trust’s Annual Plan for 2013/14, which detailed how the Trust would achieve the corporate objectives it had set itself for the year, delivered through a range of programmes, each with key aims, work-streams, milestones and measures of success identified. The Board also approved a Board Assurance Framework (BAF) for the financial year. The BAF sets out and rates the principal risks to the achievement of the Trust’s corporate objectives for the year, together with the controls and sources of assurance through which the risks are managed. The BAF states that it will be subject to review following the end of each quarter and that in-depth risk reviews will be undertaken through a schedule approved by the Board. This paper jointly presents a review at the end of quarter three of the Annual Plan delivery, reviewing progress against delivery of the corporate objectives, and the BAF which assesses the risks to the achievement of these objectives


A number of the risks within the register extract present implications for care. The BAF is an inherent part of the arrangements through which management addresses those implications.


The BAF forms an important part of the Trust’s risk management arrangements, linked to the Risk Register.


A number of the risks within the BAF present financial implications. The BAF is an inherent part of the arrangements through which management addresses those implications.


A number of the risks within the BAF present human resource implications. The BAF is an inherent part of the arrangements through which management addresses those implications.



Recommendation The Board is asked to:

a) REVIEW and NOTE progress against the Annual Plan 2013/14;

b) REVIEW and NOTE the Board Assurance Framework. Communication and Consultation

Chief Executive, Executive Directors, Directors of Clinical Services

Appendices

Corporate Objectives Progress Report Board Assurance Framework Review of risks E1 and E2



WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST

To: Board Date: 01 May 2014

From: Oliver Phillips, Head of Strategic Planning

Andy Gray, Company Secretary

Agenda Item: 11

FOR DECISION

ANNUAL PLAN AND BOARD ASSURANCE FRAMEWORK 2013/14: QUARTER 4 REVIEW

1.00 INTRODUCTION 1.01 At its meeting in April 2013 the Board approved the Trust’s Annual Plan for 2013/14, which

detailed how the Trust would achieve the corporate objectives it had set itself for the year, delivered through a range of programmes, each with key aims, work-streams, milestones and measures of success identified.

1.02 The Board also approved a Board Assurance Framework (BAF) for the financial year. The BAF

sets out and rates the principal risks to the achievement of the Trust’s corporate objectives for the year, together with the controls and sources of assurance through which the risks are managed. The BAF states that it will be subject to review following the end of each quarter and that in-depth risk reviews will be undertaken through a schedule approved by the Board.

1.03 This paper jointly presents a review at the end of quarter four of the Annual Plan delivery,

reviewing progress against delivery of the corporate objectives, and the BAF which assesses the risks to the achievement of these objectives.

2.00 RECOMMENDATIONS The Board is asked to:

a) REVIEW and NOTE outcomes against the Annual Plan 2013/14; b) REVIEW and NOTE the Board Assurance Framework.

3.00 PROGRESS ON DELIVERING THE ANNUAL PLAN 3.01 Every year the Trust publishes its Annual Plan (to be replaced by the Operational Plan in

2014/15), which outlines how the Trust will achieve its corporate objectives for the year. For 2013-14 the Trust agreed corporate objectives for the year, linked back to the strategic themes of patient experience, outcomes, safety, providing local services, being joined-up, improvement and sustainability.

3.02 Corporate delivery programmes were put in place to ensure that these corporate objectives were delivered. Each of these corporate delivery programmes were detailed in the Annual Plan, outlining the aims of the programme, the key work streams, the measures of success to be used and the corporate objectives supported. Where appropriate, quarterly milestones were also identified.

3.03 This report will be provided to Board quarterly to update the Board on progress against each of the corporate delivery programmes. This report (Appendix 1) summarises the key aims and work-streams of each programme to the end of quarter 4, reporting on progress and the programme status. Please refer to the Trust’s Dashboards where outcome measures are reported.

4.00 CORPORATE OBJECTIVES - AT A GLANCE 4.01 This quarterly report is structured against our seven strategic objectives ‘We Care’. There are 14

corporate objectives (labeled A1 to G3) – which in turn are supported by 25 groups of delivery programmes. Each group of delivery programmes has been RAG rated.

4.02 Generally excellent progress has been made across the range of objectives for 2013/14. There is one area which has been given a Red rating where progress is significantly behind expectation. This relates to corporate objective [D1] Implement our long-term Clinical Services Strategy. The proposal to relocate the Ophthalmology service in Worthing to Southlands Hospital has been subject to some delay during 2013/14 whilst the Trust reviewed its Estate Strategy for Southlands Hospital. This review has concluded and a Business Case for the move to Southlands will be presented to the Trust Board in the first six months of 2014/15.

5.00 REVIEW OF THE BOARD ASSURANCE FRAMEWORK 5.01 Executive Directors have reviewed the risks assigned to them, assessing the validity of the risks,

their gross and net ratings, and the effectiveness of the controls and sources of assurance used to manage the risks.

5.02 No changes have been made to the net and gross ratings this quarter. Changes to the

effectiveness of controls and actions required are shown in the BAF in bold. 5.03 Alongside the review of the BAF, in accordance with the schedule approved by the Board (and

where the risk rating is greater than 12), two risks have been subject to in-depth reviews, and these are attached.

Page 2 of 12

Corporate Objectives 2013-14 – Quarter 4 Progress Report

Quarter 4

Real-time patient feedback programmes to include:

1. Inpatient2. Outpatient3. Maternity & Children's services

7. Improved patient experience feedback using real-time feedback for overall quality of service

[2013-14 Improvement targets agreed in Q1 at Quality Board]

1. Rollout real time to A&E (following F&F) 1. Improvement targets for the 5 domains in Real Time Patient Experience have been met (hospital environment, assistance, compassion, communication, overall experience).

Friends & Familty Test (F&F) is giving a large amount of feedback that is enabling 'real-time' changes. Text approach to receive F&F responses is also being considered.

Green

1. Inpatient Friends & Family survey programme

2. A&E Friends & Family survey programme

8. Improved Friends and Family national survey results with the aim of achieving upper quartile performance

2013-14 Improvement targets agreed in Q12 at Quality Board when comparative data is available

1. Demonstrate we are consistently using qualitative feedback to improve services2. Agree baseline response rate for Maternity F&F and identify improvement potential relative to peers3. Agree baseline and target for F&F in 2014/154. Agree F&F roll-out dates for Daycase & Outpatient services

1. Friends & Family Test (F&F) in place in A/E depts and across adult inpatient wards - return rate target of 20% has been met for Q3 and 4.

A/E has set up F&F group to review feedback, identify & deliver actions.

2. Nationally aknowldeged that accurate response rate for maternity a challenge. Maternity F&F responses will inform improvement areas monitored internally.

3.F&F baseline will be agreed as a CQUIN for 2014-15.

4. Day case F&F pilots planned to launch at Southlands and SRH in May. Outpatient pilot planned for May. Aim for full roll out by October 2014.

Green

1. National Maternity survey & Action Plan

2. National Inpatient survey & Action Plan

3. National Cancer Patient Experience Survey

4. National Chemotherapy Patient Experience Survey

1. Improved score for patient rating of overall quality of care in national surveys (outpatient and inpatient), with the longer-term aim of being in the top 20%2. Maintain excellent rating in Care and Compassion peer review3. Overall quality of service for cancer services4. Improved continuity of care in the antenatal period (2010 - 34%)5. Reduced time taken between birth and suturing of the perineum (2010 - 58%)6. Increased signposting of women to the NHS choices website (2010 - 26%)

1. Maternity improvement plan implemented in line with approved schedule

2. National Cancer & Chemotherapy improvement plans implemented in line with approved schedule

We care about….You

Commentary RAG rating

1.Work continues with user forums to ensure maternity services are responsive to women especially in the early stages of labour. All patient information leaflets now available on the website and works continues to make more information available to users. Workforce models of service delivery in progress to ensure right staff in right place at right time with appropriate skills to meet women’s needs. Improving results from F&FT using narrative reports to keep staff informed of women’s views of service.

2. Cancer survey action plan in place and patient focus group held in January to inform improvements.

3. National inpatient survey 2013-14 indicated a slight rise in the overall rating score. There has not been a national outpatient survey in 2013-14.

Care and Compassion reviews have been conducted each quarter with external peer review in October. Positve assurance received with observations in general care scoring 88% and patient and visitor interaction scoring 84%. Overall YTD scores for these odmains are 83% and 83%.

Green

[A1] Increase the number of staff and patients who would

recommend the Trust to family and friends

Executive Lead: DNPS

MilestonesMeasures of successPrimary delivery

programmesCorporate Objective

Quarter 4

[A1] Increase the number of staff and patients who would recommend the Trust to family and friends

Executive Lead: DLOD

1. Staff survey action plan (refreshed for 13/14)

2. Management & Leadership Development Programmea (MDP)

9. Improved staff survey results – top 20% for national surveys10. 10% improvement in staff who know how to raise a concern (2012-13 baseline 70%) and are confident to do so (2012-13 baseline 55%) 11. Improved staff sickness and retention rates by supporting health & wellbeing12. Reduced number of staff to staff complaints from 2012 baseline13. 20% reduction in number of formal behaviour management, discipline and capability cases (2012 baseline - 53 cases)

1. Quarterly reporting to Quality Board by Divisions

2. Health Improvement Plan - key milestones from the plan to be reported

1. Divisional staff survey action plans incorporating F&F test in place. Roll out of F&F test extended for 2014/15 in accordance with national guidance. Use of Meridan online tool and post/collection boxes planned2. H&WB co-ordinator appointed and in place. Health Improvement initiatives commenced including staff physiotherapy service; health and well being events delivered.

Achieved top 20% in national staff survey for:Staff recommending the Trust as a place to work or receive treatment (3.81, 3.69 in 2012, 3.68 nationally) % Staff Appraised in last 12 months (90%, 93% in 2012, 84% nationally).There was also a 4% improvement in the number of staff reporting having had well structured appraisals (42%, 38% 2012, 38% nationally)% Staff receiving health and safety training in last 12 months (93%, 92% 2012, 76% nationally)% staff having equality & diversity training in last 12 months (77%, 72% 2012, 60% nationally)

Green

[A1] Increase the number of staff and patients who would recommend the Trust to family and friends

Executive Lead: COO

1. Improving the Outpatient Experience

2. Referral to Treatment pathway management

14. Outpatient contact rate reduced to 0.098 per 10,000 outpatient attendances (from 0.10 in 2012-13), against an agreed demand plan and resource allocation

15. Improve perception of staff attitude and behaviour resulting in a reduced number of complaints in hotspot areas from 2012-13 baseline, with a focus on Ophthalmology and Trauma & Orthopaedic appointments in the first instance

1. Review of contacts relating to Ophthalmology and Trauma & Orthopaedics, improvement actions identified as appropriate

1. Target reduction in PALs contact rate has been achieved in Q3, and preliminary data indicates achievment in Q4 as planned.

2. Following RTT compliance failure in Q4 2014/15 due to an imbalance of demand versus available capacity a recovery programme aimed at restoring aggregate compliance by the end of Q1 2014/15 had been developed. This plan delivers an additional 2870 outpatients and 1082 inpatients/day cases above the 2013/14 run rate by the end of the quarter. This volume reduces the waiting list size and distribution to a point that can deliver aggregate compliance from Q2 2014/15, but a further 6568 outpatients and 2275 inpatients/day cases are identified in the plan above current run rate in Quarters 2-4 in order to maintain compliance from that point.

3. Both Opthalmology and Orthopaedics have been identified as key tennants in the Trust's Improvement Programme for 2014-15. As such, significant resource and focus has been placed and improvment plans are in place for both specialities, and regular meetings in place chaired by the CEO/COO.

Amber

We care about….You

Commentary RAG ratingMilestones

Measures of successPrimary delivery programmesCorporate Objective

Page 2 of 12

Quarter 4

1. CQUIN delivery

2. Enhanced Recovery Programmes

3. Enhancing Quality

4. Implementing care bundles

5. Fractured Hip Improvement Programme

6.Mortality & Morbidity Reviews

7. Safe Maternity Care (CNST Level 2)

1. Achieve a HSMR or <100 by the end of 2013-14.2. CQUIN indicators achieved that relate to quality of care (as agreed by commissioners)3. Most significant areas of care resulting in high mortality targeted, through pathway specific standardisation using the care bundle approach, focusing on hip fracture, pneumonia, COPD and heart failure, monitored through HSMR4. Acute Kidney Injury care bundle implemented in line with agreed programme5. Reduced 30-day mortality following hip fracture so that the trust lies within the middle two quartiles of mortality in the National Hip Fracture Database6. Continued achievement of maternity CNST level 2 indicators

1. CQUIN / EQ delivered in line with agreed schedule

2. Monitor improvements in line with care bundle metrics

3. Maintained CNST level 2 indicators

1. All 2013/14 CQUINs delivered in line with CQUIN schedule2. HSMR remains below 100 for 2013/14. Target reductions in crude mortality achieved for 3 of the 4 key areas identified in the Quality Account, but Acute Renal Failure mortality remains above target levels. 30 day mortality for fractured neck of femur is 8.3%, compared to 8.2% nationally.3. All Level 2 standards for the maternity CNST were completed and all the monitoring demonstrated that we did this to a very high standard. Maternity was assessed by NHSLA on 20.03.2014 to be a Level 3 CNST maternity service and found to be compliant with 49 out of the 50 standards. Only other 12 Trusts in England achieved Level 3 and only one other Trust (Countess of Cheshire Foundation Truts) achieved the high compliancy score that we did.

Green

Implementation of the Trust’s Quality Governance Action Plan

7. Continue to improve our assessment score against the ten areas in Monitor's Quality Goveranance Framework

1. Board to review (annually) progress against Action Plan

2. QRC to review clinical audit (6 monthly)

The Board Memorandum on Quality Governance action plan will be reviewed by the Quality and Risk Committee as part of its review of Quarter 4 2013/14 performance in June

Amber

[B2] Reduce our rates of avoidable

readmissions

Executive Lead: COO

1. Readmissions Service Improvement Programme

2. Enhancing quality

3. Implementing care bundles

1. Reduced 30-day readmission rate in line with our agreement with Commissioners

2. Demonstrated improvements in readmission rates for focused patient cohorts (e.g. by diagnosis chapter or group)

1. Improvement plan implemented in line with agreed schedule.

2. Clinical audit framework developed and agreed for 14/15 contractual readmissions audit, to ascertain readmission threshold

1. Clear programmes of work agreed and being signed off with CCG for implementation during 2014/152. Approach to framework for readmissions audit with CCG agreed in principle

Green

We care about….Quality

Commentary RAG ratingMilestones

[B1] Deliver the quality outcome gains

specified in the Trust’s Quality Strategy, and

demonstrate full compliance against Monitor’s Quality

Governance Framework

Executive Lead: MD

Corporate Objective Primary delivery programmes Measures of success

Page 3 of 12

Quarter 4

Safety Thermometer Programme: Catheter careVTEFallsPressure Ulcers

1. Internal Safety Thermometer - 95% harm free, 97% no new hsopital acquired harms2. Improved Trust Patient Aggregate Safety Score (PASS) score, of <100 compared to 13-14 baseline 3. No Never Events recorded

1. Confirm wards that have achieved Gold, Silver or Bronze 365 club awards for pressure ulcers2. Implementation of safety thermometer electronic 'app' in line with national programme3. Safety thermometer newsletter published within the Trust

1. 365 Club AwardsThe following wards have achieved:Gold Certificate (representing 365 days without an avoidable pressure ulcer): A&E (both sites), AMU (both sites), Birdham, Boxgrove, Chichester Suite, Chilgrove, Delivery Suite (both sites), Donald Wilson House, Graffham, ITU (both sites), Petworth, Selsey, Tangmere, Barrow, Beacon, Becket, Botolphs, Bramber, Broadwater, Brooklands, Buckingham, Burlington, Castle, Chiltington, Clapham, Courtlands, Downlands, Durrington, ESCU, Erringham and Eastbrook.Silver awards (200 days without an avoidable pressure ulcer): ACU, Middleton, Coombes and Eartham.Bronze certificates (100 days without an avoidable pressure ulcer): Ashling, Ford and Lavant.As escalation wards, Fishbourne and Ditchling reopened in September 2013 and therefore received a bronze certificate for achieving 100 days for the period September - December 2013.

2. Safety thermometer updates included in headlines. National launch of app delayed due to issues when testing in pilot sites.

3. Updates are published within 'Headlines' with monthly feedback provided to wards via safety thermometer monthly report.

Green

Electronic Prescribing and Medicines Management

4. Improved safety of prescribing by making demonstrable improvement in three specific aspects of prescribing, as identified in the annual baseline full prescribing audit and implementation of an Electronic Prescribing and Medicines Management system

1. Implementation of EPMA system commences in line with agreed schedule Full Business Case Approved by the Trust in January 2014.

Contract signed with supplier 31 March 2014.Recruitment of Project Team on target.Current state project mapping complete.

Green

Infection Control programme

5. Zero avoidable MRSA bloodstream infections that are hospital acquired, taking measures to protect the patient and aiming to remain free of avoidable MRSA 6. Reduced Clostridium Difficile cases to within a revised limit of 46 for 2013/14 (from a limit of 75 in 2012/13)

1. Continue to demonstrate high Infection Control standards including annual deep clean and 'Bioquell' of all wards

2. Environment audits continued and results reviewed, with improvement plans developed where appropriate

3. Continue visibility and communication of Infection Control team

4. Focus on C.difficile throughout the year, including C.difficile task force meetings in place since March. On-going focus on the environment , antimicrobial prescribing and isolation practice.

5. Re-launch of antimicrobial policy to focus on reducing risks of C.diff aquisition

1. MRSA bacteraemia - 4 cases for 2013/14. Following full Root Cause Analysis (RCS) of all cases one was found to be avoidable. The other 3 were found to have been unavoidable where no lapses in clinical care had led to the infection

2. C.difficilie rate ended on 57 against a trajectory of 46. Following full RCA, 24 of these cases were found to be avoidable. The total is an improvement on 2012/13 (72 cases). Limit for 2014/15 confirmed as 56 cases.

3. Run rate returned trajectory in month limit for Q2, Q3 and Q4.

Amber

[C1] Deliver the patient safety gains

specified in the Quality Strategy


Measures of successPrimary delivery programmes

MilestonesCorporate Objective

We care about….Safety


Page 4 of 12

Quarter 4

Facilities and estates environment assessments

7. Demonstrated compliance with national water standards & guidance on water sampling

1. Mitigation plan implemented in line with agreed schedule

1. Water hygiene requirements achieved

Green

1. Food Strategy Group programme

2. Intentional Rounding

3. Catering facilities programme

8. Achieved MUST scores of 80% at 24 hours & 95% at 7 days9. Demonstrated improvements in recording patient weights at appropriate points in their pathway

1. Review performance against MUST screening indicators and develop improvement plans where appropriate

1. Food Strategy group reviews MUST scores. 1. MUST screening performance remains above trajectory [see separate Quality report for trajectory). Year targets for assessment at 24 hours and 7 days have been achieved.

Green

Theatres Action Plan

10. 100% compliance with World Health Organisation (WHO) Theatre Checklist 11. 100% theatres maintained in a rolling 12-month period12. Theatre staff sickness < 3.5%13. >95% eligible theatre staff have an up-to-date appraisal14. 95% compliance with high impact interventions15. 85% theatre utilisation (list utilisation)

1. Report progress against Phase II Theatre Service Improvement Plan

2. Audit programme on track

10. Compliance with WHO Checklist remains at 100%11. Theatres maintenance remains at 100%12. Staff sickness is 5% exceeding the agreed target. Head of Nursing, HR and [main] Theatre Manager meet monthly to review and implement action plans13. Appraisl rates have improved from Q3 to 72% and currently implementing actions to improve figure further. Led by Theatre Matron.14. 99% compliance with High Impact Innovations15. Theatre Utilisation has remained steady at approx 75% and is a division priority. Work programme developed as part of Productive Theatre workstream of efficiency programme

Amber

[C1] Deliver the patient safety gains

specified in the Quality Strategy


Measures of successPrimary delivery programmes

MilestonesCorporate Objective

We care about….Safety


Page 5 of 12

Quarter 4

Emergency Floor development

1. Development of 7-day working FBC subject to OBC approval

2. Emergency Floor progressing as per schedule

1. Trust's 7-day Development Group have reviewed evidence, national guidance and developed proposals which were presented to Management Board March 2014. WSHT team visited Salford NHSFT to observe their 7-day working approach.WSHFT are working with the CCG to establish a Local Health Economy 7-day Group to achieve system-wide benefits.

2. Construction of the Emergency Floor at Worthing underway and on schedule for completion winter 2014. Operational planning including transfer of equipment in-train.

Green

Breast Screening Unit development

1. Building fully operational2. Mobile screening units in use

1. New building openend in January to patients. Building fully operational with small teething issues to address.

2. All four mobile digital units are now fully installed and functional. The age extension programme is now commencing as we start each new practice. The base site is also fully digital and functioning.

Green

Southlands ambulatory care development

1. Construction period commences at Southlands, subject to approvals Internal review of Ophthalmology completed in Q3 and findings

reviewed Dec 2013. Progress slower than anticipated due to complex nature of the development, dependency upon development of future state clinical pathways and sale of surplus estate on the site to support the required investment. Business case being developed for Trust Board consideration.

Red

Interventional Radiology 1. Complete construction at Worthing and commission new IT room2. Develop and implement Standard Operating Procedures for new IR equipment at Worthing

1. Scope of IR business case for Worthing has increased to incorporate improvements to the A&E Department. This change has resulted in delays developing the business case. Options appraisal for IR completed and feasibility underway. Capital budget approved in the Trust's internal 2014-15 capital programme. FBC in draft. Buildings works required approved by clinical teams (A&E and IR). Planned submission of FBC Q1 2014–15. Anticipated 1 year timeline for building works required.

Amber

Endoscopy services 1. Commence construction at Worthing, subject to approved plans

1. Draft OBC was presented to Board in October 2013, FBC being developed and user meetings in-train to develop the design plans. Procurement of contractor completed during Q4 and Kiers Construction appointed on a 'Design & Build' basis.

Green

Deliver alignment between the Clinical Services Strategy and Capital Investment Programme

1. Quarterly capital expenditure reviewed against forecast2. Quarterly Strategy Group review of capital programme3. Finalise 2014-15 capital programme

2013-14 Capital expenditure within 10% of budget, areas of programme slippage identified to inform 2014-15 capital programme which has been approved by Trust Board as part of the Trust's Operational Plan 2014-16.

Green

RAG ratingMilestones

[D1] Implement our long-term Clinical Services Strategy

Executive Leads: COO / DODL

1. Emergency Floor - External funding secured and main construction phase commenced

2. Brest Screening Unit - opening of building in line with agreed schedul; deployment of mobile screening units in line with business case; ability to screen an age extended population resulting in early screening/detection

4. Ophthalmology - Board approval for investment into Southlands

5. Ophthalmology - commencement of construction phase

6. Interventional Radiology - Opening of rooms at both SRH & Worthing improving resillience and removal of risks on Trust register

7. Theatre Pre-Admissions - Completion of agreed programme resulting in improved patient experience feedback

8. Endoscopy - Board approval to invest into endoscopy services at both Worthing & SRH; Continued accreditation by JAG (EXPAND); Improved capability to manage a forecast increase in demand

Corporate Objective Measures of successPrimary delivery programmes

We care about….Serving Local People

Commentary

Page 6 of 12


Quarter 4

[E1] In partnership with our emerging CCG, develop our

lead role in the local health economy for unscheduled and

planned care pathways

Executive Lead: COO

1. Unscheduled care pathways

2. Planned care pathways

1. Achieve agreed milestones in line with programme Plans

1. Deliver agreed programme plan milestonesMSK procurement progressing and ITT stage commenced 31.03.2014 in Coastal West Sussex. Result of Brighton/ Crawley MSK Tender due April 2014.

Trust successfully awarded Dermatology AQP Community Service. Project Board established and service live from 1.04.2014. Phased service redesign in progress to support 'see and treat' model, improve productivity and align capacity with activity.

Green

[E2] Ensure a successful and engaged Council of Governors

Executive Lead: DODL

Council of Governors Development Programme

1. Induction Programme delivered with positive evaluation2. Council of Governors development schedule3. Membership engagement and recruitment events held in line with agreed 13-14 schedule. 4. Positive evaluation feedback from the Annual Member Event5. Improvements in feedback from governors

1. Self-assessment of 2013-14 conducted to determine success and engagement of Council in-year

2. Council work plan agreed for 2014-15.

3. Repeat survey conducted in Q1

Workplan under-development and expected to be completed by end of April to be presented at July Council Meeting. Survey on course for Q1. Selfoassessment not undertaken during 2013-14.

Amber


Milestones

We care about….Being Stronger Together

Page 7 of 12

Quarter 4

[F1] Continue to improve the patient environment through net investment in the Trust’s Estate

Executive Lead: DoF

1. Capital investment programme 2. Refurbishment programme3. PLACE programme

1. Improved condition of the Trust’s Estate by raising standards to category B through investment into routine maintenance and the Trust’s Capital programme 2. Achieved standards for 'Patient-led Assessments of our Care Environment' (PLACE) covering food, environment and privacy & dignity

1. Commencement of Interventional Radiology at Worthing2. Commencement of Ophthalmology development at Southlands 3. Commencement of Endoscopy development at Worthing4. Delivery of refurbishment programme in line with agreed schedule5. PLACE - plan the 2014 external audits at Worthing and SRH

1. Business case for Interventional Radiology at Worthing had increased in scope significantly, to include improvements to A&E. Capital funding agreed for 2014/15 and business case being progressed again. Anticiapted submission Q1.2. Preparatory work for Ophthalmology business case undertaken. Service is focusing upon delivering immediate performance requirements and redesign pathways to inform the new unit at Southlands. 3. Endoscopy plans at Worthing developing and building contractor appointed Q4 on a 'Design & Build' basis. Full Business Case planned for Board by Q2.4. Delivery of major refurbishment programmes complted in year include Outpatinets in SRH, Main ward block WH, West Wing WH and lift refurbishment programme. Additional refurbishment undertaken within specific schemes such as Pathology and Worthing Health Education Centre5. PLACE external audits scheduled for 1st May (WRH), no formal instruction has been received for SRH and Southlands is exempt from the process as it does not have inpatients.

Amber

Improving Customer Care Service Improvement Programme

1. Increased Staff Engagement indicator in the national staff survey from 3.68 to 3.75, with the longer-term aim of achieving upper quartile performance2. Improved staff retention rates3. Improved patient feedback (national surveys & real-time) regarding their experience

1. Significant improvement in staff engagement achieved - with a rise in score to 3.78 in National Survey2.3. Significant improvements in national inpatinet surveys and on Friends and Family Score

Green

Improving Imaging and Diagnostic pathways Service Improvement Programme

1. Active clinical engagement through the appointment of clinical leads acting within an agreed governance structure2. Improved operational performance relative to peers3. Integrated business meetings held for all modalities4. Demonstrated achievement of efficiencies 5. Workforce reviewed to ensure skills and capacity match demand forecasts

1. Implementation of service improvement plan in line with agreed schedule 1. A final end of project report has been produced. All

documentation and pathways produced as part of this project have been disseminated to Radiology. Key deliverables included revised Trust wide pathway, standardised MR protocols, new Trust-wide referral form and patient information implemented, regular governance meetings implemented and clinical engagement and leadership for change embedded within Department.

Green

Development of future initiatives and programme management function

1. Identification of service improvement areas2. Support to programme manage available: initiatives delivered on time and within allocated resources; timely escalation of risk

1. Approval for 2014-15 service improvement workplan

2. Programme management reports regularly produced to assist effective delivery

1. Service improvement workplan linked closely to Trust Efficiency Programme. Key prioirities identified to include orthopaedics, ophthalmology, theatre productivity etc.2. Reguilar reporting to Management Board and Service Change Executive has bveen undertaken. Reporting arrangements being reviewed in light of Efficiency Programme requirements

Green

Commentary RAG ratingCorporate Objective Measures of successPrimary delivery programmes

Milestones

[F2] Deliver coordinated service

improvement programmes across

the Trust

Executive Lead: DODL

We care about….Improvement

Page 8 of 12

Quarter 4

Procurment programme to replace the current IT core server hardware and software infrastructure

1. Provision of a resilient IT environment capable of adequate disaster recovery 2. Fast & reliable user access to core systems (e.g. PAS, email, files)3. 100% of all users have a single sign-on by Q34. Availability of scaleable IT infrastructure to support additional systems e.g. Paper Light, Clinical Portal and Electronic Prescribing and Medicines Management

1. 100% of key applications available through single sign-on2. IT systems supported

1. New computer room and upgrade of the disaster recovery room are now complete and the server equipment has been installed and commissioned. Migration of services from the old servers is due to commence in May. 2. Email and Single sign on will be priority and still on track for late Q1.

Amber

Develop a portal to enable a single point of access called 'Gateway'

1. Implementation of a portal to enable reporting through a single point of access 2. Simplified access control and security based on users login3. 100% of users have appropriate portal access in Q2

1. Integrate data from EPMA, Pathology MES and ITU system into data warehouse in-line with their deployment schedules

1. Awaiting Clinical Informatics Strategy to develop the gateway further and data from available core applications including Patientrack now complete.

Amber

Electronic Document & Records Management and a Clinical Portal procurement

1. Clinical efficiency benefits realised from 2014/15 Q1 as documents migrate from paper to electronic storage.2. In 2013/14, maintenance (i.e. no expansion) of medical records storage requirements, with the long-term view of reducing medical records storage reduced to zero capacity over the 4-year contract term. 4. Treasury funding secured, in partnership with local partners to procure and subsequently successfully deploy the system in line with agreed schedule

1. Commence implementation of the EDRM & CP solution in-line with agreed deployment schedule

1. The pre-qualification questionnaire was published in December as planned and from a long list of 12 suppliers, 5 were shortlisted to proceed to invite to tender(ITT). The ITT was published in March and responses due back by the end of March. National timescales still require clarity but the local work to select a preferred supplier is due to complete by June/July. Following selection the full business case will have to be approved locally, then at the collaborative level before being submitted to HSCIC. The aim is to be in a position to award the contract in Q4.

Amber

1. Development of agreed quality metrics and audit tool

1. Improved data quality metrics and a data quality audit tool developed2. Improved data quality across 3 areas: 1) ‘Outpatients not arrived’, 2) ‘To come in dates in the past’, 3) ‘Ward spot checks’3. Improved SUS quality data reports4. Reduced number of duplicate patient registrations from 2012 baseline

1. Report to Quality Board regarding second batch of metrics selected

DQ checks and reporting now being completed routinely. Additional metrics have been added to the report which will be ongoing.

Green

[F4] Optimise the contribution of our staff

in the planning and delivery of our services

Executive lead: DODL

1. Staff appraisal

2. Medical Revalidation

3. Management & Leadership Development Programmes

4. Strategic planning of services including Clinical Services Strategy implementation

1. Increased Staff Engagement Indicator from 3.68 to 3.75, with the longer-term aim of achieving upper quartile performance2. Increased Staff Survey Response rate from 47% (2012) to 55% (2013)

1. Trust Brief audit repeated2. Regular staff briefing sessions held at Southlands with senior leaders3. CEO meetings (bi-monthly) with employees at 6-months service, improvement actions/themes identified each quarter4. OCOT regular briefing updates for multi-prof group via email

1. Trust Brief Audit carried out in March and April. Results to be shared with Board in Q1.2. Southlands briefings now incorporated into monthly Trust Brief cycle.3. CEO meetings ongoing4. OCOT briefings ongoing

- Staff engagement score 2013 improved to 3.78 - Second and third cohort of Leadership Development Programme commenced for Senior Nurses and Multi-disciplinary group

Green


[F3] Develop a comprehensive

Information Management &

Technology strategy and start

implementation

Executive Lead: DoF


Milestones

We care about….Improvement

Page 9 of 12

Quarter 4

[G1] Maintain an acceptable Financial Risk Rating

Executive Lead: DoF

CIP Programme

1. Required year end financial position of £5,2m surplus achieved2. Trust’s Cost Improvement Programme target of £18m achieved3. Trust’s Cost Improvement Programme delivered within acceptable Clinical Quality Impact thresholds4. Repayment of debt in line with agreed schedule

1. Achieve required financial risk score 2. Achievement of CIP programme against agreed phasing profile 3. Achievement of CIP programme within approved quality metric parameters4. Repayment of debt against agreed schedule

1. The draft Trust accounts report an underlying surplus of £1m in line with the Trust's control total. The final position will be confirmed after the accounts have been audited and approved.

2. In order to determine a final year end result, the Trust agreed a position with the local CCG, resulting in some specific CIP schemes being absorbed within that agreement. This allowed the Trust to deliver the revised surplus despite showing some CIP schemes nominally under-achieving.

3. Throughout the year the Finance & Investment Committee and the Quality & Risk committee have regularly reviewed the CIP schemes to ensure there are no adverse impacts on quality of services. No concerns were raised during the year.

4. Repayment of debt as planned in March 2014 was made on time and in full.

Amber

[G2] Maintain a Monitor Governance rating of no worse than Amber Green throughout the year

Executive Lead: COO

Divisional performance monitorted through Divisional Integrated Performance meetings

1. Perform consistently well across all of Monitor Governance rating criteria

1. Ensure performance against key metrics (A&E, MRSA, Cdiff, 18 weeks, Diagnostics and Cancer waits) Monitor Amber-Red rating for Quarter 4 due to 18 weeks RTT

and C Diff targets. Recovery plan for RTT in place and reducing rates of Cdiff infection now apparent

Amber

[G3] Continue the development and implementation of Service Line Management (SLM)

Executive Lead: COO

SLM Programme assured through SLM Board and supported by SLM Technical Group

1. Development of SLM information and infrastructure in line with agreed programme

1. Finalise suite of quality metrics at divisional level2. Financial and activity analysis of SLR information undertaken regularly at DIP meetings3. Complete preparations for more formal launch of SLM for April 2013

1. SLR information continues to be produced and refined. Clinical leadership programme provides a focus on SLM. The single information portal is still under development and is being managed through the development of the Trust's information strategy

Amber

RAG rating

We care about….The Future


MilestonesCommentary

Page 10 of 12

BOARD ASSURANCE FRAMEWORK 2013/14 RISK REVIEW REPORT: QUARTER 4 2013/14 Risk Description:

Corporate Objective: E1: In partnership with our emerging CCG, develop our lead role in the local health economy for unscheduled and planned care

BAF Reference: E1.1: External partners fail to help deliver demand management programmes (LHE) and capacity / demand alignment is compromised

Last reporting date: Q3 2013/14 (related risk) Risk review - consider at least the following questions:

1. is the risk still valid? 2. has the risk changed/is it described accurately? 3. has the risk occurred? 4. are there any links to the Risk Register?

Risk: External partners fail to help deliver demand management programmes (LHE) and capacity / demand alignment is compromised. The risk is still valid. Across both ‘planned’, ‘unscheduled’ and ‘proactive’ care, strengthened governance arrangements were put in place in Q4 2012/13, reporting through to Coastal Cabinet. Alongside, “Lead Provider” arrangements have been established for unscheduled (WSHT) and proactive (SCT) care, and in relation to the WSHT LP role, a new contractual model under discussion to enable the trust to optimise delivery and performance further. One Call/One Team (OCOT) does appear to be having an impact and augmentation in 2014-15 under discussion. Under planned care, MSK procurement process underway and Dermatology services secured. Impact – consider at least the following questions:

1. if the risk has occurred, what impact did it have on the organisation? 2. if not, what impact would the risk have if it occurred?

The risk has not occurred. Controls – consider at least the following questions:

1. are the controls still relevant and sufficient? 2. are the controls operating effectively? 3. what progress has been made with the improvement action described in the BAF? 4. what improvements are required, if any? 5. is it possible to evidence the controls?

Ongoing engagement with LHE partners and commissioners through Urgent care Board and Single Performance Conversation (SPC) to ensure success of integrated work streams including the Lead Provider development. Coastal Cabinet being strengthened 2014/15. Manage Divisional planned and unscheduled care programmes to improve access and discharge arrangements. There is good evidence for the controls – meeting minutes, correspondence, agreed plans for services, etc. Assurance – consider at least the following questions:

1. are the sources of assurance still relevant and sufficient? 2. are the sources of assurance in place? 3. are there any additional sources of assurance which can now be introduced? 4. what progress has been made with the improvement action described in the BAF? 5. what improvements are required, if any? 6. is it possible to evidence the sources of assurance?

Sources of assurance relevant, sufficient, and in place. Evidence available: Revised Accountability Agreement between LHE partners outlining responsibilities for each organisation (pending).

Page 1 of 2

Coastal Cabinet, and Service Delivery Board meeting papers where relevant. EG OCOT Steering Board (monthly) and OCOT Operational Meeting (weekly). Review of Annual Plan progress at Divisional Integrated Performance Review Panel and Board meetings. Risk Owner: Date: Jane Farrell, Chief Operating Officer / Deputy Chief Executive.

24/04/14

Page 2 of 2

BOARD ASSURANCE FRAMEWORK 2013/14 RISK REVIEW REPORT: QUARTER 4, 2013/14 Guidelines for completion: Please complete each of the sections below, ensuring that the entries are concise but sufficiently descriptive to facilitate a Board/Committee discussion about the risk. The report should be no longer than two A4 pages. Risk Description:

Corporate Objective: E2: Support our Council of Governors to fulfil its role.

BAF Risk: We don’t reap the benefits of a Council of Governors as part of our development as an FT.

Last reporting date: January 2014

Risk review Since licensing we have worked with Council of Governors to develop their role and to develop relationships and working arrangements between the Council and the Board of Directors

Impact No specific risk has emerged: reasonable progress is being made Controls Membership and Nominations and Remuneration Committee now meeting and undertaking actions as agreed. New Trust support mechanisms in place. 2014-15 meeting schedule confirmed and full Council workplan under development. Governor involvement increasing and workshops to support the development of Trusts 5-year Strategy are in place. Assurance Assurance appears adequate, but will be kept under review with the Council

Risk Owner: Date: Denise Farmer, Director of OD & Leadership 1st May 2014

Reference Corporate Objective Executive Lead Risk(s) Gross Risk Rating Controls Sources of Assurance Net Risk Rating Areas for Improvement and Action Required

Risk Register Reference

Ref Description Likelihoo Impact Total Likelihood Impact TotalWe care about youA1 Increase the number of staff and patients who would

recommend the Trust to family and friendsDNPS 1 We incurr adverse feedback regarding patient experience

from our patients and the public and media.4 4 16 Provision of patient monthly safety metrics to

provide public assurance.Monthly review of RTPE feedback to ensure that public concerns are identified and resolved in a timely fashion.

Monthly Divisional Integrated Performance Review Panel meetings

Stakeholder engagement and feedback

Peer reviews of Care & Compassion

Review of the Safety Thermometer.

Partnership working with the Patients Association.

The Communications Team work closely with the local press in the handling of media relating to the Trust.

National Staff survey results

Sit & See review

CQC Insight report Friends & Family Test

National in-patient and out-patient surveys, and monitoring of action plans at Board and/or Quality & Risk Committee

National Staff Survey

Monthly Quality report and Board, including RTPE data & Friends & Family Test

Routine quarterly & exceptional reports to Management Board and Quality & Risk Committee regarding CQC Quality Risk Profile

Patients’ stories to the Trust Board

CQC visits

Activity trends variations

Increased referrals into the organisation through the choose and book process or other routes

Partnership working with the Patients Association.

Friend & Family test results

2 4 8 Note: RTPE = Real-time Patient Experience

Enhanced roll-out of RTPE.

Improved information to public regarding complaint process.

Improved partnership working with public regarding discharge information and medication.

Review and improvements in the Outpatient and booking service.

Further development of engagement strategy, including through Council of Governors

Enhanced roll-out of the National Family and Friends Test with OPD

Introduction of the Care Challenge by Patients Association and CNO England.

Review the recommendations of the Patient Associations complaints campaign.

132, 151, 159, 275, 338, 383, 430, 440, 463

We care about qualityMD 1 We fail to implement care pathways adequately in order to

improve mortality3 4 12 Care bundle progress monitored at monthly

Divisional Integrated Performance Review Panel meetings.

Development of site-specific metrics to demonstrate processes in place and working

Reporting of care bundle process metrics to Board.

Feedback data from Enhancing Quality (EQ) programme to Board

Reporting of site specific care pathway data to Board

Monthly diagnosis group-specific mortality reporting to Board

3 4 12 Timeliness of data needs improving through increased automation of data capture. MD review of notes and care pathway

None

MD 2 We fail to produce timely and adequate information in relation to Enhancing Quality and other CQUIN payments

3 4 12 2 4 8 Information capture systems, for example through Patientrack or other near to patient databases need prioritisation in development

None

MD 3 We fail to programme manage the quality improvements relating to CQUIN & other quality improvement initiatives

3 4 12 2 4 8 PMO function needs to be recruited and embedded. Action to implement electronic discharge summaries

None

MD 4 We fail to engage broad clinical leadership in outcome improvement work

3 4 12 All clinical leaders' objectives include quality improvement goals

Regular communications re outcomes as a measure of quality to all staff, especially medical staff

Undertake Patient Safety Culture questionnaire in three priority areas

Objectives for Chiefs of Service and Clinical Directors

Attendance by Chiefs of Service at monthly Board Committee meetings

Quality Account priorities agreed by Board

2 4 8 Need to ensure adequate infrastructure for quality improvement work as well as showing compliance

Need to develop and implement patient safety culture questionnaire. Radiology Review

None

B2 Reduce our rates of avoidable readmissions COO 1 We fail to improve access and discharge arrangements 4 3 12 Manage Divisional unscheduled care programmes to improve access and discharge arrangements

Progress the development of the Emergency Floor at Worthing

Utilise Lead Provider role to strengthen control and delivery

Formalise work programme under Service Improvement Executive.

Coastal Cabinet meeting papers.

Quarterly review of Annual Plan progress at Divisional Integrated Performance Review Panel and at Board meetings.

Approval of business case for Emergency Floor.

Exception reports via both One Call, One Team Delivery Board and Service Improvement Executive.

3 3 9 None

We care about safetyDNPS 1 Delivery of sub-optimal patient care and / or patients have a

poor experience3 4 12 2 4 8Deliver the patient safety gains specified in the Quality

Strategy

B1 Deliver the quality outcome gains specified in the Trust’s Quality Strategy, and demonstrate full compliance against Monitor’s Quality Governance Framework

Achievement of internal V.T.E. benchmark.

Theatre safety programme, 100% compliance

Programme management approach to EQ / CQUIN and enhanced recovery programmes through Service Improvement Team

Strengthen capacity within Information Team

Monthly board report on CQUIN and EQ to show timeliness of data

Quality Board report.

SHA patient safety metrics.

Provision of patient monthly safety metrics to Quality Board provides public assurance.

C1 132, 136, 239, 275, 348, 355, 383, 403, 404, 446, 447, 463

DNPS 2 Financial penalties due to failure to maintain appropriate standards and thresholds

5 4 20 2 4 8

with WHO checklist.

Implementation of zero tolerance for prescribing incidents.

Theatre Safety action plan

y

Quality performance scorecard.

NRLS reporting framework.

SHA peer reviews

CQC unannounced visit.

Insight report

Reporting of theatre improvement plan (incorporating Never Event Action Plan) reports to Board, and NED attendance at the Theatre Patient Safety Group and all divisional Clinical Governance Reviews.

NHSLA Level 2 achievement.

CNST Level 3 acheived

Monthly RTPE to ensure that public concerns are identified and resolved in a timely fashion.

Monthly integrated performance reviews.

Stakeholder feedback.

Quarterly Care & Compassion reviews

Theatre Improvement Plan, incorporating Never Event Action Plan

Infection Control Operational Group Patient Safety Thermometer

NRLS incident reporting data

CCG & LAT meeting

We care about serving local peopleCOO / DLOD 1 The Trust does not have capacity to deliver changes at the

scale and pace envisaged.3 4 12 3 4 12 Strategy agreed by Board. Capacity to

deliver changes supplemented through Efficiency Programme.

None

COO / DLOD 2 The Trust does not secure the external and internal support for the changes it is proposing.

3 4 12 2 4 8 None

We care about being stronger togetherE1 In partnership with our emerging CCG, develop our

lead role in the local health economy for unscheduled and planned care pathways

COO 1 External partners fail to help deliver demand management programmes (LHE) and capacity / demand alignment is compromised.

5 4 20 Ongoing engagement with our commissioners through Coastal Cabinet and Single Performance Conversation to ensure success of integrated workstreams including the Lead Provider development.

Manage Divisional planned and unscheduled care programmes to improve access and discharge arrangements.

Reporting to Coastal Cabinet monthly and to Service Delivery Boards weekly to monitor the delivery and effectiveness of planned and unscheduled care demand management schemes.

Revised Accountability Agreement between LHE partners outlining responsibilities for each organisation (pending).

Coastal Cabinet and Service Delivery Board meeting papers.

Review of Annual Plan progress at Divisional Integrated Performance Review Panel and Board meetings.

4 4 16 338, 345, 348, 422, 438, 410, 440

DLOD 1 We don't reap the benefits of a Council of Governors as part of our development as an FT

2 4 8 2 3 6 None

Co Sec 2 The Council of Governors fails to discharge its formal/statutory duties

2 4 8 2 3 6 None

We care about improvementDoF 1 Clinical areas are unavailable due to operational activity

levels being higher than planned.4 3 12 Projects timetabled through plans to be undertaken

during less busy periods.

Operational Capital Group for engagement between Estates and clinical Divisions

Quarterly capital progress reports to F&I Committee 3 3 9

DoF 2 Large number of simultaneous projects stretch internal project management capacity.

4 3 12 Projects spaced over the year through plans.

Additional capacity secured where required.

Quarterly capital progress reports to F&I Committee 3 3 9

DoF 3 External approval for Business Cases not granted in timescale anticipated.

3 3 9 Correspondence with (former) Strategic Health Authority and with Trust Development Authority

Approval notifications received and reported to Board.

1 1 1 No longer applicable

F2 Deliver coordinated service improvement programmes across the Trust

DLOD 1 Inappropriate or insufficient focus and resourcing causes us to fail to deliver the appropriate pace and scale of improvements needed

4 4 16 Service improvement priorities and resources agreed at Service Improvement Board, based on Annual Plan

Resources to be flexed as necessary to deliver priorities

Quarterly annual plan progress report to Board

CIP delivery reports to F&I Committee and Board

Patient survey results (re priority relating to customer care)

Monthly performance reports to Board

Service Improvement Board minutes

2 3 6 SI capacity strengthened through appointment of Commercial Director and leadership from Efficiency Programme

None

DoF 1 Pre / mid implementation the Trust's IT system fail, thus compromising clinical services and business continuity

4 5 20 IT systems monitored continuously

Backup systems in place

Maintenance contracts in place for key systems

Monthly report on progress to the Finance & Investment Committee

Board review and approval of proposals, ie. business case

3 5 15 A business case has been developed to deliver improvements to the infrastructure

DoF 2 The Executive Team does not have the capacity to deliver an agreed IM&T strategy

3 3 9 Executive Team agreement of the components of the IM&T Strategy

Paper setting out components of IM&T Strategy

IM&T strategy presented to Board.

1 1 1 The component parts of the strategy need to be agreed by the Executive Team. Strategy has been approved

DoF 3 There is insufficient Internal capacity to support IT infrastructure changes.

3 4 12 Business case includes resources to manage implementation

Business Case to April Board 3 4 12

DLOD 1 We fail to implement culture changes required to improve staff engagement

3 4 12 Engagement strategy inc. Trust Brief, Appraisals Staff survey and regular real time surveys

Regular staff meetings inc Board walkabouts and attendance at Trust Briefs

Organisational Development reports to Board

2 4 8 Largely positive feedback from staff survey - need to continue to build on work to date

None

DLOD 2 The personal and professional impact of service change disengages staff

3 3 9 Engagement strategy inc. Trust Brief, Appraisals Staff survey and regular real time surveys

Regular staff meetings inc Board walkabouts and attendance at Trust Briefs

Organisational Development reports to Board

Evidence of staff engagement in service changes/business cases: impact assessment of planned service changes on staff

3 3 9 Revised engagement plan being developed

None

Council of Governors development plan

Foundation Trust Constitution, Terms of Reference, Role Descriptions

Feedback from Governors; from Board; from members

Minutes of Council and Committee meetings

F1

D1 Implement our long-term Clinical Services Strategy

E2 Support our Council of Governors to fulfil its role

Optimise the contribution of our staff in the planning and delivery of our services

F4

F3

Key committees established, Schedule of meetings produced

Continue to improve the patient environment through net investment in the Trust’s Estate.

52, 79, 126, 127, 132, 146, 180, 214, 233, 423, 297, 252, 288, 309, 319, 338, 377, 365, 382, 383, 396, 421, 433, 450, 456, 457

Greater integration of corporate and divisional planning functions to maximise resource.

Secure additional ad-hoc resource on specific projects when necessary.

Service Improvement Executive will strengthen oversight of delivery for major developments.

Clinical strategy agreed by the Board and shared with external partners

Emergency Floor Business Case approved by the Board.

Board approved plans for the R&R Block in place.

Coastal Cabinet meeting papers.

Develop a comprehensive Information Management & Technology strategy and start implementation

63, 141, 151, 225

We care about the futureDoF 1 Failure to deliver efficiency programme in full 3 5 15 Programme Management office being set up to

track performance and oversee delivery. Interim arrangements in place until Programme Director is appointed. Weekly Efficiency Porgramme Steering Group chaired by CEO. Divisional Integrated Performance Review Panel meetings

Budget holder meetings

Reports to F&I Committee and Board. Weekly Efficiency Porgramme Steering Group

3 5 15 402

DoF 2 FT application process diverts focus from financial management and control.

3 5 15 FT application process neraring conclusion. Reports to F&I Committee and Board 1 1 1 Process complete None

DoF 3 The financial constraints in the local health economy impact the Trust's ability to realise its income expectations

4 5 20 Regular monitoring of contract information within the Trust

Regular dialogue with commissioners

Swift resolution of areas of disagreement

Monthly to F&I Committee and Board

Monthly Executive-led meetings with commissioners

Financial Risk Ratings

3 5 15 None

COO 1 A mismatch between demand and capacity leads to access targets not being met

3 4 12 Ongoing engagement with our commissioners through Coastal Cabinet and Single Performance Conversation to ensure success of integrated workstreams including the Lead Provider development.

Reporting to Coastal Cabinet monthly and to Service Delivery Boards weekly to monitor the delivery and effectiveness of planned and unscheduled care demand management schemes.

Single Performance Conversation meeting papers.

Coastal Cabinet and Service Delivery Board meeting papers.

Daily and weekly reporting of high-risk areas.

Daily heat map reporting.

Monthly reports to the Board.

Exception reports from Directors of Clinical Services to Chief Operating Officer.

2 4 8

COO 2 The planned productivity and efficiency improvements do not deliver the required capacity.

3 4 12 Monitoring and management of performance through Divisional Integrated Performance Review Panel meetings and the Board.

Daily and weekly monitoring of access targets and enhanced risk mitigation measures.

Divisional Integrated Performance Review Panel and Board meeting papers.

2 4 8

COO 1 1. A failure to secure the necessary capacity to deliver Service Line Management, including IT infrastructure, information management and training.

3 4 12 2 4 8 None

COO 2 2. Ownership and leadership of the programme throughout the organisation.

3 4 12 2 4 8 None

Clear programme plan owned and managed by the SLM Programme Board.

Service Line review at Divisional Integrated Performance Review Panel meetings.

Papers from SLM Board and Divisional Integrated Performance Review Panel meetings.

Quarterly report to Finance & Investment Committee.

Continue the development and implementation of Service Line Management (SLM)

G3

G2

G1 Maintain an acceptable Financial Risk Rating

338, 345, 348, 387, 422, 440

Maintain a Monitor Governance rating of no worse than Amber Green throughout the year

To: Trust Board

Date of Meeting: 1st May 2014 Agenda Item: 12

Title

Operational Plan and Capital Programme 2014-16


Denise Farmer, Director of Organisational Development and Leadership

Prepared by

Oliver Phillips, Head of Strategic Planning

Status

Available under FoI

Summary of Proposal

This paper presents the proposed Trust’s Operational Plan for 2014-16 for review


Directly impacts on quality of care


Directly links to all seven ‘We Care’ strategic objectives


Detailed within the paper.


Will be specific to elements of the plan

Recommendation The Board is asked to: APPROVE the 2014-16 Operational Plan


The operational plan has been developed through Trust business planning, engaging a range of stakeholders and has been shared with the Local Negotiating Committee and Employee Partnership Forum

Appendices

WSHFT Operational Plan 2014-16

To: Trust Board Date:27th March 2014

From: Oliver Phillips, Head of Strategic Planning Agenda Item:

FOR: APPROVAL

OPERATIONAL PLAN 2014-2016

1.00 INTRODUCTION

1.01 Western Sussex Hospitals NHS Foundation Trust is required as part of Monitor’s Annual Planning Guidance, to submit an Operational Plan, covering a two year period, outlining what the Trust’s objectives are for the period and how it intends to achieve these objectives. The Operational Plan is attached to this paper for review.

2.00 SUMMARY OF PROPOSAL

2.01 Following guidance issued by Monitor on 23rd December 2013, Western Sussex Hospitals NHS Trust was required to submit an Operational Plan, covering the years 2014/15 and 2015/16 to Monitor by 4th April 2014. This replaces the previous Annual Plan submission requirement, which only covered a two-year period.

2.02 The Operational Plan describes how the Trust will deliver the Corporate Objectives through a range of programmes across the Trust. In addition to this the Trust is required by the guidance to cover the following areas

• the short term challenge facing the local health economy

• the Trust’s quality plans

• the operational requirements and capacity to meet expected demand

• the productivity, efficiency and CIPs programme to ensure the Trust delivers a robust financial performance

• a supporting detailed financial plan with summary

2.03 The Trust’s Corporate Objectives were reviewed and agreed by the Board in January 2014, each of which directly relates to the strategic objectives the Trust has agreed through its vision and values – ‘We Care’. The Operational Plan sets out the workstreams that the Trust will be undertaking in order to achieve these objectives.

2.04 The development of the Operational Plan has involved a wide range of staff and stakeholders including Trust Governors and Coastal West Sussex CCG. The final draft was reviewed at Board Seminar in March 2014 and was submitted to Monitor following approval at the March 2014 Board (in Committee). The ‘productivity, efficiency and CIPs’ programme, together with the detailed financial plan, were reviewed at the Finance and Investment Committee in March 2014.

2.05 Following submission on 4th April, the Operational Plan will undergo a thorough review process by Monitor to test the robustness of the plan. Monitor are holding an initial review meeting with the Trust’s Executive Team

at the beginning of May, and will received further feedback by the end of May 2014.

2.06 The Trust is also required to submit its 5-year strategic plan to Monitor by the end of June 2014. This will build on the Operational Plan and the Trust’s Clinical Services Strategy (approved by the Board in January 2014) and outline the longer term programmes of work the Trust will need to undertake to remain sustainable on a clinical, operational and financial basis. The Trust is engaging with key stakeholders on the development of this plan.

3.00 RECOMMENDATION

The Board is asked to:

a) APPROVE the Operational Plan for 2014-16

Western Sussex Hospitals NHS Foundation Trust

Operational Plan 2014–16

TABLE OF CONTENTS

Contents Page

1. Executive Summary

2. Operational Plan

A. The Short-Term Challenge

B. The Trust’s Quality Plans

1. The Trust Vision and Strategic Objectives

2. Drivers for Change

3. Corporate Quality Objectives

4. Our Programmes of Work

5. Risks, Risk Management and Governance

C. Operational Requirements and Capacity

D. Productivity, Efficiency and Cost Improvement

Programmes

3. Supporting Financial Information

4. Appendices

2

4

4

4

4

6

9

11

21

22

26

34

40

1

1. Executive Summary The intention of this plan is to clearly set out the operational priorities for Western Sussex Hospitals NHS Foundation Trust (WSHFT) over the coming two years. In July 2013 the Trust achieved Foundation Trust (FT) status, and in this plan we demonstrate how we intend to use this as a springboard to take us from an already high performing organisation to one that has an enhanced and growing reputation for delivering great care for patients. To continue to improve from our current levels of quality and performance will not be easy, particularly given the demographic and financial challenges we are facing. However we firmly believe that it is through putting quality first and focusing on doing the right things for patients that we will also improve our efficiency and productivity. In this plan we firstly describe the short-term challenge, giving a précis of the changes the local health economy will be facing: an increasingly elderly and frail population, increases in patients with long-term conditions and continued public sector restraint in resources. We then provide a summary of the Trust’s vision and values, which are focused on improving the quality of care we offer, and show how these are translated into longer term strategic themes for the organisation. An outline of the drivers for change is then provided, which provides a brief summary of our Clinical Services Strategy (provided as an Appendix to the plan). It also highlights National Drivers, Commissioner requirements and priorities for quality improvement. The next section details our Corporate Objectives for the next two years, linked to our strategic themes. These are our priorities for delivery and shape our programmes of work. In section B, these priorities are broken down further to the specific programmes of work, with a summary of the purpose, milestones and outcomes expected from each one. These will be supported by detailed quarterly milestones for the two year period, progress against which will be reported to the Board. We also give a description of how we both manage and mitigate the risks associated with the delivery of the programmes of work. Section C describes the operational requirements and capacity to deliver the Operational Plan, summarising the activity, beds and workforce that will be required. Crucially it highlights the risks to fluctuations in demand and how this will be mitigated. Finally, section D provides an overview of how we will meet the financial challenge we face through a comprehensive productivity, efficiency and cost improvement programme. This describes both the size of the challenge, the key transformational and traditional workstreams that have been put in place to deliver the savings

2

required and a summary of the programme management and governance arrangements we have put in place to ensure delivery.

3

2. Operational Plan

SECTION A - The Short-Term Challenge

Western Sussex Hospitals NHS Foundation Trust is a high performing, high quality organisation with an excellent track record of delivery against a range of quality, performance and financial measures. It is however, facing a period of unprecedented change and challenges that will require a step-change in the level of transformation required in order to build and improve on these sound foundations. We have worked closely with our key Commissioner, Coastal West Sussex Clinical Commissioning Group (CCG), to identify the challenges facing the local health economy over the coming years. In summary, we know that we need to address:

• An increasingly elderly and frail population, the over 85 years of age population is forecast to grow by 13% over the next five years, which will lead to a rise in demand for health care services

• Increases in the number of people with long-term conditions, such as chronic obstructive pulmonary disease (COPD), diabetes and dementia

• Continued public sector restraint in resources for the foreseeable future resulting in a potential gap between income and demand for services of £201m by 2019 across the local health economy

• Through its proactive and unscheduled care programme, a commissioner intent to provide more care for its population outside of the acute setting, through preventative and Community-based services.

• How the Better Care Fund is likely to impact on the local health economy in 2015/16.

Based on these challenges, the Trust has identified that it will need to deliver an efficiency programme of at least £30m over the next two years. The key purpose of this Operational Plan is to demonstrate how the Trust intends to further its quality-based vision and values against a backdrop of a significant efficiency programme.

SECTION B – The Trust’s Quality Plans

Section B1 – the Trust’s Vision and Strategic Objectives

Western Sussex Hospitals quality plans are built upon its vision ‘We care’ and the strategic objectives that link to this vision. These are summarised in the table below. Our quality plans for 2014/15 and 2015/16 are focused on ensuring we deliver on our core strategic objectives.

4

We Care – Our Strategic Themes

A. We care about you:

Embed a culture of customer focus throughout the Trust to ensure that we treat patients with kindness, dignity and respect.

This will be evidenced through improvements in our patient survey, and in real-time feedback from patients and carers.

B. We care about quality:

Provide the highest possible quality of care to our patients.

We will do this through focusing on a range of measures to improve clinical effectiveness.

C. We care about safety:

Ensure that our services are the safest we can make them.

We will do this by eradicating avoidable hospital acquired infections, investing to provide the right environment for patient services and continually striving to improve our clinical outcomes.

D. We care about serving local people:

Ensure that we can meet the needs of our local population, both now and in the future by providing the right range of services, improving accessibility and providing care closer to home where possible.

E. We care about being stronger together:

Work closely in partnership with our Commissioners and other providers in order to provide streamlined, integrated care for patients, removing duplication and improving the quality and efficiency of the care we provide.

F. We care about improvement:

Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation.

G. We care about the future:

Ensure the sustainability of our organisation by continuing to meet our National targets and financial performance, and investing in appropriate infrastructure and capacity.

5

Section B2 – Drivers for Change

This section outlines the drivers for change for the Trust for the coming planning period – including both external drivers and internal drivers.

2.1 The Trust’s Clinical Services Strategy

Following the attainment of FT status in July 2013, the Trust has refreshed its Clinical Services Strategy, which was approved by the Board in January 2014. The strategy ( provided as Appendix 1) sets out the broad strategic direction for the Trust and sets out the principles upon which our strategic development will be based. Importantly for our Operational Plan, it highlights five strategic implementation programmes for the Trust:

1. Developing services at Southlands Hospital (including Ophthalmology) 2. Improving the use of Acute Medicine resources across the local health

economy 3. Rationalising surgery across the Trust 4. Exploiting our commercial opportunities 5. Reshaping our Cancer services.

2.2 National Policy and Regulation

The Trust’s Operational plan responds to the key priorities outlined in ‘Everyone Counts – Planning for Patients 2014/15 to 2018/19’. The plan demonstrates how the Trust is responding to the recommendations in the Francis Report, the report on NHS Services, Seven Days a Week, by Professor Sir Bruce Keogh, and the report on patient safety, A promise to learn – a commitment to act: improving the safety of patients in England, by Don Berwick. It also reflects the requirements on NHS Foundation Trusts set out in the Compliance Framework.

2.3 Commissioner Requirements

The Trust’s Operational Plan has been developed in consultation with the Trust’s main commissioners of services, Coastal West Sussex CCG. The CCG has produced its operational plan, which highlights the areas it is prioritising for transformation. Those relevant to the Trust are:

• Urgent and proactive care – providing more responsive and integrated urgent and emergency services, for a growing number of people living with one or more long-term conditions

• Planned care – commissioning better access, more streamlined pathways and improved outcomes for patients needing elective care and treatment. This includes the procurement under a prime provider model for musculo-skeletal (MSK) services

• Children, young people and maternity – giving children the best possible start through excellent maternity and children’s services, especially for children with complex and chronic conditions.

6

The CCG operational plan also highlights the impact and opportunity of the Better Care Fund in 2015/16. The Trust is discussing this with partners locally, but it has not been explicitly factored into the income assumptions for 2015/16.

The Trust is also reviewing its plans with its other main Commissioners, NHS England (Surrey & Sussex) covering specialist services and our Sexual Health service.

2.4 Priorities for Improvement in the Quality of Care

The Trust is proud of the improvements it has made in the quality of care it provides, which can be shown in the reductions in mortality made, consistently good reports from the CQC and significant improvements in our patient experience as evidenced by the National Inpatient Survey. However, the Trust is keen to consolidate and improve in a number of quality areas. Following a consultation workshop in February 2014 with senior staff, non-executive directors of the Trust, and representatives of our stakeholder organisations (our CCG, Healthwatch West Sussex and West Sussex Health and Adult Social Care Committee), we have identified four specific areas for improvement for the period of the Operational Plan. These also feature in the Trust’s Quality Account. Priority 1: Improving the Hospital Care of Patients Suffering a Stroke The Sentinal Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence based standards. We wish to improve the outcome of our patients who have a stroke by ensuring that we meet the elements of care set out by SSNAP and to ensure that both Acute Hospitals within the Trust provide the same level of service. We will contribute to regional stroke configuration work as the best configuration for stroke thrombolysis (hyperacute stroke units) is unclear. Priority 2: Improving the Hospital Care of Patients with Dementia The Trust can be proud of the progress made in the area of dementia care in 2013/14. We have achieved high (above target) levels of compliance with all three parts of the Dementia Assessment. However, we recognise that recognition of dementia and the impact this disease has on care, length of stay and functional outcome needs to be more integrated into everyday working. This will be delivered through the development of a dementia strategy for the Trust that will set out actions and milestones for this key quality improvement area.

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Priority 3: Reducing Avoidable Mortality and Improving Clinical Outcomes – Focusing on Acute Kidney Injury and Early Recognition of Clinical Deterioration In 2014/15 and 2015/16, we wish to maintain our Dr Foster Hospital Standardised Mortality Rate at a level below 100, i.e. better than similar NHS Trusts. We also aim to maintain or reduce further our Summary Hospital-level Mortality Indicator score in 2014/15 and 2015/16. We will continue to seek further reductions in crude mortality and will focus especially carefully on mortality in patients admitted with acute kidney injury (AKI). A key element of our approach to reducing avoidable mortality and improving clinical outcomes is to get even better at recognising as early as possible when the condition of very unwell patients is deteriorating. We will use Patientrack as an essential tool in helping us to do this; however, we will review how the system is being used and ensure that this and other interventions are applied systematically to maximise their benefits to patients. We will explore in the coming months the targets that can be set to provide meaningful information about our performance in early detection of clinical deterioration. Priority 4: Infection Control a.) Clostridium difficile infection In 2014/15 and 2015/16, we will maintain our continuous programme of measures to control and reduce hospital acquired infection, and investigate any cases using Root Cause Analysis. We have a ‘zero tolerance’ approach when applying and monitoring our infection control policy. The limits we have been set this year for hospital acquired infection are zero avoidable cases for MRSA bacteraemia and 56 cases for Clostridium difficile (C. diff) in 2014/15.

b.) Surgical site infection (Orthopaedic and Colorectal Surgery) Surgical site infection is a potentially avoidable cause of morbidity. We have established robust data collection systems over 2013/14 and are working with surgical teams to improve our current surgical site infection rates.

There are also some specific issues where we will be taking urgent action to address where we have concerns regarding the quality of services provided. These are:

• The quality of care provided for Endoscopy patients at Worthing Hospital. The Trust had developed and approved an outline business case to improve the capacity and environment of its Endoscopy services, which the Trust plans to implement during 2014/15

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• Improvements in the vascular pathway between ourselves and our tertiary providers. Vascular surgical services are now provided as a networked service, centred around Brighton & Sussex University Hospitals. We are working with our network partners to ensure that quality and safety of services provided to our patients are of consistently high standards.

Section B3 – Corporate Quality Objectives

The Trust has agreed its Corporate Objectives for 2014–2016, which are set out in the table below. These objectives are focused on improving the quality of care we provide, in keeping with our vision and values.

Strategic Theme Corporate Objectives

We Care about you, the patient

Improve the overall experience patients receive from our Trust, through:

• Our improving customer care programme

• Improving staff satisfaction and engagement

• Access to services; compliance with national targets

• Implementing new technology such as the call management and appointment booking system.

We Care about Quality

Deliver quality improvements internally and as agreed in partnership with our local CCG:

• Improve and reshape our Cancer services across the Trust

• Provide an improved and consistent Breast Cancer service across the Trust

• Deliver the CQUIN programme

• Improvements in clinical outcomes including mortality rates in AKI and early detection of clinical deterioration

• Make a significant improvement in the quality of care offered to stroke patients

• Improve the quality of care offered to patients with dementia.

We Care about Safety

Deliver improvements to maintain and enhance patient safety through:

• Ensure zero MRSA avoidable hospital acquired infections

• Ensure hospital acquired C. diff cases remain within the

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limit for 2014/15 of 56

• Ensure improvements in our surgical site infection rate

• Implementation of the seven-day working programme

• Ensuring a comprehensive response to the Francis report

• Implementation of Electronic Prescribing and Medicines Administration (EPMA) across the Trust.

We Care about Serving Local People

Progress our strategic clinical service change programmes to improve access and quality for local people, including:

• Complete the Emergency Floor development at Worthing Hospital

• Improve the services and fabric of Southlands Hospital including the relocation of Ophthalmology services from Worthing Hospital

• Complete our strategic Endoscopy development across the Trust

• Finalise and begin to implement our Cancer strategy including provision for local radiotherapy.

We Care about Being Stronger Together

In partnership with our local CCG, develop our lead role in the local health economy for unscheduled and planned care pathways:

• Implement our long-term Acute Medicine clinical services strategy, with a focus on:

• Admission avoidance schemes

• Reducing length of stay

• Reducing avoidable readmissions.

• Develop and redesign our MSK portfolio in collaboration with local provider partners in preparation for the contract award from the MSK procurement.

We Care about Improvement

Continue to develop and deliver leadership development programmes:

Deliver coordinated service improvement programmes across the Trust in priority areas including Ophthalmology, Orthopaedics, Imaging and Breast Services incorporating where appropriate Enhanced Recovery programmes.

We Care about Implement our Clinical Services Strategy:

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the Future • Review the Trust’s internal configuration for Emergency Surgery out of hours and implement any recommendations from the review

• Further inpatient surgical rationalisation across the Trust

• Exploit the Trust’s commercial opportunities, including Any Qualified Provider tenders and Private Patient activity, to support our core NHS business.

Maintain an acceptable Monitor continuity of service risk rating throughout the period.

Maintain an acceptable Monitor governance rating throughout the period.

Section B4 – Our Programmes of Work

The following section outlines the key programmes of work to deliver our objectives over the coming two years. It describes the purpose of each of the programmes and a summary the key milestones and outcomes for each programme. These programmes will each have detailed quarterly milestones, which will be reported to the Board as a progress report against implementation of the operational plan.

1. We care about you, the patient – improving the overall experience patients receive from our Trust

Programme Purpose Milestones and Outcomes

Develop and deliver the Trust’s Customer Care training programme

The Trust is introducing a major change to the way it improves customer care by introducing ‘The Western Way’ an innovative approach to training, recruitment, induction and appraisal thatseeks to transform the way Trust staff interact with patients and their carers

• Introduction of new induction programme

• Pilot revised training approach with groups of current staff members

• Revised recruitment process introduced

• Roll out of training programme across the Trust

Staff engagement programme

Ensure constant improvement and value is added through enabling staff to identify and lead improvements for patients

• Review of the Trust’s Communication and Engagement strategy

• Delivery of phase one of the Trust’s Health and

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Wellbeing strategy

Improving access to elective care, in particular through redesign of Ophthalmology and Orthopaedic pathways

Improve access to elective care to ensure the Trust meets its 18 weeks and Cancer waiting targets. Introduce specific service improvement programmes in Orthopaedics and Ophthalmology to drive improvements in access and productivity

• Recovery and sustain achievement of aggregate referral to treatment (RTT) delivery

• Maintain Cancer waiting times targets throughout the period

• Further develop the Trust’s service improvement programmes in Orthopaedics and Ophthalmology in order to improve productivity, patient experience and shorter waiting times

Call management booking system

To introduce new technology that will enhance the patient experience whilst delivering internal efficiency and productivity improvements

• Deploy SMS text reminder functionality

• Commence interface development between Call Handling System and the Patient Administration System

• Standardise the Call Centre model across the Trust

Promote the use of telecare across the Trust

Telecare can be used to increase convenience and improve productivity across the Trust. It enables scarce clinical resources to be better used to manage patients closer to home where appropriate and enables further cross-site working within the Trust

• In conjunction with local health economy partners, establish a review group to identify the opportunities for telecare across Secondary, Community and Primary care

• Implement pilot schemes – including COPD readmissions programme

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2. We care about quality – delivering improvements in the quality of care we provide


Improve and reshape our Cancer services

The Trust intends to reshape its Cancer services, to provide an improved accessible and equitable service across the Trust. The provision of all Cancer services, including individual tumour groups chemotherapy, radiotherapy acute oncology and end of life care are being considered

• Board approval of updated Trust Cancer Strategy

• Review of MDT clinical leadership, structure and function

• Tumour group level reviews initiated

• Clear specification agreed for Oncology services

• Future radiotherapy provision determined

• Revised Oncology service in place

Review and improve the Breast Cancer service

To lead a programme of service improvement across breast screening and cancer pathways with the aim of standardising clinical pathways and improving sustainability of the service

• Implement integrated governance and training sessions

• Agree new clinical pathways where appropriate

• Review opportunities to centralised specialist surgery to improve patient outcomes

• Deliver an Enhanced Recovery Programme to reduce the length of time patients need to stay in hospital post-surgery

Deliver the programme of quality improvements specified through CQUINs

To deliver the improvements in quality and innovation sought by the Trust’s Commissioners through the CQUIN programme, both for the CCG and NHS England

• Achieve improvements as specified in the CQUIN agreement

Service improvement to reduce mortality for

Deliver improvements in the mortality rate for patients with AKI focusing on acting

• Continue to implement Enhancing Quality programme for AKI

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AKI on early recognition of clinical deterioration

• Use improved Patientrack functionality to improve early recognition

Ensure early recognition of clinical deterioration

To allow early intervention and decision making in patients who are deteriorating. This will improve likelihood of recovery or allow more appropriate end of life care discussions

• Consistent application of track and trigger systems across the Trust

• Early recognition of sepsis and application of sepsis care bundles

Improve our stroke services

To deliver improvements in quality of care as outlined by SSNAP audit

• Agree model of hyperacute stroke care for the Trust

• Deliver timely admission to specialist stroke ward for all patients with a stroke

• Agree model for managing TIA service

Improve the care we provide to dementia patients

To embed the progress made in 2013/14 within the usual business processes of clinical teams

• Develop and deliver a Dementia Strategy for the Trust

3. We care about safety – delivering improvements to maintain and enhance patient safety


Implement the seven day working programme

In response to the Francis and Keogh report, initiate the introduction of seven day working across the Trust to improve the safety of care provided and access to high quality care

• Complete Gap Analysis • Develop full

implementation plan • Seek business case

approval for the development of seven day working services

• Pilot and implement the new services

Responding to the Key themes in the Frances report ‘Patients first and

In response to the Francis report, the Trust has introduced a programme of work containing nine distinct

• Each of the workstreams has clear milestones and where appropriate integrated into the other

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foremost’ workstreams designed to address the issues raised in the report

programmes within the Trust’s plans

• Progress on implementation of the programme of work to be reported quarterly to the Board

Implementation of EPMA

To deliver significant patient safety benefits, enabled through the purchase and deployment of an IT system, by reinforcing best practice in medicines prescribing and administration, and providing clinical decision support for users thereby significantly reducing prescribing and medications administration errors

• Establish agreed project groups

• Recruit support team • Deliver infrastructure

upgrades • Configure EPMA system • Deliver staff training for

new system • Agree pilot locations • Roll-out new system

Continue to reduce the numbers of healthcare acquired infections (HCAI)

To maintain zero tolerance on all HCAI in order to increase the safety of patient care

• Maintain Executive review of all Root Cause Analyses of hospital acquired cases of MRSA and C. diff

• Deliver the quarterly Trust wide deep clean programme

• Maintain full compliance with antimicrobial prescribing

• Maintain zero tolerance to non-compliance with HCAI principles

• Play an active role in the local health economy HCAI task force

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4. We care about serving local people – make progress in delivering our strategic clinical change programmes


Open the Emergency Floor at Worthing Hospital

Create an ‘Emergency Floor’ at Worthing Hospital, bringing together the Acute Medical Unit, the Surgical Assessment Unit and the Elderly Care Assessment areas into a single assessment area for emergency admissions in order to provide better integrated care and reduce the length of time patients stay in hospital

• Building and equipping work underway

• Emergency Floor due to open November 2014

Develop Southlands Hospital including the relocation of Ophthalmology services

Invest in Southlands Hospital to develop it as a thriving Ambulatory Care centre, with Ophthalmology at the heart of the development. To dispose of surplus land/buildings on the site to support the investment requirements for the retained Hospital

• Agree future clinical model for Ophthalmology

• Develop architect plans for Southlands Hospital

• Deliver a business case to Trust Board and receive approval to proceed

• Obtain residential planning consent for the surplus land at Southlands

• Market and sell surplus area

Implement improvements in our Endoscopy services

Invest in Endoscopy to enhance patient experience, improve patient flow and efficiency. Reduce operational risk through an equipment replacement programme. To maintain accreditation from the Joint Advisory Group (JAG) at St. Richard’s and re-achieve accreditation at Worthing – a ‘kite mark’ of a well-run Endoscopy Department

• Deliver a business case to Trust Board and receive approval to proceed to remodel the Worthing Department

• Complete remodelling works at St. Richard’s

• Replace decontamination washers at St. Richard’s Achieve JAG accreditation

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5. We care about being stronger together – develop our role in delivering emergency and planned care


Improve our Acute Medicine care pathways and reduce length of stay through service improvement

Through a review of specific care pathways where the Trust has longer than average length of stay, improve the internal processes to streamline patient care, thereby improving the quality of care and reducing length of stay

• Detailed pathway reviews undertaken in heart failure, pneumonia, COPD and cardiac conditions

• Improvement programme instituted, identifying and dealing with restraints in the current system

• Roll out improvement programme across all areas affected

Further develop our Lead Provider role within the One Call One Team programme

The ‘One Call One Team’ service, which is proving successful in reducing the number of short stay admissions, will be further enhanced in conjunction with the Trust’s partners to provide a comprehensive service where healthcare professionals will have one number to call to access a range of services including Community Geriatricians, Rapid Assessment and Intervention Team, GP in A&E, Paramedic Practitioner and Dementia Crisis Team

• Specification and internal milestones to be agreed with the CCG

Improve our MSK service with partners in response to the prime provider procurement

Coastal West Sussex CCG are proposing a procurement of MSK services for a five-year period, seeking to appoint a ‘prime provider’ who will be responsible for the entire patient pathway. The Trust, in conjunction with partners,

• Successfully complete the Invitation to Tender process

• Aim to be appointed as joint prime provider of MSK services from January 2015 onwards

• Deliver a reformed and integrated MSK service

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has been successful at pre-qualification questionnaire (PQQ) stage, and needs to work with these partners to improve patient pathways to ensure a successful outcome to the procurement process

for patients from 2015 onwards

Reduce the level of readmissions through a series of targeted projects

In the audit of readmissions carried out during 2013 a number of themes emerged that has resulted in the development of a range of improvement projects including:

• COPD Virtual Ward • Early notification of

admission • Post-surgery

specialist nurse • End of life care • Emergency

outpatient surgical clinics

• Improving catheter care

• Following confirmation of funding all projects will be piloted during 2014 and evaluated for their effectiveness in reducing readmissions

6. We care about improvement – delivering service improvement and leadership development programmes across the Trust


Further develop the Trust’s Leadership Development programmes for Clinicians, Nurses and Managers

The Trust has started its second year of Leadership Development plans and is extending the programme to cover Nurses and Managers as well as Clinicians. The aim is to equip a cadre of staff to have the skills to manage the Trust through the challenging future it faces

• Work with the University of Chichester to continue to shape and deliver the Leadership Development Programme

• Conduct an evaluation of the effectiveness of the Leadership programme

Develop and deliver service improvement

To encourage all staff to adopt and use evidence-based service change and

• Deliver a LEAN awareness training

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learning programmes (including Lean training)

improvement tools to improve the quality of service they deliver

course • Establish a resources

and knowledge library to support individuals

• Develop and implement a comprehensive, longer-term training programme

7. We care about the future – implementing our Clinical Services Strategy and maintain an acceptable financial risk rating and governance rating


Review the Trust’s internal configuration for Emergency Surgery out of hours

The Trust currently runs two separate out of hours rotas for Surgery and Trauma at each site. The Trust is reviewing this arrangement to see whether a more efficient and sustainable model can be developed

• With the help of external support, review the potential configuration options for out of hours surgical cover across two acute hospital sites

• Consult and if appropriate implement any changes to the out of hours arrangements

Rationalisation of Urology Services

To transform urological care to ensure sustainable, quality-led patient pathways for both outpatient and inpatient services. This will involve a level of centralisation/specialisation and establishing one-stop-shop clinics in outpatient settings

• Deliver a business case to Trust Board and receive approval to proceed

• To implement the business case options

• To pilot one-stop-shop outpatient (with investigation) clinics

Complete the reconfiguration of our Pathology services

Achieve service integration and configuration aims in partnership with an external provider. This will focus in areas such as: redesigning the services to maximise efficiencies, cut out waste, implement new technologies and enhance service responsiveness and quality, and reduce the overall footprint of the

• Continue to roll-out the agreed implementation programme

• Complete building works at St. Richard’s

• Implement new technologies e.g. Pathology testing equipment, Order Communications etc.

• Implement new

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laboratory service Pathology procedures to optimise efficiencies

Develop and expand Private Patient services

The Trust has recognised the opportunity to increase the contribution from private healthcare carried out in its hospital settings.

Through greater engagement with Consultants with private practices, enhancements to the facilities offered, and increased marketing, the volume of work undertaken in the Trust Private Patient Units can be increased, generating a financial contribution that can support the delivery of NHS services, whilst giving patients a choice of health care delivery

• Deliver a business case that generates options to expand and improve Private Patient facilities in Worthing and generate income

• Set up new joint private practice committee to engage with practicing Consultants

• Set up website and marketing strategy to improve profile and access to information

• Improvements to facilities at Worthing completed

Exploit commercial opportunities

The Trust has identified a number of opportunities to more fully exploit the commercial opportunities it has as a major healthcare provider including:

• Responding to tender opportunities both within West Sussex and further afield

• Develop services in areas where specialist expertise exist, both as a specialist centre in our own right where appropriate and with tertiary partners

• Through improvements in the service offered,

• Being part of a successful tender for Coastal West Sussex MSK

• Increasing activity and income levels for specialist services by attracting patients

• Improving market share in elective surgical specialties

• Review of back office and support areas to identify partnering opportunities

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and disseminating information on those services, minimise the number of patients who choose another provider to have their NHS Care

• Partnering with other organisations where appropriate to deliver more effective and efficient services

Introduce a comprehensive Programme Management Office for the efficiency programme

As has been indicated in the context above and further detailed in section D below, the Trust faces an unprecedented challenges in delivering an efficiency programme totalling at least £31m over two years

Given the scale of the challenge, the Trust is reinforcing its infrastructure to support an efficiency programme of this scale whilst also providing additional capacity and expertise to enable delivery of the programme

• Establish a Programme Management Office to help develop and enable the delivery of the efficiency programme

• Establish a robust governance framework to ensure Board oversight and further support the Quality Impact Assessment of workstreams

Section B5 – Risks, Risk Management and Governance

The risks to the organisation achieving its Corporate Objectives are captured in the Trust’s Board Assurance Framework. The Board Assurance Framework is being developed but is as yet incomplete as the risks to delivery will not be fully known until the contract negotiations with our key commissioners are complete. The completed Board Assurance Framework is due to be presented to the Board in April 2014.

All of the Trust’s cost improvement programmes, captured as our efficiency programme in section D of this plan, are subject to Quality Impact Assessments. The Trust has a robust and comprehensive quality governance process, which ensures that no efficiency programmes that harm patient care are allowed to proceed and

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closely monitors the programmes once they are in place to ensure that the quality of care is not adversely affected.

All cost improvement programmes are required to complete a Quality Impact Assessment and these are reviewed by the Medical Director and Nursing Director and given a risk rating.

The Board ensures scrutiny of the impact of efficiency programmes through the Quality and Risk Committee and the Audit Committee. The Quality and Risk Committee scrutinise three key documents at each meeting: the Monitoring of Quality Impact Assessments, the trust Risk Register and the quarterly updated Board Assurance Framework.

In addition, the Committee also receives the output from Clinical Governance Reviews together with feedback from those Committees looking at Patient Experience and Feedback.

The Quality and Risk Committee is able to draw this information together to highlight areas where quality may be of concern and to ensure that the root cause is identified and risks mitigated.

A specific dashboard is provided to the Finance and Investment Committee on a monthly basis to review whether the more significant efficiency programmes are having an adverse effect on quality.

The Audit Committee seeks additional assurance through the use of Internal Audit to the Assurance Framework process.

SECTION C – Operational Requirements and Capacity

Section C1 – Inputs Required to Meet Expected Activity Levels

Detailed activity, financial and workforce information for the period of the Operational Plan is provided in Appendix 2. This section provides a summary of the assumptions used to determine the expected demand for services, the capacity available to meet this demand and the workforce required to deliver these activity levels.

Activity Planning Assumptions

As part of the annual planning process, the Trust has constructed detailed activity and capacity plans to anticipate the expected levels of demand and hence provision requirements by service in 2014/15.

The activity baseline is predicated on April–November 2013 activity levels. This is forecast forward to a full year effect using historic trends for non-elective care and working days for elective and outpatient care. The Trust adds a growth assumption based upon Office of National Statistics population projections by age and sex that are standardised according to the historic specialty level demographic breakdown of activity. There is an additional growth assumption for endoscopies relating to expected National and Local growth in endoscopy demand. The Trust has added a

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material increase in elective activity (predominantly day cases) to meet increasing demand within the context of 18 week performance requirements. This additional activity is predicated on growth in the admitted waiting list size in 2013/14, plus additional activity to reduce the RTT backlog. The same calculation is used for non-admitted patients, factoring in downstream conversions to follow up and outpatient procedure, and conversions to elective day case/inpatient admission.

The Trust is currently reviewing risk associated with the CCG demand management (Quality, Innovation, Productivity and Prevention [QIPP]) plans.

This activity is also converted into capacity requirements, such as numbers of beds, theatre sessions and outpatient clinics based on historic seasonal trends. An adjustment associated with the planned development of the Emergency Floor at Worthing has been built into the bed capacity plan.

These assumptions are the principle foundation of the Trust financial plan and budget setting process. The table below shows the planned change in elective, non-elective, outpatient and A&E activity over the period of the Operational Plan.

Change in activity from 2013/14–2015/16

2013/ 2014

Growth 18 Wks 2014/ 2015 Plan

Growth 18 Wks 2015/ 2016 Plan

Daycase 49,079 291 5,327 54,696 383 -1,198 53,881

Elective 10,108 58 168 10,333 72 10,406

Non-Elective 52,755 470 53,225 474 53,699

Outpatients 469,750 3,397 11,910 485,057 485,057 A&E Attendances 136,645 3,484 140,130 140,130

Physical Capacity Summary

This activity is converted into capacity requirements such as numbers of beds, theatre sessions and outpatient clinics based on historic seasonal trends.

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The table below shows the forecast change in physical capacity for 2014/15 in terms of the Trust’s bed base. Increases in beds due to growth and achievement of the 18 weeks RTT target are offset by Service Developments that are described in our efficiency programme. An adjustment associated with the planned development of the Emergency Floor at Worthing has been built into the bed capacity plan.

Change in beds from 2013/14–2015/16

Bed Type

2013/2014

Growth

18 Wks

Eff. Prog.

2014/ 2015 Plan

Growth

18 Wks

Eff. Prog.

2015/ 2016 Plan

Daycase 69 0 6 76 -1.4 -1.5 73

Elective 76 0 1 -3.75 74 74

Non-Elective 838 8 -14.5 832 8 -16.5 823

Total 984 9 7 -18 981 8 -1 -18 970

Workforce Summary

The table below provides a bridge between the whole-time equivalents (WTE) employed by the Trust in 2013/14 and those planned for 2014/15 and 2015/16, with the associated financial changes.

In developing the efficiency programme (see section D below) the Trust has captured the impact this will have on workforce. There are some significant changes envisaged over the two-year period, which include:

• A significant reduction in the use of agency staff across a wide range of efficiency measures

• A reduction in the use of waiting list initiatives (WLIs) with more work being undertaken in plain time

£m WTE £m WTEOpening Balance (247.98) 6,155.47 (246.10) 6,114.03

Activity Changes (0.42) 71.25 (0.42) (2.68)Service Developments (1.44) 19.13 0.25 (3.21)Efficiency Programme 8.94 (154.32) 5.16 (56.64)Pay Inflation (3.83) (5.34)Contingency (0.60) (0.60)Other (0.76) 22.50 (0.02) (14.30)

Closing Balance (246.10) 6,114.03 (247.07) 6,037.20

2014/15 2015/16

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• A review of Consultant job plans to ensure that the Trust’s medical workforce is delivering the right work to meet the demands of the service

• A reduction in WTE in some specific areas of work • A change in skill mix resulting in a change in the makeup of staff.

Section C2 - Risks to fluctuations in demand

Unscheduled Care - There has been as successful reduction in the numbers of admissions over the past 12 months in WSHFT attributable to the joint work between local health economy partners. However, there has been no discernible impact on the numbers of patients with a longer length of stay; there is in fact evidence that the acuity of patients who have been admitted to hospital has increased over the past year. As part of its draft operational plans the CCG is planning a 15% reduction in non-elective admissions between now and 2017, at a time when the population over 85 years of age is increasing by 13% over the same period. Whilst the Trust is supportive of the CCGs ambition to reduce admissions, there is a significant risk associated with this reduction target. For 2014/15, Coastal West Sussex CCG is proposing QIPP programmes that aim to reduce non-elective admissions by 1,300 through an expansion of the ‘One Call One Team’ programme, plus a further 1,440 admissions through its ‘Proactive Care’ programme.

The Trust is reviewing the proposed QIPP programmes and, although supportive of the direction of travel, it has ongoing concerns regarding the deliverability of this scale of admission reduction. In terms of mitigation, should the proposed levels of reduced admissions occur, the Trust has sufficient flexibility in both its staffing and bed base to ensure that costs are removed. Should the reductions in activity proposed not materialise, the Trust will be paid for the activity it undertakes through the contract.

Planned Care – Activity plans have been agreed with our main commissioners for planned care for the year 2014/15. Reductions in the levels of planned care signalled by commissioners were built into the Trust’s contracts and capacity plans for 2013/14. Overall, these reductions did not materialise, with sharp increases in particular specialties such as Cancer services, Ophthalmology and Respiratory Medicine. These changes, coupled with an unexpected drop in the numbers of patients in the 0–4 week cohort, have resulted in non-compliance against the RTT target from January 2014.

In the light of the experience of 2013/14, Trust plans for 2014/15 are predicated on absorbing observed demand levels, anticipated population driven growth and unmet demand in 2013/14. The Trust therefore seeks to deliver waiting list reduction and sustainable compliance via increased activity levels throughout the year. Our plans commit the Trust to a period of non-compliance in quarter one of 2014/15 to recover the waiting list size and backlog element to sustainable levels; however, non-compliance has become unavoidable due to the unplanned increase in demand described above, which will deteriorate through 2014/15 unless a recovery programme is delivered.

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The Trust has developed an extensive recovery programme targeting nine specialties that make the biggest contribution to aggregate compliance. This programme outlines the actions to restore aggregate compliance by the end of quarter one 2014/15, and delivers an additional 2,870 outpatient appointments and 1,082 inpatients/day cases above the 2013/14 run rate by the end of the quarter. This volume reduces the waiting list size and distribution to a point that can deliver aggregate compliance from quarter two 2014/15, but a further 6,568 outpatients appointments and 2,275 inpatients/day cases are identified in the plan above current run rate in quarters two to four in order to maintain compliance from that point onwards.

Detailed action programmes are in place for each of the specialties concerned. Each action plan describes baseline throughput, uplift requirement by activity type, the identified uplift schemes to meet that requirement and forecast compliance. These action plans correlate with the volumes proposed by the Trust to form the Indicative Activity Plan for the 2014/15 contract.

Each scheme has clinical manpower allocated on a named clinician basis, space allocation confirmed and support service allocations including: diagnostics, OPD/theatre nursing, medical records resources and receptionist staff. Each scheme is led by a divisional working group accountable to a weekly delivery board chaired by the Director of Performance and attended by all four Directors of Clinical Service (DCS). In turn, DCSs and the Director of Performance are subject to a weekly oversight and scrutiny meeting with the Chief Operating Officer. Corporate assurance will be provided via the Management Board and the WSHFT Trust Board Performance Report.

SECTION D – Productivity, Efficiency and Cost Improvement Programmes

This section summarises the Trust’s Efficiency programme for 2014/15 and 2015/16. It provides details on how the size of the efficiency programme has been determined and the assumptions on which this is based. The programme contains basic efficiency improvements, alongside transformational change, redesign and step-change initiatives.

The Trust has endeavoured to ensure that all areas of operations and activity have been included in the design of the programme and that interrelationships have been identified, documented and will be individually and collectively managed and tracked.

The efficiency programme is structured by workstream each with a nominated Executive Director responsible for its development and delivery. Oversight of the programme is through a weekly Efficiency Programme Steering Group, chaired by the CEO , comprising workstream leads and Divisional Directors as well as all of the Executive Team. More details on the structure of the programme are provided in Appendix 3.

The programme will be supported through a Programme Management Office, led by a Programme Director. This post is in the process of being recruited to so an interim

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Programme Manager is coordinating this, supported by a dedicated team until the permanent arrangements are in place.

In developing plans and assessing delivery risks alongside everything else the organisation is looking to achieve over the next two years, this places demands on staff and managers.

As an organisation that has delivered cost reductions year on year, the task becomes different and if not in all cases more difficult. The organisation therefore needs to adapt its approach in some circumstances to deliver in areas that have proved a challenge in previous years. The Trust has reinforced its governance arrangements and has a well-developed programme as a result of the approach adopted in constructing these plans.

Efficiency Programme by Revenue Source

Almost 90% of the efficiency programme in 2014/15 is generated through reductions in expenditure and productivity gains and the remaining 11% from income generation and commercial opportunities. Half of the efficiencies are delivered through planned reductions in the pay bill. Most of this will be achieved by reducing flexible labour costs and skill mix review, although there is a headcount reduction planned across some of the schemes.

In 2015/16 almost 80% of the risk adjusted plans are generated from expenditure reductions and productivity improvement.

A breakdown of the revenue sources of the required efficiencies across the next two years is provided below:

Efficiency Programme Headroom

The table below provides a breakdown of the required efficiencies to be delivered in 2014/15 and 2015/16 and the value of identified schemes. It therefore displays the consequential headroom that has been factored into the plans:

As the Trust continues to develop plans there is an expectation to build up further headroom for the next two years. As an organisation with £370m turnover, all

Pay Non Pay Income Total£000s £000s £000s £000s

2014/15 8,942 7,846 2,202 18,99047.1% 41.3% 11.6%

2015/16 5,158 3,989 2,056 11,20346.0% 35.6% 18.4%

HEADROOM ANALYSIS

Planned Savings Annual Plan Headroom£000s £000s £000s

2014/15 22,787 18,990 3,7972015/16 18,207 11,203 7,004

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transactions, expenditure and other opportunities will be rigorously reviewed, in order to build up headroom and contingency for the current financial year. The development of the efficiency programme has required the commitment and engagement of the organisation. The schemes have been risk assessed and where the values attributed to schemes have been reduced work will be undertaken to mitigate those risks, increase the values and ideally create further headroom.

The Workstreams

In summary the principal workstreams for 2014/15 and 2015/16 cover the following areas:

A. Back office and corporate support– procurement and corporate services

B. Operational productivity – Acute Medicine, Enhanced Recovery, Productive Theatre and Outpatients

C. Diagnostics – Pathology, Imaging and CSSD D. Service reconfiguration – Ophthalmology, Orthopaedics and Best

Practice Tariff E. Facilities and Estates – Carbon management, estate rationalisation

and, hard and soft FM F. Clinical Productivity – Medical workforce and medicines management G. Workforce – Nursing, Therapies, management costs, terms and

conditions, admin and clerical, bank and agency H. Commercial Opportunities – Private Patients, Provider to Provider and

coding.

The approach has been to develop a programme on a thematic basis, rather than in organisational silos, which are owned across the organisational structure. The plans apply an increasingly greater focus on a transformational approach to the delivery of some key services. These are:

• Acute Medicine flow and the Emergency Floor • Productive Theatre • Ophthalmology service reconfiguration • Orthopaedics service redesign • Diagnostic services - Pathology and Imaging service redesign.

All workstreams have been subject to a risk assessment that reflects the development of the schemes, complexity of implementation and an assessment against the risks to delivery. A table providing a summary of each workstream, incorporating the risk assessment is provided below:

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Work streams

Planned Savings pre

risk adjustment

Annual Plan (Required

Savings)

Planned Savings pre

risk adjustment

Annual Plan (Required

Savings) £'s £'s £'s £'s

Back Office & Corporate SupportProcurement 3,000,000 2,449,091 2,000,000 1,230,700Back Office 1,113,340 996,874 500,000 307,675

4,113,340 3,445,965 2,500,000 1,538,375Operational ProductivityPatient Flow 650,000 373,591 950,000 584,583Enhanced Recovery 238,048 197,629 132,903 81,782Productive Theatre 1,000,000 774,835 698,666 429,924Outpatients 561,000 420,750 1,058,629 651,428

2,449,048 1,766,805 2,840,199 1,747,717DiagnosticsPathology 798,750 734,850 1,416,250 871,489Imaging 900,000 747,180 97,065 59,729CSSD 953,000 953,000 875,000 538,431

2,651,750 2,435,030 2,388,315 1,469,649Service ReconfigurationOpthalmology 1,808,576 1,356,433 2,901,302 1,785,316Orthopaedics 889,095 738,130 2,340,000 1,439,919Best Practice Tarriffs 711,000 513,894 0 0

3,408,671 2,608,457 5,241,302 3,225,235IM&TPaper Light 43,000 43,000 0 0Clinical Information Systems 0 0 200,000 123,070

43,000 43,000 200,000 123,070Estates & FacilitiesCarbon Management 56,145 56,145 300,000 184,605Estate Rationalisation 500,000 330,000 0 0Hard & Soft FM 1,720,900 1,720,900 500,000 307,675

2,277,045 2,107,045 800,000 492,280Clinical ProductivityMedical Workforce 650,000 487,500 650,000 399,978Medicines Management 906,800 752,825 1,292,700 795,463

1,556,800 1,240,325 1,942,700 1,195,441Clinical WorkforceNursing 1,165,848 1,109,385 227,312 139,876Therapies 454,340 417,996 108,000 66,458CNST & NHSLA 354,954 354,956 0 0

1,975,142 1,882,337 335,312 206,334WorkforceManagement Costs 500,000 330,000 100,000 61,535Terms & Conditions 1,123,490 932,726 190,000 116,917Admin & Clerical 250,000 187,500 250,000 153,838Bank & Agency 763,625 572,720 199,375 122,685

2,637,115 2,022,946 739,375 454,975Commercial OpportunitiesPrivate Patients 534,500 491,740 500,000 307,675Provider to Provider 140,239 116,426 100,000 61,535Commercial Partnerships 0 0 319,400 196,543Coding 1,000,000 830,200 300,000 184,605

1,674,739 1,438,366 1,219,400 750,358

Total 22,786,650 18,990,276 18,206,603 11,203,434

2014/15 2015/16

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A. Corporate Support and Back office

Within this programme the Trust will deliver improved value for money for its back office support functions whilst ensuring they meet the needs of front line clinical services they support. Through the in-depth analysis by service and supplier the procurement programme will:

• Increase contract coverage, compliance, benchmarking, spend aggregation and collaboration

• Review current goods provision through NHS Supply Chain to secure best value for money

• Review and prioritise resource for all contracts due for renewal over next 12 months to deliver the biggest wins

• Comprehensive review of maintenance contracts • Ensure engagement of procurement function at the beginning of all tendering

activity • Prioritise contracts for fixed price agreement to avoid inflation.

B. Operational Productivity

This programme focuses on improvements in both length of stay and reductions in readmissions leading to reductions in bed requirements and temporary staffing. The initial focus for 2014/15 comprises:

• Emergency Floor at Worthing Hospital • Internal efficiencies programme – focusing on predictive discharge, ward

rounds, TTOs, imaging and other areas that hamper patient flow • A range of programmes will focus on reducing the numbers of inappropriate

readmissions.

Further work in development that will have a significant impact in 2015/16 is integrating the Surgical Assessment Unit and Medical Assessment Units at St Richard’s Hospital. The workstream is also closely aligned to the integration of the unscheduled care pathway across the local health economy and the local initiative of ‘One Call One Team’. Enhanced Recovery focuses on elective inpatient pathways by procedure to identify opportunities to improve patient outcomes and speed up a patient's recovery after surgery through clinical review of current practice, variation analysis and benchmarking to achieve the required length of stay reductions and bed capacity. Focus for this workstream is: colorectal, breast, urology, gynaecology and shoulder pathways. The Productive Theatre improvement programme is to systematically deliver significant improvements in theatre safety, efficiency and patient care. Building upon improvements already achieved through the end-to-end pathway analysis to remove ‘waste’ activities, streamline the patient pathway and improve productivity. The aim is to significantly rationalise surgical activity equivalent to two Theatres across two years, whilst maintaining current activity levels. There are some quick wins identified

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including a reduction in premium (WLI) payments, a reduction in the cost of surgical loan sets and the closure of one of the Trust’s theatres has already been identified. The Outpatients workstream includes transition to a nurse-led outpatient follow-up model to release consultant resource and release further benefits from the Call Centre IT system to improve patient experience and reduce DNA rates.

C. Diagnostics

The Imaging programme will embed the MRI service improvement benefits delivered in 2013/14 and deliver similar programmes for CT and ultrasound. This will require skill mix review and a change in working practices to improve access across the week, facilitated by strengthened PACS and informatics support. The reconfiguration and modernisation of Pathology services approved by the Board in 2012 is already underway. Operational efficiency, workforce optimisation will deliver 20% savings within Pathology. Implementation of new technologies including end to end IT connectivity and the provision of private sector support for service development is critical to this being delivered. Repatriation of send away tests and consolidation through one provider will also deliver significant cost reductions. D. Service Reconfiguration Two of the key transformational workstreams are within the service reconfiguration programme: Clinical pathways in Ophthalmology will be redesigned to achieve a sustainable delivery model of care. This redesign includes:

• A review of the skill mix • Development of roles and responsibilities to deliver new pathways • Optimisation of Consultant resources.

Opportunities to improve productivity will be exploited through variation analysis by procedure, clinician and benchmarking undertaken to agree consistent standards. Freeing up capacity through productivity improvements to deliver an increased activity plan (RTT compliance and future steady state) is a key component of the 2014/15 plan. Increasing ophthalmic market share primarily within Sussex by transferring the service from Worthing to Southlands Hospital will enable the transformation of this service to deliver sustainable benefits in the medium-term, which is reflected in 2015/16 plans. An Orthopaedic Improvement Group has been established, chaired by the Chief Executive, to drive through transformational productivity improvements in Orthopaedics. These will result in cost reductions across the clinical pathway including flexible medical staff resources as well as theatre efficiencies and produce standardisation. In addition this provides further opportunities to secure additional income through Best Practice Tariff and the repatriation of NHS work being seen at non-NHS Hospitals.

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E. Facilities and Estates

The most significant component of this workstream is rationalisation of the Estate and five properties have been identified as potential opportunities for sale or to serve notice on rented of facilities. In addition, plans are underway to reconfigure switchboard services and there are some minor changes planned for the back office functions within the Facilities Department. There are also commercial opportunities identified for income generation across a number of areas. The Trust is beginning to look at options for a commercial strategic energy partner to maximise cost savings in the medium-term and this is reflected in the planning assumptions for 2015/16. F. Clinical Productivity This programme seeks to maximise efficiency of Consultant workforce through a refreshed job planning process, aligned to Consultant appraisal under the leadership of a new Medical Director. The approach is to agree team productivity data and measures, embed performance management, review capacity within new team job plans (to deliver demand) and reduce temporary pay as result of these measures. Within the Nursing workforce work is underway to further standardise shift handovers in the short-term alongside effective deployment of resources for specialling dementia patients and strengthening controls to reduce use of non-framework agencies. Longer-term priorities are focused on the use and grading of Clinical Nurse Specialists, review of nursing in non-acute areas to optimise skill mix and the use of Advanced Nurse Practitioners to cover medical locums. Within this programme there is also a comprehensive review to secure best value for money on medicines expenditure through effective procurement and ensuring efficient processes surrounding the use of medicines. G. Workforce This programme will ensure the most effective application of local pay arrangements. A significant component is recruitment and retention premia and this agreement is already underway. A review of management structures across both main Hospital sites and opportunities to review duplication and spans of control is planned to release benefit across the next two years. The Trust will optimise the use of flexible labour ensuring greater integration into operational requirements, effective and efficient rostering whilst standardising practices to improve costs. Opportunities to engage a commercial partner in the delivery of some aspects of this will also be explored. H. Commercial Opportunities Through a transformational approach to the Trust’s business model there are a range of opportunities to establish significant commercial partnerships. The Trust has developed a commercial strategy to provide the framework for this programme in the medium-term and has appointed to a new Commercial Director post to take these initiatives forward over the next two years.

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The Trust has ambitious plans to enhance and expand its Private Patient activities. A marketing strategy, including a dedicated website and a new Consultant joint private practice committee to increase Consultant engagement is central to this programme. A range of opportunities are being scoped to deliver significant benefit in 2015/16. Current projects supported include the market testing for car parking services at Worthing Hospital, the provision of accommodation and transport services and the opportunity to review delivery of laundry services to the Trust. Detail of the phasing of the specific workstreams across 2014/15 and 2015/16 is given in Appendix 4.

Quality Impact Assessment

A robust quality impact assessment process has been implemented to ensure the Trust has the appropriate steps in place to safeguard quality when embarking on and delivering any efficiency plan or transformation programme and is consistent with Monitor guidance. Once documentation is complete, an initial assessment is made by the Director of Nursing and the Medical Director. Schemes that have satisfied the basic assessment are then reviewed through the Trust’s Quality and Risk Committee.

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3. Supporting Financial Information

The financial projections that support the Operational Plan are provided in Appendix 2. These have been calculated based on an assessment of the quality priorities, operating requirements, and the productivity and efficiency initiatives contained within the plan. The table below summarises the 2014/15 and 2015/16 financial plan.

Income and Expenditure Plan for 2013–2016

Income The Trust has assumed that the terms of the contract agreed with commissioners will be that full payment by results applies.

2013/14 2014/15 2015/16FOT Plan Plan£m £m £m

Income 380.86 377.80 373.94

Pay (247.98) (246.10) (247.07)Non-Pay (111.23) (104.08) (102.08)Total Operating Expenditure (359.21) (350.18) (349.14)

EBITDA 21.65 27.62 24.80

Depreciation and Amortisation (12.83) (14.40) (14.40)Profit/(Loss) on Disposal 0.09 0.00 0.97Impairment of fixed assets (1.07) (1.12) (1.42)Finance Costs (0.93) (1.11) (0.96)Interest Receivable 0.05 0.05 0.05Public Dividend Capital Dividend (6.90) (6.93) (7.02)Total Non-Operating Items (21.59) (23.51) (22.78)

Net Surplus/(Deficit) 0.06 4.11 2.02

Adjustments to Retained Surplus DeficitImpairments 1.07 1.12 1.42Donated Assets (0.11) (1.80) (0.00)

Underlying Operational Performance 1.02 3.43 3.44

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There has been very close working between the Trust and Lead Commissioner (Coastal West Sussex CCG) in relation to contract agreements for 2014/15, which has enabled a jointly agreed activity and finance baseline position, shared income assumptions and the financial risk across respective organisations. Although small differences remain the construction of the contract will provide for the management of these risks in year. The significant financial risk within commissioning plans is demand management plans (QIPP) to reduce activity volumes for unscheduled care and planned care. The value of these schemes from the Lead Commissioner is £8.2m. The nature of these plans across the local health economy has been shared and an assessment has been made of consequential impact on the Trust. The CCG has made provision for risks of slippage or non-delivery of some plans up to 50%. There is also recognition that should QIPP deliver in full the Trust will be unable to release stranded costs. In addition the Trust has provided for delivery of QIPP schemes up to 20% to recognise cost reductions should the activity and income reductions be delivered. As a consequence there is an overall gap of £3.5m between both organisations reflecting differing levels of confidence of the impact of QIPP schemes across the local health economy. The Trust and CCGs are still to finalise the components of CQUIN that has £8.1m income attributed to the delivery of key quality indicators. This comprises 2.5% of the value of the service level agreement with the Commissioners. The Trust has agreed a RTT recovery plan with the Lead Commissioner that equates to £6.1m of additional activity in total 2014/15. Over 85% of this activity is with the Lead Commissioner. The income and costs associated with delivery are reflected in the plan. The income plan also reflects the anticipated increases in income for Private Patients and Provider to Provider agreements, which are a component of the efficiency programme.

Costs The key drivers of the expenditure assumptions are as follows:

• Effect of the underlying run-rate in 2013/14 • Impact of the Trust’s efficiency plans • Anticipated price inflation pressures • Impact of approved service developments and investments • Impact on the Trust of activity plans and capacity.

The Trust must deliver £19m of efficiency savings in 2014/15 to deliver £3.4m surplus. Plans up to £22.6m have been identified to date, recognising the requirement for over-programming to mitigate risks to delivery. Based on the Trust’s efficiency programme the implementation of current plans will reduce the cost base by £14.4m. A further £4.6m of the efficiency programme will be delivered through a range of initiatives, which will deliver an increased income contribution to the Trust. For 2015/16 the Trust is required to deliver further efficiencies of £11.2m through productivity improvements and commercial opportunities. A significant component of these plans is the full year effect of transformational programmes from 2014/15.

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Inflationary pressures, including funding for National Pay Awards, recognition of non-pay price inflation and increases in clinical negligence contributions have been estimated as £7.0m in 2014/15 and £8.5m in 2015/16. The financial plan also recognises the impact of the Planned Care programme referenced previously. The most significant component of expenditure budgets is pay costs. The Financial Plan assumes overall pay expenditure will increase by £6.5m above 2013/14 levels, prior to the impact of the efficiency programme. The impact of the efficiency programme on the pay bill is estimated to be £8.9m. A significant component of the pay bill reductions will be delivered through a reduction in flexible labour and skill mix changes so this will not wholly be reflected as a reduction in the funded headcount. Capital Plans The Capital Programme has been informed by Divisional business planning and the Trust’s Clinical Services Strategy. Prioritisation has taken place at two formal meetings in January and February 2014. These meetings consisted of multi-professional representation to fully inform the programme. The agreed programme is shown in the table below: Capital Programme 2014/15 and 2015/16

Each year the Trust receives donations from ‘Love Your Hospital’ and the ‘League of Friends’, funding both capital and revenue items traditionally. Donated assets have been assumed at £1.75m in 2014/15 and £0.95m in 2015/16 to fund specific schemes within the Trust’s Capital Programme. Potential schemes have been identified internally and dialogue with our Charities commenced to secure funding. A risk-based approach to prioritisation has been adopted, taking into account the Trust’s risk register, clinical standards/requirements, patient experience etc. The

36

schemes identified consider business cases already Trust Board approved and those with approval in principle by the Service Change Executive. The key programmes within the capital programme are:

• Endoscopy redevelopment – as outlined in our Operational Plan programmes of work, the redevelopment of our Endoscopy services is a key quality improvement, improving patient flow, patient experience and efficiency, and will allow the Trust to meet the forecast growth in demand for Endoscopy services

• The Emergency Floor at Worthing Hospital – this will integrate care of the Elderly, Surgical and Acute Medical assessment into a single area and will result in a major improvement in patient care. The Emergency Floor is a key enabler to drive additional productivity through reductions in length of stay for unscheduled care patients

• Southlands Hospital: To deliver the Trust’s commitment to develop Southlands Hospital, external investment of £4.5m has been included within the plan to support the development of Ophthalmology at Southlands, moving the current service from Worthing Hospital. This investment will be subject to a business case in early 2014/15 to demonstrate the economic benefits of the development

• Day Surgery at Worthing – as highlighted in the Trust’s Clinical Strategy (Appendix 1) addressing the lack of a dedicated Day Surgery Unit (DSU) at Worthing Hospital is a strategic priority for the Trust. The Trust envisages enabling work to take place in 2015/16, with further capital investment required in 2016/17 before a new DSU becomes operational

• Interventional Radiology- the Trust is replacing and upgrading its Interventional Radiology services at Worthing Hospital as an essential part of providing a modern and safe acute service

• CT Scanner – one of the two CT Scanners at St. Richard’s Hospital is in need of replacement and upgrading.

In addition to these schemes, the Trust has allocated significant capital sums to information management and technology, replacement medical equipment and a range of Estates Enabled Schemes covering sustainability, refurbishment, minor works and backlog maintenance. Due to the significant number of ongoing schemes early in 2014/15 there will be a review of priorities for 2015/16 recognising the current over-programming of the capital programme. Liquidity At the 1st April the Trust will have £9.5m outstanding on the working capital loan draw down on Foundation Trust authorisation. The Trust is expected to maintain a cash balance of at least the value of the outstanding working capital loan. £1m will be repaid on this loan each year in two equal instalments in quarter one and quarter three. There is an additional working capital loan balance from the predecessor Trust of £2.4m as at the beginning of April 2014. This outstanding balance will be repaid in full during 2014/15.

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Rolling cash flow forecasts will continue to be used to manage cash and to report the liquidity position to the Board. The Trust summary balance sheet is shown in the table below: Trust Balance Sheet 2013 – 2016

The balance sheet reflects the following key movements:

• Non-current assets: reflect capital investment net of depreciation

• Trade and other receivables: reduce in 2014/15 due to the receipt of cash from NHS England that relates to the 2013/14 financial year

2013/14 2014/15 2015/16FOT Plan Plan £m £m £m

Non Current Assets 260.85 269.36 269.70

Inventories 6.48 6.48 6.48Trade and Other Receivables 14.66 11.57 11.07Other Current Assets 3.67 3.67 3.67Cash 10.50 13.80 16.25Non Current Assets held for Sale 2.60 1.48 0.00Total Current Assets 37.91 37.00 37.47

Trade and Other Payables (11.30) (11.35) (11.40)Non Commercial Loans (4.57) (2.28) (2.40)Accruals (16.32) (17.44) (17.44)Other Current Liabilities (0.99) (0.93) (1.00)Total Current Liabilities (33.18) (32.00) (32.24)

Net Current Assets 4.73 5.00 5.23

Non Commercial Loans (26.93) (32.03) (31.01)Provisions (2.45) (2.38) (2.31)Finance Leases (2.28) (1.92) (1.56)Total Non Current Liabilities (31.65) (36.33) (34.88)

Total Assets Employed 233.92 238.03 240.05

Public Dividend Capital 238.69 238.69 238.69Retained Earnings/(Accumulated Losses) (45.42) (41.31) (39.29)Revaluation Reserve 40.65 40.65 40.65Total Taxpayers' and Others' Equity 233.92 238.03 240.05

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• Non-current assets held for sale: are the portion of the Southlands estate declared surplus by the Trust Board in 2013. The Trust is currently reviewing its options for the disposal of land and buildings at Southlands Hospital. A decision is expected to be made by the Trust Board early in 2014/15 and may lead to a change in associated elements of the financial plan

• Commercial loans: reflect the repayment of working capital loans, as described in the liquidity section, repayment of existing capital loans and draw down of further capital investment loans, as described in the capital section.

Risk Ratings A Continuity of Service Risk Rating (CoSRR) of 3is maintained throughout the period. The phased plan maintains a debt service cover rating of at least two during the period. The liquidity metric is maintained at a minimum of 3 during the period.

Key Risks There are a number of risks in delivering the financial plan. These will be closely monitored along with financial performance throughout the year. These have been summarised below:

• The impact of QIPP schemes and the ability to either take out stranded costs if schemes deliver in full or the affordability for Commissioners to pay in full for over-performance above contracted activity levels. Mitigation of this risk is the close monitoring of activity levels in year and formalising escalation triggers within the contract for significant variance to plan. There has also been discussion with Commissioners who recognise the principle of stranded costs for the Trust

• Agreement of a contract with Specialist Commissioners has been delayed whilst the 2013/14 income position has been resolved. A contract offer has been received by the Trust and the Trust is in discussion with the area team to progress the outstanding differences

• The scale of required savings to deliver the planned surplus is the largest target the Trust has been required to achieve so delivery of the efficiency programme in full is a risk. This will be mitigated by significantly enhancing the infrastructure to support the programme with a robust reporting framework and an approach that enables delivery through enhanced capacity and project management expertise as well as Executive led work streams. A rolling programme of identifying pipeline schemes will give headroom in line with £3m already identified

• The cost of delivery of the Planned Care workstream and achievement of aggregate RTT compliance within the cost envelope assumed within the plan will require close scrutiny and rigorous tracking of costs, particularly in the first quarter. Agreement of additional resource to enable this will be reviewed and signed off by the Director of Operations and the Director of Finance.

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4. Appendices

The following appendices have been provided as part of the Trust’s Operational Plan.

Appendix 1 – WSHFT Clinical Services Strategy

Appendix 2 – Financial Template (submitted separately)

Appendix 3 – Efficiency Programme Structure

Appendix 4 – Phasing of Efficiency Programmes

Appendix 5 – Downside Risks and Mitigation

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To: Board of Directors


Title

2014/15 Financial Plan


Karen Geoghegan, Director of Finance

Prepared by

Karen Geoghegan, Director of Finance

Status

Disclosable

Summary of Proposal This paper provides the Board of Directors with an update on the Financial Plan for 2014/15 following approval in March 2014. Implications for Quality of Care

A Quality Impact Assessment has been undertaken for all work streams within the Efficiency Programme and reviewed at Quality and Risk committee in April 2014.


G1: Maintain an acceptable Financial Risk Rating


Financial Performance Report


Not applicable

Recommendation It is recommended that the Board of Directors note the Financial Plan for 2014/15 following approval in March 2014 and note the progress to the plan since last month. Communication and Consultation

Not applicable

Appendix

Appendix 1 as noted in the paper

Introduction The purpose of this paper is to provide the Board of Directors with the Trust’s 2014/15 Financial Plan for review and approval. This follows on from the paper approved by the Finance and Investment Committee in March 2014. The purpose of this paper is to confirm the iterations to the plan since last month and present the 2014/15 Financial Plan to the Board for approval. It also confirms the progress that has been made to further develop the efficiency programme and the outcome of negotiations with commissioning partners to finalise agreements. The main elements in the composition of the financial plan are as follows:

• A summary of the key principles of the Financial Plan • Income assumptions and planned activity levels during 2014/15 • The 2014/15 Acute Services Contract with commissioners • Planned expenditure including emerging cost pressures • Efficiency Programme plan • Expenditure Control Totals for Divisions and the sign off process • Capital Plan • Liquidity • Continuity of Service Risk Rating • Key Risks

On 4 April 2014 the Trust submitted the Annual Plan to Monitor. The key components of the plan are as follows:

• The Trust's income assumptions are now closely aligned to the planning assumptions of the lead Clinical Commissioning Group, Coastal West Sussex and reflected in the contract that has been agreed. The proposed contract with Specialist Commissioners is not as closely aligned but there is a shared understanding of the relative financial risks and these will need to be concluded prior to the contract being agreed.

• The income plan assumes the contract will operate under PbR rules including application of fines and penalties mandated in the national contract although agreement has been reached regarding re-investment of these for specific projects

• The income plans assume delivery in full of the 18 week pathway to achieve aggregate compliance by the end of Q1 which has been agreed and signed off with the lead commissioner

• The income plan recognises a limited delivery of QIPP schemes to reduce unscheduled care admissions in 2014/15 over and above 2013/14 outturn levels. Although this is less than CCG plans, the commissioners have attributed a 50% level of risk to their planning assumptions which reflects the potential non-delivery of some plans

• CQUIN schemes are being finalised and the plan assumes delivery of these in full which equates to £8.1m

• The Trust is planning to deliver £3.4m surplus (0.9%) • The Efficiency requirement of the Trust is £19m

Summary of Key Principles of the Financial Plan The financial plan is based on the current requirements of the Monitor Financial Risk Rating (CoSR) regime. The financial plan for 2014/2015 is therefore set to meet a number of key criteria, consistent with the Trust’s Foundation Trust status:

• An overall CoSR of ‘3’ in year • Retain a minimum 0.5% contingency • Delivery of an Operating Surplus to enable repayment of the working capital loan • Maintaining a minimum cash balance at least equal to the outstanding balance of the FT

working capital loan. A summary of the Trust Income and Expenditure plan, profiled by quarter is outlined below;

30th June 2014

30th September 2014

31st December 2014

31st March 2015

£m £m £m £m £m

Income 93.60 96.06 94.84 93.30 377.80

Pay (61.85) (61.42) (61.27) (61.56) (246.10)Non-Pay (27.26) (25.66) (25.64) (25.52) (104.08)

Total Operating Expenditure (89.11) (87.08) (86.91) (87.08) (350.18)

EBITDA 4.49 8.98 7.93 6.22 27.62

Depreciation and Amortisation (3.51) (3.50) (3.61) (3.78) (14.40)Profit/(Loss) on DisposalImpairment of fixed assets (1.12) 0.00 0.00 0.00 (1.124)Finance Costs (0.14) (0.44) (0.14) (0.39) (1.11)Interest Receivable 0.01 0.01 0.01 0.01 0.05Public Dividend Capital Dividend (1.73) (1.73) (1.73) (1.73) (6.93)Total Non-Operating Items (6.50) (5.65) (5.46) (5.90) (23.51)

Net Surplus/(Deficit) (2.01) 3.33 2.46 0.33 4.11

Adjustments to Retained Surplus DeficitImpairments 1.12 0.00 0.00 0.00 1.12Donated Assets (0.45) (0.45) (0.45) (0.45) (1.80)

Underlying Operational Performance (1.33) 2.88 2.02 (0.12) 3.43

Quarter Ending2014/15

Total

A more detailed quarterly income and expenditure account is shown in Appendix 1. Due to phasing of the efficiency programme the Trust is reporting a planned deficit in Q1. The overall impact on the Trust of the NHS Operating Framework 2014/15 is an aggregate1.6% deflation of the tariff. In agreement with commissioners it has been assumed that there is aggregated growth across the Trust equal to 0.7%. The exception to this is targeted growth to treat the activity backlog to deliver Referral to Treatment (RTT) aggregate compliance by the end of Q1 and to maintain compliance for the rest of the year.

2

Intensive and detailed work in collaboration with CCG commissioner colleagues has been undertaken to ensure there is an agreed baseline for activity and income assumptions. This has enabled an agreed position for activity volumes and the application of PbR rules for a 2014/15 baseline, prior to the application of QIPP schemes. A summary of the income and expenditure plan in 2014/15 and the movement from a 2013/14 PbR baseline is provided in the Table overleaf;

3

2013/14 Out-turn

Non Recurrent

Items 13/14

Income Deflator

Part Year Effects incl. counting &

coding changes

CLRN hosting budgets Growth

Service Developments &

FYE Business Cases

Removal of T & O

Uplift RTT Inflation ContingencyFrancis Report

Non Operating

Items QUIPP Other

2014/15 Plan prior to Efficiencies

Efficiency Programme

2014/15 Plan

£m £m £m £m £m £m £m £m £m £m £m £m £m £m £m £m

Income 381.02 (4.00) (5.70) 2.85 (7.47) 2.00 0.80 6.14 1.80 (1.70) (0.14) 375.60 2.20 377.80

Pay (247.85) (0.89) 0.90 (0.42) (0.94) 0.59 (1.44) (3.83) (0.60) (0.42) (0.14) (255.04) 8.94 (246.10)Non-Pay (111.15) (1.11) 6.52 (0.41) (0.21) 0.42 (1.53) (3.12) (1.20) (0.13) (111.93) 7.85 (104.08)Efficiency ProgrammeTotal Operating Expenditure (359.01) 0.00 0.00 (2.00) 7.41 (0.83) (1.15) 1.01 (2.97) (6.95) (1.80) (0.42) 0.00 0.00 (0.26) (366.96) 16.78 (350.18)

EBITDA 22.01 (4.00) (5.70) 0.85 (0.06) 1.17 (0.35) 1.01 3.17 (6.95) (1.80) (0.42) 1.80 (1.70) (0.40) 8.63 18.99 27.62

Depreciation and Amortisation (12.86) (1.54) (14.40) (14.40)Profit/(Loss) on Disposal (0.06) 0.06 0.00 0.00Impairment of fixed assets (6.84) 5.71 (1.12) (1.12)Finance Costs (0.97) (0.15) (1.11) (1.11)Interest Receivable 0.04 0.01 0.05 0.05Public Dividend Capital Dividend (7.05) 0.12 (6.93) (6.93)Total Non-Operating Items (27.72) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.21 0.00 0.00 (23.51) 0.00 (23.51)

Net Surplus/(Deficit) (5.71) (4.00) (5.70) 0.85 (0.06) 1.17 (0.35) 1.01 3.17 (6.95) (1.80) (0.42) 6.01 (1.70) (0.40) (14.88) 18.99 4.11

Adjustments to Retained Surplus DeficitImpairments 6.84 (5.72) 1.12 1.12Donated Assets (0.10) (1.70) (1.80) (1.80)

Underlying Operational Performance 1.03 (4.00) (5.70) 0.85 (0.06) 1.17 (0.35) 1.01 3.17 (6.95) (1.80) (0.42) (1.41) (15.56) 18.99 3.43

Anticipated Income Assumptions and Planned Activity Levels during 2014/15 The key assumptions in relation to planned income which are included in the plan are as follows;

• Tariff prices will reduce overall by a net aggregate 1.62%. This includes the 4% efficiency requirement which is embedded in the 2014/15 PbR tariff and reflects the casemix of the Trust. The overall impact of this for the Trust is a net £5.7m reduction in income.

• The Trust has assumed that the terms of the contract agreed with commissioners will be

that full PbR applies. Plans therefore assume financial penalties will apply to at least a value of £1.6m. The commissioners have agreed a programme of re-investment of penalties from readmissions either within the Trust or with other providers with the purpose of reducing exposure to future fines.

• The Trust and CCGs have agreed components of CQUIN which has £8.1m income attributed to the delivery of key quality indicators. This comprises 2.5% of the value of the SLA with commissioners, excluding pass through payments.

• The Trust has agreed a RTT recovery plan which equates to £6.1m of additional activity in 2014/15 across all commissioners. The income and costs associated with delivery are reflected in the plan.

The impact of commissioning plans agreed across the health economy is reflected in the Financial Plan. The Trust has worked closely with the lead commissioner to agree income assumptions and mitigate the financial risk across respective organisations. Although small differences remain the construction of the contract will provide for the management of these risks in year. As a consequence the overall affordability gap with the lead CCG is £3.4m, prior to the application of the new MSK contract in Q4, reflecting differing levels of confidence of the impact of QIPP schemes across the health economy. A summary of the planned contract income to the Trust is outlined in the Table below;

£m2014/15 Income Baseline 314.78

RTT Recovery 6.13Colorectal Screening 1.00NICE Guidance Changes 1.18

Dementia 0.40One Call One Team 1.40Out of Area Sexual Health 0.40Other Services 3.93

Counting and Coding 0.00

Cancer Drugs Fund 0.50Recharges and FP10s 0.61

Readmissions (1.64)

QIPP (1.70)

CQUINS 8.19

Total 335.17

All of these assumptions have been shared and discussed with local commissioners and are reflected in the Financial Plan submission to Monitor in April. This has ensured that there is a clear understanding of the income and consequential risks in plans submitted by the Trust and local commissioners. A breakdown of the planned contract income for 2014/15 is summarised in the Table below.

£m £mNHS Coastal West Sussex 260.52NHS Horsham and Mid Sussex 4.69NHS Brighton and Hove 3.70NHS Crawley 0.28NHS High Weald and Lewes Havens 0.17NHS Eastbourne and Hailsham 0.15NHS Hastings and Rother 0.06Sub-total Sussex CCGs 269.58Hampshire CCGs 6.96Surrey CCGs 0.50Non Contracted Income and Overseas Visitors 3.91CCG Income 280.95

West Sussex County Council 5.47

NHS England (Specialised Services) 48.75

Total Income 335.17

A breakdown of the total income plan is outlined below:

£mIncome from Activities 335.17Other Income for Patient Care 9.342Education Training and Research 9.805Other Operating Income 23.478Total Income 377.80 A component of the efficiency programme is anticipated increases in income for private patients and provider to provider agreements; these are included in the table above. Planned Expenditure 2014/15 including Emerging Cost Pressures The key drivers of the expenditure assumptions in the Financial Plan 2014/15 are outlined below;

• Effect of the underlying run-rate in 2013-14 • Impact of the Trust’s efficiency plans • Anticipated price inflation pressures • Impact of approved service developments and investments • Impact on the Trust of activity plans and capacity

The income and expenditure trends in the latter half of 2013-14 demonstrate a significant increase in the expenditure run-rate of the Trust. Although the Trust has been busier during the latter part of the year, if this underlying run-rate were to continue during 2014-15 this could add further risk to the financial plan.

6

The Trust has calculated a financial gap for 2014/2015 based upon a range of assumptions incorporated in the Operating Framework as well as a range of local pressures. These pressures combined total £19m; the value of the 2014/15 efficiency programme. This represents 5.4% of the controllable cost base and is required to deliver £3.4m surplus. Plans up to £21.6m have been identified to date, recognising the requirement for over-programming to mitigate risks to delivery. Based on the Trust Efficiency Programme to deliver a minimum £19m the implementation of current plans will reduce the cost base by a minimum £16.8m. A further £2.2m of the efficiency programme will be delivered through a range of initiatives which will deliver an increased income contribution to the Trust. Further detail of the Trust Efficiency Programme 2014/15 is provided in the next section of this paper. Within the PbR tariff there is £6.95m funding assumed for inflationary pressures. This includes funding for national pay awards and some recognition of non-pay price inflation. It has been estimated that these pressures will total £6.5m since £0.5m will be allocated to the procurement workstream to recognise cost avoidance to mitigate non-pay inflation pressures. The overall increase in the cost base as a consequence of approved service developments is £1.2m. A proportion of these costs are recovered in the income agreement with the commissioners, leaving £0.35 net costs to be recovered within the financial plan. The most significant component of expenditure budgets is pay costs. The Financial Plan assumes overall pay expenditure will reduce by £1.7m from 2013/14 levels. Reducing the pay bill is fundamental to the Trust’s plan. Although efficiency plans will reduce pay expenditure by £8.9m, this is partially offset by inflationary pressures and some significant service developments and approved investments in clinical workforce reflected in the plan. A breakdown of the movements in pay expenditure are summarised in the Table below;

7

£'m WTE

13/14 Outturn (247.85) 6,142.18

Inflation (3.83)Activity Growth (0.42) 14.60Removal of T & O uplift 0.59 (4.00)RTT (1.44) 19.30CLRN (hosting arrangements cease) 0.90 (14.00)Francis Report (0.42) 5.53FYE Cquins posts (0.09) 1.00FYE Breast screening (0.27)Commercial Manager Private Patients (0.03)Ward Model amendments (non Francis) (0.23)OCOT Geriatrician (0.14) 1.002nd Cath Lab (0.25) 2.00A&E Consultant & ENP's (0.38) 3.00Cancer Posts (0.03) 2.00Endoscopy (0.05)Paeds Diabetes (0.04) 1.00Executive team Changes (0.13) 1.00Health Intelligence, Access & OP Improvement (0.19) 3.00Other (0.14) 5.77Contingency (0.60)CIP schemes * 8.94 (112.54)

Planned Pay Expenditure 2014/15 (246.10) 6,070.84 *CIP schemes net impact WTE Average WTE across the year 120.07 Cost of delivering the income CIP’s (7.53) Net WTE reduction as per Monitor 112.54 The movement in WTEs for the efficiency programme is indicative at this stage and includes areas where there may be changes in flexible pay costs rather than substantive posts. The Efficiency Programme 2014/2015 The overall efficiency requirement of the Trust is £19m. This equates to 5.4% of the controllable cost base. A summary of the components of the affordability gap which requires £19m efficiency benefits is summarised below;

8

CORE FINANCIAL GAP 2014/15

£'000 £'000

2013/14 Outturn - Control Total 1,023

add: non-recurrent income & expenditure 2013/14 (6,342)less: full year-effect of 2013/14 schemes 1,075

2013/14 Normalised Surplus/(Deficit) (4,244)

impact of 14-15 prices (12,300)

local cost pressures (1,287)

Impact of Activity Growth 14/15 2,989

Financing costs 1,051

Contingency (1,800)

Surplus Target (3,400)

2014/15 Financial Gap - Efficiency Requirement (18,991) The Efficiency Programme will be delivered through a combination of specialty based plans and transformational programmes. The development and implementation of plans is managed through a series of workstreams, led by an Executive Director. The oversight and delivery of the Efficiency Programme is undertaken by the Efficiency Programme Steering Group, chaired by the CEO. All programmes undertake a Quality Impact Assessment (QIA). An initial risk assessment review has been undertaken by the Chief Nurse and Medical Director followed by sign off by the Quality and Risk committee in April. The following underlying principles have been applied to development of the programme;

• All specialties are required to increase their financial contribution (surplus) within Service Line Reporting (SLR) principles through targeted reduction of the cost base

• All clinical divisions are required to deliver a minimum 4% contribution through a

reduction in direct costs and all non-clinical areas have a targeted reduction of up to 5.4%.

• Any additional efficiency requirement is targeted to specific areas based on identified

transformational change programmes and related opportunities.

• The efficiency programme will deliver almost half of efficiencies by reducing the pay bill, this equates to almost 4% of the 2013/2014 planned pay expenditure.

• All workstreams are led by a member of the Executive Team. The Trust is in the process

of establishing a programme office to strengthen the governance arrangements of the programme led by a Programme Director who will have oversight of the efficiency programme.

9

An outline of the Efficiency Plan 2014/15 is set out below: Cost Improvement Programme 2014/15 and summary 2015/16

Workstreams 2015/16Q1 Q2 Q3 Q4 Total Total

Back Office & Corporate SupportBack Office 203,392 263,451 323,260 323,237 1,113,340 64,375 Procurement 749,998 750,000 750,001 750,001 3,000,000 2,500,000 Back Office & Corporate Support Total 953,390 1,013,451 1,073,261 1,073,238 4,113,340 2,564,375

Clinical ProductivityMedical Workforce - - 325,000 325,000 650,000 650,000 Medicines Management 104,500 207,200 291,050 304,050 906,800 381,400 Clinical Productivity Total 104,500 207,200 616,050 629,050 1,556,800 1,031,400

Clinical WorkforceCNST & NHSLA 88,739 88,739 88,739 88,739 354,954 - Nursing 303,901 337,633 372,733 385,733 1,400,000 227,312 Therapies 68,500 155,967 277,233 199,900 701,600 108,000 Clinical Workforce Total 461,140 582,338 738,705 674,372 2,456,554 335,312

Commercial OpportunitiesInformation Quality Improvement 100,000 300,000 300,000 300,000 1,000,000 200,000 Commercial Partnerships - - - - - 319,400 Private Patients 124,625 228,625 228,625 228,625 810,500 1,250,000 Provider to Provider 16,347 16,347 53,772 53,772 140,239 74,850 Commercial Opportunities Total 240,972 544,972 582,397 582,397 1,950,739 1,844,250

DiagnosticsCSSD 15,000 15,000 15,000 15,000 60,000 - Imaging 127,114 106,280 255,465 211,140 700,000 144,560 Pathology 191,562 191,563 207,813 207,813 798,750 1,127,083 Diagnostics Total 333,677 312,843 478,278 433,952 1,558,750 1,271,643

Estates & FacilitiesCarbon Management 7,129 16,141 16,310 16,907 56,486 65,840 Estate Rationalisation - - 250,000 250,000 500,000 58,572 Hard & Soft FM 398,120 415,760 430,760 476,260 1,720,900 3,600 Estates & Facilities Total 405,249 431,901 697,070 743,167 2,277,387 128,012

IM&TClinical Information Systems 77,760 77,760 100,885 68,385 324,789 260,750 Paper Light - 4,197 33,286 33,286 70,768 625,774 IM&T Total 77,760 81,957 134,170 101,670 395,557 886,524

Operational ProductivityEnhanced Recovery 24,069 60,619 71,327 82,033 238,047 132,902 Outpatients 7,831 129,793 190,214 233,162 561,000 1,058,629 Patient Flow - 100,000 175,000 375,000 650,000 850,000 Productive Theatre 45,500 106,500 318,000 529,999 1,000,000 555,999 Operational Productivity Total 77,400 396,913 754,541 1,220,194 2,449,048 2,597,530

Service ReconfigurationBest Practice Tariff opportunities - 52,500 116,500 176,000 345,000 - Ophthalmology 398,406 443,826 488,500 477,845 1,808,576 3,551,302 Orthopaedics 52,250 263,115 263,115 283,115 861,595 721,365 Service Reconfiguration Total 450,656 759,441 868,115 936,960 3,015,171 4,272,667

WorkforceAdmin & Clerical - - 125,001 125,001 250,002 250,002 Bank & Agency - - - - - - Management Costs - 166,667 166,667 166,667 500,000 75,000 Terms & Conditions 131,200 249,104 371,593 371,593 1,123,490 468,978 Workforce Enablers - - - - - - Workforce Total 131,200 415,771 663,261 663,261 1,873,492 793,980

Grand Total 3,235,943 4,746,786 6,605,848 7,058,261 21,646,838 15,725,693

Minimum Delivery requirement 2,671,000 4,429,000 5,826,000 6,060,000 18,986,000 11,203,000

Headroom 564,943 317,786 779,848 998,261 2,660,838 4,522,693

2014/15

10

Although the Trust is required to deliver £19m, savings plans valued at £21.6m have been identified thus far and will continue to be constructed to deliver more than the minimum target to provide headroom for potential slippage on some schemes. The plan is phased to deliver a minimum £2.7m in Q1 (15%) which will require 23% in Q2 and a further 62% to be delivered in Q3 and Q4 at a time when the hospital is usually busiest. This will be an additional challenge to ensure delivery of the programme is not compromised by operational pressures. The programme is split across pay, non-pay and income, including WTE impact. On this basis a minimum £8.9m reduction in the pay bill is required; this comprises almost 50% of the total programme. There is further refinement underway in terms of the attribution of schemes across these headings within some workstreams. All plans have completed Project Outline Document supported by a phased financial plan and implementation plan. There is still further work to do to identify all cost reductions to cost centre and account code level and more detailed work is in progress to ensure the granular detail required for delivery An Efficiency Plan matrix is in the process of being constructed for each Division and corporate department to ensure that the savings identified by each area are mapped across to the workstreams and vice versa. This is to ensure the development and implementation of plans are fully integrated across service lines and workstreams and that there is clear accountability for delivery of plans. Formal weekly sessions for the efficiency programme overseen by the interim Programme Manager to enable work streams to develop plans in partnership with the clinical Divisions are in place from April 2014. The Efficiency Programme Steering Group has been in place since early March to track development of the efficiency programme. The Trust has also developed outline plans for 2015/16 to support the 2 year plan submission to Monitor but work is on-going to develop these in more detail. Expenditure Control Totals for Divisions and the Sign Off Process Baseline budgets in the Clinical Divisions and Facilities & Estates Directorate have been realigned to reflect gaps from unidentified savings in 2012/13 and 2013/14 and approved investments in year. In addition, the 2014/15 delegated budgets have been uplifted to reflect any anticipated costs incurred to deliver confirmed activity levels in commissioning plans. Divisional control totals have been set which reflect these changes and a realignment of pay and non-pay budgets to more closely reflect 2013/14 outturn levels is expected. The budgets for the corporate directorates are on a roll-over basis. Formal budget sign-off meetings with the Director of Finance and Chief Operating Officer are set up for early May. The funded establishment reflects all funded posts in 2013/14 plus the additional posts for approved service investments. A review of nursing templates on wards has been undertaken in year, led by the Director of Nursing and the outcome of this review is reflected in baseline budgets. Control totals incorporating up to 5.4% cost reduction target have been issued to divisions and corporate departments. There will be further refinement to these as workstream plans are finalised and the financial impact of known service developments are confirmed. A process is in place for formal sign off of control totals in early May for all areas to coincide with the reporting timetable for Month 1 2014/15.

11

Capital Plans The capital programme has been informed by Divisional business planning and the Trust’s Clinical Services Strategy. Prioritisation has taken place at two formal meetings consisting of multi-professional representation in January and February 2014. The programme was presented to the Trust Board in March and is summarised in the table below:

2014/15 Q1 Q2 Q3 Q4£m £m £m £m £m

Endoscopy 4.79 0.00 0.25 2.02 2.52Estates Enable Schemes 4.00 0.89 1.02 1.02 1.07Emergency Floor 3.85 1.57 1.73 0.56 0.00Southlands 3.00 0.00 0.00 1.25 1.75Information Technology schemes 1.89 0.33 0.29 0.36 0.91Medical Equipment 1.80 0.00 0.00 0.90 0.90Interventional Radiology 1.69 0.00 0.00 0.40 1.29Pathology 1.02 0.80 0.12 0.00 0.10CT Scanner 0.80 0.00 0.00 0.00 0.80Day Surgery, Worthing 0.00 0.00 0.00 0.00 0.00Overprogramming 0.00 0.00 0.00 0.00 0.00Total Investment 22.84 3.60 3.41 6.50 9.34Charitable Funding (1.75) (0.44) (0.44) (0.44) (0.44)Net Investment by Trust 21.09 3.16 2.97 6.06 8.90 Each year the Trust receives donations from Love Your Hospital and the League of Friends, funding both capital and revenue items traditionally. Donated assets have been assumed at £1.75m in 2014/15 to fund specific schemes within the Trust’s capital programme. Potential schemes have been identified internally, and dialogue with our Charities commenced to secure funding. A risk-based approach to prioritisation has been adopted, taking into account the Trust’s risk register, clinical standards/requirements, patient experience etc. The schemes identified consider business cases already Trust Board approved, and those with approval in principle by the Service Change Executive. The key programmes within the capital programme are:

• Endoscopy redevelopment – as outlined in our operational plan programmes of work, the redevelopment of our Endoscopy services is a key quality improvement , improving patient flow, patient experience and efficiency, and will allow the Trust to meet the forecast growth in demand for Endoscopy services

• The Emergency Floor at Worthing Hospital – this will integrate care of the elderly, surgical and acute medical assessment into a single area and will result in a major improvement in patient care. The Emergency Floor is a key enabler to drive additional productivity through reductions in length of stay for unscheduled care patients

• Southlands Hospital: To deliver the Trust’s commitment to develop Southlands Hospital, external investment of £4.5m has been included within the plan to support the development of Ophthalmology at Southlands, moving the current service from Worthing Hospital. This investment will be subject to a business case in early 2014/15 to demonstrate the economic benefits of the development

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• Interventional Radiology- the Trust is replacing and upgrading its Interventional

Radiology services at Worthing Hospital as an essential part of providing a modern and safe acute service

• CT Scanner – one of the two CT Scanners at St. Richard’s Hospital is in need of replacement and upgrading

In addition to these schemes, the Trust has allocated significant capital sums to IM&T, replacement Medical Equipment and a range of Estates enabled schemes covering sustainability, refurbishment, minor works and backlog maintenance. Due to the significant number of schemes and the limited resources available for capital investment there will be on-going review of priorities, in particular for 2015/16, recognising the current over-programming of the capital programme in 2015/16. Liquidity As at 1st April the Trust will have £9.5m outstanding on the working capital loan draw down on FT authorisation. The Trust is expected to maintain a cash balance of at least the value of the outstanding working capital loan. £1m will be repaid on this loan each year in two equal instalments in Q1 and Q3. There is an additional working capital loan balance from the predecessor Trust of £2.4m as at the beginning of April. This outstanding balance will be repaid in full during 2014/15. Rolling cash flow forecasts will continue to be used to manage cash and to report the liquidity position to the Board The Trust summary balance sheet is shown in the table below

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30th June 2014

30th September

2014

31st December

2014

31st March 2015

Plan Plan Plan Plan£m £m £m £m

Non Current Assets 260.94 260.88 263.77 269.36

Inventories 6.48 6.48 6.48 6.48Trade and Other Receivables 15.57 14.57 13.07 11.57Other Current Assets 5.17 5.17 5.17 3.67Cash 18.50 17.49 21.45 13.80Non Current Assets held for Sale 1.48 1.48 1.48 1.48Total Current Assets 47.19 45.19 47.65 37.00

Trade and Other Payables (11.32) (11.33) (11.34) (11.35)Non Commercial Loans (4.69) (3.48) (3.48) (2.28)Accruals (19.17) (17.44) (19.17) (17.44)Other Current Liabilities (2.56) (0.86) (2.63) (0.93)Total Current Liabilities (37.74) (33.11) (36.62) (32.00)

Net Current Assets 9.45 12.08 11.02 5.00

Non Commercial Loans (33.81) (33.17) (32.67) (32.03)Provisions (2.48) (2.45) (2.41) (2.38)Finance Leases (2.19) (2.10) (2.01) (1.92)Total Non Current Liabilities (38.47) (37.71) (37.09) (36.33)

Total Assets Employed 231.92 235.24 237.71 238.03

Public Dividend Capital 238.69 238.69 238.69 238.69Retained Earnings/(Accumulated Losses) (47.42) (44.10) (41.63) (41.31)Revaluation Reserve 40.65 40.65 40.65 40.65Total Taxpayers' and Others' Equity 231.92 235.24 237.71 238.03

As at

The balance sheet reflects the following key movements:

• Non Current Assets: reflects capital investment net of depreciation • Trade and Other Receivables: reduce in 2014/15 due to the receipt of cash from NHS

England that relates to the 2013/14 financial year. • Non Current Assets held for Sale: the portion of the Southlands estate declared surplus

by the Trust Board in 2013. The Trust is currently reviewing its options for the disposal of land and buildings at Southlands Hospital. A decision is expected to be made by the Trust Board early in 2014/15 and may lead to a change in associated elements of the financial plan.

• Commercial Loans: reflect the repayment of working capital loans, as described in the liquidity section, repayment of existing capital loans and draw down of further capital investment loans, as described in the capital section

14

Continuity of Service Risk Rating The table below summarises the financial risk rating based upon the 2014/15 financial plan. A Continuity of Service Risk Rating (CoSRR) of 3 is maintained throughout the period. The phased plan maintains a debt service cover rating of at least 2 during the period. The liquidity metric is maintained at a minimum of 3 during the period.

30th June 2014

30th September

2014

31st December

2014

31st March 2015

Plan Plan Plan PlanRevenue Available for Capital Service £m 3.80 12.09 19.33 24.86Capital Service £m (2.45) (6.58) (9.02) (13.10)Capital Service Cover metric times 1.55 1.84 2.14 1.90Capital Service Cover rating 2 3 3 3

Cash for CoS liquidity purposes £m 1.50 4.12 3.07 (2.96)Operating Expenses within EBITDA, Total £m (89.11) (176.19) (263.10) (350.18)Liquidity metric days 1.5 4.2 3.1 (3.0)Liquidity rating 4 4 4 3

Continuity of Service Risk Rating 3 4 4 3 Key Risks for 2014/2015 There are a number of significant risks in delivering the financial plan. These will be closely monitored along with financial performance through the year. These have been summarised below;

• The impact of 8.2m QIPP schemes in full and the ability to either take out stranded costs if schemes deliver in full or the affordability for commissioners to pay in full for over-performance above contracted activity levels. Mitigation of this risk is the close monitoring of activity levels in year and formalising escalation triggers for significant variance to plan. The plan also recognises some financial provisions that have been made against these risks both by the CCG and the Trust.

• A contract with Specialist Commissioners presents a risk whilst agreement is still to be secured. However, resolution of 2013-14 income has significantly reduced the risk from the position previously stated. A contract offer has been received by the Trust which is less than the income assumed in the plan. The Trust is in discussion with the Area Team to progress the outstanding differences and is preparing for a formal resolution of these.

• The scale of required savings to deliver the planned surplus is the largest target the

Trust has been required to achieve so delivery of the Efficiency Programme in full is a risk. This will be mitigated by enhancing the infrastructure to support the programme with a robust reporting framework and an approach which enables delivery through enhanced capacity and project management expertise as well as Executive led work streams.

• The cost of delivery of aggregate RTT compliance within the cost envelope assumed

within the plan will require close scrutiny and rigorous tracking of costs, particularly in

15

Q1. Agreement of additional resource to enable this has been reviewed and a sign off process by the Director of Operations and the Director of Finance is in place.

Next Steps Although the Financial Plan 2014/15 is now finalised there are some aspects which require further refinement. The key components of these are as follows;

• Agreement of the contract with NHS England for Specialist activity

• Further detail on the implementation plans to ensure delivery of the efficiency programme for schemes not confirmed at budget code level

• Final sign off of the delegated control totals across all operational areas. Recommendation It is recommended that the Board of Directors note the Financial Plan for 2014/15 following approval in March 2014 and note the progress to the plan since last month. Karen Geoghegan Director of Finance April 2014

16

Appendix 1 Income and Expenditure Account

2014/15 30th June 201430th September

201431st December

2014 31st March 2015Plan Plan Plan Plan Plan£m £m £m £m £m

Income from Activities 335.17 83.08 85.39 84.12 82.59Other Income for Patient Care 9.34 2.24 2.37 2.38 2.36Education, Training and Development 9.81 2.45 2.46 2.46 2.44Other Income 23.48 5.84 5.85 5.88 5.90Total Income 377.80 93.60 96.06 94.84 93.30

Medical Staff (69.99) (17.60) (17.63) (17.42) (17.35)Nursing Staff (94.48) (24.00) (23.77) (23.45) (23.26)Scientific, Therapeutic and Technical (35.59) (8.96) (8.91) (8.87) (8.85)Non Clinical Staff (45.44) (11.29) (11.12) (11.23) (11.80)Pay Reserves (0.60) 0.00 0.00 (0.30) (0.30)Total Pay (246.10) (61.85) (61.42) (61.27) (61.56)

Drugs (31.35) (7.90) (7.86) (7.80) (7.79)Clinical Supplies and Services (33.57) (9.51) (8.31) (7.93) (7.83)Non Clinical Supplies and Services (4.32) (1.10) (1.08) (1.08) (1.07)Other Operating Expenses (34.84) (8.75) (8.41) (8.84) (8.83)Total Non Pay (104.08) (27.26) (25.66) (25.64) (25.52)

Total Operating Expenditure (350.18) (89.11) (87.08) (86.91) (87.08)

EBITDA 27.62 4.49 8.98 7.93 6.22

Depreciation and Amortisation (14.40) (3.51) (3.50) (3.61) (3.78)Profit/(Loss) on Disposal 0.00 0.00 0.00 0.00 0.00Impairment of fixed assets (1.12) (1.12) 0.00 0.00 0.00Finance Costs (1.11) (0.14) (0.44) (0.14) (0.39)Interest Receivable 0.05 0.01 0.01 0.01 0.01Public Dividend Capital Dividend (6.93) (1.73) (1.73) (1.73) (1.73)Total Non-Operating Items (23.51) (6.50) (5.65) (5.46) (5.90)

Net Surplus/(Deficit) 4.11 (2.01) 3.33 2.47 0.32

Adjustments to Retained Surplus DeficitImpairments 1.12 1.12 0.00 0.00 0.00Donated Assets (1.80) (0.45) (0.45) (0.45) (0.45)

Underlying Operational Performance 3.43 (1.33) 2.88 2.02 (0.13)

To: Trust Board


Title

Quarterly Submission to Monitor


Marianne Griffiths, Chief Executive

Prepared by


Status

Disclosable

Summary of Proposal

The Board needs to sign off the proposed submission before upload to Monitor. Monitor will assess the trust’s performance for the last quarter and will discuss any issues in a review meeting the date of which is to be confirmed.


No direct implications – the report seeks assurance that quality of care standards are maintained


G1 Maintain an acceptable financial risk rating; G2 Maintain a Monitor Governance rating of no worse than Amber Green throughout the year


No direct implications – the report seeks assurance that the financial plan is maintained going forward


None

Recommendation The Board/Committee is asked to APPROVE the submission


To public Board meeting.

Appendices

1 Internal checklist 2 Governance submission

This report can be made available in other formats and in other languages. To discuss your requirements please contact the Company Secretary on 01903 285288.

To: Board of Directors Date: 1 May 2014

From: Andy Gray, Company Secretary Agenda Item: 14

FOR DECISION

QUARTER 4 2013/14 MONITOR MONITORING RETURN

1. INTRODUCTION 1.1. At its meeting on the 27th March the Board noted that the April Board

meeting would take place on 1st May , after the deadline for the Monitor Quarterly Submission and therefore delegated authority to the Chair and Director of Finance sign the appropriate declarations.

1.2. The Board of Directors is asked to review our current performance as presented and the attached self-certification checklist attached at Appendix 1. The Board is asked to note the statement at Appendix 2 which has been signed.

1.3. At the end of Quarter 2 the trust had a narrative governance rating. Monitor

notified the Trust on the 4th March of its decision “that it will not open an investigation to assess whether the Trust could be in breach of its licence at this stage for financial risk or for C.Difficile performance. The Trust’s governance risk rating has been reflected as Green.”

1.4. Following 1.3 above as at Quarter 3 the Trust was assessed by Monitor as

having a Continuity of Service Rating of 3 and a Governance Rating of Green.

2. SUMMARY OF SUBMISSION

2.1. The return covers the period January to March 2014. In making this return,

the Board of Directors is considering performance against the Annual Plan for 2013-14, derived from the Integrated Business Plan submitted to Monitor for authorisation.

3. RECOMMENDATION

3.1. The Board is asked to APPROVE the submission to Monitor.

Appendix 1 Monitor Quarterly Reporting Exception Checklist The following checklist is taken from the Compliance Framework (note that this has not been updated into the 2013 Risk Assessment framework which supersedes the Compliance Framework) FOR THE PERIOD JANUARY TO MARCH 2014 Lead QUARTER 4 Finance / KG • Unplanned significant reductions in

income or significant increases in costs

No

Finance / KG • Requirement for additional working capital facilities

No

Finance / KG • Failure to comply with the NHS Foundation Trust Annual Reporting Manual

No

Finance / KG • Discussions with external auditors which may lead to a qualified audit report

No

Finance / KG • Transactions potentially affecting the financial risk rating and/or resulting in an ‘investment adjustment’

No

Governance/AG • Removal of director(s) for significant contractual or non-contractual dispute with another NHS body

No

Finance / KG • Adverse report from internal auditors

No

Governance/CS • Risk of failure to maintain registration with the Care Quality Commission

No

Governance /CS/AG

• Significant third party investigations that suggest material issues with governance e.g. fraud or Care Quality Commission reports of ‘significant failings’

No

Governance/CS • Care Quality Commission responsive or planned reviews

16th January Themed Mental Health Act compliance review All detentions lawful and compliant

Governance/CS • Outcomes or findings of Care Quality Commission responsive or planned reviews

Visit on 12th December Minor actions noted All now compliant

Governance/CS • Other patient safety issues which reflect quality governance issues (e.g. serious incidents)

No

Finance / KG • Performance penalties to commissioners

No

All • Enforcement notices from other bodies implying potential or actual

None

breach of any other requirement of the licence, e.g.:

o Health and Safety Executive or fire authority notices

o Material issues impacting on the trust’s reputation

o Adverse reports from overview and scrutiny committees

o Patient group and Healthwatch concerns

Appendix 2

Worksheet "Governance Statement"Click to go to index

In Year Governance Statement from the Board of Western Sussex Hospitals

The board are required to respond "Confirmed" or "Not confiirmed" to the following statements (see notes below)

For finance, that: Board Response

4 Confirmed

For governance, that:11 Not Confirmed

OtherwiseConfirmed

Signed on behalf of the board of directors

Signature Signature

Name Name

Capacity [job title here] Capacity [job title here]

Date Date

The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21, Diagram 6) which have not already been reported.

The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

A 1) C.diff non-compliance in 2013/14 relates to atypical performance in Q1, with compliance from that point

replicating planned levels. In 2014/15, the Trust will maintain the continuous programme of measures to control and investigate any cases using Root Cause Analysis. 2) Following RTT compliance failure in Q4 2013/14 due to an imbalance of demand versus available capacity an recovery programme aimed at restoring aggregate compliance by the end of Q1 2014/15 had been developed. This plan delivers an additional 2870 outpatients and 1082 inpatients/day cases above the 2013/14 run rate by the end of the quarter. This volume reduces the waiting list size and distribution to a point that can deliver aggregate compliance from Q2 2014/15. A further 6568 outpatients and 2275 inpatients/day cases are identified in the plan above current run rate in Quarters 2-4 in order to maintain compliance from that point. Both Q1 Recovery Plan and on-going activity planning assumptions have been agreed with the CCG and reflected in the 14/15 contract (IAP)

B

To: Board


Title

Register of Interests


Marianne Griffiths, Chief Executive

Prepared by


Status

Disclosable

Summary of Proposal

It is good corporate governance practice for Directors to declare any professional or personal interests which are relevant to their roles at the Trust. This ensures that any relevant interests are identified proactively and are managed to ensure that there is no actual or perceived improper influence over decisions taken by the Board. The Trust’s policy on declaration of interests, requires that Directors declare at meetings any interests which are directly relevant to matters being discussed at those meetings. Directors are also required to record their interests in the Register of Interests. It is good practice for this to be received by the Board at least annually. The attached Register of Interests has been updated this month. The Register is updated at this time of the year in order that declarations are current at the financial year-end, and thereby support the audit of the annual accounts. At the request of the Trust’s External Auditor, Ernst & Young, Directors were asked to declare any interests relevant to Love Your Hospitals charity as well as to the Trust.


None


Monitor Code of Governance and Audit Requirement


None


None

Recommendation The Board is asked to NOTE the Register of Interests


Chairman, Chief Executive, Executive Directors, Non-executive Directors

Appendices

Register of Interests, April 2014



WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST AND LOVE YOUR HOSPITAL CHARITY REGISTER OF DIRECTORS’ INTERESTS : April 2014 Ref Name Job Title Interests Declared Fit and Proper

Person declaration

DOI 14-01 Mike Viggers Chair No Declarations Yes DOI 14-02 Bill Brown Non Executive Director No Declarations Yes DOI 14-03 Joanna Crane Non Executive Director No Declarations Yes DOI 14-04 Tony Clark Non Executive Director - Lay Chair for Kent, Surrey and Sussex Deanery Yes DOI 14-05 Jon Furmston Non Executive Director - Full Time employee of BT at its Headquarters Division. BT

supplies Telecoms services to the NHS but I am not employed or incentivised by that Division’s work.

Yes

DOI 14-06 Martin Phillips Non Executive Director - Magistrate on Sussex Western Bench - Employment Specialist for West Sussex Citizens Advice Bureaus - Member of remuneration Committee for Adur District Council - Member of Brighton, Hove and Worthing Relate

Yes

DOI 14-07 Marianne Griffiths Chief Executive Director and co-owner of Eden Consulting, which works in social care. No direct work undertaken. No connection with the business of the Trust.

Yes

DOI 14-08 Dr George Findlay Medical Director No Declarations Yes DOI 14-09 Denise Farmer Director of Organisational

Development and Leadership

No Declarations Yes

DOI 14-10 Jane Farrell

Deputy Chief Executive and Chief Operating Officer

No Declarations Yes

DOI 14-11 Karen Geoghegan Director of Finance No Declarations Yes DOI 14-12 Cathy Stone Director of Nursing and

Patient Safety I work as an occasional specialist advisor to the CQC for which I do not receive payment. Fee’s are paid direct to the Trust.

Yes

DOI 14-13 Andy Gray Company Secretary (Board Attendee)

Director of PFG Consultancy which has not yet traded and which would have no relationship to Western Sussex Hospitals NHS Foundation Trust.

Yes

Last updated: April 2014 and Noted by the Board, 1 May 2014

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